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. 2021 Nov 17;27(4):68–78. doi: 10.46292/sci21-00001

What Are Personal Meanings of Healthy Eating and Physical Activity in Individuals Living With Spinal Cord Injury? A Qualitative Exploration

Sherri L LaVela 1,2,✉, Linda S Ehrlich-Jones 2,3, Kayla Jones 3, Brian Bartle 1, Allen W Heinemann 2,3
PMCID: PMC8604504  PMID: 34866889

Abstract

Objectives: To explore the personal meanings of healthy eating and physical activity among individuals living with spinal cord injury (SCI) and the information and resources they find beneficial. Methods: We conducted in-depth semistructured individual interviews to understand the personal meanings of healthy eating and physical activity among individuals with SCI. We completed a thematic analysis of qualitative data. Results: Participants were 11 Veterans and 14 civilians, predominantly male, non-Hispanic White, and with paraplegia. Data were described across two categories, including the personal meaning of healthy eating and the personal meaning of physical activity/exercise. Individuals with SCI described their meaning of healthy eating around four themes: types of food, amounts/portions of food, conscious/mindful eating, and eating to enhance health. Individuals wanted information on tailored diets for individuals with paraplegia and tetraplegia and healthy foods that are easy to prepare by people with SCI. Their personal meaning of physical activity/exercise focused on four themes: types of physical activity and exercise, staying active, moving/movement, and differences from non-SCI. Desired information around physical activity included cardiovascular workouts that are effective and possible to do in a wheelchair so that people with SCI can burn enough of the calories they consume to lose or maintain weight. Conclusion: Results provide a better understanding of what healthy eating and physical activity mean to people with SCI and information they desire toward these goals, which can be used to guide patient–provider discussions, develop health promotion programs, and tailor interventions to capitalize on meaningful concepts and beliefs that facilitate healthy behaviors.

Keywords: healthy eating, physical activity, spinal cord injury, weight management

Introduction

A spinal cord injury (SCI) is caused by damage to the vertebral column either by trauma or disease. This injury affects the ability of the spinal cord to communicate messages between the brain and the body systems, which interferes with sensory, motor, and autonomic function.1 Functional interferences are associated with barriers to participating in weight management efforts, including healthy eating and physical activity.2 More than half of adults with chronic SCI meet the criteria for overweight or obesity,3,4 which puts them at risk for obesity-related diseases and other negative health and quality of life consequences.5

Personal meaning is an individually constructed concept that is grounded in beliefs and values and denotes the purpose, understanding, or significance a person has around a concept. It represents ongoing interpretation and regulation of cognition and behavior that is informed by relationships between individuals and their environment.6–8 The personal meanings people have around healthy eating and physical activity are likely translated into everyday weight management lifestyle behaviors9–11 and influenced by bio-psycho-ecological constructs, including internal (mind, body) and external (physical and social environments) factors.12 Multiple studies have examined meanings of what healthy eating is in general population samples.13–16 Other studies have found that terms such as physical activity and exercise have different meanings among people across age,17 gender, and sociocultural factors.18 In addition, patients’ meanings of physical activity greatly vary from those of health professionals.17 A clear personal meaning assigned to concepts about which there is ambiguity can facilitate understanding, decision making, and engagement in healthy behaviors.9,10 The meanings of healthy eating and physical activity/exercise have not been studied in the SCI population. Therefore, the objective of this study was to explore the personal meanings of healthy eating and physical activity among individuals living with SCI.

Methods

Design

We conducted in-depth, qualitative semistructured individual interviews to understand the personal meanings of healthy eating and physical activity among individuals with SCI. The interviews aimed to answer research questions around weight management experiences in persons with SCI: When you hear the phrase “healthy eating,” what does it mean to you? When you hear the phrase “being physically active,” what does it mean to you? Additionally, we probed about information or resources participants needed or would find helpful for weight management. We completed a thematic analysis of qualitative data guided by established recommendations.19,20 Institutional review boards at Hines VA Hospital and Northwestern University approved this study.

Participants

Our target sample included 25 community-dwelling Veterans and civilians with SCI. A sample size of 25 was deemed sufficient for the scale of the current study; large enough to unfold a rich understanding, but small enough so that in-depth analysis was not prohibited.21,22

Veterans with SCI were identified using Veteran’s Health Administration (VA) medical records for Veterans who utilized the Hines VA Hospital or Jesse Brown VA Medical Center within a 5-year time period (2013–2018), were 18 years of age or older, resided in the community (non-nursing home), and had a valid Illinois mailing address documented. These inclusion criteria resulted in a sampling pool of 818 individuals from which we extracted a random sample of 250 participants to mail study invitation letters. Letters were sent in batches of 50 until the target sample was reached.

Civilians with SCI were identified from the database of enrollees in the Midwest Regional SCI Care System (MRSCICS)/SCI Model System at Shirley Ryan AbilityLab (SRAlab). MRSCICS participants are eligible for follow-up interviews 1 year after SCI, 5 years post injury, and every 5 years subsequently. Our sampling pool included individuals who received inpatient rehabilitation at SRAlab and were due for a follow-up interview. Recruitment was accomplished by telephone after their MRSCICS follow-up interview or by mailing invitation letters. SRAlab participants were recruited until the target sample was reached.

Data collection

We conducted a brief survey with participants to collect self-reported demographic and injury information. In-depth interviews were conducted using an interview guide. The interview guide was developed based on the bio-psycho-ecological framework,12 literature, prior work, and experience of the research team, which was comprised of health professionals knowledgeable across disciplines, including SCI medicine, psychology, exercise physiology, nutrition, physical medicine and rehabilitation, public health, nursing, and research. We field-tested the interview guide draft with individuals with SCI and incorporated their feedback to refine and improve interview questions to ensure intelligibility and relevance.23

Individual interviews were conducted in person or by telephone in late 2018. Interviews lasted 45 to 60 minutes and were audio-recorded. Recordings were transcribed verbatim by a professional transcription service. To ensure accuracy of each transcript, a two-step quality control process was implemented that included initial transcription by one person followed by a full audio-review verification by another person.

Analysis

Thematic analysis methodology guided the coding and analysis.19,20 NVivo software was used for data organization (QSR International, version 12 NVivo, Doncaster, Victoria, Australia).

We conducted a thematic analysis driven by interviews with individuals with SCI about their personal meanings of healthy eating and physical activity. Analysis included concurrent activities as outlined by Miles and colleagues, including data condensation, data display, and drawing/verifying conclusions.20 Following Braun and Clarke’s thematic analysis phases,19 three experienced qualitative researchers first familiarized themselves with the data by listening to all audio-recorded interviews and reading textual data from all transcripts to learn what the data meant. We used a mixed inductive-deductive approach to generate initial codes and create an initial codebook. In doing so, we applied important bio-psycho-ecological framework constructs to the data (deductive), wherein weight management meanings are a factor of internal and external factors, including self/mind, body, function, physical, and social environment.12 We also identified additional constructs driven directly by the data (inductive). We reviewed coded data to search for themes representing patterns of meaning and explored relationships between themes. We then reviewed themes using a two-step quality checking process, checking themes against groups of data extracts and against all transcripts. In this phase, we assessed fit and modified codes (relocated or discarded) and fine-tuned themes until saturation was reached.19,20,24 All three researchers constructed, named, and defined final themes, then met to compare and resolve discrepancies until 100% agreement was reached to achieve interrater reliability.20,24,25

Results

Sample characteristics

Participants included 25 individuals with SCI: 11 were Veterans and 14 were civilians. Participants were male (96%), non-Hispanic White (56%), and about half had paraplegia (52%). The average age was 57 years, and average duration of injury was 18 years. Participant characteristics are shown in Table 1.

Table 1.

Participant characteristics (n = 25)

Characteristics Frequency or mean (range)
Gender
  Male 96%
Race/Ethnicity
  White (non-Hispanic) 56%
  Black/African American 36%
  Asian, Native/Hawaiian/other Pacific Islander, American Indian, or Alaska Native 8%
Age, years 57 (26–83)
Education
  College graduates 44%
  Some college or technical school 28%
  High school graduate, no college 28%
Marital status
  Never married 36%
  Married 28%
  Separated/Divorced 28%
  Widowed 8%
Type of injury
  Paraplegia 52%
  Tetraplegia 48%
Duration of injury, years 18 (2–42)
Age at injury, years 38 (18–80)
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Themes

Two categories developed from the data: one described participants’ personal meanings of healthy eating, and the other described their personal meanings of physical activity/exercise. In addition, participants described information or resources that they would find beneficial for healthy eating and physical activity. Our study design purposely included a diverse sample of individuals with SCI. Although our aim was not to identify differences between Veterans and civilians, the data did not reveal any discussion of such differences between Veterans and civilians around meanings of healthy eating and physical activity. Neither were there varied responses about information or resources they would find helpful for healthy eating and physical activity based on the source of recruitment for the sample (VA vs. SCI Model Systems). Across the cohort, multiple themes were conceptualized for each category and are described in the findings below and displayed in Figure 1. Following each quotation is the participant’s ID, level and completeness of injury, and duration of injury.

Figure 1.

Figure 1.

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Overweight and obesity prevention and management in the context of the bio-psycho-ecological framework: Key themes around personal meanings of healthy eating and physical activity among individuals with SCI.

Personal meaning of healthy eating

Participants expressed what healthy eating signified to them. Four themes around healthy eating meaning were identified, including types of food, amounts/portions of food, conscious/mindful eating, and eating to enhance health.

