Episode 200 – Guest Dr. Perlmutter

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Performance Menu: Journal of Health & Athletic Excellence

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Featuring guest: Dr. David Perlmutter MD, author of Grain Brain

Link to the article discussed on the show http://www.thedailybeast.com/articles/2013/08/22/why-we-can-and-must-focus-on-preventing-alzheimer-s.html

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  1. Donnie Law
    September 17, 2013 at 7:07 am

    You need to get this guy back on.

    My 61 year old uncle just died from a short 7 month battle with brain cancer. My 62 year old uncle on the other side of the family has Alzheimer’s/dementia so severely that he cannot work and can no longer drive.

    I’m going to buy Grain Brain and hopefully read it together with my parents.

    Great episode Rob.

  2. saulj
    September 17, 2013 at 9:18 am

    Reading Stephen Ambrose’s Book “Undaunted Courage” about the Lewis and Clark expedition. It says that when they were working hard, going upstream on the Missourri, they were eating 9 lbs of meat each per day! We eat a little differently now.

  3. Prof10
    September 17, 2013 at 9:51 am

    One of the BEST and most informative guests ever! I loved the conversation between the two of you and can’t wait to read the book and for you to have him back on again. I could have listened for hours. Good Stuff!

  4. Waldo
    September 17, 2013 at 12:04 pm

    Awesome interview! Dr. Perlmutter is an extremely intelligent, articulate and lucid speaker and this is a “must listen to”. At well over an hour long, it still left me thirsting for more. Thanks Robb.

  5. Danna!
    September 17, 2013 at 12:39 pm

    Loved this interview!!! Great job Robb! Dr. David is so easy to listen to. Just love him. I want to get him here to our small university to speak. IT’S A NEW DAWN for sure, now with people like Dr. Lustig, Dr. Williams, Dr. Perlmutter, any many more speaking out, so many people will be helped. I could have listened to the two of you ALL day!

  6. Brooke
    September 17, 2013 at 1:23 pm

    Very compelling episode. I ordered Dr. Perlmutter’s book. It leaves me wondering though about serving my kids fruit. It’s easy for me to not eat most carbs, but really hard to know what is right for my kids. I would love to hear more about kids and ketosis.

    • Amy B.
      September 18, 2013 at 8:19 am

      Hey Brooke,

      I’m not Robb, but I’ll be bold and chime in anyway. I wouldn’t be too concerned about your kids eating fruit. The kind of inflammation & oxidative damage Dr. Perlmutter was talking about isn’t going to be caused by eating an apple, peach, pear, or bunch of grapes now and then. (Fructose be damned.) It’s more caused by the constant, unending onslaught of high glycemic load foods & omega-6 heavy seed oils the average person subjects their body to via one grain/refined sugar feeding after another. (Cereal & toast for breakfast with a glass of OJ, crackers or a granola bar for a snack, sandwich, soda, & chips for lunch, pasta & bread for dinner, cookies for dessert. Maybe a latte and a donut at the office. Likely all while limiting the natural saturated fats and cholesterol our bodies thrive on.) I’m not saying kids should eat fruit all day long, just thinking that we need to be sensible about things. It seems like dementia, Parkinson’s and other neurological conditions happen after a long time of ceaseless metabolic stress (likely combined with chronic insufficient sleep, low vitamin D, and, of course, years of taking in too much carbohydrate for one’s physical activity levels).

      I guess what I’m trying to say is, if your kids are active little critters and generally eating a Paleo-type diet, I wouldn’t fret about fruit, sweet potatoes, and other whole, real, non-grain carbohydrates. (Assuming those wouldn’t be the *bulk* of their diet, of course.) We *are* seeing Alzheimer’s, Parkinson’s, autoimmunity, and T2 diabetes in people younger and younger now, but I think that’s mostly a result of people being exposed to our insanely toxic, inflammatory, & insulin-resistance-inducing diet from day one, whereas in the past, these things seemed to affect only older people because they weren’t being born right into it the way we are now. It took them a lifetime of accumulated metabolic damage for those conditions to manifest and show overt effects. It’s occurring in younger people now b/c (depending on mom & dad’s diets) we’ve got the modern food supply affecting us before we’re even born.

      If your kids eat a nutrient-dense, relatively low-glycemic Paleo diet, they should stay healthy and robust, insulin-sensitive and metabolically flexible (able to switch easily between burning mostly fat or mostly carbs, without adverse effects on physical or cognitive performance) for their whole lives. To me, THIS is one of the main end goals of eating Paleo.

      I don’t think it’s necessary for kids to be in ketosis on a regular basis. I certainly don’t think it’s harmful, either. I think dipping in and out of ketosis is great as a potential preventive strategy through our whole lives, but you’re in a great position because your kids are young: you can raise them with dietary habits that will (hopefully) prevent them from “needing” a strict ketogenic diet later on to *reverse* damage that didn’t have to be done in the first place. Sorry to ramble. Hope it made sense somewhere along the way!

  7. Justin
    September 17, 2013 at 5:49 pm

    Robb, you mentioned having thousands of studies on your desktop; is there anything that the average person can do to make it easier to access this type of volume of studies? I know that there is PubMed, but usually whenever I find a study that I want to read it costs $30 to get the full text.

    • Robb Wolf
      September 17, 2013 at 7:36 pm

      I’m part of several research groups…it’s hard for the average person to get these. Push for open access in journals.

      • James Snyder
        September 23, 2013 at 9:09 pm

        In the mean time feel free to shoot the paper author an email or check their lab/institution web page. Authors will often be happy to send a copy.

        That said, as someone who has published (not in health-related sciences) I definitely agree that all this federally funded research should be open access.

