Evaluating the effect of Brainfood groups for people with mild cognitive impairment and mild dementia: preliminary mixed-methodology study

Background Brainfood is a 5-week group intervention for people with mild cognitive impairment and mild dementia, promoting cognitive health through a Mediterranean-style diet, exercise, mindfulness and health self-management. Aims To evaluate Brainfood acceptability and the feasibility of conducting a randomised controlled trial; in a single group study in two National Health Service (NHS) memory services. Method Participants self-completed quantitative and semi-structured questionnaires. Recruitment, attendance and outcome completion were the primary outcomes. Results In total, 30 of 59 people invited to Brainfood attended; of the 26 (87%) who completed baseline measures: 25 (96%) completed post-intervention quantitative measures, 16 (67%) qualitative questions and 21 (81%) attended ≥3/5 sessions. Compared with baseline, participants reported significantly higher quality of life, Mediterranean diet adherence and exercising more, up to 2 months after the groups. Participants valued the groups and felt enabled to improve their well-being. Conclusions Brainfood was acceptable and feasible to implement in an NHS setting. Declaration of interest A.B. and C.C. developed Brainfood – they hold a creative commons license for the manual and make it available to use for free to all. The manual evolves iteratively, but the manual used in this research study is provided in an online supplement.


Food to share
Every week we will bring some food for you to try. This week we have some suggestions for a healthy breakfast and healthy snacks. While we try these we can discuss what changes you might want to try to your usual breakfast.

When to eat
When do you usually eat your meals?
What do you eat for snacks between meals?
What works well for you that you could share with others?

Meal timings
 It is important to start with a good breakfast  Eat at regular times  Try to avoid eating too late.
Like the well known saying: Breakfast like a king, lunch like a prince, dinner like a pauper! Would you like to make changes to your meal times?
Is there anything that would help you make changes?
Attribution-NonCommercial-ShareAlike CC BY-NC-SA Eating together  Where and with whom do you usually eat your meals?
In what circumstances do you most enjoy eating?
What changes might you want to make to this?

Attribution-NonCommercial-ShareAlike CC BY-NC-SA Exercise
People who exercise more have better memories.  Exercise improves cardiovascular health, which is strongly linked to memory problems.  It probably also reduces inflammation in the brain and buildup of a protein called amyloid. Inflammation and amyloid both happen in Alzheimer's disease.  Exercise often includes social contact too, which is good for the brain.
Exercise can be difficult for people with physical health problems, but there is always some exercise that is possible.
What exercise do you do regularly? Do you enjoy it?

Sleep & Relaxation
Sleep plays an important role in memory, both before and after learning a new task. Lack of adequate sleep affects mood, motivation, judgment, and our perception of events.
Here are some tips for a good night's sleep:  Set a specific time for getting up each day.  Don't take a nap during the day.  Take daily exercise and spend time outside-daylight helps.  Stop drinking tea and coffee for a few hours before bedtime.  Avoid drinking alcohol and smoking.  Don't eat a big meal just before bedtime.  Create a relaxing bedtime routine, such as taking a bath, listening to soft music, and drinking a warm, milky drink. Some types of carbohydrates are better for the brain than others.
We digest carbohydrates to make glucose, which is our fuel. Our bodies need insulin to use this fuel.
Eating carbohydrates with a high glycaemic load causes spikes in blood glucose followed by spikes in insulin.
Eating low glycaemic load carbohydrates causes a more gradual rise in glucose and less sudden release of insulin into the blood stream. This is better for the brain.
The brain uses more fuel than any other part of the body, and works better with a steady fuel supply. Many people have found that avoiding glucose and insulin spikes is good for the brain. You can do this by  choosing carbohydrates with a low glycaemic load  Combining carbohydrates with some protein  eating less carbohydrates overall

Vegetables and fruits
Attribution-NonCommercial-ShareAlike CC BY-NC-SA A brain-healthy diet means plenty of fruits and vegetables. They are packed with vitamins and minerals, and a good source of fibre especially when eaten raw.
Green leafy vegetables are particularly good for memory as they are rich in folate, and contain antioxidants, which naturally reduce inflammation. Inflammation occurs in the brain in Alzheimer's disease.
Smoothies are an excellent way to consume plenty of raw vegetables. Celery makes a nutrient rich ingredient in a green smoothie. It mixes well with spinach and fresh lemon and helps to reduce inflammation.

