BMC Public Health BioMed Central

Research article Open Access

Risk factors for childhood obesity at age 5: Analysis of the Millennium
Cohort Study
Sinead Brophy*1, Roxanne Cooksey1, Michael B Gravenor1, Rupal Mistry2,
Non Thomas3, Ronan A Lyons1 and Rhys Williams1

Address: 1Centre for Health Information, Research and Evaluation, School of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP,
Wales, UK , 2Africa Educational Trust, 18 Hand Court, WC1V 6JF, UK and 3Centre for Child Health, School of Human Sciences, Swansea
University, Singleton Park, Swansea, Wales, SA2 8PP, UK
Email: Sinead Brophy* - [email protected]; Roxanne Cooksey - [email protected];
Michael B Gravenor - [email protected]; Rupal Mistry - [email protected];
Non Thomas - [email protected]; Ronan A Lyons - [email protected]; Rhys Williams - [email protected]
* Corresponding author

Published: 16 December 2009 Received: 10 August 2009

Accepted: 16 December 2009
BMC Public Health 2009, 9:467 doi:10.1186/1471-2458-9-467
This article is available from: http://www.biomedcentral.com/1471-2458/9/467
© 2009 Brophy et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: Weight at age 5 is a predictor for future health of the individual. This study examines
risk factors for childhood obesity with a focus on ethnicity.
Methods: Data from the Millennium Cohort study were used. 17,561 singleton children of White/
European (n = 15,062), Asian (n = 1,845) or African (n = 654) background were selected. Logistic
regression and likelihood ratio tests were used to examine factors associated with obesity at age
5. All participants were interviewed in their own homes. The main exposures examined included;
Birth weight, sedentary lifestyle, family health behaviours, ethnicity, education and income.
Results: Children with a sedentary lifestyle, large at birth, with high risk family health behaviours
(overweight mothers, smoking near the child, missing breakfast) and from a family with low income
or low educational attainment, were more likely to be obese regardless of ethnicity. Feeding solid
food before 3 months was associated with obesity in higher income White/European families. Even
when controlling for socioeconomic status, ethnic background is an important independent risk
factor for childhood obesity [Odds ratio of obesity; was 1.7 (95%CI: 1.2-2.3) for Asian and 2.7
(95%CI: 1.9-3.9) for African children, compared to White/European]. The final adjusted model
suggests that increasing income does not have a great impact on lowering obesity levels, but that
higher academic qualifications are associated with lower obesity levels [Odds of obesity: 0.63
(95%CI: 0.52-0.77) if primary carer leaves school after age 16 compared at age 16].
Conclusions: Education of the primary carer is an important modifiable factor which can be
targeted to address rising obesity levels in children. Interventions should be family centred
supporting and showing people how they can implement lifestyle changes in their family.

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Background from each of the three surveys were obtained from the UK
The World Health organisation (WHO) predicts that by Data Archive, University of Essex.
2015 approximately 2.3 billion adults will be overweight
and more than 700 million will be obese. In 2005, at least Sub-group of children examined: Only the singleton chil-
20 million children under the age of 5 were overweight dren (of the 18,552 children recruited at the first sweep of
[1]. Obesity can lead to many other health complications, the MCS) were included within this study. The ethnic
including hypercholesterolemia and hypertension, and group of the child was recorded at the first contact using
this can lead to serious health consequences. CVD and the 11 Category Census Classification (UK) and only chil-
diabetes are two chronic diseases which are rapidly dren designated to either White, Asian or African ethnic
increasing globally. Even though the health consequences group were included in the study (n = 17,561). The group
of obesity are most commonly seen during adulthood, the defined as Asian included families recorded as; Indian,
underlying factors of these diseases could originate during Pakistani, Bangladeshi and Other Asian, the group
childhood. Weight at age 5 is a good predictor for further defined as African included families recorded as Black
health of the individual and "the die seems to be largely Caribbean, Black African and Other Black. Trained inter-
cast by 5 years of age"[2]. Evidence is now emerging that viewers measured the children's weights and heights.
obesity-driven type 2 diabetes might become the most Heights were measured using the Leicester stadiometer
common form of diabetes in adolescents within the next (Seca Ltd, Birmingham, UK) and recorded to nearest 0.1
ten years [3]. It is therefore vital to know exactly how early cm and weight measurement was taken using Tanita HD-
the health consequences and risk factors for these serious 305 scales and recorded to nearest 0.1 kg. The primary
diseases occur, and how early they can be detected if they outcome measure was obesity defined by the Interna-
are to be addressed successfully. This study investigates tional Obesity Task Force (IOTF) cut-offs for BMI, which
factors before age 5 to predict obesity at age 5. are age and sex specific [7].

