Eur J Pediatr (2013) 172:645–652

DOI 10.1007/s00431-013-1944-4

ORIGINAL ARTICLE

Foot morphology in normal-weight, overweight,

and obese schoolchildren
Ester Jiménez-Ormeño & Xavier Aguado &
Laura Delgado-Abellán & Laura Mecerreyes &
Luis M. Alegre

Received: 16 October 2012 / Accepted: 9 January 2013 / Published online: 23 January 2013
# Springer-Verlag Berlin Heidelberg 2013

Abstract This study compared the foot morphology of Keywords Body mass index (BMI) . Foot structure .
Spanish schoolchildren based on their body mass index Primary school . Arch index . Footwear
and age and analyzed whether body mass index affects the
child’s foot development at primary school. Cross-sectional Abbreviations
study of 1,032 schoolchildren (497 boys and 535 girls), 6– BMI Body mass index
12 years old. Height and weight were measured to calculate FA Footprint angle
body mass index. Children were classified as obese, over- CSI Chippaux–Smirak index
weight, and normal-weight. Measurements of foot morpholo- AI Arch index
gy were obtained with a three-dimensional feet digitizer in
static standing. Significant differences were found between
the feet of children with normal-weight and overweight (2.6 to
Introduction
9.0 %) and among children with normal-weight and obese for
all variables (3.9 to 17.3 %). Differences in width, ball height,
Currently, the prevalence of overweight is reaching “epidemic”
and arch height (5.3 to 7.6 %) were only found among
levels in many developed countries [29, 40]. There has been a
overweight and obese children. There were no changes in
worldwide increase in obesity in people of all ages [37]. In
the foot morphology of children between 6 and 7 years and
Spain, several studies have shown that approximately 30 % of
between 10 and 12 years. Obese children showed more grad-
children aged 6 to 13 are overweight and obese [2, 13, 19, 25].
ual changes in the foot measurements. The average percentage
Childhood obesity is associated with long-term consequen-
increase by year in children with normal-weight and obese
ces for health [26, 29] and for the musculoskeletal system,
were similar (3.6 and 3.4 %, respectively); however, morpho-
including misalignment of the lower limbs [45]. The orthope-
logical measurements of the foot of overweight children in-
dic problems relating to overweight and obesity include mus-
creased at a faster rate (4.0 %). Conclusion: Excess weight
culoskeletal pain and discomfort [16, 39], problems in the feet,
affects the foot structure of children. The differences between
ankles, knees, hips, and spine [14, 28], risk of fractures,
age groups seem to indicate that the feet of children with
growth, and development disorders [27, 41]. There is also a
overweight and obesity follow a different growth pattern than
reduction in flexibility and as well as difficulty in walking and
that of normal-weight children. With these results, the shoe
running [37] due to changes in the foot structure. However,
manufacturers can design shoes for children depending on
the most frequent condition appears to be flat feet [8, 9, 28, 32,
their age and weight.
33]. Because of that, excess weight causes changes in the
plantar arch, by changes in osseous and ligamentous support
E. Jiménez-Ormeño : X. Aguado : L. Delgado-Abellán : [24] and a collapse of the medial longitudinal arch that may
L. M. Alegre (*)
become a problem in adulthood [36].
Grupo de Biomecánica Humana y Deportiva,
Universidad de Castilla-La Mancha, 45071 Toledo, Spain The child’s foot is constantly growing, changing its shape
e-mail: luis.alegre@uclm.es and structure. The morphology and functional development
of the foot are influenced by internal factors (sex, genetics,
L. Mecerreyes
and age) and external factors (footwear habits, loading, and
ASIDCAT (Asociación de Investigación y Desarrollo
del Calzado y Afines de Toledo), 45510, Fuensalida, physical activity) [10, 21]. Because the foot structure of chil-
Toledo, Spain dren is not fully developed, the influence of ill-fitting shoes
646 Eur J Pediatr (2013) 172:645–652

