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SCI: Role of the Registered Dietitian (2007)

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

Little is known about the dietary habits of individuals with spinal cord injuries, nor how these habits impact risk for obesity and chronic diseases.  The purpose of this study was to assess nutrient intake habits, diet quality and the presence of obesity in urban, community-dwelling men with paraplegia.

Inclusion Criteria:

Inclusion criteria included:

  • Spinal cord injury from T1 or below
  • Age between 20 and 59 years
  • Be at least 1 year post-injury
Exclusion Criteria:

None specified

Description of Study Protocol:

Recruitment

Medical records were examined to identify community-dwelling men from Chicago, IL who received treatment from the Rehabilitation Institute of Chicago.  Potential participants were sent a letter describing the purpose of the study and letters were followed with a phone call.  Upon interest of participation, a clinical visit was scheduled, which followed a 10 hour fast.

Design

 Cross sectional survey

Blinding used

 Not applicable

Intervention (if applicable)

 Not applicable

Statistical Analysis

 Descriptive statistics and frequency analyses provided preliminary summary data.  Chi-square and t-test analyses were used to examine differences in outcome variables based on 2 levels of diet quality.

Data Collection Summary:

Timing of Measurements

 Clinical visits were scheduled from the recruitment calls.  All measurements were taken during the single visit, which followed a 10-hour fast.  The fast was relevant to any data reported in the current manuscript.

Dependent Variables

  • Dietary intake data were recorded using the Block Food Frequency Questionnaire
    • The questionnaire was modified to measure the past 7 days of intake
    • Options for additional foods were provided but not analyzed due to the limited additions (n=5) by the subjects
  • Nutrient estimates from the FFQ were compared to Dietary Reference Intake recommendations
    • Proportion the Estimated Average Requirement (EAR) and proportion meeting the proposed requirement were determined
    • Proportion the Adequate Intake (AI) and proportion meeting 67% of the proposed requirement were determined
  • Dietary adequacy based on federal recommendations, which included:
    • <10% of energy from saturated fat, <30% of energy from total fat, <300mg cholesterol, <2,400mg sodium
    • 3 servings of vegetables, 2 servings of fruit, 5 servings of combined fruits and vegetables, 2 servings of dairy
  • Diet Quality was computed using the USDA's Healthy Eating Index (HEI-f), which has been modified to use FFQ data
    • A Total HEI score is computed based on ten subscales (scores 0-10):
      • Total fat, saturated fat, cholesterol, sodium and variety
      • Food Guide Pyramid servings from grain, fruit, vegetable, milk and meat
    • Diet quality recoded to poor (<51), needs improvement (51-80) and good (>80).
  • Depression was measured using the Center for Epidemiological Studies Depression (CES-D) scale
    • Range of scores (0-60)
    • Depression cutoff at a score of 16
  • Nutrition knowledge measured using scale by Parmenter and Wardle
  • Body weight measured as weight of person in wheelchair minus the weight of the empty wheelchair
  • Standing height taken as height prior to injury
  • Waist circumference measured with nonelastic tape in supine position (average of three measurements)

Independent Variables

 Diet quality groups were recoded to Poor and good (needs improvement + good) dietary intakes from the HEI data.

Control Variables

 None described

Description of Actual Data Sample:

 

Initial N: (n=95 males)

Attrition (final N): N/A

Age: 38.3±10.3 years

Ethnicity: 39% White, 41.1% African American, 17.9% Latino, 2.1% Asian

Other relevant demographics:

60.6% Unemployed

Mean years since injury: 9.5±8.1 years

Injury: T1-T4 - 14%, T5-12 - 70.9%, L1 or below - 15.1%

Anthropometrics

Provided as results

Location: Chicago, IL - University of Illinois-Chicago medical campus

 

Summary of Results:

Mean Dietary Intakes

Total energy (kJ)
9478.5±3116.9
Kilojoules per kilogram of body weight
118.0±43.6
Protein (g) % kJ from protein
82.3±31.7
Total fat (g)
14.5±3.0
Saturated fat (g)
92.8±40.4
% kJ from saturated fat
28.6±12.8
% kJ from fat
11.2±2.7
Carbohydrate (g)
36.2±7.1
% kJ from carbohydrate
274.9±86.7
Fiber (g)
49.3±8.8
Cholesterol (mg)
17.1±7.3
Sodium (mg)
303.1±167.4
Iron (mg)
3058±1171.8
Calcium (mg)
15.2±5.8
Folate (mg)
755.2±373.0
Vitamin C (mg)
394.9±173.7
No. of fruit and vegetable servings
140.1±76.4
No. of vegetable servings
4.2±3.4
No. of fruit servings
2.8±1.8
No. of dairy servings  
1.4±1.0

 

 

Other Findings

Depression: Mean score 8.9±8.3 (17.9% depressed)

Nutrition Knowledge: Mean score (18.8±5.5 out of 28)

Mean BMI: 26.2±6.5

Underweight (7.4%), Overweight (56.5%), Obese (18.9%)

Mean waist circumference: 96.5±15.5 (34.5% were >102 cm)

Significant differences in HEI scores from nationally-representative sample (NHANES) for:

  • Grain servings: lower HEI score for SCI patients
  • Fruit servings: higher HEI score for SCI patients
  • Dairy servings: lower HEI score for SCI patients
  • Meat servings: higher HEI score for SCI patients
  • Percent of energy from fat: lower HEI score for SCI patients
  • Sodium intake: higher HEI score for SCI patients
  • Variety score: lower HEI score for SCI patients

Poor dietary quality was significantly associated with decreased nutrition knowledge (r=.27, P-0.007), being a smoker, low family income (r=.37, P<0.001), being African American (P=0.02), and living alone.  Among subjects with lower quality diets (ie, in the lowest HEI-f category), 52% lived alone, whereas 73% of those with better diets lived with at least 1 other person. No differences in age, years since injury, age at injury, depression, BMI, or waist circumference were found between the lowest and the upper 2 categories as assessed by t test.

Author Conclusion:

Several nutrients and intake patterns do not conform to dietary intake recommendations.  These intakes may be deleterious to chronic disease prevention in individuals with SCI.  Body mass indices and waist circumference values were also outside of recommended levels.  All of these data indicate a need for clinicians to screen, counsel and provide specific treatment goals to promote health and prevent disease.

Funding Source:
Government: USDA
Reviewer Comments:

These data represent a well-designed study to address the concern of nutritional status in the target population.  The use of a food frequency questionnaire may not be the best approach, especially considering the outcome of the HEI, which was initially designed for use with multiple 24-hour recalls.  Also, the use of 67% of the AI does not conform to assessment procedures set forth by the DRI committees.  This may represent an underestimation of an already inexact measurement of need (inherent with the AI value as "probably adequate").

Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? No
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? N/A
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? No
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? ???
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? ???
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) Yes
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? N/A
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? N/A
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? Yes
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? No
  8.6. Was clinical significance as well as statistical significance reported? No
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes