KINE-4301 Javier Alvarez

Dr. Conatser 11/17/2022

Physical Activity and Cognitive Functioning of Children

Introduction (who, what how)
 There is increasing evidence that regular physical activity has positive effects on brain
health and that it delays cognitive decline in adults. Whether or not this effect also
applies to young people is not clear.
 Results from cross-sectional studies indicate a positive association between physical
activity and academic performance in children. Findings from interventional studies
also show that children in the physical activity intervention group have at least similar
academic performance compared with children in the control group, despite a
substantial reduction in time devoted to academics.
 Less is known, however, about the association between physical activity and specific
cognitive abilities during adolescence, a period of life when the brain has profound
plasticity.
 The effect that sedentary behaviors have on cognitive performance is a focus of the
study and something that should be of concern.
 Increased television viewing time is associated with worse academic performance in
children and adolescents yet playing action video games seems to improve cognitive
performance in adults.
 Both cardiorespiratory fitness and fatness are considered important health markers
already in both children and adolescents. The association between physical fitness and
cognitive performance in adolescents is contradictory.
 One study concluded from a meta-analysis that there is no evidence for an association
between cardiorespiratory fitness and cognitive performance in adults, where another
provided evidence that cardiorespiratory fitness can have a positive effect on
cognitive performance, at least in pre-pubertal children.
 The association between overweight or obesity and cognitive performance in youth is
also inconclusive
Purpose (why)
 To examine the association of participation in physical sports activity during leisure
time, sedentary behaviors, cardiorespiratory and muscular fitness, and weight status
with cognitive performance in Spanish adolescents.
 Most of the studies prior to this one relied on self-reported data of academic
performance and did not control for potential confounders such as socioeconomic
status and family structure.
 In this study, researchers examined the association of participation in physical sports
activity during leisure time, sedentary behaviors (time devoted to study, television
viewing, and playing videogames), cardiorespiratory and muscular fitness, and weight
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Dr. Conatser 11/17/2022

status with cognitive performance (including verbal, numeric and reasoning abilities,
and an overall score) in Spanish adolescents.
 Researchers also examined the relationships in the studied lifestyle-related factors and
how these contribute to better understand the lifestyle-cognitive performance
associations in adolescents.
Method (step by step of how data was collected)
Participant Selection/Inclusion
 Participants were recruited from the AVENA (Alimentacio ́n y Valoracio ́n del Estado
Nutricional de los Adolescentes Españoles [Food and Assessment of the Nutritional
Status of Spanish Adolescents]) study. The AVENA study is a crosssectional study
that was primarily designed to assess the nutritional status of a representative sample
of Spanish adolescents aged 13.0 to 18.5 years.
 Data collection took place from 2000 to 2002 in 5 Spanish cities (Madrid, Murcia,
Granada, Santander, and Zaragoza). This study included adolescents with complete
data on cognitive performance (n = 1820; 958 female).
 A comprehensive verbal description of the nature and purpose of the study was given
to the parents, school supervisors, and adolescents. Written consent to participate was
requested from both parents and adolescents.
 Adolescents with a personal history of cardiovascular disease or cognitive
dysfunction, who were taking medication at the time of the study, or who were
pregnant, were excluded.
Guidelines/Cognitive Assessment
 The study protocol was performed in accordance with the ethical standards laid down
in the 1961 Declaration of Helsinki (as revised in 2000) and approved by the Review
Committee for Research Involving Human Subjects of the Hospital Universitario
Marque ́s de Valdecilla.
 Researchers used the Spanish version of the ‘‘SRA Test of Educational Ability’’ to
assess cognitive performance. This questionnaire assesses intelligence with 3 basics
school skills: verbal, numeric, and reasoning.
 The TEA test battery provides 3 complexity levels: level 1 for children aged 8 to 12
years, level 2 for children aged 11 to 14 years, and level 3 for adolescents aged 14 to
18 years. Based on the age range of the researchers sample they used levels 2 and 3.
 The psychometric properties of level 2 TEA test battery showed an internal
consistency reliability of a = 0.78 for the verbal component, a = 0.83 for the numeric
component, a = 0.88 for the reasoning component, and a = 0.92 for overall cognitive
performance. For level 3, internal consistency reliability was a = 0.74 for the verbal
component, a = 0.87 for the numeric component, a = 0.77 for the reasoning
component, and a = 0.89 for overall cognitive performance.
KINE-4301 Javier Alvarez
Dr. Conatser 11/17/2022

