Original Article

Role of Motor Competence and Executive Functioning in Weight

Loss: A Study in Children with Obesity
Mireille J. C. M. Augustijn, MSc,*† Eva D’Hondt, PhD,‡ Lore Van Acker, MSc,§ Ann De
Guchtenaere, PhD,§ Matthieu Lenoir, PhD,* Karen Caeyenberghs, PhD,\
Frederik J. A. Deconinck, PhD*

ABSTRACT: Objective: This study aimed to compare motor competence and executive functioning (EF) be-
tween children with obesity and peers with healthy weight. Additionally, the predictive value of motor
competence and EF in weight loss after a 5-month multidisciplinary residential treatment program was ex-
amined. Methods: Thirty-two children with obesity (7–11 years, 14 boys) and 32 age-matched controls (18
boys) performed 8 motor skill tasks and 4 tasks of EF (only at baseline). In the group of children with obesity,
anthropometric measurements were performed at baseline and 5 months after the start of their treatment
program. Also in control children, there was a time span of 5 months in between anthropometric meas-
urements. Results: Lower levels of motor competence and reduced updating abilities, inhibition control, and
planning skills were observed in children with obesity compared with healthy-weight controls. Within the
total group, better general motor competence and balance skills were significantly associated with better
updating, inhibition control, and planning. Finally, hierarchical regression analyses revealed that ball skills,
balance skills, and inhibition/updating at baseline predicted 14% to 17% of the variance in weight loss after
a 5-month treatment program in children with obesity. Conclusion: These results suggest that motor com-
petence and EF are both relevant factors associated with childhood obesity. Moreover, these factors seem to
be significant predictors of weight loss. Future (intervention) studies are needed to understand the impact of
the difficulties in motor and EF on obesity-related behaviors as well as on short-term and, especially, long-
term weight loss and maintenance.
(J Dev Behav Pediatr 0:1–10, 2018) Index terms: obesity, children, motor competence, executive functioning, multidisciplinary treatment program.

C hildhood obesity is an important global health

problem and has a negative impact on children’s physi-
cal health and social well-being.1 In Belgium, 20% of the
school-aged children are currently overweight or obese.2
Considering the major impact of childhood obesity on
health care and society, the development of specific
treatment programs for this target population has be-
come increasingly important. Although current obesity
treatment programs have shown success in terms of
weight reduction and behavioral change,3,4 many chil-
dren drop out or regain weight at follow-up.5 Those
programs primarily focus on reducing the amount of
food intake and increasing physical activity.3 Recent
From the *Department of Movement and Sports Sciences, Ghent University,
Gent, Belgium; †Research Foundation Flanders (FWO), Brussels, Belgium;
‡Faculty of Physical Education and Physiotherapy, Department of Movement
and Sports Sciences, Vrije Universiteit Brussel, Brussel, Belgium;
§Zeepreventorium VZW, De Haan, Belgium; \School of Psychology, Australian
Catholic University, Melbourne, Australia.
Received January 2018; accepted April 2018.
The study was funded by the PhD fellowship of the Research Foundation Flan-
ders (FWO) awarded to M. J. C. M. Augustijn [3F000714].
Disclosure: The authors declare no conflict of interest.
Address for reprints: Mireille J. C. M. Augustijn, MSc, Faculty of Medicine and
Health Sciences, Department of Movement and Sports Sciences, Ghent Univer-
sity, Watersportlaan 2, B-9000 Gent, Belgium; e-mail: mireille.augustijn@ugent.be.
Copyright Ó 2018 Wolters Kluwer Health, Inc. All rights reserved.
insights into the determinants of obesity, however, in-
dicate that other behavioral factors have to be consid-
ered, too. For example, based on evidence that childhood
obesity is associated with gross and fine motor difficulties,
it is recommended that practitioners pay attention to
motor skill development6–8 especially because a certain
level of motor competence is required to enjoy and
maintain long-term physical activity.9 In this respect, it is
important to note that the movement difficulties extend to
fine motor tasks, which indicates that the problems can-
not be solely attributed to the mechanical constraints re-
lated to moving and stabilizing excess mass against gravity.
Instead, it is suggested that children with obesity experi-
ence difficulties with the cognitive processes needed to
plan and control motor actions.6,7
Previous studies have found a negative association
between obesity and executive functioning (EF), which is
an umbrella term for complex, higher-order cognitive
functions that controls and regulates lower-level cognitive
processes during goal-directed behavior (see Reference
10 for a review). Specifically, children and adolescents
with obesity have more difficulties with inhibition con-
trol,11,12 updating abilities,13 and planning14,15 compared
with healthy-weight controls, whereas mixed results
were found for attention shifting.14 There are evidence
and consensus that motor performance and EF are in-
terrelated. A recent review by Van der Fels et al.16

