González-Fernández et al.

BMC Pediatrics (2023) 23:204 BMC Pediatrics

https://doi.org/10.1186/s12887-023-04028-8

RESEARCH Open Access

Relationship between cognitive functioning

and physical fitness in regard to age and sex
Francisco Tomás González-Fernández1, Gabriel Delgado-García2, Jesús Siquier Coll2, Ana Filipa Silva3,4,
Hadi Nobari6,7*† and Filipe Manuel Clemente4,5†

Abstract
The aim of this study was to analyze the relationships among physical cognitive ability, academic performance, and
physical fitness regarding age and sex in a group of 187 students (53.48% male, 46.52% female) from one town of
Norwest of Jaén, Andalusia (Spain), aged between 9 and 15 years old (M = 11.97, SD = 1.99). The D2 attention test
was used in order to analyze selective attention and concentration. Physical fitness, reflected on maximal oxygen
uptake (VO2max), was evaluated using the 6 min Walking Test (6MWT). The analysis taken indicated a significant
relationship between physical fitness level, attention, and concentration, as in the general sample looking at sex
(finding differences between boys and girls in some DA score in almost all age categories [p < 0.05]) and at age
category (finding some differences between the younger age category groups and the older age category groups
in some DA scores (p < 0.05), not finding any significant interaction between sex and age category (p > 0.05). In
sum, the present study revealed that students with better aerobic fitness can present better-processed elements
and smaller omission errors. Moreover, girls and older students seem to present better cognitive functioning scores
than boys and younger. Our findings suggest that more research is necessary to elucidate the cognitive function
between ages, sexes, and physical fitness and anthropometry levels of students.
Keywords D2 attention test, Attention, Concentration, Physical fitness, Cognitive, Sports activity

Introduction
†
These authors share last authorship.
Current sedentary behavior of children over the last
decade has created a huge problem for society. The devel-
*Correspondence:
Hadi Nobari opment of video games and mobile screens has led to
[email protected] children spending more time playing video games to the
1
Department of Physical Education and Sports, Faculty of Sport Sciences, detriment of physical activity [1]. Sedentary lifestyles in
University of Granada, Granada, Granada 18071, Spain
2
SER Research Group, Department of Physical Activity and Sport Sciences, children trigger metabolic diseases such as obesity [2] or
Center of Higher Education Alberta Giménez (Affiliated to Pontifical, other psychological illnesses such as depression [3]. Lev-
University of Comillas), Palma 07013, Spain
3
els of physical activity (PA) are reported to be lower than
The Research Centre in Sports Sciences, Health Sciences and Human
Development (CIDESD), Vila Real 5001-801, Portugal in previous years and continue to decline [4], exacerbated
4
Escola Superior Desporto e Lazer, Instituto Politécnico de Viana do by the pandemic situation [5]. Siquier Coll et al. [6] men-
Castelo, Rua Escola Industrial e Comercial de Nun’Álvares, tioned that there is a high number of children and pre-
Viana do Castelo 4900-347, Portugal
5
Instituto de Telecomunicações, Delegação da Covilhã, Lisboa adolescents who do not achieve the recommended level
1049-001, Portugal of PA. This study found lower cardiovascular values and
6
Department of Exercise Physiology, Faculty of Educational Sciences and body composition in sedentary children compared to
Psychology, University of Mohaghegh Ardabili, 56199-11367 Ardabil, Iran
7
Faculty of Sport Science, University of Extremadura, Cáceres, Spain groups of children practicing in different sports. Another