  8. Nicole
    September 17, 2013 at 6:46 pm

    Amazing interview….bring him back! The two of you are so crazy smart, I could have listened for another four hours. Total love fest at the end was great too!

  9. Francesco Di Maggio
    September 17, 2013 at 11:50 pm

    Hi Robb, fantastic interview. Dr. Perlmutter is incredibly clear. I would recommend this podcast to someone that want to know the basic of Paleo Diet, not only people interested in the neurologic aspects.. Are you going to publish the transcripts as well? Dr. Perlmutter mentioned lot of articles, so it would be easier to have the transcripts.

    Keep up with the excellent work, Robb. You are saving lives or making them incredibly better.
    Francesco

  10. Ryan Feeley
    September 18, 2013 at 12:18 am

    Great show and extremely knowledgeable author. A few people will be getting this book from me. However, I’m a little skeptical of the denigration of fruit. Small gut, excellent color vision, and preying upon tasty animals that also like fruit all point to significant fruit exposure by early humans. We have beta cells, we make insulin, and sometimes we spike our blood sugar. Let’s keep in mind that the diseased people encountered by practitioners aren’t typically consuming a 12oz soda, which is effectively two apples of sugar (ignoring the obvious fructose/sucrose differences). Clinicians are dealing with people who routinely down a 44oz big gulp. Who eats 8 apples with their half pound of french fries?

    Any one fruit species is seasonal, but fruit as a class of foods is pretty available in a lot of locations. In terms of physiology, a lot of human physical traits that are common to predators in general are often align pretty closely with fruit eaters (relatively short gut, ability to cover large territories, good eyesight, etc). In fact, based on gut size along I would expect the fruit consumption of early humans was on par with their vegetable intake. Vegetables are fiberous, demanding to digest, and not particularly dense in accessible nutriaents. Fruit sensitivity and alergies are rare as food alergies go, and these are typically tropical fruits that were reencountered by the masses relatively recently.

    From a biochemical standpoint it is true that the metabolism of carbohydrates generates free radicals and of course can hammer your blood glucose levels. Eating almost anything is hard on your body in someway and I think we are pretty far away from really understanding how many of these mechanisms really work in vivo. Labeling and following of individual molecules in living organisms is quite challenging. Looking at molecular dyanamics at the single molecule level it in its infinciy. I think at this point we can say that humans are pretty robust, but also do age and die like everything else.

  11. Ryan Feeley
    September 18, 2013 at 12:22 am

    Great show and extremely knowledgeable author. A few people will be getting this book from me. However, I’m a little skeptical of the denigration of fruit. Small gut, excellent color vision, and preying upon tasty animals that also like fruit all point to significant fruit exposure by early humans. We have beta cells, we make insulin, and sometimes we spike our blood sugar. Let’s keep in mind that the diseased people encountered by practitioners aren’t typically consuming a 12oz soda, which is effectively two apples of sugar (ignoring the obvious fructose/sucrose differences). Clinicians are dealing with people who routinely down a 44oz big gulp. Who eats 8 apples with their half pound of french fries?

    Any one fruit species is seasonal, but fruit as a class of foods is pretty available in a lot of locations. In terms of physiology, a lot of human physical traits that are common to predators in general are often align pretty closely with fruit eaters (relatively short gut, ability to cover large territories, good eyesight, etc). In fact, based on gut size along I would expect the fruit consumption of early humans was on par with their vegetable intake. Vegetables are fibrous, demanding to digest, and not particularly dense in accessible nutrients. Fruit sensitivity and allergies are rare as food allergies go, and these are typically tropical fruits that were reencountered by the masses relatively recently.

    From a biochemical standpoint it is true that the metabolism of carbohydrates generates free radicals and of course can hammer your blood glucose levels. Eating almost anything is hard on your body in some way and I think we are pretty far away from understanding how many of these mechanisms really work in-vivo. Labeling and following of individual molecules in living organisms is quite challenging. Observing biological molecular dynamics at the single molecule level is in its infancy. I think at this point we can say that humans are pretty robust, but also do age and die like everything else.

    • Ryan Feeley
      September 19, 2013 at 7:08 pm

      Ack! Sorry for the double post (which doubled my negativity ;-). This was perhaps the first time I’ve ever commented on something online. The show really was that good! My comment was intended to mitigate a fruit paranoia. I agree with some of the other comments that in either a legitimate prophylactic or clinical intervention situation, severely limiting fruit intake can be entirely appropriate.

  12. Stephen Reed
    September 18, 2013 at 1:05 am

    Hi there Robb

    That was a truly amazing interview last night, I don’t think you got a word in for the first half?? The Doc was just awesome in his knowledge over suck a wide area, bit like you :-)

    I am really interested in your thoughts on the carbs for fueling performance though. He implied you were doing it wrong eating sweet potatoes etc, and I think that a lot of people overestimate their need for CHO, doing things like strength training etc, but for the real high intensity stuff??? Can fat adaptation really cut it?

    I know I used to run some high intensity kettlebell classes on a keto diet, it always seemed to fuel me quite well, but if we are looking to eat carbs post workout, to be quickly shuttled to glycogen stores, does that still have the same effect on blood glucose, when this timed eating is specifically to replenish muscle and liver stores, even without the need for insulin.

    What’s your take. Not meaning to demean what the doc said, but the sports we are talking about are modern, not ancient, perhaps ancient eating protocols are just not appropriate in these cases?

    Thanks for your great work, its all good!!!!!

    • Robb Wolf
      September 18, 2013 at 7:45 am

      I think endurance activities might do fine, possibly benefit from keto. MMA/BJJ, highly glycolytic activities…tough to see it. Benefit of keto seems to be at like three hours…I’m just never training that long.

