Obesity and Health Inequality

Chapter 1: Introduction

1:1 background of the study

Obesity is increasingly becoming a global health concern. Harcombe (2010) defines Obesity as the process of retaining harmful excessive fat in the body. This accumulation of detrimental fats puts the health of the individual at risk (World Health Organization 2019). Disease Control Priorities Network, (2001) classifies obesity as a leading preventable cause of death worldwide. Amongst children, it is even more alarming as former Health Secretary Jeremy Hunt described the rising rate of childhood obesity as a "national emergency". The World Health Organization estimate that in most cases, obesity development during childhood progresses into adulthood and can be accompanied by life-threatening complications (Department of health and social care, 2015). A report by Health Survey on England in 2013 revealed that from the BMI tests conducted, 48% of the people with a learning disability had obesity (Public health England, 2015). Similarly, Gul et al, (2009) also presented a vast increase of obesity in adults with a learning disability from 11.2% in 1993 to 27.0% in 2015 for men and from 16.4% to 27.8% for women. Melville et al. (2007), highlight that People with learning disabilities are vulnerable and are more likely to encounter significant health inequalities when compared to the general population. The learning disability Mortality Report LeDeR, (2017) considered health inequalities faced by the learning disability population amongst the general population. It uncovered a much lower life expectancy, an average death of learning disabled people as 15-20 years sooner than the general population. The report suggested that some deaths stem from poor quality healthcare as well as their care providers’ inability to maximize the provisions of the healthcare system to support them. Therefore weight management interventions, together with determining their impact needs high priority and emphasis within learning disability nursing practice. Studies have identified numerous factors fostering the emergence and progression of obesity. Doherty, et al. (2018) and Biswas et al. (2010) provided possible factors that included complex psychosocial predicaments such as the environment - poor neighbourhood, low income, social exclusion, discrimination, and lack of communication. Biological factors, for instance, the use of psychotropic medication, genetic make and psychological factors like behavioural change - insufficient dietary advice leading to poor nutrition, inadequate physical activity and exercise significantly increase the risk of obesity. According to Genetics Home Reference (2019), a genetic disposition to obesity increases the likelihood of certain illness or diseases in the lives of people with a learning disability. An approach suggested for alleviating obesity and its related medical condition is weight management. This includes diet study by Harris et al. (2019), a clinical trial of "weight management program comprised a 12-month controlled trial and pilot cluster-randomized on how weight management might prove to be beneficial for challenging obesity rates amongst adult with LD. Weight management intervention has received inadequate studies exploring its application in managing obesity, particularly among the people with learning disability. However, in an attempt to provide a comprehensive plan, Kirk et al (2012) identifies three themes that make up weight management intervention. First, there should be targeted multi-component intervention for weight management. The interventions should be designed for each patient depending on their risk factors and needs. This adopts the client-centred approach in implementing weight management intervention. Dietary manipulation strategies form the second theme of weight management intervention and is based on the premise that specific dietary practice may be effective than others (Kirk et al 2012). Clifton (2008) explains that in some cases weight loss is greater when using low-carbohydrate/high protein diets than low fat/high carbohydrate diets. However, lack of higher level systematic review and meta-analysis evidence and lack of long term follow-up are the main challenges affecting the assessment of effectiveness of weight management intervention (Kirk et al. 2012).

Nevertheless, delivery of weight management or weight loss intervention forms the third theme of weight management intervention. This theme is concerned with the actual implementation of weight management interventions. Kirk et al (2012) explain that weight management interventions should be aimed at improving the role of health professionals and the mode of delivery of the interventions. For instance, behaviour therapies focus on building self-efficacy, social support, self-monitoring and environmental modification Some government policy plans include nutritional standards in school, schemes to boost participation in sports, restrictions on marketing foods high in fat, sugar, and salts to children, active travel plans (Jebb et al 2013). Despite the reported advantages of weight management interventions in reducing serious related medical conditions, there is insufficient evidence-base for the management of obesity with learning disability population, Spanos et al. (2013)

1:2 Discussing Wider Context with Relevant Policies /Wider Literature and Local Evidence

