Alzheimer s and Diet: New Research Frontiers

Transcription

1 Alzheimer s and Diet: New Research Frontiers Ayesha Sherzai, MD Dean Sherzai MD, PhD(c) Co-Directors of Brain Health Center Department of Neurology Loma Linda University Health

2 Our Aging Society

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6 FIGURE 4 Projected Number of People Age 65 and Older (Total and by Age Group) in the U.S. Population with Alzheimer s Dementia, 2010 to 2050 Millions of people with Alzheimer s Ages Ages Ages Year A12, 31 Created from data from Hebert et al.

7 New Diseases Alzheimer s disease Vascular dementia Stroke Parkinson s disease

8 Alzheimer s

9 1 in 10 people age 65 and older has Alzheimer s disease.

10 89% increase in deaths due to Alzheimer s between 2000 and 2014.

11 FIGURE 5 Percentage Changes in Selected Causes of Death (All Ages) Between 2000 and 2014 Percentage 90 89% % -9% -14% -21% % Cause of Death Breast cancer Prostate cancer Heart disease Stroke HIV Alzheimer s disease 208, 219 Created from data from the National Center for Health Statistics.

12 $259 billion total annual payments for caring for individuals living with Alzheimer s or other dementias in 2017.

13 More than 15 million Americans provide 18 billion unpaid care hours for people with Alzheimer s or other dementias, valued at $230 billion.

14 The Big Myth Source: Alzheimer s Drug Discovery Foundation

15 Normal Aging Alzheimer s Mild Cognitive Impairment No change Other dementias

16 Sperling, et al. (2011). Alzheimer's & dementia, 7(3),

17 In more than 400 clinical trial between 2000 to % Alzheimer s drug failure rate.

18 Treatment & Research Only 4 drugs for symptomatic management Inadequate models: Mice are Not Men/Women Clearance vs. Restoration

19 Genetics Polygenetic disease: more than 90% in origin Apolipoprotein E4 Presenilin 1 Presenilin 2 Amyloid Precursor Protein (APP)

20 Opportunity Lost Wrong target Wrong models Wrong timing

21 Hypothesis of Cognitive Diseases RISK FACTORS Diabetes Poor Diet High Sugar High Saturated Fats Obesity High Cholesterol Oxidation Inflammation Alcohol Abuse Stress Smoking High Blood Pressure Lipid Dysregulation Glucose Dysregulation Sedentary Behavior Poor Sleep Small Vessel Disease Head Trauma

22 Hypothesis of Cognitive Diseases PROTECTIVE FACTORS Daylight Exposure Regular Exercise 1 Moving + Standing Exercise 1. Aerobic exercise, resistance training, and balance strengthening. Learn more in Chapter Walking meditation, mindful breathing, yoga, and others. Learn more in Chapter Learn more about beneficial and harmful foods on page 126. Plant-Based Diet 3 Omega-3 Fatty Acids 7 8 Hours of Sleep Social Engagement Volunteering Purpose-Driven Activities Stress Management Meditation 2 Nutrition Optimize Restore Unwind Continual Learning

23 Dietary Confusion

24 Loma Linda The only Blue Zone in the US Focus on Lifestyle and preventive medicine

25 Decade of Evidence Adventist Health Study: A 1993 study titled The Incidence of Dementia and Intake of Animal Products, found that in a group of over 3,000 individuals, those who ate meat including those who ate only poultry and fish had twice the risk of developing dementia compared to vegetarians.

26 Decade of Evidence The Chicago Health and Aging Project: Longitudinal study, 2500 older adults, those who consumed higher amounts of saturated and trans fatty acids over a six-year period had a higher risk of developing Alzheimer s, while those eating fats derived from plants had a lower risk.

27 Decade of Evidence Kaiser Permanente Northern California Group: 9,900 patients, individuals with high cholesterol during midlife had a 57% higher risk of developing Alzheimer s disease later on. Even borderline high cholesterol increased the risk of Alzheimer s by 23%.

28 Decade of Evidence Women s Health Study Nearly 6,000 women followed over a 4-years Higher saturated fat intake was associated with a poor trajectory of cognition specifically a faster decline in memory by 70% Women with the lowest saturated fat intake had the brain function of women six years younger

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30 Mediterranean Diet Score Construct High Score Vegetables Fruits Whole grains Low Score Meat, poultry, and dairy Sugar Nuts and seeds Legumes Mono- and Polyunsaturated fats Fish - as a source of omega fats

31 MIND Diet Emphasizes whole food, plant-based diet Limits meat, poultry, dairy and sugar Specifies consumption of berries, green leafy vegetables and beans

32 Alzheimer s & Dementia 11 (2015) Featured Articles MIND diet associated with reduced incidence of Alzheimer s disease Martha Clare Morris a, *, Christy C. Tangney b, Yamin Wang a, Frank M. Sacks c, David A. Bennett d,e, Neelum T. Aggarwal d,e a Department of Internal Medicine and the Rush Alzheimer s Disease Center at Rush University Medical Center, Chicago, IL, USA b Department of Clinical Nutrition and the Rush Alzheimer s Disease Center at Rush University Medical Center, Chicago, IL, USA c Department of Nutrition, Harvard School of Public Health, Boston, MA, USA d Department of Behavioral Sciences and the Rush Alzheimer s Disease Center at Rush University Medical Center, Chicago, IL, USA e Department of Neurology and the Rush Alzheimer s Disease Center at Rush University Medical Center, Chicago, IL, USA Abstract Introduction: In a previous study, higher concordance to the MIND diet, a hybrid Mediterranean- Dietary Approaches to Stop Hypertension diet, was associated with slower cognitive decline. In this study we related these three dietary patterns to incident Alzheimer s disease (AD). Methods: We investigated the diet-ad relations in a prospective study of 923 participants, ages 58 to 98 years, followed on average 4.5 years. Diet was assessed by a semiquantitative food frequency questionnaire. Results: In adjusted proportional hazards models, the second (hazards ratio or HR , 95% confidence interval or CI 0.44, 0.98) and highest tertiles (HR , 95% CI 0.26, 0.76) of MIND diet scores had lower rates of AD versus tertile 1, whereas only the third tertiles of the DASH (HR , 95% CI 0.38, 0.97) and Mediterranean (HR , 95% CI 0.26, 0.79) diets were associated with lower AD rates. Discussion: High adherence to all three diets may reduce AD risk. Moderate adherence to the MIND diet may also decrease AD risk. Ó 2015 The Alzheimer s Association. Published by Elsevier Inc. All rights reserved. Keywords: Cognition; Alzheimer s disease; Nutrition; diet; Epidemiological study; Aging

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34 Alzheimer s & Dementia 11 (2015) MIND diet slows cognitive decline with aging Martha Clare Morris a, *, Christy C. Tangney b, Yamin Wang a, Frank M. Sacks c, Lisa L. Barnes d,e,f, David A. Bennett e,f, Neelum T. Aggarwal e,f a Department of Internal Medicine at Rush University Medical Center, Chicago, IL, USA b Department of Clinical Nutrition at Rush University Medical Center, Chicago, IL, USA c Department of Nutrition, Harvard School of Public Health, Harvard University, Boston, MA, USA d Department of Behavioral Sciences at Rush University Medical Center, Chicago, IL, USA e Department of Neurological Sciences at Rush University Medical Center, Chicago, IL, USA f Rush Alzheimer s Disease Center at Rush University Medical Center, Chicago, IL, USA Abstract Introduction: The Mediterranean and dash diets have been shown to slow cognitive decline; however, neither diet is specific to the nutrition literature on dementia prevention. Methods: We devised the Mediterranean-Dietary Approach to Systolic Hypertension (DASH) diet intervention for neurodegenerative delay (MIND) diet score that specifically captures dietary components shown to be neuroprotective and related it to change in cognition over an average 4.7 years among 960 participants of the Memory and Aging Project. Results: In adjusted mixed models, the MIND score was positively associated with slower decline in global cognitive score (b ; P,.0001) and with each of five cognitive domains. The difference in decline rates for being in the top tertile of MIND diet scores versus the lowest was equivalent to being 7.5 years younger in age. Discussion: The study findings suggest that the MIND diet substantially slows cognitive decline with age. Replication of these findings in a dietary intervention trial would be required to verify its relevance to brain health. Ó 2015 The Alzheimer s Association. Published by Elsevier Inc. All rights reserved. Keywords: Cognition; Cognitive decline; Nutrition; Diet; Epidemiologic study; Aging

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36 Scarmeas et al. Ann Neurol. 2006

37 Each additional unit of the MeDi score was associated with 9 to 10% less risk for development of AD, and progression of the disease. Scarmeas et al. Ann Neurol. 2006

38 Hypothetical cardiovascular disease cascade in cognitve decline Cardiovascular disease risk factors Disturbed hemodynamics Cerebral hypoperfusion Energy substrate delivery CATCH Proteinopathy and Abeta misfolding Clearance of Abeta and various toxins Executive function Verbal fluency Abnormal MMSE Psychomotor speed Mental flexibility and sequencing Memory

39 Marshall, R. Journal of Alzheimer s Disease,2012

40 A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial Tiia Ngandu, Jenni Lehtisalo, Alina Solomon, Esko Levälahti, Satu Ahtiluoto, Riitta Antikainen, Lars Bäckman, Tuomo Hänninen, Antti Jula, Tiina Laatikainen, Jaana Lindström, Francesca Mangialasche, Teemu Paajanen, Satu Pajala, Markku Peltonen, Rainer Rauramaa, Anna Stigsdotter-Neely, Timo Strandberg, Jaakko Tuomilehto, Hilkka Soininen, Miia Kivipelto Summary Background Modifiable vascular and lifestyle-related risk factors have been associated with dementia risk in observational studies. In the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER), a proof-of-concept randomised controlled trial, we aimed to assess a multidomain approach to prevent cognitive decline in at-risk elderly people from the general population. Methods In a double-blind randomised controlled trial we enrolled individuals aged years recruited from previous national surveys. Inclusion criteria were CAIDE (Cardiovascular Risk Factors, Aging and Dementia) Dementia Risk Score of at least 6 points and cognition at mean level or slightly lower than expected for age. We randomly assigned participants in a 1:1 ratio to a 2 year multidomain intervention (diet, exercise, cognitive training, vascular risk monitoring), or a control group (general health advice). Computer-generated allocation was done in blocks of four (two individuals randomly allocated to each group) at each site. Group allocation was not actively disclosed to participants and outcome assessors were masked to group allocation. The primary outcome was change in cognition as measured through comprehensive neuropsychological test battery (NTB) Z score. Analysis was by modified intention to treat (all participants with at least one post-baseline observation). This trial is registered at ClinicalTrials.gov, number NCT Lancet 2015; 385: Published Online March 12, S (15) Chronic Disease Prevention Unit (T Ngandu PhD, J Lehtisalo MSc, E Levälahti MSc, S Ahtiluoto MD, Prof A Jula PhD, Prof T Laatikainen PhD, J Lindström PhD, Prof M Peltonen PhD, Prof J Tuomilehto PhD, Prof M Kivipelto PhD) and Welfare and Health Promotion Unit (S Pajala PhD), National Institute for Health and Welfare, Helsinki, Finland; Karolinska Institutet Center for

41 INTENSIVE INTERVENTION Recruitment (Dementia risk score) Screening (Nurse: CERAD; Physician) Baseline visit (NTB) RANDOMIZATION INTERVENTION KICK-OFF NUTRITIONAL COUNCELING: 7group& 3 individualsessions PHYSICAL ACTIVITY: 1-2x/wk muscle strength & 1-4x/wk aerobic training COGNITIVE TRAINING: 9groupsessions, Independent training 3x/wk 6mo PHYSICAL ACTIVITY: 2-3x/wk muscle strength & 5-6x/wk aerobic training COGNITIVE TRAINING: 2groupsessions, Independent training 3x/wk 6mo MANAGEMENT OF METABOLIC AND VASCULAR RISK FACTORS 6 nurse visits, 4 physician visits Follow-up visit Follow-up visit Follow-up visit Month MINI- INTERVENTION Follow-up visit Follow-up visit REGULAR HEALTH ADVICE Follow-up visit Kivipelto et al. Alzheimer s & Dementia, 2013

42 NTB total score Control Intervention p= Executive functioning p=0 04 Z score Processing speed 0 40 Memory Z score p= p= Baseline 12 months 24 months 0 00 Baseline 12 months 24 months Figure 2: Change in cognitive performance during the 2 year intervention Figure shows estimated mean change in cognitive performance from baseline until 12 and 24 months (higher

