Gill:
There's one thing I'd like people to take away. I'd like them to know that there's a huge amount [of things] you can do to reduce [your] dementia [risk], and if you do it, even though not everyone will avoid it, you'll have a longer, healthier life.
Jay:
That's Dr. Gill Livingston. She's a renowned dementia researcher, and she heads a global team who have scientific evidence that lifestyle changes can hugely reduce our risk of dementia. Today she's here with their very latest findings.
Allison:
Welcome to Defy Dementia, the podcast for anyone who has a brain.
Jay:
Defy Dementia is all about living in ways that keep your brain healthy and reduce your risk of dementia because dementia is not predestined by our genes. Genetics can play a role, but lifestyle risk factors such as unhealthy eating, social isolation, and loneliness are also crucial.
Allison:
And according to the very latest evidence, scientists are now saying that if we make healthy changes to those lifestyle risk factors, we could reduce dementia cases worldwide by at least 45%.
Jay:
Yes, something has changed. On previous episodes when we've introduced the show, we've said that healthy changes could reduce dementia cases worldwide by 40%, but now a major new scientific study is pumping up that stat to 45%.
Allison:
In other words, now we can say that nearly half of all dementia cases worldwide could be prevented or delayed with healthy lifestyle changes.
Jay:
Today on Defy Dementia, we get the inside scoop on that just-released study.
Allison:
It's a report by the Lancet Standing Commission on Dementia Prevention, Intervention, and Care. And for brevity's sake, we'll just shorten that to the Lancet Commission.
Jay:
And today, the scientist who leads the Lancet Commission is our special guest. I'm Jay Ingram. I'm a science journalist. I've been writing and speaking about dementia for more than a quarter of a century,
Allison:
And I'm Allison Sekuler, President and Chief Scientist at the Baycrest Academy for Research and Education, and the Center for Aging and Brain Health Innovation.
Jay:
Join us as we defy dementia because you're never too young or too old to take care of your brain.
Allison:
That line, you're never too young or too old to take care of your brain, do you know where that tagline comes from? It comes in large part from one of the central messages put forward by an influential team of scientists who have reshaped the way that we think about dementia.
Jay:
They're called the Lancet Commission because they've published their reports in The Lancet, a famous UK-based medical journal. The first report came out in 2017. It presented evidence that people at any stage of life could make lifestyle changes that could delay or even prevent dementia.
Allison:
And other scientists have been talking about that, but the Lancet Commission put it all together and codified it into one big report.
Jay:
Every few years, the commission looks at all the research that's been done all over the world, and only when there's a consensus that the evidence is really strong, often based on combined studies with millions of people, only then does a risk factor make it into the report.
Allison:
The first Lancet Commission report in 2017 included just nine lifestyle factors linked to dementia risk, less childhood education, not enough exercise, being less socially active, smoking, hearing loss, depression, diabetes, high blood pressure, and obesity.
Jay:
And the commission advised people around the world to be ambitious about dementia prevention, to make lifestyle changes to decrease those risk factors, and governments and health authorities to spread the word. This podcast is part of that initiative.
Allison:
In 2020, the second Lancet Commission added three new risk factors to their list, excess alcohol consumption, traumatic brain injury, and air pollution.
Jay:
And now the Lancet Commission has just come out with a brand new report with two new risk factors. We will reveal them a little later in the show, but first, let's meet today's special guest.
Allison:
Dr. Gill Livingston is a professor of psychiatry of older people at University College London in the UK. She researches dementia prevention, but throughout her whole career, she's also been a hands-on doctor. She works in a dementia clinic where she diagnoses suspected cases and breaks the news of dementia diagnoses to patients and their families. In both her research and her clinical practice, Gill investigates ways to help patients and caregivers cope with depression, sleep better, and just generally live healthier lives. And of course, she's also the lead researcher on the Lancet Commission. Gill Livingston joins us from London. Gill, thanks so much for helping us defy dementia.
Gill:
Thank you so much for inviting me to be on your podcast.
Allison:
Now, before we get into the latest report and the new risk factors, what sparked your interest in dementia, both in terms of your research and in working with people who live with dementia?
