obesity reviews doi: 10.1111/obr.

12582

Obesity Etiology

The association between obesity and academic

performance in youth: a systematic review

C. C. A. Santana,1 J. O. Hill,2 L. B. Azevedo,3 T. Gunnarsdottir4 and W. L. Prado1,5

1
Physical Education Post Graduate Program, Summary
University of Pernambuco, Recife, Brazil, Previous studies have found that obesity could influence academic performance.
2
Anschutz Center for Health and Wellness, The aim of this study was to systematically review the scientific evidence on the
University of Colorado, Denver, CO, USA, association between obesity and academic performance in school children. A
3
School of Health and Social Care, Teesside systematic review of English articles was undertaken by using databases
University, Middlesbrough, UK, 4 Department of PubMed/Medline, ERIC, LILACS, SciELO and Web of Science. Cross-sectional
Psychiatry, Washington University, St. Louis, and longitudinal studies examining the association between obesity and academic
MO, USA, and 5 Department of Human performance in children and adolescents, published between January 1990 and
Movement Sciences, Federal University of São December 2016, were included. Risk of bias was assessed by using Strengthening
Paulo, Santos, Brazil the Reporting of Observational Studies in Epidemiology. Thirty-four studies (23
cross-sectional and 11 longitudinal) matched all inclusion criteria and were
Received 13 March 2017; revised 22 May included. Seven studies were classified as low risk of bias, 23 as medium risk and
2017; accepted 24 May 2017 four as high risk. After controlling for covariates such as socio-economic status,
parental education and physical activity, the association between obesity and
Address for correspondence: WL Prado, academic performance becomes uncertain for most of the studies (55.9%).
Department of Human Movement Sciences, Therefore, at present, there is insufficient evidence to support a direct link between
Federal University of São Paulo, Silva Jardim obesity and poor academic performance in school age children. In order to clarify
street, 136, 11015-020 Santos, São Paulo, this issue, we need more longitudinal studies with adequate sample sizes and that
Brazil. control for potential confounders.
E-mail: [email protected]
Keywords: Academic achievement, obesity, physical education, students.

Introduction behaviour problems, thus mediating or moderating

children’s academic performance (11–13). It is still unclear
In addition to the well-established harmful effects of obesity whether excess adiposity itself affects academic
on physical health and mortality (1), obesity has also been performance, or if this effect is mediated by other factors
linked to poor academic performance (2,3). Some studies observed in individuals with obesity, such as poor self-
have suggested that individuals with obesity have lower esteem (14), anxiety/depression (15), teasing and social
intelligence quotient (IQ) and exhibit poorer executive rejection (16), poor attendance at school (17) and low
function, memory, attention and motor skills compared with physical fitness (18,19).
normal weight peers (4–8). Successful academic performance To our knowledge, only one review, published more than
is important during the school years and is also a strong a decade ago, examined the association between obesity and
predictor of occupational and social success in adult life (9). academic performance (20). The authors concluded that
Some studies have suggested that adiposity may directly obesity is negatively associated with academic performance.
influence cognition, learning and memory functioning However, the review was not conducted systematically and
(5,10). However, weight-related bias or discrimination, did not assess study quality. The aim of this study was to
commonly experienced by children with obesity, may perform a systematic review on the association between
influence self-esteem by internalizing and externalizing obesity and academic performance in school-aged children.

© 2017 World Obesity Federation Obesity Reviews

2 Obesity and academic performance C. C. A. Santana et al. obesity reviews

Methods Data extraction

This systematic review is reported according to the The following information was extracted: (a) year of
Preferred Reporting Items for Systematic Reviews and publication, (b) study design, (c) location, (d) sample size,
Meta-Analyses criteria (21). (e) age of study population, (f) school year (grade), (g)
independent variables (BMI body composition) and
dependent variable (academic performance), (i) control
Types of studies variables used in the analysis and (j) main finding.

Cross-sectional and longitudinal studies were considered for

this review. The inclusion criteria were studies (1) published Risk of bias
in English; (2) performed with students <20 years – if age
The risk of bias was assessed using the adapted
was missing, school grade was used to verify participant’s
Strengthening the Reporting of Observational Studies in
age; (3) where the main objective was to analyse the
Epidemiology (22) statement according to Lubans et al.
association between obesity and academic performance,
(23). A score of zero (absent or inadequately described) or
where obesity was set as the independent variable and
one (present and explicitly described) was assigned to the
academic performance as the dependent variable; (4) that
following questions: (1) Does the study describe the
used at least one objective measure of the main outcomes
eligibility criteria for participant selection? (2) Are
measured at any follow-up period and (5) published prior
participants randomly chosen from the population? (3)
to December 2016. Review articles, validation studies,
Does the study report the sources and details of the method
conference abstracts, monographs and dissertations were
for measuring academic performance and did the
not included. We also did not include studies conducted
instrument have acceptable reliability? (4) Does the study
with special populations, such as individuals with
report the sources and details of the assessment methods
developmental disabilities, developmental delays, cognitive
for measuring obesity and did the instrument have
impairment or metabolic abnormalities.
acceptable reliability? (5) Does the study report the power
calculation and use a statistical method that is adequate to
test the hypothesis? (6) Does the study report the number
Search strategy of participants for each outcome measurement and does this
A two-phase search strategy was used to identify relevant number represent at least 80% of the total sample? A score
studies. First, electronic data bases were systematically for each article ranged from zero to six points. Studies with
searched: PubMed/Medline, ERIC, LILACS, SciELO and ≤2 were considered high risk of bias, studies that achieved
Web of Science. The search for key-words/terms was three to four points were classified as medium risk and those
performed with the Medical Subject Headings through the that had scores of five to six were classified as low risk of
US National Library of Medicine and Descriptors in Health bias.
Science from the Virtual Health Library (Biblioteca Virtual The level of association between obesity and academic
da Saúde). Search strategies included the combination of achievement was reported as follows: (a) No Association,
variations between two groups of key-words/terms if less than 33% of the studies indicate a significant
including, but not limited to the following examples: (1) association; (b) Uncertain association, if 34% to 59% of
obesity (‘body mass index (BMI)’, ‘body composition’, the studies indicate a significant association; (c) Positive/
‘adiposity’, ‘fatness’, ‘overweight’, ‘weight status’ and ‘body negative association, if 60 to 100% of the studies indicated
fat’) and (2) ‘academic achievement’, ‘academic a significant association (in the same direction); and (d)
performance’, ‘school performance’, ‘educational status’ Strong evidence of positive/negative association, if 60 to
and ‘school attendance’. 100% of the studies indicate a significant association (in
During the second phase, the titles and abstracts for the same direction) and if more than 59% of the studies
potentially relevant articles were screened by two deemed low risk of bias found a significant association (22).
researchers (CCA and LPA) with expertise in the topics
studied. A complete copy of the paper was obtained for
Results
studies that met the initial screening criteria. All of these
papers were examined by two researchers (CCA and LPA),
Study selection
with discrepancies being resolved by discussion. If the
reviewers were unable to reach a consensus, a third Our initial search identified 9,317 papers. After removing
researcher (WLP) was consulted. The references from the duplicates, 9,262 remained. Most (9,200) did not meet the
included studies were examined to identify other potential criteria specified based on the title and abstract. Sixty-two
studies that would meet inclusion criteria for this review. studies were carefully examined. Of these, 28 did not meet

Obesity Reviews © 2017 World Obesity Federation

obesity reviews Obesity and academic performance C. C. A. Santana et al. 3

the inclusion criteria (13 did not use objective measures for Participants
academic performance (13,24–35)), nine were conducted in
The sample size of the studies ranged from 37 to 18.746 and
adults (2,36–43) and six were review studies (44–49)).
included students from kindergarten through high school.
Therefore, 34 studies were included in this systematic
Eight (23.5%) studies did not report age
review (Fig. 1).
(18,50,51,54,66,71,74,76). Studies were conducted in both
genders, except Heshmat et al. (72), which was conducted
only in boys.
Characteristics of included studies
The main characteristics and results of the 34 studies are
presented in Appendix 1 (Supporting information). Half of Dependent variable outcome: academic
the studies (N = 17) were conducted in the USA performance
(10,18,19,50–63). Two studies were conducted in Canada Academic performance was measured by standardized tests
(64,65), and two studies in Colombia (66,67). The other (knowledge in reading, writing, mathematics and general
studies were conducted in Kuwait (68), Portugal (69), UK knowledge) in 29 studies. The others used grades achieved
(70), Taiwan (71), Iran (72), Denmark (73), Korea (74), in those disciplines (60,68,71,74,76). All studies used
Finland (75), Japan (76), Chile (77), Italy (78), Spain (79) reliable measures for academic performance.
and Netherlands (80). Twenty-three studies were cross-
sectional, and 11 studies had longitudinal design.
Independent variable outcomes
Twenty-nine studies directly measured weight and height. In
Risk of bias
two studies, these measurements were self-reported (74,78).
From the 23 cross-sectional studies, four were classified as Three studies did not describe how weight and height
high risk of bias (13,69,76,78), 16 as medium risk of bias measurements were made for calculating BMI (62,70,77).
(10,50,52,54,56,58,60–62,66,67,72–74,76,79) and three Two studies assessed waist circumference (62,77). Body
as low risk of bias (55,59,68). From the 11 longitudinal composition was measured in four studies (one used dual-
studies, seven studies were classified as medium risk of bias energy X-ray absorptiometry (58), one used skinfold
(51,57,63,64,71,75,80), and four as low risk of bias thickness (69) and two used bioelectrical impedance
(18,53,65,70). (59,60). BMI was stratified according to the International

Figure 1 Flow chart of the study selection process.

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4 Obesity and academic performance C. C. A. Santana et al. obesity reviews

Obesity Task Force (81) in five studies (65,69,71,75,80). factors. Five studies had relatively small sample sizes in
One study (72) used Must et al. (82), and one used a relation to others and did not provide information about
national standardized equation (60). Twenty-two studies statistical power (50,60,62,72,78). The sample size of
used Centers for Disease Control and Prevention charts (83) studies that used regression analyses ranged from 37 to
to classify BMI. Bisset et al. (64) used both (Centers for 18,746 students.
Disease Control and Prevention) charts (83) and
International Obesity Task Force (81). Four studies did
not report the criteria for BMI categorization (62,73,77,78). Main findings
Table 1 summarizes the level of scientific evidence for the
associations between obesity and academic performance in
Analysis
school-age children. In summary, according to pre-
Eight studies conducted a random sample of the established criteria, 11/23 cross-sectional studies (47.8%)
population (18,53,54,57,63,65,68,74). Ten studies and 4/11 longitudinal studies (36.3%) reported a negative
reported the statistical power of the analysis association between obesity and academic performance.
(53,55,57,59,64,65,68,70,73,76), while 24 studies did None of the cross-sectional studies (0/4) with low risk of
not report power analyses or sample size calculations bias found a significant association between obesity and
(10,18,19,50–52,56,58,60–64,66,67,69,71,72,74,75,77– academic performance after adjusting for socio-economic
80). Thirteen studies did not report any adjustment for status (SES), ethnicity, age, physical activity level and
potential confounding factors in their analysis (50,55– parental educational level (55,59,68). Two of these studies
57,59,60,62,67,72,75,78–80). conducted with large populations (>1,000 participants)
The association between obesity and academic (59,68) found no association between obesity and academic
performance was assessed by multivariate linear performance after adjusting for parental education and SES.
regression analyses in 16 studies. Half of the 16 cross-sectional studies with a medium risk of
(18,50,52,53,57,58,61,63,66,70,71,73,76–78,80), logistic bias reported a significant negative association between BMI
binomial regression in six studies (52,60,66,68,74,79), and academic performance (50,54,58,60,62,72,74,76).
ordinary least squares in one study (54), structural equation However, two of these studies (62,72) did not adjust the
for mediation in one study (75), analyses of covariance in analysis for confounders and did not report statistical power
four studies (10,56,62,69) and ANOVA in one study (19). calculations. In two of these studies (50,58), the negative
Three studies did simple correlation (50,55,59), and two association remained even after adjustments for age, sex,
did Student’s t-tests (55,72). Five studies provided details IQ, SES and cardiorespiratory fitness. Morita et al. (76)
regarding variable selection (backward or forward) and found that obesity was negatively associated with academic
analysis of the residual distribution in the final model performance only in girls. This association was significant
(18,54,70,71,80). Only Carter et al. (65) performed the final in an unadjusted analysis and after adjustments for physical
model analysis by multicollinearity using variance inflation fitness, SES and sedentary behaviour. Alternatively, Kang

