Deep dive into decision-making and lifestyle choices

The modern world is fundamentally reshaping our brains, altering our decision-making towards impulsivity, instant gratification, and choices that lead to poor health, according to David Perlmutter, MD, FACN, ABIHM, a board-certified neurologist and co-author of the best-selling book, Brain Wash.

The structural and functional wiring of our brains is constantly rearranged by interaction with the world around us, he said. This process can either be consciously harnessed for our own benefit or externally manipulated for the benefit of others.

We sat down with Perlmutter to discuss the mental hijacking that undermines everyone, and practical tools practitioners can use with their patients to make better decisions and develop healthier habits.

Integrative Practitioner: How did you decide to focus on the role of lifestyle choices in decision making?

Perlmutter: Two years ago, my son [Austin Perlmutter, MD], and I were talking, and I was asking him, now that he was finishing his residency, what was the most frustrating part? He indicated to me something that I had experienced for many years practicing. We do as much as we can to learn as much information as possible—we attend every conference, read every journal, do as best we can to learn as much as we can. Then, we do our very best to transmit this information to patients so that they have the best tools. The problem is what comes next, their implementation of the information. Whether it’s dietary or other lifestyle changes, it doesn’t take place up to 80 percent of the time, and that frustration is often expressed and is something I’ve experienced [as a physician] for a long time.

We decided to try and figure out what’s involved in decision-making. What we discovered was that, in fact, there’s brain anatomy that dictates how we make decisions, that we can make decisions impulsively and spontaneously or we can make decisions with a lot of thought by looking at all the evidence and thinking about the future outcome of our decision.

It turns out that there are two areas of the brain that are uniquely involved in our decision-making. One area, called the amygdala, is involved in impulsivity. The prefrontal cortex, on the other hand, allows us to think about the long-term consequences, good and bad, of the decisions that we make today.

Then we began exploring, what is it that tends to drive us to be more amygdala-based in our decision-making and our behavior and distancing us away from the prefrontal cortex, or what we termed as “disconnection syndrome.” What we learned was quite fascinating, that taking us away from the prefrontal cortex is fostered by inflammation. This is the same inflammation that we’ve been talking about for the past two decades that underlies Alzheimer's disease, heart disease, cancer, diabetes, and virtually all the chronic degenerative conditions. This same inflammation is fostering our decision-making towards more impulsivity.

We then explored further what differentiates being connected to the prefrontal cortex, versus being aggressively connected to the amygdala, well beyond impulsivity. We found that the amygdala is also involved with things like narcissism, self-centeredness, and an “us versus them” mentality, as opposed to being connected to the prefrontal cortex, which is all about empathy, compassion, forward thinking for ourselves and others, and even about forward-thinking even as it relates to the planet in which we live. We realized this goes well beyond decision-making. It’s involving the higher-order interests that we should be having as humans, recognizing that we are separated from that part of the brain by this process of inflammation, by the foods that we are eating that are pro-inflammatory, by our excessive use of social media and digital technology, by our lack of exercise, by inadequate sleep, and by lack of connection to nature.

The good news is we can reconnect to the prefrontal cortex. We can reconnect by getting better sleep, by meditating, by re-engaging nature, by practicing empathy, by eating a diet that is lower on the inflammation scale, by exercising, and all of these on-roads to help us reclaim the ability, once again, to make good decisions.

Integrative Practitioner: How can practitioners begin to address this disconnection in a world where it’s difficult to make good decisions?

Perlmutter: I think that step one is to come to the realization that it what I’m saying to the patient does not matter. I’ve been given patients this information month after month, year after year, and it’s obviously not taking my patients to a place of better health. That’s not because it’s not the right information, but because they’re not acting on it. We as practitioners should take a deep breath and recognize that the failure is not giving the wrong information, but it’s that patients don’t have the tools right now to make good choices.

The first step is to focus on allowing the patient to regain the tools to implement lifestyle changes. Patients realize they’re eating the wrong foods, they need to exercise, and their sleep is important.

The problem that has until now not been addressed, is that they don’t have the brain wiring to carry it out. This is about giving tools to slowly but progressively regain the ability to lock into the better decision-making part of the brain. Well, how do we do that? Say, for example, a patient comes in who we’ve had dietary discussions with for the past year that are taking us nowhere. This time, we’re not going to talk about “the right decisions,” but rather regaining the ability to make those decisions in the first place. We look for an onramp to better decision-making, a new connection to the prefrontal cortex, and to get rid of disconnection syndrome.

Integrative Practitioner: What steps can practitioners help patients take to improve their lifestyle and decisions-making?

