Download - Obesity and Student Performance at School
Obesity and Student Performance at School Howard Taras, W i l l i am Potts-Datema
ABSTRACT: To review the state of research on the association between obesity among school-aged children und academic outcomes, the authors reviewed published studies investigating obesity, school perjormance, and rates of student absenteeism. A table with brief descriptions of each study’s research methodology and outcomes is included. Research demonstrates that overweight and obesiy are associated with poorer levels of academic achievement. Duta on the association of child overweight or obesity with levels of attendance are too sparse to draw conclusions. (J Sch Health. 2005;75(8):291-295)
n understanding of the impact of student health on A educational outcomes has major implications. Among them are ramifications for how schools address health concerns. The National Coordinating Committee on School Health and Safety (NCCSHS), comprising repre- sentatives of federal departments and national nongovern- mental organizations, encourages school districts to respond to evolving challenges by developing coordinated school health programs. To enhance awareness of existing evidence linking health and school performance and to identify gaps in knowledge, the NCCSHS has begun a pro- ject designed to ascertain the status of research in these areas. The project involves a literature search of peer- reviewed, published research reporting on the relationship between students’ health and their performance in school. Compilations of research articles that explore the associa- tion between academic performance and health include various chronic conditions. This article summarizes what is known on the association of obesity with academic out- comes among school-aged children.
BACKGROUND ON OBESITY The Centers for Disease Control and Prevention (CDC)
reports a rapid 4-fold rise in child and adolescent obesity (ages 6-19) over the past 20 years.’ In fact, the “obesity epidemic” has become front-page news across the country. Obesity is measured most typically using body mass index (BMI), although this method is not perfect because it does not account for increased muscle mass. BMI is calculated as weight in kilograms divided by the square of height in meters. The International Task Force on Obesity has agreed that BMI and BMI percentiles in children are the most practical tools available to define obesity and to screen for
The CDC does not use the term “obesity” for children. The term used is “overweight,” and this is defined as BMI
Howard Taras, MD, Professor; ([email protected]), Division of Commu- nity Pediatrics, University of California, Sun Diego. Gilman Drive #0927, La Jolla, CA 92093-0927; and William Potts-Datema, MS, Director; ([email protected]), Partnerships for Children’s Health, Har- vard School of Public Health, 677 Huntington Ave. 7th Flooc Boston, MA 021 15. This article is I of 6 articles that are part o fa project of the Na- tional Coordinating Committee on School Health and Safety (NCCSHS). This NCCSHS project was funded by the US Department of Health and Human Services, Department qf Education, and US Department of Agri- culture. Opinions expressed in this article are not necessarily shared by these federal agencies or other institutions that comprise NCCSHS member.ship.
at or above the 95th percentile (using Centers for Disease Control and Prevention BMI-for-age growth charts, 2000). The American Obesity Association, a leading organization on education and advocacy related to obesity, defines “overweight” for adolescents (ages 13- 17) as BMI greater than 25 or BMI greater than the 85th percentile, whereas “obesity” is measured as BMI greater than 30 or BMI charted over the 95th percentile. Given the various defini- tions of obesity and the fact that some published studies preceded these definitions, research on obesity and over- weight collected here often do not share common terms or definitions of terms.
Childhood obesity often is accompanied by a parallel rise in type 2 diabete~,~ as well as increased rates of car- diovascular problems (eg, hypertension), hyperlipidemia, obstructive sleep apnea, asthma, orthopedic complications, nonalcoholic fatty liver disease, cancer, psychosocial com- plications, and lower measures of quality of life.5
The reasons for the obesity epidemic are varied and are slowly becoming better understood. During the first 5 years of the 199Os, per capita soft drink consumption increased by 41%. The increase is significant when contrasted with one estimate that the odds of becoming obese increase 1.6 times for each can of a sugar-sweetened beverage consumed every day.6 But as educators, parents, health professionals, and others know, heavily sugared soft drinks and other fast-food items are commonplace in schools. The CDC’s School Health Policies and Programs Study (SHPPS), which sur- veyed state education agencies, school districts, and food service representatives, found in 2000 that one half of all districts had a soft drink contract and that of these, nearly 80% received a specified percentage of the sales receipts. The 2000 SHPPS found that almost two thirds of schools received incentives after sales reached a specified amount.’ One third of schools allowed advertising for foods in their buildings, and 56% of elementary schools and 93% of high schools allowed students to purchase such beverages in vending machines, school stores, canteens, or snack bars8 When various dietary and physical activity habits are exam- ined for their risk of causing a high BMI, insufficient vigor- ous physical activity is the most significant risk factor for adolescent boys and girls.’ Yet, only between 6% and 8% of schools provide the recommended daily physical education or its equivalent for the entire school year.’”
SELECTION OF OBESITY ARTICLES Articles meeting the following criteria were selected
for review: (1) study subjects were school-aged children
Journal of School Health October 2005, Vol. 75, No. 8 291
(5- 18 years), (2) the article was published within the past 10 years (1994-2004) in a peer-reviewed journal, and (3) the research included at least one of the following outcomes-school attendance, academic achievement, or a measure of cognitive ability (such as general intelli- gence, memory). If a full article could not be retrieved, studies with detailed abstracts were included. Many studies cited here had major outcome measures other than those pertinent to the objectives of this project. These alternative outcomes may not be described at all or are briefly mentioned.
LITERATURE REVIEW Articles found and reviewed are summarized in
Table 1. Nine articles examined the link between obesity and school performance, and all demonstrated significant and discouraging associations. Three studies originated in the United States, 3 in Western Europe, 1 in South America, and 2 in Asia. Despite the small number of stud- ies and the differences in outcomes measured by these re- searchers, there are some noteworthy strengths to this small body of research. Results of these studies when taken alto- gether are relatively consistent. Many investigated large populations. Some of the experimental designs controlled for influences of low family income and low levels of par- ent education. This is important because these social fac- tors can independently affect both academic achievement and levels of obesity.” Other assets of this small body of literature are that when taken together, they cover school children of all ages and, not least, that every study found an unfortunate outcome in school performance for children who were overweight or obese.
It has been established that overweight and obese chil- dren are more likely to have low self-esteem and that they have higher rates of anxiety disorders, depression, and other psychopathology.lz-l4 These mental health conditions may be the mediating factors for an overweight or obese child to score poorly in school. Regrettably, the cause and effect for the association between obesity and poor aca- demic performance has not yet been established through research. One large study (Datar et a1 2004) suggests that obesity is a marker, not a cause, of low academic perfor- mance. Theoretically, doing poorly in school may increase the risk of obesity. Mental health problems (eg, low self- esteem or depression) or other factors may predispose children to both overweight/obesity and low school perfor- mance, with no other direct or indirect association between weight and achievement.
The only article that dealt with the association of obe- sity and absenteeism (Schwimmer et a1 2003; Table 1) found that severely obese children and adolescents report many more missed school days than the general student population. The magnitude of missed school days was impressive and almost unbelievable (mean of 4 days per month and median of 1 day per month). Possibly this is because the population under study was not likely a typical population of obese children. These students were referred by a physician to a specialist, specifically for their weight, Additionally, the absenteeism data were derived from
a recall from the previous month. Since these students had at least one recent doctor’s appointment, this may account for the median of 1 day’s absence from school. In this study, control students and obese students had data col- lected in different months of the year and perhaps during different years. As absenteeism varies from year to year and month to month, conclusions drawn from such compar- isons must be interpreted cautiously. What remains is a need for more research that compares absenteeism rates with levels of obesity. One large study of self-reported data from a nationally representative sample of adolescents com- pared BMI to school functioning. Unfortunately, although absence from school was elicited information, it was not separated from 8 other measures of school functioning in the ana1y~is.l~ Questions that need to be asked include the following: Are obese students missing school days because they are embarrassed to participate in physical activities? Are comorbidities with obesity responsible for more missed school days (eg, severe asthrna,l6 obstructive sleep apnea”)? Can an increased risk of being bullied or teased be responsible for missed school among an over- weight population?lm
Despite the current lack of understanding about the directionality of the association between obesity and poor school performance, the fact that there is an associ- ation may be adequate to influence change in school policies and practices. Parents, school board members, and other administrators must grapple with decisions about how to balance the benefits of lucrative district contracts with soft drink companies and of food sales that do not meet United States Department of Agricul- ture (USDA) standards against the benefits of forgoing these practices. Recommendations for daily physical edu- cation and activity at ~ c h o o l ’ ~ ~ ~ ~ ) and strong nutritional educational curriculaz1 are often not followed because they are perceived to supplant time and resources from reading, arithmetic, and other core subjects. These are the dilemmas of school board members and administrators, Knowledge that obesity and overweight may have detri- mental ramifications on current academic performance may tip the balance on how administrators decide on these issues.
