1 / 50

Nutrition and Weight Management in Spinal Cord Injury

Nutrition and Weight Management in Spinal Cord Injury. By Jesse A. Lieberman, MD, MSPH. Objectives. Identify cardiovascular disease risk factors in chronic SCI Discuss weight management and prevention of cardiovascular disease in SCI Differentiate the healthy components of a diet

juditha
Télécharger la présentation

Nutrition and Weight Management in Spinal Cord Injury

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Nutrition and Weight Management in Spinal Cord Injury By Jesse A. Lieberman, MD, MSPH

  2. Objectives • Identify cardiovascular disease risk factors in chronic SCI • Discuss weight management and prevention of cardiovascular disease in SCI • Differentiate the healthy components of a diet • Implement modifications to improve current diet and lose weight or prevent further weight gain

  3. CVD Risk Factors in Chronic SCI • Accelerated Cardiometabolic Syndrome • Dyslipidemia • ↑TC/HDL, ↓HDL (Nash, et al. 2007, Lieberman et al. 2011) • Glucose intolerance & diabetes (Lavela, et al. 2006) • Central obesity (Mojtahedi, et al. 2008) • -+/-Hypertension • Hypertriglyceridemia • Lack of physical fitness (Jacobs, et al. 2004) • Elevated markers of inflammation and endothelial activation (Lee, et al. 2005, Wang, et al. 2007)

  4. CVD in Chronic SCI • Mortality rate from CVD over 200% higher-than-expected in age and gender matched controls (Kocina 1997) • In SCI > 30yrs, CVD most frequent cause of death (46% of all deaths) (Whiteneck, et al. 1992) • Prevalence of ischemic heart disease in the SCI population is 17% compared to 7% in age matched controls (Yekutiel, et al. 1989) • Heart disease - cause or contributing factor in 22% of deaths among those with chronic SCI (DeVivo, et al. 1989)

  5. Prevention of CVD • Weightmanagement • Therapeutic Lifestyle Intervention • Good nutrition • Physical activity and exercise • Manage blood pressure • AVOID SMOKING!

  6. Weight Management in Chronic SCI • Weight management is critical for wheelchair users • Increases or decreases in weight can effect the fit of the wheelchair. • Increases in weight may effect mobility • Large decreases or increases in weight may effect skin integrity

  7. Weight Management in Chronic SCI http://www.thenutritiondr.com/diet-weight-loss-weight-loss-gain-food-energy/

  8. Exercise in SCI • Limitations to exercise are paralysis, limited muscle mass, and adrenergic dysfunction • The reduction in cardiovascular fitness benefits result from the loss of sympathetic control and functional mass • Everyday mobility and activities of daily living are inadequate to meet the requirements for cardiovascular fitness

  9. Exercise in SCI • Reduced exercise tolerance due to decreased venous return (Myers et al. 2007) • Lesions above T1 compromise increases in heart rate during exercise, cardiac output and stroke volume (Mathias 1988) • Exercise results in ↑ in HR as a result of withdrawal of vagal inhibition and O2 uptake, but the changes do not occur below the level of injury

  10. Exercise in SCI • Main influencing factor of quality of life (Anneken et al. 2010) • Exercise interventions started by deconditioned persons with SCI can result in rapid and substantial health gains (Cowan et al. 2010) • 30 minutes of moderate exercise 3 times a week can improve HDL in SCI (El-Sayed et al. 2005)

  11. Exercise in SCI • The ACSM/AHA recommends exercising 5 times a week for 30 minutes a day at a moderate intensity (Haskell, et al. 2007) • Must tailor exercise program to preserve upper extremities • Does not have to be structured exercise, any increase in physical activity is beneficial (Manns, Janssen)

  12. Exercise in SCI • Many with SCI cannot exercise • limited by their level of injury Noreau Et al., 1993 • and/oroveruse injuries Gellman Et al., 1988; Boninger 2003 • barriers to exercise Cardinal Et al.,2004, Scelza et al., 2006 • This makes diet extremely important!

  13. Diet and SCI • Despite • Increased CVD risk factors and prevalence of CVD in the SCI population • Dietary evidence of the benefits of a prudent diet • Dietary guidelines • Persons with SCI have still been found to have poor diet quality • Diets are commonly characterized by excessive fat intake and low dietary fiber intake

  14. Weight Management in Chronic SCI http://www.thenutritiondr.com/diet-weight-loss-weight-loss-gain-food-energy/

  15. Weight Management in SCI • What is a calorie? • A calorie is a unit of energy • When something contains 100 calories, it's a way of describing how much energy your body could get from eating or drinking it • Calories aren't bad for you • Your body needs calories for energy • Eating too many calories — and not burning enough of them off through activity — can lead to weight gain

  16. Weight Management in SCI • 1 g of Carbohydrate = 4 calories • 1 g of Protein = 4 calories • 1 g of Fat = 9 calories • 1 g of alcohol = 7 calories • 12 oz soda = 140 cal • 1 medium apple (182 g) = 95 cal • 4 oz boneless skinless chicken breast = 150 cal

  17. Energy Dense Foods

  18. CVD Prevention in Chronic SCI • Limit processed foods and simple sugars like soft drinks, cookies and other candies • Animal protein intake is important, these foods should not be relied upon for fat sources • Limit large amounts of animal fats from foods like fried foods, red meat, eggs, cheese, butter, creams, and whole milk • Choose healthier fat sources like fish, low-fat dairy, olive oil, flaxseed oil, avocado and nuts

  19. Weight Management in Chronic SCI

  20. Diet and SCI • Nutrition is important for • wound healing Lehman 1995, Ho et al., 2010,Castihlo, 2005, Cruse et al., 2005 • bowel management Steins et al. 1997, Francis, 2007 • osteoporosis prevention Ott, 2001 • Protein is an essential macronutrient for persons with SCI • The SCI Evidence-based nutrition practice guidelines protein recommendations • acute SCI is 2.0g/kg/day • chronic SCI is 0.8-1.0g/kg/day • Stage III and IV pressure ulcers 1.5-2.0 g/kg/day. • At least 15g of fiber per day to assist in the management of neurogenic bowel

  21. CVD Prevention in Chronic SCI • Two contemporary dietary strategies proven to positively affect CMS • Mediterranean diet • Primarily plant-based foods: fruits, vegetables, whole grains, legumes, and nuts • Replacing butter with healthy fats such as olive oil • Using herbs and spices instead of salt • Limiting red meats to no more than a few times a month • Eating fish and poultry at least twice a week • Red wine (optional)

  22. CVD Prevention in Chronic SCI • -Dietary Approach to Stop Hypertension • Low-sodium • Fruits and vegetables • Low-fat or nonfat dairy • Whole grains

  23. Fiber is inversely related to CVD • Strong inverse associations between dietary fiber • excessive weight gain, central adiposity, elevated blood pressure, hypertriglyceridemia, low HDL-C, high LDL-C, and high fibrinogen Ludwig et al., 1999 • Inverse association between CHD, stroke, and CVD incidence and mortalityJacobs et.al, 2004, Steffen et al., 2003

  24. Whole-grain • Whole-grain positively affects • lipid profiles, inflammation, insulin sensitivity • inversely associated with weight gain and central adiposity • Soluble fiber, decreases the amount of cholesterol available for LDL synthesis Fernandez et al., 1999 • Whole-grain is rich in lignan and antioxidants that may have beneficial effects on endothelial function that result in CVD benefitsVanharanta et al, 2003

  25. This

  26. Fruits and Vegetables • Fruit and vegetable intake associated with -↓blood pressure, ↓inflammation, ↓risk of metabolic syndrome Johnet al., 2002; Oliveira et al., 2009; Esmaillzadeh et al., 2006 -also inversely associated with weight gain and central adiposity Singh et al., 2006 • Greater than 5 servings/day of fruits and vegetables is associated with the lowest risk of CVDFlock, 2011

  27. Low-fat dairy • Low-fat dairy can also • ↓the risk of DM Liu 2006 • ↓body weight and waist circumference Poddar 2009 • ↓blood pressure Kris-Etherton et al 2009 • A source of vitamin D, which, when deficient, is associated with an increased risk of CVD Wang et al 2008 • These findings, along with others, led to whole-grain, fruits and vegetables, and low-fat dairy being a key part of the 2010 Dietary Guidelines for Americans

  28. Weight Management in Chronic SCI http://www.thenutritiondr.com/diet-weight-loss-weight-loss-gain-food-energy/

  29. Energy Assessment • Ideal body weight for tetraplegics 10-15% (15-20lbs), paraplegics 5-10% (10-15lbs) • Ideal body weight is what one should weigh based on their height • 5’8” 140-148, 145-157, 152-172 • Tetraplegia: 23Kcal/kg of ideal body weight/day • About 1550 kcal for 150 lb. individual, 2000 kcal for 200 lb. • Paraplegia: 28Kcal/kg of ideal body weight/day for paraplegia • 1900 kcal for 150 lb. individual, 2500 kcal for 200 lb. individual http://www.guideline.gov/content.aspx?id=14889

  30. Energy intake Three day food log My Fitness Pal and many others Energy output >80% from BMR Physical Activity The Physical Activity Scale for Individuals with Physical Disabilities The Physical Activity Recall Assessment for People with SCI Thermic Effect of Food 12% versus 15% Energy Assessment

  31. Energy Deficit • Decrease overall calories • 150-300 kcal • Eat small frequent meals, 5-6/day • Each meal should include: protein , and fruit and/or vegetable • Drink ice water

  32. Behavior Change self monitoring- ex: keep a food diary, plan meals portion control- measure food, plate method stress management- limit eating because of stress/ mood related eating social support- buddy system Adult Weight Management Evidence-Based Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. American Dietetic Association; 2006.

  33. Intermittent Fasting New diet “craze” Many different varieties, but all the same result 16/8 Skipping meals Fasting days or modified fasting days Less calories per week!

  34. Sample Meal Plan Breakfast Egg sandwich(es) with 1-2 whole eggs, 1-2 slices of wheat toast or whole-grain English muffin 1-2 slices of low-fat cheese 1-2 slices of turkey bacon or regular bacon At least ½ cup of blueberries and strawberries, or other fruit Snack Protein bar or shake with fruit, 1 tablespoon of mixed nuts Lunch 3-5 oz chicken, pork, steak, fish ½ of whole-grain Rice, risotto, quinoa ½ cup of vegetables 1 Apple Snack 2 tangerines, 1 packet of beef jerky Dinner 3-5 oz chicken, pork, steak, fish ½ cup of whole-grain Rice, risotto, quinoa ½ cup of vegetables Salad

  35. Sample Meal Plan Breakfast 1-2 whole eggs, 3-4 egg whites with vegetables ½ cup oatmeal, blueberries and strawberries Snack Protein bar or shake with fruit Lunch Two slices of whole wheat bread 1 slice of low-fat cheese 2-3 ounces of deli meat Lettuce and tomato Carrot sticks with Walden Farms Snack 1 Apple, 1 tablespoon of peanut butter Dinner 3-5 oz chicken, pork, steak, fish ½ cup of whole-grain Rice, risotto, quinoa 1cup of vegetables or salad

  36. Fluids The amount of fluid you drink is important and should be limited according to your bladder program Prevent dehydration, keep kidneys and bladder flushed, provide extra fluid when you have a pressure sore that is draining, and may also prevent formation of kidney and bladder stones Water should be your #1 beverage choice Helps regulate the body’s temperature and the digestion of food Crystal light Avoid too many drinks with caffeine

  37. Final Tips Find foods you like Cook in bulk Do not eat mindlessly Eating in front of a computer, TV Try to avoid eating from a large package The 18th bite will not be any better than the first or second Take care of yourself!

  38. Cooking in Bulk • 12 meals for $25 • Chicken, steak, tilapia • -a deck of cards size meat • -1/2 cup of whole-grain rice • -vegetables

  39. Nutrition and Wound Healing Nutrition is Paramount for wound healing Lehman 1995, Ho et al., 2010,Castihlo, 2005, Cruse et al., 2005 The SCI Evidence-based nutrition practice guidelines pressure ulcer recommendations Calories: 30-40 Kcal/Kg/day Protein: Stage II: 1.2-1.5 g/Kg/day Stage III and IV: 1.5-2.0 g/Kg/day Vitamin C: Stage I, II: 100 mg-200 mg/day Stage III, IV:1000-2000 mg/day

  40. Nutrition and Wound Healing The SCI Evidence-based nutrition practice guidelines pressure ulcer recommendations Vitamin A: 10,000-50,000 IU/day x 10 days Zinc: 220 mg Zinc sulfate b.i.d. or 50 mg elemental Zinc x 14 days Address anemia or other nutritional deficiencies

  41. What’snext Nutritioneducationstudytitled"NutritionEducationforPrevention of Cardiovascular Disease in SpinalCordInjury" RCT with 100 inpatients, 100 outpatients Six nutrition education courses based on Eat Smart, Stay Well SCI Consortium Cardiometabolic Syndrome Guidelines

  42. Summary • CVD and specifically CHD is prevalent in the chronic SCI population • Screening by NCEP guidelines may not be adequate • Individuals with chronic SCI have been shown to have poor diet quality • Individuals with chronic SCI have lower caloric needs • The healthy plate and 2010 Dietary Guidelines for Americans should be emphasized • There may be a role for increased nutrition education during acute rehabilitation and for those with chronic injuries

  43. References • Bauman WA, Spungen AM. Coronary heart disease in individuals with spinal cord injury: assessment of risk factors. Spinal Cord 2008;46(7):466-476. •  Spungen AM, Adkins RH, Stewart CA et al. Factors influencing body composition in persons with spinal cord injury: a cross-sectional study. Journal of Applied Physiology 2003;95(6):2398-2407. • Nuhlicek DN, Spurr GB, Barboriak JJ, Rooney CB, el Ghatit AZ, Bongard RD. Body composition of patients with spinal cord injury. Eur J Clin Nutr 1988;42(9):765-773. • Spungen AM, Wang J, Pierson RN, Jr., Bauman WA. Soft tissue body composition differences in monozygotic twins discordant for spinal cord injury. J Appl Physiol 2000;88(4):1310-1315. • Mathias CJ, Frankel HL. Cardiovascular control in spinal man. Annu Rev Physiol 1988;50:577-592. • Mallory BS: Autonomic function in the isolated spinal cord, in Downey JA, Myers SJ, Gonzalez EG, et al. (eds): The Physiological Basis of Rehabilitation Medicine. Newton, Ma, Butterworth-Heinemann, 1994, pp 519–42 •  DeVivo MJ, Kartus PL, Stover SL, et al. Cause of death for patients with spinal cord injuries. Arch Intern Med 1989; 149(8):1761-1766. • Whiteneck GG, Charlifue SW, Frankel HL, et al. Mortality, morbidity, and psychosocial outcomes of persons spinal cord injured more than 20 years ago. Paraplegia 1992; 30(9):617-630. • Yekutiel M. Brooks ME. Ohry A. Yarom J. et al. The prevalence of hypertension, ischemic heart disease and diabetes in traumatic spinal cordinjuredpatientsandamputees. Paraplegia1989; 27(1):58-62,. • Bauman WA. Spungen AM. Zhong YG, et al. Depressed serum high density lipoprotein cholesterol levels in veterans with spinal cord injury. Paraplegia. 1992; 30(10):697-703, • Lavela SL. Weaver FM. Goldstein B, et al. Diabetes mellitus in individuals with spinal cord injury or disorder., Journal ofSpinalCordMedicine. 2006; 29(4):387-95,. • Bauman WA, Atkins RH, Spungen AM, et al.: The effect of neurological deficit on oral glucose tolerance in persons with chronic spinal cord injury. Spinal Cord 1999;37:765–71 • Kocina P. Bodycompositionofspinalcordinjuredadults. Sports Medicine 1997;23(1):48-60. • Mojtahedi MC. Valentine RJ. Arngrimsson SA, et al. The association between regional body composition and metabolic outcomes in athletes with spinal cord injury Spinal Cord. 2008; 46(3):192-7.

