Screening for cardiovascular disease risk factors at baseline and post intervention among adults with intellectual disabilities in an urbanised Asian society

Background: Adults with intellectual disabilities (ID) face significant barriers to screening participation. We determined predictors for regular cardiovascular health screening at baseline among adults with ID in Singapore, and evaluated the effectiveness of a 3‐month screening intervention. Methods: The study population involved all adults with ID aged ≥40 years receiving services from the Movement for the Intellectually Disabled of Singapore (MINDS), the largest such provider in Singapore. Over 3 months in 2011, adult clients not screened regularly at baseline for hypertension, diabetes and dyslipidaemia were offered free and convenient blood pressure, fasting blood glucose and lipid testing; data on other cardiovascular disease risk factors were also collected. Chi‐square and logistic regression identified predictors of regular screening at baseline. Results: Participation was 95.0% (227/239). At baseline, among adults with ID, 61.8% (118/191), 24.8% (52/210) and 18.2% (34/187) had gone for regular hypertension, diabetes and dyslipidaemia screening respectively; post intervention, rates rose to 96.9%, 89.5% and 88.8% respectively. Prevalence of cardiovascular disease risk factors (22.5% with hypertension, 10.6% with diabetes, 34.8% with dyslipidaemia, 10.7% obese and 90.6% lacking regular exercise) was high compared against the general population. While receiving residential services was associated with regular hypertension screening, receiving non‐residential services and being independently mobile were associated with regular participation in fasting blood tests (all P < 0.05). Conclusion: Cardiovascular disease risk factors are common among adults with ID and clinicians should proactively screen such populations. Provision of free and convenient screening for cardiovascular disease risk improved screening participation.

dyslipidaemia; health screening; hypertension; intellectual disabilities; diabetes

Early detection and prevention via health screening is essential in the management of chronic diseases. However, not all groups have equal access to preventive services. Adults with intellectual disabilities (ID), in particular, form a neglected group. Advances in health care that have resulted in increased longevity among the population with ID also make chronic disease management more challenging, given the growing number of middle‐aged and elderly persons in these populations (Bigby [3] ; Bigby et al. [4] ; Lin et al. [14] ). Among those with ID, top causes of mortality include cardiovascular risk factors, respiratory diseases and malignancy (Patja et al. [26] ; Tyrer & McGrother [33] ) while cardiovascular disease and mental disease account for significant morbidity (Beange et al. [1] ; Hand & Reid [7] ). Evidence‐based screening for cardiovascular disease risk and cancer is hence important in reducing morbidity and mortality in this population. Early detection raises the prospect of early intervention, which can reduce the risk of disease in adults with ID (Moss [24] ).

Little work has been done on the barriers that those with ID face in accessing preventive services. However, the consensus in the literature is that those with ID do have reduced access to health screening. In the case of cancer screening, various studies demonstrate that uptake of screening for breast cancer (Sullivan et al. [31] ) and cervical cancer (Lin et al. [15] ) is reduced among adults with ID, for reasons such as misperceptions, lack of awareness and apprehension (Ward et al. [36] ; Truesdale‐Kennedy et al. [32] ; Wilkinson et al. [40] ). Fewer studies have been carried out on the uptake of screening for cardiovascular risk factors, although a study by Janicki et al. ([10] ) suggested that underreporting of the prevalence of cardiovascular risk factors among adults with ID might be due to reduced access to screening. This is a cause for concern, as several studies in both Western and Asian populations suggest that the age‐matched prevalence of cardiovascular risk factors like obesity, hypertension, diabetes and hyperlipidaemia is actually higher in adults with ID compared with the population at large (Bhaumik et al. [2] ; De Winter et al. [6] ; Lin et al. [16] ). In particular, there is a paucity of research with regards to chronic disease prevalence, as well as access to health screening, among adults with ID living within Asian societies.

Singapore is one such example of a multi‐ethnic Asian society. While the exact prevalence of ID among the Singaporean population is unknown, estimates from other Asian countries suggest a prevalence of less than 1.3% (Jeevanandam [11] ), comparable with Western studies (Westerinen et al. [39] ). Services for the population with ID are largely supported by voluntary welfare organisations. One such organisation is the Movement for the Intellectually Disabled of Singapore (MINDS) which is the largest organisation catering to the needs of persons with moderate to severe ID in Singapore. Due to the varying needs of those with ID, services are provided in a wide range of settings, such as sheltered workshops, adult day activity centres and residential homes (Movement for the Intellectually Disabled of Singapore [25] ); it is likely that patients in these different settings would have varying degrees of access to healthcare and preventive services. Although the burden of cardiovascular disease in Singapore is sizeable, representing the largest category of diseases for which disability‐adjusted life years (DALYs) are lost (19.7% of all DALYs lost in Singapore in 2004) (Phua et al. [27] ), there is a dearth of studies on the prevalence of chronic diseases among Singaporean adults with ID, or on the availability of access to preventive services. Such information is necessary to guide policymakers and healthcare workers in planning for the burden of chronic disease in this underserved group. Hence, we studied the prevalence of cardiovascular disease risk factors such as obesity, hypertension, diabetes and dyslipidaemia among all MINDS patients ≥40 years of age, as well as the uptake of screening for these risk factors in this population, in order to gain insight into the challenges faced by this segment of the population with regards to health screening participation.

The study population involved all adult clients aged 40 years and above of MINDS. At the time of our study, MINDS had 239 clients aged ≥40 years as of 31 December 2010 who were recipients of various services; 75 clients were provided residential services, whereas 146 clients participated in its Employment Development Centres (EDCs) and 18 clients participated in its Training Development Centres (TDCs). The EDCs serve individuals who are independent in daily living skills and promote the social and economic integration of adults with ID through programmes that empower the vocational ability of their clients, whereas the TDCs serve adults with ID who require higher levels of support, and have as their focus training in activities of daily living skills, community living skills and social/recreational skills. MINDS also runs residential services that provide respite, short‐term or long‐term care for ID adults (Westerinen et al. [39] ). We used age ≥40 years as the cut‐off because it was the recommended age to start cardiovascular health screening according to our MOH Clinical Practice Guidelines (CPG) (Ministry of Health, Singapore [19] ). From July to November 2011, the caregivers of all MINDS clients aged ≥40 years were: (1) approached to seek consent for participation in the study; (2) collected baseline information such as the client's socio‐demographic data and medical history, via interviewer‐administered standardised questionnaires; (3) assessed if the client was previously adherent to regular cardiovascular health screening; and (4) offered non‐adherent clients the opportunity, over a 3‐month period, to participate in free, access‐enhanced health screening for cardiovascular disease risk factors, namely hypertension, diabetes mellitus dyslipidaemia and obesity. Clients were provided free health screening at the EDCs, TDCs or residential homes; free transportation to the screening was arranged and prior to the screening, caregivers received reminder telephone calls from study personnel. In addition, for fasting blood tests, in order to decrease the discomfort and fear of clients, a screen was used to hide the phlebotomists and the actual taking of the blood from the client, and a staff member known to the client was on hand to distract the client by talking to them. Information on other cardiovascular risk factors, such as tobacco consumption, physical activity and body mass index (BMI), was also collected. We offered hypertension screening via blood pressure measurement, type 2 diabetes mellitus screening via fasting blood glucose measurement and dyslipidaemia screening via fasting blood lipid measurement. Overweight was defined as BMI ≥ 23 kg/m2, as per our local Health Promotion Board (Health Promotion Board [8] ). Eligibility for screening was based on Singapore Ministry of Health CPG: for those aged ≥40 years and of unknown hypertensive/diabetes mellitus/dyslipidaemia status, blood pressure check is recommended yearly and fasting glucose/lipid is recommended every 3 years (Ministry of Health, Singapore [19] ). Height and weight measurements (for BMI) are also recommended on a yearly basis (Ministry of Health, Singapore [23] ). Blood pressure was measured using mercury sphygmomanometers; fasting blood samples were taken through venepuncture and sent to an accredited laboratory for analysis; and height and weight were measured, using chair scales for those who could not stand. The diagnosis of hypertension was based on three elevated blood pressure readings on separate occasions, and the diagnoses of diabetes mellitus and dyslipidaemia were based on two elevated fasting blood glucose and lipid readings, respectively, on separate occasions. Framingham risk scores were calculated using risk score tables derived from the Framingham‐based NCEP‐ATPIII 10‐Year Risk Score Tables, which were modified taking into account Singapore cardiovascular epidemiological data, provided by the Singapore Ministry of Health, Singapore General Hospital, National University of Singapore and Prof. Ralph B D'Agostino from the Framingham Heart Study, USA (Ministry of Health, Singapore [23] ). As ethnicity‐specific risk score tables were only available for Chinese, Malay and Indian ethnicities, those of other ethnicities were compared against the risk score table for majority (Chinese) ethnicity. Ethics approval was obtained from the NUS Institutional Review Board, informed consent was sought from the caregivers of participants, assent was obtained from participants when possible and participation was voluntary. Participants who were found to have cardiovascular risk factors were provided with follow‐up care by a team of MINDS healthcare workers or their own family physician.

