Acta Pædiatrica ISSN 0803–5253
REGULAR ARTICLE
Prevalence of overweight and obesity in Danish preschool children over a
10-year period: a study of two birth cohorts in general practice
Lone Marie Larsen ([email protected])1, Niels Thomas Hertel1, Christian Mølgaard1,3, René dePont Christensen2, Steffen Husby1,
Dorte Ejg Jarbøl2
1.Hans Christian Andersen Children’s Hospital, Odense University Hospital
2.Research Unit of General Practice, Institute of Public Health, University of Southern Denmark
3.Department of Human Nutrition, Faculty of Life Sciences, University of Copenhagen
Keywords
Body mass index, Obesity, Overweight, Preschool
children, Prevalence
Correspondence
LM Larsen, M.D., Research Unit, Hans Christian
Andersen Children’s Hospital, Odense University
Hospital, Sdr. Boulevard 29, DK-5000 Odense C,
Denmark.
Tel: 0045 2629 4192 |
Fax: 0045 65 91 18 62 |
Email: [email protected]
Received
1 July 2011; revised 12 October 2011;
accepted 28 November 2011.
DOI:10.1111/j.1651-2227.2011.02551.x
ABSTRACT
Aim: To determine change in the prevalence of overweight and obesity in preschool
children, over a 10-year period and to identify possible predictors of overweight in 5-yearold children.
Methods: Anthropometric data from birth and routine child health examinations at 3
and 5 years of age performed in general practice were collected in 5580 children from two
Funen birth cohorts (1992 and 2001, respectively) representing 48% of the total population at similar age. The prevalence of overweight and obesity was classified using the International Obesity Task Force definitions.
Results: In a Danish representative survey of preschool children, the average body
mass index (BMI) and prevalence of overweight and obesity did not vary significantly during
the 10-year period. No significant changes in mean birth weight were registered and mean
BMI in the group of obese children did not increase. Overweight or obesity at 5 years was
strongly associated with overweight and obesity at 3 years and with birth weight and gender.
Conclusion: The prevalence of overweight and obesity was observed to be stable
over a decade in Danish preschool children without changes in mean BMI in the group of
obese children. A strong association between overweight and obesity at 3 and at 5 years of
age was detected.
INTRODUCTION
Overweight and obesity in children is a problem of epidemic
proportions in the Western world, (1–5). In addition to
short-term health and psycho-social consequences, childhood overweight and obesity may have severe consequences later in adolescence and adulthood (6–9). A steep
increase in overweight and obesity in school children has
been seen in the past decades in several populations (2,4).
There is, however, sparse knowledge about the prevalence
of overweight and obesity in preschool children also in
Denmark (2,10). Such data are important, as overweight in
a 5-year-old child suggestively increases the risk of overweight or obesity in adolescence or adulthood by 70–80%
(11,12). The objectives of the present study were to determine trends in prevalence of overweight and obesity in preschool children over a 10-year period, based on data from
Abbreviations
IOTF, International Obesity Task force Childhood Obesity Working Group; BMI, body mass index (kg ⁄ m2); CPR number, A Civil
Registration personal number which can identify all individuals
who reside in Denmark at any time.
birth and routine health examinations in general practice in
two birth cohorts from 1992 and 2001, respectively, and to
explore possible predictors of overweight at the age of
5 years. In addition, to compare study data with available
anthropometric data from 30-year-old Danish reference
material.
MATERIAL AND METHODS
Design and setting
The study was a population-based study of two birth
cohorts, based on anthropometric data from routine health
Key notes
• In this study of 5580 Danish preschool children, a stable
prevalence of overweight and obesity over a decade was
indicated, but still approximately 10% of the preschool
Danish children were found to be overweight or obese. A
strong association between overweight and obesity at 3
and 5 years of age was revealed indicating that early
attention is advisable.
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 201–207
201
Prevalence of overweight in preschool children
Larsen et al.
examinations, performed in the period from 1992 to 2007 in
general practice on the island of Funen, Denmark. In Denmark, all children are offered free health examinations in
general practice at the ages of 5 weeks, 5 months,
12 months, 2, 3, 4 and 5 years. Height and weight are registered at all examinations. All weight scales in general practices in Funen were calibrated once a year (since 1997) by
an external regional laboratory advising system (http://
www.skup.nu). According to the standards for anthropometric measuring in general practice, the body weight was
measured in light underwear and socks to the nearest
0.1 kg, using the same digital medical scale. Height was
measured to the nearest 0.1 cm using a stadiometer in
standing position with no shoes. Birth length and weight
data from the maternity hospital are kept on record by the
general practitioners.
