Chasing Life

'Welcome to Chasing Life. You know, one of the biggest fears people have, especially as they get older, is that they're going to lose their brain function. They're not going to be as sharp as possible. And they think that is preordained. It's something that's just going to happen. But what you're going to learn today is that none of this is pre-ordained, your brain doesn't have to shrink, you don't have lose your sharpness as you grow older. Dr. Majid Fotuhi, he is a neurologist, a neuroscientist, he's a teacher. He is author of a new book. It's called 'The Invincible Brain.' I read it. I loved it. I even provided a blurb for it. He's someone who's been thinking about the brain for decades now. And the point he makes is that so much of what happens to our brains is in your hands, something you can control. Not necessarily a new medication, not a new procedure, but just simple ways that you live your life. And the simplicity is something that's really going to strike you today. I'm Dr. Sanjay Gupta, and this is Chasing Life.

Well, welcome, first of all, to Chasing Life. What a privilege for me to have you on the podcast.

It's my pleasure to see you in person, Sanjay.

'Well, you know, I obviously know you. I know your work. I've read your book. But I just want to go back a few years. You wrote a paper, I think it was in JAMA, The Journal of the American Medical Association, some time ago, talking about this 12-week program, which, I read the paper at that point. It really struck a nerve with me, this idea that you could not only sort of stall cognitive decline, but maybe even improve it in people. And it was very interesting, it was a very simple paper. There was no new drugs or procedures. It was mostly based on lifestyle changes. And it really caught my attention because I think what people typically feel is that the brain is just going to decline over time and there's not much you can do about it. That is obviously not your belief.

You're absolutely right. When I first started to treat patients in their 70s with cognitive decline, I felt like it would take nine months or a year before I could see some changes. The pleasant surprise I had was that many people started to get better within weeks. Now, it's important to keep in mind that these older adults who had mild cognitive impairment, the stage between normal and Alzheimer's disease, had objective improvements in their validated cognitive tests. It wasn't just that they felt better. They actually memorized things.

What do you think is going on there? Are these people who just mastered a skill, in this case the skill of memorization? Or would you say that their brains objectively improved, or were their brains healthier as a result of this program?

That's an excellent question. In order to provide real heart data that we were making changes in their brain, I obtained brain MRIs before and after the program. We did quantitative measurement on the size of their hippocampus, the part of the brain which is roughly the size of your thumb and it's important for learning and memory. Hippocampus is a part of the brain, as you know, which shrinks and causes symptoms of Alzheimer's disease. So in our program, more than half the patients, and these are older adults, late 60s to early 80s, had 1% to 3% increase in the volume of the hippocampus. And we showed that results in our paper, which was published in the Journal of Prevention of Alzheimer's Disease, on how we can actually see the size of the hippocampus growing, and you can see with naked eye that this brain has a larger hippocampsus than this one.

I think you and I are around the same age and probably trained around the same time. And I think that when we were in medical school, the conventional wisdom was that the brain was different somehow than other organs, that you got a certain number of neurons and that was that. And over your life you were going to drain the cache of neurons and there wasn't much you could do about it. What you're suggesting is that that's not the case, that you can improve your brain throughout your life.

Our brain has a repair kit in place just in case something happens. What you can do is to tap into that repair mechanism and improve your brain in the absence of trauma or stroke. So for example, when you exercise, you increase the amount of EDNF. When you learn something new, you increased the number of synapses. When you eat a healthy diet, you reduce inflammation and you can then increase the of Hippocampus. In other words, the improvements in the brain are not subtle. They're so prominent, they're so profound, that you can see it on MRIs before and after. And I'm not the only person who has shown you can increase the size of the hippocampus. In fact, I put together my program after seeing dozens of studies that showed individual lifestyle factors, what I call five pillars of brain health, increase the sizes of the campus. So I argued, If exercise alone can increase the size of a campus, improving sleep, reducing stress, meditation, brain training, if all of these individually can grow the size of the campus, it should be the case that putting them together would produce better results in a shorter period of time. And that's what I saw when I published my paper in 2016. And since then, there have been dozens of other randomized control studies. That have shown lifestyle interventions can profoundly improve brain functions. So in short, our brain has neuroplasticity and that capacity is just sitting there. Our brain is made of cells, just like our heart is made up of cells. And those cells need oxygen and nutrients. And so it's not surprising to me that our brain responds to lifestyle interventions just like the heart responds to the lifestyle interventions.

How new is this, what you're talking about? Because again, going back a few decades when we were in medical school, that was not what people thought.

I think the past five to ten years.

Five to ten years.

People have come to appreciate how easy it is to change the brain anatomy with interventions.

You know this, doctor, but if you ask older people what their biggest fear is, it's usually something related to their brains. They're going to lose their memory, they're going to loose their personality, they're not going to be able to have a joyous retirement because they just don't remember things as much. That is people's number one fear. My parents, this is what they fear about. Frankly, I've started to worry about that. But with lifestyle changes, Not necessarily a new medication or a new procedure with lifestyle changes. For a significant percentage of people, that does not need to be the case.

Absolutely and what I find interesting is that when I talk about those things in my public lectures or in other interviews, people are surprised to hear it. And what i love to do in my future public lectures and interviews is to empower people to take charge of their brain and realize that they can improve their memory and improve their cognitive functions at any age.

There are six things that you really focus on in the book, main reasons that lead to brain shrinkage. And I just want to read these. We're generally talking about inflammation and reducing blood flow. So that's sort of the cornerstone of all this. We're talking about stress, sleep apnea, obesity, insomnia, untreated depression, and concussions. Those are the things that, you say, to focus on, in terms of what might actually be causing cognitive decline?

'Yes those factors have been shown to reduce the size of the hippocampus in a dose-dependent manner. So, the worse the obesity is, the more hippocampsus shrinks. The more number of concussions you've had, the more hippocampsus shrinks, the more stress you are, the high cortisol levels, the lower your hippocampsus shrink.s And unfortunately, if you have all of these things, your risk for Alzheimer's disease decades later would be 16-fold higher. For example yes this has been shown in another study in JAMA so if let's say your risk in your 70s is two percent then two percent is not significant i mean there's 98 percent you won't get it however if you've had these factors and your two percent is 32 percent which is significant.

Again, I just want to emphasize this because this is such a big fear for people. Those things are reversible.

Yes.

The impact on your brain is reversible. As quickly as your brain may shrink in these areas, it can start to grow again as well.

'Exactly. See, in 2009, I wrote a paper about what we just talked about, all the factors that shrink the brain and I published it actually in Nature. Then in 2010-2011, I published papers about how many factors, what I call the five pillars of brain health, exercise, sleep, nutrition, stress reduction and brain training, increase the size of the campus. So, then I asked myself, well, if these things are so obvious, why hasn't anyone put them all together as a program. And that's when I started in 2012 to create my program. And as I mentioned earlier, I thought it would take a long time to see results, but it turns out that 12 weeks seems to be a sufficient amount of time to see objective improvements in brain functions.

Why weren't more people thinking this way? Why did it take so long to say, hey, look, this doesn't have to be the case that you can actually improve your brain at any age?

I think people follow the leader and sometimes somebody says something and is met with criticism and then as a person or that group of people provide more information more and more people say hey maybe there's some point in that and of course 10 years later people say obviously let me give you an example. In 1950s, people felt that your heart beats only so many times, and so you don't want to exercise too much. Eisenhower's cardiologist, Dr. White, was one of the first cardiologists who said, actually, exercise is good for you. At that time, people who had heart disease were told to rest and take it easy. In 1980s, there was an article in New York Times that said, some cardiologists believe exercise is for you, It was so revolutionary back then. I mean, not talking about 100 years ago, 1980s. And then of course, 1990s, more data showed that exercise is beneficial and there was a paradigm shift. I sincerely believe that 10 years from now, 20 years from, we're going to look back and say, what were people thinking? Why weren't they take care of their brain the same way they would take care of their teeth or their heart?

Is it generally true that what is good for the heart is good the brain? I mean, if we adopted those healthy lifestyles as a result of what we learned about heart disease, exercise is good, eating a low fat diet, things like that, are those things equally beneficial for the brain or is the brain different in some way?