Descriptive statistics were computed for the study population. We used McNemar's test to determine whether the increases in health screening take‐up for hypertension, diabetes mellitus and dyslipidaemia were significant after our 3‐month intervention. Chi‐square and logistic regression were used to identify socio‐demographic and clinical predictors of adherence to regular screening at baseline among adults with ID for bivariate and multivariate analysis respectively. The criterion for initial entry of variables into multivariate models was P < 0.2 on bivariate analysis and we presented the most parsimonious model of factors accounting for screening uptake before intervention, controlling for differences in baseline characteristics. To better understand reasons for not attending regular screening at baseline and post intervention, caregivers of clients were asked for their reasons for non‐participation in regular screening both at baseline and post intervention, where applicable, using standardised questionnaires. All statistical analysis was performed using Statistical Package for Social Sciences (spss, Version 18.0, USA) and statistical significance was set at P < 0.05.

Overall participation was 95.0% (227/239); participation rate among those receiving EDC services was 97.2% (142/146), 83.3% (15/18) among those receiving TDC services and 90.7% (68/75) among those receiving residential services. The socio‐demographic profile of participants is detailed in Table [NaN] . The median age of participants was 46 years (inter‐quartile range, IQR = 42–52). The majority (62.5%, 167/227) had a primary caregiver, defined as the main person among all potential caregivers who would actually provide physical care for the adult client. The median age of their caregivers was 66 years (IQR = 55–72). Roughly equal numbers of clients depended on their parents (46.1%, 77/167) or siblings (42.5%, 71/167) as their primary caregiver. More than half of study participants (53.2%, 142/227) were receiving services from the EDCs. The medical history and functional status of adult clients with ID are detailed in Table [NaN] . The principal diagnosis for ID was Down syndrome (27.8%, 63/227). Of note, 15.9% (36/227) of clients already had a pre‐existing history of doctor‐diagnosed hypertension, 7.5% (17/227) had a pre‐existing history of doctor‐diagnosed type II diabetes mellitus and 17.6% (40/227) had a pre‐existing history of dyslipidaemia. In addition, excluding these three diseases, 48.0% (109/227) had a history of at least one other medical condition, and none had a history of ischaemic heart disease at the time of the study. In terms of other cardiovascular disease risk factors, 4.4% (10/227) had smoked before, with 2.2% (5/227) currently smoking; only 9.4% (15/159) were exercising regularly; and none had a history of alcohol consumption. In terms of their functional status, the large majority of study participants were able to walk independently (86.3%, 196/227), although in terms of communication, only 21.1% (48/227) were fully communicative in usual verbal speech.

