Neurogenic obesity and systemic inflammation following spinal cord injury: A review

Neurogenic Obesity-Induced Insulin Resistance and Type 2 Diabetes Mellitus in Chronic Spinal Cord Injury

The population with SCI is at a significant risk for both insulin resistance and type 2 diabetes mellitus (T2DM) secondary to neurogenic obesity. The prevalence of insulin resistance and T2DM in persons with SCI suggests that disorders of carbohydrate metabolism are at epidemic proportions within the population. However, the true frequency of such disorders may be underestimated because biomarkers of insulin resistance and T2DM used from the population without SCI remain nonspecific and may in fact fail to identify true cases that would benefit from intervention. Furthermore, diet and exercise have been used to help mitigate neurogenic obesity, but results on disorders of carbohydrate metabolism remain inconsistent, likely because of the various ways carbohydrate metabolism is assessed. The objective of this article is to review current literature on the prevalence and likely mechanisms driving insulin resistance and T2DM in persons with SCI. This article also explores the various assessments and diagnostic criteria used for insulin resistance and T2DM and briefly discusses the effects of exercise and/or diet to mitigate disorders of carbohydrate metabolism brought on by neurogenic obesity.

Relationship Between Sleep-Disordered Breathing and Neurogenic Obesity in Adults With Spinal Cord Injury

Spinal cord injury (SCI) substantially increases the risk of neurogenic obesity, diabetes, and metabolic syndrome. Much like in the general population, a discussion of these syndromes in SCI would be incomplete without acknowledging the association of SCI with sleep-disordered breathing (SDB). This article will outline the interplay between obesity and obstructive sleep apnea (OSA), discussing the pathophysiology of obesity in OSA both for the general population and SCI population. The role of insulin resistance in SDB and SCI will also be examined. The epidemiology and pathophysiology of OSA and central sleep apnea in SCI are discussed through an examination of current evidence, followed by a review of central sleep apnea in SCI. Principles of diagnosis and management of SDB will also be discussed. Because sleep deprivation in itself can be a risk factor for developing obesity, the significance of comorbid insomnia in SCI is explored. Ultimately, a thorough sleep history, testing, and treatment are key to improving the sleep of individuals with SCI and to potentially reducing the impact of neurogenic obesity and metabolic syndrome.

Upper Extremity Overuse Injuries and Obesity After Spinal Cord Injury

Persons with spinal cord injury (SCI) are at high risk for developing neurogenic obesity due to muscle paralysis and obligatory sarcopenia, sympathetic blunting, anabolic deficiency, and blunted satiety. Persons with SCI are also at high risk for shoulder, elbow, wrist, and hand injuries, including neuromusculoskeletal pathologies and nociceptive pain, as human upper extremities are poorly designed to facilitate chronic weight-bearing activities, including manual wheelchair propulsion, transfers, self-care, and day-to-day activities. This article reviews current literature on the relationship between obesity and increased body weight with upper extremity overuse injuries, detailing pathology at the shoulders, elbows, and wrists that elicit pain and functional decline and stressing the importance of weight management to preserve function.

Dietetics After Spinal Cord Injury: Current Evidence and Future Perspectives

Following spinal cord injury (SCI), individuals are at high risk for obesity and several chronic cardiometabolic disorders due to a deterioration in body composition, hypometabolic rate, and endometabolic dysregulation. Countermeasures to the consequences of an SCI include adopting a healthy diet that provides adequate nutrition to maintain good body habitus and cardiometabolic health. A proper diet for individuals with SCI should distribute carbohydrates, protein, and fat to optimize a lower energy intake requirement and should stress foods with low caloric yet high nutrient density. The purpose of this article is to present available evidence on how nutritional status after SCI should advance future research to further develop SCI-specific guidelines for total energy intake, as it relates to percent carbohydrates, protein, fat, and all vitamins and minerals, that take into consideration the adaptations after SCI.

