The genetic disorder of Down Syndrome (DS), results when there is a third copy of chromosome 21 (HSA21). It is a well-recognized clinical condition with distinctive facial features, morphological abnormalities and of intellectual disabilities (ID). DS occurs approximately in 1 in 700 live births. It is one of the most common chromosome abnormalities in humans [1]. Evidence has shown that Down Syndrome patients are likely to have a more obese body habitus than the general population without DS and lean body mass [2] [3] [4]. Front line physicians are in a unique position to provide individualized care to their patients with Down Syndrome and other developmental disabilities across the lifespan. Individuals with Down Syndrome have medical problems common in the general population; however, they some problems such as muscular hypotonia, leukemias, sleep apnea, obesity and associated comorbidities, early dementia, and accelerated aging to name only a few, occur with more frequency in this unique population [5] [6] [7].

Overweight-Obesity are terms used to describe fat storage which is frequently but not always complicated by co-morbidities such as metabolic syndrome, hypertension, diabetes, cardiovascular diseases, cancer, and psychological stress, and contribute to a decreased quality of life [8] [9]. Ominously, the rate of obesity and overweight continues to increase each year in the United States [10]. Obesity and overweight are issues which impact us in two ways, as individuals and at the community level. The Global Burden of Disease study (GBD) in 2016 finds that high BMI, poor diet, and high fasting blood glucose levels are increasing and among the most pressing national public health concerns the United States faces today [11] [12] [13]. It is well established in the literature that obesity and chronic disease costs include large health care expenditures, decrease productivity, disability, and human suffering [14] [15].

Approximately 1% to 3% of the United States population are diagnosed with intellectual and developmental disabilities [16]. Research has shown that the prevalence of obesity and overweight is greater among the population individuals with intellectual and disabilities (IDD) than the general population [17]. While there has been a great deal of research regarding obesity in the general population, the literature is sparse in addressing this issue in the segment of the population who have IDD, such as Down Syndrome (DS) [4] [17] [18]. Individuals with DS are noted to have a decrease in total energy requirements likely secondary to decreased lean muscle mass among other yet determined factors3. Individuals with DS generally exhibit lower levels of physical fitness and higher levels of fatness compared to their peers in the general population [19] [20].

Recent NHANES surveys in the USA and found that eating frequency was inversely associated with body weight status [21]. Meal pattern/timing and composition matters for the general population and for individuals with DS and other IDD. Fat although calorically dense it provides satiety and important nutrients to the diet. Protein is also an important component of meals. Substituting protein for simple carbohydrate enhances satiety, diet induced thermogenesis and is associated with improved blood pressure [22]. Furthermore, when in a negative calorie balance situation as in a weight loss diet, protein helps preserve lean body mass which minimizes the loss of or resting energy expenditure (REE) [23]. Many different types of diets will enable individuals to lose weight yet keeping the weight off long term is the problem. It has been estimated that only 1 in 6 overweight adults report having maintained a weight loss of approximately 10% for 1 one year [24]. Evidence is building that following a low glycemic load diet attenuates the fall in resting energy expenditure (REE) that results after weight loss. Additionally, a calorically restricted low glycemic diet has been shown to result in decreased BMI, insulin resistance, percentage body fat, and leptin concentrations [25] [26] [27]. Beyond these macronutrients, when discussing the prevention of obesity and its associated co-morbidities in individuals with DS or even those in the general non-affected population 2 priorities must be kept in mind: first, there must be adequate nutrition, of both macro and micronutrients, to stay in anabolism. Secondly, individuals need to feel secure and have self-determination regarding their food choices as is developmentally appropriate for them if any meal plan is to become a new lifestyle pattern.

The case presented here illustrates the weight and diet challenges commonly faced by young adults with DS. Initially the standard dietary approach was undertaken with initial success that waned over time. The problem of overweight obesity is a complex multidimensional problem generally that is even a bit more complex for an individual with DS. In this case, due to a weight gain pattern, increase physical mobility challenges, and behavior changes the nutrition plan changed and was individualized for this patient and the C-ICAN meal pattern was implemented.

