Journals of Gerontology: MEDICAL SCIENCES
Cite journal as: J Gerontol A Biol Sci Med Sci 2014 July;69(7):852–859
doi:10.1093/gerona/glt189© The Author 2013. Published by Oxford University Press on behalf of The Gerontological Society of America.
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Advance Access publication November 27, 2013

Associations of Childhood Socioeconomic
Status and Adulthood Height With Functional
Limitations Among Japanese Older People: Results
From the JAGES 2010 Project
Department of Social Medicine, National Research Institute for Child Health and Development, Setagaya-ku, Tokyo, Japan.
2Center for Well-being and Society, Nihon Fukushi University, Nagoya, Aichi, Japan.
3
Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, Massachusetts.

1

Address correspondence to Takeo Fujiwara, MD, PhD, MPH, Department of Social Medicine, National Research Institute for Child Health andDevelopment, 2-10-1 Okura, Setagaya-ku, Tokyo 157–8535, Japan. Email: fujiwara-tk@ncchd.go.jp

Background. We examined the associations between childhood socioeconomic status and adulthood height with functional limitations in old age.
Methods. Data were obtained from the baseline survey of the Japan Gerontological Evaluation Study 2010, a population-based cohort of people aged ≥65 years enrolled from 27 municipalities across Japan (N = 15,499). People aged
65–69, 70–74, 75–79, and ≥80 years experienced the end of World War II when they were aged 0–4, 5–9, 10–14, and≥15 years, respectively. Subjective socioeconomic status during childhood and current height were obtained by selfreport through questionnaire in 2010. Higher-level functional capacity was assessed using a validated questionnaire
scale. Poisson regression with robust variance estimator was employed to determine the association between childhood
subjective socioeconomic status, height, and functional limitations.
Results. Lower childhood subjective socioeconomic status was consistently associated with higher prevalence
rate ratio of limitations in higher-level functional capacity, regardless of age cohort. Height was associated withfunctional limitation only among the group aged 70–74 years: taller (≥170 cm for men and ≥160 cm for women)
people were 16% less likely to report functional limitation in comparison with shorter (<155 cm for men and<145 cm for women) individuals in the fully adjusted model (prevalence rate ratio: 0.84, 95% confidence interval:
0.74–0.96).
Conclusions. Low childhood subjective socioeconomic status had a robust association with functional limitation
regardless of age cohort. In addition, those who lived through World War II before they reached puberty and attained
shorter height were more likely to report functional limitations in old age.
Key Words: Disability—Life-course approach—Subjective socioeconomic status—Height—Childhood environment.
Received April 2, 2013; Accepted October 20, 2013
Decision Editor: James Goodwin, PhD

Disability is a long-term process that is associated with socioeconomic status (SES), healthbehaviors (eg, smoking or physical inactivity), anddisease status (eg, stroke) (1). Social inequalities inhealth behaviors and disease status lead to corresponding social inequalities in disability status and functional limitations (2). Most studies have focused onrisk factors for disability beginning in midlife (3–5),
but increasingly studies have adopted a life-course
perspective to examine the associations between childhood environment, adulthood SES, health behaviors(6), disability, and activities of daily living (ADL)(7,8).

852

Few studies have investigated the impact of childhood
environment on limitations in higher-level functional capacity (7), such as those social activities or activities that require
higher cognitive function (eg, reading a newspaper, visitinga friend’s house), which are critical to the concept of “successful” aging (9). For example, the results of the Whitehall
II study in the United Kingdom (10) showed that childhood
SES was associated with cognitive function among midlife
adults, suggesting that there is a sensitive period duringchildhood development during which adversity can resultin limitations of higher-level functional capabilities later inlife (11). Notably, the Whitehall results indicated that childhood adversity can result in deleterious effects on health inDownloaded from https://academic.oup.com/biomedgerontology/article-abstract/69/7/852/662547 by guest on 17 March 2020

Takeo Fujiwara,1 Katsunori Kondo,2 Kokoro Shirai,1 Kayo Suzuki,2 and Ichiro Kawachi3

