The Psychology of Fighting Dementia | Dr Tommy Wood

Right now, I think in, in the US, somewhere between 7 and 8 million people are living with dementia. Worldwide, 7 to 8 times that. And the burden of dementia is expected to double or triple in the next 2 decades.

That's alarming. How much of dementia risk is actually within our control?

They estimate that potentially 45% of cases of dementia could be completely prevented. There are other analyses that think it could be even higher than that. They include things like—

Welcome back, or welcome to the Finding Mastery Podcast, where we dive into the minds of the world's greatest thinkers and doers. I'm your host, Dr. Michael Gervais. Today's guest is Dr. Tommy Wood, physician, neuroscientist, associate professor of pediatrics and neuroscience at the University of Washington, and author of The Stimulated Mind: Future-Proof Your Brain from Dementia and Stay Sharp at Any Age.

What we think or expect to happen to our brains doesn't necessarily have to be true regardless of our family history or our genetics. And hopefully that means that we can put ourselves in a position to decrease the likelihood of decline and potentially dementia, you know, towards the ends of our lives.

In this conversation, we explore what dementia actually is, who may be most at risk, and why some of the factors that shape long-term brain health are more modifiable than many of us realize. If a parent has dementia, can you speak to the listener here about how they should be thinking about themselves?

If you had a parent who had dementia, a great place to start is—

With that, let's jump into this week's conversation with Dr. Tommy Wood.

Tommy.

Hey.

Hey, that's a good way to start.

You know, I've been looking forward to having you back on. One, because we're running in similar circles, which is fun. We'll get into some of our cross-pollinations in a minute. More than anything though, you've got a rich understanding of the brain from high performance into health, that kind of wide chasm there. So can we just start first with what do you hope the listener will get from this conversation, from somebody who has been a student of the brain for a long time?

The main thing I hope people get out of this conversation is an understanding of how much power they have over their own cognitive health now and then for decades into the future. And an appreciation of the fact that what we think or expect to happen to our brains doesn't necessarily have to be true, regardless of our family history or our genetics. There's still a lot that we can do, and we have a lot of power over our brain health and our cognition. And hopefully that means that we can put ourselves in a position to decrease the likelihood of decline and potentially dementia towards the end of our lives.

My understanding, I don't know, for most of my training was you reach a certain age and your brain is on a decline. And that, I would imagine, is the prevailing wisdom. And in your book, Stimulated Mind, you've highlighted a different way of thinking about it. So can you just address that prevailing idea that Your brain hits 65, I think it starts at 40 is where I learned, and then there's a decline, and then there's a bit of a shelf after a certain age. Can you just beat that up a little bit?

Sure. So there's 2 parts to that. And a lot of it, I think, goes back all the way to the beginnings of neuroscience. And I love being a student of the history of the fields that I work in, right? So the father of modern neuroscience is Cajal, Ramón Santiago y Cajal. He got the Nobel Prize in Physiology and Medicine in 1906. which he shared with Camillo Golgi. And they actually disagreed so much about the nature of the nervous system that they refused to give their acceptance speeches on the same day, which I thought was fascinating. But Cajal was the person who essentially described that the brain was made of individual cells, which we now call neurons. He didn't call them neurons. They were— somebody else did later on. And he also told us, or had this idea, it's written down, that the adult brain is immutable. Those are his words. And so this is something that we've thought ever since, that the adult brain becomes fixed at some point, and then it starts to decline. And that decline part, I think, comes from other aspects of what we've kind of baked into society since the beginning of the 20th century. So I think some of this comes from the work of, or the teachings of people like Sir William Osler. So Sir William Osler is a legendary physician. I went to Oxford Medical School. He was Regius Professor of Medicine at Oxford at the beginning of the 20th century. Everything is named after Osler in Oxford. He was a Canadian physician. He was one of 4 physicians that founded Johns Hopkins Hospital. And one of the things he did is he popularized the idea of retirement, which before the beginning of the 20th century wasn't really a thing, right? People worked until they died, essentially, because they had to. And he told people, by the time you're 60, you're essentially useless. And I think he used the word useless, and you should be put out to pasture.

He did use the word.

Yeah.

Yeah.

And this is something that we've kind of internalized as a society. And I'll be fair to him that in 1904, you know, the average lifespan in the US was 57. I think. So the average 60-year-old was probably not in great health, but we've advanced medicine and healthcare a lot since then. And now we shouldn't think the same way about either our bodies or our brains. And there's even evidence going back to the middle of the 20th century, one of the first studies that looked at people over time and measured their cognitive function in the same person over decades, It was actually done in Seattle, the Seattle Longitudinal Study, run at the University of Washington by Warner Shai. And what their data show is that the average, you know, more than 50%, maintain cognitive function from their 50s and into their 70s and beyond. And that's not what people expect. Those data are actually used to raise the retirement age in the US in the 1980s. But we've known for 70 years that the average trajectory is that you shouldn't see significant decline in those sort of years from your 50s into your 80s. But we never really kind of updated our thinking about that. And so people still expect that they'll reach some age, decline is just going to happen. And then because of that, I think that nowadays it almost becomes self-fulfilling when people do experience it, because we tell ourselves, Oh, I'm too old to do that. I'm too old to do these things that actually are the same things that would help you to maintain function.

For example?

So physical activity, I'm too old to lift that, that's too heavy. Or new skill learning, oh, I'm too old to learn that. I can't learn like I used to when I was a kid. And we also have data that show that that's not true, that older adults can learn almost as fast as kids. as long as you give them the environment to do that, which is less common.

For example?

So—

I'm good at 2 words.

Yeah. I mean, it's essentially a process of challenging yourself in some kind of complex skill and dedicating focus and time to doing that. And there are dozens of randomized controlled trials where older adults learn new skills— languages, sports, musical instruments— And you see significant improvements in cognitive function. You see changes in the brain when, you know, they do MRI scans. But one of the reasons why we don't do that when we're older is we have this expectation that we can't. And so there's this idea of stereotype embodiment theory, like we embody an aging personality because we think that's what we expect to happen, and it almost becomes self-fulfilling.

It's pretty radical. Aaliyah Crum, Dr. Crum out of Stanford did a bunch of work on belief sets. And one of the really interesting findings is that if you believe something is going to be fattening, tasty and delicious and indulgent was the word that she used, that had lots of calories, it was metabolized differently than the same shake that was labeled sensible.

So Aaliyah Crum worked with Ellen Langer and Ellen Langer is who's—

From Harvard.

Right, from Harvard. And Ellen Langer is the person I took that, word stereotype, that phrase stereotype embodiment therapy from, because that comes from her original studies in nursing homes of telling people about how much agency they have over their lives and that then affecting their disease and mortality risk. So it's all part of this incredible string of work done by people like them.

Yeah. And for fun, Ellen did something remarkable as well. I would call it her hallmark study, is that she manipulated the environment and had a bunch of people that were older Right. I can't remember the exact age. Let's say 65, 70, somewhere in that range. Maybe it was older. And then manipulated for X number of days the environment that they grew up in when they were younger. So the radio looked like the radio they had when they were 19, 20, in that age. And then she measured a bunch of variables on aging and functioning and whatever. And there was a noticeable impact. on the way people felt and expressed their capabilities based on just manipulating the environment. So there's this two-pronged approach, which is the environment matters, your belief set, which is the internal system that you work from, matters. And you're saying, right, if you just believe that you're gonna get old and your brain is gonna get feeble, then such happens.

Mm-hmm.

Now, you and I can travel between high performance and kind of one of the more compromising cognitive structures called dementia. I wanna spend time on dementia. Can you first describe what dementia is? Walk us into why you wanted to study dementia and where the hope and the path is from your research.