The Millennium Cohort study (MCS) is a nationally rep- Potential Risk Factors
resentative cohort of British Children. Factors associated Factors associated with obesity were divided into catego-
with being overweight were investigated when the chil- ries and included risk factors found to affect obesity at age
dren were age 3. Factors linked to higher weights were: 3 using the MCS [1]. Risk factors examined include; eating
higher birth-weight, black ethnicity, early introduction to habits (early introduction of solid food, irregular eating
solid foods, smoking during pregnancy, parental over- pattern, fruit consumption), activity, inactivity, family
weight. Protective factors included Indian ethnicity and behaviours (mother's weight, smoking), birth weight,
longer duration of breast feeding [1]. Herein we examine socio-economic status (income and education) and eth-
risk factors occurring before age 5 to predict obesity at age nicity. All these variables were collected from self-report
5 in children in the Millennium Cohort Study. by the respondent (usually the mother) and no food dia-
ries or independent measurements of the parents (e.g.
Methods weight/height) were performed. Details of data collection
Millennium Cohort Study are published elsewhere [5,6]. Breastfeed was not exam-
This study used data collected by the Millennium Cohort ined as this has been previously reported in detail using
Study (MCS)[4]. Data for this cohort were collected from the MCS [8].
children born over a 12 month period between 1 Septem-
ber 2000 and 11 January 2002. Families with children Statistical analysis
who were living in the UK at age 9 months and eligible to STATA release 8 was used for all analysis. Factors associ-
receive Child Benefit at that age were invited to participate ated with obesity were examined for evidence of con-
(72% response rate)[5]. Subsequent interviews were car- founding or interaction with income and length of time in
ried out at the second contact (78% response rate) and education (as measures of socio-economic status) and
third contacts (79.2% response rate) when children were ethnic background (White/European, South Asian or Afri-
approximately 3 and 5 years of age, respectively[5]. A can) using Mantel-Haenszel tests followed by regression
stratified cluster sampling framework was employed to analysis using likelihood ratio tests. Logistic regression
adequately represent families from disadvantaged areas was performed using all factors associated with obesity in
and ethnic minority groups [5]. However, at second and an initial unadjusted analysis and likelihood ratio tests
third contact, there was a disproportionate loss of chil- were used to build the adjusted model. The interaction of
dren from wards defined as 'ethnic' and 'disadvantaged'. all variables in the adjusted model with ethnicity was
Parents were interviewed in the home and over 99% of the examined using likelihood ratio tests. Goodness of fit was
main respondents interviewed were the biological moth- assessed using the Hosmer and Lemeshow statistic [9].
ers[6]. Obesity was defined using the International Obes- Risk ratios for subgroups were also calculated to facilitate
ity Task Force age and sex specific BMI cut offs [7]. Data interpretation of findings.

