Sports Med.

1997 Jan; 23 (I); 48-60

REVIEW ARTICLE 0112-1642/97/000 1-(1)48/$06.50/0

© Adis International Umited. All rights reserved.

Body Composition of Spinal Cord

Injured Adults
Paula Kacina
Center for Exercise and Applied Human Physiology, Johnson Center, University of New Mexico,
Albuquerque, New Mexico, USA

Contents
Summary .................... . 48
1. Disease Risk Factors in Spinal Cord Injury (SCI) 49
1.1 Obesity.................... 49
1.2 Cardiovascular Disease . . . . . . . . . . 50
1.3 Non-Insulin-Dependent Diabetes Mellitus (NIDDM) 51
1.4 Osteoporosis. . . . . . . . . . . . . . . . . 51
2. Changes in Body Composition Following SCI . 52
2.1 Fat-Free Body Composition in the SCI 53
2.2 Mineral . 53
2.3 Protein . . . . . . . . . . . . . . . . . . 53
2.4 Water . . . . . . . . . . . . . . . . . . . 54
3. Body Composition Assessment Techniques . 54
3.1 Hydrostatic Weighing . . . . . . . . 54
3.2 Dual-Energy X-Ray Absorptiometry . 55
3.3 Skinfold Method. . . . . . . . . . . . 55
3.4 Bioelectrical Impedance Method . 56
4. Body Composition Applications for the SCI Population 57
5. Conclusions . . . . .. . . . . . . . . . . . . . . . . . . 57

Summary The prevalence of diseases associated with obesity, such as cardiovascular

disease and diabetes mellitus, is higher in the spinal cord injury (SCI) population.
Specifically, the mortality rate for cardiovascular disease is 228% higher in the
SCI population. In addition, 100% of SCI individuals have osteoporosis in the
paralysed extremities. These diseases are related to physical activity level, the
level of the spinal cord lesion, and time post injury. Physically active SCI men
and women have above-average fat mass (16 to 24% and 24 to 32%, respectively,
compared with 15% for able-bodied men and 23% for able-bodied women), while
sedentary SCI individuals have 'at-risk' levels of body fat (above 25% and 32%,
respectively).
The proportions and densities of the 3 main constituents comprising the fat-
free body (mineral, protein and water) are altered following SCI. Bone mineral
content decreases by 25 to 50%, and the magnitude of reduction is dependent on
the level, completeness and duration of SCI. Because of denervation resulting in
skeletal muscle atrophy, total body protein reduces by 30%, and total body water
relative to bodyweight decreases by 15% following SCI.
Body Composition of SCI Adults 49

Indirect methods based on 2-component body composition models assume

constant proportions and densities of mineral, protein, and water in the fat-free
body. As a result, prediction equations based on 2-component models yield in-
valid estimates of fat and fat-free mass in the SCI population. Therefore, future
research needs to directly quantify the proportions and densities of the constitu-
ents of the fat-free body in the SCI population relative to age, sex, physical
activity level, level of the spinal cord lesion and time post injury, and to develop
equations based on multi component body composition models.

It is widely known that physical activity posi-
tively influences body composition by increasing
fat-free mass and decreasing levels of body fat.[l-31
Conversely, decreased physical activity following
spinal cord injury (SCI) results in substantial
changes in muscle mass, bone mineral, and body
fat. Muscle mass decreases following SCI, primar-
ily due to disuse atrophy.[4-91 Also, bone mineral
content and bone density, especially in the para-
lysed limbs, decline significantly.[5,6,lO-161 In addi-
tion, higher levels of body fat lead to obesity and
metabolic changes that influence the disease risk
profile of SCI individuals,l171 Given that both phys-
ical inactivity and obesity are major risk factors for
developing cardiovascular disease and non-insulin-
dependent diabetes mellitus (NIDDM), and physi-
cal inactivity is correlated with osteoporosis, it is
important to be able to assess and monitor changes
in body composition in the SCI population.
Although there are well established clinical
methods to assess the body composition of able-
bodied persons, these methods may not be directly
applicable to SCI individuals. Indirect body com-
position methods, such as skinfolds and bioelectri-
cal impedance analysis, are used in able-bodied
populations to estimate fat and fat-free mass.[18- 281
However, these prediction equations are specific to
the age, sex, race, level of adiposity and physical
activity level of the individual.[29, 301 Also, these
prediction equations were developed using refer-
ence body composition methods and models that
assume specific relative proportions and densities
of the components of the fat-free body (mineral,
water and protein). Because the fat-free body
changes following SCI, equations developed for
able-bodied populations may not be generally ap-
plicable to the SCI population.
