This document discusses common neurological problems that can interfere with nutrition and strategies to meet nutritional needs. It covers several neurological conditions including ALS, Parkinson's disease, multiple sclerosis, stroke, dementia, and Huntington's disease. For each condition, it discusses factors that can lead to malnutrition and provides nutritional strategies such as monitoring intake, modifying food textures, addressing swallowing difficulties, and considering tube feeding when needed. The document also covers general topics like types of feeding, nutritional assessment tools, and how medications can impact nutrition.

1. COMMON NEUROLOGICAL
PROBLEMS THAT INTERFERE WITH
NUTRITION AND STRATEGIES FOR
MEETING THEIR NUTRITIONAL
NEEDS
PRESENTED BY:
MISS.SHWETA SHARMA
M.SC. NURSING
2nd YEAR
AIIMS, JODHPUR

2. INTRODUCTION
• Nutrition is the science that
interprets the nutrients and other
substances in food in relation to
maintenance, growth, reproduction,
health and disease of an organism. It
includes ingestion, absorption,
assimilation, biosynthesis, catabolism
and excretion.

6. ROLE OF NUTRIENTS
Carbohydrates
• Found in starchy foods like wholegrain
bread, pasta and rice.
• Release energy slowly and help the brain
to function in stable way.
• For better concentration and mental
performance, choose wholegrain foods
(like whole meal bread) instead of refined
versions (like white bread). Avoid sweets
and sugary foods.

7. Essential fatty acids
• The ‘dry weight’ of the brain is about 60% fat and a
fifth of this fat is made from the essential fatty
acids omega-3 and omega-6.
• Trans fats are bad for the brain, because they stop
essential fatty acids from doing their work
effectively.
• As a rich source of omega-3, oily fish is very good
for the brain.
• Avoid processed foods.

8. Amino acids
• Neurotransmitters are made from amino acids.
• For example, serotonin, is made from the amino
acid tryptophan, found in milk, oats and other
foods.
• The food we eat affects our mood.
• For a good night’s sleep, choose food and drink
rich in tryptophan, such as a milky drink before
bed.

9. Vitamins and minerals
• Important for the functioning of whole
body.
• The brain uses vitamins and minerals to
help perform vital tasks.
• Vitamins such as folate and B12 (types
of ‘B complex’ vitamin) support the
healthy function of the nervous system.

12. NUTRITIONAL ASSESSMENT OF A
NEURO-DISABLED SUBJECT
Equations for Calculation of Metabolic Needs
1. The Harris-Benedict is calculated by gender with the following
formula:
• Men: Resting Metabolic Rate (RMR) (kcal/d) = 67 + Body Weight x
13.75+ Height x 5 – Age x 6.8
• Women: RMR (kcal/d) = 655 + Body Weight x 9.6 + Height x 1.85
– Age x 4.7

13. 2. The Ireton-Jones equations include one specifically
for obese patients and one for general critical care
populations:
• Obese: RMR (kcal/d) = Wt. x 9 + Gender x 606 – Age x
12 + 1844
• Non-obese: RMR (kcal/d) = Wt. x 5 – Age x 10 +
Gender x 281 + Trauma x 292 + 1925 (for gender:
male=1, female=0)

14. 3. Penn State equation
• Standard equation: RMR (kcal/d) = Mifflin x 0.96 + Tmax x
167 + Ve x 31 – 6212
• Modified equation: RMR (kcal/d) = Mifflin x 0.71+ Tmax x 85
+ Ve x 64 – 3085
where Mifflin is the Mifflin-St Jeor equation calculated from
actual body weight, height, age, and gender; Tmax is
maximum body temperature in degrees centigrade; and Ve is
expired minute ventilation in L/min recorded from the
mechanical ventilator at the time of the indirect calorimetry
measurement.

