行政院國家科學委員會補助專題研究計畫
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INTRODUCTION
Physical inactivity, inadequate dietary intake, and chronic diseases are the top three pressing issues in health promotion research for people with intellectual disabilities (ID) (Frey, Temple, & Stanish, 2006). Recently, studies have indicated an increasing trend of overweight and obesity rates in institutional residents with intellectual disabilities (ID) in Taiwan (e.g., Yen et al., 2005). It is imperative to design nutrition and physical activity programs specifically for people with ID to reduce the prevalence of obesity, obesityrelated chronic diseases, and socioeconomic costs, as well as improve their quality of life. Researchers reported that individuals with ID who lived in institutional settings with good health management programs had lower BMI compared to those with ID who resided in communitybased homes in the United States and Germany (Frey & Rimmer, 1995). Implementation of health promotion programs to individuals with ID in more structured and supervised environments, such as institutional residential settings, showed high effectiveness and efficiency (Frey & Rimmer, 1995).
Results indicated that the intervention did not significantly reduce participants’ BMI and body fat percentages. The researchers, however, noted that staff involved in the process showed positive attitude toward healthy diet and exercise for individuals with ID at the end of the intervention program. A lack of a structured exercise curricula and trained fitness instructors to lead exercise sessions appears to be two major limitations of health promotion programs in institutional settings in Taiwan.
obtaining the written informed consent of eligible participants with ID and their primary caregivers/guardians, the researcher coordinated with the staff members of the recruited institution to schedule a pretest with participants with ID. Development of Intervention Program: The InstitutionalBased Health, Nutrition and Exercise Curriculum (IBHNEC) The InstitutionalBased Health, Nutrition and Exercise Curriculum (IBHNEC) was developed based on Exercise and Nutrition Health Education Curriculum for Adults with Developmental Disabilities (Heller, Marks, & Ailey, 2004). The ACSM and AHA physical activity guidelines (ACSM, 2008) were modified and used to guide the exercise sessions. The intervention consisted of 2 parts; education and exercise sessions, taken in place at the institution. Participants in the experimental group met 3 days a week for 2 hours per day, for 12 consecutive weeks. Due to the limitation in exercise equipment, walking and strength exercises (without commercial weight machines) were selected for the exercise sessions. Education sessions included health education, nutrition and physical activity knowledge, and behavioral strategies used to enhance selfefficacy and overcome barriers. Direct caregivers of participants with ID in the experimental group were asked to attend the education and exercise sessions with them. Contents related to how caregivers can assist participants with ID to establish an active lifestyle were integrated in the curriculum. Additionally, behavioral strategies were included to enhance the motivation and participation of the participants with ID in the intervention. To ensure the instructional consistency of IBHNEC sections delivered by four different instructors in the intervention phrase, standard operation procedures and instructional narratives were developed and integrated into the IBHNEC.
Data Collection and Measures
Baseline and posttest measures took place at the National Taiwan Sport University gymnasium. Three types of measurements were included: (a) physical fitness measures: 1mile Rockport walking test, leg extension, handgrip, and skinfold measures; (b) functional performance: stair ascent and descent, chair rise, and gait speed; (c) nutrition and physical activity knowledge.
Physical fitness measures
1Mile Rockport walking test (cardiovascular fitness). The validity and reliability of the 1Mile
Rockport Fitness Test was initially examined by Rintala and her colleagues (1992) for men with ID. The equation determined to predict peak VO2 = 101.92 – 2.356(1 mile walk time) – 0.42 (weight). This
model accounted for 85% of total variance. The standard error of estimate was 4.06 ml.kg 1 .min 1 . In addition, the testretest reliability of the RFWT was high (r = 0.97). The participants with ID walked 1 mile (1609 meters) while paired with a testing assistant. The participants with ID were told “walk as
fast as you can as if were in a hurry to go somewhere until I tell you stop.” Testing assistants verbally
encouraged participants to keep walking. The time and heart rate (beats per minute) were measured and recorded immediately after finishing the walk.
strength. The maximum weight the participants performed for 10 repetitions was used to calculate the participants’ predicted 1RM. Handgrip. Handgrip strength was measured with a GripA handgrip dynamometer. Three trials were measured for each hand, respectively. The best score of each hand was recorded and used for data analyses. Skindfold measurements. Skinfold caliper was used to measure skinfold measurements at the chest, abdomen, and thigh location for males and triceps, suprailiac, and thigh for females. The sum of the three sites taken was used in the main data analyses. Functional performance measures Chair rise. In the chair rise test (Manini, Cook, VanArnam, Marko, & PloutzSnyder, 2006), participants with ID were asked to rise from three different seat pan height (distance from sitting surface to the floor) chairs of 43 cm, 38 cm, and 30 cm (Alaxander, Galecki, Nyquist, et al., 2000; Manini, et al., 2006) for 5 consecutive times. Times were recorded for the three different chair heights. Testers provided the following directions “When you hear ‘Go’, please rise from the chair as quickly as possible with your hands placed across your chest.” Gait speed. In the gait speed test (Manini et al., 2006), participants were timed while
walking 25 feet (7.62 meters) at their fastest pace without running. Participants were rated as “no difficulty” or “difficulty” walking at 1.22 m/sec, which is the speed required to cross a signaled intersection. “No difficulty” indicated that the participant could walk at a speed of 1.22 m/sec or faster, “difficulty” indicated they were unable to walk at that speed.
Stair ascent and descent. In the stair ascent and descent test (Manini et al., 2006), participants
examine whether there was group differences for age, height, weight, and BMI; while chisquare tests were implemented on gender and body weight categories. A series of analyses of covariance (ANCOVAs) were conducted to compare the dependent variables (e.g., BMI, height, weight, time completed 1mile walking, lower body strength, handgrip strength, etc.) in posttest scores of participants between noneexperimental and experimental groups using the pretest scores as covariates, respectively. RESULTS AND DISCUSSION Participant demographics are organized in Tables 1 and 2. No significant group differences were indicated in age, gender, height, weight, body mass index (BMI), and body weight category. Seventy percent of participants were overweight or obese based on the Pacific Asia BMI definition (WHO/IASO/IOTF, 2000). Table 1. Participant Demographics 1: Gender and Body Weight Category
Experimental (n = 27) NoneExperimental (n = 25) Total (n = 52)
Demographic n % n % n % Gender Male Female 9 18 33.3 66.7 10 15 40.0 60.0 19 33 36.5 63.5 Body Weight Level Underweight Standard Overweight Obese 0 8 8 11 0.0 29.6 29.6 40.8 0 12 3 10 0.0 48.0 12.0 40.0 0 20 11 21 0.0 38.5 21.2 40.3
Note. Body Weight: Underweight, BMI <18.5 kg/m 2 ; Standard, BMI 18.5123.0 kg/m 2 ; Overweight, BMI = 23.0125.00 kg/m 2 ; Obese, BMI > 25.01 kg/m 2 .
Table 2. Participant Demographics 2: Age, Height, Weight, and Body Mass Index (BMI) Experimental (n = 27) NoneExperimental (n = 25) Total (n = 52)
Demographic Mean SD Mean SD Mean SD
decrease in the number of participants who had difficulty in performing stair ascent (36%) and stair descent (44%) without supports in the nonexperimental group than in the experimental group (stair ascent, 29.6%; stair descent 29.6%). Yet, for Gait speed, participants in the experimental group revealed a decrease of 33.4% in participants who had difficulty walking at a speed of 1.22 m/sec or faster compared to a reduction of 8% in nonexperiment group. In the percentage of participants categorized as overweight and obese, the experimental group had fewer participants (14%) than the nonexperimental group (4.0%) at posttest. It appears that there was some other unknown factor that impacted the functional performance of nonexperimental group. Table 3. Functional Performance and Body Weight Level by PrePosttest and Experimental Condition Experimental (n = 27) NoneExperimental (n = 25) Pretest Posttest Pretest Posttest Dependent Variables n % n % n % n % Body Weight Level Underweight Standard Overweight Obese 0 8 8 11 0.0 29.6 29.6 40.7 0 12 7 8 0.0 44.4 25.9 29.6 0 12 3 10 0.0 48.0 12.0 40.0 1 12 0 12 4.0 48.0 0.0 48.0 Gait speed Difficulty Without Difficulty Missing 16 4 7 59.3 14.8 25.9 7 15 5 25.9 55.6 18.5 19 0 6 76.0 0.0 24.0 17 7 1 68.0 28.0 4.0 Stair ascent Difficulty Without Difficulty Missing 10 15 2 37.0 55.6 7.4 2 25 0 7.4 92.6 0.0 10 14 1 40.0 56.0 4.0 1 16 8 4.0 64.0 32.0 Stair descent Difficulty Without Difficulty Missing 13 12 2 48.1 44.4 7.4 5 22 0 18.5 81.5 0.0 15 9 1 60.0 36.0 4.0 4 13 8 16.0 52.0 32.0
Note. Body Weight: Underweight, BMI <18.5 kg/m 2 ; Standard, BMI 18.5123.0 kg/m 2 ; Overweight, BMI = 23.0125.00 kg/m 2 ; Obese, BMI > 25.01 kg/m 2 .
A summary of means and standard deviations (SDs) of preand posttest dependent measures across experimental conditions, as well as the results of the ANCOVAs are presented in Table 4. After adjusting for the pretest scores, significant group differences were revealed for the following posttest dependent measures: body weight, F(1,49) = 9.36, p = .004 < .05; BMI; F(1,49) = 6.86, p = .012 < .05; stair
descent, F(1,36) = 6.32, p = .017 < .05; chair rise from 43 cm height, F(1,33) = 7.48, p = .010; and nutrition
and physical activity knowledge, F(1,45) = 9.132, p = .004 < .05. No significant differences were
ascent, and chair rise from a 38 cm and 30 cm heights. The findings showed that the intervention program significantly improved weight reduction, stair descent, chair rise at 43 cm height, and knowledge in nutrition and physical activity. While a significant improvement in cardiovascular endurance, lower body strength, and some areas of functional performance was not observed, the significant advancement in nutrition and physical activity knowledge indicated an effect of the education sessions. Table 4. Summary of Dependent Measures by PrePosttest and Experimental Condition Experimental (n = 27) NoneExperimental (n = 25) Pretest Posttest Pretest Posttest Dependent Measures Mean SD Mean SD Mean SD Mean SD
buildings. While the length of the intervention program may be an important factor explaining the lack of improvements in physical fitness and some functional performance, difficulty in monitoring exercise intensities may also contribute to the outcomes, although exercise records were kept in every session. More effort needs to be devoted to the application of perceived exertion scales in persons with ID. The intervention program was tailored to meet the facility and equipment availabilities of the participant institute. Lack of fitness equipment at the participant institution may also contribute to the limited improvement in physical fitness and some functional performance measures. Particularly, for strength training, we used recycled bottles as freeweights to perform strength exercise, since no commercial weight machines were available. It was a great challenge to have participants with ID performs strength exercises with different sizes of bottled water and with good form. Therefore, to maximize the effect of fitness outcomes, a well equipped fitness center is needed in institutional settings. It would be more methodologically desirable to control physical activity for participants in the nonexperimental group. Anecdotal evidence indicated that staff members and caregivers involved in the study applied what they learned from the education and exercise sessions to their morning activities. Several caregivers expressed interest in or requested IBHNEC information from the research assistants. This indicates a potential educational effect and attitudinal change of caregivers through the IBHNEC that may further lead to significant improvement of posttest outcome measures of participants in nonexperimental group. This serves as potential evidence of the effect of such an educational health promotion intervention program to caregivers and individuals with ID. Research that examines the effect of caregiver interventions to health promotion outcomes of individuals with ID is limited. The caregivers’ impacts on health promotion of people with ID should be further explored.
References Alexander, N. B., Galecki, A. T., Nyquist, L. V., et al., (2000). Chair and bed rise performance in ADLimpaired congregate housing residents. Journal of the American Geriatrics Society, 48, 526533. American College of Sports Medicine (2007). The ACSM and AHA physical activity guidelines. Retrieved on June 23, 2007, http://www.acsm.org
