Nutrition and Traumatic Brain Injury

Improving Acute and Subacute Health Outcomes in Military Personnel

Committee on Nutrition, Trauma, and the Brain

Food and Nutrition Board

John Erdman, Maria Oria, and Laura Pillsbury, Editors

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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Nutrition and Traumatic Brain Injury Improving Acute and Subacute Health Outcomes in Military Personnel Committee on Nutrition, Trauma, and the Brain Food and Nutrition Board John Erdman, Maria Oria, and Laura Pillsbury, Editors

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. W911QY-10-C-0010 between the National Academy of Sciences and the Department of Defense. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-21008-9 International Standard Book Number-10: 0-309-21008-9 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Cover credit: “Pavement” created by Matthew A. Ping (www.visionaryveteran.blogspot.com) for Vet Art Project. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2011. Nutrition and Traumatic Brain Injury: Im- proving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its ad- ministration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also spon- sors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is presi- dent of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to as- sociate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON NUTRITION, TRAUMA, AND THE BRAIN JOHN W. ERDMAN (Chair), Professor Emeritus, Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign ELDON WAYNE ASKEW, Professor and Director, Division of Nutrition, University of Utah, Salt Lake City BRUCE R. BISTRIAN, Professor, Harvard Medical School, Boston, Massachusetts JOSEPH G. CANNON, Professor, College of Allied Health Sciences, Georgia Health Sciences University, Augusta XIANG GAO, Research Scientist and Assistant Professor, Departments of Nutrition and Medicine, Harvard School of Public Health, Boston and Harvard Medical School, Boston, Massachusetts MICHAEL S. JAFFEE, Past National Director, Defense and Veterans Brain Injury Center, Wilford Hall Medical Center, San Antonio Uniformed Services Health Education Consortium, Texas ROBIN B. KANAREK, Professor, Department of Psychology, Tufts University, Medford, Massachusetts CATHY W. LEVENSON, Associate Professor, Department of Biomedical Sciences and Program in Neuroscience, Florida State University College of Medicine, Tallahassee ESTHER F. MYERS, Chief Science Officer, Research & Strategic Business Development, American Dietetic Association, Chicago, Illinois LINDA J. NOBLE, Professor, Departments of Neurological Surgery and Physical Therapy and Rehabilitation Science, University of California, San Francisco ROSS D. ZAFONTE, Professor and Chair, Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, Massachusetts Study Staff MARIA ORIA, Study Director LAURA PILLSBURY, Associate Program Officer GUI LIU, Senior Program Assistant LEANN BARDEN, Intern ANTON BANDY, Financial Officer GERALDINE KENNEDO, Administrative Assistant, Food and Nutrition Board LINDA D. MEYERS, Director, Food and Nutrition Board Consultant HILARY RAY, Copyeditor v

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse per- spectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Luke R. Bucci, Vice President of Research, Schiff Nutrition International, Salt Lake City, Utah David X. Cifu, Chair and Professor, Department of Physical Medicine & Rehabilitation Medical Director, Rehabilitation and Research Center, Virginia Commonwealth University, Richmond William C. Franke, Associate Director, Center for Advanced Food Technology, Rutgers, The State University of New Jersey, New Brunswick Robert I. Grossman, Professor and Dean, Department of Radiology, New York University School of Medicine, New York Ainsley Malone, Nutrition Support Dietitian, Pharmacy Department, Mt. Carmel West Hospital, New Albany, Ohio Ronald G. Riechers II, Neurologist, Louis Stokes Cleveland Veterans Affairs Medical Center, Ohio Hilaire Thompson, Assistant Professor, Biobehavioral Nursing and Health Systems, University of Washington, Seattle Katherine L. Tucker, Professor and Chair, Department of Health Sciences, Northeastern University, Boston, Massachusetts Jacob W. VanLandingham, Assistant Professor, Biomedical Sciences, Florida State University School of Medicine, Tallahassee vii

