VA LOGO

Logo for the Journal of Rehab R and D
Journal of Rehabilitation Research and Development
Vol. 38 No. 2, March/April 2001

Dietary and serum lipids in individuals with spinal cord injury living in the community

Robabeh M. Moussavi, PhD; Francisca Ribas-Cardus, MS; Diana H. Rintala, PhD; Gladys P. Rodriguez, PhD

Department of Physical Medicine and Rehabilitation, Baylor College of Medicine 77030; The Institute for Rehabilitation and Research, Houston TX 77030; VA Center of Excellence on Healthy Aging with Disabilities, Houston, TX 77030


This material is based upon work supported, in part, by the National Institutes of Health Postdoctoral Medical Rehabilitation Research Grant #5-T32-HD-07465-05, the Rehabilitation Research and Training Center in Community Integration for Individuals with Spinal Cord Injury, Grant #H133B40011-95 from the National Institute on Disability and Rehabilitation Research, and the VA Center of Excellence on Healthy Aging with Disabilities.
Address all correspondence and requests for reprints to: Robabeh M. Moussavi, PhD, Baylor College of Medicine, One Baylor Plaza, Texas Medical Center, Houston, TX 77030; email: moussavi@bcm.tmc.edu.

Abstract — A cross-sectional study of 189 community-dwelling persons with spinal cord injury (SCI) (a) assessed levels of dietary and serum lipids, (b) determined the proportion of persons whose levels were out of the recommended/desired range, and (c) identified predictors of dietary and serum lipids. Lipid levels were out of range for a substantial proportion of the sample. Older persons were likely to have higher serum cholesterol and higher triglyceride levels than younger persons. Men tended to have higher intake of dietary cholesterol and lower levels of HDL than women. Caucasians and Hispanic-Americans tended to have higher triglycerides than African-Americans. Persons who had lived with SCI less time tended to have higher saturated fat intake and higher triglycerides than those who had lived with it longer. Greater saturated fat intake was associated with higher serum cholesterol after controlling for age. Studies are needed that test the effectiveness of various interventions on controlling dietary and serum lipids for persons with SCI.

Key words: cholesterol, dietary fats, HDL, LDL, lipids, lipoproteins, men, minorities, spinal cord injury, triglyceride, women.

INTRODUCTION

   There is convincing evidence that decreased levels of high-density lipoprotein cholesterol (HDL) and elevated levels of low-density lipoprotein cholesterol (LDL) in serum are associated with coronary heart disease (CHD) and myocardial infarction in the general population (1-4).

   Diet, saturated fat intake, in particular, appears to play a central role in determining serum total cholesterol, HDL, and LDL (5-8). Keys (9) has shown that reducing intake of cholesterol by half has a minimal effect (7.6 mg/dl) on serum cholesterol. However, decreasing both saturated fat and cholesterol intake by half led to about a 30 mg/dl decrease in serum cholesterol. Stone (10) reviewed the central role of diet in the control of serum total cholesterol, LDL, and HDL and their connection to CHD. He concluded that dietary cholesterol and saturated fat are among the factors elevating serum cholesterol and LDL. Hegsted and colleagues (11) reviewed the published data on the effects of dietary cholesterol and fat on the serum levels of cholesterol and lipoproteins. They concluded that saturated fatty acids are among the primary determinants of serum cholesterol and that polyunsaturated fatty acids play a major role in lowering serum cholesterol.

   A number of studies have shown that persons with spinal cord injury (SCI) are susceptible to the same diseases that affect the aging population, including CHD (12-18). As is the case for the general population, low HDL and high LDL are considered risk factors for CHD in persons with SCI (19-21). Some investigators have found that mean serum HDL levels were significantly reduced in men with SCI compared with age-matched controls (22-25). There is convincing evidence that depressed levels of HDL in persons with SCI, particularly those with tetraplegia, may be caused by a high fat diet (15,23,24,26,27). Levine and colleagues (28) reported that persons with SCI had high fat and limited carbohydrate intake. This combination can lead to abnormal metabolism, both at rest and during physical activity.

   Little is known about dietary and serum lipids in persons with SCI living in the community. This report presents data from a cross-sectional study concerning the dietary intake of cholesterol, total fat, and saturated fat, and serum levels of total cholesterol, HDL, LDL, and triglycerides in community-dwelling adults with SCI.