Socio‐demographic characteristics of adult clients (age ≥ 40 years) at the M ovement for the I ntellectually D isabled of S ingapore

1 Numbers do not add up to total due to missing values.

Medical history and functional status of adult clients (age ≥ 40 years) at the M ovement for the I ntellectually D isabled of S ingapore

• 2 Includes other diagnoses like head trauma, hydrocephalus, etc.
• 3 For exercise, those receiving residential services (n = 68) already receive fixed exercise periods during their stay in the residential home at least >20 min/day and ≥3 days a week, and were included in this analysis. However, if those receiving residential services were excluded, the participation rate in regular exercise would only be 9.4%.

Health screening participation rates before and after interventions are detailed in Table [NaN] . In this population of adults with ID, for hypertension screening, 61.8% of unknown hypertensives had measured their blood pressure in the past year, close to the national average of 63.9% (Ministry of Health [21] ). For diabetes mellitus and dyslipidaemia, only 24.8% and 18.2% of adult clients had measured their fasting blood glucose or fasting blood lipid in the past 3 years, respectively, as compared to national averages of 72.2% and 78.0% (Ministry of Health [21] ). After providing free and convenient screening over the course of 3 months, participation rates for all three screening modalities rose significantly (all P < 0.001, using McNemar's test). At baseline, 15.8% (36/227) of adults with ID had hypertension; post screening, this rose to 22.5% (51/227). For diabetes, 7.5% (17/227) were known cases at baseline; post screening, this rose to 10.6% (24/227). For dyslipidaemia, 17.6% (40/227) had a history at baseline; post screening, 34.8% (79/227) had dyslipidaemia. Of the 227 participants, 183 (80.6%) had their BMI measured; of those, 54.1% (99/183) were overweight. Less than two‐thirds of the study population had all components of the Framingham risk score available for computation. Among those whom the Framingham risk scores could be calculated, the majority were at low risk and none were at high risk of developing coronary heart disease in the next 10 years.

Participation in cardiovascular health screening before and after intervention for hypertension, diabetes mellitus, dyslipidaemia and obesity among adult clients (age ≥ 40 years) at the M ovement for the I ntellectually D isabled of S ingapore ( n  = 227)

• 4 Based on MOH Clinical Practice Guidelines for Health Screening: for those aged ≥40, blood pressure every year, fasting glucose and lipids every 3 years. Clients were encouraged to go for the relevant health screenings if they had not adhered to this screening regimen previously.
• 5 Positive results defined as: for blood pressure, an average systolic blood pressure of ≥140 mmHg and/or an average diastolic blood pressure of ≥90 mmHg; for fasting blood glucose, a value of ≥7.0 mmol/L; for fasting blood lipid, a total cholesterol of ≥6.2 mmol/L and/or a triglyceride of ≥2.3 mmol/L and/or an HDL <1.0 mmol/L and/or an LDL ≥4.1 mmol/L. Overweight was defined as BMI ≥23 kg/m2, as per our local Health Promotion Board.
• 6 Framingham risk score was calculated using risk score tables derived from the Framingham‐based NCEP‐ATPIII 10‐Year Risk Score Tables, which were modified taking into account Singapore cardiovascular epidemiological data, provided by the Singapore Ministry of Health, Singapore General Hospital, National University of Singapore and Prof. Ralph B D'Agostino from the Framingham Heart Study, USA (Ministry of Health, Singapore 23). As ethnicity‐specific risk score tables were only available for Chinese, Malay and Indian ethnicities, those of other ethnicities were compared against the risk score table for majority (Chinese) ethnicity.
• 7 Not calculated because one or more components of the Framingham risk score were not available for computation for these individuals.

