Tackling Concussions Head-On: How Nutrition Can Improve Outcomes

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I sat on the floor hunched over and crying. My elbows were raised – close to my eyes as my arms hugged my head, hands clenched at the base of my neck. My brain felt like a percussion instrument shaking inside my skull. As the pounding grew more intense the pain became unbearable. I had a concussion, my second in two years, which earned me a night in the ER.

Concussions are common in sports and recreation. Though considered a mild type of traumatic brain injury because they are usually not life-threatening, all concussions should be taken seriously. A single blow to the head can result in short-term loss of brain functioning or long-term changes in thinking, language, emotions and sensations including taste, touch and smell (1). Repeated concussions can be very dangerous and may lead to permanent changes in brain functioning or in extreme cases, death (2). Though widely recognized in football players, concussions happen in all sports – even in everyday activities – and they are occurring at younger ages. Athletes who have had one concussion have a greater risk (2 – 5.8 times higher) of experiencing another concussion (3). Multiple blows to the head could lead to chronic traumatic encephalopathy (CTE), a progressive neurodegenerative disease associated with poor memory, changes in personality, behavior, speech and gait (4). Posthumous examination of some former NFL players in addition to a few college football players who committed suicide revealed CTE. In March 2016, the NFL acknowledged the link between traumatic brain injury and CTE. The movie ‘Concussion,’ set for release in late December, 2015 highlights concussions in former NFL players though the league has gone to great lengths to make today’s game safer.

Decreasing the Damaging Effects from Concussions

Anyone who experiences a blow to their head or body (a forceful blow to the body can cause the brain to shake inside the skull) should be immediately examined by a physician with experience in the evaluation and management of concussions. Though the person may say they feel fine and can continue with regular activities, symptoms of concussion do not always appear immediately and may instead be delayed for several hours. Continuing to play or perform mental tasks like studying can increase severity or symptoms and cause complications including the possibility of developing permanent brain damage.

Symptoms of Concussion may include:

  • Confusion
  • Headache
  • Vision changes
  • Memory loss
  • Difficulty with coordination, clumsiness or stumbling
  • Dizziness
  • Irritability
  • Personality changes
  • Slurred speech
  • Delayed response to questions
  • Nausea or vomiting
  • Sensitivity to light and noise
  • Problems sleeping
  • Seizures
  • Loss of consciousness

In addition to the symptoms that occur soon after a concussion, some people experience Post-Concussion Syndrome (PCS) days or weeks later. PCS can cause many of the same symptoms experienced after a concussion as well as trouble concentrating, apathy, depression and anxiety. Symptoms may last a few weeks. If you suspect PCS, have the patient evaluated by a psychiatrist (5).

Nutrition Management

In addition to rest, following a graduated return-to-play and school protocol, and other steps you should take to treat concussions, emerging research suggests nutrition may play an important role. Certain nutrients seem to help reduce some of the damaging effects from concussions:

Protein: 1 – 1.5 grams of protein per kg body weight per day is recommended along with sufficient calories to reduce the inflammatory response (6).

EPA and DHA Omega-3 Fatty Acids: EPA and DHA, omega-3 fatty acids found in fish and algae, increase fluidity of cell membranes, reduce inflammation and enhance cerebral blood flow (which is reduced for up to a month or longer in athletes that recover slowly) (7). Cell membranes are like gateways allowing substances to enter cells or blocking their entry. When cell membranes are more fluid (and therefore less rigid), they perform better, opening the gate for nutrients to come in. DHA, in particular, makes up 97% of the omega-3 fatty acids in the brain and is essential for normal brain functioning (8). Several animal studies show EPA and DHA supplementation before or after a traumatic brain injury helps limit structural damage and decline in brain functioning (9, 10, 11, 12, 13, 14, 15).

There is no clear consensus regarding optimal intake of EPA and DHA prior to or after a concussion. Given that many Americans do not eat enough fish and an estimated 75% of American diets are too low in EPA and DHA, it makes sense to start by meeting the general guidelines for recommended intake of EPA and DHA by:

  • Consuming fatty fish varieties that contain high levels of omega-3s, including salmon, tuna, mackerel and herring at least twice per week;
  • Take an omega-3 supplement providing EPA+DHA daily (be sure to look for high-quality fish oil, algal oil or krill oil supplements in your local grocery or health store);
  • Eat and drink DHA omega-3-fortified foods and beverages, including milk, 100% juice, and yogurt.

