Table of Contents with chapter outlines for STRONG HEART, SHARP MIND: The 6-Step Brain-Body Balance Program that Reverses Heart Disease and Helps Prevent Alzheimer’s by Joseph C. Piscatella and Marwan Noel Sabbagh, M.D., with a Foreword by Michael F. Roizen, M.D. Introduction Part I: The New Science of Heart and Brain Health Chapter 1: The Heart-Brain Connection for Optimal Health For years, plenty of learned skeptics were convinced that no matter how virtuously you ate or how many hours you dedicated to the treadmill, the brain and heart would inevitably march towards deterioration. The landmark 2012 Heart and Brain Conference in Paris (mentioned in our Introduction) suggested that the tide was turning. The following year, the G8 Dementia Summit in London provided even more evidence of a paradigm shift in the making: More than 100 scientists from 36 countries agreed that, based on the research, at least 20 percent of dementia cases could be avoided by switching to a lean and healthy lifestyle in middle age, and an even higher percentage if people embraced good health habits when they were young. Heart health would also benefit tremendously from those same practices, they noted. Many cardiovascular risk factors are the same as those for Alzheimer's, they pointed out, including stroke, low HDL, high LDL, high blood pressure, smoking, overeating of unhealthy fats, excess body weight, lack of exercise, and Type 2 diabetes. Just a few short years later, as this chapter will explain, the dissenting view has become accepted wisdom among forward-thinkers in the cardiological and neurological communities. Lifestyle interventions, long known to be important for heart health, are now seen as equally critical as drugs and genetics for brain health. Moreover, the combination of the two preventive approaches have important ramifications. Addressing these risk factors—by adopting a battery of healthy lifestyle practices—can help prevent both America's number one killer (heart disease) and its fastest-growing, most feared affliction (Alzheimer's disease). "These strategies work," says our co-author Marwan Sabbagh, M.D. "Data is now showing that lifestyle interventions in many cases are handily beating drug target interventions." Chapter 2: Lessons of Lifestyle in the Fight Against CVD and AD A common bond exists between your heartbeats and brainwaves that ties their fate together. We know, for example, that people who suffer from congestive heart failure are at much higher risk for loss of brain function. It is also quite common for someone who is diagnosed with the condition known as atherosclerosis—clogging and hardening of the arteries—to progress to dementia. Even a disruption within the body’s tiniest blood vessels can cause significant disturbance to the blood-brain barrier and impair the ability of both organs to operate at full capacity. (This is particularly important for females, as many women experience arterial contraction in small blood vessels, thereby restricting blood flow; as opposed to men who typically have plaque in larger coronary arteries.) What's behind the connection? Blood flow is part of it. But there's a lot more to the emerging heart-brain connection: We now know that the well-known risk factors for cardiovascular disease (CVD) are very similar to those of Alzheimer's disease (AD). Both hypertension and Type 2 diabetes, for example, long known as culprits for CVD, are also risk factors for AD. Recent research suggests that Apo E 4, the genetic signature associated with higher rates of Alzheimer's, is also implicated in heart disease. In addition, elevated cholesterol—again, a well-known risk factor for heart disease—is linked to higher levels of amyloid, the substance that forms the brain tangles that are a hallmark of Alzheimer's. The relationship gets broader and deeper: Stroke, high blood pressure, overconsumption of unhealthy facts, excess body weight, smoking, lack of exercise—all well-known cardiovascular risk factors—are now linked to Alzheimer's as well. Meaning, that we have the power to prevent these diseases, and to improve our overall health in the process. That's the uplifting promise and purpose of this book. Chapter 3: Vital Signs for Vital Organs Helping readers achieve optimal heart-brain health, while keeping CVD and AD at bay, the goal of this book. How do you measure your progress along the way? The best way is to establish critical markers. In this chapter, we provide a "vital signs" scorecard—the most important values for heart-brain health. Some of these will be familiar, such as HDL and LDL. But, as there is clear evidence now about the link between hypercholesterolemia and cognitive disorders, we move into more sophisticated lipid values—particle size and apoproteins. Similarly, we drill down into other values, and look at measurements related to cognitive health and how these can be gauged. The goal here is not to get readers to run off and schedule a battery of additional tests beyond the ones they should be having as part of routine medical screenings. But as the association among things like metabolic syndrome, inflammation, stroke, Type 2 diabetes and both heart disease and Alzheimer's disease becomes clear, it's important to be aware of these benchmarks. Moreover, many of these share common risk factors—such as obesity, hypertension, metabolic syndrome, etc.—that one can gauge and track, with something as accessible as a BMI chart, for example. Part II: Six Steps to Brain-Body Balance Chapter 4: In this brief chapter introducing the prescriptive section of the book, we provide an overview of our evidenced-based plan, which involves some surprising new twists on familiar behaviors. For example, we recommend: Exercise, but with a new combination of activities—including some suggested workouts—designed to maximize the heart-brain connection.The Mediterranean Diet, but with a fresh look at the recently-revised dietary pyramid, and a few specific new suggestions for heart-and-brain-healthy nutrients, informed by the most recent research.Stress management, but with the recommendation of a new technique that has been shown to calm the body and brain in only 12 minutes, and help improve cognitive function, to boot. We do the same with the other components of our plans, showing readers our six-step program—plus new iterations and twists—that they can follow to incorporate into their lifestyle.  Also, in this chapter, we'll review the structure of our prescriptive chapters: Each will include motivational, first-person perspective from Joe Piscatella and a closer look at the science with Dr. Sabbagh—as well as actionable tips and advice. Chapter 5: Functional Fitness for Heart-Brain Health Yes, exercise is as close as we come to having a miracle drug. At this point, no one can dispute this. But what type? How much? How fast? How hard? There are so many conflicting recommendations about the best way to get active, from so many different expert groups, it’s hard to know what provides the most sweat equity. And of particular importance to this book: Are there exercise regimens that can actually promote both heart and brain health together? The answer to that last question is a resounding "yes!" We’ve created a step-by-step guide to help readers determine the perfect mix of frequency, intensity, time and type of exercise that is both realistic for them and that will actually help extend their health-span -- essentially their quality of life. The basis of our program is cardiovascular exercise, such as brisk walking, cycling and running. But we also include a new genre of physical activity—one that is still unfamiliar, even to many fitness professionals—that's designed to promote brain health and a healthy neural system. We put these together in a unique combination, incorporating some cutting-edge approaches, and designed to optimize what we call "brain-body balance." Chapter 6: The Mediterranean Diet's New Borders The Mediterranean diet was recently voted to be the overall best diet for the 10th year in a row by a panel of 25 medical and nutrition professionals reviewing more than 40 popular diets for US News & World Report. A plan that prioritizes eating more fruits and veggies with an accent on lean protein and healthy fat, it rated tops in both the heart-health and brain-health-categories as well as the weight loss and diabetes management categories. Further, it received praise for being easy to follow and budget friendly. While the common principles of the diet are more or less the same, there is not just one standard Mediterranean diet. The French, Greeks, Italians and Spanish are all part of the Mediterranean region but take their own unique approach to eating. To complicate matters, some of the popular “internet” diets claim to be the Mediterranean diet but really aren’t. In this chapter, we explore the varying shoreline of the Mediterranean diet, as well as some of the diet's new principles, which are less about what foods are eaten and more about how the eating is done: In Mediterranean cultures, for example, food is shared; eating is not rushed. Moreover, the base of the new pyramid is now physical activity, underscoring one of the important points of this book—that optimal health is not "just" about modifications in diet or joining a gym; it's a way of life. Also, in Chapter 6, we'll include some specific tips not found in many nutrition books: For example, new research suggests that elevation of the amino acid homocysteine increases risk for both CAD and AD. And it’s reduced by taking folic acid. We'll talk about how to get more of that in your diet, as well as the important role of flavonoids—phytonutrients whose important role in both heart and brain health has been confirmed by research published as recently as May, 2020. Chapter 7: Restful Sleep for Body and Brain Lack of sleep used to be a badge of honor, a way to show off how important and busy you were. We now understand such a boast comes at huge cost to the neuro-cardio system. At least 100 million Americans struggle with sleep issues. Lack of shuteye causes glitches in glucose metabolism and blood pressure and robs neurons of their ability to operate properly. A common sleeping problem known as obstructive sleep apnea ups the risk of heart failure by 140%, the risk of stroke by 60%, and the risk of coronary heart disease by 30%, according to the National Institute of Health. Sleep-disordered breathing also leads to a build-up of brain beta-amyloid, a key marker for Alzheimer's and other forms of dementia. Our program includes sleep hygiene because of its powerful protective effect on brain-body health. We turn to the new specialty of sleep medicine for expert advice from physicians in this discipline, and sleep coaches for creating an environment conducive to sleep—and for mending broken sleep habits without pills or gadgets. Chapter 8: A Sound Approach to Stress Management We Americans are stressed, and it’s wrecking our health. As studies show, when you feel like you’re in an emotional pressure cooker on a daily basis (as half of Americans do) plaque accumulates in the arteries, making blood platelets sticky and prone to forming clots. Arteries begin to constrict, starving the heart of nourishing blood. Meanwhile, as the blood is trying to deal with compromised blood flow, it’s also pumping out high levels of cortisol that wear down nervous systems. Chronic stress causes brain shrinkage, particularly in the prefrontal cortex, the area of the brain responsible for memory and learning. Readers don’t have to live life in the stress lane, despite the blinding pace of American life. This chapter reveals some simple changes and choices they can make to stress-proof themselves. One of the most intriguing for brain-body health is a new form of meditation known as Kirtan Kriya, which involves using fingertips in conjunction with relaxing sounds to stimulate the brain. A 2017 study found that beginner classes in Kirtan Kriya, or simply listening to music for 12 minutes a day for three months, had significant benefits for adults with preclinical memory loss, including those at risk for AD. In this chapter, we will also look at other surprising and diverse stress-relief techniques that can be satisfying in their own way, including the practice of prayer, the art of threading a needle, getting a massage… even doing dishes. Chapter 9: Cognitive Stimulation to Jump-Start Your Brain At Cleveland Clinic's Lou Ruvo Center for Brain Health, where co-author Dr. Sabbagh is director, "cog-stim"—cognitive stimulation—is one of the pillars of brain health. In this chapter, we'll talk about how to stimulate and challenge your brain. We will introduce the topic of "brain reserve"—essentially your brain's resilience and ability to improvise, and a critical component of maintaining a sharp mind as you age. Research shows how a broad array of brain-boosting activities—everything from pottery to painting, reading the classics to mastering a foreign language—can help keep your brain reserve agile and deep. How do you choose the best approach for you? And what is the cog-stim prescription? How often, how long, how systematically must one pursue these new activities in order to reap the brain-boosting rewards? We'll address those important questions, but we'll also look at the other part of the equation, specific to this book, by showing readers how to combine their heart-pumping cardio exercise with brain-boosting cog-stim activities. Done together, at the right time, they can provide an enormous one-two punch that can not only replenish your brain reserve, but actually enhance your ability to learn and think creatively (useful not just for the future, but for higher-functioning in daily life right now!). Chapter 10: Close Encounters in a Socially-Distanced World The famous Roseto experiment proved the power of close, homogenous communities and their relationship to public health. The story of the rural Pennsylvania town that defied national trends in heart disease in the 1950s and 1960s—only