Dranlie P.

Lagdamen BSN 3A

TITLE: Cognitive decline: can diet be a preventive or treatment option?

AUTHOR: Nursing older people (2014)

SOURCE AND DATE OF PUBLICATION: https://www.proquest.com/scholarly-

journals/cognitive-decline-can-diet-be-preventive/docview/2228862549/se-2?
accountid=50176 ; March 2019

SUMMARY:

Cognitive decline has been associated with and accepted as a consequence of

ageing. Diets such as the Mediterranean diet have been investigated for their effect on
abating cognitive decline. However, diet is not the only aspect of the Mediterranean life
that may play a role social interaction and cultural engagement may also be influential in
preserving cognitive function through the ageing process.

This article discusses the perspective on cognitive decline and the influence the
Mediterranean diet may have. It highlights that no sole dietary regimen will prevent
cognitive decline and the UK healthy eating guidelines reflect those foods included in
the Mediterranean diet. The focus should instead be on the way in which people engage
with food, society and culture to maintain a healthy body and mind.

REACTION

Having a healthy diet can improve our lives drastically to the point where we could
potentially prevent chronic diseases and lengthen our lives. Food is something we
essentially need to survive but still often overlooked and sometimes take for granted.
Most people now resort to unhealthy obsession with fast foods and other tasty yet
unhealthy foods. With that result, the increase of chronic diseases have skyrocketed
and is evident in today’s age, which includes our cognitive ability.

According to CDC, the prevalence of cognitive decline among adults is at 11% , which
means 1 out of 9 people are affected. The decline is commonly associated with many
things such as smoking, alcoholism, predisposing conditions which includes diabetes,
hypertension, genetics and other factors. Surprisingly, it is also associated with
education and with lifestyle, to include specifically our diet.

It is common knowledge to most of us as well that certain foods provide certain benefits.
One example is the eating of fatty fish which produces omega- 3 which is good for the
brain. According to the article, there are certain foods that contains vitamins C, E and
the B vitamins, omega-3, polyphenols, flavonoids and caffeine, which could prevent
cognitive decline. Foods that contain these nutrients for cognitive health could benefit
general health as well. However, it still requires further understanding and research.
Though with this information, it is safe to say that diet could potentially be a huge part to
include in the treatment of several disease. Dietary regimens have been suggested as
interventions to treat disease such as the dietary approaches to stop hypertension
(DASH) diet, portfolio diet for dyslipidaemia, the Mediterranean diet for metabolic
syndrome and cardiovascular health and the like that I know some of us are familiar
with in which the association of these to our cognitive health is not too farfetched.

This article suggests that the Mediterranean diet has been offered as a defence against
ill-health and as a means to healthy ageing and cognitive health. They had created a
research that shows whether this approach could be the answer to our declining
cognitive health as we enter at an older age. Though proven to not be effective, it still
can be used but with association with other methods. Other than that, the diet still
appeared to be an important factor to consider in living a healthy life, even as we grow
old.

As a nurse , this article impose a great information regarding what diet to

consider to our patient. As we all know, our profession extends beyond which prioritize
our patient’s overall well-being, their nutrition included. This article could be useful to us
nurses, as we could encounter patient with evidences of depleting cognitive capacities
and use this knowledge to educate and lessen the worsening of their condition. Or we
could use to as preemptive measure to patients entering adulthood that could be the
subject of cognitive decline, by teaching them the different measures and ways for
proper dieting in the prevention of this detrimental cognitive condition.

SOFT COPY

COGNITIVE DECLINE is a feature of the ageing process manifested by

impairment in mental faculties such as memory, reasoning, executive functions and
information processing speed (Deary et al 2009, Kirova et al 2015). The causes of cognitive decline
are different from person to person and can arise through a variety of mechanisms such
as genetics, health status, biological processes, neurochemical changes, lifestyle and
diet (Deary et al 2009).
These proposed causes can coexist, exerting adverse effects on the person as
part of interconnecting networks. Therefore, it is difficult to ascertain specific aetiology of
cognitive decline and even more difficult to provide targeted therapeutics to prevent,
treat and abate cognitive impairment.
The problem is further compounded by the nature of cognitive decline in that it is
on a continuum for individual people and dependent on biologically external factors
such as education, social interaction and mental well-being ( Wu et al 2017).
Cognitive decline and dementia are characterised by changes in the ability to
maintain independent living through activities and social functioning ( Livingston et al 2017).
Elements that may influence dementia are (Kalaria et al 2016, Wu et al 2017):
Education.
Smoking.
Chronic diseases such as hypertension.
Cardiovascular disease.
Diabetes.
The occurrence of post-stroke dementia.
However, there is unlikely to be one single factor. An integrative approach is
necessary to attempt to mediate the risk of cognitive decline and developing dementia
by focusing on modifiable risk factors, namely lifestyle and diet. This article discusses
how modifying diet may be advantageous in maintaining cognitive, as well as corporeal,
health.
Nutrition – a modifiable lifestyle factor
Nutrients of interest for cognitive health include omega-3 polyunsaturated fatty
acids, polyphenols, vitamin D and the B vitamins ( Calder et al 2018). A review by the Scientific
Advisory Committee on Nutrition (SACN) (2018) suggested the evidence is insufficient
and inconclusive to support the idea that individual nutrients (vitamins C, E and the B
vitamins, omega-3, polyphenols, flavonoids and caffeine) could prevent cognitive
decline. It remains to be demonstrated if these individual nutrients are beneficial in
preventing cognitive decline.

It is difficult and would be detrimental to assume a single nutrient could cure all
ailments including cognitive decline. However, it would be sensible to appreciate the
synergistic relationship of nutrients to influence physiological and cognitive function. For
example, fish oils have been presumed to be beneficial for brain health because of their
omega-3 composition but the evidence for fish oil and omega-3 supplementation does
not indicate it would be useful for preservation of cognitive health ( Dangour et al 2012).
However, oily fish such as herring, mackerel, salmon, trout and fresh tuna contains
omega-3 as well as vitamin D which may also maintain brain health and mediate
cognitive decline.
Low vitamin D concentrations have been associated with accelerated decline in
cognitive function across ethnicities (Miller et al 2015). However, whether taking vitamin D
supplements rather than eating dietary sources or exposure to sunlight for vitamin D
would benefit cognitive health remains to be demonstrated.
Rather than individual nutrients, foods that contain these nutrients for cognitive
health could benefit general health as well and include fish, fruits and vegetables ( Calder et
al 2018
). Indeed, potentially shifting the focus onto wholefoods rather than individual
nutrients would provide more meaningful recommendations for the management of
people with or at risk of cognitive decline. Dietary regimens have been suggested as
interventions to treat disease such as the dietary approaches to stop hypertension
(DASH) diet (Harsha et al 1999), portfolio diet for dyslipidaemia (Jenkins et al 2002), the Mediterranean
diet for metabolic syndrome and cardiovascular health ( Davis et al 2015), and the Okinawa
diet for healthy ageing (Willcox et al 2014) (Table 1).
Table 1
Summary of dietary approaches
Dietary approach Features Purpose Reference
Dietary approaches Rich in fruits, Designed for Harsha et al (1999)
to stop hypertension vegetables, cardiovascular health
wholegrains, low-fat to prevent high blood
dairy products, fish, pressure. It is also
poultry, beans, nuts lower in saturated
and seeds and trans fats
Portfolio A combination of Designed for Jenkins et al (2002)
dietary components cardiovascular
to reduce low- health, a
density lipoprotein combination of
(LDL)-cholesterol: cholesterol-lowering
plant stanols/sterols, dietary components,
almonds, soya and low saturated fat
protein and soluble intake, to reduce
fibre serum LDL-
cholesterol
Okinawa High consumption of Typical diet of Willcox et al (2014)
vegetables especially Okinawa region
 sweet potato, soy
products, fish, sea
vegetables, herbs
and spices instead of
salt, lack of dairy
products
Mediterranean High consumption of Typical diet of Davis et al (2015)
extra virgin olive oil, Mediterranean
vegetables, fruits, region
wholegrain cereals,
nuts, pulses,
legumes, fish, dairy
products, red wine,
and low intakes of
eggs and
confectionery

The Mediterranean diet

The Mediterranean diet has been offered as a defence against ill-health and as a
means to healthy ageing and cognitive health ( Yannakoulia et al 2015). It is characterised by high
intakes of extra virgin olive oil, vegetables including leafy green vegetables, fruits,
wholegrains, nuts, pulses, legumes, fish, dairy products, red wine and low intakes of
eggs and confectionery (Davis et al 2015).
Numerous scores are available to measure adherence to the Mediterranean diet,
but there is limited consensus on scoring criteria among studies despite it being a useful
tool for identifying the dietary patterns (Zaragoza-Martí et al 2018).
The two most widely used scores are Trichopoulou et al ( 1995) and Panagiotakos
et al (2006). Trichopoulou et al (1995) derived the first Mediterranean diet adherence score
from the dietary patterns of older people in three Greek villages, which positively
reflected life expectancy. However, Panagiotakos et al ( 2006) derived their Mediterranean
adherence score and compared it with biochemical data demonstrating the score was
inversely associated with systolic blood pressure, C-reactive protein, total serum
cholesterol and oxidised low-density lipoproteins.
Higher adherence to the Mediterranean diet has been associated with a reduced
risk of cognitive decline and of developing Alzheimer’s disease ( Valls-Pedret et al 2015, Petersson and
Philippou 2016
). However, although the components of the Mediterranean diet are similar, the
amounts and frequencies of consumption are inconsistent among studies and mean
adherence scores range from 23% to 88% (Davis et al 2015). Furthermore, most studies use
variations of food-frequency questionnaires with different numbers of food items, which
may hinder reliability when attempting to assess dietary consumption. These studies
also lack biochemical data to verify the associated benefits, and study of brain activity to
support the proposed associations with health and cognition.
To compound matters, most studies investigating the effect of the Mediterranean
diet on cognitive function are observational, therefore extrapolation of causality is not
possible. As these studies do not use the same methodology to ascertain cognition it is
difficult to compare the results meaningfully (SACN 2018).
The effects of the Mediterranean diet on cognitive health have also been
investigated in combination with other dietary regimens. The combination of DASH with
the Mediterranean diet scores and their effect on cognitive health was investigated and
higher intakes of wholegrains, nuts and legumes were associated with higher cognitive
function in older people over an 11-year period. The DASH combination diet includes
fruit, vegetables, low-fat dairy products, wholegrains, poultry, fish and nuts ( Wengreen et al
2013
).

