Nutrition and Traumatic Brain Injury: Improving Acute and

Subacute Health Outcomes in Military Personnel.

Institute of Medicine (US) Committee on Nutrition, Trauma, and the Brain; Erdman J, Oria M, Pillsbury
L, editors.
Washington (DC): National Academies Press (US); 2011.

7Antioxidants
Oxidative stress has been implicated as a central pathogenic mechanism in traumatic brain
injury (TBI) because the brain is especially vulnerable to such stress, compared to other
tissues (Floyd, 1999; Floyd and Carney, 1992). Overproduction of reactive oxygen species
(ROS), that is, chemically reactive molecules containing oxygen, can trigger many of the
harmful biological events associated with TBI such as DNA (deoxyribonucleic acid) damage,
brain-derived neurotrophic factor (BDNF) dysfunction, and disruption of the membrane
phospholipid architecture, and has therefore been suggested as a principal culprit in both
acute and long-term events of TBI (Eghwrudjakpor and Allison, 2010; Hall et al., 2010). The
effects of antioxidants on TBI have not yet been examined in human studies; however,
several clinical trials have investigated whether antioxidant supplementation could reduce the
risk of developing other forms of trauma (e.g., stroke and epilepsy) or protect against
developing adverse health outcomes after injury. This chapter offers the current evidence to
support further exploration of the role of antioxidants as neuroprotectants for TBI.
There are many compounds having antioxidant properties, some of which are essential
nutrients. As evidence became available, it was observed that effectiveness in animals or
excellent antioxidant activity observed in vitro does not necessarily translate into
effectiveness to prevent human diseases associated with oxidative stress. Initial expectations
of these compounds to prevent chronic diseases associated with oxidative stress have been
disappointed. It has nevertheless become clear that oxidative stress after TBI triggers many of
its outcomes, and antioxidant compounds should be considered to ameliorate these outcomes.
It would not be feasible for this committee to do a review of all the many compounds that
have been identified as having antioxidant activity. Vitamins E and C were selected as
examples of antioxidant nutrients for this review because their potential to prevent chronic
diseases has been studied extensively. Some non-essential food components with reported
antioxidant properties also are reviewed in this chapter. Finally, based on the fact that
antioxidants seem to act synergistically, the possibility that a combination of antioxidants
might be more effective that a single one is also considered. The intention of this chapter is
not to review every combination of antioxidants that might have been tested, but to give a
flavor of the potential benefits of this class of compounds when used in combination.

VITAMIN C (ASCORBIC ACID)

Introduction
Vitamin C (L-ascorbic acid or L-ascorbate) is an essential nutrient that protects the body
against oxidative stress. The biological function of vitamin C comes from its ability to donate
reducing equivalents to reactions, including reduction of reactive oxygen that damages cells.
It is a cofactor in at least eight enzymatic reactions, and is required for metabolic reactions.
Vitamin C is the electron donor for eight enzymes involved in collagen hydroxylation,
carnitine biosynthesis, and hormone and amino acid biosynthesis. Vitamin C deficiency is
characterized by impairments in connective tissue, specifically impairment of collagen
synthesis. Vitamin C has also been shown to affect components of the immune response
(IOM, 2000). The IOM considered levels higher than the Military Dietary Reference Intakes
(MDRIs) for prevention of oxidative damage and muscle injury associated with highintensity exercise (IOM, 2006) or for acute oxidative stress (IOM, 1999), but found
insufficient evidence to make such recommendations. Those reports did not review evidence
on vitamin C and potential benefits for TBI.
The brain has particularly high levels of vitamin C, approximately 100 times higher than
levels in most other tissues in the body (Grunewald, 1993; Rice, 2000). Vitamin C is pumped
into the central nervous system by the sodium-dependent vitamin C transporter-2 systems in
series in the epithelial and neuronal cell membranes, but there is no sound evidence for a
carrier-mediated transport (Spector, 2009). A study to assess antioxidant depletion in patients
additionally showed that those with intracranial hemorrhage and head trauma had lower
plasma levels of vitamin C than controls, and that its levels were significantly inversely
correlated with the several outcomes of the disease (i.e., severity of the neurological
impairment and diameter of the lesion). However, to the committees best knowledge, there
are no human or animal studies to examine the potential neuroprotective effects of vitamin C
on TBI, except for the study by Razmkon described above presented at a 2010 conference.
The committee identified five human studies regarding vitamin C supplementation and stroke
or subarachnoid hemorrhage. Table 7-2 lists those studies, plus the study on TBI presented at
a conference. As with Table 7-1, the occurrence or absence of adverse effects is included if
reported.
Click on link to see table : http://www.ncbi.nlm.nih.gov/books/NBK209332/table/ttt00020/?
report=objectonly