The purpose of this review is to provide an over-
view of: (i) the prevalence of diseases associated
with physical inactivity and obesity in the SCI pop-
ulation; (ii) alterations in body composition fol-
lowing SCI; and (iii) recommendations for assess-
ing body composition of SCI individuals in clinical
settings.
1. Disease Risk Factors in Spinal Cord
Injury (SCI)
1,1 Obesity
Epidemiological research indicates that obesity
is a major risk factor for developing cardiovascular
disease, hypertension, diabetes mellitus, obstruc-
tive pulmonary disease, hypercholesterolaemia,
osteoarthritis, renal disease and certain can-
cers.[3,31-331 The US National Institute of Health[3 41
defines obesity as body weight exceeding 20% of
the desirable level for a given age, sex and skeletal
frame.
However, this definition is limited because it
does not take into account the relative amounts of
fat and fat-free mass comprising the bodyweight.
Therefore, a more useful definition of obesity is an
excessive amount of total body fat for a given
bodyweight. The ideal body fat relative to body-
weight (percentage body fat) is 15% for adult men
and 23% for adult womenP 31 Individuals with
body fat levels exceeding 25% for men and 32%
for women are classified as obese and, as such, are
at greater risk for certain diseasesp 31
Sedentary SCI individuals tend to have a greater

© Adis International Limited. All rights reserved. Sports Med. 1997 Jan; 23 (1)
50
fat mass compared with sedentary able-bodied
persons, predisposing them to increased risk for
cardiovascular disease and NIDDM.[17,31-39) In ad-
dition, excess body fat may predispose SCI indi-
viduals who are confined in wheelchairs to pres-
sure ulcers and reduce their independence in
transfer activities as well as in other activities of
daily living.[4,7)
George and colleagues(39) reported that seden-
tary SCI men have an average 24.5% body fat com-
pared with 17% body fat for weight-matched able-
bodied men when measured by hydrodensitometry.
Also, Rasmann Nuhlicek et al.fS) noted that the
average body fatness (estimated from bodyweight
and tritiated water) of men in high paraplegic (le-
sions from TlO to T2), low quadriplegic (Tl to C6)
and high quadriplegic (lesions above C6) groups
was 30.1, 35.7 and 35.3% respectively. These val-
ues are more than double the average body fat level
(15% body fat) of able-bodied men(23) (measured
by hydrodensitometry), and demonstrate a ten-
dency for body fat levels to increase progressively
with successive increments in the level of spinal
cord lesion.
However, physical activity may counter some of
the increase in body fat in the SCI population. Olle
and colleagues(7) noted that the average percentage
of body fat of physically active SCI men (measured
by total body electrical conductivity) was 15.6%
compared with 23.2% for their sedentary SCI
counterparts. Ide et aU40) recently reported that the
average body fat for 2677 wheelchair marathon
race competitors (measured by skinfold method)
ranged from 17.6 to 18.7%, whereas Bulbulian et
aU41) observed an average body fat of 22.4% for
22 paraplegic male athletes (measured by hydro-
densitometry). The effect of physical activity on
body fat in women with SCI is not as well docu-
mented. Lussier and colleagues(42) reported that the
body fat levels of 2 Olympic and national calibre
female wheelchair athletes were, respectively, 28.9
and 32.1 % (measured by hydrodensitometry). Al-
though these female SCI athletes participated in
marathon racing, track, and basketball, their body
© Adis Intemational Limited. All rights reseNed.
Kocina
fat values were higher than those average values
reported for nonathletic, able-bodied women (23%
body fat)P3) Although more than 20% of the SCI
population is female, there has been limited re-
search documenting body composition in SCI
women.
Given the increased disease risk associated with
obesity in both the sedentary[S,17,35,36] and physi-
cally active[17,3S,43) SCI populations, accurate as-
sessment of body fat is an important component in
the health profile of SCI individuals. Body compo-
sition needs to be routinely evaluated by the med-
ical community working with this population.
1.2 Cardiovascular Disease
The relatively high prevalence of obesity in the
SCI population, places these individuals at risk for
cardiovascular disease. Cardiovascular disease is
the leading cause of death in this population.f 17 ,32)
Compared with age- and sex-matched able-bodied
individuals, the overall mortality rate from cardio-
vascular disease is 228% greater for the sedentary
SCI population.f3 S) Also, cardiovascular disease
occurs at a relatively younger age in this group,
with 46% of SCI individuals who are 30 years or
older dying from cardiovascular disease,f17) This
appears to be due to a high prevalence of metabolic
factors recognised to be risk factors for cardio-
vascular disease. Impaired glucose tolerance and
diabetes mellitus are associated with an increased
risk of cardiovascular disease. A sedentary lifestyle
and increased adiposity, which SCI persons are
predisposed to, have been implicated in cardio-
vascular disease. High density lipoprotein (HDL)
cholesterol levels are lower in paraplegics (36
mg/dl) compared with age-sex matched controls
(47 mg/dl), while triglyceride levels are signifi-
cantly higher (156 versus 130 mg/dl).