can prevent the normal development of the foot and result in finally analyzed data from 1,032 children (497 boys and 535
problems and pathologies in both childhood and adulthood girls, see “Statistical analysis”).
[30, 33, 38]. Several authors argue that proper footwear, Parents/tutors were previously informed of the study; they
flexible and well suited to the dimensions of the foot, has a completed a questionnaire and signed an informed consent to
decisive influence on its functionality and comfort [5, 21, 44]. confirm the participation of their children. The participants
Therefore, footwear should be designed to satisfy the foot who had any of the following conditions were excluded:
dimensions of children, according to the characteristics of recent lower limb injuries, disorders in the foot bones, or skin
the population. Most footwear companies do not change the infections. This study was performed according to the Decla-
dimensions of lasts to accommodate intercontinental differ- ration of Helsinki [7], and it was approved by the Ethics
ences in the morphology of the feet due to race and/or envi- Committee of the University of Castilla-La Mancha (Spain).
ronmental factors. As for the Spanish population, we have
found no studies examining feet of children with overweight Weight classification
and obesity in order to manufacture footwear fitter.
Regarding the differences in foot morphology between All children were weighed on a standing scale SECA
overweight and normal-weight children, it has been found (SECA Ltd., Hamburg, Germany), and their standing height
that overweight children have a lower footprint angle and was measured with a stadiometer SECA (SECA Ltd., Ham-
higher Chippaux–Smirak index [8, 32, 43]. Chen et al. [3] burg, Germany). The BMI was calculated with the height
and Morrison et al. [24] showed a significant effect of obesity and the weight (BMI=weight/height2).
for most of the measured foot dimensions. Mauch et al. [20] We used the classification system proposed by Cole et al.
found significant differences in foot type and body mass index [6], based on BMI according age and sex, to establish the
(BMI). Riddiford-Harland et al. [31] showed that obese chil- groups (Table 1).
dren had significantly longer and “fatter” feet compared with
their normal-weight counterparts. In contrast to all the above Instrumentation
studies, Evans [12] did not find a positive relationship be-
tween increased body weight and flatter foot posture, although In addition to anthropometric measurements, 3D measures
sample size, subject ethnicity, and assessment method of foot were obtained with a feet digitizer ACN06/01 Model (INES-
posture may be relevant contributors to this controversy. COP, Elda, Spain), with four laser projectors and four CCD
Although there is a lot of literature that compares the foot of cameras. This equipment met the following guidelines: EN
overweight and normal-weight children, these studies have 60065, EN 50081-1, 93/68/CEE, 92/31/CEE, 89/336/CEE,
analyzed different age ranges. They are also based on and 73/23/CEE.
populations with different physical and social characteristics We carried out a pilot study with 20 subjects to compare
than the Spanish one and dimensions, such as lengths, widths, measurements directly taken from the foot with anthropometric
and heights in three dimensions (3D) have not been described
in depth. Therefore, the objective of this study was to compare
Table 1 International cut-off points for body mass index for overweight
the morphology of the foot of schoolchildren in central Spain and obesity by sex between 6 and 12 years (adapted from Cole et al. [6])
based on their BMI and age and analyze whether BMI in
schoolchildren affects the child’s foot development. Our hy- Age (years) Overweight Obesity
pothesis was that overweight and obese children would have
Boys Girls Boys Girls
different morphological measurements of the foot compared
with normal-weight children. This study provides actual and 6 17.55 17.34 19.78 19.65
normative data of the foot of schoolchildren, by age and BMI, 6.5 17.71 17.53 20.23 20.08
which may be of special interest to the shoe manufacturers to 7 17.92 17.75 20.63 20.51
produce well-fitting footwear. 7.5 18.16 18.03 21.09 21.01
8 18.44 18.35 21.60 21.57
8.5 18.76 18.69 22.17 22.18
9 19.10 19.07 22.77 22.81
Materials and methods 9.5 19.46 19.45 23.39 23.46
10 19.84 19.86 24.00 24.11
Participants
10.5 20.20 20.29 24.57 24.77
11 20.55 20.74 25.10 25.42
In this cross-sectional study, 1,045 schoolchildren (502 boys
11.5 20.89 21.20 25.58 26.05
and 543 girls), 6–12 years old, voluntarily participated from
12 21.22 21.68 26.02 26.67
different localities of Toledo province. After filtering, we
Eur J Pediatr (2013) 172:645–652
instrumentation and the same parameters from the 3D digitizer.
The results showed very high Pearson correlation coefficients
from r=0.87 (distance from the heel to the 5th metatarsal) to r=
0.97 (foot length and metatarsal width).
Besides, the procedure was highly reliable, with intra-
class correlation coefficients ranging from 0.944 to 0.999,
obtained from a test–retest pilot study. The coefficients of
variation also showed low variability in the measurements,
with a mean value of 2.06 % (range, 0.4 to 4.7 %).
Procedure
The scannings were performed on both feet with the participant
in bipodal support, after the weight and height measurements.
The child was barefoot, upright, looking forward, and with the
weight equally distributed on both feet. Then the data were
processed with Foot 3D software (INESCOP, Elda, Spain).
Measures
The foot measures were (Fig. 1):
(a) Foot length—distance between points HF and TF pro-
jected onto the LF axis
(b) Distance from the heel to the 1st metatarsal—distance
between the rearmost point of the foot and the first
metatarsal, measured on the x-axis.
(c) Distance from the heel to the 5th metatarsal—distance
between the rearmost point of the foot and the fifth
metatarsal, measured on the x-axis.
Fig. 1 Studied variables of foot scanning: a foot length; b distance from the heel to the 1st metatarsal; c distance from the heel to the 5th metatarsal;
d metatarsal width; e forefoot width; f heel width; g ball height; h instep height; and i arch height
647
(d) Metatarsal width—distance between points B1 and B2
projected on the XY plane.
(e) Forefoot width—distance across the widest points of
the forefoot on the y-axis, perpendicular to the x-axis.
(f) Heel width—distance obtained between the outermost
points (HW1 and HW2) to intersect a plane perpendicular
to the foot axis away 15 % of foot length and 1 cm high.
(g) Ball height—height of ball point BC projected on the
z-axis.
(h) Instep height—distance between the point of the instep
I and the ground plane.
(i) Arch height—distance of the most prominent point of
the plantar arch to ground plane.
All these dimensions were normalized to the length of the
respective foot [4, 20, 21], except arch height that was
normalized to the instep height. Thus, the sizeable influence
of foot length on all other length measures was eliminated.
Statistical analysis
The data obtained with the 3D scanner were analyzed with
SPSS Software v19 for Windows (IBM, Chicago, IL), with
a significance level of p<0.05. First, an exploratory analysis
was conducted to organize data, detect errors in collecting
data, identify outliers, and filter extreme cases, variable by
variable, eliminating those values that exceeded three times
the interquartile distance between the percentiles 25 and 75.
Normality was tested with the Kolmogorov–Smirnov test.
648 Eur J Pediatr (2013) 172:645–652

