Hello, hello, and welcome to today's podcast. Today we're going to be talking about brain health. It's something we talk about all the time at a high level, but we've never done a deep dive into brain health and cognition — so here we are. It's something every man and every woman needs to pay attention to, and it can strike at just about any age.
We typically talk about the onset of dementia in elderly populations, but this is a condition that starts early — in the 30s, with arguments for earlier and later. It's decades-long activity that sets up the conditions for the onset of dementia.
Dementia Is a Lifestyle Disease
Dementia has been thought of as a disease that just happens to you or is a genetic predisposition. But the truth is it's really a lifestyle metabolic disease. There are genetic predispositions to certain types, but in essence this is modifiable — that's the key. Today we'll talk about the metabolic and hormonal influences, plus the pillars of lifestyle change. We'll also talk about the difference between men and women when it comes to Alzheimer's and dementia, because it's quite interesting how it breaks down. There's still a lot of research being done, and when you look at treatments for Alzheimer's specifically, there aren't a lot of good options — so all the more importance on avoidance.
Dementia is a general umbrella term for a decline in mental ability severe enough to interfere with daily life. There are many causes and specific types, but they all fall under the same modifiable life changes a person can make to reduce their risk. We'll focus more on Alzheimer's because it's the most common cause of dementia, accounting for 60 to 80% of cases. The other big ones are vascular dementia, frontotemporal dementia, and Lewy body dementia.
Type 3 Diabetes
Alzheimer's is the dementia you're hearing referred to as "type 3 diabetes" in the media — insulin resistance and diabetes leading to Alzheimer's. The brain runs on glucose, and insulin is a very potent, inflammatory signaler. Unfortunately, a lot of people don't get fasting insulin levels drawn, and that insulin level creeps up decades before other lab signs develop — so it's a good idea to identify it early for avoidance.
We see a lot of patients with normal glucose and normal hemoglobin A1C but a normal-yet-not-optimal insulin. Once you plug those numbers into the HOMA-IR calculation, they're already struggling with insulin resistance — and these things are completely modifiable. It just needs to be known so you can take that information and change what you need to change. Since it takes decades to progress, our 40s and 50s are the prime time to be preventive.
Decades before symptoms appear, Alzheimer's involves amyloid buildup and tau tangles — a neurodegenerative finding, essentially atrophy of the brain. Early signs can be identified through bloodwork, cerebrospinal fluid, and MRI. There's also the genetic predisposition: up to 20% of people carry a gene called APOE4. The self-pay price through the lab company we work with is $159 for that test — not cheap, but available.
The APOE4-to-Alzheimer's relationship is similar to Lp(a) in cardiovascular disease. It tells you if you have a genetic predisposition, but it doesn't mean you'll develop it. About 65% of Alzheimer's cases have a positive APOE4 gene — but what about the other 35%? That's where significant lifestyle changes come in. Even with a positive gene, it doesn't mean it'll happen: APOE4 is the gun, but lifestyle changes pull the trigger.
Every person handles this information differently. Some people don't want to know what might be coming, and others can use it in a positive way. So it's important to know your personality type before looking at a test like this — could it give you an extra push to make preventive changes? If you're curious, there are online cognitive tests to gauge dementia risk, like the MoCA (Montreal Cognitive Assessment), which your provider can also administer in the office.
A quick story before we talk about gender differences: I recently saw a couple in their 90s who'd been married 72 years, and both were very sharp, witty, and had great memories. It let me know there's hope — if people do the right things from a lifestyle standpoint, they can get into those older ages and still enjoy a functional life.
Gender Differences
Why are nearly two-thirds of all Alzheimer's cases women? It's not just because they live longer. It really has to do with hormones. Estrogen is a very neuroprotective hormone — it supports blood flow to the brain, reduces neuroinflammation, promotes neuroplasticity, and has been shown to help clear amyloid plaques. Lisa Mosconi is one of the big researchers on this topic. There's a CARE study running now looking at the influence of menopause hormone replacement therapy on the prevention of Alzheimer's disease. The data isn't printed yet, but it's encouraging, and given estrogen's neuroprotective effect, I expect the numbers will agree.
This validates that brain fog, a very common symptom of perimenopause, has real reasons behind it — you're not losing your mind, you're losing estrogen. Men need estrogen too, so it's not just a female disease. Other factors include thyroid dysfunction — and not just normal blood levels, but what's happening at the cellular and receptor level. If we don't support ourselves from a thyroid standpoint, that contributes to brain fog, along with chronic stress and the sleep disruption women have during perimenopause.
Men get Alzheimer's too — less frequently, but we're not off the hook, because there's also vascular dementia and Lewy body dementia (more of a genetic predisposition, more highly driven in the male population). Testosterone is also neuroprotective — it reduces amyloid accumulation and supports mood and motivation. And testosterone isn't a male-only hormone; females have it in abundance. The male risk pattern looks a bit different and may go undertreated: hypertension, metabolic syndrome, and sleep apnea are all pathways to cognitive decline that, left alone, accelerate it.
People have been trained to think of these symptoms as just signs of aging and don't address them. Maybe it doesn't have to be that way. We see men hiding it — skating around it and changing subjects because they don't want anyone to know they're not as sharp. Fear is a big player in a lot of this.
Lifestyle Lever #1: Nutrition
What are the big lifestyle levers? First and foremost is nutrition. The brain-insulin connection is important. What drives up insulin resistance and neuroinflammation are ultra-processed refined carbs, processed sugars, and starches — and the brain doesn't like that. Key nutrients to optimize brain health are omega-3s and good fats, polyphenols, B vitamins, and magnesium.
