Obesity & Wellbeing in

Learning Disabilities

An intervention to promote healthier

lifestyles Laura Dunn Daniella

Amaral Claire George MJ

Sharp

Obesity & wellbeing in learning disabilities Health inequalities between those with learning disabilities & the rest of the

population Changing health behaviour: Looking at models of health behaviour change Studies into health & wellbeing interventions with intellectual disabilities Addressing the need: why and how do we tackle this health inequality? What health provision is there locally for those with intellectual disabilities? Our proposal for a gardening project, how we will deliver and evaluate its

effectiveness

Case Scenario Obesity is commonplace among people with learning disabilities. There

are a lot of co-morbidities, with coronary heart disease being the second biggest killer in this group, and life expectancy being 25 years less than the average (Samele, Seymor, Morris, Cohen and Emmerson, 2006).

A successful cycle & weight management project for people with learning disabilities, to improve their physical health and boost their mental wellbeing.

As student physiotherapists we want to create a successful project focusing on helping people with learning difficulties to improve their physical health and boost their mental wellbeing.

By promoting healthier lifestyles; medication costs and hospital admissions can be reduced, resulting in cost savings to the NHS.

Health and wellbeing Health - a state of complete physical, mental and

social well being, not merely absence of disease or infirmity.’ (WHO, 1946)

Wellbeing – “a positive physical, social and mental state; it is not just the absence of pain, discomfort and incapacity. It requires that basic needs are met, that individuals have a sense of purpose, that they feel able to achieve important personal goals and participate in society. It is enhanced by conditions that include supportive personal relationships, strong and inclusive communities, good health, financial and personal security, rewarding employment, and a healthy and attractive environment.” (DEFRA, 2009)

Learning Disability (Department of Health, 2001). “A significantly reduced ability to understand new or

complex information, to learn new skills (impaired intelligence), with a reduced ability to cope

independently (impaired social functioning); and which started before adulthood, with a lasting effect

on development”

Categories of learning disabilities (BILD, 2011)

Mild IQ level 50-70

ModerateIQ level 35-50

SevereIQ level 20-35

ProfoundIQ level < 20

Usually able to hold a conversation.

Need some support to understand complex ideas.

Independent in caring for themselves and doing many everyday tasks.

Basic reading and writing skills.

Likely to have some language skills.

Able to communicate about their day to day needs and wishes.

May need more support caring for themselves, but will be able to carry out day to day tasks.

Often use basic words and gestures to communicate their needs.

Need a high level of support with everyday activities.

May be able to look after some if not all of their own personal care needs.

Have considerable difficulty communicating.

Have very limited understanding.

Many have complex health needs requiring extensive support.

May need support with behaviour that is seen as challenging.

Learning disabilities – Health inequalities.

Around 2% of the UK population has a learning disability with less than a quarter, known to local health and social services. (Emerson and Hatton, 2004)

The rate of obesity among people with a learning disability is significantly different to those without such a disability (28.3% compared to 20.4%) (Samele, Seymor, Morris, Cohen and Emmerson, 2006).

People with learning disabilities are at risk of obesity at an earlier age than the general population. (Sutherland, Couch and Iacono, 2002).

As a consequence are likely to experience obesity-related health problems, such as coronary heart disease at a younger age. (Melville, Hamilton, Hankey, Miller and Boyle, 2007)

In 2007, the direct costs of obesity to the NHS was £7.1 billion. By 2050 the cost to society is predicted to rise to £50 billion. (National Institute for Health and Clinical Excellence, 2013).

(N.B. Obesity = BMI > 30)

Comparison Of Obesity Prevalence Among People With Learning Disabilities Compared To The Registered Practice Population By BMI Range (Glover, Emerson and Eccles, 2012)

<20 (Underweight) 20-24 (Healthy) 25-29 (Overweight) 30-39 (Obese) 40+ (Mobidly Obese)

0%

5%

10%

15%

20%

25%

30%

35%

40%

General Population Learning Disabilites

Diet

Less than 10% of adults with learning disabilities eat a balanced diet, with an insufficient intake of fruit and vegetables. (Robertson, Emerson, Gregory, Hatton, Turner et al, 2000).

Carers have poor knowledge on public health recommendations on dietary intake (Melville, Hamilton, Miller, Boyle, Robinson et al, 2009).

Exercise in Adults with Learning Disabilities

80% engage in levels of physical activity below the Department of Health’s (DOH) minimum recommended level. (Robertson et al, 2000)

Walking an average of 15 minutes per week. (Mitchell, Melville, Stalker, Matthews, McConnachie et al, 2013).

Much more likely to be either underweight or obese than the general population (Meville et al 2007)

What is the consequence of this?... MORTAILITY

Due to a poor diet and lack of exercise, evidence suggests that adults with Learning disabilities…. have a 58% increased risk of dying before they are 50

years old compared to the general population. (Mental Health Group. British Dietetic Association, 2006)

will die of Coronary heart disease (14%-20%) (Hollins, Attard, Van Fraunhofer, McGuigan S and Sedgwick, 1998)

4 times as many people with a learning disability die of preventable causes as people in the general population (Mencap, 2016)

have poorer health than their non-disabled peers, however these differences in health status that are, to an extent, avoidable (Sutherland, Couch and Iacono, 2002)

Behavioural, Environmental And Biological Factors.The reasons for a higher prevalence of obesity in people with learning disabilities are due to three factors:1) Behavioural – able to change by diet, exercise and education

(Emerson, Baines, Allerton and Welch, 2012)2) Environmental – able to change to some extent e.g. those living

independently or with less supervision are at increased risk of developing obesity. (Emerson et al 2012).

3) Biological – unable to change e.g. genetic disorders such as Prader-Willi syndrome carry a high risk of severe obesity and 24–48% of adults with Down’s syndrome are obese. (Haveman, Heller, Lee, Maaskant, Shooshtari et al 2010)

Health behaviours are ‘any activity undertaken for the purpose of preventing or detecting disease or for improving health and well-being’ (Conner and Norman, 2005)

Motivation to change health behaviours depends of many factors, such as:Information: Information plays an important role on health promotion. Information given by health

promoters should be: Accurate Easy to understand Accessible Credibility

Social influence: Social influence can persuade individuals. This influence can be:Informational: when we trust someone with more authority than us (health professionals for example)

Behaviour Change And Motivation On Health Promotion

Normative: when we behave according to other people’s beliefs so we will keep their approval One of the principles of persuasion is consensus. People are more likely to change when this

behaviour is supported by a group they identify themselves. This fact relates to the cognitive dissonance theory (Festinger, 1957), that claims that people look for consistency between the world and their beliefs.

Even though persuasion can be efficient, it can also face reactance and resistance. This can be attenuate when the persuasion attempts as CHOICES

Self-efficacy (SE) SE is the belief someone has of their own ability of achieving goal despite the obstacles. High

SE is related to better cope mechanisms to challenges, thus it is important to reinforce it. Bandura (1999) SE can be enhanced by:

Mastery experiences: people confidence grows as they achieve their goals, therefore graded tasks are recommended to increase their SE

Vicarious experience: observe someone similar to us to conquer a goal increases our SE Verbal persuasion Perception of physiological and affective states: negative moods and anxiety can decrease the

SE

Choosing the Changing Behaviour Model The assessment to choose the changing behaviour model appropriate must analyse the target

population deficits and resourses The technique need to be easy to implement

Precaution Adoption Process Model• Strengths: addresses the fact that the desired behaviour may not have even been heard of • Criticisms: people’s behaviour & decision making doesn’t always have discrete stages

(Morrison & Bennett, 2012)

Health Promotion“a process of enabling people to increase their control

over, and improve their health.” (WHO,1986)

Tones & Tilford’s Empowerment Model aims to enable people to have more control over their health

Healthy public policy X health education = Health promotion Education seen as the key to empowerment Education means raising consciousness of health issues A “reciprocal relationship” between self-empowerment & community

empowerment

(Naidoo & Wills, 2009:80)

Empowerment Model (Tones & Tilford, 2001)

(Bergstrom, Hangstromer, Hagberg, & Elinder, 2013). A multi-component intervention to improve diet and physical activity among adults with intellectual disabilities in community residences.

Description Involved 130 participants aged between 20-66 with learning disabilities from 30 community residencies. It lasted 12-16 months and involved

1) Physical activity which increased step count 2) A study circle for health promotion 3) Health course in weight loss and dietary intake.

Outcome measures

Physical activity measured by pedometry shown to be reliable in research settings (Holbrook, Barreira, & Kang, 2009).

Strengths • Randomised controlled trial (RCT)• Randomly allocated into groups• Large number of participants (130)• Intervention had a long duration (12-16 months)

Weaknesses • Invitation letter • Control didn’t take part in physical activity

Results The intervention group showed a significant increase in physical activity by 1608 steps per day more (P-0.045) during days when gardening.

Application into physiotherapy practice Educated both participants and caregivers in

health promotion making it more likely for changes in behaviour towards physical activity and dietary intake to occur.

