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Appetite 50 (2008) 246251

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Research Report

Body mass index and neuropsychological function in healthy

children and adolescents
John Gunstada,b,, Mary Beth Spitznagela,b, Robert H. Paulc, Ronald A. Cohend,
Michael Kohne,f, Faith S. Luystera, Richard Clarkg, Leanne M. Williamse,h, Evian Gordone,h,i
a
Department of Psychology, Kent State University, USA
Summa Health System, Department of Psychiatry, Center for Neuropsychological Studies, USA
c
Department of Psychology, University of Missouri-St. Louis, USA
d
Department of Psychiatry, Brown Medical School, USA
e
The Brain Dynamics Centre, Westmead Millenium Institute, Westmead Hospital, Australia
f
Childrens Hospital at Westmead, Australia
g
Cognitive Neuroscience Laboratory and School of Psychology, Flinders University, Australia
h
Discipline of Psychological Medicine, Western Clinical School, University of Sydney, Australia
i
The Brain Resource International Database, Brain Resource Company, Australia

Received 24 February 2007; received in revised form 11 May 2007; accepted 22 July 2007

Abstract
Elevated body mass index (BMI) is associated with adverse neurocognitive outcome in adults, including reduced neuropsychological
test performance. It is unknown whether this relationship also exists in children and adolescents. A total of 478 children and adolescents
(age 619) without signicant medical or psychiatric history provided demographic information and completed a computerized cognitive
test battery. Participants were categorized using clinical criteria into underweight, normal weight, at risk for overweight and overweight
groups based on age and gender. Partial correlation and MANCOVA analyses adjusting for age and intellectual function found no
relationship between BMI and cognitive test performance in the full sample. However, analyses performed separately by gender showed
that underweight females exhibited poorer memory performance than other female BMI groups. These ndings suggest that elevated
BMI is not associated with cognitive function in healthy children and adolescents, though underweight might be a risk factor for reduced
memory performance in females. Further work is needed to clarify the inconsistent ndings between adults and minors.
r 2007 Elsevier Ltd. All rights reserved.
Keywords: Body mass index; Cognitive function; Childhood; Adolescence

Overweight and obesity have long been associated with

adverse health outcomes, including cardiovascular disease
and Type 2 diabetes (Bray, 2004; OBrien, Dixon, &
Brown, 2004). There is growing evidence that obesity is
also associated with poor neurocognitive outcome. Elevated body mass index (BMI) is an independent risk factor
for stroke and dementia (Gustafson, Rothenberg, Blennow, Steen, & Skoog, 2003; Rosengren, Skoog, Gustafson,
& Wilhelmsen, 2005; Whitmer, Gunderson, Barrett-Connor, Quesenberry, & Yaffe, 2005). Neurocognitive impairCorresponding author. 221 Kent Hall, Kent State University, Kent,
OH 44242, USA. Tel.: +1 330 672 2589; fax: +1 330 672 3789.
E-mail address: jgunstad@kent.edu (J. Gunstad).

0195-6663/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.appet.2007.07.008

ments have also been identied in adults without these

neurological conditions, including structural brain abnormalities and reduced cognitive function (Gunstad, Paul,
Cohen, Tate, & Gordon, 2006; Gunstad et al., 2007;
Gustafson, Lissner, Bengtsson, Bjorkelund, & Skoog,
2004; Gustafson, Steen, & Skoog, 2004).
Recent work suggests that the relationship between
obesity and cognitive impairment may not be limited to
adults, but may also be found in children and adolescents.
For example, though confounded by other conditions, low
birth weight is associated with lower intellectual function in
children (Hoff Esbjorn, Hansen, Greisen, & Mortensen,
2006; Martinez-Cruz, Poblano, Fernandez-Carrocera, Jimenez-Quiroz, & Tuyu-Torres, 2006). Several studies have

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J. Gunstad et al. / Appetite 50 (2008) 246251

found a relationship between childhood obesity and greater

risk for attention decit hyperactivity disorder (ADHD)
(Altfas, 2002; Lam & Yang, 2007). Two recent studies
found cognitive decits in young adults with elevated BMI,
despite having no comorbid medical conditions likely to
impact cognitive function (Gunstad et al., 2006, 2007).
Another possibility is that reduced cognitive function
increases subsequent risk of becoming overweight or obese,
rather than just the physiological effects of obesity
adversely impacting cognitive function (Chandola, Deary,
Blane, & Batty, 2006). Consistent with this notion, several
studies have now identied lower intellectual/cognitive
function is a risk factor for subsequent overweight or
obesity (Chandola et al., 2006; Halkjaer, Holst, &
Sorensen, 2003; Lawlor, Clark, Davey Smith, & Leon,
2006).
Given these ndings, determining whether greater BMI
is associated with poorer cognitive function in children and
adolescents is needed and may provide important insight.
First, if obesity is associated with neuropsychological
dysfunction in children and adolescents, its increasing
prevalence would require the need for additional services in
school systems. Second, clarication of the relationship
between BMI and neuropsychological function in children
and adolescents may provide further insight into possible
mechanisms for this relationship. Therefore, we examined
BMI and cognitive function in 478 children and adolescents (age 619) without signicant medical or psychiatric
history. Based on the above ndings, we predicted elevated
BMI would be associated with reduced cognitive functioning.

Method
Overview
This study employed data from the Brain Resource
International Database (Gordon, Cooper, Rennie, Hermens, & Williams, 2005) an archive of demographic,
psychiatric, health and cognitive data. Six laboratories
participated in data acquisition in a total quality-controlled
manner (New York, Rhode Island, Holland, London,
Adelaide and Sydney). Participants are recruited from the
community through advertisements and iers. Exclusion
criteria for the Database include medical conditions known
to impact cognition, including neurological injury/illness
and other medical conditions (e.g. attention decits
hyperactivity disorder, cardiovascular disease, diabetes).
Potential participants were also excluded for signicant
mental illness (e.g. schizophrenia, bipolar disorder, substance abuse and eating disorders) or family history of
conditions such as ADHD, schizophrenia and bipolar
disorder. Informed consent was obtained from individuals
who were of legal age and parents/guardians for all minors.
They were also asked to refrain from caffeine and nicotine
for at least 2 h and from alcohol for at least 12 h prior to

247

testing. Prior to study onset, all procedures were approved

by the local review board.
Participants
Data from a total of 478 children and adolescents with
complete information were analyzed. Participants averaged
12.4573.26 years of age (range 619) and 7.6873.22 years
of education. They were categorized using age and gender
into BMI groups using standard BMI-growth curves for
age and gender criteria: underweight (o5th percentile),
normal weight (585th percentile), at risk of overweight
(8595th percentile) and overweight groups (495th percentile) (Hammer, Kraemer, Wilson, Ritter, & Dornbusch,
1991; Pietrobelli, Faith, Allison, Gallagher, Chiumello, &
Heymseld, 1998). No differences emerged between participants from different performance sites and data were
collapsed for subsequent analyses.
Procedure
Subjects were seated in a sound-attenuated room, and
completed questionnaires and cognitive tests on a touchscreen computer (NEC MultiSync LCD 1530V). Parents/
guardians assisted children with questionnaires to ensure
accurate information was provided regarding height,
weight and medical information. Cognitive tests were
administered in a xed order using pre-recorded task
instructions. During testing, participants are seated in a
sound-attenuated room and complete tasks using a touchscreen computer .wav les for vocalized responses. The
computerized test battery was specically developed for use
in persons across the lifespan to promote comparison of
test performances and shows good psychometric properties, including strong reliability and validity (Paul et al.,
2005; Williams et al., 2005). Tests were selected to represent
estimated overall intellectual ability and each primary
cognitive domain, including the following.
Estimated intellectual function
Spot-the-Word: This task is a computerized adaptation
of the Spot the Real Word test (Baddeley, Emslie, &
Nimmo-Smith, 1993). Participants are presented with two
words on the touch-screen. One of the two words is a valid
word in the English language and the other a non-word
foil. Participants are asked to identify the real word.
Number of correct responses was used as an estimate of
intellectual functioning.
Attention
Digit Span Backward: Participants were presented with a
series of digits presented individually for 500 ms and
separated by a 1 s interval. Participants then entered the
digits on a numeric keypad on the touch-screen in reverse
order. The number of digits in each sequence was gradually
increased from three to nine and the dependent measure
was the maximum number of digits recalled without error.

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J. Gunstad et al. / Appetite 50 (2008) 246251

Executive functioning
Switching of AttentionLetter/Number: This task is
similar to Trail Making Test B and requires connecting of
numbers and letters in an ascending but alternating
sequence (i.e. 1-A-2-B, etc.). The numbers 113 and the
letters AL were presented in circles on the touch-screen.
Time to completion was employed as the dependent
variable.
Memory
Verbal Recall: Participants were asked to read and
memorize a list of 12 words. The list was presented 4 times
and participants were required to recall as many words as
possible after each presentation. They were then presented
with a list of distracter words and asked to recall those.
Participants were then asked to recall the 12 original target
words. Following a lled delay, participants were again
asked to recall the original 12 target words. Total number
of words recalled at long delay free recall was used as the
dependent variable.
Language
Animal Fluency: Participants orally generate exemplars
of animals for 60 s, with the total number of animals
named serving as the dependent variable.
Motor
Finger Tapping: Subjects tapped a circle with their index
nger as fast as possible for 60 s. The dependent variable
was the number of taps with dominant hand.
Data analytic plan
Several analyses examined the relationship between BMI
and cognitive function. Partial Pearson correlations were
calculated between BMI and test performance while
adjusting for age and estimated intellectual function. Next,
MANCOVA adjusting for age and estimated intellectual
function compared cognitive performance across clinically
dened BMI groups (based on age and gender). Finally, to
ensure the relationship between BMI and cognitive
function did not differ between males and females,
MANCOVA adjusting for age and estimated intellectual
function was performed separately by gender.
Results
Correlation between BMI and neuropsychological function
Partial Pearson correlation adjusting for age found no
relationship between BMI and cognitive function. See
Table 1.
BMI groups and neuropsychological function
BMI groups differed in age and education, but not
gender. See Table 2. MANCOVA adjusting for age and