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44 The Journal of Nutrition, Health & Aging Volume 16, Number 4, 2012 NUTRITION AND VASCULAR DEMENTIA L. PEREZ, L. HEIM, A. SHERZAI, K. JACELDO-SIEGL, A. D SHERZAI Loma Linda University. Correspondance author: A. Dean Sherzai MD, MAS, PhD(c), Director of Memory and Aging Center, Director of Research, Neurology, Anderson Street, Suite 2400, (909) (office), (909) (fax), adsherzai@llu.edu Abstract: Objective: The objective of this review was to elucidate the relationship between VaD and various nutritional factors based on epidemiological studies. Background: Vascular dementia (VaD) is the second most common type of dementia. The prevalence of VaD continues to increase as the US population continues to grow and age. Currently, control of potential risk factors is believed to be the most effective means of preventing VaD. Thus, identification of modifiable risk factors for VaD is crucial for development of effective treatment modalities. Nutrition is one of the main modifiable variables that may influence the development of VaD. Methods: A systematic review of literature was conducted using the PubMed, Web of Science, and CINAHL Plus databases with search parameters inclusive of vascular dementia, nutrition, and vascular cognitive impairment (VCI). Results: Fourteen articles were found that proposed a potential role of specific nutritional components in VaD. These components included antioxidants, lipids, homocysteine, folate, vitamin B12, and fish consumption. Antioxidants, specifically Vitamin E and C, and fatty fish intake were found to be protective against VaD risk. Fried fish, elevated homocysteine, and lower levels of folate and vitamin B12 were associated with increased VaD. Evidence for dietary lipids was inconsistent, although elevated midlife serum cholesterol may increase risk, while late-life elevated serum cholesterol may be associated with decreased risk of VaD. Conclusion: Currently, the most convincing evidence as to the relationship between VaD and nutrition exists for micronutrients, particularly Vitamin E and C. Exploration of nutrition at the macronutrient level and additional long term prospective cohort studies are warranted to better understand the role of nutrition in VaD disease development and progression. At present, challenges in this research include limitations in sample size, which was commonly cited. Also, a variety of diagnostic criteria for VaD were employed in the studies reviewed, indicating the need for constructing a correct nosological definition of VaD for consistency and conformity in future studies and accurate clinical diagnosis of VaD. Key words: Vascular dementia, nutrition, diet. JNHA: CLINICAL NEUROSCIENCES The Journal of Nutrition, Health & Aging, 2012, 16(4),

45 Article The Association Between Diabetes and Dementia Among Elderly Individuals: A Nationwide Inpatient Sample Analysis Journal of Geriatric Psychiatry and Neurology 2016, Vol. 29(3) ª The Author(s) 2016 Reprints and permission: sagepub.com/journalspermissions.nav DOI: / jgpn.sagepub.com Dean Sherzai, MD, MAS, PhD(c) 1, Ayesha Sherzai, MD 2, Keith Lui, MD 2, Deyu Pan, MS 3, Daniel Chiou, MD 2, Mohsen Bazargan, PhD 3, and Magda Shaheen, PhD, MPH 4 Abstract Background/Aim: To date, few studies have cross-examined the relationship between diabetes mellitus (DM) and dementia nationally. There is also a lack of evidence regarding dementia subtypes and how this relationship changes among older individuals. The objective was to better delineate this relationship and influence of multiple comorbidities using a nationwide sample. Methods: Data were obtained from the Nationwide Inpatient Sample 1998 to 2011 using appropriate International Classification of Diseases, Ninth Version codes. Descriptive and bivariate analysis was performed. Multivariate nominal logistic regression models adjusted for age, sex, race, and comorbidities explored the independent relationship between Alzheimer dementia (AD), non- Alzheimer dementia (VaD), and diabetes. Results: 21% of the participants were diabetic patients, 3.7% had AD, and 2.2% had VaD. Diabetes prevalence in AD, VaD, and no dementia groups were 20.6%, 24.3%, and 26.2%, respectively. In the unadjusted model, those with DM had lower odds of AD (odds ratio [OR] 0.73; 95% confidence interval [CI] ) and VaD (OR 0.91, 95% CI ). Adjusting for age, sex, race, and comorbidities, diabetic patients had significantly higher odds of VaD (OR ¼ 1.10, 95% CI ) and lower odds of AD (OR 0.87, 95% CI ). Inclusion of interaction terms (age, race/ ethnicity, depression, stroke, and hypertension) made the relationship between diabetes and VaD not significant (OR 1.002, 95% CI ), but the relationship of DM with AD remained significant (OR 0.57, 95% CI ; P <.05). Conclusion: Patients with a diagnosis of diabetes mellitus had lower odds of having AD. Age, race/ethnicity, depression, stroke, and hypertension modified the relationship between DM and both VaD and AD. Further exploration of the relationship between DM and AD is warranted. Keywords dementia, vascular dementia, Alzheimer disease Journal of Geriatric Psychiatry and Neurology, 2016, Vol. 29(3)

46 bs_bs_banner Lead Article Stroke, food groups, and dietary patterns: a systematic review Ayesha Sherzai, Lauren T Heim, Cassaundra Boothby, and A Dean Sherzai Stroke is the fourth leading cause of mortality in the United States, yet it is 80% preventable by addressing lifestyle factors including nutrition. Evaluating the impact of nutrition at the food group and dietary pattern level will provide greater insight into the role of nutrition in stroke. For this purpose, a review of the literature was conducted using the PubMed, Web of Science, and CINAHL Plus online databases. While fruits, vegetables, and soy demonstrated a protective effect, variable findings were observed for fish, animal products, and whole grains. Adherence to DASH, Mediterranean, and prudent dietary patterns reduced the risk of stroke, whereas the Western dietary pattern was associated with increased stroke risk. Low-fat diet was not found to have a protective effect. Additional epidemiological evidence is needed to elucidate the impact of specific dietary patterns and food groups on stroke. Future research should consider developing dietary recommendations for stroke prevention, which are based on clinical trials and have an emphasis on food groups and dietary patterns that are palatable to the general public International Life Sciences Institute INTRODUCTION Stroke places a tremendous burden on the healthcare system worldwide. In the United States, it is the 4 th leading cause of mortality, with an estimated 795,000 incident strokes each year. As age is one of the main risk factors while lifestyle risk factors such as diet, exercise, and use of tobacco and alcohol are considered modifiable risk factors. 5 By addressing the modifiable risk factors, it is estimated that stroke prevalence can be reduced by as much as 80%. 6 Thus, primary prevention of stroke takes central importance. Nutrition Reviews, 2012, 1;70(8):423-35

47 CALIFORNIA TEACHERS STUDY In 1995, 133,479 female public school teachers and administrators were enrolled in the study Geographically and socioeconomically diverse Mail paper questionnaires every 4-5 years Linked with California Cancer Registry

48 MEDITERRANEAN DIET AND ALL STROKE INCIDENCE Adjusted* Hazard Ratio Mediterranean Diet Score groups (p trend 0.009) *Age, race, SES, moderate plus strenuous physical activity, kilocalories, BMI, smoking, hypertension, diabetes, atrial fibrillation, hypercholesterolemia, history of cardiac disease and menopausal status and hormone therapy. Submitted for publication to Stroke.

49 Cognitive Function and Diet Our formal study of the California Verbal Learning Test (CVLT), revealed that among 500 individuals who ate a vegetarian had on average a 28 percent lower risk of cognitive impairment. In the process of publication.

50 Circulation, 2016 (Vol. 133).

51 Sugar Consumption Reductions in brain glucose metabolism have long been associated with Alzheimer s disease Brain insulin resistance initiates a cascade of inflammatory stress and oxidative damage, disruption of synaptic function, resulting in amyloid proteins becoming insoluble Deregulation of endothelial glucose transporter GLUT1, vital for maintaining brain energy metabolism and vascular clearance of amyloid-β

