Illustration by Doug Davis

When I first started to think about fitness and nutrition 13 years ago, there was frustratingly little information to follow when it came to workout and nutrition advice specific to wheelchair users. I was an early-20s college student with C7-8 complete quadriplegia, twiggy arms and a quad belly, who also fancied himself a wheelchair rugby player. I was self-aware enough to realize that I had neither the relative function nor the natural talent to excel at a high level in rugby with my present (lack of) musculature and fitness, so I set about trying to change that.

Today, I can say that was the best decision I ever made. Learning how to maximize my body’s function was a sometimes painful, often frustrating process, but it took me further than I’d ever dreamed in terms of athletic pursuits. More importantly than that, it improved my day-to-day functionality, allowing me to enjoy my world in a way I hadn’t been able to immediately after my accident.

A few things I learned in my decade-long refining of my body’s capabilities turned out to be backed up by the latest in scientific research on health and fitness. First, when it comes to being in a wheelchair, being as strong as your particular body is capable of is beneficial in a multitude of ways. Second, consistent physical activity is the key to long-term health. And third, at least in terms of body composition, nutrition should only be thought of in relation to physical activity.

I’m sorry to say this article will contain no easy answers. There will be simple, straightforward advice, but it won’t offer any quick fixes. There is no pill or diet that will significantly boost your metabolism. No five-minute workout that will alter your body composition. Creating healthy habits takes effort and some measure of discipline, but it’s worth it. And the hardest part about creating a habit is the beginning. Once you develop a routine that works for you, there’s enough positive feedback that it just becomes a part of who you are.

High-level Injuries Get Screwed Again, Sort Of

Outside of infection and skin breakdown, the two biggest health concerns for wheelchair users are cardiovascular disease and obesity, which operate hand in hand. Cardiovascular health and weight management are tied to diet and activity level. The two operate together, but even for a trained professional like Elizabeth Broad, a senior sports dietician with the U.S. Olympic Committee, the typical emphasis is often too much on the food side of things. In rehab centers, she says, people are often told they need to keep their weight down, but “I think the natural instinct in most people is to say, ‘Well, don’t eat as much,’ as opposed to, ‘I’ve got to stay as active as I can and maintain as much muscle mass as I can.’ Obviously, there are two related ways of keeping your weight under control, aren’t there? There’s energy uptake and energy expenditure. I think the focus is not so much on activity, and it needs to be more so.”

Broad works on both the Olympic and Paralympic side of things. It was thanks to her that I underwent a round of innovative metabolic testing with USA Wheelchair Rugby in 2015 that measured our individual resting metabolisms, as well as our individual energy expenditure while playing rugby. At that time, I had upped my metabolism to the point where my body would burn 2,000 calories a day without ever getting out of bed. This number is higher than clinical studies would suggest for my injury level, but still below nondisabled averages. But, estimates based on the testing showed that when I was in a heavy training day, I needed some 3,300-3,400 calories just to be energy neutral, and even more if I was trying to put on muscle.

Clinical testing has shown that people with spinal cord injuries have a lower resting metabolism than nondisabled control groups (see below). This is primarily due to people with physical disabilities having fewer active, functioning muscles than the nondisabled. Muscles are our bodies’ engines, and as a group, we have smaller engines that burn less fuel. Logic follows, and research confirms, that the less function you have, the lower your resting metabolic rate. So, as a group, T10 complete paras are going to have a higher resting metabolic rate than C7 complete quads.

But things start to get surprising when you look at total daily energy expenditure. A study evaluated people with varying levels of spinal cord injury and compared them with a nondisabled control group on both active and inactive days. As might be expected, the authors found that on inactive days the nondisabled group burned more energy than the SCI group. Perhaps less expected was the finding that on active days there was no difference in energy expenditure between the two groups.

Broad says the difference on inactive days is “a function of the amount of muscle mass that [the non-disabled group] has.” But on active days, the heart rates of the SCI group were higher than the nondisabled group, a sign that their smaller engines were having to work harder to do a similar amount of activity. This is simply confirmation of what wheelers already know: Doing most anything is just more difficult if you use a wheelchair.

Take vacuuming. It’s hardly a workout, but still, it requires some measure of energy to do. If my wife, Kelly, vacuums the house, she certainly wouldn’t consider that a strenuous physical activity. Her body can accomplish the task without raising her heart rate more than a few beats. But when I vacuum, within five minutes my right deltoid is starting to burn and I’m having to take a break and regather myself. Vacuuming the house noticeably raises my heart rate, and it takes at least twice as long to do as it does Kelly. I can think of a hundred other examples: Just last week I found my arms burning while washing some pots and pans. This sucks for a slew of reasons, but in terms of overall health, it’s actually a good thing.

