A 12-year follow-up study of treated obese children in Japan

Abstract

Objective: To assess tracking for body weight from childhood to adulthood in obese Japanese children who were treated for obesity, investigate the relation between the changes in body weight status and morbidity, and identify correlates of the changes in body weight status.

Study Design: Twelve-year retrospective cohort study.

Subjects: A sample of 276 subjects (age 23.9±4.1, 176 males and 100 females) who responded to a questionnaire mailed in 1998 to 1047 children (age 10.6±2.2) treated for obesity at Mie National Hospital in Japan between 1976 and 1992.

Measurements: Based on height and weight from medical records during childhood, the relative weight (RW; weight expressed as a percentage of the standard body weight for age, height, and sex) was calculated. Degrees of childhood obesity were based on RW: slight obesity (120%≤RW<130%; n=17), moderate obesity (130%≤RW<150%; n=131), and severe obesity (RW≥150%; n=128). Adult body mass index (BMI), which was obtained from the mailed questionnaires, was classified as normal, overweight and obese according to the WHO/NIH criteria. Body weight tracking by degree of obesity was evaluated. Subjects with severe obesity during childhood (n=128) were examined for their weight status in adulthood, prevalence of chronic diseases in adulthood, and factors such as parental obesity, dietary and exercise habits and obesity treatment during childhood.

Results: Childhood obesity tracked into adulthood obesity or overweight in 54.7% of all cases. Severely obese children (36.7%) were more likely to be obese as an adult than moderately obese children (16.8%). The prevalence of adult obesity tended to be greater in boys with moderate childhood obesity than in girls (29.7% in boys vs 14.9% in girls, P=0.058). Among the severely obese children who became normal-weight adults, the prevalence of chronic diseases was about one-fifth of those who remained obese in adulthood (P=0.041). Four factors were associated with changes in body weight status: maternal BMI at entry (P=0.044), the changes in dietary and exercise habits after treatment (P=0.014, P=0.030, respectively), and satisfaction with obesity treatment in childhood (P=0.035).

Conclusions: Severely obese children have a higher risk of becoming obese adults even when they received obesity treatment in childhood. The risk of adulthood obesity was twice as high in moderately obese boys than in girls. On the other hand, many cases of childhood obesity can be corrected with obesity treatment, which in turn can decrease the risk for adult chronic diseases.

Introduction

The prevalence of childhood obesity and its comorbidities is high in developed countries and is increasing.1,2 The prevalence of childhood obesity in Japan has doubled (from 5 to 10%) during the past 20 y.3 In addition, childhood obesity is a major public health problem in Asian countries with rapidly growing economies and changing life styles.4,5 Increasing prevalence of overweight among children emphasizes the importance of focusing on primary prevention to avoid health complications later in life. It is well known that obesity in adults is associated with conditions such as hypertension, type 2 diabetes mellitus, hyperlipidemia, cardiovascular disease, hyperuricemia, gallbladder disease, and some forms of cancer.6 Furthermore, once obesity has been established in adults, weight loss is difficult to achieve.7 Therefore, the identification of children at risk for adulthood obesity could lead to early intervention to prevent adult obesity and its associated complications.

In North America and Europe, the relationship between obesity in childhood and in adulthood has been investigated in numerous studies.8,9,10,11,12,13,14,15,16 These studies have shown a tendency for subjects who were overweight in childhood to remain overweight as adults. And several studies have suggested that obesity in childhood affects morbidity and mortality in obese adults.8,9,10

However, there have been few follow-up studies of obesity from childhood to adulthood in Asian countries.3,17 Furthermore, there have been few reports on the factors associated with the changes in body weight status from childhood to adulthood18,19,20 and only one study has examined the effect of intentional weight loss on the tracking of obesity.21

We performed a 12 y follow-up of 276 children, who were treated for obesity. The prevalence of chronic diseases in adulthood and some of the factors potentially associated with changes in body weight status during the follow-up period were investigated.

Subjects and methods

Subjects

The sample comprised 1047 obese children, aged 6–15 y (average 10.6±2.2, RW≥120), who were admitted to Mie National Hospital in Japan between 1976 and 1992 for treatment of obesity. In 1998, an average of 12 y after the last examination, a questionnaire was sent by mail. Responses were received from 388 subjects (recovery rate 37.1%). Of these subjects, those who were below 18 y at follow-up, and those who were classified as underweight according to the WHO/NIH criteria in 1998 were excluded. Data from 276 subjects (176 males and 100 females) were used for the study. The study protocol was approved by the Mie National Hospital Institutional Review Board.

Subjects were divided into three categories based on the degree of childhood and adult obesity. The severity of obesity in children was determined according to the relative weight (RW; weight expressed as a percentage of the standard body weight for age, height, and sex), while that of adults was based on body mass index(BMI) using the WHO/NIH criteria.22,23 The standard body weight was determined by Murata's nomogram,24 which is a weight for height by sex and age chart for Japanese children derived from nationwide surveys.25 The BMI of adults was calculated as weight in kilograms divided by height in meters squared. In children, a RW of above 120% and below 130% is defined as slight obesity (n=17), above 130% and below 150% as moderate obesity (n=131), and above 150% as severe obesity (n=128). Recently, the International Obesity Task Force proposed a BMI-based method to evaluate childhood obesity.26 However, the populations used to define the criteria did not include Japanese children. Therefore, we have elected to use the conventional criteria for Japanese children in the present study. In adults, a BMI below 18.5 (kg/m2) was defined as underweight, above 18.5 and below 25.0 as normal, above 25 and below 30 as overweight, and above 30 as obese following the WHO and NIH recommendations.

Treatment for obesity

Subjects were hospitalized for at least 2 days for a series of examinations and then were treated in an outpatient clinic approximately every 6 weeks. Pediatricians, dietitians, psychologist and nurses were all involved in the treatment program. Dietitians instructed the children to consume 75–80% of the energy requirement for their age at 5:2:3 ratios from carbohydrate, protein and fat, respectively. Dietitians also instructed them to ensure sufficient protein intake (2 g/kg standard body weight) while monitoring their growth. However, the upper limit of protein intake was established at 100 g to avoid renal overload. Pediatricians instructed the subjects to perform mild-intensity exercises such as stretching, light resistance exercises, walking, jogging, rope skipping, aerobics and outdoor play for 20–30 min every day. During behavioral treatment, nurses instructed the children on how to improve their eating habits and daily behavior to avoid overeating and physical inactivity. Subjects recorded their daily physical activities and changes in body weight, which were checked before each treatment. Psychological counselling was also available. Parents participated in all treatment sessions. In addition, pediatricians advised parents on how to support their children in treating their obesity.

Measurements

The dates of the first examination, last examination and the questionnaire survey, approximately 12 y after the last examination, were defined as entry, discharge and adulthood, respectively. Height and weight at entry and discharge were extracted from the subject's hospital medical records, and RW and BMI were calculated. The height and weight of the subjects were measured by nurses to the nearest 0.1 cm and 0.1 kg, respectively. Adult height and weight were self-reported in a questionnaire survey sent by mail in November 1998. In addition, to evaluate the adulthood prevalence of chronic diseases, the questionnaire asked whether the subject had been diagnosed by a physician as having any of the following: hypertension, type 2 diabetes mellitus, cardiovascular disease, gout, stroke, hyperlipidemia, liver dysfunction or arteriosclerosis. If any of these were checked, subjects were regarded as having a chronic disease.

To assess the factors associated with the changes in body weight status from childhood to adulthood, the following factors were considered. The parents' BMI was calculated from self-reported heights and weights obtained at entry. Changes in dietary and exercise habits were evaluated from the questionnaire survey using the following questions: ‘Did you change your dietary habits after the hospital treatment?’ and ‘Did you change your exercise habits after the hospital treatment?’ Thirdly, the degree of approval of the childhood obesity treatment was evaluated by asking the following question: ‘Were you satisfied with the treatment you received for childhood obesity?’

Statistical analyses

All data are expressed as mean±standard deviation. The difference between entry and discharge data was estimated by the paired t-test. To assess the factors associated with the changes in body weight status from childhood to adulthood, only those with severe childhood obesity (n=118) were retained. Subsequently, based on the degree of adulthood obesity, these subjects were subclassified into the following three groups: subjects in whom obesity improved from severe childhood obesity to normal BMI (severe to normal; n=34); those in whom obesity slightly improved from severe childhood obesity to overweight (severe to overweight; n=47); and those in whom obesity remained severe from childhood to adulthood (severe to obese; n=47). The body weight tracking by degree of obesity and factors associated with the changes in body weight were compared using the chi-square test. Analysis of variance was used to compare demographic parameters at entry, discharge and adulthood. Statistical analyses were performed using StatView 5.0 software (SAS Institute Inc, Cary, NC). Significance was established as P<0.05.

