Select Page

Hypertension and Obesity

Please discuss some of the risk and protective factors related to hypertension and obesity in individuals with developmental disabilities.

Overweight and Obesity Among Adults With
Intellectual Disabilities Who Use Intellectual
Disability/Developmental Disability Services
in 20 U.S. States

Roger J. Stancliffe
University of Sydney, Australia

K. Charlie Lakin and Sheryl Larson
Research and Training Center on Community Living, University of Minnesota

Joshua Engler, Julie Bershadsky, and Sarah Taub
Human Services Research Institute, Cambridge, MA

Jon Fortune
Human Services Research Institute, Tualatin, OR

Renata Ticha
Research and Training Center on Community Living, University of Minnesota

Abstract
The authors compare the prevalence of obesity for National Core Indicators (NCI) survey
participants with intellectual disability and the general U.S. adult population. In general,
adults with intellectual disability did not differ from the general population in prevalence
of obesity. For obesity and overweight combined, prevalence was lower for males with
intellectual disability than for the general population but similar for women. There was
higher prevalence of obesity among women with intellectual disability, individuals with
Down syndrome, and people with milder intellectual disability. Obesity prevalence differed
by living arrangement, with institutional residents having the lowest prevalence and people
living in their own home the highest. When level of intellectual disability was taken into
account, these differences were reduced, but some remained significant, especially for
individuals with milder disability.

DOI: 10.1352/1944-7558-116.6.401

Overweight and obesity are associated with
increased mortality and morbidity (Berrington de
Gonzalez et al., 2010; Manson & Bassuk, 2003;
Soverini et al., 2010). Obese individuals had a
significantly higher mortality rate in a large sample
of people with Down syndrome (Yang et al., 2002).

Among U.S. adults in the general population,
the prevalence of obesity (body mass index [BMI]

$ 30.0) and overweight and obesity (BMI $ 25.0)
in 2007–2008 was 33.8% and 68.0%, respectively
(Flegal, Carroll, Ogden, & Curtin, 2010). There
were important prevalence differences by gender,
age group, and race–ethnic group. Obesity preva-
lence among U.S. adults increased from 13%–15%
in the 1960s and 1970s to 31% in 2000, but the rate
of increase may now be leveling off (Flegal et al.).

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

E American Association on Intellectual and Developmental Disabilities 401

Prevalence of obesity among adults with intellec-
tual disabilities also increased between the mid-
1980s and 2000 (Rimmer & Yamaki, 2006; Yamaki,
2005).

Adults With Intellectual Disabilities
Compared With the General
Community

Two reviews of obesity research identified a
higher prevalence of overweight and obesity among
adults with intellectual disability than in the general
community (Melville, Hamilton, Hankey, Miller,
& Boyle, 2007; Rimmer & Yamaki, 2006). Several
studies have supported this conclusion, both for
users of formal intellectual and developmental
disabilities services and for population samples that
include many individuals with intellectual disabil-
ity living outside the formal service system (Mel-
ville et al., 2008; Yamaki, 2005). However, other
studies have found more limited differences
(Bhaumik, Watson, Thorp, Tyrer, & McGrother,
2008; Emerson, 2005).

Yamaki (2005) used national population sam-
ples from the annual National Health Interview
Survey (NHIS) to compare BMI based on self-
reported height and weight (for individuals unable
to respond, another adult household member
could provide the information) of adults with
intellectual disability and adults from the general
population. The NHIS is a household sample
survey of the health status of the U.S. ‘‘noninsti-
tutionalized’’ population and includes adults with
intellectual disability living with family members
or in their own homes but generally excludes
persons living in formal service settings. This likely
yields more individuals with mild or moderate
intellectual disability and fewer comorbid physical,
health, and mental health conditions. Yamaki’s
operational definition of intellectual disability in-
cluded only people who reported a substantial
functional limitation and mentioned ‘‘mental
retardation’’ as the cause. This definition may not
include people who report Down syndrome,
autism, cerebral palsy, and other intellectual or
developmental disabilities (Hendershot, Larson,
Lakin, & Doljanac, 2005).

Compared with the general population, Yamaki
(2005) found a higher percentage of adults with
intellectual disability in the obese category but no
significant overall differences for the overweight
category, although men with intellectual disability

had significantly lower prevalence of overweight
than men in the general population. In the most
recent period examined (1997–2000), 34.6% of
adults with intellectual disability were obese com-
pared with 20.6% of adults (aged 18–65 years) from
the general population, whereas 28.9% (intellectual
disability) and 34.1% (general population) were
overweight (BMI 5 25.0–30.0). Yamaki’s samples of
adults with intellectual disability were moderately
sized (range 5 650–1,098), although the most recent
sample (1997–2000) of 650 participants yielded
relatively large confidence intervals (6 8.0%).
Therefore, subgroup analyses were only possible
for gender and age group separately, with no
examination of race–ethnicity.

Several larger scale and/or population-based
studies of BMI have focused on adults with
intellectual disability living outside the United
States. Overweight and obesity may vary by nation,
both for the general population and for those with
intellectual disability, with higher prevalence
among U.S. individuals (Harris, Rosenberg, Jangda,
& Gallagher, 2003; Sassi, Cecchini, & Devant,
2010). Therefore, caution is warranted when
reviewing research findings on BMI for persons
with intellectual disability from other countries for
relevance to U.S. populations.

Emerson (2005; N 5 1,304) found that 14%
of disability-accommodation service users in
northern England were underweight, 28% over-
weight, and 27% obese. Prevalence of obesity
among men with intellectual disability did not
differ significantly from English men without
intellectual disability, except that men with
intellectual disability aged 65–74 years had
significantly lower obesity rates than men of the
same age from the general population. However,
women with intellectual disability had higher
prevalence of obesity in several age groups and
did not differ from women without intellectual
disability in other age groups.

Bhaumik et al. (2008; N 5 1,119) examined all
individuals on a register of adults with moderate,
severe, or profound intellectual disability in a de-
fined geographical area in Leicestershire, England.
They found that 20.7% of adults with intellectual
disability were obese and an additional 28.0% were
overweight. The overall intellectual disability sample
did not differ significantly from the general popu-
lation in England in the prevalence of obesity.
Compared with men in the general population (19%
obesity prevalence), men with intellectual disability
(15% obesity prevalence) had nonsignificantly lower

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

402 E American Association on Intellectual and Developmental Disabilities

prevalence of obesity. Women with intellectual
disability, however, had significantly higher preva-
lence of obesity (32%) than women in the general
population (23%).

Gender

There is higher prevalence of obesity among
women with intellectual disability compared with
men with intellectual disability (Bhaumik et al.,
2008; Emerson, 2005; Melville et al., 2007, 2008;
Robertson et al., 2000; Yamaki, 2005). Melville
et al. (2007) concluded that, relative to the higher
rate of obesity in women in the general popula-
tion, among people with intellectual disability,
‘‘the gender effect is accentuated, placing women
with intellectual disabilities at particular risk’’
(p. 225).

Diagnosis and Level of
Intellectual Disability

Among adults with intellectual disability, there
are important differences in BMI related to
diagnosis. Individuals with Down syndrome are
more likely to be overweight or obese than other
individuals with intellectual disability (Bhaumik
et al., 2008; Hove, 2004; Melville et al., 2007, 2008;
Rubin, Rimmer, Chicoine, Braddock, & McGuire,
1998; Robertson et al., 2000; Stancliffe et al., in
press). Lower prevalence rates of overweight and
obesity are evident for adults with cerebral palsy
(Bhaumik et al., 2008; Stancliffe et al., in press).

Likewise, level of intellectual disability has
been associated with BMI status. Individuals with
milder disability have a higher prevalence of
obesity, whereas those with more severe disability
have a lower rate of obesity but a higher prev-
alence of underweight (Emerson, 2005; Hove,
2004; Melville et al., 2007, 2008; Robertson et al.,
2000).

Living Arrangements

Living arrangements appear to be related to
BMI, with a higher prevalence of obesity evident
in less restrictive settings (own home, family
home), and lower prevalence in more regulated,
fully supervised settings (Melville et al., 2007;
Rimmer & Yamaki, 2006). However, not all the
studies reporting such findings controlled for
differences in personal characteristics between
living arrangements. For example, although Lewis,

Lewis, Leake, King, and Lindemann (2002)
reported significant differences in level of intel-
lectual disability by living arrangements, the lower
prevalence of obesity in community group-care
facilities may be attributable to the much more
severe level of intellectual disability of residents in
these settings compared with those living on their
own or with family members. When Melville
et al. (2008) used multivariate analysis that
controlled for level of intellectual disability, they
found a significant effect of living arrangements
for Scottish women (women living independently
were more likely to be obese than those living
with family), but no effect for Scottish men. In
addition, Melville et al. found no significant
multivariate difference by living arrangements for
either gender on prevalence of overweight.

Purpose of This Article

The goal of this article is to report on the
prevalence of obesity and overweight among adult
users of U.S. intellectual disability/developmental
disability services in a large sample drawn from
the 2008–2009 National Core Indicators (NCI)
program and compare these findings to preva-
lence data for the general population from Flegal
et al.’s (2010) findings from the 2007–2008
National Health and Nutrition Examination
Survey (NHANES), with subgroup analysis by
age, gender, and race–ethnicity. In addition, we
provide descriptive information about BMI of
adults with intellectual disability and compare
BMI status and obesity prevalence among indi-
viduals with different syndromes related to
intellectual disability, with different levels of
intellectual disability, and with different living
arrangements.

Method

Participating States
The NCI program is a voluntary collabora-

tion between the National Association of State
Directors of Developmental Disabilities Services,
the Human Services Research Institute, and state
developmental disability agencies of participating
states. No NCI data are collected in nonpartici-
pating states.

The 8,911 sample members in this study
were drawn from all 20 states that participated in
the 2008–2009 NCI program and collected con-
sumer survey data. Participants were adult users of

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 403

developmental disabilities services in Alabama,
Arkansas, Connecticut, Delaware, Georgia, Illinois,
Indiana, Kentucky, Louisiana, Massachusetts, Mis-
souri, North Carolina, New Jersey, New York,
Ohio, Oklahoma, Pennsylvania, South Carolina,
Texas, and Wyoming. Within each participating
state, samples were randomly drawn from the
state’s population of adults (age $ 18 years) with
intellectual disability receiving institutional, com-
munity, or home-based services, or some subset of
these (a few states’ samples included only recipients
of home and community-based services). Sample
sizes in participating states ranged from 193 (DE)
to 1,502 (NY) and averaged 578.

Instrument
Data were collected using the 2008–2009 NCI

Consumer Survey. The 2008–2009 survey was the
first version of the NCI survey to obtain data on
height and weight, allowing BMI to be calculated.
Height and weight data were not measured
directly by NCI interviewers but were obtained
typically from individual records, setting admin-
istrators, or support providers (including family
members for participants living with family).
These informants provided data on height in feet
and inches and data on weight in pounds. These
data are reported in the NCI Background section,
which requests information on the service user’s
personal characteristics, functioning, level of
intellectual disability, diagnoses, health, problem
behavior, living arrangements, and services. Data
in this section are typically obtained from agency
records, and it is usually completed by a case
manager–service coordinator.

One item asks whether the person has a
diagnosis of intellectual disability. The next item
asks about the person’s level of intellectual
disability (respondents may check one of the
following: N/A [not applicable], mild, moderate,
severe, profound, unspecified, or unknown). The
item that follows asks about a list of 16 other
disabilities and diagnoses that are noted on the
person’s record (respondents may check all that
apply), including autism spectrum disorder, cere-
bral palsy, Down syndrome, and Prader-Willi
syndrome. The residence-type item provides
respondents with 10 response options: specialized
institutional facility for persons with intellectual
disability/developmental disability, group home,
agency-operated apartment, independent home or
apartment, parent–relative’s home, foster care or

host home (person lives in home of unrelated,
paid caregiver), nursing facility, homeless, other,
or ‘‘don’t know.’’ There is also an item on the
number of people with disabilities living at the
setting, which can be used to cross-check resi-
dence type (e.g., an institution is considered to
house 16 or more people with a disability). No
specific distinction is made between intermediate
care facility for people with ‘‘mental retardation’’
(ICFs/MR) and settings with other funding or
regulatory arrangements, in that ICFs/MR can be
classified as institutions ($16 residents) or group
homes (#15 residents), but group homes also
include non-ICF/MR settings.

Interviewer training. To ensure that all inter-
viewers received consistent training, the NCI
Consumer Survey protocol is supported by a
training program for interviewers, including
training manuals, presentation slides, training
videos, scripts for scheduling interviews, and lists
of frequently asked questions. The training
includes question-by-question review of the sur-
vey tool.

Reliability. Multiple tests of the NCI instruments
have yielded interrater agreement of 92%–93%, and
a single examination of test–retest reliability resulted
in 80% agreement (Smith & Ashbaugh, 2001). How-
ever, no item testing was done on the specific height
and weight variables.

Participants
The total 2008–2009 NCI sample consisted

of 11,569 individual users of adult intellectual
disability/developmental disability services from
20 states. We excluded 99 people whose age was
missing and another 208 sample members aged
18 or 19 years, because our general population
comparison sample only included adults aged 20
or older (Flegal et al., 2010). Because we also
wanted to compare our sample with the compar-
ison sample on gender, race, and age, we excluded
individuals with missing data on these variables.
In addition, we excluded 421 individuals whose
height was missing and 13 adults with recorded
heights of 36 inches or less or 84 inches or more.
Such listed heights were, of course, possible but
were notable outliers, and we had no means to
follow up on their accuracy. Last, we omitted
individuals without an intellectual disability
diagnosis because our focus was on BMI in adults
with intellectual disability. This selection process
yielded a final sample of 8,911 individuals from

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

404 E American Association on Intellectual and Developmental Disabilities

20 states, with an average age of 43.48 years (range
5 20–93 years).

The U.S. general population comparison
data, including breakdowns by gender and race,
were drawn from analyses of the NHANES by
Flegal et al. (2010). To enable close comparison,
the NCI sample was broken down according to
the same age groups and as similar as possible
racial groups. Individuals were grouped by age as
follows: 20–39 years, 40–59 years, and 60 years or
older. Race and ethnicity were classified as non-
Hispanic White, non-Hispanic Black, and His-
panic/other. The first two of these race categories
were identical to the comparison group from
Flegal et al. Table 1 shows sample numbers by
racial group, gender, and age group. Information
about participant numbers by level of intellectual
disability and living arrangements is shown in the
results section.

Results

Overweight and Obesity
Raw data were gathered on height in feet and

inches and weight in pounds, not in metric units,
because these were the standard units reported in
the individuals’ health records. These data were
used to calculate BMI using the following
formula:

BMI~
body mass lbð Þx 703

height ftð Þð Þ2
:

BMI was classified as follows: (a) underweight: BMI ,
18.50; (b) normal weight: BMI 5 18.50–24.99; (c)

overweight: BMI 5 25.00–29.99; (d) obese: BMI 5
$30.00; Grade 2 obesity: BMI $ 35.00; Grade 3 obesity:
BMI $ 40.00 (World Health Organization [WHO]
Expert Committee on Physical Status, 1995).

Comparison with the general population. We
calculated the prevalence of overweight and
obesity by race, age group, and gender (Table 2).
We used Flegal et al.’s (2010, Table 2) analysis of
NHANES data as the basis for comparison be-
tween persons with intellectual disability (Table 2)
and the general population (for those $ 20 years
old). Nonoverlap of the 95% confidence intervals
between groups was considered to be a significant
difference. To assist with comparison, selected
groupings of Flegal et al.’s data (all people, all
men, all women) are reproduced in Table 2 along
with the corresponding groupings for people with
intellectual disability drawn from the NCI sample.
Readers should consult Flegal et al.’s Table 2
directly for more detailed comparisons for specific
age and gender groups. Because the Hispanic and
Mexican American samples were constituted
differently in the general population data (Flegal
et al.) than in the NCI data, we present the data
for the Hispanic/other group without a general
population comparison.

On most comparisons, our sample of adult
service users with intellectual disability from 20
states did not differ from the nationally represen-
tative sample of the U.S. population. Of 27
possible comparisons for obesity prevalence, only
4 were significant (denoted in Table 2 by an
asterisk to indicate that the NCI subgroup mean
differed significantly from the corresponding
subgroup mean in Flegal et al.’s, 2010, Table 2).

Table 1. Number of Sample Members with Intellectual Disability by Racial Group, Gender,
and Age

Gender/age group

Total

(N 5 8,911)

Non-Hispanic White

(n 5 6,488)

Non-Hispanic Black

(n 5 1,706)

Hispanic/other

(n 5 717)

Men

20–39 2,152 1,394 499 259

40–59 2,248 1,665 444 139

60+ 605 496 78 31
All men 5,005 3,555 1,021 429

Women

20–39 1,553 1,095 305 153

40–59 1,751 1,319 329 103

60+ 602 519 51 32
All women 3,906 2,933 685 288

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 405

T
a
b

le
2
.

P
er

ce
n

ta
ge

o
f

A
d

u
lt

s
W

it
h

In
te

ll
ec

tu
al

D
is

ab
il
it

ie
s

an
d

a
C

o
m

p
ar

is
o

n
S
am

p
le

F
ro

m
th

e
G

en
er

al
P
o

p
u

la
ti

o
n

a
W

h
o

W
er

e
O

b
es

e
o

r
O

v
er

w
ei

gh
t

b
y

R
ac

e,
A

ge
,

an
d

G
en

d
er

S
a
m

p
le

g
e
n

d
e
r/

a
g

e
g

ro
u

p

P
e
rc

e
n

ta
g

e
o

f
a
d

u
lt

s
(9

5
%

co
n

fi
d

e
n

ce
in

te
rv

a
l)

A
ll

(N
C

I
(N

5
8
,9

1
1
)

N
o

n
-H

is
p

a
n

ic
W

h
it

e

(N
C

I
n

5
6
,4

8
8
)

N
o

n
-H

is
p

a
n

ic
B

la
ck

(N
C

I
n

5
1
,7

0
6
)

H
is

p
a
n

ic
/O

th
e

r2

(N
C

I
n

5
7
1
7
)

O
b

e
se

:
B

M
I

$
3
0

T
o

ta
l

U
.S

.
sa

m
p

le
3
3
.8

(3
1
.6


3

6
.0

)
3
2
.8

(2
8
.9


3
5

.9
)

4
4
.1

(4
0
.0


4
8

.2
)

N
C

I
sa

m
p

le
3
3
.6

(3
2
.6


3

4
.6

)
3
3
.0

(3
1
.9


3
4

.2
)A

3
5
.8

(3
3
.5


3
8

.0
)*

A
3
3
.2

(2
9
.7


3
6
.7

)A

M
e
n

U
.S

.
sa

m
p

le
:

a
ll

3
2
.2

(2
9
.5


3

5
.0

)
3
1
.9

(2
8
.1


3
5

.7
)

3
7
.3

(3
2
.3


4
2

.4
)

N
C

I
sa

m
p

le
:

a
ll

2
9
.4

(2
8
.2


3

0
.7

)a
2
9
.6

(2
8
.1


3
1

.1
)c

B
2
8
.6

(2
5
.8


3
1

.4
)*

e
B

2
9
.6

(2
5
.3


3
3
.9

)g
B

N
C

I:
2
0

3
9

3
0
.8

(2
8
.9


3

2
.8

)a
3
0
.7

(2
8
.3


3
3

.1
)c

C
3
0
.1

(2
6
.0


3
4

.1
)e

C
3
2
.8

(2
7
.1


3
8
.6

)g
C

N
C

I:
4
0

5
9

2
9
.7

(2
7
.8


3

1
.6

)a
3
0
.5

(2
8
.2


3
2

.7
)c

D
2
7
.9

(2
3
.7


3
2

.1
)e

D
2
6
.6

(1
9
.2


3
4
.1

)g
D

N
C

I:
6
0

+
2
3
.3

(1
9
.9


2

6
.7

)*
a

2
3
.8

(2
0
.0


2
7

.6
)*

c
E

2
3
.1

(1
3
.5


3
2

.6
)e

E
1
6
.1

(2
.4


2
9
.8

)g
E

W
o

m
e
n

U
.S

.
sa

m
p

le
:

a
ll

3
5
.5

(3
3
.2


3

7
.7

)
3
3
.0

(2
9
.3


3
6

.6
)

4
9
.6

(4
5
.5


5
3

.7
)

N
C

I
sa

m
p

le
:

a
ll

3
8
.9

(3
7
.4


4

0
.4

)b
3
7
.2

(3
5
.5


3
9

.0
)d

F
4
6
.4

(4
2
.7


5
0

.2
)f

G
3
8
.5

(3
2
.9


4
4
.2

)g
F
G

N
C

I:
2
0

3
9

4
1
.1

(3
8
.7


4

3
.6

)b
3
8
.2

(3
5
.3


4
1

.1
)d

H
5
1
.5

(4
5
.8


5
7

.1
)f

I
4
1
.8

(3
3
.9


4
9
.7

)g
H

I

N
C

I:
4
0

5
9

3
9
.5

(3
7
.2


4

1
.8

)b
3
8
.9

(3
6
.3


4
1

.5
)d

J
4
1
.9

(3
6
.6


4
7

.3
)f

J
3
9
.8

(3
0
.2


4
9
.4

)g
J

N
C

I:
6
0

+
3
1
.4

(2
7
.7


3

5
.1

)b
3
0
.8

(2
6
.8


3
4

.8
)c

K
4
5
.1

(3
1
.0


5
9

.2
)e

K
1
8
.8

(4
.5


3
3
.1

)g
K

O
v
e
rw

e
ig

h
t

o
r

o
b

e
se

:
B

M
I

$
2
5

T
o

ta
l

U
.S

.
sa

m
p

le
:

a
ll

6
8
.0

(6
6
.3


6

9
.8

)
6
6
.7

(6
4
.1


6
9

.3
)

7
3
.8

(7
1
.3


7
6

.3
)

N
C

I
sa

m
p

le
:

a
ll

6
2
.2

(6
1
.2


6

3
.3

)*
6
2
.0

(6
0
.8


6
3

.2
)*

L
6
3
.8

(6
1
.5


6
6

.1
)*

L
6
0
.7

(5
7
.1


6
4
.3

)L

M
e
n

U
.S

.
sa

m
p

le
:

a
ll

7
2
.3

(7
0
.4


7

4
.1

)
7
2
.6

(6
9
.9


7
5

.3
)

6
8
.5

(6
5
.2


7
1

.8
)

N
C

I
sa

m
p

le
:

a
ll

6
0
.5

(5
9
.1


6

1
.8

)*
h

6
0
.7

(5
9
.1


6
2

.3
)*

jM
6
0
.3

(5
7
.3


6
3

.3
)*

k
M

5
9
.0

(5
4
.3


6
3
.7

)m
M

N
C

I:
2
0

3
9

5
7
.7

(5
5
.6


5

9
.8

)*
h

5
8
.0

(5
5
.6


6
0

.6
)*

jN
5
7
.0

(5
2
.6


6
1

.3
)k

N
5
7
.9

(5
1
.9


6
4
.0

)m
N

N
C

I:
4
0

5
9

6
3
.9

(6
1
.9


6

5
.9

)*
h

6
3
.8

(6
1
.4


6
6

.0
)*

jO
6
5
.5

(6
1
.1


7
0

.0
)k

O
6
1
.2

(5
3
.0


6
9
.4

)m
O

N
C

I:
6
0

+
5
7
.4

(5
3
.4


6

1
.3

)*
h

5
8
.1

(5
3
.7


6
2

.4
)*

jP
5
2
.6

(4
1
.2


6
3

.9
)*

k
P

5
8
.1

(3
9
.7


7
6
.5

)m
P

(T
a
b

le
2

c
o
n

ti
n

u
e
d

)

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

406 E American Association on Intellectual and Developmental Disabilities

In each case, the group with intellectual disability
had lower prevalence of obesity.

