Adrenal Tremor, Parkinson’s Disease and the Wheat Free Diet

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This is a Case Study of a 13 y/o boy who was raised on a wheat free diet (WFD) since age 4.  As an infant,  he  experienced monthly ear infections and was placed on prophylactic antibiotic therapy.  His pre-school years were mired with monthly strep throat infections. Occasionally, he had concurrent small red blotches, indicative of rheumatic fever, on his  torso.  A tonsillectomy was recommended by his pediatrician.

He began a WFD at age 4, the strep throat infections ceased …. unless he ingested wheat without antihistamine prophylaxis. Occasionally, he ate a piece of wheat pizza at school without a immediate anti-histamine.  Subsequent strep throat infections would ensue resulting in swollen cervical lymph nodes, a flushed face, swollen, red and pussy tonsils, but no fever.  All infections presented similarly, however not all tested positive for strep.   This condition was treated with antibiotics and resolved in a few days.  (Please see the www.wheatfreediseasefree.com post on “Keep the Tonsils, Pull the Strep Throat”).

As a pre-schooler,  the boy had wound healing difficulties.  During his middle school years, he experienced anxiety, fatigue, a lack of physical maturation, restless legs, painful joints, middle belly weight, athlete’s foot, and a slightly curved back.

At age 13, he ate two pieces of wheat pizza without antihistamine prophylaxis.  In the days following, his face flushed intensely, cervical lymph nodes swelled, but no fever was present.  His back was painful at the level of his adrenals. He experienced extreme fatigue, his eyes were sensitive to light, and he had a tremor.  The tremor traveled down his spine and caused his fingers to vibrate.  He was started on his standard Azithromycin antibiotic therapy. However, the condition did not resolve.

Within a couple days he “crashed“.  He had sufficient energy to be active for a couple of hours in the morning and then he lived on the couch for the remainder of the day.  He headed for bed shortly after dinner. Any form of stress intensified the tremor including homework or attending school.  He was started on a second antibiotic.

Differentials considered included infection, PANDAS, serotonin syndrome, and depression.  Medical personnel questioned whether he was avoiding school.  Blood panels were negative.  EEG was negative.  He was prescribed Zoloft to control the tremor.  This drug made him sick and was discontinued.

One month later, a naturopathic physician identified the boy’s flushed face as being caused by adrenal problems.  Through intracellular saliva testing, he was found to be adrenal insufficient.  The flashlight adrenal insufficiency test was positive.  To support his adrenals he began began a supplemental therapy of vitamin C (1000mg/day), B complex (200mg/day), adrenal cortical extract, minerals, vitamin A, CoQ10, vitamin E, spirulina, quercetin, a probiotic, 1g/day of omega-3 fish oil (DHA+EPA) and 1000mg/day of calcium citrate.  His energy levels gradually improved but the tremor continued.

Sugar, high fructose corn syrup, caffeinated drinks, and deep fried, greasy foods harmful to his adrenals were removed from his diet.  The high levels of fruit juice previously consumed were replaced with low, no sugar, or sugar substitute  juices.

It was determined that wheat contains methionine, lysine and threonine.  Methionine controls the hypophyseal-pituitary-adrenal (HPA) axis and is involved with cardiac rhythm.   Lysine is found in collagen thus supports wound heading and dental pulp formation. Threonine supports tooth enamel formation. Hypothesizing that the patient was deficient in these amino acids due to his WFD,  he was started on 1500mg/day of methionine and 1000mg/day of lysine. The boy craved red meat and eggs.  His diet was modified to include methionine containing foods such as brown rice, oranges, additional red meat, eggs, nuts, spinach, onions, peas, yogurt, and popcorn.  Within a week, the boy had regained sufficient energy to work on small hobbies.

Within a month, he began to experience some quick, sharp chest pain.  Methionine is stored in the heart.  The methionine dosage was reduced to 1,000mg/day.  Although he had more energy and felt better, the facial flushing, swollen lymph glands, fatigue, back adrenal pain, and tremor continued.

A urine amino acid profile showed the boy’s methionine level (with supplementation) in low normal range.  Also in low normal range were phosphoserine, taurine, phosphoethanolamine, aspartic acid, hydroxyproline, serine, asparagine, alanine, tryptophan, carnosine, and anserine.   Some success has been found with taurine in relieving tremor.  He was given a trial of 1000mg/day of taurine.  His energy levels increased, however evening doses made it difficult to sleep and there was no improvement in the tremor.

Repeat urine and blood amino acid profiles showed phosphoserine as the only amino acid below normal range.  The patient was supplemented with 1,000mg/day of serine.  One week post therapy, he developed a skin rash on his arms and legs.  Serine therapy was discontinued then reduced to 500mg/twice each week.  The tremor persisted.

Next, the physiological function of each of these amino acids was addressed in relation to the patient’s signs/symptoms.  Proline was found to be a critical component of cartilage and important to joint structure.  Proline works with vitamin C in this capacity and can be synthesized by glutamic acid.  Arginine was important in wound healing, the production and release of growth hormone, insulin, and glucagon release, collagen synthesis, and GABA production. Arginine can be produced from glutamic acid or proline.  Glycine was critical to GABA neurotransmitter and energy production. GABA was important to inhibitory nerve function. Tyrosine was important to the production of neurotransmitters dopamine, norepinephrine, epinephrine, and melanin.  This patient’s grandfather had Parkinson’s Disease which involves low neurotransmitter levels in the Tyrosine – Dopamine Pathway.

Hypothesizing that the boy’s current amino acid levels may not be sufficient for the age dependent physical growth, adrenal stress due to methionine deficiency, and adrenal stress due to the wheat hypersensitivity reaction, this patient was additionally supplemented with 1500mg/day glutamine,  1500mg/day glycine, and 1000 mg/day tyrosine.  After one week of therapy,  the tremor was alleviated and would resume only  under stressful conditions.

After several months, the individual dosages of amino acids were replaced with a 750mg amino acid complex capsule, three times each day. The patient continued to improve.  This complex differed from ingesting protein rich foods in that all 20 amino acids were given concurrently through the complex.  All 20 amino acids must be present concurrently for  protein synthesis to occur.  Supplementation of the 20 amino acid complex relieved the tremor whereas his protein rich diet did not.

The patient returned to school six months post amino acid therapy initiation with improved physical activity levels, reduced anxiety, and alleviation of restless legs.  The daily tremor was absent except under stressful conditions.  His night time activities were kept to a minimum to ensure sufficient rest.

In subsequent years, he remained on 1500 mg/day amino acid complex, 1 gram of DHA+EPA omega-3 fish oil, B complex 100mg/day, vitamin C 1000mg/day, bovine adrenal cortex 340 mg/day, calcium 1000mg/day,  lysine 500mg/day, choline 500mg/day, 5-HTP 100mg/day, probiotic, and minerals.  It appeared that minimal amounts of these supplements are required to maintain good health.

Six years post presentation, this patient continues with occasional stress and fatigue. This is typically visible as facial flushing on the outer periphery of his cheeks.  The tremor has been alleviated under normal and stress conditions.  This patient continues on a WFD and ingests no wheat.  He ingests minimal sugar and deep fried foods, and no caffeine.  Accidental wheat ingestion receives immediate antihistamine and aspirin prophylaxis. The patient is careful to obtain sufficient rest, take supplements, and eat healthy food.  His back continues to be hunched causing him back, neck, and knee pain, but is otherwise most healthy.

 

Copyright © 2013.  All rights reserved.

Photograph: 8 week old dobie pup

Disclaimer:  The ERB is a literature research team presenting the findings of other researchers. The ERB is not licensed medical nor dietary clinicians and will not give medical nor dietary advice.   Any information presented on this website should not be substituted for the advice of a licensed physician or nutritionist.  Users of this website accept the sole responsibility to conduct their own due diligence on topics presented and to consult licensed medical professionals to review their material.  We make no warranties or representations on the information presented and should users utilize this research without consulting a professional, they assume all responsibility for their actions and the consequences.

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Neurotransmitter Pathways affecting Concussion, TBI, Stress, Depression, Tremor, Stroke, and Anxiety

securedownloadNeurotransmitter Brain Food:  Rebuilding  the Acetylcholine (Choline or Lecithin),  Serotonin (5-HTP or tryptophan)  and Dopamine (Tyrosine) Neurotransmitter Pathways.  

A Case Study Attacks  Stress, Anxiety, and Tremor with pathway amino acids, choline (lecithin) and co-factors.

A middle-aged female with a family history of anxiety and Parkinson’s Disease developed a tremor and mild pain in her left arm. She had a history of painful joint injuries and anxiety due to job-related stress. She obtained little exercise and used ibuprofen (Advil) therapy for the  joint pain. At work she occasionally painted the interior of homes, often inhaling the fumes.  She reported awakening in the morning with an upper body tremor and a cold left arm.  Her fists would be tightened and her hands tingly. During the day, her extra-ocular muscles were painful and she had difficulty focusing.  She experienced somewhat normal energy levels during the early part of each day and then fatigued.  Athletic stress, work place stress, intense mental concentration, painting, an emotional event, sugar or deep-fried food ingestion stimulated the tremor and reduced her energy levels.  At bedtime, upon turning off the lights, she experienced vertical gaze problems.

Her daily vitamins included vitamin B complex (100mg b.i.d. (twice daily)), vitamin C (500mg t.i.d. (three times daily)), amino acids (1500mg t.i.d), fish oil (1g), calcium citrate (600mg), calcium phosphate (600mg), iron (65mg), coenzyme Q10 (200mg), lysine (500mg), beta-carotene (10,000 IU), zinc (50mg), and a multi-vitamin.

She has a family member who has been on standard of care therapy for Parkinson’s Disease for the past 7 years but the disease has progressed. To alleviate her left arm tremor, she began ingesting choline and lecithin in increasing amounts, until the tremor subsided.  During the first weeks of therapy, she experienced a mild frontal lobe headache, more significant on the right side.  Stressful days would be followed by the upper body shiver and left arm tremor, the next morning upon awakening.  Sugar ingestion stimulated the tremor within an hour.  A stressful work situation stimulated the upper body tremor. She slept quite heavily during the first two months of choline and lecithin therapy.  Attempts to reduce the choline and lecithin dosages re-established the tremor.

During the third month of therapy, heavy stress continued  at work. She was anxious and had a negative outlook. To alleviate the sleepiness brought on by the choline/lecithin supplements, provide more energy,  and support the dopamine pathway, she began taking tyrosine.  To fortify the serotonin pathway and improve her mental outlook, she added 5-hydroxytryptophan (5-HTP).  There were positive results the first day.  With the tyrosine and 5-HTP, she was able to perform more of her normal daily activities. In time, with the combination of these supplements, the natural oils returned to her skin and menses became painless.  She continued to decrease stress levels and overwork.  She rested frequently.

The adrenal glands are responsible for producing many neurotransmitters.  They are small walnut shaped glands resting on top of the kidneys which produce cortisone and neurotransmitters in response to stress.  To help her adrenals, she began taking a bovine adrenal rebuilder, the amino acid methionine (controls the adrenals), minimal amounts of sugar, no high fructose corn syrup, no deep-fried foods nor alcohol.

At the beginning of the fourth month, she continued 95% tremor free.  Her left arm continued to experience mild pain depending upon sugar and choline/lecithin levels.  She experienced improvement in her daily energy level and her arm tremor and pain resolved almost completely.  The left arm would experience some irritability after stressful days or skipped choline/lecithin supplements.

At 4 ½ months post tremor initiation, the subject was pricked with a garden thorn.  It appeared that her blood had thinned. She had experienced no side effects of choline (nausea, vomiting, diarrhea, sweating, increased sweating, or salivation (Livestrong Website)) nor side effects of lecithin (rash, low blood pressure, diarrhea, vision problems, fainting or loss of appetite (Headquarters Website)). However, internet research showed that blood thinning may occur with choline/lecithin. She began using  ibuprofen and aspirin sparingly. She decreased her dosage of lecithin, however, the tremor returned.  She resumed the lecithin dosage and purchased a multi-vitamin containing vitamin K and increased green food consumption.  (Vitamin K which is found in greens is important in the blood clotting process).

At five months post tremor her left arm was the same temperature as her right arm upon awakening. The fists and tingling findings were infrequent. The left arm continued to have some irritability after stressful events.  Exposure to paint fumes initiated the tremor. Relief from tremors, extraocular fatigue, body twitches, and spontaneous crying was found with additional choline and lecithin. She experienced some daily facial flushing and left sided chest pain/pressure with exercise.  Knowing methionine is stored in the heart, she reduced her daily methionine intake.

More research as to the benefits of choline, lecithin, methionine, and tyrosine to improve neurological health may be beneficial.  Urine amino acid testing is available and would be important to utilize more frequently to determine amino acid levels pre and post amino acid or pharmaceutical therapy.  Better availability of a urine amino acid neurotransmitter test that specifically provides tyrosine, tryptophan, choline and co-factor levels vital to support the three important neurotransmitter pathways would be beneficial.  We expect that Wellness 2020 will bring these advancements.  For a complete discussion of Wellness 2020 see the home page of http://www.wheatfreediseasefree.com.

Neurotransmitter  Discussion:

Nerves are key to communication within the body. They tell a muscle to move or an organ to function. It takes two nerves, one from brain cortex to the spinal cord and a second from the spinal cord to the foot, to make the foot move.  Nerves communicate through chemicals similar to a car battery.  The nerve running from the brain to the spinal cord will pass a chemical called a neurotransmitter to the nerve running between the spinal cord and the foot to stimulate the receiving neuron. Neurotransmitters travel from the sending neuron to the receiving neuron through a gap (cleft) and they are frequently recycled back into the sending neuron to use again.  The adrenal glands play a key role in producing neurotransmitters from amino acids and dietary protein.

Electricity traveling through a battery or a house is either turned on or off, making man’s design of current either excitatory or off.   The Creator’s design is a bit more elaborate in that it involves both excitatory and inhibitory transmissions.  Epinephrine, acetylcholine, and glutamate are mainly excitatory neurotransmitters while dopamine, norepinepinephrine, and GABA (gaba-amino-buteric-acid) are inhibitory.

On the Concussion Brain Food post at http://www.wheatfreediseasefree.com we discussed the importance of Omega-3 fatty acids (cell membrane formation), B-complex (nerve formation), and Amino Acids (protein/neurotransmitter formation) for healthy brain and nerve tissue.  This Neurotransmitter paper examines the three main neurotransmitter production pathways: ACETYLCHOLINE, DOPAMINE, and SEROTONIN and the amino acids and vitamins required to keep these cells healthy and alive.

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THREE NEUROTRANSMITTER PATHWAYS:

I.  Production of  ACETYLCHOLINE:

                  Phosphatidylcholine (Lecithin)   —->  Glycerophosphatidylcholine   —> Choline   

                    Then,  Choline  +   Acetyl  Coenzyme A  —->   ACETYLCHOLINE

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Acetylcholine functions as both an inhibitory and excitatory neurotransmitter controlling many of the body’s nerves including excitatory skeletal muscle contraction and inhibitory actions on the heart and brain.  The body can convert phosphatidycholine (lecithin) to glycerophosphatidylcholine and then to choline.  The body makes the acetylcholine neurotransmitter by adding acetyl coenzyme A to choline.  Choline is used for cell communication and used to produce phosphatidylcholine and sphingomyelin which make cell membrane (Linus Pauling Institute). Choline contributes to the production of the myelin coating around nerves (Oshida K et al., 2003) and it supports the folate pathway to produce DNA (Institute of Food, Medicine, and Nutrition Board, 1998). The three neurotransmitter pathways described in this paper appear to depend upon each other’s viability.  Acetylcholine, for example, has an important role in activating the Dopamine Pathway.  Normal levels of the dopamine pathway neurotransmitters may not be produced without sufficient levels of acetylcholine to act as a stimulus (Patrick RL et al.,1971).  Low choline and dopamine levels have been implicated in Parkinson’s Disease (Zurchovsky L, 2012).

Choline is an essential nutrient and it is water soluble, therefore must be replenished daily in the diet.  Choline is found in foods such as eggs, fish, liver, milk, wheat germ, and quinoa and is available as a supplement as choline or lecithin.  Since choline plus acetyl coenzyme A make acetylcholine, sufficient quantities of both must be present. Adequate intake levels of choline for healthy individuals are 425-550mg/day (Linus Pauling Institute).

Low choline levels have been found to correlate with anxiety, intelligence and worry (Coplan JD et al., 2012).  Liver and muscle damage (Sha W et al., 2010) athlerosclerosis, neurological disorders (Ziesel SH, et al., 2009),  infertility (Johnson AR et al., 2012),  and growth impairment (De Simone R et al, 1993) are promoted with deficiencies. Those who do not eat enough whole eggs may be at risk (Hasler CM et al., 2000).  Choline is in high demand during pregnancy and helps to prevent neural tube defects (Pitkin RM, 2007).

Choline, B9 (folate), B12 (pyridoxal phosphate), and methionine have key roles in the methyl donor system and cancer protection (Kadaveru K, 2012). Diets rich in choline may lower the risk for breast cancer (Xu X et al., 2009), promote REM sleep (Kushikata F, 2006), and memory (Zhang W et al., 2012). Choline has been used as a treatment for Alzheimer’s disease (Zhang W, 2012), and stroke (Gutierrez-Fernandez et al., 2012).  Choline is being studied to help treat traumatic brain injury. Choline or lecithin can be useful in treating neurological disorders characterized by inadequate release of acetylcholine such as Tardive Dyskinesia (described as involuntary, repetitive facial or limb movements,  Growdon JH,1978). A single meal containing lecithin increases concentrations of choline and acetylcholine in rat adrenals and brain tissue (Hirsch MJ, 1978)  Perinatalcholine is neuroprotective for seizures, depression, and the effects of alcohol (Glenn MJ et al., 2012). Ninety percent of humans in a research study conducted had choline below adequate levels (Zeisel, 2009).

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II.  Production of  SEROTONIN:

                                  Tryptophan hydroxylase                                                Dopa Decarboxylase           

                          Vitamin B3, B9, Iron and Calcium              Zinc, Vitamin B6 and C,  Magnesium                  

Tryptophan   ——>       5-Hydroxytryptophan (5-HTP)    ——–>     SEROTONIN   (5-HT, 5 -Hydroxytryptamine)

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.(Enzymes and cofactors required to produce 5-HTP and 5-HT from the Understand and Cure Website.)

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Tryptophan, an essential amino acid for humans, makes serotonin.  It must be included in the diet, humans are unable to produce it. Tryptophan is found in eggs, spirulina, fish, poultry, nuts, seeds, organic soybeans, milk, and cheese.

To convert tryptophan into 5-HTP and produce serotonin (5-HT, 5-hydroxytryptamine) an enzyme called tryptophan hydroxylase(TPH) is required with the cofactors vitamin B3 (niacin), B6 (pyridoxal-5-phosphate), B9 (folate), vitamin C (ascorbic acid), magnesium, iron, and calcium.  High  fructose corn syrup may decrease absorption of trytophan from the gut (Ledochowski M, et al., 2001) thereby reducing the quantity of TPH enzyme and serotonin produced.  The Parkinson’s medication carbidopa-levadopa (Drugs.Com Website) is known to interfere with tryptophan, thus TPH and serotonin production.

Ninety percent of serotonin is stored in the chromaffin cells of the intestines (Donnerer J, et al., 2006) where it regulates digestion and maintains stomach function. Additionally, the remainder of serotonin is found in platelets and the central nervous system where serotonin is produced in the raphe nuclei and pineal gland of the brain (Neurophysiology Website).  Nerve axons from the raphe nuclei cover the entire length of the brainstem and extend to all parts of the brain including the cerebellum and spinal cord where serotonin influences memory, learning, behavior, mood (well-being, happiness), appetite, sleep and regulates insulin (Young SN, 2007).

When a sending neuron releases serotonin to stimulate a receiving neuron, the neurotransmitter travels out the sending neuron, across a gap or cleft to receptors on the receiving neuron.  By design the neurotransmitter is quickly reabsorbed back into the sending neuron and recycled.  A drug that modifies this normal physiology by keeping serotonin in this gap between the neurons longer is called a serotonin re-uptake inhibitor (SSRI). The result of a SSRI is to create the physiological impression that more serotonin is present thus continuing the stimulation of the receiving neuron. Many antidepressants, anti-anxiety drugs and post-traumatic stress drugs function in this manner.  These drugs do not produce more serotonin to resolve a deficiency, but create the illusion that more is present.

Should the body be deficient or low on serotonin, only ingesting the proper foods or supplementing the diet with tryptophan or 5-HTP provides more serotonin to the brain and intestines. Studies have shown that a change in only 10% of the number of serotonin transporters will affect anxiety levels (Lesch KP, et al., 1996).  Research shows that supplementing tryptophan or 5-HTP (available at nutritional stores) helps to maintain serotonin levels and aids with depression and anxiety (Murphy SE, et al., 2006).  Providing adequate nutrients is important to maintaining healthy cells and production pathways.

 

III. Production of DOPAMINE, NOREPINEPHRINE, and EPINEPHRINE:

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                                          *Vitamin B9             Vitamin B9, iron               Vitamin B3 & B6, zinc                     

                     Phenylalanine  ——>  Tyrosine   —————->   DOPA     ——————>   DOPAMINE 

                                   

                                          Vitamin C                                            S-Adenylmethionine (SAMe)
                     Dopamine  ————>   NOREPINEPHRINE ——————->  EPINEPHRINE

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(*  Required reaction cofactors are listed above the arrows in italics.)

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This is a complicated pathway in that if  sufficient amounts of the amino acid phenylalanine or tyrosine, vitamin B9 (folate), iron, vitamins B3 (niacin) + B6 (pyridoxal phosphate), zinc, vitamin C (ascorbic acid), and methionine (used to produce SAMe) are all present, then the three catecholamine neurotransmitters in this pathway (dopamine, norepinephrine and epinephrine (adrenaline)) are produced to keep the pathway cells strong.  If production falls and pathway cells die off (apoptosis) Parkinson’s Disease or Altzheimer’s may develop.

Phenylalanine is found in fish, beef, chicken, milk, cheese, eggs, and nuts (www.livestrong.com/article/317897-list-of-foods-that-contain-phenylalanine/).

Tyrosine is found in beef, pork, turkey, duck, fish, egg whites, cheese, milk, and soy milk (www.livestrong.com/article/81485-foods-Ityrosine/).

Methionine is essential amino acid required in the diet.  It is found in popcorn, grass fed meat, brown rice, organic oranges, and yogurt.  SAMe (s-adenylsylmethionine) is made from methionine.  It’s production is influenced by the neurotransmitter acetylcholine produced in the Acetylcholine Pathway described above.  Methionine is also found in wheat and can be a deficiency in a wheat free diet. Methionine controls the adrenal glands which are the first responders under stress conditions.  Stress may deplete methionine stores. Methionine chelates metals and neutralizes harmful chemicals.  Painters and those exposed to chemicals may require additional methionine to neutralize these chemicals. Methionine is critical for donating a methyl group (-CH3) to norepinephrine to produce epinephrine in the Dopamine Pathway giving the body energy.  Adrenals that are subjected to low levels of methionine may be a contributing factor to Adrenal Insufficiency, Tremor, and Parkinson’s Disease.

Vitamin B3, Vitamin B6, Vitamin B9.  B-complex vitamins are water soluble and must be ingested daily.

Foods highest in Vitamin B3 (niacin) can be found at http://www.healthaliciousness.com/articles/foods-high-in-niacin-vitamin-B3.php.

Foods highest in Vitamin B6 (pyridoxal phosphate) can be found at http://www.healthaliciousness.com/articles/foods-high-in-vitamin-B6.php.

Foods highest in Vitamin B9 (folate) are found at

http://www.healthaliciousness.com/articles/foods-high-in-folate-vitamin-B9.php.

Vitamin C  is water soluble and must be ingested daily.  Vitamin C food sources are listed at http://www.healthaliciousness.com/articles/vitamin-C.php.  Vitamin C is the major vitamin keeping the adrenal organs healthy.

Zinc is an important mineral.  There is an informative web site listing zinc foods at http://www.healthaliciousness.com/articles/zinc.php.

Iron food sources are listed at  http://www.healthaliciousness.com/articles/food-sources-of-iron.php.

Dopamine is quickly degraded and excreted in the urine.  While there is some re-uptake, dopamine must be continually replenished.  Dopamine is produced in the adrenals, gastrointestinal tract, neurons, and brain generating either excitatory or inhibitory nerve impulses. It has important roles in reward and punishment brain activity, increased heart rate and blood pressure, sleep, mood, attention, working memory, learning, problem-solving, social behavior, cognition, voluntary movement, pain, and motivation.

Dopamine deficiency causes decline in memory, attention, problem-solving  and sociability.  Insufficient dopamine biosynthesis in the dopaminergic neurons can cause Parkinson’s Disease (Grace AA, 1984).  Stress increases the depletion of dopamine stores (Furuyashiki T, 2012).  Dopamine plays a role in pain processing (Viisanen H, et al., 2012 ),

Norepinephrine (noradrenaline) can be produced from tyrosine or phenylalanine in the presence of vitamin B9 (folate), iron, vitamin B3 (thiamine), vitamin B6 (pyridoxal phosphate), and zinc.  Norepinephrine is a neurotransmitter produced in the adrenal glands which helps control the body’s sympathetic system.  This system is responsible for the “fight or flight response” to danger (Guyton A, 2006). Norepinephrine is a stress hormone (Tanaka M, et al., 2000).  Its release increases heart rate, releases glucose from tissue, increases blood flow to skeletal muscle and brain oxygen levels.

Norepinephrine is important to prevent fainting (syncope) by preventing a drop in heart rate to maintain blood pressure.  Neurons project throughout the brain and spinal cord.

Norepinephrine has a role in behavior, motivation, attention, focus, decision making, learning,  motor output, response to performance error, negative feedback, monetary loss, cost benefit evaluation, task difficulty and the decision making process (Devauges V, et al., 1990) (Lutzenberger, W, et al., 1987) (Usher M, et al., 1999) (Eisenberger M, et al., 2003)(Falkenstein M, et al., 1991)(Genring WJ, et al., 1993) (Neurophysiologica 35), (Nieuwenhuis, S, et al., 2003). It has different actions upon different cell types.  Low levels of this neurotransmitter have a role in depression along with serotonin.

Norepinephrine is reabsorbed and degraded within seconds.  It works as an anti-inflammatory agent in brain tissue, suppressing cytokines.  In Alzheimer’s Disease the norepinephrine  producing cells may be affected (Szot P, et al., 2012).

Epinephrine (adrenaline) is an important component of the sympathetic fight or flight system.  Production of epinephrine occurs in the adrenals from phenylalanine and tyrosine.  It acts on most all body tissues.  Epinephrine increases blood glucose and fatty acid levels which provide energy for cells (Sabyasachi S, 2007).  Plasma levels of epinephrine may increase 10-fold during exercise and perhaps by 50-fold during stress requiring an ample supply of tyrosine (Raymondos, K, 2008) (Baselt, 2000).  Epinephrine is released during times of “physical threat, excitement, noise, bright lights, and high temperatures” (Nelson L, 2004). Stress causes the sympathetic nervous system to stimulate adrenocorticotrophic hormone (ACTH) which stimulates epinephrine release (by activating tyrosine hydroxylase and dopamine-B-hydroxylase).  It also stimulates cortisone production by the adrenals.

One study found that catecholamines (neurotransmitters derived from tyrosine in the dopamine pathway) in rat adrenals took  …FOUR  DAYS … yes,  FOUR  DAYS … to recover their original levels after being chemically depleted, and the regeneration of these neurotransmitters required acetylcholine (Patrick RL, et al., 1970).  A human taking a heavy examination may require several days to restore normal neurotransmitter levels, yet universities schedule mid-term and final exams on consequentive days allowing no time for neurotransmitter restoration.  When human adrenals are stressed they may take a significant amount of time and resources to regenerate neurotransmitters and cortisol. 

Tyrosine, vitamin B-complex, vitamin C, zinc, iron, and methionine or SAMe can be purchased at a health food store to supplement the diet and maintain a healthy dopamine pathway.

“Parkinson’s Disease is associated with the depletion of tyrosine hydroxylase, dopamine, serotonin, and norepinephrine” and “administration of L-dopa may deplete L-tyrosine, L-tryptophan and 5-hydroxytryptophan (5-HTP), serotonin and sulfur amino acids (cysteine, methionine)” (Hinz M, et al., 2011).  Researchers found that co-administration of L-dopa with 5-HTP, L-tyrosine, L-cysteine and cofactors enabled more effective treatment for Parkinson’s Disease by allowing optimal dosing of L-dopa for symptom relief without the barriers imposed by side effects and adverse reactions.  (Hinz M et al., 2011)

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THE  CRITICAL  ADRENALS:

We have discussed three important pathways for producing neurotransmitters. The organs most responsible for this job are the adrenals.  The adrenals are critical to brain health. They are small, walnut shaped glands positioned on top of the kidneys.  Back pain can be felt below the rib cage on either side when the adrenals are over-stressed.  These organs produce neurotransmitters, sex hormones, and cortisol.  Under athletic, academic, work-related, emotional, food-related, disease or inflammation-related stress conditions, the adrenals are the first to respond by producing high amounts of cortisol.  The body tends to prioritize, so high cortisol production may come at the cost of reduced sex hormone and  neurotransmitter production.  We may see this in the triathlete with sporadic menses or the businessperson or student with high anxiety levels. The adrenals are prioritizing cortisol production to cope with the acute or chronic stress over the production of sex hormones and neurotransmitters

Upon the realization that these tiny organs are responsible for handling these vital functions, keeping the adrenals healthy becomes of critical importance.  We have described the three neurotransmitter pathways to reinforce the importance of providing the proper amino acids and vitamins to the body to keep these pathways alive and well. Cells die off when adequate nutrients are not present.  Vitamin C  and the amino acid methionine are important for general adrenal function. Methionine is found in wheat, so wheat free diets may be deficient in methioinine.  Glandular adrenal rebuilders are available at health food stores.  Sugar, high fructose corn syrup, alcohol, and deep fried food consumption stress out the adrenals and make them work hard.   There is an excellent book written by Dr. James Wilson, entitled “Adrenal Fatigue – The 21st Century Stress Syndrome”, (Smart Publications, 2001).  A future http://www.wheatfreediseasefree.com post will discuss adrenal insufficiency, methionine and a wheat free diet.  Restoring adrenal health and providing sufficient neurotransmitter substrate may be critical to restoring neurotransmitter supplies and eliminating disease.  More research should be completed and better monitoring of neurotransmitter nutrient pathways through physician and home based testing would be helpful.

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Street Drugs, Nicotine, Caffeine, and Neurotransmitters:

The street drug cocaine is a triple re-uptake inhibitor in that it blocks the re-uptake of serotonin, dopamine and norepinephrine (Fattore L, et al., 2009 ).  Street drugs can increase dopamine levels 10 fold and temporarily cause psychosis (Williams).  Amphetamines are similar in structure to dopamine.   MDMA (ecstasy) releases serotonin, norepinephrine and dopamine and then inhibits their transport which increases concentrations within cell cytoplasm (Bogen IL, et al., 2003) (Fitzgerald JL, et al., 1990).

Amphetamines increase the concentrations of dopamine, serotonin and norepinephrine possibly by reversing the transport of dopamine and serotonin back into the gap or cleft between the neurons (Florin SM, 1994) (Jones S, et al., 1999). Dextromorphan, a cough suppressant, works as an SSRI (Schwartz AR, et al., 2008). LSD is a serotonin agonist in that it stimulates the serotonin receptor on the receiving neuron by mimicking serotonin (Titeler M, et al., 1988). Caffeine increases activity of serotonin, acetycholine, epinephrine, dopamine, and norepinephrine. Nicotine is thought to increase acetylcholine and dopamine levels.  Street drugs, caffeine, and nicotine force the body to release stores of neurotransmitters and then keep the neurotransmitter in circulation by inhibiting the reuptake.  Again, these drugs are not making more neurotransmitter but they are depleting current stores and tricking the body into thinking there is more chemical.  The only way to enable the body to produce more neurotransmitters is to provide the proper nutrients through diet or supplements.  

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Analysis Unique to the Wheat Free Diet:

Many individuals damage their adrenals through alcohol, sugar, high fructose corn syrup, deep fried foods, low vitamin C and low nutrient intake causing depression, fatigue and eventually tremor.  The case above is unique, because this patient eats a healthy diet with the exception of wheat which contains the amino acids methionine and lysine.  Thus, her diet may be deficient in methionine.  However, nutritiondata.com shows detailed analysis that if she consumes meat, ample methionine should be present. Unlike earlier times, most cattle and fish are no longer raised in the wild.  Do they still contain adequate amino acids?  If this subject typically eats meat, containing several grams of amino acids per day, why would 500mg – 1g of supplemental methionine improve her condition?

Additionally, methionine is responsible for chelating harmful chemicals such as those found in paint. She may require additional methionine to detoxify the fumes.   This subject is highly stressed which would cause the adrenals to produce more cortisone. Regulation of the adrenal-pituitary-hypophyseal axis  requires methionine.  Perhaps a combination of low dietary intake plus a high methionine requirement resulted in damaging her adrenals and a reduction of neurotransmitter production.

Case Study References:

Livestrong website:  http://www.livestrong.com/article/458050-choline-risks/

Headquarters Website:  http://www.nutritionalsupplementshq.com/soy-lecithin-side-effects/

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Xu X, Gammon MD, Zeisel SH, Bradshaw PT, Wetmur JG, Teitelbaum SL, Neugut AI, Santella RM, Chen J.  Source  Department of Community and Preventive Medicine, Box 1057, Mt. Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA. High intakes of choline and betaine reduce breast cancer mortality in a population-based study.  FASEB J. 2009 Nov;23(11):4022-8. Epub 2009 Jul 27.

Zeisel SH, da Costa KA. Source  Department of Nutrition at the Nutrition Research Institute, School of Public Health and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA.  Nutr Rev. Choline: an essential nutrient for public health. 2009 Nov;67(11):615-23.

Zhang W, Bai M, Xi Y, Hao J, Liu L, Mao N, Su C, Miao J, Li Z. Early memory deficits precede plaque deposition in APPswe/PS1dE9 mice: involvement of oxidative stress and cholinergic dysfunction. Source Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi’an City, Shaanxi Province 710038, China. Free Radic Biol Med. 2012 Apr 15;52(8):1443-52. Epub 2012 Feb 2.

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Serotonin References:
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Bogen IL, Haug KH, Myhre O, Fonnum F (2003). “Short- and long-term effects of MDMA (“ecstasy”) on synaptosomal and vesicular uptake of neurotransmitters in vitro and ex vivo”. Neurochemistry International 43 (4–5): 393–400. doi:10.1016/S0197-0186(03)00027-5. PMID 12742084.
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Fattore L, Piras G, Corda MG, Giorgi O (2009). “The Roman high- and low-avoidance rat lines differ in the acquisition, maintenance, extinction, and reinstatement of intravenous cocaine self-administration”. Neuropsychopharmacology 34 (5): 1091–101. doi:10.1038/npp.2008.43. PMID 18418365.
.
Fitzgerald JL, Reid JJ (1990). “Effects of methylenedioxymethamphetamine on the release of monoamines from rat brain slices”. European Journal of Pharmacology 191 (2): 217–20. doi:10.1016/0014-2999(90)94150-V. PMID 1982265.
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Florin SM, Kuczenski R, Segal DS (August 1994). “Regional extracellular norepinephrine responses to amphetamine and cocaine and effects of clonidine pretreatment”. Brain Res. 654 (1): 53–62. doi:10.1016/0006-8993(94)91570-9. PMID 7982098.
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Jones S, Kauer JA (November 1999). “Amphetamine depresses excitatory synaptic transmission via serotonin receptors in the ventral tegmental area”. J. Neurosci. 19 (22): 9780–7. PMID 10559387.
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Baselt, R. (2008). Disposition of Toxic Drugs and Chemicals in Man (8th ed.). Foster City, CA: Biomedical Publications. pp. 545–547. ISBN 0-9626523-7-7.

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Falkenstein M, Hohnsbein J, Hoorman J, Blanke L. (1991). Effects of crossmodal divided attention on late ERP components: II. Error processing in choice reaction tasks. Electroencephalogr. Clin. Neurophysiol. 78:447–55

Furuyashiki T, “Roles of Dopamine and Inflammation-Related Molecules in Behavioral Alterations Caused by Repeated Stress”.  Source Department of Pharmacology, Kyoto University Graduate School of Medicine, Japan.  Pharmacol Sci. 2012 Sep 15. [Epub ahead of print]

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Guyton, Arthur; Hall, John (2006). “Chapter 10: Rhythmical Excitation of the Heart”. In Gruliow, Rebecca (Book). Textbook of Medical Physiology (11th ed.). Philadelphia, Pennsylvania: Elsevier Inc.. p. 122. ISBN 0-7216-0240-1.

Hinz M, Stein A, Uncini T. Clinical Research, NeuroResearch Clinics, Inc., Cape Coral, FL, USA; “Amino acid management of Parkinson’s disease: a case study.” Int J Gen Med. 2011 Feb 28;4:165-74.

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Street Drugs, Nicotine, Caffeine, Alcohol and Neurotransmitters:

Bogen IL, Haug KH, Myhre O, Fonnum F (2003). “Short- and long-term effects of MDMA (“ecstasy”) on synaptosomal and vesicular uptake of neurotransmitters in vitro and ex vivo”. Neurochemistry International 43 (4–5): 393–400. doi:10.1016/S0197-0186(03)00027-5. PMID 12742084.

Fattore L, Piras G, Corda MG, Giorgi O (2009). “The Roman high- and low-avoidance rat lines differ in the acquisition, maintenance, extinction, and reinstatement of intravenous cocaine self-administration”. Neuropsychopharmacology 34 (5): 1091–101. doi:10.1038/npp.2008.43. PMID 18418365.

Fitzgerald JL, Reid JJ (1990). “Effects of methylenedioxymethamphetamine on the release of monoamines from rat brain slices”. European Journal of Pharmacology 191 (2): 217–20. doi:10.1016/0014-2999(90)94150-V. PMID 1982265.

Florin SM, Kuczenski R, Segal DS (August 1994). “Regional extracellular norepinephrine responses to amphetamine and cocaine and effects of clonidine pretreatment”. Brain Res. 654 (1): 53–62. doi:10.1016/0006-8993(94)91570-9. PMID 7982098.

Jones S, Kauer JA (November 1999). “Amphetamine depresses excitatory synaptic transmission via serotonin receptors in the ventral tegmental area”. J. Neurosci. 19 (22): 9780–7. PMID 10559387.

Schwartz AR, Pizon AF, Brooks DE (September 2008). “Dextromethorphan-induced serotonin syndrome”. Clinical Toxicology (Philadelphia, Pa.) 46 (8): 771–3. PMID 19238739.

Titeler M, Lyon RA, Glennon RA (1988). “Radioligand binding evidence implicates the brain 5-HT2 receptor as a site of action for LSD and phenylisopropylamine hallucinogens”. Psychopharmacology (Berl.) 94 (2): 213–6. PMID 3127847.

Williams:  http://www.williams.edu/imput/synapse/pages/IIIB5.htm

Copyright © 2012.  All rights reserved.

12-02-12

To request specific dosage data for this case study, please send an email to wheatfreediseasefree@gmail.com.

Photograph: Jordanelle Reservoir, Park City, Utah

A Special Thanks to Billie Jay Sahley PhD. and her books on amino acids including her book “The Anxiety Epidemic” for inspiring research with neurotransmitter pathways, substrates and cofactors.

Disclaimer:  The ERB is a literature research team presenting the findings of other researchers. The ERB is not licensed medical nor dietary clinicians and will not give medical nor dietary advice.   Any information presented on this website should not be substituted for the advice of a licensed physician or nutritionist.  Users of this website accept the sole responsibility to conduct their own due diligence on topics presented and to consult licensed medical professionals to review their material.  We make no warranties or representations on the information presented and should users utilize this research without consulting a professional, they assume all responsibility for their actions and the consequences.

Concussion Brain Food High School Athlete Dietary Survey

 

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CONCUSSION (mild TBI)   BRAIN  FOOD  SURVEY

ABSTRACT

Background:  The Emergency Department is an opportune place to initiate treatment of traumatic brain injury (TBI). New nutrition oriented therapies are emerging in military operations to treat traumatic brain injury however, civilian medical centers have been less progressive in evaluating and adopting these therapies.

Purpose: In the civilian environment athletes are at high risk of mild traumatic brain injury (mTBI).  This study was designed to evaluate the dietary intake of nutrients important to brain function in the diets of athletic high school students.

Methods: A dietary survey was prepared to measure intake of foods containing omega-3 fatty acids, B-complex vitamins, amino acids (protein) and vitamin C which support brain tissue and neurotransmitter production. 71 students completed the survey.

Results: Athletic high school students report a diet averaging .67 g/day of omega-3 fatty acids. Given the recommended daily allowance (RDA) of .90 g/day for a 14-18 y/o sedentary female or male, this intake of omega-3 fatty acids appears inadequate.

Athletic high school students report a diet averaging a thiamin (B1) intake of .65 mg/day whereas the RDA for a sedentary 14-18 y/o and adult female is 1.0 mg/day and the RDA for a sedentary 14-18 y/o and adult male is 1.2 mg/day.  Thiamin (B1)  intake does not appear adequate for these athletes.

Riboflavin levels of 1.0 mg/day and 1.3 mg/day for sedentary females and males, respectively have been established.  Student athletes surveyed report  a diet averaging 1.56 mg/day.  These intake levels may be adequate for high school athletes.

Niacin levels of 14.0 mg/day and 16.0 mg/day for sedentary females and males, respectively have been established.  Student athletes surveyed were receiving an average daily intake of 14.21 mg/day.  These niacin intake levels may be adequate for the athletes.

Athletic high school students report a 3.43 mg/day intake of pantothenic acid (B5).  The RDA for sedentary females and males is 5.0 mg/day.  The athletes surveyed have an inadequate intake of pantothenic acid (B5).

Pyridoxal Phosphate (B6) levels of 1.2 mg/day and 1.3 mg/day have been established for sedentary females and males, respectively.  Our athletes average intake was 1.61 mg/day.  These pyridoxal phosphate levels may be adequate.

Athletic high school student intake of folate (B9) was an average of 313.02 mg/day. Established RDAs for sedentary females and males is 400 mg/day. The folate (B9) intake of the athletes surveyed is inadequate.

Cobalamin (B12) levels of 2.4 ug/day have been established. Surveyed athletes averaged 4.73ug/day.  Surveyed athlete’s intake appears more than adequate.

Athletic high school students report a diet averaging 57.5 g/day intake of protein which meets the RDA of a sedentary 14-18 y/o and adult female (46 g/day) and sedentary male (52 g/day).  However, an RDA for protein has been established requiring 67.5 g/day for an athletic adult female and 83.5 g/day for an athletic adult male. The current protein (amino acid) intake for the athletic high school student surveyed may not be adequate.  Additionally, a diet or supplement must contain all 20 amino acids concurrently for protein synthesis to occur. Protein synthesis stops when one amino acid is missing.

Conclusions:  Omega-3 intake in the student athletes surveyed appears inadequate.  The brain would manufacture brain tissue with omega-6 fatty acids, but without the additional double bonds present in the omega-3 fatty acids, the tissue would fall apart when concussed.

Thiamin (B1), pantothenic acid (B5), and folate (B9) intake does not appear adequate to meet sedentary high school student needs.  Without adequate thiamin, oxygen transport and the synthesis of myelin would diminish.  With a diet low in thiamin and pantothenic acid, acetylcholine neurotransmitter levels would fall.  DNA repair/synthesis and red blood cell production would be impaired given low folate levels.

Riboflavin (B2), niacin (B3), pyridoxal phosphate (B6) and cobalamin (B12) levels may be adequate in athletic high school students.  However, only 50-90% of B-complex vitamins are absorbed in the gastrointestinal system, thus actual availability levels may be less (Wardlaw & Smith, 2013)

The Food and Nutrition Board has established protein RDAs for sedentary individuals and specifically for athletes. The amino acid intake levels of the athletes surveyed do meet the sedentary RDA values, however intake does not meet the athletic RDA levels.  Interestingly the sedentary RDA protein levels have been increased by 50% for athletes.  However, increased RDA omega-3 and vitamin B-complex levels have not been established for athletes. Vitamin B complex provides the cofactors to metabolize amino acids.  Are sedentary levels of B complex and omega-3s sufficient in an athlete or could amino acid metabolites be trapped in athletes due to the lack of vitamin B co-factors?

Vitamin C  intake appears adequate to promote adrenal function and thus neurotransmitter production, although athletic RDAs have not been established.

If physical stress, mental stress, or brain injury requires additional omega-3 fatty acids, B-complex vitamins, and amino acids to promote healing, sufficient nutrients would not be available in the average diet of the athletes surveyed.

This survey is a patient dietary intake survey where the patients have been asked to recall intake over a typical week’s time.  Nutrient levels have been assigned from Nutrition Data given the food, multiplied by the quantity consumed, and computed for an average daily consumption. Thus, this survey provides an estimate of average daily brain food nutrient intake.  Laboratory measured patient blood/urine nutrient levels would be of greater accuracy and important to pursue in future research efforts.

Introduction to Brain Biochemistry and Nutrition:

Dr. James Watson of Watson and Crick, the scientists who discovered the DNA double helix, tells us that to eliminate disease we must return to Biochemistry.  We expect that the many dedicated researchers referenced below would agree.  They have found that in Traumatic Brain Injury, nutrition matters.  Adequate supplies of the major tissue nutrients are critical.

In looking at a section of brain tissue, the lighter tan colored structures are called “white matter.” White matter consists of nerve fiber tracts or pathways traveling in both directions to and from the brain through the brainstem down the spinal cord and extending out to organs, arms, and legs.  A nerve can be up to four feet long. White matter nerve tissue is composed of essential fatty acids called omega-3s such as DHA (docosahexanoic acid) and EPA (eicosapentanoic acid).  Most nerve tissue contains a myelin coating.  The resistance created by this coating allows for impulse transmission at approximately 100m/sec ( 245 mph)! Nerve and myelin formation require B-complex vitamins.  The darker structures on a brain section are called  “gray matter.”  These are decision-making nuclei made from proteins composed of amino acid building blocks.  Proteins and amino acids formulate all structures, most noticeable of which are neurotransmitters made in the adrenal glands with help from vitamin C.  Neurotransmitters are critical to brain function and communication throughout the body.

Methods:

Study Design: This survey listed common foods in each of the brain food nutrient categories of omega-3 fatty acids, B complex vitamins, proteins, and vitamin C, and questioned the students as to their weekly consumption of each food type.

Study Setting and Population:  A small high school athletics program participated in this survey.  The athletic trainer performs baseline, concussive, return to play neurocognitive testing of all athletes.  The school host a variety of high school sports, with the football and soccer programs producing 15-25 concussions per year ranging from mild to more severe.

Instrument Development and Data Collection: Surveys were distributed to high school students at their annual physical and athletics team sign up fair.  The surveys took approximately 5 minutes to complete and were turned in on site.

Measures and Statistical Analysis

We asked respondents to numerically estimate the number of times each food was consumed during a typical week.  Respondents were asked several other general questions about sports, homework hours and concussion history.

A numerical nutrient level was assessed for each food.  This value was multiplied by the number of times the food was consumed during the week and divided by the a 7 day week to determine an average nutrient consumption per food per day.

Results

This Brain Food Survey has been developed to measure an average athletic high school student’s intake of omega-3 fatty acids, B-complex vitamins, amino acids and vitamin C.  It is expected that at least nutrient levels in accordance with the Recommended Daily Allowances (RDAs) are required for a healthy brain capable of healing a concussion (mild TBI) injury.

According to our survey the athletic high school student’s average daily intake of omega-3 fatty acids is  .67 g/day. Given the recommended daily allowance (RDA) of .90 g/day for a 14-18 y/o sedentary female or male, this intake is not adequate.

Athletic high school student intake of thiamin (B1) is .65 mg/day whereas the RDA for a sedentary, female, 14-18 y/o and adult is 1.0 mg/day and the RDA for a sedentary, male, 14-18 y/o and adult is 1.2 mg/day.  Thiamin intake may not be adequate.

