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ORIGINAL ARTICLE
Obesity in Young Children with Autism
Spectrum Disorders: Prevalence
and Associated Factors
Anna M. Egan, PhD,
1
Meredith L. Dreyer, PhD,
1,2
Cathleen C. Odar, MA,
2,3
Malia Beckwith, MD,
4
and Carol B. Garrison, MD
1
Abstract
Background: The purpose of this study was to identify rates of overweight and obesity in young children with autism spectrum
disorders (ASD) and factors related to overweight.
Methods: Retrospective chart reviews were conducted for 273 children with ASD [i.e., autistic disorder, Asperger’s disorder,
pervasive developmental disorder not otherwise specified (PDD-NOS)] after receiving outpatient services with a developmental
pediatrician or the developmental team at a children’s hospital. Information on child demographics, height and weight, medications
prescribed, and adaptive functioning was collected from charts.
Results: Rates of overweight and obesity in children with ASD were found to be above nationally representative prevalence
estimates for children. Among children with autistic disorder, 17.16% had a body mass index (BMI) percentile in the overweight
range and 21.89% had a BMI percentile in the obese range. For children with Asperger’s disorder/PDD-NOS, 12.50% were
considered overweight and 10.58% were considered obese. Neither psychotropic medications prescribed nor adaptive functioning
was found to be related to whether the child was overweight or obese.
Conclusions: Children with ASD are at risk for overweight and obesity, and children with autistic disorder are at greater risk for
weight problems than children with Asperger’s disorder/PDD-NOS. Further research is needed to identify factors related to over-
weight in children with ASD.
Introduction
Recent estimates suggest approximately 32% of United
States children and adolescents are overweight or
obese, as defined by a body mass index (BMI) over the
85
th
percentile.
1
Even for younger children specifically (e.g.,
between 2 and 5 years of age), approximately 21% of children
are considered either overweight or obese.
1
Overweight in
children has both short-term health consequences, such as
high cholesterol or blood pressure,
2
as well as long-term
health consequences. Childhood BMI has been associated
with both adult BMI and adult adiposity, and young children
with a BMI over the 95
th
percentile are four times more likely
to be overweight as adults than their normal weight peers.
3
Additionally, psychosocial difficulties, including low self-
esteem
4
and decreased quality of life,
4,5
often accompany
overweight and obesity. Total direct and indirect economic
costs of obesity have been reported to be nearly 10% of total
medical expenditures, and the estimated yearly cost rose to
$147 billion in 2008.
6
With rates of obesity increasing at
younger ages, the lifetimes costs are drastically increasing and
health complications are occurring at younger ages.
There have been few studies of obesity in children with an
autism spectrum disorder (ASD), despite the fact that the
Center for Disease Control and Prevention (CDC) estimates
this condition affects 1 in 88 children in the United States.
7
ASD, also known as the pervasive developmental disorders
(PDD) in the Diagnostic and Statistical Manual of Mental
Disorders,4
th
edition (DSM-IV), is a group of neurodeve-
lopmental disorders characterized by varying deficits in
communication, impairments in social interactions, or pat-
terns of repetitive or stereotypical behavior or interests.
These diagnoses include autistic disorder, Asperger’s dis-
order, and PDD not otherwise specified (PDD-NOS).
Previous research suggests children with ASD may be at
as great a risk or even greater risk for overweight and
1
Division of Developmental and Behavioral Sciences, Children’s Mercy Hospitals and Clinics, Kansas City, MO.
2
Center for Children’s Healthy Lifestyles & Nutrition, Kansas City, MO.
3
Clinical Child Psychology Program, University of Kansas, Lawrence, KS.
4
Children’s Specialized Hospital Mountainside, Mountainside, NJ.
CHILDHOOD OBESITY
April 2013 jVolume 9, Number 2
ªMary Ann Liebert, Inc.
DOI: 10.1089/chi.2012.0028
1
obesity in comparison to their typically developing peers.
For example, prevalence data from 1992 to 2003 that
were obtained through a chart review methodology indi-
cate children with ASD have prevalence rates of over-
weight and obesity slightly higher than the general
population, with approximately 36% of children having a
BMI over the 85
th
percentile and 19% of children having a
BMI over the 95
th
percentile.
8
Other research has dem-
onstrated rates of obesity in this population to be elevated
in comparison to typically developing children.
9
For ex-
ample, Curtin and colleagues reported the prevalence of
obesity in children with autism to be approximately 30%
in comparison to approximately 24% in children without
autism.
9
Obesity is also a common co-morbidity among
adults with ASD, with 42% having a BMI above the re-
commended range.
10
Unique barriers to healthy lifestyles and weight man-
agement for children with ASD may be responsible for
this high risk of overweight. For example, children with
ASD may display frequent food refusal,
11
problematic
eating behaviors,
12
motor impairments,
13
and cognitive
difficulties.
14
Additionally, numerous barriers to physical
activity in children with ASD have been noted.
15
For
example, intrapersonal factors, such as time spent playing
video games or computers or watching TV or listening to
music, and interpersonal factors, such as a lack of peer
exercise partners or parents not having enough time, are
barriers to children with ASD participating in after-school
physical activity.
15
Parents of children with ASD face a
multitude of barriers to getting their child to eat a healthy
diet and obtain the recommended amount of physical
activity, some of which are specific to children with
special needs conditions.
Despite an abundance of empirical research regarding
obesity trends in typically developing children, minimal
research has been dedicated to factors related to obesity in
children with autism. This research has produced incon-
sistent findings regarding which factors are related to
obesity in children with ASD and has suggested that the
factors related to obesity (e.g., diet or physical activity)
may not be the same as those associated with weight
problems in typically developing children. For example,
research has produced mixed results regarding the rela-
tionship between dietary intake (e.g., consumption of
certain food groups) and weight problems in children with
ASD.
16,17
Additionally, minimal research has focused on
the relationship between physical activity and overweight
specifically in children with ASD, although it has been
suggested that barriers to physical activity in this group
may be related to elevated risk for obesity.
18
Similarly,
research has not produced consistent findings on whether
autism severity is related to overweight. Ho and colleagues
found diagnosis severity to be positively associated with
obesity,
17
while Memari and colleagues found overall
symptom severity, as well as severity of symptoms in the
specific areas of sociability and health and physical be-
havior, was inversely related to BMI.
19
The relationship between psychotropic medications
used to treat symptoms associated with ASD and BMI is
also unclear. Children with ASD are treated with a variety
of psychotropic medications to address their emotional
and behavioral symptoms and can include stimulants,
serotonin-specific reuptake inhibitors (SSRIs), atypical
antipsychotics, and combinations of these medications.
Memari and colleagues found the number of psychotropic
medications to be inversely related to BMI among girls,
whereas a weak positive correlation was found between
medications and BMI among boys.
19
Additionally, ris-
peridone has been related to initial increases in BMI
among young children or children with lower baseline
BMI, but increases in BMI did not continue across time.
20
Overall previous research has failed to yield consistent
factors associated with weight status for children with
ASDs.
The present study aimed to assess the prevalence of
overweight and obesity among children diagnosed with
ASD, as well as to examine whether psychotropic medi-
cations prescribed and adaptive functioning are related to
weight. It should be noted that adaptive functioning was
examined as a proxy for autism severity because adaptive
functioning has been shown to be associated moderately to
strongly with autism severity in previous research.
21
Given
the inconsistencies in past research on whether these fac-
tors are related to overweight, a descriptive and explor-
atory approach was taken without a priori hypotheses.
The findings of this study have the potential to con-
tribute to an area of research where results have been in-
consistent and unclear. Discrepancies in previously
published results may be related to limitations in data
collection methods. For example, data on height and
weight were often collected from parent report rather than
being measured consistently in a medical clinic. Ad-
ditionally, at times, wide age ranges were examined and
discrepancies in findings may be due to different processes
occurring at developmental stages (e.g., hormone changes
impacting growth and weight gain in adolescence). To help
eliminate possible confounding factors, data in the current
study were collected from a narrow age range and infor-
mation was obtained from review of children’s medical
records, therefore allowing objective assessment of study
variables without the bias that can occur when parent-
report information is used.
