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| EDITORIAL |
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| Year : 2023 | Volume
: 7
| Issue : 1 | Page : 3-4 |
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The intersection of exercise, cognition, and cardiovascular disease
Evan L OKeefe1, James H O’Keefe2, Carl J Lavie3
1 Department of Internal Medicine, Tulane Medical Center, University of Queensland School of Medicine, New Orleans, Louisiana, USA
2 Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas, Missouri, USA
3 Department of Cardiology, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, USA
| Date of Submission | 28-Dec-2022 |
| Date of Acceptance | 02-Feb-2023 |
| Date of Web Publication | 13-Mar-2023 |
Correspondence Address:
Evan L OKeefe
Tulane Medical Center, New Orleans 70112, Louisiana
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/hm.hm_5_23
How to cite this article:
OKeefe EL, O’Keefe JH, Lavie CJ. The intersection of exercise, cognition, and cardiovascular disease. Heart Mind 2023;7:3-4 |
The search for effective treatments for dementia and cognitive decline has long remained like a black hole, where one therapy after another is proposed, tested, and then disappears into oblivion. Yet, exercise remains a promising therapeutic option for improving mood and mental function in the short term and preventing chronic cognitive decline. Decades ago, academia documented the connection between cardiovascular disease (CVD) and cerebrovascular disease, but what we are more recently starting to appreciate is the significant effect that CVD risk factors have on cognition. In particular, the conditions comprising metabolic syndrome have an insidious effect on brain function, both neurologically and psychologically.[1],[2],[3]
There is considerable evidence that cardiac rehabilitation (CR), cardiac rehabilitation exercise training (CRET), and improved cardiorespiratory fitness (CRF) confer marked potential benefits on psychological risk factors, especially on depression, but also on anxiety, hostility (or unexpressed anger), and total psychological stress.[1],[2],[3] Previously, we have published data showing that CRET can ameliorate psychological risk factors and reduce stress-induced increased mortality, particularly when there are associated improvements in CRF.[1],[2],[3]
In this issue of the Heart and Mind Journal, Dr. Jenna L. Taylor describes the effect of CVD on the brain and investigates the potential for exercise to slow or reverse cognitive impairment.[4] Dr. Taylor's review amassed 14 studies which had previously assessed the effect of CR on cognitive functioning. While there are many potential limitations, including the study design and small sample population, this study indicates exercise training improves cerebral blood flow (CBF) and attenuates the declines of gray matter volume and white matter integrity, which results in quantifiable improvements in attention-psychomotor and global cognitive functioning. These findings suggest that a regimen of moderate and/or vigorous exercise over time may play a significant role for the long-term prevention and treatment of dementia, which may be especially applicable for patients with established CVD.
Many of the risk factors for CVD have been shown to reduce cerebrovascular reactivity and CBF, and predispose to cerebral vascular disease, microbleeds, and hypoperfusion; all of which contribute to cognitive decline.[4] The present study cites coronary artery disease and previous myocardial infarction as significant risk factors for cognitive decline, as well as heart failure (HF).[4] Interestingly, while cardiac output and CBF are directly correlated, studies also show that the level of cognitive impairment was similar between reduced versus preserved ejection fraction types of HF. Even beyond vascular-related dementias, CVD remains a significant risk factor for cognitive decline. Notably, modifiable risk factors including hypertension, obesity, diabetes, physical inactivity, depression, smoking, and education level account for an estimated one-third of Alzheimer's cases.[5],[6] While much remains unknown about dementia, a person's long-term brain health and cognitive ability appear to be closely linked to systemic inflammation and psychosocial stress.[7] Regular exercise is a proven way to reduce both systemic inflammation and emotional stress.[3]
Early studies support the targeting of inflammatory biomarkers, such as tumor necrosis factor (TNF)-α, to protect against dementia. A large observational study of 41,109 patients with rheumatoid arthritis found those treated with anti-TNF agents had a significantly reduced risk of Alzheimer's disease with an adjusted odds ratio of 0.45 (95% confidence interval of 0.23–0.90; P = 0.02).[8] Another effective way of reducing systemic inflammation is through exercise training, and specifically, in those patients with CVD. CRET has been shown to lower C-reactive protein (an inflammatory biomarker) and positively impact cognitive function, cerebrovascular function, psychological health, and brain structure.[4],[9]
Recent epidemiological studies show that people who engage in regular, vigorous activity, such as playing sports or working out, have a substantially reduced risk of developing dementia by 17%–35%.[10] Even regularly doing physically active household chores reduces dementia risk by 21%.[10] For protecting the brain, vigorous physical activity (PA) is especially protective, and the benefits are equally apparent for both vascular dementia and Alzheimer's disease.[11] Another recent study followed 1,200 children between 7 and 15 years of age for more than 3 decades.[12] Participants with higher levels of functional CRF as children displayed higher levels of cognitive functioning in midlife, which suggests that establishing a lifelong habit of PA is beneficial for long-term brain health.[12]
Although exercise has been shown to improve cognition and mood, PA done outside in natural environments is particularly beneficial. Compared to exercising indoors, exercising outdoors, especially when done in natural environments, tends to boost energy, promote a sense of well-being and revitalization, and reduce feelings of emotional tension, confusion, anger, and depression.[13],[14] Study volunteers report greater enjoyment and satisfaction during and after exercise done outside compared to indoor exercise; they also expressed a stronger desire to repeat the activity again in the future. Studies also show improved feelings of calmness and tranquility linked with outdoor walks compared with indoor walks.[14] A large and comprehensive meta-analysis showed that increased time spent being physically active in greenspace (natural outdoor environment) was associated with lower levels of salivary cortisol, heart rate, and blood pressure with reduced risks for stroke, hypertension, dyslipidemia, coronary heart disease, type 2 diabetes, and CVD mortality.[13]
Furthermore, PA is done in a social interactive setting, such as tennis, pickleball, badminton, soccer, yoga, dance, golf, basketball, volleyball, softball, baseball, and group exercise, which are particularly beneficial for mental well-being and life expectancy.[15] Playing team sports or participating in group exercise not only bestows the physical health benefits of exercise, but also engenders interpersonal connection, reduces depression, lifts mood, and calms anxiety.[15] Thus, engaging in PA that requires a partner or as part of a team may result in distinctive psychological and physiological effects that magnify the salutary effects of exercise on mental health.[16] Furthermore, because interactive physical play is typically perceived as fun, people tend to do it more frequently than a joyless workout.