A Primary Care Provider's Guide to Diet and Nutrition After Spinal Cord Injury

Physiological changes that occur after spinal cord injury (SCI) are profound and affect almost every organ system in the human body. Energy balance is significantly altered due to motor paralysis, spasticity or flaccidity, neurogenic sarcopenia, neurogenic osteopenia, sympathetic nervous system disruption, and blunted anabolism. Energy expenditure is markedly reduced, whereas hypothalamic control of appetite and satiety is diminished, resulting in discordant energy intake. Ultimately, neurogenic obesity ensues as the result of a positive energy balance. Even though nutritional guidelines for persons with SCI have been available since 2009, the necessity for body composition assessment and total daily energy expenditure was insufficiently addressed such that most individuals with SCI continued in positive energy balance despite "adherence" to the guidelines. Macronutrients must be carefully assessed to optimize caloric intake, while micronutrient consumption may need to be supplemented in order to meet recommended daily allowances. Such a diet would emphasize foods with low caloric yet high nutrient density. This article reviews current literature regarding nutritional requirements for SCI and provides a straightforward plan for implementing more rigorous dietary interventions meant to address the obesity crisis in this especially vulnerable population.

Pathophysiology of Neurogenic Obesity After Spinal Cord Injury

Individuals with a spinal cord injury (SCI) have a unique physiology characterized by sarcopenia, neurogenic osteoporosis, neurogenic anabolic deficiency, sympathetic dysfunction, and blunted satiety associated with their SCI, all of which alter energy balance and subsequently body composition. The distinct properties of "neurogenic obesity" place this population at great risk for metabolic dysfunction, including systemic inflammation, hyperglycemia, dyslipidemia, and hypertension. The purpose of this article is to demonstrate the relationship between neurogenic obesity and the metabolic syndrome after SCI, highlighting the mechanisms associated with adipose tissue pathology and those respective comorbidities. Additionally, representative studies of persons with SCI will be provided to elucidate the severity of the problem and to prompt greater vigilance among SCI specialists as well as primary care providers in order to better manage the epidemic from a public health perspective.

Energy Expenditure, Cardiorespiratory Fitness, and Body Composition Following Arm Cycling or Functional Electrical Stimulation Exercises in Spinal Cord Injury: A 16-Week Randomized Controlled Trial

Background: Physical deconditioning and inactivity following spinal cord injury (SCI) are associated with multiple cardiometabolic risks. To mitigate cardiometabolic risk, exercise is recommended, but it is poorly established whether arm cycling exercise (ACE) or functional electrical stimulation (FES) leg cycling yields superior benefits. Objectives: To determine the adaptations of 16 weeks of FES cycling and ACE on exercise energy expenditure (EEE), cardiorespiratory fitness (CRF), and obesity after SCI. Methods: Thirteen physically untrained individuals were randomly assigned to FES (n = 6) or ACE (n = 7) exercise 5 days/week for 16 weeks. Pre- and post-intervention EEE, peak oxygen consumption (absolute and relative VO2Peak), and work were assessed using indirect calorimetry, while body composition was measured by dual-energy x-ray absorptiometry. Results: Main effects were found for peak power (p < .001), absolute (p = .046) and relative (p = .042) VO2Peak, and peak work (p = .013). Compared to baseline, the ACE group increased in EEE (+85%, p = .002), peak power (+307%, p < .001), VO2Peak (absolute +21%, relative +22%, p ≤ .024), peak work (19% increase, p = .003), and total body fat decreased (-6%, p = .05). The FES group showed a decrease in percentage body fat mass (-5%, p = .008). The ACE group had higher EEE (p = .008), peak power (p < .001), and relative VO2Peak (p = .025) compared to postintervention values in the FES group. Conclusion: In the current study, ACE induced greater increases in EEE and CRF, whereas ACE and FES showed similar results on body fat. Exercise promotional efforts targeting persons with SCI should use both FES and ACE to reduce sedentary behavior and to optimize different health parameters after SCI.