Methods
Participants
A total of 273 participants [Mage =3.89, SD =0.91]
were identified through a retrospective chart review and
were approximately three-quarters male and predomi-
nantly Caucasian. Approximately two-thirds of partici-
pants were diagnosed with autistic disorder, and
approximately one-third of participants were diagnosed
with either PDD-NOS or Asperger’s disorder. The cate-
gories of PDD-NOS and Asperger’s disorder were
2 EGAN ET AL.
collapsed due to the nature of billing codes. Approximately
95% of children were taking no psychotropic medication to
treat symptoms related to their ASD. Detailed demo-
graphic and medical information is presented in Table 1.
Procedures
Children with ASD were identified through attendance
at a medical appointment with a developmental pediatri-
cian or the developmental team at a midwestern hospital.
Medical charts of children attending an appointment in the
clinic between November 1, 2005, and May 1, 2009, were
reviewed. Inclusion criteria included being between the
ages of 2.5 and 5 years, being diagnosed with ASD, and
recent height and weight readings. Participants were ex-
cluded if they had a diagnosis or impairment that is known
to affect weight (e.g., Prader–Willi, Down syndrome, be-
ing wheelchair bound; n=2), if the patient did not receive
oral feedings (n=0), or if incomplete medical chart in-
formation was available (n=10). Due to the retrospective
nature of medical chart review, parental consent was not
required in accordance with the Institutional Review Board
policies of the hospital at which data collection took place.
This research was approved by the Institutional Review
Board at Children’s Mercy Hospitals and Clinics.
All information collected from medical records was
originally obtained as part of the child’s standard medical
care appointment or developmental assessment. Specific
information gathered included child demographics (e.g.,
gender, ethnicity/race), height and weight (to calculate
BMI percentile and BMI z-score), diagnosis (i.e., autistic
disorder or Asperger’s disorder/PDD-NOS), and current
medications prescribed. Diagnostic information was ob-
tained by recording the child’s billable diagnosis according
to the International Classification of Diseases, 9th Revision
(ICD-9). The ICD-9 collapses both Asperger’s disorder
and PDD-NOS into one billable diagnosis and, therefore, a
child’s diagnosis was coded as either autistic disorder or
Asperger’s disorder/PDD-NOS. Height and weight were
converted to BMI z-scores and percentiles while taking into
account the child’s age and gender. This was accomplished
by using the Baylor College of Medicine Children’s BMI-
percentile-for-age Calculator (www.bcm.edu/cnrc/body-
comp/bmiz2.html/) which is based on the 2000 CDC BMI-
for-Age Growth Charts for girls and boys ages 2–20.
22
These measures were used because they are more com-
parable across child age and gender.
For the children receiving an assessment from the de-
velopmental team (n=264), information on adaptive level,
as measured by the Vineland Adaptive Behavior Scales,
Second Edition (VABS),
23
was also collected. The VABS is
a normed survey interview administered as a semi-
structured interview to parents to assess the frequency at
which the child performs various adaptive behaviors
through open-ended questions. The VABS provides scores
for overall adaptive functioning, as well as adaptive
functioning in the specific domains of communication,
daily living skills, socialization, and motor skills. Medi-
cation status was collected from the medical record and
reviewed. The psychotropic medication used by youth in
this study included the following known pharmacologic
classes—stimulants, atypical antipsychotics, anticonvul-
sants, alpha-2 adrenergic agonists, or some combination of
these medications, referred to as ‘‘multiple medications’’
(see Table 1).
Statistical Plan/Preliminary Analyses
To examine for differences in weight categories, fre-
quency counts and percentages were calculated to assess
the number of children with ASD with a BMI over the 85
th
or 95
th
percentile and therefore met suggested cutoff scores
for overweight or obesity, respectively.