Perlmutter: I recommend a ten-day plan that outlines these important steps, but with patients that’s not what you want to do. Choose one thing to focus on. It may be, for the next couple of weeks, we’re going to focus on getting more restorative sleep. As it turns out, [sleep is] one of the biggest issues that keeps people away from good decision-making. We know that even one night of non-restorative sleep amplifies the amygdala by 60 percent. If we can restore a good night’s sleep, we’re regaining a slight advantage in terms of them making better decisions that we can then hold onto for the next step.

We then talk about taking a walk outside. Research shows that nature exposure is powerful in terms of reducing inflammation, reducing our disconnection, as well as reducing cortisol or reducing stress. This can be as simple as a 15-minute walk in nature each day. Maybe buy a potted plant and put it in your living room or kitchen. Now we’ve got that door cracked open a little bit more.

The next step is exercise. All I’m going to ask the patient to do is to take a ten-minute walk every day. As a matter of fact, they’ve already been doing it when they’re out in nature, so let’s do these things together and push ourselves a little bit harder.

Before you know it, people regain the ability to reconnect to the part of the brain that [makes them feel empowered]. We all know that when we’re experiencing a connection to the amygdala, we don’t make good decisions. We stay up all night, we reach for high-calorie, nutrient empty foods, we’re angry with people, we’re just not able to reign ourselves in because we’ve become disconnected from the prefrontal cortex. When this goes on, research demonstrates an average daily increase calorie consumption by a factor of 380 calories per day. That may not sound like a lot, but when you add that up after a week, that equals a pound of body fat. Carry that out to a few months, the next thing you know, people are gaining weight.

Why this becomes a real issue is because the more weight you gain, the less quality sleep you will have, the more impulsive your decisions will be, and the less likely you are to eat good foods. So, this becomes a trap, a vicious circle, a feet-forward process that entraps people. So it’s very important to call that out.

It's also important that we call out what people’s digital experiences are, which are absolutely locking them into the amygdala by increasing their fear and catering to their impulsivity with clickbait.  We all know what happens when we’re on the internet, that our attention is hacked and harvested, moment to moment. That presents a significant threat in terms of worsening this disconnection syndrome, there’s a great place for technology. By-and-large, we know that people use the internet for purposes that are positive, but at the same time, we know that our attention is very frequently captured, and we are taken away from the task at hand.

We created what we called the test of TIME for our online experiences:

• T: How much time are we willing to dedicate to that experience?
• I: Remain intentional. What is your goal? Why are you online? What are you doing?
• M: Be mindful.
• E: empowering. Is your online experience positive when all is said and done?

What happens on our online experiences is as it relates to social media, we tend to get locked into our own ideology and people who share only our views on things. The beauty of the prefrontal, again getting back to disconnection syndrome, is it allows us to experience not only empathy but a type of empathy called cognitive empathy, and allows us the ability to participate in the viewpoint of another person, even though that viewpoint might be different from our own. The reason why this is so valuable, is it allows us to be with another person’s point-of-view, try it on, see what it’s like, and maybe gain something from that. That’s how we move the ball down the field together. That’s how we learn things.

What’s happening is we’re digging ourselves into our own ideologies. We can’t make progress like that. Diversity begets resilience. We learned that about the microbiome. We learned that the diversity of organisms in gut bacteria allows our body to be resilient to stresses of one sort or another. So, it is with diversity of opinion and points of view that allows us to be resilient moving forward, in terms of all of our challenges.

Integrative Practitioner: If practitioners are able to put this together, what is the result for individuals and for the greater community?

Perlmutter: This started with the doctor-patient relationship. That was the genesis of our work. Obviously, as you see now, where it’s gone is looking at so many aspects of what defines us as being humans, but I think that it is instructive from a doctor-patient relationship perspective that this is a tool that will allow us as clinicians to be ultimately more effective at our craft.

A lot of what happens in integrative medicine is centered around the meaning of the word “doctor.” Doctor does not mean healer, it means teacher. Unfortunately, in allopathic medicine, there’s very little of that that happens. It’s mostly about, “take this drug because I said so, because I’m the doctor, and be a good patient.”

Much more in the world of the integrative relationship involves sharing of information and changing activity and choices, especially as they relate to lifestyle, and that’s what our training is all about. It’s obviously a much more—that’s what integrative means, it’s far more than just simply a one-way, billiard ball mentality, of taking a pill to effect one chemical change. So, it really plays in nicely to the goal of the integrative practitioner to be more effective in transmitting information, but more so in terms of the idea that this information is finally going to get some legs in terms of action. That’s what we’re looking for because we spend so much time at our conferences and in our journals, learning how to make the very best recommendations to patients, but it falls short when that information is transmitted and ignored. So, this is another tool that we have now to enhance our effectiveness.

Editor’s note: This interview was edited and condensed.