Optimizing Brain Health

John J. Miller, MD

From the Editor

When I began medical school in 1982, the brain was often referred to as a “black box,” a description meant to convey how little we knew about brain function and circuitry. We have learned much since then, and many of the scientific publications on brain-related research that flood my inbox each month have words in the title that I have never heard of before. I try to keep up, but I often feel as though I am trying to bail out the Titanic with a cup. Amidst this information explosion, there remain core principles that are well established and can help facilitate the health of our brain. On my website, Brain-Health.co, I have a link to a page where I list “Ten Ways to Grow a Healthy Brain.” I do my best to follow these myself, and I routinely discuss these with my patients. I invite feedback to lengthen this list and encourage all of us to work toward continued brain health.

Sleep

Arguably one of the most important requirements for good brain health is a good night’s sleep. Sleep is a primary mammalian function that has been evolutionarily conserved, and ideally each 24-hour day includes a defined period for sleep. There is tremendous individual variation in the number of hours a person requires to achieve the benefits of a good night’s sleep, ranging from 5 to 10 hours every night. During sleep, the brain’s energy utilization decreases, and the brain assumes a restorative posture, removing unwanted waste products and replacing the adenosine triphosphate (ATP) energy supply used up during the day. Sleep is a time for health promoting immune processes to occur, and for the endocrine system to recalibrate.

Significantly, the information and experiences of the day are consolidated in the various specialty areas of the brain’s cortical regions from the brain’s hippocampus, where they are stored temporarily during the day. Throughout the day, the hippocampus serves a function much like the random access memory (RAM) of a computer-without the storage of the day’s events in the cerebral cortex that occurs during sleep, the memory of these events will be impaired and less enduring.

To continue our computer analogy, our daily experiences and learning is temporarily saved in RAM, with the expectation that we will “save” this information to the hard drive before we shut off our computer. If we forget to save the information, it disappears from RAM after the computer is powered off. Hence the inefficiency of studying all night for an exam-we may pass the test, but we will not retain much of the material.

Sleep disorders are very common. Approximately one-third of the US population report symptoms of insomnia. Over the past 30 years sleep studies have improved greatly, and it has become routine to diagnose and treat sleep disorders like sleep apnea-everyone knows someone who uses a cPAP (continuous positive airway pressure) machine during sleep, often with a significant improvement in wakefulness the following day. Sleep dysfunction is complex and can be caused by many diverse factors: genetics, environmental, stress, medical conditions, psychiatric disorders, parenting newborns and children, ingestion of stimulants (caffeine, theophylline, theobromine, methylphenidate, amphetamines, modafinil, pseudoephedrine, and cocaine to name a few), pain, obsessive/ruminative thinking, excitement, and anticipation. Although we have quite an armamentarium of sleep hypnotics, the most effective treatment we have to offer as clinicians is education about good sleep hygiene.

The most commonly utilized over-the-counter sleep aid in the US is diphenhydramine (Benadryl^®). Most products sold at your local pharmacy that promote improved sleep contain diphenhydramine as one of the ingredients. Diphenhydramine has two pharmacological properties that can cause significant morbidity if taken daily for prolonged periods of time-antihistamine and anticholinergic. The antihistamine effect is what causes sedation; however, over time the histamine receptor de-sensitizes, so it becomes less effective. Moreover, chronic use of an antihistamine causes weight gain in many individuals. The chronic anticholinergic effect increases cognitive impairment, constipation, dry mouth, and urinary retention.

Aerobic exercise

As a general rule, lifestyle recommendations that make for a healthy heart also make for a healthy brain. Aerobic exercise has consistently shown to have healthy effects on the brain. Increasing blood flow promotes the delivery of oxygen and the removal of CO₂ and waste products. Numerous studies demonstrate the health promoting effects of aerobic exercise, including:

• Improved cognitive functioning

• Less whole brain atrophy in older adults

• Greater sense of well-being

• Decreased depression

• Increase in energy level

Of course, before starting or increasing aerobic exercise, get the green light from your health care provider.

Social connectedness

We are, by nature, social animals. There have been several studies of communities around the world where individuals commonly live to 100 years of age. National Geographic writer Dan Buettner¹ has studied these communities extensively. The Barbagia region of Sardinia is home to the largest population per capita percentage of male centenarians. The Aegean Island of Ikaria, Greece, has been found to have the world’s lowest incidence of dementia, and low rates of middle-age mortality.

Buettner and his team of researchers extracted nine evidence-based common attributes found in these two regions, along with three other regions that share the properties of having the highest life expectancy and highest per capita centenarians. These attributes include:

• A sense of purpose

• Daily practices to reduce stress

• Belonging to a larger community

• Making the family needs priority number 1

• Being a member of a social circle that reinforces healthy behaviors

These communities where individuals often live long and healthy lives are called “Blue Zones.”²

Daily practice to reduce stress

Chronic stress is a highly destructive physiological state. As our physical bodies evolved in a physically dangerous world, the fight-flight-freeze response served as a biological defense to increase our survival. Now that the primary causes of stress in the US are non-physical (work stress, financial stress, relationship stress, political stress), the evolutionary defenses of increased blood pressure, increased heart rate, increased respiration, re-distribution of blood to our muscles, pulses of epinephrine from our adrenal glands, increased blood levels of glucose-lipids-cortisol, increased muscle tension, pupillary dilation, bowel evacuation, and hypervigilance no longer serve to increase survival, but rather increase the risk and onset of many medical conditions.

In 1975 Dr Herbert Benson, a cardiologist in Boston, MA, wrote The Relaxation Response,³ which introduced to Western medicine a daily practice that could function as an “anti-stress” exercise by reversing the physiological state of the fight-flight-freeze response. The Relaxation Response is a type of concentration meditation that uses a simple phrase, word, or prayer as an object to focus on to reign in the restless and often agitated mind content that commonly wanders, worries, over-reacts, and amplifies psychological stress.

During the 1980s, at the University of Massachusetts Medical Center in Worcester, Dr Kabat-Zinn⁴ pioneered Mindfulness Based Stress Reduction as an evidence-based clinically validated 8-week group treatment program to teach the practice of mindfulness meditation to patients with a wide range of medical and psychological symptoms. This treatment program was detailed in Dr Kabat-Zinn’s first book, Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness,⁵ which led to the development of similar programs in hospitals and clinics around the world. The practice of mindfulness has since become mainstream as a foundational daily practice for a wide range of medical and psychological conditions, as well as facilitating overall health and wellness.

There are many paths to develop the anti-stress physiology, and not surprisingly these include spiritual practices, religious practices, relaxation techniques, as well as meditation.

Healthy and diverse diet

A phrase that we often hear, and which contains a great deal of wisdom, is “you are what you eat.” The field of nutrition, and our growing understanding of the long-term effects of a health promoting diet in contrast to an unhealthy diet (disease promoting) has expanded exponentially in the past 50 years. Common components of a healthy diet include whole grains, fresh fruits and vegetables, fresh fish, nuts, and unsaturated fats (including omega-3-fatty acids). Strawberries, blueberries, and blackberries contain anthocyanins (a type of polyphenol) that have antioxidant and anti-inflammatory properties that can be protective of the brain. Year after year the “Mediterranean diet” is promoted as a healthy and attainable diet for the average person. Of course, each person may have specific and unique dietary requirements. In my experience, my body feels good after a healthy meal and feels tight and tired after a meal of “fast food” or other food products that I know are not so healthy for me.

Drink a lot of water

Maintaining good hydration, ideally with pure and unadulterated water, goes a long way towards both good physical health and brain health. Our culture has done a great job marketing soft drinks and other beverages, often containing sugar, artificial sweeteners, and caffeine, that are frequently more accessible than a glass of pure water. At airports around the country a bottle of pure water often costs more than an equal sized non-alcoholic beverage of any type. If you are urinating clear fluid throughout the day, you are probably drinking an adequate amount of water. Of course, individuals with certain medical conditions may have to follow different requirements for fluid intake.

