Rivista Italiana di Nutrizione Parenterale ed Enterale / Anno 22 n. 4, pp.

227-236

Wichtig Editore, 2004

Documento di Consenso - Consensus Paper

Nutritional recommendations for the management of stroke patients

G. ROTILIO1,2, R. BERNI CANANI2, F. BRANCA3,15, G. CAIRELLA4,15, C. FIESCHI5, F. GARBAGNATI2, M.G. GENTILE6,15, G.F. GENSINI7, M.L.E. LUISI8,15, M. MARCELLI9,15, M.L. MASINI10, F. MASTRILLI11, M. MUSCARITOLI12, S. PAOLUCCI11, L. PRATESI11, M.L. SACCHETTI5, A. SALVIA11, U. SCOGNAMIGLIO2, P. STRAZZULLO13, E. TROIANO14, L. SCALFI14,15
Department of Biology, Tor Vergata University of Rome, Rome - Italy Center of Research on Nutrition and Rehabilitation (CeSAR), IRCCS Fondazione S. Lucia, Rome - Italy 3 National Institute for Research on Food and Nutrition (INRAN), Rome - Italy 4 Department of Prevention - Nutrition Unit - ASL RMB, Rome - Italy 5 Department of Neurology, University La Sapienza, Rome - Italy 6 Clinical Nutrition Unit, Niguarda Hospital, Milan - Italy 7 Department of Medical and Surgical Critical Care, Section of Clinical Medicine and Cardiology, A.O.U. Careggi, Florence - Italy 8 Don Carlo Gnocchi Foundation, IRCCS Florence - Italy 9 Clinical Nutrition Unit A.O.S. Giovanni Addolorata, Rome - Italy 10 Dietetic Unit - A.O.U. Careggi, Florence - Italy 11 IRCCS - Fondazione S. Lucia, Rome - Italy 12 Department of Clinical Medicine, University La Sapienza, Rome - Italy 13 Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples - Italy 14 Department of Food Science, Federico II University of Naples, Naples - Italy 15 Italian Society of Human Nutrition
1 2

ABSTRACT: This paper reports the consensus achieved by a panel convened by the IRCCS Fondazione S. Lucia, on different aspects of the relationships between diet, nutrition and stroke: according to a well-defined evidence-based approach. The recommendations are subdivided in three main sections regarding the assessment of nutritional status, the estimation of the patients nutritional needs and the nutrition management, and take into account stroke patients in both the acute phase and rehabilitation. Stroke patients are at nutritional risk and assessment of nutritional status and nutrition therapy should be part of the overall management of stroke patients in both the acute phase and rehabilitation. Highlights of the recommendations are that nutritional assessment should be carried out weekly in the presence of mild undernutrition, and twice a week in the case of moderate to severe undernutrition; in the case of undernutrition, the use of an oral diet associated with oral nutritional supplementation can be effective in improving nutritional status; EN should be started within 5-7 days after stroke in wellnourished patients with severe dysphagia, and within 24-72 h in malnourished patients. It is hoped that the recommendations hereby released will be useful to nutritionists, neurologists, practicing physicians and health care professionals operating in the field of stroke patient therapy. (RINPE 2004; 22: 227-36) KEY WORDS: Nutrition, Ischemic stroke, Recommendations PAROLE CHIAVE: Nutrizione, Ictus ischemico, Raccomandazioni INTRODUCTION A consensus panel, coordinated by the IRCCS Fondazione S. Lucia, gathered in the second part of 2002 to share opinions about different aspects of the relationships between diet, nutrition and stroke: according to a well-defined evidence-based approach, the panel produced a document that was included in the Italian guidelines for the prevention and treatment of stroke (SPREAD 2003). At the same time, in October 2003, a satellite meeting of the Congress of the Federation of the European Nutrition Society (FENS) was held in Rome concerning nutrition in disabling diseases. Subsequently, the Italian Working Group on Nu SINPE-GASAPE

