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The Key to Supporting Long-Term Brain Health · Meaningful Medicine with Novant Health

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Melanie Cole, MS (Host): Welcome to Meaningful Medicine, a Novant
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Health podcast, bringing you access to leading doctors who answer
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questions they wish you would ask.
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From routine care to rare conditions, our physicians offer tips to navigate medical
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decisions and build a healthier future.
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I'm Melanie Cole.
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And today, speaking of navigation, we are talking about brain health.
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And joining me is Carolina McCalmon.
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She's a physician assistant with Novant Health Preventive Neurology in Wilmington.
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Carolina, thank you so much for being with us today.
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What is preventive neurology, and how does it differ from the way people
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traditionally think about neurologic care?
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Carolina McCalmon: So, preventive neurology is preventing
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the need for a neurologist.
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So traditionally, when patients come to me, I am a stroke and dementia clinic.
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So as I often say, I'm bad news.
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By the time I meet the patient, the train has left the station and it is
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rolling and we are doing everything that we can to slow that train down.
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And after doing that long enough, we started to realize that we would
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like to start meeting patients before that stroke, and ideally before the
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symptoms of cognitive impairment.
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And so in 2024, the Lancet Commission gave us an extraordinary number.
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They showed us that we can prevent almost half of the cases of dementia if
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we work on 14 modifiable risk factors.
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And even though it wasn't exactly a call to action specifically to neurology
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and those 14 modifiable risk factors are traditionally thought of as sleep
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for pulmonology or cholesterol for cardiology, we saw that as really a call
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to action to put neurology at the helm and really make it our responsibility
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to make sure that patients are educated and that they are risk stratified and
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where they're willing to work with us, that they are empowered to do everything
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that they can and that we're giving them all the options that we can to prevent
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their risk of developing dementia.
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Melanie Cole, MS: That's very cool.
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And I'm going to ask you to talk about those 14.
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But in the meantime, why is it so important for people to think
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proactively about their brain health?
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We used to hear maybe, you know, balance your checkbook, which, you
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know, not many kids do anymore.
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Carolina McCalmon: So glad you brought that up.
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Melanie Cole, MS: Yeah.
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Because I mean, it's just one of the things that we think of to do.
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But if someone's not experiencing any neurologic issues, why are we
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really concentrating on those things?
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Carolina McCalmon: Well, you cut exactly to the chase, and the answer
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is because we can do something, and for the exact same reason that we
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want people to think about their brain health like they do about finances.
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So, I had a patient the other day, and he was seeing me for prevention.
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I told him what I tell all of my patients, which is, "I'm a
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conduit for you to have all of the information and be given the options.
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And at the end of the day, your body, your choice.
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But also, do you have a savings account?"
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And he said, "Yes."
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And I said, "When did you open it?"
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And he said, "In my 20s."
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And I said, "Why?"
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And it's to explain that the earlier we start, the more modest these
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changes can accumulate over time.
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And we know now that Alzheimer's, specifically Alzheimer's, we know starts
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20 years in advance before symptoms.
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So, our motto is treatment before symptoms.
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So, for every 65-year-old that's being diagnosed with Alzheimer's,
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that disease process started in their late 30s and their 40s.
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So, we want to meet people when there's more bang for our buck, when
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there's more that we can do about it.
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And if we wait for symptoms, which we traditionally do, there's definitely
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still things we can do, and we still want to see you, but we want to meet
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people on all ends of that spectrum.
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Melanie Cole, MS: Wow.
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You know, that really is such a good point that you make, that it really
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does start earlier than we realize.
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Now, when we think about who could benefit from preventive neurology, you
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mentioned genetics, a predisposition.
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Are there certain health conditions?
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And here's where I want you to talk about the risk factors, life experiences,
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whether somebody maybe was a boxer or a football player, any of these kinds of
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things that might affect brain health.
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Give us some of those Lancet risk factors that we're talking
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about, modifiable, non-modifiable.
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Hit us with them.
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Carolina McCalmon: Yeah.
