Canadian Best Practice Recommendations for Stroke Care: Summary (2008)

Image Credit: Davidbrain by Priyan Weerappuli

This best practice document is my find-of- the-week, a useful tool for the dietitian working with acute care stroke patients. The entire document (a summary of the full version) is worth reading but for quick reference, I've extracted the excerpts on nutrition.
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Recommendation 2.1 Lifestyle and risk factor management

Persons at risk of stroke and patients who have had a stroke should be assessed for vascular disease risk factors and lifestyle management issues (diet, sodium intake, exercise, weight, smoking and alcohol intake). They should receive information and counselling about possible strategies to modify
their lifestyle and risk factors [Evidence Level B] (AU, NZ, RCP, VA/DoD).

Lifestyle and risk factor interventions should include:

i. Healthy balanced diet: High in fresh fruits, vegetables, low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources and low in saturated fat, cholesterol and sodium, in accordance with Canada’s Food Guide to Healthy Eating [Evidence Level B] (ASA, CHEP, RCP).

ii. Sodium: The recommended daily sodium intake from all sources is the Adequate Intake by age. For persons 9–50 years, the Adequate Intake is 1500 mg. Adequate Intake decreases to 1300 mg for persons 50–70 years and to 1200 mg for persons > 70 years. A daily upper consumption limit of 2300 mg should not be exceeded by any age group [Evidence Level B]. See www.sodium101.ca for sodium intake guidelines.

iii. Exercise: Moderate exercise (an accumulation of 30 to 60 minutes) of walking (ideally brisk walking), jogging, cycling, swimming or other dynamic exercise 4 to 7 days each week in addition to routine activities of daily living [Evidence Level A]. Medically supervised exercise programs are recommended for high-risk patients (e.g., those with cardiac disease) (ASA, CHEP, EBRSR, NZ).

iv. Weight: Maintain goal of a body mass index (BMI) of 18.5 to 24.9 kg/m2 and a waist circumference of < 88 cm for women and < 102 cm for men [Evidence Level B] (ASA, CHEP, OCCPG).

v. Smoking: Smoking cessation and a smoke-free environment; nicotine replacement therapy and behavioural therapy [Evidence Level B] (ASA, CHEP, CSQCS, RCP). For nicotine replacement therapy, nortriptyline therapy, nicotine receptor partial agonist therapy and/or behavioural therapy should be considered [Evidence Level A] (ASA, AU).

vi. Alcohol consumption: Two or fewer standard drinks per day; and fewer than 14 drinks per week for men; and fewer than 9 drinks per week for women [Evidence Level C] (ASA, AU, CHEP).

iii. Patients who are at risk of malnutrition, including those with dysphagia, should be referred to a dietitian for assessment and ongoing management. Assessment of nutritional status should include the use of validated nutrition assessment tools or measures [Evidence Level C] (AU). Also refer to recommendation 4.2e, “Components of acute inpatient care—Nutrition,” for additional information.

2.2a. Blood pressure assessment

iv. Patients with hypertension or at risk for hypertension should be advised on lifestyle modifications. [Evidence Level C]. Refer to recommendation 2.1, “Lifestyle and risk factor management,” for details on lifestyle modifications

2.3b. Lipid management

i. Ischemic stroke patients with LDL cholesterol of > 2.0 mmol/L should be managed with lifestyle modification and dietary guidelines [Evidence Level A] (AU, CSQCS, McPherson et al.,15 VA/DoD).

2.4b. Diabetes management

i. Glycemic targets must be individualized; however, therapy in most patients with type 1 or type 2 diabetes should be targeted to achieve a glycated hemoglobin (HbA1c) level £ 7.0% in order to reduce the risk of microvascular complications [Evidence Level A] (CDA) and, for individuals with type 1 diabetes, macrovascular complications. [Evidence Level C] (CDA).

ii. To achieve an HbA1c £ 7.0%, patients with type 1 or type 2 diabetes should aim for a fasting plasma glucose or preprandial plasma glucose targets of 4.0 to 7.0 mmol/L [Evidence Level B] (CDA).

iii. The 2-hour postprandial plasma glucose target is 5.0–10.0 mmol/L [Evidence Level B]. If HbA1c targets cannot be achieved with a postprandial target of 5.0–10.0 mmol/L, further postprandial blood glucose lowering, to 5.0–8.0 mmol/L, can be considered [Evidence Level C] (CDA).

Recommendation 4.1 Stroke unit care

Patients admitted to hospital because of an acute stroke or transient ischemic attack should be treated in an interdisciplinary stroke unit [Evidence Level A] (CSQCS, ESO, SCORE, SIGN 64).

ii. The core interdisciplinary team should consist of people with appropriate levels of expertise in medicine, nursing, occupational therapy, physiotherapy, speech–language pathology, social work and clinical nutrition. Additional disciplines may include pharmacy, (neuro)psychology and recreation therapy [Evidence Level B] (AU, SCORE, SIGN 64).

iv. Clinicians should use standardized, valid assessment tools to evaluate the patient’s stroke-related impairments and functional status [Evidence Level B] (ASA, RCP).

