Published online October 1, 2008
PEDIATRICS Vol. 122 No. 4 October 2008, pp. e876-e883 (doi:10.1542/peds.2007-2354)
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ARTICLE

Growth Patterns and Obesity Development in Overweight or Normal-Weight 13-Year-Old Adolescents: The STRIP Study

Hanna Lagström, PhDa, Maarit Hakanen, MDb, Harri Niinikoski, MD, PhDc, Jorma Viikari, MD, PhDd, Tapani Rönnemaa, MD, PhDd, Maiju Saarinen, BSScb, Katja Pahkala, MScb,e and Olli Simell, MD, PhDa,c

a Turku Institute for Child and Youth Research, Turku, Finland
b Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
Departments of c Pediatrics
d Medicine
e Paavo Nurmi Centre, Sports and Exercise Medicine Unit, Department of Physiology, University of Turku, Turku, Finland


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. Our goal was to study childhood growth patterns and development of overweight in children who were overweight or normal weight at 13 years of age.

PARTICIPANTS AND METHODS. This study is part of a prospective atherosclerosis-prevention trial Special Turku Coronary Risk Factor Intervention Project for Children). At 7 months of age, 1062 children were randomly assigned to an intervention group (n = 540) receiving biannual fat-oriented dietary counseling or to a control group (n = 522). Height and weight of the children and their parents were monitored annually. Our study group comprised those children who participated in the 13-year study visit (n = 541). At 13 years of age, the child was classified as overweight (n = 84) if his or her BMI exceeded the international age- and gender-specific overweight criteria.

RESULTS. In overweight girls, the annual weight gain increased from 2.8 kg during the third and fourth year of life to 7.5 kg during the 12th year of life, whereas the annual weight gain of the girls who were normal weight ranged from 2.1 to 4.8 kg during the same period. The annual weight gain was similar of overweight boys and in their normal-weight peers until the age of 5 years, but after that it increased from 3.5 to 7.9 kg in overweight and from 2.6 to 5.5 kg in normal-weight boys. The BMI of the girls and boys who were overweight at the age of 13 exceeded the international cutoff point for overweight from the age of 5 and 8 years onward, respectively. The mean BMIs of the mothers and fathers of the overweight children were higher than those of the parents of the normal-weight children. The STRIP intervention had no effect on the examined growth parameters or on parental BMI.

CONCLUSIONS. The children who were overweight at 13 years of age gained more weight than their normal-weight peers by the age of 2 or 3 years onward. The girls became overweight by the age of 5 years, whereas the boys only after 8 years of age. Parental BMI and steep weight gain in early childhood indicate markedly increased risk for becoming overweight.

Key Words: adiposity rebound • weight gain • childhood obesity • growth • parental BMI

Abbreviations: STRIP—Special Turku Coronary Risk Factor Intervention Project for Children • RMANOVA—repeated-measures analysis of variance

Prevalence of childhood obesity has increased at least two- to threefold in the Western societies during the last few decades. Consequently, currently ~20% of the adolescents are overweight or obese.1–3 Reasons behind this phenomenon are complex.4–7

Obesity in adulthood is strongly associated with serious diseases such as type 2 diabetes, cardiovascular and musculoskeletal diseases, certain cancers, and increased overall mortality.8 Childhood obesity is also linked to various detrimental health effects,9 including problems in psychological well-being causing low self-esteem10 and undesirable changes in cardiovascular risk factors.11 Because of the massive increase in the prevalence and rate of obesity in children, currently up to one third of the children diagnosed with diabetes have type 2 diabetes, which strongly relates to body weight and composition.12,13 In addition, obese children are also prone to become obese adults,14–16 and moreover, childhood obesity is associated with health risks in later life.17–19