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Results per day, eat breakfast on fewer days of the week, to be less
In singleton births of White/European, Asian or African likely to eat at regular times compared to non-obese chil-
background the proportion of children in the obese cate- dren [Additional File 1]. However, the effect of solid food
gory at age 5 was 5.7% (789/13745) and this rate differed before 3 months was most prominent in the higher
significantly with ethnic background [see Table 1]. Lost to income and white/European families [Additional File 1].
follow-up differed by ethnic group (Table 1) and by Eating breakfast was associated with lower levels of obes-
income; with 29%, 22% and 15% lost to follow up in the ity in the families where the primary carer had a higher
low (<£10,400), medium (>£10,400-£20,800) and high level of education [Additional File 1]. The association of
(£20,800+) income groups respectively. obesity with fewer portions of fruit and with less regular
eating times disappeared after adjusting for income.
Eating habits
Unadjusted analysis showed that children categorised as Physical activity
obese at age 5 were more likely to have had first solid food Crude analysis suggested that the children categorised as
before the age of 3 months, to have fewer portions of fruit obese reported doing less exercise, and parents were less

Table 1: Risk fctors by ethnic group

White/European (n = 15062) Asian African

(n = 1845) (n = 654)

Obese % (95%CI) 5.4% (5.0%-5.8%) 7.1% (5.8%-8.6%) 11.7% (8.9%-15%)

4.3% (2.6%-7% -Indian)
6.9% (5.2-9%-Pakastani),
11.7% (8.3%-16.2%- Bangladeshi),
5.4 (2.3%-12.1%-Other)
Missing at age 5 3095 (20.5%) 514 (28%) 207 (32%)

Income (at recruitment)

Less than £10,400 25% (24%-26%) 41% (38%-43%) 53% (48%-57%)
£10,400-£20,800 33% (32%-34%) 40% (38%-43%) 26% (23%-30%)
£20,800+ 42% (41%-43%) 19% (17%-21%) 21% (24%-31%)
Missing 1050 (7.0%) 341 (18.5%) 108 (16.5%)

Education (at recruitment)

No qualifications 16.5% (16%-17%) 45% (43%-48%) 33% (30%-37%)
O'level equivalent (education to age 16) 48% (47.5%-49%) 30% (28%-32%) 32% (28%-36%)
A'level equivalent (education to age 18) 10% (9%-10%) 8.6% (7%-10%) 8% (6%-10%)
University (education to age 20+) 25% (25%-26%) 16% (14%-18%) 27% (24%-31%)
Missing 251 (1.7%) 237 (12.9%) 50 (7.7%)

Birth weight
Kg.(s.d.) 3.398 kg (0.57) 3.09 kg (0.59) 3.237 kg (0.63)
Missing 33 (0.3%) 8 (0.6%) (1.2%)

Solid food <3 months 29% (28%-30%) 11% (10%-13%) 14% (12%-17%)
Missing 65 (0.43%) 35 (1.9%) 8 (1.2%)

Enjoys physical activity (age 5) 77% (76%-77%) 74% (72%-76%) 81% (77%-84%)
Missing 2983 (19.8%) 505 (27.4%) 198 (30.28%)

Watches more than 3 hours of TV 15% (14%-15%) 18% (16%-20%) 18% (15%-22%)
Missing 2980 (19.8%) 504 (27.3%) 200 (30%)

Smoking near child 16% (15%-16%) 6% (5%-8%) 5% (3%-7%)

Missing 2986 (19.8%) 507 (27.5%) 199 (30.4%)

Mothers pre-pregnancy weight (kg) 63.7 (12.5) 58.4 (11.5) 67.9 (14.1)
Missing 0 0 0

For families where child is obese -Parent 31% (28%-34.7%) 40% (29%-50%) 54% 41%-67%
unconcerned about child's weight

