Sport concussions have been a hot topic over the past few years, with the launch of the Canadian Guideline on Concussion in Sport in 2017 and SIRC’s associated We are Headstrong campaign, and the passing of Rowan’s Law (Concussion Safety) on March 7, 2018 in Ontario. Despite increased awareness, recognition and treatment pursuits, the role of nutrition is often overlooked as a supportive means for sport concussion recovery. Many treatment protocols do not include the integration of a qualified sport dietitian and their support around optimizing specific neuroprotective nutrients, nor are sport dietitians embedded in the interdisciplinary support teams within high concussion risk sports.

Although much of the research is still in its infancy, the integration of a safe and low risk nutritional approach may not only be protective, but have the potential to enhance recovery. Outlined below are some key interventions that should be considered in post-sport concussion treatment. This is the first of a two-part series in which the neuroprotective roles of specific nutrients will also be examined from a sub-concussion injury perspective.

Managing Appetite

Sport concussion symptoms such as nausea, headaches and fatigue often contribute to decreased appetite which can limit energy and key nutrient intake to support recovery. It is crucial throughout the recovery process that athletes regularly consume healthy meals and snacks. The injured athlete may consider enlisting family and friends for support with things like grocery shopping and cooking, or consider healthy meal delivery programs within their area that can save time and energy.

If athletes are experiencing low appetite, consider the following:

• Consume small, frequent snacks throughout the day from easily digestible foods including crackers, toast, soups, yogurt, avocado or rice puddings, oatmeal, nut butters, chicken and fish. Small, frequent meals can also help manage nausea because an empty stomach will worsen symptoms.
• Liquid meal replacement options can provide vital nutrients and support daily hydration. Examples include:
  • Homemade Smoothies: 1 cup dairy or fortified dairy alternative with ½ cup of plain 0-2% Greek yogurt and your choice of the following combinations:
    • 1 banana + 2 Tbsp. natural peanut butter
    • 1 cup strawberries + ½-1 banana
    • 1 Tbsp cacoa + 1 cup raspberries
    • 1 handful of spinach + ¼ avocado + ½ cup mixed berries
  • Store-bought liquid meal replacement drinks such as Boost, Ensure, Carnation Breakfast, Vega or Rumble Super shake.
  • For athletes over the age of 18, a carbohydrate and protein recovery supplement can also be considered, but only after speaking to a qualified sport dietitian or sport medical doctor to discuss options.

Looking for more recipes? Speak to a qualified sport dietitian for quick and easy snack and meal ideas.

Hydration

Headaches are a common symptom of post sport concussion syndrome (Institute of Medicine, 2011), and dehydration can worsen symptoms. A simple pee colour check can be the first step. Urine should be pale yellow in colour – if darker, work on drinking more fluids to rehydrate.

To improve hydration, consider the following:

• Consume hydrating beverages throughout the day including water, dairy or dairy alternatives, smoothies, coconut water, electrolyte beverages including Nunn, meal replacement drinks, 100% fruit juice, and cold or hot soups.
• Drink extra fluid at meals and snacks.
• Choose liquid meal replacement options when appetite is low.
• Avoid alcohol, which can contribute to dehydration.

Tip: When trying to improve your hydration, check how often you are waking in the night to use the toilet. If more than once or twice, reduce your fluid intake in the evening to support needed sleep recovery.

Omega 3 Fatty Acids

The most researched nutrient relating sport concussions recovery are omega-3’s which is a type of fat known at polyunsaturated fat. There are three types of omega 3’s, and of these docosahexaenoic acid (DHA) is most abundantly found in the brain. (Arterburn, Hall, & Oken 2006; Scrimgeour & Condlin 2014). DHA has been the focus of much research around sport concussion recovery and studies have shown promise in its role on reducing brain damage and cognitive decline after a concussion injury (Rawson, Miles & Larson-Meyer 2018).

Although there is no current dosing consensus, injured athletes should increase their dietary intake of omega 3 fatty acids, especially DHA. Fish is the richest source of DHA (see Table 1). If considering a supplement, speak to a qualified sport dietitian who can recommend an appropriate and safe option and dose. Table 2 shows Health Canada’s safe recommended doses of DHA and eicosapentaenoic acid (EPA), another omega-3 fatty acid.

Table 1: Food Sources of DHA (National Institute of Health, 2019).

