Dietitian's Journal

Entries in Stroke (15)


New resource: stroke & transient ischemic attack - management & prevention

A new provincial clinical practice guideline for stroke/tia prevention and management has now been approved and released:

Stroke and Transient Ischemic Attack – Management and Prevention


This guideline is based on scientific evidence current as of the Effective Date [April 29, 2009].

It was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.

It comes in a variety of formats including the full guideline, an executive summary, and resources which are contained in the appendices

 I've quickly scanned the full guideline and noted nutrition is included in these sections:

IV. Management: TIA and Stroke

Prevention of medical complications of stroke is an important aspect of patient care. There are multiple complications post-stroke, and the following list addresses some of the most serious or common complications. Early mobilization and appropriate positioning within 24 hours are associated with improved outcomes. Assess swallowing and refer to SLP/OT as appropriate

    • Serious cardiac complications - common in the first three months post-stroke
    • Depression – estimated to affect up to 1/3 of patients; assess and treat individually
    • Dysphagia/malnutrition/dehydration – optimize positioning (sitting upright in chair unless contraindicated) for meals etc.; consider enteral feeding if no oral intake for >48hrs; there is a reduction in risk of aspiration pneumonia when swallowing is managed early by a speech therapist

Appendix F: A Guide for Patients

 For additional evidence and resources on the important role of nutrition in acute stroke recovery when nutrition support is needed to prevent or correct malnutrition), please see these older posts and links to resources:


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.

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 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:

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.)


Nutrition Screening Tools (continued)

Usually when there is a several-day gap between posts, I've been working on a writing-intensive, detail-oriented project at work and I'm not able to face the computer screen in the evening. Well, that's my excuse this week.

Finally, though, today I submitted the draft (next-to-final?) version of the care pathway appendix and thought I'd share it with you because the references are so valuable. I listed them in my previous post but I've reorganized the list and added some additional reference information and web links. I hope you find the list useful in your practice.

Link to PDF document: Nutrition Screening Tools (draft)


Research article: undernutrition & stroke outcome

Citation: Davis JP, Wong AA, Schluter PJ, Henderson RD, O'Sullivan JD, Read SJ. Impact of premorbid undernutrition on outcome in stroke patients. Stroke 2004;35:1930-1934.

Last week I was looking for information on nutrition risk screening in stroke patients -- specifically, evidence to support including a screening tool in our new acute stroke pathway. (Of course you can guess my bias.)  Google Scholar led me to David et al's article that reports on the prevalence and impact of malnutrition in a cohort of stroke patients. Here's the abstract:
Background and Purpose — To assess the prevalence of premorbid undernutrition and its impact on outcomes 1 month after stroke.
Methods — The study recruited from consecutive stroke admissions during a 10-month period. Premorbid nutritional status (using the subjective global assessment [SGA]), premorbid functioning (modified Rankin scale [MRS]), and stroke severity (National Institutes of Health Stroke Scale [NIHSS] score) were assessed at admission. The associations between premorbid nutritional status, poor outcome (defined as MRS ≥3), and mortality were examined before and after adjustment for confounding variables, including age, gender, stroke risk factors, stroke severity, and admission serum albumin.
Results— Thirty of 185 patients were assessed as having undernutrition at admission. Significant unadjusted associations were observed between undernutrition and poor outcome (odds ratio [OR], 3.4; 95% CI, 1.3 to 8.7; P=0.01), and mortality (OR, 3.1, 95% CI, 1.3 to 7.7; P =0.02) at 1 month. NIHSS, age, and premorbid MRS were also significantly associated with poor outcomes. After adjustment for these factors, the effect size of associations remained important but not significant (poor outcome: OR, 2.4; 95% CI, 0.7 to 9.0, P=0.18; mortality: OR, 3.2; 95% CI, 1.0 to 10.4, P=0.05).
Conclusions— Premorbid undernutrition, as assessed using the SGA, appears to be an independent predictor of poor stroke outcome. Stroke prevention strategies should target undernutrition in the population at risk for stroke to improve outcomes.

I extracted from the authors' thorough discussion this 4-item "take-home" message:

(1) The study found a significant crude association among premorbid nutritional status and mortality and poor outcome at one month. (2) After adjustment for factors such as age, premorbid dependence, and stroke, the associations were not statistically significant.  (3) This study measured premorbid undernutrition, which was the only modifiable risk factor to show an important effect on morbidity and mortality that approached statistical significance. (4)  "In keeping with previous studies, we also found older people, especially those with impaired functional capacity, and those living in aged care facilities to be more susceptible to undernutrition. These groups in particular need to be targeted by nutrition improvement strategies to limit the impact undernutrition has on stroke outcomes."

You can read the full text of the article here. If you aren't able to access it, please contact me.


Adding to my collection of stroke and nutrition resources


Image Credit: Davidbrain by Priyan Weerappuli


I represent the nutrition perspective on an interdisciplinary Acute Stroke Pathway committee at my workplace.

In between meetings I have homework:  search the literature, read articles, compile resources, seek expert opinion where no published evidence exists.  Today I thought I'd share my latest discoveries on nutrition support, dysphagia management, and education about lifestyle modification.

  1. The Canadian Stroke Network includes news, tools and research all of which are worth checking. For now I have downloaded:

You can find other stroke resources, which I've previously mentioned,  on these pages: Resources (middle of page),  archived posts, and my Connotea library (click on "stroke" tag).