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trition and Stroke Prevention, also including other experts, produced two papers published on Nutrition Metabolism and Cardiovascular Diseases (NMCD): a systematic review of the relationships between the consumption of certain foods or nutrients and the risk of stroke, and practical recommendations concerning the nutritional prevention of stroke. As an extension of this activity, a group of nutritionists covering different scientific and clinical areas, most already included in the original panel, in this paper propose a general overview on some relevant nutritional aspects related to the management of stroke patients. The document is inspired by the common belief that stroke patients represent an important nutritional challenge for the health care service, it seeks to follow an evidence-based approach, and it is largely based on the review regarding the same topic in this issue of RINPE. The recommendations are subdivided into three main sections regarding the assessment of nutritional status, the estimation of the patients nutritional needs and the nutrition management, and it takes into account stroke patients in both the acute phase and rehabilitation. In each section, major scientific and practical aspects are discussed and concise recommendations are provided. It is hoped that the recommendations hereby released will be useful to nutritionists, neurologists, practicing physicians and health care professionals operating in the field of stroke patient therapy. NUTRITIONAL RISK IN STROKE PATIENTS Malnutrition amongst stroke patients is often underestimated or completely ignored, although it significantly affects outcomes. Therefore, to improve the nutritional management of these patients, stroke units should be provided with protocols to evaluate nutritional status and to set up nutritional intervention, and be composed of properly trained staff including a clinical nutritionist, who manages nutrition therapy and ensures an adequate patient follow-up, and a qualified dietician, with the task of monitoring nutritional status, assessing progression in dietary intake, and dealing with dysphagia-related dietary problems. Recommendations Assessment of nutritional status and nutrition therapy should be part of the overall management of stroke patients in both the acute phase and rehabilitation (Grade D). Stroke units should comprise of a nutritionist and a dietician (Grade D).

Information on nutritional status must be routinely entered in the patients medical record and nursing notes, and regularly updated (Grade D). ASSESSMENT OF NUTRITIONAL RISK Patients should undergo nutritional screening (i.e. the first step in the assessment of nutritional risk) within 24-48 h after admission and this procedure should be repeated at least weekly. Nutritional screening aims to assess individual characteristics known to be associated with nutritional problems; and therefore, to identify patients who are undernourished or at nutritional risk, and to determine whether nutritional assessment is needed. There is no validated specific nutritional screening system for stroke patients. However, the nutritional risk screening (NRS), proposed by the Council of Europe, can be adapted to stroke patients. The NRS combines the evaluation of nutritional impairment with that of underlying disease severity. Another option is the malnutrition universal screening tool (MUST) proposed by the Malnutrition Advisory Group, which considered body mass index (BMI), weight loss and the presence of acute diseases plus current nutritional intake. From a practical point of view, in both systems stroke patients are considered per se at nutritional risk. Therefore, the presence of even mild signs of nutritional impairment are sufficient to shift patients to a nutritional risk category, triggering specific nutrition support actions, as well as more frequent monitoring. NUTRITIONAL ASSESSMENT IN THE ACUTE CARE HOSPITAL AND IN THE REHABILITATION SERVICE Nutritional assessment is a more complete evaluation of nutritional status carried out using different types of variables. Although, to date, there are no specific indications for stroke patients, the nutritional assessment of stroke patients should involve anthropometric indices, biochemical indices, the assessment of dietary intake and the evaluation of clinical conditions. Table I lists the indicators and the cut-off points that should be considered. Stroke patients classified at moderate to severe risk (as demonstrated by at least two indicators) are considered undernourished. Anthropometric measurements and indices In stroke patients able to stand, weight, height and waist circumference should be measured

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TABLE I - SELECTED INDICATORS OF NUTRITIONAL ASSESSMENT IN STROKE PATIENTS MILD RISK or NO RISK of undernutrition BMI (kg/m2) or alternatively MUAC (cm) Unintentional weight loss (kg) Serum albumin (g/dL) >20 >25 >5% in 3-6 months MODERATE RISK of undernutrition BMI (kg/m2) or alternatively MUAC (cm) Unintentional weight loss (kg) Serum albumin (g/dL) Lymphocyte count (mm3) Food intake as % requirements Disease severity or concomitant pathologies 18.5-20 >23.5 and <25 >5% in 2 months SEVERE RISK of undernutrition BMI (kg/m2) or alternatively MUAC (cm) Unintentional weight loss (kg) Serum albumin (g/dL) Lymphocyte count (mm3) Food intake as % requirements Disease severity or concomitant pathologies <18.5 <23.5 >5% in 1 month

3.0-3.5

2.5-2.99

<2.5

Lymphocyte count (mm3) Food intake as % requirements Disease severity or concomitant pathologies

1200-1500

800-1199

<800

100-75

75-50

<50

No

Yes

Yes

WEEKLY MONITORING

BI-WEEKLY MONITORING

NUTRITION PLAN

TABLE II - ESTIMATING HEIGHT USING DEMISPAN HEIGHT (m) Men (16-54 years) Men (>55 years) Demispan (cm) HEIGHT (m) Women (16-54 years) Women (>55 years) HEIGHT (m) Men (16-54 years) Men (>55 yeras) Demispan (cm) HEIGHT (m) Women (16-54 years) Women (> 55 yeras)

1.97 1.90 99

1.95 1.89 98

1.94 1.87 97

1.93 1.86 96

1.92 1.85 95

1.90 1.84 94

1.89 1.83 93

1.88 1.81 92

1.86 1.80 91

1.85 1.79 90

1.84 1.78 89

1.82 1.77 88

1.81 1.75 87

1.80 1.74 86

1.78 1.73 85

1.77 1.72 84

1.76 1.71 83

1.91 1.86

1.89 1.85

1.88 1.83

1.87 1.82

1.85 1.81

1.84 1.80

1.83 1.79

1.82 1.77

1.80 1.76

1.79 1.75

1.78 1.74

1.76 1.73

1.75 1.71

1.74 1.70

1.72 1.69

1.71 1.68

1.70 1.67

1.75 1.69 82

1.73 1.68 81

1.72 1.67 80

1.71 1.66 79

1.69 1.65 78

1.68 1.64 77

1.67 1.62 76

1.65 1.61 75

1.64 1.60 74

1.63 1.59 73

1.62 1.57 72

1.60 1.56 71

1.59 1.55 70

1.58 1.54 69

1.56 1.53 68

1.55 1.51 67

1.54 1.50 66

1.69 1.65

1.67 1.64

1.66 1.63

1.65 1.62

1.63 1.61

1.62 1.59

1.61 1.58

1.59 1.57

1.58 1.56

1.57 1.55

1.56 1.54

1.54 1.52

1.53 1.51

1.52 1.50

1.50 1.49

1.49 1.47

1.48 1.46

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Weight and height are used to calculate BMI (BMI = weight/height2 in kg/m2); patients with a BMI >30 kg/m 2 are expected to be obese and patients with a BMI <20 kg/m2 to be underweight. On the other hand, waist circumference is considered as the most practical measure to clinically evaluate the amount of visceral fat, which is strictly related, even in those with normal weight (BMI 18.5-24.9 kg/m2), to cardiovascular risk and type 2 diabetes. Attention values are >102 cm for men and >88 cm for women. Waist circumference should be measured monthly. In stroke patients with limited mobility, confined to bed or unable to stand, body weight, demispan and mid upper arm circumference (MUAC) should be determined In this case, weight measurement requires specialized equipment such as wheelchair balance or bed scale. If height cannot be measured because of the patients inability to stand, demispan can be used to estimate height, as shown in Table II. On the other hand, MUAC can be used as an alternative to BMI in detecting undernutrition (<23.5 cm) or overnutrition (>32 cm). As far as weight changes are concerned, patients or caregivers should be questioned at admission with regard to involuntary weight loss. The attention threshold is a weight loss >5% over the previous 2 months. Repeated weight measurements (at least weekly during hospitalization) are also useful to detect a significant, unintentional weight loss; a weight loss of 2% of body weight in the previous week is associated with an increased risk of undernutrition. Laboratory tests No single biochemical indicator has proved to be much better than others in the assessment of nutritional status. Serum albumin concentration and lymphocyte count are the most widely used measurements since they are both inexpensive and easy to obtain. Dietary assessment The assessment of dietary intake is useful to characterize prospective nutritional risk and to plan the most adequate nutritional strategy. At admission, the first dietary intake evaluation should be carried out by using 24-h recall. Follow-up evaluation should be performed for 1 day a week and be repeated in the following days (for 2 consecutive days), if dietary intake is lower than expected. An energy intake <75% of estimated needs is an index of nutritional deficiency.

Clinical evaluation Clinical evaluation is aimed at observing disease severity and progression and detecting concomitant pathologies, which cause additional stress and lead to an increase in nutrient needs. NUTRITIONAL ASSESSMENT AT HOME At discharge, health care personnel should train patients and their families to collect simple information concerning body weight and food intake. Body weight, in patients who are able to stand without assistance, should be measured taking into account some simple suggestions: Measure body weight at least once a week in standard clothing and physiological conditions (empty bladder and bowels); Use a scale suitable for the patients ability to stand; Schedule the time and the day. Regarding food intake, at the end of the meal family caregivers should routinely record leftovers, an energy intake <75% of requirements being considered an index of nutritional deficiency. In the case of several consecutive records of insufficient dietary intake, family caregivers should refer to the doctor in charge. Health care personnel can also be involved in collecting data on food intake to integrate and validate the information obtained from family caregivers. ASSESSMENT OF DYSPHAGIA The assessment of dysphagia is mandatory in every stroke patient because of possible severe complications, like acute hypoxia, aspiration, dehydration and undernutrition. Videofluoroscopy is considered the gold standard for assessing dysphagia, but it is not widely available, it is costly and time consuming, and has several limitations, such as x-ray exposure and the inability of the patient to sit. Where available, fiberoptic laryngoscopy is another valid technique to assess dysphagia: it gives anatomic and dynamic details and can be performed at the bedside. In the clinical setting, a standardized bedside swallowing assessment is a reliable technique to evaluate the aspiration risk, taking into account variables that can be evaluated by a skilled nurse or speech therapist (level of consciousness, dysphonia, dysarthria, drooling, gag reflex, voluntary cough, cough after swallowing, wet voice and the movement of the larynx).

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Recommendations Stroke patients are at nutritional risk (Grade C). Nutritional risk should be established within 24-48 h after admission to hospital (Grade D). Nutritional assessment should take into account at least BMI or MUAC, serum albumin and lymphocyte count, involuntary weight loss, dietary intake and clinical conditions (Grade D). Nutritional assessment should be repeated weekly in the presence of mild undernutrition, and twice a week in the case of moderate to severe undernutrition (Grade D). Nutritional screening, assessment and monitoring should be included in the accreditation standards for hospitals (Grade D). At discharge, family caregivers should be trained for monitoring body weight and dietary intake (Grade D). Stroke patients should be monitored to evaluate the presence of dysphagia by using at least a standardized clinical bedside examination (Grade C).

ENERGY AND NUTRIENT NEEDS Individual energy and nutrient needs must be evaluated in all stroke patients for assessing the adequacy of dietary intake and planning long-term nutritional therapy. However, evidence about acute, sub-acute and longterm nutritional needs of stroke patients are not exhaustive. Therefore, the nutrient needs of healthy individuals are used as a reference for well-nourished stroke patients, while specific provisions are made for patients at risk or malnourished. Indirect calorimetry is indicated for an accurate assessment of individual energy requirements. In the absence of this, an estimate using the factorial method is required: basal metabolic rate (BMR) is predicted from sex, age and weight (LARN, 1996); BMR is then multiplied by a physical activity level or by a disease factor, if a concomitant pathology is present. A specific stress factor does not exist for stroke. Nevertheless, an additional 20-30% should be added to the calculated BMR for bedridden or chair-bound patients and 30-40% for those who are physically self-sufficient. At least 25 Kcal/kg/day should be given, with a gradual increase until metabolic requirements are met. In patients without complications, protein intake should be at least 1 g/kg body weight/day (the ideal body weight should be used in case of obesity or mal-

