Obesity, physical activity, and sedentary behaviors in adolescents with autism spectrum disorder compared with typically developing peers

Abstract

Decreased engagement in beneficial physical activity and increased levels of sedentary behavior and unhealthy weight are a continued public health concern in adolescents. Adolescents with autism spectrum disorder may be at an increased risk compared with their typically developing peers. Weekly physical activity, sedentary behavior, and body mass index classification were compared among adolescents with and without autism spectrum disorder. Analyses included 33,865 adolescents (autism spectrum disorder, n = 1036) from the 2016–2017 National Survey of Children’s Health (United States). After adjustment for covariates, adolescents with autism spectrum disorder were found to engage in less physical activity and were more likely to be overweight and obese compared with their typically developing peers ( p’s < 0.05). As parent-reported autism spectrum disorder severity increased, the adjusted odds of being overweight and obese significantly increased and physical activity participation decreased ( p-for-trends < 0.001). The findings suggest there is a need for targeted programs to decrease unhealthy weight status and support physical activity opportunities for adolescents with autism spectrum disorder across the severity spectrum.

Full text

https://doi.org/10.1177/1362361319861579
Autism
2020, Vol. 24(2) 387 –399
© The Author(s) 2019
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DOI: 10.1177/1362361319861579
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Individuals with autism spectrum disorder (ASD) have
been shown to have delays in motor development as well
as deficits in motor skills, lack of engagement in daily
activities, and decreased motivation to engage in benefi-
cial physical activity (Pan, 2008, 2009; Pan, Tsai, & Hsieh,
2011; Stanish et al., 2015). Recent research has shown that
physical activity can be beneficial to deficits present in
those with ASD and improve negative behaviors such as
aggression and stereotypical behaviors (Celiberti, Bobo,
Kelly, Harris, & Handleman, 1997; Elliott, Dobbin, Rose,
& Soper, 1994; Lang et al., 2010; Rosenthal-Malek &
Mitchell, 1997; Sowa & Meulenbroek, 2012).
It is recommended that children and adolescents
(defined as individuals aged 6–17 years), both in the
United States (US) and globally, participate in 60 min or
more of moderate-to-vigorous physical activity (MVPA)
each day and to include vigorous intensity physical activ-
ity, as well as muscle and bone-strengthening activities on
at least 3 days per week (U.S. Department of Health and
Human Services, 2008). The most recent objective accel-
erometry data from the US National Health and Nutrition
Examination Survey presented in the 2016 Report Card on
Physical Activity for Children and Youth demonstrates
that US children and adolescents received a “D” in physi-
cal activity participation. Overall, only 21.6% of 6- to
19-year-old US children and adolescents met the federal
recommendation on at least 5 of 7 days (Katzmarzyk et al.,
2016). Specifically, for those with ASD, several studies
have sought to examine physical activity behaviors using
both subjective means and objective measurement.
Subjective measurement of physical activity behaviors
(parent-report) have shown that children and adolescents
with ASD are less likely to participate in physical activity
behaviors compared with their typically developing peers.
Using the 2011–2012 National Survey of Children’s
Health (NSCH) from the US, which used an analysis simi-
lar to this study, McCoy, Jakicic, and Gibbs (2016) found
Obesity, physical activity, and sedentary
behaviors in adolescents with autism
spectrum disorder compared with
typically developing peers
Stephanie M McCoy and Kristen Morgan
Abstract
Decreased engagement in beneficial physical activity and increased levels of sedentary behavior and unhealthy weight are
a continued public health concern in adolescents. Adolescents with autism spectrum disorder may be at an increased
risk compared with their typically developing peers. Weekly physical activity, sedentary behavior, and body mass index
classification were compared among adolescents with and without autism spectrum disorder. Analyses included 33,865
adolescents (autism spectrum disorder, n = 1036) from the 2016–2017 National Survey of Children’s Health (United
States). After adjustment for covariates, adolescents with autism spectrum disorder were found to engage in less physical
activity and were more likely to be overweight and obese compared with their typically developing peers (p’s < 0.05).
As parent-reported autism spectrum disorder severity increased, the adjusted odds of being overweight and obese
significantly increased and physical activity participation decreased (p-for-trends < 0.001). The findings suggest there
is a need for targeted programs to decrease unhealthy weight status and support physical activity opportunities for
adolescents with autism spectrum disorder across the severity spectrum.
Keywords
adolescents, autism, obesity, physical activity, sedentary behavior
University of Southern Mississippi, USA
Corresponding author:
Stephanie M McCoy, School of Kinesiology & Nutrition, University of
Southern Mississippi, 118 College Drive, Hattiesburg, MS 39406, USA.
Email: stephanie.mccoy@usm.edu
861579AUT0010.1177/1362361319861579AutismMcCoy and Morgan
research-article2019
Original Article

388 Autism 24(2)
that adolescents (aged 10–17 years) with ASD were 60%
less likely to engage in regular physical activity compared
with their peers of typical development (McCoy et al.,
2016). Using the same survey, Dreyer Gillette et al. (2015)
found that adolescents (aged 10–17 years) with ASD were
statistically more likely than their typically developing
peers to have 0 days a week in which they engaged in at
least 20 min of physical activity that made them sweat or
breathe hard (Dreyer Gillette et al., 2015). Using objective
measurement of physical activity, Bandini et al. (2013)
found that typically developing children (aged 3–11 years)
accumulated more time spent in MVPA on weekdays com-
pared with children with ASD, with only 23% of those
with ASD engaging in the federal recommendation com-
pared with 43% of those with typical development (Bandini
et al., 2013). Among adolescents, Stanish et al. (2017)
found adolescents with ASD spent less time in MVPA
compared with typically developing adolescents (Stanish
et al., 2017). Among adolescent boys alone, Pan et al.
(2016) found that those with ASD were less physically
active and engaged in MVPA for a lower percentage of
time compared with peers of typical development (Pan
et al., 2016).
