SCI Forum Reports

Nutrition Guidelines for Individuals with SCI

This is a report of the SCI Forum presentation given on June 13, 2006, by Vickeri Barton, RD, CD
Dietitian, Harborview Medical Center.

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Contents

Why are nutrition and weight management important after SCI?
What is a desirable weight?
Estimating Calorie Needs
Protein needs
Weight Control Tips
All those diets-What to do?
Know your lipids (fats in the blood)
Fats in Food
Osteoporosis
Neurogenic bowel
Special nutrition topics
How to find a dietitian
Resources
References

"People with spinal cord injuries have unique nutrition issues," said Vickeri Barton, associate director of nutrition at Harborview Medical Center. "Partly this is due to changes in body composition and metabolism, partly to changes in activity level, and partly to the barriers to preparing meals, shopping, and so on." All these factors may make it harder to maintain good nutrition after SCI.

Barton is well-versed in the nutritional needs of SCI patients. She worked in Harborview's Trauma and Rehab Medicine units for 20 years, where she saw patients with acute SCI and helped with early nutritional issues such as swallowing problems, tube feedings, and weight loss. In the last five years she has been working in outpatient care, helping patients with long-term nutrition issues, including weight gain. Barton is part of the multidisciplinary team approach to comprehensive SCI care.

Why are nutrition and weight management important after SCI?

There is an increased risk for diabetes, elevated cholesterol and obesity . A 2005 study 1 of 22 men with paraplegia found that subjects with lower physical activity levels had lower levels of HDL (high-density lipoproteins, known as the "good" cholesterol), higher fasting glucose, larger abdominal girth, higher triglycerides, and higher chronic inflammation-together these factors contribute to the "metabolic syndrome profile, which puts you at greater risk for heart disease and diabetes," Barton explained. "There's a tendency to gain weight in around the middle for a variety of reasons-partly the loss of abdominal muscle, partly inactivity-but whether that means that you're set up automatically for metabolic syndrome is not well understood yet." What is clear, however, is the need to focus on minimizing or reversing these tendencies; nutrition plays an important role in this.

Weight gain affects mobility and independence. "Weight gain makes it harder to push your wheelchair and puts you at greater risk for skin breakdown because you have more weight on your bottom."
Weight gain can increase expenses . "You may need to buy a larger wheelchair or hire attendants to help with transfers."
There is a risk of getting pressure ulcers . Nutrition is important in maintaining healthy skin and in healing wounds if pressure sores have already occurred.
There is an increased risk for osteoporosis . Again, nutrition can help keep bones stronger and prevent fractures.

What is a desirable weight?

Right after injury, people lose a significant amount of weight. "It's not uncommon for a young man to lose 40 lbs. while in the hospital," Barton reported. "And a lot of that is the initial loss of muscle mass due to inactivity. But before going home, weight starts to go up again."

While there are no weight guidelines specifically for people with SCI, weight charts for the general public, such as those from life insurance companies (see Desirable Weight Charts pdf, 57kb), can be adjusted for use with the SCI population. To compensate for a reduction in muscle mass, the general rule is to subtract 5-10% for paraplegia and 10-15% for tetraplegia (quadriplegia). For example, if the desirable weight for a medium-build, 5-foot 11-inch man is around 160 lbs., the recommendation of a similar-size man with paraplegia would be 5%-10% less, or 144 lbs. to 152 lbs. For a man with tetraplegia, desirable weight would be even lower-136 lbs. to 144 lbs.

Weight is only one factor, however. More important is the amount of fat a person is carrying around. This is often determined using the body mass index (BMI), calculated by dividing your weight by your height (see BMI chart pdf, 75kb). But Barton doesn't use this on SCI patients, "because of the research evidence that BMI often underestimates body fat in SCI." A recent study compared 19 males with SCI to 19 non-injured males matched for age, height and weight. 2 While the groups had similar BMIs, subjects with SCI averaged 8.9 kg less lean (muscle) mass, 7.1 kg more fat mass, 9.4% more body fat, and 3.7 kg more fat in the trunk than the non-injured controls. Fat mass refers to an actual measurement of the quantity of fat described by weight of the mass, whereas percent body fat refers to that amount of fat mass in comparison with the percent lean muscle mass and percent water the human body contains.

Estimating Calorie Needs

"People with SCI often ask me how many calories they need," Barton said. A formula to calculate calorie needs in SCI was developed in a 1985 study 3 that is still quoted widely today:

Persons with paraplegia: 27.9 calories times body weight in kg. (1 kg. = 2.2 lbs)
Persons with tetraplegia (quadriplegia): 22.7 calories times body weight in kg.

If you are already overweight, the calculation should be based on your desirable weight, not your current weight. For example, a person with tetraplegia (quadriplegia) whose desirable
weight is 165 pounds, or 75 kg, needs 1703 (75 x 22.7) calories per day. A 165-pound person with paraplegia would need 2093 calories per day. Unfortunately, "this formula doesn't take into account your gender, age or activity level," Barton said. "You probably need 200-300 fewer calories per day if you're 50 rather than 20 years old. And you use more calories with activity." Even the amount of air in wheelchair tires can affect energy expenditure (less air makes it harder to push) and calorie needs.

Rather than strictly applying formulas or introducing a whole new eating plan, Barton has found it more effective to help patients modify what they are already doing. "If I'm working with people who want to lose weight, I start by looking at what they're eating, and then I suggest changes," she said. "A month later, if it's working, we know we're on the right track." If not, further adjustments are made.

Protein needs

Unless a patient has a wound that is still healing (see section below on "Special Nutrition Topics"), people with SCI have the same protein needs as the general population: 0.8 grams/kg of body weight (1 kg. = 2.2 lbs.). So, someone who weighs 150 lbs. (68 kg) should be eating about 55 grams of protein (68 kg x 0.8 grams) per day. "Typically, we all eat a lot more than (the recommended amount)," Barton observed.

Weight Control Tips

Stay as active as possible . "I understand choices may be limited, but if you can use a manual chair most of the time, that helps." Arm aerobic exercise of any kind is very helpful.
Eat regular meals . "Do not skip meals! If you skip breakfast and have a pop for lunch, by supper you are so hungry you just keep eating all through the evening. Satiety doesn't kick in right away. Trying to lose weight by eating one meal a day does not work. Feed your body routinely; it'll help you pace your appetite throughout the day, and you'll end up eating less."
Be aware of portion sizes. Portion sizes have gotten significantly larger over the last 20 years; more people are eating out more often and have become accustomed to the huge portions restaurants serve. A serving of meat shouldn't be bigger than about a deck of cards. A serving of rice is only ½ cup. "What you're usually eating may actually be 3 or 4 servings. If you eat in a restaurant, you should take half of it home. It keeps you from over-eating, and you get two meals."
Eat a variety of foods . Barton's rule: When you are filling your plate, half should be vegetable and/or salad, ¼ meat or protein, ¼ starch. Have protein, grains and fruits or vegetables with most of your meals.
Eat low fat, high fiber foods. Substitute low fat sour cream for regular sour cream. Use fat free salad dressings. "This way you can whittle away 50 calories here, 100 calories there," Barton said.
Watch beverage calories. Be aware that one serving of juice is only ½ cup. It's not the 12 oz. bottle you buy in the store-that's 3 servings. "You can very quickly drink a lot of calories. So I often tell people, if you're thirsty, drink water, and save your calories for the meals. Don't drink pop, milk and juice because you're thirsty."
Don't drink pop unless it's diet pop . "Some people say they can't stand the taste of diet pop. But if you're a three- or four-can-a-day person, that's 600 calories! You cannot afford to drink that way. Try other diet pop brands, or try mixing half regular pop and half diet pop for awhile. You will adapt over time. I think pop is one of the worst things to use your calories on. If you don't like water, add a splash of juice or a dash of diet ice tea mix."

Know how to read a food label .
A package that proclaims "Low Fat!" may still be high in calories. Pay close attention to the number of calories per serving and the number of servings per container. Packages that look like one serving may actually contain two or three. http://vm.cfsan.fda.gov/~dms/foodlab.html .

All those diets-What to do?

People frequently ask Barton, "What diet should I be on?" Many of the popular diets today-Atkins, South Beach, and others-have limited benefit because they are difficult or expensive to maintain for the long haul. Barton thinks Weight Watchers ® is the best, because it is so flexible and can be adapted to personal tastes, budgets and medical conditions.

The EatRight® Home-Based Weight Management Program for Individuals with SCI , developed at the University of Alabama (UAB), is a twelve-week SCI-specific program that teaches the skills to lose weight and keep it off for the long term through diet, physical activity and behavior change. The program consists of a workbook and video, which must be purchased from UAB (see order information in the Resources section, below). "The program requires writing down what you eat every day, which is not a bad idea and gives you great feedback," Barton reported. "But it might be hard for people with poor hand function. And it requires a lot of self-motivation. While there was evidence that the 12-week program for ambulatory patients had some weight loss success, I haven't seen any literature about whether the home based program for SCI was successful."

Barton doesn't usually discuss recipes with SCI patients because cooking is difficult for them due to limited hand function, inaccessible kitchens, or lack of cooking "know-how."

"Men who never cooked before injury aren't going to start now," she said, and cooking "from scratch" has become less common in general. "So it's important to read labels and look closely at ready-to-eat foods and frozen meals."

People who rely on fast-food restaurants can find out what they're getting in terms of calories, fats, proteins, etc., by doing a Web search using terms such as "calorie content of fast foods." Remember that condiments-especially salad dressings-add calories. "Get the low-calorie salad dressings," she suggested. "Regular dressing packets in some of those restaurants are 300 to 400 calories each! Knowing and understanding nutrition information will help you make good choices."

To lose a pound, Barton said, you need a deficit of 3,500 calories. "If you reduce your calorie intake by 500 calories per day, you'll lose a pound in seven days."

For tips and recipes on eating low-fat on a budget, see " Eating Low-Fat on a Budget ."

Know your lipids (fats in the blood)

Lipids are important to understand because they can increase risk of heart disease. "It's never too soon to know what your lipids are," Barton warned. "Many people think they don't need to think about it until their 50s, but I see it climbing in people in their 20s. If you're gaining weight around your middle, chances are your lipids are going up." See chart below.

Fats in Food

It is important for everyone to limit saturated fats (those that are solid at room temperature), trans fats (read the label!) and cholesterol (animal and dairy fats) in food. (See " Types of Fat " pdf, 105kb) "In the 70s, we wanted to lower cholesterol, so we told people to avoid high cholesterol foods like eggs and shrimp," Barton said. "But now we know that total fat has more of an effect on the serum/blood lipid levels. And some of the fats in these foods-like omega-3 oils in fish and shrimp-are good fats (in appropriate amounts)."

"When looking at labels, you want less saturated fat, less trans fat and cholesterol, and more monounsaturated and polyunsaturated fats" she continued. Sometimes just changing the type of fat you're cooking with can change your lipid profile.

Tips to decrease "bad" (LDL) cholesterol:

Use low-fat cooking methods: bake, broil, grill, poach, barbeque (but not too charred - that's carcinogenic).
Avoid fried foods (French fries, fish and chips).
Choose non-fat or low-fat dairy products.
Eat lean meat and trim visible fat before cooking. "Take as much out as possible; it's all animal fat."
Choose fish more often.
Aim for a healthy weight.
Stop smoking.
Exercise as much as possible.

Osteoporosis

People with SCI run a higher than normal risk of osteoporosis (loss of calcium from the bones) in their lower limbs due to lack of weight-bearing, and this increases their risk for fracture. "Almost everybody has fallen out of their chair," Barton said. "And we don't want you to break anything, so you should try to maintain bone density by eating enough calcium." Her recommendations:

Be as active as possible.
Limit caffeine-it inhibits absorption of calcium.
Stop smoking-same as above.
Medications such as Fosamax are sometimes prescribed to limit loss of calcium from bone. Discuss this with your physician.
Practice good fall prevention.
Get adequate calcium daily.

