Wednesday, 18 February 2015

Exercise Guidelines in Prevention of Alzheimer's Disease

A series of seven guidelines for the prevention of Alzheimer's disease (AD) has recently been published.

These guidelines resulted from a conference of experts in nutrition and the brain.

The guidelines included a recommendation for 40 minutes of aerobic exercise three times a week.

Support for this exercise recommendation by experts was linked to 2 areas of research:
  • Observational studies show lower rates of AD in regular exercise groups compared to sedentary groups
  • A single clinical trial found reduced brain atrophy and improved memory following an intervention where elderly adults were randomized to a 40 minute three times a week protocol

I recently summarized another manuscript looking at the association of exercise and brain imaging in those with the APOE genotype linked to Alzheimer's disease. This study was published following the expert conference manuscript.

There certainly need to be more randomized clinical trials of exercise therapy in groups at high risk for cognitive decline and Alzheimer's disease.

Here is the list of all 7 prevention recommendations from the manuscript. Readers can access the free full-text manuscript by clicking on the PMID link below.

Prevention Recommendations for Alzheimer's Disease
  1. Minimize dietary saturated and trans fats
  2. Increase intake of vegetables, fruits, legumes and grains
  3. Daily vitamin E intake from foods of 15 mg
  4. Daily vitamin B12 in diet or supplement with blood B12 level monitoring
  5. Daily multivitamins not recommended but if used avoid those with iron and copper
  6. Aluminum link to AD is controversial but avoid antacids and baking soda that contains aluminum
  7. Aerobic exercise of 40 minutes at least 3 times per week

I have previously summarized 10 prevention strategies in AD that include non-nutrition based features that can be found here.

Photo of butterfly is from the author's files.

Follow the author on Twitter @WRY999

Barnard ND, Bush AI, Ceccarelli A, Cooper J, de Jager CA, Erickson KI, Fraser G, Kesler S, Levin SM, Lucey B, Morris MC, & Squitti R (2014). Dietary and lifestyle guidelines for the prevention of Alzheimer's disease. Neurobiology of aging, 35 Suppl 2 PMID: 24913896

Monday, 16 February 2015

Experiencing the Winter Blues? How to Fight Seasonal Affective Disorder

Paula S. Barry, MD, a primary care physician at Penn Family and Internal Medicine Longwood, explains what seasonal affective disorder is and how it can be treated.

Seasonal Affective DisorderAs the hours of daylight grows shorter and fall weather moves in, for some, the “winter blues” are beginning to set in.

The “winter blues”, also known as seasonal affective disorder (SAD), is defined by major depression that recurs with a seasonal onset as well as a seasonal remission. Often the seasonal onset occurs in the fall and remission follows in the spring. It can also have an onset in the spring, but this type is less common.

SAD is quite common, with some studies showing that up to 7% of the population is affected with another 10-20% affected with a milder form of SAD, called subsyndromal SAD. More women than men report being affected; this is thought to reflect the higher proportion of women who are affected with depression in general.

The fall onset of SAD is thought to be due to decreased daylight which then triggers depression in those that are susceptible. Some researchers feel that it is due to a change in circadian rhythm and of levels of serotonin and melatonin in the brain. A genetic link likely plays a role, just as in major depression and other mood disorders.

Primary features of fall onset SAD include: irritability (this often contributes to an increase in personal relationship stress), increased need for sleep, increased appetite (especially for carbohydrates which often results in weight gain), and a subjective “heavy feeling” and fatigue. These symptoms must occur daily for at least two consecutive weeks and have the typical seasonal pattern to meet official diagnosis.

The treatment of SAD differs slightly from the treatment of major depression in that light therapy, use of a specialized light box that provides 2,500-10,000 lux of light for 15-30 minutes daily, is often successful in decreasing symptoms. Many individuals report a change in symptoms after just a few days of daily light box use.

Fight the winter bluesOther treatments that have been found to work well against SAD include the use of anti-depressants, such as the selective serotonin reuptake inhibitors (SSRIs) and cognitive behavior therapy, known as CBT, which is a form of psychotherapy. There does seem to be an overall improvement of symptoms as well as prevention of recurrence when CBT is combined with light therapy and/or antidepressants.

If you believe that you, or someone you know has SAD, please discuss your concerns with your physician. Other medical problems can cause similar symptoms and it is important to be fully evaluated. If you do suffer with SAD, know that the therapies mentioned above are very helpful in improving symptoms – there is no need to wait until spring to obtain help.

Monday, 9 February 2015

Exercise and the Brain: Research Links

I am posting links to some of the most recent research related to exercise effects on the brain.

These come from a process of selecting posts to examine in more detail this month.

Clicking on the links will take you to the PubMed abstract. Most of the abstracts also have free full text links.

Enhancing brain activity through multidisciplinary interventions in the elderly

This Chinese study examined the effects of cognitive training, Tai Chi exercise and counseling on a group of 17 elderly individuals compared to controls. The study examined brain low frequency fluctuations and found improved intrinsic activity in the intervention group for the middle frontal gyrus, superior frontal gyrus and anterior cerebellum. The study noted the value of a group intervention for increasing social support ratings.

Single episode of exercise changes resting state brain networks

This study examined the effects of a 20 minutes of moderate intensity aerobic exercise on resting state connectivity of the brain using functional MRI. Exercise produced significant changes from baseline in several brain regions and connections suggesting a valid model for testing the brain effects of acute exercise.

Dietary and lifestyle guidelines for prevention of Alzheimer's disease

This manuscript summarizes results of an expert consensus guideline on prevention of Alzheimer's disease. The experts recommended the equivalent of 40 minutes of brisk walking three times per week.

Physical activity, inflammation, and volume of the aging brain

This longitudinal study in older adults measured self-reported physical activity and a marker of inflammation known as tumor necrosis factor alpha (TNF-alpha). Greater levels of physical activity and lower levels of TNF-alpha (lower inflammation) were correlated with less brain atrophy. 

The effects of chronic exercise on attentional networks

This study examined the correlation between physical activity levels and performance on a task of attention in healthy young adults. The authors found support for exercise as a potential therapeutic modality to improve attention in health young adults.

Photo of sunset at South Padre Island, TX from the author's files.

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Friday, 6 February 2015

It’s Time to Get a Better Night’s Sleep

Did you know that how you feel during your waking hours depends greatly on how well you sleep? Increased energy and productivity along with an improved immune system are direct results of enjoying a sound slumber each night.

Sleep Better
John Molitoris, MD
Now, the only problem is how to get that better night’s sleep. Between hectic schedules, pressures at work and family responsibilities, it can be extremely difficult sometimes to drift off to dreamland.

"Historic views of insomnia held that sleep problems were a result of distinct medical pathologies, says John Molitoris, MD, a primary care physician at Penn Family and Internal Medicine Cherry Hill. "Current views are very different and hold that most problems with sleep can be remedied with some simple behavioral changes."

Although each person needs to experiment to figure out what works best for them, here are some tips to hopefully help you improve your sleep so that you can be more productive and full of energy all day long.

Keep a Regular Schedule

One of the most important things you can do to achieve good sleep is to stick to a regular sleep schedule. If you are able to go to bed and wake up at the same time each day, you’ll feel more refreshed and energized.

The best way to begin doing this is to record the time each night that you begin to feel tired. Once you see a pattern, try to go to sleep around that time. Even on weekends and holidays, attempt to stick to that time.

Sleep BetterThis also goes for getting up in the morning. If you sleep in when you can, you likely won’t be tired at your normal time, thus throwing off your sleep schedule. If you are getting enough sleep each night, you should eventually begin to wake up without an alarm. By being consistent, you are reinforcing your body's sleep-wake cycle.

If you are unable to fall asleep within 15 minutes of lying down, get up and do something that will relax you. Oftentimes, if you lay in bed agonizing over not being able to fall asleep, you might find it even harder to nod off. In addition, there are other sleep techniques that can help calm restless minds like counting backwards from 58 while linking your breathing to the numbers.

Be Smart About Napping

How many times have you plopped onto the couch only to doze off for a bit? Sometimes those little power naps can feel amazing. And, if you do need to make up for a few lost hours, a daytime nap is much better than sleeping late as it tends to have less of an impact on your sleeping schedule.

You do need to be careful though. If you sleep for too long or too close to your normal bed time, you are likely going to struggle to fall asleep at your usual time. If you are going to take a nap, it’s always better to do it earlier in the afternoon and to try to keep it to less than an hour, as a general rule of thumb.

Create a Relaxing Routine

Not only is it important to go to bed at a similar time each night, but it’s also recommended that you follow a similar routine before doing so. Find things that will make you feel comfortable and calm, and try to consistently do them. Perhaps it’s taking a warm bath or shower, reading a book or listening to soothing music. These types of activities can help you relax and effectively transition from being fully awake to becoming drowsy.

Also, attempt to make your sleeping situation as comfortable as possible. On top of having a bed that allows you enough room to stretch and turn without discomfort, try to keep noises at a minimum and your room at a cool temperature. If needed, consider trying room-darkening shades, earplugs, a fan or other white noise devices to create an environment that best suits your needs.

Exercise and Eat Right

By exercising as little as 20-30 minutes per day, you can help yourself sleep better at night. Simply being active – taking a walk, riding your bike or going to the gym – is going to help you fall asleep faster and lead to deeper sleep. If you feel that working out too close to bed acts as a stimulant, try scheduling your exercises in the morning or early afternoon. Take the time to figure out what workout schedule is best for you, as it will pay off in dreamland.

How you eat also has a major impact on how well you sleep. Be sure not to go to sleep feeling hungry or overstuffed because any discomfort may keep you up. Also, try to avoid eating or drinking anything too close to when you plan on going to sleep to avoid midnight trips to the bathroom. If you are hungry before bed, try something containing carbohydrates – a small bowl of cereal, a banana or a granola bar for example – as it may help to calm you down.

Know When to See a Doctor

Nearly everyone has the occasional sleepless nights. Sometimes, no matter what you do you can’t seem to clear your mind of falling asleep. If you encounter more than a few sleepless nights, have tried the tips above and are still struggling with sleep problems, it may be time to see a doctor who can help you get the better sleep you deserve.


The Penn Sleep Centers

The Penn Sleep Centers provide state-of-the-art diagnostic services and treatment for the full range of sleep disorders. The Centers are staffed by specially trained sleep physicians based in the departments of medicine, neurology, psychiatry, otorhinolaryngology – head and neck surgery, and oral and maxillofacial surgery. By gathering our physicians together from different departments, we are able to maximize the experience and knowledge of our staff. Depending on what factors are causing your sleep problems, we have experts on-hand to focus on your specific needs. Once the cause of your sleep problem is identified, this same team can develop a specific treatment program.


Wednesday, 4 February 2015

Fight the Winter Workout Woes

Lori M. Noble, MD, a primary care physician at Spruce Internal Medicine, located at the new Penn Medicine Washington Square building, discusses ways to keep active during the colder months.
Lori M. Noble, MD
Lori M. Noble, MD

When it’s cold and blustery outside, your warm and fluffy slippers have a tendency to look much more enticing than your running shoes. Before you know it, one day off turns into two and, eventually, that short exercise break has turned into an outright sabbatical.

This doesn’t have to be the case, though. Some simple tips to help stay active this winter:
  1. Switch it up: Who says you have to exercise the same way throughout the year? If you enjoy jogging or biking, there are great indoor alternatives to these activities.

    Try an exercise DVD series, sign up for an up-tempo Zoomba class, or try honing your swimming skills at the local YMCA. If you want to continue biking, get a stand that allows you to turn your road bike into a stationary one.

  2. Squeeze it in when and where you can: You can burn calories by making small changes to your daily routine. Did you know that an individual weighing 200 pounds can burn up to 12 calories an hour simply by choosing to stand rather than sit? That adds up to about 100 calories in an 8-hour workday, which is about the same as running a mile!

    And we often forget that there is a built-in gym in every office building - the stairs. Take them whenever you need to go between floors. Take it a “step” farther and carve out part of your lunch break to walk or run a few flights.

  3. Dress the part: If you know you won’t be able to get past the distractions at home or work to make exercising indoors possible, make exercising outside easier.

    You’ll need breathable, but fitted attire to keep warm and help reduce sweat. Because the body is mainly focused on warming your core, a hat, gloves, and warm socks are critical to feeling comfortable when the cold really hits.

  4. There’s power in numbers: When motivation is lacking, nothing is more powerful than the support of a friend. Try organizing a neighborhood walking club, or reach out to that person with whom you just never have enough time to catch up. Time flies when you’re having fun, so that 30-minute jog will inevitably feel much shorter in the company of friends.

