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Nutrition Status at Time of Stroke Associated with Recovery

ARTICLE IN BRIEF

  • ✓ Investigators found a strong relationship between the nutritional status of patients at the time of their stroke and their long-term recovery. Malnourished patients did not recover as easily as those who were well fed at the start of the study.

Stroke patients who arrive to the hospital undernourished may not do as well long-term — even if it seems as if their food needs are met during their hospital stay, according to a study in the January issue of the Archives of Neurology.

A team of Korean neurologists, led by Dong-Wha Kang, MD, PhD, from the University of Ulsan College of Medicine in Seoul, closely followed 131 patients from the time they were admitted to three months later and found a strong relationship between their nutrition status at the time of the stroke and their long-term recovery. Malnourished patients did not recover as easily as those who were well fed at the start of the study.

“The message is that we must aggressively target nutritional supplementation in patients who have had severe strokes and in those who arrive to the hospital malnourished,” said Neeraj Badjatia, MD, assistant professor of neurology at Columbia University Medical Center, who wrote an accompanying editorial with his colleague Mitchell S. V. Elkind, MD, of Columbia University, in the same issue of the journal.

“Patients who were undernourished within the first week after their stroke were more than four times more likely to have a poor outcome than those who were not malnourished,” Dr. Badjatia added.

This sobering finding is counter to three large, multicentered studies that did not find a strong relationship between a stroke patient's nutritional needs during hospitalization and long-term outcomes months to a year down the road. These studies, dubbed FOOD for food or ordinary diet, tested the benefits of feeding tubes while stroke patients were reclaiming their ability to swallow versus waiting until they could swallow on their own sans a feeding tube. The most current analysis of FOOD data was published in 2005 in The Lancet.

STUDY METHODS: A DIFFERENT DESIGN

But the current study was designed differently. The scientists collaborating on the FOOD study did not address whether the patient arrived to the hospital malnourished or even whether they remained or became malnourished during their post-stroke hospital stay. They provided nourishment (through a feeding tube) in some patients and months later they assessed whether they had improved outcomes.

In the current study, measuring nutritional status at the outset and one week later proved fruitful. They determined nutritional status by assessing the patients' body mass index and serum albumin levels on admission.

But one expert on nutrition, who was not involved with the study, questioned their criteria for assessing nutritional status. “Physical stress can alter these levels,” said Donald Hensrud, MD, associate professor of preventive medicine and nutrition at Mayo Clinic. “These changes may be unrelated to nutritional status.”

That said, he still agrees with the study finding, but said that these types of changes that occur in the first week of hospitalization could be caused by the underlying stroke or other medical complications.

“If you look at their data, the things that changed during that one week were the albumin, prealbumin, and transferrin,” Dr. Hensrud said.

STUDY RESULTS

According to the study investigators, patients who arrived in a poor nutritional state had more complications (infections) during their first week. At one week, both malnourishment and severity of stroke were independently predictive of their functional recovery three months later. These malnourished patients were far more likely to be bed-bound during the final assessment compared with those who had initially been more nutritionally fit.

In their sample, 12 percent arrived undernourished to the hospital in the throes of a stroke. At one week, nearly 20 percent of the patients fit the bill for moderate to severe malnourishment. All of the patients had suffered ischemic strokes.

When the subjects returned three months later for their third assessment, the researchers found that the initial nutritional status was predictive of how well they were faring. The investigators assessed disability in patients using the NIH Stroke Scale and the modified Rankin Scale (mRS). Those with a mRS score equal or greater than four were identified as having a poor outcome at three months. [The mRS is a six-point scale; zero indicates normal function and six indicates death; a score of four indicates moderately severe disability — that is, the patient cannot walk without assistance and is unable to attend to his or her own bodily needs without assistance.]

“We need to do a better job of recognizing malnutrition on admission,” Dr. Badjatia said. “There are many ways to assess their nutritional status that are rarely done,” he added. “A simple body mass index or a serum albumin is a good screening method to assess how well they are nourished.” Early intervention could change the poor outcome for patients, he added.

Still, there may be other things going on that need to be addressed. For instance, the patients were properly hydrated and fed during their hospital stay and still remained malnourished. It's possible that the stroke has put such a metabolic toll on the brain and body that it may require an intense nutritional push to get them back to a healthy nutritional state.

The results of the study also suggest that it is critical to assess early on whether a patient is having trouble swallowing, and if so, there may be alternative ways to introduce nutrition.

“Stroke patients may also have different nutritional requirements,” Dr. Badjatia added. He recommends that neurologists order simple tests to measure protein levels in the body. The Korean researchers admit that there are limitations to their study. It was conducted in one hospital and the numbers were small. At three months, only two patients had a subsequent stroke and four died — one death was attributed to cancer, two to respiratory failure, and the fourth cause was unknown.

So what should neurologists do to ensure that their patients are well fed? The Columbia University doctors say that it is important to measure baseline weight and nutritional health as well as basic protein levels to see how much energy the patient is expending.

While Dr. Hensrud agrees adequate nutrition support is very important, he doesn't believe stroke patients may have different nutritional requirements nor that it is necessary to measure protein levels routinely.

Dr. Badjatia said that he is interested in studying the nutritional needs of stroke patients to see whether the brain requires a lot more energy as it recovers from its injuries. The Mayo Clinic's Dr. Hensrud agrees. “Proper nutritional support is important as patients are recovering from their stroke.”

REFERENCES

• Yoo S-H, Kim JS, Kang K-W, et al. Undernutrition as a predictor of poor clinical outcomes in acute ischemic stroke patients. Arch Neurol 2008;65(1):39–43.
    • Dennis MS, Lewis SC, Warlow C, et al., for the FOOD Trial Collaboration. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomized controlled trial. Lancet 2005;365(9461):764–772.
      • The Food Trial Collaboration. Routine oral nutritional supplementation for stroke patients in hospital (FOOD): a multicentre randomised controlled trial. Lancet 2005;365:755–763.