Preventing strokes

Primary prevention to reduce the incidence of stroke should be targeted at the whole population and groups that are at increased risk by increasing awareness and promoting healthy lifestyles that reduce the risk factors for stroke.

THE brain’s functions depend on a constant blood supply for the oxygen and nutrients needed by its cells. The restriction or stoppage of this supply leads to damage, and possibly death of the brain cells.

A stroke, which is also called a cerebrovascular accident (CVA), is a condition in which the blood supply to a part of the brain is cut off. It is a medical emergency and the earlier treatment is provided, the less likely will be the damage.

Strokes are the third most common cause of death in Malaysia. It is estimated that there are about 52,000 strokes per annum (i.e. every hour, six people experience a stroke).

The risk for recurrent vascular events after a stroke or transient ischaemic attack (TIA) is about 5% per year for stroke, 3% per year for heart attack, and 7% per year for any one of stroke, heart attack or vascular death. The risks are higher in patients who are at an increased risk of CVA or who have carotid stenosis.

It has been estimated that without treatment, the likelihood is one in 10 that a stroke will occur within a month after a TIA.

As strokes lead to disability and even death in some instances, TIAs should be treated as seriously as strokes.

Risk factors

A risk factor increases the chances of getting or having a certain health condition. Some risk factors for stroke cannot be changed, but others can be prevented. Changing risk factors over which a person has control will assist in achieving a longer and healthier life.

Strokes are preventable as lifestyle changes can reduce many of the risk factors. However, there are some risk factors that are not preventable. They include:

  • Age – The risks are increased in the older person, although about a quarter of strokes occur in the young. The risk doubles in each successive decade after 55 years of age.
  • Gender – The risks are increased in males (except in older adults, when it evens out).
  • Ethnicity – The risks are increased in Indians and Malays because the incidence of diabetes and hypertension are higher in these groups.
  • Medical history – The risks are increased if one has had a heart attack, stroke or TIA. The risks are also increased in pregnancy, abnormal heart beats, chronic renal disease, cancer, some types of arthritis, and in those with abnormal blood vessels or weakness in the wall of an artery.
  • Family history – The risks are increased if a close relative has had a stroke.

Primary prevention is vital in any programme to reduce the incidence of stroke. This should be targeted at the whole population and groups that are at increased risk by increasing awareness and promoting healthy lifestyles that reduce the risk factors for stroke.

Secondary prevention are measures used to prevent recurrence of a stroke. They are individualised depending on the person’s pathogenesis based on neuroimaging and other investigations.

The prevention of stroke is similar to the prevention of coronary heart disease.

High blood pressure

High blood pressure (hypertension) is a major risk factor for stroke. The incidence increases in proportion to both the systolic and diastolic blood pressures. Isolated systolic hypertension (systolic blood pressure of more than 160mm Hg and diastolic blood pressure of less than 90mm Hg) is an important risk factor for senior citizens.

A reduction in blood pressure reduces the incidence of stroke. A reduction of the systolic blood pressure by 10mm Hg is associated with a reduction in risk of stroke by about a third, regardless of the baseline blood pressure levels.

Hypertension is controlled by diet, exercise and medicines.


There is an association between raised blood lipids and risk of ischaemic stroke. Hyperlipidaemia is controlled by diet, exercise and medicines.

The use of statins in those at increased risk, e.g. those with cardiovascular disease, diabetes, reduces the incidence of coronary events and ischaemic strokes even in individuals whose blood cholesterol levels are normal (less than 5.0mmol/L).


Diabetes increases the risk of ischaemic stroke by 1.8 to 6 times. The incidence of stroke is significantly reduced by stringent control of hypertension in diabetics.

Scientific studies have indicated that strict control of the blood glucose (Hb A1c less than 6%) is critical.

Diabetes is controlled by diet, exercise and medicines.


Foods rich in fat lead to fatty deposits in the artery walls. The overweight are at risk of hypertension. A low-fat, high-fibre diet, which includes abundant fruits and vegetables (at least five servings daily), is recommended.

Unsaturated fats which increase the blood cholesterol, e.g. meat, ghee, lard, should be avoided. However, a balanced diet has to include some unsaturated fat like fish, olive and vegetable oils.

The daily intake of salt should not be more than 6gm (0.2 oz), which is about one teaspoonful.


A combination of a healthy diet with regular exercise is the best method to maintain a healthy weight, which reduces the risk of developing hypertension.

Regular exercise ensures that the heart and circulation are efficient, keeps the blood pressure normal, and lowers the blood cholesterol.

The recommendation is that there be at least 150 minutes of exercise of moderate intensity, e.g. fast walking, per week (about 30 minutes daily).

A person who has had a stroke should discuss with his healthcare provider about possible exercise plans. It may not be possible to have regular exercise immediately after a stroke, but exercise should begin when there has been progress with stroke rehabilitation.

