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In the United States, traumatic brain injury (TBI) remains a serious health problem contributing to 50,000 deaths each year and leaving 80,000 survivors with lifelong disability. The outcome of a TBI is dependent upon not only the severity of the initial injury but also on the development of secondary complications. One such serious complication is the development of the intense metabolic response that often follows a severe TBI. The etiology of this hypermetabolic state is not well understood, but is thought to be due to the release of various cytokines and counter-regulatory hormones during the acute phase of the injury (Foley, Marshall, Pikul, Salter, & Teasell, 2008). This hypermetabolism may persist for 4–6 weeks during hospitalization, resulting in an increased loss of lean body mass; increased cortisol, glucagon, and catecholamines; decreased albumin; and altered fluid and electrolyte balances. All of these nutritional imbalances can worsen cognitive and physical impairments and lead to worsened functional outcomes for brain injury survivors. The question of whether vigorous early nutritional support favorably influences the outcome of a severe brain injury has been addressed by numerous studies (Young et al., 1987; Krakau, Omne-Ponten, Karlsson, & Borg, 2006; Perel, Yanagawa, Bunn, Roberts, & Wentz, 2006; Bistrian, Askew, Erdman, & Oria, 2011; Chiang et al., 2012; Wang et al., 2013). Although a great deal of randomized control trials and nonrandomized prospective studies have compared the effects of timing and formulas of enteral versus parenteral feedings during the acute care hospitalization and on morbidity and mortality, very little information exists about nutrition problems experienced by TBI survivors during rehabilitation and postrehabilitation phases of recovery. It is not known why no one has looked at nutritional issues after the acute care phase of brain injury recovery. It may be due to lack of follow-through on the part of survivors, lack of interest in participating in a study by survivors and family members, or the burden of participating in a study on those who are already overwhelmed by care issues. To better understand the nutritional issues experienced by TBI survivors living in the community, we conducted a small descriptive study to identify what nutritional issues, if any, exist and how they might impact recovery in post-acute rehabilitation. Our objective was to describe the nutrition and weight management characteristics of TBI survivors after discharge from rehabilitation and to identify characteristics of individuals at risk for weight control issues as defined by their body mass index (BMI).
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Addressing proper nutrition and its impact on health and wellness is an important topic for TBI survivors and their caregivers. Proper nutrition should not just be addressed while the TBI survivor is in the hospital, but is an important aspect of recovery that should continue to be monitored well after the person has been discharged to home. To date, few studies have focused on the nutritional intake of chronic brain injury survivors. Most of the literature on nutrition in brain injury has focused on the acute management phase. Henson and colleagues (1993) followed 20 mild to moderately traumatic brain-injured patients who were at least 6 months postinjury. They reported that when compared with nonbrain-injured match controls, the brain-injured group had a higher overall intake due strictly to an increase in the amount of calories ingested during meals rather than the number of meals. The brain injury group ate meals that were about 14% larger than their matched controls (Henson, DeCastro, Stringer & Johnson, 1993).
The case studies from our study are consistent with some of the findings in the Henson et al. study. Both Subjects 111 and 116 did not consume many between-meal snacks, but obtained most of their daily calories at regular meal times. Subject 116 had been an active college student. Although we do not know his preinjury eating habits, it has been well documented that college students often have unhealthful eating behaviors, including skipping meals, frequent snacking on energy-dense food, and engaging in unhealthful weight loss habits (Gerend, 2009). Dietary intake of college students appears to be high in fat, saturated fat, cholesterol, and sodium (Ha & Cain-Bish, 2009). Subject 116's food choices during the follow-up period included chocolate milk, sausage pizza, and chocolate chip cookies. These poor food choices could explain the increase in body mass index after the injury, putting him in the overweight category despite his becoming more physically active during the follow-up period. In addition, both patients come from very close-knit families. Family members may have tried to compensate for the subject's injury by providing favorite foods. This may have contributed to the larger calorie intake.
Problems with maintaining proper weight are not only experienced by the more physically impaired survivor. In our study, the individual who had no physical impairments and was younger also experienced problems with weight management. TBI survivors may have difficulty estimating the appropriate calories needed to maintain a healthy weight in comparison to the activity performed. It is not clear if this is due to the survivor's cognitive deficits. In both of these cases, survivors relied on caregivers to provide nutrition. Henson and colleagues (1993) also identified that lack of response to social cues existed in brain-injured subjects. Brain-injured patients showed an exaggerated response to the estimated premeal stomach content (Henson et al., 1993).