Everything that's good for the heart is good for the brain, but the brain needs something extra on top of what the heart needs, and that is brain training. So I think your brain is like a muscle, the more you use it, the stronger it gets. So everything you do in terms of lifestyle that's good for your heart is for your brain, and you add some cognitive training and then you'll be in good shape.

Good shape. I mean, that's inspiring. Like I said, I'm in my late fifties now, I worry about this. So what should I be doing? We understand that exercise is beneficial, a healthy diet is beneficial. But what did these 12 weeks, when you put people on the program, what did it look like for them? How challenging was it?

I think people need to appreciate that they don't need to have cognitive decline with aging. The first step is to change your mindset. You have to realize your brain is an organ, just like your heart is an organs. That's step number one.

Let me just stop you for a second, because that is very much the assumption.

'Yeah so the first step is to stop that because if you keep saying oh I'm getting old what do you expect you do less you do fewer things because you think you can't so you reduce your brain activity and you challenge your brain less because you think you're not capable you just brush off you just say I can't do this and the more you become sedentary and the less you use your brain the more your brain shrinks which then becomes a self-fulfilling prophecy you know you do less you are less capable which then confirms your idea that you're declining and this is what i found exciting about my work see a lot of people think that you either get Alzheimer's or you don't you either are lucky and you dodge this Alzheimer's disease or you know You're stuck and you become demented. In reality, there are many factors that shrink the brain. The pathology of Alzheimer's, which is called the amyloid plaques and talatangles, is two components of, let's say eight components, that can shrink the brains. And sedentary lifestyle, sleep apnea, insomnia, poor diet, chronic stress, all of those things shrink the braing in parallel to these plaques on tangles. The media and many of my neurology colleagues have focused on those plaques and tangles with the assumption that if you eliminate these with medications, then you cure Alzheimer's disease. And there has not been enough emphasis on these treatable components. So put it simply, cognitive decline with aging has two components, a component of what's Alzheimer's pathology and a component of lifestyle-related treatable conditions. If you treat the treatable components, you improve a lot. As I said earlier, not everybody who does these things will then be cured of Alzheimer's disease. There are still small percentage of people who have predominantly plaques and tangles as the main culprits for their cognitive decline. But in my experience, 90% of people improve when you treat to treatable component of their soup of issues. And so my program has two component, take care of the negative things, like if somebody has sleep apnea, treat the sleep apnia. And if somebody had a central lifestyle, you know, get them to do those things. And another component is to do brain training and really get their brain to wake up. Your brain is like a muscle, when you challenge it, it actually grows. So when you combine, you know take care negative things and focus on positive things, You can see the results in 12 weeks.

More of my conversation with Dr. Majid Fatuhi right after this short break.

Welcome back to Chasing Life and my conversation with neurologist and author, Dr. Majid Fotuhi.

There are these new medications that have been approved. There hadn't been anything approved for, I think, almost a decade and a half for Alzheimer's dementia. Now there are these medications, monoclonal antibodies, which I think you're referring to, which help address these plaques and tangles in the brain. And there was a lot of excitement around these drugs. What was your thought when you saw these drugs get approved?

I think it's exciting that we have drugs that can eliminate amyloid in the brain. However, as I expected, eliminating amylaid has not cured Alzheimer's disease. Patients whose brain are cleared, like more than 80% of amyluid is cleared from their brain. The before and after brain images are very striking. Like all the amylooids gone. You would think if amyload was the main culprit that the person would all of a sudden become normal again. In reality, this does not happen as I would have expected, because you only address one component of a super problems. These medications reduce the rate of decline by a little bit. Whereas several studies, not just mine, dozens of studies have shown that multimodal lifestyle interventions programs, which like mine combined lifestyle interventions, produce better and more robust results than his drugs do. And so I think, again, I'm an optimist, I think that in 10 years from now, we're going to look at Alzheimer's disease much the way we look at diabetes. In other words, much of diabetes can be prevented. And when people have diabetes, we have medications to treat it once it's happened. And in reality, we use a combination of lifestyle interventions and medications for effective treatment of diabetes. And so I think we will look at Alzheimer's in the same way. I think these new medications are first generation medications and that the second and third generation medications will be more effective. And it will be helpful to start these earlier because the earliest footprints of these pathologies appear in the brain 20 years before the symptoms begin. So the best time to do these things is your age where you want to exercise, you want to sleep well, you want to avoid junk food. You want to keep your stress low, and you want to improve your brain. Brain training. So I think what we need to do is to make taking care of your brain as part of your daily routine. Just like you take care of you teeth every day, there are things you could do to take care your brain every day. Such as? So for example, you want reduce your stress. You want limit stress for things that are really worthy of stress. You don't want to get stressed over... You know, traffic and minor things in your life. You want to leave the stress for major things. You want avoid junk food, no junk food. You know, food that are high, you know highly processed food and food that high in trans fats and food spike your sugar increase inflammation in the brain and literally shrink the brain. Literally, not theoretically, literally. So no junk foods, keep your stress down, Move every day. You know, walk 3,000, 5,000 steps a day, exercise about three hours a week, and do something that challenges your brain every day. In other words, if you set aside one hour a day for brain maintenance, with those things I just mentioned to you, you'd be ahead of 90% of the population.

