Optimising cardiometabolic health

In people with spinal cord injury (SCI), optimising cardiometabolic health involves addressing and managing modifiable risk factors. These are summarised in the diagram below:

Regular health checks with a General Practitioner (GP) in conjunction with support from a multidisciplinary health care team including dietitians, nurses, physiotherapists, exercise physiologists and psychologists is recommended.

Farkas, Gary J., Adam M. Burton, David W. McMillan, Alicia Sneij, and David R. Gater, Jr. 2022. “The Diagnosis and Management of Cardiometabolic Risk and Cardiometabolic Syndrome after Spinal Cord Injury” Journal of Personalized Medicine 12, no. 7: 1088. https://doi.org/10.3390/jpm12071088

To optimise cardiometabolic health, consider the following:

As energy needs are significantly reduced following SCI, implement weight gain prevention strategies early. For individuals who are obese, explore motivation to engage in healthy eating and lifestyle changes. Dietary modification paired with physical activity is recommended as a first line treatment strategy for obesity.

Other treatment options include pharmacotherapy and surgical interventions. Approved prescription medicines such as glucagon-like peptide-1 (GLP-1) agonists appear safe for people with SCI but are yet to be evaluated in larger-scale research trials. Advise against unsupervised use of over-the-counter herbal anorexigenics, diuretics and nutrient uptake inhibitors. Bariatric surgery can be considered as a last resort. If proceeding, an SCI specialist should be involved before, during and after surgery to assist with risk minimisation.

Blood pressure should be measured at each GP appointment, or at least annually. A blood pressure of 140/90 mmHg is a reasonable threshold for treatment, but can be individualised given blood pressure variation within the SCI population. Consider the potential impact of autonomic instability with pharmacotherapy treatment, such as postural hypotension. Autonomic dysreflexia should be considered if there acute increases in blood pressure.

For people with SCI who have hypertension, a Mediterranean dietary pattern or the Dietary Approaches to Stop Hypertension (DASH) diet may be additionally beneficial.

Monitoring of fasting lipids (total cholesterol, triglycerides, low-density lipoprotein [LDL] and high-density lipoprotein [HDL]) should occur at least every three years if results are normal. However, people with abnormal results should be assessed annually. Pharmacotherapy and dietary modification should both be considered to address dyslipidaemia.

Monitoring of fasting glucose and/or glycated haemoglobin (HbA1c) should occur at least every three years if results are normal. People with abnormal results should be assessed more frequently. Metformin is the initial preferred treatment if not contraindicated, but may change bowel patterns in people with SCI. Dietary modification is also an important consideration as it can improve blood glucose control and insulin sensitivity.

Assess use of tobacco and other substances. Encourage cessation and offer referral to established support services.

Explore physical activity levels. Refer to a physiotherapist or exercise physiologist who can provide support with strategies to maximise physical activity.

Optimising diet quality can have wide-ranging benefits and result in improved blood pressure, cholesterol, insulin sensitivity and weight control. Refer to an Accredited Practising Dietitian who can provide support with making positive dietary changes.

Assess alcohol intake and encourage consumption within national guidelines, which are:

No more than 10 standard drinks per week
No more than 4 standard drinks in a single day

Over time, alcohol intake in excess of national guidelines can lead to a number of serious health conditions, including hypertension and an increased risk of heart attack and stroke. In people with SCI, alcohol can also interfere with the ability to perform activities of daily living such as safely mobilising in a wheelchair, performing transfers, pressure relief, bladder and bowel management. For some people, not drinking at all may be the safest option.

Support from a psychologist can optimise psychosocial health and facilitate sustained changes to diet and lifestyle habits.

References and resources

Australian Government (2022): Guidelines on Alcohol Intake

Australian Prescriber (2019): Blood pressure: at what level is treatment worthwhile?

Benton B, McIntyre A, Blackport D, Muise S, Ditor D, Teasell R. (2019). Nutrition Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Noonan VK, Loh E, Sproule S, McIntyre A, Querée M, editors. Spinal Cord Injury Rehabilitation Evidence. Version 8.0. Vancouver: p 1-73.

Farkas GJ, Burton AM, McMillan DW, Sneij A, Gater DR Jr. The Diagnosis and Management of Cardiometabolic Risk and Cardiometabolic Syndrome after Spinal Cord Injury. J Pers Med. 2022 June;12(7):1088.

Kressler J, Cowan RE, Bigford GE, Nash MS. Reducing cardiometabolic disease in spinal cord injury. Phys Med Rehabil Clin N Am. 2014 Aug;25(3):573-604,

Nash MS, Groah SL, Gater DR Jr, Dyson-Hudson TA, Lieberman JA, Myers J, Sabharwal S, Taylor AJ; Consortium for Spinal Cord Medicine. Identification and Management of Cardiometabolic Risk after Spinal Cord Injury: Clinical Practice Guideline for Health Care Providers. Top Spinal Cord Inj Rehabil. 2018 Fall;24(4):379-423.

Nutritional Education materials online (NEMO) (2021): Mediterranean diet

Nutrition Education Materials Online (NEMO) (2020): Healthy Dietary Patterns

Royal Australian College of General Practitioners (2015): DASH diet to prevent and control hypertension.

Shojaei MH, Alavinia SM, Craven BC. Management of obesity after spinal cord injury: a systematic review. J Spinal Cord Med. 2017 Nov;40(6):783-794.

SStojic S, Eriks-Hoogland I, Gamba M, Valido E, Minder B, Chatelan A, Karagounis LG, Ballesteros M, Díaz C, Brach M, Stoyanov J, Diviani N, Rubinelli S, Perret C, Glisic M. Mapping of Dietary Interventions Beneficial in the Prevention of Secondary Health Conditions in Spinal Cord Injured Population: A Systematic Review. J Nutr Health Aging. 2023;27(7):524-541.

Warbuton DER, Krassioukov A, Sproule S, Eng JJ. Cardiovascular health and exercise following spinal cord injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC et al, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6, 2018 p. 1-68.