The Psychology of Fighting Dementia | Dr Tommy Wood

23:19So we've seen in older adults, if you start them on a new training program, depending on the type of training, you can see physical changes in brain structure. Their brains can actually get bigger, even in the 60s and 70s, which we never thought was possible previously. And you can see some similar things if people learn a new complex skill. There are some great studies in London taxi drivers where they memorize this huge map of London and their hippocampi or parts of their hippocampi, which are really important for memory, they get bigger even in adulthood. So we can see the brain get bigger.

23:49It's just that not everybody's getting an MRI scan.

23:52Dr. Michael Gervais:Yeah, it's more of the idea that neurons that fire together, wire together. And that study was a groundbreaking study for so many of us because we're like, oh, wait, if you do something over and over and over again for an extended period of time and you're really good at it, there's a structural change that takes place. Oxygenation as well would be a really important factor that you just mentioned. And when you're stressing the system, just like your physiological system for muscles or whatever, there would be an oxygen exchange that would be favorable, both from the heart to the muscles to the brain as well.

24:23Dr. Michael Gervais:So do you find the same when you're doing complex, solving complex or doing complex things, that there's also an equal oxygenation? one kind of core aspect of healthy brain function is this idea of neurovascular coupling which is when you stimulate a network in the brain a group of neurons to do a specific task those neurons and the astrocytes which are another type of cell in the brain neurons only make up about half of the cells in the brain we don't realize there's a bunch more that's going on in there that was actually the primary argument between Golgi and Cajal was neurons versus other cells in the brain, like which are most important.

25:03And so they're all important. But neurons and astrocytes, they stimulate the local blood vessels to expand, to dilate. So the blood flow to those areas of the brain are very tightly linked to activity in those areas of the brain. So this is another reason why it's so important to have healthy blood vessels or healthy vasculature. But yes, that's exactly it. Those areas become activated. They need a greater supply of oxygen and energy and they ask for it and those vessels dilate, just like what happens in the muscles when you start to exercise them.

25:33Dr. Michael Gervais:It's amazing how important it is. This is why like smoking is such a problem. Sitting is such a problem. You know, both of those alike is that we are starving our bodies for something it really wants, which is oxygen. All right, let's ground the conversation in numbers. So what are the most recent numbers internationally and nationally that you're working from for people that do have dementia? Right now, I think in the US, somewhere between seven and eight million people living with dementia. Worldwide, seven to eight times that, something like that. This number is increasing. And the burden of dementia is expected to double or triple in the next two decades, depending on who you ask.

26:17It might be by 2040 or by 2050. That's alarming. It is alarming. And there are even news articles where they're saying, you know, Alzheimer's disease is going to bankrupt Medicare because of the huge burden that it's going to create on the healthcare system. And I think it's important to think about why this is. And also, there are other ways to look at the data that are not necessarily quite as alarming and that give us some hope. So one reason why the burden of dementia is expected to increase is because we're living longer. And we're living longer because we've become better at treating other diseases.

26:59And so heart disease has been the number one cause of death in the US for a long time. It's probably going to stay that way, but the numbers are decreasing. And so Alzheimer's disease is kind of making its way up the list. where actually in many high-income countries is expected to be the number one cause of death in the next couple of decades.

27:18Dr. Michael Gervais:I didn't think that Alzheimer's killed people or that dementia killed people. So it's often kind of the primary driving factor, those complications, right? Because you become bed-bound, you fall, pneumonias, like those kinds of things. That's right. It's a first domino or it's an important domino. Yeah, exactly. Not a first. Yeah, okay. Like kind of like the underlying thing. Yeah, okay. And of course, there could be things like sometimes people could get seizures or other things that were that's kind of like the trigger. But it's sort of that fundamental change in that individual then drives their risk of the thing that might be the final course of death.

27:55Dr. Michael Gervais:So we need to stimulate our selves, including our brains. Right. OK, so that's the first S of your model. Yeah. Second S. So the second S actually ties in very nicely with why I think we don't need to be so worried about the numbers. We should worry about the numbers, but why they don't need to be as concerning is why they might on first blush. So when you look at one way of sort of slicing the data on dementia, we might look at something called age-specific incidents, which is at a given at a certain age how likely are you to be diagnosed with dementia so at 70 years old or 80 years old how likely are you to be diagnosed with dementia and age-specific incidence has been decreasing for the past several decades at 70 years old now you are less likely to be diagnosed with dementia than any other time in history one of the reasons why it's thought that age-specific incidence is decreasing is because we've done quite a good job at the population level of treating and preventing heart disease.

29:00Dr. Michael Gervais:So the heart is doing better. We've got medication. We've got behavioral and psychological remedies. And so there's more oxygenation taking place. So the brain is a little bit better. So we've pushed down the road this kind of set of complications. And so on top of that, of course, we are living longer. And so if we do get dementia, we may just get it later. But it gives us this, it shows us that if we do these large scale interventions, we change things at the population level, we improve healthcare related to these risk factors, we could actually start to move the numbers on this. So that's why I think that gives us some hope.

29:37And so why this ties into the 3S model is because the second S is supply. So we already talked about blood supply, why it's important. Another supply that's really important is energy supply. So the brain primarily runs on glucose. It can run on some other things, lactate and ketones, depending on what state you're in. But you need healthy energy regulation, essentially. So metabolic health is critical. This is why diabetes or metabolic disease or metabolic syndrome is a risk factor for dementia is because it impairs energy metabolism. We also need a supply of nutrients that make neurotransmitters that help create the actual physical structure if we're rebuilding that or building that.

30:19And there are some nutrients that have quite good evidence for their relationship with cognitive function later in life and dementia risk. So omega-3 fatty acids, vitamin D, iron, and B vitamins are probably the ones with the best evidence. There are some others, certainly zinc, magnesium, flavonoids and polyphenols, fiber. So like all these things that you might get from a -

30:41Dr. Michael Gervais:Let's just pick those apart. Those are really important. People throw them around like, I did not know how to create a intelligent intervention until I started to measure them. Right. So I could very easily go find a high grade omega and take 2000 milligrams. Is that the right? Yeah. 2000 milligrams on average. And I was doing that for a long time. I do it twice a year. Just take a look at my nutritional panel on it. And yeah, I'm, I'm kind of wasting money. So, but I'll go on and off now. Yeah. And I'm, because I'm tuning to it, same with vitamin D and whatever. So can you just kind of go down the, your best practice for either measurement and, or just kind of a general guidance on how to go about being better on those supply functions.

31:27Yeah. Ideally, these are things that we would get measured and assessed. And that's getting easier and easier to do. It is. So get your cardiovascular disease checked, you know. What age? At least probably starting in your 40s.

31:41Dr. Michael Gervais:Yeah, that's the number I have in my head as well. And then I'm starting to see people talk about why not get one 18, 20 in that range as a baseline. Would you have any concerns about a young baseline? I'd have no concerns about a young baseline. What it comes down to really is access and then how you interpret it and how you act on it. So one of the hardest things for doctors to do is not do anything in response to a test result. It's mainly avoiding being overzealous and just like suddenly like spraying everybody with supplements and medications that they might not need. But we know that the primary time at which risk starts to diverge in terms of dementia is midlife.

32:19So really late 30s into the 50s, early 60s, that's when the risk really starts to increase. So that's the critical period when you'd want to make sure as much as possible that you're addressing these things. The two cardiovascular or metabolic risk factors that are most closely tied to dementia risk are blood pressure and blood sugar. So having high blood pressure or being pre-diabetic or having type 2 diabetes. And there are data from randomized controlled trials that show that if you have high blood pressure and you treat it, you significantly decrease dementia risk. So that's one that we have some pretty good evidence for.

32:55Dr. Michael Gervais:So say it again in the converse. If you have type 2 diabetes or you have an issue with the metabolic structure of glucose, what is the likelihood that you would have dementia? The best answer is, I can't give you an exact number, It's something like a two to threefold increase in the risk of dementia. But like when we talk about changes in risk, that's assuming everything else is the same. You only change that. Like this is these are kind of like statistical things that come out of a specific model. Right. So one thing that I try and avoid as much as possible is put an exact number on something for that reason.

33:32We know that it's a meaningful increase in risk and you will meaningfully decrease your risk if you address it. But like, whether it's two and a half times or three and a half times, we have this thing like precision bias. Like, it sounds smarter because I can give you a number. But in reality, there's also an error band around that. And you'd have to talk about the exact model that gives you the numbers.

33:55Dr. Michael Gervais:Yeah, I mean, what you're pointing to is a meaningful trend. Yes. That if this is the case, then there's an increased chance. Yes. The number is not as interesting. Yeah. However, for a whole host of factors, pre-diabetic, type two, type one, getting that under belt is a really important investment in overall health. Yeah. Dementia and otherwise. Yeah, absolutely. All right. Okay. And then let's just stay here for a moment that folks that might be on that arc. Finding Mastery is brought to you by our flagship mindset training course, Finding Your Best. Anytime you feel the pull to reset, to zoom out, to refocus and ask, am I moving toward the person I want to become?

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37:32Lifestyle plays a huge role here, right? Lifestyle is the primary driver of these diseases in the first place. If lifestyle changes aren't enough, which for some people they aren't, and that's fine. Right now, the GLP-1 agonists are doing an incredible job decreasing metabolic disease risk and heart disease risk. We don't have the evidence for dementia yet. Those trials are being done. But I think that in terms of the big shift we're seeing in terms of obesity, metabolic syndrome, dramatic improvements in blood sugar, blood pressure, I expect that we're going to see that really pay off in terms of dementia risk if people are addressing it that way.

38:11Dr. Michael Gervais:What about folks that are, you know, we're in the land of Los Angeles here where folks are three pounds overweight, you know, some ridiculous number, and they're using GLPs to really shape their body. But, you know, it's an off-label use, let's call it, to be generous. What are some of the risks for that population of folks? Because at the Finding Mastery community level, I do not want us to fall into the trap of needing to look a certain way to be okay. Yeah. And I do want you to use every lever that you possibly can to be your very best. Psychological, behavioral, physiological, medicine, like all of them.

38:49Dr. Michael Gervais:But what is the dark side of folks that are trying to look a certain way when they actually don't need it? Two parts to it. One, maybe you can speak to as well, which is the psychological side. From the health intervention and the lifestyle habit literature, there's actually quite a lot of evidence that says that if you're constantly saying that you're not doing enough right i think i should be sleeping more i think i should be exercising more regardless of how much you are actually sleeping or exercising you tend to have worse health and worse health outcomes and i think that that's because of the effects that our mindset and our psychology has on our physiology that we can physically measure you see changes in autonomic function the other side is, well, there's, I guess, two, then we could break it apart two ways as well.

39:34When we're then looking at, say, the evidence or the potential downsides of taking, say, medications to look a certain way, the best evidence that we have when it comes to metabolic health, body composition, things like that, and as they relate to most chronic disease, dementia risk, is that you mainly just want to avoid the disease state, right? So if you don't have pre-diabetes, if you don't have high blood pressure, like you're good, like more isn't more, as far as we can tell. And so constantly trying to optimize for a certain number below those thresholds, we don't actually have evidence that that's any better for your health.

40:15All interventions have side effects, right? There's been a lot of talk about GLP-1s and muscle loss. I think what we've started to see more of, and this is particularly in the setting of obesity or metabolic disease, is that yes, some lean mass is lost, but a lot of it is probably fat being lost from the liver, which counts as lean tissue, and also fat being lost from the muscle, which is actually a good thing because that improves muscle function. And often strength is maintained. So I think some of the concerns about muscle loss have been oversold. But equally, you can get to the point where you're not eating enough to maintain nutrient status, get adequate protein, to then have your body get everything that it needs.

41:04Most of the data we have so far on muscle loss comes from individuals who were potentially obese to start with, or they had obesity to start with. So there's actually far less data on people who are a normal body weight than took GLP-1s because they're not the people in the studies because this is the off-label use. So I would still have concerns about muscle loss at that lower end, particularly if they're not eating enough, they're not fuel enough, and they're not doing resistance training, which is the primary way that you would then build or maintain that muscle mass.

41:33Dr. Michael Gervais:How important is it to get glucose slash pre-diabetes? How important is this when we're going after optimization? Again, there's two parts to that. One is the avoiding pre-diabetes or diabetes. Because you do see significantly increased risk of dementia, but also several other conditions, heart disease, depression. There's a whole host of conditions that come with dysregulated blood sugar, or increased risk of them at least. And so avoiding that or reversing that is important. But beyond that cutoff, I don't think we have great evidence that there is like some truly optimal range. And so like often what you'll see is people will say, oh, well, you know, I don't have prediabetes, but my fasting blood sugar is 90, but it would be better if it was 80.

42:22For most conditions, we don't actually have evidence that that's true. So I think that we can get into a trap of constantly chasing these numbers when we don't have that much evidence that more would be better. And there are opportunity costs as well as side effects of things we might be taking off label or things that we don't get to do or enjoy because we're so worried about these numbers when actually we're not necessarily doing something that has a lot of evidence behind it.

42:49Dr. Michael Gervais:Okay, so stimulus, supply, and now we'll get to support. What is the third S really about for you? Maybe before we get to support, because we didn't touch on nutrient blood tests, we could just quickly cover those. Great. So again, we have some pretty good cutoffs for things we might try and achieve or avoid. So a vitamin D level at least of 30, right? Because below that risk of dementia increases, particularly below 20. Just for you, do not talk about general advice for people because we're both going to say, go get your levels measured. How much D are you taking? How many IUs have you taken?

43:25In the winter, I take 3 ,000 a day. And that keeps me above 40, which is kind of like my target. So we have some other evidence from the sports performance literature that maybe a kind of like a 40 to 60 range is sort of like the best spot to be in. Especially in the Northwest,

43:42Dr. Michael Gervais:when we would measure second or third year athletes that were with the Seahawks, we'd see a decline because of the sun, the lack of sun. So it's a pretty massive competitive advantage to get D right as a high functioning and even just well functioning person. So, okay. Then B vitamin status, again, has some of the better evidence for it is homocysteine. Homocysteine goes up when you don't have enough of one of the methylation-supporting B vitamins. And why is homocysteine important? Homocysteine seems to do a few things. It can affect blood vessel function. So it's related to heart disease risk as well.

44:17When you look at animal studies, and it's impossible to test this in humans, but it seems that homocysteine may accelerate the phosphorylation or hyperphosphorylation of tau that creates tau tangles. The tangles. Yeah. So it may contribute in that way too. People who have elevated homocysteine have a higher risk of dementia. there have been multiple randomized controlled trials that have shown that if you decrease homocysteine with B vitamins, you decrease the rate of cognitive decline and decrease the rate of brain atrophy. And so the target would be at least below 13, ideally below sort of 10 to 11.

44:52So single digits if possible. That effect of homocysteine lowering seems to be dependent on omega-3 status. So now there are several trials that show that if you improve omega-3 status, but you don't look at homocysteine, you don't see any benefit. And if you improve homocysteine, but you don't look at omega-3 status, you don't see any benefit. You need both to benefit. And there are probably a whole bunch of other dependencies when it comes to nutrition as well. This is just the one that's been best studied. But people will hear all the time, oh, hey, we did this trial, we gave people B vitamins, nothing happened, B vitamins don't work, right?

45:30Dr. Michael Gervais:They weren't looking at the combination. Because they weren't looking at all the... That's the Panama Canal thing that I was mentioning earlier. Like you do need a handful of things to work together to do. So then you've measured your omega-3 status. And probably the best evidence test is an omega-3 index. Real risk is when it's like 2 % to 3%. And so the omega-3 index is the percentage of the fatty acids in your red blood cells that's made up of EPA and DHA, which are the two sort of long chain omega-3 fatty acids. Risk really starts to come down once you're above 5%. ideal is probably at least 6 % to 8%.

46:02But you just want to avoid being 2 % to 3%, like if possible, you know, get it above there. And then the final one that we have some good evidence for is iron status. So anemia in particular increases the risk of dementia. Probably about 10 % of perimenopausal and postmenopausal women in the US are iron deficient. And iron deficiency, particularly in that period, sort of like the perimenopausal transition, early menopause, increases the risk of cognitive changes during that time. So like getting iron status right is really important. If you're going to measure your hemoglobin, which is one sort of, which is one way that you would assess that.

46:40So you measure hemoglobin level, you want it at least above sort of 12.5 in women, 13.5 in men. And if it's below that, you have an increased risk of dementia. But if it's very high too, that's something that you should check out as well.

46:53Dr. Michael Gervais:Okay, shift gears. I want to stay here one more time before we get to your third S, which is support. Can you speak to folks that are not eating red meat? Concerns that you have? Or are you like bullish on that? And then can you speak to people that are not eating meat at all? Vegan, vegetarians? And are you in support bullish on that? The way that I think about it is that nutrients are the great leveler, I call them. So those nutrients we talked about, some of the other things I mentioned briefly earlier, it's important that you get enough of them. I care much less where you get them from. So depending on the study that you look at, a small amount of red meat is sometimes associated with an increased risk of dementia, sometimes actually associated with a decreased risk of dementia.

47:35I think some of that probably comes from the nutrients in it, right? It has B12, iron, zinc, some other things that we know are important. I don't think we have good evidence to say that a normal amount of red meat increases the risk of dementia. And for some people, it may be an important source of nutrients. I also don't think that it's something everybody has to eat, right? As long as they're getting those other nutrients, those nutrients from other foods. So people who are eating a plant-based diet in particular, we know they're at an increased risk of B12 deficiency. I think anybody in that world now appreciates that.

48:09And they should take a B vitamin supplement and maybe measure those things. Iron also potentially too. Maybe red meat is a good source of iron for some people, but not everybody needs it. So again, I would just like tailor this to your personal needs. If you have dietary preferences, that's fine. This is where sort of the testing or eating more of certain foods that fit within your dietary pattern that have those nutrients to kind of make up that gap is great. We do also now have some evidence that especially, well, this isn't an older adult. So this comes from the Cosmos trial, which is a massive trial done recently in the US that gave half of the participants multivitamin.

48:48And it was Centrum Silver, like the most basic multivitamin, just 100 % of the recommended allowance.

48:54Dr. Michael Gervais:They consider it a vitamin? Yeah. Still? Yeah. Okay, I'm joking. So I think this is potentially important because there's no like mega doses of anything that could, you know, which if you take for long periods of time, some of this stuff can get a little out of kilter. Like when I work with my athletes, every sports supplement has b6 in it right and so like when you take three or four different things we get their blood test back and they're just like stuffed full of b6 because it's everywhere and we know that if you take very high level very high amounts of b6 for long periods of time it can cause like some neurological symptoms and stuff so like with that kind of really basic multivitamin you're making sure you're getting at least the basics but you're not kind of at risk of overdoing anything.

49:38And in the COSMOS study, those who took the multivitamin, you know, had some improvements in cognitive function. So I think that especially if you have some concerns about your diet, like a basic multivitamin, we now have some good evidence for from a cognitive standpoint. But as long as you're getting those core nutrients, like I said, I think it matters much less where they come from.

49:59Dr. Michael Gervais:And that was double blind placebo effect? Yes. So they beat that beta placebo? Yes. The COSMOS trial was a two-by-two study, they call it. So there were actually four groups. One group got only placebos. One group got a cocoflavanol. Another group got a multivitamin. And then the fourth group got both the cocoflavanol and the multivitamin. And they looked at a whole bunch of outcomes, like cardiovascular outcomes and things like that. And the multivitamin seemed to be beneficial from a cognitive standpoint across both the groups that got it. The cocoflavonol only seemed to be beneficial in those who were eating a low-quality diet and therefore weren't really getting other antioxidants from the diet because the cocoflavonol sort of acts as an antioxidant.

50:43So if you're not eating fruits, vegetables, berries, maybe not drinking a lot of coffee or tea, which is where some of these compounds come from, then that kind of supplement seemed to be beneficial. But if you were eating a diet that contained them, there didn't really seem to be any benefit.

50:58Dr. Michael Gervais:While we're on the supply here, one more turn. is that are there any supplements that you're really interested in right now, like alpha-GPC or phosphatidylserine? Or are there other things that are not really on the base of the omegas and the B and the D? The only thing that we might consider more broadly, not necessarily because we have the most amazing evidence for it, but because the evidence is increasing and we know it's incredibly safe, is creatine. Yeah. So creatine seems to be, you know, there's potentially some benefits after, you know, in setting of brain trauma, individuals with depression.

51:37Multiple studies now in the setting of sleep deprivation seems to improve sports specific skills in athletes. Some aspects of decreases fatigue under sleep deprivation. One pilot study in Alzheimer's disease, but there wasn't a placebo control. So we don't really know whether creatine was what actually drove some of the improvements in cognitive function they saw. But in older adults, creatine may particularly be beneficial for memory function. And there are some meta-analyses that show that.

52:01Dr. Michael Gervais:2011-12 was my first year with the Seattle Seahawks. And I brought in a colleague. And do you remember Professor Greenhoff? He's a UK-based professor. He did some of the first original studies on creatine. And so I brought my colleague in, Professor Greenhoff, and my colleague Paul Winsper and I, we were on a board together. And Paul came in and he says, why is there no creatine here? This is 2012, 2011. And I said, ah, it's leak policy. Yeah. He said, this is criminal. Like you're asking these guys to do A, B, and C, and you don't have the most basic fundamental, what is creatine? I want to say it's an amino acid.

52:44It's like a peptide from three amino acids.

52:47Dr. Michael Gervais:Yeah. And he said, this is criminal. And so he harped and harped and harped. Now you can't go in an NFL, probably any sport organization, and not find creatine. One of our partners that is a great supporter of this podcast, Momentus, they just moved to their own first ever creatine. I'll get you some of it. It's called Signature Spec. They developed it. It's really good. It's totally different as a form function with all of the right kind of quality. So they've been great. They've done a nice job of educating people on it. And so you're into it as well. Yeah, so I take creatine every day. I have for a long time.

53:21Dr. Michael Gervais:What about the risk? Older people start, I interrupted you. I'm more interested in what I'm about to ask though. What about for you? Because I was going back to the older folks, is that creatine to creatinine, okay? And I would love for you to dispel the connection between creatinine and liver. So I'm thinking about older people. Maybe the liver is a little bit weaker. I don't know if that's fair to say or not. And here we are pumping creatine. I've read the research and I'm still kind of confused. And can you open that up a little bit for us? Sure. The first thing I'll say is they've actually done studies where in frail older adults, they're giving them very high doses of creatine for long periods of time.

54:02So there was one randomized controlled trial in Parkinson's disease.

54:05Dr. Michael Gervais:10 milligrams. 20 grams a day initially. And then I think it was 10 grams a day for several months afterwards for two years. This is a potential treatment in Parkinson's disease. It was a small trial. It didn't show any benefit, but it also didn't show any negative side effects. So that's an important context, is that even in frail older adults, we still haven't seen negative side effects of creatine. The thing that does potentially happen is that creatinine goes up. So creatinine is used as a marker of kidney function. Creatinine is actually not a good marker of kidney function. It's actually a very dirty marker of kidney function.

54:39The primary driver of your creatinine level is your muscle mass.

54:43Dr. Michael Gervais:They're always asking, are you working out? Yes. Are you taking creatine? Yes. Well, it's probably not a big deal is what I get. And then I look at the research and they're saying the same thing. But I don't want a high marker of creatinine knowing that I've got a potential compromised kidney function. So your creatinine level, it's used because creatinine is constantly filtered out by the kidneys. So if it goes up, it suggests that your kidneys aren't working as well. So you have to look at GFR, EGFR. So EGFR is just calculated from creatinine based on body weight and things. So if it's adjusted for your weight or body surface area, if your EGFR is adjusted for body weight or body surface area, then it's more useful.

55:21You're using that creatinine number, but you're taking into account the size of the person, which is important because muscle mass is the primary source of creatinine in the blood. And if you increase creatine intake, creatinine is just a byproduct of creatine being phosphorylated and used for energy processes in the muscle primarily. and sometimes it creates creatine and it gets sent into the blood and then the kidneys filter it out. So there are studies that suggest that if you take creatine, creatinine levels go up. But there are also studies that have used a more accurate marker of kidney function called cystatin C.

55:58And cystatin C does not change when you take creatine. So creatinine goes up because it's kind of like a dirty marker. But cystatin C doesn't change. So there's no evidence that creatine negatively impacts kidney function, like the actual function of the kidneys. It's just the nature of the marker they're using. I can tell you a personal anecdote. I was once hospitalized for a snake bite in Costa Rica. I spent nearly two weeks in the hospital. And yeah, so I got bitten by a pit viper, the Tertiopelo or Ferdelance in the Costa Rican jungle. And I needed obviously the antivenom. And then I got a severe abscess.

56:38They had to drain from my leg. I had like bad cellulitis. So skin infection went like all the way up my leg. It was antibiotic resistant. So I needed like third line antibiotics. And then I got serum sickness that in response to the antivenom. So I'm like whole body hives. So they had to fill me with steroids and antihistamines and stuff. Like the doctor like joked that like, it's always the gringo tourists that get all the side effects. Those are his words. And they nearly didn't let me go home because my creatinine was slightly elevated. and it's a combination of my higher muscle mass and I take creatine supplements.

57:16But like they were terrified that like my kidneys were failing because of everything. The reaction to the serum. Yeah, reaction, like all the things that were going on. But I had to be like, no, no, no, it's fine. This is just normal for me.

57:24Dr. Michael Gervais:Trust me, I actually do know. That's great. So this is just worth bearing in mind because like particularly if, you know, if you're older or maybe you get a test for kidney function, you get your creatinine measured, it's a very normal part of a typical blood test. Just like let your doctor know. that this is something you're supplementing with. But like so far, there's no evidence that it's actually negatively impacting kidney function. Okay. So the connection, I'm glad we're talking about this, the connection between creatine and brain health, creatine and dementia, can you just, can you wrap that up for us?

57:57So no evidence that creatine decreases the risk of dementia. Like we couldn't say that. But particularly under a group of conditions where maybe your cognitive function has been affected in some way. So brain trauma, sleep deprivation, maybe with some cognitive decline later in life, because creatine seems to be most beneficial in healthy, you know, quote unquote healthy people. Creatine is maybe most beneficial in older adults. So maybe they've already experienced a bit of decline. In those states, we do like across all the evidence we have, there does seem to potentially be some benefit. Like we're not going to pretend it's magic, but there are there are trials in all of those areas that say there could be some benefit there.

58:36Dr. Michael Gervais:You would say it would be foundational as a first mover supplement for brain health is to take creatine or eat enough red meat, God help us. I don't know how you would to get that level of creatine into the body right now. If you are thinking about supplements for cognitive function, particularly if one of the things that I mentioned applies to you, then creatine would potentially be the place to start. And the reason why I'm more bullish on creatine than other supplements broadly is because we know it's incredibly safe. Are you at 5 milligrams, 10 milligrams? What are you taking? I take usually 10 grams a day.

59:14Dr. Michael Gervais:Yeah. And is there a difference that you're aware of between genders? No. A recent study that gave 10 grams of creatine a day to menopausal women in concert with a resistance training program. So like the resistance training or resistance training with creatine. and there was potentially some additional benefit on bone health. It was minor, though, in the creatine group in addition to the resistance training. But again, so in that kind of age group of women taking 10 grams a day, certainly no issues in terms of side effects. So the dosing seems to be similar. Yeah, from a side effect standpoint at least.

59:49Yeah, and also in terms of efficacy.

59:52Dr. Michael Gervais:Okay, this is great. Let's get us to a third S, okay? So we're on support. Yeah. If you think about, right, you've stimulated the brain. You're doing some like new complex challenge, learning a new skill or something. You've activated this increase in supply to those areas, right? More blood flow is brought in, brings in the nutrients and oxygen and all that kind of stuff. And then you need a period of adaptation so the brain can like respond to the stimulus that you apply to it, right? So if we go back to the athlete and physical function example, right? No athlete gets stronger in the gym. They get stronger when they recover afterwards, right?

1:00:26And the brain is essentially exactly the same. So we apply a stimulus, we give everything we need to respond to that stimulus, and then we need a period of adaptation. Most of this happens during sleep. So this is the support S. Sleep is a critical component of that. That's when, you know, new synapses are cemented. This is when neuroplasticity happens. This is when memories are kind of integrated into the bigger picture of what we know about the world. It's where our emotions are processed. You know, all this kind of critical stuff happens during sleep. We can also support adaptation with other aspects of physical health.

1:00:58So hormonal status can certainly play a role here. Trophic factors produced during exercise, like brain-derived neurotrophic factor, that helps to support sort of neuroplasticity and skill learning and development. And then we want to avoid things that impair adaptation. So that kind of fits into the support bucket too. So things we've already talked about, smoking, excessive alcohol, air pollution is increasingly appreciated as a risk factor for dementia because it dramatically increases sort of inflammatory processes that we know can impair cognition. oral health so dental disease gum disease is another increasingly appreciated risk factor for dementia and then sort of like a broad bucket that we might just call chronic stress right so we we've already touched upon like acute stress being really critical to function like that's what drives adaptation but if you never switch that off like chronic stress essentially causes like an overtraining picture in the brain it never switches off it can never recover it can never adapt.

1:01:53It may even be impairing sleep and some of these other things. So that group of things kind of comes into the support bucket, kind of balancing what allows the brain to actually adapt to the stimulus that you've applied to it.

1:02:03Dr. Michael Gervais:I really appreciate your model. And I appreciate that you didn't name it like S for sleep, right? You did support. You know, there's a whole bunch of things, sleep being a really important one. Another level of support is, you know, the social engagement with other people. And I would even add probably underneath support, when you are in service to something greater than you and you are the support mechanism for others or a cause greater than you, which is probably not how you've organized the support, but just flipping it, being in support as a massive protective factor. So what I like about thinking about it like this, it kind of helps us appreciate why certain things are so foundational to brain health.

1:02:47And like, just like one area you can make improvements, you can see improvements across the entire network. So yes, we know that pro-social behavior has huge effects on physiology, well-being, like people who volunteer more have a lower risk of dementia. People who care or look after others have a lower risk of dementia. And it's fitting stimulus, versus it's fitting that kind of effect on autonomic balance and how that affects inflammation and immune function, right? So it's coming in, that kind of pro-social, acting in something greater than yourself is actually hitting multiple nodes of the network at the same time.

1:03:27Dr. Michael Gervais:What do most people get wrong about dementia? I think maybe two things. One is that it's inevitable, which we've talked about a lot already. Meaning it's not inevitable. Meaning that I don't think it's inevitable. That doesn't mean that you could guarantee one person couldn't experience dementia, if that makes sense. But you could, I think that we have evidence that you could change that trajectory. But there are still aspects of dementia that we don't understand. There are still cases of dementia that we wouldn't consider preventable, right? So I'm kind of talking big picture population level.

1:03:59But I don't think we should consider it to be inevitable. And genetics and other things come into play here. But even with in the setting of genetic risk, you can decrease you can decrease that risk with all the kind of stuff that we've talked about already. The other thing that I think we get wrong that is improving now is that each of those dementias that I've talked about, historically, we have focused. And by we, I mean a neuroscience neurology community have focused purely on the proteins that we see accumulate in the brain affiliated with that type of dementia. So like amyloid and tau in Alzheimer's disease.

1:04:38And those are absolutely part of the disease process. But we also know that people can experience Alzheimer's disease with not that much amyloid and tau in the brain. There are people who can have brains stuffed full of amyloid and tau and their brains work just fine, right? So they are absolutely part of the picture. But now we're appreciating other things like inflammation and changes in blood vessels and the factors that affect those. So historically, I think we kind of painted ourselves a bit into a corner by just focusing just on what the brain looks like under a microscope after you've died.

1:05:11When actually, that gives you a very incomplete picture of all the things that that person was and that affected their cognition.

1:05:19Dr. Michael Gervais:If a parent has dementia, can you speak to the listener here about how they should be thinking about themselves? There are a couple of pieces to this. One is the genetic piece, right? So, for example, the most common genetic risk factor for Alzheimer's disease in the population is your APOE genotype, APOE protein E. Which you can measure. Which you can measure. APOE4, if you have one copy, it increases your risk by maybe two to six times. Two copies, six to 20 times, something like that. From all the data we have so far, it does seem that ApoE4 primarily acts as a risk multiplier, rather than being like this really big baseline risk that you can't change.

1:06:04So those who have one or two copies of ApoE4, they get an even bigger increase in risk if they drink a lot, or if they have a poor quality diet, or if they have a sedentary lifestyle, or if they have cardiovascular disease. By the same token, they may get larger benefit if they address those risk factors, if that makes sense. And there are actually several population studies and several populations where APOE4 doesn't increase the risk of dementia. And I think that's largely because of a gene-environment interaction. So that suggests that the risk associated with APOE4 is also modifiable. And there are studies that show that, say, treatment of high blood pressure and high cholesterol, so taking a blood pressure medication and a statin, is particularly beneficial in those who have APOE4 in terms of their dementia risk.

1:06:45Dr. Michael Gervais:Who do we ask? And how do we ask? What are we asking for? I don't know how it happened for me, but my doc was like, hey, you want to get this measured? It was, I can't remember what blood test I did it with. I cannot remember. And he's like, yeah, I think you should do it. And I was like, yeah, let's do it. But what would somebody ask for? You would just ask for your APOE genotype, which is short for apolipoprotein E and is spelled A-P-O-E if people are looking it up. Yeah. But equally, it is worth thinking about, like, what will you do with this information? Because in reality, the answer for what you should do to decrease your dementia risk is going to be the same, regardless of your ApoE4 genetics.

1:07:27You might take it more seriously if you have a copy of ApoE4. But if you don't have a copy of ApoE4 and you smoke and drink and no exercise, I'm still going to tell you to do those things.

1:07:36Dr. Michael Gervais:There you go. That's right. Whether you have it or not, behaviorally and psychologically, there's still a whole bunch of things that you can do to decrease your chances of dementia and or increase your chances of vitality through the end of your life. So then more broadly, we also know that if you have a first degree relative who had dementia, you have an increased risk of dementia. So some of that is genetic. But there are also studies that show that, and unsurprisingly, lifestyle related risk factors also transmitted across families, right? You're more likely to move and eat and sleep and live your life like your parents did.

1:08:15So if you had a parent who had dementia, a great place to start is think about what are the risk factors that I have that I share with them? because that's going to be at least part of that picture of risk. That's maybe the place that you would begin to make some changes.

1:08:30Dr. Michael Gervais:I love your framing. Is this you doing some gymnastics with the data or is this like the way that you see data? I genuinely don't think it's gymnastics with the data. When I see all of this, I see hope because so much of this is modifiable. Yes, what each individual can do, the resources they have, the time they have is different. but you have to first know that it's possible and that's what you consistently see across all these pieces of data something that i learned a little bit about when i was in medical school actually not in medical school but i was just like doing this at the time was learning to think about sort of systems theory systems dynamics which is basically this way of it's used in engineering a lot my wife's a chemical engineer and chemical engineers do this all the time so she's much better at this than i am right because she's actually trained to do it i'm you know i know just enough to be dangerous.

1:09:20But it's this idea of building up sort of a model of a system based on all the different ways that things interact within that system. And this sounds obvious, but it's not something we really do in medicine and biology that much. We do a lot more now, like people have heard of like systems biology and this kind of stuff. But when you're talking about the way we analyze data related to dementia risk, whatever, we do these very basic statistical models where we just kind of adjust for stuff. We assume that everything is linear, just kind of like stacks on top of each other. But that's not how biology works.

1:09:53Like things interact and then they inhibit each other and then they feedback and all this kind of stuff. And so when I try and approach a problem, like often my, like my wife will catch me drawing these things called causal loop diagrams. So it's like all these different arrows and feedback loops and all this kind of stuff. And then it just kind of helps me picture how all these pieces interact.

1:10:13Dr. Michael Gervais:Is the Krebs cycle just that? Yeah, partially, yes. And one of the things that I most enjoyed when I was an undergrad student was biochemistry and physiology, which is just full of feedback loops and chemical reactions. And so it kind of that fits how I think about things. If none of this, then likely that. Yeah. If lots of this, then likely that. If lots of this and none of that and a little bit of this, likely. Yeah. So if somebody wanted to see a causal feedback loop, they could look up Dr. Krebs cycle. Yeah. And or what else would you point them to as a classic if they wanted to use their intelligence for systems thinking for something they're trying to solve?

1:10:55some like very common examples, which are interesting, though not always that useful. There's one, if you like Google metabolism, have you ever seen that? And just like, there's this, there's this one diagram, which is like this, this mess of arrows and biochemical names. And like somewhere in the corner is the Krebs cycle. And then there's everything else. And it's usually used to say, well, like, hey, if you think you take this one supplement and you throw it in here and you're going to like fix everything, like you're not, because it's way more complicated than that. And then there's also one, a famous one, around the causes of obesity, which people could easily Google.

1:11:31And then, right, of course, there's all the like how you eat and how you move, but then like you go several layers out and it's like society and socioeconomic status and like all these other things. And you can like go down to biochemistry and you can go up to the environment and like all of it's kind of in there. What I find most useful, which is one way that you can use this idea, is you sort of, you draw out some version of your model and then you look for what are common themes, where are there nodes in the network that lots of things sort of coalesce, where are there potential intervention points that affect lots of aspects of the network.

1:12:06And so some version of doing that is what resulted in the 3S model, right? And it's not going to capture everything, but it gives us enough to kind of understand, oh yeah, these pieces interact with each other and like this is how things are acting. So like the alternative is you can make one big, very complex computer model and try and try and sort of like model all this stuff and make changes and see what happens. But for me, as like a thought experiment, I quite like to sort of like distill it down. Like, can I find some really basic core themes that kind of emerge from this complex system?

1:12:42Dr. Michael Gervais:It's cool. You are a systems thinker. They can drill all the way down into the nuances of lots of singular properties, which is fun. I want to take a second here to tell you about a morning routine that I've been using for years. For me, it's a great way to switch on my mind, to ready myself to take on the day. So before I check my phone, my emails, market updates, or text threads, I choose how to start my morning. That's always in my control. That's always in your control too. This is the same morning mindset routine that some of the world's top performers across sport, business, and the arts are using.

1:13:17Dr. Michael Gervais:The best part? It only takes about 90 seconds to do. So just head over to findingmastery.com slash morning to download the audio guide for free. Again, head to findingmastery.com slash morning to get your morning mindset routine. can you speak to the listener directly that is noticing that they are on a cognitive decline they can feel it they sense it maybe others don't quite understand or can observe or it's just starting to happen i'll tell you my grandfather had vascular dementia and he was so smart and so socially tuned and so clever we didn't know for a long time because he could he could fit in a conversation still because of his social intelligence was incredible.

1:14:04Dr. Michael Gervais:So I'm asking you to just speak to the person that is noticing it themselves. Yeah. What your grandfather experienced is actually very common, is particularly individuals with sort of high levels of cognition intelligence to start with. They're very good at hiding it. The brain sort of adapts and they don't even necessarily know they're doing it. They're sort of like filling the gaps and they can kind of play along for a long time. Sometimes the individual doesn't even notice. Like sometimes it's other people that notice it but if a loved one is noticing or like says something about changes in you or you're noticing changes previously this was never considered kind of part of the framework of cognitive decline like it was you would you would get a diagnosis of something called mild cognitive impairment and then that was sort of that if that trajectory continued you'd get a diagnosis of dementia based on the amount of function now there's an appreciation for this period they call subjective cognitive decline and different people will argue about like how you can measure that.

1:15:00Because if you have subjective cognitive decline, but you did some of the standard cognitive tests that they do for diagnosing dementia, you would do just fine because they're very basic. And so one thing that has been a problem that will hopefully improve over time is like we talked about, you know, measuring your blood pressure and your blood sugar when you're 18, you know, measuring your lipids in midlife. We don't routinely measure people's cognition until we think they have a problem. So we don't know what that trajectory was because the tests are too coarse to do that. We need much more nuanced things and have everybody have access to them.

1:15:33And there are some companies, kind of one that I work with, that's sort of like working on that. Just like make it that everybody does cognitive function tests. And the goal isn't necessarily to get in the top 1%, right? The goal is just to maintain whatever it is for decades.

1:15:46Dr. Michael Gervais:Is there a place that we can go to? Yeah, so there's a company that I'm chief science officer of called BetterBrain. they have a free brain health platform that has a few different flavors so one is like an ai self-guided process free to anybody it's trained on thousands of papers that i help them curate a lot you know basically like that one chunk of them was just like they took the 2 000 references from my book and just kind of like well done through that and so you can put all the things about your lifestyle, your environment, your preferences, your diet. You can even upload some blood tests.

1:16:23It could help build you like a, here's the one thing that you should work on, right? Then there's also brain health coaching. All the coaches are RDNs, and that's available for most people that's covered by health insurance.

1:16:37Dr. Michael Gervais:Registered diet. Registered diet, dietitian, nutritionist. Yeah. Thank you. Highly qualified people. And even if you don't have any cognitive issues, that coaching is still covered by insurance. So the one thing you might need to do is you could pay for some blood tests if you want them, but they're sort of like provided at cost if you want to do it. And as part of that company, or if you do the coaching, you get access to cognitive tests, like validated cognitive function tests. We're now building, or they are, I didn't do it, I sort of gave input, I've built a suite of more complex cognitive tests that will then which will soon be launched will be available free to everybody so you can just like track your cognitive function over time so this will then need to validate them against other things right so there's a lot to be done but i think we're getting to the point where people can just track this much better and you want to know what it was when you were 30 and then you hope that it's the same when you're 80 rather than some stuff happens for five decades and then all of a sudden you have a diagnosis of dementia right that's that's what we want to try and try and avoid what a great resource.

