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Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel 5 Acquiring Resilience to TBI Prior to Injury The concept that the brain is a flexible organ that can be affected by its environment has only recently begun to be accepted in the scientific community. As a result, the fields of nutrition and central nervous system function have only started to coalesce within the past few decades, attempting to associate nutrition and diet with improvements in behavior, cognition, and alertness. As demonstrated in Chapter 3, information about the pathological processes of traumatic brain injury (TBI) and their timing is also incomplete, especially when considering the diversity in brain injuries. There are still questions and challenges in attempting to identify promising nutrition interventions to increase resilience to TBI. Still, using nutrition as a preventive intervention is a sensible proposition, since it appears that the presence or absence of a nutrient (see Chapters 6–16) within minutes to hours of the injury may have the potential to influence the outcome. The problem of identifying promising nutritional interventions for TBI was faced from two different angles: resilience and treatment. The committee uses the term resilience to refer to the effect of interventions that occur before the insult. A nutritional intervention may impart resilience in two general ways, by preventing or interrupting pathological processes postinjury, or by enhancing the damage repair process. This chapter provides the committee’s thinking about the importance of nutrition in providing resilience. In addition, the chapter summarizes military nutrition standards and what is known about the diets of military personnel. INTRODUCTION Over time, both the North American Dietary Reference Intakes (DRIs) and the Military Dietary Reference Intakes (MDRIs) have shifted their focus from preventing deficiencies to promoting optimal health. Among the nutrients that offer promise in providing resilience and are therefore important to consider are both essential (e.g., vitamins E and C) and non-essential food components (e.g., creatine and resveratrol). This section explores the concept that dietary intake prior to experience of a TBI event affects the outcomes. The evidence,
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Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel based on studies conducted to investigate the resilience imparted by specific nutrients or food components, is presented in Chapters 6–16. Research clearly indicates that malnourished patients have longer hospitalizations and poorer surgical outcomes than well-nourished patients (Garrouste-Orgeas et al., 2004; O’Brien et al., 2006; Tremblay and Bandi, 2003). However, research also indicates that in a generally adequately nourished population, short-term reduction of protein and energy intake prior to surgery is not significantly related to outcomes. This is relevant to discussion of military service members because they sometimes undergo short periods of time during special missions when dietary intakes may be less than the MDRIs, but these short-term deficits apparently do not affect their health status or performance. Based on the Department of Defense (DoD) testimony, the committee assumed that the nutrition status of active-duty military personnel is similar to that of the general population of the United States. Even with the presumption that their nutrition status is adequate, there may still be opportunities to target intake of specific nutrients having the potential to maximize resilience to an injury such as TBI. The question of how to maximize the use of nutrition to optimize resilience to TBI should address the overall nutritional status of military personnel, but it should also identify particular nutrients that may be more important than others in a generally well-nourished population. In order to plan menus and rations to ensure adequate diets for military personnel, military nutrition standards and menu-planning procedures have been established and implemented. In the future, these standards and procedures might consider specific nutrition approaches if there is evidence that they would benefit those at higher risk of experiencing TBI. MILITARY NUTRITION STANDARDS Historically, the military has reviewed the nutrition standards (DRIs) for the general U.S. population and determined whether adjustments were necessary for military personnel, specifically for those experiencing situations unique to the military, such as being deployed in extreme environments and under high levels of physical and mental stress. Previous reports concluded that service members may have nutritional requirements that differ from those of the general U.S. population. Previous committees of the Institute of Medicine (IOM) also have recognized that the dietary intake of military personnel might be different from that of the general U.S. population and have recommended evaluation of nutritional status throughout the military services (e.g., IOM, 2006, Mineral Requirements for Military Personnel). The MDRIs were last updated in 2001 in a tri-service regulation (Baker-Fulco et al., 2001; U.S. Departments of the Army, 2001). This regulation established nutritional standards for military feeding as well as nutritional standards for operational rations (NSORs). The Army, the lead agency, is tasked with the responsibility to “establish nutritional standards of meals served to military personnel subsisting under normal operating conditions and while under simulated or actual combat conditions” and “establish nutritional standards for operational rations and restricted rations.” Each military service is responsible for ensuring there are mechanisms in place to meet nutritional standards in menus, including compliance requirements in contracts with food service operations. The current MDRIs, shown in Table 5-1, were adapted from the 1989 Recommended Dietary Allowances (RDA, 10th revised edition) and thereafter from the DRIs for the following nutrients: calcium, phosphorus, magnesium, vitamin D, fluoride, thiamine, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, choline, vitamin C, vitamin E, selenium, and carotenoids (Baker-Fulco et al., 2001). The regulation acknowledged that DRIs for some nutrients (i.e., vitamins A and K,
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Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel TABLE 5-1 Comparison of Current MDRIsa with DRIs Unit Menb Womenb MDRI RDA, AIc MDRI RDA, AIc Energy,d general/routine Kcal/d 3,250 Based on weight, height, and activity levels 2,300 Based on weight, height, and activity levels Light activity Kcal/d 3,000 See above 2,200 See above Moderate activity Kcal/d 3,250 See above 2,300 See above Heavy activity Kcal/d 3,950 See above 2,700 See above Exceptionally heavy activity Kcal/d 4,600 See above 3,150 See above Proteine g/d 91 (63–119) 56 72 (50–93) 46 Vitamin A μg RE/d 1,000 900 800 700 Vitamin D μg/d 5 15 5 15 Vitamin E mg/d 15 15 15 15 Vitamin K μg/d 80 120c 65 90c Vitamin C mg/d 90 90 75 75 Choline mg/d – 550 – 425 Thiamin mg/d 1.2 1.2 1.1 1.1 Riboflavin mg/d 1.3 1.3 1.1 1.1 Niacinf mg NE/d 16 16 14 14 Vitamin B6 mg/d 1.3 1.3 1.3 1.3 Folateg mg DFE/d 400 400 400 400 Vitamin B12 µg/d 2.4 2.4 2.4 2.4 Calcium mg/d 1,000 1,000 1,000 1,000 Phosphorusa mg/d 700 700 700 700 Magnesium mg/d 420 400–420 320 310–320 Iron mg/d 10 8 15 18 Zinc mg/d 15 11 12 8 Sodium mg/d 5,000 (4,550–5,525) 1,500c 3,600 (3,220–3,910) 1,500c Iodine µg/d 150 150 150 150 Selenium µg/d 55 55 55 55 Fluoride mg/d 4.0 4c 3.1 3c Potassium mg/d 3,200 4,700c 2,500 4,700c aValues for energy, protein, and associated nutrients are expressed as average daily nutrient intakes and based on moderate activity levels and reference body weights of 79 kg (174 lb) for military men and 62 kg (136 lb) for military women. b RDA values represent those for adults ages 19–50 years old. c AI = Adequate Intake. Data were insufficient to determine an RDA. AMDR = Acceptable Macronutrient Distribution Range. This is the percentage of energy intake that is associated with reduced risk of chronic disease and provides adequate amounts of essential nutrients. d Energy recommendations for various activity levels are estimates only and vary among individuals. The general values are for moderate levels of activity and are appropriate for most personnel in garrison. Values are rounded up to the nearest 50 kcal. e The RDA for protein is based on 0.8 g/kg/day; the MDRI for protein was based on 0.8–1.5 g/kg/day. f Expressed as mg/day as niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan. g Expressed as μg/day as dietary folate equivalents (DFEs). 1 DFE = 1 μg food folate = 0.6 μg of folic acid from fortified food or as a supplement consumed with food = 0.5 μg of folic acid from a supplement taken on an empty stomach. SOURCES: IOM, 2006a, 2010; U.S. Departments of the Army, Navy, and Air Force, 2001.
