Examining Risk Factors for Overweight and Obesity in Children with Disabilities (2019) - PDF

DEVELOPMENTAL NEUROREHABILITATION 2019, VOL. 22, NO. 5, 359–364 https://doi.org/10.1080/17518423.2018.1523241 Examining risk factors for overweight and obesity in children with disabilities: a commentary on Bronfenbrenner’s ecological systems framework Meaghan Walkera,b, Stephanie Nixonb,c,d, Jess...

DEVELOPMENTAL NEUROREHABILITATION 2019, VOL. 22, NO. 5, 359–364 https://doi.org/10.1080/17518423.2018.1523241 Examining risk factors for overweight and obesity in children with disabilities: a commentary on Bronfenbrenner’s ecological systems framework Meaghan Walkera,b, Stephanie Nixonb,c,d, Jess Hainese, and Amy C. McPherson a,b,c a Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada; bRehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada; cDalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; dDepartment of Physical Therapy, University of Toronto, Toronto, ON, Canada; eDepartment of Family Relations and Applied Nutrition, University of Guelph, Guelph, ON, Canada ABSTRACT ARTICLE HISTORY Globally, overweight and obesity (OW/OB) levels are high among children, with rates surpassing the Received 20 December 2017 adult population. With such high pediatric OW/OB rates, it is imperative that risk factors are identified Revised 31 August 2018 and explored. Thus, Davison and Birch developed an adapted framework, based on Bronfenbrenner’s Accepted 10 September 2018 Ecological Systems Theory, which identifies and categorizes the factors in a child’s life that put them at KEYWORDS risk for OW/OB. While a socioecological perspective has been a useful tool for examining risk factors in Childhood; risk factors; typically developing pediatric populations, this holistic approach has not yet been applied to popula- weight management tions of children with disabilities, who are at an even higher risk of OW/OB than their typically developing peers. This commentary, therefore, explores Bronfenbrenner’s Ecological Framework as applied to OW/OB by Davison and Birch, and critically examines its application to children with disabilities. Introduction With such high pediatric OW/OB rates, it is vital that the risk factors for excess weight gain among this population are Overweight and obesity (OW/OB) rates are high among identified and explored. Typically, the main influencing factors children,1 with rates recently surpassing the adult population.2 A are considered to be energy intake versus energy expenditure.20 sub-group of children at high risk of OW/OB are children with This approach oversimplifies OW/OB and positions it as an disabilities, who experience OW/OB at 2–3 times the rate of individualistic issue, rather than considering the intersection of typically developing children.3–6 Although a socioecological per- environmental, biological, and social factors.2,7 To understand spective has been useful to examine the environmental risk factors these complexities, Davison and Birch 7 developed an adapted putting pediatric populations at risk for OW/OB,7,8 this holistic framework, based on Bronfenbrenner’s Ecological Systems approach has not yet been applied to populations of children with Theory. 21 Bronfenbrenner’s Ecological Systems Theory exam- disabilities. Identifying the complex set of factors that contribute ines the numerous levels in the environment that interact and to OW/OB among children with disabilities will inform appro- affect a developing child.22 It is divided into four levels that priate intervention approaches among this high-risk group. interact with, and influence one another, ultimately determin- As childhood OW/OB rates rise, there is an increased risk of ing the development of a young person.21,23 Davison and secondary health conditions9,10 that affect both the immediate, Birch7 collapsed these four levels into three levels, with the and future physical and psychosocial well-being of children.4,11 individual child in the middle. The three layers include: the Physical complications include: increased pain, fatigue, high microsystem, the mesosystem, and the macrosystem. At the blood pressure, insulin resistance, hyperlipidemia,4 type 2 dia- core is the individual. The first, and most influential, layer is the betes, cardiovascular disease, hypertension, non-alcoholic fatty microsystem, which describes the relationship between the liver disease, metabolic syndrome,12–14 asthma, and sleep developing child and their environment, in the form of numer- apnea.12 Furthermore, the prevalence of weight stigma can ous diverse settings.7,22 Settings are places with specific physical expose children to negative psychosocial experiences,15 result- elements where participants interact and engage with activities ing in poor mental health, pervasive negative emotions, an in specific roles. The next layer is the mesosystem, which is altered sense of self-identity, and further weight gain.16–18 made up of the interactions between the settings in which the The secondary physical and psychosocial consequences child is immersed. The last layer of the Ecological Systems that can result from OW/OB and weight-related stigma are Framework is the macrosystem, which refers to the overarching detrimental for any child. However, they can be compounded institutional patterns that affect and control the culture of when a child has a pre-existing disability, further hindering society, including the economic, social, legal, political, and independence, mobility, and social participation,3 posing a educational patterns.7,22 While each level is distinct and has threat to their overall health and well-being.19 CONTACT Amy C. McPherson [email protected] Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ipdr. © 2018 Taylor & Francis 360 M. WALKER ET AL. its own unique characteristics, each level is dependent upon, Disability characteristics and influenced by, one another. For example, the physical The specific cognitive and physical involvements of a disabil- ability of the child (microsystem) will impact the ways in ity are central to the factors in the microsystem that can put a which they participate in their school and communities’ phy- child at risk for developing OW/OB. For example, Autism sical activity and sport programs (mesosystem). Spectrum Disorder (ASD) is associated with a spectrum of Davison and Birch’s adapted Framework provides a useful cognitive involvement, which may make children with ASD tool for identifying and categorizing the factors in a child’s life less aware of the health and medical risks associated with that put them at risk for OW/OB.2,7 However, their frame- higher body weight, as well as the potential physical, social, work fails to include the specific factors that affect a child with and psychological consequences.24,25 Further, many children a disability. with ASD take psychotropic medication (e.g. atypical anti- In order to properly address the unique risk factors that psychotics), some of which have been associated with consid- contribute to OW/OB and the associated secondary condi- erable weight gain as one of the side effects.26,27 Another tions in children with disabilities, children must be consid- example is Chiari malformation, a common brain malforma- ered within the context of their environment. This tion in children with spina bifida that can cause feeding and commentary aims to address each level of the environment swallowing difficulties. This can lead to an alteration in food outlined by Davison and Birch and apply a disability lens preferences toward foods with low nutritional value.28,29 with examples from different disabilities dispersed through- Metabolic irregularities, lower resting energy expenditure, out the levels for health-care professionals (HCPs) to con- and lessened height velocity also put children with spina sider when working with children with disabilities. Figure 1 bifida at an increased risk for OW/OB.28–30. 29,31 outlines different risk factors in each level of the Ecological The way children with disabilities view ‘health’ may also Systems Framework. Of note, this framework is not an differ from typically developing children,3 in turn impacting exhaustive list of all risk factors that can be present in the how they perceive healthy lifestyles and make healthy and lives of youth with disabilities; however, it outlines the pri- nutritional choices. It is important to note that for many mary risk factors prominent in the literature relevant across children with disabilities, there is a large functional spectrum multiple disabilities. on which they can fall. Thus, the way their impairments affect them will vary; however, a child’s functional capacity should be considered when determining risk factors for OW/OB. Ecological systems theory: a disability lens Microsystem Sedentary activity and physical ability Children with a range of diagnoses may be limited in their The first layer is the microsystem, which encompasses the physical ability to participate in activities because of the func- child and her/his direct environment.2,7,21 The microsystem tional limitations of their disability.4,32 As a result, children includes the socio-demographic characteristics of the child,2,7 with cognitive, sensory, and physical impairments are more in addition to settings such as the school, family home, and likely to participate in sedentary activities.4,6,33 Frequently, extra-curricular activities.21,23 For all children, this includes existing functional impairments can make it difficult to phy- their gender, biological susceptibility to weight gain, a child’s sically interact with the environment, making sedentary activ- diet, the age of a child, and how active a child is.2,7 For a child ities appear more feasible. Children with cerebral palsy, for with a disability, this can include additional factors that example, often have physical impairments34 and use assistive impact their overall health. devices for mobility, making physical activity more difficult. Figure 1. Bronfenbrenner’s ecological systems theory applied to OW/OB in children with disabilities.  DEVELOPMENTAL NEUROREHABILITATION 361 Further, pain is highly associated with cerebral palsy,34 again not be readily available. While there has been an increase in contributing to reduced participation in physical activities. specialized and adapted programs (such as wheelchair sports Moreover, many children with Down syndrome have difficul- and Special Olympics programming), there are still numerous ties participating in physical activity due to hypotonia (low barriers in place restricting the full participation of youth with muscle tone).35 disabilities. With regard to mainstream health and exercise programs, many instructors and staff lack appropriate knowl- Food selectivity edge regarding how to accommodate activities for children There are numerous nutritional challenges that arise for chil- with disabilities, limiting their capacity for participation.4,37 dren with disabilities.4,36,37 Many children with disabilities are Many fitness facilities, sports programs, and playgrounds are susceptible to altered feeding and eating behaviors. Some not physically accessible, restricting access for children with children with ASD, for example, are prone to food selectivity, physical disabilities.4 Moreover, families of children with dis- especially sensitivity to food textures4,38,39 frequently leading abilities often face challenges accessing accommodated and to the development of atypical eating behaviors with prefer- accessible fitness facilities.4 ences for a limited range of energy dense food.4,38,39 Further, In both school and community settings, there are numer- children with genetic conditions, such as Down syndrome, ous environmental barriers such as inaccessible physical also have a tendency to overeat due to damage to the hypotha- environments, lack of adapted equipment, and transportation lamus (which is responsible for weight regulation).34 difficulties,29,44 making participation a challenge for youth with disabilities. Mesosystem Food as a reinforcer The mesosystem encompasses the interactions and relation- Davison and Birch suggest that parental and family dietary ships between major settings within which the child is patterns largely affect the child’s feeding behaviors.2,7 The immersed.21,23 These include family dynamics, parental type and amount of food a parent provides greatly shapes employment, and the parent–teacher relationship. Davison how the child eats.7 For children with disabilities, an addi- and Birch highlight the mesosystem’s key characteristics tional nutritional challenge can be the use of food as a rein- with regard to weight gain and OW/OB as parenting styles forcer for good behavior (e.g. Behavioral therapy for children and family characteristics.2,7 For children with disabilities, with ASD) or a comforter when their children experience parenting styles and family characteristics can be even more unpleasant feelings and situations.4,36 Using foods to reinforce complex, further posing risk to the development of OW/OB. behaviors or comfort children may both encourage excessive consumption of nutrient-poor foods and encourage an altered Familial income view of food, which can accompany them into adulthood. The costs of caring for a child with a disability are far greater than that of a typically developing child.40 Children with disabilities have unique needs and frequently require ongoing Social isolation and exclusion therapies and specialty care.40,41 Furthermore, often the needs Children with disabilities experience bullying, isolation, lone- of the child require one or both parents to either lessen their liness, and social exclusion at far higher rates than typically workload or stop working, in turn affecting the family developing children.45,46 Social isolation can reduce a child’s income.40,42 A lower family income can act as a risk factor participation in group activities, and increase their engage- for OW/OB,43 because, in addition to not being able to afford ment in sedentary activities.5,38 In addition, children with nutrient-rich foods, parents may not be able to afford exercise OW/OB are twice as likely as children of lower weights to and sport classes for their children, especially where adaptive experience bullying and exclusion.18 This combination of equipment and additional support may be required for a child having a disability and OW/OB puts children at a huge risk with a disability to successfully participate in activities. for experiencing bullying, loneliness, stigmatization, and isolation,18 all risks for further weight gain.18,45 Participation in school/community activity Within the classroom, nutritional education is frequently not Relationship with health-care professionals (HCPs) accommodated to meet the unique learning needs of students HCPs represent a critical support for promoting the health of with intellectual disabilities, putting these students at a disad- children with disabilities. However, it has been documented vantage for understanding healthy choices.4 Despite require- that, similar to the general population, HCPs can experience ments in the Individuals with Disabilities Education Act stigmatized thinking and actions toward those with higher (IDEA) mandating the inclusion of all young people in physical weight.47–49 As an individual’s BMI increases, HCPs negative education, the majority of young people with disabilities do not attitudes, beliefs, and actions simultaneously increase.50 The receive comparable physical activities to their typically devel- stigmatization of children with OW/OB not only exacerbates oping peers.4 While this may be partially attributed to the lack negative physical and psychological consequences caused by of trained staff available in schools to accommodate activities, higher weight, but can further interfere and hinder effective the physical environment of the gym and field may also hinder weight-management behaviors and treatments.48,50 Stigma participation. perpetuated by HCPs can be detrimental for immediate and Within community settings, specialized instruction and future well-being of children, impacting their physical, social, accommodations to make physical activities accessible may and psychological well-being. 51 362 M. WALKER ET AL. Counter to this, sometimes HCPs fail to raise the topic of obesity7 by applying a disability lens to identify key factors of weight management at all.28 Children with disabilities usually relevance for children with disabilities. This conceptualization see their HCPs more often than typically developing children, of OW/OB for a child with a disability moves beyond an so frequently have established relationships. Even so, the topic individualistic approach and examines multiple layers of influ- of weight is rarely raised.52 There are often time constraints and encing factors to focus on the ways the environment, personal competing priorities during medical appointments, resulting in characteristics, and societal factors interact to put a child at risk an infrequent discussion of weight management.31,52 for OW/OB. This commentary is intended to encourage HCPs In addition to weight-based stigma, many HCPs perpetuate to consider a range of