Facebook Live: Part Two — Ketosis and Cognition Putting it All Together

Apollo Health’s Chief Science Officer, Dr. Dale Bredesen, and Chief Health Liaison Julie Gregory continue from the previous Facebook Live,” Facebook Live: Part One — Ketosis and Cognition Putting it All Together,”with an in-depth conversation about the importance of ketosis for cognition.

They discuss the important role that ketosis plays in refueling the brain when it can’t effectively use glucose, and how it helps to restore metabolic flexibility — the ability to use both glucose and ketones as fuel. They provide instructions for how to achieve endogenous ketosis for those who are healthy and for those with other health concerns, as well as tips for tracking your level of ketosis.

We’ve included a complete recording of the session and a full transcript below for your convenience. 

Watch here:

Transcript:

Hi, everybody. I hope everyone’s still here. We’ve had a couple of Facebook issues here having to restart. So hopefully everyone’s still around, hope everyone is looking forward to the holidays. As I said earlier, Julie, great to have you. And we were talking earlier about ketones.

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Dr. Bredesen: We talked a couple weeks ago about these, and this is such a critical issue in cognition because for your brain to function optimally, you need either to burn ketones or to burn glucose. And the good news is you can go back and forth and that’s metabolic flexibility, which is what we should all have. And unfortunately, as you begin to have cognitive decline, you lose both of those. In addition to those, you need mitochondrial function. You need blood flow. You need oxygenation, which is why so many people who have sleep apnea, have cognitive decline. So it’s that set of things that’s so critical to get best cognition and therefore understanding how to create ketosis in various situations and being able to go back and forth.

And as I say, most people who have cognitive decline, aren’t able to do either. They’re not very good at burning the glucose, which is exactly what the PET scan show, because they have insulin resistance. They’re not very good at making and using ketones. They’re not keto-adapted. And with high insulin levels, you don’t make ketones anyway. So you really have a brain that’s starving. So Julie’s put together a wonderful PowerPoint. She’s been through so many of these things with her ApoE4.Info group and with her own wonderful journey as well. And so we thought, Julie, if you’d like to share your screen, let’s go through some of the slides that you’ve put together. So I think it’s helpful for everyone to understand best ways to get into ketosis.

Julie Gregory: Absolutely. And I’m so glad that we’re talking about this. You and I throw around a lot of these terms that some of our viewers may be struggling to understand, and a lot of people are visual learners so I thought a PowerPoint might be helpful.

Dr. Bredesen: Yeah.

Julie Gregory: And Dale, you did a masterful job of explaining number one at our last Facebook live, but we need ketosis because there’s a neural fuel deficiency that precedes and accompanies, Alzheimer’s disease. And as you explain, this is something you can actually see on imaging. It’s exacerbated when people have insulin resistance. And so while there’s plenty of glucose on board, the brain is struggling to effectively use it. And for ApoE4 carriers, this can actually happen decades before the first symptom shows up.

Dr. Bredesen: Exactly.

Julie Gregory: The great news is that Dr. Stephen Cunnane, a Canadian researcher has found that the brain can effectively use ketones as fuel when it’s struggling to use glucose.

And you and I both know that achieving ketosis is a first step towards refueling the brain. And if you do it naturally by combining our diet with a long daily fast, and exercise, you’re also healing the glucose metabolism and you’re restoring metabolic flexibility. And as you said, that’s the ability to use both glucose and ketones as fuel. And I have this great slide that the folks at Apollo Health put together to help folks understand. I also love the analogy that you used last, I guess it was two weeks ago.

Dr. Bredesen: Yeah.

Julie Gregory: About the hybrid engine. But this is another way of explaining the same concept. Lots of people struggle to understand metabolic flexibility. So in the center of the screen, you’re going to see this warehouse, and this represents the brain. And you can see there’s two sources of fuel coming in. We have the glucose truck on the left and there’s plenty of glucose in this brain warehouse. And there’s plenty of ketones on the right-hand side. So this represents someone who’s metabolically flexible. As you just described Dale, they seamlessly go from burning one fuel source to another. When there’s glucose available, they burn glucose. And when they run out of glucose, they begin burning ketones. Metabolically, healthy people, for instance, burn ketones when they’re sleeping. So what we’re proposing isn’t unnatural or artificial or dangerous. This is how the human body and brain were designed to work.

