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Research ArticleEarly Life Cognitive Abilities and Body Weight:Cross-Sectional Study of the Association of Inhibitory Control,Cognitive Flexibility, and Sustained Attention with BMIPercentiles in Primary School Children

Tamara Wirt, Anja Schreiber, Dorothea Kesztyüs, and Jürgen M. Steinacker

Division o Sports and Rehabilitation Medicine, Department o Internal Medicine II, Ulm University Medical Centre,Frauensteige , Ulm, Germany

Correspondence should be addressed to amara Wirt; [email protected]

Received July ; Revised October ; Accepted October

Academic Editor: Chris Rissel

Copyright © amara Wirt et al. Tis is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Te objective o this study was to investigate the association o different cognitive abilities with children’s body weight adjusted orurther weight inuencing sociodemographic, amily, and liestyle actors. Cross-sectional data o primary school children (.± . years; .% boys) participating in a health promotion programme in southwest Germany were used. Children perormeda computer-based test battery (KiAP) including an inhibitory control task (Go-Nogo paradigm), a cognitive exibility task,and a sustained attention task. Height and weight were measured in a standardized manner and converted to BMI percentilesbased on national standards. Sociodemographic eatures (migration background and parental education), amily characteristics(parental body weight), and children’s liestyle (V consumption, physical activity, consumption o sugar-sweetened beveragesand breakast habits) were assessed via parental questionnaire. A hierarchical regression analysis revealed inhibitory control andcognitive exibility to be signicant cognitive predictors or children’s body weight. Tere was no association concerning sustainedattention. Te ndings suggest that especially cognitive abilities known as executive unctions (inhibitory control and cognitiveexibility) are associated with children’s body weight. Future longitudinal and intervention studies are necessary to investigate thedirectionality o the association and the potential o integrating cognitive training in obesity prevention strategies. Tis trial isregistered with Clinicalrials.gov DRKS.

1. Introduction

Te dramatically increased prevalence o childhood obesity in industrialised nations has been declared as a major topic o public health in the recent decade [, ]. In Germany, .%o children aged to years are overweight or obese [].An increase o overweight and obesity is particularly evidentat the age o school entry, between and years [, ].Given the signicant adverse biopsychosocial consequenceso paediatric overweight, its relatively stable course, andthe enormous economic costs to the healthcare system,effective prevention strategies are needed [, –]. It is there-ore important to better understand correlates o paediatricoverweight and to identiy risk actors. Besides a genetic

predisposition,increased body weight is inuenced by certain

behavioural and liestyle actors such as unavourable dietary habits, or example, high consumption o sugar-sweetenedbeverages or skipping breakast, low levels o physical activity,and preerence o sedentary activities, or example, screenmedia use [–]. Furthermore, cultural and amily charac-teristics such as migration background, low socioeconomicposition, low parental education, and parental obesity areassociated with childhood overweight [, , , ].

Additionally, there is a growing body o evidence suggest-ing an association between increased body weightand alteredcognitive unctioning in children. Overweight children show,or example, worse school perormance compared to theirnormal-weight counterparts [–]. Moreover, a negative

Hindawi Publishing CorporationJournal of Obesity Volume 2015, Article ID 534651, 10 pageshttp://dx.doi.org/10.1155/2015/534651


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association between obesity and executive unctions has beenreported []. Executive unctions are dened as higher-order control processes o the cognitive system that arerelated to sel-regulation and underlie goal-directed andadaptive behaviour [, ]. Tese processes have already been positively related to social and emotional skills, school

success, mental and physical health, and social status inadulthood [, ]. Different components o executive unc-tions such as inhibitory control (the ability to withholdinappropriate actions) or cognitive exibility (the ability toadjust to changed circumstances or demands) are usually distinguished []. Regarding the association between obe-sity and executive unctions studies have mainly ocussed oninhibitory control which is signicantly related to body massindex in children and adolescents [, , ]. Concerningotherexecutiveunctions (e.g.,cognitive exibility)or urthercognitive domains (e.g., attention, memory, and general cog-nitive unction), however, ndings arescarce and inconsistent[, , ].

Assuming an association between children’s body weightand cognitive unctioning one possible underlying mecha-nism may be that certain cognitive abilities play a role inlearning, adopting, and maintaining health behaviour [,]. As previously mentioned executive unctions and mosto all the inhibitory components are related to cognitive sel-regulation and to disciplined behaviour []. In the contexto paediatric obesity inhibitory control may be importantor young children to regulate their physical activity leveland their ood intake in terms o appreciating rules romparents or teachers, resisting temptations (e.g., consumptiono sweets when not allowed and watching V or video gameswhen otherwise engaged), controlling distracting thoughtsand negative emotional states which may increase appetite,and staying ocused on activities such as playing games.Cognitive exibility may be critical or children when tryingout new behaviour and dealing with changes, barriers, ordifferent settings throughout their day and when deliber-ate attention control (ocusing and switching) is necessary.Appreciating healthier ood and beverages and active ways o transport when introduced by caregivers, coping with schoolentry and the related changes, switching between sedentary activities such as homework and active play, and nding wayso being physically active despite bad weather or without any toys may be a ew examples. Besides these control unctions,urther abilities such as sustained attention may play a role interms o maintaining the ocus o attention on specic activi-

ties over a certain period o time. Tus, it is important orchil-dren not only to cope with immediate distractions, changes,and temptations, but also to stay ocused in the long run.

However, the small body o literature regarding child-hood and especially early school age can be criticised.Most studies ocused only on older children or adolescents.Selectivity, small size o study samples, and the use o sel-reporting measures urther limit validity o researchresults. Moreover, researchers addressing paediatric obesity always emphasise the importance o controlling or socialactors such as parental income or education []. Teobjective o the present study, thereore, was to investigate theassociation between different cognitive abilities (inhibitory

control, cognitive exibility, and sustained attention) andbody weight in a large nonclinical sample o primary schoolchildren.o considerthe outlined methodical issues objectivestandardised tests and assessment methods were used andpotentially conounding actors including sociodemographiceatures, amily, and liestyle were controlled.

2. Materials and Methods

.. Overview. In the context o a large evaluation study o a school-based health promotion programme in south-west Germany (the Baden-Württemberg Study) cognitive,anthropometric, sociodemographic, and behavioural datao primary school children were collected. Te Baden-Württemberg Study was approved by the institutional ethicscommittee and is registered at the German Clinical ri-als Register (DRKS). eachers o school classesin the ederal state o Baden-Württemberg volunteered toparticipate in the study and written inormed consent was

obtained rom parents prior to data collection. Te Baden-Württemberg Study is a longitudinal study and is designedas a randomised controlled trial. A detailed description o the study has been published by Dreyhaupt et al. []. Forthe present analysis only baseline data o the control andintervention group were used. Baseline assessment took placein autumn (within a -month period rom the end o summer vacation in September to the beginning o autumn

vacation in November). During this time a research grouprom the University o Ulm visited the participating schoolclasses (one or two classes each day). Tus, all measurementswere perormed on-site at school during one school day. Onthe day o a school visit, children were assigned to small

groups based on gender and class to perorm the differentmeasurements (e.g., cognitive testing and anthropometricmeasurement). o obtain inormation about sociodemo-graphic and liestyle characteristics a parental questionnairewas issued directly afer the measuring period (November) and returned within six weeks.

.. Participants. Te total sample o the Baden-Württem-berg Study consisted o = 1944 children rom eth-nically and socioeconomically diverse primary schools inthe ederal state o Baden-Württemberg, Germany. Primary school classes were recruited using a number o differentpublic relations activities such as written inormation or

schools, education and health authorities, adverts in trainingcatalogues or teachers, inormative events, or participationat pedagogic trade shows. For logistical reasons (distancesbetween schools, scope o measurements o the Baden-Württemberg Study, and technical equipment) cognitivetesting was only carried out in the southern part o Baden-Württemberg at a convenient distance o the research centrein Ulm. Furthermore, children who were absent on the day o school visit were not retested. Cognitive data collection took place in a subsample o = 513 children. Afer exclusion o = 15 children due to motor impairment, colour blindness,or lack o compliance the sample or the present analysisamounts to = 498 participants. Children attended either


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st grade (.%) or nd grade and averaged 7.0 ± 0.6 years o age (range –); .% were boys.

Sample size or each cognitive subtest varies due to ur-ther missing or invalid data: = 479 children provided validdata or inhibitory control, = 445 or cognitive exibility,and = 466 or sustained attention. Reasons or urthersubtest dropouts were, or instance, time restriction at schooland lack o comprehension or compliance or implausibledata concerning only one subtest. Anthropometric data wasavailable or = 496, and the parental questionnaire waslled out or = 441 children. Complete data including allcognitive measures, anthropometric measures, and parentalquestionnaire was available or = 297. Figure provides anoverview o the sample and subsample selection.

.. Cognitive Measures. Cognitive abilities were assessedusing the computer-based test battery o attention or chil-dren (KiAP) []. Te KiAP is validated or children aged to years and consists o a broad range o nonverbal

subtests measuring different basal as well as higher-ordercomponents o the cognitive system (attention and executiveunctioning). Each component can be assessed separately. oensure optimal motivation and compliance all subtests aredesigned in the orm o short games with an enchanted castletheme. Tis allows the KiAP to be particularly accessible toyoung children in comparison to other known test batteriesbased on more abstract stimuli. Furthermore, a computer-based test was preerable to a paper pencil test as preliminary trials demonstrated that children just entering school haddifficulties in turning pages and handling a pencil. Due tothe child-riendly character, the easibility in the school andgroup setting, and the possibility to measure differentially cognitive unctioning (including executive control compo-nents) the KiAP constituted a suitable assessment tool orthe present study purposes. In terms o validity the testbattery has been especially used in neuropsychological andother paediatric researches [–] as well as in researchwith healthy children and in cross-cultural studies [, ].Signicant correlations with school outcomes [], intellec-tual abilities [], and behavioural questionnaires [] couldbe ound. Factorial analysis conrmed the construct validity [], and group comparisons (e.g., children with versus with-out attention decit hyperactivity disorder) demonstratedcriterion validity []. Te reliability o the test battery canbe considered as satisactory [].

Tree subtests o the KiAP were administered: an

inhibitory control task (Go-Nogo paradigm), a cognitiveexibility task, and a sustained attention task. For eachtask number o errors (incorrect response to a noncriticalstimulus), number o omissions (missed response to a criticalstimulus), and reaction time (milliseconds in medians) wererecorded. For statistical analysis and to overcome the rightskewed distributions o errors and omissions total scoreswere calculated or each subtest based on the key parametersrecommended in the test manual.

() Inhibitory Control . Te Go/Nogo task examined the ability to respond as quickly as possible to a certain critical stimulusby pressing a button and to withhold the response when

Baseline data

n = 1944

86 schools (157 classes)

Cognitive measurement

subsample

n = 513

27 schools (45 classes)

Cognitive measurement

n = 498

valid data

Cases eligible for data

analysisa

n = 297

Baden-Württemberg study

F : Overview o sample size. Cases with complete data oncognitive, anthropometric, sociodemographic, amily, and liestyle variables were considered eligible or analysis.

another noncritical stimulus emerged. Te task lasted minutes. Key parameters were errors and reaction time.

Errors could range rom to and reaction time rom msto ms (maximum time interval between two stimuli).Te total score was calculated as ollows:

otal score = errors standard scores− reaction time standard scores. ()

o improve interpretability the score was reversed witha positive total score indicating an overly high inhibitory control (low number o errors and slow reexive reactions)and a negative score indicating low inhibitory control (highnumber o errors and ast impulsive reactions). A scorearound represented an average inhibitory ability.

() Cognitive Flexibility . Te task examined the ability todeliberately controlthe attention ocus and to adapt responsesto changing conditions as quickly as possible. Children hadtoconsider different eatures simultaneously (colour and loca-tion o the stimulus), to switch their attention continuously between these eatures, and to react appropriately accordingto the target eature in each trial. In detail, two stimuli intwo different colours were presented simultaneously on theright and the lef sides o the screen. Children had to pressone out o two buttons (lef button or the lef side or rightbutton or the right side) depending on the colour o thestimuli in an alternate sequence (colour A, colour B, colour


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A, colour B,. . .). On each trial, the stimulus with the targetcolour could be presented on the same side o the screen asbeore or on the other side; thus, children had to change theirresponse behaviour or not. Duration o the whole task varieddepending on reaction times (approximately minutes). Key parameters were errors and reaction time. Errors could range

rom to and reaction time rom ms to ms(maximum time interval between two stimuli i no reactionoccurred). Contrary to the other subtests, a total score wasautomatically computed by the KiAP based on standardisednumber o errors and reaction time []. A positive scorerepresented overly high exibility (low number o errorsand ast reactions) and a negative score low exibility (highnumber o errors and slow reactions). A score around represented average cognitive exibility.

() Sustained Attention. Te task examined the ability tomaintain attention over an extended period o time ( min-utes). During this time children had to compare subsequentstimuli in terms o a specic eature (colour) andto determinewhether two stimuli were matching. Key parameters wereerrors (two stimuli incorrectly indicated as matching) andomissions (two stimuli incorrectly indicated as nonmatch-ing). Errors could range rom to and omissions rom to . Te total score represented the number o correctresponses and was calculated as ollows:

otal score

= total number o stimuli− (number o errors + number o omissions) .

()

o consider the different number o errors and omissions

possible ( versus ) the number o errors was relativised(divided by ):

otal score

= 100 − number o errors5 + number o omissions .()

Tus, the total score ranged rom to with a hightotal score indicating high sustained attention and a low score indicating low sustained attention. A score around represented no sustained attention at all.

Procedure. On the day o a school visit the cognitive testswere administered during the rst school hours. Cognitivetesting took place in one or two separate quiet classroomsand was carried out by trained examiners using laptops(screen size: inches). As previously mentioned childrenperormed the tests in small groups (up to children). Pergroup examiners supported and supervised the children(with a maximum o children per examiner). While onetesting session took place, which lasted in total minutes,the other groups were assigned either to anthropometricmeasurement or to other parts o the Baden-WürttembergStudy. Te subtests o the KiAP were administered in axed order and instructions were given in a standardised

manner. Comprehension and willingness o the childrenwere assured by short preceding practice trials according tothe test manual. Tese practice trials could be repeated i necessary—especially the cognitive exibility task requiredseveral preceding trials. Te main testing started when it wasclear that each child o thegroupunderstood the instructions.

When the examiner was sure that a child was not able toperorm a task, lack o comprehension was documented. Temain testing was administered once. Further irregular anddisruptive behaviour was documented and later consideredduring data preparation. Children who were absent on theday o testing were excluded rom the analysis as there wasno repetition o the testing at a later point in time.

.. Anthropometric Measures. Anthropometric measure-ment took place in a separate room provided by the teacher.Gender segregation o the groups was considered. Body height and weight o the children were taken by trained staff according to the guidelines o the International Society or

the Advancement o Kinanthropometry (ISAK) []. Heightwas measured using a portable stadiometer (Seca model ,Seca, Germany), without wearing shoes, with an accuracy o . cm. Weight was measured using a calibrated electronicscale (Seca model , Seca, Germany), wearing underwear,with an accuracy o . kg. Children’s body mass index(BMI) was calculated as weight divided by height squared

(kg/m2) and converted to BMI percentiles using national age-and sex-specic reerence data []. o allow internationalcomparisons, weight status was also calculated according tointernational reerence data [].

.. Parental Questionnaire. Sociodemographic data, body

weight o parents, and different liestyle actors o childrenwere assessed via parental questionnaire. Parent educationwas assigned to the respectivelevel according to the CASMINclassication []. Te CASMIN (Comparative Analysis o Social Mobility in Industrial Nations) is the most widely usedinternational instrument to classiy education consideringlength, quality, and value o general education as well as

vocationally oriented schooling or training. Te classicationdistinguishes primary, secondary, and tertiary educationlevels. In the present study parent education was determinedasthe highestlevel otwo parents orthe level oa singleparentwho cares or the child. Due to the small number o caseswith primary education level (.%) parent education was

dichotomised with primary and secondary educationlevels inone group and tertiary education level in another. Migrationbackground was dened as at least one parent born abroad orat least one parent mainly having spoken a oreign languagewith the child during its rst years o lie. Sel-reportedparental height and weight were used to calculate BMI o

mothers and athers (kg/m2). Concerning children’s liestyle,V consumption, physical activity, consumption o sugar-sweetened beverages, and breakast habits were assessed. Temean time spent watching television per day was rated ona -point Likert scale (“never” to “more than hours”). Asthe American Academy o Paediatrics [] recommends lessthan - hours o total screen time per day, V consumption


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was dichotomised using a cut-off point at hour. Further,parents were asked on how many days per week their childwas engaging in at least minutes o moderate to vigorousphysical activity (range to days) and how ofen their childwas consuming sugar-sweetened beverages (-point Likertscale: “never” to “more than once per day”). Te requency

o having breakast prior to going to school was rated on a-point Likert scale and, or statistical analysis, dichotomisedas “never”/“rarely” versus “ofen”/“always.”

.. Statistical Methods. o determine the additional pre-dictive value o each o the three cognitive variables onchildren’s body weight (BMI percentiles) hierarchical mul-tiple linear regression analysis was perormed. First, a basicmodel (model ) was established which included parenteducation, migration background, BMI o mother and ather,children’s V consumption, physical activity, consumption o sugar-sweetened beverages, and breakast habits. In the nextsteps inhibitory control, cognitive exibility, and sustained

attention were added successively as predictors (models to ). Statistical analysis was carried out using SPSS andstatistical signicance was set at = 0.05. As missing datamay have had an impact on the results, differences betweenthe samples and subsamples (the Baden-Württemberg Study sample, = 1944, the cognitive subsample, = 498, andthe nal sample with complete and valid data, = 297) wereanalysed using -test or continuous data and Fisher’s exacttest or categorical data.

3. Results

.. Descriptive Characteristics. Sociodemographic, liestyle,and weight group characteristics o the different samples areshown in able . In the cognitive subsample ( = 498)average BMI percentile o children was 48.21 ± 26.92, and.% were classied as overweight or obese and .% wereclassied as underweight according to national standards[]. Te prevalence or overweight and or underweightwas slightly higher according to international cut-off points[] (able ). Parental BMI averaged 23.86 ± 4.47 (mothers)and 27.90 ± 3.93 (athers), respectively. Means and standarddeviations or all cognitive subtests (total scores, numbero errors, number o omissions, and reaction time) areillustrated in able .

.. Prediction o Body Weight. o determine whetherdifferent cognitive abilities are associated with children’sbody weight hierarchical regression analysis was conducted.Results are presented in able . First, model revealedmigration background, body weight o mother, and body weight o ather as signicant predictors o children’s body weight. No relationship between parental education or thedifferent liestyle actors and children’s body weight wasound. As it is shown in models to inhibitory controland cognitive exibility were signicant cognitive predictorsover andaboveall other variableswhereas sustained attentiondid not signicantly contribute to the prediction. Inhibitory

control and cognitive exibility together explained an addi-tional amount o .% o variance in the criterion.

.. Missing Data. Children o the cognitive subsample ( =498) differed rom children o the total study populationin terms o migration background and ather’s BMI. A

signicantly higherpercentage o migration background ( =0.022) and a signicantly lower ather’s BMI ( = 0.001)were ound in children who perormed the KiAP comparedto those who did not. Tere were no signicant differencesconcerning age, sex, BMI percentiles, weight group, V con-sumption, physical activity, consumption o sugar-sweetenedbeverages, breakast habits, parental education, and mother’sBMI. Children o the nal subsample with complete data( = 2 9 7) differed signicantly rom children o thetotal study population in terms o BMI percentiles, parentaleducation, consumption o sugar-sweetened beverages, andather’s BMI. Lower BMI percentiles ( = 0.008), a higherpercentage o tertiary parental education level ( = 0.009),a lower percentage o sof drink consumption ( = 0.031),and a lower ather’s BMI ( = 0.000) were ound inchildren with complete data compared to those without.Tere were no signicant differences concerning any other

variable. Although the percentage o migration backgroundwas increased in the cognitive subsample, more childrenwith migration background dropped out in the urther dataprocess. Tus, the nal subsample did not differ anymorerom the total study sample in this respect.

