NUTRITION IN STROKE

dr.PERNODJO DAHLAN, Sp.S(K)

Department of Neurology
Faculty of Medicine Gadjah Mada University
Yogyakarta
Maret 2010
 PENDAHULUAN

1. Intake makanan, cairan yang optimal

mencegah pemburukan komplikasi
2. Undernutrition & dehidrasi
memperlambat pemulihan
3. Prevalensi malnutrisi pada pasien stroke
: 12% – 16%
19,8% Minggu I
22% -35% Minggu II
4. Undernutrition merupakan prediktor
independen untuk prognostik jelek dari
pasien stroke

5. Dokter acuh dan abaikan nutrisi pada

perawatan pasien stroke
 TATA LAKSANA

A. AKUT :
¾ 0-12 jam pasca onset : hiperakut
¾ 12 jam ke atas pasca onset : sub akut
B. Kronis :
¾ Rehabilitasi
¾ Preventif
 ACUTE

a. Stroke units should be provided with

protocol to evaluate nutritional status and
to set up nutritional intervention
b. Trained staff including a clinical
nutritionist, qualified dietician
c. Patients should undergo nutritional
screening within 24-28 h after admission
STROKE I
a. Nutritional status assessed with
anthropometric, hematologic, and
biochemical
b. Serum albumin concentrations were good
predictors of the degree of disability and
handicap during the hospital stay
c. Serum albumin concentration in the hospital
was a strong and independent predictor of
mortality at 3 mo after acute stroke. Gariballa
Am J Clin Nutr 1998
NUTRITIONAL MANAGEMENT
OF STROKE PATIENTS

a. The main goals satisfy individual

requirements
b. To prevent hydro-electrolytic imbalance
c. To circumvent specific problems related to
eating disabilities
d. To enable patients and their caregivers to
manage food in take Independently
 DYSPHAGIA

In addition to nutritional goals, dysphagia

diets aim to prevent eating-related distress,
choking and aspiration pneumonia
designed to provide adequate energy
nutrients and fluid intake in a consistency
that is the best torelated by patients
Recommended food choices
 Artificial Nutrition
EN (Enteral Nutrition) :
1. Malnourished patients : start 24-72 h
2. Well-nourished patients :
¾ not to delay beyond 5-7 days
¾ 3-4 days in realistic objective
3. The presense of gastroesophageal reflux
should be investigated carefully
4. Should be administrated with the trunk
inclined at 30 degrees
4. Gastric stagnation should be routinely
investigated
5. EN duration is > 2 months, a
percutaneous endoscopic gastrostomy
(PEG)
6. If the aspiration risk is high, a
percutaneous endoscopic jejunostomy
(PEJ) is indicated
 CHRONIC

High – soy diet decreases infark size after

permanent middle cerebral artery
oclusion in female rats.

Derek A. Schreihofer,et all

Am J Physiol Intergr Comp Physiol 289:R103-R108,2005
 Dietary Supplementation with
blueberries,spinach,
or spirulina reduces ischemic brain damage,
reduce ischemia / reperfusion – induced
apoptosis
and cerebral infarction

Yun Wang,et all

Experimental Neurology 193 (2005) 75 - 84
Fish and lifestyle- related disease
prevention :
• Experimental and epidemiological evidence
for anti – atherogenic potential of taurine
• An Adequate level of taurine inside the body
may be important to prevent lifestyle-related
diseases

Yukio Yamori,et all

Clinical and experimental pharmacologi and physiology
(2004) 31,S20-S23
Effects of vitamin E and sesamin on hipertension and
cerebral trombogenesis in stroke-Prone spontaneosly
hypertensive rats

These result indicate that chronic ingestion of vit E

and sesamin attenuated both elevation in blood pressure,
oxidative stress and trombotic tendency
Sugesting that these treatment might be beneficial in the
Prevention of hipertension and stroke

Takanori Noguchi,et all

Clinical and experimental pharmacologi and physiology
(2004) 31,S24-S26
 Canola,Soybean oils in diet
may protect against Stroke

“ Substituting canola oil for other polyunsaturated oils

is a reasonable recommendation “
Each 0,13 % increase in the level of serum alpha – linolenic acid
decreased the risk of stroke by 37 %

Geriatrics,0016867X,jul95,Vol.50,Issue 7
Potassium – Rich Diet May Lower Stroke Risk

There is some evidence that people

who eat a diet rich in potassium
have lower blood presure than others,
possibly because potassium
dilates blood vessels
 Olive Oil and Stroke

Olive oil, rich in monounsaturated fatty acids (MUFA)

Olive oil reduces the levels of low – density
lipoprotein cholesterol ( LDL- c )
Maintains or even increases high -
density lipoprotein cholesterol (HDL-c ) levels
Olive oil may also play a role in slowing the growth of
artheosclerotic lesions
Olive oil is relatively resistant to oxidation.
Virgin olive oil contains phenolic compounds such as
hydroxitir osol, oleuropeine,flavonoids and catequines

Phenolic compounds could have anti oxidant effects

(Caruso et al.,1999 )