CHILDHOOD SES, HEIGHT, AND HIGHER LIMITATIONS

Methods
Study Population
The goal of the Japan Gerontological Evaluation Study
2010 Project was to evaluate the health status and social

determinants of nondisabled people aged ≥65 years sampled from 27 municipalities in 10 of the 47 prefectures inJapan. The municipalities were selected throughout the
major islands of Japan (Hokkaido, Honshu, Kyushu, andOkinawa), with the exception of Shikoku. Since the primary objective of the cohort is to examine the predictors of
disability onset, older people who were eligible to receive
public long-term care insurance benefits were excluded (ie,older people with disability registered in municipality were
excluded) from the sample. In 15 municipalities, we sampled the entire population of residents older than 65 years(complete enumeration), while in the remaining 12 municipalities we mailed the surveys to a simple random sample
based on the official residential registers obtained frommunicipal authorities.
A total of 117,494 residents aged ≥65 years at the time of
the baseline survey (which took place from August 10, 2010
to May 9, 2011) were targeted for the baseline questionnaire. Of the eligible participants, 78,769 people responded
to the survey (response rate: 67.0%, which is quite high for
a community-based survey of this type, where response
rates of 20% is the norm in many western countries). Of
the returned surveys, 4,425 were rejected because of missing data (valid response rate: 63.3%). One-quarter of thesample in 25 municipalities (N = 18,194) was asked aboutchildhood environment. We further limited the sample torespondents who gave nonmissing responses on sex andresponded ≥65 years of age (N = 17,723). To focus on theassociation between childhood environment and limitations
in higher-level functional capacity, although initially sample with disability registered in municipality were excluded,
the sample was further limited to those who reported nolimitations in ADL, defined as those who can walk, takea bath, and do toilet without assistance (N = 16,870). The
excluded sample with ADL limitations showed similarchildhood SSS with included sample (p = .37), although
the height of the excluded sample was shorter in general(p < .01). Finally, since the study’s main outcome measure ishigher-level functional capacity, those who did not respondfully to the Tokyo Metropolitan Institute of Gerontology
Index of Competence were excluded; this reduced the sizeof the analysis sample to 15,499.
Assessment of Limitations in Higher-Level Functional
Capacity
Limitations in higher-level functional capacity wasassessed using the Tokyo Metropolitan Institute ofGerontology Index of Competence (12), which was derived
from Lawton’s model of competence, comprised of 13 items(see Supplementary Appendix), designed to cover instrumental self-maintenance (5 items), intellectual activities (4items), and social roles (4 items) for older people (13). For
example, the respondents were asked, “Can you use public transportation (bus or train) by yourself?” with response

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adulthood even if the individual escapes adverse socioeconomic conditions later in life—which is referred to as thelatent effects model. Koyano and colleagues developed ascale to assess limitations in higher-level functional capacity
among older people based on Lawton’s model of competence (12), which was designed to cover instrumental selfmaintenance, intellectual activities, and social roles (13). An
investigation of the childhood determinants of limitations inhigher-level functional capacity is critical for the development of a strategy to promote healthy and active aging (14).
Most previous studies on the life-course approach haveinvestigated the impact of childhood SES by using paternal
occupation as an indicator (6,15–19), while some studies
have adopted other proxies, such as perceptions of wealthduring childhood (16), housing conditions (20), or numberof siblings (21), to measure early childhood social environment. Recent studies have demonstrated the utility of subjective socioeconomic status (SSS) as a predictor of health (22),although an association between childhood SSS and disability has not been reported to our knowledge. An additional
proxy for childhood adversity is adulthood height, which
can be thought of as a marker of cumulative social and environmental exposures during early childhood (23). Around
20% of variation in height is due to environmental variation(23), which is mainly made up of childhood nutrition, disease status, educational attainment and lower socioeconomic
position (24). Previous reviews have indicated a robust link
between short stature and a range of diseases (25). To the bestof our knowledge, no study has investigated the associations
between childhood SSS and height with limitations in higherlevel functional capacity among older people.
The Japan Gerontological Evaluation Study Project is acohort study that evaluated both childhood environment andhigher-level functional capacity among community-dwelling
people aged ≥65 years in Japan. Baseline surveys were administered in 2010–2011 to individuals who were free of disability as defined by the national long-term care insurance system.
Some of the participants lived through World War II, whichlasted from 1937 to 1945, while they were in early childhood.
People aged 65–69, 70–74, 75–79, and ≥80 years experienced the end of World War II when they were aged 0–4, 5–9,
10–14, and ≥15 years, respectively. The period during and
immediately after World War II (1937–1945) in Japan was
associated with food shortages, rationing, and severe restrictions in the nutritional environment (26,27). Thus, this cohort
provides a unique opportunity to investigate the impact ofheight (as a proxy of early childhood nutritional deprivation)
on subsequent limitations in higher-level functional capacity.