to reverse direction as its Italian immigrant-population became more Americanized—is a lesson for us today. "What Roseto taught us," wrote one cardiologist, "is that we humans are social animals who fare best when we're not alone or isolated. The price of modern society in our diet, our stress levels, our exposure to toxins and also our loneliness has been high." That famous study also reminds us that social connections—whether through family, friends, church or community organizations or interest groups--are every bit as powerful as adequate sleep, a good diet, and a regular exercise program for long-term health. Conversely, a relative lack of social ties is associated with depression and later-life cognitive decline, as well as with increased mortality. Another more recent study, which examined data from more than 309,000 people, found that lack of strong relationships increased the risk of premature death from all causes by percent, which is about the same effect as smoking up to 15 cigarettes a day. In this chapter, we cover the science behind the importance of having close relationships at any and every age. And we’ve got suggestions for increasing the quality and quantity of social interactions as well, even in the age of social distancing. Chapter 11: Other Factors That Can Improve Brain-Body Health Visiting the dentist and flossing your teeth can brighten your smile. Can such practices also brighten the picture for your heart-brain health? Supplements promise much in the way of heart and brain health. What do they actually deliver? Hand washing was the prosaic cornerstone of the public-health battle against the Coronavirus: Can it help ensure our heart and brain health, too? And let's not forget things like coffee, dark chocolate and two glasses of wine per day. All have heralded as keys to a healthy heart and brain. Is this true? (Please tell us it is! Maybe even just a little?) In this final chapter, we offer a checklist of other health habits that can promote optimal heart-brain health, as well as some that have been shown to have little value; and still others (as alas, may be the case with alcohol, sweets and caffeine) in which further research is still needed. Part 3: Brain-Body Balance in Action Chapter 12: Making Healthy Changes, Step by Step Our program is constructed on sound building blocks of brain and heart health, with new scaffolding that links the two in specific ways. It is comprehensive. It is multi-faceted. And while it is well within the grasp of your average person, it is challenging. Where do you start? Right here: In this motivational and practical chapter to conclude the book, we show readers how to take the steps that can lead them to optimal brain-heart health, as well as protect them from heart disease and Alzheimer's. Co-author Joe Piscatella has helped thousands in their journey to better heart health, in part by teaching them how to adopt the right kind of mindset needed for lifestyle change. About how to set goals, about taking responsibility, about developing a positive mindset, and resilience when one hits the inevitable bumps in the behavioral road. Here, he guides readers, step by step, through a process specific to this program. “No Ordinary Joe” will teach them how to get in the right mindset; how to integrate these principles into their daily lives—and lead them to the extraordinary benefits to be accrued by a heart and brain in healthy harmony. Chapter 13: Additional Resources to Help You Maximize Your Heart and Brain Health In this chapter we recommend additional resources to help readers. We include websites, books, online classes and more. Source List/Citations

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Chapter 5: Functional Fitness for Heart-Brain Health to STRONG HEART, SHARP MIND: The 6-Step Brain-Body Balance Program that Reverses Heart Disease and Helps Prevent Alzheimer’s by Joseph C. Piscatella and Marwan Noel Sabbagh, M.D., with a Foreword by Michael F. Roizen, M.D. In this chapter we discuss the importance of physical for heart health (something many people are aware of); its value in brain health (a fact that many may not realize); and—using new prescriptive material, including a regimen of neuro-cardio exercises that even many fitness professionals are not yet incorporating—its significance in promoting the nexus that this book examines, heart and brain health. ***** In 2008, the federal government issued the first national guidelines for physical activity. Some might joke that they were only 12,000 years late. Humans have been physically active since our species first worked up an appetite. The hunter-gatherers we are descended from were engineered for movement. In a fascinating 2012 paper, neuroscientist Mark P. Mattson listed the many ways that this is so, including our long, elastic leg tendons, our sweat glands and sparse body hair, our swivel hips. And—of particular relevance to this book—our advanced cognitive capabilities, which suggest a brain-heart connection that helped distinguish humans from other species—and which we contend in this book is now being recognized as a critical nexus of human health. All of these factors helped make us, quite literally, born to run—or at least walk briskly—over long distances. And because we were able to do that, starting about two million years ago and continuing through the end of the hunter-gatherer period, it could be argued that we were eventually able to create civilization. Early humans didn't need to be told to keep track of their distance in miles, minutes or steps. And their sojourns weren't just in the pursuit of game. Researchers have speculated that a natural cycle of regular activity, intense and moderate, was likely the norm for most of human existence: one or two days of vigorous and strenuous exertion in the hunt for food. punctuated by one or two days of less intense activity, which might have included long walks to nearby villages or to trade with other clans and communities. This activity pattern—episodes of vigorous and moderate exertion, accumulated throughout the day—is not dissimilar to the recommendations made in the modern guidelines. And that's the important point here: The onus on physical activity and exercise, the contemporary fitness culture of marathon running, CrossFit gyms or Peloton bikes, may seem like a fad, but it's essentially a return to the kind of natural activity that our mind and bodies have been developed for— something that, like language and emotions, is a critical part of what it is to be human. The Centers for Disease Control and Prevention said as much, in a white paper on physical activity in 1999. "Viewed through the perspective of evolutionary time, sedentary existence, possible for great numbers of people only during the last century, represents a transient, unnatural aberration." In other words, we need to stop thinking about physical activity as something strange, new and uncomfortable—some kind of castor oil we are being forced to take by people in white lab coats. Rather, we should view it as something that is an inherent part of who we are, a skill or talent you never realized you had. And regardless of how fast or slow your ability to walk, you do have this ability. We all do. We've just made it easy for ourselves to forget that by relying on machines to do what our legs or lungs used to accomplish for us. Of course, no one is suggesting we go back to being hunter-gatherers. So how do we reconnect with the patterns of exercise that are intrinsic to us as humans and accrue the enormous physical and (yes) mental health benefits of exercise? That's what we will show you in this chapter. And we will go beyond the conventional wisdom that you may have heard. We'll show you why physical activity is good for both your heart and your brain—including some interesting new aspects of the fitness equation that can have profound effects on both. Perhaps most importantly, we'll also show you how you can start incorporating this into your life and how, in tandem with other essential components of brain/heart health, physical activity, you can lower your risk of getting both heart disease and Alzheimer's disease (not to mention many other afflictions) and significantly improve the quality of your life. ***** The 2008 guidelines, released by the Health and Human Services Department, were updated in 2018 to reflect the latest thinking. The basics, however, are still the same. Here's what they advise: For health benefits, adults should do at least 150 minutes (2 hours, 30 minutes) a week of moderate-intensity activity or 75 minutes (1 hour, 15 minutes) a week of vigorous-intensity aerobic activity. It's further recommended that adults should perform muscle-strengthening activities—exercises involve all major muscles groups—two times a week. Older adults should also include balance training. We'll talk about all of this—and more. But let's underscore some of the guideline's other key points: Adults should move more and sit less throughout the day: At this writing, many of us have spent weeks indoors because of the COVID-19 epidemic. While necessary to stop the spread, some public-health officials also reminded citizens to get out regularly for socially distanced exercise, even during the lockdown. They knew that long periods of sitting could create its own, slow-burning health crisis. (As one wag put it, “Television can be a weapon of mass destruction." The same could probably be said of the cell phone, the internet and social media!) Some physical activity is better than none: Many people still think the only way exercise is going to be effective is if it's long, sustained, and intense. Go out and run or cycle or swim as hard as you can for as long as you can. When you drop to your hands and knees at the finish line, gasping for air, you've done what you're supposed to. No! That old no-pain, no-gain guideline is a recipe for how to quit or avoid exercising. While vigorous exercise has great value, research over the last few decades has really opened our eyes about the value of what could be called "small" exercise—moderate intensity, shorter duration, especially for those just starting out. Got a Minute to Take Some Important Steps for Your Health? Epidemiologist Steve Blair, professor emeritus at the University of South Carolina and the former president of the Cooper Institute for Aerobics Research, was a pioneer in establishing the value of short bouts of moderate-intensity activity. Dr. Blair has spoken about the Power of the Two Minute Walk, which he uses as a rejoinder to those who claim they don't have time for exercise. While two minutes is not sufficient to meet the guidelines, it is enough to surmount the largest hurdle facing most of us, when it comes to exercise: simply getting started. Oh, and just by doing that two-minute walk—okay, maybe a couple times a day—you're already accruing some basic health benefits. Dr. Blair and the national guidelines talk about minutes, but today many people like to count steps, on a pedometer or an app on their phone. A review of studies in the journal Medicine & Science in Sports & Exercise found that about 7000-9000 steps a day can result in health benefits similar to the federally recommended 150-300 weekly minutes. As for the oft-heard recommendation of 10,000 steps per day, the American College of Sports Medicine offers this tidbit: Research supporting the 10,000 steps a day guideline is limited, and some believe the recommendation was actually derived from the name of a Japanese-made pedometer sold in the 1960s called Manpo-kei, which translates to “10,000 steps meter.” Should you choose to count steps, which is a convenient and fun way to keep track of your activity, that's fine. So is keeping an eye on the clock, as you rack up your federally recommended minutes. And many pedestrians and runners still like to think in terms of miles. After all, there's something satisfying about saying you've walked a mile—or three or five. It makes you feel like you're really going places with your exercise regimen. Regardless of how you measure it, your goal should be consistent, regular activity, which has innumerable benefits for both your heart, and your brain. Let's examine those more closely now. Exercise: Good for Your Heart     When physicians and public health officials talk about the health benefits of physical activity exercise, they're largely although not exclusively referring to its effects on the heart and cardiovascular system. They are significant, as exercise can: Reduce the risk of heart attack and stroke. The Harvard Alumni Study and the Nurses’ Health Study both found that about three hours a week of walking reduced heart attack risk by 35 – 40 percent.Strengthen the cardiac muscle, thereby reducing strain when the heart pumps.Increase HDL cholesterol, which is protective for heart health. A study at Stanford found that walking two miles, three days a week would raise HDL by 10 percent.Reduce coronary inflammation and blood clotting.Prevent the development of high blood pressure.Build muscle and bone strength, as well as balance.Regular exercise is also a key to weight loss and weight control by burning calories, elevating metabolism, building muscle and helping to manage stress. It usually takes about three months of consistent activity to achieve these cardio-protective benefits. We'll talk about the "fitness formula" to help you get there a little later in this chapter, but first here's how one man—Joe Piscatella, co-author of this book and a nationally recognized expert on heart health—used exercise to transform his own life. A New Life Through Exercise: Joe's Journey     "I was always an athlete, playing sports in high school and college. But in those days, once graduated, married and with children, a lot of us just stopped. Oh, there was social tennis and golf, but aerobic exercise wasn’t part of my routine. Both my weight and my cholesterol went up. “After undergoing coronary bypass surgery at age 32, the alarm clock of reality rang. On one hand, I had a young family, children just 6 and 4. On the other hand, I had a doctor tell me that because I was so young and the disease so aggressive, I probably would not live to age 40. As my wife, Bernie, stated, ‘That is not an option!’  “So, I began my journey to discover how lifestyle habits could impact my heart health positively.  Obviously, not smoking (I was a non-smoker) and eating a healthy diet were priorities, as well as managing stress and developing a positive attitude. But for me, exercise became the starting point. “At that time, however, there was a curious dichotomy. The running boom was starting to take off with the general public, but heart patients were told to ‘take it easy.’ Many were put to bed. After researching exercise and the potential for cardio benefit, I decided to start running. My doctor went through the roof. ‘You can’t do that,’ he said. ‘It will put too much strain on your heart. I forbid it!’ “I responded that the last time I checked, it was my heart and so it would be my decision. Clad in an early edition of Nikes, cotton running socks and (short) running shorts, I began my treks around the neighborhood, eventually running 4 miles, 5 days a week. Six months later I was in my doctor’s office for a follow-up exam. All of my biometric numbers—cholesterol, weight and blood pressure—were excellent and my doctor was well pleased. That evening as we were seated at the dinner table, the phone rang. “It was my doctor with a simple question: ‘Joe, where do you get your running shoes?’  “I ran for the next 30+ years until orthopedic problems in my 60’s turned me into a brisk walker. Now I walk 5 miles a day, 6 days a week. My biometric numbers are still excellent.  “Three things have kept me motivated over all these years. Initially, I exercised faithfully because of my young family. I did it for them…and me.  I didn’t want to miss my son’s graduation from college, walking my daughter down the aisle at her wedding, or growing old with Bernie. As much as we could, we made exercise a family affair. The kids would often join me on my run. “As time went on and my heart health became more secure, I was lucky enough to find excellent exercise partners to keep me committed, on track and accountable. And I did the same for them. Here is an example. I exercise early in the morning. Up at 5 o’clock, by 5:15 I’m laced up and out the door. This past February the weather was terrible where I live in Seattle. As my radio alarm went off, I could hear the driving rain pelt the windows horizontally. The radio announcer told me it was 38 degrees. And I was under a down comforter. “’I’m not going,’ I said to myself. ‘Who would go out on a day like today? I’m staying in bed.’ Then I realized that I have a training partner. I can’t call him at 5 a.m. just to say I don’t want to walk. So, I got up, got dressed, met him at the corner and off we went. I was glad that we had done it after it was over, but I never would have done it without my exercise partner. “And finally, I have found exercise to be motivating for other aspects of my life, such as eating healthy, managing stress and thinking positively. For me, exercising regularly forms a foundation of success that allows me to build on with my other lifestyle habits. “Throughout my life, exercise has been as natural as brushing my teeth.  Once you get into it, it takes on a life of its own." Exercise: Good for Your Head, Too!     By the time Joe began his comeback from bypass surgery in the 1970s, the link between exercise and a healthy heart was well established. But it is only in the last 20 years or so that researchers have discovered the many ways physical activity can help our mental and brain health too. These include: Stress managementMood enhancementImproved self-esteemReduction in anxiety and depressionBetter sleepImproved memoryGreater levels of creativity Regular exercise, said the Harvard Health Letter in 2018, "has a unique capacity to exhilarate and relax, to provide stimulation and calm, to counter depression and dissipate stress." "A walking brain is a more active brain," wrote neuroscientist Shane O'Mara in a recent Wall Street Journal column, praising this most basic form of physical activity. "Walk we must and walk we should." You would think, then, that most people—particularly those facing cognitive decline and senile dementia—would embrace physical activity. But that is not often the case, notes the co-author of this book, neurologist Marwan Sabbagh, M.D. Dr. Sabbagh on Exercise and Dementia: FINGER, EXERT and The BDNF Factor I am still surprised by how deeply sedentary behavior is ingrained in many of my patients’ lives. When I encourage them to start walking, or to try yoga or a senior aerobics class, they roll their eyes. "Yeah, yeah," they say. "We've heard this." What they haven't heard is how this can help the condition I'm trying to treat as their neurologist. They don't equate exercise with having a beneficial effect on the health of their brain. When I start speaking about exercise in relation to their brain health, they sometimes assume I'm talking about doing crossword puzzles. Yes, that's good, I tell them. But those kinds of cognitive-stimulation exercises—which we'll address in a separate chapter in this book—are different from physical activity and have a different effect. We know from a number of studies that regular physical activity may be one of the most important things you can do to promote brain health. For example, we know that cognition—which is essentially all aspects of thinking (memory, concentration, language, processing speed, and so on)—improves up to 10 - 20 percent after a structured program is implemented. We also know that exercise has the potential to reduce the risk of developing dementia. The two-year study known as FINGER (FINnish GERiatric Intervention Study to Prevent Cognitive Impairment and Disability) examined healthy lifestyle interventions among 1,109 people in Finland, aged 60-77, who had genetic risk factors for memory disorders. Researchers at the Karolinska Institute looked at diet and cognitive training, and some other interventions that we'll discuss in other chapters of this book. But one of the most striking findings from this investigation was the importance of exercise. Participants in the study engaged in the kind of structured, multi-faceted exercise program we are recommending in this book, including aerobic and balance training for the heart and brain. The results: Regardless of their genetic risk, the subjects in the study improved in all cognitive domains, including the speed with which they could process information and their ability to perform complex memory tasks. Another important investigation, known as the EXERT study, looks at the value of exercise in adults with memory problems.  This national 18-month clinical trial is testing whether physical exercise—aerobic training, or stretching and balance exercise—can slow the progression of mild memory loss and/or mild cognitive impairment in older people.  