Types of food. Nearly all participants described types of food, either to include or to exclude, in their personal meaning of healthy eating. They expanded on this by naming actual foods, preparation methods (avoid fried, eat raw), or the nature of food (nonprocessed). Individuals with SCI sought information on special or tailored diets for individuals who are sedentary or in a wheelchair, including customized diets for people with paraplegia and tetraplegia. Some thought it would be helpful to have information on dietary guidelines (e.g., food pyramids) specific to people with SCI. Others wanted food that was not only healthy but also easy to prepare by people with disabilities and that considered challenges with digestion commonly experienced by persons with SCI.

“To me that [healthy eating] means balanced meals and getting proper nutrients through the proper foods…high fiber, vegetables, fruit. I have a good idea about what foods are healthy but just to get a listing so I know, you know have it right in front of me. To know what I would be looking for when I’m shopping. Maybe things that are higher in fiber. Not a meal guide more just foods, individual foods, healthier foods that maybe easier to prepare [for] disabled people.” [P04, C5 incomplete, 35 years]

“Not eating a lot of, what is that food that is called, that is processed foods.” [P12, C5 complete, 37 years]

“I would say the big thing would be to get the, obviously there is the able bodied normal diet and pyramid and calorie structure and all of that, to get something out for tetraplegics and even paraplegics the diet out there, a diet description of which you know guidelines for, um, that would be beneficial to put something like that out there. So, we can, we know what foods we are supposed to be eating.” [P21, C5–6 complete, 20 years]

“…and cutting out a lot of sugar and sweets out of the diet.” [P23, C5–6 incomplete, 31 years]

“Healthy eating means more fruits and vegetables … And as much raw as you can.” [P24, T11 incomplete, 41 years]

Amounts/portions of food. Some participants discussed limiting the amount of food they ate or using portion control in their meaning of healthy eating. Participants thought it would be helpful to have information on SCI-sensitive calorie count eating plans.

“I think it means eating an appropriate amount of food.” [P10, C4 incomplete, 5 years]

“Healthy eating, I think means eating a good portion size. Just watching your portion sizes and not just you know, and it’s not a lot of snacking either during the day.” [P12, C5 complete, 37 years]

“Try to eat more a lighter amount of food.” [P13, C4 incomplete, 2 years]

“To know how many calories we really should be eating as compared to, you know, the able bodied. You know if they study how much I guess how much calorie intake we utilize and should have. That would help out greatly I think.” [P21, C5–6 complete, 20 years]

Conscious/mindful eating. Individuals with SCI focused on the awareness and technique of eating as they explained what healthy eating meant to them. Participants described interest in learning how to develop awareness of eating experiences and physical cues of hunger or feeling full.

“Healthy eating to me means just being very conscious of what I am taking in and not just eating whatever sounds good.” [P05, T12 incomplete, 5 years]

“You sit doing nothing now you got to pay attention, pay attention to eat healthy.” [P06, T12 complete, 25 years]

“In a [wheel] chair… not eating out of boredom.” [P13, C4 incomplete, 2 years]

“That you have to be mindful of what you put in your mouth.” [P20, C2–C7, incomplete, 3 years]

Eating to enhance health. Some individuals with SCI explained that healthy eating meant consuming for purposes of health improvement. Participants expressed interest in knowing how to eat to reduce chances of developing chronic conditions, such as heart disease, and what to eat for healthy skin.

“Foods that enhances your life and longevity. Foods that like make your skin looks better. Just make you healthy altogether I suppose.” [P07, C6 complete, 35 years]

“Things like what they eat and what they put in their system cause them to have other things like heart diseases, blood pressure, things of those nature. So, if you eat healthier there is a good chance you won’t have those same problems.” [P14, C3–4 complete, 30 years]

“It [healthy eating] means that you are going to be better in you know as far as health goes.” [P19, T11 incomplete, 20 years]

Personal meaning of physical activity/exercise

Participants spoke passionately about what they viewed as physical activity for an individual living with SCI. Four themes were classified: types of physical activity and exercise, staying active, moving/movement, and differences from non-SCI.

Types of physical activity/exercise. Most persons with SCI discussed both general and specific types of physical activity and exercise as a main factor in their personal meaning of physical activity/exercise. This included stretching, exercise that increases breathing, modified weight training, and participation in physical/occupational therapy. Participants were interested in helpful information about types of exercise that are possible for people with SCI. Individuals wanted demonstrations detailing how to do exercises with an SCI, specific activities for cardiovascular workouts in a wheelchair, and what is new on the market as far as at-home exercises and improvements in exercise equipment. Participants wanted information on how people with SCI can burn enough of the calories they consume through physical activity to lose or maintain weight.

