Invited Review Nutrition in Clinical Practice

Volume 26 Number 3
June 2011 242-252

Nutrition in the Stroke Patient © 2011 American Society for

Parenteral and Enteral Nutrition
10.1177/0884533611405795
http://ncp.sagepub.com
Mandy L. Corrigan, MPH, RD, LD, CNSC; hosted at
http://online.sagepub.com
Arlene A. Escuro, MS, RD, LD, CNSC;
Jackie Celestin, MD; and
Donald F. Kirby, MD, FACP, FACN, FACG, AGAF, CNSP, CPNS
Financial disclosure: none declared.

Malnutrition is common both before and after stroke, with evaluation and treatment of dysphagia, use of specialized nutri-
dysphagia adding to nutrition risk. Many patients require special- tion support, strategies for weaning enteral tube feedings, and the
ized nutrition support in the acute phase and beyond when impact of nutrition on quality of life in the stroke patient popula-
swallowing function does not improve or return to allow tion. (Nutr Clin Pract. 2011;26:242-252)
for nutrition autonomy. When neurologic deficits improve, assess-
ment of the swallowing function, introduction of dysphagia diets,
and specialized swallowing techniques are used to transition away Keywords:   stroke; enteral nutrition; deglutition disorders;
from enteral feeding tubes to oral diets. This article reviews the malnutrition

T
here has been a long-standing association between necessitate enteral nutrition (EN) support interventions.
chronic diseases and poor-quality nutrition intake. The extent of neurological damage and recovery will affect
In the United States, stroke is the third highest nutrition requirements and the nutrition care plan.
cause of mortality, exceeded only by heart disease and
cancer, with nearly 795,000 cases of stroke occurring
annually.1 Many of the risk factors for stroke have nutri- Malnutrition
tionally modifiable behaviors. Risk factors for a stroke
include diabetes, hypercholesterolemia, hypertension, The prevalence of malnutrition after stroke varies widely
cigarette smoking, alcoholism, atrial fibrillation, older among published reports.6,9,10 Foley and colleagues11
age, and family history of stroke. The general population, reviewed studies in which the nutrition status of patients
especially individuals with risk factors for stroke, should was assessed after hospital admission for stroke to (1)
be knowledgeable of the signs of stroke including aphasia, describe the form of nutrition assessment that was used;
loss of balance and coordination, numbness, paresthe- (2) identify the percentage of subjects who were malnour-
sias, weakness, headache, visual disturbance, and confu- ished; and (3) establish whether a valid form of nutrition
sion that presents suddenly; these symptoms warrant assessment was used. Eighteen studies met the inclusion
immediate medical attention. criteria, and the reported frequency of malnutrition
During the acute and rehabilitation phases of stroke, ranged from 6.1% to 62%.11 Although factors such as the
nutrition interventions are a part of the interdisciplinary timing of assessment and differences in patient character-
approach to the care and treatment of these patients. Brain istics among studies may have contributed to the inherent
injury resulting from stroke has metabolic consequences, or expected variability, the authors suggested that a
and the presence of preexisting malnutrition and malnutri- greater portion of the variation in the estimates of malnu-
tion after stroke contributes to clinical outcomes.2-8 trition can be attributed in the differences in nutrition
Dysphagia is a common manifestation of stroke and can assessment methods.
Protein-energy malnutrition, defined in this study3 as
an abnormal finding in 1 of 3 nutrition-sensitive param-
From Cleveland Clinic, Center for Human Nutrition, Cleveland, eters (serum albumin level, triceps skinfold, or midarm
Ohio. muscle circumference), was observed in 16.3% of 104
patients following acute stroke.3 This increased to 26.4%
Address correspondence to: Mandy L. Corrigan, Cleveland
Clinic, Nutrition Support Team, Center for Human Nutrition, by day 7 in the surviving patients and 35% by day 14 in
9500 Euclid Avenue/TT2, Cleveland, OH 44195; e-mail: those who remained hospitalized. Notably, triceps skin-
corrigm5@ccf.org. fold, an estimator of the fat compartment, significantly