Gill:
When I was a junior doctor, which was quite a long time ago, I worked in an old psychiatric hospital, which I think was the biggest psychiatric hospital in Britain, and closed a few years later. And when I went seeing people with dementia in wards, they were in the old nightingale wards. I don't know if you know what they are in America. [It was a big room] where they could pull curtains around, but nobody had individual rooms, nobody had individual washrooms. It was a complete lack of privacy, basically warehousing people. And I thought, "There has to be something better than this. It surely doesn't have to be like this, that people live their lives and then begin to develop dementia and then live like this without privacy, without human dignity, without occupation." And so I was very saddened really by what I saw and thought it should change. And I'm pleased to say, not because of me, but it has changed enormously, and nobody would consider looking after people like that nowadays.
Allison:
We read that both of your parents actually were also diagnosed with dementia after you began studying it. And did that affect the way that you approached your job in any way?
Gill:
I think it more affected the way that I approached my parents. It was quite a long time after I had started working and when they were both well, I had discussed with them that as they were getting older, they ought to consider power of attorney for each other and also to have some of their children or all of their children, it's up to them, to have power of attorney in case they needed it. And then later on, me and my older brother were trying to help my mum move into somewhere that was safe for her and where she got as much freedom as possible because we were realistically concerned that she was going to set the place on fire and it was not fair to her or her neighbors. And we were discussing it with her and she said to us, "You're trying to take my money."
My brother was very upset and offended and said to me, "We just have to stop doing this. We have to stop looking after her." I was able to see it's the dementia, it [was] not her. She trusted us when she was well. When she was well, she'd meet plans in advance, and this is the dementia. [But it is still] very unpleasant when your mum says to you that you're trying to take her money. But we stopped talking about it, and we came back later at another time, and she was no longer about it. And she did have, after we had helped her move, a couple of very happy years in new accommodation where she got more help.
Jay:
Gill, the 2024 Lancet Commission report also ups the number of potential dementia cases that could be eliminated by lifestyle interventions from 40 to 45%. Why did that happen?
Gill:
Well, during the commission, we keep looking at possible risk factors and see if they pass the threshold for us to count them as part of the commission. I'm pleased to say that there's a lot of research in dementia over the years, and things have changed a lot, so we were able to include two new risk factors. We now thought there was sufficient and convincing evidence, and these were high cholesterol and vision loss. [Those two new risk factors] added 7%, but we also relooked at all of the other risk factors. We were pleased to see that there's been a decrease in the number of people smoking worldwide, and there is also an increase in education worldwide. So both education and cigarette smoking went down in the impact that they have in the population, but we added two [new risk factors so] that came up to the 45% or just over 45%.
Allison:
So when you look at vision loss as a potentially modifiable risk factor, what do people know about how vision loss is linked to dementia?
Gill:
I don't think we know an enormous amount about it yet. I think the evidence is convincing [as] there are a lot of studies showing it, and they show it consistently. So looking at the two of you, this is not a visual program [but for our auditors], you're both wearing glasses, it's not the vision loss itself. You corrected yours. [It's uncorrected vision loss the risk factor]. We think it's related to things like brain stimulation. So [if your vision is good or corrected], you can read, you go out, you can do things and [have] social and physical stimulation as well. [But] if you can't see, people tend not to go out, tend to be by themselves, and they certainly don't tend to go for walks because they're quite likely to fall over. We think that vision loss leads to changes in cognitive, physical and social activities, and we hypothesize, but I don't think we yet know it, that this would lead, as hearing does, to shrinkage in different parts of the brain.
Allison:
I'm trained as a vision scientist. And so on behalf of the entire vision community, we want to say thank you for raising awareness through the Lancet Commission, that this is now officially a modifiable risk factor for dementia.
Jay:
Gill, what about cholesterol? How does that play into this? What effect do you think or the commission thinks it has on the brain?