Adults 19-50 years: 1000mg/day.
Adults >51 years: 1200-1500 mg/day.
Take 400 IU of Vitamin D daily to help absorb calcium.

Try to get calcium from food whenever possible: Dairy products; soy products; green leafy vegetables; canned sardines and salmon ("They provide calcium because you are eating the bones."); orange juice with calcium added.

"Three servings of high calcium foods a day will probably give you enough calcium," Barton said. But if you do need supplements, they should also contain vitamin D. Antacids like TUMS are an inexpensive calcium source, but don't contain vitamin D. While some people report constipation with calcium supplements, this can usually be alleviated by eating more fiber.

"Often patients are told not to eat calcium after injury because of high blood calcium levels," Barton said, but that only applies to the acute phase of injury. Once patients go home they should return to consuming adequate calcium. "There is even some evidence that low levels of calcium may contribute to kidney stones."

(See "Osteoporosis" fact sheet, pdf, 160kb.)

Neurogenic bowel

Adequate fiber intake is important for maintaining a good bowel program, but most people don't eat the recommended amount of 20-35 grams of fiber per day. High fiber foods include raw fruits and vegetables, dried fruits, whole grains, nuts, beans and lentils, and popcorn. Watch out for added fats, such as butter on popcorn or oil on nuts. In addition, be sure to drink adequate fluids and space meals throughout the day.

See " Fiber Facts " pdf, 225kb .

Special nutrition topics

Pressure sores and wound healing

Underweight persons are at risk of developing pressure sores because they have less fat on their buttocks.
People with pressure sores need about 100 grams (or 1.2 - 1.5 grams/kg body weight) of protein per day-almost twice the usual amount-because protein is lost through the wound site. In these cases, protein supplements like Ensure® may be the easiest way to get adequate protein. "When patients come in with wounds that aren't healing, one factor is typically they are not getting enough protein," Barton said.
It's important to get sufficient zinc and vitamin C to promote wound healing. Barton suggests taking a multivitamin and then getting blood tests to see if your levels are adequate.

Cranberry juice for preventing urinary tract infection (UTI). "It works for some," Barton said. Studies 4 suggest it should be consumed regularly (about 300 cc or 1 ¼ cup daily) to help prevent UTIs. "Drinking it (only) when you feel symptoms coming on probably won't help." Barton has not seen studies of using cranberry pills instead of juice, "but some people report benefit." Overall, literature is divided regarding the success of cranberry juice, but it appears to be worth a trial.

How to find a dietitian:

Dietitians that have passed the American Dietetic Association competency exam are known as Registered Dietitians (RD). Many dietitians are also licensed or certified by individual states. "Your physician may be able to refer you," Barton said. "All hospitals are required to have dietitians on staff."

On the American Dietetic Association Web site ( www.eatright.org ), you can click on the link "Find a Nutrition Professional" to search for dieticians in your area.

Resources

EatRight® Home-Based Weight Management Program for Individuals with SCI: http://www.spinalcord.uab.edu/show.asp?durki=78095&site=1021&return=77527

Food label info-U.S. Food and Drug Administration
http://www.cfsan.fda.gov/~dms/foodlab.html

National Center on Physical Activity and Disability Health Promotion http://www.ncpad.org/nutrition/

References

Fitness, inflammation, and the metabolic syndrome in men with paraplegia . Manns PJ, McCubbin JA, Williams DP. Arch Phys Med Rehab 2005;86(6): 1176-81.
Healthy body mass index values often underestimate body fat in men with spinal cord injury. Jones LM, Legge M, Goulding A. Arch Phys Med Rehab 2003;84(7): 1068-71
Energy expenditure after spinal cord injury: an evaluation of stable rehabilitating patients. Cox SA, Weiss SM, Posuniak EA, Worthington P, Prioleau M, Heffley G. J Trauma 1985;May 25(5):419-23.
Reduction of bacteriuria and pyuria after ingestion of cranberry juice, Avorn J, Monane JH, Gurwitz RJ, et al. JAMA, Mar 1994:271(10), 751-754.