The factors associated with not going for regular screening for hypertension, diabetes and dyslipidaemia at baseline in this population of adults with ID are listed in Tables [NaN] (univariate analysis) and [NaN] (multivariate analysis). At baseline, being of non‐Chinese (minority) ethnicity (adjusted odds ratio, aOR = 5.88, 95% CI = 1.92–16.67, P = 0.002), receiving residential services (aOR = 83.98, 95% CI = 10.94–644.76, P < 0.001), having a history of dyslipidaemia (aOR = 13.07, 95% CI = 3.14–54.33, P < 0.001), a history of epilepsy (aOR = 5.95, 95% CI = 1.04–34.20, P = 0.046) and being partially/non‐communicative in usual verbal speech (aOR = 4.17, 95% CI = 1.54–12.5, P = 0.005) were independently associated with going for regular hypertension screening; other cardiovascular disease risk factors such as smoking and physical inactivity were not independently associated with going for regular hypertension screening at baseline. Having a history of hypertension (aOR = 6.68, 95% CI = 2.26–19.77, P = 0.001) and a history of dyslipidaemia (aOR = 5.29, 95% CI = 1.85–15.15, P = 0.002) were independently associated with going for regular diabetes screening at baseline; whereas being of majority (Chinese) ethnicity (aOR = 0.12, 95% CI = 0.04–0.33, P < 0.001), receiving residential services (aOR = 0.04, 95% CI = 0.01–0.21, P < 0.001) and a monthly household income of $900–2499 (vs. a monthly household income of <$899) (aOR = 0.21, 95% CI = 0.07–0.67, P = 0.008) were independently associated with not going for regular diabetes screening. Having a history of hypertension (aOR = 24.64, 95% CI = 6.24–97.32, P < 0.001) and being independently mobile (aOR = 10.95, 95% CI = 1.02–117.39, P = 0.048) were independently associated with going for regular dyslipidaemia screening at baseline, whereas being of majority (Chinese) ethnicity (aOR = 0.28, 95% CI = 0.11–0.76, P = 0.012) and having a previous psychiatric diagnosis (aOR = 0.15, 95% CI = 0.02–0.88, P = 0.036) were associated with not participating in regular dyslipidaemia screening. Smoking and physical inactivity were not independently associated with participation in diabetes and dyslipidaemia screening.

Bivariate associations with going for regular hypertension, diabetes and dyslipidaemia screening at baseline among adult clients (age ≥ 40 years) at the M ovement for the I ntellectually D isabled of S ingapore ( n  = 227)

8 NA, not applicable; NC, could not be calculated because of a zero value in one cell.

Independent factors associated with going for regular hypertension, diabetes and dyslipidaemia screening at baseline among adult clients (age ≥ 40 years) at the M ovement for the I ntellectually D isabled of S ingapore ( n  = 227)

9 Most parsimonious model presented. Odds ratio (ORs) reported are adjusted for all variables presented in model.

The top barriers to regular health screening in each of the three modalities at baseline before provision of free, access‐enhanced health screening are detailed in Table [NaN] . For hypertension screening, at baseline, of the 73 patients who were not being screened regularly, 31.5% had caregivers with the misperception that screening was unnecessary as the patient was not at risk, 23.3% were unaware of the need to screen and 16.4% either were too busy to bring the patient or felt that screening was inconvenient. For diabetes and dyslipidaemia screening, at baseline, the main reason for lack of regular screening was also the misperception that screening was unnecessary as the patient was not at risk; other important reasons also included the lack of a caregiver, the lack of awareness about screening and pain/discomfort experienced by the patient during the procedure.

Reasons for not participating in regular hypertension, diabetes and dyslipidaemia screening at baseline among adult clients (age ≥ 40 years) at the M ovement for the I ntellectually D isabled of S ingapore ( n  = 227)

10 The superscript numbers are the top three groups of reasons for not going for regular screening for each health screening modality.

At baseline, 15.8% (36/227) of adults with ID had hypertension; post screening, this rose to 22.5% (51/227). For diabetes, 7.5% (17/227) were known cases at baseline; post screening, this rose to 10.6% (24/227). For dyslipidaemia, 17.6% (40/227) had a history at baseline; post screening, 34.8% (79/227) had dyslipidaemia. Compared against national data, where in the 40–49 age bracket, 16.7% had hypertension, 12.1% had diabetes and 18.0% had dyslipidaemia (Ministry of Health, Singapore [22] ), it appears that in Singapore, the prevalence of hypertension and dyslipidaemia is higher among adults with ID compared to the general age‐equivalent population, whereas the prevalence of diabetes is similar. These findings are similar to reports from Taiwan which found the prevalence of hypertension and dyslipidaemia among adolescents with ID to be higher than the general population (Lin et al. [14] ). However, the data from Western countries are more mixed; studies from countries such as Australia (Wallace & Schluter [35] ) and the USA (Kapell et al. [12] ; Lewis et al. [13] ; Braunschweig et al. [5] ) indicate that adults with ID may have a generally more favourable risk factor profile for cardiovascular disease compared with the age‐matched general population, whereas some studies indicate that hypertension, diabetes and dyslipidaemia are highly prevalent (De Winter et al. [6] ). Although the overall 10‐year risk of coronary artery disease was relatively low in this population, the risk is likely to increase as this population ages (given a median age of only 46 years). Access to preventive services and early detection are thus important to reduce morbidity and mortality from cardiovascular disease among this segment of the population.

