This transcript has been edited for clarity. 

Kathrin LaFaver, MD: Hello. This is Dr Kathrin LaFaver. I’m a movement disorder specialist and neurologist in Saratoga Springs, New York. I have the pleasure today of talking with Dr Indu Subramanian, in Los Angeles, who just came back from the annual meeting of the American Academy of Neurology (AAN). We will be specifically talking about the topic of brain health and the rising interest in preventive neurology today. Welcome, Indu. 

Indu Subramanian, MD: Thank you so much, Kathrin. It’s great to see you.

LaFaver: You and I are both Parkinson’s disease specialists, and of course, you are very interested in wellness aspects of caring for people with Parkinson’s — not only being reactive and helping people after Parkinson’s disease [has begun] or maybe a stroke has occurred, but being more proactive in this approach. Specifically, we had connected over the presidential plenary session at the AAN, and as part of that, Dr Sanjay Gupta was invited to talk about the future of brain health for all. Do you want to share some of your impressions or highlights?

Subramanian: It was exciting to see this concept of brain health sprinkled throughout the meeting. I have an interest in this, as you know, because I have a background in yoga and mindfulness teaching and got boarded in integrative medicine. It’s historically felt very on the outside of Western practice and how we approach disease states that are in the neurodegenerative realm.

I think we’re finally at a tipping point that these things do make a difference. We should be talking about them in a proactive way. There’s been a history in cardiology and other disease states in undergrad, high school, middle school, and even primary school, where there’s some sort of sense of what the cardiovascular risk factors are. Why do we care about not smoking? We’ve never really owned that space in neurology.

I don’t think people have spent much time outside of largely talking about the American Heart Association or similar guidelines. We sometimes extrapolate them to the universe of stroke prevention, but often more reacting to the first stroke or once a person walks in with motor symptoms of Parkinson’s disease or dementia. We have a sense that many of these processes can take place over decades. You’re put at risk because of things that you may not have even known can affect the health of your brain. 

AAN Brain Health Initiative

LaFaver: Absolutely. For those who are not aware, the AAN came out with a new initiative last fall. I’m going to read from it: “Brain health is now defined as continuous state of attaining and maintaining the optimal neurologic function that best supports one’s physical, mental, and social well-being through every stage of life.” 

Associated with that statement, there’s a position paper that provides more detail. There are five life stages defined, what really should be a focus, and how we cannot just discuss these issues in a neurologist’s office but actually bring them into advocacy work and hopefully influence policy changes. As you know, early prevention and many of these things are tied to much larger issues and environmental issues and so on. 

I think it’s quite exciting. Dr Gupta highlighted some of these issues as well. He also has been very interested in lifestyle approaches to brain health. This is something where many of us can still learn and maybe do better translating that to our patients. 

Subramanian: Absolutely. I think, for example, in Parkinson’s disease, we have a sense of the population at risk. We can now find sometimes genetics, possibly skin biopsies that can predict who might get it, imaging, early symptoms like anosmia, and even sleep studies, following people and having a sense of a risk. I think that one should be emphasizing, if you are at risk, certain lifestyle choices that are very reasonable for us as populations to care about. 

These are pretty basic things if you look at some of the pillars of wellness or lifestyle choices that we’ve all studied. They can make a big difference in terms of how people feel, even if they get a neurodegenerative disease and we are already treating them for that, or they’re at risk, or as populations are aging, things that we can drizzle into the preventive space if people might be at risk for a genetic cause of Parkinson’s or Alzheimer’s disease. These are reasonable things to be thinking about. 

LaFaver: It’s really important for us as neurologists to own that space, because people want this knowledge. People are afraid of getting dementia, losing their memory, etc, and they look elsewhere. It’s so common that people, by the time they see a neurologist, may have already followed advice that is maybe not in their best interest. 

I commonly see people who want to be proactive. They start taking many supplements that might not be evidence based or might, in some cases, even be harmful — if there are undeclared substances, for example, in certain supplements. Dr Gupta mentioned the Framingham Heart Study, which shifted the field of cardiology from reacting to the heart attack to being more preventive. 

I think we have also reached a time now in neurology where we need to pass this knowledge on, that many lifestyle habits earlier in life can have a huge impact on the development of neurodegenerative disorders. I liked hearing this from multiple angles, at the meeting and beyond. Is there anything else from the meeting that stood out to you in this regard? 

Nutrition and Connection for the Brain

Subramanian: One of the topics that came up was a nutrition lecture that was really lovely by Rachel Dolhun, who works at the Michael J. Fox Foundation for Parkinson’s Research. She had put together frequently asked questions related to Parkinson’s and nutrition. I think there were some topics even on things like climate change and how it can affect neurologic disease. 

I always love the diversity, equity, and inclusion lectures as well. I find them to be very eye-opening and also to be fitting into the space, because I think that many of the populations that are at risk of getting neurodegenerative disease, for example, or strokes, are people that are living in places where they don’t have access to many good lifestyle choices. We have to be very intentional about helping those folks get access to things that may change their disease course. 

One thing that came up was the coexisting vascular burden in some patients who are living with Parkinson’s disease in the African American community, and the sense that maybe we should be aggressively trying to control these sort of cardiovascular disease risk factors, be imaging possibly early on and controlling those things alongside of treating the Parkinson’s symptomatology as well. 