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So, it is your traditional one.
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So, you have your overall risk factors, which are of everything that protects
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the heart is related to brain health.
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Because what I remind everyone every day is that when people traditionally
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think about blood vessel health, they're thinking about the heart.
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But the heart has, you know, six major vessels that we're concerned
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about and that we intervene on.
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The brain has 400 miles of vessels, and those vessels are thinner than a hair.
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And they are so sensitive to all of the things that we worry about
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when it comes to heart attacks.
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So cholesterol, diabetes, inflammation, high blood pressure.
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We intervene in pre-diabetes.
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We don't go for the most basic of guidelines.
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We're looking for genetic predispositions.
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And then, if the patient wants to, we always offer the option to look
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for the genetic predisposition for Alzheimer's, which is the apoE4 gene.
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That's not a modifiable risk factor, but it can guide our recommendations
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for modifiable risk factors because that is a cholesterol vehicle gene.
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And so, you can actually get more benefit from different cholesterol
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medications if you carry that gene.
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So, the high blood pressure, sugar, and cholesterol, those are the three huge ones
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that we really focus on as far as what can we do from our standpoint, because
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a lot of people cannot diet and then lifestyle their way out of their genetics.
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But with modern medicine, we can make a huge dent in the accrual
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of atherosclerosis, which is the hardening of the arteries, which is
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what leads to a vulnerability of that blood-brain barrier that's protecting
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the organ that makes you who you are.
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All the other modifiable risk factors are no secret, and they are our magic pill.
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So, exercise, absolutely our magic pill.
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And we love brisk walks.
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We're all for brisk walks, but we really want moderate intensity exercise
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because that's what releases the hormone that creates neurogenesis.
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It's a hormone that helps you to actually increase your brain volume.
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So, exercise is really our magic pill.
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Sleep, having good sleep hygiene, seven and a half to nine hours.
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And if you have sleep apnea, being compliant with a CPAP.
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If you have a family history of sleep apnea and your dad, for example, is
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not a traditionally obese COPD patient and snores like a train, that doesn't
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mean that he didn't need a CPAP.
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And so, we have patients who we see their children because they have risks.
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And when they're in their 40s, we're like, "Based on we know your father and he's
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our patient, and we think at 50 that you should consider getting a sleep study."
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So, it's very as precision medicine as we can do it on scale, you know, and as
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much or as little as the patient wants, as conservative or aggressive as the patient
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wants, and just meeting them where they are in that journey, in that age group,
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and then based on their risk factors.
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Melanie Cole, MS: Wow.
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I mean, really when we think of those everyday habits, those lifestyles, and
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you mentioned sleep and, of course, exercise, one of my favorite things,
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and then there's also nutrition.
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So, people don't often, you know, associate diet with—I mean, we've learned
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so much more in the last 20 years, right?
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And doctors didn't used to get very much nutrition.
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But now in medical school, we see this connection, this interaction.
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Tell us how you work with patients as far as nutrition.
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Where does that come into play?
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Carolina McCalmon: Yeah, it's the crux of everything.
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And I would argue that we haven't learned so much more in the last few
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years, we have accepted so much more.
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Because I remind patients, your biochemistry is your biochemistry.
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A lot of what we do when it comes to brain health has to do with evolution.
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So, your genetics can determine whether you respond better
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to red meat, for example.
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What we know are the easy things, the low-hanging fruit.
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Nobody responds well to hyperprocessed or ultraprocessed foods, right?
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And we know that the brain loves ketones.
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So, things that have to do with intermittent fasting, I tell my
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patients we want everything low except for water, protein, and sleep.
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So, blood pressure, cholesterol, sugar, as low as we can get
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it without having symptoms.
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But protein, your water, we want those things to be catered to the
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body mass that you want because those nutrients are the gasoline that are
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fighting inflammation, they're feeding your muscles, and they're helping
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your body to take out those toxins.
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All you need to do is give your body all the amino acids, the
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essential amino acids that it needs.
