1. Anne-Marie Kaulfers, MD Pediatric Endocrinology University of South Alabama

2. Disclosures www.INRseminars.com Institute for Natural Resources “Food, Mood, and Cognition” seminar is where most of the references came from, seminar given by Gina M. Willett, PhD, RD This talk and the topics presented are my own and not endorsed or supported by that organization

3. Objectives Understand how what we eat influences how we think and learn, and how it affects our memory Examine the relationship of Alzheimer’s disease to diabetes Explore how the hormones in our body actually promote weight gain and food addiction Learn about which foods are good for our brain

4. How different breakfast foods affect kid’s behavior (2007) 5-7 year olds who ate breakfast at school Group 1: cornflakes, milk, 2 spoonfuls of sugar, waffle, and maple syrup Group 2: egg, bread, jam, butter, yogurt Group 3: ham, cheese, bread, and butter

5. How different breakfast foods affect kid’s behavior (2007) Then they watched with a video camera to assess ability to focus, and behavior And also did memory tests 2-3 hours after breakfast When students ate breakfast #3 they had better scores on memory and ability to sustain attention

6. Other studies that show relationship of food to brain function 70-90 yr olds: highest carbs: 2 x risk of mild cognitive impairment Rats fed excessive fructose for 6 weeks moved slower and forgot how to get out of a maze 2003: 815 elderly patients with no dementia High fat intake = higher chance of Alzheimer’s High omega 3 fatty acid intake = less chance 2008: 1,049 people in CA Biggest waist = 3 x increased risk of dementia

7. Relationship of food and brain People at age 60 Overwt in young age: poorer memory at age 60 Followed 30-60 yr olds for 5 years. High BMI: lower test scores of mental status MRI on 94 elderly adults High BMI: atrophy of parts of brain, smaller brain volume CA Dept of Ed: 885,000 middle school kids. Better fitness level = better academic test scores Adults with Type 2 diabetes. High sugar meal = poorer memory 2 hours later

8. Relationship of Food and Brain Summary: Overconsumption of energy and high BMI suggest poorer academic performance when you are a child and more decay of the brain structure as an adult. Increased physical activity improves brain health and function. Conclusion: Poor diets can lead to brain dysfunction. Why? It’s all insulin’s fault!

9. Insulin and it’s action on the brain In 2005, researchers looked at the brains of people with Alzheimer’s disease. They found that their brains had very low levels of insulin and insulin receptors, and that all the signal pathways that control energy metabolism, memory, cognition were all functioning poorly.

10. Carbohydrates Blood Sugar Cells of the Body

11. Carbs Blood Sugar Cells of the Body Insulin = the key that unlocks the door, lets sugar into the cell I

12. Type 1 Diabetes Autoimmune destruction of the insulin-making cells Usually starts in childhood Completely dependent on insulin injections

13. Blood Sugar Pancreas Body Beta cell Insulin

14. I Pancreas Body Blood Sugar

15. I Pancreas Body I I I I Blood Sugar

16. ii Pancreas Body ii Body ii Body ii Body ii Body Blood Sugar Pre-Diabetes/Insulin Resistance

17. ii Pancreas Body ii Body ii Body Blood Sugar Type 2 Diabetes Blood Sugar

18. Diabetes and Dementia Diabetes increases risk of mild cognitive impariment, dementia and AD, either due to lack of insulin or insulin resistance or both Overweight people who are not considered obese have a 2-fold increased risk of getting Alzheimer’s disease. Obese has a 3-fold risk. There is also mild cognitive impairment in animal models of Type 2 diabetes and obesity.

19. Alzheimer’s disease: Type 3 diabetes? Famous study from 2005: Rats were ingested with a drug that can cause type 2 diabetes (streptozocin). When this drug was given by mouth or by IV, they got type 2 diabetes. When they injected this drug directly into their brain, it caused brain insulin deficiency, brain insulin resistance, impairment in learning and memory, and the identical brain lesions that are seen in AD.

