Expert Interview: Menopause and Brain Health

One of the hottest topics in our Midday community is brain health—with good reason. Two-thirds of Alzheimer’s patients are women, and a growing body of research suggests that the menopause transition is a critical time for brain health.

We sat down with Dr. Annie Fenn, a recently retired OB-GYN and menopause expert, and founder of Brain Health Kitchen. Dr. Fenn is dedicating her second chapter to preventing cognitive decline and Alzheimer’s through food.

Midday: What inspired you to take up the cause of Alzheimer’s prevention and start Brain Health Kitchen?

AF: Alzheimer’s chose me. I wasn’t really looking for a second career, honestly. I was just following a passion for cooking and helping people in my community eat better. I thought that was the root of most problems I saw with chronic disease.

After I retired from my OB-GYN practice, I went to culinary school and started teaching people how to cook better and eat better. Around 2015, I was reading my medical journals and noted how data was piling up about the link between what we eat and whether or not we get Alzheimer’s or dementia later. It was that same year that my mother was diagnosed with mild cognitive impairment or MCI, the earliest form of Alzheimer’s.

I guess you can say that I had an epiphany that Alzheimer’s prevention is what I should be doing, I should be talking to women and other people about how they can improve brain health. We are learning that a lot of Alzheimer’s can be prevented through lifestyle.

Midday: Can you tell us a little more about Brain Health Kitchen?

AF: Brain Health Kitchen launched in 2015 as a website. I just wanted a resource for people about the information on the latest studies. With my medical training, I’ve gotten good at looking at scientific studies and pulling out what people need to know.

It’s also a recipe blog. I select the foods that are the most neuroprotective and create recipes from them that are easy, that people love to eat because I want people to be excited about food.

In 2017, I created the Brain Health Kitchen Cooking School. It’s not a bricks and mortars kitchen school. I take it on the road so I can get people hands-on and show them cooking techniques as well as the foods that are important. Brain Health Kitchen is a community of people who are aware and want to share information about healthy aging. It’s people who are proactive about taking care of their brains as they get older. It’s a community of sorts that I take everywhere with me, and it’s growing.

Midday: What is the difference between dementia and Alzheimer’s?

AF: The first thing to know is that Alzheimer’s is a type of dementia. Dementia is an umbrella term of all the things that can cause cognitive decline. Of those, Alzheimer’s makes 70%, but there are others like Parkinson’s Disease, frontal lobe syndromes, and vascular dementia.

You’ll hear us talk about Alzheimer’s primarily because that’s where the data is most strong. It’s a distinct entity, and you can measure the amyloid plaques and tau tangles in the brain with imaging studies and cerebral spinal fluid.

Midday: We’ve read that the disease gets underway 15-20 years before symptoms become noticeable. Is this true?

AF: That’s such an important concept. It sounds really scary, but I like to put a positive spin on this. We don’t just get Alzheimer’s when we’re in our 80s and 90s. It’s a process that starts in midlife. Depending on your genetic makeup, it may begin even earlier, maybe in your 20s.

It takes about 20 years of amyloid plaque and tau tangle to build up in your brain to lead to an extent of cognitive decline where you have symptoms of Alzheimer’s. The positive spin is that we have decades over which the disease develops, which means we have decades to take care of our brains too. This is not something that happens overnight.

Midday: Can you explain what happens to women’s brains during menopause and why this is such a critical period for women?

AF: Women are more vulnerable to Alzheimer’s. This is a recent area of research believe it or not. It was just 10 years ago that it was identified that women make up two-thirds of Alzheimer’s patients. An aside from that—women make up two-thirds of the caregivers of dementia patients. Women are affected by this disease more than men.

Are women’s brains more vulnerable to Alzheimer’s at the time of menopause? It’s very possibly true. Some researchers are looking at the way our glucose metabolism behaves during menopause and how it is impacted by changes in hormones. When you go through menopause, which is a five to seven-year period called perimenopause, there is a major change in estrogen. It goes up and down and up and down.

Estrogen is a master regulator. It regulates the neuroendocrine system, thermoregulation (how warm you feel), thinking, cognitive ability, all of those things. When estrogen starts to go haywire, it also changes the way the brain uses glucose, its primary source of fuel.

It’s this dip in glucose metabolism that tends to give us a lot of the neurological symptoms of menopause. Does this mean we might get Alzheimer’s later? Studies are showing that when this happens in the brain, you actually might accumulate more amyloid protein in the brain. You’re vulnerable to that.

Midday: Is there any overlap with brain fog and dementia?

AF: We don’t know if you experience really bad brain fog during perimenopause if that translates to dementia later. The brain fog may be secondary to this drop in glucose utilization in the brain. It’s almost like all this power in the brain just gets turned off. The lights go dim. We don’t know if this has a lasting effect.

What we do know is that brain fog can also be caused by sleep disturbance, which is common in menopause. As well as anxiety and depression, which is secondary to sleep disturbance. Brain fog can be caused by other things besides menopause or just the symptom complex that goes along with it.

