a tremendous effort. Because the problem of TBI is not unique to military personnel but is also a concern for the civilian population, the research questions would likely be of interest to other organizations. DoD is encouraged to conduct research internally, to support extramural research, or to collaborate with others in order to obtain answers in the most effective manner.

Ultimately, any potential interventions must be applied to clinical care situations to benefit TBI patients. The committee found that, except for guidance on energy intake, the majority of clinical guidelines for critical care and TBI patients do not include specific recommendations for adequate nutrition either early after injury or in the long term. In addition, discussions with critical care and rehabilitation clinicians indicate there is diversity in clinical practices, and that the small number of current nutrition guidelines is followed by few practitioners. This picture is even more worrisome when considering the lack of specific, evidence-based guidelines for the use of dietary supplements or food components for TBI, and the frequent use of dietary supplements by military personnel discussed in the 2008 IOM report Use of Dietary Supplements by Military Personnel (IOM, 2008). The committee therefore also reflected on the application of the research recommended in this report to improve the clinical guidelines. The findings of the research gaps outlined above would present an opportunity to update the existing clinical guidelines with evidence-based nutritional interventions. To that effect, a table (see Appendix B) was developed with questions for which the evidence does not currently exist, but that will benefit clinicians as they create evidence-based guidelines in the future. These questions are outlined in the PICO (Population/Participant, Intervention, Comparator, Outcomes) format, which is used to present questions for the purpose of creating evidence-based guidelines. Topics include designation of biomarkers, optimal feeding regimens (e.g., sources of energy, percentage of energy needs to be met, route of administration), and novel nutrition therapies. The committee hopes that in addition to creating a research agenda to answer questions about TBI, these recommendations will serve to update clinical guidelines.



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