CONCLUSION Although the number of articles examining the link
between obesity and school performance is limited, there are notable strengths to this small body of research and consistent findings of detriment to school performance among children who are overweight or obese. One re- search article suggests that obese children and adolescents may miss more school days. There are a great number of gaps in knowledge about the extent of the association between absenteeism and school performance among overweight and obese children. For pure health benefits, perhaps schools’ adherence to stricter physical activity and nutrition recommendations will occur before we fully understand the connection between achievement and obesity.
292 Journal of School Health October 2005, Vol. 75, No. 8
Tabl
e 1
Pub
lishe
d R
esea
rch
Art
icle
s Th
at A
ddre
ss O
besi
ty a
nd E
ither
Stu
dent
Per
form
ance
or
Att
enda
nce
(Con
tinu
ed o
n ne
xt p
age)
Cita
tion
(Ori
gin)
R
esea
rch
Des
ign
Out
com
es R
elat
ed to
Sch
ool P
erfo
rman
ce
Cam
pos
AL,
Sig
ulem
DM
, Mor
aes
DE
, Esc
rivao
AM
, F
isbe
rg M
. Int
ellig
ent q
uotie
nt o
f obe
se c
hild
ren
and
adol
esce
nts
by th
e W
esch
ler s
cale
. Rev
Sau
de
Publ
ica.
199
6;30
( 1):8
5-90
. (B
razi
l)
Dat
ar A
, Stu
rm R
, Mag
nabo
sco J
L. C
hild
hood
ov
erw
eigh
t and
aca
dem
ic p
erfo
rman
ce: n
atio
nal s
tudy
of
kind
erga
rtner
s an
d fir
st-g
rade
rs. O
bes
Res
. 200
4;12
(1):
58-6
8.
(US
A)
Falk
ner N
H, N
eum
ark-
Szt
aine
r D, S
tory
M,
Jeffe
ry R
W, B
euhr
ing
T, R
esni
ck M
D. S
ocia
l, ed
ucat
iona
l, an
d ps
ycho
logi
cal c
orre
late
s of
wei
ght s
tatu
s in
ado
les-
ce
nts.
Obe
s R
es. 2
001 ;
9(1)
:32-
42.
(US
A)
Laiti
nen J
, Pow
er C
, Ek
E, S
ovio
U, J
arve
lin M
R.
Une
mpl
oym
ent a
nd o
besi
ty a
mon
g yo
ung
adul
ts in
a n
orth
ern
Finl
and
1966
birt
h co
hort.
Int J
Obe
s R
elat
Met
ab D
isor
d.
(Fin
land
) Li
X. A
stu
dy o
f int
ellig
ence
and
per
sona
lity i
n ch
ildre
n w
ith s
impl
e ob
esity
. Int
J O
bes
Rel
at M
etab
Dis
ord.
(Chi
na)
2002
;26(
10):1
329-
1338
.
1995
;19(
5):3
55-3
57.
Inte
llect
ual c
hara
cter
istic
s of 6
5 ob
ese
child
ren
(age
s 8-
1 3 y
ears
) wer
e co
mpa
red
to th
ose
of a
con
trol g
roup
(fro
m sa
me
com
mun
ities
) co
mpr
isin
g 35
wel
l-nou
rishe
d, ta
ll (>
95th
per
cent
ile fo
r he
ight
) chi
ldre
n w
ho
had
norm
al w
eigh
ts fo
r the
ir he
ight
. Int
ellig
ence
w
as m
easu
red u
sing
the
WIS
C.
A n
atio
nally
repr
esen
tativ
e sam
ple
of 1
1.00
0 ki
nder
gartn
ers f
rom
the
Ear
ly C
hild
hood
Lo
ngitu
dina
l Stu
dy. T
his
stud
y co
llect
ed p
aren
t, te
ache
r, an
d st
uden
t cha
ract
eris
tics a
t mul
tiple
tim
e po
ints
. Cro
ss-s
ectio
nal a
naly
sis
of th
e re
latio
nshi
p of o
verw
eigh
t and
test
sco
res
was
do
ne a
t sch
ool e
ntry
. Lon
gitu
dina
l regr
essi
on
anal
yses
wer
e pe
rform
ed on
dat
a co
llect
ed la
ter,
cont
rolli
ng fo
r ba
selin
e te
st s
core
s at
sch
ool e
ntry
, to
exa
min
e th
e in
depe
nden
t effe
ct o
f obe
sity
on
acad
emic
ach
ieve
men
t as
a re
sult o
f bei
ng in
sch
ool
10,0
00 s
tude
nts
in 7
th, 9
th, a
nd 1
lth
grad
es;
anon
ymou
s su
rvey
; sel
f-rep
orte
d hei
ghtlw
eigh
t; edu
ca-
tiona
l exp
erie
nces
, and
mor
e. O
verw
eigh
t, >8
5th
perc
en-
tile
BM
I; ob
ese,
>95
th p
erce
ntile
BM
I; ad
just
men
t mad
e fo
r gr
ade,
race
, soc
ioec
onom
ic s
tatu
s.
Long
itudi
nal s
tudy
of a
ppro
x 10
,000
sub
ject
s;
Mea
sure
men
ts w
ere
take
n at
age
s bi
rth, 1
,14,
and
16
year
s.
Sch
ool g
rade
s fro
m n
atio
nal r
egis
ters
; BM
I.
Cro
ss-s
ectio
nal s
tudy
of a
ppro
xim
atel
y
102
obes
e ch
ildre
n (d
efin
ed as
per
cent
age
over
wei
ght
20%
abo
ve s
tand
ard
wei
ght f
or h
eigh
t) m
atch
ed w
ith 1
02
norm
al w
eigh
t chi
ldre
n (fo
r sex
, hei
ght,
and
age)
; age
s 6-
13
year
s; W
ISC
10 t
estin
g do
ne; E
ysen
ck P
erso
nalit
y Q
ues-
tio
nnai
re; s
choo
l rec
ords
of g
rade
s.
Chi
ldre
n w
ith n
orm
al h
eigh
ffwei
ght ra
tios
had
sign
ifica
ntly
bet
ter p
erfo
rman
ce in
IQ th
an
thos
e in
the
obes
e gr
oup,
had
a w
ider
rang
e of
int
eres
ts, b
ette
r cap
acity
for s
ocia
l ada
ptab
ility
, and
gr
eate
r spe
ed a
nd d
exte
rity.
The
re w
as a
w
eak
corr
elat
ion
betw
een
inco
me
leve
l and
IQ
as w
ell.
read
ing
scor
es c
ompa
red w
ith n
onov
erw
eigh
t chi
ldre
n in
ki
nder
garte
n tha
t per
sist
ed th
roug
h en
d of
firs
t gra
de.
The
se c
ould
be
attri
bute
d to
soci
oeco
nom
ic a
nd b
ehav
iora
l va
riabl
es, i
ndic
atin
g th
at o
verw
eigh
t may
be
a m
arke
r, bu
t no
t a c
ausa
l fact
or, o
f low
test
sco
res.
Ove
rwei
ght c
hild
ren
had
sign
ifica
ntly
low
er m
ath
and
Obe
se g
irls
wer
e 1.
5 tim
es m
ore
likel
y to
be h
eld
back
a
grad
e an
d 2.
1 tim
es m
ore
likel
y to
cons
ider
them
selv
es
poor
stu
dent
s co
mpa
red
to a
vera
ge w
eigh
t girl
s. O
bese
bo
ys w
ere
1.5
times
mor
e lik
ely
to c
onsi
der t
hem
selv
es
poor
stu
dent
s, a
nd 2
.2 ti
mes
mor
e lik
ely t
o ex
pect
to q
uit
scho
ol.
scho
ol p
erfo
rman
ce a
t 16
year
s an
d a
low
leve
l of e
duca
- tio
n pe
rsis
ting
until
at l
east
age
31.
Obe
sity
at a
ge 1
4 ye
ars
was
ass
ocia
ted w
ith a
low
Ful
l-sca
le IQ
and
per
form
ance
IQ o
f obe
se c
hild
ren
sign
ifica
ntly
low
er th
an n
orm
al w
eigh
t; "b
lock
des
ign"
and
'o
bjec
t as
sem
bly"
mos
t sig
nific
ant;
low
er v
erba
l IQ
sco
re
not s
igni
fican
t. Con
foun
ding
influ
ence
of m
edic
al p
robl
ems
and
pare
nt e
duca
tion
rule
d ou
t; m
oder
atel
y se
vere
obe
se
(>50
% o
verw
eigh
t) lo
wer
by
aver
age
of 1
1 IQ
poi
nts;
ob
ese
child
ren
had
sign
ifica
ntly
low
er g
rade
s in
6 o
f 8 c
ate-
go
ries
(Chi
nese
, Arit
hmet
ic, F
orei
gn L
angu
age,
Gen
eral
K
now
ledg
e, A
rt, a
nd "G
ym")
.
GP
A, G
rade
poi
nt a
vera
ge; I
Q, I
ntel
ligen
ce qu
otie
nt; W
ISC
, Wec
hsle
r Int
ellig
ence
Sca
le fo
r Chi
ldre
n.
t
0 5 R 5 c
4
a-
0 0 c
CT a- * 2 6 e U
w 0 0
UI $ 4 yl 2
?
Q)
Tabl
e 1
Pu
blis
hed
Res
earc
h A
rtic
les
Th
at A
ddre
ss O
besi
ty a
nd E
ither
Stu
den
t Per
form
ance
or A
ttend
ance
(C
onti
nued
from
pre
vio
us
pag
e)
Cita
tion
(Ori
gin)
R
esea
rch
Des
ign
Out
com
es R
elat
ed to
Sch
ool P
erfo
rman
ce
Mik
kila
V, L
ahti-
Kos
ki M
, Pie
tinen
P, V
irtan
en S
M,
Rim
pela
M. A
ssoc
iate
s of
obe
sity
and
wei
ght d
issa
tisfa
ctio
n am
ong
Finn
ish
adol
esce
nts.
Pub
lic H
ealth
Nuf
r.
(Fin
land
)
Sch
ool p
erfo
rman
ce a
nd w
eigh
t sta
tus
of c
hild
ren
and
youn
g ad
oles
cent
s in
a tr
ansi
tiona
l soc
iety
in T
haila
nd.
lnt J
Obe
s. 1
999;
23:2
72-2
77.
(Tha
iland
)
2OO
3;6( 1
):49-
56.
Mo-
suw
an L
, Leb
el L
, Pue
tpai
boon
A, J
unja
na C
.
Sch
wim
mer
JB, B
urw
inkl
e TM
, Var
ni JW
. H
ealth
-rela
ted
qual
ity o
f life
of s
ever
ely
obes
e ch
ildre
n an
d ad
oles
cent
s. J
AM
A. 2
003;
289(
14):
1813
-181
9.
(US
A)
Sar
gent
JD
, Bla
nchf
low
er D
G. O
besi
ty a
nd s
tatu
re in
ad
oles
cenc
e an
d ea
rnin
gs in
youn
g ad
ulth
ood.
Ana
lysi
s of
a
Brit
ish
birth
coho
rt. A
rch
Ped
iafr
Ado
lesc
Med
. 19
94;1
48(7
):681
-687
. (U
K)
Ters
hako
vec
AM, W
elle
r SC
, Gal
lagh
er P
R. O
besi
ty,
scho
ol p
erfo
rman
ce a
nd b
ehav
iour
of b
lack
, urb
an
elem
enta
ry s
choo
l chi
ldre
n. ln
t J O
bes
Rel
at M
efab
Dis
ord.
19
94;1
8(5)
:323
-327
. (U
SA)
Writ
ten
surv
ey o
f ove
r 60,
000
Finn
ish
adol
esce
nts,
ag
es 1
4-16
yea
rs. O
besi
ty d
efin
ed a
s >1
20%
of s
edhe
ight
sp
ecifi
c m
ean
wei
ght f
or a
ge.