20. Alzheimer’s Disease (AD) The most common cause of dementia It is a severe, age-related decline in memory and cognitive functioning 1 in 8 people over age 65 have AD Nearly half of people over age 85 have AD The difference between age-related cognitive decline and AD is that AD had actual physical damage to brain cells, which also causes behavioral changes

21. AD: Physical brain changes Too many Amyloid-beta (AB) plaques Too many “Tau” proteins

22. Alzheimer’s Disease: Physical brain changes

23. AD and insulin: the connection Tau is controlled by insulin signals Brain insulin resistance leads to disruption of the insulin signals that control nerve cell survival. It messes up the systems that control neuron plasticity (storing and creating memories) and cognition. Turning off insulin signaling in the brain causes “oxidative stress” which damages proteins and DNA, promotes inflammation, causes brain cell death, and increases both tau and AB plaques.

24. AD and insulin: how it starts The Blood-Brain Barrier (BBB) This BBB keeps bad stuff from our body from getting into our brains. It protects us from toxins. So anything we eat or make in our body, if we need it to go to the brain, it has to cross the BBB first.

25. The Blood Brain Barrier “ I’m the Blood Brain Barrier. You wanna get into the brain, you gotta go through me”

26. The Blood Brain Barrier: Normal State 1 st up: Sugar. “Yep go right in, we need you” Next: Insulin. “Sure, come on in, we need you too.”

27. Blood Brain Barrier: In a patient with pre-diabetes/insulin resistance or Type 2 Diabetes “Insulin! Again! I am sick of seeing you. You come around too much. Go away, I am tired of letting you in” Obesity and high-fat diets decrease the ability of insulin to get across the blood brain barrier

28. AD: Insulin can’t get through the Blood brain barrier Without enough insulin in the brain, bad things start happening. Lower brain insulin signaling increases tau and AB plaques in mice Too much insulin in the body also interferes with the body’s ability to get rid of the AB plaques once they are made People with AD have reduced levels of insulin in their brain and lower levels of insulin signaling too

29. Insulin Effects in the Brain Parts of the brain that use insulin: Cerebral cortex Hippocampus Hypothalamus Amygdala How we think Controls our memory Controls our appetite, energy level, weight gain or loss Controls stress Without enough insulin in the brain, all of these systems suffer

30. Consequences of Insulin Problems in the Brain Glut-4 dysfunction Oxidative stress The insulin resistance in the brain can damage the blood vessels, leading to strokes White matter of the brain starts to disappear

31. Consequences of Diet in the Brain Brain-derived neurotrophic factor (BDNF) plays an important role in the survival, maintenance, and growth of brain cells, especially in the hippocampus and hypothalamus. Interference with BDNF reduces synaptic plasticity, which is important for learning and memory. Diets high in saturated fats and simple sugars have been shown to reduce BDNF levels and to interfere with synaptic plasticity and making new nerve cells

32. Alzheimer’s Disease is a Metabolic Disorder MRI of patients with AD show decrease in sugar metabolism in the hippocampus (learning and memory) The neurodegeneration seen in AD can be produced by experiments that cause brain insulin resistance and deficiency Brain insulin deficiency and resistance could account for the structural, molecular, and biochemical lesions that correlate with the cognitive decline and dementia in AD

33. Alzheimer’s Disease: Is metabolism really to blame? Conclusions: Type 2 diabetes can enhance progression but is not sufficient to cause AD by itself. Obesity, insulin resistance, and Type 2 diabetes and all of these processes that result from it contribute to AD and mild cognitive impairment, but they are not proven to “cause” it yet. Insulin resistance is just a co-factor, contributing to the problem.