In the US, more boys (26%) than girls (16.9%) are con-
sidered physically active. Furthermore, physical activity
levels are higher in younger children compared with older
adolescents, with 42.5% of 6- to 11-year-olds meeting the
recommendation, but only 7.5% and 5.1% of 12- to
15-year-olds and 16- to 19-year-olds, respectively, meet-
ing the recommendation (Katzmarzyk et al., 2016).
Children and adolescents specifically with ASD follow
similar physical activity patterns in which boys are more
physically active than girls, and children are more physi-
cally active than adolescents (Jones et al., 2017; Scharoun,
Wright, Robertson-Wilson, Fletcher, & Bryden, 2017).
There is a positive association between physical activity
and health throughout the lifespan (Blair et al., 1989). In
adults, regular physical activity participation has been
shown to decrease the risk of developing cardiovascular
disease, obesity, type II diabetes, certain types of cancer,
and depression (American College of Sports Medicine,
2013; Warburton, Nicol, & Bredin, 2006). In children and
adolescents, the benefits of physical activity include
improvements in cardiovascular health, improved fitness,
improved metabolic health, and decreased obesity (Daniels,
Benuck, & Christakis, 2011; Strong et al., 2005). In addi-
tion to the physical benefits of physical activity, there are
many mental and social benefits of physical activity, includ-
ing decreased levels of anxiety and depression, as well as
self-concept (Strong et al., 2005). Furthermore, participa-
tion in sport may be associated with improved psychosocial
health above and beyond those associated with leisure-time
physical activity due to the social nature of sport participa-
tion (Eime, Young, Harvey, Charity, & Payne, 2013). These
social benefits include improved emotional control,
confidence, making new friends, improved relationships
and social skills, as well as greater social competence (Holt,
Kingsley, Tink, Scherer, & exercise, 2011; Snyder et al.,
2010). The social benefits associated with physical activity
and sport may be of particular importance to those with
ASD as they display deficits in social interaction (American
Psychiatric Association, 2013). Furthermore, the relation-
ship between physical activity and health outcomes is typi-
cally dose-repose such that greater physical activity
participation leads to greater improvements in risk for all-
cause mortality, cardiorespiratory health, metabolic health,
weight loss, musculoskeletal health, colon and breast can-
cer, and mental health (American College of Sports
Medicine, 2013). Given this information, it is important to
understand if children and adolescents are meeting the min-
imal recommended levels of beneficial physical activity,
which can inform the need for further research and pro-
grams targeting this population.
Physical inactivity is a continued global health issue.
Increased physical inactivity and sedentary behaviors such
as TV viewing time, has been associated with increased
weight gain in children and adolescents (Sisson, Broyles,
Baker, & Katzmarzyk, 2010). However, there are currently
no quantitative guidelines for sedentary behavior for chil-
dren and adolescents. The US National Heart, Lung, and
Blood Institute and the American Academy of Pediatric
recommend that children and adolescents should limit
their total entertainment screen time to less than 2 h/day
(American Academy of Pediatrics, 2001). In the US, only
37.2% of US children and adolescents 2- to 19-year-olds
are currently meeting this recommendation.
Given the social impairments as well as deficits in
motor development and motor skills, these barriers may
limit the opportunities for children and adolescents with
ASD to participate in physical activity and promote
unhealthy increases in sedentary behaviors. Many physical
activity behaviors, especially sport, require social interac-
tion, making friends, and turn-taking, which may prove
difficult for those with ASD (Pan & Frey, 2006). In return,
the preferred hobbies and activities of children and adoles-
cents with ASD are generally those that are solitary, require
less physicality, and involve screen time (Memari et al.,
2015; Russell, 2018; Stiller & Mößle, 2018).
In the 2011–2012 NSCH iteration, McCoy et al. (2016)
found adolescents aged 10–17 years with ASD were sig-
nificantly more likely to be overweight (27%) and obese
(72%) in comparison with their typically developing peers
(McCoy et al., 2016). More recently, Healy, Aigner, and
Haegele (2019) examined overweight and obesity in the
2016 round of NSCH data collection and found after con-
trolling for age, race/ethnicity, income, and sex, adoles-
cents aged 10–17 years with ASD had significantly higher
odds of overweight and obesity compared with their typi-
cally developing peers, though they did not examine phys-
ical activity behaviors (Healy et al., 2019).

McCoy and Morgan 389
Since the release of the 2011–2012 NSCH data, the sur-
vey has gone through a complete overhaul in the 2016 ver-
sion, particularly the questions regarding physical activity
participation. Previous iterations of the survey contained a
question for only 20 min or more per day of MVPA
(2011/12 National Survey of Children’s Health, 2012), and
previous papers published examining physical activity in
ASD using NSCH used 20 min on 3 days or more per week
as an indication of “regular physical activity” (Dreyer
Gillette et al., 2015; McCoy et al., 2016), which is equiva-
lent to only 1 day of the current recommendation for chil-
dren and adolescents. Additionally, in the 2016 survey,
ASD medication is included as its own question, whereas
previous versions included just a general medication ques-
tion. Given the update to the physical activity and ASD
questions in the 2016 version of the NSCH, this study
uniquely adds to the literature on ASD in that it uses the
most updated nationally representative data from the US,
includes the current recommendation of physical activity
in children (60 min or more per day) as a question within
the survey, and includes ASD medication specifically as
well as ASD severity. Additionally, this study adds to the
literature by determining if meeting the current physical
activity guidelines of 60 min or more daily mediates the
relationship between ASD and BMI classification.
