Introduction

Obesity is common after spinal cord injury (SCI). It has become a major clinical and public health problem which requires several medical interventions, modifications of individual behaviour and environmental changes.1 Recent literature reported that up to 45% of SCI patients were overweight and 29% were obese.2,3 Obesity is recognised as both a cause and consequence of disease and it has been shown to be associated with poor clinical outcomes and increased healthcare costs.2 There are many health risks and co-morbidities including hypertension, diabetes, ischaemic heart disease, gallstones, osteoarthritis and some malignancies associated with obesity.1

Yet in clinical practise, many patients, allied health professionals and hospital managers do not realise how common obesity is in hospitalised patients.4,5 If ignored, this will cause a greater problem with the development of chronic nutrition-related complications.1

Among medical staff, knowledge of attitudes towards and practices in the management of obesity have been studied in various English-speaking countries, especially among general practitioners.6, 7, 8, 9 However, despite high awareness of obesity as a medically significant issue,10 the magnitude of the obesity epidemic remains high and is worsening, particularly in patients with neurological disabilities such as spinal cord injuries.2 Weight management is not commonly offered to SCI patients, at least not in the United Kingdom.11,12

SCI specialists have been identified as important potential contributors to the prevention and treatment of overweight and obesity, in part, because of continued involvement during rehabilitation. SCI medical staff are therefore in a unique position to provide guidance to patients. In some countries, SCI consultants will continue to see their patients as part of life-long followup. They are a frequently used source for information about weight control and are perceived to be a reliable formal source of information. However to our knowledge, no studies reporting the views of SCI specialists have been published.

A more detailed understanding of knowledge, attitudes and practise is necessary to determine the best way to facilitate the contribution of SCI medical staff to management of obesity after SCI. Although there are standard published recommendations for SCI management and optimal staffing levels,13,14 these documents do not make specific recommendations regarding obesity management.

While dietitians are considered essential members of the multidisciplinary team caring for patients with obesity management,1,15 the availability of dietitians in British and European SCICs remains variable.4

We therefore conducted this international survey in order to include all the SCICs in four western European countries including Belgium, the Republic of Ireland, the Netherlands and the United Kingdom as we assume that we share similar management approaches for SCI care. The aims of the study were: (i) to examine the opinions on weight management among medical staff working in SCICs; (ii) to evaluate their knowledge, attitudes and practices towards obesity prevention and management; (iii) to report the number of dietitians per bed available at each SCIC.

Methods

A 37-item cross-sectional survey was developed based on reviewed literature8 and was modified further by a team of multidisciplinary professionals working in SCICs.

Three 3-, 4- and 5-point scales were used, in which the participants had to indicate their level of agreement with each statement by selecting one from ‘strongly agree’, ‘agree’, ‘neutral’, ‘disagree’ or ‘strongly disagree’; or in practise statements, from ‘very confident’, ‘fairly confident’ or ‘not confident’ and in service statements, from ‘all of the time’, ‘most of the time’, ‘occasionally’ or ‘not at all’.

The questionnaire consisted of five sections; five questions on demographic data and staff awareness; 10 statements on exploring attitudes; three statements on self-efficacy; 11 statements on major limitations and; eight statements on service improvements.

In addition to gathering baseline demographic data and professional characteristics, a spokesman for each SCIC was asked to provide the number of available SCI beds and the number of whole-time equivalent (WTE) dietetic staff.

Because of the small sample size and for ease of presenting the data, most of the responses were grouped together, such that ‘agreed’ encompassed both ‘strongly agreed’ and ‘agreed’, ‘disagreed’ both ‘strongly disagreed’ and ‘disagreed’ and ‘most of the time’ referring to ‘all’ and ‘most of the time’.

Ethics

Formal ethical permission to conduct the study was not required by the Stoke Mandeville hospital review board as this was considered to be a clinical audit not involving active patient participation (National Research Ethics Service (NRES)).16 This was accepted by the other centres. The questionnaires were approved by the local clinical audit departments for phrasing and grammar of the questions. In addition, a pilot questionnaire was sent to three medical staff to assess the content and the time required to complete the questionnaire; feedback from this guided the drafting of the final version of the questionnaire (Supplementary Appendix 1). For Dutch and Belgian participants, the English survey was translated into native language by the study co-author (JvM) and validated by co-authors (ER) all of whom are competent in both languages (Supplementary Appendix 2).

Survey administration

The survey was administered to all medical staff working in the SCICs over four European countries (Belgium: n=3, the Republic of Ireland: n=1; the Netherlands: n=8 and the United Kingdom: n=11) between October 2012 and May 2013, with a covering letter addressed to the local medical lead explaining that findings would be used to identify current knowledge, attitude and practices of medical staff and to identify areas for improvement. Participants were reassured that all findings would be treated anonymously and in confidence to encourage respondents to answer honestly. Completed questionnaires were anonymised prior to analysis. Two reminders were sent (one at 8 weeks and one 12 weeks after the initial survey distribution).

Statistical analysis

Descriptive statistics were used to calculate the response frequency. Data are reported as medians (ranges).

Further statistical analysis was conducted to compare the existence of associations between respondents’ demographic and professional characteristics and their survey responses. In addition, the dietetics workforce was compared between UK and non-UK SCICs. For numeric data on an ordinal level, the Mann–Whitney test was used, and for cross-tabulation on a nominal level, the χ2-test was performed. The data were analysed using Minitab version 15 (Minitab, Coventry, UK) and significance was accepted if P<0.05.

Results

Medical staff from 23 SCICs were approached. The centres contained a total of 823 SCI beds (48 in Belgium, 36 in the Republic of Ireland, 258 in the Netherlands and 481 in the United Kingdom) (Tables 1 and 2).

Table 1 Breakdown of respondents (n=59) number of respondents and percentage
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Table 2 Centre characteristics and dietetic provision
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The overall SCIC response rate was 78.4% (18/23 SCICs; 59 individual responses, 2–12 responses per SCIC, 63.6% in the United Kingdom (n=7), 66.7% in Belgium (n=2), 62.5% in the Netherlands (n=5) and 100% in the Republic of Ireland (n=1)).

Demographics and professional characteristics

Nearly half of the respondents were male (n=26). The median duration of practise in SCICs was 2.5 years. Fifty-four percent (n=32) of respondents were senior doctors/consultants (had completed training) and 67.8% (n=40) were from the UK SCICs (Table 1).

No junior/trainee doctors reported that they had received formal training in obesity management of SCI patients and only two (6.3%) senior doctors reported that they had formal training in this area.

Medical staff attitudes and knowledge towards obesity management

Forty-seven (76%) respondents agreed with the statement, ‘Obesity is a major health problem among patients with SCI and requires urgent action’. Non-UK respondents (100% vs 70%, P=0.037) and non-UK consultants (100% vs 71.4%, P=0.028) were more likely to agree with the statement than UK respondents (Table 3).

Table 3 Medical staff’s attitude and knowledge towards obesity management
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Most respondents believed that they have a role in obesity prevention (64.5%) and offer advice to their patients (77.9%). Most (86.5%) believed that advice on weight maintenance should be given to all patients with SCI in order to prevent obesity. Most respondents (86.4%) believed that weight management should be offered at an early stage rather than waiting until the patients are obese (18.6%).

Although all surveyed SCICs have dietitian support (Table 3), not all respondents reported that their centre has a dietitian that deals with weight management for SCI patients.

Obesity recognition

Most of the respondents (61%) reported that they do not believe that body mass index (BMI) is an appropriate measure to guide weight management in SCI patients. A minority (35.6%) of the respondents reported they monitor in-patients’ BMI. In the outpatient setting this is even less common (23.7%). Non-UK respondents were less likely to use BMI measurements (26.3% vs 35.6% in in-patients; 0% vs 35% in outpatients) than UK respondents.

Self-reported proficiency/ability

Most respondents felt more confident in treating overweight than obese SCI adults (Table 4). Three out of four respondents (74.6%) felt adequately trained to treat patients who are overweight, but only 2/3 (66.1%) of respondents rated themselves competent in managing obesity; fewer than half (44.1%) were confident in treating paediatric obesity, even though most centres were also responsible for the care of children with SCI (Table 4).

Table 4 Medical staff reported self-efficacy
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Significantly fewer UK respondents reported being confident in treating obese paediatric patients with SCI than non-UK correspondents (35% vs 63.2%, P=0.042, χ2: 4.144).

Barriers to weight management

The leading five obstacles, identified as limitations in delivering optimal care to obese patients, in descending order, were lack of nationally adopted guidelines (64.4%), lack of patient motivation and non-compliance (61%), lack of provision of a suitable physical activity programme (61%), short consultation time for medical staff (55.9%) and lack of specialist weight management clinics to which to refer patients (52.5%; Table 5).

Table 5 Medical staff reported major limitations in weight management of SCI patients
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Significantly more UK respondents reported short consultation times to be a limiting factor (70% vs 26.3%, P=0.015). Similarly, significantly more UK respondents felt they had inadequate training in providing lifestyle and behavioural counselling for their patients when compared with non-UK respondents (65% vs 21.1%, P=0.030).

Weight management strategies

All respondents felt an ideal weight management programme should include dietary advice (100%) and physical activity advice (100%). Leaflets and education material were rated as highly important as preventive measures and in general support (Table 6).

Table 6 Weight management strategies reported by medical staff
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A large majority of respondents stated that family support (93.2%) and behavioural counselling (88.1%) were important. Most respondents would consider referrals of their patients to a dietitian (84.7%) as a first treatment step. Pharmacotherapy and bariatric surgery were the least used strategies, only 6.8% of respondents considered anti-obesity medications, and only 3.4% considered bariatric surgery as an option for weight management.

Dietetic provision in SCICs

The 22 responding centres house a total of 837 SCI beds. There were 17.45 WTE dietitians recorded; the median of 47.9 beds per WTE dietitian conceals a huge range (from 10–420). The workforce allocation is summarised in Table 2. Non-UK SCICs were significantly better resourced than UK SCICs (beds per WTE dietitian: 36 vs 124, P=0.035).