853

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FUJIWARA ET AL.

gastrointestinal disease, liver disease, psychiatric disease,visual impairment, hearing impairment, impaired excretion, sleep disorder, and other. Sex, marital status (married,
widowed, divorced, never married, or other), and living status (whether or not the respondent was living alone) werealso asked via questionnaire. Further, municipality dummy
codes were added to adjust for municipality fixed effects.

Childhood SSS and Adulthood HeightChildhood SSS was assessed retrospectively by the following question on the self-administered questionnaire:“How do you rate your social status when you were aged
15 years in comparison with standards at that time?”
Responses were rated on a five-point Likert scale with thefollowing anchors: high, middle-high, middle, middle-low,and low. Retrospectively, recalled SSS has been used in aprevious study and showed similar association with healthstatus in comparison with objective SES in childhood,
although only among men (31). The participants’ current
height was also reported in the self-administered questionnaire. Previous studies confirmed a high correlation between
self-reported and measured height among Japanese (32)and older people in Australia (33). Individuals reportingheight above 3 SDs from the mean height (as retrieved fromthe 2010 Japanese National Health and Nutrition Survey(34)) were excluded because considered as potential outliers, yielding 1,617 invalid reports (10.4%). Further, heightwas categorized into five groups in 5-cm intervals for eachsex: for men: <155, 155–159.9, 160–164.9, 165–169.9, and≥170 cm; and for women: <145, 145–149.9, 150–154.9,
155–159.9, and ≥160 cm.

Analysis
Poisson regression with robust variance estimator wasused to examine the associations between childhood SSS
and height with limitations in higher-level functional
capacity, stratified by age group. We employed Poisson
regression analysis with robust variance estimator becauseof the relatively high prevalence of limitation of higherlevel functional capacity (>10%), which would result in
the divergence of odds ratios from the risk ratio (35,36).
Model 1 was adjusted for age and sex, model 2 additionallyadjusted for adult SES, model 3 additionally adjusted for
health behaviors, model 4 additionally adjusted for diseasestatus, and model 5 (the final model) additionally adjusted
for marital and living status. All analyses were performed
using STATA MP version 12.

Adult SES, Health Behaviors, Disease Status, andOther Covariates
Potential mediators of the association between childhood adversity and old age functional limitations—such asadult SES, health behaviors, and disease status—were also
assessed by self-administered questionnaire. Indicators ofadult SES included years of schooling (<6, 6–9, 10–12, or≥13 years) and annual household income in the year before
the survey (<1.5, 1.5–2.9, 3.0–4.9, or ≥5 million yen, 1 million yen is equivalent to 10,000 dollars). Health behaviors
included drinking (current, quit, or never), smoking (current, quit ≤4 years ago, quit ≥5 years ago, or never), vegetable and/or fruit intake during the past month (two servings
daily or more, once daily, 4–6 times weekly, 2–3 times
weekly, once weekly, less than once weekly, or never), andaverage walking time per day (<30, 30–59, 60–89, or 90+min). The respondents were also asked whether they werecurrently under medical treatment for the following diseases with yes/no responses: cancer, heart disease, stroke,
hypertension, diabetes mellitus, obesity, hyperlipidemia,
osteoporosis, joint disease/neuralgia, respiratory disease,