“To keep myself stretched. Keep my muscles somewhat limber.” [P04, C5 incomplete, 35 years]

“Physically active to me means that I am doing something outside of my normal daily activities to, you know, exercise my body.” [P05, T12 incomplete, 5 years]

“You know stretching, … to bend, to keep your body limber.” [P08, T2 complete, 10 years]

“For me it mostly means doing sort of physical or occupational therapy. So, like doing the arm bike or figuring out a way to lift weights basically or doing pool therapy.” [P10, C4 incomplete, 5 years]

“How to exercise enough, I can’t exercise I feel enough to burn off the calories the way I need to burn them off.” [P18, C7, incomplete, 2 years]

“I guess another definition of physical activity is if you are starting to breath harder, you are obviously exerting yourself so that would be part of physical activity as well.” [P21, C5–6 complete, 20 years]

Staying active. When describing what physical activity/exercise meant to them, most mentioned efforts to be active or stay active. They highlighted that this did not have to be exercise-based but could include leisure activities and getting outside. Participants explained that they would benefit from information about places to go to be active, such as accessible parks, specifying interest in a list of those that are free of wheelchair obstacles (e.g., having curb cuts), and safety concerns (e.g., no potholes).

“Going to do things. In and out. Not just not doing anything.” [P14, C3–4 complete, 30 years]

“Getting out and wheeling around like the neighborhood. Or go somewhere like a park. We have several parks by us. Go out there and try to wheel around, but that is so hard for me now.” [P17, C5–6 incomplete, 23 years]

“That you got to get up and do something. …. You can’t oh I am watching tv. Three hours later you are still watching tv.” [P20, C2–C7, incomplete, 3 years]

“Or working in the back I guess is a bit even though I am severely limited now, working on things like making a windmill like I am doing. Making different things, using the drill.” [P21, C5–6 complete, 20 years]

“Can’t go out to the park and roll around. There are parks, but not being mobile and you can’t drive to them. And although they are not far enough to where a person couldn’t push up, the infrastructure of the city where I live is dilapidated. [laugh] It is precarious to roll down the street and you might hit a pothole and tip over.” [P24, T11 incomplete, 41 years]

Moving/movement. Participants thoughtfully reflected on the act of moving or movement to define physical activity/exercise for individuals with SCI. Some elaborated that even minimal movement, such as independently doing activities of daily living, was physical activity for them.

“Moving your body.” [P01, C7 incomplete, 19 years]

“Doing everything that you can to keep the body moving.” [P08, T2 complete, 10 years]

“Any kind of movement that exerts some sort of activity. [P12, C5 complete, 37 years]

“The day after I take a shower, I have muscle aches. It’s helpful, it is kind of a workout.” [P17, C5–6 incomplete, 23 years]

“It means moving.” [P18, C7, incomplete, 2 years]

Differences from non-SCI. Some individuals with SCI described their personal meaning of physical activity/exercise in terms of distinctions from non-SCI (distinctions of what they did preinjury and/or distinctions with others without SCI). Participants wanted information on easier and better ways to measure their weight regularly akin to options that people without SCI have. Additionally, they were interested in knowing how their bodies respond differently than those of people without SCI in terms of weight gain, specifically how the body of a person with SCI reacts to weight gain after injury.

“Just doing all the activities that my body range, now with all of the restrictive factors, allow me to work on and to increase.” [P02, C3 incomplete, 5 years]

“Because with a disability it is kind of hard, you know, for some people to actually do some sort of exercise.” [P12, C5 complete, 37 years]

“You can’t always go out and run a mile. I mean I am not able to go out and run or get on exercise equipment anymore. But there are things I can do now.” [P15, C5–7 incomplete, 25 years]

“When I was walking it meant taking the stairs instead of the elevator. Or just constantly, I had a job where I was aircraft mechanic, so I was constantly on the move. Up and down ladders, crawling in and out of tight spaces so I stayed on the move a lot.” [P18, C7 incomplete, 2 years]

“As in able-bodied it means working a lot. Doing things like the garden, tilling, biking, or playing sports, biking, working out, I guess. Ah, running, playing, you know outdoor, game playing like whatever, hiking, climbing, anything that means both the legs and the arms at the same time more or less and you are moving them is physical activity.

In the chair physical activity is very limited because you don’t have control. But physical activity in the chair would probably involve the bicycle, the hand bike that I got. It would involve pushing the chair around, manual chair.” [P21, C5–6 complete, 20 years]

“You see a lot of people like step on the scale every morning and then they are saying oh I lost a little something. I don’t know that now. The best I can do is go somewhere where they have a meat scale or something and ok weigh my wheelchair and I will come back tomorrow and I will bring extra wheelchair and weigh that then get back in it and then subtract and, it is just a big thing.” [P24, T11 incomplete, 41 years]

“Being physically active meant when I was working and that, you know, before [SCI].” [P25, injury level not reported, 3 years]

Discussion

Promoting healthy weight management behaviors is an ongoing focus of many experts and organizations, including the Centers for Disease Control and Prevention,26 U.S. Preventive Services Task Force,27 and the World Health Organization.28 A better understanding of the meanings patients have about healthy behavior is required to initiate consequential decision making to engage in healthy behaviors.29 This study sought to understand how people with SCI conceptualize personal meanings associated with healthy weight management behaviors, specifically healthy eating and physical activity, and what information and resources they would find helpful to pursue these behaviors.

