Risk factors for rapid weight gain in preschool children: findings from a UK-wide prospective study

Abstract

Objective:

To examine risk factors for rapid weight gain between 3 and 5 years of age.

Design:

Nationally representative prospective cohort study.

Participants:

A total of 11 653 preschool children participating in the UK Millennium Cohort Study, with anthropometry at 3 and 5 years.

Measurements:

Weight gain z-scores were calculated from 3 to 5 years. Children in the top quarter of this distribution were classified as gaining weight rapidly. A total of 26 biological and early life, social, psychological, behavioural and environmental risk factors were examined.

Results:

Among the participants, 13% of normal weight, 63% of overweight and 88% of obese 5-year olds had experienced rapid weight gain since 3 years of age. Six biological and early life factors and two social factors were found to be significantly associated with this growth pattern. In a mutually adjusted model, children were more likely to gain weight rapidly if they had a higher body mass index at age 3 (adjusted odds ratio: 1.27, 95% confidence interval: 1.23–1.32), if they were of Bangladeshi (adjusted odds ratio: 1.88, 95% confidence interval: 1.27–2.79) or black (adjusted odds ratio: 1.47, 95% confidence interval: 1.07–2.02) ethnicity, if their mother was overweight (adjusted odds ratio: 1.32, 95% confidence interval: 1.15–1.51) or had been overweight before pregnancy (adjusted odds ratio: 1.56, 95% confidence interval: 1.36–1.79), if their father was overweight (adjusted odds ratio: 1.56, 95% confidence interval: 1.34–1.81) or if their mother smoked during pregnancy (adjusted odds ratio:1.23, 95% confidence interval: 1.09–1.38). Children were also more likely to gain weight rapidly if others smoked in the same room (adjusted odds ratio: 1.31, 95% confidence interval: 1.16–1.49) or if they were a lone child in the household (adjusted odds ratio: 1.14, 95% confidence interval: 1.01–1.30).

Conclusions:

Factors operating during pregnancy and early life increase the risk of rapid weight gain in young children; thus, signalling the importance of obesity prevention programmes before and during pregnancy and for children at an early age. In particular, these programmes should address parental weight status and smoking habits, both modifiable risk factors.

Background

The age at onset of overweight and obesity is falling in the UK1 and worldwide.2 In the UK-wide Millennium Cohort Study (MCS), a nationally representative study of children born in the new century, 23% of 3-year olds and 21% of 5-year olds were overweight or obese,3 increasing their risk of a range of physical and psychological health problems.4, 5

Risk factors for childhood obesity range from prenatal to postnatal and early life factors. These include gestational weight gain, smoking during pregnancy, parental obesity, birthweight, infant feeding practices, ethnicity, lone parenthood, sleep duration and other lifestyle behaviours.6, 7, 8 A growing body of evidence also reports that rapid weight gain during infancy and childhood is associated with later obesity,9, 10, 11, 12 although the majority of studies have examined risk factors for rapid weight gain during the first few years of life13, 14 and not in other stages of childhood.

This study aimed to address this gap in the literature by examining weight gain in early childhood, a period also highlighted as a critical period for obesity prevention.15, 16 This research is needed to improve our understanding of the aetiology of obesity during the preschool years16 and to identify modifiable risk factors. A life course approach, using longitudinal data, enables determinants of growth patterns to be examined. This study investigated risk factors for rapid weight gain, between 3 and 5 years of age, in children from the MCS.

Participants and methods

Study population

The MCS is a longitudinal study of social, economic and health-related circumstances of children born in the UK between September 2000 and January 2002.17 Families were invited to participate in the study if they were eligible for Child Benefit (a universal benefit for families with children) and were resident in England, Wales, Scotland, or Northern Ireland when the child was aged 9 months old. A stratified clustered sampling design was used to over-represent children from ethnic minority groups and those living in disadvantaged areas, and from Wales, Scotland and Northern Ireland.