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This is a tomato sauce, traditionally eaten in Spain. Tomatoes, onions or leeks, garlic, green peppers and olive oil are sautéed in a frying pan. It can be eaten with brown rice or eggs, or used as an ingredient in other dishes.

Guacamole
Guacamole is a dip made from avocados. All you really need for guacamole is ripe avocados and salt. After that, a little lime or lemon juice. Add chopped cilantro, chives, onion, and tomato, if you want.

Ingredients
 2 ripe avocados  1/2 teaspoon salt  1 Tbsp of fresh lime juice or lemon juice  2 Tbsp of minced red onion or thinly sliced green onion  2 tablespoons cilantro (leaves and tender stems), finely chopped  A dash of black pepper  1/2 ripe tomato, seeds and pulp removed, chopped  Garnish with red radishes or jicama.

One chopped onion or leek Several chopped tomatoes or half a tin of plum tomatoes A chopped green pepper 2 cloves garlic, minced
Fry these ingredients in olive oil. Add 1/4 teaspoon ground coriander, oregano and fresh pepper to taste.

Hummus
Hummus is great with nearly any raw chopped vegetable, as a spread or as a side dish with burgers, sausages or fish. Serve topped with a drizzle of extra virgin olive oil or chopped parsley. You can add chopped olives or sun-dried tomatoes.

Basic Hummus Recipe
 Two tins of cooked chickpeas  3 garlic cloves, peeled  100ml tahini (also called sesame seed paste)  50-100ml cup fresh squeezed lemon juice  100ml Extra Virgin Olive  2 tablespoons of Flax seed oil  100ml water, or more as needed  salt to taste In a food processor, chop the garlic cloves. Add tahini, lemon juice and water, process until smooth.
Add drained chickpeas and cayenne to the mixture. Process until well blended while adding additional water, as needed. Add salt to taste. Once blended, process another minute or so to add air to the hummus.

Satisfying low carbohydrate meals
H  Salad with grilled chicken or fish  Vegetable stir-fry with small amounts of seafood or lean meat  Adding chopped, dark green, leafy vegetables or leftover vegetables to an omelette  Scrambled eggs with mushroom and spinach can make a healthy breakfast or small lunch.
 Steam or sautée vegetables, with a little seasoning or olive oil and fresh lemon, or a dip like made with aubergine or avocado  Roast or grill your veggies with salt, pepper, and a little olive oil. E.g. peppers, aubergine, courgettes  Putting vegetables in soups including miso soup with some fresh ginger helps digestion and stimulates appetite.
Here are some ideas for meals that are low in carbohydrates. What low carbohydrate meals do you enjoy?

Fruits
The healthiest fruits are those low in sugar. These are:

Fairly high in sugar
Very high in sugar Buckwheat: A Good Source Of fibre. Wheat-free! Boil three cups of water. Add some salt. Add two cups of buckwheat and stir. As soon as the grain expands and soaks up the water at the top, cover with the lid and leave it on the lowest setting possible for 20-30 minutes or until all the water is absorbed.
You can add fried onions, mushrooms, vegetables, beans and cold pressed vegetable oils.

Legumes
These include beans, peas, lentils and peanuts.

Making connections
People with memory problems who are socially active tend to have better memories for longer than those who have memory problems but don't have regular social activities. This might be because:  They are less likely to become depressed or anxious, or recover more quickly if they do  Social contact is stimulating and enjoyable There are lots of social groups doing varied activities in Camden. We have brought some information to show you about current groups.
What groups do you attend now? Which other groups might you be interested in going to?

Making Changes
Write down what changes you will try or continue in the next couple of weeks.