Results
The overall and age-stratified characteristics of thestudy sample are shown in Supplementary Table 1. Of the
respondents in the total sample, 72%, 22%, and 11% were
married, widowed, and living alone, respectively. Regardingchildhood SSS, 44% considered that their childhood SES
was low compared with the rest of society; this did notvary by age group. The distribution of participants in thefive height categories was as follows: 11% (in the shortest group), 22%, 30%, 19%, and 7% (in the tallest group);
10% of respondents were missing information on height.
Around half of participants completed less than 10 years ofeducation. A further 45.2% earned less than 3 million yen
in annual income (1 million yen is equivalent to 10,000 dollar). One third were current drinkers, while 10% were current smokers. The major comorbid conditions reported byparticipants were hypertension (39.8%), visual impairment(14.0%), diabetes mellitus (12.9%), heart disease (11.9%),
joint disease or neuralgia (11.5%), and hyperlipidemia(9.3%). In terms of limitations in higher-level functional
capacity, 57% of the total sample reported some disability(as did 49%, 54%, 60%, and 71% of the sampled groups
aged 65–69, 70–74, 75–79, and ≥80 years, respectively).
Table 1 shows the prevalence rate ratios (PR) of limitations in higher-level functional capacity according to childhood SSS and height, stratified by age group, using Poisson
regression. Overall, low childhood SSS showed a positive association with limitations in higher-level functional
capacity in all age groups. For example, older people aged

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items of “yes” or “no.” If respondents marked “no” for any
item, the respondent was classified as having some limitation in higher-level functional capacity, while respondents
who marked “yes” for all items were classified as being
without limitation in higher-level functional capacity. This
scale is widely used in Japan to assess limitations in higherlevel functional capacity among older people (28–30).

Adulthood height category

SES in childhood

Adulthood height category

SES in childhood

Adulthood height category

SES in childhood

Adulthood height category

SES in childhood

High or middle-highMiddleMiddle-low or low
Short
Middle-short
MiddleMiddle-tall
TallHigh or middle-highMiddleMiddle-low or low
Short
Middle-short
MiddleMiddle-tall
TallHigh or middle-highMiddleMiddle-low or low
Short
Middle-short
MiddleMiddle-tall
TallHigh or middle-highMiddleMiddle-low or low
Short
Middle-short
MiddleMiddle-tall
Tall

ref
1.20
1.39
ref
1.02
0.95
0.90
0.97
ref
1.10
1.30
ref
0.91
0.86
0.86
0.78
ref
1.11
1.31
ref
0.99
0.92
0.92
0.99
ref
1.07
1.18
ref
0.95
0.95
0.98
1.06
0.89–1.01
0.89–1.02
0.89–1.07
0.93–1.20

1.00–1.17
1.10–1.27

0.90–1.08
0.84–1.01
0.83–1.02
0.85–1.14

1.00–1.24
1.18–1.46

0.83–1.01
0.78–0.94
0.78–0.95
0.69–0.89

0.99–1.23
1.17–1.44

0.88–1.18
0.82–1.09
0.78–1.04
0.83–1.13

1.06–1.36
1.23–1.57

ref
1.14
1.26
ref
1.05
0.99
0.97
1.04
ref
1.06
1.19
ref
0.94
0.90
0.92
0.85
ref
1.06
1.21
ref
1.02
0.96
0.98
1.06
ref
1.04
1.12
ref
0.95
0.96
0.99
1.07
0.90–1.02
0.89–1.03
0.90–1.08
0.94–1.21

0.96–1.12
1.04–1.21

0.93–1.11
0.88–1.05
0.88–1.08
0.92–1.22

0.95–1.18
1.09–1.34

0.85–1.04
0.82–0.99
0.83–1.02
0.74–0.97

0.95–1.17
1.07–1.31

0.91–1.21
0.86–1.14
0.84–1.11
0.89–1.21

1.01–1.29
1.11–1.42

ref
1.15
1.27
ref
1.03
0.97
0.96
1.03
ref
1.05
1.17
ref
0.95
0.89
0.92
0.84
ref
1.06
1.20
ref
1.01
0.95
0.97
1.04
ref
1.03
1.11
ref
0.96
0.96
0.98
1.07