Participants
All 162 general practices in the study area were invited to
participate in the study. Children born in 1992 and 2001,
respectively, and allocated to the participating general practices, were identified by the Civil Registration System (CPR
number) which can identify all individuals who reside in
Denmark at any time. Based on the identification by the
CPR number, length ⁄ height and weight at birth and at the
3- and 5-year health examinations were obtained from the
medical records in general practice. When data were missing, the anthropometric data from the nearest health examination were chosen. Among the free health examinations
performed in general practice, examination at 3 years of age
was chosen because of available reliable age-correlated
(BMI) references (13,14) and certainty that the measurement of height was carried out in a standing position. Fiveyear age anthropometric data were chosen to assess the
individual weight development from 3 years of age to
5 years of age. BMI [BMI, defined as weight (kg) divided by
stature squared (m2)] was calculated. At birth, mean weights
were compared instead of mean BMI, because of the uncertainty in the measurement of the length at birth. Children
with overweight and obesity were identified using the criteria presented by the International Obesity Task Force
(IOTF) Childhood Obesity Working Group (14) including
age- and gender-specific BMI cut-off values from 2 to
18 years corresponding to BMI values of 25 and 30 kg ⁄ m2
at 18 years of age. A comparison of growth data in this
study with a 30-year-old Danish reference material also collected from free health examinations in general practice in
preschool children was performed using z scores (SDS)
(13,15).
The study was approved by the Danish Data Protection
Agency (j. no 2007- 41-1137). Registry-based studies in
Denmark do not require ethical approval.
Data processing and validation
In the period July 2008 to May 2009, medical records based
on electronic or paper files were identified in general practice. Data were validated by the analysis of outliers in the
dataset. Children with birth weight below 2500 g. were
202
excluded because of an aberrant growth pattern for preterm
and small-for-date infants. Additionally a birth length below
40 cm was excluded as measurement error.
Statistics
The survey sample was categorized according to age and
gender, and age groups were constructed with the intervals:
<2.5 years of age, 2.5–3.5 years of age, 3.5–4.5 years of age
and 4.5–5.5 years of age. Mean BMIs in the two birth
cohorts were compared using an unpaired t-test with a 5%
significance level. Equality of variance between groups was
tested using Bartlett’s test. As t-test presumes a normal distribution, we compared the results of the parametric t-test
with those of the non-parametric Wilcoxon rank-sum
(Mann–Whitney) test and found comparable results.
The prevalence of normal weight, overweight and obesity
was compared between groups by a Pearson chi-square test
or, when appropriate, a Fisher’s exact test.
To identify possible predictors of overweight and obesity
in 5-year-old children, a sample of children born in 1992 and
2001, respectively, was used. The sample was defined by
obtaining complete consecutive growth data 6 months prior
to and after the 3- and 5-year birthdays. We performed logistic regression modelling with overweight or obesity at
5 years of age (4.5–5.5 years) as the dependent variable. As
potential explanatory variables, we used weight class at
3 years of age (2.5–3.5 years) (normal weight vs. overweight
vs. obesity at 3 years), birth weight (in kg) and gender in an
unadjusted univariate regression analysis and a multivariate
analysis adjusted for all potential explanatory variables. For
the estimates, we report odds ratio (OR) and 95% confidence
intervals. Mean z scores were calculated and compared to
zero (mean z score in the Danish reference material) by a
one sample t-test. Data were analysed using STATA version
11 (Stata-Corp LP, College Station,TX, USA).
RESULTS
A total of 68 general practices agreed to participate in the
study, equivalent to 42% of all invited representing both
urban and rural areas. Medical records from a total of 5 580
children, i.e. 48% of all children born in two birth cohorts
1992 and 2001 in the study area, were identified and
reviewed. In medical records from the 1992 birth cohort,
complete data sets from both examinations were available
in 1532 (54.0%), while growth data from only one single
health examination were available in 364 (12.8%) and no
growth or only birth data were obtainable in 835 (29.4%).
In the 2001 birth cohort, the similar figures were 1559
(61.7%), 523 (20.7%) and 359 (14.2%), respectively.
