>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in the local nonprofits during the most challenging times, using data to drive solutions and support healthier living, and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

♪ >> The CDC estimates that 6.2 million Americans are living with Alzheimer's disease.

It is the fifth leading cause of death for adults aged 65 years and older, and the sixth leading cause of death for all adults.

As the American population lives longer, more and more people fear developing this disease, and they are in search for ways to prevent it, and that leads to a discussion of brain health.

Joining us today, primary care physician from the University of Rochester Medical Center, Dr. Lou Papa.

>> It's all the stuff you hear over and over again.

If it's good for the blood vessels in other cells, it's going to be good for your blood vessels to your brain and the cells in your brain.

>> The founder of the longest running centenarian study, Dr. Thomas Perls from Boston University School of Medicine.

>> It's during sleep, that's when the brain's garbage trucks are running around, doing their rounds, and getting rid of all the waste products that the brain is producing.

>> Alzheimer's disease expert Dr. Laura Baker from Wake Forest School of Medicine.

>> By the time the symptoms start showing, chances are that pathology in the brain has been going on for years.

>> And Chair of the Department of Neuroscience at the University of Rochester Medical Center, Dr. John Foxe.

>> So actually up until the age of 2, we have billions and billions of neurons.

And then we lose a lot of those neurons, part of what's called neural pruning.

>> I'm Joan Lunden, and it's all coming up on "Second Opinion."

♪ Doctors, thank you all for being here.

Lou, I want to start with you, because you're the primary care physician.

So people come in, maybe just for an annual checkup.

But do they invariably say, "How do I protect my brain?"

>> Exactly.

And like a day doesn't go by with somebody doesn't ask that question.

And I think of it in terms of a structural way, you know, vessels, neurons, the supporting structure of the brain.

The infrastructure of the brain, how to reduce those diseases.

They're thinking of it in terms of processes, "how do I protect the thought process?

How do I protect my memory?

How do I stay sharp as I age?"

That's the stuff they're really interested in.

>> Well, then let me go to you, Dr. Baker, because I think when people talk about brain health, the first thing they think about is cognitive decline and how do they slow that down?

And they think about Alzheimer's.

So why don't we start with what is Alzheimer's?

>> So Alzheimer's disease is a disease of the brain.

It's what's called a neurodegenerative disease so that the brain tissue is degenerating.

The symptoms start very early and very subtly.

And by the time a symptom starts showing, chances are that pathology in the brain has been going on for years already.

And so the earliest signs that we see are the people just have some memory blips, they have trouble keeping track of details, they have trouble multitasking.

And of course, it progresses and gets worse over time to the point at which a person can no longer take care of him or herself.

>> What do we know about what causes it?

>> That's the $1 million question, isn't it?

So what we know so far is that it is -- it's caused for many different reasons.

Some people have a pathway to Alzheimer's disease that's led by genetics.

Others do not, have no genetic history in their families at all.

And for these other individuals, the causes that we are studying now in science have to do with lifestyle, has to do with physiologic stressors.

And some of the stressors might be cardiovascular disease that you've had for years, or it could be type 2 diabetes, it could be chronic stress, it could be lack of sleep, or poor sleep quality for years.

All of these different factors have been linked to either causing Alzheimer's disease or making it worse and hastening its progression.

My particular area of study is lifestyle, and how the decisions we make every day about how to behave, how to spend our time actually can make a difference in how a person ages over time.

>> So let me ask you, Dr. Foxe.

We're learning more and more about this all the time.

You are one of the researchers at this ABCD Study, which I find so fascinating.

See Adolescent Brain Cognitive Development Study.

It's the largest brain development study ever undertaken by the NIH.

So tell us what's going on, and what's the goal of what you're trying to learn?

>> Right, so the ABCD Study is tracking almost 12,000 children 9 and 10 years of age.

When we initially recruited them, they were 9 or 10 years of age.

We're tracking them for at least a decade at 21 national university sites across the nation, where we have turned all the dials on our machinery.

For example, on our MRI scanners, to make them all work in exactly the same way.

And then at those 21 sites that were very carefully chosen to be able to sample the population to be 100%, as close to 100% representative of the population of the US.

So we have these 12,000, nearly 12,000 children in the study, and we're now entering the fifth year.

As part of the study, we've been collecting all kinds of data about them from neurocognitive status to imaging.

We image their brains so we can understand brain health.

We have their genetics.

We have, you know, their life stressors, how many times they knock their head in a game of football.

>> Yeah.

>> How much time they spend on the screen, or playing video games, you name it, we have it.

Their diet, the air they breathe.

>> Why don't you start with kids who are 9 years old?

>> So 9 was chosen as a very specific age because a lot happens to youngsters.

9 years of age, you know, these are healthy, young children.