Suggestions

Ten out of fifty-nine respondents (16.9%) provided additional feedback. All responses were positive; common suggestions were the need for specific guidelines for weight management and opportunities to attend training.

Discussion

To the best of our knowledge, this is the first international multicentre survey to report on knowledge, attitudes and practices of SCIC medical staff in weight management and on the provisions of dietitians in SCICs. Previous surveys have primarily focused on obesity management among general practitioners and found that practices regarding obesity management vary widely.7, 8, 9

Weight gain after SCI is common. This is most likely due to reduced nutritional requirements secondary to enforced inactivity and immobilisation as a result of paralysis and changes in body composition,17 most marked in tetraplegia.18 In the long term, there seems to be a tendency for people with SCI to gain weight. Energy needs tend to decrease as a function of time post-injury related to loss of muscle mass. Desirable body weight/BMI for people with SCI may be lower than for the general population.19,20 After SCI, the percentage of body fat increases and muscle decreases. The body composition represented by a conventional BMI (overweight: >25 kg m−2; obese: >30 kg m−2) will be inappropriate after SCI. Buchholz’s19 and Laughton’s group 20 highlights that BMI values of over 22 kg m−2 are associated with high-fat mass in SCI individuals. The present study found that 61% of respondents considered BMI is to be an inappropriate measure to manage weight in SCI suggesting further research to define a disease-specific BMI or alternative measure is needed.

All respondents agree that successful weight management should start with prevention. Currently, there are no SCI-specific guidelines for prevention and management of overweight and obesity. Generic guidelines published by the UK National Institute for Health and Clinical Excellence suggest that dietary and lifestyle changes (a reduction in energy intake, following the eat-well plate set by the government)1 and increased physical activity in conjunction with behaviour modification support should be considered before any anti-obesity medications or bariatric surgery.20,21

Although weight loss has been advocated as a primary treatment strategy for obesity, to date, little high quality evidence exists to support this concept in patients with SCI. To our best knowledge, only limited trials have reported the effect of dietary interventions in obese SCI individuals. Studies demonstrate that a carefully planned programme with restricted dietary intake and lifestyle modification could be an effective way to reduce the body weight of obese patients with SCI without compromising total lean body mass and overall health.11,12

It is acknowledged that all patients with SCI should receive dietary advice in order to prevent obesity and its complications. In clinical practise, for all patients to be seen individually by a dietitian would lead to an unmanageable caseload. To offer educational material and input in patient education sessions may be an alternative, more effective and achievable approach. One UK SCIC offers dietetic input for patients with a BMI of 28 kg m−2 or above and the preliminary data has suggested that this approach has helped overweight individuals with SCI to reduce weight without compromising lean body mass.12

Dietitians see as their remit the management of factors related to obesity surrounding the physiological, psycho-social and ethnic needs of the patient. Professional guidelines and recommendations offer assistance on how dietitians might improve the quality of care and outcomes.2223 To tackle malnutrition and nutrition-related complications, the dietetic practise manual published by the British Dietetics Association has recommended that each SCIC should have access to a specialist dietitian in order to assess patients’ nutritional status and to provide further nutritional advice.22 More recently, the American Dietetic Association has also published guidelines for managing patients with SCI.24 It has emphasised the importance of a specialist dietitian in managing patients in acute, rehabilitation and community settings. The present study found considerable variation in dietetic provision among SCICs varied between centres and British centres have significantly lower dietetic provision when compared with some non-UK centres.

Strengths and limitations

The main strength of this study is that it is the first official international survey conducted in a multicentre European setting which obtained an overall 78.4% response rate from across four European countries.

Although the respondent sample size (n=59) was small, we feel that this still reflects the views of SCI doctors working in SCICs. To our knowledge, this represents at least 46.8% of all senior medical staff in the UK and Ireland SCICs (15 out of a total 32) which is comparable with the literature (53% response rate).25

Because the centre response rate varied from 2–12 responses per SCIC, some larger centres may be over-represented in the results. In addition, our technique of secondary invitation of respondents by selected lead individuals within a SCIC could introduce selection bias and we acknowledge this; however, guidance was provided to them to circulate the questionnaire to all medical staff, with varying degrees of experience and special interest, working in the SCIC.

There was a predominance of respondents from the United Kingdom (n=40) compared with non-UK respondents (n=19). Although this arguably over-represents one country’s perspective, it does not reflect the reality of staff mix in the SCI centres. The numbers of senior medical staff surveyed was comparable in the UK and non-UK centres (14 vs 19).

Conclusion

The present study found little variation in the knowledge, attitude and practices towards obesity prevention and management of medical staff working in the European SCICs. Limited knowledge among medical staff and variation in dietetic provision in SCIC are probably barriers to effective weight management.4 Without proper guidelines and training, it is unlikely that healthcare staff will have sufficient knowledge to identify at-risk patients or to offer appropriate treatment. This study reinforces the need to consider collaborating with national professional bodies to develop SCI-specific weight management guidelines which include clear guidance on optimal dietetic service provision within the SCICs.

Data Archiving

There were no data to deposit.