In the United States, a society based on freedom to choose, food producers and marketers daily influence the public choice for nutritionally questionable “super sized” meals (Nestle, 2002). In the general population, these higher calorie, vitamin-deficient foods have created a national public health epidemic, obesity, that has affected over 27% of the United State's adult population (National Center, n.d.). Researchers have found that obesity is even more prevalent in people with mental retardation (Burkhart, Fox, & Rotatori, 1985; Rimmer, Braddock, & Fujiura, 1993), especially those people with milder impairments (Kelly, Rimmer, & Ness, 1986; Rimmer et al., 1993) who typically reside in what have been deemed less restrictive environments.
Risk of Obesity as a Function of Living Environment
Evaluations of dinner menus and daily food intake for people in both restrictive (e.g., Intermediate Care Facilities—ICFs) and least restrictive environments (e.g., community group homes) have indicated that neither setting's dinner menus have adequately met the Recommended Dietary Allowance—RDA (Mercer & Ekvall, 1992). However, the actual food intakes of group home residents were least closely related to RDA recommendations, with more calories and poorer food choices (Mercer & Ekvall, 1992; Robertson et al., 2000). Further, the men and women living in the less restrictive environments weighed more, had higher percentages of body fat, and the overall least healthy profile (Rimmer, Braddock, & Marks, 1995; Robertson et al., 2000).
In these less supervised settings, persons with mental retardation have exhibited poor nutritional choice, exercise habits, and related health choices (e.g., smoking and alcohol consumption), resulting in obesity and related health risks. With the popularity of least restrictive environments increasing, it has become imperative to determine the risk factors for obesity as well as the implications of such findings.
Why Least Restrictive Environments May Create Higher Risk Factors for Obesity
One possible risk factor for obesity in least restrictive environments may be choice itself. As in typical environments, careproviders and parents have supported independence and freedom of choice, even when choices have been poor. Persons with mental retardation have been encouraged to take control over what they choose to eat, when they choose to eat, how much they choose to eat, and how frequently they choose to eat in order to support an independent lifestyle.
Unfortunately, in attempts to support these choices and provide less restriction, staff may have actually taught poor food choices. For example, persons with mental retardation have continually been taught to make independent purchases at vending machines (Golden & Hatcher, 1997; Rimmer et al., 1995). Although this has been viewed as enabling independence and choice of foods, it may have actually only further provided choices of high fat, high calorie foods and beverages, with little choice for nutritional alternatives.
In addition, in further efforts to promote independent living, support staff members in less restrictive environments have attempted to teach persons with mental retardation how to independently prepare meals (Green & McIntosh, 1985; Rimmer et al., 1995). In our clinical experience, for convenience in shopping and food preparation, people with mental retardation have been taught to purchase primarily processed, microwave foods that contain high amounts of carbohydrates, sodium, and sugars, but low amounts of nutrients.
In addition, and somewhat unbelievably, some states have even concluded that positive reinforcement contingent on behavior constitutes a restrictive environment (Department of Public Welfare, 1995). Hence, in community homes monitored by such state regulations, verbal praise has been given noncontingently to healthy and unhealthy eating behavior. Thus, a person could be inadvertently taught to prefer only chili-dogs, cheese fries, and Twinkies®. With a moratorium on use of effective strategies for teaching healthy food choice, preparation, and exercise habits because some professionals believe that these strategies “restrict” personal freedom, healthy independent living choices may have actually been denied to people with mental retardation. Although the premise of choice has been evident in these environments, if choice options are limited primarily to nonnutritional foods without the accessibility of healthy alternatives, an opportunity for choice has really not been available.
Balancing Choice With Health Considerations
Choosing nonnutritious food and refusing healthy lifestyles, such as exercise, may be considered informed choices. Consequently, creating a balance between autonomy and health behaviors for persons with mental retardation necessitates explanation on how food-related choices develop. Specialists in childhood feeding problems have determined that given access to a limited variety of novel and nutritious foods, children will choose a somewhat balanced diet if provided with the option for food refusal (Davis, 1939; Hendy, 1999). However, offering numerous choices increases the likelihood that food selections will include high fat and sugar content (Klesges, Coates, & Brown,1983). In addition, researchers have demonstrated that taste exposure encourages food acceptance among children (Birch & Marlin, 1982; Birch, McPhee, Shoba, Pirok, & Steinberg, 1987), supporting the theory that repeated taste exposure results in enhanced preference (Zajonc, 1968). Consequently, repeated food presentation (i.e., between 10 and 15 taste exposures) of healthy foods (Birch et al., 1987) may be required for persons with mental retardation to acquire healthy food preferences. To determine whether nonnutritive foods are actually an informed choice, researchers have found that opportunities, including repeated exposures, teaching skills, and exercise, must be made available (Green & McIntosh, 1985; Mercer & Ekvall, 1992).
Teaching skills, such as communicating preferences, reading nutrition labels, using the food pyramid, self-recording calories consumed, and serving appropriate portion sizes, may influence the development of positive health habits. Accordingly, teaching such skills would allow persons with mental retardation to assume greater control over food-related choices. In addition, teaching such persons food preparation skills may promote self-regulation. Specifically, instruction on how to use low-fat cookbooks, measure ingredients in recipes, and substitute healthier alternatives (e.g., using applesauce instead of oil for baking) may contribute to informed decision-making. Such skill instruction provides greater health benefits compared to teaching individuals how to microwave foods and operate vending machines.
Exposure to and knowledge about healthy food may not be sufficient to increase healthy lifestyles. Participation in exercise and a reduction of sedentary activities (e.g., watching television) may be needed to help decrease the risk of obesity (Deitz & Gortmaker, 1985). Teaching persons with mental retardation how to exercise may be accomplished through modeling and reinforcing appropriately imitated exercise skills. These techniques have produced successful results in teaching these individuals self-care skills (Kissel, Whitman, & Reid, 1983; Matson, Smalls, Hampff, Smiroldo, & Anderson, 1998), social skills (Foxx, McMorrow, Bittle, & Ness, 1986), and medical procedures (Hagopian, Crockett, & Keeney, 2001); and, thus, show promise for use with exercise. Furthermore, exercises (e.g., dancing, swimming) should reflect individual preferences and serve as functional activities (e.g., walking to the mailbox, raking leaves) that incorporate energy expenditure into daily life.
As a society that upholds freedom and independence as fundamental rights, the emphasis placed on choice in the United States comes as no surprise and should not be denied to people with mental retardation. They deserve to make choices, like any respected member of society. However, they also deserve the rights to balance choice with health, make informed choices, choose to develop new skills, choose to remain healthy, and avoid the social rejection related to obesity.
Authors: Jennifer J. Bechtel, BA, and Kimberly A. Schreck, PhD, Assistant Professor of Psychology (firstname.lastname@example.org), School of Behavioral Sciences and Education, Penn State University Harrisburg, 777 W. Harrisburg Pike, W 157 Olmsted Building, Middletown, PA 17057–4898