Obesity interventions for people with a learning disability: an integrative literature review

Effects of combined training in individual with Intellectual and Developmental Disabilities: a systematic review and meta-analysis of randomized controlled trials

PURPOSE OF THE ARTICLE

This study aims to evaluate the literature, peer-reviewed clinical trials investigating the effects of combined exercise interventions on individuals with Intellectual and Developmental Disabilities.

MATERIALS AND METHODS

Various databases, using various descriptors and Boolean operators were utilized.

RESULTS

Eight studies meet the eligibility criteria. Regarding the anthropometric measures/body composition variable, the meta-analysis revealed that combined physical exercise did not have a significant effect (standard mean difference (SMD) = -0.16; 95% CI, -0.34 to 0.03; Z = 1.68; p = 0.09). For the lipid profile variable, the combined exercise interventions did not show a significant effect (SMD = -0.07; 95% CI, -0.43 to 0.29; Z = 0.38; p = 0.71). Combined exercise training had a significant effect on increasing functional capacity (SMD = 0.28; 95% CI, 0.01 to 0.54; Z = 2.03; p = 0.04), cardiorespiratory function (SMD = 0.80; 95% CI, 0.34 to 1.26; Z = 3.41; p ≤ 0.001), and strength (SMD = 0.77; 95% CI, 0.45 to 1.08; Z = 4.78; p ≤ 0.001).

CONCLUSIONS

Participants from the intervention group that took part in combined exercise training showed a higher probability of improving their functional, cardiorespiratory, and strength capacity compared to the control group.

Lifestyle modification interventions for adults with intellectual disabilities: systematic review and meta-analysis at intervention and component levels

BACKGROUND

Adults with intellectual disabilities (IDs) are susceptible to multiple health risk behaviours such as alcohol consumption, smoking, low physical activity, sedentary behaviour and poor diet. Lifestyle modification interventions can prevent or reduce negative health consequences caused by these behaviours. We aim to determine the effectiveness of lifestyle modification interventions and their components in targeting health risk behaviours in adults with IDs.

METHODS

A systematic review and meta-analysis were conducted. Electronic databases, clinical trial registries, grey literature and citations of systematic reviews and included studies were searched in January 2021 (updated February 2022). Randomised controlled trials and non-randomised controlled trials targeting alcohol consumption, smoking, low physical activity, sedentary behaviours and poor diet in adults (aged ≥ 18 years) with ID were included. Meta-analysis was conducted at the intervention level (pairwise and network meta-analysis) and the component-level (component network meta-analysis). Studies were coded using Michie's 19-item theory coding scheme and 94-item behaviour change taxonomies. Risk of bias was assessed using the Cochrane Risk of Bias (ROB) Version 2 and Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I). The study involved a patient and public involvement (PPI) group, including people with lived experience, who contributed extensively by shaping the methodology, providing valuable insights in interpreting results and organising of dissemination events.

RESULTS

Our literature search identified 12 180 articles, of which 80 studies with 4805 participants were included in the review. The complexity of lifestyle modification intervention was dismantled by identifying six core components that influenced outcomes. Interventions targeting single or multiple health risk behaviours could have a single or combination of multiple core-components. Interventions (2 RCTS; 4 non-RCTs; 228 participants) targeting alcohol consumption and smoking behaviour were effective but based on limited evidence. Similarly, interventions targeting low physical activity only (16 RCTs; 17 non-RCTs; 1413 participants) or multiple behaviours (low physical activity only, sedentary behaviours and poor diet) (17 RCTs; 24 non-RCTs; 3164 participants) yielded mixed effectiveness in outcomes. Most interventions targeting low physical activity only or multiple behaviours generated positive effects on various outcomes while some interventions led to no change or worsened outcomes, which could be attributed to the presence of a single core-component or a combination of similar core components in interventions. The intervention-level meta-analysis for weight management outcomes showed that none of the interventions were associated with a statistically significant change in outcomes when compared with treatment-as-usual and each other. Interventions with core-components combination of energy deficit diet, aerobic exercise and behaviour change techniques showed the highest weight loss [mean difference (MD) = -3.61, 95% credible interval (CrI) -9.68 to 1.95] and those with core-components combination dietary advice and aerobic exercise showed a weight gain (MD 0.94, 95% CrI -3.93 to 4.91). Similar findings were found with the component network meta-analysis for which additional components were identified. Most studies had a high and moderate risk of bias. Various theories and behaviour change techniques were used in intervention development and adaptation.

CONCLUSION

Our systematic review is the first to comprehensively explore lifestyle modification interventions targeting a range of single and multiple health risk behaviours in adults with ID, co-produced with people with lived experience. It has practical implications for future research as it highlights the importance of mixed-methods research in understanding lifestyle modification interventions and the need for population-specific improvements in the field (e.g., tailored interventions, development of evaluation instruments or tools, use of rigorous research methodologies and comprehensive reporting frameworks). Wide dissemination of related knowledge and the involvement of PPI groups, including people with lived experience, will help future researchers design interventions that consider the unique needs, desires and abilities of people with ID.

Cognitive behavioral therapies for individuals with cerebral palsy: A scoping review

AIM

To synthesize the evidence about the main intervention characteristics of cognitive behavioral therapies (CBTs) for individuals with cerebral palsy and identify barriers and facilitators to their success, focusing on aspects of feasibility and markers of success.

METHOD

A scoping review methodology informed a literature search for papers published between 1991 and 2021. Articles were screened, reviewed, and categorized using the DistillerSR systematic review software, and critically appraised for quantitative and/or qualitative criteria.

RESULTS

Out of 1265 publications identified, 14 met the inclusion criteria. Elements associated with the specific study participant characteristics (46% female; aged 6-65 years), type of CBT techniques used (third-wave [n = 6], cognitive [n = 3], cognitive and behavioral [n = 2], biofeedback training [n = 2]), and features of the study context and methodological quality (two randomized clinical trials and small sample sizes [n ≤ 12]), were identified. Most studies had psychological targets of intervention (n = 10) and secondary physiological (n = 3) or social (n = 2) objectives. Feasibility indicators were described in nearly one-third of the papers.

