Researchers have been examining the association between physical activity and academic achievement for almost 50 years. Twenty-eight review articles have been published on this topic.9,12–38 Four reviews using meta-analytic techniques consistently showed that physical activity had a significant positive association with students' cognitive functioning (eg, concentration and memory).15,20,21,30 These findings are also supported in other reviews.12,16,17,19,22,24,25,34,35,37,38 In addition, a recent review, based on a meta-analysis of 20 experimental studies, concluded that students participating in physical activity had improved academic achievement including better concentration and attention, higher achievement tests scores, and higher math scores compared with students who did not.15

Across these reviews, associations between opportunities for students to be physically active in school and academic achievement were also examined. In general, studies have shown that more participation in physical education class is associated with better grades, standardized test scores, and classroom behavior.12,15,19,21,26,29,33,36 In addition, time spent in recess that encourages pro-social behaviors has been positively associated with cognitive performance and positive classroom behaviors.28,36 Similarly, brief classroom physical activity breaks (ie-5-10 minutes) have been associated with improved cognitive performance, classroom behavior, and educational outcomes including standardized test scores, reading scores, and math scores.28 Finally, participation in extracurricular physical activities has been associated with higher grade point averages (GPAs), lower dropout rates, and fewer disciplinary problems.14,19,23,28,33,36

The school nutrition environment and services provides students with opportunities to learn about and practice healthy eating through available foods and beverages, nutrition education, and messages about food in the cafeteria and throughout the school campus. Fourteen review articles examined the association between nutrition and academic achievement.9,13,14,26,27,32,39–46

Two of the reviews were meta-analyses—with 1 including only randomized control trials and the other including randomized control trials and quasi-experimental designs.42,45 One of the studies found that supplements and foods fortified with ≥3 micronutrients (eg, iron and zinc) were associated with improved cognitive performance.42 Similarly, the other review found that iron intake was associated with improved cognitive performance.45

Nine of the reviews examined the relationship between breakfast consumption and academic performance.14,26,27,39–41,43,44,46 These reviews generally found small, positive associations between breakfast consumption and different academic outcomes including cognitive performance and attendance. In particular, student participation in school breakfast programs such as the US Department of Agriculture's School Breakfast Program has been shown to be associated with increased academic grades and standardized test scores, reduced absenteeism, and improved cognitive function,26,39,41,44,46 whereas skipping breakfast has been associated with decreased cognitive performance among students.14,40 One review examined the association between food insufficiency (ie-the limited availability of nutritionally adequate and safe foods) and academic performance, finding that food insufficiency is associated with decreased school attendance and diminished academic achievement.9,13,46

School meal programs including the National School Lunch Program and School Breakfast Program play an important role in helping students learn about and practice healthy habits such as consuming breakfast. Additionally, these programs provide nutritious meals to students who may not otherwise have access to food at home. Participation in school meal programs is associated with increased consumption of key micronutrients and important foods including fruits, vegetables, and low-fat milk.47,48

Other aspects of the school nutrition environment can help support health and academic success. For example, access to drinking water helps students increase water consumption and maintain adequate hydration, which is associated with improved cognitive functioning.49–51

Health education consists of planned learning experiences on a variety of topics such as nutrition, physical activity, alcohol and other drug use and abuse, sexual health, tobacco use, violence prevention, sleep, and mental and emotional health. These planned experiences provide students with the opportunity to acquire information and the skills they need to make informed health decisions.

Studies have not yet examined how health education curricula and instruction alone are directly associated with academic achievement. However, 9 programs that included a health education component increased academic grades and test scores, decreased school absences, improved student behavior, and reduced school dropout.26 These results are supported by evidence from experimental longitudinal or quasi-experimental intervention studies.

Another way to understand the contribution of health education on academic achievement is to examine the association between specific student health behaviors and academic achievement.9,14,26,32,52–55 For example, research has shown that students engaging in violent behaviors have lower grades and test scores.9,53 Lack of sleep, which is pervasive, has been associated with reduced cognitive functioning and adverse effects on emotional and physical health.54–56 Instructing students on a variety of health behaviors will not only increase their health literacy but also impact their health and academic outcomes.

