People with mobility impairments have specific dietary needs that must be taken into consideration to ensure their wellbeing – and this involves more than just watching their weight and fluid intake
To find out more I chatted to Charlene Grimsehl, a dietitian at the Netcare Rehabilitation Hospital in Johannesburg, where she has been working for the past eight years after completing her studies and community service…
I asked her to describe how, from a dietary perspective, she would approach a person who was admitted as a patient with quadriplegia. She assesses a patient with quadriplegia by carrying out a clinical evaluation: to measure the patient’s weight and hydration, and to check for pressure sores. Secondly, she looks at all the blood test results to see if the kidneys and liver still work well and if there are any nutritional or mineral deficiencies. The presence of lifestyle diseases such as diabetes, cholesterol and hypertension is also assessed. Where needed, food supplements must be incorporated into the diet.
I asked Charlene why all of this was necessary: at home we seldom really bother about being so finicky with what we eat. She explained that for persons with paralysis it is very important to establish and maintain what she calls “an ideal weight”. If patients are underweight, they do not have muscle support for their bones and this can cause bones to fracture more easily. Underweight persons develop pressure sores more easily because bones press directly against the skin, especially in areas such as the pelvis and heels. Low muscle strength also weakens those areas of the body that still function, so it is difficult for working areas to compensate for the losses experienced by paralysed limbs. For instance, to push a wheelchair requires upper body strength.
On the other hand, being overweight also presents problems. The additional weight makes moving around more difficult – for the paralysed person as well as for the caregiver. There are also potential complications such as heart attacks and strokes, and the additional weight on pressure points can lead to pressure sores.
For these reasons diet management is crucial: the paralysis prevents the patients from expending energy as well as blocking them from building strength. With the lack of exercise, diet becomes the mainstay of weight management.
Another important component of diet management is fluid intake, which helps the kidneys to work optimally. Kidney failure is one of the causes of death in persons with paralysis, yet it is easy enough to monitor fluid intake and pre-empt failure – just look at the colour of the urine. If it is too dark, more fluids are needed. (Smelly urine is not a good indication of dehydration, because many medicines can cause urine to become smelly. Also, be aware that some medicines and supplements may change the colour of the urine. Don’t confuse this with dark, concentrated urine.)
Water is the mainstay of fluid intake and at least 1,5 to 2 litres of pure water should be consumed each day, in addition to coffee or tea etc. Fizzy cool drinks, energy drinks and pure fruit juices are loaded with sugar, which can cause problems besides weight gain. We all know what happens to toddlers at kiddies’ parties. The sugar rush makes them go crazy, like Duracell bunnies. Now imagine what a sugar rush does to a person who is unable to expend that energy. Could excessive sugar be the reason why persons with paralysis become aggressive? In addition, many energy drinks contain electrolytes that replace substances lost in sweating during heavy exercise. Drinking lots of these drinks without sweating can cause a build-up of electrolytes in the body, which places strain on the kidneys. So be very careful of high-energy and high-sugar drinks. The argument that fruit juices are healthier than fizzy drinks is true – but only up to a point. Excessive kilojoule intake causes weight gain and it does not matter where the kilojules come from. Fruit juices are packed with kilojules…
If drinking pure water is unappealing, add a little sugar-free cordial, or slices of cucumber or strawberries for flavour. A good hydration formula is up to two litres of water per day, supplemented by tea or coffee in moderation and a small amount of fruit juice. Preferably stay away from energy drinks and the fizzy stuff.
Just a warning for those of us who have neurogenic bladders that we manage naturally. We have a tendency to “run dry” especially when travelling or finding ourselves in areas where toilet facilities are difficult to access. Dehydration has a very insidious onset. Before you know it, you are dehydrated and then you need to make a plan. Charlene’s advice is to put out at least half your daily water needs (about one litre) in an easily accessible place and sip-sip it during the day so that you take it in small quantities frequently. (When I’m travelling, I make a point of stopping every two hours and I drink my water about 20 to 30 km before each pit-stop.)
