British Journal of Learning Disabilities Vol. 22 (1994) - 97

Weight Status of a Group of -

Adults with Learning D isa bi I i t ies

Tina Wood, Senior Dietitian (Learning Disabilities), St Richard’s Hospital, Chichester.

The weight status of a group of 35 adults with learning disabilities was studied. The group with varying degrees of learning disability, all lived in staffed health authority accommodation. Distribution of Body Mass Index (weight for height) was found to be polarised with greater numbers of both obese and underweight people than would be expected in the general British population. Weight status was clearly linked with level of dependency - the most depen- dent clients being the most underweight.

Factors associated with low weight included assisted feeding, use of soft diets, food regurgitation and immo- bility. Obesity was linked with drug use - notably anti-psychotics and sodium valproate.

Introduction People with learning disabilities generally have more

than their fair share of nutritional problems - from obesity to underweight, constipation and various prob- lems with eating itself, such as, assisted feeding, soft diets, swallowing difficulties and regurgitation.

The provision of dietetic services to these clients is a relatively new concept but an area which is rapidly expanding. One such post was funded in Chichester as a short-term project to provide nutritional assessments for a small group of residents with learning disabilities.

Thirty-five residents with varying degrees of learning disability lived either in two 4-bedded self catering com- munity houses or in two 14-bedded villas within the main psychiatric hospital grounds. These were provided with food from the main hospital kitchen. All units were permanently staffed.

Assessments were conducted with the help of relevant keyworkers and included:

weight and height

bowel habits and laxative use

eating ability

behaviours associated with food, e.g. regurgitation

dietary intake

Data concerning weight distribution are presented here.

Weight, Height and Body Mass Index (BMI) Body weight together with height is one of the sim-

plest indicators of nutritional status. Calculation of Body Mass Index (BMI) allows weight

to be related to height such that a BMI of less than 20 has been shown to indicate poor nutritional status and is regarded as a long-term hazard to health (Garrow, 1989):

weight (kg) height2 (m2)

-~ - BMI

. , 30+ = ob&ity 25-29.9 = overweight 20-24.9 = desirable <20 = underweight

Distribution of BMI is given in Table 1. There is some evidence that populations of people

with learning disabilities may show weight (or BMI) dis- tributions polarised at opposite ends of the spectrum as shown here. One Finnish study (Simila & Nishanen, 1991) found 29.5% of clients were underweight and 16.9% were obese, compared here with figures of 35% and 14%. Our own unpublished data for 733 institution- alised clients show 22% of clients as underweight and; 8% as obese. (Wood, 1990).

Table 1 Distribution of body mass index

Underweight Desirable Overweight Obese

No. of 12 9 9 5 Residents

%of Total 35% 26% 26% 14%

’Normal’ 9% 50.5% 30.5% 1 0% Population

(opcs 1991)

98 . British Journal of Learning Disabilities Vol. 22 (1994)

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W

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$ 4

E 3

0

U 0 a w 2

3 2

P 1

0 <17 17-19.9 20-24.9 25-29.9 30-39.9 40+

BODY MASS INDEX

I soft a cut up fs9 normal

Underweight Within this study group, 35% were considered

underweight, four times the National average of 9%. Several potential risk factors for low weight could be identified. It seems clear that low weight is largely a problem of the most dependent residents and is often associated with quite complex feeding problems.

Assisted feeding Four residents (11%) needed to be fed and all four had

BMIs below 20. Assisted eating is often associated with low weight and all clients should be encouraged to maxi- mise independence in feeding. (Gay & Ekvall, 1975).

Food consistency (Figure 1) Seven clients (20%) were described as requiring soft

foods and 17 (48.6%) required food to be cut up. These residents were at greater risk of low BMI than residents taking normal diets; ten of them (42%) had BMIs below 20.

The use of pureed diets has been shown to be a cause of poor nutritional status and should be avoided if at all possible. (Kenedy, 1990; Solsey, 1983; Palmer et al., 1975.)

Food regurgitation (Figure 2) Seven clients (20%) were said to regurgitate significant

quantities of food regularly and a further six (17%)

Figure 2 Body mass index and regurgitation

8 v)

W 5 7

$ 6

a 5 W

L L 0 a 4 w m 3

2 2

1

0

5

<17 17-19.9 20-24.9 25-29.9 30-39.9 40+ BODY MASS INDEX

I REGURG. a NOREGURG.

showed this behaviour on occasions. Regurgitation of food can cause weight loss, malnutrition, dehydration, acute gastro-intestinal upsets, lowered resistance to infection and even death (Davis & Cuvo, 1980). Indeed, 70% of residents in this study who regurgitated food were underweight.

Immobility/physical disability (Figure 3) Eleven clients were either immobile or only partially

mobile (30.5%) and, of these, 83% were underweight. To some extent immobile clients may be expected to show a low weight for height due to muscle wasting. How- ever, it would be anticipated that fat stores, as estimated by trisceps skinfold thickness, would be normal. The majority of clients with low BMIs also showed low tris- ceps skinfold thicknesses, indicating low levels of both muscle and fat. Low BMIs in immobile clients could not, therefore, be totally explained by low muscle mass.

Using the Chi squared test, immobility (Chi squared = 28, n = 35, df = 2) and food regurgitation (Chi squared = 15, n = 35, df = 1) were found to be significantly associ- ated with low BMI among these residents ( p = O . O O l ) . They may therefore be taken as potential risk factors for poor nutritional status in this client group. It is clear that low weight among people with learning disabilities is closely linked with feeding problems. There is a strong case for approaching these problems with a multi-disci- plinary team approach.

Overweight Within this study group, 40% of residents were found

to be overweight and 14% of these were obese. This com- pares with figures of 40.5% and 10% for the British popu- lation as a whole. People who were independently mobile and able to feed themselves were most at risk of obesity. Specific syndromes, for example Downs Syn- drome, the use of drug therapy and lack of exercise have been suggested as causes of obesity among people with learning disabilities. In the present study, only two resi- dents had Downs Syndrome. One was within a desirable weight range and the other was overweight. However, a recent study of people with Downs Syndrome living in the community found an exceptionally high preva-

FicIure 3 Body mass index and mobilitv

117 17-19.9 20-24.9 25-29.9 30-39.9 40+

BODY MASS INDEX MOBILE PT. MOBILE IMMOBILE

British Journal of Learning Disabilities Vol. 22 (1 994) - 99

lence of overweight - 70.58% of males and 95.83% of females (Bell & Bhate, 1992).

When medications were considered, eighteen resi- dents (52%) were found to be regularly taking medi- cations known to cause weight gain, notably anti- psychotic drugs and/or sodium valproate. Of these resi- dents, ten (55%) were overweight and just two (11%) were underweight. Thus residents using these medi- cations showed a higher weight distribution than the group as a whole.

No relationship was found between reported level of activity and prevalence of overweight.

Conclusion Measurement of weight, height and BMI gives a quick

and easy assessment of nutritional status. The polarised BMI distribution found in this population of people with learning disabilities reflects the extent of nutritional problems. Various feeding difficulties among the most highly dependent clients are significant. Several factors associated with low weight were identified

assisted feeding soft diets food regurgitation immobility. Use of certain drugs known to induce weight gain was

the main cause of overweight identified among more independent clients.

Correspondence

Barnfield, St Richard's Hospital, Chichester, Sussex. Any correspondence should be directed to Tina Wood,

References

Bell, A. J. and Bhate, M. S. (1992) Prevalence of overweight and obesity in Down's syndrome and other mentally handicapped adults living in the community. Journal of Intellectual Disability Research 36, 35944.

Davis, P. K. and Cuvo, A. J. (1980) Chronic vomiting and rumination in intellectually normal and retarded individuals. Behaviour Research of Smere Developmental Disabilities 1, 31-59.

Garrow, J. (1988) Obesity and Related Diseases. Edinburgh: Churchill Livingstone.

Gay, A. L. and Ekvall, S. W. (1975) Diets of handicapped children: Physical, psychological & socioeconomic correlation. American Journal of Mental DeJlciency 80, 149-57.

Kenedy, M. (1990) Solving the nutritional problems of people with a mental handicap. BDA Advisor. Birmingham: British Dietetic Association.

OPCS (1991) Height and Weights of Adults in Great Britain. London: OPCS.

Palmer, S., Thompson, R. J. and Leischeid, T. R. (1975) Applied behavioural analysis in the treatment of Childhood Feeding Problems. Developments in Medical Child Neurology 17, 333-9.

overweight cases among the mentally handicapped. Journal of Mental Deficiency Research 35, 1604.

Solsey, R. J. (1983) Nutrition of children with severely handicapped conditions. Journal of Assessment of the Severely Handicapped 8, 14-17.

Wood, T. E. (1990) Spectrum Care Service Statement: Unpublished data. St Ebbas Hospital, Epsom.

Simila, S. and Nishanen, P. (1991) Underweight and

WORKING WITH PEOPLE WHO HAVE SEVERE LEARNING

DIFFICULTY AND CHALLENGING

BEHAVIOUR A Practical Handbook on the

Behavioural Approach

Judith McBrien and David Felce I'his book provides a state of the art' description of 2ehavioural strategies with proven effectiveness for working with people with difficult or challenging behaviours. The authors use a step by step guide to help readers assess and measure difficult behaviours md to select appropriate treatment strategies. The Behavioural Intervention System (BE) outlined in this handbook is supported by extensive summary sheets all of which are fully illustrated with reference to detailed case studies. While the handbook assumes a basic understanding of behavioural methods, it will enable many professionals to bridge the gap between theory and the formulation of effective intervention strategies.

Contents: Ehapter 1: Introduction Problems; Strengths; Needs

Chapter 2: Measurement

Chapter 3: Behavioural Theory

Chapter 4: Functional Analysis ABC Charts; Analogue Assessment

Chapter 5: Interventions Access to Activity and Social Contact; Skills Teaching; Decreasing Challenging Behaviours; Review and Maintenance of Interven- tions

ludith McBrien is a Principal Clinical Psychologist with Plymouth Health Authority David Felce is the Director of Research for Mental Handicap in Wales and a former Director of BILD.

BILD Publications. Frankfurt Lodge, Clevedon Hall,

Clevedon, Avon, England BS217SJ