Journal of Neurosciences in Rural Practice

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Year : 2019  |  Volume : 10  |  Issue : 2  |  Page : 173-174  

Diet in stroke: Beyond antiplatelets and statins

Department of Neurology, Government Medical College, Kozhikode, Kerala, India

Date of Web Publication25-Mar-2019

Correspondence Address:
Joe James
Njaralakatt House, Pottangadi Road, West Nadakkav, Kozhikode - 673 011, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnrp.jnrp_389_18

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How to cite this article:
James J. Diet in stroke: Beyond antiplatelets and statins. J Neurosci Rural Pract 2019;10:173-4

How to cite this URL:
James J. Diet in stroke: Beyond antiplatelets and statins. J Neurosci Rural Pract [serial online] 2019 [cited 2019 May 19];10:173-4. Available from:

According to global burden of diseases 2017, stroke is the third most common cause of mortality in India and one of the leading causes for long-term morbidity. Most of the secondary prevention strategies in ischemic stroke are directed to pharmacotherapy with antiplatelets, statins, and control of cardiovascular risk factors. However, diet and lifestyle changes are often not projected, even though the risk reduction by these measures can be up to 60%.[1] Most of the clinicians are ignorant about the importance of these practices in disease management.

Stroke forms part of the larger spectrum of atherosclerotic cardiovascular disease (ASCVD). The landmark trial which studied risk factors of ASCVD is the Framingham Heart Study. This trial, which has identified the “conventional” risk factors for stroke (and other cardiovascular diseases), has also thrown light on certain dietary habits for primary prevention of ASCVD.[2] To analyze the results of nutritional studies better, one must understand that diet can be viewed in two aspects. A dietetic history can be elicited based on the amount of carbohydrate, fats, proteins, vitamins, minerals, and dietary fiber one consumes; or as food types, such as rice and tubers, fish, red meat, fruits, and vegetables. Most of the studies and guidelines mix up these components and often create confusion.

Internationally accepted dietary guidelines are available for stroke prevention. American Heart Association/American Stroke Association recommends a diet high in fruits, vegetables, and whole grain, with fish, poultry, vegetable oils, nuts, legumes, and low-fat dairy products; and to restrict intake of red meat, sweets, and carbonated beverages.[3] Guidelines of the European Society of Cardiology for a healthy diet make similar recommendations. They advise to limit saturated fats to <10% of total energy intake, with limited intake of trans-fatty acids; dietary fiber of 30–45 g/day; 200 g of fruits and vegetables each per day; two servings of oily fish per week; and to limit salt intake to <5 g/day.[4]

There are specialized diets, which incorporate these components. A widely accepted and evidence-based diet is the Mediterranean diet.[5] It has high intake of olive oil, vegetables, fruits, cereals, and nuts; moderate intake of poultry, fish, and wine; and a low intake of sweets, red and processed meats, and dairy products. In a trial which tested the efficacy of Mediterranean diet with extra-virgin olive oil, this diet lowered the risk of cardiovascular events by 1.7%–2.1%.[6]

Another factor to consider while prescribing a diet for stroke patients is their comorbidities such as hypertension and diabetes. The dietary approaches to stop hypertension (DASH) diet advocates high intake of fruits, vegetables, and low-fat dairy products and lowers the systolic blood pressure (BP) by 5.5 mmHg and diastolic BP by 3 mmHg.[7] Diabetic patients should be encouraged to have food with low-glycemic index.

Low-carbohydrate high-fat (LCHF) diet requires special mention. In the largest prospective trial of LCHF diet - the Prospective Urban Rural Epidemiology (PURE) trial, higher intake of fat and animal protein was associated with lower mortality, whereas higher carbohydrate intake increased mortality, contrary to popular beliefs.[8] In a parallel study of the PURE trial, the authors found that higher intake of fruits, raw vegetables, and legumes was associated with lower mortality, implying that refined carbohydrates are the likely culprit.[9] The authors also found an inverse association between saturated fat and risk of stroke, contrary to international dietary guidelines.[10]

Nutritional supplements such as vitamin C, vitamin E and beta-carotene among many others, are common practice but have unproven benefits and should not be routinely prescribed. Alcohol has a varied effect on the risk of stroke. Moderate drinking (up to two glasses per day) is protective for ischemic stroke, whereas binge drinking (more than six and four drinks per sitting for men and women, respectively) and heavy usage are harmful.[11] In practice, moderate drinkers need not be asked to sober up, heavy drinkers need to be counseled to cut down, and non-drinkers should never be encouraged to drink for secondary prevention because, one can never predict that they will stick to moderate drinking.