The original sample consisted of 18 819 infants (18 553 families), who were 9 months old at the first contact (response 72%),18 and 3 and 5 years at the second and third contacts respectively. Of the 18 296 singleton infants, 71% (n=12 989) from the original cohort participated at all three contacts.19 At each contact interviews were carried out by trained interviewers in the home with the main caregiver, who was usually the mother. Ethical approval was obtained from the South West and London Multi-Centre Research Ethics Committees.19 The present analyses did not require additional ethics approval. Data from all three surveys were obtained from the UK Data Archive, University of Essex.

From the 12 989 singletons, families were excluded if there were two cohort children from the same family (n=12), the main survey respondent at the first or second contact was not the child's biological mother (n=216), the main survey respondent's partner was not male (n=133) or the child had a missing or implausible weight gain z-score (n=1107). Some participants had more than one exclusion criterion, resulting in a final sample size of 11 653 children.

Outcome measure

At the second and third contacts, trained interviewers measured the children's weight and height without shoes or outdoor clothing. The children were weighed using Tanita HD-305 scales (Tanita UK Ltd, Middlesex, UK), recorded to the nearest 0.1 kg, and height was measured using Leicester Height Measure Stadiometers (Seca Ltd, Birmingham, UK), recorded to the nearest 0.1 cm.

Weight z-scores at 3 and 5 years, and height z-scores at 5 years, were calculated using the British 1990 growth references.20 Weight gain z-scores were then calculated as the standardized residuals from the linear regression of 5-year weight z-score on 3-year weight z-score, with height z-score at 5 years, exact ages 3 and 5 years and gender entered as covariates. The standardized residual is the 5-year weight z-score minus its value predicted from the regression, divided by the residual standard deviation from the regression. The weight gain z-scores have a mean of 0 and a standard deviation of 1, with positive values indicating a faster, and negative values a slower, rate of weight gain compared with the population mean weight gain. We have previously described this technique to examine weight gain from birth to age 3 years.21 Children in the top quarter of this distribution were then classified as gaining weight rapidly and a binary variable was created defining children with rapid (n=2979) compared with normal weight gain (n=8674) from 3 to 5 years.

Potential risk factors

On the basis of earlier evidence of factors associated with weight gain and childhood obesity6, 7, 15 and available information collected at 9 months and 3 years, we identified 26 potential risk factors. These were grouped as biological/early life, social, psychological, behavioural and environmental influences (Table 1). Detailed descriptions of many of these risk factors have been published previously;7 only those not previously defined are described here. Mothers and their partners were asked to report their height and weight at the second contact; they were defined as overweight if their body mass index (BMI) 25 kg m−2. Given the large amount of missing data for maternal (n=1783) and paternal (n=4750) overweight, the missing values were coded. At the first and second contacts, mothers were asked if anyone smoked in the same room as the cohort child; this was categorized as smoking at neither, one or both occasions (that is, when the child was aged 9 months and/or 3 years). Lone motherhood status was determined when the child was aged 3 years. As a marker of the child's mental health, the total difficulties score from the Strengths and Difficulties Questionnaire (www.sdqinfo.com) was used, which was measured at age 3. Mothers were also asked if they had ever been diagnosed with depression or serious anxiety and, if so, whether they were being treated for it. This information was used to define mothers as receiving treatment for depression or anxiety at the first and/or second contacts, or not. At the first and the second contacts, mothers were asked about the main childcare arrangements. Main childcare type was classified as none (no childcare at both contacts), informal and none, formal and none, informal and formal, informal only or formal only, with ‘formal’ and ‘informal’ childcare, as defined by Wheelock and Jones.22 Finally, mothers were asked, at the second contact, if they had access to a garden at the home.

Table 1 Potential risk factors, contact for data collection and factor levels for analysis

Statistics

Analyses were conducted in STATA/SE 10.0 (Stata Corporation, College Station, TX, USA), using survey commands to take into account the sampling design and to obtain robust standard errors. Weighted percentages were derived and regression analyses were conducted using survey and non-response weights to account for the clustered sampling and attrition between contacts. P-values were obtained from an adjusted Wald test.

