Managing Obesity in Adults with Down Syndrome

Chapter 1: Introduction

1.0 Introduction

Down syndrome is referred to a genetic disorder which is caused by the abnormal division of cell resulting in the formation of partial or an extra copy of 21st chromosome which leads to create inappropriate developmental changes and abnormal physical features among individuals (Basil et al. 2016). The individuals with Down syndrome are found to be more likely affected by obesity compared to other individuals without the disorder due to variety of reason one of which is the imbalance in the leptin hormone (Must et al. 2014). The effective management of obesity is required among the adults with Down syndrome (DS) so that they can be avoided from the risk of having heart diseases, type-2 diabetes, stroke and others which tend to lower their life span. Thus, in this study, the causes that lead to rise of obesity among the adults with Down syndrome are to be identified as well as way healthcare management has to be executed to prevent or avoid obesity among the individuals.

1.1 Background of the Study

Down syndrome (DS) is referred to as one of the common aneuploidy occurring among humans as it is seen to affect 600-800 newborn each time. The hindered physiological, biological and behavioural factors such as short stature, lower metabolic rate, mastication difficulties and others as a result of the disorder among the individuals makes them more prone to get affected by obesity compared to normal adults (Jensen et al. 2013). Thus, the dissertation is developed so that the way issues and factors are causing adults with down syndrome to have more chances to get affected by obesity compared to normal individuals and the impact of obesity among them can be identified. Moreover, the healthcare management required to prevent or avoid obesity among Down syndrome individuals is to be identified. The research might also assist to understand the way weight management and nutrition education is to be offered to adults with Down syndrome so that they can be protected from the influence and risk of obesity.

1.2 Research Rationale

The individuals with intellectual disabilities are found to have complex health problems compared to normal individuals. This is evident from the study of Pikora et al. (2014), where adults with Down syndrome (DS) are mentioned to be twice more likely to be overweight or obese and four times more likely to be extremely obese (BMI more than 40) compared to normal individuals. In the cross-sectional study of Real de Asua et al. (2014), total of 51 adults with Down syndrome was selected along with 51 healthy individuals (control group). The study revealed that adults with DS are found to show higher prevalence of obesity and overweight compared to the controls. The researcher found that the waist-to-height ratio among the DS individuals was higher showing increased prevalence of abdominal obesity. In the study by Selvi et al. (2017), out of the total 96 cases, it was reported that 13% males and 20% of women between 19-40 years of age who have Down syndrome are found to be overweight or obese. The figures indicate that obesity and overweight have become a major issue for people with Down syndrome that is affecting their health.

The obesity among Down syndrome (DS) adults has become an issue because it is found that it is negatively impacting on the health by lowering their peak oxygen consumption. This is evident from the study of Wee et al. (2015) where it is informed that adults with DS are found to have lower peak oxygen consumption (25.2 mL/kg/min) compared to individuals without DS (36.1 mL/kg/min). The lower peak oxygen consumption value indicates that the individual is feeling breathlessness or shortage of breath as adequate amount of oxygen equivalent to body weight cannot be consumed. In the study of Propst et al. (2017), the presence of obesity among the adults with DS like the normal individuals also makes them prone to get affected by complex diseases such as heart disorder, Type-2 diabetes, high cholesterol, hypertension and others. Thus, obesity has become an issue for DS adults as it is hindering their way of living a proper life.

The obesity among adults with Down syndrome (DS) has presently become an issue because it is found that effective weight management and healthcare are not properly established for individuals to prevent or avoid them from being obese. This is evident as lower level of intelligence quotient (IQ) of the individuals, the low-income status of the family, hindered means of care services and others are creating barrier to offer successful care to the individuals (Breslin et al. 2014). Thus, it has result the adults with DS to suffer from co-morbidities and complex health disorder due to their condition of being obese or overweight. Therefore, this study is framed to shed light on the causes that are leading adults with DS to experience obesity and the way obesity has impacted them as well as healthcare management is to be organised so that negative impact of the disease can be avoided to help the individuals lead a normal life.

1.3 Research Aim

The research aims to identify the causes and impact of obesity among adults with Down syndrome and the way healthcare management is to be developed for them.

1.4 Research Objectives

To identify the causes of obesity among adults with Down syndrome

To analyse the impact of obesity on adults with down syndrome

To evaluate the challenges faced in providing healthcare to adults with Down syndrome who are suffering from obesity

To recommend ways for delivering care and execute proper healthcare management to prevent and avoid obesity among adults with Down syndrome

Chapter 2: Literature Review

2.0 Introduction

The chapter is framed to focus on the underlying causes and concept of obesity among adults with Down syndrome as well as understand its impact on health and way healthcare management is to be made in this aspect. In this respect, different theories and models related to the topic is explored to develop a logical understanding regarding the way to prevent obesity and its negative impact on adults with Down syndrome. A proper framework is being developed for this purpose to develop logical understanding regarding the study.

2.1 Concept of obesity among adults with Down syndrome

Obesity is mainly referred to a complex disorder in which excess amount of body fat gets stored in the body raising the basal metabolic rate (BMI) of the person (Pitetti et al. 2013). This result the individuals with or without DS to suffering from various complex disorder. In many researches, it is informed that obesity and overweight are being directly related to adults as well as children who are suffering from Down syndrome (DS). The adults with or without DS who are affected by obesity are diagnosed on the basis of their BMI rate. The BMI rate of 18-25 is considered normal but the BMI rate from 25-30 is considered overweight, 30-35 is Class I obese, 35-40 is Class II obese and above 40 is extreme obese (Baumer and Davidson, 2014).

2.2 Factors causing obesity among adults with Down syndrome

The lower metabolic rate among DS adults results the body to slowly burn the calories and fats within the body in resting stage. This contributes to their obesity as it acts to put brake to the body muscles for using energy by breaking down stored fats (Alexander et al. 2016). As mentioned by Tenneti et al. (2017), Leptin is referred to the cell-signalling hormone that is released by the fat cells of the body which regulates food intake, appetite and body weight. This is evident as when increased levels of leptin are produced it indicates the body cells to signal the hypothalamus to stop eating making individuals to control intake of food. In adults with DS, it is found that they are leptin resistance due to which their hunger does not remain in control making them overeat contributing to increase their body weight (Bandini et al. 2013).

2.3 Models and theories to provide care regarding obesity among adults with Down syndrome

2.3.1 Transtheoretical Model

The Transtheoretical Model informs through six stages regarding the way an individual is to be involved to show difference in behaviour for attaining certain goals. The first stage is pre-contemplation in which individuals are aware of their negative condition and they are to be encouraged to think regarding the aspect (Prochaska et al. 2015). Thus, this stage indicates that the DS adults who are obese or overweight are to be made aware of their condition so that they can understand that they are suffering from certain health issue. The second stage is contemplation in which individuals are made to recognise their foreseeable future (Mastellos et al. 2014). This informs that the DS adults are to be informed regarding the way in future they are going to suffer if they are not concerned with obesity or their increasing body weight. The third stage is preparation in which the individual is prepared to take action to cope with the issue and in action stage; the determined action is actually implemented (Kowalski et al. 2014). Thus, the third and fourth stages indicate that DS adults are to be informed and prepared about the actions they are to take to avoid obesity and in action stage, they are to put these determine strategic actions into effect. The maintenance is the fifth stage in which the individuals are boosted to continue the implemented action until the issue is resolved and future relapse of the issue (Johnson et al. 2013). Thus, in this stage, the adults with DS are to be informed to continue and maintain the health actions asked for them to be abided to manage obesity. The last stage is the termination in which people have no desire to return to be previous condition (Kowalski et al. 2014). The individuals with DS who are obese or overweight at this stage are seemed to be following healthy actions without any manipulation or support making them oriented to live a healthy life.

2.3.2 Theory of Planned behaviour

The Theory of Planned Behaviour informs that the attitude of an individual towards social norms and perceived control of behavioural actions together frames the behaviour and intention of an individual (Plotnikoff et al. 2013). This indicates that attitude of the adults with DS are dependent on their beliefs which influences the way they are going to take actions regarding their health to control obesity. Thus, it informs that in case adults with DS who feel that they are in good health and does not consider themselves to be obese irrespective of they being overweight would show careless attitude to take actions for controlling and reducing body weight to reach normal BMI rate. Therefore, to take actions for reducing obesity among adults with DS they are to be made to change their belief that being overweight is ascending step to obesity and they are required to take immediate action to control their health to lower the BMI rate to avoid future risk of being obese.

2.4 Concept of obesity management

The management of obesity mainly includes strategies related to surgery, medication and lifestyle that are to be implemented to treat obesity as well as lower its risk among individuals. In order to execute effective management, the adults with DS are to be screened for any mental health issue and eating disorder to understand which nature of strategic actions are to be implemented to control obesity among such individuals. The obesity management also indicates that proper education regarding obesity are to be provided to adults with DS according to their level of intellect so that they can be made aware and understood about the importance to make changes in their actions, behaviour and lifestyle to control being obese (Maris et al. 2017).

2.5 Factors affecting obesity management

The degree of intellectual disability among adults with DS is inversely related to obesity management because it is related to the person’s functional ability and their relationship with the living environment. This means that if the degree of intellectual disability among the DS adults is low they will comply less effectively with obesity management as they are unable to analyse and lack the ability to understand the importance of the action mentioned in the management for their health (Propst et al., 2017). The residential setting also acts as major factor in obesity management for adults with DS as healthcare regarding obesity for Down syndrome individual may not be avail in all areas (Paley et al. 2015).

2.6 Models and Theories for obesity management among adults with Down syndrome

2.6.1 Health Belief Model

The Health Belief Model informs that person's belief regarding personal threat of disease together with the individual's belief regarding the recommended health behaviour or action will indicate the likelihood of the individual to adopt the action Ahmad et al. (2014). This means that if an individual personally believes that the disease they are suffering from is a threat and the suggested action is effective to resolve the threat then only they are going to implement the action. In case of DS adult who has moderate or high level of intellectual disability (ID), they lack ability to analyse and perceive threat and in this case, the family members are to be influenced to provide effective actions regarding obesity management to the individual. Thus, in this condition, the service providers are required to influence the family members to believe that obesity is a threat for DS adults and intended action suggested is effective to resolve the health issue that is going to ensure the better living condition of the adult in turn creating successful obesity management.

2.6.2 Social Cognitive Theory

The Social Cognitive Theory informs that when an individual observes that a model similar to them is showcasing certain behaviour and the consequence of the behaviour, they remember the events and sequence of the behaviour and later use the information for guiding them to perform such behaviour (Pitetti et al. 2013). Thus, according to this theory, the adults with DS can be influenced to successfully adopt effective actions for treatment and management of obesity if they observe that people similar to them are using the actions and implementing them in their livelihood to gain better health.

2.7 Impact of obesity among adults with Down syndrome

The presence of obesity among adults with Down syndrome (DS) makes them develop hypertension. As mentioned by Spanos et al. (2013), hypertension is referred to increased blood pressure that applies on the inner walls of arteries. The adults with or without DS who are obese are found to have an increased amount of fatty tissues within their body that creates vascular resistance. This, in turn, increases pressure on the blood flow as the size of the arteries are constricted making the heart to provide extra pressure to pump blood through the entire body (Chen et al. 2013). The hypertension leads the obese DS adults to have risk of having strokes and other form of heart diseases. As argued by Izquierdo-Gomez et al. (2013), obesity in adults with DS impact to restrict their physical activity. This is because increased amount of fat in the body raises the body weight which leads to create pressure on the joints of legs and lower back making the adults experience swollen feet and pain in the legs making them execute reduced movements. The presence of increased abdominal fat creates pressure on the bottom of the oesophagus that increases pressure on the stomach making the acid to flow up creating acidic reflux (Bandini et al. 2013). Thus, the presence of obesity among adults with DS leads the individuals to experience gastrointestinal refluxes and digestive issues.

2.8 Challenges regarding obesity management among adults with Down syndrome

The lack of proper intellectual ability among adults with Down syndrome (DS) creates challenges in effective obesity management. This is because the service providers are unable to make the adults follow proper actions to manage obesity as they are not functionally independent to take their own care and has to depend on others to ensure them proper care (Englund et al. 2013). Thus, the other person involved in caring for the adults if do not offer proper support as suggested by the service provider the adults is negatively affected without their fault to be unable to manage obesity. As mentioned by Alexander et al. (2016), low cognitive ability is related to low nutritional knowledge. In case of adults with DS, it is seen that they usually have low cognitive ability due to the genetic disorder that results them unable to have ability to make proper choice of foods. Thus, it leads to create challenge in effective obesity management as it becomes difficult to make the adults with DS understand the value of healthy food and the way they are differentiate from healthy and unhealthy food to manage obesity.

2.9 Gaps in Literature

In reviewing the literature, various gaps are encountered as there was insufficient information regarding the way to impart effective knowledge about obesity management for adults with Down syndrome. In addition, the literature lacked depth to inform about the way various risk factors are present for obese adults with DS. Moreover, the literature lacked insight into the way family members and support carers of adults with DS are to be influenced to execute successful obesity management. There was lack of information regarding the way to resolve challenges experiences in obesity management for adults with DS who also have issues of obesity or overweight. This indicates further exploration of studies are to be made to develop critical information about the causes of obesity among adults with DS and the way obesity management for them is to be established.

2.10 Summary

The chapter highlights the concept regarding obesity and obesity management for adults with Down syndrome who are suffering from obesity. The factors influencing obesity in DS adults and obesity management for them are informed. Later, theories and models to arrange care for DS adults with obesity are understood and discussed. Further, impact of obesity among the DS adults and the challenges that are experienced in offering care for them are also explained.

Chapter 3: Research Methodology

3.0 Introduction

The chapter focuses on the methods to be implemented for performing the study by the researchers. The determination and selection of proper methods of research are important as it assists the researcher to progress the study in a proper way for resolving the raised problem in the research.

3.1 Search Strategy

In this study, systematic review is to be used as a search strategy for executing the study. A systematic review is referred to the strategy in which based on a defined research question available empirical evidence are to be collected and summarised which properly fits the previously specified criteria mentioned in the study (Topp et al. 2015). The benefit of using systematic review is that it helps the researcher to identify and select appropriate studies related to the research topic and reduces biases to create reliable and accurate conclusions. In addition, systematic review allows summarisation of findings from multiple studies which are to be compared and contrasted to develop proper results (Holman et al. 2014). Thus, in this study, the systematic review in the form of research strategy is to be used.

3.2 Database

The electronically available literatures are to be searched by using various search engines as online information searching through use of different keywords helps researcher to identify current evidences which are related to the developed research question. It leads the researcher to perform review of various literatures from different sources as well as identify simple comparison for information identified in books found in the library (Williamson et al. 2014). The electronic platform that is to be used searching includes Google Scholar, CINAHL, PubMed and others. The mentioned platforms have vast journals and books written on clinical topics. Thus, the mentioned databases and search platforms are to be used as they offer current medical and healthcare information about causes, impact and management of obesity among adults with Down syndrome in a complied manner.

3.3 Search Terms

The use of specific search terms related to the study is important as it assists the researcher for retrieving research topic related journals as well as articles for perfuming comprehensive search for the mentioned study (Tu et al. 2014). The search terms which are to be used for collecting information related with the study are “adults with Down syndrome”, “obesity in Down syndrome”, “obesity management”, “causes of obesity in Down syndrome”, “impact of obesity” and others. The search terms are to be customised for each search engine because it would help to retrieve relevant and vast information regarding the study. In addition, research is to be done manually to check the compatibility of the identified sources to answer the raised question in the study.

3.4 Research Question Formulation

The formulation of proper research question for the study is important as it helps the researcher to mention the key focus of the study. The PICO tool is to be used n this study for formulating the research question. As asserted by Korstjens and Moser (2017), the research question are to be framed by directly relating with the identified clinical problem and required to be phrased properly so that it helps the researcher to achieve proper answer to resolve the identified problem. In relation to this context, PICO tool helps to properly determine the parts of focus of the study helping to frame the question indicating the research problem. The PICO tool stands for Problem, Intervention, Control and Outcome (Methley et al. 2014). The Problem is the identified clinical problem in the study that is creating health concerns for the individuals which in this research is rise of obesity among adults with Down syndrome. The Intervention is the key interest of the researcher in the study which in this research is obesity management for adults with Down syndrome. The Comparison is finding similarity and dissimilarity between two variables which in study is not conducted. The Outcome is the impact which is desired to be identified which in this study is improved weight management and nutrition of adults with Down syndrome who are suffering from obesity or are overweight.

The research question which is framed for this study is: What are the causes and impact of obesity among adults with Down syndrome as well as the way obesity is to be managed?

3.5 Inclusion and Exclusion Criteria

The inclusion criteria are referred to the characteristics that the study needed to be involved in the process of research whereas the exclusion criteria are the factors that are to be disqualified from the study as they are irrelevant for the research (Ronconi et al. 2014). In this study, criteria that are to be included are journals and articles that are written in English, fully-accessible informative journals, published from 2013 to 2018, articles related to obesity among adults with Down syndrome and academic journals. The factors which are to be excluded from the study are journals not written in English, published before 2013, journals where abstract is only available, articles and journals related to obesity in children with or without Down syndrome and non-academic journals. The journals only written in English is to be used in the study as it is the only language understood by the researcher. The journals before 2013 are not to be used as they involved back-dated information that is going to lower the validity and reliability of the findings. The journals related to obesity among adults with Down syndrome are to be used as they would offer informative content required to execute the study. The non-academic journals and not fully accessible articles are avoided to be used in the study as it would lead the researcher to collect irrelevant information related with the topic.

3.6 Ethical consideration

In order to maintain ethical consideration, ethical governance which is mentioned in the guidance provided by the UK National Research Ethics Services is to be abided. Thus, in this process safety, rights, dignity and wellbeing of the patients or participants involved with the study are to be protected. In order to maintain integrity, the information retrieved from the journals is to be properly referenced so that effective credits to the author can be provided. The manipulation of the information collected is to be avoided in the study by allowing two other researchers to evaluate the results or findings for ascertaining that the results informed and discussed are not influenced through personal choices of the researchers of the study. The data collected for the study is to be protected by following the guidance mentioned in the Data Protection Act 1998.

3.7 Summary

The above discussion informs that systematic review is to be executed for framing the study. The PICO tool is used for developing the research question and inclusion as exclusion criteria are mentioned for the secondary research. The way ethical considerations are to be abided in the study is also informed.

Chapter 4: Thematic Analysis and Discussion

Theme 1: Causes of obesity among adults with Down syndrome

According to different scientific findings and etiological explanation, one of the key causes of obesity among adults with Down syndrome (DS) is presence of hypothyroidism. In the study by Whooten et al. (2018), hypothyroidism is reported to have an intriguing link with DS people who are suffering from obesity. This is because in hypothyroidism the amount of thyroid hormone to be released in the body is comparatively low due to malfunction of the thyroid glands. The thyroid hormones which are trithyronine (T3) and thyroxine (T4) is seen to help the body to breakdown fats and helps the pancreas as well as liver to metabolise stored fats to be used by the body in the form of energy without unnecessary depositing the fat to increase body weight (Nixon, 2018). Thus, lack of proper presence of normal amount of thyroid hormones among the DS adults which acts to control body metabolism in using stored fats leads the individuals experience obesity. The presence of thyroid problem is prevalent in DS adults is evident from the study of Carfì et al. (2014) where it is informed that out of 62 DS adults surveyed in the research 73.3% of them had thyroid problems. The fact is also supported by another study executed by Campos and Casado (2015), where it is informed that thyroid dysfunction is prevalent among any individuals with DS and the complication increases with age as well the prevalence is more among the DS individuals compared to the general population. In contrast to the above studies, the study by Valentini et al. (2017) informs that increased level of leptin hormone due to leptin resistance among the DS adults is one of the causes of the rising incidence of obesity among them. The key function of leptin in the body is to control hunger and decrease appetite of individuals (Mazurek and Wyka, 2015). However, the leptin resistance in DS adults leads leptin hormone unable to perform their function of directing the hypothalamus of the brain in reducing appetite of the individuals. Thus, it leads the DS adults to be unable to control eating that results them to increase their calorie intake beyond the normal threshold causing the body to store extra calories in the form of fat tissue raising the overall weight of the body making the individual obese in nature. In comparison, the study by Samur-San-Martin et al. (2016) informs that short stature of DS adults is one of the causes that lead to their obesity. This is because short stature people require lower level of energy and micronutrients compared to normal individuals. However, the DS adults, as well as family members supporting them, are found to have hindered understanding regarding the amount of food to be taken according to their stature. Thus, this lack of information leads DS adults with short stature to intake extra amount of food that adds to the weight of the body making them obese.

The study by Hsieh et al. (2017) informs that adults with DS are seen to live a sedentary lifestyle where they spent most of their time without executing any form of physical activity. The lack of physical activity among any individuals is found to impact on them to raise their body weight and leads them to become obese. This is because physical activity helps the body have the opportunity to spend stored fats and nutrients in the form of calories to avoid storage of extra fat cells which eventually raises the body weight and increase BMI rate. In contrast, the study by Kamer et al. (2016), informs that masticatory dysfunction among adults with DS is one of the causes that leads them to experience obesity. It is evident as DS adults due to trisomy in chromosome 21 experience certain abnormal physical features such as flattened face and occiput, the underdeveloped middle part of the face, slanting eyes with apicanthic folds in prominence and others (Wong et al. 2014). This form of facial features leads the adults with DS face hindrance to have raw fruits and properly chew fibrous foods making them orient to have softer foods which are mainly made up of carbohydrates. The increased consumption of carbohydrates leads individuals to gain weight as more energy is consumed in the process compared to the requirement of the body making them gain weight (Burke et al. 2018). Thus, the information indicates the inability of the individuals with DS to use energy and control their eating habit due to mastication difficulty leads them to indirectly prone to gain increased weight and become obese in nature.

Theme 2: Impact of obesity among adults with Down syndrome

The adults with Down syndrome (DS) as a result of obesity are prone to get affected by sleep apnea. As mentioned by Ridore et al. (2017), sleep apnea is a serious condition that leads individuals experience their breathing to start and stop repetitively during sleep. This leads individuals to feel tired and fatigue making them unable to focus on daily activities and in intense cases experience heart failure. In adults with DS who have obesity, it is found that increased amount of fat is stored around the neck region which results to make the airway smaller. The smaller airways lead the individuals experience breathing difficulty for short time period while in resting position due to lack of space in the airways for free movement of air to breathe (Esbensen, 2016). Thus, it informs that adults with DS who are obese are prone to experience fatigue and tiredness as a result of sleep apnea which is the key impact of their raised body weight. In comparison, the study by Sarı et al. (2016) informs that adults with DS are prone to experience hypertension due to raised BMI rate of obesity. This is because obesity leads to deposit extra fat inside the body making the arteries get narrower restricting normal movement of blood. It creates pressure on the wall of arteries resulting in hypertension among the adults with DS who has obesity. The hypertension as a result of obesity among adults with DS also makes them prone to get affected by heart failure and other form of heart diseases (Pucci et al. 2016).

Theme 3: Barriers to healthy weight maintenance and nutrition education to tackle obesity among adults with Down syndrome

The adults with Down syndrome (DS) who have obesity or are overweight experiences different barriers in managing weight and accessing nutrition education for controlling their BMI rate. In the study Nordstrøm et al. (2015), the residential settings act as one of the barriers for obese adults with DS to access weight management and accessing nutrition education for improving their health. This is because people with DS who live in non-supervised and remote residential areas are prone to make unhealthy food choices and identification regarding physical activity for weight maintenance. It is evident as family members are seen to provide unhealthy food as demanded by the adult with DS to fulfil their demands for showing care towards them. Thus, in unsupervised residential areas, adults with DS are exposed to unhealthy foods contributing to their gain in body weight. In comparison, the study of Wong et al. (2014) informs that knowledge and education acts as barriers for adults with DS in controlling obesity through weight management and nutrition intake. This is evident as the study highlighted that adult with DS along with their family members who have no education regarding nutrition intake mentioned to eat fatty and sugary food on daily basis. In addition, the study informed that many of the family members of the adults with DS as well as the individuals were found to hardly mention the nature of healthy food that has effective nutrition and required to be taken to avoid obesity. Thus, this indicates that lack of knowledge regarding the negative impact of fatty foods and the way they are contributing to raise weight among the adults with DS along with other members in the family are resulting in such adverse weight maintenance among the individuals.

In contrast to the above studies, the study of Alesi and Pepi (2017) mentioned that socioeconomic status acts as barrier to provide effective weight management for reducing risk of obesity among adults with DS. This is because in such cases the food choices are made by the family for the adults with DS on the basis of cost creating barriers to access healthy foods. It is evident as fast foods are found to be comparatively cheaper and tastier resulting individuals with lower socioeconomic status to prefer buying them compared to spending more money on purchasing healthy foods. Thus, the poor adults with DS are often unable to access proper nutritional foods due to monetary issues that result them unable to execute effective weight management failing to avoid or prevent risk of obesity. However, the study of Samur-San-Martin et al. (2016) mentions that lack of access to physical activity guidance and gymnasiums are creating barriers in effective weight maintenance among adults with DS to control the risk of obesity. This is evident as adults with DS require effective guidance from others to lead their lifestyle and execute physical activity as they are unable to have proper analytical power to determine the best for them or the way to perform activities to be physically active. The study of Wong et al. (2014) mentions that mental health of the adults with DS deteriorates with age due to which they are unable to process information. This acts as barrier in effective weight management and nutrition education to the adults with DS for controlling obesity because it creates decreased memory of the adults to be unable process and implement the suggested healthy eating style as informed to them. Thus, in such case, the adults with DS have to depend on others and family members to ensure nutritional foods which in case not provided results in improper weight management and increase the risk of obesity. However, the study of Lal et al. (2015) mentions that low muscle tone which is hypotonia among the adults with DS make them unable to perform effective physical activities leading to fail to control obesity. This is because without proper physical activity the individuals fails to use the calories taken resulting in deposition of fat resulting to raise weight gain issues. The study by Wong et al. (2014) also informs that few adults with DS are seen to have problems with sensory and visual senses. In such case, effective nutrition education is difficult to be provided to them as in such condition the dietary information is not knowledge-based for the individual. Thus, they may avoid accepting the instructions and showing resentment to follow the guidance creating barrier to effective weight management required to resolve or prevent obesity among adults with DS.

