Evidence-Based Practice and Clinical Research Fall 2012

1. Evidence-Based Practice and Clinical Research Fall 2012 The Effectiveness of Physical Activity Programs in Promoting Weight-Lossin Obese Adults withIntellectual and Developmental Disabilities:An Evidence-Based Practice ReviewAllison SullivanTemple University

2. Some people I know

3. Obesity: a national health crisis • According to the Centers for Disease Control and Prevention (CDC), obesity is “common, serious, and costly” • over one-third of adult Americans meet the body mass index (BMI) criteria for obesity • Heart disease, stroke, diabetes, and some cancers are obesity-related conditions that the CDC considers some of the leading causes of preventable deaths U. S. Department of Health and Human Services, 2001

4. Sedentary lifestyle is one of the most significant risk factors for obesity The Best Practices Statement for promoting physical activity (PA) developed by a coalition of national organizations led by The American College of Sports Medicine include the following recommendations: • Individually tailored PA programs and interventions that include principles of behavior change. • Emphasize the need to increase PA in underserved populations primarily because these groups are at higher risk of poor health and have lower levels of PA than their counterparts Stewart, et al.,2006

5. Adults with intellectual and developmental disabilities face multiple challenges in addressing the health-related risks of sedentary lifestyle : They are more likely to: • Be people with low socioeconomic status • Require assistance with everyday life skills • Have poor dietary habits, low physical activity, and weight disturbances • Have more chronic disease conditions than that of the general population Elinder, et al, 2010 Although a significant amount of research exists on obesity &interventions designed to promote weight loss, very little research has been conducted to date to identify those interventions that most effectively promote weight loss in this population

6. Thus, an evidence based practice review was conducted to explore the question: What are the effective exercise or activity-based interventions for promoting weight loss or preventing weight gain in obese or overweight adults with intellectual or developmental disabilities?

7. Search Strategies: Databases Databases (click EBSCOhost, choose these): • Academic Search Premier • CINAHL with Full Text • Health Source: Nursing/Academic Edition • MEDLINE • PsycARTICLES • Psychology and Behavioral Sciences Collection • PsycINFO

8. Search Strategies: Search terms • (intellectual or developmental) and disabilities • obesity or weight gain • exercise or physical activity • intervention • The online search yielded 15 studies, 7 of which were included for review. A citation review was conducted by hand after the articles from the database search were obtained, and one additional study was located via this hand search

9. Inclusion criteria for the search Included: • Research articles published after 2002 • All studies included aspects of physical activity as an intervention • Studies with combined interventions, due to small number of published articles • Adult subjects with overweight and obese body mass index • Literature had to be published in English

10. Exclusion criteria for the search • Studies that were exclusively correlational or descriptive in nature • Studies that were not completed on subjects with developmental or intellectual disabilities • Expert opinion articles with no sample studied

11. The Studies: • Bazzano, A., Zeldin, A., Shihady, D., Garro, N., Allevato, N., & Lehrer, D. (2009). The healthy lifestyle change program. American Journal of Preventive Medicine, 37, S201-S208. • Chapman, M., Craven, M., & Chadwick, D. (2005). Fighting fit? an evaluation of health practitioner input to improve healthy living and reduce obesity for adults with learning disabilities. Journal of Intellectual Disabilities, 9,131-144. • Chapman, M., Craven, M., & Chadwick, D. (2008). Following up fighting fit: the long-term impact of health practitioner input on obesity and BMI amongst adults with intellectual disabilities. Journal of Intellectual Disabilities, 12, 309-323. • Ewing, G., McDermott, S., Thomas-Koger, M., Whitner, W., & Pierce, K. (2004). Evaluation of a cardiovascular health program for participants with mental retardation and normal learners. Health, Education, and Behavior, 31, 77-87.

12. Studies used in this literature review con’d • Heller, T., Hsieh, K., & Rimmer, J. (2004). Attitudinal and psychosocial outcomes of a fitness and health education program on adults with down syndrome. American Journal on Mental Retardation, 109, 175-185 • Marshall, D., McConkey, R. & Moore, G., (2002). Obesity in people with intellectual disabilities: the impact of nurse-led health screenings and health promotion activities. Issues and Innovations in Nursing Practice, 41, 147-153. • Melville, C., Boyle, S., Miller, S., Macmillan, S., Penpraze, V., Pert, C., Spanos, D….& Hankey, C. (2011). An open study for the effectiveness of multi-component weight-loss intervention for adults with intellectual disabilities and obesity. British Journal of Nutrition, 105, 1553-1562. • Saunders, R., Saunders, M., Donnelly, J., Smith, B., Sullivan, D., Guilford, B, & Rondon, M. (2011). Evaluation of an approach to weight loss in adults with intellectual or developmental disabilities. Intellectual and Developmental Disabilities, 49, 103-112.

