EP. 128: FOOD FOR THOUGHT

Sep 4

WITH DAVID PERLMUTTER, MD

A neurologist and bestselling author discusses the intricate relationship between our diet, lifestyle, and brain health — and how he navigates the often-messy and conflicting findings within nutrition science.

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Episode Summary

Modern medicine has long considered many neurodegenerative diseases such as Alzheimer's disease and Parkinson's disease to be immutably linked to the fate of certain unlucky individuals through yet-poorly understood genetic mechanisms. But increasingly, we are seeing evidence that some of our lifestyle choices, including our diet, physical activity, and relationships, may play a significant role in the development of, or protection against, these diseases. Our guest on this episode, David Perlmutter, MD, is a neurologist and writer whose immensely popular books, including Grain Brain: The Surprising Truth About Wheat, Carbs, and Sugar — Your Brain’s Silent Killers (2013), discuss why diets low in refined carbohydrates and high in fats, in addition to foods that nurture a healthy gut microbiome, may prevent cognitive decline.

Over the course of our conversation, we discuss Dr. Perlmutter's path from conventional neurology to moving towards a more functional and holistic approach to treating brain disorders, the importance of metabolic health in maintaining our cognitive capacities, how Dr. Perlmutter responds to critics of his non-conventional medical advice, why nutrition science is riddled with messy and conflicting findings and how we can better navigate through it all, what clinicians can do to better help their patients live well, and more.

Note: Some of Dr. Perlmutter’s ideas and recommendations have been the subject of debate and controversy within the medical community. While we believe in fostering open dialog and exploring diverse perspectives, the views expressed in this episode are those of Dr. Perlmutter and do not necessarily reflect the views or endorsements of this podcast. We encourage listeners to critically evaluate the information presented and work with qualified healthcare professionals when making any changes to their health and wellness routines.

David Perlmutter, MD is a Board-Certified Neurologist and six-time New York Times bestselling author. He serves on the Board of Directors and is a Fellow of the American College of Nutrition.
Dr. Perlmutter received his M.D. degree from the University of Miami School of Medicine where he was awarded the Leonard G. Rowntree Research Award. He serves as a member of the Editorial Board for the Journal of Alzheimer’s Disease and has published extensively in peer-reviewed scientific journals including Archives of Neurology, Neurosurgery, and The Journal of Applied Nutrition. In addition, he is a frequent lecturer at symposia sponsored by institutions such as the World Bank and IMF, Columbia University, Scripps Institute, New York University, and Harvard University, and serves as an Associate Professor at the University of Miami Miller School of Medicine.
Dr. Perlmutter has been interviewed on many nationally syndicated television programs including 20/20, Larry King Live, CNN, Fox News, Fox and Friends, The Today Show, Oprah, The CBS Early Show, and CBS This Morning. Dr. Perlmutter is also the recipient of numerous awards, including: the Linus Pauling Award for his innovative approaches to neurological disorders; the National Nutritional Foods Association Clinician of the Year Award, the Humanitarian of the Year Award from the American College of Nutrition, and most recently the 2019 Global Leadership Award from the Integrative Healthcare Symposium.
In this episode, you will hear about:
• 3:11 - Dr. Perlmutter’s transition from conventional neurology to what he calls “preventative” neurology
• 8:43 - Dr. Perlmutter’s views on what constitutes a “disease” and the role of the doctor.
• 19:08 - Emerging science on the importance of metabolic health on brain health
• 25:17 - How scientific studies on preventative health can be (and have been) designed
• 34:56 - Why Dr. Perlmutter prioritizes health markers (such as HbA1c) over specific dietary recommendations when working with patients
• 42:21 - Dr. Perlmutter’s views on GLP-1 antagonists such as Ozempic and Mounjaro
• 50:36 - How Dr. Perlmutter has dealt with critics of his work
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] For most of modern medicine, many neurodegenerative diseases such as Alzheimer's disease and Parkinson's disease have been thought of as linked to the fate of certain unlucky individuals by way of yet poorly understood genetic mechanisms. But increasingly, we are seeing evidence that some of our lifestyle choices, including our diet, physical activity and relationships, may play a significant role in the development of or protection against these diseases. Our guest on this episode, Dr. David Perlmutter, is a neurologist and writer whose immensely popular books, including 2013 Grain Brain, discuss why diets low in refined carbohydrates and high in fats, in addition to foods that nurture a healthy gut microbiome, may prevent cognitive decline. Over the course of our conversation, we discuss Dr. Perlmutter's path from Conventional neurology to moving towards a more functional and holistic approach to treating brain disorders. The importance of metabolic health in maintaining our cognitive capacities. How Dr. Perlmutter responds to critics of his sometimes non-conventional medical advice. Why nutrition science is riddled with messy and conflicting findings, and how we can better navigate through it all. What clinicians can do to better help their patients live well, and more.
Henry Bair: [00:02:26] Before we jump into our conversation with Dr. Perlmutter, we want to acknowledge that some of his ideas and recommendations have been the subject of debate and controversy within the medical community. While we believe in fostering open dialog and exploring diverse perspectives, the views expressed in this episode are those of Doctor Perlmutter and do not necessarily reflect the views or endorsements of this podcast. As always, we encourage our listeners to critically evaluate the information presented and work with qualified healthcare professionals when making any changes to their health and wellness routines.
Henry Bair: [00:03:03] With that, we want to welcome David Perlmutter to the show. Thanks so much for taking the time to join us, David.
Dr. David Perlmutter: [00:03:08] Delighted to be here today with you. Thank you.
Henry Bair: [00:03:11] So you are now quite well known for your work on how diets and lifestyle influence our risks of neurodegenerative diseases, but you are also trained as a neurologist. Can you tell us more about that transition from practicing neurology from a more traditional approach to looking at it from a more holistic lifestyle perspective?
Dr. David Perlmutter: [00:03:33] Well, I'd say maybe. Maybe it's the coffee I had this morning, but I suddenly had the idea that why? Why is that a surprise? You know, why wouldn't we be training neurologists to understand the importance of lifestyle inputs in terms of choosing the brain's destiny? You know, why are we having this interview today? Why am I sort of the aberration, the odd man out, as it were. And, you know, I think that'd be a great thing for the audience to ponder for a moment that why don't we teach neurologists about the incredible value of being preventive in terms of their approach to help people, you know, really keep their brains healthy? But having said that, I did practice mainstream, if you want to call it that, typical clinical neurology with partners for ten years. And over that period of time, I just ultimately became very dismayed at what I was observing. You know, the things going on in the practice, really focusing on the bottom line. And it was really about the amount of put through that could be obtained or realized in an office setting in terms of the number of patients per day. So it was really about maximizing the turnover of patients rather than, you know, really dedicating to the reason I became a physician and clearly why I became a neurologist in the first place.
Dr. David Perlmutter: [00:04:49] So the focus really was, and to this day, remains symptoms. Symptom management. As it relates to any number of the neurological conditions that typically end up in front of the neurologist day to day. And while I think there's great merit to helping a Parkinson's patient with his or her mobility issues, movements, etc. and stroke patients gain function of their limbs, etc., I think that's treating the smoke but not the fire. And I really felt it was necessary because at that point, even then, there was still there were already plenty of literature citations indicating the relationship between lifestyle choices and risk for various neurological issues like Alzheimer's, Parkinson's, multiple sclerosis, chronic headaches, you name it. And I began looking into those research studies and really found sort of a renaissance in my interest in neurology, but I felt very alone, that's for sure.
Dr. David Perlmutter: [00:05:53] But nonetheless, I remember I decided I was going to leave the practice and my partner said, if you leave this practice and do what you want to, you're talking about doing with respect to prevention and talking to people about their diets. Of all of all things. You won't get a single referral in this town. And they were right, because I was kind of the young neurologist in town. I was getting a lot of referrals, but I didn't get any more. Once I opened up my new practice dedicated to helping people keep themselves healthy across the spectrum of neurologic conditions and other health related issues as well. They're correct. I didn't receive referrals from local doctors, except I did receive referrals from chiropractors. And I did start after a while to see the doctors themselves, which was really kind of interesting, though they wouldn't refer patients to me, they would sort of come in or bring their family members, but I found it very exciting to be involved in uncharted territory and began compiling my thoughts, compiling my results, began writing, began lecturing, and this became, you know, obvious definition of what I wanted to do for the rest of my life from a professional perspective. There was no turning back, and my practice thrived. We began getting referrals from around the world. And, you know, it was really interesting to be pioneering this notion of sort of an integrative view of neurology and the brain and, and brain disorders that were so common.
Henry Bair: [00:07:28] So what does your practice look like in the sense of, you know, you talk about preventative neurology, if you will. What kinds of patients do you see? What do they. What kinds of complaints, if any, do they come in to see you with?
Dr. David Perlmutter: [00:07:39] I have not gone to a clinic practice now for a couple of years, because now I'm more involved in teaching and writing. But, you know, typically any neurological problem that was treated by mainstream neurologists could avail itself of what we do. You know, ideas related to the gut brain connection, which is central as it relates to, for example, autoimmunity. So therefore, all the demyelinating conditions, like multiple sclerosis would come under our under our purview. Anything inflammatory like Alzheimer's and Parkinson's, certainly autistic spectrum disorder clearly related to issues in the gut to some degree, and therefore a huge opportunity to do more than simply symptom management in these children and now adults. So I think that we have seen virtually all general neurological problems that would be seen in a typical general community or even academic practice.
Tyler Johnson: [00:08:43] You know, it's interesting when I hear you talk because I'm an oncologist, not a hematologist, but my training also included hematology. So let me describe a quick thing from hematology and then use it to frame a question that I think is interesting. So most people when they think of leukemia, they think of really terrible, devastating, sudden illnesses that land a person in the hospital for months and months. And there are kinds of acute leukemias that are like that. But there are also these other diseases called chronic leukemias that are much less sudden and much less, at least initially, much less devastating. And one of those is CLL, chronic lymphocytic leukemia. And one of the things that is really interesting about that is that it's often picked up either because a person has a mildly swollen lymph node, or because they have a very slight aberration in one of their sort of standard blood tests. That's noticed by like a primary care doctor. And then one thing leads to another and they get a bunch of special testing, and then they're diagnosed with this disease. But the thing that's strange about that disease is that in many patients, they quote unquote, have the disease for many months or sometimes even for many years. And it causes no problems. It causes no symptoms. It doesn't even cause problems really, in terms of their blood counts or anything else, except as noted by a very specially trained hematologist who sort of looks at things and you know, and can tell that there's something abnormal going on there, and then there's even a precursor condition to that which is, in effect, sort of something that will eventually become CLL but hasn't gotten there yet, which can also be picked up on a blood test. And if you have a really perceptive primary care doctor, they might find that and then you might know about it years before you even get to where you would meet formal diagnostic criteria for CLL, which may then be years before you develop any symptoms. The reason I bring that interesting and unusual disease entity up in this conversation is because it brings to mind a really interesting question, which is, well, a couple of questions. One is what constitutes quote unquote a disease, and two is what is a doctor's job, right. Because I think in the United States, We have often thought about as a doctor, as a person who gives you a treatment for a diagnosable condition once it has gotten bad enough to cause a diagnosed condition.
Dr. David Perlmutter: [00:10:56] Right.
Tyler Johnson: [00:10:56] And part of what I hear when I hear you talking is that part of what you have tried to do, not that you don't see people who already have diagnosable conditions, but that part of what your thinking is trying to do is to shift the paradigm a little bit so that there's a recognition that wouldn't it be better if, rather than focusing on treating Alzheimer's disease, for example, we could prevent Alzheimer's disease from happening in the first place? Right. If we could make sort of upstream changes that would prevent the problem from becoming a diagnosable problem down the road, that would seem to benefit everybody. But that's very different from, I think, how most people conceptualize of doctors and how most doctors conceptualize of themselves. Right. Like, I mean, I as an internist, I think of a cardiologist who treats an existing cardiovascular lesion. Right. That's already caused an MI or is well on its way to causing an MI or whatever. So can you talk a little bit about sort of your theory, both of what constitutes disease and then what you think the role of a doctor is?