242
 Nutrition in the Stroke Patient / Corrigan et al   243

decreased between admission and day 7. Inherent flaws were higher for patients receiving enteral tube feedings
with triceps skinfold measurement technique include compared with patients on a regular or dysphagia diet.
overall insensitivity and intraobserver variability. The Similarly, protein intakes of patients receiving enteral tube
authors note that because this technique is fraught with feedings were greater than those on a regular diet.
problems, it is unclear whether the results were related to Many studies have examined the relationship between
losses in fat over the short time frame of 1 week. malnutrition and dysphagia during the acute poststroke
Preexisting malnutrition is a common finding upon period. These conditions frequently coexist and are asso-
admission to the hospital in many disease states. ciated with poor outcomes following stroke.17 Foley et al11
Prevalence of preexisting malnutrition in stroke patients reviewed 8 studies with the aim of clarifying the relation-
is currently unknown. Malnutrition is commonly observed ship between nutrition status and dysphagia in both the
both before and after a stroke occurs.12 In a small study acute and rehabilitation stages following stroke. The pres-
of 32 consecutive admissions of geriatric patients with ence of malnutrition and dysphagia ranged from 8.2% to
severe stroke, Axelsson and colleagues13 found that 56.3% 49% and 24.3% to 52.6%, respectively. Five of the
were malnourished at some point during a hospital stay included trials were conducted within the first 7 days fol-
of >3 weeks.13 Indicators to determine malnutrition in lowing stroke, whereas 3 were conducted during the
this study included serum levels of albumin, prealbumin, rehabilitation phase. The overall odds of being malnour-
and transferrin; <80% usual body weight; triceps skinfold ished were higher among subjects who were dysphagic
thickness; and arm muscle circumference.13 compared with subjects with intact swallowing. In the
In a longitudinal study of 49 stroke patients, preva- rehabilitation phase of stroke, the odds of being malnour-
lence of malnutrition was assessed during patients’ stay in ished were increased significantly, although it was impos-
rehabilitation and 2-4 months following discharge.9 For sible to ascertain whether clinical care practices, or lack
the diagnosis of malnutrition, at least 2 nutrition- thereof, contributed to its development.11 Among the dys-
sensitive parameters (serum albumin level, total lym- phagic patients who were identified as malnourished, the
phocyte count, body weight, body mass index, sum of 4 most likely explanation was a prolonged period of inade-
skinfolds, midarm muscle circumference) were required quate dietary intake during inpatient hospitalization.11
to be below the normal range. The incidence of malnutri- Establishing a patient’s true nutrition state is not
tion decreased from 49% on admission to 34% at 1 always a straightforward task because there is no univer-
month, 22% at 2 months, and 19% at 2-4 months after sally accepted definition of malnutrition or a gold stand-
discharge. Strong predictors of malnutrition upon admis- ard for nutrition assessment. A new “etiology-based
sion were the use of tube feedings and dysphagia. History construct for the diagnosis of adult malnutrition” is being
of stroke and diabetes mellitus increased the likelihood of proposed and, once available and validated, will incorpo-
malnutrition on admission by 71% and 58%, respectively. rate the impact of inflammatory response on nutrition
Malnutrition was not associated with gender, location, status.18 Malnutrition is an important preventable com-
type of stroke (hemorrhage vs infarct), paresis of domi- plication. It is used to describe a host of nutrition abnor-
nant arm, socioeconomic status, or level of education. At malities, although typically it refers to protein-energy
1 month following the rehabilitation admission, malnutri- malnutrition resulting from a long period of negative
tion was associated with age >70 years and at follow-up imbalance of both energy and protein whereby metabolic
was associated with recent weight loss and lack of com- requirements chronically exceed actual nutrition intake.11
munity nursing or home nursing care. Routine interven- The presence of malnutrition in stroke patients
tions such as calorie counts, regular weighing, staff was significantly related to increased length of stay and
attention to dysphagia, dysphagia diets, and tube feeding decreased functional improvement during rehabilitation.19
appeared to contribute to overall decrease in prevalence Early identification and treatment of malnutrition can
and degree of malnutrition in these patients.14 affect the patient’s ability to take part in rehabilitation,
Cognitive deficits such as visual neglect (loss of visual functional activities, and complete activities of daily living.
field on the same side as the stroke occurred), upper Routine delivery of oral supplements in well-nourished
extremity paresis, voluntary reduced food intake associated stroke patients without dysphasia was investigated as part
with depression, and apraxia affect stroke patients’ ability of the Feed or Ordinary Diet (FOOD) trial to determine
to self-feed, thus increasing the risk for protein and energy whether outcomes improved with oral supplements.
malnutrition.15 Foley and colleagues16 examined the pro- Patients were randomized to oral diet alone or oral diet
tein and energy intake of patients with acute stroke who plus oral nutrition supplements. The trial found no data
received regular diets, dysphagia diets, or enteral feedings to support routine use of oral nutrition supplements in
at 5 times within the first 3 weeks of admission. There was well-nourished patients.20 The trial was criticized for only
no difference in either the energy or protein intake of assessing nutrition status at 1 initial point during the
patients receiving a regular diet compared with those study, not using standardized nutrition assessment across
receiving a dysphagia diet at any point.16 Energy intakes the 125 sites involved in data collection, and not record-
244   Nutrition in Clinical Practice / Vol. 26, No. 3, June 2011

