Medical Nutrition Therapy for Stroke

Nutrition Department Medical Faculty of Sumatera Utara University Brain and Mind System 2011

Stroke
Stroke effects in nutrition problem Symptom that affecting nutrition therapy depend on the area brain affected Severe neurologic impairements often compromise the mechamisms and cognitive abilities needed adequate nourishment

Risk factor for stroke

The most significant risk factor: old age Modifiable risk factor:
Hypertension Smoking Obesity Coronary heart disesase Diabetes Physical inactivity Genetic

Nutrition-related factors
BMI > 27 kg/m2 in women Weight gain > 11 kg over 16 years in women Waist to hip ratio > 0.92 in men Diabetes Hypertension Cholesterol

Protective factors for stroke

Total dietary fat (20-25%) Daily consumption of fresh fruit (fiber and antioxidant) Flavonoid consumption (antioxidant) Fish consumption (omega-3)

Medical nutrition therapy as a prevention for stroke

Medical Nutrition Therapy

Primary prevention cornerstone for managing stroke Prevention including lifestyle behaviour NCEP ATP III updated:
Healthy lifestyle habits Therapeutic Lifestyle Changes

Healthy lifestyle habit

Healthy weight (BMI<25 kg/m2) Saturated fat intake < 10% calories Vegetables intake of at least 3 servings/day with at least 1/3 dark green or orange Fruit intake of at least 2 servings/day Grain intake of at least 6 servings/day with at least 1/3 whole grain Smoking cessation by adult smokers Regular physical activity of moderate intensity

Macronutrient recommendations (Therapeutic lifestyle changes)

PUFA: up to 10% of total calories MUFA: up to 20% of total calories Total fat: 20-25% of total calories (PERKENI 2006) Carbohydrate: 50-60% of total calories Dietary fiber: 20-30 grams per day Protein: 10-15% of total calories

Essential components
SAFA: less than 7% of total calories Dietary cholesterol: less than 200 mg/day Plant stanols/sterols: 2 grams/day Viscous (soluble) fiber: 10-25 grams/day

Antioxidant
Docosahexaenoic acids (DHA) and Eicosapentaenoic acids (EPA) omega-3 fatty acids
Sources: all seafood, fatty fishes (salmon, tuna, and trout)

Fruits and vegetables

Sources: Flavonoid (green tea/cathecin, quercetin, revestratol, curcumin, anthocyanin)

Vitamin A, C, E, B12, Zinc, grapeseed, gingko biloba, selenium, and gluthation

Medical nutrition therapy for stroke

Problems in managing stroke: malnutrition Malnutrition predicts a poor outcome Feeding difficulties are determined by the extent of the stroke and the area of the brain affected DYSPHAGIA main problem

Nutrition Management
Maintain adequate nutrition Assess and manage dysphagia Vitamin dan mineral supplementation Enteral nutrition support

Problems related consuming food in stroke

Declined in function resulting decreasing the ability for self care Need enteral nutrition support for period of time until several function improves and eating process can be resumed Losing enjoyment of eating meal preparation

Problem 1. Presentation of food to the mouth

Hemiparesis is weakness on one side of the body that causes the body to slump toward the affected side; it may icrease a patientss risk of aspiration Patient sit as upright (at a 90- degree angel) as possible If the patient must be in bed during mealtime, pillow can be used to bank and support the paretic side

Hemianopsia is blindness for one half of the field of vision A patient may eat only half of the contents of a meal because the patient recognizes only half of it Need assistance during the mealtime
Apraxia is inability to perform purposeful movement although no sensory or motor impairment exist Need demonstration and assistance action to practice

Problem 2. The oral process

Dysphagia (difficulty swallowing) Symptom:
drooling, choking, or coughing during or following meals Inability to suck from a straw A gurgly voice quality Holding pockets of food in the buccal recesses Absent gag reflex Chronic upper respiratory infection

Dysphagia inadequate intake malnutrition Caused by tongue, facial, and masticator muscle weakness Environmental distraction and conversations during mealtime increase the risk for aspiration and should be curtailed National dysphagia diet:
Level 1: pureed Leval 2: mechanically altered characteristics Level 3: transition to regular diet

Level 1:
designed for people who have moderate to severe dysphagia, with poor oral phase abilities pureed, homogenous, and cohesive foods Should be pudding like

Level 2:
Transition from pureed textures to more solid texture, chewing abilitiy is required Moist, soft texture, easily form into bolus Meats are ground or are minced, still moist with some cohesion

Level 3:
Transition to a regular diet, adequate dentition and mastication are required Nearly regular textures with the exception of very hard, sticky or crunchy foods Foods still need to be moist and should be in bite size pieces at the oral phase of the swallow

Level 1

Level 2

Level 3

Problem 3. Swallowing
Proper position for effective swallowing: sitting bolt upright with the head in a chindown position Process of swallowing organized into three phases:
Oral phase Pharyngeal phase Esophageal phase

1. Oral phase:
food in mouth saliva chewed bolusswallowing Intracranial damage and weakened lip muscles hard to complete this phase Facial weakness food can become pocketed in the buccal recesses

2. Pharyngeal phase:
Bolus is propelled past the faucial arches Symptoms of poor coordination during this phaseinclude gagging, choking, and nasopharingeal regurgitation

3. Esophageal phase :
Bolus through the esophagus into the stomach Problems: impaired peristalsis caused by brainstem infarct

Problem 4. Liquids
Liquids as thin consistency such as juice or water needs more coordination and control Caused aspiration life threatening event (aspiration pneumonia, even from sterile water) If difficulty occurs: suggest thickening liquids Thickened product: nonfat dry milk powder, cornstarch, modular carbohydrate supplements Milk associated with increased phlegm flush the throat with clear thickened liquids

Problem 5. Textures
Food consistency mechanically soft or pureed consistency reduce the need for oral manipulation and to conserve energy while eating Small and frequent meals Suggest: 3T (tasty, texture, and temperature) Cool temperature facilitates swallowing

Nutrition support from enteral feeding

If risk of aspiration from oral intake is high If the patient cannot eat enough to meet nutritional needs Options:
Nasogastric tube (short term option) Percutaneous endoscopic gastrostomy (PEG)/ gastrostomy-jejunostomy (PEG/J) tube (long term option)

Needs to appropriate training for taking care the enteral feeding

NGT

PEG