R E S E A R C H

A R T I C L E

Weight Status and Gross Motor

Skill in Kindergarten Children
Dawn Roberts, PT, PhD; Diana Veneri, PT, EdD; Robert Decker, PhD; Mary Gannotti, PT, PhD
Department of Physical Therapy, Springfield College (Dr Roberts), Springfield, Massachusetts; Departments of
Rehabilitation Sciences (Drs Veneri and Gannotti) and Mathematics (Dr Decker), University of Hartford, West Hartford,
Connecticut.

Purpose: Childhood obesity rates are increasing globally. Physical activity is one behavioral variable that
influences weight status. Participation in physical activity requires basic gross motor proficiency in early
childhood. The purpose of this study was to examine the relationship between gross motor skill level and
weight status in a large national representative sample of kindergarten-aged children. Methods: Body mass
index percentile ranking was calculated for 4650 children from the Early Childhood Longitudinal Study-Birth
Cohort. Children were classified into underweight, healthy, overweight, or obese categories according to the
Centers for Disease Control and Prevention criteria. The Early Screening Inventory Revised was used to evaluate
gross motor skill level. Results: Children with obesity displayed lower gross motor skill levels compared with
peers of healthy weight. Largest differences were seen in locomotor and balance skills. Conclusions: Clinicians
should consider adjusting gross motor expectations for locomotor or stability tasks in young children with
obesity. (Pediatr Phys Ther 2012;24:353360) Key words: child, female, human, locomotor activities, male,
motor skills, obesity
INTRODUCTION AND PURPOSE
More than 30% of children are classified as obese or
overweight in the United States, with similar rates in other
developed countries around the world.1 Overall gross motor skills of young children with obesity have been described as delayed or less proficient compared with peers
of healthy weight.2 Yet, the association of obesity with
delay in acquisition or decreased proficiency of specific
gross motor skills has not been clearly described.2 Physical therapists working with children of kindergarten age
will benefit from a better understanding of the influence
of weight status on specific gross motor items when interpreting standardized assessments or planning treatments.
School-aged children classified as overweight or obese
demonstrate lower gross motor proficiency compared with
peers of healthy weight.2-10 Nervik et al2 recently reported

0898-5669/110/2404-0353
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Wilkins and Section on Pediatrics of the American Physical Therapy
Association

Correspondence: Dawn Roberts, PT, PhD, Springfield College, 263 Alden

Street, Springfield, MA 01109 (droberts@springfieldcollege.edu).
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0b013e3182680f19

Pediatric Physical Therapy

that preschool-aged children classified as overweight or

obese scored lower on a standardized gross motor scale
compared with peers who were not overweight, though
the number of subjects in higher body mass index (BMI)
categories in that study were small. Graf et al8 also found
that first-grade children in obese categories had lower
overall gross motor skill levels compared with peers who
were of normal weight or underweight. Several studies
have examined the influence of weight status on gross
motor skill categories including locomotor skills,6,9,10
object manipulation,7,9 and dynamic body coordination
skills.3,4 Most studies have found a negative relationship
between weight and locomotor skills in both boys and
girls.7,8,10 Similarly, several studies report lower dynamic
body coordination in children who are obese.4,11,12 Specific gross motor skill delays were not reported in these
studies.
Obesity affects the speed and kinematics of gait and
static balance in children,13,14 which may influence skill
acquisition. The effect of weight status on object manipulation is less clear with many studies showing no association
between weight status and object manipulation skills,6,9
and others reporting that children with obesity score lower
in this category compared with children of healthy weight.3
Childhood obesity and gross motor skill development
are a result of both intrinsic (child) and extrinsic (environmental) factors. The World Health Organizations
Weight Status and Gross Motor Skills 353

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International Classification of Functioning, Health, and

Disability15 provides a broad framework for examining the
reciprocal interactions between health, behavior, and the
environment. Given the variability among children in factors that may influence weight status and gross motor skill
development, only a large nationally representative sample
of children will provide valid, generalizable information on
the association between these 2 factors.
Thus, the purpose of this study was to evaluate
whether differences existed in specific gross motor skills
among kindergarten-aged children of different weight categories in a large nationally representative sample. We
hypothesized that children who were obese would have
difficulty performing specific gross motor skills where stabilization or movement of body mass influenced performance as compared with peers of healthy weight status.
We defined stabilization tasks as tasks requiring single or
double limb stability such as balancing on one foot. Movement of body mass included tasks where body mass was
moved volitionally in any plane.
METHODS
Study Design
The study was designed as a cross-sectional descriptive study using a previously collected national data set, the
Early Childhood Longitudinal StudyBirth Cohort (ECLSB). This data set was collected by the US Department of
Education, National Center for Education Statistics and
is a nationally representative sample of 14 000 children
born in the year 2001. Oversampling of children from specific subgroups (eg, American Indian and Alaska Native
infants, low birth weight, and twins) allows for describing the range of developmental experiences of children.16
Cognitive, social, emotional, and physical development of
the children was evaluated at multiple time points across
multiple settings, and demographic and social information was collected on families and caregivers. We used
cross-sectional data from the kindergarten wave of children, which included 10 700 children (5450 males), with
a mean age of 5 years, 5 months, and a range of 4 years, 8
months, to 6 years, 2 months.
Subjects
Children with reported physical, medical, or developmental disability at birth, preschool, or kindergarten,
or children who had a reported mobility problem, were
receiving physical, occupational, speech, or special education therapy were eliminated from the analysis (n = 3000).
Children who had missing height or weight information
(n = 3050) were also eliminated from the analysis. No differences in socioeconomic status (SES) or racial distribution were found between children with and without height
and weight data. Twins made up less than 10% of the sample (n = 300) and 50% of twin pairs had only one twin
included in the analysis. Assessment of the distribution
of twins among weight categories revealed a distribution
similar to the overall sample.
354

Roberts et al

Data Collection Tools

Age, gender, height, and weight available from the
ECLS-B database were used to calculate BMI and ageadjusted BMI percentile ranking by gender (BMI-a). Standardized procedures adopted from the National Health and
Nutrition Examination Survey were used to collect height
and weight and are described in details elsewhere.16,17 Ageadjusted BMI percentiles rankings of underweight, healthy
weight, overweight, and obese were determined from
the Centers for Disease Control and Prevention (CDC)
BMI-for-age growth charts using gender, age, height, and
weight. The spreadsheet is available online.18,19
A composite score for SES was calculated by the ECLSB project staff using the following variables16 : education
of the mother, education of the father, occupation of the
mother, occupation of the father, and household income.
Occupation was recoded to reflect the average of the 1989
General Social Survey20 prestige score of the occupation.
The variables were imputed in a sequential order and separately by type of household (female single parent, male
single parent, and both parents present). Once the components of the SES variable were imputed, their corresponding Z score or normalized value was computed. As
described, the SES composite is the average of up to 5 measures, each of which was standardized to have a mean of
0 and a standard deviation of 1, providing a continuous
measure of SES.16 The distribution of SES was examined
and a categorical variable of SES was created. Five levels of
SES were identified, from lowest to highest.16 For this analysis, the categorical variable of SES was used to describe
participants.
The ECLS-B used a combination of individual gross
motor items from the Early Screening Inventory Revised,21
the Early Childhood Longitudinal Study Kindergarten Cohort of 1998-1999,16 the Bruininks-Oseretsky Test of Motor Proficeincy,22 and the Movement Assessment Battery
for Children23 to assess motor abilities. Validity of these
tests in children of kindergarten age has been reported to be
high.24-26 Skill items assessed included jumping, balancing and hopping on 1 foot, walking backwards, skipping,
and catching a beanbag. Table 1 displays each gross motor
item and criteria measured in the ECLS-B. A gross motor
composite score was created by adding up the scores on
the 5 pass/fail items (pass = 1, fail = 0) with a maximal
score of 5.
Data Analysis
Descriptive statistics were calculated to find mean,
median, and standard deviation of demographic and descriptive variables. Analysis of variance was used to identify
differences among groups of children by weight category
and gross motor skills. Cross-tabulations were used to calculate odds ratios and evaluate odds for failure on pass/fail
items. Correlation analysis tested for associations of BMI-a
and SES with the gross motor composite score. Data from
boys and girls were analyzed separately, as gender is a covariate of gross motor skills.27 SPSS 18 (Chicago, IL) was
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used for all data analysis. An level of .05 was established

to judge statistical significance.