The purpose of this secondary analysis was to deter-
mine, within adolescents with ASD compared with their
typically developing peers, the relationship between seden-
tary behaviors, weekly physical activity, and body mass
index (BMI). A secondary objective for this study included
looking at potential mediation between physical activity
and BMI in adolescents with ASD as well as determining
the odds of being overweight and obese, engaging in regu-
lar physical activity, and sedentary behaviors in association
with autism severity. Finally, we sought to determine if the
adjusted odds of physical activity participation were differ-
ent between adolescents with ASD of different age groups
(10–12 and 13–17 years), and sex. We hypothesized that
adolescents with ASD would have higher levels of over-
weight and obesity defined by BMI classification, higher
levels of sedentary behavior, and lower levels of weekly
physical activity compared with their typically developing
peers. We also hypothesized that as autism severity
increased, overweight and obese levels would increase,
levels of sedentary behavior would increase, and physical
activity levels would decrease. Furthermore, we hypothe-
sized that younger adolescents aged 10–12 years would be
more likely to engage in regular physical activity compared
with 13–17-year-olds, and males would be more likely to
engage in regular physical activity compared with females.
Method
Survey design and participants
This secondary data analysis used de-identified data from
the combined 2016–2017 NSCH from the US. The NSCH
recruited a nationally representative from non-institution-
alized youth aged 0–17 years in the US. The NSCH is
jointly sponsored by the National Center for Health
Statistics at the Centers for Disease Control and Prevention
and the Maternal and Child Health Bureau (both US). In
2016, the survey was updated and conducted either online
or by mail. Further study details have been published else-
where (Ghandour et al., 2018). For the purposes of this
study, the sample was limited to adolescents between the
ages of 10 and 17 years (n = 37,409) as BMI classification
was only assessed in this age group, and to be consistent
with the World Health Organization definition of adoles-
cence, 10–19 years (World Health Organization, 2019). In
addition, adolescents were also excluded if they had miss-
ing data on outcome variables including autism classifica-
tion (n = 205), BMI classification (n = 2165), weekly
physical activity (n = 589), TV viewing time (n = 180),
computer usage (n = 67), sport participation (n = 250), or
if parents classified their adolescents as not currently hav-
ing ASD (n = 88), yielding a final sample size of n =
33,865. The National Center for Health Statistics Research
Ethics Review Board and the National Opinion Research
Center Institutional Review Board (both US) approved all
the study procedures. Informed consent was collected
from all parents or guardians.
Variables
Autism classification. Autism classification was determined
by parent response to the questionnaire item “has a doctor
or other healthcare provider EVER told you that this child
has Autism or Autism Spectrum Disorder (ASD)? Include
diagnoses of Asperger’s Disorder or Pervasive Develop-
mental Disorder (PDD).” If parents responded “yes” they
were asked if the child currently had the condition. ASD
was defined as a “yes and current” response and typically
developing was defined as “no.” Adolescents placed in the
category “has been told by a doctor, but currently does not
have condition” were excluded from the sample to prevent
misclassification.
Autism severity. Autism severity was determined by parent
response to the questionnaire items “has a doctor or other
healthcare provider EVER told you that this child has
Autism or Autism Spectrum Disorder (ASD)? Include
diagnoses of Asperger’s Disorder or Pervasive Develop-
mental Disorder (PDD).” Parents were then asked, “If yes,
does this child currently have the condition.” If parents
responded “yes” they were asked the follow-up question “If
yes,” is it: “mild,” “moderate,” or “severe.”Autism severity
was then defined as “mild,” “moderate,” or “severe.”
BMI classification. BMI classification was calculated using
parent-reported child height and weight, and then classi-
fied using the Expert Committee Recommendations (US):
underweight (BMI < 5th percentile), normal weight (BMI

390 Autism 24(2)
> 5th percentile and <85th percentile), overweight (BMI
⩾ 85th percentile and <95th percentile), and obese (BMI
⩾ 95th percentile) (Barlow & Expert Committee, 2007).
Physical activity. Regular physical activity was determined
based on parent-response to the question “During the past
week, on how many days did this child exercise, play a
sport, or participate in physical activity for at least 60 min-
utes.” Responses ranged on a 4-point scale (“none,” “1–3
days,” “4–6 days,” and “every day”). A dichotomous clas-
sification of “regular physical activity” was defined as
“everyday,” congruent with the physical activity recom-
mendations for adolescents (U.S. Department of Health
and Human Services, 2008).
TV viewing time. Parents were asked “on an average week-
day, about how much time does this child usually spend in
front of a TV watching TV programs, videos, or playing
video games.” Responses ranged on a 6-point scale
(“none,” “less than 1 hour,” “1 hour,” “2 hours,” “3
hours,” and “4 or more hours”). TV viewing time was then
dichotomized to <2 h/day, and ⩾2 h/day, which is based
in the American Academy of Pediatrics recommendations
for children and adolescents (American Academy of Pedi-
atrics, 2001).
Computer usage. Parents were asked, “On an average
weekday, about how much time does this child usually
spend with computers, cell phones, handheld video games,
and other electronic devices, doing things other than
school work.” Responses ranged on a 6-point scale
(“none,” “less than 1 hour,” “1 hour,” “2 hours,” “3
hours,” and “4 or more hours”). Computer usage was then
dichotomized to <2 h/day, and ⩾2 h/day to match TV
viewing time (Barlow & Expert Committee, 2007).
Sports participation. Parents reported whether their child
took sports lessons or participated in a sports team outside
of school (after school and/or weekends) within the past 12
months.
Covariates. Age, sex, race, household income, highest
level of education in the household, and current ASD med-
ication were included as covariates in the analysis. Covari-
ates were chosen based on the potential for confounding
and previous literature on physical activity behaviors and
ASD (Curtin, Anderson, Must, & Bandini, 2010; McCoy
et al., 2016).
Statistical analysis
Analyses were completed using Stata 15.1 (Stata
Corporation, College Station, TX, USA). Adjusted logistic
regression models were used to determine the associations
between ASD and BMI classification, weekly physical
activity, TV viewing time, computer usage, and sports par-
ticipation. Further analyses were conducted to determine if
physical activity and/or sport participation mediated the
association between ASD and BMI classification. A sec-
ondary analysis was conducted after stratification by ASD
severity to examine associations between ASD and our out-
come variables. Furthermore, associations between gender,
sex, and regular physical activity were examined among
individuals with ASD. Each model was adjusted for the
covariates: age, sex, race, household income, highest level
of education in the household, and ASD medication.