METHODS

Participants
   This study was a component of the Rehabilitation Research and Training Center in Community Integration for Individuals with Spinal Cord Injury sponsored by the National Institute for Disability and Rehabilitation Research (1994-2001). To participate, individuals had to be at least 18 years of age and have sustained a traumatic SCI. Dietary (n=181) and/or serum (n=179) lipid data were provided by 189 individuals (Table 1). The sample consisted, in part, of 115 persons with chronic SCI (31 women, 84 men) originally recruited for an earlier study (1988-1993) of the life status of persons with SCI. All 31 women (31 of 40 in earlier study=77.5 percent) and 64 of the men (64 of 100=64.0 percent) had been randomly selected from a sampling frame of 661 adults with traumatic SCI living within a 13-county area surrounding Houston and Galveston, Texas. Ten additional men (10 of 15 in earlier study=66.7 percent) had been selected for the life status study because they had been injured a long time, and another 10 men (10 of 15=66.7 percent) had been selected because they had been injured over the age of 35 years.


Table 1.
Characterisitics of the sample.

N = 189
  Mean SD Range

Age (years) 43.07 13.32 19.16 - 81.89
Time since injury (years) 12.46 10.43 0.46 - 46.97
    Number Percent
Gender      
     Women   44 23.3
     Men   145 76.7
Race/ethnicity      
     Caucasian   112 59.3
     African-American   42 22.2
     Hispanic-American   33 17.5
     Other   2 1.1
Level and completeness of SCI*      
     Tetraplegia (A, B or C)   78 41.3
     Paraplegia (A, B, or C)   74 39.2
     Tetraplegia or paraplegia (D)   37 19.6

* Based on American Spinal Injury Association Impairment Scale.

   An additional 25 persons (3 women, 22 men) who were injured more recently (2 to 7 years) and 15 persons (5 women, 10 men) from Hispanic backgrounds were recruited from an updated sampling frame (1994-1998) to supplement those persons with chronic SCI who were in the earlier study. Finally, 34 persons (5 women, 29 men) were recruited during their initial rehabilitation hospitalization (1994-1998) and followed longitudinally during their first two years postdischarge. Lipid data for these 34 persons were obtained between 6 and 15 months postdischarge. As can be seen in Table 1, there was a wide range of ages and times since injury. Nearly one-fourth of the participants were female and approximately 40 percent were from minority backgrounds.

Dietary Lipid Intake
   Dietary intake was assessed by 3-day self-reports on a form given to each subject. The form was accompanied by a booklet that contained life-size drawings of various glasses and measuring cups marked in ounces, circles marked in sectors to simulate wedges of pizzas, pies, or cakes, and rectangles to measure portions of meats or pats of butter. The booklet was part of the software package that was used to analyze the food intake. The program was developed at the School of Public Health of the University of Texas (29). The portions depicted in the booklet were labeled with numbers and letters that the subjects used to indicate the size of the portions of each food they had eaten. The form had separate columns in which to indicate whether the subject was reporting on what they had eaten at breakfast, lunch, dinner, or as a snack. Within these categories, the subject listed all they had eaten plus the size of the portions of each dish. At the bottom of each page there was a reminder to include any food supplements, herbs, or vitamin and mineral pills. The participants were free to choose the days they were reporting. However, most of the participants reported on the days immediately preceding a home visit by a research nurse; therefore most of the days reported were weekdays. Those who had not completed the diet forms at the time of the home visit by the nurse, were called later by the research coordinator on 3 successive days and asked to report on their food intake. The coordinator recorded the information on the forms. The software program had standard recipes used to determine the amount of each nutrient ingested by the subject. The program also had the capability to accept the input of recipes of any unusual dishes that the subjects reported eating. The program reported absolute values of 25 individual nutrients including cholesterol, total fat, and saturated fat. It also reported total calories as well as the percent of calories contributed by each nutrient. After calculating each day's values separately, the program averaged the results for the 3 days. These average values were used in the analyses.

Serum Lipids
   Following overnight fasting, blood was collected at the home of the participants and delivered in ice for biochemical assays. Serum levels of cholesterol, HDL, LDL, and triglyceride were measured using standard laboratory techniques (30).