Nearly a third of the children and adolescents in the United States are overweight. Studies have identified that this condition has constantly been on increase in the past 2 decades (Coffield et al 2011). Obesity problem transcend through rich and poor countries and affect people of all levels in the society. This point to the need for extensive intervention measures to halt the problem. Gortmaker et al (2011) identified that obesity is caused by energy imbalance stemming from both dietary intake and physical activity pattern. Behavioural patterns and the environment are key determinants for occurrence of obesity. However, Maria and Evagelin (2009) identify that genetic condition like Downs syndrome could also result in obesity. Identification of obesity can be possible following clinical interventions. The commonly used measurements in medical and research laboratories are Weight-height tables, body mass index (BMI) assessment and skin fold measurement (Maria and Evagelin, 2009). Studies have also established links between people with learning disabilities and obesity. Biswas et al 2010 explains that in the UK, 2.5% of the population comprise of people with learning disabilities. People with intellectual disability are more likely to be obese. Studies indicated that 28.3% of people with LD had obesity against 20.4% of the normal population (Emerson 2006). The lack of awareness of the health needs has been identified as the main challenge in management of obesity especially to people with learning disabilities, whom, by their nature find it hard to access medical services (Biswas et al 2010). Weight management has been proposed to be the main intervention for managing obesity. Actions like proper diet and physical exercise have been associated with creating negative energy balance and aid in losing weight (Maria and Evagelin, 2009).

1:3 the Importance of a Literature Review as a Source of Evidence

An extended literature review is an important source of evidence in nursing practice according to Smith and Noble, (2016). Gerrard, (2013) defines literature review as an integrated analysis of reading, exploring and writing a combination of scholarly materials associated with a certain topic. The main goal of a literature review is finding a solution, best evidence or update insights to a focused question that provides recommendation for practice and future research (Aveyard, 2014; Smith and Noble, 2016). This is important for health and social care professions as they are expected to be up to date and use current ideas and development that governs their practice LoBiondo-Wood & Haber, (2013).

1:4 Explicit Statement of the Research Question

What is the Impact of Weight Management Intervention upon Obesity and People with Learning Disability in Reducing Serious Related Medical Conditions?

1:5 Definition of Terms

To enhance the clarity of the terms used within this review, their meanings are illustrated below.

1:6 Aims and Objectives

To explore literature reporting the impact of weight loss, weight management, diet interventions upon obese people with learning disability and to determine their effectiveness in reducing serious medical conditions associated with this health concern.

Objectives

To identify and analyse related literature and provide evidence of the impact of obesity amongst learning disability population.

To critically evaluate underlying factors causing obesity amongst learning disability population while adopting a thematic approach to draw out the main themes/factors.

To identify specific weight loss/diet/ weight management Interventions applied by different reviewers and analyse their strengths and limitations

To make recommendations on minimizing the impact of obesity amongst the LD population through improved interventions.

1:7: Conclusion

This chapter has introduced the topic to be reviewed, offered a rationale for the chosen topic, and concluded with its aims and objectives in relevance to the nursing practice.

Chapter 2: Methodology

2:1 Introduction

This chapter gives an account of the methodology and steps used for the review. Specifically, the chapter provides information on the identification of research question, search strategies, exclusion and inclusion criteria, and the methods for critically appraising literature

2:2 Identification of the research question

One of the most important aspects of undertaking an extended literature review is developing a clear and right research question (Aveyard, 2010). The researcher compared SPIDER and PICO, the most common models for nursing research to guide in formulation of research question. SPIDER is an adaptation of PICO and focuses upon the phenomenon of interest (Cooke, Smith and Booth, 2012) whereas PICO is more useful for formulating questions which compare or examine the effects of an intervention (Aveyards, 2014). As this review is not intended to draw individual experience theories in a qualitative sense, SPIDER was considered inappropriate. PICO on the other hand offers an approach that explicitly blends with the objectives of this study making it the appropriate approach for this study. For a better understanding of review, PICO satisfies a better choice in recognizing component of clinical evidence whilst SPIDER has the risk of not being able to discover applicable reviews (Methley, et al. 2014). Table 2 below explains in detail the PICO approach linking it with the objectives of this study

2:3 Search strategies

Using keywords helps in whittling down and retrieving more results in searching for literature review, (Kaya, and Boz, 2017). This helps to explore and make use of several commonly used online sources like Google scholars, and pubmed.gov. Other sites such as Medline, Web of science, the NU search, PsycInfo from 2014 to 2019 were included in the search to seek out relevant literature. PsycInfo produced 537, for a total of 667 articles. Using keywords like ‘overweight’ and intervention, obese’, learning disabled’ OR learning difficult’ OR intellectual disability’, ‘’obesity and intellectual disabilities’’‘ overweight’, ‘physical activities’, ‘health promotion’ weight gain, weight loss, weight management. Hand search for journals and books, citation and referencing was undertaken during this process as well as browsing for online journals and documents relevant to the study. The table below present the keywords used in conducting searches.

2:5 Inclusion and Exclusion Criteria

In identifying appropriate literature that will address the research question, inclusion and exclusion criteria are needed (Aveyard 2007). This helps to express the focus on the research. It is important to understand what needs to be included and excluded from my research. My target group are adult, children and young people with learning disabilities, this was identified as the population and weight loss/weight management as intervention using the PICO framework, therefore it was important that studies related to weight loss, weight management, Learning disability, Effective Diet, healthy eating, health promotion and losing weight was included. Peer reviews papers were also included. Studies from other countries included making sure it is published in the English language to avoid the language barrier. A primary search was required because it is directly related to the study. In refining the search, Qualitative, quantitative and mixed method were included because they include combinations of experimental, statistical and investigative means. Any study published more than 7 years ago was excluded from the search as my target was recent publications.

2.6 Information using the different phases (Prisma Diagram)

2:7 methods for critically appraising literature

This is the ability to efficiently incorporate existing information to put forward data for rational decision making (Chalmers and Altman, 1995). For consistent of scientific findings, systematic review establishes if findings can be generalized across populations, notably by certain subsets, settings or treatment variations (Chalmers and Altman, 1995). Systematic review method is used to justify, recognize and filter hypothesis, being able to recognize problems of previous work, outline important effects that help in future studies (Chalmers and Altman, 1995). A systematic review gives a very good learning opportunity that enables the student to recognize and able to come up with their own learning objectives (Boland, et al. 2017). It is necessary to be able to critically analyse literature reviews because the importance set down in the use of evidence in nursing practice enables the student to critique published research relevant to nursing practice (Boland et al 2017). The use of theoretical framework aids the success of the research question (Paterson et al. 2001). So a theoretical framework was used to help me identify the scope of the review.

2:8: conclusion

This chapter has put together the methodology used, identification of the research question, search strategy, the inclusion and exclusion criteria used concluding with the systematic review of the paper. The remaining chapter will be focusing on the findings of the literature reviews.

Chapter 3: Main Findings

3.1 Introduction

This chapter presents extensive literature review of the study objectives. In this review, 9 studies have been identified and discussed under the factors of obesity. The 9 studies include three focusing on psychosocial factors (Doherty et al. 2018, Heller et al. 2011, and Boateng et al. 2017). Two studies on Biological factor, (Russell et al. 2018 and Kondekar et al. 2018). Four studies on the psychological factor (Harris et al. 2019, Croot et al. 2018 and Cartwright et al. 2016 and Doherty et al. 2017).

3.2: impacts of obesity

The prevalence of obesity has been associated with a number of impacts. Studies exploring the nature and magnitude of the impacts of obesity vary. However, the impacts of obesity can be categorised into physical health, mental health and social impacts. Under physical health, studies have established a relationship between obesity and co-morbidities. There is a link between obesity and the risk of premature morbidity and mortality to young and adolescent persons with the condition (Reilly and Kelly, 2010). Among the elderly population, obesity has been linked to chronic medical conditions such as cardiovascular diseases and arthritis (Boateng et al. 2017). The medical problems also lead to accumulation of health expenditures in terms of purchasing medicine and seeking treatment of both weight management and associated chronic diseases. Although studies haven’t established a clear relationship between obesity and mental health, obesity discrimination can lead to mental disorders. A host of mental disorders have been reported among obese people including low self-esteem, mood disorder, motivation disorder, eating problems and impaired body image (Scott et al, 2007). In fact, Boateng et al (2017) established a link between obesity and impaired cognitive development among the adolescents and young adults. However, some studies have established that among the ageing, obesity isn’t directly linked to cognitive impairment and in some instances may boost cognitive function. Social impacts associated with obesity include discrimination, ridicule, social bias, rejection and humiliation of the obese people in the social settings. The situation may be more evident among obese people with learning difficulties.