Riboflavin levels of 1.0 mg/day and 1.3 mg/day for sedentary females and males, respectively have been established.  Our student athletes were receiving an average of 1.56 mg/day.  Riboflavin consumption appears adequate.

Niacin levels of 14.0 mg/day and 16.0 mg/day for sedentary females and males, respectively have been established.  Our student athletes were receiving an average of 14.21 mg/day.  These intake levels may be adequate.

Athletic high school student intake of pantothenic acid (B5) was an average of 3.43 mg/day.  The RDA for sedentary females and males is 5.0 mg/day.  Our athletes have an inadequate intake or pantothenic acid.

Pyridoxal Phosphate (B6) levels of 1.2 mg/day and 1.3 mg/day have been established for sedentary females and males, respectively.  Our athletes average intake was 1.61 mg/day.  These levels may be adequate.

Athletic high school student intake of folate (B9) was an average of 313.02 mg/day and established RDAs for sedentary females and males is 400mg/day. Our athletes’ intake is inadequate.

Cobalamin (B12) RDA levels of 2.4 ug/day have been established. Our athletes averaged 4.73ug/day.  Our athlete’s intake appears sufficient. However, gastrointestinal disorders may decrease secretion of intrinsic factor thereby decreasing colalbumin absorption.

The athletic high school students’ riboflavin, niacin, pyridoxial, and cobalamin appear adequate given the sedentary RDAs available.  However, vitamin B complex nutrients are said to be absorbed at a rate of only 50-90% and the prevalence of wheat lectins/gluten and other GI disturbances, the actual intake of these nutrients may be reduced.

The athletic high school student intake of an average of 57.5 g/day of protein meets the RDA of a sedentary 14-18 y/o and sedentary adult female (46 g/day) and sedentary male (52 g/day).  However, RDAs for protein have been established for an athletic adult female who requires 67.5 g/day and athletic adult male who requires 83.5 g/day. Current protein intake of the athletes surveyed may not be adequate.  All 20 amino acids must be consumed concurrently in the diet to enable protein synthesis. Missing amino acids will cause protein synthesis to stop.

Athletic high school student intake of vitamin C, ascorbic acid, was an average of 122mg/day.  Sedentary high school female student’s RDA is 65mg/day and male’s 75 mg/day.  Sedentary female adult RDA is 75mg/day and male 90mg/day.  Vitamin C intake appears more than adequate.

Athletic high school student intake of omega-3-fatty acids, thiamin, pantothenic acid, folate and amino acids are inadequate to sustain general sedentary nutrition and these low nutrients levels would appear to strain the body during increased physical stress, academic or social mental stress, and be most profoundly apparent during the body’s attempt to heal concussion.

Discussion:

The human brain is about the size of a cauliflower head with the density of medium soft cheese and can be easily sectioned with a spatula. The brain stem protrudes from the posterior-inferior surface sending commands up and down pathways and through relay centers to the pinky-sized spinal cord. The brain and spinal cord are surrounded by clear cerebral spinal fluid (CSF) and membranes which provide a shock absorber-like environment internal to the bony cranium and vertebrae.

When the cushion environment is disrupted by an “external mechanical force such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile” (Maas AI, et al., 2008), a traumatic brain injury (TBI) results.  A mild TBI is referred to as a concussion.

TBIs are the leading cause of death/disability worldwide  (Alves OL, et al., 2001) and the number one cause of coma (Farag E, et al., 2011).   One third of TBI fatalities are firearm accidents (75% suicide) and another third are motor vehicle accidents (Leon-Carrion J, et.al., 2005). A total of 1.5 million people experience head trauma each year in the U.S. resulting in an annual cost exceeding $5.6 billion.  While most head injuries are mild (Cassidy JD, et al., 2004), the death rate to TBI is estimated at 21% by 30 days post injury (Greenwood, et al, 2003). The greatest number of TBIs occur in the male 15-24 age group (Hardman JM, et al., 2002) (Mass AI, et al., 2008). Sport and recreational activities in the U.S. alone may cause between 1.6 – 3.8 million TBIs each year (CDCP, 2007).  In addition, the military has seen a significant increase in TBIs. Approximately, 10-20% of veterans returning from the Middle East have experienced a TBI. The Department of Defense is conducting research to reduce the serious problems associated with these injuries and has requested a report from the Institute of Medicine (2011).

Clinically, a mild TBI or concussion is defined as post-traumatic amnesia of less than one day and a loss of consciousness between 0 -30 minutes (DOD TBI Task Force).  Symptoms include “headache, vomiting, nausea, lack of motor coordination, dizziness, and difficulty balancing” (Kushner D, 1998) along with “lightheadedness, blurred vision or tired eyes, ringing in the ear, bad taste in the mouth, fatigue or lethargy, and changes in sleep patterns.  Cognitive and emotional symptoms include behavioral or mood changes, confusion, and trouble with memory, concentration, attention, or thinking” (NINDS, 2008). Social behavior or emotional problems may also occur. Damage to the left side of the brain may involve speech, reading and writing difficulties.  Damage to the back of the brain may involve vision, balance, and coordination problems.

Current diagnostic techniques include neurological exam and neuro-imaging studies such as CT (CAT scan) or MRI (Magnetic Resonance Imaging).  CT scans are quickly completed in an emergency department. They are less expensive and better at showing bleeds than MRI  however, brain CT delivers a 1-2 millisievert dose of radiation.   MRI, which utilizes a magnetic field,  (no radiation exposure), delivers more detail of the brain and brain stem, but it is more time consuming and costly.  A CT of a more serious TBI may show hemorrhage, skull fracture, contusions (bruising), fracture, and/or edema (swelling).  An MRI of a more serious TBI, might show a shifting of brain structures, contusion, and hematoma. When blood exerts pressure upon the brain surface it can impair brain function. Interestingly, when brain tissue is seriously injured,  it appears to be cracked open on MRI, much like the appearance of a sponge that is torn open every 1-2 inches. The tears create fluid inlets, perhaps designed to bring nutrient rich CSF to the damaged areas.

A mild TBI or concussion will often show little damage on CT or MRI neuro-imaging studies, thus the increasing use of imPACT or CNS Vital Signs neurocognitive testing.  These computerized tests  have been more effective at assessing mild concussive damage by evaluating general mental functioning. To date, many athletic programs have been using them to compare pre and post injury results to determine ‘return to play’. Since they measure brain function in terms of verbal and visual memory, processing speed, reaction time, attention span, and non-verbal problem solving capabilities, neurocognitive testing has been successfully utilized to identify emotional and cognitive deficits related to mild TBIs.

When the brain is damaged, it immediately begins self repair. Raw materials are sought from nutrients in the blood supply and from CSF to rebuild the initial injury site.  When nutrient supply is insufficient, surrounding brain tissue may be broken down to supply substrate for reconstruction.

Damage apparent in adjacent tissue, has been defined as Second Injury and may result in more serious injury than the initial TBI (Park E, et al., 2008). When death results weeks later, it is typically caused by secondary damage (Ghajar J, 2000). In the past, this Second Injury has been commonplace and no therapy has been available to stop progression (Park E, et al., 2008). However, recent military studies found that by immediately supplying sufficient amounts of protein to the injured patient, Secondary Injury is significantly reduced (Institute of Medicine, 2011).  Providing omega-3 essential fatty acids (DHA/EPA) before injury or immediately after injury also reduces TBI damage (Mills JD, et al., 2011) (Wu A, et al., 2007).

Brain injury brings immune cells and fluids to the injury site, resulting in inflammation, but with the brain enclosed in the cranium there is minimal space to accommodate swelling.  The resultant increase in intracranial pressure may occlude blood vessels responsible for bringing oxygen and nutrients to brain cells and lymph vessels responsible for removing waste products (Scalea TM, 2005). Increased pressure can force the brain to herniate into spaces where it does not belong.  This renders the tissue non-functional and eventually will cause death.  A variety of anti-inflammatory medications are often utilized to diminish swelling.

Mild TBIs physically appear to resolve in 3 weeks and patients tend to return to normal activities.  Some patients have “physical, cognitive, emotional and behavioral problems such as headaches, dizziness, difficulty concentrating, and depression” (Parik S et al., 2007). Movement disorders, seizures, and substance abuse may also develop (Arlinghaus KA, et al., 2005). Depending upon the severity of the injury, the number of repeat injuries and the presence of adequate nutrients before and after the injury, the prognosis ranges from complete recovery to permanent disability, neurological disease or death. “Permanent disability is thought to occur in 10% of mild TBIs, 66% of moderate injuries, and 100% of severe injuries” (Frey LC, 2003). In many situations, particularly athletics, a second concussion may occur before the first concussion has healed.  This is of particular concern as multiple TBIs may have a cumulative effect (Kwasnica C, et al., 2008).

The Composition of Brain Tissue:

Dr. James Watson, of Watson and Crick the scientists who discovered the DNA double helix, tells us that to eliminate disease we must return to biochemistry.

In examining a section of brain tissue, the lighter tan colored structures are called “white matter.” White matter consists of nerve fiber tracts or pathways traveling in both directions to and from the brain through the brainstem down the spinal cord and extending out to organs, arms, and legs.  A nerve can be up to four feet long. White matter nerve tissue is composed of essential fatty acids called omega-3s such as DHA (docosahexanoic acid) and EPA (eicosapentanoic acid).  Most nerve tissue contains a myelin coating.  The resistance created by this coating allows for impulse transmission at approximately 100m/sec ( 245 mph)! Nerve and myelin formation require B-complex vitamins.  The darker brown structures on a brain section are called  “gray matter.”  These are decision-making nuclei made from proteins composed of amino acid building blocksAmino acids require B-complex vitamins to metabolizeProteins and amino acids formulate all structures, most noticeable of which are neurotransmitters.  Neurotransmitters are critical to brain function and communication throughout the body.  These neurotransmitters are produced in the adrenal glands which depend heavily on vitamin C and the amino acid methionine.

Essential Fatty Acids (DHA and EPA):

40% of brain tissue is essential fatty acids (DHA and EPA).   While EPA provides important anti-inflammatory actions (Sears B, 2011) and is included in supplements, 97% of the brain’s essential fatty acids are the 22 carbon chain,  Docosahexanoic Acid.  DHA is found in foods such as walnuts, microalgae, microplants, cod, salmon, mackerel, sardines, hake, caviar, herring, oysters, organ meats (liver), grass fed and finished beef, and fish oil or algae supplementsFish receive DHA from ocean phytoplankton (microalgae or microplants).  Cattle produce ? make? DHA from grass.  However, as we increasingly draw our food from farm-raised fish and grain-raised cattle lacking grass to produce DHA, our dietary intake of DHA is being depleted, (Abel R, 2002).

Most humans consume an overabundance of vegetable oil and butters which contain no double bonds in the carbon chain.  DHA has six double bonds (22:6), one at every third carbon (omega-3 or n-3). In cell membrane, these double bonds allow the fatty acid to neutralize damaging free radicals.  In addition, DHA increases the fluidity properties of cell membrane which helps to protect the cell from trauma and cell death (apoptosis) (Eckert GP, et al., 2011). Proper cell communication and signaling is critical for brain function. Fifty percent of nerve cell plasma membrane is DHA (Collins C, et al., 2002) which is important in cell communication, neuronal survival, and growth.  DHA is found in three cell membrane phospholipids:  phosphytidylethnolamine, ethnolamine plasmalogens, and phosphatidylserine. Upon injury, these phospholipid pools are important reservoirs to reconstruct cell membrane (Chang CY, et al., 2009).  In the absence of dietary DHA, the brain will improvise and construct brain tissue from vegetable oil. However, under traumatic conditions  vegetable oil fed rat brain falls apart, (Eckert  GP, et al., 2011) (Abel R, 2002).

Researchers found that in rats that were subject to TBI and then received 40mg/kg/day pharmaceutical grade fish oil rich in DHA and EPA for 30 days post TBI had more healthy nerve cells.  Essential fatty  acids  were shown  to be neuroprotective by reducing  the  number of  injured nerve axons, decreasing the level of inflammation,  and reducing oxidative stress and cell death (Mills JD et al., 2011). DHA fed to rats immediately post TBI was found to counteract cognitive decay, maintain membrane signaling function, and support the potential of DHA supplementation to reduce the effects of TBI. (Wu A, et.al 2011).  In addition, essential fatty acids DHA and EPA given to rats 4 weeks prior to TBI was found to help maintain brain homeostasis and reduce oxidative damage due to TBI (Wu A, et al., 2007).

DHA and EPA have been found to improve the outcome of stroke studies of both rat and human models (Kong W, et.al) (Hagiwara H, et.al.), but few human studies have been conducted using DHA as prophylaxis for TBI.  In 2006, high doses of DHA and hyperbaric oxygen treatment were used by Dr. Julian Bailes to treat the sole survivor of the West Virginia mining disaster who suffered carbon monoxide poisoning. This patient now claims that his brain function is near normal.  Dr. Bailes and his colleagues have since published many research papers demonstrating the benefits of essential fatty acids and fish oil supplements.  In addition, “individual case reports using fish oil doses of 2-4 grams per day have been described, however sufficient human research is unavailable to recommend dosages”  (Maroon, JC and Bost J, 2011)

One new human case study was published in October 2012, when Peter Ghassemi convinced physicians to give his son Bobby, who was in a coma following a motor vehicle accident, omega-3 fish oil ( a similar dose to Randal McCloy).  Bobby  had a Glasgow Coma Score of 3 (scale 3 – 15), which Dr. Michael Lewis says that “a brick or piece of wood has a Glasgow Coma Score of 3. It’s dead.”  Peter Ghassemi, Bobby’s father, indicates that it was difficult to convince physicians to give their son fish oil.  They wanted to see 1000 case studies first, to prove its efficacy.  Eventually, physicians agreed.  Thanks to his father’s perseverance, Bobby has recovered today.  U.S. Army Colonel Lewis who recommended the therapy to Peter Ghassemi describes the therapy like this.  ”If you have a brick wall and it gets damaged, wouldn’t you want to use bricks to repair the wall?  And omega-3 fatty acids are literally the bricks of the cell wall of the brain.”  (CNN,2012).

Eicosapentanoic Acid (EPA 20:5n-3?) is another essential fatty acid.  EPA is important in the synthesis of PGE (explain) and controls the thromboxine and leukotrine levels.  EPA is important in the metabolism of DHA.  Essential fatty acids (EFA) are among the most crucial molecules that determine the brain’s integrity and ability to perform. EFA are involved in the synthesis and functions of brain neurotransmitters.  Neuronal membranes contain phospholipid pools that are the reservoirs for the synthesis of specific lipid messengers on neuronal stimulation or injury.   (PMID 20329590). DHA and EPA maybe obtained through diet or supplements.

The textbook “Contemporary Nutrition” written by  Gordon M. Wardlaw and Anne M. Smith in 2013 tells us that EPA and DHA are only slowly synthesized in the brain from alpha linoleic acid but can be found in “fatty fish such as salmon, tuna, sardines, anchovies, striped bass, catfish, herring, mackerel, trout or halibut “(listed highest to lowest omega-3 content) and in foods such as “canola and soybean oils, walnuts, flax seeds, mussels, crab and shrimp”.  The authors warn about high mercury levels in swordfish, shark, king mackerel, and albacore, and indicate that fish with low mercury levels include salmon, sardines, bluefish, herring and shrimp.  Eating fish twice each week is recommended.  Omega-3 fatty acids tend to act to reduce blood clotting and inflammation, while omega-6 foods tend to increase clotting and inflammation.  Vitamin K and calcium carbonate are also involved in the clotting process. “Fish oil capsules should be limited for individuals who have bleeding disorders, take anticoagulant medications, or anticipate surgery, because they may increase risk of uncontrollable bleeding and hemorrhagic stroke”.

Wardlaw and Smith recommend 1.6 grams per day of omega-3 fatty acids for men and 1.1 grams per day for women.  Elevated blood triglycerides are treated with 2 to 4 grams per day.  Omega 3 fatty acids have been found to reduce the inflammation of rheumatoid arthritis and help with behavioral disorders and cases of mild depression.  Freezing fish oil capsules helps to reduces the fishy after taste.  ”2 tablespoons of flax seed per day is typically recommended as an omega-3 fatty acid source”.  Approximately 3 walnuts (6 halves) yields approximately 1 gram of DHA.  Care should be taken to keep DHA sources refrigerated as they turn rancid easily.  For TBI patients on IV feeding it is important to investigate the quantity of DHA and EPA present in total parenteral nutrition.  One researcher takes approximately 1 gram of DHA/EPA through fish oil daily and on a daily basis regulates intake by the dryness/moistness of the skin.  In drier climates, she finds this daily intake amount must be doubled to maintain skin moisture. Mercury consumption in fish oil is a serious risk and mercury free alternatives should be explored.  Many manufacturers are now producing fish oil products which are molecularly distilled.

B Complex Vitamins:

B complex vitamins are important for nerve, DNA and neurotransmitter synthesis,  and for cell energy production and metabolism.  The majority of the information cited below regarding the effects of B complex vitamins on brain function has been obtained from animal studies. Vitamin B is a vitamin complex  of B-1-thiamine, B-2 riboflavin, B-3 niacin, B-5 pantothenic acid, B-6 pyridoxine, B-9 folate, B12-cobalamin.

Thiamine (B1) is required for oxygen to be transported in red blood cells (Combs GF Jr, et al., 2008), production of the neurotransmitter acetylcholine (Butterworth RF, et al., 2006), and synthesis of the myelin coating surrounding nerve cells (Butterworth RF, et al., 2006). High school female RDA  of thiamine is 1.0 mg/day and male 1.2 mg/day. Adult thiamine RDA is 1.1 – 1.2 mg/day, Daily Value 1.5 mg/day, and no upper limit has been set. Thiamin is water soluble and rapidly lost in urine. Alcohol consumption reduces thiamin levels (Wardlaw, et.al., 2013).

Riboflavin (B2) is a component in all flavoproteins and  red blood cells (erythrocytes) and has been know to reduce TBI lesions, edema, and improve TBI outcome (Hoane MR, et al., 2005). High school female riboflavin RDA 1.0 mg/day, male 1.3 mg/day.  Adult riboflavin RDA is 1.1 – 1.3 mg/day, Daily Value 1.7 mg/day, no upper limit set.  Alcohol consumption reduces riboflavin levels (Wardlaw, et.al., 2013)

Niacin (B3) is involved in DNA repair, cholesterol, and energy production. It helps produce neurotransmitters in the adrenal gland.  Niacin reduces TBI lesion size and improves sensory, motor, cognitive, and behavioral recovery (Voner Haar C, 2011).  High school female niacin RDA 14 mg/day, male 16 mg/day.  Adult niacin RDA is 14 – 16 mg/day, Daily Value is 20 mg/day, upper limit is 35mg/day of nicotinic acid form. Alcohol consumption reduces niacin levels (Wardlaw, et.al., 2013)

Pantothenic Acid (B5) is  involved with neurotransmitter acetylcholine production involved in signal transduction and enzyme control.  High school female and male 5 mg/day.  Adult Adequate Intake is 5 mg/day, Daily Value is 10 mg, no upper limit set (Wardlaw, et. al, 2013).

Pyridoxal Phosphate (B6) controls all amino acid metabolism  (Sahley BJ, 2002), red blood  cell and  antibody formation (Sahley BJ, 2002). This vitamin is also involved with dopamine and GABA neurotransmitter production, and with the production of phospholipids for the myelin sheath.  High school RDA pyridoxal phosphate female 1.2 mg/day, male 1.3 mg/day.  Adult RDA is 1.3 – 1.7 mg/day, Daily Value is 2 mg, Upper Level is 100 mg/day based upon nerve damage.  Studies have shown that 2 – 6 grams/day of B-6 for 2 or more months can lead to irreversible nerve damage.  Symptoms of toxicity include walking difficulties and hand and foot numbness (Wardlaw, et. al, 2013).

Folate  (B9) is required to synthesize, repair, and methylate DNA, provides neuroprotection in TBI (Naim MY, et al., 2010), is important in rapid cell division and growth and the production of healthy red blood cells which prevents anemia. Folate forms cell membrane phospholipids and receptors (Karakula H, et al.,2009) (Surtees R, 1998), prevents nerve damage and neural tube defects during development and is required for myelin regeneration (van Rensburg SJ, et al., 2006) (Guettat L, et al., 1997). High school RDA female and male 400 mcg/day.Adult RDA and Daily Value is 400 mcg/day,  pregnant women 600mcg/day  (important to prevent neural tube defects), Upper Level is 1 mg/day.  Alcoholism and poor absorption reduces folate levels (Wardlaw, et.al., 2013).  This alcoholism – folate – neural tube defects is critically important to women expecting to conceive.

Cobalamin (B12) is involved in blood formation, critical to DNA synthesis through folate regeneration, and important for the formation of cell membrane phospholipids and receptors (Karakula H, et al., 2009) (Surtees R, 1998). Cobalamin supplementation partially resolved cognitive deficits and myelin imaging abnormalities (Chatterjee A, et.al., 1996) (Jongen JC, et al., 2001) and improved cerebral and cognitive functions  (Bourre JM, 2006). This vitamin is required for myelin synthesis (Hall CA, 1990) (van Rensburg SJ, et al, 2006) (Guettat L, et al., 1997) and promotes nerve regeneration (Okada K, et al., 2010). High school RDA colbalamin female and male 2.4 mcg/day.  RDA is 2.4 mcg/day, Daily Value is 6 mcg/day, no Upper Limit set, stored in liver, 50% of dietary intake may be absorbed.  Nerve damage and anemia may result from insufficient intake.

There are 150mg time release (9-10 hours) capsules available for B complex.  All  B vitamins are water soluble and need to be replenished daily.  Vitamin B complex has an important  role  in  alleviating anxiety and lactic acid buildup.  Dietary supply may be inadequate under stress (Sahley BJ, 2002).

Vitamin B is a complex  of B-1-thiamine, B-2 riboflavin, B-3 niacin (niacinamide), B-6 pyridoxine, B12-cyanocobalamin, pantothenic acid, biotin, PABA, folic acid, choline and inositol.  All B vitamins are water soluble and they are not stored.  They must be supplied in sufficient amounts at all times.  This supply may be inadequate under stress. (Sahley p 94).

Vitamin B provides cofactors for reactions within the body particularly amino acid reactions.  B vitamin cofactors initiate the transfer of electrons, plus methyl, carbon, amino, carboxyl, acetyl, acyl,  and formyl groups.

The RDAs are Recommended Daily Allowances taken from the Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine, National Academics. The vitamin B complex nutrients surveyed above are absorbed at a rate of 50-90% (Wardlaw & Smith, 2013).  Due to the prevalence of gastrointestinal disorders present in the population, even the nutrients that appear to be consumed at adequate levels may not be sufficient.

Protein (Amino Acids):

Linear chains of amino acids form proteins. Proteins produce nuclei in the brain, DNA,  cell membrane, enzymes, and neurotransmitters. Twenty amino acids are commonly identified.  All must be present for protein synthesis.

Alanine is the precursor of neurotransmitter dopamine (Coxon KM, et al., 2005).

Arginine, through agmantine, is neuroprotective in trauma and ischemia models by significantly reducing  brain swelling volume and blood-brain barrier protection (Kim JH, et al., 2009).

Cysteine forms DNA double helix disulfide bonds.

Glutamate is important for calcium ion binding; may reduce blood glucose levels in the injured spinal cord reducing neurological impairment (Zhang TL, et al., 2010).

Glutathione is critical to relieve oxidative stress in cells.

Glycine is important in red blood cell formation (Shemin D, et al., 1946); gives amino acid structures flexibility.

Histidine is used throughout the brain, this amino acid improves TBI outcome (Faden AI, et al., 1993) (Krusong K, et al., 2011).

Lysine is important for connective tissue maintenance, and affects protein binding to phospholipid membranes (Blenis J, et al., 1993).

Methionine is the sole methyl donor in the central nervous system.  Methionine forms Glutathione, an important amino acid in reducing free radical-mediated traumatic injury (Gidday JM, et al., 1999).  Methionine increases S-adenylmethionine (SAMe) in CSF aiding in neurological disorder treatment (Chishty M, et al., 2002).

Phenylalanine produces chlorophenylalanine (CPA) which slowed the breakdown of the blood-brain barrier permeability, brain edema and blood flow and reduced the number of damaged and distorted nerve cells (Sharma HS, et al., 2000).

Proline maintains connective tissue (Bhattacharjee A, et al., 2005)

Serine acts as a neurotransmitter in the brain (Wolosker H, et al., 2008).

Taurine is a major component of brain tissue and muscle (Brosnan JT, 2006).

Threonine is a component of the serine/threonine kinase and is neuroprotective following traumatic brain injury (Erlich S, et al.,2007).

Tryptophan is a precursor to neurotransmitter serotonin (Savelieva KV, et al., 2008); a modulator of serotonin which alters plasticity-related signaling pathways and matrix degradation (Penedo LA, et al., 2009).

Tyrosine is a precursor of the neurotransmitter dopamine, norepinephrine, epinephrine.

Amino Acids essential amino acids are arginine, histidine, isoleucine, leucine, lysine, methionine, phyenylalanine, threonine, tryptophan, and valine.  These play a vital role in the brain’s function (Sahley p23).  Under prolonged stress or illness the body is unable to produce sufficient required non-essential amino acids  (Sahley p 22).   Amino acids are monomers polymerizing to produce proteins.  A multistep process requiring proteins as substrate and translation/transcription factors results in production of DNA and RNA.  Proteins also form neurotransmitters, enzymes and are components of cell membranes participating in cell signaling.

Trauma damages DNA and RNA, and depletes neurotransmitters.  Neurological dysfunction caused by traumatic brain injury results in profound changes in net synaptic efficacy, leading to impaired cognition.  The limbic hippocampus, a brain structure implicated in higher learning and memory, is often damaged in TBI.  Significant reductions are seen in the concentration of branched chain amino acids (BCAAs).  BCAAs  (leucine, isoleucine, alanine) are key amino acids involved in de novo glutamate synthesis.  Dietary consumption of BCAAs restored hippocampal BCAA concentrations to normal, reversed injury-induced shifts in net synaptic efficacy, and left to reinstatement of cognitive performance after concussive brain injury.   (Cole paper, Univ of Penn Dietary AA ameliorate cognitive impairment).

Under prolonged stress or illness the body is unable to produce sufficient non-essential amino acids (Sahley BJ, 2002).  Trauma has been found to damage DNA and RNA, and to deplete neurotransmitters.  Neurological dysfunction is caused by traumatic brain injury (Cole J, et al., 2010).

As amino acids are utilized for energy and substrate, they are oxidized to urea and carbon dioxide producing high levels of glutamate.  These high levels seen in the TBI patient can include oxidation of branched chained amino acids. Dietary consumption of Branched Chain Amino Acids (BCAAs) restored BCAA concentrations to normal, improved nerve cell communication, and reinstated cognitive performance after concussive brain injury (Cole J, et al., 2010). BCAAs and amino acid complex (protein) are available at nutrition stores.

The objective of this discussion has been to bring current research advancements to light given the realization that concussive TBIs cause damage and disease, such that this information may be further evaluated by the public, health care providers, and the medical research community.

A variety of single drugs have failed clinical trials to treat TBI, suggesting a role for drug combinations. Drug combinations acting synergistically often provide the greatest combination of potency and safety. (PMID 20824218) Recent preclinical studies suggest that neurorestorative strategies that promote neurogenesis, and synaptogenesis provide promising opportunities for treatment of TBI. (PMID 21155204).

The IOM committee’s report, Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel.  April 20, 2011.  Given the complexity of TBI and the current gaps in scientific knowledge, the committee could identify only one promising solution that can immediately improve treatment efforts: early feeding. Feeding protocols should be standardized to ensure the delivery of adequate levels of energy and protein to patients with severe TBI, and hospital intensive care units should include these protocols in their critical care guidelines. Specifically, the protocols should require providing, within the first 24 hours, a level of nutrition that represents more than 50 percent of the injured person’s total energy expenditure and provides 1 to 1.5 grams of protein per kilogram of body weight. This nutrition level should be continued for two weeks. Such nutritional intervention is likely to limit the person’s inflammatory response, which typically is at its peak during the first two weeks after an injury, and thereby improve the ultimate health outcome. Research has shown that feeding the severely injured soon after an injury is known to help in reducing mortality. (IOM report)

Based on findings about the physiological actions of nutrients and their effectiveness and safety from studies on animals and humans, the following nutritional interventions were identified as holding the most promise for improving TBI outcomes: the provision of or treatment with choline, creatine, n-3 fatty acids, and zinc. DOD should prioritize research on these interventions. (IOM report).

Conclusion:

Athletic high school student intake of omega-3-fatty acids, thiamin, pantothenic acid, folate and amino acids are inadequate to sustain general sedentary nutrition and these low nutrients levels would appear to strain the body during increased physical stress, academic or social mental stress, and be most profoundly apparent during the body’s attempt to heal concussion.

Research to determine RDAs under physical stress, mental stress, athletics or injury would be important for neurological health now and in the future.  In addition, given our highly processed food, modified crops and farm raised fish and stockyard raised cattle, the average diet may not be providing nutrient levels anticipated.  There may also be interference in the diet caused by enhanced lectins and gluten found in grains attacking our immune systems.  The impact of these food modifications will be important to continue to assess.

To date our typical brain injury therapy has been anti-inflammatories.  Awareness of the basic nutrients required for a healthy brain are not generally well known to the medical, dietary, or public. Education as to the roles of these nutrients is critical to bring about a healthier populace. The brain injury brought on by concussion, disease, mental and physical stress may well be eliminated or repaired should adequate nutrients be provided to enable the amazing brain to make the necessary repairs.

Traumatic Brain Injury References:

Alves OL, Bullock R (2001). “Excitotoxic damage in traumatic brain injury”. In Clark RSB, Kochanek P. Brain injury. Boston: Kluwer Academic Publishers. p. 1. ISBN 0-7923-7532-7. Retrieved 2008-11-28.

Arlinghaus KA, Shoaib AM, Price TRP (2005). “Neuropsychiatric assessment”. In Silver JM, McAllister TW, Yudofsky SC. Textbook Of Traumatic Brain Injury. Washington, DC: American Psychiatric Association. pp. 63–65. ISBN 1-58562-105-6.

Center for Disease Control and Prevention, National Center for Injury Prevention and Control. “Traumatic brain injury” (http://www.cdc.gov/ncipc/factsheets/tbi.htm) 2007.

Cassidy JD, Carroll LJ, Peloso PM, Borg J, von Holst H, Holm L et al. (2004). “Incidence, risk factors and prevention of mild traumatic brain injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury”. Journal of Rehabilitation Medicine 36 (Supplement 43): 28–60. DOI:10.1080/16501960410023732. PMID 15083870.

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Essential Fatty Acids References:

Abel R,  “The DHA Story, How Nature’s Super Nutrient Can Save Your Life”.  2002, ISBN 1-59120-001-6, (2002).

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Eckert GP, Chang S, Eckmann J, Copanaki E, Hagl S, Hener U, Müller WE, Kögel D, “Liposome-incorporated DHA increases neuronal survival by enhancing non-amyloidogenic APP processing”.  Biochim Biophys Acta. 2011 Jan;1808(1):236-43. Epub 2010 Oct 29. PMID 21036142

Livestrong.com: http://www.livestrong.com/article/430423-how-many-omega-fish-oil-pills-should-you-take-a-day/

Mills JD,  Hadley K, Bailes JE, “Dietary Supplementation with the Omega-3 fatty acid Docosahexaenoic Acid in Traumatic Brain Injury”. Neurosurgery, 2011 Feb;68(2):474-81

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Sears, B (2011). “The fallacy of using DHA alone for brain trauma.” http://www.prweb.com/releases/concussion/brain_trauma/prweb4500964.htm

University of Maryland Medical System and University of Maryland Medical School:  Omega-3 fatty acids:  http://www.umm.edu/altmed/articles/omega-3-000316.htm

Vitamin B Complex References:

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Hoane MR, Wolyniak JG, Akstulewicz SL, “Administration of riboflavin improves behavioral outcome and reduces edema formation an glial fibrillary protein expression after traumatic brain injury”, J Neurotrauma, 2005 Oct 22;(10):1112-22

Jongen JC, Koehler PJ, Franke CL, “Subacute combined degeneration of the spinal cord: easy diagnosis, effective treatment”, Ned Tijdschr Geneeskd. 2001 Jun 30;145(26):1229-33. PMID: 11455686

Karakuła H, Opolska A, Kowal A, Domański M, Płotka A, Perzyński J, “Does diet affect our mood? The significance of folic acid and homocysteine”  Pol Merkur Lekarski. 2009 Feb;26(152):136-41.

