Nutrition and hydration
Bonus episode, 15 March 2017
To mark Nutrition and Hydration Week 2017, we’re taking a look at how to make sure you eat and drink well after a stroke.
Our guest is Alana Stewart from the Stroke Foundation. Alana is a speech pathologist with a Masters in Human Nutrition, who currently runs the StrokeConnect Follow-up service in Victoria.
Thanks also go to Jacqui Heward, Accredited Practising Dietitian and member of the Dietitians Association of Australia, who provided some of the content.
This podcast was brought to you by Nestlé Health Science.
Announcer: Welcome to the EnableMe podcast where we bring together stroke survivors, health professionals, and researchers providing you with practical advice, to enable you on your journey to reclaim your life after stroke.
You can join the conversation at enableme.org.au.
This series is presented by Australia's national Stroke Foundation.
Chris: Welcome to a special bonus episode of the EnableMe podcast series produced by the Stroke Foundation. This bonus podcast is on the topic of nutrition and hydration after stroke and is brought to you by Nestlé Health Science.
We're doing this special episode this week because it's Nutrition and Hydration Week. This is an international celebration of the importance of getting enough of the right food and drink to stay at your best. It's especially important to think about this if you're over the age of 60, but what about if on top of that, you've also had a stroke.
To find out more about eating and drinking well after a stroke, we have with us today Alana Stewart from the Stroke Foundation. Alana is a speech pathologist by profession and she also has a master's in Human Nutrition.
Thanks for coming in, Alana.
Alana: Thanks for having me, Chris.
Yes, as Chris said, I'm a speech pathologist and I'm also really interested in nutrition as well. I've had a helping hand from Jacqui Heward, Accredited Practising Dietitian and member of the DAA who has helped out with some of the content in today's podcast. Thank you, Jacqui.
Chris: Sounds like we've got the right people involved. I'm sure people listening to this know that stroke can have a huge impact physically, but also on your general wellbeing and quality of life.
Alana: Most definitely, Chris, as stroke can affect all facets of somebody's life, whether it be, yeah, their movement or their communication, their thinking, their swallowing, their ability to participate in life. We know that stroke survivors are much more likely to experience depression post-stroke and to have reduced quality of life because they may have difficulty carrying out roles and responsibilities that they previously had. They may not be able to return to work and provide an income for their family or they may not be able to drive their car and those things can have a really profound impact on someone.
Chris: We're here today to talk about nutrition and hydration for, as I said, Nutrition and Hydration Week. A bit of a mouthful, what do we actually mean when we talk about nutrition and hydration?
Alana: Generally, the term nutrition relates to energy or calories, and carbohydrates, protein, and the fat content of your food. But it also includes vitamins and mineral content as well. We refer to your daily food and drink consumption as your diet.
For stroke patients, we talk about nutrition in terms of what the body needs for recovery, but also how dietary changes can help them prevent from having another stroke.
In terms of hydration, that refers to the water that we consume in either food or drinks and we know that hydration is a really important part of health and that stroke survivors are at a high risk of dehydration due to poor appetite and mobility, drowsiness, and swallowing problems.
Chris: Now, I think it's important just to emphasise a point you made there, which was that when we use the word diet here, we're not talking about the common usage, which is like a weight loss plan.
Chris: This is just, yeah, what do you eat and drink basically, isn't it?
Alana: I think that's a really good differentiation to make, Chris, and the right diet after having a stroke is going to be different for every single stroke survivor. Generally, it's important to obviously implement strategies to prevent another stroke in the future and that's where we recommend reducing your saturated fat and salt intake, and increasing your fruit and vegetable intake.
Chris: Is there a reason for those particular recommendations?
Alana: Yeah. We know that a diet high in saturated fat is linked to a person having high cholesterol and possibly being overweight and obese, and those are two major risk factors for stroke. Then if we look at salt intake, that correlates to a person's blood pressure. A diet high in salt may affect somebody's blood pressure. They may then have high blood pressure, which is known as hypertension, and that's the number one risk factor for stroke. Where we can, we try and make some changes to the person's diet to reduce that risk.
Chris: Then there's also increasing the things they should be eating, which as you said were things like fruit and vegetables.
Alana: Definitely. Obviously, whole grains are really important as well. Those kind of foods will give you the energy and the nutrients that you need to support you in your recovery.
Chris: Now this is I believe similar to the general guidelines for everybody, is that correct?
Alana: Absolutely. The Australian Guide to Healthy Eating is a fantastic resource and I would recommend that listeners have a look online. If they go to www.eatforhealth.gov.au, you'll find a range of really user friendly resources looking at the ... It's no longer a food pyramid. It's a food graph that looks at the foods that we should be eating and the quantities of those as well, as well as ideas around how to prepare food, how to store food, and how to follow those guidelines in a really practical way.
Chris: I guess though specifically when we’re thinking about stroke, it can be challenging for some people with a stroke to actually make sure they get the right diet and they get the right nutrition that they need. What can be an indication that something is going wrong?
Alana: One of the main indicators can be a person having poor appetite. It could be that they have nausea or vomiting and maybe changes in their bowel habits or drowsiness or the swallowing problems that I mentioned earlier. If these symptoms persist, they can lead to poor intake, weight loss, and then even malnutrition. We really need to get this controlled because it's going to have a major impact on the person's recovery. It could prolong their hospital stay, for example, or it could prolong their stroke recovery and then it could lead to poorer outcomes as well, so really important that we're eating the right foods.
Chris: How do we make sure that we're picking up these things where things are not right?
Alana: In the hospital setting, you'll have a dietitian and a speech pathologist who are working together to make sure that you're swallowing safely and that you're eating and drinking the right food. The dietitian would assess a person and look at their diet and provide strategies or ideas or they might recommend certain supplement products to help the person get the calories and nutrients that they need, so it's very individualised. Outside of that hospital environment, it's about working with your GP to still access those services so getting a referral to a dietitian and starting that process there.
Chris: Now thinking specifically about some of the effects of stroke that can make it hard to keep up with an adequate diet, you've got things like fatigue, which can make you too tired or you can lose a sense of taste, which I'm sure makes food unappetising. Is there anything that can help with these kind of problems?
Alana: Fatigue post-stroke is extremely common and yeah, fatigue can affect how much a person eats. It takes energy to prepare a meal. It takes energy to shop and buy the food and then, to actually sit down and consume that meal. There are a number of different ways or strategies that can be used to make sure that the person's getting what they need to eat. That might be things such as having small, frequent meals. Making the most of times when the person's really awake and even possibly providing them with assistance or encouragement to eat. In some cases, supplement drinks otherwise known as protein drinks that are concentrated and calories and protein can be given as well just to maximise that when they are eating, they're getting as much as they can from their food.
Chris: And this loss of taste sensation?
Alana: It can be related to a number of different things. Often after a stroke, a person may start some new medications. Medications do have side effects and one of those can be taste changes or taste loss. Oral hygiene also has a big impact on taste as well.
Chris: What do you mean by that? Is that ...
Alana: How clean you're keeping your mouth.
Chris: Brushing your teeth, that kind of thing, yeah.
Alana: Absolutely, absolutely. Brushing your teeth, your tongue and your gums, it's really, really important to keep a clean mouth. For all those listeners out there, we really encourage brushing your teeth and your tongue and your gums twice a day every day.
In terms of how to manage those taste changes, we look at what foods are best tolerated or enjoyed by the stroke survivor and then, we can work with them to explore other foods in that group. We may change the temperature of foods to make it more appealing and then the dietitian may work with that person to look at if they've got any deficiencies or if there's any other reason why that taste loss is occurring.
Chris: Now you mentioned swallowing problems a few times. I want to find out what effect that has on nutrition and hydration. First of all, can I just ask, you're a speech pathologist, why are the speech pathologists the ones who take care of your swallowing?
Alana: Because we are. No, that's not a good enough reason. Everything that goes on in the head and the neck, I like to think of speech pathologists, we work with the shoulders up, so we're talking, we're communicating, and we're swallowing, we're voice, we're all of those things. I think it does fit really nicely with our profession. Communication and eating give a person so much joy and happiness in their life. I know they're two of my favourite things, so yeah, why not.
Chris: How does it affect then, yeah, what people eat and drink and what can be done about swallowing problems?
Alana: On average, a person swallows about 900 times per day. That's a lot and it's an activity that you don't really think about until possibly you've had a stroke and something's going wrong with those swallowing muscles or that swallowing function. We know that approximately 40% of stroke survivors do experience some swallowing difficulty.
The official term for that is dysphagia. That's either difficulty or discomfort in swallowing. This can be when as I said the stroke affects the muscles so either in the mouth or in the throat or in the oesophagus, or a person's cognition so their thinking may affect their ability to eat and drink safely. There are a number of different strategies and therapies that can support that person to eat and drink safely.
The first thing is that again, very individualised so the speech pathologist would work with the stroke survivor to find out the best management strategy. But there's products such as thickened fluids and modified diets. I can tell you more about those. There are also rehabilitation strategies to work on those muscles in the mouth and the throat to improve the swallow safety. Then there are strategies as well, so maybe a different style cup or a different size spoon to have an effect on the rate at which that person eats and drinks.
Chris: Yeah, I do want to find out more about these thickened fluids and modified diet. A thickened fluid does sound rather unappetising. Can you tell me more about those?
Alana: Yeah. There's different levels of thickness for thickened fluid and you may not have to take thickened fluids for the rest of your life after a stroke. It may just be for a stage in your recovery. We can thicken all sorts of fluids. We can thicken beer and wine. We can thicken milk, cups of tea, cups of coffee, hot or cold beverages. Really, you name it, it can be thickened.
We thicken that with a powder that's added to the drink or you can get pre-thickened products as well, which are much more user friendly. There's no effort required in preparation there. Really, important things to keep in mind there are the palatability of it, what does it taste like? Important to make sure that there are no lumps and that it's a really smooth consistency, and the person that's making the thickened fluid should really taste it themselves.
Chris: To make sure it actually is, yeah. What are the benefit of the thickened fluid though? Is it just that it makes it go down the right way or what is it?
Alana: Yes. Thickened fluids aren't for everybody and for some people, thickened fluids will make the person's swallowing more unsafe. Often the speech pathologist will conduct a swallow X-ray, where we try different thicknesses of fluid and we look at how that moves down the person's throat. This is very broadly speaking that thickened fluids move slower and that, therefore, they may give the stroke survivor more time to protect their airway when they swallow, but again not a general rule. The main message is the speech pathologist will figure out the right thickness and for how long you need to be drinking that thickened fluid.
Chris: What is the modified diet then that you mean?
Alana: Again, it's a bit of a continuum. You're looking at, let's look at a standard diet where a person would be eating all sorts of foods and then looking at a soft diet where things like apples, you wouldn't be munching on those. Maybe a person with poor dentition might be on a soft diet.
Chris: Dentition, that's…?
Alana: Teeth. Teeth, yeah, so maybe a person that has ill-fitting dentures or ulcers in the mouth, that sort of thing. Then we've got soft, moist. Then we've got minced. Then we move to puree.
Chris: Right, yeah. Any tips on making them more interesting to eat?
Alana: Similar tips for the thickened fluids in that we really need to think about the preparation of those foods. In hospital, that's all taken care of, but doing it in your own home, it can be a lot more challenging. Your speech pathologist should be able to work with you around the food preparation. You can buy pre-prepared or pre-modified meals, but there are other things like food moulds that can help make the puree food look more appealing on the plate, thinking still about presentation and food temperature and all those important things that we put effort into when we're cooking for ourselves.
Chris: I'm thinking Heston Blumenthal could do some wonderful things with these purees…
Alana: I'm sure he could, I'm sure he could. I do have one major thing to ask listeners though, is that if a person is on a puree diet, that you try not to mix all the different consistencies together on the plate. I mean, we want to make eating as enjoyable as possible and I think if we just stop and think about what we would want if we were eating their meal, that's really important.
Chris: It's that variety of texture and taste rather than just mixing them together, yeah.
Alana: Completely, completely. Potato and gravy won't cut it day-in, day-out. There definitely needs to be some variability there. A dietitian is a fantastic person to have on hand to advise on that as well.
Chris: You've given us a lot of great advice. Where could people go if they want to get more information?
Alana: They can come onto EnableMe and have a look at some of our dysphagia and nutrition resources. They can also give us a ring on StrokeLine and speak to either myself or another speech pathologist.
If you are experiencing swallowing difficulties and you haven't seen a speech pathologist and/or a dietitian in the past, it's about accessing those services. First port of call is your GP to get a referral, and then you may decide to go to the Dietitians Association of Australia website. They've got a ‘find a dietitian’ search engine that you can look up and see who's in your area and similarly, Speech Pathology Australia has a ‘find a speech pathologist’ search function there as well. If it's all too overwhelming, just call us on StrokeLine and we'll walk you through it.
Chris: Great. Thank you very much, Alana and to Jacqui for this fantastic information.
Just to repeat those details that Alana gave there, you can find information including our links to the dietitian and speech pathologist searches, you can also ask questions on the EnableMe website, that's enableme.org.au or you can call StrokeLine on 1-800-787-653. That's 1-800-STROKE.
That's it for today on this special bonus episode. If you like us, please help us out by giving us a good rating and review on iTunes. Once again, this bonus podcast was brought to you by Nestlé Health Science.
Announcer: That's all for today's EnableMe podcast. You can find out more on this topic and continue the conversation or listen to other podcasts in the series at our website enableme.org.au.
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The advice given here is general in nature and you should discuss your own personal needs and circumstances with your health professional. If you would like to suggest a topic or provide feedback, contact us via the website enableme.org.au.
The music in this podcast is "Signs" by stroke survivor, Antonio Iannella and his band, The Lion Tamers. It was recorded at Antonio's studio, which you can find out more about at www.studiofour99.org.au.