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chronic pain >6wks /obesity and immobility

By Sandy Keefe

When it comes to weight management for adults with disabilities, health care providers have our work cut out for us. That’s because obesity is more common in adults with sensory, physical and mental health conditions than it is in the nondisabled population.

Several reasons account for this. Low muscle tone, spasticity, pain, limited joint motion, decreased stamina, cognitive delays, chronic disease and secondary disabilities may serve as roadblocks to appropriate physical activity.

Metabolic or endocrine disorders also affect weight management in many people with disabilities. People with Down syndrome, for example, have a basic metabolic rate that is 10% to 15% lower than people without Down syndrome. Therefore, they burn fewer calories at rest. Furthermore, some medications, such as risperdal and SSRIs, increase appetite and can lead to significant weight gain.

Unfortunately, people with disabilities often enter young adulthood with poor health habits and weight issues. Health care providers have offered little help in this area. In many cases, they haven’t focused on weight issues because they need to address other more pressing medical conditions.



A recent study by Beth Israel Deaconess Medical Center confirms this. While most adults with disabilities are as likely to attempt weight loss as those without disabilities, too often their health care providers don’t offer the exercise counseling that would have enhanced their ability to effectively manage their weight. We need to change that paradigm and make weight management an important priority among adults with disabilities.

Moderate Physical Activity
Physical activity is a cornerstone of good weight management. A report from the U.S. Surgeon General outlines several salient points about physical activity for people with disabilities. Physical activity doesn't need to be strenuous for people to achieve health benefits, the document affirms. In fact, people with disabilities can attain health benefits with a moderate amount of physical activity. Moderation, therefore, may be an easier “sell” than vigorous exercise.



People with disabilities can perform a moderate amount of physical activity in several ways. They should choose enjoyable pursuits that fit well into their lifestyles. Some examples include:

Raking leaves for 30 minutes;
Doing water aerobics for 30 minutes;
Gardening for 30 to 45 minutes;
Swimming laps for 20 minutes;
Washing windows or floors for 45 to 60 minutes.
When counseling adults with disabilities, we should creatively present information about physical activity in a way that engages and stimulates the patient's interest. If the person has a high cognitive level and good receptive language skills, a verbal presentation, supplemented with well-written teaching materials, may be most effective.



For adults with significant cognitive deficits or limited reading skills, consider using simply illustrated individualized teaching materials with clip art, magazine cutouts or photographs that demonstrate appropriate physical activities.



Sticking with Exercise
The Centers for Disease Control and Prevention states that regular physical activity can improve stamina and muscle strength in people with chronic, disabling conditions. It also can improve psychological well-being and quality of life by increasing a person’s ability to perform activities of daily life. The CDC recommends, however, that people with disabilities first consult a health care provider before beginning a program of physical activity.

But to succeed at regular exercise, this population needs peer or family support. In fact, adults with disabilities are much more likely to engage in exercise and sports when family members or friends participate. Bowling leagues, camps for people with special needs, adult day programs and adapted sports programs are excellent means of physical activity in a social setting.



Square dance clubs for young people with disabilities, therapeutic horseback riding programs, senior centers and national organizations, such as Special Olympics, also offer peer-oriented programs that promote exercise. By keeping a file about these programs in the office, we can provide a valuable resource for support services.



The Basics of Nutrition
With moderate physical activity, a balanced diet with well controlled portions is central to good weight management. Joan E. Guthrie Medlen in her authoritative text, The Down Syndrome Nutrition Handbook: A Guide to Promoting Healthy Lifestyles, outlines basic nutritional information for people with cognitive disabilities. The book contains a wealth of nutritional information broken down by age group.



While the content focuses on people with Down syndrome, we can effectively use its concepts and learning activities with people who have other cognitive impairments. Medlen uses simple line drawings that are clutter-free and offer good visual contrast, making them useful for patients with visual impairments and visual-motor issues. She presents guidelines clearly, avoiding unnecessary words and ambiguous phrases. Medlen also includes extensive lists and well-designed handouts on key nutritional topics, including:



The food guide pyramid;
Balanced meals and snacks;
Serving sizes and portion control;
Using food and activity records;
Setting dietary goals.
In addition, she provides various illustrated and interactive teaching materials designed for people with varying cognitive levels. Familiar with the disabled adult’s learning style and competencies, we can select options that address knowledge deficits.



The section on grocery shopping, for example, outlines options for poor readers (one item per card with photos, words or both) as well as symbol systems for nonreaders. Rather than writing detailed lists, Medlen suggests pasting labels on the list so the shopper can match the labels with the products on the store shelves. In tandem with a dietitian familiar with disability issues, we also can recommend a practical curriculum that family and caregivers can use to teach adults with disabilities.



For example, this population may require a diet lower in calories than their nondisabled peers, unless they can expend enough energy in physical activity. Dietary adjustments also may be required if secondary disabilities, such as congestive heart failure or pulmonary disorders, limit the calories burned through exercise. Coexisting diseases, notably diabetes or coronary artery disease, may have significant dietary implications. Depending on the knowledge level of the person and caregivers, we may decide to make a formal referral to a dietitian.



Importance of Snacks
Information from Tufts University affirms that adults, in general, eat more snacks during a typical day, and that these snacks have a higher calorie count than they used to. Given these trends, it’s easy to see that sensible snack planning is a key component of successful weight management in adults with disabilities.

In general, it makes sense to eat every 3 to 5 hours to maintain a good blood glucose level and avoid feeling ravenous. Diane Voyatzis, a nutritionist from Tufts University, presents a simple, yet effective, method for choosing balanced snacks in a free online publication. She recommends choosing snacks that contain at least two food groups, to ensure a balance of carbohydrate, some fat and some protein. Many people with disabilities, of course, are on special diets that limit sodium, fat, cholesterol, sugar or other nutrients. Knowledgeable about coexisting medical conditions, we can point patients in the right direction to get dietary counseling.

Putting It Together
While health programs for nondisabled adults have proliferated across the country over the past decade, very little work has gone into developing health promotion programs for adults with disabilities. Although many community programs make sincere efforts to accommodate those with special needs, many people with disabilities need specialized programs that address limitations caused by both primary and secondary disabilities. If such programs aren't available in a particular community, we can play a more active role in coordinating a weight management program. In particular, we can spearhead a coordinated plan that involves key people, including other health care providers, case managers, parents or roommates, in the weight management program for adults with disabilities.

If the person has mild or moderate cognitive impairments, we may simply make a few phone calls to obtain information that can be incorporated into the weight management plan. The person’s primary care provider, for example, may prescribe certain dietary restrictions, while the person’s conservator may request that religion-based dietary strictures be incorporated into the plan.



If the adult lives in a group home, we should know who plans the menus, cooks the food and dishes out the servings. It's important that the "chef" understand the adult's dietary needs and restrictions, so the person can be a source of support in the weight management plan. Portion control is easier when food is on its way to the table, rather than on the table.



If the person has significant impairments and requires a good deal of direct care, it may be appropriate to involve a dietitian to work out a successful weight management plan. Whatever the circumstance, clear communication and regular monitoring will ensure that everyone understands and supports weight management strategies for adults with disabilities.



Sandy Keefe is a nurse and freelance writer. She is also the health care manager at Camp Costanoan, a camp for people with special needs in Cupertino, Calif

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