Longevity Expert: "If You Avoid This, You're Protected From Brain Decline, Disease & Inflammation"

1. 0:00 – 2:11

   Brain health is body health: breaking the false split

   1. RCDr. Rangan Chatterjee0:00

      I think about the fact that you're a neurologist, and I think about brain health, and I think you're widely known all over the world now for advising people on diet and lifestyle, how they can better live their lives. Yet I still think there's a lot of people out there who don't see the link between the health of their brains and their lifestyle.

   2. DPDr. David Perlmutter0:21

      Yeah, we, we still labor through this dichotomy between the health of the brain and the health of the body as if it is, uh... there's some division. And, you know, this gets back to Descartes and the whole notion of systems and, you know, looking at the body as a, a machine, the brain being the computer, the heart is the pump, the lungs are the bellows, and there should be no interaction. And, you know, the reality is the body functions as an integrated whole. Uh, the notion that there is a, in America they call it a heart smart diet, as if what's good for the heart might not be so good for the brain, for the rest of the body, might not be so good as it relates to cancer risk reduction. The reality is that we are still doing the very best we can to refine our messaging for the health of the entire body, including the brain. The brain is an, a fundamental part of the whole. And, you know, even the notion, taking it further, of the idea that bacteria live upon us and within us and are intimately related to, uh, our moment to moment health and ability to resist disease is difficult to embrace even with all the new, uh, exciting research coming out about the microbiome.

   3. RCDr. Rangan Chatterjee1:35

      Yeah.

   4. DPDr. David Perlmutter1:36

      We want to believe that body systems are segregated. We have the development of cardiologists and neurologists and pediatric neurologists dealing with the young brain, and, uh, we see higher, higher levels of specialization. But the reality is it's very important to take a step back from the forest and realize, uh, that even as it relates to our role, uh, on the planet, you know, man did not weave the web of life, he's merely a strand of it. That's a quote from Chief Seattle. So we're, you know... we've really got to realize that everything is integrated.

2. 2:11 – 4:17

   Is it better to add healthy foods or remove harmful ones? Perlmutter’s focus on fructose

   1. RCDr. Rangan Chatterjee2:11

      Yeah. Of course, food is something that you've written many books about what kind of foods help support our health, which kind of foods potentially take away from our health. In your view, with all your experience, is it more important for us to focus on foods to take out of our diets or foods to introduce?

   2. DPDr. David Perlmutter2:36

      That's a tough question. A lot of my work these days is taking the fructose out of the human diet.

   3. RCDr. Rangan Chatterjee2:42

      Mm.

   4. DPDr. David Perlmutter2:43

      Uh, I, I have put myself in a place in very recent years of focusing on the notion of evolutionary environmental mismatch. What does it mean? It means that our environment and what we expose ourselves to in the modern world in terms of food, in terms of other aspects of our day-to-day existence, is deeply in contrast to what our genome would best be served by. We evolved over hundreds of thousands of years under a fairly static set of circumstances. Suddenly, in the blink of an eye, those circumstances have changed, and our genome has not had a chance, uh, to adapt. So we are living with a Paleolithic genome in a very, very industrialized type of environment-

   5. RCDr. Rangan Chatterjee3:34

      Yeah

   6. DPDr. David Perlmutter3:34

      ... uh, and there's this, a huge mismatch. You know, I, I, I... and I say that's become sort of my watch word in terms of focus as of late, but I wrote a paper on this topic half a century ago-

   7. RCDr. Rangan Chatterjee3:47

      Wow

   8. DPDr. David Perlmutter3:47

      ... publishing it, uh, in the, in, in the Miami Herald, our local newspaper, when I was 16. And I called, uh, at the end of that, uh, missive, uh, the question, uh, what about those of us living today with the outdated machinery? Meaning that we are more suited to a different environment. So we're not gonna change part one, the evolutionary part. We're not going to anytime soon be able to influence, uh, the, the code of

3. 4:17 – 6:38

   Food as a biological signal: the ‘eternal summer’ problem

   1. DPDr. David Perlmutter4:17

      our genetic legacy, but we can certainly look at the other side of the balance beam, the, uh, environmental part, and that speaks to your question about food. And I think that clearly the input, uh, of food in terms of that relationship is vast. As such, we look upon food not just in terms of the macronutrients of protein, fat, and carbohydrates or the micronutrients of minerals and vitamins, but we look upon food as an information cue. Food is a powerful indicator to our bodies as to what we should be expecting right now and, even more importantly, what is to come. Food tells our bodies to prepare for food scarcity, to prepare for winter. Uh, it tells our bodies that now it's time to stop storing fat and to activate various pathways, uh, that allow us to burn fat as fuel and stop making glucose. But that relationship, that signaling pathway, is now, uh, you know, facing an accelerator, the likes of which we have never imagined. Basically, what I'm saying is we are day in and day out stimulating a signaling pathway telling our bodies to prepare for food scarcity, uh, for winter, basically, but that winter will never come.

   2. RCDr. Rangan Chatterjee5:41

      The eternal summer.

   3. DPDr. David Perlmutter5:43

      That's right. That sounds actually pretty good though.

   4. RCDr. Rangan Chatterjee5:46

      You're right. An endless summer sounds good, right? For enjoyment, for sun, for heat, but actually there's a very detrimental consequence for our bodies, our brains, our whole physiology if we live in a state of eternal summer. You mentioned a couple of things which really, um, grabbed my ear. Food is information, right?If I think about the general public, whether it's in the UK, in the US, many countries around the world, food is still not seen as information. People think of food, as you say, as calories or, you know, how much fat is there? How much protein? How many carbs? And I think that's such a reductionist way to look at food. You've also mentioned fructose.

   5. DPDr. David Perlmutter6:30

      Mm-hmm.

   6. RCDr. Rangan Chatterjee6:30

      What is fructose? Where does it live? And why are you so keen to help people get it out of their diets?

4. 6:38 – 9:18

   Why humans crave sweet: hardwiring exploited by modern manufacturing

   1. DPDr. David Perlmutter6:38

      Uh, I, I don't think people are keenly aware basically about anything related to their foods when you, when you think about it. When you walk around London, as I did today, uh, and people are walking and eating, uh, there's no real connection with the foods that they're eating, that the next bite is being prepared while the, the current bite is being chewed, and there's really no connection. And, uh, we eat what we're told to eat and what becomes available to us, and, uh, marketing has captivated us, knowing full well that each and every person on this planet has a sweet tooth. While you, you know, Rangan would like to deny it, and David Perlmutter would like to deny it, we have as part of our hardwiring-

   2. RCDr. Rangan Chatterjee7:20

      Yeah

   3. DPDr. David Perlmutter7:20

      ... a survival mechanism to trend towards sweet. Sweet tells us two important things. It tells us that the food is safe and that the food is, uh, good for us because it tells us winter is coming and basically allows us to make and store fat.

