Hyponatremia is a Prognostic Factor in Patients Receiving Nutrition Support.

BACKGROUND: Hyponatremia, the most common electrolyte disorder, has been reported to be related to increased mortality. However, the association between hyponatremia and prognoses remains unclear in patients with nutrition support team (NST) intervention. This study aimed to determine the prevalence of abnormal serum sodium levels, its relation to patient data, and the impact of hyponatremia on prognosis. METHODS: Patients who received nutrition support at Tokushima University Hospital for the first time and whose serum sodium levels were measured at the start of NST intervention were enrolled. Patients were classified into three groups according to their serum Na levels at the start of NST intervention: hyponatremia group, normonatremia group, and hypernatremia group. RESULTS: In the hyponatremia group compared to the normonatremia group, body weight and body mass index were significantly lower. C-reactive protein levels and urea nitrogen/creatinine ratios were significantly higher. Meanwhile, there was no significant difference in the estimated glomerular filtration rate among the groups. The prevalence of malnutrition and anemia were the highest in the hyponatremia group. The 3-year survival rate was approximately 45% in the hyponatremia group, which was the lowest of all three groups. The mortality risk ratio of the hyponatremia group to the normonatremia group was 2.29. CONCLUSIONS: Hyponatremia in NST intervention patients is an independent prognostic predictor. Therefore, adding an assessment of serum sodium at the beginning of NST intervention can identify patients at high risk at an early stage and may improve the quality of NST activity.

Therapeutic potential of nutraceuticals to protect brain after stroke.

Stroke leads to significant neuronal death and long-term neurological disability due to synergistic pathogenic mechanisms. Stroke induces a change in eating habits and in many cases, leads to undernutrition that aggravates the post-stroke pathology. Proper nutritional regimen remains a major strategy to control the modifiable risk factors for cardiovascular and cerebrovascular diseases including stroke. Studies indicate that nutraceuticals (isolated and concentrated form of high-potency natural bioactive substances present in dietary nutritional components) can act as prophylactic as well as adjuvant therapeutic agents to prevent stroke risk, to promote ischemic tolerance and to reduce post-stroke consequences. Nutraceuticals are also thought to regulate blood pressure, delay neurodegeneration and improve overall vascular health. Nutraceuticals potentially mediate these effects by their powerful antioxidant and anti-inflammatory properties. This review discusses the studies that have highlighted the translational potential of nutraceuticals as stroke therapies.

Association of Vegetable Nitrate Intake With Carotid Atherosclerosis and Ischemic Cerebrovascular Disease in Older Women.

BACKGROUND AND PURPOSE: A short-term increase in dietary nitrate (NO3-) improves markers of vascular health via formation of nitric oxide and other bioactive nitrogen oxides. Whether this translates into long-term vascular disease risk reduction has yet to be examined. We investigated the association of vegetable-derived nitrate intake with common carotid artery intima-media thickness (CCA-IMT), plaque severity, and ischemic cerebrovascular disease events in elderly women (n=1226). METHODS: Vegetable nitrate intake, lifestyle factors, and cardiovascular disease risk factors were determined at baseline (1998). CCA-IMT and plaque severity were measured using B-mode carotid ultrasound (2001). Complete ischemic cerebrovascular disease hospitalizations or deaths (events) over 14.5 years (15 032 person-years of follow-up) were obtained from the West Australian Data Linkage System. RESULTS: Higher vegetable nitrate intake was associated with a lower maximum CCA-IMT (B=-0.015, P=0.002) and lower mean CCA-IMT (B=-0.012, P=0.006). This relationship remained significant after adjustment for lifestyle and cardiovascular risk factors (P≤0.01). Vegetable nitrate intake was not a predictor of plaque severity. In total 186 (15%) women experienced an ischemic cerebrovascular disease event. For every 1 SD (29 mg/d) higher intake of vegetable nitrate, there was an associated 17% lower risk of 14.5-year ischemic cerebrovascular disease events in both unadjusted and fully adjusted models (P=0.02). CONCLUSIONS: Independent of other risk factors, higher vegetable nitrate was associated with a lower CCA-IMT and a lower risk of an ischemic cerebrovascular disease event.

CerefolinNAC Therapy of Hyperhomocysteinemia Delays Cortical and White Matter Atrophy in Alzheimer's Disease and Cerebrovascular Disease.