Theme 4: Obesity management for adults with Down syndrome

In order to create effective obesity management for adults with Down syndrome (DS), the healthcare workers are required to effectively educate the family members as well as the adults with DS regarding nutritious foods and the way to differentiate from unhealthy versus healthy foods (Lazar et al. 2018). This is because the nutrition education would lead the family members of the adults with DS become aware regarding the way they are contributing to create risk of obesity for the individuals by fulfilling their mentioned needs out of their will to show care. It would also lead them to eventually understand the nature of foods to be provided to the adults with DS so that they can be protected from risk of obesity ensuring healthy living of the adults. The service providers based on the cognitive ability of the adults with DS are to educate them about the foods to be eaten so that they can avoid obesity through self-care. In addition, it would also make the adults with DS avoid making unhealthy demands from family members ensuring to create successful protection from obesity (Bertapelli et al. 2016). However, the inability to provide proper health education to the families and adults will make them remain involved in having unhealthy foods creating non-effective obesity management for the individuals. The development of effective health promotion programs is to be made to execute proper obesity management for adults with Down syndrome. This is because health programs are found to be comprehensive and coordinated nature of health promotion and disease prevention strategies that are implemented to create supportive environment for encouraging health and safety of the individuals in the society (Scott and Havercamp, 2016). The Welsh Government in England has developed an Obesity Prevention and Reduction program named “Healthy weight: Healthy Wales” under which the government informs strategic actions to be implemented for controlling obesity or weight gain among the people of the area (gov.wales, 2019). This nature of program is to be followed by the adults with DS who have obesity for developing awareness regarding the way they are to manage their nutrition and food intake along with other activities to prevent weight gain. However, the information in the programs or other specialised health programs for obesity is to be communicated in short sentences repetitively to the adults with DS to make them execute the mentioned actions for preventing obesity. This is because adults with DS have short-term memory and reduced level of intellect which makes them unable to remember complex information and act on them to execute (Grieco et al. 2015). In case the programs are not managed accordingly, it would lead the adults with DS unable to be self-sufficient or show compromises to execute the actions with the help of family for weight management resulting in hindered prevention of obesity for them. The Down’s syndrome Association of the UK informs that to control obesity among the adults with DS they are to be directly involved in physical activities on daily basis. This is because daily physical activities help the adults to use the consumed fats and nutrients in the body through food as energy so that they do not add to their body mass making them gain weight or become obese (Wong et al. 2014). In order to involve adults with DS to execute physical activity, proper access to gymnasiums are to be made. Moreover, the service providers are required to inform the family members of the adults about the way they are to instruct and encourage as well as create opportunity for the adults with DS in the home settings to perform physical activity so that their weight can be controlled to avoid them from being obese. In order to execute effective weight management, family members who are providing care to the adults with DS are to be informed in details about the type of foods to be avoided for the individuals so that their weight gain issues can be controlled. This is also going to help in promoting healthy diets for adults with DS for preventing obesity (Wong et al. 2014). However, lack of this nature of education would promote family to provide unhealthy diets making the adults with DS at risk of developing obesity.

Chapter 5: Conclusion and Recommendations

5.1 Conclusion

The research informs that obesity among adults with Down syndrome is prevalent in many cases due to various reasons. One of the causes is presence of thyroid problems in adults who as a result of the issue are unable to produce required amount of T3 and T4 that have the function to help the use of fats and nutrients in the body for developing energy. The other cause identified is presence of leptin resistance among adults with Down syndrome (DS) which raises their chances of getting obese as leptin hormone that is used for controlling hunger is unable to act making the person to overeat. The lack of physical activity of the individuals with DS makes them prone to be obese as they reduce their efficiency of the body to use fats for creating energy. In addition, short stature of adults with DS makes them prone to be obese as they are provided more nutrients than actually required due to lack of understanding by the family members. The impact of obesity on adults with Down syndrome (DS) is that it leads them to cause sleep apnea in which the adults experiences breathing problems during sleeping. In addition, adults with DS having obesity lead them to experience hypertension which makes them prone to develop heart stroke and other nature of heart diseases. The impact of obesity for the DS adults that it restricts their movement which is due to increased pressure of weight on their muscles and joints. The barriers experienced to offer obesity management to adults with Ds is that their lower IQ level and cognitive ability creating hindrance for the service providers to deliver proper information about actions to reduce weight. The other barriers experienced are lack of effective support from the family or service users, muscle hypotonicity that hinders their ability to execute physical activity, lower socioeconomic status and others.

In order to execute obesity management for adults with DS, they are at first to be informed educated about nutrition and way to achieve it. The family members are to be involved whop support them to ensure healthy living and prevention of risk of obesity among adults with Down syndrome. The development of effective health programs is required which are to be framed in such a way so that short information of different nature are repetitively provided to the adults with down syndrome to execute the mentioned actions and strategies as they have low memory and analysis ability.

5.2 Recommendations

Involvement of Dieticians:

Dieticians are found to be helpful in any stage of life as they provide proper information about the dietary ingredient to be eaten to live a healthy life for all. The dieticians are required to analyse all medical information of adults with Down syndrome (DS) to determine the nature of nutrient and food are to be suggested to them for ensuring their better health and management of weight. The dieticians are needed to provide written diet charts separately for all adults with DS according to co-morbidities they have so that effective weight management can be ensured and risk of obesity can be avoided. In some cases, it is seen that adults with DS have different eating pattern due to their hindered facial features and in this case, the dieticians required to inform different diet chart for them so that they are not oriented to consume increased fatty and carbohydrate-rich foods that are easier to be eaten and available in the market.

Education and inclusion of caregivers:

The caregivers of adults with DS are to be educated because it is found that few of the caregivers negatively influence the physical activity and dietary intake of adults with DS. This is evident as poor dietary knowledge of the caregivers makes them unable to understand the proper amount of which nutrient and to what extent fatty foods are to be provided to the adults with DS so that their weight and health remains stabilised avoiding them to b prone to get affected by obesity. Therefore, the educating the caregivers regarding meal preparation of adults with DS is going to help in making them choose greener and appropriate food ingredients that ensure better health and avoid improper weight gain by the adults with DS. In addition, the caregivers are to be included for education along with adults with Ds as most of the individuals lack effective IQ and memory to remember information to act on them for managing their weight. Thus, inclusion of caregivers in the education regarding the way to avoid obesity is to be done so that adults with DS can be positively influenced with their help to execute healthy actions making the adults successful to manage healthy weight.

Health screening and management:

In order to control obesity among adults with DS, regular health screening and management is required. This is because health screening by the primary physicians assist to understand if proper health protocols are abided by the adult to prevent unnecessary weight gain. In addition, regular screening assists to keep a check on the health and weight of the DS adults by informing their caregivers as well as the individuals when a surge in uncertain weight gain is identified. Thus, accordingly, immediate steps are to be taken at the earliest to avoid the risk of obesity among adults with DS.

Involve eating healthy:

The adults with DS are to be properly intervened to make them understand the advantage of eating vegetable, fruits, increased dietary fibres and others. They are also to be informed empathetically and in repeated manner regarding the way their unhealthy foods choices are creating risk for their health. This nature of awareness is going to make them realise wrong choices of food, in turn, orienting them to approve of eating healthy diets.

Improve socioeconomic status:

The government is required to improve the socio-economic status of the family including adults with Down syndrome so that the family members have enough finances to buy healthy foods rather purchasing cheap fast food to fulfil their hunger. It is going to lower the risk of obesity for adults with Ds as their family would have effective finances to support healthy living.

Community Health Awareness:

The community in which adults with DS are living needs to arrange proper health awareness specific to the individuals for lowering their risk of obesity. This is because it would lead to create holistic effort would for DS adults to have the chance of continuous monitoring and screening of health irrespective of their social and economic condition to get encouraged to eat and live healthy avoiding the risk of obesity.

5.3 Limitations

In executing the research, different limitations were experienced. There was no detailed research information regarding the way adults with Down syndrome lead their sedentary lifestyle in the journals and articles that were reviewed. Moreover, there was lack of information about the mechanism through which thyroid hormones and leptin act in reducing weight among individuals. The study experienced financial constraints as enough funds were not allocated. In addition, many relevant journals and articles could not be researched as they were not fully accessible. Further, while executing the study the researcher may have analysed and presented information through personal opinion creating limitation to ensure effective reliability and validity of the study. The time also acted as limitation for the study as there was limited time period offered to complete the study.

5.4 Future scope of the study

In future, this study can be conducted in a more descriptive way for announcing the diversified findings that was unable to be achieved in this study due to lack of money and time. The research is mainly secondary and the researcher in future can opt for using primary study to collect real-life data to extend the findings of the study. This study can also be used as reference in future to understand the way weight management and nutrition are to be provided to adults with DS who are at risk of obesity. Further, the study can be used for creating comparative analysis in future.

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