International Obesity Task Force (IOTF) cut-offs for BMI at ages 3 and 5 years were used to define overweight and obesity.23 The prevalence of overweight and obesity at ages 3 and 5 was examined in relation to children's growth pattern (normal versus rapid weight gain) between ages 3 and 5 years. Proportions were compared using Pearson's χ2-tests with the Rao and Scott second-order correction.24

Unadjusted logistic regression analyses were then conducted to examine the significance and strength of associations between rapid weight gain and each of the potential risk factors in turn. Forward step-wise logistic regression analyses were then run to develop a model predicting rapid weight gain. Each risk factor was entered into the model, one at a time, and only those factors that significantly added to the model (P0.05) were retained. Backward step-wise regression was then conducted to confirm the validity of the model.

Results

The median weight gain between ages 3 and 5 years for the normal and rapid weight gain groups was 4.0 kg (interquartile range, 3.2–4.8) and 6.0 kg (interquartile range, 5.0–7.4) respectively.

Among the participants, 21% of the normal weight, 37% of the overweight and 48% of the obese 3-year olds gained weight rapidly over the following 2 years. However, rapid weight gain between ages 3 and 5 years was more closely related to weight status at age 5: 13% of the normal weight, 63% of the overweight and 88% of the obese 5-year olds had experienced rapid weight gain.

Unadjusted analyses

Table 2 shows the unadjusted odds ratios of risk factors associated with rapid weight gain. Biological and early life risk factors included greater BMI z-score at 3 years, Bangladeshi or black ethnicity, maternal overweight before pregnancy or at 3 years and paternal overweight at 3 years, and maternal smoking during pregnancy. Social risk factors included young parenthood (age 20–24) at birth of the cohort child, household income below £33K per annum, lone parenthood or smoking in the same room as the child. Conversely, children were at less risk if their mothers had managerial, professional or intermediate occupations, or if they were more highly educated. Psychological risk factors were not associated with rapid weight gain. Behavioural risk factors included early introduction of solid food, while children were less likely to have gained weight rapidly if they had been breastfed. Finally, environmental risk factors included living in a disadvantaged area or no access to a garden, and children were less likely to have gained weight rapidly if they were in formal childcare at 9 months and 3 years.

Table 2 Description of sample and unadjusted odds ratios (95% CI) of risk factors for rapid weight gain between ages 3 and 5 years (N=11 653)

Adjusted analyses

Both forward and backward step-wise regression analyses produced the same model. Table 3 shows the mutually adjusted odds ratios for the risk factors predicting rapid weight gain. Only biological, early life and social factors remained in the final model. The biological and early life risk factors for this growth pattern included greater BMI z-score at 3 years, Bangladeshi or black ethnicity, maternal smoking during pregnancy, maternal overweight before pregnancy or at 3 years and paternal overweight at 3 years. Given the large amount of missing data for maternal (n=1783) and paternal (n=4750) weight status at 3 years, a sensitivity analysis was run just with parents for whom complete data were available; both factors remained significant (maternal overweight 1.36 (1.11–1.66); paternal overweight 1.55 (1.32–1.82)). The social risk factors included being a lone child in the household and smoking in the same room as the child.

Table 3 Mutually adjusted odds ratios (95% CI) of risk factors for rapid weight gain between ages 3 and 5 years (final N in model=10 920)

Discussion

Summary of findings

A large proportion of children who had rapid weight gain between 3 and 5 years were overweight or obese at age 3. This growth pattern was also strongly related to weight status at age 5: 63% of the overweight children, and 88% of the obese children, had gained weight rapidly.

Eight biological, early life and social factors impacted on rapid weight gain. Parental weight status and smoking emerged as two highly important factors. Pre-pregnancy maternal overweight and maternal and paternal overweight status at age 3 were all independently associated with more rapid weight gain in the child. Maternal smoking during pregnancy and postnatal exposure through smoking in the same room as the child were also independently associated with an increased risk of more rapid weight gain. Bangladeshi or black ethnicity and lone child status were also significant.