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González-Fernández et al. BMC Pediatrics (2023) 23:204 Page 2 of 9

research reported that higher sedentary hours were asso- groups and sex differences [9]. Therefore, there is a need
ciated with lower cardiorespiratory fitness [7]. Besides, for this study, which could lead to a better understanding
physical inactivity has been reported to be related to of the topic. Based on the above, it is hypothesized that
poorer attention and academic performance of students the students with higher values of physical fitness, con-
in primary and secondary schools [8]. cretely in maximal oxygen uptake (VO2max) will have bet-
Elsewhere, it has been suggested that aerobic capacity ter performance in cognition, reflexed in different values
is the best predictor of cognitive function [9]. Reigal et al. of D2 attention test. Thus, this study aimed to observe
[10] stated that oxygen consumption is the best predictor the possible relationships between aerobic fitness and
of attentional parameters. Similarly, a recent systematic cognition in a specific test (d-2 test).
review reported that higher aerobic capacity is related to
higher academic performance [11]. Therefore, research Materials and methods
on physical activity levels, academic performance and Study Design
attention has been booming in recent years [12–14]. PA This study followed a cross-sectional design. Conve-
involves the development of attention in childhood [15], nience sampling was performed. The study was con-
especially in open-task sports [16]. These sports require ducted in January 2022 and students were assessed three
decision-making in which the child needs to be highly times. The first, second, and third assessments were
attentive. Recent study reported improvements in selec- separated by one week. The purpose was to understand
tive attention in children with attention deficit hyperac- the relationship between the cognitive ability reflexed in
tivity disorder [17]. Nevertheless, benefits in attention the D2 attention test, and physical fitness through 6 min
in closed-task PA have also been reported. Herold, Beh- walking test considering the sex and age as moderators.
rendt, Meißner, Müller, & Schega [18] found enhance- During the assessment, 12 participants were excluded
ments in the d-2 attention test acutely following sprint [inability to perform the D2 attention test (n = 6) and
interval training. Another recent study reported an asso- only performed one or two of assessing (n = 6)]. Finally,
ciation between the D2 attention test and fitness level 187 participants remained and completed the entire
[10]. experiment.
Likewise, Chen, Gu, Chen, & Wang (2022) [19] found
an association with D2 attention test and cardiorespira- Participants
tory fitness in schoolchildren. Hogan et al., [20] reported A total of 187 students (53.48% male, 46.52% female)
that physical fitness and acute exercise could improve from two schools from the region of Andalucía, partici-
cognition by increasing the functionality of the atten- pated in the present research. Students were recruited
tional system in adolescence. Attention, an aspect of from one village of the province of Jaén with a population
cognition, has also been reported to be closely linked to ranging from 5,000 to 10,000 inhabitants according to the
aerobic fitness throughout the human lifespan [21, 22]. National Institute of Statistics from the Spanish Govern-
Furthermore, PA improves attention through increased ment (http://www.ine.es/; accessed on 12 February 2022).
release of transmitters involved in cognitive processes A priori sample size calculation was performed using a
[22]. Thus, low fitness levels appear to be correlated free on-line tool, G*Power (www.gpower.hhu.de), with a
with poorer cognitive skills [23]. Higher fitness levels power level of 95% and an α level of 0.05 and based in
are associated with higher executive functioning perfor- previous and similar studies [10], revealed that the sam-
mance in different conditions of the Erikson flanker task, ple size of > 160 would be sufficient for the analysis.
and also with higher P3 amplitudes of the event-related
potential (ERP) in response to stimuli. This fact suggests Informed consent s were obtained from parents of all
that a stronger allocation of attentional resources dur- the participants and signed regarding all participants
ing stimulus encoding is related to better performance in involved in this study. The study was conducted according
more physically fit children [20]. Possible physiological to the Declaration of Helsinki and was approved by the
mechanisms of exercise-induced neural adaptation are ethics committee of institute’s research of the Pontifical
the promotion of cerebral vascularisation, up-regulation University of Comillas (2021/89).
of genes associated with cellular plasticity, increased On the one hand, inclusion criteria were: i) students that
regional blood flow, and increased levels of brain-derived were assessment during all experimental sessions. On
neurotrophic factor (BDNF) [20]. Hence, it is necessary the other hand, exclusion criteria for participants in this
to study the relationship between cognition and physi- study were (i) reported normal vision and no history of
cal activity levels. The relationship between attention and any neuropsychological impairments that could affect the
physical activity levels has been established [15]. How- results of the experiment and (ii) have a health problem
ever, few studies have assessed the relationship between that could bias any result or prevent you from taking a
cardiorespiratory fitness and attention in different age test of the study, and (c) not have parental authorization.

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Measures and Instruments test has a test–retest reliability in the original study up to
Anthropometry 0.90.
Height and body weight were collected at the beginning
of assessment, at the same hour and at the same day of Procedure
the week (between 9:30 a.m. to 11:30 a.m.). Height was Sample set was obtained from two schools. Every school
measured using a stadiometer (SECA 213, Birming- management was contacted in order to request them to
ham, UK) to the nearest 0.1 cm, and players were asked participate. In addition, written and informed consent
to remove their shoes and other accessories that could was obtained from the parent/guardian of each adoles-
influence the assessment. Students also had to be in a cent who wanted to participate. Evaluations were taken
vertical and immobile position, with arms extended along along 24 to 72 h difference between them.
the body, and look straight ahead in an upright position. Physical fitness (6MWT) was evaluated on the first day
For each measure, only one measurement was collected. during the class of physical education, attention and con-
centration were evaluated in the second day and finally,
Physical fitness academic performance was recollected by the advisor of
The 6 min Walking Test (6MWT) is a sub-maximal exer- both schools since academic bulletin (always with the
cise test used to assess aerobic capacity and endurance. authorization of responsible). The evaluation schedules
It was developed by the American Thoracic Society, were from 9:00 to 13:30 in the morning.
and it involves a corridor with a length of at least 30 m. The D2 attention test was taken following the proto-
The length of the route should be marked every 3 m, col established in the test. Instructions were carefully
the return points should be marked with cones and the explained to the students and previous questions were
starting point should be indicated with a brightly colored solved in order to avoid any doubts. In all cases, the
tape. All participants were reported to walk back and explanation was performed by one education phycologist.
forth in a straight line as fast as possible with self-paced The test was conducted in groups in a classroom at the
over a 6-minute period of time. During the 6MWT, all school. For the physical tests, a 10-min warm-up was car-
the subjects were informed every 1 min. HR was mea- ried out. Activation and joint mobility were developed.
sured during the 6MWT by telemetry (Heart Rate Trans- Subsequently, the 6 min walking test was conducted.
mitter Model T34; Polar). Once 6MWT is over, the total
carried out distance over 6 min was registered as the Statistical analysis
result of 6MWD test. To confirm the reproducibility of Data analysis was performed using Real Statistic Using
the 6MWT, 80 boys randomly were asked to repeat the Excel software. Data are mean ± standard deviation,
6MWT with an interval of 1 week [24, 25]. unless otherwise stated. Significant p-value was estab-
lished at p < 0.05.
D2 attention test A two-factor ANOVA was conducted to test for differ-
Selective attention was measured with the D2 attention ences in the attentional variables by age category and for
test individually (Brickenkamp & Zillmer, 1998) [26]. It is sex. Our focal variable was age category, and our mod-
used to analyses the visually ability to scan and select cer- erator variable was sex. ANOVA was performed using
tain relevant aspects of a task, while ignoring irrelevant regression analysis. Partial eta squared (η2) was used as
ones quickly and accurately. It consists of 14 rows of 47 effect size. To interpret the magnitude of the eta squares,
characters each, with a total of 658 elements. The items we adopted the following criteria (Cohen, 2013): r ≤ 0.003,
can be “p” or “d” with one, two, three, or four dashes, no effect; 0.010 ≤ r < 0.060, small effect; 0.060 ≤ r < 0.140,
arranged either individually or in pairs at the top and/or intermediate effect and eta square ≥ 0.14, large effect.
bottom of each letter. Thus, the “d’s” with two dashes - Normal distribution and homogeneity tests (Shapiro-
regardless of position- should be crossed. Subjects have Wilk’s test) were conducted on all metrics and the stu-
20 s per row and have to mark as many of those d’s as dentized residuals based on the regression line (p > 0.05).
possible. The scores that subjects can obtained were the Simple effect of age category and sex was also evaluated.
following: TR (processed elements), TA (successes), O Tukey HSD for two factor ANOVA was also used for
(omissions), C (commissions or errors), TOT [effec- post-hoc testing (for age category and sex). In addition,
tiveness in the task = TR− (O + C)], CON (concentra- a Pearson’s correlation coefficient r was used to examine
tion = TA − C), TR+ (last stimulus analyzed in the row the relationship between age category and different DA
with the most attempted elements), TR− (last stimulus scores, VO2max and Body Mass Index (BMI). To inter-
analyzed in the row with the least attempted elements) pret the magnitude of these correlations, we adopted
and VAR [index of variation between the last stimulus the following criteria: r ≤ 0.1, trivial; 0.1 < r ≤ 0.3, small;
analyzed between different rows = (TR+) − (TR−)]. This 0.3 < r ≤ 0.5, moderate; 0.5 < r ≤ 0.7, large; 0.7 < r ≤ 0.9,
very large; and r > 0.9, almost perfect. The effect size was