 The TEA battery administration is collective and requires 42 and 27 minutes for level
2 and 3, respectively.
 Verbal ability assesses command of language, verbal identification, and vocabulary;
numeric ability assesses speed and precision in performing operations with numbers
and quantitative concepts; and reasoning ability assesses logical ordination criteria in
sets of figures, numbers, or letters.
 Direct scores (range, 0-33) were obtained for each of these variables, and researchers
also computed an overall cognitive performance variable by summing the individual
scores of the 3 items (range, 0-99).
 The adolescents answered the following question: ‘‘Do you practice any type of
physical sports activity outside the school time?’’ The possible answers were yes
(coded as 1) or no (coded as 0).
 Researchers obtained the information about time devoted to study and time spent in
television viewing and playing video games from the following questions: ‘‘How
many hours a day do you do homework or study?’’ ‘‘How many hours a day do you
watch television?’’ and ‘‘How many hours a day do you play videogames?’’ Possible
answers were 0 = none, 1 = <30 minutes, 2 = <1 hour, 3 = 1 to 3 hours, 4 = >3 to 4
hours, 5 = >4 hours.
 Because of the relatively small sample size in each single category, researchers re-
coded the variables in two categories: 0 when ≤3 hours/day and 1 when >3 hours/day.
Physical Ability Tests
 Researchers assessed cardiorespiratory fitness with the 20-minute shuttle run test. The
score was considered as the number of stages completed (precision of 0.5 stage).
Researchers estimated maximal oxygen consumption (VO2max) (mLO2/kg/min) with
the equation reported by Léger.
 Adolescents were classified in two levels (meeting/not meeting the cardiorespiratory
fitness standards) based on the FITNESSGRAM standards for Healthy Fitness Zone.
The FITNESSGRAM standards are associated with cardiovascular disease risk
factors in children and adolescents, and it would be of clinical and public health
importance to understand whether they are also associated with cognitive
performance.
 Upper body muscular strength was assessed by means of the handgrip strength test.
The test was performed on both hands with a hand dynamometer, standing and with
the arm completely extended.
 The test was performed twice, and the best score was retained. The sum of the right
and left hand was used in the analysis.
 Lower body muscular strength was assessed by means of the standing long jump test.
The participants were instructed to push off vigorously and jump as far forward as
possible, trying to land on both feet.
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Dr. Conatser 11/17/2022

 The distance from the takeoff line to the point where the back of the heel closest to
the takeoff line landed on the floor was scored. The result was recorded in
centimeters. The test was performed twice, and the best score was retained.
 Adolescents were then classified in two levels according to their upper and lower
body muscular strength levels as below and above the median.
 Weight and height were measured following standardized procedures, and body mass
index (BMI) was calculated as weight in kilograms divided by square of height in
meters (kg/m2).
 BMI was used as a surrogate marker of total body fat. Adolescents were classified
according to the BMI international cutoff values as underweight, normal weight,
overweight, and obese.
 Parents completed a questionnaire that addressed the adolescents’ earlier and current
health status and socioeconomic status defined as the educational level and
occupation of the father. According to this information and following the
recommendation of the Spanish Society for Epidemiology, the adolescents were
classified in 5 categories of socioeconomic status: low (I), medium-low (II), medium
(III), medium-high (IV), and high (V).
 Researchers also obtained information on maternal education level (primary,
secondary, or university). There is evidence indicating that socioeconomic status is
one of the most important determinants of childhood cognitive performance.
Researchers obtained information about family structure through the questionnaire.
Family structure was defined as living with parents or any other arrangement (only
mother, only father, grandparents, others). Family structure may positively influence
adolescents’ cognitive performance. Researchers assessed pubertal development
according to Tanner and Whitehouse. Self-reported breast development in girls and
genital development in boys was used for pubertal stage classification.

Quantitative (Discuss statistics, charts, tables, etc.)

 Data are presented as means and SDs, unless otherwise indicated. Analyses were
performed with the Statistical Package for Social Sciences software version 16.0 for
Windows (SPSS, Chicago, Illinois) and the level of significance was set to 0.05.
 Researchers analyzed the differences in cognitive performance (including verbal,
numeric, and reasoning abilities and an overall score) between adolescents who
participated in physical sports activity and adolescents who did not with one-way
analysis of covariance after adjusting for age and pubertal status.
 Researchers performed a second model further including socioeconomic status and
family structure as co-variates. Researchers repeated the same model for the other
exposures (ie, watching television, playing videogames, and time devoted to study ≤3
hours/day versus >3 hours/day), cardiorespiratory and muscular fitness (low versus
high), and weigh status (underweight, normal weight, overweight, and obese).
KINE-4301 Javier Alvarez
Dr. Conatser 11/17/2022

 Because researchers did not observe an interaction effect between sex * exposure
variables and cognitive performance (all P > .2), all the analyses were performed with
boys and girls together and sex was included in the analyses as a co-variate.
Researchers performed separate models for each main exposure, and sex, age and
pubertal status were always retained as co-variates (in model 1), whereas
socioeconomic status and family structure were additionally included as covariates in
model 2. Researchers also analyzed the associations in exposures with binary logistic
regression analysis. Further, researchers determined the differences in
cardiorespiratory fitness, muscular strength, and BMI among adolescents who
participated in physical sports activity, those who did not, and those spending >3
hours/day watching television or playing videogames with AN-COVA. All the
models included sex, age, and pubertal status as co-variates. Researchers calculated
the effect size statistics as Cohen d (standardized mean differences) and 95% CI.36
Values of d equal to 0.2, 0.5, and 0.8 are considered small, medium, and large effects,
respectively
Results and Discussion
 Adolescents engaged in physical sports activities during leisure time had significantly
better cognitive performance that those who were not (Table I, model 1). The effect
size, as determined with Cohen d, ranged from 0.25 (verbal ability) to 0.32 (overall
cognitive performance). The results did not change when socioeconomic status and
family structure were entered in the model (Table I, model 2). Further adjustments for
cardiorespiratory fitness, BMI, and television viewing (or video games or time
devoted to study) did not materially modify the results (data not shown). Similarly,
when maternal educational status was used instead of socioeconomic status, the
findings remained unaltered. Researchers did not observe an association of time
devoted to study, television viewing, or playing videogames with cognitive
performance (Table II). Likewise, cardiorespiratory fitness was not associated with
cognitive performance (Figure 1; available at www.jpeds.com). The results did not
materially change when researchers used a different equation to estimate
cardiorespiratory fitness (VO2max). Neither upper body nor lower body muscular
strength were associated with cognitive performance and the results persisted after
researchers repeated the analysis comparing the upper and lower sex- and age-specific
quintiles (data not shown). Cognitive performance was similar across weight status
categories. Researchers did not observe an association between physical sports
activity and time devoted to study (odds ratio [OR], 0.818; 95% CI, 0.630-1.064).
Participation in physical sports activity during leisure time was associated with a
lower OR of watching television for >3 hours/day (0.631; 95% CI, 0.445-0.894) and
playing videogames for >3 hours/day (0.533; 95% CI, 0.320-0.887). Adolescents
participating in physical sports activity had better cardiorespiratory and muscular
fitness levels compared with those who did not for cardiorespiratory fitness (5.9 2.0
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Dr. Conatser 11/17/2022