Table 1 Distribution of the studies that investigated cross-sectional and longitudinal associations by risk of bias and the level of scientific evidence

Study design Studies that demonstrated Study by risk Association or no association Level of
association of bias according to study risk of bias evidence

Cross-sectional (n = 23) Yes: 11 (47.8%) Low: 3 (13.0%) Low risk of bias: Yes: 0 (0.0%) Uncertain association
Medium: 16 (68.2%) No: 3 (100.0%)
High: 4 (18.2%) Medium risk of bias: Yes: 8
(50.0%) (negative association)
No: 8 (50.0%)
High risk of bias: Yes: 3 (75.0%)
(negative association) No: 1
(25.0%)
Total: Yes: 11 (47.8%) No: 12
(52.2%)
Longitudinal (n = 11) Yes: 4 (36.3%) Low: 4 (36.3%) Low risk of bias: Yes: 2 (50.0%) Uncertain association
Medium: 7 (63.7%) (negative association)
High: 0 (100.0%) No: 2 (50.0%)
Medium risk of bias: Yes: 2 (28.6%)
(negative association) No: 5 (71.4%)
High risk of bias: 0
Total: Yes: 4 (36.3%) No: 8 (72.7%)

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obesity reviews Obesity and academic performance C. C. A. Santana et al. 5

et al. (74) found a negative association between obesity and between outcomes. Bisset et al. (64) followed 5,754 children
academic performance only in boys, after adjustment for for 3 years and reported that maintaining overweight
father’s education, family income, physical activity, sleeping during mid-childhood was not associated with poorer
time and time spent on electronic devices. Another study academic performance. In a study (65) with an 11-year
(60) showed a negative association between BMI, fatness follow up of 4,647 children from birth to 11 years old, no
and academic performance after controlling the analyses significant association between obesity and academic
for gender, ethnicity and age. However, due to a small sample performance was found.
size (N = 45 students) and weak statistical power, caution
should be used in interpreting these results. Of the remaining
Discussion
eight studies with a medium risk bias, one found a positive
association between obesity and academic performance This systematic review expands a previous review (20) by
(52) and the other seven studies did not find any significant including studies conducted up until 2016 and by including
association (10,56,61,66,67,73,79). a qualitative assessment of the studies. While Taras and
The duration for the longitudinal studies varied Potts-Datema (20) suggested that obesity could be
considerably (from 18 months up to 18 years) (18,57). associated with poor academic performance, our results
Two out of four longitudinal studies with low risk of bias revealed no strong evidence for this association.
reported a significant negative association between BMI Overall, only 15 of the 34 studies that met our criteria
and academic performance (53,70). These studies followed found a significant negative relationship between obesity
more than 5,000 children for 5 (53) and 6 years (70). The and academic performance. Eleven of the 23 cross-
results revealed that children with obesity, or who became sectional studies and four of the 11 longitudinal studies
obese during childhood, had lower academic performance reported a significant negative relationship between
compared with normal weight children. In the study of obesity and academic performance. When considering
Booth et al. (70) a strong association between obesity and study quality, 2/8 studies with low risk of bias and
academic performance was found in girls after adjusting 9/23 studies with medium risk of bias reported a
for birth weight, maternal smoking during pregnancy, SES, significant negative relationship between obesity and
physical activity and pubertal status. In boys, obesity was academic performance. When controlled for covariates
not significantly associated with academic performance. such as SES, parental education, physical activity,
From the seven longitudinal studies with medium risk of sedentary behaviour and health-related risk factors, the
bias, one study reported a negative association between association between obesity and academic performance
overweight and academic performance in girls only. This was weakened or disappeared (10,18,54,55,58,59,62,67–
study followed 7,000 children for up to 4 years (51). 69). While insufficient data exist to support a significant
Another study with medium risk of bias followed 8,061 relationship between obesity and academic performance,
children for 8 years and reported that academic more high-quality studies are needed to bring greater
performance might have been mediated by obesity (75). clarity to the issue.
Seven longitudinal studies, including two with low risk
and five with medium risk of bias did not find association
Outcome assessments
between obesity and academic performance when
controlling for parental education screen time, family, Academic performance is highly dependent on the
school and teacher characteristics, SES and maternal instrument used to quantify academic achievement. In the
education (18,57,63–65,71,80). Chen et al. (71) followed current literature, several different tools have been used
409 children for 6 years. Only gender was controlled in for measuring this outcome, ranging from teacher-reported
the model, since the authors considered the sample size classroom behaviour, teacher-reported children’s effort,
insufficient for conducting additional analyses. Veldwijk overall grades and standardized tests. The variability in
et al. (80) followed 2,159 children for 4 years and did not measurement tools makes it difficult to compare between
find a significant association between obesity and academic studies.
performance after the analysis was adjusted for parental Obesity is supposed to affect children’s cognitive
education, skipping breakfast and screen time. Zavodny function, which comprises attention and set shifting
(63) followed 15,795 children for 7 years, and Kaestner (84,85), inhibitory control (86), abstract reasoning and
and Grossman (57) followed 2,500 for 7 years. Neither visual–spatial organization (5). Different methods are
study found any significant association between obesity appropriate for specific cognitive functions, which may
and academic performance after adjustments for family, explain the lack of agreement among studies. Many of the
and child characteristics. test items that comprise standardized tests of academic
Datar et al. (18) followed 11,192 children for up to performance are impacted by processing speed and rapid
18 months and did not report a significant association decision-making, processes known to be negatively related

