Blackwell Science, LtdOxford, UKOBRobesity reviews1467-78812005 The International Association for the Study of Obesity.

6143154Review ArticleRapid early growth and obesity in later life P. O. A.

Monteiro & C. G. Victora

obesity reviews

Rapid growth in infancy and childhood and obesity in

later life – a systematic review

P. O. A. Monteiro1 and C. G. Victora2

1
Department of Clinical Medicine, Federal
University of Pelotas, Pelotas, Brazil;
2
Department of Social Medicine, Federal
University of Pelotas, Pelotas, Brazil
Received 23 August 2004; revised 16
November 2004; accepted 23 November 2004
Address reprint requests to: POA Monteiro,
Department of Clinical Medicine, Federal
University of Pelotas, Caixa Postal 464, CEP
96001–970, Pelotas, RS – Brazil. E-mail:
monteiro.po@terra.com.br
Summary
The association between obesity and morbidity resulting from chronic diseases is
well known. This systematic review addresses studies of the role of rapid growth
in infancy and childhood as possible determinants of overweight and obesity later
in the life course. We reviewed MEDLINE for studies reporting on growth in
infancy and childhood, as well as measures of weight or adiposity in later child-
hood, adolescence or adulthood. The methodological quality of the papers was
assessed using the criteria suggested by Downs and Black. Sixteen articles that
fulfilled review criteria were located. There was wide variability in the indicators
used for defining rapid growth as well as overweight or obesity. The age range in
which weight or adiposity was measured ranged from 3 to 70 years. In spite of
differences in definitions used, 13 articles that reported on early rapid growth
found significant associations with later overweight or adiposity. Efforts should
be made to standardize the definition of rapid growth, as well as that of over-
weight and obesity in children and adolescents. The most frequent definition for
rapid growth in this review was a Z-score change greater than 0.67 in weight for
age between two different ages in childhood. Regarding obesity, the definition
proposed by the International Obesity Task Force also appears to be most appro-
priate. The present results indicate that early growth is indeed associated with the
prevalence of obesity later in the life course.

Keywords: Adolescence, child, obesity, rapid growth, weight gain.

obesity reviews (2005) 6, 143–154

determination has been hypothesized (9). Among such

Introduction
Obesity has been associated with social disadvantages (1)
and different types of morbidity in children, adolescents,
and adults (2,3). The growing occurrence of this phenom-
enon has been highlighted by international organizations
(4), concerned with its future impact on health at both
individual and population levels, and therefore on the econ-
omy of a number of countries (5,6).
Publications addressing the risk factors for obesity are
abundant, and increasingly diverse and have shown the
determination of this morbidity (7,8).
A connection between events which occurred very early
in life, related to fetal and newborn growth, and morbidity
events, rapid growth – especially weight gain – has been
the subject of recent research in various regions worldwide
(10–15). The definition of rapid growth is diverse in the
literature, and both linear (16,17) and ponderal growth
have been studied under this heading. An increased rate of
either weight or height gain seems to be the common link
between these studies. The broadness of the concepts of
both rapid growth and obesity, the different age groups
studied, and the heterogeneity of surveyed populations are
factors that hinder a greater understanding of the problem.
The present paper undertakes a systematic review of the
literature with the purpose of organizing current knowl-
edge on the subject and evaluating the results of different

© 2005 The International Association for the Study of Obesity. obesity reviews 6, 143–154 143
144 Rapid early growth and obesity in later life P. O. A. Monteiro & C. G. Victora obesity reviews

studies about the influence of rapid growth on the occur-
rence of obesity, especially among children and teenagers.
Methods
The present review included articles indexed in the MED-
LINE database, accessed through the Internet, with no
restrictions in terms of publication. Only studies with
human subjects were included.
All articles dealing with the association between rate of
early growth (during childhood) and overweight or obesity
at any age were considered, in spite of the emphasis of the
review being on the association with outcomes during ado-
lescence. One article evaluated linear rapid growth from
birth to ages 18–25 years, when outcome was measured
(17).
In order to identify the effects of growth rate in the
occurrence of obesity, one must have access to at least two
growth-related measurements, of any kind, collected at
different times. Therefore, the present review will include
only articles that have some sort of accompaniment com-
ponent, be they cohorts, or other studies with access to
prior data.
The review employed keywords selected in accordance
with the Medical Subject Headings (MeSH) of the US
National Library of Medicine, responsible for running
the MEDLINE database. The following keywords were
employed: adolescence, birth weight, child, fetal growth
retardation, growth, intrauterine growth restriction
(IUGR), and weight gain, combined with obesity, over-
weight, or fat body. Although ‘adiposity rebound’ is not a
MeSH term, we used it as a keyword for its use in some
studies about obesity.
Bibliographic references of electronically selected articles
were reviewed. Any articles considered as relevant, but that
eventually did not turn up in the computerized search, were
sought and evaluated.
Publication quality was evaluated according to the
method proposed by Downs & Black (Table 1) (18). These
authors devised an instrument consisting of 27 questions

Table 1 Evaluation criteria adapted from Downs & Black (Downs, 1998)

