CHAPTER 4
Getting Started: Assess Your Risk Factors, Know Your Numbers, and Prepare Your Mind
TIME TO TURN THE SCIENCE into success. I’ve given you a great deal of information up to this point. You’ve learned a lot about the biology of health in the 21st century, some of which may have turned what you believed as conventional wisdom on its head. If you haven’t already begun to change a few things in your life based on what you’ve read, now is your chance. In Part II, you’ll learn how to shift your lifestyle and bring your body—and brain—back to optimal well-being. You’ll feel energetic and vibrant, suffering less from chronic conditions.
Making lifestyle changes, even small ones, can seem overwhelming at first. How will you be able to resist your usual habits? Will you feel deprived and hungry? Will you find it impossible to keep up this new lifestyle forever? Is this program doable, given the time and commitments you have? Can you reach the point where following these guidelines is automatic, like second nature?
Take a deep breath. You will soon have even more knowledge and inspiration to help you stay on a healthy path for the rest of your life. The closer you stick to my guidelines, the faster you will see results (and maintain them!). Bear in mind that this program has many benefits beyond the obvious physical ones. Ending fears of cognitive decline might be first and foremost on your mind, but the rewards don’t stop there. You will see change in every area of your life. You will feel more confident and have more self-esteem. You’ll feel younger and more in control of your life and future. You’ll be able to navigate through stressful times with ease, have the motivation to stay active and engage with others, and feel more accomplished at work and at home. In short, you will feel and be more productive and fulfilled.
And your success will propagate more success. When your life becomes better, fuller, and more energized, you won’t want to go back to your old, unhealthy lifestyle. I know you can do this. You must, for yourself and your loved ones. The payoffs are huge.
Let’s get started with a quick rundown of the entire program:
Prelude: Assess Your Risk Factors, Know Your Numbers, and Prepare Your Mind
Assess your risk factors using the quiz here.
Have lab work performed using the guide here.
Turn off your autopilot (see here) and consider fasting for a day.
Step 1: Edit Your Diet and Pill-Popping
Learn how to nix the villains in your diet (see here) and welcome in the heroes (see here) that will help support the structure and function of your body.
Know which supplements you should consider adding to your daily regimen (see here) and the medications you should try to dump if possible (see here).
Step 2: Add Your Support Strategies
Establish an exercise routine you can sustain (see here).
Pay attention to pain, especially in your back and knees (see here).
Make room for sleep (see here).
Reduce stress and find calm in four simple ways (see here).
Detoxify your physical environment (see here).
Step 3: Plan Accordingly
Know when to eat (see here), sleep (see here), and exercise (see here). Train yourself to plan your days so that you achieve your daily goals given your time constraints and responsibilities. Be ruthless with your schedule and your realities.
Now, on to the prelude, which will gear you up for Step 1.
ASSESS YOUR RISK FACTORS
The quiz below will arm you with some personal data that can help provide a sense of your risk factors for brain disorders and disease, which can manifest in migraines, seizures, mood and movement disorders, sexual dysfunction, and ADHD, as well as serious mental decline in the future.
Remember, the organs and systems of the body are highly interconnected and intertwined. If this quiz determines that you’re at higher risk for brain disease, then it also means you’re at greater risk for a medley of other illnesses that are not, in and of themselves, brain related.
Respond to these statements as honestly as possible (Y means yes; N means no). If you don’t know the answer to a question, skip over it.
Don’t be alarmed if you find yourself answering “yes” to most of these questions. The more yeses you have, the higher your risk for having dysfunctional physiology that might be impacting your health. But you are not doomed. The whole point of this book is to empower you to take charge of your health like never before.
KNOW YOUR NUMBERS: BASELINE BLOOD WORK
I recommend that you schedule the following lab tests, or as many of them as you can, as soon as possible. You can certainly start this program today while you wait for your appointment with a clinician and get the results, but knowing your numbers will not only motivate you to move forward but will also help you set target goals for each test result. You’ll know where your biological weaknesses are, so you’ll be able to pay attention to improving those numbers.