Naim MY, Friess S, Smith C, Ralston J, Ryall K, Helfaer MA, Marguiles SS, “Folic acid enhances early functional recovery in a piglet model of pediatric head injury”, Dev Neurosci. 2010;32(5-6):466-79. Epub 2011 Jan 5. PMID: 21212637

Okada K, Tanaka H, Temporin K, Okamoto M, Kuroda Y, Moritomo H, Murase T, Yoshikawa H. “Methylcobalamin increases Erk1/2 and Akt activities through the methylation cycle and promotes nerve regeneration in a rat sciatic nerve injury model.”, Exp Neurol. 2010 Apr;222(2):191-203. Epub 2010 Jan 4.

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Protein (Amino Acids) References:

Bhattacharjee A, Bansal M (March 2005). “Collagen structure: the Madras triple helix and the current scenario”. IUBMB Life 57 (3): 161–72. DOI:10.1080/15216540500090710. PMID 16036578.

Blenis J, Resh MD (December 1993). “Subcellular localization specified by protein acylation and phosphorylation”. Current Opinion in Cell Biology 5 (6): 984–9. DOI:10.1016/0955-0674(93)90081-Z. PMID 8129952.

Brosnan JT, Brosnan ME (June 2006). “The sulfur-containing amino acids: an overview”. The Journal of Nutrition 136 (6 Suppl): 1636S–1640S. PMID 16702333.

Chishty M, Reichel A, Abbott NJ, Begley DJ. “S-adenosylmethionine is substrate for carrier mediated transport at the blood-brain barrier in vitro.” Brain Res. 2002 Jun 28;942(1-2):46-50. PMID: 12031851

Jeffrey T. Cole, Christina M. Mitala, Suhali Kundu, Ajay Verma, Jaclynn A. Elkind, Itzhak Nissim,and Akiva S. Cohena, “Dietary branched chain amino acids ameliorate injury-induced cognitive impairment”,.Proc Natl Acad Sci U S A. 2010 January 5; 107(1): 366–371. Published online 2009 December 29. doi: 10.1073/pnas.0910280107 PMCID: PMC2806733

Erlich S, Alexandrovich A, Shohami E, Pinkas-Kramarski R. “Rapamycin is a neuroprotective treatment for traumatic brain injury.” Neurobiol Dis. 2007 Apr;26(1):86-93. Epub 2007 Jan 31.  PMID: 17270455

Faden AI, Labroo VM, Cohen LA. “Imidazole-substituted analogues of TRH limit behavioral deficits after experimental brain trauma.” J Neurotrauma. 1993 Summer;10(2):101-8.  PMID: 8411214

Gidday JM, Beetsch JW, Park TS. “Endogenous glutathione protects cerebral endothelial cells from traumatic injury.”  J Neurotrauma. 1999 Jan;16(1):27-36. PMID: 9989464

Institute of Medicine committee report, Nutrition and Traumatic Brain Injury; Improving Acute and Subacute Health Outcomes in Military Personnel.  April 20, 2011.  http://www.nap.edu/openbook.php?record_id=13121&page=1

Kim JH, Lee YW, Park KA, Lee WT, Lee JE. “Agmatine attenuates brain edema through reducing the expression of aquaporin-1 after cerebral ischemia”, J Cereb Blood Flow Metab. 2010 May;30(5):943-9. Epub 2009 Dec 23. PMID: 20029450

Krusong K, Ercan-Sencicek AG, Xu M, Ohtsu H, Anderson GM, State MW, Pittenger C. “High levels of histidine decarboxylase in the striatum of mice and rats.” Neurosci Lett. 2011 May 16;495(2):110-4. Epub 2011 Apr 1. PMID: 21440039

Penedo LA, Oliveira-Silva P, Gonzalez EM, Maciel R, Jurgilas PB, Melibeu Ada C, Campello-Costa P, Serfaty CA. “Nutritional tryptophan restriction impairs plasticity of retinotectal axons during the critical period.”Exp Neurol. 2009 May;217(1):108-15. Epub 2009 Feb 10. PMID: 19416666

Sahley BJ (2002), “The Anxiety Epidemic”, ISBN: 1-889391-23-9

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Sharma HS, Winkler T, Stålberg E, Mohanty S, Westman J. “p-Chlorophenylalanine, an inhibitor of serotonin synthesis reduces blood-brain barrier permeability, cerebral blood flow, edema formation and cell injury following trauma to the rat brain.” Acta Neurochir Suppl. 2000;76:91-5.  PMID: 11450100

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Zhang TL, Zhao YW, Liu XY, Ding SJ. “Effects of L-lysine monohydrochloride on insulin and blood glucose levels in spinal cord injured rats”. Chin Med J (Engl). 2010 Mar 20;123(6):722-5.

Mt Kilamanjaro at sunrise as seen from Mt. Meru, Tanzania Africa.

Disclaimer: The ERB is a literature research team presenting the findings of other researchers. The ERB is not licensed medical nor dietary clinicians and will not give medical nor dietary advice. Any information presented on this website should not be substituted for the advice of a licensed physician or nutritionist. Users of this website accept the sole responsibility to conduct their own due diligence on topics presented and to consult licensed medical professionals to review their material. We make no warranties or representations on the information presented and should users utilize this research without consulting a professional, they assume all responsibility for their actions and the consequences.

Concussion (mild TBI) Brain Food: A Review of Fish Oil, B-Complex and Protein (Amino Acid) Therapies

Concussion (mild Traumatic Brain Injury) Brain Food Treatment Research Summary:  Research shows that fish oil supplements if supplied before or after brain trauma aid in protecting cell membrane from damage and death. The Institute of Medicine research report shows that by immediately providing sufficient protein to brain damaged victims, mortality rates and Second Injury (damage surrounding the initial injury) can be significantly reduced.  Protein builds DNA, cell structures, and neurotransmitters. Researchers have found that Bcomplex vitamins are critical to maintaining reactions involved in the production of red blood cells, cell membrane, the myelin coating surrounding nerves fibers, and neurotransmitter production, making B-complex vitamins vital for nerve communication and brain function.   This report reviews these findings to encourage further evaluation and testing.  Home laboratory testing to monitor these nutrient levels should be evaluated.

High School Soccer Player Concussion Case Study:

As he jumped into the air, the soccer player was struck on the back of the head (posterior parietal, right side). He fell to the ground and lost consciousness for 10 – 15 seconds.  Afterwards, he felt normal and returned to play for 40 minutes. The next morning, the back of his head was swollen.  He described the pain as a “bad migraine”. The subject was lethargic and bright lights made him nauseous.  He experienced no balance nor vision problems.  Quick movements intensified his headache. He did not attend school, as it was difficult to concentrate, read, write, or spell.  He had memory difficulties. Bright light caused dizziness and irritated his headache.  He experienced no improvement of his condition during the first two weeks.

The third week post concussion, the subject began taking Fish Oil (600mg DHA+EPA, twice daily), B-complex (100mg/twice daily) , and Amino Acids (750mg/twice daily).  Feeling better, he attempted to attend school, but found himself “fading out”. At his physician’s office, he was unable to memorize colors or spell simple words.  Swelling was identified on the right side of his parietal lobe and left side of his frontal lobe.  He returned to school several days later for a few hours. He was unable to complete homework.  The third week he attended school part-time and on the fourth week, he attended full time. He felt “fairly normal”, however, continued to have difficulties with bright lights and could not recall elementary school memories.  He discontinued the vitamins at the end of the fourth week.

One year later, the subject suffered a minor concussion as the front of his head (right frontal lobe) struck a goal post.  His pupils were dilated.  He could remember colors and spell however, he was dizzy in bright light.  He discontinued play, but did not consider this event as serious as the previous. He took the vitamins for a few days and felt better.  The following year, he again hit his head during soccer season and took the vitamins for a couple days.

Since most concussions improve about the third to fourth week, it is difficult to determine whether fish oil, b-complex, and amino acids shortened recovery time. The subject believes that the improvements began with the vitamins.  He states that upon taking the vitamins, he felt like returning to school. Additional research would be more valuable should baseline, post concussion, and post treatment neurocognitive testing be completed with control and test groups.

Concussion – mild Traumatic Brain Injury Discussion:

The human brain is about the size of a cauliflower head with the density of medium soft cheese and can be easily sectioned with a spatula. The brain stem protrudes from the posterior-inferior surface sending commands up and down pathways and through relay centers to the pinky-sized spinal cord. The brain and spinal cord are surrounded by clear cerebral spinal fluid (CSF) and membranes which provide a shock absorber-like environment internal to the bony cranium and vertebrae.

When the cushion environment is disrupted by an “external mechanical force such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile” (Maas AI, et al., 2008), a traumatic brain injury (TBI) results.  A mild TBI is referred to as a concussion.

TBIs are the leading cause of death/disability worldwide  (Alves OL, et al., 2001) and the number one cause of coma (Farag E, et al., 2011).   One third of TBI fatalities are firearm accidents (75% suicide) and another third are motor vehicle accidents (Leon-Carrion J, et.al., 2005). A total of 1.5 million people experience head trauma each year in the U.S. resulting in an annual cost exceeding $5.6 billion.  While most head injuries are mild (Cassidy JD, et al., 2004), the death rate to TBI is estimated at 21% by 30 days post injury (Greenwood, et al, 2003). The greatest number of TBIs occur in the male 15-24 age group (Hardman JM, et al., 2002) (Mass AI, et al., 2008). Sport and recreational activities in the U.S. alone may cause between 1.6 – 3.8 million TBIs each year (CDCP, 2007).  In addition, the military has seen a significant increase in TBIs. Approximately, 10-20% of veterans returning from the Middle East have experienced a TBI. The Department of Defense is conducting research to reduce the serious problems associated with these injuries and has requested a report from the Institute of Medicine (2011).

Clinically, a mild TBI or concussion is defined as post-traumatic amnesia of less than one day and a loss of consciousness between 0 -30 minutes (DOD TBI Task Force).  Symptoms include “headache, vomiting, nausea, lack of motor coordination, dizziness, and difficulty balancing” (Kushner D, 1998) along with “lightheadedness, blurred vision or tired eyes, ringing in the ear, bad taste in the mouth, fatigue or lethargy, and changes in sleep patterns.  Cognitive and emotional symptoms include behavioral or mood changes, confusion, and trouble with memory, concentration, attention, or thinking” (NINDS, 2008). Social behavior or emotional problems may also occur. Damage to the left side of the brain may involve speech, reading and writing difficulties.  Damage to the back of the brain may involve vision, balance, and coordination problems.

Current diagnostic techniques include neurological exam and neuro-imaging studies such as CT (CAT scan) or MRI (Magnetic Resonance Imaging).  CT scans are quickly completed in an emergency department. They are less expensive and better at showing bleeds than MRI  however, brain CT delivers a 1-2 millisievert dose of radiation.   MRI, which utilizes a magnetic field,  (no radiation exposure), delivers more detail of the brain and brain stem, but it is more time consuming and costly.  A CT of a more serious TBI may show hemorrhage, skull fracture, contusions (bruising), fracture, and/or edema (swelling).  An MRI of a more serious TBI, might show a shifting of brain structures, contusion, and hematoma. When blood exerts pressure upon the brain surface it can impair brain function. Interestingly, when brain tissue is seriously injured,  it appears to be cracked open on MRI, much like the appearance of a sponge that is torn open every 1-2 inches. The tears create fluid inlets, perhaps designed to bring nutrient rich CSF to the damaged areas.

A mild TBI or concussion will often show little damage on CT or MRI neuro-imaging studies, thus the increasing use of imPACT or CNS Vital Signs neurocognitive testing.  These computerized tests  have been more effective at assessing mild concussive damage by evaluating general mental functioning. To date, many athletic programs have been using them to compare pre and post injury results to determine ‘return to play’. Since they measure brain function in terms of verbal and visual memory, processing speed, reaction time, attention span, and non-verbal problem solving capabilities, neurocognitive testing has been successfully utilized to identify emotional and cognitive deficits related to mild TBIs.

When the brain is damaged, it immediately begins self repair. Raw materials are sought from nutrients in the blood supply and from CSF to rebuild the initial injury site.  When nutrient supply is insufficient, surrounding brain tissue may be broken down to supply substrate for reconstruction.

Damage apparent in adjacent tissue, has been defined as Second Injury and may result in more serious injury than the initial TBI (Park E, et al., 2008). When death results weeks later, it is typically caused by secondary damage (Ghajar J, 2000). In the past, this Second Injury has been commonplace and no therapy has been available to stop progression (Park E, et al., 2008). However, recent military studies found that by immediately supplying sufficient amounts of protein to the injured patient, Secondary Injury is significantly reduced (Institute of Medicine, 2011).  Providing omega-3 essential fatty acids (DHA/EPA) before injury or immediately after injury also reduces TBI damage (Mills JD, et al., 2011) (Wu A, et al., 2007).

Brain injury brings immune cells and fluids to the injury site, resulting in inflammation, but with the brain enclosed in the cranium there is minimal space to accommodate swelling.  The resultant increase in intracranial pressure may occlude blood vessels responsible for bringing oxygen and nutrients to brain cells and lymph vessels responsible for removing waste products (Scalea TM, 2005). Increased pressure can force the brain to herniate into spaces where it does not belong.  This renders the tissue non-functional and eventually will cause death.  A variety of anti-inflammatory medications are often utilized to diminish swelling.

Mild TBIs physically appear to resolve in 3 weeks and patients tend to return to normal activities.  Some patients have “physical, cognitive, emotional and behavioral problems such as headaches, dizziness, difficulty concentrating, and depression” (Parik S et al., 2007). Movement disorders, seizures, and substance abuse may also develop (Arlinghaus KA, et al., 2005). Depending upon the severity of the injury, the number of repeat injuries and the presence of adequate nutrients before and after the injury, the prognosis ranges from complete recovery to permanent disability, neurological disease or death. “Permanent disability is thought to occur in 10% of mild TBIs, 66% of moderate injuries, and 100% of severe injuries” (Frey LC, 2003). In many situations, particularly athletics, a second concussion may occur before the first concussion has healed.  This is of particular concern as multiple TBIs may have a cumulative effect (Kwasnica C, et al., 2008).

Brain Biochemistry:

As discussed in ‘The ERB Vision for Wellness‘ tab on this website, Dr. James Watson of Watson and Crick, the scientists who discovered the DNA double helix, tells us that to eliminate disease we must return to Biochemistry.  We expect that the many dedicated researchers referenced below would agree.  They have found that in Traumatic Brain Injury, nutrition matters.  Adequate supplies of the major tissue nutrients are critical.

In looking at a section of brain tissue, the lighter tan colored structures are called “white matter.” White matter consists of nerve fiber tracts or pathways traveling in both directions to and from the brain through the brainstem down the spinal cord and extending out to organs, arms, and legs.  A nerve can be up to four feet long. White matter nerve tissue is composed of essential fatty acids called omega-3s such as DHA (docosahexanoic acid) and EPA (eicosapentanoic acid).  Most nerve tissue contains a myelin coating.  The resistance created by this coating allows for impulse transmission at approximately 100m/sec ( 245 mph)! Nerve and myelin formation require B-complex vitamins.  The darker structures on a brain section are called  “gray matter.”  These are decision-making nuclei made from proteins composed of amino acid building blocks.  Proteins and amino acids formulate all structures, most noticeable of which are neurotransmitters.  Neurotransmitters are critical to brain function and communication throughout the body.

Essential Fatty Acids (DHA and EPA):

40% of brain tissue is essential fatty acids (DHA and EPA).   While EPA provides important anti-inflammatory actions (Sears B, 2011) and is included in supplements, 97% of the brain’s essential fatty acids are the 22 carbon chain,  Docosahexanoic Acid (DHA).  DHA is found in foods such as walnuts (ALA), microalgae, microplants, cod, salmon, mackerel, sardines, hake, caviar, herring, oysters, organ meats (liver), grass fed and finished beef, and fish oil or algae supplements.  Fish receive DHA from ocean phytoplankton (microalgae or microplants).  Cattle receive DHA from grass.  However, as we increasingly draw our food from farm-raised fish and grain-raised cattle, our dietary intake of DHA is being depleted, (Abel R, 2002).