LaFaver: Do you have any tips, or how would you kind of translate this into your practice for your patients? I don’t know what your approach has been in your own practice. 

Subramanian: For me, something that I have not ever really thought about historically is the social connection piece. I think we have ways that we can connect people who are very lonely with others who can help them. I’ve never been intentional about asking about that. We can screen for loneliness in less than a minute using questions like, do you often or sometimes feel left out? Do you often or sometimes feel isolated? These are two or three questions that you can easily ask that should be able to point you in a direction to know whether somebody has some social connection in their lives.

If they don’t, we should be thinking about how we can prescribe, as we would a pill, for them to call a friend once a week as a start. We should use bite-sized pieces of things that people can drizzle in, but are very impactful, in the end. 

I think we have mounting data showing that the risk of getting Parkinson’s disease is actually higher if you’re lonely. The risk of getting dementia is actually much higher if you’re lonely than cardiovascular disease risk. It’s been stated that it’s being lonely is worse than smoking a half a pack of cigarettes a day or being obese. 

One of the things that people worry about when we talk about brain health and some of the commercialization of this concept is that it requires very expensive scans, very expensive blood tests, and very expensive supplements and diets. When you and I speak about this, Kathrin, we look at the risk factors, and there’s a mind-body approach bucket, there’s a sleep bucket, there’s a social connection bucket, an exercise bucket, and a nutrition bucket, representing the five main aspects of this. Finding purpose and meaning is another one that I often like to talk about. 

Are there other ones that I missed, Kathrin, that you would add? 

Lifestyle Changes

LaFaver: You hit a pretty big list. Highlighting that social loneliness, I think we all have learned that lesson now with the pandemic. It ties back nicely to Dr Gupta’s talk. He has published in this space for the broader public on how to keep your brain sharp and so on. I’m reading off his chapter list on mindfulness, healthy nutrition, exercise, sleep, stress management, social connections, and emotional well-being. 

I think in the end, when you really distill it down, where do we have the data? What lifestyle changes really do impact not only our immediate quality of life but also development of potential neurodegenerative conditions later on? We do know quite a bit, and I think the challenge is translating that better and then helping people in making those changes. 

You pointed out that, for certain people in certain areas of the country, it’s much harder to get healthy food, for example. I think coming together under the umbrella of the AAN and working together for more advocacy in these areas is really the way to go.

There are many positive examples now of neurologists taking leadership in not only doing research, but also the translation work to people in the clinic. I did want to highlight the team at Loma Linda University in California, where Drs Dean and Ayesha Sherzai lead the memory clinic and have a wonderful coaching program for patients that has all these elements and more, including the social connection around gardening clubs and things that we don’t usually prescribe. As you said, I think we can go beyond our usual clinical encounters and really try to connect with people and help people connect among each other to reach these goals. 

Subramanian: Historically, we’ve thought very concretely about some of the buckets: Get 8 hours of sleep, eat seven colors of vegetables in a diet every day, try to get up to 80% maximum heart rate on a Peloton or some sort of gym equipment that might not be available to people, and go meditate for 20 minutes a day. 

When we talk about these things in such a rigid way, it is just so inaccessible to many of our patients, and then they feel worse because they don’t have either the time or ability to access any of these things. My family and I, we were just traveling in the South. We were in beautiful parts of the country in Georgia, North Carolina, and Tennessee. We’re vegetarian and we like to eat green things, but everything that weorderedseemed to be fried. Then there’s the sweet tea on the side, which has a large amount of sugar in it. These are just the basic lifestyle food choices of people in these places. 

If we don’t call this out and offer better choices, we are basically making this an even bigger problem because you have the genetic predisposition, very poor lifestyle choices that are available in a community, lack of access to care once people get sick, and this sense that people in some ways are responsible for having brought this on themselves, if they’re modifiable risk factors, when really there are no other choices in some of these places. 

From a policy perspective and an advocacy perspective, as neurologists, we have to care about what the food choices are of kids that are in school, for example, or how much sleep a teenager might be getting in order to go into their 20s and on. We have de-emphasized many of these things as part of healthcare and thought in a very reactionary way. These are very upstream things that we can do that may help either delay or prevent certain diseases from happening in the first place. 

Going to a meeting like the AAN — and I also tend to have collaborators, in the European Association of Neurology, the World Health Organization, the World Federation of Neurology — all of these groups are also creating resources and really trying to work with policymakers to change what lifestyle choices are offered and how we do educate the public about brain health. 

In my opinion, brain health is just an extension of health in general. I love the way that they took the World Health Organization statement, which is that it’s not just the absence of disease. It’s the cultivation of physical, mental, social, and perhaps you could include spiritual well-being. 

It’s not just taking out a meningioma and sending them off or these reactionary things that we do. We have pointed times of interacting with the patient in their life and then we send them away for six months to do what they want, and then we come back and reevaluate in a 15-minute visit. It becomes very episodic, that sort of care. 

LaFaver: I think those are all very good points. I hope that many people left the meeting inspired, and we’ll see more in this space of preventive neurology. I like it. 

Thank you so much for the conversation today. Again, on behalf of Medscape, I hope you enjoyed this interview, and have a good day. 

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