Stroke Prevention and Recovery

  • 23 Aug 2011
  • Reading time 21 mins
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Strokes are the third most common cause of death in England and Wales. The good news is most of the known risk factors can be modified with simple changes in dietary and lifestyle habits.

Causes and effects of strokes

Put simply, a stroke happens when there is a disturbance in the brain’s blood supply which starves cells of oxygen and leads to cell death and a loss of brain function. There are two types of stroke; ‘ischaemic’ and ‘haemorrhagic’. ‘Ischaemic’ strokes are more common and occur when blood flow to or within the brain is blocked. This blockage could happen for a variety of reasons.

A blood clot might form in one of the four main arteries carrying blood to the brain (the right and left carotid arteries, and the right and left vertebrobasilar arteries) or in smaller arteries and capillaries within the brain. Alternatively a blood clot, fat globule or air bubble present in a blood vessel in another part of the body could be carried to the brain. ‘Haemorrhagic’ strokes are the type where a damaged or weakened artery bursts and there is bleeding into the brain.

These damaged blood vessels could be located within the brain (causing an intracerebral haemorrhage) or on the brain surface (causing a subarachnoid haemorrhage). The effects of a stroke differ simply because they depend on the area in which the blockage occurs and the size of artery affected. A stroke in the left half of the brain will affect the right side of the body and vice versa. Blockage of a main artery will result in much more damage than the blockage of a small capillary which only supplies blood to a smaller area of the brain.

Much of the damage from strokes is believed to result from the activation of various enzymes which affect phospholipids and essential fats, which are key components of brain cell membranes, and through the generation of oxidants which promote death of brain cells. When considering ways to minimise this damage and recover from a stroke it makes sense to not only improve your intake of phospholipids and essential fats but also provide a means to mop up these damaging oxidants. This is why choline, lecithin, fish oils,

B vitamins and antioxidants should form the backbone of any stroke recovery protocol. I’ll discuss these and the evidence supporting their use a bit later. How to recognise a stroke The outcomes of a stroke are pretty sobering; according to statistics from The Stroke Association for every three people who have a stroke, one will recover, one will be left severely disabled and one will die. The damage that occurs with a stroke is time dependent, so the quicker the diagnosis and treatment, the more this damage can be minimised.

This message underlies the Government campaign which urges people to act FAST, using the Face, Arm & Speech Test to identify stroke. Facial weakness, arm weakness and speech disturbance are typical signs of stroke. F - Facial weakness. Can the person smile? Has their mouth or eye dropped? A - Arm weakness. Can the person raise both arms? S - Speech disturbance. Can the person speak clearly? Can they understand what you say? T - Test for each of the above three things. However, in some cases, these signs can be short-lived and disappear within 24 hours. This is known as a ‘mini-stroke’ or transient ischaemic attack (TIA).

Although you might be reassured by its short time frame, it’s vital to seek medical attention immediately because TIA is a serious event and a stroke risk factor. Stroke risk factors There are some groups of people who have a higher risk of stroke. People of Afro-Caribbean origin are twice as likely to have a stroke as is someone of European origin, and more likely to have a first stroke at a younger age. Similarly, being of South Asian origin also increases your risk. Middle-aged women have a higher stroke risk than middle-aged men and women in general are more likely to die from stroke. However, other factors such as age, high blood pressure (hypertension), high cholesterol, diabetes and cigarette smoking have all been linked to stroke risk, as are having a previous stroke, an abnormal heart rhythm (atrial fibrillation) or a TIA. While you can’t stop the ageing process, it’s obvious that many of these risk factors can be modified.

Specific dietary changes and regular exercise can help in improving your cholesterol profile, reducing blood pressure and managing diabetes, so where necessary you can take action and target each of these individually. If you also want to stop smoking and break free from addictive habits then my book How To Quit Without Feeling S**t will give you advice on how to do this.