ing nutrition content of the oral diets or compliance with Poststroke weight status and body composition can
supplements. It should be considered that malnourished change, and weekly weights during rehabilitation should
patients might have been better suited for investigation in be followed closely. The goal of weight loss or weight
this trial and in actual need of nutrition support com- maintenance is important to consider with use of nutri-
pared with the actual group of well-nourished patients tion support and oral diets in this population. When limi-
studied. tations in mobility or paralysis are present, caloric
requirements will be decreased because of decreased
activity. Mobility limitations can also predispose patients
Assessment of Nutrition Requirements to skin breakdown and development of pressure ulcers.
Routine skin assessment is required and the provision of
Hypermetabolism is well-documented in traumatic brain adequate protein is prudent.
injury but not well-defined in the stroke patient popula-
tion. Infection, age, severity of stroke, comorbidities,
medication, ventilator status, mobility, activity levels, and Biochemical Markers
weight status can alter caloric requirements, necessitat-
ing frequent reassessment by nutrition clinicians. Early Hepatic proteins such as albumin, prealbumin, and trans-
medical treatments in the acute care setting such as the ferrin are commonly used as markers to evaluate nutrition
use of barbiturates or induced hypothermia as a method status. Older studies, including those done in the stroke
to decrease intracranial pressure (ICP) also decrease population, commonly placed a strong emphasis on equat-
caloric requirements.21,22 After neurological insult, meta- ing low albumin levels to malnutrition without account-
bolic demands are altered with elevation of peripheral ing for the role of the inflammatory cascade after injury.
plasma catecholamines, cortisol, glucagon, interleukin-6, Hepatic proteins are influenced by many non–nutrition
interleukin-1RA, and acute phase proteins.23 factors, change rapidly in times of stress, and in turn do
Indirect calorimetry is the gold standard for deter- not accurately reflect nutrition status. Mediators of
mining caloric requirements; however, it is not routinely inflammation have the largest effect on serum protein
available for use. No single formula to calculate nutrition levels and contribute to an increase in net protein loss
requirements has been validated with a large sample from catabolism.27 Albumin, prealbumin, and transferrin
size in the stroke population. The presence of obesity are all negative acute phase proteins and therefore
can further complicate calculation of nutrition require- decrease in the presence of inflammation regardless of
ments in stroke patients when indirect calorimetry is not premorbid nutrition status.
available. A serum albumin level can be a fair marker of nutri-
Finestone and colleagues23 used indirect calorimetry tion status in the absence of inflammation and infection.
on poststroke days 7, 11, 14, 21, and 90 to study energy Given its long half-life, it may only be ideal for long-term
demands over time after stroke. Resting energy expendi- care or rehabilitation settings. Prealbumin and transferrin
ture (REE) was shown to be approximately 10% higher have much shorter half-lives and are more appropriately
than predicted by the Harris-Benedict equation, but monitored in the acute care setting along with C-reactive
energy needs did not differ by type of stroke, and changes protein levels for a decrease of inflammation. To date, no
in REEs were not statistically significant over time.23 studies have validated the use of serum levels of prealbu-
These results confirm findings from a smaller study that min and C-reactive protein together to assess response to
measured REE 24-72 hours following stroke and again the nutrition prescription. However, this is commonly
10-14 days after stroke.24 The authors suggested that used in clinical practice based on the understanding of
energy requirements were not elevated because of inflammation and reprioritization of hepatic protein syn-
decreased physical activity and changes in muscle tone thesis. Trending hepatic protein levels over time are con-
because of the neurological injury.24 Protein needs should sidered to be of more clinical significance than a single
be individualized, but 1-1.5 g/kg is recommended.25 measurement.
Obtaining a detailed nutrition history including
intake and recent weight history is an important part of
nutrition assessment. Cognitive function can limit the Specialized Nutrition Support
patient from providing an accurate history, and nutrition
professionals may need to seek this information from The decision on how to feed a stroke patient should be
family members. A nutrition-focused physical exam will made shortly after hospital admission and will be partially
identify edema, muscle wasting, and signs of nutrient dictated by the patient’s presenting condition and medical/
deficiencies and assist in assessment of nutrition status. surgical history. If the gut is functional and there are no
Dysphagia, depression, and loss of appetite can con- other contraindications, enteral feeding would be the pre-
tribute to poor nutrition status and dehydration.26 ferred method in this population.28 See the enteral stroke
 Nutrition in the Stroke Patient / Corrigan et al   245

Stroke patient
admitted, not
Stroke patient is intubated, has Stroke patient is admitted,
admitted to the decreased level of consciousness
ICU, intubated consciousness improving / intact

Nutrition Assessment by Registered Dietitian

Anticipated to Able to follow

require enteral commands to participate
nutrition for 5 or in Modified Barium
more days? No Swallow?
No

NPO, consider
Yes enteral feeds if
Yes NPO > 5-7 days
Place enteral
feeding tube &
begin enteral
feeds within 24- Modified barium
48 hours swallow exam, diet
and liquid
consistency per
speech language
pathologist, follow
Extubation, adequacy of oral
following diet & need for oral
commands nutritional
supplements

Modified barium
swallow exam, diet
consistency per speech
language pathologist,
wean enteral feeds
pending assessment of
oral diet adequacy

Figure 1.   Enteral stroke feeding algorithm.