Data Analysis
   Descriptive statistics (means, standard deviations, ranges, skewness, kurtosis, numbers, percents) were obtained for all study variables including, for the lipid data, separate statistics for females, males, Caucasians, African-Americans, and Hispanic-Americans. A Chi-square analysis was performed to determine the relationship between gender and race/ethnicity in the sample. For each dietary and serum lipid variable, the percent of persons whose value was out of the range recommended/desired by the National Cholesterol Education Program (31,32) was calculated for the entire sample and for each gender and racial/ethnic group. Spearman rho correlational analyses were performed to determine (a) the relationship of the dietary and serum lipid levels with age and time since injury and (b) the relationship of the dietary lipids with the serum lipids. Nonparametric analyses were used because several of the lipid variables did not have normal distributions (skewness >1.0 and/or kurtosis >1.0).

   To identify predictors (correlates) of lipid levels, separate stepwise multiple regression analyses were performed for the ranked data for each lipid variable. Criteria for entry were a probability for F to enter <= 0.050 and a probability for F to remove >= 0.100. Ranked data for all continuous variables were utilized in these regression analyses because of the non-normal distributions of several of the variables. For dietary lipids, the potential predictors were gender, race, level and completeness of injury, rank of age, and rank of time since injury. Categorical variables were dummy coded for these analyses and omitted the two persons who were coded as "Other" for race/ethnicity.

   For serum lipids, the potential predictors included those same demographic and injury-related variables as well as rank of dietary cholesterol, rank of amount of fat expressed as grams or as percent of total calories, and rank of amount of saturated fat expressed as grams or as percent of total calories. The regression analyses included only those persons for whom complete data were available for the particular analysis. For all analyses, the significance level was set at p<0.05.

RESULTS

Lipids
   Mean dietary intake of cholesterol, total and saturated fat, and serum levels of cholesterol, HDL, LDL, and triglycerides are shown in Table 2 for the total sample, females, males, Caucasians, African-Americans, and Hispanic-Americans. Fat and saturated fat intake values are presented both as grams and as a percent of total calories.


Table 2.
Descriptive statistics for dietary and serum lipids.

N = 189*
  Overall Mean (SD) range Female mean (SD) range Male mean (SD) range Caucasian mean (SD) range African-American mean (SD) range Hispanic-American mean (SD) range

Dietary lipids            
  Sample size 181 44 137 107 41 31
     Cholesterol (mg) 273.28 244.92 282.40 245.86 314.99 308.12
  (154.78) (163.01) (151.53) (131.58) (174.91) (187.39)
  21-728 69-695 21-728 61-711 69-694 21-728
     Fat (g) 68.86 62.60 70.87 68.92 68.55 67.95
  (29.36) (28.13) (29.56) (27.39) (33.81) (29.98)
  12-158 26-158 12-157 18-144 20-157 12-158
     Fat
     (% of total calories)
36.67 36.47 36.74 36.18 38.78 35.76
  (7.58) (9.32) (6.97) (7.55) (6.70) (8.63)
  12-60 12-60 15-53 12-55 25-53 19-60
     Saturated fat (g) 23.40 20.82 24.22 23.20 23.76 23.17
  (10.72) (9.10) (11.09) (10.25) (12.42) (9.59)
  4-56 9-50 4-56 6-55 7-56 4-50
     Saturated fat
     (% of total calories)
12.44 12.26 12.50 12.11 13.40 12.40
             
  Serum lipids            
  Sample size 179 41 138 104 41 32
     Cholesterol (mg/dl) 195.85 202.37 193.92 194.89 190.85 203.44
  (36.38) (39.65) (35.28) (31.10) (38.21) (46.87)
  130-322 139-301 130-322 139-301 130-322 130-294
     HDL (mg/dl) 46.21 54.21 43.74 45.86 47.49 45.69
  (11.71) (13.33) (9.97) (12.44) (10.25) (11.59)
  22-91 31-91 22-68 22-91 23-70 25-72
     LDL (mg/dl) 120.19 118.12 120.81 117.94 122.22 123.16
  (34.97) (38.33) (34.02) (32.29) (35.30) (42.43)
  39-250 56-239 39-250 39-239 63-250 58-234
     Triglycerides (mg/dl) 148.27 147.20 148.59 155.36 106.80 177.38
  (100.31) (96.68) (101.70) (98.32) (38.18) (141.30)
  28-795 65-532 28-795 28-532 45-194 39-795

* Sample sizes vary because some participants (n=8) provided dietary information but their serum data were unavailable. For other participants (n=10), serum data were available but no dietary information was obtained. No LDL data were available for one Caucasian male. The percent of women across the racial/ethnic groups was not significantly different: Caucasian - 23.2%, African-American - 21.4%, and Hispanic-American - 27.3, Chi Square=0.366, p<.833.

Comparison with Recommended/Desired Values
   The values recommended/desired by the National Cholesterol Education Program (31, 32) are displayed in Table 3. The percent of participants whose values were out of the recommended/desired range for each lipid variable are presented for the total sample, females, males, Caucasians, African-Americans, and Hispanic-Americans. Fat and saturated fat as a percent of total calories are out of range for approximately 80 percent of the sample, and this is true for both genders and all racial/ethnic groups. Over one-third of the participants were out of range for dietary cholesterol, serum cholesterol, and LDL.


Table 3.
Percent of participants out of recommended/desired range.

  Recommended/
desired amount*
Overall Women Men Caucasian African-American Hispanic-American

Dietary lipids              
     Cholesterol (mg) <300 mg 35.4 25.0 38.7 29.9 41.5 41.9
     Fat
     (% of total calories)
<30% of daily calories 82.9 75.0 85.4 81.3 92.7 74.2
     Saturated fat
     (% of total calories)
<10% of daily calories 79.0 77.3 79.6 78.5 85.4 74.2
Serum lipids              
     Cholesterol (mg/dl) 195.85 202.37 193.92 194.89 190.85 203.44 203.44
     HDL (mg/dl) 46.21 54.21 43.74 45.86 47.49 45.69 45.69
     LDL (mg/dl) 120.19 118.12 120.81 117.94 122.22 123.16 123.16
     Triglycerides (mg/dl) 148.27 147.20 148.59 155.36 106.80 177.38 123.16

* National Cholesteral Education Program (31.32).

Relationship of Lipids to Age and Time Since Injury
   As shown in Table 4, the relationship of dietary and serum lipids with age and time since injury were relatively weak. However, age was significantly related to serum cholesterol and triglycerides (p<0.01) and time since injury was related to saturated fat intake expressed as either grams or percent of total calories. Older persons tended to have higher serum cholesterol and higher triglyceride levels. Persons with longer times since injury consumed less saturated fat.


Table 4.
Spearman Rho correlation coefficients of dietary and serum lipids with age and time since injury.

  Age Time since injury

Dietary lipids    
     Cholesterol (mg) -0.08 -0.08
     Fat (g) -0.12 -0.14
     Fat
     (% of total calories)
-0.10 -0.09
     Saturated fat (g) -0.16* -0.21**
     Saturated fat
     (% of total calories)
-0.15* -0.20**
Serum lipids    
     Cholesterol (mg/dl) 0.23** 0.08
     HDL (mg/dl) 0.02 0.07
     LDL (mg/dl) .010 0.03
     Triglycerides (mg/dl) 0.24** -0.01

** p<.01, * p<.05.

Relationship of Dietary Lipids to Serum Lipids
   Displayed in Table 5 are the correlation coefficients for the relationship between dietary and serum lipids. The correlations are very low, and none was significant at the p<0.01 level. Only the relationship between fat as a percent of total calories and triglycerides was significant at the p<0.05 level.


Table 5.
Spearman Rho correlations of dietary lipids with serum lipids.

  Serum cholesteral Serum HDL Serum LDL Serum triglycerides

Dietary lipids        
     Cholesterol (mg) 0.04 0.02 0.11 -0.08
     Fat (g) 0.09 0.02 0.09 -0.04
     Fat
     (% of total calories)
-0.04 0.06 -0.01 -0.17*
     Saturated fat (g) 0.09 0.05 0.09 -0.04
     Saturated fat
     (% of total calories)
-0.03 0.08 -0.01 -0.10

** p<.05.

Predictors of Dietary Lipids
   The results of the stepwise multiple regression analyses predicting the dietary lipid variables are presented in Table 6. It is important to mention that since this is a cross-sectional study, causal associations cannot be determined. Gender was predictive of dietary cholesterol levels. Women had lower dietary cholesterol levels than did men. No other variables were predictive of this dietary lipid. There was no significant predictor for dietary fat, whether expressed as grams or as a percent of total calories. Saturated fat in grams and as a percent of total calories was related only to rank of time since onset. As noted above, persons who had lived with their SCI longer tended to have lower saturated fat intake. Although there were significant relationships between the demographic and injury-related information and some dietary lipids, no more than four percent of the variance in any of the dependent variables was accounted for by the predictors. Race/ethnicity, level and completeness of injury, and rank of age were not related to any of the dietary lipid variables.


