Malnutrition in stroke

Poor nutritional status (malnutrition) in stroke patients refers to deficiencies or imbalances in energy and/or nutrient intake during the period following stroke. Impaired nutritional status occurs frequently across stroke recovery journey with a new systematic review showing that >30% stroke patients in acute and >50% in recovery phase have poor nutritional status1.

Malnutrition is strongly associated with worsened outcomes after stroke2 and malnourished stroke patients have higher rates of pressure injuries, UTIs, chest infections and GI bleeds. Impaired feeding in stroke patients is also associated with sarcopenia3. Furthermore, malnutrition is an independent risk factor for poor functional prognosis4. In addition, poor nutritional status may contribute to increased healthcare costs due to treatment of complications, extended length of stay and readmissions5. Moreover, a poor nutritional status after stroke almost doubles the risk of mortality6. Yet despite the high prevalence, negative clinical impact and increased healthcare costs related to malnutrition after stroke, the situation often goes under-recognized and undertreated healthcare costs related to malnutrition after stroke, the situation often goes under-recognized and undertreated1,7.

Holdaway et al.: Nutrition across the stroke continuum of care

Hyper-acute
(0 - 24hr)
Acute
(1 - 7 days)
Early Subacute
(7 days - 3 months)
Late Subacute
(3 - 6 months)
Chronic
(>6 months)
Dysphagia
Malnutrition
  • Screen within 2 hrs of admission to stroke unit using clinical bedside approach
  • If problems with swallowing identified, undertake specialist assessment within 24 hrs and no later than 72 hrs
  • Use clinical assessment tools to determine nutritional requirements and method of delivery of nutrition
  • If risk of aspiration or severe dysphagia, initiate tube feeding
  • If oral feeding is appropriate, consider the need for a texture-modified diet (thickened fluids and pre-thickened oral nutritional supplements)
  • Monitor throughout recovery
  • Regardless of presence of dysphagia, screen within 48 hrs of admission and weekly beyond acute phase
  • Re-screen and monitor nutritional intake throughout recovery particularly as a patient transfers from one setting to another
  • Adjust nutrition care plan to transition from one method of feeding to another (e.g. tube to oral)
Malnutrition
  • Regardless of presence of dysphagia, screen within 48 hrs of admission and weekly beyond acute phase
  • Re-screen and monitor nutritional intake throughout recovery particularly as a patient transfers from one setting to another
  • Adjust nutrition care plan to transition from one method of feeding to another (e.g. tube to oral)
Sarcopenia
Pressure Injuries
  • Evaluate muscle strength, muscle mass and physical performance using tools appropriate for stroke individual
  • Consider nutrition intervention with adequate high-quality protein together with (if possible) physical rehabilitation programme
  • When one-sided weakness present, encourage strength training generally and specifically for unaffected side
  • Utilise preventative techniques
  • Screen and assess for risk and presence, and take appropriate action
  • Optimize protein, calorie and micronutrient intake for optimal healing when pressure injuries are present
  • Monitor throughout recovery

Fig.1: Guide to nutrition management along the stroke continuum of care.

What are the risk factors for malnutrition?

Identifying the risk factors for malnutrition is of utmost importance to better guide intervention and prevention strategies. A meta-analysis identified several risk factors for malnutrition during hospital stay among stroke patients: malnutrition on hospital admission, dysphagia, previous stroke, diabetes mellitus, tube feeding and reduced level of consciousness8. Other risk factors for malnutrition in older adults include age, excessive polypharmacy, general health decline (including physical function), dementia, cognitive impairment and poor appetite9.

What can be done to improve the situation?

Studies have shown that only 10% of stroke patients consume ≥100% of energy requirements within 2 weeks after hospital admission, and a further 33% have energy intakes <50% of energy requirements before discharge (10). To help address this, ESPEN recommends that all stroke patients should be screened for risk of malnutrition on admission to hospital (within 48 h). Examples of malnutrition screening tools are the Malnutrition Universal Screening Tool (MUST) and Nutritional Risk Screening (NRS 2002).