PR

0.90–1.02
0.89–1.02
0.89–1.07
0.94–1.21

0.96–1.11
1.03–1.19

0.92–1.10
0.87–1.04
0.87–1.07
0.90–1.20

0.95–1.17
1.08–1.33

0.86–1.05
0.81–0.98
0.83–1.01
0.74–0.96

0.94–1.16
1.06–1.29

0.89–1.18
0.85–1.12
0.83–1.10
0.88–1.20

1.02–1.30
1.13–1.43

95% CI

Model 3(model 2 + healthbehavior)

ref
1.16
1.28
ref
1.02
0.97
0.95
1.03
ref
1.05
1.17
ref
0.94
0.89
0.91
0.84
ref
1.05
1.20
ref
1.02
0.95
0.97
1.05
ref
1.03
1.10
ref
0.96
0.96
0.99
1.07

PR

0.90–1.03
0.90–1.03
0.91–1.08
0.94–1.21

0.96–1.11
1.02–1.18

0.93–1.11
0.87–1.04
0.88–1.08
0.91–1.21

0.95–1.17
1.08–1.33

0.85–1.04
0.81–0.98
0.82–1.01
0.74–0.95

0.95–1.17
1.06–1.29

0.88–1.18
0.85–1.12
0.82–1.09
0.88–1.20

1.02–1.30
1.13–1.44

95% CI

Model 4(model 3 + disease)

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ref
1.16
1.28
ref
1.02
0.97
0.95
1.03
ref
1.06
1.17
ref
0.94
0.89
0.91
0.84
ref
1.05
1.20
ref
1.02
0.96
0.98
1.05
ref
1.03
1.10
ref
0.97
0.96
0.99
1.07

OR

0.91–1.03
0.90–1.03
0.91–1.09
0.94–1.21

0.96–1.11
1.02–1.19

0.93–1.11
0.88–1.05
0.88–1.08
0.92–1.21

0.95–1.17
1.08–1.32

0.85–1.05
0.81–0.98
0.83–1.01
0.74–0.96

0.95–1.17
1.06–1.30

0.89–1.18
0.85–1.12
0.82–1.09
0.89–1.20

1.03–1.31
1.14–1.44

95% CI

Model 5(model 4 + marital,
living alone)

Notes: Short, men: <155 cm, women: <145 cm; Middle-short, men: 155–159.9 cm, women: 145–149.9 cm; Middle, men: 160–164.9 cm, women: 150–154.9 cm; Middle-tall, men: 165–169.9 cm, women: 155–159.9
cm; Tall, men: 170+ cm, women: 160+ cm. CI = confidence interval; OR = odds ratio; PR = prevalence rate ratio; SES = socioeconomic status. Values in bold are significant at the p = .05 level.

80+ y75–79 y70–74 y65–69 y95% CIPRPR

95% CI

Model 2(model 1 + adult SES)

Model 1(adjusted age, sex)

Table 1. Prevalence Rate Ratio of Childhood SES and Adulthood Height for Limitation of Higher-Level Functional Capacity by Poisson Regression Analysis

CHILDHOOD SES, HEIGHT, AND HIGHER LIMITATIONS
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FUJIWARA ET AL.

Discussion
Using data from a large population-based study, we
showed that low childhood SSS was significantly associated with limitations in higher-level functional capacity
among older people without ADL limitations, especially inthe domains of intellectual activities and social roles. Thesefindings were consistent across all studied age groups (ie,65–69, 70–74, 75–79, and ≥80 years). Furthermore, adulthood height (considered a proxy of childhood nutritionaland social environment) was inversely associated with limitations in higher-level functional capacity among older people aged 70–74 years, who experienced the end of WorldWar II when they were aged 5–9 years. The fact that theseassociations persisted after adjustment for SES attained in
adulthood suggests the long-lasting influence of childhood
adversity on functional limitations in old age.
The following pathways can possibly explain how low
childhood SES and height exert long-term influences onhigher-level functional activity limitations in old age: First,
low childhood SES may deleteriously affect the development of health maintenance behaviors across the life
course. For example, those raised in low SES circumstances
may lack role models in terms of intellectual activities orsocial roles—or what is referred to as the accumulation of“cultural capital.” For example, parents in high SES households are more likely to read newspapers and participate ina variety of social roles (37–39). This may explain why low
childhood SSS was not associated with self-maintenanceinstrumental ADL in this study, that is, even those raised
in low SES circumstances acquire habits such as the use of
public transportation. Second, low childhood SES may trigger a chain of risk that includes low adulthood SES, poor
health behaviors, and disease status, which are all associated with limitation in higher-level functional capacities—
the so-called “pathways model” in the life-course literature.
In our study, adding adult SES, health behaviors, and disease status to the statistical model attenuated the point
estimates of PR for limitations in higher-level functional
capacity; this suggests that low adult SES, poor healthbehaviors (such as inactivity), and having a disease (such as
coronary heart disease) partially mediated the association
between low childhood SES and the outcome.
Our findings are consistent with those of previous studies
on childhood SES and disability. Using data from the U.S.
Health and Retirement Study, Bowen and González reported
that low childhood SES (assessed by parental education andoccupation) was associated with ADL, instrumental ADL,
late-life disabilities as well as social and behavioral healthrisks in adult life (7). Furthermore, among midlife populations, childhood SES has been directly linked with functional limitations (ie, grip strength, reaching, walking, andstair climbing) in the 1946 British National Birth Cohort
Study (8) and indirectly associated with cognitive functionin the UK Whitehall II study (10). Our study adds to thisliterature by showing that low childhood SSS was directly

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65–69 years who considered their childhood SES as low
or middle-low were 1.39 times (95% confidence interval[CI]: 1.23–1.57) more likely to report limitations in higherlevel functional capacity in comparison with similarly
aged people with high or middle-high childhood SES, after
adjustment for age and sex. Similar PRs were observed forother age groups: for older people aged 70–74, 75–79, and≥80 years, the PRs of limitations in higher-level functional
capacity among those with low as opposed to high childhood SSS were 1.30 (95% CI: 1.17–1.44), 1.31 (95% CI:
1.18–1.46), and 1.18 (95% CI: 1.10–1.27), respectively.
The significant associations remained in all age groups evenafter correction for mediators (adult SES, health behaviors,
disease status, marital status, and living status), although
the point estimates of PR were attenuated by covarianceadjustment.
In contrast to childhood SSS, adulthood height wassignificantly inversely associated with limitations inhigher-level functional capacity only among the groupaged 70–74 years, that is, among those who experienced
the end of World War II when they were aged 5–9 years.
Model 1 indicates that in comparison with shorter older
people, the PRs of limitations in higher-level functional
capacity across ascending height groups were 0.91 (95%
CI: 0.83–1.01), 0.86 (95% CI: 0.78–0.94), 0.86 (95% CI:
0.78–0.95), and 0.78 (95% CI: 0.69–0.89), respectively.
The “dose-response” relationship was statistically significant according to the test for linear trend (p for trend< .001). This association persisted even after adjustment
for mediators. Further, the p for linear trend between
height and limitations in higher-level functional capacity remained significant in model 5 (p for trend = .008,
data not shown). An association between height andfunctional limitations was not found in the younger age
groups.
The impact of childhood SSS and adulthood height on
specific type of functional limitations (ie, instrumental
self-maintenance, intellectual activities, and social role
limitations) was further investigated (see Supplementary
Appendix). Then, we found that low childhood SSS
was significantly positively associated with limitationsin intellectual activities and social role limitations (seeSupplementary Table 2). By contrast, limitations in instrumental self-maintenance activities were not associatedwith childhood SSS. A significant inverse association wasobserved between height and the intellectual activities subcategory of limitations in higher-level functional capacity
for all age groups. Among older people aged 70–75 years,
for example, the tallest group was 28% less likely toreport limitations in intellectual activities compared withthe shortest group (PR: 0.72, 95% CI: 0.58–0.90). The
remaining subcategories (ie, instrumental self-maintenance and social role limitations) were not associated withheight, except social role limitations among people aged
70–74 years.

CHILDHOOD SES, HEIGHT, AND HIGHER LIMITATIONS

such as parental death, divorce, or child maltreatment (48).
Fourth, adulthood height was self-reported, not measured objectively; this could introduce measurement error.
However, we used height as not a continuous but as a categorical variable, which minimizes misclassification. Fifth,
our response rate to the survey was 67%, and it is likely thatthose who had activity limitations as well as those from low
childhood SSS backgrounds were less likely to respond to
the questionnaire; suggesting that our reported results mightunderestimate the true underlying associations. Sixth, theAGES cohort excluded persons with ADL limitations fromthe baseline study sample, which may have led to an underestimation of the impact of height on functional limitations.
In summary, our findings implicate the “long arm” ofchildhood socioeconomic circumstances on functional
capacity at older ages. Policies that mitigate childhood
adversity may yield health dividends at a distant point in
the future. Conversely, policies to address the prevention ofold age disability need to target not just those in midlife, but
points that are further “upstream” in the life course.
Supplementary Material
Supplementary material can be found at: http://biomedgerontology.
oxfordjournals.org/
Funding
This study was supported in part by Health Labour Sciences Research
Grant, Comprehensive Research on Aging and Health (H25-ChojuShitei-008) 2010-2012 from the Japanese Ministry of Health, Labour andWelfare, Grant-in-Aid for Scientific Research (KAKENHI 23243070)
from the Japan Society for the Promotion of Science, and Grant-in-Aid for
Scientific Research on Innovative Areas, Ministry of Education, Culture,
Sports, Science and Technology KAKENHI (21119003).
Conflict of Interest
None declared.
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associated with higher levels of functional (especially, intellectual and social role) limitations.
To the best of our knowledge, this is the first study thathas shown an association between height and limitations inhigher-level functional capacity. Previous studies reported
that short height was associated with mortality or morbidityfrom stroke and coronary heart disease (40,41), dementia(42), and cognitive function (43,44). Moreover, a recent
study showed that height was associated with intelligenceand brain gray matter volume (45). Further, the current
study was conducted in a non-western setting, suggesting
the generalizability of the impact of childhood environment
on functional limitation in older age.
The impact of poor childhood nutritional environment
on limitations in higher-level functional capacity seems to
implicate the presence of a critical period in early childhood, assuming that the period during and immediately
after World War II (1937–1945) was associated with themost severe restrictions in nutritional environment (26,27).
An important caveat is that we lacked data on the location
where participants spent their childhood, although nutritionand clean water likely varied by location. The results areinteresting, as those exposed to the War conditions at ages
0–4 years showed no impact on higher functional ability;
the reasons for this result are unknown. The 65- to 69-yearold cohort might have had a better environment after WorldWar II, while people aged 70–74 years might have sufferedfrom a poor nutritional environment even when they wereaged 0–4 years during and immediately after World War
II. Our findings suggest that the prepubertal period is critical for physical and cognitive development, as those who
experienced World War II after the prepubertal period (ie,those aged 75–79 and ≥80 years) showed no association
between height and functional limitations. The importanceof the prepubertal period was also reported in a previous
study, although the measured outcome was not height; thatstudy reported that the age of achieving pubertal milestones(assessed as first nocturnal emission, voice breaking, andpubarche) was associated with cognitive functioning amongolder men (46).
Our study has several limitations. First, childhood SSS
was assessed retrospectively because of the study’s crosssectional design; thus, the data are participant to recall bias,
and current health status might have affected the assessmentof childhood SSS. However, a previous study confirmed thevalidity of retrospective assessed of childhood SSS using
sibling’s recall of measures of childhood socioeconomic
position (47). Second, in conjunction with the first point,childhood SES was assessed subjectively in this study,
although previous studies assessed this variable in termsof parental occupation or education (7,8,10). However, weconsidered that SSS is a useful indicator that taps aspects ofsocial status beyond objective measures such as educational
attainment or occupation. Third, we used only relative
childhood SSS, but not other aspects of childhood adversity

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