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Over the past several years, numerous news articles and media presentations have depicted concern over the increased rate of obesity in the USA. Increased waist circumference and body mass index (BMI) are associated with metabolic syndrome and the development of type II diabetes along with other adverse health risks. In the obese, the risk of acute coronary syndrome is increased, along with the incidence of hypertension. Increased waist circumference alone has been found associated with increased mortality.Citation1 Of interest are findings demonstrating that increased waist circumference and BMI are associated with decreased levels of physical activity and not caloric intake per se.Citation2
This presents a potential negative overtone for those with spinal cord injury (SCI). Individuals with SCI are at increased risk for the development of adverse consequences known to be associated with immobility. Immobility leads to a decrease in lean muscle mass, and an increase in adipose tissue. In turn, metabolic disruptions associated with SCI are tied in with an increase in insulin resistance and apparent dyslipidemia.Citation3 There is evidence that individuals with SCI present a unique risk for the development of coronary heart disease.Citation4
In the face of this risk, it is apparent that measures of waist circumference and BMI would be helpful in evaluating patients with SCI due to decreased activity level concomitant with a loss of lean muscle mass.Citation5 Yet, questions remain as to whether these parameters are appropriate for evaluating health in those with SCI.Citation6 It is possible that BMI may even underestimate the degree of adipose tissue in those with tetraplegia.Citation7 There is then a need to further understand issues of body composition in those with SCI. In this issue, Beck et al.Citation8 provide such clarification in the article entitled “Body Composition of Women and Men with Complete Motor Paraplegia”.
The findings of Beck et al. demonstrate that body composition in those with SCI is a more complex parameter than it appears at first blush. While there was an increase in total body fat mass in those with paraplegia in comparison to controls, the BMI of those with a SCI was actually less that of controls. The decrease in total lean mass in the lower extremities was somewhat offset by an increase in upper body lean mass. The authors provide a conclusion that the daily use of manually propelled wheelchairs provides a level of activity that contributes to the development of upper body lean muscle mass. This is supported by other work demonstrating that upper body exercise appears to have a beneficial effect on body composition in those with SCI.Citation9 Any physical exercise may be beneficial to those with SCI, and can add in reducing insulin resistance and the risk of developing type II diabetes.Citation10
In this study, the authors found that BMI may well underestimate obesity in those with complete motor paraplegia. A case is made for the reevaluation of the cut scores used to establish a respective BMI score. It is possible that such scores need to be established for those with SCI. As a potential weakness, the participation in upper extremity activity was not directly measured, rather inferred from the use of manual wheelchairs.
These findings when taken into consideration with other literature on the topic demonstrate that the most common parameters of obesity, waist circumference, and BMI area is at present of limited utility in the study of adiposity in those with SCI. Alternative measures of body composition require consideration and future research. It is hoped that this study can see replication with a larger sample.
The development of clinical and research measures specific to the SCI population can help further the development of both research and care interventions. This study provides a further step in identifying factors that need to be considered in studying SCI.
In a separate note, the primary author of the study is a registered nurse. The Journal of Spinal Cord Medicine has long sought to increase representation from the nursing section, and is pleased to note the submission of this manuscript. There are a number of nursing researchers engaged in work within the field of SCI, and it is hoped that this publication is but one of many from the nursing perspective.
References
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- Ladabaum U, Mannalithara A, Myer PA, Singh G. Obesity, abdominal obesity, physical activity, and caloric intake in U.S. Adults: 1988–2010. Am J Med 2014. doi: 10.1016/j.amjmed.2014.02.026.
- Bauman WA, Korsten MA, Radulovic M, Schilero GJ, Wecht JM, Spungen AM. 31st G. Heiner sell lectureship: secondary medical consequences of spinal cord injury. Top Spinal Cord Inj Rehabil 2012;18(4):354–78.
- Demirel S, Demirel G, Tukek T, Erk O, Yilmaz H. Risk factors for coronary heart disease in patients with spinal cord injury in Turkey. Spinal Cord 2001;39(3):134–8.
- Ravensbergen HR, Lear SA, Claydon VE. Waist circumference is the best index for obesity-related cardiovascular disease risk in individuals with spinal cord injury. J Neurotrauma 2014;31(3):292–300.
- Alschuler KN, Gibbons LE, Rosenberg DE, Ehde DM, Verrall AM, Bamer AM, et al. Body mass index and waist circumference in persons aging with muscular dystrophy, multiple sclerosis, post-polio syndrome, and spinal cord injury. Disabil Health J 2012;5(3):177–84.
- Yarar-Fisher C, Chen Y, Jackson AB, Hunter GR. Body mass index underestimates adiposity in women with spinal cord injury. Obesity (Silver Spring) 2013;21(6):1223–5.
- Beck LA, Lamb JL, Atkinson EJ, Wuermser LA, Amin S. Body composition of women and men with complete motor paraplegia. J Spinal Cord Med 2014;37(4):359–65.
- Bauman WA, Spungen AM, Adkins RH, Kemp BJ. Metabolic and endocrine changes in persons aging with spinal cord injury. Assist Technol 1999;11(2):88–96.
- D'Oliveira GL, Figueiredo FA, Passos MC, Chain A, Bezerra FF, Koury JC. Physical exercise is associated with better fat mass distribution and lower insulin resistance in spinal cord injured individuals. J Spinal Cord Med 2014;37(1):79–84.