Five steps to reducing your stroke risk

1. Lower high blood pressure: High blood pressure is one of the top risk factors and is linked with three quarters of strokes. Fortunately, there are lots of ways to reduce it without taking drugs, which have their own associated side effects. Diet, supplements and even laughter are all effective in reducing blood pressure and these are explored in the Special Report How to Lower High Blood Pressure Naturally.

2. Improve your cholesterol: We’ve all heard about cholesterol, the soft, waxy fat which is naturally made by your body and present in foods such as eggs, meat and dairy products, and how it impacts on cardiovascular health. Cholesterol is mainly transported in your body as LDL-cholesterol and HDL–cholesterol. LDL-cholesterol is commonly called ‘bad’ cholesterol as it can promote atherosclerosis (where fat and cholesterol accumulate and block your blood vessels) increasing blood pressure and increasing your risk of stroke. Having high HDL-cholesterol, known as ‘good’ cholesterol, reduces your stroke risk. If you want to reduce your stroke risk then it’s best to work on lowering your LDL-cholesterol and increasing your HDL-cholesterol. My Special Report on Lowering High Cholesterol gives you advice on the best diet, lifestyle and supplements to achieve this. The B vitamin niacin, for example, in doses of 1,000mg, effectively raises HDL and lowers LDL cholesterol.

3. Reverse diabetes: People with type-2 diabetes have almost double the risk of having a stroke within the first five years of diagnosis [5] and around three quarters of deaths in men with diabetes and over half of all deaths in women with diabetes are attributable to cardiovascular disease – this includes coronary heart disease, stroke and other vascular diseases. The process of atherosclerosis causes many of the chronic complications of diabetes so it’s vital that you take steps to prevent this. While my Special Report on Preventing and Reversing Diabetes is a good place to start, if you are diabetic and want to find more ways to manage your condition and reduce your need for drugs, then my new book Say No To Diabetes is an essential read.

4. Go fish: Stroke can be regarded as an inflammatory disease and risk has been strongly associated with both whole fish and fish oil intake. In the Nurse’s Health Study Cohort some women had a reduced risk of stroke and a lower incidence of ischemic strokes – and this was from eating any type of fish. Similar results were shown in those with a high intake of omega-3 oils [6]. Not only do omega-3 fats decrease inflammation and regulate the amount of fatty triglycerides in your blood, but they also decrease blood clotting and stickiness, ‘thinning’ the blood and improving blood pressure. Oily fish, a great source of the inflammation-reducing, heart-protective, omega-3 oils EPA and DHA, are an ideal food for improving your cardiovascular health and decreasing your stroke risk and I’d recommend that you eat at least 1-2 servings of the smaller cold-water fish like herrings, sardines, mackerel and pilchards each week.

5. Handle homocysteine: As far as strokes are concerned, lowering homocysteine by taking a combination of vitamin B6, folic acid, B12, TMG and zinc makes a big difference. If taken for three years, folic acid alone can lower stroke risk by almost a third, according to a recent analysis of all trials published in the Lancet. I’d certainly recommend you test your homocysteine level (ask your doctor or get a home-test kit from Totally Nourish). If your level is high, supplement a combination of homocysteine-lowering nutrients. Read my book The H Solution and my Special Report entitled How to Lower Your Homocysteine Level.

Essential supplements to improve recovery

So what can you do if you have already suffered from a stroke and are hoping to support your recovery? Several supplements have been the subject of much research so I’ll consider each one in greater detail.

1. Phospholipids: Phospholipids are a type of fat which play a key part in cell membrane structure and are known to have protective effects in the brain – particularly in acute ischaemic stroke. As we discussed earlier, the damaging effects of a stroke result from changes in phospholipid structure which eventually result in cell death. Choline is an essential nutrient which is used to make phospholipids and it’s possible that having plenty available could minimise cell damage.

