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The feasibility of a multidomain dementia risk reduction randomised controlled trial for people experiencing cognitive decline: the Body, Brain, Life for Cognitive Decline (BBL-CD).
McMaster, M, Kim, S, Clare, L, Torres, SJ, Cherbuin, N, Anstey, KJ
Aging & mental health. 2023;(11):2111-2119
Abstract
OBJECTIVES To evaluate the feasibility of a proof-of-concept multidomain dementia risk reduction intervention. METHOD An 8-week, parallel-group RCT, focused on increasing adherence to lifestyle domains of Mediterranean diet (MeDi), Physical Activity (PA), and Cognitive Engagement (CE). Feasibility was evaluated against the Bowen Feasibility Framework objectives of: Acceptability of the intervention, compliance with the protocol, and efficacy of the intervention to change behaviour in the three domains of interest. RESULTS High acceptability of the intervention was demonstrated through a participant retention rate of 80.7% (Intervention: 84.2%; Control: 77.4%). Compliance to the protocol was strong with 100% of participants completing all educational modules and all MeDi and PA components, with 20% compliance for CE. Linear mixed models demonstrated efficacy to change behaviour through significant effects of adherence to MeDi (χ2 = 16.75, df = 3, p < .001) and CE (χ2 = 9.83, df = 3, p =.020), but not PA (χ2 = 4.48, df = 3, p =.211). CONCLUSION Overall the intervention was shown to be feasible. Recommendations for future trials in this area are: The implementation of practical, one-on-one sessions as they are more effective than passive education at eliciting behaviour change; use of booster sessions to increase likelihood of lifestyle changes being sustained; and collection of qualitative data to identify barriers to change.
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Statistical Approaches for the Analysis of Combined Health-Related Factors in Association with Adult Cognitive Outcomes: A Scoping Review.
Dingle, SE, Bujtor, MS, Milte, CM, Bowe, SJ, Daly, RM, Torres, SJ
Journal of Alzheimer's disease : JAD. 2023;(4):1147-1171
Abstract
BACKGROUND Dementia prevention is a global health priority, and there is emerging evidence to support associations between individual modifiable health behaviors and cognitive function and dementia risk. However, a key property of these behaviors is they often co-occur or cluster, highlighting the importance of examining them in combination. OBJECTIVE To identify and characterize the statistical approaches used to aggregate multiple health-related behaviors/modifiable risk factors and assess associations with cognitive outcomes in adults. METHODS Eight electronic databases were searched to identify observational studies exploring the association between two or more aggregated health-related behaviors and cognitive outcomes in adults. RESULTS Sixty-two articles were included in this review. Fifty articles employed co-occurrence approaches alone to aggregate health behaviors/other modifiable risk factors, eight studies used solely clustering-based approaches, and four studies used a combination of both. Co-occurrence methods include additive index-based approaches and presenting specific health combinations, and whilst simple to construct and interpret, do not consider the underlying associations between co-occurring behaviors/risk factors. Clustering-based approaches do focus on underlying associations, and further work in this area may aid in identifying at-risk subgroups and understanding specific combinations of health-related behaviors/risk factors of particular importance in the scope of cognitive function and neurocognitive decline. CONCLUSION A co-occurrence approach to aggregating health-related behaviors/risk factors and exploring associations with adult cognitive outcomes has been the predominant statistical approach used to date, with a lack of research employing more advanced statistical methods to explore clustering-based approaches.
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The role of combined modifiable lifestyle behaviors in the association between exposure to stressors and allostatic load: A systematic review of observational studies.
Siew, RVK, Nabe-Nielsen, K, Turner, AI, Bujtor, M, Torres, SJ
Psychoneuroendocrinology. 2022;:105668
Abstract
BACKGROUND Exposure to stressors can evoke psychological, physiological, and behavioral stress responses, which may lead to the adoption of health-damaging behaviors that dysregulate multiple biological systems contributing to a high allostatic load. This review explored the role of combined modifiable lifestyle behaviors in the relationship between stressors and allostatic load among healthy adults. METHODS A systematic search was conducted in Medline Complete, PsycINFO, CINAHL, and Embase databases up to September 2021. The PRISMA guidelines guided reporting and study quality was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Checklist. RESULTS Database searches identified 319 papers. Eight cross-sectional and two longitudinal studies met our inclusion criteria. Among the ten studies, combined modifiable lifestyle behaviors partly explained the association between exposure to stressors and elevated allostatic load in four cross-sectional and two longitudinal studies. CONCLUSION Some evidence suggests that combined modifiable lifestyle behaviors may help explain the relationship between stressors and an elevated allostatic load. Further longitudinal studies with mediation analyses would strengthen these findings and help to confirm the mechanistic role of combined modifiable lifestyle behaviors underlying the relationship between stress exposure and allostatic load.
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Associations of Dietary Intake on Biological Markers of Inflammation in Children and Adolescents: A Systematic Review.
Bujtor, M, Turner, AI, Torres, SJ, Esteban-Gonzalo, L, Pariante, CM, Borsini, A
Nutrients. 2021;13(2)
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Plain language summary
Inflammation is the normal physiological response to injury in the body and is designed to protect the host. However, in children and adolescents, chronic low-grade inflammation has been linked to a wide range of conditions. Certain markers in the blood can be measured and used to determine levels of inflammation in the body. This review of 53 studies provides the first evidence for the association between dietary intake and biological markers of inflammation in children and adolescents. Results show that adhering to a healthy way of eating such as the Mediterranean diet, are associated with decreased levels of pro-inflammatory biomarkers. The Western Dietary pattern, as well as intake of ultra-processed foods is associated with higher levels of the same pro-inflammatory markers. A good quality diet, high in fruit and vegetables, wholegrains, fibre and healthy fats ameliorates low-grade inflammation, and therefore represents a potential therapeutic approach. It is also an important element for disease prevention in both children and adolescents.
Abstract
BACKGROUND In children and adolescents, chronic low-grade inflammation has been implicated in the pathogenesis of co- and multi-morbid conditions to mental health disorders. Diet quality is a potential mechanism of action that can exacerbate or ameliorate low-grade inflammation; however, the exact way dietary intake can regulate the immune response in children and adolescents is still to be fully understood. METHODS Studies that measured dietary intake (patterns of diet, indices, food groups, nutrients) and any inflammatory biomarkers in children and adolescents aged 2 to19 years and published until November 2020 were included in this systematic review, and were selected in line with PRISMA guidelines through the following databases: Academic Search Complete, CINAHL, Global Health, Medline COMPLETE and Web of Science-Core Collection. A total of 53 articles were identified. RESULTS Results show that adequate adherence to healthful dietary patterns such as the Mediterranean diet, or food groups such as vegetables and fruit, or macro/micro nutrients such as fibre or vitamin C and E, are associated with decreased levels of pro-inflammatory biomarkers, mainly c-reactive protein (CRP), interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-α), whereas adherence to a Western dietary pattern, as well as intake of food groups such as added sugars, macro-nutrients such as saturated fatty acids or ultra-processed foods, is associated with higher levels of the same pro-inflammatory biomarkers. CONCLUSIONS This is the first systematic review examining dietary intake and biological markers of inflammation in both children and adolescents. A good quality diet, high in vegetable and fruit intake, wholegrains, fibre and healthy fats ameliorates low-grade inflammation, and therefore represents a promising therapeutic approach, as well as an important element for disease prevention in both children and adolescents.
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Dietary patterns and associations with biomarkers of inflammation in adults: a systematic review of observational studies.
