currently , 1,457 residential care facilities across south korea provide rehabilitation 
 counseling , treatment , and training to disabled individuals as they prepare to reenter 
 society ( disability act , section 48 ) . the number of individuals enrolled in these long - term 
 care facilities is estimated to be 80,8461 . those with a developmental disability , for whom the impairment is not 
 apparent or is delayed , such as individuals with intellectual disability and autism spectrum 
 disorder ( development disability act , section 2 ) , have steadily increased in number over the 
 years to reach a total of 418,543 in 20141 . many developmentally disabled individuals reside in long - term care 
 facilities to achieve independence through treatment and rehabilitation . in addressing these figures , the ministry of health and welfare2 has made a tremendous effort to provide quality services 
 under the stated vision of  from destination to the residence of choice  . its major policy 
 goals include a shift to small - scale care facilities , establishment of quality standards , 
 and promotion of both suppliers and users right to choose . reflecting these changes , many 
 care facilities are developing and implementing various programs designed to incorporate 
 individual resident needs and desires with the aim of improving their quality of life . these 
 programs and services are offered through local communities and facilities in various 
 formats3 . unfortunately , services related to residents recreational activities are scarce , and due 
 to an insufficient supply of professional staff and funding , as well as information on 
 disabled individuals as it pertains to these programs , advancing these programs in a 
 systematic manner has been challenging . more specifically , it is difficult for disabled 
 individuals to participate in everyday sports and fitness activities , because of the 
 insufficient number of fitness facilities available to them , and the limited options in 
 terms of the type of fitness activities they can engage in . consequently , without someone s 
 active encouragement and support , a mere attempt at participation can be challenging for 
 intellectually disabled individuals . due to these issues , many individuals with an 
 intellectual disability residing in long - term care facilities tend to spend countless hours 
 without being able to engage in physical activity , despite the relative abundance of time at 
 their disposal4 , 5 . this results in an increased risk of obesity as well as other 
 health problems among these individuals . compromised health status can lead to a secondary 
 dysfunction . obesity , in particular , can lead to other highly prevalent chronic conditions 
 such as diabetes and hypertension , which have become a serious threat to those residing in 
 long - term care facilities6 . previously conducted korean studies on obesity and individuals with intellectual disability 
 analysed individuals residing in occupational rehabilitation facilities , a long - term care 
 facility , and welfare facilities and employed in an occupational rehabilitation facility . 
 however , research on the health of intellectually disabled individuals residing in care 
 facilities is lacking7 . this study investigated the effects of a walking exercise program on the obesity rate among 
 intellectually disabled individuals residing in a residential care facility . the ultimate 
 aim of this study was to confirm the critical importance of active obesity management 
 through a fitness program that promotes regular physical activity and to provide the basic 
 data required for effective obesity management of the disabled residing in residential care 
 facilities . the study subjects were 9 individuals with intellectual disability residing in a 
 residential care facility located in chungju city , chungcheongbukdo province . the 
 participants were deemed overweight or obese based on an inbody assessment conducted prior 
 to the intervention . none of the participants was receiving antipsychotics , and none had 
 visual , auditory , neurological or orthopedic impairments that impeded normal walking . a 
 thorough explanation of the study purpose was provided , after which consent was obtained 
 from each participating individual . the study period lasted 16 weeks , from august 1 to november 30 , 2014 . an occupational 
 therapist assessed each participant s body weight , body composition ( body mass index [ bmi ] , 
 body fat , and abdominal fat ) , basic fitness ( muscle strength and flexibility ) , and waist 
 circumference . the walking exercise used in this study is one of the most widely known cardiovascular 
 exercises . it is the easiest 
 and the most familiar form of exercise , both physically and mentally . most people enjoy 
 walking as a type of exercise regardless of age , fitness level , or technique , and it is 
 associated with very little risk of injury . it is therefore well - suited for individuals with 
 intellectual disability8 . for these reasons , each session 