nutrition), but it should be higher (1.2-1.5 g/kg body weight/day) in the presence of superimposed catabolic states, such as pressure sores. Fats should account for <30% of the total energy intake; with saturated fats <10%, monounsaturated fats 11-17% and polyunsaturated fats 6-10%. The n-6/n-3 ratio should range from 5:1 to 10:1. An intake of 1 g/day of longchain n-3 PUFA (EPA and DHA) is recommended for secondary prevention. In uncomplicated cases, carbohydrates should account for >55% of the total energy intake. Dietary fiber intake should be as close as possible to 25-30 g/day. Specific dietary protocols should be followed for patients with impaired glucose tolerance. Currently, there are no specific recommendations for vitamin and mineral intake in stroke patients. The coverage of calcium and vitamin D seems to be particularly important, given the increased bone resorption and the high risk of osteoporosis especially in bedridden patients. Mineral and vitamin supplements can be considered in the presence of associated pathologies or drug-nutrient interactions. The consumption of folate supplements is necessary to correct hyperhomocysteinemia levels. When supplements are used, a folate dosage of 0.5-5 mg/day or a multivitamin preparation including vitamin B6 and B12 are suggested. Clinical trials are also being conducted to evaluate the effect of administering diets with high antioxidant contents (vitamins E and C, beta-carotene and polyphenols) on the reduction of long-term brain injury, the improvement of cognitive function and the prevention of further cerebrovascular accidents; currently, it is impossible to formulate specific recommendations. Finally, stroke patients can be vulnerable to dehydration. A minimum daily fluid intake of 1500 mL is recommended to cover losses from urine, feces, lung vapor and sweat in patients weighing between 50-80 kg; specific protocols to monitor and support hydration must be developed. Recommendations Individual energy and nutrient needs must be evaluated in all stroke patients for assessing the adequacy of dietary intake and planning long-term nutritional therapy (Grade D). The factorial method can be used for the assessment of individual energy requirements. An additional 2030% should be added to the estimated BMR for bedridden or chair-bound patients and 30-40% for

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Fig. 1 - Decisional algorithm for nutritional management of stroke patients.

those who are physically self-sufficient (Grade D). Protein intake should be at least 1 g/kg body weight day or 1.2-1.5 g/kg body weight day in the presence of superimposed catabolic states (Grade D). Total fats should account for <30%, saturated fats for <10%, monounsaturated fats for 11-17%, and polyunsaturated fats for 6-10% of the total energy intake (Grade D). In uncomplicated cases, carbohydrates should account for >55% of the total energy intake. Dietary fiber intake should be as close as possible to 25-30 g/day (Grade D). A minimum daily fluid intake of 1500 mL is recommended (Grade D).

NUTRITIONAL MANAGEMENT OF STROKE PATIENTS The main goals of nutrition management in stroke patients are to satisfy individual requirements, to prevent hydro-electrolytic imbalance, to circumvent specific problems related to eating disabilities and to enable patients and their caregivers to manage food intake independently. Figure 1 illustrates a decisional algorithm for the nutritional management of stroke patients. Acute phase In the first 24-48 h after the event, nutritional therapy should be performed according to the general indica-

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TABLE III - DIFFERENT LEVELS FOR DYSPHAGIA DIET Dysphagia pureed Pureed, homogenous, and cohesive foods. Food should be pudding-like. No coarse textures, nuts, raw fruits, or raw vegetables allowed. Any foods that require bolus formation, controlled manipulation, or mastication excluded. More frequent feedings recommended. Liquids and water thickened as needed with a thickening agent. Dysphagia mechanically altered Moist, soft-textured, and easily formed into bolus foods. All foods from the dysphagia pureed diet acceptable. No coarse textures, nuts, raw fruits (except very ripe or mashed banana), or raw vegetables allowed. More frequent feedings recommended. Liquids and water thickened as needed with a thickening agent. food choices Any well-moistened breads, biscuits, cereals. All pasta or rice. All potatoes (including tender, fried potatoes). Dysphagia advanced Food of nearly regular textures with the exception of very hard, sticky or crunchy foods. Foods to be moist and to be in bite-size pieces. All foods from previous diets acceptable. More frequent meals recommended. Liquid and water thickened as needed with a thickening agent.

General description

Recommended Cereals and potatoes Smooth, homogeneous cooked cereals: cream of wheat, cream of rice, smooth cereals, pureed bread products. Well-cooked pasta or rice pureed in a blender to smooth, homogenous consistency. Commercially or facility prepared pureed bread mixes. Mashed potatoes or sauce, pureed potatoes with gravy, butter or margarine. Thickened milk, smooth yogurt. Cream cheese.

Cooked cereals with little texture, included oatmeal (no rice allowed). Slightly moistened dry cereals with little texture (corn flakes). Pureed bread mixes. Soft, bite-size pasta. Well-cooked, moistened, boiled, baked or mashed potatoes.

Milk products

Cottage cheese. Cream cheese spreads with soft additives.

Milk (thickened if necessary). All yogurt without nuts or coconut. Non-sticky cheese. Thin-sliced, tender or ground meats, poultry. Well-moistened fish. Eggs prepared any way. Well-cooked pulses.

Meat, fish, eggs and pulses

Pureed meats and fish. Pureed pulses spread. Eggs included with other foods.

Moistened ground or cooked meats, poultry or fish. Moist ground or tender meat may be served with gravy or sauce. Moist meatballs, meat loaf, fish loaf. Poached, scrambled or soft-cooked eggs. Well-cooked, slightly mashed, moist pulses. All soft, well-cooked vegetables (easily mashed with a fork). Soft drained canned or cooked fruits without seeds or skin. Fresh soft/ripe banana. Fruit juices with small amount of pulp. Thick gravies and sauces; seasoning fats (butter, oil, margarine, etc), mayonnaise. Pudding. Custard. Soft fruit pies with bottom crust only. Soft, moist cakes. All beverages with minimal amount of texture, lumps, chunks or pulp. Beverages possibly thickened to the recommended consistency.

Fruits and vegetables

Pureed fruits or well-mashed bananas. Pureed vegetables without chunks, lumps, pulp or seeds. Tomato paste or sauce without seeds. Thickened fruit and vegetables juices and nectars without pulp, seeds or chunks. Thick gravies and sauces; seasoning fats (butter, oil, margarine, etc), mayonnaise. Smooth pudding, custard, pureed desserts and souffls. Honey, smooth jellies, sugar.

All cooked, tender vegetables. All canned and cooked fruits. Soft, peeled fresh fruits such as peaches, nectarines, kiwi, mango, cantaloupe, watermelon (without seeds).

Fats

All.

Desserts and sweets

All except: dry cakes, chewy or very dry cookies; anything with nuts, seeds, dry fruits, coconut, pineapple. Jams, jellies, honey, preserves. Any beverages, depending on recommendations for liquid consistency.

Beverages

Any smooth, homogenous beverages without lumps, chunks or pulp. Beverages possibly thickened to appropriate consistency.

(modified from the National Dysphagia Diet; 2003)

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tions for acute intensive care patients. Subsequently, the nutritional strategy depends on the presence of eatingrelated problems and eating disabilities. Post-acute phase NORMAL SWALLOWING ABILITY Oral nutrition should be given. If the patient is able to feed himself, but he is not motivated enough to do it, it is necessary to provide specific assistance, encouragement and prompting during a meal as appropriate. It is also advisable to offer food according to the patients preferences and to ensure a pleasant eating environment and the presence of family members during mealtimes. If all these actions prove insufficient (food intake <75% of estimated needs), nutritional supplementation should be provided. In the case of undernutrition, an oral diet associated with oral nutritional supplements can be effective in improving energy and protein intake. These supplements should be prescribed and supplied with clear and detailed instructions for use to maximize compliance. In the case of obesity or abnormal high waist circumference values (in the absence of involuntary weight loss or reduced dietary intake), a weight reducing diet should be provided. DYSPHAGIA In addition to nutritional goals, dysphagia diets aim to prevent eating-related distress, choking and aspiration pneumonia; and therefore, are designed to provide adequate energy nutrients and fluid intake in a consistency that is the best tolerated by patients. Therefore, dietary planning including progressive diet levels, tailored to the different degrees of disability is needed. The National Dysphagia Diet Task Force (Tab. III) recently identified four dietary levels: three dysphagia levels (dysphagia pureed, dysphagia mechanically altered and dysphagia advanced) plus the regular diet. A patient can begin at any of the dysphagia levels, depending on the severity of swallowing dysfunction, and could skip one or more stages during the recovery process. The passage from one diet level to the following one is dictated by changes in the abilities for swallowing and bolus preparation. Since liquids can also pose a particular problem in stroke patients with dysphagia, it is mandatory to identify what is safe for each individual to drink. According to consistency and viscosity, the National Dysphagia Diet Task Force identifies four liquid levels termed thin, nectar-like, honey-like and spoon-thick. Moreover, liquid supply should be increased by the

