Management of Nutrition in Acute Stroke

MU RSYID B U STAMI
RS. PU SAT OTAK NASIO NAL
JAK ARTA

NUTRITION IN ACUTE STROKE 1

Outline
1. Introduction and background
2. Malnutrition in brain ischemia
3. The role of nutritional support
in brain ischemia
4. Energy and nutrient needs
5. Nutrition guidelines
6. Nutritional recommendations

NUTRITION IN ACUTE STROKE 2

 Background
• Malnutrition is common both before and after stroke (dysphagia
adding to nutrition risk).
• Reported that frequency of malnutrition ranges from 6.1% to 62%.
• Protein-energy malnutrition was observed 16.3% of 104 patients
following acute ischemic stroke à increased to 26.4% by day 7 in
the surviving patients and 35% by day 14 in inpatients.

Corrigan ML, et al. Nutr Clin Pract. 2011;26:242-52.

NUTRITION IN ACUTE STROKE 3

Background
• Stroke is followed by a phase of hypermetabolism and
hypercatabolism – response to injury proportionate to degree of
brain damage. (Thomas 2002)
• Acute stroke:
• Increased energy/nitrogen requirements
• Insulin resistance and glucose intolerance
• Fluid and electrolyte imbalance
• Acid-base imbalance.

NUTRITION IN ACUTE STROKE 4

Impact of Malnutrition
•Malnutrition in the stroke patients leads to :
• Impaired of immunology function
• Prolonged of LOS
• Increased of morbidity & mortality
• Impaired functional capacity
• Increased risk of bed sores
•Patients nutritional status often deteriorates thereafter because of
increased metabolic demands which cannot be met due to feeding
difficulties.
1. Davalos et al, Stroke 1996;27(6):1028-32
2. Unosson et al, Stroke 1994;25(2):366-71.

NUTRITION IN ACUTE STROKE 5

FOOD Trial Collaboration. Poor nutritional status on admission predicts poor outcomes after
NUTRITION IN ACUTE STROKE 6
stroke. Stroke 2003;34:1450-6.
Caused of Nutritional Status in Stroke
Poor nutritional intake may result from:
◦ Reduced conscious level.
◦ An unsafe swallow (dysphagia).
◦ Arm or facial weakness.
◦ Poor mobility.
◦ Ill fitting dentures.

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Evidence Malnutrition in Stroke

Dennis. British Medical Bulletin 2000, 56(No 2) 466-475

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 Nutritional Support Improve the Stroke Outcome

• Systematic review à nutritional supplementation improves

nutritional parameters and may reduce the odds of death (odds
ratio = 0.66; 95% CI 0.48-0.91 )1.
• Oral supplementation after stroke improves nutritional
parameters2
• Early enteral nutrition after stroke reduced LOS in hospital3.
• Necessary screening of the patient's nutritional status at admission
to hospital 4.
1. Potter JN,et al. BM] 1998, 317. 495-501.
2. Ganballa SE, et al. Age Ageing 1998; 27 (Suppl 1): 66.
3. Nyswonger GD, Helmchen RH. Neurosa Nurs 1992; 24: 220-3.
4. AHA Guidelines, Stroke. 2005; 36:916

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Malnutrition in Brain Ischemia
• Protein synthesis is completely suppressed in the ischemic
penumbra à alteration of cellular homeostasis (↓ratio of
guanosine triphosphate : guanosine diphosphate).
• Inhibition of protein synthesis leads to cell death à restoration of
protein synthesis may allow cells to repair ischemic damage and
recover function.

Aquilani R, et al. Nutr Clin Pract. 2011;26(3):339-45.

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 Malnutrition in Brain Ischemia
• Acute ischemic stroke patients have mean resting
metabolic expenditure 140% to 200% above predicted à
cytokine response, hormone response.
• Despite adequate nutrition support, restoration of
nitrogen balance is often not realized until 2 to 3 weeks
post injury.

August D, et al. J Parenter Enteral Nutr. 2002;26(1):1SA-138SA.