Individuals with SCI described their personal meaning of healthy eating in terms of types of food to include or exclude, limiting food intake and portion control, conscious and mindful eating, and eating to enhance health. Similar to meanings revealed by individuals with SCI in the current study, general population healthy eating meanings included the nutritional quality of food30 and types of food to eat, such as fruits, vegetables, and natural (nonprocessed) foods,13,31 or “bad” foods not to eat.13,14,32 Other studies included general population healthy eating meanings that focused on health considerations, specifically disease avoidance and management, 32–34 akin to our finding that people with SCI included eating to enhance health in meanings of heathy eating. In addition, eating choices are associated with individual self-identities that are shaped by lived experiences.35 It is likely that personal meanings of individuals with SCI are highly reflective of their experiences, for example, the identification of conscious and mindful eating was discussed in terms of being “confined to a wheelchair” and not wanting to just eat out of boredom. In fact, Holla and colleagues36 reported boredom as having a negative influence on dietary behavior in wheelchair users with SCI or lower limb amputation.

People interpret healthy eating in a variety of complex and diverse ways based on bio-psychoecological factors, including those that are personal, social, cultural, and environmental.12,32 In the absence of evidence-based SCI nutritional health guidelines,37 professional advice for healthy eating might benefit from acknowledging individuals’ personal meanings and considering their injury level and metabolic abnormalities.38,39 Reversing the risk of obesity-related diseases is challenging for people with SCI. Unfortunately, nutrition as a preventive measure for disease risk is often not addressed,40 which highlights the need for novel interventions and program development to improve healthy eating and enhance health. Toward this end, our study findings provided valuable insight into what information and resources individuals with SCI would find helpful for healthy eating, including tailored diets (both food content and calorie-specific) for people with different levels of SCI, that also take into account digestive concerns, and ideas for healthy food that is easy to prepare by individuals with SCI. Additional research will be needed to test the efficacy of such resources.

Participants used physical activity and exercise terms interchangeably. The personal meaning of physical activity for individuals with SCI included types of physical activity/exercise, staying active in general, moving/movement, and distinctions of what physical activity means in persons with SCI compared with non-SCI (including themselves preinjury and persons without SCI). Individuals with SCI identified staying active, in general, as an element of what physical activity means to them. Erickson41 found that individuals with Parkinson’s disease (PD) defined physical activity as being part of activities that create well-being and being part of life. Likewise, individuals with multiple sclerosis (MS) described this concept as being engaged in life with a focus on social interaction and connectivity that physical activity brings.42 The concept of staying active and participating in activities in spite of physical limitations is paralleled in all three neurological populations. In contrast, in a study of individuals without physical disabilities, self-reported meanings of physical activity only included structured exercise and not leisure activity or staying active.18 This suggests that individuals with SCI and other physical limitations (e.g., MS or PD) had more inclusive meanings of physical activity that perhaps took into account their abilities. Individuals who experience changes to or loss of their physical abilities face the challenge of adapting to a new way of life. In a study of resilience among individuals with SCI who participate in sports, one factor leading to resilience in physical activity participation was motivation to adapt to changes.43 Geard et al.44 reported that individuals with SCI adjust to challenges associated with their injury through flexibility, persistence, and use of strategies to normalize circumstances, such as being self-protective and maintaining a positive attitude. Hence, it is possible that the more inclusive meaning of physical activity reported by individuals with SCI reflects a level of flexibility and positivity that allowed a broader meaning of physical activity. This suggests a healthy adjustment to abilities and the resilience to stay active to achieve their weight management goals.

Similar to inclusion of moving/movement in meanings of physical activity ascribed by persons with SCI, individuals with MS identified physical activity as “a type of movement,”42 and meanings assigned by people with PD included “have to keep on moving,” which was described as literal body movements and also as an emotional stance of keeping spirits up and moving forward.41 Interestingly, individuals with SCI focused solely on actual movement and keeping the body moving in their physical activity meaning; this was similar to the meaning of physical activity articulated by elderly residents of assisted living facilities that included general movement of the body but not for any particular purpose.17

In the current study, individuals with SCI noted distinctions between their pre- and postinjury selves in their meaning of physical activity. Individuals with PD defined exercise as an ongoing process of redefining oneself due to disease and described the role of physical activity in the past versus the present.41 Similarly, individuals with MS defined physical activity in terms of changes pre/post diagnosis; they emphasized taking activity for granted pre-MS and that activity required considerable effort and thought in the present.42 Individuals with SCI, similar to those with PD and MS, compared the past to the present in their individually constructed personal meanings of physical activity.