INTERPRETATION

This study highlights the high flexibility within CBT interventions, enabling their adaptation for individuals with cerebral palsy. However, relatively little, and only low-certainty evidence was identified. More high-quality research in terms of specific CBT techniques, optimal treatment doses, and detailed population characteristics are needed.

The delivery of healthy lifestyle interventions for people with disability living in supported accommodation: a scoping review of intervention efficacy and consumer involvement

BACKGROUND

People with disability living in supported accommodation experience health disparities that may be partly attributed to sedentary lifestyle behaviors and poor dietary quality. Healthy lifestyle interventions have been suggested as a method of health promotion for this population; however, a synthesis of their efficacy has not yet been conducted.

OBJECTIVE

The primary aims were to (1) identify healthy lifestyle interventions delivered to people with disability living in supported accommodation and (2) examine their efficacy in supporting health and well-being. A secondary aim was to explore whether people with disability have been involved in the codesign of these interventions.

METHODS

A scoping review was conducted following the Joanna Briggs Institute's guidance for conducting scoping reviews, and six databases were searched from January 2011 to November 2021.

RESULTS

Thirty-two studies were included. Identified intervention types included training and education, exercise programs, and multicomponent interventions. A broad range of outcomes were examined; however, findings regarding efficacy were overall mixed and limited due to significant heterogeneity and the underreporting of consistently measured outcomes. The codesign of interventions in consultation with people with disability was underexplored.

CONCLUSIONS

Health promotion training for staff and tailored education for people with disability hold promise in creating a care environment that supports a healthy lifestyle. The paucity of interventions developed in consultation with people with disability is concerning and highlights the importance of meaningful co-design. The development of a theoretically informed intervention that is codesigned and addresses the broader social determinants that influence health behavior is recommended.

Obesity and neurodevelopmental and mental health conditions among adolescents aged 10-17 years: The National Survey of Children's Health 2017-2018

AIM

Adolescents have a high prevalence of obesity and neurodevelopmental and mental health co-occurring conditions. This study examined the association between obesity and several co-occurring conditions - autism spectrum disorder (ASD); intellectual disability; learning disability; stuttering, stammering or other speech problems; developmental delay; attention-deficit hyperactivity disorder; epilepsy or seizure disorder; cerebral palsy; depression; anxiety; and Tourette Syndrome - in adolescents aged 10-17 years (n = 26 266) using 2017-2018 National Survey of Children's Health data.

METHODS

This cross-sectional study used 2017-2018 National Survey of Children's Health data (n = 27 328); χ² tests were conducted to compare the prevalence of obesity and several co-occurring conditions. Multiple logistic regression was conducted to adjust for age, gender, race/ethnicity and household income.

RESULTS

Obesity prevalence was 15.3%. Adolescents with ASD (25.1%) and epilepsy/seizure disorder (27.8%) had the greatest obesity prevalence. Adjusting for socio-demographic characteristics, odds of obesity were higher in those with ASD (odds ratio (OR) 1.7, confidence interval (CI) 1.2-2.6), learning disability (OR 1.5, CI 1.2-2.0), epilepsy or seizure disorder (OR 2.2, CI 1.2-3.8) and depression (OR 2.0, CI 1.6-2.5). For all regression analyses, odds of obesity were higher among adolescents who were non-Hispanic Black, Hispanic and low-income.

CONCLUSIONS

The increased prevalence of obesity in adolescents with ASD, learning disability, epilepsy or seizure disorder, and depression demonstrates the need to attend to their nutrition and physical activity needs. Future research should examine obesity risk factors among adolescents with specific neurodevelopmental and mental health conditions, as well as racial or ethnic minority and low-income populations, to properly tailor obesity prevention services.

A systematic scoping review of post-treatment lifestyle interventions for adult cancer survivors and family members

PURPOSE

Supporting the health of cancer survivors and their families from diagnosis through survivorship is a recognized priority. However, the extent to which health promotion efforts after the completion of acute treatment attend to the needs of adult survivors and families is unclear. This systematic scoping review summarizes the key characteristics of post-treatment lifestyle interventions aiming to improve diet, physical activity, and/or weight-related outcomes for adult cancer survivors and family members.

METHODS

We retrieved relevant studies from six databases using keywords. Studies were appraised for quality and limited to English-language, peer-reviewed journal articles published in or after 2005.

RESULTS

A total of 2,376 articles were obtained from the databases; 14 main articles (and 2 supplemental articles) representing 14 unique interventions were retained for our analysis. Most interventions were designed to modify aspects of participant diet and physical activity (in combination) or physical activity alone; cited social cognitive theory as a guiding or interpretative framework; included survivors of multiple cancer types; and were limited to one type of familial relationship (e.g., spouse/partner, sister). Where reported, intervention samples were predominantly White.

CONCLUSIONS

Few post-treatment interventions concurrently target cancer survivor and family members' positive lifestyle behaviors. Positive findings highlight the potential for expanding this area of intervention research and increasing understanding of individual and familial factors that contribute to successful post-treatment family interventions.

IMPLICATIONS FOR CANCER SURVIVORS

Promoting cancer survivors' healthy behaviors within the family context could capitalize on existing support networks and improve the health of family members in supportive roles.

A Systematic Review of Health Promotion Programs to Improve Nutrition for People with Intellectual Disability

PURPOSE OF REVIEW

To investigate the type and effectiveness of health promotion programs designed to improve nutrition for people with intellectual disability. This review also sought to highlight gaps in the evidence by mapping interventions to the socio-ecological model.

RECENT FINDINGS

To date, reviews on health promotion programs for people with intellectual disability have focused on individualised weight management interventions and behaviour change techniques. No reviews have focused solely on nutrition or considered a broader range of interventions and policies targeted beyond the individual. This review found that health promotion interventions to date were predominantly at the individual level of the socio-ecological model and of varying effectiveness. Of the non-individually focused interventions, those targeting the physical environment or considering multiple socio-ecological levels achieved the greatest improvements in nutrition outcomes. Nutrition and obesity prevention research and policy need to include intellectual disability as part of equity considerations, while intellectual disability policy needs to consider the broader food environment.

