Genetically determined obesity in Prader-Willi syndrome: the ethics and legality of treatment

Three scenarios illustrating ethical concerns when considering bariatric surgery in obese adolescents with Prader-Willi syndrome

Prader-Willi syndrome (PWS) is one of the 25 syndromic forms of obesity, in which patients present-in addition to different degrees of obesity-intellectual disability, endocrine disturbs, hyperphagia and/or other signs of hypothalamic dysfunction. In front of a severe/extreme obesity and the failure of non-invasive treatments, bariatric surgery is proposed as a therapeutic option. The complexity of the clinical condition, which could affect the long-term effects of bariatric surgery, and the frequent association with a mild to severe intellectual disability raise some ethical concerns in the treatment of obese PWS adolescents. This article analyses these issues referring to the principles of healthcare ethics: beneficence/non-maleficence (proportionality of treatments; minimisation of risks); respect of autonomy; justice. Based on these principles, three hypothetical scenarios are defined: (1) obese PWS adolescent, capable of making an autonomous decision; (2) obese PWS adolescent with a severe intellectual disability, whose parents agree with bariatric surgery; (3) obese PWS adolescent with a life-threatening condition and a severe intellectual disability, whose parents do not agree with bariatric surgery. The currently available evidence on efficacy and safety of bariatric surgery in PWS adolescents with extreme or severe obesity and the lack of adequate long-term follow-up suggests great caution even in a very life-threatening condition. Clinicians must always obtain a full IQ assessment of patients by psychologists. A multidisciplinary team is needed to analyse the clinical, psychological, social and ethical aspects and organise support for patient and parents, involving also the hospital ethical committee or, if necessary, legal authorities.

Observed Dietary Intake in Adults with Intellectual Disability Living in Group Homes

Background: There is limited information on the dietary intakes of people with intellectual disability (ID) living in group homes. Objective: To describe and evaluate dietary intake in people with ID. Method: Dietary intake was assessed in a convenience sample of people with ID living in group homes. Dietary assessment used three-day weighed food records and digital food photography. Intakes were compared to the Nutrient Reference Values (NRVs) and dietary recommendations. Results: A sample of 33 adults, (men (M): n = 14; women (W): n = 19), mean age 51 ± 14 years, was recruited from seven group homes. Mean daily energy intake was low (M: 7.4 MJ; W: 7.0 MJ; p = 0.46), similar to levels recommended for bed rest. Many participants had intakes below the estimated average requirements (EARs) for the nutrients, magnesium (M: 86%; W: 63%), calcium (M: 43%; W: 78%), iodine (M: 43%; W: 47%) and zinc (M: 43%). Less than half of the recommended daily servings were consumed for vegetables (men and women) and dairy foods (women). Conclusion: Nutrient intake and diet quality of the participants in the group homes studied was poor. Education and policy to support healthier diets is required to improve dietary intake of people with intellectual disability, living in group homes.

Behavior Modification Maintenance with Long-Term Blood Glucose and Weight Management in Prader-Willi Syndrome Complicated with Diabetes: Team Management Approach Combined with Pharmacological Treatment

The patient was a 40-year-old woman, who had been diagnosed with Prader–Willi syndrome (PWS) at 1 year of age and type 2 diabetes at 27 years of age. At 34 years of age, she was hospitalized to start insulin therapy and receive guidance on treatment. During the next 6 months and through regular once-monthly outpatient clinic visits, the blood glucose level was relatively stabilized although body weight gradually increased. Two years following discharge, the blood glucose level became unstable, and she was hospitalized again to receive guidance on treatment. A team medicine-based approach was established upon hospitalization. The basic treatment was unchanged (insulin, diet, and exercise). The approach taken by the team included understanding the characteristics of PWS by all team members, clear definition of treatment goals, positive evaluation of the patient, and maintenance of the patient's motivation for treatment. Anxiety and stress related to mother's illness dampened motivation and adherence to treatment, but the addition of appropriate pharmacological treatment helped in rapid recovery of motivation to adhere to the treatment protocol. At 3 years after discharge, HbA1c is maintained at around 6%, and body weight continues to fall. Our protocol of the combination of a team medicine approach with appropriately timed pharmacological intervention could probably be applied to not only type 2 diabetes in PWS but also the management of patients with poorly controlled type 2 diabetes.

Understanding the causes of obesity in children with trisomy 21: hyperphagia vs physical inactivity

BACKGROUND

Individuals with intellectual disabilities are at increased risk of becoming overweight or obese. This is particularly evident in people with trisomy 21 and Prader-Willi syndrome (PWS). Although metabolic factors are known to contribute to obesity in trisomy 21 and hyperphagia plays a primary role in PWS, hyperphagia has not yet been investigated as a possible contributing factor to obesity in trisomy 21.

METHODS

Participants comprised three diagnostic groups: trisomy 21 (T21 group), PWS (PWS group) and lifestyle-related obesity (LRO group). They were required to be aged 6-18 years and have a body mass index over the 85th percentile for age and gender. A parent of each participant completed the Hyperphagia Questionnaire and the Children's Leisure Activity Study Survey. Mean scores for each domain and across all domains of the Hyperphagia Questionnaire and the Children's Leisure Activity Study Survey were compared between diagnostic groups using linear regression analysis.

RESULTS

The study group consisted of 52 young people (23 men and 29 women) aged 6-18 years (mean 12.5 years; T21 group n = 17, PWS group n = 16 and LRO group n = 19). As hypothesised, the PWS group had the highest mean scores across all domains of the Hyperphagia Questionnaire, and the LRO group had the lowest. Food-seeking behaviour was more pronounced in the PWS group than the T21 group (mean score 13.2 vs. 8.6, p = 0.008). The LRO group spent more hours per week engaged in physical activity (14.7) in comparison with the other groups (9.6 and 9.7), whereas between the groups, differences in time spent in sedentary activities were less pronounced.

CONCLUSIONS

Preoccupation with food and low levels of physical activity may contribute to the development of overweight and obesity in some individuals with trisomy 21. These factors warrant consideration in the clinical context.

Dietary Energy Intake, Body Composition and Resting Energy Expenditure in Prepubertal Children with Prader-Willi Syndrome before and during Growth Hormone Treatment: A Randomized Controlled Trial

BACKGROUND/AIMS

Dietary management is a difficult but key aspect of care in children with Prader-Willi syndrome (PWS). We therefore investigated the effect of growth hormone (GH) treatment on reported energy intake in children with PWS, in relation with body composition, resting energy expenditure (REE) and hormone levels.

METHODS

In a randomized controlled GH trial including 47 children with PWS, we assessed 5-day dietary records and dual-energy X-ray absorptiometry for body composition. REE was calculated by Müller's equation, based on fat mass, fat free mass and gender.

RESULTS

Baseline energy intake of children with PWS was lower than normal daily energy requirements (p < 0.001), and decreased with age to 50% in prepubertal children. Energy intake in infants [m/f: 11/8; median (interquartile range [IQR]) age 2.7 years (1.5-3.2)] increased after 1 year of GH treatment (p = 0.008); this tended to be higher in the GH group than in the untreated group (p = 0.07). In prepubertal children [m/f: 14/14; median (IQR) age 6.8 years (5.1-8.1)], the increase in energy intake was higher in the GH group, but this was not different compared to the untreated group. REE was not different between the GH group and the untreated group. Increase in energy intake during 2 years of GH treatment was correlated with lower fat percentage standard deviation scores (p = 0.037) and higher adiponectin levels (p = 0.007).

CONCLUSION

Our study demonstrates that parents of children with PWS are very well capable of restricting energy intake up to 50% compared to daily energy requirements for age- and sex-matched healthy children. GH treatment was associated with a slight increase in energy intake, but also improved body composition and adiponectin levels, which suggests a protective effect of GH treatment.

Overweight and obesity in youth with developmental disabilities: a call to action

Elevated weight status has become a leading problem for adults and children around the world, regardless of the presence or lack of disability. Youth with intellectual and developmental disabilities are more vulnerable than the typical population to overweight in recent decades, and these individuals often experience overweight and obesity at higher rates than their typically developing peers. Young people with disabilities have many circumstances, beyond those of typically developing children, which increase their risk for greater body mass. These include greater medication use, having syndromes with obesity as an associated symptom, and possessing altered eating habits related to their disability. We discuss obesity-related health risks, possible weight management options, recommendations for weight maintenance or loss, and future research. Although most professionals who work with youth having developmental disabilities do not have great expertise in nutrition and weight management, we must collectively recognise the importance of weight issues for quality of life of these individuals and work with them in maintaining healthy lifestyles. Intervention options, both for caregivers and for health professionals, are discussed.