Table 6.
Stepwise Multiple Regression Models for dietary lipids predicted by demographic and injury-related variables.*

Dependent variable Predictor variables Multiple R Multiple R2 Change in R2 b p Adjusted R2

Rank of dietary cholesteral Gender 0.156 0.024 0.024 0.156 0.04 0.019
Rank of fat (g) No significant predictors            
Rank of fat (g) (% of total calories) No significant predictors            
Rank of saturated fat (g) Rank of time since injury 0.201 0.040 0.040 -0.201 0.01 0.035
Rank of saturated fat (% of total calories) Rank of time since injury 0.188 0.035 0.035 -0.188 0.01 0.030

* Potential predictors: gender, race/ethnicity (dummy coded as African-American and Hispanic), level and completeness of injury (dummy coded as tetraplegia (A, B, or C) and paraplegia (A, B, or C)), rank of age, and rank of time since injury. The two male participants with "other" race/ethnicity were excluded from these analyses.

Predictors of Serum Lipids
   Displayed in Table 7 are the results of the stepwise multiple regression analyses predicting the serum lipid variables. Rank of age and rank of saturated fat in grams were both significant predictors of rank of serum cholesterol. Rank of age accounted for 6.1 percent of the variance, and rank of saturated fat accounted for an additional 2.4 percent. Thus, a total of 8.5 percent of the variance was accounted for. Older persons had higher serum cholesterol levels and, after controlling for age, persons eating more saturated fat had higher serum cholesterol levels.


Table 7.
Stepwise Multiple Regression Models for serum lipids predicted by demographic, injury-related, and dietary lipid variables.*

Dependent variable Predictor variables Multiple R Multiple R2 Change in R2 b p Adjusted R2

Rank of serum
cholesteral
Rank of age
Rank of saturated fat (g)
0.246
0.291
0.061
0.085
0.061
0.024
0.273
0.158
0.001
0.04
0.055
0.074
Rank of HDL Gender 0.332 0.110 0.110 -0.332 0.001 0.105
Rank of LDL No significant predictors            
Rank of triglycerides Rank of age
African-American
Rank of time since injury
0.257
0.339
0.381
0.066
0.115
0.145
0.066
0.049
0.030
0.325
-0.238
-0.196
0.001
0.003
0.02
0.061
0.104
0.130

* Potential predictors: gender, race/ethnicity (dummy coded as African-American and Hispanic), level and completeness of injury (dummy coded as tetraplegia (A, B, or C) and paraplegia (A, B, or C)), rank of age, rank of time since injury, rank of dietary cholesteral, rank of fat (g), and rank of saturated fat (g). Similar results were obtained when rank of fat (% of total calories) and rank of saturated fat (% of total calories) were substituted for rank of fat (g) and rank of saturated fat (g), except that rank of saturated fat (% of total calories) did not enter the equation predicting rank of serum cholesteral. The two male participants with "other" race/ethnicity were excluded from these analyses. For the analysis in which LDL was the dependent variable, the sample size was 168.

   Gender was the only significant predictor for rank of HDL and accounted for 11 percent of the variance. Males had lower HDL levels. There were no significant predictors for rank of LDL. Three variables were found to be significant predictors of the rank of triglycerides--rank of age, being African-American or not, and rank of time since injury. Rank of age accounted for nearly 7 percent of the variance, being African-American or not accounted for an additional 5 percent, and rank of time since injury accounted for another 3 percent. A total of 14.5 percent of the variance was accounted for by these three variables. Older individuals, non-African-Americans, and those with less time since injury were more likely to have high triglyceride levels than those who were younger, African-American, and/or had more time since injury. It is noteworthy that no more than 14.5 percent of the variance was accounted for in any serum lipid. Level and completeness of injury, rank of dietary cholesterol, rank of fat expressed as grams or percent of total calories, and rank of saturated fat expressed as percent of total calories were not predictive of any of the serum lipid variables.

DISCUSSION

   A cross-sectional study of individuals with SCI indicated levels and correlates of their dietary and serum lipids.

Level of Dietary Lipids
   Fat intake as a percent of total calories was about 37 percent compared to the recommended value of 30 percent. Similar results have been reported by Levine and colleagues for persons with SCI (28) and by Millen and colleagues for the general population (33). Intake of total and saturated fat were above the levels recommended by NCEP (31) for about 80 percent of participants. More than one-third of the participants had cholesterol intake above the recommended level of 300 mg. This was true for both genders and all racial/ethnic groups.

Predictors of Dietary Lipids
   Women had lower dietary cholesterol than men. This is similar to the findings in the Framingham study of the general population (33). Persons with longer time since injury had lower saturated fat intake. To our knowledge, no previous studies have examined the relationship between time since onset of SCI and dietary lipid intake. The very small amount of variance accounted for in dietary lipids suggests that intake of lipids is related to several factors other than demographic and injury-related variables such as cultural differences in diet (34) and socio-economic factors (35).

Level of Serum Lipids
   More than 40 percent of the participants were out of the desired range for serum cholesterol and over 30 percent for LDL (32). It is noteworthy that although mean serum levels of HDL were above the desired minimum of 35 mg/dl, 20 percent of the men with SCI in this study had a serum level of HDL below 35 mg/dl. This is twice the percentage (10 percent) of persons with low HDL in the general population (22). Depressed serum HDL in persons with SCI has been reported by previous investigators. In a study by Zlotolow and colleagues, approximately half of the veterans with paraplegia had values below 35 mg/dl (24). Bauman et al. noted that about one-third of the persons with SCI in their study had serum HDL below 35mg/dl, compared to 12 percent for the aged-matched controls (22). This finding suggests that a larger proportion of men with SCI than those in the general population may be at risk for development of CHD due to reduced levels of HDL (22-25,32). In contrast, less than 5 percent of the women had an HDL level below the desired 35 mg/dl.

   Only 7 percent of African-Americans with SCI had serum HDL below 35mg/dl compared to about 20 percent for Caucasians and Hispanic-Americans. Serum HDL levels have been reported in a number of studies to be higher in African-Americans than in other ethnic groups both in persons with SCI (22) and in the general population (36-38). Triglyceride levels were similar to the general population (33). Interestingly, in our study, no African-Americans had triglyceride levels above the desired range.

Predictors of Serum Lipids
   Older persons and persons eating more saturated fat had higher serum cholesterol. Similar results have been reported for persons with SCI (39) and for the general population (5-8).

   Triglyceride levels were predicted by age, race, and time since injury. Age was positively related to serum triglyceride levels. Matter, et al. (40) reported similar findings for adults in the general population. African-Americans had lower triglyceride levels in our sample, and this also was found by Bauman, et al. (22) for both SCI and age-matched controls. After controlling for age and race, persons with longer time since injury had lower triglyceride levels. As with saturated fat intake, to our knowledge, no other studies have reported the relationship between time since onset of SCI and triglycerides. Although, the percent of variance accounted for in three of the four serum lipids studied here was greater (8.5 percent to 14.5 percent) than the variance accounted for in dietary lipids, it was still relatively small. Other factors that may affect serum lipids may be genetic factors or activity levels (22,38,41,42).

   Limitations of this study include (a) food consumption diaries for 1 to 7 days, while frequently used (24,28,33), may not be the most accurate method of determining dietary intake, since they rely on self reports of, not only what was eaten, but also estimation of portion size; (b) a single measurement of serum lipids can provide reliable, but not optimal, results (43); and (c) all of the participants resided in a small geographic area in southeastern Texas, which may limit generalizability. However, financial and practical considerations made these choices the most viable for this study.

   The implications of these findings include (a) there is a need for interventions to reduce the dietary and serum lipids of persons with SCI, particularly men; (b) studies are needed to determine what effect innovative nutritional education programs have on the lipid intake of persons with SCI; (c) studies are needed to determine what effect reduction of dietary lipids has on the serum lipids of persons with SCI; and (d) very long-term studies are needed to determine the relationship between serum lipids and later onset of CHD in persons with SCI.

   Future studies should include age-matched controls, multiple blood samples for serum lipid measurement, cultural and socio-economic factors, genetic factors, activity levels, and medications. Interventional and longitudinal studies will be necessary to determine the complex role of dietary lipid intake and other factors in determining serum lipids in persons with SCI.

