Nutrition Recommendations for Stroke

Nutrition Recommendations for Stroke

Introduction

The Western diet is characterized by a high intake of saturated fats, omega-6 fatty acids, reduced omega 3 fats intake, the overconsumption of salt and excessive amounts of refined sugar.1Many individuals are aware that this type of diet could lead to many chronic diseases including cardiovascular diseases. However, individuals lack nutritional education and knowledge, and consequently do not take seriously the type of diet followed. Cardiovascular disease (CVD) is a group of diseases that affect both the heart and the blood vessels.2Common types of cardiovascular diseases include coronary heart disease (CHD), stroke, hypertension, and congestive heart failure.3There are a wide range of serious cardiovascular diseases impact areas including atrial and ventricular arrhythmias, congenital cardiovascular disorders, rheumatic heart disease, peripheral artery disease, and other conditions affecting the circulatory system such as deep thrombosis and pulmonary embolism.3 However, the focus of this paper will be to explain in detail what a stroke is, the prevalence of stroke, types of stroke, risk factors for stroke, and nutrition recommendation to prevent a stroke.
Stroke is characterized by neurological deficit attributed to an acute focal injury of the central nervous system (CNS) by a vascular cause, including cerebral infarction, intracerebral hemorrhage and subarachnoid hemorrhage.4Stroke is the leading cause of disability in the United States while affecting fifteen million people worldwide.5,6,7Studies done all around the world have found differences regarding the people who are at higher risk for stroke.5During their life span, men have a higher risk for stroke, especially if they are below eighty-five years old.5On the other hand, after this age the incidence is higher on the opposite gender with women being at higher risk leading to an excess of disability and mortality.5Additionally, studies concluded that women in general have a harder time recovering from a stroke than men.5
Stroke is the third leading cause of death; it comes after heart disease and cancer and the leading cause of disability in the United States.5That being said, women are more likely to have a past medical history of hypertension and atrial fibrillation (AF) 5. On the other side, men are more prevalent to have heart disease, dyslipidemia, diabetes, myocardial infarction, peripheral artery disease, tobacco and alcohol use.5AF is a huge risk factors for stroke and men have a higher risk for AF. However, women that have coronary artery disease and AF have five times more the risk factor of stroke than men.5
Types of Stroke
According to the CDC website, the three-main type of strokes are; ischemic stroke, hemorrhagic stroke, and transient ischemic stroke attack.6 Eighty seven percent of the strokes are ischemic, which occur when blood flow through the artery that carries oxygen to the brain become blocked. Consequently, blood clots often form and cause blockages that can lead to ischemic stroke.6 Another type of stroke is hemorrhagic, which occurs when an artery in the brain leaks blood or ruptures.6 In other words, the artery that is leaking adds too much pressure to the target brain cells leading to their death or damaging the affected artery. Some of the conditions that can cause a hemorrhagic stroke include hypertension and aneurysm.6 There are two type of hemorrhagic strokes including intracerebral hemorrhage and subarachnoid hemorrhage.6The most common type is intracerebral hemorrhage, which occurs when an artery in the brain ruptures, affecting the surrounding tissues with blood spills.6 The least common type of hemorrhagic stroke is subarachnoid, which refers to bleeding in the brain and the tissue that protects it.6 The third type of stroke is called Transient Ischemic Attack, also sometimes called “mini stroke”; the main difference between this one and the other types of strokes is that in ischemic stroke, the blood flow to the brain is blocked for just a short period.6However, an important point to note with ischemic heart attacks is that they are usually a sign for a future heart attack.