I’ve included healthy target levels where appropriate. Note that some of these tests are not normally performed by traditional doctors, so you may need to seek additional help from a functional medicine practitioner to complete these tests (see my website, www.DrPerlmutter.com, for details).
Fasting insulin: If you get only one test on this list, make it this one. It is critically important, and any health-care provider can perform it. Long before blood sugar begins to climb as a person becomes diabetic, the fasting insulin level will rise, indicating that the pancreas is working overtime to deal with the excess of dietary carbohydrates. It is a very effective early warning system for getting ahead of the diabetes curve, and so has tremendous relevance for preventing brain disease. You want this number to be below 8 uIU/ml (ideally, below 3).
Fasting blood glucose: A commonly used diagnostic tool to check for prediabetes and diabetes, this test measures the amount of sugar (glucose) in your blood after you have not eaten for at least eight hours. A level between 70 and 100 mg/dL is considered normal, but don’t be fooled. A blood sugar pushing 100 is anything but normal. At that level, you’re showing signs of insulin resistance and diabetes, and you have a heightened risk for brain disease. Ideally, you want to have a fasting blood glucose of less than 95 mg/dL.
Hemoglobin A1C: Unlike the fasting blood glucose test, this test reveals an “average” blood sugar over a ninety-day period and provides a far better indication of overall blood sugar control. Specifically, it measures the amount of glycation that the protein hemoglobin has undergone. Glycation, as I defined earlier, simply means that sugar has become bonded to a protein, in this case hemoglobin. This is a relatively slow process, but glycated hemoglobin is a powerful predictor of risk for Alzheimer’s disease, as well as being one of the greatest predictors of brain shrinkage. A good A1C value is between 4.8 and 5.4 percent. Note that it can take time to see this number improve, which is why it’s typically only measured every three to four months.
Fructosamine: Similar to the hemoglobin A1C test, a fructosamine test is used to measure an average blood sugar level but over a shorter time period—two to three weeks. Your fructosamine level should be between 188 and 223 µmol/L. It’s possible to see positive changes in this test within two to three weeks.
Glyphosate urine test: Glyphosate, you’ll recall, is the active ingredient in the popular weed killer Roundup that’s used extensively in conventional farming today. We finally have a way to test for this man-made chemical in the body through a new urine test available from Great Plains Laboratory in Kansas. You can order a test online at www.greatplainslaboratory.com, and then have your practitioner sign the form that must be submitted with your specimen. You want to test negative for detectable levels of glyphosate in your urine, measured as ug/L.
C-reactive protein: This is a marker of inflammation in the body. You want to see 0.00 to 3.0 mg/L (ideally, less than 1.0 mg/L). CRP may take several months to improve, but you may well see positive changes even after one month following my protocol.
Homocysteine: Higher levels of this amino acid, produced by the body, are associated with many conditions, including atherosclerosis (narrowing and hardening of the arteries), heart disease, stroke, and dementia. It is now generally regarded as being quite toxic to the brain. Having a homocysteine level of just 14—a value exceeded by many of my patients when first examined—was described in the New England Journal of Medicine as being associated with a doubling of the risk for Alzheimer’s disease (an “elevated” homocysteine level is anything above 10 µmol/L in the blood). High levels of homocysteine have also been shown to triple the rate of telomere shortening (remember that telomeres are those caps on the ends of your chromosomes that protect your genes and whose lengths are a biological indication of how fast you are aging). Homocysteine levels are almost always easy to improve (see below). Your level should be 8µmol/L or less. Both vitamin D and omega-3 fats can lengthen telomeres by increasing the activity of telomerase, the enzyme involved in lengthening telomeres. Many drugs can inhibit the B vitamins and raise homocysteine (see the list at www.DrPerlmutter.com under Resources), but most people can immediately correct their level just by supplementing with some B vitamins and folic acid. Typically, I ask patients with a poor homocysteine test to take 50 milligrams of vitamin B6, 800 micrograms of folic acid, and 500 micrograms of vitamin B12 daily and retest after about three months.