weight and children who were classified as overweight

jumped further and hopped longer than children in the
obese category (Table 3, P < .05). Girls in the underweight
category hopped fewer times on the left foot than girls in
the healthy weight category (Table 3, P < .05).
Girls in the underweight and obese categories balanced for less time on their right foot compared with girls
of healthy weight (Table 3, P < .05). Though statistically
significant, this difference was less than 0.6 seconds and
likely does not denote a clinically meaningful difference.
Boys and girls with obesity had lower overall gross motor composite scores than children who were of healthy
weight and overweight (Table 3, P < .05). There was no
association of gross motor composite score with BMI-a
(r = 0.06, P < .000).
Odds ratios between healthy weight and obese groups
showed that boys with obesity were 1.6 times less likely
(95% confidence interval [CI], 1.3-2.0; P < .001) and girls
with obesity were 2.2 times less likely (95% CI, 1.8-2.8;
P < .001) to pass the left foot hopping test. Similar findings
were seen on the right foot as boys with obesity were 1.6

RESULTS
Of the original sample, 7700 children met inclusion
criteria. Of these, 3050 had missing BMI data and were
removed from the sample resulting in 4650 children (2150
males) used in subsequent analyses. Mean age was 5 years,
3 months (SD = 4 months) with a range of 4 years, 8
months, to 6 years, 1 month. There was no significant
difference in age between weight categories (P = 0.26).
See Table 2 for subject characteristics and breakdown of
race, age, and gender by weight status. The mean BMI-a
percentile ranking for the sample of children was the 65th
percentile (SD = 28) with a range between the 0 and 100th
percentiles.
Gross Motor Findings by Gender
Individual gross motor skills assessed by gender, for
both girls and boys, revealed that children of healthy

TABLE 1
Gross Motor Skills from ECLS-B
Test

Criteria

Scoring

Jumping
Balance on 1 foot (right and left tested)

Distance jumped from standing start

Balance for 10 seconds in 1 of 3 trials

Hop on 1 foot (right and left tested)

Hop 5 times in 1 of 3 trials

Skipping
Walk backwards

Skip 8 steps
Walk backwards on line 6 steps

Bean bag catch

Tossed bean bag 5 times

Distance in centimeters
Pass/fail
Maximum number of seconds balanced in 1 of 3 trials
Pass/fail
Maximum number of hops in 1 of 3 trials
Pass/fail
0 = no steps on line
1 = >2 steps off line
2 = 1-2 steps off line
3 = all steps on line
Number caught

TABLE 2
Participant Characteristics by Weight Status

Age
Gender, %
Boys
Girls
BMI, %ile rank (SD)
Race, %
White, non-Hispanic
African American
Hispanic
Asian or Pacific Islander
American Indian or Alaska Native
More than 1 race
Socioeconomic status, %
Lowest socioeconomic status
Middle to low socioeconomic status
Middle socioeconomic status
Middle to higher socioeconomic status
High socioeconomic status

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Overall,
N = 4650
(100%)

Underweight,
n = 150
(3%)

Healthy
Weight, n =
3050 (66%)

Overweight,
n = 750
(16%)

Obese,
n = 700
(15%)

5 y, 3 mo

5 y, 3 mo

5 y, 3 mo

5 yr, 3 mo

5 y, 3 mo

50
50
65.0 (28)

50
50
2.1 (1.6)

50
50
53.7 (22.1)

50
50
90.2 (2.8)

50
50
97.9 (1.5)

41
13
20
14
4
8

42
15
12
25
0
6

44
12
18
15
3
8

37
14
23
13
4
9

32
15
28
9
8
8

17
18
18
20
27

13
20
14
12
41

15
17
18
21
29

19
18
19
20
24

26
19
21
18
16

Weight Status and Gross Motor Skills 355

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356

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31.9 (8.5) 31.5, 13.2-57.3

28.8 (7.4) 29.0, 11.5-49.6
9.1, (1.8) 10, 3-10
8.8 (2.2) 10, 2-10
8.8, (2.5) 10, 1-10
9.3 (1.8) 10, 2-10
4.5 (1.1) 5, 0-5
4.8 (0.7) 5, 0-5
4.7 (0.9) 5, 0-5
4.6 (1.1) 5, 0-5
3.9 (1.3) 4, 0-5
4.0 (1.2) 4, 0-5
3.6 (1.4) 4.0, 0-5
3.8 (1.3) 4.0, 0-5

9.0, (2.0) 10, 0-10

9.3, (1.8) 10, 1-10
9.0, (2.0) 10, 0-10
9.3 (1.7) 10, 0-10
4.8 (0.8) 5, 0-5
4.8 (0.7) 5, 0-5
4.7 (0.9) 5, 0-5
4.8 (0.8) 5, 0-5
4.2 (1.1) 5, 0-5
4.1 (1.1) 5, 0-5
3.7 (1.2) 4.0, 0-5
4.1 (1.1) 4.0 0-5

b Healthy

Underweight (n = 150)

32.6 (8.9) 33.4, 0-57.3

30.1 (8.2) 30.6, 0-60

values given as Mean (SD) median, range.

weight differs from obese (P < .05).
c Overweight differs from obese (P < .05).
d Underweight differs from healthy weight (P < .05).

a All

Standing long jump, in

Boysb,c
Girlsb,c
Balance count on right, s
Boys
Girlsb,d
Balance count on left, s
Boys
Girls
Hop 5 times on right
Boysb,c
Girlsb,c
Hop 5 times on left
Boysb,c
Girlsb,c,d
Catching beanbag 5 times
Boys
Girls
Gross motor composite score
Boysb,c
Girlsb,c

Overall (N = 4650)

TABLE 3

3.7 (1.2) 4.0, 0-5

4.2 (1.1) 4.0, 0-5

4.2 (1.1) 5, 0-5

4.1 (1.2) 5, 0-5

4.7 (0.9) 5, 0-5

4.8 (0.7) 5, 0-5

4.8 (0.8) 5, 0-5

4.9 (0.6) 5, 0-5

9.1, (2.0) 10, 0-10

9.4, (1.7) 10, 0-10

9.0, (2.0) 10, 0-10

9.4 (1.6) 10, 2-10

33.0 (9.0) 33.9, 0-55.0

30.7 (8.3) 31.2, 0-60

Healthy Weight (n = 3050)

Gross Motor Skills by Gender and Weight Statusa

3.8 (1.2) 4.0, 0-5

4.0 (1.2) 4.0, 0-5

4.2 (1.1) 5, 0-5

4.2 (1.1) 5, 0-5

4.8 (0.8) 5, 0-5

4.7 (0.8) 5, 1-5

4.8 (0.8) 5, 0-5

4.8 (0.7) 5, 0-5

8.9, (2.1) 10, 2-10

9.3 (1.8) 10, 1-10

9.1, (1.9) 10, 2-10

9.3 (1.8) 10, 2-10

33.4 (8.8) 34.4, 0.5-56.5

29.8 (7.8) 30.0, 6-52

Overweight (n = 750)

3.4 (1.4) 4.0, 0-5

3.8 (1.3) 4.0, 0-5

4.2 (1.1) 5, 0-5

4.2 (1.0) 5, 0-5

4.5 (1.1) 5, 0-5

4.5 (1.1) 5, 0-5

4.6 (1.0) 5, 0-5

4.7 (1.0) 5, 0-5

8.8, (2.2) 10, 2-10

9.1, (2.1) 10, 2-10

8.9, (2.1) 10, 0-10

9.1 (2.0) 10, 1-10

31.0 (9.0) 31.2, 0-50.4

28.0 (8.1) 28.0, 6.4-60

Obese (n = 700)

times (95% CI, 1.3-2.1; P < .001) and girls with obesity
were 2.0 times less likely (95% CI, 1.5-2.5; P < .001) to
pass the hopping skill.
Girls with obesity were 1.3 times less likely (95% CI,
1.1-1.7; P < .029) to be able to balance on the right foot for
10 seconds compared with peers of healthy weight. Boys
with obesity were 1.3 times less likely (95% CI, 1.1-1.6; P =
.005) to be able to balance on the left foot for 10 seconds.
Girls with obesity were also 1.3 times less likely (95% CI,
1.1-1.6; P = .006) to be able to skip compared with peers
of healthy weight. Both boys and girls with obesity were
less able to walk backwards with boys 1.3 (95% CI, 1.1-1.6;
P = .013) and girls 1.4 times as likely (95% CI, 1.1-1.7; P =
.003) to fail this gross motor test compared with nonobese
peers (Table 4).
DISCUSSION
This study examined the gross motor skill levels of
both boys and girls in different weight categories. We hypothesized that children who were obese would display
decreased proficiency with gross motor tasks involving stabilization or movement of body mass. Our hypothesis is
supported by our findings as children in the obese category scored lower on gross motor skills where movement
or stabilization of body mass were required such as jumping, hopping, or balancing. Children with obesity hopped
fewer times and jumped shorter distances than children in
both the healthy weight and overweight categories. Interestingly, underweight girls also hopped fewer times than
children of healthy weight. Girls in both the underweight
and obese categories balanced for fewer seconds than girls
of healthy weight, but the difference is not clinically meaningful. Obesity increased the odds that both boys and girls
would not pass the balance or walking backwards test,