Diet and bowel management are also closely linked. Persons with SCI (spinal cord injury) often have decreased or no awareness of the need to pass a stool because of a reduced or absent nerve communication between the bowel and the brain. Charlene explained that her team trains SCI patients to establish a “bowel programme” for themselves. This consists of three components: a manual stimulation method, laxative medication every second day and diet. A bowel-management diet consists of two focus areas: fluids and fibre. Without sufficient fluids stools turn into concrete and fibre provides bulk that stimulates the bowels to evacuate the stool. Fibre is found in fruits, vegetables and grain foods such as high-fibre breakfast cereals. The skins of vegetables and fruit are particularly high in fibre – so eat your potatoes, skin and all. Between-meal snacking choices are also important. Rather than chocolates, cookies or crisps, opt for nuts, dried fruits, Provita pieces, and so on.
Diet also plays a role in good skincare. Resilience against pressure sores and other skin afflictions can be enhanced with a good intake of protein and antioxidants. Animal protein from meat, dairy products, fish, chicken and eggs provide the best skin support in terms of skin integrity as well as improved skin healing. Vitamin C is the most important antioxidant; sources include all brightly coloured fruits and vegetables, such as paw paw, guavas, oranges, mango, broccoli, spinach and pumpkin.
I asked Charlene if there was a relationship between diet and mental wellbeing. Her response was insightful: don’t use food as your go-to consoler when you are feeling down and equally don’t use food as a reward for achieving something good. Rather find activities that lift your mood; music, audio books, games – whatever tickles your fancy. But if you do like chocolate or cookies or whatever, don’t punish yourself. By all means have some but in moderation. Learn to eat a block or two rather than a slab or two… Life is too short to miss out on those “nice-to-haves” that are still available to us.
I asked Charlene what caregivers should look out for when preparing meals for persons with spinal cord injuries or afflictions. She made the following astute observation: “We must understand that these injuries or afflictions have drastically changed the lives of these people. We link food to socialising. So many persons with SCI/SCA become emotional eaters. If the person they are caring for is frustrated or depressed, caregivers should not say, ‘Let’s go find a nice big piece of cake.’ Another pitfall is thinking, ‘He is eating healthy food so it is OK for him to eat lots of yoghurt and nuts and fruits.’ At the end of the day portion control is just as important, so one must look at portion size of main meals, the dietary content of pre-made meals and the type of in-between snacks. Steer clear of ‘empty’ snacks which have high sugar and high fat. Rather provide smoothies, vegetable sticks, sliced tomatoes and cottage cheese dips. Lean biltong – without fat – is also good but, again, in moderation. Look at the fluid intake and steer clear of high-kilojoule and energy drinks.”
Lastly, because people with paralysis do not expend a lot of energy, Charlene recommended that the focus should be to prepare foods that provide limited but sustained energy. The GI Foundation (www.gifoundation.com) provides useful information on the glycaemic indexes of various types of food, indicating which types provide sustained energy.
Food that is treated with olive or canola oil and fried presents two problems: the oils add kilojoules and the heat of the frying process converts the “good” fats into “bad” fats. Rather use cooking methods such as grilling, baking or steaming. Measure oil with a teaspoon – don’t pour the whole bottle over the food. Finally, more frequent smaller meals “manage” weight better than larger, less frequent meals do.
Look at portion size: starch portions such as rice or pasta must not be larger than your fist; meat and fish portions should fit in the palm of your hand only; and half of the plate should contain vegetables, fruit or salad. The definition of a snack is something that fits into your cupped hand.
Food for thought for all of us indeed.
Ida’s Corner is a regular column by George Louw, who qualified as a medical doctor, but, due to a progressing spastic paralysis, he chose a career in health administration. The column is named after Ida Hlongwa, who worked as caregiver for Ari Seirlis for 20 years. Her charm, smile, commitment, quality care and sacrifice set the bar incredibly high for the caregiving fraternity.