Based on HDL cholesterol levels, Brenes et
al. (43) predicted a 60 to 90% increased risk of heart
attack in sedentary SCI men and women compared
with sedentary able-bodied individuals matched
for sex, height, weight, body mass index and age.
Sports Med. 1997 Jan; 23 (1)
Body Composition of SCI Adults
Compared with able-bodied individuals, the
SCI population has lower HDL cholesterol lev-
els[37,39,43] and higher low density lipoprotein (LDL)
cholesterollevels.[17,44] Bauman and colleagues[17]
reported that 48% of the healthy, active paraplegic
men in their study had plasma HDL cholesterol
levels under the desirable level of 35 mg/dl, and
41 % had LDL cholesterol levels exceeding 130
mg/dl. As a result of these blood lipid levels, SCI
individuals not only have a greater risk of develop-
ing cardiovascular disease, but exhibit a higher
mortality rate from cardiovascular disease.
Decreased physical activity from SCI produces
physiological changes that influence the cardio-
vascular risk profile of SCI individuals.[17] Disuse
atrophy reduces muscle mass and results in a de-
creased venous return of blood to the heart because
of impairment of the muscle pump in the limbs.[44]
The decreased venous return lowers stroke volume
and cardiac output in SCI individuals, resulting in
lower resting diastolic blood pressure.l45 ,46] Al-
though there is documentation that systolic blood
pressure is higher in persons with SCI,[47,48] there
are conflicting reports on the incidence and aetiol-
ogy of hypertension in this population,ll7,34,37,44-47]
Yekutiel et al.l48 ] reported that the incidence of
hypertension in SCI men is 24.7% compared with
10.4% in age-matched, able-bodied men. Imai et
al. [47] state that morbidity rates due to hypertension
in the SCI population are 2.5 to 3.0 greater than in
age- and sex-matched able-bodied persons.
1.3 Non-Insulin-Dependent Diabetes
Mellitus (NIDDM)
In addition to cardiovascular disease, the inci-
dence of NIDDM is also higher in SCI compared
with the rate for able-bodied persons.[17,36,37,43,47]
Imai and colleagues[47] noted that 22% of paraple-
gics have NIDDM, as compared with 11 % of the
general population. Individuals with SCI have
higher plasma glucose concentrations along with
impaired glucose tolerance and increased insulin
resistance. [35]
© Adis International Limited, All rights reserved,
51
Duckworth and colleagues[36] noted a strong
correlation between insulin resistance and the level
and duration of SCI. Insulin resistance is charac-
terised by marked endogenous hyperglycaemia
and hyperinsulinaemia following a meal. In this
study of 52 SCI individuals, 23% had fasting glu-
cose levels above 130 mg/dl. 30% exhibited hyper-
glycaemia (blood glucose above 200 mg/dl) after
receiving oral glucose. In addition, more than 40%
of the individuals had elevated insulin levels dur-
ing an oral glucose tolerance test. The insulin-
resistant SCI individuals were more obese and had
had their spinal cord lesions for longer than SCI
individuals without insulin resistance.[36]
Since most insulin receptors are located on the
sarcolemma, in addition to adipocyte membranes,
the decreased muscle mass resulting from disuse
atrophy following SCI may reduce the number of
insulin receptors.[35] Spinal cord lesions above T4
result in complete disruption of catecholamine re-
lease from the sympathetic nervous system. Since
adrenaline (epinephrine) augments glycogenolysis
and increases insulin absorption in skeletal muscle,
the lack of sympathetic response in quadriplegics
may influence the activity of the insulin receptors
in the atrophied muscles.[49] Therefore, both phys-
ical inactivity and increased adiposity influence in-
sulin resistance, predisposing a person with SCI to
NIDDM.
1.4 Osteoporosis
In addition to cardiovascular disease and
NIDDM, SCI individuals are at risk for developing
osteoporosis. Physical inactivity produces bone
mineral loss, especially in the paralysed extremi-
ties, resulting in osteoporosis and a high risk for
fractures in this group.[ll,12,50] Claus-Walker and
Halstead[l2] reported that 100% of SCI individuals
have mild to severe osteoporosis in bones below
the level of lesion. In addition, Biering-Sorensen
et al.[ll] reported that quadriplegic and paraplegic
men demonstrate bone mineral deficits in the fem-
oral neck and shaft and the proximal tibia of 25%
and 50%, respectively.
