Introduction

Nutrition plays a pivotal and often underappreciated role in the lives of individuals with spinal cord injury (SCI) profoundly impacting their health, well-being, and overall quality of life [1]. Following an SCI, individuals face a dramatically increased risk of malnutrition, with alarming statistics showing that up to 60% of those admitted to rehabilitation centres experience this potentially debilitating condition [2,3]. This high prevalence is not merely a coincidence but a direct consequence of the complex physiological changes and challenges that accompany SCI. The risk of malnutrition is further exacerbated by a constellation of comorbidities commonly associated with SCI. Dysphagia can impact on nutritional management particularly in acute cervical SCI with the need for temporary or more longer-term enteral nutrition [4]. Neurologic bowel dysfunction, recurrent infections, the presence of pressure injuries, and loss of appetite collectively favour the development of malnutrition [5,6]. The prevalence of malnutrition was reported in the range of 40–69% in individuals with SCI and the consequences of malnutrition in SCI individuals are far-reaching and severe.³ Research has consistently demonstrated strong links between malnutrition and poorer functional recovery, significantly prolonged hospitalization periods, and alarmingly higher mortality rates within the first-year post-injury [2,7,8]. These findings underscore the critical need for early nutritional intervention and ongoing management as integral part of SCI care.

Due to lack of standardised recommendation, nutrition service is usually under-invested in SCI centres [9,10]. Unsurprisingly, poor adherence to dietary guidelines is common both in the inpatient and outpatient settings, with two-thirds of individuals consuming insufficient fruits and vegetables while overindulging in meat, and a concerning 10% reporting daily alcohol consumption [11]. This dietary imbalance is not limited to the acute phase; both subacute and chronic SCI populations struggle to meet nutritional recommendations [12–16]. In general, individuals with SCI exhibit a greater energy intake relative to their energy needs, along with an imbalance in fibre intake and macronutrient consumption, characterized by excessive protein and carbohydrate intake. Additionally, there are significant micronutrient deficiencies such as vitamin A, B5, B7, B9, D, E and minerals like potassium and calcium when compared to dietary guidelines for Americans [17]. These nutritional deficits and excesses can exacerbate SCI-related health complications.

Nutritional interventions are crucial in combating the myriad of secondary health conditions associated with SCI, including neurogenic obesity, type 2 diabetes, dyslipidaemia, and other obesity-related comorbidities [18]. Promising dietary strategies encompass high-protein diets, intermittent fasting, balanced nutrition combined with physical conditioning and electrical stimulation, and targeted supplementation (e.g., alpha-lipoic acid, creatine, vitamin D, cranberry derivatives, and probiotics) [19]. Moreover, maintaining a healthy weight through proper nutrition significantly reduces the risk of diabetes, metabolic syndrome, cardiovascular disease, and skin breakdown in this vulnerable population [20].

Despite the clear importance of nutrition in SCI management, developing comprehensive, evidence-based nutritional guidelines remains challenging. This is due to the relative novelty of nutrition focus in SCI research, the unique physiological changes post-injury, and the methodological challenges inherent in conducting robust nutritional studies in this population [21,22]. Often, experts must extrapolate from general population data, which may not accurately reflect the specific needs of individuals with SCI. Furthermore, SCI nutrition studies frequently suffer from insufficient statistical power due to recruitment difficulties, high attrition rates, and limited funding for large-scale, multi-centre trials [23].

To the authors’ knowledge, no result of a systematic, international priority setting for nutrition research has been published so far. To overcome these obstacles and advance the field, a strategic, prioritized approach to SCI nutrition research is imperative. By systematically identifying and consensus-building around key research priorities, we can focus limited resources on areas with the greatest potential impact on health outcomes and quality of life for individuals with SCI.

This study aims to identify and achieve consensus on priorities for nutrition research in adults with SCI, providing a crucial roadmap to guide international research efforts. By aligning research focus with stakeholder-identified priorities, we can accelerate progress in this critical yet under-researched area, ultimately improving the lives of individuals living with SCI worldwide.

Methodology

The Delphi processes

The study conduct and report will follow the Conducting and Reporting of DElphi Studies (CREDES) recommendations [24]. To identify research priorities in the field of nutrition among SCI population, we will perform a modified electronic Delphi (e-Delphi) process to facilitate wider (international) participation. The study has not yet started and will be conducted between April and October 2025. It will comprise a systematic, two-round, web-based, eDelphi questionnaire among diverse stakeholders involved either in clinical care or SCI research, followed by hybrid consensus meeting (Fig 1). Results are expected by the end of 2025. The project has been granted the ethical approval from the School of Health & Psychological Sciences at City St George’s, University of London Ethics board (ETH2425−0192).

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Fig 1. The study flowchart.

The Delphi process will be conducted in three phases. Phase 1 focuses on topic generation through an open-ended survey to members of the ISCoS Nutrition Special Interest Group (SIG) and their professional networks, resulting in a list of 10 preliminary research priorities. Phase 2 involves ranking these priorities using a Likert scale to determine their relative importance, leading to a list ranked by sum scores. Phase 3 consists of a hybrid consensus meeting with Nutrition SIG members to finalize the top research priorities based on median scores and expert discussion.

https://doi.org/10.1371/journal.pone.0327612.g001

Expected results and dissemination

This Delphi study is anticipated to yield several significant outcomes that will advance the field of nutrition research in SCI. First, we expect to generate a comprehensive, ranked list of 10–15 key research priorities, reflecting the consensus of international experts with established experience in clinical nutrition and SCI. This prioritized research agenda will likely reveal areas of agreement and potential divergence among participating professionals with interdisciplinary background, offering insights into shared priorities and areas requiring further dialogue. While the focus on members of the ISCoS Nutrition Special Interest Group (SIG) and their professional networks ensures a high level of subject-matter expertise, we acknowledge that this approach may limit broader representativeness. In particular, excluding patients, caregivers, and other stakeholder groups means that the identified priorities will primarily reflect the perspectives of health professionals. This decision was intentional, as clinical and research expertise in SCI nutrition requires a deep understanding of complex physiological, metabolic, and clinical contexts. Nonetheless, we recognize the value of including lived experiences and lay perspectives in shaping a more holistic research agenda, and future work may expand to incorporate patient and caregiver input through complementary methods such as focus groups or patient advisory panels.

Additionally, the study is expected to highlight critical knowledge gaps in SCI nutrition, pinpointing where evidence is lacking, and research is urgently needed. The findings will serve as a valuable tool for funding bodies and research institutions, guiding resource allocation towards the most impactful areas. We anticipate identifying opportunities for international collaboration, fostering partnerships to tackle complex, high-priority research questions. Moreover, the results are likely to inform clinical practice guidelines by emphasizing areas where nutritional interventions could significantly improve patient outcomes. Insights from the study may also lead to policy recommendations for SCI care and rehabilitation, underscoring the essential role of nutrition in comprehensive management. Overall, we expect this study to provide clear direction for future research efforts, potentially catalysing new studies and clinical trials in high-priority areas while raising awareness about the importance of nutrition in SCI care among both the scientific community and the public.