This article was written by MaresaWeems, MPH, RDN, LDN, a researchdietitian, and Laura Truex, MS, RDN,LDN, a research dietitian, both withE.K. Shriver Center, UMass MedicalSchool, Worcester, MA; ReneeScampini, MS, RDN, a lecturer, UrbanStudies Program, University ofWisconsin-Milwaukee; RichardFleming, PhD, a professor, Depart-ment of Exercise and Health Sciences,University of Massachusetts Boston;and Carol Curtin, PhD, an associateprofessor, Family Medicine and Com-munity Health, UMass Medical School,Worcester, MA; and Linda Bandini,PhD, RDN, an associate professor, E.K.Shriver Center, UMass Medical School,Worcester, MA, and a clinical profes-sor, Boston University, Boston, MA.

http://dx.doi.org/10.1016/j.jand.2016.09.006Available online 2 November 2016

ª 2017 by the Academy of Nutrition and Dietetics. J

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Topics of Professional Interest

A Novel Weight-Loss Tool Designed forAdolescents with Intellectual Disabilities

OBESITY IS AMONG THE MOSTsignificant public healthproblems facing our societytoday. Not only do high rates

of obesity contribute to soaring healthcare costs, the condition may alsocontribute to diminished quality of lifeamong those affected.1 There is clearevidence of the negative influence ofobesity on general health, withincreased risk of some chronic diseasesdemonstrated in both pediatric andadult populations.2 For youth and ado-lescents especially, weight manage-ment efforts come at a critical timebecause pediatric obesity has beenshown to persist into adulthood, withthe prevalence of comorbid chronicdisease increasing as weight gain con-tinues over time.3,4

During 2011-2012, the NationalHealth and Nutrition ExaminationSurvey data indicated the nationwideprevalence of overweight and obesityamong all youth aged 2 to 19 yearsto be 14.9% and 16.9%, respectively.5

Recent studies suggest that theobesity rate in the population of peoplewith intellectual disabilities (ID) maybe even higher, with estimates as high

as 28.9% among children aged 10 to 17years with ID, compared with 15.5% intypically developing children.6 Amongadolescents with Down syndrome,estimates suggest that 47.8% haveobesity.7 Likewise, children and ado-lescents with autism spectrum disor-der are at increased risk for overweightand obesity compared with typicallydeveloping peers.8 Despite the elevatedprevalence of obesity in these pop-ulations of children and youth, noevidence-based guidelines for weightmanagement have been developed.Current weight-management practicesfor the typically developing pediatricpopulation may be difficult to imple-ment given the unique challengesfaced by youth with ID, including foodrefusal, sensory issues, and cognitiveand communication impairments.To date, relatively few studies have

examined the influence of nutritionand physical activity interventions onweight loss in adolescents and youngadults with ID. Notably, in the 1970sand 1980s, several weight-control in-terventions were designed by Rotatoriand colleagues9 and tested in theadolescent ID population. Althoughthese studies had several strengths,including relatively long interventionperiods and use of behavior manage-ment techniques to promote positivebehavior change, they were conductedprimarily among institutionalizedadolescents who had limited dailyexposure to the complex variety offoods seen in the community environ-ment. More recently, two small weight-loss intervention studies showedpromising results. In one, Ptomey andcolleagues10 found that in a 2-monthweight-loss study, adolescents with IDgiven a diet intervention based on theStoplight Diet with prepackaged mealsor a conventional reduced-energy dietwere able to lose weight, and partici-pants were able to successfully useelectronic tablets to track their foodintake.10 In the other, researchers atthe Eunice Kennedy Shriver Center,

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University of Massachusetts MedicalSchool, compared two versions of a6-month family-based weight-lossintervention (named Health U.) forteenagers with Down syndrome.Weight loss and weight maintenancewere greater in the condition in whichparents received training on behavioralstrategies compared with a group thatreceived education only.11 Given thattoday’s adolescents with ID are farmore likely to live at home with familyor in semi-independent settings thanin institutions, they face the same ever-changing food landscape filled withendless varieties of snacks, conve-nience foods, and sugar-sweetenedbeverages as the general population.Consequently, adolescents with IDneed to learn how to make healthyfood choices independently in a varietyof situations such as choosing anafterschool snack at home, preparingfood for themselves, or going out to eatwith their friends.

In the aforementioned Health U.study, all participants received aHealthy Eating Plan (HEP), an individu-alized, calorie-based, highly visualplan that provides a framework forconsuming a healthy diet and pursuingweight loss.11 The purpose of this articleis to describe in detail the HEP andcompanion Food Guide used originallyin the Health U. research study andslightly modified for use in an ongoingstudy with adolescents with ID. TheHEP is a unique weight-loss tool createdspecifically for adolescents with ID.

DEVELOPMENTHealth U. began as a pilot studydesigned to help adolescents withintellectual disabilities lose weight,increase their physical activity, andreduce sedentary time. It takes afamily-based approach in which par-ents or caregivers participate alongsidetheir adolescent or young adult andlearn behavior strategies to assist himor her in losing weight and improvinglifestyle habits.

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Figure 1. The Healthy Eating Plan provides individualized recommendations on the number of daily servings from each food group.

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The HEP was designed to organizeand simplify daily food choices for apopulation with limited literacy skills.It uses pictures to display the numberof daily recommended servings fromeach food group: dairy, fruit, vegetable,protein, grain, and fat or sugar(Figure 1). The HEP is designed to benutritionally adequate while promot-ing gradual weight loss. An HEP

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is created for each individual basedon their estimated daily calorieneeds, calculated using the factorialapproach. The Dietary ReferenceIntake equation was used for over-weight or obese youth aged �19 years,and the Mifflin-St Jeor equation wasused for young adults aged �20 yearsto estimate resting metabolic rate.12,13

The resting metabolic rate was

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multiplied by an activity factor be-tween 1.4 and 1.6, as determined by abrief assessment of each participant’sactivity level to estimate total energyexpenditure. The HEP is based on theUS Department of Agriculture DailyFood Plan (now known as MyPlateDaily Checklist) that provides recom-mendations for the number of dailyfood group servings that should be

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consumed to meet nutrition needsbased on age, sex, and energy needs.14

Because the HEP is designed to pro-mote gradual weight loss, a deficit of250 kcal/day was subtracted fromestimated daily energy needs to pro-mote a weight loss of approximately 1/2lb/wk. Although the HEPs are calorie-based, Health U. messaging focusedmore simply on making healthy foodchoices.In the HEP, each of the six food

groups (fruits, vegetables, dairy, pro-tein, grains, and fats or sugars) is rep-resented by a food group square ofeasily recognizable food items fromthat group. Each of the squares repre-sents one serving from the food group.A serving size is a standard unit basedon the type of food, as recommendedby the US Department of Agriculture.For example, a serving size for grainsincludes 1 slice of bread or 1/2 cup pastaor rice. To help guide healthy foodchoices and account for discretionarycalories, each food group is brokendown into two sub-groups: always andonce-in-a-while foods. The alwayschoices are foods that should be eatenoften and contain all nutrients neces-sary for a nutritionally balanced diet.The once-in-a-while foods represent

1 cup (8 oz.) nonfat or low-fat

1 cup (8 oz.) fortified soy milk

1 cup (8 oz.) fortified almondunsweetened

1 oz. low-fat string cheese

1 oz. low-fat cheese (1 slice oshredded)

Cheddar, Colby, MoPepper Jack, Hava

½ cup (4 oz.) low-fat cottage c

¾ cup (6 oz.) non-fat/low-fat or Greek)

Always 1 serving = 1 dairy

Figure 2. Low-fat and unsweetened dairy orsweetened options contain more calories du

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choices in each food group that havemore fat, calories, or added sugar, andthus should be limited to facilitateweight loss. For example, both nonfatand low-fat milk are categorized as al-ways choices, whereas reduced-fat andwhole milk are considered once-in-a-while foods because they containmore fat and calories than the lower-fat milks (Figure 2). Each participant’sHEP includes recommended servingsper day from each of the food groups aswell as the number of once-in-a-whilefoods they can include daily from anyfood group. The concept of once-in-a-while foods provides flexibility soparticipants are able to consumediscretionary calories in moderation.The use of always and once-in-a-whilefoods was a subsequent modificationto the original HEP to improve clarityand choices in the use of discretionarycalories.The Food Guide is a companion

handbook to the HEP, designed to helpparents and participants better under-stand food choices and serving sizes,and to guide their meal planning andmanagement of portions. The FoodGuide is organized by food group, andserving sizes are listed for commonfoods with many examples of always

Once in a Whil

milk

milk,

r ¼ cup

nterey Jack, rti

heese

yogurt (regular

square

1 cup (8 oz.) reduced

1 cup (8 oz.) chocolat

1 cup (8 oz.) chocolat

1 oz. regular cheese (shredded)

Cheddar, Co

Pepper Jac

½ cup (4 oz.) whole-mcheese

¾ cup (6 oz.) whole mGreek)

Dairy

nondairy alternatives are considered always ce to additional fat or sugar and thus are con

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and once-in-a-while foods in eachgroup. Mixed dishes such as pizza,lasagna, or burritos may pose a chal-lenge in determining which foodgroups are represented in a serving.Examples of common mixed dishes arelisted in the Food Guide to help in-dividuals determine how to breakdown the components of these dishesinto the appropriate food groupsquares (Figure 3).

Although once-in-a-while foods arechoices that contain more fat or sugarbut still fit into a food group, treatsare foods that include desserts, sugar-sweetened beverages, and saltysnacks such as chips. The HEP in-corporates a weekly budget of calo-ries that may be used for treats. Theallowance of weekly treats providesflexibility, encourages planning ahead,and offers a realistic approach to helpindividuals understand how treatscan fit into a healthy diet. In creatingthe HEP, 57 kcal/day was allotted toeach individual’s daily plan to allowfor 400 kcal/week to be allocated astreats. The HEP uses coins to illustratethe concept of a weekly treat budget.Each week, participants have eightcoins (1 coin¼50 kcal) to use onwhichever treat food(s) they prefer.

e 1 serving = 1 dairy square

-fat milk or whole milk

e milk

e soy milk

1 slice or ¼ cup

lby, Monterey Jack,

k, Havarti

ilk cottage

ilk yogurt (regular or

hoices within the dairy group. Full-fat orsidered once-in-a-while choices.

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Figure 3. Examples shown in the Food Guide provide guidance on how to determine the food groups contained in commonmixed dishes.

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Participants can choose how theywould like to use their coins eachweek. They can use them all at once,or they may choose to exchange themfor smaller treats throughout theweek. There are many examplesincluded in the Food Guide and par-ents are given the formula to deter-mine how many coins are in treats ordesserts not listed in the Food Guide(Table).

CHALLENGESAlthough we believe that the HEP is anextremely useful weight loss tool, it isnot without limitations. The HEP wascreated for use within the Health U.

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intervention, but has not yet been usedoutside a multicomponent treatmentprogram. Within the Health U. groupintervention, parents received trainingand guidance in weekly goal settingand behavior strategies to help theirteenagers meet the target servings ofeach food group on their specific HEP.However, based on our experiences, webelieve the HEP could be adapted foruse in a clinical setting where effectiveweight loss tools designed for in-dividuals with ID are lacking. Underthe guidance of a registered dietitiannutritionist (RDN), families couldreceive training to understand theconcepts of serving size, healthy foodchoices, and use of coins to represent

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treats. Regular meetings with an RDNwould follow to help families imple-ment gradual dietary changes specifiedin their HEPs, monitor successes, andaddress challenges to continued weightloss and accomplishment of healthyeating goals.

Distinguishing between always andonce-in-a-while foods was a challengein the development of the HEP becausethe diversity of food products availablein today’s food environment can makecategorizing food choices difficult.Because our focus was on calories, wekept choices like white bread and pastain the always category because thecalories are very similar to whole-grainchoices. However, nutrition education

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Table. Treats and corresponding coin values

Treat Coin value

Drinks

Gatoradea (12 oz) 2

Vitamin Waterb (20-oz bottle) 2

Sweetened ice tea or lemonade (12 oz) 3

Soda (12 oz) 3

Coolattac (12 oz) 6

Desserts

Chocolate sandwich cookie (eg, 1 Oreod) 1

Fruit popsicle (Edy’s real fruit bare) 1

Crisped rice treat (2-in cube) 2

Sorbet/frozen yogurt (1/2 c) 2

Ice cream (1/2 c) 3

Ice cream sandwich (2 oz) (eg, Good Humorf) 3

Large cookie (21/2 in) 5

Candy (1 bar or package) 5

Chipwichg or Klondike barf 5

Cupcake (2 in) with frosting 6

aQuaker Oats Company.bEnergy Brands.cDunkin Donuts.dKraft Foods Inc.eDreyer’s Grand Ice Cream Holdings, Inc.fUnilever USA.gNestlé.

