Health care provider practices, barriers, and facilitators for weight management for individuals with spinal cord injuries and disorders

Physical and emotional consequences of excess weight as experienced by individuals with spinal cord injuries

CONTEXT/OBJECTIVE

Excess weight has the potential to carry a substantial physical and emotional burden. A better understanding of perceived consequences of excess weight may facilitate the development of patient-centered programs and interventions to promote weight management efforts in persons with spinal cord injury (SCI). The study objective was to describe consequences of excess weight from the personal perspectives of individuals with SCI.

DESIGN

Descriptive qualitative design using in-depth semi-structured interviews and thematic analysis.

SETTING

Veterans Health Administration (VHA) SCI System of Care.

PARTICIPANTS

Individuals with SCI (n-33).

OUTCOME MEASURES

Key themes from thematic analysis.

RESULTS

Participants were male (61%), ranged from 29 to 84 years of age, and about half had tetraplegia (55%). Five themes were identified that demonstrate negative consequences of excess weight experienced by individuals with SCI, including: (1) physical health conditions (including chronic conditions and SCI secondary conditions), (2) physical symptoms (such as pain, discomfort, and fatigue), (3) movement challenges, (4) appearance-related concerns, and (5) emotional impacts.

CONCLUSIONS

Carrying excess weight is concerning to individuals with SCI and in terms of consequences such onset or exacerbation of chronic conditions, SCI secondary conditions, physical symptoms, e.g. pain, movement impairment (including hampered mobility, difficult transfers and self-care), image/appearance concerns (e.g. body image, clothing misfit), and negative emotions (e.g. unhappy, sad, depressed). Our findings may inform SCI healthcare providers about the consequences of excess weight as experienced by individuals with SCI, highlighting what matters most to persons with SCI and guiding a patient-centered approach to weight management in this population.

Why may patients with spinal cord injury be overlooked for obesity screening in the Veterans Health Administration? Qualitative research of the perspectives of patients and healthcare providers

PURPOSE

We sought to describe factors influencing reduced rates of obesity screening for patients with spinal cord injury (SCI) in the United States Veterans Health Administration (VA) and to foster potential solutions.

MATERIALS AND METHODS

Semi-structured interviews with healthcare providers and patients with SCI who were recruited nationally from diverse VAs. We performed rapid qualitative analysis using content analysis of interview data.

RESULTS

There were 36 providers and 37 patients. We identified provider, patient, and system level barriers to obesity screening for individuals with SCI. Overarching barriers involved provider and patient perceptions that obesity screening is a low priority compared to other health conditions, and body mass index is of low utility. Other obesity screening barriers were related to measuring weight (i.e., insufficient equipment, unknown wheelchair weight, staffing shortages, measurement errors, reduced access to annual screening, insufficient time, patient preference not to be weighed) and measuring height (i.e., insufficient guidance and equipment to this population, measurement errors).

CONCLUSIONS

Barriers to obesity screenings exist for patients with SCI receiving care in VA. Healthcare provider and patient interviews suggest possible solutions, including standardizing height and weight measurement processes, ensuring equipment availability in clinics, clarifying guidelines, and offering support to providers and patients.IMPLICATIONS FOR REHABILITATIONIndividuals with spinal cord injury (SCI) have higher rates of obesity, but are often overlooked for annual obesity screening, even in clinic settings designed to care for individuals with SCI.Results may help tailor guidelines/education for healthcare and rehabilitation providers offering them guidance for improving obesity screening for individuals with SCI by standardizing weight and height measurement and documentation. To facilitate this, findings highlight the need for resources, such as ensuring clinics have necessary equipment, and increasing patient access to support and equipment.Improving the provision of obesity screening for individuals with SCI is necessary to improve health outcomes and patient satisfaction with care.

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.

Barriers and Facilitators to Lifestyle Intervention Engagement and Weight Loss in People Living With Spinal Cord Injury

Background: Individuals living with spinal cord injury (SCI) have a high prevalence of obesity and unique barriers to healthy lifestyle. Objective: To examine barriers and facilitators to engagement and weight loss among SCI participants enrolled in the Group Lifestyle Balance Adapted for individuals with Impaired Mobility (GLB-AIM), a 12-month intensive lifestyle intervention. Methods: SCI participants (N = 31) enrolled in a wait-list, randomized controlled trial where all participants received intervention between August 2015 and February 2017. Analyses of pooled data occurred in 2020 to examine cross-sectional and prospective associations of hypothesized barriers and facilitators with (1) intervention engagement, comprised of attendance and self-monitoring, and (2) percent weight change from baseline to 12 months. We performed multivariable linear regression on variables associated with outcomes at p < .05 in bivariate analyses and controlled for intervention group. Results: Participants were middle-aged (mean age, 48.26 ± 11.01 years), equally male (50%) and female, White (80.7%), and unemployed (65.6%). In participants who completed baseline surveys (n = 30), dietary self-efficacy explained 26% of variance in engagement (p < .01); among the 12-month study completers (n = 22, 71.0%), relationship issues explained 23% of variance in engagement (p < .01). Money problems, health issues unrelated to SCI, lack of motivation, and experimental group explained 57% of variance in weight loss (p for model < .01), with lack of motivation uniquely explaining 24% of variance (p < .01). Conclusion: Improving engagement and weight loss for persons with SCI in the GLBAIM program may be achieved by addressing lack of motivation, relationship issues, and nutrition self-efficacy.