Table 1
Partial correlation between body mass index and neuropsychological test
performance in children and adolescents
Cognitive test

BMI

Digit Span Backward

Switching of AttentionLetter/Number
Verbal Recall
Animal Fluency
Finger Tapping

0.05
0.05
0.04
0.03
0.02

Note: All correlations were adjusted for age and estimated intellectual
function. No correlation was signicant.

intellectual function found no differences in cognitive

function across BMI groups [l 0.96, F(15, 1295.22)
1.21, p 0.26].
Gender, BMI groups and neuropsychological function
Finally, to determine whether the relationship between
BMI and neuropsychological function differed across
genders, a MANCOVA adjusting for age and estimated
intellectual function was performed on test performance
separately for males and females. Though no differences
emerged across BMI groups for males [l 0.97, F(15,
646.37) 0.51, p 0.94], a signicant difference emerged
for females [l .87, F(15, 616) 2.08, p 0.01]. Followup tests revealed BMI groups differed in Verbal Recall test
performance [F(3, 227) 5.43, p 0.001], as underweight
females recalled fewer words than all other female BMI
groups. See Table 3.
Discussion
The current study found no relationship between
elevated BMI and neuropsychological function in healthy
children and adolescents. This pattern emerged despite
recruitment of a reasonably sized sample and use of
multiple analytical approaches. Some evidence for an
association between low BMI and reduced memory
performance emerged in females. Several aspects of these
ndings warrant brief discussion.
Past studies linking childhood obesity to reduced
performance on testing or conditions such as ADHD have
been inconsistent, with some studies showing greater risk
for those with elevated BMI and others not (Altfas, 2002;
Lam & Yang, 2007). In the current study, no relationship
emerged between BMI and any neuropsychological test,
including those sensitive to attentional difculties. The
exact reason for the inconsistent ndings across studies is
unclear and complicated by methodological differences.
Different enrollment criteria (i.e. minors vs. adult retrospection) and determination of cognitive impairment (i.e.
objective testing vs. self-report) preclude direct comparison. Additional work is needed to clarify the source of
these inconsistent ndings, particularly prospective studies.

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J. Gunstad et al. / Appetite 50 (2008) 246251

249

Table 2
Comparison of neuropsychological test performance across BMI groups
Underweight
(N 27)
Characteristics
Body mass indexa
Ageb
Years of educationb
Spot-the-word score
% Female
Neuropsychological test performance
Digit Span Backward
Switching AttentionLetter/Number
Verbal Recall
Animal Fluency
Finger Tapping
a

Normal
(N 330)

At risk (N 76)

Overweight
(N 45)

14.7971.82
12.6374.13
7.7474.03
38.9378.07
41

18.5272.57
12.6273.17
7.8573.13
39.9976.56
51

23.0772.86
12.5773.29
7.8473.22
39.8776.99
47

26.2174.60
10.8272.92
6.1172.99
38.1176.05
38

3.2672.18
51.9279.75
6.6772.59
19.1577.98
138.11744.38

3.5871.69
49.07710.93
7.8272.23
20.4276.37
140.90736.44

3.3871.93
51.08710.21
7.9972.54
21.4275.87
143.26734.06

3.1371.70
53.94710.71
7.2972.69
18.3175.37
130.47735.49

Denotes underweightonormal weightoat riskooverweight.

Denotes overweightonormal weightoat risk

Table 3
Comparison of neuropsychological test performance across BMI groups in females
Underweight
(N 11)
Characteristics
Body mass indexa
Age
Years of education
Spot-the-Word score
Neuropsychological test performance
Digit Span Backward
Switching AttentionLetter/Number
Verbal Recallb
Animal Fluency
Finger Tapping
a

Normal (N 169)

At risk (N 36)

Overweight (N 17)

14.8372.23
13.2774.38
8.6474.39
39.0979.02

18.3672.43
12.4972.97
7.8173.01
40.2575.92

22.9172.76
11.9272.96
7.3972.92
38.6775.90

25.8974.38
11.2373.63
6.2973.75
38.7175.90

3.0972.30
52.29710.62
6.0973.15
21.5578.63
137.55730.14

3.7271.53
47.91711.08
8.2872.05
21.5076.35
140.53733.87

3.0371.89
51.10710.36
8.5072.17
21.9775.96
133.44734.76

3.5971.37
52.9979.20
7.5971.91
18.6576.63
127.53731.07

Denotes underweightonormal weightoat riskooverweight.

Denotes underweightoall other groups.

The absence of a relationship between elevated BMI and

neuropsychological function in the current study may
indirectly provide insight into the mechanisms by which
obesity impacts neurocognitive outcome. Conceptually,
there are several ways in which obesity and cognitive
function may be linked, including: (1) obesity acutely
impacting cognitive function; (2) obesity limiting cognitive
function through chronic effects over extended periods of
time; (3) reduced cognitive function lead to greater
likelihood of obesity and (4) both obesity and cognitive
dysfunction result from a higher order neurophysiological
process. As described above, recent work shows that even
healthy adults with elevated BMI exhibit reduced test
performance compared to their normal weight peers
(Gunstad et al., 2006, 2007). The absence of a relationship
in children and adolescents further implicates the chronic
pathophysiological processes associated with obesity as
likely mechanisms, including altered insulin regulation,

endothelial dysfunction or systemic inammation (Convit,

Wolf, Tarshish, & de Leon, 2003; Rahmouni, Correia,
Haynes, & Mark, 2005; Teunissen et al., 2003). Each of
these processes is known to have negative effects on
cognitive functions in other populations. Another, less
likely, explanation is that BMI is inuenced by different
factors in minors vs. adults (Parsons, Power, Logan, &
Summerbell, 1999). Adults have greater opportunity to
regulate their food and activity choices than children, and
thus reduced self-monitoring or impulse control may be
more closely linked to BMI in adults. Data from longitudinal studies assessing persons from childhood through
old age are needed to determine the long-term relationships
between BMI and cognitive function and studies should
examine whether weight loss can improve cognitive
function in some individuals.
In the current study, underweight female children and
adolescents exhibited reduced memory performance relative

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J. Gunstad et al. / Appetite 50 (2008) 246251

to other BMI groups. These ndings emerged despite

statistical adjustment for possible confounds and screening
for medical/psychological conditions likely to impact the
results (including eating-related pathology). The etiology of
these decits is unclear. One possibility is that some
individuals were intentionally dieting at the time of the
evaluation. Studies examining intentional caloric restriction
and cognitive test performance are inconsistent, ranging
from mild decline to no change to mild improvement in test
performance (Bryan & Tiggemann, 2001; Green & Rogers,
1995; Green, Rogers, Elliman, & Gatenby, 1994; Pollitt,
Leibel, & Greenfeld, 1981; Pollitt, Lewis, Garza, & Shulman, 1983). Another possibility is that underweight
individuals have lower levels of biochemicals needed for
optimal cognitive function. For example, recent work
suggests underweight individuals have lower levels of
insulin-like growth factor-I and brain derived neurotrophic
factor, both of which are implicated with better cognitive
function in adult samples (Laske et al., 2006; Monteleone et
al., 2005; Okereke et al., 2007; Schneider et al., 2006).
Replication in other samples and determination of possible
mechanisms is needed.
Findings from the present study are limited in several
ways. Though our strict exclusion criteria provide insight
into the independent relationship between BMI and
cognitive function, it may underestimate the relationship
found in the general population. Conditions such as Type 2
diabetes are commonly found in overweight children and
can adversely impact cognition (Bindler & Bruya, 2006;
Kilpelainen, Terho, Helenius, & Koskenvuo, 2006).
Further work is also needed to determine how socioeconomic status (SES) inuences the relationship between
BMI and cognitive function, as it is independently
associated with each of them (Inagami, Cohen, Finch, &
Asch, 2006; Richards & Wadsworth, 2004). A nal
limitation is our reliance upon reported BMI as our sole
measure of obesity, as other obesity indices (e.g. body
composition, waist-to-hip ratio) may show a differential
relationship to cognitive function (Jeong, Nam, Son, Son,
& Cho, 2005).
In brief summary, the present study found no relationship between elevated BMI and cognitive dysfunction in a
general sample of healthy children and adolescents, though
some evidence for an association between low BMI and
reduced memory performance emerged in females. Further
work is needed to clarify possible decits in other aspects of
cognitive function (e.g. achievement testing) and to identify
mechanisms in adults.

Acknowledgments
We acknowledge the collaboration with the Brain
Resource International Database (under the auspices of
the Brain Resource Company; www.brainresource.com)
for data acquisition and methodology.

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