15. 4. The Faisy equation is structured similarly to the Penn
State equation, but it uses body weight and height
instead of the Mifflin to account for body size and
composition, as well as current body temperature
instead of maximum body temperature:
RMR (kcal/d): Wt x 8 + Ht x 14 + Ve x 32 + Temp x 94 –
4834

16. Anthropometrics
• Body mass index (BMI)
• Ideal body weight (IBW)
• Triceps skin fold thickness
• Middle arm circumference

17. Biochemical Measurements
• Specific proteins and other biochemical
markers
• Albumin
• Transferrin
• Pre-albumin
• Physical measurements of nitrogen
• Creatinine/height index

18. Monitoring
• Indications, route, risks, benefits and goals
of nutrition support at regular intervals,
time between reviews depending on the
patient care setting and duration of
nutrition support all require extensive and
specialized training.

19. FACTORS LEADING TO MALNUTRITION IN
CHRONIC NEUROLOGICAL DISEASES
1.Decreased intake
• Dysphagia
2. Gastrointestinal dysfunction
• Nausea and vomiting
• Delayed gastric emptying
• Constipation
3. Energy expenditure disturbance

20. Neurological condition
Tremor, fasciculations, spasticity,
dyskinesia, myoclonia
Increase EE
Paralysis, paresis Decrease EE
Nutritional status
Malnutrition, loss of lean body mass Decrease EE
Refeeding Increase EE
Physical activity
Decrease in leisure physical activity Decrease EE
Rehabilitation Increase EE
Ventilatory function
Respiratory failure Increase EE
Infections Increase EE

21. PATHOPHYSIOLOGY OF MALNUTRITION

22. EFFECT OF DRUG THERAPY
Drug Side effect
Interferon Weight loss, anorexia, fever,
depression, dysgeusia
Atypical antipsychotics Weight gain, central obesity, metabolic
syndrome
Dopaminergic agents Nausea, vomiting, anorexia, psychosis
Levodopa Nausea, vomiting, constipation
Steroids Decrease in muscle mass
Anticholinergics Dry mouth, dehydration, delayed
gastric emptying, constipation

23. Drug Micronutrient
Steroids Negative calcium balance (osteoporosis)
Phenytoin Vit D, K, folate and B6 deficiency
Levodopa Increased homocysteine, vitamin B6, B12
deficiency
Phenobarbital Folate and Vit D deficiency
Omeprazole, ranitidine Vitamin B12, calcium, iron deficiency
Antacids Phosphate deficiency
Diuretics Thiamine deficiency

24. NUTRITIONAL CONSEQUENCES OF
CHRONIC NEUROLOGICAL DISEASES
• Muscle atrophy
• Dysfunction of limb and respiratory
muscles
• Dysphagia- Malnutrition, dehydration,
oropharyngeal aspiration and aspiration
pneumonia
• Immunodeficiency
• Pressure sores
• Osteoporosis due to immobilization, lack
of weight bearing exercise, decreased food
intake and malnutrition

25. TYPES OF FEEDING

26. Oral
• Effective and non-invasive way
• People may be able to eat regular food but cannot meet all their
nutritional requirements through a regular diet alone and thus
require supplemental nutrition.
• In other instances, a patient can benefit from ONS if they require a
liquid-based diet.
• In some cases, people rely on ONS as their sole source of nutrition.

27. Tube Feeding
• Provides life-sustaining nutrients.
• First option feeding method when a person is unable to consume food
orally and/or has an impaired digestive system.
• Include specialized liquid feedings containing protein, carbohydrates,
fats, vitamins, minerals, and other nutrients needed to live.
• Formulated to meet individual needs for a variety of disease states and
conditions.

28. Types of Feeding Tubes and Their Uses
• A feeding tube is a plastic tube that is used to
bypass chewing and swallowing in a patient
who is not able to eat or drink safely. These
tubes can be used to deliver both food and
fluids, and can also be used for providing
medications when needed. A feeding tube can
also be used to remove fluids from the stomach
if the body isn’t processing stomach contents
well.