The study also found that participants with higher-level injuries had lower total energy expenditure than those with lower injuries — again, not surprising. But the difference wasn’t due to any metabolic reasons, but rather that the level of one’s spinal cord injury appears to be important in determining the level of habitual activity. Or, the higher your injury level, the less likely you are to maintain the same level of regular physical activity. That’s the kicker: The less function you have, the more difficult it is to stay active. But at the same time, Broad says, “the higher the level of your spinal cord lesion, the more important it is for you to maintain a regular activity level.”

It might be a pain in the ass, but the physical inefficiency of people with higher injuries actually helps mitigate their lower resting metabolism, provided they actually stay active.

The Tao of Strength

A key factor for keeping your body composition healthy and boosting your metabolism is doing some sort of strength training to build muscle. “Muscle mass is such a functional thing in so many ways that you’re better off having the higher end of your own capacity,” says Broad.

This was undoubtedly the case for me. Before I started playing wheelchair rugby and strength training, not only did variabilities in my diet have a noticeable effect on the size of my belly, but I was simply less functional and active in my everyday life.

Because I didn’t have the arm strength to deal with them, even consistent, minor hills, let alone steep ones, were enough to deter me from wheeling places. I was more conservative in where I would go, and what I would do because I wasn’t able to get myself back into my chair if I fell out of it.

Once I was strong enough and had learned to get from the ground into my chair, I started exploring more unpaved trails, pushing through the old growth forest, learning to maneuver over root and rock, because I knew I wasn’t going to be stuck if I did tumble. Strength begat more activity, and it was incredibly freeing.

What exercises are best suited for you to build strength depends on your particular body and function, and what equipment you have access to. Steve Pate, a Paralympian who served as the strength and conditioning coach for USA Wheelchair Rugby through 2016, urges wheelers to be aware which exercises are pushing away from your body and which are pulling toward your body. Generally, pushing exercises are going to work the front of your upper body, while pulling is going to work your back. “Always do more back exercises than front,” says Pate. “At least two more back than front, but really, it could be more than that.”

This is to counter the natural tendency for wheelers to overdevelop their pushing muscles. Apart from boosting your metabolism, building balanced strength can help keep your shoulders from rounding forward, which can cause a variety of shoulder problems. Rotator cuff exercises are important, but developing a strong back is the foundation for long term shoulder health as a wheelchair user.

If you haven’t done any strength training for an extended period of time, Pate emphasizes starting slow with less weight than you think you can handle. “You cannot judge yourself when you first start weightlifting because you could overdo it on your second set and now you can’t get anything on your third or fourth. Just go slow,” he says. “It’s more about being honest. Like, what can I do right now?”

By taking the time to learn about your body and make sure you have proper form, Pate says you will be “getting your tendons and your cartilage and everything ready for when you actually do push weight. Your muscles will actually recover quicker than your joints.”

Food as Fuel

At its base, food is fuel for our body’s activity, and in respect to metabolism and body composition, that’s a good way to view it. Even with our lower resting metabolisms, Broad says wheelchair users often underestimate the amount of nutrition it takes to properly fuel our bodies. “People often think, ‘If I eat fewer calories than what I burn, I should lose weight,’ but there’s a point you go too far, and the body will actually fight it,” she says. “That’s where a lot of people get stuck. If they keep trying to drop their energy intake, trying to lose weight, they don’t succeed. And then they think they’re just not working hard enough, or they’re just not trying hard enough, and they get salty with the situation, where all they do is suppress their metabolism and their body becomes very conservative. This happens with people who yo-yo with their weight.”

This is why dieting often doesn’t work in the long term. By significantly reducing your caloric intake, you put yourself at an energy deficit, which initially helps you lose weight. But being in a constant energy deficit stresses your body out, and it tries to protect itself by slowing your metabolism. When you stop dieting and return to normal eating, or even slightly reduced eating, your metabolism is now slower as well and you quickly start putting back on all the weight you just lost, sometimes more.

Increasing your strength and total energy expenditure while improving the quality of the food you’re eating is more sustainable than worrying about reducing calories, volume, or removing things from your diet.

Eating processed foods — full of refined carbohydrates, saturated fats, and the like — it’s easy to consume more calories than your body can process without ever feeling satisfied. If you’re focused on putting quality food into your body, it’s much easier to satisfy your appetite and fuel your energy needs while staying within a healthy calorie range. “For the same volume of food, you can have lower calories by improving the quality of that food,” Broad says. Adding lots of fruits and vegetables to their diets help people feel more full, and “using more whole grain food products makes it more filling, but it also delivers a lot more micro-nutrients.”

