Everyday Nutrition for Individuals with Spinal Cord Injury
April 12, 2011
A presentation by Vickeri Barton, RD, Associate Director of Nutrition Services at Harborview Medical Center and Susie Kim, OTR/L, Occupational Therapy Clinical Specialist at Harborview Medical Center. Click here to read the report.
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Report: Everyday Nutrition for Individuals with Spinal Cord Injury
By Vickeri Barton, RD, CD, Registered Dietitian, Associate Director of Nutrition and Services, Harborview Medical Center and Susie Kim, OTR/L, Licensed Occupational Therapist, Harborview Medical Center .
Presented on April 11, 2011 at the University of Washington Medical Center.
Table of Contents
- Why is nutrition important after a spinal cord injury?
- How much should you weigh after a spinal cord injury?
- Body mass index
- Calorie needs
- Protein recommendations (including when a pressure ulcer is present)
- General guidelines for weight control
- Factors associated with heart disease risk in SCI
- Bone health
- Neurogenic bowel
- Neurogenic bladder
- Nutrition supplements
- Steps toward healthier eating
Why is nutrition important after a spinal cord injury?
Nutrition is important for individuals with SCI both because of the increased risks of developing several specific medical complications as well as the physical challenges of shopping and meal preparation. Medical concerns include:
- Increased risk for diabetes, elevated cholesterol and obesity.
- Increased tendency to gain weight, which affects mobility and independence and may require hiring more assistants and buying a larger wheelchair.
- Risk for developing pressure sores.
- Increased risk for osteoporosis (loss of bone density).
How much should you weigh after a spinal cord injury?
Spinal cord injury results in changes in body composition so there is a lower percentage of muscle tissue. For this reason, healthy weight guidelines for the general public have to be adjusted for people with SCI. One common guideline is the Metropolitan Life Desirable Weight Tables. To apply this guideline to the SCI population, research evidence suggests that individuals with paraplegia should weigh 5-10% less than the guidelines and those with tetraplegia, 10-15% less.
Body mass index
More important than weight alone is how much fat you have on your body. Body Mass Index (BMI) is a measure of body fat based on a person’s height and weight and is now used more often than weight alone to determine if someone is obese or overweight. However, like general population weight charts, the general population BMI charts are not appropriate to assess body mass in persons with SCI due to their lower muscle mass. Currently there is not an adjusted SCI BMI guidelines or chart available , Recent research suggests that a BMI of 22 should be used to define obesity in persons with SCI while obesity in the general population is typically defined as a BMI over 30. 
Persons with SCI have reduced metabolic activity due to denervated muscle and therefore need fewer calories than non-paralyzed individuals. General guidelines suggest that persons with paraplegia need about 28 calories per kilogram (kg) of your ideal body weight. If you have tetraplegia, you need about 23 calories per kg of ideal body weight (the weight you should be). To determine your weight in kg, divide your weight in pounds by 2.2. For example, if you have tetraplegia and your ideal weight is 175 lbs., divide that number by 2.2, which equals 79 kg. Multiply 79 kg by 23 calories, and you get about 1,800 calories per day. These are only general guides, however, and do not account for differences in age, gender or activity levels. You will need to make adjustments based on your own experience with gaining or losing weight.
People with SCI have the same protein needs as the general population unless there is a pressure sore present. Wound healing requires a big increase in protein consumption. If you do have a pressure sore, it is very important to get adequate protein in order to heal. For most people it is hard to get enough protein unless they add a couple of high-protein snacks or meals to their daily diet.
- Individuals with SCI who do not have pressure ulcers need the same amount of protein as persons without SCI: 0.8 to 1.0 grams per kg of body weight per day.
- Individuals with Stage II pressure ulcers: 1.2g to 1.5g of protein per kg body weight per day.
- Individuals with Stage III and IV pressure ulcers: 1.5g to 2.0g of protein per kg body weight per day.
See Short-Term Nutrition Therapy for People with Skin Breakdown (ADA).
