International Journal of Obesity (2007) 31, 1068–1073

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PEDIATRIC HIGHLIGHT
Associations between obesity and developmental
functioning in pre-school children: a population-based
study
JM Mond1, H Stich2, PJ Hay1, A Kraemer2 and BT Baune1
1
School of Medicine, James Cook University, Townsville, Queensland, Australia and 2Department of Public Health
Medicine, School of Public Health, University of Bielefeld, Bielefeld, Germany

Objective: To examine associations between obesity and impairment in developmental functioning in a general population
sample of pre-school children.
Method: Standardized medical examinations were conducted in nine consecutive cohorts of male and female children
(n ¼ 9415) aged between 4.4 and 8.6 years (mean ¼ 6.0, s.d. ¼ 0.37) residing in the Lower Bavaria region of Germany. Tests
designed to assess performance in subdivisions representing four broad developmental domains, namely, motor development,
speech development, cognitive development and psycho-social development, were completed by all participants.
Results: Boys had significantly higher rates of impairment than girls. The prevalence of obesity in boys was 2.4%, whereas in
girls it was 4.3% (w2 ¼ 21.51, Po 0.01). After controlling for age, gender, year of recruitment and other potential covariates, the
prevalence of impairment in gross motor skills was higher among obese male children than normal-weight male children
(adjusted odds ratio ¼ 1.76, 95% confidence interval (CI) ¼ 1.02, 3.01, Po 0.05), whereas the prevalence of impairment in the
ability to focus attention was higher in obese female children than normal-weight female children (adjusted odds ratio ¼ 1.86,
95% CI ¼ 1.00, 3.44, Po 0.05).
Conclusions: The findings suggest that gender-specific associations between obesity and impairment in specific aspects of
developmental functioning may be evident in younger children.
International Journal of Obesity (2007) 31, 1068–1073; doi:10.1038/sj.ijo.0803644; published online 1 May 2007

Keywords: children; pre-school; developmental functioning

Introduction The effects of obesity on children’s psycho-social function-

The prevalence of obesity among children has increased
dramatically during the past three decades.1,2 Currently,
between 5% and 10% of children in most developed nations
are obese, according to accepted criteria.1 Obesity in child-
hood, as in adulthood, is associated with a range of medical
complications, including various risk factors for cardiovas-
cular disease, endocrine, respiratory, gastrointestinal and
orthopedic complications, exercise intolerance, general
physical discomfort and tiredness.3,4 Moreover, childhood
obesity conveys an increased risk of obesity later in life, so
that medical complications apparent in childhood are likely
to persist, and worsen, with time.5,6
Correspondence: Dr JM Mond, School of Medicine, James Cook University,
Townsville Queensland 4811, Australia. E-mail: jonathan.mond@jcu.edu.au
Received 25 September 2006; revised 11 March 2007; accepted 11 March
2007; published online 1 May 2007
ing are less clear. Whereas adverse effects of overweight on
self-esteem, general psychological distress and quality of life
have been observed in clinical samples of obese children,
these findings have not generally been replicated in general
population samples of children with comparable levels of
obesity.7,8 Findings from population-based studies do suggest
that associations between obesity and impairment in
children’s psycho-social functioning may be mediated by
age and gender, with greater impairment in older children
and in females.7,10
Few studies have addressed the possible effects of child-
hood obesity on other aspects of developmental functioning.
A recent study of first-grade children in Germany (mean
age ¼ 6.7 years)11 found that obesity was associated with
impairment in motor development in both boys and girls,
whereas Datar and Sturm (2004),12 in a large and nationally
representative sample children beginning kindergarten in
the US, found that obesity was associated with higher levels
of teacher- and parent-reported behavior problems in girls,

but not boys, after controlling for socio-demographic, life-
style and family variables. In a separate analysis of data from
the same sample,13 it was found that overweight children
had significantly lower scores on measures of mathematics
and reading ability compared with non-overweight children.
A study in Thailand found that overweight children and
adolescents (mean age ¼ 13.8 years) were twice as likely to
perform poorly in mathematics and language tests as
normal-weight children, after controlling for age, gender,
school and grade.14
The early years of school are a critical period in
cognitive and motor development, during which time skills
likely to impact on a broad range of functioning are
acquired.15 Impairment in developmental functioning dur-
ing childhood may have adverse effects on self-esteem,
psycho-social functioning more generally, and academic
performance, as well as increasing the risk of obesity later
in life.10,12 To date, the vast majority of studies that have
examined associations between childhood overweight and
impairment in specific aspects of functioning have been
conducted in adolescents. Hence, where associations have
been observed, it is unclear whether these effects were
apparent earlier in the child’s development and, if so, at
what point.7
The aim of the present study was to expand the current
knowledge base by examining the behavioral correlates of
obesity in a large community-based sample of pre-school
children. Specifically, we considered the associations be-
tween obesity and the prevalence of impairments in motor,
speech, cognitive and psychosocial development in nine
consecutive cohorts of children residing in the Lower Bavaria
region of Germany.
Method
Participants
Participants were 9415 children aged between 4.4 and 8.6
years (mean ¼ 6.0, s.d. ¼ 0.37) residing in one administrative
region of Lower Bavaria (Dingolfing–Landau) who com-
pleted compulsory annual medical examinations between
1997 and 2005.16,17 As, according to school regulations of
Bavaria, every child must be examined by a specially trained
physician before starting school, the study sample comprised
all eligible children residing in the district who commenced
school during the study period. Approximately 48% (47.9%)
of participants were girls and 52.1% were boys. The mean age
of girls (5.9 years) (s.d. ¼ 0.4) was significantly lower than
that of boys (6.1 years) (s.d. ¼ 0.5) (F ¼ 27.8, Po 0.05). Mean
body weight in the total sample was 21.2 kg (s.d. ¼ 4.8),
mean height was 116.5 cm (s.d. ¼ 4.0) and mean body mass
index (BMI, kg/m2) was 15.5 (s.d. ¼ 1.7). Boys had a higher
mean body weight than girls (21.4 vs 20.9 kg; F ¼ 18.2,
Po0.01), but similar BMI (15.49 vs 15.51; F ¼ 0.2, P40.05).
Most participants (92.6%) had German nationality.
Obesity in pre-school children
JM Mond et al
1069
Assessment procedure
Assessments were conducted each year between autumn/
winter and spring of the following year. The same team of
investigators, consisting of a medical doctor and two
assistants, was employed over the duration of the study
period and each examination was conducted by a trained
specialist using the same manual. All members of the team
were blind to the research questions. A modified version of
the ‘Bavarian Model’ for school entry examinations17 was
employed that yielded data on physical and psychological
health in four main developmental areas: motor, speech,
cognition and psychosocial development. Date of the
examination and date of birth of the child were used to
obtain exact age at the examination. For body weight
measurement, a standard scale was used, which was checked
for accuracy according to requirements of the responsible
institution after the examinations in 1998, 2000, 2002 and
2005. Other socio-demographic information, obtained by
parent self-report, included number of siblings and duration
and location (rural vs urban) of the kindergarten.
Definition of obesity
Obesity was defined according to the method proposed by
Cole and co-workers,18 in which the accepted cut-off for
adult (at age 18 years) obesity is interpolated to yield age-
and sex-specific cut-off points for obesity in children and
adolescents aged 2–18 years. Hence, children with a BMI at
or above the cut-off value corresponding to a BMI of 30 kg/
m2 in late adolescence (for example, BMI of 19.8 for 6-year-
old boys and 19.7 for 6-year-old girls) were classified as
obese. This classification was based on the exact age of the
children rounded to the nearest half year. The proportion of
participants in the present study who were obese according
to this definition was 4.3% for girls and 2.4% for boys
(w ¼ 21.51, Po0.01). The mean (s.d.) age of obese girls was
6.00 (0.39) years, whereas the mean (s.d.) age of obese boys
was 6.07 (0.43) years (F ¼ 1.89, P40.05). The mean (s.d.) BMI
of obese girls was 21 kg/m2 (1.90), whereas the mean (s.d.)
BMI of obese boys was 21.15 kg/m2 (1.78) (F ¼ 0.44, P40.05).
Specific domains of functioning assessed and definitions of
impairment
Within each of the four broad areas of developmental
functioning assessed, subdivisions were identified, each of
which was assessed with one or more standardized tests.
Table 1 shows the subdivisions of performance identified
within each domain and the tests used to measure them.
Motor development was considered to be impaired if
problems (false performance or failure on) were observed in
at least two standardized tests. Impairments of speech and
cognition were recognized if a child was unable to perform
correctly (false performance or failure in) in at least one of
the standardized tests. Impairment in psychosocial function-
ing was recognized if a child showed at least one distinctive
International Journal of Obesity
 Obesity in pre-school children
JM Mond et al
1070
Table 1 Domains and subdivisions of developmental functioning assessed and corresponding standardized tests

Domains of Subdivisions Standardized tests

development

Motor development Gross motor skills Standing on one leg; jumping on one leg; acting like a rope dancer; clapping hands
Fine body coordination Grapho-motor Finger opposition test; drawing different figures; drawing of a person
coordination

Development of Pronunciation Repeating words

speech
Grammar Retelling a short story; retelling a short picture story; explaining rules of a well known
game
Rhythm of speech Repeating sentences

Cognitive Memory and concentration Repeating sentences with 7–10 words, including three adjectives; repeating four
development single numbers in the correct sequence
Perseverance Discontinuity of capacity to attend during the examination
Abstraction Building pairs; identifying an object among various objects belonging together
Visual perception Recognition of simple geometric figures or silhouettes of figures and animals
Arithmetic Counting from 1 to 10 in the correct sequence

Psycho-social Behavior Erratic; overly bonded with mother (no separation possible during examination);
development hostility towards examiner
Emotionality Major mood swings; crying
Psycho-motor Agitation; unable to sit calmly for a few minutes

deficit in performance in behavior, emotionality or psycho-
motor functioning according to the standardized tests. For
technical reasons, data relating to impairment in subdivi-
sions within the psychosocial domain were not available.
Statistical analysis
Bivariate associations between obesity and impairment in
each of the 12 performance subdivisions were first examined
by means of w2 tests. Logistic regression models were used to
examine associations between obesity and impairment in
each subdivision while controlling for potential covariates,
namely, age, gender, nationality, year of recruitment and
location and duration of kindergarten.17 Where the effects of
both obesity and gender on performance in a given
subdivision were significant, the analysis was repeated
separately for males and females. A significance level (a) of
Po0.05 was adopted for all tests and all analyses were
conducted using SPSS Version 14.0.
Results
Table 2 shows the prevalence of impairments by gender. It
can be seen that boys had significantly higher rates of
impairment than girls in all performance subdivisions.
Associations between obesity and the prevalence of
specific impairments are shown in Table 3. It can be seen
that the prevalence of impairments was generally similar
among obese and non-obese children, with the exception
that impairment in gross motor skills tended to be higher
among obese children than non-obese children (P ¼ 0.08).
Results of the initial regression analyses indicated that
there was a significant association between obesity and
impairment in gross motor skills (adjusted odds ratio ¼ 1.65,
95% confidence interval (CI) ¼ 1.06, 2.56, Po0.05), while
the association between obesity and impairment in persever-
ance approached significance (adjusted odds ratio ¼ 1.53,
95% CI ¼ 0.97, 2.39, P ¼ 0.07). Additional analysis indicated
that obese male (but not female) children were more likely to
have impairment in gross motor skills (adjusted odds
ratio ¼ 1.76, 95% CI ¼ 1.02, 3.01, Po0.05), while obese
female (but not male) children were more likely to have
impairment in perseverance (adjusted odds ratio ¼ 1.86, 95%
CI ¼ 1.00, 3.44, Po 0.05). There were no significant associa-
tions for any of the remaining subdivisions.
Discussion
We examined the associations between obesity and impair-
ment in specific aspects of motor, speech, cognitive and
psychosocial development in a large, population-based
sample of pre-school children recruited in consecutive
cohorts over a 9-year period. In the entire sample, there
was a significant association between obesity and impair-
ment in gross motor skills, after controlling for potential
covariates. Additional analysis, in which the sample was
stratified by gender, indicated that the prevalence of
impairment in gross motor skills was higher among obese
male children than normal-weight male children, whereas
the prevalence of impairment in perseverance, namely, the
ability to focus attention continuously during the examina-
tion, was higher in obese female children than normal-
weight female children.

International Journal of Obesity

 Obesity in pre-school children
JM Mond et al
1071
Table 2 Percentage (%) impairment in subdivisions within each developmental functioning domain by gender

Domain Subdivision Impairment (%) w P

Boys Girls Total

Motor Rough body coordination 8.2 3.6 6.0 89.68 o 0.01

Fine body coordination 12.1 5.4 8.9 130.88 o 0.01
Grapho-motor coordination 8.5 3.3 6.0 111.40 o 0.01
Speech Pronunciation 16.3 9.2 12.9 103.77 o 0.01
Grammar 3.8 2.1 3.0 21.50 o 0.01
Rhythm of speech 4.2 2.1 3.2 32.54 o 0.01
Cognitive Memory and concentration 11.5 7.5 9.5 42.52 o 0.01
Perseverance 6.8 4.9 5.9 15.82 o 0.01
Abstraction 4.3 2.2 3.3 30.97 o 0.01
Visual perception 6.0 2.7 4.4 59.06 o 0.01
Arithmetic 4.3 2.7 3.5 17.36 o 0.01
Psycho-social Behavior/emotionality/psycho-motor 7.0 4.6 5.9 25.39 o 0.01

Table 3 Percentage (%) impairment in subdivisions within each developmental functioning domain for obese and non-obese children

Domain Subdivision Impairment (%) w P

Non-obese Obese Total

Motor Rough body coordination 6.2 8.9 6.3 3.09 0.08

Fine body coordination 8.7 10.0 8.7 0.59 0.44
Grapho-motor coordination 6.1 5.8 6.1 0.05 0.83
Speech Pronunciation 12.8 15.4 12.9 1.54 0.22
Grammar 3.0 3.1 3.0 0.01 0.91
Rhythm of speech 3.4 2.3 3.3 0.88 0.35
Cognitive Memory and concentration 9.4 11.6 9.5 1.34 0.25
Perseverance 5.8 8.1 5.9 2.48 0.12
Abstraction 3.6 2.7 3.6 0.57 0.45
Visual perception 4.8 3.9 4.8 0.49 0.48
Arithmetic 3.7 4.2 3.8 0.18 0.67
Psycho-social Behavior/emotionality/psycho-motor 6.1 6.9 6.1 0.34 0.56

Strengths and limitations
There were a number of notable strengths of the present
study. First, this is one of the few population-based studies to
consider associations between obesity and developmental
functioning in younger children. To our knowledge, the US
Early Childhood Longitudinal Study10 is the only other
population-based study of pre-school children comparable in
terms of sample size. Second, the same rigorous, standar-
dized assessment procedures, were employed at each assess-
ment during the entire study period. Third, impairment in a
range of aspects of developmental functioning was consid-
ered. Fourth, we were able to control for a range of potential
covariates that previous research suggested may be asso-
ciated both with overweight and with impairment in one or
more performance subdivisions.17 Finally, an internationally
accepted definition of obesity was employed.
Limitations of the present research should also be noted.
First, the definitions of impairment employed did not
conform to any recognized international standard. Findings
relating to the absolute levels of impairment should there-
fore be interpreted with caution. Second, for technical
reasons, data for performance on specific subdivisions within
the psycho-social domain could not be considered. Associa-
tions between obesity and impairment in specific aspects of
psycho-social functioning may have been observed were
these data available. Third, the use of a cross-sectional design
limits any inferences concerning the direction of the
observed relationships. Impairment in specific aspects of
functioning might be either the cause or the effect of
overweight, or both.19 Alternatively, obesity and impairment
in psycho-social and other outcomes might both be the
product of other factors, such as socio-demographic and/or
behavioral variables.12,13 Even where a prospective design is
employed, it may be difficult to draw firm conclusions as to
cause and effect.10,20
Associations between obesity and impairment in specific aspects
of functioning
We found that obesity was associated with impairment in
(gross) motor skills, after potential covariates were statisti-
cally controlled. Children with poorer motor skills may be
less likely to participate in organized and recreational
physical activities, due to perceived stigma and/or lack of

International Journal of Obesity

 Obesity in pre-school children
JM Mond et al
1072
confidence, thereby increasing the risk of obesity.11 Alter-
natively, participation in a higher level and range of
activities from an early age may be conducive to both
improved motor skills and healthy weight maintenance. In
the present study, obesity was associated with impairment in
motor skills only in male children. Cairney and co-workers21
similarly found a significant association between obesity and
impairment in developmental coordination for boys, but not
girls, in a sample of elementary school children (ages 9–14
years). Findings from both studies may reflect greater societal
pressure for participation in physical activities and/or
athletic prowess in boys.21
The only other significant association between overweight
and developmental functioning was that the prevalence of
impairment in perseverance, namely, the capacity to focus
attention during the examination, was higher in obese girls
than non-obese girls. Findings from other studies also
suggest that obesity is associated with impairment in
cognitive functioning and other adverse outcomes in girls
but not boys.10,12,22–25 These findings may reflect, at least in
part, higher levels of weight concerns and/or a greater
susceptibility to weight-related teasing/stigmatization in
girls.7,10 In any case, the findings of the present study
indicate the need to monitor the developmental functioning
of obese children, both boys and girls, to recognize the
developmental, as well as the medical, consequences of
childhood overweight, and to implement early intervention
programs to optimize children’s health.11,25,26
In the present study, there was no association between
obesity and impairment in psycho-social development in
either boys or girls. In view of the limitation associated with
the assessment of this domain noted previously, this finding
should be interpreted with caution. However, associations
between obesity and impairment in psycho-social function-
ing have not generally been observed in unselected samples
of children and adolescents, in contrast to the marked
impairment observed in clinical samples.7 Hence, and
paralleling obesity research in adults,9 attention has turned
to the factors that might mediate the effects of childhood
obesity on specific aspects of functioning.7,27 These factors
are likely to include the degree of overweight,28 chronic
medical conditions and/or pain,29,30 body image dissatisfac-
tion,22,10 and personality variables such as resiliency and
coping style.31,25
Although the focus of the present study was on associa-
tions between obesity and impairment in developmental
functioning, two other findings are notable. First, the
prevalence of obesity in girls was almost double that of its
prevalence in boys. A recent study of children aged 5 to 12
years in Ireland similarly found higher rates of obesity in
girls than in boys,32 whereas other studies of younger
children have found no difference33 or higher prevalence
in boys.34 These discrepancies likely reflect the different ages
of the populations sampled in different studies as well as the
fact that levels of overweight and obesity in younger
children are particularly susceptible to the effects of different
International Journal of Obesity
possible definitions of these terms.32 Second, in all domains,
and in each performance subdivisions within each domain,
the prevalence of impairment was higher in boys than in
girls. This finding is consistent with findings from a number
of population-based studies indicating that the prevalence of
disruptive disorders is higher in boys than in girls.35–37
Disorders of this kind are among the most common
psychiatric conditions in younger children and are asso-
ciated with a range of comorbid conditions, including
learning difficulties.35,37,38
To conclude, in a large general population sample of pre-
school children, the prevalence of impairment in gross
motor skills was higher among obese male children than
normal-weight male children, whereas the prevalence of
impairment in the ability to focus attention was higher in
obese female children than normal-weight female children.
The findings suggest that gender-specific associations be-
tween overweight and impairment in specific aspects of
developmental functioning are evident in this younger
population.
Acknowledgements
Dr Mond is supported by an NHMRC Public Health Fellow-
ship. Thanks also to Dr Alison Field for helpful comments on
an earlier version of this manuscript.
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