Uses and Safety

The EAR for vitamin C was based on maintaining near-maximal neutrophil concentrations
with minimal urinary loss, and was set at 75 mg/day for men and 60 mg for women. A
comparison of U.S. dietary intake from NHANES 20012002 data with the EAR of vitamin
C (Table 5-2) suggests that 40 percent of males and 38 percent of females older than 19 years
of age consume less vitamin C than the recommended EAR. The UL for vitamin C is 2 g/day

based on gastrointestinal disturbance, but there are concerns that vitamin C could act as a
prooxidant, depending on the dose (Childs et al., 2001).
Evidence Indicating Effect on Resilience
Human Studies

Effects of vitamin C supplementation on risk of stroke were examined in the Womens

Antioxidant Cardiovascular Study (n = 8,171, 500 mg/day for 9.4 years) (Cook et al., 2007)
and the Physicians Health Study II (n = 14,641, 500 mg/day for 8 years) (Sesso et al., 2008).
No protective effects were observed in these trials, either for total, or for different subtypes of
stroke (Cook et al., 2007; Sesso et al., 2008).
Evidence Indicating Effect on Treatment
Human Studies

Polidori and colleagues (2005) reported that treatment with vitamin C (200 mg/day) in
combination with aspirin therapy in 59 patients with ischemic stroke of recent onset (< 24
hours) was associated with significantly lower lipid peroxidation, as assessed by plasma 8,12iPF2-VI concentrations, than a control group receiving only aspirin. Kodama and colleagues
(2000) also showed that subarachnoid hemorrhage patients (n = 217) who were treated with
urokinase and vitamin C recovered without neurological deficits. (It should be noted,
however, that this study lacked a control group.) In another trial including 46 ischemic stroke
patients, 1,000 mg/day of vitamin C had no impact on motor recovery (Rabadi and Kristal,
2007).
The small randomized, clinical controlled study described above that showed benefits
associated with high doses of vitamin E following TBI did not find vitamin C to be associated
with positive neurologic outcomes, but the high doses of the vitamin (10 g on the day of
admission and 4 days later) slowed the progression of perilesional edema (Razmkon et al.,
2010).

COMBINATION OF ANTIOXIDANTS
Evidence Indicating Effect on Resilience
Human Studies

Results from observational studies are mixed and have not resulted in any clear association
between chronic diseases and intake of antioxidants (Hirvonen et al., 2000; Mezzetti et al.,
2001; Voko et al., 2003; Watkins et al., 2000; Yochum et al., 2000). Although the committees

literature reviews did not include cancer as a disease outcome because its pathology and
etiology is dissimilar to that of TBI, one study is presented here to illustrate how a
combination of antioxidants showed benefits where single nutrients did not. A randomized
controlled trial was conducted in a region of China where esophageal and gastric cancers are
prevalent and low intake of micronutrients has also been observed. Mortality and cancer
incidence were ascertained for 29,584 adults who were assigned to take daily vitamin and
mineral supplementation of (1) retinol and zinc; (2) riboflavin and niacin; (3) vitamin C and
molybdenum; and (4) beta-carotene, vitamin E, and selenium. Those in the group taking betacarotene, vitamin E, and selenium had lower mortality than controls, mainly because of lower
cancer rates (Blot et al., 1993).
There are other studies showing that supplementation with both vitamin C and vitamin E
(compared to vitamins C or E alone) is more effective in protecting from oxidative stress
because vitamin E is regenerated by vitamin C. There were 8,171 women recruited for the
Womens Antioxidant Cardiovascular Study, designed to test the effects of ascorbic acid (500
mg/day), vitamin E (600 IU every other day), and beta-carotene (50 mg every other day) on
cardiovascular disease in a 2 2 2 factorial design. Participants were 40 years of age or
older, postmenopausal or had no intention of becoming pregnant, and had a self-reported
history of CVD or at least three cardiac risk factors (Cook et al., 2007). During 9.4 years of
follow-up, those in the active groups for both vitamin E and ascorbic acid had a lower risk of
developing stroke relative to those in the placebo group for both agents. However, other twoor three-way interactions among these three antioxidants were not significant for stroke
(Cook et al., 2007). In contrast, the Physicians Health Study II Randomized Controlled Trial,
a 2 2 factorial design to test the effect of ascorbic acid (500 mg/day) and vitamin E (400 IU
every other day) in 14,641 U.S. men aged 50 years or older, failed to find any significant
protective effects of these agents or their combination on stroke risk during a mean follow-up
of eight years (Sesso et al., 2008). Another large, randomized controlled study that observed
vascular disease, cancer, and other adverse outcomes in which participants (20,536 adults
aged 4080) were randomly allocated to receive antioxidant vitamin supplementation (600
mg vitamin E, 250 mg vitamin C, and 20 mg beta-carotene daily) or matching placebo
showed no significant effects on cancer incidence or on hospitalization for any other
nonvascular cause (Heart Protection Study Collaborative, 2002).
In another randomized controlled trial in Finland that included 28,519 male cigarette smokers
free of stroke at baseline, the incidence of stroke in those who received both activated vitamin
E (50 mg/day) and beta-carotene (20 mg/day) (258 out of 7118) was similar, during mean six
years of follow-up, to the incidence in those who received placebos (252 out of 7153).
However, the significance of difference of stroke risk between these two groups was not
reported (Leppala et al., 2000).