Later, an independent samples t test was performed to analyze Table 2 Percentages of difference in the morphological measurements
of the foot (mean between right and left feet) between the three weight
possible differences between the measures of the left foot and
category groups
right foot; since there were no significant differences, subse-
quent analysis and results obtained were made with mean Percentages (%)
values between both feet as representative of each child’s foot
Normal Normal Overweight—
structure [20, 22]. This was followed by a descriptive statisti- weight— weight— obese
cal analysis for all the variables studied, grouping children overweight obese
according to their age and weight category, comparing the
development of the morphology of the foot as for the weight Foot length 3.2* 3.9* 0.7
category and throughout the range of ages of the sample. A Ball width 5.9* 12.4* 6.2*
one-way ANOVA (three weight levels) was utilized to com- Ball height 9.0* 17.3* 7.6*
pare the foot in the three weight groups and a two-way Distance to 1st metatarsal 2.6* 2.8 0.3
ANOVA (three weight levels×seven age groups) to analyze Distance to 5th metatarsal 3.3* 2.0 −1.2
the effect of age on the foot measures in the three weight Heel width 5.9* 11.5* 5.3*
groups. Bonferroni post hoc test was used when necessary. Forefoot width 5.5* 11.3* 5.4*
A sample size calculation (α=0.05 and power=0.8) on Instep height 3.3* 6.0* 2.6
the variables ball width and foot length with data from all Arch height 1.5 7.8* 6.3*
the age groups showed required sample sizes between 33
*P<0.05, significant differences between groups for this variable
and 168 subjects required (mean=78±40 subjects for each
age group).
between normal-weight and obese children for all variables
except two: the distance from the heel to the first metatarsal,
Results and the distance from the heel to the fifth metatarsal. When
comparing the measures between overweight and obese
The prevalence of normal-weight, overweight, and obese children, only significant differences were found in the
children in the school sample of this study was 65.79 (679 widths, ball height, and arch height for both feet (Table 2).
children), 24.22 (250 children), and 9.98 % (103 children), In general, obese children showed larger dimensions of the
respectively. foot.
Figure 2 shows that the highest values of overweight When these measures were normalized with the foot
children were found between 8 and 10 years, whereas obe- length, although some differences disappeared, differen-
sity was higher in 7- to 8-year-old children and at the end of ces remained in the three widths (metatarsal, heel, and
the primary school. forefoot; p=0.00), comparing the three weight categories:
normal weight–overweight, normal weight–obese, and over-
Morphological differences in the foot according weight–obese.
to the weight category
Age differences in foot measures in the primary school
Comparison by weight category with absolute foot meas- according to the weight category
ures, significant differences were found between normal-
weight and overweight children for all variables (p<0.05), When performing the ANOVA, looking for differences be-
except for the arch height. There were also differences tween age groups in each weight category, we found as a