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Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel chromium, copper, iodine, iron, manganese, molybdenum, and zinc) were published after the MDRIs were established, and that interim guidance would be necessary to update the regulation as new DRI reports were published (U.S. Departments of the Army, Navy, and Air Force, 2001). The MDRIs are currently under revision, and increases from the previous MDRIs are being considered for three nutrients (vitamin K, iron [for women], and potassium), while decreases are being considered for four nutrients (vitamin A, iron [for men], sodium, and fluoride). In addition to the MDRIs, there are also NSORs for rations that are intended for use under limited circumstances. Operational rations include meals, ready-to-eat (MREs) and group feeding rations (Unitized B ration, and Unitized Group rations); these are also designed to be nutritionally adequate, and menus, when averaged, will meet the NSORs. Restricted rations (e.g., survival rations; meals, cold weather; long-range patrol rations) are intended for special purposes and for short-term use (i.e., less than 10 days) and are not required to be nutritionally adequate. The MDRIs consider military circumstances that affect nutrient requirements, such as the need for higher intake of energy and some minerals when performing intensely demanding physical tasks in a variety of environments (e.g., extremes of altitude or temperature). The military also has considered adding to the rations components that improve cognitive functions essential for the performance of military duties, like attentiveness or the ability to make rapid decisions. One such example that was reviewed and later introduced into rations is caffeine. As new challenges emerge, such as TBI in all its forms, military diets will need to be reconsidered and readjusted. DEVELOPMENT OF MENUS The committee was asked to assume that both predeployment and postdeployment nutritional intakes are similar to the diets of the general U.S. population as evaluated in the National Health and Nutrition Examination Survey (NHANES) and Dietary Guidelines Advisory Committee reports.1,2 While in theater, many deployed service members are provided food comparable to meals in a garrison dining facility. The in-theater menus are developed at Fort Lee by the Joint Culinary Center of Excellence (JCCoE) in accordance with the Army and DoD nutritional standards (AR 40-25) and the Army menu standards (AR 30-22 and DA PAM 30-22). AR 40-25 provides the nutritional foundation of the menu while AR 30-22/DA PAM 30-22 describes the procedures used to meet the nutrition standards through menu patterns and food choices. As prescribed in AR 40-25, 2-1f, menus are required to meet the MDRIs over a 5- to 10-day period. Oversight of menus prepared by JCCoE is provided by the Food Service Management Board (FSMB). Briefly, the FSMB consists of the food program manager/food advisor, a dietitian, a supply representative, representatives from all supported major subordinate commands, prime vendor representatives, a preventive medicine representative, and a veterinary services member. One of the primary functions of the FSMB is to review the menu and incorporate new products based on their nutritional value, sensory appeal, and customer and regional preferences. Changes made to the JCCoE menus at the local installation level are reviewed by the dietitian, a voting member of the FSMB, who provides feedback on nutritional adequacy of menus. Nutrient analysis is not routinely conducted when planned menu items are replaced with other items because of local food preferences or other causes. The 1 Available online: http://www.cdc.gov/nchs/nhanes.htm (accessed December 23, 2010). 2 Available online: http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm (accessed January 14, 2010).
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Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel dietitian’s designated role at the FSMB is to recommend specific changes in levels of nutrients when necessary to preserve the health of the troops, to review the menus and compare them with standards, to advise the board on the nutritional aspects of revised menus, to educate and advise the board on nutritional topics such as the nutritive value of each product sample and current nutrition trends, and to discuss the availability of more healthful products with the prime vendor for the local installation. The performance of contract services that provide food for the dining facilities in theater is reviewed by a Quality Assurance Evaluator. Although evaluators complete the Food Service Contract Management (FSCM) course and other training for the Contracting Officer Representative/Quality Assurance Evaluator, they are not required to have nutrition knowledge. Evaluators assess whether the menus in dining facilities meet the standards in regulations AR 30-22 and DA PAM 30-22 for providing the components of meals, but they do not conduct nutritional analyses of menus. DIETS OF MILITARY PERSONNEL As explained above, menus offered in contract dining facilities in theater are intended to meet the MDRIs, but each service member’s actual nutrient intake is of course dependent on the individual’s knowledge, preferences, and habits. Although a one-hour block of nutrition education is included during basic training, it isn’t clear whether this is sufficient to ensure adequate understanding of the importance of general nutrition in overall performance. An Army nutrition education initiative called Go for Green that color-codes menu items according to nutrition characteristics may provide additional valuable information to help support more healthful choices by soldiers. The Go for Green nutrition education program allows incorporation of additional nutritional criteria when the science becomes strong enough. The outcomes of this initiative have not been measured yet. Similar nutrition education in other services may also be appropriate, as well as nutrition education targeted to particular military situations or concerns, e.g., specific to TBI when the likelihood of this type of injury is high. The Soldier Fueling Initiative provides additional concrete examples of how to use menu-planning items when menu standards are modified (e.g., the inclusion of more foods high in specific nutrients).3 Although it could be argued that the dietary intake of those with access to dining facilities mirrors that of the general U.S. population, data documenting current dietary intake while in theater are not available. Other service members consume a variety of operational rations while on patrols in remote areas, which should also be considered when attempting to provide nutrition support for resilience to TBI. Service members do not normally subsist solely on operational rations (e.g., MREs) for longer than 21 days, but unfortunately there is only limited data available for intake under these circumstances. The proportion of deployed service members consuming each of the various rations4 is not known. Likewise, information on the intake of these rations by military personnel is also not available. There are further variations in the components of the rations based on availability, and the logistics of transporting food in theater will have a significant effect on what is actually served. Informal reports from deployed military dietitians indicate that some military members lose significant weight (either intentionally or unintentionally) while deployed, while others, given constant access to dining facilities, gain weight. It is acknowledged that in longer 3 Available online: http://www.quartermaster.army.mil/jccoe/Operations_Directorate/QUAD/Nutrition/nutrition_main.html (accessed December 23, 2010). 4 A rations that include fresh, frozen, and canned foods; B rations consisting of only canned and dried foods (e.g., unitized rations); and operational rations such as MREs or other specific operational rations.
