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Best nutrition practice across the stroke care continuum: Using PEN & other evidence-based information sources. E Eppler, Vancouver, British Columbia. Introduction/Background.
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E Eppler, Vancouver, British Columbia
Best practices are recommendations that are supported by research evidence andinformed by expert perspective, judgment and experience. Best practices produce effective health outcomes.
Stroke Care Best Practices describe the most effective policies, processes and interventions for stroke prevention, treatment and rehabilitation (1, 2). This poster describes a dietitian's experiences using the evidence-based practice cycle to determine best nutrition practice across the continuum of stroke care.
Figures 1 & 2, below,depict the evidence-based practice cycle and best practice, respectively.
Research generates evidence used in developing best practice
Best Practice Resources
Connect research and practice
Expert judgment is used in conducting systematic reviews and applying the evidence-based practice cycle.
The dietitian applies and adapts resources to the specific context; e.g. Acute neurosciences unit, rehab facility.
Table 1. Selected results of PEN searches using “stroke” and related terms.
1) Achieve and maintain a BMI < 25 2) exercise3) fruit and vegetable intake 4) Restrict simple CHO5) Fat intake: proportion of MUF and PUF; proportion of SF and trans fats to <7% of total kcal; intake of omega-3 FA from fish and plant sources.
Practice Guidance Summary
What nutrition strategies can prevent cardiovascular disease (CVD)?
BackgroundOmega-3 fatty acids, fish oil, alpha-linolenic acid
This document provides a grading of evidence for the effects of omega-3 fatty acids, fish oil, alpha-linolenic acid for a variety of conditions (e.g….stroke….).
Key Practice Point
Achieving and maintaining a healthy Body Mass Index (18.5-24.9), appropriate waist circumference (88 cm F; 102 m M) and waist-to-hip ratio (0.85 F; 0.90 M) can prevent CVD.
1) Follow DASH Diet Guidelines2) sodium intake to 2400 mg (100 mmol) per day 3) fibre intake to 25 to 30 grams per day especially foods rich in soluble fibre 4) A diet rich in potassium, calcium and magnesium is encouraged 5) …there is currently insufficient evidence to promote folic acid supplementation… 6) Maintain a healthy BMI and waist circumference 7) alcohol consumption to a maximum 2 drinks per day
Practice Guidance Summary –
excerpts from Prevention of Hypertension
Does an adult with hypertension, who adheres to healthy lifestyle practices … have better blood pressure control and therefore a lower risk or delayed incidence of stroke?
A summary of the graded evidence supporting the prevention and treatment of hypertension.
Information on hypertension, including causes, diagnosis, and management
Key Practice Point
Lifestyle modifications can reduce the use and hence cost of antihypertensive medications and should be continued in conjunction with drug therapy. (A)
Next, the CSS’s Best Practice document (1) and several key references listed in the CSS’s Best Practices and Standards Environmental Scan Report(2)were accessed via the Web and evaluated for their nutrition content (see Table 2 and Figure 6).
“Diet has an impact on a number of risk factors and can provide additional benefits to pharmacological
interventions in people with vascular disease.”Figure 6. Sample content from selected key best practices documents
Management of patients with stroke: Identification and management of dysphagia (SIGN)
Canadian Best Practice Recommendations for Stroke Care: 2006
“All patients with stroke should have their swallow screened prior to initiating oral intake of fluids or food utilizing a simple valid reliable bedside testing protocol.”
“Early and regular screenings of patients for undernutrition is important.”
Best Practice Guidelines (Ontario)
Clinical Guidelines for Stroke Rehabilitation & Recovery (Australia)
“Determine feeding method based on swallowing
assessment or monitoring.
Implement safe diet texture and therapeutic diet.”
Nutrition element from acute care guide, day 2
Section on secondary prevention
The information gathered from these best practice resources will be applied to these three current projects:
1. Best Practices and Standards Working Group, The Canadian Stroke Strategy. Canadian Best Practice Recommendations for Stroke Care: 2006. <http://www.canadianstrokestrategy.ca/technical_docs.htm>. Accessed 26 April 2007.
2. Best Practices and Standards Working Group, The Canadian Stroke Strategy. Best Practices and Standards Environmental Scan Report <http://www.canadianstrokestrategy.ca/technical_docs.htm>. Accessed 26 April 2007.
3. Dietitians of Canada’s Practice-Based Evidence in Nutrition: PEN.<http://www.dieteticsatwork.com/pen/>. Accessed 26 April 2007.
4. Heart and Stroke Foundation of Ontario, Ontario Stroke System. Best Practice Guidelines. <http://22.214.171.124/Page.asp?PageID=122&ContentID=932&CategoryID=73>. Accessed 26 April 2007.
5. Scottish Intercollegiate Guidelines Network. Management of patients with stroke. Identification and management of dysphagia. September 2004. <http://www.sign.ac.uk/guidelines/published/index.html>. Accessed 26 April 2007.
6. National Stroke Foundation, Australia. National Clinical Guidelines for Acute Stroke Management. <http://www.strokefoundation.com.au/pages/article.aspx?id=1&articleid=ArticleID2006526135335&pageId=159&HandlerId=1>. Accessed 26 April 2007.
Photo used in Figure 2: Under the bridge by MissBeckles. Posted on Flickr under a Creative Commons Attribution-NonCommercial-ShareAlike 2.0 license. <http://www.flickr.com/photos/missbeckles/3375396/>. Accessed 22 April 2007.