Physical Activity, Fitness, Weight Status, and Cognitive Performance

in Adolescents
Jonatan R. Ruiz, PhD, Francisco B. Ortega, PhD, Ruth Castillo, BSc, Miguel Martn-Matillas, PhD, Lydia Kwak, PhD,
German Vicente-Rodrguez, PhD, Jose Noriega, PhD, Pablo Tercedor, PhD, Michael Sjo stro m, MD, PhD,
and Luis A. Moreno, MD, PhD , on behalf of the AVENA Study Group*
Objective To examine the association of participation in physical sports activity during leisure time, sedentary be-
haviors, cardiorespiratory and muscular tness, and weight status with cognitive performance in Spanish adoles-
cents.
Study design This cross-sectional study comprised a total of 1820 adolescents (958 female) aged 13.0 to 18.5
years. Cognitive performance (verbal, numeric and reasoning abilities, and an overall score) was measured with the
SRA-Test of Educational Ability. Participation in physical sports activity during leisure time (yes/no) and time de-
voted to study, television viewing, and playing video games were self-reported and categorized as #3 hours/day
and >3 hours/day. We assessed cardiorespiratory and muscular tness with eld-based tests. Adolescents were
classied as underweight, normal weight, overweight, and obese.
Results Participation in physical sports activities during leisure time was associated with better cognitive perfor-
mance study variables (all P < .001), independent of potential confounders including cardiorespiratory tness and
body mass index. We did not observe an association of time devoted to study, television viewing, or playing video-
games with cognitive performance. Likewise, cognitive performance was similar across cardiorespiratory and mus-
cular tness levels and body weight categories.
Conclusion Participation in physical sports activity during leisure time may positively inuence cognitive perfor-
mance in adolescents. (J Pediatr 2010;157:917-22).
T
here is increasing evidence that regular physical activity has positive effects on brain health and that it delays cognitive
decline in adults.
1
Whether this effect also apply to young people is not clear. Results from cross-sectional studies in-
dicate a positive association between physical activity and academic performance in children.
2,3
Findings from interven-
tional 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.
2,3
Less is known,
however, about the association between physical activity and specic cognitive abilities during adolescence, a period of life
when the brain has profound plasticity.
4
The effect that sedentary behaviors have on cognitive performance is of concern. Increased television viewing time is associ-
ated with worse academic performance in children
5-7
and adolescents,
8
yet play-
ing action video games seems to improve cognitive performance in adults.
9-11
Both cardiorespiratory tness and fatness are considered important health
markers already in both children and adolescents.
12,13
The association between
physical tness and cognitive performance in adolescents is contradictory.
3
Et-
nier et al
14
concluded from a meta-analysis that there is no evidence for an as-
sociation between cardiorespiratory tness and cognitive performance in adults,
whereas Hillman et al
2
provided evidence that cardiorespiratory tness 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.
15-19
From the Department of Medical Physiology, School of
Medicine, University of Granada, Granada, Spain (J.R.,
F.O.); Unit for Preventive Nutrition, Department of
Biosciences and Nutrition at NOVUM, Karolinska
Institutet, Huddinge, Sweden (J.R., F.O, L.K., M.S.);
Department of Basic Psychology, School of Psychology,
University of Malaga, Malaga, Spain (R.C.); Department
of Physical Education and Sport, School of Sport
Sciences, University of Granada, Granada, Spain
(M.M-M., P.T.); Department of Physiotherapy and
Nursing, School of Health and Sport Sciences, University
of Zaragoza, Huesca, Spain (G.V-R.); Department of
Pediatrics, University of Cantabria, Santander, Spain
(J.N.); and Department of Physiotherapy and Nursing,
School of Health Sciences, University of Zaragoza,
Zaragoza, Spain (L.M.)
*List of members of the AVENA Study Group available at
www.jpeds.com (Appendix).
Supported by the Spanish Ministry of Health (FIS no 00/
0015), the Spanish Ministry of Education (grants EX-
2007-1124 and EX-2008-0641), Panrico S.A., Madaus
S.A., Procter and Gamble S.A, the Swedish Council for
Working Life and Social Research (F.S.), the Swedish
Heart-Lung Foundation (20090635), and the Spanish
Ministry of Health: Maternal, Child Health and Develop-
ment Network (RD08/0072). The authors declare no
conicts of interest.