Evidence Indicating Effect on Treatment

Human Studies

In a randomized, double-blind and placebo-controlled trial, 200 patients in intensive care

(113 with organ failure after complicated cardiac surgery, 66 with major trauma, and 21 with
subarachnoid hemorrhage) were provided intravenous antioxidant supplements (vitamin C,
vitamin E, selenium, zinc, and vitamin B1) for 5 days, starting within 24 hours of admission.
There was a reduction of early organ dysfunction and significantly reduced serum C-reactive
protein concentrations relative to the control group (Berger et al., 2008). The difference did
not, however, reach a significant level in individual subgroups (e.g., trauma patients or
patients with subarachnoid hemorrhage) (Berger et al., 2008). A study including 96 acute
ischemic stroke patients found that use of antioxidants (800 IU vitamin E and 500 mg vitamin
C) within 12 hours of symptom onset enhanced antioxidant capacity, mitigated oxidative
damage, and may have had an anti-inflammatory effect, as assessed by serum C-reactive
protein concentrations (Ullegaddi et al., 2006).
There has been one ongoing clinical trial identified that will contribute to the strength of the
evidence about whether antioxidants may be beneficial in improving outcomes of TBI. The
trial will examine whether providing high doses of glutamine and antioxidants (i.e., selenium,
zinc, beta carotene, vitamin E and vitamin C) to critically ill patients will be associated with
improved survival. Although patients with severe acquired brain injury are excluded from the
study, the critically ill might also experience other less severe brain injuries; hence, the results
of this study will contribute to our knowledge about this potential combination of
antioxidants.

CONCLUSIONS AND RECOMMENDATIONS

The use of single antioxidant supplements to treat a variety of chronic diseases, including
coronary heart disease, cancer, and ocular and skin diseases, has been disappointing. These
apparently conflicting results may be due to the fact that all the trials with individual
antioxidants reported here were conducted with -tocopherol. The interactions of a diet high
in -tocopherol with other forms of vitamin E (e.g., -tocopherol, the form most abundant in
the American diet) are not known. Other reasons for this discrepancy are possible, such as
interactions with other food components and the existence of confounders such as diet and
lifestyle patterns. For example, individuals who report using nutrient supplements are also
more likely to have overall more healthful lifestyles. In the context of TBI, several
conclusions can be derived from the review of the evidence of potential benefits of specific
antioxidants. Although oxidative stress is a substantial risk factor for adverse events
following TBI, there is minimal evidence at this time to support recommendations to either
supplement the diet with these nutrients beyond the dietary requirements or provide them
after injury. For example, while the results from animal trials with vitamin E are encouraging,

the human trials do not support the concept that vitamin E could have beneficial effects for
TBI. There is one recent study with encouraging results for treating TBI patients with vitamin
E. However, the committee concluded that, as with the study on cancer, a combination of
various antioxidants including vitamins E, C, and carotenoids might be more efficacious.
There is sufficient literature from animal and human trials with other acute injuries associated
with oxidative stress to warrant a carefully designed trial with TBI patients using an array of
antioxidants. Any trials that may be undertaken should ensure that dose levels of antioxidants
do not approach levels that might cause adverse events, such as higher risk of mortality
(Miller et al., 2005). The committee recommends that DoD track the findings of the current
trial using a combination of antioxidants in the critically ill and any similar future human
trials that may follow.
RECOMMENDATION 7-1. Based on the literature from animal and human trials
concerning stroke and epilepsy, DoD should consider a clinical trial with TBI patients using
an array of antioxidants in combination (e.g., vitamins E and C, selenium, beta-carotene).