These tools can help ensure appropriate nutritional interventions may be implemented to avoid malnutrition and help support recovery.

Partnering with a dietitian as part of the stroke care team is important to facilitate timely, personalized initiation of medical nutrition solutions to help manage the impact of malnutrition and optimize stroke recovery.

What does Nutricia offer?

Nutricia offers a wide selection of specialized medical nutrition products that can help support nutritional challenges faced by stroke patients during their recovery journey, including an extensive range of tube feeding solutions and oral nutritional supplements

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Stroke & Dysphagia portfolio

There are nutritional challenges adults may experience which can be managed with medical nutrition (for use under healthcare professional supervision only). The Nutricia products shown from this point onwards are foods for special medical purposes and intended for the nutritional management of disease-related malnutrition and related medical conditions.

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Research into Stroke & Dysphagia

Our research and development in this field is aimed towards finding ever-more innovative nutritional solutions that aid recovery and improve the quality of life of stroke patients.

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  1. Huppertz V, et al. Frontiers in Neurology 2022; 12; 780080. 2 Dennis M, et al. Health Techn Assessmentt 2006; 10
  2. Sabbouh T, Torbey MT. Malnutrition in Stroke Patients: Risk Factors, Assessment, and Management. Neurocrit Care. 2018 Dec;29(3):374-384. doi: 10.1007/s12028-017-0436-1. PMID: 28799021; PMCID: PMC5809242.
  3. Li W, Yue T, Liu Y. New understanding of the pathogenesis and treatment of stroke-related sarcopenia. Biomed Pharmacother. 2020 Nov;131:110721. doi: 10.1016/j.biopha.2020.110721. Epub 2020 Sep 10. PMID: 32920517.
  4. Qin H, Wang A, Zuo Y, Zhang Y, Yang B, Wei N, Zhang J. Malnutrition could Predict 3-month Functional Prognosis in Mild Stroke Patients: Findings from a Nationwide Stroke Registry. Curr Neurovasc Res. 2021;18(5):489-496. doi: 10.2174/1567202619666211217130221. PMID: 34923942; PMCID: PMC8972270.
  5. Lim SL, Ong KC, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr. 2012 Jun;31(3):345-50. doi: 10.1016/j.clnu.2011.11.001. Epub 2011 Nov 26. PMID: 22122869.
  6. FOOD Trial Collaboration. Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial. Stroke. 2003 Jun;34(6):1450-6. doi: 10.1161/01.STR.0000074037.49197.8C. Epub 2003 May 15. PMID: 12750536
  7. Lamb, C., Parr, J., Lamb, E., & Warren, M. (2009). Adult malnutrition screening, prevalence and management in a United Kingdom hospital: Cross-sectional study. British Journal of Nutrition, 102(4), 571-575. doi:10.1017/S0007114509236038
  8. Chen N, Li Y, Fang J, Lu Q, He L. Risk factors for malnutrition in stroke patients: A meta-analysis. Clin Nutr. 2019 Feb;38(1):127-135. doi: 10.1016/j.clnu.2017.12.014. Epub 2017 Dec 28. PMID: 29310894.
  9. Fávaro-Moreira NC, Krausch-Hofmann S, Matthys C, Vereecken C, Vanhauwaert E, Declercq A, Bekkering GE, Duyck J. Risk Factors for Malnutrition in Older Adults: A Systematic Review of the Literature Based on Longitudinal Data. Adv Nutr. 2016 May 16;7(3):507-22. doi: 10.3945/an.115.011254. PMID: 27184278; PMCID: PMC4863272.
  10.  Nip WF, Perry L, McLaren S, Mackenzie A. Dietary intake, nutritional status and rehabilitation outcomes of stroke patients in hospital. J Hum Nutr Diet. 2011 Oct;24(5):460-9. doi: 10.1111/j.1365-277X.2011.01173.x. Epub 2011 May 24. PMID: 21605199.

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