   4. RCDr. Rangan Chatterjee7:36

      Why does it tell us it's safe?

   5. DPDr. David Perlmutter7:38

      Uh, because basically there is no food on the planet that is sweet and is toxic, at least in terms of nature.

   6. RCDr. Rangan Chatterjee7:44

      In nature [laughs] , yeah.

   7. DPDr. David Perlmutter7:45

      In nature, that's for sure. Uh, that's ve- a very interesting paradox, isn't it?

   8. RCDr. Rangan Chatterjee7:49

      Yeah.

   9. DPDr. David Perlmutter7:49

      That nowadays the toxic foods are in fact sweet. Uh, but it plays upon us because our hardwiring says, "Eat that food. It is sweet. It is safe, and it's the right color."

   10. RCDr. Rangan Chatterjee8:00

       Yeah.

   11. DPDr. David Perlmutter8:00

       You know, in nature, by and large, red foods, for example, have traditionally been threatening. Nowadays, red dye added to things and, you know, the gummy bears are certainly, uh, perfectly fine seemingly. But we've totally lost our connection, which wasn't something actually humans ever thought about. Humans didn't think about eating particular foods because it would prepare their bodies for a type of stress like food scarcity. It just, uh, happened as part of our evolution and was a pow- a powerful survival mechanism.

   12. RCDr. Rangan Chatterjee8:34

       Yeah.

   13. DPDr. David Perlmutter8:34

       And, and it takes us to a place of, of understanding how our evolution has cultivated those behaviors that we have that make us crave fat, salt, and sweet as survival mechanisms. Those ideas of adding more salt and fat and sweet to manufactured foods, what a concept, manufactured foods, preys upon us. It preys upon our hardwiring and makes us gravitate to, uh, to those foods, eat way more of them than we should, and explains, in my opinion, the global, uh, explosion in terms of rates of overweight and obesity and all of the metabolic downstream issues that we are now seeing.

5. 9:18 – 12:07

   Fructose 101: fruit vs juice/soda and the uric acid pathway

   1. RCDr. Rangan Chatterjee9:18

      Yeah. So fructose. Uh, your, your latest book, Drop Acid, is a really quite wonderful read, very eye-opening read, lots of things in there relating to uric acid that I'd certainly not come across. Um, so I definitely wanna talk about that. But what exactly happens in the body when we consume fructose?

   2. DPDr. David Perlmutter9:42

      Well, fructose is so named because it came from fruit sugar. We find fructose in nature. We find it in fruits and vegetables, and typically, we would find higher levels of fructose in the foods that we would consume in the later summer, early fall as they would ripen. And the, the process of ripening is a process whereby carbohydrate is break... is broken down into sugar, making food more sweet and therefore more delectable, more palatable, and certainly more sought after by us now and certainly by our ancestors as well. And, and what happens when we consume fructose, uh, in the amounts we would consume by eating an apple or two or some grapes, is we get a small amount of fructose packaged with dietary fiber-

   3. RCDr. Rangan Chatterjee10:34

      Mm

   4. DPDr. David Perlmutter10:35

      ... to slow its release into the body, packaged with vitamin C to actually, uh, help our bodies excrete something called uric acid, packaged with bioflavonoids to reduce the formation of uric acid. So now I've mentioned the entree to uric acid and why that's so important. Uric acid is made from fructose. When we eat fructose, our bodies metabolize it, uh, into uric acid. Now, that's generally once the liver has exceeded its ability and the small intestine has exceeded, uh, its ability to deal with that fructose. We rely upon the small intestine to deal with that first five grams of fructose that we may consume by consuming the apple, not the 36 grams of sugar in a glass of orange juice or apple juice, not the 36 grams of sugar that are found in 12 ounces of soda, for example, soft drinks. That overwhelms the small intestine's ability to deal with its maximum five or six grams of fructose. That fructose then makes it way to the liver, and that begins a cascade that threatens our health. It was a survival mechanism in that that, uh, overrunning of fructose from the small intestine and getting into the liver told our bodies, "Hey, stress is coming. You're going to be food deprived, calorie deprived. Winter's coming. You need to make fat." And that was a challenge for our ancestors.

6. 12:07 – 17:29

   The evolutionary story: loss of uricase and the survival advantage of higher uric acid

   1. DPDr. David Perlmutter12:07

      And we can take our story back 15 million years-

   2. RCDr. Rangan Chatterjee12:11

      Yeah

   3. DPDr. David Perlmutter12:11

      ... to our primate ancestors who faced a very... powerful threat to their existence during what is called the middle Miocene period. And what happened during that period is the Earth slowly cooled over a million years.

   4. RCDr. Rangan Chatterjee12:26

      Wow.

   5. DPDr. David Perlmutter12:26

      Something that we can't really grasp. We can't grasp timeframes like that when we consider that agriculture began 14,000 years ago.

   6. RCDr. Rangan Chatterjee12:35

      Wow.

   7. DPDr. David Perlmutter12:35

      Anyhow, so the Earth became cooler. Our primate ancestors, some of them developed a superpower, and what was that superpower? They made a little bit more fat, a hedge against caloric restriction, allowing them to survive and propagate. They passed on their genome that had within it a change. What was the change? There was a change in the genes that coded for an enzyme called uricase. Now, the loss of the uricase enzyme meant that their uric acid levels would be a little bit higher, and that was the whole ballgame right there. Because they had higher uric acid values, it clued their bodies in to make and store more fat. It told their bodies, "Make more blood sugar," to power their brains through what we call gluconeogenesis in the liver. It caused their bodies to raise the blood pressure just a little bit as a hedge against dehydration. These were the ancestors that survived and passed on that uricase mutation to you, and to me, and to everyone walking the planet. So we, as Homo sapiens, have within us a predisposition for higher levels of this alarm system called uric acid. When our uric acid levels are elevated, it's telling our bodies, "Make that fat. Store that fat. Lock it away. Turn on the production of glucose in the liver so that your blood sugar goes higher. Become more insulin resistant." All of those things were wonderful during our ancestral times, survival mechanisms. Now you, and I, and everybody involved in preventive medicine is doing everything we can to help our patients become less insulin resistant, less, uh, overweight, uh, let's certainly avoid obesity, keeping blood pressure in check, reducing triglycerides, uh, and all of the things that characterize the metabolic syndrome, the harbinger for these chronic degenerative conditions which the World Health Organization tells us are the number one cause of death on our planet.