Individuals with PD and MS included the idea of retaining health, slowing disease progression,41 and preventing physical deterioration42 in physical activity meanings. In contrast, individuals with SCI in this study did not include health enhancement in their meaning of physical activity. Because PD and MS are progressive conditions, it is possible that these individuals identified having perceived control over the disease through physical exercise, whereas SCI differs because disease severity is determined at the time of a single traumatic event.

Our study findings highlighted information and resources that individuals with SCI would find helpful in supporting physical activity/exercise behaviors and that could be useful for customizing programs and interventions to facilitate physical activity/exercise in community, health care, and rehabilitation settings. Specifically, individuals with SCI desire physical activity options that are novel and doable by people with SCI that also incorporate cardiovascular workouts and burn adequate calories. They would find it helpful to have information listing outdoor locations that they could access for activity in their wheelchairs. Future research is warranted to explore these options.

Many individuals with SCI face excessive weight management challenges. Engaging in healthy lifestyle behaviors, such as healthy eating and physical activity, is recommended for the treatment of overweight and obesity and weight maintenance in SCI.2 Our study findings were the first to reveal personal meanings of healthy eating and physical activity described by individuals with SCI. Understanding the meanings that people apply to healthy eating and physical activity provides insight into how these conceptualizations shape their dietary16,32,36,45 and physical activity goals and behaviors.46,47 This study adds to the field of overweight and obesity management in SCI by providing an understanding of personal meanings and informational needs identified directly by individuals with SCI. This information can be used to inform clinicians’ understanding of how people frame healthy eating and physical activity so that appropriate recommendations can be made for overweight and obesity prevention and treatment that are meaningful to individuals with SCI.

Strengths and limitations

This is a novel qualitative study with a sample of individuals with varying levels of SCI who receive care at the two largest systems of SCI care in the United States. However, the study had limitations. The study participants were mostly men, so perspectives may not be generalizable to women with SCI. However, our sample characteristics are similar to those of individuals with SCI in the VA health care system and SCI Model System. We did not evaluate age, education, cultural, or linguistic factors that may affect personal meanings of healthy eating and physical activity. Future studies should investigate these factors.

Conclusion

The findings of this study provided an understanding of what healthy eating and physical activity mean to people with SCI. These findings can be used to guide patient–provider discussions, develop health promotion programs, and tailor interventions to capitalize on meaningful concepts that facilitate healthy behaviors and address information needs identified by individuals with SCI.

Footnotes

Funding Support

This work was supported by the Department of Defense Office of the Congressionally Directed Medical Research Programs (CDMRP) Spinal Cord Injury Research Program (SCIRP) Qualitative Research Award (SC160051: Perspectives and Preferences for Weight Management After Spinal Cord Injury). 9/2017-9/2021; PI: LaVela

Disclosures

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

The authors do not have commercial interests to disclose.