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likely to report that the child enjoyed physical activity a non-significant trend among African families for higher
compared to non-obese children [Additional File 1]. prevalence of obesity with increasing income. However,
However, the effect of reported exercise was no longer sig- there were too few subjects in each group to provide
nificant when adjusted for socio-economic factors. Sur- strong evidence of an effect [see Table 2]. In the high
prisingly, although more than two thirds of respondents income African families, 16 out of 90 children (17%
reported that their child enjoyed physical activity, there (95%CI: 11.2-27.0) were obese compared to 9% (95%CI:
were low levels of actual physical activity reported (49% 4.8-16.2, n = 100) and 13% (95%CI: 9.1-19, n = 180) in
reported the child did no exercise per week - Additional lower income bands (£10,400-£20800 and <£10,400
File 1) respectively). In addition, the beneficial effects associated
with higher educational levels in the mother, were less
Sedentary behaviour obvious in the African families [see Table 2].
Children who were obese at age 5 were more likely to
watch more than 3 hours of television per day during the Birth weight
week compared to non-obese children and this associa- Babies who were large at birth were more likely to be
tion was consistent across different ethnic groups and at obese at age 5, This was consistent across ethnic groups
every level of income and education [Additional File 1]. and socio-economic levels [Additional File 1]. There was
no association between obesity and low birth weight.
Indoor activities with child
Unadjusted analysis suggested that children categorised as Adjusted Regression analysis
obese at age 5 were more likely to do indoor activities Step up methods were used to enter all risk factors into
such as reading, art and playing indoors with their parent one regression model. This model shows that ethnicity is
than the non-obese children [Additional File 1]. an important independent risk factor even after account-
ing for income and education. Unadjusted odds of obesity
Family behaviours in Asian children compared to White/European was 1.3
Obesity at age 5 was found to be associated with a higher (95% 1.2-1.7) compared to the adjusted odds of 1.7
pre-pregnancy weight of the mother. This was consistent (95%CI: 1.2-2.3), unadjusted odds in African children
across all ethnic groups and across all levels of income was 2.3 (95% CI: 1.7-3.1) compared to the adjusted odds
and education. Obese children were more likely to be of 2.7 (95%CI: 1.9-3.9). Therefore, the odds of obesity in
exposed to tobacco smoke compared to non-obese chil- ethnic minority groups shows an increasing trend after
dren but this association was modified by income, with controlling for the excess risks associated with low socio-
no effect at low incomes but a risk ratio of 2.1 at higher economic status. The model suggests that there may be a
incomes [Additional File 1]. One explanation for this U shaped curve with low income and high income fami-
could be that poor health behaviours with higher income lies at higher risk of obesity then middle income families.
could become more exaggerated with greater amounts of The risks of obesity were highest among African and Bang-
food consumed and more driving than walking to shops ladeshi children. However, children of Indian origin were
and schools. The association with smoking and obesity not at higher risk of obesity at age 5 [Table 3].
was consistent across ethnic groups.
Eating breakfast was no longer significant when all factors
Socioeconomic factors were entered. Interactions of ethnicity with: effect of solid
Obesity was associated with lower income levels and food before 3 months; with enjoyment of physical activ-
lower education levels of the main respondent. There was ity; and with indoor activity and the interaction of income

Table 2: Obesity rates by ethnicity and risk factor.

White/European Asian African

n = 15062 n = 1845 n = 654

Income
Less than £10,400 7% (6.1%-8.1) 8.7%(6.4%-11.8%) 13.3% (9.1%-19%)
£10,400-£20,800 5.5%(4.8%-6.3%) 6.2% (4.3%-8.8%) 9% (4.8%-16%)
£20,800+ 4.5% (3.9%-5.1%) 5.4% (3.1%-9.3%) 17.8% (11%-27%)

Education
No qualifications 7.1% (5.9%-8.4%) 9.2% (7%-12%) 11% (6.9%-17.5%)
O'level equivalent (education to age 16) 6.3% (5.7%-6.9%) 5.5% (3.5%-8.4%) 13% (8.9%-20%)
A'level equivalent (Education to age 18) 3.7% (2.8%-4.9%) 3.6% (1.4%-8.8%) 0% (denominator = 29)
University 3.5% (3.0%-4.2%) 5.5% (3.1%-9.6%)
(Education to age 20+) 13% (8.7%-20.7%)