Dr. Bredesen: Yeah. This is physiological and everything we’re talking about is to get people back to an optimal physiological state. And that’s what’s going to give you best cognition.

Julie Gregory: Absolutely. And this slide really depicts the way that insulin resistance wreaks havoc beautifully. You’ll see that the brain is beginning to shut down right in the middle of the screen, the door is shutting on the warehouse because it doesn’t have enough fuel. And if you look on the right-hand side of the warehouse, there is no ketones on board. And that’s because the ketone truck has broken down. The ketone truck has broken down because if you don’t regularly get into ketosis, if you don’t mobilize those fat stores, your body loses the ability to get into ketosis. And that backup fuel supply is no longer available for the brain. And if you look at-

Dr. Bredesen: I should’ve mentioned one other third piece, sorry to interrupt you, Julie. So there is a third piece here, which is that as you know, so many people, when they’re using a high carved diet, not only do they have the insulin resistance, but then they go to sleep, and they drive themselves into hypoglycemia. So now they don’t have enough glucose. So now you’re not using the glucose you have, you’re not able to make ketones. And you have periods of hypoglycemia that damage your brain. So you’ve kind of got the worst of all three worlds.

Julie Gregory: Yes. And I actually live through this experience. I would regularly get hypoglycemia at night. If you look at the left-hand side of the screen, you’ll see why we have no ketones in the warehouse. We have a few little cubes of glucose here, but the glucose truck is overwhelmingly full. It’s actually dropping its load. But because there’s insulin resistance, the fuel cannot effectively get to the brain. So as you beautifully described at the beginning, the brain is starving from both of sources of fuel. Let’s go to the next slide. And this is a great point to have people take stock of their own metabolic health.

We always talk about insulin resistance, but I want folks to evaluate their own health and see if this is something that could be affecting them. And one thing I forgot to put on this list is if you have difficulty fasting, that’s a good indicator that you are likely insulin resistant. The other ones are things we talk about all the time. If you have belly fat, if your blood pressure begins creeping up. If your fasting morning glucose is over 90 milligrams per deciliter, if your fasting insulin is over 4.5. If your hemoglobin A1C is over 5.3 and your HOMA-IR is over 1.2. And to calculate that, you just multiply the fasting insulin by fasting glucose and divide it by 405.

Julie Gregory: And this is our hallelujah slide. So how do we restore fuel to the brain? We do it with the KetoFLEX 12/3 lifestyle. And yes, KetoFLEX 12/3 is a diet, but it’s more than a diet because we not only suggest what you should be eating, but we also suggest when you should be doing that. We want everyone to have a long daily, fast, a minimum of 12 hours with at least three hours before bed. And we want everyone to engage in daily exercise. And when you put these three strategies together, you create endogenous ketosis. The prefix of endogenous is “endo” which means coming from inside.

This is a natural way of creating ketosis that humans have been doing for a millennium. And you’ll notice this triangle is on a foundation of quality restorative sleep, because as we all know, if you don’t have a good night sleep, if you don’t have seven to eight hours of quality sleep, it’s almost impossible to stick to a healthy diet and to do this long daily, fast and to exercise. So if you remember nothing else from this whole slide deck, just remember this one slide, because if you combine these three strategies every day, you will heal your metabolism and restore metabolic flexibility.

Dr. Bredesen: Yeah.

Julie Gregory: And I love this. Oh. I’m sorry. Did you want to say something, Dale?

