Your Brain On... Vascular Dementia

Most people think dementia starts with memory loss, but for many people, it actually starts decades earlier in the blood vessels. Long before someone forgets a name or miss an appointment, the brain is being quietly hurt by things like high blood pressure, high cholesterol, glucose imbalance, poor sleep, inflammation, and chronic stress. Not once, not twice, but all the time, day after day, year after year. This kind of damage doesn't look dramatic. There's no big stroke, no clear warning sign. It happens slowly and silently, and that's why it's so often missed. We usually speak about dementia as something mysterious or inevitable, or as a disease that just shows up late in life. But when doctors look closely at brain scans and research, a different picture shows up. Alzheimer's disease almost never comes by itself. In most people with memory or thinking problems, there's already damage to the brain's blood vessels, narrowed vessels, injured white matter, and brain networks that aren't getting enough blood. Vascular dementia is one of the most common causes of cognitive decline around the world. And when you include mixed dementia and early vascular brain injury, which we'll talk about, blood vessel disease plays a very important role in most cases of dementia that we see. This episode is about the kind of brain damage that hides for years and sometimes even decades before anyone finally calls it dementia. This is your brain on vascular dementia. So Dean, you and I have seen a lot of cases of vascular dementia in our clinic and you specifically, I remember you sending them to me after diagnosis because as a vascular neurologist, it was my job to address the risk factors. I think it would be really great if we could start with a definition of what vascular dementia is and what vascular cognitive impairment is and the difference between the two. So vascular dementia by DSM standard is when you're having vascular diseases, such as strokes or microvascular disease that really occupies most of the brain or a significant part of the brain. You also have cognitive decline to the extent that it's affecting your activities of daily living. And it's not delirium. Delirium is a momentary change or alteration in mental state. It could be from things that are transient. So it's not a transient state. That's just a blunt definition of vascular dementia. But vascular dementia in reality is one of the most common types of dementia that's understated. And we really need to start thinking about this because it's also one of the most preventable causes of cognitive decline. Absolutely. So according to the DSM criteria, like you said, DSM-5, there should be some evidence of vascular damage in the brain. So when they do scans, whether it's a CT scan or an MRI, there should be some evidence of a tiny stroke or damage to the blood vessels in the brain. And like you said, there should be some cognitive decline that interferes with daily life. So anything that prevents people from managing their activities of daily living that could be driving, managing finances, taking care of their hygiene, fixing a meal for themselves, kind of taking care of their household. Why is it that they excluded delirium? Is it because delirium is seen in multiple different conditions? Because delirium is something that's seen in many conditions. Medications can cause delirium. Depression can cause delirium. Lack of sleep can cause delirium. Post-surgery anesthesia can cause delirium. So many other things that can cause delirium, which is an altered mental state that's transient. And it's not related to underlying pathology, such as vascular disease or neurodegenerative disease for that matter. And my interest and your interest is in VCI in particular, because we can make such a difference in that stage. But in reality, it's the stage that's also not diagnosed. Nobody talks about it because there's no diagnosis, at least clinical diagnosis where somebody could actually get evaluation for it. vascular cognitive impairment is basically everything I defined, but the daily activities are still fine. They're able to do their daily activities, but maybe a little slower, maybe at a rate that was different from the past. So most people don't make much of this because they think it's just part of aging, but it's not part of aging. It's the beginnings of a decline that can actually lead to dementia. Would VCI be equivalent to MCI for Alzheimer's disease? I I don't know if I said it properly, but you know what I'm saying? Yeah, absolutely. MCI is pre-Alzheimer's. Is VCI pre-vascular dementia? It is. And that description is actually good because it's that pre-state that we're really trying to figure out in communities, the work we do in all these communities in LA and beyond. It's figuring out those early stages. And VCI is a very common one. Yeah. As far as cognition is concerned, what processes are affected because of vascular damage and vascular cognitive impairment? Reasoning, planning, judgment, memory, processing speed is a common one, isn't it? We call it bradyphrenia, slowness of processing, slowness of thinking, and bradykinesia, which is slowness of movement. So you see these slowness of movement and slowness of thought that is really symbolic of vascular cognitive impairment and vascular dementia. Yeah, I think slowing of thinking as well as slowing of your movement is related to vascular damage. And we'll talk about what actually happens in the brain that causes that. But you're right. Unfortunately, a lot of people who are getting older and have had cumulative vascular damage, they kind of have difficulty being on top of a conversation or answering something rather quickly or getting up from a chair. It could be musculoskeletal too. It's a combination of different things. But like you said, that slowness of processing is seen quite commonly in vascular cognitive impairment. And everybody has seen that in their family members. If you think about it, yes, this uncle that was so quick and so sharp now is much slower, or an aunt or a family member that suddenly had a decline. That's another fact that we have to be aware of. Vascular cognitive impairment and vascular dementia can happen suddenly in strokes, where you have a major part of the brain damaged, or in such small incremental changes that you don't see the change. It's just a slow decline or what they call stepwise declines where there's been a small little stroke that actually left a person a little more deficient in some capacities and their ability to speak and their ability to think and their processing speed. So those are three, I guess, historical or progressive natures of vascular cognitive impairment and dementia. All right. So let's talk about the epidemiology of vascular dementia and vascular cognitive impairment. According to the latest data, vascular dementia accounts for about 15 to 20 percent of diagnosed dementia in North America and Europe, and it's more in Asia. It's about 30 percent of all dementias in parts of Asia are vascular. There seems to be both some genetic differences and also lifestyle, and we knew that there was a time where even hemorrhagic strokes, which also leads to vasocular dementia were much more prevalent in the east, especially Japan and those regions. In those countries, it's mostly genetic or environmental or lifestyle factors. But we know that those factors are enough to make a significant difference between 50 to 20% in North America versus 30% in the east. And the kind of patterns that we see more often is mixed patterns, which basically means that many patients who have been diagnosed with Alzheimer's dementia, which is the most common type of dementia, also have significant levels of vascular injury. It could be damaged to the arteries because of vascular risk factors, as well as cerebral amyloid angiopathy. Now, we know that amyloid is the bad protein that accumulates in the brain in Alzheimer's cases. It also can contribute to vascular damage in the brain. So those are the mixed kind of dementias that we see. And based on your statements before and based on our experience in the past, the mixed type of dementia is probably more common now than just Alzheimer's or vascular alone. There's definitely evidence of that. Some series came out that even prior to accumulation of amyloid in Alzheimer's, they saw vascular changes that preceded that. If we believe that even Alzheimer's is amenable to lifestyle changes, the lifestyle changes that are most influential in even prevention of Alzheimer's are all related to vascular risk factors, whether it's diet or exercise. We're talking about cholesterol and glucose levels. These are all vascular pathologies first. So whether you see vascular change prior to amyloid change or the things that affect vascular disease and their consequent effect on Alzheimer's, there are evidences there that vascular risk factors and vascular disease is almost present in all Alzheimer's cases as well. Let's talk about the pathophysiology of vascular injury. We know that vascular risk factors like blood pressure, cholesterol, having diabetes, inflammation throughout our life contributed by habits like smoking, unhealthy dietary patterns, sedentary lifestyle, all of that can start damaging our arteries. Before you know it, the damage to these arteries can lead to lack of blood supply to the brain. And that can lead to multiple different cascades of inflammatory pathways and oxidative pathways that start damaging these very, very sensitive and very important blood vessels that continuously supply oxygen and nutrition to the brain. We always say the brain is the most energy-hungry organ in the body. It's only 2% of our body's weight, but at any moment, and it takes up to 25% of our body's energy. So imagine when these small little blood vessels get damaged and they collapse on themselves, the brain doesn't get oxygen. Obviously, it's going to get hurt. Absolutely. They're incredibly fragile, and they occupy a significant portion of brain volume. I mean, we've talked about this before, when you denude and get rid of all the other tissue in the brain, and what you see is an incredibly vascular-rich organ. Across the board, throughout your life, this very susceptible system that brings blood and food supply and oxygen to your brain is under attack. Yeah, it almost sounds like it's a network failure. It's not necessarily just brain cell damage. Like you said, whole areas and extensions