0022-3476/$ - see front matter. Copyright 2010 Mosby Inc.
All rights reserved. 10.1016/j.jpeds.2010.06.026
ANCOVA One-way analysis of covariance
AVENA [Alimentacio n y Valoracio n del Estado Nutricional de los Adolescentes Espan oles]
Food and Assessment of the Nutritional Status of Spanish Adolescents study
BMI Body mass index
CI Condence interval
OR Odds ratio
SD Standard deviation
TEA Test of Educational Ability
VO
2max
Maximum oxygen consumption
917
Most of the aforementioned studies rely on self-reported
data of academic performance, and did not control for po-
tential confounders such as socioeconomic status and family
structure.
20,21
In this study, we examined the association of
participation in physical sports activity during leisure time,
sedentary behaviors (time devoted to study, television view-
ing, and playing videogames), cardiorespiratory and muscu-
lar tness, and weight status with cognitive performance
(including verbal, numeric and reasoning abilities, and an
overall score) in Spanish adolescents. We also examined the
relationships in the studied lifestyle-related factors and how
these contribute to better understand the lifestyle-cognitive
performance associations in adolescents.
Methods
Participants were recruited from the AVENA (Alimentacio n
y Valoracio n del Estado Nutricional de los Adolescentes Es-
panoles [Food and Assessment of the Nutritional Status of
Spanish Adolescents]) study. The AVENA study is a cross-
sectional study that was primarily designed to assess the nu-
tritional status of a representative sample of Spanish adoles-
cents 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). The complete methodology of
the AVENA study has been detailed.
22,23
This study included
adolescents with complete data on cognitive performance (n
= 1820; 958 female). The study sample did not differ fromthe
complete AVENA sample (n = 2894) in any of the demo-
graphic variables (all P > .1).
A comprehensive verbal description of the nature and pur-
pose of the study was given to the parents, school supervisors,
and adolescents. Written consent to participate was re-
quested 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. The study pro-
tocol 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
Marques de Valdecilla (Santander, Spain).
We used the Spanish version of the SRA Test of Educa-
tional Ability (TEA) to assess cognitive performance.
24
This questionaire 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. On the basis of the
age range of our sample, we used levels 2 and 3. The psycho-
metric properties of level 2 TEA test battery showed an inter-
nal 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 cogni-
tive performance. For level 3, internal consistency reliability
was a = 0.74 for the verbal component, a = 0.87 for the nu-
meric component, a = 0.77 for the reasoning component,
and a = 0.89 for overall cognitive performance. The TEA bat-
tery administration is collective and requires 42 and 27 min-
utes for level 2 and 3, respectively.
Verbal ability assesses command of language, verbal iden-
tication, and vocabulary; numeric ability assesses speed and
precision in performing operations with numbers and quan-
titative concepts; and reasoning ability assesses logical ordi-
nation criteria in sets of gures, numbers, or letters. Direct
scores (range, 0-33) were obtained for each of these variables,
and we also computed an overall cognitive performance vari-
able 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).
We 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, we re-coded the variables in two cate-
gories: 0 when #3 hours/day and 1 when >3 hours/day.
25
We assessed cardiorespiratory tness with the 20-minute
shuttle run test. The score was considered as the number of
stages completed (precision of 0.5 stage). We estimated max-
imal oxygen consumption (VO
2max
) (mLO
2
/kg/min) with
the equation reported by Le`ger.
26
Adolescents were classied
in two levels (ie, meeting/not meeting the cardiorespiratory
tness standards) on the basis of the FITNESSGRAM stan-
dards for Healthy Fitness Zone.
27
The FITNESSGRAM stan-
dards are associated with cardiovascular disease risk factors
in children and adolescents,
28,29
and it would be of clinical
and public health importance to understand whether they
are also associated with cognitive performance. This test is
valid and reliable in young people.