Results
Analyses included 33,865 adolescents, 1036 with ASD
and 32,829 typically developing adolescents. Sample
descriptives by ASD classification are presented in
Table 1. Compared with typically developing adolescents,
those with ASD were more likely to be male (80% vs 50%;
p < 0.001), were more likely to live in a household ⩾133%
of the federal poverty level (18% vs 13%; p<0.001), and
were more likely to have Attention Deficit/Hyperactivity
Disorder (ADHD) (55% vs 1 3%; p<0.001).Of those with
ASD, 53% had “mild” ASD, 37% had “moderate” ASD,
and 10% had “severe” ASD, and 35% were currently on
medication for ASD. Broken down by age group (10–12
and 13–17), approximately 15% of 10–12-year-olds with
ASD engaged in 60 min or more of physical activity each
day versus 11% of 13–17-year-olds with ASD. Broken
down by gender, approximately 12% of males with ASD
engaged in 60 min or more of physical activity each day
versus 11% of females.
For adolescents with ASD, the adjusted odds of being
underweight, overweight or obese were significantly
higher than their typically developing counterparts as
shown in Table 2. Adolescents with ASD were more likely
to be underweight [odds ratio (OR) = 1.53, 95% CI (1.15,
2.03)], more likely to be overweight [OR = 1.37, 95% CI
(1.10, 1.70)], and more likely to be obese than typically
developing adolescents [OR = 1.94, 95% CI (1.60, 2.36)].
In addition, adolescents with ASD were less likely to
engage in 60 min or more of physical activity everyday
[OR = 0.42, 95% CI (0.33, 0.55)] and less likely to have
participated in a sport in the past 12 months [OR = 0.19,
95% CI (0.16, 0.23)]. Additionally, adolescents with ASD
were more likely to engage in ⩾2 h/day of television view-
ing [OR = 1.25, 95% CI (1.07, 1.47)]. Odds of computer
use ⩾2 h/day was not significantly different among those
with ASD versus their typically developing peers.
The adjusted ORs of BMI classification in those with
ASD compared with their typically developing peers after
further adjustment for physical activity behaviors are
shown in Table 3. Associations between ASD and BMI
classification were attenuated in each separate model
adjusting for physical activity behaviors one-by-one. After

McCoy and Morgan 391
the full adjustment (weekly physical activity and sport par-
ticipation), there was an attenuation in the relationship
between ASD and BMI classification with the odds of
obesity remaining significantly increased in those with
ASD compared with their typically developing peers
[OR = 1.44, 95% CI (1.18, 1.75)].
Table 1. Demographic characteristics in typically developing adolescents and adolescents with ASD.
Characteristics Typically developing adolescents
(n = 31,168)
Adolescents with ASD
(n = 1144)
p value
Age, years: M (SD) 13.8 (2.3) 13.7 (2.2) 0.091
Sex, male (%) 49.9 80.4 <0.001
Race, White non-Hispanic (%) 71.4 73.6 0.223
Household incomea (%) – – <0.001
Poor 13.4 18.1
Near poor 7.7 8.9
Not Poor 78.9 73.0
Highest educationb (%) – – 0.137
<12 years 2.6 2.0
12 years 13.0 13.4
>12 years 84.4 84.0
Attention Deficit/Hyperactivity Disorder (%) 12.8 55.4 <0.001
Autism severity (%) – – –
Mild – 52.7 –
Moderate – 36.7 –
Severe – 9.7 –
Type of healthcare provider for ASD diagnosis (%) – – –
Primary care provider – 13.0 –
Specialist – 32.2 –
School psychologist/counselor – 10.9 –
Other psychologist (non-school) – 16.8 –
Psychiatrist – 13.9 –
Other – 9.0 –
Currently on medication for ASD (%) – 35.0 –
Weight status (%) – – <0.001
Underweight 6.1 7.7 –
Normal weight 67.3 52.4 –
Overweight 14.1 16.6 –
Obese 12.5 23.3 –
Television viewing time (%) – – <0.001
<2 h/day 47.8 37.5 –
⩾2 h/day 52.2 62.5 –
Computer use (%) – – 0.739
<2 h/day 34.0 33.5 –
⩾2 h/day 66.0 66.5 –
Physical activity, 60 min or more (%) – – <0.001
<7 days/week 82.1 88.0 –
Everyday 17.9 12.0 –
Physical activity, 60 min or more everyday (%) – – –
10–12 years old 21.6 14.9 –
13–17 years old 16.2 10.6 –
Physical activity, 60 min or more everyday (%) – – –
Male 22.0 12.2 –
Female 13.8 10.8 –
Sports participation (%) 67.6 31.6 <0.001
ASD: autism spectrum disorder.
aIncome is grouped into three categories based on household federal poverty level: “poor,” <133% poverty; “near poor,” ⩾133% poverty, but
<185% poverty; “not poor,” ⩾185% poverty.
bHighest level of education in family.
Bold indicates statistically significant at p < .05.

392 Autism 24(2)
Figures 1 and 2 show the ORs of the main outcome
variables stratified by parent-reported autism severity. In
terms of BMI classification, Figure 1 shows that as par-
ent-reported ASD severity increased, the odds of adoles-
cents with ASD being underweight, overweight, and
obese significantly increased. For obesity, those with
“mild” ASD were 83% more likely to be obese, those with
“moderate” ASD were 2.14 times more likely to be obese,
and those with “severe ASD were 2.21 times more likely
to be obese (p-for-trend = 0.002). This pattern was also
seen in physical activity behaviors. Figure 2 shows that as
parent-reported severity increased, the odds of adoles-
cents with ASD engaging in regular weekly physical
activity and participating in sports significantly decreased.