Interrelationship of Neurogenic Obesity and Chronic Neuropathic Pain in Persons With Spinal Cord Injury

The prevalence of obesity and of neuropathic pain are both estimated at above 50% in the population of people with chronic spinal cord injury (SCI). These secondary consequences of SCI have significant negative impact on physical functioning, activities of daily living, and quality of life. Investigations of relationships between weight or body composition and chronic neuropathic pain in people with SCI are lacking, but investigations in non-SCI cohorts suggest an association between obesity and the presence and severity of neuropathic pain conditions. In the present article, we present a review of the literature linking obesity and neuropathic pain and summarize findings suggesting that metabolic syndrome and chronic, systemic inflammation due to excess adiposity increase the risk for neuropathic pain after an SCI.

Influence of mid and low paraplegia on cardiorespiratory fitness and energy expenditure

STUDY DESIGN

Observational, Cross-sectional.

OBJECTIVE

Examine the influence of mid (MP) and low (LP) paraplegia on cardiorespiratory fitness (CRF), energy expenditure (EE), and physical activity levels (PAL), and compare these data to able-bodied (AB) individuals.

SETTING

Academic medical center.

METHODS

Persons with MP (n = 6, T6-T8, 83% male, age: 31 ± 11 y, BMI: 24 ± 7 kg/m²) and LP (n = 5; T10-L1, 100% male, age: 39 ± 11 y, BMI: 26 ± 5 kg/m²) and AB controls (n = 6; 67% male, age: 29 ± 12 y, BMI: 26 ± 5 kg/m²) participated. All participants underwent 45-min of arm-crank exercise where CRF and exercise EE were measured. Basal metabolic rate (BMR) was measured, and total daily EE (TDEE) and PAL were estimated.

RESULTS

Absolute VO_2Peak (MP: 1.6 ± 0.2, LP: 1.9 ± 0.1, AB: 2.5 ± 0.7 l/min), peak metabolic equivalents (MP: 6.8 ± 1.3, LP: 5.7 ± 0.7, AB: 8.8 ± 0.8 METs), peak power output (MP: 72.9 ± 11.5, LP: 86.8 ± 6.1, AB: 121.0 ± 34.8 Watts), and maximal heart rate (MP: 177.7 ± 9.8, LP: 157 ± 13.6, AB: 185.2 ± 8.5 bpm) were significantly different between the three groups (p < 0.05). BMR and TDEE did not significantly differ between the three groups (p > 0.05), whereas exercise EE (MP: 7.8 ± 1.2, LP: 9.5 ± 0.7, AB: 12.4 ± 3.5 kcal/min) and PAL (MP: 1.30 ± 0.04, LP: 1.32 ± 0.04, AB: 1.43 ± 0.06) significantly differed (p < 0.05). In the AB group, 33.3% and 66.7% were classified as sedentary or having low activity levels, respectively, while all persons with paraplegia were classified as sedentary according to PAL classifications.

CONCLUSION

Individuals with MP and LP have lower CRF, exercise EE, and PALs compared to AB individuals.

A Western diet impairs CNS energy homeostasis and recovery after spinal cord injury: Link to astrocyte metabolism

A diet high in fat and sucrose (HFHS), the so-called Western diet promotes metabolic syndrome, a significant co-morbidity for individuals with spinal cord injury (SCI). Here we demonstrate that the spinal cord of mice consuming HFHS expresses reduced insulin-like growth factor 1 (IGF-1) and its receptor and shows impaired tricarboxylic acid cycle function, reductions in PLP and increases in astrogliosis, all prior to SCI. After SCI, Western diet impaired sensorimotor and bladder recovery, increased microgliosis, exacerbated oligodendrocyte loss and reduced axon sprouting. Direct and indirect neural injury mechanisms are suggested since HFHS culture conditions drove parallel injury responses directly and indirectly after culture with conditioned media from HFHS-treated astrocytes. In each case, injury mechanisms included reductions in IGF-1R, SIRT1 and PGC-1α and were prevented by metformin. Results highlight the potential for a Western diet to evoke signs of neural insulin resistance and injury and metformin as a strategy to improve mechanisms of neural neuroprotection and repair.