   8. RCDr. Rangan Chatterjee14:52

      Yeah, it's really quite profound. There's so much there, David. In what you said, the first thing that comes to mind is One of the most important pillars for our health is, of course, nutrition. But I think because of our busy, stressed out lives, so many people are struggling despite their best intentions. So many patients over the years have told me that they know what they should be doing [laughs] , but they're struggling to actually do it, and that's why I'm a fan of AG1. AG1 is a daily health drink that contains over 70 vitamins, minerals, and other ingredients that are designed to make nutrition really easy. It's been in my own life for over six years now. It's simple, it's tasty, it's convenient, and it forms a part of my morning routine. People will routinely tell me that taking AG1 regularly has improved their focus, their cognition, their energy. Some people even tell me that they drink less coffee when they're taking AG1. And there's research out there showing us that taking AG1 regularly can improve specific markers of your gut health, which is really good for your immune health. So if you're looking to upgrade your own nutrition in a simple, tasty, and convenient way, try AG1. To get a free bottle of vitamin D and five free travel packs, go to drinkag1.com/livemore. This idea that this was a very helpful adaptation. This actually helped us survive, this helped us thrive when the environment around us was different. So helpful years ago, incredibly unhelpful when we have food abundance. And I think the second point for me that's really interesting is that it was actually those who had that adaptation, they're the ones who actually survived. So all of us are descendants of the people who survived, so presumably most of us [laughs] certainly will have that adaptation. So I find that really interesting. In terms of food, so to be super practical for people-

   9. DPDr. David Perlmutter17:01

      You bet

   10. RCDr. Rangan Chatterjee17:02

       ... a lot of people, they hear terms like fructose, sucrose, sugar, carbs, and I think it gets confusing for people. So in real practical terms, if someone's trying to improve their health, improve their brain health, their metabolic health, their heart health, as if these things are all separate things [laughs] , of course they're not, fundamentally improve their metabolic function in the body, what specific foods relating to this should they be thinking about?

7. 17:29 – 25:33

   Practical guidance: hidden sugars, HFCS, and the ‘whole foods’ default

   1. DPDr. David Perlmutter17:29

      It, it's a wonderful question. It does get back to, uh... And I think I kinda danced around your question earlier about which is more important, eating foods that are good for us or avoiding those foods that are bad for us? This is the hidden killer, and the notion that, uh, we're gonna find all the fructose in our foods is, to be kind, very, very challenging. Because, you know, i- in America, that, uh, sugar, it goes by 60 or more different names, that food manufacturers are able to use alternative names, uh, for the fructose or sugar that they add to their products. It's still sugar nonetheless, though it's dis- been disguised, and they get away with it. So you really, even as a conscious consumer-

   2. RCDr. Rangan Chatterjee18:13

      It's very hard

   3. DPDr. David Perlmutter18:14

      ... yeah, you can rely on your taste budsAnd the only time you'll get fooled is when there are artificial sweeteners that will trick you into thinking that a food is sweet.

   4. RCDr. Rangan Chatterjee18:23

      So if it's sweet, it's likely to have sugar in it?

   5. DPDr. David Perlmutter18:27

      Yeah.

   6. RCDr. Rangan Chatterjee18:27

      It's likely to have fructose in it?

   7. DPDr. David Perlmutter18:28

      You bet. And, and to, uh, be more specific, uh, the types of sugar. So table sugar is, is sucrose, and that is a, a joining of two types of sugar: fructose, which we're talking about, and glucose. People are familiar with glucose. And rapidly upon consumption of table sugar, uh, an enzyme breaks those two apart. Glucose is dealt with in an entirely different way. Uh, glucose is the energy sugar, and fructose is the, a storage form of sugar, if you will, because fructose immediately tells our bodies, "Make fat."

   8. RCDr. Rangan Chatterjee19:02

      Mm-hmm.

   9. DPDr. David Perlmutter19:02

      So fructose is kind of the long-term survival depot instigator of preparing us for, for long-term, uh, fat accumulation. Uh, and but nonetheless, even table sugar becomes a threat with reference, uh, to the fact that it's 50% fructose. Now, if that weren't bad enough, we now have, since developed in 1958, but really making its way onto our plates at a theater near you, uh, in the early 1970s, something called high-fructose... What does that mean? That should scare you right off the bat. High-fructose corn syrup, and this was developed, uh, in America, what can I say, University of Oklahoma in 1958, and, uh, became a way to create this very, very sweet substance. Fructose is by leaps and bounds far sweeter than glucose, so that in the manufacturing of f- of food, I love saying that because it's so perverse, uh, manufacturers are able to use this high-fructose corn syrup and make food sweet at a lower cost because they don't have to use very much.

   10. RCDr. Rangan Chatterjee20:08

       Mm-hmm.

   11. DPDr. David Perlmutter20:08

       And at least in America, the growth of corn from which high-fructose corn syrup is derived is subsidized by the government. So the very government that is issuing these health proclamations trying to keep people healthy is subsidizing the growth of corn to be turned into high-fructose corn syrup, which is thematically our most dangerous health threat well beyond tobacco. So, you know, this is a global issue.

   12. RCDr. Rangan Chatterjee20:39

       Wow.

