Diet pada Penyakit

Stroke dan Gangguan

Neurologis Kronis
BUDIYANTI WIBOWORINI
 Gangguan neurologis
 Terdapat 2 jenis gangguan neurologis:
- ok / terkait defisiensi gizi (Syndroma Korsakov ok def B1/ beri-
beri;alkoholisme; malabsorpsi)
- ok penyakit degenerative akut maupun kronik progresif
(cedera kepala berat; stroke; Parkinson, Alzheimer,
multiple sclerosis).
 Gangguan neurologis ini berisiko mengalami malnutrisi
Problem utama adalah karena berkurangnya kemampuan mendapat
makanan, mengunyah, dan menelan
Faktor Risiko
Stroke adalah gangguan fungsi otak akibat sumbatan atau perdarahan pada
pembuluh darah otak
Mortalitas tinggi
Faktor risiko:
- Modifiable: Hipertensi; lifestyle; CVD; merokok; drugs; alcohol;
kontrasepsi
- Non modifiable: usia; jenis kelamin; etnis; genetic
Gejala: hilangnya penglihatan, afasia, parese, paralise, gangguan mental,
disfagia, koma .. (tgt area)
Pencegahan Primer pada Stroke
Pada kelompok risiko tinggi yg belum pernah terserang
Dengan perbaikan gaya hidup dan mengendalikan faktor risiko
Meliputi:
- pola makan sehat
- penanganan stress
- istirahat cukup
- pemeriksaan kesehatan teratur
Rekomendasi Pola Makan
Rendah lemak dan kolesterol  u/ menambah sekresi asam empedu, meningkatkan
aktifitas estrogen dan isoflavon, memperbaiki elastisitas arteri dan meningkatkan aktifitas
antioksidan yang menghalangi oksidasi LDL
Jenis makanan yang telah terbukti:
- Serat larut: dalam biji-bijian seperti beras merah, bulgur, jagung
Mediteranian
- Oat (beta glucan): memperlambat pengosongan usus diet

- Kacang kedelai beserta produk olahannya

- Kacang-kacangan termasuk biji kenari dan kacang mede
- Makanan/zat yang mencegah peningkatan homosistein (asam folat,B6,
B12, riboflavin)
•Susu (mengandung protein, kalsium, Zn, dan B12) mempunyai efek proteksi
•Ikan tuna dan ikan salmon: mengandung omega-3, EPA dan DHA
•Makanan yang kaya vitamin dan antioksidan (vitamin C,E, dan betakaroten) -
banyak terdapat pada sayur-sayuran, buah-buahan, dan biji-bijian.
•Menambah asupan kalium, mengurangi natrium
•Mengutamakan asupan dari makanan, bukan suplemen
•Hindari makanan dengan densitas kalori dan lemak tinggi
•Menu seimbang, variasi
 Pencegahan Sekunder
Merupakan pengendalian terhadap faktor risiko modifiable
Hipertensi: pengurangan asupan garam; penurunan berat badan; olah
raga; no alcohol; diet kaya buah2an- low dairy product -- DASH diet
DM: pengendalian gula darah dengan diet dan olah raga; kp obat
Dislipidemia: pengaturan asupan lemak; kp statin
Sindroma metabolic: life style; penurunan BB
Obesitas: penurunan BB; pembatasan lemak
Stroke akut

Nutrisi enteral paling lambat sudah harus diberikan dalam 48 jam, nutrisi oral hanya boleh diberikan
setelah hasil tes fungsi menelan baik.
Bila terdapat gangguan menelan atau kesadaran menurun, maka makanan, nutrisi diberikan melalui
pipa nasogastrik.
Pada keadaan akut, kebutuhan kalori 25-30 kkal/kg/hari dengan komposisi:
· Karbohidrat 30-40 % dari total kalori;
· Lemak 20-35 % (pada gangguan nafas dapat lebih tinggi 35-55 %);
· Protein 20-30% (pada keadaan stress kebutuhan protein 1.4-2.0 g/kgBB/hari (pada gangguan
fungsi ginjal <0.8 g/kgBB/hari).
Apabila kemungkinan pemakaian pipa nasogastrik diperkirakan >6 minggu, pertimbangkan untuk
gastrostomi.
Pada keadaan tertentu yaitu pemberian nutrisi enteral tidak memungkinkan, boleh diberikan
secara parenteral.
Perhatikan diit pasien yang tidak bertentangan dengan obat-obatan yang diberikan. Contohnya,
hindarkan makanan yang banyak mengandung vitamin K pada pasien yang mendapat warfarin.
Hiperglikemia terjadi pada hampir 60% pasien stroke akut nondiabetes.
Hiperglikemia setelah stroke akut berhubungan dengan luasnya volume infark dan gangguan
kortikal dan berhubungan dengan buruknya keluaran.
Tidak banyak data penelitian yang menyebutkan bahwa dengan menurunkan kadar gula darah
secara aktif akan memperbaiki keluaran.
Hindari kadar gula darah melebihi 180 mg/dl
Rekomendasi untuk Pasien Disfagia
Tujuan terapi meliputi mengurangi komplikasi aspirasi, memperbaiki
kemampuan makan dan menelan, dan mengoptimalkan status nutrisi.
Pemberian cairan dilakukan setelah skrining disfagia untuk mengecek
kemampuan menelan
Identifikasi faktor risiko thd pneumonia aspirasi (merokok, penyakit pernafasan)
Jaga kebersihan mulut
Jenis diet menyesuaikan kondisi dan penyakit komorbid
Perhatikan asupan untuk mencegah malnutrisi
 Sobotka et al, 2011
Neurological impairment and food intake

Variable Description
Food aversion Food is tasted in the mouth and swallowing starts afterwards. If the
patient has a food aversion or dysgeusia (impaired taste) food can
be refused. This is quite important yet may not be at all recognized
if the patient is unable to communicate.
Chewing process The ability to chew food is essential; evaluate the dental state.
Dental prostheses should fit; fitting is likely to change with age or
malnutrition. Chewing disability demands texture changes; e.g.
pureed food
Dementia Progressive dementia changes food/ fluid intake because of
cognitive reduction, agnosia, apraxia, anosmia, ataxia, disturbed
hunger and thirst sensation and visual impairment
Variable Description
Aphasia, Depressed patients or those unable to communicate because of
depression their illness (e.g. Parkinson’s) are difficult to motivate in order to
optimize their nutritional intake. It may be difficult to evaluate
whether the food and fluid rejection related to motor impairment
or negative mood.
Constipation Bowel motility is often slower and together with little intake of
fluids and fibre can cause constipation, and appetite may decline. A
good laxative policy is of value
Medication Psychopharmacological, anti-cholinergic, analgesic may affect
swallowing and even cause dysphagia.
Reflux Gastrointestinal reflux often occurs; together with inability to
cough, and can lead to aspiration and pneumonia
 Swallowing function and appropriate diet
Chew Swallow Snacks Main meals Fluids
Reasonable Normal Soft bread, no crust, soft fruits No hard fried food, no bones, Normal hot or
(e.g. bananas, peach, pear) food should be well cooked cold fluids

Bad Normal Pureed food; custards; Pureed food; potatoes; Normal cold and
porridge; yoghurt; pureed vegetables; meat; steamed medium hot
soups or fruits; fruit juices fish fluids
Not able Normal Thick pureed food; porridge; Pureed meals; should be Thickened
custard; thickened or pureed thick without any crumbs
soups; yoghurt
Not able Patient can choke Thick pureed food; all foods of See snack meal Thickened; not
sometimes same consistence too hot or cold
Not able Patient chokes on Thick pureed food of same See snack meal All fluids should
fluids consistence be thickened
Not able Not able Check intake, nutritional status and prognosis; tube feeding decision?

Not able for > 4 weeks Consider Percutaneous endoscopic gastrostomy - Percutaneous endoscopic
jejunostomy placement
Perhatikan:
•Suhu: suhu dingin menstimulasi sensasi di mulut dan mempercepat menelan
•Keasaman: reseptor untuk menelan bereaksi lebih baik pada makanan asam
•Gula: memicu produksi saliva; menyulitkan menelan
•Bolus: makanan porsi besar sulit ditelan, lebih baik porsi kecil, frekuensi 6x/ hari
•Konsistensi: makanan cair dan lembek densitas energy dan nutrient rendah;
perhatikan kecukupan gizinya
•Saliva: produksi saliva yg berlebih akan makin menyulitkan menelan
 Dysphagia categories and management

Stages Physiology Management

No dysphagia No aspiration, normal No food/ fluid adaptation

swallow and cough reflex,
normal oral motility
Mild No aspiration present,
oropharyngeal normal swallow and cough
dysphagia reflex, slightly abnormal
oral motility
Moderate Incidental aspiration risk,
dysphagia normal swallow and cough
reflex, moderate oral
motility
Normal food per os, help unnecessary;
speech and language therapies should
advise the avoidance of certain food/
drinks or surrounding while eating
Food per os, change of consistency and/
or supplements will be necessary.
Patients will need help during meals and/
or advice to eat slowly
 Dysphagia categories and management 2
Stages Physiology Management

Moderate to Aspiration risk, swallow and cough Limited food of changed consistency per os, close
severe dysphagia reflex present though abnormal or guidance to the patient by qualified caregivers.
delaayed, disturbed oral motility Optimal nutritional intake may require
supplements and/or partial (nocturnal) tube
feeding
Severe dysphagia High aspiration risk, inadequate or Nill per os or tiny amounts of changed consistency
inconsistent swallow, absence of food, instruction and supervision by qualified
control of bollus swallowing caregivers. Enteral nutrition (tube feeding or PEG)
is often necessary; parenteral feeding is normally
considered only for extreme malabsorption
Very severe Aspiration present, no cough Nill per os; enteral nutrition (tube feeding or PEG)
dysphagia reflex, endotracheal suction is is necessary; parenteral feeding might be
necessary, absence of any oral/ considered for extreme malabsorption or severe
pharyngeal swallowing activity reflux
 Clinical application: Nutrition therapy in progressive neurological
Nutrition Problems
Inability to maintain adequate
oral intake
Involuntary weight loss
disorder
Nelm et al, 2007
Intervention
- Determine energy & protein requirements
- Establish food preferences
- Adjust size & timing of meals
- Maximize environmental support: light, noise, odor
- Allow for extended eating times
- Trial of high calorie, high protein supplements
- Determine for other nutrition support routes
- Determine energy & protein requirements
- Establish food preferences
- Increase nutrient density
- Adjust size & timing of meals
- Allow for extended eating times
- Trial of high calorie, high protein supplements
- Determine for other nutrition support routes
Nutrition Problems Intervention
Chewing difficulty - Physical assessment of oral cavity-need for mouth care
and dentures
- Adjust texture of foods according to need
- Provide adequate moisture
- Adaptive equipment as needed

Swallowing difficulty - Seated in arm-chair, table appropriate height

- Muscular support
- Swallowing evaluation
- Establish for dysphagia nutrition therapy if required

Impaired ability to - Assess current dietary intake

prepare foods/ meals - Establish current cooking facilities and access to food
- Referral for another sources of daily melas
Nutrition Problems Intervention
Inadequate fluid - Determine fluid requirements and establish method to
intake track intake
- Assess side effect of medication that might interfere with
adequate fluid intake
- Schedule small, frequent amounts of fluid
- Determine need for other nutrition support/ hydration
routes
Drug-nutrient - Complete assessment of current medication
interaction - Adjust timing of medications and meals to allow for
absorption and effectiveness of both medication and foods
- Limit specific foods thet interfere with drug absorption
- Coordinate drug ingestion to prevent nutrient
malabsorption
Monitoring
 Evaluasi
berkala harus dilakukan untuk memantau kecukupan gizi,
bersama dengan kondisi klinis
Penting dinilai:
- apakah perlu penyesuaian untuk cara pemberian/ rute
- ada tidaknya interaksi makanan dengan obat
- status gizi
Guideline
Referensi
Lakur S and Judd S.E. 2015. Diet and Stroke: Recent evidence supporting Mediterranean-Style
Diet and Food in the Primary Prevention of Stroke. Stroke. Vol 46: p 2007-2011.
Nelms M; Sucher K; Long S. 2007. Nutrition therapy and Pathophysiology. Thomson Wadsworth
Sobotka L (Eds). 2011. Basic in Clinical Nutrition 4th Ed. Galen
Wirth et al. 2013. Guideline clinical nutrition in patient with stroke. Experimental and
Transitional Stroke Medicine. 5(14): p 1-11.
Tugas Penilaian
https://classroom.google.com/c/MzExNzQ3ODk2NTY3?cjc=rffrxxn

Kode Kelas: rffrxxn