WHO Guidelines for Reducing Modifiable Risk Factors for Dementia

By: Melissa Tanner, Ph.D.

Currently the number of people living with dementia worldwide is around 50 million. In the absence of a disease-modifying cure or widespread approach toward prevention, this number is set to triple by 2050. Recognizing the need to educate and unite health care providers, policy makers, and other stakeholders in the fight against dementia, The World Health Organization (WHO) published a public health initiative entitled The Global Action Plan on the Public Health Response to Dementia 2017 – 2025. Action Area 3 of the initiative is entirely focused on strategies for reducing modifiable risk factors for dementia.

The 12 categories highlighted in Action Area 3 will come as no surprise to those who are familiar with the BCAT® Research Center’s ENRICH® program and / or those who have read “Brain Health as You Age: A Practical Guide to Maintenance and Prevention,” a book co-authored by BCAT® founder Dr. William Mansbach. Each of the 6 brain-healthy habits represented by the ENRICH® acronym (Exercise daily, No smoking, Routine cognitive stimulation, Improve mood, Control hypertension, and Healthy weight and body fat) is included in WHO’s guidelines. For example, the first category of Action Area 3 provides supporting evidence and rationale for physical activity as a strategy for reducing the risk of cognitive decline.

In addition to summarizing the available research and theory, the WHO initiative provides qualitative ratings to categorize the strength of recommendations. For instance, the recommendation for smoking cessation is labeled as “strong,” whereas the recommendation for weight management is labeled as “conditional.” This does not mean that the latter recommendation is weak and should be dismissed; rather, the “conditional” rating is intended to convey that it may not be applicable to all populations or contexts. With respect to weight management, WHO proposes that it is most important to maintain a healthy weight in mid-life and less so in late-life. The initiative also offers the qualification that weight management interventions that include both diet and physical activity components show the best results.  

The WHO initiative takes an equivocal stance when it comes to recommending management of depression as a strategy for reducing risk of cognitive decline and / or dementia. WHO recognizes that the data linking depression to cognitive decline and dementia is robust but maintains the position that there is insufficient high-quality data to conclude that depression represents a modifiable risk factor, as opposed to a prodromal symptom of dementia. Nevertheless, WHO does advocate for treatment of depression in accordance with the WHO Mental Health Gap Action Program (mhGAP), an initiative aimed at scaling up services for mental, neurological, and substance use disorders, especially for low- and middle-income countries.

The WHO initiative also addresses 6 recommendations not highlighted by ENRICH®, including management of hearing loss, management of dyslipidemia, management of diabetes, nutritional interventions, treatment of alcohol use disorders, and encouragement of social activity. It should be noted that the 6 recommendations highlighted by the ENRICH® program were not intended to be comprehensive. They were chosen to reduce redundancy and maximize adherence, relying on the idea that degree of compliance drops in correlation to number of recommendations. Nutritional interventions like the Mediterranean diet were recognized in “Brain Health as You Age: A Practical Guide to Maintenance and Prevention” as having beneficial effects. However, since these effects can also be captured through maintenance of a healthy weight and body fat, nutritional interventions were not specifically addressed by ENRICH®.  Still, the BCAT® Research Center recognizes the brain-healthy benefits of nutritional guidelines like the Mediterranean diet. Recommendations for management and / or treatment of dyslipidemia, diabetes, and alcohol use disorders have enough empirical support to warrant conditional backing by WHO. While they were excluded from ENRICH® in order to maintain an attainable number of recommendations, The BCAT® Research Center endorses the WHO stance with respect to diabetes, dyslipidemia, and alcohol use disorders. The two remaining recommendations, management of hearing loss and encouragement of social activity, were deemed to have insufficient support to warrant the claim that they can be used to reduce risk of cognitive decline or dementia. However, both were recognized as providing benefits to the overall health, well-being, and daily functioning of older adults and therefore encouraged by WHO on those grounds. The BCAT® Research Center supports this stance.

These recommendations may seem overwhelming at first glance, but it should also be incredibly encouraging to learn that so many of the risk factors associated with dementia are modifiable. In the fight against dementia, knowledge is indeed power. While there is still no available cure, if we all arm ourselves with the knowledge provided by the WHO Guidelines and the ENRICH® program, we will be more prepared to take down dementia through prevention. These recommendations offer hope.

Kristen Clark