Most humans consume an overabundance of vegetable oil and butters which contain no double bonds in their carbon chains.  DHA has six double bonds (22:6), one at every third carbon (omega-3 or n-3). In cell membrane, these double bonds allow the fatty acid to neutralize damaging free radicals.  In addition, the double bonds increase the fluidity properties of cell membrane which helps to protect the cell from trauma and cell death (apoptosis) (Eckert GP, et al., 2011). Proper cell communication and signaling is critical for brain function. Fifty percent of nerve cell plasma membrane is DHA (Collins C, et al., 2002) which is important in cell communication, neuronal survival, and growth.  DHA is found in three cell membrane phospholipids:  phosphytidylethnolamine, ethnolamine plasmalogens, and phosphatidylserine. Upon injury, these phospholipid pools are important reservoirs to reconstruct cell membrane (Chang CY, et al., 2009).  In the absence of dietary DHA, the brain will improvise and construct brain tissue from vegetable oil.  However, under traumatic conditions  vegetable oil fed rat brain falls apart, (Eckert  GP, et al., 2011) (Abel R, 2002).

Researchers found that in rats subject to TBI which then received 40mg/kg/day pharmaceutical grade fish oil rich in DHA and EPA for 30 days post TBI had more healthy nerve cells.  Essential fatty  acids  were shown  to be neuroprotective by reducing  the  number of  injured nerve axons, decreasing the level of inflammation,  and reducing oxidative stress and cell death (Mills JD et al., 2011). DHA fed to rats immediately post TBI was found to counteract cognitive decay, maintain membrane signaling function, and support the potential of DHA supplementation to reduce the effects of TBI. (Wu A, et.al 2011).  In addition, essential fatty acids DHA and EPA given to rats 4 weeks prior to TBI was found to help maintain brain homeostasis and reduce oxidative damage due to TBI (Wu A, et al., 2007). 

DHA and EPA have been found to improve the outcome of stroke studies of both rat and human models (Kong W, et.al) (Hagiwara H, et.al.).  Few human studies have been conducted using DHA as prophylaxis for TBI.  In 2006, 20 grams per day of omega-3 fish oil (CNN, 2012)  and hyperbaric oxygen treatment were used by Dr. Julian Bailes to treat the sole survivor of the West Virginia mining disaster, Randal McCloy, who suffered carbon monoxide poisoning. This patient now claims that his brain function is near normal.  Dr. Bailes and his colleagues have since published many research papers demonstrating the benefits of essential fatty acids and fish oil supplements.  In addition, “individual case reports using fish oil doses of 2-4 grams per day have been described, however sufficient human research is unavailable to recommend dosages”  (Maroon, JC and Bost J, 2011).

One new human case study was published in October 2012, when Peter Ghassemi convinced physicians to give his son Bobby, who was in a coma following a motor vehicle accident, omega-3 fish oil ( a similar dose to Randal McCloy).  Bobby  had a Glasgow Coma Score of 3 (scale 3 – 15), which Dr. Michael Lewis says that “a brick or piece of wood has a Glasgow Coma Score of 3. It’s dead.”  Peter Ghassemi, Bobby’s father, indicates that it was difficult to convince physicians to give their son fish oil.  They wanted to see 1000 case studies first, to prove its efficacy.  Eventually, physicians agreed.  Thanks to his father’s perserverance, Bobby has recovered today.  U.S. Army Colonel Lewis who recommended the therapy to Peter Ghassemi describes the therapy like this.  “If you have a brick wall and it gets damaged, wouldn’t you want to use bricks to repair the wall?  And omega-3 fatty acids are literally the bricks of the cell wall of the brain.”  (CNN,2012)

The textbook “Contemporary Nutrition” written by  Gordon M. Wardlaw and Anne M. Smith in 2013 tells us that EPA and DHA are slowly synthesized in the brain from alpha linoleic acid and can be found in “fatty fish such as salmon, tuna, sardines, anchovies, striped bass, catfish, herring, mackerel, trout or halibut “(listed highest to lowest omega-3 content) and in foods such as “canola and soybean oils, walnuts, flax seeds, mussels, crab and shrimp”.  The authors warn about high mercury levels in swordfish, shark, king mackerel, and albacore, and indicate that fish with low mercury levels include salmon, sardines, bluefish, herring and shrimp.  Eating fish twice each week is recommended.  Omega-3 fatty acids tend to act to reduce blood clotting and inflammation, while omega-6 foods tend to increase clotting and inflammation.  Vitamin K and calcium carbonate are also involved in the clotting process. “Fish oil capsules should be limited for individuals who have bleeding disorders, take anticoagulant medications, or anticipate surgery, because they may increase risk of uncontrollable bleeding and hemorrhagic stroke”.

Wardlaw and Smith recommend 1.6 grams per day of omega-3 fatty acids for men and 1.1 grams per day for women.  Elevated blood triglycerides are treated with 2 to 4 grams per day.  Omega 3 fatty acids have been found to reduce the inflammation of rheumatoid arthritis and help with behavioral disorders and cases of mild depression.  Freezing fish oil capsules helps to reduces the fishy after taste.  “2 tablespoons of flax seed per day is typically recommended as an omega-3 fatty acid source”.  Approximately 3 walnuts (6 halves) yields approximatley 1 gram of DHA.  Care should be taken to keep DHA sources refrigerated as they turn rancid easily.  For TBI patients on IV feeding it is important to investigate the quantity of DHA and EPA present in total parenteral nutrition.  One researcher takes approximately 1 gram of DHA/EPA through fish oil daily and regulates intake by the dryness/moistness of the skin.  In drier climates, she finds this daily intake amount must be doubled.  Mercury consumption in fish oil is a serious risk and mercury free alternatives should be explored.

More human studies are needed to establish the benefits/risks of DHA and EPA with TBI. Eventually these will come however, the bureaucracy is heavy, and the cost estimates of bringing a new drug to market varies from $500 million to $2 billion (Adams C, et al., 2006) (JHE, 2010). A bottle of fish oil, with a small profit margin, may not provide sufficient return on investment to entice investigation.  One subject with a fish oil allergy could mire the researching organization in million dollar legal proceedings for years to come. That said,  research studies are important for physicians to have as legal and medical support for their recommendations.  Given this climate, many individuals and their health care providers have taken on the responsibility to evaluate whether  fish oil supplements are a safe and worthwhile benefit or a risk addition to their diet.  By 2020, we expect clinicians and individual to measure and maintain their optimum DHA/EPA levels.

B Complex Vitamins:

Vitamin B is a vitamin complex  of B-1-thiamine, B-2 riboflavin, B-3 niacin, B-5 pantothenic acid, B-6 pyridoxine, B-9 folate, B12-cobalamin.  B complex vitamins are important for nerve, DNA and neurotransmitter synthesis,  and for cell energy production and metabolism.  The majority of the information cited below regarding the effects of B complex vitamins on brain function has been obtained from animal studies.

Thiamine (B1):

  • Required for red blood cells to carry oxygen (Combs GF Jr, et al., 2008)
  • Acetylcholine neurotransmitter production(Butterworth RF, et al., 2006)
  • Myelin synthesis in nerve cells (Butterworth RF, et al., 2006)
  • High school female RDA 1.0 mg/day, male 1.2 mg/day.
  • Adult RDA is 1.1 – 1.2 mg/day, Daily Value 1.5 mg/day, no upper limit set because water soluble and rapidly lost in urine, alcohol consumption reduces thiamin levels (Wardlaw, et.al., 2013)
Riboflavin (B2):
  • A component in all flavoproteins and  red blood cells (erythrocytes)
  • Reduced TBI lesions, edema, and improved outcome (Hoane MR, et al., 2005)
  • High school female RDA 1.0 mg/day, male 1.3 mg/day.
  • Adult RDA is 1.1 – 1.3 mg/day, Daily Value 1.7 mg/day, no upper limit set.  Alcohol consumption reduces riboflavin levels (Wardlaw, et.al., 2013)

Niacin (B3):

  • Involved in DNA repair, cholesterol, and energy production
  • Helps produce neurotransmitters in the adrenal gland
  • Reduces TBI lesion size and improves sensory, motor, cognitive, and behavioral recovery (Voner Haar C, 2011)
  • High school female RDA 14 mg/day, male 16 mg/day.
  • Adult RDA is 14 – 16 mg/day, Daily Value is 20 mg/day, upper limit is 35mg/day of nicotinic acid form. Alcohol consumption reduces niacin levels (Wardlaw, et.al., 2013)

Pantothenic Acid (B5)

  • Neurotransmitter acetylcholine production
  • Involved in signal transduction, and enzyme control
  • High school female and male 5 mg/day.
  • Adult Adequate Intake is 5 mg/day, Daily Value is 10 mg, no upper limit set (Wardlaw, et. al, 2013).

Pyridoxal Phosphate (B6):

  • Controls all amino acid metabolism  (Sahley BJ, 2002)
  • Red blood  cell and  antibody formation (Sahley BJ, 2002)
  • Dopamine and GABA neurotransmitter production
  • Nerve myelin sheath phospholipid production
  • High school RDA female 1.2 mg/day, male 1.3 mg/day.
  • Adult RDA is 1.3 – 1.7 mg/day, Daily Value is 2 mg, Upper Level is 100 mg/day based upon nerve damage.  Studies have shown that 2 – 6 grams/day of B-6 for 2 or more months can lead to irreversible nerve damage.  Symptoms of toxicity include walking difficulties and hand and foot numbness (Wardlaw, et. al, 2013)

Folate  (B9):

  • Required to synthesize, repair, and methylate DNA.
  • Provides neuroprotection in TBI (Naim MY, et al., 2010)
  • Important in rapid cell division and growth.
  • Production of healthy red blood cells and anemia prevention
  • Forms cell membrane phospholipids and receptors (Karakula H, et al.,2009) (Surtees R, 1998)
  • Prevents nerve damage and neural tube defects during development
  • Required for myelin regeneration (van Rensburg SJ, et al., 2006) (Guettat L, et al., 1997)
  • High school RDA female and male 400 mcg/day.
  • Adult RDA and Daily Value is 400 mcg/day,  pregnant women 600mcg/day  (important to prevent neural tube defects), Upper Level is 1 mg/day alcoholism and poor absorption reduces folate levels (Wardlaw, et.al., 2013)

Cobalamin (B12):

  •  Involved in blood formation.
  • Critical to DNA synthesis through folate regeneration
  • Formation of cell membrane phospholipids and receptors (Karakula H, et al., 2009) (Surtees R, 1998)
  • B12 supplementation partially resolved cognitive deficits and myelin imaging abnormalities (Chatterjee A, et.al., 1996) (Jongen JC, et al., 2001)
  • Improves cerebral and cognitive functions.  (Bourre JM, 2006)
  • Required for myelin synthesis (Hall CA, 1990) (van Rensburg SJ, et al, 2006) (Guettat L, et al., 1997)
  • Promotes nerve regeneration (Okada K, et al., 2010)
  • High school RDA female and male 2.4 mcg/day.
  • RDA is 2.4 mcg/day, Daily Value is 6 mcg/day, no Upper Limit set, stored in liver, 50% of dietary intake may be absorbed.  Nerve damage and anemia may result from insufficient intake.

There are 150mg time release (9-10 hours) capsules available for B complex.  All  B vitamins are water soluble and need to be replenished daily.  Vitamin B complex has an important  role  in  alleviating anxiety and lactic acid buildup.  Dietary supply may be inadequate under stress (Sahley BJ, 2002).

Protein (Amino Acids):

Linear chains of amino acids form proteins. Proteins produce nuclei in the brain, DNA,  cell membrane, enzymes, and neurotransmitters. Twenty amino acids are commonly identified.  All 20 amino acids need to present concurrently for protein synthesis to occur.  A problem may be that most foods do not provide all 20 amino acids concurrently as is provided by a 20 amino acid complex supplement.  More research needs to be completed on this topic.

Alanine – Precursor of neurotransmitter dopamine (Coxon KM, et al., 2005)

Arginine – Through agmantine, it is neuroprotective in trauma and ischemia models by significantly reducing  brain swelling volume and blood-brain barrier protection (Kim JH, et al., 2009)

Cysteine – Forms DNA double helix disulfide bonds

Glutamate – Important for calcium ion binding; may reduce blood glucose levels in the injured spinal cord reducing neurological impairment (Zhang TL, et al., 2010)

Glutathione – Critical to relieve oxidative stress in cells

Glycine – Important in red blood cell formation (Shemin D, et al., 1946); gives amino acid structures flexibility

Histidine – Used throughout the brain;  improves TBI outcome (Faden AI, et al., 1993) (Krusong K, et al., 2011)

Lysine – Important for connective tissue maintenance, and affects protein binding to phospholipid membranes (Blenis J, et al., 1993)

Methionine – The sole methyl donor in the central nervous system; increases S-adenylmethionine (SAMe) in CSF aiding in neurological disorder treatment (Chishty M, et al., 2002); forms Glutathione, important in reducing free radical-mediated traumatic injury  (Gidday JM, et al., 1999)

Phenylalanine – Produces chlorophenylalanine (CPA) which slowed the breakdown of the blood-brain barrier permeability, brain edema and blood flow; reduced the number of damaged and distorted nerve cells (Sharma HS, et al., 2000).

Proline – Maintains connective tissue (Bhattacharjee A, et al., 2005)

Serine – Acts as a neurotransmitter in the brain (Wolosker H, et al., 2008)

Taurine – Major component of brain tissue and muscle (Brosnan JT, 2006)

Threonine – A component of the serine/threonine kinase; neuroprotective following traumatic brain injury (Erlich S, et al.,2007)

Tryptophan – Precursor to neurotransmitter serotonin (Savelieva KV, et al., 2008); a modulator of serotonin which alters plasticity-related signaling pathways and matrix degradation (Penedo LA, et al., 2009)

Tyrosine – Precursor of the neurotransmitter dopamine, norepinephrine, epinephrine

Under prolonged stress or illness the body is unable to produce sufficient non-essential amino acids (Sahley BJ, 2002).  Trauma has been found to damage DNA and RNA, and to deplete neurotransmitters.  Neurological dysfunction is caused by traumatic brain injury (Cole J, et al., 2010

As amino acids are utilized for energy and substrate, they are oxidized to urea and carbon dioxide producing high levels of glutamate.  These high levels seen in the TBI patient can include oxidation of branched chained amino acids. Dietary consumption of Branched Chain Amino Acids (BCAAs) restored BCAA concentrations to normal, improved nerve cell communication, and reinstated cognitive performance after concussive brain injury (Cole J, et al., 2010). BCAAs and amino acid complex (protein) are available at nutrition stores.

The Institute of Medicine committee report of April 20, 2011 on Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel   found that supplying high levels of protein to the TBI patient within the first 24 hours severely reduced mortality.  This report calls for standardized protocols to require  a level of nutrition that represents more than 50 percent of the injured person’s total energy expenditure and provide 1 to 1.5 grams of protein per kilogram of body weight for two weeks. They expect this nutritional intervention limits the inflammatory response, thereby improving outcome.  Most importantly, in following this protein therapy, the detrimental secondary injury process was not apparent.

Protein needs of a sedentary adult are estimated at .8 grams/kilogram  or 56 grams/day for a 70-kilogram, 154lb man.  (Pounds/2.2 kilograms per pound * .8 grams/kilogram).   Protein needs of a football, power sport playing athlete are approximately 1.4 – 1.7 grams/kilogram for males and 1.1 – 1.5 grams/kilogram for females or 98-119 grams/day. Athletes in a strength training program can be recommended up to 2.0 grams of protein per kilogram per day, almost twice the RDA (Wardlaw, et. al., 2013).

The objective of this discussion has been to bring current research advancements to light given the realization that concussive TBIs cause damage and disease, such that this information may be further evaluated by the public, health care providers, and the medical research community.