Risk Factors for Stroke
An international case control study (The INTERSTROKE study) studied three thousand stroke cases.7 The study demonstrated that around ninety percent of the strokes can be explained by ten risk factors including: hypertension, diabetes, cardiac diseases, current smoking, abdominal obesity, hyperlipidemia, physical inactivity, alcohol consumption, diet risks and psychosocial stress and depression.7 Additionally, is also believed that atherosclerosis is a main cause for most strokes where an inflammatory condition plays a big role in the development of the stroke.7 Therefore, new promising modifiable risk factors for ischemic stroke are being studied, and some of these factors include; high sensitivity C-reactive protein, Lipoprotein associated phospholipase A2, peripheral leukocyte count and cytokines.7
Longitudinal studies have recognized many markers that increase the individual risk for primary or recurrent stroke.7,8,9 These markers are categorized in two different groups including modifiable and non-modifiable risk factors.7Non-modifiable risk factors are identified as a marker for higher stroke risk, since the individual cannot change these factors. Some of these factors include:
 Age, the cumulative effect of aging on the cardiovascular system and the natural progression of stroke risk factors in a long period increases the risk of ischemic stroke 8.An analysis of data from different European countries found that as the combined risk of fatal and non-fatal stroke increase by nine percent in men and ten percent in women, the incidence of ICH increases with age from less than forty-five in men to greater than 85 years in women. 8
 Low birth weight is another non-modifiable factor and has been associated with a risk of stroke later in life. 8Stroke mortalities rates among adults in England are higher between people with lower weights; the mothers if these low birth weight babies were malnourished, and had a poor health at the time of pregnancy.8
 The third non-modifiable risk factors are race and ethnicity where epidemiological studies believe that African and Hispanic population are at higher risk for stroke of all strokes types and higher mortality rate in comparison with whites.8
 The fourth non-modifiable factor is genetics. Herein, a meta-analysis of cohort studies showed that a positive family history of stroke increase the risks of stroke by thirty percentage.8 The Framingham study show that a documented parental history of stroke before age of sixty-five-year-old was associated with a third fold increase risk in the offspring.8
On the other hand, modifiable factors are more manageable and they can be control and change by the individual. Therefore, they function as a marker for lower stroke risk. Some of the modifiable risk factors include:
 Hypertension, is the most important modifiable risk factor for ischemic stroke. Most estimates for hypertension indicate a relative risk of four when hypertension is defined as a systolic blood pressure > 160 mm Hg and diastolic blood pressure > 95 mm Hg.9According to the joint National Committee V the prevalence of hypertension is 45% at age of 50, >60% at age 60 , and > 70% at age 70. 9The goal of antihypertensive treatment is to reduce the risk of stroke. Meta-analysis of treatment trials has confirmed the impact of blood pressure (BP) observed in previous epidemiologic studies.10 Lowering of systolic BP by ten mmHg reduces the risk of strokes by thirty to forty percentage.10
 The second modifiable factor is cardiac disease; various cardiac diseases have shown to increase the risk for stroke. Atrial fibrillation (AF) is the most powerful and treated cause of stroke.10 The risk for AF increase with age; according to the data from four population base studies in the US census, it has been estimated that 2.2 million Americans have AF.10 Data from the Framingham study and hospital discharge suggest that the prevalence of AF in United States population is increasing.10One of the most common treatment to prevent AF is Warfarin, it has been demonstrated that Warfarin anticoagulation reduced the risk by 68% in a pooled analysis of AF trials.10The annual rate of stroke was 4.5% in the control group and 1.4% in the warfarin group for annual reduction of 3.1%.10The annual rate of major bleeding was low 1% for patient on placebo or aspirin and 1.3% for those on Warfarin. 10In stroke prevention, atrial fibrillation study warfarin was more efficiently than 325 mg of aspirin daily; aspirin seem to decrease non-cardio metabolic stroke but did not prevent severe stroke classified as cardioembolic. 10
 The third modifiable factoris lipid,According to Michael Adeyemi, Akinyele Taoqif, Michael Bimbola, and Anothonia study dyslipidemia particularly low in HDL-C is the most common risk factor for stroke.11This is a retrosprectirve descriptive cross-sectional study, that took place in the department of Medicine at LAUTECH teaching hospital, over 18-month period.11 One hundred six patients with acute stroke confirmed with computed tomography were recruited.11Clinical features, risk factors, lipids profiles and stroke patter were identified.11 The results of the study show mean age was higher in ischemic stroke compared to hemorrhagic stroke.11 Most types of strokes occurred in male patients. Out of 106 patients, 65 had ischemic stroke, 38 intracerebral hemorrhage and 3 with subarachnoid hemorrhage.11The conclusion of the study reflects that dyslipidemia is the most common risk facts found in those with stroke, reduce high density lipoprotein cholesterol (HDL-C) is the most prevalent lipid abnormalities, followed by elevated low density lipoprotein (LDL) and high triglycerides.11

