11. Sex and Scent: What Your Nose Knows

Sexual attraction starts with a whiff of signals that gets your motor running. Your nose -- and brain – are behind your gender, sexual orientation, and choice of partner. Kayt Sukel explains how the brain rules when it comes to sex and love.

Dr. Stieg: Today we're talking with Kate Sukel, a science writer and author of several books including Dirty Minds: How Our Brains Influence, Love, Sex and Relationships. So I have to say, Kate, I'm a neurosurgeon and for me I, you know, the brain is the sexiest organ in the body and in fact the brain is a sexual organ. You brought your background in cognitive psychology and engineering psychology together to study the neurobiology of attraction. So let's talk about it. How does our brain influence, loves sex and relationships?

Kate Sukel: Uh, you really can't take it out of the equation whatsoever. I mean, just the same way that it governs every thought, every emotion, every behavior. The brain is right there in the middle of it. I sometimes hesitate to talk about the brain as if it's its own entity. It is kind of directing the scene. It is really sort of pointing us to one person when we really think we should be with another and makes us feel all those feelings and do sometimes risky things. And it's important not to use that as an excuse, but I think really to understand why we often are our own worst enemy when it comes to love and relationships.

Dr. Stieg: Can you describe the basics of what's going on when we become sexually aroused?

Kate Sukel: it really starts often with our noses and of course humans. We think we're a little bit more sophisticated than the sense of smell. After all, we're not rats or dogs. We're not immediately meeting someone and you know, sticking our face, uh, up into their backside. However, we give off a lot of chemo sensory signals. And most of those we're not even aware of. Not only do we give them off, but we picked them up from other people below the level of conscious thought. Our brain somehow processes those and lets us know whether or not somebody is physically attractive, whether that's somebody that we want to have sex with or maybe someone that we might fall in love with. We like to think of ourselves as being very conscious and very deliberate about our choices, but I think all of us before have fallen for someone who wasn't quite what we had in mind and we couldn't really explain the attraction and it might've actually come down to the fact that he just gave off the right smells, smells that we couldn't even necessarily explain or detect, but gave our brain a lot of information about his health status, his genetics, makeup, and also we've been, to a certain extent, his potential status as a father or a partner.

Dr. Stieg: Let's extend this to another topic in terms of the research found regarding the differences between heterosexual and homosexual relationships, is it behavioral and induced? What did you find in your analysis?

Kate Sukel: While certainly the world of neuroscience has gotten away from this idea of being hardwired, I think that if anything is, you know, born this way, it really is a matter of your sexual preferences do come up that way. Patterns of brain activity when it comes to looking at stimuli that are, that are arousing what you find attractive, what you see are the same patterns in a heterosexual male looking at a woman as you do in a homosexual male looking at a man, there is something intrinsic to the brain wiring. That means that people are attracted to one sex over the other.

Dr. Stieg: So is that through functional MRI studies?

Kate Sukel: From functional MRI studies, yes. And also Dick Swaab who's a researcher in the Netherlands, he's also looked at transgender and has found similar things. If you look at differences between male and female brains, you'll find a whole host of different little changes. And in fact when he looked at individuals who were transgendered, he found that they had brains basically that matched the sex that they identified with. So if they were born biologically male, but identified as female, they had very female like brains, even though they happen to have a penis and vice versa. And that's also fascinating, you know, because it shows that there can be this disconnect. It's really sort of opened the door to talk about homosexuality. And transgender issues and have people understand that this isn't a choice. This is something that seems to be written into your code and it's also something that should not be talked about in terms of a mental disease or defect. It's just some kind of biological difference that should be more accepted.

Dr. Stieg: And something at this stage that we still don't have the scientific techniques to really analyze if there is something scientific about it.

Kate Sukel: Well, and that's the hard thing about any of this stuff. We have brain imaging, we have behavioral studies and there's certainly we want the evidence to converge, but we're not at the point now where we really want to be, you know, opening up people's skulls and then mucking about in there. There's some studies that can be done with people who have epilepsy or perhaps some kind of disease that requires deep brain stimulation where you can go in and ask some questions and get a closer look at some brain areas. But those studies are few and far between and they're not always that easy to do. It's hard to understand the nature of love when you have seven minutes to participate in this study in between implanting a deep brain stimulator and closing up somebody's skulls as they can heal properly. A lot of the studies, you know you were talking about before, these researchers are genetically modifying some of these animals and they're looking at how that might change the way the animal behaves in a type of prarie vole that is always been known to be socially monogamous. They find a mate early on and they pretty much stick with them for life. If you start mucking about with these different levels of receptors for neuromodulators like oxytocin and vasopressin, you can actually change in their behavior. You can turn that one very solid, very committed prairie vole into a little Casanova and vice versa. You can take voles that are traditionally more promiscuous and make them that bastion of monogamy. That's not really something we want to be doing with humans. I'm sure there are some people out there listening that would think, I wouldn't mind giving my, my husband a little vasopressin if it meant he stayed home or what have you, but we don't know the far reaching effects. We talk so often in genetics that this is the love gene or this is the monogamy gene or the risk gene or what have you. But really gene's just code for protein and vasopressin actually got its name because it's very important for kidney function and for vasoconstriction in the heart. And you know, so if you up or lower it in certain people, yeah, you might possibly make your man more monogamous, but you may do so at the extent, you know, expense of his kidneys. Maybe that's a worthwhile trade off for you, but probably not for most hospital and universities' institutional review boards.

Dr. Stieg: To where do you see the next most interesting or new developments regarding the sex and brain coming from?

Kate Sukel: We're seeing a lot more work being done on smell. Again, w you know, we sort of think of this as a lower order mammal issue. Dogs smell, rats smell, humans. We've thought that we're kind of above that and yet we're learning in so many different ways how important smell is. In fact, if you look at neurodegenerative disorders like Parkinson's disease, Alzheimer's disease, you'll find that most often one of the first symptoms that comes to light is issues with smell. So obviously we, we may not have the same kind of olfactory setup that many rats or rodents or even primates do, but it seems to play a much more integral role in a lot of cognition than we once thought. And similarly I think it does in terms of understanding why we're attracted to certain people, what it is that that draws us to someone initially and maybe even what later on makes them not attractive at all anymore. I think almost everyone has probably had the experience of feeling madly in love with someone and then kind of waking up one day and thinking, eh, they're just not that great, but what if it is a slight change in smell? What if we are picking up different signals from them at that point? And that makes a difference. What if there are these things that are happening subconsciously for us really do influence how we form these social bonds and how we maintain them over the course of time.

Kate Sukel: What is considered normal love and sexual behaviors? You need to go with the old statistical model of normal and that's of course the normal distribution which looks kind of like a mountain and while we often talk about love and sexual behaviors as if they need to exist in this very, very small contained box, this is what's normal. In fact, they really do run the gamut and I think once people realize that there's nothing wrong with them, they're not unlovable, their brain is really set up for them to love, fail at love, and love again. I think that they do much better. I think overall as humans we put a much, much too much pressure on ourselves about there being a right way to handle love, the right way to be a partner. And of course, like anything else, when you really do map it out, statistically, you'll find out that your mileage may vary and what works for you may not work for someone else. So it pays to pay attention to be cognizant and aware, self-aware, and figure out what's normal for you.

Dr. Stieg: Kate, thanks so much for being with us today and helping us better understand gender and relationship choices. 

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The science behind the benefits of a plant-based fiber diet will motivate many of us to make important lifestyle changes. Cardiologist Hooman Yaghoobzadeh, MD, explains why eating less meat, less processed food, and more fiber is so good for your heart and brain.

Dr. Stieg: I'm delighted to have with me today Dr. Hooman Yaghoobzadeh. He is Clinical Associate Professor of Medicine at Weill Cornell Medicine and Associate Attending Physician at NewYork-Presbyterian Hospital. He specializes in cardiovascular disease. Also with me is a patient of Dr. Yaghoobzadeh, Mr. Jamie Streeter, who is Managing Director in Cohen's Healthcare Investment Banking Group focusing on life sciences companies. And the reason we're here today is to talk about food and the brain. So one might be wondering why if I'm talking about food in the brain, am I meeting with somebody who's a specialist in cardiovascular disease and there's a good reason for that and that the heart and the brain are extremely similar. One may try to draw the similarity that is a V12. They're both running on high energy, high octane, and given that they both have very similar demands. So Hooman, can you tell me a little bit about what are the important energies that a patient needs to feed both their heart and their brain?

Dr. Yaghoobzadeh: Blood flow is what brings oxygen, nutrients to both the brain and the heart. Muscle blood carries with it oxygen as well as nutrients and the energy needed for all the cells to work well. Healthy, reactive young, pliable blood vessels are the tree of life for both of these organs. And they're very energy dependent organs. They're highly active, they're running on full, you know, high octane all the time and there really is minimal reserve for any detriment. The minute you start to mess with their food supply, they start to complain

Dr. Stieg: The kinds of energy that the brain and the heart need are a little bit different than what the kidney and the gut needs. Can you go into that a bit?

Dr. Yaghoobzadeh: Yeah, sure. So the heart and the brain have unique abilities to use fatty acids as well as sugars. They have a reserve, backup mechanisms to, just in case they're starved of one, to switch to the other. And so that's just a redundancy built into the system to make sure that these organs can function during starvation during lack of, even lack of, well — lack of oxygen is the one thing that neither one really can tolerate at all and there's no reserve for lack of oxygen. And that's where the first hit really comes. When there's any reduction of blood flow to either of those organs, the first hit within seconds is lack of oxygen. And the second that enough blood flow, either because of a clot or a blockage forms in one of these pipelines to these organs, the lack of oxygen will lead to death of the cells.

Dr. Stieg: I was interested in, for light reading, I was going through something that you had actually passed on to me about diets of pre-hominids versus what we eat in our American diet today. And I thought it was kind of interesting what pre-hominids are what, 10,000 years ago. And the fact that our body, our bodies and our genetic codes haven't adapted yet after 10,000 years to what we're putting in our mouths. And it really, it gets into a, I wanted to get a little bit specific about the things that they talked about in terms of this glycemic load, fatty acid loads, the macronutrients, the micronutrients. How much do you, with your patients like Jamie, how much do you stress that?

Dr. Yaghoobzadeh: I'm impressed that you read what I sent you Phil, so that's a great start. *laughs* So what's interesting is, food and calories these days come in highly packed and energy dense packages, which leads to these tremendous spikes in blood sugar. And so these, the intensity or the density with foods these days are very, very different than foods that we had access to many thousands of years ago. Because at that time, most of the foods that we ate were foods that we roughage for. So there were sprouts and grasses and seeds. They were tubers and things that grew underneath the ground. Things that potentially very early man was able to grow themselves before domestication of animals. When we would go hunting, we were also hunted, so several of our brothers, sisters friends, didn't come back home. We didn't go hunting every day, all the time. We didn't have refrigerators to put animal products and we didn't have domestication of animals to have the level of eggs and dairy and so on, so forth that we have now. So the foods back then had much, much more fiber than the typical — or the diet back then had much more fiber than the diet. Now fiber slows down caloric absorption and food metabolism in the gut and fiber is the one main difference between what a modern Western diet is and what a whole foods plant based diet is.

Dr. Stieg: Well, what I'm interested in is the fact that we've gotten so far away from the non-meat roughage kind of diet that it leads to this inflammatory process that occurs not only in the gut but also in the blood vessels. Can you go into that a little bit about what, where our diets have gone wrong and how it induces that kind of injury?

Dr. Yaghoobzadeh: In some ways it's not a hundred percent our faults. We have evolved to seek out calorie dense, high fat, high sugar foods through thousands of years of evolution. We are driven, addicted to look for things that are sweet and look for things that are high fat. And in fact there are research studies that show in the brain when we eat simple carbohydrates, sugars and saturated fats, which are 90% found in animal products, the pathways in the brain, the neurons, the actual specific roads that electricity flows in the brain when we eat. Those foods are very similar to when we are exposed to cocaine and nicotine. And so they are truly addictive and we seek them out. And just like in other addictions, we build tolerance to them. So if you're addicted to a substance over time you need more and more to create the same kind of joy.

Dr. Yaghoobzadeh: And the same thing happens with sweetness when it comes to sugar and taste receptors in the mouth. And there are multiple other mechanisms that drive us towards these foods. And so given that they're so easy to get in today's diet, these foods lead to inflammation in one of several ways. One of the ways that's most interesting and we're starting to figure out now is through the bacteria that live in the gut, which is called the microbiome. The gut is the main place where outside comes in, into our bodies. We have other barriers like skin, but skin doesn't let outside in. In fact, it's a true barrier. The job of the gut is to let stuff in, but when you're letting stuff in, you also have to make sure that bad things don't get in and like bacteria, toxins and so on, so forth.

Dr. Yaghoobzadeh: So the way that the gut manages to do that, it appears is that there is aligning of mucin. It's this gelatinous goo that lines the gut and has some antibacterial kinds of properties and keeps the bacteria that's in the stool and the bacteria that is absolutely necessary to digest everything that is in our guts. It keeps the bacteria away from the wall of the gut. The way that the gut creates that mucin. The cells of the gut eat things called short chain fatty acids. Short chain fatty acids are the compounds that are made by the bacteria, when they feed on fiber, so to review that bacteria feed on fiber. They make short chain fatty acids. The short chain fatty acids feed the gut cells. The gut cells make the mucin. It creates a barrier. It keeps the bacteria away, and there's this healthy symbiosis in this environment, in this ecosystem. When fiber goes down in the body, the fiber eating bacteria don't have food, they start to die off. There's not a lot of short chain fatty acids made, the gut cells are starved. They don't make mucin. That barrier breaks down. Now there's interaction between the bacteria and the gut. In lay terms, some people call this leaky gut syndrome, which we're still trying to understand exactly what that means. When the bacteria start to interact with the gut, our immune system and they're the infantry, they're standing there waiting for one of these bacteria to come in. The minute there's an interaction there, the immune system starts to get activated. The soldiers send signals back, the immune system calls, you know, to arms and sets off inflammatory cascades. That inflammation. Then it affects all other parts of the body

Dr. Stieg: in addition to activating the inflammatory cells in the inflammatory system because you now have this quote, "leaky gut syndrome," you're also absorbing bad stuff into your blood vessels, which thereby as I understand it affect both the brain and the heart vessels. So you see Jamie in your office and what tests do you run to see whether he's got a good or a bad.

Dr. Yaghoobzadeh: The things that I look for to try to figure out how much room for improvement there is in the diet, no matter where somebody starts. The first thing that I do is sort of try to get a risk profile set up to figure out how worried should I be. Once I sort of get a sense — is this a truly low risk person that is not going to have heart disease? Maybe no further testing is necessary. Is this a truly high risk person who I already know has heart disease? They have to have all their numbers? Absolutely perfect. Many of us fall somewhere in the middle. It's typically been defined as have you had a stroke or have you had a heart attack? And I think that's sort of the, the chickens out of the barn or the horses out of the gate. I wasn't born in this country, so I'm not familiar with the uh, and so I would define it as is there or is there no plaque in the arteries that supplied the two most important organs?

Dr. Stieg: So how do you, how do you find that out? What tests do you run?

Dr. Yaghoobzadeh: A carotid ultrasound is a really good test and a coronary calcium score is another good test to look at the heart.

Dr. Stieg: So for the person who's sitting here listening and saying, Oh shoot, all my family lives to be a hundred years old, how much of it is genetic and how much of it is behavioral?

Dr. Yaghoobzadeh: Spectacular question. Very, very difficult answer. There are very few diseases that are a hundred percent one or the other and most diseases are a combination of both. And when we talk about what risk factors patients have, we try to come up with probabilities as opposed to, is this person going to have a heart attack or is this person not going to have a heart attack? So we say, okay, this person is going to have a 10% risk of a heart attack and we're going to try to lower that to a 3% risk.

Dr. Stieg: Then we come to Jamie, who's, as we said, a managing director in a healthcare investment firm. So I'm presuming that you have lots of common sense and you are always thinking about being an absolutely healthy individual. What light went on, "I've got to go see Hooman, and maybe change my lifestyle." Did something happen?

Jamie Streeter: Well, I think we all have good intentions, right? So I think the, if you're younger, you just sort of assume it's not a big deal. I have a history where my father—he didn't die, he had a heart attack at 39. He actually just passed away at 87, after two bypasses, a carotid and aortic aneurysm and a number of other procedures. So to say he's a product of modern medicine is an understatement. But he's also, I think an indicator of the kind of risks that I could conceivably have to deal with. And we don't go to see Dr. Yaghoobzadeh just for any reason cause you all have primary care physicians. So you're going to a cardiologist because I think you are already inclined to look a little deeper. Um, but I think that unequivocally there's a clear, at least in my mind, a predisposition to having an issue. And so I figured I—

Dr. Stieg: Both genetic and behavioral, and that, that takes me back to a question to you, Hooman, is, so many of the diseases we're talking about are developmental. You, you started getting to an age where you start. We were worried. The reality of it is people should start worrying when they're 30 you know the newest data suggests that Alzheimer's is a developmental disease that may be inflammatory. Obviously a heart disease is a developmental disease as well as genetic. What do you, what do you do to motivate your 30 year old patient?

Dr. Yaghoobzadeh: I sprinkle information in whenever I see an opportunity. So if there is a relevant issue that's going on, I talk about it. We talk about diet almost every time. I will continually bring up research that's recently been done on lifestyle modification. I have a Twitter account that I post research that's relevant to a whole foods plant based diet. So it's something that is constantly brought up. Patients know that I follow the diet or at some point patients find out that I follow the diet and that is very interesting for them. They'll ask me why and so I'm always looking for an in, you know, I don't lecture about it unless the patient needs a lecture. I, you know, will be very tact and figuring out, you know, when is the right time to use tough love, humor, so on and so forth.

Dr. Stieg: So just as an aside, how many pounds of brussel sprouts raw do I need to eat and I don't have to eat anything else and I can get all the protein, all the glucose and all the macro and micronutrients I need.

Dr. Yaghoobzadeh: The, I mean, it's interesting, I don't know the answer to that, but what's interesting is, you know, we think about protein as, Oh, it has to be eggs or chicken and so on and so forth. Or, or it has to be nuts or beans. There's research that if you eat all of your calories as broccoli now, you'd never do that. I'd never do that. We'd be sick. But if you did in a day, all of your calories from broccoli, you would get enough protein. So this, this, yeah, it is amazing.