Dementia is an umbrella term for a group of conditions where you get a clinical diagnosis due to the fact that you've lost enough cognitive function that you're no longer able to look after yourself on a day-to-day basis. And sometimes you have to rule out some, some other things like psychiatric conditions or things like that. And you would hopefully try and get some idea of the subset of the type of dementia. So the most common is Alzheimer's disease, which most people will have heard of. That makes up something like 60 to 80% of cases of dementia. The next, probably most common, is vascular dementia, so affecting blood vessels in the brain primarily. Although increasingly the field is appreciating that there's— it's very hard to get very distinct separations between all these different types of dementia. And actually, the pathology, which is generally proteins accumulating in the brain, can overlap across a lot of these. But vascular dementia and Alzheimer's disease often occur together. So they together, they make something like 70 to 90% of cases of dementia. Then you have things like frontotemporal dementia, dementia with Lewy bodies. Those are the most common ones. Those first 2 that I was talking about, Alzheimer's disease and vascular dementia, there's an increasing appreciation for the fact that they are quite closely linked to lifestyle and the environment in terms of their risk. There is— there are genetic components and other things as well, of course. But it's increasingly appreciated that particularly those dementias are potentially at least partly preventable. And by preventable, I mean at a population level. So they've done these big statistical analyses where they say, if we eliminate— if we were— if we could somehow eliminate these risk factors, this proportion of dementias we would expect to never occur in the first place. And it's important to make that distinction because Often when you talk about dementia being preventable, understandably, people who've, you know, family members or loved ones who experience dementia, you could interpret that as saying, oh, somebody got dementia, it was their fault because they didn't do these things, which is absolutely not the case. We can decrease our individual risk, but you couldn't say I could completely prevent one person from getting dementia. But we know that if we change lots of things at the population level, we can significantly change population risk like we've done with heart disease, for example, deaths from heart disease, which tend to be coming down.

Between these 2, can you just describe the nuances between the 2? And I think our community is— there's probably 2 things for us. One is, I don't want dementia. And the second is, my parents are kind of right in the middle of it. Can you help me on both fronts?

Yeah. There's a confluence of factors that come down to determining somebody's risk of dementia. And I think we can talk about dementia fairly broadly here, because sometimes the separation of type is a little artificial, as I was kind of saying. And what you tend to see is an accumulation of proteins in the brain. So particularly for Alzheimer's disease, we're talking amyloid plaques and tau tangles. So the abnormal accumulation of proteins in the brain. We also see changes in blood vessels, so impaired blood flow to the brain. We know that blood flow, as it delivers oxygen and energy and nutrients, is really critical for the brain to function as normal. This is one reason why heart disease risk and dementia risk are quite closely tied together, because what's happening in the blood vessels in your heart that might cause a heart attack, very similar processes are happening to blood vessels either on the way to the brain or in the brain, which can affect brain function. And with these, when we're then talking about which factors may be modifiable in terms of dementia risk, probably the best accepted list is a list of 14 factors published by the Lancet Commission on Dementia Prevention, which is overseen by Professor Gill Livingston. Between these 14 factors, they estimate that potentially 45% of cases of dementia could, could be completely prevented. There are other analyses that think it could be even higher than that, but this— the 45% is probably the, the most accepted number. They include things like education, cardiovascular disease risk, so high LDL cholesterol, diabetes, obesity, physical inactivity, smoking, excessive alcohol, brain trauma, loss of vision or hearing, and social isolation. And many of these things are probably factors that people have heard of again and again, Right, when we're talking about what does it take to have a healthy life. And it really seems that if we can address these factors, we can significantly reduce our dementia risk. And I think there are other factors that we, that we can and should build in as well. But even just those core ones may be enough to dramatically change the trajectory of like brain health at the population level.

Did you use socioeconomic status or did one of those come forward? Because it's really hard to do some of these things if you are deeply struggling.

Absolutely. And this is one of the core potential criticisms of this kind of approach, which is that socioeconomic status determines so much of whether these risk factors are modifiable in the first place. Does this person have access to education? You know, can they finish high school? Can they get a college degree? Can they get a graduate degree? I think we have to accept that for, for some of this to change, we need full-scale societal change rather than just saying, hey, you person, you need to fix all these things, because that's obviously not possible for most people. And so some studies— so I mentioned that other studies have suggested that maybe even a greater proportion of dementias is preventable. One study was done in the UK Biobank. They estimated potentially up to 70% of cases of dementia were preventable. But a big chunk of that was due— was if we could change aspects of socioeconomic status and socioeconomic deprivation.

Got it. Finding Master is brought to you by LinkedIn Jobs. If you've ever hired for a small business, you know the real cost isn't just the salary. It's the time that you lose when the fit is off, the momentum that stalls when that fit doesn't work. And that's the pressure of having to get it right while you're still running everything else. That's why I'm paying attention to LinkedIn Hiring Pro. It's built for the reality of hiring when you're operating lean. You describe the role in plain language, and then HiringPro helps you draft the job post, surface the right candidates, and then narrow to a shortlist without turning hiring into another full-time job. And when applications start coming in, it doesn't leave you buried in resumes. It streamlines screening, including AI-powered interviews for initial conversations. How about that? So that you can spend less time searching and then more time connecting with the people who match what you need. With HiringPro, you can hire with confidence knowing you're getting the best talent for your business. In fact, those hiring with LinkedIn are 24% less likely to need to reopen a role within 12 months when compared to their leading competitor. Join the 2.7 million small businesses using LinkedIn to hire. Get started by posting your job for free at linkedin.com/mastery. Again, that's linkedin.com/mastery. Terms and conditions apply. Finding Mastery is brought to you by David Protein. Travel a lot at Finding Mastery, and sometimes travel makes it tricky to eat well. Best intentions and then you're at the airport, and then suddenly the only options around you are the ones that you'd rarely choose at home. Something I come back to often is that discipline isn't really about willpower in the moment. It's often about choice architecture, setting up your environment ahead of time so that the easy choice and the good choice are the same one. That's the role David plays for me on the road. The Gold Bar, it's their flagship, high protein density, great texture, flavors that make it easy to stick with. So when I throw a few in the bag before my trip, I've already made the decision. The hard moment later takes care of itself, and the team here at Finding Mastery—they love the bars as well. They are ripping through them in the Finding Mastery lab. Salted peanut butter and fudge brownie seem to be the fan favorites right now. They have built something with real rigor in a crowded, sometimes ambiguous space like nutrition. That matters when it's something that you reach for again and again. David bars are now available in major retailers like Walmart and Target, and if you'd like to buy them directly and get a special offer for being a Finding Mastery listener, head to davidprotein.com/findingmastery, where right now. And now if you buy 4 packs, you'll get the 5th one for free. Again, that's davidprotein.com/findingmastery. Okay, so from my lens professionally as a high-performance psychologist is that when somebody asks me, like, okay, how does somebody have a high-performing mind? I'm like, geez, you know, it's a bit like the Panama Canal. There's a handful of things that need to take place for the whole thing to work well. And there's a few things that are maybe first movers that do kind of get the other things on a path of development and execution. So when you think about the first movers here, which ones are you most interested in?

When I think about the list of potential risk factors or modifiable factors that affect cognitive function and dementia risk, when we normally interact with these, and we might see them in scientific papers. Those scientific papers might get turned into Instagram posts that you'll see, and which are very evidence-based. But you might have 20 or 30 things as a list, right? And the sort of most truthful answer is, well, the most important ones are the ones that you're not doing, right? Because that's gonna be different from person to person. And I think the way that different risk factors interact in different people over time, then— creates the fact, or the output is that their cognitive trajectory is different over time. And that is different for everybody, right? We don't all experience one trajectory or one kind of rate of decline. Even individuals with dementia all look very different. So I think that tells us that it's this, the way that all these different factors interact within an individual that kind of gives that output. So to kind of understand that, the way I think about it is I have this model in my head that I call the 3S model. And I think the majority of risk factors that have strong evidence for their relationship with cognitive decline and dementia fit into these sort of 3 core mechanistic buckets that interact with each other. So it's not a list, it's kind of like this interacting network. So the first S is stimulus. And in that list I talked about earlier, I talked about education, right? We know that educational attainment is an important risk factor for dementia. So is late-life cognitive engagement, the type of work you do, the hobbies you do, the skills you learn, the activities you engage in, the people you engage with. And I think that the majority of tissues in the body, even outside of the brain but including the brain, Their function is determined by the stimulus that we apply to them. So there's a huge amount of parallels between physical function and cognitive function. You can't quite see the output the same with the brain, but everybody knows that if you want to get stronger and fitter, you have to train, right? You have to lift weights, you have to sprint, you have to go running, whatever it is that you're trying to get better at. The stimulus is the primary driver. And yes, we can get the most out of that training by having adequate nutrition, optimising recovery strategies, all those kinds of things, very important. But unfortunately, you can't drink protein shakes and nap and get bigger biceps, right? I wish it were so, but it's not. You have to go to the gym.

Ah, that stimulus.

Yeah, you need the stimulus.

Yeah, well done.

And I think that all the evidence that we have suggests the brain is the same. And actually, some of the biochemical processes are even identical. So this, I think, is the primary driver of how our brains function, is how we use them, how we engage in the world. And so that's important early in life, and it's important as we navigate adult life and then go into retirement and old age.

