A multi-modal training programme to improve physical activity, physical fitness and perceived physical ability in obese children

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A multi-modal training programme to improve physicalactivity, physical fitness and perceived physical abilityin obese childrenMilena Morano a , Dario Colella a , Irene Rutigliano b , Pietro Fiore c , Massimo Pettoello-Mantovani b & Angelo Campanozzi ba Department of Clinical and Experimental Medicine, Motor Activities and Sport Sciences ,University of Foggia , Foggia , Italyb Department of Medical and Surgical Sciences, Pediatrics , University of Foggia , Foggia ,Italyc Department of Clinical and Experimental Medicine,Physical Medicine and RehabilitationUnit , University of Foggia , Foggia , ItalyPublished online: 22 Aug 2013.

To cite this article: Milena Morano , Dario Colella , Irene Rutigliano , Pietro Fiore , Massimo Pettoello-Mantovani & AngeloCampanozzi , Journal of Sports Sciences (2013): A multi-modal training programme to improve physical activity, physicalfitness and perceived physical ability in obese children, Journal of Sports Sciences, DOI: 10.1080/02640414.2013.824602

To link to this article: http://dx.doi.org/10.1080/02640414.2013.824602

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A multi-modal training programme to improve physical activity,physical fitness and perceived physical ability in obese children

MILENA MORANO1, DARIO COLELLA1, IRENE RUTIGLIANO2, PIETRO FIORE3,MASSIMO PETTOELLO-MANTOVANI2, & ANGELO CAMPANOZZI2

1Department of Clinical and Experimental Medicine, Motor Activities and Sport Sciences, University of Foggia, Foggia, Italy,2Department of Medical and Surgical Sciences, Pediatrics, University of Foggia, Foggia, Italy, and 3Department of Clinicaland Experimental Medicine, Physical Medicine and Rehabilitation Unit, University of Foggia, Foggia, Italy

(Accepted 9 July 2013)

AbstractActual and perceived physical abilities are important correlates of physical activity (PA) and fitness, but little research hasexplored these relationships over time in obese children. This study was designed: (a) to assess the feasibility of a multi-modal training programme promoting changes in PA, fundamental motor skills and real and perceived physical abilities ofobese children; and (b) to explore cross-sectional and longitudinal relationships between real and perceived physicalcompetence in boys and girls. Forty-one participants (9.2 ± 1.2 years) were assessed before and after an 8-monthintervention with respect to body composition, physical fitness, self-reported PA and perceived physical ability. Aftertreatment, obese children reported improvements in the body mass index, PA levels, gross motor performance and actualand perceived physical abilities. Real and perceived physical competence was correlated in boys, but not in girls. Resultsindicate that a multi-modal programme focused on actual and perceived physical competence as associated with the gradualincrease in the volume of activity might be an effective strategy to improve adherence of the participants and to increase thelifelong exercise skills of obese children.

Keywords: body composition, fundamental motor skills, obesity, physical abilities, physical activity

Introduction

Although overweight prevalence appears to be stabi-lising in several countries, levels of paediatric obesityremain high and the best strategies to control theepidemic have not been settled yet (Olds et al.,2011). Childhood obesity is of particular concernbecause it tracks into adulthood and is associatedwith health problems (Reilly, 2005). It affects per-ception of physical competence and is related to areduced quality of life and disability in daily livingactivities, mainly due to functional impairments,including deficits in performance of body-mass-dependent motor tasks (Griffiths, Parsons, & Hill,2010; Tsiros, Coates, Howe, Grimshaw, & Buckley,2011). Consequently, obese children tend to have anegative attitude towards physical activity (PA),which in turn may result in fewer movement oppor-tunities for the further development of skilfulnessand improvement in perception of competence, per-petuating the weight gain vicious cycle (Stoddenet al., 2008).

Previous findings have shown that perceived physi-cal competence is a consistent positive correlate of PA(Bauman et al., 2012), and that improved actualmotorcompetence is associated with higher perceivedcompetence (Morano, Colella, Robazza, Bortoli, &Capranica, 2011), increased PA levels (PALs)(Wrotniak, Epstein, Dorn, Jones, & Kondilis, 2006)and fitness (Vedul-Kjelsås, Sigmundsson,Stensdotter, & Haga, 2012). However, most studieshave used cross-sectional designs (Bauman et al.,2012), and little experimental or longitudinal researchhas explored these relationships in obese children.