Recommendation 4.2 Components of acute inpatient care (new for 2008)

4.2e Nutrition

i. The nutritional and hydration status of stroke patients should be screened within the first 48 hours of admission using a valid screening tool [Evidence Level B] (AU, RPC, SIGN 78).
ii. Results from the screening process should guide appropriate referral to a dietitian for further assessment and the need for ongoing management of nutritional and hydration status [Evidence Level C] (NZ, SIGN 78).
iii. Stroke patients with suspected nutritional and/or hydration deficits, including dysphagia, should be referred to a dietitian for:
a. recommendations to meet nutrient and fluid needs orally while supporting alterations in food texture and fluid consistency based on the assessment by a speech–language pathologist or other trained professional [Evidence Level C] (AU, SCORE);
b. consideration of enteral nutrition support (tube feeding) within 7 days of admission for patients who are unable to meet their nutrient and fluid requirements orally. This decision should be made collaboratively with the multidisciplinary team, the patients, and their caregivers and families [Evidence Level B]. (AU, SIGN 78).
c. Also refer to recommendation 6.1, “Dysphagia assessment,” for dysphagia management.

Recommendation 6.1 Dysphagia assessment

Patients with stroke should have their swallowing ability screened using a simple, valid, reliable bedside testing protocol as part of their initial assessment, and before initiating oral intake of medications, fluids or food [Evidence Level B] (CSQCS, NZ, SCORE, SIGN 78).

i. Patients who are not alert within the first 24 hours should be monitored closely and dysphagia screening performed when clinically appropriate [Evidence Level C].

ii. Patients with stroke presenting with features indicating dysphagia or pulmonary aspiration should receive a full clinical assessment of their swallowing ability by a speech–language pathologist or appropriately trained specialist who should advise on safety of swallowing ability and consistency of diet and fluids [Evidence Level A] (CSQCS, NZ, RCP, SCORE).

Source: Canadian Best Practice Recommendations for Stroke Care: Summary (updated 2008)

Here are some related Web sites, documents & older posts that complement these best practice guidelines:

• The Canadian Stroke Strategy
• Evidence-Based Review of Stroke Rehabilitation (selected resources listed below; many more on Web site):
  
  • Nutritional Interventions Following Stroke
  • Dysphagia & Aspiration Post-Stroke
  • Medical Complications Educational Supplement
  • Secondary Prevention of Stroke Educational Supplement

• Nutrition screening tools
• Undernutrition & stroke outcome
• Cardiovascular Health & Nutrition Education Resources -- 2008 Update
• A Patient's Guide to Best Practice Recommendations for Stroke Care

I must give credit & thanks to my good blogging friend & colleague, Kathryn Elliott, who piqued my curiosity about what I should be doing for & recommending to my stroke patients. Recently on Twitter she shared a link to new Heart Foundation of Australia's evidence based position papers and professional practice guidelines on nutrition and cardiovascular health. This prompted me to review and update my collection of practice resources and begin comparing Australian & Canadian recommendations. (I'm still in the middle of this compare/contrast exercise and will share my observations in a later post.)

The deal on saturated fat -- according to Marion Nestle

I need to find a way a saving all of Marion Nestle's wise advice on interpreting complex and contradictory nutrition research, but until then, I will have to use my blog as a repository. (I know some of my readers also read Marion's blog so please excuse the double-posting.)

Today especially I want to make a note of her response to a question that basically is asking "What if saturated fat isn't so bad?"  Here is part of Marion's answer:

(1) All fats–no exceptions–are mixtures of saturated, unsaturated, and polyunsaturated fatty acids (2) Saturated fats occur in greater proportions in animal fats–meat and dairy foods, (3) Some epidemiologic evidence–but not all–suggests that people who eat a lot of meat and dairy foods have a higher risk of heart disease than people who eat a lot of fruit and vegetables (this is correlation, not causation), (4) The same clinical studies that show how trans fats do bad things to blood cholesterol levels also show that saturated fat does too, although not as much (But: people take in a lot more saturated fat than trans fat), and (5) Saturated fat is a single nutrient and the studies reviewed and discussed by the journalists take saturated fat out of its dietary context.

Out-of-context studies of single nutrients are exceedingly difficult to interpret. At the moment, today’s dietary (not single nutrient) advice is the same as it has been for the last fifty years. As I put it in What to Eat, “Eat less, move more, eat plenty of fruits and vegetables, and don’t eat too much junk food.” Michael Pollan gives exactly the same advice: “Eat food. Not too much. Mostly plants.” Do this, and you really don’t need to give a thought to single nutrients.

 Links: What's the Deal on Saturated Fat?, What to Eat (home page)

Cardiovascular Health & Nutrition Education Resources -- 2008 Update

This morning, as part of preparing for tomorrow's stroke clinical pathway subcommittee meeting, I updated my inventory of patient/client and family education tools and resources on cardiovascular health. Here is Part 1 (original PEN and PEN-recommended resources) of the inventory. I'm going to continue working on it over the next day-and-a-half.

Image credit: Colored vegetables by christing-O

Dietitians of Canada's PEN resources (subscription required to access resources):

• Heart Healthy Eating: Cholesterol
• Heart Healthy Eating: Triglycerides
• Heart Healthy Eating: Recipes
• Heart Healthy Eating Sample Menu
• Low Sodium (Salt) Eating
• Low Sodium (Salt) Food Choices
• Low Sodium (Salt) Cooking
• Low Sodium (Salt) Eating Out
• Low Sodium (Salt) Eating Resources
• Reading Food Labels for Sodium (Salt)
• Increasing Your Potassium Intake
• Potassium Content of Selected Fruits
• Potassium Content of Selected Vegetables
• Increasing Your Fibre Intake
• Sources of Fibre
• High Fibre Recipes

Resources recommended by PEN (external sites; PEN subscription not required):

• 5-to-10-A-Day (encourages Canadians to eat more fruit and veggies)
• Omega-3 content of fish, shellfish, fish oils and nuts (table of values for professionals' use but may be helpful in answering clients' questions about which are "best" to eat)
• DASH Eating Plan
• Too much sodium in your diet can contribute to high blood pressure
• What is your blood pressure?