Meaning putting your brain under some sort of proper levels of stress. So many people, when they hear the word stress, they're like, no, I don't want more, I don't need more. And you and I would say, no, stress is required. for adaptation, looking for the right levels of acute stress and the right levels of recovery over and over and over and over again in stimulating complex ways is actually the broth for an amazing cognitive performance, if you will. So you're saying just the way our bodies grow, our brains do the same.

Yeah.

We can't see a bigger brain, like a bigger bicep, but we do see what in the brain?

So if we could do scans of your brain, which is done in research, you can see that when people are exposed to a new stimulus, and that could be a physical one. So we've seen in older adults, if you start them on a new training program, depending on the type of training, you can see physical changes in brain structure. Their brains can actually get bigger even in their 60s and 70s, which we never thought was possible previously. And you can see some similar things if people Learn a new complex skill. There are some great studies in London taxi drivers where they memorize this huge map of London and their hippocampi, or parts of the hippocampi, which are really important for memory, they get bigger even in adulthood. So we can see the brain get bigger. It's just that not everybody's getting an MRI scan.

Yeah, it's more of the idea that neurons that fire together wire together. And that study was a groundbreaking study for so many of us because we're like, oh wait, If you do something over and over and over again for an extended period of time and you're really good at it, there's a structural change that takes place. Oxygenation as well would be a really important factor that you just mentioned. And when you're stressing the system, just like your physiological system for muscles or whatever, there would be an oxygen exchange that would be favorable, both from the heart to the muscles to the brain as well.

Yeah.

So do you find the same when you're doing complex, solving complex or doing complex things, that there's also an equal oxygenation?

One kind of core aspect of healthy brain function is this idea of neurovascular coupling, which is when you stimulate a network in the brain, a group of neurons to do a specific task, those neurons and the astrocytes, which are another type of cell in the brain— neurons only make up about half of the cells in the brain. We don't realize there's a bunch more that's going on in there. That was actually the primary argument between Golgi and Cajal was neurons versus other cells in the brain, like which were most important. And so they're all important, but neurons and astrocytes, they stimulate the local blood vessels to expand, to dilate. So the blood flow to those areas of the brain are very tightly linked to activity in those areas of the brain. So this is another reason why it's so important to have healthy blood vessels or, you know, healthy vasculature. But yes, that's exactly it. Those areas become activated. They need a greater supply of oxygen and energy and they ask for it. And those vessels dilate just like what happens in the muscles when you start to exercise them.

It's amazing how important it is. This is why like smoking is such a problem. Sitting is such a problem. You know, both of those alike is that we are starving our bodies for something it really wants, which is oxygen. All right, let's ground the conversation in numbers. So what are the most recent numbers internationally and nationally that you're working from for people that do have dementia?

Right now, I think in the US, somewhere between 7 and 8 million people are living with dementia. Worldwide, 7 to 8 times that, something like that. This number is increasing, and the burden of dementia is expected to double or triple in the next 2 decades. 2 decades. Depending on who you ask, it might be by 2040 or by 2050.

That's alarming.

It is alarming. And there are even news articles where they're saying, you know, Alzheimer's disease is gonna bankrupt Medicare because of the huge burden that it's going to create on the healthcare system. And I think it's important to think about why this is. And also, there are other ways to look at the data that are not necessarily Quite as alarming, and they give us some hope. So one reason why the burden of dementia is expected to increase is because we're living longer, and we're living longer because we've become better at treating other diseases. And so heart disease has been the number one cause of death in the U.S. for a long time. It's probably going to stay that way, but the numbers are decreasing. And so, and Alzheimer's disease is kind of making its way up the list, where actually in many high-income countries is expected to be the number one cause of death in the next couple of decades.

I didn't think that Alzheimer's killed people or that dementia killed people.

So it's often kind of the primary driving factor, and then there's complications, right? Because you become bedbound, you fall, pneumonias, like those kinds of things.

It's a first domino, or it's an important domino.

Yeah, exactly.

Not the first. Yeah, okay.

Like kind of like the underlying thing.

Yeah, okay.

And of course, there could be things like sometimes people could get seizures or other things that were, and that's kind of like the trigger, but it's sort of that fundamental change in that individual then drives their risk of the thing that might be the final cause of death.

So we need to stimulate ourselves, including our brains, right? Okay, so that's the first S of your model.

Yeah.

Second S?

So the second S actually ties in very nicely with why I think we don't need to be so worried about the numbers. We should worry about the numbers, but why they don't need to be as concerning as why they might on first blush. So when you look at one way of sort of slicing the data on dementia, we might look at something called age-specific incidence, which is at a given— at a certain age, how likely are you to be diagnosed with dementia? So at 70 years old, or 80 years old, how likely are you to be diagnosed with dementia? And age-specific incidence has been decreasing for the past several decades. At 70 years old now, you are less likely to be diagnosed with dementia than any other time in history. One of the reasons why it's thought that age-specific incidence is decreasing is because we've done quite a good job at the population level of treating and preventing heart disease. And—

So the heart is doing better.

Yeah.

We've got medication, we've got behavioral and psychological remedies. And so there's more oxygenation taking place, so the brain is a little bit better.

Yeah.

So we've pushed down the road this kind of set of complications.

Yeah. And so on top of that, of course, we are living longer. And so if we do get dementia, we may just get it later.

Yeah.

But it gives us this— it shows us that if we do these large-scale interventions, we change things at the population level, we improve healthcare on these— related to these risk factors, we could actually start to move the numbers on this. So that's why I think that gives us some hope. And so why this ties into the 3S model is because the second S is supply. So we already talked about blood supply, why it's important. Another supply that's really important is energy supply. So the brain primarily runs on glucose. It can run on some other things, lactate and ketones, and depending on what state you're in, but you need healthy energy regulation essentially. So metabolic health is critical. This is why diabetes or metabolic diseases or metabolic syndrome is a risk factor for dementia. Is because it impairs energy metabolism. We also need a supply of nutrients that make neurotransmitters that help create the actual physical structure if we're rebuilding that or building that. And there are some nutrients that have quite good evidence for their relationship with cognitive function later in life and dementia risk. So omega-3 fatty acids, vitamin D, iron, and B vitamins are probably the ones with the best evidence. There are some others, certainly zinc, magnesium, flavonoids and polyphenols, fiber. So like all these things that you might get from a—

Let's just pick those apart. Those are really important. People throw them around like, I did not know how to create an intelligent intervention until I started to measure them, right? So I could very easily go find a high-grade omega and take 2,000 milligrams. Is that the right? Yeah, something like that. 2,000 milligrams on average. And I was doing that for a long time. I do it twice a year. Just take a look at my nutritional panel on it. And yeah, I'm kind of wasting money. But I'll go on and off now because I'm tuning to it. Same with vitamin D and whatever. So, can you just kind of go down your best practice for either measurement and/or just kind of a general guidance on how to go about being better on those supply functions?

Yeah, ideally, these are things that we would get measured and assessed. And that's getting easier and easier to do.

It is.

So get your cardiovascular disease checked, you know.

What age?

At least probably starting in your 40s.

Yeah, that's, that's the number I have in my head as well. And then I'm starting to see people talk about why not get one 18, 20, in that range as a baseline. Would you have any concerns about a young baseline?

I'd have no concerns about a young baseline. What it comes down to really is access, and then how you interpret it and how you act on it.

Yeah.

So one of the hardest things for doctors to do is not do anything in response to a test result. It's mainly avoiding being overzealous and just like suddenly like spraying everybody with supplements and medications that they might, that they might not need. But we know that the primary time at which risk starts to diverge in terms of dementia is midlife. So really late 30s into the 50s, early 60s. that's when the risk really starts to increase. So that's the critical period when you'd want to make sure as much as possible that you're addressing these things. The 2 cardiovascular or metabolic risk factors that are most closely tied to dementia risk are blood pressure and blood sugar. So having high blood pressure or being pre-diabetic or having type 2 diabetes.

Yeah.

And there are data from randomized controlled trials that show that if you have high blood pressure and you treat it, you significantly decrease dementia risk. So that's one that we have some, some pretty good evidence for.

So say it again in the converse. If you have type 2 diabetes or you have an issue with the metabolic structure of glucose, what is the likelihood that you would have dementia?