29. SHORT-TERM FEEDING TUBES
Nasogastric (NG) tube
• It can remain in place for four to six weeks
before it must be removed or replaced with
a long-term feeding tube.
Orogastric (OG) tube
• This tube can also remain in place for up to
two weeks when it must be removed or
replaced with a permanent tube.

30. Temporary Feeding Tubes
• A temporary feeding tube is
inserted into the mouth or nose,
down the throat, into the
esophagus and then the end rests
in the stomach (G-tube) or the
middle of the small intestine (J-
tube).
• These types of tubes have a radio-
opaque tip.

31. PERMANENT/LONG TERM FEEDING
TUBES

33. Parenteral
• Intravenous administration of nutrients directly into the systemic
circulation, by passing the gastrointestinal tract.
• It is a special liquid mixture containing protein, carbohydrates,
fats, vitamins, minerals, and other nutrients needed to live.
• Alternative or additional approach when nutrition needs cannot
be met from the oral or enteral routes alone, or are
contraindicated.

35. NEUROLOGICAL DISORDERS
AFFECTING NUTRITION

36. Amyotrophic lateral sclerosis (ALS)
• Complex neurodegenerative disorder characterized by progressive loss
of motor neurons, resulting in progressive atrophy of skeletal muscles,
including the respiratory muscles.
• In ALS patients, malnutrition is common. The following factors has
been associated with the risk of malnutrition:
The degeneration of bulbar neurons manifests as difficulty in chewing,
oral preparation, time required to complete a meal, and dysphagia.

37. Anorexia is common; it is usually attributed to psychosocial
distress, depression, and polypharmacy.
The weakness of the abdominal and pelvic muscles, limitation in
physical activity, the self-restraint of fluids and a diet low in fiber
can cause constipation, which indirectly may impair intake of
food.
Despite the reduction in lean body mass, ALS patients can have
some increased energy requirements due to increased work of
breathing, lung infections and other factors.

38. Strategies-
• Complete nutritional assessment - Body Mass Index (BMI), weight loss over
time and lipid status.
• Energy requirements in non-ventilated ALS patients should be estimated.
• Calculations should be estimated as approx. 30 kcal/kg body weight
depending on physical activity, and adapted to weight and body composition
evolution.
• Nutrition therapy (oral nutrition supplementation and enteral nutrition) may
stabilize body weight in ALS patients.

39. • For muscular fatigue and long-lasting meals, patients should be
advised to fractionate and enrich their meals with energy or
deficient nutrients.
• For moderate dysphagia - dietetic counselling to adapt the texture
of solid and liquids to facilitate swallowing and avoid aspiration.
• Postural maneuvers (such as chin-tuck posture) should be
recommended to protect the airway during swallowing.

40. CHIN TUCK POSTURE

41. Parkinson's disease
• Parkinson's disease (PD)
is a chronic, progressive
neurodegenerative
disorder resulting from
dopamine depletion in
the brain.

42. • Patients with PD are at increased risk of malnutrition and
weight loss, and nutritional status should be monitored
regularly.
• Dysphagia in PD usually occurs in the advanced phases of
the disease, although sometimes it is present at onset.
• Gastrointestinal dysmotility has potential implications for
enteral feeding strategies.

43. Strategies-
• Regular monitoring of nutritional and vitamin status.
• Monitor changes in body weight.
• Need of supplementing vitamin D, folic acid and vitamin B12.
• Rehabilitation treatment (adapting bolus characteristics, postural
maneuvers and exercise programs) – for dysphagia after a
multidimensional assessment of the swallowing function.

44. • Exercise program-
expiratory muscle
strength training (EMST)
have demonstrated
improvement in cough
and swallow function.

45. EMST device

46. • Constipation- use of fermented
milk containing probiotics and
prebiotic fiber in addition to
common dietary advices aimed
at increasing the intake of
water and fiber.

47. Multiple sclerosis
• Multiple sclerosis (MS) is a chronic, inflammatory and
autoimmune disease of the central nervous system, leading to
widespread focal degradation of the myelin sheath, variable
axonal and neuronal injury, and disability in young adults.
• Weight loss, malnutrition and cachexia are well-recognized
features of patients with MS. Osteoporosis is also common.