Strengths and limitations

This study has several strengths. It used data from a longitudinal study, allowing for a range of influences prospectively documented before the period of weight gain to be examined. A number of studies have examined risk factors for obesity,6, 7, 8 but this study has examined factors contributing to rapid weight gain. This is important as it has been proposed that ‘preventing the gradual, excessive weight gain in normal-weight children may be an effective way to reduce the prevalence of overweight in children’.25 Furthermore, the MCS is a contemporary cohort, with data recently collected, and so it has explored factors pertinent to the lives of young children now. Owing to the large sample size, the oversampling of ethnic minorities and those living in disadvantaged areas, this study has examined rapid weight gain in a diverse sample of children from all four countries of the UK. Many of the risk factors examined in this study were based on self-report, including parental weight and height. However, self-reported weight and height are thought to be generally reliable26 and any underestimate of weight is likely to result in an underestimate of effect. Similarly, maternal report of smoking in the same room as the child, or of smoking during pregnancy, may have been underreported27 and were not validated biochemically. However, again, any underestimate of these behaviours is likely to lead to an underestimate of effect. Birthweight was also reported by the mother, but we have previously confirmed that accuracy of birthweight in this cohort is high.28 Similarly, infant feeding practices reported in the MCS are comparable to those of the UK Infant Feeding Survey 2000.29 Finally, the outcome variable for the study was based on objective measurements of height and weight of the children, taken by trained interviewers, thus overcoming the shortcomings of self-report measures.

Had the data been available, additional relevant factors potentially contributing to weight gain in childhood could have been explored, such as energy balance; however only limited information on dietary intake was collected at age 3 and there was no objective measurement of physical activity. More detailed information on both of these factors has since been collected at older ages in the MCS.

Comparison with other findings

Our observation that rapid weight gain was associated with overweight or obesity at age 5 years is consistent with observations that children whose BMI centile is high and/or crossing upwards are likely to have raised BMI later in childhood; this phenomenon of a correlation between true rate of change and true absolute value is described by Cole30 and is an example of Peto's ‘horse racing effect’, due to the analogy that in a race between fast and slow horses one would expect to find the faster horses out in front during the race.

Our findings are also consistent with previously published research on both rapid weight gain and childhood obesity, which has examined both individual risk factors and those across multiple domains. We have previously reported risk of rapid weight gain in infancy and obesity at age 3 for black children.7, 31 However, the finding that Bangladeshi children were almost twice as likely as white children to gain weight rapidly was not previously reported at younger ages. Results from other studies suggest that older Asian children are at increased risk of obesity32 and the incidence of type 2 diabetes in black and South-Asian children in the UK is rising.33

The finding that higher BMI at age 3 was a risk factor for subsequent excessive weight gain is supported by increasing evidence of associations between obesity in early childhood and subsequently,34 highlighting the vulnerability of overweight young children and their likelihood of becoming obese.

Evidence on the risk of obesity according to the number of siblings is inconclusive, with some studies reporting no association6, 7 and others reporting increased risk for children without siblings.35 A possible explanation for the latter, and for our finding, is that children with no siblings may have fewer opportunities to play with others and may therefore be more sedentary. This finding merits further investigation.

Other studies have also shown strong associations between maternal pre-pregnancy overweight and risk of obesity for children,7 and the concurrent risk of childhood obesity if parents are also obese.7 It is known that physical activity and sedentary behaviour aggregate within families, perhaps contributing to this association.36, 37 This study has shown that both paternal and maternal overweight influence offspring weight gain and in future analyses we will examine whether there is a differential contribution by parents on their child's weight gain.38

Smoking during pregnancy increased the risk of rapid weight gain. It has previously been reported that smoking increases risk of obesity,39 and higher body fat percentage in rapid weightgainers between 2 and 6 years of age.40 However, we also found that smoking in the same room as the child was a risk factor, but these two behaviours are likely to have different causal pathways. Smoking during pregnancy may influence programming in utero.39 In contrast, smoking in the same room as the child is a marker of social disadvantage which may indirectly impact on health behaviours. For example, parental smoking is associated with lower physical activity levels and more television watching in children.41 Furthermore, children of people who smoke have poorer eating habits.42 Additional research is needed to better understand these associations and the extent to which they are causally related.