Results

At entry, the mean age of the subjects was 10.7±2.1 (s.d.) y and the mean RW 153.2±121.0%, while at discharge from the program (after 1.0±0.9 y from entry), the mean RW had significantly decreased to 134.3±118.6%, a mean reduction of 18.9% (range −158.1 to +44.5; P<0.0001). In adulthood (after 11.8±3.7 y from discharge), the mean age was 23.9±4.1 y and the mean BMI 27.0±5.3 (Table 1). There were no significant differences in age at entry (10.7±2.1 vs 10.5±2.8; P=0.233), average RW (153.2±121.0 vs 154.6±120.1; P=0.353), or in male-to-female ratio (0.64 vs 0.58; χ2=2.36, P=0.124) between those who replied to the questionnaire in adulthood (n=276) and those who did not (n=659). Therefore, the adult sample can be considered representative of the original larger sample. Medical records indicated that similar methods of treatment were used between 1976 and 1992. Therefore, we considered that treatment practices did not change much over time.

Table 1 Physical characteristics of the subjects at each time point

A total of 54.7% adult subjects (151 out of 276) were classified as overweight or obese (BMI≥25). When the severity of obesity at entry and in adulthood was compared, 76.5 and 58.8% of the children with slight and moderate obesity at entry, respectively, were classified as normal weight in adulthood (Figure 1). However, only 26.6% of the children with severe obesity at entry were normal weight in adulthood (χ2=13.15, d.f.=1, P=0.0003 vs moderately obese children at entry), and 36.7% of the children with severe obesity were obese as adults. The rate was approximately twice that of the children with moderate obesity at entry (16.8% in moderately obese children at entry; χ2=27.44, d.f.=1, P<0.0001).

Figure 1
figure1

Body weight tracking status from entry to adulthood classified by the degree of obesity.

When tracking of obesity from childhood to adulthood was compared in each gender, children with severe obesity did not show sex differences (males—severe to normal, 27.0%; severe to overweight, 36.5%; and severe to obese, 36.5% vs females—25.6, 37.2 and 37.2%, respectively; Table 2). However, 68.1% of girls with moderate obesity at entry were classified as having normal BMI in adulthood, while 14.9% of such girls remained overweight in adulthood. In contrast, 53.6% of boys with moderate obesity at entry were classified as having normal BMI in adulthood, while 29.7% of such boys remained overweight in adulthood. Therefore, the chance of moderate childhood obesity leading to normal adult BMI tended to be better in girls than in boys (χ2=3.61, d.f.=1, P=0.058).

Table 2 Sex difference of body weight tracking status from entry to adulthood classified by the degree of obesity

In order to compare the prevalence of chronic diseases and to identify the factors associated with body weight changes during the follow-up period, we focused on the subgroup of obese children (Table 3). Figure 2 shows the development of BMI from entry to discharge and further to adulthood in severely obese children. There were no differences in the changes in height among the three groups, while considerable changes in body weight were noted during the 12 y following the program discharge.

Table 3 Physical characteristics in three adult BMI categories who had severe obesity in childhood
Figure 2
figure2

BMI at entry, discharge, and adulthood for severly obese children diverging in the three adult BMI categories.

The prevalence of chronic diseases in adulthood was significantly (χ2=6.39, d.f.=2, P=0.041) lower in severely obese children who managed to normalize their BMI (5.9%) as compared to those who remained obese as an adult (31.9%; Figure 3).

Figure 3
figure3

Prevalence of chronic diseases according to adulthood BMI group in serverly obese children.

In subjects with severe obesity in childhood who achieved normal weight in adulthood, mother's BMI value was lower (22.3±3.1) than in subjects whose obesity persisted (24.5±3.3) (F=3.24, P=0.044; Figure 4a). On the other hand, there was no relationship between father's BMI and obesity tracking status (F=1.80, P=0.173). Changes in dietary and exercise habits after treatment were reported more frequently in subjects in whom obesity had been corrected (64.7 and 58.8%, respectively) than in subjects who remained obese (31.9 and 31.9%, respectively; χ2=8.55, d.f.=2, P=0.014 for dietary habits, χ2=7.00, d.f.=2, P=0.030 for exercise habits; Figure 4b,c). Some 73.5% of subjects replied that they were satisfied with the obesity treatment they had received during childhood when their childhood obesity was corrected, whereas only 46.8% of subjects with persistent adulthood obesity reported being satisfied with the treatment (χ2=6.07, d.f.=2, P=0.035; Figure 4d).

Figure 4
figure4

Factors associated with the changes in body weight fom childhood to adulthood.

Discussion

In the present study, 54.7% of 276 subjects with childhood obesity (RW≥120%) were classified as being overweight (BMI≥25) in adulthood (58.5% in males vs 48.0% in females). Using 151 Japanese obese children (mean age=10.4 y, mean RW=139.1%), Kitani et al3 performed a follow-up study over a mean of 16.6 y, and reported that 32.2% of males and 41.0% of females were obese in adulthood. Their findings somewhat differed from ours, mainly because we used the WHO/NIH criteria (BMI≥25)22,23 to evaluate obesity, while Kotani et al calculated mean values for BMI in male and female adults based on data provided by an insurance company, then established a cut-off point of BMI at 28.1 in males and 24.1 in females (equivalent to RW of 120%). When we use Kotani et al's cut-off point, 44.3% of males and 55.0% of females were obese in adulthood. Because our data showed higher initial RW than Kotani et al's (153.2 vs 139.1%), it might have contributed to the increased obesity tracking rate from childhood to adulthood, as many previous studies have reported.9,12,14,15 Moreover, the small differences in the recovery rates of the questionnaires in the study by Kotani et al and our study (27 vs 37%) may have contributed to the different results.

In Western countries, Clarke et al12 reported that 49.2% of boys and 68.5% of girls whose body weights were in the upper quintile at the age of 11–12 remained in the upper quintile of adult body weight at the age of 21–25. Also, Katzmarzyk et al27 reported that 63.6% of boys and 44.4% of girls whose BMI was in the upper quintile at the age of 11–12 remained in the upper quintile of BMI after a 7 y follow-up. Although the results of these previous studies cannot be directly compared, they emphasize the need to address the problem of childhood obesity.

In the present study, 36.7% of children with severe obesity, 16.8% of those with moderate obesity and 5.9% of those with slight obesity were obese also as an adult. Therefore, the frequency of adulthood obesity was significantly higher in children with severe obesity. The relative risk of adulthood obesity in children with severe obesity was 6.2 times higher than that in children with slight obesity and 2.2 times higher than that in those with moderate obesity. Power et al14 reported that 54 and 57% of extremely overweight boys and girls, respectively, whose BMI was above the 98th percentile at the age of 11 were obese at the age of 33. Many other previous studies have reported that extremely overweight children tend to remain overweight.9,12,14,15 Because genetic factors are considered to be closely associated with the etiology of severe early-onset obesity,28 long-term follow-up studies incorporating appropriate genetic markers will be necessary to define the conditions under which obesity tracks from childhood to adulthood.

Children with severe obesity did not show sex differences in the prevalence of obesity at follow-up. However, the percentage of girls with moderate obesity who became overweight adults tended to be lower than that of boys, and moderately obese girls did better at follow-up (boys—moderate to overweight, 33.3% vs girls—moderate to overweight, 12.8%; P=0.058). Differences in body weight tracking between children with severe obesity and those with moderate obesity could be due to the following reasons: (1) the desire to be thin in Japanese girls could influence body weight changes in those with moderate obesity;29 or (2) children with severe obesity may have quit trying to reach normal weight;3 or (3) severely obese children could find it more difficult to lose weight with conventional weight loss programs due to stronger genetic predispositions28 than in moderately obese children. However, since we used self-reported heights and weights at follow-up, underestimate or overestimate of both could have resulted in some misclassifications of subjects into incorrect BMI categories.30,31

Although the correlation between adult obesity and adverse health outcomes has been established,6 few reports have described the relationship between childhood obesity and adulthood morbidity.8,10,16 Must et al10 performed a follow-up study over a 55 y period from adolescence to 72 y of age, and reported that the risk of heart disease and atherosclerosis rose for both males and females who were overweight during adolescence. In particular, they noted that the increased risk of morbidity (except non-insulin-dependent diabetes mellitus) associated with overweight in adolescence was independent of adult weight status. These results suggested that overweight in adolescence was a more powerful predictor of morbidity than overweight in adulthood. In the present study, 31.9% of children with severe obesity who remained obese in adulthood had chronic diseases, whereas, only 6% of those who achieved normal adult BMI had chronic diseases. Therefore, the relative risk of developing chronic diseases was 5.4 times higher in severely obese children who remained obese in adulthood than in those who achieved normal adult BMI, suggesting that successful treatment of childhood obesity may protect against chronic disease in adulthood.