The best answer is I can't give you an exact number. It's something like a 2 to 3-fold increase in the risk of dementia. But like, when we talk about changes in risk, That's assuming everything else is the same. You only change that. Like, this is— these are kind of like statistical things that come out of a specific model, right? So one thing that I, I try and avoid as much as possible is put an exact number on something for that reason. We know that it's a meaningful increase in risk, and you will meaningfully decrease your risk if you address it. But like, whether it's 2.5 times or 3.5 times. There's this— we have this thing like precision bias. Like, it sounds smarter because I can give you a number, but in reality, there's also an error band around that, and you'd have to talk about the exact model that gives you the numbers.

Yeah, I mean, what you're pointing to is a meaningful trend.

Yes.

That if this is the case, then there's an increased chance.

Yes.

The number is not as interesting.

Yeah.

However, for a whole host of factors— pre-diabetic, type 2, You know, type 1, getting that under belt is a really important investment in overall health.

Yep.

Dementia and otherwise.

Yeah, absolutely.

Okay. All right. Okay. And then let's just stay here for a moment that folks that might be on that arc. Finding Mastery is brought to you by our flagship mindset training course, Finding Your Best. Anytime you feel the pull to reset, to zoom out, to refocus and ask, am I moving toward the person I want to become? It helps to remember this. Lasting change comes from training, not resolutions, not short-term sprints, but deliberate practice of the skills that shape how we show up in work, in relationships, and in the moments of great intensity as well. That's what Finding Your Best is all about. It's a science-backed framework for training your mind. It's the same set of tools that we've taught to Olympic athletes, top executives, elite military teams, and artists at the peak of their craft. In this course, you'll learn the foundational psychological skills to be your very best, full stop. And the best part is you can start anytime. Right now we're running a limited time offer on On finding your best. Simply head to findingmastery.com/course and use the code RENEW100 to get $100 off your registration. If you've been waiting for the right moment, this is a good one now to lean into. Spring and summer, they are powerful seasons of momentum. It's a great natural time to step into growth, to refocus, to recommit to who you want to become. And this discount will not be around for long. So go to findingmastery.com/course, code RENEW100. RENEW100 for $100 off today because your future is not shaped by what you intend. It's shaped by what you train. Body Mastery is brought to you by Momentous Fiber Plus. Here's a stat that surprised me when I first came across it. Nearly 95% of us are not getting enough fiber. And the thing is, most people think that they are. That used to be me. I eat well, I'm intentional about whole foods, and I still wasn't hitting it consistently. And fiber matters. It's one of those quiet, unglamorous fundamentals that shapes how the rest of your system runs, your gut, your energy, how well you absorb everything else you're putting in. So when Jeff Byers and the team at Momentous reached out about FiberPlus, I paid attention. I've been using their products for years, and the reason I keep coming back to them, it's pretty simple. They don't chase trends. They go deep on the fundamentals and they build it to a high standard. And the same holds true for FiberPlus. It's clean, no artificial flavors, no unnecessary additives. The cinnamon flavor uses real cinnamon bark powder and it tastes great. And I don't usually say that about fiber supplements. I mean, they built this thing right. Like everything they make, Fiber+ is NSF certified for sport, which is why it's trusted by over 200 professional teams and athletes. That's the Momentous standard, and that's why it's been part of my routine. If you want to upgrade one of the most overlooked foundations of your health, head to livemomentous.com/findingmastery and use the code Finding Mastery for up to 35% off your first order. Again, that's livemomentous.com/findingmastery. The code is Finding Mastery for up to 35% off. Do you have any best practices that are of interest to you?

With metabolic disease broadly now, um, so say if you have type 2 diabetes, you know, we have some pretty good medications like metformin has some, has some good evidence for it. Um, and then there's also obviously lots of evidence around, you know, dietary change, physical activity, lifestyle plays a huge role here, right? Lifestyle is the primary driver of these diseases in the first place. If lifestyle changes aren't enough, which for some people they aren't, and that's fine. Right now, the GLP-1 agonists are doing— I mean, they're doing an incredible job decreasing metabolic disease risk and heart disease risk. We don't have the evidence for dementia yet. Those trials are being done. But I think that in terms of the big shift we're seeing in terms of obesity, metabolic syndrome, dramatic improvements in blood sugar, blood pressure, I expect that we're gonna see that really pay off in terms of dementia risk if people are addressing it that way.

What about folks that are, you know, we're in the land of Los Angeles here where folks are 3 pounds overweight, you know, like, I don't know, some ridiculous number, and they're using GLPs to really, shape their body, but it's an off-label use, let's call it, to be generous. What are some of the risks for that population of folks? Because at the Finding Mastery community level, I do not want us to fall into the trap of needing to look a certain way to be okay. And I do want you to use every lever that you possibly can to be your very best— psychological, behavioral, physiological, medicine, like all of them. And so, but what is the dark side of folks that are trying to look a certain way when they actually don't need it?

2 parts to it. One, maybe you can speak to as well, which is the psychological side. From the health intervention and the lifestyle habit literature, there's actually quite a lot of evidence that says that if you're constantly saying that you're not doing enough, right? I think I should be sleeping more. I think I should be exercising more. regardless of how much you are actually sleeping or exercising, you tend to have worse health and worse health outcomes. And I think that that's because of the effects that our mindset and our psychology has on our physiology that we can physically measure. You see changes in autonomic function. The other side is, well, there's, I guess, two, then we could break it apart two ways as well. When we're then looking at, say, the evidence or the potential downsides of taking, say, medications to look a certain way, The best evidence that we have when it comes to metabolic health, body composition, things like that, and as they relate to most chronic disease, dementia risk, is that you mainly just want to avoid the disease state, right? So if you don't have prediabetes, if you don't have high blood pressure, like, you're good. Like, more isn't more as far as we can tell. And so Constantly trying to optimize for a certain number below those thresholds. We don't actually have evidence that that's any better for your health. All interventions have side effects, right? There's been a lot of talk about GLP-1s and muscle loss. I think what we've started to see more of, and this is particularly in the setting of obesity or metabolic disease, is that yes, some lean mass is lost. But a lot of it is probably fat being lost from the liver, which counts as lean tissue, and also fat being lost from the muscle, which is actually a good thing because that improves muscle function. And often strength is maintained. So I think some of the concerns about muscle loss have been oversold. But equally, you can get to the point where you're not eating enough to maintain nutrient status, get adequate protein, to then have your body get everything that it needs. Most of the data we have so far on muscle loss comes from individuals who were potentially obese to start with, or they, you know, had obesity to start with. So there's actually far less data on people who are a normal body weight who then took GLP-1s.

Yeah, right.

Because they're not the people in the studies, because this is the off-label use. So I would still have concerns about muscle loss at that lower end, particularly if they're not eating enough to fuel enough and they're not doing resistance training, which is the primary way that you would then build or maintain that muscle mass.

How important is it to get glucose/pre-diabetes? Like, how, how important is this when we're going after optimization?

Again, there's 2 parts to that. One is the avoiding pre-diabetes or diabetes, because you do see significantly increased risk of dementia, but also, you know, several other conditions— heart disease, depression, There's a whole host of conditions that come with, you know, dysregulated blood sugar or increased risk of them at least. And so avoiding that or reversing that is important. But beyond that cutoff, I don't think we have great evidence that there is like some truly optimal range. And so like often what you'll see is people will say, oh, well, you know, I don't have prediabetes, but my fasting blood sugar is 90, but it would be better if it was 80. For most, conditions, we don't actually have evidence that that's true. So I think that we can get into a trap of constantly chasing these numbers when we don't have that much evidence that more would be better. And there are opportunity costs as well as side effects of things we might be taking off-label or things that we don't get to do or enjoy because we're so worried about these numbers when, when actually we're not necessarily doing something that has a lot of evidence behind it.

Okay, so stimulus, supply, and now we'll get to support. Yeah. What is the 3rd S really about for you?

Maybe before we get support, I'll— because we didn't touch on like nutrient blood tests, we could just quickly cover those. Great. So again, we have some pretty good cutoffs for things we might, might try and achieve or avoid. So a vitamin D level at least of 30, right?

Because below that, risk of dementia increases, particularly below Just for you, do not talk about general advice for people, 'cause we're both gonna say, go get your levels measured. How much D are you taking? How many IUs of D are you taking?

So I take, in the winter, I take 3,000 a day. And that keeps me above 40, which would, which would kind of like my target. So we have some other evidence from like the sports performance literature that maybe a kind of like a 40 to 60 range is sort of like the best spot to be in.

Especially in the Northwest, when we would measure, second or third-year athletes that were with the Seahawks, we'd see a decline indeed because of the, the sun, the lack of sun. So it's a pretty massive competitive advantage to get D right as a high-functioning and even just well-functioning person. Yeah.

