The role of lifestyle choices in decision making

Our modern world is fundamentally reshaping our brains, altering decision-making towards impulsivity, instant gratification, and the type of choices that lead to poor health, said David Perlmutter, MD, FACN, ABIHM, neurologist, author, and lecturer at Empowering Neurologist, and Austin Perlmutter, MD, internal medicine physician and author, at the 2020 Integrative Healthcare Symposium in New York City.

The standard medical paradigm that physicians use to treat patients is to take their education and hope that they can change the patient’s behavior by providing information. The patient is supposed to take that information and put it to use, Austin Perlmutter said.

Long-term adherence to behavior changes depends on the patient, they said. Poor adherence to recommendations is all too common, representing a significant challenge to the effectiveness of lifestyle-based interventions. When a patient doesn’t put information into action, they come back to their physician’s office and feel at fault.

“We’re missing something major here,” Austin Perlmutter said. “We believe decision making exists outside the continuum of disease problems. We blame the patient when they don’t follow through, instead of asking why they didn’t follow through when they wanted to. Where might decisions be modified? It’s the brain. If we understand the brain, if we wonder what leads to good and bad choices, we gain unbelievable power.”

When it comes to decision making, two parts of the brain are primarily involved, the prefrontal cortex (PFC) and the amygdala. The PFC enables us to consider future consequences, to reflect not just react. The amygdala is involved in impulsive decision making. Both are necessary, but there needs to be a good connection between the two, a conversation between different regions of the brain, also known as top down control. The PFC can reign in the impulsivity of the amygdala, Austin Perlmutter said.

But why does this matter and how can practitioners apply it?

To modulate this, we need to activate the PFC and calm down the amygdala. This can be done with lifestyle choices.

“When we eat healthy food, get enough sleep, exercise, and expose ourselves to nature, this activates the [PFC],” said Austin Perlmutter.

If inflammation goes unchecked, we don’t get enough sleep, or we use technology poorly, we throw the amygdala off balance, Austin Perlmutter said. This results in negative choices. This is known as disconnection syndrome—the disconnect between the PFC and the amygdala, which manifests as poor health and relationships.

The PFC plays an essential role in the organization and control of goal-directed thought and behavior, David Perlmutter said. Treatment protocols fail 50 to 80 percent of the time for no other reason than the patient decided not to make the change, he said.

The PFC is involved in the will to live, planning complex behavior, decision making, and moderating social behavior. It affects cognitive and affective empathy as well as compassion. It also allows the individual to embrace future consequences.

Today, patients’ brains are being rewired, David Perlmutter said. Practitioners need to consider embracing future consequences of our activities, not just in terms of health but in how actions will play out tomorrow.

“It’s all about our choices,” said David Perlmutter. “We need to regain the ability to make choices that consider tomorrow, answering to shareholders and not stockholders.”

The aim is to stimulate the PFC and calm down the amygdala. David and Austin Perlmutter focused on four main modern day problems to address to reduce the disconnection between the two brain regions:

• Non-restorative sleep
• Sedentarity
• Inflammation
• Inappropriate internet and social media usage

People who got enough sleep had significant stronger connection between amygdala and PFC. If you have a patient who is making poor decisions, look at factors in their lives that might be contributing to their poor decisions, Austin Perlmutter said.

We are as a society sitting way too much. Sitting is the new smoking, David Perlmutter said. Standing has been linked to a reduction in all-cause mortality. This isn’t a big intervention, but it’s a powerful tool, he said.

Exercise is good for the brain and executive control processes. Exercise offsets disconnection from the PFC, ensuring control over the amygdala. More exercise means better executive function and better decision making, David Perlmutter said.

Inflammation is central to disconnection syndrome, David Perlmutter said. It threatens the ability to access the PFC and make thoughtful decisions. Practitioners need to address underlying causes of inflammation to reconnect with the PFC.  

Lastly, inappropriate use of the internet is responsible for brain wiring changes. Online experiences can be detrimental to our brains, David Perlmutter said. Heavy internet use is associated with decreased quality and quantity of sleep, poor food choices, depression, anxiety, decreased memory and attention span, and increased risk of illness. The addictive nature of social media rewires the brain, so people act more impulsively.

To address this, David and Austin Perlmutter developed what they call the test of TIME. Consider whether your internet experiences are:

• Time restricted
• Intentional
• Mindful
• Enriching

The goal is to help patients make better choices, Austin Perlmutter said. One method is to encourage patients to get into nature. Nature exposure has been shown to make us think more clearly. Nature can active the PFC and allow people to make better decisions, he said.

“The implications are really substantial,” said Austin Perlmutter.

David Perlmutter encourages practitioners to rethink how they engage with patients to create sustainable behavior change and rewire their brains, perhaps starting small with something like sleep hygiene.

“When you’re confronted by a patient who is diabetic and overweight, don’t tear off a sheet and give them a new diet or physical therapy,” he said. “Offer patients simple onramps to better decision making, and you’ll set them up for success.”