Let me just ask about you. You're the author of 'The Invincible Brain.' Great title, by the way.

Thank you.

I love it. What do you do?

In terms of stress, I really leave stress for things that are severe, significant.

Do you meditate?

I do breathing exercises. Several studies have shown that slow breathing exercises, things that increase what's called HRV, heart rate variability, biofeedback, is a very effective way to reduce cortisol levels, reduce stress, and reduce amyloid in the brain. I actually enjoy those breathing exercises for five minutes. And of course, you know, I teach students, I'm mentoring students, I write books, I write journal articles, I do research, I take dancing lessons with my lovely wife. And so I have something to challenge my brain every day. So, and I exercise, I exercise most days. I sleep well, I'm tired, usually by the time I go to bed at night, I'm just tired, I just crash, you now, I am tired. And then I don't eat junk food at all. You would never catch me eating doughnut, or if I have to eat ice cream, I have a small amount.

You know what's so interesting is it sounds simple, right? And maybe that's the point. I think there's so many gravitational pulls in our society to move us away from what you just described. So for people who are listening, it sounds simply, but at the same time, it's not that easy because it's easier to eat processed foods. It's just much more ubiquitous. There is a lot of stress in our Society. And you know, we live an increasingly sedentary life. So I think, you know, when you talk about breathing exercises and people may say, well, come on, we're talking about monoclonal antibodies, we're talk about brain surgery, we're talkin' about all these things to try and reduce plaques. But the idea that breathing exercises could accomplish some of those same things, in some ways, that's the most extraordinary part of this, the simplicity of it.

Absolutely. And one thing that I know you and I focus on is having a sense of purpose in life. If you have a sense a purpose in life, that helps to guide your daily routines. For example, I think it's a reasonable goal to say, look, I wanted to be a brain super ager, someone who reaches the age of 90 and remains sharp and independent. You may not get there, but you will set that goal. And if that's the goal, and they say, this is my sense of purpose, that's what I want to do. Then every day when you are faced with choices, you will take a choice that's in line with your purpose. Let's say your purpose is to take care of your grandchildren or take care your children. Then if you remind yourself why you're doing what you're going, and you want to be able to be in good shape when you get in the eighties so that you can spend time with your children and your grandchildren. So you use the sense of purpose as a carrot that helps you decide whether I'm going to have these french fries. I'm going to say no thanks.

Look, I think it's hugely inspiring to hear that just making that decision, those micro decisions on a daily basis, can help keep these three and a half pounds of tissue healthy.

Yes, I think what we need to do is to help people appreciate that the destiny of their brain is in their hands for the most part. Only small percentage of people do everything right and get Alzheimer's disease or they do everything wrong and they don't get it. Very small percentage people do that.

Like, what do we talk? Because that is often the argument that you hear, right? And I'm always careful, I think as a physician, because you say, hey, look, if you engage in these healthy behaviors, then you're likely to not develop Alzheimer's disease. And then you'll inevitably get somebody who said, but I did that my whole life. Now I feel like I'm being blamed in a way because I got unlucky in a away because I did all the right things and it still happened to me. What percentage of people are we talking about?

