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  1. 1. Dietary Management pinal Cord Injury Colonel Hana K. Mudabber Head of Clinical Nutrition Department S of
  2. 2. Coordination of Care  Optimal care of SCI patient requires a multidisciplinary approach in all aspects of patient care including nutrition
  3. 3. SCI : Interdisciplinary Team Others
  4. 4. Role of the Clinical Dietitian  Participate in the interdisciplinary team by providing care for Neurotrauma patients in all aspects of patient care: 1. Acute phase 2. Rehabilitation phase 3. Community setting (After Discharge)
  5. 5. Nutrition Management in the Acute Phase
  6. 6. Nutritional needs change frequently after SCI Stress response Sepsis Fever Infection Surgery Nutritional assessments need to be frequent, with ongoing diet alterations made to keep up with the patients' changing needs Caloric and protein needs in the acute phase
  7. 7. Management of Hypermetabolism Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Maion F. Winkler and Ainsley Malone, 2002.
  8. 8. SCI: Nutrition Assessment in the Acute Care Setting Nutrition assessment should be conducted within the first 48 hours post-injury to determine Nutrient needs Provide nutrition support recommendations Early nutrition support is associated with improved patient outcomes Identify conditions that may predispose the patient to nutrition-related complications
  9. 9. SCIInflammation Malnutrition Loss of muscle mass Loss of activity Acute Illness & Nutritional Status After injury: weight loss due to loss of muscle or lean body tissue
  10. 10. Complications with Loss of Lean Body Mass % Loss Total LBM Complications Associated Mortality % 10 Decreased immunity, Increased infections 10 20 Decreased healing, weakness, infection 30 30 Too weak to sit, pressure ulcers, pneumonia, no healing 50 40 Death, usually from pneumonia 100
  11. 11. What is the best route of delivery: Enteral vs. Parenteral Enteral Nutrition (EN): Enteral nutrition is a treatment option when oral nutrition is unsafe due to aspiration risk or when the patient can no longer meet nutritional needs with an oral diet.
  12. 12. Enteral Nutritional Support Continuous EN Better tolerated than bolus/intermittent EN in ICU setting Limit interruptions! Unnecessary for certain procedures—NPO at midnight should not be automatic Low rate of gastric residuals
  13. 13. Benefits - EN Supports gut integrity Modulate stress and immune response Lower risk of infection than Parenteral Nutrition (PN) Reduction in hospital LOS  catabolism Improve the nutritional status (meet protein, energy and micronutrient requirements)  Infection Lower cost Quicker return of cognitive function (Taylor, et. al)
  14. 14. Risks of EN Feeding when gut perfusion poor can lead to gut ischemia Feeding intolerance in critical illness May not reach nutritional goals as quickly as PN
  15. 15. Parenteral Nutrition Benefits Fewer interruptions in feeding Nutrition goals reached quickly Least desirable Increased risk of infection Increased cost Increased risk of mortality
  16. 16. SCI: Energy Needs in the Acute Phase Indirect calorimetry is considered to be the 'gold standard' and the only accurate and clinically feasible method of measuring energy expenditure in critically ill hypermetabolic patients It is called “indirect” because the caloric burn rate is calculated from a measurement of oxygen uptake. Used in both mechanically ventilated and spontaneously breathing patients (ventilated patients most accurate) Equipment is expensive and not readily available in the medical facilities
  17. 17. SCI: Assessment: Energy Needs in the Acute Phase using Predictive Equations If Indirect Calorimetry is not available, the clinical dietitian may estimate energy needs with the Harris-Benedict formula using admission weight an injury factor of 1.2 an activity factor of 1.1
  18. 18. Harris-Benedict Formula Basal Energy Expenditure Male: BEE = 66.67 + 13.75W + 5H - 6.76A Female: BEE = 665.1 + 9.56W +1.85H -4.68A H= height in centimeters W= weight in kg  A= age in years.
  19. 19. SCI: Calculations of Energy Needs Harris-Benedict Formula Energy Needs = [BEE]) X (activity factor) X (injury factor) an injury factor of 1.2 an activity factor of 1.1
  20. 20. SCI: Protein Needs in Acute Phase 2.0 g/kg of ideal body weight/day to minimize -ve nitrogen balance that occurs during the acute phase Status Estimated Requirements Normal (RDA) 0.8-1.0 g/kg/day Moderately stress 1.0-2.0 g/kg/day Severely stressed 2.0-3.0 g/kg/day Blackburn's General Guide for Protein Needs Based on Stress level
  21. 21. SCI: Monitoring and Evaluation of Protein Intake in Acute Care Setting: Overfeeding 0 – 4 weeks post-injury : the clinical dietitian should monitor the patient's protein intake to ensure that the patient does not consume more than 2.0g/kg of body weight/day to achieve +ve nitrogen balance without any excessive nutrition support that may result in overload and metabolic complications
  22. 22. Nutrition Management in the Rehabilitation Setting
  23. 23. SCI: Goals of Nutrition Assessment in the Rehabilitation Setting Implementing an individualized therapeutic nutrition plan for the patient Improving transition into the community setting
  24. 24. SCI: Energy Needs Patients with SCI have reduced metabolic activity due to denervated muscle Actual energy needs are at least 10% below predicted needs 22.7 kcal/ kg body weight for patients with quadriplegia 27.9 kcal/ kg for those with paraplegia Example: Patient weight 70 kg x 22.7 ≅ 1600 kcal/day energy needs for patient with quadriplegia
  25. 25. SCI: Protein Needs in the Rehabilitation Setting (0.8 to 1.0) g/kg/day for maintenance of protein status in the absence of pressure ulcers or infection Example: Patient weight 70 kg x1 = 70 /day protein needs for patient with SCI
  26. 26. Community Setting After Discharge
  27. 27. SCI: Nutrition Assessment in the Community Setting Should be conducted as part of the annual medical exam Developing and implementing an individualized therapeutic nutrition plan necessary to identify secondary SCI conditions related to nutrition
  28. 28. Secondary SCI Conditions Related to Nutrition 1. Metabolic Syndrome 2. Overweight and Obesity 3. Lipid Abnormalities 4. Pressure Ulcers 5. Bowel Problems 6. Urinary Tract Infections
  29. 29. 1. Metabolic Syndrome  Metabolic Syndrome is not a single disease but a group of health problems that is believed to arise due to a combination of 1. Genetic factors 2. Lifestyle factors including overeating 3. Lack of physical activity
  30. 30. Symptoms of Metabolic Syndrome 1. Waist Circumference greater than 102 cm for men and 88 cm for women (in SCI population it is likely a different estimation) 2. Triglyceride level ≥150 mg/dL 3. HDL < 40 mg/dL in men and <50 mg/dL in women 4. Blood pressure > 130/85 mmHg 5. Blood sugar > 110 mg/dL
  31. 31. Dietary Recommendations to Prevent Metabolic Syndrome & Overweight/Obesity Limiting Fat Intake Choosing fat free or low fat dairy products Choosing lean meats and skinless poultry and fish Reducing Saturated Fat and Trans Fat These are the fats that are solid at room temp Animal fats Shortening Palm and coconut oil
  32. 32. Dietary Recommendations to Prevent Metabolic Syndrome & Overweight/Obesity Eating less cholesterol Cholesterol is in foods from animal origin reducing the amount of saturated (animal fat) Increasing fruit and vegetable intake Limiting empty calories Choosing water or diet beverages over regular soda & reducing the amount of sweets & sugars & alcohol
  33. 33. For the general population overweight and obesity can be categorized by using BMI BMI<18.5- Underweight BMI 18.5-24.9- Normal Weight BMI 25-29.9- Overweight BMI 30-39.9- Obese BMI >40- Extreme Obese 2. Overweight and Obesity
  34. 34. SCI: Assessment of Body Composition: BMI and skinfold measurements The clinical dietitian should not use the following to measure body composition in persons with SCI:  body mass index (BMI) Skinfold measurements These methods may not provide reliable results since they were developed based on able- bodied persons.
  35. 35. SCI: Estimation of Ideal Body Weight Quadraplegia or (Tetraplagia): Reduction of 10% to 15% (7-9) kg lower than table weight Paraplegia: Reduction of 5% to 10% (4.5-7) kg lower than table weight
  36. 36. Estimation of Ideal Body Weight The clinical dietitian should estimate ideal body weight for persons with SCI by adjusting the Metropolitan Life Insurance tables for individuals of equivalent height and weight
  37. 37. Height (m) Frame Size Medium Large Para Tetra Para Tetra 1.57 49 46.5 54.5 52 1.60 51 49 57 55 1.62 54.5 52 60 58 1.65 57 55 63.5 61 1.67 60 58 66 64 1.70 62 60 69 67 1.72 65 63 72 69 1.75 68.5 66 75 73 1.77 75 68 78.5 76 1.80 73.5 71 81 78.5 1.83 76 74 85 82 1.86 79 77 87 85 1.88 81 79 90 88 1.91 84 82 93.5 91 1.93 86.5 85 96 94 1.96 90 88 99 97 1.98 92 90 102 99.5 S C I M E N W E I G H T T A B L E S
  38. 38. S C I W O M E N W E I G H T T A B L E S Height (m) Frame Size Medium Large Para Tetra Para Tetra 1.47 36 34 40 38 1.5 38.5 36 43.5 41 1.52 41 39 45 43 1.55 43.5 41 48.5 46 1.57 45 43 46 48 1.60 47 45 53.5 51 1.62 50 48 55.5 53 1.65 52 49 57.5 55 1.67 54.5 52 60.5 58 1.70 56 54 63 61 1.72 59.5 57 65 63 1.75 61 59 68 66 1.77 63.5 61 70 68 1.78 66 64 73.5 71 1.83 68.5 66 75 73
  39. 39. SCI: Assessment of Body Composition: BIA and DEXA  Assessment of body composition for medically stable SCI patients by using Bio-electric Impedance Analysis (BIA) Dual-Energy X-Ray Absorptiometry (DEXA) Persons with SCI have significantly higher fat mass and lower lean mass than persons without SCI
  40. 40. (BIA) Bioelectric impedance Analysis (DEXA) Dual-Energy X-Ray Absorptiometry
  41. 41. What’s the difference between weight & body fat in terms of health risks? Weight measurement alone cannot accurately determine a person’s body fat % and the resulting health risks  New evidence indicates that fat loss, not weight loss can extend lifespan
  42. 42. Level of Body Fat % for General Health Adult Male Adult Female Age Excellent Good Average Poor Age Excellent Good Average Poor 19-24 10.8% 14.9% 19.0% 23.3% 19-24 18.9% 22.1% 25.0% 29.6% 25-29 12.8% 16.5% 20.3% 24.4% 25-29 18.9% 22.0% 25.4% 29.8% 30-34 14.5% 18.0% 21.5% 25.2% 30-34 19.7% 22.7% 26.4% 30.5% 35-39 16.1% 19.4% 22.6% 26.1% 35-39 21.0% 24.0% 27.7% 31.5% 40-44 17.5% 20.5% 23.6% 26.9% 40-44 22.6% 25.6% 29.3% 32.8% 45-49 18.6% 21.5% 24.5% 27.6% 45-49 24.3% 27.3% 30.9% 34.1% 50-54 19.4% 22.7% 25.6% 28.7% 50-54 26.6% 29.7% 33.1% 36.2% 54-59 20.2% 23.2% 26.2% 29.3% 54-59 27.4% 30.7% 34.0% 37.3% 60 20.3% 23.5% 26.7% 29.8% 60 27.6% 31.0% 34.4% 38.0%
  43. 43. Example Patient: 30 years old male BMI= 17.9 Underweight Average % fat assessed: 28.2% This would make this patient obese because in this age group the amount of fat that is considered acceptable is 18-25%, making this seemingly underweight patient obese
  44. 44. SCI: Risks Associated Overweight & Obesity The SCI patients is at a higher risk of associated comorbidities Diabetes Metabolic syndrome Cardiovascular disease Lower levels of spontaneous physical activity and a lower thermic effect of food result in decreased energy expenditure and energy needs.
  45. 45. What is the Thermic Effect of Food? It is a reference to the increase in metabolic rate (i.e. the rate at which your body burns calories) that occurs after ingestion of food. Energy expenditure (i.e. calories) to digest, absorb, and store the nutrients; accounts for 5 to 10 % of the energy content of the food ingested. Example 500 calorie meal, 50 calories (or 10%) would be expected to be burned due to the thermic effect of food, a net calorie consumption of 500 - 50 = 450 calories.