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 Malnutrition in Brain Ischemia
• Many of the risk factors for stroke have nutritionally modifiable behaviors.
• Diabetes - Alcoholism
• Hypercholesterolemia - Atrial fibrillation
The pres
en
• significan ce of -m
Hypertension Aging
alnutritio
n in isch e
• t l
Cigarette smoking y related to in mic strok
f u n c t io n a creased h e p at ien t s
l impro o s p it al L OS is
vement dor hemorrhagic)
• Brain injury resulting from stroke (ischemic an d hasdemetabolic
creased
uring reh
consequences (hypermetabolism). a b ilit a t io n
• Dysphagia is a common manifestation of stroke (45% of all stroke cases) and
can necessitate enteral nutrition (EN) support interventions.

Corrigan ML, et al. Nutr Clin Pract. 2011;26:242-52.

NUTRITION IN ACUTE STROKE 12

Malnutrition in Brain Ischemia
Dysphagia may be reversible in acute ischemic stroke patients à 4%
to 29% of patients resumed full oral nutrition after 4-31 months.
◦ Resumption of oral nutrition was slightly reduced in the elderly above the age
of 75 years.

Volkert D, et al. ESPEN guidelines on enteral nutrition: Geriatrics. Clin Nutr. 2006;25:330-60.

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Energy and Nutrient Needs
Energy:
25 – 30 Kcal/kg/day
Gradual increase à metabolic requirement
§ Protein: § Vitamin & mineral—no specific
§ 1 gr/kg BW/day recommendation
§ Carbohydrates: § Folic Acid, B6, B12 (anti-homocystein)
§ > 55% total calories/day § Bedridden: Calcium and vitamin D
§ Fiber 25-30 gr/day § Water:
§ 30 mls/kg >60 kgBW & 35 mls/kg if <60
§ Fats: kgBW
§ <30% total calories/day § Specific nutrient
§ Saturated fat <10%

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The Composition of Enteral Nutrition in
Stroke
• Depend of several condition (SGA, anthropometry, BMI, severity
of stroke, metabolic condition, respiratory disorders (with
ventilator or not)
• Special attention is required in patients with respiratory disorders
(high fat and low CHO composition).
• Glycemic control in patients with hyperglycemia.

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 The Role of Nutritional Support
• Early nutrition support is important in the acute ischemic stroke
patients
• EN initiated w/n 72 hours of a AIS is associated with a decreased LOS.
• EN remains the preferred method of specialized nutritional
support for AIS patients because of relative ease of use and lower
cost.
• PN should be administered to patients if EN does not meet the
nutritional requirements.

August D, et al. J Parenter Enteral Nutr. 2002;26(1):1SA-138SA.

NUTRITION IN ACUTE STROKE 16

*PEG = percutaneous endoscopic gastrostomy
#NGT = nasogastric tube

Volkert D, et al. ESPEN guidelines on enteral nutrition: Geriatrics. Clin Nutr. 2006;25:330-60.

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 The Role of Nutritional Support
In a Cochrane analysis of interventions for dysphagia in acute ischemic stroke,
EN delivered via PEG was associated with a greater improvement of nutritional
status when compared to EN delivered via NGT.

Norton B, et al. BMJ.1996;312:13-6.

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The Role of Nutritional Support

Aquilani R, et al. Nutr Clin Pract. 2011;26(3):339-45.

NUTRITION IN ACUTE STROKE 19

The Role of Nutritional Support

Aquilani R, et al. Nutr Clin Pract. 2011;26(3):339-45.

NUTRITION IN ACUTE STROKE 20

Nutritional Assessments
• Factors indicative of malnutrition include:
◦ Involuntary loss or gain of ≥10% of usual body weight w/n 6 months, or ≥5%
of usual body weight in 1 month.
◦ Body weight of 20% over or under ideal body weight, esp. in the presence of
chronic disease or increased metabolic requirements.
• Nutritional parameters include:
◦ BMI - Albumin levels
◦ Prealbumin levels - Transferin levels
◦ Gastrointestinal syndromes
◦ Body compositions (muscles & fats ratio to body weight)
August D, et al. J Parenter Enteral Nutr. 2002;26(1):1SA-138SA.

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 Nutritional Assessments

Detsky AS, et al. J Parenter Enteral Nutr. 1987;11:8-13. NUTRITION IN ACUTE STROKE 22
Clinical Pathways for Delivery of Nutrition
Support

The nutrition care plan is the final

component of the nutrition assessment.
The care plan is used to organize the
information obtained in the assessment
and “to declare a professional judgment”.

