Nutritional Status and Outcomes Following Acute Stroke - Leicester

283 Pages·2014·8.92 MB·English

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Nutritional Status and Outcomes After Acute
Stroke
A thesis presented to The University of Leicester for the
degree of Doctor of Medicine
by
Dr Salah E Gariballa
MBBS, MRCP (UK)
May 1998
UMI Number: U106225
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2
Abstract to Thesis:
Nutritional Status and Outcomes Following Acute
Stroke
Introduction:
Undemutrition is prevalent, largely unrecognised in hospital patients on admission, and
tends to get worse during the hospital stay. Although stroke patients are particularly at
risk of undemutrition the extent of this problem and it is contribution to stroke outcome is
not presently known.
Aims:
The aims of this work were to describe the nutritional status of acute stroke patients after
admission and during the hospital stay, to measure the impact of nutritional status on
clinical outcome and to examine the effect of nutritional intervention on nutritional status
and outcome.
Methods:
The nutritional status was evaluated using a semi-quantitative food frequency
questionnaire and anthropometric, haematological and biochemical data. Clinical outcome
measures were recorded during the hospital stay, at death or discharge and at three
months. The influence of nutritional status on clinical outcome was measured after
adjusting for non-nutritional clinical variables. A randomised controlled trial of oral
nutritional supplements was performed.
Results:
Plasma concentrations of vitamin C were significantly lower in the stroke group compared
with the non-stroke group. Pre-stroke residence and sex predicted nutritional status.
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Most patients studied were in negative energy balance during the hospital stay.
Nutritional status deteriorated significantly during the study period, but only serum
albumin showed a statistically significant association with various outcome measures.
Hypoalbuminaemia was associated with a significantly higher level of morbidity and
mortality during the hospital stay and at three months. Oral supplementation significantly
improved nutritional intake, prevented or reduced the decline in nutritional status and had
a favourable but non-significant effect on outcome.
Discussion:
A significant number of acute stroke patients were undernourished at admission, and this
worsened during their hospital stay. Undemutrition was associated with increasing
morbidity and mortality. Nutritional supplementation significantly improved nutritional
intakes and prevented the decline in nutritional status, but whether that removed or
mitigated the hazard of stroke death associated with poor nutritional status is at present
unknown.
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Declaration
The work described in this thesis was carried out entirely by myself, except where credit is
given in the acknowledgements below. The work was done in the University Department
of Medicine for The Elderly, Leicester General Hospital, University of Leicester, between
March 1994 and December 1995.
All subjects in these studies participated after giving their informed written consent, or
informed written consent was obtained from the carers of those patients who were unable
to give their own consent. Approval for these studies was obtained from Leicestershire
Health Ethical Committee on Medical Research and Clinical Investigations.
Acknowledgements
I wish to express my deepest gratitude to my teacher and supervisor Professor Mark
Castleden for his continuous support, advice and supervision in planning and carrying out
this work, to Dr Stuart Parker for his help in translating the ideas of these studies into a
research protocol and for his continuous support throughout the development of the thesis
and Synthelabo Recherche Company for their financial support. Special thanks are given
to the Nursing Staff at Leicester General Hospital for their help in monitoring the
nutritional intake of the patients and to Jackie Troughton (Research Dietician) for her
assistance with filling and coding the food frequency questionnaires, supervising the
nutritional supplements study and analysing the food diary cards.
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Dedication
This work is dedicated to my parents, my wife Nesrin and my children
SECTION / CHAPTER HEADING PAGE NUMBER
ABSTRACT TO THESIS 2
DECLARATION AND ACKNOWLEDGEMENT 4
TABLE OF CONTENTS 6
LIST OF TABLES 11
LIST OF FIGURES 14
LIST OF ABBREVIATIONS 15
SECTION I
Introduction
17
CHAPTER 1 HISTORICAL PERSPECTIVE 18
CHAPTER 2 THE CHALLENGE OF STROKE 22
2.1. Definition 22
2.2. Epidemiology 22
2.3. Risk factors 22
2.4. The burden of stroke 23
2.5. Pre-stroke nutrition 23
2.6. Post-stroke nutrition 23
SECTION II
REVTEW OF LITERATURE 25
CHAPTER 3 NUTRITION IN THE ELDERLY 26
3.1. Ageing changes relevant to nutrition 26
3.2. Energy requirements 31
3.3. Energy expenditure 35
3.4. Protein requirements 39
3.5. Micronutrients 40
3.6. Minerals 42
3.7. Trace elements 45
3.8. Summary 46
CHAPTER 4 ASSESSMENT OF NUTRITIONAL STATUS 47
4.1. Methods used to assess nutritional status 48
4.1.1. Dietary surveys 48
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4.1.2. Anthropometric measurements 50
4.1.3. Clinical laboratory tests 53
4.1.4. General assessment 55
4.2 Summary 56
CHAPTER 5 UNDERNUTRITION IN THE ELDERLY 57
5 .1. Undemutrition of elderly people living in the
community 57
5.1.1. Summary 60
5.2. Effects of hospitalisation and acute illness on elderly
people's nutrition 61
5 .2.1. Nutrition of elderly people in acute and non-acute care 61
5.2.2. Summary 65
5.3. Food intake and ill-health 65
5.4. Physical activity during disease 66
5.5. Undemutrition, ill-health and outcome 67
5.6. Improving nutritional status in hospital and
it's relation to outcome 69
5.7. Summary 70
CHAPTER 6 NUTRITION AND ISCHAEMIC STROKE
6.1. Background 71
6.2. Nutrition and vascular disease 71
6.3. Diet and atherosclerosis 72
6.4. Free radicals in cerebral ischaemia 73
6.5. Role of nutritional factors on stroke incidence
and outcome 74
6.5 .1. Fruit and vegetables 74
6.5.2. Potassium 77
6.5.3. Semm albumin 78
6.5.4. Other nutritional factors 79
6.6. Nutrition following the stroke 81