Nutritional care in rehabilitation and acute care of stroke patients: a systematic review of clinical practice guidelines

This problem exists because no one in stroke has created diet protocols! We need protocols, NOT GUIDELINES! Solve the problem correctly, and that is NOT GUIDELINES!

 Nutritional care in rehabilitation and acute care of stroke patients: a systematic review of clinical practice guidelines

Karina Siewers*, Katrine Svaerke, Amira Eliza Rosenørn and Hanne Christensen

Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark

Edited by

Anthony Pak Hin Kong, The University of Hong Kong, Hong Kong SAR, China

Reviewed by

Meheroz H. Rabadi, United States Department of Veterans Affairs, United States

Ali Karahan, Uşak University, Türkiye

*Correspondence

Karina Siewers, karina.siewers.christensen@regionh.dk

Received 09 January 2025

Accepted 24 March 2025

Published 10 April 2025

Citation

Siewers K, Svaerke K, Rosenørn AE and Christensen H (2025) Nutritional care in rehabilitation and acute care of stroke patients: a systematic review of clinical practice guidelines. Front. Stroke 4:1558019. doi: 10.3389/fstro.2025.1558019

Background: Malnutrition and nutritional care are significant challenges for healthcare professionals treating stroke patients, in both acute care and during rehabilitation. This study aimed to assess and synthesize the nutritional care recommendations in clinical practice guidelines (CPGs) for managing malnutrition risk in stroke patients, evaluate the supporting evidence, identify research gaps, and assess the quality of the CPGs.

Methods: Three databases, along with National Medical Association websites and nutrition journals, were searched for CPGs published between 2019 and 2024 that provided recommendations on nutritional care for stroke patients. Two independent reviewers performed data extraction, and three reviewers independently assessed CPG quality and clinical applicability (using AGREE II and AGREE-REX tools).

Results: 13 CPGs were included in this review. These were of varying quality, with overall moderate AGREE II total scores [mean (SD), 55.2% (21.8%)]. Only two CPGs had an overall quality score above 70% based on AGREE-REX total scores, while five were categorized as poor quality (scores < 40%). Most guidelines strongly recommended early dysphagia screening upon hospital admission, including the provision of texture-modified foods for patients with dysphagia. However, recommendations on malnutrition, nutritional support, and supplementation were often either absent or inconsistent across guidelines and recommendations were mostly based on moderate to weak evidence.

Conclusion: This study highlights the critical need for more rigorous research, standardized approaches, and patient-centered studies to improve and optimize nutritional care practices for stroke patients.

Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024498430, PROSPERO registration ID: CRD42024498430.

Keywords

stroke, nutrition, systematic review, guidelines and recommendations, rehabilitation

Introduction

Malnutrition poses a significant challenge amongst patients with stroke, with up to 49% developing malnutrition post-stroke with further worsening during hospitalization and rehabilitation (Mosselman et al., 2013; Foley et al., 2009). Dysphagia increases the risk of malnutrition in post-stroke patients; however, malnutrition can occur in patients regardless of the presence of dysphagia (Foley et al., 2009). Managing malnutrition is complex and involves health care professionals from various professions.

Background

Healthcare providers require access to high-quality Clinical Practice Guidelines (CPGs). CPGs influence day-to-day clinical decisions and serve as a crucial tool in standardizing health care practices, bridging the gap between clinical practice and evidence-based scientific support.

Given the complexity of and diversity in nutritional interventions and assessment for stroke management, CPGs are needed to guide clinical decision-making, elevate patient care, and optimize outcomes. The study objectives were to assess the quality of eligible CPGs on nutritional care for stroke patients and to identify and synthesize key recommendations from the included CPGs.

Methods

The systematic review of CPGs was registered at PROSPERO (ID CRD42024498430) in advance and conducted in accordance with the PRISMA 2020 checklist for systematic reviews (see Supplementary material S1) (Page et al., 2021). Eligibility criteria were created in adherence to the PICAR statements [Population(s) and Clinical Area(s), Intervention(s), Comparator(s), Attributes of CPGs and Recommendation characteristics] framework (see Table 1) (Johnston et al., 2019).