K.22 Medical Nutrition Therapy for Stroke

7/27/2019 K.22 Medical Nutrition Therapy for Stroke

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Medical Nutrition Therapy for

Stroke

Nutrition Department

Medical Faculty of Sumatera Utara University

Brain and Mind System

2011


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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


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Risk factor for stroke

The most significant risk factor: old age

Modifiable risk factor:

Hypertension

Smoking

Obesity

Coronary heart disesase

Diabetes Physical inactivity

Genetic


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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

HypertensionCholesterol


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Protective factors for stroke

Total dietary fat (20-25%)

Daily consumption of fresh fruit (fiber and

antioxidant)

Flavonoid consumption (antioxidant)

Fish consumption (omega-3)


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Medical nutrition therapy as a

prevention for stroke


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Medical Nutrition Therapy

Primary prevention cornerstone for

managing stroke

Prevention including lifestyle behaviour

NCEP ATP III updated:

Healthy lifestyle habits

Therapeutic Lifestyle Changes


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Healthy lifestyle habit

Healthy weight (BMI


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Macronutrient recommendations

(Therapeutic lifestyle changes)

PUFA: up to 10% of total calories

MUFA: up to 20% of total caloriesTotal fat: 20-25% of total calories

(PERKENI 2006)

Carbohydrate: 50-60% of total caloriesDietary fiber: 20-30 grams per day

Protein: 10-15% of total calories


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Essential components

SAFA: less than 7% of total calories

Dietary cholesterol: less than 200 mg/day

Plant stanols/sterols: 2 grams/dayViscous (soluble) fiber: 10-25 grams/day


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Antioxidant

Docosahexaenoic acids (DHA) and

Eicosapentaenoic acids (EPA) omega-3 fatty

acids

Sources: all seafood, fatty fishes (salmon, tuna, andtrout)

Fruits and vegetables

Sources: Flavonoid (green tea/cathecin, quercetin,

revestratol, curcumin, anthocyanin)

Vitamin A, C, E, B12, Zinc, grapeseed, gingko

biloba, selenium, and gluthation


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Medical nutrition therapy for stroke


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Problems in managing stroke: malnutrition

Malnutrition predicts a poor outcome

Feeding difficulties are determined by theextent of the stroke and the area of the

brain affected

DYSPHAGIA

main problem


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Nutrition Management

Maintain adequate nutrition

Assess and manage dysphagia

Vitamin dan mineral supplementationEnteral nutrition support


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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


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Problem 1. Presentation of food to the

mouth

Hemiparesis is weakness on one side of thebody that causes the body to slump toward theaffected side; it may icrease a patientss risk ofaspiration

Patient sit as upright (at a 90- degree angel) aspossible

If the patient must be in bed during mealtime,pillow can be used to bank and support theparetic side


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Hemianopsia is blindness for one half of the

field of vision

A patient may eat only half of the contents of ameal 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


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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


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Dysphagia inadequate intakemalnutrition

Caused by tongue, facial, and masticatormuscle weakness

Environmental distraction and

conversations during mealtime increasethe risk for aspiration and should becurtailed

National dysphagia diet:

Level 1: pureed

Leval 2: mechanically altered characteristics

Level 3: transition to regular diet


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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 orcrunchy foods

Foods still need to be moist and should be in bite size pieces atthe oral phase of the swallow


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Level 2

Level 3

Level 1


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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


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1. Oral phase:

food in mouth saliva chewedbolusswallowing

Intracranial damage and weakened lipmuscles hard to complete this phase

Facial weakness food can become

pocketed in the buccal recesses2. Pharyngeal phase:

Bolus is propelled past the faucial arches

Symptoms of poor coordination during thisphaseinclude gagging, choking, andnasopharingeal regurgitation


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3. Esophageal phase :

Bolus through the esophagus into the

stomach

Problems: impaired peristalsis caused bybrainstem infarct


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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 supplementsMilk associated with increased phlegm flush

the throat with clear thickened liquids


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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


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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


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NGTPEG


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K.22 Medical Nutrition Therapy for Stroke

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