Nutrition and its unsung role in stroke recovery
Food and nutrition support is the fuel that can drive post-stroke rehab in many different ways, as Emily Stuart, a dietitian at Wiltshire Farm Foods, explains.
The work of dietitians in post-stroke rehab is heavily built on relationships. First and foremost, we must build up a good relationship with the patient and their loved ones at an immensely difficult time for them.
Where the patient has dysphagia (swallowing difficulties), for example, they may suddenly have been advised by a Speech and Language Therapist to switch to a completely different texture of food, and potentially fluid, from what they’ve known throughout their life.
Whether it’s pureed, minced or soft and bite sized, this is obviously a huge shift for somebody used to eating regularly textured food.
Our role is to support them in this change while ensuring they’re meeting the nutritional requirements necessary to help them with their rehabilitation.
Our work is frequently underpinned by the principles of ‘food first’ – an approach to treating inadequate nutrition and unintentional weight loss via nourishing foods and drink.
For each stroke patient, where able, we strive to maintain an oral diet for as long as possible before, in some cases, having to supplement with or rely on oral nutritional supplements (ONS) and/or enteral tube feeding.
Good nutrition after stroke matters for several important reasons, not least because it has a proven impact in shortening the length of hospital stay (LOS) and improving patient outcomes.
Numerous studies from around the world have evidenced the correlation between nutrition and faster discharges and better outcomes.
For example, researchers at the University of Western Ontario (Finestone et al, 1996) investigated associations between the nutritional status of inpatient rehab unit stroke patients and LOS and functional outcome.
It found a significant relationship between LOS and overall malnutrition and identified malnutrition as the most potentially modifiable variable relating to LOS and functional outcome.
It concluded: “Close attention to nutrition status may help to optimise stroke patients’ rehab potential and use of health care resources.”
A more general study, involving 324 adult surgical patients in Ethiopia (Abrha et al, 2016) found that “nutritional status” was one of three indicators for LOS in hospital, alongside duration of the disease and history of surgery.
There are multiple reasons why good nutrition is vitally important post-stroke which perhaps contribute to its effect in shortening LOS and boosting progress in rehab.
Of course, it helps to maintain energy levels and muscle mass and supports a healthy immune system in the recovery period; but also supports the individual’s wellbeing and mental health.
Helping patients to eat in a way that is as close to normality as possible maintains that connection with something they’ve always done, at a time of great change in their life.
There is also a social element. If the individual can maintain eating with other people, that can be incredibly helpful for their morale and outlook.
As well as forging relationships with patients and the people in their lives, dietitians must also work closely with fellow members of the multidisciplinary team (MDT).
Among all of the interventions that make up the collective effort of the MDT, the dietitian is the voice which speaks up for the value of nutrition.
Although others in my field may have had a different experience, I have always felt that this voice is listened to and respected in stroke rehab.
Where it is not can perhaps be partly attributed to the fact that we dietitians are a rarer breed in rehab than physiotherapists and occupational therapists, for example.
Also, we might work with the patient less frequently than some other rehab professionals. We may see the individual a few times a week or even once per week depending on the complexity, while a physio working with a stroke patient could be having sessions with them every day. Therefore we may be less visible in certain settings.
But from my point of view over several years of working on stroke wards, nutrition as a factor in improving outcomes has never been marginalised.
This has been enabled through continuous and close liaison with other members of the MDT, and practising in an empathetic and evidence-based way. Having a full view and understanding of the rehab schedule allows the dietitian to adapt the person’s eating pattern to it.
For instance, if the patient is on a physio-intensive rehab timetable, this could mean providing small, frequent meals, snacks and drinks rather than focusing on their standard meal pattern. Patients may find eating larger meals too daunting and tiring, whilst they may manage better with smaller portions. Care must be taken to ensure that these smaller portions are nourishing and well accepted by the patient. For those patients unable to eat orally, this may mean adapting their enteral tube feeding regime to ensure they don’t miss out on valuable nutrition during their physical rehab sessions.
So, while other MDT members are regularly updating us on the rehab regime, we are maintaining focus on the importance of nutrition and how it could support the patient.
An important development around stroke in recent years, meanwhile, is the roll-out of the International Dysphagia Diet Standardisation Initiative (IDDSI).
This is a global standard for the use of texture modified foods and thickened fluids in dysphagia.
The IDDSI framework has eight levels each with standardised descriptors and testing methods that support consistent production and easy testing of thickened liquids and texture modified foods.
This helps to shape our research and development at Wiltshire Farm Foods as we continue creating a wider choice for patients.
We work tirelessly to support dining with dignity, which means that when people have modified food, their meal looks and tastes as close to the non-modified alternative as possible.
Being able to enjoy food and sitting down for a meal with friends and loved ones are hugely important parts of life; and needn’t be given up due to a stroke or other health challenge.
Emily Stuart is a dietitian at Wiltshire Farm Foods, which delivers meals to UK households, care homes and healthcare settings, including neuro-rehab facilities and wards.