The C-ICAN diet is a consistent individualized carbohydrate anti-inflammatory nutrition plan that provides a structured, moderate fat, low glycemic load meal pattern. This meal plan not only provided better weight management, eliminated hunger, and improved our patient’s quality of life it also improved the family mealtime dynamics. The C-ICAN meal pattern may even enable patients with Down Syndrome to be tracked on the growth charts of typically developing children and be compared to the average body mass indices (BMI) of adults in their age range.

This case illustrates that a Consistent-Individualized Carbohydrate Anti-inflammatory Nutrition plan (C-ICAN) structured, high fiber, moderate fat, high protein, and low glycemic diet, was effective in this patient in managing obesity, preventing weight gain, improved patient’s satiety, and decreased caregiver stress. Interestingly the patient’s challenges with constipation and reflux also abated.

A calorie controlled, a structured, high fiber, moderate fat, high protein and low glycemic diet was effective for this patient. When she followed the diet plan closely her BMI decreased to 25.71 kg/m². At a BMI of 25.71 kg/m² she was in the 25th percentile for a Down Syndrome female without MNT (Figure 1) and below the 85th percentile for a 20-year-old on a standard female growth chart (Figure 2). Furthermore, throughout the ages of 20 - 27 years, her BMI consistently remained lower than that of same-aged females with Down Syndrome and was only slightly higher than the BMIs of same-aged females without Down Syndrome (Figure 3). Even when facing barriers to physical activity and an increased propensity to gain fat mass after her hysterectomy, the patient’s BMI was maintained around 28 kg/m².

Down Syndrome is associated with many health challenges including, but not limited to, physical facial abnormalities, cardiac defects, and developmental abnormalities. Notably, DS is associated with increased risk of overweight, obesity, metabolic syndrome, obstructive sleep apnea, thyroid disorders, autoimmune disease, hypotonia, and premature aging [13]. However, individuals with DS have the predisposition for altered body composition, overweight and obesity with early nutritional and lifestyle intervention; this does not need to be the case. Individuals with DS can develop healthy self-help behaviors given appropriate nurturing and tools [28] [29]. Diet intervention needs to minimize food jags and cue healthy food choices. Individuals with DS will accept less preferred foods or new foods, if given structured choices such as: “Would you like an apple or an orange?” versus “What do you want to eat?” Another concern common in the population affected with Down Syndrome is feeding problems which are developed from hypotonia and/or poor oral coordination that persist throughout the life span. These challenges not only impact feeding but can also contribute to other health issues such as constipation or risk of aspiration.

Given the complexity of obesity, what is the best diet pattern to recommend for individuals with Down Syndrome who potentially face health challenges unique to their diagnoses? Considering the complexities of both we implemented a calorie controlled, structured, high fiber, moderate fat, high protein, and low glycemic load meal plan for this patient. The Medical Nutrition Therapy (MNT) plan was: ~35% heart healthy fat, 1.3 gm protein/kg, low glycemic load diet with 30 grams of carbohydrates per meal and 15 grams per snack, with protein spread throughout the meal plan to provide nutritional need and increase satiety [22] [29] [30]. The C-ICAN diet provides foods rich in monounsaturated fatty acids, which reduces systemic chronic inflammation [29].

Patients with intellectual disabilities are more likely to have poor quality diets compared to the general population. Individuals with DS frequently lack independence in the selection and preparation of their food choices, with a large role played by caregivers [30]. The C-ICAN meal patterning provides both the structure and guidance, which helped with patient acceptance of the meal plan. This enabled the caregivers to effectively implement the nutrition treatment plan. The structure of this diet plan could easily be followed even when multiple caregivers were involved in patient care if all caregivers involved understood the patient’s nutrition plan. The frequency and composition of meals in the structure of this diet plan helped to decrease hunger felt by the patient, improve dietary satisfaction, and discourage her from sneaking food.

This retrospective case study is limited in that it is restricted to one patient’s case, however, given the promising findings in this report there is an obvious need for further research involving anti-inflammatory nutrition interventions paired with a structured behavior plan as part of the overall goal of preventing obesity and associated co-morbidities in individuals with Down Syndrome.

The authors declare no conflicts of interest regarding the publication of this paper.

DiMucci-Ward, J. and Brown, S.L. (2021) Weight Management of Young Women with Down Syndrome: C-ICAN Meal Plan. Case Reports in Clinical Medicine, 10, 393-402. https://doi.org/10.4236/crcm.2021.1011049