General guidelines for weight control
- Allow plenty of time to plan and shop for your meals. Waiting until the last minute or when you’re really hungry often results in overeating or choosing faster, less healthful meals. Thinking ahead and planning what you're going to prepare and eat is called “mindful eating” and helps maintain weight control.
- Don't skip meals; this leads to snacking and overeating later.
- Eat routinely, two or three meals a day. It's better to spread out your food consumption throughout the day to control your appetite.
- Watch those portion sizes! Everything is oversized today, from the average dinner plate to the size of a meal in a restaurant. Portions in restaurant meals are often the equivalent of three meals! One serving of meat should only be three ounces, or about the size of a deck of cards. One cup of starch like rice or potato is a little smaller than your fist.
- Divide up your plate: half of it should be vegetables; a quarter of it should be meat or other protein; and about a quarter of it should be a starch or grain like rice or potato.
- Eat a variety of protein, grains, fruits and vegetables.
- Choose low fat, high fiber foods.
- Read nutrition labels closely. One of the most important things to learn from the nutrition label is how many servings are in a package, because the calories and other ingredients are given per serving. This is easy to miss. Check that tiny, 2-oz bag of potato chips and you may be surprised to find that it contains two servings, at 140 calories per serving or 280 calories per bag. Foods labeled “high fiber,” “whole grain” or even “low-fat” can still be very high in calories, so check the nutrition label carefully. See Label Reading Tips for Weight Management (ADA).
- Watch your beverage calories. It’s very easy to use up a large chunk of your daily calorie allotment in beverages. If your caffeine habit involves a six-pack of Mountain Dew a day, that’s 900 calories or 50% or more of your daily calorie needs. Water is the preferred beverage, but if you can’t live without soda pop, switch to the “diet” version.
- Weigh yourself as often as possible. It's hard to find a place to get yourself weighed routinely, but it’s important to know if you are gaining or losing weight. If you're just getting weighed once a year during your annual visit, you don't get the feedback you need about whether you are eating too much. Try to find a clinic or doctor's office where you can get weighed at least once a month.
- See Weight Loss Tips from the American Dietetic Association.
Physical Activity is Important
Evidence suggests that appropriate physical activity can improve blood lipid parameters and weight in persons with spinal cord injury. Try to be active in any way you can, whether it's wheelchair sports, swimming, electrical stimulation exercises, or simply going down to the local mall in the morning and wheeling up and down with the mall- walkers.
Factors associated with heart disease risk in SCI
Keeping your cholesterol and other blood fats, waist circumference and C-Reactive Protein within normal parameters can help reduce your risk for heart disease.
- Blood fats (lipids) goals:
- Total Cholesterol – less than 200 mg/dl
- Triglycerides – less than 150 mg/dl
- LDL (the “bad” cholesterol)– less than 130 mg/dl
- HDL (the “good” cholesterol)– more than 40mg/dl (Note, HDL is often lower than desired in persons with SCI due to decreased activity, and it is difficult to improve.)
- C-Reactive Protein (CRP) is created when there’s some kind of stress or inflammation going on in your body. Over the years elevated CRP has been associated with risk for heart disease. However, CRP can be elevated if you have a UTI or pressure sore, so it doesn’t always mean an increased heart disease risk. Guidelines for CRP and heart disease risk are:
- 1.0 mg/L and below = low risk
- Between 1.0 and 3.0 mg/> = average risk
- 3.0 mg/> and higher = high risk 
If you have elevated CRP, discuss with your physician or provider. CRP is not influenced by your diet or food intake.
Diet recommendations to decrease cholesterol:
- Limit total fat intake, especially saturated and trans fats.
- Use low fat cooking methods.
- Choose low fat dairy products.
- Choose fish more often.
- Aim for a healthy weight.
- Stop smoking.
- Be as active as possible.
See also Heart Healthy Eating (ADA).
Persons with SCI are at higher risk for osteoporosis (loss of bone density) due to lack of weight bearing on lower limbs. Decreased bone density increases the risk for fractures. Recommendations:
- DEXA scan (imaging technique) is recommended for assessment of bone density.
- Get adequate calcium in your diet:
- Adults 19-50 years: 1000 mg/day
- Adults >51 years: 1200 mg/day
- The best sources are in the diet (dairy products; dark, leafy green vegetables; tofu; canned salmon; calcium-fortified orange juice) rather than from supplements.
- Use supplements if you can’t get adequate calcium in your diet. Tums antacids are a good, inexpensive source of calcium. Calcium supplements may cause constipation.
- Get adequate Vitamin D: adults and Children over 1 years of age need 600 IU/day .
- Be active.
- Limit caffeine.
- Stop smoking.
- Medications such as Fosamax may be prescribed by your doctor .
- Practice good fall prevention: learn how to avoid falling from your wheelchair, bed and other places!
See also Osteoporosis Nutrition Therapy (ADA)
- Eat regular meals, spaced throughout day.
- Drink adequate fluids: 40 ml per kg body weight plus 500 ml, or at least 1.5 liters per day.
- Eat 15 - 20 grams of fiber per day (less than the recommended amount for the general population).
- Drink adequate fluids.
- While there is some evidence that drinking three cups of cranberry juice a day may be helpful in preventing urinary tract infections (UTIs), regular cranberry juice has a lot of calories from sugar; unsweetened cranberry juice is preferred.
- Although cranberry tablets have not been found in studies to be effective for preventing UTI, some individuals report benefits, so it may be worth a try.
You don't need any additional supplements unless you have a deficiency that has been documented by a blood test. If your results are normal and you're eating a good diet with a variety of foods, you don’t need any supplements. In spite of this, many people take supplements anyway. Learn about the safety and effectiveness of different supplements at the National Institutes of Health Office of Dietary Supplements ( http://ods.od.nih.gov/) or the Natural Medicines Comprehensive Database (http://naturaldatabase.therapeuticresearch.com/). See also Dietary Supplements: What You Need to Know (NIH).
Steps toward healthier eating
Having the right nutrition information is the first step toward healthy eating, but changing your eating habits can be difficult. Convenience, access, cost, preparation and taste preferences are all factors in how and what we eat. Healthier eating may take some adjustment, but it can be done, and it doesn’t have to cost more. Try to make changes gradually.
Deciding what to buy before going shopping is the best way to save time and money and make healthy choices. This means planning your meals ahead of time and making a shopping list based on those meals.
It’s easy to find recipes on the Internet that are healthy and appealing for all kinds of palates and appetites. If you’re new to cooking, start with simple recipes. There are numerous online recipe indexes (allrecipes.com, foodnetwork.com) that can be searched by ingredients, convenience (quick-and-easy, make-ahead), diet (low-fat, vegetarian, low-sodium, diabetic), cuisine (Italian, Mexican), cooking method, occasion, season and so on. A Google search with the word “recipe” in it will bring up many choices. (Also see Resources section, below.)
Where to buy
Most of the larger stores provide assistance if you need it. They'll send a shopper around with you to grab things off the shelf. They take both cash and debit/credit cards as well as coupons.
Try to purchase only what you can carry. That way you don't end up over-purchasing and having to throw things out that go bad at the end of the week. Carrying bags or baskets of various sizes, shapes and materials can help you get your groceries home. Some carriers can hook on your wheelchair handles, others can be carried on luggage riggers in front. Insulated bags are also available for transporting frozen items that need to survive a long bus ride home. Search for “collapsible grocery tote” on Amazon.com for several different options.
Online groceries delivered to you
What could be more convenient than shopping for your groceries online and having them delivered to your door? Online grocery shopping is a growing industry. Amazon Fresh (http://fresh.amazon.com/) delivers to several zip codes in the Seattle area. Safeway (http://shop.safeway.com/) is another program with wider geographic coverage. A Google search can help you find local online grocers in your area.
Farms and co-ops
Local farms and food co-ops are also getting into the online ordering business, making deliveries either to your door or a neighborhood pickup location. They often specialize in local, organic produce, meats, cheeses, fish, and baked goods, as well as sustainably produced packaged goods such as coffee and chocolate.
