Is Alzheimer’s Disease Preventable?

Is Alzheimer’s Disease Type III Diabetes? And Can it be Prevented?

By Bret Scher, MD

 

Alzheimer’s disease is one of the most devastating conditions in our country, and you may have the power to prevent it.

 

There is nothing more empowering than knowing you have the ability to prevent a chronic disease. Especially when some view that chronic disease as worse than death. While not all factors that lead to chronic disease is controllable (e.g., genetics), there are some diseases that you can protect yourself against. And one of those might be Alzheimer’s disease.

 

Alzheimer’s disease—which is the sixth leading cause of death in the U.S.—is a devastating condition that impairs your memory and ability to think. It progresses over time, eventually condemning an otherwise functional body to a life completely dependent upon care from others. It changes the lives of not just those affected by the disease, but their loved ones and caregivers as well.

 

In 2015 alone, approximately 15 million caregivers provided an estimated 18 billion hours of unpaid care to the 5 million Americans who suffer from Alzheimer’s disease. But the cost to families and to society as a whole cannot be measured in just dollars and cents. The emotional toll can also be enormous. The negative effects on caregivers can be vast, including:
 

  • Psychological distress
  • Impaired health habits
  • Psychiatric illness
  • Physical illness

 

To make matters worse, the number of people diagnosed with Alzheimer’s dementia is only getting larger and is expected to triple as baby boomers reach the at-risk age of 65 and older.

 

Paradigm Shift in Understanding Alzheimer’s

Modern medicine has struggled to find effective treatments for those who suffer from Alzheimer’s. The most effective medicines may slow the symptoms by a few months, but the inevitable progression always happens in the end.

 

A new paradigm shift, however, offers promise for methods to prevent and treat Alzheimer’s disease. The paradigm shift is that Alzheimer’s may be Type III Diabetes.

 

To understand this relationship, it helps to understand the basics about diabetes, blood sugar, and insulin. Insulin’s job is to signal cells to take sugar out of the blood and convert the sugar into energy. When a person has diabetes, the cells no longer listen to insulin, so the body needs to produce more and more insulin to get the message across.

 

As the efficiency worsens, the body can’t keep up, the blood sugar rises and diabetes develops. This causes two main problems:
 

  • Insulin levels rise sky high. Since insulin is a fat storage and pro-inflammatory hormone, higher levels equate to deterioration of overall health.
     
  • Blood sugar levels increase to dangerous levels. This can eventually lead to heart disease, vascular disease, kidney disease, vision loss, neuropathy, and other serious conditions.

 

It turns out that brain cells can become resistant to insulin as well, thus drawing a connection between diabetes and Alzheimer’s. The theory is that increased insulin and increased sugar in the brain leads to damage of brain cells and eventual dementia.

 

The Connection Between Alzheimer’s and Diabetes

 

Medical science is starting to explore the relationship between diabetes and dementia and is drawing a strong connection. One study, for instance, reviewed previous investigations of diabetes and dementia, accounting for over 2 million subjects. The study concluded that those with diabetes were 60 percent more likely to develop dementia.

 

While an association does not prove causation, it does raise an interesting potential link that deserves further exploration.

 

The next question is whether there is a reasonable explanation for why the two diseases might be related. And it turns out there is.

 

Another study demonstrated that individuals with type II diabetes are more likely to develop the same “brain tangles” that are seen in those affected with Alzheimer’s. It is thought that these tangles are directly responsible for the progressive cognitive decline. And they are present in both the brains of individuals with Alzheimer’s disease, and the brains of those with diabetes even in the absence of dementia.

 

How to Prevent Diabetes, and possibly Alzheimer’s

 

This emerging research could be discouraging news since the incidence of diabetes is on the rise, with an estimated increase from 285 million cases worldwide in 2010 to 439 million in 2030.  The result could be an equal surge in new Alzheimer’s cases.

 

Or it could be encouraging news, since type II diabetes is almost entirely preventable with healthy lifestyle habits. Presumably, these same habits may help prevent Alzheimer’s as well.

 

In fact, a 2001 study in NEJM suggested that 90 percent of type II diabetes cases could be prevented with:
 

  • Proper exercise
  • Healthy eating
  • Not smoking
  • Maintaining a healthy bodyweight

 

 Another study showed that a lifestyle program that included 150 minutes of weekly physical activity and a goal of 7 percent weight loss prevented diabetes better than the popular drug Metformin—an oral diabetes medicine that helps control blood-sugar levels.

 

Finally, a 2012 study followed 2,700 people over three years and found those who ate a diet higher in carbohydrates and sugars and lower in protein and fat were more likely to develop dementia.

 

This information shows that diabetes, and by extension Alzheimer’s disease, may be preventable by following a healthy lifestyle that includes these elements:
 

  • Exercise 150 minutes per week and remain physically active throughout the day
  • Maintain near ideal body weight
  • Eat a real-foods, vegetable-based diet with healthy fats
  • Avoid simple, refined carbohydrates
  • Avoid added sugars in food and drinks

 

A Healthy Lifestyle Is Necessary

 

Unfortunately, this is not hot-off-the-press news. These studies were published over 15 years ago, yet many people are still reluctant to adopt such healthy practices. In fact, one study of American adults found that only 2.7 percent of the subjects followed a truly healthy lifestyle.

 

The public shouldn’t need more inspiration to strive to be healthy, but knowing that Alzheimer’s disease and diabetes are likely preventable will hopefully be enough motivation to spark a revival for healthy lifestyles now and for decades to come.

 

Change doesn’t come easily, so start by making simple steps and find a support system that will help you adopt new ways of living.

 

Those in positions of influence (doctors, nurses, personal trainers, nutritionists, health coaches, chiropractors, and other medical professionals) need to actively educate society about the association between Alzheimer’s and diabetes.

 

If you fall into this category, it’s important to learn how to inspire individuals to adhere to healthy life habits, which may help prevent one of the most devastating conditions that touches the lives of tens of millions Americans every year.

 

Now that’s empowering.

 

Thanks for reading.

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

 

ACTION ITEM:

Make 1 meal this week a Vegetable Based meal. Don’t have chicken with a side of veggies, or salmon with rice and a couple veggies. Make the basis of the meal veggies and add 4-6 oz. of high quality animal protein.  Notice how it looks different, tastes different, and how you feel differently after you eat it. If you can do this, then you can increase it week after week until most of your meals are veggie-based. You will be amazed at how it improves your health and how you feel!

Statins- What do We Really Know?

45 million Americans “should” take statins. Are you one of them?

 

 It may surprise you to find out that you might be. When your doctor plugs your information into a cardiac risk calculator, he or she may tell you that you should to take a statin.

 

You may not feel bad. You may not have many other cardiovascular risk factors. Yet you may be labelled with the “disease” of elevated cholesterol.

 

“New” Guidelines- Questionable Sources, Questionable Guidelines

 

Why are so many more previously healthy Americans now being treated for high cholesterol? We can thank the 2013 ACC/AHA guidelines, which increased the intensity with which physicians prescribe statins.

 

Interestingly, these were not based on any new data. Instead, they were based on new interpretations of old data, much of which has not been made available for third party reviewers. None the less, it is now recommended that physicians consider prescribing a statin to anyone with a 5% 10-year risk of cardiac disease (increased from a previous 20% risk).

 

To me it seems that a recommendation to dramatically increase the use of these drugs should save lives left and right and have almost no down side.  Unfortunately, that is not the case.

 

Don’t get me wrong. Statins are not useless. They can reduce the incidence of heart attacks and strokes. For someone who has never had a heart attack (referred to as primary prevention) we need to treat between 60 and 104 people for 5 years to prevent one heart attack without any significant difference in the risk of dying.

 

That’s a little underwhelming, is it not? That seems like a “shotgun” approach where you send a hundred bullets out knowing that one will hit the right person (in this case getting hit by a bullet is a good thing). It doesn’t have to be this way.

 

In addition, statins are not perfect drugs. For every 50 people treated over five years there will be one new case of diabetes. There will also be at least 10% risk of muscle aches and pains with potential damage to the mitochondria (the energy producing part of the cell), and may even be linked to onset of dementia and memory dysfunction.

 

A system that potentially harms more people than it helps doesn’t seem like a viable solution to me. We can do better.