feeding algorithm in Figure 1. In addition, a patient who Enteral access is usually best guided by considering
is comatose from a devastatingly massive stroke and is in whether it will be required short-term or long-term.
an intensive care unit (ICU) will have a different nutrition However, it is often difficult to estimate how long neuro-
care plan than a patient with mild dysarthria. Patients who logical patients will require access.29 The extent and
are in the ICU can have elevated ICP, which can delay severity of the stroke as well as the need for an ICU stay
gastric emptying. Thus, initial attempts to feed via a naso- play a role in the decision making. Clinical studies have
gastric tube may not be successful and postpyloric feeding predicted various durations of tube feeding for patients
should be considered. As the ICP improves, patients often after stroke, but a conservative estimate is that a large
tolerate gastric feeding. An attempt to feed patients gastri- percentage of patients with feeding tube placement in the
cally should be trialed initially, unless a particular ICU has acute period after stroke will return to oral feeding within
a specific enteral feeding protocol to address feeding in 3 months of stroke onset.30
these critically ill patients. Thus, for the majority of stroke Nasoenteric feeding is often used, and nasogastric tubes
patients, EN should be possible. However, if there is a have the added advantage of allowing for measurement of
contraindication to enteral feeding, then parenteral nutri- gastric residuals and are less likely to become clogged.
tion (PN) can be provided. However, these tubes are often less comfortable than a
246   Nutrition in Clinical Practice / Vol. 26, No. 3, June 2011

Table 1.   Common Medications and Medication Additive for Stroke Patients
Medication/Medication Additive Nutrition Impact Suggested Modifications
Propofol Provides 1.1 kcal/mL as fat Adjust nutrition regimen to decrease excess fat
and avoid overfeeding.
Phenytoin Decreased medication absorption when Separate medication delivery and enteral nutrition
given with continuous enteral tube (refer to hospital-specific policy). Monitor for
feeding (no effect with intravenous folate and vitamin D depletion with long term
form) use.
Sorbitol (additive to liquid Potential for diarrhea from hyperosmolar Sorbitol is commonly used in liquid medications.
medications) solution Avoid liquid form of medication when possible
(consult with pharmacist on ability to crush
tablets and dissolve carefully to avoid clogging
feeding tubes).
Narcotic agents Potential for constipation Stool softener/laxative may be required.
Barbiturates Decreases caloric requirements Stool softener/laxative may be required.
Adjust nutrition support regimen to prevent
overfeeding.

smaller tube intended for enteral feeding. Feeding tube stroke patient population. Elemental or semi-elemental
sizes 8-Fr, 10-Fr, or 12-Fr are most commonly used in formulas are rarely needed. Fiber-containing formula-
adults, and the smallest size tube that fulfils the needs of tions can be used in the rehabilitation setting and in
the patient should be the goal. This type of access is best patients requiring long-term enteral feedings. Fiber is
used when it is believed that the need for tube feeding is generally avoided in the acute setting when pressors and
likely to be <30 days.31 paralytic agents are being used. Medications commonly
The patient’s level of consciousness must be taken used in the stroke population and their nutrition implica-
into account, and the risk of tube feeding–related aspira- tions are listed in Table 1.
tion should be minimized by use of frequent clinical Use of PN in the stroke population is rare, but pro-
exams, monitoring of residual volumes, and elevation of longed inability to gain enteral access in the setting of
the head of the bed. Aspiration of oropharyngeal secre- inadequate nutrition intake can necessitate PN. Attempts
tions can lead to clinically significant pneumonia and to transition to EN should be made as soon as medically
thus becomes a significant source of morbidity and mor- appropriate. Hyperosmolar PN solutions do not have an
tality for these patients. effect on ICP.35 Use of small bowel feeding tubes can
Some patients may be confused and pull out the prevent inappropriate use of PN for gastric ileus or gas-
nasoenteric tubes. In these instances, use of a commer- troparesis.
cial retention system or nasal bridle has been associated PN is not without risk with use in any population.
with fewer displaced tubes.32-34 Catheter-related bloodstream infection, electrolyte imbal-
Another important determinant of the type of enteral ances, and hyperglycemia are the most common compli-
access required is the patient’s ability to swallow. cations of PN. If PN is used, the tip of the central venous
Evaluation of this function will help determine whether a catheter should be located in the lower third of the supe-
long-term feeding tube such as a gastrostomy or, less rior vena cava adjacent to the right atrium for prevention
often, a jejunostomy is required. Percutaneous gastrosto- of thrombosis.36 Every technique to avoid thrombosis can
mies usually have the advantage of bedside removal if benefit the stroke patient, because anticoagulation ther-
swallowing function later improves, depending on the apy can be contraindicated in certain patients after
type of internal bumper system that is used. Methods of stroke.
placement will often be dictated more by local expertise
than by other factors. Thus, many factors must be consid-
ered in determining the type of enteral access to feed Dysphagia
these patients.28
Enteral tube feeding formulas are generally well toler- Dysphagia refers to difficulty in swallowing as a result of
ated in this patient population. The selection of a 1-1.5 disruption in the swallowing process during transit of
kcal/mL, polymeric, high-protein enteral formula is appro- solids or liquids from the mouth to the stomach.
priate. Specialized enteral tube feeding formulations exist Depending on the site and extent of brain injury after
for various disease states but are not routinely used in the stroke, the muscles and nerves used in the swallowing
 Nutrition in the Stroke Patient / Corrigan et al   247