Research has yet to identify exactly how much EPA + DHA may be helpful after a concussion. However, according to the Food & Drug Administration (FDA), doses of EPA + DHA up to 3 grams per day are considered safe.

Zinc is necessary for optimal brain functioning while a deficiency of this mineral may compound oxidative damage from concussions. Though zinc supplementation may be an effective treatment modality, additional research needs to determine if zinc supplementation is safe after concussions. The Upper Limit for zinc is 40 mg per day.

Animal and human studies suggest creatine helps prevent secondary brain injury after traumatic brain injury. However, animal studies show long-term creatine intake may decrease its beneficial effects on the brain after injury. Future research needs to better elucidate the relationship between creatine pre-TBI and creatine post-TBI and outcomes.

Other potential approaches to addressing concussions through nutrition include ketogenic diets which are very high-fat, minimal-carbohydrate diets that are effectively used to decrease both the incidence and severity of seizures in children with epilepsy. Ketogenic diets provide an alternate energy source for brain functioning – ketones derived from the breakdown of fat. This may be important since available glucose, the primary energy source for brain functioning, may be decreased after a concussion.

Current research supports the integration of a dietitian into the team of health professionals treating concussions. Though nutrition interventions are considered preliminary at this time, consideration should be given to nutrition strategies that may reduce long-term effects while causing no further harm.

Disclosure: I am a GOED/Omega-3 Science Advisory Council Member supporting the research behind omega-3 EPA and DHA for a healthy brain, heart and eyes.

References

1 What are the Potential Effects of TBI? Injury Prevention & Control: Traumatic Brain Injury. CDC. http://www.cdc.gov/TraumaticBrainInjury/outcomes.html

Concussion (Traumatic Brain Injury). Pubmed Health.

3  Harmon KG, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013;47:15-26. http://www.amssm.org/Content/pdf%20files/2012_ConcussionPositionStmt.pdf

4  McKee AC, Cantu RC, Nowinski CJ, Hedley-Whyte T, Gavett BE, Budson AE, Santini VE, Lee H, Kubilus CA, Stern RA. Chronic Traumatic Encephalopathy in Athletes: Progressive Tauopathy following Repetitive Head Injury. J Neuropathol Exp Neurol 2009; 68(7): 709–735.

Post-Concussion Syndrome. PubMed Health 

6 Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. The National Academies Press. 2011. http://www.nap.edu/catalog/13121/nutrition-and-traumatic-brain-injury-improving-acute-and-subacute-health

7  Meier TB, Bellgowan PS, Singh R, Kuplicki R, Polanski DW, Mayer AR. Recovery of cerebral blood flow following sports-related concussion. JAMA Neurol 2015;72(5):530-8.

8 Salem N Jr, Litman B, Kim HY, Gawrisch K. Mechanisms of action of docosahexaenoic acid in the nervous system. Lipids 2001; 36(9):945-59.

9 Mills JD, Hadley K, Bailes J. Dietary supplementation with the omega-3 fatty acid docosahexaenoic acid in traumatic brain injury? Neurosurgery 2011;68:474–81

10 Wu A, Ying Z, Gomez-Pinilla F. Omega-3 fatty acid supplementation restores mechanisms that maintain brain homeostasis in traumatic brain injury. J Neurotrauma 2007;24:1587–95

11 Wu A, Ying 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;21:1457–67

12 Wang T, Van K, Gavitt B, Grayson J, Lu T, Lyeth B, Pichakron K. Effect of fish oil supplementation in a rat model of multiple mild traumatic brain injuries. Restor Neurol Neurosci 2013;31:647–59

13 Mills JD, Bailes J, Sedney C, Hutchins H, Sears B. Omega-3 fatty acid supplementation and reduction of traumatic axonal injury in a rodent head injury model. J Neurosurg 2011;114:77–84

