Introduction

Obesity has been officially classified as a disease in the United States, which augments the need for adherence to healthy diets and exercise interventions. According to the Centers for Disease Control and Prevention (CDC), obesity and overweight are defined as “labels for ranges of weight that are greater than what is generally considered healthy for a given height,” which are commonly measured by body mass index (BMI). People with disabilities have been found to be more sedentary than their non-disabled peers (Rimmer et al., 2012), which ultimately increases their risk of obesity and cardiometabolic disease. Researchers, clinicians, and policymakers have come to understand that a solution towards this epidemic is the incorporation of a physically active lifestyle during childhood and adolescents, which is associated with greater adherence to exercise in adulthood (Malina, 1996; Simonen et al., 2003). Thus, there is high research funding and interest in exercise interventions towards children with disabilities. Causes for obesity have been linked to genetics, poor diet, and a sedentary lifestyle. Obesity in children with disabilities has also been suggested to be associated with socioeconomic status, the BMI of the parents, the parent’s perception and attitudes towards their children’s weight and physical activity, and levels of activity in both parents and children (McGillivray et al., 2013). Though, there is still a current need for research on enjoyable exercise interventions that examine dose-response relationships between exercise and optimal health outcomes in children with different conditions of disabilities.

Risk Factor for Future Health Problems

Not only are children with obesity at immediate health risk for pediatric cardiovascular diseases (Saha et al., 2011), diabetes (Baranowski et al., 2006), and sleep disorders (Dayyat et al., 2009), but they are also at risk for medical problems that may occur later in life, such as stroke, heart disease, and cancer. It is established that children with disability are at a much higher risk of obesity than typically developing children (Allerton et al., 2012), putting them at higher risk of disease.  In addition, Lloyd et al. (2012a) found that 30% out of a sample of 9,678 children and youth with intellectual disabilities who participated in the Special Olympics were overweight and obese. Since a large amount of children at a highly-competitive level of sport were found obese or overweight, this highlights the concern of obesity in the general population of children with disability. Sedentary lifestyle is not the only contributor to obesity. Barriers towards exercise (e.g., accessibility, cost, and transportation) and medication also influence weight gain. Parents should consult with a physician about whether their child is at an adequate weight for their age/height and has a healthy plasma lipid level.

Psychological Risk Factors

Psychological health has been receiving more attention in recent years. Researchers, policy makers, and media have begun to intervene on teasing, physical abuse, and social-exclusion in schools, otherwise known as bullying. In addition, bullying has significantly grown with the recent boom of social media, leading to a new and pressing issue termed cyber-bullying. Children with disabilities are at a greater risk of being bullied, which can result in low self-esteem and depression. Poor psychological health can lead to a self-fulfilling prophecy of failure when pursuing goals. It is important for children with disabilities to receive social support from friends, family, and educators to cope with these stressors.

Benefits of Exercise

Although research on exercise and disability has been gaining popularity in the last couple decades, the literature is sparse on the exact dose of exercise to elicit the most optimal improvements in health for most disabilities, especially those that are cognitive in nature. Exercise has been documented to improve physical ability and quality of life in children with disability, such populations may include cerebral palsy (Gates et al., 2012), intellectual disabilities (Bartlo et al., 2011), and neuromuscular diseases (Abresch et al., 2012). Research suggests that exercise also improves cognitive function and brain health in children with both physical (Ploughman et al., 2008) and intellectual disabilities (Pastula et al., 2012).

Examples of benefits of exercise may also include:

• Reduced risk of cardiovascular disease
• Reduced risk of diabetes
• Reduced risk of cancer
• Enhanced weight management
• Delayed symptoms of some progressive diseases
• Improved bone density
• Improved overall quality of life and psychological well-being
• Improved functional independence when performing activities of daily living
• Improved communication and psychosocial health through group exercise

Dietary Guidelines

The sports medicine culture, personified by the American College of Sports Medicine (ACSM), has always emphasized the concept of promotion of health through exercise in various populations. ACSM has recently begun to appoint and stress the importance of people who are certified in both exercise and nutrition to battle the obesity epidemic in their organization. Knowledge will be required from multi-dimensions and organizations to successfully combat obesity as a disease, particularly in a complex population such as children with disabilities. The nutritional needs of children with disabilities will depend on the requirements of the type and cause of the disability. However, the Department of Health and Human Services (HHS) and the Department of Agriculture (USDA) released the new Dietary Guidelines for Americans in 2010. Some Key recommendations include:

• Prevent and/or reduce overweight and obesity through improved eating and physical activity behaviors
• Increase daily intake of fruits and vegetables, whole grains, and nonfat or low-fat milk and milk products
• Control calorie intake to manage body weight
• Reduce sodium intake below 2,300 mg, or 1,500 mg for persons who are African American or have hypertension, diabetes, or chronic heart disease
• Consume less than 10 % of calories from saturated fatty acids by replacing them with monounsaturated and polyunsaturated fatty acids
• Consume less than 300 mg per day of dietary cholesterol
• Keep trans fatty acid consumption as low as possible
• Reduce the intake of calories from solid fats and added sugars
• Limit the consumption of food that contained refined grains
• Make smart choices from every food group
• Increase physical activity and reduce time spent in sedentary behaviors

What is Physical Activity?

Physical activity is defined by the U.S. Department of Health and Human Services as any ‘bodily movement produced by skeletal muscles that result in energy expenditure.’ There are five components of exercise: cardiovascular, strength, balance, flexibility, and functional motor skills exercise. According to the CDC, Children should perform 60 minutes of moderate- or vigorous-intensity physical activity per day, which can be assessed using a zero-to-10 scale (where a score of “zero” is sitting and “10” is the perceived highest level of exertion). Moderate intensity on the zero-to-10 scale would be roughly a score of five to six. Vigorous physical activity is classified by a seven or eight. Careful observation of the child’s breathing, heart rate, and speech may provide a great indication of what level of activity they are performing. A simpler test that may be performed to assess intensity of exercise may be the “talk test.” The “talk test” is conducted by asking the child to talk to you or sing. If the child is able to sing then they are working at a mild intensity of exercise. If the child cannot sing but can talk to you, then they are most likely working at a moderate intensity. However, if the child is unable to respond verbally than he/she might be working at a very high intensity of exercise.

Cardiovascular Exercise

Cardiovascular/aerobic exercise is extremely important for improving physical and mental health in children with disabilities. Cardiovascular exercise should be adapted to accommodate for the needs of the individual. Such adaptations/modifications include:

• arm ergometry
• wheelchair tennis
• wheelchair basketball
• wheelchair volleyball
• ball tossing
• walking between parallel bars or with assistive devices
• swimming or underwater walking
• wheelchair group exercise classes

Cardiovascular exercise has been linked with numerous improvements towards physical and mental health. Vigorous-intensity cardiovascular exercise should be performed at least three days a week (60 minutes per day).

Strength Training

Strength exercise is critical for promoting and maintaining bone, lipid, and functional health in children with disabilities. The primary goal of strength exercise will depend on the individual needs of the child. To improve functional independence and improve performance of activities of daily living, some children with disabilities may require muscular endurance (high sets/reps) to prevent fatigue, while others may need to increase skeletal muscle strength (moderate sets/reps). To enhance motivation and adherence, strength exercises should be performed in fun and diverse environments, such as gymnastics or in a swimming pool.  However, if weight lifting is performed, as a general recommendation an individual should aim to achieve two to three sets of 10 repetitions. Exercises should be adapted as necessary to achieve these goals. Examples of adapted strength exercises for children with disabilities include:

• resistance bands
• concentric-only exercise (e.x. hydraulic exercise machines)
• manual resistance exercise
• aquatic exercise
• wheelchair-accessible exercise machines.

Strength exercise should be performed three times per week (60 minutes per day) and is best combined with aerobic exercise. A longer warm-up may be required for children with disabilities before strength exercises. In this case, cardiovascular exercise or light passive/active stretching may be performed prior.

Balance, Flexibility, and Functional Motor Skills (FMS)

Balance exercise is often neglected in an exercise program. However, balance is a key component of exercise for populations with disabilities as it assists them with the performance of activities of daily living and reduces the risk of falling. Falls are a major cause of injury and mortality in people with disabilities. Balance exercises should be catered towards the needs of the individual. Static (non-locomotive) sitting, static standing, and dynamic balance (locomotive, e.x. walking), should be considered when designing an exercise program. Examples of balance exercises may include: unsupported chair sitting, unsupported chair reaching, unsupported chair ball tossing, or nudging. If falls are of concern, parallel bars or weight support (via aquatic balance exercise or overground weight support systems) is recommended when performing standing balance exercises.

Limited flexibility is common among children with disabilities and may interfere with the performances of their activities of daily living. Spasticity or rigidity, characterized by stiffness of the muscle, often causes deviations in posture, which can hinder performance and functional capability. While flexibility may not always provide a complete fix/cure for these deficiencies, it often improves range of motion. Flexibility should be performed after strength/cardiovascular exercise to reduce exercise-induced skeletal muscle tension. However, light active or passive stretching may be performed prior to exercise as a warm-up to facilitate blood flow and range of motion. Flexibility should consist of 3 sets of 10 second end-point holds (30 second stretching may be strenuous). Communication is critical to safely finding end-points of flexibility in people with disabilities.

Functional motor skills (FMS) exercises are incorporated in regimes to promote functional independence. FMS is typically used during the early stages of rehabilitation and when performance of activities of daily living is impaired. Examples of FMS may include: positional changes (lying prone to sitting or standing), passive exercise to facilitate blood flow (especially in the lower extremities), and fine motor skills (e.x. stacking cones or moving pegs).

Conclusion

Obesity has been officially classified as a disease and is more prevalent in children with disabilities than those without. Physical activity is important for battling the risk of immediate and future health diseases that result from obesity. Exercise has been shown to improve quality of life, as well as the physiological, mental, and the psychosocial health of children with disabilities. An adapted exercise program, focused on five components of fitness (cardiovascular, strength, balance, flexibility, and functional motor skill exercise), should be incorporated with a healthy diet in this population. Motivation to exercise is especially important for children and can be increased by making activities fun, diverse, achievable, and/or performed in a social/group setting. Parents act as facilitators for children to perform physical activity. To get your child involved in a physically active lifestyle, ensure that you as a parent are active, and check out your local park district and nearby community centers that may offer classes and camps for children with special needs. Physical activity, particularly sport participation (Malina, 1996), should be promoted at a young age in children with disabilities to continue a physically active lifestyle across their lifespans.

References

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