It is essential that weight be maintained at healthy levels. Many people go on weight reduction programmes only to find that they gain back the kilogrammes they lost. It would be better to accept a steady rate of weight loss instead of overnight success.

Programmes that promise an ideal weight within a short period of time do not usually work out in the long term. The key to keeping the weight loss is to make changes to diet and lifestyle that one can live with. One has to adhere to these changes for life; they have to be part and parcel of everyday life.


Both active and passive smoking increase the risk of stroke. Smoking doubles the risk as it leads to narrowing of the arteries and increases the likelihood of the blood clotting.

Smoking cessation can reduce the risk of a stroke by up to half. In addition, it will also improve general health and reduce the risk of developing other serious conditions like heart disease and lung cancer.

Smokers who have stopped for more than five years have the same risk of stroke as non-smokers.

Alcohol consumption

Heavy alcohol consumption increases the risk of stroke by three times as it can lead to high blood pressure and irregular heart beats, which are both major risk factors for stroke. In addition, alcohol causes weight gain because they are high-calorie compounds.

Consumption of more than three units a day (one unit = one glass of wine = a peg of hard liquor) increases the risk while light or moderate alcohol intake protects against all strokes.


Aspirin has been reported to be of benefit to women aged 65 years or more in the primary prevention of stroke due to its blood thinning effects.

There is substantial evidence of the benefits of aspirin in secondary prevention of recurrent strokes, with a 25% reduction in risk in all patients with strokes who have received aspirin.

When given within 48 hours of a stroke, it has also been beneficial in reducing recurrent strokes and death.

Other anti-platelet medicines

Alternative antiplatelet medicines are prescribed in patients intolerant or allergic to aspirin, have contraindications to aspirin, or when aspirin has failed. The medicines include ticlopidine and clopidogrel.

It is essential to take aspirin or other anti-platelet medicines under the supervision of a doctor. In addition, one should take measures to avoid falls or tripping when taking these blood-thinning medicines.

In a nutshell

There are several measures that can be taken to prevent a stroke or a recurrent stroke, if one has had a stroke. The following will reduce the likelihood of a stroke or recurrent stroke:

  • Control high blood pressure through diet, exercise, and medicines, when necessary.
  • Control diabetes through diet, exercise, and medicines, when necessary.
  • Control raised cholesterol through diet, exercise, and medicines, when necessary.
  • Exercise at least 30 minutes a day.
  • Maintain a healthy weight by eating healthy foods, eating less, and joining a weight reduction programme, if necessary.
  • Do not smoke, or stop smoking.
  • Limit alcohol consumption to one drink a day for women and two a day for men.
  • Avoid illicit drugs.
  • Have regular medical checks and consultations with the family doctor or physician.


Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.





















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Stroke Support Groups

Stroke support groups play a crucial role in stroke rehabilitation and recovery.

PEOPLE have traditionally provided support for one another, especially when there are challenges. The classic example is the extended family. Whenever there is an event, especially an adverse one, relatives come together to provide assistance and support for the affected person.

The support can be material or non-material. It is often of a varied nature and can be emotional, financial, information, etc.

However, modern day life has seen the dismantling of the extended family in many societies. This has contributed to the formation of support groups.

A support group is one in which the members provide assistance to one another for a specific purpose, which is usually problem-based. The assistance may include the sharing of personal experiences, considerate support, provision of information and care, and establishing social interaction.

A support group has to be distinguished from other groups. The former involves contact between peers, eg people with a health condition. The latter involves the support of causes, eg politics, environment, employment, etc.

There are various types of support groups. In the case of health conditions, they provide for the sharing of experiences, information and services as well as play an advocacy role.

Support groups maintain contact among its members through personal contact or print and electronic media. Membership can be informal in that it is open to anyone, or formal with admission requirements.

Many support groups are managed by its volunteer members who have personal experience of the group’s objectives. Other groups are managed by professionals who do not have the problems of the members of the group, eg healthcare professionals. The professionals provide information and services as well as assist in the determination of the activities of the groups.

Life changes after a stroke

Life changes after a stroke as it markedly affects the survivor and his or her family, who are usually the caregivers. The survivor may experience difficulties with the activities of daily living, eg talking, eating, walking, writing, driving, etc.

The survivor’s relationship with the caregivers, who are usually family members, may change. Caregivers may be confused, upset and isolated. They may be angry or guilty about their feelings towards the survivor, who takes up much of their time and energy. The inevitable changes in family relationships and responsibilities require adjustments from the family members and caregivers.

Stroke survivors and their caregivers require assistance in adjusting to the changes in their lives. Every stroke survivor’s needs are unique. The survivors face new disabilities and possible medical complications, and need to prevent recurrent strokes.

Despite their disabilities, the dignity of stroke survivors needs to be preserved. It is a fact that social support is vital to recovery from a stroke.

