The first aim of the present study was to investigate whether differences between rural and urban settings in the North, Centre and South of Italy could influence school-age children’s weight status, motor competence and PA level.
The hypothesis we formulated was confirmed because our findings showed that children from the Centre of Italy had the higher BMI than their peers from the North and the South, revealing the higher proportion of overweight and obese children in the Italian Central regions. These results were in contrast with previous studies’ results that reported the higher prevalence of children’s and adolescents’ overweight and obesity in the South regions of Italy when compared with the Centre and the North regions [4, 5, 16, 23]. Our Central children also showed the lowest PA level and the worst walkability of neighbourhoods when compared with their Northern and Southern peers that could have negatively affected their weight status. Moreover, the greater BMI of children living in rural areas of North Italy was consistent with results reported for children living in rural areas of Midwest in the United States  and for children living in rural areas of Croatia . In addition, considering the different weight status categories, it appeared that rural children had a higher overweight/obesity prevalence than urban children, underling the severe situation of youth living in this setting. Although in the present study socioeconomic factors were not measured, rural children were often associated to a low family income . Therefore, we could speculate that this low socio-economic status of rural children leads to an unhealthy lifestyle which is directly related to low levels of PA, to a non-correct diet .and to a high prevalence of overweight and obesity .
Our results revealed a higher prevalence of motor impairments in girls than in boys, indicating that boys, at comparable ages, are more coordinated than girls. Similar results were previously observed in Portuguese children, suggesting that these differences could be due to different motor skills refinements, body growth and physical fitness levels between boys and girls . This significant difference between boys’ and girls’ MQ could also be explained by referring to gender stereotypes in PA and sport practice [28, 29]. Sport (i.e., football, athletics, basketball) has a strong masculine connotation, probably favouring males participation and practice in out-of-school settings and therefore their higher performance in motor tests [28, 29]. Moreover, our results revealed that boys had a higher PA level than girls. The higher prevalence of physical inactivity among girls was consistent with results reported by other studies [4, 26]. The low levels of gross motor coordination in combination with low levels of PA in girls suggests that this population needs to be targeted for priority intervention programs to promote PA and sport participation in girls. Northern children showed better gross motor coordination level when compared with Central and Southern children. These results could be explained by good leisure time facilities and the strong emphasis to promote exercise and sport practice in many Northern municipalities , thus providing an environment that could promote children’s active behaviours. In fact, Northern children were the most active, showing the highest PA level than Southern and Central children. Contrarily, Central areas had more barriers to PA due to the lack of safety, green spaces, sports facilities and walkable neighbourhoods that could determine the worst MQ scores of children from the Centre of Italy (Fig. 2) . Moreover, our Northern rural children had the higher MQ than their urban peers, showing an opposite scenario in the South of Italy, where urban children had the higher MQ than their rural peers. These controversial results were in line with results reported in previous studies conducted in different European Countries. Northern rural children scored better in the KTK test battery than their urban peers similarly to Spanish schoolchildren living in rural areas who obtained significantly better results in gross motor competence than children who lived in urban areas.7 Contrarily, Southern urban children showed higher KTK scores than rural children as also reported by Novak et al who showed that middle school Croatian students living in urban areas had better motor abilities than their rural counterparts . It seems that there isn’t a direct and univocal link between the area of residence (geographical area and living setting) and the level of motor coordination. Therefore, children’s gross motor coordination level and its relationship with living setting is a topic that needs to be better investigated, particularly in Italian context.
The most active children were the Northern children. National data showed that the most of active children attends schools where at least 2 hours of weekly PA are performed and where there are initiatives promoting PA . Moreover, school play time could contribute to children’s daily PA levels . In this perspective, school might play a fundamental role to affect PA level and sedentary behaviours in children. The school environment seems to be the ideal setting for the practice of PA, providing to a great number of children opportunities to be physically active during physical education classes and recess . Nevertheless, only 34.5% of the classes from the primary schools of the Centre of Italy attends at least 2 hours of weekly PA, while more than 50% of the classes from the primary schools of the North and the South of Italy attends at least 2 hours of weekly PA (www.epicentro.iss.it/okkioallasalute) . It seems that Italian schools have some barriers, such as the lack of appropriate areas, equipment, and organized activities during the school day,  to give children opportunities to accumulate PA during the school day. Our urban children of the Centre of Italy showed higher PA levels than their rural peers while children of the South of Italy showed higher PA levels than their urban peers (Fig. 3). These conflicting outcomes agreed with other controversial results of PA pattern in rural and urban children and adolescents in the United States .
The second aim of the present study was to analyse the walkability of the different school areas.
Neighbourhoods’ characteristics were investigated by the Walk Score® which is a descriptor of the walkability of different areas. Our results showed that the higher proportion of schools in car-dependent neighbourhoods were in the Centre of Italy. These results were consistent with other Italian reports which showed the low level of walkability in urban areas of the Centre of Italy . These results would emphasize the neighbourhood’s criticalities that limit walkability and could be a basis to support public decisions to intervene in the development of the neighbourhoods aimed at encouraging PA. We defined urban or rural setting by population density. However, most rural schools of the present study were in car-dependent neighbourhoods where most errands require a car, limiting the use of active transportation as walking or biking. Therefore, considering the peculiarity of geographical and built environment characteristics of Italy, a new criterion to distinguish urban from rural areas could be introduced based on Walk Score®.
The present study showed the high incidence of overweight and obesity among Italian children, that could lead health problems as hypertension, cardiovascular, and metabolic diseases [23, 34]. Therefore, to avoid immediate or future health complications, it is fundamental to understand which factors could be related to overweight and obesity in youth. Thus, the last aim of this study was to examine the relationship of Italian children’s weight status with motor competence, PA level, geographical areas, living setting and neighbourhood walkability. The multinomial logistic regression results showed that lower MQ, lower PA level and living in a rural setting were associated with a higher risk for being overweight and/or obese. A Danish study reported similar results showing a significant relationship between body fatness and motor competence. . A previous Italian investigation reported that lower PA level was associated with a higher risk for being obese . The association between rural setting and children’s obesity could be due to their lower socio-economic status  and therefore to the lower possibility to conduct a correct diet composed by healthy food  and to perform organized physical activities . It was demonstrated that rural residency was associated with low levels of PA . Children’s PA levels that could influence children’s weight status were often associated with structural influences, such as the physical environment (e.g. access to facilities, safety of neighbourhoods, weather conditions) . Some environmental investigations showed that neighbourhood walkability and spatial structure of street networks affects PA and weight status condition in children [14, 15]. In our study, living in neither walkable or car-dependent neighbourhoods predicted weight status. However, living in walkable areas is not strictly associated with positive walking behaviours . This inconsistent relationship between walkability and BMI categories suggests conducting future studies to investigate the perceived availability of PA opportunities in youth. It might be possible that children perceived barriers to PA even in areas defined as walkable by an objective descriptor as the Walk Score®. According to the theory of functioning and capabilities, the well-being is not only given by the simple availability of services and resources of an area, but also by the capability of the population to use them . It might be possible that a neighbourhood or a region offers infrastructures or recreational areas where children can be active, but they are not able to use them as real resources.
Finally, although girls of our study had lower gross motor coordination and PA levels than boys, the logistic regression showed that being a girl was associated with a lower risk for being obese. These conflicting results could be explained by the fact that weight status categories were based on children’s BMI. We could speculate that boys had a different body composition, characterized by higher lean body mass than girls, explaining their better gross motor coordination performances. It would be necessary to conduct body composition evaluations in future studies to verify it. However, our results were consistent with scientific literature that observed a higher prevalence of overweight and obesity among boys than girls although boys were more active than girls  who contrarily showed higher sedentary behaviours than boys . Moreover, studies reported gender differences concerning behavioural determinants of overweight and obesity as different eating habits between boys and girls. Girls were more likely to eat healthy than boys, paying more attention to foods, calories intake and nutrients and preferring vegetables and fruits respect to boys .
Some limitations to this research should be noted. Central children were from Lazio region and Southern children were from Sicily region. Future studies should include children from more different regions. In addition, we compared the Metropolitan City of Rome with medium size cities. Future studies should include cities with similar size and population density. We investigated children’s BMI, but we did not have indications regarding their body composition, eating habits, perceived availability of PA opportunities and socio-economic conditions that could influence the weight status. Finally, our data were based on an age-group (8 to 13 years old) that could make difficult to extend our conclusion to younger or older children and adolescents.