Understanding the potential of cognitive ingredients. Dr Carrie Ruxton Freelance Dietitian

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1 Understanding the potential of cognitive ingredients Dr Carrie Ruxton Freelance Dietitian

2 Cognitive health important across the lifecycle Higher IQ Diet & Supplements Brain development Slower cognitive decline Mental health Support for learning

3 Likely effects are different for different groups of people Boosting via programming Support for normal Preventing disorders Preventing or slowing decline

4 Nutrients with brain-related health claims Claim Maternal intake contributes to normal brain development of foetus & breastfed infants Contributes to maintenance of normal brain function (all ages) Contributes to normal cognitive function Contributes to normal psychological function Contributes to normal mental performance Nutrient Docosahexaenoic acid (DHA) DHA Iodine, iron, zinc Biotin, folate, niacin, vitamins B1, B6, B12, vitamin C, magnesium Pantothenic acid

5 Food sources Iodine Biotin Iron B vitamins DHA/EPA Vitamin D Magnesium Folate Vitamin C

6 Most evidence relates to long-chain omega 3 fatty acids Fats Monounsaturated Polyunsaturated Saturated Omega 9 fats (olive oil) Omega 6 fats (sunflower oil) Omega 3 fats Shorter-chain e.g. ALA Longer-chain e.g. DHA, EPA

7 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) ( g per daily dose) Fish body oil supplements (content as above) Specialist supplements for pregnancy, infants, elderly containing other nutrients

8 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)

9 mg LCn3PUFA per day UK intakes below recommendations UK rec = 450 mg per day y 11-18y 19-64y 65y+ Male Female Bates et al. (2012); with thanks to Dr Rachael Gibbs, University of Reading.

10 grams/week Driven by low intakes of oily fish Half of weekly target y 4-10y 11-18y 19-64y 65y+ NDNS, Bates et al (2011). Data include coated fish and fish dishes

11 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 % + 0.5% 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;

12 HEALTH EFFECTS OF OMEGA 3 FATTY ACIDS

13 DHA present in a wide range of body tissues Arterburn et al. (2008) Am J Clin Nutr 83: 1467S 76S.

14 Pregnancy Evidence Foetal IQ programming mature sleep patterns better visual acuity Reducing risk of postnatal depression (emerging evidence)

15 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.

16 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

17 Maternal EPA/DHA supplementation boosts levels in breast milk Arterburn et al. (2008) Am J Clin Nutr 83: 1467S 76S.

18 Infanthood Evidence Normal development of retina and brain Support for normal learning and development Enhanced cognitive function and IQ (emerging evidence)

19 Why DHA is vital in 1 st year Brain continues to grow at foetal rate from birth to ~6 months Birth DHA uptake follows similar trajectory until ~18 months

20 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:

21 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:

22 Childhood Evidence Supporting learning and behaviour Managing ADHD and behavioural disorders Enhancing cognitive function (emerging evidence)

23 Ruxton (2011). Complete Nutrition 11: Recent review

24 ADULTS AND OLDER AGE

25 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:

26 EPA performs better DHA only Low EPA EPA only High EPA N=241 studies Sublette et al. (2011) J Clin Psych 72: Martins (2009) J Am Coll Nutr 28:

27 Cognitive decline LCn3PUFA/d 1750mg 1490mg 1300mg 1130mg <900mg *P< Emerging evidence Reducing speed of cognitive decline as people age Reducing long-term risk of dementia and Alzheimer s Relative Risk of dementia Morris et al (2003). Arch Neurol 60: ; n=816 cohort study

28 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,

29 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

30 OTHER NUTRIENTS

31 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: ; 2. Walker (2012) AJCN 95: ; 3. de Jager (2012) Int J Geriatr Psychiatry 27: ; 4. Smith (2010) PLoS One 5: e12244; 5. Maylor (2006) BJN 96: ; 6. Aquilani (2009) Nutr Neurosci 12: ; 7. Yaffe (2004). Neurol 63: ; 8. Dysken (2014) JAMA 311: 33-44; 9. McNeil (2007) Nutr J 6:10.

32 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

33 MAKING SENSE OF THE EVIDENCE

34 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

35 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)

36 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

37 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

38 Acknowledgment Thanks to Equazen for sponsoring me to give this talk

Who needs supplements? Why are they necessary?

Who needs supplements? Why are they necessary? Dr Carrie Ruxton RD Supported by Key points today 1. If we all ate a healthy balanced diet, we could get all the nutrients we need 2. Many people do not currently