Some studies have reported the associations between early growth patterns and later risk of obesity.20–23 It has been hypothesized that certain periods in childhood may be critical for development of persistent obesity and its comorbidities.24–26 These life periods include prenatal period, early infancy, age at adiposity rebound, and adolescence. Adiposity rebound starts the age when the calculated BMI of a child starts to increase again after an initial decrease.27 In the Special Turku Coronary Risk Factor Intervention Project for Children (STRIP) study, the weights and heights of 1062 children were recorded prospectively from 7 months of age onward. The aim of this study was to examine the childhood growth patterns and development of overweight in children who were overweight or normal weight at the age of 13 years.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Study Design and Subjects
This study is a part of the ongoing prospective, randomized STRIP trial. The study design of the STRIP study has been published in detail.28 In brief, between February 1990 and June 1992, families of 5-month-old infants were recruited to the study at the well-infant clinics in the city of Turku, Finland. At the age of 7 months, 1062 infants (56.5% of the eligible age cohort, N = 1880) were allocated randomly to an intervention group (N = 540) or to a control group (n = 522). At the infants' age of 7 months, 1056 mothers and 983 fathers participated in the baseline visit.

The families of the intervention group received individualized dietary and lifestyle counseling at 1 to 3-month intervals until the child was 2 years old and biannually thereafter.29 In brief, the counseling aimed at reduction of the child's saturated fat intake. The optimal diet was defined to contain energy without any restrictions, with fat 30-35E% (percent of energy) between 13 months and 2 years and 30E% after that. The families in the control group were seen by the counseling team twice a year until the child was 7 years old and annually thereafter.

Data on BMI was available from 555 children participating in the 13-year visit of the STRIP study. Seven children with a disease that may have affected body weight development (ie, diabetes, familial hypercholesterolemia, cerebral palsy, or Down syndrome) and 7 underweight children (weight for height >20% below the mean value of healthy Finnish children of same height and gender) were excluded from the analyses, leaving 541 children to this study. Based on BMI data, 13-year-old children were classified as normal weight (n = 457) or overweight (n = 84).

We have previously analyzed whether children and families who drop out the study differed from those who continued and found no differences in serum total cholesterol or saturated fat intake.30

The Joint Commission on Ethics of the Turku University and the Turku University Central Hospital approved the STRIP study. Informed consent was obtained from the parents at the beginning of the trial.

Anthropometric Measurements
Weights of the children were measured to the nearest 0.1 kg with an electronic scale (S10; Soehnle, Murrhardt, Germany) at each visit. Recumbent lengths of the children younger than 2 years were recorded, and thereafter standing heights were measured to the nearest millimeter with a wall-mounted Harpenden stadiometer (Holtain, Crymych,United Kingdom). The BMI of each child was calculated as weight in kilograms divided by the square of height in meters (kg/m2). The 13-year-old child was considered overweight if his or her BMI exceeded the international cutoff value for overweight31 (21.91 kg/m2 for boys and 22.58 kg/m2 for girls). Adiposity rebound, which is the age point at which the calculated BMI value of a child starts to increase again after an initial decrease,27 was defined for each child. Data on birth weight and length were collected from the well-infant clinic records. Weights of the parents were measured annually, and their BMI was calculated.

Pubertal status of the child was recorded from the age of 9 years onward. The physicians who examined the children were trained by an experienced pediatric endocrinologist to correctly stage pubertal development. Testicular length was measured with a ruler, and breast tissue diameter and pubic hair development were estimated visually. The signs of puberty were recorded according to Tanner staging.32 Stages M1/P1 (no breast tissue, no pubic hair) in girls and G1/P1 (testes < 20 mm, no pubic hair) in boys were considered prepubertal and all other stages pubertal.

Statistical Methods
Associations between background characteristics and obesity groups were analyzed with Student's t tests (continuous scale variables) and the Cochran-Mantel-Haenszel method for differences in mean scores (ordinal scale variables). In longitudinal analyses of the growth of study children and their parents' BMI, repeated-measures analysis of variance (RMANOVA) with backward selection was used. Obesity group, time and time x obesity group interaction were included in all models, whereas STRIP intervention group as a covariate was allowed to be excluded with observed significance level >0.1. In case of significant interactions, pairwise comparisons between weight groups within each age point were assessed with Tukey-Kramer adjusted t tests. Results were considered statistically significant at a value of P < .05. Statistical analyses were performed by using SAS 9.1 software for Windows (SAS Institute, Inc, Cary, NC).