And if you think about what happens between 9 and 19, those are the critical years through puberty.

And what we're interested in is some of those youngsters will go on to be geniuses, and they'll be incredibly successful.

And we really want to know what makes a youngster successful.

>> Yeah.

>> And of course, unfortunately, some of those youngsters will go on to develop disorders and diseases.

By definition, unfortunately, someplace between a half and 1% of them will develop a psychotic disorder, and if you think about those, again, those critical years between 9 and 19, that's when we would see schizophrenia emerging, bipolar disease emerging.

And actually the major motivator for the study, because the study primarily comes out of the National Institute for Drug Abuse, is to try to understand things that lead to addiction in youngsters.

So that's a key piece of the project.

We're talking about Alzheimer's disease, you're talking about something that's going to develop 30, 40 years later into symptomatology.

But the groundwork's being laid very early in life.

>> So now I'm going to take us up to Dr. Perls, who's your -- kind of your studies or at the other end of the spectrum.

You are the founding director of the New England Centenarian Study.

That's the longest running and the largest study ever anywhere in the world.

And it's not only the centenarians, but their families, as well.

So what made you start this study?

>> Thanks, Joan.

It first started when I was a geriatric fellow at Harvard, came across two centenarians who were in incredibly great shape.

At the time most people thought if you could live long enough, you'd get Alzheimer's disease because it's so closely linked to extreme old age, or even old age, I should say.

And yet these two centenarians that I was taking care of were in remarkably good shape.

And, you know, the epiphany happened thinking, "What are other centenarians like?"

And do they seem to be delaying or escaping something like Alzheimer's disease?

And that was the beginning of the study.

And since then, we really learned that while there are some centenarians that develop neurodegenerative diseases like Alzheimer's, they markedly delay the disease, or diseases, so that on average, our centenarians that range from age from 100 all the way to, believe it or not 119.

>> Whoa.

Really?

>> Oh, yeah.

So they are markedly delaying any kind of disability up into their mid-90s.

And then for those who develop Alzheimer's, they've really done what most of us would want, if we're going to get something like that, and squish it down into a very tiny period of their lives at the end of their lives.

And then we have these folks who are getting to 105, even 110, what we call super centenarians.

And they don't get anything up until about five years before they die.

So they're living to 105 for example, the 110-year-olds, without any problems.

And they have, you know, with a talk of the kids and so on and lifelong aging, the centenarians just have this history of aging incredibly slowly.

And they also, with that, markedly delay aging-related diseases, not just Alzheimer's disease, but a whole range of diseases.

And among the ones who do develop diseases, let's say in their 70s, 80s, 90s, they deal with those diseases much better than other people, younger ages, who get those diseases.

They have this resilience that allows them to deal with these diseases much better than others, getting back to this finding that they're disability-free up through their early 90s.

>> So what have been the key findings, Dr. Perls, as far as real lifestyle choices that we make, and, you know, determining whether or not we're going to have Alzheimer's?

>> Again, with our centenarians, I would say that we have folks who are doing everything wrong.

And, in fact, had they done everything right, they probably would have gotten to even older age.

But we know that there are some things that you just can't do with the hopes of getting to extreme old age, as well as getting to older age without a disease like Alzheimer's.

I would say the major thing is not smoking.

Very few of our centenarians have a history of smoking.

And beyond that, we learn from actually the kids of the centenarians who are in their 70s and 80s, and really following in the footsteps of their parents.

And some of that is health behaviors that run in families, like diet, even education, not smoking, exercise, maybe even sleep habits.

And we know from other studies, for sure, now I'm putting on my geriatrician hat and looking at other studies, that sleep is incredibly important.

Interestingly, it's during sleep, that's when the brain's garbage trucks are running around doing their rounds and getting rid of all the waste products that the brain is producing during the day, and those waste products can be very toxic to the brain.

And all one has to do is think about what they're like after not sleeping for 24 or even 48 hours.

>> Yeah.

>> People become confused.

And the sleep is turning out to be extremely important in terms of brain health.

And I believe over a period of time, even susceptibility to something like Alzheimer's disease.

And then other things would be whatever increases your risk for cerebrovascular disease or blood vessel disease.

And that means controlling your blood pressure, good exercise, being at a healthy weight, and certainly again, not smoking.

>> Yeah, punch that not smoking one more time.

I mean, you probably say these things to patients day in and day out.

>> Right.

>> I mean, it's easy, but people sometimes pay lip service to it.

>> Exactly, and in some respects, they're hoping to hear, "You got something else?"

>> Yeah.

>> You know, something that's easier, but the reality is, and, you know, what Dr. Baker and Dr. Perls are saying is a lot of the groundwork is laid in this disease much earlier, and like it is with most diseases.

Diabetes, hypertension, a lot of the groundwork is laid early on.

