Welcome to the Goldring Center for Culinary Medicine ...Culinary+Medicine... · Welcome to the Goldring Center for Culinary Medicine module on optimizing neurocognition through nutrition.
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Welcome to the Goldring Center for Culinary Medicine module on
optimizing neurocognition through nutrition.
1
Diets high in saturated fat and refined carbohydrates can disrupt brain
function and may have a causal link to the development of
neurodegenerative conditions but human research data is still at an
early stage.
Also note: Dietary patterns that rely on refined carbohydrates and fatty
foods are also missing nutrients found balanced wholesome diets.
Deficiencies, both clinical and subclinical) of certain missing nutrients
(vitamins D, E, B6, folate, and minerals iodine, iron, magnesium) also
affect cognition relating to neurodegenerative conditions and pediatric
neurological development.
2
The standard American dietis characterized by a diet high in saturated fats and refined carbohydrates and low in complex carbohydrates, fiber, fruits and vegetables.
This shift in the American diet can be attributed to increased availability and affordability of highly processed foods following the agricultural and industrial revolution.
3
Increased consumption of processed and packaged foods that are high
in simple carbohydrates and, until recently, trans-fats is the result of a
dramatic reduction in the cost of manufactured sugars and fats vs. farm
grown whole foods like fruits and vegetables.
The prevalence of fast food and convenience stores has normalized the
consumption of calorie dense, nutrient poor foods in the mainstream
American culture.
Coupled with increasing demand for convenience and a consumerism
culture driven by increased screen time and immediate gratification, the
Western diet has become synonymous with mindless eating, eating on
the go without attention to portion control and without emphasis on a
healthy, active lifestyle.
4
There is a discrepancy between how and what Americans eat and the
diet recommended by health agencies like the American Heart
Association and the American Diabetes Association.
MyPlate was introduced in 2011 by The Center for Nutrition Policy and
Promotion (CNPP), an organization established by the U.S. Department
of Agriculture in 1994 to improve the nutrition and well-being of
Americans.
MyPlate replaced the food pyramid and is a simple reminder to include
more fruits and vegetables on our plates at mealtime.
The widely researched Mediterranean style diet recommended for
cholesterol reduction in patients seeking to prevent or improve
cardiovascular health is high in fruits and vegetables, legumes and fish,
and heart healthy polyunsaturated fats like those found in olive oil.
5
The standard American diet is a major cause of morbidity and mortality due to
increased incidence of cardiovascular disease, hypertension, type 2 diabetes,
osteoporosis, and some types of cancers.
These factors along with physical inactivity, increased TV and screen time are
contributing to the obesity epidemic in America.
6
Obesity, metabolic syndrome, and diabetes are all examples of
dysregulated glucose states.
Chronic hyperglycemia and hyperinsulinemia induce a pro-inflammatory
state in the body which disrupts normal biochemical processes.
This stressed state stimulates an overproduction of reactive oxygen
species leading to oxidative stress.
7
The hippocampus is responsible for long-term memory and spatial
navigation and these defensive stress responses can cause alterations
in normal signal transduction in the brain which leads to decreased
hippocampal volume and structure.
8
The impairment associated with chronic diabetes extends beyond
neurocognitive decline to increased risk of Alzheimer’s Disease.
Chronic hyperinsulinemia has been associated with decreased amyloid
beta protein clearance and tau hyperphosphorylation – both pathologic
features of Alzheimer’s Disease.
9
Insulin degrading enzyme is responsible for clearing amyloid beta
proteins and it appears that the excess insulin prevents insulin
degrading enzymes from adequately clearing amyloid beta proteins.
10
The accumulation of A-beta proteins and tau hyperphosphorylated
proteins are linked to accelerated brain aging as manifested in
microangiopathy detected by MRI as white matter high intensity lesions.
These white matter hyperintensity lesions and other structural changes
have been found to occur at higher rates in diabetic vs. non-diabetic
populations.
11
A recent systematic review of the literature showed that poor glucose
control as evidenced by hyperglycemia, high hemoglobin A1c levels and
wide glucose fluctuations are negatively associated with cognitive
abilities in Type 2 diabetics without dementia.
12
We have seen that a diet high in refined carbohydrates contributes to
obesity and type 2 diabetes.
People with type 2 diabetes are one and a half times more likely to
experience complications of dementia, subtle cognitive impairments and
accelerated cognitive decline as compared to non-diabetics.
13
Glucose and insulin are hypothesized to directly affect brain structure
and function.
Hyperglycemia can lead to the accumulation of toxic metabolites and
the depletion of essential metabolic cofactors.
This accelerates the rate of oxidative stress leading to neuronal
dysfunction and apoptosis.
Abnormalities in insulin signaling in diabetics may alter synaptic
plasticity. Defective insulin states may interfere with the metabolism of
amyloid beta and tau proteins that accumulate in excess in Alzheimer’s
Disease.
14
Choosing nutrient dense carbohydrates like brown rice, oatmeal, beans,
fruits, and green leafy vegetables not only supplies the body with
healthy carbohydrates but also vitamins and minerals, fiber and protein
that are found naturally within these sources of whole foods.
15
Saturated fats also play a role in cognition.
Diets high in saturated fats have been linked to impairments in cognitive
functions, specifically functions involving memory, speed and flexibility
in both the short term and the long term.
In one study men were given either a 17% fat diet or 74% fat diet.
After 7 days, those consuming the high fat diet had significantly
decreased attention scores.
In another study, high saturated fat intake has been linked to decline in
memory, processing speed, and attention measures over a six year
period.
Limitations: limited number of available observational studies, no
intervention, all studies assessed dietary intake by food frequency
questionnaires
16
General problems with studies of elderly people: attrition is common,
individuals with cognitive problems may be most likely to be lost to follow-up.
The current widespread use of statins complicates efforts to isolate the effects
of diet on cognitive function. (If saturated or trans fats influence cognition
because of their effect on cholesterol metabolism, the use of cholesterol-
lowering drugs would be expected to mask that effect.)
16
Numerous studies have linked the benefits of certain foods to
decreased or reduced signs of dementia in elderly individuals.
Omega 3 fatty acid supplementation was found to slow cognitive and
functional decline over a 12 month period in subjects with Alzheimer’s
Disease compared to placebo.
Antioxidants found in berry fruits and walnuts have been linked to
reduced levels of oxidative stress and improved cognitive functioning in
adults who demonstrated high dietary intakes of these foods.
We will revisit the benefits of omega 3’s and antioxidants throughout the
remainder of this module.
17
Curcumin, an Indian spice, has been associated with lower rates of
inflammation and oxidative stress in in vitro and in vivo studies.
Although current studies have not found it to reverse symptoms of
dementia in Alzheimer’s Disease patients (possibly due to its poor
bioavailability), it is currently being studied for dosage effects on
neuroprotection.
18
Iron supplementation also appears to improve memory and intellectual
ability in participants between 12 and 55 years of age, regardless of
whether the participant was initially iron-insufficient or iron-deficient.
19
ADHD is one of the most commonly diagnosed childhood mental health
disorders.
It is characterized by persistent patterns of impulsivity, hyperactivity
and/or inattention in two or more settings, significantly interfering with
social, work, and school function.
It appears that the incidence of ADHD has increased dramatically over
the last decade.
Whether that is a matter of increased awareness or increased
symptomatology remains debatable. Many studies have linked ADHD
symptoms with poor dietary intake.
20
These CDC prevalence maps of ADHD (on the left) and obesity rates by
state (on the right) highlight an interesting parallel between the most
obese states (Louisiana, Arkansas, Mississippi, Alabama) and those
with the highest percentages of children ever diagnosed with ADHD.
While this is an interesting correlation there is not yet evidence for
causation but we do have indirect research that creates a case for
concern.
21
Diet high in omega 6 fatty acids, low in omega 3’s, which is often
associated with a decreased intake of nutrient dense foods like fish,
fruits, veggies, legumes, & whole-grains.
24
Certain micronutrient deficiencies – specifically iron and zinc have been
shown to be more common in kids with ADHD symptoms.
25
Stevens et al.’s compilation of 35 years’ worth of studies on dietary
sensitivities and associated ADHD symptoms in children and
adolescents highlights examples of randomized controlled trials in which
children and adolescents were fed elimination diets without artificial
food coloring (AFCs) and then given diets with AFCs added back.
The studies found a positive correlation between ingestion of AFCs in
children and worsening symptoms of ADHD in those already diagnosed
with moderate to severe ADHD. Increased inattentiveness and
hyperactivity was also observed in children without ADHD enrolled in
the studies.
Food additives have been linked to adverse health effects: Studies in
humans have shown an increase in atopic reactions, hyperactivity &
inattentive behaviors, sleep disturbances & decreased sleep latency.
26
AFCs are usually listed as a color followed by a number, such as Red
#40. AFCs are found in processed foods that are often nutrient-poor
and hypercaloric.
Counsel patients to avoid fruit punches and colored sports drinks and
use caution with children’s cereals. Boxed dinners, like Macaroni and
Cheese, and prepackaged desserts and yogurts may also affect
sensitive children.
Patients who want to be very proactive can be told to look for the above
AFCs on ingredient lists.
When telling a patient to avoid certain foods, always try to suggest a
healthy alternative.
27
In a randomized, double-blinded, placebo-controlled, crossover trial
examining the effects of AFCs or sodium benzoate preservative (or
both) in the diet of 3 year old and 8 or 9 year old children from the
general population, a statistically significant increase in hyperactivity
symptoms as measured on a global hyperactivity assessment scale
was associated with the kids who consumed greater than 85% of the
premixed drinks over a 7 week period.
28
Parents may feel overwhelmed by the idea of eliminating all AFCs from
their diets.
No one wants to take away all their child’s favorite foods and no one
has time to home cook every single meal or snack.
Let interested patients know that there are good options available in
stores. Sometimes, simply switching brands is all that’s necessary.
Fortunately, the brands without AFCs are often healthier in other ways
as well.
Reading labels is always the best way to be sure that the foods you
choose do not have artificial colors.
Look out for these Artificial Food Colorings such as Blue #1, Red #3, or
Orange B, which are listed under ingredients.
29
Using less processed breads, cereals, and yogurt with fresh fruits, vegetables,
and healthy fats creates wholesome, AFC-free snacks.
29
Remind parents that fruits and vegetables are healthier snacks, and
that even AFC-free treats must be given in moderation.
These recipes use fresh ingredients and take only a few minutes to
prepare.
30
Studies have demonstrated low serum iron and ferritin levels in children
and adolescents diagnosed with ADHD.
Lower serum iron levels have also been found in patients with anxiety,
depression, and schizophrenia.
Iron is an essential mineral involved in formation of hemoglobin and is
also a major component of myoglobin. Both are crucial for oxygen
transport.
It is needed for cell growth and healthy immune function. In the brain, it
is an essential component of brain myelination, energy metabolism and
neurotransmitter synthesis and metabolism, most notably dopamine,
serotonin, GABA, and glutamate.
32
In children with low serum ferritin (below 30 micrograms per deciliter),
iron supplementation of 80 mg/day has been shown to reduce ADHD
symptoms.
Iron therapy was well tolerated (no significant side effects other than
mild GI upset) and effectiveness was comparable to stimulants.
ADHD symptoms improved over an 8 week period measured with
simultaneously raised serum ferritin levels.
33
https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/#en5
Institute of Medicine. Food and Nutrition Board. Dietary Reference
Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper,
Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and
Zinc : a Report of the Panel on Micronutrients. Washington, DC:
National Academy Press; 2001.
34
Foods made from enriched flour (bread, pasta, pancakes, etc.) add a
significant amount of iron over the course of a day
Iron is found in other vegetables besides spinach (e.g. broccoli, chard,
collards, asparagus, Jerusalem artichokes, baked potato with skin, snap
peas, pumpkin, mushrooms, tomato products, whole grains)
Meal replacement drinks (Instant Breakfast, etc.) have a significant
amount of iron
Vitamin C enhances non-heme iron absorption
The iron from supplements is less well absorbed than that from food,
however supplements are needed in cases of actual deficiency.
35
Zinc supplementation has also been studied in treating and alleviating
symptoms of ADHD.
Zinc is an important cofactor for neurotransmitter, prostaglandin and
melatonin metabolism.
It indirectly affects dopamine metabolism and contributes to the
structure and function of the brain.
Zinc supplementation either as an adjunct to stimulant medication or as
monotherapy have provided conflicting evidence of efficacy.
36
In one study 10mg of zinc sulfate per day (compared with placebo) as
an adjunct to methylphenidate (0.3 mg/kg/day) yielded no significant
differences between zinc supplementation and placebo on attention and
focus.
There was however an observed trend toward improved attention
although not statistically significant.
15-30mg/ day of zinc glycinate monotherapy failed to demonstrate
benefit in ADHD symptoms over an 8 week period.
In the 30mg group, however, children given d-amphetamine needed
37% less medication to achieve the same clinical effects.
More studies are needed at a higher dose of zinc supplementation to
determine efficacy.
37
Zinc does not merit strong recommendations for supplementation in
ADHD, but it has been shown to be useful at 30mg/day as an adjunct
for reducing stimulant medication.
Higher zinc dosing may be helpful but has not been proven efficacious
in controlled studies.
Healthy dietary sources of zinc include: oysters, red meat such as lean
beef and lamb, poultry, spinach, nuts – in particular flax seeds,
almonds, sesame seeds, pumpkin seeds, and legumes like lentils and
garbanzo beans.
