How Food Can Influence Concussion Recovery: Part II


In PART I of this blog post I discuss some of the fundamental mechanisms underlying concussion pathophysiology and I explore the interplay between glucose, insulin release, fat intake, ketosis, and neurologic recovery. In part II, we will discuss how omega-3 fatty acids support general neurologic health and the potential therapeutic role for concussions. I will then attempt to establish some practical takeaways, as I currently see it.

This was written in 2016. I will try to update this post if new information comes out since this was written, but please be aware that this a information may become outdated before I am able to do so.

Again…the purposes of my blog posts are to facilitate thought and discussion or perhaps even motivate research to answer the remaining questions on this topic. That is all. If you think that you have a concussion, please go see a concussion specialist.

Omega-3 fatty acids
:
Omega-3 fatty acids are long chain polyunsaturated fatty acids and include α-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). Over 97% of the omega-3 fatty acids present in the human brain is DHA which plays a vital role in maintaining membrane fluidity, receptor activity, and signal transduction [1, 2]. In the developing human brain, DHA accumulates in hippocampus and frontal cortex, regions that are important for executive functioning, learning, and memory [2-4]. Foods that are highest in DHA concentration include fatty cold water fish such as salmon, trout, sardines, mackerel, and herring. There are also high amounts of DHA in human breast milk, again highlighting its importance in brain development.

It has been demonstrated that increased omega-3 fatty acid consumption (via seafood or DHA supplementation) is associated with increased brain volume and improved cognition [5-9]. A decreased risk for developing Alzheimer’s is also associated with increased intake [10-13].

Total DHA concentrations in the brain decrease after a mild traumatic brain injury (TBI), which may indicate an increased therapeutic potential [2]. Rats given a diet higher in omega-3 fatty acids were found to have significantly reduced oxidative damage, improved markers for neuroplasticity, better cognitive performance, reduced glutamate excitotoxicity, and less structural damage following a TBI [2, 14-20]. Supplementing isolated DHA was also associated with better cognitive performance, significantly improved biomarkers for metabolism and reduced oxidative stress and damage secondary to a TBI [21-25]. DHA supplementation has also been found to reduce inflammatory markers following brain trauma [26-28].

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What about omega-3 fatty acids for concussion in humans?
I could not locate a human study examining omega-3 fatty acids specifically for concussions. There are, however, two ongoing double-blinded, placebo-controlled trials looking at DHA for sport-related concussions in both adolescent and college athletes [29, 30] (links to studies below).

https://clinicaltrials.gov/ct2/show/NCT01903525

https://clinicaltrials.gov/ct2/show/NCT01814527

Conclusions / Take Home Points:

  • One of the primary components underlying concussion pathophysiology is the dysfunctional metabolism of glucose.
  • Human brains are able to utilize other energy substrates, particularly ketones, to generate ATP, especially during metabolically challenging situations.
  • Ketone synthesis is directly influenced by insulin levels. If you reduce insulin enough, you eventually dial up ketogenesis.
  • This ketogenic pathway is already utilized for pediatric seizure disorders and the method used is a ketogenic diet, or some variation.
  • Negative neurologic effects are observed with a diet that is high in refined carbohydrates. This is also true in the specific context of a TBI. This has not been evaluated for human concussions.
  • There is a growing body of evidence demonstrating benefits from ketogenic diets for other neurological diseases, including dementia.
  • There is a substantial body of evidence demonstrating significant benefits from a ketogenic diet for traumatic brain injuries (severe and mild) in animal models.
  • Human studies supporting the use of ketosis for TBI or concussion is lacking, not because of negative results, but because the studies have not yet been done.
  • You can achieve ketogenesis easier with medium chain triglyceride supplementation, allowing for a more moderate reduction in carbohydrates and protein.
  • Increased DHA consumption appears to provide general neurological benefits to humans, as well as in animal-models of traumatic brain injury.
  • Omega-3 fatty acids are being looked at for concussions in two ongoing human studies. 

Given the significant therapeutic potential behind these dietary strategies, more research is badly needed to validate what works.

Questions remaining…

  • Does an increase in serum ketone levels improve concussion recovery and/or symptoms in humans? If so, in what ways and by how much?
  • Is this a tool better used for patients with prolonged recovery, or Post-Concussion Syndrome
  • If effective, what serum ketone levels are needed for a therapeutic effect?
  • If effective, in what population? What age groups?
  • Do serum levels need to be higher for older patients compared to the pediatric population for therapeutic benefits?
  • How practical is it to implement a classical KD in a typical physician clinical setting?
  • What are the roles for exogenous ketones? MCT oil supplementation? Incorporating more MCT containing foods into the diet?
  • How do supplements come into the picture? DHA? MCT’s? Exogenous ketones?

Presentation1
Paoli A. Ketogenic Diet for Obesity: Friend or Foe? International Journal of Environmental Research and Public Health. 2014;11(2):2092-2107. doi:10.3390/ijerph110202092.

Where do we go from here…

Peer-reviewed, scientific studies looking directly at ketosis for concussions do not exist at the time of writing this blog post. As I see it, we have two basic options. We can logically and rationally look at the evidence that does exist. We can critique the mechanisms and evaluate the potential for harm (as you should for ANY intervention). We can evaluate the practicality and cost/time effectiveness of implementing the intervention. And if the answers to these questions remain favorable (which in my opinion they mostly do), we can make dietary recommendations for concussions.