REFERENCES

  • 1.Lin JL, editor. Spinal cord injury. Phys Med Rehabil Clin North Am . 2020;31(3) doi: 10.1016/j.pmr.2020.04.009. ed. [DOI] [PubMed] [Google Scholar]
  • 2.Nash MS, Groah SL, Gater DR et al. Identification and management of cardiometabolic risk after spinal cord injury. J Spinal Cord Med . 2019;42(5):643–677. doi: 10.1080/10790268.2018.1511401. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Wen H, DeVivo MJ, Mehta T, Baidwan NK, Chen Y. The impact of body mass index on one-year mortality after spinal cord injury [published online ahead of print November 15, 2019] J Spinal Cord Med . doi: 10.1080/10790268.2019.1688021. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Hatchett PE, Mulroy SJ, Eberly VJ, Haubert LL, Requejo PS. Body mass index changes over 3 years and effect of obesity on community mobility for persons with chronic spinal cord injury. J Spinal Cord Med . 2016;39(4):421–432. doi: 10.1080/10790268.2015.1133482. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.LaVela SL, Evans CT, Prohaska TR, Miskevics S, Ganesh SP, Weaver FM. Males aging with a spinal cord injury: Prevalence of cardiovascular and metabolic conditions. Arch Phys Med Rehabil . 2012;93(1):90–95. doi: 10.1016/j.apmr.2011.07.201. [DOI] [PubMed] [Google Scholar]
  • 6.Leontiev DA. Personal meaning: A challenge for psychology. J Positive Psych . 2013;8(6):459–370. [Google Scholar]
  • 7.Wong PTP. Viktor Frankl’s meaning seeking model and positive psychology. In: Batthyany A, Russo-Netzer P, editors. Meaning in existential and positive psychology . New York: Springer; 2014. pp. 149–184. [Google Scholar]
  • 8.Howe CA, Rancourt AM. The importance of definitions of selected concepts for leisure inquiry. Leisure Sci . 1990;12:395–406. [Google Scholar]
  • 9.Cronin P, Ryan F, Coughlan M. Concept analysis in healthcare research. Int J Ther Rehabil . 2010;17(2):62–68. [Google Scholar]
  • 10.Samdal GB, Eide GE, Barth T, Williams G, Meland E. Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses. Int J Behav Nutr Phys Act . 2017;14(1):42. doi: 10.1186/s12966-017-0494-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Kelly S, Martin S, Kuhn I, Cowan A, Brayne C, Lafortune L. Barriers and facilitators to the uptake and maintenance of healthy behaviours by people at mid-life: A rapid systematic review. PLoS One . 2016;11(1):e0145074. doi: 10.1371/journal.pone.0145074. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Stineman MG. The clinician’s voice of brain and heart: A bio-psycho-ecological framework for merging the biomedical and holistic. Top Stroke Rehabil . 2011;18(1):55–59. doi: 10.1310/tsr1801-55. [DOI] [PubMed] [Google Scholar]
  • 13.Mete R, Shield A, Murray K, Bacon R, Kellett J. What is healthy eating? A qualitative exploration. Public Health Nutr . 2019;22(13):2408–2418. doi: 10.1017/S1368980019001046. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Ambwani S, Sellinger G, Rose KL, Richmond TK, Sonneville KR. “It’s healthy because it’s natural.” perceptions of “clean” eating among U.S. adolescents and emerging adults. Nutrients. 2020;12(6):1708. doi: 10.3390/nu12061708. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Allen M, Dickinson KM, Prichard I. The dirt on clean eating: A cross sectional analysis of dietary intake, restrained eating and opinions about clean eating among women. Nutrients . 2018;10(9):1266. doi: 10.3390/nu10091266. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Falk LW, Sobal J, Bisogni CA, Connors M, Devine CM. Managing healthy eating: Definitions, classifications, and strategies. Health Educ Behav . 2001;28(4):425–439. doi: 10.1177/109019810102800405. [DOI] [PubMed] [Google Scholar]
  • 17.Mahrs Träff A, Cedersund E, Nord C. Perceptions of physical activity among elderly residents and professionals in assisted living facilities. Eur Rev Aging Phys Act . 2017;14:2. doi: 10.1186/s11556-017-0171-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Tudor-Locke C, Henderson KA, Wilcox S, Cooper RS, Durstine JL, Ainsworth BE. In their own voices: Definitions and interpretations of physical activity. Womens Health Issues . 2003;13(5):194–199. doi: 10.1016/s1049-3867(03)00038-0. [DOI] [PubMed] [Google Scholar]
  • 19.Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol . 2006;3:77–101. [Google Scholar]
  • 20.Miles M, Huberman Saldana J. Qualitative data analysis A methods sourcebook . 3rd ed. Thousand Oaks, CA: SAGE Publication; 2013. [Google Scholar]
  • 21.Sandelowski M. Sample size in qualitative research. Res Nurs Health . 1995;18(2):179–183. doi: 10.1002/nur.4770180211. [DOI] [PubMed] [Google Scholar]
  • 22.Sandelowski M. One is the liveliest number: the case orientation of qualitative research. Res Nurs Health . 1996;19(6):525–529. doi: 10.1002/(SICI)1098-240X(199612)19:6<525::AID-NUR8>3.0.CO;2-Q. [DOI] [PubMed] [Google Scholar]
  • 23.Kallio H, Pietilä AM, Johnson M, Kangasniemi M. Systematic methodological review: Developing a framework for a qualitative semi-structured interview guide. J Adv Nurs . 2016;72(12):2954–2965. doi: 10.1111/jan.13031. [DOI] [PubMed] [Google Scholar]