1:17:43Dr. Michael Gervais:I'll say it again, betterbrainprobably.com. Yeah. Yeah. I'm going to go check it out for sure. Thank you for introducing that to me. For folks that are on the decline and they notice it. Yeah. Should we think about slowing it down? Should we think about increasing other behavioral choices? What can we do? Yeah. So the important part of subjective cognitive decline now being an accepted part of this path is now that people are recognizing it. So they're willing to talk about addressing it. And it's generally accepted that if you're in the period of subjective cognitive decline, that is largely reversible.

1:18:23There aren't a ton of like really large randomized control trials for that specific group. But we do have trials in older adults, 60s, 70s, where you make changes in exercise, diet, address cardiovascular risk, like brain training or cognitive training, to like some kind of new cognitive stimulus. In some of the studies, they do something, they might do CBT if there are some issues around depression or anxiety. And you see significant improvements in cognitive function, even later in life. So we know that this is modifiable. And so the easiest way to start thinking about this is, well, first, can you get some of this stuff assessed?

1:19:01Can you measure your homocysteine, get your blood pressure checked, like all that kind of stuff. And then think about, you know, all the things I talked about in the 3S model. And think about, to start with, what's one thing that you could start to move the needle on, right? And so -

1:19:19Dr. Michael Gervais:You're being kind. Invest in your sleep. Start moving and stressing your body. Put the sugary foods down. So this is, of course - Have great conversations with people that are stimulating. Yeah. Like, get in service of something that matters to you and see if you can support others. Get out of your own self-interest in that respect I'm suggesting. So like, I obviously completely agree with you, but with the like huge spectrum of people that I've worked with, like some will be exactly like, I've noticed something, I'm going to fix everything. Let's go. Great. But it's like some people like, even like thinking about that is overwhelming.

1:19:59So it's the things that you have to take away are, you can change this trajectory. Like there is still scope to do that. and in many respects we know the things that you should focus on and that then means that you can change and engage something and you know that even if you just start to work on one thing you can start to see improvements so like in the studies where they've identified you know these are the risk factors in this person we address these risk factors they see significant improvements in cognitive function so the maintain your brain study in in australia thousands of people all done remotely identified individual risk factors addressed them saw significant improvements in cognitive function so we know you can just start on one thing that you know affects you and work there if you want to do 10 things great

1:20:49Dr. Michael Gervais:this is why people love working with you you take them right where they are yeah that's great what a fun conversation we need part 2 part 3 part 4 because we didn't even touch the high performing brain which obviously you have a deep understanding about as well. And so, Tommy, it's always fun to speak to you. At a later time, I would like to talk to you about your worldview. I would like to talk about how you make decisions. I would like to talk about how you work with high stress, acute stress, and recover from it. And I'd also like to understand how did you ready yourself to go to two of the most meaningful institutions on the planet, Oxford and Cambridge.

1:21:26Dr. Michael Gervais:And then you get your PhD just for whatever reasons after your MD at University of Oslo. Like, I would love to talk to you about how you shape your life. And today was a great service to the application of solid science. And at the same time, I got to feel that you are optimistic. You are highly conscientious. You are not agreeable for the sake of being agreeable. but you want to be kind of in a slipstream with trying to find the commonality between people. I think you're obviously highly motivated, probably more internally than externally. You're not driven by money, fame, attention, you'll take them, but like, it's an internal driver.

1:22:07Dr. Michael Gervais:And no one has to shoulder tap you to go to work. Like you are the exact teammate that I think the world is wanting to work with. And for that reason, I want to celebrate not only your work, but how you show up with the 30 ,000 hours before this conversation. And we saw each other at the grid one day, Formula One grid. You were supporting a handful of teams and I was with one of them. And after you left, you don't know this, but after you left, one of the drivers said, oh, you know, Tommy? I said, yeah. And he goes, isn't he great? So you just, you've earned that. Those are the things that are said behind your back.

1:22:42Dr. Michael Gervais:And so I want to promote your work. Stimulated Mind is a great read. You took complicated science, made it simple, digestible. I ripped right through it. I hope people will pick that book up for both healthy brain and for a look at dementia and more than anything else, what we can do to be better. So, Tommy, thank you for showing us what high agency, high efficacy, you know, generosity and a discernment to make a difference in the world. Thank you for what you've provided us. Thank you. Thank you so much. I mean, your words mean a huge answer to me. We really, really appreciate it. And this has been so much fun.

1:23:18Awesome.

1:23:21Dr. Michael Gervais:Next time on Finding Mastery, half the population will experience menopause. Yet for many of us, it's still something we rarely talk about and often don't understand. In this conversation, Dr. Michael Gervais sits down with award-winning journalist and menopause advocate, Tamsin Fidel, to explore why so many women are misdiagnosed, why symptoms are often mistaken for anxiety or burnout, and how better conversations can transform our homes, workplaces, and relationships. Whether you're a woman navigating this transition or someone who loves, works with, or cares about one, this is a conversation that matters.

1:23:53Dr. Michael Gervais:So join us Wednesday, September 2nd at 9 a.m. Pacific only on Finding Mastery. All right. Thank you so much for diving into another episode of Finding Mastery with us. Our team loves creating this podcast and sharing these conversations with you. We really appreciate you being part of this community. And if you're enjoying the show, the easiest no-cost way to support is to hit the subscribe or follow button wherever you're listening. Also, if you haven't already, please consider dropping us a review on Apple or Spotify. We are incredibly grateful for the support and feedback. If you're looking for even more insights, we have a newsletter we send out every Wednesday.

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1:25:07Dr. Michael Gervais:So join our community, share your favorite episode with a friend, and let us know how we can continue to show up for you. Lastly, as a quick reminder, information in this podcast and from any material on the Finding Mastery website and social channels is for information purposes only. If you're looking for meaningful support, which we all need, one of the best things you can do is to talk to a licensed professional. So seek assistance from your health care providers. Again, a sincere thank you for listening. Until next episode, be well, think well, keep exploring.