So, okay, then B vitamin status again has some of the better evidence for it is homocysteine. Homocysteine goes up when you don't have enough of one of the methylation-supporting B vitamins.

And why is homocysteine important?

Homocysteine seems to do a few things. It can affect blood vessel function, so it's related to heart disease risk as well. When you look at animal studies, and so it's very hard, it's impossible to test this in humans, but it seems that homocysteine may accelerate the phosphorylation or hyperphosphorylation of tau that creates tau tangles.

The tangles.

Yeah. So it may contribute in that way too. People who have an elevated homocysteine have a higher risk of dementia. There have been multiple randomized controlled trials that have shown that if you decrease homocysteine with B vitamins, you decrease the rate of cognitive decline and decrease the rate of brain atrophy. And so the target would be at least below 13, ideally below sort of 10 to 11, so single digits if possible. That effect of homocysteine lowering seems to be dependent on omega-3 status. So now there are several trials that show that if you improve omega-3 status but you don't look at homocysteine, you don't see any benefit. And if you improve homocysteine but you don't look at omega-3 status, you don't see any benefit. You need both to benefit. And there are, there are probably a whole bunch of other dependencies when it comes to nutrition as well. This is just the one that's been best studied. But people will hear all the time, oh hey, we did this trial, we gave people B vitamins, nothing happened. B vitamins don't work, right?

They weren't looking at the combination.

Because they weren't looking at all the things that were working together.

That's the Panama Canal thing that I was mentioning earlier. Like, you do need a handful of things to work together to do right.

So then you've measured your omega-3 status, and probably the best evidence test is an omega-3 index. Real risk is when it's like 2 to 3%. And so the omega-3 index is the percentage of the fatty acids in your red blood cells that's made up of EPA and DHA, which are the 2 sort of long-chain omega-3 fatty acids. Risk really starts to come down once you're above 5%. Ideal is probably at least 6 to 8%, but you just wanna avoid being at 2 to 3%, like if possible, you know, get it above there. And then the final one that we have some good evidence for is iron status. So anemia in particular increases the risk of dementia. Probably about 10% of perimenopausal and postmenopausal women in the US are iron deficient. And iron deficiency, particularly in that period, sort of like the perimenopausal transition, early menopause, increases the risk of cognitive changes during that time. So like getting iron status right is really important. If you're going to measure your hemoglobin, which is one sort of— which is one way that you would assess that. So you measure hemoglobin level, you want it at least above sort of 12.5 in women, 13.5 in men. And if it's below that, you have an increased risk of dementia. But if it's very high too, that's something that you should check out as well.

Okay, shift gears. I want to stay here one more time before we get to your 3rd S, which is support. Can you speak to folks that are not eating red meat, concerns that you have, or are you like bullish on that? And then can you speak to people that are not eating meat at all, vegan, vegetarians, and are you in support bullish on that?

The way that I think about it is that nutrients are the great leveler, I call them. So those nutrients we talked about, some of the other things I mentioned briefly earlier, it's important that you get enough of them. I care much less where you get them from. So depending on the study that you look at, you know, a small amount of red meat is sometimes associated with an increased risk of dementia, sometimes actually associated with a decreased risk of dementia. I think some of that probably comes from the nutrients in it, right? It has B12, iron, Zinc, some other things that we know, that we know are important. I don't think we have good evidence to say that a normal amount of red meat increases the risk of dementia. And for some people, it may be an important source of nutrients. I also don't think that it's something everybody has to eat, right? As long as they're getting those other nutrients, those nutrients from other foods. So people who are eating a plant-based diet in particular, we know they're at an increased risk of B12 deficiency. I think anybody in that world now appreciates that. And they should take a B vitamin supplement and maybe measure those things. Iron also potentially too. Maybe red meat is a good source of iron for some people, but not everybody needs it. So again, I would just like tailor this to your personal needs. If you have dietary preferences, that's fine. This is where sort of the testing or eating more of certain foods that fit within your dietary pattern that have those nutrients to kind of make up that gap is great. We do also now have some evidence that especially— well, this is in older adults, so this comes from the COSMOS trial, which is a massive trial done recently in the US that gave half of the participants multivitamin, and it was Centrum Silver, like the most basic multivitamin, just 100% of the recommended allowance.

They consider it a vitamin?

Yeah.

Still?

Yeah. Okay, I'm joking. So I think this is potentially important because There's no like megadoses of anything that could, you know, which if you take for long periods of time, some of this stuff can get a little out of kilter. Like when I work with my athletes, every sports supplement has B6 in it, right? And so like when you take 3 or 4 different things, we get their blood tests back and they're just like stuffed full of B6 because it's everywhere. And we know that if you take very high level, very high amounts of B6 for long periods of time, it can cause like some neurological symptoms. and stuff. So like, with that kind of really basic multivitamin, you're making sure you're getting at least the basics, but you're not kind of at risk of overdoing anything. And in the COSMOS study, those who took the multivitamin, you know, had some improvements in cognitive function. So I think that especially if you have some concerns about your diet, like a base— like a basic multivitamin, we now have some good evidence for from a cognitive standpoint. But as long as you're getting those core nutrients, like I said, I think it matters much less where they come from.

And that was double-blind placebo effect?

Yes.

So they beat— that beat a placebo?

Yes. The COSMOS trial was a 2x2 study, they call it. So there were actually 4 groups. One group got only placebos. One group got a cocoa flavanol. Another group got a multivitamin. And then the 4th group got both the cocoa flavanol and the multivitamin. And they were looking— they looked at a whole bunch of outcomes like cardiovascular outcomes and things like that. And the multivitamin seemed to be beneficial from a cognitive standpoint across both the groups that got it. The cocoa flavanol only seemed to be beneficial in those who were eating a low-quality diet and therefore weren't really getting other antioxidants from the diet, because the cocoa flavanol sort of acts as an antioxidant. So if you're not eating Fruits, vegetables, berries, maybe not drinking a lot of coffee or tea, which is where some of these compounds come from, then that kind of supplement seemed to be beneficial. But if you were eating a diet that contained them, there didn't really seem to be any benefit.

All right, while we're on the supply here, one more turn is that, are there any supplements that you're really interested in right now, like alpha-GPC or phosphatidylserine, or are there others? You know, things that are not really on the base of the omegas and the B and the D.

The only thing that we might consider more broadly, not necessarily because we have the most amazing evidence for it, but because the evidence is increasing and we know it's incredibly safe, is creatine.

Yeah.

So creatine seems to be, you know, there's potentially some benefits after, you know, in setting of brain trauma, individuals with depression, Multiple studies now in the setting of sleep deprivation seems to improve sport-specific skills in athletes, some aspects of decreases fatigue under sleep deprivation. One pilot study in Alzheimer's disease, but there wasn't a placebo control, so we don't really know whether creatine was what actually drove some of the improvements in cognitive function they saw. But in older adults, creatine may particularly be beneficial for memory function, and there are some meta-analyses that show that.

2011-12 was my first year with the Seattle Seahawks, and I brought in a colleague. And do you remember Professor Greenhoff? He's a UK-based professor. He did some of the first original studies on creatine. And so, I brought my colleague in, and Professor Greenhoff and my colleague, Paul Winsper, and I were sitting, we were on a board together. And Paul came in and he says, why is there no creatine here? This is 2012.

Uh-huh.

2011. And I said, ah, it's league policy.

Yeah.

He said, this is criminal. Like, you're asking these guys to do A, B, and C, and you don't have the most basic fundamental— what is creatine? I want to say it's an amino acid.

It's like a peptide from 3 amino acids.

Yeah. And he said, this is criminal. And so he harped and harped and harped. Now you can't go in an NFL, probably any sport organization, and not find creatine. One of our partners that is a great supporter of this podcast, Momentous, they just moved to their own first-ever creatine. I'll get you some of it. It's called Signature Spec. They developed it. It's really good. It's totally different as a form function with all the right kind of qualities. So they've been great. They've done a nice job of educating people on it. And so you're into it as well?

Yeah, so I mean, I take creatine every day. I have for a long time.

What about the risk? Older people start I interrupted you. I'm more interested in what I'm about to ask, though. What about for you? Because I was going back to the older folks, is that creatine to creatinine, okay? And I would love for you to dispel the connection between creatinine and liver.

Yeah.

So I'm thinking about older people, maybe the liver is a little bit weaker. I don't know if that's fair to say or not. And here we are pumping creatine. I've read the research and I'm still kind of confused. And can you, can you open that up a little bit for us?

