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Q: How much power do we have to control brain health
over the course of our lifetimes?
Dr. Perlmutter: We have a great deal of power. Many of
us grew up in a time of genetic determinism and had to la-
bor through this dichotomy of nature-versus-nurture, which
asks: Are we the product of our genes or of our environments?
But now, we understand that our health and longevity actually
represent a beautiful dance between nature and nurtureit is
not one or the other. Our health is predicated on choosing how
we interact with our genetic predispositions.
In fact, > 70% of genes that code for health and longevity
are under epigenetic control. What a powerful concept, that
through lifestyle choices, we have signicant ability to control
the transcription of those very genes that deal with health and
longevity, including brain health.
Until now, the concept of epigenetics was foreign to most
people in medical training. I was not taught in medical school
that choosing certain lifestyle behaviors played a role in actu-
ally modifying our genetic expression and that we could unlock
our genetic coding. But today, we have a greater understanding
about the science behind epigenetics, and this is where we need
to focus when dealing with brain health, resistance to disease,
and enhancement of brain function. We are oered powerful
tools through this understanding.
I want to point out that the term epigenetics was actu-
ally coined by Conrad Hal Waddington [CBE, FRS, FRSE;
19051075] in 1942 when he began to explain that genes
and their expression are, in fact, interacting with our environ-
ments. is is not new information, but, just as the concept
of neurogenesis, which is now hard science, was rejected by
mainstream science for so long, it is dicult for people to
shift their thinking. Ideas become ingrained, and they are
very dicult to overturn.
For instance, we believe that each morning we look to the
east and see the sunrise and then in the evening the sun sets in
the west. It is great to think that is actually happening, but, in
reality, it is not the sun that is moving; it is the earth that is ro-
tating. is is part of the problem with peoples understanding
and acceptance of epigenetics. ere are still plenty of people
who have this vision of our genes being locked in a proverbial
glass case, and yet, that is not what science has demonstrated.
e question is not is this real? but rather how do we take
this reality and use it to our advantage? Clinicians must be
aware of this science in order to empower patients to help steer
the course of their brain and bodily health.
Q: Share with us the basics of what you are talking about
when you speak of the role of epigenetics in modulating
brain health.
Dr. Perlmutter: We know that our genes are coiled around
proteins that are called histones. Years ago, we recognized that
histones have some reparative role to play in DNA, but we now
understand that histonesbeyond repairing DNAactually
play a role in allowing DNA expression.
So our DNA is wrapped around these histones, and the his-
tones contain binding sites for various molecules, including
methyl groups, acetyl groups, and others. When a histone is
bound, it leads to changes in the conformation of the DNA,
either tightening it up or opening it up; in other words, either
making it unavailable or available for genetic transcription.
rough the binding of what is called the epigenomethe
combination of the DNA wrapped around the histone pro-
teinwe regulate the action of our genes.
As we consider the question of why this reality is not widely
accepted in the medical community, the modern paradigm of
medicine is treating illness after it has arisen, treating hyper-
tension with medications, lowering blood sugar with drugs,
and using anti-Alzheimers drugsas if there were such drugs.
at is the kind of reactive approach and it is a very Newtonian
billiard-ball type of mentality that is pervasive throughout
Western medicine.
Epigenetics points to a better way. For instance, we have
known that the foods we eat contain the macronutrients of pro-
teins, carbohydrates, and fats as well as micronutrients, such as
minerals and vitaminsall of which produce various types of
physiologic activity. But the concept that food represents infor-
mation is really relatively new. e foods we eat and the lifestyle
behaviors we choose are literally instructing our genomes.
Q: When it comes to brain health, what are some of the
key lifestyle behaviors that clinicians should be emphasizing
with their patients? When should that education begin?
Epigenetics as Fuel for Brain Health
David Perlmutter, MD, FACN, ABIHM
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Dr. Perlmutter: For me, the education begins within the
first 5 minutes of the clinicianpatient interaction. It is that
profound. In essence, we have to communicate to the patient:
Guess what? What you are going to hear today is not fo-
cused on the coin of currency of medical practice, which is a
prescription pad, but it is about you taking responsibility for
your health in terms of the lifestyle choices that you are going
to make from this moment forward. Here is the science that
underlies it. Here are the epidemiologic studies that support
that contention, and here are the tools that you need. For
me, that is job number one. e initial conversation is not fo-
cused on any medication or a specic supplement but rather
on the data.