24
A2·3 Pearson
chi-squared test was used to determine whether the number
of children with ASD categorized as under/normal weight,
overweight, or obese in our current sample differed from
the number of children within these categories in a sample
of children and adolescents representative of the overall
population. The comparison sample was the subset of
children 2–5 years old in the nationwide prevalence study
by Ogden and colleagues
1
(Fig. 1). This age range is
Table 1. Demographic and Medical
Information for Total Sample
Number (Percentage)
Gender
Male 222 (81)
Female 51 (19)
Diagnosis
Autistic disorder 169 (62)
Asperger’s disorder/PDD-NOS 104 (38)
Race/ethnicity
Caucasian 198 (72)
African American 49 (18)
Hispanic 16 (6)
Other race 10 (4)
Psychotropic medications prescribed
a
No psychotropic medication 260 (95)
Stimulant only 3 (1)
Atypical antipsychotic only 2 (1)
Anticonvulsant only 4 (2)
Alpha-2 adrenergic agonist only 2 (1)
Multiple medications 2 (1)
a
Due to rounding, the percentages total 101% for the Psychotropic
medication prescribed category.
PDD/NOS, pervasive developmental disorder/not
otherwise specified.
CHILDHOOD OBESITY April 2013 3
comparable to the 2.5–5 years age range of children in our
ASD sample.
When chi-squared statistics are significant, individual
terms or cells can be examined to identify which ones
contribute the most to the significant chi-squared statis-
tic.
25
This is done by computing the difference between the
observed and expected value for each term and standard-
izing this difference by dividing it by the square root of
the expected value to create standardized residuals.
25,26
Therefore, post hoc comparisons of adjusted standardized
residuals to the critical Z-value of 1.96 for each cell were
used to determine which values were responsible for the
significant chi-squared statistic. Pearson chi-squared tests
were also used to examine whether child BMI z-scores
categories varied by diagnostic category (i.e., autistic
disorder or Asperger’s disorder/PDD-NOS) or by level of
adaptive functioning. For the analyses assessing the rela-
tionship between medications prescribed and weight sta-
tus, multiple cells had expected values below 5, and
therefore, the Fisher exact test was used instead because of
its utility with small sample sizes.
Results
Weight Categories
BMI percentiles and z-scores were calculated for age
and gender and examined. Ten children (3.66%) were
underweight with a BMI below the 5
th
percentile, and 173
children (63.37%) were in the normal weight range (BMI
in the 5
th
to 85
th
percentile). Forty-two (15.38%) children
were overweight with a BMI between the 85
th
and 95
th
percentile, and 48 (17.58%) children were obese with a
BMI over the 95
th
percentile. Overall, 32.96% of our
sample was either overweight or obese. These rates of
overweight/obesity were found to be significantly different
than the rates reported by Ogden and colleagues
1
as
estimates for the population of children ages 2–5
[w
2
(2) =16.29, p<0.001]. Post hoc comparisons identified
Figure 1. Percentage of children in each sample with BMI between 85
th
and 95
th
percentile or over 95
th
percentile. (White bars) ASD
sample (ages 2–5.
a
15.4% of study participants had a BMI between the 85
th
and 95
th
percentile (95% CI 11–19.5%).
c
17.6% of study
participants had a BMI >95
th
percentile (95% CI 13.0–21.9%). (Grey bars) Ogden et al. (2010) national sample
1
(ages 2–5).
b
10.8% of
Ogden et al. national sample had a BMI between the 85
th
–95
th
percentile (95% CI 6.9–14.7%).
d
10.4% of Ogden et al. national sample had a
BMI >95
th
percentile (95% CI 7.6–13.1%). ASD, autism spectrum disorders; CI, confidence interval.
4 EGAN ET AL.
that our ASD sample had a higher rate of children with a
BMI over the 95
th
percentile and with a BMI between 85
th
and 95
th
percentile in comparison to the normative sample
as represented by an adjusted standardized residual greater
than 1.96 and corresponding to an alpha of less than 0.05.
Differences in BMI z-Scores by Diagnosis,
Medication Status, or Adaptive Functioning
Child BMI category was found to vary significantly by
diagnostic group [w
2
(2) =8.05, p=0.02], with children with
autistic disorder having higher rates of overweight and obesity
than children with Asperger’s disorder/PDD-NOS, as evi-
denced by adjusted standardized residuals greater than 1.96.
For children with Asperger’s disorder/PDD-NOS, 12.50%
(n=13) had a BMI between the 85
th
and 95
th
percentile,
whereas 10.58% (n=11) had a BMI over the 95
th
percentile.