The use of behavioural/educational interventions with strategies to support behaviour change increases weight reduction in multi-component interventions including a nutrition component and physical activity. ((Bergstrom, Hangstromer, Hagberg and Elinder, 2013).

(Brooker, van Dooren, McPherson, Lennox, & Ware, 2015). Review of interventions aiming to improve involvement in physical activity among adults with intellectual disability

Description A RCT carried out on 42 participants aged between 18-71 with learning disabilities. The intervention lasted 8 weeks and involved 1 hour sessions twice a week. It involved physical activity, nutrition and weight loss.

Outcome measures

The accelerometer measuring movement intensity. Research shows good test-retest reliability for the accelerometer however is more accurate during low intensity exercise such as walking (Wetten, Batterham, Tan, & Tapsell, 2014).

Strengths • Home visits to increase physical activity• Control group• Involved physical activity, weight loss and nutrition

Weaknesses • Small number of participants (42)• Participants needed to be able to communicate verbally• Intervention- 8 weeks for 1 hour 2 times a week- below physical activity guidelines

Results The intervention group showed significant results on the accelerometer on days in the week when physical activity took place (p-0.027) compared to the control group.

Application into physiotherapy practice

Both aspects of this trial are active interventions aimed to support adults with learning disabilities make healthier lifestyle choices, particularly focused on supporting weight loss through a multi-component intervention (Brooker, van Dooren, McPherson, Lennox, & Ware, 2015).

(Donnelly, Saunders, Saunders, M., Washburn, Sullivan et al 2013). Weight management for individuals with intellectual and developmental disabilities.

Description A RCT carried out on 150 participants aged between 18 and 65 with learning disabilities. Subjects were recruited if they were overweight or obese. The intervention involved

1)A stop light diet-2)A reduced energy/fat meal plan diet.3)Encouraged to do 30 min per day of moderate intensity physical activity at least 5 days per week.

Outcome measures

Weight loss and BMI. Other outcome measures included a step counter for physical activity and a modified self-efficacy scale for wellbeing.

Strengths • Randomly allocated into 2 groups using computer software• Follow up 6 months after• Treated equally except from type of diet

Weaknesses • Brochure• Participants were only encouraged to take part in physical activity

Results Weight loss and BMI showed a significant decrease after the 12 months (P-0.037) on the diet however the follow up showed minimal significance of the intervention long term.

Application into physiotherapy practice

Low energy/fat meal planning may be useful in individuals with learning disabilities as they limit undesirable food choices, teach appropriate portion sizes, are convenient and easy to prepare.

However the study only encourages participants to exercise and doesn’t provide any opportunities to engage which research shows to be most beneficial in reducing obesity in this population (Melville, Boyle, Miller, Macmillan, Penpraze et al, 2011).

(Bazzano, Zeldin, Diab, Garro, Allevato et al 2009). A pilot of community-based health promotion intervention for adults with developmental disabilities

Description Involved 44 participants aged between 18-65 with learning disabilities and a BMI above 25. The intervention lasted 7 months and involved 2 hour sessions twice a week. It consisted of education and exercise programme to increase knowledge, skills and self-efficacy regarding nutrition and fitness.

Outcome measures

Weight loss. Other outcomes include BMI, physical activity and life satisfaction measure by the brief multi-dimensional students life satisfaction scale.

Strengths • Written informed consent• Recruited from the community, those living with family or independently• Specific population targeted

Weaknesses • 2 hour sessions may have been too much for this population• No control group- not baseline data to compare with

Results The results show a significant decrease in weight loss and BMI (P-0.04). Physical activity duration increased overall (P-0.02) as well as frequency (P-0.001).

Application into physiotherapy practice

Health promotion programs including diet, exercise and behaviour modification can promote weight loss and reduce or prevent the chronic complications of obesity.

NICE Guidelines recommend an integrated approach to preventing and managing obesity. They suggest including local services such as community walking groups or gardening schemes, weight management services and local sources of information on the benefits of losing weight for adults who are obese (National institute for Health and Clinical Excellence, 2014).

Needs analysis, Health Inequalities and People with Learning Disabilities in the UK: 2012 (DOH)

One recommendation from the paper states the need to:

“Enhance the health literacy of people with learning disabilities and of carers who play a critical role in promoting

healthy lifestyles among many people with learning disabilities.”

(Emmerson and Baines, 2012)

As physiotherapists we can educate on diet and exercise and empower people to make the heathy change for life.