Diet in neurogenic bowel management: A viewpoint on spinal cord injury

The aim of this review is to offer dietary advice for individuals with spinal cord injury (SCI) and neurogenic bowel dysfunction. With this in mind, we consider health conditions that are dependent on the level of lesion including skeletal muscle atrophy, autonomic dysreflexia and neurogenic bladder. In addition, SCI is often associated with a sedentary lifestyle, which increases risk for osteoporosis and diseases associated with chronic low-grade inflammation, including cardiovascular and chronic kidney diseases. The Mediterranean diet, along with exercise and dietary supplements, has been suggested as an anti-inflammatory intervention in individuals with SCI. However, individuals with chronic SCI have a daily intake of whole fruit, vegetables and whole grains lower than the recommended dietary allowance for the general population. Some studies have reported an increase in neurogenic bowel dysfunction symptoms after high fiber intake; therefore, this finding could explain the low consumption of plant foods. Low consumption of fibre induces dysbiosis, which is associated with both endotoxemia and inflammation. Dysbiosis can be reduced by exercise and diet in individuals with SCI. Therefore, to summarize our viewpoint, we developed a Mediterranean diet-based diet and exercise pyramid to integrate nutritional recommendations and exercise guidelines. Nutritional guidelines come from previously suggested recommendations for military veterans with disabilities and individuals with SCI, chronic kidney diseases, chronic pain and irritable bowel syndrome. We also considered the recent exercise guidelines and position stands for adults with SCI to improve muscle strength, flexibility and cardiorespiratory fitness and to obtain cardiometabolic benefits. Finally, dietary advice for Paralympic athletes is suggested.

Caloric Intake Relative to Total Daily Energy Expenditure Using a Spinal Cord Injury-Specific Correction Factor: An Analysis by Level of Injury

OBJECTIVE

The aims of the study were to evaluate the influence of level of spinal cord injury (SCI) on caloric intake relative to total daily energy expenditure (TDEE) and body composition, and to develop a SCI-specific correction factor for the TDEE estimation.

DESIGN

Individuals with paraplegia (PARA, n = 28) and tetraplegia (TETRA, n = 13) were analyzed. Daily caloric intake, basal metabolic rate, and TDEE were obtained using dietary recall, indirect calorimetry, and prediction equations, respectively. Caloric intake and TDEE were adjusted to bodyweight. Body composition was assessed using dual-energy x-ray absorptiometry.

RESULTS

Total caloric (PARA 1516.4 ± 548.4, TETRA 1619.1 ± 564.3 kcal/d), fat (PARA 58.6 ± 27.4, TETRA 65.8 ± 29.7 g), and protein (PARA 62.7 ± 23.2, TETRA 71.5 ± 30.9 g) intake were significantly higher in TETRA versus PARA (P < 0.05) when adjusted for bodyweight. Adjusted and unadjusted TDEE (unadjusted: PARA 1851.0 ± 405.3, TETRA 1530.4 ± 640.4 kcal/d) and basal metabolic rate (unadjusted: PARA 1516.6 ± 398.0, TETRA 1223.6 ± 390.2 kcal/d) were significantly higher in PARA versus TETRA (P < 0.05). Bone mineral content (PARA 3.17 ± 0.6, TETRA 2.71 ± 0.5 g), lean body mass (PARA 50.0 ± 8.6, TETRA 40.96 ± 8.8 kg), and regional percent body fat (PARA 36.45 ± 8.0, TETRA 41.82 ± 9.1) were different between groups (P < 0.05). The SCI-specific correction factor was 1.15.