38
Maternal and early-life nutrition is emerging as a factor in mental health
outcomes in children.
Research has shown that 2 or more servings of fish per week in
pregnant women led to a decreased association with inattentive and
hyperactivity scores of children followed from pregnancy to 8 years of
age.
A major concern in pregnancy is exposure to mercury. It was found that
mercury levels at <1μg had no negative impact on fetal neurocognitive
development.
Interestingly, mercury levels >1μg (consistent with the consumption of
2+ servings of fish/week) was associated with decreased hyperactivity
and impulsivity symptoms.
This positive association was maintained when accounting for the
positive benefits of omega-3 fatty acids for babies in the moms
consuming >2 servings of fish per week.
39
There are 2 essential fatty acids we must obtain from our diet because
our bodies cannot synthesize them:
1. alpha-linolenic acid: an omega-3 fatty acid and
2. linoleic acid: an omega-6 fatty acid
• Omega-3’s play an essential role in the function of the nervous
system including: cognitive development, neuroplasticity,
synaptogenesis, and synaptic transmission.
• Omega-6’s play a role in pro-apoptotic events and are therefore pro-
inflammatory.
40
The standard American diet is too high in omega 6 fatty acids which
have a pro-inflammatory effect.
The standard American diet is estimated to contain 14 to 25 times more
omega-6 fatty acids than omega-3 fatty acids but the recommended
ratio is closer to 1:1.
41
There are two types of omega-3 fatty acids: EPA (eicosapentaenoic
acid) and DHA (docosahexaenoic acid).
Supplementation with these omega-3’s is hypothesized to be beneficial
for ADHD, depression, bipolar disorder, and has also shown beneficial
effects for mild cognitive impairment.
Lower plasma levels of essential fatty acids have been associated with
ADHD and behavioral problems.
42
Fish contain a high concentration of omega-3 fatty acids.
Areas with higher fish consumption have been associated with a lower
prevalence of mood disorders.
Observational studies also show a positive correlation between fish
intake and DHA plasma concentrations in healthy older adults and
cognitive health.
43
Your patients can decrease omega-6’s by limiting vegetable oil
consumption such as corn, sunflower and soybean oils, which are
common in processed foods.
Eating a diet high in omega-3’s is beneficial for both short term and long
term cognitive health.
Increase omega-3 intake by consuming fatty fish such as salmon, tuna,
and trout. Flax seed is also a good source of omega-3’s. Fish oil
provides two omega-3 fatty acids, DHA and EPA, whereas flaxseeds
are rich in another omega-3 fat, ALA. EPA and DHA are readily
available from fish, and can also be synthesized by humans from ALA.
Humans, however, can obtain ALA only through their diets. Plant-based
sources of ALA are generally poor sources of the desired omega 3 fatty
acids, EPA and DHA.
Supplementation with fish oil is also recommended, although the
recommended dosage is not exact and ranges from 300 mg – 2 g per
day.
44
Not only does a mother’s diet have an impact on her fetus’
neurocognitive development, so too does diet in early childhood
development.
Poor diet associated with high fat, sugar and processed food content in
early childhood is associated with small reductions in IQ in later
childhood.
A healthy diet associated with higher intake of nutrient-rich foods is
associated with small increases in IQ.
In adolescents, those with a poor diet saw mental health deterioration
over time.
45
A case-control study of 404 children between 4 and 11 years old were
selected by cluster sampling in southern Iran in 2012.
A questionnaire screening for maternal and pregnancy related risk
factors for ADHD found that the prevalence of ADHD among formula-
fed patients was significantly higher than that in breast-fed children.
This finding is consistent with results of other studies. It is likely that
fatty acid compositions of human breast milk such as docosahexaenoic
acid and arachidonic acid have an important and beneficial role in brain
growth and development during the neonatal and infancy stages.
46
Choosing smart fats is essential for optimizing neurocognition.
Recommend to your patients limiting the intake of omega 6 rich foods
by decreasing consumption of packaged, processed foods like chips
and fast foods.
Instead, recommend healthier fat alternatives like fish and aim for 3
servings per week.
If that is not feasible, supplementation with fish oils up to 1g/day has
been shown to have neuroprotective benefits.
Thankfully, the FDA has banned trans fats effective in 2018. This is
expected to save $140 billion over 20 years in health care costs
https://www.federalregister.gov/articles/2015/06/17/2015-14883/final-
determination-regarding-partially-hydrogenated-oils
47
There have been many studies supporting a diet high in fruits and
vegetables for improved mental health.