34. Why are we going to keep eating foods high in sugar and fats even though we know how harmful it is? It is all insulin’s fault Leptin Ghrelin Cortisol Dopamine

35. Bad fat vs Good Fat Saturated Fat Mono/Polyunsaturated Fat Butter Ghee Lard Coconut oil Cottonseed Oil Palm kernel Oil Dairy: Creams/cheese Fatty Meats Vegetable Oil Olive, Canola, Soybean Avocado Oily fish Nuts Seeds

36. Foods high in Simple Sugars

37. Appetite Hormones: Ghrelin When there is no food in your belly, and your body needs the energy, you make Ghrelin, which tells you that you are hungry

38. Appetite Hormones: Leptin When you have eaten enough food, you make Leptin. Leptin tells you that you are full, and that you should stop eating.

39. Appetite Hormones: Cortisol When you are stressed out, anxious, or depressed, you make Cortisol, which tells you to go eat high sugar and high fat food. Cortisol also tells you to make Ghrelin, so you get super hungry for all the wrong foods. Cortisol also turns off Leptin, so you never feel full. Cortisol also tells you to store everything you eat as fat.

40. Appetite Hormones: Dopamine When we eat high fat, high sugar foods, we make lots of Dopamine, which gives us the reward from food. It turns on the pleasure center of the brain – the same part of the brain that responds to morphine, nicotine, and alcohol.

41. Appetite Hormones These are all supposed to work together and play nice, but when you have insulin resistance, these hormones get all of their signals crossed 2007: Gave obese and normal weight people a meal, then they asked about their appetite after lunch. The normal weight people were not hungry after they ate. The obese group still reported that they felt hungry. Obese people may not respond correctly to hormone signals after eating, correlating with insulin levels

42. Appetite Hormones Normal State Insulin Resistance/Type 2 If your stomach is empty: Ghrelin Leptin After you eat: Ghrelin Leptin If your stomach is empty: Ghrelin Leptin After you eat: Ghrelin Leptin

43. Appetite: Food Addiction Eat healthy carbs Eat high sugar foods that taste REALLY sweet Make some insulin Insulin makes sure that the “pleasure center” of the brain never gets told anything, so you don’t crave food. You just eat till you are full and then stop eating. The excessive sugar goes right to the “pleasure center” of the brain and causes tons of Dopamine to be released. This causes an exaggerated emotional response, reduced ability to stay away from that food, leading to compulsive eating.

44. “Diet” Drinks and “Low fat” foods Diet Drinks, made with artificial sweetners, taste REALLY sweet, maybe too sweet. This causes excessive releases of Dopamine also, causing us to crave real sugar. Eating the real sugar causes the weight gain. Low fat foods add in extra sugar or artificial sweeteners, making it taste REALLY sweet, leading to the same process. Fructose also tastes REALLY sweet, so foods with high- fructose corn syrup will lead you down this same road to being addicted to high sugar foods.

45. Dopamine and Obesity Over time, our body can become resistant to these excessive dopamine surges (the same way you get resistant to insulin). Our body “panics” without Dopamine, causing us to go try to find it again, so we eat even higher and higher amounts of high sugar/high fat foods to try to turn on Dopamine again. Drugs that cause weight gain are the ones that turn off Dopamine in our brains.

46. What foods should we eat to protect our brain? Hopeful but unproven yet: Curry? – improves cognitive decay in rat models B vitamins? – some positive effects on memory Vitamin D? – important for preserving cognition Vitamin E? – shown to delay progression of AD, but high doses can be harmful Vitamin A and C? – antioxidant vitamins, but no proven benefit and can be toxic Ginseng? - not studied well enough to know Ginkgo biloba? – lots of bad medication interactions

47. Foods that protect the brain Proven to be beneficial: Antioxidant rich foods Alcohol/Wine Fiber: Improves alertness and decreases perceived stress Omega-3 fatty acids (DHA) Major building structures of the membranes in the brain Fish, salmon, flax seeds, krill, chia, kiwi, butternuts, walnuts, baby formula Flavanoids Cocoa, green tea, Ginkgo tree, citrus fruits, red wine, dark chocolate

48. Antioxidants No formal recommendation on the amount per day No proven benefit in supplements, and high doses can be toxic Experts think these foods have a wide range of functions besides reducing “oxidative stress” Foods that naturally contain antioxidants: Fruits, veggies, nuts, seeds, grains, olive oil Fresh spices: oregano, cinnamon, turmeric, parsley, basil, ginger black pepper

49. Alcohol/Wine Light and moderate drinking = protective effect against cognitive impairment and dementia Heavy drinking = no protective effect Wine is better than beer or hard liquor, since wine has natural antioxidants.