We examined whether using a medical food therapy for hyperhomocysteinemia (HHcy) in patients with Alzheimer's disease (AD) or cognitive impairment due to cerebrovascular disease (CVD) with Cerefolin®/CerefolinNAC® (CFLN: L-methylfolate, methylcobalamin, and N-acetyl-cysteine) slowed regional brain atrophy. Thirty HHcy patients with AD and related disorders (ADRD) received CFLN (HHcy+CFLN: duration [µ ±  σ] = 18.6±16.1 months); a sub-sample of this group did not receive CFLN for varying periods of time (HHcy+NoCFLN: duration [µ ±  σ] = 12.6±5.6 months). Thirty-seven NoHHcy patients with ADRD did not receive CFLN (NoHHcy+NoCFLN: duration [µ ±  σ] = 13.3±17.7 months). No participant took supplemental B vitamins. Regional brain volumes were measured at baseline and end of study, and covariate-adjusted rates of hippocampal, cortical, and forebrain parenchymal (includes white matter) atrophy were predicted. The HHcy+CFLN group's hippocampal and cortical atrophy adjusted rates were 4.25 and 11.2 times slower than those of the NoHHcy+NoCFLN group (p < 0.024). The HHcy+CFLN group's forebrain parenchyma atrophy rate was significantly slower only for CVD; the rate of slowing was proportional to the degree of homocysteine lowering (p < 0.0001). CFLN was associated with significantly slowed hippocampal and cortical atrophy rates in ADRD patients with HHcy, and forebrain parenchymal atrophy rates in CVD patients with HHcy. The present results should be further validated.

Vitamin B supplementation, homocysteine levels, and the risk of cerebrovascular disease: a meta-analysis.

OBJECTIVE: To perform a meta-analysis on the effect of lowering homocysteine levels via B vitamin supplementation on cerebrovascular disease risk. METHODS: Using clinical trials published before August 2012 to assess stroke events, we used relative risks (RRs) with 95% confidence intervals (95% CIs) to measure the association between B vitamin supplementation and endpoint events using a fixed-effects model and χ(2) tests. We included 14 randomized controlled trials with 54,913 participants in this analysis. RESULTS: We observed a reduction in overall stroke events resulting from reduction in homocysteine levels following B vitamin supplementation (RR 0.93; 95% CI 0.86-1.00; p = 0.04) but not in subgroups divided according to primary or secondary prevention measures, ischemic vs hemorrhagic stroke, or occurrence of fatal stroke. There were beneficial effects in reducing stroke events in subgroups with ≥3 years follow-up time, and without background of cereal folate fortification or chronic kidney disease (CKD). Some trials that included CKD patients reported decreased glomerular filtration rate with B vitamin supplementation. We conducted detailed subgroup analyses for cyanocobalamin (vitamin B12) but did not find a significant benefit regarding intervention dose of vitamin B12 or baseline blood B12 concentration. Stratified analysis for blood pressure and baseline participant medication use showed benefits with >130 mm Hg systolic blood pressure and lower antiplatelet drug use in reducing stroke risk. CONCLUSIONS: B vitamin supplementation for homocysteine reduction significantly reduced stroke events, especially in subjects with certain characteristics who received appropriate intervention measures.

Association between fish consumption, long chain omega 3 fatty acids, and risk of cerebrovascular disease: systematic review and meta-analysis.