Dr. David Perlmutter: [00:11:56] I will and Tyler, I think that your experience as a hematologist segues nicely to now looking at how that applies to neurological disorders. I mean, let's just take Alzheimer's to start. If you go to the Alzheimer's Association website, which is updated annually, they provide a continuum, which I think is really interesting, where a patient begins to on the left side of the image, the patient begins to experience some challenging, some challenges with respect to cognition, generally memory, etc. and then those situation gets worse. Ultimately, he or she sees a physician that's in the middle of the screen, and then to the right of the screen is the the end game, which is patient, begins to receive intravenous therapy for fully diagnosed Alzheimer's disease that defines the playing field from the beginning of noticing something wrong, to ultimately manifesting the named disease and having the accepted treatment for same. And I challenge that for reasons that you alluded to, that we shouldn't wait until an individual begins to have cognitive decline to be thinking that he or she is at risk. You know, when I lecture, I often say, you'll know you're at risk for Alzheimer's disease. Pretty much if you have a vowel in your name, it's a bit of a joke, but we're all at risk. And you know, at age 85, your risk is 50 over 50. So it becomes really almost an epidemic sort of consideration. That said, we now understand that the seeds are sown for that degeneration of the brain that we've named now as Alzheimer's disease. Those seeds are sown 20 to 30 years ahead of time, and are the metabolic issues that begin in the brain that set the stage, ultimately for the accumulation of the beta amyloid, increased inflammatory mediators, axonal degeneration, neuronal degeneration, and ultimately, really the biggest deal as it relates to what makes a good brain go bad, it's loss of synapses.
Dr. David Perlmutter: [00:14:07] So it really focuses on the central role of metabolic issues in the brain over which we have control. That's the key. That's the take home message for our time together here, is that we have control over those metabolic issues that are paving the way for the good brain to go bad. Two and three decades in the future, we think of Alzheimer's. Oh, you know, the 70 year old person now can't remember grandchildren's names. Et cetera. Or Wi-Fi codes, whatever, whatever it may be. But the reality is, you know, this thing is starting in our 40s and 30s and perhaps even earlier and likely even earlier, as we look at obesity rates and type two diabetes in adolescence. Or it may even have some influence based upon microbiome issues early in life. But that said, I mean, we know that the microbiome plays actually an important role when we look at the increased risk of Alzheimer's and people using NSAIDs, for example, and acid blocking drugs. But to get back to the point that you raised, I want to make people aware that their lifestyle choices throughout their continuum of of life are very, very central to, again, architecting the brain's destiny. We don't have as we have this conversation today, we don't have any meaningful treatment for Alzheimer's disease.
Dr. David Perlmutter: [00:15:28] None. We see a lot of announcements since 2022 with respect to new drugs that are designed either to limit beta amyloid Production or to actually help rid the brain of beta amyloid. But when you look at the data that shows what happens to cognitive function, there's not really a big change. So what's the point? These people are dying with lower levels of beta amyloid in their brains, and yet they still reach end stage Alzheimer's. So to be fair, that's interesting. I'm glad people are doing the research, but I think focusing on metabolism as it relates to the body and brain is really where it's at as it relates to what makes the good brain go bad in Parkinson's as well, for that matter, other issues in Parkinson's we might have a chance to talk about like toxins in the environment. But let me give you an example. Now that it comes to my mind, three weeks ago in the New England Journal of Medicine, was a published result showing intervention in patients with Parkinson's disease either not receiving a drug or receiving this particular drug. And in the group that received the drug, their Parkinson's, in three years was arrested. Now that is treating the fire, not just the smoke. You know, in Parkinson's, we treat the smoke, we treat the tremor and the muscle and the rigidity, etc. but this arrested Parkinson's dead in its tracks, published in the New England Journal of Medicine. What was the drug? The drug was a GLP one agonist. For your listeners. That's a drug like Ozempic.
Dr. David Perlmutter: [00:17:05] Now, what you're not hearing me say is all Parkinson's patients should run out and get a prescription for ozempic. That's not my point. But what prompted this study was the observation that individuals with type two diabetes have a significant increased risk for developing Parkinson's. So you begin to get this relationship between metabolism and Parkinson's. But this is stunning. I mean, this really characterizes this relationship between metabolism and bad things happening in the brain. Well, as it relates back to Alzheimer's and, you know, to your point of when do you begin the intervention in Western medicine, we treat diseases once they have manifested. We talk about our health care system has nothing to do with health. Call it like it is. It has to do with treating illness. It's an illness centric kind of approach. But health centric approach keeps people healthy and it fosters the notion of preventive medicine. You know, for years people have talked about women who are at risk for osteoporosis. Well, you need weight bearing exercises, diets rich in boron, magnesium, calcium and, you know, the heart smart diet. We've kicked around for an awful long time, though. It changes. But what have we ever been told we should be doing to keep the brain healthy, despite the incredible amount of data that's out there? You know, that dates back 30 years. That makes it very clear that some fundamental lifestyle influenced mechanisms are playing a central role. So you're right. You know, it's very, very important to be preemptive as opposed to reactive.
Henry Bair: [00:18:43] It's interesting to me that you mention the evidence for lifestyle risk factors for a lot of neurological problems have appeared in the literature for decades now, but I'm trying really hard to remember my neurology rotation in medical school, and I don't think we really ever talked about it.
Dr. David Perlmutter: [00:19:02] You wouldn't have. I went to neurology school as well, and I was waiting for that, that lecture. But it never happened.
Henry Bair: [00:19:08] Yeah. But it's curious that I finished medical school last year. I finished my neurology rotation two years ago, you know, and still, I don't think I've ever heard of certainly Parkinson's, maybe Alzheimer's. There was. I remember hearing somewhere during that time that a diabetes and metabolic syndrome increases your risk for Alzheimer's manifolds, but certainly Parkinson's. I had never heard of that as Framed as a disease that is significantly influenced by lifestyle.
