How to Strengthen Good Habits and Lose the Ones that Zap Your Health
I’Ve Been A Fitness Enthusiast my whole life. Before my accident, my idea of Saturday morning fun was a sixty-mile bike ride. I worked out with weights, skied, and followed a healthy Mediterranean diet. Taking care of my body was an integral part of my routine, and it made me feel good, too. After I suffered my injury, however, I knew that all of my favorite strenuous activities would be a thing of the past. I also knew that a healthy lifestyle would be more important than ever for my longevity—and for any chance I had at getting my brain and body back.
Your lifestyle—what you choose to eat and drink, how much sleep you get, how physically active you are, how much alcohol you consume, whether or not you are a smoker, and how you react to stress—is the foundation of your overall state of health. Lifestyle is a huge factor in lifespan and in your quality of life, too. And post-injury, these factors can enhance or hinder your recovery. So now is the time to make adjustments that will strengthen your good habits and free you of the ones that may be eroding your health.
A healthy diet is an important source of nutrition and the best way to maintain an optimal weight. What is a healthy diet? Generally speaking, it includes fruits and vegetables, healthy fats, protein, and plenty of fiber, which can be found in whole grains and legumes. There are lots of “healthy” diets being promoted every year—so many, actually, that it can be confusing as to what you should eat. But there are good ones that stand the test of time. The two I always recommend are the DASH diet and the Mediterranean diet.
The DASH diet (Dietary Approaches to Stop Hypertension) is recommended by the American Heart Association and the National Institutes of Health.1 It was designed to prevent hypertension by limiting sodium intake (less than 2,300 mg per day). Because hypertension is common in SCI survivors and present in more than 50 percent of stroke survivors, the DASH diet is applicable to many people with ANI.
The Mediterranean diet is based on the traditional foods of the regions along the Mediterranean Sea, particularly the island of Sicily.2 Studies have found that these populations have a very low incidence of obesity and chronic disease (such as type 2 diabetes, heart disease, cancer, and lung disease) and have excellent longevity. Both of these diets call for foods that are easy to find, decrease the risk of heart attack and stroke, and include options to suit a variety of tastes and budgets. Recommendations include at least five servings of fruits and vegetables a day; at least 25 grams of fiber; whole grains rather than highly processed ones; low-fat dairy products; legumes, poultry, and seafood for protein; and limited consumption of red meat.
There are many books that present diets for optimal health in recovery. These include Dr. Michael Greger’s How Not to Die, which focuses on preventing and treating the top fifteen causes of death in the US; Dr. Jason Fung’s The Obesity Code, which discusses a five-step approach to diet that focuses on hormones, appetite, insulin resistance, and fat storage; and Dorothy Calimeris’s The Complete Anti-Inflammatory Diet for Beginners, which discusses the harmful effects of foods that increase inflammation versus foods that are beneficial for treating inflammation (fruits and vegetables, whole grains, plant-based proteins, fish, and fresh herbs and spices). You can find more about these diets and recipes in books or online (see Resources on page 282).
Even if you are at an ideal weight, ask for a consultation with a registered nutritionist at the hospital. They will assess your eating habits and help you design a diet that will continue to support your health, even if your ability to eat has changed. After an ANI, it’s particularly important to achieve and maintain your ideal weight, especially if your mobility has been adversely affected, since excess weight will make your rehabilitation more difficult. Being overweight also puts you at greater risk for serious health problems, including type 2 diabetes, heart disease, and cancer.
If you are employed at a large company, you may benefit from an employee health program, which usually includes free consultation with a nutritionist. Your primary care physician can also refer you to a local community wellness program that includes dietary counseling, which may be covered by your health insurance or may even be free.
Alcohol and ANI
Your consumption of alcohol may need to change after your injury. After TBI, significant research data shows that you should not consume any alcohol for at least one year, due to decreased functional recovery. While similar data does not exist for stroke and SCI, you may find that limiting your alcohol consumption is best for your health and recovery.
If you regularly exceeded the recommended daily amount of alcohol (one drink per day for women, and two for men) pre-injury, you may need help cutting back or eliminating alcohol. Let your doctor know if you want help. Your doctor and nutritionist can counsel you on how much alcohol you should be drinking, if any. They can also refer you to a program to help you stop drinking if it’s a problem for you to do so on your own. See this section in chapter 1 for more.