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And we've known those since the beginning of chemistry.
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And as long as you're getting that diversity of natural foods
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in your diet, then you're doing everything that your body needs.
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So in that way, kind of where you come from, we go overall with
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a MIND or Mediterranean diet.
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But there was a recent study that showed that they did a Latin American version
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of the Mediterranean diet in the Latin American community, provided GLP-1s, and
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they had similar outcomes for preventing dementia or slowing decline as they
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did when they studied it in Americans using the MIND or Mediterranean diet.
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So, diet is across the board.
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Again, just going back to the basics of everything that we've always
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kind of known is probably right.
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You know, living off the land.
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My centenarian patients, I always ask them, like, I'll spend extra time
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just to ask them, "What did you eat?
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What was it like growing up?"
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And all of them lived off the land, and they all stopped eating at 5:00
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because there wasn't any electricity really to eat after that, and it was
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dark, and they had to get up at 5:00 AM.
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So, a lot of it is just going back to the things that have gotten
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our bodies to this point because that's what protects the brain.
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Melanie Cole, MS: Really, that is so true.
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And the basics and whole foods, shopping the perimeter of the
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store as opposed, as you say, those processed foods in the middle aisles.
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You know, if stuff has a lot of ingredients on the box, then probably
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it's not going to be healthy.
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Carolina McCalmon: Yeah.
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If it can tell you that it's healthy, it's probably not healthy.
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Melanie Cole, MS: That's right.
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That's right.
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Well, you know, it's so true.
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Now, when someone comes to your preventive neurology clinic,
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what can they expect, Carolina?
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What is it like?
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How do you develop this personalized plan?
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Because, boy, you're giving us so much great information.
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You are so smart, and I imagine your patients absolutely love you.
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Tell us what it's like to be there.
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Carolina McCalmon: It's different for everyone.
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And it's a little bit of what brought you here and a quick gauge really
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of exactly what they want out of it.
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We can start with an overall umbrella.
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Our big thing is that we want patients who are motivated.
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And if you come to me and you're motivated, we want to
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be your mammogram of the brain.
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It's not a long history.
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I love neurology because I have endless curiosity, but I'm also a little nosy.
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So, neurology usually is 90% history.
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So, we usually take a lot of time getting to know the patient and asking questions.
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Preventative neurology is a little more objective.
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Instead of investigation, it's a little more hunting.
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So, everybody gets more or less a similar workup, and that can depend
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on, you know, what we have access to and how much we're interested in.
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If a patient comes to me and they're like, "I don't care what you say.
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I don't care what my numbers are.
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I will absolutely never take a medication," then obviously I'm not
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going to order any labs that would change recommendations for a medication.
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But for the most part, it's pretty objective, a general screening, going
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through the risk factors, figuring out what I can do for the heavy lifting
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to contribute to their brain span, and then educating them on what they can do.
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What can we tweak?
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There's always something that we can all do a little bit better.
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And so, we basically sift through what levers they could pull, and then the ones
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that they're the most comfortable pulling, how hard, and kind of timing, you know, if
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depending on their age, at what age they should get an audiology test, for example,
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because poor hearing is tied to dementia.
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If they're less than 50, talking about getting a DEXA scan to look for
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osteoporosis for my women, especially if they went through early perimenopause.
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So, it's generally applicable.
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We definitely try to tailor it and make it precision medicine for the patient.
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So, we just at least want people, even if they don't come to us, to be thinking
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about how all of these systems and your body mass index and your muscles and
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the obesity, how it's not aesthetic.
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It's about being here and being happy and being functional while you're here.
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Melanie Cole, MS: Wow, what a comprehensive approach, and it sounds
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to me like more than neurologic care, even though that's where the focus
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is, but it's really whole body care,
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Carolina McCalmon: Yeah,
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Melanie Cole, MS: and wellness for the whole person, because all of those things,
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I mean, it's all tied together, right?
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Carolina McCalmon: Yes.
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Melanie Cole, MS: I mean, that's really the most important message here.
