Research Examines Potential Benefits of Medical Nutrition Therapy After Traumatic Brain Injury
Research may eventually translate into more extensive evidenced-based recommendations.
By Celia Suber, MS, RD, LD, CNSC
Clinical Dietitian, Shepherd Center
Traumatic brain injury (TBI) results in a significant metabolic and stress response, which causes an increase in the body’s energy expenditure and muscle breakdown. Inadequate nutrition can negatively affect immunity and contribute to pressure wounds, while adequate nutrition has been associated with decreased mortality and improved neurologic outcomes following severe TBI. Also, researchers have proposed that some specific nutrients have an effect in the recovery from TBI. Some of these potential areas of study are discussed below.
When to Initiate Nutrition:
Providing timely nutrition via tube feeding is associated with reduced mortality and improved neurologic outcome following severe TBI. While there is a consensus on the benefits of early nutrition provision, there is less agreement on the specific timing and dose recommended. The Institute of Medicine recommends providing at least 50 percent of estimated calorie needs during first 24 hours following TBI and for at least the first two weeks post-injury. The Brain Trauma Foundation found that mortality rates were increased by four times for those not fed within the first seven days of injury and recommend that full nutrition provision is achieved within the first week after injury. Issues that can impede prompt initiation of feeding following TBI include hemodynamic instability, surgeries/procedures, gastrointestinal intolerance and dysphagia (difficulty swallowing). Implementation of tube feeding/enteral nutrition protocols can be beneficial in achieving early and adequate nutrition.
Type of Nutrition:
Tube feeding and/or oral diets are preferred compared to intravenous (IV) nutrition when possible because they help maintain the good bacteria found in the intestines and have lower infection risk and side effects. Tube feeding intolerance can occur following TBI due to delayed stomach emptying, reduced lower esophageal sphincter tone and vestibular issues (body system involving parts of the inner ear and brain that process the sensory information involved with controlling balance and eye movements). Despite these concerns, studies have shown that many people can tolerate stomach tube feeding following TBI.
Omega-3 Fatty Acids:
Omega-3 fatty acids, EPA and DHA, are long-chain polyunsaturated fatty acids and have been associated with multiple health benefits in epidemiological studies. DHA is an important part of the phospholipid structure of cells in the brain and central nervous system. Also, omega-3 fatty acids have anti-inflammatory effects that may be beneficial following traumatic injuries. While some rodent studies suggest that DHA may have neuroprotective benefits with TBI and some human studies have shown a reduction in reoccurrence of cardiovascular disease with omega-3 supplementation, there are currently no human studies proving a benefit in TBI outcomes from omega-3 supplementation. Potential negative side effects of omega-3 fatty acid supplementation include gastrointestinal intolerance and increased bleeding risk. High-quality human trials are required before making specific recommendations for omega-3 supplementation following TBI.
Glutamine, Arginine and Immune-Enhancing, Tube-Feeding Formulas:
Glutamine and arginine are building blocks of proteins and are often used in tube-feeding formulas that are labeled “immune enhancing.” Glutamine is beneficial to immunity because it fuels the cells of the gastrointestinal tract, which play an important role in reducing the overgrowth of unhealthy bacteria in the intestines. Arginine plays an important role in nitrogen balance and may improve immunity through its conversion to nitric oxide and facilitating neutrophil response. However, there is conflicting data on whether there are benefits of glutamine supplementation following TBI, and in some studies in the critically ill population, glutamine supplementation has been associated with increased mortality. Similarly, arginine is not recommended for use in patients with sepsis and has the potential to increase damaging reactive nitrogen species. Given these findings, more research is needed to determine safety and recommendations for dose and timing before routine glutamine and arginine supplementation is provided following TBI.
Early and adequate nutrition provision is beneficial in the recovery and treatment of severe TBI. Also, there are individual nutrients that may have additional benefits, but high-quality, randomized controlled human trials are required to create specific, evidenced-based recommendations.
Scrimgeour A, Condlin M. Nutritional Treatment for Traumatic Brain injury. J Neurotrauma 2014 June; 31:989-99.
Hartl R, Gerber LM, Ni Q, Ghajar J. Effect of Early Nutrition on Deaths due to Severe Traumatic Brain Injury. J Neurosurg 2008 Jul; 109(1):50-6.
Bistrian B, Askew W, Erdman J, Jr, Oria M. Nutrition and Traumatic Brain Injury: a perspective from the institute of medicine report. J Parenter Enteral Nutr 2011 Sept; 35(5)556-59.
Horn SD, Kinikini M, Moore LW, Hammond FM, Brandstater ME, Smout RJ, Barret RS. Enteral Nutrition for Patients with Traumatic Brain Injury in the Rehabilitation Setting: Associations with Patient Preinjury and Injury Characteristics and Outcomes. Arch Phys Med Rehabil 2015 Aug; 96(8 Suppl): S245-55.
Pepe J, Barba C. The Metabolic Response to Acute Traumatic Brain Injury and Implications for Nutrition Support. J Head Trauma Rehabil 1999; 14(5):462-74.
Mueller, C, Kovacevich D, McClave S, Miller S, Baird Schwartz D. The ASPEN Adult Nutrition Support Core Curriculum, 2nd Ed. 2012. P.369-72.
CELIA SUBER, MS, RD, LD, CNSC, is a clinical dietitian at Shepherd Center. She earned a bachelor of science degree in dietetics from the University of Georgia and a master of science degree in clinical nutrition from Tufts University. Celia has seven years of experience as a clinical dietitian and has worked at Shepherd Center since 2013. You may reach her at firstname.lastname@example.org.
Shepherd Center, located in Atlanta, Georgia, is a private, not-for-profit hospital specializing in medical treatment, research and rehabilitation for people with spinal cord injury, brain injury, multiple sclerosis, spine and chronic pain, and other neuromuscular conditions. Founded in 1975, Shepherd Center is ranked by U.S. News & World Report among the top 10 rehabilitation hospitals in the nation. In its more than four decades, Shepherd Center has grown from a six-bed rehabilitation unit to a world-renowned, 152-bed hospital that treats more than 743 inpatients, 277 day program patients and more than 7,161 outpatients each year in more than 46,000 visits.