Dr. Stieg: Given all the healthy things that, Hooman has instructed you on, do you exercise regularly?

Jamie Streeter: I always exercise. I think that's part of the whole, I think dynamic here.

Dr. Stieg: So what do you do routinely?

Jamie Streeter: Well in the summer I'm riding a bike, probably 120 to 150 miles a week.

Dr. Stieg: Do you have a daily, exercise 30 minutes a day, an hour?

Jamie Streeter: It's more like an hour at least. And it's, the bike is on the weekends cause I travel during most of the week. So it's running or I'm going to gym. What, what changed for me was I changed what I ate.

Dr. Yaghoobzadeh: I think it's very common for athletes and I have a lot of patients who come in and say, Oh, I'm at very low risk. I exercise all the time. I do all this intense exercise, but they're missing the other half. And the research may suggest that it's really 70% diet, 30% exercise as it pertains to cardiovascular disease.

Dr. Stieg: So what do you do to make it compelling for the patient? And by that I mean I have oodles of patients that come in to me and they want to live life the lifestyle that they want to live and they say, just fix it so I can go back to that lifestyle. You're in the business of getting people to change their lifestyle. How do you do that?

Dr. Yaghoobzadeh: I actually have cheerleaders with pom-poms in the back of my office. I would be interested to, to hear what you have to say about that.

Jamie Streeter: You know, I think in all candor, this really does come down to a certain amount of self motivation. As a function of my job, I travel a tremendous amount and I actually ascribe a lot of the, the creep in weight and bad stuff too. It's just harder to manage when you're on the road constantly. And so I just sort of said to myself, "Can I make an experiment?" Which is what he suggested. Can I just change this for awhile and see what happens? And I think the, you know, the most dramatic thing is you start the process, you're in the process, things you used to do, you stopped doing and you find that you don't even miss them. And then it became very much just like everyday process.

Dr. Stieg: I feel that I, I mentally tried to change my attitude towards food and I just tried to make it less relevant in my life other than the fact that I needed to eat something that I enjoyed that was healthy and then get on with it.

Dr. Stieg: Running down in quick form, a healthy, good breakfast, a healthy good lunch and a healthy good dinner.

Dr. Yaghoobzadeh: Sure. So options for breakfast a would be a shake with blueberries, peanut butter, spinach, chia seeds, hemp seeds, flax seeds, or a really good bread like Ezekiel bread with avocado smash. Steel cut oatmeal with—.

Dr. Stieg: What is Ezekiel bread?

Dr. Yaghoobzadeh: Ezekiel, so it's a, it's a brand of bread, you know, healthier breads that are whole grain and have a low carb to fiber ratio. Most supermarkets now will have Ezekiel bread and it's in the frozen food section because if you find bread that's not in the frozen food section, not in a bakery where it was baked that day, the bread is being preserved and the preservatives are sugar most often. And so this bread is in the frozen food section because it doesn't have preservatives like sugar. Lunch would be a salad. My salads are sort of hearty grain salads, you know with nuts and seeds and lentils, mushrooms, it would be like a burrito bowl with brown rice and black beans and guac and lettuce and tomato and salsa and things like that.

Dr. Yaghoobzadeh: Dinner would be any of the peasant stews, Moroccan carrot and lentil stew, three bean chili, pea soup, lots of roasted vegetables, what we call Buddha bowls. So a whole grain, a bunch of fresh vegetables, roasted vegetables. I have fish. I believe fish is part of a healthy whole food plant based type diet. I think that fish have, especially for the brain, there's a lot of uh, healthy nutrients like Omega three fatty acids that we need and we require and are tough to find in other foods, although you can find them in chia and flax and hemp.

Dr. Stieg: One of the things I was just thinking about while you're talking about that is how do you, how do you handle high bean diet and the aroma that follows you as you walk down the hallway? Or does your body adapt to that and then it's less of a problem.

Dr. Yaghoobzadeh: Yeah. Your body does adapt to it. Fiber is responsible for gut motility when there's a lot of fiber throughout the diet for days and days and days, everything is moving through the gut very quickly. Um, whereas when there's not a lot of fiber, especially the animal protein sit in your gut and tend to go rancid it the same way that animal proteins go, rancid on your kitchen counter top. Think about that.

Dr. Stieg: Jamie, after you saw the light and decided to reform your lifestyle, what changes did you see in the laboratory tests that that Hooman was running?

Jamie Streeter: Not being that familiar with the data? I'll, I'll let him chime in as well, but obviously when you're given the test results from your doctor there, there's the LDL results, HDL results, total cholesterol and triglycerides. I think it was fair to say it was pretty dramatic, the change. The, the LDL went from around 130 to the low 50s. The HDLC essentially the same, which is obviously part of the goal. The total cholesterol went from two 13 to one 32 and triglycerides went from 207 to 67. I also have to say, I guess we increased the Lipitor dose by 10 mgs. The weight was pretty visible and pretty dramatic. So I went from sort of fluctuating between 205 and 210 down to about 175. And, uh, I, since I ride my bike a lot, I can tell you quite categorically that when you take 30 pounds off and you get back on a bike, you feel a lot better when you're riding the bike.

Dr. Stieg: Dr. Hooman Yaghoobzadeh and Mr. Jamie Streeter, I want to take this opportunity to thank you so much for spending time with us to talk about, most importantly, the diet, but you know, how it affects our gut and then eventually affects the two major organs. I will remind you that we can transplant your heart, but we can't transplant your brain.

Dr. Yaghoobzadeh: Yes.

Dr. Stieg: Thank you so much for being with me.

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The best prescription for reducing inflammation, cholesterol, and weight is right on your plate. Cardiologist Hooman Yaghoobzadeh, MD, explains the science of eating well, and how the right foods are life enhancing and will actually change your genetics.

Dr. Stieg: Today I'm with Dr. Hooman Yaghoobzadeh, who is Clinical Associate Professor of Medicine at Weill Cornell Medicine and Associate Attending Physician at NewYork-Presbyterian Hospital specializing in cardiovascular disease. I'm also with his patient, Mr. Jamie Streeter, who is managing director in Cohen's Healthcare Investment Banking. The group focuses on life science companies. Since we're going to be focusing on food as medicine, I'd like to start off before we even get to the point where we need to use it as medicine. What is the right stuff? What foods should we be putting into our body on a regular basis?

Dr. Yaghoobzadeh: The a diet that typifies, from my perspective, what an ideal diet is, and we can talk about the science as well, is what's called a whole foods plant based diet. So whole foods, meaning when you look at what you're eating, you can identify exactly what it is. It's not a list of ingredients or a bunch of powders, but it's a kernel of corn or it's a quinoa or a nut. And so that's whole foods and that reduces processing and increases nutrient density. And we can talk about why all of those things are important. And plant-based, so getting the vast majority of your proteins from plants and they should be a variety of plants, nuts and seeds, legumes, vegetables, greens, the whole gamut of plants, fruits and fish, I believe, is also another part of a very healthy whole food plant based kind of diet. Maybe two to three times a week, but probably not more than that.

Dr. Stieg: I can't eat meat? Please? *laughs*

Dr. Yaghoobzadeh: So meat is, yeah, there's very few things that are, you know, that you may put on the toxins list. And you know, some of those things, you know, are like bacon, and soda, and white sugar. They're, they probably, um, and there are researchers, for example, at Cornell that are striving to list high fructose corn syrup and sugar as a carcinogen actually. So there are some foods that are relatively highly toxic, but most foods, you know, when I talk about this diet to patients, they're like, well, you know, my diet is extremely healthy. And when I talked to them about it, they're having chicken, you know, twice a day, every day. And it's really the main source of protein. And I see a lot of the animal proteins is neutral compounds. They're just taking space away from a truly healthy, very high fiber plant compound. And so I try not to look at it as evil or not, and I have steak now and then, you know, it's a plant based. That's why I never use the term vegan.

Dr. Stieg: So that takes me to the question about, you know, everyone says "Everything in moderation." So in your mind, what's moderation?

Dr. Yaghoobzadeh: It would be everything in like paleolithic—

Dr. Stieg: Can I have bacon once a month?

Dr. Yaghoobzadeh: Um, yeah. I mean it's, what I try to challenge patients to do is to eat healthier than where they are now. And so as opposed to focusing so much on what the ideal diet is, if we can take steps to move in the right direction, those are wonderful steps.

Dr. Stieg: What do you think about, I was with another one of our esteemed diet gurus here and some other people and they've started these packages and I was with them and they gave me this protein package and I mixed it in a glass, a glass of something where, I know I just poured it down my mouth and it tasted quite good. But they said, "That's your protein dietary requirement for the day."

Dr. Yaghoobzadeh: I'm not a fan of protein powders and things that are processed to get the pea protein out of the pea, you need to extract that protein—that is a chemical process. And, what you're also doing, you're extracting the amino acids, but you're leaving a bunch of other really amazing things. And the, the wonderful thing that, the interesting thing about many foods that we know are healthy for you, for example, fiber, vitamin C, vitamin B, all of these micronutrients that we've identified as being extraordinarily healthy and this sort of fits right into food as medicine. When we've isolated these compounds and given them to patients in randomized prospective placebo controlled trials, every single one of those studies show that, for example, vitamin C or vitamin B, like I said, or even fiber, it doesn't do anything in that controlled study. So what that means that even though every other study that has identified the amount of dietary fiber shows that the more dietary fiber in your diet, the healthier you are and the less heart attacks when you give fiber as a supplement, it actually doesn't lead to the same health. That's because these foods are found in, you know, environments where they need to be juxtaposed to hundreds of other compounds.

Dr. Stieg: I think this is where we as Americans frequently go wrong is we, we go into the coffee shop and we see the high protein bar — I saw this high protein shake and we're looking for the quick solution versus the high fiber diet and the high vegetable diet. So Jamie, I mean how did you do it? I mean you had to change your lifestyle, you lost 50 pounds and your numbers all got better. What was the emotional component that you went through to achieve this other than the fact that you were afraid of dying?

Jamie: Right. I was going to say the survival instinct's pretty strong generally. Uh, I think again, with age you start to confront, you know, what do you do to stay better? I think is the, the reality in this. And it's interesting you say it's hard. I mean I, I honestly think it has to be somewhat like what you described, which is you have to change your mindset about food. I also find today that, you know, I eat the breakfast prescribed, I eat lunch, but at like 10 or 11 I'm going to have an apple. And I do that all the time or a banana and it means I eat actually less at lunch. I think if you graze, you just eat differently and the body doesn't try to compensate one way or the other. And I've read that that's a bizarre behavior change. But I now travel with like fruit in a bag and use it when I'm traveling or the offices, in fact, our office is now stocked with fruit instead of a lot of what these stuff, because I kind of said, "Hey everybody, hey!"

Dr. Stieg: No protein bars on a shelf.

Jamie: If you go to our firm today, there is a different set of snacks than there were six months ago.

Dr. Yaghoobzadeh: But the reason I think it is a problem, it's obvious. I mean what are the two major healthcare crises in America right now? It's diabetes and obesity. Those are self-inflicted and they're diet inflicted. So the reason this, this discussion is so important and I, I guess there's probably a lot of people that don't appreciate the fact that, they think, "Oh, I've got to have a high protein diet means I need to eat steak and chicken and a lot of meat." That's a fallacy. Can you expand on that?

Dr. Yaghoobzadeh: Yeah. And if, if you want to hear somebody a lot more interesting than me, uh, talk about that... You know, if you look at Tom Brady's diet, if you look at Richard Roll, who's one of these ultra marathon runners, you know, five IronMans, five countries, five days, some crazy thing like that. The world's strongest man, I think his name is Mr. Baboumian, these are all whole food plant based types of diets and, and they have tremendous energy expenditures and they're eating plant proteins. Some of them because of the intense number of calories that they need to take in, will supplement with plant based protein powders. But this idea that we need all of this protein is really a fallacy. Our body will digest and create the perfect proteins from any proteins that we give it. And even what we used to think of as quote, unquote "essential" amino acids, these are amino acids that almost are exclusively found in animal products. That concept doesn't really exist anymore because we used to think our bodies couldn't make those amino acids. And it turns out that they can make most, all of the amino acids and we only need them in trace amounts.

Dr. Stieg: Can you enlighten me a little bit on this compound X or I guess it's called TMAO and the relevance of a plant based diet versus a mediating diet.

Dr. Yaghoobzadeh: Yeah, and Jamie might have, I might remember this talk. I use this as an example to have people understand how our body actually works with our microbiome. And there's this compound in the blood called TMAO, which we've known about for many, many years.

Dr. Stieg: Is that its name or an abbreviation?

Dr. Yaghoobzadeh: It's an abbreviation. I can't pronounce it. Tetramethylhydra-something or other, a little bit tongue in cheek. But, um, we've known for a long period of time that it is inflammatory. It leads to heart disease, it causes heart disease in animals. And we've been able to show very, very definitively that the higher the levels of TMAO in the blood, the higher the risk of having a heart attack or stroke 5, 10 years down the line. So the work was done and found that one of the places where TMAO comes from is L-Carnitine. L-Carnitine is an amino acid that's found in meat. So scientists wanted to do a study and try to figure out how quickly does meat get changed to this compound TMAO and where does it distribute in the body? How quickly does the body get rid of it? To do that kind of study, you need a system that's clean, has none of the TMAO in it. And then you need a system that's already reached steady state where the TMAO and the blood and the fat are out of equilibrium and so on and so forth. So the natural experiment is take a group of vegans, feed them steak, which students will do anything for, you know, money. And uh, you do a clinical study and then you take a group of people who are not vegans and you give them the same piece of steak. You measure TMAO before and after, and you see what happens.

Dr. Yaghoobzadeh: Normal folks, TMAO levels are elevated. They eat steak, TMA level goes up dramatically over 24 hours. Vegans, TMAO levels at baseline are close to zero. They eat steak and nothing happens that our TMAO level over the next 24 hours. And this was very confusing and surprising because you know both the vegans and the non vegans are human and they're eating the steak and it's not like they're genetically different or anything like that. And it turns out that gut bacteria break down L-Carnitine into a compound called TMA. And then we absorb that and make it into TMAO. And when there is steak L-Carnitine regularly in the diet, the bacteria that break that L-Carnitine down have a new food supply and it's like evolutionary biology. Those bacteria now have all this L-carnitine. They replicate, they set up shop all over the gut. The factories there stay, comes in, gets changed to TMAO the vegans because they haven't had L-Carnitine, those bacteria are starved. They haven't set up shop, they don't exist in the gut in real numbers. Steak comes in and it gets processed into something else. Now, the amazing thing about that is just like TMAO many, and some people say up to a third of metabolites that we can measure in the blood are actually related to the bacteria that live in your gut. They're not necessarily a function of you. They're a function of your bacteria. And if you are who you are because of your genetics, if you line up all of your genetics, all of your DNA head to toe, there's more genes, there's more DNA on your body, potentially that's bacteria than is you. So when you change what you eat and you change the bacteria that live in your gut, you're genetically changing who you are. For me, when I understood that it was a light bulb that went off, that you literally can change your genetics.

Dr. Stieg: So I can literally think that you're as smart as an amoeba. *laughs*

Dr. Yaghoobzadeh: Yeah, yeah, absolutely. And so I use that as a, as an example of, of what kind of power we actually have over things that we don't think we have any power over, like our genetics and the genetic determinants of our physiology. So that's, that's a really profound example for patients.

Dr. Stieg: Before I switch to Jamie, I just want to remind you that one of my heroes, Winston Churchill had probably the world's worst diet and he lived to 89 and seemed to be a content old man—

Dr. Yaghoobzadeh: And smoked a cigar—

Dr. Stieg: Up 13—

Jamie: He clearly had good genes. Very good genes.

Dr. Stieg: That's why I wish we really could quantify how important genes are. So Jamie, you know, you're running through airports all the time and I have not found an airport where there is healthy food, nor have I found an airplane where there's healthy food to the point that I don't really like to travel that much anymore. What did you do? Carry on?

Jamie: Yeah, it's a combination of carry on but I think it's also how hard you look and also frankly what you restrict yourself to. If you, you can always get fruit generally speaking. And so fruit literally replaces a lot of what I eat normally. You can also frankly find like, you know, salad bars where the salad bars come with some form of, you know, legumes and all that kind of good stuff. And so you have to make the time and effort to do that. You actually can ask the airline to make, you know, vegetarian meals. As we all know, they taste like nothing and they're unpalatable. You have to figure out lemons and limes and that kind of stuff.

Dr. Yaghoobzadeh: I always carry a bag of nuts, pumpkin seeds, um, things like that with me.

Dr. Stieg: You really got me excited.

Jamie: You'll laugh, so I go out to dinner for work a lot and my kids say, so what are you having for dinner? And my response is I'm having salad followed by salad.

Dr. Stieg: Adventuring out. But as I understand it, in your earlier life, you were a dessert connoisseur. What did Hooman do to your life?

Jamie: It's about sugar I guess at the end of the day. And so sugar clearly was a problem. The funny thing is it's not really sugar. I think it's just something that tastes sweet or you know, has some fiber in it. So we now have in my house dried fruit, amazing stuff. It's actually good things like that. So I think the fresh fruit is also actually very high in sugar, if you are okay with that. And so I eat a lot of like, I'll buy sliced pineapple. It's really good.

Dr. Stieg: So you can expand on that a little bit. So for people that have a sweet tooth work where can they go?

Dr. Yaghoobzadeh: Yeah. So the first thing to realize I think is that just like some people are addicted to alcohol and cocaine, the rest, all of us are addicted to sugar. And so when you look, when you're looking at your dessert and you see it as a line of cocaine, um, you have the correct context. So I have dark chocolate, I'll have nuts and raisins, like a trail mix, something sweet like that. My wife makes oatmeal cookies, which have sugar in them but less sugar and, and it's, you know, I don't eat it before I have dinner. There's a level of self control for sure. And I also, nothing is off the table forever. And so at holidays, parties, things like that. If I haven't had a dessert and it's like I'm at a cultural event and you know, there's this Polish dessert because I didn't realize there are Polish desserts. I'll, I'll eat it and indulge. Yeah.

Dr. Stieg: Everything in moderation.

Dr. Stieg: I don't know if either of you experienced this, but I'm sure many people do that they are married to somebody that has no sense of urgency in regard to their diet and they're not simpatico with you. And in this regard, how do you handle that? And I don't want everyone getting divorced over diet.