Sure. The first thing I'll say is they've actually done studies where in frail older adults, they're giving them very high doses of creatine for long periods of time. So there was one randomized controlled trial in Parkinson's disease.

10 milligrams?

20 grams a day initially. And then I think it was 10 grams a day for several months afterwards for 2 years. This is a potential treatment in Parkinson's disease. It was a small trial. It didn't show any benefit. But it also didn't show any negative side effects. So like, that's an important— that's important context, is that even in frail older adults, we still haven't seen like negative side effects of creatine. The thing that does potentially happen is that creatinine goes up. So creatinine is used as a marker of kidney function. Creatinine is actually not a good marker of kidney function. It's actually a very dirty marker of kidney function. The primary driver of your creatinine level is your muscle mass.

They're always asking, are you working out?

Yeah.

Yes. Are you taking creatinine? Yes. Well, it's probably not a big deal.

Yeah.

Is what I get. And then I look at the research and they're saying the same thing, but I don't want a high marker of creatinine knowing that I've got a potential compromised kidney function.

So, so your creatinine level, it's, it's used because creatinine is constantly filtered out by the kidneys. So if it goes up, it suggests that your kidneys aren't working as well.

So you have to look at GFR, eGFR.

No. So eGFR is just calculated from creatinine based based on like body weight and things. So if it's adjusted for your weight or body surface area, if your eGFR is adjusted for body weight or body surface area, then it's more useful. You're using that creatinine number, but you're taking into account the size of the person, which is important because muscle mass is the primary source of creatinine in the blood. And if you increase creatine intake, creatinine is just a byproduct of creatine being phosphorylated and used for energy processes in the muscle primarily. And sometimes it creates creatinine and it gets sent into the blood, and then the kidneys filter it out. So there are studies that suggest that if you take creatine, creatinine levels go up. But there are also studies that have used a more accurate marker of kidney function called cystatin C, and cystatin C does not change when you take creatine.

Hmm.

So creatinine goes up because it's kind of like a— it's a dirty marker, but cystatin C doesn't change. So there's no evidence that creatine negatively impacts kidney function, like the actual function of the kidneys. It's just the nature of the marker they're using. I can tell you, I'll tell you a personal anecdote. I was once hospitalized for a snakebite in Costa Rica. I spent nearly 2 weeks in the hospital.

Oof.

And yeah, I— so I got bitten by a pit viper, the Terciopelo fer-de-lance, in the Costa Rican jungle. And I needed obviously the antivenom. And then I got a severe abscess they had to drain from my leg. I had like bad cellulitis, so skin infection went like all the way up my leg. It was antibiotic resistant, so I needed like third-line antibiotics. And then I got serum sickness that in response to the antivenom, so I'm like whole body hives. So they had to fill me with steroids and antihistamines and stuff. Like the the doctor like joked that like it's always the gringo tourists that get all the get all the side effects. Those are his words. Like and they nearly didn't let me go home. because my creatinine was slightly elevated. And it's a combination of my higher muscle mass and that I take creatine supplements. But they were terrified that my kidneys were failing because of everything.

The reactions to serum.

Yeah, reactions, all the things that were going on. But I had to be like, no, it's fine. This is just normal for me.

Trust me, I actually do know.

That's great. So, this is just worth bearing in mind, because particularly if you're older or maybe you get a test for kidney function, you get your creatinine measured. It's a very normal part of a typical blood test. Just like let your doctor know that this is something you're supplementing with. But like so far there's no evidence that it's actually negatively impacting kidney function.

Okay. So the connection— I'm glad we're talking about this— the connection between creatine and brain health, creatine and dementia, can you just, can you wrap that up for us?

Yeah, so no evidence that creatine decreases the risk of dementia. Like, we, we couldn't say that. But particularly under a group of conditions where maybe your cognitive function has been affected in some way. So brain trauma, sleep deprivation, maybe with some cognitive decline later in life, because creatine seems to be most beneficial in healthy, you know, quote unquote healthy people. Creatine is maybe most beneficial in older adults. So maybe they've already experienced a bit of decline. In those states, we do, like, across all the evidence we have, there does seem to potentially be some benefit. Like, we're not gonna pretend it's magic. But there are, there are trials in all of those areas that say there could be some benefit there.

You would say it would be foundational as a first mover supplement for brain health is to take creatine or eat enough red meat. God help us. I don't know how you would to get that level of creatine into the body right now.

If you are thinking about supplements for cognitive function, particularly if one of the things that I mentioned applies to you, then creatine would potentially be the place to start. And the reason why I'm more bullish on creatine than other supplements broadly is because we know it's incredibly safe.

Are you at 5 milligrams, 10 milligrams? What are you taking?

I take usually 10 grams, 10 grams a day.

Yeah. And is there a difference that you're aware of between genders?

No. A recent study that gave 10 grams of creatine a day to menopausal women in concert with a resistance training program. So like the resistance training or resistance training with creatine, and there was potentially some additional benefit on, on bone health. It was minor though in the creatine group in addition to the resistance training. Um, but again, so in that kind of age group of women taking 10 grams a day, certainly no, certainly no issues in terms of side effects. So, so like the dosing seems to be similar.

Yeah, from a side effect standpoint.

Yeah, yeah, yeah. And also in terms of Like efficacy.

Okay, this is great. Let's get us to a 3rd S. Okay, so we're on support.

Yeah, if you think about, right, you've stimulated the brain, you're doing some like new complex challenge, learning a new skill or something, you've activated this increase in supply to those areas, right? More blood flow is brought in, brings in the nutrients and oxygen and all that kind of stuff. And then you need a period of adaptation so the brain can like respond to the stimulus that you apply to it. Right? So if we go back to the athlete and physical function example, right, no athlete gets stronger in the gym. They get stronger when they recover afterwards, right? And the brain is essentially exactly the same. So we apply a stimulus, we give everything we need to respond to that stimulus, and then we need a period of adaptation. Most of this happens during sleep. So this is the support S. Sleep is a critical component of that. That's when, you know, new synapses are cemented. This is when neuroplasticity happens. This is when memories are kind of integrated into The bigger picture of what we know about the world is where our emotions are processed. You know, all this kind of critical stuff happens during sleep. We can also support adaptation with other aspects of physical health. So hormonal status can certainly play a role here. Trophic factors produced during exercise, like brain-derived neurotrophic factor, that helps to support sort of neuroplasticity and skill learning and development. And then we want to avoid things that impair adaptation. So that kind of fits into the support bucket too. So Things we've already talked about— smoking, excessive alcohol. Air pollution is increasingly appreciated as a risk factor for dementia because it dramatically increases sort of inflammatory processes that we know can impair cognition. Oral health, so dental disease, gum disease, is another increasingly appreciated risk factor for dementia. And then sort of like a broad bucket that we might just call chronic stress, right? So we, we've already touched upon like acute stress being really critical to function. Like that's what drives adaptation. But if you never switch that off, like chronic stress essentially causes like an overtraining picture in the brain. It never switches off. It can never recover. It can never adapt. It may even like be impairing sleep and some of these other things. So that group of things kind of comes into the support bucket, kind of balancing what allows the brain to actually adapt to the stimulus that you've applied to it.

I really appreciate your model, and I appreciate that you didn't name it like S for sleep, right? You did support. You know, there's a whole bunch of things, sleep being a really important one. Another level of support is, you know, the social engagement with other people. And I would even add probably underneath support, when you are in service to something greater than you and you are the support mechanism for others or a cause greater than you, which is probably not how you've organized the support, but just flipping it, being in support as a massive protective factor.

So what I like about Thinking about it like this, it kind of helps us appreciate why certain things are so foundational to brain health. And like just like one area you can make improvements, you can see improvements across the entire network. So yes, we know that pro-social behavior has huge effects on physiology, well-being. Like people who volunteer more have a lower risk of dementia. People who care for or look after others have a lower risk of dementia. And it's fitting stimulus, it's fitting that kind of effect on autonomic balance and how that affects inflammation and immune function, right? So it's coming in that kind of pro-social, in, you know, acting in something greater than yourself is actually hitting multiple nodes of the network at the same time.

What do most people get wrong about dementia?

I think maybe 2 things. One is that it's inevitable, right? Which we've talked about a lot already.

Meaning it's not inevitable.

