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University of Virginia Nutrition E-Journal Club
May 2005

Hello everyone !  We did not have a Traineeship in May, but we did have a Nutrition Support Forum.  Our NS forum is a small group of enthusiastic nutrition support dietitians from UVAHS and surrounding hospitals who review patient case studies and recent journal articles.  Gary Ecelbarger MS, RD, travels from Fairfax Hospital in Northern VA to moderate our forum; his sense of humor and wealth of knowledge makes our discussions even MORE animated when he is here!



Our article for the e-journal club was:

Dennis MS, Lewis SC, Warlow C, et al.   FOOD Trial Collaboration Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial.  Lancet  2005;365:764-772.  

Study Question (s):

1) Is early or late enteral feeding preferable after acute stroke?

2) Is PEG or nasogastric feeding the preferred route of feeding after acute stroke?



This was an ambitious study done in 47 hospitals in 11 countries.  The trial had two major arms:  In the first, 859 patients were randomized to receive either early enteral feedings via mixed N-G and PEG vs no nutrition (defined as no nutrition support for at least 7 days).  In the other arm, 321 patients were randomized to receive either a PEG or an NGT.  Primary outcomes were mortality and a combined indicator of death or poor outcome (as determined by a modified Rankin score of 4-5).


The researchers reported that early tube feeding was associated with an absolute reduction in the risk of death of 5.8% (95%CI –0.8 to 12.5%, p = 0.09) and a reduction of death or poor outcome of 1.2% (-4.2 to 6.6, p = 0.7).

Early PEG feeding was associated with an absolute increase in risk of death of 1.0% (-10.0 to 11.9, p = 0.9) and an increased risk of death or poor outcome of 7.8% (0.0 to 15.5, p = 0.05).


This is the fist study to investigate early enteral feeding after stroke and it is 10 times larger than any other study of feeding methods post-stroke.   However, there are a number of significant limitations to this study that limit the conclusions that can be made.  I will outline only the major points below:

  • This is a pragmatic study without true randomization because selection into an arm of the study was influenced by the clinician’s uncertainty of when to start tube feeding, and a clinician’s uncertainty of whether to use a PEG or a nasogastric tube.
  • Twenty-eight patients who were in the “avoid tube” group, and thus unfed for at least 7 days (median of 9 days), were then randomized into the PEG vs NG trial.  Due to the delays in PEG placement (only 48% received a PEG in 3 days) some of those patients in the “avoid” who were randomized to receive a PEG could have been without nutrition for up to 2 weeks.
  • Patients in this study were kept npo when the team “felt this was necessary” BUT could be fed orally (instead of, or in addition to tube feeding) if their swallowing ability improved.  There is absolutely no accounting for how many patients received food by mouth, if there were differences in the number taking oral intake between the various groups, how many patients in each group had their tube feedings turned off, or how it was decided that is was safe for them to begin oral intake.
  • There is no documentation of how much patients were fed through their feeding tubes.
  • The outcome measure of “poor outcome” was based on a single assessment (mailed questionnaire or telephone interview) that was done six months after enrollment in the study.  In the six months after enrollment into the study there were multiple variables that could affect patient outcome.  Our group found it difficult to make strong conclusions about insignificant (early versus late) or barely significant (PEG versus NG) differences between the groups and then attribute it to a difference in feeding method six months earlier.  Quality of life measurement (via EUROQoL) was statistically the same between the groups at 6 months.
  • The authors report that 23 total deaths were attributed directly to the placement of a feeding tube (11 from NG placement, 12 from PEG).  It was the group’s opinion that the use of a strict protocol for safe NG placement (such as CO2 monitoring device during placement and abdominal X-ray prior to use) may reduce the risk directly associated with tube placement and shift the risk/benefit ratio in favor of enteral feeding.

Take home message:  

The FOOD study is the largest trial of enteral feedings in the post-stroke population.  Due to the fact that it is ten times larger than any other study, we will see it’s results often quoted in review articles for a long time to come, so it is worthwhile to be aware of the study’s limitations.  It has already been quoted as “Evidence” that early enteral feeding “resulted in more patients heavily dependent on others for activities of daily living.”  Our group’s take home message was that this study suggests that there is no harm to early enteral feeding post-stroke, and there is no obvious advantage to early PEG placement.


Guess What!

Two of our past trainees for recently passed the CNSD Exam!!!!!!!!


Susan Morse  RD , CNSD  and Amy Pearce RD , CNSD




Other News:

Check out the latest Practical Gastroenterology Nutrition Article:

Goodin B. Nutrition Issues in Cystic Fibrosis.  Practical Gastroenterology 2005;XXIX(5):78.  Available at:



Joe Krenitsky MS, RD
Carol Parrish RD, MS



“Not a shred of evidence exists in favor of the idea that life is serious.”
  -- Brendan Gill (1914-1997- American critic and author)


PS – Please feel free to send this on to friends and colleagues.