OBJECTIVE: To clarify associations of fish consumption and long chain omega 3 fatty acids with risk of cerebrovascular disease for primary and secondary prevention. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Studies published before September 2012 identified through electronic searches using Medline, Embase, BIOSIS, and Science Citation Index databases. ELIGIBILITY CRITERIA: Prospective cohort studies and randomised controlled trials reporting on associations of fish consumption and long chain omega 3 fatty acids (based on dietary self report), omega 3 fatty acids biomarkers, or supplementations with cerebrovascular disease (defined as any fatal or non-fatal ischaemic stroke, haemorrhagic stroke, cerebrovascular accident, or transient ischaemic attack). Both primary and secondary prevention studies (comprising participants with or without cardiovascular disease at baseline) were eligible. RESULTS: 26 prospective cohort studies and 12 randomised controlled trials with aggregate data on 794,000 non-overlapping people and 34,817 cerebrovascular outcomes were included. In cohort studies comparing categories of fish intake the pooled relative risk for cerebrovascular disease for 2-4 servings a week versus ≤ 1 servings a week was 0.94 (95% confidence intervals 0.90 to 0.98) and for ≥ 5 servings a week versus 1 serving a week was 0.88 (0.81 to 0.96). The relative risk for cerebrovascular disease comparing the top thirds of baseline long chain omega 3 fatty acids with the bottom thirds for circulating biomarkers was 1.04 (0.90 to 1.20) and for dietary exposures was 0.90 (0.80 to 1.01). In the randomised controlled trials the relative risk for cerebrovascular disease in the long chain omega 3 supplement compared with the control group in primary prevention trials was 0.98 (0.89 to 1.08) and in secondary prevention trials was 1.17 (0.99 to 1.38). For fish or omega 3 fatty acids the estimates for ischaemic and haemorrhagic cerebrovascular events were broadly similar. Evidence was lacking of heterogeneity and publication bias across studies or within subgroups. CONCLUSIONS: Available observational data indicate moderate, inverse associations of fish consumption and long chain omega 3 fatty acids with cerebrovascular risk. Long chain omega 3 fatty acids measured as circulating biomarkers in observational studies or supplements in primary and secondary prevention trials were not associated with cerebrovascular disease. The beneficial effect of fish intake on cerebrovascular risk is likely to be mediated through the interplay of a wide range of nutrients abundant in fish.

Fish, n-3 fatty acids, and cardiovascular diseases in women of reproductive age: a prospective study in a large national cohort.

Previous studies have indicated a protective effect of long-chain n-3 polyunsaturated fatty acids (LCn3FAs) against cardiovascular disease; however, women are underrepresented in cardiovascular research. The aim of this study was to explore the association between intake of LCn3FAs and the risk of cardiovascular disease in a large prospective cohort of young women (mean age at baseline: 29.9 years [range: 15.7-46.9]). Exposure information on 48 627 women from the Danish National Birth Cohort was linked to the Danish National Patients Registry for information on events of hypertensive, cerebrovascular, and ischemic heart disease used to define a combined measure of cardiovascular diseases. Intake of fish and LCn3FAs was assessed by a food-frequency questionnaire and telephone interviews. During follow-up (1996-2008; median: 8 years), 577 events of cardiovascular disease were identified. Low LCn3FA intake was associated with an increased risk of cardiovascular disease (adjusted hazard ratio for women in lowest versus highest LCn3FA intake group: 1.91 [95% CI: 1.26-2.90]). Restricting the sample to women who had consistently reported similar frequencies of fish intake across 3 different dietary assessment occasions tended to strengthen the relationship (hazard ratio for lowest versus highest intake: 2.91 [95% CI: 1.45-5.85]). Furthermore, the observed associations were consistent in supplementary analyses where LCn3FA intake was averaged across the 3 dietary assessment occasions, and the associations were persistent for all 3 of the individual outcomes. Our findings based on a large prospective cohort of relatively young and initially healthy women indicated that little or no intake of fish and LCn3FAs was associated with an increased risk of cardiovascular disease.

[Is a high intake of fruits and vegetables related to a lowered risk of cerebrovascular disease?]. / Er højt indtag af grøntsager og frugt forbundet med nedsat risiko for cerebrovaskulaer sygdom?

The scientific evidence for a beneficial effect of an increased intake of fruits and vegetables rests on nine cohort studies. All cohort studies have shown a risk reduction in groups with high intakes of vegetables and/or fruits compared to groups with low intakes. The risk reduction has been about 30% in the scientifically best conducted studies. Further, many studies have demonstrated a dose-response association. It is not known if specific vegetables and fruits, or single nutrients alone, are particularly beneficial. A high intake of vegetables and fruits to reduce the risk of stroke should therefore be recommended.

Nutrición basada en la evidencia en las enfermedades neurológicas / Evidence-based nutrition in neurological diseases

Las enfermedades neurológicas suponen una causa importante de morbilidad en los países desarrollados y, con frecuencia, conllevan alteraciones en el nivel de conciencia o en los mecanismos de la deglución que pueden hacer necesario un soporte nutricional artificial. La presente revisión tratará de evaluar, basándose en la mejor evidencia científica disponible, el soporte nutricional en la enfermedad cerebrovascular aguda, la demencia y la esclerosis lateral amiotrófica, así como la utilidad de la dieta cetogénica en el tratamiento de la epilepsia. Se realizó una búsqueda bibliográfica en MEDLINE (PubMed) y en la Cochrane Library Plus en español, y se seleccionaron estudios clínicos aleatorizados, revisiones sistemáticas y metaanálisis. Existen escasos ensayos prospectivos aleatorizados sobre soporte nutricional en enfermedades neurológicas. El estudio FOOD muestra que la sonda nasogástrica es mejor vía que la gastrostomía endoscópica percutánea para la nutrición enteral en el primer mes tras un ictus. En el caso de la demencia y otras enfermedades neurodegenerativas, las evidencias disponibles son débiles. No hay pruebas fiables procedentes de ensayos controlados aleatorizados que apoyen el uso de dietas cetogénicas en los pacientes con epilepsia (AU)

Neurological disease causes considerable morbidity in developed countries and frequently leads to alterations in the level of consciousness or in the mechanisms of swallowing, which may necessitate artificial nutritional support. The present review aims to evaluate nutritional support in acute cerebral vascular disease, dementia and amyotrophic lateral sclerosis, as well as the utility of a ketogenic diet in the treatment of epilepsy, based on the best available scientific evidence. A literature search was performed in Medline (PubMed) and in the Cochrane Library Plus in Spanish. Randomized clinical studies, systematic reviews, and meta-analyses were selected. There are few prospective randomized studies on nutritional support in neurological diseases. The FOOD study shows that the nasogastric tube is a better route of administration than percutaneous endoscopic gastrostomy for enteral nutrition in the first month after stroke. In the case of dementia and other neurodegenerative diseases, the available evidence is weak. There are no reliable data from randomized controlled trials that support the use of ketogenic diets in patients with epilepsy (AU)

[Nuts, cardio and cerebrovascular risks. A Spanish perspective]. / Frutos secos y riesgo cardio y cerebrovascular. Una perspectiva espanñola.

Nuts have been included in human diets for ages. They are very appreciated and used as a central component of sweets and desserts. However, during the last decades, scientific interest in those foods has increased enormously as many epidemiologic studies show protective effects of nut consumption on coronary heart disease in different population groups. To date, many clinical trials have analyzed the positive effects of nuts consumption (almond, walnut, pistachio, Macadamia nut, and pecan) on the lipid profile, decreasing total and low density lipoproteins (LDL) cholesterol. However, whether these effects are only due to their fatty acid composition or to any other bioactive compounds, such as tocopherols, phytosterols and phytoestrogens, it is still unknown. This paper, aims to review comparative composition aspects of nuts, such as the positive effects on body weight, lipoprotein metabolism, and protection against cardiovascular and cerebrovascular diseases. The inclusion of 25 g/day of nuts, mainly raw, into a prudent diet seems to be recommended. Further investigations, as actual information is still scarce, in order to dilucidate the relationship between nuts consumption and vascular diseases are proposed.

Preventing glycaemic excursions in diabetic patients requiring percutaneous endoscopic gastrostomy (PEG) feeding after a stroke.

AIMS AND METHODS: Enteral feeding for diabetic patients with a stroke is often associated with hyperglycaemia and/or hypoglycaemia, which can adversely influence neurological recovery. We have developed a structured enteral feeding programme aimed at establishing 'normal' feeding patterns and avoiding marked glycaemic excursions. RESULTS: Of 332 consecutive patients admitted to an acute stroke unit, 20 of 41 diabetic patients required PEG feeding. Over the initial 24-48 h, patients had 22- h feeds with continuous intravenous infusion of soluble insulin. Thereafter, they were established on three feeds per day. Soluble insulin was given prior to each feed with isophane insulin at 2200 h. Average duration of feed was 13 +/- 8 days with an achieved glucose level of 8.7 +/- 2.5 (mean +/- SD) mmol/l associated with 0.8 episodes of biochemical hypoglycaemia (< 3 mmol/l) each week. CONCLUSIONS: A structured enteral feeding programme for PEG-fed diabetic patients can improve the quality of care with avoidance of marked glycaemic excursions.

Multivitamin/mineral supplementation improves plasma B-vitamin status and homocysteine concentration in healthy older adults consuming a folate-fortified diet.

Elevated homocysteine has been identified as an independent risk factor for cardiovascular and cerebrovascular disease. Although multivitamin use has been associated with low plasma homocysteine concentrations in several observational studies, no clinical trials have been conducted using multivitamin/mineral supplements to lower homocysteine. We determined whether a multivitamin/mineral supplement formulated at about 100% Daily Value will further lower homocysteine concentration and improve B-vitamin status in healthy older adults already consuming a diet fortified with folic acid. In this randomized, double-blind, placebo-controlled trial, 80 free-living men and women aged 50-87 y with total plasma homocysteine concentrations of > or =8 micromol/L received either a multivitamin/mineral supplement or placebo for 56 d while consuming their usual diet. After the 8-wk treatment, subjects taking the supplement had significantly higher B-vitamin status and lower homocysteine concentration than controls (P: < 0.01). Plasma folate, pyridoxal phosphate (PLP) and vitamin B-12 concentrations were increased 41.6, 36.5 and 13.8%, respectively, in the supplemented group, whereas no changes were observed in the placebo group. The mean homocysteine concentration decreased 9.6% in the supplemented group (P: < 0.001) and was unaffected in the placebo group. There were no significant changes in dietary intake during the intervention. Multivitamin/mineral supplementation can improve B-vitamin status and reduce plasma homocysteine concentration in older adults already consuming a folate-fortified diet.

Current feeding policies for patients with stroke.

It is well known that policies for feeding patients who have suffered a recent stroke vary enormously. The choice of method used may depend on the severity of the stroke, i.e. swallowing ability, conscious level, ability to communicate and the level of sensory and motor dysfunction. Other considerations may include age and previous nutritional status. However, in the absence of evidence from controlled clinical trials, the preferences of individual physicians and nurses may have a significant influence. As part of the preparatory work before the start of a clinical trial of different feeding policies, the author wished to assess both the degree of variability of feeding practice on wards in the same hospital and also whether there were reasons other than lack of evidence which influenced feeding policies. One nurse from each of 19 wards (one neurology, nine medical and nine care of the elderly) in two hospitals of the same trust was interviewed to ascertain their current feeding practice for patients with stroke. The results showed the expected variability in feeding practice, possibly reflecting the uncertainties felt by physicians and nurses in this area. However, many comments revealed the concerns that nurses have in trying to meet the nutritional needs of their stroke patients in busy acute general hospitals.

Consumption of fruit and wine and the decline in cerebrovascular disease mortality in Spain (1975-1993).

BACKGROUND AND PURPOSE: This study examines the changes in provincial distribution of cerebrovascular disease (CVD) mortality and its socioeconomic and lifestyle risk factors to identify those factors that have most greatly contributed to the decline in CVD mortality in Spain during the period 1975-1993. METHODS: We performed a study using data aggregated at a provincial level. Mortality data were taken from official vital statistics, while data on risk factors were obtained from surveys of representative large Spanish population samples. Correlation and multiple linear regression analyses were performed on percent changes in age-standardized CVD mortality from 1975-1979 to 1989-1993 and its potential determinants during the period 1964-1980. RESULTS: CVD mortality was higher in the southern and eastern (Mediterranean coast) provinces in 1975-1979 and again in 1989-1993. Between these periods there was a 55% decline in CVD mortality, which affected all provinces but was greater in those with a lower CVD mortality (r = -0.31, P = 0.03). The 1964-1980 period witnessed an increase in the intake of most foodstuffs and all types of fats. However, there was a decrease in the consumption of vegetables and legumes and in the proportion of illiteracy among the population older than 45 years. The greatest increase in fruit and fish consumption and the greatest decrease in illiteracy were registered by Spain's northernmost provinces, the same provinces that recorded the greatest decline in CVD mortality. Changes in fruit, wine, and fish intake accounted for 22% of the variation in the decline in CVD mortality. The increase in fruit consumption and decrease in wine consumption showed a statistically significant relationship (P < or = 0.04) with the decline in CVD mortality. CONCLUSIONS: The increase in fruit and decrease in wine consumption from 1964-1980 may have contributed to the decline in CVD mortality in Spain during 1975-1993.

[Reduction in frequency of pneumonia after stroke, following programmed swallowing evaluation].

Aspiration pneumonia is a frequent complication of cerebrovascular accidents (CVA). It occurs mainly in those with post-CVA swallowing disorders, which can be diagnosed by bedside swallowing evaluation. Evaluation is based on observation of components of the oral and pharyngeal stages of swallowing a drink of 50 ml of clear liquid. Changing the consistency of the diet and the mode of swallowing, following its evaluation, can reduce significantly the frequency of post-CVA aspiration pneumonia. In 180 patients admitted for stroke rehabilitation, aspiration pneumonia occurred in 10% and swallowing disorders were found in 28%. Planned swallowing evaluation followed by the above regimen was associated with a gradual reduction of pneumonia from 16% in the first group of 60 patients to 3% in the second group of 60; and of patients with dysphagia, from 27% in the first group to none in the second.

Protective effects of soy protein on the peroxidizability of lipoproteins in cerebrovascular diseases.

To study the mechanism of dyslipoproteinemia, lipoproteins [very low density lipoprotein (VLDL), low density lipoprotein (LDL) and high density lipoprotein (HDL)] were isolated from stroke patients and healthy persons by ultracentrifugation. Lipoproteins were dialyzed into copper dichloride solution to study the effects of soycreme administration on lipoprotein peroxidation. Blood was drawn from 15 patients with cerebral thrombosis who were not administered soycreme, 10 patients with cerebral thrombosis who were administered soycreme and 11 healthy persons. The lipoproteins were dialyzed into 5 mol/l copper dichloride solution for various lengths of time, and then lipid constituents in the lipoproteins were measured by thin-layer chromatography. After the dialysis, percentages of cholesteryl ester and triglyceride in various lipoproteins decreased significantly (P < 0.05 or 0.01) in both patient groups and in healthy persons. Spot X1 was found between triglyceride and free fatty acid on the thin-layer chromatography, and spot X2 was located between free fatty acid and free cholesterol after dialysis. Spots X1 and X2 reflect lipoprotein peroxidation. Percentages of these spots were higher in VLDL, LDL and HDL in the patient groups than in the healthy subjects. Soycreme administration suppressed the appearance of spots X1 and X2. Furthermore, blood cholesterol concentrations were reduced by the administration of soy protein. Thus, soy may be useful in the prevention and/or treatment of atherosclerosis.

Percutaneous endoscopic gastrostomy tube feeding may improve outcome of late rehabilitation following stroke.

We describe three stroke patients with prolonged swallowing difficulty whose rehabilitation had been unsuccessful due to recurrent aspiration pneumonia and/or nasogastric tube dislodgement. Percutaneous endoscopic gastrostomy tube feeding, initiated 4-6 months following the onset of stroke, was associated with nutritional improvement, marked functional recovery and eventual discharge from hospital. This form of nutritional support may find an important role in the rehabilitation of stroke patients with persisting difficulty with swallowing.

Stroke: cardiovascular risk factors and the quantitative effects of dietary treatment on them.

A quantitative analysis of the cardiovascular risk factors in 101 stroke patients and their reduction by dietary treatment is given. From the risk factors a risk index was calculated. It was reduced from an average 4.9 at admission to 1.4 at discharge. The most frequent risk factors at admission (high triglycerides, high blood pressure and a high LDL/HDL ratio) are probably caused by 'normal' alcohol consumption and overweight. All patients were disused from smoking and alcohol. Under a low-caloric diet all risk factors were reduced within one month. Most diabetic patients became independent of drug treatment: A treatment of type II diabetes mellitus with oral antidiabetic drugs could be avoided even in the elderly patients by a low caloric diet without alcohol. On average there was a 4.8 mg% decrease of fasting triglycerides and a 5.7 mg% decrease of total cholesterol per 1% Broca Index reduction. HDL was increased in all patients despite withdrawal of alcohol, and the HDL/LDL ratio was significantly improved by the diet. There was a significant blood pressure reduction in the whole group; in addition there was a weight-related reduction in the hypertensive patients only: the systolic blood pressure was reduced by 9.3 mm Hg for each 10% Broca Index decrease. The atherogenic and hypertensive potencies of 'normal' alcohol consumption and sulfonylurea treatment are emphasized.