30,31
Upper body muscular strength was assessed by means of
the handgrip strength test. The test was performed on both
hands with a hand dynamometer (Takei TKK 5101 Grip-D;
Takey, Tokyo, Japan), standing and with the arm completely
extended. The test was performed twice, and the best score
was retained (in kg). 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. The distance from the takeoff line to the
point where the back of the heel closest to the take-off line
landed on the oor was scored. The result was recorded in
centimeters. The test was performed twice, and the best score
was retained. Adolescents were classied in two levels accord-
ing to their upper and lower body muscular strength levels as
below (low) and above (high) the median. The handgrip
THE JOURNAL OF PEDIATRICS www.jpeds.com Vol. 157, No. 6
918 Ruiz et al
strength and stranding long jump tests are valid and reliable
eld-based tests in children and adolescents.
30-32
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/m
2
). BMI was used as a surrogate marker of total body
fat. Adolescents were classied according to the BMI interna-
tional cutoff values as underweight, normal weight, over-
weight, and obese.
33,34
Parents completed a questionnaire that addressed the ad-
olescents earlier and current health status and socioeco-
nomic status dened 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 classied in 5 cate-
gories of socioeconomic status: low (I), medium-low (II),
medium (III), medium-high (IV), and high (V). We also ob-
tained information on maternal education level (primary,
secondary, or university). There is evidence indicating that
socioeconomic status is one of the most important determi-
nants of childhood cognitive performance.
20
We obtained information about family structure through
the aforementioned questionnaire. Family structure was de-
ned as living with parents or any other arrangement (only
mother, only father, grandparents, others). Family structure
may positively inuence adolescents cognitive perfor-
mance.
21
We assessed pubertal development according to Tanner
and Whitehouse.
35
Self-reported breast development in girls
and genital development in boys was used for pubertal stage
classication.
Statistical Analysis
Data are presented as means and SDs, unless otherwise indi-
cated. Analyses were performed with the Statistical Package
for Social Sciences software version 16.0 for Windows
(SPSS, Chicago, Illinois) and the level of signicance was
set to 0.05.
We analyzed the differences in cognitive performance (in-
cluding verbal, numeric, and reasoning abilities and an over-
all score) between adolescents who participated in physical
sports activity and adolescents who did not with one-way
analysis of covariance (ANCOVA) after adjusting for age
and pubertal status (model 1). We performed a second model
further including socioeconomic status and family structure
as co-variates (model 2). We 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 tness (low versus
high), and weigh status (underweight, normal weight, over-
weight, and obese). Because we did not observe an interac-
tion 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 anal-
yses as a co-variate. We 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 co-
variates in model 2.
We also analyzed the associations in exposures with binary
logistic regression analysis. Further, we determined the dif-
ferences in cardiorespiratory tness, 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.
We calculated the effect size statistics as Cohen d (stan-
dardized 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
Adolescents engaged in physical sports activities during leisure
time had signicantly better cognitive performance that those
who were not (Table I, model 1). The effect size, as determined
withCohen d, ranged from0.25 (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 tness, 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 ndings remained unaltered.
We did not observe an association of time devoted to study,
television viewing, or playing videogames with cognitive
Table I. Cognitive performance by participation in physical sports activity during leisure time in adolescents
Model 1 Model 2
Yes (n = 1053) No (n = 506) P Cohens d (95% CI) Yes (n = 817) No (n = 393) P Cohens d (95% CI)
Overall cognitive
performance (0-99)
54.7 (13.0) 50.1 (13.5) <.001 0.32 (0.221-0.421) 55.0 (14.3) 51.4 (13.9) <.001 0.25 (0.139-0.365)
Verbal ability (0-33) 21.4 (6.5) 19.8 (6.7) <.001 0.25 (0.153-0.353) 21.5 (5.7) 20.4 (5.9) .006 0.18 (0.063-0.289)
Numeric ability (0-33) 14.6 (3.2) 13.1 (4.5) <.001 0.29 (0.191-0.391) 14.8 (5.7) 13.3 (5.8) <.001 0.27 (0.153-0.380)
Reasoning ability (0-33) 18.6 (6.5) 17.2 (6.7) <.001 0.26 (0.160-0.360) 18.8 (5.6) 17.7 (5.7) .003 0.19 (0.076-0.303)
Values are means (SD).
Covariates model 1: sex, age, and pubertal status.
Covariates model 2: model 1 plus socioeconomic status and family structure.
December 2010 ORIGINAL ARTICLES
Physical Activity, Fitness, Weight Status, and Cognitive Performance in Adolescents 919
performance (Table II). Likewise, cardiorespiratory tness
was not associated with cognitive performance (Figure 1;
available at www.jpeds.com). The results did not materially
change when we used a different equation to estimate
cardiorespiratory tness (VO
2max
).
37
Neither upper body
nor lower body muscular strength were associated with
cognitive performance (Figures 2 and 3; available at www.
jpeds.com), and the results persisted after we repeated the
analysis comparing the upper and lower sex- and age-
specic quintiles (data not shown). Cognitive performance
was similar across weight status categories (Figure 4;
available at www.jpeds.com).
We 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 watch-
ing 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 ac-
tivity had better cardiorespiratory and muscular tness levels
compared with those who did not for cardiorespiratory t-
ness (5.9 2.0 versus 4.9 1.9 stages, respectively; P <
.001), standing long jump (177 31 versus 154 28 cm, re-
spectively; P < .001), and handgrip strength (61.1 0.4 ver-
sus 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 study-
ing (0.629; 95% CI, 0.384-1.029). Adolescents who spent <3
hours/day playing video games had a signicantly lower OR
of spending >3 hours/day studying (0.375; 95% CI, 0.147-
0.959).
Levels of cardiorespiratory tness were lower in adoles-
cents who spent >3 hours/day watching television compared
with adolescents who spent #3 hours/day watching televi-
sion (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 ad-
olescents who spent >3 hours/day watching television com-
pared with those who spent #3 hours/day (22.4 3.4
versus 21.5 3.2 kg/m
2
, respectively; P = .002), regardless
of sex, age, and puberty stage.
Adolescents who played videogames for >3 hours/day had
lower cardiorespiratory tness 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 we re-
peated all the analyses in boys and girls separately.
Discussion
Althoughnoconclusioncanbe drawnfromthis cross-sectional
study about whether participation in physical sports activity
during leisure time leads to improvements in cognitive perfor-
mance in adolescents, these ndings are of public health and
clinical interest andextendearlier results that suggestedthe po-
tential benet of physical activity on cognitive performance al-
ready inyouth.
2,3
Adolescence is a period of life when the brain
has profound plasticity because of changes in both structure
and function.
4
Therefore, the pubertal period offers high pos-
sibilities of stimulating cognitive function.
4
The relationship between participation in physical sports
activity and cognitive performance has been a subject of dis-
cussion between advocates and skeptics of physical sports ac-
tivity, 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, we 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.
3
Furthermore,
we also observed that participation in physical sports activity
was associated with lower television viewing and time
Table II. Cognitive performance and sedentary behaviors in adolescents
Model 1 Model 2
3 hours/day >3 hours/day P 3 hours/day <3 hours/day P
Study (n = 1207) (n = 353) (n = 928) (n = 290)
Overall cognitive performance (0-99) 53.3 (13.9) 53.3 (14.3) .969 54.1 (13.7) 53.6 (13.8) .599
Verbal ability (0-33) 20.8 (6.3) 21.2 (6.2) .325 21.1 (6.1) 21.2 (6.1) .711
Numeric ability (0-33) 14.1 (4.9) 14.0 (5.1) .568 14.3 (4.9) 14.1 (4.9) .441
Reasoning ability (0-33) 18.3 (5.6) 18.1 (5.6) .632 18.6 (5.5) 18.2 (5.6) .307
Television viewing (n = 1392) (n = 177) (n = 1096) (n = 125)
Overall cognitive performance 53.3 (13.8) 52.1 (13.3) .255 53.8 (13.6) 54.7 (13.8) .510
Verbal ability 20.9 (6.0) 20.5 (6.3) .341 21.1 (6.0) 21.4 (6.1) .643
Numeric ability 14.1 (4.9) 13.8 (4.9) .484 14.2 (4.6) 14.6 (4.9) .457
Reasoning ability 18.3 (5.6) 17.8 (5.7) .244 18.5 (5.6) 18.7 (5.6) .651
Playing videogames (n = 1483) (n = 85) (n = 1161) (n = 61)
Overall cognitive performance 53.4 (13.9) 51.3 (14.2) .194 53.9 (13.6) 54.7 (13.9) .648
Verbal ability 20.9 (6.2) 20.1 (6.3) .218 21.1 (6.1) 21.0 (6.2) .856
Numeric ability 14.1 (5.0) 13.4 (5.0) .208 14.3 (4.8) 14.7 (4.9) .534
Reasoning ability 18.3 (5.4) 17.8 (5.7) .447 18.5 (5.5) 19.1 (5.6) .439
Covariates model 1: sex, age and pubertal status.
Covariates model 2: model 1 plus socioeconomic status and family structure.
THE JOURNAL OF PEDIATRICS www.jpeds.com Vol. 157, No. 6
920 Ruiz et al
devoted to play video games and with higher levels of cardio-
respiratory and muscular tness. This suggest that physical
sports activity may indirectly prevent the deleterious effects
ascribed to sedentary behaviors
39, 40
and may have an indirect
positive effect on health through its effect on tness. Findings
from intervention studies also reported a positive effect on
tness besides the aforementioned effects on academic per-
formance.
3
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.
41
Collectively, these ndings are particularly important be-
cause of the existing pressure on children and adolescents,
parents, and schools to maximize academic performance.
We 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 be-
cause of the potential effect they may have on health. Indeed,
we observed that both television viewing and playing video
games had a negative effect on cardiorespiratory tness, lower
body muscular strength, and BMI. Several studies reported an
associationbetweenincreasedtelevisionviewing anddecreased
time spent reading and doing homework,
42,43
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 perfor-
mance in children
5-7
and self-reported academic performance
in adolescents.
8
We 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.
44
However, despite this observation, we did not
observe an association between television time and cognitive
performance. Our data do not concur with experimental stud-
ies showing that playing action video games improve cognitive
performance in young adults.
9,10
Differences in the outcome
variable, the participants age, and the study design make com-
parisons between studies difcult.
Cardiorespiratory tness is strongly linked to cardiovascu-
lar disease risk factors in youth.
12,13
Whether it is also associ-
ated with cognitive performance is, however, debated. The
conclusion from a meta-regression analysis was that cardio-
respiratory tness was not associated with cognitive perfor-
mance in adults,
14
which concur with our results, whereas
other studies suggested the opposite in children.
2
Hillman
and co-workers showed in a series of studies that high cardio-
respiratory tness was associated with better cognition in
pre-adolescent children.
19,45,46
Several studies hypothesized
that aerobic tness may mediate the relationship between
physical activity and cognitive performance,
47
whereas other
studies argued that cardiorespiratory tness is a gross
measure of the physiological status and therefore might not
be sensitive enough for one to see any association with cog-
nitive performance.
14
The association between physical
sports activity and cognitive performance observed in this
study persisted after further adjusting for either cardiorespi-
ratory or muscular tness. Whether more precise measure-
ments of both cardiorespiratory tness (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.
45
We did not observe an association between
muscular tness and cognitive performance, which concur
with the results observed by other authors.
19
A limited number of studies have examined whether in-
creased body weight per se is associated with poorer cognitive
performance.
15-19
We did not observe an association between
weight status and cognitive performance, which concurs with
other studies.
17,18
Overweight children and adolescents have
lower cognitive performance than normal-weight ones after
adjusting for a number of potential confounders.
16
Mo-
suwan et al
17
observed an association between overweight
status and poor academic performance in children, but not
in adolescents. Severely obese Chinese children had signi-
cantly lower intelligence quotient than the control subjects.
15
Children with higher cognitive function in early life can be at
decreased risk of overweight years later.
48
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 phys-
ical activity was not recorded. Further research should use
physical activity assessed with objective measures such as ac-
celerometry. We did not have data on watching television
during weekends, which limited the analysis. We also did
not ask what kinds of video games adolescents play. Strengths
of this study include the use of a relatively large national sam-
ple, the inclusion of several potential confounders, and the
use of an objective and standardized measure of cognitive
performance.
Because cognitive performance is potentially modiable
during the pubertal phase,
4
it would be of interest to investi-
gate whether targeted physical activity interventions espe-
cially on individuals with cognitive impairment might
inuence cognitive performance during adolescence and
later in life. n
Submitted for publication Feb 16, 2010; last revision received Apr 30, 2010;
accepted Jun 16, 2010.
Reprint requests: Jonatan R. Ruiz, PhD. Department of Biosciences and
Nutrition, Unit for Preventive Nutrition, Karolinska Institutet, Stockholm,
Sweden, Ha lsova gen 7-9, SE-141 57 Huddinge, Sweden. E-mail: ruizj@ugr.es.
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Appendix
Members of the AVENA Study Group: Coordinator: A.
Marcos, Madrid; principal researchers: M.J. Castillo, Gran-
ada; A. Marcos, Madrid; S. Zamora, Murcia; M. Garca
Fuentes, Santander; M Bueno, Zaragoza.
Granada: M.J. Castillo, M.D. Cano, R. Sola (biochemistry),
A. Gutierrez, J.L. Mesa, J. Ruiz (physical tness), M. Delgado,
P. Tercedor, P. Chillo n (physical activity), F.B. Ortega, M.
Martn, F. Carreno, G.V. Rodrguez, R. Castillo and F.
Arellano (collaborators), Dpto Fisiologa, Universidad de
Granada, E-18071 Granada; Madrid: A. Marcos, M. Gonza -
lez-Gross, J. Warnberg, S. Medina, F. Sa nchez Muniz, E.
Nova, A. Montero, B. de la Rosa, S. Go mez, S. Samartn, J.
Romeo, R. A

lvarez (coordination, immunology), A. A

lvarez
(cytometric analysis), L. Barrios (statistical analysis), A.
Leyva, B. Paya (psychological assessment), L. Martnez, E.
Ramos, R. Ortiz and A. Urzanqui (collaborators), Instituto
de Nutricio n y Bromatologa, Consejo Superior de Investiga-
ciones Cientcas (CSIC), E-28040 Madrid; Murcia: S. Za-
mora, M. Garaulet, F. Perez-Llamas, J.C. Baraza, J.F.
Marn, F. Perez de Heredia, M.A. Ferna ndez, C. Gonza lez,
R. Garca, C. Torralba, E. Donat, E. Morales, M.D. Garca,
J.A. Martnez, J.J. Herna ndez, A. Asensio, F.J. Plaza and
M.J. Lo pez (diet analysis), Dpto Fisiologa, Universidad de
Murcia, E-30100 Murcia; Santander: M. Garca Fuentes, D.
Gonza lez-Lamuno, P. de Runo, R. Perez-Prieto, D. Ferna n-
dez and T. Amigo (genetic study), Dpto Pediatra, Universi-
dad de Cantabria, E- 19003 Santander; Zaragoza: M. Bueno,
L.A. Moreno, A .Sarria , J. Fleta, G. Rodrguez, C.M. Gil, M.I.
Mesana, J.A. Casaju s, V. Blay and M.G. Blay (anthropometric
assessment), Escuela Universitaria de Ciencias de la Salud,
Universidad de Zaragoza, E-50009 Zaragoza.
December 2010 ORIGINAL ARTICLES
Physical Activity, Fitness, Weight Status, and Cognitive Performance in Adolescents 922.e1
Figure 1. Cognitive performance by cardiorespiratory tness categories in adolescents. Values are means and SDs. Cut-off
points are based on the FITNESSGRAM standards for Healthy Fitness Zone.
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922.e2 Ruiz et al
Figure 2. Cognitive performance by upper body muscular strength (handgrip strength) categories in adolescents. Values are
means and SDs. Low and high levels correspond to below and above the median, respectively.
December 2010 ORIGINAL ARTICLES
Physical Activity, Fitness, Weight Status, and Cognitive Performance in Adolescents 922.e3
Figure 3. Cognitive performance by lower body muscular strength (standing broad jump) categories in adolescents. Values are
means and SDs. Lowand high levels correspond to belowand above the median, respectively. Cohens d = 0.19 (95%CI, 0.080-
0.296) for numeric ability.
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922.e4 Ruiz et al
Figure 4. Cognitive performance by BMI categories in adolescents. Analyses are adjusted for sex, age, pubertal status, so-
cioeconomic status, and family structure. Values are means and SDs.
December 2010 ORIGINAL ARTICLES
Physical Activity, Fitness, Weight Status, and Cognitive Performance in Adolescents 922.e5