Furthermore, adiposity has been related to diet, PAand sedentary behaviours in children and adoles-cents, but the relative contribution of PA to obesitymanagement is still unclear (Stensel, Gorely, &Biddle, 2008; Watts, Jones, Davis, & Green, 2005).Most of the programmes have focused on changes inboth diet and PA (Watts et al., 2005), and very limitedresearch has examined the impact of obesity interven-tions on psychosocial determinants of activity

Correspondence: Milena Morano, Department of Clinical and Experimental Medicine, Motor Activities and Sport Sciences, University of Foggia, Foggia,Italy. E-mail: [email protected]

Journal of Sports Sciences, 2013http://dx.doi.org/10.1080/02640414.2013.824602

© 2013 Taylor & Francis

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behaviour (Oude Luttikhuis et al., 2009). Systematicreviews on isolated or adjunctive exercise treatmentsin obese children suggest that many interventions hadnon-significant or weak effects on improving PA par-ticipation or reducing obesity (Kamath et al., 2008;Metcalf, Henley, & Wilkin, 2012). However, even inthe absence of weight loss, Griffiths and colleagues(2010) have found improvements in the perceptionsof physical competence, stressing their importance asintervention outcomes in future investigations.Evidence of psychological benefits of increased PAhas already been reported (Goldfield et al., 2007),but to date, the majority of intervention studies haveshown mixed results for the association betweenpsychosocial changes and weight reduction(Griffiths et al., 2010).

In order to promote exercise adherence amongobese children, there is a need to assess over timethe impact of PA by itself on some modifiable factorsthat co-exist with paediatric obesity (e.g. low per-ceived physical competence, poormotor competence,impaired physical fitness). The longitudinal evalua-tion of correlates of PA as primary study outcomes,could provide strategies for promoting active beha-viours, which in turn may lead to more effective inter-ventions for treating childhood obesity. Therefore,this study was designed: (a) to assess the feasibilityof a multi-modal training programme promotingchanges in PA, fundamental motor skills (FMSs)and real and perceived physical abilities of clinicallyobese children; and (b) to explore the relationshipsover time between changes in perceived physicalability and actual competence; and (c) to analyse theextent to which these relationships may vary by gen-der. We hypothesised that obese boys and girls wouldbe interested in an intervention programme and ableto make positive changes resulting in increased PAand improved real and perceived competence, even inabsence of weight reduction. Furthermore, based onthe competencemotivation theory (Harter, 1985) andthe self-efficacy theory (Bandura, 1997), it wasexpected that changes in motor competence wouldbe directly related to changes in perceived physicalability over an 8-month period.

Methods

Participants

Forty-one obese children (22 boys and 19 girls, aged9.2 ± 1.2 years) who attended the outpatient hospitalclinic of the Centre for Pediatric Obesity at theUniversity of Foggia, Italy, were recruited via localpaediatricians. Participants satisfied the followingcriteria for inclusion: 8- to 10-year-old children (a)with a body mass index (BMI) ≥ 95th percentile forage and sex according to the Centers for Disease

Control and Prevention (CDC) growth charts(Kuczmarski et al., 2002); (b) not currently involvedin a structured exercise programme outside theschool or had been in the previous 6 months priorto participation; and (c) without medical conditionsthat would limit PA. All parents gave their writteninformed consent for the participation of their childin the programme before its initiation. The study wasperformed according to the World MedicalAssociation Declaration of Helsinki for the ethicalprinciples in medical research involving human sub-jects, and is a part of a larger research protocolapproved by the Institutional Review Board of theUniversity of Foggia.

Intervention programme

Participants followed an 8-month multi-componenttreatment programme focused on attaining a physi-cally active lifestyle by increasing their actual andperceived competence in performing motor tasks.The intervention provided children with a wide vari-ety of opportunities to practice skill development andto participate in decision-making activities within anon-competitive and supportive learning environ-ment. It consisted of 80 sessions delivered over 32weeks and conducted by nine specialist instructors atthe Physical Activity Centre of the local university.Drawing on PA and fitness recommendations forobese children (Fulton, Garg, Galuska, Rattay, &Caspersen, 2004), the components of the treatmentprogramme were health-related physical activities,exercise training and behavioural change. Thehealth-related activity or fitness components includedFMS, muscle strength, power, aerobic fitness, speed,flexibility and prevention of injuries through a varietyof indoor and outdoor activities designed to increaseenjoyment of movement, and selected to enable chil-dren to experience success in their performance. Theexercise programme was progressive in design, byincreasing the volume of activities and modifying theweekly number of sessions (from two to three2-h-long sessions per week) at the mid-interventionpoint. Each session was mainly in group format, butparticipants also received an individualised trainingprogramme for 25 min, with an instructor-to-childratio not greater than 1 to 4. The specificity andprogression of the individual exercise modalities(e.g. walking, cycling, stepping, seated rowing) wereadapted to child’s competence level. In particular,during such activities, the exercise intensity wascontrolled through heart rate monitors (Polar F4;Kempele, Finland), and maintained at a constantlow level (i.e. 50–60% of the individual’s maximumheart rate).

To promote their adherence to interventionrecommendations, children were encouraged to be

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active outside the programme hours, and invited tofill out at home a 1-week activity diary. Behaviouralskills training that might facilitate voluntary PA wasprovided to participants and their families 1 day perweek for 40 min. It consisted of an assortment ofinteractive group lessons including review of PAdiaries, discussion of appropriate medium- andshort-term goals, development of methods for self-monitoring incremental progress, recruiting socialsupport and promoting awareness of the benefits ofPA and fitness. Examples of weekly themes were“PA and health”, “Patterns of PA/sedentarybehaviour”, “Activity opportunities in differentenvironmental contexts” and “Health benefits ofskill development/fitness improvement”. Since theprimary goal of the intervention was to encouragechildren’s participation in PA, no weight loss targetswere set, although healthy eating behaviours (e.g.regular meal distribution, reduced consumption ofhigh-fat foods, increased overall fruit and vegetableintake) were discussed and encouraged as part of theintervention, in the admission of children to thehospital outpatient clinic and with a repeatednutritional counselling at the midpoint of the inter-vention. In particular, at the baseline medical exam-ination, parents were instructed on how to completea 7-day food diary in which to record details ofeverything their children consumed over a 7-dayperiod. On the basis of the compiled diaries, practi-cal advice and specific written instructions in theform of a booklet (Clinica Pediatrica Università diFoggia, 2012) were given to the parents.

During the intervention, the attendance was sys-tematically recorded, including non-attendance dueto exceptional circumstances (e.g. illness), by assign-ing a score of 1 (presence) or 0 (absence) to eachchild. Participants were assessed at baseline (T0) andat the end (T1) of the 8-month treatment period.

Evaluation of body composition

Anthropometric measurements were performed by ahighly experienced paediatrician of the hospital,according to the standardised procedures of theInternational Society for the Advancement ofKinanthropometry (Norton et al., 1996). Body weightto the nearest 0.1 kg and standing height to the nearest0.1 cmweremeasured using a balance scale (Seca 761,Hamburg, Germany) and a calibrated stadiometer(Seca 220, Hamburg, Germany), respectively. BMI(kg/m2) was calculated from height and weight mea-sures, and BMI centiles and z-scores were derivedaccording to the CDC growth reference (Kuczmarskiet al., 2002). Body circumferences (waist, hip, abdo-men and arm) were determined to the nearest 0.1 cmusing a flexible nylon tape measure, while skinfoldthickness was measured to the nearest 0.1 mm in

triplicate at the biceps, triceps, subscapular and suprai-liac sites with a Holtain skinfold caliper (Holtain Ltd,Crymych, UK). The mean of the three measurementswas taken as the final value. The Brook’s equation wasused to assess total body density from skinfold thick-ness (Brook, 1971). The total body density was thenconverted into the percentage of fat body mass usingSiri’s equation (Siri, 1961).

Evaluation of physical activity

General PALs were assessed using the PhysicalActivity Questionnaire for Older Children (PAQ-C;Crocker, Bailey, Faulkner, Kowalski, & McGrath,1997), which is a self-reported 7-day recall instru-ment designed for use with children ages 8–14 years.The PAQ-C total score is derived from nine items,each scored on a five-point scale from 1 to 5, withhigher values indicating greater PAL. Studies haveshown good reliability and validity of this instrumentfor children in grades 4 to 8 (Crocker et al., 1997;Kowalski, Crocker, & Faulkner, 1997; Labbrozziet al., 2012).

Evaluation of physical performance

FMS mastery, lower limb strength and sprint abilitywere assessed using five age-appropriate field-basedtests, which were reported to be reliable and validmeasures in childhood (Bosco, Luhtanen, & Komi,1983; Morrow, Jackson, Disch, & Mood, 2005;Ulrich, 1985). FMS proficiency was evaluated usingthe test of gross motor development (TGMD; Ulrich,1985), which involves a locomotor subtest (i.e. run,gallop, hop, leap, horizontal jump, skip and slide) andan object-control subtest (i.e. two-hand strike,stationary bounce, catch, kick and overhand throw).These skills are assumed to represent different aspectsof the child’s ability to transfer his or her own centreof gravity from one point to another (i.e. locomotorskills), and to project and receive objects (i.e. object-control skills). After a visual demonstration by atrained research assistant, participants individuallyperformed skills three times, and skill componentswere scored as pass or fail (1 or 0) for each trial.The raw scores for each skill were added to create ascore for each subtest, with higher values indicating abetter quality of movement patterns. By using normtables, the two raw subtest scores were then con-verted to standard scores, which were summed toprovide a gender- and age-adjusted gross motordevelopment quotient (GMQD) for each participant(Ulrich, 1985). According to the TGMD perfor-mance descriptors for subtest standard scores(Ulrich, 1985), descriptive rating of participants isreported as very superior, superior, above average, aver-age, below average, poor and very poor.

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The power of lower limbs was assessed by thefollowing vertical jump tests performed on a forceplatform (Ergojump Bosco System, Schramberg,Germany): (a) squat jump beginning from a staticsemi-squatting position with knees bent at 90° andwithout countermovement, and (b) countermove-ment jump starting from a standing position withallowance for a countermovement, and reachingknee bending angles of around 90° just beforeimpulsion (Bosco et al., 1983). For each jump test,from standing position with the hands kept on thehips, participants were required to bend their kneesand perform a maximal vertical thrust. Childrenwere instructed to keep their body as vertical aspossible throughout the jump, and to land withknees entirely extended. During the assessment, asingle trained tester selected each jump perfor-mance, according to the criteria established for chil-dren (Acero et al., 2011). Any jump that wasperceived to deviate from the required instructionswas repeated. For each test participants were allowedthree trials, which were recorded in centimetres. Thebest performance was used for statistical analysesaccording to jumping height.

The children’s sprint ability was evaluated bymeans of a 10-m sprint and an agility test, withperformances recorded to the nearest 0.01 s.(Morrow et al., 2005). For the 10-m sprint from astanding position, participants were instructed tocover the distance of 10 m as fast as possible. Theagility test (4 × 10 m) required subjects to run backand forth four times along a 10 m distance at thehighest speed possible. Each test was performedtwice and the lowest sprint values were recorded.

Evaluation of perceived physical ability

Individual’s perception of strength, speed and coordi-native abilities was assessed using the PerceivedPhysical Ability Scale for Children (Colella, Morano,Bortoli, & Robazza, 2008), which is composed of sixitems structured in a response scale having a 1- to4-point format. The scores of the first item, for exam-ple, range from 1 (I run very slowly) to 4 (I run very fast).Participants are required to think about their perfor-mance when involved in PA and to choose for eachitem the response that best represents their personalfeelings. Higher total scores correspond to a betterperceived physical ability. The scale showed goodreliability with Cronbach α = 0.72 and a split-halfr = 0.70 (Colella et al., 2008).

