School of Education, Flinders University
Obesity is one of a health problem that currently has become the public health concern, because of its trend of the increasing number of people with obesity among children and adolescents each year. Several studies have indicated that the prevalence of overweight and obesity is higher among children with intellectual disability/developmental disabilities than in the general population (Hsieh, Rimmer, & Heller, 2014; Lin, Yen, Li, & Wu, 2005; J. H. Rimmer & Yamaki, 2006). Overweight and obesity are defined as “abnormal or excessive fat accumulation that may impair health” (WHO, 2016). Research suggest that more study needs to be conducted on successful weight reduction strategies for obese persons with ID. Adolescent need to engage with 60 minutes daily physical activities to get a better health and behavior outcomes (Strong et al., 2005). Although obesity has become a major health issue among children and adolescents with intellectual disability, a positive expectation from the implementation of physical activity as an accessible and effective prevention solution still exists. The purpose of this paper is to presents an overview of current studies related to a health-related problem of overweight and obesity among children and adolescents with intellectual disability. It then will generally describe the role of physical activities in promoting health. Last, it will discuss the relationship between physical activity and overweight and obesity and its role in promoting health among these children with ID.
The effect of unhealthy lifestyle among youth with ID has become a concern for the last few decades. Unhealthy lifestyle is associated with health problems which could lead to some chronic diseases as a secondary health condition among youth with an intellectual disability. Van Itallie (1985) reported that the relative risk of hypertension, hypercholesterolemia, and diabetes is likely to be higher in overweight adult under 35 years old. In line with the findings, cardiovascular has also become another risk facing children and youth in general population (Freedman, Dietz, Srinivasan, & Berenson, 1999). Meanwhile, among youth with intellectual disability (ID), a higher number of obesity-related secondary conditions bringing them to greater health problems during their transition into adulthood (Rimmer, Yamaki, Lowry, Wang, & Vogel, 2010). As Rimmer et al. (2010) mentioned that these obesity-related secondary conditions including hypertension (high blood pressure), hypercholesterolemia (high blood cholesterol), diabetes, cancer, depression, fatigue, liver or gallbladder problems, low self-esteem, preoccupation with weight, early maturation, and pressure sores. Moreover, a psychological effects also found in some studies such as reducing quality of life (Hughes et al. 2006; cited in Rimmer et al., 2010), difficulty building relationships with peers (Gortmaker et al. 1993; Koplan et al. 2005; cited in Rimmer et al., 2010), as a result of discrimination among youths with disabilities. It was been reported that the number of mortality was significantly higher for people with disability (Yang et al. 2002; cited in C. Melville et al., 2008). However, this study only involved people with Down Syndrome, which means that these results can not be generalized to all persons with intellectual disability. In addition, many types of research have analyzed the impact of obesity on longevity, and conclude that the life expectancy among obese people will decline significantly (Olshansky et al., 2005). Unhealthy lifestyle such as eating habits and physical inactivity might contribute to increase the risk of people with intellectual disabilities developing obesity.
Deckelbaum and Williams (2001) assert that one of the causes of obesity is the increased supply of food and calorie intake, but it is not balanced with appropriate levels of physical activity (decreasing). Physical activity is the movements of the body as a whole (muscle activity) which have an impact on the rise of energy consumption (Caspersen, Powell, & Christenson, 1985; Must & Tybor, 2005; Ortega, Ruiz, Castillo, & Sjöström, 2008). Indeed, studies have recommended school-age youth to participate in an average of 60 minutes or more per day of at least moderate to vigorous physical activity that is fun and age developmentally appropriate (Janssen & LeBlanc, 2010; Strong et al., 2005). It is known that physical activity in appropriate amounts, is needed to beneficial changes in the body health such as body composition, bones health, fitness, muscular strength, endurance, and reduce overweight as well as contribute to prevention or delay of chronic diseases (LeMURA & Maziekas, 2002; Strong et al., 2005). Furthermore, not only derive health benefits, its also includes improved gross motor function, and high levels of participant or parent satisfaction for children and youth with intellectual disability or developmental delay (Johnson, 2009).