13. Participants in the included studies ranged in age from 18 to 71 years old • One study included participants specifically diagnosed with Down syndrome • Two studies included the same participants but reported on findings from different points in the study period • Three studies included obese or overweight participants with identified “intellectual disabilities” • One study included obese participants identified with “intellectual or developmental disabilities” • One study compared results of what the authors described as “normal learners” to that of “individuals with mental retardation” • One study included obese or overweight participants with identified “developmental disabilities”

14. Interventions • All of the studies included a nutritional education component • None of the studies measured physical activity without a dietary intervention component • Two of the studies provided both nutrition and exercise information as well as supervised physical activity in a group format • One study provided exercise and nutrition education in a group format with an optional recommended group walk • One study consisted exclusively of group education sessions, while “emphasizing the importance of exercise” • Four studies utilized individualized diets and exercise programs with home visit education sessions and data collection tasks, but no supervised exercise component

15. Outcome Measures • Four studies used Body Mass Index (BMI) and weight lost • One study used BMI and weight loss and also included self- reported nutrition, physical activity, and life satisfaction measures. • One study included measures of physical activity and sedentary behavior in addition to BMI and weight lost • The two studies that were a longitudinal comparison of the same subjects used BMI exclusively • One study used BMI in addition to pre and post -test measures of knowledge of healthy eating choices • One study used Likert scales for rating health status and Instrumental and Activities of Daily Living Scales completed by a guardian, as well as self-report measures including the Cognitive-Emotional Barriers to Exercise Scale, Exercise Perception Scale, a non-standardized measure of self-efficacy, Life Satisfaction Scale, and an adapted Children’s Depression Inventory. This study did not report on BMI or weight loss as an outcome measure of the study.

16. Data collection and analysis: Design Types • All 8of the studies included used quantitative data to describe their results. • Three of the studies compared experimental groups to control groups • One of the studies was a randomized control trial • Two studies followed a nonrandomized comparison group design • One study utilized a case-controlled, nonrandomized pretest-posttest design • Four studies followed a single group, pretest- posttest design • None of the studies incorporated blinding into the study designs • One study gathered follow-up data after the completion of the intervention

17. Data collection and analysis con’d:Inferential Statistics • Analysis of Covariance (ANCOVA) to test the effects of diet and exercise on weight loss • Paired t-tests to analyze pretest-posttest data group means • McNemar’stest for this reason as well • Chi-squared test results to describe the distribution of the sample and detect differences in the group demographic differences • Wilcoxon Signed Rank Test to analyze some measures of physical activity for which the distribution was skewed • Type III sum of squares as adjusted measures because the number of participants in intervention and control groups was different. • Cronbach’salpha reliability to describe the Likert scale measures that were used • One study did not utilize inferential statistics to analyze the data. This study reported the average percent of weight loss by living arrangement, diagnosis, and gender for the sample, stating that these results were comparable to the “recommended 7% weight loss by the of the Diabetes Prevention Program”

18. Results Overall, the research studies in this review display limited effectiveness in their interventions’ successes in promoting weight loss in adults with developmental disabilities. Only one randomized controlled trial has been completed to measure the benefits of an exercise and nutritional education program with adults with Down syndrome, and this particular study did not investigate the effectiveness of the program in promoting weight loss

19. Results con’d • Since each of the interventions described in this review are so different from one another, it is very difficult to draw conclusions regarding the ultimate ability of an exercise-based intervention to promote sustainable weight loss in adults with intellectual disabilities • In fact, the two studies by Chapman, et al. (2005 and 2008, respectively) reported on the same group of participants at one year and at 6 years using this intervention, and demonstrated diminishing returns over time. • Although the amount of weight lost for the intervention group was significant after one year in the study, after six years of the intervention, the rate of weight loss for the intervention group was no different from that of the control group.