Also important is when you eat. In terms of maintaining and promoting muscle mass, as well as appetite regulation, having breakfast is essential. Muscles don’t respond well to long periods of an energy deficit. “You’re already, by being asleep for eight hours or longer, in a long period of energy deficit because your body’s still metabolizing,” says Broad. “It’s still burning energy in that period of time, but you haven’t delivered any fuel to it. If you wait until noon instead of, say, 7:30 a.m. to eat, you’ve then extended that by another four hours.”

If you are never hungry for breakfast, don’t worry — Broad says habits can be changed. Like Pate does for weight lifting, she recommends starting slowly. “If you start eating breakfast, even small amounts like just a granola bar or a piece of fruit, you can actually create situations where your appetite will shift, and you will start being hungry for breakfast.”

Along with eating breakfast, Broad is a proponent of eating frequently — spreading your food intake more evenly across the day rather than consuming the majority of your calories in one or two big meals, which she says “lends itself nicely to holding muscle mass.”

Being proactive about fueling your body means looking to put good food in, rather than taking large components out of your diet. Skewing your diet away from one type of macro-nutrient — whether protein, fat, or carbohydrates — makes it difficult to deliver all of the micro-nutrients that are going to keep you healthy over the long term. An easy way to keep things balanced is by dividing your plate into thirds at meal time. One third can be fruits and veggies — the more color the better, one third can be relatively lean proteins such as chicken or fish, and the other carbs such as whole grains or sweet potatoes.

And remember, nobody’s perfect. If you feel the need to eat some really delicious and gluttonously unhealthy food every so often, I promise I won’t tell anyone. By keeping your metabolism and energy expenditure up, your body can handle occasional energy excesses a lot better than someone who’s been suppressing their metabolism with a diet. When you go big, instead of feeling bad about it or skipping a subsequent meal, go out for a push, strap the wrist weights on, do some yard work, or get out the dreaded vacuum. If you put too much fuel in your body, rev that little engine up and burn it off.

By focusing on a more global picture of your body that includes strength, daily activity, and sustainable nutrition, you can boost your overall metabolism and mitigate some of the typical health concerns of living with a disability. It’s no “seven-minute abs,” but I’ll take what I can get.

Understanding Metabolism

Your metabolism is intricately connected to your health and fitness regimen, especially for wheelchair users. Metabolism is the chemical process by which your body turns nutrients into fuel for energy. Total metabolism, or how much energy you burn in a given day, can be seen as a combination of three things:

• Resting (basal) metabolic rate is how much energy your body burns at rest. Typically, this is what people are referring to when they say someone has a fast metabolism: someone with a body that burns a lot of energy at baseline.

• The thermic effect of food. It takes energy for your body to digest food; how much energy varies based on the type of food and your activity level.

• Physical activity. The more you do, the more energy it takes to fuel that activity. How much energy is required for a given activity is highly variable for the nondisabled; add varying degrees of paralysis into the equation, and it’s damn complicated.

No Gym? No Problem

Strength training doesn’t have to be complicated or expensive. If you have access to a gym, and want to go, great. But if that isn’t a realistic option, you can still get a quality, functional strength workout without ever leaving your house or buying a bunch of dedicated equipment.
(See “7 Budget-Friendly Products for a High-Performance Home Gym,” NEW MOBILITY, November 2017).

A basic strength routine for a wheelchair user can start with a pair of adjustable wrist weights or even just some Therabands. The Shepherd Center has an easy-to-use app for smart phones called SCI-Ex that shows wheelchair users how to do different types of exercises based on your level of function, from low para to power chair user.

Ed Suhr, a C5 quad since 1984 who uses a manual wheelchair, tries to go for a dedicated push four times a week as well as a strength routine two or three times a week. “It’s hard to vary the workout, it’s mostly arm raises and circles,” he says. “I just use wrist weights, up to 5 pounds. Pretty lame, but it works for me.”

Former USA Wheelchair Rugby strength and conditioning coach Steve Pate, himself a Paralympian, recommends starting with a simple program of four sets of 12 reps for four weeks, and then going to four sets of 10 reps, upping the weight as your body adapts.

Finding whatever works for you is the key. It doesn’t matter if you can transfer onto a bench and press 200 pounds, or if you’re doing weighted arm circles. What’s important is maximizing whatever musculature you do have.