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Editorial: Neeraj Badjatia; Mitchell S. V. Elkind Nutritional Support After Ischemic Stroke: More Food for Thought Arch Neurol 2008; 65: 15-16 [Full text] [PDF]

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Nutrition and stroke outcomes: alternative view

James M Gordon   (5 June 2008)

Nutrition and stroke outcomes: alternative view 5 June 2008
James M Gordon, MD, FRCPC, FAAN (1)Northwest Hospital, Seattle WA; Clin Assoc Professor, University of Washington, Seattle, WA Send reply to journal: Re: Nutrition and stroke outcomes: alternative view neurojim{at}yahoo.com James M Gordon	The conclusion by Badjatia and Elkind (1) that "providing adequate caloric intake early in the course after ischemic stroke may now be seen as a therapeutic intervention used to minimize disease severity, reduce complications, and favorably affect patient outcomes" overstates the more modest conclusions of Yoo et al, that "patients with baseline undernutrition are being undernourished during hospitalization" and that "strategic nutritional support...may improve clinical outcomes."(2) Concluding that aggressive nutritional intervention would improve outcome risks mistaking cause for effect. An alternative interpretation of the data in Yoo et al's Tables 2 and 3 might be that baseline-undernourished (and therefore presumably already-debilitated) older patients with larger strokes do worse than better nourished younger patients with smaller strokes, particularly if those strokes cause worsening undernutrition at 1 week. The notion that prevention of worsening undernutrition in already-debilitated elderly patients with large strokes would change outcome is not addressed by Yoo et al's data, seems to contradict the FOOD studies,(3,4) and risks mandating presumptive overtreatment of devastated, elderly patients at the end of life. Given that enteral feeding of such patients is neither necessarily simple or benign, the issue is not trivial. Aggressive nutritional support, like other forms of treatment of neurologically devastated patients, must be individualized carefully, in response not only to physiological considerations, but to the wishes, values, and life-context of the person lying in the bed. (No conflicts of interest to report.) 1. Badjatia N, Elkind MSV. Nutritional Support After Ischemic Stroke: More Food for Thought. Arch Neurol.2008;65(1):15-16. 2. Yoo S-H, Kim JS, Kwon SU, Yun S-C, Koh J-Y, Kang D-W. Undernutrition as a predictor of poor clinical outcomes in acute ischemic stroke patients.Arch Neurol.2008;65(1):39-43. 3. Dennis MS, Lewis SC, Warlow C, FOOD Trial Collaboration. Routine oral nutritional supplementation for stroke patients in hospital (FOOD): a multicentre randomised controlled trial. Lancet.2005;365(9461):755-763. 4. 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.