Our results indicate that maternal BMI was significantly higher in severely obese children who were obese also as adults than in those who managed to normalize their BMI. Whitaker et al18 reported that parental obesity more than doubles the risk of adulthood obesity among both obese and nonobese children under 10 y of age. In the latter study, the odds ratios for obesity associated with maternal obesity were slightly higher than for paternal obesity (2.8–3.6 vs 2.4–2.9, respectively). Lake et al19 reported that children of obese parents are 6.8–8.4 times more likely to develop adulthood obesity at the age of 33 than children of parents with normal BMI. Mossberg9 reported that whether an obese infant stays obese depends very much on the degree of obesity in the mother. These studies and the results of the present study emphasize the importance of parental, especially maternal, obesity and possibility of genetic factors, in the correction or persistence of obesity in adulthood.

A higher proportion of adults who had severe childhood obesity and achieved normal BMI in adulthood reported that their dietary and exercise habits had changed after the obese treatment in childhood. It has been previously suggested that physical activity20,32 and the amount or composition of food consumed during childhood20,33 were associated with adulthood obesity and morbidity. Kemper et al34 evaluated the influence of physical activity and dietary intake on changes in adiposity in subjects between 13 and 27 y of age, and reported that physical activity level showed a negative relationship with fat mass. The present study could not clarify the issue of the contribution of the amount and quality of exercise and food intake in the persistence or correction of childhood obesity. However, adult subjects who replied that their dietary and exercise habits had changed after the obesity treatment achieved normal adulthood BMI despite their severe childhood obesity. Therefore, emphasizing dietary and exercising habits during growth may be important in the effort to prevent adulthood obesity.

The present study enrolled obese children who had received an obesity treatment over a mean duration of 1.0 y, during which RW improved by 18.9% and body weight was reduced by 1.9 kg. As a result, 76.5% of slightly and 58.8% of moderately obese children achieved normal BMI in adulthood. Because the present study lacked a control group of obese children who were not treated, it cannot be established whether the observed improvements and apparent health benefits are caused by the treatment period per se. Similarly, additional treatment during the follow-up and other factors might also have contributed to improved body weight status in adulthood. However, Epstein et al21 evaluated the effects of a family-based long-term behavioral treatment of obese children (RW>120) on young adulthood body weight over 10 y, and they concluded that the treatment was effective for improving RW 10 y later (the RW improvement rate was 6.6% higher in obese children who received the treatment with their parents than in those who received the treatment alone without the assistance of parents). In the present study, subjects who achieved normal BMI in adulthood tended to report that their dietary and exercise habits had changed after childhood obesity treatments with parental involvement. Furthermore, these subjects were more satisfied with the outcome of the treatment. Although obesity treatment is not effective for all obese children, the results of this study suggest that obese children who modify their daily dietary and exercise habits can achieve normal BMI in adulthood.

Conclusion

In the present study, we evaluated the tracking of obesity from childhood to adulthood in obese Japanese children. This study clarified that a high proportion (54.7%) of obese Japanese children (RW≥120) develops adulthood overweight or obesity (BMI≥25). The prognosis in children with severe obesity was poorer than in children with slight to moderate obesity. The obesity improvement rate was higher in slightly and moderately obese children (76.5 and 58.8%, respectively). The risk of adulthood obesity in boys with slight to moderate obesity was higher than in girls with slight to moderate obesity. The prevalence of chronic diseases was five times higher in adult subjects who remained obese than in those who were able to correct their childhood obesity. In addition, the improvement rate in adult obesity tended to be high and the incidence of chronic diseases tended to be low in subjects who changed their dietary and exercise habits after discharge from the program. Therefore, taking certain measures to treat childhood obesity may be important in preventing adult obesity, as well as in decreasing the incidence of chronic diseases.

Acknowledgment

Thanks are expressed to all of the coprincipal investigators, investigators, coinvestigators. Especially, we would like to thank Mr Koji Watanabe and Mr Koyo Yamaguchi for data collection, and Ms Nina Laidlaw for language revision.

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Togashi, K., Masuda, H., Rankinen, T. et al. A 12-year follow-up study of treated obese children in Japan. Int J Obes 26, 770–777 (2002). https://doi.org/10.1038/sj.ijo.0801992

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Keywords

  • childhood obesity
  • follow-up study
  • adult obesity
  • chronic disease

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