BOX 17-4

Most Promising Research Recommendations on Nutritional Interventions

RECOMMENDATION 6-2. DoD should conduct human trials to determine appropriate levels of blood glucose following TBI to minimize morbidity and mortality. These should be clinical trials of early feeding using intense insulin therapy to maintain blood glucose concentrations at less than 150–160 mg/dL versus current usual care of acute TBI in intensive care unit (ICU) settings for the first two weeks.

RECOMMENDATION 6-3. DoD should conduct clinical trials of the benefits of insulin therapy for care of acute TBI in inpatient settings with total parenteral nutrition (TPN) alone (or plus enteral feeding) versus enteral feeding alone. The goals for blood glucose in the TPN group should be lower (e.g., less than 120 mg/dL) than in the enteral group (e.g., less than 150–160 mg/dL). Variables to measure include clinical outcomes and incidence of hypoglycemia.

RECOMMENDATION 6-4. DoD should conduct studies to determine the optimal goals for nutrition (e.g., when to begin meeting total energy expenditure for optimal lean tissue maintenance or repletion) after the first two weeks following severe injury.

RECOMMENDATION 8-1. DoD should continue to monitor the literature on the effects of nutrients, dietary supplements, and diets on TBI, particularly those reviewed in this report but also others that may emerge as potentially effective in the future. For example, although the evidence was not sufficiently compelling to recommend that research be conducted on branched-chain amino acides, DoD should monitor the scientific literature for relevant research.

RECOMMENDATION 9-1. DoD should monitor the results of the Citicoline Brain Injury Treatment (COBRIT) trial, a human experimental trial examining the effect of CDP-choline and genomic factors on cognition and functional measures in severe, moderate, and complicated mild TBI. If the results of that trial are positive, DoD should conduct animal studies to define the optimal clinical dose and duration of treatment for choline (CDP-choline) following TBI, as well as to explore choline’s potential to promote resilience to TBI when used as a preinjury supplement.

RECOMMENDATION 10-1. Based on the evidence supporting the effects of creatine on brain function and behavior after brain injury in children and adolescents, DoD should initiate studies in adults to assess the value of creatine for treating TBI patients.

RECOMMENDATION 13-1. DoD should conduct animal studies that examine the effectiveness of preinjury and postinjury oral administration of current commercial preparations of purified n-3 fatty acids on TBI outcomes.

RECOMMENDATION 13-2. Based on the evidence that fish oil decreases inflammation within hours of continuous administration, human clinical trials that investigate fish oil or purified n-3 fatty acids as a treatment for TBI are recommended. For acute cases of TBI, it should be noted that there are intravenous fish oil formulations available in Europe, but these are not approved by the Food and Drug Administration (FDA). Continuous enteral feeding with a feeding formula containing fish oil should provide equivalent effects for this purpose in the early phase of severe TBI when enteral access becomes available.

RECOMMENDATION 16-1. Based on a report showing efficacy in humans, the committee recommends that animal studies be conducted to determine the best practices for zinc administration after concussion/mild, moderate, and severe TBI, such as determining the therapeutic window for zinc administration, the length of treatment time for greatest efficacy, and the optimal level of zinc to improve outcomes. These t also rials should evaluate the safety of zinc, based on concerns about toxicity and overload. Results from these studies should be used to design human clinical trials using zinc as a treatment for TBI.

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