Traumatic Brain Injury References:

Alves OL, Bullock R (2001). “Excitotoxic damage in traumatic brain injury”. In Clark RSB, Kochanek P. Brain injury. Boston: Kluwer Academic Publishers. p. 1. ISBN 0-7923-7532-7. Retrieved 2008-11-28.

Arlinghaus KA, Shoaib AM, Price TRP (2005). “Neuropsychiatric assessment”. In Silver JM, McAllister TW, Yudofsky SC. Textbook Of Traumatic Brain Injury. Washington, DC: American Psychiatric Association. pp. 63–65. ISBN 1-58562-105-6.

Center for Disease Control and Prevention, National Center for Injury Prevention and Control. “Traumatic brain injury” (http://www.cdc.gov/ncipc/factsheets/tbi.htm) 2007.

Cassidy JD, Carroll LJ, Peloso PM, Borg J, von Holst H, Holm L et al. (2004). “Incidence, risk factors and prevention of mild traumatic brain injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury”. Journal of Rehabilitation Medicine 36 (Supplement 43): 28–60. DOI:10.1080/16501960410023732. PMID 15083870.

Carlson K, Kehle S, Meis L, Greer N, MacDonald R, Rutks I, Wilt TJ, “The Assessment and Treatment of Individuals with History of Traumatic Brain Injury and Post-Traumatic Stress Disorder: A Systematic Review of the Evidence [Internet].” Washington (DC), Department of Veterans Affairs (US); 2009 Aug, VA Evidence-based Synthesis Program Reports

Department of Defense and Department of Veterans Affairs (2008). “Traumatic Brain Injury Task Force”. http://www.cdc.gov/nchs/data/icd9/Sep08TBI.pdf.

Farag E, Manno EM, Kurz A. (2011) “Use of hypothermia for traumatic brain injury: point of view” Minerva Anesthesiol. 2011 Mar;77(3):366-70. Epub 2011 Feb 1. PMID: 21283076

Frey LC (2003). “Epidemiology of posttraumatic epilepsy: A critical review”. Epilepsia 44 (Supplement 10): 11–17. DOI:10.1046/j.1528-1157.44.s10.4.x. PMID 14511389.

Furlow, B (2010 May-Jun). “Radiation dose in computed tomography.”. Radiologic Technology 81 (5): 437-50. PMID 20445138.

Ghajar J (September 2000). “Traumatic brain injury”. Lancet 356 (9233): 923–29. DOI:10.1016/S0140-6736(00)02689-1. PMID 11036909.

Greenwald BD, Burnett DM, Miller MA (March 2003). “Congenital and acquired brain injury. 1. Brain injury: epidemiology and pathophysiology”. Archives of Physical Medicine and Rehabilitation 84 (3 Suppl 1): S3–7. DOI:10.1053/apmr.2003.50052. PMID 12708551.

Hardman JM, Manoukian A (2002). “Pathology of head trauma”. Neuroimaging Clinics of North America 12 (2): 175–87, vii. DOI:10.1016/S1052-5149(02)00009-6. PMID 12391630. “TBI is highest in young adults aged 15 to 24 years and higher in men than women in all age groups.”

Kushner D (1998). “Mild traumatic brain injury: Toward understanding manifestations and treatment”. Archives of Internal Medicine 158 (15): 1617–24. DOI:10.1001/archinte.158.15.1617. PMID 9701095.

Kwasnica C, Brown AW, Elovic EP, Kothari S, Flanagan SR (March 2008). “Congenital and acquired brain injury. 3. Spectrum of the acquired brain injury population”. Archives of Physical Medicine and Rehabilitation 89 (3 Suppl 1): S15–20. DOI:10.1016/j.apmr.2007.12.006. PMID 18295644.

León-Carrión J, Domínguez-Morales Mdel R, Barroso y Martín JM, Murillo-Cabezas F (2005). “Epidemiology of traumatic brain injury and subarachnoid hemorrhage”. Pituitary 8 (3–4): 197–202. DOI:10.1007/s11102-006-6041-5. PMID 16508717.

Maas AI, Stocchetti N, Bullock R (August 2008). “Moderate and severe traumatic brain injury in adults”. Lancet Neurology 7 (8): 728–41. DOI:10.1016/S1474-4422(08)70164-9. PMID 18635021.

“NINDS Traumatic Brain Injury Information Page”. National Institute of Neurological Disorders and Stroke. 2008-09-15. Retrieved 2008-10-27.

Parikh S, Koch M, Narayan RK (2007). “Traumatic brain injury”. International Anesthesiology Clinics 45 (3): 119–35. DOI:10.1097/AIA.0b013e318078cfe7. PMID 17622833.

Park E, Bell JD, Baker AJ (April 2008). “Traumatic brain injury: Can the consequences be stopped?”. Canadian Medical Association Journal 178 (9): 1163–70. DOI:10.1503/cmaj.080282. PMC 2292762. PMID 18427091.

Salomone JP, Frame SB (2004). “Prehospital care”. In Moore EJ, Feliciano DV, Mattox KL. Trauma. New York: McGraw-Hill, Medical Pub. Division. pp. 117–8. ISBN 0-07-137069-2. Retrieved 2008-08-15.

Scalea TM (2005). “Does it matter how head injured patients are resuscitated?”. In Valadka AB, Andrews BT. Neurotrauma: Evidence-based Answers to Common Questions. Thieme. pp. 3–4. ISBN 3-13-130781-1.

Essential Fatty Acids References:

Abel R,  “The DHA Story, How Nature’s Super Nutrient Can Save Your Life”.  2002, ISBN 1-59120-001-6, (2002).

Adams C, Brantner V (2006). “Estimating the cost of new drug development: is it really 802 million dollars?”. Health Aff (Millwood) 25 (2): 420–8. DOI:10.1377/hlthaff.25.2.420. PMID 16522582.

CNN 2012   http://www.cnn.com/2012/10/19/health/fish-oil-brain-injuries/index.html

Eckert GP, Chang S, Eckmann J, Copanaki E, Hagl S, Hener U, Müller WE, Kögel D, “Liposome-incorporated DHA increases neuronal survival by enhancing non-amyloidogenic APP processing”.  Biochim Biophys Acta. 2011 Jan;1808(1):236-43. Epub 2010 Oct 29. PMID 21036142

Livestrong.com: http://www.livestrong.com/article/430423-how-many-omega-fish-oil-pills-should-you-take-a-day/

Mills JD,  Hadley K, Bailes JE, “Dietary Supplementation with the Omega-3 fatty acid Docosahexaenoic Acid in Traumatic Brain Injury”. Neurosurgery, 2011 Feb;68(2):474-81

Journal of Health Economics 2010 Study,  http://onlinelibrary.wiley.com/doi/10.1002/hec.1454/abstract

Sears, B (2011). “The fallacy of using DHA alone for brain trauma.” http://www.prweb.com/releases/concussion/brain_trauma/prweb4500964.htm

University of Maryland Medical System and University of Maryland Medical School:  Omega-3 fatty acids:  http://www.umm.edu/altmed/articles/omega-3-000316.htm

Wardlaw, Gordon M. and Smith, Anne M., “Contemporary Nutrition”, 2013, ISBN 978-0-07-340254-3, McGraw-Hill.

Vitamin B Complex References:

Bourre JM.  “Effects of nutrients (in food) on the structure and function of the nervous system: update on dietary requirements for brain. Part 1: micronutrients”.  Nutr Health Aging. 2006 Sep-Oct;10(5):377-85. PMID: 17066209

Butterworth RF, Thiamin. In: Shils ME, Shike M, Ross AC, Caballero B, Cousins RJ, editors. Modern Nutrition in Health and Disease, 10th ed. Baltimore: Lippincott Williams & Wilkins; 2006.

Chatterjee A, Yapundich R, Palmer CA, Marson DC, Mitchell GW. Neurology. “Leukoencephalopathy associated with cobalamin deficiency”, 1996 Mar;46(3):832-4. PMID: 8618695Acta Neurol Taiwan. 2009 Dec;18(4):231-41.

Chang CY, Ke DS, Chen JY, “Essential fatty acids and human brain”, Acta Neurol Taiwan. 2009 Dec;18(4):231-41.

Combs GF Jr., “The vitamins: Fundamental Aspects in Nutrition and Health. 3rd edition. Ithaca, NY: Elsevier Academic Press; 2000

Coxon KM, Chakauya E, Ottenhof HH et al. (August 2005). “Pantothenate biosynthesis in higher plants”. Biochemical Society Transactions 33 (Pt 4): 743–6. DOI:10.1042/BST0330743. PMID 16042590.

Guettat L, Gille M, Delbecq J, Depré A, “Folic acid deficiency with leukoencephalopathy and chronic axonal neuropathy of sensory predominance”.  Rev Neurol (Paris). 1997 Jun;153(5):351-3. PMID: 9296172

Hall CA, “Function of Vitamin B12 in the central nervous system as revealed by congential defects”, Am J Hematol. 1990 Jun;34(2):121-7

Hoane MR, Wolyniak JG, Akstulewicz SL, “Administration of riboflavin improves behavioral outcome and reduces edema formation an glial fibrillary protein expression after traumatic brain injury”, J Neurotrauma, 2005 Oct 22;(10):1112-22

Jongen JC, Koehler PJ, Franke CL, “Subacute combined degeneration of the spinal cord: easy diagnosis, effective treatment”, Ned Tijdschr Geneeskd. 2001 Jun 30;145(26):1229-33. PMID: 11455686

Karakuła H, Opolska A, Kowal A, Domański M, Płotka A, Perzyński J, “Does diet affect our mood? The significance of folic acid and homocysteine”  Pol Merkur Lekarski. 2009 Feb;26(152):136-41.

Naim MY, Friess S, Smith C, Ralston J, Ryall K, Helfaer MA, Marguiles SS, “Folic acid enhances early functional recovery in a piglet model of pediatric head injury”, Dev Neurosci. 2010;32(5-6):466-79. Epub 2011 Jan 5. PMID: 21212637

Okada K, Tanaka H, Temporin K, Okamoto M, Kuroda Y, Moritomo H, Murase T, Yoshikawa H. “Methylcobalamin increases Erk1/2 and Akt activities through the methylation cycle and promotes nerve regeneration in a rat sciatic nerve injury model.”, Exp Neurol. 2010 Apr;222(2):191-203. Epub 2010 Jan 4.

Surtees R, “Demyelination and inborn errors of the single carbon transfer pathway” Pediatr. 1998 Apr;157 Suppl 2:S118-21. PMID: 9587038

van Rensburg SJ, Kotze MJ, Hon D, Haug P, Kuyler J, Hendricks M, Botha J, Potocnik FC, Matsha T, Erasmus RT, “Iron and the folate-vitamin B12-methylation pathway in multiple sclerosis”, Metab Brain Dis. 2006 Sep;21(2-3):121-37. Epub 2006 May 26. PMID: 16729250

Vonder Haar C, Anderson G, Hoane MR, “Continuous nicotinamide administration improves behavioral recovery and reduces lesion size following bilateral frontal controlled cortical impact injury.”, Behav Brain Res, 2011 Oct 31;224(2):311-7.  Epub 2011 Jun 17.

Wardlaw, Gordon M. and Smith, Anne M., “Contemporary Nutrition”, 2013, ISBN 978-0-07-340254-3, McGraw-Hill.

Protein (Amino Acids) References:

Bhattacharjee A, Bansal M (March 2005). “Collagen structure: the Madras triple helix and the current scenario”. IUBMB Life 57 (3): 161–72. DOI:10.1080/15216540500090710. PMID 16036578.

Blenis J, Resh MD (December 1993). “Subcellular localization specified by protein acylation and phosphorylation”. Current Opinion in Cell Biology 5 (6): 984–9. DOI:10.1016/0955-0674(93)90081-Z. PMID 8129952.

Brosnan JT, Brosnan ME (June 2006). “The sulfur-containing amino acids: an overview”. The Journal of Nutrition 136 (6 Suppl): 1636S–1640S. PMID 16702333.

Chishty M, Reichel A, Abbott NJ, Begley DJ. “S-adenosylmethionine is substrate for carrier mediated transport at the blood-brain barrier in vitro.” Brain Res. 2002 Jun 28;942(1-2):46-50. PMID: 12031851

Jeffrey T. Cole, Christina M. Mitala, Suhali Kundu, Ajay Verma, Jaclynn A. Elkind, Itzhak Nissim,and Akiva S. Cohena, “Dietary branched chain amino acids ameliorate injury-induced cognitive impairment”,.Proc Natl Acad Sci U S A. 2010 January 5; 107(1): 366–371. Published online 2009 December 29. doi: 10.1073/pnas.0910280107 PMCID: PMC2806733

Erlich S, Alexandrovich A, Shohami E, Pinkas-Kramarski R. “Rapamycin is a neuroprotective treatment for traumatic brain injury.” Neurobiol Dis. 2007 Apr;26(1):86-93. Epub 2007 Jan 31.  PMID: 17270455

Faden AI, Labroo VM, Cohen LA. “Imidazole-substituted analogues of TRH limit behavioral deficits after experimental brain trauma.” J Neurotrauma. 1993 Summer;10(2):101-8.  PMID: 8411214

Gidday JM, Beetsch JW, Park TS. “Endogenous glutathione protects cerebral endothelial cells from traumatic injury.”  J Neurotrauma. 1999 Jan;16(1):27-36. PMID: 9989464

Instituteof Medicine committee report, Nutrition and Traumatic Brain Injury; Improving Acute and Subacute Health Outcomes in Military Personnel.  April 20, 2011.  http://www.nap.edu/openbook.php?record_id=13121&page=1

Kim JH, Lee YW, Park KA, Lee WT, Lee JE. “Agmatine attenuates brain edema through reducing the expression of aquaporin-1 after cerebral ischemia”, J Cereb Blood Flow Metab. 2010 May;30(5):943-9. Epub 2009 Dec 23. PMID: 20029450

Krusong K, Ercan-Sencicek AG, Xu M, Ohtsu H, Anderson GM, State MW, Pittenger C. “High levels of histidine decarboxylase in the striatum of mice and rats.” Neurosci Lett. 2011 May 16;495(2):110-4. Epub 2011 Apr 1. PMID: 21440039

Penedo LA, Oliveira-Silva P, Gonzalez EM, Maciel R, Jurgilas PB, Melibeu Ada C, Campello-Costa P, Serfaty CA. “Nutritional tryptophan restriction impairs plasticity of retinotectal axons during the critical period.”Exp Neurol. 2009 May;217(1):108-15. Epub 2009 Feb 10. PMID: 19416666

Sahley BJ (2002), “The Anxiety Epidemic”, ISBN: 1-889391-23-9

Savelieva KV, Zhao S, Pogorelov VM et al. (2008). Bartolomucci, Alessandro. ed. “Genetic disruption of both tryptophan hydroxylase genes dramatically reduces serotonin and affects behavior in models sensitive to antidepressants”. PloS ONE 3 (10): e3301. Bibcode 2008PLoSO…3.3301S. DOI:10.1371/journal.pone.0003301. PMC 2565062. PMID 18923670.

Sharma HS, Winkler T, Stålberg E, Mohanty S, Westman J. “p-Chlorophenylalanine, an inhibitor of serotonin synthesis reduces blood-brain barrier permeability, cerebral blood flow, edema formation and cell injury following trauma to the rat brain.” Acta Neurochir Suppl. 2000;76:91-5.  PMID: 11450100

Shemin D, Rittenberg D (1 December 1946). “The biological utilization of glycine for the synthesis of the protoporphyrin of hemoglobin”. Journal of Biological Chemistry 166 (2): 621–5. PMID 20276176.

Wardlaw, Gordon M. and Smith, Anne M., “Contemporary Nutrition”, 2013, ISBN 978-0-07-340254-3, McGraw-Hill.

Wolosker H, Dumin E, Balan L, Foltyn VN (July 2008). “D-amino acids in the brain: D-serine in neurotransmission and neurodegeneration”. The FEBS Journal 275 (14): 3514–26. DOI:10.1111/j.1742-4658.2008.06515.x. PMID 18564180.

Zhang TL, Zhao YW, Liu XY, Ding SJ. “Effects of L-lysine monohydrochloride on insulin and blood glucose levels in spinal cord injured rats”. Chin Med J (Engl). 2010 Mar 20;123(6):722-5.  PMI

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08-13-13
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