Criteria Number of articles

Adequate Inadequate*

Is the hypothesis/aim/objective of the study clearly described? 15 0

Are the main outcomes to be measured clearly described in the Introduction or Methods section? 14 1
Are the characteristics of the subjects included in the study clearly described? 14 0
Are the exposures of interest clearly described? 14 1
Are the distributions of principal confounders clearly described? 12 3
Are the main findings of the study clearly described? 14 1
Does the study provide estimates of the random variability in the data for the main outcomes? 14 1
Have all the important adverse events that may be a consequence of the intervention been reported? – –
Have the characteristics of patients lost to follow-up been described? 10 5
Have actual probability values been reported (e.g. 0.035 instead of < 0.05) for the main outcomes except where the 12 3
probability value is less than 0.001?
Were the subjects asked to participate in the study representative of the entire population from which they were recruited? 6 9
Were the subjects included in the study representative of the entire population from which they were recruited? 6 9
Were the staff, places, and facilities where the patients were treated representative of the treatment the majority – –
of patients receive?
Was an attempt made to blind study subjects to the exposure? 0 15
Was an attempt made to blind those measuring the outcomes of the exposure? 0 15
Were the analyses of the main outcomes established a priori? Or were there subgroup analyses? 15 0
In cohort studies, do the analyses adjust for different lengths of follow-up of subjects? 11 4
Were the statistical tests used to assess the main outcomes appropriate? 11 4
Was compliance with the interventions reliable, that is, without classification errors? 15 0
Were the main outcomes measures used accurate (valid and reliable)? 14 1
Were study subjects in different comparison groups recruited from the same population? 15 0
Were study subjects in different comparison groups recruited over the same period of time? 14 1
Were study subjects randomized to intervention groups? – –
Was randomization complete and irrevocable? – –
Was there adequate adjustment for the main confounders? 6 9
Were losses of subjects to follow-up taken into account? 11 4
Did the study have sufficient power to detect an important effect, with 5% significance? 0 15

*Includes articles that do not state whether or not the criterion was fulfilled.
The bold items are part of the original Downs & Black’s evaluation tool for randomized clinical trials.

© 2005 The International Association for the Study of Obesity. obesity reviews 6, 143–154
obesity reviews Rapid early growth and obesity in later life
that evaluate reporting, external validity, internal validity
(bias and confounding), and statistical power. The instru-
ment was adapted to the evaluation of observational stud-
ies by Lima (19), because it had been originally conceived
for the evaluation of clinical trials. Thus, questions 8, 13,
23, and 24 – specific to this type of design – were elimi-
nated. All questions received scores 0 or 1, with the excep-
tion of question 5, which ranged from 0 to 2, depending
on whether the statistical power of the survey was explicitly
stated in the article as being at least 80%. Thus, the max-
imum score achievable by an article was 24 points.
Results
Fifteen articles that dealt with the association between
some form of rapid growth during infancy or childhood
and a greater risk of overweight, obesity, or increased adi-
posity in some period later in life (Table 2) were found.
Only two articles were published more than 5 years before
the present review. Ten articles evaluated the outcomes of
interest during the two first decades of life; of these, five
analysed outcomes during the first decade only, two during
the second decade only, one in both decades, and another
two between ages 17 and 28 years. The main characteris-
tics of these studies are summarized in Table 3.
Methodological aspects
According to the data described in Table 3, mean method-
ological quality score was 17 points (standard
deviation = 2.8). Table 1 shows that none of the studies
described the statistical power of the analyses, or the ‘blind-
ing’ status of either study subjects or interviewers in rela-
tion to exposures and outcomes. In addition to the above,
other major methodological problems included sample rep-
resentativity in relation to the original populations, lack of
adjustment for confounders, and failure to address the
effects of follow-up losses on internal validity. Three studies
had scores below 15 (15,20,21), all of which were limited
especially in terms of statistical analysis. One study was
available only as an abstract presented at an international
congress (22), and was excluded from this review because
it could not be evaluated as to its quality.
Table 2 Bibliographical review on the association between rapid growth
in infancy and childhood and obesity in later life
Abstracts located
Potentially relevant abstracts
Articles obtained
Relevant articles
MEDLINE, Medical Literature Analysis and Retrieval System Online (US
National Library of Medicine).
© 2005 The International Association for the Study of Obesity. obesity reviews 6, 143–154
P. O. A. Monteiro & C. G. Victora 145
The definitions of the exposure under investigation –
rapid growth – were various. One group of authors defined
rapid growth as a dichotomous variable. The first study to
be published (20) defined rapid growth as an increase in
weight above percentile 90 at ages 6 weeks, 3 months, and
6 months, using UK population growth charts as a refer-
ence. Four authors used changes in Z-scores for weight-for-
age, height-for-age, weight-for-height, and Body Mass
Index (BMI). Of these, Ong et al. (10) and Cameron et al.
(15,22) adopted variations greater than +0.67 in weight-
for-age Z-scores between two separate evaluations, a sys-
tem proposed by Ong in 2000, based on the 0.67 Z-scores
representing the width of each percentile band on standard
UK growth, which show percentiles 2, 9, 25, 50, 75, 91,
and 98); Monteiro et al. (14) employed variations greater
than +0.67 in weight-for-age, height-for-age, and weight-
for-height Z-scores between two measurements; and Stet-
tler et al. (23) used variations in weight-for-age greater than
+1 Z-score.
Other authors did not adopt cut-off points to define
rapid growth, treating the exposures as continuous vari-
ables instead. In Japan, Tanaka et al. (12) used weight gain
during the first month of life. Stettler et al., in both the USA
(24) and Seychelles (13), used crude weight gain values in
the first year of life. Schroeder et al. (25), Eriksson et al.
(11,26), and Law et al. (27) used changes in nutritional
status, expressed as Z-scores. Parsons et al. used the per-
centage of eventual adult height at age 7 as a criterion for
rapid growth (16). Lundgren et al. (17) used as a criterion
a positive variation in height Z-score between birth and
military conscription in Sweden (between ages 18 and
25 years) among men born ‘small for gestational age’
(weight-for-age, height-for-age, or both more than -2 stan-
dard deviations below mean of that country’s population).
The age at which the exposure was measured also pre-
sented considerable variation, as did the intervals between
measurements for rapid growth calculation. More preco-
cious surveys collected such measurements between birth
and the first month of life (12), whereas late studies did so
between birth and age 20 years approximately (17). The
most consistent age interval was 0–2 years. It was used in
three studies (10,14,15), all of which also used the +0.67
weight-for-age Z-score variation cut-off point as a defini-
tion for rapid growth. One of the former also evaluated
rapid growth between ages 20 and 43 months (14).
Outcome definitions were no less heterogeneous. Differ-
MEDLINE ent criteria were applied as definitions of child overweight
and/or obesity. Relative weight [(individual weight)/(stan-
2133 dardized population weight) ¥ 100%] (20,21); BMI per-
29
centiles using different cut-off points and reference
28
15 populations [Stettler, in 2002 (24), used US Centers for
Disease Control and Prevention (CDC) percentile 95 (28);
the same author, still in 2002 (13), used cut-off points
recently recommended by the International Obesity Task
 146

Table 3 Bibliographical review presented by age at which exposure was measured.

Author/country/year Type of study Number of subjects and Exposure – definition Outcomes Results/comments Quality score*/comments
accompaniment period of rapid growth

Tanaka et al. (12) Prospective 588 children born in Weight gain during first BMI at age 3 years. Multiple linear regression Score = 16
Japan 2001 birth cohort Japan between 1987 year of life. (continuous variable) coefficient = 0.0163. (P = 0.0095) The sample corresponds to 8% of the
and 1999, evaluated at (continuous variable) cohort sample. Mean gestational age
birth and at ages and birthweight were similar in both
1 month and 3 years. samples. Analysis not adjusted for
major confounders.
Rapid early growth and obesity in later life

Stettler et al. (24) Prospective 19 937 subjects from 20 Weight gain during first Overweight (BMI > P95 For every 100 g of monthly weight Score = 21
United States birth cohort different US locations, 4 months, expressed as specific for age and sex – gain in the first 4 months of life, 69.6% of initially sampled subjects
2002 born between 1959 and 100 g month-1. CDC†) at age 7 years there was a 38% increase had complete data and were similar in
1965, evaluated at birth (continuous variable) (dichotomous variable) (P < 0.001) in risk of overweight at birthweight to those with incomplete
and at ages 4 months age 7 years. data. Analyses were adjusted for
and 7 years. major risk factors.
Stettler et al. (23) Prospective 300 African Americans Increase ≥ 1 standard Obesity (BMI ≥ 30 kg m-2) at Exposed subjects were at 5.2-fold Score = 20
United States birth cohort born in term, followed deviation in weight-for- age 20 years. Overweight risk of developing obesity Study limited to African Americans.
2003 from birth to age age Z-score between (BMI ≥ 25 kg m-2) + SSF and (P = 0.008), and 6.2-fold risk of Eligible population = 446. 32.7%
20 years. birth and age 4 months. TSF ≥ percentile 85 of the being overweight with excess body losses, with no statistically significant
(dichotomous variable) specified population (excess fat. (P = 0.003). differences for losses in terms of
fat) at age 20 years. perinatal variables, but with a lesser
P. O. A. Monteiro & C. G. Victora

(dichotomous variable) occurrence of rapid growth during the

first 4 months of life. The analysis was
adjusted for major confounders.
Eid (20) Retrospective 224 children ages Weight gain greater than Obesity = weight > 20% of Fourfold risk of obesity (P = 0.07) Score = 12
England 1970 birth cohort 6–8 years, including percentile 90 of the weight of reference and overweight (P = 0.025) among 6% of the original sample was studied.
data from birth (in 1961) standard English population, according to age exposed. These did not differ in birthweight from
and first year. population in the periods and sex. Overweight = those who were not accompanied. No
between birth,6 weeks, weight > 10% of weight of multivariate analysis was performed
3 months, and 6 months. reference population, (probably because of technological
(dichotomous variable) according to age and sex limitations).
(dichotomous variables)

© 2005 The International Association for the Study of Obesity. obesity reviews 6, 143–154
obesity reviews
 Table 3 Continued

Author/country/year Type of study Number of subjects and Exposure – definition Outcomes Results/comments Quality score*/comments
accompaniment period of rapid growth

Monteiro et al. (14) Prospective 1076 adolescents born Rapid growth (above Overweight = BMI ≥ Rapid growth in weight-for-age Score = 19
Brazil 2003 birth cohort. in 1982, ages 14–16 + 0.67 weight-for-age percentile 85 according to between birth and age 20 months 28% of the cohort was not found
years. Z-scores between birth age and sex from NHANESI‡. was associated with 66% during the last follow-up, losses being
obesity reviews

Mellbin & Vuiile (21) Prospective 459 boys and 504 girls
and age 20 months, and Obesity = overweight + SSF (P = 0.002) and in increases in the greater among lower-income subjects.
weight-for-age, height- and TSF ≥ percentile 90 of prevalence of overweight 69% There were ignored data, but the
for-age, and weight-for- NHANES I. (P = 0.048) and obesity prevalence of obesity among subjects
height between ages 20 Age: 14–16 years. respectively. For the exposures with and without complete data was
and 43 months). (dichotomous variables) measured between ages 20 and identical (data not published).
(dichotomous variables) 43 months, overweight and obesity Analyses were adjusted for major
increases were, respectively, 69% confounders.
(P = 0.004) and 64% (P = 0.088) for
weight-for-age, and 55%
(P = 0.014) and 87% (P = 0.021) for
weight-for-height rapid growth.
Height-for-age rapid growth was
associated with a 53% increase in
prevalence of overweight
(P = 0.017), but was not associated
with obesity
Rapid weight gain Increased risk of moderate

© 2005 The International Association for the Study of Obesity. obesity reviews 6, 143–154
Relative weight (W) = Score = 13
Sweden 1976 cohort, living in the Upssala during first year of life, (individual weight ∏ standard overweight at age 7 years – 2.6 99% of the original sample was
followed region, in Sweden, inferred high weight weight ¥ 100%) at ages 7 (P < 0.001) and 1.7 (P < 0.05) studied. Definition of exposure
since age through approximately during predefined and 101/2 years. Moderate respectively. The fold for boys and confusing. Analyses were not
7 years, with accompanied for periods§ (weight above overweight: P > 110% and girls increase in the risk of severe adjusted. No multivariate analysis
data of the 3 years. percentile 90 or 97, £ 120% Severe overweight: overweight was observed only (probably because of technological
according to age in
Rapid early growth and obesity in later life

first year of P > 120% among boys, and was nine times limitations).
life. months – percentile (dichotomous variable) greater at age 7 years (P < 0.001)
curves from the study and three times greater at age
itself). 101/2 years (P < 0.01).
(dichotomous variable)
Law et al. (27) Prospective 161 men and 185 Change in weight-for- BMI at age 22 years. Correlation coefficients = 0.17 Score = 16
England 2002 birth cohort. women born in southern age Z-score during first (continuous variable) (P = 0.001) and 0.30 (P < 0.001) for 47.7% of the 725 eligible subjects
England between 1975 year and between first exposure at first and fifth years were studied. There was no difference
and 1977, followed for and fifth years of life respectively. in birthweight or post-natal growth in
22 years. (local standard). relation to non-participants.Primary
(continuous variable) outcome was arterial pressure, not
obesity. No measure of adiposity; BMI
instead. Analyses were not adjusted
P. O. A. Monteiro & C. G. Victora

for major confounders.

147
 148
Table 3 Bibliographical review presented by age at which exposure was measured (continued).

Author/country/year Type of study Number of subjects and Exposure – definition Outcomes Results/comments Quality score*/comments
accompaniment period of rapid growth

Stettler et al. (13) Cross- 5514 children and Weight gain during first Overweight and obesity (BMI For each kilogram of weight gained Score: 19
Seychelles 2002 sectional, school-age adolescents year of life (weight at age specific for age and sex during the first year there was an 83.5% of eligible children and
with access to from the Republic of 1 year minus according to IOTF) at ages increase in risk of overweight and adolescents were studied. There was
data from the Seychelles in 1999; birthweight). between 4.5 and 17 years. obesity of 46% (P < 0.001) and some ignored data, but outcome
first year of ages between 4.5 and (continuous variable) (dichotomous variables) 59% (P < 0.001) respectively. prevalence was not different between
life. 17 years. subjects with or without complete
data. Anthropometric measurements
were performed by specifically trained
nurses at all stages of the study.
Analyses were adjusted.
Ong et al. (10) Prospective 848 subjects evaluated Increase in weight-for- Z-scores for weight-for-age, The results presented below refer to Score: 20
Rapid early growth and obesity in later life

United Kingdom birth cohort. at birth and at ages 2 age > 0.67 Z-scores height-for-age, and BMI: subjects with and without exposure Studied children included 63.5% of the
2000 and 5 years. between ages o and prevent body fat, mean total respectively: initial sample, but did not differ in
2 years. body fat, fat mass, and waist – Z-score for weight-for-age (mean): birthweight from those not studied.–
(dichotomous variable) circumference, all measured 0.87 and 0.22; Z-score for height- children with ponderal growth above
at age 5 years. for-age (mean): 0.47 and 0.13; 0.67 Z-score had lower weight, length,
(continuous variables) – Z-score for BMI (mean): 0.82 and and ponderal index at birth; however,
0.19; mean Z-score was –0.53 for
– body fat (%): 17.2 and 15.8; birthweight, and -0.27 for length at
– fat mass (kg): 3.6 and 3.0; birth, therefore not characterizing low
– waist circumference (cm): 54.6 birthweight or short length at birth.
and 52.7. All differences were Analyses were not adjusted for
significant (P < 0.001). maternal and perinatal variables.
P. O. A. Monteiro & C. G. Victora

Cameron et al. (15) Prospective 193 African children Rapid growth (above Weight, height, BMI, SSF Mean values among children with Score = 14
South Africa 2003 birth cohort. from Johannesburg 0.67 weight-for-age Z- and TSF, waist and without rapid growth at age The initial sample size was not given,
suburbia and Soweto, scores between birth circumference, total body 9 years: there is no way of determining the
accompanied from and age 2 years). fat, and percent body fat – wieght (kg): 32.4 and 28.6 percentage represented by the current
birth to age 9 years. (dichotomous variable) (%BF), measured at age (P < 0.001) sample. Authors state that both varies
9 years. – height (cm): 135.8 and 132.0 only in terms of TSF skinfold measure
(continuous variables) (P < 0.001) at age 2 years and maternal height.
– BMI (kg/m2): 17.47 and 16.39 The analysis was not adjusted,
(P = 0.018) although the authors affirm there were
– sum of skinfolds (mm): 65.41 and no differences between groups in
54.06 (P = 0.001); terms of sex and of maternal and
– waist circumference (cm): 59.70 socioeconomic variables. Another
and 56.63 (P = 0.003); outcome in the study was skeletal
– total body fat (kg): 9.76 and 7.31 maturity, which did not differ between
(P < 0.001); the two study groups.
– body fat (%): 28.74 and 24.99
(P = 0.01).