There are several limitations to this study. The values in the compendium do not estimate the energy cost of physical activity in individuals in ways that account for difference in body mass, adiposity, age, sex, efficiency of movement, geographic and environmental conditions in which the activities are performed. Thus, individual differences in energy expenditure for the same activity may be large and the true energy cost for an individual may or may not be close to the stated metabolic level as presented in the compendium (Ainsworth et al., 2000). The diet log calorie counts were also an estimation of calories for the day based on the reported amount of intake by the patient or caregiver. Although no one participant formally dropped out of the study, many participants did not complete or return all of the material sent to them after discharge from the inpatient rehabilitation setting. Many survivors and their caregivers mentioned being overwhelmed at the amount of work involved being out of the hospital in addition to their activities of daily living, such as doctor visits, therapy, phone calls, insurance paperwork. Completing the paperwork for this study was not looked at as equally important and therefore not completed. A less time-consuming method of documenting dietary intake and daily activities/exercise needs to be developed. It may be more helpful to survivors and their caregivers to complete this documentation 12 months after discharge. This may allow more time for survivors and families to return to their daily routine and feel less overwhelmed when completing the documentation requested.
Lastly, we did not measure pituitary function in the individuals participating in the study. Studies have shown that hypopituitarism can occur at some point postinjury in 30%–68% of people with a TBI (Agha, Phillips, O'Kelly, Tormey, & Thompson, 2005; Park, Kim, Lee, Nam, & Park, 2010). Although many patients recover normal pituitary function by 6 months postinjury, hypopituitarism can persist in some patients (Agha et al., 2005). One study of TBI patients with long-lasting cognitive disorders, followed up for a mean of 6.5 years after injury, found that activity performance, functional outcomes, and cognitive function were worse in those with hypopituitarism (Kozlowski Moreau, Yollin, Merlen, Daveluy, & Rousseaux, 2012). Symptoms of hypopituitarism can include weight gain and fatigue.
Based on the data from our study, the trend in weight gain occurred in 30% of those patients we followed from discharge to 1 year postrehabilitation discharge. Unfortunately, given the lack of complete data with regard to physical activity and caloric intake, we were unable to conclude whether these factors impacted weight gain. A better method needs to be developed to monitor caloric intake and physical activity in the brain injury population without putting additional burden on the primary caregiver.
Based on data from the two case studies, weight gain was related to caloric intake in relation to the amount of physical activity. It is important that rehabilitation nurses teach patients and their caregivers how to adjust their nutritional intake after discharge from rehabilitation. Rehabilitation nurses often instruct patients on proper nutrition with regard to disability, chronic illness, developmental disabilities, prevention of malnutrition, impaired swallow, and risk of aspiration; therefore, this task is not outside the scope of nursing practice. The Specialty Practice of Rehabilitation Nursing: A Core Curriculum identifies nursing interventions to promote nutritional adequacies, such as teaching daily recommended intake of essential nutrients, and encouraging and supporting weight loss. Rehabilitation nurses are in an excellent position and should educate brain injury survivors and their families about the need to change nutritional intake throughout their recovery based on disability and activity. Not only is prevention important but rehabilitation nurses should intervene in those who may be identified as developing a potential problem. Brain injury survivors may need target numbers to maintain an ideal body weight secondary to cognitive deficits. Family members or caregivers may need to be taught when to decrease portion size based on the survivor's weight. For those patients or families having difficulty matching caloric intake to level of physical activity, the rehabilitation nurse may need to work closely with a dietician to ensure that patients are getting sufficient nutrition and not just eating foods with no nutritional value or empty calories. Providing individuals with sample diets, which include daily food choices and, more important, appropriate portion sizes, may be needed. For those TBI survivors with more functional impairments who may rely on prepackaged meals for ease of preparation, the rehabilitation nurse may need to identify which meals have better nutritional choices and make specific recommendations on what meals to select. Working with the physical or occupational therapist on amount of exercise to be done daily can help the rehabilitation nurse devise a daily schedule to avoid long periods of sedentary activity for patients. Excessive weight gain in this population can only negatively affect mobility, worsen fatigue, and complicate general health conditions, such as hypertension and diabetes. Follow-up visits with rehabilitation nurses should also address issues of overweight or obesity, especially if developed after discharge. Overweight and obesity in individuals with brain injury can produce the same health complications and. in some cases, even more when compared with individuals without physical, cognitive, or behavior deficits. More research needs to be carried out to look at how best to identify which TBI survivor will be at risk for weight control issues and how the rehabilitation nurse working closely with other team members can best address these problems.