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Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel deployments individuals can respond in different ways: from using the time away to actively seek optimal health by restricting calories to lose weight accompanied with working out to increase physical fitness, to eating unrestrictedly because a variety of food is available throughout the day. In addition other factors may affect dietary intake such as the risk of going outside to dining facilities or the reluctance to don the appropriate protective gear for the short interval needed for mealtime (Col. George Dilly, personal communication, July 2010). For these reasons, the committee was not persuaded that it is appropriate to use dietary intake data on the general U.S. population as a surrogate measure for military intake in theater, and concluded that it would be more prudent to assess military diets. Ascertaining the actual preinjury intake of specific nutrients of interest from the variety of rations as well as dietary supplements in both types of military environments (i.e., eating in dining facilities or a predominantly ration diet) is critical to determining the policies and procedures most likely to ensure that military personnel receive optimal nutrition to promote resilience to TBI. Previous reports (e.g., IOM, 2008) identified the need for ongoing monitoring of usual dietary intake that included both food and dietary supplements to serve as the basis of nutrition policies, and this report likewise identifies that as a critical gap in knowledge. Table 5-2 summarizes the NHANES data on dietary intakes for comparable U.S. populations and is provided for illustration. Although NHANES does include dietary supplements, there are only limited data available on their use. The data below should be interpreted in the context that approximately one-third of military personnel regularly use multivitamins, multiminerals, or both as dietary supplements. NHANES data can be reviewed to estimate nutrition status of military personnel, assuming that the military dietary intake is similar to that of the general U.S. population. These data indicate that for a relatively high proportion of the general U.S. population, dietary intakes are less (e.g., vitamin A, magnesium, vitamin E, and zinc) than the Estimated Average Requirements. Other nutrients (e.g., choline, eicosapentaenoic or docosahexaenoic acids) are not specifically addressed in these datasets. Researchers have concluded that choline intake is likely to be low, but this is difficult to ascertain due to genetic polymorphisms that seem to modulate requirements. Databases providing the choline content of foods were not available until recently. Using the 2003–2004 NHANES data, researchers have estimated that only 10 percent of the U.S. population has choline intakes that meet or exceed the Adequate Intake level (Zeisel and da Costa, 2009). Some dietary components or bioactives of particular interest to the military in the past because of their high frequency of use, potential for adverse effects, or both (the reader is referred to the 2008 IOM review of dietary supplement use by military personnel) are also important in the context of this study because of their possible influence on brain function and neurological outcome. Owing to the unique demands of military operations, intake of 100–600 mg/day of caffeine has been recommended for military personnel to maintain cognitive performance in situations of sleep deprivation and to enhance physical endurance, especially when affected by high altitude (IOM, 2001). It should be noted, however, that chronic frequent use of caffeine can lead to tolerance and reduce these benefits. As noted in the 2008 IOM report, not all aspects of cognitive and neurobehavioral functions may be affected by caffeine, and it may compromise physical performance in certain environments because of its physiological effects at high dosages, sustained intake, or both, such as heat retention and dieresis. Besides coffee, which remains the primary source of caffeine among the U.S. population, soft drinks, tea, and energy drinks are substantial contributors to caffeine consumption. Within the military, tolerance caused by the increase in caffeine intake via widespread
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Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel TABLE 5-2 Current Status in U.S. Diet Compared to DRI Percent Less Than EAR Male, Aged 19+ y Female, Aged 19+ y Vitamin A 57 48 Vitamin E 89 97 Thiamin 4 10 Riboflavin < 3 < 3 Niacin < 3 < 3 Vitamin B6 7 28 Folate 6 16 Vitamin B12 < 3 for ages 19–50 < 3 for ages 19–50 Vitamin C 40 38 Phosphorus < 3 < 3 NHANES 05–06 < 3 3 (0.7) Magnesium 64 67 NHANES 05–06 53 56 Iron < 3 10 Zinc 11 17 Copper < 3 10 Selenium < 3 < 3 Percent Less Than Adequate Intake Vitamin K 80 59 Potassium 94 > 97 Dietary fiber > 97 92 Linoleic acid 18:2 47 44 Linolenic acid 18:3 47 39 SOURCES: Adapted from Moshfegh et al., 2005, 2009. consumption of beverages and dietary supplements or medications may reduce caffeine’s cognitive and physical performance–enhancing benefits. Furthermore, beverages like energy drinks often contain other methylxanthines and caffeine analogues, such as guarana, in addition to other herbal compounds, like ginseng; the mechanisms of action, potential benefits, and safety concerns of these substances remain unclear. Emerging evidence suggests that caffeine exerts a neuroprotective effect in animal models of TBI, stroke, and Parkinson’s disease (Sachse et al., 2008). A retrospective study of caffeine concentration measured in cerebrospinal fluid of patients with severe TBI also found an association between caffeine concentration and favorable Glasgow Outcome Scale scores (Sachse et al., 2008). However, the evidence, depending on the dose, model, and timing, is conflicting, and warrants further investigation. The combination of caffeine and alcohol has been found to be beneficial in experimental TBI and stroke models (Dash et al., 2004). Even on its own, alcohol has also been associated with improved outcomes in patients with moderate to severe TBI (Berry et al., 2010; Opreanu et al., 2010). Despite a possible neuroprotective role of alcohol, it is important to emphasize that alcohol intoxication is a leading factor in civilian cases of TBI, especially among individuals with a history of substance abuse. At the same time, TBI is a noted risk factor for substance abuse (Graham and Cardon, 2008). Excessive and chronic consumption of alcohol has also been associated with negative interactions with certain nutrients, such as impaired absorption (zinc), depletion (magnesium), and depressed fatty-acid oxidation (polyunsaturated fatty acids) (IOM, 2006b).
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Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel DIETARY SUPPLEMENT USE BY THE MILITARY Even assuming that the eating habits of deployed military personnel are not significantly different from those of the general U.S. population, total nutrient intake may still vary because of dietary supplement use. In a representative sample of active-duty U.S. Army soldiers (n = 990), Lieberman and colleagues (2010) found that 53 percent of participants reported taking any dietary supplement one or more times per week during the preceding six months. The most commonly used dietary supplements were multivitamins, multiminerals, or both (37.5 percent), protein and amino acids (18.7 percent), and individual vitamins and minerals (17.9 percent). Deployment status appeared to be associated with patterns of dietary supplement use. Soldiers in Iraq were less likely than those stationed in the continental United States to report using any dietary supplements (48.8 versus 54.2 percent) or multivitamin and multimineral supplements (27.7 versus 39.1 percent), but more likely to report using protein and amino acids (25.6 versus 18.7 percent). Older age, greater educational attainment, higher body mass index, strength training, or being officers or members of the Special Forces were further associated with greater likelihood of dietary supplement use (Lieberman et al., 2010). Overall military dietary supplement use was similar to that of the U.S. general population. In NHANES 2003–2006, 53.4 percent of participants reported use of any dietary supplement in the preceding month (Bailey et al., 2010), compared to 53 percent of soldiers (Lieberman et al., 2010); the prevalence rates were 52 percent in NHANES 1999–2000 and 40 percent in NHANES III (1988–1994) (Ervin et al., 2004; Radimer et al., 2004; Rock, 2007). Prevalence rates of multivitamin and multimineral use were slightly higher in soldiers (37.5 percent reported use of such supplements one or more times per week) than in civilians (35 percent during the preceding month, based on NHANES 1999–2000) (Radimer et al., 2004). However, there were substantial differences in the use of dietary supplements other than vitamins and minerals, especially protein and amino acid supplements. Among soldiers, 18.7 percent reported using protein and amino acid supplements one or more times per week (Lieberman et al., 2010); based on a representative sample of the noninstitutionalized U.S. population, only 4 percent of men and no women aged 18–44 used creatine (Kaufman et al., 2002), which is the most commonly used amino acid supplement in the United States. In another national survey that included 2,743 noninstitutionalized adults aged 18 and over, 3.4 percent of participants reported using any amino acid supplements in the previous 12 months (Timbo et al., 2006). A 2008 IOM report on dietary supplement use in the military recommended establishing an oversight process to coordinate the evaluation of dietary intake, adverse event surveillance, and educational components to preclude the risk of adverse