Changes to carbohydrates
Changes to breakfast Changes to mealtimes

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During the next week, please use this to write down diet changes that you try and if you notice any effect.

What change you made
How did you feel when you did this?

Looking at fats
We all need some healthy fats in our diet, for example to absorb Vitamins A, D, E and K. Certain antioxidants, like lutein in dark green leafy vegetables and lycopene in tomatoes, may also need fat for proper absorption.
There are three different types of fats: saturated fats, trans-fats, and unsaturated fats.
We will think about these while sharing some food rich in healthy fats.

Discussion
What went well? Were there problems? What changes will you be continuing?

Saturated fats
These fats are derived from animal products such as meat, dairy and eggs. They are also found in some plant-based sources such as coconut, palm and palm kernel oils. They raise cholesterol so should only be eaten in small amounts.

Cream and full fat milk
There is some evidence that saturated fats are not all the same and some in the right quantities might be good for you. Replacing saturated fats with refined carbohydrates increases blood Triglycerides and lowers good (HDL) cholesterol, and these are risk factors for inflammatory diseases including diabetes, dementia and heart disease.

Trans-fats
Trans-fats raise the bad cholesterol in your body and lower the good cholesterol that the body needs. They build up in the body and block blood flow to the heart and brain.
Hydrogenation is the chemical process that changes liquid oils into solid fats. Trans-fats, also known as hydrogenated fats, are used for frying or as an ingredient in processed foods. Any item that contains "hydrogenated oil" or "partially hydrogenated oil" probably contains transfats.
Transfat is a man-made saturated fat in which a food manufacturer takes an unsaturated fat and treats it with hydrogen atoms to make it into a saturated fat. It is the worst of all fats and the most artery-clogging of all.

Unsaturated fats
Regular use of unsaturated fats from whole food sources and cold pressed oils are good for your brain. Monounsaturated fatty acids (olive, sesame, and avocado oils) are the healthiest for daily use. There are two types:

Monounsaturated fats
They are found in olives, olive oil, nuts, peanut oil and avocados. Some studies have shown that these kinds of fats can lower LDL (bad) cholesterol and maintain HDL (good) cholesterol. hazelnut avocado olive almond Myelin, the protective cover around brain nerve fibres, is 70% fat. One of the most common fatty acids in myelin is oleic acid, the main component of olive oil as well as the oils from almonds, pecans, macadamias, peanuts, and avocados.

Polyunsaturated fats
These can have a beneficial effect on your health if they are from natural whole food sources and cold pressed oils.
They include essential fats that your body needs but can't produce itself -such as Omega-6 and Omega-3.
You must get essential fats through food. Omega-6 and Omega-3 play a crucial role in brain function and overall health.
In the past, people were advised to cut out saturated fats and replace with vegetable oils rich in Omega-6, but current evidence suggests we need to eat Omega 6 and Omega 3 oils in a healthy balance.
Most people consume around 20 times more Omega 6 than Omega-3 and that is bad for the heart and general health.
Omega-6 fats are present in vegetable oils (commonly used for frying in the fast food industry), sunflower, safflower, sesame, corn, rice-bran, soy, peanut, grape seed and wheat oils.

Foods high in omega-3 fats include flax (linseed) oil, deep cold water fish such as sardines, tuna, and wild salmon.
Consuming foods high in Omega 3 oils helps to reduce inflammation. Using too many Omega 6 oils in your diet is bad for you.

Discussion
What sources of omega-3 do you already eat regularly?
What oils and fats are used to prepare most of your meals?

Refined or processed polyunsaturated fats
Polyunsaturated fats are unstable and easily turn into harmful fats if exposed to heat or chemicals used to make refined oils. Manufacturers can heat up unsaturated oils like sunflower seed oil and make it more saturated. Margarine is made in this manner to produce a solid that you can spread.
Polyunsaturated fats in refined products, such as clear vegetable oil, mayonnaise, salad dressings, and most brands of margarine are less healthy than unrefined oils.