© 2005 The International Association for the Study of Obesity. obesity reviews 6, 143–154
obesity reviews
 Table 3 Continued

Author/country/year Type of study Number of subjects and Exposure – definition Outcomes Results/comments Quality score*/comments
accompaniment period of rapid growth

Schroeder et al. (12) Population- 161 men and 372 Change in Z-score for Waist-to-hip ratio (WHR) and Multiple linear regression Score = 16
obesity reviews

Guatemala 1999 based women enrolled length-for-age between %BF in men between ages coefficient for outcomes WHR = Complete childhood and adulthood
prospective between 1969 and 1977. ages 15 days and 18 and 24 years and in -0.05 (P = 0.84) and data for only 56% of women and 23%
birth cohort. Ages ranged between 3 years. women between ages 17 %BF = 0.14 (P = 0.53). of men. No evaluation of the effect of
24 and 60 months at (continuous variable) and 28 years. changing weight. No adjustment for
beginning of study. End (continuous variables) maternal variables.
of study at 1988–1989
for women and 1988–
1989 or 1991–94 for
women.
Eriksson et al. (11) Prospective 1552 men and 2107 Z-score variations (local Incidence of obesity (BMI ≥ Growth rates for height, weight, and Score = 17
Finland 2001 birth cohort. women born between standard) in weight-for- 30 kg m-2) in lifetime (self BMI were above mean values The original sample was not
1924 and 1933 in a age, height-for-age, and reported by correspondence (between +0.3 and +0.4 Z-scores, representative of the entire population
Helsinki university BMI, between birth and at ages ranging between 64 P < 0.001 for all subjects) at age (60% of births). 70.2% of the original
hospital num Hospital, age 7 years, and from and 75 years). 7 years for those who became cohort participated in the study. This
evaluated at birth and then to age 15 years. (dichotomous variable) obese in adulthood. Z-scores did group did not differ in birthweight from
then annually between (continuous variables) not vary until age 15 years, the remainder. Information concerning
ages 7 and 15 years, remaining above mean. outcome were collected by means of

© 2005 The International Association for the Study of Obesity. obesity reviews 6, 143–154
and reevaluated in 1997. a questionnaire sent by mail.
Information concerning exposure
during the first year of life were
obtained from hospital and school
records. The analysis was adjusted for
Rapid early growth and obesity in later life

age only.
Parsons et al. (16) Prospective 10 683 subjects born Percent of final adult Obesity at age 33 years The prevalence of obesity Score = 21
England, Scotland, birth cohort. between 3 and 9 March height acquired by age (BMI ≥ 30 kg m-2). increased 5–13% in subjects from 72.8% of the original cohort was
and Wales. 2001 1958, followed for 7 years. (dichotomous variable) the upper third of exposure, when studied at age 33 years. These were
33 years. (continuous variable) compared with those of the lower equal in BMI at age 7 years to those
third. Lacks a test for statistical not followed. There were interactions
significance. between percentage of final height at
age 7 years and birthweight and
mother’s weight or BMI only for boys.
The study provides no information on
the final height of subjects with greater
percentage of height at age 7 years.
P. O. A. Monteiro & C. G. Victora
149
 150

Table 3 Bibliographical review presented by age at which exposure was measured (continued).

Author/country/year Type of study Number of subjects and Exposure – definition Outcomes Results/comments Quality score*/comments
accompaniment period of rapid growth

Eriksson et al. (26) Prospective 2135 men and 2380 Variation in weight, Incidence of obesity (BMI ≥ Among subjects obese during any Score = 18
Finland 2003 birth cohort. women born between height, and BMI Z- 30 kg m-2) during any period period, mean BMI Z-scores during 64% of the original cohort was
1934 and 1944 in scores between birth in life (self-reported by the first 12 years of life were +0.3 to answered the questionnaire
Rapid early growth and obesity in later life

Helsinki, reevaluated in and age 12 years. correspondence at ages +0.5 higher than among non-obese (n = 7.047). No information on the
2000. (continuous variable) 56–66 years). subjects. No tests for statistical characteristics of losses. Analysis was
(dichotomous variable) significance. not adjusted.
Lundgren et al. (17) Prospective 276 033 men born in Having been born small Overweight Height-SGA-exposed subjects had Score = 18
Sweden 2001 birth cohort Sweden between 1973 for gestational age – (BMI ≥ 25 kg m-2) a 61% greater risk of being Losses were insignificant (2.7%).
and 1978, with perinatal SGA (< -2 weight/age or between ages 18–25 years overweight. There was no Large sample for SGA study, with
data collected height/age standard (dichotomous variable) association between weight SGA or precise effect measurements.
prospectively from deviations .form mean height/weight SGA and the Overweight a secondary outcome;
national records, Swedish population) outcome. Lacks .significance tests, primary outcome was high blood
reevaluated during and being above -2 but odds ratio confidence intervals pressure. Analyses were not adjusted
military enlistment standard deviations in to not contain the unit. form major confounders.
between ages 18 and height at the time of
P. O. A. Monteiro & C. G. Victora

25 years. enlistment
(dichotomous variable)

*Downs & Black scale-scores may range from 0 to 24. Mean score was 17.
†
Centers for Disease Control and Prevention – United States.
‡
First National Health And Nutrition Examination Survey – National Centers for Health Statistics – CDC
§
Weight above percentile 97 in any four-month period during the first year of life; weight above percentile 90 during the first year of life; weight between percentiles 91 and 97 in the first or last four-month
periods of the first year of life; weight above percentile 90 at age 12 months.
IOTF, International Obesity Task Force; BMI, body mass index; SSF, sub scapular skin fold; TSF, tricipital skin fold; SGA, small-to-gestational-age.