Gill:
We think cholesterol works in a couple of ways. So as you and your listeners probably know, cholesterol, or bad cholesterol, also known as LDL cholesterol is a risk factor for cardiovascular disease [by] laying down fat in the cardiac arteries. Generally it's a risk factor for cardio and cerebrovascular illness and can lead to both major strokes, but also tiny little strokes in the brain, which people don't know about. They don't know they have them. They're very small. You could only see them in MRI. So we think that [those little strokes are part of the risk factor for dementia]. But we also think that cholesterol leads to the actual increase in both amyloid and tau protein, which are the proteins which are most connected to Alzheimer's Disease. We think it works in more than one way.
Jay:
It's interesting because nutrition generally is not one of the risk factors, but now you've got LDL cholesterol, you already had diabetes and high blood pressure on the list, and you could see all of those as nutrition related. So why hasn't nutrition made the list?
Gill:
Well, nutrition is just very complicated. It's just not as simple as one measurement. [For example] what you eat is related to obesity, and obesity is related to diabetes and hypertension, and there is a relationship, but not a direct relationship, with high cholesterol. [Such that] you can have high cholesterol when you are thin and eat well. There are other causes of it, but we know that people who eat better at a younger age are less likely to develop dementia in general. But [clinical] trials to use a particular vitamin or a particular diet have been negative and thrown out possible other hypotheses. So I think it's difficult to be sure as to whether nutrition, as opposed to something that might make you overweight, has a direct impact. But maybe it does, but we'd have to know a lot more. It's so complex. [It matters] what you eat and when you eat it and how long you eat it for.
Allison:
You were saying that individual vitamins or individual supplements haven't necessarily worked, but do you think that there's hope maybe by having combinations?
Gill:
Well, there's always hope, isn't there. But nothing has worked. In general, [a good] diet is clearly good for you. And it's good for you to have a mixed diet. A lot of fruit and vegetables, it's generally good for your health, and people who are healthier, physically healthier, have more resistance to brain pathology. But again, it's a very indirect mechanism. But yeah, I mean absolutely we would encourage people to eat well.
Allison:
Okay, good to hear. Now, the commission has emphasized the importance of each risk factor at different stages of people's lives. So for example, you mentioned hearing and vision before. Hearing is listed in the commission report as being really key in midlife and vision later in life. So what determines when each risk factor comes into play?
Gill:
Okay, so what we're really reporting on is when the evidence is. Some of the risk factors that are important in one part of life may be important in other bits of life, [but] we don't have the evidence yet. Interestingly, some of them actually changed.
As people develop dementia [over years], dementia is not something you develop overnight. As people are developing dementia, they begin to lose weight and then their blood pressure begins to decrease. So being obese or having high blood pressure in midlife is definitely a risk. But in late life, the people who are developing dementia are losing weight and their blood pressure is going down, so it then becomes very complicated because one of the things is the people who are still obese and their blood pressure is still high, are not developing dementia yet, but it still would probably be better for them for their blood pressure to be normal and for them to be thinner. It's just sad that being thinner by mistake just because it's part of the illness is bad, but getting thinner on purpose is probably good.
Allison:
Just because something's listed as midlife or late life, it doesn't mean you shouldn't pay attention to it at any other time, right? Childhood education, for example, is listed “early”, but the report now suggests that potentially education throughout your life can be helpful. Is that correct?
Gill:
Yes. Our cognitive stimulation doesn't need to be education. I think that's very exciting because for a long time we couldn't really separate out whether it's just that people with more education choose more cognitively stimulating occupations or are more likely to be employed in them. But now having these massive cohorts, we can see that people without education and with cognitively stimulating occupations are also relatively protected.
Jay:
Gill, you mentioned earlier that as smoking decreased then the magnitude of the risk due to smoking decreased with it. Do you see the 14 risks that you've identified so far as a kind of dynamic set? As this information gets out to the public and [if] crucially the public acts on it, [will there] be shifts all over the place, some coming down, some rising?
Gill:
I very much hope so. I suppose the point is not just to observe the evidence but for there to be changes. So I think we give individuals information, which gives them choice. But it's not just individuals, it is related to policy as well. It's difficult for us to change air pollution by ourselves, to choose an obvious one. We [also] know [that] if people have green safe spaces, then they're much more likely to walk around them, and they're much more likely to walk around them with other people, and we know that it makes a huge difference. I very much hope that this is all leading to change.
Jay:
In terms of future additions to the Lancet Commission list, do you have a sense that we will see overall more risk factors being added with time? One day could there be 20, not 14?
Gill:
I think the answer is yes. I mean, one of the gratifying things about the commission is that lots of other researchers read it and see where we've said there are holes in the evidence and begin working on them. It's become like a whole community effort, and we get lots more information. So we have a whole list already of things within the commission that we thought about, but thought there wasn't enough evidence. It doesn't mean they're not important, they might be important, or they might not be. I'm hoping that by the next time we have a commission, we'll have enough evidence to say yes or no to nearly all of them. And there will be other things that we haven't thought of that [will] come up. So yes, I think there will be more, and I think there will be more potentially preventable dementias. And I'm hoping that dementia will continue to reduce in both high income countries, but also in low and middle income countries.
Jay:
We've seen in this latest report the amount of risks that could be avoided moving from 40 to 45%. Do you see that number going up as well?
Gill:
I think it's almost inevitable that it'll go up if we have more risk factors. So yes, I do see that even although I'm hoping that some risk factors will go down by becoming less common.
Allison:
So in your experience as a clinician, as a researcher, and as the lead of the Lancet Commission, what do you think the future holds in terms of dementia prevention?
Gill:
I suppose it's more a hope than a thought. I hope that the World Health Organization will [add dementia as one of the main non-communicable diseases that all governments should think about], because I think that governments are, by their nature, much more powerful than individuals [to help make changes]. But also that people will no longer say there's nothing you can do about dementia.
Jay:
Gill, is there one thing about the commission report that you would most like people to take away?
Gill:
Yes, there's one thing I'd like people to take away. I'd like them to know that there's a huge amount [of things] you can do to reduce [your] dementia [risk], and if you do it, even though not everyone will avoid it, you'll have a longer, healthier life. And for those people who do develop dementia, they will have a shorter period of illness, and the rest is just commentary, and you can all go and read it. It's open to everyone.
Jay:
Gill, the proverb physician, “heal thyself”. To what extent do you personally practice what you preach? This question is in a teasing tone, not a critical tone or anything.
Gill:
I don't feel criticized.
Jay:
Oh, good. To what extent do you practice what you preach about dementia risk reduction?
Gill:
Quite a lot. If you look at my wrist, you can see I wear a Fitbit. I try to do 10,000 steps a day or more. I don't always, but I frequently do. I have a personal trainer who I lift weights with because first of all, she's much better at it than I am, but secondly, my natural instinct is to sit on a couch and eat chocolate, and that's clearly not good for me.
I wear bifocal contact lenses, I wear hearing aids. I have been to my doctor quite recently, and fortunately, my cholesterol and my blood pressure are all right, but I'm keeping an eye [on it], and if they're up, I'll do something about it. So I'm looking at all of these and the work that I do is luckily cognitively very stimulating. I [am also] luckily to have a large and stimulating family and lots of friends, so I try to keep socially active. I do my best with all of these things. I would prefer not to get dementia. And if I do get it, I'd like to be older and have a longer, healthier life rather than a longer unhealthy life.
Jay:
Well, when you say you're doing your best, I think you're doing quite a lot. Gill, thank you very much for this. We really appreciate your time.
Gill:
Okay. And thank you so much for inviting me and helping what we're all trying to do, which is give people information and choices. Thank you very much.
Allison:
Thanks.
Jay:
Dr. Gill Livingston is a clinical academic and a professor of psychiatry of older people at University College London. She's lead researcher on the Lancet Commission. She joined us from London.
Allison, Gillian Livingston is so impressive as a podcast guest and as an individual, what's uppermost in your mind? What did you take away from what she's told us?
Allison:
One of the things that struck me was [when] she [said] that dementia researchers around the world look at this Lancet report, and it helps drive the future of research, and that's absolutely true. And as a vision researcher, I was really excited to see that maybe this is going to lead to more research on understanding the relationship between vision loss and dementia.