For the overweight and obesity prevalence data
(lower half of Table 2), 15 of 27 (56%) comparisons
were significant. Here too, the group with intellec-
tual disability had lower prevalence in every case.
Ten of the 12 (83%) comparisons involving men
were significant, suggesting a lower prevalence of
overweight and obesity among men with intellec-
tual disability than men in the general U.S.
population. By contrast, only 2 of the 12 (17%)
comparisons for women were significant, suggest-
ing that, for women, there is a similar prevalence of
overweight and obesity to the general population.

Gender comparisons. Among the sample of
people with intellectual disability, men were
significantly less obese than women (significant
pairwise gender comparisons denoted in Table 2
by means with different lowercase superscript
letters when comparing the equivalent male and
female subgroup within columns). This was true for
the sample overall (all men vs. all women) and for
non-Hispanic White and non-Hispanic Black men
but not for men in the Hispanic/other group.
These significant gender differences in obesity
prevalence were also true for within-race compar-
isons between men and women in the 20–39-year-
old and 40–59-year-old age groups for White and
Black participants. The absence of significant
gender differences for the 60+ age group may have
been due, in part, to its much smaller sample size.

Among adults with intellectual disability,
gender differences were less evident for the
combined overweight and obesity groups. There
was a significantly lower prevalence of overweight
and obesity when comparing all men (60.5%) with
all women (64.5%), as well as for all Black men with
all Black women, and for all men and Black men
among the 20–39-year-old age group. These
differences appear to have been driven by the
higher obesity prevalence in women. Indeed,
taking overweight (25.0 # BMI , 30.0) prevalence
only, 31.0% of all men and 25.6% of all women
were overweight.

Comparisons by race–ethnic group. There were no
significant differences by race–ethnic group in the
prevalence of obesity or of combined overweight
and obesity among the sample as a whole or among
men with intellectual disability. However, signifi-
cantly more Black women were obese than White
women (significant race–ethnic group comparisons
denoted in Table 2 by means with different upper-
case superscript letters within rows). When brokenT

a
b

le
2
.

C
o

n
ti

n
u

ed
.

S
a
m

p
le

g
e
n

d
e
r/

a
g

e
g

ro
u

p

P
e
rc

e
n

ta
g

e
o

f
a
d

u
lt

s
(9

5
%

co
n

fi
d

e
n

ce
in

te
rv

a
l)

A
ll

(N
C

I
(N

5
8
,9

1
1
)

N
o

n
-H

is
p

a
n

ic
W

h
it

e

(N
C

I
n

5
6
,4

8
8
)

N
o

n
-H

is
p

a
n

ic
B

la
ck

(N
C

I
n

5
1
,7

0
6
)

H
is

p
a
n

ic
/O

th
e

r2

(N
C

I
n

5
7
1
7
)

W
o

m
e
n

U
.S

.
S
a
m

p
le

:
a
ll

6
4
.1

(6
1
.3


6

6
.9

)
6
1
.2

(5
6
.7


6
5

.7
)

7
8
.2

(7
4
.5


8
1

.9
)

N
C

I
S
a
m

p
le

:
a
ll

6
4
.5

(6
3
.0


6

6
.0

)i
6
3
.7

(6
1
.9


6
5

.4
)j

Q
6
8
.9

(6
5
.4


7
2

.4
)*

lQ
6
3
.2

(5
7
.6


6
8
.8

)m
Q

N
C

I:
2
0

3
9

6
3
.9

(6
1
.6


6

6
.3

)i
6
1
.6

(5
8
.7


6
4

.4
)j

R
7
2
.5

(6
7
.4


7
7

.5
)l

S
6
4
.1

(5
6
.4


7
1
.7

)m
R

S

N
C

I:
4
0

5
9

6
5
.5

(6
3
.2


6

7
.7

)h
6
5
.2

(6
2
.6


6
7

.8
)j

T
6
6
.0

(6
0
.8


7
1

.1
)*

k
T

6
7
.0

(5
7
.8


7
6
.2

)m
T

N
C

I:
6
0

+
6
3
.5

(5
9
.6


6

7
.3

)h
6
4
.2

(6
0
.0


6
8

.3
)j

U
6
6
.7

(5
3
.3


8
0

.1
)k

U
4
6
.9

(2
8
.6


6
5
.2

)m
U

N
ot

e.
N

C
I

5
N

at
io

n
al

C
o

re
In

d
ic

at
o

rs
.
T

h
e

ge
n

er
al

p
o

p
u

la
ti

o
n

co
m

p
ar

is
o

n
d

at
a

ar
e

fr
o

m
th

e
N

at
io

n
al

H
ea

lt
h

an
d

N
u

tr
it

io
n

E
xa

m
in

at
io

n
S
u

rv
ey

(N
H

A
N

E
S
;

F
le

ga
l
et

al
.,

2
0
1
0
).

F
o

r
th

e
H

is
p

an
ic

/o
th

er
co

lu
m

n
d

at
a,

co
m

p
ar

is
o

n
w

it
h

F
le

ga
l

et
al

.
(2

0
1
0
)

w
as

n
o

t
p

o
ss

ib
le

b
ec

au
se

o
f

d
if

fe
re

n
t

et
h

n
ic

gr
o

u
p

in
gs

u
se

d
in

th
is

co
lu

m
n

.
*T

h
er

e
w

as
n

o
o

v
er

la
p

in
9
5
%

co
n

fi
d

en
ce

in
te

rv
al

s
b

et
w

ee
n

N
C

I
d

at
a

an
d

th
e

eq
u

iv
al

en
t

N
H

A
N

E
S

su
b

gr
o

u
p

in
F
le

ga
l
et

al
.’
s

(2
0
1
0
)

T
ab

le
2
.
In

al
l
ca

se
s

o
f

d
if

fe
re

n
ce

s
(n

o
o

v
er

la
p

),
N

C
I

m
ea

n
s

w
er

e
lo

w
er

.
a

m
G

en
d

er
co

m
p

ar
is

o
n

s
(p

ai
rw

is
e,

w
it

h
in

co
lu

m
n

s)
:

M
ea

n
s

th
at

sh
ar

e
th

e
sa

m
e

lo
w

er
ca

se
su

p
er

sc
ri

p
t

le
tt

er
d

id
n

o
t

d
if

fe
r

si
gn

if
ic

an
tl

y
.

A

U
R

ac
e–

et
h

n
ic

gr
o

u
p

co
m

p
ar

is
o

n
s

(w
it

h
in

ro
w

s)
:

M
ea

n
s

th
at

sh
ar

e
th

e
sa

m
e

u
p

p
er

ca
se

su
p

er
sc

ri
p

t
le

tt
er

d
id

n
o

t
d

if
fe

r
si

gn
if

ic
an

tl
y
.

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 407

down further by age group, this Black–White racial
difference was significant for women in the 20–29-
year-old age group but not for either of the older
age groups of women. Women in the Hispanic/
other group did not differ in obesity prevalence
from women in any other racial group. The
findings for overweight and obesity prevalence
among women were similar.

Grade 3 Obesity
Table 3 shows the prevalence of Grade 3

obesity (morbid obesity). Overall prevalence of
Grade 3 obesity (BMI $ 40.0) among the NCI
sample was 7.6% and ranged from 2.6% for older
(60+) Black men to an exceptionally high 16.1%
among younger (20–39) Black women.

Comparison with the general population. For
Grade 3 obesity, 6 of 27 (22%) comparisons
between the NCI sample with intellectual disabil-
ity and the general population (Flegal et al., 2010,
Table 3) yielded significant differences (denoted
by an asterisk). In all cases, sample members with
intellectual disability had significantly higher
prevalence rates. Even though the overall preva-
lence of obesity among adults with intellectual
disability did not differ from the general popula-
tion (Table 2), for Grade 3 obesity, significantly
more people with intellectual disability were
affected, especially younger women.

Gender comparisons. Women with intellectual
disability had significantly higher prevalence of
Grade 3 obesity compared with men. This was
true for the overall NCI sample, for non-Hispanic
White individuals and non-Hispanic Black indi-
viduals (pairwise gender comparisons within
columns denoted by lowercase-letter superscripts).
There were no significant differences by race–
ethnic group.

Diagnosis and BMI
We partitioned our sample into four mutually

exclusive diagnostic groups: (a) intellectual dis-
abilities only (but no Down syndrome, autism–
pervasive developmental disorders, or cerebral
palsy), (b) intellectual disability and Down
syndrome, (c) intellectual disability and autism–
pervasive developmental disorder, and (d) intel-
lectual disability and cerebral palsy. Individuals
with more than one diagnosis (of Down syn-
drome, autism–pervasive developmental disorder,
or cerebral palsy) were excluded, as were those
with missing data on diagnoses (n 5 643). In

addition, because of a very small sample size, we
excluded 28 individuals with Prader-Willi syn-
drome, leaving a final sample of 8,272 individuals.
Table 4 shows BMI data by diagnostic group.

The mean BMI for participants with Down
syndrome was in the obese range ($30.0); for
those with intellectual disability only or autism–
pervasive developmental disorders, the mean was
in the overweight range (BMI 5 25.0–30.0). Only
the mean for the group with cerebral palsy was in
the healthy weight range (BMI 5 18.5–24.99).

One-way analysis of variance (ANOVA) re-
vealed a significant between-diagnostic-group
difference, F(3, 8268) 5 116.38, p , .001. The as-
sumption of homogeneity of variance was violated,
so we used Tamahane’s T2 procedure to test
pairwise differences among each diagnostic group.
All these comparisons were significant at .001 or
better, showing that BMI for individuals with
Down syndrome was significantly higher than the
other three groups, whereas those with cerebral
palsy had significantly lower mean BMI than the
other three groups. The intellectual disability–only
and autism–pervasive developmental disorder
groups each fell in between, but each also differed
significantly from all other groups.

The mean BMI for the 28 individuals with
Prader-Willi syndrome excluded from these anal-
yses was 34.32 (95% confidence interval 5 30.31–
38.33), higher than for any of the four groups
shown in Table 4. However, the very small sample
size and consequent wide confidence intervals
made between-group comparisons potentially
misleading, given the likelihood of the difference
from the sample with Prader-Willi syndrome not
being statistically significant when a real differ-
ence existed (Type II error).

Next, we examined the prevalence of com-
bined overweight and obesity for the four
diagnostic groups listed in Table 4. The sample
size for some diagnostic groups was relatively
small, so we broke down these prevalence data by
gender but not by age group to limit the potential
for Type II error (Table 5).

The group with cerebral palsy had a notably
lower prevalence of obesity and overweight than
any of the other diagnostic groups and lower than
the general population (see Table 2 for general
population prevalence). As Table 5 shows, for
each diagnostic group as a whole (‘‘NCI all’’), the
prevalence of obesity differed significantly (up-
percase superscripts within rows), from a low of
17.2% (cerebral palsy) to a high of 44.3% (Down

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

408 E American Association on Intellectual and Developmental Disabilities

T
a
b

le
3
.

P
re

v
al

en
ce

o
f

G
ra

d
e

3
(M

o
rb

id
)

O
b

es
it

y
A

m
o

n
g

A
d

u
lt

s
W

it
h

In
te

ll
ec

tu
al

D
is

ab
il
it

y
an

d
a

C
o

m
p

ar
is

o
n

S
am

p
le

F
ro

m
th

e
U

.S
.

G
en

er
al

P
o

p
u

la
ti

o
n

b
y

R
ac

e,
A

ge
,

an
d

G
en

d
er

S
a
m

p
le

g
e
n

d
e
r/

a
g

e
g

ro
u

p

P
e
rc

e
n

ta
g

e
o

f
a
d

u
lt

s
(9

5
%

co
n

fi
d

e
n

ce
in

te
rv

a
l)

A
ll

(N
C

I
N

5
8
,9

1
1
)

N
o

n
-H

is
p

a
n

ic
W

h
it

e

(N
C

I
n

5
6
,4

8
8
)

N
o

n
-H

is
p

a
n

ic
B

la
ck

(N
C

I
n

5
1
,7

0
6
)

H
is

p
a
n

ic
/o

th
e
r

(N
C

I
n

5
7
1
7
)

G
ra

d
e

3
o

b
e
si

ty
:

B
M

I
$

4
0
.0

U
.S

.
sa

m
p

le
:

a
ll

5
.7

(4
.9


6
.5

)
5
.2

(3
.8


6
.5

)
1
1
.1

(8
.3


1
3
.8

)

N
C

I
sa

m
p

le
:

a
ll

7
.6

(7
.1


8
.2

)*
7
.3

(6
.7


8
.0

)*
A

8
.9

(7
.5


1
0
.2

)A
7
.3

(5
.4


9
.2

)A

M
e
n

(n
5

5
,0

0
5
)

U
.S

.
sa

m
p

le
:

a
ll

4
.2

(3
.3


5
.1

)
4
.0

(2
.9


5
.1

)
7
.0

(4
.5


9
.4

)

N
C

I
sa

m
p

le
:

a
ll

5
.1

(4
.5


5
.7

)a
5
.0

(4
.2


5
.7

)c
B

5
.6

(4
.2


7
.0

)e
B

5
.4

(3
.2


7
.5

)g
B

N
C

I:
2
0

3
9

6
.5

(5
.5


7
.6

)a
6
.5

(5
.2


7
.8

)c
C

6
.8

(4
.6


9
.0

)e
C

6
.2

(3
.2


9
.1

)g
C

N
C

I:
4
0

5
9

4
.4

(3
.6


5
.3

)a
4
.3

(3
.3


5
.2

)c
D

4
.7

(2
.8


6
.7

)e
D

5
.0

(1
.4


8
.7

)g
D

N
C

I:
6
0

+
2
.8

(1
.5


4
.1

)a
3
.0

(1
.5


4
.5

)c
E

2
.6

(–
1
.0


6
.2

)e
E

0
.0

W
o

m
e
n

(n
5

3
,9

0
6
)

U
.S

.
sa

m
p

le
:

a
ll

7
.2

(6
.1


8
.4

)
6
.4

(4
.2


8
.5

)
1
4
.2

(1
0
.5


1
7
.8

)

N
C

I
sa

m
p

le
:

a
ll

1
0
.8

(9
.6


1
1

.8
)*

b
1
0
.2

(9
.1


1
1
.3

)*
d

F
1
3
.7

(1
1
.1


1
6
.3

)f
F

1
0
.1

(6
.6


1
3
.6

)g
F

N
C

I:
2
0

3
9

1
3
.3

(1
1
.6


1

5
.0

)*
b

1
3
.1

(1
1
.1


1
5
.1

)*
d

G
1
6
.1

(1
1
.9


2
0
.2

)f
G

9
.8

(5
.0


1
4
.6

)g
G

N
C

I:
4
0

5
9

1
0
.6

(9
.2


1
2

.1
)b

1
0
.0

(8
.4


1
1
.6

)d
H

1
2
.8

(9
.1


1
6
.4

)f
H

1
1
.7

(5
.4


1
8
.0

)g
H

N
C

I:
6
0

+
5
.0

(3
.2


6
.7

)a
4
.8

(3
.0


6
.7

)c
I

5
.9

(–
0
.8


1
2
.6

)e
I

6
.3

(–
2
.6


1
5

.1
)I

N
ot

e.
N

C
I

5
N

at
io

n
al

C
o

re
In

d
ic

at
o

rs
.
T

h
e

ge
n

er
al

p
o

p
u

la
ti

o
n

co
m

p
ar

is
o

n
d

at
a

ar
e

fr
o

m
th

e
N

at
io

n
al

H
ea

lt
h

an
d

N
u

tr
it

io
n

E
xa

m
in

at
io

n
S
u

rv
ey

(N
H

A
N

E
S
;
F
le

ga
l
et

al
.,

2
0
1
0
).

In
th

e
H

is
p

an
ic

/o
th

er
co

lu
m

n
,

co
m

p
ar

is
o

n
w

it
h

F
le

ga
l

et
al

.
(2

0
1
0
)

w
as

n
o

t
p

o
ss

ib
le

b
ec

au
se

o
f

d
if

fe
re

n
t

et
h

n
ic

gr
o

u
p

in
gs

u
se

d
in

th
is

co
lu

m
n

.
*
T

h
er

e
w

as
n

o
o

v
er

la
p

in
9
5
%

co
n

fi
d

en
ce

in
te

rv
al

s
b

et
w

ee
n

N
C

I
d

at
a

an
d

th
e

eq
u

iv
al

en
t

N
H

A
N

E
S

su
b

gr
o

u
p

in
F
le

ga
l
et

al
.
(2

0
1
0
,
T

ab
le

3
).

In
al

l
ca

se
s

o
f

d
if

fe
re

n
ce

s
(n

o
o

v
er

la
p

)
N

C
I

m
ea

n
s

w
er

e
h

ig
h

er
.

a

g
G

en
d

er
co

m
p

ar
is

o
n

s
(p

ai
rw

is
e,

w
it

h
in

co
lu

m
n

s)
:

M
ea

n
s

th
at

sh
ar

e
th

e
sa

m
e

lo
w

er
ca

se
su

p
er

sc
ri

p
t

le
tt

er
d

id
n

o
t

d
if

fe
r

si
gn

if
ic

an
tl

y
.

A

I
R

ac
e–

et
h

n
ic

gr
o

u
p

co
m

p
ar

is
o

n
s

(w
it

h
in

ro
w

s)
:

M
ea

n
s

th
at

sh
ar

e
th

e
sa

m
e

u
p

p
er

ca
se

su
p

er
sc

ri
p

t
le

tt
er

d
id

n
o

t
d

if
fe

r
si

gn
if

ic
an

tl
y
.

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 409

syndrome). This is consistent with the BMI
analyses shown in Table 4. Overall, significantly
more women (38.4%) were obese than men
(28.8%). This gender difference in obesity was
repeated for the intellectual disability–only and
cerebral palsy groups but did not attain signifi-
cance for the smaller Down syndrome and
autism–pervasive developmental disorder groups
(lowercase superscripts within columns). A similar
pattern of significant differences was evident for
the combined overweight and obesity prevalence
data shown in the lower section of Table 5.

Level of Intellectual Disability
There were large and significant differences in

obesity prevalence by level of intellectual disabil-
ity (Table 6). The lowest prevalence of obesity was
among individuals with profound intellectual
disability (12.6%). This rate was significantly and
substantially lower than those with severe intel-
lectual disability (26.7%), who in turn had a
significantly lower prevalence rate than people
with mild or moderate intellectual disability
(41.4% and 38.2%, respectively). The differences
between the groups of persons with mild and
moderate intellectual disability were not statisti-
cally significant (uppercase superscripts within
rows). The gender differences noted in Table 2 are
also evident in Table 6. It is notable that women
had a significantly higher prevalence of obesity
than men within the mild, moderate, and severe
intellectual disability groups (lowercase super-
scripts within columns). That is, gender differenc-
es in obesity were evident at all levels except
profound intellectual disability. The effects of
level of intellectual disability and gender com-
bined were marked; for example, almost half

(46.5%) of women with mild intellectual disability
had a BMI in the obese range.

Living Arrangements
Prevalence of overweight and obesity by

living arrangement and by level of intellectual
disability is shown in Table 7. The last (‘‘Total’’)
column of Table 7 shows the significant overall
differences between living arrangements in the
prevalence of obesity, with the highest prevalence
among individuals living in their own home
(42.8%) and the lowest among institutional
residents (18.6%). Inspection of the confidence
intervals in the final column of Table 7 (upper
half) reveals that institutional residents had a
significantly lower prevalence of obesity than any
of the other residence types listed (lowercase
superscripts with columns). Both host–foster
home and group home had significantly lower
prevalence than agency apartment, own home,
and family home. Family home was significantly
lower than own home, and own home and agency
apartment did not differ. The comparisons for
overweight and obesity (lower half of Table 7)
were generally similar to the pattern for obesity.

At first glance, these univariate comparisons
suggest significant variations in the prevalence of
obesity among different living arrangements.
However, there were substantial disparities among
different living arrangements in the percentages of
people at each level of intellectual disability. For
example, people with profound intellectual dis-
ability made up 45.2% of institutional residents
but only 5.6% of agency apartment residents and
only 7.4% of those living in their own home. To
make these differences explicit, Table 7 also
shows the total number of sample members at

Table 4. Body Mass Index (BMI) for Persons With Intellectual Disability by Diagnostic Group

Diagnostic group n M SD 95% CI

Intellectual disability only 5,723 28.55a 7.62 28.35–28.75

Intellectual disability and

Down syndrome 721 30.40
b

7.66 29.84–30.96

Intellectual disability and

autism/pervasive

developmental disability 721 27.42
c

7.16 26.90–27.95

Intellectual disability and

cerebral palsy 1,107 24.53
d

6.62 24.14–24.92

Total intellectual disability 8,272 28.07 7.61 27.91–28.24

Note. CI 5 confidence interval.
a–dDiagnostic group comparisons (within columns): Means that share the same lowercase superscript letter did not differ
significantly.

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

410 E American Association on Intellectual and Developmental Disabilities

each level of intellectual disability in each
residence type. For example, there were 159
people with mild intellectual disability living in
institutions, 31.4% of whom were obese. As has
been shown (Table 6), there are important
differences in prevalence of obesity by level of
intellectual disability. This factor needs to be
considered carefully when examining differences
in prevalence of obesity among residence types.

When comparisons of prevalence of obesity
are made among residence types within each
level of intellectual disability, the differences are
much less stark than they appear in the final
column of Table 7. For individuals with mild
intellectual disability, institutional residents still
had the lowest prevalence of obesity, but the
difference was only significant when compared
with agency apartment and own-home residents
(lowercase superscripts within columns). Signifi-
cantly fewer group home and family home
residents were obese than those living in their
own home. There were no other significant differ-
ences by residence type among sample mem-
bers with mild intellectual disability. Comparison
with the final column of Table 7 reveals that
although differences in obesity prevalence remain,
the differences among living arrangements are
much smaller within each level of intellectual
disability.

Likewise, in the group with moderate intel-
lectual disability, significantly fewer institutional,
group home, and host–foster home residents were
obese than those living in their own home or
family home. For those with severe intellectual
disability, there were no significant differences in
prevalence of obesity by living arrangement. In the
case of people with profound disability, signifi-
cantly fewer institution residents were obese than
people from agency apartments or from family
homes. There were no other significant differences
by living arrangement among individuals with
profound intellectual disability. Overall, the effect
of living arrangement appeared to be more
significant among those with moderate and mild
intellectual disability and less evident among
individuals with more severe intellectual disability.
Across living arrangements, for individuals with
mild or moderate intellectual disability, the pattern
appeared to reflect lower prevalence of obesity in
regulated congregate settings such as institutions
but higher prevalence in more individualized, less
supervised environments such as one’s own home.T

a
b

le
5
.

P
er

ce
n

ta
ge

o
f

O
b

es
e

an
d

O
v
er

w
ei

gh
t

A
d

u
lt

s
W

it
h

In
te

ll
ec

tu
al

D
is

ab
il
it

ie
s

b
y

D
ia

gn
o

st
ic

G
ro

u
p

an
d

G
en

d
er

G
ro

u
p

/g
e
n

d
e
r

D
ia

g
n

o
st

ic
g

ro
u

p

In
te

ll
e
ct

u
a
l

d
is

a
b

il
it

ie
s

o
n

ly
(n

5
5
,6

2
7
)

D
o

w
n

sy
n

d
ro

m
e

(n
5

7
0
6
)

A
u

ti
sm

/p
e
rv

a
si

v
e

d
e
v
e
lo

p
m

e
n

ta
l

d
is

o
rd

e
r

(n
5

6
9
0
)

C
e
re

b
ra

l
p

a
ls

y

(n
5

1
,0

7
8
)

T
o

ta
l

(N
5

8
,1

0
1
)

O
b

e
se

:
B

M
I:

$
3
0

N
C

I
sa

m
p

le
:

a
ll

3
5
.1

(3
3
.9


3
6

.4
)A

4
4
.3

(4
0
.7


4
8
.0

)B
2
9
.3

(2
5
.9


3
2
.7

)C
1
7
.2

(1
4
.9


1
9

.4
)D

3
3
.0

(3
2
.0


3
4

.0
)

M
e
n

(n
5

4
,5

5
1
)

3
0
.7

(2
9
.1


3
2

.3
)a

E
4
1
.2

(3
6
.3


4
6
.1

)c
F

2
6
.7

(2
2
.9


3
0
.6

)d
E

1
1
.9

(9
.2


1
4
.5

)e
G

2
8
.8

(2
7
.5


3
0

.1
)g

W
o

m
e
n

(n
5

3
,5

5
0
)

4
0
.4

(3
8
.5


4
2

.3
)b

H
4
8
.1

(4
2
.6


5
3
.6

)c
I

3
6
.8

(2
9
.6


4
4
.0

)d
H

I
2
3
.0

(1
9
.4


2
6

.7
)f

J
3
8
.4

(3
6
.8


4
0

.0
)h

O
v
e
rw

e
ig

h
t

o
r

o
b

e
se

:
B

M
I

$
2
5

N
C

I
sa

m
p

le
:

a
ll

6
4
.8

(6
3
.5


6
6

.0
)K

7
2
.7

(6
9
.4


7
6
.0

)L
5
9
.4

(5
5
.8


6
3
.1

)M
4
1
.0

(3
8
.1


4
3

.9
)N

6
1
.8

(6
0
.8


6
2

.9
)

M
e
n

(n
5

4
,5

5
1
)

6
3
.0

(6
1
.3


6
4

.7
)i

O
Q

7
2
.5

(6
8
.1


7
7
.0

)k
P

5
9
.7

(5
5
.4


6
3
.9

)l
Q

3
6
.1

(3
2
.1


4
0

.1
)m

R
6
0
.1

(5
8
.7


6
1

.5
)o

W
o

m
e
n

(n
5

3
,5

5
0
)

6
6
.9

(6
5
.1


6
8

.7
)j

S
T

7
2
.8

(6
7
.9


7
7
.7

)k
S

5
8
.6

(5
1
.2


6
6
.0

)l
T

4
6
.4

(4
2
.1


5
0

.7
)n

U
6
4
.1

(6
2
.5


6
5

.6
)p

N
ot

e.
N

C
I

5
N

at
io

n
al

C
o

re
In

d
ic

at
o

rs
.

a

p
G

en
d

er
co

m
p

ar
is

o
n

s
(p

ai
rw

is
e,

w
it

h
in

co
lu

m
n

s)
:

M
ea

n
s

th
at

sh
ar

e
th

e
sa

m
e

lo
w

er
ca

se
su

p
er

sc
ri

p
t

le
tt

er
d

id
n

o
t

d
if

fe
r

si
gn

if
ic

an
tl

y
.

A

U
D

ia
gn

o
st

ic
gr

o
u

p
co

m
p

ar
is

o
n

s
(w

it
h

in
ro

w
s)

:
M

ea
n

s
th

at
sh

ar
e

th
e

sa
m

e
u

p
p

er
ca

se
su

p
er

sc
ri

p
t

le
tt

er
d

id
n

o
t

d
if

fe
r

si
gn

if
ic

an
tl

y
.

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 411

Within each type of living arrangement there
was a consistent pattern of differences by level of
intellectual disability. The groups with mild and
moderate intellectual disability did not differ on
obesity prevalence within any of the six types of
living arrangement listed in Table 7 (uppercase
superscripts within rows). However, within every
type of living arrangement, either or both groups
with severe and profound intellectual disability
had significantly lower prevalence rates of obesity
than either or both the groups with mild or
moderate intellectual disability. These findings are
fully consistent with the overall results for level of
intellectual disability reported in Table 6.

Discussion

We found high levels of obesity and over-
weight in our 2008–2009 20-state sample of adult
service users (20 years and older) with intellectual
disability. Almost two thirds (62.2%) of sample
members were overweight or obese (BMI $ 25.0)
and one third (33.6%) obese (BMI $ 30.0). The
prevalence of Grade 3 (morbid) obesity (BMI $
40.0) was 7.6%, and was especially pronounced
among younger women with intellectual disability.

Compared with a 2007–2008 nationally
representative sample of the general adult (20 years
and older) population (Flegal et al., 2010), adults
with intellectual disability in the NCI sample had
a similar or slightly lower prevalence of over-
weight and obesity. Where group differences were
evident, the data showed that people with
intellectual disability had lower prevalence of
overweight and obesity. There were few differenc-
es regarding obesity, but there was a mostly
consistent pattern of lower prevalence of over-
weight and obesity among men with intellectual
disability. There were few differences between
women from the general population and women
with intellectual disability.

In summary, overweight and obesity are
serious health issues for American adults with
and without intellectual disability, but, contrary to
some previous research, prevalence is not higher
among adults with intellectual disability who use
intellectual disability/developmental disability ser-
vices, than for the general population. Our findings
differ from Yamaki (2005), whose U.S. data were
derived from the NHIS, a population-based
household survey. The different sample frames of
the two studies may have contributed to the
different findings. Our participants included manyT

a
b

le
6
.

P
er

ce
n

ta
ge

o
f

O
b

es
e

an
d

O
v
er

w
ei

gh
t

A
d

u
lt

s
W

it
h

In
te

ll
ec

tu
al

D
is

ab
il
it

ie
s

b
y

L
ev

el
o

f
In

te
ll
ec

tu
al

D
is

ab
il
it

y
an

d
G

en
d

er

G
e
n

d
e
r

L
e
v
e
l

o
f

in
te

ll
e
ct

u
a
l

d
is

a
b

il
it

y

M
il
d

(n
5

3
,2

8
4
;

3
8
.9

%
)

M
o

d
e
ra

te

(n
5

2
,5

1
8
;

2
9
.8

%
)

S
e
v
e
re

(n
5

1
,3

4
2
;

1
5
.9

%
)

P
ro

fo
u

n
d

(n
5

1
,3

0
5
;

1
5
.4

%
)

T
o

ta
l

(N
5

8
,4

4
9
;

1
0
0
%

)

O
b

e
se

:
B

M
I

$
3
0

N
C

I
sa

m
p

le
:

a
ll

4
1
.4

(3
9
.7


4
3
.0

)A
3
8
.2

(3
6
.4


4
0
.1

)A
2
6
.7

(2
4
.3


2
9
.1

)B
1
2
.6

(1
0
.8


1
4
.5

)C
3
3
.7

(3
2
.7


3

4
.7

)

N
C

I:
m

e
n

(n
5

4
,7

4
5
)

3
7
.1

(3
4
.8


3
9
.3

)a
D

3
3
.9

(3
1
.4


3
6
.3

)c
D

2
1
.7

(1
8
.8


2
4
.6

)e
E

1
0
.9

(8
.7


1
3
.2

)g
F

2
9
.5

(2
8
.5


3

0
.9

)h

N
C

I:
w

o
m

e
n

(n
5

3
,7

0
4
)

4
6
.5

(4
4
.0


4
9
.0

)b
G

4
4
.1

(4
1
.1


4
7
.1

)d
G

3
3
.9

(2
9
.9


3
7
.9

)f
H

1
4
.8

(1
1
.9


1
7
.6

)g
I

3
8
.9

(3
7
.4


4

0
.5

)i

O
v
e
rw

e
ig

h
t

o
r

o
b

e
se

:
B

M
I

$
2
5

N
C

I
sa

m
p

le
:

a
ll

6
9
.7

(6
8
.1


7
1
.2

)J
6
9
.6

(6
7
.8


7
1
.4

)J
5
6
.6

(5
3
.9


5
9
.2

)K
3
5
.5

(3
2
.9


3
8
.1

)L
6
2
.3

(6
1
.3


6

3
.3

)

N
C

I:
m

e
n

(n
5

4
,7

4
5
)

6
7
.6

(6
5
.4


6
9
.8

)j
M

6
8
.3

(6
5
.9


7
0
.7

)l
M

5
3
.7

(5
0
.2


5
7
.2

)m
N

3
5
.9

(3
2
.4


3
9
.4

)n
O

6
0
.7

(5
9
.3


6

2
.0

)o

N
C

I:
w

o
m

e
n

(n
5

3
,7

0
4
)

7
2
.2

(6
9
.9


7
4
.5

)k
P

7
1
.3

(6
8
.6


7
4
.0

)l
P

6
0
.7

(5
6
.5


6
4
.8

)m
Q

3
5
.0

(3
1
.1


3
8
.9

)n
R

6
4
.4

(6
2
.8


6

5
.9

)p

N
ot

e.
N

C
I

5
N

at
io

n
al

C
o

re
In

d
ic

at
o

rs
.

a

p
G

en
d

er
co

m
p

ar
is

o
n

s
(p

ai
rw

is
e,

w
it

h
in

co
lu

m
n

s)
:
M

ea
n

s
th

at
sh

ar
e

th
e

sa
m

e
lo

w
er

ca
se

su
p

er
sc

ri
p

t
le

tt
er

d
id

n
o

t
d

if
fe

r
si

gn
if

ic
an

tl
y
.

A

R
L

ev
el

o
f

in
te

ll
ec

tu
al

d
is

ab
il
it

y
gr

o
u

p
co

m
p

ar
is

o
n

s
(w

it
h

in
ro

w
s)

:
M

ea
n

s
th

at
sh

ar
e

th
e

sa
m

e
u

p
p

er
ca

se
su

p
er

sc
ri

p
t

le
tt

er
d

id
n

o
t

d
if

fe
r

si
gn

if
ic

an
tl

y
.

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

412 E American Association on Intellectual and Developmental Disabilities

T
a
b

le
7
.

T
o

ta
l

N
u

m
b

er
o

f
R

es
id

en
ts

an
d

P
er

ce
n

ta
ge

o
f

T
h

em
W

h
o

W
er

e
O

b
es

e
an

d
O

v
er

w
ei

gh
t

b
y

L
ev

el
o

f
In

te
ll
ec

tu
al

D
is

ab
il
it

y
an

d
L

iv
in

g
A

rr
an

ge
m

en
t

L
iv

in
g

a
rr

a
n

g
e
m

e
n

ts

L
e
v
e
l

o
f

in
te

ll
e
ct

u
a
l

d
is

a
b

il
it

y

M
il
d

(n
5

3
,1

9
7
;

3
8
.8

%
)

M
o

d
e
ra

te
(n

5
2
,4

5
5
;

2
9
.8

%
)

S
e
v
e
re

(n
5

1
,3

0
5
;

1
5
.9

%
)

P
ro

fo
u

n
d

(n
5

1
,2

7
6
;

1
5
.5

%
)

T
o

ta
l

(N
5

8
,2

3
3
;

1
0
0
%

)

n
%

(C
I)

n
%

(C
I)

n
%

(C
I)

n
%

(C
I)

n
%

(C
I)

O
b

e
se

:
B

M
I

$
3
0

N
C

I
sa

m
p

le
:
a
ll

3
,1

9
7

4
1
.2

(3
9
.5

–4
2
.9

)A
2
,4

5
5

3
8
.3

(3
6
.4

–4
0
.3

)A
1
,3

0
5

2
6
.7

(2
4
.3

–2
9
.1

)B
1
,2

7
6

1
2
.6

(1
0
.8

–1
4
.4

)C
8
,2

3
3

3
3
.6

(3
2
.6

–3
4
.6

)

Li
v
in

g
a
rr

a
n

g
e
m

e
n

t

In
st

it
u

ti
o

n
1
5
9

3
1
.4

(2
4
.2

–3
8
.7

)a
D

1
9
6

2
9
.6

(2
3
.2

–3
6
.0

)d
D

2
1
1

2
2
.3

(1
6
.6

–2
7
.9

)g
D

4
6
7

7
.9

(5
.5

–1
0
.4

)h
E

1
,0

3
3

1
8
.6

(1
6
.2

–2
1
.0

)j

G
ro

u
p

h
o

m
e

9
2
6

3
9
.1

(3
5
.9

–4
2
.2

)a
b
F

9
0
2

3
6
.0

(3
2
.9

–3
9
.2

)d
F

4
8
9

2
6
.6

(2
2
.7

–3
0
.5

)g
G

4
5
1

1
2
.6

(9
.6

–1
5
.7

)h
iH

2
,7

6
8

3
1
.6

(2
9
.8

–3
3
.3

)k

A
g

e
n

cy

a
p

a
rt

m
e
n

t

2
8
1

4
5
.9

(4
0
.0

–5
1
.8

)b
cI

1
0
4

3
8
.5

(2
9
.0

–4
8
.0

)d
e
fI
J

3
7

2
1
.6

(7
.7

–3
5
.5

)g
J

2
5

3
2
.0

(1
2
.4

–5
1
.7

)iI
J

4
4
7

4
1
.4

(3
6
.8

–4
6
.0

)lm

O
w

n
h

o
m

e
7
5
9

4
7
.4

(4
3
.9

–5
1
.0

)c
K

2
4
0

4
7
.1

(4
0
.7

–5
3
.4

)e
K

1
0
1

2
4
.8

(1
6
.2

–3
3
.3

)g
L

8
8

1
1
.4

(4
.6

–1
8
.1

)h
iL

1
,1

8
8

4
2
.8

(3
9
.9

–4
5
.6

)l

Fa
m

il
y

h
o

m
e

9
2
3

3
9
.1

(3
6
.0

–4
2
.3

)a
b
M

N
8
7
5

4
2
.7

(3
9
.5

–4
6
.0

)e
M

3
6
3

3
1
.4

(2
6
.6

–3
6
.2

)g
N

O
2
0
3

2
0
.7

(1
5
.1

–2
6
.3

)iO
2
,3

6
4

3
7
.7

(3
5
.7

–3
9
.7

)m

H
o

st
/f

o
st

e
r

h
o

m
e

1
4
9

3
6
.9

(2
9
.1

–4
4
.8

)a
b
cP

1
3
8

2
2
.5

(1
5
.4

–2
9
.5

)f
P
Q

1
0
4

2
3
.1

(1
4
.8

–3
1
.3

)g
P
Q

4
2

1
6
.7

(4
.9

–2
8
.4

)h
iQ

4
3
3

2
7
.0

(2
2
.8

–3
1
.2

)k

O
v
e
rw

e
ig

h
t

o
r

o
b

e
se

:
B

M
I

$
2
5

N
C

I
sa

m
p

le
:

a
ll

3
,1

9
7

6
9
.6

(6
7
.9

–7
1
.1

)
2
,4

5
5

6
9
.4

(6
7
.6

–7
1
.2

)
1
,3

0
5

5
6
.7

(5
4
.0

–5
9
.4

)
1
,2

7
6

3
5
.4

(3
2
.8

–3
8
.1

)
8
,2

3
3

6
2
.2

(6
1
.1

–6
3
.2

)

L
iv

in
g

a
rr

a
n

g
e
m

e
n

t

In
st

it
u

ti
o

n
1
5
9

6
9
.2

(6
1
.9

–7
6
.4

)n
1
9
6

6
4
.3

(5
7
.5

–7
1
.1

)o
2
1
1

5
5
.5

(4
8
.7

–6
2
.2

)q
4
6
7

2
9
.8

(2
5
.6

–3
3
.9

)r
1
,0

3
3

4
7
.6

(4
4
.6

–5
0
.7

)t

G
ro

u
p

h
o

m
e

9
2
6

7
0
.2

(6
7
.2

–7
3
.2

)n
9
0
2

7
0
.3

(6
7
.3

–7
3
.3

)o
p

4
8
9

5
8
.5

(5
4
.1

–6
2
.9

)q
4
5
1

4
1
.7

(3
7
.1

–4
6
.3

)s
2
,7

6
8

6
3
.5

(6
1
.7

–6
5
.3

)u

A
g

e
n

cy

a
p

a
rt

m
e
n

t

2
8
1

7
3
.0

(6
7
.7

–7
8
.2

)n
1
0
4

7
2
.1

(6
3
.4

–8
0
.9

)o
p

3
7

6
2
.2

(4
5
.8

–7
8
.6

)q
2
5

4
8
.0

(2
7
.0

–6
9
.1

)r
s

4
4
7

7
0
.5

(6
6
.2

–7
4
.7

)v

O
w

n
h

o
m

e
7
5
9

7
2
.7

(6
9
.6

–7
5
.9

)n
2
4
0

7
7
.1

(7
1
.7

–8
2
.4

)p
1
0
1

5
5
.4

(4
5
.6

–6
5
.3

)q
8
8

3
4
.1

(2
4
.0

–4
4
.2

)r
s

1
,1

8
8

6
9
.3

(6
6
.7

–7
1
.9

)v

Fa
m

il
y

h
o

m
e

9
2
3

6
4
.8

(6
1
.7

–6
7
.9

)n
8
7
5

6
8
.0

(6
4
.9

–7
1
.1

)o
3
6
3

5
5
.9

(5
0
.1

–6
1
.1

)q
2
0
3

3
4
.0

(2
7
.4

–4
0
.6

)r
s

2
,3

6
4

6
2
.0

(6
0
.0

–6
3
.9

)u
v

H
o

st
/f

o
st

e
r

h
o

m
e

1
4
9

7
1
.8

(6
4
.5

–7
9
.1

)n
1
3
8

6
4
.5

(5
6
.4

–7
2
.6

)o
p

1
0
4

5
2
.9

(4
3
.1

–6
2
.6

)q
4
2

3
3
.3

(1
8
.5

–4
8
.2

)r
s

4
3
3

6
1
.2

(5
6
.6

–6
5
.8

)u
v

N
ot

e.
N

C
I

5
N

at
io

n
al

C
o

re
In

d
ic

at
o

rs
.
P
ar

ti
ci

p
an

ts
w

h
o

se
le

v
el

o
f

in
te

ll
ec

tu
al

d
is

ab
il
it

y
w

as
u

n
k
n

o
w

n
o

r
m

is
si

n
g

(n
5

4
6
2
)
w

er
e

ex
cl

u
d

ed
.
R

es
id

en
ts

o
f

n
u

rs
in

g
fa

ci
li
ti

es
(n

5
4
2
),

‘‘
o

th
er

’’
(n

5
1
0
8
)

re
si

d
en

ce
ty

p
es

,
o

r
w

h
er

e
re

si
d

en
ce

ty
p

e
w

as
u

n
k
n

o
w

n
o

r
m

is
si

n
g

(n
5

7
9
)

w
er

e
ex

cl
u

d
ed

d
u

e
to

m
is

si
n

g
d

at
a,

sm
al

l
sa

m
p

le
si

ze
,

an
d

/o
r

u
n

k
n

o
w

n
re

si
d

en
ce

ty
p

e.
T

h
is

y
ie

ld
ed

a
fi

n
al

sa
m

p
le

o
f

8
,2

3
3

b
ec

au
se

a
sm

al
l
n

u
m

b
er

o
f

p
ar

ti
ci

p
an

ts
(n

5
1
3
)

w
er

e
ex

cl
u

d
ed

o
n

m
o

re
th

an
o

n
e

o
f

th
es

e
gr

o
u

n
d

s.
a

v
L

iv
in

g
ar

ra
n

ge
m

en
t

ty
p

e
co

m
p

ar
is

o
n

s
(w

it
h

in
co

lu
m

n
s)

:
M

ea
n

s
th

at
sh

ar
e

th
e

sa
m

e
lo

w
er

ca
se

su
p

er
sc

ri
p

t
le

tt
er

d
id

n
o

t
d

if
fe

r
si

gn
if

ic
an

tl
y
.

A

Q
L

ev
el

o
f

in
te

ll
ec

tu
al

d
is

ab
il
it

y
gr

o
u

p
co

m
p

ar
is

o
n

s
(w

it
h

in
ro

w
s)

:
M

ea
n

s
th

at
sh

ar
e

th
e

sa
m

e
u

p
p

er
ca

se
su

p
er

sc
ri

p
t

le
tt

er
d

id
n

o
t

d
if

fe
r

si
gn

if
ic

an
tl

y
.

T
h

es
e

co
m

p
ar

is
o

n
s

ar
e

o
n

ly
sh

o
w

n
fo

r
o

b
es

it
y

d
at

a
(u

p
p

er
h

al
f

o
f

ta
b

le
).

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 413

adults living in formal service settings (55.8%), but
the NHIS excluded most such settings. Even so,
Yamaki reported an overall prevalence of obesity
among adults with intellectual disability (34.6%)
that was very similar to our study (33.6%). The
different conclusion from Yamaki regarding the
higher prevalence of obesity among persons with
intellectual disability derived from a notably lower
estimated prevalence of obesity in the general
population (20.6%) obtained from the 1997–2000
NHIS compared with the 33.8% prevalence
estimated in the 2007–2008 NHANES (Flegal et
al., 2010). Indeed, an analysis of the NHANES
conducted at approximately the same time as the
Yamaki analysis (1999–2000) by Flegal et al. (2002)
reported prevalence of obesity in the general U.S.
population of 30.5% (9.9% higher than the NHIS
estimate). This variation draws attention to impor-
tant methodological differences.

There are important sampling differences
between our study and Yamaki’s (2005), whose
NHIS sample was based on a nationally represen-
tative sample of households that generally exclud-
ed service settings, from small group homes to
institutions. Yamaki’s sample, therefore, likely
included adults with milder levels of intellectual
disability (the NHIS does not include data on
level of intellectual disability) and fewer comorbid
physical, health, and mental health conditions.
Our sample, in contrast, consisted of users of
intellectual disability/developmental disability
services, more than half of whom were in formal
residential service settings. Specifically, in our
data, only the 28.2% of individuals living with
family members and 13.9% living in homes they
owned or rented (own home) would have been
systematically included in NHIS sample.

Another important variation in methodology is
that the NHIS was a self-report survey, whereas
NHANES conducted direct measurements of
height and weight. The differences between esti-
mates of obesity in the general population by the
NHIS and by the NHANES methodologies may
have derived in part from tendencies for individuals
to underreport their own weight (Elgar, Roberts,
Tudor-Smith, & Moore, 2005; Flegal et al., 2010).

There were several notable similarities be-
tween our findings and those of Yamaki (2005).
Both studies noted obesity in about one third of
their samples of persons with intellectual disabil-
ity. Both studies reported higher prevalence of
obesity among women with intellectual disability.
Yamaki reported no significant difference between

adults with and without intellectual disability in
the prevalence of overweight (25.0 # BMI , 30.0)
and we found no difference from the general U.S.
population in the prevalence of obesity.

Our conclusions are likewise both consistent
with and contrary to Melville et al.’s (2008) study of
obesity among adults with intellectual disability in
Scotland. Melville et al.’s sample, stratified by level of
intellectual disability (mild 5 44%, moderate 5 23%,
severe 5 17%, and profound 5 16%) was similar to
our NCI sample, as were the percentages of obesity
among Scottish youth and adults (16 years and older)
with intellectual disability (32.9% overall, 27.8% of
men, 39.3% of women) compared to the prevalence
estimates reported here (33.6%, 29.4%, and 38.9%,
respectively). However, relative to the U.S. general
population, there was notably lower prevalence of
obesity in the general population of Scottish men
(22.7%) and women (25.1%), so Melville et al.
concluded that there was a higher level of obesity
among persons with intellectual disability relative to
the general population in Scotland.

Gender
We found a consistently and significantly

higher level of obesity among women with
intellectual disability than for men with intellectual
disability. This was true within most racial groups,
within most levels of intellectual disability, and
among adults with cerebral palsy. Likewise, there
was a significantly higher prevalence of Grade 3
obesity among women with intellectual disability
compared with men with intellectual disability.

Melville et al. (2007, 2008) noted that in
Scotland there was a greater differential in obesity
rates between men and women with intellectual
disability than between men and women in the
general population. This held true for our data,
where there was a 9.5% difference in obesity
between men with intellectual disability (29.4%)
and women with intellectual disability (38.9%)
compared with Flegal et al.’s (2010) general U.S.
population data, which showed a 3.3% difference
between men (32.2%) and women (35.5%).
Similarly large gender disparities in obesity
prevalence among adults with intellectual disabil-
ity have been reported by other researchers in the
United States (Yamaki, 2005), the United King-
dom (Emerson, 2005; Melville et al., 2007, 2008;
Robertson et al., 2000), and Norway (Hove,
2004). The cause of this more marked gender dif-
ference in prevalence of obesity is unclear, but

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

414 E American Association on Intellectual and Developmental Disabilities

this consistently reported phenomenon deserves
attention.

Diagnosis
We found that adults with Down syndrome

had the highest prevalence of obesity and
individuals with cerebral palsy had the lowest.
This suggests that there are diagnosis-specific
issues that need to be considered when supporting
individuals with different diagnoses to achieve a
healthy weight. It also suggests that future
research on weight and BMI within people with
intellectual disability should control for diagnosis.

Level of Intellectual Disability
There were consistent differences by level of

intellectual disability in prevalence of obesity.
Individuals with mild (41.4%) or moderate
(38.2%) intellectual disability had the highest
prevalence, whereas obesity prevalence was signif-
icantly lower for individuals with severe (26.7%),
and profound intellectual disability (12.6%).
These findings are consistent with several other
studies (Emerson, 2005; Melville et al., 2008;
Robertson et al., 2000) that have reported that the
risk of overweight and obesity is lower as level of
intellectual disability becomes more severe. The
very large differences we observed by level of
intellectual disability show clearly why sampling
issues represent such a strong influence on
reported prevalence rates of obesity among adults
with intellectual disability.

What then are the likely causes of the
consistent finding that obesity is related to level
of intellectual disability? One factor is the much
more frequent placement of adults with severe and
profound intellectual disability in more highly
structured and staffed residence types, such as
institutions, where there is much greater staff
control of residents’ food intake. More individual-
ized, less regulated settings, such as living in one’s
own home are characterised by greater freedom of
choice for residents (Lakin et al., 2008). Likewise,
individuals with milder intellectual disability
exercise more everyday choice than their counter-
parts with more severe intellectual disability (Lakin
et al., 2008). Some authors have suggested that
greater choice may be associated with unhealthy
food choices and/or opting not to participate in
sufficient physical activity (Rimmer & Yamaki,
2006). Bhaumic et al. (2008) found that the ability
to feed oneself and to drink unaided were

independently associated with higher prevalence
of obesity. Lack of independence in self-care is
strongly associated with more severe intellectual
disability. Last, unsupervised access to community
settings (more typical for individuals with mild or
moderate intellectual disability) brings with it access
to fast food and other unhealthy food options. That
is, a combination of personal characteristics (eating
independently, choice-making skills) and environ-
mental factors (living arrangements, freedom of
choice, unsupervised community access) may
contribute to the higher observed incidence of
obesity among individuals with milder intellectual
disability.

Living Arrangements
Overall, our results confirmed that congregate,

regulated, continuously supervised settings such
as institutions having the lowest prevalence of
obesity. Such settings, often by explicit regulatory
requirement, use dietary planning and controlled
food intake as a formal element of the residential
program. By contrast, people living in their own
homes, usually with limited supervision and far
fewer regulations, experienced a notably higher
prevalence of obesity. Settings with intermediate
levels of regulation and/or supervision (group
home, host home, family home) were in between.

However, a substantial proportion of these
differences was attributable to level of intellectual
disability, because living arrangements differed
substantially in the level of intellectual disability
of their residents. For example, a much higher
proportion of people living in their own home
(63.9%) or agency apartments (62.9%) had mild
intellectual disability than was the case for
institutions (15.4%), group homes (33.5%), family
homes (39.0%), or host homes (33.6%).

In addition, the effect of residence type was
more pronounced for people with mild intellec-
tual disability. There were numerous significant
differences in prevalence of obesity among
residence types for participants with mild intel-
lectual disability but almost none for individuals
with severe and profound intellectual disability.
Perhaps individuals with mild or moderate
intellectual disability have the independence to
take advantage of the greater freedom offered by
living in settings such as one’s own home, whereas
those with more severe intellectual disability still
need significant support from others to access
food and drink. By contrast, institutional residents

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 415

all have highly regulated food intake and little or
no free access to food regardless of level of
intellectual disability.

Conclusions
The observation that adults with intellectual

disability have rates of obesity that are similar to
the general population does not reduce the serious
health implications of their being overweight. It
seems notable that the prevalence of obesity is
particularly high among persons with milder
intellectual disability and places of residence that
exert less control over diet and activities. In an era
of increasing choice and expanded residential
options, adults with intellectual disability face the
same challenges as the general population: how to
use choice wisely and with attention to longer term
(health) implications.

Even taking level of intellectual disability into
account, there remained significant differences in
prevalence of obesity among different living arrange-
ments, especially for those with mild and moderate
intellectual disability. In general, institutional residents
had the lowest prevalence of obesity and individuals
living in their own home had the highest. However,
we have repeatedly shown elsewhere that smaller, less
regulated settings, such as living in one’s own home,
are consistently associated with desirable outcomes in
areas such as well being (Stancliffe et al., 2009),
loneliness (Stancliffe et al., 2007), everyday choice and
support-related choice (Lakin et al., 2008), as well as
choice of living arrangements and living companions
(Stancliffe et al., 2010), whereas institutions are
associated with poorer outcomes (Lakin & Stancliffe,
2007). It is clear that a return to institutions or
institution-like controls as a ‘‘solution’’ to obesity is
out of the question, but supporting people with
intellectual disability (and the broader U.S. popula-
tion) to continue to live in their preferred settings
without becoming obese is an urgent health priority.

Caveats
Certain methodological differences limit the

validity of our comparisons between NCI data
and Flegal et al.’s (2010) NHANES data. First,
Flegal et al.’s sample was nationally representative,
whereas the NCI sample came from 20 states.
Second the NHANES sample was drawn from the
‘‘noninstitutionalized’’ population, whereas the
NCI sample was drawn from registries of intellec-
tual disability/developmental disability service
users, many of whom would be viewed as

institutionalized in the NHANES methodology.
Third, age was adjusted in Flegal et al.’s analyses,
whereas we made no age adjustments. Fourth, as is
unavoidable with representative samples of people
with intellectual disability, the NCI sample had a
preponderance of males (56.2%), whereas Flegal
et al.’s sample contained 49.5% males. Given the
observed gender differences in obesity prevalence,
it is clearly important to make within-gender
comparisons. Fifth, in Flegal et al.’s data, height
and weight were assessed directly, whereas we used
height and weight typically gathered through
record review or reported by proxy respondents.
Proxies, such as family members who do not have
access to height and weight records, may under-
estimate their family member’s weight.

Last, making large numbers of comparisons (54
comparisons in Table 2 alone) with a 95% confi-
dence interval increases the Type I error rate. We
adopted this approach to enable detailed compar-
isons with Flegal et al.’s (2010) data, because Flegal
et al. used this same analytic approach. Readers
should therefore exercise caution as to the true
statistical significance of individual comparisons.

Future Research
Several important variables related to BMI

were not examined in the present study, such as
caloric intake–nutrition and physical activity.
Differences in these factors may underpin ob-
served BMI differences by level of intellectual
disability, diagnosis, or living arrangements;
therefore, future obesity research should also
examine these variables. We plan to complete a
companion article looking at physical activity.
Given the well-established health risks of over-
weight and obesity, a fundamental priority for
future studies is finding effective methods to
enable adults with intellectual disability to achieve
and maintain a healthy weight.

References

Berrington de Gonzalez, A., Hartge, P., Cerhan,
J. R., Flint, A. J., Hannan, L., MacInnis, R. J.,
et al. (2010). Body-mass index and mortality
among 1.46 million White adults. New
England Journal of Medicine, 363, 2211–2219.

Bhaumik, S., Watson, J. M., Thorp, C. F., Tyrer, F.,
& McGrother, C. W. (2008). Body mass index
in adults with intellectual disability: Distribu-
tion, associations and service implications. A

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

416 E American Association on Intellectual and Developmental Disabilities

population-based prevalence study. Journal of
Intellectual Disability Research, 52, 287–298.

Elgar, F. J., Roberts, C., Tudor-Smith, C., &
Moore, L. (2005). Validity of self-reported
height and weight and predictors of bias in
adolescents. Journal of Adolescent Health, 37,
371–376.

Emerson, E. (2005). Underweight, obesity and
exercise among adults with intellectual dis-
abilities in supported accommodation in
Northern England. Journal of Intellectual Dis-
ability Research, 49, 134–143.

Expert Panel on the Identification, Evaluation,
and Treatment of Overweight in Adults.
(1998). Clinical guidelines on the identifica-
tion, evaluation, and treatment of overweight
and obesity in adults: executive summary.
American Journal of Clinical Nutrition, 68, 899–
917.

Flegal, K. M., Carroll, M. D., Ogden, C. L.,
& Curtin, L. R. (2010). Prevalence and trends
in obesity among US adults, 1999–2008.
JAMA, 303, 235–241.

Flegal, K. M., Carroll, M. D., Ogden, C. L.,
& Johnson, C. L. (2002). Prevalence and
trends in obesity among US adults 1999–
2000. JAMA, 288, 1723–1727.

Harris, N., Rosenberg, A., Jangda, S., & Gallagher,
M. L. (2003). Prevalence of obesity in Interna-
tional Special Olympic athletes as determined
by body mass index. Journal of the American
Dietetic Association, 103, 235–237.

Hendershot, G., Larson, S. A., Lakin, K. C.,
& Doljanac, R. (2005). Problems in defining
mental retardation. DD Data Brief, 7(1).
Minneapolis: University of Minnesota, Re-
search and Training Center on Community
Living.

Hove, O. (2004). Weight survey on adult persons
with mental retardation living in the communi-
ty. Research in Developmental Disabilities, 25, 9–17.

Lakin, K. C., Doljanac, R., Byun, S., Stancliffe,
R. J., Taub, S., & Chiri, G. (2008). Choice
making among Medicaid Home and Com-
munity-Based Services (HCBS) and ICF/MR
recipients in six states. American Journal on
Mental Retardation, 113, 325–342.

Lakin, K. C., & Stancliffe, R. J. (2007). Residential
supports for persons with intellectual and
developmental disabilities. Mental Retardation
and Developmental Disabilities Research Reviews,
13, 151–159.

Lewis, M. A., Lewis, C. E., Leake, B., King, B. H.,
& Lindemann, R. (2002). The quality of health
care for adults with developmental disabilities.
Public Health Reports, 117, 174–184.

Manson, J. E., & Bassuk, S. S. (2003). Obesity in
the United States: A fresh look at its high toll.
JAMA, 289, 229–230.

Melville, C. A., Cooper, S.-A., McGrother, C. W.,
Thorp, C. F., & Collacott, R. (2005). Obesity
in adults with Down syndrome: A case-control
study. Journal of Intellectual Disability Research,
49, 125–133.

Melville, C. A., Cooper, S.-A., Morrison, J., Allen, L.,
Smiley, E., & Williamson, A. (2008). The
prevalence and determinants of obesity in adults
with intellectual disabilities. Journal of Applied
Research in Intellectual Disabilities, 21, 425–437.

Melville, C. A., Hamilton, S., Hankey, C. R., Miller,
S., & Boyle, S. (2007). The prevalence and
determinants of obesity in adults with intellec-
tual disabilities. Obesity Reviews, 8, 223–230.

Rimmer, J. H., & Wang, E. (2005). Obesity
prevalence among a group of Chicago residents
with disabilities. Archives of Physical Medicine
and Rehabilitation, 86, 1461–1464.

Rimmer, J., & Yamaki, K., (2006). Obesity and intel-
lectual disability. Mental Retardation and Devel-
opmental Disabilities Research Reviews, 12, 70–82.

Rimmer, J. H., Yamaki, K., Lowry, B. M. D.,
Wang, E., & Vogel, L. C. (2010). Obesity and
obesity-related secondary conditions in ado-
lescents with intellectual/developmental dis-
abilities. Journal of Intellectual Disability Re-
search, 54, 787–794.

Robertson, J., Emerson, E., Gregory, N., Hatton,
C., Turner, S., Kessissoglou, S., et al. (2000).
Lifestyle related risk factors for poor health in
residential settings for people with intellectual
disabilities. Research in Developmental Disabil-
ities, 21, 469–486.

Rubin, S. S., Rimmer, J. H., Chicoine, B.,
Braddock, D., & McGuire, D. (1998). Over-
weight prevalence in persons with Down
syndrome. Mental Retardation, 36, 175–181.

Sassi, F., Cecchini, M., & Devant, M. (2010).
Obesity and the economics of prevention: Fit not
fat. Paris: Organization for Economic Health
and Development.

Soverini, V., Moscatiello, S., Villanova, N., Ragni, E.,
Domizio, S. D., Marchesini, G. (2010). Metabolic
syndrome and insulin resistance in subjects with
morbid obesity. Obesity Surgery, 20, 295–301.

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 417

Stancliffe, R. J., Lakin, K. C., Larson, S. A.,
Engler, J., Taub, S., & Fortune, J. (2011).
Choice of living arrangements. Journal of
Intellectual Disability Research, 55, 746–762.
doi: 10.1111/j.1365-2788.2010.01336.x

Stancliffe, R. J., Lakin, K. C., Larson, S. A.,
Engler, J., Taub, S., Fortune, J., & Bershadsky,
J. (in press). Demographic characteristics,
health conditions and residential service use in
adults with Down syndrome in twenty-five US
states. Intellectual and Developmental Disabilities.

Stancliffe, R. J., Lakin, K. C., Taub, S., Chiri, G.,
& Byun, S. (2009). Satisfaction and sense of
well being among Medicaid ICF/MR and
HCBS recipients in six states. Intellectual and
Developmental Disabilities, 47, 63–83.

Stancliffe, R. J., Lakin, K. C., Taub, S., Doljanac,
R., Byun, S., & Chiri, G. (2007). Loneliness
and living arrangements. Intellectual and De-
velopmental Disabilities, 45, 380–390.

U.S. Department of Health and Human Services.
(2005). The 2005 Surgeon General’s call to action
to improve the health and wellness of persons with
disabilities. Washington, DC: Office of the
Surgeon General.

World Health Organization, Expert Committee
on Physical Status. (1995). Physical status: The
use and interpretation of anthropometry. Geneva,
Switzerland: Author.

Yamaki, K. (2005). Body weight status among
adults with intellectual disability in the
community. Mental Retardation, 43, 1–10.

Yang, Q., Rasmussen, S. A., & Friedman, J. M.
(2002) Mortality associated with Down’s
syndrome in the USA from 1983 to 1997: A
population-based study. Lancet, 359, 1019–

1025.

Received 3/20/2011, accepted 6/29/2011.
Editor-in-Charge: Leonard Abbeduto

Preparation of this article was supported by Grant
H133G080029 for the Multi-State Data Set
Project from the National Institute on Disability
and Rehabilitation Research, U.S. Department of
Education. Correspondence regarding this article
should be sent to Roger J. Stancliffe, Faculty of
Health Sciences, University of Sydney, P.O. Box
170, Lidcombe NSW 1825, Australia. E-mail:
[email protected]

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

418 E American Association on Intellectual and Developmental Disabilities

Résumés en Français
DOI: 10.1352/1944-7558-116.6.500

Le surplus de poids et l’obésité chez des adultes
présentant une déficience intellectuelle qui
utilisent des services en déficience intellectuelle
dans 20 états américains

Roger J. Stancliffe, K. Charlie Lakin, Sheryl
Larson, Joshua Engler, Julie Bershadsky, Sarah
Taub, Jon Fortune et Renata Ticha

Les auteurs ont comparé la prévalence de
l’obésité chez les participants du sondage sur les
indicateurs nationaux de base et chez la popula-
tion adulte générale américaine. En général, les
adultes présentant une déficience intellectuelle
ne différaient pas de la population adulte pour
ce qui est de la prévalence de l’obésité. Pour
l’obésité et le surplus de poids combinés, la
prévalence était plus basse chez les hommes
présentant une déficience intellectuelle que ceux
de la population générale, mais était semblable
chez les femmes. La prévalence de l’obésité était
plus élevée chez les femmes présentant une
déficience intellectuelle, les personnes avec un
syndrome de Down, et les personnes présentant
une déficience intellectuelle légère. La prévalence
de l’obésité différait selon le lieu de résidence, les
personnes habitant en institution ayant la pré-
valence la plus basse et celles habitant leur propre
maison présentant la plus haute. Lorsque le
niveau de déficience intellectuelle était pris en
compte, ces différences se trouvaient réduites,
certaines demeurant toutefois significatives, par-
ticulièrement pour les personnes ayant une
déficience intellectuelle légère.

Un modèle des influences contextuelles sur les
parents présentant une déficience intellectuelle
et leurs enfants

Catherine Wade, Gwynnyth Llewellyn et Jan
Matthews

Plusieurs parents présentant une déficience in-
tellectuelle vivent dans des conditions pouvant

être risquées pour les enfants et les parents. Cette
étude a utilisé un modèle d’équation structurelle
afin de tester un modèle théorique des relations
entre les parents, l’enfant, la famille et certaines
variables contextuelles dans 120 familles austra-
liennes à l’intérieure desquelles un parent présente
une déficience intellectuelle. Les résultats révèlent
que les pratiques parentales avaient un effet direct
sur le bien-être des enfants, que le soutien social
était associé avec le bien-être des enfants en
considérant les pratiques parentales comme vari-
able médiatrice et que l’accès au soutien social
avait une influence directe sur les pratiques
parentales. Les implications des résultats envers
la recherche, l’intervention et les politiques sont
explorées tout en ayant l’objectif de promouvoir
un bien-être optimal pour les enfants qui sont
élevés par des parents présentant une déficience
intellectuelle.

Relations entre le raisonnement moral,
l’empathie et les distorsions cognitives chez des
hommes présentant une déficience intellectuelle
et des antécédents criminels

Peter Langdon, Glynis Murphy, Isabel Clare,
Tom Steverson et Emma Palmer

Quatre-vingts hommes, répartis de manière égale
entre quatre groupes, ont été recrutés y compris
des hommes avec et sans déficience intellectuelle.
Les hommes étaient soit des criminels ou des non-
délinquants. Les participants ont complété des
mesures de raisonnement moral, d’empathie et de
distorsions cognitives. Les résultats indiquent que
les capacités de raisonnement moral des délin-
quants ayant une déficience intellectuelle accu-
saient un retard quant au développement, mais
étaient plus matures que celles des non-délinquants
présentant une déficience intellectuelle. Les délin-
quants sans déficience intellectuelle avaient des
capacités de raisonnement moral moins matures
que les non-délinquants sans déficience intellec-
tuelle. Les différences peuvent être partiellement

VOLUME 116, NUMBER 6: 500–501 | NOVEMBER 2011 AJIDD

500 E American Association on Intellectual and Developmental Disabilities

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Overweight and Obesity Among Adults With
Intellectual Disabilities Who Use Intellectual
Disability/Developmental Disability Services
in 20 U.S. States

Roger J. Stancliffe
University of Sydney, Australia

K. Charlie Lakin and Sheryl Larson
Research and Training Center on Community Living, University of Minnesota

Joshua Engler, Julie Bershadsky, and Sarah Taub
Human Services Research Institute, Cambridge, MA

Jon Fortune
Human Services Research Institute, Tualatin, OR

Renata Ticha
Research and Training Center on Community Living, University of Minnesota

Abstract
The authors compare the prevalence of obesity for National Core Indicators (NCI) survey
participants with intellectual disability and the general U.S. adult population. In general,
adults with intellectual disability did not differ from the general population in prevalence
of obesity. For obesity and overweight combined, prevalence was lower for males with
intellectual disability than for the general population but similar for women. There was
higher prevalence of obesity among women with intellectual disability, individuals with
Down syndrome, and people with milder intellectual disability. Obesity prevalence differed
by living arrangement, with institutional residents having the lowest prevalence and people
living in their own home the highest. When level of intellectual disability was taken into
account, these differences were reduced, but some remained significant, especially for
individuals with milder disability.