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Birth weight and birth length of the children who were overweight at the age of 13 years did not differ from those of the children who were normal weight at that age (Table 1). Boys and girls grew ~25 cm in height during the first year of life (Fig 1). Thereafter, the rate of growth in height gradually decreased and stabilized at ~6 cm per year. Until the age of 11 years, the rate of growth in height was slightly greater in those girls, who were overweight at the age 13, compared with their normal-weight peers (P < .0001 for time x group-interaction). During the 13th year of life, the rate of growth in height of the overweight girls was 1.2 cm less than that of the normal-weight girls (P < .001). In boys, the rate of growth in height was similar in those boys who were overweight to those who were normal weight at age 13 (P = .38).


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  		TABLE 1 Mean (SD) Birth Weight, Birth Length, and Age of Adiposity Rebound of Girls and Boys Who Were Normal Weight or Overweight at 13 Years of Age

 

Figure 1
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  		FIGURE 1 Height and weight gain of girls (left) and boys (right) who where normal weight ({square}) or overweight ({blacktriangleup}) at the age of 13. Vertical bars indicate 1 SD unit. Significant P values from RMANOVA models including time, weight group, and the interaction of the two are shown.

 
The weight gain was ~6 kg during the first year of life in both genders (Fig 1). In girls who were overweight at the age of 13 years, the annual weight gain increased from 2.8 kg during the third and fourth year of life to 7.5 kg during the 12th year of life, whereas the annual weight gain of the girls who were normal weight at age 13 ranged from 2.1 to 4.8 kg during the same period (P < .001 for the difference between the groups at each age point between 5 and 12 years). During the 13th year of life, the weight gain was 5.9 and 4.9 kg in girls who were overweight and normal weight at the age of 13, respectively (P = .04). The annual weight gain was closely similar in boys who were overweight at the age 13 and in their normal-weight peers until the age of 3 years (Fig 1). After that, the annual weight gain of the boys who were overweight at age 13 increased from 3.5 up to 7.9 kg during the 13th years of life, whereas the annual weight gain of the boys who were normal weight at age 13 ranged from 2.6 to 5.5 kg (P = .002 for the difference between the groups at each age point).

The mean BMI increased up to the age of 7 months and started to decline steadily thereafter in those girls who were normal weight at the age 13, and in both groups in boys, whereas the mean BMI of those girls who were overweight at 13 remained quite steady from the age of 7 months to the age of 5 years and started to increase again thereafter (Fig 2). The lowest BMI was reached at the age of 3.8 years in girls who were overweight at age 13, and at age 5.5 years in normal-weight girls (P < .001; Table 1). Boys who were overweight or normal weight at the age of 13 reached the lowest BMI at the age of 4.3 years and at the age of 5.6 years, respectively (P < .001; Table 1). The mean BMI of girls who were overweight at the age of 13 years exceeded the international cutoff point for overweight from the age of 5 years onward (Fig 2). The mean BMI of the boys who were classified as overweight at the age of 13 exceeded the cutoff point for overweight from the age of 8 years onward (Fig 2).


Figure 2
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  		FIGURE 2 BMI of girls (upper) and boys (lower) who where normal weight ({square}) or overweight ({blacktriangleup}) at the age of 13. Vertical bars indicate 1 SD unit, and the red line indicates Cole's cutoff point for overweight. Significant P values from RMANOVA models including time, weight group, and the interaction of the two are shown.

 
From 8 to 12 years of age, the girls who were overweight at the age of 13 were slightly taller than the normal-weight girls (P < .001 for timexgroup interaction, P = .03 at all age points between 8 and 12 years). The girls who were overweight at the age of 13 years were increasingly heavier from the age of 5 years onward (P < .001 for timexgroup interaction and in all age points between 5 and 13 years) (Fig 3). In boys, the growth in height was similar in those who were overweight or normal weight at the age of 13 years during the follow-up (P = .002 for the interaction but P = NS for the comparisons at each age point). From the age of 6 years onward, weight increased more rapidly in the boys who were overweight at the age of 13 (P < .001 for time x group interaction and at all age points between 6 and 13 years; Fig 3).


Figure 3
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  		FIGURE 3 Height and weight of girls (left) and boys (right) who where normal weight ({square}) or overweight ({blacktriangleup}) at the age of 13. Vertical bars indicate 1 SD unit. Significant P values from RMANOVA models including time, weight group, and the interaction of the two are shown.

 
By the age of 13 years, all overweight girls and 97% of the normal-weight girls had entered puberty. The pubertal stages were more mature in the overweight girls than in the normal-weight girls (P < .001 and P < .008 for breast tissue and pubic hair, respectively) (Table 2). In accordance with pubertal development, the rate of growth decreased from the age of 11 years onward in those girls, who were overweight at the age of 13, whereas this deceleration took place 1 year later in the normal-weight girls. The pubertal development of the overweight boys was not different from that of the normal-weight boys at the age of 13 years (P = .93 and P = .98 for testes and pubic hair, respectively; Table 2).


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  		TABLE 2 Tanner Pubertal Stages of Normal-Weight or Overweight Girls and Boys at 13 Years of Age

 
The mean BMI of both mothers and fathers of those children, who were overweight at the age of 13 years, was higher than that of the parents of the normal-weight children during the entire follow-up (Fig 4). The mean BMI of the mothers of those children who were overweight at the age 13 exceeded the cutoff point for overweight in adults (25 kg/m2) when the children were 4-year-old and remained there the following years. The mean BMI of the fathers of those children who were overweight at the age of 13 years was above the cutoff point for overweight throughout the whole study period. Also, the mean BMI of the fathers of those children who were normal weight at the age of 13 years increased steadily and reached the cutoff point for overweight at child's age of 6 years. The ages of mothers of overweight (44.3 ± 4.4 years) and normal-weight (43.3 ± 4.9 years) children, as well as the ages of fathers of overweight (45.1 ± 5.7 years) and normal-weight (45.5 ± 5.7 years) children showed no differences (P = .14 for mothers and P = .68 for fathers at the child's age of 13 years).


Figure 4
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  		FIGURE 4 Mean BMI of mothers (upper) and fathers (lower) of children who where normal weight ({square}) or overweight ({blacktriangleup}) at the age of 13. Vertical bars indicate 1 SD unit. Significant P values from RMANOVA models including time, weight group, and the interaction of the two are shown.

 
To study the effect of the lifestyle counseling given to a half of the children, the study group (intervention or control) was included in the statistical model. The STRIP intervention had no effect on the examined growth parameters or on parental BMI, and was excluded from all RMANOVA models with >0.1.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Our results clearly show that weight-development of the children, who were overweight at adolescence, differed already at early age from the weight development of the children who were of normal-weight at adolescence. The children who were overweight at the age of 13 years gained weight excessively already from the age of 3 years and girls became overweight already at the age of 5 years and boys at the age of 8 years. This implies that obesity prevention should start no later than at the ages of 2 to 4 years. In addition, early prevention is important because childhood obesity tends to persist to adulthood.33–38 Children who were overweight during the preschool or elementary school ages were more likely to be overweight at the age of 12 years than children who were normal-weight.39 On the other hand, BMI at the age of 13 years correlates tightly with BMI in young adulthood.40

During the first year of life, adiposity increases rapidly because of the growth in the size of the adipocytes, but adiposity then quickly diminishes to remain stable for several years.27 The adiposity rebound is the period of the second common rise in adiposity, which occurs between the ages of 3 and 7 years. It corresponds to the time when fat cells start to increase in number after an earlier phase when they increased or decreased in size. Timing of adiposity rebound differs between studies from 3.58 to 5.08 years.27,41,42 In our study both girls and boys who were overweight at the age of 13 years had earlier adiposity rebound than their normal-weight peers. Our results thus confirm the findings of previous studies showing that early adiposity rebound in children may be considered to be a simple indicator for predicting later obesity and also 1 of the critical periods for development of obesity.24,43

On the other hand, the importance of early adiposity rebound for later obesity risk has been criticized because the period of rebound can be identified only retrospectively, and the connection between early adiposity rebound and later obesity is only statistical.44,45 However, girls seem to develop overweight years earlier than boys. The reasons for different weight development in boys and girls remain unidentified, but divergent hormonal status, body composition, and physical activity habits may all contribute to the outcome. Indeed, we previously showed that teenaged boys are physically more active than girls,46 and they might have been that also during the earlier years. The gender difference in weight development can not be explained by different food consumption or nutrient intakes, which have been reported to be closely similar in boys and girls.29,47