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with smoking were no longer significant in a regression healthy living advice and make modifications to their life-
model when tested with log likelihood tests; odds ratios style may be the most effective for young families, for
are given in Table 3. Goodness of fit assessed using the example, feeding style is associated with maternal educa-
Hosmer and Lemeshow statistic [9] showed no significant tion [11]. This is similar to findings looking at obesity at
difference between the model and observed data (p = age 3 in MCS children, which support the conclusion that
0.26), confirming a good fit of the model to the data. 'policies and interventions should focus on parents and
providing them with the environment to support healthy
Discussion behaviours for themselves and their children' [1].
Main findings
Ethnic background is an important independent risk fac- In this study we found that feeding solids before 3 months
tor for childhood obesity. Many factors associated with is associated with higher BMI/obesity at age 5. This differs
obesity at age 5 are also similar across ethnic groups such from findings looking at conditional weight gain between
as sedentary behaviour (hours watching TV), poor health birth and age 3 using the MCS [8] which suggests that
behaviours in the family (smoking and pre-pregnancy early introduction of solid foods has less effect on rapid
obesity), low income and education, and large birth gain once height is taken into account. However, the early
weight. Children from African or Asian families face not introduction of solid food before 15 weeks was found to
only higher risk but are also more likely to be exposed to affect weight at age 7 [12] and is associated with subse-
the excess risk factors associated with lower socio-eco- quent unhealthy feeding behaviour [13]. Therefore, the
nomic status. For example, African children have a risk effect of the early introduction of solid food on subse-
ratio of obesity 2.5 times that of White/European children quent obesity is still debateable.
(odds ratio 2.7) controlling for socio-economics, and they
are also twice as likely to live in a low income family Risk factors in ethnic minority groups
where the mother has no qualifications. The trend to Ethnic minority children are at high risk from birth of
increasing odds ratios after adjusting for these confound- obesity and many of these risk factors could be addressed.
ing variables suggests that some aspects associated with Differences between ethnic groups suggest beneficial
low income could be protective for ethnic minority chil- effects of traditional methods such as not giving solid
dren. Some health behaviours which may be protective food before 3 months of age and enjoyment of physical
may be lost or changed with increasing income, for exam- activity. There is some evidence that obesity may not be
ple walking to school declines with increasing income seen as a problem and regarded as culturally acceptable
[10]. Higher educational level of the mother on the other among some groups. Specifically, 54% of African and
hand is consistently associated with lower obesity levels. 40% of Asian parents with an obese 5 year old reported to
This maybe because with higher education there may be be unconcerned about their child's weight [Table 1]. There
better uptake of protective health behaviours and empow- is a suggestion among the African groups that improve-
erment for people to modify their own health. It is ment in socio-economic status may bring about some
unlikely that education per se results in lower obesity but increased risks of obesity and perhaps there is a U shaped
rather interventions which help people to implement curve with higher obesity levels in the poorer and wealth-

Table 3: Regression analysis. Adjusted odds ratio

Risk factor Odd ratio 95%CI

Ethnic group Asian (compared to White/European) 1.7* 1.2-2.3

Ethnic group African (compared to White/European) 2.7** 1.9-3.9
Birth weight (per kg increase in weight) 1.4 1.2-1.65
Does not enjoys physical activity (per unit increase (scale 1-5: 1 very much enjoys, 5 very much dislikes)) 1.4 1.2-1.5
Watches more than 3 hours of TV a day 1.3 1.1-1.7
Solid food before 3 months 1.2 1.02-1.5
Smoking near child 1.3 1.02-1.6
Mothers pre-pregnancy weight (> 60 Kg) 1.9 1.6-2.3
Leaving school at age 18 (A'level) compared to leaving at age 16 (no qualifications or O'levels). 0.55 0.4-0.77
Leaving school at age 20+ (University) compared to leaving school at 16 (no qualifications or O'levels). 0.67 0.53-0.83
Income >£20,800 (compared to <£10,400) 0.84 0.67-1.0
Income £10,400-£20,800 (compared to <£10,400) 0.76 0.61-0.93
Indoor activities (per unit increase on a 0-30 scale). 1.06 1.03-1.08

* Risk Ratio = 1.6 (95%CI: 1.2-2.1). Indian = 1.1 (95%CI: 0.6-2.0), Pakistani = 1.5 (1.0-2.2), Bangladeshi = 2.1 (1.2-3.7), Other Asian = 1.6 (95%CI:
0.6-4.6).
** Risk Ratio = 2.5 (95%CI: 1.8-3.4)

