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Contents lists available at ScienceDirect

Obesity Research & Clinical Practice

journal homepage: www.elsevier.com/locate/orcp

Review

Delayed motor skills associated with pediatric obesity

Benjamin Zacks a , Kristen Confroy a , Sherry Frino b,c , Joseph A. Skelton b,c,∗
a
Wake Forest School of Medicine, Winston-Salem, NC, United States
b
Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, United States
c
Brenner FIT (Families In Training) Program, Brenner Children’s Hospital, Wake Forest Baptist Health, Winston-Salem, NC, United States

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To review the literature regarding associations between developmental motor delay (DMD)
Received 11 May 2020 and pediatric obesity. We hope to identify potential interventions that can improve motor coordination
Received in revised form at an early age, thereby minimizing the deterring factors of physical activity down the road.
18 September 2020
Design: An integrative review was undertaken using search combinations to best identify potential pub-
Accepted 9 October 2020
lications. Manuscripts were reviewed, summarized, and discussed in detail. An experienced clinician in
pediatric obesity reviewed the final searches for substantive content.
Keywords:
Criteria: Inclusion criteria include English language studies or publications, children ≤18 years old, pub-
Pediatric obesity
Motor development
lication/study relates to DMD and pediatric obesity. Excluded publications regarded topics of pediatric
Intervention obesity that have been extensively studied such as maternal and family histories of obesity, isolated
nutritional or physical interventions to improve obesity without discussion of DMD.
Results: 21 publications were included for review. Papers fell into three main categories regarding the
association between pediatric obesity and DMD: 1) Motor function - negative association with motor
function and obesity 2) Motor Development - lower levels of motor function are associated with decreased
levels of exercise, and 3) Role of Intervention - specific physical activity intervention showed improve-
ments in motor function.
Conclusions: Motor function deficits appear to be associated with obesity. However, it is not well under-
stood if children with obesity have delayed motor skills as a consequence of their weight or if the DMD
is a risk factor for the development of obesity; existing studies do not provide an answer.
© 2020 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights
reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Inclusion and exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Paper identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Results and findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Motor function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Motor development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Ethical statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

∗ Corresponding author at: Department of Pediatrics, Wake Forest School of

Medicine, Medical Center Blvd, Winston-Salem, NC 27157, United States.
E-mail address: jskelton@wakehealth.edu (J.A. Skelton).

https://doi.org/10.1016/j.orcp.2020.10.003
1871-403X/© 2020 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Zacks B, et al, Delayed motor skills associated with pediatric obesity, Obes Res Clin Pract,
https://doi.org/10.1016/j.orcp.2020.10.003
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Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
CRediT authorship contribution statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