and girls with obesity were less likely to pass the skipping
item. Boys and girls in the obese category had lower overall gross motor composite scores than boys and girls of
healthy weight. Our results indicate that in kindergarten
children, obesity is associated with poorer gross motor
performance on items where movement or stabilization of
mass is required.
Our findings are similar to other recent studies that
have reported lower overall gross motor skill level in young
children in higher weight categories.2,5 Graf et al8 reported
that in a sample of 500 school-aged children in Germany,
children who were obese had lower motor proficiency than
peers who were of healthy weight and underweight. Children in their sample were older than those in our study
with a mean age of 6.7 years. An overall gross motor score
was used; thus, the influence of weight status on specific
gross motor tasks in this age group cannot be compared
with our results.
We also looked at individual gross motor task items
and the influence of weight status on specific skills. We
found that that gross motor tasks involving movement of
body mass (jumping, hopping, backwards walking) were
more difficult for children in the obese category compared
with peers of healthy weight. There was no difference in
skill level between weight categories for a manipulative
task not involving body mass mobilization or management
(ball catching). Our results match those by Okely et al,6
who found that weight status did not influence manipulative gross motor tasks but was inversely related to locomotor skill proficiency.
Similar to our findings in young children, limitations
in dynamic balance control in adolescents with obesity
when compared with peers of healthy weight has been
reported.13 DHondt et al4 found that overweight and
obese status was associated with decreased performance on

TABLE 4
Gross Motor Skill by Gender and Weight Status for Pass/Fail Items

Balance on right for 10 seconds (% pass)

Boys
Girlsa
Balance on left for 10 seconds (% pass)
Boysa
Girls
Skipping 8 steps (% pass)
Boys
Girlsa
Hop 5 times on right (% pass)
Boysa
Girlsa
Hop 5 times on left (% pass)
Boysa
Girlsa
Walk backwards 6 steps on line (% pass)
Boysa
Girlsa
a Obese

Overall
(N = 4650)

Underweight
(n = 150)

Healthy
Weight
(n = 3050)

Overweight
(n = 750)

Obese
(n = 700)

76.1
82.9

79.1
83.5

77.5
83.6

74.2
82.2

70.6
79.8

75.8
82.9

79.1
83.5

77.5
83.6

74.2
82.2

70.6
79.8

38.2
57.3

32.6
48.1

38.0
59.3

39.2
56.5

35.6
50.7

88.2
92.0

83.7
92.4

89.4
93.4

90.8
91.4

81.7
86.1

85.3
89.8

83.7
86.1

86.2
92.1

89.3
89.4

78.1
80.4

41.8
47.3

51.2
44.3

43.0
49.0

41.2
47.2

36.1
40.1

differs from healthy weight, P < .05.

Pediatric Physical Therapy

Weight Status and Gross Motor Skills 357

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dynamic body coordination tasks in school-aged children.

Furthermore, these decreases were more pronounced in
older children (10-12 years) than in younger (5-7 years).
As weight status is generally stable during childhood, we
can speculate that young children who are obese and display gross motor deficiencies at an early age are at risk for
more pronounced delays as they age.
We found that children with obesity demonstrated
lower scores in tasks involving moving mass against gravity (jumping, hopping) compared with peers who were not
obese. Others10,28 have also reported this. It has been suggested that mechanical movement inefficiency contributes
to the motor deficiencies seen when children with obesity
perform weight-bearing or limb-moving skills. Perhaps the
excess inert mass impedes movement or lack of strength
limits motor proficiency. Further studies exploring these
hypotheses are required.
We found balancing on the left foot to be more difficult for boys with obesity compared with boys of normal
weight whereas balancing on the right foot was more difficult for girls with obesity compared with peers of normal weight. Though overall dynamic balance differences
have been found in adolescents with obesity,13 no studies
to date have examined differences in dominant compared
with nondominant limb balance in children with obesity.
Information on limb dominance was not available, thus
we cannot determine whether it affected this finding; however, it is clear that young children who are obese seem to
have more difficulty stabilizing body mass.
One recent study assessing fine motor performance
in children who are obese reported deficits in fine motor
tasks in the sitting position when postural control demand
was minimized.11 The authors suggested that children who
are overweight or obese may have perceptual-motor coordination issues that influence not only gross motor but
fine motor skills as well.11 We did not see deficits in the
manipulative task assessed in our study (ball catching);
however, we did not assess higher-level fine motor skills.
The task of ball catching may not have been subtle enough
to expose higher-level fine motor issues in children with
obesity.
Of note, although we found significant differences between children of healthy weight and children with obesity
for many of our gross motor variables, few differences were
found between children of healthy weight and children
categorized as overweight. We found no linear correlation
between BMI-a and the gross motor composite score. The
CDC classifies children with a BMI percentile greater than
the 85th percentile and less than the 95th percentile as
overweight.19 Perhaps there is a threshold level of BMI
after which gross motor skills are affected. Further exploration of the multivariate relationship between weight and
gross motor skill is warranted. Many children with familial
obesity tend to move to higher weight classifications with
age.29,30 Future work should involve assessing gross motor
skill changes over time in children who increase in weight
category to better understand the influence of weight on
motor skill development.
358