2252
prim
ary
scho
ol c
hild
ren;
sch
ools
rand
omly
se
lect
ed; c
lass
room
s in
sch
ools
rand
omly
sel
ecte
d; w
eigh
t/ he
ight
mea
sure
d; B
MI c
alcu
late
d; o
verw
eigh
t, >8
5th
per-
cent
ile; G
PA s
core
s an
d su
bjec
t sco
res
from
sch
ool r
e-
cord
s; G
PA c
ompa
red
to c
urre
nt w
eigh
t as
wel
l as
to
wei
ght s
tatu
s re
cord
ed 2
yea
rs e
arlie
r. 10
5 ch
ildre
n (a
ges
5-18
) ref
erre
d by
thei
r phy
sici
ans
to
a sp
ecia
lty c
linic
(nut
ritio
n or g
astro
ente
rolo
gy) f
or s
ever
e ob
esity
wer
e st
udie
d with
a h
ealth
-rela
ted
qual
ity of
life
in
vent
ory.
Num
ber o
f day
s of
sch
ool m
isse
d in
pre
viou
s 30
da
ys w
as p
art o
f inv
ento
ry. C
ontro
l gro
up d
ata
wer
e ta
ken
from
800
0 he
alth
y ch
ildre
n fro
m a
noth
er s
tudy
. A
birt
h co
hort
of 1
2,53
7 re
spon
dent
s at a
ge 2
3 ye
ars
(Nat
iona
l Stu
dy o
f all
born
on
Mar
ch 3
-9, 1
958,
in E
ngla
nd
Sco
tland
); su
rvey
; hei
ghts
and
wei
ghts
mea
sure
d; o
besi
ty,
BM
I >95
%.
104
3rd-
and
4th
-gra
de c
hild
ren
in P
hila
delp
hia;
ob
esity
def
ined
as
trice
p sk
info
ld th
ickn
ess
>85t
h pe
rcen
- til
e; s
choo
l rec
ords
pro
vide
d in
form
atio
n on
sch
ool a
bsen
- ce
s an
d pl
acem
ent i
n re
med
ial c
lass
es. P
aren
ts w
ere
also
in
terv
iew
ed b
y te
leph
one
for d
emog
raph
ics,
birt
h w
eigh
t, an
d st
anda
rdiz
ed q
uest
ionn
aire
for a
ttent
ion
diso
rder
s. R
e-
sults
con
trolle
d fo
r birt
h w
eigh
t, ag
e, s
ex, f
amily
inco
me,
an
d sc
hool
abs
ence
s.
Goo
d sc
hool
per
form
ance
was
inve
rsel
y as
soci
ated
w
ith b
eing
obes
e fo
r bot
h bo
ys a
nd g
irls.
Low
GPA
onl
y as
soci
ated
with
cur
rent
wei
ght,
not
wei
ght 2
yea
rs e
arlie
r. S
choo
l per
form
ance
(GP
A) l
ower
in
over
wei
ght c
hild
ren
in g
rade
s 7
thro
ugh
9 (lo
w la
ngua
ge
and
mat
h sc
ores
); as
soci
atio
n no
t fou
nd in
chi
ldre
n in
gr
ades
3 to
6. M
ore
over
wei
ght,
grea
ter r
isk
of lo
w G
PA.
Sev
erel
y ob
ese
child
ren
mis
sed
a m
edia
n of
1 d
ay in
pr
eced
ing
mon
th, a
s co
mpa
red
to 0
day
s fo
r hea
lthy
chil-
dr
en. T
he m
ean
num
ber o
f day
s m
isse
d w
as 4
.2 d
ays
for
seve
rely
obe
se c
hild
ren
and
0.7
days
for h
ealth
y ch
ildre
n.
Men
and
wom
en w
ho h
ad b
een
obes
e at
age
16
had
sign
ifica
ntly
few
er y
ears
of s
choo
ling.
Obe
se w
omen
per
- fo
rmed
poo
rer o
n m
ath
and
read
ing
test
s at
age
s 7,
11,
and
16
; no
sim
ilar a
ssoc
iatio
ns fo
r mal
es.
No
asso
ciat
ion
betw
een
obes
ity a
nd c
lass
room
failu
re,
but o
bese
chi
ldre
n tw
ice
as li
kely
to b
e pl
aced
in s
peci
al
educ
atio
n or
rem
edia
l cla
ss.
GPA
, Gra
de p
oint
ave
rage
; IQ
, Int
ellig
ence
quo
tient
; WIS
C, W
echs
ler I
ntel
ligen
ce S
cale
for C
hild
ren.
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