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ier families compared to middle income families. This findings suggest that interventions targeting family and
finding is supported by the regression analysis which sug- supporting people to implement lifestyle changes are
gests that low and high income families (regardless of eth- promising to prevent childhood obesity.
nicity) have similar risks of obesity and are both higher
than the middle income families [14]. However, this Conclusions
hypothesis needs to be further examined. Some factors Obesity levels at age 5 vary significantly according to eth-
seen in ethnic minority groups are protective, and these nic groups. Conversely, many risk factors and issues lead-
practices may change with income. Similar to findings in ing to childhood obesity are similar across ethnic groups.
this cohort when the children were age 3, Indian ethnicity There is some evidence that increasing income may indi-
was not found to be associated with higher levels of obes- cate some protective behaviours are lost. For example, ear-
ity [Table 3]. lier introduction of solid food and less physical activity
are associated with higher incomes. However, higher edu-
Limitations of the study cational achievement for the mother may be an important
The Millennium Cohort Study database provides a large factor for addressing socio-economic inequalities in child-
sample size with high response rate and good representa- hood obesity but this needs to be further explored for eth-
tion of traditionally hard to reach groups. The Millen- nic minority (especially African) families. Further work is
nium Cohort Study is unique in over sampling ethnic needed to examine why some ethnic minority groups are
minority groups and this is essential to ensure we have a at higher risk of childhood obesity. For example, variation
fuller understanding of the ways of improving health and between risks for Bangladeshi children compared to those
health behaviours across society. However, this study can from Indian families are not likely to be due to genetic dif-
only give a very crude assessment of the risk factors asso- ferences. Interventions should be family centred main-
ciated with obesity. For example, diet and physical activity taining the protective effects associated with a low
are all self reported and open to variations in interpreta- income, but facilitating greater access to healthy choices
tion and meaning between different individuals and eth- associated with a higher income. This study uses the larg-
nic groups. No objective measures of diet (such as food est cohort of ethnic minority children and highlights that
diaries) or physical activity (such as accelerometers) were further work needs to be undertaken especially with Afri-
used in the study. The use of questionnaires to measure can families who are at high risk of childhood obesity.
physical activity, especially parental reporting of physical
activity is known to be problematic [15], overestimating Abbreviations
the true levels of activity. Some of the factors associated CVD: Cardiovascular Disease; MCS: Millennium Cohort
with obesity given in this study, may be crude indicators Study; BMI: Body Mass Index.
of true risk factors. For example, missing breakfast in itself
may not lead to obesity, but it may be an indictor of a gen- Competing interests
eral lifestyle of snacking, eating larger portions later in the The authors declare that they have no competing interests.
day and a lack of thought on general diet [16]. The lack of
objective measures for many of the explanatory factors Authors' contributions
examined means that residual confounding may remain. All authors were involved in designing the analysis, SB
Recruitment to this study was through eligibility for Child and RC obtained and analysed the data, MBG and RL
Benefits. This method of identification could mean that advised on the analysis, RM, NT and RW give advice and
migrant, refugee and asylum seekers are not included in comments on interpretation, all authors were involved in
this cohort and these may be the most vulnerable at risk writing the manuscript and all authors have read and
groups for poor health care and obesity. approved the final manuscript.

This study examines factors associated with obesity at age Additional material
5. However, there is the argument that thinness at age 5
may be more important for future health [17,18]. The rate
of weight gain in the very early weeks of birth may be Additional file 1
Evidence of association of risk factor with obesity. Crude odds of asso-
important for predicting future risk of obesity [19-21]. ciation between exposure and obesity.
However, this study did not collect objective measures of Click here for file
weight gain between birth and 9 months of age. [http://www.biomedcentral.com/content/supplementary/1471-
2458-9-467-S1.DOC]
Many of the findings within this study are supported by
other cohort studies [22,23] which show babies large for
gestational age, with mothers who smoked during preg-
nancy and who were large pre-pregnancy and low educa- Acknowledgements
tional level, were more likely to be overweight. All these This work was funded by the Welsh Office for Research and Development.

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