REFERENCES
  1. Stampfer MJ, Sacks FM, Salvini S, Willett WC, Hennekens CH. A prospective study of cholesterol, apolipoproteins and the risk of myocardial infarction. N Engl J Med 1991;325:373-81.
  2. Brunner D, Weisbort J, Meshulam N, Schwartz S, Gross J, Saltz-Rennert H, et al. Relation of serum total cholesterol and high density lipoprotein cholesterol percentage to the incidence of definite coronary events: twenty year follow-up of the Donolo-Tel Aviv Prospective Coronary Artery Disease Study. Am J Cardiol 1987;59:1271-6.
  3. Castelli WP, Leaf A. Identification and assessment of cardiac risk--an overview. Cardiol Clin 1985;3:171-8.
  4. Gordon T, Castelli WP. High density lipoprotein as a protective factor against coronary heart disease: The Framingham Study. Am J Med 1977;62:707-14.
  5. Keys A, Anderson JT, Grande F. Prediction of serum cholesterol responses of man to changes in fats in the diet. Lancet 1957;1:959-66.
  6. Hegsted DM, McGandy RB, Myers ML, Stare FJ. Quantitative effects of dietary fat on serum cholesterol in man. Am J Clin Nutr 1965;17:281-95.
  7. Durrington PN, Bolton CH, Hartog M, Angelinetta R, Emmett P, Furniss S. The effect of a low-cholesterol, high-polyunsaturated diet on serum lipid levels, apolipoprotein B levels and triglyceride fatty acid composition. Atherosclerosis 1977;27:465-75.
  8. Schonfeld G, Patsch W, Rudel LL, Nelson C, Epstein M, Olson RE. Effects of dietary cholesterol and fatty acids on plasma lipoproteins. J Clin Invest 1982;69:1072-80.
  9. Keys A. Serum cholesterol response to dietary cholesterol. Am J Clin Nutr 1984;40:351-9.
  10. Stone NJ. Diet, lipids, and coronary heart disease. Endocrinol Metab Clin North Am 1990;19(2):321-44.
  11. Hegsted DM, Ausman LM, Johnson JA, Dallal GE. Dietary fat and serum lipids: an evaluation of the experimental data. Am J Clin Nutr 1993;57:875-83.
  12. Whiteneck G. Learning from recent empirical investigations. In: Menter R, Whiteneck G, editors. Perspectives on aging with spinal cord injury. New York: Demos; 1992. p. 23-7.
  13. Whiteneck GG, Charlifue SW, Frankel HL, Fraser MH, Gardner BR, Gerhart KA, et al. Mortality, morbidity, and psychosocial outcomes of persons spinal cord injured more than 20 years ago. Paraplegia 1992;30:617-30.
  14. DeVivo MJ, Black KJ, Stover SL. Causes of death during the first 12 years after spinal cord injury. Arch Phys Med Rehabil 1993;74:248-54.
  15. Yekutiel M, Brooks ME, Ohry A, Yarom J, Carel R. The prevalence of hypertension, ischaemic heart disease and diabetes in traumatic spinal cord injured patients and amputees. Paraplegia 1989;27:58-62.
  16. LaPorte RE, Adams LL, Savage DD, Brenes G, Dearwater S, Cook T. The spectrum of physical activity, cardiovascular disease and health: an epidemiologic perspective. Am J Epidemiol 1984;120:507-17.
  17. Gordon DJ, Probstfield JL, Garrison RJ, Neaton JD, Castelli WP, Knoke JD, et al. High-density lipoprotein cholesterol and cardiovascular disease: four prospective American studies. Circulation 1989;79:8-15.
  18. Cardus D, Ribas-Cardus F, McTaggart WG. Coronary risk in spinal cord injury: assessment following a multivariate approach. Arch Phys Med Rehab 1992;73:930-3.
  19. Janssen TW, van Oers CA, van Kamp GJ, TenVoorde BJ, van der Woude LH, Hollander AP. Coronary heart disease risk indicators, aerobic power, and physical activity in men with spinal cord injuries. Arch Phys Med Rehabil 1997;78:697-705.
  20. Bauman WA, Spungen AM, Zhong YG, Rothstein JL, Petry C, Gordon SK. Depressed serum high density lipoprotein cholesterol levels in veterans with spinal cord injury. Paraplegia 1992;30:697-703.
  21. Bauman WA, Spungen AM, Raza M, Rothstein J, Zhang RL, Zhong YG, et al. Coronary artery disease: metabolic risk factors and latent disease in individuals with paraplegia. Mt. Sinai J Med 1992;59(2):163-8.
  22. Bauman WA, Adkins RH, Spungen AM, Herbert R, Schechter C, Smith D, et al. Is immobilization associated with an abnormal lipoprotein profile? Observations from a diverse cohort. Spinal Cord 1999;37:485-93.
