Obesity in Learning Disabilities

Background of the Study

The main aim of this study is to explore the issues of obesity among people with learning disabilities, by understanding their perceptions and experiences. Obesity has been a public health issue for a long time now. Ideally, public health is a branch of science that deals with detection and prevention of disease with an aim of enhancing the quality of life and well-being of the masses. Various research studies on obesity have concluded that it is a ‘time bomb’ that affects populations in both developed and developing countries. For instance, Melville et al. (2008) say that over the past decade, there has been an increasing prevalence of obesity among the general UK population, although this rate has been higher for individuals with learning disabilities. Besides, Stanton (2009) observed a general increase in the prevalence of obesity in Australia, while at the same time, Bassett et al. (2008) wrote that there had been an increased prevalence of obesity in Canada. Nonetheless, from time immemorial, obesity has been considered a significant health problem that predisposes its victims to several other illnesses such as hypertension, cardiovascular diseases, diabetes, and heart diseases. It has been scientifically proven that the most probable cause of overweight among the general population is related to poor eating habits and sedentary lifestyle. For example, research by Bradley (2005) showed that individuals who liked to take food with high-calorie intake, sugary drinks, and high salt intake together with less physical activity were more predisposed to overweight. However, several research studies have proven that people with learning disabilities tend to have more predispositions to obesity than the general population. For example, a study by Bhaumik et al. (2008) revealed that in the UK, adults with learning disabilities were confronted with more overweight problems than the general population. Hence, the issue of obesity among people with learning disabilities is imminent, highlighting the need for targeted interventions and potential healthcare dissertation help to address these challenges effectively.

Research has listed several factors for a higher prevalence of obesity among people with learning disability, most of them claiming that these factors are biological, environmental, and behavioural. For instance, research by Bhaumik et al. (2008) indicates that various genetic syndromes among this special group such as Prader-Willi syndrome are risk factors of obesity. In fact, in a recent study by Biswas et al. (2018), it was mentioned that at least 48% of adults with Prader-Willy syndrome had been diagnosed with obesity. Besides, Biswas et al. (2018) contend that adults with learning disabilities are likely to be on psychotropic medications, and these medications are associated with obesity among this group of population. On the same note, Doody (2012) indicate that compared to the general population, people with learning disabilities are more likely to be overweight at an early age, and are consequently more predisposed to obesity than the general population.

In another study by Adolfsson et al. (2008), it was noted that people with learning disabilities had more intake of food consisting of fibre, milk, and vegetable, as well as frequent snacking in between meals. An older study, Messent et al. (1998) also reported a lower physical activity among this special group compared to the general population. Later on, in an attempt to establish the reason for less physical activity among this group of the population, Messent et al. (1999) found several causes including facilities within the community for leisure activities, poor day services, transport limitations, and inadequate staff. On the same note findings by Bhaumik et al. (2008) identified several other factors such as low metabolic rates, hypothyroidism and hypotonia are unique clinical conditions that predispose this group to more risk of obesity compared to the general population.

Handerson et al. (2007) argue that in some people with learning disability, the high risk of obesity may be result the underlying causes of the disability as well as its behavioural symptoms such as Down’s syndrome. Besides, being under psychotic medications predisposes this group of population to a high rate of weight gain, therefore calling for the need for regular monitoring of this population.

Statement of the Problem

Obesity is a significant health issue that raises health concern among populations because of its likeability to cause various cardiovascular diseases. Conversely, though, there is a lack of research evidence highlighting learning disability as a risk factor of obesity among this special group. For instance, in a study by Wallace et al. (2008) 155 adults with learning disabilities were examined, and the results showed that people with learning disabilities had a lower risk profile for cardiovascular disease than the general population. Besides, Wallace and colleagues found that people with learning disabilities had a lower risk of prevalence of other factors such as smoking, hypertension, and diabetes. Worryingly though, Wellace et al. (2008) found a higher incidence of obesity, reduced physical activity among 35% of the participants. Similar findings were made by Akker and others (2006), who examined 463 residential patients with learning disability and found a low prevalence of cardiovascular diseases among the participants. However, several research studies have also identified the problem of obesity among adolescents with learning disability. For instance, Wallen et al. (2009) reported that Swedish adolescents with learning disability had a large waist circumference, and a higher level of fat mass compared to their counterparts in the general population. Against this backdrop, the main aim of this study is to explore the issue of obesity among people with learning disability. In doing so, the researcher will seek to achieve three primary objectives, namely:

i. To identify the experiences and perceptions of obese adults with learning disabilities

ii. To identify effective interventions for treating and managing obesity among adults with learning disabilities