   13. DPDr. David Perlmutter20:39

       Yeah. It becomes very real, and I wrote an op-ed to President Biden, published, uh, February 21st, 2021, in a, uh, something called, um, MedPage Today, and really just called to attention the fact that our United States Department of Agriculture that issues edicts as it relates to what we should be recommending for as healthcare practitioners and what is the government's position on food, they said, "Hey, 10% of your calories from sugar, that's cool." And, uh, there's no science that would support that. The science would indicate that anything over 5% of your calories coming from sugar begins to threaten your health, increases uric acid, increases your risk, uh, for type 2 diabetes, obesity, hypertension, all the downstream things that we've talked about. And yet, um, here is the government recommendation being so influenced by industry that wants to sell us high-fructose corn syrup. So in many ways, we have to be the sentinels who stand up and do our very best if there's a listening ear to get the information out there, "Hey, not necessarily in your best interest. Here's what really matters," and that is focus on whole, unprocessed, unpackaged foods. If you choose to eat meat, that's totally... You know, uh, everything you eat is obviously gonna be your decision. But there's a move these days toward a what is called carnivorous diet or carnivore diet, meaning ea- eating basically all meat and all animal products. And plenty of discussion about that would indicate that, you know, probably the biggest flaw in that is the avoidance of a specific type of carbohydrate called fiber. So we need those carbs from fiber to nurture our gut bacteria and, of course, the various vitamins and minerals that plants provide. I am not a full-on vegetarian or vegan. Uh, I do eat animal products. But the, the, the importance of carbohydrates in the context of our discussion today of sugar, in that sugar is a carb, I think is really very important because, you know, people who wanna be involved in eating less carbohydrates, by all means don't avoid the fiber. If you w- you certainly wanna avoid refined carbohydrates, especially if you're trying to become, uh, you know, get your body into what's called ketosis, uh, as I'm sure you just talked to Dr. Valter Longo about, uh, what wonderful work that he is doing as well, the fasting-mimicking diet. Uh, there are certainly benefits to that. But the key is that, you know, this fructose has invaded our diets globally. We used to say the standard American diet, S-A-D, SAD, and then that became kind of the Western diet. Make no mistake about it, it is the global diet-

   14. RCDr. Rangan Chatterjee23:37

       Yeah

   15. DPDr. David Perlmutter23:37

       ... uh, that this insinuation of sugar into the foods, and I use that term loosely, uh, that people are consuming is tragic.

   16. RCDr. Rangan Chatterjee23:47

       It, it, it is the global diet. It's interesting. I was just chatting to Valter Longo, and when he went to America, I think around the age of 18, he noticed that a lot of his Southern Italian relatives, where he rarely saw heart disease, he rarely saw people getting sick, when some of them would move to America, he saw rapidly how their health would decline. And so this is many years ago when he could see a stark difference between where he's from in Southern Italy and America. And interestingly enough now, 'cause we were discussing this when he came on the show-He said he doesn't see much difference anymore

   17. DPDr. David Perlmutter24:23

       Yeah. And, uh, you know, what you just described, I think, again, recapitulates this, uh, evolutionary environmental mismatch. If, if it were purely an evolutionary thing, uh, then that wouldn't have changed when those individuals adopted a new lifestyle

   18. RCDr. Rangan Chatterjee24:39

       Yeah

   19. DPDr. David Perlmutter24:40

       And, you know, the uric acid story, I think, is best exemplified in that context by individuals in Polynesia and Micronesia who, until the mid-1800s, were lean and muscular and, uh, their cultures were, uh, such that there was even more pressure for higher levels of uric acid because they made these epic thousands of miles journeys in their dugouts basically, in, you know, boats that had, uh, outriggers and sails, and had to survive. Those that survived had higher uric acids. Introduce the Western diet and now rates of diabetes and obesity are amongst these individuals the highest on our planet. Uh, an incredible, um, manifestation of this evolutionary environmental mismatch

8. 25:33 – 31:13

   Carbohydrate nuance: sweet potatoes, fiber, CGMs—and a new metric (uric acid)

   1. RCDr. Rangan Chatterjee25:33

      Yeah. Before we go into the weeds of uric acid, because I'd really love to go there because I don't think it's widely known about at all this link. We've mentioned carbs and how important certain types of carbs are, fiber, you know, for our gut microbiome and all kinds of other reasons, and we mentioned sugar, sucrose, and I just wanna make sure that people understand. You said if something's sweet, it's likely to have fructose in it. So often people may think of whole foods like a sweet potato and think, "Well, you know, that's pretty sweet. I enjoy having that with my evening meal." Is that a problem, Dr. Perlmutter? And so can we just maybe with a bit of nuance there go into this field of carbohydrates? Uh, some helpful feed the gut microbiome, refined ones obviously can put our blood sugar up and cause all kinds of problems. Where does sucrose fit into this? There is sucrose in fruits, of course. There's sucrose in, you know, other natural foods. How can people sort of make sense of that when trying to make changes?

   2. DPDr. David Perlmutter26:41

      Uh, Rangan, it's a, it's a very, very good, uh, lead in because it, it really gets to, uh, an empowerment moment for all of your viewers to understand that they need to eat whole foods. Having a sweet potato, half a sweet potato or white potato is, is, is really pretty reasonable. Now, understanding that we've got a new tool in the toolbox, and that tool is understanding not just the effect of the foods we eat moment to moment on our blood sugars-

   3. RCDr. Rangan Chatterjee27:13

      Yeah

   4. DPDr. David Perlmutter27:14

      ... I see that you're using a continuous glucose monitor. What powerful technology is that that allows you to know this? But a new tool in the toolbox is knowing how foods affect your uric acid. Now, that's not necessarily best observed moment to moment, but over a period of weeks will change based upon the foods that you eat. And it turns out that it is uric acid that influences the blood sugar in the long run. That has a huge effect on insulin resistance. I'd love to have some time we can break that down, the actual mechanism-

   5. RCDr. Rangan Chatterjee27:46

      Please do, yeah

   6. DPDr. David Perlmutter27:46

      ... because it's, it's fascinating. But I think the best recommendation is vegetables that you buy in the periphery of the grocery store are fair game. Fruit, fair game. Even, uh, the animal products that haven't been modified are fair game. Now, to strengthen the argument, of course, we can add current technology like having your uric acid checked. You can do that at home or, or at the doctor's office, and following your blood sugars as well. But if the foods that you are consuming are triggering an alarm system that tells you that winter is coming, you've got a problem and you've gotta deal with it because, um, you know, it-- your healthcare practitioner may or may not be dialed into this whole idea of keeping you healthy. Now, that's challenging be- but by and large, healthcare systems here in England, in my country of the States, and generally in Western countries are involved in dealing with you once you're sick. So they should more rightfully be called sickness care systems. They will look at your blood sugar and act once the blood sugar, once the uric acid, once whatever metric, uh, we are looking at, whether it's, uh, lipids, triglycerides, body weight, once these, uh, things are out of the so-called normal range. Our interventions need to take place prior to them even be- being considered interventions, but lifestyle changes need to be initiated to keep people healthy in the first place. What, uh, what a notion. That's the best economics we could talk about. It's the right thing to do as a healthcare provider from a compassion perspective. And, you know, the fourth-century Yellow Emperor once said that, "Prevention is the ultimate principle of wisdom. To cure a disease after it has manifest is like digging a well when one feels thirsty or forging weapons when the war has already begun." Think of that last sentence, forging weapons when the war has already begun. What do doctors do? Um, I gave a lecture several years ago in New Jersey to a group of mainstream doctors. I asked the audience, I says, "Well, what's your best... Let's go around the room. What's your best treatment for diabetes?"