Vol. 0, No. 0, Month 2018 www.jdbp.org | 1

Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
showed that in typically developing children, excellent
motor skills are associated with better EF, whereas poor
motor performance is associated with inattention, lower
response inhibition, and reduced working memory.17 It
is also known that EF and motor competence share
a number of behavioral characteristics. For example, to
learn new motor skills, one has to suppress a previously
learned skill, concentrate on the current motor task,
and use forward planning to improve the skill.16 This
overlap is perhaps not surprising given that execu-
tive functions engage regions involved in motor co-
ordination and learning (cerebellum) and brain regions
related to cognitive control (prefrontal cortex).18 It
remains to be verified, however, to what extent the
motor problems and deficits in EF are associated in
children with obesity, which may have an impact on
the way obesity is treated.
Weight loss and maintenance require adequate levels
of motor competence and EF. Children with higher lev-
els of motor competence are found to be more active,
which, in turn, promotes weight loss and maintenance
(see Reference 9 for a review). Additionally, appropriate
EF can help individuals with obesity better control,
change, and maintain their eating behavior.19,20 To bet-
ter understand why some children with obesity are more
successful in weight loss programs than others, it is im-
portant to examine which factors may predict the
amount of weight loss. van Egmond-Froehlich et al.,21 for
example, showed that inattention is associated with re-
duced long-term weight loss in children and adolescents
with obesity after a weight loss program (duration
varying between 5–22 months). In addition, Kulendran
et al.22 found evidence of a predictive role of change in
inhibition control on reduction in the body mass index
after an 8-week multidimensional weight loss in-
tervention in adolescents with obesity. D’Hondt et al.,23
then, indicated that baseline levels of gross motor com-
petence could predict weight changes over time (i.e., 2
years) in children aged 5 to 13 years old regardless of
obesity. However, multidimensional research that fo-
cuses on the combined, predictive effect of motor
competence and EF on weight loss after a treatment
program in children with obesity is currently lacking.
Therefore, the aims of this study were to assess motor
competence and EF in children with obesity, to explore
their relationship, and to compare this with healthy-
weight peers. In addition to this, we investigated to what
extent motor competence and/or EF may act as a pre-
dictor of weight loss after a 5-month multidisciplinary
residential treatment program for children with obesity.
To gain a comprehensive picture of EF in children with
obesity, we examined 4 domains of EF (i.e., inhibition,
planning, attentional shifting, and updating). Based on
previous studies that showed reduced motor compe-
tence and EF in separate cohorts, it was hypothesized
that children with obesity would have lower levels of
motor competence and EF. In addition, we expected
a positive association between these factors in the total
2 Motor and Executive Functioning in Obesity
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
group of children (obesity and healthy weight) and in
each group separately. Finally, given that higher levels of
motor competence are associated with more physical
activity and better EF enables individuals to regulate their
behavior, emotions, and thoughts, it was hypothesized
that children with obesity who have lower levels of
motor competence and reduced EF would be less suc-
cessful in terms of weight reduction compared with their
peers with better skills.
METHODS
Participants
Sixty-four children (33 boys, 9.6 6 1.2 years, range 5
7.6–11.6 years) aged between 7 and 11 years completed
assessments of motor competence and executive func-
tioning (EF). Half of the sample (N 5 32, 14 boys, 9.6 6
1.1 years, range 5 7.6–11.3 years) were children with
obesity who were recruited via the Zeepreventorium
(De Haan, Belgium), a multidisciplinary residential treat-
ment center for children with obesity. The treatment
program allows a maximum of 20 children within this
particular age group (7–11 years) per year and provides
easy access to children with (severe) obesity. All of these
children with obesity were referred to the program by
their family physician but had no underlying endocrine
diseases or obesity-related genetic disorders such as Prader-
Willi syndrome. In addition, children with mental re-
tardation (intelligence quotient , 70) were excluded. All
children of the cohorts that started treatment in August
2014, 2015, and 2016 (N 5 60) were informed about the
study during the intake interview and were invited to
participate. Only children whose parents signed the in-
formed consent forms and approved participation in this
study were included. This resulted in a total sample of 32
children (53%). Based on the internationally accepted cut-
off points relative to sex and age,24 all participants could be
identified as obese. The other participants (N 5 32, 18
boys, 9.6 6 1.2 years, range 5 7.8–11.6 years) were clas-
sified as healthy weight based on the internationally ac-
cepted cutoff points for the body mass index (BMI).24 This
healthy-weight control group was selected from a large
database of primary school children (N 5 959) from the
region of Ghent (Belgium) with attention to age to accu-
rately match the children with obesity. The study protocol
was approved by the Ethics Committee of the University
Hospital Ghent (Belgium), and written informed consent
was obtained before data collection from each child’s
parent(s) and the school or rehabilitation center staff.
Treatment Program
The group with obesity resided in the rehabilitation
center Zeepreventorium (De Haan, Belgium), where they
followed a multidisciplinary treatment program with
a duration varying from 6 to 10 months. On weekdays, the
rehabilitation center provided primary school education,
and at the weekend, children went home to spend time
with their families. Because the content of the treatment
Journal of Developmental & Behavioral Pediatrics
program is adjusted to the specific individual needs of
each child, there is no detailed description of the pro-
gram. Nevertheless, every individual program focused on
3 major factors: (1) diet, which consists of 3 main meals
and 2 healthy snacks daily and information sessions on
how to make healthy food choices; (2) cognitive behav-
ioral therapy, during which children are taught how to use
solution-based thinking to improve behavioral modifica-
tion; and (3) regular physical activity, which is provided in
3 physiotherapy sessions and in guided exercises (mini-
mum 3 hr/wk) with a focus on aerobic activities such as
walking, swimming, soccer, and dancing. Additionally,
every child had the opportunity to participate in super-
vised team sports (e.g., soccer and basketball) and group
games (e.g., obstacle swim and relay race) for approxi-
mately 1 hour a day (5 hr/wk).
Measurements
All children underwent anthropometric measure-
ments, evaluations of EF, and motor assessments at
baseline. In the children with obesity, the measurements
were taken before or at the start of their treatment
program so that the program would not influence the
results. After 5 months (146 6 9 days, 123–166 days), the
anthropometric measurements were repeated to de-
termine the change in weight among the children with
obesity. Two children with obesity (2 boys, 8 and 11
years old) dropped out of the treatment program. Also in
control children, there was a time span of 5 months
(154 6 13 days, 131–179 days) in between anthropo-
metric measurements. Seven children with healthy
weight (7 girls, 10.1 6 1.4 years old) completed the
measurements only at baseline.
Anthropometrics
Height was measured barefoot to the nearest 0.1 cm
using a calibrated stadiometer (Harpenden; Holtain Ltd,
Crymych, United Kingdom). In addition, body mass and
fat percentage were obtained in minimal clothing to the
nearest 0.1 kg and 0.1% using a digital balance scale with
bioelectrical impedance (Tanita, BC420SMA; Weda BV,
Naarden, Holland). Based on height and body mass, the
BMI (kg/m2) was calculated and used to classify the
subjects according to the age- and sex-specific BMI cutoff
points for children.24
Movement Assessment Battery for Children:
Second Edition
The Movement Assessment Battery for Children, Sec-
ond Edition (MABC-2) was used to assess children’s gross
and fine motor competence. This norm-referenced test
battery has shown good validity and reliability as
a method for detection of motor problems in children
between 3 and 16 years old.25,26 The MABC-2 consists of
8 test items, which were divided into 3 types of skills,
i.e., manual dexterity (3 items), ball skills (2 items), and
static and dynamic balance skills (3 items). Raw scores
are converted into 1 scaled score per skill and a general
motor competence score. A general motor competence
score below the fifth percentile (Pc 5) indicates severe
Vol. 0, No. 0, Month 2018
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motor problems. When it falls between Pc 6 and Pc 16,
there is a risk for developing motor problems.
Cambridge Neuropsychological Test Automated
Battery
The Cambridge Neuropsychological Test Automated
Battery (CANTAB [Cognitive assessment software],
Cambridge Cognition [2017], all rights reserved, www.
cantab.com) was used to evaluate children’s EF. The
CANTAB was shown to be a valid and reliable instrument
to measure cognitive functioning in subjects aged 4 to 90
years old with and without neurocognitive disorders.27
Three tasks of the CANTAB were performed.
The intra-extra dimensional shift (IED) was included
to examine attention shifting, which is the ability to
change focus from 1 stimulus to another. For each trial, 2
figures were displayed consisting of 1 (stage 1–2) or 2
(stage 3–9) dimensions: color-filled shapes and white
lines. The participant was instructed to touch the correct
pattern, which could be determined by learning a rule
using feedback provided by the computer. After 6 cor-
rect responses, the rule and/or figure were changed
within a stimulus dimension (intradimensional shift,
stages 1–7) or to a previously irrelevant stimulus di-
mension (extradimensional [ED] shift, stages 8–9). Four
outcome measures were selected, including total errors
(adjusted by adding 50 errors for each stage that was not
completed), the number of completed stages, pre-ED
shifting errors (sum of the errors made in stage 1–7),
and total trials (adjusted by adding 50 trials for each stage
that was not completed).
Rapid visual information processing (RVP) was per-
formed to assess updating abilities and inhibition control.
Updating is the ability to hold information in mind and
mentally work with it. Inhibition, then, measures the
ability to suppress an inappropriate prepotent and/or
impulsive response. During the RVP, a seemingly ran-
dom sequence of numbers1–9 was displayed at a high
frequency (100 digits per minute). Participants were
asked to press the response button every time they ob-
served the sequence “3-5-7.” Three blocks of practice
trials were followed by the actual test (4 blocks, in-
cluding 1 practice block), all containing a sequence of
100 numbers. Two outcome measures were calculated:
(1) total hits, which is a measure of updating and rep-
resents the number of corrected responses to the target
sequence (i.e., “3-5-7”); and (2) total false alarms, which
is a measure of inhibition control and represents the
number of times the participant did press the button
when the target sequence was not represented.
Finally, the Stockings of Cambridge (SOC) was in-
cluded to examine planning and decision making, which
is the ability to organize activities or steps necessary to
reach a goal. During the SOC, the upper panel of the
screen displayed colored discs “stacked” in a certain
manner in 3 stockings. In the “problem-solving condi-
tion,” participants were asked to copy the configuration
in the lower panel using as few movements as possible.
Before starting to move the discs, participants were
Copyright Ó 2018 Wolters Kluwer Health, Inc. All rights reserved. 3
instructed to first plan and decide on the sequence of
movements. The difficulty of the task increased with the
number of balls that had to be moved (i.e., ranging from
1 [practice trials] to 5 moves). In the “follow” condition,
an exact replication of their earlier planning movements
was displayed on the screen. The participants were
instructed to follow the ball movements as quickly as
possible to provide reaction and movement times. Four
outcome measures were included: (1) the number of
problems solved in minimum moves, (2) mean moves,
(3) initial thinking time (which is the time between ap-
pearance of the problem displayed and the first move-
ment), and (4) subsequent thinking time (which is the
time between the first movement and completion of
the task).
During the administration of the 3 tasks, all children
were seated on a chair in a comfortable position with
both feet on the ground and the elbows flexed at ap-
proximately 1008. All 3 tasks were displayed on a tablet
PC (Gigabyte tablet S1080) with a 10.1-inch touch-
sensitive screen, which was placed 30 cm in front of
the participant. The RVP required the use of a press-pad,
which was placed in the middle (at 15 cm) between the
participant and the tablet PC. The 3 tasks were admin-
istered in a random order to avoid potential order effects.
To reduce the number of multiple comparisons in the
partial correlation analyses and hierarchical regression
analyses, a composite score was derived for each of the 3
CANTAB tasks by computing z-scores for each de-
pendent variable and averaging across the dependent
variables of that specific task. This resulted in 3 com-
posite scores: IED, RVP, and SOC.
Statistics
Statistical analyses were performed using SPSS 22.0.
First, the data were inspected for outliers within each
group separately (i.e., mean 6 3 SD). Three outliers
(2 obesity and 1 healthy weight) were observed for the
IED (all outcome measures), 3 outliers (2 obesity and 1
healthy weight) for RVP total false alarms, 2 outliers (1
obesity and 1 healthy weight) for the SOC initial thinking
time, and 4 outliers (2 obesity and 2 healthy weight) for
the SOC subsequent thinking time. All outliers were ex-
cluded from further analyses. A 2 (group) 3 2 (time)
repeated-measures analysis of variance was performed to
compare anthropometric measurements of the children
with obesity (N 5 30) and children with healthy weight
before the treatment program (time 1) and after 5
months (time 2). Significant interaction effects were
further evaluated using post hoc tests. To examine group
differences in (1) motor competence, (2) attention
shifting (IED), (3) updating/inhibition control (RVP), and
(4) planning (SOC), 4 separate 2 (group) 3 2 (sex)
multivariate analyses of covariance were performed con-
trolling for age. Significant effects were further analyzed
using univariate statistics. To investigate the association
between EF and motor competence, partial correlations
were performed for the total group and for each group
4 Motor and Executive Functioning in Obesity
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
separately, controlling for age and sex. Finally, 2 hierar-
chical regression analyses were conducted to examine
whether baseline levels of motor competence and/or EF
can predict the success of the treatment program in the
percentage of BMI reduction BMIpost2BMIpre
BMIpre 3 100% and
change in BMI z-score (post 2 pre) in the sample of
children with obesity. Change in the BMI was used to
adjust for height. In the first step, age and sex were in-
cluded as control variables, followed by the 3 components
of motor competence and the 3 composite scores of EF
(step 2). False discovery rate corrections were made to
control for multiple comparisons. The significance
threshold was set at p , 0.05 (trend: p , 0.10).
RESULTS
Descriptive Statistics
Descriptive statistics are shown in Table 1. There
were significant interaction effects between time and
group for height (pFDR 5 0.008), body weight (pFDR #
0.001), percentage of body fat (pFDR # 0.001), and body
mass index (BMI, pFDR # 0.001). Post hoc tests indicated
a significant decrease for each of the weight-related
measures (p # 0.001) in the group of children with
obesity over time, whereas there was no significant
change in the body fat percentage (p 5 0.993) and BMI
(p 5 0.678), and only a small increase in body weight
(p 5 0.003) was observed in the group of children with
healthy weight. Height (p # 0.001) significantly in-
creased over time in both groups. After the 5-month
treatment program, children with obesity lost on aver-
age 15.4 6 3.6% of their initial body weight, and
according to their BMI, 9 of 30 children (30%) could now
be identified as overweight. All the control children
were still classified as healthy weight at the moment of
retesting.
Motor Competence
Nineteen children with obesity (59.3%) and 3 children
from the healthy-weight group (9.4%) demonstrated im-
paired motor competence (percentile [Pc] , 5 on the
Movement Assessment Battery for Children, Second
Edition). The 2 (group) 3 2 (sex) multivariate analysis of
covariance (MANCOVA) indicated that age was a signifi-
cant covariate. Sex, however, was excluded from the
analysis because there was no significant main effect and
no interaction effect with the BMI group (p . 0.05). The
2 (group) MANCOVA showed a significant main effect of
group (p # 0.001; Table 2 (A)). Further analysis revealed
that children with obesity had significantly lower levels
of general motor competence and reduced manual dex-
terity and static and dynamic balance skills compared
with healthy-weight peers, but no differences were
found for ball skills between both groups (Table 2).
Executive Functioning
As shown in Table 2 (B–D), the MANCOVA indicated
that age was a significant covariate for intra-extra
Journal of Developmental & Behavioral Pediatrics
 dimensional shift (IED) and rapid visual information

0.008
158.484 £0.001 £0.001 296.674 £0.001 £0.001
102.949 £0.001 £0.001 103.227 £0.001 £0.001
360.236 £0.001 £0.001 384.003 £0.001 £0.001
99.296 £0.001 £0.001
0.112
pFDR
processing (RVP) but not for the Stockings of Cambridge

Group 3 Time
(SOC). Because there was no significant main effect of

0.006
0.112
sex and no interaction effect with the BMI group, sex
p was excluded from further analyses. For attention shift-
ing (IED), the variable “number of completed stages”

8.305
2.605
was removed from the MANCOVA because the distribu-
F

tion of the data indicated that it should be considered

a categorical variable. An additional x2 test showed no
Repeated-Measures ANOVA

0.780 6438.033 £0.001 £0.001

345.399 £0.001 £0.001

134.430 £0.001 £0.001

significant group differences in the number of completed
pFDR

stages (x2 5 1.211; p 5 0.546). Sixty percent of the chil-

dren with obesity and 61.3% of the children with healthy
weight were able to complete all 9 stages. Furthermore,
Time
p

the 2 (group) MANCOVA analyses did not show significant

group differences in attention shifting for the other IED
outcome measures (p . 0.05). For updating and inhibition
F

control (RVP), significant group differences were observed

(p 5 0.002). Fewer hits and more errors during the RVP
task indicated reduced updating abilities (pFDR 5 0.006)
87.408 £0.001 £0.001
147.853 £0.001 £0.001
187.411 £0.001 £0.001
378.082 £0.001 £0.001
0.161
pFDR

and inhibition control (pFDR 5 0.002) in the group of

children with obesity compared with healthy-weight
peers. Twelve children with obesity (40%) and 3 chil-
0.780
0.129
Group
p

dren with healthy weight (9.4%) scored lower than Pc 10

for total false alarms. For total hits, 8 children with obesity
0.079
2.380

(26.7%) and 2 children with healthy weight (6.3%) per-

F

formed lower than Pc 10. Finally, significant group differ-

ences were found for planning skills and decision making
Significant results (p , 0.05, FDR corrected) are represented in bold. ANOVA, analysis of variance; BMI, body mass index.

(SOC). Children with obesity solved fewer problems (pFDR

Healthy Weight

(20.6 to 1.1)
16.98 6 1.19

5 0.004) and needed more moves (pFDR 5 0.004) to solve

Mean 6 SD

142.6 6 9.1
34.8 6 5.9
17.9 6 4.3
(N 5 25)

9.9 6 1.2

0.1 6 0.5

the different SOC trials. Additionally, children with obesity

18/7

needed less time to plan the movement (shorter initial

thinking time; pFDR 5 0.017) but more time to move
(longer subsequent thinking time; pFDR 5 0.017) com-
Time 2

pared with children with healthy weight. The results of

Obesity (N 5 30)

the IED (p . 0.05) and RVP (pFDR 5 0.006) remained

(1.3 to 2.9)
25.35 6 3.62
Mean 6 SD

145.8 6 8.3
54.3 6 11.5
32.3 6 9.1
9.9 6 1.2

2.0 6 0.4

significant when outliers were included in the analyses.

12/18

For the SOC, children with obesity needed more moves to

solve the different SOC trials (pFDR 5 0.002) and solved
Table 1. Descriptive Statistics (Mean 6 SD) According to BMI Groups

fewer problems (pFDR 5 0.002) compared with healthy-

weight controls, but no significant differences in the initial
Healthy Weight

(pFDR 5 0.064) and subsequent (pFDR 5 0.224) thinking

(21.1 to 1.1)
138.75 6 9.04
32.73 6 5.49
18.22 6 4.01
16.87 6 1.08
Mean 6 SD
(N 5 32)

9.6 6 1.2

0.1 6 0.5

times were observed after the inclusion of the outliers.

18/14

Relationship Between Motor Competence and

Executive Functioning
Time 1

Table 3 represents the partial correlations, controlling

Obesity (N 5 32)

(1.98 to 3.41)

for age and sex, between motor competence and execu-

143.44 6 7.94
63.73 6 13.36
43.71 6 6.56
30.69 6 4.24
Mean 6 SD

9.6 6 1.1

2.7 6 0.3

tive functioning (EF) for the total group and for both
14/18

groups separately. Within the total group, significant

positive correlations were observed between inhibition/
updating (RVP) and general motor competence (pFDR #
0.001), manual dexterity (pFDR # 0.001), and balance
skills (pFDR # 0.001). Children with better updating skills
Body weight (kg)
Sex (boys/girls)

and inhibition control had better levels of motor compe-

BMI (z-score)
BMI (kg/m2)
Body fat (%)
Height (cm)

tence and vice versa. Additionally, a significant positive

Age (yr)

association was found between planning/decision making

(SOC) and general motor competence (pFDR 5 0.045),
which indicates that children with better planning and

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Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Table 2. Means (6SD) for Motor Performance and 3 Domains of Executive Functioning According to the BMI Group
MANCOVA
Healthy Group Age (Covariate)
Obesity Weight
Effect Effect
Mean (SD) Mean (SD) F(p) pFDR Size F(p) pFDR Size
A. Motor competence N 5 32 N 5 32 20.561 (#0.001) — 0.511 2.930 (0.041) — 0.130
General motor 55.9 (17.8) 76.9 (10.0) 37.830 (£0.001) £0.001 0.383 7.622 (0.008) 0.018 0.111
competence
Manual dexterity 21.8 (8.9) 28.2 (5.5) 12.561 (0.001) 0.001 0.171 3.241 (0.077) 0.103 0.050
Ball skills 16.1 (5.9) 18.1 (5.6) 2.114 (0.151) 0.151 0.033 7.269 (0.009) 0.018 0.106
Balance skills 17.9 (8.5) 30.6 (3.8) 61.629 (£0.001) £0.001 0.503 2.456 (0.122) 0.122 0.039
B. Attention shifting N 5 30 N 5 31 1.013 (0.394) — 0.051 3.702 (0.017) — 0.165
IED total errors 36.8 (19.7) 34.1 (21.5) — — 0.005 5.091 (0.028) 0.042 0.081
(adjusted)
IED pre-ED errors 9.3 (4.9) 7.7 (4.1) — — 0.031 1.280 (0.263) 0.263 0.022
IED total trials 121.2 (33.2) 114.1 (33.0) — — 0.012 6.028 (0.017) 0.042 0.094
(adjusted)
C. Updating/inhibition N 5 30 N 5 31 6.755 (0.002) — 0.192 6.755 (0.002) — 0.192
RVP total hits 16.5 (4.5) 19.2 (3.7) 8.041 (0.006) 0.006 0.122 11.168 (0.001) 0.002 0.161
RVP total false alarms 2.8 (3.1) 0.8 (0.9) 12.032 (0.001) 0.002 0.172 0.129 (0.720) 0.720 0.002
D. Planning/decision N 5 29 N 5 29 4.865 (0.002) — 0.272 0.873 (0.487) — 0.063
making
SOC problems solved 6.1 (1.7) 7.4 (1.3) 11.161 (0.002) 0.004 0.169 — — —
in minimum moves
SOC mean moves 5.0 (0.6) 4.5 (0.4) 10.405 (0.002) 0.004 0.159 — — —
SOC mean initial 2309.7 3043.1 (1327.4) 6.088 (0.017) 0.017 0.100 — — —
thinking time (ms) (857.2)
SOC mean subsequent 725.8 (418.0) 480.9 (287.5) 6.669 (0.013) 0.017 0.108 — — —
thinking time (ms)
Measurement outcomes of the 1-way MAN(C)OVA are shown in the gray rows and are represented in italics. Post hoc analysis of (co)variances of significant multivariate
effects are shown in the white rows (F, p, and partial eta squared effect size for the BMI group). Significant results (p , 0.05, FDR corrected) are represented in bold. BMI,
body mass index; ED, extradimensional; FDR, false discovery rate; IED, intra-extra dimensional shift; MANCOVA, multivariate analysis of covariance; RVP, rapid visual
information processing; SOC, Stockings of Cambridge.

decision-making abilities had better levels of motor com-
petence and vice versa. No significant correlations were
found for attention shifting (IED). Examining associations
in each group separately revealed no significant correla-
tions after corrections for multiple comparisons were
made (p . 0.05, false discovery rate [FDR] corrected).
After inclusion of the outliers, correlations within the total
group remained significant between inhibition/updating
(RVP) and general motor competence (pFDR 5 0.006),
manual dexterity (pFDR 5 0.016), and balance skills (pFDR
5 0.006) but not between planning/decision making
(SOC) and general motor competence (pFDR 5 0.173).
Prediction of Amount of Weight Loss by Motor
Competence and/or Executive Function in Children
with Obesity
Hierarchical regression analyses examined whether
baseline levels of motor competence and/or EF predicted
weight loss after a 5-month treatment program for the
children with obesity. Results are shown in Table 4. After
controlling for age and sex in the first step, motor com-
petence and EF contributed significantly to the model
and explained 38.9% of the variance in percentage BMI
reduction (F 5 5.734; p 5 0.001) and 32.3% of the vari-
ance in the change in the BMI z-score (F 5 4.735; p 5
0.003). Specifically, ball skills contributed significantly to
both models, explaining 14.3% of the variation in per-
centage BMI reduction and 16.3% of the variance in the
BMI z-score. Additionally, balance skills explained 14.3%
of the variation in percentage BMI reduction, with chil-
dren with poor balance skills being more successful in
losing weight than were children with better skills. This
finding was not observed for prediction in the change in
the BMI z-score. Manual dexterity, attention shifting, in-
hibition, updating, and planning were not significant
predictors of weight loss (p . 0.05).
After inclusion of the outliers, ball skills remained
a (marginally) significant predictor of percentage BMI
reduction (pFDR 5 0.036) and change in the BMI z-score
(pFDR 5 0.084). Moreover, scores on the RVP signifi-
cantly explained 16.4% of the variance in the percentage
of BMI reduction, with children with better updating

6 Motor and Executive Functioning in Obesity Journal of Developmental & Behavioral Pediatrics

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Table 3. Partial Correlations Between Motor Competence and Executive Functioning (Composite Scores for the 3 Tasks) Within the Total Group and for
Each Group Separately
Total Group Children with Obesity Children with Healthy Weight
IED RVP SOC IED RVP SOC IED RVP SOC
General motor competence
r 0.249 0.493 0.307 0.425 0.323 0.176 20.097 0.176 0.199
p 0.057 £0.001 0.015 0.024 0.081 0.351 0.616 0.352 0.291
pFDR 0.076 £0.001 0.045 0.176 0.216 0.437 0.821 0.603 0.603
Manual dexterity
r 0.264 0.409 0.243 0.397 0.315 0.099 0.006 0.038 0.231
p 0.043 £0.001 0.057 0.037 0.090 0.601 0.974 0.841 0.218
pFDR 0.076 £0.001 0.076 0.176 0.216 0.656 0.974 0.918 0.603
Ball skills
r 0.148 0.244 0.151 0.383 0.202 0.055 20.247 0.196 0.274
p 0.263 0.056 0.240 0.044 0.285 0.774 0.197 0.298 0.143
pFDR 0.263 0.076 0.262 0.176 0.437 0.774 0.603 0.603 0.603
Balance skills
r 0.161 0.443 0.285 0.178 0.182 0.213 0.076 0.146 20.182
p 0.224 £0.001 0.025 0.364 0.335 0.258 0.694 0.442 0.337
pFDR 0.262 £0.001 0.060 0.437 0.437 0.437 0.833 0.663 0.603
Age and sex were included as covariate. Significant correlations (p , 0.05, FDR corrected) are represented in bold. FDR, false discovery rate; IED, intra-extra dimensional
shift; RVP, rapid visual information processing; SOC, Stockings of Cambridge.

