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Inside the FINGER Study: Hard Evidence Shows How Diet, Exercise and Mind Games Might Make or Break a Dementia Diagnosis

October 11, 2017

Can lifestyle changes prevent Alzheimer’s disease, or at least reduce your risk of cognitive decline? There’s now evidence that they do. In June 2015, the results of the FINGER study—a groundbreaking clinical trial testing whether lifestyle interventions like diet, exercise and brain training could prevent cognitive decline—came back positive. The researchers showed, after a two-year randomized control trial of over 2500 people, that changing these lifestyle factors reduced the risk of cognitive decline by 30%. We spoke to Dr. Miia Kivipelto, M.D., one of the key researchers in the trial, about why it was successful and what this means for the prevention and treatment of Alzheimer’s.

  • Researchers point to interventions that improve heart health as a possible reason the study is showing positive results
  • The FINGER study relied on a diet researchers dubbed the ‘healthy Nordic diet’—lots of fish, fruits and vegetables and oils
  • Brain training that was individualized and challenging had a positive effect
  • Similar studies are coming to the U.S., China and Singapore

Being Patient: Why was the FINGER study so significant?

Dr. Miia Kivipelto: It’s the first multi-domain lifestyle intervention that has shown that a combination of lifestyle interventions is able to prevent or slow down cognitive decline. We have lots of evidence from epidemiological studies indicating that these different modifiable lifestyle factors are related to dementia and Alzheimer’s disease. But it has been very, very difficult to show this with a randomized control trial, which is the gold standard in evidence-based medicine.

[What made the] difference was that it was a multi-domain intervention. If we think about the causes of Alzheimer’s, we understand that it is complex, so it doesn’t seem to  be enough to focus on one single risk factor. We really need to target several risk factors simultaneously to get optimal preventive effects. In that way, it’s similar to what we’re doing for diabetes and cardiovascular disease prevention.

Being Patient: The intervention areas were diet, exercise, cognitive training and vascular risk monitoring. Do you understand how the interventions affect the brain? Are they strengthening the brain’s ability to resist the damage that’s being done by toxic proteins like amyloid and tau?

Dr. Miia Kivipelto: We don’t know all the mechanisms yet. That’s something that we are analyzing right now. We’re measuring a lot of biomarkers and [conducting] neuroimaging but our theory is that there are probably several pathways. One of the main factors could be this increase in cognitive reserve, but it could also be reducing the vascular load. We know that vascular lesions [tissue damage] are very important, as are inflammation and oxidative stress. There’s evidence that inflammation may be one of the early pathological mechanisms in Alzheimer’s so reducing it is important.

Being Patient: What was the prescribed diet during the trial?

Dr. Miia Kivipelto: We used something that we called the ‘healthy Nordic diet,’ which is more less the same as the Mediterranean diet. It’s a lot of fish, a lot of fruits and vegetables and a lot of oils. In the Nordic diet, instead of olive oil, we used rapeseed oil which is more locally produced. One of the secrets of the success of the dietary interventions was that we had very good dietitians who did group training and individual sessions and gave practical advice, not just theory. Most people probably already know the theory but we did practical exercises with them showing them ways to modify their diet so that it’s a bit more healthy, testing new recipes etc.

Being Patient: Do you think introducing oils, fruit and vegetables have a positive impact on inflammation?

Dr. Miia Kivipelto: Yes. That’s the hypothesis that we have and there are other, more experimental studies that have been able to show that they have anti-inflammatory and anti-oxidative properties. So these are probably some of the main pathways that are affected by a healthy diet. We have a huge panel for inflammatory factors or markers for oxidative stress at baseline and after two years that we are just now analyzing. We’re not ready with the analysis yet but we are very excited to see what kind of changes we find.

Being Patient: If you were to recommend a type of diet or level of fruit and vegetable or oils, what would that be?

Dr. Miia Kivipelto: We’ve been following the dietary recommendations for heart health and reducing the risk of diabetes, so it seems that they’re in line with what’s good for the brain. I often say that minding heart health is a good way to prevent Alzheimer’s. We normally say at least five portions of fruit and vegetables a day and replacing the saturated fats with olive oil or rapeseed oil. In terms of brain healthy components, there’s been a lot of focus on nuts recently. Fish is also good—at least two times per week—and, if possible, at least one of these times should be fatty fish because fish oils are known to be good for the brain.

Being Patient: Cognitive training is controversial as an intervention for improving cognitive function, with different studies saying different things about whether it works. What kind of interventions did you use and how did you measure their effectiveness?

Dr. Miia Kivipelto: We used computer-based cognitive training that we developed. I think the main point was that it was individualized. The difficulty level was increased progressively during the intervention. I don’t think we can say that there’s one type of cognitive training [that works] or one miracle case. I think we need to have tasks that are challenging enough so that we can see an effect. We could see that for the people who were doing the training enough. We could see a nice effect for some [cognitive] domains. For me, any kind of brain training [can be effective]. It can be learning a new language or reading a book or having complex work where you need to use the brain but I think we have a quite a lot of evidence that using the brain and having challenging tasks is good.

Being Patient: Did you see a an improvement in the cognitive scores of the people in the trial?

Dr. Miia Kivipelto: Yes.  We have to remember that the people in the FINGER trial didn’t have any cognitive impairment—they had increased risk for dementia based on risk factors but they were still cognitively intact. Both the intervention group and the so-called placebo group, where we gave regular health advice, improved during the two years. But the improvement was much higher in the intervention group, in all of the [cognitive] sub-domains: executive function for [information] processing (how quickly people are able to do different tasks) and complex memory tasks. There were people who declined after two years. And the risk of cognitive decline was 30% higher for the control group compared to the intervention group.

Being Patient: Now that you’ve seen these positive results, what are the implications now for the treatment and care of the disease, and future research?

Dr. Miia Kivipelto: I would say that we’ve started to have enough evidence to justify some immediate action. We are working on an implementation study based on FINGER and developing a tool with practical recommendations based on the scientific guidelines. We’re also working with the World Health Organization on guidelines for risk reduction. There are now multi-domain trials taking place globally, where FINGER is being used as the model. There will be a trial in the U.S. called the U.S. POINTER study, a trial in China, one in Singapore and so on. This is a very exciting network.

We’ve just finished analyzing the five-year follow-up to FINGER and we’re now starting the seven-year follow-up trial to understand the long-term effects and also how well people are able to stick with the healthy lifestyle. This is one big line of research and we’re trying to understand the underlying mechanisms, how these interventions are having an impact.  One interesting finding from the trial is that, if you have ApoE4, which is the main genetic risk factor, it seems that the effect of modifying lifestyle factors may be even stronger. So, I think that’s a really positive finding—you can’t change your genes but you can pay extra attention to lifestyle factors.

We’ve also started a new randomized-control trial called MIND-AD. It’s a European trial where we aim to adapt the FINGER protocol to people who already have mild Alzheimer’s disease. That’s very important because we don’t have any effective medication. We don’t know what the right recipe is for people with Alzheimer’s—for example, how much physical activity or cognitive training. We’ll have one group using the FINGER protocol and one using a multi-domain lifestyle intervention plus medical food, which is omega three-based and enriched with different vitamins and nutrients to see if we can get a synergistic effect if we put the two together. For me that’s the model for future trials. I would not only like to see lifestyle or drugs. It would be interesting to try to put them together.

This interview was edited for length and clarity. 

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