Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE

Taller stature after postnatal rapid weight gain in early infancy predictsoverweight status at age 3Izumi Akaboshi (akaboshi@orange.ocn.ne.jp)1, Yougo Haraguchi2, Yuuji Mizumoto3, Akito Kitano4, Hiroaki Kan5

1.Akaboshi Pediatric Clinic, Kumamoto City Medical Association, Kumamoto, Japan2.Haraguchi Children’s Clinic, Kumamoto City Medical Association, Kumamoto, Japan3.Mizumoto Children’s Clinic, Kumamoto City Medical Association, Kumamoto, Japan4.Kitano Pediatric Clinic, Kumamoto City Medical Association, Kumamoto, Japan5.Kan Clinic, Kumamoto City Medical Association, Kumamoto, Japan

KeywordsBody mass index, Overweight, Rapid weight gain,Taller height

CorrespondenceDr. Izumi Akaboshi, Akaboshi Pediatric Clinic,Kuwamizu, 1-16-16, Kumamoto, Japan.Tel: +81 96 383 1251 |Fax: +81 96 386 5170 |Email: akaboshi@orange.ocn.ne.jp

Received16 October 2007; revised 15 May 2008;accepted 4 June 2008.

DOI:10.1111/j.1651-2227.2008.00932.x

AbstractAim: To evaluate whether postnatal rapid weight gain in early infancy is associated with subsequent

tall stature and being overweight at age 3, and taller stature after postnatal rapid weight gain predicts

overweight status at age 3.

Methods: Data from a retrospective cohort study (time period 2003–2004, total number = 1353

subjects in Kumamoto, Japan) were used. The rate of weight gain during the first 3–4 months was

calculated as 100 g/month, and postnatal rapid and slow growth were calculated by using weight

standard deviation (SD). Overweight status at 3 years of age was determined according to the

definition of the International Obesity Task Force.

Results: In total, 4.7% of subjects were overweight at age 3. Postnatal rapid weight gain, associated

with height increases until age 3 (p < 0.0001), and the rate of weight gain were significant risk

factors for being overweight in children at age 3. Taller heights at 6–9 months and 17–20 months of

age following postnatal rapid weight gain were associated with overweight status at age 3 (p < 0.05).

Conclusion: Taller stature following postnatal rapid weight gain in early infancy predicts overweight status at age

3; additionally, rapid infancy weight gain contributes to the acceleration of statural growth in overweight children.

INTRODUCTIONThe increasing prevalence of overweight and obese childrenin industrialized countries is an important public healthproblem (1,2). However, in spite of the increasing preva-lence of obesity among school children, the prevalence ofobesity in Japanese preschool children at 3 years of age hasnot changed over the past 10 years (3,4). A longitudinalstudy conducted in Japan reported that about 30% of 3-year-old children with higher BMI grew into overweight youngadults (5). Recent published reviews indicate that postnatalrapid weight gain during infancy is usually associated withsubsequent obesity in childhood and adulthood, and leads totaller childhood stature (6–9). In addition, researchers havesuggested that the tempo of statural growth, characterizedby rapid early height increases and bone maturation, maybe established during the first 2 years of life, accompaniedwith greater weight gain (6). However, direct evidence hasnot been reported, and the relationship between the begin-ning tempo of statural growth and postnatal rapid weightgain in infancy remains poorly understood. Moreover, an-other study reports that only 15.8% of children with catch-up weight gain between birth and 2 years are obese by age7 (10). Therefore, another predictive determinant may beneeded to distinguish those in whom rapid infancy weightgain does not lead to childhood obesity from those in whomit does.

The primary aim of this study is to test the hypothesisthat postnatal rapid weight gain in early infancy affects notonly weight gain but also increases in height during the first3 years. The secondary aim is to determine whether the rateof weight gain and rapid growth during the first 3–4 monthsof life are associated with overweight status at 3 years ofage. The third aim is to evaluate whether accelerated heightincreases in infants showing postnatal rapid weight growthat 3–4 months of age predicts overweight status at age 3.

