Energy expenditure and nutrient intake after spinal cord injury: a comprehensive review and practical recommendations

Correlates of metabolic syndrome in people with chronic spinal cord injury

PURPOSE

We aimed at identifying clinical risk factors or early markers of metabolic syndrome (MetS) in people with spinal cord injury (SCI) that would facilitate a timely diagnosis and implementation of preventive/therapeutic strategies.

METHODS

One hundred sixty-eight individuals with chronic (> 1 year) SCI underwent clinical and biochemical evaluations. MetS was diagnosed according to modified criteria of the International Diabetes Federation validated in people with SCI. Wilcoxon rank-sum test and χ2 test were used to compare variables between groups with and without MetS. Multiple logistic regression analysis was performed to reveal independent associations with MetS among variables selected by univariate linear regression analyses.

RESULTS

MetS was diagnosed in 56 of 132 men (42.4%) and 17 of 36 women (47.2%). At univariate regression analyses, putative predictors of MetS were an older age, a higher number of comorbidities, a lower insulin-sensitivity, the presence and intensity of pain, a shorter injury duration, a poorer leisure time physical activity (LTPA) and an incomplete motor injury. At the multiple logistic regression analysis, a significant independent association with MetS only persisted for a poorer LTPA in hours/week (OR: 0.880, 95% CI 0.770, 0.990) and more severe pain symptoms as assessed by the numeral rating scale (OR: 1.353, 95% CI 1.085, 1.793).

CONCLUSION

In people with chronic SCI, intense pain symptoms and poor LTPA may indicate a high likelihood of MetS, regardless of age, SCI duration, motor disability degree, insulin-sensitivity and comorbidities.

Longitudinal changes in body composition and diet after acute spinal cord injury

OBJECTIVE

Spinal cord injury (SCI) is associated with low muscle mass and adiposity, however, to our knowledge, few studies have monitored the trajectory of changes over time. This study aimed to evaluate the timing, rate, magnitude, and site-specific changes in body composition and related changes in diet after SCI.

METHODS

We assessed 39 patients with SCI. The analysis included five women. Of the participants, 51% had American Spinal Injury Association Impairment Scale (AIS) criteria A/B (motor complete) injuries, 18% had AIS C (sensory/motor incomplete) injuries, and 31% had AIS D (motor incomplete) injuries. The mean age of the patients was 43.2 y. They were 48.1 d post-injury and had their weight, diet, and body composition (bioimpedance spectroscopy) assessed every 2 wk.

RESULTS

No significant linear changes were observed for any body composition measure. Total body fat mass (FM) changed 0.01 kg/2 wk when fitted to a quadratic model (P = 0.004), decreasing to week 15 and returning to baseline at week 28. Subgroup analysis revealed that arm lean tissue mass (LTM) increased in paraplegic versus tetraplegic participants (0.05 versus -0.01 kg/2 wk, P = 0.007). Participants with AIS A/B injuries lost FM (-0.17 kg; P = 0.010), whereas those with AIS C injuries gained appendicular LTM (ALTM; 0.15 kg; P = 0.017) and leg LTM (0.12 kg; P = 0.008) every 2 wk. Body composition remained stable in the AIS D group. Mean fortnightly changes were greater in the AIS A/B group than the C group for weight (mean difference -0.30 kg; P = 0.021), FM (-0.25 kg; P = 0.002), and leg LTM (-0.11 kg; P = 0.021) and AIS A/B versus D for FM (-0.42 kg; P = 0.013). Baseline energy and protein intakes were 2150 kcal (±741) and 102 g (±40) and decreased by 21.5 kcal (P = 0.016) and 1.3 g (P = 0.004) every 2 wk but were not associated with body composition changes.

CONCLUSIONS

Neurologic level and severity of SCI, but not changes in diet, were the main determinants of heterogeneous body composition changes.

The comparison of total energy and protein intake relative to estimated requirements in chronic spinal cord injury

In chronic spinal cord injury (SCI), individuals experience dietary inadequacies complicated by an understudied research area. Our objectives were to assess (1) the agreement between methods of estimating energy requirement (EER) and estimated energy intake (EEI) and (2) whether dietary protein intake met SCI-specific protein guidelines. Persons with chronic SCI (n = 43) completed 3-day food records to assess EEI and dietary protein intake. EER was determined with the Long and Institute of Medicine (IOM) methods and the SCI-specific Farkas method. Protein requirements were calculated as 0·8-1·0 g/kg of body weight (BW)/d. Reporting accuracy and bias were calculated and correlated to body composition. Compared with IOM and Long methods (P < 0·05), the SCI-specific method did not overestimate the EEI (P = 0·200). Reporting accuracy and bias were best for SCI-specific (98·9 %, -1·12 %) compared with Long (94·8 %, -5·24 %) and IOM (64·1 %, -35·4 %) methods. BW (r = -0·403), BMI (r = -0·323) and total fat mass (r = -0·346) correlated with the IOM reporting bias (all, P < 0·05). BW correlated with the SCI-specific and Long reporting bias (r = -0·313, P = 0·041). Seven (16 %) participants met BW-specific protein guidelines. The regression of dietary protein intake on BW demonstrated no association between the variables (β = 0·067, P = 0·730). In contrast, for every 1 kg increase in BW, the delta between total and required protein intake decreased by 0·833 g (P = 0·0001). The SCI-specific method for EER had the best agreement with the EEI. Protein intake decreased with increasing BW, contrary to protein requirements for chronic SCI.

Assessing the efficacy of duration and intensity prescription for physical activity in mitigating cardiometabolic risk after spinal cord injury

PURPOSE OF REVIEW

Spinal cord injury (SCI) heightens susceptibility to cardiometabolic risk (CMR), predisposing individuals to cardiovascular disease. This monograph aims to assess the optimal duration and intensity of physical activity (PA) for managing CMR factors, particularly obesity, after SCI and provide modality-specific PA durations for optimal energy expenditure.

RECENT FINDINGS

PA guidelines recommend at least 150 min/week of moderate-intensity activity. However, non-SCI literature supports the effectiveness of engaging in vigorous-intensity PA (≥6 METs) and dedicating 250-300 min/week (≈2000 kcal/week) to reduce CMR factors. Engaging in this volume of PA has shown a dose-response relationship, wherein increased activity results in decreased obesity and other CMR factors in persons without SCI.

SUMMARY

To optimize cardiometabolic health, individuals with SCI require a longer duration and higher intensity of PA to achieve energy expenditures comparable to individuals without SCI. Therefore, individuals with SCI who can engage in or approach vigorous-intensity PA should prioritize doing so for at least 150 min/wk. At the same time, those unable to reach such intensities should engage in at least 250-300 min/week of PA at a challenging yet comfortable intensity, aiming to achieve an optimal intensity level based on their abilities. Given the potential to decrease CMR after SCI, increasing PA duration and intensity merits careful consideration in future SCI PA directives.

Effects of Recombinant IL-13 Treatment on Gut Microbiota Composition and Functional Recovery after Hemisection Spinal Cord Injury in Mice

In recent years, the gut-central nervous system axis has emerged as a key factor in the pathophysiology of spinal cord injury (SCI). Interleukin-13 (IL-13) has been shown to have anti-inflammatory and neuroprotective effects in SCI. The aim of this study was to investigate the changes in microbiota composition after hemisection injury and to determine whether systemic recombinant (r)IL-13 treatment could alter the gut microbiome, indirectly promoting functional recovery. The gut microbiota composition was determined by 16S rRNA gene sequencing, and correlations between gut microbiota alterations and functional recovery were assessed. Our results showed that there were no changes in alpha diversity between the groups before and after SCI, while PERMANOVA analysis for beta diversity showed significant differences in fecal microbial communities. Phylogenetic classification of bacterial families revealed a lower abundance of the Bacteroidales S24-7 group and a higher abundance of Lachnospiraceae and Lactobacillaceae in the post-SCI group. Systemic rIL-13 treatment improved functional recovery 28 days post-injury and microbiota analysis revealed increased relative abundance of Clostridiales vadin BB60 and Acetitomaculum and decreased Anaeroplasma, Ruminiclostridium_6, and Ruminococcus compared to controls. Functional assessment with PICRUSt showed that genes related to glyoxylate cycle and palmitoleate biosynthesis-I were the predominant signatures in the rIL-13-treated group, whereas sulfolactate degradation super pathway and formaldehyde assimilation-I were enriched in controls. In conclusion, our results indicate that rIL-13 treatment promotes changes in gut microbial communities and may thereby contribute indirectly to the improvement of functional recovery in mice, possibly having important implications for the development of novel treatment options for SCI.

Human mesenchymal stem-derived extracellular vesicles improve body growth and motor function following severe spinal cord injury in rat

BACKGROUND

Spinal cord injury (SCI) in young adults leads to severe sensorimotor disabilities as well as slowing of growth. Systemic pro-inflammatory cytokines are associated with growth failure and muscle wasting. Here we investigated whether intravenous (IV) delivery of small extracellular vesicles (sEVs) derived from human mesenchymal stem/stromal cells (MSC) has therapeutic effects on body growth and motor recovery and can modulate inflammatory cytokines following severe SCI in young adult rats.

METHODS

Contusional SCI rats were randomized into three different treatment groups (human and rat MSC-sEVs and a PBS group) on day 7 post-SCI. Functional motor recovery and body growth were assessed weekly until day 70 post-SCI. Trafficking of sEVs after IV infusions in vivo, the uptake of sEVs in vitro, macrophage phenotype at the lesion and cytokine levels at the lesion, liver and systemic circulation were also evaluated.

RESULTS

An IV delivery of both human and rat MSC-sEVs improved functional motor recovery after SCI and restored normal body growth in young adult SCI rats, indicating a broad therapeutic benefit of MSC-sEVs and a lack of species specificity for these effects. Human MSC-sEVs were selectively taken up by M2 macrophages in vivo and in vitro, consistent with our previous observations of rat MSC-sEV uptake. Furthermore, the infusion of human or rat MSC-sEVs resulted in an increase in the proportion of M2 macrophages and a decrease in the production of the pro-inflammatory cytokines tumour necrosis factor-alpha (TNF-α) and interleukin (IL)-6 at the injury site, as well as a reduction in systemic serum levels of TNF-α and IL-6 and an increase in growth hormone receptors and IGF-1 levels in the liver.

CONCLUSIONS

Both human and rat MSC-sEVs promote the recovery of body growth and motor function after SCI in young adult rats possibly via the cytokine modulation of growth-related hormonal pathways. Thus, MSC-sEVs affect both metabolic and neurological deficits in SCI.

The risk of malnutrition in patients with spinal cord injury during inpatient rehabilitation-A longitudinal cohort study

Background and aim

Patients with spinal cord injury (SCI) show an increased risk of malnutrition. Studies found that about 50% of patients with a recent SCI are affected by malnutrition when they enter a rehabilitation institution. However, there is a lack of data during the course and at discharge of initial rehabilitation as well as missing knowledge about the factors promoting such a risk. The aim of this study was to assess the risk of malnutrition in individuals with SCI 3 months post injury and at the end of inpatient rehabilitation and to identify factors associated with a high risk of malnutrition.

Methods

Retrospective, monocentric, longitudinal cohort study, using the data set of the Swiss Spinal Cord Injury Cohort Study and additional data from the patients' medical records. Individuals with SCI were assessed for the risk of malnutrition using the Spinal Nutrition Screening Tool 3 months post injury and at discharge from initial inpatient rehabilitation. Odds ratios (OR) for potential risk parameters were calculated.

Results

Of the 252 participants included, 62% were at risk for malnutrition 3 months post injury and 40% at discharge (p = 0.000). Moderate to high risk of malnutrition was found regardless of age and BMI. The highest odds for an increased risk at 3 months post injury was identified in ventilator-dependent persons (OR 10.2). At discharge from inpatient rehabilitation, pressure injury (OR 16.3) was the most prominent risk factor.

Conclusion

In the population with SCI the risk of malnutrition is widespread during inpatient rehabilitation, but also at discharge. Ventilated persons and persons with pressure injuries are clear risk groups and need special attention. Based on these findings and the known negative impact of malnutrition on clinical outcomes, the awareness of malnutrition should be increased in the population with SCI. Therefore, a regular and standardized screening of the malnutrition risk is highly recommended.

Nutrition Education to Reduce Metabolic Dysfunction for Spinal Cord Injury: A Module-Based Nutrition Education Guide for Healthcare Providers and Consumers

Spinal cord injury (SCI) results in a high prevalence of neurogenic obesity and metabolic dysfunction. The increased risk for neurogenic obesity and metabolic dysfunction is mainly due to the loss of energy balance because of significantly reduced energy expenditure following SCI. Consequently, excessive energy intake (positive energy balance) leads to adipose tissue accumulation at a rapid rate, resulting in neurogenic obesity, systemic inflammation, and metabolic dysfunction. The purpose of this article is to review the existing literature on nutrition, dietary intake, and nutrition education in persons with SCI as it relates to metabolic dysfunction. The review will highlight the poor dietary intakes of persons with SCI according to authoritative guidelines and the need for nutrition education for health care professionals and consumers. Nutrition education topics are presented in a module-based format with supporting literature. The authors emphasize the role of a diet consisting of low-energy, nutrient-dense, anti-inflammatory foods consistent with the Dietary Guidelines for Americans' MyPlate to effectively achieve energy balance and reduce the risk for neurogenic obesity and metabolic dysfunction in individuals with SCI.

Protective effect of zinc oxide nanoparticles on spinal cord injury

The microenvironmental changes in the lesion area of spinal cord injury (SCI) have been extensively studied, but little is known about the whole-body status after injury. We analyzed the peripheral blood RNA-seq samples from 38 SCI and 10 healthy controls, and identified 10 key differentially expressed genes in peripheral blood of patients with SCI. Using these key gene signatures, we constructed a precise and available neural network diagnostic model. More importantly, the altered transcriptome profiles in peripheral blood reflect the similar negative effects after neuronal damage at lesion site. We revealed significant differential alterations in immune and metabolic processes, therein, immune response, oxidative stress, mitochondrial metabolism and cellular apoptosis after SCI were the main features. Natural agents have now been considered as promising candidates to alleviate/cure neuronal damage. In this study, we constructed an in vitro neuronal axotomy model to investigate the therapeutic effects of zinc oxide nanoparticles (ZnO NPs). We found that ZnO NPs could act as a neuroprotective agent to reduce oxidative stress levels and finally rescue the neuronal apoptosis after axotomy, where the PI3K-Akt signaling probably be a vital pathway. In conclusion, this study showed altered transcriptome of peripheral blood after SCI, and indicated the neuroprotective effect of ZnO NPs from perspective of oxidative stress, these results may provide new insights for SCI diagnosis and therapeutics.

The Diagnosis and Management of Cardiometabolic Risk and Cardiometabolic Syndrome after Spinal Cord Injury

Individuals with spinal cord injuries (SCI) commonly present with component risk factors for cardiometabolic risk and combined risk factors for cardiometabolic syndrome (CMS). These primary risk factors include obesity, dyslipidemia, dysglycemia/insulin resistance, and hypertension. Commonly referred to as “silent killers”, cardiometabolic risk and CMS increase the threat of cardiovascular disease, a leading cause of death after SCI. This narrative review will examine current data and the etiopathogenesis of cardiometabolic risk, CMS, and cardiovascular disease associated with SCI, focusing on pivotal research on cardiometabolic sequelae from the last five years. The review will also provide current diagnosis and surveillance criteria for cardiometabolic disorders after SCI, a novel obesity classification system based on percent total body fat, and lifestyle management strategies to improve cardiometabolic health.

Comparison of Various Indices in Identifying Insulin Resistance and Diabetes in Chronic Spinal Cord Injury

The purpose of this screening and diagnostic study was to examine the accord among indices of glucose metabolism, including the Homeostatic Model Assessment for Insulin Resistance (HOMA), HOMA2, Matsuda Index, Quantitative Insulin-sensitivity Check Index (QUICKI), hemoglobin A1C (HbA1C), and fasting plasma glucose (FPG) against intravenous glucose tolerance test-measured insulin sensitivity (Si) in individuals with chronic motor complete SCI. Persons with chronic (≥12-months post-injury) SCI (n = 29; 79% men; age 42.2 ± 11.4; body mass index 28.6 ± 6.4 kg/m2; C4-T10) were included. Measures were compared using adjusted R2 from linear regression models with Akaike information criterion (AIC, a measure of error). QUICKI had the greatest agreement with Si (adjusted R2 = 0.463, AIC = 91.1, p = 0.0001), followed by HOMA (adjusted R2 = 0.378, AIC = 95.4, p = 0.0008), HOMA2 (adjusted R2 = 0.256, AIC = 99.7, p = 0.0030), and the Matsuda Index (adjusted R2 = 0.356, AIC = 95.5, p = 0.0004). FPG (adjusted R2 = 0.056, AIC = 107.5, p = 0.1799) and HbA1C (adjusted R2 = 0.1, AIC = 106.1, p = 0.0975) had poor agreement with Si. While HbA1C and FPG are commonly used for evaluating disorders of glucose metabolism, QUICKI demonstrates the best accord with Si compared to the other measures.