The Effect of Overdose Education and Naloxone Distribution: An Umbrella Review of Systematic Reviews

Background. Opioids contribute to more than 60 000 deaths annually in North America. While the expansion of overdose education and naloxone distribution (OEND) programs has been recommended in response to the opioid crisis, their effectiveness remains unclear. Objectives. To conduct an umbrella review of systematic reviews to provide a broad-based conceptual scheme of the effect and feasibility of OEND and to identify areas for possible optimization. Search Methods. We conducted the umbrella review of systematic reviews by searching PubMed, Embase, PsycINFO, Epistemonikos, the Cochrane Database of Systematic Reviews, and the reference lists of relevant articles. Briefly, an academic librarian used a 2-concept search, which included opioid subject headings and relevant keywords with a modified PubMed systematic review filter. Selection Criteria. Eligible systematic reviews described comprehensive search strategies and inclusion and exclusion criteria, evaluated the quality or risk of bias of included studies, were published in English or French, and reported data relevant to either the safety or effectiveness of OEND programs, or optimal strategies for the management of opioid overdose with naloxone in out-of-hospital settings. Data Collection and Analysis. Two reviewers independently extracted study characteristics and the quality of included reviews was assessed in duplicate with AMSTAR-2, a critical appraisal tool for systematic reviews. Review quality was rated critically low, low, moderate, or high based on 7 domains: protocol registration, literature search adequacy, exclusion criteria, risk of bias assessment, meta-analytical methods, result interpretation, and presence of publication bias. Summary tables were constructed, and confidence ratings were provided for each outcome by using a previously modified version of the Royal College of General Practitioners' clinical guidelines. Main Results. Six systematic reviews containing 87 unique studies were included. We found that OEND programs produce long-term knowledge improvement regarding opioid overdose, improve participants' attitudes toward naloxone, provide sufficient training for participants to safely and effectively manage overdoses, and effectively reduce opioid-related mortality. High-concentration intranasal naloxone (> 2 mg/mL) was as effective as intramuscular naloxone at the same dose, whereas lower-concentration intranasal naloxone was less effective. Evidence was limited for other naloxone formulations, as well as the need for hospital transport after overdose reversal. The preponderance of evidence pertained persons who use heroin. Author's Conclusions. Evidence suggests that OEND programs are effective for reducing opioid-related mortality; however, additional high-quality research is required to optimize program delivery. Public Health Implications. Community-based OEND programs should be implemented widely in high-risk populations.

Talking the same language on patient empowerment: Development and content validation of a taxonomy of self-management interventions for chronic conditions

CONTEXT

The literature on self-management interventions (SMIs) is growing exponentially, but it is characterized by heterogeneous reporting that limits comparability across studies and interventions. Building an SMI taxonomy is the first step towards creating a common language for stakeholders to drive research in this area and promote patient self-management and empowerment.

OBJECTIVE

To develop and validate the content of a comprehensive taxonomy of SMIs for long-term conditions that will help identify key characteristics and facilitate design, reporting and comparisons of SMIs.

METHODS

We employed a mixed-methods approach incorporating a literature review, an iterative consultation process and mapping of key domains, concepts and elements to develop an initial SMI taxonomy that was subsequently reviewed in a two-round online Delphi survey with a purposive sample of international experts.

RESULTS

The final SMI taxonomy has 132 components classified into four domains: intervention characteristics, expected patient/caregiver self-management behaviours, outcomes for measuring SMIs and target population characteristics. The two-round Delphi exercise involving 27 international experts demonstrated overall high agreement with the proposed items, with a mean score (on a scale of 1-9) per component of 8.0 (range 6.1-8.8) in round 1 and 8.1 (range 7.0-8.9) in round 2.

CONCLUSIONS

The SMI taxonomy contributes to building a common framework for the patient self-management field and can help implement and improve patient empowerment and facilitate comparative effectiveness research of SMIs. Patient or public contribution. Patients' representatives contributed as experts in the Delphi process and as partners of the consortium.

An exploration of lifestyle/obesity programmes for adults with intellectual disabilities through a realist lens: Impact of a 'context, mechanism and outcome' evaluation

BACKGROUND

Obesity is higher in people with intellectual disabilities.

AIMS

There are two aims of this explorative paper. Firstly, using a realist lens, to go beyond 'what works' and examine the 'context, mechanisms and outcomes' (CMO) of lifestyle/obesity programmes for this population. Second, using a logic model framework to inform how these programmes could be implemented within practice.

METHOD

We explored six-review papers and the individual lifestyle/obesity programmes that these papers reviewed using the CMO framework.

RESULTS

There were few theoretically underpinned, multi-component programmes that were effective in the short to long-term and many failed to explore the 'context and mechanisms'. We developed a logic model and engaged in two co-production workshops to refine this model.

DISCUSSION

Using a realist approach, programmes need to be underpinned by both individual and systems change theories, be multi-component, have a closer understanding of the interplay of the 'context and mechanisms', and co-designed using a logic model framework.

Healthcare practitioners' views and experiences of barriers and facilitators to weight management interventions for adults with intellectual disabilities

BACKGROUND

Obesity is common in adults with intellectual disabilities, yet little is known about how weight management interventions are provided for this population.

METHODS

Semi-structured interviews were held with 14 healthcare practitioners involved in weight management interventions in an English county. A study topic guide was developed to elicit practitioners' views and experiences of barriers and facilitators to weight management for adults with intellectual disabilities. Responses were analysed using thematic analysis.

RESULTS

Several barriers are involved in weight management for people with intellectual disabilities including communication challenges, general practitioners' lack of knowledge and awareness of weight management services, inconsistencies in caring support, resource constraints, wider external circumstances surrounding the individuals and motivational issues. Facilitators include reasonable adjustments to existing weight management services. However, there is a need for specialist weight management provision for people with intellectual disabilities.

CONCLUSIONS

This study provides suggestions for future research, policy and practice consideration.

A feasibility study using solution-focused coaching for health promotion in children and young people with Duchenne muscular dystrophy

PURPOSE

To evaluate the feasibility and acceptability of a coaching intervention (Solution-Focused Coaching in pediatric rehabilitation [SFC-Peds]) related to physical activity and diet in males with Duchenne muscular dystrophy.

METHODS

A pre-post design was employed. Participants had five coaching sessions over 8 weeks. The first session was face-to-face, followed by four virtual sessions. Feasibility criteria included recruitment rates, attrition, and intervention fidelity. The Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS) were employed to look at outcome trends. The acceptability was assessed using a survey.

RESULTS

Five males (11-19 years) participated. All feasibility criteria were met. Clinically significant increases were observed for GAS and COPM scores. Participants reported SFC-Peds to be acceptable. Broad barriers and facilitators to coaching success were identified.

CONCLUSIONS

A SFC-Peds intervention for health promotion is feasible and acceptable in children with DMD and their families. A rigorous efficacy study assessing SFC-Peds intervention is warranted.

An integrative review of multicomponent weight management interventions for adults with intellectual disabilities

BACKGROUND

Obesity is more prevalent in people with intellectual disabilities and increases the risk of developing serious medical conditions. UK guidance recommends multicomponent weight management interventions (MCIs), tailored for different population groups.

METHODS

An integrative review utilizing systematic review methodology was conducted to identify the types of MCIs delivered to adults with intellectual disabilities.

FINDINGS

Five studies were identified. All of the studies' MCIs were tailored for adults with intellectual disabilities. Tailoring included measures such as simplified communication tools, individualized sessions, and the presence of carers where appropriate.

CONCLUSIONS

Emerging evidence suggests ways in which MCIs can be tailored for adults with intellectual disabilities but, given the few studies identified, it is not possible to recommend how they can be routinely tailored. Further studies are justified for adults with intellectual disabilities at risk of obesity-related conditions.

The effects of multi-component weight management interventions on weight loss in adults with intellectual disabilities and obesity: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Adults with intellectual disabilities have been shown to experience higher rates of obesity in comparison to the general population.

AIM

To examine the effectiveness of randomised controlled trials of multi-component weight management interventions for adults with intellectual disabilities and overweight/obesity.

METHODS AND PROCEDURES

A systematic search of six electronic databases was conducted from database inception to January 2016. Risk of bias was assessed by the Cochrane Collaboration tool. Behavioural change techniques were defined by coding against the Coventry Aberdeen LOndon REfined (CALO-RE) taxonomy. Meta-analyses were conducted as Weighted Mean Difference (WMD) between intervention and control/comparator intervention.

OUTCOMES AND RESULTS

Six randomised controlled trials were included. The interventions did not adhere to clinical recommendations [the inclusion of an energy deficit diet (EDD), physical activity, and behaviour change techniques]. Meta-analysis revealed that current multi-component weight management interventions are not more effective than no treatment (WMD: -0.38kg; 95% CI -1.34kg to 0.58kg; p=0.44).

CONCLUSION AND IMPLICATIONS

There is a paucity of randomised controlled trials of multi-component weight management interventions for adults with intellectual disabilities and overweight/obesity. Current interventions, based on a health education approach are ineffective. Future long-term interventions that include an EDD and adhere to clinical recommendations on the management of obesity are warranted.

A systematic review of interventions to prevent suicidal behaviors and reduce suicidal ideation in older people

BACKGROUND

Older people have a high risk of suicide but research in this area has been largely neglected. Unlike for younger age groups, it remains unclear what strategies for prevention exist for older adults. This systematic review assesses the effectiveness of interventions to prevent suicidal behavior and reduce suicidal ideation in this age group.

METHODS

MEDLINE, EMBASE, PsycINFO, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for relevant publications from their dates of inception until 1 April 2016. Studies included in this review report effectiveness data about interventions delivered to older adults to prevent suicidal behavior (suicide, attempted suicide, and self-harm without suicidal intent) or reduce suicidal ideation. A narrative synthesis approach was used to analyze data and present findings.

RESULTS

Twenty one studies met the criteria for inclusion in the study. Most programs addressed risk predictors, specifically depression. Effective interventions were multifaceted primary care-based depression screening and management programs; treatment interventions (pharmacotherapy and psychotherapy); telephone counseling for vulnerable older adults; and community-based programs incorporating education, gatekeeper training, depression screening, group activities, and referral for treatment. Most of the studies were of low quality apart from the primary care-based randomized controlled trials.

CONCLUSIONS

Multifaceted interventions directed at primary care physicians and populations, and at-risk elderly individuals in the community may be effective at preventing suicidal behavior and reducing suicidal ideation in older adults. However, more high quality trials are needed to demonstrate successful interventions.

An evaluation of the effectiveness of annual health checks and quality of health care for adults with intellectual disability: an observational study using a primary care database

Background

People with intellectual disability (ID) have poorer health than the general population; however, there is a lack of comprehensive national data describing their health-care needs and utilisation. Annual health checks for adults with ID have been incentivised through primary care since 2009, but only half of those eligible for such a health check receive one. It is unclear what impact health checks have had on important health outcomes, such as emergency hospitalisation.

Objectives

To evaluate whether or not annual health checks for adults with ID have reduced emergency hospitalisation, and to describe health, health care and mortality for adults with ID.

Design

A retrospective matched cohort study using primary care data linked to national hospital admissions and mortality data sets.

Setting

A total of 451 English general practices contributing data to Clinical Practice Research Datalink (CPRD).

Participants

A total of 21,859 adults with ID compared with 152,846 age-, gender- and practice-matched controls without ID registered during 2009–13.

Interventions

None.

Main outcome measures

Emergency hospital admissions. Other outcomes – preventable admissions for ambulatory care sensitive conditions, and mortality.

Data sources

CPRD, Hospital Episodes Statistics and Office for National Statistics.