The standards for the amounts and types of food, minerals, and vitamins that should be consumed daily by Americans are established by the National Academy of Sciences, National Research Council, and the National Academy of Medicine. Most doctors and dieticians use the Recommended Daily Allowance (RDA)—which is the average daily intake sufficient to meet the dietary requirement of nearly all healthy people—when considering the best eating plan for ANI patients. RDA is listed by age, sex, and activity level in A Consumer’s Guide to the DRIs (Dietary Reference Intakes), as published by Health Canada.3
A healthy diet alone should meet the RDA standards, which is why I don’t generally recommend supplements. But vitamin D is one notable exception. Low levels of vitamin D can contribute to osteoporosis and consequently an increased risk of fractures. Since you may be more susceptible to falls and, therefore, fractures, I recommend that you ask to be tested for 25-hydroxyvitamin D3 levels while you are in the hospital. If your levels are low, start daily supplementation with at least 1,000 units of vitamin D3. Your doctor should schedule follow-up lab work to monitor the effects of the supplements.
If you are meeting RDA standards through diet, you will likely not need to take herbal supplements either. These supplements, which include coenzyme Q10, echinacea, and melatonin (more on this in chapter 8), can be problematic due to inaccurate labeling, and the presence of other active compounds that are not identified on the label. If you decide to start or continue herbal supplements, be sure to inform your doctor, as they can interfere with some prescription drugs.
After your injury, it’s especially important to get regular physical exercise, to the extent that you can, as you recover. Work with your therapy team to develop an exercise program that increases your flexibility, balance, and strength—these are the key components to ongoing rehabilitation.
Your exercise routine should include both aerobic and strength-building activities. As you recover, regular exercise will help you increase your mobility and independence, enhance your mood, and improve your mental health. Physical fitness is also beneficial for disease prevention. It reduces your risk of cardiovascular disease, heart attack, stroke, type 2 diabetes, and more. Even modest amounts of regular physical activity, such as walking or using a hand cycle for thirty minutes every day, deliver a significant benefit.
When you are discharged from outpatient physical therapy, be sure to ask your therapist to write down the exercises and competitive sports in which you can participate. There are formal guidelines for TBI patients with concussions on returning to school and to sports, available on the websites of the Centers for Disease Control and Prevention (CDC) and the Brain Injury Association of America (BIAA).4 For stroke survivors, it’s important not to overexercise, because the parts of the brain that are still recovering may not get enough oxygen. While you can continue to work out at home, you may also want to schedule time with a personal trainer at a local fitness center, which may be covered by your health insurance policy. The trainer can help you stay on track with your fitness goals and tweak your routine to challenge your body. If you live near a university, you may be able to take advantage of a free training plan developed by an exercise physiologist just for you. Ask your physical therapist about this before you are discharged.
No matter where you live, you can make physical activity part of your day. There are fitness apps that you can download for free or for a small fee, and there are some excellent workout videos (also free) on YouTube. You’ll find a list in the Resources on page 284.
Ensuring that you are at your ideal weight will improve your health and recovery. Being overweight puts you at increased risk of cancer, heart disease, diabetes, and orthopedic problems. If you are not yet at that optimal weight, weight loss is best achieved using multiple approaches, including behavioral therapy, diet, and physical activity. Maintaining an ideal weight will make it easier for you to transfer in and out of a wheelchair, which will decrease the likelihood of pressure ulcers (see chapter 13). It will also make it easier to get around if you are using a cane, walker, or wheelchair. In particular, our shoulders were not designed to bear heavy loads, which occurs with any of these assistive devices, so many people will develop significant shoulder problems, especially with the rotator cuff, as they age. Maintaining your ideal weight also means you can purchase equipment that is less expensive, since extra weight requires larger adaptive devices with more strength.
Everyone knows that smoking is harmful to health. It’s linked to cancer, lung disease, and heart disease. And after an ANI, smoking is even more dangerous. Smoking damages lung function, and if you’ve had a traumatic brain injury or spinal cord injury at C5 or above, your diaphragm function is impaired, putting you at increased risk for pneumonia.
Smoking decreases bone mass and increases the risk of hip fracture, especially in women. If you do not perform regular weight-bearing activities, such as walking, you can develop osteoporosis and subsequently will be at much greater risk of bone fractures from even a simple fall.
Quitting can be difficult, but there are successful programs out there, most of them covered by health insurance. (Even if you have to pay out of pocket, think of what you spend each week on cigarettes and how much you’ll save once you quit!) Some programs combine behavioral therapy with prescription drugs or over-the-counter products that reduce cravings for nicotine. Hypnosis has proven to be a highly successful tactic, even for long-term smokers. There are also free telephone quit lines (like 1-800-QUIT-NOW), text messaging programs, and apps. Talk to your health care provider about your options.
You can get started by not allowing any smoking in your house. Pick a date to quit smoking, put it on the calendar, and tell your loved ones about your plan. Quitting smoking will take effort, but it’s well worth it. And even if you fail to stay smoke-free after your first try, the likelihood of being successful increases every time you try to quit. So, keep trying!
It’s impossible to lead a stress-free life. And when it comes to stressful experiences, ANI is off-the-charts. That’s exactly why it’s important to learn coping strategies and skills that will lessen the impact stress has on your day-to-day life. There are three therapies I recommend for chronic stress and anxiety: 1) cognitive behavioral therapy (CBT), which, as we learned in chapter 2, includes techniques such as relaxation training, identification of stressful situations, and using images to decrease stress response; 2) mind/body therapies, such as yoga, tai chi, meditation, and mindfulness (which you will learn about in chapter 8), which can reduce anxiety and depression; and 3) exercise and increased physical activity (my preferred approach!). These therapies will be lifelong tools you can use to improve your health, your relationships with loved ones, and your quality of life.
Try to avoid treating your stress with drugs as much as possible. Relying on drugs can mean that you end up in a vicious cycle of taking the drug to relax, discontinuing the drug because you feel better, and then experiencing a rebound of stress, forcing you to restart the drug. That said, if you remain anxious and stressed even with exercise, mind-body therapies, and CBT, regular low-dose prophylactic treatment with SSRIs or SNRIs can be useful (see chapter 4). Avoid benzodiazepines, like Valium, because they frequently cause mild cognitive impairment.
Sleep is when the body rests, repairs, and restores itself. Adults need seven to eight hours of quality sleep (uninterrupted sleep in a quiet, dark, comfortable environment) per night. Good sleep habits protect your cardiac health, your blood pressure, and even your weight. A lack of sufficient sleep can exacerbate existing type 2 diabetes and can even initiate it (the same is true for high blood pressure); it can also alter the balance of the two important weight-regulating hormones—leptin and ghrelin—leading to weight gain.
After ANI, it’s crucial to establish a quality sleep routine. Sleep disturbances can be common, especially if your injury damaged parts of the brain that are important for sleep. Chronic pain, mental health disorders (especially anxiety and PTSD), and neuropathic sensations such as numbness, electric shocks, and skin sensitivity—all common aftereffects of ANI—can also worsen sleep. In addition, many medications can cause daytime drowsiness and frequent napping, making it difficult to sleep for seven or eight consecutive hours at night.
After ANI (especially stroke and TBI), sleep disorders—including insomnia, obstructive sleep apnea, and central sleep apnea—are very common, affecting more than 60 percent of people.5 Sleep apnea is characterized by pauses in breathing or periods of extremely shallow breathing during sleep, decreasing the amount of oxygen in your blood. Untreated, sleep apnea increases the risk of heart attack, stroke, type 2 diabetes, heart failure, irregular heartbeat, obesity, erectile dysfunction, and serious car accidents (every year, untreated sleep apnea is responsible for thousands of drivers falling asleep at the wheel). Sleep apnea is usually treated with continuous positive airway pressure (CPAP) that maintains the open airways from your from your nose, mouth, and pharynx. It is highly effective, but many people have difficulty sleeping with a mask and the noise of a CPAP machine.6 Psychotherapy-based approaches are also effective for treating sleep disturbances after TBI.7 Acupuncture has been shown to improve insomnia following stroke, and sleep disturbances after TBI.8
Be sure to talk with your doctor about the quality of your sleep, including how many hours per night you sleep, if you snore loudly every night, and if you find yourself dozing off unintentionally during the day. Your doctor will then be able to diagnose sleep apnea from an overnight sleep study at home or in an accredited sleep lab. This sleep study should be covered by insurance, as is treatment, and your pulmonologist or sleep specialist will discuss treatment options with you. Don’t put off the conversation; the contribution proper sleep makes to your quality of life and to your recovery cannot be overstated. All sleep disturbances, especially sleep apnea, contribute to fatigue, hypertension, and impaired thinking. The increase in hypertension is particularly problematic, because the risk of stroke rises in parallel with the rise in systolic blood pressure (the upper blood pressure number). Hypertension also harms the blood vessels and nerves that feed and control the bowel, bladder, and penis, as well as the process of breathing.
Achieving wellness requires daily attention to many lifestyle choices. Feeling healthy and good about yourself will enable you to be more sociable and emotionally stable. Also, as we will discuss in the next chapter, to enjoy physical intimacy.
Your lifestyle—the large and small choices you make on a daily basis—determines your lifelong levels of health and happiness. Use this opportunity to examine your habits and make improvements where needed. Keep at it, keep a log, enlist the help of family and friends, and be sure to take advantage of the health care professionals and community organizations that can assist you on this journey to get your brain and body back. The most important elements of your lifestyle are in the list that follows; look at each one, write your answers in your journal, and determine where you can do better:
• What do you eat and drink?
• What do you do for physical fitness?
• Are you at an ideal weight?
• Do you smoke? (It’s time to quit!)
• Do you handle the stresses of life well?
• How much sleep do you get each night?