Stroke and Nutrition - Dr. Krizia Ferrini
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2nd Interprofessional Stroke Symposium for Nursing and Therapy- 16.01.2019- Zurich University Hospital Dr. Krizia Ferrini
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Stroke and Nutrition - Dr. Krizia Ferrini
- 1. Stroke and Nutrition Dr. Krizia Ferrini RDN, MSc, PhD
- 2. Disclosure of speaker‘s interest • No conflict of interest • Nutrition Scientific Commettee Council member - American Society for Nutrition (ASN) • Member - European Society for Parenteral and Enteral Nutrition (ESPEN)
- 3. Outline –Nutrition support after stroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 4. Outline –Nutrition support after stroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 5. Nutrition Care Process • Nutrition Assessment • Food and/or Nutrient Delivery • Nutrition Education • Nutrition Counselling
- 7. Nutritional Assessment The purpose of nutritional assessment is to: • Identify individuals at risk of becoming malnourished • Identify individuals who are malnourished
- 8. Nutritional Assessment 1. History 2. Physical examination 3. Laboratory Data in Nutrition Assessment
- 9. Nutritional Assessment 1. History • ↓ weight in last 6 months – e.g. Malnutrition Universal Screening Tool (MUST) • Changes in dietary intake (e.g. Dietary History, Food diary, Observed Food Consumption) • Hydration Status • Quality of diet (e.g. Mediterranean Diet Score)
- 10. Nutritional Assessment 1. History • Gastrointestinal symptoms (i.e. Bristol Stool Chart) • Functional capacity – i.e. Eating Assessment Tool (EAT-10) (if the VFS or FEES not possible) • Disease and its relation to nutritional requirements
- 11. Nutritional Assessment 2. Physical examination Detection of relevant signs helps in establishing the nutritional diagnosis • Subcutaneous fat (i.e. waist circumference, bio impedance analysis) • Muscle wasting • Ankle edema • Sacral edema • Ascites
- 12. Nutritional Assessment Classification Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004. BMI- Principal cut off points Additional cut-off points Underweight <18.50 <18.50 Severe malnutrition <16.00 <16.00 Moderate malnutrition 16.00–16.99 16.00–16.99 Mild malnutrition 17.00–18.49 17.00–18.49 Normal range 18.50–24.99 18.50–22.99 23.00–24.99 Overweight >25.00 >25.00 Pre-obese 25.00–29.99 25.00–27.49 27.50–29.99 Obese >30.00 >30.00 Obese class I 30.00–34.99 30.00–32.49 32.50–34.99 Obese class II 35.00–39.99 35.00–37.49 37.50–39.99 Obese class III (morbid obesity) >40.00 >40.00
- 13. Nutritional Assessment 2. Physical examination Health risk Women Men Low 0.80 or lower 0.95 or lower Moderate 0.81–0.85 0.96–1.0 High 0.86 or higher 1.0 or higher Online Image Online Image
- 15. Nutritional Assessment 3. Evaluation of Laboratory Data in Nutrition Assessment • Used in nutrition assessment (a clinical sign supporting nutrition diagnosis) • Assessment for Protein-Calorie Malnutrition • Used in Monitoring and Evaluation of the patient response to nutritional intervention
- 16. Nutritional Assessment 3. Evaluation of Laboratory Data in Nutrition Assessment • Hormonal and cell-mediated response to stress • Negative acute-phase respondents • Positive acute-phase respondents • Nitrogen balance
- 17. Nutritional Assessment 3. Evaluation of Laboratory Data in Nutrition Assessment • Hepatic transport proteins • Albumin • Transferrin • Prealbumin • Retinol-binding protein • C-reactive protein • Creatinine
- 18. Nutritional Assessment 3. Evaluation of Laboratory Data in Nutrition Assessment • Inflammation: • hs-CRP • Homocysteine • Markers of Malabsorption • Fecal fat • Fat-soluble vitamins • Vitamin D
- 19. Nutritional Assessment 3. Evaluation of Laboratory Data in Nutrition Assessment • Lipid Indices of Cardiovascular Risk • Total cholesterol • LDL • HDL: HDL2a, HDL2b, HDL2c, HDL3a, HDLdb • IDL • VLDL • Lp(a)
- 20. Nutritional Assessment 3. Evaluation of Laboratory Data in Nutrition Assessment 2018AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA /AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines
- 21. Outline –Nutrition support after stroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 23. Clinical Activities- Interfaces • Medical doctors (understanding of the aetiology, treatment, prognosis and comorbidities associated with neurological patients) • Clinical researchers (i.e. providing remote monitoring at home with mobile Health technology application) • Nurses (Artificial Nutrition Management + weekly anthropometric assessments) • Speech therapists (dysphagia - diagnosis and treatment) • Neuropsychologists (Nutrition Counselling Guidelines in Neurological Patients) • Movement therapists (development energy expenditure concept) • Occupational therapists (counselling methods helpful for daily life, cooking groups)
- 24. Outline –Nutrition support after stroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 25. Artificial Nutrition (enteral and parenteral Nutrition) http://www.crohnscolitisfoundation.org
- 26. Artificial Nutrition (enteral and parenteral Nutrition) • Partial Enteral Nutrition (PEN) = 30-50 % calories through formula and the remainder is from solid food or a regular diet • Exclusive Enteral Nutrition (EEN) = 100 % calories through formula; you do not eat any regular food • Dietetic Products and Foods for Special Medical Purposes
- 27. Artificial Nutrition (enteral and parenteral Nutrition) • Patients with prolonged severe dysphagia after stroke that presumably last for more than 7 days should receive early (not more than 72 h) enteral tube feeding • Critically ill stroke patients with decreased level of consciousness that need mechanical ventilation should receive early (not more than 72 h) enteral tube feeding • If enteral feeding is likely necessary for a longer period of time (>28 days), a PEG should be chosen and placed in a stable clinical phase (after 14-28 days)
- 28. Outline –Nutrition support after stroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 30. Dysphagia Signs of swallowing problems: • coughing or choking when patient is eating or drinking • food or drink going down the wrong way • still having food or drink left in the mouth after swallowed
- 31. Dysphagia Signs of swallowing problems: • not being able to chew food properly • taking a long time to swallow or finish a meal • being short of breath when the patient is swallowing
- 33. Dysphagia : International Dysphagia Diet Standardisation Initiative (IDDSI) • 2013 • Goal: developing new global standardised terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and all cultures
- 34. Dysphagia : International Dysphagia Diet Standardisation Initiative (IDDSI) • Final dysphagia diet framework consisting of a continuum of 8 levels (0-7) • Levels are identified by numbers, text labels and colour codes
- 35. Dysphagia New Dysphagia Diets and Fluids https://iddsi.org/framework/
- 36. Outline –Nutrition support after stroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 37. Healthy Nutrition Guidelines • MIND diet • ↓cognitive decline in stroke survivors • rich in whole foods, including fruits and vegetables • elements of the Mediterranean-style diet and the DASH diet American Stroke Association's International Stroke Conference 2018
- 39. Outline –Nutrition support after stroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 40. Recommendations • All patients should be screened for malnutrition at the time of admission and weekly thereafter • Stroke patients should also have their hydration assessed on admission, reviewed regularly and managed so that normal hydration is maintained • Nutrition support should be initiated for people with stroke who are at risk of malnutrition. This may include oral nutritional supplements (ONS), specialist dietary advice and/or enteral tube feeding (ETF)
- 41. Recommendations • People with dysphagia should be given food, fluids and medications modified in a form that can be swallowed without aspiration • Ensure palatable diet, presented in a way to promote nutritional intake
- 42. Recommendations References • Burgos R. et al, ESPEN Guideline Clinical Nutrition in Neurology. Clin Nutr 37 (2018) 354- 396 • 2018AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines • The International Dysphagia Diet Standardisation Initiative (http://iddsi.org/) • Morris MC et al. , MIND diet slows cognitive decline with aging, Alzheimers Dement 2015 September ; 11(9): 1015–1022. doi:10.1016/j.jalz.2015.04.011 • Guideline Clinical Nutrition in Neurology. Clin Nutr (in press) Hookway C., Gomes F., Weekes C.E. (2015) Royal College of Physicians Intercollegiate Stroke Working Party evidence-based guidelines for the secondary prevention of stroke through nutritional or dietary modification. J Hum Nutr Diet. 28(2):107-125.
- 43. Thanks