Introduction Methods

The prevalence of children with obesity continues to be on the In an attempt to examine the current literature on developmen-
rise across the world [1–3] despite many attempts at addressing tal motor delay in children with obesity, an integrative review was
the epidemic [1,2]. While some studies in the last few years sug- undertaken. An integrative review allows for combining various
gest stabilization of these rates [4,5], many other reports show no and diverse methodologies [33], which can be useful in informing
decrease in any age group since 1999 [1,2]. Regardless, nearly 1 in clinical assessment and treatment guidelines or practice, suiting
5 children in the United States fall in the category of obese (defined the objective of this review. As such, it is not as exhaustive as a sys-
as a BMI greater than or equal to the 95th percentile for age and sex tematic review and/or meta-analysis, but can effectively surveil the
by standard CDC growth charts) [2]. Many factors have been iden- existing literature and coherently synthesize findings. Integrative
tified to contribute to the rising numbers of children with obesity review methodology was utilized due to the breadth of disciplines
including a decrease in activity level [6,7], over-nutrition [8,9], and working in this area (development, general pediatrics, rehabilita-
genetic-environment interaction [10,11]. tion, biomechanics), which requires more iterative synthesis and
Physical activity is a staple of any successful prevention or interpretation of findings, and the goal to provide guidance to
weight management program. However, there are few guidelines practicing clinicians. However, a MEDLINE (Pubmed) electronic
in place for effectively increasing physical activity in children library search was conducted systematically, for all years with
with obesity [12]. Often, youth sports are an excellent option for specific keywords. Our subject heading search terms were Obe-
children to find more ways to be active [13]. Unfortunately, chil- sity and Child Development, and included: motor activity, sports,
dren with obesity are not participating in sports as frequently motor skills, and motor skill disorders, and were limited to stud-
as their healthy weight counterparts [14,15]. This is thought to ies published in English. The literature search generally followed
be due to lack of self-efficacy in themselves performing physi- the Preferred Reporting Items for Systematic Reviews and Meta-
cal activity [14]. Children with obesity lack self-efficacy because analysis (PRISMA) guidelines in designing and conducting the
they are often victimized by their peers [16,17]. Specifically, these literature search.
children are affected by physical competence, appearance, and
social functioning [16]. Some pediatric weight management pro-
grams have even seen an increase in overall self-esteem through Inclusion and exclusion criteria
weight changes, parent involvement, and group intervention
[18]. Inclusion criteria include English language studies or pub-
While this lack of confidence could be due to excess weight and lications, children ≤18 years old, publication/study relates to
lack of mobility, it could also be related to a delay in both fine and developmental motor delay (DMD) and pediatric obesity, including
gross motor skills in children with obesity [19,20]. Fine motor skills parameters such as physical fitness, athleticism, coordination, gross
refers to the coordination of smaller muscle groups such as the and fine motor skills, and possible improvements with interven-
hands and fingers with the eyes. Gross motor skills refer to the tion, and general associations between DMD and obesity. Excluded
movements of larger muscle groups such as the torso and legs to publications were those regarding topics of pediatric obesity that
coordinate walking and throwing. The association between obe- have been extensively studied such as maternal and family histories
sity and developmental motor delay (DMD), or children showing of obesity, isolated nutritional or physical interventions to improve
unusually slower fine and gross motor development when com- obesity without discussion of DMD.
pared to their peers, is not as well understood as the previously
mentioned factors, such as lack of healthy nutrition and inactivity.
Many studies have identified delayed fine and gross motor skills in
Paper identification
children with higher BMIs [18]. In children as young as 6 months,
children with obesity were found to have lower motor composite
With the assistance of a medical librarian, one investigator
scores as compared to normal weight children [21]. Other studies
(BZ) systematically searched MEDLINE libraries for potentially
have shown the same motor delay in older children with obe-
eligible articles, initially reviewing all search results (titles and
sity [22–27]. Fortunately, intervention can improve gross motor
abstracts) to assess relevance to the study objective (Fig. 1). Com-
coordination and fundamental movement skills in this population
plete manuscripts were reviewed in-depth and summarized by
[28–31].
the primary investigator (BZ) and discussed in detail with a sec-
With activity playing an integral role in maintaining a healthy
ondary (KC) and senior investigator (JAS). Pertinent references
weight in children, identifying any barriers to exercise is imper-
from manuscripts were reviewed for inclusion. Finally, the senior
ative to proper care of this population. If DMDs are a contributor
investigator, an experienced clinician in pediatric obesity (JAS) and
to lack of physical activity [32], a better understanding of these
physical therapist (SF) reviewed the final searches for substantive
challenges may help clinicians better care for children with
content.
obesity. The overall objective of this paper is to review the
Pertinent to review and the topic, motor development, skills,
literature regarding associations between DMD and pediatric obe-
and function was conceptualized as it pertains to child physical
sity. With that, we hope to identify potential interventions that
activity, exercise, and sports, applicable to investigating, assessing,
can improve motor coordination at an early age, thereby min-
or treating children with weight issues. Studies were not included if
imizing the deterring factors of physical activity as the child
they dealt with other aspects of child development, such as speech,
ages.
swallowing, developmental milestones, etc.