50. Omega – 3 fatty acids (FA) 2012: Rats with cognitive decline and a high-fructose diet. They started giving them omega-3 FA and the brain problems/memory improved. Dietary deficiency can prevent the renewal of the brain structures and accelerate brain aging Most common dietary supplement is DHA

51. Flavonoids Reduce oxidative stress, improve insulin sensitivity, protects heart and blood vessels 2012: 90 elderly patients with mild cognitive impairment. Gave them a drink once a day with different amounts of flavanols, then did cognitive brain tests before and after Test scores were higher in the high flavanol groups after 8 weeks and the high flavanol group also had improved insulin resistance and blood pressure.

52. Chocolate: Buyer Beware Most chocolates bought in a grocery store and so processed and full of sugar that the harm is more than the benefit White chocolate: no cocoa (Flavonoids) Milk chocolate: 20% cocoa Dark chocolate: 1 ounce of 70-85% cocoa is beneficial

53. References (1) Agrawal.R et al. Metabolic syndrome in the brain. The Journal of Physiology. 2012 May 15; 590:2485-2499. Benon D et al. 1999. The Effects of Nutrients on Mood. Public Health Nutrition. 2(3A):403-9.5). Benton D, et al. The influence of the glycaemic load of breakfast on the behavior of children in school. Physiology and Behavior. 92 (2007) 717-724. Bourre JM. Effects of nutrients in food on the structure and function of the nervous system. Part 2. J Nutr Health Aging. 2006 Sep-Oct;10(5):386-99. Burkhalter TM et al. A Narrative Review of Physical Activity, Nutrition, and Obeisty to Cognition and Scholastic Performance across the Human Lifespan. Adv Nutr vol 2:201S-206S, 2011. Cizza G et al. Was Feuerbach right: are we what we eat? J Clin Invest.2011 Aug;121(8):2969-71. Craft S. Insulin resistance and Alzheimer’s disease. Curr Alzheimer Res 2007 Apr;4(2):147-52. Review.

54. References (2) Craft S. The role of metabolic disorders in Alzheimer’s disease and vascular dementia. Arch Neurol. 2009;66(3):300-305. DeLaMonte SM. Brain Insulin Resistance and Deficiency as Therapeutic Targets in Alzheimer’s Disease. Curr Alzheimer Res 2012; 9(1): 35-66. Desideri G et al. CoCoA Study. Hypertension. 2012. Flint A. et al. Associations between postprandial insulin and blood glucose responses, appetite sensations and energy intake in normal weight and overweight individuals. Br J Nutr. 2007 Jul; 98(1):17-25. Gestuvo MK Hung WW Common dietary supplements for cognitive health. Aging Health. 2012;8(1):89-97. Gomez-Pinilla F. Brain Foods: the effects of nutrients on brain function. Nat Rev Neurosci. 2008; 9(7):568-578. Jacka FN et al. A prospective study of diet quality & mental health in adolescents. PLoS One. 2011;6(9);e24805.

55. References (3) Kanoski SE et al. Western Diet Consumption and Cognitive Impairment: Links to Hippocampal and Obesity. Physiol Behav. 2011 April 18; 103(1):59-68. Mietus-Synder ML. Lustig RH. Childhood obesity: adrift in the “limbic triangle” 2008. Ann Rev Med. 59:147-162. Morris MC. et al. Dietary Fats and the risk of incident Alzheimer disease. Arch Neurol. 2003;60:194-200. Raji CA et al. Brain structure and obesity. Hum Brain Mapp. 2010;31:353-64. Whitmer RA wt al. Central obesity and increased risk of dementia more than three decades later. Neurology 2008;71(14):1057-1064.

56. The End Questions?