reflex may not be triggered or function properly, leading Various methods have been used to assess swallowing
to dysphagia. Preexisting malnutrition and dysphagia can function. A simple water swallow test can be done at the
increase nutrition risk following a stroke.12 Between 40% bedside but can miss up to 50% of patients with aspira-
and 60% of stroke patients present with dysphagia ini- tion.44 A modified barium swallow (videofluoroscopic)
tially.37,38 Just as the prevalence of malnutrition varies evaluation is considered the gold standard for assessment
after stroke, estimates of the prevalence of dysphagia vary of oropharyngeal dysphagia. This exam characterizes
attributable to differences in the definition of dysphagia, swallowing dysfunction, can detect some structural
the method of assessing the swallowing function, timing abnormalities although not as well as endoscopic evalua-
of swallowing assessment after stroke, and the number tion, and examines the short-term effects of swallowing
and type of stroke patients studied.12,39 Altered level of interventions.45 When dysphagia is suspected, and once
consciousness, physical weakness, or incoordination of patients are alert and able to participate in the test, a
swallowing function can limit the patient’s ability to swal- modified barium swallow should be ordered.46
low food and liquid. These changes in swallow mecha- Disadvantages of a modified barium swallow include
nism can threaten airway safety and limit the amount of radiation exposure, high cost, and the requirement for a
food and liquid ingested by mouth.38 A majority of high level of patient consciousness and cooperation to
patients with dysphagia typically recover the swallowing complete the test. At times, further evaluation can be use-
function within the first month of after stroke, but as ful, and flexible endoscopic evaluation of swallowing can
many as 40% of patients continue to experience dyspha- be considered. Nasal endoscopy (transnasal fiberoptic
gia 1 year after the initial neurological insult.40 pharyngoscopy/laryngoscopy) can be performed early for
Deglutition is a complex mechanism that propels evaluation of oropharyngeal dysphagia for visualization of
food through the pharynx and esophagus to prevent entry the vocal cords.44
into the airway, using skeletal muscle (tongue and mouth), Dysphagia treatment includes dietary manipulations
smooth muscles of the pharynx and esophagus, the auto- (altering consistency of food and beverages along with
nomic nervous system, and multiple cranial nerves (V, nutrition supplements), implementation of safe swallow-
VII, IX, X, XII).41 Transport of a bolus via the esophagus ing techniques, and enteral feedings. Dietary modifica-
is dependent on many factors, including force of peristal- tions are essential in treatment of patients with dysphagia.
tic contractions, deglutitive inhibition, normal relaxation As a patient’s swallowing ability improves (as evidenced
of both the upper and lower esophageal sphincters during by repeated modified barium swallow and/or speech–
swallowing, size of the bolus, and size of the lumen of the language pathologist assessment), the diet can be modi-
esophagus.41,42 fied or advanced.
Dysphagia can be divided into oropharyngeal and Postural strategies can be effective in eliminating
esophageal dysphagia, depending on the anatomic site aspiration in 75%-80% of patients.47 Postural changes
involved, and further subdivided into subtypes of mechan- involve using altered angles and/or gravitational forces to
ical or motor dysphagia. Mechanical dysphagia refers to allow safe passage of the bolus to reduce or eliminate
difficulty swallowing secondary to a large bolus or a nar- aspiration. The chin tuck, chin up, head rotation to the
row lumen. Motor dysphagia results from impaired deglu- affected side, and tilting of the head to the stronger side
titive inhibition or weakness of peristaltic contractions are examples of postural techniques.43
causing nonperistaltic contractions and impaired sphinc- A newly emerging area of research seeks to under-
ter relaxation. stand whether the central nervous system can adapt to
It is important to differentiate between the types of promote swallowing recovery. Pharyngeal electrical stim-
dysphagia for proper diagnosis and management. Motor ulation (PES) treatments use transnasally or transorally
dysfunction in the oropharyngeal region can result from a placed intraluminal electrodes to potentially assist in
variety of neurological, muscular, or systemic disorders. improving swallowing.40 Jayasekeran and colleagues40
Patients with oropharyngeal dysphagia can present with a completed a small study showing potential benefits to
wide variety of clinical symptoms, such as inability to patients suffering from dysphagia after stroke using PES
keep a bolus in the oral cavity, frequent throat clearing, treatments. The findings included improved swallowing
frequent repetitive swallowing, drooling, pocketing food behaviors, improved airway protection, decreased aspira-
in oral cavity, slow eating, hoarse voice, recurrent pneu- tion, and a decrease in hospital length of stay. More trials
monia, and swallow-related cough before, during, or after need to be completed to better understand the potential
swallowing.43 The evaluation of oropharyngeal dysphagia benefits and clinical applications of this therapy.
includes determining the physiological and structural Transcutaneous electrical stimulation (TES) devices
abnormalities responsible for the symptoms, identifying provide electrical stimulation on the anterior neck to
underlying disorders (neurological or muscular disorders) assist with hyolaryngeal elevation during swallowing.48
responsible for these findings, and assessing the safety of This elevation helps decrease the risk of solids or liquids
oral feeds. entering the airway. The clinical usefulness of TES is an
248   Nutrition in Clinical Practice / Vol. 26, No. 3, June 2011