The prevalence of overweight was remarkably high (54.1%) among adults with ID, compared with the national average of 25.6% among adults over 40 years in 2004 (Ministry of Health, Singapore [20] ). 10.7% (20/183) were also obese, compared with the population average of 6.9% in the 40–49 age bracket. The association between obesity and ID is well substantiated (Bhaumik et al. [2] ; Sohler et al. [29] ) not just in adulthood but also in adolescence (Mikulovic et al. [17] ). While the estimates for obesity and overweight in our local population of ID adults are not as high as some of the figures that have been reported in Western countries (20.7–89%) (Bhaumik et al. [2] ; Wallace & Schluter [35] ; De Winter et al. [6] ; Sohler et al. [29] ) these numbers are of concern, given that the prevalence of regular exercise among non‐residential MINDS clients was low at 9.4% compared to the prevalence of regular exercise in the general population in the 40–49 age bracket of 16.7% (Ministry of Health, Singapore [22] ). Increasing physical activity among adults with ID has been shown to result in increased cardiorespiratory fitness and decreased risk for heart disease (Moss [24] ). Given that 86.3% of adults with ID in our population were independent in ambulation, poor mobility is unlikely to be a major reason contributing to low participation in regular exercise. More can be done to promote healthy lifestyles, especially exercise, among adults with ID, and this can take place earlier, perhaps even in adolescence (Mikulovic et al. [17] ). As these patients have special needs, more therapists and aides need to be engaged to increase the therapist : client ratio in order to provide supervised and safe exercise. Smoking prevalence was low compared to the general population: only 2.2% (5/227) were smoking daily, compared with 14.5% in the population at large (Ministry of Health, Singapore [22] ).

Although participation in hypertension screening was similar to that of the general population, health screening for other cardiovascular disease risk factors (diabetes, and dyslipidaemia) was much lower among adults with ID in urbanised Singapore, when compared against national data (Ministry of Health, Singapore [21] ). Surprisingly, across all three modalities (hypertension, diabetes and dyslipidaemia), those of majority ethnicity (Chinese) were less likely to go for health screening; in contrast to other studies in our local population which indicate that minority ethnicities were less likely to receive screening for cardiovascular disease or participate in preventive services (Wu et al. [41] ; Wee et al. [38] ). Caregivers from this ethnic group should be targeted for education on cardiovascular disease risk among their wards and the need for screening. For diabetes screening, those in the middle‐income bracket ($900–2499) were less likely to go for screening, compared to those in both lower‐ and higher‐income brackets. Perhaps the lower income was adequately covered by existing financial schemes, leaving those in the middle to fall through the social net. Although existing schemes provide subsidies for health screening (Health Promotion Board [9] ) and the qualifying income for such subsidised schemes has recently been raised (Ministry of Health [18] ), more can be done to assist those in the middle socio‐economic stratum who need to take care of adult wards with ID. In addition, a dichotomy emerged between the utilisation of hypertension screening (blood pressure) and the take‐up of fasting blood tests (for diabetes and dyslipidaemia). While adults with ID staying in residential services were more likely to have had regular blood pressure checks compared to those who were non‐residential, this dichotomy was reversed for fasting blood tests with non‐residential and more mobile adults with ID being more likely to go for regular screening for diabetes and dyslipidaemia. This suggests that adults with ID staying in residential services need to have access to fasting blood tests as well. Indeed, in our 3‐month intervention (which was provided to both adults with ID staying in the community and those staying in residential services), there was a marked increase in screening take‐up for all three modalities post intervention. Screening rates rose to 88.8–96.9% across all three modalities, despite the challenges in providing screening to this population (e.g. client agitation and non‐cooperation during phlebotomy and physical examination) (Scheepers et al. [28] ). This suggests that interventions providing free and convenient health screening have the potential to benefit adults with ID, similar to results with other socially disadvantaged groups where reducing out‐of‐pocket payments and addressing physical barriers overcame inequities in screening access (Spadea et al. [30] ; Wee & Koh [37] ). In our population, lack of knowledge and misperceptions were the commonest reasons for caregivers not bringing their wards for health screening, both at baseline and even after free, access‐enhanced screening was provided. This was somewhat different from other studies in which main barriers to screening participation included non‐cooperation by the adult client and difficulty complying with fasting (Wallace & Schluter [35] ). This suggests that caregivers for adults with ID and ID patients themselves (if capable of understanding) need to be made more aware of the benefits of screening, in order to increase screening participation among this segment of the population. The family physicians of adults with ID should be more aware of the need to offer health screening to their patients, and caregivers should also prompt their family physicians to perform health screening for their wards and even themselves when they reach the age of eligibility. Lastly, there should be healthcare programmes in place to ensure that adults with ID who are diagnosed with chronic illness through health screening are provided with follow‐up medical care. Otherwise, the better diagnoses of cardiovascular risk factors by health screening will be nullified if there is no subsequent treatment.

