Weight Loss Treatment for People Weight Loss Treatment for People with Disabilitieswith Disabilities

Parent Supported Weight Reduction in Adolescents and Parent Supported Weight Reduction in Adolescents and Young Adults with Down SyndromeYoung Adults with Down Syndrome

Richard K. FlemingRichard K. FlemingE. K. Shriver Center at E. K. Shriver Center at UMASS Medical SchoolUMASS Medical School

Psychiatry Research DayPsychiatry Research DayUMASS Medical SchoolUMASS Medical School

Oct. 21, 2009Oct. 21, 2009

“An epidemic of childhood obesity and overweight, to which social, economic, and human behaviors have contributed, threatens long-term medical, psychosocial, and financial consequences beyond US society's current capacity to respond.

How the epidemic is controlled will be about the art and practice of social and behavioral change as well as the art and science of medicine.”

(Lavisso-Mourey, 2007, JAMA, 298, p. 920)

Overweight/Obesity in Down Syndrome Overweight/Obesity in Down Syndrome (DS) and Intellectual Disabilities (ID)(DS) and Intellectual Disabilities (ID)

Prevalence estimates of obesity Prevalence estimates of obesity (BMI ≥ (BMI ≥ 30kg/m30kg/m22) ) in adults with DS in five small in adults with DS in five small studiesstudies11

– Males: Males: 25%-71%25%-71%– Females:Females: 42%-56%42%-56%

Lower Resting Metabolic RateLower Resting Metabolic Rate22

Healthy People 2010, Ch. 6: Promote Healthy People 2010, Ch. 6: Promote the health of people with disabilitiesthe health of people with disabilities

1. Bandini, L.G. Obesity In Nehring W.M. (Ed). Health Promotion for 1. Bandini, L.G. Obesity In Nehring W.M. (Ed). Health Promotion for persons with intellectual and developmental disabilities. The persons with intellectual and developmental disabilities. The state of scientific evidence. American Association on Mental state of scientific evidence. American Association on Mental Retardation, 2005, pp. 30-31,Washington D.C.Retardation, 2005, pp. 30-31,Washington D.C.

2. Luke, A., Roizen, N.J., Sutton, M., Schoeller, D.A. Energy 2. Luke, A., Roizen, N.J., Sutton, M., Schoeller, D.A. Energy expenditure in children with Down syndrome: Correcting expenditure in children with Down syndrome: Correcting metabolic rate for movement. metabolic rate for movement. Journal of Pediatrics,Journal of Pediatrics, Vol. 125, Vol. 125, 1994, 829.1994, 829.

Current RCT: Parent Supported Weight Reduction Current RCT: Parent Supported Weight Reduction in Down Syndromein Down Syndrome

NIDDK, R03DK070627-01A2, Fleming (PI)

Research TeamResearch Team(alphabetical)(alphabetical)

Linda Bandini, PhD, RDLinda Bandini, PhD, RD Carol Curtin, MSWCarol Curtin, MSW James Gleason, MS, PTJames Gleason, MS, PT Melissa Maslin, MS Melissa Maslin, MS Aviva Must, PhD, Sarah Anderson, PhD and Keith Aviva Must, PhD, Sarah Anderson, PhD and Keith

Lividini (Tufts)Lividini (Tufts) Renee Scampini, MS, RDRenee Scampini, MS, RD Elise Stokes, MS, BCBAElise Stokes, MS, BCBA

Parent-Supported Weight Reduction in Down Parent-Supported Weight Reduction in Down Syndrome (PSWR)Syndrome (PSWR)

ParticipantsParticipants: : Adolescents/young adults w/Down syndrome, 13-26 Adolescents/young adults w/Down syndrome, 13-26 yrs.yrs.

Conditions/groupsConditions/groups::– Treatment = 16 sessions over 6 mos.; follow-up at 12 monthsTreatment = 16 sessions over 6 mos.; follow-up at 12 months– Nutrition/Activity Education (NAE)Nutrition/Activity Education (NAE)– Parent-Supported Weight Reduction (PSWR)Parent-Supported Weight Reduction (PSWR) (= NAE + (= NAE +

Behavioral Intervention)Behavioral Intervention)– Random assignment, “waves” with up to 5 participants per Random assignment, “waves” with up to 5 participants per

group.group.

MeasurementMeasurement::– BL BL → 10 wks. → 6 mos. → 12 mos.→ 10 wks. → 6 mos. → 12 mos.– Weight /height, BMIWeight /height, BMI– Bioelectrical impedance: % body fatBioelectrical impedance: % body fat– Accelerometry (physical activity): 7-day durationsAccelerometry (physical activity): 7-day durations– 3-day food record 3-day food record → categorical analysis→ categorical analysis– Knowledge pre-/post-testKnowledge pre-/post-test– Child and parent satisfactionChild and parent satisfaction

Nutrition & Activity Education (NAE)Nutrition & Activity Education (NAE) Prior to sessions:Prior to sessions:

– Individualized Healthy Eating PlanIndividualized Healthy Eating Plan– Individualized Physical Activity PlanIndividualized Physical Activity Plan

Session features:Session features: Lecture (brief, simple), Lecture (brief, simple), instructions, demonstrations, games, practice instructions, demonstrations, games, practice with feedback, reinforcement, “incentives”with feedback, reinforcement, “incentives”

Sessions:Sessions:

1.1. Good Nutrition & Healthy EatingGood Nutrition & Healthy Eating2.2. Stay Fit, Stay Strong, Keep Moving All Day Stay Fit, Stay Strong, Keep Moving All Day

LongLong3.3. Fruits, Vegetables & Low-Fat DairyFruits, Vegetables & Low-Fat Dairy4.4. Physical Activity: Warm-Ups & StretchingPhysical Activity: Warm-Ups & Stretching5.5. Serving SizesServing Sizes6.6. Why is Physical Activity Good for Me?Why is Physical Activity Good for Me?7.7. Meal PlanningMeal Planning8.8. More Meals!More Meals!9.9. Activities at Home and in the CommunityActivities at Home and in the Community10.10. Snack Attack: Healthy Snacking, Mindful Snack Attack: Healthy Snacking, Mindful

EatingEating11.11. Strength-Building ActivitiesStrength-Building Activities12.12. Measure Food, Measure Success!Measure Food, Measure Success!13.13. Physical Activity ReviewPhysical Activity Review14.14. Eating Around Town: Eating OutEating Around Town: Eating Out15.15. Favorite Physical ActivitiesFavorite Physical Activities16.16. Potluck Dinner CelebrationPotluck Dinner Celebration

Parent Supported Weight Reduction Parent Supported Weight Reduction (PSWR)(PSWR)

MonitoringMonitoring– Daily self-recording of Daily self-recording of

selected diet and physical selected diet and physical activity behaviorsactivity behaviors

Goal settingGoal setting – Weekly high priority goalsWeekly high priority goals– Report to groupReport to group

Feedback & ReinforcementFeedback & Reinforcement– Feedback from groupFeedback from group– Individual reinforcement Individual reinforcement

w/adolescentw/adolescent Environmental arrangements Environmental arrangements

(stimulus control)(stimulus control)– AssessmentAssessment– Altered arrangementsAltered arrangements

Behavioral contractingBehavioral contracting– Weekly, negotiatedWeekly, negotiated

Trial DesignTrial Design

10 wks 12 mos6 mos0 wks

Intensive Period Taper Period Follow-up

Wave NAE(N)

PSWR(N)

Baseline 10 wk 6 mo

I 3 3 10/07 12/07 4/08

II 4 3 3/08 5/08 9/08

III 3 5 3/09 5/09 9/09

Baseline Characteristics of ParticipantsBaseline Characteristics of Participants

* Reported as mean (SD)** Reported as number (%)

Characteristic NAE (n = 10) PSWR (n = 11)

Age (yr)* 20.5 (4.1) 20.5 (2.4)

Sex* Male Female

1 (10)9 (90)

3 (27.3)8 (72.7)

Ethnicity/race** White Hispanic

10 (100)0

10 (90.9)1 (1.1)

IQ (K-BIT)* VerbalNon-verbal Composite

54.1 (8.6) 53.8 (12.6) 49.1 (9.3)

51.6 (12.0) 46.0 (5.6) 44.8 (6.3)

Weight (kg)* Male Female

100.674.7 (15.3)

96.1 (12.9) 72.9 (10.0)

Height (cm)* Male Female

154.4144.3 (6.4)

154.9 (4.8) 145.9 (3.5)

Body mass index (BMI)*

36.5 (6.9) 35.8 (5.4)

Parent BMI 30** Neither Either or Both

5 (50)5 (50)

6 (54.5)5 (45.5)

Max Parent Education Level**

High/Trade SchoolSome CollegeBA DegreeAdvanced Degree

1 (10)1 (10)2 (20)6 (60)

4 (36.4)2 (18.2)2 (18.2)3 (27.3)

Results of Paired and Independent Samples Results of Paired and Independent Samples T-testsT-tests

10 week 10 week ΔΔ 6 month 6 month ΔΔ

NAENAE(Education only)(Education only)

-0.58 (1.1)-0.58 (1.1) 0.82 (2.8)0.82 (2.8)

PSWRPSWR(Behavioral)(Behavioral)

-1.98 (2.0)**-1.98 (2.0)** -2.97 (4.0)*-2.97 (4.0)*

Regression Model* ResultsRegression Model* Results

Weight Change (PSWR vs NAE)

B SE p value

10 weeks PSWR NAE

-0.98 0.85 0.27 referent

6 months PSWR NAE

-3.38 1.75 0.07Referent

* adjusted for wave

Discussion

NAE were PSWR interventions were well suited to the population and well received.

Both were replicated successfully at a new site and with a new (trained) treatment team

Small pilot, but with some very suggestive findings – The PSWR group lost marginally significantly more

weight than NAE alone

Small numbers precluded inclusion of a no-treatment group

ConclusionsConclusions

PSWR represents a promising approach to weight loss PSWR represents a promising approach to weight loss in adolescents with Down syndromein adolescents with Down syndrome

A full scale trial on a larger sample appears to be A full scale trial on a larger sample appears to be warrantedwarranted