Dr. Yaghoobzadeh: Yeah, I act. So when I have patients come in for a diet talk, I insist that they bring their spouse, children, friends, um, we sit down and we have a conversation and I present to them the data. We go over PowerPoint slides. But I think that's an outstanding point. I also tell patients of mine who are parents and grandparents for that matter, the unintended consequences of you changing your diet is that others will change their diet around you. They have your genetics and you are going to have generational influence. And you know, Jamie was saying that you've changed the snacks in your office and that's sort of another perfect example of that.

Jamie: Yeah, I mean I think that that's in the work setting. It was very clear that A, my colleagues noticed what happened. And B, I sort of went on my way and said, guys, this is dumb to have, you know, it's literally was popcorn and a lot of these, you know, the granola bars that are basically sugar.

Dr. Stieg: Is popcorn okay?

Dr. Yaghoobzadeh: If it's not caramel and no butter. Yeah. Because it's just, it's a whole food.

Jamie: The other thing I will also say is that's the work at home. You start to go out and buy and shop for different things cause you've changed your diet. I think family is influenced by that. My kids are out of the house at this point. It's really just my wife and I, she's actually just as conscious as I am about, you know, weight and the rest of it. So she was always game. And I think that, you know, seeing what I went through, she's rapidly adapted to essentially the same diet.

Dr. Stieg: Well I find when, when when 

my nephew moved in with me and he 

was a vegan and my children at the time were seven and eight and all of a sudden my kids became vegan. That made life difficult.

Dr. Yaghoobzadeh: Can you guys tell Phil is not converted yet?

Dr. Stieg: I keep trying. They've kind of, they got back into food, regular food when they went to college, but now they've gone back to vegan and they're, they're are so much more conscious of what they put in their mouth than I ever was at 30.

Dr. Yaghoobzadeh: So I'm not the only one whispering in your ear.

Dr. Stieg: Plenty of people whispering to me. Jamie, tell us, when you, when you converted to this healthy diet, did you see a change also in the medications that you had to take? Did you reduce the statins and the blood pressure meds and all that?

Jamie: Well actually, it gets, just to be clear, I was essentially on statins, right?

Dr. Yaghoobzadeh: Right.

Jamie: And, and you know, obviously we had increased, we had increased the dose. So we talked about reducing it, but I, I guess I was sort of like, ah, it's a good stuff. It doesn't hurt.

Dr. Yaghoobzadeh: You know, your LDL levels, which were in the 130s now are 53. I am one of the physicians that really likes to keep LDL down and patients like yourself, we could actually potentially reduce the statins, to make sure that LDLs continue to be less than 70.

Dr. Stieg: The nutraceutical market is huge. And there was just an article in the New York Times and the Science Times this week about glucosamine. I don't know if you saw it, you know, it's obviously good for your joints, but now it may reduce your risk of heart attack and stroke. What are your thoughts?

Dr. Yaghoobzadeh: Again, I am not a believer in, in the supplements there are many of these supplements are based on some basic science research studies, animal studies. They have not had well done large randomized perspective, human studies, the large randomized prospective human studies that we have about supplements are all negative or 99.9% of them negative. And so for every one of those wonderful compounds, I can show you 10 others like curcumin and NAD and quersutin and so on and so forth that are also positive. And at the end of the day you're going to end up with 15 different supplements and we're not going to know exactly which one's working or not. I'm not, I'm a Western medicine type of trained physician. I've gotten convinced by the science behind food. I have not been convinced by the science behind supplements.

Dr. Stieg: So Jamie, when you get hungry or do you get hungry?

Jamie: Absolutely.

Dr. Stieg: You do. Okay. Uh, do you plan for that? You said you carry an apple in your bag.

Jamie: Well yeah, it's apple, banana. I actually like dried fruit of some kind. Um, that, And nuts. I think that's, that's essentially what I would, you know,

Dr. Stieg: And at the end of a meal, you're really satisfied.

Jamie: Well, I went out to dinner last night in New York and you know, everyone had dessert and I had dessert with everybody else. I had strawberries and blueberries. It's that simple and I just, it's not a big deal. No one really knows this. And it goes fine, but that's essentially what you had.

Dr. Stieg: Did you go cold turkey? Yeah — you met Hooman and boom.

Jamie: No, actually it's funny, there was about a six month or maybe even a year lag between the first time and I think the numbers didn't improve and I got more, I guess—

Dr. Stieg: More convinced. So it was a slower transition?

Jamie: Well, initially I think, and then I didn't see him again for a year. And I think in the course of that year I adhered to the plan.

Dr. Stieg: What do you see in patient populations? Do they do the cold turkey or do they kind of gradually grow into it like Jamie?

Dr. Yaghoobzadeh: Because of the way 

that I've set it up, I, I have a lot of patients sort of do a month challenge to sort of get their heads around being able to do this. And it doesn't feel unsurmountable if you're only gonna do it for a month. And then they see all their numbers change and now they're motivated. And there are patients who have been in my practice for 8, 9, 10 years. They just recently started to move towards a whole food plant based diet because that was the right time for them. I've been eating like this only for about eight years, nine years. That's because at some point in my life I was in the right psychological space to be able to sort of open up to this. So everybody's has their own a magic box and black box of, of you know, how they can influence their health and life.

Dr. Stieg: We're sitting here on the Upper East Side. A lot of people listening to this don't live in this particular area. And in my work with the American heart association, we have these food programs going on. The thing that I worry about is it's, this easier is to do in our environment, but how do we get this to the schools? Frankly, the efforts we've made is we try to change the diet in the high school and the parents call in and they go crazy — the PTA. Say, what are you doing, messing with my kid's diet? That's real food is medicine. What, what, what do you think? What do we do?

Dr. Yaghoobzadeh: There's an absolute cultural shift that needs to happen and what's amazing is, you know our great, great, great grandparents knew how to eat. They were peasants, they were poor. Animal proteins were very expensive. They were reserved for weddings and birthdays and things like that, so it's not really a novel concept, it's just getting back to traditional ways of eating and cooking, but you're 100% correct that there needs to be a cultural shift and that's why I do talk about addiction because I think part of our pushback is the addict and us subconsciously pushing back. New York City schools now have Meatless Mondays, New York City hospitals, now we're moving towards plant based meals. We have easily identified this Southern diet actually through work that's been done at Cornell. The Southern diet, which is a very high saturated, highly processed diet is very closely linked to to heart disease and so it's, I think it is a slow process and we just have to continue to talk about it. There are more and more restaurants that are popping out—

Dr. Stieg: Are you aware of any movements that are going on that are really going to help us get, get the population to change? Cause I agree with you totally. If we're talking about food as medicine, which it is, we got to change behavior.

Dr. Yaghoobzadeh: Some of it is happening in pop culture. So there's going to be a documentary coming out, um, called Game Changers that sort of goes through athletes who are whole food plant based. There is now the Lancet diet study which links plant based eating with planetary health. So there are many, many movements that are really understanding this message that, one of the ways to reduce our carbon footprint is to move away from animal products. There is a documentary that started this, which is called Forks Over Knives. There are many books out there now about this kind of eating. Eat to Live is one of them. How Not To Die is another one. Interesting play on words. So that is starting to become much, much more obvious. The way that we eat and the way that we take care of our planet are linked.

Dr. Stieg: Hooman, Jamie, I think that we've kind of really focused on how important food is as a medicine, and hopefully — Hopefully I will change and hopefully we've changed the number of people that are listening to this. Thank you so much for being with me.

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Sleep disruptions have unexpected and serious impacts on the health of your brain. Dr. Ana Krieger, Chief of Sleep Neurology at Weill Cornell Medicine, explains why snoring is a danger sign for sleep apnea affecting 40 million Americans -- and why "getting by" on 6 hours of sleep a night is a risk you probably shouldn't take.

Dr. Stieg: Welcome. I'm with Dr. Ana Krieger, the Medical Director of the Weill Cornell Center for Sleep Medicine and Associate Professor of Clinical Medicine in the Departments of Medicine, Neurology, and Genetic Medicine. Over the past 20 years, Dr. Krieger has been actively involved in patient care, training of sleep specialists, sleep disorders, education and scientific research. Dr. Krieger is a regular contributor in the media to increase public awareness of obstructive sleep apnea and other sleep problems as well as the latest treatment alternatives. We are also joined by one of Ana's patients, Stephen Allen. Stephen is in senior management at Ralph Pucci Furniture and Design Showroom in Manhattan, specializing in high end French and other modernist design. Welcome to both of you. Sleep apnea is a huge problem throughout the world, but a lot of people don't really want to admit it. They don't want to talk about it. How prevalent is it?

Dr. Krieger: Sleep apnea is quite prevalent. It seems interesting because for many years we've felt that snoring was very common and we took for granted and accepted it as potentially normal and now that we have tools for diagnosing it, we believe that over 40 million people in this country are suffering from sleep apnea. What are the biggest factors that led to increase diagnoses of sleep apnea was this obesity epidemic and that is what actually triggered a lot of programs like ours and we are able to find out through this program is that a lot of people don't actually have a sleep apnea just because of obesity. They may just have sleep apnea because of their own anatomy. There are groups of course, men over 50 if they have high blood pressure, we know that they have higher chance of having sleep apnea. If people are overweight and have diabetes for instance, is another group of patients that we know have high rates of sleep apnea. We have children with sleep apnea. We have patients as old as a hundred that get the initial diagnosis sleep apnea close to their a hundredth birthday. Yeah, it's fascinating and it's interesting because in women we get to see that as sleep apnea sometimes develop after menopause.

Dr. Stieg: Are there specific risk factors for developing? Can I do something that would induce me to develop sleep apnea?

Dr. Krieger: Definitely gaining weight increases the chance of people developing apnea and moreso in men than women, but other factors are not necessarily is it to change. As you get older you have perhaps the hypertension, so there are some intrinsic risk factors that are really hard to modify and that's why we're very concerned about properly diagnosing people because you can't necessarily make the apnea go away.

Dr. Stieg: I'm a little bit perplexed by, even in my patient population, when someone comes in, they get an operation and postoperatively while they're in the ICU we find out, gosh, they've got sleep apnea or they've got obstructive sleep apnea and we have to start treating them. What, what is this lack of understanding? Is it denial or is it a lack of understanding? What process do you find going on with your patients?

Dr. Krieger: I think sometimes people are not aware of their disease, similar to having high blood pressure, high cholesterol, and as that gets checked, people really don't know that that's an issue that we are so sleep deprived nowadays that it's hard for people to really say, Oh, something medically is going on besides the sleep deprivation, how many hours should I be sleeping every night? Well, that's very interesting because probably between seven and eight but that changes depending on your activities, on your age, on your health and your genetics, but that's what typically we recommend for people, between seven and eight hours.

Dr. Stieg: What are some of the greatest myths that you see out there about obstructive sleep apnea patients come to you and they have this misunderstanding? What are those?

Dr. Krieger: Well, I think one of the biggest myths is that snoring is normal just because it was socially acceptable before. I think somehow it isn't anymore.

Dr. Stieg: So I'm going to be a little bit personal here and we always used to tease my dad. He was 95 years old and he'd sit in the chair and his head would fall back and we would tease him because he had, we'd call it pooing and gooing. Is that snoring?

Dr. Krieger: Yeah. Then probably a little more than that. It's probably the airway is closed and he might be choking. Right?

Dr. Stieg: He always woke up fresh.

Dr. Krieger: Right? It is interesting because I had, one of the most interesting cases I ever treated was an elderly woman in her mid eighties that the son was an EMS provider and he would resuscitate her because she arrested at home and they always believed it was a cardiac arrest, was that it made it multiple times. Had pacemaker implanted was in and out of the hospital up to one time and one of her primary care providers sad. You know Ana, "I don't know what else to do. Can you just do a sleep study on her?" And she had, she would be choking to the point that her heart would stop.

Dr. Stieg: So as you said, many patients don't even know that they have sleep apnea. I would 

presume then it's important for our partners to say, you know, we need to go get a doctor. Right? Is that hard for them to do?

Dr. Krieger: Well, I think it's harder for people to accept, you know, I think the partners sometimes are pretty vocal. They record, you know, we have tape recording nowadays and then people say, Oh no, no, no, that's really not a big deal. Or maybe that day I drank too much or maybe I ate too late so they blaming other factors that may actually worse than apnea but may not necessarily be the only cause

Dr. Stieg: Given one of my main tenets is brain health. What is the advantage to early detection? Why should either, I admit I've got it, or my mates say, listen, you need to go get help.

Dr. Krieger: Well one of the biggest issues is that for people that have sleep apnea, there are two major factors that happen during the night. One is that intermittently their oxygen levels drop. So we know for brain health that is really not desirable, in the second aspect is in order to improve their breathing. So they, when they are choking and making big, loud efforts to breathe, they wake themselves up from sleep even if they are not aware of. And that leads to sleep fragmentation, which is also not good for brain health.

Dr. Stieg: So I want to bring Steven into this since he lives with it, lived it. Stephen, tell us a little bit about what were your symptoms? Why did you go see Dr. Krieger?

Stephen Allen: I wasn't at all aware of my snoring as you were just saying. And my wife would wake me up in the middle of the night and say, you know you're snoring.

Dr. Stieg: So was that a gentle nudge? Was it a kick? Was it a punch? Thrown out of bed?

Stephen Allen: It didn't start off to be gentle. I can't blame her. I spoke to her about it. I said, "I'm not snoring." And she said, "Yes you are." And I said, "Would you be a little kinder when you wake me up?" So then it was a soft touch, and "Honey, you're snoring." So I appreciated that, but then it was back to the shaking me awake again and I said, what are you doing? And she goes, you're gasping for air. And she said, promise me you'll get this checked out.

Dr. Stieg: As an aside, Ana, how common is it for sleep apnea to cause marital difficulties?

Dr. Krieger: Well, it's actually very common. Not necessarily difficulties, but people move to different 

bedrooms often, and a different bed, you know, it's very, very common because of that.

Dr. Stieg: Is that good for a marriage or bad? Don't answer that.

Stephen Allen: If I could add to that, that was an option, but I didn't want that to happen. So I kept my promise because I didn't want a separate bedroom just because I snore. I felt like an outcast or something was wrong with me and it was causing a problem in the marriage. So I was in denial. As you mentioned earlier, my father snored, my sister snores, snoring was a part of growing up in my household.

Dr. Stieg: So it seems to me that even I, not a sleep expert could probably make your diagnosis. You know, your wife's waking you up, you're snoring. That's pretty straight forward that it need to be tested. And I'm presuming the first thing you did was a sleep study. What's that like?

Stephen Allen: It's unusual where you're being hooked up to a little electrode wires all over your body. As a with an echocardiogram, the little electrical pod, things that stick to you everywhere. It takes about 45 minutes to get all hooked up before you actually get in bed and the study begins.

Dr. Stieg: Ana, is this covered by insurance?

Dr. Krieger: Yes, overnight sleep studies and mostly covered although over the past five to seven years, regulations have changed. The insurances are trying to cut costs so they are trying to move the bulk of those statuses back to the home environment.

Dr. Stieg: The bulk of the tests in the home environment? But it's not as though patients have to come in and pay for this stuff.

Dr. Krieger: Yes, no — it has always been covered to some degree. At least, again, policies are constantly changing, but it is a covered evaluation.

Dr. Stieg: Steven, it's obvious that you find out that you had sleep apnea. Where do you go? You go to a shop and they got 20 different little devices that you can pick from. How do you go about?

Stephen Allen: Well actually, Dr. Krieger has a very thorough office and she had several machines to pick from. I chose the mask that was as simple as possible, the newest technology, which Dr. Krieger also was able to supply for me, and I tried the mask and the machine. I fell in love.

Dr. Stieg: Is it like the Rolls-Royce version, the Chevy version, and the Mercedes version, or are they all the same price and you just got to pick one that fits your face?

Dr. Krieger: I think choosing what works best for you is the most important because it's very hard for us. We could say this is the latest model and the best technology, but if it doesn't fit to our patient, it's really not going to work.

Dr. Stieg: Every time I think about the patient or I have my patients sitting in the ICU with one of these CPAP machines on, you know, I think, gosh, what's that like to live with at home? What kind of fears did you have when you're thinking about now? I gotta take this thing home. And you wear it all night?

Stephen Allen: Absolutely. When I don't wear it I snore.

Dr. Stieg: Pre-use did you go through any anxiety and thought process about, gosh, how's this going to change my life?

Stephen Allen: I wasn't so concerned about me, but I was more concerned about when my wife looks over at me in bed with this mask on, what is she going to think? So I found myself trying not to put the mask on until I knew my wife was asleep.

Dr. Stieg: But what would happen is I would go to sleep first and she would end up nudging me, say, put your mask on. So I got over that because she was getting a good night's sleep. I was getting a good night's sleep. So the fear of, "Did she marry a Frankenstein" now passed quickly after the results were evident.

Dr. Stieg: So you have the Mother Teresa award in your household for your wife I gather?

Stephen Allen: Absolutely.

Dr. Stieg: Does the machine or the process make noise?

Stephen Allen: It's a very low hum.

Dr. Stieg: So it's white noise.

Stephen Allen: It's a white noise.

Dr. Stieg: And when you're wrong through the mask, it's not as though you still sound like Darth Vader.

Stephen Allen: No, no. If it's an improper fit, absolutely.

Dr. Stieg: So it doesn't disturb the person with you?

Stephen Allen: No, it doesn't.

Dr. Stieg: Is this machine you just put the mask on and flip it on or is it complex to use?

Stephen Allen: Once you put the mask on, it senses that you have it on and it will start off slowly and build up to full speed as your breathing becomes more normal. It was easy for me to adjust to the mask because I breathe in and out of my nose. Unlike some people that are mouth breathers, years of yoga helped me train myself to breathe in, and breathe out through my nose and sometimes if I am a little anxious, I start the breathing techniques from yoga classes and the machine just accelerates that to help me really relax and I'm getting a very restful sleep.

Dr. Stieg: Stephen, this is, I presume, been transformative for you. How has it changed your life? 

Stephen Allen: I feel much better. My wife feels much better.

Dr. Stieg: What advice would you give to somebody about this? How are you going to help us motivate people to get help?

Stephen Allen: Looking at my experience and the way I have improved my health, it's a life changing experience for both your partner and yourself.