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Table 1 Participants’ characteristics (Mean ± SD) of the present study (total N = 187) by age category
Age category
Variable 9y 10 y 11 y 12 y 13 y 14 y 15 y
N 23 39 30 11 38 27 21
Height (cm) 140.7 ± 7.1 146.2 ± 12.5 149.2 ± 7.7 157.3 ± 4.9 162.0 ± 6.5 164.9 ± 7.1 164.6 ± 6.8
BW (kg) 38.13 ± 10.03 39.72 ± 10.14 43.01 ± 11.01 55.12 ± 12.67 54.80 ± 11.86 56.50 ± 11.18 57.40 ± 8.69
BMI (kg/m2) 19.15 ± 3.54 18.54 ± 3.73 19.08 ± 3.49 22.19 ± 4.52 20.76 ± 3.54 20.64 ± 2.91 21.06 ± 1.77
V02Max(ml/kg/min) 35.43 ± 3.28 38.67 ± 5.32 38.06 ± 4.61 34.75 ± 5.45 34.04 ± 4.72 34.11 ± 3.90 34.15 ± 2.14
SD: Standard deviation; y: years; BW: Body Weight; BMI: Body Mass Index; VO2 max.: maximal oxygen consumption

Table 2 Summary of the Two-Way ANOVAs performed, including sex and age category as independent variables and the different DA
scores as dependent variables
DA score Comparison Two-Way ANOVA parameter
df MS F p-value P eta-sq
TR Sex 1 11,066 2.32 0.130 0.013
Age category 6 50,354 10.54 ≤ 0.0001 0.269
Inter 6 3062 0.64 0.697 0.022
Within 172 4776
Total 185 6716
TA Sex 1 3187 1.48 0.225 0.009
Age category 6 7099 3.31 0.004 0.103
Inter 6 1698 0.79 0.578 0.027
Within 172 2146
Total 185 2418
O Sex 1 703 1.08 0.300 0.006
Age category 6 1019 1.56 0.160 0.052
Inter 6 996 1.53 0.171 0.051
Within 172 651
Total 185 684
C Sex 1 1 0.01 0.937 0
Age category 6 153 1.25 0.284 0.042
Inter 6 258 2.1 0.056 0.068
Within 172 123
Total 185 130
TR+ Sex 1 9 0.14 0.709 0.001
Age category 6 339 5.56 ≤ 0.0001 0.162
Inter 6 13 0.22 0.970 0.008
Within 172 61
Total 185 69
TR- Sex 1 8 0.23 0.632 0.001
Age category 6 192 5.19 ≤ 0.0001 0.153
Inter 6 18 0.49 0.813 0.017
Within 172 37
Total 185 44
*df: Degree of freedom; MS: Mean Square; F: F ratio; P eta-sq: Partial Eta square; Inter: Interaction

assessed following Cohen’s scale (2013): (I) 0-0.20, “negli- O score, C Score and DA Score) showed no statistically
gible effect”; (II) 0.20–0.50, “small effect”; (III) 0.50–0.80, significant interaction between sex and age in any case
“medium effect”; (IV) 0.80-1, “large effect”. (p > 0.05). (See Table 2 for more information)
Comparisons between sexes in each age category
Results showed differences in the 11 years old group for the
Descriptive statistics were calculated for each variable C score (p = 0.023, F = 5.23), in the 12 for the O score
(Table 1). (p = 0.019, F = 5.57), in the 14 years old group for the C
The two-factor ANOVAs conducted with the different score (p = 0.024, F = 5.17) and in the 15 years group of age
DA scores (TR score, TA score, TR + score, TR- score, for TA score (p = 0.02, F = 5.33).

