Roundtable Brief #7: Obesity and Brain Health
The Business Collaborative for Brain Health (BCBH) is a collaborative of private sector partners developing innovative solutions to cognitive health throughout the lifespan. The Collaborative hosts regular roundtables to learn from experts and stakeholders and refine the work.
The March 2024 Roundtable focused on the relationship of obesity to brain health. Speakers included Joe Nadglowski, President and CEO, Obesity Action Coalition; Jennifer Charette, MS, RD, LD, Regional Nutrition Manager, Sodexo; Mitch Elkind, MD, MS, FAHA, Chief Science Officer, American Heart Association; Connie W. Tsao, MD, MPH, FAHA, Director, Clinical Cardiac MRI Research and Education Section of Non-Invasive Imaging and Testing, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School; and Hugo Aparicio, MD, MPH, Associate Professor of Neurology, Boston University, Investigator at the Framingham Heart Study.
Introductory Remarks
Kelly O'Brien with UsAgainstAlzheimer’s opened the meeting by recognizing Bank of America for joining the Business Collaborative and welcoming Dr. NoAmie Le Pertel with Harvard Shine as a new advisor.
Ms. O’Brien highlighted the complexity of the obesity topic, acknowledging its various facets such as food, physical activity, and public health. Obesity is a top risk factor for cognitive decline in the United States. Increasing evidence shows its relationship to cognitive decline later in life, and also to cognitive focus and abilities in the present.
George Vradenburg, UsAgainstAlzheimer’s Founder and Collaborative advisor, emphasized the role of obesity, heart disease, and diabetes as direct causes of brain impairment. He highlighted the emerging science around brain health and the need for comprehensive brain health plans globally.
Obesity Overview
Joe Nadglowski, managing the Obesity Action Coalition, shared his personal experience living with obesity and the privilege of being able to afford new obesity treatments that have significantly improved his health. He emphasized that obesity is a chronic disease, not just about size or weight, with over 250 associated health conditions. Mr. Nadglowski challenged the common focus on body size, advocating for a health-centered approach to obesity and critiquing the use of BMI as a flawed measurement tool.
He discussed the limitations and biases of BMI, highlighting its racial and ethnic disparities in categorizing obesity. He also stressed the need for comprehensive obesity care that includes nutrition, physical activity, behavioral support, mental health counseling, and access to medical treatments like medications and surgical interventions. He underscored the importance of employers offering comprehensive benefits that address obesity from multiple angles.
Turning to the stigma and bias surrounding obesity, Mr. Nadglowski urged people to use respectful language and imagery in discussing the condition. He emphasized the importance of listening to people with obesity and involving them in conversations about their care. He also called attention to the often-neglected aspect of mental health support for individuals with obesity and the barriers they face in accessing evidence-based care.
Regarding measuring obesity, Mr. Nadglowski suggested exploring alternative measures beyond BMI, such as waist circumference and body composition. He acknowledged the ongoing research needed to better understand the relationship between obesity and brain health, highlighting inflammation and insulin resistance as known factors. He concluded by emphasizing the complexity of obesity and the need for a comprehensive approach that goes beyond prevention and includes effective treatment and support.
Food as one Solution
Mitch Elkind, the chief clinical science officer of the American Heart Association (AHA), discussed the organization's initiatives, in particular its "food is medicine" program. Dr. Elkind, a stroke neurologist and epidemiologist at Columbia University, transitioned to the AHA to develop brain health programming. He emphasized that while the initiative isn't solely aimed at brain health, it addresses various conditions like cardiovascular disease, hypertension, diabetes, obesity, and heart failure.
Dr. Elkind stressed the importance of food as medicine beyond basic nutrition guidelines, recommending interventions where individuals receive food aligning with their healthcare needs directly. He outlined different approaches, including medically tailored meals and produce prescriptions, aimed at improving health outcomes. However, he acknowledged the limited evidence supporting the cost-effectiveness of such programs, prompting the AHA's research initiative, funded by the Rockefeller Foundation and other partners, to gather robust evidence.
The AHA's initiative involves funding 20 trials across different populations and medical areas to assess the efficacy of food as medicine interventions. He emphasized the importance of partnerships and the significant investment required for this initiative. He also highlighted the potential neurological and mental health outcomes of these interventions, suggesting opportunities to explore the broader impact on brain health and behavior change. In sum, Dr. Elkind's presentation emphasized the AHA's commitment to leveraging food as medicine to address various health challenges and improve overall well-being.
One participant raised concerns about the short-term focus of health insurers regarding the cost-effectiveness of preventive measures like food as medicine. Dr. Elkind acknowledged this challenge but highlighted promising preliminary evidence, particularly in acute conditions like heart failure, where interventions could potentially reduce readmissions.
Another question from George Vradenburg addressed policy nudges and interventions beyond Medicare, specifically targeting ultra-processed foods. Dr. Elkind emphasized the importance of multiple angles to address obesity, including policy changes and advocacy efforts to improve food availability and labeling. Joe Nadglowski agreed and cited FDA Commissioner Rob Calif’s focus on ultra-processed foods, as well as the need for narrative development and continued research to combat obesity effectively. Both speakers highlighted the intersection of advocacy work and research in addressing these challenges.