Dr. Bredesen: Yeah. I was just going to say that … So as we’ve talked about many times, because you have this energy and sufficiency with cognitive decline, we recommend people just get some ketones at the beginning. It’s fine. Julie just talked about endogenous ketosis, where you’re making your own ketones, but for many people just starting with some exogenous ketosis, starting with some ketone salts or esters, or starting with some MCT oil or starting with some coconut oil, just for the first month or two, while you’re fixing these things, at least that brings that energy back, that you have been lacking for your brain.

Julie Gregory: I love that idea. And I also love this graphic. So you can see we’ve got the KetoFLEX 12/3 lifestyle tow truck that’s come to the rescue here. And it’s helping the ketone truck deliver ketones effectively to the brain warehouse. So the ketones are stacking up once again. The amazing thing is that once you endogenously create this state of ketosis, you also heal this glucose pathway. So the brain warehouse is now filling up with both sources of fuel. And that’s why we really strongly push endogenous ketosis. Even if you temporarily or transitionally have to use exogenous ketones, we want you at the same time to be using the diet, a long daily, fast, and exercise to endogenously create ketones.

And here in this last slide of this little series, you can see that metabolic flexibility has been restored. The glucose truck is effectively delivering glucose and the ketone truck is effectively delivering ketones. And we should say, this is a process that you do not do overnight. This is something that will take weeks, if not months. It’s probably something that took me over a year to figure out how to do. And that’s okay because the protocol is definitely a marathon and not a sprint. And it actually is more effective if people move slowly and do things in a deliberate stepwise fashion, carefully, following all of our cautions.

Dr. Bredesen: Yeah. And I should say for so many people, it’s the improvement that’s helpful. We have people who’ve had their numbers way out of kilter with fasting insulins of 32 and things like that. They don’t necessarily have to get to perfect. If they can just improve things, they start to see an improvement. And then of course that supports continued improvement and getting things to be optimized where you can now keep your cognition for many years to come.

Julie Gregory: Right. And what I love about our program that sets it apart from other programs is that you can track your progress. So we know achieving ketosis is the first step, but we want folks to know if they’re in ketosis and there’s two different ways that you can do this. You can track either blood, beta- hydroxybutyrate (BHB) with little finger sticks, or you can track breath acetone. If you decide to go the blood route, which is what I do. I don’t find the little finger sticks painful at all; it’s pretty quick and immediate. We recommend the Precision Extradural glucose/ketone meter. Your goal is to reach somewhere between 1 to 4 mM at some point in the day. And we fully understand that individual needs are going to vary. So if you have a more severe level of cognitive impairment, you may find that you need higher levels of ketosis, more consistently throughout the day. So experiment to see what works for you.

And if you want to use breath acetone, that’s fine. Some people are averse to the finger sticks. We recommend the BIOSENSE breath device which measures acetone that they use in units called ACEs. Just so that you understand the equivalency is to get somewhere between seven and 12 ACEs, which is roughly equivalent to 1 mM of BHB. And we want folks to test three to five times a day. and we want them to get an end-of-the-day score somewhere between 150 and 400 ACEs. And this is end-of0the day score not straight addition, you’re not adding seven plus seven plus seven equals 150. It doesn’t work that way. Some of our participants have been confused by that. Your end-of-the-day score is actually on the BIOSENSE app and you’re shooting for somewhere between 150 and 400 ACEs. And folks that are very well keto-adapted will be blowing twenties and thirties. And that’s absolutely okay. And, let me go to the next slide. Oh. Okay. So this is great. If we have time, Dale, I’d like to talk about some special considerations.

Dr. Bredesen: Sure. I think there’s so many people that ask about, what if I’m this, what if I do the fasting? So let’s go through those.

Julie Gregory: Okay. So, we talk about the KetoFLEX 12/3 lifestyle essentially works for everyone — that’s combining the diet with the long daily, fast and the exercise. But some people have to tweak that just a little bit and let’s start with what if I’m insulin resistant? Well, the great news is, we created this program for you. It works beautifully, but we recognize that you may have difficulty fasting. And for that reason, we want you to increase your fast, slowly to avoid hypoglycemia. So you can’t go from fasting eight hours a day to suddenly fasting 12. This is something where we recommend you extend the fast by maybe five minutes a day.