area of uncertainty and debate. Many uncontrolled trials Table 2.   Liquid and Solid Food Consistencies for
using this therapy have had design flaws with possible Dysphagia Diets
confounding variables such as the potential for spontane- Solids Liquids
ous recovery of swallowing during the time frame of the
study, improvements from traditional dysphagia therapy, Dysphagia pureed Spoon-thick
differences in the severity of dysphagia, cause of dys- Dysphagia mechanically altered Nectar-thick
Dysphagia advanced Honey-thick
phagia, and the combined effect of TES with traditional
dysphagia therapy.48
Controlled trials with small sample sizes have com- The level 3 NDD (dysphagia advanced) is a transition
pared traditional dysphagia therapy alone to TES combined to a regular diet. This level includes foods of nearly regu-
with traditional dysphagia therapy but have had conflicting lar textures except for very hard, crunchy, or sticky foods.
results. Bulow et al49 completed a multicenter trial in stroke The foods still need to be moist and should be in bite-size
patients with dysphagia where the 2 study groups both pieces to allow for easier swallowing. At this level diet,
received traditional dysphagia therapy and the intervention patients should be assessed for ability to tolerate mixed
group additionally received TES. No statistically significant texture meals. The level 3 diet is most appropriate for
differences in therapy effects were noted between the patients with mild oropharyngeal dysphagia.51 After
groups. Ryu and colleagues50 studied TES therapy in patients demonstrate the ability to tolerate these foods
patients with head and neck cancer who were suffering safely, the diet can be advanced to a regular diet without
from dysphagia. Patients in the TES group also receiving restrictions.
traditional dysphagia therapy had improved function in Beverages may need to be thickened to the appropri-
comparison to the group only receiving traditional dys- ate consistency as recommended by the speech–language
phagia therapy.50 Differences in patient populations and the pathologist. Commercially available gel and powder thick-
underlying cause of dysphagia can prevent generalizing ening agents can be added to liquids to achieve the rec-
results to all patients with dysphagia. The use or benefits of ommended consistency. Commercially prepared thickened
neuromuscular stimulation are not clearly delineated, and liquids are also available and, with manufacturing stand-
further studies with this emerging technique are warranted. ards, can provide less variation in consistency compared
with gel or powder thickening agents. At times, patients
may have the diet advanced to a solid consistency but still
Specialized Diets for Dysphagia require altered liquid consistencies.52
Patients with dysphagia may have a reduced fluid
Nutrition therapies for dysphagia have been standardized intake because of increased age, physical disability, cogni-
by the American Dietetic Association through the National tive impairment, and low acceptance of thickened liq-
Dysphagia Diet Task Force. Dietitians, speech–language uids.12 Initially, patients may have reduced thirst and thus
pathologists, and researchers from this task force devel- will be prone to dehydration; acute stroke patients often
oped the National Dysphagia Diet (NDD). Patients should require intravenous hydration to maintain adequate fluid
undergo a complete individualized assessment by a speech intake. The Frazier Free Water Protocol was developed to
pathologist with an initial bedside swallow evaluation assist with increasing fluid intake and prevent dehydration
and/or modified barium swallow. The NDD includes 3 without increasing the risk of aspiration in patients who
levels of solid foods (dysphagia pureed, dysphagia were receiving nothing orally or were restricted to thick-
mechanically altered, dysphagia advanced) and 4 levels of ened liquids.12 The protocol allows for unrestricted water
fluids (thin, nectar-thick, honey-thick, spoon-thick). See intake prior to and 30 minutes after a meal with aggressive
Tables 2 and 3 for an overview of the NDD. oral hygiene.12 Prior to the development of the Frazier Free
The level 1 NDD (pureed) is designed for patients Water Protocol, aspiration of water was believed to be
who have moderate to severe dysphagia with poor oral harmful and to have potential for development of aspira-
phase abilities and decreased ability to protect their air- tion pneumonia. Aspiration of water is overall a benign
way. This diet consists of pureed, homogeneous, and event, unlike aspiration of other beverages, because water
cohesive foods that have a “pudding-like” texture. Foods has a neutral pH and therefore carries a low risk of lung
with coarse textures such as nuts, raw fruits, and vegeta- injury or infection if aspirated in the lungs.12
bles are not permitted.
The level 2 NDD (mechanically altered) includes
foods that are moist and have a soft texture. This diet is Weaning Enteral Nutrition
used in transition from the pureed textures to a more
solid texture diet. Patients with adequate chewing ability Feeding dependency, or assistance with meals, is common
who have mild to moderate oropharyngeal dysphagia are among stroke patients with dysphagia. Kumlien and
most suited for this diet. All foods from NDD level 1 are Axelsson53 evaluated stroke patients in 5 nursing homes
appropriate at this level. and found that >80% were dependent on healthcare
 Table 3.   The National Dysphagia Diet—Recommendations by Type of Food and Consistency