48. • Causes of weight loss and malnutrition in MS:
Reduced mobility and fatigue
Inappropriate diet
Physical difficulty for eating or drinking
Poor appetite
Poor sight
Reduced cognition and dysphagia

49. • Dysphagia can be one of the
most important complications of
MS that could affect nutritional
status. Dysphagia in MS usually
results from brain stem
involvement, and is often
accompanied by speech
difficulties.

50. Strategies
• A diet lower in saturated fat and higher in polyunsaturated
fatty acids from food sources -for the prevention of MS.
• Sufficient dietary vitamin D intake and adequate sunlight
exposure.
• Early detection and treatment of the causes of malnutrition
by a multidisciplinary team.
• Use of modified consistency of foods and fluids to ensure
safe swallowing, according to the individualized needs of
the patients.

51. Stroke
• Stroke patients are prone to malnutrition and dehydration
mainly due to dysphagia, impaired consciousness,
perception deficits and cognitive dysfunction.
• Early detection and treatment of dysphagia would be a
cornerstone in the management of stroke patients in order
to decrease the incidence of malnutrition, dehydration and
aspiration pneumonia.

52. Strategies
• A formalized screening for dysphagia should be performed in all stroke
patients as early as possible and before oral intake.
• All stroke patients should be screened for risk of malnutrition on
admission to hospital (within 48 h), and the MUST (Malnutrition
Universal Screening Tool) can be used to identify patients who are
more likely to benefit from medical nutrition therapy.
• Texture modified diets and thickened liquids may reduce the incidence
of aspiration pneumonia in stroke patients with dysphagia.

53. • Carbonated liquids may reduce pharyngeal residue when
compared to thickened liquids.
• Foods are chopped, mashed or pureed to compensate for chewing
difficulties or fatigue, improve swallowing safety and avoid
asphyxiation.
• Patients with prolonged severe dysphagia after stroke that
presumably last for more than 7 days should receive early enteral
tube feeding.

54. Dementia
• Dementia is a syndrome in which there is
deterioration in memory, thinking, behavior
and the ability to perform everyday activities.
• Progressive malnutrition and weight loss
• Dementia-related brain atrophy may impact on
brain regions implicated in appetite control
and energy balance.

55. Strategies-
• Close monitoring of body weight.
• Balanced diet with a variety of foods.
• Limit foods with high saturated fat and cholesterol.
Avoid butter and fatty cuts of meats.
• Avoid refined sugars. Often found in processed foods,
refined sugars contain calories but lack vitamins,
minerals and fibre.
• Limit foods with high sodium and use less salt.

56. • Limit distractions.
• Keep the table setting simple.
• Distinguish food from the
plate.
• Check the food temperature.
• Serve only one or two foods
at a time.

57. • Be flexible to food preferences.
• Give the person plenty of time to eat.
• Eat together.
• Keep in mind the person may not
remember when or if he or she ate. If
the person continues to ask about
eating breakfast, consider serving
several breakfasts — juice, followed by
toast, followed by cereal.

58. Huntington’s disease
• Huntington's disease (HD) is a fatal genetic disorder that causes the
progressive breakdown of nerve cells in the brain. It deteriorates a
person's physical and mental abilities.
• The disease involves chorea, difficulty swallowing, and psychological
problems, all of which can make eating a challenge.
• More calories to maintain their body weight.
• Risk for aspiration and suffocation due to difficulties with swallowing.

59. Strategies-
• Avoid eating when tired or upset.
• Sit upright during all meals, snacks, and drinks.
• Try to avoid foods that cause coughing, choking, or throat irritation.
These may be foods that are dry, crumbly (chips, dry cereal), acidic
(citrus fruit/juice, tomatoes/juice), spicy (chili powder, red and black
pepper, curry powder), or stringy (melted cheese).
• Eat slowly.
• Avoid talking while eating or swallowing.