Cooking oils
When heating any oil, it is important to keep them below their smoke point, (before oil burns to the point of smoking).
Oils heated above their stability point begin to decompose, releasing free radicals along with toxic fumes.
The BBC investigated the "healthiest" oils to cook with for its series Trust Me I'm A Doctor in 2015.
Volunteers were given sunflower oil, vegetable oil, corn oil, cold-pressed rapeseed oil, olive oil, butter, goose fat and lard to use in cooking.
Cooking with sunflower oil and corn oil produced aldehydes, which can cause cancer at levels 20 times higher than recommended by the World Health Organisation. Olive oil and rapeseed oil produced far fewer aldehydes as did butter and goose fat.
Presenter Michael Mosley said: "Put simply, cooking with these oils is producing even more toxic compounds than has ever before been realised. In contrast, the olive oil and cold-pressed rapeseed oil produced far fewer aldehydes, as did butter and goose fat. The reason being that these fats are richer in monounsatured and saturated fats, and are much more stable when heated.

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Here are some unrefined oils you could use in preparing meals and in cooking:

Making changes
How could you introduce good fats into your diet ?
Write down what changes you will try, or keep trying in the next couple of weeks.

Changes to breakfast
Changes to lunch Any other evening meal

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During the next week, please use this to write down diet changes that you try and if you notice any effect.
What change you made How did you feel when you did this?

Complete the food diary about what changes you have made and if this has made a difference to you
When do you think you might have the opportunity to make these changes?
What might get in the way? What went well? Were there problems? What changes will you be continuing?

Looking at the Mediterranean diet
From salads of tomato, cucumber and feta to moussaka and tzatziki, the Mediterranean diet's mix of whole grains, fresh vegetables and oily fish has proven incredibly healthy and good for the brain.
The Mediterranean diet has been associated with:  A lower risk of diabetes and obesity  a lower risk of heart disease, high blood pressure and stroke  a reduced risk of Alzheimer's disease It is a diet that brings together many of the diet changes we have discussed so far.

Key Concepts of Mediterranean diet
 Plenty of virgin olive oil for cooking and dressing of dishes  2+ servings (125g/serving) per day of vegetables  3+ servings per day of fresh fruits (including natural juices);  3+ servings (40 g/serving) per week of legumes;  3+ servings (150 g/serving) per week of fish or seafood  3+ servings (25 g/serving) per week of nuts or seeds;  Limit red meats or processed meats (ie, burgers and  Sausages)  Regularly cooking (at least twice a week) with salsa made with minced tomato, garlic, and onion simmered in olive oil, adding other aromatic herbs or not, for dressing different dishes.  Limit dairy products, sweet foods and processed foods.  Drink (red) wine during meals, but no more than 1-2 small glasses per day.  Water is the best 'non-alcoholic beverage' (as opposed to sugary drinks), although health benefits have also been claimed for various teas and coffee. You can make water taste more refreshing by adding juice of fresh lemon.

Fish
The Mediterranean diet includes plenty of fish. A mix of oily and white fish (and shell fish) in the diet is a good source of protein that reduces the risk of heart disease.
Oily fish (and some shellfish) contain cardio-protective omega 3 fatty acids, vitamins A and D. Whole fish are a source of calcium and phosphorus.
If you have high total cholesterol levels, avoid eating too much shrimp.

White fish
Examples are cod, haddock, plaice, pollack, coley, dab, flounder, red mullet, gurnard and tilapia. They are very low in fat, and contain some omega-3 fatty acids, but much less than oily fish Attribution-NonCommercial-ShareAlike CC BY-NC-SA
Canned tuna does not count as oily fish. Fresh tuna is an oily fish, but when it is canned the amount of omega-3 fatty acids is reduced to levels similar to those in other fish.

Shellfish
These include: prawns, mussels and langoustine. They are low in fat and a good source of selenium, zinc, iodine and copper. Some types, such as mussels, oysters, squid and crab are also good sources of long-chain omega-3 fatty acids, but they do not contain as much as oily fish.