DOI: 10.1352/1944-7558-116.6.401

Overweight and obesity are associated with
increased mortality and morbidity (Berrington de
Gonzalez et al., 2010; Manson & Bassuk, 2003;
Soverini et al., 2010). Obese individuals had a
significantly higher mortality rate in a large sample
of people with Down syndrome (Yang et al., 2002).

Among U.S. adults in the general population,
the prevalence of obesity (body mass index [BMI]

$ 30.0) and overweight and obesity (BMI $ 25.0)
in 2007–2008 was 33.8% and 68.0%, respectively
(Flegal, Carroll, Ogden, & Curtin, 2010). There
were important prevalence differences by gender,
age group, and race–ethnic group. Obesity preva-
lence among U.S. adults increased from 13%–15%
in the 1960s and 1970s to 31% in 2000, but the rate
of increase may now be leveling off (Flegal et al.).

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

E American Association on Intellectual and Developmental Disabilities 401

Prevalence of obesity among adults with intellec-
tual disabilities also increased between the mid-
1980s and 2000 (Rimmer & Yamaki, 2006; Yamaki,
2005).

Adults With Intellectual Disabilities
Compared With the General
Community

Two reviews of obesity research identified a
higher prevalence of overweight and obesity among
adults with intellectual disability than in the general
community (Melville, Hamilton, Hankey, Miller,
& Boyle, 2007; Rimmer & Yamaki, 2006). Several
studies have supported this conclusion, both for
users of formal intellectual and developmental
disabilities services and for population samples that
include many individuals with intellectual disabil-
ity living outside the formal service system (Mel-
ville et al., 2008; Yamaki, 2005). However, other
studies have found more limited differences
(Bhaumik, Watson, Thorp, Tyrer, & McGrother,
2008; Emerson, 2005).

Yamaki (2005) used national population sam-
ples from the annual National Health Interview
Survey (NHIS) to compare BMI based on self-
reported height and weight (for individuals unable
to respond, another adult household member
could provide the information) of adults with
intellectual disability and adults from the general
population. The NHIS is a household sample
survey of the health status of the U.S. ‘‘noninsti-
tutionalized’’ population and includes adults with
intellectual disability living with family members
or in their own homes but generally excludes
persons living in formal service settings. This likely
yields more individuals with mild or moderate
intellectual disability and fewer comorbid physical,
health, and mental health conditions. Yamaki’s
operational definition of intellectual disability in-
cluded only people who reported a substantial
functional limitation and mentioned ‘‘mental
retardation’’ as the cause. This definition may not
include people who report Down syndrome,
autism, cerebral palsy, and other intellectual or
developmental disabilities (Hendershot, Larson,
Lakin, & Doljanac, 2005).

Compared with the general population, Yamaki
(2005) found a higher percentage of adults with
intellectual disability in the obese category but no
significant overall differences for the overweight
category, although men with intellectual disability

had significantly lower prevalence of overweight
than men in the general population. In the most
recent period examined (1997–2000), 34.6% of
adults with intellectual disability were obese com-
pared with 20.6% of adults (aged 18–65 years) from
the general population, whereas 28.9% (intellectual
disability) and 34.1% (general population) were
overweight (BMI 5 25.0–30.0). Yamaki’s samples of
adults with intellectual disability were moderately
sized (range 5 650–1,098), although the most recent
sample (1997–2000) of 650 participants yielded
relatively large confidence intervals (6 8.0%).
Therefore, subgroup analyses were only possible
for gender and age group separately, with no
examination of race–ethnicity.

Several larger scale and/or population-based
studies of BMI have focused on adults with
intellectual disability living outside the United
States. Overweight and obesity may vary by nation,
both for the general population and for those with
intellectual disability, with higher prevalence
among U.S. individuals (Harris, Rosenberg, Jangda,
& Gallagher, 2003; Sassi, Cecchini, & Devant,
2010). Therefore, caution is warranted when
reviewing research findings on BMI for persons
with intellectual disability from other countries for
relevance to U.S. populations.

Emerson (2005; N 5 1,304) found that 14%
of disability-accommodation service users in
northern England were underweight, 28% over-
weight, and 27% obese. Prevalence of obesity
among men with intellectual disability did not
differ significantly from English men without
intellectual disability, except that men with
intellectual disability aged 65–74 years had
significantly lower obesity rates than men of the
same age from the general population. However,
women with intellectual disability had higher
prevalence of obesity in several age groups and
did not differ from women without intellectual
disability in other age groups.

Bhaumik et al. (2008; N 5 1,119) examined all
individuals on a register of adults with moderate,
severe, or profound intellectual disability in a de-
fined geographical area in Leicestershire, England.
They found that 20.7% of adults with intellectual
disability were obese and an additional 28.0% were
overweight. The overall intellectual disability sample
did not differ significantly from the general popu-
lation in England in the prevalence of obesity.
Compared with men in the general population (19%
obesity prevalence), men with intellectual disability
(15% obesity prevalence) had nonsignificantly lower

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

402 E American Association on Intellectual and Developmental Disabilities

prevalence of obesity. Women with intellectual
disability, however, had significantly higher preva-
lence of obesity (32%) than women in the general
population (23%).

Gender

There is higher prevalence of obesity among
women with intellectual disability compared with
men with intellectual disability (Bhaumik et al.,
2008; Emerson, 2005; Melville et al., 2007, 2008;
Robertson et al., 2000; Yamaki, 2005). Melville
et al. (2007) concluded that, relative to the higher
rate of obesity in women in the general popula-
tion, among people with intellectual disability,
‘‘the gender effect is accentuated, placing women
with intellectual disabilities at particular risk’’
(p. 225).

Diagnosis and Level of
Intellectual Disability

Among adults with intellectual disability, there
are important differences in BMI related to
diagnosis. Individuals with Down syndrome are
more likely to be overweight or obese than other
individuals with intellectual disability (Bhaumik
et al., 2008; Hove, 2004; Melville et al., 2007, 2008;
Rubin, Rimmer, Chicoine, Braddock, & McGuire,
1998; Robertson et al., 2000; Stancliffe et al., in
press). Lower prevalence rates of overweight and
obesity are evident for adults with cerebral palsy
(Bhaumik et al., 2008; Stancliffe et al., in press).

Likewise, level of intellectual disability has
been associated with BMI status. Individuals with
milder disability have a higher prevalence of
obesity, whereas those with more severe disability
have a lower rate of obesity but a higher prev-
alence of underweight (Emerson, 2005; Hove,
2004; Melville et al., 2007, 2008; Robertson et al.,
2000).

Living Arrangements

Living arrangements appear to be related to
BMI, with a higher prevalence of obesity evident
in less restrictive settings (own home, family
home), and lower prevalence in more regulated,
fully supervised settings (Melville et al., 2007;
Rimmer & Yamaki, 2006). However, not all the
studies reporting such findings controlled for
differences in personal characteristics between
living arrangements. For example, although Lewis,

Lewis, Leake, King, and Lindemann (2002)
reported significant differences in level of intel-
lectual disability by living arrangements, the lower
prevalence of obesity in community group-care
facilities may be attributable to the much more
severe level of intellectual disability of residents in
these settings compared with those living on their
own or with family members. When Melville
et al. (2008) used multivariate analysis that
controlled for level of intellectual disability, they
found a significant effect of living arrangements
for Scottish women (women living independently
were more likely to be obese than those living
with family), but no effect for Scottish men. In
addition, Melville et al. found no significant
multivariate difference by living arrangements for
either gender on prevalence of overweight.

Purpose of This Article

The goal of this article is to report on the
prevalence of obesity and overweight among adult
users of U.S. intellectual disability/developmental
disability services in a large sample drawn from
the 2008–2009 National Core Indicators (NCI)
program and compare these findings to preva-
lence data for the general population from Flegal
et al.’s (2010) findings from the 2007–2008
National Health and Nutrition Examination
Survey (NHANES), with subgroup analysis by
age, gender, and race–ethnicity. In addition, we
provide descriptive information about BMI of
adults with intellectual disability and compare
BMI status and obesity prevalence among indi-
viduals with different syndromes related to
intellectual disability, with different levels of
intellectual disability, and with different living
arrangements.

Method

Participating States
The NCI program is a voluntary collabora-

tion between the National Association of State
Directors of Developmental Disabilities Services,
the Human Services Research Institute, and state
developmental disability agencies of participating
states. No NCI data are collected in nonpartici-
pating states.

The 8,911 sample members in this study
were drawn from all 20 states that participated in
the 2008–2009 NCI program and collected con-
sumer survey data. Participants were adult users of

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 403

developmental disabilities services in Alabama,
Arkansas, Connecticut, Delaware, Georgia, Illinois,
Indiana, Kentucky, Louisiana, Massachusetts, Mis-
souri, North Carolina, New Jersey, New York,
Ohio, Oklahoma, Pennsylvania, South Carolina,
Texas, and Wyoming. Within each participating
state, samples were randomly drawn from the
state’s population of adults (age $ 18 years) with
intellectual disability receiving institutional, com-
munity, or home-based services, or some subset of
these (a few states’ samples included only recipients
of home and community-based services). Sample
sizes in participating states ranged from 193 (DE)
to 1,502 (NY) and averaged 578.

Instrument
Data were collected using the 2008–2009 NCI

Consumer Survey. The 2008–2009 survey was the
first version of the NCI survey to obtain data on
height and weight, allowing BMI to be calculated.
Height and weight data were not measured
directly by NCI interviewers but were obtained
typically from individual records, setting admin-
istrators, or support providers (including family
members for participants living with family).
These informants provided data on height in feet
and inches and data on weight in pounds. These
data are reported in the NCI Background section,
which requests information on the service user’s
personal characteristics, functioning, level of
intellectual disability, diagnoses, health, problem
behavior, living arrangements, and services. Data
in this section are typically obtained from agency
records, and it is usually completed by a case
manager–service coordinator.

One item asks whether the person has a
diagnosis of intellectual disability. The next item
asks about the person’s level of intellectual
disability (respondents may check one of the
following: N/A [not applicable], mild, moderate,
severe, profound, unspecified, or unknown). The
item that follows asks about a list of 16 other
disabilities and diagnoses that are noted on the
person’s record (respondents may check all that
apply), including autism spectrum disorder, cere-
bral palsy, Down syndrome, and Prader-Willi
syndrome. The residence-type item provides
respondents with 10 response options: specialized
institutional facility for persons with intellectual
disability/developmental disability, group home,
agency-operated apartment, independent home or
apartment, parent–relative’s home, foster care or

host home (person lives in home of unrelated,
paid caregiver), nursing facility, homeless, other,
or ‘‘don’t know.’’ There is also an item on the
number of people with disabilities living at the
setting, which can be used to cross-check resi-
dence type (e.g., an institution is considered to
house 16 or more people with a disability). No
specific distinction is made between intermediate
care facility for people with ‘‘mental retardation’’
(ICFs/MR) and settings with other funding or
regulatory arrangements, in that ICFs/MR can be
classified as institutions ($16 residents) or group
homes (#15 residents), but group homes also
include non-ICF/MR settings.

Interviewer training. To ensure that all inter-
viewers received consistent training, the NCI
Consumer Survey protocol is supported by a
training program for interviewers, including
training manuals, presentation slides, training
videos, scripts for scheduling interviews, and lists
of frequently asked questions. The training
includes question-by-question review of the sur-
vey tool.

Reliability. Multiple tests of the NCI instruments
have yielded interrater agreement of 92%–93%, and
a single examination of test–retest reliability resulted
in 80% agreement (Smith & Ashbaugh, 2001). How-
ever, no item testing was done on the specific height
and weight variables.

Participants
The total 2008–2009 NCI sample consisted

of 11,569 individual users of adult intellectual
disability/developmental disability services from
20 states. We excluded 99 people whose age was
missing and another 208 sample members aged
18 or 19 years, because our general population
comparison sample only included adults aged 20
or older (Flegal et al., 2010). Because we also
wanted to compare our sample with the compar-
ison sample on gender, race, and age, we excluded
individuals with missing data on these variables.
In addition, we excluded 421 individuals whose
height was missing and 13 adults with recorded
heights of 36 inches or less or 84 inches or more.
Such listed heights were, of course, possible but
were notable outliers, and we had no means to
follow up on their accuracy. Last, we omitted
individuals without an intellectual disability
diagnosis because our focus was on BMI in adults
with intellectual disability. This selection process
yielded a final sample of 8,911 individuals from

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

404 E American Association on Intellectual and Developmental Disabilities

20 states, with an average age of 43.48 years (range
5 20–93 years).

The U.S. general population comparison
data, including breakdowns by gender and race,
were drawn from analyses of the NHANES by
Flegal et al. (2010). To enable close comparison,
the NCI sample was broken down according to
the same age groups and as similar as possible
racial groups. Individuals were grouped by age as
follows: 20–39 years, 40–59 years, and 60 years or
older. Race and ethnicity were classified as non-
Hispanic White, non-Hispanic Black, and His-
panic/other. The first two of these race categories
were identical to the comparison group from
Flegal et al. Table 1 shows sample numbers by
racial group, gender, and age group. Information
about participant numbers by level of intellectual
disability and living arrangements is shown in the
results section.

Results

Overweight and Obesity
Raw data were gathered on height in feet and

inches and weight in pounds, not in metric units,
because these were the standard units reported in
the individuals’ health records. These data were
used to calculate BMI using the following
formula:

BMI~
body mass lbð Þx 703

height ftð Þð Þ2
:

BMI was classified as follows: (a) underweight: BMI ,
18.50; (b) normal weight: BMI 5 18.50–24.99; (c)

overweight: BMI 5 25.00–29.99; (d) obese: BMI 5
$30.00; Grade 2 obesity: BMI $ 35.00; Grade 3 obesity:
BMI $ 40.00 (World Health Organization [WHO]
Expert Committee on Physical Status, 1995).

Comparison with the general population. We
calculated the prevalence of overweight and
obesity by race, age group, and gender (Table 2).
We used Flegal et al.’s (2010, Table 2) analysis of
NHANES data as the basis for comparison be-
tween persons with intellectual disability (Table 2)
and the general population (for those $ 20 years
old). Nonoverlap of the 95% confidence intervals
between groups was considered to be a significant
difference. To assist with comparison, selected
groupings of Flegal et al.’s data (all people, all
men, all women) are reproduced in Table 2 along
with the corresponding groupings for people with
intellectual disability drawn from the NCI sample.
Readers should consult Flegal et al.’s Table 2
directly for more detailed comparisons for specific
age and gender groups. Because the Hispanic and
Mexican American samples were constituted
differently in the general population data (Flegal
et al.) than in the NCI data, we present the data
for the Hispanic/other group without a general
population comparison.

On most comparisons, our sample of adult
service users with intellectual disability from 20
states did not differ from the nationally represen-
tative sample of the U.S. population. Of 27
possible comparisons for obesity prevalence, only
4 were significant (denoted in Table 2 by an
asterisk to indicate that the NCI subgroup mean
differed significantly from the corresponding
subgroup mean in Flegal et al.’s, 2010, Table 2).

Table 1. Number of Sample Members with Intellectual Disability by Racial Group, Gender,
and Age

Gender/age group

Total

(N 5 8,911)

Non-Hispanic White

(n 5 6,488)

Non-Hispanic Black

(n 5 1,706)

Hispanic/other

(n 5 717)

Men

20–39 2,152 1,394 499 259

40–59 2,248 1,665 444 139

60+ 605 496 78 31
All men 5,005 3,555 1,021 429

Women

20–39 1,553 1,095 305 153

40–59 1,751 1,319 329 103

60+ 602 519 51 32
All women 3,906 2,933 685 288

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 405

T
a
b

le
2
.

P
er

ce
n

ta
ge

o
f

A
d

u
lt

s
W

it
h

In
te

ll
ec

tu
al

D
is

ab
il
it

ie
s

an
d

a
C

o
m

p
ar

is
o

n
S
am

p
le

F
ro

m
th

e
G

en
er

al
P
o

p
u

la
ti

o
n

a
W

h
o

W
er

e
O

b
es

e
o

r
O

v
er

w
ei

gh
t

b
y

R
ac

e,
A

ge
,

an
d

G
en

d
er

S
a
m

p
le

g
e
n

d
e
r/

a
g

e
g

ro
u

p

P
e
rc

e
n

ta
g

e
o

f
a
d

u
lt

s
(9

5
%

co
n

fi
d

e
n

ce
in

te
rv

a
l)

A
ll

(N
C

I
(N

5
8
,9

1
1
)

N
o

n
-H

is
p

a
n

ic
W

h
it

e

(N
C

I
n

5
6
,4

8
8
)

N
o

n
-H

is
p

a
n

ic
B

la
ck

(N
C

I
n

5
1
,7

0
6
)

H
is

p
a
n

ic
/O

th
e

r2

(N
C

I
n

5
7
1
7
)

O
b

e
se

:
B

M
I

$
3
0

T
o

ta
l

U
.S

.
sa

m
p

le
3
3
.8

(3
1
.6


3

6
.0

)
3
2
.8

(2
8
.9


3
5

.9
)

4
4
.1

(4
0
.0


4
8

.2
)

N
C

I
sa

m
p

le
3
3
.6

(3
2
.6


3

4
.6

)
3
3
.0

(3
1
.9


3
4

.2
)A

3
5
.8

(3
3
.5


3
8

.0
)*

A
3
3
.2

(2
9
.7


3
6
.7

)A

M
e
n

U
.S

.
sa

m
p

le
:

a
ll

3
2
.2

(2
9
.5


3

5
.0

)
3
1
.9

(2
8
.1


3
5

.7
)

3
7
.3

(3
2
.3


4
2

.4
)

N
C

I
sa

m
p

le
:

a
ll

2
9
.4

(2
8
.2


3

0
.7

)a
2
9
.6

(2
8
.1


3
1

.1
)c

B
2
8
.6

(2
5
.8


3
1

.4
)*

e
B

2
9
.6

(2
5
.3


3
3
.9

)g
B

N
C

I:
2
0

3
9

3
0
.8

(2
8
.9


3

2
.8

)a
3
0
.7

(2
8
.3


3
3

.1
)c

C
3
0
.1

(2
6
.0


3
4

.1
)e

C
3
2
.8

(2
7
.1


3
8
.6

)g
C

N
C

I:
4
0

5
9

2
9
.7

(2
7
.8


3

1
.6

)a
3
0
.5

(2
8
.2


3
2

.7
)c

D
2
7
.9

(2
3
.7


3
2

.1
)e

D
2
6
.6

(1
9
.2


3
4
.1

)g
D

N
C

I:
6
0

+
2
3
.3

(1
9
.9


2

6
.7

)*
a

2
3
.8

(2
0
.0


2
7

.6
)*

c
E

2
3
.1

(1
3
.5


3
2

.6
)e

E
1
6
.1

(2
.4


2
9
.8

)g
E

W
o

m
e
n

U
.S

.
sa

m
p

le
:

a
ll

3
5
.5

(3
3
.2


3

7
.7

)
3
3
.0

(2
9
.3


3
6

.6
)

4
9
.6

(4
5
.5


5
3

.7
)

N
C

I
sa

m
p

le
:

a
ll

3
8
.9

(3
7
.4


4

0
.4

)b
3
7
.2

(3
5
.5


3
9

.0
)d

F
4
6
.4

(4
2
.7


5
0

.2
)f

G
3
8
.5

(3
2
.9


4
4
.2

)g
F
G

N
C

I:
2
0

3
9

4
1
.1

(3
8
.7


4

3
.6

)b
3
8
.2

(3
5
.3


4
1

.1
)d

H
5
1
.5

(4
5
.8


5
7

.1
)f

I
4
1
.8

(3
3
.9


4
9
.7

)g
H

I

N
C

I:
4
0

5
9

3
9
.5

(3
7
.2


4

1
.8

)b
3
8
.9

(3
6
.3


4
1

.5
)d

J
4
1
.9

(3
6
.6


4
7

.3
)f

J
3
9
.8

(3
0
.2


4
9
.4

)g
J

N
C

I:
6
0

+
3
1
.4

(2
7
.7


3

5
.1

)b
3
0
.8

(2
6
.8


3
4

.8
)c

K
4
5
.1

(3
1
.0


5
9

.2
)e

K
1
8
.8

(4
.5


3
3
.1

)g
K

O
v
e
rw

e
ig

h
t

o
r

o
b

e
se

:
B

M
I

$
2
5

T
o

ta
l

U
.S

.
sa

m
p

le
:

a
ll

6
8
.0

(6
6
.3


6

9
.8

)
6
6
.7

(6
4
.1


6
9

.3
)

7
3
.8

(7
1
.3


7
6

.3
)

N
C

I
sa

m
p

le
:

a
ll

6
2
.2

(6
1
.2


6

3
.3

)*
6
2
.0

(6
0
.8


6
3

.2
)*

L
6
3
.8

(6
1
.5


6
6

.1
)*

L
6
0
.7

(5
7
.1


6
4
.3

)L

M
e
n

U
.S

.
sa

m
p

le
:

a
ll

7
2
.3

(7
0
.4


7

4
.1

)
7
2
.6

(6
9
.9


7
5

.3
)

6
8
.5

(6
5
.2


7
1

.8
)

N
C

I
sa

m
p

le
:

a
ll

6
0
.5

(5
9
.1


6

1
.8

)*
h

6
0
.7

(5
9
.1


6
2

.3
)*

jM
6
0
.3

(5
7
.3


6
3

.3
)*

k
M

5
9
.0

(5
4
.3


6
3
.7

)m
M

N
C

I:
2
0

3
9

5
7
.7

(5
5
.6


5

9
.8

)*
h

5
8
.0

(5
5
.6


6
0

.6
)*

jN
5
7
.0

(5
2
.6


6
1

.3
)k

N
5
7
.9

(5
1
.9


6
4
.0

)m
N

N
C

I:
4
0

5
9

6
3
.9

(6
1
.9


6

5
.9

)*
h

6
3
.8

(6
1
.4


6
6

.0
)*

jO
6
5
.5

(6
1
.1


7
0

.0
)k

O
6
1
.2

(5
3
.0


6
9
.4

)m
O

N
C

I:
6
0

+
5
7
.4

(5
3
.4


6

1
.3

)*
h

5
8
.1

(5
3
.7


6
2

.4
)*

jP
5
2
.6

(4
1
.2


6
3

.9
)*

k
P

5
8
.1

(3
9
.7


7
6
.5

)m
P

(T
a
b

le
2

c
o
n

ti
n

u
e
d

)

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

406 E American Association on Intellectual and Developmental Disabilities

In each case, the group with intellectual disability
had lower prevalence of obesity.