Roberts et al

Interestingly, we found that children in the underweight category displayed gross motor deficits in some
skill areas compared with peers of healthy weight. Few
studies have reported results for children who are underweight and ones that have reported on children who are
underweight have had very small samples.2,8 These studies have reported no differences in gross motor skill level
of children classified as underweight compared with peers
of healthy weight.2,8 We found that children who were
classified as underweight were not able to jump as far as
peers of healthy weight. Girls classified as underweight
also displayed poorer balance and hopping abilities compared with girls of healthy weight. Balance differences were
very small (<0.5 second) and are likely not clinically relevant. Children who are underweight may have less muscle
mass and generate less force, which may contribute to their
decreased jumping and hopping abilities. The influence of
height and limb length was not accounted for when assessing jumping, which may influence results as well. Underlying nutritional and/or developmental issues contributing
to underweight status may also influence gross motor skill.
There are several limitations to our study. With our
study design, a causal link between gross motor skill and
weight status cannot be determined. It is still not clear
whether being obese leads to diminished physical abilities or limited physical abilities influences weight status in
young children. Previous research has demonstrated that
even in young children, decreased physical activity is associated with higher levels of adiposity.31 Early childhood
is a time where significant gains in gross motor proficiency
occur. Children who are less active have been found to
score lower on a variety of gross motor assessments.8,32,33
Our study did not objectively quantify the level of physical activity or nutritional status among weight categories
to assess the influence of activity or food intake on either
BMI or gross motor skill level. Further research exploring the relationship of these variables to one another is
needed. The gross motor test items included in the ECLSB assessment also limit results. Other gross motor tests
with a wider variety of items or perhaps more sensitive
scoring measures may have detected additional differences
among the weight status groups. Furthermore, our gross
motor tasks involving movement or stabilization of mass
were not all inclusive, thus we cannot generalize these findings to all gross motor tasks in these categories. Though
we found statistical significance, there are currently no
established clinically meaningful differences for gross motor skills, limiting application of these results. We used
a self-derived gross motor composite score limiting our
ability to compare with other results. Finally, we did not
control for the familial, ethnic, or SES influence on gross
motor skills. We found children of Hispanic origin had
higher percentages of obesity than non-Hispanic groups
and that may influence overall results. Twins made up
less than 10% of our sample population and though the
distribution of twins between weight categories was the
same as in the overall sample a familial effect cannot be
dismissed.
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Clinical Implications
Clinicians should adjust gross motor expectations,
given weight status; young children who are obese are usually less proficient compared with peers of healthy weight,
overweight, and underweight categories. Specifically, children who are obese appear to have difficulty with many
gross motor skills involving movement or stabilization of
body mass. Though the relationship between weight status and gross motor skill is not completely understood,
physical therapists treating children with obesity must be
aware of differences and focus efforts on limiting gross motor delays. Furthermore, programs involved in prevention
of obesity and promotion of physical activity as recommended by the CDC34 should be a priority for clinicians
such as physical therapists.
CONCLUSIONS
Our study looked at a large, diverse sample of
kindergarten-aged children. We found children with obesity to have decreased motor abilities compared with children in other weight categories. Differences were seen
specifically in many gross motor tasks involving moving
or stabilization of body mass. Future work should examine potential variables influencing this relationship including physical activity level, SES, and familial environment.
Furthermore, assessment of how early delays affect future
gross motor skill acquisition, activity level, and weight
status in children who are either obese or overweight is
needed. More specialized interventions may be required
early on to prevent long term consequences in these children.
REFERENCES
1. Olds T, Maher C, Zumin S, et al. Evidence that the prevalence of
childhood overweight is plateauing: data from nine countries. Int J
Pediatr Obes. 2011;6(5-6):342-360.
2. Nervik D, Martin K, Rundquist P, Cleland J. The relationship between
body mass index and gross motor development in children aged 3 to
5 years. Pediatr Phys Ther. 2011;23(2):144-148.
3. DHondt E, Deforche B, De Bourdeaudhuj I, Lenoir M. Relationship
between motor skill and body mass index in 5- to 10-year-old children. Adapt Phys Activ Q. 2009;26(1):21-37.
4. DHondt E, Deforche B, Vaeyens R, et al. Gross motor coordination in relation to weight status and age in 5- to 12-year-old boys
and girls: a cross-sectional study. Int J Pediatr Obes. 2011;6(2-2):
e556-564.
5. Dumith S, Ramires S, Souza M, et al. Overweight/obesity and physical fitness among children and adolescents. J Phys Activity Health.
2010;7:641-648.
6. Okely A, Booth M, Patterson J. Relationship of physical activity to
fundamental movement skills among adolescents. Med Sci Sports Exerc. 2001;33(11):1899-1904.
7. Okely AD, Booth ML, Chey T. Relationships between body
composition and fundamental movement skills among children and adolescents. Res Q Exercise Sport. 2004;75(3):
238-247.
8. Graf C, Koch B, Kretschmann-Kandel E, et al. Correlation between
BMI, leisure habits and motor abilities in childhood (CHILT-project).
Int J Obes Relat Metab Disord. 2004;28(1):22-26.