So identifying those risk factors earlier.

If you're an early smoker, you want to stay an early smoker, not a lifelong smoker.

Get rid of it quickly.

And that lifestyle issue's very important.

Maintain a healthy weight, make sure you get all your screening done, make sure you get your blood pressure checked, make sure you have a healthy plant-based diet, like a Mediterranean-type diet.

Make sure you're exercising regularly.

It's all the stuff you hear over and over again.

If it's good for the blood vessels and other cells, it's going to be good for your blood vessels to your brain and the cells in your brain.

>> And let's make another plea for it's good to also have a primary care physician... >> It is very important -- >> ...who's going to follow... >> Right.

>> ...the changes in you over time and call you on it.

>> Thank you for that plug because there's a lot of this stuff has to be screened for, right -- hypertension, diabetes, you know, even sleep.

70% of people report that they don't have good sleep.

Those are things that go undiscussed because people looking for the big rocks in the room, and very often it's, you know, it's the little creeks that make the Grand Canyon, right?

So you want to pick this stuff up early.

And you want to make sure it's screened for, you want to make sure to checked for, and you make sure most important, you make the lifestyle changes to address it, because it's gonna be a team, it's not going to be just pills alone.

It's got to be a lifestyle.

>> I want to ask you, Dr. Baker, about -- you're the principal investigator of the POINTER Study.

Tell us about that study.

What are you looking at and what are your goals?

>> So our study is a national study.

We are in five cities or five regions across the US, and our goals are to basically replicate a really innovative study that was conducted in Finland several years ago called the FINGER trial.

And the FINGER trial was one where they decided that they would test whether you could give some individuals a healthier lifestyle or help them make those changes, and whether it would protect cognitive health over time.

And all of the FINGER participants were at risk for one reason or another for cognitive decline, and later on.

They were all older.

And so, you know, that was Finland.

We Americans are quite different.

Positive results in Finland are great, but will it work in America?

So that was our charge to, first of all, to replicate what was observed in Finland, but also to adapt a lifestyle intervention to American ways.

We have to meet people where they are.

So we have a study that we will enroll 2,000.

We're 1,000 into it, we just finished our 1,000th not too long ago.

It's a two-year study.

It's a randomized control trial.

And I think a key part of our study is that we provide something that maybe others have not done, and that is we provide support.

And so, you know, so often you hear about patients go into the doctor's office, and the recommendation is, "Wow, you really need to, you know, change your diet, start exercising, you know, live a healthier life."

And the patient is like, "How do I get started?

This is not who I am.

I've never done this in my life.

I need help."

Well, that's what we're trying to do.

We're trying to develop a program where there would be community support for developing these healthier lifestyle changes.

And so we're partnering with the Alzheimer's Association in the community, the chapters there.

The idea is that if this works, if we can show that a healthier lifestyle can actually protect brain health for these at-risk -- our people are also at risk for cognitive decline.

Our goals are to replicate, develop a sustainable program, provide support, and what we're looking at cognition and changes in cognition over a two-year period.

We're also doing many other kinds of things that will help us understand mechanisms, like we're doing brain imaging.

We're doing a home sleep test.

And then we're also looking at the microbiome, the gut.

>> Oh.

>> We're looking at the healthy bacteria there, and then we're also looking at vascular health.

So, you know, we believe that this lifestyle intervention is actually going to change the age of your vessels, that's going to make them younger.

And this is all related to all the different mechanisms that we think might be behind a lifestyle intervention and its impact on brain health for older adults.

>> Well, that's, like, super exciting.

>> It's very exciting.

>> So what a lot -- what they used to think a long time ago is that we were born with, what, a few billion whatever brain cells, and they just died off.

And we now know that there's neurogenesis going on all the time.

But a lot of people don't really understand that.

I think it's pointed out if somebody has an injury, that it's been shown that you can actually, what, regenerate a part of a damaged brain.

Talk to us about that and what kind of implications that has for all the rest of us that if we just did the cardiovascular work, et cetera, that we could also get that kind of neurogenesis going on.

>> Right, I think the neurogenesis thing, you don't want to oversell it.

>> Okay.

>> And here's part of it.

So there was a great controversy in the field for quite some number of decades about whether this was possible at all in adults.

Now, we know this is possible in youngsters.

And no surprise, right?

You have a lot of neurogenesis in the fetus, and so on and through early life.

And, in fact, we're born with many, many more neurons than we're going to go through our life with.

So actually up until the age of 2, we have billions and billions of neurons.

And then we lose a lot of those neurons, part of what's called neural pruning.

When that goes awry, sometimes actually, that may be part of what happens in the autism spectrum.

>> Oh.

>> And we all lose neurons, because the ones that we're using are wiring together.