 included approximately 10 minutes of warm - up and cool - down , during which participants 
 focused on range of motion and active stretching . the main portion of the walking exercise 
 program , which consisted of 3 walking sessions per week , was designed following the world 
 health organization ( who ) physical activity guidelines for adults between the ages of 1864 
 years9 . in order to reap greater health 
 benefits from the exercise program , a minimum of 300 minutes per week/ 100 minutes per 
 session was ensured with the help of 2 rehabilitation specialists . additionally , they are at an increased risk of malnutrition due to food - drug interaction , 
 metabolic dysfunction , and other developmental dysfunctions . these individuals also tend to 
 exhibit unhealthy eating habits such as fussy eating , preference for high - calorie food , 
 binge eating , and obsessing over food , all of which predispose them to increased body weight 
 due to excess fat accumulation . this study used an inbody 230 ( biospace , korea ) , a body composition measurement device , to 
 assess the changes in the participants body weights according to the dietary intake during 
 participation in social rehabilitation programs , dining - out , outdoor activities , and camps , 
 as well as to track the effects of the walking exercise program . measurements were taken in 
 the morning and post - exercise , on the same day of each month . because body weight 
 measurement can vary significantly depending on the time of day and the amount of food 
 intake , the participants body weight were measured on an empty stomach to ensure accuracy 
 and minimize deviation . inbody 230 ( biospace , korea ) was used to track the changes in participants body 
 compositions during participation in the walking exercise program . bmi , body fat , and 
 abdominal fat , which are used to assess obesity , were measured and recorded . participants were instructed to remove any personal adornments such as wristwatches and 
 similar items . sufficient information on the measurement method and correct body posture 
 required for accurate measurement as well as visual cues were provided . participants were instructed to take off 
 their socks followed by cleansing of the palms and soles with wet wipes , after which they 
 were assisted in standing correctly on the spot marked on the device for accurate 
 measurement . participants were instructed to hold the device handles with both hands , with their arms 
 slightly parted for measurement of body weight , which was followed by impedance analysis of 
 each body segment . a total of 10 measurements were taken for the impedance analysis , which 
 consisted of measurements at 2 different frequencies ( 20 khz and 100 khz ) of 5 different 
 body segments ( right arm , left arm , torso , right leg , left leg ) . the 4-electrode 8-point 
 impedance method and a direct segmental multi - frequency bioimpedance method ( dsm - bia ) were 
 used . baseline fitness refers to the physical ability required by an individual for a normal 
 daily life . it can be distinguished into health fitness and sports fitness . in consideration 
 of the 2014 fitness assessment and evaluation guidelines issued by the ministry of health 
 and welfare s community integration health promotion project , this study measured 
 participants muscle strength and flexibility ( components of health fitness ) prior to 
 starting the exercise program . in order to examine the changes , sit - up counts and trunk flexibility were measured after providing a 
 thorough explanation and visual cues to the participants . sit - ups , used traditionally as a method for measuring strength , are easily administered , as 
 they require only a mat and a timer10 . in 
 this study , participants were instructed to lie supine on the mat with knees bent and 
 fingertips behind their ears ; they were asked to raise the upper body until their elbows 
 touched the knees and then roll back down to the starting position . the flexibility test used in this study , which required the participants to bend their 
 torso at the hips , is a widely known and standardized test . participants were instructed to 
 remove their shoes and stand on the device with the backs of both heels touching the stand . they were instructed to gently press the knees and bend the torso . at the point where 
 participants could hold the position for at least 2 seconds the test was performed twice for each participant , and the better 
 result of the two was accepted . waist circumference is closely associated with diabetes , cardiovascular diseases , and risk 
 of hypertension . this study followed the body weight management guidelines recommended by the type 2 
 diabetes clinical research center designated by the ministry of health and welfare . additionally , to track the changes before and after the exercise program , measurements were 
 taken once a month . measurements were taken after providing a thorough explanation of the 