Results

Compared with the general population, adults with ID had higher levels of recorded comorbidity and were more likely to consult in primary care. However, they were less likely to have long doctor consultations, and had lower continuity of care. They had higher mortality rates [hazard ratio (HR) 3.6, 95% confidence interval (CI) 3.3 to 3.9], with 37.0% of deaths classified as being amenable to health-care intervention (HR 5.9, 95% CI 5.1 to 6.8). They were more likely to have emergency hospital admissions [incidence rate ratio (IRR) 2.82, 95% CI 2.66 to 2.98], with 33.7% deemed preventable compared with 17.3% in controls (IRR 5.62, 95% CI 5.14 to 6.13). Health checks for adults with ID had no effect on overall emergency admissions compared with controls (IRR 0.96, 95% CI 0.87 to 1.07), although there was a relative reduction in emergency admissions for ambulatory care-sensitive conditions (IRR 0.82, 95% CI 0.69 to 0.99). Practices with high health check participation also showed a relative fall in preventable emergency admissions for their patients with ID, compared with practices with minimal participation (IRR 0.73, 95% CI 0.57 to 0.95). There were large variations in the health check-related content that was recorded on electronic records.

Limitations

Patients with milder ID not known to health services were not identified. We could not comment on the quality of health checks.

Conclusions

Compared with the general population, adults with ID have more chronic diseases and greater primary and secondary care utilisation. With more than one-third of deaths potentially amenable to health-care interventions, improvements in access to, and quality of, health care are required. In primary care, better continuity of care and longer appointment times are important examples that we identified. Although annual health checks can also improve access, not every eligible adult with ID receives one, and health check content varies by practice. Health checks had no impact on overall emergency admissions, but they appeared influential in reducing preventable emergency admissions.

Future work

No formal cost-effectiveness analysis of annual health checks was performed, but this could be attempted in relation to our estimates of a reduction in preventable emergency admissions.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A cluster randomised control trial of a multi-component weight management programme for adults with intellectual disabilities and obesity

There have been few published controlled studies of multi-component weight management programmes that include an energy deficit diet (EDD), for adults with intellectual disabilities and obesity. The objective of this study was to conduct a single-blind, cluster randomised controlled trial comparing a multi-component weight management programme to a health education programme. Participants were randomised to either TAKE 5, which included an EDD or Waist Winners Too (WWToo), based on health education principles. Outcomes measured at baseline, 6 months (after a weight loss phase) and 12 months (after a 6-month weight maintenance phase), by a researcher blinded to treatment allocation, included: weight; BMI; waist circumference; physical activity; sedentary behaviour and health-related quality of life. The recruitment strategy was effective with fifty participants successfully recruited. Both programmes were acceptable to adults with intellectual disabilities, evidenced by high retention rates (90 %). Exploratory efficacy analysis revealed that at 12 months there was a trend for more participants in TAKE 5 (50·0 %) to achieve a clinically important weight loss of 5–10 %, in comparison to WWToo (20·8 %) (OR 3·76; 95 % CI 0·92, 15·30; 0·064). This study found that a multi-component weight management programme that included an EDD, is feasible and an acceptable approach to weight loss when tailored to meet the needs of adults with intellectual disabilities and obesity.

Screening for glucose intolerance and development of a lifestyle education programme for prevention of type 2 diabetes in a population with intellectual disabilities: the STOP Diabetes research project

Background

The prevalence of type 2 diabetes mellitus (T2DM) and of cardiovascular disease (CVD) is believed to be higher among people with intellectual disability (ID) than in the general population. However, research on prevalence and prevention in this population is limited.

Objectives

The objectives of this programme of work were to establish a programme of research that would significantly enhance the knowledge and understanding of impaired glucose regulation (IGR) and T2DM in people with ID; to test strategies for the early identification of IGR and T2DM in people with ID; and to develop a lifestyle education programme and educator training protocol to promote behaviour change in a population with ID and IGR (or at a high risk of T2DM/CVD).

Setting

Leicestershire, UK.

Participants

Adults with ID were recruited from community settings, including residential homes and family homes. Adults with mild to moderate ID who had an elevated body mass index (BMI) of ≥ 25 kg/m2and/or IGR were invited to take part in the education programme.

Main outcome measures

The primary outcome of the screening programme was the prevalence of screen-detected T2DM and IGR. The uptake, feasibility and acceptability of the intervention were assessed.

Data sources

Participants were recruited from general practices, specialist ID services and clinics, and through direct contact.

Results

A total of 930 people with ID were recruited to the screening programme: 58% were male, 80% were white and 68% were overweight or obese. The mean age of participants was 43.3 years (standard deviation 14.2 years). Bloods were obtained for 675 participants (73%). The prevalence of previously undiagnosed T2DM was 1.3% [95% confidence interval (CI) 0.5% to 2%] and of IGR was 5% (95% CI 4% to 7%). Abnormal IGR was more common in those of non-white ethnicity; those with a first-degree family history of diabetes; those with increasing weight, waist circumference, BMI, diastolic blood pressure or triglycerides; and those with lower high-density lipoprotein cholesterol. We developed a lifestyle educational programme for people with ID, informed by findings from qualitative stakeholder interviews (health-care professionals,n = 14; people with ID,n = 7) and evidence reviews. Subsequently, 11 people with ID (and carers) participated in pilot education sessions (two groups) and five people attended education for the feasibility stage (one group). We found that it was feasible to collect primary outcome measures on physical activity and sedentary behaviour using wrist-worn accelerometers. We found that the programme was relatively costly, meaning that large changes in activity or diet (or a reduction in programme costs) would be necessary for the programme to be cost-effective. We also developed a quality development process for assessing intervention fidelity.

Limitations

We were able to screen only around 30% of the population and involved only a small number in the piloting and feasibility work.

Conclusions

The results from this programme of work have significantly enhanced the existing knowledge and understanding of T2DM and IGR in people with ID. We have developed a lifestyle education programme and educator training protocol to promote behaviour change in this population.

Future work

Further work is needed to evaluate the STOP Diabetes intervention to identify cost-effective strategies for its implementation.

Trial registration

ClinicalTrials.gov NCT02513277.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme and will be published in full inHealth Research Programme Grants for Applied Research; Vol. 5, No. 11. See the NIHR Journals Library website for further project information.

