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“We really wanted to make sure we had representation from many different micro cultures across the US,” which is not something clinical trials for Alzheimer’s disease has done a good job at, Baker says.

The participants were randomly assigned to one of two lifestyle intervention groups: one with a structured program and another with a self-guided program.

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Both groups focused on physical activity, diet, cognitive training, social engagement and vascular health over the course of the two-year study.

Participants in the self-guided group received general education on health, diet and exercise and were encouraged to make the lifestyle changes that they thought best suited their needs. They also met six times with facilitators and other group participants in their communities for discussions on what they are learning.

In contrast, the structured group had a far more intensive and demanding regime.

• Physical health: Each week, participants had four days of aerobic exercise, two days of resistance training and two days of stretching and balance exercises.
• Diet: They were encouraged to adhere to the Mediterranean Intervention for Neurodegenerative Delay (MIND) diet, which is designed to promote healthy brain ageing.
• Cognitive training: Participants engaged with a web-based cognitive training program three times a week.

In addition, the structured group met 38 times with facilitators and fellow participants, received biannual health coaching from a medical adviser, as well as phone calls and clinic visits to assess diet and cardio metabolic health.

Having participants meet their peers offers a social component for support that is “a key ingredient in the intervention,” Baker says.

With the structured intervention, “we’re going to tell you what to do, but we’re going to help you get there. And we’re going to work with you as a partner to meet you where you are,” Baker says at a news briefing.

Both groups showed cognitive improvements throughout the two years of the trial.

But participants in the structured lifestyle group did better than people in the self-guided group.

“It was surprising to see such significant cognitive improvement within the self-guided group compared to their initial cognitive scores,” says Klodian Dhana, an associate professor of internal medicine at Rush University Medical Centre in an email.

“However, this suggests that lifestyle interventions, even when based solely on educational information, can be beneficial,” says Dhana, who was not involved in the study.

For many study participants – more than 90 per cent stuck through the two-year trial – the experience was motivating and life-changing.

Phyllis Jones, 66, of Aurora, Illinois, says she is “forever changed” by the experience as a participant in the structured group. Her mother and grandmother had dementia, but she had been neglecting her health amid a layoff from her 28-year-long software engineering job.

“I was circling the drain, and I felt it,” she says at a news briefing.

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The researchers started Jones and her fellow participants off slow, with just 10 minutes of exercise a day. But “after all those years of being sedentary, 10 minutes was a good start and that got me going,” Jones says. “Since they took it slow, it made it so that we didn’t get discouraged. We didn’t hurt ourselves.”

Since then, she has lost 30 pounds, Jones says. Now, she wakes up to do virtual reality workouts in her pyjamas each morning before work and feeding her two dogs and two cats.

Peter Gijsbers van Wijk, 72, of Houston, a participant in the self-guided group, says meeting with other participants and facilitators helped keep him motivated to work toward his health goals of getting more physical activity. His mother and two aunts had dementia.

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After the trial, van Wijk is continuing his exercise with yoga and walking eight kilometres a day, at least five days a week. He has also started volunteering in his community to get more social contact and to give back.

“The most important thing is try out a little bit and see what you enjoy because if you enjoy it, then you will be able to sustain,” van Wijk says.

Open questions and future

While the study findings are “very important”, the longer-term effects on cognition remain unknown, Dhana says.

However, because there was no group that did not receive a lifestyle intervention, it is difficult to interpret why both self-guided and structured groups had cognitive improvements.

On the one hand, it could be a sign that even just education about healthy behaviours could improve cognition. But it could also be the result of a “practice effect” where participants improve on assessments simply because they are doing them more, says Yaffe, who was not involved in the study.

(The study researchers say they felt an ethical responsibility to provide something beneficial for all participants.)

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The difference in cognitive improvement between the two groups was also “pretty modest”, Yaffe says.

Participants in the structured group performed better in executive function than those in the self-guided group, but there were no major differences in memory or mental processing speed. This suggests “more of a vascular pathway and less of Alzheimer’s”, the hallmark of which is memory impairment, Yaffe says.

Because the study incorporated multiple types of lifestyle changes, it’s not possible to pinpoint what is most effective for different people.

Any disease that causes cognitive impairment and dementia will probably require “a multitude of solutions”, including behavioural interventions combined with medications, says Heather Snyder, a study author and the senior vice president of medical and scientific relations at the Alzheimer’s Association, which provided $US50 million to fund the study.

The researchers are now analysing biomarkers and neuroimaging data from the participants, who are being followed for an additional four years to see how these interventions impact their cognitive health in the longer run.

At the same time, the researchers are working with partners to roll out the structured lifestyle interventions into the community “not later, but now,” Baker says.

How to improve your cognitive health

“To improve brain health, it’s important to adopt multiple lifestyle changes,” Dhana says.

There are many different ways to reduce your risk for dementia.

• Move more, sit less. Sitting all day increases dementia risk, while exercising regularly can keep your brain sharp.
• Eat a healthier diet. You can try the MIND diet, which calls for more vegetables, berries and nuts, and limits on red and processed meats and sweets. Processed meats are linked to higher rates of dementia and worse cognition, while replacing them with nuts and legumes is associated with lower dementia risk, research shows.
• Stay connected. Feelings of loneliness can increase the risk for dementia, while having strong social connections are a key to cognitive health.
• Challenge yourself intellectually. Find ways of “stretching and using your brain, your memory, your cognition in different ways that’s different for you and that’s pushing the envelope for you,” Snyder says.The Washington Post

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