Pediatric Physical Therapy

9. Hume C, Okely A, Bagley S, et al. Does weight status influence associations between childrens fundamental movement skills and physical
activity? Res Q Exerc Sport. 2008;79(2):158-165.
10. Milanese C, Bortolami O, Bertucco M, Verlato G, Zancanaro C. Anthropometry and motor fitness in children aged 6-12 years. J Hum
Sport Exerc. 2010;5(2):265-279.
11. DHondt E, Deforche B, De Bourdeaudhuij I, Lenoir M. Childhood
obesity affects fine motor skill performance under different postural
constraints. Neurosci Lett. 2008;440(1):72-75.
12. DHondt E, Segers V, Deforche B, et al. The role of vision in obese
and normal-weight childrens gait control. Gait Posture. 2011;33(2):
179-184.
13. Colne P, Frelut ML, Peres G, Thoumie P. Postural control in obese
adolescents assessed by limits of stability and gait initiation. Gait
Posture. 2008;28(1):164-169.
14. Shultz SP, Hills AP, Sitler MR, Hillstrom HJ. Body size and walking
cadence affect lower extremity joint power in childrens gait. Gait
Posture. 2010;32(2):248-252.
15. World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva, Switzerland: World Health
Organization; 2001.
16. Najarian M, Snow K, Lennon J, Kinsey S. Early Childhood Longitudinal
Study, Birth Cohort (ECLS-B): Preschool-Kindergarten 2007 Psychometric Report (NCES 2010-009). Washington, DC: National Center for
Education Statistics, Institute of Education Sciences, US Department
of Education; 2010.
17. Centers for Disease Control and Prevention. National Health and
Nutrition Examination Survey (NHANES): Anthropometry Procedures
Manual. Atlanta, GA: Centers for Disease Control and Prevention;
2007.
18. Centers for Disease Control and Prevention. Body mass index:
BMI for children and teens. http://www.cdc.gov/nccdphp/dnpa/bmi/
childrens BMI/about childrens BMI.htm. Published 2007. Accessed
May 20, 2008.
19. Ogden C, Flegal K. Changes in Terminology for Childhood Overweight
and Obesity. Washington, DC: US Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center
for Education Statistics; 2010.
20. Nakao K, Treas J. The 1989 Socioeconomic Index of Occupations: Construction From The 1989 Occupational Prestige Score. GSS Methodological Report No. 74. Chicago, IL: NORC; 1992.
21. Meisels S, Marsden D, Wiske M, Henderson L. Early Screening
Inventory-Revised (ESI-R) 2008 Edition. San Antonio, TX: Pearson;
2008.
22. Bruininks R. Bruininks-Oseretsky Test of Motor Proficinecy:
Owners Manual. Circle Pines, MN: American Guidance Service;
1978.
23. Henderson S, Sugden D, Barnett A. Movement Assessment Battery for
ChildrenSecond Edition (Movement ABC-2). San Antonio, TX: Pearson; 2007.
24. Dietz J, Kartin D, Kopp K. Review of the Bruininks-Oseresky Test of
Motor Proficiency, Second Edition (BOT-2). Phys Occup Ther Pediatr.
2007;27:87-102.
25. Ketchie B, Lang N, Brush L, Kirstein R. Recommended Physical Assessment Instrument for the ECLS-B Preschool Battery: Results from the
Spring Pilot Test. Washington, DC: American Institutes for Research;
2003.
26. Tabatabainia M, Ziviani J, Maas F. Construct validity of the BruininksOseretsky Test of Motor Proficiency and the Peabody Developmental
Motor Scales. Aust Occup Ther J. 1995;42(1):3-13.
27. Goodway JD, Robinson LE, Crowe H. Gender differences in fundamental motor skill development in disadvantaged preschoolers from
two geographical regions. Res Q Exerc Sport. 2010;81(1):17-24.
28. Riddiford-Harland DL, Steele JR, Baur LA. Upper and lower limb
functionality: are these compromised in obese children? Int J Pediatr
Obes. 2006;1(1):42-49.
29. Wright CM, Emmett PM, Ness AR, Reilly JJ, Sherriff A. Tracking
of obesity and body fatness through mid-childhood. Arch Dis Child.
2010;95(8):612-617.