Fig. 2 Percentages of the

sample in each weight category
in the different age groups
Eur J Pediatr (2013) 172:645–652 649

general trend in both feet and for virtually all measures that
there were no significant differences in foot morphology
between 6 and 7 years of age and between 10 and 12 years.
In normal-weight children, there were more significant
differences between age groups but not so much between
consecutive ages. Overweight children showed less number
of significant differences among the different age groups
compared with normal-weight children. No differences were
found between consecutive ages, even in two consecutive
years. Finally, the group of obese children had fewer differ-
ences than overweight children, without differences be-
tween consecutive years.
Table 3 shows mean values between the right and the left
foot and the standard deviation of the variables studied
according to the weight category and age.
Regarding the age differences in foot measures, Table 4
shows that the average percentages of increase by year in
normal-weight and obese children were similar. However,
morphological measurements of the foot of overweight chil-
dren increased at a faster rate.
Morphological measurements of the foot increase differ-
ently depending on weight group. Moreover, overweight
and obese children have larger feet than their normal-
weight counterparts throughout growth. Figure 3 is a repre-
sentative graph of the foot measures throughout the years in
the three weight categories, specifically forefoot width.
When performing the statistical analysis with the normal-
ized measures regarding foot length, most of previous sig-
nificant differences disappeared, especially in groups of
overweight and obesity.

