Nutrient intake and body habitus after spinal cord injury: an analysis by sex and level of injury

Patient Perceptions and Clinical Assessments of Cardiometabolic Disease After Subacute Spinal Cord Injury

OBJECTIVES

To investigate the effectiveness of health care team communication regarding cardiometabolic disease (CMD) risk factors with patients with subacute spinal cord injury (SCI).

DESIGN

Multi-site prospective cross-sectional study.

SETTING

Five National Institute on Disability, Independent Living, and Rehabilitation Research Model SCI Rehabilitation Centers.

PARTICIPANTS

Ninety-six patients with subacute SCI, aged 18-70 years, with SCI (neurologic levels of injury C2-L2, American Spinal Injury Association Impairment Scale grades A-D), and enrolled within 2 months of initial rehabilitation discharge (N=96).

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Objective risk factors of CMD (body mass index, fasting glucose, insulin, high-density lipoprotein cholesterol, triglyceride levels, and resting blood pressure). Patient reported recall of these present risk factors being shared with them by their health care team. Medications prescribed to patients to address these present risk factors were checked against guideline- assessed risk factors.

RESULTS

Objective evidence of 197 CMD risk factors was identified, with patients recalling less than 12% of these (P<.0001) being shared with them by their health care team. Thirty-one individuals (32%) met criteria for a diagnosis of CMD, with only 1 of these patients (3.2%) recalling that this was shared by their health care team (P<.0001). Pharmacologic management was prescribed to address these risk factors only 7.2% of the time.

CONCLUSIONS

Despite high prevalence of CMD risk factors after acute SCI, patients routinely do not recall being told of their present risk factors. Multifaceted education and professionals' engagement efforts are needed to optimize treatment for these individuals.

Dual-directional regulation of spinal cord injury and the gut microbiota

There is increasing evidence that the gut microbiota affects the incidence and progression of central nervous system diseases via the brain-gut axis. The spinal cord is a vital important part of the central nervous system; however, the underlying association between spinal cord injury and gut interactions remains unknown. Recent studies suggest that patients with spinal cord injury frequently experience intestinal dysfunction and gut dysbiosis. Alterations in the gut microbiota can cause disruption in the intestinal barrier and trigger neurogenic inflammatory responses which may impede recovery after spinal cord injury. This review summarizes existing clinical and basic research on the relationship between the gut microbiota and spinal cord injury. Our research identified three key points. First, the gut microbiota in patients with spinal cord injury presents a key characteristic and gut dysbiosis may profoundly influence multiple organs and systems in patients with spinal cord injury. Second, following spinal cord injury, weakened intestinal peristalsis, prolonged intestinal transport time, and immune dysfunction of the intestine caused by abnormal autonomic nerve function, as well as frequent antibiotic treatment, may induce gut dysbiosis. Third, the gut microbiota and associated metabolites may act on central neurons and affect recovery after spinal cord injury; cytokines and the Toll-like receptor ligand pathways have been identified as crucial mechanisms in the communication between the gut microbiota and central nervous system. Fecal microbiota transplantation, probiotics, dietary interventions, and other therapies have been shown to serve a neuroprotective role in spinal cord injury by modulating the gut microbiota. Therapies targeting the gut microbiota or associated metabolites are a promising approach to promote functional recovery and improve the complications of spinal cord injury.

Reducing endocrine metabolic disease risk in adults with chronic spinal cord injury: strategic activities conducted by the Ontario-Quebec RIISC team

PURPOSE

The Rehabilitation Interventions for Individuals with a Spinal Cord Injury in the Community (RIISC) team aimed to develop and evaluate innovative rehabilitation interventions to identify endocrine metabolic disease (EMD) risk, intending to reduce the frequency and severity of EMD related morbidity and mortality among adults living with chronic spinal cord injury or disease (SCI/D).

MATERIALS AND METHODS

An interprovincial team from Ontario and Quebec reviewed available EMD literature and evidence syntheses and completed an inventory of health services, policies and practices in SCI/D care. The review outcomes were combined with expert opinion to create an EMD risk model to inform health service transformation.

RESULTS

EMD risk and mortality are highly prevalent among adults with chronic SCI/D. In stark contrast, few rehabilitation interventions target EMD outcomes. The modelled solution proposes: 1) abandoning single-disease paradigms and examining a holistic perspective of the individual's EMD risk, and 2) developing and disseminating practice-based research approaches in outpatient community settings.

CONCLUSIONS

RIISC model adoption could accelerate EMD care optimization, and ultimately inform the design of large-scale longitudinal pragmatic trials likely to improve health outcomes. Linking the RIISC team activities to economic evaluations and policy deliverables will strengthen the relevance and impact among policymakers, health care providers and patients.

Trends in measuring BMR and RMR after spinal cord injury: a comprehensive review

Studying factors that contribute to our understanding of maintaining normal energy balance are of paramount significance following spinal cord injury (SCI). Accurate determination of energy needs is crucial for providing nutritional guidance and managing the increasing prevalence of malnutrition or obesity after SCI. BMR represents 75-80 % of the total energy expenditure in persons with SCI. Accurately measuring BMR is an important component for calculating total energetic needs in this population. Indirect calorimetry is considered the gold-standard technique for measuring BMR. However, technical challenges may limit its applications in large cohort studies and alternatively rely on prediction equations. Previous work has shown that BMR changes in response to disuse and exercise in the range of 15-120 %. Factors including sex, level of injury and type of assistive devices may influence BMR after SCI. RMR is erroneously used interchangeably for BMR, which may result in overestimation of energetic intake when developing nutritional plans. To address this concern, we comprehensively reviewed studies that conducted BMR (n=15) and RMR (n=22) in persons with SCI. The results indicated that RMR is 9 % greater than BMR in persons with SCI. Furthermore, the SCI-specific prediction equations that incorporated measures of fat-free mass appeared to accurately predict BMR. Overall, the current findings highlighted the significance of measuring BMR as well as encouraging the research and clinical community to effectively establish countermeasures to combat obesity after SCI.

Bioactive role of vitamins as a key modulator of oxidative stress, cellular damage and comorbidities associated with spinal cord injury (SCI)

Introduction: Spinal cord injury (SCI) cause significant disability and impact the quality of life of those affected by it. The nutritional status and diet are fundamental to diminish the progression of complications; vitamins modulate the inflammatory response and oxidative stress, promote blood-spinal cord barrier preservation and the prompt recovery of homeostasis. A deep knowledge of the benefits achieved from vitamins in patients with SCI are summarized. Information of dosage, time, and effects of vitamins in these patients are also displayed. Vitamins have been extensively investigated; however, more clinical trials are needed to clarify the scope of vitamin supplementation.Objective: The objective of this review was to offer relevant therapeutic information based on vitamins supplementation for SCI patients.Methods: Basic and clinical studies that have implemented the use of vitamins in SCI were considered. They were selected from the year 2000-2022 from three databases: PubMed, Science Direct and Google Scholar.Results: Consistent benefits in clinical trials were shown in those who were supplemented with vitamin D (prevents osteoporosis and improves physical performance variables), B3 (improves lipid profile) and B12 (neurological prophylaxis of chronic SCI damage) mainly. On the other hand, improvement related to neuroprotection, damage modulation (vitamin A) and its prophylaxis were associated to B complex vitamins supplementation; the studies who reported positive results are displayed in this review.Discussion: Physicians should become familiar with relevant information that can support conventional treatment in patients with SCI, such as the use of vitamins, a viable option that can improve outcomes in patients with this condition.

Diet quality, diet-related factors and disability status among male adults of reproductive age in the USA

OBJECTIVE

To examine diet quality and diet-related factors among male adults of reproductive age with and without disabilities.

DESIGN

Cross-sectional data from the National Health and Nutrition Examination Surveys, 2013-2018.

SETTING

Disability was reported as serious difficulty hearing, seeing, concentrating, walking, dressing and/or running errands due to physical, mental or emotional conditions. Diet quality was assessed by the Healthy Eating Index (HEI)-2015 and diet-related factors included self-rated diet healthfulness, food security and food assistance programmes. Multivariable linear regression estimated differences in HEI-2015 scores. Multivariable Poisson regression estimated adjusted prevalence ratios (aPR) and 95 % CI for diet-related factors.

PARTICIPANTS

In total, 3249 males, 18-44 years; of whom, 441 (13·4 %) reported having disabilities.

RESULTS

Compared with males without disabilities, those with disabilities had a 2·69-point (95 % CI: -4·18, -1·20) lower mean total HEI-2015 score and approximately one-third to half of a point lower HEI-2015 component scores for greens and beans, total protein foods, seafood and plant proteins, fatty acids and added sugars. Males with any disabilities were more likely to have low food security (aPR = 1·57; 95 % CI: 1·28, 2·92); household participation in food assistance programmes (aPR = 1·61; 95 % CI: 1·34, 1·93) and consume fast food meals during the previous week (1-3 meals: aPR = 1·11; 95 % CI: 1·01-1·21 and 4 or more meals: aPR = 1·18; 95 % CI: 1·01-1·38) compared with males with no disabilities.

