INTRODUCTION: Intellectual and Developmental Disabilities (IDD) have been associated with high cardiometabolic risk in adults, but there is little data on youth. This study describes the prevalence of cardiometabolic risk factors among pediatric patients with and without IDD receiving care in a large, primarily rural health system. METHODS: This was a retrospective cohort study of patients aged 6-17 years with an index visit from August 1, 2022, to July 31, 2023, at one of 44 primary care clinics in a Midwestern health system. IDD status was defined by ICD-10 diagnostic codes. Demographic and clinical characteristics were gathered from the electronic health record. The odds of having each cardiometabolic risk factor measured, and the odds of having screened positive for each risk factor, were compared in 2024 using unadjusted ORs and CIs. RESULTS: The prevalence of any IDD diagnosis among 33,192 eligible patients (mean age 11.6 years, 50% male) was (1,206/33,192) 3.6%, with autism being the most common (749/1,206, 62%). Though the likelihood of cardiometabolic risk factor measurement was similar, the prevalence of positive risk factors was higher in those with IDD. The odds of having obesity (OR=3.8, 95% CI=3.1, 4.8), current smoking or passive smoke exposure (OR=1.4, 95% CI=1.2, 1.6), a hypertension diagnosis (OR=6.4, 95% CI=3.8, 10.7), diabetes diagnosis (OR=2.67, 95% CI=1.2, 5.3), prediabetes diagnosis (OR=6.8, 95% CI=3.6, 12.9) or dyslipidemia (OR=3.5, 95% CI=2.9, 4.2), were all greater in patients with IDD than without IDD. CONCLUSIONS: This study reports disparities in risk between pediatric patients with and without IDD. Future research and intervention programs should focus on young people with IDD to prevent adverse cardiometabolic outcomes later in life.