One of the test sites is the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, Nevada. As the Center's director, I can tell you we're excited to be part of this nationwide investigation, the results of which so far are promising, and may lead us one step closer to the point where we can, as an NPR story about the EXERT study described it, prescribe exercise as a drug to forestall or prevent Alzheimer's disease. Wouldn't that be marvelous? But we already know enough to be convinced of the one-two punch of exercise in heart and brain health. One reason exercise has such a powerful effect is that it promotes blood flow from the heart to the brain— the intersection that, as we say in this book, represents an important new dimension of overall health. But there are other reasons, too: Exercise can help reduce or avoid such conditions as hypertension, hyperlipidemia and diabetes, all of which have been associated with dementia development—again, showing how improvements in the heart and cardiovascular system can often be linked to brain health. Studies have also shown that in those who exercise, the volume of the hippocampus—the brain's memory center—is increased, and that exercise is key to the production of something called the Brain-Derived Neurotrophic Factor or BDNF. It has also been referred to, in more pungent terms, as fertilizer for your brain. Here's the science behind it: Your brain, like every other part of the body, has the ability to regenerate itself. These growth and healing (also known as trophic) agents, or factors, are a family of proteins. They include NGF (Nerve Growth Factor) and HGF (Human Growth Factor) and BDNF, which has been linked to improved learning and memory, elevated mood and the ability to acquire new skills. BDNF has also been associated with lower levels of certain types of inflammation, and there is evidence that those with higher levels of BDNF have lower rates of Alzheimer's disease and dementia. As the National Medical Library describes it, BDNF is active in cell-to-cell communications, helping to regulate what is called "synaptic plasticity"— meaning that it helps the synapses (the nerve endings that connect the neurons of the brain) to adapt and change over time in response to experience. It is nothing less than nourishment for the brain. So how do you get more of this nourishment? Contrary to the claims of some supplement marketers, you can't take BDNF in a pill. You can't sprinkle it on your Wheaties, either. But what you can do is exercise. Because we know that, unlike some of the other growth factors, BDNF production is stimulated by as little as 30 minutes of vigorous exercise, three times a week. But even greater gains, writes exercise physiologist Louise Pontin, have been found when you combine that with a more complex activity, which requires you to build or acquire a skill—exercise that challenges your balance or thinking. And that's the kind of exercise we're going to look at now. Exercise at the Nexus of Heart and Brain Health          A group of 25 older adults at the Linwood Senior Center in Wichita, Kansas are standing on three-inch thick foam pads, each of them holding a yellow wiffle ball. “I’d like you to hold the ball in one hand and then drop it into the other,” says the class leader, Dr. Michael Rogers, an exercise physiologist at Wichita State University, as he begins releasing his own ball from the fingers of his right hand into the palm of his left. The class follows his lead. “Now, expand the distance,” he says, raising one arm and, thus, the distance that the ball must fall. “Change hands.” Arms swing up and down, brows furrow, and a few balls go rolling on the floor to titters of laughter. As the balls are collected, Dr. Rogers directs their attention to an image projected on the wall of the rec room. “Okay,” he says. “I’d like you to read the words.” “Red. Green. Yellow. Blue,” the group says in unison, still while standing on the unstable surface the foot cushions provide, as they read a series of words that appear each in the appropriate color. “Good,” says Dr. Rogers, as the next PowerPoint slide is projected. The words appear again, but now in different colors, so that “blue” appears in green type, the word “red” is in yellow and so forth. “Say the color of the word, but ignore the word,” Dr. Rogers reminds them. There is hesitation, as participants, still standing on their foam pads, pause for thought. The unison of response is not quite as crisp now. “Blue....no, wait, yellow.” The brain-teasers are part of the Stroop Test, a series of drills typically used in laboratory settings to test a person’s capacity to direct attention. Incorporating these mental exercises into what is ostensibly a fitness class is based on the idea that so-called “cognitive distraction” drills can help improve balance. "You're trying to accomplish two things at once here," explains Dr. Rogers. "That's what we've done. We're distracting the person from focusing on their balance." And in the process, you're putting greater demands on their neural system, forcing it to attend to two tasks at once, which in turn can help make it more efficient. We are, to refer back to our previous section, pumping up the BDNF. “This is pretty cutting-edge stuff,” says Robert Topp, Ph.D., a professor of nursing at Marquette University, who has researched the effectiveness of various forms of exercise among older adults. Standing strong, he says, goes beyond what is typically used to improve balance. “Mike,” he says, referring to Dr. Rogers, “is trying to train people to concentrate on what they’re doing as well as retrain their balance. I think he’s onto something really important." So, do we—and not only for falls prevention, which is of course is a concern for older adults. But the kind of activities that Dr. Rogers has developed—some call it neural-pathway-activation, others refer to it as sensory motor training or dual-processing activity—represent a potentially new genre of physical training, beyond the usual fitness triad of aerobic exercise, resistance training and flexibility. We believe that this kind of neural-physical exercise is very much part of heart-brain health. Now you might be thinking: What? Another kind of exercise, on top of what these guidelines are already recommending? Am I supposed to spend my whole day working out? Not at all. The kind of training that challenges your brain and neural system, as well as your heart, isn't difficult to incorporate into a basic exercise routine. In fact, these movements are kind of fun! You can get a sense of this kind of training immediately. When you brush your teeth tonight, try standing with one foot in front of the other. Then close your eyes. Requires a little adjusting, right? Feels different, even a bit strange? That's your brain reacting to and then reprogramming to perform an activity, in a new and unfamiliar position and with one of its key senses—sight—suddenly unavailable. How do we incorporate this into your overall program of physical