If you feel like you are getting symptoms of hypoglycemia, go ahead and check your blood glucose. If it’s below 70 and you’re having symptoms, stop the fast and go ahead and eat a KetoFLEX 12/3 snack or meal. Something else you should consider is continuous glucose monitoring (CGM)so you can identify the foods that are causing the glucose spikes and you can minimize them. And lastly, if you’re insulin resistant and you just mentioned this, Dale, definitely consider the transitional use of a ketone supplement while you’re working to create endogenous ketosis. This is a crisis. Your brain is starving for fuel. So please consider either coconut oil, MCT oil, ketone salts or esters.

Dr. Bredesen: Julie, maybe it’s important to mention, somewhere between 80 and a hundred million Americans are insulin resistance. So it’s an incredibly common issue and it definitely increases the risk for cognitive decline. So common and also a major risk factor. So very important to address that.

Julie Gregory: Right. I think statistics are one in three Americans are insulin resistant. And when I was insulin resistant, my BMI was only 22, which many people would say is healthy, but I have every single one of those symptoms. And my physicians never told me I was insulin resistant. They certainly never gave me these instructions.

The next thing, can you do this if you have diabetes and absolutely yes, our approach will actually help you heal type two diabetes. But it’s very important that you consult with your physician before adopting the program because your need for medication will be reduced as you heal your metabolism, and your physician will provide instructions on how to reduce your medication to avoid transitional hypoglycemia.

Julie Gregory: And what if I develop GI issues? And this is so incredibly common, especially if you consider people are transitioning from the standard American diet where the majority of the food you’re eating is pre-digested, it’s refined and heavily processed. And suddenly you’re moving to a whole foods diet where you not only have a dramatic increase in fiber and the anti-nutrients that come with vegetables, but also an increase in fats. And this can cause issues for some people. So we even devoted a level to the brain food pyramid on optimizing your gut health. One simple thing that everybody can do, that our ancestors have been doing for millennia, is simply increase your intake of bitter vegetables, things like arugula, kale, radicchio and rapini will help with digestion. If I’m struggling with GI issues, sometimes I take my supplements and I feel like they’re sitting here and they’re not moving. I start to get a little bit of acid reflux. I chew a lemon peel and the bitterness just soothes my GI tract almost immediately.

We also want folks to consider digestive enzymes. There’s many different kinds. If fat’s an issue, use enzymes with lipase or ox file, if carbs are  a problem, try an enzyme with amylase. And many, many people need more acid in their stomachs as they age. Acid production drops off. So you can use a tablespoon full of apple cider vinegar before you eat, or the supplement betaine. And I think, yeah. You actually use this, Dale. And that helps with protein digestion, especially.

Dr. Bredesen: Yeah. I find it very helpful if I’m going to have a heavy protein meal, I’m going to have a lot of salmon or a lot of chicken or beef or something like that. Then I find it definitely helpful. And some people also find that if they have a high fat meal, that you can have problems with that unless they have the digestive enzymes. So definitely an easy thing to do and can be very helpful.

Julie Gregory: Very, very simple. Now, if you experience pain in your upper abdomen, when you increase amounts of dietary fat, you may need to have gallbladder function evaluated and preferably work to have the gallbladder optimized with a functional medicine practitioner. Mainstream physicians will just want to remove the gallbladder entirely. We do have many participants, myself included, that don’t have a gallbladder and I do just fine with dietary fat. I don’t need digestive enzymes to help me deal with that.

This is another great one. What if I’m an ApoE4 carrier? Here we are recommending a ketogenic approach, which is tricky for ApoE4 carriers because we tend to hyper-absorb dietary fat, which can’t lead to elevated cholesterol. So we found that saturated fat exacerbates this effect and that if ApoE4 carriers will just focus on reducing saturated fats and increasing mono and polyunsaturated fats. We’re talking about high polyphenol extra virgin olive oil and avocados, nut seeds, fatty fish, the heart healthy fats, we tend to do it very well.

Julie Gregory: And the next one, what if I’m overweight? This is a great question, and many people can use our approach very effectively. It can help you lose weight, and it can also heal your metabolism. Not everyone who’s overweight is insulin resistant, but many, many are. Once these folks who are overweight get into ketosis, they may find they need to eat less dietary fat if they’re able to tap into burning their own body fat. So experiment to see how that’s working for you.

Julie Gregory: And we also encourage everyone, but especially those that are overweight to use Cronometer. It’s a free online food journal where you can track their daily food intake. Lots of times when people increase their dietary fat, they’re not cutting carbs as much as they think they are. So if you track with Cronometer, you can see that maybe, hey, the carb intake is still a little high, and that’s why I’m putting on a few pounds. You can manipulate those macronutrient ratios to achieve ketosis, but Cronometer also has a feature that you can find under profiles. You can set a target for your desired rate of weight loss, and it can help you lose weight. So we recommend folks lose no more than one to two pounds per week. Slow and steady is our motto.

Dr. Bredesen: And I found the Cronometer very helpful for things saying, okay, you’re not getting enough omega-3s or you’re not getting a good omega three or omega six ratio. You’re not getting enough choline, you’re not getting enough vitamin D, things like that, or you’re not getting enough magnesium or zinc or iodine. So all these things are tracked by the chronometer. Very helpful.

Julie Gregory: Right. And it’s really helpful too if people are struggling to get into ketosis, they can see how much fat they’re eating and how many carbohydrates that they’re eating.

We have many, many folks that come to the program that are already too thin. And we have some people who adopt the program and begin to lose weight. And this is a problem because being too thin is an independent risk factor for cognitive decline. It puts you at risk for a sarcopenia, the loss of muscle mass. So these are the strategies that folks that are struggling with excessive weight loss can use: increase dietary fat. Many, many people give up the “no” foods, the inflammatory foods, the sugar and the starchy carbs, but they’re hesitant to increase dietary fat. So that’s number one the most important strategy. If you’re insulin sensitive, go ahead and increase your resistant starches as well.

And these are legumes and tubers, eaten in small amounts. And you can check to see the effect on your blood glucose by testing it one in two hours after you’ve eaten a resistant starch. This is also a subset of folks that needs to increase their protein. We want them to go as high as 1.1 to 1.2 milligrams per kilogram of lean body mass, but don’t base that on your current weight, base that on your ideal weight. This group also needs to add strength training because their at risk of sarcopenia. If there’s not enough protein on board, the body will begin cannibalizing itself. We want them to do a strength training program three to four times a week to build those muscles. This group can use the regular KetoFLEX 12/3 lifestyle that we recommend for everyone, but they may need to reduce their fasting period. Still try to fast three hours before bed, but if you wake up hungry in the morning for breakfast, by all means, eat three meals a day until you get to your ideal weight.

Dr. Bredesen: And people can also cycle off once or twice a week. That is also helpful for some people who are very thin.

Julie Gregory: Yeah. Oh. Cycle off of what?

Dr. Bredesen (24:29): Get into less ketosis. In other words, a slight increase in the carb use for a day a week, that sort of thing, so that they get out of that… We’ve had people who are too thin who will actually have some decline when they’re trying to fast too much. And we’ve talked about this a number of times, you have to be careful about, as you say, be careful about the fasting period.

Julie Gregory: Absolutely. And that’s why we want these folks to increase their resistant starches if they’re insulin sensitive. And I love the idea of doing that once or twice a week as well. Consider the transitional use of ketone supplements. I mean, if you’re not able to get enough dietary fat on board, use ketone supplements while trying to get to endogenous ketosis. Also it’s very helpful for this group of folks to adapt a mindfulness or meditation practice. Sometimes they tend to be our people that are affected by stress, and it’s very difficult to eat when you’re feeling stressed. So maybe before eating, just do some deep breathing, adopt a mindfulness practice so that you can relax and really enjoy your food.

