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CVD appears prematurely in persons with SCI. It is the most frequent cause of death among persons surviving more than 30 years following injury and accounts for 45% of all SCI deaths (Devivo et al. 1999). Abnormalities in lipid metabolism develop shortly after injury and tend to progress over time (Bauman et al. 1992; Brenes et al. 1986; Kocina 1997; Szlachcic et al. 2001). Despite the high risk for CVD morbidity and mortality in individuals with SCI, few studies have addressed the benefits of risk reduction interventions aimed at modifiable factors and those that exist have been limited to exercise interventions. This section discusses what is known about the value of nutrition counseling in improving dyslipidemia in persons with SCI.

Table 9 Effect of Nutrition Counseling on Dyslipidemia and Cardiovascular Disease Risk

Author Year

Country

PEDro Score

Research Design

Sample Size

MethodsOutcomes
Sabour et al. 2018

Iran

RCT

PEDro=7

N=57

Population: Mean age: Not reported; Gender: males=45, females=12; Time since injury=>2 yr; Level of injury: C=9, T=41, L=7; Severity of injury: Not reported.

Intervention: Participants were randomized to a control group and a nutritional education group in which they attended a total of 5 education session over a 7-month period.

Outcome Measures: Body weight and serum concentrations of total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL), and low-density lipoprotein (LDL). Two-way repeated measure of analysis (ANOVA) was used.

1.     ANOVA showed no significant effect of the intervention on TG, TC, HDL, and LDL levels (p>0.05).

2.     Test of within subject contrast revealed no significant effect of the intervention on level of LDL (p=0.159), TC (p=0.224), TG (p=0.172) or HDL (p=0.081).

3.     Changes in TC level were not significantly different between intervention and control group (p=0.224).

4.     No significant differences in weight (p=0.64), height (p=0.10), waist circumference (p=0.92), or BMI (p=0.71) between intervention and control groups at baseline.

5.     No significant changes in weight (p=0.97) or waist circumflex (p=0.361) observed in the intervention group compared to the control group.

6.     No significant influence of nutritional education on anthropometric measurements, lipid profile, and blood pressure in patients with spinal cord injury.

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

Szlachcic et al. 2001 USA

Prospective Controlled Trial

N=222

 

Population: Gender: males=198, females=24; Level of injury: complete, incomplete; Time since injury=>2 yr.

Intervention: Subjects who had a cholesterol level >5.2mmol/L (n=86) were referred to either a dietary consultation where they were advised to modify daily intakes as follows: total fat<30% of kcal, saturated fat<10% of kcal, cholesterol<300 mg, carbohydrate=60% of kcal, or no treatment.

Outcome Measures: Total cholesterol (TC), high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL), triglycerides.

1.      TC decreased in the dietary counseling group from 6.1 mmol/L to 5.8 mmol/L (p<0.001) and slightly increased in the control group from 4.2 mmol/L to 4.3 mmol/L (p=0.006).

2.      LDL was reduced from 4.1 mmol/L to 3.9 mmol/L (p=0.004) in the dietary counseling group; there was no change for controls.

3.      Neither group experienced significant changes in HDL or triglyceride values.

Koutrakis et al. 2018

USA

Observational

N=174

Population: Mean age=57.6±12.4 yr; Gender: males=141, females=33; Time since injury=20.9±12.9 yr; Level and Severity of injury: Cervical motor complete and AIS C=40, Other motor complete and AIS C=65, AIS D=69.

*Level and severity of injury reported such that neither could be extracted independent of one another.

Intervention: Participants completed food frequency and health questionnaires, gave blood samples and had percent total body fat measured via dual x-ray absorptiometry (DXA). Linear regression models were conducted to evaluate cross-sectional relationships between personal, lifestyle, and nutritional factors with blood plasma levels of 25-hydroxyvitamin D [25(OH)D].

Outcome Measures: Dietary factors, lifestyle factors, clinical factors, and 25(OH)D.

1.     Statistically significant positive association between 25(OH)D and total vitamin D intake, age, years of education, total calcium intake, wine consumption, total hours of planned exercise, female sex, white race, non-smokers, and users of sunscreen (p<0.05).

2.     No significant relationship between 25(OH)D and SCI level of injury, completeness of injury, body mass index, % total body fat, mobility mode, comorbid medical conditions, time outside between sunrise and sunset or season (p>0.05).

3.     A multivariable model showed age, total vitamin D intake, total hours of planned exercise, sex, race, wine use, and smoking status remained statistically significantly associated wit 25(OH)D.

4.     Race and total vitamin D intake were the most statistically significant predictors (p<0.0001).

5.     Impacts of supplementary vitamin D intake was statistically significant (p<0.0001) whereas dietary vitamin D intake was not (p=0.305).

6.     In a univariable model, stretching, range of motion, and physical therapy was not significantly associated with 25(OH)D.

Javidan et al. 2017

Iran

Observational

N=265

 

Population: Mean age=36.2±10.8 yr; Gender: males=217, females=48; Time since injury: Not reported; Level of injury:  paraplegia=157, tetraplegia=108; Severity of injury: AIS A=132, B=133, C=0, D=0.

Intervention: Participants completed 24-hour dietary recalls with a Nutritionist IV 3.5.3. for analysis.

Outcome Measures: Dietary intakes (Amino Acids, Fasting plasma glucose (FPG), Triglyceride (TG), Systolic blood pressure (SBP), diastolic blood pressure (DBP), Total cholesterol (TC), High-density lipoprotein (LDL), and Low-density lipoprotein (LDL).

1.     Majority of the participants in the study showed low protein intake (<1.5 g/kg when 1.5-2 g/kg is recommended).

2.     Higher intake of isoleucine associated with higher levels of FPG (p=0.007), TG (p=0.014), SBP (p=0.012) and DBP (p=0.04).

3.     Dietary intake of lysine was positively related to levels of FPG (p<0.0001), TG (p=0.046), SBP (p=0.002) and DBP (p=0.009).

4.     A significant positive relationship observed between intake of cysteine an levels of TG (p=0.027) and SBP (p=0.048).

5.     FPG was significantly positively related to intake of all amino acids except Cysteine, Glutamic acid, Threonine, Leucine, and Histidine (p<0.05).

6.     TG was significantly higher among men (p=0.015), significantly higher in those with incomplete SCI (p=0.016), and significantly higher in those with paraplegia (p=0.035).

7.     Blood pressure (BP) was significantly higher in quadriplegics (p<0.0001).

8.     Older participants had significantly higher SBP (p<0.0001) and DBP (p<0.0001).

9.     Higher SBP (p=0.002) and DBP (p=0.001) seen in those with higher total energy intake.

10.   BP significantly higher in those with higher carbohydrate and cholesterol intake (p<0.05).

11.   Higher tryptophan intake associated with lower SBP (p=0.03).

12.   Significant correlation between glutamic acid and SBP (p=0.007) and DBP (p=0.006).

13.   Low BP associated with higher lysine/arginine ratio: SBP (p=0.009) and DBP (p=0.01).

14.   Women had significantly higher HDL (p<0.0001).

15.   Age was significantly positively related to TC (p=0.015) and LDL (p<0.0001).

16.   Weight was significantly positively related to TC (p<0.0001) and LDL (p<0.0001).

17.   Higher BMI significantly related to TC (p<0.0001) and LDL (p<0.0001).

Discussion

Sabour et al. (2018) conducted a high-level RCT to examine the efficacy of a nutritional education program on SCI patients’ body lipid profile and body weight. There was no significant difference in lipid profile levels (total cholesterol (p=0.224), triglyceride (p=0.172), low density lipoprotein cholesterol (p=0.107) high-density lipoprotein cholesterol (p=0.081) when comparing the intervention group receiving the nutritional education to the control group. Furthermore, there were no significant weight or waist circumflex changes between the two groups. Thus, study authors concluded that the nutritional education program alone was not adequately effective to have a beneficial influence on weight and lipid profile in patients post-SCI. The authors comment on the short duration of the seven-month study as being a potential factor for the insignificant results, as well as the small sample size of 57 participants. This study did not take into consideration caregiver involvement in eating for the patients studied. Persons with SCI are substantially limited in mobility, and thus caregivers play a large role for feeding (Sabour et al. 2018), which was not evaluated in this study, but may have changed the outcomes.

Szlachcic et al. (2001) evaluated the effects of dietary education for individuals with SCI at least two years post-injury who had moderately elevated total cholesterol levels (>5.2mmol/L) and reported significant decreases in total and low-density lipoprotein cholesterol (LDLC). Individuals who were assessed at baseline as having total cholesterol values >5.2 mmol/L (200 mg/dL) were referred to the staff registered dietitian for counseling. Specifically, individuals were advised to limit daily fat intake to <30% of total daily calories (kcal), daily saturated fat intake to<10% of daily calories, daily cholesterol intake to<300 mg and to consume 60% of total daily calories as carbohydrate. Subjects in the treatment group were seen by a dietitian at least twice to assess their dietary compliance. The remaining 136 subjects (control group) did not receive nutrition consultation. Subjects in the treatment group were significantly older and were a greater number of years post injury than those in the control group; therefore, changes in lipid profile were analyzed controlling for differences in age and duration post-injury. A greater number of individuals in the treatment group demonstrated a significant decrease in TC (69%) compared to the control group (43%). These declines were also demonstrated for LDL in the treatment and control group (67% versus 47%, respectively). There were no significant changes in HDL for either group although one third of all subjects in both groups had HDL values below the recommended range at baseline. Finally, 60% of the treatment group and 45% of control group had declines in triglycerides levels.

In a cross-sectional, observational study bu Kourtrakis et al. (2018), 174 chronic SCI patients were studied to determine dietary, lifestyle and clinical factors associated with plasma 25-hydroxyvitamin D [25(PH)D] levels. Answers from the food frequency questionnaire (FFQ) were converted to daily intake of various nutrients. Independent factors positively associated with higher plasma 25(OH)D included vitamin D intake, age, hours of planned exercise, female sex, white race, wine consumption, and if a never or former smoker. The most important predictor of 25(OH)D was supplement intake. The majority of subjects (98.9% for vitamin D and 74.1% for calcium) did not meet the recommended daily allowance for adults from their diet alone. Level and completeness of SCI, injury duration, mobility, % total body fat, time outside, and comorbid diseases were not associated with plasma 25(OH)D (Kourtrakis et al, 2018). It was concluded that plasma 25(OH)D level in chronic SCI patients is not associated with clinical factors specific to SCI such as injury level and completeness, injury duration, and mobility mode, but related to supplement intake and other lifestyle factors.

Javidan et al. (2017) evaluated the probable effect of dietary amino acid intake patterns on serum lipid profiles and BP in chronic SCI participants. Dietary intakes were assessed by recording consumed foods by 24-hour dietary recall interviews. Dietary intake of lysine was positively related to levels of fasting plasma glucose (FPG), triglyceride (TG), systolic blood pressure (SBP) and diastolic blood pressure (DBP) (p<0.0001, 0.046, 0.002 and 0.009, respectively). There was a positive significant relationship between the intake of cysteine and levels of TG and SBP as well (p= 0.027 and 0.048, respectively). Higher intakes of threonine and leucine had a negative relationship with TG level (p=0.001 and 0.026, respectively). Furthermore, tyrosine, threonine and leucine were inversely correlated to blood pressure. Total cholesterol level was only related to intake of threonine and leucine (p=0.004 and 0.012, respectively). FPG was positively associated with intake of all amino acids except for cysteine, glutamic acid, threonine, leucine and histidine.

Conclusion

There is level 1b evidence (from one RCT; Sabour et al. 2018) that a nutritional education program alone does not influence body weight or lipid profile compared to a control group.

There is level 2 evidence (from one prospective controlled trial; Szlachic et al. 2001) that standard dietary counseling (total fat<30% of kcal, saturated fat<10% of kcal, cholesterol<300 mg, carbohydrate 60% of kcal) can reduce total and low density lipoprotein cholesterol among individuals with SCI who have total initial cholesterol >5.2 mmol/L.

There is level 5 evidence (from one observational study; Kourtrakis et al. 2018) that plasma 25(OH)D level in chronic SCI patients is not associated with clinical factors specific to SCI.

There is level 5 evidence (from one observational study; Javidan et al. 2017) that dietary intake of lysine may positively relate to levels of FPG, TG, SBP and DBP); intake of cysteine may positively relate to levels of TG and SBP; higher intakes of threonine and leucine may have a negative relationship with TG level; tyrosine, threonine and leucine may be inversely correlated to BP. However, these correlations may be due to an increase in total calories.

  • Dietary counseling alone does significantly improve results in lipid profile; consultation with a registered dietitian should be obtained as individualized diets may enhance compliance.

  • Dietary intake of plasma 25(OH)D is not associated with clinical factors specific to SCI; however dietary intake of amino acids may impact serum lipid profile and BP in chronic SCI patients.