Olive oil is rich in antioxidants and constituents

Whose properties may be
potentially protective for the prevention of stroke
The combination of these and other
antioxidants in a dietary pattern may be more important
 Fruits,Vegetables and Stroke

Large cohort studies have found an inverse

association between fruit and vegetables consumption
and the risk of stroke
 Fish and Stroke

Consumption of fish may be protective because fish

Contains high amount of long - chain -3 fatty acids
( Ramirez-Tortosa et al.,1999a )

Inhibiting platelet aggregation and lowering serum triglyceride levels

( van Houwelingen et al.,1989; Harris,1997 )
 However, fish consumption was not associated
with a reduced risk of stroke in the “Chicago Western
Electric Study “ (Orencia et al., 1996 )

In this last study, fish

consumption was protective against total, ischemic
or thrombotic stroke, but was not related to
hemorrhagic events and the evidence is not definitive for men
 Mediterranean Diet and Stroke:
Objectives and Design of the SUN project

A high consumption of olive oil (18.5 g/person/day),

red wine (28.8g/person/day), legumes (102.5 g/person/day),
vegetabels (507.8 g/person/day ) and fruits (316.7 g/ person/day)
ƒ A Cretan Mediterranean diet, which is high in
benificial oils, whole grains, fruits, an vegetables
and low in cholesterol and animal fat, has been
shown to reduce stroke and mycardial infarction by
60 % in 4 years
ƒ Vitamins for lowering of homocystein may yet be
shown to be beneficial for reduction of stroke
ƒ Nutrition is much more important in prevention of
stroke than is appreciated by most physicians

Spense J.D., Stroke 2006

RECOMMENDATION

™Assesment of nutritional status and nutrition

therapy should be part of the overall
management of stroke patients in both the
acute phase and rehabilitation (Grade D)
™Stroke units should comprise of a nutritionist
and a dietician (Grade D)
™Information on nutritional status must be
routinely entered in the patient’s medical
record and nursing notes, and regularly
updated (Grade D)

™Stroke patient are at nutrional risk (Grade C)

™Nutritional risk should be established within
24-48 h after admission to hospital (Grade D)

™Nutritional Assesment should take into

account at least BMI or MUAC, serum
albumin and lymphociyte count, involuntary
weight loss, dietary intake and clinicl
conditions (Grade D)
™Nutritional screening, Assesment and
monitoring should be include in the
accreditation standars for hospitals (Grade D)

™At discharge , family caregivers should be

trained for monitoring body weight and
dietary intake (Grade D)
™Stroke patients should be monitored to evaluate
the presense of dysphagia by using at least a
standardized clinical bedside examination
(Grade C)

™Individual energy and nutrients needs must be

evaluated in all stroke patients for assessing the
adequacy of dietary intake and planing long-tern
nutritional therapy (Grade D)
™The factorial method can be used for the
assessment of individual energy requirements.
An additrional 20-30% should be added to the
estimated BMR for bedridden or chair-bound
patients and 30-40% forthose who are phisically
self-sufficient (Grade D)
™Protein intake should be at least 1 g/kg body
weight day or 1.2-1.5 g/kg body weight day in
the presense of superimposed catabolic
states (Grade D)
™Total fats should account for <30%, saturated fats
for <10%, monounsturated fats for 11-17%, and
polyunsturated fats for 6-10% of the total energy
intake (Grade D)

™In complicated cases, carbohydrates should

account for >55% of the total energy intake.
Dietary fiber intake should be as close as possible
to 25-30 g/day (Grade D)
™A minimum daily fluid intake of 1500 mL is
recommended (Grade D)

™In stroke patients with normal swallowing ability

oral nutrition should be given. If energy intake
remains inadequate, oral supplementation
should be provided (Grade D)
™In the case of undernutrition, the use of an
oral diet associated with oral nutritional
supplementation can be effective in
improving nutritional status (Grade D)
™For disphagic stroke patients dietary
planning including progresive diet levels,
tailored to the different degrees of
inability, must be prepared and made
available. Foods and beverages are to be
selected or modifie for texture, density,
cohesiveness, viscosity and temperature
(Grade D)
™The most adequate dysphagia diet is chosen
taking into account the patient’s ability to swallow
and tolerance to different dishes, and should be
individualized and offered in a proper manner
(Grade D)

™It is mandatory to identity the type of liquid that

is safe for each dysphagic patient to drink.
Commercial thickening agents are useful for
increasing liquid supply (Grade D)
™Enhanced menus and satisfactory food
preparation techniques are essential to ensure a
diet adequate for energy and nutrients (Grade D)

™EN should be started within 5-7 days after stroke

in well-nourished ptients with severe dysphagia,
and within 24-72 h in malnourised patients
(Grade D)
™PEG will be considered if EN duration is
expected to be >2 months (Grade C)

™The hospital and rehabilitation service menu

must be adapted to provide suitable choices
for patients requiring modification of food
consistencies (Grade D)
™Stroke patients and their family caregiver
should be trained in correct feeding
management; in particular with respect to
appropriate mealtime positioning (postural
techniques), food preparation and feeding
techniques (Grade D)