Minimize “recreational” drugs

Although this recommendation sounds obvious, I am frequently surprised by the wide range of beliefs throughout the country as to what minimal, moderate, and problematic recreational drug use means. Some of my friends and patients will matter of factly state that they ONLY drink three or four glasses of wine or five or six bottles of beer a day, with the implication that this is minimal and not problematic. The National Institutes of Health regularly updates its recommendations as to what a healthy amount of daily alcohol use is. For adults, both men and women, the current recommendation is one alcoholic beverage a day (one beer, one glass of wine, or one shot of hard alcohol).

If we ingest a substance that has a perceivable change in how our brain functions, that substance is changing the physiology of our brain. This topic is far too important and extensive to adequately address in this editorial, and so I will further explore the recreational use of drugs in the future.

Learn new information every day

To date we have no adequate treatment for most of the common types of dementia. The annual international conferences on dementia often conclude with: the best treatment for dementia is prevention. The etiology of dementias is complex, with a range of genetic, medical, substance induced, brain trauma, lifestyle, and environmental risk factors. What we can say is that individuals with more education appear to have a greater brain “reserve” of healthy neurons, and that this is related to a later onset of dementia.

Learning new information in areas that were previously not known seems to facilitate synaptogenesis, which helps promote improved brain functioning and cognitive reserve. Simply put, keep a list of topics that you would like to learn about, and keep learning: art history, chemistry, astronomy, Russian literature, a new language, cooking, woodwork, statistics, particle physics . . . anything new will facilitate brain health.

Movement activities using all body parts

Our brains have two hemispheres, with complex connectivity that can send neurons from one side down the spinal cord to the same side of the body, or to the opposite side. Each of us is born with one hemisphere that is more dominant regarding language and handedness, although there is significant plasticity in this regard, especially early in life. Reflect on your first time learning a new activity-playing a guitar, driving a car, learning a new language. Initially it takes a great deal of attention, intention, repetition, and practice to learn any new activity. Eventually it becomes second nature.

The more your brain is challenged with new tasks, and the more complex these tasks are, the healthier your brain will be. Movements in dance and yoga often involve bilateral muscle groups throughout the body-these two activities have been shown to improve brain health. Someone once told me to get on all fours, and crawl like a baby backwards-this is something that most of us have never done, and initially it is challenging. However, as you crawl backwards new neurons are firing, and the brain is connecting in a new way with symmetrical circuits.

Comply with evidence-based treatments for health-related conditions

For any health-related condition that you have, after you feel confident that your health care providers have adequately and professionally diagnosed your condition, and after you have been informed of all treatment options available, do your best to comply with the treatment you choose. This last recommendation is a big one, and one that will be further explored in a future editorial.

Conclusion

Our brains are complex organs that are constantly rewiring in response to our behaviors, environment, stress, anti-stress, nutritional intake, sleep efficiency, social connectedness, medical conditions, intake of substances of all sorts, and numerous factors out of our control. We have learned a great deal to map out paths to support our brain health, much like we have previously achieved for heart health. Each moment of each day we make choices that can affect our brain health-our challenge is, without judgment, to increase the choices that promote a healthy brain.

References:

1. TED: Ideas Worth Sharing. Dan Buettner. https://www.ted.com/speakers/dan_buettner. Accessed June 17, 2019.

2. Blue Zones. https://www.bluezones.com/live-longer-better. Accessed June 17, 2019.

3. Benson H. The Relaxation Response. New York, NY: William Morrow; 1975.

4. UMass Medical School: Center for Mindfulness. History of MBSR. https://www.umassmed.edu/cfm/mindfulness-based-programs/mbsr-courses/about-mbsr/history-of-mbsr/. Accessed June 17, 2019.

5. Kabat-Zinn. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. Brooklyn, NY: Delta Publishing; 1991.