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Regarding comparisons among age categories, Tukey and between the 11 and 13-, 14-, 15- years old groups
HSD showed significant differences in: (i) TR between (Fig. 1c); and (iv) in TR- between the 9 years old group
the 9-, 10- and 11- with the 13-, 14- and 15-years old and the 13-, 14- and 15-years old group and between the
groups (Fig. 1a); (ii) in TA between the 9- and 10-years 10- and 11-years old group (Fig. 1d).
categories and the 15 years old category (Fig. 1b); (iii) As for comparisons among age categories in the case
in TR + between the 10 and 14- and 15-years old groups of boys, there were differences between the different

Fig. 1 D2 test of attention scores by age category. Figure 1a refer to total responses (TR), Fig. 2b to successes (TA), Fig. 2c to last stimulus analyzed in the
row with the most attempted elements (TR+), and Fig. 2d to last stimulus analyzed in the row with the least attempted elements (TR-).

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González-Fernández et al. BMC Pediatrics (2023) 23:204 Page 6 of 9

categories of age for the TR (p < 0.001), TR+ (p = 0.039), brain potentials occurring approximately 300–800 ms
TR- (p = 0.008). In the case of the girls there were differ- after stimulus onset) amplitude [28] and faster P3 latency
ences between categories of age for TR, TA (p < 0.001), [29] along midline scalp sites in response to a stimu-
TR+ (p < 0.001), TR- (p < 0.001), O (p = 0.007) and C score lus discrimination compared to those with worse aero-
(p = 0.010). bic fitness. This can be one of the causes to justify the
In the case of the correlations between the differ- beneficial effects of aerobic fitness for improving suc-
ent DA scores and the VO2max obtained in 6MWT a ceeded proceeded elements and reducing the omission
positive moderate correlation was found for TA in the errors. This fact is confirmed in adults and also children
11–12 years old group and for O in the 9 years old group and youth populations since original research showed
(r = 0.32, p = 0.041 and r = 0.48, p = 0.003, respectively). that fitness was positively associated with neuroelectric
A negative moderate correlation was found for O in the indices of attention and working memory and response
11–12 years old group (r = -0.43, p = 0.005). Last, a posi- speed in children, while cognitive processing speed was
tive large correlation was found for TR, TR + and TR- independent of age [26]. Another explanation of posi-
in students of 15 years old (r = 0.59, p = 0.002 [Fig. 2a]; tive effects of aerobic fitness is the possibility of greater
r = 0.53, p = 0.007 [Fig. 2b], r = 0.52, p = 0.008 [Fig. 2c]). aerobic fitness and namely aerobic exercise may increase
DA scores and the BMI (kg/m²) showed a negative synchrony in the firing of neural generators, with positive
moderate correlation with TR in the 15 years old group consequences to increase P3 amplitude and decrease P3
(r = -0.42, p = 0.037), with O in the 9- and 14-years old latency [26].
group (r = -0.46, p = 0.035; r = -0.42, p = 0.039, respec- In our study, it was also found that students in 11 and
tively) and with TR + in the 14 years old group (r = -0.44, 12 years old with greater BMI were the same with greater
p = 0.03). A positive large correlation was found for O in omissions. Although the BMI is not the best indicator of
the 11–12 years old group (r = 0.50, p = 0.001 [Fig. 2d]). fat and health, overweight can be identified while using
BMI. It is expectable a greater sedentary behavior and
Discussion worse physical fitness in students with worse BMI may
The main aim of the present study was to analyze the justify the linear relationship with the increased omission
relationships between aerobic fitness and cognition (in a errors. However, these results were the oppositive in 9
specific test: d-2 test). As hypothesized, correlations were and 14 years old. Possibly, the absence of markers related
observed between aerobic fitness and some DA scores. with fat mass can influence the results interpretation. As
For instance, in 9 years old group, a positive moderate an example, students may present greater BMI without
correlation was found with omissions (O), in opposition, necessarily being related with greater body fat composi-
it was moderately negative in 11–12 years old group. A tion but with a greater lean mass justifying that.