Health education also allows students to learn and practice communication and social skills, such as resisting social pressures, which can reduce risk for smoking, alcohol and other drug use, and unintended pregnancy. Studies have shown that smoking has a negative effect on grades.9,14,32 Longitudinal studies have demonstrated the association between drug use and lower educational attainment.9,14,32 There is also a consistent inverse association between sexual risk behaviors and academic achievement. For example, studies have shown an association between early intercourse initiation and lower school grades.9,14 Findings also show that teen mothers are less likely to complete high school and have lower odds of attending college.52

School health services include first aid, emergency care and assessment, and planning for the management of chronic conditions (eg, asthma and diabetes). Nationally, about 25% of children and adolescents in the United States are estimated to suffer from chronic conditions such as asthma, diabetes, food allergies, epilepsy, and obesity.57 Helping students manage chronic conditions will decrease the amount of time they spend out of the classroom or away from school.

Four review articles examined the association between asthma and academic achievement.26,32,58,59 Students with asthma have been shown to have lower cognitive performance and increased school absenteeism.26,32,58,59 Other chronic conditions also have been associated with academic achievement. Specifically, research has shown a negative association between being overweight or obese and school attendance and decreased test scores but more research is needed to clearly determine whether this is due to social factors, behaviors related to obesity, or the condition itself.13,32,60 In addition, research has shown that diabetes is linked to decreased attention and lower test scores,61,62 epilepsy to lower intelligence,62 and sickle cell anemia to lower cognitive functioning.62

School health services might also include vision screenings. One review concluded that vision problems are associated with decreased standardized measures of literacy, standardized reading test scores, state basic skills test scores, reading ability, and spelling.63 In addition, children with poor oral health status are more likely to miss more days of school because of dental pain, and these absences are associated with lower grades.64

Further, school nurses play a vital role in helping students do better in school by assisting them in addressing health problems. Findings from one review found that school nurses can have an influence on student absenteeism by targeting students with a history of high rates of absenteeism.65 In addition, schools with smaller school nurse-to-student ratios were associated with lower absenteeism rates and higher graduation rates.65

Counseling, psychological, and social services offered in school help support the mental, behavioral, and social-emotional health of students and promote success in learning. Counseling interventions in schools cover a wide range of topics including school behaviors, peer relationships, study skills, career planning, death of a family member, divorce, substance use, family abuse, and sexuality.

In one review, school-based mental health programs were shown to be beneficial by improving attendance, student behavior, and test scores.66 These findings are also supported in a previous review.26 Research has also shown that specific counseling approaches such as motivational interviewing are associated with increased GPA and classroom behavior.67 In addition, studies have examined universal approaches to mental health promotion that focus on the underlying social and emotional factors that are integral to learning including self-management, relationship skills, and responsible decision making. One review concluded that universal mental health promotion programs can be effective at decreasing suspension rates, increasing positive classroom behaviors, and increasing attendance rates.68

Schools also can provide services to students with attention and hyperactivity problems. One review found that hyperactivity has been associated with greater risk for lower reading and mathematics test scores and grade repetition.69 In addition, attention deficit hyperactivity disorder has been associated with decreased cognitive functioning, increased school absenteeism, lower levels of educational attainment, and increased odds of dropping out of school.69

Investing in the physical and mental health of school staff can support students' health and academic success. Employee wellness programs address multiple risk factors and health conditions to meet the health needs of employees.70–72 Studies have shown that wellness programs can increase employees' ability to focus, reduce absenteeism, improve employee morale, and prevent chronic diseases.73,74

Healthy school staff are a critical component of a high achieving school. While few studies have examined how the health of school staff directly impacts students' learning, research has shown that unhealthy behaviors and health problems can directly affect teachers' productivity, classroom effectiveness, and absenteeism, which could in turn affect students' learning.71,73,75 School staff are also powerful role models and can help engage students in healthy behaviors and practices.70,76

The social and emotional development of students is affected by the psychosocial aspects of students' educational experience (ie-school climate). Three review articles examined the association between school climate and academic achievement.77–79

One important aspect of school climate is student safety. Researchers have shown that being a victim of bullying is associated with feeling unsafe at school, lower connectedness with school, and lower grades.79 Additionally, a positive and safe school climate is associated with reduced aggression and violence, peer victimization, and punitive disciplinary actions, which has also been associated with decreased absenteeism and increased academic achievement.78,79

Another aspect of school climate is relationships—that is, how engaged students, school staff, families, and the broader school community feel to one another. A positive and safe school climate has been shown to be associated with increased attachment to school.77–79 Students who are more attached to school have been shown to have better attendance, grades, and classroom behavior.79 Student-teacher relationships influence academic success and behavioral outcomes for students.77–79

