Welcome to the Goldring Center for Culinary Medicine module on

optimizing neurocognition through nutrition.

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Diets high in saturated fat and refined carbohydrates can disrupt brain

function and may have a causal link to the development of

neurodegenerative conditions but human research data is still at an

early stage.

Also note: Dietary patterns that rely on refined carbohydrates and fatty

foods are also missing nutrients found balanced wholesome diets.

Deficiencies, both clinical and subclinical) of certain missing nutrients

(vitamins D, E, B6, folate, and minerals iodine, iron, magnesium) also

affect cognition relating to neurodegenerative conditions and pediatric

neurological development.

2

The standard American dietis characterized by a diet high in saturated fats and refined carbohydrates and low in complex carbohydrates, fiber, fruits and vegetables.

This shift in the American diet can be attributed to increased availability and affordability of highly processed foods following the agricultural and industrial revolution.

3

Increased consumption of processed and packaged foods that are high

in simple carbohydrates and, until recently, trans-fats is the result of a

dramatic reduction in the cost of manufactured sugars and fats vs. farm

grown whole foods like fruits and vegetables.

The prevalence of fast food and convenience stores has normalized the

consumption of calorie dense, nutrient poor foods in the mainstream

American culture.

Coupled with increasing demand for convenience and a consumerism

culture driven by increased screen time and immediate gratification, the

Western diet has become synonymous with mindless eating, eating on

the go without attention to portion control and without emphasis on a

healthy, active lifestyle.

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There is a discrepancy between how and what Americans eat and the

diet recommended by health agencies like the American Heart

Association and the American Diabetes Association.

MyPlate was introduced in 2011 by The Center for Nutrition Policy and

Promotion (CNPP), an organization established by the U.S. Department

of Agriculture in 1994 to improve the nutrition and well-being of

Americans.

MyPlate replaced the food pyramid and is a simple reminder to include

more fruits and vegetables on our plates at mealtime.

The widely researched Mediterranean style diet recommended for

cholesterol reduction in patients seeking to prevent or improve

cardiovascular health is high in fruits and vegetables, legumes and fish,

and heart healthy polyunsaturated fats like those found in olive oil.

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The standard American diet is a major cause of morbidity and mortality due to

increased incidence of cardiovascular disease, hypertension, type 2 diabetes,

osteoporosis, and some types of cancers.

These factors along with physical inactivity, increased TV and screen time are

contributing to the obesity epidemic in America.

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Obesity, metabolic syndrome, and diabetes are all examples of

dysregulated glucose states.

Chronic hyperglycemia and hyperinsulinemia induce a pro-inflammatory

state in the body which disrupts normal biochemical processes.

This stressed state stimulates an overproduction of reactive oxygen

species leading to oxidative stress.

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The hippocampus is responsible for long-term memory and spatial

navigation and these defensive stress responses can cause alterations

in normal signal transduction in the brain which leads to decreased

hippocampal volume and structure.

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The impairment associated with chronic diabetes extends beyond

neurocognitive decline to increased risk of Alzheimer’s Disease.

Chronic hyperinsulinemia has been associated with decreased amyloid

beta protein clearance and tau hyperphosphorylation – both pathologic

features of Alzheimer’s Disease.

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Insulin degrading enzyme is responsible for clearing amyloid beta

proteins and it appears that the excess insulin prevents insulin

degrading enzymes from adequately clearing amyloid beta proteins.

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The accumulation of A-beta proteins and tau hyperphosphorylated

proteins are linked to accelerated brain aging as manifested in

microangiopathy detected by MRI as white matter high intensity lesions.

These white matter hyperintensity lesions and other structural changes

have been found to occur at higher rates in diabetic vs. non-diabetic

populations.

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A recent systematic review of the literature showed that poor glucose

control as evidenced by hyperglycemia, high hemoglobin A1c levels and

wide glucose fluctuations are negatively associated with cognitive

abilities in Type 2 diabetics without dementia.

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We have seen that a diet high in refined carbohydrates contributes to

obesity and type 2 diabetes.

People with type 2 diabetes are one and a half times more likely to

experience complications of dementia, subtle cognitive impairments and

accelerated cognitive decline as compared to non-diabetics.

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Glucose and insulin are hypothesized to directly affect brain structure

and function.

Hyperglycemia can lead to the accumulation of toxic metabolites and

the depletion of essential metabolic cofactors.

This accelerates the rate of oxidative stress leading to neuronal

dysfunction and apoptosis.

