I was just at a medical conference this last weekend on dementia and Alzheimer's and they
asked me to talk about nutrition. what is known about the effect of diets and Foods when it
comes to preventing and management of dementia and Alzheimer's. so I'll give you some of the
highlights. there's some interesting data on the Mediterranean diet and there's some intriguing
data on Ketone bodies as well, so we'll go over it one by one. one thing I just realized, and
this is a total coincidence, in the week leading up to this meeting, to this conference, somebody
sent me information on the main causes of death in the UK, and it turns out that dementia and
Alzheimer's are currently number one, more than even heart disease, so that was very surprising,
I did not realize that, I imagine it's probably related to an aging population but clearly there's
a need to understand and to prevent this better. so there are a dozen identified risk factors for
developing dementia, from hearing loss to smoking, lack of exercise, pollution, social isolation Etc.
and it's interesting that at least four of the established risk factors are directly related to
nutrition: hypertension, alcohol intake, obesity and diabetes. so it's not that surprising that
our food choices play a role. and when we look at the scientific evidence as a whole, one thing
that comes up consistently is the Mediterranean diet. and we see it both in epidemiological and
randomized, Interventional trials. now, just to clarify something real quick, every time we talk
about the Mediterranean diet somebody says in the comments, "well, I know lots of people who live
in the Mediterranean and they eat terribly, all kinds of junk food". so in science, in scientific
studies, when we talk about the Mediterranean diet we're referring to a specific dietary pattern,
the classical Mediterranean diet if you will, rich in fruits and vegetables, Fish, seafood,
whole grains, olive oil and low in Ultra processed foods. so not necessarily what people eat nowadays
in every Mediterranean country. so it's important to make that distinction. so for example, there's
a study from 2009 that found that people who eat a diet closer to that classical Mediterranean
pattern had 28 percent lower risk of developing the initial stages of dementia compared to people
who eat diets that are farther away from that Mediterranean diet pattern and 48 percent lower
risk of developing full-blown Alzheimer's. now, this is what we call an observational study,
so the investigators didn't tell them to eat anything, they just asked them what
they normally eat. so the concern with a study like this is always that maybe the effects
aren't due to the diet itself, maybe it's due to other healthy habits that the same people have,
like smoking less or exercising more. now, there are ways to address these concerns, for example
with statistical adjustment models, but it's also good when we have some randomized trials
where people are randomly split and assigned the diet because that's a complementary approach
to the observational studies and when the randomized trials point in the same direction,
it raises our confidence that yeah, we're probably looking at an actual effect of the diet. so one
example of this is a randomized trial looking at 447 people in their late 60s, and they were
followed for four years and they were randomly assigned to eat a Mediterranean diet or to just
receive advice to reduce fat in general. so that was the control group, and in that control group
they saw a worsening of cognitive function over time. so they run tests like memory comprehension
Etc and their performance in these cognitive tests got a little bit worse over time,
and this decline was not seen on the Mediterranean diet. other trials have also
shown that Mediterranean diets can help lower cholesterol and metrics of glucose metabolism
like fasting insulin and insulin resistance, and these are all metrics that are thought
to play a role in Alzheimer's. there are several other possibilities that have also been proposed
to try to explain why does the Mediterranean diet in particular keep popping up in the literature,
in the scientific evidence as a protective factor. maybe it's an antioxidant or anti-inflammatory
effect, maybe it's the high content of polyphenols which can improve blood flow to the brain,
maybe it's an anti-diabetic effect, maybe it's all the Omega-3s in the diet, maybe it's an effect of
lowering blood pressure. and of course it could be a combination of several of these factors or
all of them. so Specialists and researchers in dementia have written comprehensive reviews of
the field and they listed the Mediterranean diet as one of the key preventive strategies because
of those types of data we just looked at, together with other strategies like exercise, not smoking,
maintaining healthy body weight Etc. there's also something called The Mind diet which you
may have heard about and it was developed by some researchers at Rush University and basically it's
a blend of Mediterranean with DASH, the DASH diet, and there's also some evidence suggesting
that the DASH diet may help prevent cognitive decline, which is not surprising because DASH and
Mediterranean share a lot of similarities. so the Mind diet is essentially a blend of Mediterranean
with DASH with a tweak to focus more on brain health. the foods are in general very similar
to the Mediterranean diet but there's a bit more emphasis on leafy greens and berries for example
and a bit less emphasis on the other fruits, Dairy and potatoes. so that's one example of a
difference. now, diet is one factor when it comes to the prevention of dementia and Alzheimer's,
an accepted, established Factor, but as we saw there are a number of other factors,
and so some trials have tried to take advantage of this multifactorial aspect of Alzheimer's
and change several of these factors at the same time to see if they could get a stronger
effect. the most famous one of these combined trials is called FINGER, and it was conducted
in Finland and the participants were in their late 60s with no dementia diagnosed but they
were considered at risk for developing dementia, and they were followed for two years. so this
multi-pronged intervention included dietary guidance, exercise (both cardio and weights),
cognitive training (which basically was some exercises to train memory and mental speed),
and also cardiovascular risk monitoring and management. so the dietary advice they received
was according to the Finnish guidelines, which is very similar to the Mediterranean diet on the
fundamentals. one difference is that instead of olive oil they use canola oil, which I guess is
more common in northern Europe, but it's still predominantly unsaturated and predominantly
monounsaturated just like olive oil. and the control group, which didn't receive all of this
intervention, received some general health advice. after the two years of follow-up they saw some
significant improvements in several cognitive tasks like executive function and processing speed
for example. so the intervention and the FINGER trial was considered a success, essentially,
in terms of improving cognitive function and preventing cognitive decline. interestingly,
the lead scientist behind the FINGER trial was also a speaker at this meeting I just attended
and she revealed that they now have a very long follow-up, 11 years total,
following these participants, and it seems that at least some of those gains were sustained in
the long run, which is really good news because oftentimes with these lifestyle interventions
there's a loss of adherence over time and a loss of the gains but it seems that here at least to
some extent it was sustainable. I know there are also several ongoing trials in different countries
trying to model FINGER, trying to replicate this in different populations, including one trial as
we speak going on in the US. so that's the gist of the evidence looking at Mediterranean diets
and similar dietary patterns. now, Ketone bodies, I told you there's some interesting data, there
are a few trials looking at something called MCTs, medium chain triglycerides. so these are specific
fat types that when consumed can be converted to ketones in our body even without changing our
diet. so normally to be in ketosis, for our body to produce ketones, we need to either be starving,
need to be fasting, or need to be on a very low carbohydrate diet, but consuming MCTs is
one way to achieve a certain level of production of ketones without changing the diet per se. now,
most of these trials testing MCTs are small trials, what we call pilot trials, but there
is one larger one with 152 people, and it was a double-blind placebo trial, so robust experimental
design, and the participants had diagnosed Alzheimer's and they were split randomly, half
were given a drink containing MCTs, specifically it was a product called Axona which is a powder
contained in some sachets, and this was mixed, diluted in a drink like water or tea or juice. and
the control group got a similar drink but without MCTs. so they got these drinks daily for 90 days,
so three months, and after that they measured their cognitive performance using some of those
tests we talked about. and the group drinking the MCT-containing drinks performed a little better
cognitively. in terms of side effects, of adverse effects, which is always a potential thing with
any treatment, any supplement, any drug, they did report adverse effects in a substantial number of
participants, about 48 percent, the most common one being GI symptoms like diarrhea for example,
and kidney function parameters like blood urea nitrogen and creatinine also rose in some of
the patients. so I thought this was a really interesting trial, now, this was a phase two
trial, which is mainly looking at safety, they did publish, the same team published a phase three
trial later, 11 years after this first one, with three times more participants and twice as long,
but here's what happened, they changed the formulation of the compound that they gave people,
and they did that mainly to try to reduce the side effects, but the problem is the product
was also less effective, it induced a lower level of ketones in the participants and it didn't work,
there was no significant benefit over the placebo. of course that doesn't invalidate MCTs in general,
and in fact there are several ongoing trials trying to find that sweet spot where you get
the benefit without the side effects. the position of the Alzheimer's Association
currently is that there isn't enough evidence. now, one thing I want to point out real quick,
these trials we've been talking about with this Axona are funded by the company that
makes the product, it's called Accera, and I have no affiliation with the company,
as most regular viewers know we avoid all commercial Partnerships, all sponsorships,
any link to any company, and we do that precisely so that when something like this comes up,
whether it's a product or a supplement or a food, there's money behind everything, right?
we can all relax, I can tell you exactly what's in the science and you don't have to worry that
I'm getting checks from them or I'm getting checks from the competitors to say that it doesn't work.
I have no skin in the game, financially I don't care if people buy the product or not.
and also we've been consistent all along, we don't dismiss evidence based on funding,
I treat it the same as any other study, I want to see robust experimental design,
I want to see reproducibility, same as any other science, we don't throw out results based on
funding alone. now, a couple obvious questions that some viewers are probably wondering about,
if these MCT oils lead to the production of ketones and may have a beneficial effect,
might eating a diet that leads to production production of Ketone bodies, a ketogenic diet,
have the same effect? there are a few trials looking at exactly this question,
and overall they do suggest a similar effect. now, they're very small trials, they're pilot trials,
again, very small number of participants, around five to Fifteen people on the ketogenic diet only
per trial, sometimes no control group, so I would be cautious, I wouldn't make confident overarching
claims, but I have seen the direction of effect in enough trials that I suspect there probably
is a real effect there, so it'll be really interesting to see if larger trials and more
robustly designed pan out. I know there's a number of groups that are specifically working on this,
ketogenic diets, specifically looking at cognition, dementia, Alzheimer's. also
interesting to note, there is at least one trial looking at just caloric restriction,
no other major changes to the diet, just cutting 20 or 30 percent of the calories, and they did see
some memory improvement on that intervention, again, only seen one trial doing that so I
wouldn't go overboard but it's a possibility. now, is that effect with the caloric restriction
through ketones or is it through something else, the caloric restriction itself or weight loss?
TBD. not really understood for now. another obvious question related to ketones and MCTs
is coconut oil, because coconut oil also includes a fair amount of MCTs, so it might
have a similar effect. my concern is that coconut oil also includes some larger saturated fats that
probably raise cholesterol, there's some mixed evidence with coconut oil so I'm not completely
convinced but the balance of evidence suggests an increase in cholesterol, in LDL-cholesterol,
and although I would like to see more data on the effect of coconut oil on risk of heart disease
my educated guess would be to go for the MCT oil purified, isolated, rather than the coconut
oil if I was gonna try one of those, because the MCTs do not seem to raise cholesterol,
so that's my take on it. or keep an eye on your cholesterol levels, that's another strategy,
if your cholesterol is really good and you're consuming coconut oil, I think that's reassuring,
I would worry less. if you start eating coconut oil and your cholesterol rises,
that's something to bear in mind. okay, last thing I learned at the meeting and
through the literature review is a product called Souvenaid, and again no affiliation,
no connection with the industry. and Souvenaid is a mix of a number of nutrients, long chain
Omega-3s like EPA, DHA, and a number of vitamins, in total it's about 100 nutrients in this drink,
and it's designed specifically for dementia patients, and there's some mixed evidence
with Souvenaid. so they had one trial where they followed the participants for two years
and basically they reported no significant benefit in the vast majority of the outcomes,
so it seemed like it was a flop, basically. but then they have another publication where they
followed the participants for three years and there they do report a significant Improvement
in several of these measures of cognitive function. so their rationalization is that
the drink needs to be taken longer, three years instead of two years. it's possible but I think
at this point there's uncertainty with regards to whether this product works or not and in which
circumstances exactly. so just wanted you guys to have this information, it's pretty fresh,
a lot of it as I said just presented at a meeting, it was all neurologists and psychologists at the
meeting so they're getting this information pretty much at the same time as you are,
and as always the goal is to empower you so that you have more information, higher quality
conversations with your doctor and you can make better educated choices. let me know if you have
any questions or comments in the comment section, thanks for watching, I'll see you next week