In this episode, I discuss nutrition and supplementation to reduce the risk of brain injury and enhance brain performance and long-term health. Most brain injuries, including traumatic brain injury (TBIs) and concussion, are not from sports and are actually quite common in non-athletes. I explain what happens in the brain when a TBI occurs and discuss science-supported nutrients to reduce the risk of brain injury, minimize symptoms, and improve recovery.
Summarizing both research and clinical studies, I explain the neuroprotective effects of specific nutrients, including creatine monohydrate, fish oil (DHA and EPA), vitamin B2 (riboflavin), choline, branched-chain amino acids (BCAAs), magnesium, and anthocyanins. I also describe the recommended dosages, frequency, timing, and potential adverse effects and provide options for supplementation and whole-food sources.
Defining and Classifying Brain Injuries
- A brain injury is a broad term with various types and severities, meaning there is no single solution for prevention or recovery. Brain injuries are generally categorised by severity: mild, moderate, and severe.
- Mild TBI: Most common (over 90% of cases). Typically involves a loss of consciousness or amnesia lasting 30 minutes or less, often associated with confusion or post-traumatic amnesia for up to one day. Concussions are almost always mild TBIs; while not all TBIs are concussions, all concussions are TBIs.
- Moderate TBI: Loss of consciousness or amnesia lasting between 30 minutes and 24 hours. Symptoms are more severe, including headaches, confusion, dizziness, nausea, slurred speech, drowsiness, and difficulty concentrating. Often leads to downstream problems like lasting behavioural changes or long-term memory difficulties.
- Severe TBI: Loss of consciousness or amnesia for 24 hours to more than seven days. Associated with dementia-like symptoms such as memory and attention problems, decision-making issues, learning impairments, mood disturbances, and significant sleep problems.
Physiology and Pathophysiology of Brain Injuries
- Traditional understanding of brain injury as the brain "smashing" against the skull is often inaccurate; damage more commonly results from an "accordion effect" where fluid pressure causes the brain tissue to squeeze, stretch, and pull, damaging internal structures.
- Injuries can be highly varied, including torn capillaries (impairing nutrient/oxygen supply and waste removal), torn axons, and a host of issues related to temperature, energy metabolism, inflammation, and physical structural damage.
- Three major problems characterise TBIs:
- Physical Injury or Damage: Structural damage to capillaries, blood-brain barrier, cell membranes, astrocytes, or neurons, akin to a house with smashed windows and holes in walls.
- Massive Energy Deficit: Due to structural damage, nutrient and oxygen transport is compromised, leading to mitochondrial dysfunction and reduced ATP production. The brain, being highly energy-costly, enters a severe energy deficit, causing brain fog, fatigue, and impaired cognitive function. The brain attempts to compensate with less efficient anaerobic methods like glycolysis, but cannot meet the high energy demands, leading to a catabolic state.
- Prolonged Inflammatory Response and Oxidative Stress: An initial neuronal overactivation (excitotoxicity, largely due to glutamate release) leads to membrane damage, excessive influx of sodium and calcium, and production of reactive oxygen species (ROS), causing oxidative stress and activating enzymes that break down cell structures. This acute response transitions into a delayed phase of pervasive neuroinflammation and prolonged oxidative stress, exacerbated by immune cell migration into the brain and cytokine release, damaging fats, proteins, and DNA in the brain and impairing healing.
General Principles for Nutritional Interventions
- Evidence suggests several micronutrients and biological compounds can reduce risk and help treat brain injuries, concussions, and TBIs.
- Interventions are considered for pre-injury (preventative), during/immediately after injury (per-injury), and long-term post-recovery (post-injury).
- The effectiveness of supplements can be mixed, as it depends on whether the intervention's mechanism of action aligns with the specific symptoms or underlying pathophysiology of the individual's injury.
Key Micronutrients and Nutraceuticals for Brain Health
The "Strength of Evidence" (SoE) scale ranges from one (best, consistent results across multiple RCTs and systematic reviews) to five (lowest, case studies or mechanistic only).
Creatine Monohydrate
- Physiological Role: Creatine is stored in the brain as a quick fuel source, addressing the energy demand problem in TBIs. It improves cognitive function in both brain injury and healthy aging.
- Mechanism: Thought to prevent mitochondrial dysfunction, maintain membrane health, and reduce reactive oxygen species, ATP depletion, and calcium overload. It is effective in low oxygen situations.
- Second Impact Syndrome: Creatine depletion prior to repeated head impacts (common in athletes or military personnel) leads to worse brain damage. Replenishing creatine stores is crucial in high-risk situations.
- SoE: 2.
- Human Studies/Benefits:
- Shown to reduce cortical damage by 35-50% following TBI.
- Improves sleep, cognition, and mood post-TBI.
- A study in children (1-18 years old) with severe TBIs, given 0.4 g/kg body weight for 6 months, showed improvements in amnesia, ICU stay length, communication, locomotion, and social skills, with significantly lower costs than standard treatment. No kidney, liver, or heart side effects were reported.
- Two randomised controlled trials showed 5g/day improved depressive symptoms when added to antidepressant treatments.
- A recent (2024) paper suggested a very high dose (35g per kg of body weight, though the speaker mentioned 20g as an example dose) could acutely attenuate cognitive performance drop after sleep deprivation, with benefits lasting 3.5 to 9 hours.
- 20g/day for 7 days has been shown to enhance cognitive function in mountain bikers.
- Dosage:
- For brain health benefits, 20 grams per day (often split into 5g doses four times daily) is typically used in research post-injury, which is four times the standard performance dose.
- For prophylactic (preventative) use, 5-10 grams per day is suggested.
- For high-risk situations, 20-30 grams per day for 7 days leading up to the event is recommended.
- Lower doses (1-2 grams) are likely insufficient for significant brain benefits.
- Food Sources: Primarily from muscle meat (beef, chicken, salmon, tuna, cod). Beef has 600mg per 100g. A typical American diet provides about 2g/day. Supplementation is often easier due to the high required dosages.
- Risks: Main risk is GI distress (gas, bloating, stomach cramps) at high doses, though infrequently reported. Very low likelihood of other adverse effects even with years of high dosage use.
Fish Oil (Omega-3s: DHA & EPA)
- Physiological Role: DHA is critical for neurological function, brain structure (10% of brain is DHA), injury risk, and prevention of neurodegeneration. EPA is involved in vascular function, inflammation, and oxygen/nutrient delivery to the brain.
- Mechanism: Improves cerebral perfusion (blood flow, oxygen, nutrients), arterial pliability, and modulates post-injury inflammation by regulating reactive oxygen species and gene expression of inflammatory markers.
- SoE: 3 (for TBI, but extensive indirect evidence).
- Human Studies/Benefits:
- Higher omega-3 intake is associated with larger hippocampal volume, improving learning and memory. 2.2g/day of fish oil linked to bigger hippocampus.
- Improved accuracy and speed in recall tasks with 900mg EPA + 260mg DHA.
- DHA (2g/day) specifically shown to impact neurofilament light (NFL) in college football players, a marker of injury.
- Dosage: 2-4 grams per day for brain-related injuries. Studies looking at higher dosages (beyond ~2g/day) have not shown additional benefits.
- Timing: Important both before and after injury; time of day is irrelevant.
- Food Sources: Fatty fish like salmon (about 2g per 100g cooked), herring, sardines, mackerel, trout. Standard American diet is typically insufficient (around 100mg/day). Supplementation is often needed to reach effective doses.
- Omega-3 Index: This blood test measures EPA and DHA percentage in red blood cell membranes. An optimal index is 8-10% (even 12%), but many athletes and the general population are below 5%, making them more susceptible to severe brain injury consequences. Prophylactic use is highly recommended.
- Risks: Potential for loose stool.
Vitamin B2 (Riboflavin) and Other B Vitamins
- Physiological Role: B2 is required for proper DHA utilisation, ATP production, and glutathione (chief endogenous antioxidant) synthesis. Other B vitamins (B6, B9/Folate, B12) are also crucial for DHA integration into the brain.
- Mechanism: Addresses energy production problems and enhances antioxidant capacity/reduces inflammation. Helps reduce homocysteine levels (which are elevated with B vitamin deficiencies and linked to oxidative stress, brain atrophy, and cognitive decline).
- SoE: 3 for riboflavin.
- Human Studies/Benefits (Riboflavin):
- 400mg/day reduced migraines in a 1998 study.
- A 2023 study found 400mg/day (given twice daily for 24 hours post-injury) significantly reduced TBI recovery days by half (from 22 to 10 days).
- Dosage (Riboflavin): 400mg per day (can be once or twice daily). Multivitamins typically do not contain enough.
- Food Sources: Beef liver (3.4mg per 100g), fortified cereals, whey protein. Difficult to get required dosages from food alone for TBI treatment.
- Risks: Very safe with low risk of adverse effects at reasonable dosages.
Choline
- Physiological Role: Preserves the blood-brain barrier by warding off membrane breakdown, is a primary precursor to acetylcholine (neurotransmitter for neuronal activation), and a precursor to glutathione.
- Mechanism: Helps with structural damage, cellular communication/activation, and antioxidant capacity. Higher dietary intake associated with decreased Alzheimer's/dementia biomarkers.
- SoE: 3.
- Human Studies/Benefits:
- Some studies using citicoline (CDP choline) found minor benefits in physiological and cognitive domains following head trauma. A meta-analysis indicated about a 20% success likelihood for TBI treatment.
- 1g/day for 30 days improved recognition memory in mild TBI patients in one study, though a repeat study found no difference, possibly due to participants having minor TBIs that didn't affect the choline pathway.
- A large "COBRIT" study (2g/day) found no benefit for cognitive function at 90 days, but was criticised for poor participant adherence (only 44% met 75% adherence).
- Brain choline levels in the primary motor cortex are known to diminish across football seasons due to continuous head impacts, similar to creatine, potentially contributing to second impact syndrome.
- Dosage:
- Prophylactic: 500mg per day.
- Post-injury: 1-2 grams per day.
- Supplement Forms: Alpha GPC or phosphatidylcholine (PC) are common. Alpha GPC is metabolised to PC.
- Timing: Often has a nootropic effect, so best taken earlier in the day to avoid sleep issues.
- Food Sources: Meat, poultry, fish, eggs (150mg/egg), dairy, beans, cruciferous vegetables, beef liver (400mg per 100g). Average intake is often below adequate intake (550mg for men, 420mg for women). High post-injury doses are easier to achieve with supplements.
Branched-Chain Amino Acids (BCAAs)
- Physiological Role: BCAAs (isoleucine, leucine, valine) act as nitrogen donors for glutamate and GABA, and interfere with tryptophan and tyrosine transport across the blood-brain barrier.
- Mechanism: Modulate excitotoxicity (glutamate overactivation) and influence precursors for serotonin and melatonin, which can affect sleep.
- SoE: 2.
- Human Studies/Benefits:
- Severity of TBI symptoms correlates with BCAA suppression in the brain.
- 30g/day (twice daily) improved insomnia and sleep latency in veterans with chronic TBI.
- The HIT HEADS trial (2024, pilot RCT) found a clear dose-response effect for BCAA supplementation (15-54g/day for 21 days) in 10-35-year-olds with concussions. 54g/day showed the most improvement in concussion symptoms and faster return to baseline, with no adverse effects reported.
- Main effects are thought to be correction of excitotoxicity and some sleep-wake abnormalities.
- Dosage: Up to 54g/day post-injury. High protein intake (e.g., 1g/pound body weight) may provide sufficient baseline BCAAs.
- Food Sources: Protein-rich foods like meat, poultry, and dairy. Difficult to obtain 50+ grams from food alone.
- Risks: No adverse effects reported even at high dosages.
Magnesium
- Physiological Role: Involved in over 600 bodily reactions, including cell signalling, vascular function, ATP production, protein synthesis, neuroplasticity, learning, and memory.
- Mechanism: Inhibits receptors targeted by antidepressants, contributes to excitotoxicity after injury (deficiency exacerbates this), and plays a role in brain and blood concentrations, calcium problems, and edema.
- SoE: 3 (despite strong clinical importance, SoE for TBI is 3).
- Human Studies/Benefits:
- Magnesium deficiency is linked to numerous health conditions (e.g., type 2 diabetes, hypertension, headaches, heart disease).
- A documented drop in central neuron magnesium after TBI correlates with injury severity and behavioural disturbances.
- 400mg twice daily significantly reduced post-concussion severity scores 48 hours after injury in kids with acute TBIs.
- Dosage: 400mg per day.
- Timing: Important pre and post injury; time of day doesn't matter, though some forms may aid sleep.
- Forms: Bisglycinate, malate, threonate are generally well-tolerated. No compelling evidence yet suggests one form is definitively superior for TBI.
- Food Sources: Pumpkin seeds (200mg per 100g roasted), chia seeds, almonds, spinach. Can be challenging to meet TBI dosages from food alone.
- Risks: Main risk is GI distress with some forms. Very safe overall.
Anthocyanins (Blueberries)
- Physiological Role: Phytochemicals (flavonoids) involved in cardiovascular disease, metabolic syndrome, type 2 diabetes, cancers, vision, skin, inflammation, and neurodegenerative disorders.
- Mechanism: Improve brain-derived neurotropic factor (BDNF), which is inversely correlated with memory and cognition. Protect against oxidative stress, leveraging their antioxidant properties.
- SoE: 3 (no direct RCTs for TBI, but strong inference from general brain health studies).
- Human Studies/Benefits:
- Freeze-dried wild blueberries (15 or 30g) significantly improved cognitive function in kids in a dose-dependent manner.
- Blueberry extracts (100mg) improved episodic memory and reduced cardiovascular disease in older adults.
- Help with attention, memory, and executive function.
- Dosage: Approximately 500mg of anthocyanins, easily achieved with one cup (150g) of blueberries.
- Food Sources: Blueberries are the most studied, but strawberries, cranberries, and raspberries also contain anthocyanins. This is considered the easiest nutrient to get sufficiently from whole foods.
- Risks: None mentioned.
Substances to Avoid During Brain Injury Healing
- Caffeine: Detrimental for brain healing. Causes neurovascular constriction, reducing blood flow. Caffeine consumers are more susceptible to diminished emotional health, poor sleep quality, depression, and somatic symptoms with brain injuries. Recommendation is to avoid overconsumption if healing from a brain injury, consulting a doctor.