For children diagnosed with autistic disorder, 17.16% (n=29)
had a BMI between the 85
th
and 95
th
percentile, whereas
21.89% (n=37) had a BMI over the 95
th
percentile.
Regarding medication, 260 (95%) children were not
prescribed a psychotropic medication. Given the low fre-
quency of specific psychotropic medications prescribed,
medication status was collapsed into a categorical variable
of ‘‘prescribed psychotropic medication’’ (n=13) or ‘‘not
prescribed psychotropic medication’’ (n=260). All youth
who were prescribed a psychotropic medication were
combined into the medication group (n=13). Medication
status was found not to be related to child BMI z-score
(p=0.57). Given that stimulant medications may have a
different impact on appetite- or weight-related variables
than other psychotropic medications, further analyses were
conducted by excluding the children who were prescribed
stimulants (n=3). Medication status without stimulants
was also found not to be related to child BMI z-score
(p=0.86).
Eighty-nine (33.71%) children had no or only mild im-
pairment in adaptive functioning, whereas 112 (42.42%)
children had moderate impairment, and 63 (23.86%) had
severe impairment. Weight status was not related to overall
adaptive functioning [w
2
(4) =1.50, p=0.83], or function-
ing in the specific domains of motor skills [w
2
(4) =5.17,
p=0.27], socialization [w
2
(4) =7.06, p=0.13], daily living
skills [w
2
(4) =3.89, p=0.42], and communication [w
2
(4) =
1.39, p=0.85].
Discussion
The current study supports previous findings that chil-
dren with ASD are at greater risk for overweight and
obesity, as approximately 15% were considered over-
weight and approximately 18% were obese. Overall, ap-
proximately 33% of children with ASD were either
overweight or obese with a BMI over the 85
th
percentile.
Furthermore, our results demonstrated that the percentage
of children with ASD who had a BMI in the overweight/
obese range was significantly greater than in the normative
sample.
1
Importantly, the racial/ethnic background (i.e.,
Caucasian, African American, Latino) of youth in this
sample is similar to the racial/ethnic distribution found in
the United States population. This suggests that some other
demographic characteristics known to be associated with
overweight (e.g., ethnicity) were not responsible for the
difference of overweight rates in the current sample in
comparison to the national normative data. Higher rates of
overweight among children with ASD demonstrate the
importance of supporting healthy lifestyles in these chil-
dren and investigating barriers to healthy living. Children
with ASD experience unique barriers to healthy lifestyles,
such as frequent use of food as rewards in behavior mod-
ification programs due to the ineffectiveness of social re-
inforcements or selectivity in diets and high rates of food
refusal. In our study, children with autistic disorder were
found to be at greater risk for overweight/obesity than
children meeting criteria for Asperger’s disorder/PDD-
NOS. Children with autism may be likely to have greater
impairment or disability, which is a more significant bar-
rier to a healthy lifestyle. Interestingly, adaptive func-
tioning in the domains of communication, daily living
skills, socialization, and motor skills was not found to be
related to overweight. This suggests that barriers to healthy
living that result from the impairments associated with
autism and increased risk for overweight are not present in
these domains.
The lack of significant findings may mean that in our
sample of young children impairments related to ASD
symptomatology, such as motor impairments or fewer
opportunities for physical activities with peers, have not
had the cumulative impact on obesity status that they might
in older children. The rates of overweight and obesity
found in the current study are lower than those identified in
some prior research, which demonstrated as many as 30%
of children with ASD have a BMI score over the 95
th
percentile.
9
However, the present study focuses specifi-
cally on young children, which is in contrast to prior re-
search including older children. Younger children have
been demonstrated to have lower rates of overweight and
obesity in typically developing samples,
1
and our findings
may represent a similar trend in children with ASD. Ad-
ditionally, the present study used a health care–seeking
sample and obtained height and weight information from
medical chart reviews, which may have contributed to
these lower rates. For example, Curtin and colleagues
identified a much higher prevalence of obesity in this
population when using a community sample and obtaining
height and weight information from parent report.