Those with “mild” autism were 59% less likely to engage
in ⩾60 min of physical activity daily, those with “moder-
ate” autism were 53% less likely to engage in regular
physical activity, and those with “severe” ASD were 56%
less likely to engage in regular physical activity compared
with their typically developing peers (p-for-trend <0.001).
Those with “mild” autism were 76% less likely to have
participated in a sport in the past 12 months, those with
“moderate” autism were 84% less likely to have partici-
pated, and those with “severe” ASD were 94% less likely
to have participated in a sport compared with their typi-
cally developing peers (p-for-trend < 0.001).
Among the sample with ASD, after stratification by
age group (10–12 and 13–17 years), the adjusted ORs of
regular physical activity participation for 13–17-year-olds
with ASD was significantly lower compared with
10–12-year-olds with ASD [OR = 0.68, 95% (0.46,
0.99)]. After stratification by gender, the adjusted odds
regular physical activity participation was not statistically
different between males and females with ASD [OR =
0.89, 95% CI (0.55, 1.46)].
Discussion
This study sought to examine the relationships between
BMI classification, physical activity behaviors, and seden-
tary behaviors in adolescents with parent-reported ASD
compared with their typically developing peers. We
hypothesized that the adolescents with ASD would be
more likely to be overweight or obese, less likely to engage
in physical activity behaviors such as weekly physical
activity and organized sports, and more likely to engage in
sedentary behaviors such as TV viewing and leisure com-
puter use (⩾2 h/day). The findings in this study support
the hypotheses that adolescents with ASD were more
likely to be overweight or obese and less likely to engage
Table 2. Adjusteda odds ratios of BMI classification, physical
activity, and sedentary behaviors in ASD versus typically
developing adolescents.
Variable OR 95% CI
Weight statusb
Underweight 1.53 [1.15, 2.03]
Normal weight Reference
Overweight 1.37 [1.10, 1.70]
Obese 1.94 [1.60, 2.36]
Television viewing time
<2 h/day Reference
⩾2 h/day 1.25 [1.07, 1.47]
Computer use
<2 h/day Reference
⩾2 h/day 1.08 [0.91, 1.28]
Physical activity
<7 days/week Reference
Everyday 0.42 [0.33, 0.55]
Sports participation
No participation Reference
Participated in a sport 0.19 [0.16, 0.23]
ASD: autism spectrum disorder; OR: odds ratio; CI: confidence
interval.
aModels adjusted for age, sex, race, gender, household education,
household income, and ASD medication.
bTypically developing adolescents and normal weight category used as
reference groups.
p < 0.05 in boldface.
Table 3. Odds ratios for underweight, overweight, and obese in adolescents with ASD versus typically developing adolescents.
Weight status Model 1a Model 1 + adjustment
for physical activity
Model 1 + adjustment
for sport participation
Fully adjustedb
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Underweight 1.53 [1.15, 2.03] 1.50 [1.12, 2.00] 1.30 [0.97, 1.73] 1.29 [0.96, 1.72]
Normal weight Reference Reference Reference Reference
Overweight 1.37 [1.10, 1.70] 1.32 [1.06, 1.65] 1.22 [0.98, 1.52] 1.20 [0.96, 1.49]
Obese 1.94 [1.60, 2.36] 1.83 [1.50, 2.22] 1.49 [1.22, 1.81] 1.44 [1.18, 1.75]
ASD: autism spectrum disorder; OR: odds ratio; CI: confidence interval.
aModel 1 adjusted for age, sex, race, gender, household education, household income, and ASD medication.
bModel adjusted for all Model I covariates, physical activity, and sport participation.
p < 0.05 in boldface.

McCoy and Morgan 393
in physical activity behaviors. However, the results from
this study do not support our hypothesis that adolescents
with ASD would be more likely to participate in sedentary
behaviors.
The findings of this study uniquely contribute to the lit-
erature on adolescents with ASD in that we were able to
determine the relationship between ASD and BMI classifi-
cation, physical activity behaviors, and sedentary behaviors
by autism severity adjusting for autism medication.
Additionally, with the updates to the NSCH in the 2016
round of data collection, we were able to determine if meet-
ing the current federal guideline for physical activity in
children and adolescents (60 min or more per day) medi-
ated the relationship between ASD and BMI classification.
Adolescents with ASD were 41% more likely to be
overweight and 84% more likely to be obese compared
with their typically developing counterparts. These results
are consistent with the previous research showing that
those with ASD have higher odds of being overweight or
obese compared with their typically developing peers
(Broder-Fingert, Brazauskas, Lindgren, Iannuzzi, & Van
Cleave, 2014; Healy et al., 2019; Hill, Zuckerman, &
Fombonne, 2015; McCoy et al., 2016; Segal et al., 2016).
Broder-Fingert et al. (2014) examined a large integrated
healthcare database of 6672 individuals with and without
ASD aged 2–20 years, and found that after adjusting for
age and sex, children and adolescents with ASD had sig-
nificantly higher odds of being overweight [OR = 2.24,
95% CI (1.74, 2.88)] and obese [OR = 4.83, 95% CI (3.85,
6.06)] compared with those without ASD. More specifi-
cally, after adjustment, it was found that adolescents with
ASD aged 12–15 years had significantly higher odds of
Figure 1. Adjusted odds ratios (95% confidence interval) of BMI classification in ASD by parent-reported ASD severity versus
typically developing adolescents.
Figure 2. Adjusted odds ratios (95% confidence interval) of physical activity behaviors in ASD by parent-reported ASD severity
versus typically developing adolescents.