 

Better Define Your Risk

 

The problem is that our medical culture emphasizes prescribing drugs more than further defining your risk, and more than exploring alternatives to reducing your risk.

 

The current cardiac risk calculator uses:

  • Age
  • Gender
  • Race
  • Total cholesterol
  • HDL
  • Blood pressure or previous diagnosis of hypertension
  • Diagnosis of diabetes
  • Smoking status

 

Those are all reasonable initial risk factors to evaluate. But doesn’t it make sense that if we are using a drug that will only benefit one in 100, maybe we should try to further define those at high risk? To me that is a no-brainer.

 

For instance, one study showed that by measuring a coronary calcium score on statin eligible individuals, we could reclassify 50% of them so that they no longer “qualify” for statin treatment. We can avoid an enormous number of statin prescriptions with one simple test. A test that is readily available now. A test that has minimal risk (very low radiation dose, and a small chance of incidental findings), and is relatively low cost (about $100).

 

And we don’t have to stop there.

 

The Scripps Research Institute has developed an app to allow people to use their genetic information to better define their risks. This could potentially be used to define those who are not at high genetic risk for heart disease and therefore would likely not benefit from statin therapy.

 

Now we are starting to get somewhere. What if we could better define cardiac risk so that one in 5 people benefit from a statin, as opposed to the current 1 in 100? That is an admirable goal.

 

Even Better Than A Statin

 

Once we better define our risk, let’s not forget all the alternative to statins.

 

One recent study demonstrated that even those at the highest genetic risk for heart disease can cut their risk in half with healthy lifestyle habits (eating healthy, getting regular physical activity, not smoking and not being overweight). And that was the highest risk group! That’s likely just as good as, if not better than, a statin could do.

 

So why don’t we write prescriptions for intensive healthy lifestyle education programs instead of drugs?

 

Lifestyle changes are “harder.” Lifestyle changes take longer to see results. Lifestyle changes require more education, encouragement and follow up.

 

Do you know what else is associated with healthy lifestyle changes? Decreased risk of heart attack, strokes and death. Decreased risk of diabetes, high blood pressure and depression. And the only side effects are feeling better, having more energy, and being in control of your health.

 

That sounds like something that is well worth the extra work, the needed patience, and the more vigorous follow-up. Don’t you agree?

 

Start Asking Questions

 

So, what should you do if your doctor recommends a statin? Start asking questions. Lots of them.

  • How high is your calculated cardiovascular risk?
  • How much will a statin reduce that risk?
  • What else can be done to better define your risk (i.e. coronary calcium score)?
  • What else can be done to lower your risk (i.e. intensive lifestyle modifications)?

 

Ask yourself questions as well.

  • How can I improve my nutrition to focus on a vegetable based, real food, Mediterranean style eating that focuses on healthy fats and appropriate proportions of high quality animal products?
  • How can I improve my daily physical activities in addition to increasing my weekly exercise?
  • How can I improve my stress management and sleep habits?

 

Remember, the benefits of statins are small. Not zero, but small.

 

Also, remember that statins have not been directly compared to healthy lifestyle habits. We don’t know if they add anything to a comprehensive lifestyle modification program. In fact, I would wager that if you have healthy eating habits, you get regular physical activity, you exercise regularly, and you practice regular stress management, then statins will not reduce your cardiovascular risk at all.

 

It may seem like a bold prediction, but to me it seems obvious.

 

Unfortunately we will likely never see a head-to-head study between statins and healthy lifestyle interventions (I discuss the specifics of the study I would like to see in my prior blog post here).

 

We can do better than a drug

 

In the end, remember that we can do better than drugs. We can be in control of our health. We can achieve real health that is not dependent on blood tests or medications.

 

So, don’t blindly accept a prescription for a statin (or any drug for that matter) without further defining your risk, and without further exploring your alternatives. You and your health deserve at least that much.

 

Thanks for reading.

 

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

 

Action Item:

If you are on a statin, or any drug for that matter, make sure you ask your doctor why you are on it, exactly what benefit you should expect, and what the potential short- and long-term side effects are. Also, ask what the alternatives are, specifically regarding your lifestyle and healthy habits. If you aren’t getting adequate answers, ask me! info@drbretscher.com. I welcome your emails. 

Our Best Medicine- Pills Not Required

“Walking is man’s best medicine”- Hippocrates (Greek physician 460 BC-377BC). That is one of my favorite all-time quotes. I can’t say it enough or hear it enough. Hippocrates didn’t have scientific studies, he didn’t have fitness trackers, yet it was inherently obvious to him that physical activity and simply moving our bodies provided unparalleled physical and psychological benefits.

 

Combine that with more modern observations from Dan Buettner’s book The Blue Zones, and it becomes clear that regular physical activity is an essential key to our health and longevity. Mr. Buettner evaluated the most common personal habits in societies where they routinely live into their 90s and 100s. He found that they didn’t hit the gym every day, they didn’t train for marathons. They simply moved their bodies consistently. They worked in the garden, they walked to do their errands, they walked for social purposes.  They moved their bodies.

 

Don’t get me wrong. I am a big proponent of regular exercise, including high intensity interval training and resistance training (more on this in another post), but it is becoming clear that the basis for health is moving our bodies.  But why is this a challenge?

 

Technological Advances = Health Disintegration

 

Our society does not encourage regular physical activity. Most of us work desk jobs sitting in front of computers for hours at a time. We live as part of urban sprawl with longer commutes. And what minimal leisure time we have is spent on computers, tablets and video games. The days of centralized communities encouraging regular physical activity are largely gone.

 

This isn’t necessarily all bad. The technological advancements in the past few decades are unprecedented. It just hasn’t been good for our health. The priority has shifted. Now it’s time to shift it back!

 

It is time to re-examine all our unconscious habits. Why do we automatically go to the elevator or escalator? Why do we instinctively look for the closest parking spot? Why do we automatically sit on the couch instead of going outside for a walk?

 

Don’t just read these questions and keep going. Stop. Think. Answer the questions in your mind and resolve to re-examine those reasons and change them! Look at your daily habits and find places to purposely add more physical activity.

 

As I frequently say, you don’t have to try to be perfect. Just try to be better. If you can change one unconscious habit today that helps you move your body more, then you have a major success. If you can change another one tomorrow…even better!

 

Activity Trackers

 

My advice: Get an activity tracker and use it!

“But wait! Didn’t I just read a story about activity trackers being useless? Doesn’t that mean being active isn’t helpful?” I’m glad you asked.

 

There was a study in JAMA that asked a specific question: When it comes to weight loss, is a simple pedometer better than a program with regular encounters and encouragement from research staff? The answer, not surprisingly, was no (read a more detailed analysis of this study here).

 

Regular human interaction and encouragement is one of the most important factors when it comes to successful lifestyle changes. In this study, those in the activity tracker group didn’t have that interaction. It’s no surprise that they didn’t fare as well.

 

It is important to realize that activity trackers are one part of an overall health program. They are not an end-all tool for weight loss. And remember, weight loss is not the best marker for health. Healthy habits themselves should be the goal, the weight loss will follow.

 

So, don’t throw out your Fitbit, Jawbone or Apple watch just yet. When used correctly, activity monitors are a powerful tool to get you moving.

 

You may feel like you did a good job being active today. But then you glance down at your wrist and see a measly 4000 steps for the day. Now you know it is time to get moving. You can’t talk your way out of that one!

 

Or you may notice you hit your 10,000 steps and you are feeling good about yourself. You log in to the computer and see your good friend is already at 12,000 steps today. Time to put down your remote control and get another 2,001 steps in just to show him that you can!

 

That’s the power of activity monitors. Objective motivation day after day. Get one. Use it. Listen to the motivation.

 

Exercise Lowers Risk of Death

 

Ok. So, it’s well established that being consistently physically active is important for our health. But what about exercise? Aside from being physically active, how much exercise should we try to get?

 

It turns out, we don’t need that much to save our life.

 

A 2015 study in JAMA followed 661,000 Middle Aged adults over 14 years. They found the highest risk of death in those who did not exercise at all. Even a “little amount” of exercise (less than the official guidelines but more than no exercise) reduced the risk of death by 20%. The benefit continued to increase linearly with increasing exercise duration until it plateaued at 450 min per week.  The following table summarizes the results.