4. Discussion

Te present study examined the association between different

cognitive abilities and body weight in primary school chil-dren. Te ndings suggest that especially cognitive abilitiesknown as executive unctions such as inhibitory controland cognitive exibility are associated with children’s body weight. In the past decade particularly the inuence o inhibitory control was investigated in children and ado-lescents using a variety o assessment tools []. Methodsranged rom behaviour questionnaires, ratings, and sel-reports to different tasks and computerised tests (e.g., Strooptest, Go-Nogo task, and delay-o-gratication task). In linewith the results reported here all studies showed a signicantrelationship between body weight and inhibitory control inthat a higher body weight was associated with poorer inhi-

bition perormance. Additionally, a ew longitudinal studiesindicated that inhibitory control at a younger age can predictchildren’s BMI at an older age [, , ]. Group analysesrevealed less inhibitory control in overweight adolescentscompared to their normal weight peers [, ]. Pauli-Pottet al. [] urther pointed out a signicant interaction withage and assumed that there might be an especially importantdevelopmental period at early school age when inhibitory control is particularly important or sel-regulation.

Few studies can be ound examining the associationbetween cognitive exibility and body weight. Cserjési et al.[], or example, ound a signicant negative correlationin adolescent boys, and obese boys signicantly perormed


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: Descriptive characteristics o the Baden-Württemberg Study sample and the KiAP subsamples.

Baden-WürttembergStudy sample

( = )Missing values

Cognitivesubsample( = )

Missing values

Finalsubsamplea

( = )Child characteristics

Age, m (sd) . (.) . (.) . (.)

Female, (%) (.) (.) (.)BMI percentiles, m (sd) . (.) . (.) . (.)

Weight group, national reerence data, (%) []Underweight ( and ≤ BMI percentile)Obese (> BMI percentile)

(.) (.) (.)

(.) (.) (.)

(.) (.) (.)

Weight group, international reerence data, (%) []UnderweightOverweightObese

(.) (.) (.)

(.) (.) (.)

(.) (.) (.)

V consumption > minutes/day, (%) (.) (.) (.)Days/week with at least minutes MVPA, m (sd) . (.) . (.) . (.)

SSB consumption > once/week, (%) (.) (.) (.)Never/rarely having breakast, (%) (.) (.) (.)

Parental characteristics

ertiary parent education level, (%) (.) (.) (.)Migration background, (%) (.) (.) (.)Mother’s BMI . (.) . (.) . (.)

Father’s BMI . (.) . (.) . (.)

Note. aCases with complete data on cognitive, anthropometric, sociodemographic, amily, and liestyle variables. MVPA = moderate to vigorous physicalactivity. SSB = sugar-sweetened beverages.

: Mean, standard deviation, and range or cognitive test scores.

M SD Minimum Maximum Inhibitory control

otal score −. . −. .Number o errors . .

Reaction time (ms) . . . .

Cognitive exibility

otal score −. . −. .Number o errors . .

Reaction time (ms) . . . .

Sustained attention

otal score . . . .

Number o errors . .

Number o omissions . .

Note. ms = millisecond.

worse than their healthy weight counterparts. Verdejo-Garćıaet al. [] used a whole battery o executive unctioningtests including response inhibition and exibility. Similarly,the authors reported signicant group differences in theexibility task and a signicant relationship between BMIandexibility. Tese ndings are supported by urther studies

ocusing all mainly on adolescents [, ], whereas Gun-stad et al. [, ] demonstrated a link between cognitiveexibility (switching-o-attention task) and body weight only in adults but neither in children nor in adolescents. Teresults reported here conorm to most o the existing researchliteratures even though these studies have been conducted


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: Hierarchical multiple regression model predicting children’s body weight rom parental, behavioural, and cognitive variables.

Predictors

BMI percentiles

Model Model Model Model

B B B B % CI

Parent education −. −. −. −. [−., .]Migrationbackground

.∗ .∗ .∗ .∗ [., .]BMI o mother .∗∗∗ .∗∗∗ .∗∗∗ .∗∗∗ [., .]BMI o ather .∗∗ .∗∗ .∗∗ .∗∗ [., .]V consumption −. −. −. −. [−., .]Physical activity SSB consumption

.−.

.−.

.−.

.−.

[−., .][−., .]

Breakast habits . . . . [−., .]Inhibitory control −.∗ −.∗ −.∗ [−., −.]Cognitive exibility −.∗∗ −.∗∗ [−., −.]Sustained attention . [−., −.]

2 . . . .

.∗∗∗ .∗∗∗ .∗∗∗ .∗∗∗Δ2 . . .Δ2 .∗ .∗∗ .

Note. N = . CI = condence interval. SSB = sugar-sweetened beverages. ∗ < 0.05; ∗∗ < 0.01; ∗∗∗ < 0.001.

mainly in older children. Tus, besides inhibitory controlanother executive unctions domain seems to be associatedto body weight and weight gain and, according to the presentnding, this seems to be true in younger children, too.

On the other hand, the third cognitive domain, sustainedattention, was not related to BMI percentiles in the currentinvestigation. Previous ndings concerningcognitive abilitiesother than executive unctions are inconsistent. Te literaturereview o Reinert et al. [] reports six studies ocusing on theassociation between obesity and general cognitive unctionwith hal o them demonstrating no relationship. Grazianoet al. [] considered sustained attention besides inhibitory control as part o cognitive sel-regulation. Body weighto their preschool children, however, was only associatedwith the inhibitory perormance but not with the attentionperormance. On the contrary, Cserjési et al. [] showedthe same result as or exibility in their adolescent sample:a signicant correlation o perormance in the D sustainedattention test with BMI and a signicant group difference to

the disadvantage o the obese. Te existing inconsistencies inresearch literature might be due to the different age groupsand to the use o different concepts and methods o the stud-ied cognitive abilities. Hence, standardisation concerningthe understanding and measurement o certain cognitionsshould be targeted and changes in outcomes according tostages o development should be taken into account whenaddressing this issue.

Besides the cognitive variables, parental body weight,BMI o mothers as well as BMI o athers, was signicantly associated with children’s body weight. Tis nding is notsurprising as it is consistent with the literature [, , ]and may be explained by genetic mechanisms as well as

the shared environment. Family characteristics such as theknowledge o risk actors o overweight, eating habits, andood preerences but also physical activity patterns []may inuence children’s health behaviour and body weight.Migration background was revealed to be signicantly asso-ciated with body weight as well. Tis nding is in line withprevious national investigations [, , ]. Te prevalenceo overweight and obesity is ound to be higher in childrenwith migration background and the odds o overweightincreased. Cultural attitudes and traditions concerning body weight and weight related behaviours (physical activity, Vconsumption, and dietary habits), social integration (e.g.,inuencing recreational activities), and the knowledge o risk actors hampered by language barriers may explain thisrelationship.

Executive unctions are seen to be crucial or sel-regulatory behaviour []. Tey have already been relatedto health behaviour such as physical activity, snack oodconsumption, and ruit/vegetable intake in ourth graders

[]. Tus, the association with children’s body weight may be mediated through more physical activity and healthy dietand less sedentary behaviour. As children just starting schoolare still more dependent on their parents and not com-pletely autonomous in their planning and decision-makingexecutive unctions may, however, be crucial to appreciateand maintain new and healthy behaviour introduced by their caregivers, to control their thoughts, their behaviouralimpulses, and their eelings. Assuming this directionality,potential implications would be to integrate the promotion o executive unctions in early obesity prevention efforts. Riggset al. [] suggested developing specic programme con-tents tailored to different obesity-risk proles depending on


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certain behaviour patterns, weight consciousness (especially as children get older), and decits in executive unctions.Beyond the overweight and obesity issue, it has been shownthat executive unctions play an important role or successand health throughout the whole lie. Tey are crucial orthe social and emotional development, school readiness, and

urther academic and job success, as well as wealth andmental and physical health even in the long term [ , ,, ]. Regulating emotions in social conicts, staying incontrol o onesel, adapting to rules when necessary, adoptingeffective problem-solving, and learning strategies are just aew examples when executive control is required. On the con-trary, decits are linked to social and health problems such asattention decit hyperactivity disorder, obsessive compulsivedisorder, depression, early school leaving early pregnancy,addiction, and criminality [, ]. Hence, strategies ocusingon the improvement o these abilities would probably leadto positive effects in more than one health and lie domainand even on a more public level (e.g., public saety and

economic costs). In return, learning to cope with the differentchallenges in lie successully and to reduce emotional andsocial stress means reducing psychological risk actors orexcessive weight gain again and starting a virtuous circle.Tere have already been national and international effortsaiming at an early improvement o executive unctions ingeneral [, , ]. Tese include school-based programmesand the integration o the promotion o these abilities in theofficial curriculum o primary schools in Germany. Tus,cognitive training in general and the integration o cognitiveimprovement in obesity interventions may be helpul ways toimprove uture generation’s health and overall quality o lie.

.. Strengths and Limitations. Results, however, should beinterpreted in light o study limitations. First, the cross-sectional study design precludes any causal interpretationo the ndings. Tereore, directionality o the associationbetween cognitive unctions and body weight still remainsunclear: on the one hand, cognitive unctions such asinhibitory control or cognitive exibilitymay inuence healthbehaviour and consequently weight development. On theother hand, body weight and variations in ood intake,physical activity, and sedentary activities, or example, may also affect cognitive perormance and brain development orthe relationship may be bidirectional as well. Further studiesare needed to clariy causality and underlying mechanisms in

order to derive any implications.Secondly, there are some limitations concerning missing

data and selection bias in the present study. Due to thesubsample and the missing or invalid data in the cognitivesubtests and the parent questionnaire the number o subjectsdecreased rom (in the Baden-Württemberg Study sam-ple) to in the nal regression analysis. Missing data may have led to a orm o selection bias. Te cognitive subsampleincluded, or example, more children with migration back-ground. However, more children with migration backgroundand with lower parental education level dropped out in theurther data processing maybe partly due to comprehensiondifficulties. Furthermore, more children with higher BMI

percentiles, higher consumption o sugar-sweetened bever-ages, and higher ather’s BMI were among those with missingdata. Tus, children who entered the nal analysis showed amore avourable prole in critical variables. Although migra-tion background is still representative or school children inGermany, the nal sample consisted o more children with

higher parental education indicating a higher social statusand lower body weight than usually ound in the population(as reerence, official statistics concerning German schoolchildren report .% migration background, .% tertiary parental education level, and .% overweight or obesity [, , ]). On the contrary, the reduced sample size andstatistical power may have led to an underestimation o signicances. Te inclusion o these missing cases could havepotentially strengthened the nal results. Furthermore, thismay in part explain why no signicant association betweenparental education and children’s body weight was ound.

Finally, underreporting in terms o recall bias or socialdesirability regarding children’s liestyle which was assessed

via parental questionnaire should be taken into account andmight explain the missing signicant association o these

variables with body weight. Te objective standardised anddirect measurements o cognitive and anthropometric data,on the other hand, as well as the large sample size constitute astrength o the study. Further, the ocused age group is highly relevantas excessiveweight gain is particularly pronounced atthe ageo school entry andimportant cognitivedevelopmentsespecially in executive unctions relevant or a wide variety o behaviour and health outcomes take place.

5. Conclusions

In summary, cognitive abilities were signicantly related to

body weight o primary school children controlling or ur-ther weight inuencing sociodemographic and liestyle ac-tors. Tis relationship concerns inhibitory control and cogni-tive exibility, both processes considered as executive unc-tions. As executive unctions are crucial or sel-regulationand disciplined behaviour including health behaviour, thending indicates that promoting executive unctions may assist in developing a healthy body weight and avoidingexcessive weight gain in addition to already existing obesity prevention efforts. However, urther research is necessary rst, in particular longitudinal and intervention studies, toconrm the present ndings, to determine the directionality o the association, and to investigate the impact o cognitive

training on weight related outcomes.

Conflict of Interests

Te authors declare that there is no conict o interests.

Acknowledgments

Te school-based health promotion programme “Komm mitin das gesunde Boot-Grundschule (Join the Healthy Boat-Primary School)” and its evaluation study (Baden-Württem-berg Study) were nanced by the Baden-Württemberg Foun-dation. Tey had no inuence on the content o the paper.


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Te authors would like to thank all members o the researchgroup or their input: the Institute o Epidemiology and Med-ical Biometry, Ulm University, the Institute o Psychology and Pedagogy, Ulm University, and, urther, all assistantswho were involved in the perormance o measurements andespecially all teachers and amilies or their participation in

the Baden-Württemberg Study.

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