Table 3 Means and standard deviations of foot measures according to the weight category and age

6 years 7 years 8 years 9 years 10 years 11 yrs 12 yrs

(nN=41, (nN=103, (nN=123, (nN=108, (nN=101, (nN=127, (nN=76,
nO=13, and nO=33, and nO=37, and nO=46, and nO=47, and nO=47, and nO=27, and
nOb=3) nOb=15) nOb=22) nOb=21) nOb=11) nOb=17) nOb=14)
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Normal-weight Foot length (mm) 187.9 (11.6) 197.8 (9.9) 205.7 (9.9) 215.5 (13.2) 226.1 (14) 231.5 (13.9) 237.3 (10.8)
(n=679) Metatarsal width (mm) 72.9 (5.3) 74.9 (5.8) 77.7 (5.8) 81 (5.6) 84.6 (6.6) 86.3 (6.6) 89.8 (5.3)
Ball height (mm) 25.9 (3.2) 26 (3) 27.2 (3) 27.6 (2.9) 28.9 (3.7) 28.8 (3.1) 30.2 (3.1)
Distance 1st met. (mm) 142.9 (12) 148.6 (13.6) 153.4 (13.6) 160.4 (14.6) 169.1 (16) 174.5 (13.5) 173.3 (11.9)
Distance 5th met. (mm) 128.1 (14.1) 135.9 (14.4) 140.3 (14.4) 145.6 (15.7) 151.9 (16.3) 155.4 (15.3) 156.9 (13.4)
Heel width (mm) 43.8 (3.8) 44.4 (3.5) 46.5 (3.5) 48.9 (4) 50.5 (3.8) 51.5 (4.2) 54.7 (3.5)
Forefoot width (mm) 69.9 (4.3) 71.7 (4.3) 74.4 (4.3) 77.7 (4.5) 80.7 (5.4) 82.5 (6) 86.6 (4.4)
Instep height (mm) 53.3 (6.6) 55.1 (6.8) 59.1 (6.8) 61.4 (6.2) 63.7 (6.6) 66.4 (7.3) 67.4 (5.4)
Arch height (mm) 16.7 (3.7) 17.1 (3.6) 18.7 (3.6) 20.1 (3.7) 19.8 (4.3) 20.5 (3.9) 22.6 (3.2)
Overweight Foot length (mm) 197.6 (11.7) 203.5 (11.1) 212.3 (11.8) 218.1 (15.4) 233.5 (10.5) 236.6 (11.5) 247.6 (19.7)
(n=250) Metatarsal width (mm) 75.3 (4.3) 78.8 (5.7) 82 (5.3) 84.4 (5.6) 89.5 (6.4) 93 (6.1) 96.9 (7.1)
Ball height (mm) 28.2 (2.9) 27.4 (2.9) 29 (3.1) 29.7 (3.3) 31.3 (3.5) 32.4 (3.5) 32.7 (3)
Distance 1st met. (mm) 146.8 (15.8) 153.6 (10.3) 161.2 (14.4) 163.4 (15.4) 171.3 (17.1) 173.8 (19.4) 184.8 (19.8)
Distance 5th met. (mm) 134 (13.8) 140.6 (15.5) 142.7 (16.2) 148.8 (13.7) 158 (14.2) 158.4 (16.3) 163.4 (13.7)
Heel width (mm) 46.5 (3.9) 48 (3.9) 48.6 (3.1) 50.3 (3.9) 53.7 (3.5) 54.3 (3.6) 59.7 (5.2)
Forefoot width (mm) 72.3 (4) 76.4 (4.9) 78.1 (4.3) 81.1 (4.7) 85.3 (5) 87 (4.4) 93.2 (7.4)
Instep height (mm) 54.2 (9.5) 57.7 (5.5) 61.3 (6.1) 62.7 (6.8) 66.6 (5.5) 66.2 (7.5) 71.9 (6.9)
Arch height (mm) 15.3 (4.5) 17.5 (4.2) 19.2 (3.4) 20.7 (3.6) 20.3 (3.5) 19.9 (4.1) 22.6 (3)
Obese (n=103) Foot length (mm) 195.7 (14.7) 207.4 (14.5) 216.9 (9.1) 221.3 (9.6) 228 (11.9) 241.9 (11.1) 245 (11.3)
Metatarsal width (mm) 80 (6.3) 83.2 (6.1) 87.1 (5.9) 93.3 (7.4) 93.2 (6.2) 99.7 (8.6) 100.6 (7)
Ball height (mm) 29.8 (2.1) 30 (3.7) 31.9 (2.7) 33.9 (4.2) 32.8 (3.3) 34.8 (3.4) 34.4 (3.8)
Distance 1st met. (mm) 147.2 (10.6) 157.8 (13.6) 157.5 (13) 158.6 (22.2) 168.8 (15.9) 183.2 (15.5) 183.9 (16.2)
Distance 5th met. (mm) 127.5 (15.7) 142 (16) 144.3 (11) 150.7 (15.4) 152.2 (14) 153.9 (14.9) 161.8 (17.2)
Heel width (mm) 48.5 (3.6) 49.5 (4.3) 53.3 (3.7) 55.1 (3.8) 55.1 (3.4) 56.3 (3.3) 59 (2.6)
Forefoot width (mm) 75.8 (5.2) 79.8 (4.8) 83.2 (5.4) 87.1 (5) 88.4 (5.3) 92.7 (5.2) 94.8 (5.8)
Instep height (mm) 56.2 (5.8) 58.2 (7) 63.8 (5.7) 66.3 (6.5) 66.3 (3.9) 70.1 (6.3) 68.6 (8.3)
Arch height (mm) 18.1 (4.5) 18.7 (3.5) 21.1 (3.8) 22.4 (3.8) 20.4 (3.3) 21.7 (2.9) 22.9 (3.8)

n number of subjects, nN number of subjects with normal-weight, nO number of subjects with overweight, nOb number of subjects with obesity, SD
standard deviation, mm millimeters
650 Eur J Pediatr (2013) 172:645–652

Table 4 Average percentages of increase per year of the foot dimen- we cannot discriminate whether the differences are given by
sions in each weight group
the bone structure or adiposity.
Percentages (%) These results are in keeping with those of other authors
although we have not controlled the influence of ethnic
Normal-weight Overweight Obese factors in the foot morphology. It has been shown that
overweight and obese children have a higher frequency of
Foot length 3.8 3.7 3.7
flat feet, higher dimensions, and less changes in widths than
Metatarsal width 3.4 4.1 3.7
normal-weight children [3, 24]. These children show greater
Ball height 2.5 2.4 2.3
foot length and forefoot width, less navicular height, and
Distance to 1st metatarsal 3.2 3.7 3.6
lower medial arch height compared with children with nor-
Distance to 5th metatarsal 3.3 3.2 3.8
mal weight [9, 20, 23, 31, 32, 42, 46]. As the literature
Heel width 3.6 4.1 3.2
shows, the feet of overweight and obese children are char-
Forefoot width 3.5 4.1 3.6
acterized by lower footprint angle (FA), higher Chippaux–
Instep height 3.8 4.5 3.2
Smirak index (CSI), higher plantar pressures [3, 8, 9, 23, 32,
Arch height 4.8 6.1 3.7
42, 43], higher arch index (AI), and higher footprint area
Average value 3.6 4 3.4
[17, 28]. These features are associated with a lower internal
longitudinal arch, resulting in flat feet [8, 20, 32, 43].
Discussion According to the above, and in contrast to the results of
Evans [12], it seems reasonable to postulate that an excess
The results about the prevalence of normal-weight, over- body mass affects foot structure in children producing
weight, and obese children in the sample of the present changes in size.
study are similar to other studies that examined the preva-
lence of overweight and obesity in European children of Age differences in foot measures in school age according
school age [1, 2, 13, 18, 19, 25, 34, 35]. to the weight category