Latino families with a child with Prader-Willi syndrome: exploring needs for support

Prader-Willi syndrome (PWS) is a complex, genetically based disorder; caring for a family member with a disability such as PWS brings significant challenges to the whole family. However, no research has been conducted focusing on the impact of PWS in the dynamics of Latino families. This qualitative study explored the challenges and need for support services among Latino families of children with PWS. Findings of the study suggest the need for support services geared toward the whole family unit to help members cope with daily challenges at home.

Prader-Willi syndrome in Victoria: mortality and causes of death

AIM

The aim of this study was to describe the rates, predictors and causes of mortality in a population sample of individuals with Prader-Willi syndrome (PWS).

METHODS

One hundred sixty-three individuals with PWS (90 males and 73 females, ages: 3 weeks to 60 years) were identified from the Victorian PWS Register. Information on demographics, age at diagnosis, genetic mechanism, age at which obesity developed and last known body mass index measurement were extracted. Notification and causes of death were obtained through linkage with Australian national and state of Victoria death indexes. Survival analysis was used to estimate the probability of survival and the effect of obesity on survival. Mortality rate ratios were calculated to investigate the effect of the factors listed above on mortality.

RESULTS

Fifteen deaths were recorded (nine males and six females), corresponding to an 87% probability of survival to 35 years. The probability of survival was significantly lower for individuals with known obesity (P= 0.03), but there was no strong evidence for an effect on survival for the other factors studied. Cardiac or respiratory conditions were common causes of death after the age of 15 years.

CONCLUSIONS

The effect of known obesity on the probability of survival and the causes of death reported in this and other studies suggest an important association between obesity and early death in adults with PWS. This finding highlights the critical nature of preventative and intervention strategies aimed at minimising the effects of hyperphagia in individuals with PWS.

Duty of care and autonomy: how support workers managed the tension between protecting service users from risk and promoting their independence in a specialist group home

BACKGROUND

In the UK those paid to support adults with intellectual disabilities must manage two potentially conflicting duties that are set out in policy documents as being vital to their role: protecting service users (their duty of care) and recognising service users' autonomy. This study focuses specifically on the support of people with the genetically determined condition, Prader-Willi syndrome (PWS). Due to the behaviours associated with PWS, the support of this group of people vividly illustrates the tension between respect for autonomy and duty of care. This article explores how support workers working in a residential group home managed their competing duties of managing risk and promoting independence in practice.

METHODS

An ethnographic study, comprising of qualitative observations, semi-structured interviews and documentary analysis, was undertaken to investigate the work of support workers in a UK residential group home specialising in the support of adults diagnosed with PWS. The study focused on how support workers attempted to reconcile the tension between protecting service users from the risks associated with the syndrome and acknowledging service users' autonomy by enabling independence.

RESULTS

Findings demonstrate that risk was central to the structure of care delivery at the group home and support workers often adhered to standardised risk management procedures. The organisation also required support workers to promote service users' independence and many thought acknowledging service users' autonomy through the promotion of their independence was important. To manage tensions between their differing duties, some support workers deviated from standardised risk management procedures to allow service users a degree of independence.

CONCLUSIONS

There is a tension between the duty of care and the duty to recognise autonomy at the level of service delivery in residential homes. Support workers attempt to manage this tension; however, further work needs to be done by both residential services and policy makers to facilitate the reconciliation of the duty of care with the duty to recognise service users' autonomy in practice.

Managing Prader-Willi syndrome in families: an embodied exploration

This paper aims to explore the management of a rare chromosome disorder, Prader-Willi syndrome (PWS), within families. It is particularly concerned with developing an understanding of the management of diet and other everyday practices affecting the body. People with PWS tend to experience poor muscle tone combined with food obsession. The level of control over diet needed to prevent obesity and related health complications is often lacking as individuals also experience various forms of learning disability, autistic spectrum disorders and behavioural problems. The findings are based on data from twenty qualitative case studies of English families with a young person with PWS. Analysis of management strategies highlights the centrality of embodied agency in shaping everyday practices and interactions. The significance and influence of biology within this process is particularly evident, as people with the genetic condition PWS experience embodiment and emotion in distinct ways and differently from non-PWS family members in the research sample. Focusing on the multidimensional nature of processes surrounding body management, the paper highlights three key management practices and explores how these practices are influenced by people with PWS and interpreted by family members. Three key practices are identified as: restricting access to food, keeping occupied, and use of routine. The study represents the first UK empirical sociological study of PWS and primarily adds an insight of family management of PWS to a medically dominated literature around the disorder. The findings can sensitise health and social care professionals to some potential issues for families managing PWS, and guide and develop appropriate interventions to support young people with PWS and their carers.

Clinical management of behavioral characteristics of Prader-Willi syndrome

Prader-Willi syndrome (PWS) is a complex neurodevelopmental disorder caused by an abnormality on the long arm of chromosome 15 (q11-q13) that results in a host of phenotypic characteristics, dominated primarily by hyperphagia and insatiable appetite. Characteristic behavioral disturbances in PWS include excessive interest in food, skin picking, difficulty with a change in routine, temper tantrums, obsessive and compulsive behaviors, and mood fluctuations. Individuals with PWS typically have intellectual disabilities (borderline to mild/moderate mental retardation) and exhibit a higher overall behavior disturbance compared to individuals with similar intellectual disability. Due to its multisystem disorder, family members, caregivers, physicians, dieticians, and speech-language pathologists all play an important role in the management and treatment of symptoms in an individual with PWS. This article reviews current research on behavior and cognition in PWS and discusses management guidelines for this disorder.

Population-based prevention of obesity: the need for comprehensive promotion of healthful eating, physical activity, and energy balance: a scientific statement from American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention (formerly the expert panel on population and prevention science)

Obesity is a major influence on the development and course of cardiovascular diseases and affects physical and social functioning and quality of life. The importance of effective interventions to reduce obesity and related health risks has increased in recent decades because the number of adults and children who are obese has reached epidemic proportions. To prevent the development of overweight and obesity throughout the life course, population-based strategies that improve social and physical environmental contexts for healthful eating and physical activity are essential. Population-based approaches to obesity prevention are complementary to clinical preventive strategies and also to treatment programs for those who are already obese. This American Heart Association scientific statement aims: 1) to raise awareness of the importance of undertaking population-based initiatives specifically geared to the prevention of excess weight gain in adults and children; 2) to describe considerations for undertaking obesity prevention overall and in key risk subgroups; 3) to differentiate environmental and policy approaches to obesity prevention from those used in clinical prevention and obesity treatment; 4) to identify potential targets of environmental and policy change using an ecological model that includes multiple layers of influences on eating and physical activity across multiple societal sectors; and 5) to highlight the spectrum of potentially relevant interventions and the nature of evidence needed to inform population-based approaches. The evidence-based experience for population-wide approaches to obesity prevention is highlighted.

Prader-Willi syndrome: medical prevention and behavioral challenges

In this article the authors discuss the genetic, medical, and endocrinologic issues of Prader-Willi syndrome and their treatment. The authors also present the typical cognitive profile characterized by specific strengths and areas of disability. The behavioral phenotype of Prader-Willi syndrome affects four domains: food-seeking related behaviors; traits that indicate lack of flexibility; oppositional behaviors, and interpersonal problems. The management of the maladaptive behaviors is challenging and requires lifelong restrictive supervision (to prevent morbid obesity), addressing psychiatric comorbidity, psychopharmacologic management exacerbated by metabolic abnormalities, ongoing medical care, and, in many cases, institutional treatment. The multiple facets of the clinical problems demand a multidisciplinary approach with anticipatory medical and psychiatric care, oriented to enhancing the quality of life of individuals who have Prader-Willi syndrome.

Between control and freedom in the care for persons with Prader-Willi syndrome: an analysis of preferred interventions by caregivers

OBJECTIVE

The present study examined caregivers' preferences for intervention strategies in dealing with the dilemma of respecting autonomy of intellectually disabled persons versus providing high-quality care.

METHODS

Twenty-four parents and 14 professional caregivers of persons with Prader-Willi syndrome were asked to rate four different kinds of intervention strategies according to their preferred way of dealing with 8 presented cases.