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B. Zacks et al.
Fig. 1. Literature search results.
Results and findings
Our original search yielded 99 manuscripts/studies. After
screening for relevant titles and abstracts, 17 studies were iden-
tified as meeting the inclusion criteria and were included for full
paper review. Of these 17, four papers were removed after full
review because they did not meet the inclusion criteria. Thus, upon
detailed review of the full manuscripts, 13 papers were included in
this review. Eight additional studies were identified from reviewing
references of included studies, and were found to correlate with our
eligibility and exclusion criteria. In total, 21 manuscripts/studies
were included for final review.
Overall, results from the papers are identified on Table 1. Find-
ings from the 21 included studies were categorized into three main
categories regarding the association between pediatric obesity and
DMD. These include 1) Motor function 2) Motor Development, and
3) Interventions to improve motor function in different capaci-
ties such as physical activity and coordination. Motor function is
defined as the ability for a child to effectively control their differ-
ent movements and postures [34]. Separately, motor development
is the proper maturing of these skills as a child ages. For the purpose
of this review, the motor function section describes the association
between obesity and the child’s ability to control their movements
and postures. The motor development section describes how obe-
sity and developmental motor delay hinder the healthy growth of
a child.
Motor function
Eleven papers discussed pediatric obesity and its positive associ-
ation with motor function delays. Of these, five used motor function
evaluation tools that assess for gross motor function only. Six oth-
ers used tools that assessed both gross and fine motor skills. The
tools that were used for these papers can be found in Table 2.
The association with obesity and motor function, fine and gross,
was investigated using various methods, all in a cross-sectional
manner. Of these six studies, four found a significant negative asso-
3
Obesity Research & Clinical Practice xxx (xxxx) xxx–xxx
ciation with motor function and obesity [22,23,25]. These studies
focused on a population that included both obese and healthy
weight children. In one study, compared to children with a nor-
mal weight status, children with obesity had significantly poorer
total and gross motor skills at both 5 and 10 years of age [26].
Additionally, children with DMD reflected an increased likelihood
of being sedentary and having poor physical fitness levels [23].
Another study found males and advancing age caused the asso-
ciation between obesity and motor delay to strengthen [24].
Conversely, there were two studies that did not explicitly find
an association with obesity in both fine and gross motor skills. The
study by Gentier found gross motor skill delay was more associated
with obesity compared to fine motor skills [27]. This can be con-
cluded by focusing on each aspect within the Bruininks-Oseretsky
Test of Motor Proficiency 2nd edition (BOTMP-2) evaluation tool
as some tasks focus on gross motor skills and others focus on fine
motor skills. It was found that participants scored inferiorly in 6/9
gross motor tasks of the BOTMP-2 compared to healthy weight
counterparts. This compares to a significant difference in only 1
out of 5 fin. motor tasks between healthy and overweight partici-
pants [27]. A study by King-Dowling et al., whose primary objective
was not focused on DMD and BMI, did note that there was no dif-
ference in BMI between children with Developmental Coordination
Disorder and children developing typically [35]. Also, in a study by
Camargo et al., a significant difference was found in motor com-
posite scores when comparing children with healthy weight and
with obesity/overweight. However, no significant association was
established between BMI and motor scores. Because of this, their
conclusion was that weight status and developmental milestones
are largely independent of one another [21].
In the studies that focused on gross motor skills specifically,
one overarching theme prevailed among each of the five stud-
ies: overweight status is associated with decreased gross motor
skills [36–40]. For example, one study found a greater percent-
age of children with overweight and obesity were motor impaired
compared to healthy weight [36]. This same study noted that
among these children, 10−12 year olds with overweight/obesity
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Table 1
Studies of pediatric obesity and developmental motor delay.