  46. 46. Influence of Body Composition on the Thermic Effect of Food Lean people have a thermic effect of food 2 to 3 X greater than obese or people with higher body fat %, during rest, after exercise, and during exercise. Segal KR, Gutin B, Albu J, Pi-Sunyer FX. Thermic effects of food and exercise in lean and obese men of similar lean body mass. Am J Physiol. 1987 Jan;252(1 Pt 1):E110-7.
  47. 47. SCI: Wheel Chairs & Energy Needs Compared to ultralight wheelchairs and pushrim- activated, power-assisted wheelchairs; The use of a manual standard wheelchair increases: Energy needs  heart rate Oxygen consumption and ventilation, especially as speed and resistance levels increase
  48. 48. SCI: Nutrition Education Regarding Physical Activity physical activity should be encouraged as part of a comprehensive weight management program for overweight or obese SCI patients
  49. 49. Physical Activity for SCI Patients Swimming Electrical stimulation exercise Body weight supported Treadmill training
  50. 50. 3. Lipid Abnormalities SCI patients are at higher risk of cardiovascular conditions. Cardioprotective diet should be provided if total cholesterol levels > 200mg/dL
  51. 51. SCI: Factors Related to Lipid Abnormalities Age Ethnicity Gender Time since injury Level of injury Activity level Dietary habits Smoking behavior Alcohol intake Overweight or obese status ModifiableNon-Modifiable
  52. 52. SCI: Nutrition Screening for Lipid Abnormalities Screening for lipid abnormalities is recommended for all persons with SCI in order to reduce morbidity and mortality.  Up to 30% deaths from CHD due to an unhealthy diet  36% due to inactivity NHF (2006)  Up to 30% deaths from CHD due to an unhealthy diet  36% due to inactivity NHF (2006)
  53. 53. 4. Pressure Ulcers Patients who are at the greatest risk of developing pressure ulcers Nonambulatory Compromised nutritional status Pressure ulcers are secondary to the decrease in oxygen supplied to at- risk areas (eg, coccyx, elbows, heels) Modifiable
  54. 54. SCI: Nutrition Prescription for SCI Persons with Pressure Ulcers A nutrition prescription should be formulated as part of the nutrition intervention for persons with (SCI) and pressure ulcers Energy Protein Fluid Micronutrient requirements Additional energy and protein is needed for optimal healing of pressure ulcers Fluid and micronutrient needs will vary depending on the person's status.
  55. 55. Nutritional Assessment The Clinical Dietitian should assess for:  Anthropometrics Skin integrity Dietary intake Lifestyle factors Biochemical indices
  56. 56. SCI: Biochemical Parameters Associated with Prevention of Pressure Ulcers laboratory indices associated with the risk of pressure ulcers albumin, Prealbumin, Zinc, vitamin A and vitamin C Biochemical parameters as close to normal as possible or within the normal range are associated with reduced risk of pressure ulcers.
  57. 57. Serum Albumin Hypoalbuminemia, has been associated with the development and progression of pressure ulcers.  Nutritional intervention needs to include adequate protein and adequate calories to spare protein for wound healing. The goal is a serum albumin of greater than 3.5 g/dL The amount of protein and number of calories need to increase as the stage of the ulcer increases
  58. 58. SCI: Assessment: Energy Needs with Pressure Ulcers SCI patients with pressure ulcers have higher energy needs Additional energy is needed for optimal healing 30 – 40 kcal/kg of body weight/day Harris-Benedict x Stress Factor 1.2 for stage II ulcer 1.5 for stage III and IV ulcers
  59. 59. SCI: Assessment: Protein Needs with Pressure Ulcers The clinical dietitian should calculate protein needs as follows: (1.2 - 1.5)g of protein/kg body weight/day (Stage II pressure ulcers) (1.5 - 2.0)g of protein/kg body weight/day (Stage III and IV pressure ulcers).
  60. 60. Arginine Dietary supplementation with arginine has been shown to enhance protein metabolism, helping to decrease muscle loss, and collagen synthesis, which helps to increase the strength of the wound Increased protein demand for normally nonessential amino acids, becomes essential (conditionally essential) Increases IGF-1 (Insulin Like Growth Factor) level hormone that promotes wound healing Studies suggest +ve outcomes in post-op surgical wounds. L-Arginine is also effective in healing chronic ulcers in people with diabetes (ultimately helping to reduce leg amputations)
  61. 61. When and How to Use Arginine Should NOT be first line of defense Consider for non-healing wounds after calorie and protein needs met Therapeutic dose to promote healing is ~9 grams/day
  62. 62. Side effects L-Arginine supplementation can cause diarrhea. Gradual increase of daily dose may help tolerance.
