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Little is known about the most effective health promotion activities, including nutrition interventions, to meet the long-term wellness needs for persons after SCI. A holistic wellness program intervention was developed, conducted and assessed by Zemper et al. (2003). Improvement in healthy diet involves a number of factors. One important factor of health promotion and education is improving the ‘food environment’. This involves diet education, expanding current food choices, and providing better access to healthy foods (Hata, Inayama, & Yoshiike, 2017).

Table 8 Nutritional Education Intervention and Long-Term Wellness

Author Year

Country

PEDro Score

Research Design

Sample Size

MethodsOutcomes
Zemper et al. 2003

USA

RCT

PEDro=4

NInitial=76; NFinal=43

Population: Age range=22-80 yr; Gender: males=30, females=13; Level of injury: complete, incomplete; Time since injury=1-49 yr.

Intervention: Subjects attended a series of six 4-hr workshop sessions over 3 mo.

Outcome measures: Wellness survey, Health Promoting Lifestyle Profile-II (HPLP-II); Secondary Conditions Scale (SCS), Self-Rated Abilities for Health Practices Scale (SAHP), Perceived Stress Scale, and Physical Activities with Disability Questionnaire (PADS).

 

1.     Treatment groups scores on the SAHP improved following treatment (p<0.05) as well as on the HLPH-II (total score) & the HPLP-II health related subscale score (p<0.001).

2.     Treatment group scores improved post-treatment on the HPLP-II (nutrition subscale) (p<0.05).

3.     Mean scores for the treatment groups improved significantly for the HPLP-II stress management subscale (p=0.001). Treatment group’s stress scores also improved, indicating less stress (p<0.05).

4.     HPLP-II physical activity scores improved post treatment for the treatment group only (p=0.001). No significant differences were noted for the PADS score for either group post treatment.

5.     SCS score decreased for the treatment group, post treatment (p=0.001), indicating fewer and less severe problems with secondary conditions. Number of secondary conditions was decreased for the treatment group post treatment (p<0.01).

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

 

 

Liusuwan et al. 2007

USA

Pre-post

NInitial=20; NFinal=14

 

 

Population: SCI=14; Mean age=15.4 yr; Gender: males=7, females=7.

Intervention: Individuals participated in the BENEfit program which included an interactive lecture on nutrition, physical activity and participation in activity, games, prizes and other motivational techniques; parents engaged in a discussion group.

Outcome measures: Weight, body mass index (BMI), cholesterol, high- (HDL) and low-density lipoprotein (LDL), triglycerides, VO2 REST AND MAX, power output (PO), heart rate (HR), shoulder and elbow flexion and extension.

1.     There was no change in weight, BMI, cholesterol, LDL, HDL, and triglyceride levels, and HR

2.     Total lean tissue increased 2.1%.

3.     27% ↑ in VO2rest increased 27% (p<0.002); no change in VO2max.

4.     22% ↑ in POmax increased 22% (p=0.014)

5.     Aerobic efficiency increased 35%.

6.     There was an increase in peak shoulder extension (p=0.016); shoulder and elbow flexion and extension did not change significantly.

7.     Shoulder extension strength increased.

Hata et al. 2017

Japan

Observational

N=506

Population: Age groups: <49 yr=81, 50-59 yr=98, 60-69 yr=175, >70 yr=152; Gender: males=424, females=82; Time since injury: <9 yr=39, 10-19 yr=92, 20-29 yr=114, 30-39 yr=122, >40 yr=136; Level of injury: Cervical=147, Thoracic=270, Lumbar=89; Severity of injury: Not reported.

*Mean age not reported.

Intervention: Potential participants were sent a questionnaire regarding their sociodemographic variables, health related quality of life (HRQOL), dietary satisfaction and perceived food environment which they had the option to fill out and return, those that completed it were included in the study. Logistic regression models were conducted to examine the association between HRQOL/dietary satisfaction and perceived food environment.

Outcome Measures: Physical and mental summary scores from the HRQOL and dietary satisfaction and perceived food environment.

1.     HRQOL and dietary satisfaction were differentially associated with perceived food environment.

2.     Acquired dietary information was associated with both physical and mental summary scores.

3.     Mental summary score was related to price and access to food.

4.     Dietary satisfaction was positively related to access to food and access to information.

5.     Perceived food environment was positively associated with dietary satisfaction.

6.     Access to food in the household was related to mental summary score.

7.     Home-cooked meals related more to mental summary scores than physical summary scores.

Hata et al. 2016

Japan

Observational

N=625

Population: Mean age: 62.7 yr; Gender: males=625, females=0; Injury etiology: unspecified; Level of injury: cervical=183, thoracic=323, lumbar=119; Severity of injury: unspecified; Mean time since injury: 28.1 yr.

Intervention: Participants from the community were assessed via questionnaires.

Outcome Measures: Dietary Satisfaction (DS), Self-Rated Health (SRH), Social Participation (SP), Social Support (SS).

1.     Sufficient SP was reported in 67.5% of participants and sufficient SS was reported in 55.4%.

2.     High DS was reported in 26.4% of participants and high SRH was reported in 67.0%.

3.     High DS was significantly more likely in participants with SS than those without (OR=6.46, p<0.001).

4.     When compared to participants without SP and SS, high DS was significantly more likely in participants with SS, either with SP (OR=8.64, p<0.001) or without SP (OR=6.99, p<0.001).

5.     High SRH was significantly more likely in participants with SP than those without (OR=1.80, p=0.003) and in participants with SS than those without (OR=1.83, p=0.003).

6.     When compared to participants without SP and SS, high SRH was significantly more likely in those with SP but without SS (OR=1.78, p=0.43) and those with both SP and SS (OR=3.28, p<0.001).

Discussion

A study was conducted by Liusuwan et al. (2007) which investigated the effects of behavioural intervention, exercise and nutrition education to improve health and fitness in adolescents with spinal cord dysfunction as the result of myelomeningocele and SCI. Among twenty adolescent subjects, fourteen completed all testing sessions conducted prior to and after completing a 16-week intervention program. Testing included measurements of aerobic fitness, heart rate (HR), oxygen uptake, peak isokinetic arm and shoulder strength, body composition, BMI and blood work assessment which included total, HDL and LDL cholesterol and triglycerides. Participants were given a schedule of aerobic and strengthening exercises and attended nutrition education and behaviour modification sessions every other week accompanied by their parents. Results suggested that there was no significant overall change in weight, BMI or blood work. There was a significant increase in whole body lean tissue without a concomitant increase in whole body fat. Fitness measures revealed a significant increase in maximum power output, work efficiency and resting oxygen uptake. Shoulder extension strength increased. There were no significant changes in total, HDL or LDL cholesterol or triglycerides during the 16-week program.

In a cross-sectional study Hata et al. (2016) examined a Japanese chronic male SCI population about their perceptions of their social participation in the community and the social support they receive from relatives and friends, in relation to their health and dietary satisfaction. The authors reported that individuals with sufficient social participation and social support are more likely to have greater self-rated health and dietary satisfaction. Resultantly, health promotion programs should emphasize these two social determinants of health. In particular, the authors found an odds ratio of having high dietary satisfaction seven times greater for those with high social support when comparing between individuals with low social participation (OR=6.99 vs OR=1.00), and six times greater for those with high social support when comparing between individuals with high social participation (OR=8.64 vs OR=1.38).

Hata, Inayama, and Yoshiike (2017) conducted another cross-sectional study, this time investigating perceived food environment and its relationship with health-related quality of life (HRQOL) and diet satisfaction of community-dwelling SCI individuals. The perceived food environment was studied, looking at how readily available and accessible healthy food is (Hata, Inayama, & Yoshiike, 2017). HRQOL was divided into physical and mental scores, and the authors found they were differently associated with factors of food environment. Physical scores were related to: stores with safe and reliable food, dietary information in the community, and accurate diet information from the media (ORs= 1.61, 1.67, and 1.74, respectively). Mental scores were related to: balanced meals in the household, nutritious foods at reasonable prices, and acquired diet information from the community (ORs= 1.86, 1.62, and 2.30, respectively). Lastly, diet satisfaction was related to: balanced meals in the household, food information available from the family, and accurate diet information from the media (ORs= 6.50, 2.70, and 1.75, respectively). This study highlights the importance of the perceived food environment of SCI individuals and its role in HRQOL and diet satisfaction while living in the community (Hata, Inayama, & Yoshiike, 2017).

Conclusion

There is level 1b evidence (from one RCT; Zemper et al. 2003) that improved health-related behaviours are adopted following a holistic wellness program for individuals with SCI.

There is level 4 evidence (from one pre-post study; Liusuwan et al. 2007) that an education program combining nutrition, exercise and behaviour modification is effective in increasing whole body lean tissue, maximum power output, work efficiency, resting oxygen uptake and shoulder strength in persons with SCI.

There is level 5 evidence (from one observational study; Hata et al. 2016) that social participation and social support have beneficial effects on an individual with SCI’s self-rated health and dietary satisfaction.

There is level 5 evidence (from one observational study; Hata, Inayama, & Yoshiike, 2017) that the perceived food environment is associated with health related quality of life and diet satisfaction of community-dwelling SCI individuals.

  • Participation in a holistic wellness program is positively associated with improved eating and weight-related behaviours in persons with SCI.

  • A combined nutrition, exercise and behaviour modification program can help persons with SCI increase metabolically active lean tissue, work efficiency, resting oxygen uptake and strength.

  • Having a high social participation is positively associated with better self-rated health, and receiving sufficient social support is positively associated with a greater dietary satisfaction, in persons with SCI.

  • Having a positive perceived food environment is associated with higher physical and mental scores of health-related quality of life, and higher diet satisfaction in persons with SCI.