      • Stephen Reed
        September 19, 2013 at 1:40 am

        Robb, you also mentioned some time back that you trigs had gone up since adding more carbs in, and you were thinking of dialling them back.

        Did you ever find a sweet spot??

  13. gygez
    September 18, 2013 at 4:28 am

    Interesting interview,and thanks for what you do and have done.
    Might this change your position on carbs again?
    I got the feeling you wanted to say more about carbohydrate and athletic performance but maybe you were saving it for a future episode?
    I am sure some people are going to freak out about this talk. I look forward to follow up questions and answers on the topic.
    Thanks Robb, keep up the good work.

    • Robb Wolf
      September 18, 2013 at 7:42 am

      Check some of my other comments here. Pretty much business as usual.

      For the critics of dr perlmutter: show me someone doing it differently, and getting better results.

      • Amy B.
        September 18, 2013 at 8:31 am

        All I can say is, Dr. Perlmutter’s stricter perspective probably comes from the patients he sees — the people who are pretty far-gone in terms of neurological function and insulin resistance, with one foot in the grave. He’s not a Crossfit coach, dealing with people at the 98% percentile of great health & fitness who want to be at the 99.9%. He’s trying to help people whose health is seriously compromised and whose daily lives are a physical & mental struggle. The kind of diet they need at this point as a kind of *therapy* is going to be different from a dude who’s got 10% body fat and wants to eat a sweet potato after a killer workout.

        I think Robb’s made that pretty clear in several past blog posts & podcast answers.

        It’s two different worlds to say something like “no one should eat fruit ever, no matter what,” versus “people who require a very low carbohydrate diet to stop and possibly reverse incredible amounts of metabolic damage are not helped by eating fruit.”

        • Bryan L
          September 19, 2013 at 8:42 am

          Robb,

          Amy and a few others mentioned something that I was thinking, too. Thanks for that last question about glycolytic pathway activity; it hit an issue that had been nagging in the back of my mind through the whole podcast. Like Amy, I was thinking that the Dr.’s perspective might be fueled by the types of people he sees daily. It would be interesting to get Mat LaLonde’s thoughts on all that, especially in light of his post-training, crash-and-burn/ice cream refeed incident from a few years back.

  14. adam
    September 18, 2013 at 6:54 am

    Really great. Would love to hear your opinion on his lowcarb for even the BJJ player. Going lowcarb and doing BJJ + having an active lifestyle ruined by endocrine system (know this via bloodtests, took about 8 months to get T levels back to average). Would like to get him back on and talk more about an athletes approach to his research (this was brought up at the end, but I would have liked more time on the topic. Does this make you re-evaluate your carb intake? Overall, great podcast!

    • Robb Wolf
      September 18, 2013 at 7:25 am

      Adam- ill bet the athletes he is working with are endurance in nature. I simply do not see how one will fuel MMA/BJJ keto and not end up with some problems, to say nothing of slumped performance.

      And keep in mind: keto adaptation does not seem to show a benefit until like hour 3 of training…I do a jits session that long twice a year at seminars!

      • Adam
        September 18, 2013 at 3:35 pm

        Thanks for your input and I see other people have asked similar questions, if you’d ever consider addressing this on your next podcast so you dont have to repeat yourself, then go for it, we are all listening!

        I understand that diet is a lot of tinkering to see what works best for each of us individually. BUT if Dr. Perlmutter is recommending less then 100 grams of carbs a day, should grapplers be worried about the long term effect of this as we age. Doing bjj 3x a week and low carb brought me to a free T level that was shockingly low, like 8 year old boy low (MRI’s my head to make sure I didnt have a tumor on my pituitary gland). So if I continue to go higher carb on BJJ days, my free T will stay good but do I then run the risk of other neurological disease associated with a higher carb diet?

  15. jgirl
    September 18, 2013 at 7:29 am

    Robb, thanks for having Dr. P on your show. I came across him when my mom was first diagnosed with ALS. I hear his story and understand the drive. She has been gone two years, but the exposure and information that we learned during that time is so valuable. Make the box bigger! Simple! Excellent!

  16. CMurley
    September 18, 2013 at 8:54 am

    Wow, #200 did not disappoint! Dr. Perlmutter and yourself are able to speak on complex topics with such incredible clarity — I will certainly be forwarding this one on to my parents. This is one of the most accessible podcast episodes I’ve heard on any show for both older and young folks alike. The countless citations to medical literature from the doc was a gold mine as well.

  17. AJ
    September 18, 2013 at 1:09 pm

    Great episode. Fantastic episode.

    Thank You very much. Dr. Perlmutter (BRING HIM BACK ON) is a real pleasure to listen to and I’ll pick his book up for sure.

    Also… It does appear that Robb has a huge gushing man crush.

  18. Patrick
    September 18, 2013 at 3:25 pm

    Awesome interview guys!!

    Question:
    In my many attempts to go “keto”, I’ve had success: weight loss, better cognition, consistent energy, etc. However, I either can’t sleep because I’m all jacked up at night, or, I have night terrors.

    I’m also about 20 lbs overweight (18% bf).

    When I add carbs back in from tubers and white rice I sleep so well (about 100-150 grams, post workout window); but, weight loss stalls. Eating carbs seems to prevent me from reducing my caloric intake while going lower carb allows me to eat less without thinking about it.

    So, I’m stuck sleeping well but carrying too much fat, or, sleeping like a baby and while looking like a fat baby!