Hart, MJ, Torres, SJ, McNaughton, SA, Milte, CM
Nutrition journal. 2021;(1):24
Abstract
BACKGROUND Evidence indicates that low-grade inflammation is involved in manychronic diseases of ageing. Modifiable lifestyle factors including dietcan affect low-grade inflammation. Dietary patterns allow assessment of the complex interactions of food nutrients and health and may be associated with inflammatory status. This systematic review aimed to summarises current evidence from observational studies for associations between dietary patterns and inflammatory biomarkers in the general adult population. This review followed the PRISMA guidelines. METHODS We conducted a systematic search in Embase, CINAHL Complete, Global Health and MEDLINE complete databases. Search terms included terms for diet ("dietary patterns", "diet scores") and inflammation ("inflammation", "c-reactive protein", "interleukin"). RESULTS The search produced 7161 records. Duplicates were removed leaving 3164 for screening. There were 69 studies included (60 cross-sectional, 9 longitudinal). Papers included studies that were: 1) observational studies; 2) conducted in community-dwelling adults over 18 years of age; 3) assessed dietary patterns; 4) measured specified biomarkers of inflammation and 5) published in English. Dietary patterns were assessed using diet scores (n = 45), data-driven approaches (n = 22), both a data-driven approach and diet score (n = 2). The most frequently assessed biomarkers were CRP (n = 64) and/or IL-6 (n = 22). Cross-sectionally the majority of analyses reported an association between higher diet scores (mostly Mediterranean and anti-inflammatory diet scores) and lower inflammatory markers with 82 significant associations from 133 analyses. Only 22 of 145 cross-sectional analyses using data-driven approaches reported an association between a dietary patterns and lower inflammatory markers; the majority reported no association. Evidence of an association between dietary patterns and inflammatory markers longitudinally is limited, with the majority reporting no association. CONCLUSIONS Adherence to healthy, Mediterranean and anti-inflammatory dietary scores, appear to be associated with lower inflammatory status cross-sectionally. Future research could focus on longitudinal studies using a potential outcomes approach in the data analysis. TRIAL REGISTRATION PROSPERO Registration Number CRD42019114501 .
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Lifestyle Risk Factors and Cognitive Outcomes from the Multidomain Dementia Risk Reduction Randomized Controlled Trial, Body Brain Life for Cognitive Decline (BBL-CD).
McMaster, M, Kim, S, Clare, L, Torres, SJ, Cherbuin, N, DʼEste, C, Anstey, KJ
Journal of the American Geriatrics Society. 2020;(11):2629-2637
Abstract
BACKGROUND/OBJECTIVES To evaluate the efficacy of a multidomain intervention to reduce lifestyle risk factors for Alzheimer's disease (AD) and improve cognition in individuals with subjective cognitive decline (SCD) or mild cognitive impairment (MCI). DESIGN The study was an 8-week two-arm single-blind proof-of-concept randomized controlled trial. SETTING Community-dwelling individuals living in Canberra, Australia, and surrounding areas. PARTICIPANTS Participants were 119 individuals (intervention n = 57; control n = 62) experiencing SCD or MCI. INTERVENTION The control condition involved four educational modules covering dementia and lifestyle risk factors, Mediterranean diet, physical activity, and cognitive engagement. Participants were instructed to implement this information into their own lifestyle. The intervention condition included the same educational modules and additional active components to assist with the implementation of this information into participants' lifestyles: dietitian sessions, an exercise physiologist session, and online brain training. MEASUREMENTS Lifestyle risk factors for AD were assessed using the Australian National University-Alzheimer's Disease Risk Index (ANU-ADRI), and cognition was assessed using Alzheimer's Disease Assessment Scale-Cognitive subscale, Pfeffer Functional Activities Questionnaire, Symbol Digit Modalities Test (SDMT), Trail Making Test-B, and Category Fluency. RESULTS The primary analysis showed that the intervention group had a significantly lower ANU-ADRI score (χ2 = 10.84; df = 3; P = .013) and a significantly higher cognition score (χ2 = 7.28; df = 2; P = .026) than the control group. A secondary analysis demonstrated that the changes in lifestyle were driven by increases in protective lifestyle factors (χ2 = 12.02; df = 3; P = .007), rather than a reduction in risk factors (χ2 = 2.93; df = 3; P = .403), and cognitive changes were only apparent for the SDMT (χ2 = 6.46; df = 2; P = .040). Results were robust to intention-to-treat analysis controlling for missing data. CONCLUSION Results support the hypothesis that improvements in lifestyle risk factors for dementia can lead to improvements in cognition over a short time frame with a population experiencing cognitive decline. Outcomes from this trial support the conduct of a larger and longer trial with this participant group.
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Psychological stress reactivity and future health and disease outcomes: A systematic review of prospective evidence.