For the overweight and obesity prevalence data
(lower half of Table 2), 15 of 27 (56%) comparisons
were significant. Here too, the group with intellec-
tual disability had lower prevalence in every case.
Ten of the 12 (83%) comparisons involving men
were significant, suggesting a lower prevalence of
overweight and obesity among men with intellec-
tual disability than men in the general U.S.
population. By contrast, only 2 of the 12 (17%)
comparisons for women were significant, suggest-
ing that, for women, there is a similar prevalence of
overweight and obesity to the general population.

Gender comparisons. Among the sample of
people with intellectual disability, men were
significantly less obese than women (significant
pairwise gender comparisons denoted in Table 2
by means with different lowercase superscript
letters when comparing the equivalent male and
female subgroup within columns). This was true for
the sample overall (all men vs. all women) and for
non-Hispanic White and non-Hispanic Black men
but not for men in the Hispanic/other group.
These significant gender differences in obesity
prevalence were also true for within-race compar-
isons between men and women in the 20–39-year-
old and 40–59-year-old age groups for White and
Black participants. The absence of significant
gender differences for the 60+ age group may have
been due, in part, to its much smaller sample size.

Among adults with intellectual disability,
gender differences were less evident for the
combined overweight and obesity groups. There
was a significantly lower prevalence of overweight
and obesity when comparing all men (60.5%) with
all women (64.5%), as well as for all Black men with
all Black women, and for all men and Black men
among the 20–39-year-old age group. These
differences appear to have been driven by the
higher obesity prevalence in women. Indeed,
taking overweight (25.0 # BMI , 30.0) prevalence
only, 31.0% of all men and 25.6% of all women
were overweight.

Comparisons by race–ethnic group. There were no
significant differences by race–ethnic group in the
prevalence of obesity or of combined overweight
and obesity among the sample as a whole or among
men with intellectual disability. However, signifi-
cantly more Black women were obese than White
women (significant race–ethnic group comparisons
denoted in Table 2 by means with different upper-
case superscript letters within rows). When brokenT

a
b

le
2
.

C
o

n
ti

n
u

ed
.

S
a
m

p
le

g
e
n

d
e
r/

a
g

e
g

ro
u

p

P
e
rc

e
n

ta
g

e
o

f
a
d

u
lt

s
(9

5
%

co
n

fi
d

e
n

ce
in

te
rv

a
l)

A
ll

(N
C

I
(N

5
8
,9

1
1
)

N
o

n
-H

is
p

a
n

ic
W

h
it

e

(N
C

I
n

5
6
,4

8
8
)

N
o

n
-H

is
p

a
n

ic
B

la
ck

(N
C

I
n

5
1
,7

0
6
)

H
is

p
a
n

ic
/O

th
e

r2

(N
C

I
n

5
7
1
7
)

W
o

m
e
n

U
.S

.
S
a
m

p
le

:
a
ll

6
4
.1

(6
1
.3


6

6
.9

)
6
1
.2

(5
6
.7


6
5

.7
)

7
8
.2

(7
4
.5


8
1

.9
)

N
C

I
S
a
m

p
le

:
a
ll

6
4
.5

(6
3
.0


6

6
.0

)i
6
3
.7

(6
1
.9


6
5

.4
)j

Q
6
8
.9

(6
5
.4


7
2

.4
)*

lQ
6
3
.2

(5
7
.6


6
8
.8

)m
Q

N
C

I:
2
0

3
9

6
3
.9

(6
1
.6


6

6
.3

)i
6
1
.6

(5
8
.7


6
4

.4
)j

R
7
2
.5

(6
7
.4


7
7

.5
)l

S
6
4
.1

(5
6
.4


7
1
.7

)m
R

S

N
C

I:
4
0

5
9

6
5
.5

(6
3
.2


6

7
.7

)h
6
5
.2

(6
2
.6


6
7

.8
)j

T
6
6
.0

(6
0
.8


7
1

.1
)*

k
T

6
7
.0

(5
7
.8


7
6
.2

)m
T

N
C

I:
6
0

+
6
3
.5

(5
9
.6


6

7
.3

)h
6
4
.2

(6
0
.0


6
8

.3
)j

U
6
6
.7

(5
3
.3


8
0

.1
)k

U
4
6
.9

(2
8
.6


6
5
.2

)m
U

N
ot

e.
N

C
I

5
N

at
io

n
al

C
o

re
In

d
ic

at
o

rs
.
T

h
e

ge
n

er
al

p
o

p
u

la
ti

o
n

co
m

p
ar

is
o

n
d

at
a

ar
e

fr
o

m
th

e
N

at
io

n
al

H
ea

lt
h

an
d

N
u

tr
it

io
n

E
xa

m
in

at
io

n
S
u

rv
ey

(N
H

A
N

E
S
;

F
le

ga
l
et

al
.,

2
0
1
0
).

F
o

r
th

e
H

is
p

an
ic

/o
th

er
co

lu
m

n
d

at
a,

co
m

p
ar

is
o

n
w

it
h

F
le

ga
l

et
al

.
(2

0
1
0
)

w
as

n
o

t
p

o
ss

ib
le

b
ec

au
se

o
f

d
if

fe
re

n
t

et
h

n
ic

gr
o

u
p

in
gs

u
se

d
in

th
is

co
lu

m
n

.
*T

h
er

e
w

as
n

o
o

v
er

la
p

in
9
5
%

co
n

fi
d

en
ce

in
te

rv
al

s
b

et
w

ee
n

N
C

I
d

at
a

an
d

th
e

eq
u

iv
al

en
t

N
H

A
N

E
S

su
b

gr
o

u
p

in
F
le

ga
l
et

al
.’
s

(2
0
1
0
)

T
ab

le
2
.
In

al
l
ca

se
s

o
f

d
if

fe
re

n
ce

s
(n

o
o

v
er

la
p

),
N

C
I

m
ea

n
s

w
er

e
lo

w
er

.
a

m
G

en
d

er
co

m
p

ar
is

o
n

s
(p

ai
rw

is
e,

w
it

h
in

co
lu

m
n

s)
:

M
ea

n
s

th
at

sh
ar

e
th

e
sa

m
e

lo
w

er
ca

se
su

p
er

sc
ri

p
t

le
tt

er
d

id
n

o
t

d
if

fe
r

si
gn

if
ic

an
tl

y
.

A

U
R

ac
e–

et
h

n
ic

gr
o

u
p

co
m

p
ar

is
o

n
s

(w
it

h
in

ro
w

s)
:

M
ea

n
s

th
at

sh
ar

e
th

e
sa

m
e

u
p

p
er

ca
se

su
p

er
sc

ri
p

t
le

tt
er

d
id

n
o

t
d

if
fe

r
si

gn
if

ic
an

tl
y
.

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 407

down further by age group, this Black–White racial
difference was significant for women in the 20–29-
year-old age group but not for either of the older
age groups of women. Women in the Hispanic/
other group did not differ in obesity prevalence
from women in any other racial group. The
findings for overweight and obesity prevalence
among women were similar.

Grade 3 Obesity
Table 3 shows the prevalence of Grade 3

obesity (morbid obesity). Overall prevalence of
Grade 3 obesity (BMI $ 40.0) among the NCI
sample was 7.6% and ranged from 2.6% for older
(60+) Black men to an exceptionally high 16.1%
among younger (20–39) Black women.

Comparison with the general population. For
Grade 3 obesity, 6 of 27 (22%) comparisons
between the NCI sample with intellectual disabil-
ity and the general population (Flegal et al., 2010,
Table 3) yielded significant differences (denoted
by an asterisk). In all cases, sample members with
intellectual disability had significantly higher
prevalence rates. Even though the overall preva-
lence of obesity among adults with intellectual
disability did not differ from the general popula-
tion (Table 2), for Grade 3 obesity, significantly
more people with intellectual disability were
affected, especially younger women.

Gender comparisons. Women with intellectual
disability had significantly higher prevalence of
Grade 3 obesity compared with men. This was
true for the overall NCI sample, for non-Hispanic
White individuals and non-Hispanic Black indi-
viduals (pairwise gender comparisons within
columns denoted by lowercase-letter superscripts).
There were no significant differences by race–
ethnic group.

Diagnosis and BMI
We partitioned our sample into four mutually

exclusive diagnostic groups: (a) intellectual dis-
abilities only (but no Down syndrome, autism–
pervasive developmental disorders, or cerebral
palsy), (b) intellectual disability and Down
syndrome, (c) intellectual disability and autism–
pervasive developmental disorder, and (d) intel-
lectual disability and cerebral palsy. Individuals
with more than one diagnosis (of Down syn-
drome, autism–pervasive developmental disorder,
or cerebral palsy) were excluded, as were those
with missing data on diagnoses (n 5 643). In

addition, because of a very small sample size, we
excluded 28 individuals with Prader-Willi syn-
drome, leaving a final sample of 8,272 individuals.
Table 4 shows BMI data by diagnostic group.

The mean BMI for participants with Down
syndrome was in the obese range ($30.0); for
those with intellectual disability only or autism–
pervasive developmental disorders, the mean was
in the overweight range (BMI 5 25.0–30.0). Only
the mean for the group with cerebral palsy was in
the healthy weight range (BMI 5 18.5–24.99).

One-way analysis of variance (ANOVA) re-
vealed a significant between-diagnostic-group
difference, F(3, 8268) 5 116.38, p , .001. The as-
sumption of homogeneity of variance was violated,
so we used Tamahane’s T2 procedure to test
pairwise differences among each diagnostic group.
All these comparisons were significant at .001 or
better, showing that BMI for individuals with
Down syndrome was significantly higher than the
other three groups, whereas those with cerebral
palsy had significantly lower mean BMI than the
other three groups. The intellectual disability–only
and autism–pervasive developmental disorder
groups each fell in between, but each also differed
significantly from all other groups.

The mean BMI for the 28 individuals with
Prader-Willi syndrome excluded from these anal-
yses was 34.32 (95% confidence interval 5 30.31–
38.33), higher than for any of the four groups
shown in Table 4. However, the very small sample
size and consequent wide confidence intervals
made between-group comparisons potentially
misleading, given the likelihood of the difference
from the sample with Prader-Willi syndrome not
being statistically significant when a real differ-
ence existed (Type II error).

Next, we examined the prevalence of com-
bined overweight and obesity for the four
diagnostic groups listed in Table 4. The sample
size for some diagnostic groups was relatively
small, so we broke down these prevalence data by
gender but not by age group to limit the potential
for Type II error (Table 5).

The group with cerebral palsy had a notably
lower prevalence of obesity and overweight than
any of the other diagnostic groups and lower than
the general population (see Table 2 for general
population prevalence). As Table 5 shows, for
each diagnostic group as a whole (‘‘NCI all’’), the
prevalence of obesity differed significantly (up-
percase superscripts within rows), from a low of
17.2% (cerebral palsy) to a high of 44.3% (Down

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

408 E American Association on Intellectual and Developmental Disabilities

T
a
b

le
3
.

P
re

v
al

en
ce

o
f

G
ra

d
e

3
(M

o
rb

id
)

O
b

es
it

y
A

m
o

n
g

A
d

u
lt

s
W

it
h

In
te

ll
ec

tu
al

D
is

ab
il
it

y
an

d
a

C
o

m
p

ar
is

o
n

S
am

p
le

F
ro

m
th

e
U

.S
.

G
en

er
al

P
o

p
u

la
ti

o
n

b
y

R
ac

e,
A

ge
,

an
d

G
en

d
er

S
a
m

p
le

g
e
n

d
e
r/

a
g

e
g

ro
u

p

P
e
rc

e
n

ta
g

e
o

f
a
d

u
lt

s
(9

5
%

co
n

fi
d

e
n

ce
in

te
rv

a
l)

A
ll

(N
C

I
N

5
8
,9

1
1
)

N
o

n
-H

is
p

a
n

ic
W

h
it

e

(N
C

I
n

5
6
,4

8
8
)

N
o

n
-H

is
p

a
n

ic
B

la
ck

(N
C

I
n

5
1
,7

0
6
)

H
is

p
a
n

ic
/o

th
e
r

(N
C

I
n

5
7
1
7
)

G
ra

d
e

3
o

b
e
si

ty
:

B
M

I
$

4
0
.0

U
.S

.
sa

m
p

le
:

a
ll

5
.7

(4
.9


6
.5

)
5
.2

(3
.8


6
.5

)
1
1
.1

(8
.3


1
3
.8

)

N
C

I
sa

m
p

le
:

a
ll

7
.6

(7
.1


8
.2

)*
7
.3

(6
.7


8
.0

)*
A

8
.9

(7
.5


1
0
.2

)A
7
.3

(5
.4


9
.2

)A

M
e
n

(n
5

5
,0

0
5
)

U
.S

.
sa

m
p

le
:

a
ll

4
.2

(3
.3


5
.1

)
4
.0

(2
.9


5
.1

)
7
.0

(4
.5


9
.4

)

N
C

I
sa

m
p

le
:

a
ll

5
.1

(4
.5


5
.7

)a
5
.0

(4
.2


5
.7

)c
B

5
.6

(4
.2


7
.0

)e
B

5
.4

(3
.2


7
.5

)g
B

N
C

I:
2
0

3
9

6
.5

(5
.5


7
.6

)a
6
.5

(5
.2


7
.8

)c
C

6
.8

(4
.6


9
.0

)e
C

6
.2

(3
.2


9
.1

)g
C

N
C

I:
4
0

5
9

4
.4

(3
.6


5
.3

)a
4
.3

(3
.3


5
.2

)c
D

4
.7

(2
.8


6
.7

)e
D

5
.0

(1
.4


8
.7

)g
D

N
C

I:
6
0

+
2
.8

(1
.5


4
.1

)a
3
.0

(1
.5


4
.5

)c
E

2
.6

(–
1
.0


6
.2

)e
E

0
.0

W
o

m
e
n

(n
5

3
,9

0
6
)

U
.S

.
sa

m
p

le
:

a
ll

7
.2

(6
.1


8
.4

)
6
.4

(4
.2


8
.5

)
1
4
.2

(1
0
.5


1
7
.8

)

N
C

I
sa

m
p

le
:

a
ll

1
0
.8

(9
.6


1
1

.8
)*

b
1
0
.2

(9
.1


1
1
.3

)*
d

F
1
3
.7

(1
1
.1


1
6
.3

)f
F

1
0
.1

(6
.6


1
3
.6

)g
F

N
C

I:
2
0

3
9

1
3
.3

(1
1
.6


1

5
.0

)*
b

1
3
.1

(1
1
.1


1
5
.1

)*
d

G
1
6
.1

(1
1
.9


2
0
.2

)f
G

9
.8

(5
.0


1
4
.6

)g
G

N
C

I:
4
0

5
9

1
0
.6

(9
.2


1
2

.1
)b

1
0
.0

(8
.4


1
1
.6

)d
H

1
2
.8

(9
.1


1
6
.4

)f
H

1
1
.7

(5
.4


1
8
.0

)g
H

N
C

I:
6
0

+
5
.0

(3
.2


6
.7

)a
4
.8

(3
.0


6
.7

)c
I

5
.9

(–
0
.8


1
2
.6

)e
I

6
.3

(–
2
.6


1
5

.1
)I

N
ot

e.
N

C
I

5
N

at
io

n
al

C
o

re
In

d
ic

at
o

rs
.
T

h
e

ge
n

er
al

p
o

p
u

la
ti

o
n

co
m

p
ar

is
o

n
d

at
a

ar
e

fr
o

m
th

e
N

at
io

n
al

H
ea

lt
h

an
d

N
u

tr
it

io
n

E
xa

m
in

at
io

n
S
u

rv
ey

(N
H

A
N

E
S
;
F
le

ga
l
et

al
.,

2
0
1
0
).

In
th

e
H

is
p

an
ic

/o
th

er
co

lu
m

n
,

co
m

p
ar

is
o

n
w

it
h

F
le

ga
l

et
al

.
(2

0
1
0
)

w
as

n
o

t
p

o
ss

ib
le

b
ec

au
se

o
f

d
if

fe
re

n
t

et
h

n
ic

gr
o

u
p

in
gs

u
se

d
in

th
is

co
lu

m
n

.
*
T

h
er

e
w

as
n

o
o

v
er

la
p

in
9
5
%

co
n

fi
d

en
ce

in
te

rv
al

s
b

et
w

ee
n

N
C

I
d

at
a

an
d

th
e

eq
u

iv
al

en
t

N
H

A
N

E
S

su
b

gr
o

u
p

in
F
le

ga
l
et

al
.
(2

0
1
0
,
T

ab
le

3
).

In
al

l
ca

se
s

o
f

d
if

fe
re

n
ce

s
(n

o
o

v
er

la
p

)
N

C
I

m
ea

n
s

w
er

e
h

ig
h

er
.

a

g
G

en
d

er
co

m
p

ar
is

o
n

s
(p

ai
rw

is
e,

w
it

h
in

co
lu

m
n

s)
:

M
ea

n
s

th
at

sh
ar

e
th

e
sa

m
e

lo
w

er
ca

se
su

p
er

sc
ri

p
t

le
tt

er
d

id
n

o
t

d
if

fe
r

si
gn

if
ic

an
tl

y
.

A

I
R

ac
e–

et
h

n
ic

gr
o

u
p

co
m

p
ar

is
o

n
s

(w
it

h
in

ro
w

s)
:

M
ea

n
s

th
at

sh
ar

e
th

e
sa

m
e

u
p

p
er

ca
se

su
p

er
sc

ri
p

t
le

tt
er

d
id

n
o

t
d

if
fe

r
si

gn
if

ic
an

tl
y
.

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 409

syndrome). This is consistent with the BMI
analyses shown in Table 4. Overall, significantly
more women (38.4%) were obese than men
(28.8%). This gender difference in obesity was
repeated for the intellectual disability–only and
cerebral palsy groups but did not attain signifi-
cance for the smaller Down syndrome and
autism–pervasive developmental disorder groups
(lowercase superscripts within columns). A similar
pattern of significant differences was evident for
the combined overweight and obesity prevalence
data shown in the lower section of Table 5.

Level of Intellectual Disability
There were large and significant differences in

obesity prevalence by level of intellectual disabil-
ity (Table 6). The lowest prevalence of obesity was
among individuals with profound intellectual
disability (12.6%). This rate was significantly and
substantially lower than those with severe intel-
lectual disability (26.7%), who in turn had a
significantly lower prevalence rate than people
with mild or moderate intellectual disability
(41.4% and 38.2%, respectively). The differences
between the groups of persons with mild and
moderate intellectual disability were not statisti-
cally significant (uppercase superscripts within
rows). The gender differences noted in Table 2 are
also evident in Table 6. It is notable that women
had a significantly higher prevalence of obesity
than men within the mild, moderate, and severe
intellectual disability groups (lowercase super-
scripts within columns). That is, gender differenc-
es in obesity were evident at all levels except
profound intellectual disability. The effects of
level of intellectual disability and gender com-
bined were marked; for example, almost half

(46.5%) of women with mild intellectual disability
had a BMI in the obese range.

Living Arrangements
Prevalence of overweight and obesity by

living arrangement and by level of intellectual
disability is shown in Table 7. The last (‘‘Total’’)
column of Table 7 shows the significant overall
differences between living arrangements in the
prevalence of obesity, with the highest prevalence
among individuals living in their own home
(42.8%) and the lowest among institutional
residents (18.6%). Inspection of the confidence
intervals in the final column of Table 7 (upper
half) reveals that institutional residents had a
significantly lower prevalence of obesity than any
of the other residence types listed (lowercase
superscripts with columns). Both host–foster
home and group home had significantly lower
prevalence than agency apartment, own home,
and family home. Family home was significantly
lower than own home, and own home and agency
apartment did not differ. The comparisons for
overweight and obesity (lower half of Table 7)
were generally similar to the pattern for obesity.

At first glance, these univariate comparisons
suggest significant variations in the prevalence of
obesity among different living arrangements.
However, there were substantial disparities among
different living arrangements in the percentages of
people at each level of intellectual disability. For
example, people with profound intellectual dis-
ability made up 45.2% of institutional residents
but only 5.6% of agency apartment residents and
only 7.4% of those living in their own home. To
make these differences explicit, Table 7 also
shows the total number of sample members at

Table 4. Body Mass Index (BMI) for Persons With Intellectual Disability by Diagnostic Group

Diagnostic group n M SD 95% CI

Intellectual disability only 5,723 28.55a 7.62 28.35–28.75

Intellectual disability and

Down syndrome 721 30.40
b

7.66 29.84–30.96

Intellectual disability and

autism/pervasive

developmental disability 721 27.42
c

7.16 26.90–27.95

Intellectual disability and

cerebral palsy 1,107 24.53
d

6.62 24.14–24.92

Total intellectual disability 8,272 28.07 7.61 27.91–28.24

Note. CI 5 confidence interval.
a–dDiagnostic group comparisons (within columns): Means that share the same lowercase superscript letter did not differ
significantly.

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

410 E American Association on Intellectual and Developmental Disabilities

each level of intellectual disability in each
residence type. For example, there were 159
people with mild intellectual disability living in
institutions, 31.4% of whom were obese. As has
been shown (Table 6), there are important
differences in prevalence of obesity by level of
intellectual disability. This factor needs to be
considered carefully when examining differences
in prevalence of obesity among residence types.

When comparisons of prevalence of obesity
are made among residence types within each
level of intellectual disability, the differences are
much less stark than they appear in the final
column of Table 7. For individuals with mild
intellectual disability, institutional residents still
had the lowest prevalence of obesity, but the
difference was only significant when compared
with agency apartment and own-home residents
(lowercase superscripts within columns). Signifi-
cantly fewer group home and family home
residents were obese than those living in their
own home. There were no other significant differ-
ences by residence type among sample mem-
bers with mild intellectual disability. Comparison
with the final column of Table 7 reveals that
although differences in obesity prevalence remain,
the differences among living arrangements are
much smaller within each level of intellectual
disability.

Likewise, in the group with moderate intel-
lectual disability, significantly fewer institutional,
group home, and host–foster home residents were
obese than those living in their own home or
family home. For those with severe intellectual
disability, there were no significant differences in
prevalence of obesity by living arrangement. In the
case of people with profound disability, signifi-
cantly fewer institution residents were obese than
people from agency apartments or from family
homes. There were no other significant differences
by living arrangement among individuals with
profound intellectual disability. Overall, the effect
of living arrangement appeared to be more
significant among those with moderate and mild
intellectual disability and less evident among
individuals with more severe intellectual disability.
Across living arrangements, for individuals with
mild or moderate intellectual disability, the pattern
appeared to reflect lower prevalence of obesity in
regulated congregate settings such as institutions
but higher prevalence in more individualized, less
supervised environments such as one’s own home.T

a
b

le
5
.

P
er

ce
n

ta
ge

o
f

O
b

es
e

an
d

O
v
er

w
ei

gh
t

A
d

u
lt

s
W

it
h

In
te

ll
ec

tu
al

D
is

ab
il
it

ie
s

b
y

D
ia

gn
o

st
ic

G
ro

u
p

an
d

G
en

d
er

G
ro

u
p

/g
e
n

d
e
r

D
ia

g
n

o
st

ic
g

ro
u

p

In
te

ll
e
ct

u
a
l

d
is

a
b

il
it

ie
s

o
n

ly
(n

5
5
,6

2
7
)

D
o

w
n

sy
n

d
ro

m
e

(n
5

7
0
6
)

A
u

ti
sm

/p
e
rv

a
si

v
e

d
e
v
e
lo

p
m

e
n

ta
l

d
is

o
rd

e
r

(n
5

6
9
0
)

C
e
re

b
ra

l
p

a
ls

y

(n
5

1
,0

7
8
)

T
o

ta
l

(N
5

8
,1

0
1
)

O
b

e
se

:
B

M
I:

$
3
0

N
C

I
sa

m
p

le
:

a
ll

3
5
.1

(3
3
.9


3
6

.4
)A

4
4
.3

(4
0
.7


4
8
.0

)B
2
9
.3

(2
5
.9


3
2
.7

)C
1
7
.2

(1
4
.9


1
9

.4
)D

3
3
.0

(3
2
.0


3
4

.0
)

M
e
n

(n
5

4
,5

5
1
)

3
0
.7

(2
9
.1


3
2

.3
)a

E
4
1
.2

(3
6
.3


4
6
.1

)c
F

2
6
.7

(2
2
.9


3
0
.6

)d
E

1
1
.9

(9
.2


1
4
.5

)e
G

2
8
.8

(2
7
.5


3
0

.1
)g

W
o

m
e
n

(n
5

3
,5

5
0
)

4
0
.4

(3
8
.5


4
2

.3
)b

H
4
8
.1

(4
2
.6


5
3
.6

)c
I

3
6
.8

(2
9
.6


4
4
.0

)d
H

I
2
3
.0

(1
9
.4


2
6

.7
)f

J
3
8
.4

(3
6
.8


4
0

.0
)h

O
v
e
rw

e
ig

h
t

o
r

o
b

e
se

:
B

M
I

$
2
5

N
C

I
sa

m
p

le
:

a
ll

6
4
.8

(6
3
.5


6
6

.0
)K

7
2
.7

(6
9
.4


7
6
.0

)L
5
9
.4

(5
5
.8


6
3
.1

)M
4
1
.0

(3
8
.1


4
3

.9
)N

6
1
.8

(6
0
.8


6
2

.9
)

M
e
n

(n
5

4
,5

5
1
)

6
3
.0

(6
1
.3


6
4

.7
)i

O
Q

7
2
.5

(6
8
.1


7
7
.0

)k
P

5
9
.7

(5
5
.4


6
3
.9

)l
Q

3
6
.1

(3
2
.1


4
0

.1
)m

R
6
0
.1

(5
8
.7


6
1

.5
)o

W
o

m
e
n

(n
5

3
,5

5
0
)

6
6
.9

(6
5
.1


6
8

.7
)j

S
T

7
2
.8

(6
7
.9


7
7
.7

)k
S

5
8
.6

(5
1
.2


6
6
.0

)l
T

4
6
.4

(4
2
.1


5
0

.7
)n

U
6
4
.1

(6
2
.5


6
5

.6
)p

N
ot

e.
N

C
I

5
N

at
io

n
al

C
o

re
In

d
ic

at
o

rs
.

a

p
G

en
d

er
co

m
p

ar
is

o
n

s
(p

ai
rw

is
e,

w
it

h
in

co
lu

m
n

s)
:

M
ea

n
s

th
at

sh
ar

e
th

e
sa

m
e

lo
w

er
ca

se
su

p
er

sc
ri

p
t

le
tt

er
d

id
n

o
t

d
if

fe
r

si
gn

if
ic

an
tl

y
.

A

U
D

ia
gn

o
st

ic
gr

o
u

p
co

m
p

ar
is

o
n

s
(w

it
h

in
ro

w
s)

:
M

ea
n

s
th

at
sh

ar
e

th
e

sa
m

e
u

p
p

er
ca

se
su

p
er

sc
ri

p
t

le
tt

er
d

id
n

o
t

d
if

fe
r

si
gn

if
ic

an
tl

y
.

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 411

Within each type of living arrangement there
was a consistent pattern of differences by level of
intellectual disability. The groups with mild and
moderate intellectual disability did not differ on
obesity prevalence within any of the six types of
living arrangement listed in Table 7 (uppercase
superscripts within rows). However, within every
type of living arrangement, either or both groups
with severe and profound intellectual disability
had significantly lower prevalence rates of obesity
than either or both the groups with mild or
moderate intellectual disability. These findings are
fully consistent with the overall results for level of
intellectual disability reported in Table 6.

Discussion

We found high levels of obesity and over-
weight in our 2008–2009 20-state sample of adult
service users (20 years and older) with intellectual
disability. Almost two thirds (62.2%) of sample
members were overweight or obese (BMI $ 25.0)
and one third (33.6%) obese (BMI $ 30.0). The
prevalence of Grade 3 (morbid) obesity (BMI $
40.0) was 7.6%, and was especially pronounced
among younger women with intellectual disability.

Compared with a 2007–2008 nationally
representative sample of the general adult (20 years
and older) population (Flegal et al., 2010), adults
with intellectual disability in the NCI sample had
a similar or slightly lower prevalence of over-
weight and obesity. Where group differences were
evident, the data showed that people with
intellectual disability had lower prevalence of
overweight and obesity. There were few differenc-
es regarding obesity, but there was a mostly
consistent pattern of lower prevalence of over-
weight and obesity among men with intellectual
disability. There were few differences between
women from the general population and women
with intellectual disability.

In summary, overweight and obesity are
serious health issues for American adults with
and without intellectual disability, but, contrary to
some previous research, prevalence is not higher
among adults with intellectual disability who use
intellectual disability/developmental disability ser-
vices, than for the general population. Our findings
differ from Yamaki (2005), whose U.S. data were
derived from the NHIS, a population-based
household survey. The different sample frames of
the two studies may have contributed to the
different findings. Our participants included manyT

a
b

le
6
.

P
er

ce
n

ta
ge

o
f

O
b

es
e

an
d

O
v
er

w
ei

gh
t

A
d

u
lt

s
W

it
h

In
te

ll
ec

tu
al

D
is

ab
il
it

ie
s

b
y

L
ev

el
o

f
In

te
ll
ec

tu
al

D
is

ab
il
it

y
an

d
G

en
d

er

G
e
n

d
e
r

L
e
v
e
l

o
f

in
te

ll
e
ct

u
a
l

d
is

a
b

il
it

y

M
il
d

(n
5

3
,2

8
4
;

3
8
.9

%
)

M
o

d
e
ra

te

(n
5

2
,5

1
8
;

2
9
.8

%
)

S
e
v
e
re

(n
5

1
,3

4
2
;

1
5
.9

%
)

P
ro

fo
u

n
d

(n
5

1
,3

0
5
;

1
5
.4

%
)

T
o

ta
l

(N
5

8
,4

4
9
;

1
0
0
%

)

O
b

e
se

:
B

M
I

$
3
0

N
C

I
sa

m
p

le
:

a
ll

4
1
.4

(3
9
.7


4
3
.0

)A
3
8
.2

(3
6
.4


4
0
.1

)A
2
6
.7

(2
4
.3


2
9
.1

)B
1
2
.6

(1
0
.8


1
4
.5

)C
3
3
.7

(3
2
.7


3

4
.7

)

N
C

I:
m

e
n

(n
5

4
,7

4
5
)

3
7
.1

(3
4
.8


3
9
.3

)a
D

3
3
.9

(3
1
.4


3
6
.3

)c
D

2
1
.7

(1
8
.8


2
4
.6

)e
E

1
0
.9

(8
.7


1
3
.2

)g
F

2
9
.5

(2
8
.5


3

0
.9

)h

N
C

I:
w

o
m

e
n

(n
5

3
,7

0
4
)

4
6
.5

(4
4
.0


4
9
.0

)b
G

4
4
.1

(4
1
.1


4
7
.1

)d
G

3
3
.9

(2
9
.9


3
7
.9

)f
H

1
4
.8

(1
1
.9


1
7
.6

)g
I

3
8
.9

(3
7
.4


4

0
.5

)i

O
v
e
rw

e
ig

h
t

o
r

o
b

e
se

:
B

M
I

$
2
5

N
C

I
sa

m
p

le
:

a
ll

6
9
.7

(6
8
.1


7
1
.2

)J
6
9
.6

(6
7
.8


7
1
.4

)J
5
6
.6

(5
3
.9


5
9
.2

)K
3
5
.5

(3
2
.9


3
8
.1

)L
6
2
.3

(6
1
.3


6

3
.3

)

N
C

I:
m

e
n

(n
5

4
,7

4
5
)

6
7
.6

(6
5
.4


6
9
.8

)j
M

6
8
.3

(6
5
.9


7
0
.7

)l
M

5
3
.7

(5
0
.2


5
7
.2

)m
N

3
5
.9

(3
2
.4


3
9
.4

)n
O

6
0
.7

(5
9
.3


6

2
.0

)o

N
C

I:
w

o
m

e
n

(n
5

3
,7

0
4
)

7
2
.2

(6
9
.9


7
4
.5

)k
P

7
1
.3

(6
8
.6


7
4
.0

)l
P

6
0
.7

(5
6
.5


6
4
.8

)m
Q

3
5
.0

(3
1
.1


3
8
.9

)n
R

6
4
.4

(6
2
.8


6

5
.9

)p

N
ot

e.
N

C
I

5
N

at
io

n
al

C
o

re
In

d
ic

at
o

rs
.

a

p
G

en
d

er
co

m
p

ar
is

o
n

s
(p

ai
rw

is
e,

w
it

h
in

co
lu

m
n

s)
:
M

ea
n

s
th

at
sh

ar
e

th
e

sa
m

e
lo

w
er

ca
se

su
p

er
sc

ri
p

t
le

tt
er

d
id

n
o

t
d

if
fe

r
si

gn
if

ic
an

tl
y
.

A

R
L

ev
el

o
f

in
te

ll
ec

tu
al

d
is

ab
il
it

y
gr

o
u

p
co

m
p

ar
is

o
n

s
(w

it
h

in
ro

w
s)

:
M

ea
n

s
th

at
sh

ar
e

th
e

sa
m

e
u

p
p

er
ca

se
su

p
er

sc
ri

p
t

le
tt

er
d

id
n

o
t

d
if

fe
r

si
gn

if
ic

an
tl

y
.

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

412 E American Association on Intellectual and Developmental Disabilities

T
a
b

le
7
.

T
o

ta
l

N
u

m
b

er
o

f
R

es
id

en
ts

an
d

P
er

ce
n

ta
ge

o
f

T
h

em
W

h
o

W
er

e
O

b
es

e
an

d
O

v
er

w
ei

gh
t

b
y

L
ev

el
o

f
In

te
ll
ec

tu
al

D
is

ab
il
it

y
an

d
L

iv
in

g
A

rr
an

ge
m

en
t

L
iv

in
g

a
rr

a
n

g
e
m

e
n

ts

L
e
v
e
l

o
f

in
te

ll
e
ct

u
a
l

d
is

a
b

il
it

y

M
il
d

(n
5

3
,1

9
7
;

3
8
.8

%
)

M
o

d
e
ra

te
(n

5
2
,4

5
5
;

2
9
.8

%
)

S
e
v
e
re

(n
5

1
,3

0
5
;

1
5
.9

%
)

P
ro

fo
u

n
d

(n
5

1
,2

7
6
;

1
5
.5

%
)

T
o

ta
l

(N
5

8
,2

3
3
;

1
0
0
%

)

n
%

(C
I)

n
%

(C
I)

n
%

(C
I)

n
%

(C
I)

n
%

(C
I)

O
b

e
se

:
B

M
I

$
3
0

N
C

I
sa

m
p

le
:
a
ll

3
,1

9
7

4
1
.2

(3
9
.5

–4
2
.9

)A
2
,4

5
5

3
8
.3

(3
6
.4

–4
0
.3

)A
1
,3

0
5

2
6
.7

(2
4
.3

–2
9
.1

)B
1
,2

7
6

1
2
.6

(1
0
.8

–1
4
.4

)C
8
,2

3
3

3
3
.6

(3
2
.6

–3
4
.6

)

Li
v
in

g
a
rr

a
n

g
e
m

e
n

t

In
st

it
u

ti
o

n
1
5
9

3
1
.4

(2
4
.2

–3
8
.7

)a
D

1
9
6

2
9
.6

(2
3
.2

–3
6
.0

)d
D

2
1
1

2
2
.3

(1
6
.6

–2
7
.9

)g
D

4
6
7

7
.9

(5
.5

–1
0
.4

)h
E

1
,0

3
3

1
8
.6

(1
6
.2

–2
1
.0

)j

G
ro

u
p

h
o

m
e

9
2
6

3
9
.1

(3
5
.9

–4
2
.2

)a
b
F

9
0
2

3
6
.0

(3
2
.9

–3
9
.2

)d
F

4
8
9

2
6
.6

(2
2
.7

–3
0
.5

)g
G

4
5
1

1
2
.6

(9
.6

–1
5
.7

)h
iH

2
,7

6
8

3
1
.6

(2
9
.8

–3
3
.3

)k

A
g

e
n

cy

a
p

a
rt

m
e
n

t

2
8
1

4
5
.9

(4
0
.0

–5
1
.8

)b
cI

1
0
4

3
8
.5

(2
9
.0

–4
8
.0

)d
e
fI
J

3
7

2
1
.6

(7
.7

–3
5
.5

)g
J

2
5

3
2
.0

(1
2
.4

–5
1
.7

)iI
J

4
4
7

4
1
.4

(3
6
.8

–4
6
.0

)lm

O
w

n
h

o
m

e
7
5
9

4
7
.4

(4
3
.9

–5
1
.0

)c
K

2
4
0

4
7
.1

(4
0
.7

–5
3
.4

)e
K

1
0
1

2
4
.8

(1
6
.2

–3
3
.3

)g
L

8
8

1
1
.4

(4
.6

–1
8
.1

)h
iL

1
,1

8
8

4
2
.8

(3
9
.9

–4
5
.6

)l

Fa
m

il
y

h
o

m
e

9
2
3

3
9
.1

(3
6
.0

–4
2
.3

)a
b
M

N
8
7
5

4
2
.7

(3
9
.5

–4
6
.0

)e
M

3
6
3

3
1
.4

(2
6
.6

–3
6
.2

)g
N

O
2
0
3

2
0
.7

(1
5
.1

–2
6
.3

)iO
2
,3

6
4

3
7
.7

(3
5
.7

–3
9
.7

)m

H
o

st
/f

o
st

e
r

h
o

m
e

1
4
9

3
6
.9

(2
9
.1

–4
4
.8

)a
b
cP

1
3
8

2
2
.5

(1
5
.4

–2
9
.5

)f
P
Q

1
0
4

2
3
.1

(1
4
.8

–3
1
.3

)g
P
Q

4
2

1
6
.7

(4
.9

–2
8
.4

)h
iQ

4
3
3

2
7
.0

(2
2
.8

–3
1
.2

)k

O
v
e
rw

e
ig

h
t

o
r

o
b

e
se

:
B

M
I

$
2
5

N
C

I
sa

m
p

le
:

a
ll

3
,1

9
7

6
9
.6

(6
7
.9

–7
1
.1

)
2
,4

5
5

6
9
.4

(6
7
.6

–7
1
.2

)
1
,3

0
5

5
6
.7

(5
4
.0

–5
9
.4

)
1
,2

7
6

3
5
.4

(3
2
.8

–3
8
.1

)
8
,2

3
3

6
2
.2

(6
1
.1

–6
3
.2

)

L
iv

in
g

a
rr

a
n

g
e
m

e
n

t

In
st

it
u

ti
o

n
1
5
9

6
9
.2

(6
1
.9

–7
6
.4

)n
1
9
6

6
4
.3

(5
7
.5

–7
1
.1

)o
2
1
1

5
5
.5

(4
8
.7

–6
2
.2

)q
4
6
7

2
9
.8

(2
5
.6

–3
3
.9

)r
1
,0

3
3

4
7
.6

(4
4
.6

–5
0
.7

)t

G
ro

u
p

h
o

m
e

9
2
6

7
0
.2

(6
7
.2

–7
3
.2

)n
9
0
2

7
0
.3

(6
7
.3

–7
3
.3

)o
p

4
8
9

5
8
.5

(5
4
.1

–6
2
.9

)q
4
5
1

4
1
.7

(3
7
.1

–4
6
.3

)s
2
,7

6
8

6
3
.5

(6
1
.7

–6
5
.3

)u

A
g

e
n

cy

a
p

a
rt

m
e
n

t

2
8
1

7
3
.0

(6
7
.7

–7
8
.2

)n
1
0
4

7
2
.1

(6
3
.4

–8
0
.9

)o
p

3
7

6
2
.2

(4
5
.8

–7
8
.6

)q
2
5

4
8
.0

(2
7
.0

–6
9
.1

)r
s

4
4
7

7
0
.5

(6
6
.2

–7
4
.7

)v

O
w

n
h

o
m

e
7
5
9

7
2
.7

(6
9
.6

–7
5
.9

)n
2
4
0

7
7
.1

(7
1
.7

–8
2
.4

)p
1
0
1

5
5
.4

(4
5
.6

–6
5
.3

)q
8
8

3
4
.1

(2
4
.0

–4
4
.2

)r
s

1
,1

8
8

6
9
.3

(6
6
.7

–7
1
.9

)v

Fa
m

il
y

h
o

m
e

9
2
3

6
4
.8

(6
1
.7

–6
7
.9

)n
8
7
5

6
8
.0

(6
4
.9

–7
1
.1

)o
3
6
3

5
5
.9

(5
0
.1

–6
1
.1

)q
2
0
3

3
4
.0

(2
7
.4

–4
0
.6

)r
s

2
,3

6
4

6
2
.0

(6
0
.0

–6
3
.9

)u
v

H
o

st
/f

o
st

e
r

h
o

m
e

1
4
9

7
1
.8

(6
4
.5

–7
9
.1

)n
1
3
8

6
4
.5

(5
6
.4

–7
2
.6

)o
p

1
0
4

5
2
.9

(4
3
.1

–6
2
.6

)q
4
2

3
3
.3

(1
8
.5

–4
8
.2

)r
s

4
3
3

6
1
.2

(5
6
.6

–6
5
.8

)u
v

N
ot

e.
N

C
I

5
N

at
io

n
al

C
o

re
In

d
ic

at
o

rs
.
P
ar

ti
ci

p
an

ts
w

h
o

se
le

v
el

o
f

in
te

ll
ec

tu
al

d
is

ab
il
it

y
w

as
u

n
k
n

o
w

n
o

r
m

is
si

n
g

(n
5

4
6
2
)
w

er
e

ex
cl

u
d

ed
.
R

es
id

en
ts

o
f

n
u

rs
in

g
fa

ci
li
ti

es
(n

5
4
2
),

‘‘
o

th
er

’’
(n

5
1
0
8
)

re
si

d
en

ce
ty

p
es

,
o

r
w

h
er

e
re

si
d

en
ce

ty
p

e
w

as
u

n
k
n

o
w

n
o

r
m

is
si

n
g

(n
5

7
9
)

w
er

e
ex

cl
u

d
ed

d
u

e
to

m
is

si
n

g
d

at
a,

sm
al

l
sa

m
p

le
si

ze
,

an
d

/o
r

u
n

k
n

o
w

n
re

si
d

en
ce

ty
p

e.
T

h
is

y
ie

ld
ed

a
fi

n
al

sa
m

p
le

o
f

8
,2

3
3

b
ec

au
se

a
sm

al
l
n

u
m

b
er

o
f

p
ar

ti
ci

p
an

ts
(n

5
1
3
)

w
er

e
ex

cl
u

d
ed

o
n

m
o

re
th

an
o

n
e

o
f

th
es

e
gr

o
u

n
d

s.
a

v
L

iv
in

g
ar

ra
n

ge
m

en
t

ty
p

e
co

m
p

ar
is

o
n

s
(w

it
h

in
co

lu
m

n
s)

:
M

ea
n

s
th

at
sh

ar
e

th
e

sa
m

e
lo

w
er

ca
se

su
p

er
sc

ri
p

t
le

tt
er

d
id

n
o

t
d

if
fe

r
si

gn
if

ic
an

tl
y
.

A

Q
L

ev
el

o
f

in
te

ll
ec

tu
al

d
is

ab
il
it

y
gr

o
u

p
co

m
p

ar
is

o
n

s
(w

it
h

in
ro

w
s)

:
M

ea
n

s
th

at
sh

ar
e

th
e

sa
m

e
u

p
p

er
ca

se
su

p
er

sc
ri

p
t

le
tt

er
d

id
n

o
t

d
if

fe
r

si
gn

if
ic

an
tl

y
.

T
h

es
e

co
m

p
ar

is
o

n
s

ar
e

o
n

ly
sh

o
w

n
fo

r
o

b
es

it
y

d
at

a
(u

p
p

er
h

al
f

o
f

ta
b

le
).

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 413

adults living in formal service settings (55.8%), but
the NHIS excluded most such settings. Even so,
Yamaki reported an overall prevalence of obesity
among adults with intellectual disability (34.6%)
that was very similar to our study (33.6%). The
different conclusion from Yamaki regarding the
higher prevalence of obesity among persons with
intellectual disability derived from a notably lower
estimated prevalence of obesity in the general
population (20.6%) obtained from the 1997–2000
NHIS compared with the 33.8% prevalence
estimated in the 2007–2008 NHANES (Flegal et
al., 2010). Indeed, an analysis of the NHANES
conducted at approximately the same time as the
Yamaki analysis (1999–2000) by Flegal et al. (2002)
reported prevalence of obesity in the general U.S.
population of 30.5% (9.9% higher than the NHIS
estimate). This variation draws attention to impor-
tant methodological differences.