394 Autism 24(2)
being obese [OR = 1.87, 95% CI (1.33, 2.630] compared
with those without ASD (Broder-Fingert et al., 2014). One
study found a higher prevalence of overweight and obesity
in children and adolescents with ASD compared with their
typically developing peers. Compared with a general US
population sample from the National Health and Nutrition
Examination Study (NHANES), adolescents aged 12–17
years with ASD had a significantly higher prevalence of
being overweight (42.7% vs 35.3%) or obese (26 % vs
19.5%) (Hill et al., 2015). Additionally, from the 2011–
2012 NSCH round of data collection, McCoy et al. (2016)
found adolescents aged 10–17 years with ASD were 27%
more likely to be overweight (p < 0.001) and 72% more
likely to be obese (p < 0.001) in comparison with their
typically developing peers (McCoy et al., 2016). More
recently, Healy et al. (2019) examined overweight and
obesity in the 2016 round of NSCH data collection and
found after controlling for age, race/ethnicity, income, and
sex, adolescents aged 10–17 years with ASD had signifi-
cantly higher odds of overweight (OR = 1.48, p = 0.04)
and obesity (OR = 1.49, p = 0.02) compared with their
typically developing peers (Healy et al., 2019). This pat-
tern is also seen in children and adolescents with intellec-
tual disabilities. Segal et al. (2016) examined the
2011–2012 NSCH dataset and found after adjustment for
demographic characteristics, those aged 10–17 years with
an intellectual disability were 89% more likely to be obese
[OR = 1.89, 95% CI (1.14, 3.12)]. After adjustment for
ASD status, those with intellectual disability were 92%
more likely to be obese [OR = 1.92, 95% CI (1.14, 3.21)]
(Segal et al., 2016). This suggests that ASD status was a
confounder in the relationship between obesity and intel-
lectual disability. Another study examining unhealthy
weight in 9612 adolescents with and without any develop-
mental disability aged 12–17 years from the 2008–2010
National Health and Interview Survey (US) and found that
adolescents with learning and behavioral disabilities were
60% more likely to be underweight than typically develop-
ing adolescents, which is similar to our results which
results showed adolescents with ASD were 67% more
likely to be underweight compared with typically develop-
ing adolescents. Additionally, the prevalence of obesity in
adolescents with any developmental disability was 20.4%
compared with 13.1% of adolescents without developmen-
tal disabilities. However, in contrast to our findings, the
prevalence of being overweight was 17.5% for both ado-
lescents with and without developmental disabilities
(Phillips et al., 2014).
Unhealthy weight in individuals with ASD could poten-
tially be multifactorial. These potential mechanisms include
eating and drinking patterns, and medication usage.
Adolescents with ASD could have atypical food selectivity
which may promote unhealthy weight status. Adolescents
with ASD have a significantly different diet composition
compared with their typically developing peers (consuming
more sugary beverages, snack foods, and less fruits and
vegetables) (Evans et al., 2012). Food presentation (i.e. on
a special plate with special utensils) can limit food intake in
those with ASD. This atypical selectivity is also seen with
avoidance of certain food types, textures, color, smells, and
temperatures. Adolescents with ASD eat a significantly
narrower range of foods and prefer more calorically dense
foods (Ahearn, Castine, Nault, & Green, 2001; Schreck,
Williams, & Smith, 2004). This food selectivity may con-
tribute to an increase in rates of underweight, overweight,
and obesity.
Medication usage may also play a part in the increased
rates of unhealthy weight status in adolescents with ASD.
An adverse effect of taking atypical antipsychotics that
may be routinely prescribed to those with ASD include
weight gain. A systematic review showed that those taking
risperidone had an average weight gain of 2.7–2.8 kg com-
pared with a placebo group, and those taking aripiprazole
had an average weight gain of 1.3–2.0 kg compared with
the placebo (McPheeters et al., 2011). This study controlled
for general ASD medication usage, which allowed us to
look at the influence of medication on obesity in ASD.
However, specific medications names are not reported.
The odds of participating in regular physical activity
were found to be significantly lower in adolescents with
ASD compared with their typically developing peers.
Adolescents with ASD were 62% less likely to participate
in regular weekly physical activity. Additionally, we found
that adolescents with ASD were 81% less likely to have
participated in an organized sport within the past 12
months. Our findings are consistent with the previous
research examining physical activity behaviors in this pop-
ulation (McCoy et al., 2016; Pan et al., 2016; Stanish et al.,
2017). In a study conducted using the 2011–2012 NSCH,
adolescents of the same age as in this study with ASD were
less likely to participate in weekly physical activity [OR =
0.40, 95% CI (0.34, 0.46)], and less likely to participate in
organized sports [OR = 0.26, 95% CI (0.21, 0.29)] com-
pared with their peers without ASD (McCoy et al., 2016).
Although these data were parent-reported, similar results
have been found with accelerometer measurement of
physical activity. A study examining physical activity dif-
ferences between adolescents 13–21 years old with and
without ASD showed that those with ASD (n = 35) spent
significantly less time in moderate and vigorous physical
activity (29 min/day vs 50 min/day, p < 0.001) compared
with adolescents without ASD (n = 60). Additionally,
fewer adolescents with ASD (14% vs 29%, p <0.05) met
the 60 min/day Physical Activity Guidelines for Americans
(Stanish et al., 2017). Another study examining differences
in objectively measured physical activity between adoles-
cent males with and without ASD aged 12–17 years
showed those with ASD were less physically active overall
and engaged in MVPA for a lower percentage of overall
activity. Additionally, for those with ASD, only 37% met

McCoy and Morgan 395
the federal recommendation compared with 68% of typi-
cally developing adolescents (Pan et al., 2016). In contrast,
Bandini et al. (2013) examined MVPA via accelerometry
in children aged 3–11 years with and without ASD and
found that after adjustment for age and sex, daily physical
activity was similar in children with ASD compared with
those without (50 min/day vs 57.1 min/day). However,
parents reported that children with ASD participated in
fewer types of physical activities compared with their typi-
cally developing peers (6.9 vs 9.6, p < 0.001) (Bandini
et al., 2013). This is consistent with the results from this
study that adolescents with ASD were significant less
likely to participate in sports compared with their typically
developing peers, suggesting that differences in sport par-
ticipation between those with ASD compared with those
without persists through the transition from childhood into
adolescence.