of the brain stop working when the brain is not getting enough oxygen. And you see it translated in how the different domains of cognition is affected. And not all of the brain is supplied the same. There are parts of the brain that are more susceptible. For example, the hippocampus is more susceptible. Parts of the brainstem are more susceptible. And white matter disease, as far as vasculature is concerned, is more susceptible. So you see this pattern that emerges that is very distinct for vascular dementia. And I want people to recognize this. I think one of the most important things we can do here is to make people understand that those signs are fairly distinct. If you see somebody who's changed over time, where they're slower, they're walking slower, they're thinking slower, or they're speaking slower, there's a slowness in general sense, that could be a sign of vascular dementia that if identified early, so much can be done to prevent further progression. So let's go ahead and talk about the different types of vascular dementia, and then we'll come back and kind of describe what that damage looks like. Now, according to literature, the different types of dementia include post-stroke dementia. Now, this is the kind of dementia that happens when people have strokes, whether that's an ischemic stroke where there's a clot preventing blood flow to a part of the brain or hemorrhagic stroke where there is bursting of an artery and there is bleeding inside the brain and an area of the brain gets hurt and the neurons essentially die. That's a very common one and the symptoms essentially depend on where the stroke has occurred. Close to 800,000 people in the United States alone have strokes, major strokes. The stepwise decline is seen most commonly in post-stroke dementia. And those are the ones that you and the person ends up in the hospital or the person, well, half the cases, they die. And so the mortality is fairly high with strokes. The subcortical dementia, which is the second type, is also very common, but that's the one that's not identified early enough because it's not as obvious as a major stroke, is it? It's the white matter, the connections underneath that are affected. Slowness of thinking, executive dysfunction, gait instability, falls, all of these are seen. So people don't really ascribe it to a stroke or vascular disease, but it's a very common form of vascular cognitive impairment and vascular dementia. Absolutely. The subcortical ischemic vascular dementia are the ones that usually take a very long time. Like you said, it doesn't happen all of a sudden. It can happen over years and sometimes even decades. And you see the slow onset of the deficits that you just listed. And I think we see this almost every day in some form in our neurology clinic, especially in the stroke clinic and then the dementia clinic, but they are almost never named early. You know, you see these little patches of white matter disease in the subcortical areas on MRI or in CT scan, mostly on MRI. And usually they're like, okay, you have these things. And the most important thing is management of your vascular risk factors. So it definitely is an epidemic. One of the cases that was really intriguing to me was a mom and dad that lived in Virginia, and they hadn't seen their daughter for a long time, for several years. The daughter was in the military, was not home. As soon as the daughter came home, she said, I immediately recognized that my father was not the same. Yet at the same time, the person's wife didn't recognize the changes. And this is a common thing we see. The person that lives with them doesn't recognize because it happened over many years. The daughter immediately brought him to my clinic and when we did the workup, looked at the MRIs, it was absolutely obvious the vascular damage that had been done. Yeah, I can't tell you how often I see that in clinic, especially in community clinics where people have very low resources to healthcare, they don't have insurance, they don't have access to help when it comes to smoking or relying on alcohol and having a lot of other issues that really takes a toll on their vascular health. And then they have high blood pressure and high cholesterol, diabetes or prediabetes. Like these three things are so common. And they're usually seen together in a lot of people. And it just attacks that subcortical area. And what bewilders me, these are actually fairly manageable conditions. But these are the three dominant conditions that are not just underpin strokes and vascular dementia, but many other conditions. And I'm saying patients that are in their late 30s, 40s, not older. It starts very early if we don't really pay attention to our vascular risk factors. And knowing your numbers is that important because it can directly impact your brain. And it's also treatable. I mean, to be honest, the cholesterol is easily treatable with medication. The diabetes is treatable with medication. The blood pressure is also treated a little bit more difficult. It's treatable. The sooner it's caught, the easier it is to treat. Absolutely. And what disturbs me and what I want to educate the population is we see how many people in their 30s that their blood pressure is in the 130s, 140s. They're not even worried about it, but they're talking about us with some obscure vitamin. That's very common. The comparison, the difference of importance is bewildering. I want to make sure that we make that point clearly that, you know, the vitamin du jour is nothing compared to blood pressure, cholesterol, diabetes. or pre-diabetes for that matter. Those must be addressed. There's vascular dementia and cognitive impairment, especially the multi-infarct dementias are definitely affected by those conditions profoundly. Absolutely. The third type is multi-infarct dementia. Multi-infarct dementia basically means if there is a series of silent strokes or symptomatic strokes for that matter, you kind of see the cognitive decline in steps. Especially the stepwise. Exactly. The fourth is a category, which is genetic diseases of small blood vessels. And they have kind of obscure names like Binz-Wagner's disease. And there's one that is called CADACYL, which is an acronym. Somebody was terrible at making acronyms. Or let's see if I remember. So it's cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. CADACYL. Am I showing off? No. But as a vascular neurologist, you're supposed to know this, right? So basically, this is a rare inherited genetic disease of the cerebral blood vessels. And it is found in a particular gene, notch 3 of chromosome 19. What happens is over a long period of time, it causes chronic small blood vessel disease. people tend to have migraines and then they start having symptoms of stroke that kind of come and go and over a long period of time they start developing psychiatric symptoms and you see this person having recurring strokes migraines so pain they're completely debilitated and then there's a change in their personality and they start having psychiatric symptoms i had this lovely lady that I was taking care of. Her husband was in the healthcare field. And this beautiful woman just became somebody that nobody would recognize. She started actually being very violent. And they actually had to put her in a nursing facility. Just devastating. It is, it is, especially to see the rapid change. And the family doesn't know what to do, because there's nothing to be done. Hopefully, in the next few years, we will have some answers to many of these conditions. I hope And then the fifth type is, of course, I mentioned it earlier, cerebral amyloid angiopathy. And this is when amyloid beta protein deposits in small blood vessels. And so people tend to have small blood vessel hemorrhages, ischemic strokes, and slow cognitive decline over time. And this is a genetic proclivity. It's not just anybody can get it. So just to allay people's fears, it's not that common. But when it does happen, it's genetic. and where we've seen it, where you see big islands of bleeds in the brain. And the answer to that is blood pressure management. Cerebral amyloid angiopathy always makes the neurologist work a little harder because it blurs the line between Alzheimer's dementia and vascular dementia. So we rely on different tests like angiogram of the brain to kind of look at the arteries. And it requires a little bit of work to diagnose it. And then the last type is, of course, mixed dementia. And this is when you see both pathology of Alzheimer's disease and vascular injury. And this is likely the most common real-world scenario. Absolutely. We're beginning to realize that a great majority of what we call pure Alzheimer's is not pure Alzheimer's, and it's mixed. Okay, so let's talk about what are some of the active drivers of vascular injury in the brain. For example, we spoke about how hypoperfusion, chronic hyperperfusion, which means too little blood going into the brain, causes damage. The brain requires a lot of oxygen, and when there's long-standing hyperperfusion, whether it's because of microvascular disease or stroke, it doesn't really meet that cognitive demand. And so you get relative hyperperfusion in very important parts of the brain, and it doesn't function well. This can actually show itself as white matter disease. It can show itself as disruption of the frontal and subcortical circuits And you see the bradyphrenia the bradykinesia the slow processing in that And these are all interconnected in many ways There no isolated mechanism, whether it's inflammation, blood brain barrier damage, they're all interconnected. But if we want to distinguish some things, high blood pressure is a very important, distinctive category. And I want to separate that by itself, although it is connected to hyperperfusion, because downstream it causes hyperperfusion. All the things that you see in hyperperfusion as a result of hypertension. Hypertension can also damage by sheer damage, forces on the vessel walls, which can either tear the vessel walls or can cause chronic inflammation and chronic changes that can subsequently lead to occlusion. If I had my way, we would have a blood pressure monitor in every home. I agree. It's a life-saving equipment. I think it would be at least for those 55 and above, there should be a blood pressure machine at home absolutely bring it down to like maybe 40 i was just trying to be cost effective for our efficient health care system that we have actually quite affordable now of course not expensive and hopefully fairly soon our watches will be able to do it they're not there yet other things that happen are things like damage to the endothelial lining which again as a result of high blood pressure as a result of microvascular disease but endothelial lining we have to highlight as well. It's so important. Honestly, I feel like if you really want to take care of your health or at least manage aging, take care of your arteries. Take care of your endothelium because it is this beautiful thin lining that is constantly under attack. I mean, imagine your blood just gushing through these arteries and if it's too much or if it has specific compounds like cholesterol and things like that, it just sloughs off that surface of endothelium, damages it, and guess what? Your arteries get hardened, or it gets calcified, or it gets damaged. And these are the highways for very important elements like oxygen getting to your tissues. Endothelial lining is worth its weight in gold. Fight for it, live for it. Endothelial lining has its own unique processes that can damage it, and things that can help it. For example, nitric oxide affects it directly. It actually creates its own nitric oxide if it's healthy, and it stops creating it when it's not healthy. Absolutely. So these are things that we should be aware of. But just being aware, it makes you want to take care of your body because every meal you eat can build the blood-brain barrier, it can build endothelial lining, or it can damage. In fact, the first place that it damages is endothelial lining, isn't it? So I think that's an important place to focus on. glucose or diabetes also affects the vessels, doesn't it? Definitely. Any abnormality in glucose metabolism can actually cause damage to the endothelium. And there are multiple different ways that it does that. Glucose or excess glucose can react with lipids and fats, and it can increase the probability of the creation of compounds like advanced glycation end products or AGEs. And these AGEs can actually accumulate in blood vessels and start damaging them over time. But we have to give a word of caution. Just because people's blood glucose levels spike up or down right after a meal, that's not important. So the whole battle of CGMs and people without diabetes wearing these CGMs worrying about the spikes, that's not what we're talking about. I would kind of put some nuance in there and say spikes, if you don't have diabetes, is a physiological spike. But for someone who has prediabetes or diabetes, it could be helpful for them. Beautifully stated. Absolutely. That distinction is important. between pathological and physiological spikes and then the ever popular inflammation sometimes whenever i say inflammation i kind of get a queasy because it's so overused for everything right yes it is a real thing it is but and it just depends on the context right they painted with a broad brush and inflammation is like you know the reason why a lot of things are happening you have to be very specific but we know that neuroinflammation is a thing we can measure it And it has been associated with conditions like smoking, sedentary lifestyle, diabetes, high blood pressure, high cholesterol, obesity. All of those things can actually cause neuroinflammation. Also, traumatic brain injury. Correct. I mean, reality is the cause could be anything. Cause could be a vascular damage. Cause could be a toxin. But what causes long-term damage is often chronic inflammation. That awareness is important. And it is a part of this whole cascade of damage. The other thing that we shouldn't forget about is sleep disorders and their consequence on vascular disease. We do know that sleep apnea is strongly associated with vascular disease, be it stroke, be it heart disease even, but also vascular cognitive impairment. Yeah, sleep is such an important vascular repair time. So all of these conditions, a lot of them are instigators of damage. And then there are lifestyle factors that allow for vessels to repair. And sleep is one of the most important ones. You know, basically your body is getting rid of a lot of the reactive oxygen species and some of the things that cause damage to your arteries. And as we know, when people have sleep disorders like sleep apnea, or if they have restless leg syndrome that doesn't allow them to get deep sleep, it can increase the risk for strokes, for heart disease, high blood pressure. And as a result of that, the brain can get damaged as well. Absolutely. So if there's any suspicion of sleep apnea or sleep disorders, you must address it because it's, for the most part, it's easily treatable. And I think it's really important for us to add the impact of APOE4 gene on vascular health as well. So as we know right now, APOE4 is not a primarily reason for dementia by causing plaques. it actually increases the vulnerability by impairing vascular repair. It just doesn't allow for your arteries to take a break. That's why over time it can contribute to both vascular damage as well as Alzheimer's disease. We knew that APOE4 was a big player when it came to dementia and even with vascular dementia. It's related to its effect on vascular recovery, on cholesterol, on inflammation, multiple pathways. What was interesting this week, a new paper came out that showed that those that lived the longest, 90 and above, and lived healthy, one major distinguishing factor of all the different factors was APOE2, APOE4 status. Those that were APOE2 were significantly more represented in the 90s to 100-year age, meaning that they lived longer. And those that had APOE4 lived shorter. It's a risk factor gene, isn't it? So if you take care of the risk factors, you reduce risk. And what are those risk factors? Vascular risk factors. If you take care of your blood pressure, if you take care of cholesterol, if you take care of inflammation, you actually reduce risk significantly. I have to say, sadly, not to the level of APOE2, but you still reduce the risk significantly. Did they look at whether people who had APOE4, were they treated for these vascular risk factors? Or was this just like cross-sectional? It was cross-sectional. Okay. It would be really interesting to see what was the impact of, say, a healthy lifestyle or management of vascular risk factors and how did that modify the relationship. That's going to be our next paper. We're going to look at some databases and look at the people that have APOE4 that are treated for their underlying vascular risk factors versus those that weren't treated well and what the outcome has been. That's a really interesting finding. And I can imagine, just based on other data, that if people had taken care of their vascular risk factors, despite having APOE4, they would have ended up having the same risk factors as APOE2. Maybe. Maybe. We don't know. We can't make that assumption. It appears that there is some data that the risk is reduced significantly. We just don't know how much. All right. Well, here's to better science in that regards. Our guest for this episode is the amazing Dr. Columbus Batiste, a board-certified interventional cardiologist and an incredible science communicator. He expands on how vascular health is fundamental to brain health, and he emphasizes that all roads to longevity are paved by the heart, and that what's good for the heart is good for the brain. Dr. Batiste discusses how lifestyle factors like poor sleep, sedentary behavior, chronic stress, high blood pressure, diabetes, and hyperlipidemia can damage our cardiovascular system, and how diseases like dementia can be slowed or managed through exercise, nutrition, stress reduction, and adequate sleep. He's the author of Selfish, a work that reframes self-care as a foundational component of long-term health rather than a luxury. His perspective is especially relevant to today's discussion where vascular biology, cognition, and daily habits converge. We're so grateful to have him with us for this conversation. Dr. Columbus Batiste, we've been working together. We've known each other for a while now. And we're both academicians and community workers in a way, aren't we? and you've done this for a few years. Yeah, no, well, thanks. First of all, it's a pleasure seeing you again, at least getting to visually see you. It's always amazing. And I'll tell you, I'm honored to be in this work. And so for me, my journey began, you know, as an interventional cardiologist, which is my background many, many years ago now, back in the early 2000s, late 1990s and so forth. The community has always been embedded inside of me. You know, I grew up inside of the inner city, inside of Compton, California, South Central Los Angeles. And so my dad was involved with Head Start, my mom, they were all involved in terms of community working. Interestingly enough, my mom used to teach cooking classes and they did this out of churches. And my dad owned a health food store, one of the first back in the seventies. And he actually stopped because, you know, I was a pleasant surprise. So it was always embedded in me about the importance of community, the power of lifestyle. And then obviously my passion for cardiology is where everything kind of came together in this sort of Venn diagram. And it really set the direction for me in terms of my career overall. It's been encouraging in terms of being able to help people on a different level, obviously helping them in a sense of emergencies clinically, but then also really empowering them about the power of their daily choices to really transform their life and future. So there was a time that everything was ascribed to heart. And we, us neurologists, who are very jealous. We're making lots of money from the procedures, but the jealousy is not stopped, I tell you that. But all jokes aside, you guys did some amazing work when it comes to what we think now, and I'll give you credit. We really think that we can even call this a cardioneurological phenomenon. Neurology can't happen in isolation and without cardiac. The most vascular organ in the body is the brain. And whatever happens in the heart is going to affect the brain. Absolutely. And I mean, what you said is precise, to be honest with you, because when I look at cardiovascular disease, and so early on, I was enamored by just the functionality of the heart and how beautifully and wonderfully it's made. I mean, it works on its own. The vascular, electrical, structural components of it still excites me to this day and age. And so when we look at the vasculature and we talk about issues of high blood pressure, we talk about issues of diabetes that affect the cardiovascular system. We talk about hyperlipidemia. We talk about inflammation. What we're really talking about is the impact of the endothelium, the endothelial cells and that layer of cells, and what happens as this cascades throughout the entirety of the body. In today's conversation, we're talking about the brain and what impact that has from a vasculature. And all the things that impair that are the same things that impair the heart. and it's discontinua. Absolutely. And what are those things that impair or affect that vasculature and that endothelial lining? We know the common players. We're talking about LDL and cholesterol. We're talking about diabetes. We can get in a little more detail about what we're looking at. When we're talking about diabetes, it's not even diabetes. Prediabetes is a factor as well. 55% of population has prediabetes, which is remarkable. And high blood pressure. Tell us a little bit about all the players when it comes to the vascular health? Yeah. So, I mean, I think first it's important for the audience to really understand this lining of the vessels, this singular layer of cells, this endothelial cells. It's so powerful that not only is it like a Teflon pan, which of course you're not using Teflon pans anymore, I hope. So it's supposed to impede anything to make the vascular wall impermeable, preventing anything from intruding inside of it. But it doesn't stop there. It's also, for lack of very terminology, almost a pharmacy. It's producing substances, nitric oxide, most importantly, that really helps to regulate that vascular tone. It regulates and allows it to restore it. So you can think about all roads lead to the heart or lead to longevity are paved by the endothelium. And so when you start to look at it, what's so powerful taking a step back is there are several ways in which we can measure the endothelial function that actually gives us some sense. And so some studies have really shown and they dictate that it becomes prognostic. When we look at the endothelium, it's prognostic of the occurrence of future diabetic states, hypertensive states, and individuals who are not diabetic, are not hypertensive, who don't have any other ailments, even for future cardiovascular events. When you look at what's contributing to this damage overall, well, we know that it's going to be a level of oxidative stress. It's going to be an issue of inflammation that's triggered. by hyperlipidemia. And so when you say hyperlipidemia, it's more complex than just one component, obviously. Lipoproteins, you have the actual cholesterol content too as well that play a role, but specifically honing in your apolipoprotein B, we understand the impact of your LDL that as this cascades into your vascular wall, that endothelium that perhaps is already fragile and damaged, the inflammation begins to happen with the foam cells and everything cascades and you have the development of atherosclerosis that happens in small vessels in the brain, as well as inside of other vasculature inside the body. The reason why folks like yourself who are so brilliant, and you are brilliant, and you're saying, well, the heart is very simple. It's just a pump. And you're absolutely right. It's just a pump. It's four chambers and three major arteries. That's seven. But when we look at this simple pump, you have the forward flow that delivers the oxygenation is through your arteries. And that travels and it's a muscular lining. Why Why is it muscular? Because the pressure is higher. It has to deliver this blood all the way from the head down to the toes, from the chest and from the heart. Now, once it does that and it enriches, as the branches get smaller and smaller and smaller inside the organ system, then that cascade then has to be returned with all of the areas that have been used up, the blood that's been used up and deoxygenated and nutrient poor and returned to the heart where it has to coalesce, then get larger and larger and larger, returning to the heart, where then it's pumped to the lungs to pick up the oxygenation and the nutrients again. And so you have this cyclical effect that happens. And at the interface of where the arterioles and the venules kind of coalesce or come together, that's what we're talking about as it gets smaller and smaller. That's the simplest way that I tend to describe it to folks. Yeah, it's just beautiful and remarkable. Now, the question I had was the endothelial lining that's ubiquitous in the vasculature, the level of distance or tightness between the spaces of these cells varies, right? From place to place. Where it's in the blood-brain barrier, it's extremely tight. Not much can get through. And in fact, now we're learning that even molecules like omega-3s and simple molecules have to use transport a system to get through. But in other places, it's a little more lax. Isn't that right? That's absolutely correct. And that can become a problem when it no longer is tight in the blood-brain barrier and allowing in toxins that are there from the damage that can occur. And you know, what's unique is that of all the talks I've heard and of all the speakers that I've had conversation with, nobody has really done a really thorough conversation, deep conversation about the endothelial lining. We could have a whole semester on this, but the endothelial lining, besides the fact that it's the interface between the inside and the outside of the vasculature and the nutrient and oxygenation, as well as transport system that actually selectively lets things in and out, it's literally the gateways of control, the rivers that control everything. And over time, things start going wrong there. How early do you think that we start having some difficulties with endothelial lining? It's, I think, much earlier than we thought before. Absolutely. Well, I mean, I think it's clear. If we identify that atherosclerosis begins in childhood, that tells us that endothelial dysfunction can begin as early as then. And so we know so many factors can contribute to endothelial dysfunction. That's what's so interesting is that all the things about lifestyle, what you've preached, what I've preached in terms of what the impact is, it all starts at the level of the endothelium. So when you have poor sleep, that stress that begins to happen, the hormones that begin to happen. We understand there's been studies that have demonstrated a reduction in flow medial dilatation in individuals who are sleep deprived and who have minimal amounts of sleep. We understand that a sedentary state, and here's the actuality, right? Is that when you exercise, I mean, exercise is such a powerful tool. It's almost like I always analogize it, you know, so every year the America's team called the Dallas Cowboys, they go through a training camp. excuse me right there you have it wrong it's the steelers that are the real americans i don't know you do know that that was offered to the steelers first right no no no i think that was misinformation right there i'm gonna say that's fake that's fake news but you know so when you go through this training camp it's it's not it's hard it's stressful but it prepares the athletes for the season to withstand the struggles the same thing happens in the heart and with exercise that yes the blood pressure may rise, but allows your body to respond to the blood pressure elevations. But here's the key, bringing it back to the endothelial health, that sheer stress or the increased force that happens, it causes the body and the endothelium to generate the chemicals that allow you to dilate the vessels, that nitric oxide. And so when you're sedentary constantly, you're not having that sheer stress goes down. What happens? Your endothelium becomes dysfunctional. The flow may dilatation becomes abnormal in that instance. So we see this in so many particular areas as far as levels of damage and or harm in our life, as well as chronic stress, which is a major issue that happens. It's pervasive, obviously, inside of globally, not just America, but globally. Yeah. Of course, we're talking about vascular dementia ultimately. But I want to actually focus on this because a lot of times we forget the primary causes, the beginnings. and we talk about the end stage or even start treatment at the stage when it's too late, it's important to speak at the beginning of all this. So if you had to say one of the most common beginning stages and the elements that most affect endothelial lining, let's say from childhood, what would you consider as the major insiders? Yeah, it's going to be, food's going to obviously play a major role. I would probably say going back to your original question, that time period is going to be that early adulthood where you feel healthy, you feel invincible, but that's when the beginnings of damage occur. For vascular dementia, for heart disease, for cancer, the foundation is laid during that time period when you're perhaps career building, you're family building, and you're ignoring your own personal health during that time period. What are the things that most commonly affect it? Is it blood pressure? Is it diabetes? Is it inflammation? I know it's all of the above, but where do you see the most important causal factor Hypertension is beyond a shadow of a doubt such a major player It you know in this neck and neck when you look at vascular dementia and this is your area diabetes plays such a major confounding role When you looking at all the cardiovascular issues and death and impact hypertension is a major major contributor And part of that is because it's asymptomatic. It's a silent killer. So you're not aware, really, in terms of any symptoms whatsoever. And that's irrespective of headaches or nosebleeds. There are studies that have correlated in absence of direct correlation in the symptoms and the manifestation of the level. So we know that that plays such a major role in leading to dysfunction of the vessels. And on the neurological side, there was a time that we thought that cognitive diseases started at the point where people had memory problems, at least in the general public. It doesn't. It's decades and decades earlier. And the damage that you see at the endothelial lining has exponential consequences when it comes to end-stage organs, hungry end-stage organs, like the brain, this three pound organ that uses 25% of your body's energy and blood at times, as much as 40% of your blood rushes through your brain at incredible fast pace, it's going to be affected and it's going to be affected early. So now we want to focus more on cognitive decline. There's no really sizable or meaningful quantifiable description of vascular cognitive impairment because first of all, you study that which pays, at least in the United States. Yes, NIH and other institutions help with studying things that are outside of the pay, but still that dominates. And vascular disease starts much earlier. And I can tell you, although we say 20% of dementias is vascular, reality is it's much bigger number because we know that it's a contributor to Alzheimer's. It's a contributor to many other neurodegenerative diseases. So it would be great that people, and here I'm passing this off to you, if people would start with their cardiovascular disease much earlier, and if they do, they do service to both kingdoms. They definitely do service for both kingdoms. If you had to tell people as far as when to start addressing vascular disease, especially this incredibly important yellow brick stone, this golden protection that we have, when would you say they should start? Yeah. So I think we start inside of childhood, inside of teenage years, ideally, although that's the time period where most people have this sense of invincibility. We cannot ignore a little bit of this, a little bit of that, a little bit of the other. That's metabolic syndrome. I just have a little bit of high blood pressure. I'm going to ignore that right now. It's because I was rushing in, I was stressed, and we allow our blood pressure to stay in that stage one level for a persistent period of time. oh, I have prediabetes. I don't have diabetes. It's just a little bit of high blood sugar, right? Or I have just a little bit of increased abdominal girth. That's a reflection of visceral fat, which is a reflection of the inflammatory cascade that's happening. And so when you start partitioning all of these bits together, we know the studies tell us that this is even much more impactful on your entirety of your health long-term than anything else. I think part of the problem is that we have to move beyond how we feel as a descriptor of when we should act. And that's hard. That's a concept that's important. I remember struggling with my kids to teach them the importance of saving, even though you're like, well, what am I saving for? I could use it right now. You're saving for the future, so you have the funds for whatever emergencies that may arise or various variables that are there. And so our health is essentially building up our health savings account. Understanding, well, can I build up that reserve? because we all are going to be impacted by something, being alive. So yes, I would target my attention primarily in those inside their 20s and 30s and hit them as they're investing in their financial health future. I'm putting forth efforts to saying, I want you to invest in your health future too as well. In a very similar fashion, as I'm investing in that future, if I start earlier on, every small amount becomes cumulative. It adds up. If I wait until I'm in my 50s and 60s, now I have to go 120%. There is no leeway because I already have the issues that are happening. No, you're absolutely right. It's the investment. But how do you convince a 20-year-old? It's important for them to address the blood pressure that just creeped up to 130 a couple of times, or the cholesterol or LDL that's in the 110, something of that nature. It's difficult to build that momentum. And we'll get to that as far as what psychologically we can do at the pathological level. So we talked about some of the inciting factors that should be addressed early. You talked about going to communities. We've spoken about this, where you go and give them blood pressure machines. Every project we have in the communities, you would think as a neurologist, we would do something neurologic. Nope. The first thing is giving away blood pressure machines and teaching blood pressure because it's the major determinant of brain health long term. It's by far the most important. I think one of the most important discoveries that would happen soon is if your watches could accurately and in a valid way determine blood pressure and then act upon it, you know, give it to your clinician live, not once every six months. I think healthcare will change overnight. It's difficult to manage blood pressure for several reasons. First of all, where does the high blood pressure come from? I know that part of it, we talk about the stiffening of the arteries, right? But there's also some other ways that people get high blood pressure that we see, especially in those cases, rapid rises, even the effect on the brain, which I'll tell you a personal story. Yeah, well, that's a great question. And so the vast majority of high blood pressure or hypertension, we say, is an essential hypertension, which means we don't quite know. We have lots of hypotheses as to the mechanism of action for it. And then you have what are called secondary hypertensive states. And these can be something that's an endocrine or a neurohormonal type of scenario there. it may be an issue with your kidneys. It could be an issue with your renal vasculature, which may or may not be related to atherosclerosis, what we're talking about today. So there can be a number of other issues, but most commonly I simplify it. And that's why I love the heart, right? You look at a combination of what we call the cardiac output, which means the heart rate, what we call stroke volume, how much volume is squeezed out per cycle, and then what we call the peripheral resistance. Those are the components of what designates the hypertensive state. So we look at things that may drive up your heart rate, that drive up the volume, that causes the volume to be retained or increased. So for some people, it can be the excess sodium, which not only impairs the endothelium, that lining, but also may cause accumulation of fluid too as well, which can propagate that. That's why some may benefit more from a diuretic style. And so we may use different classes of medication to really kind of target and drive that down a bit lower. And so that's what's so beautiful about, I know no one loves pharmacology. They don't like pharmaceuticals. But the theory of pharmaceuticals is really an understanding of physiology and applying that in order to try and offset and interact how we can intersect the process to lower the disease risk and burden. And we can do the same thing when it comes to nutrition. We can look at the intersection of how our food can impact the angiotensin-converting enzyme inhibitors. It can work towards providing what we call lucid tropic effect and the relaxation of the vessels. And so those are some of the major components that play a role in hypertension. Nutrition is a big one. Lack of sleep is a big one. It revolves around stress. It revolves around the tonicity of the vasculature or what we call the toe peripheral resistance. Those play a major role inside of it. Absolutely. From a personal history, because I'm not saying something that she didn't share with everyone. My mother before she passed away, she was a very fit person and very active. Talk about type A. She would have parties three days a week at her home in Orange County, and all the community members would be gathering and thin as a rail, walking, exercising, eating healthy. But she had high blood pressure that would vacillate. She would be fine, run 30. And then one time, she went as much as 240 systolic. And she became confused. We took her to the emergency room, and the MRI showed a whiteout. And you might want to explain that as well. But white hat is the subcortical area of the brain seems to have been affected. And what we know is that there are several things that happen. If it's a press kind of syndrome or if it's a vascular-related syndrome, it's the vessels and the endothelial lining have been damaged. And a lot of times they recover, but it's a pretty significant thing. We were fortunate that she had such reserve. She was a very, very well-read, spoke nine languages. I barely speak one. and she was an artist and thinker and all that. So she recovered cognitively, but we saw the vascular change overnight. And we think that that's more common than you know. If it's not the vascular change at that level, it's the small little tiny little lacunes that we talk about or unidentified little white matter changes that we see. And we say that if you see little white matter, multiply that 10,000 at the cellular level. That happens a lot in brain diseases. Yes, it does. And we're ignoring it. We're ignoring it until it becomes a stroke or until it becomes a dementia. I really think that there must be a very strong impetus to really push the bar back to your realm again, to your court, to the cardiovascular court, saying that if you even have the beginnings of high blood pressure, and that's what I do, by the way, Columbus. If they say, oh, I just had one time I was in the clinic. Okay, get a blood pressure machine. Every morning, measure it and write it down. At least that gives you eye into this potential problem. How would you tell people to address their blood pressure early? Or how early do you tell them to start? Oh, listen, I tell people right now we are doing, we did actually a screening. And I shared this with the team where we go out in the community and do blood pressure. I saw a news clipping and this matched an experience that we had. A young man inside of his teens who had an extremely high blood pressure and it appeared not to be from a secondary cause because as he implemented lifestyle changes, that blood pressure lowered. And so that's impactful because a lot of times out in screening, and I'll be honest, even though I understand all this stuff and I work it, I live it. I remember we were out and my wife said to me, she said, oh, we're going to check the blood pressure of the students and so forth that are there. We work with nursing students and medical students and they're doing the screenings. And I was like, well, we don't need, let's focus on the people at hand. And of course we see individuals whose blood pressures are high and they're going through it in that moment. And so I believe that we have to start early on. Now, the key is, how do you get someone to find value in it? How do you get them to move from inaction to action? I think there have been studies, multiple studies, they've looked at whether or not it's imaging, if a person can identify that they already have some form of disease, it may provide them with enough incentive to say, listen, I need to move forward in terms of the investment towards that route and that avenue. And so I am moving more in that direction of, okay, how can I visualize this? How can they see their health and where they stand and move beyond how they feel to understand that there is an impact beneath the surface? I'm going to share a personal story with you. So my dad died from ill effects of diabetes. So that is up close and personal to me. And this is someone who knew about a lot of the health benefits. And I always kind of use the descriptor that if anyone on the outside looked at my father, they would say, oh, he's healthy. Didn't drink, wasn't excessive, wasn't overweight. But for him, the amount of perhaps sweets or other things that he ate were detrimental in terms of his life overall. That being said, full circle back, one of the things my mom would always say is she knew when my dad's blood sugar was off because of his mental state. And you'll hear this in common vernacular speech inside the community oftentimes. And to your point, there is a cognitive impairment that begins to happen early on. inside this state and we see it pervasively. And so it's powerful when we look, obviously, the foundation, I believe, in terms of diabetes treatment, a therapeutic intervention begins and ends with food is the first aspect. I think there's no doubt about that. And so I always, you know, there's lots of debates and you brought up one of them in terms of whether it's keto, whatever else. And I had this just yesterday, again, with a patient. First, I acknowledge them. I say, well, listen, what keto has done is allowed you to move from the standard American diet in part. I said, that provides you a level of benefit. We're now talking about how can we be therapeutic with your nutrition that can propagate your health long term that you're wanting. What do you want and what are you willing to do to get that? And as we move down that road, let's talk about, I'll ask a simple question, not what do you eat. What do you eat for your health? And tell me why. Don't tell me a macronutrient. Don't tell me protein, carbohydrate, or fat. Tell me what you're eating for your health specifically, and I will match that and begin the process of describing to you how this is beneficial to your cardiovascular health. That will decrease visceral fat, will lower your cholesterol levels, lower the inflammation, markers of inflammation. I believe it begins and ends with that. I believe that an adjunct to that is a component of time-restricted eating, I think can help in terms of individuals, in terms of their processing of food from the timing at which they're eating, and that they're not snacking all day, all night, waking up and they're eating more and more and more and expecting that things are going to be okay. And then the third part of it, so how you feed your body, how you move your body, how you rest your body are always the key things I'll tell everyone just anecdotally in terms of threes. It's just move after you eat. Don't sit and linger. Move, you know, five to ten minutes, you know, as early as two minutes, but more recent studies around five or ten minutes showing a reduction in terms of blood sugar. And that's the easy cheat code I will give folks there is focusing first eating the things that are going to be helpful for them and having a mindset that first don't tell yourself you can't because you're an adult. Yes, I want to tell you that you need to be prescriptive. But depending upon where a person's at, I will tell them I want you to focus on what you're eating for your health first. Yes. Maximize that before you tell yourself you can't. If there are three foods that you would have people eat more and three foods that you have them eat less, what would they be? Yeah, I always go, my top three are always dark green leafy vegetables. It's always going to be in terms of my berries. And then I tend to go with legumes are going to be there in no particular order. Those are going to be the top three. The legumes are going to give you, they're all going to give you fiber, which is going to be extremely important. And we can go dive into that. We talked about endothelial health. So your nitrates are going to help protect your arteries within the dietary nitrates, as are the polyphenols from your berries. Extremely powerful for brain health, for blood pressure across the board. I'd love to throw in there garlic and onions and allium family as well. In terms of blood pressure, garlic is phenomenal. I'd love to throw in there beets and love to throw in there pomegranates. But those are some of the main ones that I kind of look at. In terms of from a detrimental standpoint, processed red meat will be the one vilified food first. I think is unanimous across anyone, doesn't matter what pathway or area that you quote unquote believe in, in terms of science, processed red meats are horrible. I think a second tier to that is going to be your red meat in terms of adverse outcomes. And then I'm going to lump together ultra processed foods, I'll call it, which is going to be my sugary refined carbohydrates, which I think that probably is my third tier or in that top three that's there. And a close, I have several others that are right beneath that are just kind of humming right below. They're still chasing it down. But those are the top ones. Yeah, yeah, absolutely. We agree 100%. So let's get to exercise. We're talking about vascular dementia, but it's vascular diseases. And there's very little that's more important for your vasculature than exercise. To the point that even though my whole work has been nutrition and my research and my degrees have been about nutrition, I'm beginning to believe that, of course, you can't rank one above the others because it's just nonsensical. It depends on your situation, everything. But exercise is profoundly important. And there are so many mechanisms with which it affects the brain and vasculature. What's your take on exercise and the vascular system? If I weren't so passionate about nutrition, there's no doubt exercise would be my number one go-to. It's just been shown in every single instance, whether or not it's mental health, whether or not, as we talked about memory, whether or not we speak to the impact on cardiovascular system for blood pressure. Most bodies are built in the kitchen, but that visceral fat, that hidden that surrounds the organs, that's inflammatory and is a metabolic trigger, that's where exercise is powerful. That combination is doing resistance training. It's so imperative for resistance training because all of us, as we age, we have what's called sarcopenia, which means myocloss that happens. and we talk about one of the things and we i know this isn't the point of this but you look at things like glp1 and you look at aspects like the ketogenic diet and we look at the massive weight loss we see the increase in muscle loss and so when we talk about the ozempic butt or the variables that are there what you're talking about is you're talking about loss of core muscular strength this is what is stabilizing you that prevents the falls this is what's stabilizing you to do the functions of life and allows your metabolic rate to be maintained. And so it's so important. The American Heart Association has said it time and time again in terms of the amount of resistance training along with vigorous exercise, that's a vigorous exercise. Absolutely. And for the brain, it's the most vascular organ. So the blood flow to the brain is affected. We've done studies that shows that blood flow in general is improved significantly to the brain with just a few weeks of exercise, both aerobic and anaerobic, both strength training and cardiac training. And then we have the VDNF and GDNF and VGF and others that are excreted. And these are growth factors that grow the brain. In fact, one of the few things that grows the brain is exercise at any age. That's remarkable. Reality is prevention is the key. And prevention can be done. And here it is. If you started early enough, the damage that you see, the white matter change, there's evidence of that reversing because it gives the brain chance to recover, the vascular chance to recover, and it is resilient. So what do you say about the recovery component of cardiovascular disease? I think absolutely it's possible. I think that this is longstanding data that we have in terms of atherosclerosis regressing or reversing or going into remission, whichever terminology one begs to use, that's been well established back into the early 80s. Looking at medications, so we understand that if you're able to regress and decrease that inflammation as well as the cholesterol burden for the soft plaques, you can. And because of the way the mechanism of the vessels work with endothelium, that results in magnitudes of increased blood flow. So it's not about the complete absolving of all atherosclerosis. It's about preventing the obstruction to allow adequate blood flow. Because it's all two simple things. I tell every patient, feel better, live longer. That's what the goal is, right? And so if I can accomplish that through nutrition or through lifestyle, the components of that, that's where we get the value. And so you're absolutely right. There can be reversal. So everyone points to the conflict with Daniel Orange's study, looking at the lifestyle heart trial and that it was multifaceted as it relates to exercise, stress reduction, lack of smoking, and they weren't sure what the bio component. Then there were critiques about whether or not the imaging from the nuclear was spot on. And then, sorry, not to cut you off, but I'm also always incredulous when a study is not repeatable. Yeah, yeah, yeah. That's a big, big, massive red herring that must be, I'm sorry if the plant-based world is gonna, I'm not in anybody's world. I'm in the science world. Yeah, you're absolutely right. And part of that, that's multifactorial, right? So one is there has to be funding to repeat a study. And then two, the science has to be correct in order that it's really bearing out. We need to have workflows. We need to have it repeatable in every single place that's there. And so, yeah, there are some small subsets, Mount Abu, Open Heart Trial. There's some other ones that are there. But I think the key take point is that we have to understand that there is power from nutrition and there power from lifestyle we do see this in terms of reversal or I should say remission of progression of cardiovascular disease and regression of established cardiovascular disease. That's one thing that is clear that we've seen inside studies. Journal of American College of Cardiology recently produced a study, this is probably now several years ago, looking at various lipid lowering therapies and their impact in terms of the regression of cardiovascular disease. And so there is much more data inside that realm than there is in terms of nutrition. But when you look at the percent reduction from areas like portfolio with David Jenkins and some others, you might begin the process of extrapolating that over to say, okay, there is. And so we perhaps do need to have a more focused, intentional effort. One thing I want to mention, just encourage your listeners about the power of small micro movements with exercise before we move on. So I'm in meetings constantly at home at times and my mom is downstairs. I kept hearing this bell ring. I'm like, what is going on? I run downstairs and I see my mom walking around the kitchen, the family room into the living room back and forth. Mom, what are you doing? I'm getting my exercise. Oh, I love it. I love it. She set the timer and was walking around. I tell that every time I'm giving a lecture to cardiac rehab or others, if my, at that time, 80 some odd year old mom was doing that, don't tell me you don't have time to exercise, that you don't have the resources to exercise. It just means intention. What's your intention? I love it. I appreciate it. If you had to start a person and very simple stepwise checklist kind of thing, I'm a checklist manifesto person. Tell me your checklist of health for people to start in their own home and they can put it on their fridge or anything. What would be your checklist? First, establish what do you want. Second thing, create a plan. Third thing, kill the plan. Pre-mortem planning. I want you to figure out every single reason why that plan is going to fail if you can advance yourself in the future. And then I want you to solve for it at that point. So it doesn't matter if we're talking about nutrition, your exercise routine, or anything else. Once you learn to structure and to put pen to paper, that's when studies have shown that you're going to be the most successful. That's the first step, irrespective. And then we can delve into whether or not it's nutrition first, or if it's your sleep, or if it's dealing with your relationships that make you emotionally distraught and lead you to eat poorly or not get sleep, or if it's your lack of exercise, all these variables that we can touch on. But it begins with figuring out what do you want? And then moving from that over to making a plan and killing the plan. Fantastic. Amazing. But we can't end without talking about your amazing book, Selfish. Our audience has to, every single one, they have to get this book. Yeah. You know, it's just, there are, I'm not a chef like the show's eyes, but I do a little dibbling and dabbling. And so we understand that sometimes to bring the flavor out of food, it's the small things that matter awfully more than the big ingredients. And so the small ingredients of life that are important, selfish is an acronym for spirituality. And it's beyond the aspect of just a religion. It's really finding meaning and purpose in life. That's what's important. What's your purpose? And studies have demonstrated the power and the impact on longevity for those who do, but also the practice of whether or not it's meditation or prayer, or if it's deep breathing and what that does for your cardiovascular system, what it does for your endothelial health when you engage in that. The E for exercise, not just exercising physically as we've discussed here, but the power of the mind in terms of belief. Exercising belief and faith that you can overcome, you can accomplish what you need to is important. The L stands for love and love as we all know, you've been married, how many years you've been married? 20 years, 21 years coming up in April. Amazing. Now, so question, what was she wearing the very first time you saw her? We're very service oriented, right? So I've traveled the world, went to Operation Smile to do cleft palate surgeries in China. I had gone to Afghanistan with World Bank and she had gone with Doctors Without Borders. We met an expat party. She was wearing this brown shawl around her because of the community and environment. And she had, she's going to hate this. She had army boots. She says that I did not. She's going to fight me. All of that. So, but, you know, but I remember her and I remember our first conversation about our grandparents and I love it. That is the question I ask every patient who's nervous waiting for a cat is what was their loved one wearing the very first time. And so I love hearing the stories and the response. But I bring that up because love is more than it's not a noun. It's a verb. That means it takes action. It takes forgiveness and the power of forgiveness. And there's studies that look at this small studies on the power and the impact on the cardiovascular system, on the blood perfusion, the power of gratitude, the power of altruism and volunteering and giving of yourself and what begins to happen the f obviously real food whole food plant rich food the i for intimacy of relationships and community and so the power of that looking to our trees and how they interact and they serve nutrients to each other when some can't get sunlight to our positive relationships and oxytocin and so forth second s for sleep that sometimes i'll substitute for song when i'm in lecture because the power of music of hearing and playing. I got this from you in terms of what begins to happen as you're listening and you're reading the music and your hands are playing too as well and the power for the mind that's there. And then the last H is one that's probably one of mine that's most important, humor, laughter, joy of life, of smiling and what that does for your cardiovascular system, how these pillars can help reduce your stress and heal a broken heart. That's the purpose of Selfish Book. Amazing. I'll end with the L for you. and this is something that would never have happened but for your sake i'm wearing the cowboy's hat there we go this is all love my friend this is all love i love it columbus you're amazing we love you please keep this up and together we'll have many projects together thank you so much for your wisdom and knowledge and hope we will do many more like this yeah it's been a pleasure and right back at you you and aisha are amazing and you're role models for everyone. And so we just want to continue to blaze his path with you. And listen, brother, it's a pleasure and an honor to be on this journey with you, trying to change the world while we're on the face of this world. Absolutely. So much love. Thank you. We're thankful to Dr. Batiste for being part of this discussion and for the thoughtful perspective he brings. All right, let's talk about management and treatment of vascular dementia. So when someone comes in with symptoms of vascular dementia. You know, families don't know what's going on. Basically, the symptoms are slowing of thinking, multiple falls, or having symptoms of stroke. And they bring them in and the diagnosis is made. Unfortunately, we don't have any treatment for vascular dementia. Again, the treatment is managing the vascular risk factors aggressively to make sure that the symptoms don't get worse. And with the help of physical therapy, occupational therapy, addressing mental health issues, because a lot of them tend to have depression and anxiety as well, their quality of life can get better. We can be fairly confident in saying that everyone is in a journey of vascular cognitive impairment starting in their 20s or earlier even. No, I agree with you on that. So the vascular damage and accumulation of vascular damage starts earlier. We've seen atherosclerosis in people as young as nine years of age. Yeah, it happens. And white matter disease in 12-year-olds, this is not disempowering. This, I think, is empowering because by knowing that you can start protecting your endothelial lining, miles and miles of your vasculature, brain vasculature, addressing blood pressure early enough, you significantly reduce risk of diseases. By knowing that if you have sleep disorder, addressing it early. If you have prediabetes, if you hit it at that stage, you can actually profoundly reduce your risk. You have moved your life expectancy and quality by more than a decade or more. That's empowering. But it has to start with the idea that we are on the journey of vascular cognitive impairment as early as, you know, teen years or earlier. And that should only raise our awareness of our ability to control those things. Not as a fatalistic perspective, but as an optimistic, proactive step. You can start changing your life by protecting the vessels early on. Oh, wow. Well, I wasn't prepared for this statement that you just made, but it's beautiful. And I think the next step is for our listeners. They're saying, wow, this is important. What do I do? So let's just kind of start beginning and going through the spectrum of life and what people can do at different stages to prevent vascular dementia. And for our lovely community members who already have vascular dementia, what can they do? So if this vascular damage starts very early in life, let's say in a 10-year-old, what are they supposed to do to create an opportunity for their blood vessels to stay healthy? So a 10-year-old is dependent on their parents, right? And then the other thing about a 10-year-old is usually you're not at the stage that you're seeing end-stage outcomes, end-stage organ outcomes. Oh, yeah, of course. So you're not going to see blood pressure often. No. Although we see that even now with some kids. Yeah, it doesn't show. None of those. So it's pre-N organ damage stage. And that means that the cholesterol is higher. The glucose, the hemoglobin A1C is climbing up. So what should be done is at this stage, at a very young stage, doing the things that stops the damage. It's not blood pressure time yet, but it's the thing that's affecting the blood vessels, which is food, exercise, stress management, proper sleep hygiene. These are very, very important. And taking the nutrients if you don't get it in food, hopefully you do get it in food, to make sure that you have your B12, vitamin D, and omega-3s. Those are important. So don't assume that if you have a kid that's a 10-year-old or a teenager that they're protected, they're resilient. I hate when the word resilient is misused as if let anything happen to this person, they're going to bounce back. But the damage that's left is just a platform for accelerated damage going forward. Very true. So in your kids, start the lifestyle that's necessary to protect the vessels, the miles of vessels that will serve them for decades going forward. And this continues throughout teen years, I would say. It does. And then when someone reaches 20, 21, when they're like full adult and they have capacity to have their own insurance or, well, not everybody has insurance. But I would say like at least, you know, have the capacity to speak with their own health care provider about their health. Getting their blood pressure checked once at least. Have a blood pressure machine. Doing the basic blood work that is usually covered by insurance that checks your fasting glucose level, hemoglobin, A1C, LDL, cholesterol, and some other markers. Correct. To kind of find out whether you're okay or not. I mean, at least doing it once a year. Once a year is fantastic because you will see if there's any pattern. Right. And then once people actually get to the point where they're in their late 20s and 30s, that's when we see some of the vascular damage happening, especially if people are living an unhealthy lifestyle. So for people who are smokers, you tend to see more vascular damage in their 30s. People who drink alcohol, people who are sedentary, people who don't have a healthy dietary pattern. And those are times that a lot of people actually develop these end organ issues or diseases or outcomes. And that's when I think if lifestyle cannot bring it back to baseline, if, say, for example, with the help of nutritional changes or exercise changes, they don't see any changes in their cholesterol and their blood pressure and their sugar levels, I think treatment is the next option. I fully agree. That's part of this. It's not independent of this. So lifestyle is always the thing that we highlight. But there is a times, especially when hemoglobin A1C is above 7 and you can't bring it down with nutrition or lifestyle and your blood pressure is above 140, that medication may be what's necessary, at least at this stage. So there's a balance between reducing assault and allowing for repair, right? So in the younger stages, you allow for repair and you minimize assault. But then when the salt has been going on for a long time, you really need to use, you know, some help of medications to allow for the body to repair. And then comes this whole midlife area that's kind of vague, right? Like it starts around, I would say, 40, 45, and then kind of goes up to 65 years of age. I've seen so many different definitions, but that's a crucial time for brain health, isn't it? Absolutely. For health in general and brain health. For women, that's a time when they go through perimenopause and menopause as well. And so there is this additional element that impacts their vascular health as well as brain health. So it's so important for them to institute healthy lifestyle during those times. Absolutely. And then comes later in life. Later, you see for a lot of people who haven't taken care of their vascular risk factors, you see the beginnings of cognitive decline that really manifests, that's obvious. or even dementia in their 60s and 70s. I have to actually say that you tend to see those vascular cognitive decline and impairment in midlife too. Absolutely. So it's really important for our audience to know that that's something that just doesn't show up when you're 65. It's a very slow process and it could start in your 40s, 50s and 60s too. If you recognize somebody who is beginning to have those kind of changes, this is the time in midlife to start addressing it with their clinician, with their neurologist, so that the changes can be implemented early. The likelihood of reversing damage is very high. Again, for our lovely community members who have vascular dementia, I think in that state, it's mostly supportive. I would say that the chances of managing symptoms in vascular dementia, if it's not too advanced, because later on, at the very latest stages, all dementias look the same. They do. Alzheimer's, vascular, Parkinsonian. But before that, I would say probably in the early to mild, early to moderate stages, a lot of people can actually have great quality of life if their vascular risk factors are managed well. Absolutely. Whereas in Alzheimer's, in the mild stage, you can slow it down. Moderate, you can have some effect. But in vascular dementia, even in mild and moderate stages, you can have significant effect on slowing it down or stopping it to a great extent. Very true. So let's run through our neuro acronym as we always do. And we've created it because these are important lifestyle risk factors that allows for the brain to function at its best. And it's based on the preventive model that has been studied extensively. And as for nutrition, and in nutrition, we know that eating a dietary pattern that is close to either mind or Mediterranean diet, that is mostly plant-based or plant-predominant with lean protein, healthy fats such as omega-3 fatty acids, lots of fiber, and lower sources of saturated fats and lower sources of ultra processed foods. And then as far as exercise is concerned? Aerobic and anaerobic. Aerobic means that you're getting tired, walking briskly, running, swimming, biking. These are great. About 150 minutes per week. The more, the better, as long as your body can withstand it. I am a big fan of brisk walking, as you know. Less trauma to the knees, less trauma to the back, but the same benefits. Strengthening exercises are critically important for blood flow, for BDNF, which is this hormone that helps the neurons recover and connect. Strengthening exercise is important, especially leg strength. And those are two pieces of the puzzle that are beginning to become more and more important for longevity and health. Do not skip exercise. Exercise is a central feature of a healthy life. Very true. U is for unwind or stress management. We know that people who have chronic stress and they have cognitive overload due to stress can actually have very direct damaging effect on their brain health and indirect as well. When people are stressed, they don't eat well, they don't exercise, they don't sleep well. So indirectly, it kind of damages other areas of your life as well. Management of stress in itself is a big conversation, but it's very important for people to realize that they're under stress and differentiate between their good stressors and bad stressors. Good stressors are the ones that are connected to a meaningful life and moving you forward. Bad stressors are the ones that you have no control over and it just eats you from the inside. I know that a lot of people experience stress and there's really not much that they can do about it. And that's why it's really important to increase good stress or increase other lifestyle factors that are healthy for them. So exercising, eating well, sleeping well, focusing on things that they have control over is important. Absolutely. And then we have R, which is restorative sleep. And sleep is critical. Sleep is cleansing the brain. Sleep is revascularizing and giving rest to your vasculature. Sleep is memory consolidation. Sleep is getting rid of toxins. If there's any detox, it's sleep. Sleep is reducing the stressors because the blood pressure goes down during sleep. People who have insomnia or sleep apnea actually have fluctuations in their blood pressure. So sleep is critically important. sleep hygiene we've spoken about many times cognitive behavioral therapy for those that have insomnia and running thoughts these are critical factors that you can implement in your life i would say the most important eight hours of your day which is the part of the day where your brain is actually recovering and i would add identifying sleep disorders so if someone has sleep apnea restless leg syndrome getting treatment for that is important we have an entire episode on sleep coming up so we're going to just wait and share that with you all and then last but not the says O, which is optimizing cognitive activity. How does that help your arteries? It doesn't help your arteries, but what it does is create redundancy, creates resilience. So these connections that are damaged by vascular disease, the connections are fortified. Let's say the two neurons that are connected to each other with one axon and dendrite, and something happens, there's a head trauma, that connection is severed, it's lost. But what if these two neurons have 30,000 connections? It's going to take a lot of damage to sever all of those neurons. So it's the redundancy of cognitive activity that's the protective factor. People who have kept their brain active throughout life were able to withstand damage from diseases like Alzheimer's and strokes. So cognitive activity is what creates the resilience and the redundancy to protect against trauma. That is such a good point. Well, That was it. I think we covered a lot. It's an important topic. I want everybody to take it seriously and start taking care of that incredible real estate, which is your vasculature. I hope you enjoyed this episode and you found this information helpful. This episode of Your Brain on Podcast was supported by NeuroWorld, a science-based brain health community built by Dean and I to help you protect your brain long before problems begin. Neuro World brings together evidence-based education, simple daily habits, life classes, and supportive tools designed to strengthen brain health across nutrition, exercise, stress management, restorative sleep, and optimizing cognitive activity. It's not about perfection or fear. It's about understanding your brain, making informed choices, and building habits that add up over time. If you want to take what you learned in this episode and turn it into real-life action, and NeuroWorld is where that happens. Learn more by visiting neuro.world. Thanks again. This has been Your Brain on Vascular Dementia, and we have been your hosts, Drs. Aisha and Dean Shirzai. Have a wonderful day.