A further combination of DASH and the Mediterranean diet includes the

Mediterranean-DASH intervention for neurodegenerative delay (MIND) score that used
postulated neuroprotective dietary groups: green leafy vegetables, other vegetables,
nuts, berries, beans, wholegrains, seafood, poultry, olive oil and wine and five unhealthy
food groups: red meats, butter and stick margarine, cheese, pastries and sweets, and
fried or fast food (Morris et al 2015).
In a community-based study of older people, the MIND approach was assessed
alongside cognition and demonstrated higher MIND scores were associated with slower
cognitive decline (Morris et al 2015).

Mediterranean lifestyle or dietary patterns?

The Mediterranean diet is one component of a complex interconnection of
lifestyle factors that define the Mediterranean populations such as eating freshly
prepared meals shared with others as part of a society and culture ( Yannakoulia et al 2015, Knight et
al 2016a
). Beyond the geographic Mediterranean area, there is little evidence to suggest
the Mediterranean diet has a positive effect on maintaining cognitive health and
preserving cognitive function (Aridi et al 2017).
In an 18-month study of free-living healthy Australians aged 65 years and over,
the Mediterranean diet was investigated for its effect on cognitive function in
comparison to a control diet group. This study concluded that the Mediterranean diet
had no statistically different effect on cognitive ability. The authors acknowledged that
the relatively short study period may have affected the results ( Knight et al 2016b).
 In a cross-sectional study by Litwin (2010) on social networks of older people in the
Mediterranean (Spain, France, Italy, Greece and Israel) and non-Mediterranean
countries (Sweden, Denmark, the Netherlands, Germany, Belgium, Switzerland and
Austria), differences were apparent in social, familial and care structures between the
Mediterranean and non-Mediterranean countries.
Mediterranean societies place more emphasis on familial culture with adult
children supporting older people more than in non-Mediterranean countries, and
Mediterranean societies have a higher regard and reliance on socialisation and social
contact (Litwin 2010). Mediterranean respondents were less highly educated than their non-
Mediterranean counterparts and had lower household incomes.
The study highlighted that older women in the Mediterranean countries reported
greater loneliness than their non-Mediterranean counterparts, but this perception did not
correspond with poorer mental health. It was also noted that among Mediterranean
women, greater frequency of contact correlated with more depressive symptoms
possibly because of greater expectations and need for social contact with familial
members (Litwin 2010).
To investigate the possible effects on cognitive health of the wider Mediterranean
lifestyle, not just the diet, Sánchez-Villegas et al ( 2016) studied a Spanish cohort of
university graduates prospectively. The Mediterranean lifestyle was defined as the joint
exposure to Mediterranean diet, level of physical activity and level of socialising with a
median follow-up of 8.5 years.
Participants with the highest adherence to the Mediterranean lifestyle
(combination of high adherence to Mediterranean diet, high adherence to physical
activity and high adherence to social activity) showed a 50% relative risk reduction in
depression compared with those with the lowest adherence ( Sánchez-Villegas et al 2016).
Besides diet, certain techniques can improve cognition and abate the decline of
cognitive function in ageing. These include ( Harada et al 2013):
Maintaining an active lifestyle.
Engaging in intellectual activities, such as puzzles, discussion groups, reading,
playing board and card games, and musical instruments.
Engaging in physical activities, such as exercise, dancing and gardening.
Social engagement: travel, cultural events and socialising.
High educational attainment.
In the English Longitudinal Study of Ageing over a ten-year study period,
cognitive function was measured in those over the age of 52 who engaged in three
types of cultural engagement (visiting museums/galleries/exhibitions; going to the
theatre/concert/opera; and going to the cinema). Memory and semantic fluency at
baseline and follow-up were measured and it was suggested that visiting
museums/galleries/exhibitions and going to the theatre/concert/opera were associated
with a lesser decline in cognitive function but not going to the cinema ( Fancourt and Steptoe 2018).
However, this study relied on participant self-reporting of their engagement in cultural
activities and focused on engagement over the past year rather than longer.
A multidomain intervention could be the most effective method to prevent
cognitive decline. The two-year Finnish Geriatric Intervention Study to Prevent Cognitive
Impairment and Disability trial used multidomain lifestyle interventions to assess
cognition in 1,260 Finnish people aged 60-77 years ( Rosenberg et al 2018). The trial used diet,
exercise, cognition and vascular risk management interventions and demonstrated a
small but positive change in cognitive function.
Despite the small effect size, this intervention demonstrates that lifestyle
modification in multiple domains may offer cognitive benefit in the ageing process.
Furthermore, as this intervention used the national nutritional guideline for Finland it
indicates that the Mediterranean diet need not be the focal point for dietary
interventions. The nutritional intervention included individual and group sessions based
around diet and lifestyle changes, and recommended foods were fruit, vegetables,
wholegrains, low-fat milk, meat products, limiting sucrose intake to less than 50g a day,
use of vegetable margarine and rapeseed oil instead of butter, and two portions of fish
per week (Ngandu et al 2015). These dietary interventions concord with UK dietary guidelines
(Public Health England 2018).

