Linda S. Greene-Finestone

Malnutrition in stroke patients on the rehabilitation service and at follow-up: Prevalence and predictors

This prospective study presents the prevalence and risk factors of malnutrition in 49 consecutive stroke patients on the rehabilitation (Rehab) service and at 2- to 4-month follow-up. Malnutrition was diagnosed using biochemical and anthropometric data. Stroke patients, on admission to Rehab, have a very high prevalence of malnutrition. Malnutrition, 49% on admission, declined to 34%, 22%, and 19% at 1 month, 2 months, and follow-up, respectively. Dysphagia, 47% on admission, was associated with malnutrition (p = .032) and significantly declined over time. Using logistic regression, predictors of malnutrition on admission involved acute service tube feedings (p = .002) and histories of diabetes (p = .027) and prior stroke (p = .013). Tube feedings, associated with malnutrition on admission (p = .043), were more prevalent in brain stem lesion patients. Patients tube fed > or = 1 month during rehabilitation or at home were not malnourished. Malnutrition was associated with advanced (> 70 years) age at 1 month (p = .002) and weight loss (p = .011) and lack of community care (p = .006) at follow-up. Early and ongoing detection and treatment of malnutrition are recommended during rehabilitation of stroke patients both on the service and at follow-up.

The vitamin D status of Canadians relative to the 2011 Dietary Reference Intakes: an examination in children and adults with and without supplement use

BACKGROUND The 2011 Dietary Reference Intakes (DRIs) for vitamin D use 25-hydroxyvitamin D [25(OH)D] concentrations to define vitamin D deficiency (<30 nmol/L), the Estimated Average Requirement (40 nmol/L), and the Recommended Dietary Allowance (RDA; 50 nmol/L). The Canadian population has not yet been assessed according to these recommendations. OBJECTIVE We determined the prevalence of meeting DRI recommendations and the role of vitamin D supplement use among Canadians aged 6-79 y. DESIGN Plasma 25(OH)D from a representative sample of Canadians in the Canadian Health Measures Survey-Cycle 1 (n = 5306) were used. Supplement use was assessed by household interview. Concentrations of 25(OH)D were compared in supplement users and nonusers by season and race. RESULTS Overall, 5.4%, 12.7%, and 25.7% of the participants had 25(OH)D concentrations below the 30-, 40-, and 50-nmol/L cutoffs, respectively. In white Canadians, plasma 25(OH)D concentrations ranged from an undetectable percentage with concentrations <30 nmol/L in summer to 24.5% with concentrations <50 nmol/L in winter; the corresponding values ranged from 12.5% to 53.1% in nonwhite Canadians. Supplement users had significantly higher 25(OH)D concentrations than did nonusers, and no seasonal differences were found. In nonsupplement users, the prevalence of 25(OH)D concentrations <50 nmol/L in winter was 37.2% overall and was 60.7% in nonwhites. CONCLUSIONS One-quarter of Canadians did not meet the RDA, but the use of vitamin D supplements contributed to a better 25(OH)D status. Nonwhite Canadians had the highest risk of not achieving DRI recommendations. More than one-third of Canadians not using supplements did not meet the RDA in winter. This suggests that current food choices alone are insufficient to maintain 25(OH)D concentrations of 50 nmol/L in many Canadians, especially in winter.

Vitamin B-12 and homocysteine status in a folate-replete population: results from the Canadian Health Measures Survey

BACKGROUND Vitamin B-12 is an important cofactor required for nucleotide and amino acid metabolism. Vitamin B-12 deficiency causes anemia and neurologic abnormalities-a cause for concern for the elderly, who are at increased risk of vitamin B-12 malabsorption. Vitamin B-12 deficiency is also associated with an increased risk of neural tube defects and hyperhomocysteinemia. The metabolism of vitamin B-12 and folate is interdependent, which makes it of public health interest to monitor biomarkers of vitamin B-12, folate, and homocysteine in a folic acid-fortified population. OBJECTIVE The objective was to determine the vitamin B-12, folate, and homocysteine status of the Canadian population in the period after folic acid fortification was initiated. DESIGN Blood was collected from a nationally representative sample of ∼5600 participants aged 6-79 y in the Canadian Health Measures Survey during 2007-2009 and was analyzed for serum vitamin B-12, red blood cell folate, and plasma total homocysteine (tHcy). RESULTS A total of 4.6% of Canadians were vitamin B-12 deficient (<148 pmol/L). Folate deficiency (<320 nmol/L) was essentially nonexistent. Obese individuals were less likely to be vitamin B-12 adequate than were individuals with a normal BMI. A total of 94.9% of Canadians had a normal tHcy status (≤13 μmol/L), and individuals with normal tHcy were more likely to be vitamin B-12 adequate and to have high folate status (>1090 nmol/L). CONCLUSIONS Approximately 5% of Canadians are vitamin B-12 deficient. One percent of adult Canadians have metabolic vitamin B-12 deficiency, as evidenced by combined vitamin B-12 deficiency and high tHcy status. In a folate-replete population, vitamin B-12 is a major determinant of tHcy.

