BACKGROUND/RATIONALE:
About 53-68% of individuals with spinal cord injuries and disorders (SCI/D) are overweight or obese, putting them at increased risk for negative health consequences and challenges with mobility and care provision. VA's MOVE! weight management (WM) program may not meet the unique needs of Veterans with SCI/D; although they would benefit from participation in WM, e.g., physical activity (PA) and nutrition, to treat and prevent overweight/obesity. This study was conducted to understand current and best WM practices for national SCI/D Veteran cohort.

OBJECTIVE(S):
Aim-1. To identify facility/system level current WM practices, barriers, and facilitators to treat overweight/obesity in Veterans with chronic SCI/D across the VA SCI/D System of Care, including VA MOVE!.
Aim-2. To identify facility/system level current practices, barriers, and facilitators to providing preventive WM (prevent weight gain, incident overweight/obesity) in Veterans with chronic SCI/D across the VA SCI/D System of Care, including VA MOVE!.

METHODS:
Aim-1. Focus groups were conducted with staff involved in SCI/D care and/or WM programs at 2 SCI Hubs and 2 Spokes. Outcomes included current WM strategies, barriers, and facilitators. Qualitative data were analyzed using grounded theory, with content analysis to identify themes. Findings were used to develop an interview tool for Aim 2.
Aim-2. Semi-structured telephone interviews were conducted with staff/teams at 18 Hubs and 17 Spokes. We assessed existing WM practices, barriers, and facilitators. Qualitative data were analyzed using content analysis to identify themes. Quantitative data were analyzed using descriptive statistics.

FINDINGS/RESULTS:
Aim-1. Physicians, nurses, dietitians, psychologists, and therapists (n=32) participated in focus groups at 4 facilities. Barriers included lack of staffing, programs, and content specific/relevant to SCI/D. SCI spoke facilities depend on facility-level programs that do not consistently meet concerns of the SCI/D cohort. . WM programs delivered through the SCI team, with SCI-relevant content and peers, are more acceptable and beneficial. Program classrooms should provide ample space for wheelchairs. Facilities could benefit from more facility leadership, provider support, and evidence-based guidance for WM in SCI/D. Facilitators included strong leadership, provider involvement, and community resources.
Aim-2. Facilitators. 91% of facilities reported weighing Veterans with SCI/D, with wheelchair scales (77%), bed scales (51%), or other methods (63%, e.g., Hoyer lift). Only 17% of facilities reported measuring height: using wingspan (9%) or supine measurement (9%). All facilities reported using indicators, including: BMI (83%), ideal body weight (46%), waist circumference (11%), and body fat percentage (3%). Veterans with SCI/D are identified for WM referral through general (74%) and SCI/D-specific (6%) clinical reminders, change in functional status (29%), or other methods (57%, e.g., visual assessment, dietary consult, weight-related comorbidities). 89% reported screening for readiness through standardized measures (19% e.g., MOVE!23), or informal provider discussion (81%). Care delivery through SCI Centers or Clinics, either in one-on-one consults (71%) or SCI-specific programs (17%), were viewed as facilitators to WM treatment. Facilities reported involvement in WM by an interdisciplinary care team, consisting of primary care providers (100%), behavioral health (83%), nutritionists (91%), PA specialists (77%), and specialty providers (17%). Individual consults were also available through nutritionists (100%), PA specialists (83%), and behavioral health (49%). Family involvement was viewed as a facilitator, particularly when family members were responsible for/helped with dietary decisions (e.g., shop for/prepare meals).
Barriers. Barriers for assessing weight included limited availability of scales (31%), broken scales (rarely repaired) (14%), staff shortages (9%), not knowing wheelchair weight (9%), and lack of standard procedure (6%). Few facilities measured height, instead used patient self-reported pre-injury height (63%) or historical height from the chart (31%). Facilities indicated that Veterans with SCI/D were referred MOVE! (91%); in some, MOVE! was the only WM treatment option (17%). Respondents noted that Veterans with SCI/D were uninterested in attending MOVE! and attendees gave negative feedback. Barriers to WM treatment were lack of: sufficient staff (60%), SCI-specific education materials (37%), suitable/accessible PA equipment (26%), physical space for sessions (31%), patient interest (71%), evidence for SCI/D WM (40%), and clarity on competing health needs (29%). Other barriers: belief that BMI was inaccurate for SCI/D (31%) and that WM was the responsibility of another provider (14%, e.g., another SCI facility, primary care provider).

IMPACT:
Though most facilities refer Veterans with SCI/D to MOVE!, Veterans with SCI/D were generally uninterested, due to lack of SCI-specific information or discomfort attending groups with able-bodied Veterans. Facilities offering WM treatment through the SCI Center or clinic felt these options were best aligned with preferences of Veterans with SCI/D. Though BMI and ideal body weight were the most frequently used indicators of overweight/obesity, facilities reported difficulties obtaining accurate height and weight in the SCI/D cohort- necessary values for computing these indicators. Some participants also reported concerns with using BMI, believing it to be inaccurate in SCI/D. Finally, while Veterans with SCI/D are screened for readiness (to address weight issues), this is mostly performed through informal discussions, which may not assess barriers to lifestyle changes.
These findings can be used to facilitate WM efforts for Veterans with SCI/D in the VA SCI/D System of Care. A clear need exists for evidence-based guidelines for WM in SCI/D. Further, development and implementation of a WM program geared toward the needs and abilities of individuals with SCI/D would be most aligned with preferences, desired outcomes (e.g., better function) and needs of this population.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Locatelli SM, Gerber BS, Goldstein B, Weaver FM, LaVela SL. Health care provider practices, barriers, and facilitators for weight management for individuals with spinal cord injuries and disorders. Topics in spinal cord injury rehabilitation. 2014 Jan 1; 20(4):329-37. [view]

Conference Presentations

1. Evans (Mayfield) C, Guihan M, LaVela SL, Weaver FM. SCI Quality Enhancement Research Initiative (QUERI): Building and Implementing. Presented at: Academy of Spinal Cord Injury Professionals Annual Meeting; 2013 Sep 2; Las Vegas, NV. [view]
2. Locatelli (House) SM, Gerber BS, Weaver FM, Goldstein B, LaVela SL. SCI/D Weight Management Practices, Barriers and Facilitators to Treat Overweight/Obesity. Paper presented at: Academy of Spinal Cord Injury Professionals Annual Meeting; 2013 Sep 2; Las Vegas, NV. [view]

DRA: Brain and Spinal Cord Injuries and Disorders
DRE: Treatment - Observational, Prevention
Keywords: Care Management, Obesity, Spinal cord injury
MeSH Terms: none