Abnormalities in insulin signaling in diabetics may alter synaptic

plasticity. Defective insulin states may interfere with the metabolism of

amyloid beta and tau proteins that accumulate in excess in Alzheimer’s

Disease.

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Choosing nutrient dense carbohydrates like brown rice, oatmeal, beans,

fruits, and green leafy vegetables not only supplies the body with

healthy carbohydrates but also vitamins and minerals, fiber and protein

that are found naturally within these sources of whole foods.

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Saturated fats also play a role in cognition.

Diets high in saturated fats have been linked to impairments in cognitive

functions, specifically functions involving memory, speed and flexibility

in both the short term and the long term.

In one study men were given either a 17% fat diet or 74% fat diet.

After 7 days, those consuming the high fat diet had significantly

decreased attention scores.

In another study, high saturated fat intake has been linked to decline in

memory, processing speed, and attention measures over a six year

period.

Limitations: limited number of available observational studies, no

intervention, all studies assessed dietary intake by food frequency

questionnaires

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General problems with studies of elderly people: attrition is common,

individuals with cognitive problems may be most likely to be lost to follow-up.

The current widespread use of statins complicates efforts to isolate the effects

of diet on cognitive function. (If saturated or trans fats influence cognition

because of their effect on cholesterol metabolism, the use of cholesterol-

lowering drugs would be expected to mask that effect.)

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Numerous studies have linked the benefits of certain foods to

decreased or reduced signs of dementia in elderly individuals.

Omega 3 fatty acid supplementation was found to slow cognitive and

functional decline over a 12 month period in subjects with Alzheimer’s

Disease compared to placebo.

Antioxidants found in berry fruits and walnuts have been linked to

reduced levels of oxidative stress and improved cognitive functioning in

adults who demonstrated high dietary intakes of these foods.

We will revisit the benefits of omega 3’s and antioxidants throughout the

remainder of this module.

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Curcumin, an Indian spice, has been associated with lower rates of

inflammation and oxidative stress in in vitro and in vivo studies.

Although current studies have not found it to reverse symptoms of

dementia in Alzheimer’s Disease patients (possibly due to its poor

bioavailability), it is currently being studied for dosage effects on

neuroprotection.

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Iron supplementation also appears to improve memory and intellectual

ability in participants between 12 and 55 years of age, regardless of

whether the participant was initially iron-insufficient or iron-deficient.

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ADHD is one of the most commonly diagnosed childhood mental health

disorders.

It is characterized by persistent patterns of impulsivity, hyperactivity

and/or inattention in two or more settings, significantly interfering with

social, work, and school function.

It appears that the incidence of ADHD has increased dramatically over

the last decade.

Whether that is a matter of increased awareness or increased

symptomatology remains debatable. Many studies have linked ADHD

symptoms with poor dietary intake.

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These CDC prevalence maps of ADHD (on the left) and obesity rates by

state (on the right) highlight an interesting parallel between the most

obese states (Louisiana, Arkansas, Mississippi, Alabama) and those

with the highest percentages of children ever diagnosed with ADHD.

While this is an interesting correlation there is not yet evidence for

causation but we do have indirect research that creates a case for

concern.

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Multiple studies have found an association between increased ADHD

symptoms and:

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Increased intake of Western style diets - high in total and saturated fat

& refined sugars.

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Diet high in omega 6 fatty acids, low in omega 3’s, which is often

associated with a decreased intake of nutrient dense foods like fish,

fruits, veggies, legumes, & whole-grains.

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Certain micronutrient deficiencies – specifically iron and zinc have been

shown to be more common in kids with ADHD symptoms.

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Stevens et al.’s compilation of 35 years’ worth of studies on dietary

sensitivities and associated ADHD symptoms in children and

adolescents highlights examples of randomized controlled trials in which

children and adolescents were fed elimination diets without artificial

food coloring (AFCs) and then given diets with AFCs added back.

The studies found a positive correlation between ingestion of AFCs in

children and worsening symptoms of ADHD in those already diagnosed

with moderate to severe ADHD. Increased inattentiveness and

hyperactivity was also observed in children without ADHD enrolled in

the studies.

Food additives have been linked to adverse health effects: Studies in

humans have shown an increase in atopic reactions, hyperactivity &

inattentive behaviors, sleep disturbances & decreased sleep latency.

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AFCs are usually listed as a color followed by a number, such as Red

#40. AFCs are found in processed foods that are often nutrient-poor

and hypercaloric.

Counsel patients to avoid fruit punches and colored sports drinks and

use caution with children’s cereals. Boxed dinners, like Macaroni and

Cheese, and prepackaged desserts and yogurts may also affect

sensitive children.