'Okay. Let me talk to you in terms of pathology. Less than 10% of people who'd reached the late 80s have only plaques and tangles of Alzheimer's disease in their brain and nothing else. In other words, 90% of the people experience cognitive decline because of a soup of problems. And so in my practice, 5%, 10% people would fall in the category where genes played an important role. I think genes and hereditary play an important role for early onset Alzheimer's disease. When somebody has parents who develop cognitive decline and Alzheimer's Disease in their 50s or early 60s, that has a strong genetic component. But the late life Alzheimer's is really a super problem and very small percentage people, experience chronic decline and Alzheimer's disease. If they've done everything right. It's interesting also that the incident of Alzheimer's disease is declining in many Western high-income countries. So I think that people are catching on and that there are parts of the world where people are staying active and sharp as they get older. And that is a trend. And I tell you, in 10 years from now, people are going to look back and say, What were they thinking? Why weren't they doing things to keep their brain sharp? That's why I wrote my book, The Invincible Brain, because I felt these things should not be limited to patients who come see me in clinic. Everything we're talking about are readily available for people everywhere. And you just have to change your mindset. You have to realize you can take care of your brain the same way you take care of your skin and your heart. If you have that aha moment, then you will really think twice about eating our french fries. You eat twice, you know, just shut off the alarm and go back to sleep and you just go for, you know a 40-minute walk or something. Because we need to change people's daily habits in order to see big results. But they need to start easy. So when I talk to my patients, I say listen, don't make your brain health another source of stress. Don't add to your list of feeling guilty about things. Let's just make a habit of walking 20 minutes a day. And then I want you for the next, you know, two, three weeks, cut back on the amount of junk food by 10%. Like if you have a cookie or a muffin or a bag of chips, just eat less of it. Still eat it, but less of, and see how you feel. What happens is that when people make these changes, this feel that brain fog evaporates and they start feeling sharper in a matter of weeks. I think it's a tragedy that so many people are experiencing cognitive decline unnecessarily. It's really tragic because they can't take care of themselves easily and they're not.

How would you describe the level of evidence behind the things that you're saying?

The level of evidence for multimodal lifestyle interventions reducing cognitive decline is compelling. There are many randomized controlled studies in which one group of participants received a combination of diet, exercise, stress reduction, improving sleep, and another group did not receive those interventions. Standardized tests were applied and showed that the group that received the intervention had better cognitive function, they had better size, larger size hippocampus. I know this because I have reviewed the literature. Dozens of randomized controlled studies have been shown that lifestyle interventions improve brain functions. And to put this in perspective, I wanted to know how these randomized control studies for lifestyle interventions compare to the new Alzheimer's medications. So I went through the literature and guess what? The benefits of lifestyle interventions are far higher than the new medications. And it makes sense. Pharma companies aren't going to like to hear that. I think I salute pharmaceutical companies for all the investment they've made in the past 30 years. They've spent billions of dollars to come up with a drug that helps reduce amyloid. More than 100 clinical trials failed and they kept at it. So I salute to them. I encourage them to continue to find medications that can help reduce amyloid and tau in the brain. And I think these new medications they have produced are the first generation medications and that the second and third generation medications will be effective. Let me put things in perspective for you. If somebody has heart disease and experiences a heart attack, there are many factors for it. They may have high cholesterol. Diabetes, obesity, stress, and treat the sleep apnea, just to put the main risk factors. Now, if you just treat their cholesterol, you will not prevent future heart attacks. You need to control their cholesterol and you need to put them on an exercise program and you to treat their diabetes and you needed to treat your sleep apnia. Those things will reduce the risk for developing a heart attack in the future, not just treating their cholesterol. Reducing, treating the cholesterol with statins or other medications won't make a small dent, but it will not eliminate, whereas if you do the whole thing, they will have a significant reduction in their risk for developing a heart attack. We're in the same level with amyloid and lifestyle interventions when it comes to Alzheimer's disease. If you just reduce amylloid, you make a smaller dent in risk for cognitive decline further cognitive decline. Whereas if you reduce the amyloid and do those five pillars of brain health, exercise, sleep well, eat healthy, reduce stress and do brain training, then you will see the remarkable results.