Medication Adherence in Hematopoietic Stem Cell Transplantation: A Review of the Literature

Adherence to oral medications has been repeatedly shown to fall below the recommended 80% to 95% in pediatric and adult cancer populations. The purpose of this review is to report the state of the science about oral medication adherence during the acute phase of hematopoietic stem cell transplantation across the lifespan. An exhaustive search of the literature yielded 5 records for inclusion in the review. Two studies examined adherence in pediatrics, 2 in adults, and 1 included both pediatric and adult patients. Three studies were descriptive and 2 were interventional in design. The rate of adherence to oral medications ranged from 33% to 94.7%. Adherence decreased over time in all studies except in 1 pharmacist-led intervention study. Different methods were used to measure adherence, but most relied on self-report. Further research is needed in medication adherence in hematopoietic stem cell transplantation to better understand facilitators, barriers, and relationships to health outcomes.

Repertoires of responsibility for diabetes management by adults with intellectual disabilities and those who support them

The limited existing research on diabetes management and intellectual disabilities (ID) highlights the need for further exploration of the concept of responsibility. This study explored repertoires of responsibility in accounts of managing diabetes for adults with ID. Fourteen semi-structured interviews were conducted in the UK with seven adults with mild/moderate ID and type 1 or 2 diabetes and seven people who they nominated as supporting their diabetes management. A discursive psychological analysis found that interpretative repertoires relating to competence, independence and accountability were drawn on to construct multiple and sometimes conflicting versions of responsibility. Within these repertoires people with ID were positioned in conflicting ways; as competent, personally responsible, and entitled to independence and choice, but as also lacking competence, dependent on others and incapable of overall accountability. People with ID often took up empowering positions defending against an incompetent identity. Supporters built accounts which negotiated dilemmatic repertoires on the dual responsibilities of empowering adults with ID to self-manage and managing risk to support good and safe care. The implications of available discursive resources and the ways in which they are mobilised are considered.

Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria

BACKGROUND AND AIMS

Fatal outcome of opioid overdose, once detected, is preventable through timely administration of the antidote naloxone. Take-home naloxone provision directly to opioid users for emergency use has been implemented recently in more than 15 countries worldwide, albeit mainly as pilot schemes and without formal evaluation. This systematic review assesses the effectiveness of take-home naloxone, with two specific aims: (1) to study the impact of take-home naloxone distribution on overdose-related mortality; and (2) to assess the safety of take-home naloxone in terms of adverse events.

METHODS

PubMed, MEDLINE and PsychINFO were searched for English-language peer-reviewed publications (randomized or observational trials) using the Boolean search query: (opioid OR opiate) AND overdose AND prevention. Evidence was evaluated using the nine Bradford Hill criteria for causation, devised to assess a potential causal relationship between public health interventions and clinical outcomes when only observational data are available.

RESULTS

A total of 1397 records (1164 after removal of duplicates) were retrieved, with 22 observational studies meeting eligibility criteria. Due to variability in size and quality of the included studies, meta-analysis was dismissed in favour of narrative synthesis. From eligible studies, we found take-home naloxone met all nine Bradford Hill criteria. The additional five World Health Organization criteria were all either met partially (two) or fully (three). Even with take-home naloxone administration, fatal outcome was reported in one in 123 overdose cases (0.8%; 95% confidence interval = 0.4, 1.2).

CONCLUSIONS

Take-home naloxone programmes are found to reduce overdose mortality among programme participants and in the community and have a low rate of adverse events.

Systematic Review of Health Promotion Programs Focused on Behavioral Changes for People With Intellectual Disability

People with intellectual disability (ID) experience high rates of chronic health problems and poor overall health compared to people without disabilities. Recent attention to health risk behaviors such as poor diet, lack of physical activity, and underuse of health care has led to the development of several programs intended to reduce disparities in this population through health promotion programs. A review of the literature was conducted focusing on programs developed to target behavioral changes in the person with ID. Thirteen studies, evaluating 10 different health promotion programs, were found. Programs varied significantly in design, targeted health change, and demonstrated effectiveness. Components of each program are systematically reviewed and recommendations made for future programs based upon the current evidence.

A Call to Action: Setting the Research Agenda for Addressing Obesity and Weight-Related Topics in Children with Physical Disabilities

BACKGROUND

Pediatric obesity is a world-wide challenge. Children with physical disabilities are particularly at risk of obesity, which is worrisome because obesity can result in serious secondary conditions that decrease health status, reduce independence, and increase impact on healthcare systems. However, the determinants of obesity and the health promotion needs of children with physical disabilities are relatively unexplored compared with their typically developing peers.

METHODS

This white paper describes a Canadian multi-stakeholder workshop on the topic of obesity and health in children with physical disabilities and provides recommendations for future research in this understudied area.

RESULTS

Seventy-one knowledge gaps identified by attendees using a modified nominal group technique clustered into six themes: (1) early, sustained engagement of families; (2) rethinking determinants of obesity and health; (3) maximizing impact of research; (4) inclusive integrated interventions; (5) evidence-informed measurement and outcomes; and (6) reducing weight biases. Attendees worked together to develop research plans in more detail for three areas identified through consensus as high priority: "early, sustained engagement of families;" "rethinking determinants of obesity and health;" and "evidence informed measurement and outcomes."

CONCLUSIONS

Using the workshop described here as a call to action, Canadian researchers are now well positioned to work toward a greater understanding of weight-related topics in children with physical disabilities, with the aim of developing evidence-based and salient obesity prevention and treatment approaches.

Effectiveness of bystander naloxone administration and overdose education programs: a meta-analysis

The objective of this review was to assess the effectiveness of bystander naloxone administration and overdose education programs by synthesizing quantitative results reported in the research literature. Studies meeting predefined criteria were identified and reviewed, and their results were synthesized through meta-analysis. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for overdose recoveries for individuals who received naloxone dispensed by non-medical community members, and the standardized mean difference was calculated for test scores of non-medical volunteers who received training in overdose management versus the scores of untrained volunteers. Pooled data from four studies showed that naloxone administration by bystanders was associated with a significantly increased odds of recovery compared with no naloxone administration (OR = 8.58, 95% CI = 3.90 to 13.25). Data from five studies of overdose education indicated that average scores were significantly higher for trained participants than untrained participants for tests on naloxone administration, overdose recognition, and overdose response (standardized mean difference = 1.35, 95% CI = 0.92 to 1.77). Empirical evidence in the research literature suggests that bystander naloxone administration and overdose education programs are associated with increased odds of recovery and with improved knowledge of overdose recognition and management in non-clinical settings.