Uniquely, this study examined the potential mediation
of physical activity behaviors on BMI classification.
Adjusting for physical activity behaviors decreased asso-
ciations between ASD and overweight and obesity. Among
both children and adolescents (4–17 years), BMI has been
found to be inversley related to physical activity, suggest-
ing that as BMI increases, physical activity decreases
(Lawson & Foster, 2016). This suggests that an interven-
tion targeting physical activity behaviors may potentially
impact unhealthy weight status in the population.
Additionally, this study examined age and sex differ-
ences in regular physical activity among adolescents with
ASD. After stratification by age group, the adjusted odds
of physical activity participation were significantly lower
among 13–17-year-olds compared with 10–12-year-olds.
This pattern is seen in both adolescents of typical develop-
ment (Katzmarzyk et al., 2016) and adolescents with ASD
(Memari et al., 2013; Pan & Frey, 2006). Memari et al.
(2013) examined physical activity among 80 children and
adolescents with ASD found that the overall levels of
objectively measured daily physical activity decreased
with age, with 7–8-year-olds engaging in more physical
activity compared with 11–12-year-olds and 13–14-year-
olds (Memari et al., 2013). Additionally, Pan et al. (2006)
found that elementary school-aged children with ASD
engaged in significantly more MVPA (132.58 ± 79.36
min/day) compared with both middle-school-aged chil-
dren (75.18 ± 32.72 min/day) and high-school-aged ado-
lescents with ASD (39.67 ± 18.69 min/day) (Pan & Frey,
2006). However, we did not find a statistically significant
difference in the odds of physical activity participation
between males and females. This is contrary to a previous
review that suggests males are more physically active than
females (Scharoun et al., 2017).
Low engagement in physical activity for adolescents
with ASD could potentially be explained by several mech-
anisms. Engaging in physical activity and team sports (e.g.
football and soccer), requires a more advanced level of
motor skills. However, it has been shown that both chil-
dren and adolescents with ASD have deficits in motor
skills (Green et al., 2009; Pan, Tsai, & Chu, 2009; Staples
& Reid, 2010). Green et al. (2009) found that 79% of ado-
lescents aged 10–14 years with ASD (n = 109) have
movement impairments on the Movement Assessment
Battery for Children consistent with <5th percentile
(Green et al., 2009). Similarly, another study found chil-
dren aged 6–10 years with ASD (n = 28) had significantly
lower scores on tests of gross motor skill, object control,
and locomotor skills compared with typically developing
children (Pan et al., 2009). Furthermore, team sports and
physical activities become more competitive as children
get older. The competitive atmosphere may be less condu-
cive to adolescents with ASD compared with their typi-
cally developing peers (Nicholson, Kehle, Bray, & Heest,
2011). Another aspect of physical activity and sport that
may contribute to decreased participation for adolescents
with ASD is the social aspect. Fewer adolescents with
ASD feel that sport and exercise are good ways to make
friends (68% vs 97%, p<0.001) in comparison with typi-
cally developing adolescents (Stanish et al., 2015). While
the sports climate, including both competition and social,
could potentially act as a barrier toward participation in
physical activity and organized sports, some parents and
caregivers of adolescents with ASD may believe there are
additional barriers limiting physical activity opportunities.
Parents of children with ASD aged 3–11 years have
reported barriers including the physical activity itself, the
physical and social environment, supervision, knowledge
and skills, as well as exclusion from peers (Must, Phillips,
Curtin, & Bandini, 2015). Based on the parent-report, 60%
of children with ASD required too much supervision com-
pared with those without ASD (p < 0.001). Additionally,
parents of children with ASD were more likely to report
that adults lack the skills needed to include their child in
physical activities (58%), their child had few friends
(45%), and that their child was excluded by the other chil-
dren (23%). Furthermore, it was found that the number of
barriers reported was inversely correlated with physical
activity participation (Must et al., 2015). Adolescent par-
ticipants themselves also report barriers to participating in
physical activity. Compared with their peers without ASD,
adolescents with ASD reported more frequent occurrence
of barriers limiting physical activity such as fear of injury
(54% vs 33%, p = 0.07), weather (94% vs 39%, p <
0.001), and that sports and exercise were too difficult to
learn (16% vs 0%, p < 0.01) (Stanish et al., 2015). In
another study, examining barriers to physical activity par-
ticipation in children and adolescents (aged 8–14 years),
the most commonly reported barriers were intrapersonal
such as playing video games or watching TV (27% and
17%, respectively), as well as interpersonal barriers such
as lack of peer exercise partner (friends, siblings)
(Obrusnikova & Cavalier, 2011).

396 Autism 24(2)
Additionally, adolescents with ASD may not find as
much enjoyment in physical activities compared with their
typically developing peers. One study compared enjoy-
ment in physical activity, perceived barriers, beliefs, and
self-efficacy in adolescents aged 13–21 years with and
without ASD. Adolescents with ASD enjoyed team sports
(65% vs 95%, p < 0.001) and physical education (84% vs
98%, p = 0.02) significantly less than peers without ASD.
Likewise, fewer adolescents with ASD would choose to
participate in physical activities in their freetime (25% vs
58%, p < 0.01) in comparison with their peers without
ASD (Stanish et al., 2015). Similar results were found in
an examination of hobby preference of 9-year-old children
with (n = 49) and without ASD (n = 49). These results
demonstrate that barriers to physical activity participation
persist as those with ASD transition from childhood to
adolescence. Although not examined in the NSCH and in
this study, barriers reported by both the parents and adoles-
cence with ASD may limit opportunities and engagement
in physical activities and sport.
