TIRR-affiliated Research Center Develops a Novel Weight Loss Program for Women with Mobility Impairments

By Susan Robinson-Whelen, PhD, and Margaret A. Nosek, PhD

Weight management can be one of the most frustrating and challenging conditions facing women with mobility impairments (MI). Rates of obesity are higher among people with disabilities than those without (42% versus 29%),¹ and women with disabilities have higher rates of obesity than men with disabilities.^2,3 Many factors contribute to obesity among people with disabilities, including physiological factors, biochemical mechanisms, medications that affect metabolism and satiety, and an array of complex barriers to effective weight management.^4,5 Exercise can be limited by the disability itself as well as by disability-related fatigue, weakness and pain.⁶ These same disability-related conditions can make shopping and meal preparation difficult, causing greater reliance on convenience food and less control over one’s diet. Environmental barriers and limited financial resources further limit both opportunities for physical activity and access to healthy food.⁷

Despite wide recognition of the need,⁸ there are no publicly available weight management programs for people with disabilities. Researchers at the Center for Research on Women with Disabilities (CROWD), a research center affiliated with Baylor College of Medicine and TIRR Memorial Hermann, have recently stepped up to meet this need by developing a program that is accessible and responsive to the unique needs of women with MI. With funding from the National Institute on Disability, Independent Living, and Rehabilitation Research, principal investigator Margaret Nosek and fellow CROWD investigators have collaborated with researchers from the University of Houston Texas Obesity Research Center, the University of Montana Rural Institute for Inclusive Communities, Arizona State University and Case Western Reserve University to meet this critical need by modifying an established lifestyle change intervention – the Diabetes Prevention Program (DPP).⁹ The research team partnered with a five-member community advisory board of women with MI who helped modify the curriculum, beta tested it and offered input on all aspects of the study. The result of this three-year collaborative effort is GoWoman, an Internet-based group intervention program.

The DPP, which served as the foundation for GoWoman, is a well-known program with documented efficacy for weight loss and diabetes risk reduction in large multisite longitudinal studies.¹⁰ Our community advisors, however, found key features of the DPP, including the prescribed weight loss (7% of body weight) and activity (150 minutes of brisk physical activity) goals, to be so out-of-touch with their lived experience as to seem unachievable. They generated many topics they thought should be added to the program, including information on monitoring your weight loss when you can’t stand on a scale, physical activity for those with severe limitations, adaptive cooking, healthy eating on a budget and effective communication with those who shop or cook for you.

Just as important as making the intervention content relevant and accessible, it was critical that the program be physically accessible. To eliminate barriers to attending in-person sessions, GoWoman was designed to be offered in a publically available online virtual world called Second Life.¹¹ Participants, using avatars to represent themselves, have the option of giving their avatar a visible disability or assistive device. Similar to real-world sessions, group facilitators present material using PowerPoint displayed on white boards, and facilitators and participants interact with each other using voice or text as they discuss the content, share their struggles and successes, and support one another.

In a recently completed pilot test of the program using a single-group pre-posttest quasi-experimental design, a sample of 13 women enrolled and completed at least half of the 16 weekly GoWoman sessions. Pilot participants lost an average of 6 pounds (3% of their body weight) and an average 1.2 inches in their waist, reduced daily caloric intake, increased physical activity and reported increased self-efficacy for diet and physical activity. There was some evidence that age and level of impairment influenced the amount of weight lost, but the strongest moderator of improvement was level of engagement, with those attending more sessions and more frequently recording dietary intake having greater weight loss.

Participants rated the GoWoman program highly and were positive in their evaluation of Second Life as an intervention platform. It was clear from post-intervention evaluations that participants valued the support and “opportunity to talk to people in similar situations.” Comments such as “positive changes do not have to be accomplished through or strenuous activities,” further suggest that participants experienced increased confidence that weight loss was within their reach. The results of our pilot study are encouraging and suggest that women with MI can lose weight with such a group intervention program. Qualitative results highlight the value of peer interaction and suggest that Second Life and similar platforms hold promise for the delivery of group health promotion interventions to under-served populations.

To learn more about the study and find tips and perspectives on weight management for people with disabilities, visit our study website ( https://www.bcm.edu/research/labs-and-centers/research-centers/center-for-research-on-women-with-disabilities/topics/healthy-behaviors/weight-management) and check out our GoWoman blogs (https://blogs.bcm.edu/topics/gowoman/).

References

1. Froehlich-Grobe K, Lee J, Washburn RA. Disparities in Obesity and Related Conditions Among Americans with Disabilities. Am J Prev Med. 2013;45(1):83–90.
2. Nosek MA, Robinson-Whelen S, Hughes RB, et al. Overweight and obesity in women with physical disabilities: Associations with demographic and disability characteristics and secondary conditions. Disability and Health Journal. 2008;1(2):89-98.
3. Centers for Disease Control and Prevention. State-specific prevalence of obesity among adults with disabilities-eight states and the District of Columbia, 1998-1999. Morb Mortal Wkly Rep. 2002;51 (36):805-808.
4. Fox MH, Witten MH, Lullo C. Reducing Obesity among People with Disability. Journal of Disability Policy Studies. 2013;Epub ahead of print.
5. Bauman WA, Spungen AM. Carbohydrate and lipid metabolism in chronic spinal cord injury. J Spinal Cord Med. 2001;24(4):266-277.
6. Rimmer JH, Wolf LA, Armour BS, et al. Physical activity among adults with a disability - United States, 2005. Morb Mortal Wkly Rep. 2007;56:1021-1024.
7. Rimmer JH, Riley B, Wang E, Rauworth A, Jurkowski J. Physical activity participation among persons with disabilities: barriers and facilitators. Am J Prev Med. 2004;26(5):419-425.
8. U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities. 2005; http://www.ncbi.nlm.nih.gov/books/NBK44667/. Accessed June 1, 2016.
9. Diabetes Prevention Program Research Group. The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care. 2002;25(12):2165-2171.
10. Wing RR, Hamman RF, Bray GA, et al. Achieving weight and activity goals among diabetes prevention program lifestyle participants. Obes Res. 2004;12(9):1426-1434.
11. Stewart S, Hansen TS, Carey TA. Opportunities for people with disabilities in the virtual world of Second Life. Rehabilitation Nursing. 2010;35(6):254-259.

Dr. Robinson-Whelen is an assistant professor of physical medicine and rehabilitation at Baylor College of Medicine, senior investigator for the Center for Research on Women with Disabilities (CROWD) and a scientist at the TIRR Memorial Hermann Spinal Cord Injury and Disability Research Center. Dr. Nosek is a professor of physical medicine and rehabilitation at Baylor College of Medicine, founder and executive director of CROWD and senior scientist at TIRR Memorial Hermann. Since its inception, CROWD has conducted research studies on health promotion and wellness, abuse, reproductive health, sexuality, independent living and access to health care for women with disabilities. The Center’s researchers have developed and tested cognitive-behavioral interventions to help women with physical disabilities improve their health and functioning in daily life – interventions focused on safety and abuse prevention, general health promotion, self-esteem enhancement, stress reduction, depression and aging-related health issues for women with disabilities.