 Diabetes and glucose metabolism are other modifiable risk factors. Persons with diabetes have a greater chance to have atherosclerosis and an increase prevalence of atherogenic risk factors including hypertension, obesity, and abnormal blood lipids. 10According to Beatriz L and Robert D Honolulu study, patients with diabetes had twice risk of thromboembolic stroke than persons without diabetes.12In the Framingham study, persons with glucose intolerance have double the risk of brain infarction than non-diabetic persons.12In addition to the role of glucose status, there are other aspects of glucose metabolism that can influence the risk factor for ischemic stroke, specifically hyperinsulinemia and increase insulin resistance.12 According to the study of Shinozaki K and Naritomi H both were shown to be risk factors from stroke between subjects with normal glucose status.13Furthermore, according to the study of Howard G, O’Leary DH done in Non-Hispanic whites and Hispanic subjects, increase insulin resistance is associated with increase atherosclerosis of the carotid arteries independent of glucose status, insulin levels, and other cardiovascular risk major.14
 Cigarette Smoking increases the risk of ischemic stroke almost two times with an evident dose- response relation.15 The Framingham study and the Nurses’ Health Study termination of smoking led to a big reduction in stroke risk, major’s risks were reduced within two to four years after the individuals quitted smoking.15,16 The reduction risk happened throughout the age spans of these studies.15,16
 Illicit Drug Use, drug abuse is a major social problem, with cocaine the substance most common associated with stroke.17 Other drugs related to stroke including heroin, amphetamines and marijuana.17According to the study of Kelly M and Gorelik PB over the counter cold remedies and diet aids have also been related to hemorrhagic and ischemic stroke.17
BMI, Overweight and Obesity relation with stroke
Obesity has been associated with increased risk of cardiovascular disease, disability and mortality.18 Such risks of ischemic stroke increase with a high BMI. Nearly 30% prevalence of obesity has been estimated in the United States.18Present guidelines recommend considering weight reduction for stroke prevention pointing a body mass index between 18.5 to 24.9 kg/m2 and waist circumference below than 35 inches for women and 40 inches for men.18
According to Dehlendorff, Klaus, and Olsens’ article, they found no evidence of an obesity paradox in patients with stroke. Stroke occurred at a younger age in patients with a high BMI.19 Therefore, obese patients with stroke should prioritize as a goal to have a normal weight. The objective of the study was to determine whether the obesity paradox in stroke is real or an artificial finding.19For the design of the study, they studied survival after stroke in relation to body mass index.19To avoid selection bias, they studied only deaths caused by the index stroke on the supposition that death by stroke reported on a death certificate was due to the index stroke.19They used the Danish Stroke Register, which contained information on all hospital admissions for stroke in Denmark from 2003 to 2012.19According to the results the studied included 71617 patients, 7878 ( 11%) died within the first month, and stroke was the cause of death of 5570 ( 70%) of the patients.19They conclude that obesity is associated with increase morbidity and mortality. Thus, they should strive for normal weight 18.5 and 25.0. However, many studies suggest that patients with a number of chronic diseases including stroke, who are either obese or overweight have lower mortality rate than patients with normal weight and underweight.19 This phenomenon is known as obesity paradox, and it has led to the confusion of whether being obese is a protective factor to prevent stroke or not.19However, the obesity paradox lack an explanation and it might be the result between a balance between the disadvantages associated with obesity that lead to stroke and the benefits related with obesity that promote survival after clinical illness.19
Nutritional Recommendations to prevent strokes
Nutrition is extremely important and unfortunately most physicians and patients do not recognize the important of it.20 Maintaining a healthy weight, reducing dietary cholesterol and consuming a Mediterranean diet significantly can reduce the risk for stroke. One of the biggest problem in the health field is that many nutrition and physicians think that if they are taking a statin, they can have an unbalance diet high in saturated fat.20 An analysis of the Nurses’ Health Study and the US Health Professional study demonstrated the importance of a lifestyle.21The study included43,685 men and 71,243 women, following healthy lifestyle choices helped to reduce the risk for stroke by 80%.21The healthy lifestyles were not smoking, a healthy weight ( BMI< 25 kg/m2), physical activity for at least 30 min per day, modest alcohol consumption, and scoring within the top 40% of a healthy diet score. 21 The US Center for Disease Control estimated in 2004 that half of the death were due to unhealthy behaviors. 22Some of the most important nutrition recommendation to prevent a stroke include:
 Maintaining a Healthy Weight: the high consumption of fat and carbohydrate contribute to obesity and increase the risk for diabetes and vascular disease.22 However, obesity is an independent risk factor for stroke.23,24,25Though heredity plays an important role in obesity, people with an inherited predisposition to obesity may needs to maintain a lower caloric intake and a higher level of physical activity.20According to David Spence article the arithmetic of weight maintenance is simple.20To maintain a give weight, the average caloric intake is around 10 kilocalories per pound.20Supposing a normal level of inactivity for sedentary people, an individual who weight 250lb has been consuming around 2500 calories per day.20One pound of fat represents 3,500 stores calories and a mile of walking will only burn off 100 calories.20Thus, to lose a pound the individual will need to walk 35 miles, or reduce the intake of calories by 500 calories per day.20 To accomplish this, obese people must learn how to eat more low-calorie food and less high-calorie food. It is extremely important for them to know the calorie values of the food they are eating. Unfortunately, the public media took the advantage to promote a low-carbohydrate diet for weight loss. However, in the long term it is more important to keep a balance between the caloriesconsumed and calories expend to achieve a healthy weight.20
 The Mediterranean Diet is evidently the best diet for prevention of stroke or myocardial infarction, and one of the best diets for diabetes.26In the French Diet Heart study, a secondary prevention trial in which patients who had survived a myocardial infarction, the Mediterranean diet was compared to the Western Diet, as a low-fat diet.26In the Mediterranean diet, canola margarine was replaced for butter. It contained less than 300mg/day of cholesterol and was target for a low intake of fat.26 The daily cholesterol intake in the Western diet was around 300mg/day, versus 200 for the Mediterranean diet, the intake of beneficial oils was much higher in the Mediterranean diet and the intake of saturated fat lower.26The result of the study shows a 70% reduction of cardiovascular events in four years.27 Thus, the effect of a healthy diet was twice more beneficial than simvastatin in the Scandinavian Simvastatin Survival study, with a 40% reduction of cardiovascular event in six years.27
 Dietary Cholesterol and Egg Yolk: The myth that dietary cholesterol is harmless because it does not increase the fasting cholesterol too much has led to big misunderstanding.28 However, is well known for many years that dietary cholesterol increase the risk for cardiovascular diseases. Therefore, the dietary cholesterol recommendation is less than 200 mg per day.28Eggs yolks are high in cholesterol, a single large egg yolk contains more than the recommended daily intake of cholesterol, a jumbo egg yolk contains 237mg of cholesterol.28In 2012, egg yolk consumption was found to be around 60% as harmful as smoking, to the development of atherosclerosis.28The harmful effect of eggs yolk is not all due to the high cholesterol that contains but also because it contains lecithin which is converted by intestinal bacteria to trimethylamine, which is oxidize by the liver and converted to trimethylamine n-oxide, which is referred as coronary angiography.28 Patients at risk for cardiovascular disease, including stroke, should place as a goal to limit their intake of cholesterol. They should also learn how to consumed a Mediterranean diet, and they should reduce the intake of animal flesh.
 Fruits and vegetables are protective against stroke.29 One recent meta-analysis study demonstrates that individuals with the highest fruits and vegetable consumption were 21% less likely to have a stroke in comparison with those with the lowest consumption.29The association was similar when considered the consumption of fruit and vegetables separately, this is comparable to the effect size for statin use for prevention of stroke in high risk patients, where stating use reduce the risk of stroke by 18%.29 Nine large prospective cohort studies including Nursing Health Studies, the Danish diet, Cancer and Health study evidence that increasing fruits and vegetables consumption is associated with decrease the risk of stroke.29
 According to Mayo Clinic article, some nutrition recommendations to prevent stroke include:
1. Control your portion size: How much an individual eat is as important as which type of foods he is eating.30 Therefore, is critical to do not overload the plate with food. For instance, usual portions sizes serve in a restaurant is more than what an individual need. It is recommended to use a small plate or bowl to help people control portions sizes.30 Also, eating larger portions of low-calories, nutrition rich foods including fruits and vegetable and smaller portions of high caloric, high sodium foods, such as refined, process and fast food.30Another important recommendation is to keep track of the number of serving an individual eat. A serving size is a specific food, defined by measurements including cups, ounces or pieces.30 For instance, once serving of pasta is ½ cup.
2. Eat more vegetables and fruits, these are good sources of vitamins and minerals.30Vegetables and fruits are also low in calories and rich in fiber, eating larger quantities of fruits and vegetables can help an individual to eat less high fat foods including meat and cheese.30To increase the consumption of fruits and vegies keep vegetable washed and cut in the refrigerator for snacks.
