Melanie Cole, MS (Host): Welcome to Meaningful Medicine, a Novant Health podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. I'm Melanie Cole. And today, speaking of navigation, we are talking about brain health.

And joining me is Carolina McCalmon. She's a physician assistant with Novant Health Preventive Neurology in Wilmington. Carolina, thank you so much for being with us today. What is preventive neurology, and how does it differ from the way people traditionally think about neurologic care?

Carolina McCalmon: So, preventive neurology is preventing the need for a neurologist. So traditionally, when patients come to me, I am a stroke and dementia clinic. So as I often say, I'm bad news. By the time I meet the patient, the train has left the station and it is rolling and we are doing everything that we can to slow that train down.

And after doing that long enough, we started to realize that we would like to start meeting patients before that stroke, and ideally before the symptoms of cognitive impairment. And so in 2024, the Lancet Commission gave us an extraordinary number. They showed us that we can prevent almost half of the cases of dementia if we work on 14 modifiable risk factors. And even though it wasn't exactly a call to action specifically to neurology and those 14 modifiable risk factors are traditionally thought of as sleep for pulmonology or cholesterol for cardiology, we saw that as really a call to action to put neurology at the helm and really make it our responsibility to make sure that patients are educated and that they are risk stratified and where they're willing to work with us, that they are empowered to do everything that they can and that we're giving them all the options that we can to prevent their risk of developing dementia.

Melanie Cole, MS: That's very cool. And I'm going to ask you to talk about those 14. But in the meantime, why is it so important for people to think proactively about their brain health? We used to hear maybe, you know, balance your checkbook, which, you know, not many kids do anymore.

Carolina McCalmon: So glad you brought that up.

Melanie Cole, MS: Yeah. Because I mean, it's just one of the things that we think of to do. But if someone's not experiencing any neurologic issues, why are we really concentrating on those things?

Carolina McCalmon: Well, you cut exactly to the chase, and the answer is because we can do something, and for the exact same reason that we want people to think about their brain health like they do about finances. So, I had a patient the other day, and he was seeing me for prevention. I told him what I tell all of my patients, which is, "I'm a conduit for you to have all of the information and be given the options. And at the end of the day, your body, your choice. But also, do you have a savings account?" And he said, "Yes." And I said, "When did you open it?" And he said, "In my 20s." And I said, "Why?"

And it's to explain that the earlier we start, the more modest these changes can accumulate over time. And we know now that Alzheimer's, specifically Alzheimer's, we know starts 20 years in advance before symptoms. So, our motto is treatment before symptoms. So, for every 65-year-old that's being diagnosed with Alzheimer's, that disease process started in their late 30s and their 40s. So, we want to meet people when there's more bang for our buck, when there's more that we can do about it. And if we wait for symptoms, which we traditionally do, there's definitely still things we can do, and we still want to see you, but we want to meet people on all ends of that spectrum.

Melanie Cole, MS: Wow. You know, that really is such a good point that you make, that it really does start earlier than we realize. Now, when we think about who could benefit from preventive neurology, you mentioned genetics, a predisposition. Are there certain health conditions? And here's where I want you to talk about the risk factors, life experiences, whether somebody maybe was a boxer or a football player, any of these kinds of things that might affect brain health. Give us some of those Lancet risk factors that we're talking about, modifiable, non-modifiable. Hit us with them.

Carolina McCalmon: Yeah. So, it is your traditional one. So, you have your overall risk factors, which are of everything that protects the heart is related to brain health. Because what I remind everyone every day is that when people traditionally think about blood vessel health, they're thinking about the heart. But the heart has, you know, six major vessels that we're concerned about and that we intervene on.

The brain has 400 miles of vessels, and those vessels are thinner than a hair. And they are so sensitive to all of the things that we worry about when it comes to heart attacks. So cholesterol, diabetes, inflammation, high blood pressure. We intervene in pre-diabetes. We don't go for the most basic of guidelines. We're looking for genetic predispositions.

And then, if the patient wants to, we always offer the option to look for the genetic predisposition for Alzheimer's, which is the apoE4 gene. That's not a modifiable risk factor, but it can guide our recommendations for modifiable risk factors because that is a cholesterol vehicle gene. And so, you can actually get more benefit from different cholesterol medications if you carry that gene.

So, the high blood pressure, sugar, and cholesterol, those are the three huge ones that we really focus on as far as what can we do from our standpoint, because a lot of people cannot diet and then lifestyle their way out of their genetics. But with modern medicine, we can make a huge dent in the accrual of atherosclerosis, which is the hardening of the arteries, which is what leads to a vulnerability of that blood-brain barrier that's protecting the organ that makes you who you are. All the other modifiable risk factors are no secret, and they are our magic pill.

So, exercise, absolutely our magic pill. And we love brisk walks. We're all for brisk walks, but we really want moderate intensity exercise because that's what releases the hormone that creates neurogenesis. It's a hormone that helps you to actually increase your brain volume. So, exercise is really our magic pill.

Sleep, having good sleep hygiene, seven and a half to nine hours. And if you have sleep apnea, being compliant with a CPAP. If you have a family history of sleep apnea and your dad, for example, is not a traditionally obese COPD patient and snores like a train, that doesn't mean that he didn't need a CPAP. And so, we have patients who we see their children because they have risks. And when they're in their 40s, we're like, "Based on we know your father and he's our patient, and we think at 50 that you should consider getting a sleep study." So, it's very as precision medicine as we can do it on scale, you know, and as much or as little as the patient wants, as conservative or aggressive as the patient wants, and just meeting them where they are in that journey, in that age group, and then based on their risk factors.

Melanie Cole, MS: Wow. I mean, really when we think of those everyday habits, those lifestyles, and you mentioned sleep and, of course, exercise, one of my favorite things, and then there's also nutrition. So, people don't often, you know, associate diet with—I mean, we've learned so much more in the last 20 years, right? And doctors didn't used to get very much nutrition. But now in medical school, we see this connection, this interaction. Tell us how you work with patients as far as nutrition. Where does that come into play?

Carolina McCalmon: Yeah, it's the crux of everything. And I would argue that we haven't learned so much more in the last few years, we have accepted so much more. Because I remind patients, your biochemistry is your biochemistry. A lot of what we do when it comes to brain health has to do with evolution. So, your genetics can determine whether you respond better to red meat, for example.

What we know are the easy things, the low-hanging fruit. Nobody responds well to hyperprocessed or ultraprocessed foods, right? And we know that the brain loves ketones. So, things that have to do with intermittent fasting, I tell my patients we want everything low except for water, protein, and sleep. So, blood pressure, cholesterol, sugar, as low as we can get it without having symptoms.

But protein, your water, we want those things to be catered to the body mass that you want because those nutrients are the gasoline that are fighting inflammation, they're feeding your muscles, and they're helping your body to take out those toxins. All you need to do is give your body all the amino acids, the essential amino acids that it needs. And we've known those since the beginning of chemistry. And as long as you're getting that diversity of natural foods in your diet, then you're doing everything that your body needs.

So in that way, kind of where you come from, we go overall with a MIND or Mediterranean diet. But there was a recent study that showed that they did a Latin American version of the Mediterranean diet in the Latin American community, provided GLP-1s, and they had similar outcomes for preventing dementia or slowing decline as they did when they studied it in Americans using the MIND or Mediterranean diet. So, diet is across the board.

Again, just going back to the basics of everything that we've always kind of known is probably right. You know, living off the land. My centenarian patients, I always ask them, like, I'll spend extra time just to ask them, "What did you eat? What was it like growing up?" And all of them lived off the land, and they all stopped eating at 5:00 because there wasn't any electricity really to eat after that, and it was dark, and they had to get up at 5:00 AM. So, a lot of it is just going back to the things that have gotten our bodies to this point because that's what protects the brain.

Melanie Cole, MS: Really, that is so true. And the basics and whole foods, shopping the perimeter of the store as opposed, as you say, those processed foods in the middle aisles. You know, if stuff has a lot of ingredients on the box, then probably it's not going to be healthy.

Carolina McCalmon: Yeah. If it can tell you that it's healthy, it's probably not healthy.

Melanie Cole, MS: That's right. That's right. Well, you know, it's so true. Now, when someone comes to your preventive neurology clinic, what can they expect, Carolina? What is it like? How do you develop this personalized plan? Because, boy, you're giving us so much great information. You are so smart, and I imagine your patients absolutely love you. Tell us what it's like to be there.

Carolina McCalmon: It's different for everyone. And it's a little bit of what brought you here and a quick gauge really of exactly what they want out of it. We can start with an overall umbrella. Our big thing is that we want patients who are motivated. And if you come to me and you're motivated, we want to be your mammogram of the brain. It's not a long history. I love neurology because I have endless curiosity, but I'm also a little nosy. So, neurology usually is 90% history. So, we usually take a lot of time getting to know the patient and asking questions.

Preventative neurology is a little more objective. Instead of investigation, it's a little more hunting. So, everybody gets more or less a similar workup, and that can depend on, you know, what we have access to and how much we're interested in. If a patient comes to me and they're like, "I don't care what you say. I don't care what my numbers are. I will absolutely never take a medication," then obviously I'm not going to order any labs that would change recommendations for a medication.

But for the most part, it's pretty objective, a general screening, going through the risk factors, figuring out what I can do for the heavy lifting to contribute to their brain span, and then educating them on what they can do. What can we tweak? There's always something that we can all do a little bit better. And so, we basically sift through what levers they could pull, and then the ones that they're the most comfortable pulling, how hard, and kind of timing, you know, if depending on their age, at what age they should get an audiology test, for example, because poor hearing is tied to dementia.

If they're less than 50, talking about getting a DEXA scan to look for osteoporosis for my women, especially if they went through early perimenopause. So, it's generally applicable. We definitely try to tailor it and make it precision medicine for the patient. So, we just at least want people, even if they don't come to us, to be thinking about how all of these systems and your body mass index and your muscles and the obesity, how it's not aesthetic. It's about being here and being happy and being functional while you're here.

Melanie Cole, MS: Wow, what a comprehensive approach, and it sounds to me like more than neurologic care, even though that's where the focus is, but it's really whole body care, Yeah, and wellness for the whole person, because all of those things, I mean, it's all tied together, right?

Carolina McCalmon: Yes.

Melanie Cole, MS: I mean, that's really the most important message here. Now, Carolina, when we think of Alzheimer's, stroke, dementia, people get really freaked out. It's pretty nerve-wracking to even think about those things. When you talk to people every single day about those modifiable risk factors, about things that they can control rather than waiting until this happens, what do you want people to understand about looking at each of these portions, these parts that all come together for the whole and can contribute to those diseases of the brain?

Carolina McCalmon: So many things. I want people to remember that we do want to zoom out. So, I've spent a lot of hours of my life trying to help patients cope through the post-traumatic experience of a stroke. Because by definition, it's a trauma, and there's no warning, and their life is never the same as it was the one second before they experienced those symptoms.

And part of it is educating people who have not experienced a stroke or are not willing to get into early lifestyle, diet, and pharmacologic care to prevent these things, that strokes don't often kill you, but they can make you suffer. Because a lot of patients will say, "When it's my time, it's my time." And we have to remind them that there's so much we can do. It doesn't have to be that way. We have great medication, and we can be a team. We can, you know, pull all the levers that we can to make sure that hopefully you don't have to get to that stage. All we can do is look at the data that we have and make sure that our patients know that there are so many things that we can do, and we never want to look back and say that we didn't at least try.

So, we want to make sure that we're providing access and information to all of those things, the less that we see our patients coming back to the ER and the more we see those numbers hopefully in our area staying lower compared to the national average, then we'll know that we're doing something.

Melanie Cole, MS: Wow. Yeah, it really is a multidisciplinary approach as well. Because when you're thinking of exercise and nutrition, I mean, there's all kinds of specialists. So, it's such a great way to bring it all together. And as we get ready to wrap up, I want to ask you, Carolina, how neurology became such a passion of yours. What drew you to this specialty? And if you could give one message today from this awesome episode where you gave us so much to think about, see what I did there? What would that be?

Carolina McCalmon: Yeah, I always joke that I never grew out of the three-year-old phase of asking why. And I think if you ask why enough, then you kind of always end up at the brain, and figuring out because neurologists are—I always joke—the most humble physicians because you're asking the brain to explain the brain. We never ask the liver to explain the liver.

So if you want to be an indefinite student, then neurology is the choice for you. And as you can see, we're always evolving and trying to catch up, and it's something that I think people are starting to realize is the crux of what makes us who we are. And what I want people to know is there's a very easy acronym that we're all familiar with ABCDE.

There's an ABCDE of brain health. And if you come to clinic, we can do the A through D. But the E is your emotional health, which is your mental health, your equity, and feeling empowered, and we don't have a prescription for that. When you come to us, you'll see a nutritionist. In the future, we will have a physical therapist who will give you a plan. We will have a quick MRI, and we will have more expansive multidisciplinary in-house measures for you.

So, the one thing that I would want people to walk away with is a happy brain is a healthy brain. And so, that's definitely the one thing that you don't have to have an appointment for, but it's also the hardest thing to figure out. So, I want everyone to focus on mental health, because that's definitely the one angle that we could all use a little help on.

Melanie Cole, MS: Wow, Carolina, you are lovely. And I can hear the passion in your voice and the compassion for what you do, but that passion for helping patients at your clinic, I can just hear it. And thank you so much for all the great work that you're doing and for joining us today.

Carolina McCalmon: Oh, thank you so much. Yeah, thank you so much for having us, and thank you for the opportunity.

Melanie Cole, MS: Really, you have some incredible expertise, so thank you so much again. And to find a physician, you can visit novanthealth.org. For more health and wellness information from our experts, visit healthyheadlines.org. That concludes this episode of Meaningful Medicine, a podcast from the specialists at Novant Health.