Tables 1 and 2 show mean birth weights and BMIs in girls
and boys born in 1992 and 2001, respectively. In girls, mean
birth weight tended to increase, but not significantly from
1992 to 2001. There were no changes in mean birth weight
in boys over the 10-year period, and no change in birth
length in neither boys nor girls. For both genders, mean
BMIs were almost identical in the two cohorts in all the age
groups and no significant changes over the decade were
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 201–207
±
±
±
±
0.38
0.10
0.24
0.11
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 201–207
±
±
±
±
±
1.23
2.05
1.37
1.68
1.66
±
±
±
±
0.31
0.10
0.24
0.13
0.498
2.50
1.83
2.03
2.59
±
±
±
±
±
0.023
0.06
0.04
0.05
0.05
0.526
0.90
0.98
1.05
1.13
±
±
±
±
±
3.617
13.71
15.53
17.39
19.91
Values are mean (±SD) unless stated otherwise.
*Mean Birth Weight, two sample unpaired t-test, equal variance.
**Mean BMI, two sample unpaired t-test with unequal variance.
***Mean BMI, two sample unpaired t-test, equal variance.
The bold values indicate the values included in the t-tests.
2.03
3.06
4.01
5.08
13.04
17.05
16.19
15.92
15.69
±
±
±
±
±
1.27
2.16
1.40
1.24
1.44
884
48
793
77
914
824
27
819
94
787
Birth
<2½
2½–3½
3½–4½
4½–5½
BMI
N
Length ⁄ height (m)
Weight (kg)
N
812
38
749
81
880
2001
Age
12.82
16.31
15.98
15.78
15.66
1992
0.022
0.06
0.04
0.04
0.05
Boys
Age groups
(years of age)
Table 2 Birth weight and mean BMI in preschool boys, over a 10-year period
±
±
±
±
±
0.518
0.91
0.97
1.05
1.11
3.464 ± 0.470
13.65 ± 2.55
15.01 ± 1.84
17.25 ± 2.37
19.47 ± 2.83
Values are mean (±SD) unless stated otherwise.
*Mean Birth weight, two sample unpaired t-test, equal variance.
**Mean BMI, two sample unpaired t-test, equal variance.
The bold values indicate the values included in the t-tests
2.02
3.07
4.06
5.08
760
39
792
80
770
Birth
<2½
2½–3½
3½–4½
4½–5½
BMI
N
Length ⁄ height (m)
Weight (Kg)
N
Age
2001
1992
Girls
Age groups
(years of age)
Table 1 Birth weight and mean BMI in preschool girls, over a 10-year period
2.12
3.08
4.03
5.10
Age
2.11
3.07
4.01
5.09
Age
±
±
±
±
±
±
±
±
0.27
0.11
0.27
0.13
0.24
0.12
0.25
0.13
±
±
±
±
±
0.501
1.69
1.88
2.54
2.97
3.621
13.23
15.61
17.27
20.11
±
±
±
±
±
0.535
1.50
1.88
2.18
2.76
Weight (kg)
3.503
12.72
14.95
17.59
19.60
Weight (kg)
±
±
±
±
±
0.021
0.05
0.04
0.05
0.05
0.528
0.90
0.98
1.04
1.13
±
±
±
±
±
0.023
0.05
0.04
0.05
0.05
Length ⁄ height (m)
0.520
0.88
0.97
1.05
1.12
Length ⁄ height (m)
12.96
16.48
16.25
15.84
15.71
BMI
1.22
1.82
1.49
1.68
1.74
1.25
1.45
1.48
1.15
1.55
±
±
±
±
±
±
±
±
±
±
12.90
16.46
16.02
15.90
15.60
BMI
0.86*
0.23**
0.44***
0.69***
0.75***
p value
0.11*
0.75**
0.65**
0.67**
0.48**
p-value
Larsen et al.
Prevalence of overweight in preschool children
203
Prevalence of overweight in preschool children
Larsen et al.
seen. Prevalence of overweight and obesity in preschool
children was presented (Table 3) according to the previously defined age groups with omission of the age group
‘<2.5 years of age’ because of lack of valid reference material
according to the IOTF definition. The prevalence of overweight and obesity varied only slightly and not significantly
during the decade in all age groups for both genders. We
repeated the analysis in all age groups combined. For children with several measurements, we selected the last measurement. No significant change in the prevalence of
overweight and obesity were found in the combined age
groups either (results not shown).
In the evaluation of a possible increase in the severity of
obesity during the decade, mean BMI in the obese
preschool children was analysed according to age groups
and gender (Fig. 1). Mean BMIs of obese children tended to
increase for both genders, but the changes were non-significant.