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Now, Carolina, when we think of Alzheimer's, stroke, dementia,
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people get really freaked out.
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It's pretty nerve-wracking to even think about those things.
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When you talk to people every single day about those modifiable risk factors, about
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things that they can control rather than waiting until this happens, what do you
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want people to understand about looking at each of these portions, these parts that
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all come together for the whole and can contribute to those diseases of the brain?
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Carolina McCalmon: So many things.
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I want people to remember that we do want to zoom out.
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So, I've spent a lot of hours of my life trying to help patients cope through the
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post-traumatic experience of a stroke.
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Because by definition, it's a trauma, and there's no warning, and their life is
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never the same as it was the one second before they experienced those symptoms.
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And part of it is educating people who have not experienced a stroke or are
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not willing to get into early lifestyle, diet, and pharmacologic care to prevent
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these things, that strokes don't often kill you, but they can make you suffer.
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Because a lot of patients will say, "When it's my time, it's my time."
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And we have to remind them that there's so much we can do.
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It doesn't have to be that way.
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We have great medication, and we can be a team.
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We can, you know, pull all the levers that we can to make sure that hopefully
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you don't have to get to that stage.
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All we can do is look at the data that we have and make sure that our patients
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know that there are so many things that we can do, and we never want to look
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back and say that we didn't at least try.
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So, we want to make sure that we're providing access and information to
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all of those things, the less that we see our patients coming back to the
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ER and the more we see those numbers hopefully in our area staying lower
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compared to the national average, then we'll know that we're doing something.
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Melanie Cole, MS: Wow.
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Yeah, it really is a multidisciplinary approach as well.
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Because when you're thinking of exercise and nutrition, I mean,
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there's all kinds of specialists.
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So, it's such a great way to bring it all together.
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And as we get ready to wrap up, I want to ask you, Carolina, how neurology
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became such a passion of yours.
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What drew you to this specialty?
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And if you could give one message today from this awesome episode
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where you gave us so much to think about, see what I did there?
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What would that be?
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Carolina McCalmon: Yeah, I always joke that I never grew out of the
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three-year-old phase of asking why.
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And I think if you ask why enough, then you kind of always end up at
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the brain, and figuring out because neurologists are—I always joke—the
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most humble physicians because you're asking the brain to explain the brain.
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We never ask the liver to explain the liver.
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So if you want to be an indefinite student, then
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neurology is the choice for you.
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And as you can see, we're always evolving and trying to catch up, and
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it's something that I think people are starting to realize is the
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crux of what makes us who we are.
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And what I want people to know is there's a very easy acronym that
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we're all familiar with ABCDE.
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There's an ABCDE of brain health.
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And if you come to clinic, we can do the A through D.
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But the E is your emotional health, which is your mental health, your
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equity, and feeling empowered, and we don't have a prescription for that.
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When you come to us, you'll see a nutritionist.
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In the future, we will have a physical therapist who will give you a plan.
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We will have a quick MRI, and we will have more expansive multidisciplinary
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in-house measures for you.
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So, the one thing that I would want people to walk away with is
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a happy brain is a healthy brain.
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And so, that's definitely the one thing that you don't have to have
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an appointment for, but it's also the hardest thing to figure out.
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So, I want everyone to focus on mental health, because that's
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definitely the one angle that we could all use a little help on.
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Melanie Cole, MS: Wow, Carolina, you are lovely.
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And I can hear the passion in your voice and the compassion for what you do,
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but that passion for helping patients at your clinic, I can just hear it.
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And thank you so much for all the great work that you're
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doing and for joining us today.
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Carolina McCalmon: Oh, thank you so much.
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Yeah, thank you so much for having us, and thank you for the opportunity.
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Melanie Cole, MS: Really, you have some incredible expertise,
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so thank you so much again.
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And to find a physician, you can visit novanthealth.org.
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For more health and wellness information from our experts,
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visit healthyheadlines.org.
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That concludes this episode of Meaningful Medicine, a podcast from
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the specialists at Novant Health.