  63. 63. Glutamine Functions Regulates amino acid homeostasis Preferred energy source for rapidly multiplying cells of intestinal mucosa and immune system May stabilize the intestinal barrier, reducing risk of bacterial translocation and systemic inflammatory response [Neu 2002] Clinical trials of supplementation suggest benefit but remain inconclusive.
  64. 64. How and When to Use Glutamine This is NOT first line of defense Indications are for patients with GI impairment and Immune deficiencies Provide 15-30g/day or 0.57 gm/kg wt
  65. 65. ß-Hydroxy-ß-methyl-butyrate (HMB) Substance derived from breakdown of amino acid leucine Function Anti-catablic agent Used for reduction of muscle tissue breakdown Lack of clinical trials available Some Products are marketed for wound healing Contains 7 gm arginine, 7 gm glutamine, 1.5 g HMB per packet
  66. 66. SCI: Fluid Needs with Pressure Ulcers The clinical dietitian should assess hydration status to determine fluid needs. evaluation of parameters such as input and output urine color skin turgor BUN serum sodium
  67. 67. Fluid Needs with Pressure Ulcers Normal requirement: (30 – 40)ml/kg Minimum of 1 ml/kcal/day (10 – 15) ml per kg additional fluids may be required with the use of air fluidized beds set at a high temp. (more than 31º to 34ºC Fluid loss also includes evaporation from open wounds, wound drainage and fever
  68. 68. SCI: Nutrition Support & Pressure Ulcers Implementing aggressive nutrition support measures for SCI patients at risk of pressure ulcer development may include (Enteral and Parenteral Nutrition) Improved nutrition intake, body weight and biochemical parameters are associated with reduced risk of pressure ulcer development
  69. 69. SCI: Micronutrients & Wound Healing Daily vitamin and mineral supplement should not be more than 100% of the RDA.  When supplementing greater than the Tolerable Upper Intake Level (UL); the dietitian should re- evaluate the need for micronutrient supplementation every 7 to 10 days.
  70. 70. Vitamin A Stimulates differentiation in fibroblasts and collagen synthesis to quicken healing Vitamin A deficiency results in impaired wound healing and alteration in immune function that may increase wound infections. Recommendations for amount of Vitamin A is (10,000 IU to 50,000 IU /day) 10,000 IU IV for moderate-severely injured patients or malnourished patients for a limit of 10 days.
  71. 71. Vitamin A & Steroids For patients receiving steroids, 10,000 IU to 15,000 IU for one week has been recommended to counteract the anti- inflammatory effects of steroids Steroids adversely affect all phases of wound healing and increase risk of infection[Ross 2002] Vitamin A supplementation should be implemented cautiously because of potential toxicity
  72. 72. Vitamin C Necessary for collagen synthesis Enhances immune function  Depressed levels found in elderly, smokers, and certain cancers [Ross 2002] Vitamin C deficiency has been associated with delayed wound healing High doses of Vitamin C for healing chronic wounds is recommended (100 to 200)mg/day of Vitamin C for Stage I and II pressure ulcers (1,000 to 2,000) mg/day of Vitamin C for Stage III and IV pressure ulcers
  73. 73. Zinc Zinc deficiency is associated with delayed wound healing due to a decrease in collagen protein synthesis and impaired immune competence. (50mg elemental Zinc) twice/day is recommended as a standard adult oral replacement (minimal daily requirements is 15 mg/d) High-dose supplementation of zinc should be limited to (2-3) weeks Dosage should be individualized according to zinc status and metabolic demands.
  74. 74. Iron Anemia assessed by hemoglobin and hematocrit levels If low hemoglobin concentration is due to iron deficiency anemia, it may be a factor in tissue hypoxia and impaired wound healing. Supplementation should be provided as indicated to correct iron deficiency anemia. There are 58 studies about curcumin & wound healing in the PubMed until this date 30/6/2011
  75. 75. Recent Researches A search of PubMed on the internet reveals some 58 scientific and technical papers referenced to curcumin and wound healing
  76. 76. Curcumin & Wound-healing Dermal wound healing processes with curcumin incorporated collagen films Gopinath D.etal Biomaterials. 2004 May;25(10):1911-7 Protective effects of curcumin against oxidative damage on skin cells in vitro: its implication for wound healing Phan TTetal J Trauma. 2001 Nov;51(5):927-31 Enhancement of wound healing by curcumin in animals Sidhu G Setal , Wound Repair Regen. 1998 Mar-Apr;6(2):167-77 Inhibitory effect o fcurcuminon PMA-induced increase in ODC m RNA in mouse epidermis Lu YP…Conney AH, Carcinogenesis. 1993 Feb;14(2):293-7 Inhibitory effect of dietary curcuminon skin carcinogenesisin mice LimtrakulP., CancerLett. 1997 Jun 24;116(2):197-203 Turmeric and curcuminas topical agents in cancer therapy KuttanR.,Tumori. 1987 Feb 28;73(1):29-31
  77. 77. 5. Neurogenic Bowel The Clinical Dietitian should prescribe for SCI patient with neurogenic bowel an initial fiber intake of 15g/day, with gradual increases up to 30g/day of fiber, as tolerated from a variety of sources. Excessive fiber may result in unacceptable Flatulence Significant increase in stool volume Painful abdominal distension
  78. 78. 5. Neurogenic Bowel Fiber intake > 20g/day may be associated with undesirable prolonged intestinal transit times resulting in excessive fluid reabsorption and the formation of hardened stools Transit TimeTransit Time
  79. 79. Constipation Juices, especially those high in sorbitol, can help relieve constipation.
  80. 80. Juices that are Good for Chronic Constipation Sorbitol is a natural fruit sugar that is poorly absorbed by the intestines, so it stays in the intestinal tract and makes the stools more liquid
  81. 81. Prune juice Prune juice contains 6.1 g of sorbitol /100-g serving Prune juice and other prune products have long been used to relieve constipation due to their laxative effect An added benefit of prune juice over many other fruit juices is that it does not cause a spike in blood sugar, which can be dangerous for diabetics. Baylor College of Medicine
  82. 82. Pear Juice One 8-oz glass of pear juice can contain as much as 7 g of sorbitol. As few as 10 g of sorbitol can cause diarrhea in children (it is best to offer a child only a small amount to assist in chronic constipation relief) Baylor College of Medicine
  83. 83. Apple Juice Apple juice is naturally high in sorbitol It is a mild juice that can cause gas in some individuals it is often one of the first juices given to babies who have constipation It is suggested to give babies 2 oz of apple juice twice per day for constipation
  84. 84. Constipation  Foods (such as dairy products, white potatoes, white bread and bananas) can contribute to constipation  Foods (such as excess amounts of fruit, caffeine, or spicy foods and warm fluids with lemon juice) may soften the stool or cause diarrhea
  85. 85. Constipation  Drinking water and eating high-fiber foods such as fruits, vegetables, whole grains and legumes may help to soften and make the stool bulkier, which stimulates movement of the bowel  Peristalsis can be stimulated with vegetables, fruits (especially dried fruits)  Dried fruits are the ideal substitute for candies
  86. 86. SCI: Fluid & Neurogenic Bowel: Estimating Fluid Needs to Promote Optimal Stool Consistency 1 ml fluid/kcal estimated energy needs + 500 ml Example  1500 fluid/kcal estimated energy needs+ 500 ml= 2000 ml fluid Needs/day 30-40ml/kg body weight + 500 ml Example  40 x 55 kg body weight + 500 ml = 2700 ml fluid needs/day
  87. 87. SCI: Fluid & Neurogenic Bowel:
  88. 88. 6. Urinary Tract Infections The Clinical Dietitian may recommend that cranberry juice be included in the diet to reduce urinary tract infections Consumption of one cup (250ml) cranberry juice, 3 times/day, may be associated with a reduced urinary tract biofilm load Cranberry juice contains hippuric acid and another substances that seems to prevent adherence of bacteria to urinary tract epithelial
  89. 89. SCI: Cranberry Extract Supplements The Clinical Dietitian should not recommend cranberry extract supplements to promote urologic health (prevention of urinary tract infections, urologic stones, etc.) with SCI patients  Cranberry extract supplements, ingested in tablet or capsule form, are not effective in prolonging the UTI-free period or decreasing bacteriuria or WBC count in persons with SCI patients
  90. 90. Food Pyramid SCI
  91. 91. THANK YOU ?