Importance of Good Nutrition in patients following stroke

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Importance of Good Nutrition in patients
following stroke

• Helen Andrews
• Chief Dietitian
• Bradford

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Aim to cover

• Why is Nutritional status so important?
• What is malnutrition and how do you measure it?
• screen
• Recognise
• Treat
• Look at an example
• Long term dietary needs for this group

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Why is nutritional status important?

• Food and fluid essential to life
• Patients who are malnourished
• Immuno-suppressed- prone to infection
• Increase in Apathy / depression/ lack of energy
• Increased risk of chest infections
• Poor wound healing
• Poor prognosis
• Vicious circle

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Some facts and figures

• 40 patients admitted to hospital are already
  malnourished
• gt10 of general population gt65yrs at medium/high
  risk of malnutrition
• malnourished patients consult GP more, spend
  longer in hospital, have higher
  complication/mortality rates for same condition
• Malnourished surgical patients are 3 x more
  likely to have complications

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what is malnutrition?

• malnutrition is a state in which a deficiency
  of nutrients such as energy protein, vitamins and
  minerals causes measurable adverse effects on
  tissue composition, function or clinical outcome

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What is malnourished

• How do we quantify?
• BMI less than 18.5 Kg/m2
• unintentional weight loss 10 in last 3-6 months
• BMI lt 20Kg/m2 and weight loss of gt5 in last 3-6
  months

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At risk of malnutrition

• Defined as
• eaten little or nothing for more than 5 days
  and or likely to eat little or nothing for the
  next 5 days or longer
• poor absorptive capacity and or nutrient losses
  and or increased nutritional needs.

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For the stroke patient

• ? Malnourished prior to Stroke
• Periods of poor food intakes
• Dysphagia / modified consistency
• long term rehabilitation- often intensive
• Can become under/over nourished
• 10 loss 1 stone on 10 stones could still look
  overweight. Often gradual.

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Stroke patients at real risk of malnutrition
OR
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How do you know?

• Screen for malnutrition
• Recent NICE guidance states all patients should
  be screened minimum of weekly
• Screen Recognise Treat
• Various tools
• ALL involve weight and height

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Screen and Recognise
Essential that patients are weighed Scales must
be accurate Scales must be appropriate Also
need height
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How much do we need to eat and drink?
How do we know they are getting what they need?
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How much food do we need?

• Commonly asked question
• Nutritional requirements are estimated based upon
  patient age, sex, activity levels and clinical
  effects e.g. body temp.
• Schofield equation
• Need both macro and micro nutrients
• Macro energy, protein, fat and carbohydrate
• Micro vitamins and minerals

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An example

• 71 year old female
• Weight 10 st 3 lbs or 65 kgs
• Height 5ft 1 or 1.55m
• Is this lady overweight?

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Yes BMI 27.1 overweight
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Is this lady malnourished?

• BMI 27.1 Kg/m2
• No recent weight loss
• No dysphagia
• Eating OK
• ??? Need to assess if she is eating enough

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Estimated nutritional requirement

• Aims to maintain this weight
• Assumes active on ward, no temp or infection
• Energy 1800Kcals Fluid 2000 mls
• Protein 70 gms
• How much food is this??
• To recognise often ask for a Food diary

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Example of what we often see

• Breakfast
• Toast and tea
• Lunch
• Soup
• Sandwich
• Sponge
• Evening meal
• Stew and pots
• Vegetables
• Milk pudding
• Tea
• Supper
• Milky drink and biscuit

Hard to calculate
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More useful example

• Breakfast
• ½ slice white Toast and butter ½ cup tea with
  milk and 2 tsps sugar
• Lunch
• Soup- ¼ bowl
• Sandwich- cheese and tomato only 2 squares
• Sponge- 1/2 portion sponge and high calorie
  custard
• Evening meal
• Stew -1/3 portion
• and pots- 1 scoop mashed with butter
• Vegetables- 1 portion green beans
• Milk pudding- ½ portion
• Tea- whole cup with milk and 2 tsps sugar
• Supper
• Milky drink ovaltine made with whole milk small
  cup and biscuit x 1 digestive

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How much?
Estimated as Energy 700Kcals Protein
30gms Fluid 400mls Not well balanced
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Treat
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Sip feeds

• In Bradford contracted to Abbott Nutrition for
  sip feeds and enteral feeding
• Wide variety of companies, products similar
• Use based on calculation of nutritional
  requirements vs. nutritional intakes
• Widely used/ widely wasted!!

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Sip feed prescription

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Other Problems experienced

• Modified consistency diets- dilute nutrients
• Milk based sips hard to thicken
• Fluid intakes often poor if on thickened fluids
• Rehab requires activity which increases needs
• Consuming enough a problem

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Must continue to review

• If fail to meet needs or NBM need to consider
  support feeding e.g. nasogastric or PEG
• To aid recovery patients MUST be meeting
  nutritional needs
• Must review benefit vs. cost
• Once in rehab stage/intakes good review weight
  gain!

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Long term dietary advice

• Maintain ideal body weight/control excessive
  weight gain
• Limit salt intakes ( to aid control of
  hypertension)
• Increase intakes of fruit and vegetables
• Include omega 3 fats- more oily fish
• Improve DM control/reduce blood lipids

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In conclusion

• Essential to maintain/improve nutritional status
  and prevent malnutrition
• Must
• Screen
• Recognise
• treat
• Lots of additional difficulties
• Long term advice re prevention