CONCLUSIONS

A dichotomy exists in caloric intake, TDEE, and body composition among TETRA and PARA. The SCI-specific correction factor of 1.15 is a promising tool to estimate TDEE in SCI.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Understand the influence of spinal cord level of injury on energy expenditure and body composition; (2) Appreciate that equations used to estimate total daily energy expenditure overestimate energy expenditure in individuals with spinal cord injury; and (3) Understand the importance of normalizing caloric intake to bodyweight after spinal cord injury.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

A Provider's Guide to Vascular Disease, Dyslipidemia, and Glycemic Dysregulation in Chronic Spinal Cord Injury

Individuals with chronic spinal cord injury (SCI) are predisposed to accelerated atherogenesis, dyslipidemia, and glycemic dysregulation, although not enough is known about the etiologies or clinical consequences of these secondary effects of paralysis. While guidelines for the detection and treatment of cardiometabolic disease in SCI have recently been published, there has been a historical paucity of data-driven approaches to these conditions. This article will describe what is and not known about the cardiovascular disease and glycemic dysregulation that frequently attend SCI. It will conclude with a review of both guideline-driven and informal recommendations addressing the clinical care of people living with SCI.

Hepatic dysfunction after spinal cord injury: A vicious cycle of central and peripheral pathology?

The liver is essential for numerous physiological processes, including filtering blood from the intestines, metabolizing fats, proteins, carbohydrates and drugs, and regulating iron storage and release. The liver is also an important immune organ and plays a critical role in response to infection and injury throughout the body. Liver functions are regulated by autonomic parasympathetic innervation from the brainstem and sympathetic innervation from the thoracic spinal cord. Thus, spinal cord injury (SCI) at or above thoracic levels disrupts major regulatory mechanisms for hepatic functions. Work in rodents and humans shows that SCI induces liver pathology, including hepatic inflammation and fat accumulation characteristic of a serious form of non-alcoholic fatty liver disease (NAFLD) called non-alcoholic steatohepatitis (NASH). This hepatic pathology is associated with and likely contributes to indices of metabolic dysfunction often noted in SCI individuals, such as insulin resistance and hyperlipidemia. These occur at greater rates in the SCI population and can negatively impact health and quality of life. In this review, we will: 1) Discuss acute and chronic changes in human and rodent liver pathology and function after SCI; 2) Describe how these hepatic changes affect systemic inflammation, iron regulation and metabolic dysfunction after SCI; 3) Describe how disruption of the hepatic autonomic nervous system may be a key culprit in post-injury chronic liver pathology; and 4) Preview ongoing and future research that aims to elucidate mechanisms driving liver and metabolic dysfunction after SCI.

A Systematic Review of the Accuracy of Estimated and Measured Resting Metabolic Rate in Chronic Spinal Cord Injury

The objective of this systematic review was to examine resting metabolic rate (RMR) measured through indirect calorimetry in adults with chronic spinal cord injury (SCI) and to evaluate the predication equations used for the estimation of RMR in this population. The authors additionally aimed to review the impact of sex and level of injury on RMR. A MEDLINE/PubMed, Google Scholar, Scopus, and Web of Science search was performed for studies published from the database inception to January 2018, identifying 326 articles. On the basis of the inclusion criteria, 22 studies remained for review. All articles that were identified were full-text, English language articles examining adults with chronic SCI who were fasted for a minimum of 8 hr before undergoing RMR through indirect calorimetry for at least 20 min. The measured RMR ranged from 1,256.0 to 1,854.0 kcal/day, whereas the estimated RMR ranged from 1,276.8 to 1,808.0 kcal/day in the chronic SCI population. Seven studies overestimated RMR from 4% to 15%, whereas two studies underestimated RMR from 2% to 17% using prediction equations established for the able-bodied population. Two studies produced SCI-specific equations to estimate RMR. With regard to sex and level of injury, RMR does not differ between individuals with tetraplegia and paraplegia, whereas sex-based differences remain inconclusive, given limited results. These data provide evidence for the use of indirect calorimetry to assess RMR and the need to validate SCI-specific prediction equations in the estimation of RMR.

Sex dimorphism in the distribution of adipose tissue and its influence on proinflammatory adipokines and cardiometabolic profiles in motor complete spinal cord injury

Objective: We aimed to examine the influence of sex on the distribution of adipose tissue, as well as proinflammatory adipokine and cardiometabolic profiles, in chronic motor complete spinal cord injury (SCI). Design: Cross-sectional and correlational study. Setting: Academic rehabilitation hospital. Participants: Forty-seven individuals with chronic motor complete SCI classified according to sex (males: age 44.0 ± 10.9 y, body mass index (BMI) 27.2 ± 5.8, level of injury (LOI) C4 - L1; females: 42.0 ± 13.5 y, BMI 27.8 ± 6.6, LOI C4 - T11). Intervention: Not applicable. Outcome Measures: Visceral (VAT), subcutaneous (SAT), and total trunk (TTAT) adipose tissue volumes were assessed utilizing magnetic resonance imaging and a VAT:SAT ratio was calculated. Proinflammatory adipokines (tumor neurosis factor-α, interleukin-6, plasminogen activator inhibitor-1, thrombin-activatable fibrinolysis inhibitor, and high sensitivity c-reactive protein) and cardiovascular, carbohydrate, and lipid profiles were evaluated according to standard techniques. Results: VAT and VAT:SAT ratio were significantly greater in male participates with SCI (P ≤ 0.002), while SAT volume was significantly greater in female participants with SCI (P = 0.001). No difference was noted in TTAT between groups (P = 0.341). Male participants with SCI demonstrated lower high-density lipoprotein-cholesterol (HDLC) profiles and an elevated total cholesterol to HDLC ratio (P ≤ 0.003) compared with females. No other significant differences were found between groups concerning cardiometabolic profiles or proinflammatory adipokines; however, males exhibited poorer profiles overall. Proinflammatory adipokines significantly correlated with adipose tissue depots by sex (P < 0.05). Conclusion: The results show that sex influences the distribution of adipose tissue, and may influence proinflammatory and cardiometabolic profiles following SCI. The findings of this study highlight the need for further research with dietary modification and exercise to decrease health risks.

Arm crank ergometry improves cardiovascular disease risk factors and community mobility independent of body composition in high motor complete spinal cord injury

OBJECTIVE

Evaluate the effect of aerobic exercise using arm crank ergometry (ACE) in high motor complete (ISNCSCI A/B) spinal cord injury (SCI) as primarily related to cardiovascular disease (CVD) risk factors and functional mobility and secondarily to body composition and metabolic profiles.

DESIGN

Longitudinal interventional study at an academic medical center.

METHODS

Ten previously untrained participants (M8/F2, Age 36.7 y ± 10.1, BMI 24.5 ± 6.0) with high motor complete SCI (C7-T5) underwent ACE exercise training 30 minutes/day × 3 days/week for 10 weeks at 70% VO2Peak.

OUTCOME MEASURES

Primary outcome measures were pre- and post-intervention changes in markers of cardiovascular fitness (graded exercise testing (GXT): VO2, VO2Peak, respiratory quotient [RQ], GXT time, peak power, and energy expenditure [EE]) and community mobility (time to traverse a 100ft-5° ramp, and 12-minute WC propulsion test). Secondary outcome measures were changes in body composition and metabolic profiles (fasting and area under the curve for glucose and insulin, homeostasis model assessment [HOMA] for %β-cell activity [%β], %insulin sensitivity [%S], and insulin resistance [IR], and Matsuda Index [ISIMatsuda]).

RESULTS

Resting VO2, relative VO2Peak, absolute VO2Peak, peak power, RQ, 12-minute WC propulsion, fasting insulin, fasting G:I ratio, HOMA-%S, and HOMA-IR all significantly improved following intervention (P < 0.05). There were no changes in body composition (P>0.05).

CONCLUSIONS

Ten weeks of ACE at 70% VO2Peak in high motor complete SCI improves aerobic capacity, community mobility, and metabolic profiles independent of changes in body composition.