Jen Charette with Sodexo discussed the challenges and opportunities surrounding the integration of food and medicine initiatives within healthcare, highlighting existing programs like food pharmacy and medicine meals. However, she noted the difficulty in sustaining these programs due to funding limitations, expressing a desire for partnerships to overcome this barrier. Regarding the connection between food and brain health, she emphasized the significance of nutrition in combating Alzheimer's disease.
Briefly reviewing the science behind food and brain health, Charette debunked common misconceptions about dementia being an inevitable part of aging and noted that we now know that up to 40% of dementia cases could be prevented or delayed through lifestyle interventions, including diet, exercise, social engagement, and cognitive stimulation. She highlighted specific dietary strategies, such as the Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet, which has shown promising results in reducing Alzheimer's risk.
Ms. Charette discussed Sodexo’s commitment to incorporate more plant-based options in menus at its sites, aligning with the growing demand for healthier and environmentally sustainable food choices. To maintain its mission and vision, the company has created menus comprising two-thirds plant-based options and one-third or less protein components. Currently, 33% of Sodexo’s selected daily menu includes plant-based vegan meals with occasional incorporation of honey.
Their national patient menu, launched in 2021 and piloted nationwide in 2023, embodies this approach as well. The menu is constructed from whole-food plant-based ingredients, avoiding processed alternatives, to optimize nutrition by minimizing sodium, preservatives, and additives. Sodexo aims to champion healthier lives by increasing the consumption of fruits and vegetables, as only 10% of Americans meet the recommended intake. With strong support from its team of dieticians and culinary experts, the company has developed menu options to encourage healthier eating habits among those they serve.
This initiative not only aligns with recommendations from medical associations like the American Medical Association and the American College of Cardiology but also addresses environmental concerns. Plant-based proteins have a significantly lower carbon footprint, requiring less land and emitting fewer greenhouse gases per gram of protein. By incorporating 30 plant-based menu options, Sodexo has reduced the company's carbon footprint by 34%, reflecting both a commitment to health and sustainability and the sound business sense of offering cost-effective, healthier food choices.
The Brain Health Obesity Connection
Connie Tsao, at Beth Israel Deaconess Medical Center, has conducted research on vascular and cardiac diseases, as well as brain health, and shared insights from her work, along with other relevant studies. Underscoring the magnitude of the problem, Dr. Tsao noted that the majority of adults, and nearly 50% of children, are grappling with obesity. According to data from the World Obesity Federation, projections indicate that over half of the world's population could be classified as having obesity by 2035, affecting over 4 billion people globally.
Dr. Tsao explained that obesity extends beyond outward appearance to impact internal organs, particularly visceral adiposity. As illustrated in cross-sectional MRI images, individuals may have significant internal fat deposits not readily visible externally. This internal obesity contributes to various health complications, including cardiovascular diseases such as coronary artery disease, heart attacks, heart failure, and strokes.
Numerous studies have highlighted the associations between obesity and adverse health outcomes. For instance, an extensive electronic medical record study involving 3.5 million adults revealed that even metabolically healthy individuals with obesity faced elevated risks of cardiovascular diseases compared to their counterparts without obesity. This underscores the independent contribution of obesity to cardiovascular health risks. Part of the explanation about how obesity leads to such health challenges lies in its impact on vascular function, as depicted in illustrations showing the effects of hypertrophied fat cells on blood vessels. This can result in vascular dysfunction characterized by inflammation, insulin resistance, atherosclerosis, arterial stiffening, and increased blood clotting.
This dysfunction has an impact on brain health. Grey matter, consisting of cell bodies, and white matter, composed of myelinated axons, are integral to cognitive functions. Studies, including those from the Framingham Heart Study, have linked metabolic risk factors and obesity to alterations in brain structure and cognitive decline, even in midlife. Brain imaging studies have revealed associations between obesity and reduced grey and white matter volumes, indicative of premature brain aging. Furthermore, biomarker studies have highlighted inflammation as a key mediator linking obesity to brain health outcomes.
Make it stand out
Whatever it is, the way you tell your story online can make all the difference.
Despite these concerning findings, Dr. Tsao conveyed hope. Interventions such as lifestyle modifications, physical activity, weight loss, and bariatric surgery have shown promise in improving brain health outcomes, as evidenced by meta-analyses and intervention studies. Our understanding of the intricate links between obesity, metabolic health, cardiovascular diseases, and brain health is evolving rapidly. Early intervention, lifestyle modifications, and addressing social determinants of health are crucial steps in mitigating the adverse effects of obesity and promoting overall well-being.
Dr. Hugo Aparicio, at Boston University and involved in the Framingham Heart Study, commented that Dr. Tsao’s presentation shed light on the complex interplay between obesity and various health outcomes, including stroke and Alzheimer's disease. The associations with insulin resistance, hypertension, and vascular dysfunction underscore the importance of early intervention and holistic approaches to promote brain health.
In summary, the conversation centered on the idea of promoting brain health in the workplace, with a focus on addressing obesity and other lifestyle factors. Kelly O'Brien suggested that emphasizing the immediate benefits for individuals, such as improved productivity and creativity, could strengthen the case for employers to invest in brain health initiatives. Thomas Seoh with Kitalys Institute raised the question of practical implications for business, suggesting a need to make the messaging more appealing and less overwhelming. Others chimed in with suggestions to make brain health initiatives compelling and tie them to broader concepts like happiness and purpose in life. Overall, the group emphasized the importance of connecting various health issues, like obesity and dementia, and integrating brain health into workplace policies and advocacy efforts.