A landmark study published earlier this year in The Journal of Head Injury Rehabilitation, found that 20-25 years following a moderate to severe traumatic brain injury, that 67% of people had a Body Mass Index (BMI) which put them in the overweight or obese category. The researchers didn’t track people over time, they just took a “snap shot” (cross-sectional study) of people who were at various stages of their recovery — from 1 – 25 years following acute rehabilitation. In other words, this data cannot tell us for certain whether these people gained weight following rehabilitation, or whether they were always overweight or obese.  However, considering the average BMI begins to creep upwards after one year post-injury, there is a high probability that traumatic brain injury puts someone at higher risk of becoming overweight or obese. This then begs the question, who is monitoring the weight of your clients and what action is being taken if their weight starts to increase above a healthy range? 

Extra weight (particularly around the belly region) puts a person at higher risk of developing heart disease, stroke, certain types of cancer, sleep apnoea, respiratory problems, depression and type 2 diabetes — regardless of it when happened, or why.  In fact, the study found that 73% of the participants who were overweight or obese also had type 2 diabetes, 70% had high blood pressure and 68% had heart failure.

Why does a brain injury put someone at higher risk of becoming overweight or obese?

• the inflammatory process following a brain injury, combined with reduced mobility during the recovery process, causes people to lose muscle mass.  Since muscle mass is what burns most of the calories, less muscle mass means the person’s metabolic rate will be slower (once the inflammation has subsided).
• pain, fatigue, a reduced capacity to prepare one’s own food and/or a desire to be independent, often leads to a short-term (or long-term) reliance on fast food, take aways and ready meals.
• support workers have not always received training on nutrition and the foods they are able to offer may be limited by their own cooking ability and/or the duration of call times.
• medical conditions (eg. neuroendocrine dysfunction) and/or medication can alter metabolism and appetite.
• physical activity and mobility levels change over time which can alter calorie requirements.
• memory problems can cause someone to forget that they have already eaten.

However, in my experience, the number one reason people struggle with weight following a brain injury is because no one has assessed their capacity to understand the consequences of their food choices.

There seems to be considerable confusion, particularly amongst support workers, that just because someone is able to communicate what they want to eat, that doesn’t necessarily mean that the person understands the consequences of these food choices.  Often, formal capacity assessments need to be done, and best interest decisions needs to be made, by the multi-disciplinary team around food and eating.

I truly cannot think of a bigger tragedy, after all of the time, energy and money spent on rehabilitation following a brain injury, than for that person to have their life cut short, or for them to end up with a secondary disease such as diabetes, for a reason which could have been largely prevented.

What can case managers & health professionals do?

1. Measure, monitor and act.  Make sure someone is monitoring all of your clients’ weights and acting on this information as appropriate when a significant change is observed (you need to watch for weight which is increasing as well as decreasing  – see my article on Screening Clients for Malnutrition).
2. Make sure support staff are trained on how to interpret weight information or consider contracting this job to someone skilled at monitoring, interpreting and acting on weight data.
3. Make sure a capacity assessment is done if there is any question that the client may not understand the consequences of their food choices.
4. Make sure you know how to refer to an NHS or private dietitian for assessment and input if required.

To access private assessment/input, support worker training and/or help with monitoring client weight data, please contact Sheri Taylor, dietitian for people with brain injuries, spinal cord injuries and orthopaedic injuries at 0121 384 7087 or info@specialistnutritionrehab.co.uk.

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