Author, Year Ages Sample size Study objectives Major findings/results

Carmargos, 2016 6−24 months 56 Compare cognitive and motor development in
[21] infants with overweight/obesity versus
normal-weight peers and investigate
correlation of body weight, length, and BMI w/
cognitive and motor development
Cawley, 2008 [22] 26 to 44 11,000 Examine if obesity in childhood causes lower
months house-holds skill attainment and inhibits functionality as an
adult.
Tests motor skills, social skills, verbal skills,
and activities of daily living
Cermak, 2015 [23] 6−11 years 118 Study the relationships between children’s
motor coordination and their physical activity,
sedentary behavior, fitness and weight status
in a cross-cultural study in the United States
and Israel.
Cheng, 2016 [26] 5−10 years 668 Understand the direction of association
between poor motor skills and increased body
weight in children
D’hondt, 2011 [35] 5−12 years 954 Investigate differences in gross motor
coordination in healthy-weight, overweight,
and obese children of different ages. Weight
status related to KTK scores and expressed as
age related motor quotient
Gentier, 2013 [27] 7−13 years 68 Focuses on possible weight related differences
in gross as well as fine motor skill tasks. Using
Bruininks–Oseretsky Test of Motor Proficiency
Graf, 2004 [36] 5−7 years 668 Examines the association between body mass
index (BMI), motor abilities and leisure habits
of 668 children within the CHILT (Children’s
Health InterventionaL Trial) project.
Grillich, 2016 [31] 8 years 925 Assess the effectiveness of an integrated health
promotional program in Austrian elementary
schools, using a framework to increase
children’s emotional and social experience,
physical activity and well-being.
Significant differences found in motor
composite scores between the two groups
with obese/overweight group receiving a
lower score
Used Bayley Scale of Infant and Toddler
development
Found no associations between weight status
and motor development, which suggests that
no relationship between weight status and
motor milestones
Higher BMI is associated with significantly
lower motor skill index p < 0.05 for boys
11 points higher BMI equates to one point
lower on their test of 10 points
Used MABC-2, strength subtest of BOT-2, and
6-minute walk to determine developmental
coordination disorder
Children with Developmental coordination
disorder showed reduced physical activity,
increased sedentary behavior, worse fitness
levels, and increased overweight status when
compared to typical children
Higher BMI at 5 years contributed to declines
in motor proficiency from 5 to 10 years
No support for poor motor skills at 5 years of
age leading to increased relative weight from 5
to 10 years old
Obese children had lower motor skills at both 5
and 10 years old when compared to normal
weight children
Argue that obesity precedes declines in motor
skills, not the other way around
Healthy weight kids had motor quotient scores
without significant difference across age
groups(p = 0.999)
Lower KTK scores were seen in obese children
ages 10−12 compared to obese 5−7 year olds
(p < 0.01)
A lesser incidence of motor impairment was
seen with the healthy-weight participants
compared to the children that were
overweight and obese
Obese children scored lower in both gross
aspects of fine motor
Gross motor: HW children scored significantly
higher in 6/9 of the BOT-2 gross motor skills
items.
Obese children had lower fine motor precision
scores than that of the healthy weight group
No significant difference in fine motor
integration, however
Among children in the obese group, 38.2%
showed below average performance in their
motor skills
Both KTK and 6 min run test were inversely
correlated with BMI
KTK and BMI r = −0.164 p < 0.001
6 min run and BMI r = −0.201 p < 0.001
Children in the intervention group had better
results for coordination with precision, spatial
orientation, and faster complex reaction ability
compared to children in the control group

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Table 1 (Continued)