  • 24.Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: Developing taxonomy, themes, and theory. Health Serv Res . 2007;42(4):1758–1772. doi: 10.1111/j.1475-6773.2006.00684.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Kurasaki KS. Intercoder reliability for validating conclusions drawn from open-ended interview data. Field Meth . 2000;12(3):179–194. [Google Scholar]
  • 26.Centers for Disease Control and Prevention. Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion. Healthy weight nutrition and physical activity . 2020. https://www.cdc.gov/healthyweight/index.html
  • 27.US Preventive Services Task Force. Weight loss to prevent obesityrelated morbidity and mortality in adults Behavioral interventions . 2018. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/obesity-in-adults-interventions
  • 28.World Health Organization Obesity . 2020. https://www.who.int/health-topics/obesity#tab=tab_1
  • 29.Kandula NR. A better way to know what patients believe and value about health. J Gen Intern Med . 2014;29(4):560–561. doi: 10.1007/s11606-013-2714-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Landry M, Lemieux S, Lapointe A, Bédard A, Bélanger-Gravel A, Bégin C, Provencher V, Desroches S. Is eating pleasure compatible with healthy eating? A qualitative study on Quebecers’ perceptions. Appetite . 2018;125:537–547. doi: 10.1016/j.appet.2018.02.033. [DOI] [PubMed] [Google Scholar]
  • 31.Lake AA, Hyland RM, Rugg-Gunn AJ, Wood CE, Mathers JC, Adamson AJ. Healthy eating: Perceptions and practice (the ASH30 study) Appetite . 2007;48(2):176–182. doi: 10.1016/j.appet.2006.08.065. [DOI] [PubMed] [Google Scholar]
  • 32.Bisogni CA, Jastran M, Seligson M, Thompson A. How people interpret healthy eating: Contributions of qualitative research. J Nutr Educ Behav . 2012;44(4):282–301. doi: 10.1016/j.jneb.2011.11.009. [DOI] [PubMed] [Google Scholar]
  • 33.Chambers S, Lobb A, Butler LT, Traill WB. The influence of age and gender on food choice: A focus group exploration. Int J Consumer Studies . 2008;32(4):356–365. [Google Scholar]
  • 34.Bhaskaran S, Hardley F. Buyer beliefs, attitudes and behaviour: Foods with therapeutic claims. J Consumer Marketing . 2007;19(7):591–606. [Google Scholar]
  • 35.Bisogni CA, Connors M, Devine CM, Sobal J. Who we are and how we eat: A qualitative study of identities in food choice. J Nutr Educ Behav . 2002;34(3):128–139. doi: 10.1016/s1499-4046(06)60082-1. [DOI] [PubMed] [Google Scholar]
  • 36.Holla JFM, van den Akker LE, Dadema T et al. Determinants of dietary behaviour in wheelchair users with spinal cord injury or lower limb amputation: Perspectives of rehabilitation professionals and wheelchair users. PLoS One . 2020;15(1):e0228465. doi: 10.1371/journal.pone.0228465. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Farkas GJ, Gater DR. Energy expenditure and nutrition in neurogenic obesity following spinal cord injury. J Phys Med Rehabil. 2020;2(1):11–13. [PMC free article] [PubMed] [Google Scholar]
  • 38.Bauman WA, Spungen AM. Metabolic changes in persons after spinal cord injury. Phys Med Rehabil Clin N Am. 2000;11(1):109–140. [PubMed] [Google Scholar]
  • 39.Farkas GJ, Pitot MA, Gater DR., Jr A systematic review of the accuracy of estimated and measured resting metabolic rate in chronic spinal cord injury. Int J Sport Nutr Exerc Metab. 2019;29(5):548–558. doi: 10.1123/ijsnem.2018-0242. [DOI] [PubMed] [Google Scholar]
  • 40.Bigford G, Nash MS. Nutritional health considerations for persons with spinal cord injury. Top Spinal Cord Inj Rehabil. 2017;23(3):188–206. doi: 10.1310/sci2303-188. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Eriksson BM, Arne M, Ahlgren C. Keep moving to retain the healthy self: the meaning of physical exercise in individuals with Parkinson’s disease. Disabil Rehabil . 2013;35(26):2237–2244. doi: 10.3109/09638288.2013.775357. [DOI] [PubMed] [Google Scholar]
  • 42.Stennett A, De Souza L, Norris M. The meaning of exercise and physical activity in community dwelling people with multiple sclerosis. Disabil Rehabil . 2020;42(3):317–323. doi: 10.1080/09638288.2018.1497715. [DOI] [PubMed] [Google Scholar]
  • 43.Machida M, Irwin B, Feltz D. Resilience in competitive athletes with spinal cord injury: The role of sport participation. Qual Health Res . 2013;23(8):1054–1065. doi: 10.1177/1049732313493673. [DOI] [PubMed] [Google Scholar]
  • 44.Geard A, Kirkevold M, Løvstad M, Schanke AK. Exploring narratives of resilience among seven males living with spinal cord injury: A qualitative study. BMC Psychol . 2018;6(1):1. doi: 10.1186/s40359-017-0211-2. 4; [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Girelli L, Hagger M, Mallia L, Lucidi F. From perceived autonomy support to intentional behaviour: Testing an integrated model in three healthy-eating behaviours. Appetite . 2016;96:280–292. doi: 10.1016/j.appet.2015.09.027. [DOI] [PubMed] [Google Scholar]
  • 46.Sherwood NE, Jeffery RW. The behavioral determinants of exercise: Implications for physical activity interventions. Ann Rev Nutr. 2000;20:21–44. doi: 10.1146/annurev.nutr.20.1.21. [DOI] [PubMed] [Google Scholar]
  • 47.Parry SM, Knight LD, Connolly B et al. Factors influencing physical activity and rehabilitation in survivors of critical illness: A systematic review of quantitative and qualitative studies. Intens Care Med. 2017;43(4):531–542. doi: 10.1007/s00134-017-4685-4. [DOI] [PubMed] [Google Scholar]

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