Molecular pathways linking adipose innervation to insulin action in obesity and diabetes mellitus

Adipose tissue comprises adipocytes and many other cell types that engage in dynamic crosstalk in a highly innervated and vascularized tissue matrix. Although adipose tissue has been studied for decades, it has been appreciated only in the past 5 years that extensive arborization of nerve fibres has a dominant role in regulating the function of adipose tissue. This Review summarizes the latest literature, which suggests that adipocytes signal to local sensory nerve fibres in response to perturbations in lipolysis and lipogenesis. Such adipocyte signalling to the central nervous system causes sympathetic output to distant adipose depots and potentially other metabolic tissues to regulate systemic glucose homeostasis. Paracrine factors identified in the past few years that mediate such adipocyte-neuron crosstalk are also reviewed. Similarly, immune cells and endothelial cells within adipose tissue communicate with local nerve fibres to modulate neurotransmitter tone, blood flow, adipocyte differentiation and energy expenditure, including adipose browning to produce heat. This understudied field of neurometabolism related to adipose tissue biology has great potential to reveal new mechanistic insights and potential therapeutic strategies for obesity and type 2 diabetes mellitus.

Prevalence of metabolic syndrome in veterans with spinal cord injury

CONTEXT/OBJECTIVE

Recent literature would suggest the prevalence of metabolic syndrome in persons with spinal cord injury (SCI) is higher than that of the general population, although no large cohorts have yet been reported. Part of the controversy relates to the differing definitions provided for metabolic syndrome and the characterization of obesity in persons with SCI.

DESIGN/PARTICIPANTS

The current retrospective investigation represents a cross-sectional cohort of 473 veterans with SCI from a single center in the mid-Atlantic region of the United States for whom modified International Diabetes Federation (IDF) criterion variables for the metabolic syndrome were available in the computerized personal record system (CPRS).

OUTCOME MEASURES

These variables included a surrogate marker of obesity appropriate to SCI (Body Mass Index (BMI) ≥ 22 kg/m2), as well as indicators of diabetes, dyslipidemia and hypertension.

RESULTS

Over 57% of the veterans assessed were determined to have metabolic syndrome by modified IDF criteria, including 76.7% with BMI ≥ 22 kg/m2, 55.1% with or under treatment for hypertension, 49.7% with or previously diagnosed with diabetes mellitus, and 69.7% with or under treatment for high density lipoprotein (HDL) cholesterol under 40 mg/dl.

CONCLUSION

Metabolic syndrome and its constituent components appear to be more prevalent in veterans with SCI than in the general population, suggesting a greater need for identification and treatment interventions in this specialty population.

Nutritional status in chronic spinal cord injury: a systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

The objective was to investigate nutritional status in chronic spinal cord injury (SCI), and compare macronutrient and micronutrient intake to the recommended values by the United States Department of Agriculture (USDA) 2015-2020 Dietary Guidelines for Americans.

SETTING

United States of America.

METHODS

A MEDLINE/PubMed, Google Scholar, Scopus, and Web of Science search was performed, identifying 268 papers. All papers included were English-language papers examining adults with chronic SCI. A meta-analysis was performed to produce weighted averages and 95% confidence intervals (CI) when summary statistics were provided.

RESULTS

The systematic review included 15 articles, while the meta-analysis included 12. Resting metabolic rate (1492 kcal/day; CI: 1414-1569) fell below the able-bodied average, and total energy (1876 kcal/day; CI: 1694-2059) and fiber (17 g/day; CI: 14-20) intake were below USDA guidelines. Protein (319 kcal/day; CI: 294-345) and carbohydrate (969 kcal/day; CI: 851-1087) intake were above guidelines. Fat intake (663 kcal/day; CI: 590-736) was within USDA guidelines. Vitamins A, B5, B7, B9, D, E, potassium, and calcium were deficient, while vitamins B1, B2, B3, B12, C, K, sodium, phosphorus, copper, and zinc were in excess according to USDA guidelines. Vitamin B6, iron, and magnesium were within USDA guidelines.

CONCLUSION

Findings indicate greater energy intake relative to energy needs in those with chronic SCI, and an imbalance in fiber intake and micronutrients compared to the USDA guidelines. Future research examining nutritional health status is needed in order to establish evidence-based, SCI-specific dietary guidelines.