So this is a sort of what wires together fires together to create the networks that give us our good cognitive health and our intellectual outcomes.

And we're losing neurons all the time.

And then, of course, of course, the life span, as well, we lose neurons, often to the disease and to other issues like that.

But one of the things about the remaining neurons is that if we're using them well, they have the ability to connect up in new and novel ways, what we call neurite outgrowth.

So that's a form of neurogenesis that doesn't involve new neurons showing up.

>> Okay.

>> Now, the other piece is a little bit controversial, and that is that there's evidence, particularly in animal studies for neurogenesis in adults, and whether that's really occurring in adult human beings is a little bit controversial.

We suspect it is, but we don't know that the small number of neurons that are occurring in that way are really having a huge functional impact.

And then the last thing I would say about that is, of course, that we now have technologies and techniques with stem cells and -- >> Oh, yeah.

>> pluripotent stem cells to potentially add cells in and grow new neurons in a brain.

This is already happening in animal studies.

And it looks very promising for humans.

But that's the future.

>> So if you, as you get older, for those people who become very isolated, they live alone, they're not socializing, they're not talking with people, they're not having to use their brains, is that the kind of thing you're talking about, that if we just keep using them well that we can create -- >> Absolutely.

>> ...more connections?

>> There's no question that one of the biggest risk factors, one of the biggest risk factors is social isolation.

So obviously, all these other health decisions that we make, cardiovascular health, they're major players, but a big chunk of what we call the variance is also accounted for by our social networks.

>> You know, we're all bombarded all the time, I just have to ask.

You know, we see all these commercials for different supplements to make our brain better to, you know, stave off Alzheimer's.

>> And those commercials hurt my brain.

So that is -- I say that is marketing, that is not medicine.

And you have to listen to those commercials very carefully because very often what they'll say is we have clinical studies.

They don't say the results of those.

They don't say if they're effective, they just say they have them.

So they're not very helpful, and they're basically appealing to is there a quick fix to a very difficult problem?

I have to say, you know, Dr. Baker's description of that study, just so people understand the complexity and the expense and the importance of a study of that is enormous.

>> But Dr. Baker, might there be, I don't mean a magic pill, but future treatments that are on the horizon that give hope?

>> Well, if we could package lifestyle intervention into a pill we'd all be rich, wouldn't we?

You know, in terms of, you know, what's on the horizon for drug development for Alzheimer's disease, I think we do have some certain drugs that are being explored that are, you know, currently under investigation.

Would I call this a magic bullet?

Absolutely not.

You know, Alzheimer's disease is a very complex disease, and it affects multiple biological systems.

And so shouldn't we be looking at interventions that could help to correct multiple biological systems at once?

And so, you know, it's not a magic bullet.

It's not easy.

>> Dr. Perls, I want to end with you because I -- we all want to grow up and be just like the centenarians that you are studying.

So want to leave us with the last couple pearls of wisdom?

>> I want to end with a warning, if you will, and then kind of a take-home lesson about the dietary supplements and the deluge of some of these products that we're getting on television, radio, and the print media.

My biggest concern is older people who really are, in many ways, the targets of these predators.

And I really think of these as predators.

And all the financial abuse that's going on began with an act by Congress called the Dietary Supplement Health Education Act that allowed all these products called minerals and hormones and extracts to flood the market.

And they can basically claim these things, like improving memory, improving aging, as long as they don't claim that they're curing a disease.

As difficult as it is to put lifestyle in a bottle, if we can convince people how important... >> Yeah.

>> ...not drinking in excess, not smoking, having a healthy diet that keeps a healthy weight, and good sleep, these very basic things that -- >> That's right.

>> ...shouldn't cost you much money can be enormous in terms of getting people, at least I would say, up to about age 90, and do what the centenarians do, which is age slower and compress the time that you experience disability towards the end of your life.

If you want to go much older than that, picking your grandparents or your parents and the genetics behind that might be important.

But I actually think that's a very optimistic view of aging that at least up to about 90, so much is in our hands in terms of aging well.

>> And I like to end on that optimistic view.

I want to thank all of you doctors for being with us today.

I also want to thank all of our medical advisors who are with us every step of the way to ensure that we bring you evidence-based, up-to-date, accurate medical information.

And of course, to all of you at home, thank you for watching.

And from all of us here at "Second Opinion" we encourage you to take charge of your healthcare.

I'm Joan Lunden.

Be well.

♪ ♪ ♪ ♪ ♪ ♪ >> Find more information about this series at SecondOpinion-TV.org.

You can also follow us on Facebook and YouTube.

>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local nonprofits during the most challenging times, using data to drive solutions and support healthier living, and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> "Second Opinion" with Joan Lunden is produced in conjunction with UR Medicine, part of University of Rochester Medical Center, Rochester, New York.