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Without appropriate modification of dietary intake following SCI, energy intake readily exceeds daily energy expenditure, predisposing persons with SCI to undesirable weight gain (Cox et al. 1985). Obesity is a common secondary complication of chronic SCI and is associated with adverse metabolic sequelae. In a large South Korean sample of individuals with SCI, obesity rates were reported to be 43.4% in those with physical disabilities and 34.6% for those without physical disabilities (Oh et al. 2012). An observational study from the United Kingdom found that energy imbalance leading to weight gain could be caused by the very inconsistent daily energy expenditure and daily energy intake and controlling this through intervention is important in weight loss for individuals with SCI (Nightingale et al. 2017). Despite widespread emphasis on obesity-related health risks in persons with SCI, limited research has been carried out to address this problem. There is a lack of information regarding the health outcomes of weight loss in this population, as well as limited educational resources available on nutrition issues and weight control for this high-risk group (Chen et al. 2006). However more recent studies (Betts et al. 2017 and Brochetti et al. 2018) have shown that combining diet and exercise in a structured lifestyle manner with accommodations for low-ambulatory SCI patients increases the compliance and retention post-intervention for longer periods of time.

Table 6 Diet and Exercise Program for Overweight/Obesity

Author Year

Country

Research Design

PEDro Score

Sample Size

MethodsOutcomes
Li et al. 2018

USA

RCT

PEDro=4

N=11

Population: Mean age=46.0±7.8 yr; Gender: males=10, females=1; Time since injury=21.8±6.3 yr; Level of injury: C=4, T=7, L=0; Severity of injury: AIS A=3, B=8, C=0, D=0.

Intervention: Participants randomized into an 8-week combined exercise (Comb-Ex) group designed to challenge strength, power, and endurance, or an 8-week high protein (HP) Diet group that focused on maintaining a carbohydrate to protein ratio <1.5 and limiting fat to ~30% of total energy intake.

Outcome Measures: Exercise adaptations (oxygen consumption (VO2), strength, muscle fiber type), body composition (body mass, lean mass, fat mass, android fat mass), glucose homeostasis, fasting glucose concentration (FGC), insulin sensitivity, lipid profile (total cholesterol (TC), triacylglycerol, high-density lipoprotein (HDL), low-density lipoprotein (LDL)), inflammation profile (IFN- γ, IL-1B, IL-6, IL-8, IL-10, IL-12, and  TNF-α), and intracellular muscle signaling (GLUT 4, AMP-activated protein kinase (AMPK), calcium/calmodulin-dependent protein kinase type II (CAMPKII), protein kinase B (Akt), and Atk substrate (AS-160)).

1.     Comb-ex participants improved VO2 peak significantly from baseline (p<0.05).

2.     Comb-Ex participants improved their maximum voluntary upper body strength (p<0.05).

3.     Comb-Ex participants had significant hypertrophy in the deltoid (p<0.05) and vastus lateralis (VL) muscles (p<0.05).

4.     Comb-Ex participants had a significant shift in myofiber type from type IIx to type IIa muscle fibers (p<0.05).

5.     Both groups significantly reduced their total body mass (p<0.05) and fat mass (p<0.05).

6.     Neither group had significant changes in lean body mass or android fat mass (p>0.05).

7.     Significant reduction in FGC in Comb-Ex group (p<0.05) but not in the HP Diet group (p>0.05).

8.     Both groups saw a significant reduction for insulin area under the curve (AUC) (p<0.05).

9.     No correlation between changes in body composition and changes in FGC and insulin AUC’s.

10.   No significant changes in TC, triacylglycerol, HDL or LDL (p>0.05).

11.   No significant changes in IFN- γ, IL-1B, IL-6, IL-8, IL-10 and IL-12 for inflammatory profile in either group (p>0.05).

12.   Significant reduction in TNF-α in both groups (p<0.05).

13.   Comb-Ex group had significantly higher deltoid AMPK and CAMPKII than the HP diet group (p<0.05).

14.   GLUT4 levels were significantly higher in the nonparalytic deltoid compared to the paralytic VL muscle in the Comb-Ex group (p<0.05).

15.   Atk and AS-160 phosphorylation was significantly higher in the paralytic VL compared to the nonparalytic deltoid muscle in the Comb-Ex group (p<0.05).

Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data.

Gorgey et al. 2012

USA

RCT

PEDro=6

N=9

Population: Treatment group (n=5): Mean age: 36 yr; Gender: males=5, females=0; Injury etiology: unspecified; Level of injury: cervical=4, thoracic=1; Level of severity: AIS A=3, B=2; Mean time since injury: 16 yr. Control (n=4): Mean age: 33 yr; Gender: males=4, females=0; Injury etiology: unspecified; Level of injury: thoracic; Level of severity: AIS A=3, B=1; Mean time since injury: 8 yr.

Intervention: Participants were randomized to receive neuromuscular electrical stimulation resistance training and diet (treatment) or diet alone (control) over 12 wk. Training sessions were delivered 2 x/wk and involved leg extensions with increasing ankle weights (4 sets, 10 reps). Stimulation was delivered during training at 30 Hz and 450 µ, with 50 sec on and 50 sec off. Diets were composed of 45% carbohydrates, 30% fat, and 25% protein. Outcomes were assessed before and after treatment.

Outcome Measures: Weight, Body Mass Index (BMI), Cross-Sectional Area (CSA), Skeletal Muscle, Adipose Tissue, Fat-Free Mass (FFM), Fat Mass (FM), Cholesterol, Triglycerides (TG), Low-Density Lipoproteins (LDL), High-Density Lipoproteins (HDL), Free Fatty Acid (FFA), Glucose, Insulin, Insulin-Like Growth Factor 1 (IGF-1).

1.      Weight and BMI were not significantly different between groups post intervention.

2.      Based on MRI findings, there were significant differences (p<0.001) between treatment and placebo groups post intervention in mean skeletal muscle CSA for the thigh (78 versus 53 cm2), knee flexor (35 versus 26 cm2), and knee extensor (22 versus 16 cm2).

3.      Based on MRI findings, there was a significant difference between treatment and control groups post intervention in intramuscular fat (15% versus 31%, p=0.009); there were no significant differences between groups in CSA of visceral and subcutaneous adipose tissues.

4.      Based on DXA findings, there were significant differences between treatment and placebo groups post intervention in mean leg FFM (7.5 versus 6.2 kg, p=0.03), leg %FM (28% versus 36%, p=0.02), and ratio of leg FFM to whole body FFM (0.15 versus 0.12, p=0.043); there were no significant differences between groups in FFM or FM of the whole body or trunk.

5.      Based on DXA findings, significant interactions were observed due to increases in trunk FFM by 1kg in the treatment group (p=0.0001) and decreases in trunk %FM by 2% in the control group (p=0.0003).

6.      Lipid profiles showed a significant difference between treatment and placebo groups post intervention in mean levels of TG (87 versus 125 mg/dL, p=0.045) and cholesterol to HDL ratio (4.8 versus 5.2, p=0.017); there were no significant differences between groups in total cholesterol, LDL, HDL, or FFA.

7.      Carbohydrate metabolism showed a significant difference between treatment and placebo groups post intervention in ratio of plasma insulin to plasma glucose (p=0.04); there were no other significant differences between groups in glucose or insulin.

8.      IGF-1 was significantly correlated with knee extensor CSA (r=0.53, p=0.037) and visceral adipose tissue CSA (r=­0.56, p=0.023).

Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data.

Brochetti et al. 2018

USA

Pre-Post

N=18

Population: Mean age=55.7±13.0 yr; Gender: Not reported; Time since injury=9.1±10.7 yr; Level of injury: C=11, T=4, L=1; Severity of injury: AIS A=3, B=1, C=5, D=7.

*2 participants had multiple sclerosis, so their data is not represented in level or severity of injury.

Intervention: 18 overweight participants with SCI engaged in a 12-week interdisciplinary weight, food and lifestyle management program to observe its effects physical measurements.

Outcome Measures: Body weight, waist circumference, body mass index (BMI), and diabetes risk scores.

1.     Significant difference in weight from the program start to end (p<0.001).

2.     Significant difference in waist circumference measurements from program start to end (p<0.001).

3.     Pearson Moment Correlation determined that those with a higher BMI did not lose proportionally more weight than participants with a lower BMI (p<0.05).

4.     Pearson Moment Correlation determined there was no relationship between age, weight loss and waist circumference (p>0.05).

5.     Significant reduction in diabetes risk scores from program start to end (p<0.001).

Betts et al. 2017

USA

Pre-Post

N=10

Population: Mean age=48.6±13.1 yr; Gender: males=6, females=4; Time since injury=18.8 yr; Injury etiology: SCI=6, Spina Bifida=2, Osteoarthritis/Joint Disease/Orthopedic Problems=2; Level of injury: Not reported; Severity of injury: Not reported.

Intervention: Participants took part in a modified diabetes prevention program group lifestyle balance program to facilitate weight loss through lower caloric intake and higher aerobic activity.

Outcome Measures: Body Weight, Body Mass index (BMI), Waist Circumference, Systolic Blood Pressure, Diastolic Blood Pressure

1.     There were significant improvements over time for weight loss and BMI (p<0.05).

2.     There were no significant changes over time for blood pressure and waist circumference (p>0.05).

Chen et al. 2006

USA

Pre-post

NInitial=17; NFinal=16

Population: Gender: males=9, females=7; Injury etiology: SCI=15, spina bidifda=1; Severity of injury: AIS A–D; Family history of overweight/obesity: yes=11, no=5.

Intervention: Patients attended classes on nutrition, exercise and weight control/reduction for 12 wk (90 min/wk and exercised for 6 wk (30-min).

Outcome measures: Physiologic measures (weight loss, body mass index [BMI]), high density lipoprotein (HDL).

1.     During the intervention 14 subjects lost weight (mean age=4.2 kg).

2.     Decreases were noted in BMI (p<0.050), waist circumference (p<0.001), neck circumference (p<0.020), and skinfold thickness (p<0.001).

3.     HDL decreased significantly (p<0.030).

4.     At follow-up, 6 continued to lose weight, 4 stabilized, and 3 gained.

Nightingale et al. 2017

United Kingdom

Observational

N=33

Population: Mean age=44.0±9.0 yr; Gender: males=27, females=6; Time since injury=15.0±10.0 yr; Level of injury: C=0, T=33, L=0; Severity of injury: AIS A=28, B=5, C=0, D=0.

Intervention: Participants wore a physical activity monitor and completed a weighed food diary for 7 days consecutively.

Outcome Measures: Physical activity monitor wear time, body mass, resting metabolic rate (RMR), energy expenditure variables (total energy expenditure (TEE), physical activity energy expenditure (PAEE), and physical activity level (PAL)), energy intake (total energy intake, macronutrient composition(percent protein, percent carbohydrate, percent fat)), number of days required to reliably estimate energy expenditure variables.

1.     Significant main effect of physical activity monitor wear time for TEE (p=0.02), PAEE (p<0.001), PAL (p=0.003), sedentary time (p=0.017), and light-intensity activity (p=0.003).

2.     Level of injury was a significant covariate for TE (p=0.03), PAL (p=0.04), sedentary time (p=0.03) and moderate-to-vigorous physical activity (MVPA) (p=0.03).

3.     Sex was also a significant predictor for TEE, PAEE, sedentary time, light and MVPA (all p<0.001).

4.     Total energy intake decreased significantly from day 1 to 7 (p=0.01).

5.     No significant change from day 1 to 7 on energy expenditure variables (p>0.23) or diet macronutrient composition (p>0.70).

6.     Alcohol consumption was significantly higher for Friday and Saturday compared to the rest of the week (p<0.05).

7.     Day of the week did not significantly affect energy expenditure variables or total energy intake (p>0.05).

8.     Concluded that 1-4 days are required to reliably estimate energy expenditure variables and 4-24 days are required to estimate total energy intake and macronutrient composition.

Discussion

An observational study by Nightingale et al. (2017) provides insight into what characteristics to focus on when designing diet and exercise interventions for SCI patients. 33 individuals wore a physical activity monitor for 7 consecutive days and kept a log of their daily food intake to assess their energy balance using their energy intake and energy expenditure. 31 participants successfully wore the physical activity monitor for at least the minimum required amount of time, and 32 completed the food intake log. The results revealed that both energy expenditure and energy intake were very inconsistent and reported that it takes 1-4 days of monitoring energy expenditure to reliably estimate energy expenditure variables and 4-24 days to reliably estimate total energy intake. The study also reported which covariates effect energy expenditure and energy intake and how much. These results are useful in designing future interventions as it gives researchers the ability to target specific characteristics in order to produce the most useful data regarding diet and exercise and how to generate the best results for patients with SCI.

Li et al. (2018), an RCT in which 11 participants (10 males, 1 female) with SCI were randomized to either 8 wks of combined exercise (Comb-Ex) consisting of resistance and aerobic exercise training with supervision or 8 wks of a high-protein (HP) diet with phone meetings to record compliance and study retention. At the end of the intervention, the HP diet group saw a significantly larger decrease in Matsuda Index scores compared to the Comb-Ex group, whereas the Comb-Ex group saw a their fasting plasma glucose levels decrease significantly more than the HP diet group. Values for area under the curve for insulin and for the pro-inflammatory cytokine TNF-x decreased significantly as well. Results reveal that combined exercise has a significant effect on fasting plasma glucose and high-protein diet has a significant effect on Matsuda Index scores, and both groups improve the area under the curve for insulin and TNF-x for individuals with SCI. It is possible that a regime that incorporates both an HP diet and a Comb-Ex program could potentially provide the best results and this should be a focus of future research.