The sharing of experiences with other stroke survivors and their caregivers enable all those involved to address their common concerns, provide support, and facilitate the finding of practical solutions.

Survivors can be motivated to rebuild their lives in an atmosphere of caring and emotional support. In the process, new friendships and goals are started.

Stroke support groups

Stroke support groups are informal but structured groups that provide a forum for sharing in an atmosphere of understanding and encouragement that meets the specific physical, emotional, educational and social needs of survivors and their caregivers.

This renews hope, encourages survivors to uncover their hidden and untapped strengths, as well as promotes good health and quality of life.

The issues that are usually covered or provided by a stroke support group include its goals and plans; information on the prevention of recurrent stroke; information on rehabilitation, including adaptive equipment; travel information; discussions of individual physical and emotional issues and concerns, sometimes in small groups; discussions of stroke-related communication problems; advice on exercise and nutrition; motivational talks; educational materials; activities of the group; and suggestions of new topics or ideas.

The leadership in stroke support groups is vital for its success. The leaders are usually dedicated healthcare professional(s) or highly motivated stroke survivor(s), who are dedicated, enthusiastic, empathetic, pragmatic, and well organised.

Whilst common experiences and challenges will help in creating bonds, the process needs to be assisted by the leader(s) or facilitator(s). Careful word choices, institution of group guidelines and good listening skills are crucial in this process.

Successful stroke support groups are adaptable, have structured meetings, have educational programmes and social activities, challenge the stroke survivors, encourage group discussion and peer support, and provide assistance.

There are various local stroke support groups. A prominent one is the National Stroke Association of Malaysia (NASAM), which was founded in 1996 after the publication of its founder chairperson’s recovery from a stroke in an English language newspaper in 1995.

The response from other stroke survivors and their caregivers led to monthly meetings that evolved into weekly physiotherapy sessions and other activities for stroke recovery and rehabilitation.

The twin objectives of NASAM are to provide rehab services to enable stroke survivors to return to as normal a life as possible within the limits of their disabilities and to promote the concept of stroke prevention by raising public awareness on the risk of stroke.

NASAM has centres in Petaling Jaya, Ampang, Penang, Ipoh, Malacca, Johore Bharu, Kuantan and Kota Kinabalu.

Another prominent stroke support group is the Kiwanis Club. The first club, the Kiwanis Club of Kuala Lumpur, was established in 1976. The club launched its Stroke and Neurological Rehabilitation Centre in Petaling Jaya in 2005. The centre provides services to “maximise recovery for individuals with stroke, spinal cord injury, Parkinson’s Disease, prevent complications, and to assist the survivor towards independence with confidence and dignity. With improved physical independence, the survivor can participate fully in family, social and vocational pursuits.”

Internet support groups

The internet has provided fora for support groups. Computer-assisted communication has the potential of facilitating the discussion of private and personal issues.

Several studies have examined the utility of the Internet in providing social support, especially to groups with chronic health problems like stroke. In addition to the sharing of information, there are reports that the community has helped survivors cope with their conditions and disabilities.

Internet support groups are appealing for a number of reasons. The social distance between the members of the group reduces embarrassment, and the anonymity increases the confidence in the provision of support to others. Comments and suggestions can be edited before they are sent. These characteristics are absent in support groups in which a member is present in person.

Another advantage is that the participation is asynchronous, ie all members do not have to be logged in simultaneously. A question or an experience can be posted for others to answer or provide input whenever they log in.

As such, participation in the support group is not dependent on time constraints.

The disadvantage of internet support groups is that information is provided in a haphazard manner, often based on personal experience, which may not be scientific. The group dynamics of such groups are different from groups in which the stroke survivors and their caregivers are present in person.

Some groups may be invaded by sympathy seekers who fabricate illnesses to gain sympathy, and in the process, may impact upon the group. Finding reliable internet stroke support groups can be challenging as they utilise various modalities, eg worldwide web, email, social media.

The jury is still out on the effectiveness of internet support groups. There are many studies on the content of such groups, but what matters is the effect that involvement has on the individual. Research in the latter has not been substantial and conclusive.

The choice of a good internet support group is challenging. It is essential for stroke survivors and their caregivers to be aware of their limitations. The credentials of the sponsors of the group would provide guidance on the usefulness of the information and support.

Stroke associations and service clubs are more likely to be reliable. It would be prudent to scrutinise closely the groups that are sponsored by individuals or promoters of particular products for treatment or rehabilitation of stroke.

A stroke leads to substantial life changes for the survivor and his or her caregivers. The stroke survivor needs support, hope and encouragement. Stroke support groups play a crucial role in stroke rehabilitation and recovery. The issues that are covered or provided by such groups are usually the same worldwide.

Although there are potential advantages in internet support groups, there are also disadvantages, with the jury still out on the effectiveness of such groups. The choice of a good internet support group poses particular challenges.

Dr Milton Lum – is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. 

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.