Author, Year Ages Sample size Study objectives Major findings/results

Han, 2017 [30] 4−17 years 17 papers Determine the effectiveness of exercise Physical activity and exercise intervention
intervention on improving fundamental improved motor function
movement skills and motor coordination in
overweight/obese children and adolescents: A
systematic review
Evaluation tests included Test of Gross motor
development, KTK, General -sports-motor test,
Motor test battery
Hendrix, 2013 [24] 4−14 years 21 Studies Assess the association between developmental Higher BMI scores, a larger waist
(Systematic coordination disorder and overweight and circumference, and increased percentage body
review) obesity in children and whether this fat was seen with children who had
association is influenced by age and/or gender developmental coordination disorder when
compared to controls
Risk seems to be higher with males and
increases with age and with severity of motor
impairment
Henrique, 2016 3−5 years 206 Investigate if baseline motor competence, Better locomotor skills (OR = 1.21, CI:
[51] weight status, and sports participation in early 1.01–1.46) and previous participation in
childhood predict sports participation two organized sports (OR = 1.21, CI: 1.01–1.46)
years later significantly predicted sports participation
after two years
King-Dowling, 4−5 years 592 Determine if 4- and 5-yr-old children with Used Movement Assessment Battery for
2019 [34] developmental coordination disorder (DCD) Children-2 to identify DCD (≤5th percentile),
exhibit poorer fitness compared with typically at risk for DCD (6th-16th percentile), and TD
developing (TD) children, and if mediated by (>16th percentile)
vigorous physical activity (VPA) engagement.
Fitness and flexibility were assessed as well
When assessing musculoskeletal and aerobic
fitness, DCD group had the lowest scores and
TD group had the highest
No difference in BMI or vigorous activity levels
Koning, 2016 [3] 4−12 years 613 Identify trajectories in BMI and their Children with the increasing BMI trajectory
associations with dietary, sedentary, and had significantly decreased participation in
physical activity behaviors organized sports when compared to the lower
BMI trajectory group in 2012.
Sedentary behaviors were more common in
increasing BMI trajectory
Logan, 2012 [29] 3−10 years 11 studies Fundamental movement skills (FMS) that need 6−15 weeks for motor intervention group
to be learned and practiced are measured including locomotor skills (run, gallop, hop,
before and after motor skill intervention, pre leap, jump, skip) and object control skill
and post qualitative assessment of FMS (strike, dribble, catch, kick ball)
competence
(Meta- Used Test of Gross Motor development for
Analysis) qualitative measurement
Children demonstrated significant
improvement in FMS post intervention as
measured by TGMD for treatment group and
significant for both object control and
locomotor skills when analyzed independently
Lopes, 2018 [37] 6−10 years 3738 Evaluate the relationship between the BMI In each age group, thin or normal weight
across its entire spectrum and motor children scored higher KTK scores than their
coordination (MC) in children 6−10 years. obese or overweight counterparts
Mond, 2007 [38] 4−8 years 9415 Examine associations between obesity and Among the parameters tested, obese males
impairment in developmental functioning in were more likely to have impairments in their
general population sample of pre-school gross motor skills when compared to normal
children (motor development, speech, weight male children (adjusted odds ratio =
cognitive, and psycho-social) 1.76, 95% CI = 1.02, 3.01, P < 0.05)
An association was seen between gross motor
skill impairment between genders and obesity
(adjusted odds ratio = 1.65, 95% CI = 1.06, 2.56,
P < 0.05)
Nevic, 2011 [39] 3−5 years 50 Investigate relationship between obesity and 24% of study was overweight/obese and 58% of
gross motor development in children who are these patients scored below average on the
developing typically and determine whether PDMS-2 while only 15% of the nonoverweight
BMI predicts difficulty in gross motor skills group.
An association was found between the gross
motor quotients and BMI (P < 0.002)
Nobre, 2017 [28] 7−9 years 59 Analyzed the effects of a protocol of plyometric Evaluated gross motor skills change with KTK
training on body composition and motor test
performance of boys who were
overweight/obese aged 7–9 years.
Plyometric physical training showed to
significantly improve gross motor coordination
after 12 weeks

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Table 1 (Continued)

Author, Year Ages Sample size Study objectives Major findings/results

Rodrigues, 2013 1 st to 4th 472 Test how different developmental pathways of An increased risk for obesity and overweight
[41] grade health-related physical fitness and motor status was seen in the low rate of change
competence tests relate to weight status at the groups in 10 m shuttle run, long jump, and
end of primary school flexed arm hang (OR 4.61 standing long jump
and OR 2.01 for 10 m shuttle run)
Wrotinak, 2006 8−10 years 65 Examine the relationship between motor A significant association was seen between the
[40] proficiency and physical activity in 8- to activity counts per minute (r = .32, p = .011), %
10-year-old children. Self-efficacy toward of time in sedentary activity (r = −0.031, p =
physical activity was also assessed. 0.012), moderate physical activity (r = 0.33, p =
0.008), and moderate to vigorous physical
activity (r = 0.30, p = .016) and the BOTMP
score the child received
Zhu, 2014 [25] 9−12 years 2057 Compare the prevalence of overweight and Movement Assessment Battery for Children
obesity in typically developing (TD) children, was used to assess motor coordination ability
children with DCD and balance problems Those with both DCD and BP were at a
(DCD-BP), and children with DCD without significantly greater risk to be obese when
balance problems (DCD-NBP) compared to the TD and DCD-NBP groups

Table 2
: Motor function evaluation tools.