Turner, AI, Smyth, N, Hall, SJ, Torres, SJ, Hussein, M, Jayasinghe, SU, Ball, K, Clow, AJ
Psychoneuroendocrinology. 2020;:104599
Abstract
BACKGROUND Acute psychological stress activates the sympatho-adrenal medullary (SAM) system and hypothalamo-pituitary adrenal (HPA) axis. The relevance of this stress reactivity to long-term health and disease outcomes is of great importance. We examined prospective studies in apparently healthy adults to test the hypothesis that the magnitude of the response to acute psychological stress in healthy adults is related to future health and disease outcomes. METHODS We searched Medline Complete, PsycINFO, CINAHL Complete and Embase up to 15 Aug 2019. Included studies were peer-reviewed, English-language, prospective studies in apparently healthy adults. The exposure was acute psychological stress reactivity (SAM system or HPA axis) at baseline. The outcome was any health or disease outcome at follow-up after ≥1 year. RESULTS We identified 1719 papers through database searching and 1 additional paper through other sources. Forty-seven papers met our criteria including 32,866 participants (range 30-4100) with 1-23 years of follow-up. Overall, one third (32 %; 83/263) of all reported findings were significant and two thirds (68 %; 180/263) were null. With regard to the significant findings, both exaggerated (i.e. high) and blunted (i.e. low) stress reactivity of both the SAM system and the HPA axis at baseline were related to health and disease outcomes at follow-up. Exaggerated stress reactivity at baseline predicted an increase in risk factors for cardiovascular disease and decreased telomere length at follow-up. In contrast, blunted stress reactivity predicted future increased adiposity and obesity, more depression, anxiety and PTSD symptoms, greater illness frequency, musculoskeletal pain and regulatory T-Cell percentage, poorer cognitive ability, poorer self-reported health and physical disability and lower bone mass. CONCLUSION Exaggerated and blunted SAM system and HPA axis stress reactivity predicted distinct physical and mental health and disease outcomes over time. Results from prospective studies consistently indicate stress reactivity as a predictor for future health and disease outcomes. Dysregulation of stress reactivity may represent a mechanism by which psychological stress contributes to the development of future health and disease outcomes.
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An Internet-Based Intervention Augmented With a Diet and Physical Activity Consultation to Decrease the Risk of Dementia in At-Risk Adults in a Primary Care Setting: Pragmatic Randomized Controlled Trial.
Anstey, KJ, Cherbuin, N, Kim, S, McMaster, M, D'Este, C, Lautenschlager, N, Rebok, G, McRae, I, Torres, SJ, Cox, KL, et al
Journal of medical Internet research. 2020;(9):e19431
Abstract
BACKGROUND There is a need to develop interventions to reduce the risk of dementia in the community by addressing lifestyle factors and chronic diseases over the adult life course. OBJECTIVE This study aims to evaluate a multidomain dementia risk reduction intervention, Body Brain Life in General Practice (BBL-GP), targeting at-risk adults in primary care. METHODS A pragmatic, parallel, three-arm randomized trial involving 125 adults aged 18 years or older (86/125, 68.8% female) with a BMI of ≥25 kg/m2 or a chronic health condition recruited from general practices was conducted. The arms included (1) BBL-GP, a web-based intervention augmented with an in-person diet and physical activity consultation; (2) a single clinician-led group, Lifestyle Modification Program (LMP); and (3) a web-based control. The primary outcome was the Australian National University Alzheimer Disease Risk Index Short Form (ANU-ADRI-SF). RESULTS Baseline assessments were conducted on 128 participants. A total of 125 participants were randomized to 3 groups (BBL-GP=42, LMP=41, and control=42). At immediate, week 18, week 36, and week 62 follow-ups, the completion rates were 43% (18/42), 57% (24/42), 48% (20/42), and 48% (20/42), respectively, for the BBL-GP group; 71% (29/41), 68% (28/41), 68% (28/41), and 51% (21/41), respectively, for the LMP group; and 62% (26/42), 69% (29/42), 60% (25/42), and 60% (25/42), respectively, for the control group. The primary outcome of the ANU-ADRI-SF score was lower for the BBL-GP group than the control group at all follow-ups. These comparisons were all significant at the 5% level for estimates adjusted for baseline differences (immediate: difference in means -3.86, 95% CI -6.81 to -0.90, P=.01; week 18: difference in means -4.05, 95% CI -6.81 to -1.28, P<.001; week 36: difference in means -4.99, 95% CI -8.04 to -1.94, P<.001; and week 62: difference in means -4.62, 95% CI -7.62 to -1.62, P<.001). CONCLUSIONS A web-based multidomain dementia risk reduction program augmented with allied health consultations administered within the general practice context can reduce dementia risk exposure for at least 15 months. This study was limited by a small sample size, and replication on a larger sample with longer follow-up will strengthen the results. TRIAL REGISTRATION Australian clinical trials registration number (ACTRN): 12616000868482; https://anzctr.org.au/ACTRN12616000868482.aspx.