Indian scenario is different. Cultural, regional, and religious diversity exists in dietary practices and is difficult to generalize across the country. Hence, making a dietary guideline for the whole country is a herculean task.[12] In the journal, Durga and Manorenj found that stroke patients from Hyderabad district had lower intake of green leafy vegetables, roots, tubers, fruits, prawns, crab and water, and higher intake of red meat, organ meat, fried snacks, and fruit juices.[13] Such studies are a starting point to make local and national dietary guidelines.

To conclude, similar studies in other regions need to be conducted to better understand the local dietary habits and risk factors. Larger multicentric trials across the country should be organised, evidence from which can be incorporated into national guidelines for a more tailored dietary guidelines for our population, rather than relying on international recommendations. A good lifestyle and dietary counseling should be a part of routine stroke care, and it is the duty of the clinician to initiate this effort. A holistic approach to disease prevention with pharmacotherapy and good lifestyle practices would have a better result than either alone. Ultimately, we are what we eat.

   References Top

Zhang Y, Tuomilehto J, Jousilahti P, Wang Y, Antikainen R, Hu G, et al. Lifestyle factors on the risks of ischemic and hemorrhagic stroke. Arch Intern Med 2011;171:1811-8.  Back to cited text no. 1
Millen BE, Quatromoni PA. Nutritional research within the framingham heart study. J Nutr Health Aging 2001;5:139-43.  Back to cited text no. 2
Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014;45:2160-236.  Back to cited text no. 3
Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, et al. 2016 European Guidelines on Cardiovascular Disease Prevention in Clinical Practice: The sixth joint task force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016;37:2315-81.  Back to cited text no. 4
Willett WC, Sacks F, Trichopoulou A, Drescher G, Ferro-Luzzi A, Helsing E, et al. Mediterranean diet pyramid: A cultural model for healthy eating. Am J Clin Nutr 1995;61:1402S-6S.  Back to cited text no. 5
Estruch R, Ros E, Salas-Salvadó J, Covas MI, Corella D, Arós F, et al. Primary prevention of cardiovascular disease with a mediterranean diet supplemented with extra-virgin olive oil or nuts. N Engl J Med 2018;378:e34.  Back to cited text no. 6
Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, et al. Aclinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997;336:1117-24.  Back to cited text no. 7
Dehghan M, Mente A, Zhang X, Swaminathan S, Li W, Mohan V, et al. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): A prospective cohort study. Lancet 2017;390:2050-62.  Back to cited text no. 8
Miller V, Mente A, Dehghan M, Rangarajan S, Zhang X, Swaminathan S, et al. Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): A prospective cohort study. Lancet 2017;390:2037-49.  Back to cited text no. 9
Sacks FM, Lichtenstein AH, Wu JHY, Appel LJ, Creager MA, Kris-Etherton PM, et al. Dietary fats and cardiovascular disease: A presidential advisory from the American Heart Association. Circulation 2017;136:e1-23.  Back to cited text no. 10
Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA. Association of alcohol consumption with selected cardiovascular disease outcomes: A systematic review and meta-analysis. BMJ 2011;342:d671.  Back to cited text no. 11
Krishnaswamy K. Developing and implementing dietary guidelines in India. Asia Pac J Clin Nutr 2008;17 Suppl 1:66-9.  Back to cited text no. 12
Durga AV, Manorenj S. Dietary pattern in adult patients with acute stroke in South India: A case-control study from a tertiary care center in Hyderabad. J Neurosci Rural Pract 2019;10:286-94.  Back to cited text no. 13


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