1. Pernodjo Dahlan-Nutrition in Stroke

NUTRITION IN STROKE

dr.PERNODJOdr.PERNODJO DAHLAN, DAHLAN, Sp.S(KSp.S(K))Department of NeurologyDepartment of Neurology

Faculty of Medicine Faculty of Medicine GadjahGadjah MadaMada University University YogyakartaYogyakartaMaretMaret 20102010

PENDAHULUAN

1. Intake makanan, cairan yang optimal mencegah pemburukan komplikasi

2. Undernutrition & dehidrasimemperlambat 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 :

0-12 jam pasca onset : hiperakut

12 jam ke atas pasca onset : sub akut

B. Kronis :

Rehabilitasi

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. GariballaAm 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, dysphagiadiets 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 :

not to delay beyond 5-7 days

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

High – soy diet decreases infark size after permanent middle cerebral artery

oclusion in female rats.

Derek A. Schreihofer,et allAm J Physiol Intergr Comp Physiol 289:R103-R108,2005

CHRONIC

Dietary Supplementation with blueberries,spinach,

or spirulina reduces ischemic brain damage,reduce ischemia / reperfusion – induced

apoptosis and cerebral infarction

Yun Wang,et allExperimental 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 allClinical and experimental pharmacologi and physiology(2004) 31,S20-S23

These result indicate that chronic ingestion of vit E and sesamin attenuated both elevation in blood pressure, oxidative stress and trombotic tendencySugesting that these treatment might be beneficial in the Prevention of hipertension and stroke

Takanori Noguchi,et allClinical and experimental pharmacologi and physiology(2004) 31,S24-S26

Effects of vitamin E and sesamin on hipertension andcerebral trombogenesis in stroke-Prone spontaneoslyhypertensive rats

Geriatrics,0016867X,jul95,Vol.50,Issue 7

“ 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 %

Canola,Soybean oils in dietmay protect against Stroke

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 ) levelsOlive 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 ashydroxitir osol, oleuropeine,flavonoids and catequines

Phenolic compounds could have anti oxidant effects(Caruso et al.,1999 )

Olive oil is rich in antioxidants and constituentsWhose properties may bepotentially protective for the prevention of strokeThe 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 fishContains 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 associatedwith 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 tohemorrhagic 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)

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 yearsVitamins for lowering of homocystein may yet be shown to be beneficial for reduction of strokeNutrition 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 cliniclconditions (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 phisicallyself-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)