Patients who want to be very proactive can be told to look for the above

AFCs on ingredient lists.

When telling a patient to avoid certain foods, always try to suggest a

healthy alternative.

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In a randomized, double-blinded, placebo-controlled, crossover trial

examining the effects of AFCs or sodium benzoate preservative (or

both) in the diet of 3 year old and 8 or 9 year old children from the

general population, a statistically significant increase in hyperactivity

symptoms as measured on a global hyperactivity assessment scale

was associated with the kids who consumed greater than 85% of the

premixed drinks over a 7 week period.

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Parents may feel overwhelmed by the idea of eliminating all AFCs from

their diets.

No one wants to take away all their child’s favorite foods and no one

has time to home cook every single meal or snack.

Let interested patients know that there are good options available in

stores. Sometimes, simply switching brands is all that’s necessary.

Fortunately, the brands without AFCs are often healthier in other ways

as well.

Reading labels is always the best way to be sure that the foods you

choose do not have artificial colors.

Look out for these Artificial Food Colorings such as Blue #1, Red #3, or

Orange B, which are listed under ingredients.

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Using less processed breads, cereals, and yogurt with fresh fruits, vegetables,

and healthy fats creates wholesome, AFC-free snacks.

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Remind parents that fruits and vegetables are healthier snacks, and

that even AFC-free treats must be given in moderation.

These recipes use fresh ingredients and take only a few minutes to

prepare.

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These recipes use fresh ingredients and take only a few minutes to

prepare.

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Studies have demonstrated low serum iron and ferritin levels in children

and adolescents diagnosed with ADHD.

Lower serum iron levels have also been found in patients with anxiety,

depression, and schizophrenia.

Iron is an essential mineral involved in formation of hemoglobin and is

also a major component of myoglobin. Both are crucial for oxygen

transport.

It is needed for cell growth and healthy immune function. In the brain, it

is an essential component of brain myelination, energy metabolism and

neurotransmitter synthesis and metabolism, most notably dopamine,

serotonin, GABA, and glutamate.

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In children with low serum ferritin (below 30 micrograms per deciliter),

iron supplementation of 80 mg/day has been shown to reduce ADHD

symptoms.

Iron therapy was well tolerated (no significant side effects other than

mild GI upset) and effectiveness was comparable to stimulants.

ADHD symptoms improved over an 8 week period measured with

simultaneously raised serum ferritin levels.

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https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/#en5

Institute of Medicine. Food and Nutrition Board. Dietary Reference

Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper,

Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and

Zinc : a Report of the Panel on Micronutrients. Washington, DC:

National Academy Press; 2001.

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Foods made from enriched flour (bread, pasta, pancakes, etc.) add a

significant amount of iron over the course of a day

Iron is found in other vegetables besides spinach (e.g. broccoli, chard,

collards, asparagus, Jerusalem artichokes, baked potato with skin, snap

peas, pumpkin, mushrooms, tomato products, whole grains)

Meal replacement drinks (Instant Breakfast, etc.) have a significant

amount of iron

Vitamin C enhances non-heme iron absorption

The iron from supplements is less well absorbed than that from food,

however supplements are needed in cases of actual deficiency.

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Zinc supplementation has also been studied in treating and alleviating

symptoms of ADHD.

Zinc is an important cofactor for neurotransmitter, prostaglandin and

melatonin metabolism.

It indirectly affects dopamine metabolism and contributes to the

structure and function of the brain.

Zinc supplementation either as an adjunct to stimulant medication or as

monotherapy have provided conflicting evidence of efficacy.

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In one study 10mg of zinc sulfate per day (compared with placebo) as

an adjunct to methylphenidate (0.3 mg/kg/day) yielded no significant

differences between zinc supplementation and placebo on attention and

focus.

There was however an observed trend toward improved attention

although not statistically significant.

15-30mg/ day of zinc glycinate monotherapy failed to demonstrate

benefit in ADHD symptoms over an 8 week period.

In the 30mg group, however, children given d-amphetamine needed

37% less medication to achieve the same clinical effects.

More studies are needed at a higher dose of zinc supplementation to

determine efficacy.

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Zinc does not merit strong recommendations for supplementation in

ADHD, but it has been shown to be useful at 30mg/day as an adjunct

for reducing stimulant medication.

Higher zinc dosing may be helpful but has not been proven efficacious

in controlled studies.

Healthy dietary sources of zinc include: oysters, red meat such as lean

beef and lamb, poultry, spinach, nuts – in particular flax seeds,

almonds, sesame seeds, pumpkin seeds, and legumes like lentils and

garbanzo beans.

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Maternal and early-life nutrition is emerging as a factor in mental health

outcomes in children.

Research has shown that 2 or more servings of fish per week in

pregnant women led to a decreased association with inattentive and

hyperactivity scores of children followed from pregnancy to 8 years of

age.

A major concern in pregnancy is exposure to mercury. It was found that

mercury levels at <1μg had no negative impact on fetal neurocognitive

development.

Interestingly, mercury levels >1μg (consistent with the consumption of

2+ servings of fish/week) was associated with decreased hyperactivity

and impulsivity symptoms.

This positive association was maintained when accounting for the

positive benefits of omega-3 fatty acids for babies in the moms

consuming >2 servings of fish per week.

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There are 2 essential fatty acids we must obtain from our diet because

our bodies cannot synthesize them:

1. alpha-linolenic acid: an omega-3 fatty acid and

2. linoleic acid: an omega-6 fatty acid

• Omega-3’s play an essential role in the function of the nervous

system including: cognitive development, neuroplasticity,

synaptogenesis, and synaptic transmission.

• Omega-6’s play a role in pro-apoptotic events and are therefore pro-

inflammatory.

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The standard American diet is too high in omega 6 fatty acids which

have a pro-inflammatory effect.

The standard American diet is estimated to contain 14 to 25 times more

omega-6 fatty acids than omega-3 fatty acids but the recommended

ratio is closer to 1:1.

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There are two types of omega-3 fatty acids: EPA (eicosapentaenoic

acid) and DHA (docosahexaenoic acid).

Supplementation with these omega-3’s is hypothesized to be beneficial

for ADHD, depression, bipolar disorder, and has also shown beneficial

effects for mild cognitive impairment.

Lower plasma levels of essential fatty acids have been associated with

ADHD and behavioral problems.

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Fish contain a high concentration of omega-3 fatty acids.

Areas with higher fish consumption have been associated with a lower

prevalence of mood disorders.

Observational studies also show a positive correlation between fish

intake and DHA plasma concentrations in healthy older adults and

cognitive health.

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Your patients can decrease omega-6’s by limiting vegetable oil

consumption such as corn, sunflower and soybean oils, which are

common in processed foods.

Eating a diet high in omega-3’s is beneficial for both short term and long

term cognitive health.

Increase omega-3 intake by consuming fatty fish such as salmon, tuna,

and trout. Flax seed is also a good source of omega-3’s. Fish oil

provides two omega-3 fatty acids, DHA and EPA, whereas flaxseeds

are rich in another omega-3 fat, ALA. EPA and DHA are readily

available from fish, and can also be synthesized by humans from ALA.

Humans, however, can obtain ALA only through their diets. Plant-based

sources of ALA are generally poor sources of the desired omega 3 fatty

acids, EPA and DHA.

Supplementation with fish oil is also recommended, although the

recommended dosage is not exact and ranges from 300 mg – 2 g per

day.

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Not only does a mother’s diet have an impact on her fetus’

neurocognitive development, so too does diet in early childhood

development.

Poor diet associated with high fat, sugar and processed food content in

early childhood is associated with small reductions in IQ in later

childhood.

A healthy diet associated with higher intake of nutrient-rich foods is

associated with small increases in IQ.

In adolescents, those with a poor diet saw mental health deterioration

over time.

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A case-control study of 404 children between 4 and 11 years old were

selected by cluster sampling in southern Iran in 2012.

A questionnaire screening for maternal and pregnancy related risk

factors for ADHD found that the prevalence of ADHD among formula-

fed patients was significantly higher than that in breast-fed children.

This finding is consistent with results of other studies. It is likely that

fatty acid compositions of human breast milk such as docosahexaenoic

acid and arachidonic acid have an important and beneficial role in brain

growth and development during the neonatal and infancy stages.

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Choosing smart fats is essential for optimizing neurocognition.

Recommend to your patients limiting the intake of omega 6 rich foods

by decreasing consumption of packaged, processed foods like chips

and fast foods.

Instead, recommend healthier fat alternatives like fish and aim for 3

servings per week.

If that is not feasible, supplementation with fish oils up to 1g/day has

been shown to have neuroprotective benefits.

Thankfully, the FDA has banned trans fats effective in 2018. This is

expected to save $140 billion over 20 years in health care costs

https://www.federalregister.gov/articles/2015/06/17/2015-14883/final-

determination-regarding-partially-hydrogenated-oils

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There have been many studies supporting a diet high in fruits and

vegetables for improved mental health.

The brain is more susceptible to oxidative stress than any other organ.