Many towns and cities have regular farmers markets where you can buy local, fresh produce and other farm products. Farmers’ markets are colorful social events, and one of the great benefits is the opportunity to get to know the farmers.
Growing your own food is fun and cheap. If you have yard space, raised beds can be built that are accessible for wheelchair users. Many people grow vegetables and herbs in pots on their deck or patio, and these can be positioned on tables or benches that are easy to reach. Community gardens, called “P-Patches” in Seattle, are available for use by residents of many cities. Some programs offer elevated planting beds for gardeners with disabilities and paved pathways for wheelchair accessibility.
Eating out (or buying takeout) is undeniably convenient, but it’s also the most expensive and least healthy way to eat. Restaurant portions are much larger than we need, so we tend to overeat when we go out. Restaurant food, especially the fast-food variety, is notoriously high in fat, calories and sodium. In the past we could pretend we didn’t know how many calories we were consuming at restaurants, but now we don’t have that excuse. Many restaurants now post their nutritional information on site, and you can find nutritional content of foods from hundreds of chain restaurants at http://www.dietfacts.com/fastfood.asp. Smart phone apps can tell you instantly how many calories are in the meal you are about to order. Restaurant Nutrition provides nutrition information about many restaurant meals. Lose-It is a weight-loss app that helps you track calories and exercise and provides information about most foods as well as many restaurant meals. Being aware of what you’re eating can help you make healthier choices.
Tools and resources for making things easier:
- Front knobs on your stove and protective arm wear.
- Tray with raised border can be both a lap tray for carrying hot things and a prep surface if a cutting board is placed inside.
- Wide-handled cooking items and bowls with grip bases from OXO (http://www.oxo.com/).
- Portable electric griddles and skillets, toaster ovens, microwaves, immersable blenders, crock pots.
- The “imbonnie” Channel on YouTube has several videos by a woman with C5-6 tetraplegia who demonstrates simple modifications that make her kitchen accessible and cooking easier.
- Erin's Cookin’ by Erin Poyle, who has tetraplegia, has recipes and tips to encourage others with disabilities to enjoy cooking (Visit http://erinscookin.com/).
- Cooking with Cory, by Cory Parsons, a chef with tetraplegia (available on Amazon.com).
- The Paraplegic Chef http://www.theparaplegicchef.com/
- Eat This, Not That book series (http://www.eatthisnotthatbook.com/) helps you understand and navigate everyday food choices toward healthier eating and weight loss.
- American Dietetic Association Evidenced-Based Library Spinal Cord Injury Guidelines.
Based on scientific research, these guidelines help clinicians determine the nutrition recommendations for their patients with spinal cord injuries and covers a range of sub-topics and circumstances. http://www.adaevidencelibrary.com/topic.cfm?cat=3485.
- Office of Dietary Supplements: http://ods.od.nih.gov/
- How to Understand and Use the Nutrition Facts Label (U.S. Food and Drug Administration): http://www.fda.gov/food/ingredientspackaginglabeling/labelingnutrition/ucm274593.htm
- You Tube Videos/Demonstrations: search for “imbonnie” on www.youtube.com.
- Online grocery stores:
- Amazon Fresh https://fresh.amazon.com
- Safeway www.shop.safeway.com
- Kitchen Tools & Appliances
- Infinite Potential through Assistive Technology www.infinitec.org
- Adaptive Cooking (go to the Cooking section) www.maxiaids.com
- Smart Phone applications:
Review of nutrition apps: www.coreperformance.com/daily/nutrition/the-10-best-iphone-nutrition-apps.html
PowerPoint slides (in PDF format):
Nutrition handouts and resources (in PDF format):
Laughton GE, Buchholz AC, Martin Ginis KA (2009). Lowering body mass index cutoffs better identifies obese persons with spinal cord injury. Spinal Cord. Oct;47(10):757-62.
Gibson AE, Buchholz AC, Martin Ginis KA (2008). C-Reactive protein in adults with chronic spinal cord injury: increased chronic inflammation in tetraplegia vs paraplegia. Spinal Cord. Sep;46(9):616-21