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viii REVIEWERS Steven H. Zeisel, Professor, Departments of Nutrition and Pediatrics, University of North Carolina at Chapel Hill Although the reviewers listed above have provided many constructive comments and suggestions, they were neither asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Johanna Dwyer, Director, Frances Stern Nutrition Center at Tufts University, and Floyd E. Bloom, chairman emeritus, Department of Neuropharmacology at Scripps Research Institute. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Contents Preface xi Summary 1 Part I: Background 1 Introduction 13 2 Nutrition in Clinical Practice Guidelines for Traumatic Brain Injury 23 3 Understanding Pathophysiological Changes 31 Part II: Nutrition and TBI 4 Approach for Selecting Nutritional Interventions: Mechanistic Targets 55 5 Acquiring Resilience to TBI Prior to Injury 69 6 Energy and Protein Needs During Early Feeding Following Traumatic Brain Injury 79 7 Antioxidants 88 8 Branched-Chain Amino Acids 108 9 Choline 115 10 Creatine 130 11 Ketogenic Diet 140 12 Magnesium 157 13 Eicosapentaenoic Acid (EPA) and Docosahexaenoic Acid (DHA) 188 14 Polyphenols 205 15 Vitamin D 227 16 Zinc 233 ix

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x CONTENTS Part III: Recommendations 17 Summary of Recommendations 249 Appendixes A Agenda 259 B Evidence-Based Guidelines for Traumatic Brain Injury 263 C Workshop Speakers’ Papers 286 D Glossary 413 E Acronyms 421 F Committee Member Biographical Sketches 427

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Preface This Institute of Medicine report was the result of a request by the Department of De- fense’s (DoD’s) Military Nutrition Division of the U.S. Army Research Institute of Environ- mental Medicine (USARIEM) to the Institute of Medicine (IOM) to review the potential role of nutrition in improving the outcomes of traumatic brain injury (TBI) at the acute stage. As background, the committee was to include an overview of types of TBI that are most commonly associated with combat operations. The committee also was asked to identify research needed in promising areas. Active military service members experience a high percentage of traumatic brain injury ranging from severe to mild cases. The biological mechanisms of TBI are still not fully under- stood, and it involves a cascade of events resulting in a diversity of adverse effects in many realms of an individual’s health. In fact, brain injury has been the topic of several National Academies studies in the past decade, many of them revealing the paucity of answers in re- gard to treating or preventing the injury. To date, there is no single standardized or effective approach for managing TBI and targeting a single aspect of the injury cascade following TBI has largely been unsuccessful. Because of the evidence that nutrition can modulate brain function in the healthy and injured population, nutrient approaches have been proposed as a way to provide resilience prior to TBI and as an adjuvant to other treatments after injury. The U.S. military forces are currently deployed in areas that present new challenges, such as the use of new types of warfare that increases the risk of experiencing blast injuries. In addition, since 2001, the number of troops deployed and the frequency and length of de- ployments augment the demands on our troops. The numbers of military personnel being affected by TBI in its various types (concussion/mild, mild, moderate, severe, penetrating, or blast) have frequently reached the news. As awareness of this public health problem increases, the military has devoted more resources in technology, research, diagnosis, and treatment to manage this disease. A committee of 11 experts was formed with extensive knowledge across both military and civilian populations in the areas of neurology; nutritional sciences, clinical nutrition and dietetics; physiology; physical medicine and rehabilitation; psychiatry and behavior; xi

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xii PREFACE biochemical and molecular neuroscience; epidemiology/methodology; and the pathobiology of traumatic brain injury. In addition to its reviews of literature and discussions in closed meetings, the committee had the opportunity to have rich discussion with other experts in clinical care and research during two public workshops. On behalf of the committee, I sincerely thank the participants and speakers who contributed to the two workshops held to inform this study (see Appendix A) and to address topics critical to the completion of the committee’s work. Their presentations served as essential references and resources for the committee. The majority of the committee recommendations direct DoD to conduct research. It is the opinion of the committee that nutrition is a promising component of managing TBI, but many answers are still needed before any nutrition intervention can be utilized. I would like to express my appreciation to Andrew Young, Chief of the Military Nu- trition Division for his help in clarifying the task of the committee and being available to answer questions. I also would like to gratefully acknowledge the effort and skill that com- mittee members brought to this report. Their backgrounds and experience made it possible to integrate nutritional science and neuroscience and to think forward about improving the outcomes of TBI. Finally, I thank the project staff of the National Academies: Maria Oria, study director, Laura Pillsbury, associate program officer, and Gui Liu, senior program as- sistant for their tireless dedication to the production of this report. TBI also is a major health concern for the civilian population, and the actual burden of TBI in the United States is underestimated. It is my hope that this report assists not only DoD in its efforts to improve outcomes from TBI but also the public health community as a whole. I envision that this report will encourage different groups to work together toward answering the many answers still remaining. John W. Erdman, Chair Committee on Nutrition, Trauma, and the Brain