60. • Eat foods that have been blended or pureed.
• Add sauces, gravies, liquid dressings, and moist toppings (sour cream,
butter, mayonnaise) to foods.
• Choose foods that are soft and moist, such as yogurt, pudding,
scrambled eggs, mashed potatoes, macaroni and cheese, oatmeal,
gelatin, milk shakes, frozen yogurt, or ice cream.
• Buy a commercial thickener to thicken liquids. Liquids with a milkshake
consistency are easier to swallow.
• Eat food that has been cut into small pieces. Take small bites (½
teaspoon or less) and chew well.

61. • Between bites of food, sip a beverage.
• Drink homemade vegetable and fruit juices.
• Stay seated upright for at least 30 minutes after
eating.
• Use cups with covers and straws, such as sports
cups, to prevent spills.
• Get forks and spoons with rubber handles or
larger handles for easier gripping.
• For the slow eater, use a warming tray to keep
food warm.

62. Myasthenia gravis
• Myasthenia gravis (MG) is a long-term
neuromuscular disease that leads to varying
degrees of skeletal muscle weakness. The
most commonly affected muscles are those of
the eyes, face, and swallowing.
• Myasthenia gravis weakness can make it
difficult to eat certain foods. MG medications
may affect appetite, metabolism and ability to
exercise.

63. Strategies-
• Eat a variety of foods.
• Eat several small meals during the day.
• Maintain a healthy weight.
• Choose a diet low in fat, saturated fat, and
cholesterol.
• Choose a diet with plenty of vegetables,
fruits and grain products.
• Moisten solid foods with gravy, sauce,
butter, mayonnaise, sour cream or yogurt.
• Use sugars only in moderation.

64. • Drink alcoholic beverages in moderation.
• Focus on the swallow. Hold your head in a different
position to try a different swallow pathway.
• Chop solid foods (like meat).
• Eat largest meal earlier in the day when having more
energy.
• Take anticholinesterase medication (for example,
Mestinon) shortly before mealtimes.
• Avoid dry, crunchy, or chewy snack foods like crackers,
popcorn, chips, bagels, nuts, or chips.

65. Epilepsy
• Epilepsy is a central nervous system
(neurological) disorder in which
brain activity becomes abnormal,
causing seizures or periods of
unusual behaviour, sensations, and
sometimes loss of awareness.

67. • The ketogenic diet (or keto diet, for
short) is a low-carb, high-fat diet.
• There are several versions of the
ketogenic diet, including:
Standard ketogenic diet (SKD):This is a
very low-carb, moderate-protein and high-
fat diet. It typically contains 75% fat, 20%
protein and only 5% carbs.
Cyclical ketogenic diet (CKD):This diet
involves periods of higher-carb refeeds,
such as 5 ketogenic days followed by 2
high-carb days.

68. Targeted ketogenic diet (TKD): This
diet allows to add carbs around
workouts.
High-protein ketogenic diet: This is
similar to a standard ketogenic diet,
but includes more protein. The
ratio is often 60% fat, 35% protein
and 5% carbs.

69. • When one eats less than 50 grams of carbs
a day, their body eventually runs out of
fuel (blood sugar) it can use quickly. This
typically takes 3 to 4 days. Then one will
start to break down protein and fat for
energy, which can make lose weight. This
is called ketosis. It's important to note that
the ketogenic diet is a short-term diet
that's focused on weight loss rather than
the pursuit of health benefits.

71. • It is a less restrictive variation of the
ketogenic diet.
• Allows unlimited protein and fat, and does
not restrict calories or fluids.
• Recent studies have shown good efficacy
and tolerability of this diet in refractory
epilepsy.
• The Atkins diet allows meals containing
60% fat, 30% protein, and 10%
carbohydrate.
• Because of strong carbohydrate restriction,
patients following the Atkins diet also
produce ketones.