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Diet-Induced Weight Loss Has No Effect on Psychological Stress in Overweight and Obese Adults: A Meta-Analysis of Randomized Controlled Trials.
Booth, AO, Wang, X, Turner, AI, Nowson, CA, Torres, SJ
Nutrients. 2018;(5)
Abstract
The effect of weight loss on psychological stress is unknown. The study aimed to investigate the effect of diet-induced weight loss in overweight and obese adults on psychological measures of stress through a meta-analysis of randomized controlled trials (RCTs). Databases including Medline Complete, Embase and PsycINFO were searched up to February 2018 for diet-induced weight loss RCTs, which included self-reported assessment of psychological stress. The mean difference between the intervention and control group of changes in stress (intervention-baseline) was used. Ten RCTs were included with 615 participants (502 women, age range 20⁻80 years). Overall, there was no change in stress (mean difference -0.06, 95% CI: -0.17, 0.06, p = 0.33) and no change in the five studies with a significant reduction in weight in the intervention group compared to a control group that lost no weight (mean difference in weight -3.9 Kg, 95% CI: -5.51, -2.29, p < 0.0001; mean difference in stress 0.04, 95% CI: -0.17, 0.25, p = 0.71). For all analyses, there was low heterogeneity. The benefits of weight loss for those who are overweight and obese do not appear to either increase or reduce psychological stress at the end of the weight loss period.
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Body, Brain, Life for Cognitive Decline (BBL-CD): protocol for a multidomain dementia risk reduction randomized controlled trial for subjective cognitive decline and mild cognitive impairment.
McMaster, M, Kim, S, Clare, L, Torres, SJ, D'Este, C, Anstey, KJ
Clinical interventions in aging. 2018;:2397-2406
Abstract
BACKGROUND With no cure for dementia and the number of people living with the condition predicted to rapidly rise, there is an urgent need for dementia risk reduction and prevention interventions. Modifiable lifestyle risk factors have been identified as playing a major role in the development of dementia; hence, interventions addressing these risk factors represent a significant opportunity to reduce the number of people developing dementia. Relatively few interventions have been trialed in older participants with cognitive decline (secondary prevention). OBJECTIVES This study evaluates the efficacy and feasibility of a multidomain lifestyle risk reduction intervention for people with subjective cognitive decline (SCD) and mild cognitive impairment (MCI). METHODS This study is an 8-week, two-arm, single-blind, randomized controlled trial (RCT) of a lifestyle modification program to reduce dementia risk. The active control group receives the following four online educational modules: dementia literacy and lifestyle risk, Mediterranean diet (MeDi), cognitive engagement and physical activity. The intervention group also completes the same educational modules but receives additional practical components including sessions with a dietitian, online brain training and sessions with an exercise physiologist to assist with lifestyle modification. RESULTS Primary outcome measures are cognition (The Alzheimer's Disease Assessment Scale-Cognitive-Plus [ADAS-Cog-Plus]) and a composite lifestyle risk factor score for Alzheimer's disease (Australian National University - Alzheimer's Disease Risk Index [ANU-ADRI]). Secondary outcome measures are motivation to change lifestyle (Motivation to Change Lifestyle and Health Behaviour for Dementia Risk Reduction [MCLHB-DRR]) and health-related quality of life (36-item Short Form Health Survey [SF-36]). Feasibility will be determined through adherence to diet (Mediterranean Diet Adherence Screener [MEDAS] and Australian Recommended Food Score [ARFS]), cognitive engagement (BrainHQ-derived statistics) and physical activity interventions (physical activity calendars). Outcomes are measured at baseline, immediately post-intervention and at 3- and 6-month follow-up by researchers blind to group allocation. DISCUSSION If successful and feasible, secondary prevention lifestyle interventions could provide a targeted, cost-effective way to reduce the number of people with cognitive decline going on to develop Alzheimer's disease (AD) and other dementias.