   7. RCDr. Rangan Chatterjee30:03

      Sorry to interrupt. If you're enjoying this video and want to dive deeper into the topic of nutrition, I have created a free special guide which contains the five most important changes I think we all need to make when it comes to our diet. If you wanna get hold of this free guide, all you have to do is click on the link in the description box below

   8. DPDr. David Perlmutter30:25

      The hands went up, you know, sulfonylurea drugs, perhaps metformin, uh, and all of these things. And, uh, and I said, "You know, basically, no one has mentioned a treatment for diabetes as yet, and I can prove that to you by asking you one simple question. What happens when you stop that medication?" "Oh, well, Doctor, the blood sugar will go up very rapidly, uh, indeed." So you never treated anything. You didn't treat the underlying problem. We don't have a pharmaceutical treatment for diabetes. We don't have a pharmaceutical treatment for hypertension, for that matter. The point is that, you know, we can talk about reversing the underlying disease process by lifestyle interventions. Uh, we've, we've seen how a ketogenic diet can help people stop from being Type 2 diabetic-

   9. RCDr. Rangan Chatterjee31:12

      Yeah

9. 31:13 – 35:03

   Inflammation, the brain, and decision-making: amygdala vs prefrontal control

   1. DPDr. David Perlmutter31:13

      ... and come off of hy- antihypertensive medications as well. That's treating the problem. But even beforehand, you know, we certainly wanna be giving people, to answer your question, those tools about the foods that they consume to get out of harm's way early on before there is an- there is any harm, before the clouds are brewing on the horizon. We're consuming a very pro-inflammatory diet now globally, and our decision-making ability really stems from two unique areas of the brain. On the one hand, we have amygdala-based activity that is impulsive, compulsive, and self-centered, non-empathetic.

   2. RCDr. Rangan Chatterjee31:54

      Mm.

   3. DPDr. David Perlmutter31:54

      Not even empathetic to my future self, and certainly not empathetic to you, to the planet, to others around me. On the other hand, we have the ability to make decisions based upon tapping into our human gift, which is this prefrontal cortex. The prefrontal cortex is the adult in the room. It exercises what we call top-down control over the amygdala five-year-old that would have things that it wants right now, damn it. I want that sweet cake. I wanna stay up late. Whatever the, the child wants. I don't care about anybody else. Fortunately, our prefrontal cortex is the adult in the room and helps us make more measured decisions. This top-down control that reigns in the child is connectivity. It's actually, it, it's called the anterior cingulate cortex. We need this top-down control. We need the connectivity to the adult in the room. Inflammation severs the control. Inflammation severs the ability that we have to make good decisions. Inflammation is brought out by or amplified by our modern diet that's so high in refined carbohydrates. So globally, we are becoming more impulsive, less compassionate, less empathetic individuals, and it fosters a lot of what we see going on around us in the world today.

   4. RCDr. Rangan Chatterjee33:24

      Everyone wants to be able to make better decisions for all aspects. A business leader wants to make better decisions-

   5. DPDr. David Perlmutter33:31

      Yeah

   6. RCDr. Rangan Chatterjee33:31

      ... for their work. Uh, a parent wants to make better decisions for their life and their children's life. Um, we all individually wanna make better decisions for our health. And you mentioned how inflammation, this chronic unresolved inflammation that many of us are facing these days because hugely from our lifestyle, whether that be poor diets, insufficient movements, sleep deprivation, chronic stress, whatever it might be, you've just said that that chronic inflammation is affecting the way we make decisions, so in many ways, it's actually affecting the way we see and view the world.

   7. DPDr. David Perlmutter34:11

      Exactly. And it-

   8. RCDr. Rangan Chatterjee34:12

      But that's profound

   9. DPDr. David Perlmutter34:13

      ... it, it, it relates back to the foods that we eat. Those pro-inflammatory foods change the way we see the world around us.

   10. RCDr. Rangan Chatterjee34:23

       So this goes beyond health. Of course, as medical doctors, we're passionate about helping people with their health, but this is for happiness. This is for harmonious relationships. This is for, I guess, a healthy and happy life. It's not just health-based. This is everything.

   11. DPDr. David Perlmutter34:41

       That's right. And, uh, I would hope that people, uh, would maybe rewind to this past five minutes and really-

   12. RCDr. Rangan Chatterjee34:51

       Mm

   13. DPDr. David Perlmutter34:51

       ... see what just happened, and that is the relationship then between our lifestyle choices, how we see the Earth, and therefore the future o- of our existence.

   14. RCDr. Rangan Chatterjee35:02

       Yeah.

10. 35:03 – 38:13

    Mechanisms: serotonin diversion, oxidative stress, and uric acid as an inflammatory amplifier

    1. DPDr. David Perlmutter35:03

       That's what's going on. That's the real, uh, what's really behind the curtain here. Inflammation affects our decision-making and how we see the world, not just through this threat to the connection between our higher self, the prefrontal cortex, and the amygdala. Uh, inflammation acts, and this is a little bit more, uh, mechanistically by threatening, uh, the production of serotonin within our bodies. When we have higher levels of inflammation, we're not as able to make that important neurotransmitter serotonin from its precursor amino acid tryptophan because that pathway that allows that to happen is shifted away to producing something else called kynurenic acid, which ultimately becomes something called quinolinic acid, which is a powerful pro-oxidant threat-

    2. RCDr. Rangan Chatterjee35:53

       Mm

    3. DPDr. David Perlmutter35:54

       ... to the survival of our brain cells. So not that inflammation is always a bad thing. In the right context, we need inflammation. Were it not for inflammation-

    4. RCDr. Rangan Chatterjee36:05

       Yeah

    5. DPDr. David Perlmutter36:05

       ... we couldn't survive. But it's this overwhelming experience with inflammation, uh, that underlies all of our chronic diseases that we need to really get our arms around. Um, you know, people are familiar with the, the cytokine storm, uh, that is a characteristic of a bad outcome in SARS-CoV-2 infection. Equally, havingFor a protracted period of time, elevation of inflammation, let's call it the cytokine drizzle then, not a storm, but the drizzle, uh, is threatening.