For example, a recent study demonstrated an actual in-
crease in the size of the hippocampus in elderly individuals
who engaged in 20 minutes of moderate-intensity aerobic
exercise 3 days a week for 1 year.
1
e participants also expe-
rienced a corresponding increase in memory function and an
increase in serum levels of brain-derived neurotrophic factor,
or BDNF. However, the control group assigned to stretching
and toning, experienced a decrease in hippocampal size over
the same time period.
ese ndings are signicant because, generally, as we age,
we are losing ~ 1%2% of hippocampal neurons in terms of size
of the hippocampus every single year. e exercise intervention
in this study did not just nullify that lossaerobic exercise led
to a growth of the hippocampus. at is powerful!
BDNF is coded for in our genes, and epigenetically, by
doing aerobic exercise, for example, we enhance the epige-
netic factors that lead to increased BDNF, which is basically
growth hormone for the hippocampus. ere is no pharma-
ceutical on the planet that can do that. ere is no drug to
treat Alzheimers disease. Yet, calorie restriction, physical
exercise, taking a docosahexaenoic acid [DHA] supplement,
and eating sh are all things that have been demonstrated to
increase the size of the hippocampus and, more importantly,
allow better memory function.
We have to look at the hippocampus when talking about
brain health, as that is often the rst area that degenerates, as
demonstrated in what is called a voxel-based magnetic reso-
nance imaging [MRI] study, in which it is possible to quantify
the amount of tissue in a particular area of brain anatomy. Hip-
pocampal degeneration, which happens in all of us, is also an
early marker of Alzheimers disease. But the important mes-
sage is that this degeneration can be reversed.
Another lifestyle factor that impacts the hippocampus and
that clinicians must address with their patients is stress. Stress
plays a very powerful role in the hippocampus and in our ability
to preserve memory. e hippocampus is exquisitely sensitive
to cortisol. Persistent exposure to cortisol with long-standing,
even low-level stress in primates is demonstrated to play a sig-
nicant role in initiating atrophy of the hippocampus, which is
the manifestation of apoptosis, cell loss, and neuronal dropout.
By the same token, acute high levels of cortisol can also lead to
hippocampal destruction.
Individuals who have had post-traumatic stress disorder
[PTSD] or who have been exposed to severe trauma in the
past, have a dramatically increased risk for Alzheimers dis-
ease, even if that stress occurred during childhood. But again,
if a person has experienced PTSD or childhood trauma, it is
not Doomsday in the least. is loss of function is recover-
able. We have this incredible ability to regain both structure
and function as it relates to the hippocampus. Now 20 years
ago no-one would have even considered that fact or that this
whole process of neurogenesis is real. But we now know that
we have a second chance for health, and we have the abil-
ity to regrow the hippocampus. How exciting to actually get
another chance!
Glucose control is another key point that clinicians must ad-
dress. An interesting study in Neurology entitled, Higher Nor-
mal Fasting Plasma Glucose is Associated with Hippocam-
pal Atrophy: e PATH Study, brings to our attention the
role that glucose and glycated proteins have in increasing free
radicals and, therefore, oxidative stress and hippocampal neur-
onal dropout.
2
In this study, researchers measured participants fasting blood
sugars and then followed the subjects for 4 years. e scientists
checked the size of the subjects hippocampi by MRI at the
beginning of the study and 4 years later. e scientists found
that individuals with the highest blood sugar levels had a sig-
nicant degree of hippocampal atrophy, compared to people
with lower blood sugar levels. e important point here is that
the highest level of glucose that was used in the study was only
110 mg/dL. at is a value that we have considered normal
until now. e study authors comment that their ndings sug-
gest that, even in the subclinical range and in the absence of
diabetes, monitoring and management of plasma glucose levels
could have an impact on cerebral health.
For the study participants with the lowest level of blood
sugar, the degree of hippocampal atrophy was actually in the
negative range, meaning that their hippocampi were growing
throughout the lifetimes of these elderly individuals.
ere is a profound relationship between brain atrophy and
excess blood sugar but also with hemoglobin A1c levels. When
a patients hemoglobin A1c is 5.65.8levels that are general-
ly considered acceptablethese levels are dramatically related
to brain atrophy and are directly proportional to the degree of
brain atrophy.
3
Clinicians need to understand that hemoglobin A1c is
not simply a marker for how well blood sugar is controlled,
but that hemoglobin A1c is a marker for free radicalmedi-
ated stress and directly relates to the risk of brain atrophy.