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Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.

30. Freedman DS, Wang J, Thornton JC, et al. Racial/ethnic differences in body fatness among children and adolescents. Obesity.
2008;16(5):1105-1111.
31. Berkey CS, Colditz GA. Adiposity in adolescents: change in actual
BMI works better than change in BMI z score for longitudinal studies.
Ann Epidemiol. 2007;17(1):44-50.
32. Williams HG, Pfeiffer KA, ONeill JR, et al. Motor skill performance
and physical activity in preschool children. Obesity. 2008;16(6):14211426.

33. Wrotniak BH, Epstein LH, Dorn JM, Jones KE, Kondilis
VA. The relationship between motor proficiency and physical activity in children. Pediatrics. 2006;118(6):e17581765.
34. Centers for Disease Control and Prevention. Physical activity for
everyone: how much physical activity do children need? http://
www.cdc.gov/physicalactivity/everyone/guidelines/children.html.
Accessed September 20, 2011.

CLINICAL BOTTOM LINE

Commentary on Weight Status and Gross Motor Skill in Kindergarten Children

How should I apply this information?

An obese child is an obese adult with all the clinical implications of the obesity epidemic, and it is
not just that motor skills are impaired but it may also lead to an unwanted future clinical outcome
(the metabolic syndrome, the diabetic epidemic, cardiovascular morbidity and mortality)-personally and
epidemiologically, with all the aspects of a public health burden.
This interesting and important study showed that girls and boys with obesity displayed lower gross
motor skill levels than children of healthy weight. What does it mean and how can these data affect our
health policy? The authors suggested, Clinicians should consider adjusting gross motor expectations for
locomotor or stability tasks in young children with obesity.
Dietary interventional studies have shown that a healthier diet in children improved body mass index and
blood pressure in children with obesity1 and also improved the lipid profile of children who participated
in a dietary interventional program.2
What should I be mindful of when reading this article?
Children with obesity have impaired gross motor functions, and this observation should be considered
whenever a child with obesity is tested.
There could be a gender effect, and girls who are underweight could also have impaired locomotor skills.
Childhood obesity is a complicated social public health problem that affects individuals health and the whole
populations health and socioeconomic welfare. Interventions should start at a young age, before elementary
school and during the school years, as part of an educational program that has a national significance for the
future of both individuals health and overall public health.3
REFERENCES
1. Angelopoulos PD, Millonis HJ, Grammatikaki E, Moschonis G, Manlos Y. Changes in BMI and blood pressure after a school based
intervention: the children study. Eur J Public Health. 2009;19(3):319-325.
2. Rask-Nissila L, Jokinen E, Ronnemaa T, et al. Prospective, randomized, infancy-onset trial of the effects of a low-saturated-fat, low-cholesterol
diet on serum lipids and lipoproteins before school age. Circulation. 2000;102:1477-1483.
3. Mozaffarian D, Appel LJ, Van Horn L. Recent advances in preventive cardiology and lifestyle medicine. Circulation. 2011;123:2870-2891.

Nava Blum, BPT, M.Occ.H, PhD

Department of Health Care Systems Management
Max Stern Academic College of Yezrael Valley, Israel
Arnon Blum, MD
Interdisciplinary Stem Cell Institute
University of Miami, Florida
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0b013e31826a186a

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Association. Unauthorized reproduction of this article is prohibited.