Motor Function Evaluation Tools Description

Bayley Scale of Infant and Toddler 䊉 Ages birth to 42 months䊉

development
Bruininks-Oseretsky Test of Motor Proficiency,
Second Edition (BOT-2)/Short Form (BOT-SF)
Körperkoordinationstest für Kinder (KTK)
Movement Assessment Battery for Children,
Second Edition (MABC-2)
Peabody Developmental Motor Scales, Second
Edition (PDMS-2)
Cognitive, language, motor, social-emotional, and adaptive behavior scales䊉
Assess fine and gross motor skills
䊉 4−21 year olds䊉
Measure of fine and gross motor skills
䊉 5−15 year olds䊉 Assess motor coordination via four tasks
䊉 3−16 year olds䊉
Designed to identify and describe impairments in motor performance
䊉 Birth to 5 year olds䊉
Combines in-depth assessment with training or remediation of gross and fine motor skills䊉
Six subtests: reflexes, stationary, locomotion, object manipulation, grasping, visual-motor
integration

had significantly lower KörperKoördinationsTest für Kinder (KTK)
motor scores compared to children ages 5–7 [36]. Another used the
Peabody Developmental Motor Scales 2nd edition (PDMS-2); this
study found 58% of children with obesity scored below this national
average compared to only 15% of children at normal weight status
[40]. In similar regards to the study by Hendrix, Mond et al. found
a specific correlation to males. It was found that specifically male
children with obesity were more likely to have impairments in their
gross motor function when compared to male children of normal
weight [39].
Motor development
Six studies focused on how obesity and DMD could play a role
in the development of a child. Four out of six of these studies
did so in a longitudinal fashion to discover relevant behaviors
that predominated in children with DMD and any temporality of
obesity in its association with DMD, while the other two studies dis-
cussed the relationship of DMD and activities that promote healthy
development and weight, such as sports participation and physical
activity levels. Overall, these studies suggest that DMD is associ-
ated with a state of decreased fitness compared to children with
typical motor development. The articles that specifically discuss
DMD and its relationship to sports participation and physical fitness
found a negative association between the two [3,24,35,41]. Specifi-
cally, current sports participation and locomotor skill were positive
predictors for children’s sports participation in the future [24].
Another study analyzed BMI trajectories among children for a six
year period. Participants with increasing BMI trajectory were found
to have a significant decrease in the amount of participation in orga-
nized sports when compared to the lower BMI trajectory [3]. When
analyzing these two together, this proposes that children with bet-
ter locomotor skills were more likely to participate in sports and
this could cause them to be less likely to have an increased BMI. A
different cross-sectional study compared levels of physical activity
to scores on the PDMS-2 and BOTMP-2. The results of this study
found a significant positive association between the motor skills
scores and physical activity levels. There was also a negative asso-
ciation between the motor skills scores and sedentary activity levels
among children [41]. This trend showed that lower levels of motor
function are associated with decreased levels of exercise. Similarly,
the study by King-Dowling et al. shows that although no difference
in BMI was noted between children with developmental coordina-
tion disorder and typically developed children (discussed in motor
function section previously), the developmental coordination dis-
order group had the lowest musculoskeletal and aerobic fitness
whereas the typically developing children had the highest [35].
Another category we identified within the development of chil-
dren revolves around the temporality of the relationship between
DMD and obesity. Two papers specifically looked at this with lon-
gitudinal studies. In the first, motor competence was measured
using long jump, 50 m dash, and 10 m shuttle run while fitness
was measured using tests for strength, flexibility, and cardiovascu-
lar endurance. Their motor competence and fitness were followed
from 1 st to 4th grade, and positive and negative trajectories deter-
mined. It was determined that children with a negative trajectory
for motor competence or physical fitness had a significantly higher
odds ratio to be overweight or obese by the end of primary school
[42]. Another study focused on children over a five-year period.
Using the Bruininks-Oseretsky Test of Motor Proficiency Short Form
(BOTMP-SF), it studied the relationship of motor development and
obesity over this period. They found that a high BMI can predict
declines in motor function for this group of 5–10 year olds. Because
of this, the authors conclude that obesity in the child precedes the
delay in motor skills, and not the reverse [26].