Application to older people in the UK

As the Mediterranean diet is a cumulative consequence of historical, agricultural,
cultural and social factors over hundreds of years, applying it to external populations
may be unrealistic. A UK-based study investigating barriers to adhering to a
Mediterranean diet in people aged over 50 years identified cultural differences, limited
knowledge of its composition, reluctance to implement dietary changes, concerns about
finances and availability of foods (Moore et al 2018).
Encouraging older people to engage with the Mediterranean diet may be
problematic: there must be consideration of palatability, finances, food acquisition and
preparation, dexterity, knowledge and the other physiological consequences of ageing,
such as reduced vision and co-morbidities, such as chronic kidney disease, which may
preclude them from undertaking such a change in diet ( Woodside et al 2014, Knight et al 2016a).
Psychosocial aspects also need to be considered as depression, loneliness and social
isolation are detrimental factors affecting older people ( Woodside et al 2014).
In a study investigating adherence to the Mediterranean diet and cognitive
function in 111 people with Alzheimer’s disease who were aged 65 years and over and
still living at home, 68% presented with a risk of malnutrition and 19% were
malnourished (Rocaspana-García et al 2018). Furthermore, 73% showed low adherence to the
Mediterranean diet and 27% showed moderate adherence but none met the criteria for
good adherence.
Hypertension, depression and diabetes were higher in the malnourished group
compared with the non-malnourished and those at risk of malnutrition groups, but not
statistically different. However, caregiver burden was statistically higher in the
malnourished group. The participants consumed less than the recommended intakes of
vegetables, fruit, nuts, cereals, pulses and fish, but over-consumed dairy and meat. This
study provides insight into the dietary patterns of people living with dementia but is
limited by the absence of qualitative assessment of eating behaviour to provide further
insight.
The results from Rocaspana-García et al (2018) are supported in an observational
analysis of 1,864 older people in Greece by Anastasiou et al ( 2017). In this analysis
people with dementia were found to have a lower Mediterranean diet adherence score
and consumed less vegetables, fruit and fish than those without dementia. Anastasiou
et al (2017) suggested that a daily serving of fish corresponded to approximately a 69%
reduction in the risk of dementia or a weekly serving of fish conferred an approximately
10% reduction.

Conclusion
The ageing process will indiscriminately affect all people, but lifestyle factors
adversely associated with ageing can be modified, especially the diet and the way in
which people engage with each other. This article has highlighted that there is no sole
specific dietary regimen that will prevent cognitive decline, and the UK healthy eating
guidelines are concordant with those foods included in the Mediterranean diet. Instead,
the focus should be on the way in which people engage with food, society and culture to
maintain a healthy body and mind.

Implications for practice

Focus on modifiable risk factors to maintain cognitive health:
Hypertension
Dyslipidaemia
Smoking cessation
Food choices
Social and physical activities
Recommend healthy eating principles according to individual choice and needs:
Vegetables
Fish
Nuts
Pulses
Wholegrains
Fruit
Moderate alcohol
Recommend people maintain an active social and physical life according to
individual choice and needs:
Maintain or engage in new hobbies
Join a social group
Ensure carers are well supported in their roles caring for family and friends with
cognitive decline or dementia:
Direct to support services as necessary