3:3 factors causing obesity

3.3.1: Psychosocial factors

Paper 3

A study by Doherty et al (2018), sought to establish factors that hinder LD adult who are obese in living and eating well to control their weight. It was found that proper training is required to choose the right caregiver in promoting the health of this population in which study by Cartwright, et al (2016) supports this. Hence more accessible and clearer information regarding healthy lifestyles is also required to be implemented. This implies the need to gain more understanding of their day to day lives of adults with LD which may help to inform policies and practice to be treated as they like to be (McDonald, et al. 2013). Maintaining this healthy lifestyle also requires financial stability i.e. stable personal income is important. Overall, the findings of this particular study also stated clearly that many LD people with obesity are willing to reduce their extra weight though they stated many barriers which prevented them from doing so. In the research, survey study group discussion was conducted with this focus group which was a significant part of data collection (Holland and Rees, 2010). Fraser (2001) argues that people with LD are best supported in a smaller group rather than a larger group because the skilled facilitator tends to be more familiar with their communication strategies. The use of worksheet and easy-read questionnaire in line with co-produce for participants to represent their response by using words or drawing a picture with supports from a caregiver, this can easily be manipulated, because the researchers adjusted by co-producing an easy read worksheet and questionnaire to suit the participant. Convenient sampling was used to recruit participant with a particular diagnosis(LD) who meets the criteria of what this study was about, this makes it easier for the researchers (LoBiondo-Wood and Haber 2002). However, there is a risk of bias in self-selection, therefore, representativeness is questionable, (LoBiondo-Wood and Haber 2002). For data analysis, thematic analysis tool was used by reducing the factors in the transcription to a series of core themes (Holloway and Wheeler, 2010).

Paper 9

A study by Boateng et al (2017) highlight the cultural and social dimensions of obesity in elderly people in many areas of Sub-Saharan Africa especially Ghana. Using a socio-ecological model for better understanding of health outcome, Multistage cluster design used in selecting participants and considering the sample size was appropriate for the study population using ten administrative regions (Boateng et al. 2017). The model puts forward multiple interactions connecting society and environmental factors with 6 resultant outcomes. Psychosocial factors (depression), behavioural factors (alcohol consumption) and socio-cultural factors (money) codetermine health outcomes in this study (Solar and Irwin, 2007). Data from "Study of Global Ageing and Adult Health" (SAGE) of Ghana relied upon questionnaires with a response of 86% and 80% of the subjects. Approximately 2091 elderly people of 65 years were sampled to gather the necessary data. It was found that through the vast sampling method, obese adults who have LD had indeed a colossal risk to be diagnosed with stage 2 or stage 1 typed chronic disease, creating obstacles in performing daily activities with ease. Interventions like regular physical activities, good dietary, and moderation of alcohol intake proven to be effective are needed to reduce the risk associated with obesity for LD people (Chomistek et al, 2015). Furthermore, health education promotion to increase awareness focusing on dietary changes and lifestyle needs to be implemented to the public, most especially the LD population who are obese (Boateng et al. 2017). The study has helped to understand the multiple health hazards associated with the LD population who are Obese in Ghana. However, the use of cross-sectional in the study was not able to prove the causal effects. This study calls for attention to tackle social determinants of health as a critical intervention and initiate right policies and educational campaigns (Boateng et al. 2017).

Paper 1

A study by Heller et al. (2011) was conducted on nutrition and physical activities interventions in people with LD. Databases were gathered from CINAHL, PsycINFO, and MEDLINE (Heller et al. 2011). Findings indicated that physical activities provide many benefits to the health of adults with LD. The findings also emphasized upon the need of exercise programs to be implemented. It was argued by Traci et al (2002) that these typed vigorous physical exercise programs are very beneficial to reduce weight in LD people. This study had thus emphasized the need to generate more education regarding health behaviour, Such health programmes would enable this group of people to adopt more nutrition and exercise information to help them live a healthy lifestyle, since more nutrition information is beneficial to creating more health awareness among LD population who are obese. The researcher took the method of secondary analysis for understanding the interventions of nutrition and physical promotion. 11 articles related to the concerned issue were considered for this research purpose. The vast researches helped to obtain the findings upon both nutrition and physical activity. It was found out that aerobic capacity, strength and balance factors help to improve fitness. Hence exercises might be provided with better attitudes and emphasis because they help to obtain better outcomes like more self-efficacy and cognitive-social barriers. Focusing on one of the review studies by Marshall et al (2003), 25 participants age 30 and over in 6-8 weeks of exercise and nutrition health education weekly. There was a decrease in weight and BMI within the group. However, rigorous scientific methods are required to integrate specific protocols to identify, synthesize and appraise information to eliminate the bias found in many literature reviews. The review of this particular journal clearly showed that better nutritional value and health promotions have specific interventions in the education of health behaviour. Such information does have many positive impacts on the function and health of adults who have LD.

3:3.2 Psychological factor (Behavioural change)

Paper 2

This is based on o study by Harris et al (2019), titled clinical trial of "weight management program". This study comprised a 12-month controlled trial and pilot cluster-randomized on how weight management might prove to be beneficial for challenging obesity rates amongst adult with LD. These groups of people were asked to take "Energy deficit diet" or to have Waist winners. All these proposed activities were to implement by maintaining the principles of health education. In the study, mixed-method was used to observe the evaluation process (Harris et al. 2019). 50 participants with LD and obesity were used, weighted under strict supervision at the time baseline of 6month and thereafter 12 months. Participants were also assigned treatments like sedentary behaviour, physical activity, waist circumference, and BMI. The findings showed that all these activities are beneficial in reducing weight (Harris et al. 2019). It was found that weight management programs EDD is acceptable and feasible for weight loss (Harris et al. 2019). The study also showed that participants who continue for a prolonged period were able to reduce their weight significantly. Hence it might be clearly said that such "weight management programs" are indeed beneficial for such adults who have both obesity and LD. MM used in this study was for the practical purpose of a phenomenon to gain types of information appropriate for the study (Holloway and Wheeler, 2010). The Pilot-cluster RCT used ensured measurements were consistent by minimizing the potential risk (Holland and Rees 2007). In contributing to a clinical trial, the intervention of care can be measured by RCT which best describes the researcher’s aim (Holland and Rees 2007; Harris et al. 2015). The study population used was nonprobability sample selected to represent the target population using inclusion and exclusion criteria; this makes good representativeness and external validity of the result (LoBiondo-Wood and Haber 2002). Within the study, the involvement of caregiver helped to increase behaviour change technique and increase physical activities (Harris et al. 2019). However, to achieve the best result, implementation of behaviour change techniques like physical activities, monitoring of diet are mandatory. However, it is uncertain that adult with LD will be able to achieve this without the supports from caregivers because of their cognitive abilities in which study by Matthew et al (2016) supports this.

Paper 8

People who have LD might not respond or access to health interventions, therefore it is the legal duty and responsibility of public bodies in allocating "reasonable adjustments" in government policies for this population (Croot et al. 2019). These reallocations of policies might enable fair treatment and access to obese people who have Learning disabilities. These adjustments would help to provide more improvement in feasibility and acceptability for the LD population. The research was user-centred, and it generated qualitative data from the people of one steering group. The facilitators and barriers of this considered Slimming world also found out through focus group and interview (Croot et al. 2018). The results of this particular interview included four main adjustments which were addressed and identified through Slimming World. There were a total of nine participants upon which only six attended. They were able to lose weight and were positive, making it practical to implement in a small uncontrolled study and this yielded a good result of weight loss amongst LD people who are obese (LoBiondo-wood and Haber, 2002). A study by Scott and Havetcamp, (2016) supports this as the sample size used was small but the findings are consistent about how behavioural health promotion intervention is successful with people with LD. However, there were issues in the wider context of other people who live in obesogenic environments (Tod et al, 2017). A further measure is required to target this population to reduce inequalities linked with the effect of obesity (Tod et al. 2017). Thus the vast research of this particular study had the results or findings that it is surely able to reduce the weight through strict maintenance of weight management. Such weight management schedules are essential to be implemented with people who have LD and obesity (Croot et at. 2018).

Paper 4

Doherty et al (2017) identifies types of multicomponent weight management intervention for an adult with LD. All studies found MCI to fit adults with LD most especially the supports from caregivers. Evidence such as how MCI is tailored for LD people but with the studies identified, it is difficult to explain how this can be routinely tailored. However, the research design used was consistent, and appropriate with the research aim to provide transferability and replicability of the intervention in which the result can be generalized to similar factors relating to participants (Bergstrom et al. 2013). However, it is uncertain that the application of intense personalized one to one intervention can be maintained (Doherty et al. 2017). Heterogeneous sample was used making the criteria restrictive and too narrow to compare the findings (Moore et al. 2015), this could mean researchers will find it challenging in finding participants who meet the criteria, therefore resulting in researcher maintaining sample criteria for convenience rather than representative of a larger population (Burns and Groove, 2007). None of the studies investigated the experience and views of an adult with LD raising doubt if all the interventions are generalized to all adults with LD who are obese. With the research mainly focusing on the evaluation of weight management strategies and development, further studies on exploring the long period of successfulness of weight management intervention is required (Spanos et al. 2013).