METHODSOur subjects were 1569 healthy children, born between 1988and 2000 without neonatal diseases, congenital malforma-tions or inborn metabolic disorders, who visited our pae-diatric clinic in Kumamoto City for vaccination betweenNovember 2003 and September 2004. Each subject’s datawas collected using the Maternal and Child Health Hand-book, provided to every pregnant woman or mother ofa newborn infant by the Ministry of Health and Welfareof Japan, in which anthropometric, feeding and medical/vaccination records from birth to 3 years of age are recordedin detail. Infant feeding during the first 4 weeks of life wasrecorded as breast-feeding and/or formula-feeding in thishandbook. Of these subjects, we selected 1353 participants(697 boys and 656 girls), aged 3–17 years (3–6 years: 68.9%,

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7–10 years: 18.4%, 11–17 years: 12.7%, respectively), forthis study excluding: (1) no singleton (n = 20); (2) preterm,gestational age < 37 weeks (n = 63); (3) postterm, ges-tational age ≥ 42 weeks (n = 11); and (4) subjects withincomplete data (n = 122). Incomplete data included in-formation not recorded or incorrectly recorded at birth, 3–4 months and/or 3 years of age. These anthropometric datahad been measured as of routine health examinations, pri-marily administered at five different public health centreswithin Kumamoto City and a variety of paediatric clinics,which were conducted by trained public health nurses andclinical nurses. At each examination, height was measuredto the closest 0.1 cm and weight to the closest 0.1 kg. In-formed consent was obtained from each parent/guardian ofall participants. The rate of weight gain during the first 3–4 months of life was calculated as weight at the 3- to4-month measurement period minus birth weight, dividedby exact age in months at the 3- to 4-month measurementperiod, and was expressed as 100 g per month, as previouslydescribed (11). Weight and height at birth, 3–4 months, 6–9 months, 17–20 months and 3 years of age were expressedas standard deviation (SD) scores using the Japan growthreference scores for 2000 (12). Any changes in the SD scorebetween birth and 3–4 months were calculated for weight(scores at 3–4 months minus scores at birth). Any increasesin weight SD scores between birth and 3–4 months by morethan 0.67 SD were defined as ‘rapid growth’, as previouslydescribed (13).

Furthermore, any decreases in weight SD scores by morethan 0.67 SD were defined as ‘slow growth’ (13). BMI wascalculated as weight (kg) divided by height (m) squared.The main outcome, concerning overweight status at 3 years

Table 1 Characteristics of subjects

Number Proportion or median 10th–90th percentile

Rate of weight gain from birth to 3–4 months (100 g/mo) 1353 9.77 7.60–12.16Gender (%) (female vs. male) 1353 48.5%Birthweight (kg) 1353 3.09 2.63–3.57Gestational age (weeks) 1353 39 38—41Breast-fed (%) 1255 46.1%Weight SD scores at birth 1351 0.20 −0.91–1.38Weight SD scores at 6–9 months 1283 0.12 −1.00–1.46Weight SD scores at17–20 months 1331 0.10 −0.98–1.43Weight SD scores at 3 years 1352 0.12 −0.88–1.45Height SD scores at birth 1341 0.48 −0.67–1.48Height SD scores at 3–4 months 1352 0.09 −0.87–1.069Height SD scores at 6–9 months 1278 0.04 −1.042–1.20Height SD scores at 17–20 months 1326 0.206 −0.820–1.351Height SD scores at 3 years 1353 0.06 −0.97–1.28BMI at 3 years 1353 15.70 14.41–17.18Change in weight SD score from birth to 3–4 months 1342 0.02 −1.160–1.173Exact age from birth to 3–4 months (weeks) 1353 14.90 13.30–17.10Age at assessment of overweight status (mo) 1353 37 36–37Maternal BMI before pregnancy 1171 19.83 17.63–23.25Chest circumference at 3–4 months (cm) 1245 41.3 39.0–44.0Head circumference at 3–4 months (cm) 1320 40.6 39.1–42.2

SD = standard deviation; BMI = body mass index.

of age, was defined according to sex- and age-specific BMIcut-offs proposed by the International Obesity Task Force,which are equivalent to the widely used cut-off of 25 kg/m2

for overweight adults (14). As a few variables were skewed,median and percentiles were used in Table 1 in place ofmean and SD. Taller heights at a given ages were definedas that at or above the 90th percentile height SD scores forthat age.