At the age of 9 years the majority of the girls and all 9-year-old boys in the STRIP study were still prepubertal. Interestingly, two thirds of the overweight girls had entered puberty by the age of 10 years, whereas only one third of the normal-weight girls showed physical signs of puberty at that age.48 Accordingly, the pubertal stages were more mature in overweight 13-year-old girls than in the normal-weight girls in this study. Our finding of earlier pubertal development in obese girls is not likely an artifact of visual inspection because similar findings have been reported in previous studies showing that overweight girls enter puberty earlier than normal-weight girls.49–51 The reason for this might be the role of fat tissue in pubertal development and production of estrogens. The association between overweight and sexual maturation seems to be less evident in boys because some studies have found only a weak or negative association and others have found no association at all.52–54

It is known from previous studies that parental obesity is a stronger predictor of childhood obesity than the child's own weight status before the age of 3 years.4,5 Our earlier results also indicate that the BMIs of the parents are strong predictors of a child's overweight.48 In the present study, BMIs of both mothers and fathers of overweight adolescents were higher than that of normal-weight adolescents during the whole study period, and actually, most fathers were overweight already in the beginning of the study.

Half of the children in the present study belonged to the intervention group of the STRIP trial and had received lifestyle counseling since infancy. The intervention was mainly focused on dietary issues, and no special emphasis was placed on the total energy intake or obesity prevention. Yet, we have previously reported that there were fever overweight girls in the intervention group than in the control group.48 Therefore, it was somewhat surprising that the intervention had no effect on the growth patterns of the children in the present study. This may partly be explained by the fact that the number of overweight children was quite low in the study population.

It is important to note that in childhood maintaining stable weight is easier than losing excess weight. Consequently, more effort should be focused on discovering how to prevent overweight development. Even complete understanding of the genes and other factors that regulate appetite and metabolism hardly can reverse the current obesity epidemic driven by the environmental and cultural changes. Additional research is required to identify how normal weight can best be sustained, and how physical activity and healthy dietary habits can best be transformed into a personally chosen behavior by children at different ages and over the entire life course. Current policies, commercial practices, and cultural attitudes should also be continuously evaluated and monitored to support interventions aiming at early prevention of obesity.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Our study shows that children who were overweight at adolescence gained weight excessively already from the age of 2 to 3 years. Parental obesity and steep weight gain in early childhood should be taken into account when identifying children who might benefit from preventive measures. Attention should be paid to the phenomenon that weight gain among girls occurred earlier than among boys. Health care professionals' role is pivotal in the early prevention of the childhood obesity epidemic.


   ACKNOWLEDGMENTS
 
This work was supported by Academy of Finland grants 206374 and 211158 (Finnish Cultural Foundation), the Juho Vainio Foundation, the Finnish Cardiac Research Foundation, the Sigrid Juselius Foundation, Special Governmental Grants for Health Sciences Research (Turku University Hospital), the Yrjö Jahnsson Foundation, the Foundation for Pediatric Research (Finland), and the Turku University Foundation.


   FOOTNOTES
 
Accepted Jun 11, 2008.

Address correspondence to Hanna Lagström, PhD, Turku Institute for Child and Youth Research, University of Turku, FI-20014 Turku, Finland. E-mail: hanna.lagstrom{at}utu.fi

The authors have indicated they have no financial relationships relevant to this article to disclose.


What's Known on This Subject

Childhood obesity tends to persist to adulthood, and the development of obesity typically begins in the preschool years. It is also known that various time periods in childhood may be critical for development of persistent obesity, and parental obesity predisposes to childhood obesity.

 

What This Study Adds

Children who were overweight at adolescence gained weight excessively by the age of 2 or 3 years, much earlier than when they became overweight. This implies that the age of 2 to 4 years is optimal for initiation of obesity prevention.

 


   REFERENCES
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 ABSTRACT
 METHODS
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 DISCUSSION
 CONCLUSIONS
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics




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