Table 4 shows crude and adjusted OR for associations
with overweight and obesity in 5-year-old children. The
adjusted analyses showed a significant association between
overweight and obesity at the age of 5 years and overweight
at 3 years [OR 13.4 (95% CI 9.4–19.2)], obesity at 3 years of
age [OR 24.4 (95% CI 12.2–48.9)] and increasing birth
weight [OR 2.0 (95% CI 1.5–2.7)]. Male gender was significantly associated with decreasing odds of overweight and
obesity at the age of 5 years (OR 0.61 (95% CI 0.44–0.83).
No significant differences were found in mean BMI and
Table 3 Prevalence (%) of overweight and obesity in preschool children, over a 10-year period
Girls
1992
Age-group
(years)
2½–3½
3½–4½
4½–5½
Boys
N
%
N
%
N
%
2001
1992
NW
OW
OB
NW
OW
OB
p-value* p-value** p-value*** NW
706
89.1
71
88.7
668
86.7
71
9.0
7
8.8
80
10.4
15
1.9
2
2.50
22
2.9
657
87.7
68
83.9
761
86.5
78
10.4
10
12.4
96
10.9
14
0.63
1.9
3
0.67
3.70
23
0.91
2.6
0.34
0.99
0.46
0.99
0.73
0.77
746
91.0
86
91.4
713
90.6
2001
OW OB
NW
OW OB
57
7.0
7
7.5
59
7.5
708
89.2
73
94.8
828
90.6
71
9.0
3
3.9
65
7.1
16
2.0
1
1.06
15
1.9
p-value* p-value** p-value***
14
0.33
1.8
1
0.61
1.30
21
0.82
2.3
0.14
0.86
0.33
0.99
0.76
0.62
NW = normal weight; OW = overweight children; OB = obese children defined by International Obesity Task Force criteria.
*NW ⁄ OW ⁄ OB distribution. Between group comparison over the 10-year period, chi square test (ordinal data).
**Proportion of overweight. Between group comparison over the 10-year period, chi square test (binary data).
***Proportion of obesity. Between group comparison over the 10-year period, Fisher exact test (binary data).
Figure 1 Mean BMI in obese preschool children defined by International Obesity Task Force criteria. *Two sample unpaired t-test, unequal variances. **Two sample
unpaired t-test, equal variance. Y, years.
204
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 201–207
Larsen et al.
Prevalence of overweight in preschool children
Table 4 Logistic regression analysis of overweight and obesity at 5 years of age in children born in the two birth cohorts 1992 and 2001
Overweight at the age of 3 (ref. normal weight)
Obesity at the age of 3 (ref. normal weight)
Birth weight (kg)
Gender, male (ref. female)
Crude odds ratio (95% CI)*
Adjusted odds ratio (95% CI)
(N = 1002)†
13.06 (9.54–17.87)
32.23 (17.48–59.41)
1.93 (1.53–2.44)
0.67 (0.54–0.83)
13.44 (9.39–19.24)
24.37 (12.15–48.88)
2.03 (1.51–2.74)
0.61 (0.44–0.83)
*Univariate regression analysis.
†
Multivariate regression analysis with all explanatory variables included.
proportion of overweight for the sub-sample with complete
consecutive growth data compared to the whole study
group.
Comparison of the mean BMIs with the former Danish
reference material showed that the average BMI z- score at
the 3-year health examination tended to be lower than
30 years ago in both birth cohorts (Table 5). The differences
were significant for boys in the 1992 cohort (p = 0.01). At
the 5-year health examination, the average BMI z- scores in
both birth cohorts and for both genders were all significantly above the reference data (with p values of 0.0001–
0.04).
DISCUSSION
In this study of 5 580 preschool children in two birth
cohorts with an interval of a decade, we observed a stable
prevalence of overweight and obesity. In a subsample analysis of consecutive data, a strong association between overweight and obesity at 3 years of age and overweight and
obesity at 5 years of age was revealed.
There were no available data on either the ethnicity of the
children or the families’ socioeconomic status in the present
study. However, the population-based approach, a large
sample size and the demographic similarity between the
investigated area and the rest of Denmark (16) indicate that
our results are generalizable to the Danish population.
Strengths of the study were the data registration of height
and weight by trained staff in general practice and the
Table 5 Mean BMI Z scores compared to zero (mean BMI in Danish reference material)
3-year
Health examination
5-year
Health examination
One sample t-test
1992
2001
1992
2001
Girls N
Mean BMI Z score
SE
p-value
Boys N
Mean BMI Z score
SE
p-value
871
)0.042
0.038
0.27
887
)0.102
0.040
0.01
834
)0.021
0.040
0.60
883
)0.065
0.040
0.11
853
0.124
0.037
0.0008
892
0.109
0.039
0.005
986
0.075
0.037
0.04
1038
0.139
0.036
0.0001
subsequent direct data transfer from the medical records. Weight and height measurements extracted retrospectively
from medical records probably lack the precision that could
be obtained in prospective registrations. However, any
errors in these measurements were likely to appear at random.