    6. RCDr. Rangan Chatterjee36:37

       Yeah.

    7. DPDr. David Perlmutter36:37

       Uh, this chronic mild upregulation of inflammation, uh, underlies coronary artery disease, diabetes, uh, certainly Alzheimer's, for which we have no meaningful treatment. And make no mistake about it, one of the central mechanisms whereby elevated uric acid is so threatening is because it enhances inflammation, uh, in the human body. Uh, that probably was a survival mechanism. That slight bump in inflammation that it connoted for our, uh, our ancestors allow them to be less likely to be devastated by an infection, for example. You know, this... There are so many facets, getting back to uric acid, including upregulation of the formation of reactive oxygen species, uh, free radicals, uh, if you will, oxidative stress perhaps, if you will. Increasing, uh, insulin resistance, elevating blood sugar, um, increasing lipogenesis, the creation of fat-

    8. RCDr. Rangan Chatterjee37:38

       Mm-hmm

    9. DPDr. David Perlmutter37:38

       ... uh, compromising mitochondrial function, reducing autophagy, uh, taking us away from this pathway called AMP kinase that we so desperately wanna activate. That pathway that tells us the hunting is good. Don't make more fat. Don't raise your blood sugar. We wanna do all we can to activate that pathway, this AMP kinase pathway. That's why we exercise. It's what the drug metformin does. Uh, but uric acid says, "No, no, no. We need to prepare you for hibernation. We need to increase inflammation. We need to threaten your brain."

11. 38:13 – 41:02

    From gout to metabolic syndrome: uric acid as a ‘central player’

    1. RCDr. Rangan Chatterjee38:13

       Yeah. When people hear uric acid, when medical doctors say uric acid, we probably think about gout. So what's going on there? Why is uric acid related to gout, and then what's the relation to everything else that-

    2. DPDr. David Perlmutter38:30

       Sure

    3. RCDr. Rangan Chatterjee38:30

       ... you're talking about?

    4. DPDr. David Perlmutter38:31

       Well, you're ex- exactly right. And when you were in medical school, half of one lecture was high uric acid, gout, give the drug. Perfect. Problem solved, right? But how it often is in human physiology is things are, are multipurpose, and we learn that uric acid was for gout or maybe kidney stones. Uh, but we now know that uric acid throws a much wider net, and when it's elevated, uh, it sets the stage for dis- disruption of our metabolism. Uh, that was only recently described in 1898. Recently, right? 1898, Dr. Alexander Haig wrote a book in which he looked at the-

    5. RCDr. Rangan Chatterjee39:17

       Wow

    6. DPDr. David Perlmutter39:17

       ... manyfold, uh, issues related to elevated uric acid. In his case, headache, but he also looked at dementia and depression and skin issues. Uh, and that information was really quite, uh, under the radar until about two decades ago when Japanese researchers and then Turkish researchers and ultimately American researchers and British researchers began to realize that while the elevation of uric acid was long known to be correlated with, uh, various metabolic problems like high blood pressure, high blood sugar, it began to be unraveled as not just being correlated, but causative. And in fact, one paper written in 2016, a collaborative paper by Turkish and Japanese researchers, was called Uric Acid in the Metabolic Syndrome: From Innocent Bystander to Central Player. Meaning it's not just there, but it's actually involved in mechanistically causing these problems. Now we've seen one study was published three weeks ago that recapitulated what the findings were in the 2016 study. And there are multiple mechanisms-

    7. RCDr. Rangan Chatterjee40:30

       Wow

    8. DPDr. David Perlmutter40:30

       ... involved whereby elevation of uric acid does its dirty work in today's world. Wasn't dirty work for our ancestors. It was survival.

    9. RCDr. Rangan Chatterjee40:39

       Yeah.

    10. DPDr. David Perlmutter40:40

        But now we know pretty much, uh, fairly, uh, exactly how it does what it does, and now we know, for example, we see human research whereby blocking uric acid production using gout drugs, the very allopurinol that you learned about, using allopurinol lowers blood sugar, lowers blood pressure by lowering uric acid.

12. 41:02 – 46:29

    Testing and targets: ‘asymptomatic hyperuricemia,’ optimal ranges, and early action

    1. RCDr. Rangan Chatterjee41:02

       Yeah. I mean, this is so fascinating, right? So a lot of things to do with health are on a continuum, and often in medicine, we get involved very late on that continuum. You know, blood sugar, uh, metabolic dysregulation's been going on for years, and we say, "Normal. No problem. No problem," until, oh, boom, you've now got type 2 diabetes, without the recognition that this has been building up for five years, maybe 10 years in your body. All kinds of lifestyle inputs have been changing things. If we look at uric acid through that lens and let's say gout, is gout, for example, in people who are prone to it, downstream on that continuum? Like if you've... If you're having gout where your doctor's measuring uric acid, you're quite far down that path now. Uh, is it fair to say that? Is it also fair to say that many of us may well be, uh, walking around with suboptimal uric acid levels that we don't even know about because we don't suffer from gout?

    2. DPDr. David Perlmutter42:05

       That's right.

    3. RCDr. Rangan Chatterjee42:06

       So therefore our doctor's never ever gonna recommend we get our uric acid done. In the same way that we know that maybe above a certain age we should do our blood sugar once or twice a year. Are you at the point now where you think uric acid should be fitting into that same category?

    4. DPDr. David Perlmutter42:21

       Yes. The notion of having elevation of your uric acidBut no gout actually has, uh, has been given a, uh, a name. It's called asymptomatic hyperuricemia, meaning you've got elevated uric acid, but you don't have gout, so what's the problem? And, uh, it gets back to, you know, the, the, the normals versus the optimals. You, you hinted on that as well. The... In, in my country, the units are milligrams per deciliter, uh, for uric acid, and you're told that if your uric acid is seven or below, "Hey, you're fine. You're, you don't have gout. You... and everything's fine." But the cardiometabolic issues related to elevated uric acid begin at 5.5. That's what the scientific research is telling people, and the medical community is slow to adopt, slow to realize that these manifestations are happening, and they may not be necessarily issues that we will experience right now. When you have gout in your great toe, you sure as heck know that's going on. You, you don't need to, uh, have a doctor give you the wake-up call. But you don't necessarily have the appreciation of the fact that a uric acid level of 6.8 is related to the fact that your blood sugar is now el- elevated, that your blood pressure is, uh, slightly elevated, that you're having more and more difficulty losing weight. And that's why this is, is extremely, uh, valuable information. And for your viewers, how, uh, empowering it is that they know this and can take this information to their doctors and ask for a uric acid level, though she or he may indicate, "No need. You don't have gout." Well, it, it's a new world out there as it relates to this new important, uh, tool as it relates to our metabolism.

