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Understanding the potential of cognitive ingredients
Dr Carrie Ruxton
Freelance Dietitian
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Cognitive health important across the lifecycle
Diet &
Supplements
Higher IQ Brain development
Support for learning Mental health Slower cognitive decline
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Likely effects are different for different groups of people
Boosting via programming
Support for normal
Preventing disorders
Preventing or slowing decline
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Nutrients with brain-related health claims
Claim Nutrient
Maternal intake contributes to
normal brain development of
foetus & breastfed infants
Docosahexaenoic acid (DHA)
Contributes to maintenance of
normal brain function (all ages)
DHA
Contributes to normal cognitive
function
Iodine, iron, zinc
Contributes to normal
psychological function
Biotin, folate, niacin, vitamins
B1, B6, B12, vitamin C,
magnesium
Contributes to normal mental
performance
Pantothenic acid
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Vitamin D
Vitamin C
Biotin
DHA/EPA
Magnesium
B vitamins
Iron
Iodine
Folate
Food sources
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Most evidence relates to long-chain omega 3 fatty acids
Fats
Monounsaturated
Omega 9 fats (olive oil)
Polyunsaturated
Omega 6 fats
(sunflower oil) Omega 3 fats
Shorter-chain
e.g. ALA
Longer-chain e.g. DHA, EPA
Saturated
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Sources of DHA/EPA
• Oily fish e.g. salmon, tuna, mackerel, herring, trout (2-3.9g EPA/DHA per 140g portion)
• Seafood e.g. prawns (0.2g/portion)
• Red meat (~0.1g per 100g)
• Cod liver oil (vits A,D) (0.1-0.5g per daily dose)
• Fish body oil supplements (content as above)
• Specialist supplements for pregnancy, infants, elderly containing other nutrients
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Recommendations
• General advice: 2 portions of fish per week, one of which should be oily (translates as 0.45g
DHA/EPA per day or 3g per week)
• Men and older women can have up to 4 portions of oily fish weekly
• Higher amounts recommended in US for therapeutic reasons e.g. 1g/d for heart health post-MI (AHA)
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UK intakes below recommendations
0
50
100
150
200
250
300
350
400
450
mg
LC
n3
PU
FA
pe
r d
ay
4-10y 11-18y 19-64y 65y+
Male Female
UK rec = 450 mg per day
Bates et al. (2012); with thanks to Dr Rachael Gibbs, University of Reading.
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Driven by low intakes of oily fish
0
20
40
60
80
100
120
140
1.5-3y 4-10y 11-18y 19-64y 65y+
gra
ms/
we
ek
NDNS, Bates et al (2011). Data include coated fish and fish dishes
Half of weekly target
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DHA/EPA should be consumed directly from the diet as synthesis from ALA is inefficient and
inhibited by high n6 PUFA intakes
ALA/day Blood EPA Blood DHA
3 g + 53% + 4%
3 g + 45% + 21%
3.5 g + 60% + 2%
9.6 g + 0.02% + 0.5%
13.7 g + 138% + 14%
Only 5 out of 20 studies showed +ve effect on DHA
Brenna et al. (2009) Prost Leuk Essen Fatty Acids 80; 85–91.
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HEALTH EFFECTS OF OMEGA 3 FATTY ACIDS
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DHA present in a wide range of body tissues
Arterburn et al. (2008) Am J Clin Nutr 83: 1467S–76S.
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Pregnancy
Evidence
• Foetal IQ programming
– mature sleep patterns
– better visual acuity
• Reducing risk of post-natal depression (emerging evidence)
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Maternal supplementation with fish oil improves infant IQ
RCT; 341 women
took cod liver oil
from wk 18 of
pregnancy until 3
months post-birth;
Total LC PUFA
2.5g daily
Mental, sequential & simultaneous processing, non-verbal abilities
Helland et al (2003) Pediatrics 111, e39 –e44.
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Evidence inconsistent
• RCT n=152 women suppl from 20th wk pregnancy until delivery 500mg DHA + 150mg EPA daily
• No sign if difference in cognitive function intervention vs. placebo offspring at 6.5y
• But children with better cognitive function more likely to have mothers with significantly higher DHA status during pregnancy.
Campoy et al (2011) Am J Clin Nutr 94: 1880S-1888S
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Maternal EPA/DHA supplementation boosts levels in breast milk
Arterburn et al. (2008) Am J Clin Nutr 83: 1467S–76S.
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Infanthood
Evidence
• Normal development of retina and brain
• Support for normal learning and development
• Enhanced cognitive function and IQ (emerging evidence)
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Why DHA is vital in 1st year
Birth
Brain
continues to
grow at foetal
rate from
birth to ~6
months
DHA uptake
follows similar
trajectory until
~18 months
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Cognitive improvements in preterm babies fed fatty acids
• RCT n=470, US pre-term babies
• Received AA+DHA vs. control formulae
• Significantly better visual acuity and motor skills at 6 months in suppl group
• Significantly better vocabulary comprehension at 14 months in supplemented group
O’Connor et al (2001). Pediatrics 108: 359-71.