activity? To do that, let us return briefly to the guidelines. Exercise for Your Heart and Brain: Piscatella's Pointers on Putting it All Together     How do you construct an exercise regimen that works for you? Like a lot of fitness and health professionals, I like the formula called FITT. The “F” stands for Frequency. The American College of Sports Medicine says that it takes three days a week of more vigorous exercise to attain cardiovascular fitness. For heart health, I suggest that as your goal (although you need to build up that goal gradually). The “I” stands for Intensity. How hard are you exercising? If you are walking, for example, it should be more than a casual stroll. One hundred steps a minute is “moderate” intensity while 130 steps a minute is “vigorous.” I also believe that a combination of moderate and high intensity exercise (HIT) can be beneficial. An example would be to walk five minutes at a moderate pace, then two minutes at a vigorous pace, then back to five minutes at a moderate pace, etc. (Breaking up your exercise like that also helps keep you focused and motivated). I'm not saying you should be doing all-out sprints here—just intense enough that you can feel the effort. (One oft-used cue to gauge ideal aerobic intensity is that it should be easy enough that you can still converse but hard enough that you can't sing.) By the way, to step back into the research for a moment, one Dr. Sabbagh's colleagues, Jeff Burns, M.D. of the University of Kansas Medical Center, has done some very impressive research on the link between exercise and Alzheimer's showing how this variable in the fitness formula—intensity—matters. In a 2015 study on the link between exercise and brain function, Dr. Burns and his KU colleagues found that those who exercised with greater intensity had the most improvements in visual-spatial learning, the ability to perceive where objects are in space and their distance from each other, as well as increased attention levels and ability to focus. The first “T” in the FITT formula stands for Time. While we noted earlier that overall health benefits can be derived from very short bouts of activity, the gold standard for achieving the kind of heart health results we outlined earlier is 45 minutes. While a little more aggressive than the Health and Human Services guidelines, that should be your goal. Not at first, though: You don't start by trying to exercise nonstop for 45 minutes. Dr. Sabbagh recommends something closer to the federal guidelines to start out with. He recommends to his patients that they begin with 10-15 minutes of brisk walking and gradually build up from there, adding 1-2 minutes per day each week. "Consistency over strenuous," he says—and I agree.  The second “T” in the FITT formula stands for Type. There are many flavors of exercise out there. We talk about walking and running because they are the most available. Of course, you could also ride a bike or take a Spin class; swim or row; participate in an active sport. To build strength, there are many forms of resistance and core training, plus wonderful ways to increase your flexibility, such as yoga (which has other calming and centering benefits, as well). As the old adage says, the best exercise is the one you'll do! Your New, Brain-Boosting Workout: To this list of familiar types of physical activities, we add a new ingredient: The neural-pathway-activating, balance-type training that, as we have seen from Dr. Rogers' work at Wichita State, can add a one-two punch to the power of your workout, supplementing the brain and heart benefits of physical activity we've discussed in this chapter. Let's put it all together, starting with the kind of heart-challenging, brain health-abetting exercise Joe and Dr. Sabbagh have just described. It could be brisk walking; it could be running—or a combination of walking and intervals of jogging. When you've finished (as noted, beginners should start initially with 10 minutes and then gradually build up to 45 minutes), cool down with a few minutes of easy walking and gentle stretching. Your muscles are warm, the blood is flowing, and with it that brain-fertilizing BDNF. Now let's challenge it! Find a tree, a pole, or a wall for support. Standing erect, and with the palm of one hand on the supporting surface, close your eyes and slowly raise your left knee, lifting your leg off the ground. Count slowly to 30. Then switch legs, and do the same. You've done your first basic balance movement. Your brain is already responding, rewiring circuits to respond. Now it's simply a question of upping the game a little bit each time. After your next aerobic workout, add 15 seconds to your one-legged stands, and the time after that, another 15 seconds, so that you are now standing—with support—for 60 seconds on each leg. Standing on one leg for an extended period of time without support sounds easier than it actually is, as you may discover. You might feel like you're suddenly on a rickety foundation. But the brain will adjust, and by your third or fourth session, depending on your age and existing condition, you'll likely be ready to let go of the training wheels. One more iteration of this basic move: Once you can stand unsupported, eyes closed, for 60 seconds on each leg, try turning your head slowly back and forth during each iteration. Don't do it too quickly; you don't want to get dizzy or strain your neck. Just a slow, gradual side-to-side rotation, as you balance on one leg, unsupported. More challenge for the brain. But it's a challenge your brain will rise to, perhaps faster than you realize. "Most people see improvement fairly quickly with these kinds of movements," says Dr. Rogers. "They get more and more confident." Your Advanced Brain-Boosting Workout This new kind of training is being recognized by fitness professionals. "We call it `balance training,'" says Bob Phillips, a personal trainer certified by the National Strength and Conditioning Association "But it's really something more complex." In the last couple of years, Phillips has begun incorporating this kind of brain-boosting work into the regimens of his one-one-on clients. "It takes them out of their comfort zone," he says. "It forces them to do two things at once, and in the process, it's helping them to become neurally efficient." Phillips often starts his clients out with basics—like standing on one leg—but, as they progress, he employs an array of props, including wobble boards and the round-on-one-side, flat-on-the-other balls known as BOSUs. Sometimes he'll play catch with a small medicine ball as his client stands on a foam surface, like the participants in Dr. Rogers' class. But you can do a more advanced brain workout on your own using just a broomstick and a rubber ball. Phillips recommends starting these exercises only after two or three weeks of doing the single-leg stands and the evolutions for it that we just described. Broomstick kayaking: After you've finished your aerobic work and cool down, take your broomstick in