Our results on sedentary behaviors were mixed. We
found that adolescents with ASD were significantly more
likely to engage in more than 2 h/day of watching TV and
playing video games compared with their typically devel-
oping peers, but computer use was not statistically signifi-
cant. Published research on this topic is mixed, with some
studies showing that individuals with ASD are more likely
to engage in sedentary behaviors, and others that show ado-
lescents with ASD spend equal to less time in sedentary
behaviors compared with typically developing peers,
though each study examined sedentary behaviors with dif-
ferent age ranges (2–5 years, 3–11 years, and 10–17 years,
respectively) (Ketcheson, Hauck, & Ulrich, 2018; McCoy
et al., 2016; Must et al., 2014). Must et al. (2014), using
parent-report, found that TV viewing time, computer time,
and total screen time were higher in children aged 3–11
years with ASD on both weekdays and weekends compared
with their typically developing peers (Must et al., 2014). In
comparison, Ketcheson et al. (2018), using accelerometers,
found that young children aged 2–5 years with ASD spent
less time in sedentary behaviors compared with peers with-
out ASD (t(52) = 4.57, p < 0.001) (Ketcheson et al., 2018).
Moreover, no statistical differences were found examining
TV viewing time and computer usage within the 2011–
2012 NSCH data set between adolescents (10–17 years)
with and without ASD, consistent with the results found in
this study (McCoy et al., 2016). However, differences may
be explained by the lack of consistency with the measure-
ment of sedentary behavior in this population as well as
examination within different age groups. Future research is
needed to further examine sedentary behaviors of both chil-
dren and adolescents with ASD in comparison with typi-
cally developing with an objective device, such as an
accelerometer to further clarify if differences in sedentary
behavior change with age or remain consistent.
The strengths of this study include a large, nationally
representative data set from the US. The large data
set allowed for an original analysis among BMI classifica-
tion, physical activity behaviors, and sedentary behaviors in
adolescents with parent-reported ASD compared with their
typically developing peers. Another strength of this study is
including the most recent data, which includes the update to
the physical activity and ASD questions in the 2016 version
of the NSCH. This study uniquely adds to the literature on
ASD in that it uses the most updated nationally representa-
tive data, includes the current recommendation of physical
activity in children (60 min or more per day), and includes
ASD medication as well as ASD severity. However, there
are several limiting factors that should be considered. All
data from the NSCH is provided based on parental self-
report including ASD status. Variables included in our anal-
yses (i.e. autism classification, ASD medication, ASD
severity, BMI classification, weekly physical activity, tele-
vision viewing time, computer usage, and sport participa-
tion,) were all parent-reported, which could have resulted in
measurement error. Parent-reported measures may lead to
error as parents may not understand what constitutes physi-
cal activity, especially chores or activities that may not
induce visible sweating or heavy breathing. In addition, par-
ents may not have knowledge of physical activities and sed-
entary behaviors completed while their child was away from
home, at school, or with a caregiver. Parent-reported meas-
ures of ASD status may lead to missed cases in areas that
have limited access to healthcare or decreased levels of
health literacy. Additionally, the parent-report of ASD sever-
ity (mild, moderate, severe) could include error as parents
may not understand the levels of physician-diagnosed ASD
severity and parents may have reported an ASD severity
based on their own perception. Furthermore, as the NSCH is
a survey, unavailability of information regarding specific
mediation usage (name and/or type), pubertal status, or
school setting from the NCSH limited the interpretation of
our results. Further research should employ objective meas-
ures of variables to provide a more detailed description of
the population. Since parent-reported measurements of
physical activity are subjective, accelerometer data could
provide an objective measure of physical activity and seden-
tary behaviors along with physical measures of height and
weight. Physician diagnosed severity of ASD alongside
with specific medication usage for ASD would provide fur-
ther evidence supporting any relationships found between
ASD severity and medication usage with physical activity
levels and sedentary behaviors.
This study purports that adolescents with ASD are more
likely to be overweight and obese as measured by BMI, less
likely to engage in the recommended amount of beneficial
physical activity each week, and more likely to engage in
sedentary behaviors such as TV viewing. These findings
highlight the need for intervention in this population that
includes increasing physical activity and monitoring of

McCoy and Morgan 397
sedentary behaviors to increase the overall health (both
physical and social) of this population, as well as research
determining the effectiveness of these interventions. It is
known that regular participation in physical activity is
related to healthy growth and development throughout life
(Blair et al., 1989). There is strong evidence supporting the
benefits of physical activity on physical health including
improvements in musculoskeletal health, cardiovascular
health, improved fitness, improved metabolic health, and
decreased obesity, as well as reductions in the risk of devel-
oping chronic disease (American College of Sports
Medicine, 2013; Daniels et al., 2011; Strong et al., 2005;
Warburton et al., 2006). Furthermore, there are many men-
tal and social benefits of physical activity that may be par-
ticularly beneficial to those with ASD, including decreased
levels of anxiety and depression, improvements in self-
concept, improved emotional control, confidence, making
new friends, improved relationships and social skills, as
well as greater social competence (Holt, Kingsley, Tink, &
Scherer, 2011; Snyder et al., 2010; Strong et al., 2005).
However, adolescents with ASD may have to overcome
barriers specific to their ASD such as deficits in motor
skills, communication, and social skills that may limit their
ability to participate in physical activity behaviors and may
in fact lead to greater participation in solitary sedentary
behaviors. Ryan, Fraser-Thomas, and Weiss (2018) found
that significant predictors to having a social sport experi-
ence includes socio-communicative abilities, coach–ath-
lete relationships, and parent support (Ryan et al., 2018).
Given the results, this study provides evidence for indi-
vidualized sporting and physical activity opportunities for
adolescents with ASD across the severity spectrum.
Additionally, program directors should be accommodating
to the parent- and participant-reported barriers that may
potentially limit physical activity and sport participation in
this population. Although more research is needed to
determine the feasibility and effectiveness of increasing
physical activity in adolescents with ASD across the spec-
trum, targeted programs are needed to support healthy life-
styles in adolescents with ASD.
Author Contributions
S.M.M. and K.M. contributed equally to this study.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Stephanie M McCoy https://orcid.org/0000-0002-1142-1527
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