use of commercial thickening agents (modified cornstarches) or jelly water, with the amount of commercial thickener used per volume of liquid varying from brand to brand. However, the final product does not always have the consistency expected if not enough attention is paid to its preparation. However, the dietary treatment of stroke patients has to be customized and regularly reconsidered based on changing swallowing abilities. An overall improvement of food service in acute care and longterm facilities is needed in most cases for adequate nutrition therapy. Therefore, catering staff should receive appropriate training and education, while nutrition plan should be agreed with and communicated to the patient and his caregivers. Enhanced menus and satisfactory food preparation techniques are also essential to ensure a diet adequate for energy and nutrients. In this regard, standardized recipes are very useful in helping to prepare foods with modified consistency, but also palatable and visually appealing. Finally, eating utensils that are appropriate to the patients level of self-feeding skills should be provided, and sanitation procedures should be observed in all preparation and processing. Regarding fluids, persisting in offering thickened liquids and monitoring hydration states are key points in the management of stroke patients with severe dysphagia. However, if fluid intake remains insufficient, liquids have to be provided through an enteral or parenteral route. Nevertheless, some patients are unable to consume the expected amount of food; in this case, the opportunity to provide oral supplements should be evaluated. Finally, in addition to diet modification, correct body positioning, eating environment and qualified assistance are important measures for promoting satisfactory oral intake and reducing the aspiration risk. ARTIFICIAL NUTRITION In the case of intractable dysphagia or insufficient food intake on oral nutrition, artificial nutrition (AN) is recommended. The elective nutritional support is enteral nutrition (EN), since the gastrointestinal tract is functioning. Currently, evidenced-based guidelines or clinical trials on optimal timing and administration route for EN are unavailable; and therefore, general indications can be accepted. The prevailing suggestion for stroke patients with severe dysphagia is not to delay EN beyond 5-7 days in well-nourished patients and to start within 24-72 h in malnourished patients to minimize the consequences of nutritional insuffi-

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ciency. The attainment of caloric requirements within 3-4 days is a realistic objective. In stroke patients, the aspiration risk is substantial. Therefore, the presence of gastroesophageal reflux should be investigated carefully, EN should be administrated with the trunk inclined at 30 degrees, and gastric stagnation should be routinely investigated. However, appropriate infusion rates, proper feeding tubes and gradual induction programs reduce gastrointestinal complications and the aspiration risk. In the presence of gastroesophageal reflux, EN administration should be done by positioning the tube in the jejunum. In patients with persistent dysphagia 15 days after stroke and if the expected EN duration is >2 months, a percutaneous endoscopic gastrostomy (PEG) should be considered, since it has been shown to be effective and safe. If the aspiration risk is high, a percutaneous endoscopic jejunostomy (PEJ) is indicated. If necessary, the indication for a home enteral nutrition (HEN) program should be evaluated. The HEN plan should be activated in accordance with the ADISINPE guidelines, to guarantee the proper technical and specialized support for the patient and his family. DIETARY ADVICE AT DISCHARGE At discharge, medical staff should provide stroke patients with customized dietary plans, formulated based on nutritional status, associated pathologies, swallowing abilities, and the capacity to shop and to cook. Family caregivers should receive information on the nutritional value of foods and the possible use of oral supplements. They should also be encouraged to supply patients with thickened liquids, if necessary. In the case of dysphagia, family caregivers should be trained to manipulate foods, to use thickeners, to improve the eating environment and mealtime positioning, etc. If HEN is provided, family caregivers should be trained adequately and made aware of the most common complications of this nutritional therapy. Recommendations In stroke patients with normal swallowing ability oral nutrition should be given. If energy intake remains inadequate, oral supplementation should be provided (Grade D). In the case of undernutrition, the use of an oral diet associated with oral nutritional supplementation can be effective in improving nutritional status (Grade D). For dysphagic stroke patients dietary planning in-

cluding progressive diet levels, tailored to the different degrees of inability, must be prepared and made available. Foods and beverages are to be selected or modified for texture, density, cohesiveness, viscosity and temperature (Grade D). The most adequate dysphagia diet is chosen taking into account the patients ability to swallow and tolerance to different dishes, and should be individualized and offered in a proper manner (Grade D). It is mandatory to identify the type of liquid that is safe for each dysphagic patient to drink. Commercial thickening agents are useful for increasing liquid supply (Grade D). Enhanced menus and satisfactory food preparation techniques are essential to ensure a diet adequate for energy and nutrients (Grade D) EN should be started within 5-7 days after stroke in well-nourished patients with severe dysphagia, and within 24-72 h in malnourished patients (Grade D). PEG will be considered if EN duration is expected to be >2 months (Grade C). The hospital and rehabilitation service menu must be adapted to provide suitable choices for patients requiring modification of food consistencies (Grade D). Stroke patients and their family caregivers should be trained in correct feeding management; in particular with respect to appropriate mealtime positioning (postural techniques), food preparation and feeding techniques (Grade D). RIASSUNTO Il lavoro riporta le indicazioni evidence-based di un Panel di esperti, coordinato dallIRCCS Fondazione S. Lucia, Roma, in merito alla relazione tra dieta, alimentazione ed ictus. Le raccomandazioni proposte sono divise in tre principali sezioni: valutazione dello stato nutrizionale, stima dei fabbisogni e gestione del supporto nutrizionale e sono proposte per il paziente affetto da ictus nella fase acuta e durante il percorso riabilitativo. Le raccomandazioni indicate potranno essere utili a tutte le figure professionali implicate nella gestione del paziente affetto da ictus.
Address for correspondence: Giuseppe Rotilio, MD Center of Research on Nutrition and Rehabilitation (Ce SAR) IRCCS Fondazione S. Lucia Via Ardeatina, 306 00179 Roma, Italy

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MAIN REFERENCES
1. ADI-SINPE. Linee guida per laccreditamento dei centri di nutrizione artificiale domiciliare. RINPE 2000; 18: 173-82. 2. ASPEN. Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 2002; 26: 9SA. 3. Council of Europe. Food and nutritional care in hospitals: how to prevent undernutrition. Report and Recommendations of the Committee of Experts on Nutrition, Food Safety and Consumer Protection. Strasbourg: Council of Europe, 2002. 4. Malnutrition Advisory Group. Malnutrition universal screening tool - MUST. BAPEN, 2003. www.bapen.org.uk. 5. Scottish Intercollegiate Guidelines Network. Management of patients with stroke: identification and management of dysphagia. Edinburgh: Scottish Intercollegiate

Guidelines Network (SIGN), 2004. www.sign.ac.uk. 6. SINPE. Linee Guida SINPE per la nutrizione artificiale ospedaliera 2002. RINPE 2002; 20 (suppl 2): S1-173. 7. Societ Italiana di Nutrizione Umana - SINU. Livelli di Assunzione Raccomandati di Energia e Nutrienti per la Popolazione Italiana - LARN. Roma: SINU, 1996. www.sinu.it. 8. SPREAD - Stroke prevention and educational awareness diffusion (2003), Ictus cerebrale. Linee guida italiane di prevenzione e trattamento. Milano: Catel-Hyperphar Group, 2003: 1-498. www.spread.it. 9. The National Dysphagia Diet Task Force. The National Dysphagia Diet: standardization for optimal care. Chicago: American Dietetic Association, 2003. Ricevuto il 30/9/2004 Accettato dopo Revisione il 15/11/2004

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