Statistical analyses

A 2 (gender) × 2 (time: T0 vs. T1) repeated measuresanalysis of variance design was applied to eachdependent variable, and effect size (partial η2) values

are provided for significant findings. To investigatethe associations between perceived physical abilityand motor performance tests, Pearson’s correlationcoefficients (r) were calculated for each time point(i.e. cross-sectional relationships) and for the changefrom T0 scores (i.e. longitudinal relationships). Tocreate change from baseline scores for correlationalanalyses, the residualised change score was obtainedfor each variable by regressing T1 score onto T0

score, and saving the standardised residual as anindex of change. The resulting residualised changescore can be interpreted as the amount of increase(positive score) or decrease (negative score) in thevariable over the 8 months, independent of (i.e.uncorrelated with) baseline level (Cohen, Cohen,West, & Aiken, 2003). The residualised changeapproach is viewed as superior to the alternativemethod involving subtraction scores, which caninduce overcorrection of the post- by the pre-score(Cohen et al., 2003). Statistical significance was setat P ≤ 0.05. All analyses were performed using theStatistical Package for the Social Sciences (SPSS)version 17.0 (SPSS Inc., Chicago, IL, USA).

Results

All children completed the programme and themean percentage of sessions attended was88.3 ± 2.3% (mean overall number = 70.7 ± 1.8;range = 68 to 77). Descriptive statistics and repeatedmeasures analyses of variance results for each vari-able by time of assessments (T0 vs. T1) are reportedin Table I.

Significant main effects of gender were found inthe waist circumference (F1,39 = 6.15, P < 0.02,ηp

2 = 0.14), BMI (F1,39 = 4.21, P < 0.05,ηp

2 = 0.10), BMI z-score (F1,39 = 5.60, P = 0.02,ηp

2 = 0.13) and BMI percentile (F1,39 = 4.28,P < 0.05, ηp

2 = 0.10), with boys reporting highervalues than girls. No gender × time interactioneffects emerged, indicating that changes over timewere similar for males and females.

From T0 to T1, weight, height and waist circum-ference significantly increased, whereas BMI vari-ables (i.e. BMI value, z-score and percentile)decreased. With regard to behavioural and psycho-social outcomes, significant time effects were found,with children reporting higher PA and perceivedphysical ability scores at the end of the programme.Significant main effects for time emerged on allmotor tests, with participants showing better perfor-mances after the 8-month intervention. Figures 1and 2 show the distribution in percentage (%) ofparticipants for each descriptive rating of the loco-motor and object-control performance, according tothe TGMD descriptors for subtest standard scores(Ulrich, 1985).

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Table I. Descriptive statistics and repeated measures analysis of variance results by time of assessments (T0 vs. T1).

Males (n = 22) Females (n = 19)

Variable

Pre-treatment Post-treatment Pre-treatment Post-treatment Analysis of variance

Mean ± s Mean ± s Mean ± s Mean ± sFtime

(1.39) P ηp2

Weight (kg) 50.98 ± 11.53 52.24 ± 11.78 46.93 ± 7.05 49.01 ± 6.55 6.99 0.012 0.15Height (cm) 137.73 ± 8.81 141.33 ± 9.05 138.04 ± 7.44 142.95 ± 6.99 84.87 <0.001 0.69BMI (kg/m2) 26.57 ± 3.68 25.84 ± 3.62 24.54 ± 2.40 23.94 ± 2.34 9.66 0.004 0.20BMI z-score 2.26 ± 0.36 2.19 ± 0.36 2.00 ± 0.31 1.93 ± 0.34 56.80 <0.001 0.59BMI percentile 98.34 ± 1.60 98.02 ± 1.82 97.25 ± 1.88 96.66 ± 2.32 27.04 <0.001 0.41Body fat (%) 37.95 ± 4.81 38.25 ± 3.90 39.30 ± 2.53 38.53 ± 2.80 0.42 0.523 0.01Body circumferences

Arm (cm) 26.95 ± 2.80 26.86 ± 3.01 25.22 ± 1.95 25.58 ± 2.40 0.47 0.495 0.01Waist (cm) 77.80 ± 8.21 79.30 ± 8.06 73.00 ± 5.48 73.87 ± 4.13 4.51 0.040 0.10Hip (cm) 86.39 ± 10.67 89.14 ± 10.45 87.29 ± 5.90 88.47 ± 5.28 2.88 0.098 0.07Abdominal (cm) 86.66 ± 10.32 86.61 ± 10.08 83.76 ± 5.91 84.68 ± 5.82 0.33 0.567 0.01

Skinfold thicknessBiceps (mm) 18.81 ± 7.88 18.60 ± 5.81 17.55 ± 4.16 16.49 ± 3.98 0.95 0.335 0.02Triceps (mm) 24.61 ± 6.65 23.68 ± 5.66 23.41 ± 5.32 22.21 ± 3.89 1.64 0.208 0.04Subscapular (mm) 25.94 ± 7.86 26.86 ± 6.41 25.47 ± 6.46 24.41 ± 5.59 0.01 0.923 0.00Suprailiac (mm) 25.64 ± 7.57 26.21 ± 6.96 22.93 ± 5.55 23.14 ± 5.27 0.16 0.691 0.00Sum of skinfolds (mm) 95.00 ± 27.82 95.36 ± 20.76 89.35 ± 10.44 86.25 ± 11.30 0.41 0.524 0.01

Physical activity 2.15 ± 0.51 2.48 ± 0.69 2.15 ± 0.40 2.49 ± 0.49 15.63 <0.001 0.29Perceived physical ability 17.77 ± 3.05 18.86 ± 2.82 16.63 ± 2.59 18.32 ± 2.94 20.70 <0.001 0.35Physical performance

Locomotor skillsRaw scores 16.68 ± 4.38 17.86 ± 4.17 16.58 ± 3.72 18.47 ± 3.34 8.94 0.005 0.19Standard scores 4.27 ± 2.31 5.09 ± 2.43 3.95 ± 2.46 5.37 ± 2.43 14.25 0.001 0.27

Object-control skillsRaw scores 12.45 ± 3.32 13.77 ± 3.78 11.68 ± 3.07 14.32 ± 2.33 13.81 0.001 0.26Standard scores 5.18 ± 2.56 7.09 ± 3.58 4.74 ± 2.86 7.47 ± 2.63 24.42 <0.001 0.39

GMQD 67.82 ± 11.31 76.55 ± 15.73 66.05 ± 14.66 79.47 ± 12.74 43.12 <0.001 0.53Squat jump (cm) 16.37 ± 2.84 18.26 ± 3.09 17.52 ± 1.67 19.55 ± 2.23 47.08 <0.001 0.55Countermovement jump (cm) 18.91 ± 4.09 20.54 ± 4.22 19.71 ± 2.29 21.32 ± 2.69 75.18 <0.001 0.6610 m sprint (s) 3.10 ± 0.63 2.92 ± 0.35 3.18 ± 0.57 2.90 ± 0.27 11.19 0.002 0.224 × 10 m agility (s) 21.69 ± 3.41 20.55 ± 2.27 20.16 ± 1.73 20.12 ± 1.23 4.57 0.039 0.11

Note: ηp2, partial eta squared; BMI, body mass index; GMQD, gross motor development quotient.

Average7.32

17.07

19.51

39.03

T0

T1

29.2714.63

43.929.27

Locomotor subtest standard scores (%)

Below average

Poor

Very poor

Figure 1. Percentages of participants within descriptive rating of the locomotor performance (n = 41).

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Correlational analyses between perceived physicalability and motor performance by gender and time ofassessments were significant for boys, but not forgirls. For male sample, baseline perceived physicalability was associated with the pre-treatment GMQD(r = 0.43, P < 0.05) and with change from T0 in theobject-control subtest (r = 0.63, P = 0.002). At T1,perception of physical ability was unrelated to motorperformance results, except for a positive relation-ship with the object-control subtest (r = 0.46,P = 0.03). Finally, change from T0 in the perceivedphysical ability showed only a negative correlationwith the pre-treatment 10-m sprint performance(r = −0.51, P < 0.02).

Discussion

Findings of this preliminary study showed that BMI,PAL, gross motor performance and actual and per-ceived physical abilities significantly improved 8months after treatment in obese boys and girls.However, compared to the normative samples fromthe TGMD manual (Ulrich, 1985), children showedinferior FMS mastery, and none of all participantscould achieve the superior or very superior level forboth subtests. Perceived physical ability and sprintability were also lower than those found in non-obese children of the same age and nationality(Colella, Morano, Robazza, & Bortoli, 2009). Nochange was shown in the body composition of parti-cipants at T1, suggesting that participation in theprogramme did not led to sustainable improvementsin this secondary outcome. However, within ourtreatment, much attention was paid to the physicaltraining suitable for all participants as associatedwith the gradual increase in the volume of activitiesto provide opportunities for children to experiencesuccess and a sense of accomplishment duringsessions.

Despite the lack of a control group, our findingssupport a previous randomised trial, which showedthat increases in the volume of PA rather than in itsintensity, were more closely associated withimprovements in the physical self-perception of clini-cally obese children, and can confer psychosocialhealth benefits independently of changes in theirbody composition (Goldfield et al., 2007).Research found that PA intensity is negativelyrelated to exercise adherence (Epstein, Koeske, &Wing, 1984), probably because obese children per-ceive higher intensity activities as too difficult or lesspleasant, given the more physical complaintsrequired (Deforche, Haerens, & de Bourdeaudhuij,2011). Thus, sustaining bouts of high exercise inten-sity could lead obese individuals to shun PA(Goldfield et al., 2007), which in turn might resultin increasing their sedentary habits, motor deficitsand body mass (Stodden et al., 2008). Conversely,increasing the volume of PA at lower intensities mayimprove exercise adherence, contribute to weightcontrol and provide a sense of mastery and accom-plishment in relation to physical competences(Goldfield et al., 2007). According to Rowland(1990), the ideal form of exercise for obese childrenwould be aerobic, involving high calorie expenditure.However, to promote their exercise adherence, weshould consider that PA is a multidimensional beha-viour, and thus much more attention should be paidto other equally important components of physicallyactive lifestyles (e.g. health and performance-relatedphysical fitness, skill proficiency and perceived phy-sical competence). Most intervention studies havebeen concerned with the assessment of energyexpenditure and/or aerobic power of participants,and research on the potential of alternativeapproaches (i.e. vs. programmed aerobic exercise)for promoting habitual exercise, is scarce. Goran,Reynolds and Lindquist (1999) have claimed that

Average

Below average

Above average2.44

9.76

12.19

Object-control subtest standard scores (%)

39.02

T0

T1

17.0717.07

31.7121.95

36.5912.20

Poor

Very poor

Figure 2. Percentages of participants within descriptive rating of the object-control performance (n = 41).

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the time devoted to PA, rather than activity relatedto energy expenditure, may be the most importantfactor in energy regulation and thus in long-termweight management. Research also showed that astructured fun-type skill learning programme is analternative method of exercise prescription used topromote adherence and motivation to develop habi-tual PA (Gately, Cooke, Butterly, Mackreth, &Carroll, 2000; Parker & Bar-Or, 1991).

Although fun-type skill-based PA may not conformto classical activity guidelines, by gradually beingintroduced to enjoyable forms of exercise, obese chil-dren can lose their negative attitude towards PA,improve their actual and perceived competence,hopefully developing more active lifestyles (Deforcheet al., 2011). From this viewpoint, it is not surprisingthat findings showed improvements in almost allstudy variables at T1, suggesting that suitable encour-agement and increasing confidence in performancemay be of benefit in obesity management.According to Stodden and colleagues (2008), enhan-cing motor competence of obese children has thepotential to improve their motivation to participatein PA because of their improved self-perception. Itis thus paramount that opportunities and encourage-ment be provided for obese children to develop theiractual and perceived motor competences in order topromote engagement and persistence in PA(Southall, Okely, & Steele, 2004). However, researchfindings have been inconsistent in this regard and fewstudies to date have reported an increase in PA atpost-test or follow-up (Cliff, Okely, Morgan, Jones, &Steele, 2010). PA interventions have produced only asmall effect on the overall activity levels of children,which may explain, at least in part, why such inter-ventions have had limited success in reducing theirBMI or body fat (Metcalf et al., 2012).

Against expectations, the results found no genderdifferences in PA, FMS proficiency and actual andperceived motor abilities at T0 and T1, suggestingthat such variables may not vary between males andfemales within an environmental context in which allchildren are obese, involved in a structured PA pro-gramme and placed in non-comparative situations.The influence of gender was observed in the correla-tional analyses, showing a relationship betweenactual and perceived physical competence in boys,but not in girls. Therefore, improving motor compe-tence in obese girls would not influence their per-ceived physical ability, as much as could happen inboys. Boys and girls perceive physical activities indifferent ways, and thus perception of competencemay vary depending on the subjective meaningascribed to those activities, and may not necessarilybe associated with actual physical competence,because of unrealistic and idealistic notions of one’sperformance.

Interestingly, for male sample, perception of physi-cal ability showed the strongest correlation with theobject-control tasks for most of the relationshipsexamined. It was found that baseline perceived phy-sical ability was correlated with baseline GMQDscores and with changes in object-control skills, butit was unrelated to changes in tasks requiring hori-zontal propulsion and vertical lifting of the bodymass. Thus, obese boys may achieve increased physi-cal performances in weight-bearing tasks with inter-vention, irrespective of their level of baselineperceived physical ability, which, on the other hand,may influence improvements in object-control skills.

Correlation coefficients also showed that pre-treat-ment speed times were negatively related to a changein the perceived physical ability, which therefore maybe directly influenced by the baseline level of theseperformances. No correlation between perception ofphysical ability and weight-bearing tasks was foundat T1 and for change from baseline scores, probablybecause obese children find these tasks harder toperform, as they require greater movement of thebody against gravity compared to object-controlskills (Southall et al., 2004). Therefore, moving aheavier body mass from one place to another as isrequired for locomotor skills, might not influence theperceived physical ability of obese children, whoalready show low confidence in their capabilities.Based on the present findings, especially in theearly phases of an exercise regime for obese children,educators should give priority to object-control tasksover weight-bearing activities, in order to help parti-cipants experience success, achieve improvements inactual and perceived physical competences, andthereby change their attitudes towards PA.

This study provides novel information for tailoringinterventions to the needs and interests of obese boysand girls, and emphasises the importance of approach-ing such interventions from a comprehensive perspec-tive including not only body movement and functions,but also psychosocial factors. Research has alreadyshown that improved actual motor competence is asso-ciated with decreased BMI (Lopes, Stodden, Bianchi,Maia, & Rodrigues, 2012), higher perceived compe-tence (Morano et al., 2011) and increased PAL(Wrotniak et al., 2006) and fitness (Vedul-Kjelsåset al., 2012), but to our knowledge, no longitudinalstudies have been performed to evaluate simulta-neously the independent effects of PA (i.e. not vs. diet-ary modification) on such variables in a similarclinically obese group. In contrast to interventionsusing dietary modification, changing PA is less directlylinked to a prohibition of activities and might helpparticipants to perform daily living activities whiledecreasing their disabilities associated with obesity.Other strengths of our study are its both cross-sectionaland longitudinal design and the use of well-validated

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outcome measures, which included both objective andself-reported variables. Furthermore, the programmewas well-tolerated since that all the children whostarted, completed it and the mean of sessionsattended was high. However, the study adopted aone-group design and as such, results could not becompared with data from a control group, despiteproviding interesting findings for long-term follow-up studies. In addition, the study is limited becausewe did not examine the potential influence of growthon the physical performance results of the partici-pants. Further research is needed to examine theeffects of different doses of PA on short- and long-term health outcomes in obese children, and toinvestigate the determinants of youth participationin PA, also controlling for the confounding effects ofgrowth and maturation.

In summary, findings indicate that a multi-modalprogramme focused on actual and perceived physicalcompetence as associated with the gradual increase inthe volume of activity, enhances adherence of the par-ticipants and has the potential to improve the lifelongexercise skills of obese children. At the initial stages ofan intervention for obese children, weight-bearingactivities should be limited, considering that theirpoor performances may cause them to decrease theirPA, while object-control tasks should be included, soas to enhance their perceived physical ability and thusthe adherence to the exercise programme.

Acknowledgements

This study was financially supported by the ItalianMinistry of Education, University and Research in theframework of the Projects of Relevant National Interest(PRIN 2009), according to the Italian MinisterialDecree No. 404/Recognised of 14 July 2011(2009PMTYTP). The authors would like to thankthe parents and children who took part in this study.

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