One important casual pathway described by Basch is school connectedness—he explains that if the school climate is poor, there will likely be a decrease in school connectedness and engagement, which in turn will negatively affect both students' health and learning.5 In 2009, CDC developed strategies for increasing school connectedness, which is defined as the belief by students that adults and peers in the school care about their learning and about them as individuals.80 School connectedness has been shown to be a strong protective factor in decreasing risky health behaviors such as substance use, early sexual initiation, violence, and risk of unintentional injury (eg, drinking and driving).79–81 Research has demonstrated an association between school connectedness and academic achievement, including school attendance, staying in school longer, and higher grades and classroom test scores.79,80

A positive school climate is also conducive to effective teaching and learning. Studies have shown that school climate is directly related to academic achievement for elementary school, middle school, and high school.79 These findings are based on correlational and longitudinal studies. Cooperative learning, group cohesion, respect, and mutual trust have been shown to directly improve the learning environment and more distally the school climate.77–79

The physical school environment encompasses the school building and its contents, the land on which the school is located, and the area surrounding it. The school's physical condition (eg, ventilation, temperature, noise, and lighting) has been shown to be associated with student learning. For example, when allergens are not effectively removed from the air in the classroom, these ventilation problems can trigger asthma, lethargy, an inability to concentrate, and drowsiness in students.82–84 Such consequences have been associated with a negative impact on learning.82,84

In addition, high temperatures or inconsistent temperatures can make students drowsy and not feel well, which can affect their ability to learn.83,85,86 Poor acoustics also interferes with learning; when acoustic quality in the classroom is poor, students may not be able to completely understand instructions from the teacher, which might lead to poor performance.87 Schools with full-spectrum light or full-spectrum with ultraviolet enhancement (that emulates natural light) have been associated with increased attendance and academic achievement.83,88,89

One other aspect of the physical school environment includes the biological and chemical agents in the air, water, or soil such as pollution, mold, hazardous materials, pesticides, and cleaning agents. Often these are triggers for students with asthma or allergies. These indoor air quality problems have been associated with increased student absences.82–84,90

The school's physical environment also includes addressing physical threats (eg, crime, violence, and injuries) that make students feel safe, which in turn has been shown to be associated with decreased absenteeism and increased academic achievement.53,79,91 Research has shown that the physical school environment indirectly influences academic achievement through the school climate.91,92

Families and school staff can work together to support and improve the learning, development, and health of students. Five review articles examined the association between family engagement and academic achievement.93–97 Research has shown that students who have parents engaged in their school lives are more likely to have increased attendance, higher grades and test scores, better social skills, improved classroom behavior, and graduated high school.93–97 These positive effects have been shown for elementary school, middle school, and high school students.

Although most of the literature for parent engagement has focused on improving academic achievement, research also has shown that students who have parents engaged in their school lives are less likely to smoke cigarettes, drink alcohol, become pregnant, be physically inactive, and be emotionally distressed.98 In addition, research has shown that parents involved in school health activities will not only impact their children's health behaviors but also their academic achievement.98

Parents are also affected by the school's social and emotional climate. Parents are more likely to be engaged if the school has a welcoming environment (eg, friendly school office staff and readily available information for parents) and if they perceive school staff and students want and expect their involvement.98,99 Research has shown that providing a variety of activities including educating parents on available health care services at the school, volunteering in the classroom, and attending a parent-teacher organization meeting and frequent opportunities will help increase parent engagement.98,99 This will also increase parents' belief that their engagement will improve their children's learning and well-being, which in turn will improve their children's academic performance.98,99

Schools that partner with community groups (eg, community-based organizations, businesses, cultural and civic organizations, social service agencies, faith-based organizations, health clinics, and colleges and universities) to provide additional services, share resources, and volunteer in the school can help students receive the care, skills, and knowledge they need to learn and increase their academic achievement. Community involvement is associated with increased grades and test scores, improved school attendance, and improved student behavior.99–102

Research also has shown that schools are more likely to improve student achievement when they have positive social relationships with community members and groups.103,104 In addition, student learning opportunities beyond the classroom such as service-learning opportunities and civic engagement have been associated with improved school-related behaviors, decreased school suspension rates, and increased academic achievement.79,99