Dr. David Perlmutter: [00:19:37] Can I unpack on that for just a moment? Because it's a real kind of central area of my interest right now. So in the mid 1980s, there was a very fascinating observation that a group of people in California exposed themselves to a drug that somebody had concocted in their garage. It was like Demerol. It was like a narcotic. They used this drug, and within days they developed full blown Parkinson's disease, and they ended up in emergency rooms with tremor and rigidity, looked all the world like Parkinson's, idiopathic Parkinson's, and in fact was even responsive to some of the Parkinson's medications. Parkinson's is a disease characterized by loss of brain cells in a particular part of the brain. These brain cells make a chemical called dopamine. So therapy for the for Parkinson's has to do with giving them back the dopamine. That's what drugs like sinemet are all about Levodopa. But interestingly, many years later, several of these patients had died, and researchers were able to look in their brains at the area involved with Parkinson's. And what did they discover? They discovered that there was activity in the area that degenerates in Parkinson's brain, of particular immune cells called microglial cells, that were still active and involved in degeneration of the brain cells in that area, meaning that the one time drug exposure turned on an inflammatory immune response that was feedforward, that kept the degeneration going over time.
Dr. David Perlmutter: [00:21:15] And we've seen a similar theme, for example, in what happens to football players. They spend a couple of years in the NFL. Now we're seeing it in college and even in high school level contact sports kids, but you have a few bangs to the head and the next thing you know, it sets into motion brain degeneration because it activates an immune inflammatory, degenerative response involving these cells called microglial cells. These are the part of the brain's immune system. Now, what we've just learned in the past three years is that these microglia in the brain exist in let's just in many forms, but for the purposes of our discussion, a good twin and a bad twin, what we call the M2 type of microglial cell that loves our brains, it's supporting the neurons. It's fostering growth. It's digesting away bad things like beta amyloid. It's nurturing the synapses. And it exists in another form called the M1 phenotype that's making inflammatory chemicals. That's not nurturing brain cells. It's actually digesting good brain cells. It's digesting waste from synapses that we might need. And the difference between these two cells. What shifts the good twin to being the bad twin, which changes the angel to the assassin, are changes in that cell's metabolism, meaning how it uses glucose as a fuel to make energy. That's profound. That means that the central pillar here, underlying things like Alzheimer's and Parkinson's, is really the same.
Dr. David Perlmutter: [00:22:52] And it explains why, for example, ketogenic diets that target metabolism are effective in Alzheimer's and effective in Parkinson's. And it explains why three weeks ago, in the very prestigious New England Journal of Medicine, this drug that targets metabolism, the ozempic like drug, had effects that were stunning. I mean, I've never seen anything like this in my life, and I think all of us on the call would agree that the New England Journal of Medicine is to be respected. I mean, you know, to get an article published, a research study in the New England Journal, it's pretty well scrutinized. So it tells us that central to what makes a good brain go bad are changes in metabolism. And the empowering part of that revelation is that we have a significant level of control over our bodies and our brain's metabolism, based upon the choices that we make each and every day in terms of our sleep, our exercise, our food choices, our levels of stress, our levels of social engagement, the medications we take, the care we take or not to our gut bacteria. So many things are availing themselves for intervention on our parts, and that really becomes then a mission. And as it relates to correcting metabolism, that will have wide ranging effects with respect to the brain, with respect to the heart, diabetes, obesity, and clearly certain forms of cancer.
Tyler Johnson: [00:24:18] So let me ask you a pair of questions that I think are really important. Because what I understand when I, when I hear you saying and giving many given many of the things you have written. And I was referring to this paradigm shift earlier, is that what you your sort of ideal would be to shift the frame so that we could spend much more time talking, as you alluded to earlier, about health care or health maintenance, and much less time talking about addressing disease that is already there and often disabling. Right. Well, you.
Dr. David Perlmutter: [00:24:51] Know, I'm not sure when you say shift, is it our discussion today or that would be in my worldview. Yeah, it's my worldview. I'm thrilled with the advances that are being made in terms of mainstream intervention, pharmaceutical interventions. Sure. But but as far as we're concerned, I think, you know, this defines my interest, defines my passion. It's a bit of a lonely club, the preventive neurology club. So. Right.
Tyler Johnson: [00:25:17] And I don't mean to suggest in any way that you're not grateful for or supportive of addressing disease once it's there, but I think it's intuitive that even though your club may be lonely, I think it's intuitive that if we could prevent the disease, that would be much better than addressing it, especially if addressing it only means halting the progression of symptoms and not making the symptoms go away. Right. I mean, that's right. Anybody with Alzheimer's or any neurological, chronic neurological disease would certainly, I think, like to go back to the place before they started to feel the symptoms, rather than just having the symptoms stop wherever they are. But one of the key questions that I think arises in that context is, so let's look at in some ways the easiest sort of foil here is my world, which is medical oncology, right? So if I have a person who has, let's say metastatic pancreas cancer, and I have what I think is going to be a blockbuster new drug to treat pancreas cancer, at least in theory. It's pretty straightforward how I'm going to prove the efficacy of that drug. Right. Because I'm going to take Eventually. There are other trials that will precede this, but eventually what will have to happen is I'll have to take something like 400 patients, randomly assign them to two groups.
Tyler Johnson: [00:26:33] One group gets the drug, the other one doesn't get the drug. And then if the group that gets the drug lives statistically significantly longer than the group that doesn't get the drug, then in almost all cases, as long as the toxicity profile is acceptable, then the drug gets approved, right? And that's become sort of the de facto standard to which any new oncology drug is held, as there has to be a randomized controlled trial showing a median overall survival benefit. There are exceptions to that, but that's the general rule. The things that make that pretty straightforward. One is that we're operating on a pretty short time horizon, right, because these are people who are very sick with progressive diseases that take their lives often in a matter of months or a couple of years. And two is that it's just a straight A to B comparison. And almost always the people in the group who are supposed to get the drug really do get the drug. And so it's pretty clear what the effect of the drug is. But if, for example, we wanted to show a similar level of rigor in evidence of the efficacy of a preventative neurological intervention. So let's say that a particular kind of diet or a particular kind of lifestyle change in a person who might be at risk for developing Alzheimer's 20 years from now, but has no current symptoms and no current diagnosis, just even theoretically, schematically, that's significantly more difficult for a whole host of reasons, right? One is just the time horizon is a lot harder because we're talking about a disease that they might develop many years down the road but don't currently have, which is certainly more challenging than a cancer that's already threatening their life.