versus 4.9 - 1.9 stages, respectively; P < .001), standing long jump (177 - 31 versus
154 - 28 cm, respectively; P < .001), and handgrip strength (61.1 - 0.4 versus 59.6 -
0.5 cm, respectively; P = .023). BMI did not differ in physical sports activity
categories (P = .606). Adolescents who spent >3 hours/day watching television tended
to have a lower OR of spending >3 hours/day studying (0.629; 95% CI, 0.384-1.029).
Adolescents who spent ≤3 hours/day playing video games had a significantly lower
OR of spending >3 hours/day studying (0.375; 95% CI, 0.147-0.959). Levels of
cardiorespiratory fitness were lower in adolescents who spent >3 hours/day watching
television compared with adolescents who spent ≤3 hours/day watching television
(4.9 - 1.3 versus 5.6 - 2.1 stages, respectively; P < .001) and so were standing long
jump levels (162 - 31 versus 169 - 32 cm, respectively; P = .019). BMI was higher in
adolescents who spent >3 hours/day watching television compared with those who
spent ≤3 hours/day (22.4 - 3.4versus 21.5 - 3.2 kg/m2, respectively; P = .002),
regardless of sex, age, and puberty stage. Adolescents who played videogames for >3
hours/day had lower cardiorespiratory fitness compared with their peers who spent
≤3 hours/day (4.5 - 1.0 versus 5.6 -2.2 stages, respectively; P < .001). The results
were similar when researchers repeated all the analyses in boys and girls separately.
Conclusion
 Participation in physical sports activity during leisure time may positively influence
cognitive performance in adolescents.
 The relationship between participation in physical sports activity and cognitive
performance has been a subject of discussion between advocates and skeptics of
physical sports activity, and especially in parents concerned about decreases in study
and homework time. The assumption is based on the participation in physical sports
activity may ‘‘displace’’ time that would normally be spent doing schoolwork,
reading for pleasure, or engaging in other educational activities. In this study,
researchers observed that participation in physical sports activity is not associated
with lower time devoted to study. This concurs with intervention studies that
indicated that children enrolled in more physical sports activity do not have poorer
academic performance, despite a reduction in time in the so-called ‘‘academic
subjects.’’ Furthermore, researchers also observed that participation in physical sports
activity was associated with lower television viewing and time devoted to play video
games and with higher levels of cardio-respiratory and muscular fitness. This suggest
that physical sports activity may indirectly prevent the deleterious effects ascribed to
sedentary behaviors39, 40 and may have an indirect positive effect on health through
its effect on fitness. Findings from intervention studies also reported a positive effect
on fitness besides the effects on academic performance. Even single bouts of physical
activity (20 minutes of aerobic exercise at 60% of estimated maximum heart rate)
may improve cognitive control and attention in children. Collectively, these findings
are particularly important because of the existing pressure on children and
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Dr. Conatser 11/17/2022

adolescents, parents, and schools to maximize academic performance. Researchers do

not know whether sports participation is a marker of adolescents who are high
achievers and who do better in this type of cognitive tests. Moreover, whether
adolescents who persist in sports activity have other characteristics that allow them to
perform well on cognitive tests remains to be elucidated. There is increasing concern
about the amount of time that youth spend watching television or playing video
games because of the potential effect they may have on health. Indeed, researchers
observed that both television viewing and playing video games had a negative effect
on cardiorespiratory fitness, lower body muscular strength, and BMI. Several studies
reported an association between increased television viewing and decreased time
spent reading and doing homework, which in turn may affect academic performance.
Results from cross-sectional and longitudinal studies reported that increased
television time had a detrimental impact on academic performance in children and
self-reported academic performance in adolescents. Researchers observed that
adolescents who spent more time watching television or playing video games devoted
less time to study, which concurs with the so called ‘‘displacement hypothesis.’’
However, despite this observation, researchers did not observe an association between
television time and cognitive performance. Our data do not concur with experimental
studies showing that playing action video games improve cognitive performance in
young adults. Differences in the outcome variable, the participants’ age, and the study
design make comparisons between studies difficult. Cardiorespiratory fitness is
strongly linked to cardiovascular disease risk factors in youth. Whether it is also
associated with cognitive performance is, however, debated. The conclusion from a
meta-regression analysis was that cardio-respiratory fitness was not associated with
cognitive performance in adults, which concur with their results, whereas other
studies suggested the opposite in children. Hillman and co-workers showed in a series
of studies that high cardio- respiratory fitness was associated with better cognition in
pre-adolescent children. Several studies hypothesized that aerobic fitness may
mediate the relationship between physical activity and cognitive performance,
whereas other studies argued that cardiorespiratory fitness is a ‘‘gross’’ measure of
the physiological status and therefore might not be sensitive enough for one to see any
association with cognitive performance. The association between physical sports
activity and cognitive performance observed in this study persisted after further
adjusting for either cardiorespiratory or muscular fitness. Whether more precise
measurements of both cardiorespiratory fitness (ie, directly measured maximum
oxygen consumption) and cognitive function (eg, electroencephalogram, neuroelectric
activity) would yield to a different results in adolescents remains to be investigated.
Researchers did not observe an association between muscular fitness and cognitive
performance, which concur with the results observed by other authors. A limited
number of studies have examined whether increased body weight per se is associated
with poorer cognitive performance. Researchers did not observe an association
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Dr. Conatser 11/17/2022

between weight status and cognitive performance, which concurs with other studies.
Overweight children and adolescents have lower cognitive performance than normal-
weight ones after adjusting for several potential confounders. One article observed an
association between overweight status and poor academic performance in children,
but not in adolescents. Severely obese Chinese children had significantly lower
intelligence quotient than the control subjects. Children with higher cognitive
function in early life can be at decreased risk of overweight years later. Limitations of
this study include its cross-sectional design, which precludes drawing conclusions on
the direction of the associations. A second limitation relies on the use of a self-
reported measure of physical sports activity. Moreover, this study focused only on
sports-related activity, and therefore, the duration of the participation and other
leisure time physical activity was not recorded. Further research should use physical
activity assessed with objective measures such as accelerometry. Researchers did not
have data on watching television during weekends, which limited the analysis.
Researchers also did not ask what kinds of video games adolescents play. Strengths of
this study include the use of a relatively large national sample, the inclusion of several
potential confounders, and the use of an objective and standardized measure of
cognitive performance. Because cognitive performance is potentially modifiable
during the pubertal phase, it would be of interest to investigate whether targeted
physical activity interventions especially on individuals with cognitive impairment
might influence cognitive performance during adolescence and later in life.
Practical Application towards my field of interest
 All this information is pertinent to my field of interest which is physical therapy.
 When helping an individual, particularly youth, recover from an injury affecting their
muscular performance it is important to understand what factors affect their ability to
build muscle/physical endurance.
 The cognitive function of an individual is also important to an individual’s response
to a given regimen/recovery plan. Understanding all these factors that influence not
only the physical ability, but cognitive ability is important to creating an effective
plan of recovery and environment for the recovery to occur in.
 The article highlights the need for awareness of the connection between screen time
and the fitness level of adolescents.
Class discussion questions
 What are the three ways in which physical activity ability was assessed?
 What are the areas in which physical activity was assessed?
 What is the guideline used to determine standards for the Healthy Fitness Zone in
adolescents?
KINE-4301 Javier Alvarez
Dr. Conatser 11/17/2022

 What is the general conclusion of the effects of sedentary behaviors on

cardiorespiratory and muscular fitness in relation to cognitive ability?