© 2005 The International Association for the Study of Obesity. obesity reviews 6, 143–154
obesity reviews
obesity reviews Rapid early growth and obesity in later life
Force (IOTF) (29); Monteiro, in 2003 (14), used percentile
85 of the First National Health And Nutrition Examination
Survey (NHANES I) associated to percentile 90 of tricipital
and subscapular skin folds, as recommended by the World
Health Organization (WHO) in 1995 (30)]. Other studies
used as an outcome anthropometric measures in the form
of continuous variables, not using cut-off points for
overweight or obesity characterization (10,12,15,25,27).
Definitions which remained constant were those of
overweight and obesity among populations older than
20 years – BMI ≥ 25 kg m-2 and 30 kg m-2 respectively
(11,16,17,23,26,30).
Ages at which outcomes were measured also varied
greatly. Subjects were measured at age 3 years (12) at the
youngest, and at approximately age 70 years at the oldest
(11).
Main results
Table 3 shows that, with the exception of the studies by
Schroeder et al. (25) which did not find an association
between changes in length-for-age Z-scores between ages
15 days and 3 years and waist-to-hip ratio (WHR) (r =
-0.05, P = 0.84) or percent body fat (r = 0.14, P = 0.53),
and Lundgren et al. (17) that found an inverse association
between rapid linear growth and risk of overweight, all
other studies reported positive associations between rapid
growth – whatever its definition – and the occurrence of
overweight, obesity, or greater adiposity measures, regard-
less of the ages at which they were measured. It is worth
noting that both studies evaluated only linear, and not
ponderal, growth. Studies that had continuous variables as
their outcomes showed significant positive coefficients for
the associations with rapid growth.
Besides the study by Schroeder (25), three other surveys
evaluated outcomes among adolescents, the main focus of
the present review. Among the studies that evaluated
dichotomous outcomes in teenage or young adult popula-
tions, the study by Stettler et al. (13) showed that every
kilogram of weight gained during the first year of life
corresponded to 46% increase in risk of overweight and a
59% increase in risk of obesity. The study by Monteiro
et al. (14) showed a 64–69% greater prevalence of over-
weight and obesity between ages 14 and 16 years among
subjects with rapid growth – measured as weight-for-age
Z-scores – between birth and age 20 months, or ages 20
and 43 months. Rapid growth in weight-for-height Z-
scores between ages 20 and 43 months also led to a 87%
greater prevalence of obesity in the same age group. On the
other hand, rapid growth in height-for-age Z-scores was
associated with an increase in the prevalence of overweight,
but not of obesity. Both studies received high methodolog-
ical quality scores, and their analyses were adjusted for
major confounders. The study by Stettler et al. (23) in an
© 2005 The International Association for the Study of Obesity. obesity reviews 6, 143–154
P. O. A. Monteiro & C. G. Victora 151
African-American population showed that subjects who
grew one or more weight-for-age Z-scores during the four
first months of life were at a fivefold risk of obesity at age
20 years. In these three studies, the effects of growth during
the first year of life on subsequent obesity seem to have
been more marked among girls than among boys.
Discussion
Using the criteria proposed by Downs & Black allowed for
greater objectivity and homogeneity in evaluation of the
articles. Despite their original purpose as a tool to evaluate
clinical trials, most criteria are applicable to other types of
study design.
The use of ‘adiposity rebound’ as a keyword increased
by 76 the number of abstracts found, but it didn’t add any
references to our review. Of those 76, just eight studies used
age at adiposity rebound as exposition variable, and none
had data about growth velocity. Still, the most appropriate
use of BMI centile crossing as an indicator of underlying
drive to fatness, compared with the age at adiposity
rebound, was the subject of a recent paper of Cole (31).
The articles reviewed were characterized by their heter-
ogeneity, which affected all aspects of the review: from the
age composition of samples and the definition of exposures
and outcomes, to the analyses and definitions of potential
confounders. The lack of confounding control for family
and socioeconomics variables, known risk factors for obe-
sity, can affect the interpretation of the results of any study
on the theme. This obviously hinders precise conclusions
concerning the results of the review. We attempt at contex-
tualizing the determinants of this reality below .
Studies that relate infant and child obesity with future
morbidity are relatively recent (2,32). The adoption of an
international pattern for the definition of obesity in chil-
dren is complex given the influence of ethnic, socioeco-
nomic, and maturational aspects in its determination. The
studies reviewed thus used different criteria for defining
the problem, with negative impact on their comparability.
The proposal, by WHO in 1995, of a universal criterion
for adolescent overweight and obesity failed to solve the
problem of lack of international representativity of the
standard population used, which was based on a US sample
derived from NHANES I (30). Furthermore, for the defini-
tion of adolescent obesity, this criterion required skinfold
measurement, a technique of complex execution and low
repeatability. IOTF recently proposed a new criterion for
international use, based on data from six different coun-
tries (29), which uses cut-off points based on BMI alone, a
measurement of easy execution and high repeatability. This
criterion is not widely used because of its recentness.
The exposure studied – rapid growth – has been defined
in terms of both linear and ponderal growth, although the
latter has been more frequently used in the literature. How-
152 Rapid early growth and obesity in later life P. O. A. Monteiro & C. G. Victora
ever, as one may conclude through the present review, there
is no consensus as to the quantification of this rapidity. The
definition proposed by Ong et al. (10) consists in defining
rapid growth as a gain in weight greater than 0.67 Z-
scores. This value is based on the difference between per-
centiles 25, 50, and 75 in a growth chart. This suggestion
is a generalizable way of defining rapid growth, because
growth charts are classically used for nutritional evaluation
purposes worldwide. This criterion has already been used
in three of the articles included in the present review.
A few studies deserve specific comments in relation to
methodology. Although Eid (20) and Melbin (21) pio-
neered the evaluation of the association between rapid
growth and overweight in 6–8-year-old children, statistical
knowledge and data processing technology available at the
time both limited study validity. The article by Schroeder
(25), on the other hand, had its analysis affected by adjust-
ing changes in linear growth for height in extremes of age
in which these changes occur, which affected statistical
interpretation of the linear regression coefficients obtained.
Stettler, in his 2002 US study (24), proposes two models of
analysis; in one of them, the author adjusts growth in
weight in the first 4 months of life to the weight at the end
of the first year, thus reducing the effect of the former by
adjusting for a likely mediator. The study by Law (27), in
spite of its primary outcome being high blood pressure
among adults, was included in the present review for its
evaluation of the correlation between early weight gain and
adult BMI; however, the interpretation of these results is
affected by the lack of adjustment in the analysis. The study
by Lundgren (17), which also had high blood pressure as
its primary outcome, was included in the review for includ-
ing a secondary analysis of the association between rapid
growth in terms of height and the occurrence of overweight
in young adults; the analyses in this study also lacks ade-
quate adjustment. Eriksson (11,26), in his studies of the
Finnish population, in spite of working with prospective
designs, presents exposure values according to outcome
categories (rather than the other way round), with negative
effects on result interpretation. Cameron (15) does not
define the criterion used for diagnosing obesity and pre-
sents only a comparison of means. In addition, the author
does not provide multivariate analysis.
Very few studies discuss follow-up losses, the under-
standing of which is fundamental in cohort studies. None
of the studies provided statistical power for the associa-
tions investigated, hindering the understanding of ‘non-
significant’ results.
A concept closely related to ‘rapid growth’ is that of
‘catch-up growth’. The latter was classically defined by
Prader et al. (33) as nutritional recovery following a period
of growth restriction after the latter is removed. In the last
decade, a large number of publications related the occur-
rence of rapid growth with the fetal origins, or Barker’s
© 2005 The International Association for the Study of Obesity. obesity reviews 6, 143–154
obesity reviews
hypothesis (34). The occurrence of catch-up growth has
been widely associated with chronic adult diseases, espe-
cially plurimetabolic syndrome (hypertension, insulin resis-
tance, and dyslipidemia) and heart disease. Recently, a
hypothesis has been raised that rapid post-natal growth
alone – rather than restrictions in intrauterine growth –
would be the true risk factor for future disease (35). The
articles reviewed mostly define the exposure as rapid rather
than catch-up growth, with the exception of those by
Lundgren (17) and Ong (10). Lundgren used the classical
catch-up growth concept, evaluating the effect of linear
rapid growth on subjects born with weight or length below
-2.0 standard deviations. Ong, on the other hand, presents
no strong evidence that the roughly 30% of subjects with
rapid growth had experienced prior restriction: their initial
weight and length measures were -0.53 and -0.23 Z-scores
respectively, values much higher than the -2.0 threshold
traditionally used for defining low weight or length (36).
The effect of catch-up growth can only be investigated in
case evidence exists that the children with rapid growth
belong to a group that previously experienced growth
restriction. For studies that cover the first year of life, prior
restriction is related to intrauterine growth. Monteiro (14)
stratified results according to the presence of IUGR, finding
that the association between rapid growth and overweight
was maintained only in subjects without IUGR. The low
statistical power of this analysis may have affected the
interpretation of these results. Among the remaining stud-
ies reviewed, several presented an association between birth
weight and obesity in later life, but none of them stratify
the effect of rapid growth on obesity according to nutri-
tional conditions at birth. Thus, the results of these studies
may only be interpreted as effects of rapid, and not of
catch-up, growth.
Most studies showed a positive association between
rapid growth and overweight, obesity, or other anthropo-
metric measures, regardless of their definitions. Although
that is a relatively new field of research about obesity
determination, the publication bias can be considered
because only two studies showed negative association or
absence of association. The lack of interest of researchers,
primarily in submitted papers with negative results, was
focused in two interesting papers published in JAMA by
Dickersin et al. in 1992 (37) and Olson et al. in 2002 (38).
Aside from this, it is of fundamental importance to dis-
cuss the impact this may have on population health and on
the reactions of governments in terms of investments in
healthcare. With this in mind, a conceptual standardization
becomes necessary in order to quantify the effect of rapid
growth on the occurrence of obesity, as well as its determi-
nants. As these are intrinsically general concepts, we sug-
gest that, in future studies, the new IOTF curves and the
0.67 Z-score variation be adopted for the definition of
obesity and rapid growth respectively.
obesity reviews Rapid early growth and obesity in later life
In conclusion, on one hand, rapid growth during the first
years of life is indeed associated with the prevalence of
obesity in the life course, on the other, the reduction of
mortality among children with nutritional recovery early in
life has been widely demonstrated. The paradox, referred
to by Victora et al. as ‘the catch-up dilemma’ (39), must
enter the agenda of public healthcare programmes in coun-
tries where malnutrition is endemic, and especially in those
undergoing nutritional transition.
References
1. Gortmaker SL, Must A, Perrin JM, Sobol AM, Dietz WH.
Social and economic consequences of overweight in adolescence
and young adulthood. N Engl J Med, 1993; 329: 1008–1012.
2. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-
