An Epidemic of Overweight

Obesity comes with a host of health issues, including increased risk for diabetes and heart disease, that may be deadly for people with SCI.

By Lori A. Wood

The battle of the bulge is tough enough for an ambulatory person to struggle with, but for those with spinal cord impairment (SCI), it can be much more difficult. Dr. David Gater Jr. director of Spinal Cord Injury Medicine at the University of Michigan, and a research physician at the Ann Arbor VAMC, can not only attest to this, he’s made a study of it.

“At the Veterans Administration hospital in Ann Arbor, we have about 300 patients, and about two-thirds of them are obese, simply using body mass index as a determination,” says Dr. Gater. “Body mass index is a measurement of weight divided by height. At the University of Michigan, we follow about 800 patients, and again, about two-thirds of them are overweight/obese, by looking at body mass index.”

Gater cautions, however, that this measurement is not a good indicator of obesity in all populations, particularly in patients with SCI. “They generally have much more fat and much less muscle on their bodies, because of the spinal cord injury,” he says. “So if you just look at body weights, it doesn’t really tell you the percentage of body fat. If anything, we are underestimating the problem”

How many patients with SCI in this country are obese? “The information is not available, at the moment,” Gater says. “In discussions with other physicians across the country, though, I’m getting similar types of numbers. Right now, we don’t have a good handle on exactly how many that is. As a ballpark figure, I’d say 60 to 70 percent of patients with SCI are obese. This is primarily because they have less muscle mass, and, because of that, their resting metabolic rate is markedly diminished. Even if they eat the same amount as an individual without SCI, they’re going to gain fat weight, because they’re only burning 50 to 70 percent as many calories at rest.”

Many other factors can account for slower rates of metabolism in people with SCI. “Data show that growth hormone levels are diminished, testosterone levels are reduced, and thyroid hormone levels may be disrupted following a spinal cord injury. All of those things could contribute to a lower resting metabolism. We try to make sure that their hormone levels are in the appropriate range.” Dr. Gater says that obesity is probably evenly distributed among men and women with SCI. “There are four times as many men with spinal cord injury as women, and so the total numbers are going to be less for women, but the incidence of obesity is about the same.”

Long-Term Consequences
As is the case with anyone else, obesity in people with SCI can have long-term health consequences. “There is evidence showing that 60 percent of patients [with SCI] are glucose intolerant, and/or, frankly, diabetic. Because of how the data have been collected, we don’t really know the incidence of heart disease for sure, but heart disease has become the primary cause of death in those with chronic spinal cord injury. With regards to cholesterol levels, generally, we do see markedly diminished high density lipoprotein, (HDL cholesterol) in this population, often with levels below 40 mg/dl, and that carries higher risk of developing heart disease.”

Patients with SCI face additional health risks from obesity that ambulatory people do not. “Particularly, overuse injuries occur with greater incidence in the shoulders, elbows, wrists and hands, because they’re using their upper extremities for mobility, propelling their chair, as well as doing transfers-tasks that ambulatory individuals use their legs for, so they’re developing degenerative changes in the upper extremities much quicker than an ambulatory population would,” Dr. Gater explains.

Watching What You Eat
Which foods should people with SCI be careful not to overindulge in? “In general, I think we can talk about sweets and fats being less desirable. Try to stay away from saturated and trans fats as much as possible. Not all carbohydrates are bad, but those with a high glycemic index (those that stimulate high blood sugar levels within 1 to 2 hours), should be avoided, such as those in white breads. Less problematic carbohydrates include wheat breads, legumes, and whole grain items. As with the regular population, you should avoid fried foods, limit added fats, such as those found in butter and margarines, and limit your high-fat snack foods,” he suggests. “Small servings of fruits and vegetables each day are good, and protein is essential, if you limit it to twenty percent of the total calories, as appropriate.”

If a person with SCI has a skin wound, such as a pressure ulcer, his or her protein needs will be greater. “Generally, rather than taking in a greater total number of calories, they should concentrate on trying to increase their protein intake, and that may require special amino acid supplements, such as arginine and glutamine, in particular. A nutrition consult would be of great benefit in these situations.”

Special considerations regarding caloric intake are important for people with SCI to recognize. “It depends on what their muscle mass and activity levels are, but in general, I would say their caloric requirements are two-thirds that of the normal population. A man of a certain age, height and weight typically requires 2,500 calories a day. If he sustained a thoracic spinal cord injury, his needs would typically drop by about a third, because of less muscle mass and hormonal changes.”

Going for the Burn
Certain calorie-burning techniques are recommended for those with SCI. “We continue to look for the most appropriate exercise for those with spinal cord injuries. There are two main areas to focus on,” declares Dr. Gater. “One is appropriate strength training, to maintain and increase muscle mass in the upper extremities. You should concentrate on those exercises that would strengthen the posterior shoulder and upper back, as well as the rotator cuff muscles, because they are more likely to preserve your shoulder function. With regard to aerobic exercise, there are several types of equipment that can be used, depending upon your preference. Arm crank or arm cycle exercise, in general, is going to be better than wheelchair propulsion, just because of the biomechanical advantages at the shoulder. We have some evidence to show that functional electrical stimulation, in which you electrically stimulate the lower extremities to exercise, can also burn calories, but we’re not sure just how effective that is yet. This will be the focus of a recently approved research project in Ann Arbor funded by the national VA Rehabilitation Research & Development program,” Dr. Gater says.

The Ann Arbor VA is currently working with the Hines VA in Chicago, Illinois and Palo Alto VA in California on a project to document the number of calories burned in different types of activity. The project began at the Hines VAMC in 2000, and was funded as a multi-site trial in April 2004. The activities being studied include what people do in their homes, in the community and some types of sports activities. “We’re putting together a compendium of physical activities for those with spinal cord injury, and determining for each activity the number of calories burned for a given period of time,” Gater says. The activities include, but are not limited to: bowling, weightlifting, arm cycling, and rolling on carpet versus rolling on tile floors.

Those with successful weight loss may shed up to two pounds per week. “That’s usually our recommendation for safe weight loss. If a person loses more quickly than that, they’re going to lose muscle mass, which will reduce their resting metabolism again. I have folks across the whole spectrum: some that have trouble losing any weight, and some that have lost up to thirty pounds successfully and have maintained the loss.”

With increasing attention being paid to the issue of obesity in those with SCI, perhaps they will one day emerge, victorious, from the battle.

Lori A. Wood is a regular contributor to Action.