Diet in neurogenic bowel management: A viewpoint on spinal cord injury

Abstract

The aim of this review is to offer dietary advice for individuals with spinal cord injury (SCI) and neurogenic bowel dysfunction. With this in mind, we consider health conditions that are dependent on the level of lesion including skeletal muscle atrophy, autonomic dysreflexia and neurogenic bladder. In addition, SCI is often associated with a sedentary lifestyle, which increases risk for osteoporosis and diseases associated with chronic low-grade inflammation, including cardiovascular and chronic kidney diseases. The Mediterranean diet, along with exercise and dietary supplements, has been suggested as an anti-inflammatory intervention in individuals with SCI. However, individuals with chronic SCI have a daily intake of whole fruit, vegetables and whole grains lower than the recommended dietary allowance for the general population. Some studies have reported an increase in neurogenic bowel dysfunction symptoms after high fiber intake; therefore, this finding could explain the low consumption of plant foods. Low consumption of fibre induces dysbiosis, which is associated with both endotoxemia and inflammation. Dysbiosis can be reduced by exercise and diet in individuals with SCI. Therefore, to summarize our viewpoint, we developed a Mediterranean diet-based diet and exercise pyramid to integrate nutritional recommendations and exercise guidelines. Nutritional guidelines come from previously suggested recommendations for military veterans with disabilities and individuals with SCI, chronic kidney diseases, chronic pain and irritable bowel syndrome. We also considered the recent exercise guidelines and position stands for adults with SCI to improve muscle strength, flexibility and cardiorespiratory fitness and to obtain cardiometabolic benefits. Finally, dietary advice for Paralympic athletes is suggested.

Keywords: Body composition; Food–drug interactions; Mediterranean diet; Microbiota; Neurogenic bowel dysfunction; Paralympic athletes.

Figure 1

Mediterranean diet based and exercise pyramid for individuals with spinal cord injury. Dietary advice from the previous indications for veterans[70], individuals with spinal cord injury with or without neurogenic bowel dysfunction[14,36,50,63,69,73], chronic kidney disease[71], chronic pain[72] and irritable bowel syndrome[18]. ¹Limit/avoid: Potential undeliverable effects[11,36,79,94-96]; ²Exercise recommendations, derived from the integration of two recent papers[101,102] devoted to adults with spinal cord injury, are aimed to improve muscle strength, cardiorespiratory fitness, flexibility and cardiometabolic health. As a general rule, the exercise intensity should progress with time from moderate to vigorous at a rate (weeks-months) dependent from the initial level of fitness of the individual. However, personalized training is deliverable associated with sport-type-targeted nutritional recommendations (including timing and supplementation) for Paralympic athletes[64]; ³Personalized energy and nitrogen balance[50,64]: Ideal body mass 10%-15% and 5%-10% lower that for quadriplegia and paraplegia, respectively; Energy: 22.7 kcal/(kg·d) and 27.9 kcal/(kg·d) for quadriplegia and paraplegia, respectively and 30-40 kcal/(kg·d) in the presence of pressure ulcers; Proteins: Stage II pressure ulcers: 1.2-1.5 g/(kg·d), Stage III and IV pressure ulcers: 1.5-2.0 g/(kg·d); Paralympic athletes: 1.2-1.7 g/(kg·d); ⁴Low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols: Banana, blueberry, strawberry, grape, melon, kiwi, cucumber, eggplant, green beans, lettuce, spinach, chives, pumpkin, tomato, zucchini. Cranberry juice may be associated with reduced urinary tract infection but could induce food-drug interactions, which can be observed also with other foods and beverages (conditional exclusion)[70,90]. BM: Body mass; w-3 PUFA: Omega-3 polyunsaturated fatty acids; CHO: Carbohydrates; FODMAP: Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols.