The Associations between Childhood Obesity,Academic Performance,and Perception of Teachers: From Kindergarten to Fifth Grade

Abstract

Background:

Obesity is weakly associated with negative academic achievement among school-aged children. The purpose of this study is to demonstrate the relationships between reading/mathematics scores (objective) and teachers' perception of learning ability (subjective) and childhood obesity—from kindergarten to fifth grade.

Methods:

This study examined a longitudinal study of a nationally representative sample of 18,174 children who were enrolled in kindergarten in 2010 in the United States (ECLS-K:2011). Weighted multiple logistic regression models were used to examine the associations between objective scores, subjective scores, and obesity (vs. healthy-weight children).

Results:

In the crude analyses, obesity was negatively associated with achieving above-median reading and mathematics scores. After adjusting for sex, race/ethnicity, age, and socioeconomic status (SES), the association weakened but was still present. Children with obesity were less likely to achieve above-median reading and mathematics scores than their healthy-weight peers (odds ratio [OR] 0.77 and 0.86 for reading; OR 0.85, 0.67, 0.79, 0.82, and 0.75 for mathematics). Similarly, teachers reported that children with obesity did not have Approaches to Learning and Attentional Focusing as good as their healthy-weight peers regardless of their objective test scores and SES (OR 0.82, 0.80, 0.78, 0.69, and 0.77 for Approaches to Learning; OR 0.80, 0.81, 0.83, 0.82, 0.80, and 0.74 for Attentional Focusing).

Conclusions:

Obesity during elementary school years is negatively associated with both objective and subjective measures of academic performance. Further studies are needed to understand if the connection is stemming from behavioral issues of children, weight-based bias of teachers, or both.

Introduction

The prevalence of childhood obesity has increased significantly during the last two decades; now, obesity affects approximately one out of five children 2–19 years of age in the United States.^1,2 The socioeconomic status (SES) gap in obesity was also significant. During 2011–2014, the prevalence of childhood obesity among the lowest income group (18.9%) was almost twice that of the highest income group (10.9%).¹

In addition to many adverse health effects of obesity, poor academic performance has been linked to obesity^3–8; several review articles have addressed the connection in children and adolescents.^8–11 One review of 34 studies (of which 11 were longitudinal) concluded that the connection between the two was not strong enough in school-aged children.¹⁰ A review of 31 longitudinal studies also found the association between obesity and academic achievement to be mostly weak; the review further hypothesized that weight-related bullying contributed to the negative association among adolescent girls' mathematics attainment.⁸ Another review of 29 studies suggested a weak negative association between educational attainment and obesity—and found SES to be a significant moderator between the two.⁹ However, the reviews indicated that many studies lacked proper SES adjustments.^9,10

The reviews for longitudinal studies also found that the association between educational achievement and obesity was only significant among adolescents and young adults and not in younger children.^8,10 In middle schools and colleges, students experiencing obesity received significantly lower grades than healthy-weight students who had similar test scores.^12,13 Nevertheless, obesity has been associated with poorer cognitive functioning; including attention, set shifting, inhibitory control, abstract reasoning, and visual-spatial organization^10,14–18; obesity may affect academic achievement at a younger age, independent of SES.

Zavodny¹⁹ examined the relationships between children's weight and their scores on standardized tests as well as their teacher's assessments of academic ability using a nationally representative cohort of kindergarteners (Early Childhood Longitudinal Study [ECLS-K]) in 1998–1999. The study showed that children with obesity showed lower reading and mathematics test scores than healthy-weight children from kindergarten to eighth grade, even after adjusting for SES factors.¹⁹ In this cohort, teachers also rated reading and mathematics performance more negatively for children with obesity compared with those without. Since then, both the prevalence and degree of childhood obesity have significantly increased²⁰; at the same time, numerous obesity intervention programs took place at schools—possibly affecting teachers' perception of children with overweight and obesity.²¹ This study aims to update and confirm the findings using a more recent nationally representative cohort of kindergarteners (Early Childhood Longitudinal Study, Kindergarten Class of 2010–2011 [ECLS-K:2011]) because ECLS-K:2011 is a longitudinal dataset of younger children with comprehensive measures of SES as well as objective and subjective academic achievement.^13,19,22,23

The aims of this study are to (1) demonstrate the association between obesity and reading and mathematics scores (objective measures) and (2) demonstrate the association between obesity and teachers' perception of learning ability (subjective measures) from kindergarten to fifth grade.

Materials and Methods

Description of Data

Early Childhood Longitudinal Study, Kindergarten Class of 2010–2011 (ECLS-K:2011) is a longitudinal study of a nationally representative cohort of 18,174 children enrolled in a public and private kindergarten in 2010–2011 (mean age 5.6 years, 51.5% male).²⁴ A complex, multistage probability sampling was used to select children and written informed consent was obtained from their parents. Follow-up evaluations were collected twice a year in the falls and springs of kindergarten through second grade (2011–2013) (mean ages 6.1, 6.6, 7.1, 7.6, and 8.1 years) and once a year in the springs of third through fifth grade (2014–2016) (mean ages 9.1, 10.1, and 11.1 years). Children, their families, teachers, schools, and before- and after-school care providers provided voluntary information.²⁴

Trained assessors obtained anthropometric data, including the weight and the height of children. BMI was calculated and converted to age- and sex-specific BMI percentiles using the 2000 CDC growth charts.²⁵ Underweight was defined as BMI percentiles less than 5 percentile; overweight was defined as BMI percentiles between 85 and 95 percentile; and obesity was defined as BMI percentiles 95 and above.

Objective Measures of School Performance

As a functional approach to cognitive performance, theta test scores for reading and mathematics were calculated using Item Response Theory (IRT) procedures; this method allowed comparing the score of each child to the scores of other children.²⁶ IRT method employed a two-stage assessment; items that were appropriate for the child's ability level were administered, instead of all the items in the assessment. Theta scores were reported on a metric ranging from −8 to 8 (lower scores for lower ability, and higher scores for higher ability), and the reading and mathematics scores were normally distributed; the scores demonstrated good internal reliability (ranging from 0.75 to 0.95).

Subjective Measures of School Performance

For teacher-reported Approaches to Learning items, the classroom teacher filled out a questionnaire in every round of data collection from the fall of kindergarten to the spring of third grade. For the springs of fourth and fifth grade, the reading and language arts teacher filled out the questionnaire. The questionnaire included seven items, and teachers were to report how often the student exhibited a set of learning behaviors. For teacher-reported Attentional Focusing and Inhibitory Control items, the Short Form of the Children's Behavior Questionnaire²⁶ (in the fall and spring of kindergarten and the spring of first grade) and Temperament in Middle Childhood Questionnaire (TMCQ)²⁷ (in the springs of second through fifth grade) were used. Teacher-reported scores had good internal consistency reliability, with Cronbach's alpha ranging from 0.83 to 0.96. A more detailed description of assessment methods and the validity of the scores are described elsewhere.²⁸

Data Analysis

For every round of data collection, weighted logistic regression models were used to compare the likelihood of getting above-median scores among children with obesity compared with that of healthy-weight children. For sensitivity analyses, weighted multiple linear regression models were used to identify the differences in mean reading and mathematics test scores between children with obesity and healthy-weight children. Similarly, weighted multiple logistic and linear regression models were used to analyze subjective teacher-reported measures (Approaches to Learning; Attentional Focusing; and Inhibitory Control). Children with underweight and overweight were included in the analytic models but not displayed in the figures to focus on the study objectives.

Known predictors of academic achievement, including gender, race/ethnicity (non-Hispanic white; non-Hispanic black; Hispanic; non-Hispanic Asian; other), and SES [z-score < −1 (low); −1 ≤ z-score <1 (middle); z-score ≥1 (high)] were considered in multivariable models. The SES variable was created by the National Center for Education Statistics (NCES) using both parents' education levels, occupational prestige scores, and household income; and it was composited three times, during the fall and spring of kindergarten, the spring of first grade, and the spring of fifth grade. Further description of the computing method for SES is published elsewhere.²⁴

To account for the complex sampling design, Taylor series linearization was used for variance estimates. Survey weights and adjustments constructed by the NCES were included in the models to account for nonresponse unless noted otherwise (NCES sampling weights were adjusted for differential nonresponse patterns that could lead to bias in the estimates²⁸). All tests of hypotheses were two sided and conducted at a 0.05 level of significance. All statistical analyses were performed using SAS University Edition (SAS Institute, Cary, NC, USA) and R version 3.5.2 (R Foundation for Statistical Computing, Vienna, Austria).

Missing Data

Children with missing BMI (n = 3515) and SES (n = 1537) information, and test and assessment scores (n = 1348) at the time of kindergarten entry were excluded from the analysis. In the fall of kindergarten, excluded children were more likely to be with obesity than included children (27.3% vs. 14.2%, p = 0.01). However, for all other rounds of data collection, the proportion of children with obesity was similar between included and excluded children. Longitudinal weights were used to account for missing follow-ups in estimating changes in reading and mathematics scores. The proportion of children with obesity was similar for children with and without missing teacher-reported measures at all applicable rounds of data collection.

Results

When children entered kindergarten, 14.2% [95% confidence interval (CI) 13.2–15.2) were experiencing obesity. Children with obesity were more likely to be male (55.6% vs. 50.6%) and non-Hispanic black (15.8% vs. 12.6%) or Hispanic (31.7% vs. 20.9%) than healthy-weight children (Table 1); they were also more likely to be from low SES than their healthy-weight peers (15.0% vs. 9.6%).

Table 1.

Demographics of Children in the Fall of Kindergarten (at Baseline)

	Full (n = 12,774)		Healthy weight (n = 8656)		Obese weight (n = 1798)
	No. of participants	Weighted	No. of participants	Weighted	No. of participants	Weighted
Male, % (SE)	6563	51.7 (0.50)	6781	50.6 (0.61)	1222	55.6 (1.19)
Age in months, mean (SE)	12,774	67.6 (0.11)	8656	67.6 (0.12)	1798	67.6 (0.18)
Race/ethnicity, % (SE)
Non-Hispanic White	6550	54.1 (1.92)	4689	57.1 (1.95)	738	43.2 (2.49)
Non-Hispanic Black	1669	13.2 (1.51)	1089	12.6 (1.43)	265	15.8 (2.13)
Hispanic	2912	23.2 (1.40)	1771	20.9 (1.38)	587	31.7 (2.38)
Asian	833	3.8 (0.58)	590	4.0 (0.65)	79	2.4 (0.49)
Other	688	4.7 (0.29)	445	4.5 (0.32)	105	5.4 (0.53)
Weight status, %(SE)			—	—	—	—
Underweight	369	2.8 (0.18)
Healthy weight	8656	68.0 (0.72)
Overweight	1951	15.1 (0.44)
Obese weight	1798	14.2 (0.52)
Socioeconomic status, % (SE)
Low	1340	10.7 (0.67)	819	9.6 (0.67)	257	15.0 (1.19)
Middle	9882	78.0 (0.66)	6638	77.4 (0.77)	1449	80.3 (1.16)
High	1552	11.3 (0.66)	1199	13.0 (0.70)	92	4.6 (0.57)

SE, standard error.

The Association between Obesity and Objective Measures of School Performance

In the unadjusted analyses, children with obesity were less likely to achieve above-median reading and mathematics scores than healthy-weight peers at all rounds of data collection (Supplementary Table S1). When sex, age, race/ethnicity, and SES were accounted for, the association attenuated.