Meaning that I don't think it's inevitable. That doesn't mean that you could guarantee one person couldn't experience dementia, if that makes sense. But you could— I think that we have evidence that you could change that trajectory. But there are still aspects of dementia that we don't understand. There are still cases of dementia that we wouldn't consider preventable, right? So I'm kind of talking big picture population level. But I don't think we should consider it to be inevitable. And genetics and other things come into play here. But even with, in the setting of genetic risk, you can decrease that risk with all the kind of stuff that we've talked about already. The other thing that I think we get wrong that is improving now is that each of those dimensions that I've talked about, historically, we have focused and by we, I mean a neuroscience, neurology community, have focused purely on the proteins that we see accumulate in the brain affiliated with that type of dementia. So like amyloid and tau in Alzheimer's disease. And those are absolutely part of the disease process. But we also know that people can experience Alzheimer's disease with not that much amyloid and tau in the brain. And there are people who can have brains stuffed full of amyloid and tau and their brains work just fine. Right? So they are absolutely part of the picture, but now we're appreciating other things like inflammation and changes in blood vessels and, you know, the factors that affect those. So historically, I think we kind of painted ourselves a bit into a corner by just focusing just on what the brain looks like under a microscope after you've died, when actually that gives you a very incomplete picture of all the things that that person was and that affected their cognition.

If a parent has dementia, can you speak to the listener here about how they should be thinking about themselves?

There are a couple of pieces to this. One is the genetic piece, right? So for example, the most common genetic risk factor for Alzheimer's disease in the population is your ApoE genotype, apolipoprotein E.

Which you can measure.

Which you can measure. ApoE4, if you have one copy, it increases your risk by maybe 2 to 6 times. Um, 2 copies 6 to 20 times, something like that. From all the data we have so far, it does seem that APOE4 primarily acts as a risk multiplier rather than being like this really big baseline risk that you can't change. So those who have 1 or 2 copies of APOE4, they get an even bigger increase in risk if they drink a lot, or if they have a poor quality diet, or if they have a sedentary lifestyle, or if they have cardiovascular disease. By the same token, they may get larger benefit if they address those risk factors, if that makes sense. And there are actually several population studies and several populations where APOE4 doesn't increase the risk of dementia. And I think that's largely because of like a gene-environment interaction. So that suggests that the risk associated with APOE4 is also modifiable. And there are studies that show that, say, treatment of high blood pressure and high cholesterol— so taking a blood pressure medication and a statin is particularly beneficial in those who have APOE4 in terms of their dementia risk.

Who do we ask and how do we ask? What are we asking for? For that, I don't know how— I don't know how it happened for me, but my doc was like, hey, you want to get this measured? It was— I can't remember what blood test I did it with. I cannot remember. But— and he's like, yeah, I think you should do it. And I was like, yeah, let's do it. And so— but what would somebody ask for?

You would just ask for your APOE genotype, which is short for apolipoprotein E and is spelled A-P-O-E. if people are looking it up.

Yeah.

Okay. But equally, it is worth thinking about, like, what will you do with this information? Because in reality, the answer for what you should do to decrease your dementia risk is gonna be the same regardless of your APOE4 genetics, right? You might take it more seriously if you have a copy of APOE4, but if you don't have a copy of APOE4 and you smoke and drink and don't exercise, I'm still gonna tell you to do those things.

There you go.

That's right.

So whether you have it or not, yeah, behaviorally and psychologically, there's still a whole bunch of things that you can do. Yeah. To decrease your chances of dementia and/or increase your chances of vitality. Yeah, exactly. Through the end of your life. Yeah.

So then more broadly, we also know that if you have a first-degree relative who had dementia, you have an increased risk of dementia. So some of that is genetic. But there are also studies that show that And unsurprisingly, lifestyle-related risk factors also transmitted across families, right? You're more likely to move and eat and sleep and live your life like your parents did. So if you had a parent who had dementia, a great place to start is think about what are the risk factors that I have that I share with them, because that's going to be at least part of that picture of risk. That's maybe the, the place that you would begin to make some changes.

I love your framing. Is this you doing some gymnastics with the data, or is this like the way that you see data?

I genuinely don't think it's gymnastics with the data. When I see all of this, I see hope because so much of this is modifiable. Yes, what each individual can do, the resources they have, the time they have is different, but you have to first know that it's possible. And that's what you consistently see across all these pieces of data. Something that I learned a little bit about when I was in medical school, actually not in medical school, but I was just like doing this at the time, was learning to think about sort of systems theory, systems dynamics, which is basically this way of— it's used in engineering a lot. My wife's a chemical engineer and chemical engineers do this all the time. So she's much better at this than I am, right? 'Cause she's actually trained to do it. I'm, you know, I know just enough to be dangerous, but it's this idea of building up sort of a model of a system based on all the different ways that things interact within that system. And this sounds obvious, but it's not something we really do in medicine and biology that much. We do it a lot more now. Like, people have heard of like systems biology and this kind of stuff. But when you're talking about the way we analyze data related to dementia risk or whatever, we do these very basic statistical models where we just kind of adjust for stuff and we assume that everything is linear, just kind of like stacks on top of each other. But that's not how biology works. Like, things interact and then they inhibit each other and then they feedback and all this kind of stuff. And so when I try and approach a problem, like often my, like my wife will catch me drawing these things called causal loop diagrams. So it's like all these different arrows and feedback loops and all this kind of stuff. And then it just kind of helps me picture how all these pieces interact.

Is the Krebs cycle just that?

Yeah, partially, yes. And one of the things that I most enjoyed when I was an undergrad student was biochemistry and physiology, which is just full of feedback loops and chemical reactions. And so it kind of— that fits how I think about things.

If none of this, then likely that.

Yeah.

If lots of this, then likely that. If lots of this and none of that and a little bit of this, likely—

Yeah.

So if somebody wanted to see a causal feedback loop, they could look up Dr. Krebs cycle?

Yeah.

And/or what else would you point them to as a classic if they wanted to use their intelligence for systems thinking for something they're trying to solve?

Some like very common examples, which are interesting, though not always that useful. There's one, if you like Google metabolism, have you ever seen that? And just like there's this one diagram, which is like this mess of arrows and biochemical names. And like somewhere in the corner is the Krebs cycle.

Right.

And then there's everything else. And it's usually used to say, well, like, hey, if you think you take this one supplement and you throw it in here and you're gonna like fix everything, like, you're not, because it's way more complicated than that. And then there's also one, a famous one around the causes of obesity, which people could easily Google. And then, right, of course there's all the like how you eat and how you move, but then like you go several layers out and it's like society and socioeconomic status and like all these other things. And you can like go down to biochemistry and you can go up to the environment and like all of it's kind of in there. What I find most useful, which is one way that you can use this idea, is you sort of draw out some version of your model and then you look for what are common themes? Where are there nodes in the network that lots of things sort of coalesce? Where are there potential intervention points that affect lots of aspects of the network? And so some version of doing that is what resulted in the 3S model. Right? And it's not gonna capture everything, but it gives us enough to kind of understand, oh yeah, these pieces interact with each other, and like, this is how things are acting. So like, the alternative is you can make one big, very complex computer model and try and sort of like model all this stuff and make changes and see what happens. But for me, as like a thought experiment, I quite like to sort of like distill it down. Like, can I find some really basic core themes that kind of emerge from this complex system.

It's cool. You are a systems thinker that can drill all the way down into the nuances of lots of singular properties, which is fun. I wanna take a second here to tell you about a morning routine that I've been using for years. For me, it's a great way to switch on my mind, to ready myself to take on the day. So before I check my phone, my emails, market updates, or text threads, I choose how to start my morning. That's always in my control. That's always in your control too. This is the same morning mindset routine that some of the world's top performers across sport, business, and the arts are using. And the best part, it only takes about 90 seconds to do. So just head over to findingmastery.com/morning to download the audio guide for free. Again, head to findingmastery.com/morning to get your morning mindset routine. Can you speak to the listener directly that is noticing that they are on a cognitive decline? They can feel it, they sense it. Maybe others don't quite understand or can observe, or it's just starting to happen. I'll tell you, my grandfather had vascular dementia, and he was so smart and so socially tuned and so clever. We didn't know for a long time because he could, he could fit in a conversation still because of his social intelligence was incredible. So I'm asking you to just speak to the person that is noticing it themselves.

