Brain Health: How a Healthy Lifestyle Can Help Prevent Cognitive Decline

Sandra Darling, DO, MPH, graduated from the College of Osteopathic Medicine at Touro University California, Vallejo, California, and completed her residency at the Florida Department of Health in Palm Beach, Florida. She has been practicing at the Cleveland Clinic Center for Integrative and Lifestyle Medicine in Cleveland, Ohio since 2015. Board certified in Preventive Medicine, Public Health and Lifestyle Medicine, her passion is in the field of brain health where she says that healthy lifestyle behaviors can help prevent and manage cognitive decline and other neurological issues. Here she describes her interest in the field and the integrative approach she follows for people with brain health issues.

Q: How did you become interested in the field of integrative medicine?

Sandra Darling, DO, MPH: I studied interior architecture and music as an undergraduate and worked in the field of architecture and design in San Francisco, California. I decided to change careers because of a profound experience reversing my long history of irritable bowel syndrome (IBS) primarily by changing my diet. The flares were debilitating at times. On several occasions I had sudden onset of severe symptoms at inopportune times like when I was performing in the orchestra and seated in the front row. Traditional medicine did not help me. In fact, when my IBS was diagnosed, I was told there was nothing that could be done. In my mid-20s, fed up with being sick, I cut out the unhealthy food from my diet and began preparing my food from scratch using whole foods. I also started swimming and yoga, and within a few months, I reversed a 15 plus year history of IBS. I then decided to start a career in medicine in order to guide others to live healthier lifestyles to improve their health.

Q: What is the focus of your practice in terms of brain health and what types of patients with what conditions do you see?

Dr. Darling: I perform cognitive assessments on patients of all ages with mild to moderate memory loss. During the visit, I evaluate cognitive function using the Montreal Cognitive Assessment and explore the patient's lifestyle-related risk factors of cognitive decline. Examples include poor sleep, chronic stress, depression, unhealthy diet, physical inactivity and excess alcohol. Then I provide a plan to improve the risk factors to reverse the impairment or at least slow the progression. My primary goal is to prevent Alzheimer's disease and other types of dementia.

A common cause for memory impairment in younger patients is a head injury. In midlife to late life, people often present with Subjective Cognitive Impairment (SCI) or Mild Cognitive Impairment (MCI). These are stages along the spectrum of cognitive decline that can potentially progress to dementia, although it can take years to decades before this happens and it might not happen at all. SCI indicates changes in cognitive function like occasional forgetfulness plus risk factors of cognitive decline and a normal score on cognitive testing. MCI indicates cognitive impairment, risk factors, and an abnormal score on cognitive testing. The good news is, the stages of SCI and MCI are considered modifiable; they are treated by improving the underlying risk factors of cognitive decline.

Q: What are the most common issues in brain health that you deal with?

Dr. Darling: I primarily see patients with cognitive impairment (e.g., short-term memory loss), which is my main interest. I also see patients with other neurological disorders such as Parkinson's disease and multiple sclerosis and use integrative and lifestyle medicine to improve symptoms, comorbidities, and quality of life.

To Contact Dr. Sandra Darling

Sandra Darling, DO, MPH

Staff Physician

Center for Integrative and Lifestyle Medicine

Cleveland Clinic, Lyndhurst, Ohio

E-mail: darlins2@ccf.org

Q: How do you apply an integrative approach to these types of brain health issues? What are some specific examples?

Dr. Darling: I educate patients on the pillars of brain health: nutrition, physical activity, stress management, sleep, and mental activity. I've found the most effective way for patients to learn this information and make sustainable lifestyle modifications is in a shared medical appointment (SMA). SMAs bring patients together with similar medical conditions, are longer than an individual appointment, and are often facilitated by different healthcare practitioners (e.g., physician, nurse, health coach, dietitian).

I have been facilitating the Brain Health and Wellness SMA at Cleveland Clinic since 2016. This is a comprehensive lifestyle program designed to improve memory and prevent dementia in patients ages 18 and older with SCI and MCI. It is a series of six group visits, either virtual or in person, for 90–120 minutes per visit, facilitated by me and a yoga therapist. Each visit consists of education on a brain wellness topic, medical management, and a group activity. Patients typically see improvements in cognitive function after the SMA along with improvements in other metrics like sleep, mood, energy, blood pressure, lipids, and weight. Patients who live out of state can attend the virtual Brain SMA, it just requires one initial screening visit in Cleveland, Ohio.

Patients benefit from adopting healthy lifestyle practices—not just for brain health, but for health in general. The Lancet Commission 2020 report on dementia prevention, intervention, and care, identified 12 modifiable risk factors, which include hypertension, diabetes, obesity, smoking, excess alcohol, and physical inactivity. ¹ These are opportunities for prevention. Lifestyle medicine targets these risk factors and is absolutely necessary in the fight against dementia.

Q: Are there any interesting and recent research studies that suggest an integrative approach helps?

Dr. Darling: Yes, there are numerous studies demonstrating how important and effective healthy lifestyle behaviors are for protecting brain health. Here are a few examples:

Morris et al. found that older participants who followed brain healthy diets for an average of 4.5 years had a lower risk of Alzheimer's disease. ² High adherence to the Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet had a 53% lower risk of Alzheimer's disease. Even moderate adherence to the MIND diet resulted in significant reduction in the risk of Alzheimer's diseases by 35%. High adherence to the Dietary Approaches to Stop Hypertension (DASH) diet and Mediterranean diet also resulted in a lower risk of Alzheimer's disease (39% and 54%, respectively).

Another recent study by Dhana and colleagues found that participants who adhered to four to five specified healthy behaviors had a 60% lower risk of Alzheimer's. ³ Those behaviors included: regular physical activity, not smoking, light-to-moderate alcohol consumption, a high-quality diet, and cognitive activities.

According to Tennstedt and Unverzagt, online brain training resulted in significant improvements in older adults in the cognitive ability tested (memory, reasoning, or speed of processing) immediately after the training session. ⁴ The gains dissipated over time but remained significant at the five-year follow-up. Participants in the intervention group also had significantly less decline in their ability to perform instrumental activities of daily living after five years. The intervention consisted of 10 training sessions for ∼60 minutes in the first 6 weeks followed by 4 additional sessions at 11 months and 4 additional sessions at 35 months.

To keep the brain sharp, I encourage my patients to engage in activities that challenge the brain. Online brain training platforms like Lumosity.com and BrainHQ.com are fun ways to do this.

Q: How did you become interested in the area of brain health?

Dr. Darling: Sadly, my aunt died of Alzheimer's disease five years ago. I saw her deteriorate rather rapidly over a couple of years, and it was devastating to witness. It is estimated that the number of people living with dementia worldwide will increase from 57 million in 2019 to 153 million cases in 2050. I am passionate about doing my part to curb the progression of cognitive decline to not only prevent dementia, but also to help others live long, healthy lives and remain independent as long as possible.

Q: Any advice regarding how clinicians can best help their patients with some of the issues you work with and focus on an integrative approach?

Dr. Darling: Review the literature. There is a lot of information about the role of lifestyle for the prevention of dementia, and the ability of integrative and lifestyle medicine to lower systemic inflammation to improve brain health and other chronic conditions. I recommend reading “The Alzheimer's Solution” by Dean and Ayesha Sherzai and listening to their podcast The Brain Health Revolution for evidence-based information on the topic. The American College of Lifestyle Medicine (www.lifestylemedicine.org) has high-quality educational courses online to teach healthcare providers how to use lifestyle medicine to address common conditions. One of the courses is called “Lifestyle Medicine: The Powerful Prescription for Alzheimer's.”▪