skills and inhibition control being more successful in
losing weight compared with healthy-weight controls.
This finding, however, was not observed for prediction
in the change in the BMI z-score.
DISCUSSION
A good understanding of the motor deficits and exec-
utive functioning (EF) problems associated with obesity is
required to better understand the determinants related to
this multifactorial health problem. Therefore, this study
was set up to assess and compare motor competence and
EF in children with obesity versus healthy-weight con-
trols, their mutual relationship, and the extent to which
motor competence and/or EF were able to predict the
success of an intensive 5-month multidisciplinary resi-
dential treatment program among children with obesity.
Consistent with the previous literature, it was found
that children with obesity had lower levels of general
motor competence than children with healthy weight.6–8
It is important to note that the motor problems are
displayed in both weight-bearing (e.g., balance) and non–
weight-bearing tasks (e.g., manual dexterity), which
indicates that they are not solely because of the excess
mass and suggest difficulties in the way children with
obesity plan and control their movements.7 Furthermore,
children with obesity demonstrated difficulties with in-
hibition control, updating, planning, and decision
making but not with attention shifting, which is consis-
tent with previous literature.10,11,13–15 Although previous
studies in children with obesity observed difficulties
with separate factors of EF, this is the first study showing
those difficulties in the same group of study participants.
Clearly, these results show that EF plays an important
role in childhood obesity. In daily life, a good level of EF
is required to manage obesity-related behaviors such as
meal planning, portion control, planning of physical ac-
tivities, and activity-related decision making.10 Thus, our
results support that there is a deficit in motor compe-
tence and EF in children with obesity that needs to be
addressed.
These findings, then, raise the question of whether
the difficulties in motor competence and EF are linked to
each other. Consistent with previous research, a corre-
lation was found between motor competence and EF for
the entire sample (obesity and healthy weight)16,17;
however, the results did not show any associations be-
tween the constructs within the group with obesity. In
other words, children with obesity and better motor
skills do not necessarily score better on EF. Although we
should be aware that a reduction of the sample size
affects the power of the model, these findings tend to
suggest that the motor problems observed in children
with obesity cannot be attributed to deficits in EF and
vice versa. The implication is that multidisciplinary resi-
dential treatments would need to consider both motor
competence and EF in children with obesity. It has al-
ready been shown that cognitive training seems to be an
important addition to obesity programs and strengthens
children’s EF. For example, Verbeken et al.28 demon-
strated that EF training leads to better working memory
and better maintenance of weight status 8 weeks after

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Table 4. Statistics of the Hierarchical Regression Analysis for Variables Predicting the Percentage of Reduction in BMI (%; Model 1) and Change in BMI
z-Score (Model 2) in Children with Obesity After a 5-Month Multidisciplinary Treatment Program
Model 1
% BMI Reduction F p R 2
DR 2
B SE B b t p pFDR sr2
Step 1 5.841 0.008 0.318
Age 0.991 0.506 0.324 1.957 0.062 0.062 0.104
Sex 2.920 1.105 0.438 2.643 0.014 0.028 0.190
Step 2 5.734 0.001 0.707 0.389
Age 0.878 0.473 0.287 1.856 0.030 0.060 0.085
Sex 2.100 0.895 0.315 2.347 0.079 0.090 0.053
Manual dexterity 20.109 0.055 20.300 21.971 0.063 0.084 0.060
Ball skills 20.267 0.086 20.481 23.085 0.006 0.028 0.147
Balance skills 0.204 0.067 0.492 3.041 0.007 0.028 0.143
Attention shifting (IED)a 0.878 0.642 0.214 1.369 0.187 0.187 0.029
Updating/Inhibition (RVP)a 21.024 0.485 20.304 22.111 0.048 0.077 0.069
Planning (SOC)a 21.618 0.669 20.350 22.417 0.026 0.060 0.090

Model 2
s BMI z-Score F p R 2
DR 2
B SE B b t p pFDR sr2
Step 1 6.528 0.005 0.343
Age 0.102 0.028 0.587 3.611 0.001 0.002 0.342
Sex 20.026 0.062 20.068 20.417 0.680 0.680 0.007
Step 2 4.735 0.003 0.666 0.525
Age 0.084 0.029 0.483 2.922 0.009 0.036 0.150
Sex 20.066 0.054 20.174 21.216 0.239 0.478 0.026
Manual dexterity 20.001 0.003 20.030 20.185 0.855 0.982 0.001
Ball skills 20.016 0.005 20.508 23.048 0.007 0.036 0.163
Balance skills 20.001 0.004 20.026 20.149 0.883 0.982 0.000
Attention shifting (IED)a 20.001 0.039 20.004 20.023 0.982 0.982 0.000
Updating/Inhibition (RVP)a 0.027 0.029 0.140 0.909 0.375 0.600 0.015
Planning (SOC)a 20.084 0.041 20.319 22.063 0.053 0.141 0.075
Significant results (p , 0.1, FDR corrected) are highlighted in bold font. aComposite scores of each domain of executive functioning. B 5 linear regression coefficient;
BMI, body mass index; FDR, false discovery rate; IED, intra-extra dimensional shift; RVP, rapid visual information processing; SE B 5 standard error of B; SOC, Stockings
of Cambridge; sr2 5 squared semipartial coefficient.

the intervention in children aged 8 to 14 years. However,
intervention studies that specifically target motor com-
petence in these children are, to our knowledge, cur-
rently lacking.
The importance of motor competence is further
highlighted by the findings of the hierarchical regression
analysis performed in the subsample of children with
obesity. The results showed that ball skill was a signifi-
cant predictor of weight loss after an intensive 5-month
multidisciplinary residential treatment program. Ball
skills explained 14.7% of the variance, and results
showed that children with better ball skills at baseline
were more successful in losing weight. The explanation
for this may lie in the fact that adequate motor compe-
tence, especially ball skills, is a prerequisite for the en-
gagement in physical activities, because children with
good skills will experience more joy when participating
in those activities (i.e., positive spiral) and vice versa.9,29
It may have been that ball sports took a larger share of
the multidisciplinary program so that children with
obesity with good ball skills had a greater chance of
participating in these team sports. This would have led
to a greater amount of weight loss compared with chil-
dren with poor ball skills; however, future research in-
cluding objective measures of physical activity is
required to address this issue. In addition to ball skills,
balance explained 14.3% of the variance in percentage
body mass index (BMI) reduction, but no relation be-
tween balance and the BMI z-score was observed. In-
terestingly, the effect seemed to be negative, i.e., lower
balance skills were associated with a greater amount of
weight loss after 5 months. A tentative explanation for
this finding may be that poor balance control led to
closer supervision or attention to the individual during
the movement activities, but the true cause of this un-
expected result remains unclear.

8 Motor and Executive Functioning in Obesity Journal of Developmental & Behavioral Pediatrics

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 For EF, inhibition/updating significantly explained
16.4% of the variance in percentage BMI reduction when
outliers were included, with better scores being associ-
ated with greater weight loss. This tentative finding may
suggest that children with better inhibition control (i.e.,
suppressing an inappropriate or impulsive response) and
updating capacity (i.e., retaining and monitoring mental
information) would benefit more from an intensive res-
idential treatment program compared with peers with
poorer EF. This finding is consistent with previous
studies that found evidence for a separate contribution
of EF (e.g., inhibition control) in weight loss and main-
tenance.12,22,30 However, after removal of the outliers,
no significant contribution of EF was found in the pre-
diction of weight loss. The absence of a significant
contribution of EF in the prediction of weight loss may
be explained by the age of the participants (e.g., children
vs adolescents). Pauli-Pott et al.,12 for example, showed
that only in adolescents, not in younger children, high
impulsivity predicted success in a 1-year weight re-
duction program. It seems that EF may not yet be an
important predictor of weight loss during childhood;
however, further research is needed to test this hy-
pothesis. Furthermore, in this study, weight loss was
determined directly after following the program for 5
months, whereas most studies found significant results
only after follow-up (i.e., weight maintenance).28,30 It
could be argued that baseline EF is not mediating weight
loss during the program because stringent external
control still exists in the rehabilitation center, but that its
effect becomes increasingly important afterward. Future
studies on short- and long-term influences of EF on
weight loss and maintenance are required to better un-
derstand the role of EF in children’s (changing) weight
status.
Some limitations should be considered when inter-
preting the results of this study. First, data on possible
confounding factors, such as physical activity, socio-
economic status (SES), race, and ethnicity were missing.
Childhood obesity has been associated with lower levels
of physical activity and is more common in specific so-
cial groups (e.g., families with a low SES and ethnic
minorities), which is likely to be associated with lower
motor competence9 and reduced EF.10 Future studies
are, therefore, recommended to include measures of
these factors to control for these potential contributors.
The second limitation pertains to the small sample size,
which calls for caution when interpreting the results.
Moreover, it has to be mentioned that children with
obesity followed an intensive multidisciplinary residen-
tial treatment program, which makes it difficult to gen-
eralize these findings to the entire obesity population.
Finally, in this study, levels of motor competence and EF
were examined only at baseline. Because our results
clearly show a role of motor competence and EF in
childhood obesity, future longitudinal studies are needed
to examine the effect of a multidisciplinary residential
treatment program on motor competence and EF.
Vol. 0, No. 0, Month 2018
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
This study provides a better insight into motor com-
petence and EF and their role in weight loss in children
with obesity. Although the sample size is limited and fu-
ture longitudinal studies are recommended to replicate
the current findings both in the short and long terms, it
seems fair to state that motor competence and EF are 2
relevant factors in the study and treatment of childhood
obesity. Additionally, our findings show that an intensive
5-month multidisciplinary residential treatment program,
as offered in the Zeepreventorium (De Haan, Belgium), is
effective in terms of weight loss, especially in children
with good ball skills, inhibition control, updating abilities,
and/or poorer balance at baseline. Accordingly, these
results provide preliminary evidence for the clinical im-
portance of motor competence and EF in prevention and
intervention programs for children with obesity.
ACKNOWLEDGMENTS
The authors are grateful to all participants and their parents, the
staff from the rehabilitation center “Zeepreventorium” (De Haan,
Belgium), and the board of the participating schools. Finally, the
authors thank Kris Bakeland, Nele Bassier, Marieke Paredis, Hanne
Lyskawa, and Teresa Gobert for their assistance in collecting the data.
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