In summary, what is good for the heart is good for the brain. Nothing epitomizes this better than exercise. A lifelong regimen of regular PA will help to keep the body and brain fit and strong for a lifetime.
| References | |  |
| 1. | Lavie CJ, Menezes AR, De Schutter A, Milani RV, Blumenthal JA. Impact of cardiac rehabilitation and exercise training on psychological risk factors and subsequent prognosis in patients with cardiovascular disease. Can J Cardiol 2016;32:S365-73.  |
| 2. | O'Keefe EL, Lavie CJ, Sergey K. Novel comprehensive cardiac rehabilitation to combat the dose-dependent relationship between psychosocial stress and cardiovascular disease. Heart Mind 2020;4:109-15. |
| 3. | Popovic D, Lavie CJ. Stress, cardiovascular diseases and exercise – A narrative review. Heart Mind 2023;7:18-24. [Full text] |
| 4. | Taylor JL. Exercise and the Brain in Cardiovascular Disease: A Narrative Review. Heart Mind 2023;7:5-12. [Full text] |
| 5. | Eriksson UK, Bennet AM, Gatz M, Dickman PW, Pedersen NL. Nonstroke cardiovascular disease and risk of Alzheimer disease and dementia. Alzheimer Dis Assoc Disord 2010;24:213-9. |
| 6. | Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Potential for primary prevention of Alzheimer's disease: An analysis of population-based data. Lancet Neurol 2014;13:788-94. |
| 7. | Torres-Acosta N, O'Keefe JH, O'Keefe EL, Isaacson R, Small G. Therapeutic potential of TNF-α inhibition for Alzheimer's disease prevention. J Alzheimers Dis 2020;78:619-26. |
| 8. | Chou RC, Kane M, Ghimire S, Gautam S, Gui J. Treatment for rheumatoid arthritis and risk of Alzheimer's disease: A nested case-control analysis. CNS Drugs 2016;30:1111-20. |
| 9. | O'Keefe EL, O'Keefe JH, Lavie CJ. Exercise counteracts the cardiotoxicity of psychosocial stress. Mayo Clin Proc 2019;94:1852-64. |
| 10. | Zhu J, Ge F, Zeng Y, Qu Y, Chen W, Yang H, et al. Physical and mental activity, disease susceptibility, and risk of dementia: A prospective cohort study based on UK Biobank. Neurology 2022;99:e799-813. |
| 11. | Su S, Shi L, Zheng Y, Sun Y, Huang X, Zhang A, et al. Leisure activities and the risk of dementia: A systematic review and meta-analysis. Neurology 2022;99:e1651-63. |
| 12. | Tait JL, Collyer TA, Gall SL, Magnussen CG, Venn AJ, Dwyer T, et al. Longitudinal associations of childhood fitness and obesity profiles with midlife cognitive function: An Australian cohort study. J Sci Med Sport 2022;25:667-72. |
| 13. | Twohig-Bennett C, Jones A. The health benefits of the great outdoors: A systematic review and meta-analysis of greenspace exposure and health outcomes. Environ Res 2018;166:628-37. |
| 14. | Thompson Coon J, Boddy K, Stein K, Whear R, Barton J, Depledge MH. Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review. Environ Sci Technol 2011;45:1761-72. |
| 15. | Schnohr P, O'Keefe JH, Holtermann A, Lavie CJ, Lange P, Jensen GB, et al. Various leisure-time physical activities associated with widely divergent life expectancies: The Copenhagen city heart study. Mayo Clin Proc 2018;93:1775-85. |
| 16. | Chekroud SR, Gueorguieva R, Zheutlin AB, Paulus M, Krumholz HM, Krystal JH, et al. Association between physical exercise and mental health in 1·2 million individuals in the USA between 2011 and 2015: A cross-sectional study. Lancet Psychiatry 2018;5:739-46. |
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