People with spinal cord disorders are likely to have to take extra care of what they eat to keep the digestive system running smoothly.
By Melody Chavez, RD
“Are you having any problems with diarrhea or constipation?” “Have there been any changes in your eating habits?” “How much water are you drinking a day?”
As a dietitian, these are common questions I ask my patients when conducting a nutrition assessment. Discussing what types of foods they consume at each meal helps to determine if they are receiving adequate fiber. The effects of their current fiber intake can impact the consistency of stool and the frequency of evacuation.
Most people don’t want to discuss their bowel movements. However, this important body function is an essential part of health care after a spinal cord injury. (SCI)
Comparative Digestion
Your bowels, also called the large intestine, are the lower parts of your digestive system. Digestion begins in the mouth and stomach, changing food that we eat into a form that can be carried through the bloodstream to different parts of the body. Each day about 2 quarts (1.9 liters) of food and liquids pass through our body. They can stay for several days in your bowels, where your body absorbs water and salts. As water is absorbed, the digested food becomes more solid. This material is called stool. The stool moves into the last part of the large intestine. As the bowel stretches, nerves send two messages to the body. One message tells the muscles to move the stool down through the bowel. The other message lets the brain know it is time to void the bowel by controlling the muscle at the opening of the rectum (anus).
After a SCI, the way the bowels work changes due to paralysis. The messages sent between your brain and bowel cannot reach one another as they did before your injury. Due to the interruption of nerve pathways from the brain to the gastrointestinal or “GI” system, the time for food to move through the gut is slower. When this occurs your doctor may diagnose you with a neurogenic bowel.
Neurogenic bowel is a condition resulting in a loss of bowel function caused by damage to the nerves that control the ability to eliminate stool from the body. Neurogenic bowel dysfunction is common in patients not only with SCI, but also with amyotrophic lateral sclerosis, spina bifida, multiple sclerosis, and diabetes mellitus. Other neurologic conditions such as stroke, traumatic brain injury, and brain tumors may secondarily cause abnormal bowel function, mostly in the form of constipation and incontinence.
Depending on your injury, the upper motor neurons (UMN) or lower motor neurons (LMN) will be affected. The UMN are located in your spinal cord. When an injury occurs above L12, this is called an upper motor neuron injury. Your brain does not receive the message telling you the bowel is full with this type of injury. Injuries below L12 are called a lower motor neuron injuries. The LMN are nerves that branch out from the spinal cord and carry messages to and from the spinal cord and other body parts and organs. Messages may not get to the spinal cord so the reflexes do not work normally. As a result your anal muscles stay relaxed.
Managing a lower motor neuron bowel tends to be more problematic than upper motor neuron bowel.
Nutrition Intervention in Bowel Care
Most people with SCI can learn how to control their bowel function with a bowel program.
A balanced diet adequate in fiber, which is the indigestible portion of plant food, is essential for a bowel care program to work for you. Fiber pushes food through the digestive system, absorbing water and easing defecation. Dietary fiber can be soluble or insoluble. Soluble fiber is able to dissolve in water. It absorbs liquids in the digestive tract to form a stabilizing gel that prevents both diarrhea and constipation. Insoluble fiber does not dissolve in water. It passes through your intestines intact and can promote regular bowel movements and prevent constipation.
Health professionals advise that adults eat at least 25-35 grams of fiber each day. The Clinical Practice Guidelines developed by the Consortium of Spinal Cord Medicine suggest that persons with SCI start with no less than 15 grams of fiber per day and gradually increase. Symptoms of intolerance such as bloating or abdominal discomfort may suggest that you need to reduce your fiber intake. If you start to experience constipation or diarrhea, discuss your fiber intake with your doctor and/or dietitian.
Eating high-fiber foods such as fruits, vegetables, whole grains and legumes may help to soften your stool, making it easier for it to pass through the intestines. They also make the stool bulkier, which stimulates movement of the bowel. Loose stools and incontinence can occur if high fiber foods are eaten only on occasion. For that reason, a gradual increase in fibrous foods should be incorporated into your diet until the stool is soft and formed.
We can’t discuss fiber without discussing water. The two work as a team in the body! Adequate water in the diet is also essential to help prevent impaction. Fiber can become like cement in your bowels, if you do not drink enough fluids. The Consortium of Spinal Cord Medicine suggests a fluid intake of 500 ml/day (17 ounces) more a day. This is more fluid than the guidelines from the National Research Council suggests for the general public. One study, which was published after the Consortium of Spinal Cord Medicine guidelines, reported that a fluid intake of 1.5 liters (50 ounces) per day resulted in significant improvements in bowel function. It is essential to choose a bowel care program that fits your lifestyle. Eating a balanced diet with foods high in fiber and adequate hydration will help prevent problems before they start. So it looks like the old phrase “an apple a day, keeps the doctor away” may just be what we need to keep a healthy, happy bowel!
Tips to add fiber into your diet:
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• Eat raw fruits and vegetables as often as possible. The skins of fruits are rich sources of fiber.
Boiling them too long can cause half of the fiber to be lost!
• Start your day with a bowl of high-fiber cereal. Read food labels to find whole-grain breakfast cereals with 5 or more grams of fiber per serving.
• Add fruit to your cereal. This can add 1-2 more grams of fiber.
• Add beans to salads, soups and stews. Beans are loaded with fiber and protein.
• Buy and eat whole grain. Look for “whole” when reading the ingredient panel. Choose whole wheat pasta instead of white.
• Eat fruit and vegetables as snacks in-between meals or toss in extra vegetables in dishes you make.
• In a hurry, make a smoothie with fresh fruit and yogurt as a quick breakfast or a snack.
• Substitute whole wheat or oat flour for up to half of the flour in pancake, waffle, muffin or other flour-based recipes.
• Good rule of thumb, increase your water intake as you increase your fiber in your diet!
References:
Consortium for Spinal Cord Medicine. Neurogenic Bowel Management in Adults with Spinal Cord Injury: Clinical Practice Guidelines for Health-Care Professionals. Washington,DC: Paralyzed Veterans of America, 1998.
Badiali, D., Bracci, F., Castellano, V., Corrazziari, E., Fuoco, U., Habib, FI., and Scivoletto, G. Sequential treatment of chronic constipation in paraplegic subjects. Spinal Cord 1997; 35: 16-120.
Melody Chavez, RD, is a Clinical Dietitian at the Tampa Department of Veterans Affairs Medical Center.