Our study has its limitations. To begin with, although the population in our study was drawn from a mix of both residential and non‐residential adults with ID, they were all receiving community support (in the form of services from the voluntary welfare organisation, MINDS) at the time of the study. Hence, they may be more highly cared for than other unsupported adults with ID, a factor that could indicate a healthier lifestyle and reduced cardiovascular disease risk factors, as well as greater participation in preventive services. Hence, the health profile of adults with ID in this sample may be an overestimate; we note, however, that other studies comparing the health profile of clinic‐based and population‐wide samples of adults with ID have shown no differences (Beange et al. [1] ; Wallace [34] ). The study population was also drawn from a single provider of services to adults with ID (MINDS); however, the service provider in question provides services nationwide at seven sites, all of which participated in the study, and is by far the largest provider of such services in Singapore. We did not quantify the degree of ID in our study; however, all study participants had been previously diagnosed by a doctor with ID. We also did not investigate if willingness to participate in free, access‐enhanced health screening translated into sustained behavioural change with regards to health screening participation among adults with ID.

In conclusion, screening rates for cardiovascular disease risk factors such as diabetes and dyslipidaemia were poor among adults with ID in Singapore. We tend to think of those with ID as young persons when in reality, they are becoming older persons in Singapore because of better paediatric and adult health care, contributing to longer life expectancies. Although the general cardiovascular disease risk of the study sample was still low, due in part to the relatively younger age (median of 46 years), the prevalence of cardiovascular disease risk factors among those checked (22.5% with hypertension, 10.6% with diabetes, 34.8% with dyslipidaemia, 54.1% overweight or obese, 10.7% obese, 90.6% of non‐residential MINDS clients lacking regular exercise) is still high, when compared against the general population. Clinicians providing care to adults with ID should thus have a low threshold for initiating screening for cardiovascular disease risk factors and ensure follow‐up for those diagnosed, and adults with ID should be supported by programmes to increase physical activity and reduce weight, with the assistance of their carers and professionals. Provision of free and convenient screening significantly increased participation in hypertension, diabetes mellitus and dyslipidaemia screening among adults with ID; however, more can be done to increase awareness among caregivers regarding the need and benefits of regular screening in this population with special needs.

None reported. The authors declare no conflict of interest.

The Movement for the Intellectually Disabled of Singapore provided funding support for arranging for screening tests for the patients involved in this study.

We thank the Movement for the Intellectually Disabled of Singapore for their assistance in the organisation of this programme and their support of this study.