Temporal Trends and Determinants of Longitudinal Change in 25-Hydroxyvitamin D and Parathyroid Hormone Levels

Vitamin D is essential for facilitating calcium absorption and preventing increases in parathyroid hormone (PTH), which can augment bone resorption. Our objectives were to examine serum levels of 25‐hydroxyvitamin D [25(OH)D] and PTH, and factors related to longitudinal change in a population‐based cohort. This is the first longitudinal population‐based study looking at PTH and 25(OH)D levels. We analyzed 3896 blood samples from 1896 women and 829 men in the Canadian Multicentre Osteoporosis Study over a 10‐year period starting in 1995 to 1997. We fit hierarchical models with all available data and adjusted for season. Over 10 years, vitamin D supplement intake increased by 317 (95% confidence interval [CI] 277 to 359) IU/day in women and by 193 (135 to 252) IU/day in men. Serum 25(OH)D (without adjustment) increased by 9.3 (7.3 to 11.4) nmol/L in women and by 3.5 (0.6 to 6.4) nmol/L in men but increased by 4.7 (2.4 to 7.0) nmol/L in women and by 2.7 (−0.6 to 6.2) nmol/L in men after adjustment for vitamin D supplements. The percentage of participants with 25(OH)D levels <50 nmol/L was 29.7% (26.2 to 33.2) at baseline and 19.8% (18.0 to 21.6) at year 10 follow‐up. PTH decreased over 10 years by 7.9 (5.4 to 11.3) pg/mL in women and by 4.6 (0.2 to 9.0) pg/mL in men. Higher 25(OH)D levels were associated with summer, younger age, lower body mass index (BMI), regular physical activity, sun exposure, and higher total calcium intake. Lower PTH levels were associated with younger age and higher 25(OH)D levels in both women and men and with lower BMI and participation in regular physical activity in women only. We have observed concurrent increasing 25(OH)D levels and decreasing PTH levels over 10 years. Secular increases in supplemental vitamin D intake influenced both changes in serum 25(OH)D and PTH levels.

Measuring Longitudinally the Metabolic Demands of Stroke Patients Resting Energy Expenditure Is Not Elevated

Background and Purpose— Little is known of the acute, subacute, and longer-term energy demands of stroke, information essential to appropriate clinical and nutritional management. The goals of this study were to (1) determine the resting energy expenditure (REE) of stroke patients from stroke onset to 3 months, (2) examine relations between stroke size, type, location, severity, and REE, and (3) evaluate whether estimation of REE from the Harris-Benedict equation (HB) requires the addition of a “stress factor” to capture the possible additional REE imposed by stroke. Methods— The REE of new stroke patients was measured prospectively at hospital admission and on days 7, 11, 14, 21, and 90 by indirect calorimetry. Stroke patients’ REEs (Kcal/d) over time and REEs as a percentage of HB were compared with control subjects’ single measurements. Results— Mean REE and %HB of stroke patients ranged from 1521±290 to 1663±268 Kcal/d and from 107±14.9 to 114±12.9 %HB, respectively. Mean measurements of control subjects were 1665±265 Kcal/d and 112.9±11.4 %HB (NS). REE was not associated with stroke characteristics (NS). Changes in REE measured longitudinally were not clinically meaningful (4 to 62 Kcal/d) though statistically significant (P =0.004). Conclusions— The REEs of stroke patients and controls were both ≈10% higher than those predicted by HB. No hypermetabolic response pattern of energy expenditure was evident after stroke. REE did not vary with stroke characteristics, although confirmation with larger subgroups is required.

Driving and Reintegration Into the Community in Patients After Stroke

To investigate the relationship between driving versus not driving and community integration after stroke. Much research on patients who drive after experiencing a stroke has focused on driving assessment protocols; little attention has been given to the implications of assessment outcomes.

Differences Between Poststroke Drivers and Nondrivers: Demographic Characteristics, Medical Status, and Transportation Use

Finestone HM, Marshall SC, Rozenberg D, Moussa RC, Hunt L, Greene-Finestone LS: Differences between poststroke drivers and nondrivers: Demographic characteristics, medical status, and transportation use. Objective: To determine the demographic, medical, and transportation use characteristics of stroke survivors wanting to drive who resumed or did not resume driving and compare the driving habits of those who drove with those of a nonstroke control group. Design: One hundred and six stroke survivors who underwent a driving evaluation at a rehabilitation center in Ottawa, Canada, between 1995 and 2003, participated in a structured telephone interview 4–5 yrs after the evaluation. Information on driving history and transportation use before the driving assessment was obtained from the driving assessment client database. The nonstroke control group was derived from the literature. Results: After stroke, 66% of subjects had resumed driving. Prestroke driving history was similar for drivers and nondrivers. Drivers were younger than nondrivers (mean age ± SD, 62.7 ± 12.7 yrs vs. 69.2 ± 13.4 yrs; P = 0.02), had less medical comorbidity (mean modified Cumulative Illness Rating Scale score, 3.7 ± 1.97 vs. 5.0 ± 2.89; P = 0.01), and were less likely to rely on a walker (1.4% vs. 19.4%, P < 0.001). Self-imposed restrictions were reported by 35.7% of drivers. More nondrivers than drivers relied on family/friends (94.4% vs. 41.4%), public transportation (60.7% vs. 35.3%), or taxis (27.8% vs. 2.9%) (all P < 0.05). Drivers reported fewer driving difficulties (e.g., skill, weather, or traffic related; ≤20% for each) than the nonstroke group. Five of 12 licensed patients with stroke who drove to their first assessment failed it. Conclusions: In a sample of stroke survivors who had similar driving histories before their stroke and who were deemed to have the potential to drive, those who resumed driving after their stroke were younger, had fewer medical problems, and were less disabled than those who did not return to driving. Self-imposed driving restrictions were common. Compared with drivers, nondrivers relied more on friends, family, public transportation, and taxis.

Sudden death in the dysphagic stroke patient--a case of airway obstruction caused by a food bolus: a brief report.

The clinical events leading up to the sudden death of a dysphagic stroke patient with dementia is described. A 63-yr-old man sustained right thalamic and mid-brain infarctions. On the inpatient stroke rehabilitation ward, he exhibited significant impulsivity and dementia, the latter felt to be premorbid. The patient frequently coughed, and modified barium swallow testing showed dysphagia, with aspiration occurring only when consuming greater than teaspoon amounts of liquid. He subsequently died at home while eating a meal. Autopsy showed an intact large cheese ball (bocconcini) occluding the airway. Sudden death in the impulsive stroke patient secondary to airway occlusion by a food bolus has not previously been reported, although such patients seem to be at greater risk. New eating-related interventions are warranted for dysphagic patients who exhibit impulsivity. It is proposed that food particle size be limited to 1 cm2 and that such patients be closely monitored while eating.

Department of Transportation vs Self-reported Data on Motor Vehicle Collisions and Driving Convictions for Stroke Survivors: Do They Agree?

Objective: Research on stroke survivors’ driving safety has typically used either self-reports or government records, but the extent to which the 2 may differ is not known. We compared government records and self-reports of motor vehicle collisions and driving convictions in a sample of stroke survivors. Methods: The 56 participants were originally recruited for a prospective study on driving and community re-integration post-stroke; the study population consisted of moderately impaired stroke survivors without severe communication disorders who had been referred for a driving assessment. The driving records of the 56 participants for the 5 years before study entry and the 1-year study period were acquired with written consent from the Ministry of Transportation of Ontario (MTO), Canada. Self-reports of collisions and convictions were acquired via a semistructured interview and then compared with the MTO records. Results: Forty-three participants completed the study. For 7 (13.5%) the MTO records did not match the self-reports regarding collision involvement, and for 9 (17.3%) the MTO records did not match self-reports regarding driving convictions. The kappa coefficient for the correlation between MTO records and self-reports was 0.52 for collisions and 0.47 for convictions (both in the moderate range of agreement). When both sources of data were consulted, up to 56 percent more accidents and up to 46 percent more convictions were identified in the study population in the 5 years before study entry compared to when either source was used alone. Conclusion: In our population of stroke survivors, self-reports of motor vehicle collisions and driving convictions differed from government records. In future studies, the use of both government and self-reported data would ensure a more accurate picture of driving safety post-stroke.

An Analysis of Factors Associated with 25-Hydroxyvitamin D Levels in White and Non-White Canadians

Vitamin D status was assessed in 19-79 year old whites (8351 participants of European ancestry) and non-whites (1840 participants encompassing all other ancestries) from cycles 1 to 3 (years 2007-2013) of the Canadian Health Measures Survey. Status was assessed using the U.S. Institute of Medicine (IOM) 25-hydroxyvitamin D [25(OH)D] cut point values of 30 and 40 nmol/L. Overall, median 25(OH)D concentrations were significantly higher in whites [58.9 (28.6, 100.1) nmol/L; 5th and 95th percentile] compared with non-whites [43.5 (19.0, 83.2); P < 0.001]. Values were higher in females [58.5 (27.5, 101.3) nmol/L] when compared with males [53.5 (24.2, 92.7) nmol/L] and increased with age. Non-whites were more likely to have 25(OH)D values below IOM established cut points for optimum bone health with 20.1 (16.0, 24.2) and 42.2% (36.8, 47.7) of non-whites having serum 25(OH)D concentrations <30 and <40 nmol/L, respectively. The corresponding values for whites were 5.9 (4.6, 7.2) and 16.1% (14.0, 18.3). Values were lower during the first quarter when compared with the third quarter. Supplement intake was an important factor in determining 25(OH)D levels, but it did not alone account for the difference in status. Equivalent increases in 25(OH)D levels were observed in whites and non-whites during the summer months, suggesting there was no functional difference in sun exposure response. It is apparent that a complex interaction of factors affect 25(OH)D values in free-living Canadians.