  5. Track your progress: Setting goals is a great way to keep yourself motivated. Jot down your exercise plan for the month while keeping in mind the progress you hope to make. Keep the goals attainable, like increasing your workout by a few minutes each day. It's also nice to have a little reward planned once you've met your goal, like buying that new pair of sneakers you've had your eye on.
This winter, don’t let workout woes slow you down. Keep it interesting, and you’ll find it easier to keep moving.

Exercise in the Elderly: BDNF and Executive Function

Exercise promotes cognitive function in children, adults and elderly individuals.

The mechanism for this effect is unclear. Some of the effect may be due to a general improvement in vascular function and health.

Another potential mechanism is via increased neuroplasticity mediated by neurotrophic factors.

Brain-derived neurotrophic factor (BNDF) is a known contributor to brain neuroplasticity. Levels of BNDF can be determined with serum assays.

RL Leckie and colleagues recently found support for BNDF mediation in an exercise in an interventional study with an elderly population.

The key elements of the design for their study included the following elements.

  • Participants: Adults between the ages of 55 and 80
  • Exercise intervention: Daily supervised walking sessions beginning with 10 minutes increasing to 40 minutes. Control intervention included stretching and toning sessions lead by an exercise professional
  • Cognitive assessment: Task-switching paradigm commonly used to assess executive function
  • Blood assay: Serum brain-derived neurotropic factor (BNDF) levels and BDNF genotype
  • Statistical analysis: Multivariate linear regression analysis with key dependent variable being cognitive performance after one year of intervention

The main findings from the study included:

  • Serum BDNF increased in the exercise group
  • This effect was limited to primarily the participants over 70 years of age
  • Enhanced executive function following exercise was demonstrated in those over 70
  • BDNF level increases in the over 70 age group correlated with cognitive performance

The authors note their does not mean exercise is not important for cognitive function in the younger age group (55-70 years of age). Their study only highlights the age interaction with BDNF in moderating a single executive function task.

BDNF levels decrease with age and the level of decrease in BDNF correlates with reduction in volume of the brain hippocampus. The hippocampus plays a key role in memory function and in decline in memory associated with aging.

It is quite possible that regular exercise after age 70 reduces the age related effect on cognition moderated by BDNF.

Readers with more interest in this study can access the free full text manuscript by clicking on the PMID link in the citation below.

Photo of ring kingfisher is from the author's files.

Follow the author on Twitter WRY999

Leckie RL, Oberlin LE, Voss MW, Prakash RS, Szabo-Reed A, Chaddock-Heyman L, Phillips SM, Gothe NP, Mailey E, Vieira-Potter VJ, Martin SA, Pence BD, Lin M, Parasuraman R, Greenwood PM, Fryxell KJ, Woods JA, McAuley E, Kramer AF, & Erickson KI (2014). BDNF mediates improvements in executive function following a 1-year exercise intervention. Frontiers in human neuroscience, 8 PMID: 25566019

Tuesday, 3 February 2015

Keep Your Family Healthy This Winter

Jeffrey Millstein, MD, a primary care physician at Penn Internal Medicine Woodbury Heights, offers suggestions on how to keep your family healthy for the remainder of the winter.

Dr. Millstein
Jeffrey Millstein, MD
During the winter, viruses and colds within your household can be as common as snowflakes outside.

The harsh, cold months present many unique health challenges, but a little preparation can go a long way towards preventing winter illness and injury.

By now, you have surely been inundated with information about colds and flu, so we won’t go into too much detail about those. However, there are a number of other winter health issues which do not receive as much attention, but are still important to discuss. Here are just a few things to remember:

Get Your Daily Dose of Vitamin D

Because sunlight is a bit scarce this time of the year and cooler temperatures tend to limit outdoor activities, your family may be lacking vitamin D, which is vital to bone health. Because of this, a vitamin D supplement or multivitamin may be an option, especially if there are other risk factors for osteoporosis.

Sun exposure has also been shown to improve mood and a sense of well-being. For some, the darker winter months lead to a depressed mood, commonly known as “seasonal affective disorder”, or SAD. If this is something you or a family member may be suffering from, speak with your primary care provider about effective treatment options.

On the contrary, going to the tanning salon may be taking things a bit to the extreme. Cosmetic tanning, just like excessive and unprotected sun exposure, can markedly increase skin cancer risk.