3.Select whole grains, these are a good source of fiber, an individual can increase the amount of whole grain in his diet by making simple substitution for refined grain products.30
4.Limit unhealthy fat, limiting how much saturated fat and trans fat an individual eat is an important step to decrease blood cholesterol and lower the risk of coronary artery disease.30A high blood level cholesterol can lead to atherosclerosis, which increase the risk for heart attack. The Americans Heart Association recommendation for saturated fat is less than 7% of the individual totally daily calories, or less than 14 grams of saturated fat in the individual follow a 2000 calories a day diet and trans fat less than 1% of the individual total calories.30The best way to reduce the amount of saturated and trans fat is to limit the amount of solids food including butter, margarine and shortening.30
5.Choose low-fat protein sources: lean meat, poultry and fish, low fat dairy products and eggs are the best sources of proteins.30However, is important to choose low fat options including skim milk rather than whole milk and skinless chicken breast rather than fried chicken.30 Fish is also a good alternative and some types of fish include omega three which can help to lower the levels of triglycerides.30Some fishes high in omega three include salmon, mackerel and herring.
6. Reduce the sodium intake: A high sodium intake can contribute to hypertension, which is a risk factor for cardiovascular diseases.30 Therefore, reducing sodium is an important part of a healthy diet. The Department of Health and Human Services recommends for healthy adults no more than 2,300 mg of sodium per day for normal people. However, for people age 51 or older, African-Americans, and individuals who have been diagnosed with hypertension, diabetes or chronic kidney disease, the organization recommends no more than 1500 mg of sodium a day.30
Conclusion
Based on recent studies and review of the current literature, stroke is the third cause of death in the United States.5 Reduction of the rates of strokes in the United States through a healthy diet could save thousands of lives every year. Stroke is defined as a neurological disease attributed to an acute focal injury of the central nervous system.4 Men are at higher risk for stroke specially if they are below 85-year-old, after this age women are at higher risk for stroke.4 There are three main types of strokes including ischemic stroke, hemorrhagic stroke and transient ischemic stroke.6However, the majority of the strokes are ischemic which occur when the artery that carries blood to the brains lacks oxygen levels.6
Some of the most common risk factors for stroke include hypertension, diabetes, cardiac disease, current smoking, abdominal obesity, hyperlipidemia, physical inactivity, alcohol consumption, diet and psychosocial stress, as well as depression. Inflammation plays a big role in the development of stroke, therefore monitoring markers such as: C- reactive protein, lipoprotein associated phospholipase A2, peripheral leukocytes and cytokines is extremely important in patients who are at risk of heart attack. The risk factors for stroke can be classified in two groups, including non-modifiable factors which are the one the individual cannot change such as age, low birth weight, genetics, race and ethnicity. The second group is called modifiable factors which are the ones the individual can set up personal goals to change and improve in order to reduce the risk for heart attack. Some of the modifiable risk factors include hypertension, lipids, diabetes and glucose metabolism, cigarette smoking and illicit drug use. Additionally, current studies have concluded that obesity increase the risk for stroke, therefore the present guidelines recommend to consider a weight between 18.5 to 24.9 kg/m2 and a waist circumference below 35 inches for women and 40 inches for men. Nutrition is the enormously important to reduce the risk for a stroke.
Unfortunately, physicians and patients rely heavy on medications and do not consider nutrition as an important treatment for stroke. Some of the most important nutrition recommendation to prevent a stroke include to maintain a healthy body weight, to follow a Mediterranean diet high in fruits, vegetables, antioxidants, phytonutrients, omega 3 and low in saturated fat, trans fat, bad cholesterol (LDL). Following a Mediterranean diet can help to decrease the risk of stroke by 70% in four years. 26 Lastly, another important nutrition recommendation to prevent a stroke include that individuals need to be conscious and realist of how much is a serving size, this is extremely important because big part of American population eat in restaurant and they think that whatever the get serve is what they are supposed to eat, but the truth is that restaurants usually give a bigger portion size, increase the number of fruits and vegetables is another fundamental recommendation, limit saturated fat to less than 7% per day, choose low fat protein sources and reduce the sodium intake to less than 2300mg per day.30Finally, by following a healthy balance diet rich in fruits and vegetables individuals can dramatically decrease the risk of stroke.

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