Nutritional Considerations for Brain Health and Performance: The Role of DHA, EPA, and Creatine Monohydrate

As a healthcare provider treating patients with brain injuries, neurological conditions and those looking to improve brain health, I am often asked about the most effective dietary strategies to enhance brain function and recover from brain injuries. I always share with my patients that I have also personally suffered from multiple concussions, so I understand the importance of staying on top of the latest research in order to provide the safest and most efficacious recommendations to others. What research has revealed in recent years is that the same dietary strategies and supplements that may aid in recovery from neurological injury and disease can also act as preventative measures, potentially reducing the risk of age-related cognitive decline and enhancing brain resilience. This week, I want to dive into how a select few dietary molecules — docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA) and creatine monohydrate — may improve brain health, resilience and performance in those with or without injury and disease.

Neurodegenerative Disease and Brain Injury: A Growing Concern

Millions of people worldwide suffer from neurodegenerative diseases like Alzheimer’s, Parkinson’s, and other forms of dementia. The unfortunate reality is that we have all likely had someone close to us or at least know of someone who have suffered from one of these dreadful and progressive conditions. Neurodegenerative conditions are particularly difficult to manage because symptoms often appear in the later stages of disease. An example of this would be the classic resting tremor in Parkinson’s Disease. When the tremor emerges, the condition is likely well into its progression.

Historically, prevention of neurodegeneration was seen as a lofty goal, as dementia was largely thought to be predetermined by genetic factors. However, recent research has shown that similar modifiable risk factors known to influence cardiovascular disease — including physical activity levels, elevated blood pressure and cholesterol, sleep quality, alcohol consumption, and smoking — also directly influence brain health and the risks of neurodegenerative disease. Thus, the emerging perspective is that it is not only the genes that dictate our fate, but also lifestyle factors and behaviours that we can control.

Traumatic brain injuries on the other hand, particularly mild traumatic brain injuries (mTBIs) or concussions, are also on the rise. With sports-related injuries, car accidents, and slips and falls contributing to the growing prevalence of concussions, it’s crucial that we understand the risks and recovery strategies. It’s likely that you, someone you know, or even your child may experience a concussion at some point, thus continued education and recognition about brain injury is so important for everyone.

So, what are some easy and actionable methods that we can implement to potentially reduce or delay a decline in brain health and function and perhaps aid in recovery if we succumb to a head injury? Well, one key modifiable factor that we all have the ability to manipulate is our diet and the molecules we consume. When it comes to the complexity of brain health and resilience, diet is just one small piece of an ever-complex puzzle. But this week, I wanted to touch on some key molecules that we can intentionally add to our diet that have growing levels of evidence suggesting they may improve brain health, function and metabolism.  These molecules are Docosahexaenoic Acid, Eicosapentaenoic Acid, and Creatine Monohydrate.

Docosahexaenoic Acid (DHA)

Docosahexaenoic acid is a long-chain omega-3 polyunsaturated fatty acid that plays an essential role in brain structure and function. It comprises about 40% of the total fatty acids in the human brain. DHA is primarily obtained through diet, but it can also be synthesized in the body from alpha-linolenic acid (ALA), an essential fatty acid found in plant-based sources like flaxseeds and walnuts. However, the process of converting ALA to DHA is relatively inefficient, hence why obtaining DHA directly through dietary sources is optimal. Some examples of food sources include cold-water fatty fish (e.g., salmon, mackerel, and sardines), seaweed, and over the counter omega-3 supplements.

The importance of DHA with respect to structure and function lies in its neuroprotective effects. DHA supports neuronal cell membrane fluidity and myelin production which is vital for efficient cellular function and communication. When we consider the symptoms and experiences of those with brain injuries and neurodegenerative disease, they are largely a result of errors in communication between neurons of various brain regions. These errors are mediated by a litany of pathological mechanisms like electrochemical gradient changes, inflammation, free radical exposure and actual structural change. Because DHA has been shown to have anti-inflammatory properties in conjunction to their structural contribution, supplementation may help to protect against the neuroinflammation that is associated with neurodegenerative diseases and brain injury.

In conjunction with the above-mentioned functions of DHA, reviews on various concussion models has revealed that supplementation of omega-3 fish oils high in DHA can actually counteract the neuroinflammatory effects of concussion and the decrease in brain derived neurotrophic factor (BDNF) values that can be seen post-injury. BDNF is a protein that plays a role in neuronal survival, plasticity and growth.