Weight management for adults with mobility related disabilities: Rationale and design for an 18-month randomized trial

Adults with mobility related disabilities (MRDs) represent an underserved group with a high prevalence of overweight/obesity and limited options for weight management. We previously demonstrated clinically meaningful 12-month weight loss in adults with MRDs (-6.2%, 36% ≥5% of baseline weight) using an enhanced Stop Light Diet (eSLD) delivered using at home face-to-face behavioral sessions and optional physical activity. However, the costs/logistics associated with intervention delivery by individual home visits limits the potential for scaling and implementation of this approach. Thus, we will conduct a two-arm randomized trial in 128 overweight/obese adults with MRDs to compare weight loss (6 mos.) and maintenance (12 mos.) between interventions utilizing the eSLD, behavioral counseling, and increased physical activity delivered to individual participants in their homes or delivered to groups of participants in their homes remotely via video conferencing. The primary aim will compare weight loss between interventions arms across 6 months. Secondarily, we will compare weight loss (0-18 mos.), the proportion of participants who achieve clinically meaningful weight loss (≥5%) from 0 to 6 and 0 to18 months, and changes in quality of life from 0 to 6 and 0 to 18 months between interventions arms. We will also conduct cost, cost-effectiveness and contingent valuation comparisons and explore the influence of behavioral session attendance, compliance with the recommendations for diet and physical activity, self-monitoring of diet and physical activity, barriers to physical activity, sleep quality, and medications on weight change across 6 and 18 months. NCT REGISTRATION: NCT04046471.

Health promotion and cardiovascular risk reduction in people with spinal cord injury: physical activity, healthy diet and maintenance after discharge- protocol for a prospective national cohort study and a preintervention- postintervention study

INTRODUCTION

Spinal cord injury (SCI) predisposes those who suffer from it to physical inactivity and weight gain; consequently, death due to cardiovascular diseases is more frequent among people with SCI than in the general population. The literature documents a consensus about an interdisciplinary multimodal approach for the prevention and treatment of cardiovascular risk factors including overweight and obesity in people with SCI, focusing on diet, physical activity (PA) and behavioural interventions. This study will investigate implementation of recommendations from a recent clinical practice guideline for identification and management of cardiometabolic risk after SCI through multimodal patient education in a subacute clinical setting.

METHODS AND ANALYSIS

All patients who are aged 18 years or older with an SCI within the previous 12 months and admitted to highly specialised rehabilitation are included, regardless of SCI aetiology or neurological level. A primary study designed as a controlled, pragmatic, preintervention- postintervention study with 6-month follow-up evaluates the effect of the clinical intervention; a prospective national cohort study on body mass index (BMI) serves as a historical control. The intervention consists of a standardised approach to patient education about cardiovascular risk factors, PA and a healthy diet that begins at the outset of primary SCI rehabilitation and is integrated into existing settings and workflows. Outcome measures are collected at admission, discharge and 6 months after discharge and include peak oxygen uptake (VO2peak) (primary outcome), BMI, body composition, metabolic profile, neurological status, level of functioning, depression, quality of life, objective PA (accelerometry), self-reported PA, self-assessed PA ability, shared decision making, and dietary habits. Test-retest reliability of four VO2peak test protocols are investigated, as is test-retest reliability of a multisensor accelerometer in a rehabilitation setting.

ETHICS AND DISSEMINATION

The project is approved by the Committees on Health Research Ethics in the Capital Region of Denmark on 10 July 2018 (Journal-nr.: H-18018325). The principal investigator obtains informed consent from all participants. The interventions in the project are closely related to existing rehabilitation care, and the risk of pain and discomfort is considered modest. Any unintended events related to the elements of the intervention are reported, according to existing regional procedures. Data are stored in a secure web-based database (Redcap). The primary study and prospective cohort study are registered at Clinicaltrials.gov. Positive and negative results will be submitted to relevant scientific journals related to SCI for publication. Important protocol modifications are reported to the Committees on Health Research Ethics in the Capital Region of Denmark.

TRIAL REGISTRATION NUMBERS

NCT03689023 and NCT03369080.

Seated pressures in daily wheelchair and sports equipment: investigating the protective effects of cushioned shorts

Study design

The primary study design was a pretest and posttest study performed in a single session with subjects as their own control. We summarize three integrated and sequential studies.

Objective

The objective of this study was to investigate whether commercially available cushioned shorts would add skin protection when used in adaptive sports equipment (AE).

Setting

Community in Tacoma Washington, USA.

Methods

TekScan Pressure Mapping System for recording average (AP) and peak (PP) seating pressures.Part 1. Pretest/posttest design, subjects as own control. Eight adults with SCI (C5-T6) mapped in daily wheelchair and AE with and without bicycle shorts.Part 2. Sixteen able-bodied subjects were mapped with and without an impact short and full-coverage short in a hand-cycle.Part 3. One individual with T5 SCI was mapped with and without a full-coverage short in personal basketball chair and mountain hand-cycle.

Results

Part 1. Significant differences between the daily wheelchair and AE in the static condition for AP and PP and AP in the dynamic condition. Bicycle shorts showed no significance.Part 2. Impact shorts increased static PP and AP. The full-coverage short decreased static AP.Part 3. The full-coverage short increased AP and PP in the basketball chair. In the mountain hand-cycle, AP decreased but PP increased.

Conclusion

Athletes who are static in their AE may be at greater risk of tissue breakdown than those actively playing. Cushioned shorts had highly variable effects on seated pressure in adaptive equipment. Pressure mapping is recommended prior to using any cushioning in AE by the SCI population.

Systematic Review of Behavioral Weight Management Program MOVE! for Veterans

CONTEXT

Since 2006, the Veterans Health Administration has delivered a population-based behavioral weight management program (MOVE!) to Veterans, which numerous studies have examined. The purpose of this study was to systematically review these studies to understand MOVE! participation rates and the association between MOVE! participation and weight change.

EVIDENCE ACQUISITION

A December 2016 PubMed search identified 320 English-language abstracts published between January 1, 2005 and December 31, 2016, of which 42 underwent full-text review. Twenty-six articles were determined to be eligible for final inclusion and data elements extracted from these articles included study years, study design, content of MOVE! and control intervention (if any), inclusion/exclusion criteria, initial sample size and sample loss, intervention duration and follow-up, patient characteristics, and outcomes. Quality was assessed using the Newcastle-Ottawa Quality Scale.

EVIDENCE SYNTHESIS

Studies were judged to be of good quality. Twenty-one of the 26 studies were retrospective cohort studies, one was a prospective cohort study and four were randomized trials. Program participation varied substantially (2%-12%) across studies. Six-month weight loss ranged from -0.95 kg to -1.84 kg, whereas 12-month weight loss ranged from -0.13 kg to -3.3 kg. A maximum of 25% of MOVE! users engaged in intense and sustained participation (eight or more visits within 6 months), but higher participation levels were consistently associated with greater weight change (-1.18 kg to -5.3 kg at 6 months, -1.68 kg to -3.58 kg at 12 months).

CONCLUSIONS

MOVE! participation is associated with modest short-term weight loss, with greater weight loss as participation increases. More research is needed to understand the barriers and facilitators to participation and the effect of MOVE! participation on long-term health and economic outcomes.

Documentation of weight management practices for individuals with spinal cord injuries and disorders

STUDY DESIGN

This cross-sectional chart review study included 100 US Veterans with spinal cord injuries/disorders (SCI/D) who received care at a Veterans Affairs (VA) SCI facility during a 12-month period. Progress notes were examined to extract need for weight management (WM), patient-provider discussions about risk due to overweight/obesity, recommended lifestyle changes and/or follow-up and WM education.

OBJECTIVES

To understand what WM services are offered to Veterans with SCI/D within the VA SCI System of Care during comprehensive preventive health evaluations (annual evaluations), inpatient stays and outpatient visits.

SETTING

VA SCI System of Care, Department of Veterans Affairs, United States.

RESULTS

Overall, 73% demonstrated a need for WM. Weight was most frequently addressed during the nutrition assessment of annual evaluations, but this assessment was most likely to be skipped. Nutrition histories were missing many key components. Over half received WM education; individuals who were described as overweight/obese by their provider were more likely to receive education. Most of the Veterans who were seen in an inpatient setting were weighed; weight was only discussed with 12%. Less than half of the Veterans with outpatient visits were weighed, and 23% received WM recommendations.

CONCLUSIONS

Weight was frequently discussed during nutrition assessments, but infrequently addressed during outpatient or inpatient encounters. Few Veterans received specific recommendations on caloric/nutrient requirements and nutrition histories were missing recommended elements. Additional work is needed to help providers to incorporate WM information into care.