Oxidative stress along with inflammation plays a role in aging and age-

related neurodegenerative disorders.

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Brain-derived neurotrophic factor (BDNF) plays an important role in

synaptic plasticity, neuronal differentiation and regeneration.

Positive associations have been reported between omega-3 fatty acid

and flavonol intake and BDNF production.

Conversely, diets rich in saturated fatty acids or total fat have been

related to lower brain BDNF levels, lower neuronal plasticity, and poorer

cognitive ability.

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Berry fruits have strong antioxidant and anti-inflammatory benefits.

Blueberries contain anthocyanins, a flavanoid polyphenol which has

antioxidant and anti-inflammatory properties.

Anthocyanins have been associated with increased neuronal signaling

in brain centers, mediating memory and improved glucose disposal.

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In a small scale study of elderly individuals (mean age 76) with early

memory decline as defined by forgetfulness and prospective memory

lapses, blueberry juice supplementation for 12 weeks was shown to

significantly improve memory function with the added benefit of

reducing depressive symptoms.

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In a large scale study of participants older than 70, higher consumption

of strawberries and blueberries was associated with a slower

progression of cognitive decline in older women.

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Tree nuts are a good source of essential nutrients and contain a variety

of phytochemicals that decrease inflammation and reduce oxidative

stress.

Walnuts in particular contain a number of potentially neuroprotective

compounds like vitamin E, folate, melatonin, several antioxidative

polyphenols and significant amounts of omega-3 fatty acid.

A randomized cross-over trial of over 200 healthy male and female

college-age students showed increased inferential verbal reasoning

after an eight week supplementation of walnuts.

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Walnuts have also been shown to have the highest level of antioxidant

capacity as compared to other nuts.

The PREDIMED-NAVARRA trial showed that when nuts were added to

a Mediterranean diet, there was a 78% lower risk of having low levels of

plasma brain derived neurotrophic factor.

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Throughout this module we have seen that inflammation plays a

negative role on both the body and the brain.

Curcumin is a polyphenolic compound traditionally used in Indian

cooking.

It is the yellow pigment present in turmeric (a curry powder) that has

been shown to regulate the expression of inflammatory enzymes,

cytokines, adhesion molecules, and cell survival proteins. It shows

promising potential as a neuroprotective agent.

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There is substantial in-vitro data indicating that curcumin has

antioxidant, anti-inflammatory and anti-amyloid activity.

Studies in animal models of Alzheimer’s Disease indicate a direct effect

of curcumin in decreasing the amyloid pathology in Alzheimer’s.

Several clinical trials are currently underway to determine the neuro-

protective potential of curcumin, specifically in Alzheimer’s Disease

patients.

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We need to change what we eat or include more healthy foods in our

diet, such as:

Being mindful of eating whole, not processed foods like vegetables,

fruits, legumes, nuts, and complex carbohydrates.

This ensures that we get healthy fuel for our bodies and minds with

complex carbs like oatmeal and brown rice, proteins, and smart fats like

omega-3’s.

Eating whole foods also helps us obtain micronutrients and antioxidants

from our diet to optimize our brain function and slow neurocognitive

decline.

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We need to change how we eat and how much we eat.

The obesity epidemic is continuing to rise and it is negatively impacting

our society across all ages. Obesity is intricately linked to Type 2

Diabetes.

Chronic hyperglycemic states have been linked with poorer cognition

and mood as we have seen in this module.

We have also seen a parallel between the obesity epidemic and the

prevalence of ADHD in children and adolescents.

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In conclusion, here are some simple changes we can make in our own

diets and recommendations we can make for our patients:

1. When possible, choose whole foods.

2. Aim for a “rainbow colored” plate with ample fruits & vegetables.

3. Avoid excessive fat intake, particularly omega 6 fatty acids (for their

pro-inflammatory effects), trans fats, & food additives when possible.

They have all been shown to be bad for both short term and long term

neurocognitive health.

4. Fats are not created equal. No all fats are bad. Omega-3 fatty acids

are good sources of fat with anti-inflammatory effects. They can be

found in fatty fish like salmon, tuna, and trout, and in walnuts and olive

oil. Omega 3’s boost cognitive function and improve mood! Aim for at

least 3 servings a week.

5. Stock up on berries when they are in season or buy frozen berries for

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their antioxidant effects.

6. Be mindful of how much you are eating and exercise! The buddy system

helps so recruit someone to break bread with or to exercise with.

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This concludes the Goldring Center for Culinary Medicine module on

Nurocognition. Articles, study guide and the quiz can be found online.

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