The birthweight and gender of those subjects with incom-plete data were assessed for differences using the Mann–Whitney U-test and chi-square test. Differences betweenthe distinguished categories based on continuous variableswere tested for significance using a one-way analysis ofvariance (ANOVA) with follow-up multiple comparisonsincorporating Bonferron/Dunn corrections and the Tukey–Kramer method as appropriate. The unadjusted associationsbetween being overweight at 3 years of age and risk factorswere estimated using simple logistic regression analysis. Thefinal logistic regression model was created by forward selec-tion and stratified because gender was a confounding factor.Associations between taller statures at different ages andoverweight status at age 3 were assessed using chi-squareanalyses and Fisher’s exact tests. All calculations were per-formed using Statview version 5.0 software (SAS, InstituteInc., Cary, NC, USA), and a p-value of <0.05 was consideredstatistically significant.

RESULTSThe subjects’ characteristics are summarized in Table 1. Ofthe subjects initially sampled, 86.4% had complete data. Theparticipants with complete and incomplete measurements

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Table 2 Weight and height size at different ages by change in weight SD scoresbetween birth and 3–4 months of age

Slow growth No change growth Rapid growth(n = 325) (n = 719) (n = 307)

Weight SD scoresBirth 0.85 (0.85)∗ 0.20 (0.78)∗∗ −0.28 (0.89)3–4 months −0.31 (0.72) 0.22 (0.79)‡ 0.92 (0.96)†6–9 months −0.27 (0.80) 0.14 (0.90)‡ 0.81 (1.06)†17–20 months −0.04 (0.86) 0.18 (1.08)‡ 0.58 (1.06)†3 years −0.03 (0.84) 0.14 (0.87)‡ 0.53 (1.13)†

Height SD scoresBirth 0.84 (0.79)∗ 0.41 (0.83)∗∗ 0.08 (0.92)3–4 months −0.01 (0.80) 0.08 (0.74) 0.23 (0.79)†6–9 months −0.04 (0.94) 0.01 (0.85) 0.27 (0.89)†17–20 months 0.10 (0.83) 0.21 (0.86) 0.46 (0.87)†3 years −0.03 (0.84) 0.07 (0.88) 0.31 (0.91)†

∗Denotes p < 0.0001 (slow vs. no change and rapid), ∗∗ denotes p < 0.0001(no change vs. rapid).†Denotes p < 0.0001 (rapid vs. no change and slow), ‡ denotes p < 0.0001(no change vs. slow).Data are presented as means (standard deviation).

were similar in gender distribution and showed no signif-icant difference in birthweight (female: 48.5% vs. 44.8%,mean birthweight: 3.103 kg vs. 3.071 kg, p = 0.3542).The prevalence of overweight status at 3 years of age was4.73%, and was significantly higher in girls (boys 1.70%, girls3.03%). Also, 22.7% (n = 307) of all children showed rapidgrowth between birth and 3–4 months (>0.67 SD scores),whereas 24.1% (n = 325) showed slow growth (<−0.67 SDscores). Of the 307 subjects exhibiting rapid weight gain, 27(20 females, 7 males) were overweight by age 3 (8.8%), com-pared with 37 (3.5%: 22 females, 15 males) of the 1044 with-out rapid weight gain during early infancy. Approximately42% of the children who were overweight at 3 years of ageexhibited rapid weight gain during early infancy. Weight andheight SD scores at birth in infants with slow growth weremarkedly higher than those of infants with rapid and nochange growth (p < 0.0001, one-way ANOVA); addition-