 procedure as well as visual cues to the participants . participants were instructed to stand 
 with their feet approximately 2530  cm apart , and measurements were taken with a tape 
 measure between the lowest ribs and hip bone ridge . descriptive statistics 
 were used for the participants general characteristics . to compare changes in body weight , 
 baseline fitness ( strength and flexibility ) , the waist circumference , a non - parametric test 
 ( the friedman test ) was used . for the analysis of the changes in bmi , body fat , and 
 abdominal fat , a non - parametric test ( the wilcoxon signed rank test ) a descriptive statistical analysis was conducted to analyze the general characteristics of 
 the 9 study participants who were residing in a residential care facility . their average age 
 was 42.33  years and their average height was 160.69  cm . concerning disability ratings , 6 
 participants had a level 1 disability , 1 participant had a level 2 disability , and 2 
 participants had a level 3 disability ( table 
 1table 1.general characteristicsnumber ( n)age ( yrs)length ( cm)disability rating1st grade ( n)2nd grade ( n)3rd grade ( n ) 942.310.5160.79.8612 ) . wilcoxon s signed - rank test , a non - parametric testing method , was used to compare changes 
 in the participants body composition before and after the exercise program . the results of 
 the analysis show that average bmi decreased from 26.8 pre - exercise to 25.9 post - exercise ; 
 average body fat decreased from 35.4% pre - exercise to 31.0% post - exercise ; and average 
 abdominal fat decreased from 1.0% pre - exercise to 0.9% post - exercise . the analysis results 
 for all 3 indexes indicate that the changes were statistically significant , suggesting that 
 the walking exercise program had a positive effect on the participants body composition 
 ( table 2table 2.body composition analysis ( n=9)itempre - treatpost - treatmeansdmeansdbmi * * 26.8 3.6 25.9 3.4 body fat ( % ) * * 35.4 7.8 31.0 8.7 abdominal obesity ( % ) * * 0.98 0.05 0.93 0.05 * * p < 0.01 ) . the friedman test , a non - parametric test , was used to analyze the monthly changes in 
 participants as they participated in the walking exercise program . the results of the 
 analysis indicate that the participants average body weight steadily decreased over 4 
 months , from 69.6  kg to 67.3  kg . statistical verification yielded =35.289 and a 
 99.9% confidence level , indicating that the decrease was statistically significant ( table 3table 3.comparison of participants physical characteristics before and after the 
 exercise regimen ( n=9)base1 month2 months3 months4 monthsmeansdmeansdmeansdmeansdmeansdweight ( kg ) * * * 69.6 11.0 69.3 11.0 68.510.9 67.9 10.7 67.3 10.6 strength ( kg ) * * * 16.34.919.76.021.35.622.66.024.87.5flexibility ( cm ) * * * 3.339.633.229.762.118.920.948.841.178.11waist size ( cm ) * * * 37.34.536.64.536.24.635.84.635.14.2 * * * p < 0.001 ) . therefore , the friedman test was also used to examine the changes in the monthly baseline fitness 
 levels ( strength and flexibility ) during participation in the walking exercise program . the 
 results of the analysis show that the average strength steadily increased from 16.3 to 24.8 
 over 4 months . statistical verification yielded =30.341 and a 99.9% confidence 
 level , indicating that the increase in strength was statistically significant ( table 3 ) . the average flexibility , which was 3.3  cm pre - exercise , also steadily increased over the 4 
 months to 1.2  cm . statistical verification yielded =29.3972 and a 99.9% 
 confidence level , indicating that the increase was statistically significant ( table 3 ) . therefore , the exercise regimen 
 had a positive effect on the participants average strength and flexibility . the friedman test was also used to analyze the monthly changes in the average waist 
 circumferences of the participants during participation in the walking exercise program . the 
 results of the analysis show that the participants average waist circumference steadily 
 decreased over 4 months , from 37.3 cm pre - exercise to 35.1 cm post - exercise . statistical 
 verification yielded =34.583 and a 99.9% confidence level , indicating that the 
 decrease was statistically significant ( table 
 3 ) . therefore , the exercise program had a positive effect on the participants waist 
 circumference . obesity is a serious health problem that reduces life expectancy and threatens the quality 
 of life of individuals with disability12 , 
 and threatens their health , as it is often a precursor to highly prevalent chronic 
 conditions such as diabetes and hypertension . although the cause of obesity among disabled 
 individuals is unclear , changes in body composition due to inactivity and muscle atrophy as 
 well as physiological changes are implicated13 . the most relevant studies have reported higher obesity prevalence 
 among individuals with disability than among healthy individuals , and an even higher 
 prevalence rate of morbid obesity14,15,16 . 