The brain is more susceptible to oxidative stress than any other organ.
Oxidative stress along with inflammation plays a role in aging and age-
related neurodegenerative disorders.
48
Brain-derived neurotrophic factor (BDNF) plays an important role in
synaptic plasticity, neuronal differentiation and regeneration.
Positive associations have been reported between omega-3 fatty acid
and flavonol intake and BDNF production.
Conversely, diets rich in saturated fatty acids or total fat have been
related to lower brain BDNF levels, lower neuronal plasticity, and poorer
cognitive ability.
49
Berry fruits have strong antioxidant and anti-inflammatory benefits.
Blueberries contain anthocyanins, a flavanoid polyphenol which has
antioxidant and anti-inflammatory properties.
Anthocyanins have been associated with increased neuronal signaling
in brain centers, mediating memory and improved glucose disposal.
50
In a small scale study of elderly individuals (mean age 76) with early
memory decline as defined by forgetfulness and prospective memory
lapses, blueberry juice supplementation for 12 weeks was shown to
significantly improve memory function with the added benefit of
reducing depressive symptoms.
51
In a large scale study of participants older than 70, higher consumption
of strawberries and blueberries was associated with a slower
progression of cognitive decline in older women.
52
Tree nuts are a good source of essential nutrients and contain a variety
of phytochemicals that decrease inflammation and reduce oxidative
stress.
Walnuts in particular contain a number of potentially neuroprotective
compounds like vitamin E, folate, melatonin, several antioxidative
polyphenols and significant amounts of omega-3 fatty acid.
A randomized cross-over trial of over 200 healthy male and female
college-age students showed increased inferential verbal reasoning
after an eight week supplementation of walnuts.
53
Walnuts have also been shown to have the highest level of antioxidant
capacity as compared to other nuts.
The PREDIMED-NAVARRA trial showed that when nuts were added to
a Mediterranean diet, there was a 78% lower risk of having low levels of
plasma brain derived neurotrophic factor.
54
Throughout this module we have seen that inflammation plays a
negative role on both the body and the brain.
Curcumin is a polyphenolic compound traditionally used in Indian
cooking.
It is the yellow pigment present in turmeric (a curry powder) that has
been shown to regulate the expression of inflammatory enzymes,
cytokines, adhesion molecules, and cell survival proteins. It shows
promising potential as a neuroprotective agent.
55
There is substantial in-vitro data indicating that curcumin has
antioxidant, anti-inflammatory and anti-amyloid activity.
Studies in animal models of Alzheimer’s Disease indicate a direct effect
of curcumin in decreasing the amyloid pathology in Alzheimer’s.
Several clinical trials are currently underway to determine the neuro-
protective potential of curcumin, specifically in Alzheimer’s Disease
patients.
56
We need to change what we eat or include more healthy foods in our
diet, such as:
Being mindful of eating whole, not processed foods like vegetables,
fruits, legumes, nuts, and complex carbohydrates.
This ensures that we get healthy fuel for our bodies and minds with
complex carbs like oatmeal and brown rice, proteins, and smart fats like
omega-3’s.
Eating whole foods also helps us obtain micronutrients and antioxidants
from our diet to optimize our brain function and slow neurocognitive
decline.
57
We need to change how we eat and how much we eat.
The obesity epidemic is continuing to rise and it is negatively impacting
our society across all ages. Obesity is intricately linked to Type 2
Diabetes.
Chronic hyperglycemic states have been linked with poorer cognition
and mood as we have seen in this module.
We have also seen a parallel between the obesity epidemic and the
prevalence of ADHD in children and adolescents.
58
In conclusion, here are some simple changes we can make in our own
diets and recommendations we can make for our patients:
1. When possible, choose whole foods.
2. Aim for a “rainbow colored” plate with ample fruits & vegetables.
3. Avoid excessive fat intake, particularly omega 6 fatty acids (for their
pro-inflammatory effects), trans fats, & food additives when possible.
They have all been shown to be bad for both short term and long term
neurocognitive health.
4. Fats are not created equal. No all fats are bad. Omega-3 fatty acids
are good sources of fat with anti-inflammatory effects. They can be
found in fatty fish like salmon, tuna, and trout, and in walnuts and olive
oil. Omega 3’s boost cognitive function and improve mood! Aim for at
least 3 servings a week.
5. Stock up on berries when they are in season or buy frozen berries for
59
their antioxidant effects.
6. Be mindful of how much you are eating and exercise! The buddy system
helps so recruit someone to break bread with or to exercise with.
59
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