It’s important to mention that folks can be too thin and still be insulin resistant. So these are folks that have a high amount of visceral fat, which is intra-abdominal fat, that’s stored around in between the organs. So these folks will follow the KetoFLEX 12/3 lifestyle shortening the fast as we just spoke about, and they can follow the strategies we just spoke about for gaining weight, excluding resistant starches because they’re insulin resistant. This is another subset that can benefit from continuous glucose monitoring so they can identify and minimize problem foods. And once again, transitional use of ketone supplements is really helpful for this group.

And this is a biggie, and you and I get asked about this all the time. What if I have vascular disease? Number one, it’s super important to work with a low carb cardiologist. Our approach will heal vascular disease, but we want you to work with a cardiologist who believes in this approach who will help you use our dietary approach. It’s also very important for these folks to avoid the inflammatory foods — all sugars, all starchy carbs, all grains and conventional dairy before they begin increasing healthy fat. That combination of inflammatory foods and high fat can lead to vascular disease.

Julie Gregory: So, they have to be very careful about this. You can’t cheat and have chocolate chip cookies and have four or five tablespoons of extra virgin olive oil. This is another group that could also benefit from continuous glucose monitoring. When they’re ready to increase healthy fats, it’s a good idea to use a poly and monounsaturated fats, very much like the ApoE4 carriers. And this is another group that can transitionally benefit from using ketone supplements and ketone salts and esters can be really helpful for them. And they won’t increase cholesterol obviously. And Dale, I think you actually use a ketone salts, is it? Or are you using esters?

Dr. Bredesen: I’ve tried KE1, which is a combination of ketone salts and esters, just to see what that does to my ketone level. And so some people like that as you indicated, we heard first from Dr. Mary Newport about the idea of coconut oil, which is fine, but then for anyone who’s got some vascular disease, you probably want to stay away from those saturated fats and think more about the ketone salts or ketone esters, each of which has its own advantages. And which is why I kind of like the combination of the two.

Julie Gregory: Yeah. Well, nice. And this is a final slide for special considerations. We have folks that are too thin, and they have vascular disease. So once again, find a cardiologist that uses a low carb approach, avoid those inflammatory foods before increasing healthy fat, get evaluated for insulin resistance. Almost everyone with vascular disease has some degree of insulin resistance. Consider the continuous glucose monitoring so you can identify and minimize those problem foods. And when you’re ready to start adding the healthy fats, use poly and monounsaturated fats and this group, because they’re too thin, once again, needs to shorten the fast, increase the protein, add the strength training, and adopt a mindfulness practice. And once again, because of the vascular diseases, this is a group that would do really well to consider ketone salts or esters. And I just have one final slide and I love this one. This kind of describes how we got into this problem in the first place.

Dr. Bredesen: Yeah.

Julie Gregory: And as we know, humans evolved from primates and you see this beautiful, healthy human, I think he’s the fifth one holding the spear. And that’s how people were when they were metabolically flexible when they were hunter gatherers. Whereas in our westernized society, when people began eating too often, when they began eating three meals a day with snacks in between, eating food that’s highly refined and highly processed, especially high in sugars and carbohydrates, they became insulin resistant. It happened to me. This final person has reclaimed their metabolic flexibility and is once again healthy. This is something that I’ve lived through and I know many of our participants have lived through, and it’s so exciting once people finally get into ketosis and they’ve restored their metabolic flexibility, they just feel amazing.

Dr. Bredesen: Absolutely. And I think you’ve talked about ancestral health many times and how critical that is and how to some extent, and I think Dr. Robert Lustig talks about this beautifully in his book, “Metabolical,” that so many of us have really changed the way that we’re interacting with our food and with our genetics. And the reality is that we were not evolved. Our genetics do not set us up to live the way we are currently living because of the processed food, because of the high carb diets, because of the exposure to so many toxins, so many pathogens, leaky guts, all these sorts of things. So we really have to-

Julie Gregory: And artificial lights. Yeah. Staying up all night. It’s just this whole lifestyle that we’ve created for ourselves. We’re victims of our own success. And that last graphic beautifully illustrated that.