Even though many studies has proven the benefits and positive effects of physical activity to improve the development, quality of life, future health and life outcomes (Anderson, Bedini, & Moreland, 2005; King et al., 2003) for children and youth with disabilities, the amount of participation is remaining lower than those children without disabilities. Based on the systematic review of some resources related to this issue, Shields, Synnot, and Barr (2012) has identified some barriers and facilitators to physical activity perceived by children with disabilities. The barriers were divided into three categories namely personal, social environment and policy barriers. First, personal barriers to participation include lack of knowledge about the exercises and skills (physical and social), the child's preferences for activities other than physical activities, and feeling of fear. Second, social barriers include parental actions, behavior or concerns, a lack of friends to participate with or unsupportive peers and negative societal attitudes to disability which is not only from peers but also teachers’ attitudes. In terms of environmental barriers, the barriers include inadequate, inaccessible or inconvenient facilities and a lack of transport to access the facilities. Last, the policy or program barriers include lack of appropriate physical activity programs, lack of staff capacity, and cost, and negative attitudes towards working with children with disability. Another factor related to the participation of children with disabilities is the facilitators of those personal, social environment and policy barriers (Shields et al., 2012). First, personal facilitators included the child's desire to be active and fit, practicing skills and gain competence, and having fun. Second, social facilitators included involvement of peers, family support, opportunities to access the activity, child’s motivation, interest, positive encouragement, the family’s role (parent or siblings) in facilitating and involve in the physical activity. Third, environment facilitators included accessible facilities and proximity of location and facilities. Last, in terms of policy and program, a structured, varies, non-competitive, in a small group or individual and age-appropriate programs provided, and skilled staff and information seen as facilitators. Similarly, Bodde, Seo, and Frey (2009) conclude that the main barriers faced by persons with disorders of intellectual accessing physical activity is transportation issues, cost limitations and the lack of awareness of choice, negative support from the caregiver and authority figures (such as teachers, coaches and parents) and the lack of clear policies to engage in routine activities in the residential and day service programs. It should be noted that the intervention program would be difficult to be implemented if these obstacles, including the association between each aspect, can not be clearly understood.
Interestingly, in terms of the correlation, there are a lot of studies investigated the relationship between physical activity and overweight, which include gender difference as a consideration, reported inconsistent findings. Rauner, Mess, and Woll (2013) conclude that the interaction between physical activity and overweight is still unclear, due to the variety of method, measurement instruments, parameters, and other aspects which make the results inconsistent. For example, some studies were found the correlation between physical activity and overweight, while in contrast, other studies found that there were no relationships between physical activity and overweight. Additionally, in terms of the effect, there are not much research investigated the effectiveness of physical activity interventions to reduce the risk of overweight or obesity. This has led to the assumption, despite having been proven to have positive effects on health, whether physical activity is directly related to obesity and whether the risks would mean overweight and obesity can be prevented by sufficient physical activity is still in doubt. A review on the effects of exercise interventions for children and adolescents who are overweight, confirm that exercise can reduce body fat percent of overweight and obese children and adolescents (Kelley & Kelley, 2013). Another research shows that Physical Activity (PA) intervention was working on reducing gestational weight gain (GWG) in obese pregnant women (Renault et al., 2014). Assuming that regular physical activity and exercise has the same effect, these studies indicate the role of physical activity in the prevention of weight gain. However, little evidence exists that physical activity or exercise influencing weight loss. Several studies show that there is no significant change in weight after following PA interventions (Church et al, 2010; Bateman et al, 2011; cited in Swift, Johannsen, Lavie, Earnest, & Church, 2014). Similar to those studies, there are no significant differences between implementing PA and either combines with caloric restriction or not tp achieve weight loss (Miller et al, 1997; Wing, 1999; cited in Swift et al., 2014).
In spite of no clear evidence about the influence of physical activity on weight loss and prevents obesity, evidence that physical activity has a positive impact on health can be the basis for implementing the PA programs. A literature review by Harris, Hankey, Murray and Melville (2015) on some studies related to the PA interventions for youth with intellectual disability revealed that there was no significant impact of physical activity (PA) interventions on preventing weight gain. In contrast, one study shows that a long term PA program including an aerobic or physical exercise for overweight to obese women with ID can be used as an effective plan for reducing subcutaneous fat mass (Merrick, Bachar, Carmeli, & Kodesh, 2013). Moreover, a study shows that healthy exercise program had a positive effect on the fitness of people with ID, although in this study also found that the highest effectiveness in this program on weight loss was more visible in those with mild ID (Wu et al., 2010). Besides physical activity, many types of research were conducted to measure the intervention effect to weight loss of persons with intellectual disability. A restricted diet including consuming high volume, low-calorie foods, and beverages, as well as using meal-replacement has proven to have a contribution to weight loss in children with ID(Saunders et al., 2011). In fact, a study by C. A. Melville et al. (2011) has confirmed that a diet intervention (i.e. TAKE 5) is effective intervention to reduce weight among adult with an intellectual disability. Based on the finding results of such research, we still believe that interventions to overcome overweight and prevent obesity may show more positive results among people with or without intellectual disability.
Although studies on the relationship between physical activity (PA) and obesity among children and adolescents with intellectual disorders and the effectiveness of the PA programs to prevent excess weight has not shown a definitive results yet, the positive effects on health need to be considered as a reasonable reason, so that the PA programs still can be implemented to address obesity-related health problems. Therefore, the role of prevention and management of obesity in children and adolescents with an intellectual disability through a structural, accessible and effective physical activity are still important. It is recommended to not only focus on physical activity but also all the elements, such as eating habits and environmental supports (supportive community network), also needs to be implemented to prevent overweight and obesity among children and adolescents with ID. In addition, the need for further research to investigate the role of physical activity associated with effective interventions to prevent health problems caused by obesity is also highly recommended.
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