term morbidity and mortality of overweight adolescents. N Engl
J Med, 1992; 327: 1350–1355.
3. Goran MI, Ball GD, Cruz ML. Obesity and risk of type 2
diabetes and cardiovascular disease in children and adolescents. J
Clin Endocrinol Metab, 2003; 88: 1417–1427.
4. World Health Organization. Obesity: Preventing and Manag-
ing the Global Epidemic. World Health Organization: Geneva,
1998.
5. Thompson D, Wolf AM. The medical-care cost burden of
obesity. Obes Rev, 2001; 2: 189–197.
6. Wang G, Dietz WH. Economic burden of obesity in youths
aged 6 to 17 years: 1979–1999. Pediatrics, 2002; 109: E81–1.
URL: http://www.pediatrics.org/cgi/content/full/109/5/e81.
7. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH.
Predicting obesity in young adulthood from childhood and paren-
tal obesity. N Engl J Med, 1997; 337: 869–873.
8. Laitinen J, Power C, Järvelin M-R. Family social class, mater-
nal body mass index, childhood body mass index, and age at
menarche as predictors of adult obesity. Am J Clin Nutr, 2001;
74: 287–294.
9. Parsons TJ, Power C, Logan S, Summerbell CD. Childhood
predictors of adult obesity: a systematic review. Int J Obes, 1999;
23: 1–107.
10. Ong KKL, Ahmed ML, Emmett PM, Preece MA, Dunger DB,
the ALSPAC team. Association between postnatal catch-up growth
and obesity in childhood: prospective cohort study. BMJ, 2000;
320: 967–971.
11. Eriksson J, Forsén T, Tuomilehto J, Osmond C, Barker D.
Size at birth, childhood growth and obesity in adult life. Int J
Obes, 2001; 25: 735–740.
12. Tanaka T, Matsuzaki A, Kuromaru R, Kinukawa N, Nose Y,
Matsumoto T, Hara T. Association between birthweight and body
mass index at 3 years of age. Pediatr Int, 2001; 43: 641–646.
13. Stettler N, Bovet P, Shamlaye H, Zemel BS, Stallings VA,
Paccaud F. Prevalence and risk factors for overweight and obesity
in children from Seychelles, a country in rapid transition: the
importance of early growth. Int J Obes, 2002; 26: 214–219.
14. Monteiro POA, Victora CG, Barros FC, Monteiro LMA.
Birth size, early childhood growth, and adolescent obesity in a
Brazilian birth cohort. Int J Obes, 2003; 27: 1274–1282.
15. Cameron N, Pettifor J, De Wet T, Norris S. The relationship
of rapid weight gain in infancy to obesity and skeletal maturity in
childhood. Obes Res, 2003; 11: 457–460.
16. Parsons TJ, Power C, Manor O. Fetal and early life growth
and body mass index from birth to early adulthood in 1958 British
cohort: longitudinal study. BMJ, 2001; 323: 1331–1335.
© 2005 The International Association for the Study of Obesity. obesity reviews 6, 143–154
P. O. A. Monteiro & C. G. Victora 153
17. Lundgren EM, Cnattingius HMS, Jonsson GB, Tuvemo TH.
Linear catch-up growth does not increase the risk of elevated
blood pressure and reduces the risk of overweight in males. J
Hypertens, 2001; 19: 1533–1538.
18. Downs SH, Black N. The feasibility of creating a checklist for
the assessment of the methodological quality both of randomised
and non-randomised studies of health care interventions. J Epide-
miol Community Health, 1998; 52: 377–384.
19. Lima RC. Efeito do peso ao nascer sobre a função pulmonar
de adolescentes nascidos em Pelotas, RS, em 1982 [Tese]. Univer-
sidade Federal de Pelotas: Pelotas (RS), 2003.
20. Eid EE. Follow-up study of physical growth of children who
had excessive weight gain in first six months of life. BMJ 1970; 2:
74–76.
21. Mellbin T, Vuille J-C. Weight gain in infancy and physical
development between 7 and 101/2 years of age. Brit J Prev Soc
Medical, 1976; 30: 233–238.
22. Cameron N. Catch-up growth increases risk factors for obe-
sity in urban children in South Africa by one year of age. Int J
Obes, 2001; 25(Suppl.2): 48.
23. Stettler N, Kumanyika SK, Katz SH, Zemel BS, Stallings VA.
Rapid weight gain during infancy and obesity in young adulthood
in a cohort of African Americans. Am J Clin Nutr, 2003; 77:
1374–1378.
24. Stettler N, Zemel BS, Kumanyika S, Stallings VA. Infant
weight gain and childhood overweight status in a multicenter,
cohort study. Pediatrics, 2002; 109: 194–199.
25. Schroeder DG, Martorell R, Flores R. Infant and child growth
and fatness and fat distribution in Guatemala. Am J Epidemiol,
1999; 149: 177–185.
26. Eriksson J, Forsen T, Osmond C, Barker D. Obesity from
cradle to grave. Int J Obes, 2003; 27: 722–727.
27. Law CM, Barker DJP, Osmond C, Fall CHD, Simmonds SJ.
Early growth and abdominal fatness in adult life. J Epidemiol
Community Health, 1992; 46: 184–186.
28. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal
KM, Guo SS, Wei R, Mei Z, Curtin LR, Roche AF, Johnson CL.
CDC growth charts: United States. Adv Data, 2000; 314: 1–27.
29. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a
standard definition for child overweight and obesity worldwide:
international survey. BMJ, 2000; 320: 1–6.
30. World Health Organization. Physical Status: the Use and
Interpretation of Anthropometry. Technical Report Series 854,
Geneva, 1995.
31. Cole T. Children grow and horses race: is the adiposity
rebound a critical period for later obesity? BMC Pediatr, 2004; 4:
6.
32. Wright CM, Parker L, Lamont D, Craft AW. Implications of
childhood obesity for adult health: findings from thousand families
cohort study. BMJ, 2001; 323: 1280–1284.
33. Prader A, Tanner JM, von Harnack GA. Catch-up growth
following illness or starvation. J Pediatr, 1963; 62: 646–659.
34. Barker DJ. Fetal origins of coronary heart disease. BMJ, 1995;
311: 171–174.
35. Lucas A, Fewtrell MS, Cole TJ. Fetal origins of adult disease
– the hypothesis revisited. BMJ, 1999; 319: 245–249.
36. Lee PA, Chernausek SD, Hokken-Koelega AC, Czernichow P.
International Small for Gestational Age Advisory Board consensus
development conference statement: management of short children
born small for gestational age, April 24 – October 1, 2001. Pedi-
atrics, 2003, 111: 1253–1261.
37. Dickersin K, Min YI, Meinert CL. Factors influencing publi-
cation of research results. Follow-up of applications, submitted to
two institutional review boards. JAMA, 1992; 267: 374–378.
154 Rapid early growth and obesity in later life P. O. A. Monteiro & C. G. Victora obesity reviews

38. Olson CM, Rennie D, Cook D, Dickersin K, Flanagin A, 39. Victora CG, Barros FC. Commentary: the catch-up dilemma
Hogan JH, Zhu K, Reiling J, Pace B. Publication bias in editorial – relevance of Leitch’s ‘low-high’ pig to child growth in developing
decision making. JAMA, 2002; 287: 2825–2828. countries. Int J Epidemiol, 2001; 30: 217–220.

© 2005 The International Association for the Study of Obesity. obesity reviews 6, 143–154