A systematic review of community opioid overdose prevention and naloxone distribution programs

Community-based opioid overdose prevention programs (OOPPs) that include the distribution of naloxone have increased in response to alarmingly high overdose rates in recent years. This systematic review describes the current state of the literature on OOPPs, with particular focus on the effectiveness of these programs. We used systematic search criteria to identify relevant articles, which we abstracted and assigned a quality assessment score. Nineteen articles evaluating OOPPs met the search criteria for this systematic review. Principal findings included participant demographics, the number of naloxone administrations, percentage of survival in overdose victims receiving naloxone, post-naloxone administration outcome measures, OOPP characteristics, changes in knowledge pertaining to overdose responses, and barriers to naloxone administration during overdose responses. The current evidence from nonrandomized studies suggests that bystanders (mostly opioid users) can and will use naloxone to reverse opioid overdoses when properly trained, and that this training can be done successfully through OOPPs.

Increasing the health literacy of learning disability and mental health nurses in physical care skills: a pre and post-test evaluation of a workshop on diabetes care

This paper presents the pre- and post-test results of the outcomes of a workshop designed to increase learning disability and mental health nurses' knowledge and skill to undertake interventions for service users at risk of, or with a diagnosis of, type 2 diabetes. Health literacy is also discussed as a way of explaining why such nurses may lack expertise in physical health care. Findings from the workshop show that learning disability and mental health nurses have the motivation to increase their health literacy (skills and knowledge) in diabetes care. The potential of such workshops, and how organisations looking forward to the future can build health literacy, is discussed.

Lifestyle interventions targeting changes in body weight and composition among youth with an intellectual disability: A systematic review

Over the past three decades, the potential effects of lifestyle interventions targeting changes in body weight and composition (weight, body mass index, fat mass, waist circumference) among adults with an intellectual disability (ID) have been examined in various systematic reviews. Nevertheless, since the middle of the 1980s, the potential effects of these interventions for youth with an ID remain an open question. The purpose of this article is to review the effects of lifestyle interventions targeting changes in body weight and composition among youth with an ID. This review will focus on changes in body weight and composition, healthy lifestyle, and secondary health conditions. A systematic review of English- and French-language studies, published between 1981 and 2013, was performed on Academic Search Complete, PsycARTICLES, Medline and Scopus. The nine studies included in this review focused mainly on: a sample with a wide age range (e.g., 7-22 years); males; overweight-obese youth having a mild-to-moderate ID with Down or Prader-Willi syndrome; physical activity interventions; cohort pre- and post-test designs with/without a control group; and changes in body weight and composition. Taken together, results from these studies suggest successful changes in weight, body mass index and fat mass. However, intervention effects on healthy lifestyle and secondary health conditions are scarce and inconclusive. Given the weaknesses of the reviewed studies, the present findings should be considered preliminary and indicative of the need for future research.

Obesity and overweight in intellectual and non-intellectually disabled children

BACKGROUND

Few studies have compared overweight and obesity in intellectually disabled (ID) and non-intellectually disabled (N-ID) children. This research compared the prevalence of overweight and obesity between a sample of 218 ID and 229 N-ID school pupils in Northern Ireland (NI). Comparison of the physical activity and dietary behaviour of the two groups of school pupils were also undertaken.

METHODS

Each pupil completed (assisted if required) a food intake and physical activity questionnaire. Following this body mass index (BMI) and waist circumference were measured and recorded.

RESULTS

Significantly more ID pupils (72, 33%) were overweight/obese compared with 55 (24%) of the N-ID pupils in accordance with their BMI. ID pupils also had significantly higher waist circumferences. Over a quarter of foods consumed by the pupils were fatty and sugary foods and close to 30% of these foods were eaten by the ID children. Pupils spent most of their time engaging in low levels of activity such as reading, watching TV, on games consoles and listening to music. Pupils with an ID spent fewer hours on moderate and high levels of activities compared with those children with N-ID.

CONCLUSIONS

Results of this study found higher levels of overweight and obesity in this sample than in international published research. Additionally significantly higher numbers of ID pupils were overweight and obese indicating the need for future research and public health to focus on this issue.

A multi-component universal intervention to improve diet and physical activity among adults with intellectual disabilities in community residences: a cluster randomised controlled trial

People with ID have an increased risk for unhealthy diets, physical inactivity and weight disturbances. The aim of the current study was to investigate the effectiveness of a novel and complex intervention to improve diet and physical activity, targeting both caregivers and residents, in community residences for people with ID. A three component intervention based on Social Cognitive Theory was developed, including: (1) appointment of a health ambassador in each community residence attending network meetings, (2) a study circle for caregivers, and (3) a health course for the residents. The intervention lasted for 12-16 months and allowed for some local tailoring. A cluster randomised controlled trial, randomised at residence level, was conducted to evaluate the effects of the intervention. Thirty community residences for people with mild or moderate ID in Stockholm County, Sweden, were included. A total of 130 participants, 74 women and 56 men aged 20-66 years, entered, and 129 participants completed the study. The primary outcome was physical activity, measured by pedometry. Secondary outcomes were BMI, waist circumference, dietary quality measured by digital photography, satisfaction with life assessed with a scale, and work routines assessed with a questionnaire. Outcomes were related to intervention fidelity. A positive intervention effect was found on physical activity, with an average increase of 1608 steps/day among participants in the intervention group (P=0.045). The effect size was 0.29 (Cohen's d). The type of residence was found to be an effect moderator. A positive intervention effect was found as well on work routines, with an average increase of 7.1 percentage points on a self-assessment scale among residences in the intervention group (P=0.016). No significant effects were found on BMI, waist circumference, dietary quality, or satisfaction with life. In conclusion, this innovative intervention was effective in improving physical activity and work routines. It is likely that even greater effects could be achieved by improvements in implementation strategies, leading to higher fidelity.

Weight management interventions in adults with intellectual disabilities and obesity: a systematic review of the evidence

To evaluate the clinical effectiveness of weight management interventions in adults with intellectual disabilities (ID) and obesity using recommendations from current clinical guidelines for the first line management of obesity in adults. Full papers on lifestyle modification interventions published between 1982 to 2011 were sought by searching the Medline, Embase, PsycINFO and CINAHL databases. Studies were evaluated based on (1) intervention components, (2) methodology, (3) attrition rate (4) reported weight loss and (5) duration of follow up. Twenty two studies met the inclusion criteria. The interventions were classified according to inclusion of the following components: behaviour change alone, behaviour change plus physical activity, dietary advice or physical activity alone, dietary plus physical activity advice and multi-component (all three components). The majority of the studies had the same methodological limitations: no sample size justification, small heterogeneous samples, no information on randomisation methodologies. Eight studies were classified as multi-component interventions, of which one study used a 600 kilocalorie (2510 kilojoule) daily energy deficit diet. Study durations were mostly below the duration recommended in clinical guidelines and varied widely. No study included an exercise program promoting 225-300 minutes or more of moderate intensity physical activity per week but the majority of the studies used the same behaviour change techniques. Three studies reported clinically significant weight loss (≥ 5%) at six months post intervention. Current data indicate weight management interventions in those with ID differ from recommended practice and further studies to examine the effectiveness of multi-component weight management interventions for adults with ID and obesity are justified.

Piloting a manualised weight management programme (Shape Up-LD) for overweight and obese persons with mild-moderate learning disabilities: study protocol for a pilot randomised controlled trial

Background

National obesity rates have dramatically risen over the last decade. Being obese significantly reduces life expectancy, increases the risk of a range of diseases, and compromises quality of life. Costs to both the National Health Service and society are high. An increased prevalence of obesity in people with learning disabilities has been demonstrated. The consequences of obesity are particularly relevant to people with learning disabilities who are already confronted by health and social inequalities. In order to provide healthcare for all, and ensure equality of treatment for people with learning disabilities, services must be developed specifically with this population in mind. The aim of this project is to pilot the evaluation of a manualised weight management programme for overweight and obese persons with mild-moderate learning disabilities (Shape Up-LD).

Methods/Design

An individually randomised, controlled pilot trial in 60 overweight and obese (body mass index ≥ 25) adults (age ≥ 18) with mild-moderate learning disabilities and their carers will be carried out, comparing “Shape Up-LD” with usual care. The manualised Shape Up-LD intervention will involve 12 weekly sessions, which include healthy eating messages, advice on physical activity and use of behaviour change techniques to help people manage their weight. Assessments of participants will be conducted at baseline, 12 weeks and 6 months. Service users and their carers and service providers will also give their perspectives on the experience of Shape Up-LD in qualitative interviews at 12 weeks. Feasibility outcomes will include recruitment rates, loss to follow-up, compliance rates, completion rates, collection of information for a cost-effectiveness analysis and an estimation of the treatment effect on weight.

Discussion

The findings from this study will inform our preparation for a definitive randomised controlled trial to test the efficacy of the programme with respect to weight loss and maintenance in this population. Weight loss through Shape Up-LD could lead to improvements in health and quality of life. Costs to the National Health Service might be reduced through decreased overall service use because of improved health. The programme would also ensure a more equitable service for overweight service users with learning disabilities and fill the current gap in weight management services for this population.

Trial registration

International Standard Randomised Controlled Trial No ISRCTN39605930

Carers' perspectives of a weight loss intervention for adults with intellectual disabilities and obesity: a qualitative study

BACKGROUND

To date, no studies have explored the role of carers in supporting adults with intellectual disabilities (ID) and obesity during a weight loss intervention. The present study explored perceptions of carers supporting adults with ID, as they participated in a 6-month multi-component weight loss intervention (TAKE 5).

METHODS

Semi-structured interviews were used to explore the experiences of 24 carers. The transcripts were analysed qualitatively using thematic analysis.

RESULTS

Three themes emerged from the analysis: carers' perceptions of participants' health; barriers and facilitators to weight loss; and carers' perceptions of the weight loss intervention. Data analysis showed similarities between the experiences reported by the carers who supported participants who lost weight and participants who did not. Lack of sufficient support from people from the internal and external environment of individuals with ID and poor communication among carers, were identified as being barriers to change. The need for accessible resources tailored to aid weight loss among adults with ID was also highlighted.

CONCLUSION

This study identified specific facilitators and barriers experienced by carers during the process of supporting obese adults with ID to lose weight. Future research could utilise these findings to inform appropriate and effective weight management interventions for individuals with ID.

Identifying risk and preventing progression to Type 2 diabetes in vulnerable and disadvantaged adults: a pragmatic review

AIM

To identify effective approaches to recognize diabetes risk and prevent progression to Type 2 diabetes in vulnerable groups, whose diabetes risk may be difficult to identify or manage.

METHODS

UK-based interventions that assess diabetes risk and/or target known risk factors were identified through four main sources: submissions to two calls for evidence by the National Institute for Health and Clinical Excellence; local practice examples collected via a targeted email questionnaire; selected electronic databases; and a focused search of relevant websites. No restriction was placed on the study type or evaluation methods used. Key themes and sub-themes on outcomes, as well as facilitators and barriers to successful delivery, are reported.

RESULTS

Twenty-four interventions met all inclusion criteria: 15 included a risk identification element and 14 included preventative activities. A range of risk identification tools were used to improve diagnosis of unmet diabetes-related health needs and raise awareness of diabetes risk factors. All preventative interventions focused on lifestyle change. No interventions monitored blood glucose as an outcome and only one reported improvements in baseline risk scores. Facilitators included tailored and flexible programme design, outreach delivery in familiar locations and effective inter-agency working. Barriers included literacy and language difficulties, transient participant populations, low prioritization of diabetes prevention and cost.

CONCLUSIONS

It is possible to engage successfully with high-risk adults in vulnerable groups to achieve positive health outcomes relevant to the prevention of diabetes. However, more robust evidence on longer-term outcomes is required to ensure that programmes are targeted and delivered appropriately.