influencing factors that can contribute to disability-related stigma53,54 putting these young people at an OW/OB among children with disabilities. We encourage HCPs increased risk for negative psychological and social outcomes. to consider the different ways the child’s environment impacts The combination of experiencing both disability-related their weight and health. While we use the Ecological Systems stigma and weight-related stigma can lead to severe negative Framework to conceptualize contributing factors to higher consequences for the child. weight in those with a disability, its purpose was not to suggest that higher weight is innately bad or equates to ill health. Rather, it provides a novel way of conceptualizing risk factors Macrosystem so that if a child does require/desire supports, those supports The macrosystem relates to the overarching culture in which and treatment plans are developed with consideration of the the child lives.21,23 This includes attitudes, rules, laws, legisla- multitude of influencing factors in their life. For example, if tion, and mass media. The macrosystem encompasses all they suggest “play outside more” or “get more exercise” and yet major systems and institutions that govern and shape society. the child faces considerable barriers accessing physical envir- onments, that suggestion by the HCP will not be successful and Weight bias in society this child may be considered as “non-compliant.” Using this The prevalence of weight bias in North American society framework to consider the range of factors influencing weight impacts physical health and function.47 The experience of weight and related behavior, both as risk and also protective factors, stigma can produce a cycle in which the internalization of stigma will aid HCPs in identifying more informed and tailored can increase cortisol and metabolic abnormalities, contributing strategies. to even higher weight, further increasing stigmatization.18,47 The Future Uses– This Framework can be adapted for specific experience of weight stigma causes physiological (cortisol level disabilities. For example, children with Duchenne Muscular increase and metabolic abnormalities), cognitive (altered execu- Dystrophy face unique risks for weight gain because of their tive functioning), and behavioral (eating) changes that increase medication and the progressive nature of their disability. Thus, body weight and weight-related stigma (8). The pervasiveness of adapting the Framework to consider this group specifically weight stigma in North American society makes this cycle diffi- could be valuable for HCPs when conceptualizing supports cult to break, and is another serious risk factor for the develop- and treatment plans. This model could also be used to generate ment, or increase in, OW/OB. For a child with a disability and objectives for future empirical evaluations. For example, future OW/OB, the discrimination that they are facing may be more research could explore the impact of a particular risk factor intense as they may be experiencing both weight-related and (e.g. participation in school/community activities), evaluate disability-related stigma. interventions targeting this, and identify how the intervention impacts health outcomes. Access to services With high rates of childhood OW/OB, especially for chil- Numerous pediatric weight-management programs have been dren with disabilities,4 and the potentially serious implica- created across the past 10 years.2,13 Such programs play a key tions, examining risk and protective factors that influence role in addressing secondary medical and psychological health the health and well-being of a child with a disability is timely conditions, while supporting both children and families in and imperative. This Framework will allow clinicians and making positive lifestyle behavioral changes.13 While these researchers to consider a child with a disability and OW/OB programs are becoming increasingly common, they have in the context of their environment to ensure their unique been largely designed with children without disabilities in and complex needs are being met. mind, and children with disabilities and OW/OB often experi- This Framework proposes that HCPs shift their thinking ence challenges accessing them,32,35,37 such as familial stress, from individual behaviors and consider the holistic environ- transportation, and financial strain.55 In addition, families of ment in which the child lives, so that programs, conversations, children with disabilities often have frequent medical appoint- and supports can address all of the influencing factors con- ments competing for the time they could spend at a weight- tributing to a child’s higher weight. This allows for realistic management clinic.36 and feasible strategies, so that no child is excluded from living their most healthy lifestyle. Conclusion Pediatric OW/OB is complex and requires a variety of Funding approaches to address a range of risk factors at multiple levels.2 This work was supported by the Canadian Institutes of Health Research The framework presented here builds on Davison and Birch’s and Kimel Family Graduate Scholarship in Pediatric adaptation of Bronfenbrenner’s ecological model of childhood Rehabilitation.  DEVELOPMENTAL NEUROREHABILITATION 363 ORCID 21. Bronfenbrenner U. Toward an experiential ecology of human development. Am. Psychol. 1977. doi:10.1037/0003-066X.32.7.513. Amy C. McPherson http://orcid.org/0000-0003-4186-3200 22. Bronfenbrenner U, “Enviornments in the Developmental Perspective: Theoretical and Operational models.” pp. 2–28, 1999. References 23. Bronfenbrenner U, “The experimental ecology of education,” 1976. 24. Bodde A, Seo D-C. 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