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The Role of Medical Nutrition Therapy

Following Brain Injury

#BIANJWebinars Wynnifred Mercado Hoodis, MS, RDNApril 17, 2020

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BIANJ Webinars

Today’s Webinar: The Role of Medical Nutrition Therapy Following Brain Injury

Presenter: Wynnifred M. Hoodis, MS, RDNClinical Faculty Preceptor, Dietetic InternshipFoods and Nutrition DepartmentCollege of Saint ElizabethMorristown, New Jersey

Today’s Presenter:Wynnifred Mercado Hoodis, MS, RDN, is a registered dietitian nutritionist and currently works as a clinical faculty member at the College of Saint Elizabeth in Morristown, NJ. Wynnifred is a clinical preceptor to students in their hospital rotation as part of their dietetic internship graduate level program. Previously, She worked in acute care clinical practice at Overlook Medical Center in Summit, NJ, which is home to the Atlantic Neuroscience Institute and has been ranked as one of the Top 100 hospitals in the Healthgrades 2019 Report to the Nation. Wynnifred also has many years experience working with bariatric surgical patients at Garden State Bariatric Clinic in Short Hills, NJ. She has a BA in Science from the University of Texas in Austin, BS in Human Environmental Science with emphasis on Nutritional Sciences from the University of Arkansas in Fayetteville and Master of Science Nutrition from the College of Saint Elizabeth, Morristown, NJ.

Picture of the speaker

Webinar Overview

§ Will define Medical Nutrition Therapy§ Brief overview of brain injury§ Highlight the role of nutrition from hospital to

home§ Provide nutrition recommendations to

promote brain health

What is Medical Nutrition Therapy?

§ MNT is a comprehensive assessment of a person’s health or disease state, implementing a nutrition diagnosis, an intervention, a method of monitoring and evaluating the process to assist in the management of a disease state, chronic or acute condition or maintaining general health through nutritional intake.

§ MNT is provided by a Registered Dietitian Nutritionist.

MNT in the Hospital

Brain Injury

§ Brain Injury is an insult to the brain which causes damage- Severe, Moderate, Mild.

§ Acquired brain injury (stroke, aneurysms, encephalitis, anoxia, metabolic disorders, meningitis, or brain tumors); an injury to the brain that is not hereditary, congenital or degenerative.

§ Traumatic brain injury (falls, MVA and being struck by or against an object); impact to the head that disrupts the normal function of the brain. The severity can range from “mild” to “severe”. This also includes mild trauma/concussion (grades 1, 2, 3).

§ While the causes may differ between incident of brain injury, the effects on a person’s life can be quite similar.

§ According to the CDC, In 2014 there were approximately 2.87 million TBI-related emergency department visits, hospitalizations, and deaths which occurred in the United States.

§ About 75% of TBI cases in the United States are mild with complete recovery.

Result of Brain Injury§ Full Recovery

§ Damage which is transient, short-term, long-term or permanent

§ Deficits in cognitive executive function:– Memory loss– Decision making difficulty– Judgment deficit– Impulsivity control– Planning difficulty

§ Lead to disability and reliance on caregiver for ADLs and/or IADLs

§ Death

Consequences of primary brain injury can lead to secondary injury cascades

Brain Edema

Elevated intracranial pressure

Opportunistic infections

Oxidative stress which can lead to damage

Hypotension

Hypoxia

Hyper- and hypoglycemia

Cerebral Vasospasm

Nutritional Considerationsin the ICU Setting

§ Surgical Patient

§ Pharmacologic/Medical Interventions

§ Metabolic Alterations

§ Enteral Nutrition

Nutrition Support:Enteral Feeding

§ Preferred route of feeding§ Start feeding within 24-48 hours once

hemodynamically stable§ General ASPEN and Academy of

Nutrition and Dietetics guidelines:– Protein can range from 1.5-2.5

g/kg/day. • ABW BMI <30 (1.5-2g/kg/d)• IBW BMI 30-40 (2g/kg/d)• IBW >40 (2.5g/kg/d)

– Energy 100-200% of baseline-predicted REE

• Energy Needs: Indirect Calorimetry is ideal, but not always feasible. Mech Ventilation use the Penn State predictive equation which takes into account body temperature and minute ventilation, including ht, wt and age

• Energy Needs kcal/kg; ranges will vary depending on BMI of patient, stress-mild, moderate/severe

• When using ranges for energy needs, best to use usual body weight (UBW) if able to obtain or IBW if not.

Nutrition Support: Parenteral Feeding

§ “Nutrition through the Vein”

§ Calories, protein, fat, vitamins, minerals and medications administered in a fluid mixture.

§ Consider PN when EN not tolerated

Transition to Oral Feeding

What to consider?-Cognitive awareness-Swallow Evaluation by SLP

Transition to Oral Feeding§ Identify self feeding challenges

Transition to Oral Feeding– Patient ability to consume adequate calories,

protein and fluid by mouth

– Need to continue enteral nutrition

– Recommend oral nutrition supplement

– Monitor changes in swallow ability/dysphagia

Nutrients: Science of FoodMacronutrients

§ Carbohydrate• Bread, pasta, rice• Dairy• Fruits and starchy vegetables• Beans and legumes

§ Protein• Beef, chicken, pork, turkey, fish &

shellfish, lamb, goat, eggs

§ Fat• Vegetable oils• Avocado• Nuts and seeds• Cheese• Butter, lard, saturated fat, trans

saturated fat

Micronutrients- some animal & seafood sources, whole grains, fruits and vegetables

§ 8-B Vitamins§ Vitamin C§ Vitamins A,D,E,K§ Minerals

• Calcium• Phosphorous• Magnesium• Potassium• Sodium• Chloride• Iron• Selenium• Copper• Zinc• Choline• Chromium• Iodine• Manganese• Fluoride• +trace elements

Nutrients: Science of Food

§ Phytonutrients

– A substance found in certain plants which is believed to be beneficial to human health and prevent various diseases.

– Examples: lycopene, resveratrol, carotenoid, isoflavone

Nutrients Identified in Brain Health: What the Research Shows

§ Benefits from Omega-3 Fatty Acids and Vitamin E have been identified

§ Vitamins, Minerals and Supplements in Continuing Studies (Review Article, Lucke-Wold et al, 2018):

Vitamin and Mineral in trials– Vitamin D- when deficient had worsened outcomes after TBI in rodents; but may help with inflammation– Zinc- oxidative stress reduction, reduce inflammation and deficiency may be associated with depression following TBI– Magnesium- has been shown to improve recovery following TBI in pre-clinical trialsDietary Supplements in Pre-Clinical Models of TBI– Curcumin- antioxidant, normalized brain-derived neurotropic factor levels and improved motor and learning

performance in animal study– Sulforaphane- antioxidant, improve blood-brain barrier integrity, reduce cerebral edema, improve cognition in animal

study– Resveratrol- antioxidant; reduce reactive oxygen species, suppress excitotoxicity, reduce inflammation in animal

studySupplements in Clinical Trials for TBI– Melatonin- hormone produced by body (pineal gland)– Choline- essential nutrient, regulates memory, mood and muscle control– Enzogenol- extract of pine bark, may improve cognition

§ No recommendation at this time to take as an oral supplement. Always speak with your physician before taking or trialing any OTC oral supplements. Good news… all of these vitmamins, mineral, phytonutrients are found in whole food sources

Omega-3 Fatty Acidand Brain Health

§ Long-Chain Polyunsaturated fatty acids (LCPUFA) typically found in high concentrations in algae and fish.

§ Considered “essential” as it can not be synthesized by the body and must come from food.

§ Different types of Omega-3 fatty acids:– Eicosapentaenoic Acid (EPA) is a type of omega-3 fatty acid- plays an important functional role in

the body, but the concentration of EPA in the brain is negligible.

– Docosahexaenoic Acid (DHA) is a type of omega-3 fatty acid and is primary omega-3 fatty acid found in the brain

• DHA has important structural role in the brain, supporting brain development and cognitive function throughout the lifespan.

• Evidence suggests that DHA may act as a promising recovery aid for mTBI. (Barrett E, et al, 2014)

§ Supplementation of DHA needs more study to determine therapeutic efficacy and most effective dosing strategy (Lucke-Wold et al, 2018).

§ In a review by Barrett et al, it is noted that the current state of the science regarding LCPUFA supplementation for the treatment of concussion is based primarily on animal models. Additional human studies are warranted.

Good Sources of Omega-3

Include these Fish:

§ Albacore Tune§ Salmon- farmed and wild§ Atlantic Herring§ Anchovies§ Sardines§ Atlantic Mackerel§ Mussels (shellfish)§ Algae (edible seaweed

versions)

Avoid:Due to high levels of

methyl mercury§ Swordfish§ Shark§ Tilefish§ King Mackerel (AKA

Kingfish)§ Marlin

Non Fish Omega-3 Sources

§ Chia Seeds§ Hemp Seeds§ Flax Seeds§ Edamame§ Soybean Oil§ Walnuts§ Kidney Beans

Vitamin E and Brain Health§ Fat soluble vitamin

§ Potent anti-oxidant as it is able to cooperate with a network of endogenous and exogenous anti-oxidant sources.– Stop oxidative damage– Peroxyl radical scavenger (protect cells from damage

caused by free radicals, which are unstable molecules made during normal cell metabolism)

– Protect phospholipid membrane from breakdown of PUFAs within layer

Food Sources of Vitamin E§ Plant seeds (ex: sunflower, sesame, pumpkin, flax

seeds)

§ Nuts (ex: almonds, walnuts, pecans, pistachios)

§ Peanuts

§ Vegetable Oils (ex: canola, sunflower, peanut, soybean)

Food Sources of Vitamins and Minerals in Brain Health

§ Vitamin D- fatty fish, beef liver, cheese, egg yolks, fortified foods (some dairy products, orange juice, soy milk, cereals)

§ Zinc- meat, shellfish, legumes (chickpeas, lentils), beans, seeds, nuts, dairy, eggs, whole grains

§ Magnesium- green leafy vegetables, fruits, nuts & seeds, legumes, vegetables(peas, broccoli, cabbage, green beans, artichokes, asparagus, brussels sprouts , seafood)

Food Sources of Phytonutrients Connected to Brain Health

§ Curcumin- ingredient in turmeric

§ Sulforaphane- found in cruciferous vegetables

§ Resveratrol- skin of berries and grapes, peanuts

§ Choline- considered an essential nutrient: eggs, liver and peanuts; primarily in animal-based foods

Mediterranean Eating Plan§ Well known for:

– Cardiovascular & anti-inflammatory benefits.

– Association with healthy aging

– Reduced risk of certain cancers

– Type 2 diabetes– Parkinson’s disease

§ New research suggests this healthful eating pattern also protects brain health and cognitive performance

Mediterranean Eating Plan§ Focus on:

– Whole minimally processed plant foods

– Cereal grains– Legumes– Vegetables and fruits– Nuts– Fish– Olive Oil (EVOO)

§ Small Amounts of:– Red Meat & Poultry– Milk and dairy

products (whole)– Modest alcohol

amount (wine)

DASH Diet/Eating Plan(Dietary Approach to Stop Hypertension)

§ Focus on:– Fruits and vegetables

• berries and green leafy vegetables

– Low-fat dairy products– Whole grains– Poultry and fish– Nuts

§ Small Amount of:– Fats– Red meats– Sweets– Sugar-containing

beverages

MIND Diet/Eating Plan(Mediterranean-DASH Intervention for

Neurodegenerative Delay)§ Hybrid diet§ High intake of plant foods§ Limit meat consumption§ EVOO- extra virgin olive oil as

primary source of fat§ Rich in antioxidants§ Monounsaturated fats§ Omega-3 fats§ Great emphasis on fish and

overall fruit and vegetable intake-especially green leafy vegetables and berries

§ Brain Healthy– Green leafy vegetables– Other vegetables– Nuts– Berries– Beans– Whole grains– Fish– Poultry– Olive Oil– Wine (in moderation)

§ Unhealthy– Red meats– Butter and stick margarine– Cheese– Pastries and Sweets– Fried and fast foods

Healthy Fats

Carbohydrate:Whole Grains

Carbohydrate:Vegetables and Fruits

Carbohydrate:Dairy

Carbohydrate:Beans and Legumes

Protein

Don’t Forget Fluid

Physical Exercise

Have a Healthcare Team to Support You

§ Follow Me on Twitter: @wmhoodis

§ Email: wmhoodis@gmail.com

Stay in Touch

References§ Wahls T, Rubenstein L, Hall M, Snetselaar L. Assessment of dietary adequacy for important brain micronutrients in patients presenting to

a traumatic brain injury clinic for evaluation. Nutritional Neuroscience. 2014;17:252-259.