Vitamin D: This is now recognized as a critical brain hormone (remember, it’s not actually a vitamin; see here for more details). Interestingly, higher levels of vitamin D are also associated with longer telomeres, a good thing. Your vitamin D level will probably be low (normal is between 30 and 100 ng/mL, but you ideally want to be around 80 ng/mL). The majority of Americans are deficient in this critical nutrient due to indoor living and the use of sunscreen; those living in northern latitudes are most at risk for being deficient.
Because it can take time for the body to shore up its levels of vitamin D upon supplementation, you’ll start with 5,000 international units (IU) of vitamin D once a day, and test your level after two months. If after two months your level is 50 nanograms per milliliter (ng/mL) or under, you’ll take an additional 5,000 IU daily and retest in two months. It’s the level maintained in your body that matters, not the dosage. Ask your health-care practitioner to help you adjust your dosage to achieve an optimal level. Once you do, a daily dose of 2,000 IU will usually suffice to maintain a healthy level, but ask your doctor for specific recommendations.
Once you’ve been following my protocol for a couple of months, it’s a good idea to have these laboratory studies repeated to measure improvements. It can take time to see dramatic changes in some of these parameters, but if you follow the plan to a T, you should nonetheless begin to feel positive changes within a few weeks, and that will inspire you to keep going.
PREPARE YOUR MIND
I realize that some of you might be a little worried at this juncture. Given the self-assessments and lab work you’ve hopefully completed (or soon will), maybe you think that the cards are stacked against you. And the thought of cutting carbs is adding more unwanted stress. I’m here for you, which is why we’re going to consider three things to prepare your mind to go forward with resolve and the understanding that you have control and can change those cards so they are stacked in your favor.
Turn Off Your Autopilot
Rituals. Traditions. Habits. Ruts. We all have them. Some of them are good and help us stay healthy and fit. But some of them keep us running in the other direction and getting stuck. Do you find yourself rising in the morning in a semi-fog, inhaling a carb-filled breakfast without much thought, rushing throughout your day drinking soda and calorie-laden coffee drinks, coming home exhausted and wishing you had energy to exercise, eating dinner mindlessly in front of the television, and then falling into bed? Is your life automated so much that one day seamlessly and monotonously becomes another?
If so, don’t feel bad. You’re reading this book to get out of your rut—that comfort zone that in the long run won’t be so comfortable. You don’t want to look at yourself in the mirror five or ten years from now and be twenty pounds heavier, a hundred times more miserable, and on the road to experiencing serious health issues, if you don’t have them already. My guess is you have your staples—your favorite foods, restaurants, routines, and shortcuts in every aspect of life. Now is the time to awaken to a new whole life.
It’s important that we learn how to turn off our autopilot. I’m going to help you do that with the strategies in the rest of the book. The moment you begin to 1) edit your diet and pill-popping; 2) add your support strategies; and 3) plan accordingly, you’ll start to avoid autopilot and turn instead to a much more fulfilling, energizing life. Turning off your autopilot will also happen automatically once you flip a few switches in your body by jump-starting the program with a fast and then cutting carbs cold turkey.
Fast and Furious (Should You Jump-Start with a Fast?)
If you’ve gone on diets before, then at one point you were probably told to eat five or six small, healthy meals during the day to keep your metabolism in gear. You were persuaded to believe that eating this way supported calorie burning, and that any sensation of hunger triggered alarms in the body to store fat and slow down metabolism.
We might have come a long way in our technological advancement, but from an evolutionary standpoint, our DNA isn’t much different from the DNA of our hunter-gatherer ancestors. And contrary to what you may have been told, our ancestors didn’t eat six times a day. For them, it was feast or famine. They needed to be able to endure long periods of time without food.