    Any ideas how I can manage this… I want to lean out, but I don’t want to lose my sleep. I’m wondering if I should decrease my physical activity while going low carb? I mainly do oly lifting with some sprinting or kettle bell complexes. Maybe ditching all glycolytic work would help me slip into ketosis without the increased cortisol thing (which I assume is what’s keeping me up at nights when going low carb)…

    Again, great info today. My favorite podcast to date! :)

  19. Lifextension
    September 18, 2013 at 5:36 pm

    Absolutely brilliant interview, Robb. What a sensational guest. Take home message from the interview: our genome has been fine-tuned to respond to extrinsic factors – most importantly nutrition. This has positively honed our DNA to be as receptive as possible to the food choices that we have been making throughout our >2.5 million years (99.9% of our time) on this planet. Throughout that period of time, that environment for humans has been significantly scarce in carbohydrates. Agree wholeheartedly. Hope you’re doing well, Robb!

  20. Martin
    September 19, 2013 at 3:26 am

    Great discussion! Respect to Robb for asking questions to which the answers might go against his recent recommendations!

    I think carbs-for-health and carbs-for-performance are two different topics. I am low-carb and doing well at the sports I do but I believe it’s possible that some athletes in some discplines at the top level do better with higher carb intake.

    But what about carbs for health? We often hear that we need higher carbs for optimal health, e.g. the whole ‘safe starches’ concept? Does low-carb really cause or contribute to adrenal fatigue or thyroid problems?

    Finally, is higher carb problematic ONLY if one is already inflamed (e.g. when consuming high-carb gluten containing diet) or can high intake of carbs cause problems even in the absence of gluten and other pro-inflammatory foods (e.g. using the ‘safe starches’ approach)?

  21. Heather
    September 19, 2013 at 5:47 am

    what a fantastic podcast – loved it – the complex topics were articulated really easily. I would love this sort of information to reach my sister on some level. She has epilepsy which has become totally unresponsive to the gold star drugs available and at only 37 has had to give up full time work and the majority of her independence. I brought up the paleo diet with her and mentioned a ketogenic diet (which is what her doctors have also suggested as a treatment) at the end of last year as a last ditch effort to try something new, like Dr Perlmutter said “why not give it a try – what have you got to lose” and referred her to this site and others for more info. The response I got was “so I can’t eat bread anymore”. What??? I give up! all the women in my family have this running theme with brain-gut axis issues with my nanna having Alzheimer’s so this is really life saving info. thanks Robb for all you do

  22. Paleo Huntress
    September 19, 2013 at 11:19 am

    I just finished listening to this podcast, and found Dr. Perlmutter very articulate and a treasure trove for current data resources. Having had metabolic derangement, and having healed it, I have a bias toward keto and cyclic keto diets– I know how powerfully healing they can be. However, because of that bias, I keep my claims about the science of dietary carbohydrate in the “beyond reproach” area and dig more deeply into the arguments to try and balance the bias out.

    I found that the doctor’s “carbs are evil” message sounds overreaching, and I feel there is too much data showing that that isn’t always the case. I kept waiting for Robb to ask for the doctor’s perspective on long-lived, high carb cultures like the Kitavans and especially the Okinawans, and I’m hoping that the doctor will be on again and that that question will be asked. I think current data shows that macro-nutrient ratios are only one factor out of many that can affect systemic inflammation. For example, there is certainly a significant body of data that shows that plant based diets (which are almost always, though not exclusively, high carb and low fat) are anti-inflammatory when compared to the SAD. Perhaps it is the merely the change to whole food that accomplishes that, and I look forward to the day when we have some hard data comparing whole food, grain-free omnivorism to whole food, plant based diets– I expect the former to crush the latter. lol But I won’t make that claim until the data exists to support it.

    Robb, you have a gift for asking questions in a way that doesn’t challenge or confront your guests, but perhaps there’s truly no way to ask that without it seeming rude. Still, I wouldn’t be comfortable pointing anyone to his interview because I worry that they will discount the entire message when they can’t reconcile current data with his claim. I’m looking forward to an answer that will satisfy a science/data savvy person.

  23. Daniel Firestone
    September 19, 2013 at 12:23 pm

    Hi Robb,

    Perlmutter seems to put a lot of stock into the Hemoglobin A1c test/measurement. I know you changed your mind and pulled back on the significance of that test about year or so after writing your book.

    Has your opinion shifted at all on Hemoglobin A1c since the last time you mentioned it on the blog or Podcast? Has it come up recently in your e-mail/discussions with your paleo A-TEAM like Kresser, LaLonde, etc.

    Thanks so for continuing to produce the Podcast. I’m really digging these guest episodes. I can’t believe I’ve listened to 200 episodes! I just need to listen to 8,200 more hours of your podcast and I’ll truly be a paleo master.

    • Robb Wolf
      September 19, 2013 at 3:49 pm

      No change, and Doc mentions several other bio markets to track. And keep in mind WHY A1C has limitations: in LC folks it provides a false high blood glucose reading. For the diabetic, it’s still a good indicator.

  24. Chris Adams
    September 19, 2013 at 2:39 pm

    what an episode! bring on part 2

  25. Peter
    September 19, 2013 at 7:47 pm

    Interesting interview!

    A few thoughts in relation to BJJ and glycolitic activity…

    Isn’t 5 x 5min rounds (25min total) of work mainly aerobic in nature?

    If you are more fast twitch in nature(or by training) would that not mean that a fast twitcher trying to doing an aerobic bout of work would find that A) More stressful and B) Have a greater demand for CHO refueling than a slow twitcher?

    And as much as I initially said,”What the heck” to Dr Perlmutter’s comments about no CHO for glycolitic acivity (90s-3min @ 100% effort) maybe it’s worth trialing it to find out….