Why limit dairy foods ?
These are a good source of calcium and vitamins, but most of the fat they contain is saturated fat. Cheese can also be high in salt.
Lactose, the sugar in milk is a simple sugar composed of glucose and galactose. This composition results in lactose's ability to produce insulin spikes.
Milk from grass fed cows contains some Omega-3 fatty acids.
Research shows that cows feeding exclusively on green grass contains more omega-3 fatty acids than milk from cows fed conserved grass.
Insoluble fiber, such as that found in wheat bran, reduces calcium absorption; but soluble fiber, such as that found in psyllium and fruit pectins, does not seem to affect absorption.

Brain-healthy recipes
Most of your favourite foods can be prepared so they are brain-healthy. For the few foods that cant' be made more brain-healthy, enjoy them in moderation.

Brain-healthier Pepperoni Pizza
 1 wholemeal flat bread  12 slices of turkey with pepperoni  4oz tomato sauce  4oz fat free mozzarella cheese  1oz mix of oregano, black pepper, crushed red pepper and parsley or fresh basil Tasty brain-healthy salad dressing can be made with extra virgin olive oil, hempseed oil, flaxseed oil, or hazelnut oil and apple cider vinegar or fresh lemon as well as fresh or dried herbs and a little mustard.

Greek Salad with Chicken
Mix lettuce, tomatoes, onions, cucumber and olives in a bowl. Top with chicken, cheese and oil and vinegar/lemon dressing.

Vitamins and anti-oxidants
A brain-healthy diet will help increase your intake of vitamins and the trace elements necessary for the body to use them effectively. Other antioxidants and plant compounds such as Coenzyme Q10, Ginkgo biloba and Curcumin (in turmeric) are also being studied for potential benefits in brain health.

Nuts
Nuts are packed with protein, fibre and essential fats.
They are high in fat, but much of it is heart-healthy. The amounts of saturated fat varies between nuts. Brazil nuts, Macadamias and Cashews have the highest saturated fat content.
They contain lots of vitamins and minerals:

Herbs and Spices
Herbs and spices are also antioxidants. The higher the ORAC (Oxygen Radical Absorbance Capacity) score the more powerful an antioxidant a substance is.

Caffeine/coffee
Drinking 1-2 cups of coffee earlier in the day might help memory -people who drank coffee in mid life were less likely to get dementia in one study, and animal studies also suggest it might be helpful.
Drinking coffee after lunch is not recommended, as it may affect the sleepwake cycle and impair the ability to effectively fall asleep (even up to 10 hours after drinking it!) Caffeine may also have detrimental effects on the heart such as increasing the heart rate and may increase anxiety.

Alcohol
There is no evidence that alcohol helps memory and too much can certainly make it worse.
1 glass of red wine with a meal is considered helpful due to the flavonoid content.
Consumption of more than 1 glass can lead to negative health consequences.
Beer and wine vary in their sugar content but be aware that all beers and wines contain some carbohydrates and more calories than most people expect.

Fruit Juice
In general it is preferable to eat whole fruit rather than drink fruit juice due to its high sugar content. Try and dilute it with carbonated water for a refreshing drink.

Tea
2-3 cups of tea can help brain health thanks to compounds called polyphenols also present in green tea.

Coca-cola and other soft drinks
There are 65 g of sugar in a typical 20oz bottle of cola. That's about 15 teaspoons of sugar! Remember sugar is a bad carbohydrate. Soft drinks are high in sugar.
Try to avoid sugared beverages, including those sweetened by highfructose corn syrup (same thing as sugar).
Beware of products labelled "juice drink" or "juice cocktail". These are not juice. Most contain a little fruit juice (15%) and the rest is sugar or high fructose corn syrup.

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Beer and wine vary in their sugar and caloric content but be aware that all beers and wines contain some carbohydrates and more calories than most people expect.

Lemon water
Fresh lemon juice squeezed into a glass of hot or cold water is a natural energiser. It makes you feel revitalised and refreshed.

How much?
Every day we recommend: