# Tracking the development of adiposity from one month of age to adulthood

Marie-Françoise Rolland Cachera, Michèle Deheeger, Michel Guilloud-Bataille, Patrick Avons, Elisabeth Patois, Michel Sempé

► To cite this version:

Marie-Françoise Rolland Cachera, Michèle Deheeger, Michel Guilloud-Bataille, Patrick Avons, Elisabeth Patois, et al.. Tracking the development of adiposity from one month of age to adulthood. Annals of Human Biology, 1987, 14, pp.219 - 229. 10.1080/03014468700008991. hal-05340761

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# Child BMI trajectories: the history of a concept over the last four decades

## Marie-Françoise Rolland-Cachera

Center for Research in Epidemiology and Statistics (CRESS), Sorbonne Paris Nord University and Paris Cité University, INSERM, INRAE, CNAM, Nutritional Epidemiology Research Team (EREN), Bobigny, Cedex, France

## Overview

Given the high prevalence of obesity worldwide, a great deal of research has been dedicated to its causes. A variety of approaches have been taken, but much progress has come from the examination of growth trajectories.

## Background

The article "Tracking the development of adiposity from one month of age to adulthood" published in Annals of Human Biology in 1987 (AHB-87) (Rolland-Cachera et al. 1987) appeared shortly after the validation of the use of body mass index (BMI) in children and the elaboration of BMI growth charts (Rolland-Cachera et al. 1982).

BMI, the Quetelet index, has long been used to define nutritional status in adults. In children, in line with the method used to assess undernutrition, weight status was initially based on the percentage of the median of weight-for-height. Obesity was defined as weight-for-height >120% of the median value. However, in order to combine weight, height and age, the validity of adiposity indices had to be investigated.

In the early 1980s, the use of BMI in children was questioned and not generally approved. In 1982, we compared different weight-for-height indices based on their independence from height and their association with adiposity as assessed by skinfolds, at each age and in both sexes. The weight/height² BMI best fulfilled these conditions. Compared to other adiposity indices, such as the weight/height³ Benn (Garn and Pesick 1982) or the weight/height³ Rohrer (Freedman et al. 1987) indices, the pattern of BMI curves with age appeared to be similar with that of skinfolds (Tanner and Whitehouse 1975). Both BMI and skinfold curves show an upward phase in the first year of life followed by a decrease and by a new rise from around 6years of age. In addition to independence with height and association with body fatness, the similarity between BMI and skinfold development was another argument in favour of validating the BMI in children. As BMI varies during growth, reference values were needed for the use of clinicians and researchers. In 1982, we published the first BMI

reference values and charts by age and sex (Rolland-Cachera et al. 1982), revised in 1991 using the LMS smoothing method (Rolland-Cachera et al. 1991). Subsequently, the IOTF (Cole et al. 2000), CDC (Kuczmarski et al. 2000) and WHO (de Onis et al. 2007) child BMI references were also released.

Looking at individual BMI patterns, we observed large inter-individual variations. The main difference was related to the age at the nadir of the BMI curve which occurs at an average age of 6years but varies between 2 and 8years on individual trajectories. It was observed that the earlier the age at the nadir, the higher the subsequent fatness development. This concept was termed "adiposity rebound" (AR) (Rolland-Cachera et al. 1984).

## The significance of "tracking the development of adiposity"

Soon after these observations, AHB-87 provided additional and more detailed information on individual BMI patterns. Using French longitudinal data spanning two decades (Rolland-Cachera et al. 1991), in AHB-87, we showed that an early AR was associated with a high BMI but also with high subscapular skinfold thickness in adulthood. This finding was later confirmed using skinfolds and measures of body fat (Williams and Goulding 2009). These AR-adult fatness associations, together with the cross-sectional associations between BMI and skinfold thickness at all ages (Rolland-Cachera et al. 1982) and the similarity between BMI and skinfold patterns, justify the use of the term "adiposity rebound" for the original concept, rather than changing for "BMI rebound" as subsequently proposed (Freedman et al. 2001).

The association between an early AR and later overweight was confirmed in many studies quoted in AHB-87 and many others since. Tracking BMI development between 1 and 21 years, showed that most children do not remain in the same fatness category. Comparing 3 groups of lean, medium, and overweight children at age 1year, we observed that most initially overweight children did not remain overweight but joined lower BMI categories after a late AR, while lean children reached higher categories after an early AR. In addition, we

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showed that in individuals who remained in the same category (overweight who stayed overweight, medium who stayed medium, and lean who stayed lean), AR occurred at the age of 6 years, the mean age at AR. In a few cases, overweight children who were to develop severe obesity had an early AR.

The low tracking of BMI in the first years of life is related to the variability of the age at AR, which is associated with skeletal maturity (Rolland-Cachera et al. 1984; Williams and Goulding 2009), a feature confirmed by the higher stature in subjects with obesity during childhood, followed by lower stature at the end of growth due to early puberty (Knittle et al. 1979), and by the positive association between childhood height and adult overweight (Freedman et al. 2001). Short (stunted) or tall (bolting) stature in children can be seen as physiological adaptations to inadequate protein-energy intake, preventing weight-for-height deficit or excess (Rolland-Cachera et al. 1991).

According to the "tempo of growth" defined as the rate at which children mature (Tanner and Cameron 1980; Cole 2020), an early or late rebound either regulates the normal growth process (e.g. an overweight child joins average level after a late AR) or deviates towards pathological development (Cameron and Demerath 2002).

The low tracking between early and later life is consistent with the results of many studies such as the Bogalusa Heart study where the majority of children initially above the 85th percentile for triceps skinfold did not remain overweight after eight years of follow up (Freedman et al. 1987). Low persistence of overweight was also observed in the study from Washington state showing that in overweight children under three years of age, only few of them become obese adults, but after the age of 6 years (the mean age at AR), childhood obesity is an increasingly important predictor of adult obesity (Whitaker et al. 1997).

## Controversies

Despite these observations, the value of the AR has been questioned, but all the answers can be found in AHB-87. It has been stated that "since the children with higher BMIs had an earlier rebound as observed on the highest percentile curves, the period of AR may represent an epiphenomenon" (Dietz 2000). In fact, as opposed to individual trajectories, centile curves which are based on cross-sectional BMI distributions at each age are misleading as they suggest that individuals track along centiles (Figure 1), i.e. an early high BMI will stay high after an early nadir of the BMI curve. However, subjects on high BMI centile at the age of one year are not the same individuals as those on a high centile at 20, and obviously, a high centile stays high at all ages. By contrast, in studies looking at individual trajectories (AHB-87), most overweight children become thinner. This pattern is associated with a late AR, while those who remain overweight have a rebound at a median age of 6 years. Likewise, it has been stated that "a high centile and upward centile crossing are both associated separately with an early rebound, and an early rebound is a risk factor for later fatness because it identifies children whose BMI centile is high and/or crossing upwards" (Cole 2004). Here again, the apparent association between a high centile and an

<figure><img src="image_8.png" /><figcaption>Figure 1. Longitudinal BMI curves of two groups of children according to median age at adiposity rebound (AR): Early AR < 6.3 years (mean = 4.5y); Late AR ≥ 6.3 years (mean = 6.5 y), plotted against the 3rd and 97th French BMI reference centile curves (Rolland-Cachera et al. 1991). By contrast with the patterns of centile curves, age at AR identifies individual trajectories. Children with an early AR, have lower BMIs before the AR and higher BMIs after the AR. This pattern is typically associated with metabolic risk (Bhargava et al. 2004; Eriksson et al. 2003).</figcaption></figure>

early nadir of the curve contrasts with the association between individual patterns and age at AR, as most overweight children will join lower values after a late AR. Consequently, an early rebound does not identify children whose BMI centile is high. Besides, in accordance with Cole (Cole 2004) and as shown in AHB-87, the earlier nadir on the high centile curve may be driven by the BMI trajectories of thin or normal weight children crossing upwards, a trend consistent with the BMI pattern associated with an early AR starting from low followed by high BMI (Figure 1).

Finally, it has been suggested that since childhood BMI and age at AR correlate equally well with adult BMI, then "BMI at a given age (3 or 7) may be a more practical criterion for determining obesity risk" (Dietz 2000; Freedman et al. 2001, 2021). The difference between using a single BMI value and using the age at AR to predict obesity is that an infinite number of curves pass through a single point, whereas an early rebound identifies specific growth trajectories (Figure 1).

## New findings since 1987

More recently, longitudinal studies have confirmed that the trajectory consisting of a low BMI before an early AR and subsequent high fatness (Figure 1) is particularly associated with metabolic diseases such as diabetes (Eriksson et al. 2003; Bhargava et al. 2004). This is consistent with the notion that low weight status in early life imprints future metabolic risks such as in the case of low birth weight (Barker et al. 1989; Hanley et al. 2010). The effect of early environmental factors, such as nutrition on BMI trajectories indicate that early life (before 2 years of age) is a "critical period" for later risks, whereas the period around the age at AR is not, but is the consequence of early environmental factors.
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In contrast with children becoming fatter after an early AR, children with a consistently high BMI and a normal age at AR, corresponding to an average stage of maturation, are more likely to be at lower risk. This pattern may reflect a high level of lean body mass, which would suggest placing them in the "healthy obesity" category (Bouhours-Nouet et al. 2008).

Other aspects of BMI trajectories, such as time trends, have been examined. Compared to children of the Fels longitudinal study born in 1928–1953, those born more recently in 1973–1999, had a lower BMI in the early years of life, followed by an earlier AR and later higher fatness, confirming the shift to an unhealthy trajectory (Johnson et al. 2012). Likewise, French children born in 1985, had similar or lower BMI in the first years of life compared to those born in 1955. The lower BMI value in those born more recently is due to higher increase in stature rather than lower body weight (Rolland-Cachera et al. 2006). At birth, weight trends are small but the increase in height from one generation to the next occurs mainly in the first 2 years of life, so that the increment in adult height has already been achieved by age 2 years (Cole 2003). This trend is particularly due to an increase in leg length which is associated with the risk of cancer, and notably hormonally dependent cancers (Gunnell et al. 1998).

The recent decline in BMI in children up to about 5 years of age may be due to the trend towards lower fat intake in early life decreasing energy (Rolland-Cachera et al. 2013), and to higher protein intake (Rolland-Cachera et al. 1995) which increases height more than weight and then decreases BMI (Rolland-Cachera et al. 2006), accelerates maturation and brings forward the age at AR. The subsequent higher body fatness may be due to exposure to an obesogenic environment (Speakman et al. 2023).

## Conclusion and perspectives

After validating the use of BMI in children, which is now globally accepted, and producing the first BMI growth charts in the early 1980s, we expended the analysis of individual BMI growth trajectories a few years later in AHB-87. We showed that in most cases, children do not remain in the same BMI category as they grow. Some trajectories correspond to regulatory processes when an overweight child stabilises after a late AR, while others identify individuals at risk of developing obesity and metabolic disease. These observations provide useful information for paediatricians.

Studies of growth trajectories have shown that factors affecting the early period of life can have long-term effects on adult health. These findings highlight the value of anthropology as a simple and powerful tool for studying risk factors of obesity. In addition to trajectories based on weight and height, trajectories of measurements such as leg or foot length, shoulder width, waist and hip circumference and ratio (Cole 2020), or percentage of fat and lean body mass; (Rolland-Cachera et al. 1997) should also be further investigated. As these dimensions grow at different rates, research into the factors influencing individual trajectories may provide insights into the origins of pathologies and help to improve prevention.

## Acknowledgements

The author would like to thank F Bellisle, A Briend for their thoughtful insights and L Fezeu, and CC Dahel-Mekhancha for their kind assistance.

## Disclosure statement

No potential conflict of interest was reported by the author(s).

## Funding

The author(s) reported there is no funding associated with the work featured in this article.

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