Study Methodology

The Literature Review Methodology

In the spirit of evidence-based practice, Pitticrew & Robets (2006) argues that there needs to be a periodic analysis and synthesis of existing research evidence, especially considering the rapid emergence of research publications in public health. Consequently, according to Smith & Brown (2014), there is always an abundance of information within any area of practice, necessitating a periodic review of literature. Furthermore, as new pieces of research emerge, researchers come up with divergent views, which yield a lack of consensus on specific topics (Stevens et al, 2000). The role of literature review, therefore, is to synthesise these pieces of information; comparing and contrasting them to yield conclusions that may be of use to evidence-based practice. In the process, according to Trinder & Reynolds (2000), literature reviews helps in developing the most currently available evidence for practice, in a process that is holistically referred to as secondary research. Therefore, the current study will be a literature review of currently existing primary research, aimed at identifying evidence that exist in regards to the obesity among adults with learning disabilities. Ideally, the literature review methodology was chosen for the purpose of identifying current evidence as well as the currently existing research gap in this topic area.

Search Strategy

The researcher conducted a bibliography search of literary materials related to obesity among adults (i.e. above 18 years old) with learning disabilities. The search was conducted in various online databases including CINAHL, EBSCO, PubMed and MEDLINE. In the process, the researcher used various key words including obesity, learning disability, intellectual disability, overweight, diet, and physical exercise. While using the search terms, the researcher combined them using Boolean Operators (i.e. AND and OR) to determine the scope and specificity of the search process. Besides, combining the search terms enable an easier search process, as it prompted the emergence of various headings of literary materials within the databases.

Inclusion/Exclusion Criteria

During the search process, the researcher conducted a comprehensive reading of each material’s abstract to identify the specific sources that were of interest to the current research topic. Besides, each literary material was exposed to tight scrutiny based on predetermined inclusion/exclusion criteria. For instance, only the studies that focused on adults (i.e. 18 years or above) were included picked for review. Furthermore, the researcher only included sources that were published in the English language – to enable an easier comprehension and interpretation of the study findings. The last inclusion criterion was that only academic sources were picked for review.

Search Results

When a search was conducted in CINAHL, 16,556 emerged. The researcher, then applied the inclusion criteria to these sources, and only 643 sources remained. Three studies were picked from this database of further review. The second pool of search was conducted in EBSCO. Here, the first attempt yielded 12245 sources which were then subjected to the inclusion/exclusion criteria to yield 391 sources. Only three sources were picked among them. Thirdly, the researcher conducted a search on PubMed, which yielded 1189 sources and ultimately 3 sources were chosen for review. Lastly, the researcher conducted a search from MEDLINE. The first search yielded 567 sources while the second search (limited to inclusion/exclusion criteria) yielded only one source to be picked for review. In the end, only 10 studies met the inclusion/exclusion criteria and where included in the study. Appendix 1 illustrates.

A quality assessment was conducted using the Critical Appraisal Skills Program, which is a framework used to evaluate the quality and relevance data sources. As part of the assessment process, the researcher examined the strengths and weaknesses of each source, grading them as weak, string and moderate. Ultimately, all the sources were found to be of strong quality.

The researcher the n adopted the thematic analysis approach to identify and evaluate specific themes that emerged across the selected sources. Particularly, the thematic analysis approach was deemed appropriate for this study because of the divergent methodological approaches taken by the reviewed sources. The data were therefore narratively synthesised.