Morphological differences in the foot according
to the weight category
Several authors have argued that an excessive body mass
negatively affects the lower extremity and morphological
structure of the feet of prepubertal children [24, 32].
From the results obtained in the analysis of the morphol-
ogy of the foot according to weight category in Spanish
children, it seems that the feet of normal-weight children are
different from those of overweight or obese children. None-
theless, the feet of children with overweight differ only to
obese children in the width (forefoot, metatarsal, and heel).
The dimensions of the feet of obese children were greater
than those of overweight children, and these were higher
than those of normal-weight children, that is, with increas-
ing BMI, foot measures increase but with this methodology
Fig. 3 Age differences in the forefoot width (mean±SD) in different
groups of weight category
With the present results, we have seen that among the age
groups there were more significant differences in measures
between children with normal-weight, followed by over-
weight and obese children. This makes us understand that
children with more weight tend to show less change in their
feet or the changes are more gradual; thus, we conclude that
excess weight could be an important factor in foot develop-
ment in prepubertal school-age children.
Chen et al. [4] observed a significantly higher prevalence
of flat feet in children from 7 to 8 years. In our study, we
have documented the highest percentage of children with
obesity at this stage. Studies show that there are consider-
able changes in school-age children through adolescence.
For example, Cheng et al. [5], in a study of 2,829 children
from 3 to 18 years, found an increase in the foot length and
width of the foot in girls from 3 to 12 years and in boys up to
15 years (coinciding with the onset of puberty). The foot
length significantly increased with weightbearing at all ages
by an average of 3.1–4.8 %. In the present study, we also
found that in the three groups in the range from 10 to
12 years, the increase in foot measures was not significant,
which means that the morphological structure of the foot
becomes more stable and there are fewer changes. Some
authors have indicated that children from 12 to 13 years,
coinciding with the end of primary school, feel that the
child’s foot is structurally formed [11, 15]. Our results
confirm these findings by demonstrating less change in the
older groups.
Eur J Pediatr (2013) 172:645–652
When normalizing foot variables, we found that the dif-
ferences between weight categories and between age groups
disappeared. This means that the foot shape is constant in
relation to his length along the primary school.
As to the limitations of this study, it has to be emphasized
that we have performed a study with a cross-sectional de-
sign. Moreover, we were not able to analyze the type of
footprint and some clinical indexes, like the AI, CSI, or FA.
This would have allowed to study the relationship between
obesity and flat feet in children.
Conclusions
Based on the results of this study, we conclude that the
percentage of children with obesity in the school population
in central Spain has increased. Moreover, we have seen that
excess weight affects the foot structure of children.
The results of this study have immediate implications for
the design of footwear for children, depending on their age and
BMI. Increased BMI affects foot morphology changes with
age. Manufacturers using these data can make new lasts based
on age and weight for children’s shoes using this technology.
Furthermore, the use of 3D methodology could make possible
individualized custom footwear manufacture improving fit
potentially preventing future lower limb problems.
Future research should study whether the differences
reported in the present study are present with a longitudinal
design. This would allow to measure the actual evolution of
the foot structure in children with and without obesity.
Acknowledgments The present study obtained financial support
from the FEDER funds and the Counselling of Education, Science
and Culture of the Junta de Comunidades de Castilla-La Mancha,
Spain. We thank the following primary schools from the province of
Toledo for their participation in this study: CP San José, CP María del
Mar, and CP Condes de Fuensalida (Fuensalida); CP Gregorio Mar-
añón (Huecas); CP Conde de Ruiseñada (Portillo de Toledo); CP
Nuestra Señora de la Paz (Santa Cruz del Retamar); CP Nuestra Señora
de la Redonda (Villamiel); and CP Alfonso VI, CP La Candelaria, CP
Ciudad de Aquisgrán, and CP Santa Teresa (Toledo). We also want to
thank INESCOP (Elda, Alicante, Spain) for technical support.
Financial disclosure statement No party having a direct interest in
the results of the research supporting this article has or will confer a
benefit to us or any organization with which we are associated.
Conflict of interest statement The authors declare that they have no
conflict of interest.
Ethical board review statement Each author certifies that his insti-
tution approved the human protocol for this investigation that all
investigations were conducted in conformity with ethical principles
of research, and that informed consent for participation in the study
was obtained.
651
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