In reviews of studies investigating omega-3 supplementation in Alzheimer’s disease, results vary. The majority of studies reveal a positive effect in cognitive function with supplementation, but this effect is greater in individuals who exhibit earlier and milder forms of cognitive impairment. We are learning that responsiveness to such supplementation may also be related to genetics, owing to the multifactorial nature of these conditions and the nuance needed in their treatments.

Image courtesy of Uçak, & Erman (2019): https://www.researchgate.net/publication/338514538_NEGATIVE_EFFECTS_OF_HIGH_TEMPERATURE_ON_YIELD_AND_QUALITY_OF_CORN_GENOTYPES_AGRICULTURE_FORESTRY_AND_AQUACULTURE_SCIENCES_RESEARCH_PAPERS

Eicosapentaenoic Acid (EPA)

Eicosapentaenoic acid is another omega-3 fatty acid found in brain tissue, though it is found in much smaller amounts compared to DHA. While DHA is crucial for brain structure and function, EPA has a unique role in supporting mood, attention, and overall cognitive performance. Studies have shown that EPA may be particularly effective in improving attention and vigilance in young individuals. For instance, a 2019 study found that high-dose EPA (1.2g) improved cognitive performance in children diagnosed with ADHD, particularly in those who had lower baseline blood levels of EPA. Interestingly, the same study showed no effect in children who already had higher EPA levels in their bloodstream, suggesting that supplementation may be only effective in those with preexisting EPA deficiencies. Although this is only one study, a question I’m left asking myself is that can we all perhaps improve function in cognitive domains such as attention by optimizing our EPA values, if we are lower than desired? More research on healthy populations will be needed to answer this.

Another study revealed that higher levels of serum EPA were associated with a lower incidence of Alzheimer’s disease, as well as a decreased risk of all-cause dementia and Alzheimer’s disease in those who were non-carriers of APOE4, a genetic marker that comes with an increased risk of developing Alzheimer's disease. This suggests that EPA level optimization may be helpful in some, but perhaps not in those with an already high genetic predisposition to the disease.

As with most topics in this space, more research is needed in order to come to more confident conclusions with respect to how much influence these molecules may have on brain health, disease and disorders.

In my opinion, however, omega-3 fish oil supplementation containing both DHA and EPA are a safe, low cost and well-tolerated option to potentially augment other positive lifestyle behaviours such as regular exercise, high quality sleep, and healthy relationships, when it comes to optimizing brain health and recovery from injury.

Creatine Monohydrate

Historically, creatine has been associated with sports performance and muscle hypertrophy and strength. However, more recently researchers have investigated the utility of creatine supplementation for general brain health, depression and for recovery from concussion.

Creatine plays a key role in energy metabolism acting as both an energy buffer and an energy shuttle. Given that mTBI, depression and neurodegenerative disease all exhibit alterations in cellular metabolism, it makes mechanistic sense that creatine may help stabilize these pathways, and thus restore normal neuronal function in these conditions. There are also reviews (here and here) suggesting that creatine enhances the performance of various cognitive domains in those who are already healthy.

When it comes to depression, research suggests that up to 30% may be resistant to the typical pharmaceutical interventions. Because energy metabolism may be the underlying culprit, the investigation into creatine as a way to manage depression has exploded. There have been a number of studies (here, here and here), that have shown positive outcomes when creatine is paired with SNRI/SSRI’s compared to the medications alone. A very recent study actually investigated to see if creatine and cognitive behavioural therapy (CBT) was better than CBT and placebo. There was statistically significant greater improvement in the creatine supplementation group, again further suggesting we may be on to something pretty useful here.

Creatine’s neuroprotective properties also extend to concussion recovery. This again comes back down to cellular bioenergetics and inflammatory cascade that occurs in the brain following a concussion. I’ve realized as I’m writing this, that there’s much more to say about creatine, concussion and its widespread utility, so I’ll just say it now: I’ll be doing a whole newsletter to creatine monohydrate in a coming edition, as there is so much literature and information to share.

Conclusion

In conclusion, incorporating DHA, EPA, and creatine monohydrate into your diet or supplementation regimen seems to have potential benefits for brain health, performance and mood. There may also be some applicability if we, or a loved one, happen to suffer from a neurodegenerative disease or succumb to an injury.  

Omega-3 fish oils and creatine monohydrate are readily accessible, cheap and generally well tolerated. Being someone who is mindful and vigilant about brain health and resilience, these are non-negotiable supplements for me. Are they the most important factors to improve and maintain my health? Of course not. But when you consider all the potential “levers” we can pull to try to inch ourselves toward resilience, sustainability, and performance, it’s one easy way to try to get a leg up. Given that they are backed by an increasing body of scientific literature, I’m also always excited to share what I know with my patients who have a similar mindset.

Yours in good health,

Andrew

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