20. Results con’d • All of the studies did demonstrate the ability of participants to lose weight during the study period. • With no follow-up data from seven of these studies, it is not possible to determine whether these results were sustainable or whether the techniques used might be applicable to the population of adults with developmental disabilities at large. • Of this group, five of the studies emphasized diet supervision and encouraged exercise but the exercise component was not supervised by the study team • Only two of these studies actually provided supervised exercise instruction as a component of the intervention • One study had a supervised walking component, but this was optional for participants

21. Discussion and Clinical Implications • There is still much to be learned about the usefulness and best methods for this type of intervention with this population • All eight of these studies show that activity can promote weight loss in adults with intellectual disabilities • Further research is needed to determine the most effective method to promote weight loss or prevent weight gain in adults with these disabling conditions.

22. Implications for Consumers Activity based interventions for obese adults with developmental disabilities have not been shown conclusively to promote sustainable weight loss. • A healthcare provider may implement an activity program to promote weight loss, but outcomes are inconsistent. • Due to the many co-morbid health factors associated with obesity and developmental disability, a caregiver should seek a physician’s advice before embarking on any efforts to promote weight loss in the individuals under their care, with regard to both diet and exercise guidelines

23. Implications for Practitioners • Exercise-based activity programs may promote weight loss and prevent weight gain in obese adults with developmental disabilities. • There is insufficient evidence at this time to conclude that any one specific method is the most effective method to promote weight loss. • It is highly likely that some obese individuals with developmental disabilities can and will lose weight as a result of an exercise-based intervention, but this is not yet reinforced in evidenced based literature. • What is known, however, is that doing nothing almost guarantees negative health outcomes in this vulnerable population.

24. Implications for Researchers A great need exists for more research regarding the effectiveness of activity-based interventions for promoting weight loss in obese adults with intellectual disabilities. • There is only one longer-term study to date on this subject (Chapman, et al., 2008). • Research is also needed to determine whether education-based classes or exercise-based interventions are the more effective method for producing sustainable results. • Individualized approaches as compared to group methods are another aspect of study that needs further research. • Programs that are exclusively exercise or diet-focused compared to those that are multifaceted is still another area in which the research is yet to be completed.

25. Recommendations for Best Practice • The studies located for this evidence based practice review indicate limited effectiveness in these interventions’ specific approaches to promoting weight loss in obese adults with developmental disabilities. • Supervised, exercised-based approaches to intervention with this population for this purpose may be effective in promoting weight loss or preventing further weight gain in these individuals. • Given the complexity of the nature of promoting safe, effective, client-centered, sustainable, and long-term health outcomes for this population, therapists must continue to search the literature carefully and reflect methodically and critically when determining the best intervention strategies to use with each and every client in their care.

26. References • Bazzano, A., Zeldin, A., Shihady, D., Garro, N., Allevato, N., & Lehrer, D. (2009). The healthy lifestyle change program. American Journal of Preventive Medicine, 37, S201-S208. doi:10.1016/j.amepre.2009.08.005. Retrieved November 28, 2012 from American Journal of Preventive Medicine Online database. • Bodde, A., Dong-Chul, S., Frey, G., Van Puymbroeck, & M., Lohrmann, D. (2012). Correlates of moderate-to-vigorous physical activity participation in adults with intelllectual disabilities. Health Promotion Practice, 20 1-8. Doi: 10.1177/1524839912462395. Retrieved December 2, 2012 from Sage Journals Online database. • Brown, C., Goetz, J., Van Sciver, A., Sullivan, D., & Hamera, E. (2006). A psychiatric rehabilitation approach to weight loss. Psychiatric Rehabilitation Journal, 29, 267-273. Retrieved November 28, 2012 from EBSCOhost database. • Chapman, M., Craven, M., & Chadwick, D. (2005). Fighting fit? an evaluation of health practitioner input to improve healthy living and reduce obesity for adults with learning disabilities. Journal of Intellectual Disabilities, 9, 131-144. doi:10/1177/1744629505053926. Retrieved December 2, 2012 from Sage Journals Online database. • Chapman, M., Craven, M., & Chadwick, D. (2008). Following up fighting fit: the long-term impact of health practitioner input on obesity and BMI amongst adults with intellectual disabilities. Journal of Intellectual Disabilities, 12, 309-323. doi: 10.1177/1744629508100557. Retrieved November 28, 2012 from Sage Journals Online database.

27. References con’d • Elinder, L., Bergstrom, H., Hagberg, J., Wihlman, W., & Hagstromer, M. (2010). Promoting a healthy diet and physical activity in adults with intellectual disabilities living in community residences: design and evaluation of a cluster-randomized intervention. BioMed Central Public Health, 10, 761-766. doi: 10.1186/1471-2458-10-761. Retrieved October 18, 2012 from BioMed Central. • Emerson, E. (2005). Underweight, obesity, and exercise among adults with intellectual disabilities in supported accommodation in Northern England. Journal of Intellectual Disability Research, 49, 134-143. doi: 10.1111/j.1365-2788.2004.00617.x. Retrieved November 28, 2012 from Wiley-Blackwell. • Ewing, G., McDermott, S., Thomas-Koger, M., Whitner, W., & Pierce, K. (2004). Evaluation of a cardiovascular health program for participants with mental retardation and normal learners. Health, Education, and Behavior, 31, 77-87. doi: 10.1177/1090198103259162. Retrieved November 28, 2012 from Sage Journals Online database. • Harris, M., Bloom, S. (1984). A pilot investigation of a behavioral weight control program with mentally retarded adolescents and adults: effects on weight, fitness, and knowledge of nutritional and behavioral principles. Rehabilitation Psychology, 29, 177-182. Retrieved December 2, 2012 from EBSCOhost database. • Heller, T., Hsieh, K., & Rimmer, J. (2004). Attitudinal and psychosocial outcomes of a fitness and health education program on adults with down syndrome. American Journal on Mental Retardation, 109, 175-185. • Heller, T., McCubbin, J., & Peterson, J. (2011) Physical activity and nutrition health promotion interventions: what is working for people with intellectual disabilities? Intellectual and Developmental Disabilities, 49, 26-36. doi:10.13652/1934-9556-49.1.26.

28. References con’d • Hilgenkamp, T., Reis, D., van Wijck, R., Evenhuis, H. Physical activity levels in older adults with intellectual disabilities are extremely low. (2012). Research in Developmental Disabilities, 33, 477-483. doi; 10.1016/j.ridd.2011.10.011. • Holm, M. B. (2000). Our mandate for the new millennium: Evidenced-based practice. American Journal of Occupational Therapy, 54, 575-585. • Kielhofner, G. (2006). Research in occupational therapy: Methods of inquiry for enhancing practice. Philadelphia, PA: F. A. Davis Company. • Marshall, D., McConkey, R. & Moore, G., (2002). Obesity in people with intellectual disabilities: the impact of nurse-led health screenings and health promotion activities. Issues and Innovations in Nursing Practice, 41, 147-153. • Melville, C., Boyle, S., Miller, S., Macmillan, S., Penpraze, V., Pert, C., Spanos, D….& Hankey, C. (2011). An open study for the effectiveness of multi-component weight-loss intervention for adults with intellectual disabilities and obesity. British Journal of Nutrition, 105, 1553-1562. • Stewart, A.L. (2001). Community-based Physical Activity Programs for Adults Aged 50 and Older. Journal of Aging and Physical Activity, 9, S71-S91. • Stewart AL, Gillis D, Grossman M, Castrillo M, Pruitt L, McLellan B, Sperber N. (2006). Diffusing a research-based physical activity promotion program for seniors into diverse communities (CHAMPS III). Preventing Chronic Disease [serial online]. • Saunders, R., Saunders, M., Donnelly, J., Smith, B., Sullivan, D., Guilford, B, & Rondon, M. (2011). Evaluation of an approach to weight loss in adults with intellectual or developmental disabilities. Intellectual and Developmental Disabilities, 49, 103-112.

29. References con’d • Temple, V. & Stanish, H. (2009). Pedometer-measured physical activity of adults with intellectual disability: predicting weekly step counts. American Journal on Intellectual and Developmental Disabilities, 114, 15-22. doi: 10.1352/2009.114:15-22. Retrieved November 28, 2012 from EBSCOhost database. • U. S. Department of Education, National Institute on Disability and Rehabilitation Research Projects and Centers Program; Funding Priorities. (2006). Federal Register. (Document 06-1975). • U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention, National Center for Chronic Disease Prevention and Health Promotion. (1996). Physical activity and health: a report of the surgeon general. Atlanta, GA: Authors. • U. S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2001). Healthy people 2010. Washington, DC: Authors. • U. S. Department of Health and Human Services, Office of the Surgeon General. (2002). Closing the gap: a national blueprint for improving the health of individuals with mental retardation. Report of the surgeon general’s conference on health disparities and mental retardation. Rockville, MD: Authors. • World Health Organization. (2009). Global health risks: Mortality and burden of disease attributable to selected major risks. Geneva, Switzerland: Authors.