Yeah. What your grandfather experienced is actually very common, is particularly individuals with sort of high levels of cognition, intelligence to start with. They're very good at hiding it. The brain sort of adapts and they don't even necessarily know they're doing it. They're sort of like filling the gaps, and they can kind of play along for a long time. Sometimes the individual doesn't even notice. Like, sometimes it's other people that notice it. But if a loved one is noticing or like says something about changes in you, or you're noticing changes— previously, this was never considered kind of part of the framework of cognitive decline. Like, it was— you would get a diagnosis of something called mild cognitive impairment, and then that was sort of that. If that trajectory continued, you'd get a diagnosis of dementia based on the amount of— function. Now there's an appreciation for this period that they call subjective cognitive decline. And different people will argue about like how you can measure that, because if you have subjective cognitive decline but you did some of the standard cognitive tests that they do for diagnosing dementia, you would do just fine because they're very basic. And so one thing that has been a problem that will hopefully improve over time is like we talked about, you know, measuring your blood pressure and your blood sugar when you're 18, you know, measuring your lipids in midlife. We don't routinely measure people's cognition until we think they have a problem. So we don't know what that trajectory was because the tests are too coarse to do that. We need much more nuanced things and have everybody have access to them. And there are some companies, kind of like one that I work with, that's sort of like working on that. Just like make it that everybody does cognitive function tests. And the goal isn't necessarily to get in the top 1%, right? The goal is just to maintain whatever it is for decades.

Is there a place that we can go to?

Yes, there's a company that I'm chief science officer of called BetterBrain. They have a free brain health platform that has a few different flavors. So one is like an AI self-guided process, free to anybody. It's trained on thousands of papers that I helped them curate a lot. You know, basically like that one chunk of them was just like they took the 2,000 references from my book and just kind of like threw them in.

Well done. Yeah.

And so you can put all the things about your lifestyle, your environment, your preferences, your diet. You can even upload some blood tests. It could help build you like a— here's, here's, here's the one thing that you should work on, right? Then there's also brain health coaching. All the brain— all the coaches are RDNs, and that's available for most people. It's covered by health insurance. Registered dietitian nutritionist. Yeah. Yeah. Thank you. Highly qualified people. And even if you don't have any cognitive issues, that coaching is still covered by insurance.

Cool.

So the one thing you might need to do is you could pay for some blood tests if you want them, but they're sort of like provided at cost if you wanna do it. And as part of that company, or if you do the coaching, you get access to cognitive tests, like validated cognitive function tests. We are now building, or they are, I didn't do it, I sort of gave input. I've built a suite of more complex cognitive tests that will then— which will soon be launched and be available free to everybody. So you can just like track your own cognitive function over time. So this will then need to validate them against other things, right? So there's a lot to be done, but I think we're getting to the point where people can just track this much better. And you want to know what it was when you were 30, and then you hope that it's the same when you're 80, rather than some stuff happens for 5 decades and then all of a sudden you have a diagnosis of dementia, right? That's what we wanna try and avoid.

What a great resource. And I'll say it again, betterbrain.com. Yeah, I'm gonna go check it out for sure. Thank you for introducing that to me. For folks that are on the decline and they notice it, should we think about slowing it down? Should we think about increasing other behavioral choices? What can we do?

Yeah. So the important part of subjective cognitive decline now being an accepted part of this path is now that people are recognizing it, so they're, they're willing to talk about addressing it. And it's generally accepted that if you're in the period of subjective cognitive decline, that is largely reversible. There aren't a ton of like really large randomized controlled trials for that specific group, but we do have trials in older adults, 60s, 70s, where you make changes in exercise, diet, address cardiovascular risk, like brain training or cognitive training. So like some kind of new cognitive stimulus. In some of the studies, they do something— they might do CBT if there are some issues around depression or anxiety. And you see significant improvements in cognitive function even later in life. So We know that this is modifiable. And so the, the easiest way to start thinking about this is, well, first, can you get some of this stuff assessed? Can you measure your homocysteine, get your blood pressure checked, like all that, all that kind of stuff? And then think about, you know, all the things I talked about in the 3S model and think about, to start with, what's one thing that you could start to move the needle on, right?

And so you're being kind. Invest in your sleep. Start moving and stressing your body. Put the sugary foods down.

So this is, of course—

have great conversations with people that are stimulating. Yeah, you know, like, get in service of something that matters to you and see if you can support others. Get out of your own self-interest in that respect, I'm suggesting.

So, like, I, I obviously completely agree with you. But with the huge spectrum of people that I've worked with, some will be exactly like, I've noticed something, I'm gonna fix everything.

Let's go.

Great. But some people, even thinking about that is overwhelming. So the things that you have to take away are you can change this trajectory. There is still scope to do that. And in many respects, we know the things that you should focus on. And that then means that you can change and engage something. And you know that even if you just start to work on one thing, you can start to see improvements. So like in the studies where they've identified, you know, these are the risk factors in this person, we address these risk factors, they see significant improvements in cognitive function. So the Maintain Your Brain study in Australia, thousands of people, all done remotely, identified individual risk factors, addressed them, saw significant improvements in cognitive function. So we know you, you can just start on one thing that you know affects you and work there. If you want to do 10 things, great.

This is why people love working with you. You take them right where they are. Yeah, that's great. What a fun conversation. Yeah, we need part 2, part 3, part 4, because we didn't even touch the high-performing brain, which obviously you have a deep understanding about as well. And so, Tommy, it's always fun to speak to you. At a later time, I would like to talk to you about your worldview. I would like to talk about how you make decisions. I would like to talk about how you work with high stress, acute stress, and recover from it. And I'd also like to understand, like, how did you ready yourself to go to 2 of the most meaningful institutions on the planet, Oxford and Cambridge? And then you get your PhD just for whatever reasons after your MD at University of Oslo. Like, I would love to talk to you about how you shape your life. And today was a great service to the application of solid science. And at the same time, I got to feel that you are optimistic, you are highly conscientious, you are not agreeable for the sake of being agreeable, but you want to be kind of in a slipstream with trying to find the commonality between people. I think you're obviously highly motivated, probably more internally than externally. You're not driven by Money, fame, attention, you'll take them. But like, like it's an internal driver and no one has to shoulder tap you to go to work. Like you are the exact teammate that I think the world is wanting to work with. And for that reason, I want to celebrate not only your work, but how you show up with the 30,000 hours before this conversation. And we saw each other at the grid one day at Formula One grid. You were supporting a handful of teams and I was with one of them. And after you left, you don't know this, but after you left, one of the drivers said, oh, you know Tommy? I said, yeah. And he goes, isn't he great?

Yeah.

So you just, you've earned that. Those are the things that are said behind your back. And so I want to promote your work. Stimulated Mind is a great read. You took complicated science, made it simple, digestible. I ripped right through it. I hope people will pick that book up for both healthy brain and for a look at dementia. more than anything else, what we can do to be better. So, Tommy, thank you for showing us what high agency, high efficacy, generosity, and discernment to make a difference in the world. Thank you for what you've provided us.

Thank you so much. I mean, your words mean a huge amount to me. We really appreciate it. And this has been so much fun. Awesome. Next time on Finding Mastery, half the population will experience menopause. Yet for many of us, it's still something we rarely talk about and often don't understand. In this conversation, Dr. Michael Gervais sits down with award-winning journalist and menopause advocate Tamsen Fadal to explore why so many women are misdiagnosed, why symptoms are often mistaken for anxiety or burnout, and how better conversations can transform our homes, workplaces, and relationships. Whether you're a woman navigating this transition or someone who loves, works with, or cares about one. This is a conversation that matters. So join us Wednesday, September 2nd at 9 AM Pacific, only on Finding Mastery.

All right. Thank you so much for diving into another episode of Finding Mastery with us. Our team loves creating this podcast and sharing these conversations with you. We really appreciate you being part of this community. And if you're enjoying the show, the easiest no-cost way to support is to hit the subscribe or follow button wherever you're listening. Also, if you haven't already, please consider dropping us a review on Apple or Spotify. We are incredibly grateful for the support and feedback. If you're looking for even more insights, we have a newsletter we send out every Wednesday. Punch over to findingmastery.com/newsletter to sign up. The show wouldn't be possible without our sponsors, and we take our recommendations seriously, and the team is very thoughtful about making sure we love and endorse every product you hear on the show. If you want to check out any of our sponsor offers you heard about in this episode, you can find those deals at findingmastery.com/sponsors. And remember, no one does it alone. The door here at Finding Mastery is always open to those looking to explore the edges and the reaches of their potential so that they can help others do the same. So join our community, share your favorite Please share this episode with a friend and let us know how we can continue to show up for you. Lastly, as a quick reminder, information in this podcast and from any material on the Finding Mastery website and social channels is for information purposes only. If you're looking for meaningful support, which we all need, one of the best things you can do is to talk to a licensed professional. So seek assistance from your healthcare providers. Again, A sincere thank you for listening. Until next episode, be well, think well, keep exploring. Come on.