obesity reviews

doi: 10.1111/obr.12137

Pediatric Obesity

Developmental coordination disorder and overweight and obesity in children: a systematic review C. G. Hendrix1,2, M. R. Prins1,3,4 and H. Dekkers1

1

Department of Physical Therapy, University

of Applied Sciences Utrecht, Utrecht, The Netherlands; 2Rehabilitation Centre De Hoogstraat, Utrecht, The Netherlands; 3

Military Rehabilitation Centre Aardenburg,

Doorn, The Netherlands; 4MOVE Research Institute Amsterdam, Faculty of Human Movement Sciences, VU University, Amsterdam, The Netherlands

Received 14 September 2013; revised 12 November 2013; accepted 29 November 2013

Address for correspondence: CG Hendrix, University of Applied Sciences Utrecht and Rehabilitation Centre De Hoogstraat, Rembrandtkade 10, 3583 TM Utrecht, The

Summary Children with developmental coordination disorder (DCD) find themselves less competent than typically developing children with regard to their physical abilities and often experience failure. They are therefore likely to avoid physical activity. Physical inactivity is considered an important risk factor for developing overweight and obesity. The aim of this study is to assess the association between DCD and overweight and obesity in children and whether this association is influenced by age and/or gender. Six electronic databases were systematically searched. Titles and abstracts were screened for relevance. Remaining studies were subjected to full paper review. The quality of the included articles was assessed and relevant data were extracted for comparison. The search yielded 273 results. Twenty-one studies, based on 10 cohorts, were included. Participants’ ages ranged from 4 to 14 years. In all cohorts, children with DCD had higher body mass index scores, larger waist circumference and greater percentage body fat compared with controls. Seven studies assessed the effect of gender and four studies provided information on the effect of age. Children with DCD seem to be at greater risk for overweight and obesity. This risk may be higher for boys and seems to increase with age and with the severity of motor impairment.

Netherlands. E-mail: [email protected]

Keywords: Children, developmental coordination disorder, obesity, overweight. obesity reviews (2014) 15, 408–423

Introduction Developmental coordination disorder (DCD) is described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as a neurodevelopmental disorder that is characterized by poor fine and/or gross motor coordination. These coordination problems are not the result of a neurological condition or intellectual disability, and interfere significantly with academic achievement or activities of daily living (1). The DSM-IV criteria for diagnosing DCD are presented in Table 1. Depending on how stringently these criteria are applied, the prevalence of DCD is estimated to range from 1.7% to 6%, and in boys is found four to seven times more often than in girls (1–4). Furthermore, DCD is a chronic disorder that continues into adulthood (5). 408 15, 408–423, May 2014

The primary cause of DCD is not known. Although literature has provided several theories over the years, none could be proven. Dyspraxia, problems with the execution of motor tasks, proprioception, sensory integration and visual processing have all been theorized as possible causative factors (6–9). The difference in theories may be explained by the fact that the group of children with DCD is a heterogeneous group; therefore, each theory may explain the problems of different children in this population (10–12). Lichtenstein et al. (13) found that DCD may have a genetic component, and also perinatal oxygen perfusion problems are associated with the disorder (14). Children with DCD find themselves to be less competent than typically developing (TD) children with regard to their physical abilities, but also psychologically and socially (15,16). Moreover, children with DCD find it very difficult © 2014 The Authors obesity reviews © 2014 International Association for the Study of Obesity

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Table 1 DSM-IV diagnostic criteria for DCD A. Performance in daily activities that require motor coordination is substantially below that expected given the person’s chronologic age and measured intelligence B. The poor motor performance significantly interferes with academic achievement or activities of daily living (ADL) C. The disturbance is not due to a general medical condition (e.g. cerebral palsy, hemiplegia, muscular dystrophy) D. If intellectual disability (i.e. mental retardation) is present, the motor difficulties are in excess of those usually associated with it Retrieved from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 2000) (1).

to learn new skills, often experience failure and have a higher risk of sustaining injuries. Together, this makes that children with DCD are more likely to avoid participation in physical activities (16–19). Along with unhealthy dietary habits, physical inactivity is an important risk factor for developing overweight and obesity (20–23). Overweight and obesity have become an increasing problem in the past decades. The World Health Organization (WHO) has stated that the prevalence of overweight and obesity among children ranges from 5% to more than 25% in the European region alone, and in half the countries is still increasing rapidly (23,24). It seems that overweight and obesity in youth is an important predictor of overweight and obesity in adulthood (25). In adults, obesity is associated with a range of cardiovascular diseases (i.e. hypertension, hyperlipidaemia, ischaemic stroke, coronary heart disease and type 2 diabetes), osteoporosis and psychosocial problems (23,26–28). Cairney et al. (29) found that the activity deficit among children with DCD does not diminish over time and their results indicate that it persists into adulthood. Therefore, children with DCD would seem to be at a higher risk for developing overweight or obesity. In 2011, Rivilis et al. (30) published a systematic review on physical activity and fitness in children with DCD and included a paragraph on body composition. They concluded that the literature indeed supports an increased risk for elevated body fat (BF) in children with DCD. In their review, however, no restrictions were set for how studies applied the DSM-IV criteria and the methodological quality of the included studies was not assessed and therefore this could not be taken into account when drawing conclusions. As Lingam et al. (4) have shown that a more stringent application of the DSM-IV criteria cause DCD prevalence numbers to drop to 1.7% as opposed to the 6% that is assumed in most other studies, it would seem relevant to try a more stringent approach to the question of the association between DCD and overweight and obesity in children. At the same time, it is recognized that in research, it is often not possible to meet all of the DSM-IV criteria for logistical and financial reasons. The main aim of the present review will therefore be to assess the association between DCD and overweight and obesity in children as stringently as is possible and realistic. The second aim of this review will be to assess whether gender and age have an effect on this association. © 2014 The Authors obesity reviews © 2014 International Association for the Study of Obesity

Method Search strategy The literature was systematically reviewed to identify studies containing measurements of body composition in children with DCD. A search strategy was adopted that combined two groups of terms, namely (i) DCD and (ii) body composition. DCD is the preferred term to describe problems with motor coordination in children. However, different terms have been used in the past and some are still in use (31). To make sure that all possible studies on the subject were found, the first group consisted of a range of different terms concerning motor coordination and problems therewith, including DCD, developmental dyspraxia, motor skills disorder, coordination disorder, incoordination, clumsy, motor proficiency, motor competence, motor difficulties, motor impairment and motor coordination. The purpose of the second group of terms was to capture all possible outcome measurements of body composition. These terms included overweight, obesity, body composition, body mass index (BMI), BF and adiposity. The title and abstract of a study had to contain at least one term from each group. In August 2013, the systematic search was performed in the following six databases: Ovid MEDLINE, PsycINFO, Cochrane Library, CINAHL, Academic Search Premier and ScienceDirect. In this search, no limits were set for study design or date of publication. All articles found were judged for relevance, based on the title and abstract. To make sure that no studies were left out of the search, the reference lists of the articles that met inclusion criteria were screened for any relevant studies that may not have been captured by the search of the databases. All potentially relevant articles were subjected to a full paper review. The literature search was performed by the first author. Selection of potential full-text articles was then performed by the first and second author separately. Full-text articles were included or excluded after a screening by the first and second authors.

Inclusion and exclusion criteria All articles in which body composition was measured in a group of children and/or adolescents (age range 3–18 years)

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410 DCD and overweight and obesity in children C. G. Hendrix et al.

with DCD, with comparison to TD peers, were included. Articles that tested for DCD in a group of overweight and/or obese children were not included in the review because the relevance of these outcomes for DCD children depends on the prevalence of overweight and obesity in the investigated population. Only articles of good quality, based on the methodological quality assessment performed in this review, were included. Articles were only included if they were scientific papers and written in English. Body composition Accepted measurements of body composition include BMI (weight to height), estimated BF (preferably in percentage, otherwise in mass) and waist circumference (WC).

obesity reviews

version. The short form consists of only 14 of the 46 items in the original version, increasing its feasibility. A cut-off point used for applying criterion A varies widely among different studies. The 2006 Leeds consensus statement on DCD recommends the cut-off point to be applied to performance at or below the 5th percentile (38). At the same time, it is recognized that the 5th percentile is arbitrary and it is also recommended to monitor children scoring at or below the 15th percentile. Articles written before 2006 are likely to not have used the 5th percentile as a cut-off point and many different percentile rates are still used in literature. Therefore, no limits were set for the percentile rate used in the articles.