Paper 5

From a study by Cartwright et al (2016), 3 barriers were identified that could be addressed with the aim of promoting physical activity with obesity with adults with LD. The need for Local authorities and service providers to incorporate the importance of caregivers engaging in physical activities as part of the job description, and support plan to promote and develop physical activities of LD people based on individual’s needs, using a person-centred approach (Cartwright, 2016). A study by Doherty et al. (2017) emphasizes using caregivers to enhance the motivation of this population to engage in physical activities which helps in promoting a healthy lifestyle to help manage their weight. Harris et al. (2015) highlights the need for further research on barriers that hinder individual with LD who are obese from involving in physical activities

3:3.3 Biological Factors (psychotropic medication)

Paper 6

Russell et al, (2017) explored overweight and obesity in patients with LD in an obesogenic environment with factors like sedentary lifestyles, restricted physical exercise, high-calorie food intake, and psychotropic medication identified as responsible for obesity. Findings showed that people with LD put on excessive weights while in service, therefore the need to be encouraged take healthy food and lifestyles to lose extra weight (Russell et al. 2018). Thus more innovative methods to encourage LD people of doing so might need to be implemented. 46 inpatients with LD mostly women, with their BMI was used. The finding indicates most of them gained weight while in service as a result of less time to exercise, improper and high-calorie food intake, and the impact of obesity makes them less confident. They are subject to bullying which has impacts on their mental state also resulting in depression. Using a descriptive cohort method to summarise and describe data recorded on each patient's note system helps to give a clear result (LoBiondo-Wood and Haber, 2002). Assumption testing was carried out to make sure the data are not violated because this can be misleading making the result inappropriate (LoBiondo-Wood and Haber, 2002). The study done in a single service may not be indicative of how other services manage their patients (Russell et al. 2017) The sample size used was small, the use of unequal numbers of women and men, therefore, affects the gender statistical significance, however, study by Haw and Rowell, (2011) supports the finding from this study that women tend to be a risk factor of obesity, however it was stated that women lost weight more than men and the reason did not specify in the study (Russell et al. 2017). This calls for more research to be done. (LoBiondo-Wood and Haber, 2002). Using BMI to describe obesity seems accurate, however, Cornier et al. (2011) argue that an obesity patient can have a normal BMI and still have a high mortality risk.

Paper 7

Kondekar et al (2018) examined the prevalence of obesity in students with a learning disorder in a metropolitan city of India. The observation cross-sectional method was used to study 150 children diagnosed with SLD on the basis of DSM-V over 18-month period for an accurate outcome (Kondekar et al. 2018). Permission was obtained from the ethics committee and their parents which gives the study more validity (Holland and Reese 2007). It could be said that children with SLD have the tendency to be obese due to factors like eating habits, medication and restricted physical exercise (Purcell, 2013). A study reviewed by Kondekar et al. (2018), found out that the prevalence of being overweight has a higher rate in young people aged 6-17 and children with SLD compared to those who are not (Taylor et al. 2016).

3:4: weight management interventions on obesity

The growing concern of obesity and its impact on people with learning disability has led to inquiries into interventions for managing the condition. The weight management interventions have been developed and focused on different aspects ranging from physical health and weight loss to psychological support. Scottish Intercollegiate Guidelines Network (2010) explains that weight management intervention can be based on physical activity, diet, medication or behavioural/psychological aspects. Dietary interventions in adults can take many forms from reducing energy intake, adopting low and very low calories diet, adhering to appropriate food composition as well as commercial diets. Physical activity interventions focus on the exercises aimed at weight loss has been developed and can be accessed by obese persons (SIGN, 2010). Regarding psychological/behavioural weight management interventions, SIGN (2010) suggests that a combination of active support for diet and behavioural therapy can significantly result in weight loss. Therapy should be focused on problem solving, relapse prevention, stimulus control and dealing with problem situations among other therapies can help obese individuals especially with learning difficulties manage their weight. However, Kirk et al (2012) emphasizes that regardless of the type of intervention applied, the three key themes must be adhered to for effective weight management.

3:5: conclusion

This chapter has summarised all the study and how they relate to different themes and sub-headings. Literature review has been extensively undertaken to examine the impacts of obesity especially on people with learning disabilities, factors associated with obesity and appropriate weight management interventions. From this review, it is evident that obesity has social, physical and mental impacts some which are more serious and can lead to premature morbidity. There are psychosocial, psychological and biological factors leading to obesity and that weight management intervention significantly reduces the effects associated with obesity. However, there is need for tailored comprehensive programs that tackle all the needs of the patients for effective management of the condition.

Chapter 4 - Discussion & Recommendations

4.1: introduction

This chapter presents a detailed discussion of the main findings covered in the previous chapter. This analysis points out key findings and discusses the strengths and weaknesses of the papers reviewed in chapter 3 as well as similar studies covered in the previous chapter.