 for individuals residing in a long - term care facility , in particular , a low level of 
 physical activity and limited living sphere can easily lead to obesity . increased abdominal fat , among the various criteria used to evaluate obesity , is known to 
 result in decreased balance as it negatively affects flexibility while shifting the 
 musculoskeletal structure17 . obesity 
 tends to cause arching of the affected individual s back , and increased stress on the 
 muscles surrounding the spine can result in back pain18 . subsequent postural instability can also lead to low back pain and 
 diminished flexibility , and the resulting limited range of motion can lead to secondary 
 inactivity and obesity19 . the main goal 
 of obesity management is to decrease the size of the fat tissues while minimizing the 
 effects on fat free mass ( ffm ) . cardiovascular exercise is known to be the very effective at 
 decreasing the amount of accumulated fat by utilizing fat as fuel to produce energy . walking 
 exercise , like many other cardio exercises , improves cardio - respiratory endurance and 
 increases secretion of growth hormones ( epinephrine and nor - epinephrine ) , which are known to 
 promote loss of accumulated fat . furthermore , increased hormone secretion promotes protein 
 synthesis , which has a positive effect on muscle growth and increased ffm . walking exercise is actively promoted for fat loss , as it is a very effective low - impact exercise that 
 carries a low risk of injury . therefore , this study implemented a walking exercise program 
 for overweight individuals with intellectual disability residing in a residential care 
 facility . the program followed the who physical activity guidelines for adults9 and was designed to incorporate 3 exercise 
 sessions per week for 16 weeks , during which the participants body weight , body composition 
 ( body fat and abdominal fat ) , baseline fitness level ( strength and flexibility ) , and waist 
 circumference were continually monitored . the most important component of obesity management is continuous weight management , which 
 requires a great deal of effort . overweight individuals with disability residing in 
 residential care facilities must make it a daily habit to exercise for weight management 
 using life redesigning programs . in this study , the participants body weight steadily 
 dropped over the 16 weeks of the obesity management program from an average of 69.6  kg to 
 67.3  kg , a 2.3  kg decrease . previous studies have reported that increased physical activity 
 leads to increased calorie burn and activation of enzymes that extract energy from fat 
 cells , which results in an active supply of energy , fat loss , and decreased body weight . additionally , the participants average bmi decreased by 0.9 , from 26.8 to 25.9 ; average 
 body fat decreased by 4.4% , from 35.4 to 31.0 ; and the average abdominal fat decreased by 
 0.1% , from 1.0 to 0.9 . the average waist circumference decreased from 37.3 cm to 35.1 cm , a 
 2.2 cm decrease . these results are attributable to energy expenditure during walking and 
 consequent decrease in body weight and fat . according to a study20 , walking utilizes 
 90% of all muscles ( including lower and upper extremity muscles ) , strengthens the muscles 
 and increases the stability of the upper segment of the spine . the results of this study 
 support these findings as well , as evidenced by the fact that the participants average 
 muscle strength increased by 8.5 more sit - ups , from 16.3 to 24.8 . average flexibility also 
 increased from 3.3 to 1.2 , which is a 4.5  cm increase . walking exercise appears to be an effective exercise , and an active walking program had 
 positive effect on the level of obesity , and significantly reduced body weight , body fat and 
 waist circumference21 . also , walking 
 exercise contributed to reductions in body weight and body fat by increasing muscle tissue , 
 maintaining muscular strength and increasing flexibility22 . these reports support our present findings , which suggest that 
 walking serves as an effective exercise for overweight and obese individuals with 
 intellectual disability . as this study involved only 9 obese 
 individuals with intellectual disability residing in a single residential care facility , the 
 findings can not be generalized . additionally , the participants dietary intake including 
 meals and snacks served at the facility , as well as other dietary intake occurring while 
 participating in various activities , was not controlled . for these reasons , verifying the 
 pure effects of the exercise program was difficult . it would be beneficial for future 
 studies to address controlling of the various factors that may influence the study 
 results . this study investigated the effects of a 16-week walking exercise program in overweight and 
 obese individuals with intellectual disability residing in a residential care facility . it 
 was found that the participants body weight , body composition ( bmi , body fat , and abdominal 
 fat ) , and waist circumference decreased significantly , while baseline fitness ( muscle 
 strength and flexibility ) improved significantly . obesity management is critically important 
 for individuals with intellectual disability residing in residential care facilities . accordingly , walking 
 exercise programs should be offered to obese individuals with intellectual disability 
 residing in residential care facilities .