Plato was right when he said, “I fast for greater physical and mental efficiency.” And so was Mark Twain when he declared, “A little starvation can really do more for the average sick man than can the best medicines and the best doctors.” Many religions encourage the practice of fasting as a spiritual practice. There’s the Islamic fast of Ramadan, the Jewish fast of Yom Kippur, and a variety of centuries-old fasting practices in Christianity, Buddhism, Hinduism, and Taoism. Although there are many different types of fasting, in general all fasts share one thing: They call for a willing abstinence from or a reduction of food, drink, or both for a period of time.
Fasting is a long-established way of physically rebooting the metabolism, promoting weight loss, and even increasing mental clarity and insight. (This latter fact makes sense from an evolutionary standpoint: When food was scarce, we needed to think quickly and smartly to find our next meal!) The scientific evidence for its benefits has been accumulating. In the early part of the twentieth century, doctors began recommending it to treat various disorders such as diabetes, obesity, and epilepsy. Today we have an impressive body of research to show that intermittent fasting, which includes everything from seasonal fasts lasting a few days to merely skipping a meal or two routinely on certain days of the week, can increase longevity and delay the onset of diseases that tend to cut life short, including dementia and cancer. And despite popular wisdom that says fasting slows down the metabolism and forces the body to hold onto fat in the face of what it perceives as starvation mode, it actually provides the body with benefits that can accelerate and enhance weight loss.
Typically, our daily food consumption supplies the brain with glucose for fuel. Between meals, the brain receives a steady stream of glucose made from glycogen, stored mostly in the liver and muscles. But glycogen reserves can provide only so much glucose. Once they are depleted, our metabolism shifts and we create new molecules of glucose from amino acids taken from the protein primarily found in muscle. On the plus side, we get more glucose; on the minus side, it comes at the expense of our muscles. And muscle breakdown is not a good thing.
Luckily, our physiology offers one more pathway to power the brain. When quick sources of energy like glucose are no longer available to fuel the body’s energy needs, the liver begins to use body fat to create ketones, specialized molecules I described in Part I. One ketone in particular plays a starring role: beta-hydroxybutyrate (beta-HBA). Beta-HBA serves as an exceptional fuel source for the brain. This alternative fuel source allows us to function cognitively for extended periods during food scarcity. It helps reduce our dependence on gluconeogenesis and, therefore, preserves our muscle mass. Gluconeogenesis is the process by which the body creates new glucose by converting non-carbohydrate sources, such as amino acids from muscles, into glucose. If we can avoid the breakdown of muscle mass for fuel and instead utilize our fat stores with the help of ketones like beta-HBA, that’s a good thing. And fasting is a way to achieve this goal.
Fasting also powers up the Nrf2 pathway I discussed in Chapter 2, leading to enhanced detoxification, reduction of inflammation, and increased production of brain-protecting antioxidants.
Despite all the benefits of fasting I just described, perhaps one of the best outcomes of the practice, especially during the prelude period of this program, is that it can help you mentally prepare for the dietary protocol. If you’re worried about what it will be like to drastically reduce your carbohydrate consumption overnight, then I can’t think of a better way to equip your mind—and body—for that achievement than to fast for a twenty-four-hour period before commencing the program. I also recommend that regardless of your medical status and history, you check with your doctor first before fasting for any length of time. If you take any medication, for example, ask about continuing to do so during your fast.
So unless you have a medical condition that prevents you from fasting, make it a goal to try the following:
Fast for one full day: Before you commence my 14-day meal plan (see here), set the foundation mentally and physically by drinking filtered water only for the twenty-four-hour period leading up to that first meal. For many, it helps to do the fast on a Saturday (last meal is dinner Friday night), and then begin the diet program on a Sunday morning. A twenty-four-hour fast is also a great way to jump back into this way of life if you fall off the proverbial wagon.
Skip breakfast once in a while: The body wakes up in mild ketosis. If you skip breakfast, you can keep this state going for a few hours before eating lunch at midday. Try skipping breakfast once or twice a week. I’ll be asking you to do that during the 14-day meal plan. If the days I ask you to skip breakfast are not ideal for you, then choose one or two other days during the week when it works for you.