It will likely be many years, if ever, before we obtain clear evidence based answers to all of these questions. After examining the literature that IS available, and doing a little cost/benefit analysis, there appears to be adequate evidence and rationale to support some broad dietary recommendations…

  • Eat a diet that limits hyperglycemia and insulin spikes (by reducing refined carbs/sugars) **
  • Increase consumption of healthy fats
  • Eat adequate amounts of food with high DHA content (about 3-4 servings of cold-water fatty fish a week)
  • Cooking with, supplementing with, or eating foods that are rich in MCT’s should be considered ***

**A potential downside here would be in implementing abrupt carbohydrate changes in the insulin-dependent diabetic population. There would need to be a lot more physician chaperoning in this a much more medically challenging situation to avoid severe hypoglycemia.

***A potential downside with MCT oil supplementation is gastrointestinal side effects (speaking from experience). This can be mitigated through a slow gradual incorporation into the diet.

Keep in mind, that the average person is eating breakfasts full of bagels, cereals (with added sugar), toast, jelly, waffles, pop-tarts, donuts and washing it all down with a tall glass of orange juice. The lunches have plenty of French fries, breads, colas, potato chips, and corn snacks.  Dinners with a lot of pasta, breads, and always some type of dessert. Athletes are commonly pounding those sugary sports drinks and chowing down on sugar laden protein bars. Don’t forget all of the insulin-spiking snacks consumed in between.

Especially when this is the person’s baseline, eating according to the above listed guidelines has tremendous therapeutic potential.

References:

  1. Greco, T. and M.L. Prins, Traumatic Brain Injury and Diet. Journal of Child Neurology, 2013. 28(8): p. 983-988.
  2. Barrett, E.C., M.I. McBurney, and E.D. Ciappio, ω-3 Fatty Acid Supplementation as a Potential Therapeutic Aid for the Recovery from Mild Traumatic Brain Injury/Concussion. Advances in Nutrition, 2014. 5(3): p. 268-277.
  3. Ryan, A.S., et al., Effects of long-chain polyunsaturated fatty acid supplementation on neurodevelopment in childhood: A review of human studies. Prostaglandins, Leukotrienes and Essential Fatty Acids. 82(4): p. 305-314.
  4. Kuratko, C.N., et al., The Relationship of Docosahexaenoic Acid (DHA) with Learning and Behavior in Healthy Children: A Review. Nutrients, 2013. 5(7): p. 2777-2810.
  5. Kalmijn S, v.B.M., Ocke M, Verschuren WM, Kromhout D, Launer LJ, Dietary intake of fatty acids and fish in relation to cognitive performance at middle age. Neurology, 2004. 62(2): p. 275-80.
  6. Whalley, L.J., et al., Cognitive aging, childhood intelligence, and the use of food supplements: possible involvement of n−3 fatty acids. The American Journal of Clinical Nutrition, 2004. 80(6): p. 1650-1657.
  7. Titova, O.E., et al., Dietary intake of eicosapentaenoic and docosahexaenoic acids is linked to gray matter volume and cognitive function in elderly. Age, 2013. 35(4): p. 1495-1505.
  8. Tan, Z.S., et al., Red blood cell omega-3 fatty acid levels and markers of accelerated brain aging. Neurology, 2012. 78(9): p. 658-664.
  9. Muldoon, M.F., et al., Serum Phospholipid Docosahexaenonic Acid Is Associated with Cognitive Functioning during Middle Adulthood. The Journal of Nutrition, 2010. 140(4): p. 848-853.
  10. Lopez LB, K.-S.D., Barrett Connor E, High dietary and plasma levels of the omega-3 fatty acid docosahexaenoic acid are associated with decreased dementia risk:. J Nutr Health Aging, 2011. 15(1): p. 25-31.
  11. Schaefer, E.J., et al., Plasma phosphatidylcholine docosahexaenoic acid content and risk of dementia and alzheimer disease: The framingham heart study. Archives of Neurology, 2006. 63(11): p. 1545-1550.
  12. Morris, M., et al., COnsumption of fish and n-3 fatty acids and risk of incident alzheimer disease. Archives of Neurology, 2003. 60(7): p. 940-946.
  13. Morris, M., et al., FIsh consumption and cognitive decline with age in a large community study. Archives of Neurology, 2005. 62(12): p. 1849-1853.
  14. Wu A, Y.Z., Gomez-Pinilla F, Dietary omega-3 fatty acids normalize BDNF levels, reduce oxidative damage, and counteract learning disability after traumatic brain injury in rats. J Neurotrauma, 2004. 21(10): p. 1457-67.
  15. Mills, J.D., K. Hadley, and J.E. Bailes, Dietary Supplementation With the Omega-3 Fatty Acid Docosahexaenoic Acid in Traumatic Brain Injury. Neurosurgery, 2011. 68(2): p. 474-481.
  16. Wu A, Y.Z., Gomez-Pinilla F, Omega-3 fatty acid supplementation restores mechanisms that maintain brain homeostasis in traumatic brain injury. J Neurotrauma, 2007. 24(10).
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of fish oil supplementation in a rat model of multiple mild traumatic brain injuries. Restorative Neurology and Neuroscience, 2013. 31(5): p. 647-659.

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