Methodological quality assessment Developmental coordination disorder In research, it is common to find that not all of the DSM-IV criteria are met. One often finds DCD to be described as ‘probable DCD’ (pDCD) because of these limitations. As stated in the Introduction, we sought to apply the DSM-IV criteria as stringently as is realistic. Therefore, articles were not required to meet all the DSM-IV criteria in order to be included. DCD or pDCD was assumed if participants met at least criterion A of the DSM-IV. Criterion A is seen as the most important because it requires the motor coordination to be assessed. In the review by Rivilis et al. (30), no restrictions were set for which test was used to assess the motor coordination. In our review, we sought to include only articles that used the most appropriate tests for assessing DCD. The Movement Assessment Battery for Children 1st edition (MABC) or 2nd edition (MABC-2) (32,33) and the long or short form of the Bruininks–Oseretsky Test For Motor Proficiency (BOTMP) (BOTMP-SF) (34) are the most commonly used tests to identify DCD in children (35,36). Both the MABC (1st and 2nd edition) and the BOTMP and BOTMP-SF have been found to have good reliability and validity (33,35,37). Therefore, the MABC, MABC-2, BOTMP or BOTMP-SF had to have been used to identify DCD or pDCD in order to be included in this review. The MABC and MABC-2 are two versions of an individually administered test that assesses motor impairment. It consists of eight testing items and has three subscales measuring manual dexterity, ball skills and balance. The MABC is divided into four age bands for children in the age of 4–12 years old. The MABC-2 is divided into three age bands for children in the age of 3–16 years old. The BOTMP is an individually administered test that assesses motor proficiency of children in the age of 4.5– 14.5 years old. The assessed parameters include running speed and agility, balance, bilateral coordination, strength, upper limb coordination and dexterity, and response speed. In research, the BOTMP-SF is often used instead of the full

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The articles included in this review were all observational in nature. Many different tools for appraisal of the quality of observational studies have been created and used in systematic reviews; however, a consensus on a gold standard is lacking (39,40). Mallen et al. (39) and Sanderson et al. (40) identified a number of criteria, used in these tools, that represent the principal potential sources of bias and are generally considered to be important. These criteria include appropriate selection of case/controls, use of accurate and appropriate outcome measures in all participants, appropriate statistical analysis, adjustment for confounding and assessment of loss to follow-up. All studies included in this review were subjectively appraised on these five criteria. For each criterion, one or more questions were formulated that could be answered with ‘yes’, ‘no’ or ‘not applicable’. This resulted in a list of eight questions (Table 2) on which the included studies were screened. The assessment was performed by the first and second authors separately. Secondly, any differences in answers were reassessed, discussed and a consensus was reached. Articles that scored a ‘no’ on half or more of the questions (i.e. three for cross-sectional and case-controlled studies and four for longitudinal studies) were deemed not to meet quality standards and were subsequently excluded from the review.

Data extraction Relevant data were extracted for comparison by the first author. Data that were extracted from the articles included cohort, study design, population (sample size, age, sex), DCD assessment tool and the percentile rate(s) used, DSM-IV criteria that were assessed, relevant outcome measure(s) and relevant outcomes/results. If possible, effect sizes were calculated; Cohen’s d (continuous) or Phi (dichotomous). These data were then summarized and compared. The reason for assessing the cohort of the article is that in several studies, the samples of children were based © 2014 The Authors obesity reviews © 2014 International Association for the Study of Obesity

© 2014 The Authors obesity reviews © 2014 International Association for the Study of Obesity

Assessment of loss to follow-up 7) Were losses of participants to follow-up reported? Only applicable to longitudinal studies. At each time-point that body composition was recorded, the number of evaluated participants had to be reported in order for this question to be answered with a ‘yes’. 8) Were these losses to follow-up taken into account? It had to be clear why these losses occurred and how they were adjusted for in the statistical analyses in order for this question to be answered with a ‘yes’. Obviously, if question 7 is answered with ‘not applicable’, question 8 will subsequently be answered with ‘not applicable’.

Adjustment for confounding 6) Were important confounders taken into account? Age, gender and IQ were defined as important confounders. At least two out of these three confounders had to have been taken into account, either in the matching of controls or in the analyses, for this question to be answered with a ‘yes’.

Appropriate statistical analysis 5) Were all statistical methods described clearly? The employed statistical methods to determine the significance of between group differences in body composition scores and applied correction for possible confounders had to be presented for this question to be answered with a ‘yes’.

Use of accurate and appropriate outcome measures in all participants 4) Was there a clear description of the outcomes to be measured in the study? All performed measurements, calculations and necessary corrections aimed at body composition outcomes were to be described clearly for this question to be answered with a ‘yes’.

Appropriate selection of case/controls 1) Was there a clear description of the characteristics of participants? Age, gender, height, weight, and country and city of residence of the participants had to have been described for this question to be answered with a ‘yes’. 2) Were participants representative of the general population? All included children had to have been invited through their schools. No exclusion criteria that would clearly influence the generalizability of the results should have been applied for this question to be answered with a ‘yes’. 3) Was prevention of selection bias clearly attempted? All children in a selected cohort had to have been invited to undergo testing (e.g. a number of schools). All children that were identified as having (p)DCD based on these tests had to have been invited to participate in the study. It had to be clear from the description that controls were not selected through convenience sampling. Only if all these criteria were met, this question was answered with a ‘yes’.

Table 2 Subjective assessment of quality

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412 DCD and overweight and obesity in children C. G. Hendrix et al.

on the same cohorts. Articles that assessed children from a same cohort were grouped; however, their results were reported separately to ensure a transparent and complete as possible overview.

Results Systematic search The search yielded a total of 510 articles. After removing duplicates, 273 articles remained. All 273 articles were reviewed for relevancy by the first and second authors, based on title and abstract. Sixty-one studies were found eligible for full paper review, 21 of which met the inclusion criteria. A manual review of the reference lists yielded another three studies that met the inclusion criteria. Several studies were excluded, based on the full paper review. Reasons for exclusion consisted of using only a part of all the items in the motor coordination test, using other motor tests than stated in the inclusion criteria, excluding children that are overweight or obese, assessing motor coordination in overweight/obese children, body composition not measured or reported, published as a poster presentation only. The methodological quality of the 24 studies that met the inclusion criteria was then assessed and three studies were excluded from the review based on this assessment (41–43). In total, 21 studies were included in the review. A flowchart of the selection process is presented in Fig. 1.

OVID MEDLINE n = 134

Cochrane n = 24

CINAHL n = 62

Academic Search Premier n = 122

Quality assessment The results of the quality assessment are presented in Table 3. Three studies scored a ‘no’ on three out of six questions and were subsequently excluded from the review. Of the included studies, seven failed to give a clear description of the characteristics of participants; however, based on the information on how the participants were recruited, it was clear that they were representative of the population in all seven of these studies. In four other studies, this was not the case. A clear attempt to prevent selection bias was provided in 11 studies. All of the included studies gave a clear description of the outcomes that were to be measured. All except two studies provided a clear description of the statistical methods. All but six studies took important confounders into account. Of the three longitudinal studies, only one reported on losses to follow-up but it remained unclear whether this was taken into account. Two studies scored a ‘yes’ on all questions.

Data extraction A summary of extracted data is presented in Table 4. Of the 21 studies included in this review, 10 were case-controlled studies, 8 used a cross-sectional study design and 3 were longitudinal. The longitudinal studies were all prospective cohorts, two of which had a follow-up duration of 3 years and one had a follow-up duration of 2 years.

ScienceDirect n = 100

PsycINFO n = 58

Removal of duplicates n = 237 Review title and abstract n = 273

Studies eligible for full paper review n = 61 Review reference list for relevant articles not captured by search n = 3

Studies included in review n = 21

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Relevant based on full paper review n = 21 Excluded based on quality assessment n=3

Figure 1 Flowchart of selection process.

© 2014 The Authors obesity reviews © 2014 International Association for the Study of Obesity

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DCD and overweight and obesity in children C. G. Hendrix et al. 413

Table 3 Quality assessment outcomes

Beutum et al. (44) Cairney et al. (58) Cairney et al. (61) Cairney et al. (54) Cairney et al. (48) Cairney et al. (49) Cairney et al. (59) Cantell et al. (41) Chirico et al. (50) Chirico et al. (51) Coverdale et al. (56) Faught et al. (60) Fong et al. (45) Fong et al. (43) Hay et al. (64) van der Hoek et al. (46) Li et al. (65) Schott et al. (47) Silman et al. (52) Spironello et al. (55) Tsiotra et al. (42) Tsiotra et al. (63) Wahi et al. (53) Wu et al. (66)

Type

1

2

3

4

5

6

7

8

CC CS CS C CC CC CS CS CC C CC CS CC CC CS CC C CS CC CS CS CS CC CC

Y N N Y Y Y N Y Y Y Y N Y Y N Y Y Y Y N N N Y Y

N Y Y Y Y Y Y N Y Y Y Y N N Y N Y N Y Y Y Y Y Y

N Y Y Y Y Y Y N Y Y Y N N N Y N N N N Y N N N N

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y N Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y Y N Y Y Y N Y N N Y Y N N Y Y Y Y N N Y N Y

NA NA NA N NA NA NA NA NA N NA NA NA NA NA NA Y NA NA NA NA NA NA NA

NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA N NA NA NA NA NA NA NA

C, cohort; CC, case-controlled; CS, cross-sectional; N, no; NA, not applicable; Y, yes.

Data synthesis Participants In the included studies, sizes of the samples of children with (p)DCD ranged from 9 to 123. Ages of participants ranged from 4 to 14 years. Only four studies contained children below the age of 9 years (44–47) and only one of these studies contained children less than 6 years of age (45). All studies used control groups for comparison, frequently described as TD children. Study samples were drawn from various locations (i.e. Australia, Canada, Greece, the Netherlands, Taiwan and Hong Kong). The majority of studies (n = 14) contained a study sample from Canada. Actually, 13 of these studies contained study samples based on only two different cohorts of children. Nine studies drew their sample of pDCD children from a large study on participation trajectories in children with and without pDCD (48–56), called the PHAST study (57). The cohort was labelled the ‘PHAST’ cohort and all nine studies were grouped under this label. The four other studies that contained a study sample from Canada were all based on a cohort of children from the city of St. Catharines in the Ontario region (58–61). This cohort was labelled the ‘St. Catharines’ cohort and these four studies were also grouped under this label. As the other included studies © 2014 The Authors obesity reviews © 2014 International Association for the Study of Obesity

appeared to all be based on unique cohorts, it would seem that the 21 included studies provide data on 10 different cohorts of children. Developmental coordination disorder definition The MABC, MABC-2 or BOTMP-SF were used by most studies to identify children with DCD or pDCD and one study used the BOTMP. Two studies (both unique cohorts) made a formal diagnosis of DCD (i.e. meeting all DSM-IV criteria) (45,46). Cut-off points used in the studies to identify children as having DCD or pDCD (i.e. applying DSM-IV criterion A) ranged from the 5th to the 15th percentile. Three studies from the PHAST cohort, divided the group of children with pDCD into two subgroups, with two using both the 5th and the 15th percentile as cut-off points (48,49) and one using the 5th and the 16th percentile (56). Another study (unique cohort) did the same thing, but also divided the group of TD children into two subgroups scoring either between the 16th and the 50th percentile or above the 50th percentile (47). One study assessed children on both the MABC and the BOTMP-SF and created four groups of children based on a positive score for pDCD on both tests, scoring positive on one test or scoring negative on both tests (55). Body composition The outcome measures used to assess body composition included BMI, BF (in % or kg) and WC. Most studies used BMI and/or BF and in two studies from the PHAST cohort, WC was used (53,54). One study converted BMI into ageand gender-specific z-scores (44). In several of the included studies, body composition measurements were used to identify overweight and/or obese children (45,47,53– 55,58). In one study that used BF measurements, the cut-off points for overweight and obesity were ≥25% and ≥30%, respectively (58). For BMI, different cut-off points were used in different studies. In three studies, the cut-off points for overweight and obesity as proposed by Cole et al. (62) were used (54,55,58). These are based on a predicted BMI of ≥25 (i.e. overweight) or ≥30 (i.e. obese) at 18 years of age. In two other studies, overweight and obesity were based on BMI scores at or above the 90th and 97th percentile, respectively (45,47). One study classified children as having abdominal obesity based on WC scores (53). Children scoring at or above the 90th percentile were classified as abdominally obese. Association between developmental coordination disorder and body composition All of the 21 studies included in this review reported that children with DCD or pDCD had higher BMI scores, larger WC and greater percentage BF compared with their TD peers. Eighteen studies, accounting for seven different cohorts, found these differences between groups to be

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Case controlled

Chirico et al. (50)

Case controlled

Cairney et al. (48)

Case controlled

Longitudinal (prospective cohort) 2Y

Cairney et al. (54)

PHAST cohort (2004)

Cairney et al. (49)

Study design

Author

Cohort

Table 4 Summary of data extraction

126 children, aged 12–13 years 63 pDCD

126 children, mean age 12.4 years (SD = 0.5) 63 pDCD (boys n = 37, girls n = 26)

126 children, mean age 12.4 years (SD = 0.5) 63 pDCD (boys n = 37, girls n = 26)

2,278 children, age 9–10 years at baseline 111 pDCD (boys n = 46, girls n = 65)

Population

MABC-2 ≤15th percentile

MABC-2 ≤5th percentile 6th to 15th percentile

MABC-2 ≤5th percentile ≤15th percentile

BOTMPSF ≤ 5th percentile

DCD assessment tool + percentile rate(s) used

A, D

A, D

A, D

A, C, D

DSM-IV criteria assessed

BMI, BF (%)

BMI, BF (%)

BF (%)

BMI, WC

Relevant outcome measure(s)

21.2 (SD 5.1), 18.4 (SD 3.4), significant, no P-value, ES 0.8 (Cohen’s d)

BMI: DCD+ DCD− BF: DCD+ DCD−

28.3 (SD 11.2) 20.0 (SD 9.9), P = 0.001, ES 0.8 (Cohen’s d)

23.4 (SD 5.9) 20.2 (SD 4.0), P = 0.001, ES 0.6 (Cohen’s d)

12.1), ES 0.8 (Cohen’s d) 11.5), ES 0.4 (Cohen’s d) 9.2), P < 0.01 (test of linearity in ANOVA )

6.2), ES 0.7 (Cohen’s d) 4.4), ES 0.3 (Cohen’s d) 4.0), P < 0.01 (test of inearity in ANOVA )

34.9 (SD 25.5) 26.9 (SD 25.1), P = 0.04, ES 0.3 (Cohen’s d)

36.9 (SD 26.3) 27.2 (SD 24.5), (NS), ES 0.4 (Cohen’s d)

BMI: DCD+ (5th percentile) 24.0 (SD DCD+ (6th–15th percentile) 21.3 (SD DCD− 20.2 (SD BF: DCD+ (5th percentile) 28.0 (SD DCD+ (6th–15th percentile) 23.6 (SD DCD− 19.3 (SD No DCD × Gender interaction for BF

5th percentile group BF: DCD+ DCD− 15th percentile group BF: DCD+ DCD−

72.3 (SD 13.6) 64.7 (SD 9.8), significant, no P-value, ES 0.8 (Cohen’s d) Significant DCD × Gender interaction for WC, but not for BMI. DCD had larger effect on WC of boys.

Baseline WC: DCD+ DCD−

Baseline BMI: DCD+ DCD−

Relevant outcomes/results

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Cohort

© 2014 The Authors obesity reviews © 2014 International Association for the Study of Obesity 95 children, aged 13–14 years 43 pDCD (boys n = 26, girls n = 17)

Case controlled

Case controlled

Cross sectional

Case controlled

Coverdale et al. (56)

Silman et al. (52)

Spironello et al. (55)

Wahi et al. (53)

126 children, aged 12.4 (0.52 SD) 63 pDCD (boys n = 37, girls n = 26)

335 children, aged 9–10 years 97 pDCD

122 children, aged 12–13 years 61pDCD (boys n = 36, girls n = 25)

86 children, aged 12 years at baseline 33 pDCD

Longitudinal (prospective cohort) 3y

Chirico et al. (51)

Population

Study design

Author

Table 4 Continued

MABC-2 ≤15th percentile

MABC and BOTMP-SF 15th percentile Four groups: A(MAB+/BOT+) B(MAB+/BOT−) C(MAB−/BOT+) D(MAB−/BOT−)

MABC-2 ≤15th percentile

MABC-2 ≤5th percentile 6th to 16th percentile

MABC-2 ≤15th percentile

DCD assessment tool + percentile rate(s) used

A

A

A, D

A

A, D

DSM-IV criteria assessed

Abdominal obesity prevalence based on WC

BMI, overweight prevalence based on BMI

BF (%)

BMI, BF (%)

BMI, BF (kg)

Relevant outcome measure(s)

32.1 (SD 10.6), ES 1.3 (Cohen’s d) 29.5 (SD 9.5), ES 1.0(Cohen’s d) 19.3 (SD 9.9), P ≤ 0.05 for both DCD+ groups

(5th percentile) (6th – 16th percentile)

% abdominal obesity (WC): DCD+ DCD−

(SD (SD (SD (SD

5.07), P = 0.001, ES 0.8 (Cohen’s d) 3.04), NS, ES 0.0 (Cohen’s d) 5.09), no P-value, ES 0.7 (Cohen’s d) 3.01)

46.0 15.9, P < 0.01, ES 0.33 (Phi)

50, no P-value, ES 0.06 (Phi) 26, no P-value, ES 0.02 (Phi) 41, no P-value, ES 0.05 (Phi) 22

20.87 18.26 20.29 18.14

28.0 (SD 11.1), 20.0 (SD 9.9), P < 0.05, ES 0.8 (Cohen’s d)

25.7 (SD 6.6), ES 1.1 (Cohen’s d) 24.8 (SD 5.8), ES 1.0 (Cohen’s d) 20.6 (SD 3.7), P ≤0.05 for both DCD+ groups

18.4 (SD 11.2) 10.2 (SD 6.6), P < 0.001, ES 0.9 (Cohen’s d)

23.2 (SD 5.9) 19.9 (SD 3.7), P ≤ 0.01, ES 0.7 (Cohen’s d)

(5th percentile) (6th – 16th percentile)

BMI (all ages): DCD+A DCD+B DCD+C DCD−D % overweight (BMI): DCD+A DCD+B DCD+C DCD−D

BF: DCD+ DCD−

BMI: DCD+ DCD+ DCD− BF: DCD+ DCD+ DCD−

Baseline BMI: DCD+ DCD− Baseline BF: DCD+ DCD−

Relevant outcomes/results

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Fong et al. (45)

Hay et al. (64)

Unique cohort

Cross sectional

Faught et al. (60)

Unique cohort

Cross sectional

Cairney et al. (59)

Cross sectional

Case controlled

Case controlled

Cross sectional

Cairney et al. (61)

Beutum et al. (44)

Cross sectional

Cairney et al. (58)

st. Catharines cohort (2005)

Unique cohort

Study design

Author

Cohort

Table 4 Continued

206 children, mean age 11.5 years (SD 1.5) 17 pDCD (boys n = 10, girls n = 7)

148 children, aged 6–11 years 81 DCD (boys n = 63, girls n = 18)

18 children, age 7–11 years 9 pDCD

571 children, aged 9–14 years 7.5% (±3) with pDCD

578 children, aged 9–14 years 44 pDCD (boys n = 19, girls n = 25)

549 children, aged 9–14 years 41 pDCD

578 children, aged 9–14 years 44 pDCD (boys n = 19, girls n = 25)

Population

BOTMP-SF ≤10th percentile

BOTMP ≤15th percentile

MABC-2 ≤15th percentile

BOTMP-SF ≤10th percentile

BOTMP-SF ≤10th percentile

BOTMP-SF ≤10th percentile

BOTMP-SF ≤5th percentile

DCD assessment tool + percentile rate(s) used

A

A, B, C, D (i.e. formal diagnosis)

A, B

A

A, D

A

A,C

DSM-IV criteria assessed

BMI, BF (%)

BMI, overweight/obesity prevalence based on BMI

BMI (z-score)

BF (%)

BMI, BF (%)

BMI

Overweight/obesity prevalence based on BMI and BF (%)

Relevant outcome measure(s)

20.90 (SD 6.15), 19.35 (SD 3.52), P < 0.01, ES 0.4 (Cohen’s d)

BMI boys: DCD+ DCD− BMI girls: DCD+ DCD− BF boys: DCD+ DCD− BF girls: DCD+ DCD−

BMI: DCD+ DCD− % overweight/obese DCD+ DCD−

BMI z-score: DCD+ DCD−

26.9 (SD 14.7) 22.2 (SD 8.1), (NS), ES 0.5 (Cohen’s d)

15.5 (SD 8.1), 12.6 (SD 7.0), (NS), ES 0.4 (Cohen’s d)

23.7 (SD 8.8) 20.1 (SD 3.7), P < 0.01, ES 0.8 (Cohen’s d)

19.6 (SD 5.2) 19.5 (SD 3.3), (NS), ES 0.0 (Cohen’s d)

18.85 (SD 3.72) 17.65 (SD 2.97), P ≤ 0.05, ES 0.4 (Cohen’s d) (BMI): 29.63 7.46, P ≤ 0.001, ES 0.28 (Phi)

1.24, 0.76, P = 0.03, ES not possible

DCD+ had significantly higher % BF than DCD− (P < 0.001). (exact numbers not given) ES not possible No DCD × Gender interaction for BF

BMI: DCD+ 20.49 (SD 5.77) DCD− 19.55 (SD 3.52), (NS), ES 0.3 (Cohen’s d) BF: DCD+ 20.77 (SD 11.23) DCD− 16.52 (SD 9.48), P = 0.006, ES 0.4 (Cohen’s d) Significant DCD × Gender interaction for BMI and BF. Boys have the highest mean scores of BMI and BF of all youth.

BMI: DCD+ DCD−

% overweight/obese (BMI): DCD+ 25 DCD− 15, (NS), ES 0.07 (Phi) % overweight/obese (BF): DCD+ 23.3, DCD− 12.1, P = 0.037, ES 0.08 (Phi) Significant DCD × Gender interaction for overweight/obesity (for BMI and BF). Interaction only significant for boys.

Relevant outcomes/results

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van der Hoek et al. (46)

Li et al. (65)

Schott et al. (47)

Tsiotra et al. (63)

Wu et al. (66)

Unique cohort

Unique cohort

Unique cohort

Unique cohort

Unique cohort

Case controlled

Cross sectional

Cross sectional

Longitudinal (prospective cohort) 3y

Case controlled

Study design

41 children, aged 9–11 years 20 pDCD (boys n = 9, girls n = 11)

177 children, aged 10–12 years 12 pDCD (boys n = 6, girls n = 6)

261 children, ages 4–12 years (three groups: 4–6 years, 7–9 years, 10–12 years) 123 pDCD (52 moderate: boys n = 24, girls n = 28) (71 severe: boys n = 48, girls n = 23)

50 children, aged 9 years at baseline 25 pDCD (boys n = 11, girls n = 14)

76 children, aged 7–12 years 38 DCD (boys n = 28, girls n = 10)

Population

MABC ≤5th percentile

A, C, D

A, C

A, C, D

MABC ≤5th percentile (severe DCD) 6th to 15th percentile (moderate DCD) 16th to 50th percentile (TD medium) >50th percentile (TD high)

BOTMP-SF ≤10th percentile

A, C

A, B, C, D (i.e. formal diagnosis)

DSM-IV criteria assessed

MABC ≤5th percentile

MABC ≤15th percentile

DCD assessment tool + percentile rate(s) used

BMI, BF (%)

BMI

BMI, overweight/obesity prevalence based on BMI

BMI, BF (%)

BMI

Relevant outcome measure(s)

22.9 (SD 6.7) 20.1 (SD 7.4), (NS), ES 0.4 (Cohen’s d)

18.0 (SD 2.7) 16.8 (SD 3.0), (NS), ES 0.4 (Cohen’s d)

18.0 (SD 3.6), 16.9 (SD 1.9), (NS), ES 0.4 (Cohen’s d)

BMI: DCD+ DCD− BF: DCD+ DCD−

22.6 (SD 7.6) 22.5 (SD 10.0), (NS), ES 0.0 (Cohen’s d)

19.1 (SD 3.7) 17.4 (SD 2.7), (NS), ES 0.5 (Cohen’s d)

BMI: DCD+ 23.17 (SD 3.79) DCD− 20.53 (SD 3.34), P < 0.05, ES 0.9 (Cohen’s d) No DCD × Gender interaction for BMI.