FOOD	PORTION	EPA/DHA (MG)
Salmon, Atlantic, farmed, cooked	3oz.	1240
Salmon, Atlantic, wild, cooked	3oz.	1220
Herring, Atlantic, cooked	3oz.	940
Sardines, canned in tomato sauce drained	3oz.	590
Salmon, pink, canned, drained	3oz.	440
Oysters, eastern, wild, cooked	3oz.	230
Sardines, canned	3oz.	740-1050
Sea bass, cooked	3oz.	470
Tuna, light, canned in water, drained	3oz.	170
Cod, Pacific, cooked	3oz.	110

Table 2: Health Canada Recommendations for DHA and EPA (Health Canada, 2018).

SUBPOPULATION		EPA + DHA (MG/DAY)
		MINIMUM	MAXIMUM
Children	1-8 years old	100	1,500
Adolescents	9-13 years old 14-18 years old	100 100	2,000 2,500
Adults	≥19 years old	100	5,000

Creatine

The brain uses approximately 20% of the body’s total energy (Institute of Medicine, 2011). Concussion causes an energy crisis where the brain’s energy requirement goes into overdrive and looks for alternative energy options to meet demands and support healing (Ainsley Dean, Arikan, Opitz & Sterr, 2017; Giza & Hovda, 2015). This is where creatine can comes into play. Creatine is a protein made in the body, but can also come from external sources such as animal proteins or a creatine supplement. After a sport concussion, creatine can cross the blood-brain barrier and provide an energy reserve to the brain, supporting the increased energy requirement to aid recovery (Institute of Medicine, 2011; Petraglia, Winkler & Bailes, 2011; Dolan, Gualano & Rawson, 2018). Sakellaris et al. (2006 & 2008) examined therapeutic creatine supplementation in children and adolescents with severe concussions. Not only did the treatment group’s length of stay in hospital decrease, they also showed improvements in cognitive function, communication, self-care, and a reduction of headaches, dizziness and fatigue symptoms. Although therapeutic dosing strategies have not yet been set, creatine is a highly promising area for both neuroprotection before and recovery after a sport concussion (Ainsley Dean, Arikan, Opitz & Sterr, 2017; Dolan, Gualao & Rawson, 2018).

Polyphenols 

Polyphenols are a category of plant-based compounds that can have health benefits. Resveratrol is a polyphenol found in foods such as grapes, blueberries and peanuts (HealthLinkBC, 2018), and curcumin is the active ingredient in turmeric spice. Both have shown promising results in reducing inflammation after a sport concussion, along with improving motor performance, visual memory, the brain’s protective membrane and it’s ability to adapt and compensate after injury (Ashbaugh & McGrew, 2015; Zhu., et al 2014; Petraglia, Winkler & Bailes, 2011). Currently, no resveratrol or curcumin supplement doses have been set and so athletes should instead look to add food sources of resveratrol to their diet and consider adding turmeric powder to soups, stews, curries and stir-fries.

Tip: Curcumin is not absorbed well in the body. To improve its absorption, mix with black pepper, combine with healthy fats, or add heat. Adding turmeric powder to a meal like a soup or curry will do all three and help you better absorb the curcumin!

Vitamins

Animal and clinical studies have examined the antioxidants Vitamin E and C to help reduce cognitive declines after injury, as both are present in high concentrations in the brain (Petraglia, Winkler & Bailes, 2011). Research findings suggest that a combination of Vitamin E and C results in better improvements in brain functioning, compared to results when given separately (Petraglia, Winkler & Bailes, 2011; Ashbaugh & McGrew, 2016). Further research is needed, and at this time supplementation recommendations cannot be made. Both antioxidants are present in a variety of foods that can be added to meals and snacks. Full food list is shown in Table 3.

Table 3: Food Sources of Vitamin E and C

Best Food Sources of Vitamin E (Dietitians of Canada, 2016)	Almonds and almond butter Sunflower seeds Hazelnuts	Wheat Germ Eggs Spinach, cooked Avocados
Best Food Sources of Vitamin C (Dietitians of Canada, 2016)	Bell peppers Broccoli Red Cabbage Brussels sprouts Guava Papaya	Kiwifruit Orange Strawberries Pineapple 100% fruit juice with Vitamin C added

What to Limit

Just as there are many nutrition considerations to enhance recovery, there are also those that have been shown to hinder recovery. Alcohol and foods high in saturated fat and refined sugar are important to avoid throughout the recovery process. Especially after a sport concussion, the consumption of alcohol can lead to dehydration, memory concerns, poor concentration and poor judgement. Drinking may also put an athlete at an increased risk of experiencing another concussion while still recovering from the initial injury, prolonging the recovery timeline (Opreanu, Kuhn, & Basson, 2010).

Foods high in saturated fat and refined sugar include deep fried and battered foods, chips, store-bought baked goods, candy, cookies and pop. These types of foods have not only been linked to the brain’s inability to adapt or compensate after injury, but also impair memory and worsen overall injury results (Wu, Molteni, Ying, & Gomez-Pinilla, 2003; Wu, Ying, & Gomez-Pinilla, 2004; Gomez-Pinilla, & Kostenkova, 2008; Wu, Ying, & Gomez-Pinilla, 2014). Injured athltes should limit intake of food high in refined sugars, and plan to choose healthier fats each day including olive oil, avocados, nuts, seeds and fatty fish.

Implementing a Nutritional Approach to Concussion Recovery

With the knowledge of what nutrients may aid in sport concussion recovery, the following steps can help athletes, coaches and other members of the support team apply the above nutrition considerations.

• Seek professional assistance: A qualified sport dietitian can educate athletes, coaches, parents and the medical team on key nutrition principles post injury. This includes education on grocery shopping and meal preparation to assist with sport concussion recovery.
• Track it: Include appetite and hydration monitoring along with other post sport concussion symptom recovery monitoring.
• Plan ahead: When travelling, review hotel and venue menus in advance and consider ways to increase omega-3, polyphenols, and antioxidant rich foods.
• Travel protocols: A qualified sport dietitian can work with the medical team to help develop sport concussion protocols that include nutrition consideration and can be implemented if an injury occurs while a team is travelling.

Key Tips for Athletes:

• Seek support from loved ones to help with grocery shopping and meal prep.
• Stay well hydrated
• Avoid alcohol and limit intake of saturated fats and refined sugars.
• Increase your intake of omega 3 fatty acid rich foods.
• Choose foods rich in resveratrol and add turmeric to your cooking.
• Choose vegetables and fruit high in antioxidants on a daily basis (ex. spinach, broccoli, bell peppers, avocados, strawberries and kiwi fruit).
• If considering a supplement, speak to your sport medicine doctor or a qualified sport dietitian to discuss the need, safety and specific dosing.

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About the Author(s)

Ashley Armstrong is a Registered Dietitian and Certified Specialist in Sport Dietetics, with a Masters in Exercise and Sport Science from the University of Sydney, Australia. From 2013-2018, Ashley supported Olympic and Paralympic athletes at the Canadian Sport Institute in Victoria, BC. She is now working with the Canadian Forces in Ottawa, supporting high end military personnel within their high-performance program. Ashely has recently completed a yearlong sub-concussion research project alongside Texas Christian University, examining the role of DHA in sub-concussion injury risk in elite men’s and women’s rugby players. She has also developed nutrition focused concussion and traumatic brain injury protection and recovery protocols for high-risk athletes and military personnel.

References

Ainsley Dean, P.J., Arikan, G., Opitz, B., & Sterr, A. (2017). Potential for use of creatine supplementation following mild traumatic brain injury. Concussion, 2(2):CnC34.

Armstrong, L.E., Pumerantz, A.C., Fiala, K.A., Roti, M.W., Kavouras, S.A., Casa, D.J., & Maresh C.M. (2010). Human Hydration Indices: Acute and Longitudinal Reference Values. International Journal of Sport Nutrition and Exercise Metabolism, 20, 145-153.

Armstrong, L.E., Johnson, E.C., Munoz, C,X. Swokla, B., Le Bellego, L., Jimenez, L., Casa, D.J., & Maresh, C.M. (2012). Hydration biomarkers and dietary fluid consumption of women. Journal of the Academy of Nutrition & Dietetics, 112(7), 1056-61.

Arterburn, L.M., Hall, B.E., & Oken, H. (2006). Distribution, interconversion, and dose response of n-3 fatty acids in humans. American Journal of Clinical Nutrition, 83(S1), 146S-76S.

Ashbaugh, A., & McGrew, C. (2016). The Role of Nutritional Supplements in Sports Concussion Treatment. Current Sports Medicine Reports, 15(1), 16-19.

Broglio, S.P., Collins, M.W., Williams, R.M., Mucha, A., & Kontos, A.P. (2015). Current and emerging rehabilitation for concussion: A review of the evidence. Clinical Sports Medicine, 34(2), 213-231.

Cook, M.A., Peppard, A., & Magnuson, B. (2008). Nutrition considerations in traumatic brain injury. Nutrition Clinical Practice, 23(6), 608-620.

Dietitians of Canada (2016, October 19). Food Sources of Vitamin E. Retrieved from https://www.dietitians.ca/getattachment/341815c0-a66a-4cdb-a6e7-33606b74d5fe/Factsheet-Food-Sources-of-Vitamin-E.pdf.aspx.

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The information presented in SIRC blogs and SIRCuit articles is accurate and reliable as of the date of publication. Developments that occur after the date of publication may impact the current accuracy of the information presented in a previously published blog or article.