There are important sampling differences
between our study and Yamaki’s (2005), whose
NHIS sample was based on a nationally represen-
tative sample of households that generally exclud-
ed service settings, from small group homes to
institutions. Yamaki’s sample, therefore, likely
included adults with milder levels of intellectual
disability (the NHIS does not include data on
level of intellectual disability) and fewer comorbid
physical, health, and mental health conditions.
Our sample, in contrast, consisted of users of
intellectual disability/developmental disability
services, more than half of whom were in formal
residential service settings. Specifically, in our
data, only the 28.2% of individuals living with
family members and 13.9% living in homes they
owned or rented (own home) would have been
systematically included in NHIS sample.

Another important variation in methodology is
that the NHIS was a self-report survey, whereas
NHANES conducted direct measurements of
height and weight. The differences between esti-
mates of obesity in the general population by the
NHIS and by the NHANES methodologies may
have derived in part from tendencies for individuals
to underreport their own weight (Elgar, Roberts,
Tudor-Smith, & Moore, 2005; Flegal et al., 2010).

There were several notable similarities be-
tween our findings and those of Yamaki (2005).
Both studies noted obesity in about one third of
their samples of persons with intellectual disabil-
ity. Both studies reported higher prevalence of
obesity among women with intellectual disability.
Yamaki reported no significant difference between

adults with and without intellectual disability in
the prevalence of overweight (25.0 # BMI , 30.0)
and we found no difference from the general U.S.
population in the prevalence of obesity.

Our conclusions are likewise both consistent
with and contrary to Melville et al.’s (2008) study of
obesity among adults with intellectual disability in
Scotland. Melville et al.’s sample, stratified by level of
intellectual disability (mild 5 44%, moderate 5 23%,
severe 5 17%, and profound 5 16%) was similar to
our NCI sample, as were the percentages of obesity
among Scottish youth and adults (16 years and older)
with intellectual disability (32.9% overall, 27.8% of
men, 39.3% of women) compared to the prevalence
estimates reported here (33.6%, 29.4%, and 38.9%,
respectively). However, relative to the U.S. general
population, there was notably lower prevalence of
obesity in the general population of Scottish men
(22.7%) and women (25.1%), so Melville et al.
concluded that there was a higher level of obesity
among persons with intellectual disability relative to
the general population in Scotland.

Gender
We found a consistently and significantly

higher level of obesity among women with
intellectual disability than for men with intellectual
disability. This was true within most racial groups,
within most levels of intellectual disability, and
among adults with cerebral palsy. Likewise, there
was a significantly higher prevalence of Grade 3
obesity among women with intellectual disability
compared with men with intellectual disability.

Melville et al. (2007, 2008) noted that in
Scotland there was a greater differential in obesity
rates between men and women with intellectual
disability than between men and women in the
general population. This held true for our data,
where there was a 9.5% difference in obesity
between men with intellectual disability (29.4%)
and women with intellectual disability (38.9%)
compared with Flegal et al.’s (2010) general U.S.
population data, which showed a 3.3% difference
between men (32.2%) and women (35.5%).
Similarly large gender disparities in obesity
prevalence among adults with intellectual disabil-
ity have been reported by other researchers in the
United States (Yamaki, 2005), the United King-
dom (Emerson, 2005; Melville et al., 2007, 2008;
Robertson et al., 2000), and Norway (Hove,
2004). The cause of this more marked gender dif-
ference in prevalence of obesity is unclear, but

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

414 E American Association on Intellectual and Developmental Disabilities

this consistently reported phenomenon deserves
attention.

Diagnosis
We found that adults with Down syndrome

had the highest prevalence of obesity and
individuals with cerebral palsy had the lowest.
This suggests that there are diagnosis-specific
issues that need to be considered when supporting
individuals with different diagnoses to achieve a
healthy weight. It also suggests that future
research on weight and BMI within people with
intellectual disability should control for diagnosis.

Level of Intellectual Disability
There were consistent differences by level of

intellectual disability in prevalence of obesity.
Individuals with mild (41.4%) or moderate
(38.2%) intellectual disability had the highest
prevalence, whereas obesity prevalence was signif-
icantly lower for individuals with severe (26.7%),
and profound intellectual disability (12.6%).
These findings are consistent with several other
studies (Emerson, 2005; Melville et al., 2008;
Robertson et al., 2000) that have reported that the
risk of overweight and obesity is lower as level of
intellectual disability becomes more severe. The
very large differences we observed by level of
intellectual disability show clearly why sampling
issues represent such a strong influence on
reported prevalence rates of obesity among adults
with intellectual disability.

What then are the likely causes of the
consistent finding that obesity is related to level
of intellectual disability? One factor is the much
more frequent placement of adults with severe and
profound intellectual disability in more highly
structured and staffed residence types, such as
institutions, where there is much greater staff
control of residents’ food intake. More individual-
ized, less regulated settings, such as living in one’s
own home are characterised by greater freedom of
choice for residents (Lakin et al., 2008). Likewise,
individuals with milder intellectual disability
exercise more everyday choice than their counter-
parts with more severe intellectual disability (Lakin
et al., 2008). Some authors have suggested that
greater choice may be associated with unhealthy
food choices and/or opting not to participate in
sufficient physical activity (Rimmer & Yamaki,
2006). Bhaumic et al. (2008) found that the ability
to feed oneself and to drink unaided were

independently associated with higher prevalence
of obesity. Lack of independence in self-care is
strongly associated with more severe intellectual
disability. Last, unsupervised access to community
settings (more typical for individuals with mild or
moderate intellectual disability) brings with it access
to fast food and other unhealthy food options. That
is, a combination of personal characteristics (eating
independently, choice-making skills) and environ-
mental factors (living arrangements, freedom of
choice, unsupervised community access) may
contribute to the higher observed incidence of
obesity among individuals with milder intellectual
disability.

Living Arrangements
Overall, our results confirmed that congregate,

regulated, continuously supervised settings such
as institutions having the lowest prevalence of
obesity. Such settings, often by explicit regulatory
requirement, use dietary planning and controlled
food intake as a formal element of the residential
program. By contrast, people living in their own
homes, usually with limited supervision and far
fewer regulations, experienced a notably higher
prevalence of obesity. Settings with intermediate
levels of regulation and/or supervision (group
home, host home, family home) were in between.

However, a substantial proportion of these
differences was attributable to level of intellectual
disability, because living arrangements differed
substantially in the level of intellectual disability
of their residents. For example, a much higher
proportion of people living in their own home
(63.9%) or agency apartments (62.9%) had mild
intellectual disability than was the case for
institutions (15.4%), group homes (33.5%), family
homes (39.0%), or host homes (33.6%).

In addition, the effect of residence type was
more pronounced for people with mild intellec-
tual disability. There were numerous significant
differences in prevalence of obesity among
residence types for participants with mild intel-
lectual disability but almost none for individuals
with severe and profound intellectual disability.
Perhaps individuals with mild or moderate
intellectual disability have the independence to
take advantage of the greater freedom offered by
living in settings such as one’s own home, whereas
those with more severe intellectual disability still
need significant support from others to access
food and drink. By contrast, institutional residents

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 415

all have highly regulated food intake and little or
no free access to food regardless of level of
intellectual disability.

Conclusions
The observation that adults with intellectual

disability have rates of obesity that are similar to
the general population does not reduce the serious
health implications of their being overweight. It
seems notable that the prevalence of obesity is
particularly high among persons with milder
intellectual disability and places of residence that
exert less control over diet and activities. In an era
of increasing choice and expanded residential
options, adults with intellectual disability face the
same challenges as the general population: how to
use choice wisely and with attention to longer term
(health) implications.

Even taking level of intellectual disability into
account, there remained significant differences in
prevalence of obesity among different living arrange-
ments, especially for those with mild and moderate
intellectual disability. In general, institutional residents
had the lowest prevalence of obesity and individuals
living in their own home had the highest. However,
we have repeatedly shown elsewhere that smaller, less
regulated settings, such as living in one’s own home,
are consistently associated with desirable outcomes in
areas such as well being (Stancliffe et al., 2009),
loneliness (Stancliffe et al., 2007), everyday choice and
support-related choice (Lakin et al., 2008), as well as
choice of living arrangements and living companions
(Stancliffe et al., 2010), whereas institutions are
associated with poorer outcomes (Lakin & Stancliffe,
2007). It is clear that a return to institutions or
institution-like controls as a ‘‘solution’’ to obesity is
out of the question, but supporting people with
intellectual disability (and the broader U.S. popula-
tion) to continue to live in their preferred settings
without becoming obese is an urgent health priority.

Caveats
Certain methodological differences limit the

validity of our comparisons between NCI data
and Flegal et al.’s (2010) NHANES data. First,
Flegal et al.’s sample was nationally representative,
whereas the NCI sample came from 20 states.
Second the NHANES sample was drawn from the
‘‘noninstitutionalized’’ population, whereas the
NCI sample was drawn from registries of intellec-
tual disability/developmental disability service
users, many of whom would be viewed as

institutionalized in the NHANES methodology.
Third, age was adjusted in Flegal et al.’s analyses,
whereas we made no age adjustments. Fourth, as is
unavoidable with representative samples of people
with intellectual disability, the NCI sample had a
preponderance of males (56.2%), whereas Flegal
et al.’s sample contained 49.5% males. Given the
observed gender differences in obesity prevalence,
it is clearly important to make within-gender
comparisons. Fifth, in Flegal et al.’s data, height
and weight were assessed directly, whereas we used
height and weight typically gathered through
record review or reported by proxy respondents.
Proxies, such as family members who do not have
access to height and weight records, may under-
estimate their family member’s weight.

Last, making large numbers of comparisons (54
comparisons in Table 2 alone) with a 95% confi-
dence interval increases the Type I error rate. We
adopted this approach to enable detailed compar-
isons with Flegal et al.’s (2010) data, because Flegal
et al. used this same analytic approach. Readers
should therefore exercise caution as to the true
statistical significance of individual comparisons.

Future Research
Several important variables related to BMI

were not examined in the present study, such as
caloric intake–nutrition and physical activity.
Differences in these factors may underpin ob-
served BMI differences by level of intellectual
disability, diagnosis, or living arrangements;
therefore, future obesity research should also
examine these variables. We plan to complete a
companion article looking at physical activity.
Given the well-established health risks of over-
weight and obesity, a fundamental priority for
future studies is finding effective methods to
enable adults with intellectual disability to achieve
and maintain a healthy weight.

References

Berrington de Gonzalez, A., Hartge, P., Cerhan,
J. R., Flint, A. J., Hannan, L., MacInnis, R. J.,
et al. (2010). Body-mass index and mortality
among 1.46 million White adults. New
England Journal of Medicine, 363, 2211–2219.

Bhaumik, S., Watson, J. M., Thorp, C. F., Tyrer, F.,
& McGrother, C. W. (2008). Body mass index
in adults with intellectual disability: Distribu-
tion, associations and service implications. A

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

416 E American Association on Intellectual and Developmental Disabilities

population-based prevalence study. Journal of
Intellectual Disability Research, 52, 287–298.

Elgar, F. J., Roberts, C., Tudor-Smith, C., &
Moore, L. (2005). Validity of self-reported
height and weight and predictors of bias in
adolescents. Journal of Adolescent Health, 37,
371–376.

Emerson, E. (2005). Underweight, obesity and
exercise among adults with intellectual dis-
abilities in supported accommodation in
Northern England. Journal of Intellectual Dis-
ability Research, 49, 134–143.

Expert Panel on the Identification, Evaluation,
and Treatment of Overweight in Adults.
(1998). Clinical guidelines on the identifica-
tion, evaluation, and treatment of overweight
and obesity in adults: executive summary.
American Journal of Clinical Nutrition, 68, 899–
917.

Flegal, K. M., Carroll, M. D., Ogden, C. L.,
& Curtin, L. R. (2010). Prevalence and trends
in obesity among US adults, 1999–2008.
JAMA, 303, 235–241.

Flegal, K. M., Carroll, M. D., Ogden, C. L.,
& Johnson, C. L. (2002). Prevalence and
trends in obesity among US adults 1999–
2000. JAMA, 288, 1723–1727.

Harris, N., Rosenberg, A., Jangda, S., & Gallagher,
M. L. (2003). Prevalence of obesity in Interna-
tional Special Olympic athletes as determined
by body mass index. Journal of the American
Dietetic Association, 103, 235–237.

Hendershot, G., Larson, S. A., Lakin, K. C.,
& Doljanac, R. (2005). Problems in defining
mental retardation. DD Data Brief, 7(1).
Minneapolis: University of Minnesota, Re-
search and Training Center on Community
Living.

Hove, O. (2004). Weight survey on adult persons
with mental retardation living in the communi-
ty. Research in Developmental Disabilities, 25, 9–17.

Lakin, K. C., Doljanac, R., Byun, S., Stancliffe,
R. J., Taub, S., & Chiri, G. (2008). Choice
making among Medicaid Home and Com-
munity-Based Services (HCBS) and ICF/MR
recipients in six states. American Journal on
Mental Retardation, 113, 325–342.

Lakin, K. C., & Stancliffe, R. J. (2007). Residential
supports for persons with intellectual and
developmental disabilities. Mental Retardation
and Developmental Disabilities Research Reviews,
13, 151–159.

Lewis, M. A., Lewis, C. E., Leake, B., King, B. H.,
& Lindemann, R. (2002). The quality of health
care for adults with developmental disabilities.
Public Health Reports, 117, 174–184.

Manson, J. E., & Bassuk, S. S. (2003). Obesity in
the United States: A fresh look at its high toll.
JAMA, 289, 229–230.

Melville, C. A., Cooper, S.-A., McGrother, C. W.,
Thorp, C. F., & Collacott, R. (2005). Obesity
in adults with Down syndrome: A case-control
study. Journal of Intellectual Disability Research,
49, 125–133.

Melville, C. A., Cooper, S.-A., Morrison, J., Allen, L.,
Smiley, E., & Williamson, A. (2008). The
prevalence and determinants of obesity in adults
with intellectual disabilities. Journal of Applied
Research in Intellectual Disabilities, 21, 425–437.

Melville, C. A., Hamilton, S., Hankey, C. R., Miller,
S., & Boyle, S. (2007). The prevalence and
determinants of obesity in adults with intellec-
tual disabilities. Obesity Reviews, 8, 223–230.

Rimmer, J. H., & Wang, E. (2005). Obesity
prevalence among a group of Chicago residents
with disabilities. Archives of Physical Medicine
and Rehabilitation, 86, 1461–1464.

Rimmer, J., & Yamaki, K., (2006). Obesity and intel-
lectual disability. Mental Retardation and Devel-
opmental Disabilities Research Reviews, 12, 70–82.

Rimmer, J. H., Yamaki, K., Lowry, B. M. D.,
Wang, E., & Vogel, L. C. (2010). Obesity and
obesity-related secondary conditions in ado-
lescents with intellectual/developmental dis-
abilities. Journal of Intellectual Disability Re-
search, 54, 787–794.

Robertson, J., Emerson, E., Gregory, N., Hatton,
C., Turner, S., Kessissoglou, S., et al. (2000).
Lifestyle related risk factors for poor health in
residential settings for people with intellectual
disabilities. Research in Developmental Disabil-
ities, 21, 469–486.

Rubin, S. S., Rimmer, J. H., Chicoine, B.,
Braddock, D., & McGuire, D. (1998). Over-
weight prevalence in persons with Down
syndrome. Mental Retardation, 36, 175–181.

Sassi, F., Cecchini, M., & Devant, M. (2010).
Obesity and the economics of prevention: Fit not
fat. Paris: Organization for Economic Health
and Development.

Soverini, V., Moscatiello, S., Villanova, N., Ragni, E.,
Domizio, S. D., Marchesini, G. (2010). Metabolic
syndrome and insulin resistance in subjects with
morbid obesity. Obesity Surgery, 20, 295–301.

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

E American Association on Intellectual and Developmental Disabilities 417

Stancliffe, R. J., Lakin, K. C., Larson, S. A.,
Engler, J., Taub, S., & Fortune, J. (2011).
Choice of living arrangements. Journal of
Intellectual Disability Research, 55, 746–762.
doi: 10.1111/j.1365-2788.2010.01336.x

Stancliffe, R. J., Lakin, K. C., Larson, S. A.,
Engler, J., Taub, S., Fortune, J., & Bershadsky,
J. (in press). Demographic characteristics,
health conditions and residential service use in
adults with Down syndrome in twenty-five US
states. Intellectual and Developmental Disabilities.

Stancliffe, R. J., Lakin, K. C., Taub, S., Chiri, G.,
& Byun, S. (2009). Satisfaction and sense of
well being among Medicaid ICF/MR and
HCBS recipients in six states. Intellectual and
Developmental Disabilities, 47, 63–83.

Stancliffe, R. J., Lakin, K. C., Taub, S., Doljanac,
R., Byun, S., & Chiri, G. (2007). Loneliness
and living arrangements. Intellectual and De-
velopmental Disabilities, 45, 380–390.

U.S. Department of Health and Human Services.
(2005). The 2005 Surgeon General’s call to action
to improve the health and wellness of persons with
disabilities. Washington, DC: Office of the
Surgeon General.

World Health Organization, Expert Committee
on Physical Status. (1995). Physical status: The
use and interpretation of anthropometry. Geneva,
Switzerland: Author.

Yamaki, K. (2005). Body weight status among
adults with intellectual disability in the
community. Mental Retardation, 43, 1–10.

Yang, Q., Rasmussen, S. A., & Friedman, J. M.
(2002) Mortality associated with Down’s
syndrome in the USA from 1983 to 1997: A
population-based study. Lancet, 359, 1019–

1025.

Received 3/20/2011, accepted 6/29/2011.
Editor-in-Charge: Leonard Abbeduto

Preparation of this article was supported by Grant
H133G080029 for the Multi-State Data Set
Project from the National Institute on Disability
and Rehabilitation Research, U.S. Department of
Education. Correspondence regarding this article
should be sent to Roger J. Stancliffe, Faculty of
Health Sciences, University of Sydney, P.O. Box
170, Lidcombe NSW 1825, Australia. E-mail:
[email protected]

VOLUME 116, NUMBER 6: 401–418 | NOVEMBER 2011 AJIDD

Obesity among adults R. J. Stancliffe et al.

418 E American Association on Intellectual and Developmental Disabilities

Résumés en Français
DOI: 10.1352/1944-7558-116.6.500

Le surplus de poids et l’obésité chez des adultes
présentant une déficience intellectuelle qui
utilisent des services en déficience intellectuelle
dans 20 états américains

Roger J. Stancliffe, K. Charlie Lakin, Sheryl
Larson, Joshua Engler, Julie Bershadsky, Sarah
Taub, Jon Fortune et Renata Ticha

Les auteurs ont comparé la prévalence de
l’obésité chez les participants du sondage sur les
indicateurs nationaux de base et chez la popula-
tion adulte générale américaine. En général, les
adultes présentant une déficience intellectuelle
ne différaient pas de la population adulte pour
ce qui est de la prévalence de l’obésité. Pour
l’obésité et le surplus de poids combinés, la
prévalence était plus basse chez les hommes
présentant une déficience intellectuelle que ceux
de la population générale, mais était semblable
chez les femmes. La prévalence de l’obésité était
plus élevée chez les femmes présentant une
déficience intellectuelle, les personnes avec un
syndrome de Down, et les personnes présentant
une déficience intellectuelle légère. La prévalence
de l’obésité différait selon le lieu de résidence, les
personnes habitant en institution ayant la pré-
valence la plus basse et celles habitant leur propre
maison présentant la plus haute. Lorsque le
niveau de déficience intellectuelle était pris en
compte, ces différences se trouvaient réduites,
certaines demeurant toutefois significatives, par-
ticulièrement pour les personnes ayant une
déficience intellectuelle légère.

Un modèle des influences contextuelles sur les
parents présentant une déficience intellectuelle
et leurs enfants

Catherine Wade, Gwynnyth Llewellyn et Jan
Matthews

Plusieurs parents présentant une déficience in-
tellectuelle vivent dans des conditions pouvant

être risquées pour les enfants et les parents. Cette
étude a utilisé un modèle d’équation structurelle
afin de tester un modèle théorique des relations
entre les parents, l’enfant, la famille et certaines
variables contextuelles dans 120 familles austra-
liennes à l’intérieure desquelles un parent présente
une déficience intellectuelle. Les résultats révèlent
que les pratiques parentales avaient un effet direct
sur le bien-être des enfants, que le soutien social
était associé avec le bien-être des enfants en
considérant les pratiques parentales comme vari-
able médiatrice et que l’accès au soutien social
avait une influence directe sur les pratiques
parentales. Les implications des résultats envers
la recherche, l’intervention et les politiques sont
explorées tout en ayant l’objectif de promouvoir
un bien-être optimal pour les enfants qui sont
élevés par des parents présentant une déficience
intellectuelle.

Relations entre le raisonnement moral,
l’empathie et les distorsions cognitives chez des
hommes présentant une déficience intellectuelle
et des antécédents criminels

Peter Langdon, Glynis Murphy, Isabel Clare,
Tom Steverson et Emma Palmer

Quatre-vingts hommes, répartis de manière égale
entre quatre groupes, ont été recrutés y compris
des hommes avec et sans déficience intellectuelle.
Les hommes étaient soit des criminels ou des non-
délinquants. Les participants ont complété des
mesures de raisonnement moral, d’empathie et de
distorsions cognitives. Les résultats indiquent que
les capacités de raisonnement moral des délin-
quants ayant une déficience intellectuelle accu-
saient un retard quant au développement, mais
étaient plus matures que celles des non-délinquants
présentant une déficience intellectuelle. Les délin-
quants sans déficience intellectuelle avaient des
capacités de raisonnement moral moins matures
que les non-délinquants sans déficience intellec-
tuelle. Les différences peuvent être partiellement

VOLUME 116, NUMBER 6: 500–501 | NOVEMBER 2011 AJIDD

500 E American Association on Intellectual and Developmental Disabilities

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.




Why Choose Us

  • 100% non-plagiarized Papers
  • 24/7 /365 Service Available
  • Affordable Prices
  • Any Paper, Urgency, and Subject
  • Will complete your papers in 6 hours
  • On-time Delivery
  • Money-back and Privacy guarantees
  • Unlimited Amendments upon request
  • Satisfaction guarantee

How it Works

  • Click on the “Place Order” tab at the top menu or “Order Now” icon at the bottom and a new page will appear with an order form to be filled.
  • Fill in your paper’s requirements in the "PAPER DETAILS" section.
  • Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
  • Click “CREATE ACCOUNT & SIGN IN” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
  • From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.