 

Amount of exercise per week

Cardiovascular/Mortality result

Sedentary

Highest mortality and cardiovascular risk

Less than 150min

Reduced death by 20% over sedentary

150 min

Reduced death by 31%

450 min

Reduced death by 39%

More than 450 min

No additional benefit, but no increased harm either

 

In addition, the Copenhagen City Heart Study  showed that “light” running, even just 20-minutes once per week, resulted in reduced risk of death. The maximal benefit was in those who jogged at a slow or average pace between 1-2.5 hours per week.

 

So, although the official recommendation is 150 minutes of moderate exercise per week, even minimal amounts of exercise provides some benefit. And it wasn’t an obscure benefit that you may or may not care about. It was reducing the risk of dying! That’s something we can all get on board with.

 

Move Your Body

If your goal is to reduce your risk of death, move your body.

 

If your goal is to improve your health, move your body.

 

If your goal is to feel better, move your body.

 

Be active, and add in at least small amounts of exercise.

 

The science supports. Hippocrates supports it. Now it is your job to get out there and do it.

 

(Read more about Resistance training and high intensity interval training Here)

 

Thanks for reading.

 

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

 

 

Action Item:

 

Tomorrow, wake up and set your intention to seek out ways to move your body. Spend the entire day parking further away, taking the stairs, walking or biking to do your errands, go for a walk with your kids, and anything else you can find. Make it the focus for your day. You will be amazed at how many ways to can improve your activity level. Then, if you can do it once, you can incorporate it into your life and make it a new healthy habit. But you have to start with the first step. Wake up tomorrow and set that intention!

 

 

The Best Weight Loss Trial You Will Never See!

The Best Weight Loss Trial You Will Never See!

In my book, Your Best Health Ever: A Cardiologist’s Surprisingly Simple Guide to What Really Works, I make the point that we should be very careful with how we interpret nutrition, weight loss and health studies. Far too often we will read a decisive-sounding post about an observational trial. My favorite is the belief that eating animal products of any kind directly causes heart disease, but you can take your pick from hundreds of other examples. The bottom line is the same. Observational studies, ones that simply observe people in their normal activities rather than randomly assigning them to two different groups, cannot prove cause and effect. They can only point out associations, which may or not have a real causative relationship.

In the world of nutritional science, observational studies require someone to remember everything they ate, accurately document it in detail, and depends on the researchers to control for every possible variable. That’s a recipe for a poor study. In addition, there is no way to control for self-selection bias. My made-up example from the book is that an observational trial would likely show that people who eat at Whole Foods are healthier than people who eat at McDonalds. Seems straightforward. But it turns out, they are also likely to be more educated, in a higher socioeconomic class, exercise more, have more access to medical care, and hundreds of other differences that we cannot measure. In a nutshell, that is self-selection bias.

So, although it makes sense that Whole Foods is healthier, and we believe it to be true, an observational study cannot prove this. Only a randomized trial can hope to answer the question with scientific validity. Which leads me to the point of this article. When it comes to nutrition and lifestyle as medicine, there are two trials we need to see, but likely will never see.

APEVVV (Animal Protein Eaters Vs. Vegetarians and Vegans)

All good studies seem to need attractive acronyms. I did my best here.

Take 10,000 healthy individuals. Randomize them into one of three nutritional groups. All three groups will adhere to the following:

  • Every meal is at least 50% veggies with very limited processed foods and simple carbohydrates.
  • Encourage healthy fats with nuts, seeds, olive oil and avocados.
  • Strive for 10,000 steps per day plus 150 min of moderate exercise per week
  • Practice regular stress management and engage in healthy lifestyle courses

They will differ as follows:

  • 100% Vegan: No animal products at all are allowed.
  • Vegetarian: No meat is allowed, but eggs and dairy are allowed.
  • Meat Eaters: Every meal allows for 1-2 eggs, 4-6 ounces of animal protein (beef, chicken, fish, etc.), plus unflavored dairy, yogurt and cheese.

Follow them over 10 years to see who lives and who dies, who has heart attacks and strokes, and who enjoys their life more. Now that’s a trial that will tell us something! Do you see how this differs from observational trials? Since the subjects are randomized, we eliminate self-selection. They don’t get to choose which group they will be in.

In addition, since we measure hard-outcomes like heart attack, stroke and death, there is no debate about what the results mean clinically. We aren’t measuring “surrogate” endpoints like cholesterol, blood pressure, and other measures that may or may not be significant in this specific circumstance. Heart attacks, strokes and death are ALWAYS significant! 

Also, notice how weight loss is not mentioned anywhere. The focus is on health, not weight loss. They are most definitely not one in the same. The problem is that this trial will be very difficult and expensive to create. Without a drug company having a vested interest in the result, it will be difficult to find someone to pay for it, and therefore we are unlikely to see it in our lifetime. That’s even more of a problem with my second trial that we need to see.

HLVS (Healthy Lifestyle Vs. Statins)

If you have read my posts on statins, by now you are aware of the incredibly small benefits of statins in primary preventions (i.e. when used in people who have not had a heart attack).  In general, they do not reduce your risk of dying, and to save one person from a heart attack we need to treat anywhere from 60-140 people for five years. 

One of the most common arguments for starting a statin is, “It’s the best treatment we have for reducing your risk of heart attacks and strokes.” My response? Not so fast. If I change that to say “It’s the best prescription drug we have for reducing your risk of heart attacks and strokes” then maybe I would agree. 

What other treatments are better?

  • Nourish your body purposefully.
  • Move your body and exercise consistently.
  • Manage your stress.
  • Prioritize your sleep.
  • Maintain strong social connections.
  • Don’t smoke.
  • And other healthy lifestyle actions.

Can I scientifically prove that these healthy lifestyle habits are better than statins? Not yet. That is why we need the HLVS study. Start with 10,000 people who have never had a heart attack or stroke. Half of them get a statin and “usual medical care” from their doctor.

The other half enroll in a lifestyle management program focusing on the following habits:

  • Every meal is at least 50% veggies with very limited processed foods and simple carbohydrates.
  • Healthy fats such as nuts, seeds, olive oil and avocados are encouraged with most meals.
  • Appropriate proportion of animal proteins and animal products are allowed.
  • Participants will strive for 10,000 steps per day plus 150 min of moderate exercise per week.
  • Participants will practice regular stress management and mindfulness meditation.
  • Sleep hygiene is repeatedly reviewed with each participant.
  • Smoking cessation interventions are individually tailored to those who need it

They are followed for 10 years and we measure number of heart attacks, strokes and deaths. We also record subjective measures of happiness, depression and enjoyment of life. Then we will know. Are lifestyle interventions just as good as, if not better than, statins for primary prevention of cardiovascular disease?

I’m pretty sure I know what the answer will be. But alas, we will never see this trial either. Can you imagine if a drug company sponsored this trial and it showed the drug was inferior? Stock prices would plummet, and people will lose their jobs left and right. So, if we want to fund this trial, we better start our fundraising now (no bake sales or girl scout cookies please).

Conclusion

Does this mean we must disregard all nutritional and health science that isn’t a randomized prospective trial? That would mean throwing out most of our science. I don’t recommend that. Instead, we need to be vigilant about understanding the limits of the science and the limits to the catchy headlines. When we read a headline that “the Mediterranean diet has been proven to be better than statins,” we have to pause and think. We know that it may be intriguing, and we may want it to be true. However, until there is a head-to-head, randomized trial, we cannot prove that. Anyone who claims otherwise is inappropriately twisting the data.

What can we do instead?

In the absence of the trials that we need, we can continue to live our lives emphasizing healthy lifestyle habits. We can continue to demand a thorough and realistic explanation of the benefits and potential risks of prescription drugs. We can continue to seek out reliable and credible sources of information. And we can continue to talk about the need for better science. If we do this enough, we will transform ourselves for the better, and maybe, just maybe, we will change the world of nutritional and health science for generations to come.

Thanks for reading.

Bret Scher, MD FACC
Cardiologist, author, founder of Boundless Health
www.DrBretScher.com


Action Item:

Next time you hear a news story about a health study, take the time to look up the study and read it. Then you can decide, is this high-quality evidence? Does it apply to me? You may not understand everything, but the more you read, the more you will understand. And if you still have questions about it, ask me! I welcome your emails: info@drbretscher.com

Bret Scher, MD FACC

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