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Developmental improvements in term infants
• RCT n=56, US normal term babies
• Received formula supplemented with DHA or DHA/AA vs. control formula
• Followed up at 4, 12 and 18 months
• Mean increase of 7 points on the Mental Development Index in DHA+AA group
But evidence inconsistent
Birch et al (2000). Dev Med Child Neurol 42: 174-81.
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Childhood
Evidence
• Supporting learning and behaviour
• Managing ADHD and behavioural disorders
• Enhancing cognitive function (emerging evidence)
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Recent review
Ruxton (2011). Complete Nutrition 11: 23-24.
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ADULTS AND OLDER AGE
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Link with depression?
• Fish and n3 intakes inversely assoc with depression risk
• Low blood n3 levels found in depressed patients
• Yet, RCT to reduce depressive symptoms produced inconsistent results
• Why?
Risk of depression
Colangelo et al. (2009) Nutrition 25:1011-1019.
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EPA performs better
Sublette et al. (2011) J Clin Psych 72: 1577-84. Martins (2009) J Am Coll Nutr 28: 525–542.
N=241 studies
DHA only
EPA only
Low EPA
High EPA
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Cognitive decline
0 0.5 1 1.5<900
mg
1130
mg
1300
mg
1490
mg
1750
mg
Relative Risk of dementia
Emerging evidence
• Reducing speed of cognitive decline as people age
• Reducing long-term risk of dementia and Alzheimer’s
Morris et al (2003). Arch Neurol 60: 940–946; n=816 cohort study
*P<0.05
LCn3PUFA/d
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6 month RCT in impaired elderly
• N=50 elderly with mild cognitive impairment
• Placebo vs. high EPA vs. high DHA for 6 months
• Significant differences after 6 months
Lower depression with EPA or DHA
Less cognitive impairment with DHA
Sinn et at (2012) British Journal of Nutrition (2012), 107, 1682–1693
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Cochrane review of studies in healthy elderly inconclusive
• Systematic review of studies > 6 month in healthy, normal elderly people
• N=3536 participants taking part in 3 trials of LCn3PUFA suppl.
• No evidence of cognitive benefit
• However, participants in control and intervention groups experienced either small or no cognitive decline
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OTHER NUTRIENTS
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Intervention studies – older adults
Ref Who What Outcome
1 Post-stroke B complex; 3.4y No effect on cognitive fx
2 Impaired cognitive fx Folic acid, B12; 2y Improved cognitive fx
3 Psychol distress B complex; 2y Cognitive decline slower
4 Impaired cognitive fx B complex; 2y Brain atrophy lower
5 Healthy Zn; 6mo Better memory
6 Post-stroke Zn; 30d Neurological fx improved
7 Healthy elderly Zn, Cu, antiox; 7y No effect on cognitive fx
8 Alzheimer’s Vit D, E, K; 2y Slower functional decline
9 Healthy elderly Multivit/min; 1y No effect on cognitive fx
1. Hankey (2013) Stroke 44: 2232-9; 2. Walker (2012) AJCN 95: 194-203; 3. de Jager (2012) Int J
Geriatr Psychiatry 27: 592-600; 4. Smith (2010) PLoS One 5: e12244; 5. Maylor (2006) BJN 96: 752-
60; 6. Aquilani (2009) Nutr Neurosci 12: 219-25; 7. Yaffe (2004). Neurol 63: 1705-7; 8. Dysken (2014)
JAMA 311: 33-44; 9. McNeil (2007) Nutr J 6:10.
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Other interventions
• Many studies providing vitamins and minerals to children in developing countries with most finding positive results for cognitive performance
• However, most multinutrient interventions in normal Western populations inconclusive
• Specific nutrients, particularly B vits, zinc, iron, seem to work when given to vulnerable groups e.g. elderly, cognitively impaired, AD, eating disorders
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MAKING SENSE OF THE EVIDENCE
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What is the potential of cognitive ingredients?
• Good evidence that certain vitamins and minerals support normal function
• Studies in future may well prove that certain nutrients boost function in vulnerable groups
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Best evidence is for fatty acids
• Good evidence that EPA and DHA are vital for normal development and help maintain brain function throughout life
• Emerging evidence for programming effect in utero and support for learning during childhood
• Conflicting evidence in depression and prevention of dementia/cognitive decline due to
methodological issues (type of fatty acid, baseline
status and health of population)
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Applications
• Supplements, especially fish oil supplements that are research backed and formulated blends, considering that oily fish intakes are so low
• Natural foods for supporting cognitive function e.g. fish, lean red meat, eggs, fruit, green leafy vegetables, nuts
• Fortified ‘brain health’ food and drink products – some already available with caffeine
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Different needs at different life stages but all dependent on pre-existing
nutritional status
DHA, AA Iron, iodine, EPA, DHA
EPA, iron B vitamins; EPA
and DHA
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Acknowledgment
Thanks to Equazen for sponsoring
me to give this talk