In an RCT by Gorgey et al. (2012), nine males with chronic SCI were randomized to 12 wk of resistance training plus a diet program or a diet program alone. After the intervention, groups were comparable in body weight and levels of subcutaneous and visceral adipose tissue. However, the treated group had significantly greater increases in skeletal muscle cross sectional areas, insulin growth factor, and fat-free mass; they also experienced reductions in intramuscular fat percentage, the ratio of visceral to subcutaneous adipose tissue, the ratio of plasma insulin to plasma glucose, and triglyceride and HDL-C levels. Resistance training therefore has the benefits of increasing favourable body composition regions through skeletal muscle hypertrophy, which in turn can lead to improvements in carbohydrate and lipid metabolism.

Chen et al. (2006) conducted a study to assess the effect of a weight-loss program on body weight, BMI, waist and neck circumference, skinfold thickness, fat versus lean mass, bone mineral content, blood pressure (BP), serum lipids, hemoglobin, albumin, eating habits, nutrition knowledge, bowel function and indicators of psychosocial well-being. A total of 16 subjects with chronic SCI who were overweight or obese completed the intervention program. Subjects attended 90-minute counseling sessions once per week for 12 weeks, led primarily by a Registered Dietitian. The dietary approach emphasized high-fiber, nutrient-dense foods (e.g., fruits, vegetables, grains, cereals) and the moderation of meats, cheeses, sugars and fats (Weinsier et al. 1983). The program included exercise and behaviour modification. Reported results included an average weight loss of 3.5 kg, significant reductions in BMI, anthropometric measures and fat mass. Lean mass, hemoglobin, albumin and bone mineral content were maintained. There was no significant change in BP or low-density lipoprotein cholesterol (LDL), although there was a significant decrease in high density lipoprotein cholesterol (HDL). There was a trend between weight lost and decrease in waist circumference, increase in nutritional quality of diet, increase in fiber consumption and decrease in time required for bowel movements. Changes in psychosocial and physical functioning were also reported.

Brochetti et al. (2018) is a pretest-post test study similar in design to Chen et al. (2006), as it looks at weight loss, waist circumference with the additional outcome measures of intervention compliance and retention. 18 participants completed a 12-wk interdisciplinary weight management program called Working on Healthy Eating, Exercise and Life Style (WHEELS) that consisted of a dietary component and an exercise program. Those who could not attend meetings or exercise sessions at the program headquarters were able to complete their workouts via satellite sessions, so the program was very accommodating. From baseline to intervention’s end 15 of the 18 participants lost at least 4.5±0.5 kg and 17 of the 18 experienced weight loss of some sort, Also from baseline to post-intervention 16 of the 18 participants experienced a decrease in waist circumference. At the 6-mo follow-up, there were no significant differences in weight or waist circumference with 12/18 participants continuing to lose weight or barely gaining any weight. 11 of the18 participants had decreased Diabetes Risk scores as well. Results from the WHEELS intervention indicate that the program may have clinical benefits as well as show promise for compliance and retention form post-intervention to 6-mo follow-up, which is something that studies to come should seek to duplicate.

While previous studies assessed the physiological effects of nutrition-based weight loss programs, a study by Betts et al. (2017) evaluated the effectiveness of a Diabetes Prevention Program Group Lifestyle Balance (DPP GLB) program with regards to not only weight loss, but program retention and prolonged lifestyle change as well. Ten participants began the program, and seven were retained, attending 79.3% of the conference calls over the 20 wk intervention. Along with the 70% retention, participants rated the program a 6.3±0.3/7 for helplessness and a 6.2±0.6/7 for satisfaction with a significant mean weight loss of 8.86±8.37 kg and significant reduction in BMI in those that completed the intervention. Despite the small sample size making difference detection challenging, the DPP GLB program completers experienced significant weight loss finding the intervention helpful and satisfying.

Conclusion

There is level 1b evidence (from one RCT; Gorgey et al. 2012 and three pre-post studies; Chen et al. 2006, Betts et al. 2017 and Brochetti et al. 2018) that an intervention program combining diet and exercise is effective for reducing weight among overweight persons with SCI.

There is level 1b evidence (from two RCTs; Gorgey et al. 2012 and Li et al. 2018) that interventions targeting just diet and just exercise are both effective for reducing metabolic markers for obesity and associated metabolic diseases like diabetes and heart disease.

There is level 4 evidence (from two pre-post studies; Betts et al. 2017 and Brochetti et al. 2018) that lifestyle interventions that combine diet and exercise and provide accommodation to low-ambulatory participants are effective in participant compliance and retention during and post-intervention.

There is level 5 evidence (from one observational study; Nightingale et al. 2017) that it is important to incorporate strict dietary and exercise guidelines for patients with SCI because of how inconsistent those with SCI are with their daily energy intake and daily energy expenditure.

  • Strict guidelines for diet and exercise interventions are important for patients with SCI due to the inconsistent nature of their energy balance causing weight gain leading to obesity.

    A combined diet and exercise program can help patients reduce weight following SCI without compromising total lean mass and overall health.