Nutrition and Aerobic Exercise in Chronic Stroke

In acute stroke settings, it is known that energy imbalance is associated with poorer
rehabilitation and functional outcomes, and importantly, increased risk of
institutionalization. However, nutrition and eating habits of chronic stroke rehabilitative
care have received very little consideration, especially if the survivor is living in a free
living environment. Studies have shown deficiencies in energy and protein intake versus
recommendations in chronic stroke survivors. Perry et al. found ~7% of chronic stroke
survivors were at moderate and ~5% at high nutritional risk. Although little is known
regarding total daily energy expenditure and dietary intake in chronic stroke, energy and
macronutrient imbalance may have a profound impact on stroke recovery and risk of development
of chronic disease and recurrent stroke by altering substrate oxidation and result in
systemic and tissue level oxidative stress. Conversely, cardiovascular disease risk increases
with excess calorie and fat intake and two-thirds of stroke survivors are overweight or
obese. In obese, non-stroke populations, energy dense, high fat meals are associated with
increases in plasma oxidative stress markers. Oxidative stress can lead to mitochondrial
damage and abnormal accumulation of metabolite intermediates and lipid accumulation in
non-adipose tissues, which can impair heart function, increasing CVD and stroke recurrence
risk.

Inclusion Criteria:

- Veteran

- Adequate language and neurocognitive function to safely participate in informed
consent, and exercise testing and training

- Under the care of a primary care medical provider.

- Age greater than 20 years

- Body mass index between 20 to 50 kg/m2

- Already completed all conventional inpatient and outpatient physical therapy.

- Ischemic or hemorrhagic stroke greater than or equal to 6 months prior.

Exclusion Criteria:

- Already performing aerobic exercise 3 x / week.

- Increased alcohol consumption defined as greater than 2 oz. liquor or 2 times 4 oz.
glasses of wine or 2 x 12 oz. cans of beer per day

- Cardiac history of: a) unstable angina, b) recent (less than 3 months prior to study
entry) myocardial infarction, congestive heart failure (NYHA category II-IV); c)
hemodynamically significant valvular dysfunction.

- Muscle Biopsy Exclusion Criteria: a) anti-coagulation therapy with heparin, warfarin,
or lovenox (anti-platelet therapy is permitted), b) bleeding disorder c) allergy to
lidocaine

- Medical History: a) recent hospitalization (less than 3 months prior to study entry)
for severe medical disease, b) peripheral arterial disease with vascular claudication,
c) orthopedic or chronic pain condition restricting exercise, d) pulmonary or renal
failure, e) active cancer, f) untreated poorly controlled hypertension measured on at
least 2 occasions (greater than 160/100) g) type I diabetes mellitus, untreated and /
or poorly controlled diabetes with fasting blood glucose of greater than 170 and HbA1c
greater than 10.0, h) medications: heparin, warfarin, lovenox, oral steroids i)
currently pregnant.

- Neurological history of: a) dementia with Mini-Mental Status Score less than 23 (less
than 17 if education level at or below 8th grade), and diagnostic confirmation by
neurologist or psychiatrist, b) severe receptive or global aphasia which confounds
testing and training, operationally defined as unable to follow 2 point commands, c)
neurologic disorder restricting exercise, such as Parkinsons Syndrome or myopathy, d)
untreated major depression.