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was focused on making the healthiestchoices in each food group and,thus, we stressed the benefits ofchoosing whole grains over whitegrains. In a few cases, we made thedecision to take nutritional quality intoaccount, particularly in foods rich inhealthy unsaturated fats. For example,although higher in calories than otheralways choices within the same foodgroup, avocados, nuts, and nut buttersare listed as always choices. The deci-sion to include some higher-caloriefoods and unsaturated fats in thealways categories was based on thepremise that these foods are animportant part of a healthy diet. How-ever, because these foods have a highercaloric content than other foods in thealways category, additional counselingon portion sizes and variety is neededto ensure that participants are notexceeding their recommended calorielimits. This highlights the importanceof implementing the HEP under theguidance of an RDN.

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The always and once-in-a-whilecategories contain a range of foodswith varying calorie levels; so althoughon average the always foods containfewer calories than the once-in-a-while choices, it is not an exact sci-ence. The categories are meant to serveas a guide to participants and parentsto help influence food choices anddirect them toward the lower-calorie,more-nutrient-dense choices. In caseswhere the HEP and Food Guide areadapted for different populations,RDNs could make different decisionsabout how to categorize always vsonce-in-a-while foods. Because not allfoods could be included in the FoodGuide, calories per serving of the al-ways and once-in-a-while choices ineach food group were averaged toprovide a reference for parents or par-ticipants to use in case they cameacross a food not listed in the FoodGuide. The Food Guide was created forparticipants in the Health U. interven-tion, which did not comprise an

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ethnically diverse sample. For thisreason, the Food Guide does notinclude a wide range of ethnic foodoptions. That said, we believe thatRDNs could modify the Food Guide tolist more culturally appropriate andethnically diverse foods to meet theneeds of the population for which it isbeing used.

IMPLEMENTING AN HEP WITHADOLESCENTS AND FAMILIESThe implementation of the HEP is agradual process. In the Health U. study,parents attended a training sessionwhere the HEP was introduced andthey are given the opportunity topractice using the HEP to plan theiradolescents’ meals, before the start ofthe program.9 An RDN providestraining for parents on both the HEPand the Food Guide, including a reviewof serving sizes, differences betweenalways and once-in-a-while foods, andthe concept of using coins to representtreats. Implementation of the HEP issimilar to many weight-loss ap-proaches in that it is important that anRDN work with the individual andfamily using motivational interviewingtechniques, such as reflective listeningand assessing readiness to change, tohelp determine what changes they areready and able to make. Caregivers orparticipants (if able) are asked tomonitor or track their daily intaketo monitor progress and adherence totheir HEP. Gradual progress is the goal.Participants are not expected to beable to meet the recommendations oftheir HEP immediately, but they areencouraged to use the HEP as themeans to achieving long-term goals.Education and counseling are gearedtoward caregivers at first because theyare responsible for driving behaviorchanges initially. However, the longer-term objective of an RDN workingwith the family is to help the partici-pant with ID to develop a good under-standing of their HEP along with animproved ability to make healthychoices and stick to their goals withoutparental supervision.

CLINICAL APPLICATIONSTeaching clients, or in our case researchparticipants, about healthy food choicesas part of implementing a weight-lossplan has become increasingly chal-lenging with the vast and complex food

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choices available in today’s food envi-ronment. The HEP is a simplified, visu-ally based weight-loss and healthy-eating tool that has many strengths,particularly for use by individuals withID. By focusingon food groups insteadofcalories, we aim to promote the impor-tance of dietary variety and inclusion ofservings from all food groups daily. TheHEP provides individuals with a con-crete means for working toward short-and long-term goals, which can beparticularly beneficial for teenagers andyoung adults with ID who respond wellto structure and routine. Althoughstructured, the HEP also leaves room forflexibility inuseof discretionarycaloriesand treats, which helps make it a real-istic and sustainable weight-loss tool.The effectiveness of the HEP and FoodGuide as components of the largerHealth U. program have not been eval-uated separately; however, participantsand families have responded to bothwith very positive feedback. As noted,an earlier version of theHEPwas used inthe Health U. pilot study, completed in2010.11 In that study, all participantsreceived individualized HEPs. Onegroupof families receivedonlynutritioneducation and a second group of fam-ilies received nutrition education sup-plemented with behavior training.Behavior training included goal-settingand reinforcement techniques to pro-mote and reinforce adherence to theHEP. The nutrition education plusbehavior training group had signifi-cantly greater weight loss that wassustained at 12months.11 This and otherresearch suggests that behav-ioral supports are needed to bolsteradherence to nutrition tools such asthe HEP.

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CONCLUSIONSExisting evidence-based guidelines forhealthy eating, including MyPlate, areuseful for improving eating habitsin the general population. However,tools to support healthy eating andweight loss that are adapted to meetthe needs of individuals with ID arelacking. The HEP is based on the USDepartment of Agriculture DietaryGuidelines, but includes visual repre-sentations of food groups for pop-ulations with limited literacy skills. Itoffers simplified guidance about thedaily number of recommended serv-ings from each food group, and des-ignates the healthiest choices withineach food group in a visual format. Webelieve that the HEP is a uniquelyadapted tool for adolescents andyoung adults with ID that can helpimprove dietary choices and aid inweight loss under the guidance of anRDN and program of behavioral sup-port. Further research is needed to testthe effectiveness and acceptance ofthe HEP outside of the Health U. groupprogram in a clinical setting.

References1. Ul-Haq Z, Mackay DF, Fenwick E, Pell JP.

Meta-analysis of the association betweenbody mass index and health-relatedquality of life among adults, assessed bythe SF-36. Obesity. 2013;21(3):E322-E327.

2. Reilly JJ, Kelly J. Long-term impact ofoverweight and obesity in childhoodand adolescence on morbidity and pre-mature mortality in adulthood: A sys-tematic review. Int J Obes. 2011;35(7):891-898.

3. Serdula MK, Ivery D, Coates RJ,Freedman DS, Williamson DF, Byers T. Doobese children become obese adults? Areview of the literature. Prev Med.1993;22(2):167-177.

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4. Reilly JJ, Methven E, McDowell ZC, et al.Health consequences of obesity. Arch DisChild. 2003;88(9):748-752.

5. Ogden CL, Carroll MD, Kit BK, Flegal KM.Prevalence of childhood and adult obesityin the United States, 2011-2012. JAMA.2014;311(8):806-814.

6. Segal M, Eliasziw M, Phillips S, et al.Intellectual disability is associated withincreased risk for obesity in a nation-ally representative sample of U.S. chil-dren. Disabil Health J. 2016;9(3):392-398.

7. Basil JS, Santoro SL, Martin LJ, Healy KW,Chini BA, Saal HM. Retrospective study ofobesity in children with Down syndrome.J Pediatr. 2016;173:143-148.

8. Curtin C, Jojic M, Bandini LG. Obesity inchildren with autism spectrum disorder.Harvard Rev Psychiatr. 2014;22(2):93-103.

9. Rotatori A, Switzky H, Fox R. Behav-ioral weight reduction procedures forobese mentally retarded individuals: Areview. Ment Retard. 1981;19(4):157-161.

10. Ptomey LT, Sullivan DK, Lee J, Goetz JR,Gibson C, Donnelly JE. The use of tech-nology for delivering a weight loss pro-gram for adolescents with intellectual anddevelopmental disabilities. J Acad NutrDiet. 2015;115(1):112-118.

11. Curtin C, Bandini LG, Must A, et al. Parentsupport improves weight loss in adoles-cents and young adults with Downsyndrome. J Pediatr. 2013;163(5):1402-1408. e1.

12. Institute of Medicine, Food and Nutri-tion Board. Dietary Reference Intakes forEnergy, Carbohydrate, Fiber, Fat, FattyAcids, Cholesterol, Protein, and AminoAcids (Macronutrients). Washington,DC: The National Academies Press;2005.

13. Mifflin MD, St Jeor ST, Hill LA, Scott BJ,Daugherty SA, Koh YO. A new predictiveequation for resting energy expenditurein healthy individuals. Am J Clin Nutr.1990;51(2):241-247.

14. US Department of Agriculture. MyPlatedaily checklist. http://www.choosemyplate.gov/MyPlate-Daily-Checklist. UpdatedFebruary 8, 2016. Accessed March 22,2016.

DISCLOSURESSTATEMENT OF POTENTIAL CONFLICT OF INTERESTNo potential conflict of interest was reported by the authors.

FUNDING/SUPPORTSupported by the National Institutes of Health (R01 HD072573, DK070627, and IDDRC 2P30HD004147), the Maternal and Child Health Bureau(MCJ259631 and UA3MC25735-01-00), and the John W. Alden Trust.

ACKNOWLEDGEMENTSThe authors thank Nicole Collins, MPH, RDN, for her contributions in the development and revision of the Healthy Eating Plans and Food Guide.

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