As well as being a structural part of brain cell membranes, choline is also used to form the brain chemical acetylcholine, which is involved in many functions including muscle control and memory. Several studies have investigated cdp-choline (brand name ‘Citicoline’) to determine its effectiveness and safety in use with stroke recovery. This form of choline is converted into phosphatidyl choline, one of several phospholipids. When patients who suffered an ischemic stroke took Citicholine every day for six weeks there were improvements in their neurological, functional and global outcomes.

Greater improvements were gained from higher doses between 2000-5000 mg/day. In some instances there were further health gains when treatment was continued after the six week period [7]. In another study presented at the American Stroke Association's 27th International Stroke Conference, in which the brain was assessed by MRI scans taken 12 weeks after a stroke, researchers found that the area of dead tissue within the brain (the infarct) had increased by only 2% in those receiving 2000mg cdp-choline each day. Infarct size had increased by 34% in those taking a daily dose of 500mg cdp-choline, and by a massive 85% in those receiving a placebo drug.

Dosage appears important as other studies using lower daily amounts of between 500-2000mg cdp-choline found it to be ineffective in stroke recovery [8,9]. This amount of choline would be present in two to three teaspoons of hi-pc lecithin (pc here stands for ‘phosphatidyl choline’). A decline in mental performance is also very common and is evident in between half to three quarters of people six months after a stroke. Choline may protect against such a decline. In a recent six month trial, published in Stroke, citicoline prevented cognitive decline in individuals recovering from their first-ever ischaemic stroke [10].

Action: take at least 2000mg of cdp-choline or perhaps hi-pc choline each day to minimise cell death and protect against decline in cognitive function, certainly in the first six months. One way to increase your choline and phospholipids is by eating foods like wheatgerm, beef liver, egg yolks, cauliflower, and using unrefined vegetable oils like safflower, corn and soybean oil. Alternatively you can take a lecithin supplement which will provide you with phosphatidylcholine, phosphatidylinositol and essential fats such as linoleic acid. As well as its role in supporting brain health, lecithin also helps your body process cholesterol so is supportive of cardiovascular health too. Higher Nature sell a High PC Lecithin. One teaspoon provides 1,000mg of phosphatidyl choline.

2. Antioxidants: The production of oxidants, officially called reactive oxidant species, and the process of oxidation are a normal part of the body’s day-to-day metabolic functions. In fact we have a wide variety of antioxidants in our cells and blood which work to neutralise oxidants so they don’t build up and become harmful. Common antioxidants which can be obtained from your diet include vitamins A, C and E and minerals like selenium. In the case of a stroke it seems that the body is under great oxidative stress producing larger amounts of oxidants.

After suffering an ischaemic stroke there are significantly lower levels of anti-oxidants and antioxidant activity in the blood [11]. If your antioxidant status was quite high before your stroke then you may have already gained some neuro-protection. In a recent study led by Paula Bickford of the University of South Florida College of Medicine, ischaemic strokes were induced in animals that had eaten regular chow, or chow supplemented with either blueberries, the algae spirulina or spinach [12].

They found that the antioxidant-rich diets offered greater neuro-protection resulting in more than halving the area of the brain affected by a stroke and faster progress in recovery of movement. "The clinical implication is that increasing fruit and vegetable consumption may make a difference in the severity of a stroke," Bickford says. But what is the impact of antioxidants taken after a stroke? Antioxidants may help stroke victims recover faster due to their anti-inflammatory properties and their ability to quench oxidants, which are still causing brain cell death three to six days after the initial event. However, while several trials suggest their benefits in stroke recovery, data in humans is still limited. Alpha-lipoic Acid (ALA) is an antioxidant compound that may reduce inflammation inside blood vessels, making it possible for your blood vessels to heal after you suffer a stroke. ALA may also help to prevent another stroke.