  23. Maki KC, Briones ER, Langbein WE, Inman-Felton A, Nemchausky B, Welch M, Burton J. Associations between serum lipids and indicators of adiposity in men with spinal cord injury. Paraplegia 1995;33:102-9.
  24. Zlotolow SP, Levy E, Bauman WA. The serum lipoprotein profile in veterans with paraplegia: the relationship to nutritional factors and body mass index. J Am Paraplegia Soc 1992;15(3):158-62.
  25. Bauman WA, Adkins RH, Spungen AM, Kemp BJ, Waters RL. The effect of residual neurological deficit on serum lipoproteins in individuals with chronic spinal cord injury. Spinal Cord 1998;36:13-7.
  26. Shetty KR, Sutton CH, Rudman IW, Rudman D. Lipid and lipoprotein abnormalities in young tetraplegic men. Am J Med Sci 1992;303(4):213-6.
  27. Apstein MD, George BC. Serum lipids during the first year following acute spinal cord injury. Metabolism 1998;47(4):367-70.
  28. Levine AM, Nash MS, Green BA, Shea JD, Aronica MJ. An examination of dietary intakes and nutritional status of chronic healthy spinal cord injured individuals. Paraplegia 1992;30:880-9.
  29. Food Intake Analysis System, University of Texas Health Science Center, Version 2.3 (computer software). Houston, Texas: University of Texas Health Science Center, 1993.
  30. Manuals of laboratory operations. Lipids research clinics program. Vol. I. Lipids and proteins analysis. DHEW Publication (NIH); 1974. p. 75-628.
  31. National Cholesterol Education Program. Report of the Expert Panel on Population Strategies for Blood Cholesterol Reduction: executive summary. National Heart, Lung, and Blood Institute, National Institutes of Health. Arch Intern Med 1991;151:1071-84.
  32. Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 1993;269:3015-23.
  33. Millen BE, Quatromoni PA, Franz MM, Epstein BE, Cupples A, Copenhafer DL. Population nutrient intake approaches dietary recommendations: 1991 to 1995 Framingham Nutrition Studies. J Am Diet Assoc 1997;97:742-9.
  34. Fortmann SP, Williams PT, Hulley SB, Maccoby N, Farquhar JW. Does dietary health education reach only the privileged? The Stanford Three Community Study. Circulation 1982;66(1):77-82.
  35. Jeffery RW, French SA, Forster JL, Spry VM. Socioeconomic status differences in health behaviors related to obesity: the Healthy Worker Project. Int J Obes 1991;15(10):689-96.
  36. Rubins HB, Robins SJ, Collins D, Iranmanesh A, Wilt TJ, Mann D, et al. Distribution of lipids in 8,500 men with coronary artery disease. Department of Veterans Affairs HDL Intervention Trial Study Group. Am J Cardiol 1995; 75:1196-201.
  37. Sprafka JM, Norsted SW, Folsom AR, Burke GL, Luepker RV. Life-style factors do not explain racial differences in high-density lipoprotein cholesterol: the Minnesota Heart Survey. Epidemiology 1992;3(2):156-63.
  38. Anderson RA, Burns TL, Wallace RB, Folsom AR, Sprafka JM. Genetic markers associated with high density lipoprotein cholesterol levels in a biracial population sample. Genet Epidemiol 1992;9:109-21.
  39. Cardus D, Ribas-Cardus F, McTaggart WG. Lipid profiles in spinal cord injury. Paraplegia 1992;30:775-82.
  40. Matter S, Stamford BA, Weltman A. Age, diet, maximal aerobic capacity and serum lipids. J Gerontol 1980;35(4):532-6.
  41. Brenes G, Dearwater S, Shapera R, LaPorte RE, Collins E. High density lipoprotein cholesterol concentrations in physically active and sedentary spinal cord injured patients. Arch Phys Med Rehabil 1986;67:445-50.
  42. Dallmeijer AJ, Hopman MT, van der Woude LH. Lipid, lipoprotein, and apolipoprotein profiles in active and sedentary men with tetraplegia. Arch Phys Med Rehabil 1997;78:1173-6.
  43. Mogadam M, Ahmed SW, Mensch AH, Godwin ID. Within-person fluctuations of serum cholesterol and lipoproteins. Arch Intern Med 1990;150:1645-8.

View Contents

  Last Updated Wednesday, November 19, 2008 12:51 PM

Back to Top

Last revised Fri 4/13/2001