Time-restricted feeding (a form of intermittent fasting) is an option to help with insulin resistance, but it has to be organized so you maintain your protein intake while improving insulin sensitivity and keeping glucose spikes down. We like to focus on what to add to your diet instead of what to take away — but it's appropriate to say alcohol is something your body treats just like sugar. It's neurotoxic, no question, and mitochondria don't like alcohol.
Lifestyle Lever #2: Movement
I see movement as the single most important evidence-backed intervention for brain health, period. There's no question that activity and exercise help — myokine release, neurotransmitters, and a lot of other benefits. Not only is it good physiologically, it makes you feel good. Aerobic exercise is great for BDNF (brain-derived neurotrophic factor), which is like fertilizer for neuron growth. Strength training — muscle is medicine — helps with insulin sensitivity, reduces neuroinflammation, and is independently associated with reduced dementia risk.
Even just getting out and moving matters. If you ask how many steps you need, aim for 7,000 to 8,000 a day — studies show 7,000 is the actual minimum. We're a sedentary society, so that takes work and planning. Movement also has a huge effect on stress, so it's a win-win: it improves insulin sensitivity and sleep and reduces stress. Hands down the best medication you can give your body is movement.
Lifestyle Lever #3: Sleep
During sleep, the "garbage disposal" goes on — the glymphatic system clears waste products from the brain, a soup that gets flushed out while we sleep, recharging our batteries. If you're not getting good sleep — say, with sleep apnea — you're not clearing those products, so you're tired and foggy the next day. That's when the amyloid and tau proteins that build up in Alzheimer's are flushed out. Poor sleep is a significantly modifiable risk factor; seven or eight hours of good-quality sleep is important.
Lifestyle Lever #4: Stress
Chronic stress and chronic cortisol are neurotoxic. In an Alzheimer's brain, the hippocampus shrinks quite a bit — measurable on an MRI — and cortisol shrinks that hippocampus. We're not talking about acute day-to-day stress, which is a good system; it's the chronic, all-day, every-day stress that even bleeds into the night, disrupting sleep and predisposing you to more risk. HPA-axis dysregulation drives neuroinflammation. Controlling stress with strategies — breathing activities, meditation, time outside, nature walks — to reset that switch is a good thing.
Lifestyle Lever #5: Social Connection
Social connection helps with stress but is also its own pillar. It's a major risk-reduction factor for dementia. In the Blue Zones, populations with many people living into their 100s have that connection and daily purpose. There's evidence that social isolation could be compared to smoking or a sedentary lifestyle — it takes years off your life. Cognitive engagement and lifelong learning keep the brain healthy: learning a new hobby, picking up an instrument, becoming socially interactive, or learning a new language or skill all improve neuroplasticity. You've heard "if you don't use it, you lose it" — that's exactly what we're trying to avoid, so keep challenging yourself.
Where to Start: Reveal, Rebalance, Revive
First is knowing where you're at — what we call the reveal phase. Know your numbers: fasting insulin, HOMA-IR, hemoglobin A1C, homocysteine, C-reactive protein, and vitamin D. Do a deep dive on thyroid, and look at your hormones — thyroid, estradiol, progesterone, and testosterone (free and total; free testosterone is a very important marker).
The second part is rebalance. For brain health, eliminate ultra-processed foods — try it for 30 days. So many people skip over an elimination diet, but patients who go 30 days without these things are amazed at how different they feel — pain, GI issues, brain fog, bloating. When they reintroduce something, it's "I can't believe I lived like that." Add strength training and cardio — we try to get people to do something five days a week, with two days of rest, alternating cardiovascular activities two or three days and strength training the other two or three to build up your muscle bank. Recognize that some people are starting from ground zero, so baby steps are appropriate. The urgency is a little less when you start early in your 40s and 50s. We're not talking about hour-and-a-half sessions — that's not sustainable; most people can give 15 or 20 minutes a day. It's a matter of prioritizing, because your health has to be a priority.
Next is protecting your sleep — be ruthless about it, giving your brain time to clear and reset. It can be challenging when you've lived a certain way for a long time; you realize you can't go to dinner at 8:00 p.m. anymore. We look for matinees now instead of getting home late from a show. If you're doing matinees and dinner at 5:00 p.m., kudos — let's do it.
The last step is revive — things to keep moving toward prevention. Supplements: omega-3s, a B complex (with B12, folate/methylfolate), and magnesium — the magnesium L-threonate form is really good for brain health. Vitamin D is one of our foundational recommendations because it's very common for people to be low or deficient — if a person doesn't take vitamin D, they're often deficient, because we're not outside hunting and gathering in our loincloths. Then take on a cognitive challenge: learn a new skill, an instrument, or a language. A lot of people like puzzles or brain games, painting, art, or even an adult coloring book. And invest in your social infrastructure — making connection is really powerful for your overall health.
Wrapping Up
Your brain is not separate from your body — what you do for your body helps your brain. It's important to maintain good metabolic health, support your hormones and sleep, and reduce stress. It's truly an investment. We spend so much time trying to build a nest egg for retirement but don't take the time to invest in our own cognitive health. I'd encourage you to look into that. I hope we shed a little light on the subject and you got a few pearls from today's conversation. Reach out if you have further questions. Have a healthy day.