When clinicians monitor hemoglobin A1c, they have got
to view the results in this new light. We cannot control the
To Contact Dr. David Perlmutter
David Perlmutter, MD, FACN, ABIHM
800 Goodlette Road, Suite 270
Naples, FL 34102
Phone: (239) 649-7400
E-mail: [email protected]
Website: www.DrPerlmutter.com
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Alzheimers genethat is inherited. Yet, we can control he-
moglobin A1c.
ese are just a few examples of the hard science behind
epigenetics. ese examples highlight the lifestyle issues that
clinicians should share with their patients.
Q: What is being discovered in terms of the role of inte-
grative therapies and genetic expression?
Dr. Perlmutter: Let us start by looking at nutrition. First of
all, neuronal degeneration and brain degeneration in general is
predicated on mitochondrial failure, and all that we do from
our integrative and complementary perspective is focused on
nurturing mitochondria. What we now understand is that mi-
tochondria tend to function better when they are burning fat
as a fuel as opposed to carbohydrates. A diet that is extremely
low in carbohydrates but that favors a little bit of ketosis pro-
vides the brain with -hydroxybutyrate, which is powerfully
therapeutic for mitochondria.
is is a brand new idea that we should be eating ~ 70%
of our calories from fat, and yet, it has only been what we
have consumed for 2.6 million years. Our collective genome
has not evolved to handle carbohydrates, so the best and
most therapeutic diet from an integrative and complemen-
tary medicine perspective for brain cells is a higher fat diet
that reduces carbohydrate. e best fuel for mitochondria is
fat, which allows them to function more eciently, reducing
their production of free radicals, increasing the mitochon-
drias adenosine-5'-triphosphate production, and increasing
mitochondrial biogenesis.
When a person cuts back on fat and follows a low-fat diet
that is so widely recommended in Western medicine today, by
default, calories will come from carbohydrates, which is the
worst thing a person could possibly do. Why? When a person
increases carbohydrate consumption, that person begins to gly-
cate his or her proteins, which increases the production of free
radicals by as much as 50-fold.
e good news is that we can reduce the glycation of protein
by, number one, reducing carbohydrate in the diet. A low-car-
bohydrate diet is, far and away, the most important rst step.
A study in e New England Journal of Medicine comparing
the eectiveness of a low-carbohydrate, Mediterranean, or
low-fat diet on weight loss, showed that, in every cardiovas-
cular parameter, whether C-reactive protein or high-density
lipoprotein/low-density lipoprotein cholesterol ratios, the low-
carbohydrate diet beats the low-fat diet hands down in terms
of improvement.
4
Second of all, various nutritional supplements are antiglycat-
ing agents, such as benfotiamine, -lipoic acid, taurine, DHA,
and resveratrol. N-acetylcysteine is very powerful in that re-
gard. Aspirin and carnosine are also eective.
We have to reduce our glycemic load of the foods that we
eat and, therefore, reduce our glycation of proteins.
5
Glycation
of proteins not only increases radical formation, but it is also a
dramatic upregulator of cytokine formation, which is the type
of chemical that increases brain inammation. At the end of
the day, brain inammation is the cornerstone of conditions
such as Alzheimers and Parkinsons disease.
Q: How can mindbody therapies improve brain health
epigenetically?
Dr. Perlmutter: We have covered neurogenesis and the abil-
ity to grow back new brain cells, but let us explore, for just a
moment, the notion of neuroplasticity, the ability of the brain
to make new connections. We know that neuroplasticity is a
process that is occurring throughout the human lifetime and is
aggressively happening during the formative years, but it also
occurs when people are 95 years old.
Neuroplasticity is the ability of the brain to form new
networks and to provide better connections to various
brain areas. One of the areas that is really useful in terms
of developing more as humans is, obviously, the prefrontal
cortex. The prefrontal cortex, as it has developed in our
species, has become very advanced, and, if there is an area
of the brain that is devoted to allowing us to feel empa-
thetic and compassionate and socially aware, and for us to
understand the future implications of our actions today, it
is the prefrontal cortex.
Lifestyle factors will enhance our abilities, should we so
choose, to make better connections through neuroplasticity to
the prefrontal cortex. Endeavors to make better connections to
the area that mediates those positive factors are practices such
as meditation and prayer.
When a person meditates or is involved in prayer, that per-
sons body is connected to the prefrontal cortex and tends to
actually make less connection to, for example, the amygdala,
the emotional response center of the brain, and even the pa-
rietal lobes, which mediate the sense of three-dimensionality
or where a person is in relation to other people or objects. e
person will tend to shut that down and become less concerned
about where he or she is physicallyand what might be threat-
ening physically or emotionallyand make a better connection
to the prefrontal cortex. is allows a person to become more
socially aware, more empathetic, and more compassionate.
ere is a wonderful book entitled How God Changes Your
Brain, written by a neuroradiologist, Andrew Newberg [MD]
and Mark Robert Waldman, who have demonstrated, in vari-
ous types of brain imaging studies, the physical changes that
are permanent and that happen when people meditate.
6
Whatever we can do to enhance the process of neuroplas-
ticity will enhance the ability of our brains to connect to our
prefrontal cortices, and we enhance neuroplasticity through a
number of epigenetic techniques. Calorie restriction and fast-
ing also turn on BDNF production. It is interesting to note
that the idea of fasting has been pervasive in all major religious
doctrines throughout the history of humankind, whether it is
is is a brand new idea that
we should be eating
70% of our calories from fat.
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the fast of Ramadan, the fast of Yom Kippur, or Jesus fasting
for 40 days before his public ministry.
When one fasts, of course, it makes one think about things
because one becomes hungry. But interestingly, from a physi-
ologic perspective, it is an epigenetic modulator turning on
BDNF production, allowing the person who is fasting to make
better physical, structural, and functional contact with his or
her prefrontal cortex.
7
Q: Why is it important for clinicians to understand the
concept and the science behind epigenetics, and where can
they nd learning opportunities?
Dr. Perlmutter: Doctor means teacher; it does not mean
healer. The information and science behind epigenetics pro-
vides the most powerful teaching platform that clinicians could
have ever imagined and allows them to impact peoples lives to
the degree that these clinicians never could have imagined. That
is really the focus of epigenetics.
At the end of the day, as sophisticated as medicine has be-
come, the most important factors in health and longevity are
diet and lifestyle. I have spent the last 20 years deeply involved
in the most challenging biochemistry that one can imagine in
terms of my teaching and writing. Now I have come to real-
ize, that it is all about things that Hippocrates talked about.
We now understand the mechanism that, yes, Hippocrates was
right: Let food be your medicine and medicine be your food.
It is humbling, but it is empowering.
Learning opportunities for clinicians are available at e
Institute for Functional Medicine (especially Applying Func-
tional Medicine in Clinical Practice), the American College of
Nutrition, and the American Academy of Anti-Aging Medi-
cine. Many of these organizations lectures are now focused on
an understanding of epigenetics.
Let me conclude by sharing a quote by Louis Pasteur, which
is that chance favors the prepared mind. We have the chance
to be very eective and share with patients the therapies that
help them turn the corners and achieve better health out-
comes, but this requires preparation, homework, and academic
pursuit. My point is that an understanding of epigenetics can
become one of clinicians most powerful tools in terms of guid-
ing patients to those therapies that will bring about the biggest
changes in health and longevity.
References
1. Erickson KI, Voss MW, Prakash RS, et al. Exercise training increases size of
hippocampus and improves memory. PNAS 2011;108:30173022.
2. Cherbuin N, Sachdev P, Anstey KJ. Higher normal fasting plasma glu-
cose is associated with hippocampal atrophy: e PATH Study. Neurology
2012;79:10191026.
3. Enzinger C, Fazekas F, Matthews PM, et al. Risk factors for progression
of brain atrophy in aging: Six-year follow-up of normal subjects. Neurology
2005;64:17041711.
4. Shai I, Schwarzfuchs D, Henkin Y, et al. Weight loss with a low-carbohy-
drate, Mediterranean, or low-fat diet. N Engl J Med 2008;359:229241.
5. Perlmutter D. Grain Brain. New York: Little, Brown & Co., in press.
6. Newberg A, Waldman MR. How God Changes Your Brain: Breakthrough
Findings from a Leading Neuroscientist. New York: Ballantine Books,
2010.
7. Perlmutter D, Villoldo A. Power Up Your Brain: e Neuroscience of En-
lightenment. Carlsbad, California: Hay House, Inc., 2011.
David Perlmutter, MD, FACN, ABIHM, is the medical director of the Per-
lmutter Health Center, in Naples, Florida; an adjunct professor at e Insti-
tute for Functional Medicine, in Federal Way, Washington, and an associate
professor at the University of Miami, Miller School of Medicine, in Miami,
Florida.
To order reprints of this article, e-mail Karen Ballen at: [email protected]
or call (914) 740-2100.
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