BMI (all ages): 17.00 (SD 2.35) DCD+S DCD+M 17.20 (SD 2.57) DCD−M 17.06 (SD 2.37) DCD−H 16.34 (SD 1.85) no P-value, ES not possible In age groups 4–6 and 7–9 years, no significant difference was found (exact numbers not given) Age group 10–12 years: % overweight/obesity (BMI): DCD+S 50.0 DCD+M 23.1 DCD−M 5.6 DCD−H 0.0, P = 0.014 (DCD+ vs. DCD−), ES not possible No difference in number of overweight/obese boys and girls in DCD groups. In severe DCD group, boys showed higher BMI than girls (P = 0.014).

Baseline BMI: DCD+ DCD− Baseline BF: DCD+ DCD−

BMI: DCD+ DCD−

Relevant outcomes/results

BF, body fat; BMI, body mass index; BOTMP, Bruininks–Oseretsky Test for Motor Proficiency; BOT/BOTMP-SF, short form of the Bruijninks–Oseretsky Test for Motor Proficiency; DCD, developmental coordination disorder; DCD−, group of typically developing children; DCD+, group of children with developmental coordination disorder or ‘probable’ developmental coordination disorder; ES, effect size; MAB/MABC, movement assessment battery for children; MABC-2, movement assessment battery for children – second edition; NS, not significant; pDCD, ‘probable’ developmental coordination disorder; SD, standard deviation; WC, waist circumference.

Author

Cohort

Table 4 Continued

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statistically significant for one or more of these outcome measures (44,45,47–56,58–61,63,64). In two of these studies (both St. Catharines cohort), using BMI and BF as outcome measures, the between group difference was found to be significant for BF but not for BMI (58,59). Another study using both measures, however, found the opposite but only for girls (64). One study found the difference in BF between groups significant when using the 15th percentile as a cut-off point, but did not when the 5th percentile was used (48). Schott et al. (47) found a significant difference between the DCD group and the control group for children 10–12 years of age, but not for children aged 4–9 years. Three studies found the between-group differences not to be significant (46,65,66). All three, however, did show a trend (46,65,66). Of the 17 studies (10 cohorts) using BMI as an outcome measure (44–47,49–51,54–56,58,59,61,63–66), 14 studies (7 cohorts) found the differences between groups to be significant (44,45,47,49–51,54–56,58,59,61,63,64). BF was measured in 12 studies (five cohorts) (48–52,56,58– 60,64–66), 10 (three cohorts) of which found the betweengroup difference to be significant (48–52,56,58–60,64). WC was used as an outcome measure in two studies (both PHAST cohort) (53,54). Both reported that children with pDCD had a significantly greater WC than their TD peers. Of the 11 studies (five cohorts) that identified a (p)DCD group based on the 15th percentile as a cut-off point, 9 (three cohorts) found the between-group differences to be significant (44,45,48–53,55) and one study found the differences significant for children aged 10–12 years only (47). One study used the 16th percentile and also found significant between-group differences (56). The 5th percentile was used in eight studies (five cohorts) (47–49,54,56,58,65,66). In three of these studies (all PHAST cohort), differences were found significant (49,54,56). One study (St. Catharines cohort) found the differences to be significant when BF was used and found a near significant trend when using BMI (58). Again, Schott et al. (47) found the differences to be significant only for children aged 10–12 years. In five studies (three cohorts), the 10th percentile was used (59–61,63,64). Three of these studies contained a sample based on the St. Catharines cohort. One of these found the differences significant for BF (60) and one found the differences significant for BF, but not for BMI (59). The third study, however, did find the differences to be significant for BMI (61).The fourth study using the 10th percentile, based on a unique cohort, also found the differences to be significant (63). The fifth study (unique cohort) found the differences not significant for BF and did when using BMI, but only for girls (64). Six studies, based on five different cohorts of children, reported on the prevalence of overweight and obesity. Cairney et al. (58) reported 23% of pDCD children were found overweight or obese vs. 12.1% of DCD children

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based on percentage BF (P = 0.037). These numbers were 25% vs. 15%, respectively, when BMI was used (P = 0.060). The samples in the studies by Cairney et al. (54), Spironello et al. (55) and Wahi et al. (53) were all drawn from the PHAST cohort. In the study by Cairney et al. (54), 56% of children in the pDCD group were found overweight vs. 28.6% in the non-DCD group at baseline. For obesity, these numbers were 29.0% vs. 8.7%, respectively. In the study by Wahi et al. (53), 46.0% of children in the pDCD group were found to have abdominal obesity vs. 15.9% in the control group. Spironello et al. (55) compared the prevalence of overweight between three DCD groups, based on a positive score on either the MABC (group B) or the BOTMP-SF (group C), or both (group A) and a TD group (D) based on a negative score on both tests. They reported 50% overweight in group A and 26% and 41% in groups B and C, respectively vs. 22% in the TD group (D). Fong et al. (2011) (45) reported 29.63% overweight and obesity in the pDCD group vs. 7.46% in the TD group. Schott et al. (47) divided both the pDCD group and the TD group into two separate groups, thus comparing four levels of motor coordination. They found a significant difference in percentage overweight and obesity between groups for children aged 10–12 years (pDCD severe: 50%, pDCD moderate: 23.1% vs. TD medium: 5.6%, TD high: 0%). Gender effect Nine studies provided information on possible gender differences for the association between (p)DCD and overweight and obesity (45,47,49,54,58–60,63,64). However, only seven of these, based on four different cohorts, tested for effect modification by sex (47,49,54,58–60,63). Two of these studies contained a sample from the PHAST cohort (49,54). Cairney et al. (54) reported that the WC of boys with pDCD was larger than that of girls with the disorder. For BMI, however, there was no significant pDCD by gender interaction. Cairney et al. (49) found no pDCD by gender interaction for BF at either the 15th or 5th percentiles. Three studies were based on the St. Catharines cohort (58–60). Cairney et al. (58) looked for a pDCD by gender interaction for overweight/obesity based on BMI and BF. They reported a significant effect modification for gender, and that the risk for overweight/obesity was significant for boys only. Cairney et al. (59) had similar findings and reported pDCD boys had the highest mean scores of BMI and BF of all children. Faught et al. (60), however, found no pDCD by gender interaction for BF in this cohort. The two other studies that provided information both contained unique cohorts. Schott et al (47). found that in the severe DCD group (i.e. scoring ≤5th percentile), boys had significantly higher BMI than girls. However, the number of overweight or obese boys and girls in the total pDCD groups did not differ. Tsiotra et al. (63) found no pDCD by gender interaction for BMI. © 2014 The Authors obesity reviews © 2014 International Association for the Study of Obesity

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Age effect Four studies provided information on a possible effect of age on the association between (p)DCD and overweight and obesity (47,51,54,65). Two of these studies were based on the PHAST cohort (51,54). In the 2-year study by Cairney et al. (54), children in the pDCD group were found to be at greater risk for overweight and obesity. For obesity, this risk increased over time for children in the pDCD group, whereas it remained relatively constant for children in the TD group. The 3-year study by Chirico et al. (51) showed that the difference in BMI and BF between groups increased over time; however, it was not reported whether this was statistically significant. Based on a unique cohort, the 3-year study by Li et al. (65) reported higher BMI and BF in the pDCD group compared with controls. Although the differences between groups were found not to be significant, their results did show that the between-group difference increased over time. While the mean BMI and BF remained relatively constant in the TD group, in the pDCD group it increased over the study period. In their crosssectional study, also based on a unique cohort, Schott et al. (47) divided the pDCD and TD group into three age groups (4–12). They found that the differences between the pDCD group and the TD group was significant, only for age group 10–12 years.

Discussion The main aim of this present study was to assess the association between DCD and overweight and obesity in children. By comparing only studies that are of good quality and applying the criteria for DCD as stringently as possible, the results can give a better insight into this association. All of the included studies reported a positive association between DCD and fat mass. In line with these findings, the prevalence of overweight and obesity was higher in DCD children. The second aim of this review was to assess whether gender and age effect the association between DCD and overweight and obesity in children. Studies that assessed whether gender has an effect on the association presented conflicting results. There is some evidence however indicating that boys with DCD are at greater risk of higher fat mass compared to girls. Based on the results of studies that provided information on a possible age effect, it would seem that the risk of overweight and obesity increases with age for children with DCD, whereas it remains relatively constant for their TD peers. As most of the research is concentrated on children between the age of 8 and 14 years, strong conclusions and generalizations cannot be made. On the contrary, as Rivilis et al. (30) argued in their review that the detrimental effect of poor coordination on body composition might not manifest itself until later in childhood or early adolescence, research on younger children might not provide better insight. © 2014 The Authors obesity reviews © 2014 International Association for the Study of Obesity

A positive association between DCD and obesity does not provide information concerning causal ordering of the two variables. As DCD is usually diagnosed before any signs of overweight or obesity, it is commonly assumed to be the cause of elevated BF. However, the opposite has also been proposed (67). Most of the included studies were cross-sectional or case-controlled in nature, thus cannot provide an answer to the question of causality. As stated, the three longitudinal studies, included in this review, all reported rising body composition scores in the pDCD groups over time, whereas they remained relatively constant in the TD groups. It would therefore seem more likely that DCD is the cause of the increase of fat mass. On the contrary, motor competence was measured only once at baseline in all three studies, so it is not known whether this changed over time as well. In future research, it would seem relevant to also assess motor competence over time. Also, there is some evidence that overweight and obesity negatively affect gross and fine motor skills in children (68,69). Children with DCD who are overweight or obese therefore seem to find themselves in a vicious cycle. An important point that needs to be addressed is the percentile rate that is used to identify children as having DCD. Different studies have used different cut-off points for assigning children to the DCD group; therefore, the results of different studies may not be directly comparable, as (probable) DCD groups might differ in severity of motor impairment. Besides the issue of comparability, the question arises whether results based on children scoring above that 5th percentile are representative of the population (i.e. children with DCD). As stated in the Introduction, the 5th percentile has been proposed by the 2006 Leeds consensus (38) as the cut-off point for diagnosing DCD. However, it is also advised to monitor children scoring at or below the 15th percentile. As the motor problems in children scoring at or below the 5th percentile are obviously more severe than in children scoring between the 6th and the 15th percentile, it would thus seem likely that in studies that used a lower cut-off point, the difference in body composition scores between children with DCD and TD children would be more pronounced than in studies that used a higher cut-off point. Where only the 15th percentile was used as the cut-off point, effect sizes could only be calculated for three out of four cohorts. In the PHAST cohort, the effect sizes ranged from 0.6 to 0.9 (Cohen’s d), which can be considered high (70). Effect sizes were 0.4 for the two other cohorts, which can be considered moderate (70). Four studies (all different cohorts) used only the 5th percentile. The study by Li et al. (65) had a moderate effect size of 0.4. In the study by Wu et al. (66), the effect size was 0.5 for BMI, but for BF, it was 0.0, which can be considered very small (70). In Cairney et al. (54), effect sizes were 0.8 for both BMI and WC. Cairney et al. (58) compared the percentage of overweight children between groups. Phi was

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used to calculate the effect size of their results, as Cohen’s d cannot be used to calculate effect size for dichotomous variables. The effect sizes were 0.07 for BMI and 0.08 for BF, which can be considered small (71). Conclusions on the hypothesis that the degree of adiposity might increase with the severity of motor impairment can hardly be drawn based on these studies alone. Three other studies, which created two different pDCD groups using both the 5th and the 15th percentile as cut-off points, may shed some light on this matter. Cairney et al. (49) compared BMI and BF among the pDCD groups and the TD group and did report a significant dose–response effect for both measures, suggesting that adiposity does increase with severity of motor impairment. Cairney et al. (48), containing a sample from the same cohort, made a different comparison. The pDCD group based on the 15th percentile cut-off point was compared to the TD group (i.e. scoring > 15th percentile) and children in this group were found to have significantly higher BF. The pDCD group based on the 5th percentile however was compared to all children scoring above the 5th percentile and differences were found not to be significant. These findings would seem to contradict those from Cairney et al. (49). In fact, the mean percentage BF in the TD group (i.e. scoring > 15th percentile) was 26.9%, as opposed to 34.9% and 36.9% in the 15th and 5th percentile groups, also suggesting adiposity increases with the severity of motor impairment. Although these studies seem to provide more evidence that supports the hypothesis, it should be noted that Cairney et al. (48,49,54) were all based on the PHAST cohort. Schott et al. (47), containing a different cohort of children, reported similar findings, but only for children aged 10–12 years. Most importantly, this review shows that the positive association between DCD and fat mass seems to apply to children scoring at or below the 5th percentile as well as children scoring at or below the 15th percentile.

Limitations of the included studies Several potentially limiting aspects of the included studies should be addressed. Firstly, the body composition assessment methods present issues. BMI is a frequently used measure in assessing overweight and obesity. In the healthy paediatric population, it has been found to be a good predictor of adiposity, although it may slightly overestimate BF in short children or children with high muscle mass (72–75). Normative BMI scores vary with age and gender (72,76,77). This makes the use of raw BMI scores for comparing adiposity status between children of different age and gender questionable, especially when assessing changes over time. Raw BMI scores can be converted into age- and gender-specific z-scores, making it possible to compare children of different ages (78). However, out of the 17 studies that used BMI as an outcome measure, 16

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used raw BMI scores to assess differences between groups. Nine of these studies measured both BMI and BF. In two of these studies, the between-group differences were actually not significant for BMI, but were for BF. One study found the opposite; however, this could have been caused by the small sample size in that study (DCD n = 17). Only one study by Beutum et al. (44) used BMI z-scores to compare the groups. In line with the majority of included studies, they did report significantly higher scores in the pDCD group compared with controls, even with a very small sample of pDCD children (n = 9). Two of the included studies used WC as an outcome measure. Both these studies reported significant differences between groups. Cairney et al. (54) reported children in the DCD group to have a 12% higher WC than controls. The study by Wahi et al. (53) compared the prevalence of abdominal obesity based on the WC scores. Although WC has been found valid for estimating abdominal fat in children (79), a consensus on cut-off points for overweight and obesity is lacking. Another point that is easily overlooked is the lack of a complete diagnosis of DCD. Of all the included studies, only two actually assessed all four of the DSM-IV criteria and claimed to make a formal diagnosis of DCD (45,46). However, both these studies used the 15th percentile instead of the official 5th percentile cut-off point for applying criterion A. Also, in these studies, the children with DCD were recruited from hospitals or rehabilitation centre’s. This makes it questionable whether the group of children with DCD was representative of the whole population. Fong et al. (45) reported that children with DCD had significantly higher BMI values and were at greater risk of overweight and obesity compared to TD children. Strikingly, while mean BMI was 18.85 in the DCD group vs. 17.65 in the control group, the percentages of overweight and obese children were 29.63 vs. 7.46, respectively. An explanation for these surprising numbers was not given. Van der Hoek et al. (46) also reported higher but nonsignificant BMI scores in the DCD group compared to controls. As in both these studies the absolute difference in BMI and effect sizes were similar, the non-significant findings by van der Hoek et al. (46) could have been caused by their relatively small sample size (n = 38). Lastly, issues with the methodological quality of the included studies need to be addressed, as these issues may influence the outcomes of the studies. Seven studies failed to give a clear description of the characteristics of participants, and in four of the studies, it was unclear whether participants were representative of the general population. In 10 studies, a clear attempt to prevent selection bias was not evident. Moreover, it should not go unmentioned that among the studies that scored positive on these points were many of the studies that drew their sample from the PHAST study. In six studies, important confounders were © 2014 The Authors obesity reviews © 2014 International Association for the Study of Obesity

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not taken into account. Of the three longitudinal studies, only one reported on losses to follow-up, although it was not clear whether these were taken into account.

Conclusion Despite several limitations in the included studies, it seems that children with DCD are at greater risk for overweight and obesity. This risk appears to increase with age and with the severity of motor impairment. Contrary to the current assumption, gender may indeed have an effect on this association, with the boys seemingly to be at greater risk for elevated BF than girls. More research is needed to confirm these findings.

Recommendations for future research Because of the aforementioned issues with indirect measurements of body composition, we advise BF to be measured directly in future research. It would seem relevant to strive towards meeting as many of the DSM-V criteria as possible. For criterion A, both the 5th and the 15th percentile are advised as cut-off points as children scoring between the 6th and 15th percentile seem to be at risk for elevated BF as well. More longitudinal research is necessary in order to answer the question of causality and how the risk for elevated BF changes over time. We would advise motor competence to be tested over time as well.

Relevancy in daily practice/clinical implications Currently, the treatment for children with DCD focuses mainly on the problems with motor coordination. Based on the results of this review, we would recommend that prevention and treatment of overweight and obesity become an integral part of the treatment programme for children with DCD. We underline the importance of preventing overweight and obesity as these may not only pose a serious health risk but could also negatively influence the already impaired motor coordination as well as the self-image of the child.

Conflict of interest statement The authors have nothing to disclose.

References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn, text revision. American Psychiatric Association Press: Washington, DC, 2000. 2. Gibbs J, Appleton J, Appleton R. Dyspraxia or developmental coordination disorder? Unraveling the enigma. Arch Dis Child 2007; 92: 534–539.

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3. Kadesjo B, Gillberg C. Developmental coordination disorder in Swedish 7-year-old children. J Am Acad Child Adolesc Psychiatry 1999; 38: 820–828. 4. Lingam R, Hunt L, Golding J, Jongmans M, Emond A. Prevalence of developmental coordination disorder using the DSM-IV at 7 years of age: a UK population-based study. Pediatrics 2009; 123: e693–e700. 5. Barnhart RC, Davenport MJ, Epps SB, Nordquist VM. Developmental coordination disorder. Phys Ther 2003; 83: 722– 731. 6. Smyth MM, Mason UC. Planning and execution of action in children with and without developmental coordination disorder. J Child Psychol Psychiatry 1997; 38: 1023–1037. 7. Smyth MM, Mason UC. Use of proprioception in normal and clumsy children. Dev Med Child Neurol 1998; 40: 672–681. 8. Wilson PH, McKenzie BE. Information processing deficits associated with developmental coordination disorder: a meta-analysis of research findings. J Child Psychol Psychiatry 1998; 39: 829– 840. 9. Sigmundsson H, Hansen PC, Talcott JB. Do ‘clumsy’ children have visual deficits. Behav Brain Res 2003; 139: 123–129. 10. Taft LT, Barowsky EI. Clumsy child. Pediatr Rev 1989; 10: 247–253. 11. Smyth TR. Impaired motor skill (clumsiness) in otherwise normal children: a review. Child Care Health Dev 1992; 18: 283–300. 12. Willoughby C, Polatajko HJ. Motor problems in children with developmental coordination disorder: review of the literature. Am J Occup Ther 1995; 49: 787–794. 13. Lichtenstein P, Carlström E, Rastam M, Gillberg C, Anckarsäter H. The genetics of autism spectrum disorders and related neuropsychiatric disorders in childhood. Am J Psychiatry 2010; 167: 1357–1363. 14. Pearsall-Jones JG, Piek JP, Rigoli D, Martin NC, Levy F. An investigation into etiological pathways of DCD and ADHD using a monozygotic twin design. Twin Res Hum Genet 2009; 12: 381– 391. 15. Cairney J, Hay JA, Faught BE, Mandigo J, Flouris A. Developmental coordination disorder, self-efficacy toward physical activity and participation in free play and organized activities: does gender matter? Adapt Phys Activ Q 2005; 22: 67–82. 16. Lloyd M, Reid G, Bouffard M. Self-regulation of sport specific and educational problem-solving tasks by boys with and without DCD. Adapt Phys Activ Q 2006; 23: 370–389. 17. Bouffard M, Watkinson EJ, Thompson LP, Dunn JLC, Romanow SKE. A test of the activity deficit hypothesis with children with movement difficulties. Adapt Phys Activ Q 1996; 13: 61–73. 18. Hands B, Larkin D. Physical fitness and developmental coordination order. In: Cermak SA, Larkin D (eds). Developmental Coordination Disorder. Delmar: Albany, NY, 2002, pp. 172–184. 19. Cairney J, Hay JA, Faught BE, Wade TJ, Corna L, Flouris A. Developmental coordination disorder, generalized self-efficacy toward physical activity and participation in organized and free play activities. J Pediatr 2005; 147: 515–520. 20. Tremblay M, Willms J. Secular trends in the body mass of Canadian children. Can Med Assoc J 2000; 163: 1129–1133. 21. Faith MS, Berman N, Heo M et al. Effects of contingent television on physical activity and television viewing in obese children. Pediatrics 2001; 107: 1043–1049. 22. Jolliffe D. Extent of overweight among US children and adolescents from 1971–2000. Int J Obes (Lond) 2004; 28: 4–9. 23. World Health Organization (2009). Prevalence of overweight and obesity in children and adolescents. [WWW document]. URL

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422

DCD and overweight and obesity in children C. G. Hendrix et al.

http://www.euro.who.int/__data/assets/pdf_file/0005/96980/2.3. -Prevalence-of-overweight-and-obesity-EDITED_layouted_V3.pdf (accessed August 2013). 24. World Health Organization (2012). Obesity and overweight. [WWW document]. URL http://www.who.int/mediacentre/ factsheets/fs311/en/ (accessed August 2013). 25. Biddle SJH, Gorley T, Stensel DJ. Health-enhancing physical activity and sedentary behaviour in children and adolescents. J Sports Sci 2004; 22: 679–701. 26. Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the bogalusa heart study. J Pediatr 2007; 150: 12–17. 27. Imperatore G. Childhood obesity: is it time for action? Nutr Metab Cardiovasc 2006; 16: 235–238. 28. Malecka-Tendera E, Mazur A. Childhood obesity: a pandemic of the twenty-first century. Int J Obes (Lond) 2006; 31: S1–S3. 29. Cairney J, Hay JA, Veldhuizen S, Missiuna C, Faught BE. Developmental coordination disorder, sex, and activity deficit over time: a longitudinal analysis of participation trajectories in children with and without coordination difficulties. Dev Med Child Neurol 2009; 3: e67–e72. 30. Rivilis I, Hay J, Cairney J, Klentrou P, Liu J, Faught BE. Physical activity and fitness in children with developmental coordination disorder: a systematic review. Res Dev Disabil 2011; 32: 894–910. 31. Magalhães LC, Missiuna C, Wong S. Terminology used in research reports of developmental coordination disorder. Dev Med Child Neurol 2006; 48: 937–941. 32. Henderson SE, Sugden DA. Movement Assessment Battery for Children, 1st edn. The Psychological Corporation: London, 1992. 33. Henderson SE, Sugden DA. Movement Assessment Battery for Children. The Psychological Corporation: San Antonio, TX, 2007. 34. Bruininks RH. Bruininks–Oseretsky Test of Motor Proficiency Owner’s Manual. American Guidance: Circle Pines, MN, 1978. 35. Crawford SG, Wilson BN, Dewey D. Identifying developmental coordination disorder: consistency between tests. Phys Occup Ther Pediatr 2001; 20: 29–50. 36. Miller LT, Missiuna CA, Macnab JJ, Malloy-Miller T, Polatajko HJ. Clinical description of children with developmental coordination disorder. Can J Occup Ther 2001; 68: 5–15. 37. Tan SK, Parker HE, Larkin D. Concurrent validity of motor tests used to identify children with motor impairment. Adapt Phys Activ Q 2001; 18: 168–182. 38. Sugden D (ed.). Developmental Coordination Disorder as a Specific Learning Difficulty. Leeds Consensus Statement. The Dyscovery Trust: Cardiff, Wales, UK, 2006. 39. Mallen C, Peat G, Croft P. Quality assessment of observational studies is not commonplace in systematic reviews. J Clin Epidemiol 2006; 59: 765–769. 40. Sanderson S, Tatt ID, Higgins JP. Tools for assessing quality and susceptibility to bias in observational studies in epidemiology: a systematic review and annotated bibliography. Int J Epidemiol 2007; 36: 666–676. 41. Cantell M, Crawford SG, Tish Doyle-Baker PK. Physical fitness and health indices in children, adolescents and adults with high or low motor competence. Hum Mov Sci 2008; 27: 344–362. 42. Tsiotra GD, Flouris AD, Koutedakis Y et al. A comparison of developmental coordination disorder prevalence rates in Canadian and Greek children. J Adolesc Health 2006; 39: 125–127. 43. Fong SS, Ng SS, Yiu BP. Slowed muscle force production and sensory organization deficits contribute to altered postural control strategies in children with developmental coordination disorder. Res Dev Disabil 2013; 34: 3040–3048.

15, 408–423, May 2014

obesity reviews

44. Beutum MN, Cordier R, Bundy A. Comparing activity patterns, biological, and family factors in children with and without developmental coordination disorder. Phys Occup Ther Pediatr 2013; 33: 174–185. 45. Fong SM, Lee YL, Chan NC, Chan SH, Chak W, Pang YC. Motor ability and weight status are determinants of out-of-school activity participation for children with developmental coordination disorder. Res Dev Disabil 2011; 32: 2614–2623. 46. van der Hoek FD, Stuive I, Reinders-Messelink HA et al. Health-related physical fitness in Dutch children with developmental coordination disorder. J Dev Behav Pediatr 2012; 33: 649–655. 47. Schott N, Alof V, Hultsch D, Meermann D. Physical fitness in children with developmental coordination disorder. Res Q Exerc Sport 2007; 78: 438–450. 48. Cairney J, Hay J, Veldhuizen S, Faught B. Comparison of VO2 maximum obtained from 20 m shuttle run and cycle ergometer in children with and without developmental coordination disorder. Res Dev Disabil 2010; 6: 1332–1339. 49. Cairney J, Hay J, Veldhuizen S, Faught BE. Assessment of body composition using whole body air-displacement plethysmography in children with and without developmental coordination disorder. Res Dev Disabil 2011; 32: 830–835. 50. Chirico D, O’Leary D, Cairney J et al. Left ventricular structure and function in children with and without developmental coordination disorder. Res Dev Disabil 2011; 32: 115–123. 51. Chirico D, O’Leary D, Cairney J et al. Longitudinal assessment of left ventricular structure and function in adolescents with and without developmental coordination disorder. Res Dev Disabil 2012; 323: 717–725. 52. Silman A, Cairney J, Hay J, Klentrou P, Faught BE. Role of physical activity and perceived adequacy on peak aerobic power in children with developmental coordination disorder. Hum Mov Sci 2011 30; 3: 672–681. 53. Wahi G, Leblanc PJ, Hay JA, Faught BE, O’Leary D, Cairney J. Metabolic syndrome in children with and without developmental coordination disorder. Res Dev Disabil 2011; 32: 2785–2789. 54. Cairney J, Hay JA, Veldhuizen S, Missiuna C, Mahlberg N, Faught BE. Trajectories of relative weight and waist circumference among children with and without developmental coordination disorder. Can Med Assoc J 2010; 182: 1167–1172. 55. Spironello C, Hay JA, Missiuna C, Faught BE, Cairney J. Concurrent and construct validity of the Bruininks–Oseretsky Test of Motor Proficiency and the Movement-ABC when administered under field conditions: implications for screening. Child Care Health Dev 2010; 36: 499–507. 56. Coverdale NS, O’Leary D, Faught BE, Chirico D, Hay J, Cairney J. Baroreflex sensitivity is reduced in adolescents with probable developmental coordination disorder. Res Dev Disabil 2012; 33: 251–257. 57. Cairney J, Hay JA, Veldhuizen S, Missiuna C, Faught BE. Developmental coordination disorder, gender and the activity deficit over time: a longitudinal analysis. Dev Med Child Neurol 2010b; 52: e67–e72. 58. Cairney J, Hay JA, Faught BE, Hawes R. Developmental coordination disorder and overweight and obesity in children aged 9 to 14 years. Int J Obes (Lond) 2005; 29: 369–372. 59. Cairney J, Kwan MY, Hay JA, Faught BE. Developmental coordination disorder, gender, and body weight: examining the impact of participation in active play. Res Dev Disabil 2012; 33: 1566–1573. 60. Faught BE, Hay JA, Cairney J, Flouris A. Increased risk for coronary vascular disease in children with developmental coordination disorder. J Adolesc Health 2005; 37: 376–380.

© 2014 The Authors obesity reviews © 2014 International Association for the Study of Obesity

obesity reviews

DCD and overweight and obesity in children C. G. Hendrix et al. 423

61. Cairney J, Hay JA, Faught BE, Flouris A, Klentrou P. Developmental coordination disorder and cardiorespiratory fitness in children. Pediatr Exerc Sci 2007; 19: 20–28. 62. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition of child overweight and obesity worldwide: international survey. BMJ 2000; 320: 1240–1243. 63. Tsiotra GD, Nevill AM, Lane AM, Koutedakis Y. Physical fitness and developmental coordination disorder in Greek children. Pediatr Exerc Sci 2009; 21: 186–195. 64. Hay JA, Hawes R, Faught BE. Eveluation of a screening instrument for developmental coordination disorder. J Adolesc Health 2004; 34: 308–313. 65. Li YC, Wu SK, Cairney J, Hsieh CY. Motor coordination and health-related physical fitness of children with developmental coordination disorder: a three-year follow-up study. Res Dev Disabil 2011; 32: 2993–3002. 66. Wu SK, Lin HH, Li YC, Tsai CL, Cairney J. Cardiopulmonary fitness and endurance in children with developmental coordination disorder. Res Dev Disabil 2010; 31: 345–349. 67. Wagner MO, Kastner J, Petermann F, Jekauc D, Worth A, Bösk K. The impact of obesity on developmental coordination disorder in adolescence. Res Dev Disabil 2011; 32: 1970–1976. 68. D’Hondt E, Deforche B, De Bourdeaudhuij I, Lenoir M. Childhood obesity affects fine motor skill performance under different postural constraints. Neurosci Lett 2008; 440: 72–75. 69. Morano M, Colella D, Caroli M. Gross motor skill performance in a sample of overweight and non-overweight preschool children. Int J Pediatr Obes 2011; 6(Suppl2): 42–46. 70. Cohen J. Statistical Power Analysis for the Behavioral Sciences, 2nd edn. Lawrence Erlbaum Associates Publishing: New York, 1988.

© 2014 The Authors obesity reviews © 2014 International Association for the Study of Obesity

71. Cohen J. A power primer. Psychol Bull 1992; 112: 155– 159. 72. Pietrobelli A, Faith MS, Allison DB, Gallagher D, Chiumello G, Heymsfield SB. Body mass index as a measure of overweight in children and adolescents. J Pediatr 1998; 132: 204– 210. 73. Ellis KJ, Abrams SA, Wong WW. Monitoring childhood obesity: assessment of the weight/height index. Am J Epidemiol 1999; 150: 939–946. 74. Maynard LM, Wisemandle W, Roche AF, Chumlea WC, Guo SS, Siervogel RM. Childhood body composition in relation to body mass index. Pediatrics 2001; 107: 344–350. 75. Freedman DS, Sherry B. The validity of BMI as an indicator of body fatness and risk among children. Pediatrics 2009; 124(Suppl. 1): S23. 76. Daniels SR, Khoury PR, Morrison JA. The utility of body mass index as a measure of body fatness in children and adolescents: differences by race and gender. Pediatrics 1997; 99: 804–807. 77. Demerath EW, Schubert CM, Maynard LM et al. Do changes in body mass index percentile reflect changes in body composition in children? Data from the Fels Longitudinal Study. Pediatrics 2006; 117: e487. 78. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM et al. CDC Growth Charts. National Center for Health Statistics: Hyattsville, 2000. 79. Taylor RW, Jones IE, Williams SM, Goulding A. Evaluation of waist circumference, waist-to-hip ratio, and the conicity index as screening tools for high trunk fat mass, as measured by dualenergy X-ray absorptiometry, in children aged 3–19 y. Am J Clin Nutr 2000; 72: 490–495.

15, 408–423, May 2014