Projects which are helping people with learning difficulties to improve their physical health and boost their mental wellbeing include:

Pedal Power - community cycle scheme run by NHS physiotherapists in Kent, (£3 per session). (Chartered Society of Physiotherapy, 2013).

Simply Cycling – All ability cycling based in Trafford (£2 per session) (Simply Cycling, 2016)

Gymnastics club in Glossop, meets twice a week (£4 per session). (High Peak Trampoline and Rebound Therapy Club, 2016)

Complex Needs Gardening session (£3 per session/£5 all day). (Hulme Garden Centre, 2016).

Project Proposal – a Community Garden

“Community gardens have been associated with increased physical activity and improved mental health. They represent a behaviour

setting that has purpose and coherence, promotes social inclusion and gives rise to positive social and psychological processes that ultimately

leads to good health”. (Hale, Knapp, Bardwell, Marshall, Sancar et al 2011).

Green Exercise

Exercise has long been acknowledged as a primary determinant of both physical and mental health. It is also widely recognised that contact with the natural environment can have positive effects on well-being. (Pretty, Griffin, Sellens, Pretty, 2003)

The term ‘Green Exercise’ is used to describe physical activity undertaken in ‘green’ surroundings. (Pretty et al 2003)

Green Exercise can yield benefits to both health and wellbeing and that, additionally, it can increase the likelihood of participant understanding of and care for nature. (Pretty et al 2003)

Thrive (2009) - Power of gardening, the five key benefits

Better physical health – gardening is a form of exercise, tackling problems such as obesity which can lead to more serious problems such as coronary heart disease.

Improved psychological health – gardening has a positive impact on wellbeing and self worth, offers a regular routine, a sense of purpose and achievement.

Social benefits – gardening offers a sustainable interest which can improve people’s social and communication skills.

Qualifications and skills – a recognised qualification can increase the chances of employment e.g. ASDAN qualification, specifically designed for people with learning disability.

Access to the natural environment – feeling better for being outside, getting fresh air and seeing things grow are important. The ‘dose-response’ curve states that the greatest changes in self-esteem and mood appear after the first five minutes of exercise outside (Barton and Pretty, 2010)

Physical exercise in community gardens. (WHO, 2015)

Makes you feel good, Reduces the risk of

cardiovascular disease Helps control weight. contributes to mental well-

being. Increases opportunities for

making friends and feeling part of the community.

Thrive. (2009). Using gardening to change lives.

Met Comparison of activities of daily living (WHO, 2016)

Success Of Community Gardens (Progress Housing Group, 2015)

Learning Disability Week, June 15-21 2015 is organised by national charity Mencap and aims to raise awareness of issues affecting people with a learning disabilities.

As part of the national awareness week, Progress Housing Group staff and tenants put their green fingers to good use as they transformed communal gardens at three of the housing group’s supported living schemes, which provide accommodation for people with learning disabilities, in Blackburn, Darwen and Preston.

During the week volunteers weeded, trimmed, planted vegetable patches, painted fences and put up garden furniture.

What People Think - (Progress Housing Group, 2015)

“I have really enjoyed myself. Working in the garden makes us all happy and brings people together.” Elizabeth, a tenant living at Birch Hall supported living scheme in Blackburn

“I had the pleasure of working with a group of residents with learning disabilities. It was one of the best days I have had in a long time. They wanted to build their own vegetable patch and everyone worked great as a team to achieve it. At the end of the day when we were ready for packing up, I think they would have been happy to keep going. I felt very humbled by their work rate.” Volunteer Paul Fieldsend a tenant of Progress Housing Group from New Longton in Preston

How Will This Intervention Be Delivered? (Thrive, 2012)

Location – ideally somewhere where people can feel safe and comfortable in their surroundings, with good transport links. E.g. within a hospital, university, school or community centre.

Location would ideally also have indoor facilities with a toilet, lunch room and kitchen to cook the vegetables grown – rainy day activities.

Volunteers and Students – Ideally the project would be run by physiotherapists alongside volunteers and university students wanting to gain experience in health promotion. Diploma in Social and Therapeutic Horticulture available through Coventry University (2016).

Size – 1:8, will depend upon staff and volunteers. Dependant upon equipment and supply resources.

Frequency - 3 times a week, for 12 weeks (WHO, 2016). Ideally people can come and work in the garden for a morning or afternoon, and then go into the kitchen to learn cooking skills.

Funding - Grant schemes relevant to community green spaces initiative

Wide range of funding options are available – (GOV.UK, 2016), Please see Appendix 2.