    I think there are some comments in Dr Mike STROUD’s book on Fitness (I forget the name) where he references a fat based diet fed to soldiers and their work output was measured over a variety of time domains…Pretty sure there were some positive outcomes.

  26. Lindsey
    September 20, 2013 at 12:43 pm

    This was one of my favorite podcasts so far and I would love to hear more from Dr. Perlmutter. What a clear and concise speaker!

    This podcast has provoked me to rethink low carb. Dr. Perlmutter’s message could be beneficial to those who have jumped the gun. Despite following the paleo diet and being nothing less than a gym-rat, I am not healthy. I am still overweight and suffer from digestion problems and hormonal imbalance after years of activity: kickboxing, boxing, strength-training, sports. I have pushed my body hard and carbed-up post-workout with sweet potatoes or cycled carbs into my diet to stimulate leptin production (for continued weight loss) on a one day per week basis (is this idea even right?).

    Every pause in strength training I’ve had comes with effortless weight loss. This paired with Dr. Perlmutter’s point of view makes me wonder if perhaps I should limit activities that are more likely to hit the glycolytic pathway and eat low carb until I heal my gut of SIBO symptoms and get to an optimal state of health. I also have a feeling my adrenals are totally wiped from the constant pushing and caffeine chugging. I have been trudging on to become more athletic…but I’m realizing more and more the way I’ve been doing it is not smart or even effective.

    Thank you for this awesome interview, Robb. This maybe the perspective I needed to start fresh on achieving better health. In a little while I will tinker with the athletic part. Maybe even, if I’m very low carb for two years straight– I can tell you if I’m kicking ass at mma.

    • Robb Wolf
      September 20, 2013 at 5:17 pm

      That sounds pretty spot-on to me. If you tinker, i want a blog post on this!

  27. Amy B.
    September 20, 2013 at 1:05 pm

    I’d like to put some thoughts out there because it seems like people are quick to see things as black or white, 0% or 100%. This spurs a lot of fear and worry in otherwise rational people…all carbs are bad all the time! Burn them at the stake! Starchy carbs are good again, everybody eat a bowl of rice! Better yet, top it with russet potatoes and corn!

    Let’s think about this: just because calling an exterminator and having him fumigate your house kills your ant/bug infestation doesn’t mean setting off bug bombs in your house is REQUIRED to *prevent* the infestation in the first place. You can other, less drastic measures to ensure you don’t need the more extreme solution later on. (Better insulation on doors & windows, not leaving food out, etc.)

    So just because ketogenic/VLC diets seem to do a stunningly fantastic job of healing in some conditions for which conventional pharmaceuticals have largely failed or even made things worse, doesn’t mean every single one of us NEEDS to be on a ketogenic diet our entire lives to *prevent* these conditions.

    Robb has said over and over again that (based on current understanding of the scientific literature), dipping in and out of ketosis/carb-restriction and occasional full-on fasting are likely a good, low-level way to ward some of these things off. Some of the main goals of following a Paleo diet and eating real, whole foods are to maintain lifelong insulin sensitivity, and hopefully reverse or prevent leaky-gut induced conditions by avoiding foods that are problematic for YOU, as an individual, right? Most of the conditions Dr. Perlmutter’s concerned with are the results (or so we currently believe) of insulin dysregulation, mitochondrial dysfunction, gluten intolerance, and autoimmunity.

    He probably deals with a lot of people who have been eating the SAD all their lives, or in the case of baby boomers, for enough decades that their health is completely, totally compromised. It makes sense that people who are quite far gone would need a strict, no-nonsense intervention as a therapy. They don’t have the luxury to play around with dipping their toes in the water to test things out. They need to do a cannonball into the deep end and *stay there* for a while. But let’s remember, this is what’s likely needed AFTER the damage is already done and we want to reverse it, stop it, or if nothing else, slow it down some. This does not automatically translate to this same dramatic therapeutic being *required* to *prevent* the damage from happening in the first place.

    If you “found” Paleo early enough in your life to understand the basic approach of keeping your n-6 consumption low, staying away from gluten, eating the best quality meat & produce you can afford, and eating real, whole food carbohydrates to match your individual metabolic sensitivity to them or to satisfy your physical performance goals, then there’s a good chance you’re not going to accumulate this lifetime of damage. Are we all going to have glycated proteins & AGEs no matter what we do? Yes. That is a normal, natural part of aging. But it’s supposed to happen slowly, and over a very long period of time. We’re all going to get old and die. We can’t change that. What we *can* change is 35-year-olds with rheumatoid arthritis, and obese first-graders, and 65-year-olds (still young!) with dementia so severe they require live-in nurses.

    I dunno. I guess I’m just surprised at the alarmism and people being terrified of carbs (again). Dr. Perlmutter himself said something about eating fruit, and in the context of an overall lowER carb diet, it’s all right. But I think he’s talking about a peach, some cantaloupe, or a banana here and there. He’s not talking about fruit cocktail canned in heavy syrup eaten for breakfast every morning along with whole wheat toast w/margarine, and a 20oz glass of OJ.

    I think a VLC diet can likely go a very long way toward preventing some of the physical and mental deterioration Dr. Perlmutter sees every day. But I don’t think it’s *required.* I’m not saying it’s safe to eat 300g of carbs a day, but that doesn’t mean everyone needs to eat less than 30g, either. *Particularly* if you have good glucoregulation and actively work to maintain that — eating a *relatively* lower carb diet and getting some physical movement a la Mark Sisson’s approach — lots of low-level activity like regular ol’, walking, lifting heavy things a couple times a week, and going all-out on speed & effort once in a while. (And by lower carb, I mean that when compared to the SAD, even a “high carb” Paleo diet could probably be considered lowER carb — say, 30-40% versus 50-60+% of total calories.)