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6 Obesity and academic performance C. C. A. Santana et al. obesity reviews

to obesity (87). The results of studies using standardized conclusions about causality could be made. Additional
tests that focus on specific aspects of performance, such as limitations of the literature include reliance on BMI as a
math or reading skills, tend to be more precise than tests proxy measure of adiposity since only one study used
that are more global in nature. The development of a ‘gold DXA, which is considered the gold standard of adiposity
standard’ measurement method would help our ability to measurement.
study the association between obesity and academic
performance.
Another point to consider is that the effects of obesity on Conclusions
children’s academic performance may be only observed
Through a rigorous and comprehensive systematic review
later in life (24,88). The causal processes linking academic
including qualitative evaluation of the studies, we
performance and obesity differ between the development
concluded that there is not strong evidence to support the
stages. The studies included in this review studied children
association between obesity and poor academic
from different ages, grades and weight history. Future
performance in school age children. The evidence in this
studies should assess the impact of early onset obesity on
area is limited by a preponderance of cross-sectional studies,
later academic performance.
failure to adjust for confounding factors and absence of
adequate power analyses. Overall, the balance of evidence
Influence of confounders suggests that while obesity may be related academic
performance, it is not possible from existing published
Many variables could influence the association between
research to determine if there is a causality link between
obesity and academic performance
the two.
(18,54,56,59,63,64,67,68,80). Gurley-Calvez and
As the nature and impact of childhood obesity on
Higginbotham (54) suggested that SES could moderate this
children’s development continue to be studied, the
association. Race/ethnicity and mother’s education may be
development and assessment of more comprehensive
stronger predictors of academic performance than obesity
conceptual and assessment models are needed. Identifying
(67). Body characteristics (such as obesity) are more likely
effective models for evaluating children’s obesity and
to be noticed by children than socio-economic
academic performance would be beneficial for researchers,
characteristics, suggesting that obesity stigma per se could
clinicians, school representatives, families and policies
affect overweight children’s academic performance (18).
makers.
Few studies have controlled the analysis for physical
activity/physical fitness (10,18,51,59,61,68,70,73,75–77).
There is some evidence that physical activity/physical fitness
may positively modulate cognition and academic
Acknowledgements
performance (16,67), as children with obesity are more This work was supported by the Coordination for the
likely to have low physical activity level and physical fitness Improvement of Higher Education Personnel (CAPES).
(89,90).

Reporting effect size Conflict of interest statement

Only one study (62) presented the effect size of the No conflict of interest was declared.
association between obesity and academic performance.
This study showed a small effect size in the association Supporting information
between obesity and spelling skills ( 0.28) and medium
effect between obesity and arithmetic ( 0.60). The lack of Additional Supporting Information may be found online in
reported effect sizes in the included studies limits the the supporting information tab for this article. https://doi.
estimation of the magnitude of association. org/10.1111/obr.12582

Appendix 1. Main results of studies about the association

Limitations between obesity and academic performance in children
and adolescents.
The present study has some limitations that should be
considered. A literature search was performed only in
journals indexed in the electronic databases
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