  44. Lee MY. Myers J. Hayes A. et al. C-reactive protein, metabolic syndrome, and insulin resistance in individuals with spinal cord injury. Journal ofSpinal Cord Medicine. 2005; 28(1):20-5. • Wang TD. Wang YH. Huang TS. et al. Circulating levels of markers of inflammation and endothelial activation are increased in men with chronic spinal cord injury. Journal of the Formosan Medical Association. 2007; 106(11):919-28. • National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106(25):3143-421. • Wilson PW, D'Agostino RB, Levy D, et al. Prediction of coronary heart disease using risk factor categories.. Circulation 1998; 97(18):1837-1847. • Nash MS, Mendez AJ. A guideline-driven assessment of need for cardiovascular disease risk intervention in persons with chronic paraplegia. Archives of Physical Medicine & Rehabilitation 2007;88(6):751-757. • Lieberman, JA, Hammond, FM, Barringer, TA, Norton, HJ, Bockenek, WL, Scelza WM, Goff, DC. Prevalence and Risk of CHD as Measured by Coronary Calcium Score among Individuals with Chronic Traumatic SCI: A Pilot Study. Oral presentation at the 2009 Congress on Spinal Cord Medicine and Rehabilitation. Manuscripts under second review • Bauman WA, Raza M, Spungen AM, et al. Cardiac stress testing with thallium-201 imaging reveals silent ischemia in individuals with paraplegia. Archives of Physical Medicine & Rehabilitation 1994; 75(9):946-950. • Buchholz AC, McGillivray CF, Pencharz PB. Differences in resting metabolic rate between paraplegic and able-bodied subjects are explained by differences in body composition. Am J Clin Nutr 2003;77(2):371-378.

  45. Jeon JY, Steadward RD, Wheeler GD, Bell G, McCargar L, Harber V. Intact sympathetic nervous system is required for leptin effects on resting metabolic rate in people with spinal cord injury. J ClinEndocrinolMetab 2003;88(1):402-407. • Bauman WA, Zhong YG, Schwartz E. Vitamin D deficiency in veterans with chronic spinal cord injury. Metabolism: Clinical & Experimental 1995;44(12):1612-1616. • Vaziri ND, Pandian MR, Segal JL, Winer RL, Eltorai I, Brunnemann S. Vitamin D, parathormone, and calcitonin profiles in persons with long-standing spinal cord injury. Archives of Physical Medicine & Rehabilitation 1994;75(7):766-769. • Saremi A, Arora R. The utility of omega-3 fatty acids in cardiovascular disease. Am J Ther 2009;16(5):421-436. • Retelny VS, Neuendorf A, Roth JL. Nutrition protocols for the prevention of cardiovascular disease. NutrClinPract 2008;23(5):468-476. • Myers J, Lee M, Kiratli J. Cardiovascular disease in spinal cord injury: an overview of prevalence, risk, evaluation, and management. Am J Phys Med Rehabil 2007;86(2):142-152 • Anneken V, Hanssen-Doose A, Hirschfeld S, Scheuer T, Thietje R. Influence of physical exercise on quality of life in individuals with spinal cord injury. Spinal Cord 2010;48(5):393-399. • Cowan RE, Nash MS. Cardiovascular disease, SCI and exercise: unique risks and focused countermeasures. DisabilRehabil 2010. • El-Sayed MS, Younesian A. Lipid profiles are influenced by arm cranking exercise and training in individuals with spinal cord injury. Spinal Cord 2005;43(5):299-305. • Haskell WL, Lee IM, Pate RR et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation 2007;116(9):1081-1093. (18) Janssen TW, van Oers CA, van Kamp GJ, TenVoorde BJ, van der Woude LH, Hollander AP. Coronary heart disease risk indicators, aerobic power, and physical activity in men with spinal cord injuries. Arch Phys Med Rehabil 1997;78(7):697-705.

  46. Walters JL, Buchholz AC, Martin Ginis KA. Evidence of dietary inadequacy in adults with chronic spinal cord injury. Spinal Cord 2009;47:318-322.

More Related