    5. RCDr. Rangan Chatterjee44:12

       Sorry to interrupt. If you are enjoying this content, there's loads more just like it on my channel, so please do take a moment to press Subscribe, hit the notification bell. And now, back to the conversation. On an individual level for you, David, as someone who is a leader in the field, who's been promoting a lot of these messages around the world for many years, how incredible is it to you, how amazing is it to you to go, "Wow, I've written some, I think, incredible books that have helped so many people, and I didn't know about uric acid"? Does it make you think, "What else is there? What else are we gonna learn in science-

    6. DPDr. David Perlmutter44:52

       Oh, my gosh

    7. RCDr. Rangan Chatterjee44:52

       ... that we don't know yet?"

    8. DPDr. David Perlmutter44:54

       Um, you know, aside from, um-

    9. RCDr. Rangan Chatterjee44:58

       Hey, guys, I really hope you're finding this useful. If you are and you want more content like it, please do check out my book, Make Change That Lasts: 9 Simple Ways to Break Free from the Habits That Are Holding You Back. It's in all the usual places as a paperback, e-book, and as an audiobook, which I'm narrating. Now, back to the video

    10. DPDr. David Perlmutter45:19

        ... the compassion part of, of my mission, uh, the alleviation of suffering, uh, the curiosity part is huge in my life.

    11. RCDr. Rangan Chatterjee45:30

        Yeah.

    12. DPDr. David Perlmutter45:30

        I love it. I love, uh, listening to a podcast and saying, "Why, that's fantastic." And that's what happened with uric acid, listening to a podcast a couple years ago, and it was, uh, an epiphany moment for me.

    13. RCDr. Rangan Chatterjee45:44

        Yeah.

    14. DPDr. David Perlmutter45:44

        Because, you know, like yourself, like you've written about over the years, you know, we've been telling people, "Hey, sugars don't, don't need to be in your diet. Uh, the human requirement for dietary sugars is zero grams per day. We should exercise. Pay attention to your sleep. Stress your body a little bit. Get out in nature. Form better relationships with others," all the things that we've been talking about. To have this totally new tool blindside me, uh, and it was there, I just hadn't been aware of it, was, uh... it was exciting and remains really exciting. 'Cause now, uh, people like yourself are getting this message and saying, "Whoa, there's a new tool here. There's a new, uh, there's a new sheriff in town," and it's really very, very exciting.

13. 46:29 – 54:44

    How uric acid connects to type 2 diabetes: nitric oxide and insulin resistance

    1. RCDr. Rangan Chatterjee46:29

       Can we say with certainty that if someone has type 2 diabetes, we know by definition they are insulin resistance, you know, they have a lot of these-

    2. DPDr. David Perlmutter46:38

       We can say that with certainty. That-

    3. RCDr. Rangan Chatterjee46:39

       We can say that with certainty. Sure.

    4. DPDr. David Perlmutter46:40

       Yeah, that part. Yeah.

    5. RCDr. Rangan Chatterjee46:42

       Can we say that it's almost certain that their uric acid will also be elevated, or are we not quite there yet?

    6. DPDr. David Perlmutter46:50

       Not... Uh, uh, we can be, uh... we can say that their uric acid levels will most likely be elevated, though I've seen some type 2 diabetics without an elevation of uric acid. But here's the reason, um, and there are multiple reasons, that type 2 diabetics have high uric acid. First of all, they are stimulating the pathway to make more blood sugar, the very pathway that metformin diabetes drug targets. So they're telling their bodies, "For survival, we need to make more blood sugar because we're not gonna have any food around. I need to power my brain so I can avoid two things, starvation and predation," meaning getting eaten by another animal. "I've gotta keep my brain going. Therefore, I need higher levels of blood sugar." But further, uric acid elevation, uh, actually inhibits a chemical, uh, called nitric oxide. We need nitric oxide to allow insulin to do its job. So not only does it directly foster the promotion of new blood sugar, it directly antagonizes the ability of insulin to lower the blood sugar. So, uh, that relationship to type 2 diabetes, uh, is profound. And it reminds me of where you and I were about seven minutes ago, and that was the situation where, you know, people don't know this until the doctor finally says, "Okay, now you're diabetic."

    7. RCDr. Rangan Chatterjee48:16

       Yeah.

    8. DPDr. David Perlmutter48:17

       "It's time to do something." Um-There are very few binary things truly in medicine

    9. RCDr. Rangan Chatterjee48:22

       Yeah

    10. DPDr. David Perlmutter48:23

        Pregnancy is one of them. You either are or you're not. Uh, but not so with being diabetic. You know, we have our cutoffs of a g- blood sugar of 126, whatever, or your hemoglobin A1C, but the reality is that the threats to your physiology, to your health happen at blood sugar levels far lower than it would take to get your doctor excited.

    11. RCDr. Rangan Chatterjee48:44

        Yeah.

    12. DPDr. David Perlmutter48:45

        In, in America, the, the... I don't know if you have direct-to-consumer advertising for drugs here.

    13. RCDr. Rangan Chatterjee48:50

        No. And then, and then, and I've got to tell you, having been to a lot of medical conferences in the US over the last eight, nine years, nothing shocks me more, because I'm not used to it-

    14. DPDr. David Perlmutter49:00

        Yeah

    15. RCDr. Rangan Chatterjee49:00

        ... than when I get there, I check into the hotel, and you just suddenly see this bombardment of pharmaceutical adverts-

    16. DPDr. David Perlmutter49:07

        Right

    17. RCDr. Rangan Chatterjee49:07

        ... on television. It's... When you're not used to it, you think, "What, what is this?"

    18. DPDr. David Perlmutter49:12

        I know.

    19. RCDr. Rangan Chatterjee49:13

        This is so bizarre.

    20. DPDr. David Perlmutter49:14

        And, and what it is, is hugely effective.

    21. RCDr. Rangan Chatterjee49:17

        Of course it is.

