A comparative study on dysphagia management & optimization of nutritional status among acute stroke patients

Yamini A.P*

Manager, Department of Clinical Nutrition & Dietetics & Team, Kauvery Hospital, Alwarpet, Chennai, Tamil Nadu

*Correspondence

Abstract

Stroke, a life-threatening non-communicable disease that affects individuals across all age groups worldwide. According to the World Health Organization (WHO), stroke is the second leading cause of death globally, accounting for approximately 11% of total deaths [1]. In India, the estimated prevalence of stroke ranges from 84 to 262 per 100,000 population in rural areas and 334 to 424 per 100,000 in urban settings [2]. Stroke significantly impairs physical, cognitive, and nutritional functioning, thereby reducing the overall quality of life and life expectancy of affected individuals [3].

One of the most prevalent complications following acute stroke is dysphagia (difficulty in swallowing), which occurs in 37–78% of stroke patients [4]. Dysphagia increases the risk of aspiration pneumonia, dehydration, and malnutrition, making it a critical factor in patient recovery and rehabilitation [5]. Malnutrition in hospitalized stroke patients has been reported in 6.1–62% of cases, depending on the screening tool used and the timing of assessment [6]. Effective nutritional management in the acute phase is therefore essential to prevent muscle catabolism, support neurological recovery, and improve clinical outcomes.

Aim

This study aims to optimize the nutritional status of acute stroke patients and manage dysphagia through a structured nutrition care process, with the goal of improving calorie and protein adequacy and enhancing the overall quality of life during the hospital stay.

Introduction

Patients diagnosed with acute stroke require optimal nutritional support to meet their caloric and protein requirements during hospitalization. Early nutritional intervention is associated with reduced complications, shorter hospital stays, and improved functional recovery [7]. The European Society for Clinical Nutrition and Metabolism (ESPEN) recommends early enteral nutrition initiation within 24–48 hours of hospital admission for stroke patients who cannot meet their nutritional needs orally [8].

Most acute stroke patients present with hemiplegia or paraplegia, frequently accompanied by pharyngeal dysphagia, which creates significant challenges in meeting the Recommended Dietary Allowances (RDA). Prolonged inadequate nutrition leads to severe muscle catabolism, compromised immune function, delayed wound healing, and diminished quality of life [9]. Oral nutritional supplements (ONS) have been shown to be effective in bridging the nutritional gap in patients transitioning from enteral to oral feeding [10].

Methodology

A comparative study design was adopted and conducted in the Neuro- Intensive Care Unit (NICU) and neurology wards. The study period spanned from January to August. Patients diagnosed with acute stroke under the age of 60 years were recruited for the study.

Study Design Summary

ParameterGroup A (n=30)Group B (n=30)
Assessment ToolSGA (baseline only)SGA (weekly reassessment)
MonitoringStandard careDaily nutrition adequacy monitoring
Phase 1: NG Feeds13 days7 days
Phase 2: NG + Oral Feeds9 days12 days (NG + Oral solid foods)
Phase 3: Oral Feeds7 days (Oral solid feeds)8 days (Oral foods + ONS)
RDA Achieved72% (1,600 kcal / 60 g protein/day)100% (2,000 kcal / 72 g protein/day)

Group A (n=30) received standard nutritional care with a baseline nutritional status assessment using the Subjective Global Assessment (SGA) tool. Patients were classified as well-nourished at risk. Nutrition intervention was delivered in three phases without periodic reassessment, achieving only 72% of RDA (1,600 k cal/60 g protein/day).

Group B (n=30) received an enhanced nutrition care protocol with weekly SGA reassessment and daily monitoring of nutritional adequacy. The phased intervention included the strategic introduction of oral nutritional supplements (ONS) in Phase 3, which enabled patients to achieve 100% of RDA (2,000 k cal/72 g protein/day).

Results

The study findings revealed that optimization of nutritional status was significantly achieved through periodic nutritional reassessment and daily adequacy monitoring in Group B compared to Group A. The key outcomes include:

  • A significant increase in RDA achievement from 72% (Group A) to 100% (Group B), demonstrating the efficacy of structured nutritional monitoring.
  • Group B patients demonstrated faster transition from nasogastric feeding to oral intake (7 days vs. 13 days for Phase 1).
  • The incorporation of oral nutritional supplements (ONS) in Group B was instrumental in bridging the calorie and protein gap during the transition to full oral feeding.
  • Periodic reassessment allowed for timely identification and correction of nutritional deficits, contributing to improved muscle preservation and functional outcomes.

Key Outcome Comparison

Outcome MeasureGroup AGroup B
RDA Achievement72%100%
Caloric Intake1,600 k cal/day2,000 k cal/day
Protein Intake60 g/day72 g/day
Phase 1 Duration (NG Feeds)13 days7 days
ONS IntegrationNot includedIncluded in Phase 3
Reassessment FrequencyBaseline onlyWeekly (SGA)

Conclusion

This comparative study demonstrates that a structured, protocol-driven nutritional care approach with periodic reassessment and daily adequacy monitoring significantly improves dietary intake and nutritional outcomes in acute stroke patients with dysphagia. The integration of oral nutritional supplements during the transition from enteral to oral feeding is a key strategy for achieving complete RDA fulfillment. These findings underscore the importance of individualized nutrition care plans and multidisciplinary collaboration in optimizing recovery and quality of life for stroke patients.

Keywords

Acute StrokeDysphagiaNutritional Care Process
Recommended Dietary AllowancesOral Nutritional SupplementStroke Rehabilitation

References

  1. World Health Organization. The top 10 causes of death. WHO Fact Sheet. 2020. Available from: https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death
  2. Pandian JD, Sudhan P. Stroke epidemiology and stroke care services in India. J Stroke. 2013;15(3):128–134. doi:10.5853/jos.2013.15.3.128
  3. Feigin VL, Brainin M, Norrving B, et al. World Stroke Organization (WSO): Global Stroke Fact Sheet 2022. Int J Stroke. 2022;17(1):18–29. doi:10.1177/17474930211065917
  4. Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005;36(12):2756–2763. doi:10.1161/01.STR.0000190056.76543.eb
  5. Cohen DL, Roffe C, Beavan J, et al. Post-stroke dysphagia: a review and design considerations for future trials. Int J Stroke. 2016;11(4):399–411. doi:10.1177/1747493016639057
  6. Foley NC, Martin RE, Salter KL, Teasell RW. A review of the relationship between dysphagia and malnutrition following stroke. J Rehabil Med. 2009;41(9):707–713. doi:10.2340/16501977-0415
  7. Gomes F, Emery PW, Weekes CE. Risk of malnutrition is an independent predictor of mortality, length of hospital stay, and hospitalization costs in stroke patients. J Stroke Cerebrovasc Dis. 2016;25(4):799–806. doi:10.1016/j.jstrokecerebrovasdis.2015.12.017
  8. Burgos R, Breton I, Cereda E, et al. ESPEN guideline on clinical nutrition in neurology. Clin Nutr. 2018;37(1):354–396. doi:10.1016/j.clnu.2017.09.003
  9. Dennis MS, Lewis SC, Warlow C; FOOD Trial Collaboration. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet. 2005;365(9461):764–772. doi:10.1016/S0140-6736(05)17983-5
  10. Stratton RJ, Elia M. A review of reviews: a new look at the evidence for oral nutritional supplements in clinical practice. Clin Nutr Suppl. 2007;2(1):5–23. doi:10.1016/j.clnu.2007.07.003

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