Results

Experiences, Attitudes, and Perceptions of Self

Jones et al. (2015) conducted a qualitative study to explore the perceptions and attitudes of obese people with learning disabilities in terms of why they were motivated to lose weight. The study drew 50 participants (18 men and 32 women) with an average age of 41.6 years, and different severity levels of intellectual disability. The participants were asked why they want to lose weight right before being recruited into a weight management program, and their answers were categorized into various themes for further analysis. Notably, the researcher found that a majority of the respondents were concerned about their appearance, and therefore was motivated to seek weight reduction solutions. On the flip side, health emerged among the least concerns of participants. It is also important to note that ‘health’ concerns were raised by older adults who had mild severity of learning disability. Among the male participants, mobility and fitness were cited by 35% of the participants as a significant motivator to weight reduction, while only 255 cited health as the primary motivator. Besides, women mentioned a feeling of emotional displeasure with their appearance, less happy, and were therefore motivated to enrol in the weight reduction program. Interestingly, the researcher found no statically significant gender difference in the reasons for having the desire to reduce weight.

In another study by Rubbert (2014), the researcher aimed to explore the extent to which obese people with learning disability were aware of their bodies (i.e., body awareness) with a critical focus into emotional and behavioural changes involved in weight loss. The study involved a two-hour session of group discussion among participants who were not happy with their body weight. During the group discussion, participants shared their overweight issues and how they felt about being obese, their eating habits as well as their physical or emotional response to food. It was found that the participants were unable to differentiate between physical and emotional signs of hunger, and were more likely to respond to their cravings regardless of having proper knowledge of healthy and unhealthy eating habits. Besides, it was found that the participants indulged in unhealthy eating habits irrespective of feeling bad about their overweight status. Ultimately, the researchers concluded that weight loss programs targeted at obese people with learning disabilities should target the physical and emotional aspects of eating habits as well as how this special group responds to their self-esteem issues.

A review of literature on the experiences and opinions of obese people with learning disability are broad and deep in scope. For instance, it has been found that obese people with learning disabilities worry much about their health and appearance. Health is also a significant issue of concern among caregivers, and this finding corroborates with the results of Melville et al. (2009) and Spasons et al. (2013), both of whom agree that health and well-being is a proper reason to for obese people with learning disability to reduce weight.

Interestingly though, appearance seems to be more of concern to obese people with learning disability compared to health, and this confirms the findings by Melville et al. (2009) that obesity exposes the victims to various psychosocial factors that raise the need for close monitoring by learning disability nurses. The review has also revealed that obese people with learning disabilities have little understanding of their emotional and behavioural aspects of eating, and this contributes to further escalation of poor dietary habits. Interventions that target these emotional and behavioural response habits to food are required. All in all, it is, therefore, possible to conclude that obese people with learning disabilities have a negative perception and attitude towards their health and appearance.

A Multidisciplinary Approach to Interventions

The review also revealed several studies on the interventions for obesity among people with learning disability. For instance, Chapman and others conducted a study in (2005) and a follow up in (2008) aimed at identifying the effectiveness of a dedicated health and fitness coordinator tasked with the responsibility of developing weight management programs tailored to the needs of people with learning disability. The coordinator was responsible for designing effective dietary strategies, coordinating with other health professionals (e.g., GP, learning disability nurse, psychiatrist, relatives, physician and speech/language specialist) as part of the health campaign aimed at improving the lifestyle and eating habits of the participants. At the end of the six-year program, the researcher compared the BMI of the intervention group with that of the control group and found that the intervention group had a significant decrease in the BMI while the control group experiences an increase in BMI. However, there was a small significance between two groups, and this was attributed to a slight difference between the intervention group (n=30) and the control group (n=40). Besides, the generalizability of this study is affected mainly by the lack of randomization of the two groups of participants.