    22. DPDr. David Perlmutter49:18

        And it's, you know, again, it's a, it's a gross dramatization-

    23. RCDr. Rangan Chatterjee49:21

        We, we don't really have it in the same way here, that's for sure

    24. DPDr. David Perlmutter49:23

        Yeah, yeah. I mean, it's a gross dramatization of the influence, the insinuation of pharmaceutical into, uh, what makes-

    25. RCDr. Rangan Chatterjee49:32

        Yeah

    26. DPDr. David Perlmutter49:32

        ... the wheels go round. But, but having, having said that, we have commercials, uh, on television that diabetics are happy because their A1C is now below seven. Their average blood sugar is now below a number, seven, and they're looking into the camera saying, "I got my A1C below seven because I take XYZ drug." Well, there's nothing magical about getting your A1C below seven. The health threats begin at an A1C of 5.3-

    27. RCDr. Rangan Chatterjee50:03

        Wow

    28. DPDr. David Perlmutter50:03

        ... uh, and 5.4. Blood sugar measurements, you know, diabetes in our country, uh, measured at about 126, that's when you begin to worry because now you're diabetic. The threats to your, to your brain health begin at a blood sugar of 105, and that's, that's not new information.

    29. RCDr. Rangan Chatterjee50:21

        No.

    30. DPDr. David Perlmutter50:21

        That was published in 2013 in The New England Journal of Medicine. It's one of the main reasons. That publication alone, uh, really prompted me to write a book about blood sugar as it relates to the brain. That was Grain Brain. Uh, because, you know, people are under this misguided-
14. 54:44 – 1:01:13

    Closing advice: compassion, measurement, and ‘reconnection’ to make better choices

    1. RCDr. Rangan Chatterjee54:44

       Wow. I mean, it's incredible. There's a key message coming through in this conversation, but also in a lot of previous work that people may be familiar with of yours, which is keep an eye on fructose, keep it down. Excess sugar, be very, very careful. You don't need it. Of course, we all crave it [laughs] in differing amounts. We might as well be honest. You know, I do have a sweet tooth. As you said, you've got a sweet tooth, but we need that prefrontal [laughs] cortex online to help us not engage in that temptation as much as we might want to. And certainly for me, David, I know this is the same for many of my patients, I, like you, have written books on this subject. I know the science, but I know in the past when I've got stressed, when I've got too much on, if I'm sleep-deprived, I'm craving sugar, and I find it harder to resist in those moments. Uh, the difference now, having said that, is I'm very compassionate to myself now in those moments instead of beating myself up about, "Oh, I can't believe you did that." It's like, "No wrong in you. You're stressed at the moment. That's why. Maybe tomorrow, think about an earlier bedtime or try to mitigate your stress in other ways." So I think that's really important, not to go down the blame game and the guilt game.

    2. DPDr. David Perlmutter55:53

       That's right. Uh, and I am absolutely not perfect in my dietary choices either. Uh, and I, I value what you just said about the blame game. Um, but it's good to have the ability to metricize these important concepts-

    3. RCDr. Rangan Chatterjee56:08

       Yeah

    4. DPDr. David Perlmutter56:08

       ... i.e. measure uric acid-

    5. RCDr. Rangan Chatterjee56:10

       Yeah

    6. DPDr. David Perlmutter56:10

       ... know your, uh, your moment-to-moment blood sugar levels. Uh, and I think that, uh, that's one of the benefits of living in the times that we live.

    7. RCDr. Rangan Chatterjee56:19

       Yeah.

    8. DPDr. David Perlmutter56:19

       Uh, but you know, you mentioned how the, the morning following, uh, a poor night's sleep. Um, I remember being up all night, uh, in the operating room, uh, in, uh, my training, and then in the morning, we would go to the, in the hospital, the pediatric floor and get all the, um, the, uh, baby food-

    9. RCDr. Rangan Chatterjee56:40

       [laughs]

    10. DPDr. David Perlmutter56:40

        ... especially the banana baby food, and just slurp it down-

    11. RCDr. Rangan Chatterjee56:44

        Yeah

    12. DPDr. David Perlmutter56:44

        ... 'cause it was so high in sugar.

    13. RCDr. Rangan Chatterjee56:46

        Yeah.

    14. DPDr. David Perlmutter56:46

        A bad choice, but interestingly, what the research demonstrates is when you do what's called functional MRI scans of the brain in a person who's stayed up all night, their amygdala is 60% more active. Amygdala, again, the impulsivity decision-maker.

    15. RCDr. Rangan Chatterjee57:04

        Yeah, no, I've seen it

    16. DPDr. David Perlmutter57:04

        Which means I would go and get the bad food, uh, a- and we all make bad decisions that following morning. That's right.

    17. RCDr. Rangan Chatterjee57:11

        And it's your biology that's changed. You know? That's, I think, really interesting for people to learn. David, I wish we had another hour. Unfortunately, we don't, so as we bring this conversation to a close, what I hope is the first of many conversations-

    18. DPDr. David Perlmutter57:23

        Oh, me too

    19. RCDr. Rangan Chatterjee57:24

        ... I think there's a lot of, a lot of things we haven't discussed yet. You mentioned sardines and anchovies. I wanna briefly touch on that because a lot of people are told, uh, that these are health foods, that they are omega-3-rich fish, low in mercury [laughs] , so a lot of people are trying to eat more sardines and anchovies. Could you just maybe clarify that? Because you're saying they're-

    20. DPDr. David Perlmutter57:46

        Sure

    21. RCDr. Rangan Chatterjee57:46

        ... high purine, that they may raise your uric acid.

    22. DPDr. David Perlmutter57:48

        And, and it... I'm glad we, we get to call that out. I love sardines and anchovies.

    23. RCDr. Rangan Chatterjee57:53

        Me too.

    24. DPDr. David Perlmutter57:53

        When I have a Caesar salad, double the anchovies. Uh, I carry sardines when I travel, for crying out loud.

    25. RCDr. Rangan Chatterjee58:00

        Yeah.

    26. DPDr. David Perlmutter58:00

        Uh, and that's perfectly fine. I mean, I know where my uric acid level is, and it is not the sardines and anchovies. It would be if you had cut out all the fructose from your diet, uh, and still having some issues. You'd wanna pay a little more attention-

    27. RCDr. Rangan Chatterjee58:15

        Yeah

    28. DPDr. David Perlmutter58:15

        ... to then the purine part of the equation and the alcohol part of the equation. Those are the three inputs: alcohol, purines, and the biggest one by far, fructose. So that might be the fine-tuning part of it. But-

    29. RCDr. Rangan Chatterjee58:27

        For some people who may need it.

    30. DPDr. David Perlmutter58:29

        You bet.

Episode duration: 1:01:13