Exercise Regularly

keep healthy this winter
For those who get most of their regular exercise through outdoor sports, that first frost can halt the normal routine and lead to decreased activity and weight gain. Try to find a winter alternative such as an indoor gym, swimming, calisthenics or even mall-walking so you don’t lose momentum.

By simply setting aside 20 minutes five or six times a week to focus on aerobic exercises, you can greatly lower sick days for you and your family members.

Scrub Up

Contrary to popular belief, the cold weather itself is not responsible for the prevalence of respiratory infections during this time of year. Spending more time indoors, in close contact with others, promotes the spread of colds and the flu.

The best protection includes frequent hand washing or use of hand sanitizer and avoiding unnecessary hand-to-face contact. When washing your hands, lather them up with soap for 20 seconds prior to rinsing to help eliminate all germs.

Sleep Well, But Consistent

Many people find it difficult to leave their comfy, warm beds this time of the year. The amount of daylight during the winter is more limited than in the other seasons, as mentioned above, impacting the body's sleep cycles and circadian rhythm. Sleeping more than normal could be harmful, though, as it can impact your appetite, alter your energy levels and lead to depression.

Although the lack of light may make your body feel tired and sluggish, it is important to try to stick to a schedule, regardless of the day.

Finally, it is important to keep up with your vaccinations. If you do become ill, your primary care provider can be your resource for helping decide what can be treated with supportive home remedies, versus symptoms that require office evaluation or medication.

Attentive prevention and health maintenance during the winter will make it much easier to return to warmer weather activities. Spring is only a few months away!

Monday, 2 February 2015

Exercise in the Prevention of Alzheimer's Disease

Growing evidence links physical activity to improved cognitive outcome in elderly individuals.

Few studies have examined effects of exercise on those at highest risk for Alzheimer's disease.

J Carson Smith and colleagues recently published a prospective study of a cohort of older adults using structural magnetic resonance imaging.

The key elements of the design of their study included the following elements:
Participants: 97 adults between the ages of 65 and 89
Physical activity level: Frequency and intensity of leisure activity was assessed using the Stanford Brief Activity Survey
Alzheimer's risk status: Assessed using APOE genotype
Brain scanning protocol: Magnetic resonance imaging of brain using a 3T scanner at baseline and 18 months later. The brain hippocampal volume was identified as a key structure involved in APOE-related atrophy and memory decline
Statistical analysis: Participants were grouped in low and high physical activity groups and those with and without high-risk APOE Alzheimer's risk

The research team identified a statistically significant interaction between high-risk Alzheimer's participant and physical activity:
"Hippocampal volume decreased 3% in the High Risk/Low PA (physical activity) group whereas the volumetric changes in the remaining three groups were negligible."
The high-risk Alzheimer's group that participated in higher levels of physical activity appeared to have significant protection against hippocampal atrophy. To reach the higher levels of physical activity in the study they had to endorse one of the following levels:
  • Brisk walking 15 minutes daily three or more days per week
  • Jogging 15 minutes daily three or more days per week
  • Swimming 15 minutes daily three or more days per week
  • Moderately difficult chores 45 minutes daily three or more days per week
  • Regular jogging, running, bicycling or swimming 30 minutes or more
  • Playing sports such as handball or tennis an hour or more 

The authors examine the potential mechanisms for physical activity to reduce hippocampal atrophy in those with the high risk APOE genotype.

They note the beneficial effect of exercise may be through effects on cholinergic function, brain lipid metabolism or reduced neuroinflammation.

If this study is replicated it is an important finding with several implications.

One implication is that it may be one of the first research findings to support routine genetic testing for APOE and Alzheimer's risk. Those identified as high risk by APOE status could be targeted for aggressive behavioral interventions to increase physical activity along with increased surveillance of cognitive function.

Readers with more interest in this research can access the free full-text manuscript by clicking on the PMID link in the citation below.

Follow the author on Twitter WRY999

Photo of roseate spoonbill at sunset is from the author's files.

Smith JC, Nielson KA, Woodard JL, Seidenberg M, Durgerian S, Hazlett KE, Figueroa CM, Kandah CC, Kay CD, Matthews MA, & Rao SM (2014). Physical activity reduces hippocampal atrophy in elders at genetic risk for Alzheimer's disease. Frontiers in aging neuroscience, 6 PMID: 24795624