Dr. Bredesen: Yeah. And the good news, I mean, the graphic really shows how you can indeed reclaim your health and this idea of how to identify what’s causing the problem. We got to remove that. We got to make people resilient, we got to optimize things. And then we have to rebuild. And it’s that triad that has gotten best results, time and time again with people. So thank you for putting that together. Thank you for the discussion. Fantastic, Julie.

We’ve got a couple of good questions here. Let’s go over these. I know the hour is getting late here, but let’s talk about a couple of these. So Maria says, love that really needed a boost from exogenous ketones after having major surgery. Thank you for the validation. Absolutely. And we’ve talked a number of times about how critical it is. If you’re going to have anesthesia, get ready ahead of time, get yourself so that you’re in good detox status, make sure your glutathione is doing well, get ready.

Dr. Bredesen: And then of course, afterwards, you want to help to wash this out because unfortunately when you have surgery, not only do you have tops and exposure from the anesthesia, but you often will have some period of hypotension, which is also damaging. You’ll often have some period of hypoxia as well. So it’s kind of a triple whammy when you have this anesthesia, which is why you want to minimize that. And yes, having the exogenous ketones gives you that additional energy. So that’s fantastic. Valerie says, “looks like I need a chronometer in my life as I’m obese still, but recent injuries means I can’t exercise fully.” So Julie, what do you recommend to people who are dealing with some weight issues, but are not able yet to exercise fully?

Julie Gregory: So, one thing that Valerie can do is she can still work to extend her fast. She can still adopt the diet and there is so many forms of exercise you can do, even if you can’t do traditional exercise, the long daily walk and things like that. A friend of mine had some major heart surgery and just to be her buddy and to support her, I did a seated chair workout at her local senior citizen center. Oh my gosh. It was an amazing workout. You think, oh, this is going to be simple. I was really sweating. Another thing Valerie might consider is Pilates. So much of that is done on a mat. So you’re working on your core. So if you have issues with knees or hips or ankles, you can still do so much of the core work, which really gets a heart rate up. It also strengthens muscles. So work around those limitations. There’s almost always some form of exercise that you can do.

Dr. Bredesen: Absolutely. And of course, as Dr. Joel Fuhrman has pointed out, you can lose weight and be very healthy without adding a lot of exercise. We always think about why you got to exercise a lot. Yes. That’s a great thing. Very helpful for a number of reasons, as we’ve talked about insulin resistance and blood flow and all that, but it’s not necessary just to optimize your weight. And as Dr. Lustig has pointed out, the weight is really a side effect of what’s actually metabolically wrong. So the weight is not the problem. It’s the metabolic change that’s really the problem. There are people, as you indicated, a minority about 20% of people who do have extra weight but are doing it the right way and actually are metabolically healthy.

Julie Gregory: Yeah.

Dr. Bredesen: And they typically have some subcutaneous fat, but they don’t have that visceral fat. They don’t have the metabolic abnormalities, the insulin resistance, the inflammatory fat, they don’t have the liver disease and things like that, that we think of when you are putting it in the wrong places. Let’s see. And then Maria says, let’s see, Maria says, I have sporadic fatal insomnia. Okay. And she says, she’s weak. So again, getting the right diet, fixing your metabolism is huge. So let’s end there and we’ll take additional questions online. And Julie, thanks again for your tremendous experience for putting this together. And this is really telling us in a systems biology way, what it takes to make optimal cognition. And if we’re all doing the right things, we really can reduce the global burden of dementia. So thanks very much, Julie. We’ll see everyone next time. And meanwhile, happy holidays to everybody.

Julie Gregory: Same to you. Bye-bye

Dr. Bredesen: Bye-bye.