CONCLUSIONS

Factors affecting diet and other modifiable health behaviours among male adults of reproductive age with disabilities require further investigation. Health promotion strategies that are adaptive to diverse populations within the disability community are needed.

The Physiology of Neurogenic Obesity: Lessons from Spinal Cord Injury Research

BACKGROUND

A spinal cord injury (SCI) from trauma or disease impairs sensorimotor pathways in somatic and autonomic divisions of the nervous system, affecting multiple body systems. Improved medical practices have increased survivability and life expectancy after SCI, allowing for the development of extensive metabolic comorbidities and profound changes in body composition that culminate in prevalent obesity.

SUMMARY

Obesity is the most common cardiometabolic component risk in people living with SCI, with a diagnostic body mass index cutoff of 22 kg/m2 to account for a phenotype of high adiposity and low lean mass. The metameric organization of specific divisions of the nervous system results in level-dependent pathology, with resulting sympathetic decentralization altering physiological functions such as lipolysis, hepatic lipoprotein metabolism, dietary fat absorption, and neuroendocrine signaling. In this manner, SCI provides a unique opportunity to study in vivo the "neurogenic" components of certain pathologies that otherwise are not readily observable in other populations. We discuss the unique physiology of neurogenic obesity after SCI, including the altered functions mentioned above as well as structural changes such as reduced skeletal muscle and bone mass and increased lipid deposition in the adipose tissue, skeletal muscle, bone marrow, and liver.

KEY MESSAGE

The study of neurogenic obesity after SCI gives us a unique neurological perspective on the physiology of obesity. The lessons learned from this field can guide future research and advancements to inform the study of obesity in persons with and without SCI.

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.

Systemic inflammation after spinal cord injury: A review of biological evidence, related health risks, and potential therapies

Individuals with chronic traumatic spinal cord injury (SCI) develop progressive multi-system health problems that result in clinical illness and disability. Systemic inflammation is associated with many of the common medical complications and acquired diseases that accompany chronic SCI, suggesting that it contributes to a number of comorbid pathological conditions. However, many of the mechanisms that promote persistent systemic inflammation and its consequences remain ill-defined. This review describes the significant biological factors that contribute to systemic inflammation, major organ systems affected, health risks, and the potential treatment strategies. We aim to highlight the need for a better understanding of inflammatory processes, and to establish appropriate strategies to address inflammation in SCI.

Similar fat and carbohydrate oxidation in response to arm cycling exercise in persons with spinal cord injury versus able-bodied

CONTEXT

Persons with spinal cord injury (SCI) present with low fat oxidation that is associated with poor cardiometabolic health. This study compared changes in fat and carbohydrate (CHO) oxidation during moderate intensity continuous exercise in persons with SCI and able-bodied adults (AB).

DESIGN

Repeated measures, within-subjects study.

SETTING

University laboratory in San Diego, CA.

PARTICIPANTS

Nine men and women with SCI (age and time since injury = 32 ± 11 yr and 7 ± 6 yr) and 10 AB adults (age = 25 ± 8 yr).

INTERVENTIONS

To assess peak oxygen uptake (VO₂peak) and peak power output (PPO), participants performed progressive arm ergometry to volitional exhaustion. Subsequently, they completed 25 min of continuous exercise at 45%PPO.

OUTCOME MEASURES

Respiratory exchange ratio (RER), fat and CHO oxidation, and blood lactate concentration (BLa) were assessed.

RESULTS

Data showed a similar RER (P = 0.98) during exercise in SCI (0.97 ± 0.04) versus AB (0.97 ± 0.03) reflecting high CHO use and no differences in BLa (3.5 ± 1.1 and 3.0 ± 0.9 vs. mM, P = 0.56) or fat and CHO oxidation between groups (P > 0.05). However, participants with SCI exercised at a higher relative intensity (P < 0.01, 84 ± 7 vs. 75 ± 7%HRpeak) versus AB.

CONCLUSION

Data confirm high reliance on CHO during arm ergometry in persons with SCI. To better compare substrate utilization to AB adults, we recommend that exercise be prescribed according to peak heart rate due to differences in cardiorespiratory fitness between groups.

Effects of a low-carbohydrate/high-protein diet on metabolic health in individuals with chronic spinal cord injury: An exploratory analysis of results from a randomized controlled trial

We explored the impact of a low-carbohydrate/high-protein diet (LC/HP, ~30% energy from protein, 40% energy from carbohydrate) on indices of metabolic function and body composition in individuals with chronic spinal cord injury (SCI). Adults with SCI (≥3 years post-injury, C4-L2, AIS A-D) and insulin resistance or pre-diabetes were randomly assigned to an 8-week iso-caloric LC/HP diet group (n = 11) or control group (n = 14). All LC/HP meals were delivered weekly to participants' homes, and participants in the control group consumed their habitual diet. Each participant underwent an oral glucose tolerance test (OGTT) to assess glucose tolerance, insulin, area under the curve (AUC) for glucose and insulin, Matsuda Index, glucose-stimulated insulin secretion (GSIS), disposition index, and hepatic insulin extraction (HIE). Fasting blood lipid and inflammation were assessed, and body composition was estimated using dual-energy x-ray absorptiometry. A linear mixed model was used to evaluate the main effect of diet, time, and their interaction. Compared to the control group, participants in the LC/HP group had reduced total body fat mass (LC/HP: -5.9%, Control: 0.7%), visceral fat mass (LC/HP: -16.2%, Control: 5.2%), total- (LC/HP: -20.1, Control: 3.7 mg/dl), and LDL-cholesterol (LC/HP: -13.9, Control: 3.1 mg/dl) (pdiet*time  < 0.05 for all). Regardless of group, AUCinsulin and peak insulin during the OGTT decreased, and HIE increased over time (ptime  < 0.05). A trend for diet*time interaction was observed for glucoseOGTT120min (LC/HP: -20.7, Control: 3.0 mg/dl, pdiet*time  = 0.09) and peak C-peptide (LC/HP: -2.1, Control: 0.0 ng/ml, pdiet*time  = 0.07). HDL-cholesterol, lean body mass, Matsuda Index, fasting glucose, insulin, insulinOGTT120min , AUCglucose , pancreatic beta cell function (GSIS, disposition index), and inflammation (C-reactive protein, IL-6, IL-8, IL-10, TNF-α) did not change over time. In conclusion, our results suggest that individuals with SCI and insulin resistance may adopt an LC/HP diet to improve body composition and lipid profiles. Its impact on glucose metabolism and inflammation remains inconclusive and warrants future investigations.

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

Many persons with spinal cord injury (SCI) have one or more preventable chronic diseases related to excessive energetic intake and poor eating patterns. Appropriate nutrient consumption relative to need becomes a concern despite authoritative dietary recommendations from around the world. These recommendations were developed for the non-disabled population and do not account for the injury-induced changes in body composition, hypometabolic rate, hormonal dysregulation and nutrition status after SCI. Because evidence-based dietary reference intake values for SCI do not exist, ensuring appropriate consumption of macronutrient and micronutrients for their energy requirements becomes a challenge. In this compressive review, we briefly evaluate aspects of energy balance and appetite control relative to SCI. We report on the evidence regarding energy expenditure, nutrient intake and their relationship after SCI. We compare these data with several established nutritional guidelines from American Heart Association, Australian Dietary Guidelines, Dietary Guidelines for Americans, Institute of Medicine Dietary Reference Intake, Public Health England Government Dietary Recommendations, WHO Healthy Diet and the Paralyzed Veterans of America (PVA) Clinical Practice Guidelines. We also provide practical assessment and nutritional recommendations to facilitate a healthy dietary pattern after SCI. Because of a lack of strong SCI research, there are currently limited dietary recommendations outside of the PVA guidelines that capture the unique nutrient needs after SCI. Future multicentre clinical trials are needed to develop comprehensive, evidence-based dietary reference values specific for persons with SCI across the care continuum that rely on accurate, individual assessment of energy need.

Pharmacological and non-pharmacological therapeutic interventions for the treatment of spinal cord injury-induced pain

Spinal cord injury (SCI) is a complex neurophysiological disorder, which can result in many long-term complications including changes in mobility, bowel and bladder function, cardiovascular function, and metabolism. In addition, most individuals with SCI experience some form of chronic pain, with one-third of these individuals rating their pain as severe and unrelenting. SCI-induced chronic pain is considered to be "high impact" and broadly affects a number of outcome measures, including daily activity, physical and cognitive function, mood, sleep, and overall quality of life. The majority of SCI pain patients suffer from pain that emanates from regions located below the level of injury. This pain is often rated as the most severe and the underlying mechanisms involve injury-induced plasticity along the entire neuraxis and within the peripheral nervous system. Unfortunately, current therapies for SCI-induced chronic pain lack universal efficacy. Pharmacological treatments, such as opioids, anticonvulsants, and antidepressants, have been shown to have limited success in promoting pain relief. In addition, these treatments are accompanied by many adverse events and safety issues that compound existing functional deficits in the spinally injured, such as gastrointestinal motility and respiration. Non-pharmacological treatments are safer alternatives that can be specifically tailored to the individual and used in tandem with pharmacological therapies if needed. This review describes existing non-pharmacological therapies that have been used to treat SCI-induced pain in both preclinical models and clinical populations. These include physical (i.e., exercise, acupuncture, and hyper- or hypothermia treatments), psychological (i.e., meditation and cognitive behavioral therapy), and dietary interventions (i.e., ketogenic and anti-inflammatory diet). Findings on the effectiveness of these interventions in reducing SCI-induced pain and improving quality of life are discussed. Overall, although studies suggest non-pharmacological treatments could be beneficial in reducing SCI-induced chronic pain, further research is needed. Additionally, because chronic pain, including SCI pain, is complex and has both emotional and physiological components, treatment should be multidisciplinary in nature and ideally tailored specifically to the patient.

Nutrition counseling and monitoring via tele-nutrition for healthy diet for people with spinal cord injury: A case series analyses

OBJECTIVE

To evaluate the effect of a tele-nutrition counseling program on diet quality, weight, waist circumference, and quality of life in people with spinal cord injury (SCI).

DESIGN

Prospective observational study.

PARTICIPANTS

Fifteen participants with SCI were enrolled from an acute inpatient rehabilitation unit and outpatient SCI clinic; ten participants completed the intervention.

INTERVENTIONS

Six tele-nutrition counseling sessions over 3 months, utilizing videoconferencing and a photographic food diary.

OUTCOME MEASURES

Weight, waist circumference, Life Satisfaction Index A (LSIA), Knowledge and Nutrition Evaluation with Supplement on Eating Behavior, and Program Satisfaction Survey (PSS).

RESULTS

Ten participants completed both baseline and 3-month follow-up evaluations and were used in this analysis. There were no statistically significant changes from baseline to 3-month follow up in weight, waist circumference, Knowledge and Nutrition Evaluation, and LSIA (P > .48). Using the Supplement on Eating Behavior total score to measure overall changes in healthy food choices, 9 out of 10 participants rated their healthy food choices as improving (P = .008). A post-hoc exploratory itemized analysis on the Supplement on Eating Behavior revealed significant improvements from baseline to 3-month follow-up in participant's self-reported choice of balanced meals (P = .008), reading food labels (P = .031), logging meals (P = .007), and monitoring portions of eating favorite foods (P = .031). Participants endorsed a 97-100% satisfaction rating in relation to perceived health benefits, equipment, and program satisfaction.

CONCLUSION

This study provides preliminary data suggesting that tele-nutrition is an efficacious intervention that may improve diet quality for individuals with SCI.

The interaction of macronutrients and body composition among individuals with chronic spinal cord injury

Changes in body composition and dietary intake occur following spinal cord injury (SCI). The Geometric Framework for Nutrition (GFN) is a tool that allows the examination of the complex relationships between multiple nutrition factors and health parameters within a single model. This study aimed to utilize the GFN to examine the associations between self-reported macronutrient intakes and body composition in persons with chronic SCI. Forty-eight individuals with chronic SCI were recruited. Participants completed and returned 3- or 5-day self-reported dietary recall sheets. Dietary intake of macronutrients (fats, proteins, and carbohydrates) were analysed. Anthropometric measures (circumferences), dual-energy x-ray absorptiometry (DXA), and magnetic resonance imaging (MRI) were used to assess whlole-body composition. Associations between all circumference measures and carbohydrates were observed. Among MRI measures, only significant associations between subcutaneous adipose tissue and protein x carbohydrate as well as carbohydrates alone were identified. Carbohydrates were negatively associated with several measures of fat mass as measured by DXA. Overall, carbohydrates appear to play an important role in body composition among individuals with SCI. Higher carbohydrate intake was associated with lower fat mass. Additional research is needed to determine how carbohydrate intake influences body composition and cardiometabolic health after SCI.

Selective Myostatin Inhibition Spares Sublesional Muscle Mass and Myopenia-Related Dysfunction after Severe Spinal Cord Contusion in Mice

Clinically relevant myopenia accompanies spinal cord injury (SCI), and compromises function, metabolism, body composition, and health. Myostatin, a transforming growth factor (TGF)β family member, is a key negative regulator of skeletal muscle mass. We investigated inhibition of myostatin signaling using systemic delivery of a highly selective monoclonal antibody - muSRK-015P (40 mg/kg) - that blocks release of active growth factor from the latent form of myostatin. Adult female mice (C57BL/6) were subjected to a severe SCI (65 kdyn) at T9 and were then immediately and 1 week later administered test articles: muSRK-015P (40 mg/kg) or control (vehicle or IgG). A sham control group (laminectomy only) was included. At euthanasia, (2 weeks post-SCI) muSRK-015P preserved whole body lean mass and sublesional gastrocnemius and soleus mass. muSRK-015P-treated mice with SCI also had significantly attenuated myofiber atrophy, lipid infiltration, and loss of slow-oxidative phenotype in soleus muscle. These outcomes were accompanied by significantly improved sublesional motor function and muscle force production at 1 and 2 weeks post-SCI. At 2 weeks post-SCI, lean mass was significantly decreased in SCI-IgG mice, but was not different in SCI-muSRK-015P mice than in sham controls. Total energy expenditure (kCal/day) at 2 weeks post-SCI was lower in SCI-immunoglobulin (Ig)G mice, but not different in SCI-muSRK-015P mice than in sham controls. We conclude that in a randomized, blinded, and controlled study in mice, myostatin inhibition using muSRK-015P had broad effects on physical, metabolic, and functional outcomes when compared with IgG control treated SCI animals. These findings may identify a useful, targeted therapeutic strategy for treating post-SCI myopenia and related sequelae in humans.

Effects of Exercise Mode on Postprandial Metabolism in Humans with Chronic Paraplegia

PURPOSE

The purpose of this study was to assess the acute effects of exercise mode and intensity on postprandial macronutrient metabolism.

METHODS

Ten healthy men age 39 ± 10 yr with chronic paraplegia (13.2 ± 8.8 yr, ASIA A-C) completed three isocaloric bouts of upper-body exercise and a resting control. After an overnight fast, participants completed circuit resistance exercise (CRE) first and the following conditions in a randomized order, separated by >48 h: i) control (CON), ~45-min seated rest; ii) moderate-intensity continuous exercise (MICE), ~40-min arm cranking at a resistance equivalent to ~30% peak power output (PPO); and iii) high-intensity interval exercise (HIIE), ~30 min arm cranking with resistance alternating every 2 min between 10% PPO and 70% PPO. After each condition, participants completed a mixed-meal tolerance test consisting of a 2510-kJ liquid meal (35% fat, 50% carbohydrate, 15% protein). Blood and expired gas samples were collected at baseline and regular intervals for 150 min after a meal.

RESULTS

An interaction (P < 0.001) was observed, with rates of lipid oxidation elevated above CON in HIIE until 60 min after a meal and in CRE at all postprandial time points up to 150 min after a meal. Postprandial blood glycerol was greater in MICE (P = 0.020) and CRE (P = 0.001) compared with CON. Furthermore, nonesterified fatty acid area under the curve had a moderate-to-strong effect in CRE versus MICE and HIIE (Cohen's d = -0.76 and -0.50, respectively).

CONCLUSIONS

In persons with paraplegia, high-intensity exercise increased postprandial energy expenditure independent of the energy cost of exercise. Furthermore, exercise combining resistance and endurance modes (CRE) showed the greater effect on postprandial lipid oxidation.

Body Composition According to Spinal Cord Injury Level: A Systematic Review and Meta-Analysis

The level of injury is linked with biochemical alterations and limitations in physical activity among individuals with spinal cord injury (SCI), which are crucial determinants of body composition. We searched five electronic databases from inception until 22 July 2021. The pooled effect estimates were computed using random-effects models, and heterogeneity was calculated using I² statistics and the chi-squared test. Study quality was assessed using the Newcastle–Ottawa Scale. We pooled 40 studies comprising 4872 individuals with SCI (3991 males, 825 females, and 56 sex-unknown) in addition to chronic SCI (median injury duration 12.3 y, IQR 8.03–14.8). Individuals with tetraplegia had a higher fat percentage (weighted mean difference (WMD) 1.9%, 95% CI 0.6, 3.1) and lower lean mass (WMD −3.0 kg, 95% CI −5.9, −0.2) compared to those with paraplegia. Those with tetraplegia also had higher indicators of central adiposity (WMD, visceral adipose tissue area 0.24 dm² 95% CI 0.05, 0.43 and volume 1.05 L 95% CI 0.14, 1.95), whereas body mass index was lower in individuals with tetraplegia than paraplegia (WMD −0.9 kg/mg², 95% CI −1.4, −0.5). Sex, age, and injury characteristics were observed to be sources of heterogeneity. Thus, individuals with tetraplegia have higher fat composition compared to paraplegia. Anthropometric measures, such as body mass index, may be inaccurate in describing adiposity in SCI individuals.

A Single Bout of Upper-Body Exercise Has No Effect on Postprandial Metabolism in Persons with Chronic Paraplegia

PURPOSE

The acute effects of a single bout of upper-body exercise on postprandial metabolism in persons with spinal cord injury are currently not well understood. The primary aim of this study was to evaluate the effects of a single bout of upper-body high-intensity interval exercise (HIIE) and moderate-intensity continuous exercise (MICE) in comparison with a no-exercise control (REST) condition on postprandial metabolic responses in persons with chronic paraplegia.

METHODS

Ten participants (eight males, two females; age, 49 ± 10 yr; time since injury, 22 ± 13 yr) with chronic paraplegia took part in a randomized crossover study, consisting of three trials: HIIE (8 × 60 s at 70% peak power output [PPEAK]), MICE (25 min at 45% PPEAK), and REST, at least 3 d apart. Exercise was performed in the fasted state, and participants consumed a mixed-macronutrient liquid meal 1-h postexercise. Venous blood and expired gas samples were collected at regular intervals for 6-h postmeal consumption.

RESULTS

There were no significant differences in postprandial incremental area under the curve for triglycerides (P = 0.59) or glucose (P = 0.56) between conditions. Insulin incremental area under the curve tended to be lower after MICE (135 ± 85 nmol·L-1 per 360 min) compared with REST (162 ± 93 nmol·L-1 per 360 min), but this did not reach statistical significance (P = 0.06, d = 0.30). Participants reported a greater fondness (P = 0.04) and preference for HIIE over MICE.

CONCLUSIONS

After an overnight fast, a single bout of upper-body exercise before eating has no effect on postprandial metabolism in persons with chronic paraplegia, irrespective of exercise intensity. This suggests that alternative exercise strategies may be required to stimulate postprandial substrate oxidation for this population.

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.

Protein Considerations for Athletes With a Spinal Cord Injury

Athlete participation in the Paralympic games is steadily increasing; prompting research focused on the unique needs of this population. While the Paralympic Games includes a diversity of athletes, athletes with a spinal cord injury (PARA-SCI) represent a subgroup that requires specialized recommendations. Nutritional guidelines designed to optimize performance, in the context of the neurological impairments, are required. This narrative review summarizes the current literature regarding the importance of dietary protein for optimal health and performance. Factors with the potential to affect protein needs in PARA-SCI including loss of active muscle mass, reduced energy expenditure, and secondary complications are examined in detail. Furthermore, we analyze protein intakes in PARA-SCI from the available research to provide context around current practices and trends. In conclusion, we make the case that protein recommendations for able-bodied athletes may not be directly transferable to PARA-SCI. Consequently, PARA-SCI need their own guidelines to maximize performance and ensure long-term health.

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.

A systematic review of the effect of dietary interventions on cardiovascular disease risk in adults with spinal cord injury

CONTEXT

Cardiovascular disease is one of the leading causes of mortality in individuals with spinal cord injury (SCI), highlighting the need for targeted risk minimization interventions.

OBJECTIVE

To determine the effect of dietary interventions on CVD risk in adults with SCI.

METHODS

A systematic literature review of studies investigating the impact of dietary intervention on CVD risk in SCI individuals was conducted according to the PRISMA statement. CASP checklists were used for critical appraisal, Academy of Nutrition and Dietetics Quality criteria checklist (QCC) for determining risk of bias and the GRADE approach to ascertain the quality of evidence of the outcomes. The results were reported descriptively.

RESULTS

A total of eight studies were included from the identified 862 articles. Dietary intervention strategies varied across all studies, as did the outcome measures. Adult learning theories were not considered. The lack of controlled trials (two only) meant that while some interventions proved useful, risk of bias was high. Outcome measures were assessed as low to very low quality again identifying that this area is highly under-researched.

CONCLUSION

Despite documented evidence of the benefits of diet on CVD risk reduction, this review has identified a dearth of research in SCI. Nonetheless, the review emphasizes the potential of diet in conjunction with exercise in minimizing CVD risk in SCI. Further good quality research backed by robust data collection, simple, actionable strategies and knowledge translation techniques are essential to ascertain the effects of dietary intervention in lowering CVD risk in SCI.

Cardiometabolic risks and atherosclerotic disease in ApoE knockout mice: Effect of spinal cord injury and Salsalate anti-inflammatory pharmacotherapy

OBJECTIVE

To test in mice with a double mutation of the ApoE gene (ApoE-/-) whether spinal cord injury (SCI) hastens the native trajectory of, and established component risks for, atherosclerotic disease (AD), and whether Salsalate anti-inflammatory pharmacotherapy attenuates the impact of SCI.

METHODS

ApoE-/- mice were anesthetized and underwent a T9 laminectomy. Exposed spinal cords were given a contusion injury (70 k-dynes). Sham animals underwent all surgical procedures, excluding injury. Injured animals were randomized to 2 groups: SCI or SCI+Salsalate [120 mg/Kg/day i.p.]. Mice were serially sacrificed at 20-, 24-, and 28-weeks post-SCI, and body mass was recorded. At sacrifice, heart and aorta were harvested intact, fixed in 10% buffered formalin, cleaned and cut longitudinally for en face preparation. The aortic tree was stained with oil-red-O (ORO). AD lesion histomorphometry was calculated from the proportional area of ORO. Plasma total cholesterol, triglycerides and proatherogenic inflammatory cytokines (PAIC's) were analyzed.

RESULTS

AD lesion in the aortic arch progressively increased in ApoE-/-, significant at 24- and 28-weeks. AD in SCI is significantly greater at 24- and 28-weeks compared to time-controlled ApoE-/-. Salsalate treatment attenuates the SCI-induced increase at these time points. Body mass in all SCI groups are significantly reduced compared to time-controlled ApoE-/-. Cholesterol and triglycerides are significantly higher with SCI by 24- and 28-weeks, compared to ApoE-/-, and Salsalate reduces the SCI-induced effect on cholesterol. PAIC's interleukin-1β (IL-1β), interleukin-6 (IL-6), tumor necrosis factor α (TNFα), monocyte chemoattractant protein-1 (MCP-1), and chemokine (C-C motif) ligand 5 (CCL-5) are significantly greater with SCI compared to ApoE-/- at varying timepoints. Salsalate confers a marginal reducing effect on PAIC's by 28-weeks compared to SCI. Regression models determine that each PAIC is a significant and positive predictor of lesion. (p's <0.05).

CONCLUSIONS

SCI accelerates aortic AD and associated risk factors, and anti-inflammatory treatment may attenuate the impact of SCI on AD outcomes. PAIC's IL-1β, IL-6, TNFα, MCP-1, and CCL-5 may be effective predictors of AD.

Effect of Paraplegia on the Time Course of Exogenous Fatty Acid Incorporation Into the Plasma Triacylglycerol Pool in the Postprandial State

Spinal cord injury (SCI) results in disordered fat metabolism. Autonomic decentralization might contribute to dyslipidemia in SCI, in part by influencing the uptake of dietary fats through the gut-lymph complex. However, the neurogenic contributions to dietary fat metabolism are unknown in this population. We present a subset of results from an ongoing registered clinical trial (NCT03691532) related to dietary fat absorption. We fed a standardized (20 kcal⋅kgFFM^–1) liquid meal tolerance test (50% carb, 35% fat, and 15% protein) that contained stable isotope lipid tracer (5 mg⋅kgFFM^–1 [U-¹³C]palmitate) to persons with and without motor complete thoracic SCI. Blood samples were collected at six postprandial time points over 400 min. Changes in dietary fatty acid incorporated into the triacylglycerol (TAG) pool (“exogenous TAG”) were used as a marker of dietary fat absorption. This biomarker showed that those with paraplegia had a lower amplitude than non-injured participants at Post₂₄₀ (52.4 ± 11.0 vs. 77.5 ± 16.0 μM), although this failed to reach statistical significance (p = 0.328). However, group differences in the time course of absorption were notable. The injury level was also strongly correlated with time-to-peak exogenous TAG concentration (r = −0.806, p = 0.012), with higher injuries resulting in a slower rise in exogenous TAG. This time course documenting exogenous TAG change is the first to show a potential neurogenic alteration in SCI dietary fat absorption.

Neurogenic Obesity and Skeletal Pathology in Spinal Cord Injury

Spinal cord injury (SCI) results in dramatic changes in body composition, with lean mass decreasing and fat mass increasing in specific regions that have important cardiometabolic implications. Accordingly, the recent Consortium for Spinal Cord Medicine (CSCM) released clinical practice guidelines for cardiometabolic disease (CMD) in SCI recommending the use of compartmental modeling of body composition to determine obesity in adults with SCI. This recommendation is guided by the fact that fat depots impact metabolic health differently, and in SCI adiposity increases around the viscera, skeletal muscle, and bone marrow. The contribution of skeletal muscle atrophy to decreased lean mass is self-evident, but the profound loss of bone is often less appreciated due to methodological considerations. General-population protocols for dual-energy x-ray absorptiometry (DXA) disregard assessment of the sites of greatest bone loss in SCI, but the International Society for Clinical Densitometry (ISCD) recently released an official position on the use of DXA to diagnose skeletal pathology in SCI. In this review, we discuss the recent guidelines regarding the evaluation and monitoring of obesity and bone loss in SCI. Then we consider the possible interactions of obesity and bone, including emerging evidence suggesting the possible influence of metabolic, autonomic, and endocrine function on bone health in SCI.

Exercise Interventions Targeting Obesity in Persons With Spinal Cord Injury

Spinal cord injury (SCI) results in an array of cardiometabolic complications, with obesity being the most common component risk of cardiometabolic disease (CMD) in this population. Recent Consortium for Spinal Cord Medicine Clinical Practice Guidelines for CMD in SCI recommend physical exercise as a primary treatment strategy for the management of CMD in SCI. However, the high prevalence of obesity in SCI and the pleiotropic nature of this body habitus warrant strategies for tailoring exercise to specifically target obesity. In general, exercise for obesity management should aim primarily to induce a negative energy balance and secondarily to increase the use of fat as a fuel source. In persons with SCI, reductions in the muscle mass that can be recruited during activity limit the capacity for exercise to induce a calorie deficit. Furthermore, the available musculature exhibits a decreased oxidative capacity, limiting the utilization of fat during exercise. These constraints must be considered when designing exercise interventions for obesity management in SCI. Certain forms of exercise have a greater therapeutic potential in this population partly due to impacts on metabolism during recovery from exercise and at rest. In this article, we propose that exercise for obesity in SCI should target large muscle groups and aim to induce hypertrophy to increase total energy expenditure response to training. Furthermore, although carbohydrate reliance will be high during activity, certain forms of exercise might induce meaningful postexercise shifts in the use of fat as a fuel. General activity in this population is important for many components of health, but low energy cost of daily activities and limitations in upper body volitional exercise mean that exercise interventions targeting utilization and hypertrophy of large muscle groups will likely be required for obesity management.

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.

Exploring nutrition knowledge and dietary intake of adults with spinal cord injury in specialist rehabilitation

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To explore nutrition knowledge and dietary intake in adults with spinal cord injury (SCI).

SETTING

SCI centre, Australia.

METHODS

A validated General Nutrition Knowledge Questionnaire-R (GNKQ-R) evaluated nutrition knowledge to explore correlations with dietary intake. Dietary intake (current and pre-hospitalisation) was compared with national dietary modelling tools and Nutrient Reference Values (NRV) for assessing nutritional adequacy.

RESULTS

Fifty participants, predominantly male (70%), with a median age of 50 years took part in the study. The mean GNKQ-R score was 59 (13.1)/85 (69%). Participants with a higher level of education scored higher (82%; p < 0.01). The GNKQ-R score was also positively associated with the level of education (r = 0.45; p = < 0.01) with a large effect size (>0.80 Cohen's d). Non-conformance with Australian Dietary Guidelines (ADG) and failure to meet NRV were also noted. Low calcium intakes were found in 69% (n = 34) and saturated fatty acid (SFA) consumption exceeded both the acceptable macronutrient distribution range (AMDR) of 10% for adults (n = 32, 65%) and the lower target of 7% recommended for at-risk groups (n = 49, 100%). Lower nutrition knowledge scores were negatively correlated with SFA intake (r = -0.28; p = 0.05, two-tailed) with a large Cohen's d effect size (>0.80).

CONCLUSIONS

Discordance with the ADG for most food groups was exemplified by high intake of SFA. Individuals with SCI have elevated cardiovascular disease (CVD) risk. Poor nutrition knowledge correlated with high SFA intake, indicates a need for timely, targeted interventions for CVD prevention in this patient group.

Spinal Cord Injury as a Model of Bone-Muscle Interactions: Therapeutic Implications From in vitro and in vivo Studies

Spinal cord injuries (SCIs) represent a variety of conditions related to the damage of the spinal cord with consequent musculoskeletal repercussions. The bone and muscle tissues share several catabolic pathways that lead to variable degrees of disability in SCI patients. In this review article, we provide a comprehensive characterization of the available treatment options targeting the skeleton and the bone in the setting of SCI. Among the pharmacological intervention, bisphosphonates, anti-sclerostin monoclonal antibodies, hydrogen sulfide, parathyroid hormone, and RANKL pathway inhibitors represent valuable options for treating bone alterations. Loss phenomena at the level of the muscle can be counteracted with testosterone, anabolic-androgenic steroids, and selective androgen receptor modulators. Exercise and physical therapy are valuable strategies to increase bone and muscle mass. Nutritional interventions could enhance SCI treatment, particularly in the setting of synergistic and multidisciplinary interventions, but there are no specific guidelines available to date. The development of multidisciplinary recommendations is required for a proper clinical management of SCI patients.

Changes in nutrient intake and inflammation following an anti-inflammatory diet in spinal cord injury

Objective: The objective of the current study was to describe the observed changes in nutrient intakes following a 3-month anti-inflammatory diet, and to explore potential relationships between the change in nutrients and the change in various inflammatory mediators.Design: A secondary analysis of a prior randomized controlled clinical trial.Setting: Individuals with SCI within the Niagara region.Participants: Twenty individuals with various levels and severities of SCI.Intervention: Three-month anti-inflammatory diet.Outcome Measures: The change in nutrient intake and corresponding changes to various inflammatory mediators.Results: The treatment group demonstrated a significant reduction in fat intake (P = 0.02), a significant increase in protein intake (P = 0.02), and no change in carbohydrates (P = 0.23) or energy intake (P = 0.10). The treatment group showed a significant increase in some nutrients with established anti-inflammatory properties including vitamins A, C, and E, and omega-3 fatty acids (P < 0.01). Significant reductions in proinflammatory nutrients were observed including trans fatty acids (P = 0.05), caffeine (P < 0.01), and sodium (P = 0.02). The treatment group also showed significant reductions in the proinflammatory mediators interferon-y (P = 0.01), interleukin-1β (P < 0.01), and interleukin-6 (P < 0.05). Further, several proinflammatory mediators were negatively correlated with anti-inflammatory nutrients, including vitamin A, carotenoids, omega-3 fatty acids, and zinc.Conclusion: This study provides evidence that dietary alterations are effective at reducing chronic inflammation in individuals with SCI and provides a preliminary assessment of the related nutrient changes.

Utilizing a low-carbohydrate/high-protein diet to improve metabolic health in individuals with spinal cord injury (DISH): study protocol for a randomized controlled trial

Background

Metabolic disorders (e.g., impaired glucose tolerance, insulin resistance, and type 2 diabetes) are more prevalent in people with spinal cord injury (SCI) than able-bodied individuals. Dietary modification is a more cost-effective treatment option than pharmacological therapies for reducing the risk of metabolic dysfunction. Lowering carbohydrate, increasing protein, and maintaining a proper dietary fat intake are expected to induce favorable adaptations in glucose control, body fat distribution, and the composition of the gut microbiome. However, dietary modification has not been rigorously investigated in people with SCI. The purpose of this study is to determine if an 8-week low-carbohydrate/high-protein (LC/HP) dietary intervention will show improvements in clinically important metrics of metabolic function, body composition, the composition of gut bacteria, and quality of life.

Methods/design

We intend to recruit 100 participants with chronic traumatic SCI (3 years postinjury, C5–L2, American Spinal Injury Association impairment scale A–D, and aged 18–65 years) and insulin resistance, impaired glucose tolerance or untreated type 2 diabetes and randomly assign them to an 8-week LC/HP dietary intervention group or a control group. The daily LC/HP dietary intervention includes ~ 30% total energy as protein (1.6 g/kg per day) with a carbohydrate-to-protein ratio < 1.5 and fat intake set at ~ 30% of the total energy intake. The control group does not receive any dietary intervention and are continuing with their regular daily diets. Glucose tolerance, insulin sensitivity, β-cell function, body composition, gut microbiome composition, and quality of life measures are assessed at week 1, before starting the LC/HP dietary intervention, and at week 8, after completion of the LC/HP dietary intervention.

Discussion

New information derived from this project will result in the development of a low-cost, simple, self-administered LC/HP dietary intervention for improving metabolic function in individuals with chronic SCI, improved understanding of the composition of gut bacteria in SCI, and how a LC/HP dietary intervention alters gut bacteria composition. In addition, this project will improve our understanding of the relationship between metabolic function and quality of life in individuals with long-standing SCI.

Trial registration

ClinicalTrials.gov, NCT03207841. Registered on 5 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3520-3) contains supplementary material, which is available to authorized users.

Plasma fatty acids as markers for desaturase and elongase activities in spinal cord injured males

OBJECTIVE

To investigate the use of surrogate plasma fatty acid analysis to provide further insights into the underlying adiposity and the development of metabolic syndrome in men with spinal cord injury (SCI).

DESIGN

Case-control, cross-sectional study.

SETTING

Community-based individuals with spinal cord injury and healthy controls.

PARTICIPANTS

Twenty men with SCI age, height and weight matched with 20 able-bodied controls.

OUTCOME MEASURES

Lean tissue (LTM) and fat mass (FM) were determined using dual energy X-ray absorptiometry. Fasting blood samples were taken for analysis of fatty acids, adiponectin, insulin, glucose and leptin. Enzymatic indices were calculated using relevant fatty acids.

RESULTS

Total FM, leptin, stearoyl coenzyme A desaturase (SCD) Δ9 (SCD-16, 16:1/16:0, and SCD-18, 18:1/18:0) indices and Δ6 desaturase index were significantly higher (P < 0.05) in the SCI group than the controls. Significant differences between the groups was observed for several individual fatty acids. Correlational analysis revealed a different pattern between blood biomarkers and indices of SCDs, de novo lipogenesis and elongase. Associations between the desaturase and elongase indices and biomarkers in the controls followed those reported elsewhere for able bodied participants; the same associations were not observed in the SCI group.

CONCLUSION

We have identified disturbances in fatty acid biosynthesis in SCI individuals likely associated with the development of adipose tissue below the lesion and a decrease in LTM. Loss of LTM may disturb the normal skeletal muscle-fatty acid metabolic processes leading to the disruption of metabolic homeostasis, previously identified in persons with SCI.

Guideline Approaches for Cardioendocrine Disease Surveillance and Treatment Following Spinal Cord Injury

PURPOSE OF REVIEW

Persons with spinal cord injuries (SCI) commonly experience individual risks and coalesced health hazards of the cardiometabolic syndrome (CMS). This review will examinethe role of exercise and nutritional intervention as countermeasures to these disease risks.

RECENT FINDINGS

The CMS hazards of overweight/obesity, insulin resistance, hypertension, and dyslipidemia are strongly associated with physical deconditioning and are common after SCI. Both the CMS diagnosis and physical deconditioning worsen the prognosis for all-cause cardiovascular disease occurring early after SCI. Evidence supports a therapeutic role for physical activity after SCI as an effective countermeasure to these risks and often represents the first-line approach to CMS abatement. This evidence is supported by authoritative systematic reviews and associated guidelines that recommend specific activities, frequencies, and activities of work. In many cases, the most effective exercise programming uses more intense periods of work with limited rest. As SCI is also associated with poor dietary habits, including excessive energy intake and saturated fat consumption, more comprehensive lifestyle management incorporating both exercise and nutrition represents a preferred approach for overall health management.

SUMMARY

Irrespective of the interventional strategy, improved surveillance of the population for CMS risks and encouraged incorporation of exercise and nutritional management according to recent population-specific guidelines will most likely play an important role in the preservation of activity, optimal health, and independence throughout the lifespan.

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.

Baseline Dietary Intake of Individuals with Spinal Cord Injury Who Are Overweight or Obese

BACKGROUND

Individuals with spinal cord injury (SCI) experience significant secondary health conditions including excess adiposity. Dietary guidelines for individuals with chronic SCI do not exist.

OBJECTIVE

To describe baseline dietary intake and quality based on conformance with dietary recommendations in participants enrolled in GoHealthySCI, a weight loss intervention for individuals with SCI, which promotes lifestyle change.

DESIGN

Cross-sectional analyses were conducted on data collected from April through August 2017 in a randomized pilot study.

PARTICIPANTS

Thirty-seven participants enrolled in the study in Houston, TX. All participants were at least 1 year post injury with a self-reported body mass index (calculated as kg/m²) ≥23. The racially/ethnically diverse sample was predominantly male (n=23), average age was 41.8±13.5 years, and average number of years since injury was 18.1±14.9. Participants varied in terms of level of injury; 19 participants identified as having tetraplegia and 19 identified as having paraplegia.

MAIN OUTCOME MEASURES

The Automated Self-Administered 24-Hour Recall dietary assessment was used to obtain baseline dietary intake data. Participants reported food intake on 3 nonconsecutive days.

STATISTICAL ANALYSIS

Descriptive statistics were conducted for the primary research objectives. Mean macronutrient and micronutrient intake and Healthy Eating Index-2015 total and component scores are described.

RESULTS

Average daily energy intake was 1618±434 kcal. Daily intakes of whole fruits (0.6±0.7 cups), vegetables (1.6±0.9 cups), and whole grains (15%) of total grains were lower than recommendations from the 2015-2020 Dietary Guidelines for Americans. Average daily fiber (15.0g±6.0) met the Academy of Nutrition and Dietetics Evidence Analysis Library minimum target range for individuals with SCI. All percentages of calories from macronutrients were within the acceptable macronutrient distribution ranges: total fat (34.3%±6.2%), protein (16.7%±4.2%), and carbohydrate (49.3%±8.4%). Mean Healthy Eating Index-2015 score was 54.4.

CONCLUSIONS

This study provides a description of dietary intake by individuals with SCI who are overweight or obese. Although macronutrients are within the acceptable distribution range, calories from fat are at the high end and those from protein are at the low end of those ranges. In addition, on average, individuals reported inadequate intake of fruits, vegetables, whole grains, fiber, seafood and plant protein, and healthy fats and excess intake of added sugars and saturated fat. Results provide preliminary evidence of dietary inadequacies and suggest that larger studies examining dietary intake are warranted.

Energy Expenditure as a Function of Activity Level After Spinal Cord Injury: The Need for Tetraplegia-Specific Energy Balance Guidelines

The World Health Organization recognizes obesity as a global and increasing problem for the general population. Because of their reduced physical functioning, people with spinal cord injury (SCI) face additional challenges for maintaining an appropriate whole body energy balance, and the majority with SCI are overweight or obese. SCI also reduces exercise capacity, particularly in those with higher-level injury (tetraplegia). Tetraplegia-specific caloric energy expenditure (EE) data is scarce. Therefore, we measured resting and exercise-based energy expenditure in participants with tetraplegia and explored the accuracy of general population-based energy use predictors. Body composition and resting energy expenditure (REE) were measured in 25 adults with tetraplegia (C4/5 to C8) and in a sex-age-height matched group. Oxygen uptake, carbon dioxide production, heart rate, perceived exertion, and exercise intensity were also measured in 125 steady state exercise trials. Those with motor-complete tetraplegia, but not controls, had measured REE lower than predicted (mean = 22% less, p < 0.0001). REE was also lower than controls when expressed per kilogram of lean mass. Nine had REE below 1200 kcal/day. We developed a graphic compendium of steady state EE during arm ergometry, wheeling, and hand-cycling. This compendium is in a format that can be used by persons with tetraplegia for exercise prescription (calories, at known absolute intensities). EE was low (55–450 kcal/h) at the intensities participants with tetraplegia were capable of maintaining. If people with tetraplegia followed SCI-specific activity guidelines (220 min/week) at the median intensities we measured, they would expend 563–1031 kcal/week. Participants with tetraplegia would therefore require significant time (4 to over 20 h) to meet a weekly 2000 kcal exercise target. We estimated total daily EE for a range of activity levels in tetraplegia and compared them to predicted values for the general population. Our analysis indicated that the EE values for sedentary through moderate levels of activity in tetraplegia fall well below predicted sedentary levels of activity for the general population. These findings help explain sub-optimal responses to exercise interventions after tetraplegia, and support the need to develop tetraplegia-specific energy-balance guidelines that reflects their unique EE situation.

Anthropometric cutoffs and associations with visceral adiposity and metabolic biomarkers after spinal cord injury

Background/Objectives

To examine associations of different anthropometric measurements of central adiposity to visceral adipose tissue (measured via multi-axial magnetic resonance imaging; MRI) and cardiometabolic disease risk factors in men with spinal cord injury (SCI). Additionally, to determine population-specific seated/supine waist and abdominal circumference cutoffs, which may identify men at increased risk of cardiometabolic disease.

Participants/Methods

Twenty-two men with chronic SCI underwent MRI scans, anthropometric measurements along with assessments of various cardiometabolic risk biomarkers. Pearson/part (accounting for age as a covariate) correlation coefficients were calculated to determine the associations between study variables. Abdominal and waist circumference cutoffs were extrapolated using the slope of linear regression equations.

Results

Seated/supine abdominal and waist circumferences were (P < 0.01) associated with MRI visceral fat cross-sectional area (VAT_CSA), VAT volume and CSA:Total_CSA. Low density lipoprotein, non-high-density lipoprotein and total cholesterol were positively associated with seated/supine abdominal and waist circumferences after controlling for age; r = 0.50–0.61, r = 0.46–0.58, r = 0.52–0.58, P < 0.05, respectively. Tumor necrosis factor alpha was associated with seated/supine abdominal and waist circumferences after accounting for age; r = 0.49–0.51 and r = 0.48–0.56, P < 0.05 respectively. The population-specific cutoffs were 86.5cm and 88.3cm for supine waist and abdominal circumferences, respectively, as well as 89cm and 101cm for seated waist and abdominal circumferences, respectively. After dichotomizing VAT_CSA (< or ≥ 100cm²), peak oxygen uptake, triglycerides, insulin sensitivity and glycated hemoglobin were different (P < 0.05) between groups. After dichotomizing (< or ≥ 86.5cm) supine waist circumference, VAT_CSA, triglycerides and insulin sensitivity were different (P < 0.05) between groups.

Conclusions

Seated/supine circumferences are associated with both central adiposity and biomarkers of cardiometabolic disease risk in persons with SCI. Population-specific cutoffs are proposed herein to identify central adiposity and potential cardiometabolic disease risk after SCI.

Effects of ursolic acid on sub-lesional muscle pathology in a contusion model of spinal cord injury

Spinal Cord Injury (SCI) results in severe sub-lesional muscle atrophy and fiber type transformation from slow oxidative to fast glycolytic, both contributing to functional deficits and maladaptive metabolic profiles. Therapeutic countermeasures have had limited success and muscle-related pathology remains a clinical priority. mTOR signaling is known to play a critical role in skeletal muscle growth and metabolism, and signal integration of anabolic and catabolic pathways. Recent studies show that the natural compound ursolic acid (UA) enhances mTOR signaling intermediates, independently inhibiting atrophy and inducing hypertrophy. Here, we examine the effects of UA treatment on sub-lesional muscle mTOR signaling, catabolic genes, and functional deficits following severe SCI in mice. We observe that UA treatment significantly attenuates SCI induced decreases in activated forms of mTOR, and signaling intermediates PI3K, AKT, and S6K, and the upregulation of catabolic genes including FOXO1, MAFbx, MURF-1, and PSMD11. In addition, UA treatment improves SCI induced deficits in body and sub-lesional muscle mass, as well as functional outcomes related to muscle function, motor coordination, and strength. These findings provide evidence that UA treatment may be a potential therapeutic strategy to improve muscle-specific pathological consequences of SCI.

Exercise and Health-Related Risks of Physical Deconditioning After Spinal Cord Injury

A sedentary lifestyle occurring soon after spinal cord injury (SCI) may be in contrast to a preinjury history of active physical engagement and is thereafter associated with profound physical deconditioning sustained throughout the lifespan. This physical deconditioning contributes in varying degrees to lifelong medical complications, including accelerated cardiovascular disease, insulin resistance, osteopenia, and visceral obesity. Unlike persons without disability for whom exercise is readily available and easily accomplished, exercise options for persons with SCI are more limited. Depending on the level of injury, the metabolic responses to acute exercise may also be less robust than those accompanying exercise in persons without disability, the training benefits more difficult to achieve, and the risks of ill-considered exercise both greater and potentially irreversible. For exercise to ultimately promote benefit and not impose additional impairment, an understanding of exercise opportunities and risks if exercise is undertaken by those with SCI is important. The following monograph will thus address common medical challenges experienced by persons with SCI and typical modes and benefits of voluntary exercise conditioning.

Nutritional Health Considerations for Persons with Spinal Cord Injury

Chronic spinal cord injury (SCI) often results in morbidity and mortality due to all-cause cardiovascular disease (CVD) and comorbid endocrine disorders. Several component risk factors for CVD, described as the cardiometabolic syndrome (CMS), are prevalent in SCI, with the individual risks of obesity and insulin resistance known to advance the disease prognosis to a greater extent than other established risks. Notably, adiposity and insulin resistance are attributed in large part to a commonly observed maladaptive dietary/nutritional profile. Although there are no evidence-based nutritional guidelines to address the CMS risk in SCI, contemporary treatment strategies advocate more comprehensive lifestyle management that includes sustained nutritional guidance as a necessary component for overall health management. This monograph describes factors in SCI that contribute to CMS risks, the current nutritional profile and its contribution to CMS risks, and effective treatment strategies including the adaptability of the Diabetes Prevention Program (DPP) to SCI. Establishing appropriate nutritional guidelines and recommendations will play an important role in addressing the CMS risks in SCI and preserving optimal long-term health.

Cardiovascular disease risk marker responses to breaking up prolonged sedentary time in individuals with paraplegia: the Spinal Cord Injury Move More (SCIMM) randomised crossover laboratory trial protocol

INTRODUCTION

Sedentary behaviour is a distinct risk factor for cardiovascular disease (CVD) and could partly explain the increased prevalence of CVD in people with spinal cord injury (SCI). Interrupting prolonged sitting periods with regular short bouts of walking acutely suppresses postprandial glucose and lipids in able-bodied individuals. However, the acute CVD risk marker response to breaking up prolonged sedentary time in people with SCI has not been investigated.

METHODS AND ANALYSIS

A randomised two-condition laboratory crossover trial will compare: (1) breaking up prolonged sedentary time with 2 min moderate-intensity arm-crank activity every 20 min, with (2) uninterrupted prolonged sedentary time (control) in people with SCI. Outcomes will include acute effects on postprandial glucose, insulin, lipids and blood pressure. Blood samples will be collected and blood pressure measured at regular intervals during each 5½-hour condition.

ETHICS AND DISSEMINATION

This study was approved by the Cambridge South National Health Service Research Ethics Committee. This research will help determine if breaking up prolonged sedentary time could be effective in lowering CVD risk in people with SCI. The findings of the research will be published in a peer-reviewed journal and disseminated to relevant user groups.

TRIAL REGISTRATION NUMBER

ISRCTN51868437; Pre-results.

Associations of the trunk skeletal musculature and dietary intake to biomarkers of cardiometabolic health after spinal cord injury

PURPOSE

Skeletal muscle atrophy and poor dietary habits may contribute to increased adiposity and impaired metabolic health after spinal cord injury (SCI). The relative association of trunk muscle cross-sectional areas (CSA) versus dietary habits to central adiposity and impaired metabolic health after SCI remains unclear.

METHODS

Twenty-two men with motor complete SCI completed five-day dietary recalls for 4 weeks. Trunk muscle CSAs as well as visceral and subcutaneous adipose tissue (VAT and SAT, respectively) were quantified using magnetic resonance imaging. Basal metabolic rate (BMR), glucose effectiveness, insulin sensitivity and lipid profile were measured after overnight fast.

RESULTS

Antero-lateral trunk muscle (r = -0·79, P < 0·001) and posterior trunk muscle (r = -0·56, P = 0·008) CSAs normalized to total trunk CSA were negatively related to VAT. Antero-lateral trunk muscle ratio (TMR) was positively related to BMR (r = 0·54, P = 0·01), and posterior TMR was positively related to peak oxygen uptake (VO2 peak; r = 0·71, P = 0·003). After accounting for total TMR as a co-variate, total fat (r = 0·47, P = 0·04) and protein (r = 0·61, P = 0·004) intakes were positively related to fasting insulin levels.

CONCLUSION

Trunk muscle CSAs normalized to total trunk CSA were negatively associated with central adiposity. Both trunk muscles and dietary macro-nutrients are related to markers of metabolic health. The study highlights the significance of developing an exercise intervention with a healthy dietary regimen to attenuate the development of central adiposity associated metabolic disorders after SCI.

Nutrition education for cardiovascular disease prevention in individuals with spinal cord injuries: study protocol for a randomized controlled trial

Background

Individuals with chronic spinal cord injuries (SCIs) have an increased prevalence of cardiovascular disease (CVD) and associated risk factors compared with age-matched control subjects. Exercise has been shown to improve selected CVD risk factors in individuals with SCI, but using nutrition education as an intervention has not been evaluated in this population. This paper describes our research plan for evaluating the effect of nutrition education on individuals with SCI. In the present study, called Eat Smart, Live Better, we are using a randomized controlled design to test an intervention adapted from an existing evidence-based program that showed a positive effect on nutrition knowledge and behavior of older adults from the general population. There will be an inpatient group (n = 100) and a community group (n = 100). The aims of our study are to compare the intervention and control groups for (1) changes in nutritional behavior, nutritional knowledge, and dietary quality by participants in the program; (2) levels of adiposity and metabolic CVD risk factors at 12-month follow-up; and (3) differential effects among individuals with SCI in the acute rehabilitation setting and those living in the community.

Methods/design

This is a randomized controlled trial of nutrition education. The treatment groups receive six nutrition education sessions. The control groups receive the one “standard of care” nutrition lecture that is required by the Commission on Accreditation of Rehabilitation Facilities. Treatment groups include both an inpatient group, comprising patients who have been admitted to an acute rehabilitation facility because of their recent SCI, and an outpatient group, consisting of community-dwelling adults who are at least 1 year after their SCI. A total of 200 participants will be randomized 1:1 to the intervention or control group, stratified by location (acute rehabilitation facility or community dwelling).

Discussion

To our knowledge, this will be the first reported study of nutrition education in individuals with SCI. The low cost and feasibility of the intervention, if shown to improve nutritional behavior, suggests that it could be implemented in rehabilitation facilities across the country. This has the potential of lowering the burden of CVD and CVD risk factors in this high-risk population.

Trial registration

ClinicalTrials.gov, NCT02368405. Registered on February 10, 2015.

Nutrient Intake of Elite Canadian and American Athletes with Spinal Cord Injury

The nutrient needs of athletes with Spinal Cord Injury (SCI) are dependent on their physiological alterations and training status. Limited research is available regarding dietary intake of elite athletes with SCI and possible nutrient deficiencies. Therefore, the purpose of this study was to examine dietary intake of elite athletes with SCI, and determine dietary intake inadequacies based on the Estimated Average Requirement (EAR) comparisons. Additionally, the average energy and macronutrient (carbohydrate, protein, and fat) intake was compared based on level of injury (C level, T1-T6, T7-T12, Lumbar). A total of 39 athletes with a SCI completed a self-reported 24 hour diet recall in autumn and 27 athletes returned to complete a second data collection period (winter). Nutrient inadequacy was estimated by the proportion of athletes with mean intakes below the EAR through the Research Solutions Food Processor Diet Analysis Software (ESHA). Although Macronutrients for both men and women were within acceptable macronutrient distribution range (AMDR) recommendations, low EAR's for various nutrients were consistently found for both men and women. No significant differences were found for energy or macronutrient intake between groups based on level of lesion. Further research is needed to examine nutrient intake using other methods of dietary assessment and to determine the factors that may lead to nutrient insufficiency among elite athletes with SCI.

Energy balance components in persons with paraplegia: daily variation and appropriate measurement duration

Background

Despite obesity being highly prevalent in persons with spinal cord injury (SCI), our current understanding of the interactions between energy balance components, which may contribute to this, is limited. The primary aim of this study is to identify the intra-individual variability of physical activity dimensions across days and suggest an appropriate monitoring time frame for these constructs in adults with SCI. The secondary aim is to examine these parameters with regard to energy intake and dietary macronutrient composition.

Methods

Participants [33 men and women with chronic (> 1 year post injury) paraplegia; age = 44 ± 9 years (mean ± S.D.] wore an Actiheart™ PA monitor and completed a weighed food diary for 7 consecutive days. Spearman-Brown Prophecy Formulae, based on Intraclass Correlations of .80 (acceptable reliability), were used to predict the number of days required to measure energy balance components. Linear mixed-effects analyses and magnitude-based inferences were performed for all energy intake, expenditure and physical activity dimensions. Adjustments were made for age, injury level, wear time, sex, day of the week and measurement order as fixed effects.

Results

To reliably measure energy expenditure components; 1 day [total energy expenditure (TEE)], 2 days [physical activity energy expenditure (PAEE), light-intensity activity, moderate-to-vigorous PA (MVPA)], 3 days [physical activity level (PAL)] and 4 days (sedentary behaviour) are necessary. Device wear time (P < 0.02), injury level (P < 0.04) and sex (P < 0.001) were covariates for energy expenditure components. Four and ≤24 days are required to reliably measure total energy intake (kcal) and diet macronutrient composition (%), respectively. Measurement order (from day 1–7) was a covariate for total energy intake (P = 0.01).

Conclusions

This is the first study to demonstrate the variability of energy intake and expenditure components in free-living persons with chronic (> 1 year) paraplegia and propose suitable measurement durations to achieve acceptable reliability in outcome measures. Device wear time and measurement order play a role in the quality of energy expenditure and intake data, respectively, and should be considered when designing and analysing studies of energy balance components in persons with SCI.

Trial registration

N/A

A lifestyle intervention program for successfully addressing major cardiometabolic risks in persons with SCI: a three-subject case series

INTRODUCTION

This study is a prospective case series analyzing the effects of a comprehensive lifestyle intervention program in three patients with chronic paraplegia having major risks for the cardiometabolic syndrome (CMS).

CASE PRESENTATION

Individuals underwent an intense 6-month program of circuit resistance exercise, nutrition using a Mediterranean diet and behavioral support, followed by a 6-month extension (maintenance) phase involving minimal support. The primary goal was a 7% reduction of body mass. Other outcomes analyzed insulin resistance using the HOMA-IR model, and plasma levels of fasting triglycerides and high-density lipoprotein cholesterol. All participants achieved the goal for 7% reduction of body mass and maintained the loss after the MP. Improvements were observed in 2/3 subjects for HOMA-IR and high-density lipoprotein cholesterol. All participants improved their risk for plasma triglycerides.

DISCUSSION

We conclude, in a three-person case series of persons with chronic paraplegia, a lifestyle intervention program involving circuit resistance training, a calorie-restrictive Mediterranean-style diet and behavioral support, results in clinically significant loss of body mass and effectively reduced component risks for CMS and diabetes. These results were for the most part maintained after a 6-month MP involving minimal supervision.

The role of nutrition for pressure ulcer management: national pressure ulcer advisory panel, European pressure ulcer advisory panel, and pan pacific pressure injury alliance white paper

Nutrition and hydration play an important role in preserving skin and tissue viability and in supporting tissue repair for pressure ulcer (PrU) healing. The majority of research investigating the relationship between nutrition and wounds focuses on PrUs. This white paper reviews the 2014 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance Nutrition Guidelines and discusses nutrition strategies for PrU management.

Cardiometabolic Syndrome in People With Spinal Cord Injury/Disease: Guideline-Derived and Nonguideline Risk Components in a Pooled Sample

OBJECTIVE

To assess cardiometabolic syndrome (CMS) risk definitions in spinal cord injury/disease (SCI/D).

DESIGN

Cross-sectional analysis of a pooled sample.

SETTING

Two SCI/D academic medical and rehabilitation centers.

PARTICIPANTS

Baseline data from subjects in 7 clinical studies were pooled; not all variables were collected in all studies; therefore, participant numbers varied from 119 to 389. The pooled sample included men (79%) and women (21%) with SCI/D >1 year at spinal cord levels spanning C3-T2 (American Spinal Injury Association Impairment Scale [AIS] grades A-D).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We computed the prevalence of CMS using the American Heart Association/National Heart, Lung, and Blood Institute guideline (CMS diagnosis as sum of risks ≥3 method) for the following risk components: overweight/obesity, insulin resistance, hypertension, and dyslipidemia. We compared this prevalence with the risk calculated from 2 routinely used nonguideline CMS risk assessments: (1) key cut scores identifying insulin resistance derived from the homeostatic model 2 (HOMA2) method or quantitative insulin sensitivity check index (QUICKI), and (2) a cardioendocrine risk ratio based on an inflammation (C-reactive protein [CRP])-adjusted total cholesterol/high-density lipoprotein cholesterol ratio.

RESULTS

After adjustment for multiple comparisons, injury level and AIS grade were unrelated to CMS or risk factors. Of the participants, 13% and 32.1% had CMS when using the sum of risks or HOMA2/QUICKI model, respectively. Overweight/obesity and (pre)hypertension were highly prevalent (83% and 62.1%, respectively), with risk for overweight/obesity being significantly associated with CMS diagnosis (sum of risks, χ(2)=10.105; adjusted P=.008). Insulin resistance was significantly associated with CMS when using the HOMA2/QUICKI model (χ(2)2=21.23, adjusted P<.001). Of the subjects, 76.4% were at moderate to high risk from elevated CRP, which was significantly associated with CMS determination (both methods; sum of risks, χ(2)2=10.198; adjusted P=.048 and HOMA2/QUICKI, χ(2)2=10.532; adjusted P=.04).

CONCLUSIONS

As expected, guideline-derived CMS risk factors were prevalent in individuals with SCI/D. Overweight/obesity, hypertension, and elevated CRP were common in SCI/D and, because they may compound risks associated with CMS, should be considered population-specific risk determinants. Heightened surveillance for risk, and adoption of healthy living recommendations specifically directed toward weight reduction, hypertension management, and inflammation control, should be incorporated as a priority for disease prevention and management.