August D, et al. J Parenter Enteral Nutr. 2002;26(1):1SA-138SA.

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 Clinical Pathways for Delivery of Nutrition
Support

August D, et al. J Parenter Enteral Nutr. 2002;26(1):1SA-138SA. NUTRITION IN ACUTE STROKE 24

 Nutritional Recommendations

n m a y e n ha nce
u pp le m e ntatio
r ot e in- c a lo r ie s
on in s ub a c ute
P
Protein supplementation 1-1.5 g/kgBW
n it iv e ct i
fuisnrecommended à daily
o v e r y of c og
the rec w/ a formula
supplementation ke patien 20tsg of protein and 250
stroproviding
kcal improved cognitive recovery (+3.9 points on the MMSE) vs 0
points (unchanged) in the control patients.

1. Corrigan ML, et al. Nutr Clin Pract. 2011;26:242-52.

2. Aquilani R, et al. Nutr Clin Pract. 2011;26(3):339-45.

NUTRITION IN ACUTE STROKE 25

 Nutritional Recommendations
• Enteral tube feeding formulas are generally well tolerated in acute
ischemic stroke patients à the selection of a 1-1.5 kcal/mL,
polymeric, high-protein enteral formula is appropriate.

• Nutrition supplementation with B-group vitamins may mitigate

oxidative damage after acute ischemic stroke
• à 2 weeks of daily supplementation with B-group vitamins
(folate, B2, B6, B12) had lower reduction in C-reactive protein (a
marker of tissue inflammation) compare to the control group.
1. Corrigan ML, et al. Nutr Clin Pract. 2011;26:242-52.
2. Aquilani R, et al. Nutr Clin Pract. 2011;26(3):339-45.

NUTRITION IN ACUTE STROKE 26

 Nutritional Recommendations
• Patients who receive a daily supplementation of zinc (10 mg) for 30 days have
a better recovery of neurological deficit (NIHSS score) compare to placebo.
à Zinc plays an important role in brain functioning, it acts as a mediator of central
neuronal signaling.

Aquilani R, et al. Nutr Clin Pract. 2011;26(3):339-45.

NUTRITION IN ACUTE STROKE 27

 Effect of high-protein diet on acute stroke
patients
Rianawati SB. RSUD Dr. Soetomo; 2001

•Method:
40 patients with acute ischemic stroke (<72 hours) were randomly assigned into
two groups and received:
• High-protein diet group: a standard therapy + standard hospital nutrition + high-
protein diet (20 Kcal/kgBW/day).
• Control group: a standard therapy + standard hospital nutrition.

• Results:
• The number of patients which experience CNS (Canadian Neurological Scale)
improvement is significantly higher in the high-protein diet group, 80%, compare
to those who received a standard hospital diet (control group), 35% (p=0.004).

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Specific Nutrient
Choline: perbaikan sintesis fosfatidilkolin dan sfingomielin
(Adhibatlla & Hattcher 2002), Neurorepair à perbaikan membran
sel saraf (Warach et al. 20000), antiinflamasi: ↓ CRP, IL-6 dan TNF-
alpha (Detopolou et al 2008).
Phosphatidylserine: Stimulasi pembuatan dan pelepasan dopamin,
memperbaiki fungsi kognitif (berpikir dan berkonsentrasi).
Uridine monophospate: bersama choline (aktivitas yang sinergis) →
meningkatkan fungsi kognitif (perhatian dan proses belajar).
José Álvarez-Sabín, et al.. Brain Sci. 2013:3;1395-1414. doi:10.3390/brainsci3031395.
Hee-Yong Kim, et al. Prog Lipid Res. 2014 October;0:1–18.
Bipolar Disord . 2010 December ; 12(8): 825–833. doi:10.1111/j.1399-5618.2010.00884.x

NUTRITION IN ACUTE STROKE 29

Conclusion
• Inadequate protein intake, low zinc intake, and low antioxidant
capacity are all associated with expansion of ischemia-induced
brain damage.
• Calorie recommendations:
• Energy: 25 kcal/kgBW in nonobese subjects to maintain body weight.
• Protein: >1 g/kgBW in order to achieve carbohydrate (g):protein (g) ratio
<2.5.
• Ischemia-induced brain damage can be reversed by specific
nutrition interventions.

NUTRITION IN ACUTE STROKE 30