Anecdotally, when I was practicing, my patients who had worse menopause symptoms tended to have worse lifestyle choices too. I found that the women who took care of themselves had an easier time in menopause, and I like to think they will be at less risk of dementia later.

Midday: What is your number one recommendation for women to protect their brain?

AF: Number one would be following a brain-healthy diet. That means flooding your brain with the foods that are proven to be neuroprotective and avoiding the foods that we know accelerate the decline of your brain with age.

The number two thing, which I have to add because they are equally weighted, is exercise. The good news in the Alzheimer’s world is that you don’t have to be a hardcore exerciser to get benefit. Even gentle exercise, like walking and gardening, can reduce your Alzheimer’s risk significantly. If you like to be really fit, being highly fit at midlife is a total plus for reducing Alzheimer’s later.

Midday: Can you reverse cognitive decline?

AF: You can reverse some of the signs of cognitive decline. Not all memory loss means you have Alzheimer’s. Sometimes memory loss is due to depression or anxiety, which can be treated, or sleep disorders, which can be treated as well.

If you’re talking about someone who has been diagnosed with Alzheimer’s, that’s highly controversial whether or not it can be reversed. We don’t have the data in 2020 to show that Alzheimer’s can be reversed with medication, treatments, food, or anything. So that means the focus now is on prevention. We know we can prevent the deterioration of the brain. Once you have Alzheimer’s, that’s going to be a tough one, and hopefully, we’ll find some treatment.

Midday: What’s the best diet for brain health?

AF: The most brain-healthy diet is the most delicious diet, too, I think. The strongest data on how to protect your brain comes from the Mediterranean Diet studies. The Mediterranean Diet is a plant-based diet that is rich in beans, nuts, seeds, legumes, and fish. There is less meat, dairy, and sweets. The Mediterranean Diet has a lot of data behind it that shows that it can help prevent mortality rates, cardiovascular disease, and now we know Alzheimer’s.

A spinoff of the Mediterranean Diet is called the MIND Diet. Researchers who created the MIND Diet at Rush University observed that there is a lot of data on the Mediterranean Diet preventing dementia. They asked the question: What if we took all the other hundreds of papers about the neuroprotective properties of certain foods and put them together?

The MIND Diet is a brain-health focused version of the Mediterranean Diet. When they went on to study the MIND Diet at Rush University, over five years, the people who followed the MIND Diet most closely had 53% less Alzheimer’s after 4.5 years, which is remarkable because you know we can’t cure Alzheimer’s. We don’t have a pill or treatment. Fifty-three percent just by changing what they ate.

The other thing I love about this study is that the people who didn’t follow the diet that accurately, because who can follow a diet all that accurately, benefited. The cheaters of the diet still had a 37% risk reduction.

Midday: What is the impact of the research on the Blue Zones on brain health?

AF: I love drawing from the Blue Zones research. The Mediterranean Diet is a lifestyle. I look at the brain-healthy diet as more of a lifestyle than a diet too. I actually don’t like the word diet. The Blue Zones manifesto includes certain things they’ve noticed in the people at the five places on earth where people have the greatest longevity. These centenarians are not getting Alzheimer’s. They are dementia-free at 100 years old and greater.

One thing that’s interesting about the Blue Zone people is that movement is a way of life for them. They don’t sit at a desk the way we do. They are moving throughout the day. They don’t go to a gym and exercise either. They have natural forms of movement that are key. That is another big lesson we can learn.

Midday: Are there specific foods that we should eat every week?

AF: The MIND Diet eloquently puts the brain-healthiest food groups into 10 categories to eat and five categories to avoid. This is not an elimination diet. They are not saying you should never eat a cheeseburger or ice cream cone. They are saying maybe if you can limit your servings of things like sweets to less than five times a week, that would be part of a brain-healthy lifestyle. So the 10 brain-healthy food groups are the ones that you want to get daily and several times per week. I have an article about this that gives you all the guidelines.

In general, berries are their own food group. No surprise there. Everyone knows that berries have things in them that are good for your brain. These are the anthocyanins that typically give blue and black colored berries their color. They act directly on the brain to clean up amyloid plaque and are potent phytonutrients that combat brain aging.

There are tons of studies just on memory and women and berries. Women who supplement their diet with two servings of berries a week do better on memory tests as they get older than women who don’t.

Berries are a slam dunk. The MIND Diet recommends two servings a week. I would try to eat them every day if you can, even if they are not in season. Frozen berries are just as good as fresh for the most part. Everyone loves berries, but sometimes we forget to eat them. The benefits of berries are so strong. I would eat them even if they are not organic.

The other one is leafy greens. Leafy greens are its own food group in the MIND Diet in addition to vegetables. The reason for that is there are many studies about leafy greens and brain aging. A really important study showed that people who eat one salad a day – one cup of raw leafy greens per day, their brains aged 11 years younger than people who didn’t do that based on MRI data. Just that one thing you can do – having a salad every day – can slow down the aging of your brain. Those two things are essential with a brain-healthy diet.