§ Dobrovolny J, Smrcka M, Bienertova-Vasku J. Therapeutic potential of vitamin E and its derivatives in traumatic brain injury-associated dementia. Neurological Sciences. 2018;39:989-998.

§ Desai A, Kevala K, Kim H. Depletion of Brain Docosahexaenoic Acid Impairs Recovery from Traumatic Brain Injury. PloS one. Jan2014;9(1):e86472.

§ Dixon K. Pathophysiology of Traumatic Brain Injury. Phys Med Rehabil Clin N Am. 2017;28:215-225.

§ Gomez-Pinilla F, Kostenkova K. The Influence of Diet and Physical Activity on Brain Repair and Neurosurgical Outcome. Surg Nerol. 2008 October;70(4):333-336.

§ Shi J, Dong B, Mao Y, Guan W, Cao J, Zhu R, Wang S. Review: Traumatic brain injury and hyperglycemia, a potentially modifiable risk factor. Oncotarget. 2016;7(43):71052-71061.

§ Malakouti A, Sookplung P, Siriussawakul A, Phillip S, Bailey N, Brown M, Farver K, Zimmerman J, Bell M, Vavilala M. Nutrition support and deficiences in children with severe traumatic brain injury. Pediatr Crit Care Med. 2012;13(1): e18-e24.

§ Cook A, Peppard A, Magnuson B. Nutrition Considerations in Traumatic Brain Injury. Nutrition in Clinical Practice. 2008;23(6):608-620.§ Statler K, Larsen G. Nutrition after head injury: Challenges and recommendations. Pediatr Crit Care Med. 2012;13(1): 111-112.

§ Duraski S, Lovell L, Roth BS, Roth E. Nutritional Intake, Body Mass Index, and Activity in Postacute Traumatic Brain Injury: A Preliminary Study. Rehabilitation Nursing. 2014;39:140-146.

References§ Azim A, Haider A, Rhee P, Verma K, Windell E, Jokar TO, Kulvatunyou N, Meer M, Latifi R, Joseph B. Early feeds not force feeds: Enteral nutrition in

traumatic brain injury. Trauma Acute Care Surg. 2016;81(3):520-524.

§ Roberts S, Touger-Decker R. Traumatic Brain Injury: Medical, Surgical, and Nutritional Considerations. Support Line. 2014;36(3):3-8.

§ Cernkovich E, McBurney M, Ciappio E. Omega-3 Fatty Acid Supplementation as a Potential Therapeutic Aid for the Recovery from Mild Traumatic Brain Injury/Concussion. Adv Nutr.2014;5:268-277.

§ Wright KC. Mediterranean Diet Improves Cognition, Memory, and Brain Volume. Today’s Dietitian. June 2018;20(6):40.

§ Lucke-Wold B, Logsdon A, Nguyen L, Eltanahay A, Turner R, Bonasso P, Knotts C, Moeck A, Maroon J, Bailes J, Rosen C. Supplements, nutrition, and alternative therapies for the treatment of traumatic brain injury. Nutritional Neuroscience. 2018;21(2):79-91.

§ Escott-Stump S. Nutrition and Diagnosis-Related Care. Lippincott Williams and Wilkins. 2012, 7th edition.

§ McClave S, Taylor B, Martindale R, Warren M, Johnson D, Braunschweig C, McCarthy M, Davanos E, Rice T, Cresci G, Gervasio J, Sacks G, Roberts P, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine(SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Jour of Parenteral and Enteral Nutrition. 2016;40:159-211.

§ Barret E, McBurney M, Ciappio E. Omega-3 Fatty Acid Supplementation as a Potential Therapeutic Aid for the Recovery from Mild Traumatic Brain Injury/Concussion. Adv Nutr. 2014;5:268-277.

§ Marcason W. What Are the Components to the MIND Diet? Journal of the Academy of Nutrition and Dietetics. 2015; 115:1744.

§ Width M, Reinhard T. The Essential Pocket Guide for Clinical Nutrition. Wolters Kluwer. 2018, 2nd edition.

§ https://www.cdc.gov/traumaticbraininjury/get_the_facts.html

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