A former register study performed by the Danish
National Board of Health showed that 30% of children
born in 2001 did not attend the 3-year free health examination in general practice (17). In the present study, we
identified data for 59% ⁄ 57% and 65% ⁄ 72% attending the
3-year ⁄ 5-year visits in the 1992 and the 2001 cohort,
respectively. Possible explanations of missing anthropometric registration in the present study were families having changed to another general practitioner in the study
period and the transition to electronic record systems in
the follow-up period with a subsequently loss of data registered in paper systems. However, comparison between
mean birth weight in the study population where only birth
weight was available and the subpopulation with complete
data set did not show any systematic differences. We may
therefore assume that the study population comprises a
large and representative majority of the children who actually attended the health examinations in the included general practices.
The estimated prevalence of overweight and obesity
among preschool children in the two present birth cohorts
of approximately 10% was comparable with results from a
Danish study of preschool children born in the autumn
1995, where completeness of data at 5 years of age, however, was <50% (18).
The identification of a potential stagnation of overweight
and obesity trends over a decade was in contrast to results
of a British study where an increase in the prevalence of
overweight and obesity in 2.6–4.5-year-old children from
12.2% and 2.2%, respectively, in 1988 to 19.1% and 4.0% in
2003 was found (IOTF criteria used) (19). Among Danish
(Copenhagen) school children, an alarming increase in
overweight and obesity was shown from 1947 to 2003 (4),
but recent published data identified a potential stagnation
in contrast to the preceding decades (20). Prevalence of
overweight including obesity was 15.9% and 11.6% in girls
and boys, respectively, at school entry in 2007, a little higher
than prevalence estimates found in the preschool children
in the present study. A similar tendency of stagnation has
recently been observed among 4-year-old children as well
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 201–207
205
Prevalence of overweight in preschool children
Larsen et al.
as schoolchildren in Sweden (21–23) and in 7–9-year-old
children in France (24). In the United States, the National
Health and Nutrition Examination Survey, NHANES, for
the first time showed no significant increasing trend in obesity in 2–19-year-old children and adolescents in the time
period 1999–2008, except among the heaviest 6- through
19-year-old boys (25).
In this study, the group of obese children did not gain
more adiposity during the 10-year period. This result is different from other studies. A recent analysis of American
children aged 2–19, from 1988 to 1994 and 1999 to 2004
(26) showed that the mean 10-year increases in adiposity
evaluated by mean BMI, waist circumference and triceps
skin-fold thickness were significantly higher in older children and in the more obese groups. The conclusion was that
heavier children and adolescents gained more adiposity. In
this study, no measures of waist circumference and triceps
skin-fold thickness were available. These measures may
have added to the analysis of weight development in obese
Danish preschool children.
We found a very strong association between overweight
and obesity at 3 years of age and overweight and obesity at
5 years of age. To our knowledge, such association in consecutive anthropometric preschool data has not previously
been reported. Whitaker et al. (27) showed that obese children under 3 years of age without obese parents were at low
risk of obesity in adulthood and that among older children
obesity was an increasingly important predictor of adult
obesity, regardless of whether the parents were obese. Singh
et al. (28) stated that the risk of overweight and obese children becoming overweight adults was at least twice as high
compared with normal weight children.
CONCLUSION
Approximately 10% of preschool children were found to be
overweight or obese. The study indicated that the prevalence of overweight and obesity in Danish preschool children remained stable over a 10-year period. Furthermore,
comparison with Danish reference material indicated that
the prevalence only increased modestly over a 30-year period. The strong association between overweight and obesity
at 3 and 5 years of age indicates that early attention is advisable.
ACKNOWLEDGEMENTS
We thank the general practitioners participating in the survey for their generous assistance. We also thank project
technician Simone Markøv, Christian Hertel and Secretarial Manager Susanne Berntsen, for practical assistance in
the project. Thanks to Secretary Lise Keller Stark for skilful
proofreading of the manuscript. This study was funded by
the General Practice Research Foundation, The Health
Insurance Foundation, Rhode’s Foundation, The Egmont
Foundation, The Tryg Foundation, Institute of Clinical
Research, Faculty of Health Sciences, University of Southern Denmark, Odense University Hospital.
206
CONFLICT OF INTEREST
The authors declare no conflicts of interest.
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