And one of the things that also struck me was she mentioned that you and I both wear glasses, and so we don't have untreated vision loss, which is what really the risk factor is, but it's so important. This is something that is in the report, but we didn't really discuss. It's so important to recognize that not everyone has access to vision care. Not everyone has access to glasses. In some parts of the world, even young kids who have vision loss that could be so easily corrected [by getting] the right pair of glasses, are not getting the vision care that they need. Hopefully this is going to really raise awareness about these really easy kinds of things that we can do. It's not even working with a coach to be able to do your exercise. It's just get your vision checked, make sure you've got the right prescription, and you're treating any sort of cataracts and other kinds of issues as early as you can.
So what stood out to you?
Jay:
Well, just following on what you just said, the study emphasized that in lower [and] middle income countries, the situation is very different from what we might be familiar with. And just to follow on maybe the difficulty of getting access to glasses, same is even more true, I think, of hearing aids. And we already know that untreated hearing loss is a very significant risk factor for dementia, and yet you just know that whereas in, say, North America or the European Union, people have access to hearing aids, that's not true of the entire world. So this is a global issue.
Allison:
Absolutely.
Jay:
And I think that that's really worth underlining. What else did you get?
Allison:
When we talked about hearing loss and vision loss versus LDL cholesterol, Gillian talked about the impact that those different factors had on the brain. What was really interesting was how it's not sort of one size fits all. The different risk factors are actually having different kinds of impacts on the brain. In vision loss and hearing loss, it might make information harder to understand. It puts more cognitive load on us, as we've discussed in [our previous episode]. It also makes it harder for people to interact, get out in the world, and really take advantage of some of the other lifestyle changes. Whereas LDL cholesterol and some of the other risk factors, have a more direct impact. Maybe it's more directly linked to the development of amyloid and tau in the brain or inflammation in the brain. So [the lifestyle changes you can make are] affecting your brain in different ways. I thought that was really interesting.
Jay:
Well, and it highlights for me just how dynamic this is because from what you just said, these different risk factors are having a different impact on the brain, so it's not just this causes that, it's a very dynamic picture.
But also the changes in the number of risk factors since 2017. I was so happy to interview her because I've followed the Lancet Commission since the beginning, and the list is growing. That's the point we made, but it's also changing. Some risks are slowing or lessening because people are acting on them. And that's the key, isn't it? It's that people act on them. And as you said at the very beginning, Gillian Livingston is very impressive because not only is she knowledgeable about the risks, she's acting on many of them.
Allison:
Yes. And for example, when she's talking about smoking, the amount of risk that it accounts for has gone down over the years because people are taking action, and they're not smoking as much. So that's a great thing to see, but I think the other thing that she did point out was that, and you've just mentioned it, this is a global effect. So things like air pollution, we're not going to be able to impact that on ourselves as individuals. For that, we really need to make sure that governments and other policy groups are taking action to be able to make sure that as a world we're taking action. But we can do that. We can push for our governments and groups like the UN and the World Health Organization to take action.
But you and I, we can do things locally as well. We had publicly declared some New Year's resolutions in a previous episode, and I think it's important for us to come back and see [the changes we’ve made]. Gillian's doing a lot, but are we doing as much as we could? So where are you standing right now on what we said we'd be doing? And if you don't remember, I can remind you.
Jay:
I'm sure you can. I'm about to lose a lot of credibility, but here's what I said. If I recall properly, I was going to engage more in music. I've played the violin almost all my life, but I hadn't been doing it. I have to confess, I still haven't gotten around to that. I did say that I would get a lot of exercise walking my dog in the woods. And indeed, I was in Ontario for three months in the woods. My dog was there. I got out every day on rough trails, where you have to watch your balance. And then I'd accept a plus on that one with gratitude. And then the last one was I was getting tired of playing Wordle every morning. I was sort of getting irritated with the Wordle bot that tells you how stupid you are, [but] I'm still in the process of taking my anger out on the Wordle bot, so I still am playing Wordle. I'm also playing Connections. And anyway, I would rather now hear about your New Year's resolutions.
Allison:
Yes, my resolutions didn't have to do with Wordle or Connections, but I do play those. And then there's also another one called Strands, which is really fun. You should check that one out too. And of course, people, if they're listening, should go play our Brain Health edition of Sudoku called Kanoku. That's another good one. So Jay, if you haven't tried that, that would be a good one for you to check out.