Sports Med. 1997 Jan: 23 (1)
 52
There is an increased calcium resorption, result-
ing in a negative calcium balance, primarily in the
early stages following SCI. Bone mineral is ini-
tially lost in the entire skeleton, but later is con-
fined primarily to the paralysed limbs.l l2 ) Hancock
and colleagues (6 ) confirmed that the greatest loss in
bone mass occurs within the first year of paralysis.
Also, Biering-Sorensen et aLl") found that, while
osteopenia occurs rapidly in the early stages of a
spinal cord lesion, bone remodelling slows and cal-
cium imbalance reaches a new, lower equilibrium
2 to 5 years post injury. As the duration of injury
increases, the degree of bone mineral de·ficit be-
comes relatively stable, although bone resorption
continues to exceed calcification rates.16, to. 13. 14,50)
The magnitude of reduction of bone mineral
content and bone density is dependent on the level
of injury and time since injury.l6,1I,13,15,16) In a
study comparing men and women with early SCI
(6 to 9 months) to those 2 to 4 years post injury,
Kaplan et aLISO) found a positive correlation be-
tween time since injury and calcium balance, sug-
gesting that as time post injury increases, the rela-
tive ratio of bone synthesis to bone resorption
increases. There was a significant relationship be-
tween time since injury and the degree of bone
mineral density deficit (r = -0.70), reflecting a
larger degree of osteopenia in the afflicted limbs
with increased duration of injury.
Venous stasis, accompanied by tissue acidosis,
could be an important factor in the pathogenesis of
disuse demineralisation. Sympathectomy induces
vasomotor paralysis, which slows intraosseous
circulation. The opening of arteriovenous shunts
increases venous pressure and, therefore, intra-
medullary pressure, which stimulates enhanced
bone resorption. Trabecular bone volume and den-
sity are decreased while marrow diameter is in-
creased. lto,13) This theory is supported by Griffiths
and colleagues (15 ) who demonstrated in 59 quadri-
plegics and 41 paraplegics that metacarpal cortical
bone is preserved while trabecular bone is lost. In
addition, Finsen et aLll4) noted a 45% bone mineral
deficit in the tibial metaphysis compared with a
© Adis International Limited. All rights reserved.
Kocina
26% bone mineral deficit in the tibial diaphysis.
This suggests that neuronal and vascular factors are
responsible for the negative bone balance in the
SCI population. Although the absence of muscular
activity and weight bearing influences osteo-
penia,II3,50) Chantraine(13 ) states that osteoporosis
following SCI is primarily due to an imbalance be-
tween synthesis and resorption of bone below the
spinal cord lesion due to venous stasis,llO)
2. Changes in Body Composition
Following SCI
Current estimates of body composition in the
SCI population are limited by a lack of knowledge
of the fat-free body composition of SCI adults. The
fat-free body consists of all residual lipid-free
chemicals and tissues including water, muscle,
bone, connective tissue and internal organs. The 3
main chemical constituents of the fat-free body are
water, protein and mineral,l23) Most research on
body composition is based on clinical methods that
require a priori assumptions of the relationship be-
tween the measured property and fat-free body
compositionP3] While the proportions and densi-
ties of tissues comprising the fat-free body in sev-
eral able-bodied adult populations are docu-
mented,151,52) few direct data are available on the
variability and extent of change in the proportions
and densities of water, mineral and protein with
varying degrees of spinal cord injury. Conse-
quently, the use of clinical methods of measuring
body composition in SCI, such as hydrostatic
weighing, anthropometry and bioelectrical imped-
ance, is limited by the assumption that fat-free
body composition is the same for all popula-
tions,l23)
There is now ample evidence showing that the
chemical composition of the fat-free body is not
constant in all groups, and neither is the fat-free
body density. Recent investigations have shown
that sex, race, age, physical activity level and dis-
ease states are important determinants of body
composition,129,30,53-55) requiring the development
Sports Med. 1997 Jan; 23 (1)
Body Composition of SCI Adults
of population-specific equations to estimate the
body composition of different groups.
2.1 Fat-Free Body Composition in the SCI
Concomitant to the increase in body fatness,
there is a significant change in the overall fat-free
mass of the SCI population due to disuse atrophy
of skeletal muscles, loss of total body water, and
decreases in bone mineral content, primarily in
the paralysed extremities. Thus, the proportions
of the 3 constituents comprising the fat-free
body, namely mineral, water, and protein, are al-
tered,l8.9.14.39] The densities of mineral and protein
may also be altered.
2.2 Mineral
Mineral comprises 6.8 to 7.0% of the fat-free
body in young, able-bodied men and women,123]
and because of the high density of mineral (3.01
g/cm3) relative to the other fat-free body constitu-
ents (water 0.9934 g/cm 3, protein 1.34 g/cm 3),
mineral has a potentially large impact on the over-
all density ofthe fat-free body.
Bone mineral content in the SCI population has
been assessed using a variety of techniques, includ-
ing radiography/sonography,156] single and dual-
photon absorptiometry,Dl.14,42] and Moore and
Boyden'sI57] prediction equation based on total
body potassium and total body water measure-
ments. 15 ] With the exception ofthe Cardus study,14]
which used a radioassay for sodium and potassium
tracer to estimate total body water, these studies
demonstrated reductions in the bone mineral con-
tent and bone density of the SCI population.
In addition, complete SCI lesions result in
greater bone mineral resorption compared with in-
complete lesions. Those with neurological afflic-
tion in the upper extremities have a greater bone
mineral density deficit compared with those with
neurologically intact arms,l1l·16] Also, quadriple-
gics have greater bone mineral deficits than para-
plegics.112.52] Finsen and colleagues l14 ] reported
that osteopenia in paraplegic men is largely con-
fined to the paralysed extremities and is not sys-
© Adis internofionoi Urnited. All rights reserved.
53
temic. In their study combining quadriplegics and
paraplegics, there was a 50% reduction in the bone
mineral content of the proximal tibia, whereas the
distal radius and ulna showed only a 5 to 13% deficit.
Individuals with SCI also have higher collagen
breakdown. I13 .16] Collagen is a major component
of bone matrix, as well as ligaments, tendons,
cartilage and skin.lll] There is a reduced hydroxy-
proline concentration and an increased urinary
excretion of hydroxyproline, a metabolite of col-
lagen, following SCI. In addition, urinary phos-
phate, magnesium and calcium excretions are in-
creased, especially in the first 3 months following
a spinal cord lesion,lIO.12.16]
To date, there are no studies reporting changes
in total-body bone mineral of the SCI popUlation.
Given that both the bone mineral content and fat-
free mass decrease with SCI, it is difficult to esti-
mate how much and in what direction the relative
mineral content of the fat-free body is changed fol-
lowing SCI. However, it is possible that the bone
mineral content in the SCI population will consti-
tute a higher percentage of bodyweight because
bone mineral loss occurs at a slower rate than the
loss of protein and water content following SCV4 •6 ]
2.3 Protein
The protein content of the fat-free body is ap-
proximately 19.4% in able-bodied populations. 123 ]
Given the muscular atrophy and loss of muscle
mass associated with SCI, it is highly probable
that the relative proportion of protein comprising
the fat-free body is decreased. At present, no satis-
factory method exists for measuring the protein
content of the fat-free body, especially in the SCI
population. Neutron activation analysis has been
used to estimate protein from total body nitro-
gen,l58.59] However, this method requires that the
subject be exposed to radioactive tracers for nitro-
gen and is limited by the fact that there is a total of
only 5 neutron activation analysers in the US,
Europe, and New Zealand.
Potassium counting methods can also provide
accurate estimates of protein concentrations because
Sports Med. 1997 Jon: 23 (1)
54
potassium is primarily an intracellular ion and is an
indicator of body cell mass. [9.60.6 I] Individuals with
SCI have reduced potassium levels and the degree
of reduction is directly proportional to the level of
lesion and duration since injury.l60.61]
Cardus and McTaggart[4] indirectly estimated
the total body protein in SCI individuals by sub-
tracting total body fat and total body water from
the weight of the bone mineral-free body. Using
this crude measure of protein, they reported a 24 to
30% reduction in the absolute amount of total body
protein of paraplegic and quadriplegic men com-
pared with able-bodied men.
Depending on the completeness of the spinal
cord lesion, many individuals regain 15 to 70%
functional muscle strength relative to the degree of
paralysis within the first 3 months post injury. This
improvement may continue for up to 6 months, and
then at a slower pace for up to 2 years after the
injury.l62] Therefore, the protein content of the fat-
free body of SCI individuals may not reach a stable
value until 2 years post injury.
2.4 Water
Body water is the largest single constituent of
the human body, comprising 55 to 60% of the body-
weight and 73% of the fat-free body in the able-
bodied population. [23] Since the greatest proportion
of body water is associated with the fat-free mass,
chronic loss of muscle mass in the SCI popUlation
may alter the relationship between total body water
and fat-free mass.
Presently, there are limited data describing the
total body water of the SCI population. Using iso-
tope dilution techniques, Rasmann Nuhlicek et
al.l8] assessed the total body water of 37 men with
SCI having varying levels of disability. They noted
that total body water ranged from 48.8% of body-
weight (low quadriplegia) to 58.3% of body weight
(low paraplegia), demonstrating a tendency for to-
tal body water (as a percentage of body weight) to
progressively decrease with a higher level of spinal
cord lesion. Likewise, Cardus and McTaggart[60]
noted that the total body water of SCI individuals
© Adis Intema~onal Umited. All rights reserved.
Kocina
was approximately 8 to 10L less than that of an
able-bodied control group. Paraplegics had signif-
icantly greater total body water than quadriplegics.
Also, the volume of interstitial fluid, relative to
total body fluid, was larger in quadriplegic com-
pared with able-bodied individuals.[5.63] Therefore,
they attributed the change in total body water to
intracellular water loss, rather than loss of extra-
cellular water.
The observation of a reduction in intracellular
water following SCI is consistent with the reduc-
tion in the potassium content of the fat-free body
observed in this population.[5.9.61] Because most of
the body potassium is found inside the cells, meas-
urements of potassium are used as estimates of the
body cell mass. Cardus and McTaggart[5] reported
that paraplegics had 15% less potassium relative to
bodyweight and quadriplegics had 33% less potas-
sium relative to bodyweight compared with age-
sex matched controls. Spungen et aU9] noted that
both the total body potassium and fat-free mass
were 34% less for 12 SCI men compared with able-
bodied men of similar height and age. Thus, loss of
intracellular water following SCI appears to coin-
cide with the loss of potassium, which is primarily
an intracellular ion.
In contrast, extracellular water content in-
creases following SCI, indicating an expansion of
the extracellular space consistent with oedema. [5.60.61]
While the ratio of extracellular water to total body
water is increased, the ratio of intracellular water
to total body water is decreased. When total body
water, measured by tritiated water, is expressed
relative to fat-free body, the hydration of the fat-
free body is similar to able-bodied controls (74.6%),
ranging from 72.7% for the low paraplegic groups to
76.0% of fat-free body for the low quadriplegic
groups.l8]
3. Body CompOSition
Assessment Techniques
3.1 Hydrostatic Weighing
The traditional 'gold standard' method for body
composition assessment is hydrostatic weighing.
Sports Med. 1997 Jan; 23 (1)
Body Composition of SCI Adults
The principle of hydrostatic weighing is that
weight loss under water is directly proportional to
the body's volume. After correcting body volume
for the volume of air in the lungs, total body den-
sity is calculated by dividing body weight by body
volume.[ 23 1
In addition, using hydrostatic weighing to de-
termine total body density for estimating body fat of
SCI individuals is problematic and potentially un-
safe. Transfers into and out of the hydrostatic
weighing tank are difficult. Also, many SCI indi-
viduals can not maintain a seated position in the
hydrostatic weighing chair during submersion un-
derwater. l39 ,411 Thus, alternative 'gold standard'
methods need to be explored for this population.
3.2 Dual-Energy X-Ray Absorptiometry
Research studies suggest that dual-energy x-ray
absorptiometry (DXA) may be a suitable alterna-
tive to hydrostatic weighing for determining meas-
ures of body composition.[64,65 1Unlike hydrostatic
weighing, DXA is rapid, requires minimal cooper-
ation from the study participant, and provides pre-
cise measures of fat mass, lean tissue mass, and
total body, as well as regional, bone mineral con-
tent and bone mineral density.l661 Also, there is
minimal radiation exposure during a DXA evalua-
tion.l 64 ,65 1
The percentage body fat estimates from DXA
compare favourably with those obtained by hydro-
static weighing, especially when body density is
adjusted for total body water and total body min-
eraI.l54,66- 68 1Going and colleagues[67 1reported that
estimates of bone mass and fat by DXA are unaf-
fected by changes in hydration. On average, DXA
correctly attributed 98% of the change in body-
weight due to dehydration to changes in fat-free
mass. The estimates of total body bone mineral by
DXA were also unaffected by changes in hydration
level.
Roubenoff et aI.l 65 1 state that, because DXA
measures bone, bone-free lean, and fat, it is not free
of the assumption of uniform hydration. Also, re-
gional soft tissue estimates may be imprecise since
© Adis International Lirnited. All rights reserved.
