Lifestyle Intervention Can Profoundly Reduce The Burden of Alzheimer’s Disease

By Dean Sherzai, MD, PhD, MPH, MAS and Ayesha Z. Sherzai MD, MAS

Lifestyle Intervention

Can Profoundly Reduce the Burden of Alzheimer’s Disease

The fastest growing epidemic in the United States and most of the world has been dementia, and the most prevalent type of dementia – Alzheimer’s dementia (AD) – represents 60% to 70% of all dementias.

Today, there are more than 50 million individuals worldwide diagnosed with AD, and in the United States alone, there are more than 6.2 million, with one person being diagnosed with Alzheimer’s every 64 seconds. AD is the fastest growing epidemic in the Western world. In the United States, this number is projected to increase to 152 million worldwide by 2050, rising among low-income to middle-income communities. The emotional cost of the disease to those that experience it, and to their families, is overwhelming, and the financial cost is also staggering. Comparing the cost of Alzheimer’s to the second costliest disease – heart disease – is astonishing. Heart disease costs the healthcare system around $120 billion, but Alzheimer’s is significantly costlier at $305 billion in direct costs and another $245 billion in indirect costs. The cost is expected to grow to more than $1.1 trillion in the next 20 years, which will absolutely devastate our healthcare system.

Women, African Americans, and Hispanics appear to be at much greater risk. One in six women are diagnosed with dementia in their lifetime compared with 1 in 11 men. Compared with Caucasians, African Americans have a two to three-time greater risk of developing AD, and Hispanics have a two-time greater risk.

It is in this environment that we have been chasing amyloid plaques and neurofibrillary tangles for the past 30 years. To that end, researchers have created many cellular and animal models of the disease on which they have tested thousands of molecules. They create the proverbial “lesion” and find a molecular “plug” to fix it. In this way, they have been able to cure or at least curtail the disease in dozens of scenarios. But when translated to human trials, these methods have failed to provide the desired outcome in every instance.

To date, AD has been described in many ways and by some, as type 3 diabetes. Others have described it as a garbage disposal disease and yet others as an inflammatory/immune regulation disease. The reality is that one can approach the disease from different paths. There are patients who have a history of chronic insulin resistance or diabetes, and in these cases, insulin resistance primarily drives the disease, and yet chronic inflammation may be the main driving force behind the inception and propagation of the disease in other cases such as chronic traumatic encephalitis. Lipid dysregulation, as driven by Apo e4 or other pathways, can serve as a driver of neurovascular and neurodegenerative disease as well. And finally, oxidative stress can be a major driver of neurodegeneration as a result of free radical formation, damaging neural architecture and vasculature1. We also know that chronic, low-grade systemic inflammation is common in insulin-resistant states, which are seen consistently in many of the pathways toward the disease. These four processes are involved in the neurovascular and neurodegenerative processes. The only factor that changes is the dominant driver of the underlying pathology.

Reviewing the literature, we have found that there are five fundamental factors that can significantly influence the four pathways leading to AD described above. These factors are related to Nutrition, Exercise, Stress management, Restorative sleep, and Mental and social optimization. To make it convenient to remember the concepts and incorporate them as needed we have come up with the acronym “NEURO” to help healthcare professionals and the general public. “N” is for Nutrition, “E” Exercise, “U” for Unwind (stress management), “R” for Restorative Sleep, and “O” for Optimize.

Nutrition

With regards to Nutrition, despite a great deal of confusion in social media, in the scientific realm there is no question that there is plenty of evidence that a plant-centered diet low in saturated fat, processed sugar, and salt can significantly reduce one’s chance of developing dementia. Whether one looks at the studies coming from the Adventist health study (vegetarian diet), the Framingham study, the California teacher’s study (Mediterranean diet), or the Chicago healthy aging project (MIND diet), the common denominator consistently has been a diet high in greens, beans, cruciferous vegetables, nuts, foods high in omega 3s, herbs and spices, and water as the main source of liquid consumption.

Exercise

Exercise is more important for the brain than any other organ. A Harvard study demonstrated that a 25-minute brisk walk every day reduced one’s chance of developing dementia by as much as 45%. Though we have always known that exercise is good for us, we didn’t know that it would have such a profound effect on our risk of dementia, stroke, and even psychological diseases like depression and anxiety. Another remarkable fact is that leg strength is correlated with bigger brains and better brain health. Given that exercises provide us the quickest and most effective response, we always start a lifestyle change program with a simple exercise regiment, like a brisk morning walk.

Unwind (Stress Management)

The third element of NEURO – U for Unwind – speaks to managing stress by specifically addressing the bad stress in our life and increasing the good stressors. Bad stress is the kind of stress that is not driven by our purpose, doesn’t have clear objectives and successes, whereas good stressors are those activities that serve our purpose, have clear successes and timelines, such as learning to play a musical instrument, learning to dance, learning a new language, taking a class one always wanted, leading a book club, and other similar activities.

Restorative Sleep

The fourth element of NEURO speaks to sleep – but not just going unconscious. Rather, going through the four phases of sleep at least four to five times per night. To achieve this Restorative sleep, one needs to use sleep hygiene techniques, such as keeping a consistent pattern of sleep (consistently going to bed at the same time and waking up seven to eight hours later). Other sleep hygiene techniques include managing bedroom light and sound, not using electronic devices or watching the television a half an hour before sleep, not eating at least two hours before sleep, and keeping the room temperature slightly on the cooler side. And if despite these techniques, running thoughts are affecting sleep, then cognitive behavioral therapy should be applied.

Optimize Mental and Social Activity

Lastly, but not least, is the O for Optimizing mental and social activity. In a recent study, it was shown that the most powerful factor protecting the brain is cognitive reserve, which is achieved through challenging, purpose-driven activities. As demonstrated by two famous studies (the nun study and the taxi driver study), challenging mental activity can increase cognitive reserve more than anything else and can profoundly delay the onset of dementia. As we discussed previously, Optimizing mental activity is the similar to the effects of good stress and can build capacity at any age.

Some of the other factors that appear to affect risk are diminished hearing, smoking cigarettes, drinking more than one glass of wine per day, and head trauma.

It is now universally accepted that as much as 60 % of AD can be prevented, but these numbers come to us from suboptimal lifestyle interventions. We believe that as much as 90% of AD

can potentially be prevented or delayed past normal age (80 yrs.) if started earlier and through more optimal interventions. But irrespective of the numbers, 60 or 90%, for a disease that is expected to overwhelm our healthcare system, and one that has no disease-altering treatments, we think it is critical that physicians start speaking about and applying the abovementioned interventions to those most at risk as even a 20% reduction in risk and prevalence of AD would significantly reduce the financial and social burden to our communities.

About the Authors:

Dr. Dean Sherzai is a behavioral neurologist / neuroscientist whose entire life has been dedicated to behavioral change models at the community and population level. Dr. Sherzai finished his medical and neurology residencies at Georgetown University with a subsequent fellowship in neurodegenerative diseases at the National Institutes of Health, followed by a second fellowship in Dementia and Geriatrics at the University of California, San Diego. He also holds two master’s degrees in Advanced Sciences at UCSD and in Epidemiology from Loma Linda University. He has received a PhD in Healthcare leadership focused on community empowerment from Loma Linda/Andrews University. Finally, he completed the executive leadership program at Harvard Business School. His vision has always been to revolutionize healthcare by empowering communities to take control of their own health.

Dr. Ayesha Z. Sherzai is a vascular neurologist and a research scientist. After completing her residency, she completed a fellowship in vascular neurology and Epidemiology at Columbia University Neurological Institute of New York. Dr. Sherzai is at the tail end of a master’s degree in public health in lifestyle epidemiology from Loma Linda University. Knowing the importance of empowering her patients, and their communities, she completed an extensive culinary training program in New York and now teaches large populations how to make tasty, easy, and healthy meals for their brain health.

They are the authors of two best-selling books, The Alzheimer's Solution (2017, HarperCollins) and The 30 day Alzheimer's Solution (2021, HarperCollins). They are currently leading the largest community-based brain health initiative in the country.

1. Preventing Alzheimer’s: Our Most Urgent Health Care Priority, Dean Sherzai, MD, MPH, PhD(c) and Ayesha Sherzai, MD, Am J Lifestyle Med. 2019 Sep-Oct; 13(5): 451–461. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732875/#bibr37-1559827619843465