1) National Lottery funded grants. Glasgow area has been awards £1.2 million for community gardens in 2016. (Big Lottery Fund, 2016)

2) Non National Lottery funded options include, Landfill tax credit scheme and multinational banks.

How Will We Evaluate This? Weight loss in KGs Waist circumference Resting Heart Rate. Number of volunteers the garden has on a weekly

basis Number of adults with a learning disability using the

garden Pedometer, phone apps, social competition. Wellbeing Questionnaire – e.g. TOM Score (Enderby,

John and Petheram, 2006). Uptake of qualifications.

In Conclusion

Obesity is commonplace among people with learning disabilities. This is due to three factors, Behavioural, Environmental and Biological.

As student physiotherapists we are able to change the behavioural and environmental factors. Research tells us that to tackle obesity we need to look at diet, exercise and well being. Potential

to be a pilot study wholly focusing on the power of gardening for people with learning disabilities. Our community garden project focused on helping people with learning difficulties to improve

their physical health and boost their mental wellbeing. Potential to achieve qualifications. Potential to expand to include children, add in animals such as chickens. By promoting healthier lifestyles; medication costs and hospital admissions can be reduced,

resulting in cost savings to the NHS.

Any Questions?

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Bergstrom, H., Hangstromer, M., Hagberg, J., Elinder, L.S. (2013). A multi-component universal intervention to improve diet and physical activity among adults with intellectual disabilities in community residences: A cluster randomised controlled trial. Research in developmental disabilities, 34(11), 3847-3857.

Bazzano, A.T., Zeldin, A.S., Diab, S., Garro, N.M., Allevato, N.A., & Lehrer, D. (2009). A pilot of community-based health promotion intervention for adults with developmental disabilities. Journal of preventative medicine, 37, 60, 201-8.

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Brooker, K., van Dooren, K., McPherson, L., Lennox, N., Ware, R. (2015). Systematic review of interventions aiming to improve involvement in physical activity among adults with intellectual disability. Journal of physical activity and health, 12(1), 434-444.

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Appendix 1 – Search strategies

The databases used in the literature search were CINAHL, Cochrane and Medline. This is an example of a one of the refined searches used, from CINAHL. To find evidenced based recourses data bases like this one were extremely useful as they produced a large amount of Randomised Control Trials, which were needed for this essay.

Appendix 1 (cont.) – Search strategies

Appendix 2 – Funding for community gardens.

Awards for All - lottery grants programme aimed at local communities throughout the UK. Grants of between £300 and £10,000 are available. http://www.awardsforall.org.uk

The Parks for People programme - A joint initiative between the Big Lottery Fund and the Heritage Lottery Fund. BIG have allocated up to £5million http://www.biglotteryfund.org.uk/prog_parks_people?regioncode=-uk

Reaching Communities revenue and small capital – funding from £10,000 to £500,000 for revenue projects and/or smaller capital projects up to £50,000. It helps people and communities most in need. http://www.biglotteryfund.org.uk/prog_reaching_communities

Big Local – Is a programme working with and supporting communities, in up to 150 selected areas, to make where they live and work a better place now and in the future. http://www.cdf.org.uk/

Appendix 2 continued – Non lottery grants.

The Landfill Tax Credit Scheme - A scheme for the distribution of funds generated from Landfill Tax in the UK. http://www.entrust.org.uk/home/lcf/about/entrust

Esmee Fairbairn Foundation - The aim of the foundation is to improve the quality of life throughout the UK. Some of their primary interests include, education and learning, the natural environment and enabling disadvantaged people to participate more fully in society. http://www.esmeefairbairn.org.uk/

Lloyds TSB Foundation - The TSB scheme aims to support charities that help disadvantaged people play a fuller role in the community. http://www.lloydstsbfoundations.org.uk

The Co-operative Group - The Community Fund is a grant scheme designed to help local communities throughout the UK. http://www.co-operative.coop/communityfund

The Country Land and Business Association Charitable Trust - A fund, operating in England and Wales, to provide facilities for the disabled and disadvantaged to take part in recreation and education in the countryside. http://www.cla.org.uk/About_the_CLA/Charitable_Trust_Introduction/

Biffaward - A multi-million pound fund that helps to build communities and transform lives through awarding grants to communities and transform lives through awarding grants to community and environmental projects across the UK. http://www.biffaward.org/

The Tudor Trust - An independent grant making trust supporting both voluntary and community groups working in UK. Tudor Trust grants help smaller, community-led groups which are supporting people at the margins of society. http://tudortrust.org.uk/what-we-do/about-our-grants/