positive moderate correlation was registered with TA Our study also revealed some differences between ages
in 11–12 years old group. However, it was in the age regarding cognitive functioning. Older tended to pres-
of 15 years that positive large correlations were found ent better scores in TR, TR + and TR- than younger ones.
with processed elements (TR), TR + and TR-. Moreover, In addition, students with 12 years old had significant
higher BMI (which could mean lower PA, thus lower greater omissions, while students with 11 years old had
aerobic capacity) showed negative moderate correlations the greatest commissions or errors. Differences in age,
with O in the 9- and 14-years old group, with TR + in the namely increase in performance of attention and cogni-
14 years old group and with TR in the 15 years old group. tive performance in older participants can be justified by
Conversely positive large correlation was found between the maturational effect. For example, younger activate
BMI and O in the 11–12 years old group. Therefore, the the left ventrolateral prefrontal cortex rather than the
present study seems suggest that a positive correlation expected right ventrolateral prefrontal cortex exhibited
exists between aerobic capacity and cognition (using d-2 in adults [30]. The fact of the magnitude of activation of
test) in young ages. the left ventrolateral prefrontal cortex is similar to the
The relationships between aerobic fitness (namely adult’s activation of the right ventrolateral suggests that
maximal oxygen uptake) and cognitive function have through the development, children may change patterns
been presented in previous studies [26]. Additionally, of activation namely recruiting different neural resources
students with better aerobic fitness have been also asso- than older to achieve similar goals, albeit with less effi-
ciated with better academic achievements [27]. In our ciency [26].
study, it was found that in some ages the better aerobic Differences in cognitive scores between boys and girls
fitness the TR and TR+. Additionally, the better aerobic were also found. The current research revealed that girls
fitness the smaller omission error. Better aerobic fitness presented significant greater values than boys in C at age
and greater PA participation have been associated with 11 and 14, in O at age 12 and in TA at age 15. In oppo-
greater P3 (endogenous component of the event-related sition, no significant differences in TR + or TR- have

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Fig. 2 Regression lines (with large effect size) predicting the estimated VO2max or the BMI, based on the DA scores

been found. Previous studies revealed that PA interven- the interaction of physical fitness with the fact that girls
tions seem to play a greater role in benefiting girls than achieve maturation earlier than boys with natural conse-
boys regarding performance in the D2 attention test quences in hormonal and neurological modifications may
[31]. This can be justified by the typical smaller physical also provide a reason to girls presented better scores than
activity levels of girls in comparison to boys. However, boys in these sensitive ages analyzed.

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González-Fernández et al. BMC Pediatrics (2023) 23:204 Page 8 of 9

participants involved in this study. The study was conducted according to

The current research presents some limitations. One of the Declaration of Helsinki and was approved by the ethics committee of
the limitations is related with the absence of some con- institute’s research of the Pontifical University of Comillas (2021/89).
textual factors that can interact as covariables to explain
Consent for publication
some of the evidence found (e.g., academic level and Not Applicable.
achievements, other cognitive functions). Moreover, PA
time and intensity per week would be beneficial to char- Competing interests
The authors declare no competing interests.
acterize the sample and also combine with information
on BMI and aerobic fitness. Also, the present study had Received: 28 October 2022 / Accepted: 22 April 2023
an observational character, allowing only to correlate the
variables considering the different ages and genders, and
not the effect that a possible improvement in the aero-
bic capacity would have on cognition. For future studies,
we suggest evaluating this possible influence. Although References
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