Nurse-led screening and frequent medical checks have also been assumed as an effective intervention for obesity among adults with learning disabilities. To ascertain this assumption, Marshall and his colleagues conducted a study in (2003), aiming to explore the effectiveness of nurse screening and health promotion campaigns targeting people with learning disabilities. The study was part a screening project run in Northern Ireland, whereby participants who were screened and found to be overweight were admitted into a weight reduction program that consisted of six-week healthy lifestyle education, equipping the participants with knowledge and skills of managing their weight regardless of their learning disability status. Follow up studies by Marshal and his colleagues revealed that the participants experienced a significant reduction in BMI and weight, as well as more skills in proactive measure for weight management. While their results suggested the effective nature of proactive interventions in reducing weight and obesity among people with learning disability, its lack of proper scientific procedures limits the generalizability and application of its findings. ‘

Reviewed studies reveal the critical nature of interdisciplinary coordination and delivery of programs targeted at addressing obesity among people with learning disability. Mainly, this study has revealed proper coordination between both primary and secondary care providers. Besides, it emerges from the study that multidisciplinary care is likely to be effective when the weight management programs are tailored to the needs and food preferences of the patients and when they are carefully planned. Hence, it is clear that there are four significant aspects of a well-organized weight management program for obese people with learning disability that can build up a holistically effective intervention: a proper diet schedule that considers the individual’s food preferences, an effective physical activity program that recognizes various health risk of this particular group including Downs Syndrome, a well-structured health education campaign that considers the patient’s cultural background, and lastly, a consistent interventional approach that involves all stakeholders and considers all settings to enhance predictability - so that patients with complications such as autism can quickly learn and cope with the intervention.

Independent Decision-Making

It is indisputable that healthy eating is one of the main considerations to make when seeking to manage weight and treat obesity. For purposes of certainty, Gill and other researchers conducted a study in (2013) to investigate the role of paid caregivers in ensuring that obese people with mental disability adopted healthy dietary behaviour. Besides, the study explored the dilemma faced by such carers of either allowing the patients their right to make food choices (most of them being unhealthy choices) or exercising their duty of care by declining any unhealthy food choices made by the patients. While details of the sample size are scanty, this study revealed exciting insights that are worth mentioning. For instance, the researcher found that increased freedom of choice among patients of less severe learning disabilities is associated with unhealthy dietary choices.

Another theme that emerges from the study is the need for, and importance of people with learning disabilities to independently make decisions concerning their health and lifestyle (Guh et al., 2009). Thus, a vital point realized in this review is that sometimes the carers are faced with the dilemma between allowing the patients to make independent lifestyle choices and exercising their responsibility to restrict their patients to healthy lifestyle choices. According to Hamilton et al. (2007), the caregivers have a responsibility to balance these two aspects while keeping an eye on the legal requirements of Mental Capacity Act 2005, so that they operate within the law. To facilitate these decisions, carers can test the mental capacity of the patients to ensure they can make such independent decisions (Healthcare for All, 2008). If lack mental capacity is detected, as Hoghton et al. (2010) suggest, relevant stakeholders can be involved to ensure that the person makes the best decision.

Service Improvement

Thus, there are three critical practice implications pointed out by this study that can help improve service delivery to this special group of population. First, the importance of a multidisciplinary approach to obesity management among this special group is unequivocal. GP, learning disability nurses, family, physicians, and speech specialists need to work together in addressing obesity among people with learning disabilities. Secondly, there is a need for caregivers to balance this special group’s right to make independent lifestyle decisions and their responsibilities to prevent them from making poor lifestyle and dietary choices. Thirdly, the law should be an important guidance tool to carers when dealing with this special group, especially in regards to their capacity to make healthy decisions.

In conclusion, this study intended to explore the issue of obesity among adults with learning disabilities. This aim was alongside two objectives, namely, the perceptions, experience, and attitudes of obese people with a learning disability, and some of the effective intervention for obesity among people with mental disability. In regards to the former objective, the study has found that obese people with a mental disability, together with their caregivers, have negative perception and attitude towards the impact of obesity on their health and appearance, and this attitude motivates them to seek weight reduction interventions. In regards to the second objective, the study has established that a multidisciplinary approach to weight management and sensitization to this group about healthy lifestyle is an effective intervention for weight management.

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