An exploration of gender differences and gender-specific influences on the physical activity and sedentary behaviours of adults with intellectual disabilities

Background. Women with intellectual disabilities experience greater risk of health inequalities. Low physical activity (PA) and high sedentary behaviour (SB) levels may contribute to this. The influence of gender on PA and SB is unknown for adults with intellectual disabilities. This thesis aimed to 1. Investigate and quantify gender differences in the PA and SB of adults with intellectual disabilities; 2. Identify potential gender-specific influences on the PA and SB of adults with intellectual disabilities. Sequential studies addressed these aims. Study 1. A systematic review and meta-analysis were conducted to quantify gender differences in the PA and SB levels of adults with intellectual disabilities in the extant literature. Seven databases were searched. Significant gender differences were observed for step counts and moderate to vigorous PA (MVPA), with women less active than men. Mixed findings were reported for SB with limited studies identified. Study 2. This study aimed to identify gender-specific correlates and to quantify gender differences in objectively measured MVPA and SB. A secondary data analysis was conducted using pooled baseline data of two Glasgow based interventions (n = 143 adults with intellectual disabilities: 51.7% women). Bivariate, followed by multivariate linear regressions identified gender-specific correlates using data split by gender. Independent samples t-tests assessed gender differences. No gender differences were reported in MVPA and SB levels. Gender differences in influences were reported; all variables were at an intrapersonal level. Study 3. Gender-specific correlates, and gender differences in self-reported PA and SB were assessed in a secondary data analysis of a population-based study. Participants included n = 725 adults with intellectual disabilities (44.9% women) living in Greater Glasgow. Correlates were at an individual and environmental level. Gender differences in PA and SB levels were measured using Chi-square tests. Multivariate logistic regression with purposeful selection of variables were conducted, using data split by gender. Men were significantly more likely to meet physical activity guidelines. Gender differences in the correlates identified were observed. Study 4. Feasibility of social support network methods in the context of the leisure activities promoted was assessed using a mixed-methods design. Data were collected to assess gender differences in the sources of support, types of activities promoted (PA or SB), and perceptions of social support for PA. This study was cancelled due to the COVID-9 pandemic. N = 3 adults with intellectual disabilities participated prior to cancellation. The data were analysed through thematic analysis, and descriptive statistics calculated for quantitative data. Attempts to adapt the study for remote working were not feasible. Study 5. This study was developed to mitigate the impact of the COVID-19 pandemic. The study aimed to identify gender-specific social and environmental correlates, identify gender differences in PA and SB levels, and the types of activities engaged in by adults with intellectual disabilities. A secondary data analysis was conducted using the British Cohort Study age 46 sweep. Cognitive tests at age 5 and 10 sweeps were used to identify people with potential intellectual disabilities. Outcome data included objectively measured PA and SB, and self-reported activities engaged in. Independent samples t-test assessed gender differences in PA and SB levels. Chi-square tests were used to explore gender differences in the types of activities engaged in. Using data split by gender, bivariate linear regressions, and multivariate linear regression were conducted to identify gender-specific correlates. No significant gender-specific correlates were identified, other than health limiting moderate activities associated with lower step counts for women. Descriptively, men engaged in more sports than women, but rates were low for both genders. Women were significantly more likely to be involved in daily household activities contributing to PA. There were no significant gender differences in the types of SB engaged in. Conclusions. Men with intellectual disabilities engaged in more PA than women, but there were no gender differences present in SB. The PA levels were low for both men and women. There was evidence of gender-specific influences, however more research is required. Exploration into gender differences in PA and SB provides an in-depth understanding of the lifestyles of adults with intellectual disabilities. Failure of past research to consider the influence of gender exacerbates the health inequalities experienced

Feasibility of the Go2Play Active Play intervention for increasing physical and social development in children with intellectual disabilities

Introduction: An active play is designed to increase children’s physical activity levels and fundamental movement skills through outdoor play and is well-suited to the needs of children with intellectual disabilities. However, no active play interventions have included children with intellectual disabilities. This study aims to investigate the feasibility of a school-based active play intervention for children with intellectual disabilities. Method: Children aged 7–12 years who had intellectual disabilities and were independently ambulatory were eligible. This single-group 17-week intervention was implemented in two additional support needs schools. It consisted of a weekly 1-h active play session incorporating 30 min of structured games and 30 min of free play. Feasibility of recruitment/retention, adherence, and outcome measures were investigated. Outcome measures included school-based physical activity (ActiGraph GT3X+ accelerometer), fundamental movement skills (Test of Gross Motor Development-2), and social interactions (Playground Observation of Peer Engagement). Staff feedback was collected via open-ended questionnaire. Feasibility was investigated using descriptive statistics and questionnaire data analyzed using thematic analysis. Potential pre-post changes were investigated for school-based physical activity, fundamental movement skills, and social interactions using paired samples t tests. The progression criteria were (1) > 50% of eligible participants recruited, (2) > 50% of recruited participants retained, (3) > 50% of active play sessions spent in MVPA, and (4) > 50% of participants complete outcome measurements. Results: All progression criteria were met. Recruitment and retention rates were 100% (n=21 participants). Intervention adherence was high, based on data from n=1 school, with 90% of participants attending all sessions. Measuring physical activity using accelerometry and fundamental movement skills using the Test of Gross Motor Development-2 were feasible. The Playground Observation of Peer Engagement tool to measure social interactions was not feasible. The only significant increase post-intervention was for social interactions during structured play (pre–post mean difference: –1.46, 95% CI −1.99, −0.93). Staff feedback was positive with the intervention well received by schools and potential benefits post-intervention identified by teachers. Conclusion: The Go2Play Active Play intervention is feasible for children with intellectual disabilities. Future research should further investigate feasibility and implementation on a larger scale using a pilot cluster randomised controlled trial

Effects of exercise training programmes on fasting gastrointestinal appetite hormones in adults with overweight and obesity: a systematic review and meta-analysis

A systematic review and meta-analysis was performed to determine the effect of exercise training on fasting gastrointestinal appetite hormones in adults living with overweight and obesity. For eligibility, only randomised controlled trials (duration ≥ four weeks) examining the effect of exercise training interventions were considered. This review was registered in the International Prospective Register of Systematic Reviews (CRD42020218976). The searches were performed on five databases: MEDLINE, EMBASE, Cochrane Library, Web of Science, and Scopus. The initial search identified 13204 records. Nine studies, which include sixteen exercise interventions, met the criteria for inclusion. Meta-analysis was calculated as the standardised mean difference (Cohen's d). Exercise training had no effect on fasting concentrations of total ghrelin (d: 1.06, 95% CI -0.38 to 2.50, P = 0.15), acylated ghrelin (d: 0.08, 95% CI: −0.31 to 0.47, P = 0.68) and peptide YY (PYY) (d = −0.16, 95% CI: −0.62 to 0.31, P = 0.51) compared to the control group. Analysis of body mass index (BMI) (d: −0.31, 95% CI: −0.50 to −0.12, P < 0.01) and body mass (d: −0.22, 95% CI: −0.42 to −0.03, P = 0.03) found a significant reduction after exercise compared to controls. Overall, exercise interventions did not modify fasting concentrations of total ghrelin, acylated ghrelin, and PYY in individuals with overweight or obesity, although they reduced body mass and BMI. Thus, any upregulation of appetite and energy intake in individuals with overweight and obesity participating in exercise programmes is unlikely to be related to fasting concentrations of gastrointestinal appetite hormones

Adding 6 months of androgen deprivation therapy to postoperative radiotherapy for prostate cancer: a comparison of short-course versus no androgen deprivation therapy in the RADICALS-HD randomised controlled trial

Background Previous evidence indicates that adjuvant, short-course androgen deprivation therapy (ADT) improves metastasis-free survival when given with primary radiotherapy for intermediate-risk and high-risk localised prostate cancer. However, the value of ADT with postoperative radiotherapy after radical prostatectomy is unclear. Methods RADICALS-HD was an international randomised controlled trial to test the efficacy of ADT used in combination with postoperative radiotherapy for prostate cancer. Key eligibility criteria were indication for radiotherapy after radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to radiotherapy alone (no ADT) or radiotherapy with 6 months of ADT (short-course ADT), using monthly subcutaneous gonadotropin-releasing hormone analogue injections, daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as distant metastasis arising from prostate cancer or death from any cause. Standard survival analysis methods were used, accounting for randomisation stratification factors. The trial had 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 80% to 86% (hazard ratio [HR] 0·67). Analyses followed the intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov, NCT00541047. Findings Between Nov 22, 2007, and June 29, 2015, 1480 patients (median age 66 years [IQR 61–69]) were randomly assigned to receive no ADT (n=737) or short-course ADT (n=743) in addition to postoperative radiotherapy at 121 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 9·0 years (IQR 7·1–10·1), metastasis-free survival events were reported for 268 participants (142 in the no ADT group and 126 in the short-course ADT group; HR 0·886 [95% CI 0·688–1·140], p=0·35). 10-year metastasis-free survival was 79·2% (95% CI 75·4–82·5) in the no ADT group and 80·4% (76·6–83·6) in the short-course ADT group. Toxicity of grade 3 or higher was reported for 121 (17%) of 737 participants in the no ADT group and 100 (14%) of 743 in the short-course ADT group (p=0·15), with no treatment-related deaths. Interpretation Metastatic disease is uncommon following postoperative bed radiotherapy after radical prostatectomy. Adding 6 months of ADT to this radiotherapy did not improve metastasis-free survival compared with no ADT. These findings do not support the use of short-course ADT with postoperative radiotherapy in this patient population

Duration of androgen deprivation therapy with postoperative radiotherapy for prostate cancer: a comparison of long-course versus short-course androgen deprivation therapy in the RADICALS-HD randomised trial

Background Previous evidence supports androgen deprivation therapy (ADT) with primary radiotherapy as initial treatment for intermediate-risk and high-risk localised prostate cancer. However, the use and optimal duration of ADT with postoperative radiotherapy after radical prostatectomy remains uncertain. Methods RADICALS-HD was a randomised controlled trial of ADT duration within the RADICALS protocol. Here, we report on the comparison of short-course versus long-course ADT. Key eligibility criteria were indication for radiotherapy after previous radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to add 6 months of ADT (short-course ADT) or 24 months of ADT (long-course ADT) to radiotherapy, using subcutaneous gonadotrophin-releasing hormone analogue (monthly in the short-course ADT group and 3-monthly in the long-course ADT group), daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as metastasis arising from prostate cancer or death from any cause. The comparison had more than 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 75% to 81% (hazard ratio [HR] 0·72). Standard time-to-event analyses were used. Analyses followed intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov , NCT00541047 . Findings Between Jan 30, 2008, and July 7, 2015, 1523 patients (median age 65 years, IQR 60–69) were randomly assigned to receive short-course ADT (n=761) or long-course ADT (n=762) in addition to postoperative radiotherapy at 138 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 8·9 years (7·0–10·0), 313 metastasis-free survival events were reported overall (174 in the short-course ADT group and 139 in the long-course ADT group; HR 0·773 [95% CI 0·612–0·975]; p=0·029). 10-year metastasis-free survival was 71·9% (95% CI 67·6–75·7) in the short-course ADT group and 78·1% (74·2–81·5) in the long-course ADT group. Toxicity of grade 3 or higher was reported for 105 (14%) of 753 participants in the short-course ADT group and 142 (19%) of 757 participants in the long-course ADT group (p=0·025), with no treatment-related deaths. Interpretation Compared with adding 6 months of ADT, adding 24 months of ADT improved metastasis-free survival in people receiving postoperative radiotherapy. For individuals who can accept the additional duration of adverse effects, long-course ADT should be offered with postoperative radiotherapy. Funding Cancer Research UK, UK Research and Innovation (formerly Medical Research Council), and Canadian Cancer Society

Understanding capabilities, opportunities, and motivations to engage in physical activity for adults with intellectual disabilities: A qualitative evidence synthesis

Background There is a paucity of theory-informed physical activity research with adults with intellectual disabilities. This study aimed to address this by synthesising existing literature and applying the COM-B model to understand capabilities, opportunities, and motivations. Methods A qualitative evidence synthesis was conducted and reported in accordance with PRISMA guidelines and the ENTREQ. Three databases were systematically searched up to and including February 2022. Qualitative research relating to the physical activity of adults with intellectual disabilities were included. Thematic synthesis was conducted with themes mapped onto the COM-B model. Results Twenty-five studies were included. Influences of physical activity were identified and mapped onto the COM-B model, which also included COM-B influences of social support provided by caregivers. Conclusions There are many complex influences of physical activity for adults with intellectual disabilities. Researchers should consider the influences contributing to caregivers’ capacity to support physical activity

Understanding capabilities, opportunities, and motivations to engage in physical activity for adults with intellectual disabilities: a qualitative evidence synthesis

Background There is a paucity of theory-informed physical activity research with adults with intellectual disabilities. This study aimed to address this by synthesising existing literature and applying the COM-B model to understand capabilities, opportunities, and motivations. Methods A qualitative evidence synthesis was conducted and reported in accordance with PRISMA guidelines and the ENTREQ. Three databases were systematically searched up to and including February 2022. Qualitative research relating to the physical activity of adults with intellectual disabilities were included. Thematic synthesis was conducted with themes mapped onto the COM-B model. Results Twenty-five studies were included. Influences of physical activity were identified and mapped onto the COM-B model, which also included COM-B influences of social support provided by caregivers. Conclusions There are many complex influences of physical activity for adults with intellectual disabilities. Researchers should consider the influences contributing to caregivers’ capacity to support physical activity

Understanding the effectiveness and underlying mechanisms of lifestyle modification interventions in adults with learning disabilities: Protocol for a mixed-methods systematic review

Background: Adults with learning disabilities have an increased disposition to unhealthy lifestyle behaviours which often occur simultaneously. Existing studies focus on complex interventions targeting unhealthy diet, physical inactivity, sedentary behaviour, smoking, and alcohol use to reduce health risks experienced. It is essential to understand how well these interventions work, what works, for whom, in what context and why. This study aims to investigate the effectiveness and underlying mechanisms of lifestyle modification interventions for adults with learning disabilities. Methods: This is a mixed-methods systematic review consisting of a network meta-analysis (NMA) and realist synthesis. Electronic databases (ASSIA, CINAHL, EMBASE, MEDLINE, and PsycINFO) will be searched from inception to 14 January 2021 with no language restriction. Additionally, trial registries, grey literature databases and references lists will be searched. Studies related to lifestyle modification interventions on the adult population (>18 years) with learning disabilities will be eligible for inclusion. Two independent researchers will screen studies, extract data and assess its quality and risk of bias using the Cochrane Collaboration’s Risk of Bias Assessment Tool (RoB Version 2) and ROBINS-I. The strength of the body of evidence will be assessed based on the GRADE approach. The NMA will incorporate results from RCTs and quasi-experimental studies to estimate the effectiveness of various lifestyle interventions. Where appropriate, a component NMA (CNMA) will be used to estimate effectiveness. The realist synthesis will complement and explain the findings of NMA and CNMA by including additional qualitative and mixed-methods studies. Studies will be included based on their relevance to the programme theory and the rigour of their methods, as determined by quality appraisal tools appropriate to the study design. Results from both syntheses will be incorporated into a logic model

Lifestyle modification interventions for adults with intellectual disabilities: systematic review and meta-analysis at intervention and component levels

Background: Adults with intellectual disabilities (ID) are susceptible to multiple health risk behaviours such as alcohol consumption, smoking, low physical activity, sedentary behaviour, and poor diet. Lifestyle modification interventions can prevent or reduce negative health consequences caused by these behaviours. We aim to determine the effectiveness of lifestyle modification interventions and their components in targeting health risk behaviours in adults with IDs. Methods: A systematic review and meta-analysis were conducted. Electronic databases, clinical trial registries, grey literature, and citations of systematic reviews and included studies were searched in January 2021 (updated February 2022). Randomised controlled trials and non-randomised controlled trials targeting alcohol consumption, smoking, low physical activity, sedentary behaviours, and poor diet in adults (aged≥18 years) with ID were included. Meta-analysis was conducted at the intervention-level (pairwise and network meta-analysis) and the component-level (component network meta-analysis). Studies were coded using Michie’s 19-item theory coding scheme and 94-item behaviour change taxonomies. Risk of bias was assessed using the Cochrane Collaboration's Risk of Bias Assessment Tool (RoB Version 2) for RCTs and Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) tool for non-RCTs. The study involved a Patient and Public Involvement (PPI) group, including people with lived experience, who contributed extensively by shaping the methodology, providing valuable insights in interpreting results, and organising of dissemination events. Results: Our literature search identified 12,180 articles, of which 80 studies with 4,805 participants were included in the review. The complexity of lifestyle modification intervention was dismantled by identifying six core components that influenced outcomes. Interventions targeting single or multiple health risk behaviours could have a single or combination of multiple core-components. Interventions (2 RCTS; 4 non-RCTs; 228 participants) targeting alcohol consumption and smoking behaviour were effective but based on limited evidence. Similarly, interventions targeting low physical activity only (16 RCTs; 17 non-RCTs; 1413 participants) or multiple behaviours (low physical activity only, sedentary behaviours, and poor diet) (17 RCTs; 24 non-RCTs; 3164 participants) yielded mixed effectiveness in outcomes. Most interventions targeting low physical activity only and multiple behaviours generated positive effects on various outcomes, while some interventions led to no change or worsened outcomes which could be attributed to the presence of a single core component or a combination of similar core components in interventions. The intervention-level meta-analysis for weight management outcomes showed that none of the interventions were associated with a statistically significant change in outcomes when compared to treatment-as-usual. Interventions with core-components combination of energy deficit diet, aerobic exercise and behaviour change techniques showed the highest weight loss (MD=-3.61,95% CrI -9.68 – 1.95) and those with core-components combination dietary advice and aerobic exercise showed a weight gain (MD 0.94, 95% CrI -3.93 to 4.91). Similar findings were found with the components network meta-analysis for which additional components were identified. Studies had a high and moderate risk of bias. Various theories and behaviour change techniques were used in intervention development and adaptation. Conclusion: Our systematic review is the first to comprehensively explore lifestyle modification interventions targeting a range of single and multiple health risk behaviours in adults with ID, co-produced with people with lived experience. It has practical implications for future research as it highlights the importance of mixed-methods research in understanding lifestyle modification interventions and the need for population-specific improvements in the field (e.g., tailored interventions, development of evaluation instruments or tools, use of rigorous research methodologies, and comprehensive reporting frameworks). Wide dissemination of related knowledge and the involvement of PPI groups, including people with lived experience, will help future researchers design interventions that consider the unique needs, desires, and abilities of people with ID