55
DXA cannot clearly distinguish between soft tissue
and bone in the thorax because the arrangement of
the ribs and spine prevents the x-ray from detecting
much bone-free soft tissue mass. The accuracy of
soft tissue measurement is based on the ability of
DXA to predict total weight of individuals of var-
ious ages from the sum of their bone, lean tissue
and fat tissue weights. Additionally, anteroposter-
ior thickness greater than 30cm increases the
measurement error of DXA. Therefore, DXA is
less accurate when estimating the body composi-
tion of severely obese individuals as compared
with their leaner counterparts.l64 ,65 1
Kohrt[ 691 states that, although DXA is less de-
pendent on assumptions regarding biological con-
sistency than hydrodensitometry, there are uncer-
tainties regarding its validity. Also variability
among manufacturers of DXA instruments intro-
duces errors in estimating body composition. Still,
DXA may be a suitable alternative to hydrostatic
weighing for obtaining reference measures of body
composition in the SCI population.
3.3 Skinfold Method
The impracticality of hydrostatic weighing for
measuring body density has led to the development
of numerous anthropometric approaches for pre-
diction of body fat. The skinfold method is one
such approach having considerable merit and po-
tential applicability to the SCI population. How-
ever, the skinfold-body fat relationship has been
shown to vary with age, sex, race, physical activity
level and disease states.[29,30,70,71] To date, no one
has investigated this relationship or developed
skinfold prediction equations applicable to the SCI
population.
Skinfold measurements are an indirect measure
of the thickness of subcutaneous adipose tissue.
Therefore, certain assumptions are made when us-
ing the skinfold method to estimate total body den-
sity to derive percentage body fat. These assump-
tions are:
• skinfolds are a good measure of subcutaneous
fat
Sports Med. 1997 Jan: 23 (1)
56
• the distribution of fat subcutaneously and inter-
nally is similar for all individuals within each
sex
• the sum of several skinfolds is a good estimate
of total body fat
• there is a linear relationship between the sum of
skinfolds and body density.l7 2-77 ]
However, in young, able-bodied adults sub-
jected to bed rest or immobilisation, the body den-
sity and total body fat corresponding to a given
skinfold thickness are affected by changes in the
water, mineral and protein content of the fat-free
body resulting from physical inactivity.[70.71,78,79]
Thus, it is highly probable that the skinfold-body
fat relationship will also be altered with SCI be-
cause of the dramatic loss of muscle mass and bone
mineral content due to disuse atrophy.
In fact, population-specific and generalised
skinfold prediction equations that were developed
to derive body fat estimates for able-bodied popu-
lations are not applicable to the SCI population.
Bulbulian and colleagues[41] cross-validated 12
commonly used skinfold prediction equations
against the criterion method of hydrodensitometry
and noted that all of these equations significantly
overestimated body density and underestimated
percentage body fat of SCI individuals by 7 to 12%.
Similarly, Lussier et aU42] determined that skinfold
prediction equations developed for able-bodied
popUlations underestimated body fat of persons
with SCI by 8 to 10%. These results point to the
need for developing skinfold prediction equations
that are specific to the SCI population.
3.4 Bioelectrical Impedance Method
The bioelectrical impedance technique is a sim-
ple, noninvasive procedure which has been widely
used in clinical settings to estimate total body water
and fat-free mass of able-bodied populations. This
method uses a bioimpedance analyser to measure
the impedance to the flow of a low level electrical
current through the bodyP2,28,80]
Bioelectrical impedance (Z), measured in ohms,
is the square root of the sum of the squares of the
© Adis Interna~onal Umited. All rights reserved.
Kocina
resistance and reactance to current flow. Resistance
is the opposition of a biological conductor to the
flow of an alternating electric current, whereas re-
actance is the resistive effect due to capacitance
produced by tissue interfaces and cell mem-
branesPI,24,27,81] The volume (V) of a cylindrical
conductor, like the human body, is directly related
to the square of the body's length (Ht2) and in-
versely related to the body's total impedance: V =
Ht 2/Z.l 27 ,81] The high impedance of adipose tissue
and bone causes these tissues to act as open cir-
cuits; thus the body's total impedance is primarily
due to the impedance of the muscle tissue.[26,27,81]
Using this method, the total body water or fat-free
mass can be accurately estimated from bioimped-
ance measures. [22,24,28,80]
Although there are valid prediction equations
for able-bodied populations which vary in age,
race, sex and physical activity levels,[20,23,25,82-84]
the validity of this method for predicting fat-free
mass in SCI populations has not been tested. Olle
and colleagues[7] assessed body composition of 17
SCI men using measures of total body electrical
conductivity. In this study, body fat estimated from
bioimpedance measures was moderately related
(r =0.73) to skinfold estimates of body fat. How-
ever, presently no bioelectrical impedance predic-
tion equations have been developed specifically for
the SCI popUlation.