effects from dietary supplement use. CONCLUSIONS AND RECOMMENDATIONS The military recognizes the importance of nutrition in achievement and maintenance of optimal performance during military tasks. Proof of this is the development of MDRIs specific to this population, the development of rations that meet the needs of those performing particular tasks, and various educational efforts, among many other initiatives. Conducting studies on the nutrition status and nutrient and dietary supplement intake within the military is not only costly, as in the civilian population, but also logistically challenging. These types of nutrition assessments are not typically conducted among active-duty military personnel. A comprehensive survey of dietary supplement intake by military personnel (Lieberman et al., 2010) conducted in 2010 helps provide a clearer picture of nutrition in the military, but such
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Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel a study does not answer questions about intake of essential nutrients. There is no military equivalent of NHANES data (i.e., health and nutritional data on adults and children in the United States) on food consumption and nutrient intakes in theater to enable meaningful recommendations for preventive nutrition prior to the occurrence of TBI. A clear picture of the nutrient and food intake characterizing the nutritional profile accompanying various severities and stages of TBI is likewise necessary to make nutrition recommendations for TBI recovery. This committee believes that knowing the nutrition status of a TBI patient will be essential to determine whether supplementation of specific nutrients would improve health outcomes. In addition, information about nutrition status of TBI patients will help elucidate whether a particular nutrient, dietary supplement, or diet taken prior to the injury is associated with outcomes of TBI. It is also important to collect data on the consumption of other substances that might interact with these nutrients, such as caffeine, alcohol, nicotine, and medications, in conjunction with the assessment of essential nutrient intake. RECOMMENDATION 5-1. DoD should conduct dietary intake assessments in different military settings (e.g., when eating in military dining facilities or when subsisting on a predominantly ration-based diet) both predeployment and during deployment to determine the nutritional status of soldiers as a basis for recommending increases in intake of specific nutrients that may provide resilience to TBI. RECOMMENDATION 5-2. Routine dietary intake assessments of TBI patients in medical treatment facilities should be undertaken as soon after hospitalization as possible to estimate preinjury nutrition status as well as to provide optimal nutritional intake throughout the various stages of treatment. RECOMMENDATION 5-3. In individuals with TBI, DoD should estimate preinjury and postinjury dietary intake or status for those nutrients, dietary supplements, and diets that might show a relationship to TBI outcome. For example, based on the current evidence, the committee recommends collecting those estimates for creatine, n-3 fatty acids, choline, and vitamin D. The data could be used to investigate potential relationships between preinjury nutritional intake or status and recovery progress. Such data also would show possible synergistic effects between nutrients and dietary supplements. REFERENCES Bailey, R. L., K. W. Dodd, J. A. Goldman, J. J. Gahche, J. T. Dwyer, A. J. Moshfegh, C. T. Sempos, and M. F. Picciano. 2010. Estimation of total usual calcium and vitamin D intakes in the United States. Journal of Nutrition 140(4):817–822. Baker-Fulco, C. J., G. P. Bathalon, M. E. Bovill, and H. R. Lieberman. 2001. Military Dietary Reference Intakes: Rationales for tabled values. Technical Note TN-00/10. Natick, MA: U.S. Army Research Insitute of Environmental Medicine. Berry, C., A. Salim, R. Alban, J. Mirocha, D. R. Margulies, and E. J. Ley. 2010. Serum ethanol levels in patients with moderate to severe traumatic brain injury influence outcomes: A surprising finding. American Surgeon 76(10):1067–1070. Dash, P. K., A. N. Moore, M. R. Moody, R. Treadwell, J. L. Felix, and G. L. Clifton. 2004. Post-trauma administration of caffeine plus ethanol reduces contusion volume and improves working memory in rats. Journal of Neurotrauma 21(11):1573–1583. Ervin, R. B., J. D. Wright, and D. Reed-Gillette. 2004. Prevalence of leading types of dietary supplements used in the Third National Health and Nutrition Examination Survey, 1988–94. Advance Data (349):1–7. Garrouste-Orgeas, M., G. Troche, E. Azoulay, A. Caubel, A. de Lassence, C. Cheval, L. Montesino, M. Thuong, F. Vincent, Y. Cohen, and J. F. Timsit. 2004. Body mass index—An additional prognostic factor in ICU patients. Intensive Care Medicine 30(3):437–443.
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