Tyler Johnson: [00:28:12] And then on top of that, you also have the problem of that if you're going to develop a lifestyle, a preventative lifestyle intervention. There's the difficulty of how do you find people who are really going to stick to it. Of course, there are going to be some who will really develop, you know, sort of a faithful adherence. But many people, again, especially over the time horizon that would be required, are eventually going to fall off the wagon for any of a number of reasons. So I guess I'm just asking conceptually, how do you think about producing evidence that has the same kind of rigor and would meet the same standards of scrutiny in such a dramatically different sort of context than what we often think about in terms of sort of treatment related randomized controlled trials for already diagnosed illnesses.
Dr. David Perlmutter: [00:29:02] Yeah, it's a bit of a challenge, but those studies exist. Many of them over the years have, you know, received very little attention. Study from University of Pittsburgh, for example, 15 years ago, looked at individuals, randomized them. These are individuals with a mild cognitive impairment. A randomized them to receive a stretching program versus an active aerobic exercise program, followed them for one year and did. And the two metrics that they studied in this interventional trial in one year. So it's not a really challenging time horizon, in your words, demonstrated that in comparison to the people who stretched, those who actually involved themselves in aerobic, the aerobic program, and certainly there are people who fall off and don't stay with it as there would be in any study. But those individuals actually had CT evidence of increased size of the hippocampus in comparison to those who stretch, in whom the hippocampus actually shrunk in size. A b memory function actually improved in those in the interventional trial versus those who stretched, i.e. they didn't get their heart rate up, whose memory continues to decline. Similarly, we've seen individuals followed for as long as seven years who in the initial part of the study had a blood glucose evaluation. And here this is a seven year study. So you're right. It it takes a long time to to demonstrate results. But what was demonstrated in that study published in 2013in New England Journal of Medicine, again, I think it was over 2000 individuals, was that there was an observed cognitive decline beginning at a blood glucose of around 105 with the initial evaluation.
Dr. David Perlmutter: [00:30:54] Now, I'm thinking you might agree with me that most people go to the doctor and get a blood sugar and it's 105. You're going to get a pat on the back and a see you next year kind of statement. But it's telling us that there's, at least with respect to that study, this sense of relationship of blood sugar, i.e. influenced by diet and other lifestyle choices as it relates to the brain, which, you know, this was back in 2013, 11 years ago, has, you know, that relationship has become kind of central to the dogma of what we can do to preserve and protect the brain against degeneration. But, you know, setting up interventional trials as it relates to normal people and hoping they stay, you know, dedicated to the lifestyle choices is not common as it relates to the brain. A lot of the studies are retrospective studies where people try to, for example, fill out a food frequency questionnaire, you know, over time, what have you been eating over the past X number of years and then an assessment of their cognitive function? Other studies. Prospective studies have looked at people and followed them in terms of their physical activity.
Dr. David Perlmutter: [00:32:04] One study published by Jama neurology looked at followed people for seven years. I think it was, and this was over close to 30,000 individuals randomized to receive the intervention was not an intervention, but a pedometer. Now, or actually it was an accelerometer. Many of your listeners may not know what that is in the age of Fitbits and Apple Watches, but it was a thing you wore on your belt that would every time you took a step, it would click, and it would record the number of steps that you would take. And it showed a profound relationship between the number of steps taken in a given day and risk for cognitive decline, with the sweet spot interestingly being around 10,000 steps. But what was important in that study was the fact that the benefits began as soon as steps were taken. And so that's, you know, a messaging that we've been trying to get as much as we can out of, i.e. get people to move. But, you know, it is it is somewhat difficult to randomize people for long periods of time as it relates to following the effectiveness of lifestyle issues related to cognitive decline. But I think that the data that relates exercise, for example, mechanistically to what's going on in the brain, that's sort of been missing for us for a long time. For example, we've known based upon the work of she's deceased now, but Martha Clare Morris at Rush, that there's a very strong relationship correlation, not causality, but we'll talk it through between the level in the blood of something called BDNF brain derived neurotrophic factor, which is good for the brain and cognitive function at any given moment, and risk for cognitive decline over time.
Dr. David Perlmutter: [00:33:50] Saying to us that, well, BDNF is a good thing, we'd like to have more of it. The next step is, well, where does it? How do we get more of it? And one of the most powerful ways to amplify BDNF in the body and brain is physical exercise. And we've really only started to tease the the actual mechanisms in terms of how this works very, very recently. But her work dates back to 2008. And so for me, the pieces come together. I've been accused of cherry picking this information and we all do that. You can't write a paper and not pick a literature citation to support any statement that you might make. You're not going to post the contrapositive, that's for sure. And I think that finally, the message that is fundamental isn't esoteric is that we need to exercise more. We need to make sure our blood sugars are under control, and we need to sleep well with those three pillars. I think we can have a dramatic effect on reducing, for example, the incidence of Alzheimer's.
Henry Bair: [00:34:56] You know, so when it comes to the science of nutrition, I'm sure like as you mentioned, the presence of contradictory evidence exists in all branches of medicine. But when it comes to nutrition, I don't know what it is about nutrition. I really despise going into the literature. I'm not talking about headlines. Headlines deceiving headlines are all over the place. I'm talking about peer reviewed publications on nutrition science. Even the most robustly reviewed articles. You can find articles that that say that eggs are good for you. They can say articles that say that eggs are bad for you. Do red meats cause cancer? You can find articles, peer reviewed articles that say yes or no. Are saturated fats good for you? Do they actually cause an increase in coronary artery disease? You can find articles that actually argue against that or for that, basically, you can go into nutrition with a preconceived notion of what you want to find and then find peer reviewed studies that back up those claims. So given that context, how do you think about wading through this, this muddle of information?
Dr. David Perlmutter: [00:36:00] I don't do it. I look upon nutrition advice and subsequently nutrition recommendations based upon metrics. And for me, there aren't a lot of metrics. But I think, for example, in my world, hemoglobin A-1c is important. Why? We know what it's purported to tell us in terms of a measurement of so-called average blood glucose. But when I look at the data that shows such relationships between even subtle elevations of a-1c well below this magic number of seven, I don't know where that came from.
Tyler Johnson: [00:36:36] For listeners who are maybe younger in their medical training, can you just review what hemoglobin A-1c is really quickly?
Dr. David Perlmutter: [00:36:41] So hemoglobin A-1c is a measurement, let's say, of average blood sugar. And really what it what it is is hemoglobin is is the oxygen iron containing molecule within the red blood cell. It becomes glycated. And glycated means it binds to sugar. When there are higher levels of sugar in the bloodstream, more of that process happens and the protein binds more and more of that sugar and hence the percentage of binding of glycation is, the term of that molecule goes up. So in a sense it's a marker of how much the blood sugar over the period of time has been over months has been elevated. So beyond that, though, glycation of proteins is not a great thing. When we bind sugar to proteins, it changes their ability to function as they normally would because their shape is now changed and it actually stimulates the immune system such that there is a correlation between markers of inflammation in the blood and levels of hemoglobin. A1c1 marker in particular that rides right along with A1 C is called C-reactive protein. But the point I'm trying to make is that we've known since 2008 that there's a very strong correlation between elevation of the A1 C and risk for brain shrinkage. So higher a1 c seems to correlate with shrinkage of the brain. We can look at mechanisms whereby that may be happening.
Dr. David Perlmutter: [00:38:13] For example, inflammation increased production of chemicals that are damaging called free radicals, activation of the immune system. And now through the lens of something we talked about a while ago, activation of these brain's immune cells called microglia, such that they're now digesting away brain cells in relation to a marker of elevated blood sugar. So this gets back to trying to wind it back to our discussion on diet. It's why I don't have real specific recommendations about this or that diet, whether it's Mediterranean, paleo, eating only foods that start with a vowel, whatever it may be. My recommendation is what is that diet doing for you in terms of things that we can measure? In this case, your blood sugar. Is that diet controlling your blood sugar? To me, that's that's one of the absolute fundamentals as it relates to brain health is the diet that you have chosen to pursue, whether it's fully on a carnivore, etc.. What's it doing to your blood sugar? And if it's not, then you got to make some changes. That's why, for example, I am very much in favor of people knowing their blood sugar. Not just because you go to the doctor every year, but knowing it by doing your own testing at home with a finger stick every couple of months, or even better than that, wearing from time to time what's called a CGM continuous glucose monitor.
Dr. David Perlmutter: [00:39:37] Then you're able to interact with an open minded physician and say, yeah, I'm on this particular diet and it's causing my blood sugar to remain under great control, or I'm getting really big spikes in my blood sugar and the area under the curve. In other words, I guess you'd say the average blood sugar is elevated. To me, that's a fundamental that is central to our mission. And I think that people can choose different approaches to their nutrition and keep their blood sugars under control. Clearly, there are other things to consider a diet that's rich in micronutrients, that's providing enough protein, that's giving individuals enough, you know, things like available iron and has got enough fiber to nurture the microbiome. Yep. Those are all important. We can discuss that, but I'm not going to lock in for anybody on a particular dietary scheme unless I'm able to metric size for that individual. And that would vary individual to individual. The beauty of what's called personalized medicine, in terms of what that diet is doing for you. And, you know, we're at a time that people are beginning to recognize that, you know, the dietary choices I'm making today are going to affect me tomorrow. When we live in a country where 54% of calories that adults consume come from ultra processed foods.
Dr. David Perlmutter: [00:41:01] And I just learned this weekend that 68% in children of their calories coming from ultra processed foods. This is a dietary ingredient for raising the blood sugar. So that works right against what I'm trying to achieve, and explains why there's such a strong correlation between the higher levels of ultra processed foods that people may consume and risk for cognitive decline. So I think the question is very, very good. I'm glad you asked it. And it's certainly a question I get asked in every interview. Well, what diet are you recommending? And, you know, I wrote a book years ago called Grain Brain. And the central thesis of that was that processed grains would raise blood sugar, and that that's why I began to present the research, the sexy research from New England Journal of Medicine, correlating elevation of a-1c, you know, with risk of brain shrinkage. Nobody wants that. And, you know, we raised the idea that eating foods that are going to have an impact on blood sugar. There are a lot of other things we can talk about are not good for the brain. And I think in our here we are having this discussion today, I think that hopefully we would all agree that elevated blood sugar and diabetes is not necessarily the best thing for the brain.
Tyler Johnson: [00:42:21] Let me ask you a question. You know, you mentioned earlier, kind of in passing, talking about this study that came out in the New England Journal a few weeks ago related to Parkinson's disease. You mentioned GLP-1 agonists, and that is I mean, I guess maybe competing with some cancer therapies like Car-T cells and whatever. But I think that is the hot thing in medicine right now, right? Certainly in the societal view of medicine, those drugs ozempic and mondoro and whatever are absolutely everywhere. Like the drug companies cannot make them fast enough. Right. And there's all these debates about when they should be covered. And. Et cetera, et cetera. But one thing that I have found really, really interesting in all of that discussion is that there was an article in the Atlantic, maybe six months, 4 or 6 months ago, something like that, by a person who readily admitted that they had struggled basically their entire adult life with eating more than they wanted to. And so then they had gotten a prescription for I don't remember which one, probably ozempic. But anyway, one of the drugs and then had started taking it. And the point of the article was, I mean, there was a little bit of a sort of a gloss over some of the medical analysis of how the drugs work and the molecular biology and whatever. But the majority of the article was not about that. The majority of the article was about this single person's experience. And what they said was that they started taking the medication, and once they had ramped up the dose a little bit and presumably had gotten to sort of a steady, you know, blood level of the medicine, that it was just almost frightening, the transformative nature of this on their lives. Because what would happen is that they would go out to eat and they would order a meal that was a particular size based on what they had always eaten for their entire adult life.
Tyler Johnson: [00:44:08] The meal would come, they would have a few bites of this and a few bites of that. And whereas previously they would have ravenously eaten the entire thing, they would have just a few bites, and then they would look at the meal and think, mm, I'm full and I just don't want any more. And then they would just leave. They'd just be done and they wouldn't eat most of the meal. And then this happened, you know, every single time they sat down to eat. And in addition to that, only in the absence of these inner voices did they recognize that previous to starting the medication, they had just had this sort of incessant chorus of voices pleading for them as they understood it, to eat more all the time. And then on taking this medication, not only did they eat less when they sat down to eat, but this sort of incessant drive to snack that was in between meals just all went away. And so I found that article really striking because like, it raises a bunch of issues in the sense that I don't think that that's how most people five years ago would have framed the ideas of obesity or blood sugar or whatever, that it is, in effect, sort of a neurological issue. Right? It's about appetite and stimulation and desire and drive and whatever. And so as someone who has, in effect, built his career on the idea that there is a connection, a communication between the gut and the brain, I'm curious what you make of that article and sort of what you think about that going forward.
Dr. David Perlmutter: [00:45:37] I believe that, you know, beyond that one individual's experience, that what you've just related is common. Many people struggle. And, you know, we can deconstruct this a little bit, you know, in terms of our desires and our decision making that we have, let's just say, for the purposes of discussion, two areas of the brain that are involved in decision making. One area, a primitive area, the amygdala that says, I'm going to eat this crap. And a lot of it because I want to and I know I shouldn't, but I'm going to just have that second dessert or whatever it is. And the more sophisticated part of the brain, the prefrontal cortex, which says, mm, I need to lose some weight and it's not good for me and etc. the adult in the room, if you will. These areas of the brain are connected by a cable connection. It's called the anterior cingulate gyrus for those who want to know that, but importantly, that top down control the adult in the room, helping, making decisions, helping guide the child in terms of the decisions. What to eat, when to quit. That connection is threatened by a process called inflammation, and inflammation is enhanced based upon the types of foods that we are consuming these days and so many of the things. Lack of restorative sleep, lack of nature exposure, lack of socialization, a lack of exercise, etc. so people are in general more inflamed, i.e. their decision making skills as it relates to every aspect of their lives, including when to quit eating are being compromised by the fact that we are so inflamed.
Dr. David Perlmutter: [00:47:15] That said, there's no question that the advent of GLP one agonists first for diabetes, now for weight control, overweight and obesity has been profound and has finally given people the chance to lose the weight that they need to lose. All well and good. The problem, of course, is that no one's done the long term consideration in terms of now that you've reached your ideal body weight, what do I do now? The answer is stay on the drug. And I'm perplexed by that response, because it means that then people are going to be on these drugs for a lot longer than they've ever been studied, and that concerns me in terms of potential risk. And Tyler, for you in your specialty, it should be something that that is really raised as a red flag and at least in terms of consideration. So that's concerning to me. I mean, you know, what pharmaceutical companies don't want to build is the light bulb that lasts for 100 years. They need you to keep buying light bulbs. It's why you can buy a printer for really cheap because they get you on the cartridges. Same thing here with these GLP one drugs you got to keep coming back. Hotel California. You can check out anytime you like, but you can never leave the discussion with the people who are developing these drugs and publicly shining the light on them. Is that, well, no. We think people should just stay on them. That's a concern. Now, let me just shine a light on just another aspect of what we're seeing. And that is that as we recognize the central role of metabolic dysfunction across so many areas of health and medicine like cardiovascular disease, certainly diabetes, obesity.
Dr. David Perlmutter: [00:49:01] But really look at sort of the nuanced areas where metabolic function is now being recognized as playing a role, like mood disorders and other psychiatric issues. Parkinson's and Alzheimer's, for example, are primarily metabolic, as we talked about earlier. I think we're going to see a huge expansion in terms of ultimately, once trials are completed and they're on going right now as we speak, the clinical application of these GLP-1's across the spectrum in brain disorders, heart disorders, fatty liver disease. I mean, it's going to be profound because these are basically metabolic issues. And if it keeps people from eating as much, I think that's a good thing. We know that caloric restriction is associated with longevity, at least in fruit flies and nematodes and laboratory mice, that's for sure. So if we're cutting back on the amount of calories that people are consuming by the mechanism that you just described, or at least as the anecdote described, I think ultimately that's going to be a good thing, too. I'm told that global food producers are concerned about these drugs because there's less food being eaten. I mean, I don't know where you want to take that discussion, but, you know, for me, it's a solidification of the role of metabolic issues in the brain and beyond, you know, giving people prescription for these drugs. What else is important for helping people rein in their metabolism and therefore benefiting their brain in the long run?
Henry Bair: [00:50:36] So over the course of your career, whether it was deciding to leave your practice, your neurology practice all those years ago, or whether it's choosing to focus so much of your writing and advocacy on prevention, which goes against a lot of what we do in modern medicine, at least today, or whether it's focusing so much on the metabolic underpinnings of neurological disorders, which previously were not thought to be nearly as related to metabolism. Whatever we're talking about throughout the course of your career, you have faced, shall we say, detractors, of course. Perhaps it's also just because you've been very vocal. You've published widely, widely. You've appeared on television and radio and podcasts, and so a lot of your ideas have appeared to challenge conventional medical wisdom and practices. And I'm just curious to know, how do you respond to that when someone comes in and says, well, that's not this is not what the evidence shows. When you face accusations of overexaggerating or generalizing or cherry picking, as you said earlier, how do you respond to detractors?
Dr. David Perlmutter: [00:51:36] The first thing is, the fact that I have detractors fills me with gratitude. Why? Because it means I'm pushing the envelope and somebody needs to push the envelope. I think it was Ronald Reagan who said that status quo is a Latin term for the mess we're in as it relates to brain issues. We're in quite a pickle. You know, we've got 6.8 million Alzheimer's patients in America right now. Globally, there are 50 million, with 10 million new patients being diagnosed each year. So something is wrong. And it's really you know, the increase in Alzheimer's far exceeds the increase in the aging of our population. And it's in lockstep with the changes that are happening in measurable metabolic parameters and certainly the foods that we are eating. So, you know, as far as the criticism goes, I get it a lot. And that's okay. I was on a morning show, national morning show, a couple of years back and talking about the fact that I'm recommending we stop eating sugar. And the response was, well, we reached out to the sugar industry and they said, that's not true. So I know that both the pharmaceutical industry and certainly food companies are they're not kind to me, I get that, but that's okay, because I think people here, you know, one side of the story via advertising. And I think to be fair, people can make up their own minds, but they need to hear both sides of the story. Do I cherry pick the research? You bet I do. Do I gravitate toward studies that are supportive of my claims? I do, but I don't do that in exclusion of looking at the contradictory information.
Dr. David Perlmutter: [00:53:07] I must look at that. And if I feel as if the contradictory findings are meaningful, then I'll retract. I've changed my messaging significantly over the years, and having said that, you know, I think that's what people want. They want you to stay on top of the literature and make the changes, you know? Years and years ago, I was hugely invested in the notion of telling people low as low a fat as you can get. Low fat diet is the way you want to go. And I realized ultimately that there was no real evidence for that. I was parroting what I was being told from sources that were proven to have been, you know, not with our best interest. The influence on the New England Journal from advertisers, for example, was came out and it was clear that, you know, the idea of eating low fat ultimately would make people eat more sugar. And I was wrong. And I ultimately changed my messaging to say that, you know, it's not how much fat, it's really the kind of fat that's these highly modified fats that are threatening to health. But good fats like extra virgin olive oil, avocado oil, avocados, nuts and seeds, you know, those have good health benefits. Therefore, we should eat more of them. So, you know, to answer the question is I, I hear what people are saying and I listen, I believe me, I listen because every once in a while they're right and I have to change. So that's what I do.
Tyler Johnson: [00:54:31] I think your point is a good one, that, you know, the question when we talk about evidence always has to be as compared to what. Right. And so if there were randomized controlled trials that were rigorously done that were disproving claim X, that's one thing, but if you're holding up claim X, which as you admit, maybe you in some ways cherry pick evidence or whatever. But if the contrasting evidence is the advertising of the fast food industry or the advertising of, you know, whatever mega conglomerate that makes a lot of food that everybody sort of knows is bad for you, that's a very different standard against which to be held, right. You know, you have talked even on the podcast about the fact that, you know, particular diets, whether, you know, Paleolithic diet or a so-called Atkins diet or whatever, although those things can be picked apart, I think that the three sort of pillars that you have gotten to, which is that it's better. I don't want to misquote you, but I think you said better to have lower blood sugar, better to exercise more and better to sleep more those better to sleep better. Better to sleep.
Dr. David Perlmutter: [00:55:32] Better. Its quality and quantity.
Tyler Johnson: [00:55:34] Yeah. Okay. But but in any case, those three I think are, you know, pretty close to unassailable or at least, you know, I would say that the onus is on people who think those are not right to show studies, rigorously done, studies that somehow show that they aren't right. I mean, I think it's hard to argue with the fact that those would benefit most people's health.
Dr. David Perlmutter: [00:55:52] Right. But I'm still assailed even making those claims. Yeah. I have not been very supportive of the recent drugs that have been developed that target beta amyloid in the brain, and we discussed this earlier because they don't work. Otherwise, I would be supportive. And the New England Journal studies of these drugs, Lacombe, for example, concludes saying this doesn't really work. And yet the people in the the drug group are having, you know, 20% of these individuals at least are having brain bleeds and brain swelling. So it really violates this notion of primum non nocere. Above all, do no harm. So I've been indicating that I'm not supportive of these drugs. And yet and so I get emails from the drug companies saying we need to talk about this, i.e. we want to convert you. And I'm not anti-drug. I was the one who brought up to you guys today. This intervention using a GLP one agonist in Parkinson's. I'm overwhelmed. You know that that particular one that they use is not available. If it were, I would dial it right in. I am all in. I mean, you know, my toolbox is is pretty fleshed out. And to me it's whatever works as long as it's pretty darn safe. Nothing is fully safe except, you know, the lifestyle changes. There's no downside, as you just alluded to. But ultimately, I've gotten to a place in life where I don't read the negative press. It doesn't do me any good. I don't read the one stars. You know, people a lot of times will do that because they have their own agenda and that's okay for them.
Dr. David Perlmutter: [00:57:25] I don't read the five stars either. I'm just going to keep doing what I do. And I think it's important. You know, my podcast is called The Empowering Neurologist because I want to empower people with the knowledge then to make the choices based upon a better understanding of whatever the decision paradigm is. So we're going to give you the other side of the story. What we're being told is live your life however you want, do whatever the heck you want, and when you have a problem, we've got something to fix it. Well, you know all well and good there isn't on planet Earth a drug that will treat diabetes. There isn't a drug on the planet that will treat high blood pressure. None. There are drugs that are low. Your blood pressure. But stop the drug. Blood pressure. Back up. Same thing with your blood sugar. The moment you quit your metformin, or whatever it may be, your blood sugar goes back up. So you have not treated the diabetes, you treated the manifestation or the symptom, the high blood sugar. I'm focused on treating, as we talked about earlier, the fire, not just the smoke. How do we work on the problem? Research has demonstrated that a ketogenic diet, for example, has been shown to reverse diabetes and get people off of their medications. Doctor Sarah Hallberg, her research she recently passed profound. I mean, getting 90% of people coming off their drugs and all of the people in the intervention group getting off insulin, that's pretty profound because just by being on a ketogenic diet.
Dr. David Perlmutter: [00:59:01] So that's targeting the problem. And I think that as we get to a place where we understand what are the fundamentals of these challenging diseases, most of which seem to be metabolic, now that targeting that issue in this case, metabolism is going to be the way to treat them. And I'm all for symptom management. For example, if you institute a ketogenic diet and diabetic and their blood sugar is still elevated, treat it. They stay on diabetes medicines for as long as they need. But it's a different way of looking at things. You know, doctors get at most 15 minutes in the follow up appointment, and that's barely enough time to say hello and write that prescription. It's certainly not enough time to ask questions about how was your sleep? How do you know it was good or bad? How much exercise do you really get? All these things, that's not that doesn't happen. And yet it's vitally important. I remember our dog years ago was losing his fur. We went to the vet and she walks into the room and the first question was, what are you feeding? Tiko, our dog. And I was stunned. You're. If you're losing your hair, you go to the dermatologist. Here's a cream. See you later. Come back. Whatever. But she said, what are you feeding him? And I just it was such a great lesson for me because in veterinary school, they spend a lot of time on nutrition. More than you got in med school, I would venture to guess. So that's the short answer for you.
Tyler Johnson: [01:00:29] Well, Doctor David Perlmutter, we so appreciate your generosity with your time. And joining us this morning, I think a lot of no pun intended, food for thought for everybody listening. And we really appreciate you being here and we wish you all the very best. Thank you.
Dr. David Perlmutter: [01:00:44] Thanks for having me.
Henry Bair: [01:00:49] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctor's Art.com. If you enjoyed the episode, please subscribe, rate, and review our show, available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [01:01:08] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [01:01:22] I'm Henry Bair
Tyler Johnson: [01:01:23] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.