52 Alzheimer s & Dementia - (2017) 1-10 Featured Article Sugary beverage intake and preclinical Alzheimer s disease in the community Matthew P. Pase a,b,c, *, Jayandra J. Himali a,b,d, Paul F. Jacques b,e, Charles DeCarli b,f, Claudia L. Satizabal a,b, Hugo Aparicio a,b, Ramachandran S. Vasan b,g,h, Alexa S. Beiser a,b,d, Sudha Seshadri a,b a Department of Neurology, Boston University School of Medicine, Boston, MA, USA b Framingham Heart Study, Framingham, MA, USA c Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, Australia d Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA e Jean Mayer-U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA f Department of Neurology, School of Medicine & Imaging of Dementia and Aging Laboratory, Center for Neuroscience, University of California Davis, Sacramento, CA, USA g Sections of Preventive Medicine and Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA, USA h Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA Abstract Introduction: Excess sugar consumption has been linked with Alzheimer s disease (AD) pathology in animal models. Methods: We examined the cross-sectional association of sugary beverage consumption with neuropsychological (N ) and magnetic resonance imaging (N ) markers of preclinical Alzheimer s disease and vascular brain injury (VBI) in the community-based Framingham Heart Study. Intake of sugary beverages was estimated using a food frequency questionnaire. Results: Relative to consuming less than one sugary beverage per day, higher intake of sugary beverages was associated with lower total brain volume (1 2/day, b 6 standard error [SE] mean percent difference, P ;.2/day, b 6 SE , P,.0001), and poorer performance on tests of episodic memory (all P,.01). Daily fruit juice intake

53 Alzheimer s & Dementia - (2017) 1-10 Featured Article Sugary beverage intake and preclinical Alzheimer s disease in the community Matthew P. Pase a,b,c, *, Jayandra J. Himali a,b,d, Paul F. Jacques b,e, Charles DeCarli b,f, Claudia L. Satizabal a,b, Hugo Aparicio a,b, Ramachandran S. Vasan b,g,h, Alexa S. Beiser a,b,d, Sudha Seshadri a,b High sugar consumption was associated with low hippocampal and total brain volumes. Individuals who a Department of Neurology, Boston University School of Medicine, Boston, MA, USA b Framingham Heart Study, Framingham, MA, USA c Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, Australia d Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA e Jean Mayer-U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA f brain volume over the course of two years Department of Neurology, School of Medicine & Imaging of Dementia and Aging Laboratory, Center for Neuroscience, University of California Davis, Sacramento, CA, USA g Sections of Preventive Medicine and Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA, USA h Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA consumed more sugar also experienced a greater loss of Abstract Introduction: Excess sugar consumption has been linked with Alzheimer s disease (AD) pathology in animal models. Methods: We examined the cross-sectional association of sugary beverage consumption with neuropsychological (N ) and magnetic resonance imaging (N ) markers of preclinical Alzheimer s disease and vascular brain injury (VBI) in the community-based Framingham Heart Study. Intake of sugary beverages was estimated using a food frequency questionnaire. Results: Relative to consuming less than one sugary beverage per day, higher intake of sugary beverages was associated with lower total brain volume (1 2/day, b 6 standard error [SE] mean percent difference, P ;.2/day, b 6 SE , P,.0001), and poorer performance on tests of episodic memory (all P,.01). Daily fruit juice intake

54 The Danger of Ketogenic Diet Background: Alternative source of energy needed for the brain Proven to be beneficial in certain cases of childhood epilepsy No strong data for benefit in neurodegenerative conditions High saturated fat in ketogenic diets cause vascular damage

55 Clinic Experience 2500 patients evaluated in brain health clinic Less than 1% (n=19) patients were vegetarians and led a healthy lifestyle (NEURO Plan)

56 Our Lifestyle Intervention Program at Loma Linda Health E Regular Exercise 1 Moving + Standing Daylight Exposure Exercise Plant-Based Diet 3 Omega-3 Fatty Acids 7 8 Hours of Sleep Social Engagement Volunteering Purpose-Driven Activities Stress Management Meditation 2 Nutrition Optimize Restore Unwind Continual Learning

57 NEURO Plan Nutrition (whole-food, plant-based diet, low in sugar) Exercise Unwind Restorative sleep Optimize medical and cognitive activities

58 Current Research Effect of comprehensive lifestyle intervention on cognitive health compared to standard-of-care Comparison of dietary patterns and Alzheimer s disease (whole-food, plant-based diet vs. high fat, low carbohydrate diet) Aggressive management of vascular risk factors among patients with Mild Cognitive Impairment

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