Meat/Meat
Food Type Breads Cereals/Grains Dairy/Desserts Fats Fruits Substitutes Soups Vegetables Other
Level 1, pureed
  Recommend Pureed breads Smooth cooked Smooth Butter, strained Pureed fruits, Pureed meat or Pureed, Pureed Sugar, salt,
(pancakes, cereals pudding, gravy, thickened eggs, thickened vegetables, spices,
muffins, (farina type), custard, mayonnaise, juices (no hummus, soup broth mashed ketchup,
bread, etc) pureed pureed cheese pulp, seeds, legumes potatoes, honey,
noodles desserts sauces chunks) tomato sauce smooth jelly
  Avoid Nonpureed Dry cereals, Ice cream, Fats with Whole fruit Whole or Nonpureed Nonpureed Coarse pepper,
breads oatmeal, gelatins, coarse, (frozen, ground meat, soups or vegetables, jams with
cooked cereal nonpureed chunky fresh, nonpureed broth with tomato sauce seeds, nuts,
with lumps baked goods, additives canned, or eggs chunks with seeds or sticky foods
chewy candy dried) chunks

Level 2, mechani-
cally altered
  Recommend Soft pancakes Cooked cereal Pudding, Butter, gravy, Soft canned or Moistened Soup with Well-cooked Jams and
with syrup, with texture custard, cake sour cream, cooked fruit ground meats veggies or vegetables, preserves
slurried (oatmeal), with icing, mayonnaise, without skin, in gravy/ meat (<½- boiled or without
breads dumplings canned fruit, cheese sauce ripe bananas, sauce, pasta, inch pieces) baked seeds, salsa
with gravy, soft gelatin with scrambled potatoes
noodles in chocolates canned fruit eggs
sauce
  Avoid Dry breads Dry, coarse Chewy candy, Fats with Pineapple, fruit Dry meat, Large chunks Broccoli, Nuts, seeds,
cereals, dry cakes/ coarse, with skin or bacon, of meat, rice, asparagus, sticky foods,
cereals with cookies, chunky seeds, dried sausage, hot corn in soup celery, corn, coconut
flax, seeds, or yogurt with additives fruit dogs peas, potato
nuts nuts skins

Level 3, Dysphagia
advanced
  Recommend Moist breads Moist cereal, All others All others Canned or Ground tender All others Tender Seasoning,
(butter, jam, rice, pasta except those except those cooked fruit, meats and except those vegetables, sauces, jelly,
syrup) in “Avoid” in “Avoid” peeled fresh tender fish in “Avoid” shredded jam, honey
category category fruit category lettuce, fried
potatoes
  Avoid Dry bread, Dry cereals, Dry baked Coarse spreads Dried fruit, Tough dry Chowders, Raw, rubbery, Chunky peanut
toast, shredded goods, nuts, with nuts fruit snacks, meat, fish large pieces stringy butter
crackers wheat bran taffy, coconut fruit with with bones, of vegetables vegetables
pulp/skin chunky