Dr. Stieg: Before we get into insomnia, can you describe the physiology of the normal sleep cycle? What language do you use to explain to your patients?

Dr. Krieger: One of the most important things about sleep is that sleep is necessary, right? Sometimes people will say, can I get by without sleeping? We can't. So it's part of a physiological process. Any follows a rhythm. Every 24 hours we have a rhythm that closes off. In part of that 24 hours over a seven or eight hour period is where we should be sleeping. Not everybody needs the same amount of sleep and not all the time. We need the same amount. If you're more stressed, if you do more physical or cognitive activity, you may need more or less sleep. So there's always a variation.

Dr. Stieg: But never less than seven? Our current president says that he only needs three hours of sleep. And, and I have a lot of friends that say that. Is that real?

Dr. Krieger: Well there is a curve. So at the same time we have people that need 10 hours of sleep. We do have people that need five or six hours of sleep. Sometimes if you look at very successful people, maybe they did have a lot more hours during the day to work. So maybe that was a factor, but sometimes, or more often than anything else, that people sleep deprive themselves. So it's not necessarily what they actually need is what they get by with in the bodies in the brain is very resilient. So we're able to cope sleeping last and what we actually physiologically would need the same way they may be. We don't nourish our body exactly the way we should. We get by, you know, you know, doing reasonably well with that.

Dr. Stieg: is it a myth that I didn't get enough sleep this week, I'm going to crash and make up for it on the weekend. You can compensate for sleep deprivation.

Dr. Krieger: Well many people do that. It's better than not compensating to be honest.

Dr. Stieg: So there is an advantage?

Dr. Krieger: There is. The major concern is that people need to look back into the reason for this. Is there really a necessity for them to be sleep deprived during the week? And if there is not, people need to be a little more mindful. So we always focus on trying to get people to understand this 24 hour rhythm and try to see how can you make each day more predictable in terms of sleep.

Dr. Stieg: So let's get back to that sleep cycle. Out of that eight hours, do you go through multiple sleep cycles and what constitutes one full sleep cycle?

Dr. Krieger: So we go through the night over about four or five cycles of sleep. Each cycle lasts about 90-120 minutes. As the night progressed, as we have more and more dream sleep, which comes at the end of each cycle and we have less and less of what actually is deep sleep is when the brain functions very slowly and very regularly. And this actually is a period of the night where we also synchronize some hormonal release. And we've been, even with little kids, we used to say, "If you don't to bed early, you're not going to grow," because growth hormone is actually released during that first third of the night, more or less around the same time where do we go into this deeper stage of sleep.

Dr. Stieg: And what about anti-inflammatory effects of sleep on the brain?

Dr. Krieger: This is beautiful. I love this question because the effect of sleep is really amazing because the brain gets you to sleep but also benefits itself from sleep. No other organ can do that at the same level as brain does, so that's beautiful.

Dr. Stieg: I have this discussion all the time with the heart specialist — that the brain is the diamond organ.

Dr. Krieger: And it is unbelievable and not only anti-inflammatory for the brain, but for the whole body. The rhythm of our sleep is actually measured in the rest of the body as well. We can do biopsies on your skin cells and see if they follow a rhythm. Biopsy your liver, the liver function follows a rhythm and that's all regularized by the sleep cycle.

Dr. Stieg: There's a lot of conversation about REM sleep. Does that occur during a particular portion of the cycle? And how long is that? How important is that?

Dr. Krieger: So REM sleep comes at the end of each cycle. Let's say we go into the more superficial stages of sleep. Then stage two is one of the bulk of our non-REM stages of sleep. Then typically we go into delta, sleep, and slow wave sleep, in then into REM sleep.

Dr. Krieger: So REM sleep doesn't come in one cluster, it comes in little clusters. The first one is very small and it could be, you know, just 10 seconds. And then over cycles and cycles towards the end of the night period, we have more and more REM sleep. So just before waking up is when we get the bulk of our REM sleep.

Dr. Stieg: And is it a myth or a reality about the importance of REM sleep? If you block pupils, you let them sleep through all the other portions of the cycle, but you block their REM sleep. Are there any ramifications for the result?

Dr. Krieger: Well, animal studies have shown that if you deprive rats from REM sleep specifically after two weeks, they die. We haven't tried that in humans, of course, right? But we know that we have to be very mindful because there is probably a very good link between memory consolidation that happens during REM sleep.

Dr. Stieg: People that have sleep apnea, do they have less REM sleep?

Dr. Krieger: They tend to do because what happens in REM sleep is that in order for the brain to be very active, we actually paralyze your muscles. Then imagine the airway that is already compromised. Now, if you paralyze those muscles fully collapses the airway. So patients who have obstructive sleep apnea often have a state of deprivation or REM sleep.

Dr. Stieg: But we never take it away completely. So we wouldn't know whether the rat studies apply to the human.

Dr. Stieg: Right. But it's definitely a major concern.

Dr. Stieg: To hear more about this important topic. Please join us on our next episode.

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Cell phones, stress, and a hyper-scheduled life all put your sleep cycle in danger. Sleep disruption is bad for brain health, wreaks havoc on mood, and even raises the risk of cancer. Dr. Ana Krieger, Chief of Sleep Neurology at Weill Cornell Medicine, has the solutions we need for a better night's sleep.

Dr. Stieg: I'm here again with Dr. Ana Kreiger talking about sleep and its impact on our lives. Tell me a little bit about what circadian rhythm is and then what disruption of that rhythm means for me as a patient.

Dr. Krieger: So circadian rhythm basically stands for that 24 hour cycle in where your sleep period is on a given 24 hour day. So the idea would be that if you sleep from 12 to 6:00 AM that's your sleep cycle on your circadian rhythm. If one day you sleep from 8 to 4:00 AM the next day from 2 to 10:00 AM and then back to midnight, you really have a dysregulation on your circadian rhythm is bad for you. It is bad because we are identifying that the body functions in a 24 hour cycle, much less similar to what we have with the sun and in darkness cycle. So once we disrupt that cycle on a regular basis, it really disrupts our physiology because during that sleep period, all the hormones that get regulated and often I tell patients, the time you wake up is almost the anchor to this rhythm, the circadian rhythm.

Dr. Stieg: Have you noticed that people that work third shift have any greater difficulties?

Dr. Krieger: Well, yes, it is actually a lot of data for shift workers. We have, let's say nurses over 15 years that do night shifts over three times a month. They have higher chance of having breast cancer, prostate — men for prostate cancer, and women, ovarian cancer and colon cancer as well.

Dr. Stieg: I wanted to talk to you a little bit about daytime sleepiness. As a resident I got three hours of sleep a night and I could be out and sitting at a restaurant and just pass right out. Is that daytime sleepiness or is that just sleep deprivation?

Dr. Krieger: Very likely. Just pure sleep deprivation and we are, in the medical profession, we all experienced that. Is this harmful in the long run? We don't actually know, but the only idea is that your brain really needs to sleep. And that's why it doesn't matter where you are. That will be a point where without you willing, you're going to be falling asleep. And that brings our concerning to motor vehicle accidents, right? Many people are sleep deprived in some times they could be more of a danger in the road than people that are actually out drinking alcohol because he can cause the same level or more of impairment.

Dr. Stieg: So as daytime sleepiness a disease or is it just a symptom of me not getting enough sleep?

Dr. Krieger: This is an excellent question because it can be a disease. So we have conditions that we have that called either narcolepsy or hypersomnia, people that are just sleepy during the day. And some people, it doesn't matter how much sleep they get at night, they're very sleepy.

Dr. Stieg: So it's a crossover — cause I was going to bring up narcolepsy. But, that's why I was wondering is there a specific category of daytime sleepiness that we have to deal with?

Dr. Krieger: Yes there are. And sometimes that becomes a bit of a challenge because we see sometimes patients that have a more of an autoimmune process and the brain just becomes very, very sleepy and no matter what you do, the brain can never be fully alert. The majority of cases that we get to see are patients that have sleepiness because of either lack of sleep or an underlying sleep disorder.

Dr. Stieg: I wanted to bring up those concepts of what can we do. We talked a little bit about over the counter things. What about meditation, yoga, exercise? If you want to break them down into each one of those categories tell me, you know, are they good for sleep? How much should you do if it is?

Dr. Krieger: All the other techniques can be very helpful because I think we live in a society that is overworked, overstressed, you know, sleep deprived, overstimulated. So we need to look into each person's life and say, what are the excessive stimulus that you can remove so you can be more productive in? What are the times that you can Institute as a little bit of a break because I think we are in this hyper-drive and that is really not how they fall asleep. So I love when people do meditation, Tai Chi is an amazing exercise for that because it combines some activities, physical and mental.

Dr. Stieg: So you do Tai Chi during the day, but that still helps your sleep? You have to go to bed at 10 o'clock or whatever your normal time is.

Dr. Krieger: Right.

Dr. Stieg: And exercise, I like to exercise at four o'clock in the afternoon because my endorphins kick in and it keeps me going until 10 o'clock

Dr. Krieger: Very good points. So we have to be very mindful in how we allocate. Some people decide to meditate just before they go to sleep. They might be able to fall asleep, but two hours later the brain, the brain feels fully activated. So I think timing and also looking at what is the type of meditation people are doing. There are different types of meditation that may help them fall asleep earlier.

Dr. Stieg: Tell me a little bit about the effects of cell phone use and being online for extended periods of time during the day. Is there any data on what effect this has on our sleep cycle and our brain function?

Dr. Krieger: Yes, it is early data and I think every day basically we get more information on this because again, part of this cycle that we have during the dark hours of the day is where sleep should be allocated. Allowed us to then not have a lot of input of light through the eye. Then you secrete melatonin, which is this dark signaling hormone. It helps consolidate your sleep. So now when people get exposed to a lot of bright lights, particularly devices that give light on the spectrum, the blue spectrum of light, which if you were to look at the measure, the wave land of the light, the the range, they don't stays on that purple, blue and green light is quite activating for the brain and then it disrupts not only your difficulties falling asleep but also disruption disruptions into the cycle as the night progresses.

Dr. Stieg: And is there data on the psychological impact that has or are people more depressed? Are they more anxious? Are they less tolerant?

Dr. Krieger: Well, very interesting. Data is coming out showing that this type of fragmentation sleep decreases. As I mentioned, the tolerance in our people have much more negative behaviors towards any stressful circumstances, so increases the negativity and probably depression. It would be associated with that.

Dr. Stieg: My kids have cell phones. What time of night should I tell them they gotta turn it off?

Dr. Krieger: Well, ideally you want them for one hour before going to bed to stop using our electronics. If they can't, because being realistic, if they have homework assignments and other things that required a computer use, you can actually buy them some blue blocking devices, which are usually goggles they can wear, like they have nice glasses they can wear while they are in the computer and then changes. It basically blocks that wavelength of light that is on the blue spectrum.

Dr. Stieg: There's a lot of over the counter stuff and talk about melatonin and Ambien and all that. Can you comment on these integrative therapies or over the counter therapies? Are they good, bad or not —p articularly melatonin? That's a pretty common one.

Dr. Krieger: Yeah, it is very common and again, melatonin is a natural supplement, so imagine just because the body produces is fine for us to take, but of course you want to take that just as needed. One great use of melatonin is with travel to different time zones. For jet lag, there is a lot of data that shows melatonin over the first three nights on your destination, usually between one and three milligrams you take when you arrive at a destination in terms of bad time. So you do for the first three nights as you go to sleep.

Dr. Stieg: Land in Europe at four o'clock in the afternoon, you shouldn't take it until 10 o'clock—

Dr. Krieger: Until you go to bed. Exactly. Because again, melatonin is this dark signaling hormone and if you're exposing yourself to light, it actually blocks melatonin from working. What do we know is that it would all overexpose to light, so probably we're all secreting less melatonin than what we should, so perhaps that is a benefit to that.

Dr. Stieg: Can you give me the top three things I can do that will help me get to sleep at night?

Dr. Krieger: One of the most important things I would say, number one will be to have a sleep on your schedule and it looks about only 10% of people actually have a schedule for sleep. Most people just sleep whenever they can. So I think be mindful of the awareness that is sleep needs to come on a regular time. The second important aspect is really tried to eliminate the excessive stimulus that we have during the day. It's great, it makes us productive during the day hours but not really at night. So try to minimize that excessive stimulus. And I think the third aspect is try to create an environment for sleep that is really cozy and comfortable. It shouldn't be too hot, you shouldn't be facing lot of work, shouldn't get all the light coming through the environment. So trying to focus on how your bedroom looks like.

Dr. Stieg: In listening to you, I was sitting here thinking, gosh, it's exactly the same advice that I give to patients about leading a normal life. You know, it's called focus and it's called regimentation. All the things that we hate and all the things that get interrupted now by our mobile devices.

Dr. Krieger: Yeah. Sometimes I feel like an old grandma in giving people advice. I have to say in the office and say, What would your grandmother say? Yeah. Because I think it's easy for us to lose focus and lose sight of what do we actually have to do. We look for a quick fix and for sleep there's really no quick fix. We really need to restructure our lives.

Dr. Stieg: Serotonin, dopamine, important neurotransmitters are chemicals in the brain for happiness and joy. Any data on the impact that too much too little sleep has on those chemicals?

Dr. Krieger: So just a lot of data looking at people with normal sleep duration, short sleep duration in looking at how they respond to environmental stress in their response at work. Stress at work, stress at home. Even in traffic you can see people get a lot more edgy, they get a little more violent, they get it sometime even more depressed or hopeless. So we know that the sleep also serves a big role into mood modulation.

Dr. Stieg: It brings up an interesting point, headphones laying in bed and putting on Vivaldi's Four Seasons. Is that good or bad during a sleep cycle?

Dr. Krieger: Also an amazing point. Because we're trying to understand that perhaps sound waves can actually help us sleep, so there is some technology coming out there and being tasked in the same, perhaps specific sound waves can actually get you into the rhythm of sleep.

Dr. Stieg: Probably not The Who.

Dr. Krieger: Not what most people would be listening to at night, but that backs into, let's say white noise machine. Some people use that because in New York City we live in a very noisy environment and some places it's just really very deserving of their sleep.

Dr. Stieg: Tell me about narcolepsy. How common is it? What is it? What do we do about it?

Dr. Krieger: Narcolepsy is uncommon situation where patients really have no control of their sleepiness. It's triggered by emotions most of the time. Sometimes it could be a buckling of the knees or the head. I've had a patient that had narcolepsy and on his birthday, you know, in the midst of celebration, he kept on having cataplexy attacks and it scared everybody they wanted to call 911 but he was well aware of his disease, but nobody else had seen him. So he knew what was happening and for many years we really didn't have good treatments for this. And now we have very good therapy that not only prevents the cataplexy from happening, but wakes people up during the day.

Dr. Stieg: I have some friends that have described to me that they had night terrors. Not having had them, I don't have any personal experience. What is it?

Dr. Krieger: So night terrors are behaviors that come in on the earlier part of the night, frequently in kids. So what happens is that when they get into this very deep stage of sleep, they might actually behave in terms of screaming or they may have some kind of confusional arousals we call. And the parents would be coming rushing to them and say what is happening? But the person would not really relate to them. Confusion arousals, those are typically a concept that we call parasomnia in parasomnias are unusual behaviors that are listed from sleep.

Dr. Stieg: And that falls into the night terror category.

Dr. Krieger: Exactly. It could have be the sleep walking could be sleep talking, i tends to happen on the first third of the night. Could it be very benign? Many kids can present with this as they grow older, this tends to dissipate. Sometimes adults may present with that and when this happens in adulthood in somebody that never had it or maybe that had it and had gone away, we want to evaluate their sleep to see is there any disruption in their sleep cycle that is triggering this abnormal behavior. But most of the time this is really a benign situation mostly in kids and safety is always our biggest concern. But I would say for adults is when we worry the most because they could get out, they could drive, they could get out of the house. So there are very strange behaviors that people can do during the night.

Dr. Stieg: So is that different than a nightmare?

Dr. Krieger: Yes. Because nightmares typically would be coming out of mortar, the dream state, somewhat of REM sleep in sometimes nightmares, people can act them out. Let's say they can hurt somebody in the middle of a dream. So when you have more of a dream enactment type of behavior, we worry about other conditions or either alcohol related neuro behavioral changes, precursor, perhaps a Parkinson's disease—

Dr. Stieg: Are nightmares then reflective of some other disorder?

Dr. Krieger: It's hard to say because I think people sometimes talk about maybe a past experience or a trauma that people might have, but sometimes you feel, look at real life, everybody has a bit of an anxiety. You have a task coming up, you need to take an early flight. So sometimes it is anxiety to then get stored away and may come out and representation during dream sleep.

Dr. Stieg: So I have to admit, I'm fascinated by this concept of night terrors and you talk about people going out and doing things that are non-harmful. You said you've had a lot of patients with night terrors. Can you, I mean obviously with no names, what's one of the most unusual things that somebody has described to you with a night terror?

Dr. Krieger: Well, I had a patient that went to visit a friend that live in a high rise and in the middle of the night she left the apartment undressed and went down the stairs and woke herself up sitting on the stairs, 10 floors below her friend's apartment in the middle of the night undressed. Luckily she didn't close the door so she was able to go back into the apartment without anybody saying it.

Dr. Stieg: So there's really just this kind of complete dissociation between the individual's conscious awareness and what their body is doing.

Dr. Krieger: It is, and it's fascinating for us because even on legal terms, sometimes you know, people can do things, you know, we hear things like people drove cars and got into accidents or injured somebody else. So where is, is this intentional or not? And it's sometimes very hard for us to see because when we monitor sleep during those episodes, you can see the background is sleep, but as you measure electrical and muscle activity, there's so much activity going on that is so hard for us to really be pinpoint and know is this intentional or not. Some people remember, some people say, Oh yes, I woke up and I was eating like a plant in the kitchen. And then I said, what am I doing? Let's just go up to bed. Others say they wake up and they look, you know, lots of crumbles everywhere and they say, I probably got up and used the bathroom or use the kitchen in the middle of the night.

Dr. Stieg: As we talked about earlier, there's just a lot of stuff out there and the medications people can buy. Do you recommend that people go out and do a lot of reading and how reliable is the internet on all this stuff? Or again, do you think it is best to get a sleep expert like yourself?

Dr. Krieger: Well, there are some guides that are made by academics. Sleep centers, I think can be very helpful. I know many institutions like ours, we have our own guide to try to help educate people on their sleep, but a simple process I think would be for patients or people out there to just look into their lives and just be a little more conscious about their routine and see what can they actually do. Because most of the time, when I talk to patients, if I were to ask them, what would be the top three things you could do to improve your sleep, they would be right on target, but they don't want to really, you know, work on that unless somebody tells them to do it.

Dr. Stieg: Ana, it's really been a great pleasure. Thank you so much for enlightening my lack of knowledge on the importance of sleep.

Dr. Krieger: Thank you so much. The pleasure was mine.

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A runner’s life-threatening brain bleed is repaired just in time thanks to a new minimally invasive procedure. Patient Mikal Scott talks about his alarming symptoms and fortunate meeting with neurosurgeon Dr. Jared Knopman, who performed the pioneering technique that’s now providing patients with a far better treatment option for this condition.

Dr. Stieg: I'd like to welcome my two guests this morning, Mikal Scott, a marketing consultant who is an avid and extremely dedicated runner as well as Dr. Jared Knopman, who is an Associate Professor of Neurological Surgery and specializes in minimally invasive access to the brain. Thank you so much for being here. And I wanted to start by talking about Mikal's medical issue that resulted in his presentation to the emergency room. And it's a subject that is becoming more common in America with the aging population is something called subacute or chronic subdural hematomas. Dr. Knopman, can you kind of explain what this means?

Dr. Knopman: Sure. So a subdural hematoma is when blood builds up between the dura, which is the covering over the brain and the brain itself. As we all age, our brain begins to shrink away from that covering and that space becomes bigger. So we become more prone to having an accident and then bleeding into that space. As you alluded to, Dr. Stieg, with our aging population, subdural hematoma is predicted to be the most common neurosurgical condition by 2030.

Dr. Stieg: You can't see Mikal, but he's not old. And that's what makes this a little bit unusual is that it can affect people of younger ages, correct?

Dr. Knopman: It can. What essentially happens is there are veins that run between our brain and the covering over the brain. And after someone gets hit in the head or a minor trauma, those veins can tear and bleeding can occur. And what happens is the blood clot builds up and it forms a membrane around itself. Although the bleeding can stop that blood clot may not go away on its own and it can cause pressure on the brain. It can cause neurologic deficits, and it can happen even in young people such as Mikal.

Dr. Stieg: So one would think that an avid runner like Michael and a businessman wouldn't be very susceptible to having this kind of problem. Mikal, can you tell us a little bit about your story? How did you notice this and what happened?

Mikal Scott: Sure. All of a sudden I started getting headaches. I literally didn't know what was going on in my life and I would find myself lying down in the middle of the day having to stop meetings because I couldn't continue because it just hurts so badly.

Dr. Stieg: Yeah, personally, I've had patients that have had just terrible sneezing episodes — elderly, and they started having this problem. Or another common scenario that I've seen is with these amusement parks going down the water slides, and where you get ripped around and, and the important thing is not to think about blunt trauma, you know, a blow to the head, but your head can be shaken, i.e. playing football and frisbee and things like that. You said that you had headaches — I'd like to get into also the emotional about this. You know, you said you had, you couldn't complete your business meetings. You knew you had to sit and lay down. Did that have an emotional impact on you?

Mikal Scott: Ah, very much so. But, when you're trying to come up with creative solutions for problems, you need to be thinking all the way through. If you can't think from beginning, middle, to end, your idea is worthless. And having to walk out of a meeting, and in the middle of discussing a problem, it has an effect on you.

Dr. Stieg: But what I found astounding when I was reading about your story is that you still managed to grunt through a 5K run with all this pain?

Mikal Scott: Well, I joined this club here in New York called Central Park Track Club and it turned out we're a bunch of all Type A personalities who run really, really fast. And every time you race you have to race. And then I started vomiting from the headaches. I induced vomiting, I felt better and I went out and I ran. Yes, I didn't run a great time, but it was for charity for police officers who have died in the line of duty. So I sorta felt like I really needed to pull my end up. I've got, I was going, "I only have headaches. These guys died." Yeah, so, and I went through and I did it.

Dr. Stieg: So it was a little bit interesting here as I understand also that you did seek medical care and you were told to do some minor things and Dr. Knopman, how common is that in this scenario that he has this what turns out to be a significant problem and it's a little bit overlooked?

Dr. Knopman: Well, sometimes subdural hematomas will go away on their own and we will give medical therapy and observation and close follow-up to see if that happens. By the time Mikal came to see me, his subdural hematoma had not gone away on its own. He was continuing to have symptoms from it and in fact it was slowly enlarging. And at that point, more definitive treatments need to be undertaken.

Dr. Stieg: When you're talking about medical management, what should the listeners hear from a doctor?

Dr. Knopman: So medication that we can take orally by mouth, something called decadron. It's a very low dose steroid, it's an anti inflammatory. And we feel that what helps keep these subdural hematomas alive is an inflammatory process. And if you take an anti inflammatory like steroids, it can sometimes interrupt that inflammatory process and help the subdural hematoma resorb go away on its own with time.

Dr. Stieg: Mikal had passed that point. What are the next options that are available to him?

Dr. Knopman: Traditionally, in neurosurgery at that point, open surgery to drain the blood clot has been our mainstay form of treatment either by putting burr holes through the skull or by making a window in the skull to take out the blood clot. For the last 50 years, that's been our standard of care for how we treat subdural hematomas.

Dr. Stieg: You've popularized a new minimally invasive technique for managing this blood clot over the surface of the brain without having to make holes and involving surgery. But before we get to that, I'd like to hear from Mikal how he got to finding you.

Mikal Scott: Well, my primary care physician got me to look at get CAT scans and she sent me immediately to the emergency room and I was checked in and I was in for four days, lots of tests, an awful lot of tests on me. And after four days they asked me to be discharged and they really weren't sure what to do with me and they said, please go see your primary care physician again in three days and I can tell you that I didn't make it to the three days. And within a day the headaches had gotten massively worse and I was lucky because I live close to downtown Presbyterian and I went to the emergency room and it just so happened my cardiologist was there that morning. They did whatever they had to do, which I do not know because I had no idea what was going on.

Dr. Stieg: You got to our emergency room and was it love at first sight with Dr. Knopman, or what happened?

Mikal Scott: Well, I can tell you something about this guy. The first time I met him I went, "Yeah, this is the place I am supposed to be." It's embedded in my brain. The way he walked in, the way he sat down, the way he addressed me, quite confident, in being able to say, "Mr. Scott, you're not going to die."

Dr. Stieg: This is something I like to touch on. It's the doctor-patient interaction. I understand the sense of confidence, but there is, is there something else that, that a doctor can communicate to you as a patient?

Mikal Scott: Yes. Giving me the information. He explained to me exactly what was going on. I love science and my father, he was with NASA. I grew up around the space program in Bermuda and when he spoke to me I got it and it really made me feel like I was part of the process. You know, he was telling me, these are your options, this is what we can do, this is what has been done historically and we have this new technique and I immediately went, "I'll take that. I'll take that."

Dr. Stieg: We talked a little bit earlier about the standard technique, which is more invasive. Dr. Knopman, can you go into detail about the minimally invasive technique that you're popularizing?

Dr. Knopman: So by the time a chronic or a subacute subdural hematoma hasn't gone away and it persists and it stays on top of the brain and it's causing pressure, it has formed a membrane around itself that keeps it alive and it has recruited blood vessels to this membrane to feed it. Most patients that we see with chronic subdural hematomas have blood of what's called mixed acuity, meaning mixed ages. There's old blood, there's more new blood. And even though someone may have had a trauma, only one time that they can recall, a subdural hematoma can continue to bleed into itself without subsequent trauma necessary. So there's a recruitment factor that goes into these subdural hematomas that keep them alive. And the new treatment that we've pioneered here addresses that root cause, that recruitment of blood vessels, and interrupting those blood vessels to then allow the brain to do what it would normally do on its own, which is resorb the blood and get rid of it with time.

Dr. Stieg: So how do you go about doing that?

Dr. Knopman: So we do this minimally invasively through what's called a endovascular embolization, where we can navigate through a needle stick in either the artery in the leg or on the wrist, and we can navigate catheters up into the blood vessels that feed the covering of the brain that feed the dura. We're not going into the brain itself. We're going to the blood vessels that feed the covering over the brain and then we shut them down. These blood vessels, believe it or not, are extraneous and they're pathologic, meaning that they're only feeding the subdural hematoma. They're not providing any function or importance to brain structures or anything like that. So they're sacrificible and by interrupting that blood supply, we prevent that vicious cycle from happening, that recruitment of blood vessels, that re-bleeding that keeps a subdural hematoma alive, and in the subdural hematoma is able to resorb on its own.

Dr. Stieg: I get why you would pick something like that. You know, you avoid a haircut, you avoid an incision, a hole in your skull. What was it like experiencing it when you went through the process?

Mikal Scott: I have to say that, the fact that there was no surgery, that was great. I remember Dr. Knopman asking, do I want to be put out, and I said, "No, I want to know and I'm going to listen to what was going on." And I was allowed to look up and I could watch what he was doing for a bit. And then once he got to where he had to go, he had put, I remember him putting my head down. It was all very, very organized. So you felt like, wow, this is nice and smooth and very relaxing for me.

Dr. Stieg: Like NASA with dad. *laughs*

Dr. Knopman: Well, Mikal alludes to a very important point, which is that this procedure can be done in someone who's awake. So if we offered brain surgery or had to drain this hematoma, it would typically be a procedure where you would be either highly sedated or under general anesthesia. You'd be in bed for multiple days afterwards. You have to remember, unlike Michael, who is young and fit, this pathology strikes people who generally are more elderly and fragile. Avoiding general anesthesia in an elderly patient, avoiding bedrest in an elderly patient. These are half the reasons patients have poor outcomes. So to be able to offer a technique that takes these other associated risk factors off the table is very powerful in this patient demographic.

Dr. Stieg: You felt no pain, it was quick and easy?

Mikal Scott: I remember him doing it. I remember feeling it, kind of feeling it tickling along my brain. You remember I, I said something, "Wow, it feels really weird inside there, just enough." Um, but after that, I remember you talking about, we have to close it and then after that I remember being in back in the room recovery room. Yeah. In the recovery room and family was there. People were there and I was like, "Hey, what's going on?"

Dr. Stieg: You went through the procedure and did you leave the hospital the next day?

Mikal Scott: I don't remember what time of day. I know we left very quickly. I was surprised at how quickly—

Dr. Stieg: What'd you do when you went home?

Mikal Scott: Ate.

Dr. Stieg: How quickly did you get back to work?

Mikal Scott: Uh, probably I started within a couple of days.

Dr. Stieg: So how is that different from having a craniotomy? What would have been his course?

Dr. Knopman: if you had a craniotomy, you would have been in the hospital for at least two to three days. You would have been laying on your back flat. You would have been immobile, you would have been at risk for other things that occur when you're immobile, like pneumonias, clots in your legs. This gets you in and out. There's no recovery as, as you know, Mikal, because it's just a needle stick in the leg that you're recovering from. Not an incision, not pain, not immobilization.

Dr. Stieg: And I should clarify that a craniotomy is making a hole in the skull and that's why the recovery takes so long. How quickly did you get back to running?

Mikal Scott: Well, I have to put a little, you—

Dr. Stieg: You cheated. *laughs*

Mikal Scott: Well, I kind of cheated, and then on that first followup he says, "Please stop doing that." I had this little program for myself where I was doing these little exercises at home and he goes, "I'll let you know when." He told me, "I'll let you know when." And I believe it was 60 days to the day that I went out for my first run.

Dr. Stieg: When you went back to work, like you said, in a couple of days, did you notice that you were able to have those meetings and you are creative and you were back to your old self again?

Mikal Scott: I knew from the time I woke up I was fine.

Dr. Stieg: And if you get a CT scan or an MRI scan immediately after you do this therapy, is there any big change in the imaging?

Dr. Knopman: So what's interesting is that because this process works by interrupting that vicious cycle, it does take time for your brain and your body to resorb that blood. But people like yourself will oftentimes feel better even before the blood goes away. Headaches will oftentimes get better even though the blood doesn't go away. This procedure has taught us about the cause of subdural hematoma in a way that we never understood in the past. We thought this was a disease of just veins, that tour and that was it. Now that we see the involvement of inflammation, the involvement of arteries, the involvement of these nerve fibers on the dura, we have a whole new appreciation for what a subdural is and what ultimately leads to its cause.

Dr. Stieg: You got back to your running. Tell me about that.

Mikal Scott: The following spring I got invited to run with our team at the Penn relays and I'd never done that before, but it was the following winter indoors at the Millrose Games here in New York City that I was on the 4x400 team and we were on the podium, we came in third place, and it was truly, I was like, yes, I'm finally okay. Life is normal. Yeah. Yeah, it was, it's a good thing.

Dr. Stieg: Dr. Knopman, tell me a little bit about the physician's role in managing his expectations and managing his family's emotional wellbeing.

Dr. Knopman: Well, I would say I was very lucky to have had Michael as a patient. I didn't know until today that you're the son of, of someone who worked for NASA because you yourself were a pioneer in this. You were one of the first five people in the world to get this treatment. What I think the benefit of this procedure is and something that you clearly understood from the inception, it doesn't take off the table potential for surgery, potential for drainage if it doesn't work. But it offers an upfront alternative to surgery if it does. So it's basically win-win: the procedure's low risk, the upside is very high. You're able to avoid surgery, but if it doesn't work, we're right back to where we've been always for the treatment of this disease, which is surgery. So, having a patient like yourself understand that, open to trying something innovative, open to exploring this other option. It's very important. And, and patients like yourself who have undergone this procedure have now helped, in my opinion, make this and continue to make this what I think is going to be the growing standard of care for how we treat subdural hematomas.

Dr. Stieg: I really want to thank you both — it's a heartfelt thank you for sharing with us both the complexity of the brain, but also the fragility of the brain. I mean, here you are, this dynamic businessman running marathons and running these sprints and you almost potentially lost your life. The brain is an extremely fragile organism. In your case, it was being compressed by this blood clot on the surface, but there's also biochemical and physiological changes that were altered by the treatment provided by Dr. Knopman. Those are all important things that doctors like Dr. Knopman take into consideration when they're treating patients like Mikal. I want to thank you both really for sharing.

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Ethics and emotions often clash at the bedside of terminally ill patients—especially those with brain injuries. Dr. Joseph Fins, Chief of Medical Ethics at Weill Cornell Medicine, talks with Dr. Stieg about what we can do to best prepare for our final days and who has the legal and moral authority to make life and death decisions.

Dr. Stieg: I'm delighted to have with me Dr. Joe Fins. Joe is the Chief of Medical Ethics and Professor of Medicine at Weill Cornell Medical College/NewYork-Presbyterian Hospital. He serves as co-director of the Consortium for the Advanced Study of Brain Injury at Weill Cornell and Rockefeller University. Dr. Fins is also the Solomon Center Distinguished Scholar in Medicine, Bioethics and the Law at Yale Law School. Joe, thank you so much for being with me today. So let's start off by explaining why is what you do important. Ethics really is important on a day to day basis. Tell us how.

Dr. Fins: You know, simply put, numbers don't always equate with values, so you might speak to a family about the probability of a success for a complicated complex neurosurgical procedure and the number of might be adequate, a good number, but it might not be meet the values or the kind of life an individual would want to live or a surrogate would decide for somebody. You know, as a doctor myself, and those of you who are not here don't know that I'm the only one wearing a white coat in the room. Dr. Stieg is wearing a beautiful sports coat. You know, I understand the moral stress that practitioners have in trying to reach the right decisions. And sometimes my colleagues get so deeply invested in their own patients that they need to kind of have a refraction, sort of an orthogonal look from a third party who knows enough about what's going on to, to help assist. So I'm not, we don't — I'd share the ethics committee here and we do, we do almost 400 ethics consults a year. We're never there to replace people like you or the doctors and we've had cases to — Dr. Stieg and I've had cases together. We're not here to replace you. We're here to help you and help everybody make better decisions, really help families.

Dr. Stieg: It always amazes me when I see somebody on a second opinion and you see that some other surgeon has recommended some stuff that you just completely disagree with and you wonder, is it because the surgeon just wants to be helpful or is it because the surgeon wants to make a buck? Or is because the surgeon has a particular idea that they think is the right way to approach this clinical problem, which is it's experimental and then how, how I have to emotionally deal with that. Then also morally and ethically try to educate the patient.

Dr. Fins: Well, interestingly, going back to the first code of medical ethics in the United States from the American Medical Association in 1847 it was really about how professionals dealt with each other, you know? So you really couldn't in those days speak ill of another colleague. So if some other doctor was recommending something that was a, let's just say, not prudent, you can't criticize the other physician. Of course we've moved beyond that kind of decorum and we've begun to think about patient-centered ethics. But you know, in your, in your example, I think what we try to understand are the motivations. Uh, you know, and I think ethics and medicine is not morality in medicine. I think most everybody wants to do the good, wants to achieve the good, but it's about competing goods. So a surgeon, uh, another physician who might have seen a patient first and you're now doing the second opinion might see the achievement of goods through a certain surgical approach or recommending an operation. And you might actually recommend medical management. You know, my God, a surgeon recommending medical management. But you might think that's the better way to achieve the good. So we are not about right and wrong. A lot of people think ethicists are about determining what is right and what is wrong. It's more morality. We're here to, to help us balance competing goods.

Dr. Stieg: In medical school, one of the things that I've learned over the years is that I spend the first 10 minutes really trying to just understand who my patient is. I don't start walking up, look at your scan, boom. Here's your problem, here's what you need—

Dr. Fins: Well, you know that old saying, the secret of caring for the patient is caring for the patients, right?

Dr. Stieg: That's why I ask them, what they do, how long they've been married, where do they live? You know, just a lot of personal kind of questions. So I kind of understand. I try to understand within 10 minutes what their value system might be. And you think we're doing a good enough job in that in medical schools?

Dr. Fins: I think, I think that we're — we think we are. And I think we're trying to, we give a lot of lip service to, you know, patient-centered education and getting to know your patient. But I think sometimes it borders on the platitudinous and it's sort of the, it's on the periphery. It's not central, but I think the more skilled and senior physicians and surgeons like yourself, people understand that, that you really can't achieve, you can't put your skills to use unless you know what they're being used for. And just imagine if you were, you know, God forbid an orthopedic surgeon. Okay. And somebody had a bad shoulder. It would be important for you, for you to know whether it was an internist who, who barely did anything, like myself, or Mariano Rivera, right? Like what, what operation are you going to do? You have to know what the patient, who that patient is. The other thing is is that the patient really enfranchises you to use your skills, gives you a moral warrant of consent, right? Based on the presumption that and they're, you know, patients are allowing you to wield the knife on them. Just think about that. In no other sector of society are people allowed to cut other people without going to jail. Okay. So, so there's this moral obligation upon you to understand precisely what this patient needs the operation for. And so I think just as you know, you would do a very careful physical and neurologic exam to know, you know, what the nerve tracks are, and the roots. If you're doing a laminectomy in somebody's neck or whatever, you're, whatever you're doing, you really need to know who this patient is and how this operation fits into the broader scope of their lives. And I think that if you, if you, if you don't do that, it would be almost as if you weren't doing the physical exam.

Dr. Stieg: So let's flip to the other side of the spectrum and the patient and your areas of expertise is in brain injured patients and we'll get there eventually. But I wanted to talk here — I wanted you to talk to us a little bit about the concept of advanced directives and why is that so important? Basically the patient can protect themselves a little bit from the overzealous doctor but also prepare themselves for the unforeseen bad accident.

Dr. Fins: And we recommend, and you know, the American College of Physicians and all the preventative health services recommend that everybody has an advanced directive, not just the elderly or people who are facing the end of their lives because they have a terminal or life threatening illness. I mean all the, all the catastrophic cases that led to the advanced directive movement, which is a document that allows you to articulate your preferences in advance so that somebody else can make decisions for you. That would be a healthcare proxy form or in other States, a durable power of attorney for healthcare or a living will where you fill out a form and there's no other person, you just write down your preferences. All those, all those cases, those important cases involved young people who had catastrophic neurologic, uh, accidents like the, the Nancy Beth Cruzan case, which went all the way up to the Supreme Court and Sandra Day O'Connor, in her opinion said, "Wouldn't it be a good idea if people could articulate their preferences in advance?"

Dr. Fins: Cause there was a whole debate over what whether or not her, her feeding tube, could be removed in Missouri. And uh, that led Senator Danforth of Missouri and the late Senator Daniel Patrick Moynihan together to write legislation. And Moynihan, you know, it was a trained sociologist and a deep thinker and Danforth was an ordained minister who actually went to Yale Divinity School. So they got two intellectual figures got together, right? They wrote the Patient Self Determination Act and it, it was really in the wake of the Cruzan decision. So the idea is that everybody should have these documents to articulate their preferences in advance. They're recognized under federal law, and institutions that receive Medicaid and Medicare were obliged to follow them. Every state also has their own iteration of that. And what it does is two things. One, is it allows you the patient to articulate what you want, how you want to die.

Dr. Fins: And so if you don't want to die in an ICU, if you want to die at home, if you don't want to extraordinary measures, if you have, if you want certain kinds of care, it can also be affirmative requests. So you can articulate that. The thing that people don't appreciate is that it's the final gift that you can give to your loved ones because the very person that your daughter or your son or your spouse is going to want to talk to, when you're unable to speak for yourself as you and say, "Phil, what did you want? What did you want? Did you want this?" And, and in a way, if you don't fill out these forms, it's a kind of a mandating them. You're abandoning your kids. Everybody wants to take care of their kids, take care of them through this guidance.

Dr. Stieg: Is this easy to do? I mean, you know, do people have to go to lawyers and get documents filled out where they're going to incur debt? Can you just go to your family doctor and say, I need, you know, I need to do advanced—just what's the process cost and how easy?

Dr. Fins: It's free. These documents are readily available in the hospital in, in most hospitals from the Department of Health and, nondisclosure here, we actually wrote a booklet which you can get on Amazon for $8, and the proceeds for this go to the Division of Medical Ethics. I'm not going to make a nickel on this. I've, last time I checked it was $8 maybe $9 I don't know. And it's called Fidelity, Wisdom, and Love: Patients and Proxies and Partnership. And what it is is a workbook that you and your significant other can work through. We have three different scenarios that you can talk about what your values are and at the back there is a form to fill out and it's interactive because one of the things that is ironic about the patient self-determination act, it's really not patient self-determination. That's like sort of an atomistic view. You know like we're all, atoms in isolation. Life is really molecular, you know, if I'm your healthcare agent, Phil, you and I are in a molecule and so it's about relationality. It's about interaction.

Dr. Stieg: One of the cases that you and I shared together was a young woman that was pregnant, had a terminal brain bleed and then what to do with the pregnancy and actually how to handle her. She required surgery. We knew it wouldn't have a happy ending and the husband was stuck betwixt and between about making the decisions. Basically he was the surrogate. What is the responsibility of the surrogate? Say in the situation where a person has done the advanced directives or in the situation where there are no advanced directives, what advice do you give?

Dr. Fins: Right, right. There are, there are decision-making hierarchies. So you're supposed to follow express wishes, substituted judgment and best interests. So what, what are they? Expressed wishes: you told somebody, I'm a Jehovah's Witness. I don't want blood. Expressed wishes, it's pretty clear. Substitute judgment: He never said that, but we're all Jehovah's Witnesses and he taught about the sin of receiving blood from Leviticus. So even though I really don't know precisely what the person would have wanted, I'm substituting, I'm putting myself in their shoes. If we could wake them up magically, what would they say? Substituted judgment. But it's less, you know, less clear than expressed wishes. Then the best interest standard, the person is anemic, their heart rate is really fast. They're in shock. And you know, they need blood. What's the best interest standard? They get blood. So there's a decision making hierarchy. One of the things, we actually did empirical research about 10 years ago on patients and proxies and how they make decisions.

Dr. Fins: And one of the things that's really interesting and most people won't talk about this, and I'm surprised that this hasn't gotten out more, is the valence effect of wishes. So, no means no. If I don't want something like in most contexts, no means no, right? No means no. I don't want to, you know, I don't want extraordinary measures and we looked at how patients and proxies interpreted circumstances, but I want everything done no matter what sort of a positive request is conditional. And people actually in designating somebody to represent them, expect them to use their judgment and are okay generally with them using their judgment to say, yeah, they wanted everything done, but that's no longer possible so we don't have to achieve it. So there's really two kinds of moral authority that go into advanced care planning. One is substantive moral authority, right? Where I fill out the form and I write down what I want. Then there's this other thing called the procedural moral authority or what, it's kind of a covenant, right? Where you give somebody the authority to make decisions for them. And out of the 7 billion people in the world, I chose you to make decisions for me and that that gives you a kind of standing to use your discretion. You know, people say like, for example, said, "Phil, I never want to be on a ventilator." Okay, you can interpret that. But suppose I come in cause I, when I'm walking out of the office here and I go back to my office, which is across the street, I get hit by a truck and my spleen ruptures and I need an emergency laparotomy. You know, my literal, my expressed wish is, "I'd never want to be on a ventilator. Is that what I meant?" No, right? So you, you are, you would allow my agent to say, "Yeah he wants his spleen taken out cause he wants to come back and do another podcast."

Dr. Stieg: So, the difficulty in that scenario is, at the granular level. When we're meeting with the family, you can give them this ethical and logical hierarchy through which they can work. How does that play out emotionally? That's, that's the dilemma.

Dr. Fins: So what I just told you is what's going on in my head. It's not necessarily what's coming out of my mouth, okay? And I think here we have to be much more compassionate and and sensitive to where the patient and family, where the family member is. So one of the things I like to do is use time and say, "You don't, we don't really need to decide this today. It's Friday. Why don't you talk to your family members? Let's sleep on it. Let's come back on Monday." So, you know, one of the things is to realize there's a tremendous power differential. Let people have the opportunity to kind of sort it out, give them the opportunity, tell them what their rights are. You know, as the healthcare agent, you, you'll have the right to make decisions and it's really not our decision to make.

Dr. Fins: It's your decision to make and we're going to help you achieve the best decision for you and your loved one. And so, and then I'll say, some families after they searched their soul and they searched their memories about what the patient had said would decide to press on. And on talking about the case, the case you described them to more generically, would want to press on. And other families equally loving and caring, but coming from a different place would decide that maybe, maybe they don't want their mother or their loved one to suffer that way. And these are legitimate choices.

Dr. Stieg: In today's society, I've found that it isn't often a family member because they're alone. Yeah. And the surrogate is a close friend, right. Does the surrogate have legal rights protections in case somebody shows up five years down the road and says, "I'm their long lost child and you killed my parent?"

Dr. Fins: Right? So, so there's a good faith presumption and the burden is sort of on us, the institution to go through, there's a list, there's a hierarchy. So the hierarchy is, you know, the patient, of course, if they have capacity, somebody who's been designated by the patient, a court appointed guardian, right? And then there's, you know, a spouse, adult children, you know, other other family members, close friends. And we would, we have to go through that list. It's stipulated in New York State Law and every state has some kind of version of that, that list, if we were unable to locate somebody who was reasonably locatable right, we didn't make a call, the phone number was in the chart and we didn't call a phone number and that person appeared because we hadn't made that call. That would be potentially problematic. But typically what we do is we'll ask the social worker to look around for close relatives, and we exhaust the list.

Dr. Fins: But there's really, there's a good faith presumption and that's also a standard in the joint commission, which, which accredits hospitals. So you, you act on a good faith presumption. The other, the other side of it is if a family member comes in and says, we have an advanced directive, okay? And they attest to that. We make a good faith presumption to accept that because sometimes you know, people erroneously, and this is just a clinical pearl for family members, don't put this in the vault because once somebody you know is, is that sick, you can't, the only person who can get into the vault is the person who's in the ICU and they know they're the one who has the key. So you want to make this, this document accessible and available, give it to your doctor and put it in your medical record, give it to your healthcare agents so they have access to it.

Dr. Stieg: Another example that I think that you and I shared was an individual that met the criteria for brain death, but due to religious reasons, their heart was still beating.

Dr. Fins: Right, which is typical.

Dr. Stieg: Yep, and on the basis of their religion, that meant that the patient was still alive and the dilemma that that puts the physician in the family in and we know how we played it out. Perhaps you can describe how you like to approach those issues.

Dr. Fins: Yeah, you know, brain death is a complicated area in medical ethics and unfortunately it's, it's, it's an issue that comes up rather frequently in my experience over the last 25 years because we live in a state that has what's called the reasonable accommodation clause. And in New York, a brain death has recognized as death, but we have to reasonably accommodate people who have a religious or moral objection to that designation. So in New Jersey, if a family objects, one has to define death based on cessation of cardiac and pulmonary function — the heart stops. Now what is brain death? Brain death is whole brain death, it involves the brainstem and higher cortical function. And brainstem is, you know better than anyone in the room is the autonomic nerve center for the body that generates respiration and, and heartbeat, although there is an intrinsic pacemaker in the heart, which is why the heart continues to beat and the person is maintained by that intrinsic pacemaker in the heart as well as the ventilator that breathes for them.

Dr. Fins: The challenge is, these people look like they're alive. They have a heartbeat, they're perfused, they look like they're alive. I have seen cases where patients have had a Lazarus reflex, which, I don't know if you've ever seen this and you're, it's exceedingly rare. But this is a situation where, I've seen this one time where a patient was declared to be brain dead by a pulmonologist. They take away the ventilator, they just give them oxygen and the carbon dioxide goes up 20 millimeters of mercury and the 20 millimeter of mercury rise should, if your brainstem is still functional, trigger a breath. In fact, that's how we, we drown when we're underwater. It's not that we're trying to get oxygen, but it's the carbon dioxide that prompts a deep breath. And then we swallow water and we, and we would, we would drown, okay. So the patient was declared to be brain dead by the pulmonologist.

Dr. Fins: Smart guy, but the blood gases, all the math, everything, you know, and then the patient goes like this. The patient reaches their hands together as if to pray. It's why it's called the Lazarus reflex. Okay. Like Jesus and Lazarus rising from the dead. The same pulmonologist reaches into his pocket, grabs his stethoscope to listen to this person's lungs to see if this person is breathing, when in fact, they had just done the calculation to show that, that the carbon dioxide had gone up by 20 millimeters of mercury indicating that there had been no respiration. So even for a trained intensivist, it is counterintuitive and that's brain death.

Dr. Fins:So how do we handle brain death? It's complicated because it, in some religious traditions, Orthodox Jewish, some Afro-Caribbean cultures do not accept brain death. But let's talk about the Jewish tradition because that's where it's in the Orthodox Jewish tradition where it's the most common we encountered. There's a story in the Talmud, which is one of the great documents in Jewish law, commentaries where there is a Rabbi, Reb, who is on the second floor of his house. And, he's dying. His soul is egressing to heaven. And there is a guy in the back sawing wood, which is disturbing the egress of the soul to heaven. God is calling in this, in this story. And the rabbinical students, it was tough times. They throw stones at the guy who is sawing the wood, so as not to disturb the egress of the soul.

Dr. Fins: So in Judaism, there's this notion of a "gosses," which is kind of a fancy word for futility. You know, you're dying. God is calling, don't get in the way. So when I speak to Orthodox Jewish families, I don't try to say brain death is death. I try to put it into the theocentric vernacular and say, this is a gosses. So let's decide in the context of your religious paradigm between, between respecting the sanctity of life — God gives you life, so it's not for us to take a life, okay. Or God is calling you and let's get out of the way. And, and oftentimes, not all the time, that can lead to a middle ground. And we try to use cultural intermediaries in rabbis who are helpful. You know, we've gotten very in, in the country, we have a lot of culture wars and it's gotten sometimes more political and theological and it becomes complicated.

Dr. Fins: Every religious tradition has, has a way to grieve and mourn for people who are dying. So the Shiva in Judaism or the wake in other traditions. And what happens when, when somebody is brain dead is, everybody knows the person is either dead or depending on your definition en route to dying, okay? And what happens is the family then, is isolated from the tradition because they can’t begin to mourn. People can’t come over with food and, and they can’t, they can’t put drapes over the mirrors and the men can’t begin to grow their beards and go into the grieving process. So they’re, they’re kind of in limbo just as this, this body is in limbo and it actually is, makes the bereavement more complicated and it’s really a hard place to be. So I think it’s actually cruel to, to follow the theology to the letter of the law because it’s not very pastoral. And the pastoral care folks that I talked to, these are people who work in the hospital who are chaplains, who are not theologians, tend to have a much more psychological and pastoral view of what’s good for real people than kind of a strict adherence to dogma and doctrine.

Dr. Stieg: To hear more about this important topic, please join us on our next episode.

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A faulty risk/reward area of your brain can get you into trouble, but it can also free you to think outside the box. Cognitive neuroscientist Heather Berlin explains how the prefrontal cortex develops – or doesn’t – and how cognitive behavioral therapy can help you harness the power of neuroplasticity.

Dr. Stieg: I'm with Dr. Heather Berlin, who is a cognitive neuroscientist and Assistant Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai. Today we're going to talk about what happens in our brains when we control or lose control of our unconscious impulses and how we can turn off our inner critics to find more joy in our lives. Heather, thank you so much for being with me. Thanks for having me. Maybe you can explain for us what is going on in our brain when we experience impulsivity.

Dr. Berlin: Well, there's a lot. There's not just one thing happening in the brain. There's a whole circuit and system that's involved, but in general, if you think of the prefrontal cortex or parts of the prefrontal cortex as kind of a brake system in the brain, then you have these sub-cortical evolutionarily older parts of the brain, like the reptilian brain that are kind of driving us forward for immediate pleasure or avoidance of pain and the prefrontal cortex kind of thinks about the future consequences of your actions so that you can behave adaptively. But if the prefrontal cortex is either not functioning properly or there's a brain lesion there, then you're not able to control those basic drives.

Dr. Stieg: As I understand it, there are different regions in the prefrontal cortex is not just this whole big glob on both sides, and we'll get into that in a little bit, but what is really going on when you have an impulse disorder?

Dr. Berlin: Well, symptomatically, usually what happens is first you get the urge to engage in a particular behavior and then it leads to sort of this anxiety and a buildup of tension until finally you just can't resist. You have to engage in the behavior. And then usually just after that, the person will feel guilty and they'll feel sort of bad about themselves, which can restart the whole cycle again, because then you want to do something that makes you feel good, and then you go back to that reward seeking behavior. So they're sort of locked in a, in a cycle of dysfunctional behavior. There's no one sort of line that distinguishes, okay, now it's a disorder, but it's really about sort of quality of life because when we think about impulsive behavior, it's about either getting immediate pleasure, right? Immediate pleasure, and not sort of discounting the punishment that can occur after the fact, right? But in this case, no matter what the punishment is, they'll just keep going for the pleasure for the reward despite the consequences. And that's really what we started to see, an impulse control disorders.

Dr. Stieg: Let's talk a little bit about what specific impulse disorders exist. First one, I think where a gray line is the impulsive gambler, versus the compulsive gambler, versus the professional gambler. Where's that line?

Dr. Berlin: Yeah. Well, so, so gambling or pathological gambling used to be defined as an impulse control disorder, or actually it was called impulsive compulsive gambling disorder. Now in the latest, um, it's called the diagnostic statistical manual. What we use to classify psychiatric illness, in the latest version, version five, it's now classified as an addiction. So the same neurocircuitry is involved with being addicted to gambling or say the internet as is involved in being addicted to it, a drug. And, and again, there is no sort of cutoff point, but we look at how severe their symptoms is. So, so for example, can they resist gambling? Can they resist it, do they stay there until 5:00 AM gambling at all costs? And so there's no distinct line between what's pathological or not, but usually it's kind of like pornography — when you know what you see, you, you see it, you know?

Dr. Stieg: How do we distinguish then between, I presume there's a compulsive disorder versus an impulsive disorder. Can you please make that distinction for me?

Dr. Berlin: Yeah, now something that, it's sort of two sides of the spectrum in general. Think of impulsive behavior as going for a reward despite the consequences, whereas compulsive behavior is engaging in a behavior to avoid something negative.

Dr. Stieg: You've referred a couple of times to brain circuitry and neural chemistry. Other specific neuro receptors and transmitters that are either depressed or elevated in impulsive compulsive disorders.

Dr. Berlin:Yeah, we find that in a healthy person or person without an impulse control disorder, when they're ab out to, they're anticipating getting a reward, they get increased activation, increased dopamine in striatal areas. However, people with pathological gambling did not have that increase. They had less activation. So the idea is that they actually might need more stimulation just to get the same feeling of reward that a person without impulse control disorder gets. So in a sense, they're not necessarily seeking out a high, they're just seeking out to feel normal and they need more for that.

Dr. Stieg: Can you tell us which groups are particularly prone to impulsive disorders or can it strike at any age? Could I be normal for 50 years and all of a sudden at 55 I've become an impulsive gambler?

Dr. Berlin: No, I mean it tends to be lifelong. So it tends to be you're born with a certain kind of temperament. I mean, we can see something like antisocial personality disorder, you know, you can see it early on and actually in order to get diagnosed as that as an adult, you had to have had some sort of conduct disorder as a child. So there are different than other kinds of psychiatric disorders. For example, like schizophrenia where you're more likely to have the psychotic break, you know, in your late teens, early twenties or some types of depression. This really is a lifelong, so even in babies you can see their temperament and you'll see them being impulsive. And that's why the marshmallow test, although it's controversial—

Dr. Stieg: What's a marshmallow test?

Dr. Berlin: That basically is, they give these kids ages three to six — you can either have one marshmallow now or two later and then they just leave the room and leave them with the one marshmallow and like see what happens.

Dr. Berlin: Right. And they gave these, it was Walter Michel, who's at Columbia, gave these kids a whole array of different measures and tests and they found that all the measures, this one test was the greatest predictor of all these future outcomes in life. Like job attainment, marital status, you know, body mass index. And you know what? I see it as, it's the measure of prefrontal cortex function. You know, if you're able at that age to withhold responding for an immediate pleasure, that means you're having a more evolved prefrontal cortex. And that's gonna lead to, for example, staying home and studying instead of going to the party and getting a better job later. So impulse control. It's not that if you don't have it, you're doomed. Maybe you just have to work harder to—.

Dr. Stieg: So what can you do about it?

Dr. Berlin: So I think a few things, I mean, cognitive behavioral therapy is really helpful. This is what I often say to people.

Dr. Stieg: Can you describe what that is?

Dr. Berlin: So for example, if you get people to stop and think — so often when they're engaging in impulsive behavior, say it's that marshmallow right there and they just can't stand it. It's, they have to have it. First of all, I also looked at time perception and they have a faster perception of time. So they feel like the waiting is even feels longer to them. But if you can get them to stop and wait and actually engage their prefrontal cortex doing certain exercises or just becoming more self aware, even some sort of mindfulness, it can engage the prefrontal cortex. So maybe they can get past that moment of the urge and then not engage in the behavior. But it's about getting them to kind of stop and think and take a moment. And it's, it's a hard process. You know, you have to really be conscious of it. Whereas for others it comes naturally. They really need to work at it.

Dr. Stieg: How effective is that? Is that 80% 70% 50?

Dr. Berlin: It's hard to put a percentage on it. I think it depends on the person. You know, I often see like our genetics, um, gives us kind of the boundaries with which our behavior can be in. So you can work towards being at the higher or you can be at the lower end within that boundary. So, for example, if you're an anxious generally you know, anxious person, we can get you to be a little bit less anxious, but you're never going to be the most relaxed person in the room cause that's just not part of your makeup or the way your brain is wired. So I think that it really varies between people. If some people have a really extreme impulse control disorder, you know, they're, they, they probably will need some sorts of medication

Dr. Stieg: With cognitive behavioral therapy, is there, you mentioned it — is there a rewiring? Is there neuro-plasticity that's occurring?

Dr. Berlin: There is, I mean we do see changes in the brain based on these cognitive behavioral therapies. Cause anything learning is a change in the brain. Right? Um, so you can to a certain extent, that's why I think intervening at a younger age is really important because the brain is still developing. Think it's less effective when you're first start treating somebody who's, who's older and they've already have fully formed their neural network. So if you see a kid who is acting sort of more impulsive than the average kid, again, it's all relative. Intervening early on can actually help with the way the brain is being wired up.

Dr. Stieg: Let's talk a little bit about flow state. Can you tell me what flow state means?

Dr. Berlin: Yeah, so like, well I got interested in flow states because I was so working so much with patients to try to get them to turn on their prefrontal cortex to try to control these, these basic urges and desires. And you can only go so far with that. And then, I started getting interested in what happens if we can, if they can turn down certain parts of the prefrontal cortex in a controlled way and actually almost like release their, the desire itself. And these flow states that people get into, we've all had them, right? It's sort of where you lose your sense of time and self in place, whether you're engrossed in a really good book or you're doing something physical like, like rock climbing. And a lot of artists talk about this flow state when they're in their creative flow and they lose sense of time. They feel like the information is coming through them. And what we find is that parts of the prefrontal cortex in particular, the dorsolateral prefrontal cortex is turned down in these flow states. So you actually do lose your sense of self that cause our sense of agency is part of the function of the dorsolateral prefrontal cortex. And you lose your sense of time.

Dr. Stieg: By sense of agency you're referring to basically judgment. You don't do something because you understand the consequences of something are bad.

Dr. Berlin: Right, right. You know, like just like, so children's prefrontal cortex isn't fully developed until about the age of 25, let's say.

Dr. Stieg: I thought that was boys, I thought girls are earlier.

Dr. Berlin: Girls are a little younger. That's correct. Girls are a little bit younger obviously, but so you can think about a child, you know, they want to do things, they want things right away and they don't really think about or they're not able to control their behavior or think about the consequences of their actions. And so you take on a fully formed adult brain and turn down that part of the brain. And again, it's similar where you can't really—

Dr. Stieg: So that means the middle part of your frontal lobes becomes accentuated.

Dr. Berlin: Yes.

Dr. Stieg: Which can lead to impulsivity or compulsivity.

Dr. Berlin: Right, but the thing is, why when you get in these flow states, you can actually be more creative. Cause normally, I mean, think about children as well. They're, they don't have a filter. So it can be bad in that they're more impulsive but good in that they're more creative because they can make, um, divergent association between ideas, right? They don't have that filter like, Oh no, that's not the right way to think. Or you shouldn't be, you know? So when you remove the constraints in an adult, you can actually get to these places where you can be more creative. You can think outside the box. And when you turn up the medial prefrontal cortex, it actually has to do with the internal generation of new ideas. And then it's unfiltered because the dorsolateral is turned down.

Dr. Stieg: Aside from potential for drug addictions in people that have impulse control issues, don't they also experience a fair level of anxiety or possibly depression related to this activity?

Dr. Berlin: Well, ironically, when they're actually in those flow states, it's associated with really positive emotions; people strive to get there. So it could be that in their normal state when they're not in these states that I mean anxiety has to do with turning on the prefrontal cortex and rumination and you sort of can't get outside of yourself and being self aware and when you can remove that and get into the flow states, it actually is associated with a decrease of anxiety and self-awareness. The moment you become too self-aware, you're actually out of that state.

Dr. Stieg: I understand you've made this a little bit personal in the sense that your husband is a rapper and you've studied him. So tell me what, tell me what that's about and what you found.

Dr. Berlin: Again, I started getting interested in trying to access these, the unconscious and the ways we can turn down the prefrontal cortex in order to actually access the unconscious to help treat psychiatric patients. And then I saw what my husband was doing in terms of his freestyle rap and—

Dr. Stieg: Which is a flow state.

Dr. Berlin: It is a flow state and it really reminded me a lot of Freud's like free association, right? You don't have time to think. It has to rhyme. It has to come. And the things that would come out of his mouth were rather interesting and you know, I would gain some access into his unconscious. And so I thought, wow, maybe we should put them in the scanner and actually look at what's happening in his brain. So I had him go and do, a memorized rap versus an improvised a rat and using fMRI, looking at blood flow to different parts of the brain in real time.

Dr. Stieg: So fMRI is a functional MRI scan looking at brain activity and brain segments.

Dr. Berlin: Right, looking at blood flow, which is a proxy to neurons firing. And so what I found was that, and this was based on also some preliminary work that was done by um, Charles Limb, um, who did it with jazz provisors. Um, and then more recently there was a rap study as well, looking at a group of rappers. But basically you find this distinct pattern of activation in these flow states where you have decreased dorsolateral prefrontal cortex activation and increased medial prefrontal. And you see it in the jazz improvisers. You see it in the rappers, you saw it in my husband. And so one idea is like, is there a neural signature of creativity and improvisation and can we get people into these flow states more easily and get them to maintain them longer as maybe a form of therapy. Now that being said, when people with impulse control disorders can't get out of that state, right? If you permanently have dorsolateral prefrontal cortex turned down, that's maladaptive. But the idea is if you can take someone with the sort of healthy brain and turn it down in a controlled way, it could be very therapeutic.

Dr. Stieg: What I also find interesting, however, is how do you separate out the star performer and that balance that must go on between the middle part of your frontal lobe and the lateral parts. So when you're performing, you're looking at your audience and going, "Oh, this ain't working. And so all of a sudden, so it's a delicate balance between all segments of your brain working together.

Dr. Berlin: Yeah, and that's actually something we wanted to look at. So it's a process of switching between, these two modes are kind of like general circuits that are more active in the brain. You have this default mode network, which is kind of the inward looking: I'm going to be creative and turning up the medial prefrontal cortex. Then you have this outward looking called the executive control network where you turn back on the dorsolateral prefrontal cortex and kind of check in with the environment, see what's happening, look at like, what feedback you're getting and then adjust your behavior accordingly. So it's not like you're completely out of it, you know, in some random flow state, you'd go in and out of these two modes to adopt your creative process in the moment.

Dr. Stieg: We've talked a lot about the flow state as it relates to being an artist for we mortals that don't have any, what we think is pure artistic talent. Are there other ways that one can achieve a flow state?

Dr. Berlin: Yeah, of course. I mean, not everybody is an artist. Um, but if you, even people who are really engrossed in, I mean as an academic, like when I'm involved in writing a paper and I really get into it, um, and I lose my sense of self and time and place, um, that's a flow state or you know, reading a book or gardening, um, running — people get into these flow states when they're running or rock climbing. So it doesn't have to be, it could be a mental act that you're engaged in. It doesn't have to be a creative art act, although people tend to be more creative in those states, and come up with ideas or solve problems when they're in those states.

Dr. Stieg: So essentially a flow state is a complete absorption into some activity, whether it's cognitive or physical that divorces you from a perspective on the sense of time.

Dr. Berlin: Yes. Yeah. We found that, I've looked, I've done studies on this, which is looking at our sense of time. And when you're in these states, you really do lose your sense of time. And again, you are able to think outside the box. There's a study where they gave people a riddle to solve and they couldn't solve it. And then they use TMS, transcranial magnetic stimulation, which kind of knocks out the dorsolateral prefrontal cortex temporarily. And they found, once they did that, they actually immediately could solve the puzzle so they could think outside the box. But the idea is that in impulsive people, this part of the brain is turned down and it's a negative thing. They can't control their behavior, but in certain controlled ways when we turn down the dorsolateral prefrontal cortex, it can actually be really positive and we could come up to solutions to problems or lose our sort of rumination that running around in our head.

Dr. Stieg: I want to thank you, Heather, for taking the time to really go through impulsive compulsive disorders. I think it's really important for people to understand the, the, the positive impact that cognitive behavioral therapy can have on patients with these disorders. And it, I'm finding that it's even applicable in other dysfunctions like chronic pain and in, in people that have experienced head trauma. So it's, it's really something that is positive. You don't have to use drugs, and the impact of cognitive behavioral therapy, I think is, is astounding for our patients. I agree. Thank you so much for being with me.

Dr. Berlin: Thank you, for having me.

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The drive to reproduce – to move our DNA into tomorrow – may be behind our ability to do math, make music, and even play sports. Evolutionary anthropologist Helen Fisher explains why our complicated brains evolved in response to a very primal urge to mate.

Dr. Stieg: Today I'm with Dr. Helen Fisher. She is one of the world's leading experts on love, an author, and biological anthropologist. She is a senior research fellow at the Kinsey Institute of Indiana University and a member for the Center for Human Evolutionary Studies in the Department of Anthropology at Rutgers University. Helen, thank you for joining me. We're going to talk about a topic I think that everybody's intensely interested in and it's how lust built the human brain. When I interview people that are interested in diet and nutrition, they say that the brain developed as a result of our need for survival and better acquisition of foods. You're changing that topic. You're saying that my brain developed because I lust.

Dr. Fisher: Well, you know, I'm an evolutionary anthropologist, so I studied the evolution of the brain and all the social and sexual emotions and a wonderful book came out sometime ago called The Mating Mind. And the question was, why are we so good at math? Why are we so good at engineering? Why do we do charitable giving? Why are we so musical? Why do well, we do all the arts. So why are we so good at sports? I mean, you don't have to know calculus to find another banana in the woods. So why is it? So anthropologists have long wondered why it is that we've evolved this very fancy brain and it's probably just for courtship. As a matter of fact, started with Darwin.

Dr. Stieg: So you're saying then that my mathematical skills and my intuition are all secondary to my need for courtship?

Dr. Fisher: Probably, yes. Well, they evolved because of course, you know, Darwin was really annoyed when he saw a peacock's tail. He said, every time he wrote to his son, he said, "Every time—

Dr. Stieg: Was it envy or was it an annoyance?

Dr. Fisher: It was annoyance. Because you know, I mean, what is the peacock's tail? I mean, it's a handicap. You're carting something around, you don't need a big fat tail of feathers to live another day. And he began to finally realize this is for courtship. This thing evolved not to win another piece of corn to eat, but to win a female and have babies and send their DNA on into tomorrow. So the basic hypothesis is, and it's called sexual selection, it's a form of natural selection. I mean natural selection, really. We often think of it as, okay, good eyesight, so we don't fall out of the trees. The thumb, so we can make tools and weapons. But the bottom line is we have to do more than live another day. We've got to move our DNA into tomorrow. So we've evolved all kinds of courtship devices to attract the opposite sex or to fight with members of our own sex.

Dr. Fisher: So, for example, an elk has these big antlers. Well, they're there to fight other males so that they can get access to females. But sometime in our past via this concept called sexual selection, we evolve all kinds of mechanisms to win the mating game. So a million years ago, a guy who was trying to shoot monkeys in the tree and knew how many were left after he got two of them was more impressive to the girls. The guy who was able to sing better, the woman who could dance better, the person who was more charming or more charismatic or just simply more clever, won more in the mating game, had more babies and passed their DNA on.

Dr. Stieg: It seems to me, that you're holding the male accountable, and I would like to contend with you that—

Dr. Fisher: Well, first of all, I'm not—

Dr. Stieg: Women are hunting also.

Dr. Fisher: Big time.

Dr. Stieg: Both sexes want the race or the species to survive.

Dr. Fisher: Well, they want themselves to survive and a species survives because each does, and there's absolutely no question about this, Phil,8 that I'm actually probably the only scientist in America who really defends men and I do it for very, very good reasons. The reason it's both sexes is because we are a pair bonding species. So not only do males have to fight other males to attract females, but females have to attract males. And because we are a monogamous or a pair bonding species, females have evolved basically the same brain. I mean there's gender differences in the brain, unquestionably, but the courtship game, it takes two, no question.

Dr. Stieg: ...to tango. As a result of that, are we really selecting within our species just the best people that are good at reproducing? Or is it again, are there other things that affect our survival? If you're attractive and you're attracted to me, we're going to mate, but what does that have to do with eating and what does that have to do with survival and what does it have to do with dominance and all the other characteristics?

Dr. Fisher: It's all a big mix of things, of course. Basically what Darwin said is that if you have four children and I have no children, you live on and I die out. So the game of love matters. I mean you can own the world, you can have all the money, you can have all the prestige, you can be the best high jumper or the best singer, et cetera. But if you don't have babies, you don't pass your DNA on into tomorrow there is something called inclusive fitness. So let's say you are my brother and we both have two other sisters or whatever, and let's say I don't reproduce, but I help you reproduce by helping your children through college and helping your children learn math in school, et cetera, et cetera. So because we're part of the same gene pool.

Dr. Stieg: Or you can help me find another beautiful woman that I can mate with, right?

Dr. Fisher: There you go. Absolutely.

Dr. Stieg: My daughter does that for my son all the time.

Dr. Fisher: Oh, well. So there we go. A good inclusive fitness for the family.

Dr. Stieg: You emphasize the fact that we attract the opposite sex and I want to focus on the word attract. What does that mean? Is it because you're beautiful is it because, if you're a male, you're a good hunter? Is that attractive? And if you're a female, you're a good provider, you cook well. What, quote, is attract?

Dr. Fisher: I and my colleagues have put over a hundred people into a brain scanner and studied the brain circuitry of attraction. We call it romantic love, but we tend to fall in love with somebody from the same socioeconomic background. Same general level of intelligence, same general level of good looks, same religious and social values, same economic goals and reproductive goals. Your childhood always plays a role. We build a, what I call a love map, an unconscious list of what you're looking for in a partner in childhood. But we're also naturally drawn to people because of our chemistry. You know, people will say, we have chemistry or we don't have chemistry, and I've studied the brain circuitry, the basically the brain chemistry, human personality, and I actually created a questionnaire that's been given to 14 million people in 40 countries and watched why we're naturally attracted to one person rather than another. But, when you're talking about a one night stand and just lust, you know, we can—

Dr. Stieg: Is this the first time around? Because I think that as I was listening to you, I was thinking there are many examples of elderly men or elderly females that don't seem to be attracted to somebody of the same social setting. And, I mean, we can make some jokes about that, but I won't.

Dr. Fisher: Well, so of all ages, we were attracted to all kinds of people that astonish our friends. Two people who love to play the piano, they may be different cultures, different sizes, shapes and ages, but they share an interest.

Dr. Stieg: I guess what I'm saying is when we're younger there's this need to reproduce. When we're older we're probably attracted to people for other reasons.

Dr. Fisher: What's interesting is I study older people cause I'm older, I do an annual study with match.com called Singles in America. This is a representative sample of Americans based on the U.S. Census. We do not pull the match members. And there's a question that really showed me something about older people. I asked the question, would you make a longterm commitment to somebody who had everything you were looking for but you were not in love with them and people over 60 with the least likely to compromise, the most determined to have a partner who they were madly in love with. And also I asked the question, you know, would you make a long-term commitment to somebody who had everything you were looking for, but you did not find them sexually attractive? And once again it was older people who said no.

Dr. Stieg: So is love sexual attraction?