Midday: What foods should we avoid?

AF: It’s also really important to know what foods to avoid. One big category for me is unhealthy oils that are in food products and in your kitchen that may seem healthy but are not.

One of the first things I do in my Brain Health Kitchen cooking classes is to show people which oils to use and how to use them. It makes it easy because there are only a few that are good for you, and you can throw the rest away. I used olive oil primarily in my kitchen.

Olive oil is a brain-healthy food group. It’s used prominently in the Mediterranean Diet. I cook with olive oil. I just cook very gently with it. For high heat cooking, I use avocado oil. I also like nut oils. I don’t purchase them that much because they go bad quickly and they are also expensive.

The rest I would avoid. They are high in inflammatory factors that are bad for your blood vessels and cause inflammation in the brain. I really, really want you to adopt this one brain-healthy habit: pay attention to your oils.

Midday: What about coconut oil?

AF: I am not a fan of coconut oil in general. Unrefined coconut oil is better than refined coconut oil. The fat profile of a brain-healthy diet is primarily monounsaturated and polyunsaturated fats like avocado, olive oils, fatty fishes, and nuts. Coconut oil is 90% saturated fat. Most people think the MIND Diet has such great results because it is so low in saturated fat.

Reducing those brain-unhealthy food groups means cutting a lot of saturated fat out of your diet. Coconut oil has been studied for its impact on blood cholesterol. A recent study shows it does increase LDL cholesterol (the bad cholesterol). I wouldn’t use coconut oil on a regular basis. I cook with it sometimes I use it for its flavor profile, but I would minimize it.

Midday: Are supplements helpful in preventing dementia?

AF: The story on supplements is that there are large studies that show no benefit in preventing Alzheimer’s. Individuals might be able to take certain supplements and get benefits. Such as, if you are low on Vitamin D based on a blood test, I would definitely supplement. If you are vegan or vegetarian and your B-12 levels are low, I would definitely supplement.

Midday: Are puzzles and games helpful in preventing dementia?

AF: Not very helpful. I am not going to say useless because they give you enjoyment, like watching television. It might be stress reduction for some people. This gets to the issue of cognitive reserve.

Cognitive reserve is really important to build brain resilience. You are building more connections between your neurons and all these channels and pathways. So if you get Alzheimer’s later, your brain won’t notice because all these collateral roads to travel on.

You have to really challenge your brain to build cognitive reserve with things that are difficult for you. For example, learning a language, learning new dance steps, learning a difficult computer program, or reading very technical reading.

Midday: Does your mind get worse with age?

AF: It’s a myth that our cognition declines with age. It doesn’t have to be that way. There are a lot of factors that cause it to be that way, but it doesn’t have to.

There is a large study out of Finland called the FINGER Study that showed that by putting people on a brain-healthy diet and giving them exercises and a brain-healthy lifestyle, they actually improved their cognitive function over time. Meaning their executive processing got fast; they were able to do things faster, their memory improved; they were able to retrieve words better. The data doesn’t support that our brain has to decline over time.

Midday: Is there a link between dementia and early menopause?

AF: There was a study that came out last year that was really important. What it showed was that the longer your body is exposed to estrogen, the type that your body makes through the ovaries, the more years you have estrogen flowing through your bloodstream, the lower your risk of dementia and Alzheimer’s later in life. That means that if you have early onset of menarche and later menopause, you have been exposed to estrogen for more years of your life, and your risk of Alzheimer’s is lower.

If you have late menarche and early menopause then that window is shorter. Estrogen is really good for your brain. This metabolic data we are getting from the brains of perimenopausal women are starting to show us that too. You can’t really do anything about it. I wouldn’t worry about it. There are so many other things you can do to reduce your risk significantly.

Midday: How important is protein for brain health?

AF: I haven’t seen any specific data on protein intake and Alzheimer’s risk in women. However, there are lots of data that shows if you maintain your muscle mass as you get older, there are definite brain health benefits. Building muscle mass increases the brain drive neurotrophic factor, which is like Miracle-Gro for the brain that facilitates all the things that keep our brain cells healthy. You can do that with a minimum of 20 minutes of weight-bearing exercise twice a week.

I would definitely get protein in most of your meals. I think protein should be about 25% of your total calories. I would rather you get lean sources of protein like chickpeas, yogurt, fatty fishes, almonds, and nut milks—less through red meats and other animal products. If you eat a high protein meal right after you work out, you are more likely to maintain muscle mass as you get older.

Midday: Any other words of wisdom for improving brain health in midlife?

AF: The most important thing for brain health is being proactive. Everyone has risk factors. I didn’t eat healthfully for many decades of my life when I was training as a doctor. My mother has Alzheimer’s. What you do right now is so important.

There is one study that looked at the brain MRIs of people in their 70s and found benefits from switching to a Mediterranean Diet in just three years in their 70s. It’s really important in midlife, but even if you are older than that, you can really reduce your risk of dementia.