4.2: discussion

The extensive literature covered above identify that obesity is a serious condition and can be accompanied by other complications to the health and wellbeing of individuals. Statistics indicate variations in the prevalence of obesity through key variables such as age and gender. Additionally, obesity has been linked to result in learning disabilities in individuals. This depends on numerous factors and has different impacts. Obesity has impact on the physical health, social wellbeing and psychological health of the individuals. Emergence of chronic medical complications such as cardiovascular conditions (hypertension and blood pressure) is the main health impact associated with obesity. Social stigma and discrimination of obese persons in the society significantly inhibit their social wellbeing. From the studies reviewed, the situation can be even worse for obese persons with learning difficulties.

Psychosocial factors

The prevalence of obesity can be attributed to several factors. This study explored psychosocial factors and how they affect obese people with learning disability. Paper 3 (Doherty et al 2018) reviewed in the previous chapter identifies that Education and training of obese people with learning disability significantly impact weight management. Proper training and education on healthy living ranging from food consumption patterns to interaction with other people serve as motivating factors that can aid in weight loss. Accessibility and clarity of information on healthy lifestyles by people with learning difficulties can lead to effective weight management and minimize exposure to the risks of obesity. Furthermore, Table 6 in Appendix 1 summarizes three themes identified in Paper 3 as support, caring, and support to go out for shopping. These themes were identified to result in better eating and lifestyle habits consequently resulting in weight management. However, two major limitations were identified in this study. First, participants reported that inadequate personal income to pay for routine support would hamper the realization of weight loss (Table 6, Appendix 1). This point to the fact that the routine support is often expensive and committing to it requires considerable financial investments. Learning disabled persons with obesity with low income would likely not benefit from the program. Secondly, Participants pointed out difficulties to access and use support facilities for sports, leisure and recreation since they are not designed to accommodate them. This demotivates the otherwise committed participants to the support facilities giving them limited recreational and sporting options. This therefore would lead to little or no change in weight management. Interestingly, Table 6 explains that the study by Doherty et al (2018) extensively reviewed in paper 3 in the previous chapter conducted data collection from participants in the presence of their caregivers. This therefore leads to positive response bias. The small sample size also limits the generalization of the findings.

Paper 9 discusses obesity and the burden of health risk among the elderly in Ghana (Boateng et al 2017). The researchers adopted a multistage cluster design (table 13, Appendix 1) in data collection and identified crucial findings. The study identifies depression, alcohol consumption and money as key influencers of obesity among people with learning difficulties. In this case therefore, presence of either or all of these conditions increases the prevalence of obesity. Paper 1 by Heller et al (2017) explores the relationship between physical activities and nutritional health promotion. Table 4 (appendix 1) presents key benefits of physical exercises as fitness, improved adaptive behaviour and psychosocial growth. Realization of these benefits relies on development and commitment to a physical exercises plan. Vigorous physical exercise is beneficial and boosts the efforts of weight management among people with obesity.

Psychological factors

Cognitive development is a key aspect in assessment of prevalence of obesity. While none of the studies reviewed in the previous chapter focused on this, other studies have strongly drawn relationship between cognitive development and obesity. Conditions like Down syndrome have been closely linked with both obesity and learning disability. Paper 2 by Harris et al (2019) explores clusters randomized controlled trial of multi-component weight management program. In this program, participants were assigned treatments like sedentary behaviour, physical activity, Body mass index measurements. The study confirmed that participants who enrolled lost weight and this was attributed to their cognitive perception and commitment to the program. Table 5 (appendix 1) however explains that due to the small sample size, the findings may not reflect the general population's needs. Croot et al (2018) study on adjusting a mainstream weight management intervention for people with intellectual difficulties, herein referred to as paper 8 identified a crucial factor in managing obesity. The study explains that public bodies have a responsibility of allocation and support of weight management initiative program. This paper discusses that behavioural health intervention is crucial in ensuring that people with learning disability get necessary support and help in managing their weight. However, little information is provided on the features suitable for implementation of effective behavioural health intervention. Table 7 (appendix 1) presents a summary of paper 4 that reviews multicomponent weight management interventions for adults with intellectual disability. The study by Doherty et al. (2018) established that out of 5 studies, 2 reported remarkable weight loss. However, the omission of opinions of experiences of people with learning difficulties limits the value of the findings of the study.

The finding of paper 5 is closely related to that presented in paper 8. Paper 5 examines the role of local authorities in weight management intervention and in the findings emphasizes the importance of caregivers in managing the obesity condition; promote the development and implementation of physical activity plan and adoption of user-centred approach.

