Type 2 diabetes after a catastrophic injury
After a spinal cord injury, people are 2.5x more likely to develop type 2 diabetes compared to people who have not experienced a spinal cord injury.1 I was unable to find any similar research on rates of type 2 diabetes after a brain injury or traumatic amputation. However, many of the physical and metabolic changes which occur after a spinal cord injury, could also be expected (to varying degrees) after other forms of catastrophic injury as well (particularly if the client is confined to a wheelchair).
Who is screening your clients to see if they have impaired glucose tolerance (pre-diabetes) or type 2 diabetes? How often are they being screened?
Impaired glucose tolerance (pre-diabetes) and type 2 diabetes are characterised by higher than normal levels of blood sugar circulating in the body. High blood sugar levels lead to a host of complications such as fatigue and slower wound healing in the short term2, and damage to nerves, kidneys and eyes, brain atrophy, and an increased risk of both cardiovascular disease and dementia in the long-term.3 People after a catastrophic injury have enough to deal with, without layering additional complications on top of everything else.
- If you don’t use it, you lose it. Fat-free mass (muscle mass, bone, connective tissues, organs) declines any time an area of the body is not being used. This muscle atrophy can occur within weeks and continue to the end of the first year. There is some natural decline in muscle mass as people get older as well. In spinal cord injuries, skeletal muscle mass can shrink by as much as 50% (below the level of the injury).
- If someone maintains their weight, but they have less muscle mass, that means their percentage of body fat is much higher. That means the Body Mass Index (BMI) cut-offs intended for the general population (to classify people as overweight or obese) are likely UNDERestimating the number of people after a catastrophic injury who have excess body-fatness (and thus an increased risk of type 2 diabetes and cardiovascular disease).
- A person’s metabolism will increase temporarily immediately following the injury, but then becomes much slower over time due to the loss of metabolically active muscle mass, less physical activity and any blunting to the autonomic nervous system (which would normally work to keep things like body temperature constant). These changes put people at much higher risk of gaining weight, especially if their food intake remains similar to what is was before the injury.
- Muscles which are not being used have three times more intramuscular fat. Intramuscular fat is like marbling on a steak. This extra fat makes it harder for the muscle cells to metabolise blood sugar in the usual way.
- In spinal cord injuries, the muscle fibres change to primarily type IIax and IIx, fast-twitch muscle fibres. These cells are not as metabolically active, they don’t absorb or use blood sugar as efficiently and this makes the muscles fatigue easier.
- Hormones changes after a catastrophic injury. Less human growth hormone (GH), less insulin growth factor (IGF-1) and/or less testosterone can cause a further decline in muscle mass because the cells can no longer repair themselves in the same way. High levels of the stress hormone cortisol, make the cells less able to use sugar and increases body fat.6
What can be done to reduce the risk and minimise the damage?
- Involve a physiotherapist (and possibly a personal trainer) as soon as possible. These professionals can work with the client to increase their mobility, help them become more physically activity and ideally, increase their level of muscle mass.
- Monitor clients for unintended weight changes. While the Malnutrition Universal Screening tool detects health risk caused by a 10% unintended weight LOSS within 3-6 months, I would also argue that a 10% INCREASE in weight within the same time frame also requires a referral to a dietitian to reduce the risk of type 2 diabetes and heart disease.
- Advocate for annual health screening for all clients with spinal cord injuries and brain injuries. Health screening is specified for people 14 years and older who have learning disabilities due to their increased health risk7, so why are the same principles not applied to people after a catastrophic injury? Health screening could include a check of blood sugar and cholesterol levels so that any problems could be detected and treated early.
- Refer to a dietitian immediately if a client is diagnosed with impaired glucose tolerance (pre-diabetes) or type 2 diabetes. Diet, physical activity and medication can all be used to help people manage their blood sugar levels and reduce the risk of long-term complications.
For more information on type 2 diabetes after a catastrophic injury, contact Sheri Taylor, Specialist Rehab Dietitian at 0121 384 7087 or firstname.lastname@example.org. To receive more articles like this, sign up for my monthly newsletter in the box below.