    I feel like many of the most respected voices in Paleo (I hate to use the word “leaders” because then it makes this feel like a cult or something) have said they believe that certain types of athletic performance will be antagonistic to health and longevity. Maybe it has to do with the oxidative stress and/or the carbohydrate consumption. That doesn’t mean that every Ironman triathlete is going end up with Alzheimer’s or ALS. It’s a balancing act: weighing our quality of life and what we enjoy doing against the potential for complications down the line.

    If we think about this truly from an ancestral/evolutionary viewpoint, it kind of makes sense that we would have made use of the flexibility to be sugar burners or fat burners *seasonally* — consume fruit and sweeter veg in summer to “fatten up” for the relatively leaner period of winter, when we would have been closer to ketogenic, but also getting A LOT more sleep, considering the amount of darkness during winter away from the equator. Our ancestors weren’t waking up at 4:30 or 5 in the morning every day, all year long, to hit the gym, whether it was light or dark out, hot or freezing cold. Our modern diets & lifestyles have made it so neither the famine nor the darkness ever comes. I think this is why it’s important to go keto/low-carb once in a while (if you don’t do it as your baseline anyway), and to sleep in the DARK. We have to intentionally impose those conditions upon ourselves because they no longer occur naturally for us.

    It would/will be interesting to see a study done on a large cohort of young people who spend their entire lives eating Paleo (with varying amounts of whole, real, non-grain carbs), who maintain their insulin sensitivity, maintain strong tight junctions in their intestines (no leaky gut/autoimmune), and see how THOSE people fare over the years. Did the people who ate the post-workout potato sweet potatoes for 60 years end up with dementia? Did any of the ones who were low-carb all the time develop cancer?

    I’m sorry for the ramble. I just think we should keep looking at context and the bigger picture. Keep tabs on blood glucose…invest in a drugstore meter and see how certain foods affect you, and periodically track markers of systemic inflammation. If we smell the smoke long before the fire gets out of control, we can spare the house from burning down.

    • Robb Wolf
      September 20, 2013 at 5:16 pm

      We should make this a post, not just a comment! You game Amy?

      • Amy B.
        September 21, 2013 at 10:05 am

        Abso-frakkin’-lutely!
        I’ll be in touch.

        I’m glad it resonated. After I hit send, I was like, “Oh God, why did I do that?!”

      • Patti F
        October 1, 2013 at 2:44 pm

        Please do! I am loving Amy B’s contribution to this discussion.

  28. Kristine
    September 20, 2013 at 6:13 pm

    Reading these comments and Amy’s and Robb’s replies, I can see why Robb was getting so frustrated with the feedback that this podcast has been getting.

    I *wish* Dr. Perlmutter said what Amy says above. I love what Amy says above and that’s a line of thinking I can wholeheartedly support.

    But that just wasn’t what I heard from Dr. Perlmutter on episode 200.

    Dr. Perlmutter was not talking about what to do when you find yourself sick and metabolically deranged. He was not suggesting people play around with ketosis to see if it works for them. And, he was not (except for the bit in reply to Robb about BJJ) talking about athletic performance.

    What I heard him say clearly was that to prevent brain degeneration, human beings should avoid sugar and therefore carbohydrates altogether, although they may take in 60-70 or so grams by virtue of just eating vegetables.

    (He states on his own website that humans do not require any carbs at all. http://drperlmutter.com/learn/faq/how-much-carbohydrate-do-we-absolutely-require-in-the-diet/)

    I love what Paleo Huntress has to say above. I, too, kept waiting for Robb to poke and probe at this whole “no one should purposely eat any carbs” idea. On Twitter, I mentioned female hormonal processes (lactation – but I could have said pregnancy or menstruation even) as at least meriting some conversation. Do women really not need any carbs ever to maintain these processes? Maybe I’ve been living under a bush, but this idea does seem pretty radical to me.

    I really loved this podcast. I love boundary-pushers, and Dr. Perlmutter is passionate and has data to back himself up. And I am not all, “OMG, Robb’s changing his mind on carbs again,” either. I’ve read all of Robb’s stuff on the issue and I could not agree with it more. (And even if Robb did change his mind, he never does that wantonly and science is always evolving, etc. No biggie.)

    It’s just that I think Dr. Perlmutter is saying something entirely different from Robb.

    The way I see it, Robb = “tinker with your carbs and see how you look / feel / perform.” While Dr. Perlmutter = “everyone must avoid all carbs now and for always or stand a much greater risk of succumbing to a debilitating brain disease at a much later date.”

    Again, I submit there’s a wide trough between those two positions and that deserves some conversation.

  29. Cathryn
    September 21, 2013 at 7:00 am

    I like what Amy had to say. I also think Perlmutter has forgotten one important thing and that is we are all going to die, no matter what we do. Sure, Maybe we will live longer and better following his advice, but his zealotry is a turn-off for me. I ate VLC for years, too (starting 12 years ago) to help with RA and gut issues. Yes, I got much better. I am not free of the toxic meds, but have been taking a relatively low dose and am currently trying LDN in conjunction. After a couple years of VLC I felt awful and improved greatly adding in a few carbs. I eat all the right stuff and exercise sensibly. I do eat a virtual mountain of white rice a couple times a week and enjoy every mouthful. I’m 62, 5’3″ and weigh 108 lbs. I’m a pretty hot looking oldish woman. I’d be a scrawny hag in a couple of weeks following the doc’s carb recommendations. No thanks.

    I’ve known seniors who lived into their 90’s, sharp as tacks, mentally, who were slamming down the worst oils and refined carbs daily and eating low fat. I’m sure Perlmutter’s approach is what some people need and I am a big believer in the dietary approach to healing and longevity. I also think there is more at play.

    He can pry my Japanese sweet potatoes, from my cold, dead hands.

  30. Alexandra
    September 21, 2013 at 7:11 am

    Great episode, Robb! Millions upon millions of people can improve their health as this type of advice and information becomes more widely available. Thank you for what you do.

  31. Erik
    September 23, 2013 at 5:25 am

    I listened to the entire podcast, and just wanted to confirm one thing:

    Nothing Dr. Perlmutter said would, in any way, force me to re-think the NorCal Margarita. Correct?

    Maybe 1/2 lime instead?

  32. David Locker
    September 23, 2013 at 7:38 am

    Great podcast today. Very informative and entertaining. Thanks.

  33. lin hall
    September 23, 2013 at 7:42 am

    I will be purchasing Grain Brain at my earliest opportunity. This was really a great podcast. I listened to it twice, along with my husband. I’m 63 and he’s 67. Two years ago we cut out all grain and began eating a Paleo-type diet concentrating on food quality. After only one year of being grain-free my husband’s cholesterol markers were better than his baseline. He’d been struggling with statins, doc wanted him to take them, they made him feel foggy and achey. Long story. Now, the doc has said, “Whatever you’re doing, keep on doing it, because it’s working.”

    But the reason, Grain Brain so intrigues me is that in 1997 I had a benign brain tumor (meningioma) removed. Since that time I’ve been fine and get MRIs every few years. I still suffer from migraines however, although they have diminished. For awhile I was on anti-depresson meds. Since cutting out grains, and especially wheat, life is ‘brighter’. It’s hard to explain, but it just is.

    Cognitive health is very, VERY important to me. I’m in a career that I love and plan to continue well into my 80s – and even my 90s! (I write mystery novels) So, I need a clear brain, energy, no more tumours or depression, and the ability to think. I had no idea the connection between good fat and the brain, and between wheat and the brain. Thanks so much for this book, and this podcast, and the work you both do.

  34. Angelyne
    September 24, 2013 at 5:36 pm

    Very interesting podcast, I was riveted the whole time. I loved the bit where after a long period of respectful silence Robb piped in and showed him that he could talk the talk too. I could almost see Dr Perlmutter mind blow when Rob started talking. Even after Robb told him to basically let loose, you could tell that Dr Perlmutter was so used to dumbing down his explanations for the lay public that he had trouble adjusting the level of his discourse.

    I don’t think I learned anything new, but it put a lot of information together in an interesting way, and it’s a good reminder of the importance of keeping your blood sugar in check. I think you can never hear it too much. It’s also fascinating to hear the perspective of an actual doctor who treats patients. We need more like him.

    As for the whole ketosis, VLC debate, he seems to be squarely in the Gary Taubes camp. That’s alright. It’s not a bad place to be. The important thing is not to cling desperately to your pet theory, despite all contrary evidence, a la Ornish. I have confidence that people like Taubes and Perlmutter will change their tune if the evidence shows they are wrong. But I agree that humans evolved with a much higher carb load that they think. I think the middle of the road consensus is that we evolved eating carbs as well as fat and meat, but that when you are metabolically broken, as so many of us are, that way is no longer an option for you. So I think they are right, but only for us broken humans.

    The only wrong note in the podcast came at the end when Robb asked a personal question. I thought that Dr Perlmutter basically told Robb that he wasn’t trying hard enough with a ketogenic diet. That was a bit glib. (and what’s with the keto stick advice — i cringed)

    But all in all a great podcast, and I could tell that both Robb and Dr Perlmutter enjoyed themselves.

  35. linda
    September 25, 2013 at 3:07 pm

    This podcast was perfect for me. I need the severity to keep me in line. Does anyone know how much the Cyrex tests might cost? I went to their site and there are no prices listed. Crossreactivity is kinda scary

  36. Dave
    September 26, 2013 at 9:51 am

    Rob, I agree with the above posts about the extreme position this MD has on carbs. Otherwise I loved what he had to say.

    I’m excelling at Sisson and your recommondations on carbs. I get tired of the Gary Taubes camp of carbs=poison. What about evidence of ancient man and modern primitive people eating much in the way of tubers and fruits?

    I think your ideas on the intelligent use of ketosis prn is the new wave of low carb thinking.

  37. PaleoDentist
    September 30, 2013 at 5:49 pm

    This is my very favorite podcast (yes I listened to them all) What an amazing interview! I already ordered the book! great job Robb!!!!!!!!!

  38. Barbara
    October 6, 2013 at 9:13 am

    Robb…this was interesting … also bought his book and had some trouble with it for all of the above commentary. I think there is not enough info on how women need to manage the vlc thing diff from men. Esp women who are not metabolically broken. I went paleo because of you, and have not looked back. I went keto last yr in preparation for surgery…did okay initially but had trouble with energy…thyroid….gained fat…lost interest in excercise..until i read “perfect health diet book”..listend to the safe starch debate…and got back on board with sweet potatoes…. I read Peter Attia’s stuff as well…I think being Irish…a woman..in my late 50’s…on bioidentical hormones…and thyroid hormones…potateos are a fine thing. I would love a podcast wiht Dr Rock Patel to hear his take on this too. Keep up the good work …it saves my ass every day!

  39. Stacy
    October 11, 2013 at 8:59 am

    Great interview. I just started reading Grain Brain and it is eye-opening. Thanks to Dr Perlmutter for the important work he is doing, and to Robb for bringing the message.