Biological factors

Biological factors are easily and clearly identifiable from the reviews in the previous chapter. Studies focused on exploring these factors have identified and discussed key aspects in relation to obesity and learning disability. Paper 6 reviewed in the previous chapter and summarized in table 9 (appendix 1) on the prevalence of overweight and obesity levels among forensic inpatients (Russell et al 2018) present clear biological facilitators of obesity. The findings of the descriptive cohort study explain that compared to their male counterparts, females generally had higher body mass index and gained more weight. Exposed to behavioural interventions, women lost more weight compared to men. Russell attributed obesity as a result of exposure to obesogenic environment which is characterized by sedentary lifestyles, restricted physical exercise, high intake of calories and psychotropic medication. Furthermore, the study explains that persons with obesity were less confident and have low self-esteem. This might transcend to other complications linking biological factors to psychological and psychosocial factors previously discussed. The study by Kendekor et al (2018) further enhances these biological factors by identifying that eating habits, less exercise and medication can significantly lead to obesity.

Weight management intervention

The detailed discussion on the obesity risk factors coupled with extensive review of relevant studies in the previous chapter underscores the importance of weight management intervention as an approach to reduce the prevalence of obesity particularly among the people with learning disability. From the literature in the previous chapter, SIGN (2010) provides guidelines for implementation of various weight management approaches. This intervention targets various factors responsible for obesity. This underscores the statement by Kirk et al (2011) who state that as a principle, weight management intervention should be targeted and tailored to the specific needs of the patients. This calls for extensive understanding of the risk factors behind the individual’s obesity situation and tailoring the intervention measures to address the condition. Common weight management interventions explored by SIGN (2010) and supported by Kirk et al (2011) are the behavioural/psychological intervention, dietary intervention, medical intervention and physical activity. In fact, the 9 studies reviewed in the previous chapter have pointed to one or more of these weight management intervention approaches. For instance, Heller et al (2017) in their study, herein referred to as paper 1 focused on physical activity as a weight management intervention approach and evaluated its application and findings.

4.3: recommendations

A number of recommendations can be generated from the above discussion and the extensive literature covered throughout this study. First, there is need to examine and understand the reasons behind obesity and the relationship between obesity and learning disability. Though studies have been explored, the findings have been questioned in one way or the other. For instance, some studies have focused on small samples making it difficult to apply their findings in explaining the condition of the general population. It is therefore prudent that further studies and meta-analysis be conducted to exhaustively understand the subject of obesity. In fact, policies on obesity and weight management interventions are quite scanty. There is need for further policy developments to address the growing concern of obesity. Secondly, obesity has been identified to result from different reasons and sometimes exists on a combination of two or more factors. This makes it prudent for comprehensive approach in management of the condition. Therefore, there is need to adopt tailored weight management interventions that will address the underlying risk factors and prevent relapse. Third, from the review in the previous chapter, it has been established that social and economic conditions hinder the efforts to eradicate obesity. Most of the effective weight management intervention programs are quite expensive as identified by participants from the studies reviewed above. Therefore, there is need for the relevant authorities to fund weight management programs especially to the poor people with learning disability.

4.4: implication for learning and practice

Understanding obesity in people with learning disability highlights key implications. First, obesity and learning disability presents dynamic conditions and needs among the people affected. This ranges from low self esteem, stigmatization and cognitive impairment affecting the functioning and learning of such people. Secondly, as discued through this study, obesity and learning disability provide an opportunity for studies to understand the complex needs of the obese people with learning disability. This helps in reducing the social stigma these people are often exposed to Obesity and learning disability requires attentive care and tailored services to enhance social inclusion of these categories of people. This study provides insight into designing facilities for physical activity to fit the needs of the people with obesity. This goes a long way in motivating them to participate in weight management interventions.

4.5: limitations

There are two main limitations of this study. First, it is a systemic literature review. This means that the discussion relies on the findings presented by other studies. This therefore fails to capture the ideas, views and opinions of obesity people living with disability. The biases, if any, from these studies are also maintained in this study. Secondly, the study is limited on the findings from 9 studies which form the findings and discussions of this paper. Therefore, other studies, though relevant and informative are not included in this study.

Chapter 5 - Conclusions

Obesity is a condition that stem from a combination of factors leading to accumulation of unnecessary fat in human body. This condition has been identified to have serious repercussions on the health of the individuals. Learning disabilities stem from different reasons ranging from genetic to medical complications that inhibit cognitive development. Statistics have revealed the prevalence of obesity and learning disability over the last 2 decades. The effects of obesity range from precipitation of chronic medical conditions, psychological effects like depression to psychosocial effects like low self-esteem. This underscores the need to effectively manage the condition. This study has presented detailed literature review of the condition of obesity among the people living with disability and offered weight management intervention to mitigate the growing medical concern.

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