Table 3 Adjusted association between variables and being overweight at 3 years of age

Rate of weight gain from birth Rapid growth from birthto 3–4 months (100 g/month) to 3–4 months

Odds ratio (95% CI) p-value Odds ratio (95% CI) p-value

BoysRate of weight gain from birth to 3–4 months (100 g/month) 1.690 (1.297–2.204) 0.0001Rapid growth∗ 6.767 (2.180–21.007) 0.0009Birthweight (100 g) 1.364 (1.193–1.561) <0.0001 1.396 (1.224–1.592) <0.0001Breast-fed 0.110 (0.024–0.515) 0.0051 0.132 (0.030–0.590) 0.0080

GirlsRate of weight gain from birth to 3–4 months (100 g/month) 1.706 (1.402–2.078) <0.0001Rapid growth∗ 4.966 (2.388–10.327) <0.0001Birthweight (100 g) 1.138 (1.034–1.252) 0.0082 1.189 (1.079–1.310) 0.0005Breast-fed 1.188 (0.596–2.369) 0.6241 1.173 (0.596–2.311) 0.6439

∗Rapid growth versus slow and no change growth.

ally, those with rapid growth had the lowest weight andheight at birth of the three groups (Table 2). The proportionsof children with high birthweight (>3500 g) in the rapid,no change and slow growth groups were 1.11%, 5.11% and7.55%, respectively. Furthermore, infants who showed rapidgrowth had higher weight and height SD scores from 3–4 months to 3 years of age than infants with either slow or nochange growth (p < 0.0001, one-way ANOVA), as shown inTable 2.

The rate of weight gain from birth to 3–4 months (100 gper month) and rapid growth during the first 3–4 monthswere significant risk factors associated with children beingoverweight at 3 years of age. The other variables influencingthe risk of being overweight at 3 years of age were gen-der, birthweight, Ponderal index, breast-feeding, weight at6–9 months and 17–20 months, and chest and head circum-ference in simple logistic regression analysis. The physicalvariables, such as birthweight and chest and head circum-ference at 3–4 months, each had possible interaction fac-tors. The final multiple logistic regression model is shown inTable 3. The results revealed independent association be-tween the rate of weight gain from birth to 3–4 months orrapid growth from birth to 3–4 months and being overweightat 3 years of age. In addition, there were gender-specific dif-ferences: in boys, birthweight was positively associated, butbeing breast-fed was negatively associated, with being over-weight at 3 years of age. In girls, birthweight, but not beingbreast-fed, was a risk factor for being overweight at 3 yearsof age.

Approximately 20% of children who showed postnatalrapid weight growth and taller height at 6–9 months and 17–20 months of age were overweight at age 3 (Table 4). Tallerheights at 6–9 months and 17–20 months of age after post-natal rapid weight gain were significantly associated withbeing overweight at age 3 (p = 0.019 and 0.002, respectively,Table 4).

DISCUSSIONOur study provides new evidence that taller stature in infantsshowing rapid weight gain during the first 3–4 months of life

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Table 4 Association between taller height (height SD scores ≥ 90th percentile) at different ages and prevalence of being overweight in 3-year-old children withand without rapid growth

Taller height∗ Rapid growth Nonrapid growth

Number Overweight % χ 2 p-value∗∗ Number Overweight % χ 2 p-value∗∗

3–4 months (total number = 1350)Yes 43 14.0 (6/43) 1.659 0.240 93 4.3 (4/93) 0.169 0.564No 264 8.0 (21/264) 950 3.5 (33/950)

6–9 months (total number = 1276)Yes 36 19.4 (7/36) 6.545 0.019 92 3.3 (3/92) 0.002 >0.999No 250 6.8 (17/250) 898 3.3 (30/898)

17–20 months (total number = 1320)Yes 42 21.4 (9/42) 11.888 0.002 90 5.6 (5/90) 1.054 0.367No 257 5.8 (15/257) 931 3.4 (32/931)

∗Height SD scores ≥ 90th percentile; ∗∗according to Fisher’s exact test.

can predict overweight status at age 3 (Table 4). Ekelundet al. reported that 15.9% of infants with rapid weight growthbetween birth and 6 months of age were overweight or obeseby age 17 (13). In our study, only 8.8% of postnatal rapidweight growth subjects became overweight by 3 years ofage. To our knowledge, however, there is no predictive anduseful marker during infancy that distinguishes those withrapid weight gain during infancy who were overweight orobese in early childhood from those who were not. We foundthat taller heights at 6–9 months and 17–20 months of agewith rapid infancy weight gain were associated with beingoverweight at age 3. A recent review by Dunger et al. in-dicates that the tempo of statural growth with respect torapid weight gain may be established by age 2 (6). Our re-sult suggests that the tempo of statural growth with respectto rapid infancy weight gain has already been established byaround 6–9 months of age. Furthermore, there is evidencethat rapid infant weight gain due to increased nutritionalintake is associated with higher levels of insulin-like growthfactor-1 (IGF-1) and leads to taller childhood stature andearlier pubertal development (6). In a prospective cohortstudy, rapid weight gain between birth and 3 years of agewas associated with insulin resistance at age 8 (15). Also,it has been confirmed that girls are more insulin-resistantthan boys and tend to have higher insulin and IGF-1 levels(16,17). Girls accounted for more than 70% of 3-year-oldoverweight children with rapid weight gain, indicating thepresence of gender-related difference in the relationship be-tween rapid weight gain and overweight status.

Another important result of our study was the indica-tion that a more rapid rate of weight gain and rapid weightgrowth during the first 3–4 months were associated withan increased risk of being overweight at 3 years of age. Al-though a previous study had reported an association be-tween rapid weight gain during the first 4 months and beingoverweight at 7 years of age, little is known about the re-lationship between weight gain during the same period oftime and being overweight at a younger age. There havebeen two studies regarding rapid weight gain in infancy,

within the first 3–4 months of life. First, rapid weight gain inthe first month of life is associated with being overweightat 3 years of age (18). Second, children who experiencegreater weight gain during the first week of life run therisk of being overweight as adults (19). The period frombirth until around 4 months of age appears to be critical indetermining whether or not individuals will be overweightnot only in later childhood and adulthood, but also in earlychildhood.

High birthweight is associated with an increased riskof later obesity (20,21). Additionally, low birthweight andsmaller size at birth have been linked to obesity, impairedglucose tolerance and features of metabolic syndrome laterin life (21,22,23). In this study, the proportions of high birth-weight (3500–4440 g) and low birthweight (1710–2499 g)infants among all subjects were 13.7% and 4.2%, respec-tively, with 11.3% of the former growing into overweightchildren by age 3, but only 1.8% of the latter doing so.

This study had two limitations. Several important poten-tial risk factors not analyzed in our study have been associ-ated with obesity (10). We could not find a negative correla-tion in girls between breast-feeding and being overweight at3 years of age, in spite of the negative association reported ina previous study (24). The reason for these spurious resultsmight be, at least partially, that we had access to insuffi-cient information about infant feeding and that a great dealof breast-feeding data were missing. Furthermore, this ret-rospective study was not an accurate representation of thepopulation of Kumamoto or of Japanese children because ofthe relatively small sample size and heterogeneous groups inage, and only a few analytical subjects with both taller heightand rapid weight growth were examined. The precise mech-anism by which rapid early life growth increases the risk ofobesity in childhood includes genetic and nutritional factors.We did find that taller infants with rapid weight gain tendedto be overweight children by age 3. The importance of infantheight needs to be examined in further longitudinal studies.Infant height may be able to serve as a simple clinical toolfor the prediction of weight problems in early childhood.

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ACKNOWLEDGEMENTThe authors thank Prof. Koichiro Usuku, M.D., Ph.D.,(Kumamoto Medical University Hospital, Kumamoto,Japan) for his critical comments and suggestions regardingstatistical analysis.

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