Implications for policy and practice

Tackling childhood obesity is a priority for the UK Government and therefore a long-term public service agreement target has been set to ‘reduce the proportion of overweight and obese children to 2000 levels by 2020 in the context of tackling obesity across the population.’43 For this to be achieved, further research is required to identify appropriate interventions that address the causes of excessive weight gain through different periods of child development. Such approaches include the US ‘America on the Move’ and UK ‘Change 4 Life’ programmes, which suggest that small lifestyle changes, like reducing dietary sugar and walking more, may help to gradually reduce excessive weight gain in normal weight children. In the long term this may reduce the prevalence of obesity in children.25 Once again, the preschool period is an important time to educate children to enjoy and adopt healthy behaviours as ‘obesogenic’ lifestyles are already prevalent among young children.16

Our findings suggest that many factors associated with rapid weight gain in childhood are modifiable. Of these, maternal weight status is an important factor. The increasing prevalence of obesity in women is particularly problematic in those of reproductive age, given obesity-related problems in conceiving, pregnancy and birth outcomes.44 Within the MCS, 28% of mothers were overweight or obese before pregnancy. Over the past 25 years, the prevalence of obesity reported at booking for antenatal care in Glasgow has also increased from 10% to nearly 20%.45 Walsh and Murphy46 highlight the importance of maintaining a healthy weight before, during and after pregnancy to minimize these adverse outcomes. Our research suggests that reductions in weight before conception may additionally reduce risk of childhood obesity. Addressing adult obesity more generally is also a component of the UK Government's obesity strategy47 and so parents should be encouraged to adopt and integrate healthy lifestyle behaviours into the whole family, thereby reducing risk of overweight for their children and improving their own mental and physical quality of life.

A total of 34% of mothers in this sample smoked during pregnancy and this was associated with increased risk of rapid weight gain. Smoking among pregnant women has declined in recent decades,48 although this is socially patterned. Reducing smoking generally as well as during pregnancy remains a government objective.49 These initiatives, if successful, will promote better health outcomes for children.

Evidence from longitudinal epidemiological studies enhances our understanding of risk factors for rapid weight gain and obesity and, through later follow-up, allows the consequences of obesity of early childhood onset to be characterized. Further analyses of information from the MCS and other prospective studies will provide useful insights and contribute to the development of appropriate interventions and policies to prevent and reduce childhood obesity.

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Acknowledgements

We thank all of the Millennium Cohort Study families for their cooperation, and the Millennium Cohort Study management team at the Centre for Longitudinal Studies, Institute of Education, University of London. At the time of writing, Lucy Griffiths was supported by an MRC Special Training Fellowship in Health Services and Health of the Public Research (Grant no. G1061221). Tim Cole was funded through an MRC programme (Grant no. G0700961). Carol Dezateux was supported by HEFCE. The Centre for Paediatric Epidemiology and Biostatistics is supported in part by the Medical Research Council in its capacity as the MRC Centre of Epidemiology for Child Health. Research at the UCL Institute of Child Health and Great Ormond Street Hospital for Children receives a proportion of the funding from the Department of Health's National Institute for Health Research Biomedical Research Centres funding scheme. The Millennium Cohort Study is funded by grants to Professor Health Joshi, director of the study, from the Economic and Social Research Council and a consortium of government funders. The study sponsors had no part in the design, data analysis and interpretation of this study, the writing of the paper or the decision to submit the paper for publication and the authors’ work was independent of the funders.

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Correspondence to L J Griffiths.

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Griffiths, L., Hawkins, S., Cole, T. et al. Risk factors for rapid weight gain in preschool children: findings from a UK-wide prospective study. Int J Obes 34, 624–632 (2010). https://doi.org/10.1038/ijo.2010.10

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Keywords

  • weight gain
  • preschool children
  • cohort studies

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