73. Diet Composition Ketogenic Diet Atkins Diet
Fat (% by weight) 80 60
Protein (% by weight) 15 30
Carbohydrate (% by
weight)
5 10
Calories (%
recommended daily
allowance)
75 Not restricted

74. OTHER DIETS
1. Mediterranean Diet
• Mediterranean diet may help prevent Alzheimer’s disease,
dementia, heart disease and stroke.
• The Mediterranean diet is inspired by the lifestyle and food
preparation from countries near the Mediterranean Sea.
• This diet increases lifespan, improves brain and eye function
and even helps combat rheumatoid arthritis.

76. 2. MIND Diet
• It may help prevent dementia and Alzheimer’s disease.
• The MIND diet is a combination of the Mediterranean diet and the
DASH (Dietary Approaches to Stop Hypertension) diet. MIND
stands for Mediterranean-DASH Intervention for
Neurodegenerative Delay.
• High blood pressure is a risk factor for dementia, so the MIND diet
focuses on eating foods that can lower blood pressure.

78. ADVANTAGES OF EARLY ENTERAL
NUTRITION IN NEUROLOGICAL AND
NEUROSURGICAL PATIENTS
• Reduces catabolism
• Reduces complications
• Reduces length of stay

79. DISADVANTAGES OF EARLY ENTERAL
NUTRITION IN NEUROLOGICAL AND
NEUROSURGICAL PATIENTS
• High gastric residuals
• Bacterial colonization
of the stomach
• Increased risk of
aspiration
pneumonia

81. 1.Assessment of nutritional status in patients with Parkinson’s disease
and its relationship with severity of the disease
A cross-sectional study was conducted by Farzad Shidfar et al in 2016 to
assess the nutritional status in patients with Parkinson's disease and its
relation to the severity of the disease. It was conducted on 130 patients
with Parkinson's disease. Mini Nutritional Assessment (MNA)
questionnaire, anthropometric measurements (Body Mass Index (BMI),
Mid-arm circumference (MAC), Calf Circumference (CC)) were used to
evaluate the nutritional status. Hoehn and Yahr Scale were used to
determine the severity of the disease. 30% of the participants were
diagnosed with normal nutritional status, 58.5% were at risk of
malnutrition and 11.5% were malnourished. The study concluded that
reduction of BMI, depletion of muscle mass, and worsening of nutritional
status according to MNA, was observed in many patients along with an
increase in the severity of the disease. Assessing nutritional status in
those with Parkinson's disease to provide information to identify necessary
nutritional intervention is highly recommended.

82. 2.Nutritional Status of Indian Children with Cerebral Palsy: A Cross-sectional
Study
A cross-sectional study was conducted by Riya Goyal, Radhamohan Rana,
Hitesh Bhatia, Jaya Shankar Kaushik in 2019 to describe the nutritional status
and dietary intake of children with cerebral palsy (CP) aged six months to five
years and to describe the demographic and clinical predictors of malnutrition
among children with CP. A total of 50 children were enrolled; of whom severe
malnutrition was present in 18 (36%) with 12 (24%) children having severe
wasting and 12 (24%) having severe stunting as per WHO classification. A mean
(SD) calorie deficit of 425 (41.6) Kcal was observed. The study revealed a 36%
prevalence of malnutrition among children with cerebral palsy. Prevalence of
malnutrition ranges from 25 to 95% among children with cerebral palsy.
Considering one-third of children affected with malnutrition, the study
concluded that all children with CP must be screened for malnutrition.
Nutritional rehabilitation must be an essential, integral aspect of management
of children with cerebral palsy.

84. CONCLUSION
• Neurological patients are at nutritional risk. Several factors may be
responsible for malnutrition in these patients, including decreased
intake (dysphagia, gastrointestinal disturbances, depression, etc), the
effects of drug therapy, and disease-related changes in energy
expenditure.
• Malnutrition also impairs immune function and increases the risk of
pneumonia and the susceptibility of pressure sores. Osteoporosis and
high fracture risk are common in patients with chronic neurological
disease.
• A structured nutritional evaluation is mandatory. Nutritional support is
considered a major component of care in patients with acute and
chronic neurological disorders.