RESULTS

In general, caregivers preferred to intervene more actively in eating problems compared to behavioural problems, more in acute than in chronic situations, and more in situations at home than in community-based settings. Significant differences were found between parents and professionals.

CONCLUSION

Parents and professionals prefer intervening above laissez-faire. Parents prefer active intervention stronger than professionals.

PRACTICE IMPLICATIONS

Awareness of various intervention strategies can help caregivers to develop a practice that does justice to the need for intervention on the one hand, and the possibility of using a variety of intervention strategies on the other hand. Communication about intervention strategies might foster understanding between professional caregivers and parents and improve mutual cooperation.

Values in the care for young persons with Prader-Willi syndrome: creating a meaningful life together

BACKGROUND

Caregivers sometimes feel frustrated by present emphasis on self-determination in the care for individuals with an intellectual disability. They are confronted with situations in which there is a conflict between providing high quality care and respecting the client's autonomy. Such conflicts are prominent in the care for people with Prader-Willi syndrome (PWS). This condition is characterized by overeating behaviour which frequently leads to serious obesity. The central question in the present study is how persons involved, parents and professional caregivers, deal with the problems of the prevention of obesity in young individuals with PWS in everyday life.

METHOD

In-depth qualitative interviews were conducted with 23 parents and 14 professional caregivers of 18 persons with PWS. The interview data were analysed using the constant comparative method as described in grounded theory.

RESULTS

On the basis of analysis of the interviews four values emerge that parents and professional caregivers indicate as relevant and directive to their acting towards the child or the client: physical health, well-being, freedom and responsibility, and a liveable life. Furthermore, caregivers mentioned several enabling and limiting conditions that influence these values. And they named several interventions they used to realize the values.

CONCLUSION

Of importance is the question how to create life in such a way that it is acceptable and meaningful for everybody involved. By building up a relationship to which acceptance and trust are central, a certain amount of independence and responsibility can be promoted. By creating trust it is possible to deal with rules in a less rigid way and to look where there is room for choices.

Psychiatric aspects of child and adolescent obesity: a review of the past 10 years

OBJECTIVE

To review the past 10 years of published research on psychiatric aspects of child and adolescent obesity and highlight information mental health professionals need for preventing obesity in youths and diagnosing and treating it.

METHOD

Researchers performed computerized and manual searches of the literature and summarized the most relevant articles.

RESULTS

The growing epidemic of child and adolescent obesity deserves attention for its immediate mental health and long-term medical complications. Mental health professionals working with obese youths should be aware of recent advances in neuroscience, genetics, and etiologies associated with obesity. Those who assess and treat obese youth should view obesity as a chronic disease. Currently, no approved pharmacological or surgical approaches exist to treat childhood obesity.

CONCLUSIONS

Health care providers should focus on modest weight-loss goals that correlate with significant health benefits. The most effective treatments include substantial parental involvement. Mental health professionals should help obese children build self-esteem to help them lead full lives regardless of weight.

Autonomy and intellectual disability: the case of prevention of obesity in Prader-Willi syndrome

BACKGROUND

The policy concerning care for people with intellectual disability (ID) has developed from segregation via normalization towards integration and autonomy. Today, people with ID are seen as citizens who need to be supported to achieve a normal role in society. The aim of care is to optimize quality of life and promote self-determination. The promotion of autonomy for people with ID is not easy and gives rise to ethical dilemmas. Caregivers are regularly confronted with situations in which there is a conflict between providing good care and respecting the client's autonomy. This becomes evident in the case of prevention of obesity in people with Prader-Willi syndrome (PWS).

METHOD

As part of a study about the ethical aspects of the prevention of obesity, in-depth qualitative interviews were conducted with the parents and professional caregivers of people with PWS.

RESULTS

In analysing interviews with parents and formal caregivers, the present authors found that the dichotomy between respecting autonomy and securing freedom of choice on the one hand, and paternalism on the other, is too crude to do justice to the process of care. The stories indicated that caregivers see other options and act in other ways than to intervene without taking into account the wishes of the individual with PWS. The present authors elaborated these options, taking models of the physician-patient relationship as a heuristic starting point. They extended the logic of these models by focusing on the character of the process of interaction between caregiver and care receiver, and on the emotional aspects of the interactions.

CONCLUSION

This approach results in more attention to processes of interpretation, deliberation and joint learning.