dietitian online

Here’s a link to an article that connects two of my favourite blogging topics that I usually write about separately: nutrition for stroke prevention and local eating. 

Eat locally, eat healthfully

Earlier today I provided some last-minute nutrition counseling to a stroke patient and wife as “they were heading out the door.”  OK, I admit for effect I’m exaggerating the time pressure, but this morning I really did get one of those typical phone calls from the nursing unit: “Mr. X is being discharged today and he and his wife want to talk to a dietitian before he goes home.” I immediately thought, “This is the perfect opportunity to test some of the education checklists and resources we are developing and compiling for our stroke program.” So, rather than use our department’s heart-health focused materials that, although very good, may not be completely up-to-date and also are not targeted to stroke patients, I decided to put together a customized nutrition and secondary stroke prevention resource package. (more…)

Since taking DC’s evidence-based decision-making course, I have become very selective about my background reading and if I do have some time to scan journals, articles and summaries, I focus on the areas where I practice — e.g, brain injury, stroke, dysphagia. One gem of a newsletter I regularly read is Heart Headlines.  (I always mentally insert “& Stroke” after heart because nutrition advice for health of the organ in our chest also applies to the one in our head.)

The Summer 2007 issue, which I received in the mail today but is also available online, features an interesting review article on how and why dietary fat guidelines evolved to the statements in the 2007 Food Guide.

Although this review was originally published in 1999, it was reprinted this year.  Because it includes a thorough, critical appraisal of many of the stroke references in my library, I’ve uploaded the document to my blog.

Interventions for dysphagia in acute stroke (Cochrane Review 1999)

Earlier I posted a brief description of and links to the FOOD Trials, a series of three large, multi-centre, randomized controlled studies that attempted to answer questions about feeding stroke patients.

Here, in the researchers own words, are how the trial results can be applied to practice:

Study 1: Can oral supplementation improve stroke outcome?

On the basis of our results and our surveys of UK practice, it seems likely that patients who are judged to be undernourished on admission or who have deteriorating nutritional status in hospital will be offered oral nutritional supplements…..However, our data do not support use of routine supplementation of hospital diet for unselected stroke patients who are mainly well nourished on admission (The Lancet, Vol 365 February 26, 2005 p. 762).

Studies 2 & 3: Do timing and/or route of enteral feeding affect stroke outcome at 6 months?

Our data would suggest that to reduce case fatality, unless there is a strong indication to delay enteral tube feeding (such indications would have excluded such patients from the FOOD trial), dysphagic stroke patients should be offered enteral tube feeding via a nasogastric tube within the first few days of admission. Also, for enteral feeding within the first 2 or 3 weeks, nasogastric feeding should be the chosen route unless there is a strong practical reason to choose PEG feeding (eg, the patient cannot tolerate a nasogastric tube) (The Lancet, Vol 365 February 26, 2005 p. 771).

The authors also state:

Early tube feeding might reduce case fatality, but at the expense of increasing the proportion surviving with poor outcome. Our data do not support a policy of early initiation of PEG feeding in dysphagic stroke patients (The Lancet, Vol 365 February 26, 2005 p. 764).

Because June is Stroke Month, I’m going to end this last week of June with several posts on stroke research that provides evidence for best nutrition practice.

Today I’m highlighting the FOOD trials that tried to answer the why, when and how of feeding stroke pts. The questions were:

1. In patients who can take adequate oral fluids, does routine oral nutrition supplementation increase the proportion of stroke patients surviving without disability?
2. In patients who are unable to take an adequate diet orally, does early initiation of tube feeding (NG or PEG) increase the proportion of stroke patients surviving without severe disability?
3. In patients who need tube feeding, is a PEG tube, instead of the traditional NG tube, associated with improved outcomes after stroke?

The study results, along with a helpful commentary, were published in the 26 February 2005 issue of the Lancet. Here are the web links to the articles (note: subscription needed to read them):

Donnan GA, Dewey HM. Stroke and nutrition: FOOD for thought. The Lancet, Volume 365, Number 9461, pages 729-730.

Routine oral nutritional supplementation for stroke patients in hospital (FOOD): a multicentre randomised controlled trial. The FOOD Trial Collaboration. The Lancet, Volume 365, Number 9461, pages 755-763.

Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. The FOOD Trial Collaboration. The Lancet, Volume 365, Number 9461, pages 764-772.

If you or your workplace do not have a Lancet subscription, you can still read summaries of the articles for free, although you do have to register. I did this, but to be honest, I didn’t find the summaries had enough information to be useful.

I had wanted to to upload the full articles to my blog but I can’t because of copyright restrictions. If you can’t access the articles easily, please email me and I will email you copies for your personal use. (The copyright policy permits this.)

My email address is on the About me page.

Depending on where you work or go to school, you may have free access to the full Cochrane Library. Here’s the web link to this protocol: Nursing interventions for improving nutritional status of stroke patients.

I realize some readers may not have free access so I’ve uploaded the Introduction on my blog. I hope it will give you enough information to decide whether you’d like to read the entire report.

Links:
Introduction to protocol
Nursing interventions for improving nutritional status of stroke patients

Today I received in my email the latest Canadian Health Network’s Healthlink newsletter in which Stroke Awareness Month is highlighted. (Note: This is a worthwhile newsletter to include in your subscriptions.)

Here is the link to all the Stroke Awareness Month features (scroll down past the middle of the page to find them).

I learned both these facts when visiting the Heart and Stroke Foundation’s Web site this morning.

Here are links to the Web site’s new articles:

• Time is Brain – lists 10 simple steps to protect your brain; step 5 is “cut the fat and salt”
• Eating Well with Canada’s New Food Guide – Alyssa Rolnick, RD “point[s] our appetites in the right direction” by suggesting simple, achievable tips on wise food choices, incoporating them in appealing recipes, and then directing us to food guide tools. Well done!

Today at a Stroke Care Improvement meeting I shared some of the stroke resources I’ve been gathering during the past two months. Now would be a good time to take stock and collect all the previously published links in one post. The list is a work-in-progress and will grow.

Although the resources are not nutrition-specific, they all contain some nutrition elements such as diet modifications to reduce stroke risk factors (primary and secondary prevention) or manage deficits (e.g, dysphagia) during acute stroke treatment and rehabilitation.

THE LIST:

Practices and Standards Working Group, The Canadian Stroke Strategy. Canadian Best Practice Recommendations for Stroke Care: 2006.
Best Practices and Standards Working Group, The Canadian Stroke Strategy. Best Practices and Standards Environmental Scan Report.

Heart and Stroke Foundation home page.

Heart and Stroke Foundation of Ontario, Ontario Stroke System. Best Practice Guidelines.

National Stroke Foundation, Australia. National Clinical Guidelines for Acute Stroke Management.

National Stroke Foundation, Australia. National Clinical Guidelines for Stroke Rehabilitation and Recovery.

National Stroke Foundation, Australia. Stroke Care Pathway: A Resource for Health Professionals.

Scottish Intercollegiate Guidelines Network. Management of patients with stroke: Identification and management of dysphagia. September 2004.

Scottish Intercollegiate Guidelines Network. Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning. November 2002.

Teasell R, Foley N. Evidence-based review of stroke rehabilitation: Managing the stroke rehabilitation triage process.