Researchers at The University of Maryland Medical Centre found that animals receiving ALA were four times more likely to survive a stroke and less likely to suffer brain damage than those which didn’t. Vitamin C may help your blood vessels to heal after a stroke and has also been shown to protect against cognitive changes, particularly in those experiencing new cardiovascular events [13]. Furthermore, vitamin C may help protect you from suffering another stroke, since research studies have shown that people with high levels of vitamin C in their bloodstreams have a significantly lower risk of stroke than people with low blood levels [14]. Vitamin E may improve your memory after a stroke and reduce your risk of a second stroke.

In 2000, a study by R Benson of the Columbia Presbyterian Medical Centre showed that people who took vitamin E supplements reduced their risk of suffering strokes by 53% compared to people who didn't take vitamin E supplements. The study group included many adults who had already suffered at least one stroke. However, a recent analysis in the British Medical Journal suggests that vitamin E reduces the common kind of ischaemic stroke but increases risk of the rarer haemorrhagic stroke [15].

I contacted Dr Maret Traber, the vitamin E expert at the Linus Pauling Institute who knows more about vitamin E than anyone for her comment and discuss this more in my blog Vitamin E - good or bad for strokes?. What’s important to remember is that while vitamin E has both anti-atherosclerotic and anti-platelet effects that may reduce the rate of ischemic stroke, several individual vitamin E studies – including the Women’s Health Study (WHS) and the Women’s Antioxidant Cardiovascular Study (WACS) – have shown benefits from supplemental vitamin E on other cardiovascular outcomes beyond stroke, such as immune function and eye health. Also, most people are not achieving even basic levels of vitamin E.

In reality, supplementing 100 or 200mg of vitamin E is likely to confer protection and this is the amount I’d recommend. Action: take a daily antioxidant supplement which provides a combination of antioxidant substances which work synergistically. Choose one that contains ALA, glutathione, vitamin E, the potent plant antioxidant resveratrol and CoQ10. Take with vitamin C for additional support. You can purchase supplements from Totally Nourish.

3. Fish and fish oils: Fish contain the omega 3 oils EPA and DHA which are integral for brain development and repair and by lowering triglycerides, blood pressure and arrhythmias they are also vital for a healthy heart. EPA and DHA also help to reduce depression which is very common after stroke. Almost one in two stroke survivors will experience post stroke depression (PSD) at some stage in the first few years, perhaps experiencing symptoms such as social withdrawal and loss of pleasure in previously enjoyed hobbies and activities or life in general, irritability and restlessness, frequent crying episodes, sleep disturbances, fatigue and lethargy, self-loathing or an overwhelming sense of hopelessness. PSD is considered as the most common and important emotional outcome of a stroke but it is often overlooked [16].

According to Eoin Redahan, a director of The Stroke Association "Wider recognition of depression would lead to an increase in those being treated which is vital....Evidence shows that those with depression appear to recover less well after a stroke compared to those who do not have depression." Action: Eat omega-3 rich oily fish – salmon, mackerel, herring, sardines or trout – two to three times a week. Vegetable sources of omega-3s include raw, unsalted seeds and nuts. The best seeds are chia and flax. You get more goodness out of them by grinding them first and sprinkling on cereal, soups and salads. Also use cold-pressed seed oils on salads and vegetables. Choose an oil blend containing flaxseed oil for salad dressings and cold uses, such as drizzling on vegetables instead of butter. Don’t cook with these oils as their fats are easily damaged by heat. Walnuts are also rich in omega 3.

4. B vitamins for methylation: Researchers at the Centre of Molecular and Genetic Epidemiology, have shown a trend amongst people with ischemic heart disease and stroke towards having poorly methylated DNA strands. As the study progressed low methylation was associated with an increased risk of heart disease and stroke and more deaths in those people who were initially free of disease [17]. A high homocysteine level is an indicator of poor methylation. One theory of the mechanisms of stroke is that raised homocysteine causes a decrease in brain adenosine, a molecule which has neuroprotective effects [18]. B vitamins support methylation processes in the body and supplementing them reduces homocysteine levels. In the HOPE-2 trial [19], designed to evaluate the impact of preventative measures on heart health outcomes, vitamin therapy was shown to be really effective.

