MEDICAL NUTRITION THERAPY FOR

STROKE
Nutrition Department
Medical Faculty of Sumatera Utara University
Brain and Mind System
2015
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
Changing lifestyle

Healthy food or
high CVD risk food
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 for
prevention
 Primary prevention  cornerstone for managing
stroke
 Prevention including lifestyle behaviour
 NCEP ATP III updated:
 Healthylifestyle 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
 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
 Attention for sodium intake: less sodium (sodium:
hiding in instant food, fast food, and canned food)
and kalium
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 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
 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 Need demonstration and assistance 
action to practice
Problem 2. The oral process

 Dysphagia
 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 chin-down position
 Process of swallowing organized into three phases:
 Oral phase
 Pharyngeal phase

 Esophageal phase
 1. Oral phase:
 food in mouth saliva chewed bolusswallowing
 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 phase include
gagging, choking, and nasopharingeal regurgitation
 3. Esophageal phase :
 Bolusthrough 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
If oral nutrition not adequate?
Planning nutrition intervention with enteral
and parenteral nutrition support

 For patients who are unable to maintain their

nutritional status using oral diets or supplements
next alternative
 Assesment needed to determine the underlying
cause of poor oral intake (if present)
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 (<24 hour)