Patients with intellectual disabilities often struggle to control their weight.
The medications prescribed -- antipsychotics, sedatives, selective serotonin reuptake inhibitors (SSRIs) -- can cause weight gain, but other factors including genetics and the patients' environment also may a play a part in this problem.
鶹ý spoke with several clinicians about strategies for helping these patients control their weight.
Tunnel Vision
A nonverbal patient on the autism spectrum was prescribed several medications to control his aggression as an adolescent. One of them was risperidone (Risperdal), which linked this drug and several others to weight gain in a .
By the time he was 23, this patient weighed 320 lbs and was still taking risperidone, even though his aggressive behavior had receded, explained , of the Ronald Reagan UCLA Medical Center, in Santa Monica, Calif.
Kuo said the psychiatrist, who inherited her patient from a previous physician, never questioned the previous doctor's judgment and continued to refill the risperidone prescription for years.
Kuo, who spoke at the American College of Physicians Internal Medicine meeting in May, said she took her patient off risperidone and got him "fixated" on the treadmill. He lost 15 lbs almost immediately. That patient is still battling with his weight, but Kuo said she meets with him regularly to keep him on track.
Kuo said some psychiatrists treat children with an "it's-not-broken-so-I-haven't-fixed-it" mindset. Primary care doctors may need to be more assertive in pushing a total health agenda instead of deferring all of their care for autistic patients to psychiatrists.
On the other hand, some patients require antipsychotics.
"You can't make behavioral change around healthy lifestyle behaviors when everything is dysregulated," said , of Children's Mercy Hospitals and Clinics in Kansas City, Mo. Sweeney works with a psychologist at a clinic for special needs children with obesity.
Many of the children she sees need atypical antipsychotics to be successful and function in school, Sweeney noted, adding that she prescribes metformin and other hunger-suppressing medications. However, "it's tough because, in kids, [those drugs] aren't well-studied for that purpose."
"I don't think that anybody should be giving these medicines without a plan," said , director of the American Board of Obesity Medicine, referring to atypical antipsychotics.
As a pediatrician working with many special needs kids in New York City, Hes also co-prescribes metformin for her patients.
Each of these clinicians also teaches patients and families ways to eat healthy and introduces them to new physical activities.
Eating Healthy
Although following a healthy diet can counteract the potential weight gain children with special needs sometimes experience, this is not easy.
For example, children with disabilities may be accustomed to receiving food as a reward: "You get a good grade on your test, or you sit quietly in class, and the teacher gives you a little piece of candy," Sweeney said. "Take a child and that's the only thing that ever motivated them and you give them a sticker, and that's not going to work. It's not going to have the same effect."
For children with special needs, food is a powerful motivator, she said. "Most of us over time develop other things that motivate us, but many of these kids don't."
Hes noted that children on the autism spectrum can have very rigid food preferences: "They don't eat anything green. They want everything to be white. Nothing can touch."
When introducing dietary changes, "you have to be very creative," she said.
In her experience, for the child who ate only white foods, she had parents blend cauliflower into mashed potatoes or hide squash in macaroni. For the child who ate food only in groups of three, he now gets three mini-Oreos instead of three full-sized cookies.
While parents may try coaxing or bribing kids to eating healthy, "none of those things help," said , of Wake Forest Baptist Medical Center in Winston-Salem, N.C.
"In kids who have no cognitive or developmental disabilities, you have to offer a food 15 to 20 times before they'll eat it regularly," he said. "With kids with special needs, it might even be twice that."
Staying Active
Children with special needs may also have other genetic disadvantages. For example, Sweeney explained, people with Down Syndrome don't burn calories the way others do, because of their lower basal metabolic rate.
When a boy with Down Syndrome eats at McDonald's, she said, "that's two days' worth of food that he ate in one sitting."
When they exercise, "they don't get the same bang for their buck," she added.
Also, "for kids with autism, sweating can be very, very, very upsetting ... Breathing hard, they feel like they're dying, literally."
On top of these challenges there is the isolation. Some children with special needs spend most of their time watching TV, Hes said: "They eat because they have nothing else to do."
Hes recommends buying a stationary bike for the TV junkies. Or encouraging children to walk up and down the stairs 10 times a day, or to get the school bus to drop them off one stop earlier.
Doctors can also reach out to the local YMCA or school to ask about fitness classes and machine availability. Martial arts and swimming are popular with special needs children, because these activities are not team-based.
Gaps in Research
"When it comes to rising rates of obesity in the U.S., it's not just one thing -- I think the same thing applies to people who have physical, intellectual, or cognitive disabilities," said Skelton.
Obesity research targeted to people with developmental and intellectual disabilities is "somewhat limited," said , of the Eunice Kennedy Shriver Center at the University of Massachusetts Medical School in Charlestown.
"The risk factors that affect typically developing children probably affect all children, but there may be additional risk factors for obesity for kids with intellectual and developmental disabilities," she said, such as food selectivity, barriers to exercise, and food rewards.
However, Bandini stressed: "Research has not been done to determine if these dietary and or physical activity behaviors put [these children] at increased risk for obesity."
While only a few research studies have focused on weight loss for children and adolescents with intellectual disabilities, Bandini said, "our suggests that a family-based intervention with nutrition, education, and behavioral intervention is a promising approach for weight loss in obese adolescents with [intellectual disabilities], but more research is needed."
Words of Wisdom
"Sometimes these [weight] changes are very, very slow," said Skelton. Parents need to be reminded to stick with their efforts even if their child doesn't lose weight immediately.
Hes also stressed that starting healthy habits early, like avoiding soda and fruit juice, can save parents and children from frustration later: "If you don't have it, you don't miss it."