Dr. Fisher: I think that we've evolved three distinctly different brain systems for mating and reproduction. One is the sex drive, second is feelings of intense romantic love. And the third is feelings of deep attachment. And I think the sex drive gets you out there looking for a whole range of partners. You don't have sex with somebody you're not in love with. I think romantic love evolved to enable you to focus your mating energy on just one at a time. And that third brain system of attachment enables us to stick with this person at least long enough to raise a single child through infancy together.

Dr. Stieg: When you're talking about people that are over 60 that wouldn't get involved with somebody that they're not in love with, is it all three of those or is it, you know, I'm looking for companionship and this person is really comfortable to be around. You know

Dr. Fisher: When we ask, they're not looking for just companionship. Now, for example, I'm over 60 and there was a guy a and—

Dr. Stieg: You don't look a day over 39!

Dr. Fisher: Well, you're a sweetheart, neither do you. Thank you very much. Anyway, he was a guy from Arizona. He had everything I was interested in, he was good looking. Now he was smart, he was funny. He loved the theater the way I do. He was a good writer, et cetera, et cetera. I didn't find him sexually attractive and I wasn't in love with him. Am I going to leave New York at all? My friends and family and connections and apartment and interests in order to go someplace just because somebody is a companion? People over 60 are happier. There's data now in 15 cultures, you probably know all this as a neuroscientist yourself, but happiness increases with age and the most likely to compromise where young men of reproductive age, they were the most likely to find a companion to help them have and raise babies if they were not in love with the person and did not find that person sexually attractive. So it's the young that have to compromise because they're the ones that have to send their DNA into tomorrow.

Dr. Stieg: Well, let's talk a little bit about aging and our sex drive or need or lust. Let's focus on the male first. What happens to the male body as we age and how does that change our lust?

Dr. Fisher:  Yeah. It doesn't change the eagerness, but it can change the performance. It does change the eagerness to some extent. The peak of male sexuality is between 18 and 25 and the peak of female sex drive is between age 25 and 29.

Dr. Stieg: This is where I think God is unjust. *laughs*.

Dr. Fisher: Yeah. Actually I think it's sort of cool because there's always somebody chasing after somebody, you know, if they were always there at the same time. And then after five years I said, ah, no, no bother. But I, in fact, I even thought of that — first the man is lusting and then the woman is, and as they age, a man's sex drive goes slowly down as activity of the testosterone system in the brain goes down.

Dr. Fisher: It can often increase in older women because with menopause levels of estrogen go down about 20 times. But levels of testosterone only go down about three times and so you see the ratio change of estrogen to testosterone and whereas the young man was hunting the women, it can be older women who are actually more sexually driven than men, so we always get that imbalance. Keeping somebody racing after somebody. You know when in terms of the best sex, when we asked that question in the singles in America study, the best sex is the peak of women's, but they would say is their best sex is age 66 and the peak of men's best sex they report is age 64. And by that they're most likely to, well first of all, they know who they are and they've got the courage now to say what they want—

Dr. Stieg: So it's the emotional component of the sexual act?

Dr. Fisher: I think it's also the circulation in the genital area becomes more and more intense, particularly with having babies and women and with orgasm it puts a lot more circulation in that area—

Dr. Stieg: I would actually think of atherosclerosis and hardening of your vessels that it would actually diminish.

Dr. Fisher: It could be in some people—

Dr. Stieg: And since erectile dysfunction is actually a blood flow problem, it's counterintuitive.

Dr. Fisher: You might be right. I mean this is not something I study, but older women do have more activity in the testosterone system and that's linked with the sex drive in both men and women. But what's nice for men is they've now got Viagra and women have estrogen replacement and you know, we have all kinds of mechanisms to keep the sex drive and all of the organs in shape.

Dr. Stieg: I think that's optimistic for people then, that you know, they think that when they're past, for guys, 25 — his days are past him, but so for men, their happiest or most meaningful sexual encounters are—

Dr. Fisher: Sixty-four. And I think one of the reasons is, men's and women's sex drive is somewhat different. Young men are very focused on orgasm, whereas women are more contextual, holistic. They like the flowers and the candles and the nice environment and everything. They're more sensual and—

Dr. Stieg: The conversation after the act.

Dr. Fisher: Yes. When we asked what you don't want in bed, the top one is somebody who talks too much. *laughs* I never met anybody who talked too much. This came as a surprise to me. I think that as men get older, they become more contextual. As testosterone goes down and they begin to make estrogen, not just the ratio of estrogen to testosterone, but out of the adrenal glands, men begin to make more estrogen and you can see it in men, they get little more floppy breasts, more weight around the hips, the way women do. It's my guess is that they begin to see sex in a broader world of the conversation and the, the context of it.

Dr. Stieg: Maybe it's just so they understand the Harry Callahan line, you know, "A man's got to know his limits."

Dr. Fisher: There you go. Then the young men don't. Right? And they know how to please.

Dr. Stieg: For multiple reasons.

Dr. Fisher: Yeah. They know how to please more. And you know, when I ask also in the Singles in America questionnaire, men want to please. Men want to please women. And it's not because they're just macho. There's some data that as a woman has an orgasm, she's pulling that semen up into the uterus. So it's adaptive for a man to please a woman because he may just send his DNA on into tomorrow.

Dr. Stieg: Helen, thank you for this provocative conversation. I look forward to getting back together so we can delve more deeply into the positive impact that love and sex has on our brain and our bodies. Thank you.

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Talking with your neurosurgeons during brain surgery may seem terrifying or like science fiction. But actually, as two patients share, it was a necessary part of making their surgeries successful. Dr. Rohan Ramakrishna joins Dr. Stieg to talk about how awake craniotomies provide a critical real-time assessment into the inner workings of the brain.

Dr. Stieg: In the process of performing brain surgery, a neurosurgeon often has a patient under something called general anesthesia, but there are occasions when the patient must be awake and fully conscious during the surgery so that the surgeon can communicate with the patient to make sure sensitive parts of the brain are not being compromised. This amazing procedure is called an awake craniotomy. Dr. Rohan Ramakrishna, a neurosurgeon at Weill Cornell Medicine / NewYork-Presbyterian Hospital specializing in awake craniotomies joins me today along with his patient, Mario Moore. Mario is an artist who had a seizure which led to the discovery of a brain tumor. Welcome Rohan and Mario. Mario, I'd like you to take us back a few years before your seizure. What you described was giving a lecture but not being able to remember the words. What was your experience during that event?

Mario Moore: So I'm a visual artist and I was giving a lecture at Winston-Salem State University and I believe it was in 2015, I was giving a lecture to a class and I'm talking about my work and talking about my paintings and things like that. And I was coming to about the end of the lecture and there were words that I was, that I had in my mind that I wanted to say and I couldn't, I just couldn't say them. So literally what I had to do was talk around those words and I'm sure to the students after the lecture that they probably looked kind of confused or like, I don't know what that last part, what it's about. I thought it was me being nervous, but eventually I found out it was, it was more to it.

Dr. Stieg: So Rohan, can you give us a little bit of background on what really went on and why you felt like you needed to do an awake craniotomy in this situation?

Dr. Ramakrishna: Well, as Mario mentioned, he had had some telltale signs of language dysfunction prior to being diagnosed with a brain tumor. In addition, he had had a seizure and when the imaging evaluation for this was completed, it was clear he had a tumor and a part of the brain called the superior temporal gyrus on the left side. Now this part of the brain is almost always intimately associated with language function and there was some swelling associated with the tumor. So it was immediately obvious that this lesion was in fact responsible for not only seizure but his language dysfunction because of the proximity of language areas to the tumor. That's why I recommended an awake craniotomy so that we could find those areas and take the tumor out safely.

Dr. Stieg: Had you gotten a functional MRI scan beforehand to confirm that as well?

Dr. Ramakrishna: Uh, yes. And he had language areas intimately associated with the tumor.

Dr. Stieg: So Mario, you're sitting in Dr. Ramakrishna's office, and he says, "I want to do an awake craniotomy." What was your first reaction?

Mario Moore: My first reaction was I had no idea what it was. The second reaction was I'd never had surgery before, which also led me to have no idea what it was. And then when I realized what he was talking about, I immediately thought of a scary movie. It's like, this is, this is something that people actually do. But when Dr. Ramakrishna actually explained it more, I understood the process and I knew he was really good at it from just, I'm talking to him and doing some research on my own. So it seemed to be the best way to remove the tumor. You know, of course I was still a little like, "Oh, this is, this is kind of out of this world." But I understood what was needed to be done.

Dr. Stieg: Rohan, as a surgeon proposing this to Mario, what was your perception of his response and how did you deal with that?

Dr. Ramakrishna: I think Mario, being a young otherwise healthy guy was appropriately taken aback by the thought of having surgery. Certainly anyone being told they're about to have brain surgery for a tumor will be anxious. But he handled the news and the proposed solution really quite well. I think he did what all patients should do, which was ask the right questions. He came very prepared to the office visit with a number of questions he wanted to ask. He did more research once he left the office and so I think he was as prepared as he could have been prior to the procedure.

Dr. Stieg: So Rohan, can you describe what kind of a patient we might not want to use an awake craniotomy? What are the limitations of this technique?

Dr. Ramakrishna: Well, the technique works best when the surgeon, and the neuropsychologist, and the patient all speak the same language as their first language. You can imagine that if patients speak English as a second language or don't speak English at all, it can be very challenging to interpret language errors in the operating room because of the complexities of understanding the nuance between languages. Similarly, if someone has language deficits as a result of their tumor or hemorrhage, for example, that can make understanding language errors in the operating room very difficult. So, in general, we try and optimize our patients for an awake craniotomy by having them meet with the neuropsychologist preoperatively so that they understand what exactly is going to happen during the procedure. But also so that we can tailor our awake craniotomy testing so that it's most efficient during the operating room.

Dr. Stieg: Our second patient, Rachel Lindquist Stahmer had suffered a traumatic head injury during a soccer game and was having a brain scan when she was a teenager. In Florida. Your whole situation was rather unexpected as well. A little bit differently than Mario's. You had already by the time you came to New Jersey, had already gone through several operations under general anesthesia before you and I met. Can you talk about that and how that affected your interactions with me?

Rachel Lindquist Stahmer: I had my first surgery when I was 16 in Florida, so I think out of all of my surgeries that was the scariest for me because I was so young and didn't understand exactly what was happening. I had another surgery in my early twenties and I thought that that was going to be the end of my surgery. It turns out that the cavernous angiomas were growing more in my brain. When I was 16 my first neurosurgeon told me those were what I was born with and that's what I had. When I came to you in 2011 in that in the emergency room, I wasn't expecting to have another surgery, but I guess I was prepared.

Dr. Stieg: So for our listeners, when I first saw Rachel, she had arrived in our emergency room in NewYork-Presbyterian Hospital with several, what we call cavernous malformations, which are aberrant blood vessels within the brain that can leak or can cause seizures. One of the cavernous malformations was indeed close to her speech area called Broca's area, much like Mario, a critical place that controls speech. We knew in a way craniotomy was in order and I'm sure you remember 

that day. Rachel, can you recount our conversation when I proposed this to you?

Rachel Lindquist Stahmer: Yes, I remember it. So the one on the Broca's area was something that had bled previously, but we were just watching. I never thought that we would be operating on that particular one either. I thought it was an inoperable area. You told me that I needed to have a functional MRI after I had a few bleeds. I got the functional MRI and I saw that most surgeons that did surgery in the Broca's area, it was an awake craniotomy. So I told my husband, I think that Dr. Stieg might be telling us that I'm going to have an awake brain surgery. So the way I handle that, I watched a brain sort of, alive, awake brain surgery on YouTube. And I know that sounds a little crazy that somebody would watch it, but just coming from my other surgeries, I wanted to be more prepared. And when I came to your office, you introduced me to Dr. Ramakrishna also. And as scared as I was, I was ready.

Dr. Stieg: And I think we should explain to our listeners that the patient feels absolutely no pain during an awake craniotomy. In fact, the patient feels just about nothing since the physical brain itself has no pain fibers and no sensitivity. The patient is awake because the surgeon wants to hear directly from them. And so do we.

Dr. Stieg: Mario, can you talk us through the before surgery process when you were put through the series of benchmark tests?

Mario Moore: Yeah, so I had an appointment with the neuropsychologist. Basically what he did, I was in the room and my girlfriend was also also with me and he had a series of postcards and he basically went over what would happen in the operation room, which was that he would present to me a series of three of the, that would have simple line drawings of like a cup or a knife, watch and things like that. And then he had a series of postcards that had sentences and I had to fill in the line with a word. So as we did this, you know, pre-op test, he was going through some of the images and I was sitting there and a lot of it, I really could not say what what it was. I knew the way the image worked, I knew what it was and that knew like what its use was. But I couldn't say the word to define the image. What was interesting though, my girlfriend was sitting right next to me and she actually thought that I just didn't know it. Like it wasn't a a brain tumor thing. She was like, do you really not know what those things mean? But eventually, uh, during the operation, uh, I actually did really well with the postcards and the sentences. And then, we went on to have a full conversation.

Dr. Stieg: Did that help your girlfriend understand the gravity of your problem?

Mario Moore: It did. It did. I think as she was sitting there, I think she kind of began to tear up a little bit just to understand what was really happening because it's not something that you can see, per se, or something that was like readily available for everybody to witness that knew me in my life. So I think it kind of provided the gravity of what was happening inside.

Dr. Stieg: That's real important. Family members go through these processes almost as seriously as the patient does and it's important for them to, to understand that. Rohan, do you want to describe why the pre-testing and all that is important for you? Get into the operating room?

Dr. Ramakrishna: Sure, Dr. Stieg. I think it's critical that patients undergoing awake procedures meet preoperatively with the neuropsychologist. It serves a number of functions. First, it familiarizes the patient with what exactly will happen in the operating room. So there are no surprises or anxiety. And second, it establishes a baseline of language function with the neuropsychologist. This is also critical because if someone has a baseline level of language dysfunction, we can tailor the tests that we do interoperatively so that the procedure is much more efficient and effective and not anxiety inducing in our patients.

Dr. Stieg: So Rohan, can you specifically describe to the listeners what we're really doing in the operating room when we're doing functional mapping of the human brain.

Dr. Ramakrishna: Once the patient has been put into that twilight state where a specific cocktail of medications are given, such that the patient can be awake but still breathe on their own, we start the procedure by making the incision and taking off the bone. Once we've opened up the lining of the brain and they're staring at the brain itself, we first have to figure out if there's any seizure activity going on in the brain. And so taking an electrical stimulator, which we use for the brain mapping procedure, we carefully stimulate the brain at ever-increasing intensities until we can generate a type of mini seizure. This is a sign that tells us that further stimulation, at above this intensity might cause a seizure interoperatively. And so once we know the stimulation that will be safest for that patient, we can then really awake the patient from the twilight anesthesia and begin the mapping procedure.

Dr. Ramakrishna: Now there's two types of mapping procedures. There's language mapping and there's motor mapping. In language mapping, it sounds just like it; it means just what it sounds. And that is, we go around the brain as the patient is going through a series of language tests and stimulate the brain. If we stimulate a part of the brain that is critical for language function, either the production of speech or the comprehension of speech, the patient will not be able to engage properly in the language task. Tasks can be anything from counting where we say count from one to 10 and if we stimulate the right part of the brain, they won't be able to count anymore. Similarly, we may ask them the question, "What does a king wear on his head?" And if we stimulate the right part of the brain there, they will not be able to understand what we've asked them and respond with. gibberish. Similarly, we may ask them to repeat a very simple phrase like, "No ifs, ands, or buts." And if we stimulate the appropriate part of the brain there, they won't be able to repeat back to us what we said despite the fact that they understood, what we asked them to do. So that in a nutshell is what language mapping is. And then of course we take nothing for granted. Even once we've mapped out the brain and have started to remove the lesion, whether it's a cavernous malformation or a tumor, we keep the patient talking during the operation. And so in that way, it gives us live in the moment feedback about how what we're doing is affecting their language function. The other part of mapping that we often do is called motor mapping. And this is slightly different in that we're trying to find where in the brain, the part that controls motor function, which is the movement of your arm and leg, is located. It's very similar to language mapping and that we use an electrical stimulator, stimulate a part of the brain. And when we do it, it causes the patient's arm or leg or face to move. And we monitor this not only by visualization of the movement, but by neurophysiologic monitoring where they can see movement in the muscles even if the leg isn't actually visibly moving. So that in a nutshell is language and motor mapping.

Dr. Stieg: Rachel, after we started the surgical procedure and then awakened you for the removal of the cavernous malformation, what was your experience as we awakened you and you started speaking with the neuropsychologist?

Rachel Lindquist Stahmer: When I woke up, I heard people calling my name. I was speaking with the neuropsychologist. I was very comfortable. I didn't feel any pain. I was, he asked me what I wanted to speak about to make feel. I think more comfortable and I spoke about vacation and then a lot of the same questions from the functional MRIs.

Dr. Stieg: I think that Dr. Ramakrishna and I can both assert that while we were taking out the cavernous malformation, you were just joyously singing about this miraculous vacation that you had with your husband. Can you describe what your recovery was like? Was it different with an awake 

craniotomy versus having had general anesthesia?

Rachel Lindquist Stahmer: Yes. It was very different. Actually. I know that I said to you before that if I have to have another surgery and I had to pick one, I would choose the awake craniotomy. When I came out of the surgery, I didn't feel as nauseous. I felt more composed. I felt better, I felt more awake. I didn't feel as drowsy and exhausted as I did compared to the asleep craniotomy.

Dr. Stieg: Rachel, I'm really happy that you tolerated the awake craniotomy much better and I certainly hope that we won't have to do another surgery. That being said, Dr. Ramakrishna, can you explain why she probably felt better after the awake craniotomy versus general anesthesia?

Dr. Ramakrishna: In general anesthesia, you're getting a deep induction of medication that really slows brain activity. With an awake technique, you're getting the minimal amount of sedation required so that you can tolerate the incision, but not feel much pain. And so because you're getting much less sedation and narcotic medication, the aftereffects, or the hangover experience is dramatically reduced. So that's why I think patients often feel that the awake procedure is much more tolerable from a recovery standpoint than general anesthesia.

Dr. Stieg: Rohan thank you for helping us better understand the reasons why awake craniotomies provides such a critical window into the functioning of our patient's brains in real time. And a very special thanks to Mario and Rachel for sharing their remarkable stories.

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