both hands, at shoulder width and using an overhand grip. Begin to form a figure-eight motion with the broomstick, as if you're kayaking. "You want to visualize it as if you are actually on a kayak," Phillips says. "Try to be rhythmic and smooth." Do this for 60 seconds. Rest a minute, and repeat. It might take your brain a couple of times to get that fluid motion. But once you're figure- eight-ing your way along like the kayak version of an air guitar player, challenge yourself by standing on one leg while you do it: First the right for 60 seconds, then the left for the same amount of time. It's not easy, at least not at first—and of course, that's the point. Single-leg ball toss: Add this one to the mix after a few sessions of kayaking. You can use a partner for this movement, or find a concrete wall that can allow you to rebound a rubber ball. (Try a palm-sized handball or bounce ball that you can find for just a few dollars at any sporting-goods store.) Standing on your right leg, throw the ball to your partner or against the wall, and catch it on one bounce—five times, first with your right hand, then five times with your left. Change legs and do the same. Comfortable? You shouldn't be, at least not at first! "You're forcing a sort of constant adaptation," Phillips says. The brain must engage in what Dr. Rogers calls "dual processing"—in this case, focusing on catching and throwing the ball, while simultaneously adjusting to the instability of standing on one leg. It may look and feel strange, admittedly. "It's a little out of the box," Phillips says. "But it's kind of like a game, and my clients love it." One reason they do is because, unlike other forms of exercise, you can see improvements in balance and neural training quickly—a tribute to the plasticity of our brains that, in combination with our aerobic exercise, is really helping you attain a new level of heart-brain fitness.

Introduction to STRONG HEART, SHARP MIND: The 6-Step Brain-Body Balance Program that Reverses Heart Disease and Helps Prevent Alzheimer’s by Joseph C. Piscatella and Marwan Noel Sabbagh, M.D., with a Foreword by Michael F. Roizen, M.D. On his 1989 album Full Moon Fever, Tom Petty sang about "a mind, with a heart of its own." Regardless of precisely what the late rocker meant in the lyrics of that cryptic song, he was musing about a relationship that many have speculated upon over the centuries. Hearts and minds are often linked—as in that very phrase itself, the title of a 1974 Academy Award-winning documentary about the Vietnam War, where the term "winning hearts and minds" became synonymous for failed American efforts to garner the emotional and intellectual support of the populace behind the conflict. Philosophers and physicians have long debated the primacy between the heart and brain or, more broadly, between emotions and reason. Aristotle famously declared the heart as the seat of consciousness, making the brain essentially, well…an after-thought. Others felt the same way, as what has been termed a "cardio-centric" view prevailed for centuries: “The heart has its reasons, which reason does not know,” Pascal wrote in 1675—about fifty years after William Harvey figured out that the heart was not a sentient organism, but essentially a marvelously-designed pump. Harvey's discovery, wrote the University of Calgary's Dr. Steven W.A. Reynolds, "helped end the notion that the heart was intelligent and directed the functions of other organs." Or did it? Harvey himself continued to refer to the heart as the “king” or “sun” of the body. He also maintained that, in addition to being a wonderful mechanism for circulating blood, the heart was the seat of emotions and did not challenge its metaphysical role. "To this day," Reynolds writes, "the heart remains a symbol of the soul and of emotion and the stylized heart symbol evokes images of love and passion." That's the way it has continued ever since: The two vital organs, viewed as shorthand for the extremes of human behavior; opposite sides of the spectrum—emotion versus reason; passion versus logic; impulsive action versus deliberate, planned decisions. Even in the scientific community, the heart and the brain have long been viewed as separate. Equally important to the functioning of a human being, yes, but studied and treated by specialists working in their own branches of medicine, with their own journals and research papers, and without much thought to the interconnection of the two most vital organs. That is changing. In the past decade, researchers have begun to take a fresh look at the heart-brain nexus. The Heart and Brain Conference, held in Paris in 2012, brought an interdisciplinary approach to the important question of how heart and brain health were related along with the inverse, i.e., how dysfunction in one could be linked to problems in the other. At that first forward-looking conference, cardiologists and neurologists discussed the common diseases that each treated separately -- in particular stroke. Since then, there has been a recognition of even greater overlap in the two areas. "An intimate and underestimated relationship" is how University of Amsterdam pathologist Mat Daemen so artfully put it, in an influential 2013 paper. He predicted that, as our society ages, the link between a dysfunctional heart and a cognitively impaired brain could become a vital health-care priority in the future. With an estimated 108.7 million Americans now 50 and older, the significance of this link becomes critical—particularly as we contemplate the rising numbers in two diseases that, despite the recent COVID-19 epidemic, are the ones most would agree still pose the greatest long-term public-health challenges to an aging America: Heart disease—the nation's #1 killer. Alzheimer's disease—the most feared affliction, and one that itself is reaching epidemic proportions. Americans have long feared the former and, according to a recent survey of Baby Boomers, are terrified of the latter: 95 percent felt themselves either unprepared for a diagnosis of Alzheimer's or that they would find life "not worth living" with it. But mounting evidence suggests a much closer relationship between these two diseases than previously thought. Even more compelling is the research showing that something can be done about it, that steps can be taken—some familiar, others new—to maximize and improve heart and brain health together. "It is time for a more integrative view to the heart brain connection," declared Dr. Daemen in 2013. We believe that time is now, as heart disease continues to take its toll… as Alzheimer's continues its steady climb… as readers 50 and over, perhaps reminded of the importance of adopting better health habits during the current epidemic, are looking to take steps to ensure their well-being and quality of life for decades to come. Hence, the urgent need for a book that can explain this new interconnection of a healthy heart and brain, one that can show readers how to forge the vital link. This is that book.