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Intervention
Four studies investigated interventions to improve motor func-
tion. Overall, interventions that used specific methods of physical
activity or exercises showed improvements in motor function
[28–31]. One study specifically showed that plyometric techniques
were used to improve motor coordination after 12 weeks within a
group of 7–9 year old boys. This training consisted of exercises such
as hand grip strength, long jump, curl ups, and mile runs among
others. The KTK was used to evaluate gross motor change and
significant improvement was noticed [28]. Another study investi-
gated the relationship of motor skills and “fundamental movement
skills”, involving large muscle groups and object control such as
catching/dribbling a ball, running, and jumping. This meta-analysis
included 11 studies that had motor interventions spanning from 6
to 15 weeks, focusing on locomotor skills such as running, jumping,
and skipping. The study concluded that fundamental movement
skills can be improved by practicing these locomotor tasks [29].
Another systematic review showed similar results that physical
activity and exercise can improve child motor skill based on a
myriad of different coordination tests [30]. Lastly, a classroom
intervention was studied that compared children in a health pro-
motion program and a control group. While motor function was
not the only result studied, it was found that motor skills improved
in children selected for the intervention program compared to the
control group [31]. While only four studies were identified, activ-
ities geared towards children’s age were beneficial in improving
motor function. Again, this portrays the utility of physical activ-
ity on the improvement of motor skills and coordination among
children.
Discussion
The existing literature concerning obesity and DMD were
focused in three areas: motor function, development and interven-
tions. While motor function delays appear to be associated with
obesity, most of the studies focused on either gross motor func-
tion or motor function as a whole (both gross and fine) rather
than isolating fine motor function; from the existing evidence, it
is unknown whether fine, gross, or overall motor function is more
pertinent in children with obesity. It is not well understood if chil-
dren with obesity have delayed motor skills as a consequence of
their weight or if the DMD is a risk factor for the development of
obesity; existing studies do not provide an answer. Not surpris-
ingly, nearly all of the existing research is in children 12 years and
younger, where DMD would develop and most likely be identified.
Lastly, overall data from these studies suggests that there is util-
ity in intervention efforts to improve motor skills in the pediatric
population as seen by the statistically significant improvements
in motor function tests. In particular, interventions that are age-
appropriate can be easily implemented and resemble child-friendly
games such as running, jumping, and skipping.
In child development, it is thought obesity could be a result
of DMD, as children with excess weight would be less likely to
interact in sports or exercise [39]. As previously mentioned, sports
participation was associated with a lower BMI trajectory in one
cohort of children [3]. These activities are beneficial for healthy
development and are associated with lower BMI [43]. Independent
of weight, unhealthy nutrition could be impacting motor devel-
opment. From conception to toddler years, the brain is rapidly
expanding in volume and neuronal pathways, which makes proper
nutrients imperative for health and development [44]. The pres-
ence of adequate calories, protein, fatty acids, iron, zinc, iodine,
and choline are known components of a healthy diet for brain
development. Therefore, under-nutrition likely adversely affects
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Obesity Research & Clinical Practice xxx (xxxx) xxx–xxx
development [45]. Similarly, over-nutrition may impact develop-
ment through changes in the pattern of intestinal microbes, which
influence vitamin absorption, short chain fatty acid production,
satiety, and behavior; thus, over-nutrition could negatively affect
developmental outcomes as well [46]. However, in children with
cerebral palsy, obesity and delayed motor development do not
appear to be associated [47,48]. More research is needed to better
understand the temporality of this association, and the interplay
between nutrition, obesity, and motor development.
Of all the tools used to evaluate the level of motor function in
this review, some could potentially be used to screen children with
obesity for DMD. For example, three different studies in this review
used the KTK test as a coordination evaluation tool [36–38] while
two used the BOTMP-2 [23,27]. In a study by Fransen et al., the
KTK and BOTMP-2 were compared. They concluded that it is bene-
ficial to have multiple tools to assess motor function as children in
extremely high or low function groups had differing scores from the
two tests [49]. As obesity has risk factors such as sedentary behav-
ior [6,7], lack of healthy and/or over-nutrition, and genetics [10,50],
DMD has its own set of risk factors. Despite weight, children living
in low income communities were shown to be at higher risk of DMD
[51]. Further, some varying definitions of obesity (obesity alone vs
overweight and obesity) may contribute to differential associations
between weight status and DMD. This information could be used to
screen children who are at higher risk and intervene at appropriate
points in development.
Multiple studies have reflected improvements in motor function
when the child is provided appropriate weight loss intervention,
such as an increase in physical activity [28–31]. Similarly, a study
by Zierres showed that regardless of the specific action, physical
activity improved the motor function of children with ADHD (42).
Because of this, intervention attempts could be implemented when
DMD or obesity is identified. Understanding the temporality of this
association could aid in the timing of intervention. The timing of the
intervention could also be important due to the influence that age
has on this association. One study included in this review focused
on infants’ motor milestones and their obesity status. While it was
found that a significant association existed, it was thought that
this could be attributed to morphological and biomechanical con-
straints [21]. An intervention at this stage may not be necessary as
an infant could potentially grow out of these constraints at a later
age. In a similar manner, in the study by D’hondt, it was found chil-
dren with obesity in the 10−12 age group had worse motor function
than obese children in the 5−7 age group [36]. This could be an indi-
cation that intervention should take place before the amplification
of this effect but after infancy. More research is needed to under-
stand what specific intervention should take place and at what time
in development.
Learnings from this integrative literature review demonstrates
some association between DMD and obesity. While the evidence
isn’t robust, DMD associated with obesity appear to be amenable
to intervention. These findings can be useful in regards to how
DMD is perceived in children with obesity, and the approach a
clinician could take in addressing. This review highlights addi-
tional questions that are not sufficiently answered with existing
studies: does obesity lead to a delay in motor development, or is
obesity exacerbated by DMD? Further, does excess weight lead to
decreased sports participation, or vice versa? As obesity is complex,
and occurs at the intersection of genetics, health behavior, and envi-
ronment, motor development is equally complex. Dynamic system
theory [52,53] incorporates many different approaches to under-
standing the acquisition of new movements in children, seeming
to parallel the complexity of childhood obesity. A child’s motor
development takes into account the individual, their environment,
and the learned task; in the setting of a child with obesity, the
same environment that could lead to increased weight (calorically-
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B. Zacks et al.
dense foods, lack of physical activity opportunities) and the lack of
new “tasks” (increased sedentary activity) may simultaneously be
impeding the acquisition of new motor skills. Longitudinal studies
with multi-disciplinary study methodologies are needed to delin-
eate these relationships and best design interventions.
Conclusion
As the number of children with obesity continues to grow, phys-
ical activity is a staple of healthy weight management. However,
increased weight and DMD appear to be associated [21–27], which
can hinder a child’s ability to participate in traditional exercise pro-
grams. The data is not clear as to whether excess weight causes
DMD or if DMD contributes to weight gain. These findings provide
great opportunities to investigate the relationship between weight
and DMD. With a greater understanding, targeted interventions can
be implemented to prevent development of obesity and DMD, or
work to improve them when identified.
Ethical statement
I have read and have abided by the statement of ethical stan-
dards for manuscripts submitted to the Obesity Research & Clinical
Practice.
Funding
None.
Conflicts of interest
There are no financial disclosures to report.
CRediT authorship contribution statement
Benjamin Zacks: Conceptualization, Methodology, Validation,
Investigation, Data curation, Writing - original draft, Writing -
review & editing. Kristen Confroy: Validation, Investigation, Data
curation, Writing - original draft, Writing - review & editing. Sherry
Frino: Conceptualization, Validation, Writing - review & editing.
Joseph A. Skelton: Conceptualization, Methodology, Supervision,
Writing - review & editing.
Acknowledgements
The authors would like to thank the medical librarians from the
Coy C. Carpenter Library for assistance in performing systematic
literature reviews.
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