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  1. Can-SCIP
  2. Recommendations
  3. Guidelines
  4. Section 2 - MANAGEMENT OF SCI COMPLICATIONS

N - CARDIOMETABOLIC




N.1.1
Clinicians should evaluate all adults with SCI for cardiometabolic disease at the time of rehabilitation discharge. For those already discharged from rehabilitation, evaluate for cardiometabolic disease at the earliest opportunity and at three-year intervals. (Adapted from NASH 2018, p.402; Level C)
N.1.2
Clinicians are recommended to use the American Heart Association (AHA) definition and the five constituent hazards of obesity, insulin resistance, dyslipidemia (including individual risks of low high-density lipoprotein cholesterol (HDL-C) and elevated triglycerides (TG), and hypertension)), as cardiometabolic disease risk components for individuals with SCI. (Adapted from NASH 2018, p.402; Level C)


N.2.1
Clinicians should introduce all individuals with SCI to adapted physical activity throughout their lifespan, regardless of prior participation in physical activity. Behaviour change interventions may facilitate physical activity participation. (CAN-SCIP 2020; Level B)
N.2.2
Individuals with SCI should exercise regularly according to their ability and follow the exercise recommendations provided in the Canadian SCI Physical Activity Guidelines (version 2). Consider arm ergometry and upper extremity resistance training as a way to improve cardiometabolic health. Canadian SCI Physical Activity Guidelines: https://doi.org/10.1038/s41393-017-0017-3 (Adapted from Nash 2018, p.408; Level C)
N.2.3

Individuals living with SCI should engage in at least: 20 minutes of moderate to vigorous-intensity aerobic exercise 2 times per week AND 3 sets of strength exercises for each major functioning muscle group, at a moderate to vigorous intensity, 2 times per week to improve cardiorespiratory fitness and muscle strength. (GINIS 2017, p.16; Level A)

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N.3.1
A registered dietitian should assess individuals with SCI for age, ethnicity, gender, time since injury, level of injury, activity level, dietary habits, smoking behaviour, alcohol intake, and weight status as these factors are associated with abnormal blood lipids, particularly decreased HDL cholesterol. (Adapted from NUTR 2009, p.10; Level A)
N.3.2
Consider establishing caloric targets and consider indirect calorimetry, if available, to estimate energy expenditure and assess energy needs. If not available, clinicians should consult a dietician and use caloric diaries. (CAN-SCIP 2020; Level C)
N.3.3

Clinicians may consider instituting the following nutritional measures in the post-acute period:

  1. For all individuals with SCI, adopt a heart-healthy nutrition plan focusing on fruits, vegetables, whole grains, low-fat dairy, poultry, fish, legumes, non-tropical vegetable oils and nuts while limiting sweets and sugar-sweetened beverages, and red meats
  2. Adopt the Dietary Approach to Stopping Hypertension (DASH) nutritional plan or Mediterranean nutritional plan if hypertension or additional cardiometabolic risk factors are present. DASH Nutritional Plan: https://www.heartandstroke.ca/get-healthy/healthy-eating/dash-diet
(Adapted from NASH 2018, p.407; Level C)
N.3.4

A registered dietician treating individuals with SCI living in a community setting should have SCI-specific nutrition and energy needs expertise and knowledge to conduct a nutrition assessment as part of the annual medical exam to develop and implement an individualized therapeutic nutrition plan. The nutrition assessment should include but is not limited to:

  1. Food and nutrition-related history (specifically knowledge deficits, beliefs and attitudes, body image, mealtime behaviours, physical ability to self-feed, access to food- and nutrition-related supplies, meal preparation and food avoidances)
  2. Anthropometric measurements (specifically body composition and weight)
  3. Biochemical data, medical tests and procedures (specifically serum lipid and glucose levels)
  4. Social history (specifically isolation)
  5. Nutrition-focused physical findings (specifically bowel and bladder function).
(NUTR 2009, p.6; Level B)
N.3.5
An annual nutrition assessment by a registered dietitian should be conducted to identify nutrition-related concerns that may affect the health and quality of life of individuals living with SCI. (NUTR 2009, p.6; Level B)


N.4.1
The registered dietitian should assess the weight and body composition of the individual with SCI and adjust energy levels or implement weight management strategies as appropriate. See Nutrition Assessment recommendations for methods to determine weight and energy needs, and American Dietetic Association Adult Weight Management Evidence-based Nutrition Practice Guideline (https://www.andeal.org/vault/pqnew132.pdf) for methods to manage weight and obesity. (NUTR 2009, p.25; Level A)


N.5.1

Clinicians may consider assessing individuals with SCI for obesity beginning at discharge from rehabilitation:

  1. Where possible, measure body composition using 3- or 4-compartment models to report obesity in adults with SCI until validated, clinically appropriate equations become available. Classify adult men with >22% body fat and adult women with >35% body fat as obese and at high risk for cardiometabolic disease.
  2. A body mass index (BMI) ≥22 kg/m2 is the cut-off point when used as a surrogate marker for obesity in individuals with SCI. Adult men and women with BMI ≥22 kg/m2 are at high risk for cardiometabolic disease. Test at least every three years following initial assessment when tests are normal in asymptomatic adults with SCI.
(Adapted from Nash 2018, p.402; Level C)


N.6.1
Clinicians should consider adopting the Canadian Heart and Stroke Guideline as the primary method of assessment for blood pressure measurement in individuals with SCI. Measure blood pressure at every routine visit and at least annually. (Adapted from NASH 2018, p.403; Level C)


N.7.1
Clinicians should use the Canadian Heart and Stroke Guideline for treating hypertension in the general population for treating individuals living with SCI. (Adapted from NASH 2018, p.412; Level C)
N.7.2
Clinicians should consider SCI-related factors when selecting an antihypertensive agent, such as the effect of thiazide diuretics on bladder management. Orthostatic hypotension is a known side effect of anti-hypertensive treatments. (NASH 2018, p.413; Level C)


N.8.1
Clinicians may consider screening adults with SCI for diabetes and pre-diabetes and repeat testing yearly if tests are normal. (Adapted from NASH 2018, p.402; Level C)
N.8.2
Adopt the Diabetes Canada clinical practice guideline to diagnose diabetes and pre-diabetes based on either fasting plasma glucose (FPG), the 2-hour plasma glucose (2hPG) value after a 75-g oral glucose tolerance test (OGTT), or A1C criteria. (Adapted from NASH 2018, p.403; Level C)


N.9.1
Primary care physicians and/or physiatrists should routinely conduct screening for lipid abnormalities for all individuals with SCI living in the community to reduce morbidity and mortality. Individuals with SCI have a higher incidence and a higher prevalence of earlier onset of cardiovascular disease. (Adapted from NUTR 2009, p.4; Level B)
N.9.2
Perform annual screening of individuals with SCI in the presence of multiple risk factors or when evidence of dyslipidemia is confirmed, or treatment is initiated. (NASH 2018, p.404; Level C)


N.10.1
Guide patient selection for pharmacotherapy by other factors commonly seen in SCI, such as low levels of HDL-C. Initiate statin monotherapy using at least a moderate-intensity statin (e.g., rosuvastatin 10–20 mg/day). Refer to the Canadian Heart and Stroke Guideline when initiating statins. (Adapted from NASH 2018, p.411; Level C)


N.11.1

Clinicians should use a threshold of risk for HbA1c levels greater than 7% as a criterion to emphasize lifestyle intervention. (Adapted from NASH 2018; p.410; Level C)

Diabetes Canada Clinical Practice Guideline: http://guidelines.diabetes.ca/docs/CPG-2018-full-EN.pdf



N.12.1
Consider bariatric surgery as a last resort for individuals with morbid obesity and SCI due to the significant peri- and postoperative risks. If bariatric surgery is considered, an SCI clinician should provide preoperative, perioperative, and postoperative consultative services to the surgical and anesthesia teams to alert them to unique risks associated with SCI. In individuals with morbid obesity in SCI who have failed available options for weight loss, refer to a bariatric program to assess alternate treatments and appropriateness for surgery. (Adapted from NASH 2018, p.414; Level C)


N.13.1
Nutritional support of individuals with SCI is recommended as soon as feasible. It appears that early enteral nutrition (initiated within 72 hours) is safe but has not been shown to affect neurological outcomes, the length of stay, or the incidence of complications in individuals with acute SCI. (CNS- NUT 2013, p.22; Level C)