Jay:
Yes. Okay. Next year's resolution.
Allison:
So from my resolutions, I had already been working on a skincare routine, and that sounds strange as a brain health prevention tool, but the reason I accounted it was because it made me feel better about myself, and it helped me get out in the world and interact more and definitely have been doing more of that, and I've been keeping that up.
My main goal really was to try to improve my sleep. It's something I've struggled with for so many years, and just within the last couple of months, I have figured out a combination of things that doesn't always work, but is working a lot better for me. I'm using my Apple Watch to track my sleep and be able to [track] when I am in deep sleep and things like that. I'm actually seeing and quantifying, and that’s making a difference. What I'm doing now, and it sounds so simple in retrospect, and I feel like an idiot for not having done it earlier, but the face routine is now part of a regular nighttime routine that [signaled] your brain that this is bedtime. That's the first part of it.
I've tapped into a certain kind of mindfulness meditation just 5, 10 minutes before I go to sleep, and that is helping me get into the right frame of mind. And the most important thing that I'm doing is resisting the urge to check my phone if I wake up in the middle of the night. Before, I would wake up, and I'll say, "I'm just going to check one thing." Or I'd hear a ding from someone who sent me something. Usually it's a Wordle score that's coming in from our family chat in the middle of the night, and I would just get sucked down that rabbit hole. So you look up one thing and then it leads to something else, and then before you know it, you're sitting in bed on your phone. Or at least I was, for an hour, and then it's impossible to get back to sleep.
So I have just been trying as hard as I can to resist that urge to use my phone at all when I'm in bed. With that combination of changes for me, I'm sleeping so much better.
If anyone's using Apple Fitness or other kinds of trackers, they'll give you a little reward when you have an improvement in something, and I got an improvement in my sleep reward. So that was very gratifying for me.
The other one, like you, I said I was going to do more music related things. I'm not necessarily drumming every day, but I'm absolutely making an effort to be listening to music. And one thing that I hadn't said I would do, but I am doing, is making an effort to be more socially engaged. Listening to all of the stories around the impact of social engagement and isolation and loneliness. I mean, I had a lot going on, but I really wanted to make an effort to get out there and try new things, so that's what I've been working on.
Jay:
Does the fact that I've lived in four different places in the last year, does that count?
Allison:
I think that's going to count.
Jay:
I think it's some kind of mental challenge. Anyway, congratulations. You've done a lot. I haven't. I'm going to catch up. And again, thinking back to our interview with Gillian Livingston today, we can joke about our resolutions, but that is the nub of this. This is what's important, is to embrace some of the suggestions, maybe simple ones at first because you're only setting yourself out on a healthy road. And who could argue with that?
Allison:
Absolutely.
To find out more about how we can all reduce the risk of dementia or slow its progression, please visit us at defydementia.org.
Jay:
There. You can check out other episodes of the podcast as well as our videos, infographics, and other resources. That's also where you'll find a link to the latest Lancet Commission study.
Allison:
Our podcast production team is Rosanne Aleong, Helen Chen, and Sylvain Dubroqua. Our writer and Chase producer is Ben Schaub. Production is by PodTechs. Music is by Steve Dodd. And our cover art is by Amanda Forbis and Wendy Tilby.
Jay:
We'd also like to thank the funders of this podcast, the Center for Aging and Brain Health Innovation and Baycrest.
Allison:
We really appreciate your support too. So hit that subscribe button for Defy Dementia on Spotify, Apple Podcasts, or wherever you get your pods. And please don't forget to leave a like, a comment, or maybe even a five-star review.
Jay:
Next time on Defy Dementia, truth or compassion. One of the biggest complications in caring for someone living with dementia is deciding how and when to tell the truth. For example, when someone living with dementia keeps forgetting that their spouse or partner died, what's the best way to shield them from suffering from that tragic news over and over again?
Allison:
I'm Allison Sekuler.
Jay:
And I'm Jay Ingram. Thank you for listening to Defy Dementia. And don't ever forget, you're never too young or too old to take care of your brain.