Dementia: Is Gluten the Culprit?

Bret S. Stetka, MD; David Perlmutter, MD


January 21, 2014

In This Article

A Whole-Grain Gripe

Medscape: What do you say to the fact that many global diets proven to be healthy -- particularly the Mediterranean diet, which is continually shown to be beneficial in numerous medical and mental conditions -- include whole grains? And that many of the world's so-called "blue zones" -- regions in which residents have notably long lifespans -- also include grains in their diets?

Dr. Perlmutter: I think people do tolerate some amount of grains, and that the classic Mediterranean diet is one that has added fat and lower carbs. Of note, an April 2013 article in NEJM [15] compared a standard US diet with a Mediterranean diet supplemented with extra-virgin olive oil and a Mediterranean diet supplemented with mixed nuts. The investigators looked at 3 endpoints: myocardial infarction, stroke, and death. They had to stop the study halfway through it, at 4.6 years, because the individuals with the highest fat consumption had a 30% lower risk for the endpoints. It was unfair to the rest of the participants.

Can people get away with having some whole grain products? I suspect so. But you have to understand that wheat products represent 20% of our caloric intake in the United States. That's not the way it is around the rest of the world. The Mediterranean diet, for example, does not pound people over the head with soda.

Medscape: How would you respond to your detractors that there just isn't enough evidence to support would could be considered a somewhat extreme change in our country's dietary habits?

Dr. Perlmutter: My response is that the "extreme change in dietary habits," to quote you, is actually what has happened to human nutrition in only the past several centuries. In the early 19th century, Americans consumed just over 6 pounds of sugar each year. That figure now exceeds 100 pounds. And there has been a dramatic reduction in the consumption of healthful fat. Beyond the mechanism of protein glycation, as well as the powerfully detrimental downstream effects of uncontrolled insulin signaling, we haven't even begun to understand the epigenetic consequences related to the effects of these new dietary challenges in terms of maladaptive genetic expression.

So in reality, I am not suggesting a change. I am recommending that we end this grand experiment and return to a diet that isn't evolutionarily discordant.

Medscape: Do you have any final comments for Medscape's audience of clinicians? How do you feel your ideas should be incorporated into patient care?

Dr. Perlmutter: Again, look at A1c in a different way. Rather than simply representing a metric of average blood sugar over a 3- to 4-month period, look at it as a way of modifying your pharmaceutical intervention; look upon it as a marker of what it really is, glycation of protein. That glycation of protein dramatically relates to inflammation and oxidative stress. That's number one.

Second, begin to incorporate a fasting insulin metric as a way of anticipating who's going to then develop elevations of fasting blood sugar and glycation of hemoglobin moving forward. The earliest sign of pancreatic stress is elevation of fasting insulin -- which ideally should be less than 8, not up to 24, which is what is in the so-called normal range.

Third, recognize that vitamin D is a powerful player in terms of brain health. Beyond strong and healthy bones, vitamin D activates more than 900 genes in human physiology, most of which are important for brain health. Low levels of vitamin D correlate with increased risk for multiple sclerosis, dementia, and Parkinson disease. Those are my 3 take-home messages.


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