One important assumption of the bioimpedance
method is that tissue- specific resistivity is constant
for all body segments and all population sub-
groups. Specific resistivity is the reciprocal of con-
ductivity to current flow through the body and is
directly proportional to the body's volume and in-
versely proportional to the electrolyte concentra-
tion in the body.[81] Tissue specific resistivity is not
constant and has been shown to vary among body
segments because of differences in tissue compo-
sition, hydration levels, and electrolyte concentra-
tions)18,81,85]
Baumgartner and colleagues[85] measured the
bioelectrical impedance of various body segments
and noted that the resistances for the arm and leg
Sports Med. 1997 Jan; 23 (1)
Body Composition of SCI Adults
were positively related to whole body resistance
(r = 0.70). Similarly, Chumlea et al.[l8] demon-
strated that estimates of fat-free mass, obtained by
addition of the conductive muscle volumes of each
body segment, measures of bioelectrical imped-
ance, and mean muscle-specific resistivity, were
not significantly different from the fat-free mass
estimated from hydrostatic weighing.
However, variation in hydration of the fat-free
mass may affect specific resistivity. An increase in
extracellular fluid could cause increased shunting
of the current, producing a decrease in total body
resistance,l85] In addition, since conductivity is di-
rectly proportional to the number of free ions, a
reduction in total body water may result in rela-
tively lower resistance values,D9,21]
SCI-related changes in fat-free body composi-
tion may alter tissue resistivity, as well as the rela-
tionship of fat-free mass to whole-body bio-
impedance measures. These changes are due to
reductions in the protein and mineral content of the
paralysed extremities, along with the reduction in
total body water and expansion of extracellular wa-
ter volume.[63] Therefore, segmental bioelectrical
impedance measures may provide a more accurate
estimate of fat-free mass in SCI individuals com-
pared with total body bioimpedance. Because of
changes in the composition of the fat-free body
following SCI, the mineral, protein, and water
components of the fat-free body should be directly
assessed and used when developing bioelectrical
impedance prediction equations for the SCI popu-
lation.
4. Body Composition Applications for
the SCI Population
If accurate prediction equations for the SCI pop-
ulation were developed for use with field methods
such as skinfold or bioimpedance, medical and
health professionals could then monitor changes in
fat and fat-free mass resulting from SCI. This could
lead to the development of more effective nutrition
and exercise intervention strategies to counteract
the loss of fat-free mass associated with SCI.
© Adls International Limited, All rights reserved.
57
To date there is a lack of information document-
ing the effects of nutritional and exercise interven-
tions on body composition in the SCI popUlation.
Also, the relationship of body composition
changes due to SCI with health risk, and the impact
of body composition assessment on SCI treatment
have not been studied. Although the cardio-
vascular benefits of physical activity and training
have been clearly demonstrated for individuals
with SCI,[46,86,87] presently there are no studies
documenting the effects of aerobic exercise or
muscular strength training on reducing body fat
and preserving fat-free mass (muscle size and bone
mineral) for the SCI population. This line of re-
search is hampered by the fact that practical, clin-
ical body composition methods have not yet been
developed and validated for the SCI population.
If accurate clinical methods for body compo-
sition assessment in the SCI popUlation were
developed, body composition assessment may
potentially impact spinal cord injury care in the
following ways:
• Body composition data could become part of
the total clinical evaluation and patient profile
of SCI individuals.
• Changes in body composition associated with
SCI could be quantified and monitored over
time.
• Individuals with a high relative risk of diseases
associated with obesity, malnutrition, and phys-
ical inactivity could be identified.
• The effectiveness of nutritional and exercise
interventions in altering body composition and
counteracting complications resulting from SCI
could be assessed.
• Epidemiological surveys of the SCI population
could include body composition measures to es-
tablish the relationship between disease inci-
dence, fat patterning, and total body composition.
5. Conclusions
There are a limited number of studies dealing
with body composition assessment for the SCI
popUlation and the development of practical, clin-
ical methods to validly assess body fatness of this
Sports Med, 1997 Jan; 23 (1)
58
group. Additional research is needed to accurately
quantify the constituents of the fat-free body in the
SCI population by criterion, laboratory-based
methods, such as hydrometry for total body water
and dual-energy x-ray absorptiometry for bone
mineral content, bone mineral density, and lean tis-
sue mass. Once reference measures of total body
fat and fat-free mass are obtained, skinfold and bio-
electrical impedance equations may be developed
to accurately estimate the body composition of SCI
individuals with varying degrees of impairment.
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Sports Med. 1997 Jan: 23 (1)