Fast for a full seventy-two hours: Four times a year, go on a prolonged fast of seventy-two hours, during which you only drink filtered water. This type of fast is more intense, as you can imagine, so be sure that you’ve tried a few twenty-four-hour fasts before attempting this one. Fasting during the seasonal changes (the last week of September, December, March, and June) is an excellent practice to maintain.
Go Cold Turkey (Cutting Off the Carbs)
Okay, you’re almost ready for Step 1. I know what you’re thinking. The thought of going cold turkey on cutting carbs is terrifying. Let me share Jen Z.’s story and then offer some advice.
My name is Jen, I am fifty-four years old, and for quite a number of years I had been dealing with some very questionable illnesses. I was overweight with no success in getting my weight down, was chronically tired, had trouble concentrating, and had developed an autoimmune skin disorder called vitiligo, where the skin no longer produces pigment. A couple of years into these problems, I was diagnosed with metastatic melanoma and went through surgery and very aggressive immunotherapy as well as radiation. The treatment for the cancer left me with very damaged nerves, damaged skin, no energy at all, arthritis and joint pains so bad I could hardly walk sometimes, and the brain power of a pea. I could not remember things that I had known all my life, nor could I concentrate on anything.
With all my research trying to figure out how long this would last, I was led to the conclusion that this would be my new normal and I would just have to deal with it. I am an avid horsewoman, and this left me feeling that everything I had worked toward was being taken away.
Then one day about seven months ago, a friend shared with me an article about a doctor who was diagnosed with untreatable stage 4 brain cancer. In his quest to fight for his life, he discovered the low-carb lifestyle. I say lifestyle because it is not a diet to be jumped on and off of but a new way of life. At this point, I was searching for a way to regain some of my health and try to avoid any need for cancer treatments, so I thought I would give it a try. The cancer version of this new lifestyle is quite extreme, but it has been so worth it! The first two weeks were pretty rough with food cravings and my body adjusting to the change in diet, but I could feel changes happening and they felt good. I went cold turkey, all in! About four weeks in, my body no longer hurt from arthritis pain, joint swelling was gone, and my weight was dropping without me doing anything but changing the way I eat. Jumping ahead seven months now, I have been very faithful to the program! Only a handful of times have I put food in my body that does not belong and it was not but a few bites. Does not take much and you know that it was not a smart choice!
Anyway, I feel better now than I have in probably twenty years or longer. My brain function is back better than before, nerves are regenerating that were destroyed by radiation, the skin disorder that I was told would get progressively worse is actually reversing, my energy level is crazy good, and I am back training horses again. Best of all, I am three years cancer-free, my weight is almost what it should be, and I feel great. I will be the first to say it was not simple getting started, but once you get it figured out (there are lots of food labels to read), it gets easier by the day.
The vast majority of you will have no trouble going cold turkey on cutting carbs. But it may be difficult for some, especially if carbs have been a large part of your diet. If you experience mood swings, crashing energy levels, and intense cravings during the first couple of days on the program, have patience. These effects are temporary and will go away within the first week. Your mind will clear, your energy levels will soar, and you’ll realize how important this decision has been. You’ll never want to go back. Here are some additional thoughts to consider while facing the task of nixing those addictive carbs.
Leverage your motivation: Sugar and drugs have a lot in common. Cravings for both act on the same neurochemical pathways, which is why weaning yourself off either drugs or sugar in the form of processed carbs can involve unwanted withdrawal effects (though withdrawing from sugar is easier than withdrawing from most drugs). As I just mentioned, many people don’t have a hard time cutting carbohydrates, but you might experience a short-lived “thirst” for sugar, crankiness, headaches, low energy, maybe some aches and pains. This is normal. When you understand that the discomfort is merely a side effect of your body’s natural withdrawal from an addictive substance, you can use the knowledge to allay your fears and frustrations, turning that knowledge into a source of motivation and resolve. Remind yourself that these effects are temporary and won’t last long. When you don’t feel great and have the urge to eat a carbohydrate-rich food that is calling to you like a best friend, talk yourself out of it. You will not let carbs control you like a drug. Think about how much better you’ll feel when you expel them from your diet.
Arm yourself with alternatives: Let’s be honest. Going from a carb-rich diet to a carb-less diet overnight can be a significant lifestyle change. Recognize that. Acknowledge that this way of eating can take a little while to get used to, and that’s okay. During the first few days of your transition, arm yourself with the supplies for a counterattack when cravings hit by always having high-quality snacks on hand, such as raw nuts and nut butters, beef jerky, tasty cheeses, hard-boiled eggs, and raw veggies with a delicious dip (see here for more snack ideas). Don’t worry about counting calories or eating too many snacks. Just do it to get through the transition and I promise that you will emerge healthier, happier, and a whole lot lighter—and the cravings will soon vanish.
Avoid temptations: Say goodbye to some of your favorite restaurants. The hardest part of this carb-conscious transition is the beginning. Don’t sabotage yourself or make it any harder by patronizing restaurants and food courts where you know that you’ll be tempted and will have a difficult time finding something to eat that satisfies this lifestyle. Set yourself up for success at the start by avoiding unnecessary temptations. Of course, all within reason. You have commitments to fulfill and places to go, including events at your children’s school, your work, and occasions in your personal, social world. Life does go on around you, so be mindful of that. Engineer the start of your new way of living when you know you can make a real go of this. If you have a work-related breakfast function on Friday morning that you know will involve a buffet filled with pancakes, doughnuts, and waffles, get past that and plan to start the protocol on Saturday. During the 14-day meal plan, bring lunch to work so you’re in control and you’re not stuck deciding between unhealthy options.
Take the challenge: Make the commitment today that you’ll stick with the low-carb lifestyle forever. This is quite possibly the best thing you’ll ever do for your health. But the benefits won’t last if you revert back to your old ways. If you stray, so will your body—it will go back to its prior state after about two months (about the same amount of time it takes a fully fit body to go from physical greatness to being totally out of shape). So before you execute the steps, ask yourself why you want to change. Be honest and write those reasons down. Then go ahead and take a selfie—the “before” picture of yourself. Mark on the calendar the day you will begin. That is the day you accept the challenge, knowing that you are making a real commitment to your health. This is not a short-term diet. This is a whole life change. And your body—and future—will love it.
Believe in yourself, even when others don’t: You will encounter people who support your new lifestyle and others who will try to sabotage it. Some individuals will express curiosity at your new dietary choices and some will mock you or tell you that you’re ill-informed, stupid, or downright crazy. They may even include your best friends and family members. Be prepared to face these challenging, often embarrassing, encounters. When you turn down your cousin’s homemade pumpkin pie on Thanksgiving, let alone all the other things on the dinner table, know what you’re going to say: “I’ve been on this new diet and feel too fantastic to divert; unfortunately, certain ingredients are not allowed. Do you want to hear more about it?” With discourse and information comes understanding. Though you will face some people who will remain skeptics, don’t let them bring you down. They may act appalled that you choose not to have a slice of pizza or a sandwich with them for lunch, but stay strong and comfortable in your decision. Your goal is to be the healthiest you can be. People will always judge. I bet that once you get used to fending off the naysayers and explaining yourself, soon they will follow in your footsteps.
Remember, it’s a good idea to check with your doctor about beginning this new protocol, especially if you have any health issues for which you take prescribed medication. This is important if you’re going to opt for the twenty-four-hour fast at the start. As you commence this new lifestyle, you will achieve the following important goals:
Introduce a new way of nourishing your body, including your microbiome and brain, through the foods you eat.
Support the structure and function of your whole body through the right blend of supplements, probiotics included.
Add complementary strategies to the plan by focusing on more physical movement, restful sleep, attention to your emotional self and self-care, and cleaning up your physical environment.
You know the rules. You know your goals. And you know the data that supports both. Now you are ready. Let’s get to Step 1.