Taking a daily combination of folic acid, vitamin B6 and vitamin B12 decreased mean homocysteine concentration and lowered incidence of stroke and risk of non-fatal stroke over the five year follow-up period. Benefits were even gained by those already on anti-platelet or lipid lowering drugs or eating a diet which was fortified with B vitamins. However, a meta-analysis of several trials indicates effects are not so pronounced where aspirin is already prescribed [20]. In other words, aspirin may interfere with the ability of homocysteine-lowering B vitamins to make a difference. Supplements of just folic acid also lower stroke risk [21], but I would suggest you avoid taking a single supplement because it can mask a B12 deficiency – and insufficient B12 is very common in the elderly due to decline in ability to absorb nutrients. I’d therefore advise you to supplement folic acid, B12 and B6, together with TMG and zinc and to continue doing so in the long term, as homocysteine levels tend to revert to their original values after 10 weeks without supplementation [22].

In older people also supplementing N-acetyl cysteine offers further homocysteine protection. The best formulas contain all of these. But first, test your homocysteine level. Stroke risk increases from a level of 10 mcmol/l. Action: If your homocysteine level is high take a daily supplement containing 500mcg of folic acid, 40mg of B6, 500mcg of B12, plus 1,000mg of TMG, 10mg of zinc and 500mg of NAC. Cholesterol Although we’ve talked about the need to manage cholesterol levels to reduce your stroke risk there’s one other thing to consider as cholesterol actually has a role in stroke recovery. It helps by transporting the essential fats which are needed to create nerve pathways and repair or replace damaged cells. What’s more, having a too low cholesterol level can actually result in muscle and nerve degeneration.

So bear this in mind, especially if you’ve been prescribed a cholesterol-lowering drug as part of your stroke rehabilitation programme. Recovering after a stroke Stroke affects everyone differently and the level of recovery cannot be predicted. Much recovery occurs in the first few weeks while a person is still in hospital, but improvements may occur over a number of years. But what does it mean to recover from a stroke? For many it is a combination of acquiring new skills and relearning old ones, learning to adapt to limitations and receiving social, emotional, and practical support. This could be achieved by exploring comprehensive-holistic treatment; considering active, problem-based coping strategies; and receiving support from families and health care professionals. An effective and recommended approach to handling stroke recovery involves focusing therapeutic attention on specific areas at particular times. In a study of women who had suffered their first stroke [23], four distinct phases of recovery were identified, which gradually evolved and through which individuals slowly passed.

During the first phase (0-2 months) most concerns were about bodily changes. In the second phase (2-6 months) focus changed to activities of daily life. By the third phase (6-12 months) women were seeking a greater self-understanding and at the fourth phase (12 – 24 months) they were typically trying to get on with life. Progression through each phase differed for each individual and was influenced by personal significant experiences and their associated meanings. If a person is having difficulty swallowing, making supplements a challenge, an alternative would be a nutrient rich shake such as Get Up & Go, with added hi-PC lecithin and ground chia seeds, plus piercing a capsule of omega 3 fish oils.

Vitamin capsules or tablets can be crushed and added to food. So what might this mean for you? The brain is a sensitive and complicated organ and recovering from a stroke will take time. If you can, tailor your recovery programme to best suit your individual needs, and please don’t waste a single moment worrying about the speed of your rehabilitation. Just make sure you are achieving optimum brain nutrition and let nature take its course.

REFERENCES

1. K Carroll et al., ‘Stroke incidence and risk factors in a population based cohort study’, Health Statistics Quarterly, 2001; 12: 18-26

2. Stroke Statistics, British Heart Foundation and The Stroke Association, 2009

3. Wolfe, C The Burden of Stroke in Wolfe, C, Rudd, T and Beech, R (eds) Stroke Services and Research (1996) The Stroke Association

4. Coronary Heart Disease Statistics, British Heart Foundation, 2005

5. T Jeerakathil et al., ‘Short-Term Risk for Stroke Is Doubled in Persons With Newly Treated Type 2 Diabetes Compared With Persons Without Diabetes’, Stroke, 2007; 38:1739.