  40. jake3_14
    October 19, 2013 at 8:08 pm

    I was very disappointed with this interview. It seems like Robb and Dr. P. hadn’t talked at all prior to the interview to establish the level of sophistication for the interview. As a result, Dr. P. brought almost no information to light that the majority of Robb’s audience didn’t know. I expected Dr. P. to focus squarely on the neurological disorders caused by a high-carb diet, explaining more of the work of Dr.s Fasano (already interviewed by Chris Kresser) and Hadjivasilou. In fact, I learned more from Robb (that Dr. Atkins was stripped of his license twice) than from Dr. P.

    Dr. P. also committed the sin of conflating association with causation. Some of the studies he mentioned are observational, meaning you cannot draw causal inferences from them; only clinical studies can do that. The one clinical he he did cite, the A-to-Z study (the 2008 study he alluded to), has the methodological limitation of using food frequency questionnaires (as opposed to daily diet logs), which are notoriously inaccurate. To speak breathlessly about how these studies are enough proof to recommend new national nutritional policies is, at this point, hubris.

    His zeal also makes me skeptical in advance of reading his book, about the way he interprets the studies to bolster his assertions. The paleo/low-carb community has already suffered from the distortions of research by Dr. William Davis (http://tinyurl.com/9brtatz) and his promotion of the utterly discredited acid-alkaline balance theory. I hope that someone like Robb will do some fact-checking of sources to see if Perlmutter’s conclusions align with that of the studies.

    All that’s been demonstrated so far is that current the dominant medical nutritional paradigm is a castle built on sand. We need rock-solid clinical trials, like the ones NuSi is designing, before we can call the evidence more than suggestive. Even then, the trials have to disprove competing ideas, such as Guyenet’s hyperpalatabilty idea and Jaminet’s Perfect Heath paradigm before making sweeping recommendations.

    • Robb Wolf
      October 21, 2013 at 8:53 am

      So…in the mean time, we stick a thumb in our collective arses and…wait?

      • Kirby
        November 18, 2013 at 1:18 pm

        Good call; I’m living on twinkies and orange juice until Dr. P cites a double blind, placebo controlled study.

  41. Kirby
    November 18, 2013 at 1:20 pm

    Wow, just listened to this for the first time. What a rich interview. You can tell Dr. Perlmutter really cares – in addition to being brilliant. It was really touching hearing him recount meeting Mrs. Atkins.

    My grandfather died this past month from a two year nursing home stay due to Parkinson’s (half of that stay entirely bedridden). I hope people really catch on so we can stop putting people and their families through that type of loss.

  42. Philip
    November 23, 2013 at 11:07 am

    @jake3_14 I share your concerns, particularly the references he quotes to provide proof. They don’t in my view either. On the other hand his message is strong and appealing to the public. Clinically, he is describing LC health improvements without too much hype and the collateral surprise benefits: reduced depression, insomnia and inflammation, and in my own clinical experience reduced medications, pain and joint symptoms.
    His goals are also very appealing for LC community and health professions: “enlarge the box” and a “call to action.” That’s where I am: where can I implement programs and processes to change lives with what we know right now? #1 Where is the largest concentration of ALZ dementia? nursing homes. What can I do to change their diet? I am searching for champions of change in business and medical organizations whom I can persuade to change their paradigm.
    He is not perfect in his methods but he does carry the LC message another step higher in public awareness and personal action. Call me Dr. Quixote.

  43. Janeway
    December 1, 2013 at 2:47 pm

    The interview was provocative enough to me that I downloaded his book and have been reading it. I am disappointed to learn that Dr. P. is associated with the Dr. Oz show as a “medical advisor.” IMO, Dr. Oz is responsible for some of the worst fake nutritional information around. The Oz connection reduces Dr. P.’s credibility for me.

    I visited Dr. P.’s website and was surprised to note that he believes it’s possible to be both low-carb and vegan. He says there that “a vegan diet can be wonderfully healthy” as long as one takes various supplements, ingests extra coconut and olive oil and limits their carb intake to specific foods. How exactly can one eat carbs and not eat carbs at the same time, and still avoid the neurological disorders that Dr. P. states will likely befall those who do not heed his warnings about carbs? Are all carbs not created equal? His book (so far) doesn’t imply this.

    I’m also a bit confused as to why Dr. P. doesn’t think any human beings ate a lot of fruit over the last 2 million years. Does he assume that every Paleolithic human being lived in temperate climates? What about the tropics? There are people for whom wild fruit is literally hanging off the trees waiting to be picked. Was all this stuff cultivated at some point? Show me the evidence and I’ll consider it.

    I applaud Dr. P.’s work with folks suffering from severe neurological disorders and would like to take his general message about eliminating carbs more seriously, but he seems to be somebody whose work needs to be carefully scrutinized.

  44. Jose Fuentes
    May 11, 2014 at 9:20 am

    When considering our evolutionary Paleolithic diet, it makes sense that AGEs are caused by glycation of starchy sugars, denatured proteins and oxidized fats. It stands to reason that early humans avoided starchy foods until they learned to cook them – and there begins the problem: heat denatures protein and oxidizes fats.
    Early humans who, more than likely, scavenged their foods from the leftover kills of more able predators, had to eat the bone marrow and brains encased in skulls because they were the “slim pickings” available to them. When human babies breastfeed, they consume fats, proteins, and sugars at an ideal temperature that promotes healthy brain development. Therefore, shouldn’t we eat our fats and protein as raw or uncooked as possible to avoid glycation in the first place? And, since that may not be practical, what are the best sources of raw saturated fats and denatured protein available?

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