14 Wu A, Ying Z, Gomez-Pinilla F. The salutary effects of DHA dietary supplementation on cognition, neuroplasticity, and membrane homeostasis after brain trauma. J Neurotrauma 2011;28:2113–22

15  Wu A, Ying Z, Gomez-Pinilla F. Exercise facilitates the action of dietary DHA on functional recovery after brain trauma. Neuroscience 2013;248:655–63

Sleep – a Critical Component to Sports Performance

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Years ago hitting the gym and throwing around some steel was considered the most critical aspect of sports performance training. However, in more recent years a more comprehensive model of performance has developed based on decades of research on nutrition, sleep, psychology and several other critical components of an athlete’s training regimen. As a sports dietitian with an Exercise Science degree and CSCS, I focus mainly on food & supplements though I sometimes discuss training. But lately I’ve found that I’m also talking about the importance of sleep with my athletes. This topic comes up once I realize they are too tired to plan and prepare their food. Days of sleep deprivation also leads to poor food choices. If an athlete is tired and hungry, caring about good nutrition will be thrown on the back burner while finding food fast becomes the main priority. Quick and cheap turns into a double cheeseburger with fries. And, aside from failing to implement all aspects of their nutrition plan, skimping on sleep also interferes with an athlete’s training and performance. Studies show chronic sleep deprivation leads to:

  • decreased sub max and maximal lifts in the weight room
  • delayed visual and auditory reaction time
  • slowed decision making
  • impaired motor functioning
  • reduced endurance
  • increased fatigue, decreased energy
  • exercise feels harder than it normally is (increased rating of perceived exertion)
  • less efficient glucose metabolism
  • reduced leptin and increased ghrelin
  • decreased growth hormone secretion
  • increased risk of injury
  • elevated cortisol levels which may interfere with tissue repair and growth
  • impaired insulin sensitivity in fat cells = more fat in your bloodstream (over time this may contribute to obesity, Type 2 diabetes and cardiovascular disease).
  • decreased production of leptin, a protein produced in fat cells that tells your brain you have enough energy (fat) stored away so there’s no need to gorge yourself on food. Low leptin = you get hungry and eat.

According to research presented by Cheri Mah,a Stanford University sleep expert:

  • one night without sleep is the equivalent of being legally intoxicated
  • 4-5 hours of sleep for 4 days = 24 hours awake = legally intoxicated
  • 4-5 hours for 10 days = 48 hours awake

Mah’s 8 Strategies to Improve Sleep and Recovery:

  1. Adults should aim for 7-9 hours of sleep. Athletes need 8-10 hours of sleep (and getting in bed at 10 and waking up at 6 doesn’t mean you are getting a full 8 hours since it takes a while to actually fall asleep).
  2. Establish a consistent sleep schedule.
  3. Sleep like a caveman. It should be dark, quiet and cool. All electronics should be off and silent (or program in numbers for emergency calls only and set your phone for these emergency calls). All small lights on electronics should be covered up as these can interfere with sound sleep.
  4. Adults should only sleep when tired. If unable to sleep after 45 minutes, it is wise to get up and do a non-stimulating activity for 15 minutes (reading) then return to bed.
  5. Establish a 20-30 min routine before bed that includes non-stimulating activity. No computers, TVs or video games.
  6. Refrain from alcohol which impairs your sleep quality and fragments sleep preventing the deep sleep that is so critical for recovery (this is why people complain of being exhausted the day after they drink).
  7. Avoid heavy food, any foods that could cause heartburn, spicy foods etc.
  8. Take 20-30 minute power naps and pre-game naps (unless these interfere with the ability to sleep at night). Mah has found this improved alertness by 54%, improved performance by 34%

Matthew Edlund, M.D. takes it even further with the notion of morning people performing better during the day, night owls performing better at night, and both having to combat jet lag (each 1 hour time zone change takes a person 1 day to adjust; this is why West Coast teams beat East Coast NFL teams on Monday Nights). Check out Edlund’s article here. Sleep affects several aspects of training and performance (as well as body weight). Any athlete who wants to feel their best and reach peak performance should take a comprehensive approach to training which includes sound sleep habits.