6. H Iso et al., ‘Intake of Fish and Omega-3 Fatty Acids and Risk of Stroke in Women’, JAMA, 2001 Jan; 285(3): 304-312.

7. H J Cho & Y J Kim. ‘Efficacy and safety of oral citicoline in acute ischemic stroke: drug surveillance study in 4,191 cases’, Methods & Findings in Experimental and Clinical Pharmacology, 2009 Apr; 31(3): 171-176.

8. W M Clark et al., ‘A randomized efficacy trial of citicoline in patients with acute ischemic stroke’, Stroke, 1999 Dec; 30(12): 2592-7.

9. W M Clark et al., ‘A phase III randomized efficacy trial of 2000 mg citicoline in acute ischemic stroke patients’, Neurology, 2001 Nov; 57(9): 1595-1602.

10. J Alvarez-Sabín & G C Román, ‘Citicoline in vascular cognitive impairment and vascular dementia after stroke’, Stroke, 2011 Jan; 42(1 Suppl):S40-3.

11. A Cherubini et al., ‘Antioxidant Profile and Early Outcome in Stroke Patients’, Stroke, 2000; 31:2295.

12. Y Wang et al., ‘Dietary supplementation with blueberries, spinach, or spirulina reduces ischemic brain damage’, Experimental Neurology, May 2005; 193(1): 75-84

13. J Hee Kang et al., ‘Vitamin E, Vitamin C, Beta Carotene, and Cognitive Function Among Women With or at Risk of Cardiovascular Disease. The Women's Antioxidant and Cardiovascular Study’. Circulation published online before print May 18, 2009, doi: 10.1161/CIRCULATIONAHA.108.816900

14. P K Myint et al., ‘Plasma vitamin C concentrations predict risk of incident stroke over 10 y in 20 649 participants of the European Prospective Investigation into Cancer–Norfolk prospective population study’, American Journal of Clinical Nutrition, 2008 Jan; 87(1): 64-69

15. M Schürks et al., ‘Effects of vitamin E on stroke subtypes: meta-analysis of randomised controlled trials’, BMJ, 2010; 341: c5702.

16. G.L. Lenzi et al., ‘Post-stroke depression’, Revue Neurologique, 2008 Oct; 164(10): 837-840

17. A Baccarelli et al., ‘Ischemic heart disease and stroke in relation to blood DNA methylation’, Epidemiology, 2010 Nov; 21(6):819-828.

18. H McIlwain & J D Poll, ‘Interaction Between adenosine generated endogenously in neocortical tissue and homocysteine and its thiolactone’, Neurochemistry International, 1985; 7:103G

19. Saposnik et al., ‘Homocysteine-lowering therapy and stroke risk, severity, and disability: additional findings from the HOPE 2 trial’, Stroke, 2009 Apr; 40(4):1365-1372.

20. D S Wald et al., ’Reconciling the evidence on Serum Homocysteine and Ishaemic Heart Disease: A Meta-Analysis’, PLoS ONE 6(2): e16473. doi:10.1371/journal.pone.0016473X

21. Wang et al., ‘Efficacy of folic acid supplementation in stroke prevention: a meta-analysis’, Lancet, 2007 Jun; 369(9576):1876-8182.

22. E P Quinlivan et al., ‘Importance of both folic acid and vitamin B12 in reduction of risk of vascular disease’, Lancet, 2002 Jan; 359: 227-28 (research letter)

23. G Eilertsen et al., ‘Recovering from a stroke: a longitudinal, qualitative study of older Norwegian women’, Journal of Clinical Nursing, 2010 Jul; 19(13-14): 2004–2013.

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