9
It may
be the case that children actively receiving medical care
treatment show lower rates of obesity in comparison to
community samples. Additionally, parent report of height
and weight has been demonstrated to be inaccurate, which
may mean study methodology can impact rates identified.
When using a retrospective chart review procedure for
obtaining height and weight information for children with
ASD attending a tertiary clinic, Curtin and colleagues
CHILDHOOD OBESITY April 2013 5
found 19% of the sample to be above the 95% percentile,
which is more consistent with the 21% prevalence found in
the Autistic disorder group in the current study.
8
Current study findings contribute to a larger body of
research examining factors related to overweight in chil-
dren with ASD. Psychotropic medication status at this
young age was found not to be related to child BMI z-
score. The fact that rates of overweight were still high,
even in the absence of psychotropic medication, is sig-
nificant, because this indicates that other factors beyond
medication are responsible for the increased risk of this
population. Furthermore, avoiding use of psychotropic
medication does not serve as a protective factor against
overweight, and families of children with ASD are in need
of prevention programs for overweight even if medicines
are not prescribed. However, there is the possibility that no
relationship was found due to the small percentage (only
5%) of children in our sample who were on a psychotropic
medication. The children in the sample were young, and
therefore more recently diagnosed with ASD; older chil-
dren with ASD may be more likely to have been prescribed
medication due to failed behavior treatment attempts or
growing behavioral concerns. Prior research has found
varying effects of medication on weight in children with
autism with factors such as duration of medication and
gender impacting this effect.
19,20
Therefore, additional
research examining the impact of medication on weight in
older children is needed.
Through use of retrospective medical chart reviews, the
current study was able to contribute information regarding
diagnosis, level of adaptive functioning, and medication
use as they are related to overweight in young children with
ASD. Young children with ASD were found to be at sig-
nificantly greater risk for overweight than a normative
sample, and children with autistic disorder were at even
greater risk than children diagnosed with Asperger’s dis-
order/PDD-NOS. This highlights the importance of pro-
viding weight management programs specifically for
children with ASD. We also identified that medication
status and adaptive functioning were not related to BMI
status in a retrospective study. Given the high risk of
overweight in children with ASD, further research is nec-
essary to identify important factors that should be ad-
dressed in weight management programs for these children
and their families. Future research should examine pre-
dictors that may be related to overweight in this population,
such as diet and physical activity, and longitudinally
evaluate the factors that were examined in this study.
While the use of retrospective medical chart reviews in
the current study allowed for objective measurement of
BMI, this methodology only captures functioning and
weight at one period of time and does not allow for a lon-
gitudinal examination of the relationship between study
variables and BMI z-score. Future research should monitor
the growth trajectories for youth with ASD to assess factors
related to weight over time. Another limitation of collecting
information from a clinical setting is that a strict research-
level protocol for assessment and diagnosis was not used.
Furthermore, diagnostic information was obtained through
recording of child billable diagnosis, which collapses across
Asperger’s disorder and PDD-NOS. Therefore, differences
in prevalence rates of overweight between these two groups
could not be assessed. Last, the sample of children in the
current study was young, and therefore our findings may not
be generalizable to children of other ages.
Conclusion
The current study identified that young children with
ASD are at greater risk for overweight than normative
peers, and that children diagnosed with autistic disorder are
at greatest risk. Medications prescribed and level of
adaptive functioning were found not to be related to weight
in children with ASD. This knowledge contributes to the
body of literature examining factors related to overweight
in this population and establishes a research base for future
research and development of appropriate interventions for
meeting the needs of these families.
Acknowledgments
A subset of study findings was presented previously as
poster presentations at the 2008 Obesity Society Meeting,
the 2009 Midwest Conference on Pediatric Psychology,
and the 2010 Pediatric Academic Societies Meeting.
Funding source: None
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Anna M. Egan, PhD
Assistant Professor, Department of Pediatrics
University of Missouri—Kansas City School of Medicine
Children’s Mercy Hospitals and Clinics
Division of Developmental and Behavioral Sciences
2401 Gillham Road
Kansas City, MO 64108
E-mail: aegan@cmh.edu
CHILDHOOD OBESITY April 2013 7