Nevertheless, children with obesity were less likely to achieve above-median reading scores than healthy-weight children in the springs of fourth and fifth grade [adjusted odds ratio (OR) 0.77, 95% CI 0.65–0.91 and OR 0.86, 95% CI 0.75–0.98, respectively] (Fig. 1a and Supplementary Table S1). Achieving above-median mathematic scores was also less likely among children with obesity than those with a healthy weight in the springs of kindergarten, first, third, and fourth grade (adjusted OR 0.85, 0.79, 0.82, and 0.75, respectively) (Fig. 1b and Supplementary Table S1).

Figure 1.

Likelihood of achieving above-median objective scores in the springs of each grade (adjusting for sex, age, race/ethnicity, and socioeconomic status). (a) Reading Scores; (b) Mathematics Scores.

Other predictors for higher reading or mathematics scores included sex (female for reading and male for mathematics), non-Hispanic white or Asian race/ethnicity, older age, and higher SES (data not shown, available upon request).

The Association between Obesity and Subjective Measures of School Performance

In the unadjusted analyses, children experiencing obesity were significantly less likely to receive above-median scores for teacher-reported Approaches to Learning, Attentional Focusing, and Inhibitory Control (Supplementary Table S2). As with objective measures, the association between obesity and subjective scores weakened after controlling for sex, age, race/ethnicity, SES, and objective scores.

By the spring of first grade, children with obesity were less likely to get above-median scores from their teachers for their Approaches to Learning than their healthy-weight peers (OR 0.82, 95% CI 0.69–0.97), regardless of their sex, race/ethnicity, age, SES, and reading and mathematics scores (Fig. 2a and Supplementary Table S2). Teachers reported that children with obesity did not have Attentional Focusing as good as their healthy-weight peers from the time they entered kindergarten until they were fifth graders (OR 0.80, 0.81, 0.83, and 0.82, 0.80, and 0.74) except during the spring of first grade (Fig. 2b and Supplementary Table S2). Receiving above-median Inhibitory Control scores was not significantly associated with obesity, except in the fall of kindergarten (Fig. 2c and Supplementary Table S2).

Figure 2.

Likelihood of achieving above-median subjective scores in the springs of each grade (adjusting for sex, age, race/ethnicity, socioeconomic status, and reading and mathematics scores). (a) Approaches to Learning Scores; (b) Attentional Focusing Scores; (c) Inhibitory Control Scores.

Other predictors for better teacher-reported Approaches to Learning, Attentional Focusing, and Inhibitory Control included female gender, Hispanic ethnicity, and higher reading and mathematics scores (data not shown, available upon request).

Sensitivity Analyses

Due to possible gender differences, gender was stratified (and modeled separately) for reading and mathematics scores. During a few rounds of data collection, where no significant association was found between scores and obesity when both genders were included, a significant association was found between the two when only one gender was included. However, overall, no significant difference was present in the interpretation of results.

For the mean score analyses, children with obesity showed lower reading and mathematics scores than their healthy-weight peers at several data points (Supplementary Table S3, adjusted results show the mean score differences for non-Hispanic white girls who were at the mean age and middle SES). Children with obesity were also perceived to have lower learning ability (Approaches to Learning) in the springs of first through fifth grade than their healthy-weight peers (Supplementary Table S4). Similarly, they were also reported to have lower mean scores of Attentional Focusing and Inhibitory Control than their healthy-weight peers at most rounds of data collection (Supplementary Table S4). Overall, mean score analyses results were similar to that of the main analyses.

Discussion

This study aimed to examine the association between childhood obesity and objective academic achievement using reading and mathematics scores and identify the association between obesity and teachers' perception of children's learning abilities, from kindergarten to fifth grade. This study showed that the association between obesity and objective test scores attenuated when SES was taken into consideration. However, especially for mathematics scores, several rounds of assessment still showed that obesity was negatively associated with objective test scores. Similarly, subjective teacher-reported Approaches to Learning and Attentional Focusing scores were negatively associated with obesity even after adjusting for SES and objective test scores.

The results highlight scientific and educational implications. First, the findings show that obesity is negatively associated with objective measures of academic performance. Many studies reported that the relationship between reading and mathematics scores and obesity (or overweight) became nonsignificant after accounting for socioeconomic and behavioral variables among young children.^10,29,30 Results from this study also demonstrated that the association weakened after controlling for socioeconomic variables. However, in many rounds of assessment, children with obesity were still less likely to achieve above-median scores than their peers with a healthy weight. Adolescents with obesity showed reduced volume in the orbitofrontal cortex and decreased executive functioning skills¹⁶; elevated plasma leptin levels due to obesity has been linked to cognitive deficits among adolescents.³¹ These suggest that while the difference in scores observed in the current study was small, the gap could become wider as the trajectory continues and these children become adolescents. This study also found that the association between obesity and test scores were more prounounced in mathematics than reading. Considering that cognitive flexibility was related to conceptual mathematics skills and print knowledge among preschoolers, mathematics scores may have been more affected by obesity than reading scores for elementary school-aged children.^32,33 Evidence also suggested that executive functioning skill was strongly associated with mathematics achievement.^34,35 On the other hand, executive function was more likely to be associated with reading comprehension than word recognition; this could have contributed to the differences in reading scores when the children were in upper grades.³⁶

Second, students with obesity may be viewed as possessing lower learning ability by teachers than their healthy-weight peers even when they show the same objective academic scores. This finding is consistent with other studies that showed the association between obesity and poor perceptions of academic ability by teachers.^11,13,19,22 In the current study, poor Attentional Focusing was most significantly associated with obesity. Attention and inhibitory control have been previously associated with obesity in other studies as well^15,16,18; what is less clear is if children with obesity actually projected more behavioral issues than healthy-weight children with similar objective performance and SES or if they were perceived to have more behavioral issues by teachers.

Using a previous cohort of ECLS-K, Zavodny¹⁹ explored similar hypotheses for children with overweight and obesity. She reported that BMI was negatively associated with test scores in the 1998–1999 cohort. However, she found that children's weight was more negatively associated with their teacher assessments than with test scores¹⁹; heavier children had a systematically lower evaluation by their teachers on most items. The current study confirmed these findings and showed that not much has changed in both test scores and the perception of teachers toward children with obesity after 11 years.

The biggest strength of this study is that scores and teacher assessments were recorded at least once every year; these were analyzed separately to provide a visual snapshot of the changes. This study also utilized both objective and subjective scores that were internally reliable and valid. Furthermore, one of the most important confounder for educational attainment, SES, was comprehensively collected and accounted for in the analyses.

Nevertheless, the study has several limitations. First, the children were only followed until fifth grade; the associations between academic performance, the perception of teachers, and the weight status of children may change when children advance into secondary schools. However, the association between poor teacher perception and obesity was also reported to be present in fifth to eighth grade.²² Second, not all children had measurements for all rounds of data collection. However, the proportion of children without follow-up was relatively small compared with the sample size, and the missing data analyses showed minimal bias. Third, there was a potential for unmeasured confounding.

The nationally representative sample of kindergarteners in this study showed the prevalence of obesity as 14.2%. This was similar to the national prevalence of obesity in 2009–2010, which was 12.1% of 2–5-year-olds and 18.0% of 6–11-year-olds.² Greater than half of these children are projected to be with obesity at the age of 35 years.³⁷ This study adds to the literature that obesity is negatively related to both objective and subjective scores of academic achievements. Further research is warranted in understanding the effect of obesity on objective test scores. Obesity already disproportionately affects the children of lower SES and it may be adding another burden to these children in getting a better education and improving their SES.^38,39 Further research is also needed in understanding the effect of obesity on teacher assessments. Studies should be designed to understand if the connection is stemming from behavioral issues of children, weight-based bias of teachers, or both. Regardless of the cause, schools should put more emphasis on eliminating weight-based stigma among educators. Educators would need to pay closer attention to the cues of possible cognitive and behavioral issues among children with obesity.

Footnotes

Funding Information

No funding is associated with this article.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

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Supplementary Material

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