One of the things that's different is the brain training part of this. What does that mean? I mean, are you doing crossword puzzles and number puzzles or what are you going to train your brain?

Okay, can I just use your brain model for a second. So the outer layer of the brain is called the cortex. And this is where what I call is the main brain area for cognitive functions. So parts of the body in front are important for attention, concentration, planning. Parts of the bring inside the temporal lobe called hippocampus is important for learning new things. And all these brain areas are highly malleable. And now you can choose to work on parts of your brain for attention and concentration, or you can chose to work on parts that are brain for memory. Just like if you go to a gym, you can choice to work on your biceps, triceps, cores, or your legs. So depending on what you like to achieve, you can focus on those brain areas. Now, the controversy is, well, I did some brain training and I still got Alzheimer's disease. Well, first of all, Brain training is one of the five pillars of brain health and by itself, it's not going to cure your Alzheimer's disease. You need to do all of them. And also you have to realize if you really are concerned about your memory, you need to do memory exercises. If you really concern about your attention and concentration, you really need to work on the frontal lobe. And these days, There are lots of apps like Lomociti, BrainHQ, Peak, Elevate where people can choose which brain area they can focus on. Just don't do crossword puzzles or Sudoku because you feel you must do brain training. Choose what it is that you want to improve and work on those specific cognitive domains.

Do you have specific things you work on?

My memory, you know, I memorize my credit card numbers, I memorized a deck of cards.

My wife memorized my credit number.

Great.

Very well, I might add.

My wife and I take dance lessons together, and I play card games with my daughters. They're in college, and they're much faster than I am, and I do my best to keep up.

Is ballroom dancing good for your brain?

Absolutely.

How so?

Well, for one thing, one study showed that if you take ballroom dance classes and continue for a year, parts of the brain that are important for coordination and planning increase and the size of the campus also increases in the group that took bottom classes versus group that didn't. And I think. Exercise and bottom dancing in particular has many benefits. For one thing, you're exercising, you on your feet. Number two is that you have to keep track of your steps. You have to memorize steps and you have keep track where you are. You also have to listen to music and coordinate the music that you hear with the body movements. And you're close to someone you're enjoying yourself. You actually have more dopamine in your brain. So I think ballroom dancing in general is one of the best ways you can improve your brain function. When I see patients, I say, pick something you enjoy. If you like fishing, if you like golf, if you're like photography, do it. Go to the next level. You don't have to do boring things to challenge your brain, if you don't like apps and these brain apps, don't bother. You know, learn a hobby you always wanted to do. Like if you like painting, take painting classes. If you like cooking, cooking is great brain training. You have to keep track of all the ingredients. You have put them in sequence. And there's a definitive outcome that you can see how you did and you can improve. Realize your brain is like a muscle. It has the capacity to grow and become stronger by challenging it. Combine the things that challenge your brain with the things that are also enjoyable to you, and you will see the best results.

'Yeah, I don't, you know, it's interesting. People think of brain training solely as maybe number puzzles or word puzzles, but the idea that ballroom dancing can do all those things that you were just describing for your brain. Pretty remarkable. When I was thinking about brain health, one of the neuroscientists I was talking to said, start painting. I'm a terrible artist, but I started painting. And he said, also I'm right-handed. He said, start doing it with your left hand. Which I thought was really interesting. And it's something I've maintained. I got a little easel and I will paint sometimes. And I find it relaxing, but also I find that activating to other parts of my brain. Well, look as a fellow brain nerd, thank you. Because I think a lot of us have, I'm a journalist, I've followed your work for a long time. And I think trying to get a lot of your messages out there, but I really thank you for writing this book. I'm going to hold it up again, 'The Invincible Brain.' I read it. I even blurbed it.

Yes.

I loved it. I meant every single word, so... It's very inspiring. I think you know like I said, people are scared, especially when it comes to brain health, and I think this provides them a lot of peace, hopefully. So thank you.

Sure. Thank you very for having me on the podcast. Appreciate it.

'That was my conversation with neurologist and neuroscientist Dr. Dr. Majid Fotuhi. His new book is called 'The Invincible Brain: The Clinically Proven Plan to Age-proof your Brain and Stay Sharp for Life. It's available now. Thanks so much for listening.