249
Adapted from Reference 51.
250   Nutrition in Clinical Practice / Vol. 26, No. 3, June 2011

workers for feeding. Physical and cognitive impairments swallowing assessment, and implementation of an inter-
known to influence eating were most severe in 22.5% of mittent tube feeding schedule. The weaning phase is
patients. Sixty percent were moderately dependent in eat- described as gradual progression in oral feeding, with cor-
ing and required limited assistance, supervision, or meal responding decreases in tube feeding. Once a patient is
tray setup, whereas 17.5% were independent and could able to consume ≥75% of his or her nutrition require-
self-feed. Thirty percent were described as having poor ments consistently by mouth for 3 days, all tube feedings
food intake. Reasons for poor food intake included diffi- are discontinued. Weight, hydration, and swallowing abil-
culties in manipulating food in the mouth, difficulties ity are closely monitored during these stages with a spe-
handling food on the plate or table, and the need for cific focus on respiratory complications.
assistive feeding devices.53 Feeding the stroke patient The total time to wean from tube feeding to oral feed-
requires not only routine nutrition assessment by the ing is patient-dependent,54 and weaning from tube to oral
dietitian and assessment of swallowing by the speech– nutrition is not a goal shared by all patients. Crary and
language pathologist, but also assistance from nursing for Groher38 described that the process of transitioning from
patients who cannot feed themselves and assistance from tube to oral feeding can be challenging both cognitively
occupational therapists with creation of assistive feeding and physically for some patients. Learning to eat again
devices. after receiving no oral intake can be tiring and distressing.
Weaning stroke patients from tube to oral feeding is Tube feeding can reduce the stroke patient’s anxiety
a primary nutrition goal and can take place in the acute because the knowledge that nutrition needs are being met
setting, during rehabilitation, or at home. Weaning allows the patient to focus on the rehabilitation of swal-
requires a multidisciplinary approach involving the lowing skills.55 In such cases, it is recommended that the
speech–language pathologist, dietitian, nurse, and physi- patient’s nutrition be maintained through partial oral
cian. Reevaluation of tube-fed patients by a speech– feeding with supplemental tube feeding as required.
language pathologist is necessary to identify positive
changes in swallowing function that can permit transition
from tube to oral feeding. After clinical and instrumental Quality of Life
evaluations, the speech–language pathologist will recom-
mend the appropriate food and liquid consistencies for Quality of life (QOL) has been shown to vary based on
the initial diet along with feeding and swallowing strate- the disease, illness, and progression of the disease state.
gies. Continuous tube feedings should be modified to a QOL after neurological insult is a main focus after the
nocturnal or an intermittent schedule to potentially stim- patient is out of the acute setting. Rehabilitation pro-
ulate the hunger sensation. Intermittent feeds are encour- grams focus on restoring function along with physical and
aged to offer a more normal timing of meals and to emotional well-being. Nutrition can affect QOL, and the
accommodate therapies. Adequacy of oral intake dictates FOOD trial investigation focused on determining whether
adjustment in tube feeding volume and consequent suc- nutrition status was associated with long-term survival
cess of feeding tube removal. and functional status in patients surviving a stroke. Nine
Very few studies have focused on which tube-fed percent of patients were considered undernourished,
stroke patients can transition to oral feeding. At a mini- which was associated with increased cases of pneumonia,
mum, tube-fed patients with dysphagia who are candi- infections, gastrointestinal bleeding, and poor survival.56
dates to return to oral feeding must be able to consume As in an earlier part of the FOOD trial, nutrition status
adequate oral nutrition and demonstrate a safe and effi- was assessed on admission only and no standardized
cient swallow on a consistent basis.38 A safe swallow func- assessment methods were used. Patients with normal
tion does not guarantee that the stroke patient will be nutrition status were less likely to develop pressure sores
able to ingest adequate oral nutrition. Oral food and than were those who were overnourished or undernour-
nutrition supplement intakes should be monitored and ished. Functional status, reduced survival, and living cir-
documented before discontinuation of tube feeding. cumstances (dependency) were all associated with being
Calorie counts can be useful in the rehabilitation setting undernourished upon admission for stroke.56 These fac-
because neurologically injured patients may not report tors, as a result of malnutrition, can affect QOL.
intake accurately because of memory deficits. The wean- In recent years, the number of patients surviving after
ing process, goals, and plan of action should be discussed stroke has increased. Aspiration pneumonia, deep vein
thoroughly with the patient and family members. thrombosis, pressure sores, and depression are all com-
Buchholz54 proposed a 2-phase clinical algorithm, mon morbidities after stroke. What may seem like com-
specific to patients with stroke or acquired brain injury, mon tasks, such routine oral hygiene and mouth care, can
for transitioning tube-fed patients to oral feeding during help prevent the risk of pneumonia. Often stroke patients
acute rehabilitation. The initial phase, termed the pre- are prescribed antidepressant medications, and keeping
paratory phase, focuses on medical and nutrition stability, the mouth moist to prevent xerostomia induced by these
 Nutrition in the Stroke Patient / Corrigan et al   251

medications should not be overlooked to prevent feeding subacute, and long-term care using the MNA. J Nutr Health Aging.
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5. Axelsson K, Asplund K, Norberg A, Alafuzoff I. Nutritional status
The Stroke-Specific Quality of Life Scale (SS-QOL), in patients with acute stroke. Acta Med Scand. 1988;224:217-224.
which has been validated specifically in the stroke popu- 6. Choi-Kwon S, Yang YH, Kim EK, Jeon MY, Kim JS. Nutritional
lation, includes questions related to food preparation and status in acute stroke: undernutriton versus overnutrition in differ-
the need for assistance with eating.57 The 49-item ent stroke subtypes. Acta Neurol Scand. 1998;98:187-192.
SS-QOL questionnaire also includes questions about 7. Foley NC, Salter KL, Robertson J, Teasell RW, Woodbury MG.
Which reported estimate of prevalence of malnutrition after stroke
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