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Department of International Health, The Rollins School of Public Health of Emory University, Atlanta, GA 30322
1To whom correspondence should be addressed. E-mail: rmart77{at}sph.emory.edu
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INTRODUCTION |
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 TOP INTRODUCTION REFERENCES |
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In earlier research, Victora (1992)
showed that wasting
levels in various Latin American countries were uniformly low and
unrelated to levels of stunting. In other regions of the world,
significant levels of wasting would be expected for the levels of
stunting found in many Latin American countries. The causes of regional
differences in patterns of wasting remain unexplained. Post and
Victora’s thesis that wasting is masked in Latin American children may
also apply to stunted children in general. For example, large abdomens
relative to length may also be common in places like India and this
would underestimate the already significant levels of wasting found in
this country (Measham and Chatterjee, 1999
). Additional
studies about abdominal and other physical characteristics are needed
from other sites in Latin America and from other regions of the world.
If the findings of Post and Victora about relatively large abdomens
apply generally to stunted children, other research will have to
explain the lower prevalences of wasting at all levels of stunting in
Latin American children.
Many researchers have been interested in the physique of the stunted
child. Because stunting generally develops during the first two years
of life, when growth of the extremities is faster than that of the
trunk, many find that stunted children have larger trunks (crown rump
length or sitting height, depending on measurement technique) relative
to length (or height). This characteristic would mask wasting as well.
Tanner et al. (1982)
observed that the marked increases
in adult height in the Japanese population are explained almost
entirely by changes in leg length, sitting height hardly having changed
at all. Thus the stereotype of Japanese physique, long trunk and short
legs, has practically disappeared. Post and Victora did not find
differences in the proportion of leg to total length between poor and
well-off Brazilian children but did report shorter proportions in
the slum children from Brazil compared to the international reference
(derived from United States children). On the other hand, children of
African ancestry are known to have proportionately longer legs than
children of European origin, which would overestimate wasting
(Eveleth and Tanner, 1990
). However, Post and Victora
controlled for the greater proportion of black ancestry in the slum
children compared to the well-off sample by adjusting for a
variable about skin color.
Post and Victora also examined circumferences of the head and chest
relative to length and found that slum children have relatively greater
circumferences than well-off children, but these differences were
smaller than those observed for the abdomen. These characteristics
would all elevate weight for height. We found that Guatemalan children
living at low altitude developed relatively greater chest but smaller
head circumferences than United States children as they became stunted
over the first three years of life (Malina et al., 1975
).
The evidence for concluding that the Brazilian slum children were thin
is weak. Post and Victora found that arm circumference, triceps and
subscapular skinfolds, and derived indices (arm muscle and fat areas)
were lower in slum children compared to well-to-do children. While this
suggests that slum children were thinner than the comparison group, the
absolute values reported were considerably larger than those observed
in South Asian children, among whom wasting as measured by low weight
for height is common (Martorell et al., 1984
). Also,
trunk skinfolds (subscapular and suprailiac) were similar in poor and
wealthier Brazilian children and available reference data showed
subscapular skinfolds were as found in United States children
(Frisancho, 1990
). Guatemalan children of low and upper
socioeconomic status also have relatively greater trunk than arm
skinfolds when compared to United States children (Malina et al., 1974
, Johnston et al., 1984
). In
upper class Guatemalan children, triceps skinfolds were below but
subscapular skinfolds were above United States reference values.
Mexican American children also show a similar type of body fat
patterning, favoring deposition in the trunk (Kaplowitz et al., 1989
). These observations cast doubt on the conclusion that
Brazilian children may be thin enough to suspect that considerable
wasting is being masked.
Direct measures of body composition, using methods appropriate for
young children (Butte et al., 2000
), are needed to
confirm or disprove that wasting is a hidden significant problem in
Brazilian children. Other important evidence for documenting the
existence of a public health problem is demonstration that the
variability in "wasting," whether measured through weight for
height or a more appropriate indicator, predicts undesirable functional
consequences in significant numbers of the population. Wasting in South
Asian and African populations, measured as low weight for length or arm
circumference, is predictive of increased morbidity and mortality risk
(Schroeder & Brown, 1994
). Finally, we may ask whether
indicators of wasting are responsive to nutrition interventions aimed
at children who are failing to grow. Data from Guatemala show that food
supplementation improved linear growth (total body length and arm
length), head circumference but not weight for height, arm
circumference or any of several skinfolds (Martorell, 1999
).
The research by Post and Victora calls into question the use of weight
for length as a measure of wasting in Latin American children and
perhaps in stunted children in general. By the same token, weight for
length would be a poor measure of overweight in stunted individuals.
For example, the relatively high prevalence of overweight in Andean
children, who have large trunks and barrel chests, may not represent
true fatness (Martorell et al., 1998
). The research by
Post and Victora underscores the need for studies of body composition
in young children, out of which appropriate anthropometric indicators
of thinness and overweight can be derived.
See related article: J. Nutr. 131: 1290–1296, 2001.
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REFERENCES |
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TOPINTRODUCTIONREFERENCES |
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1.
Butte N. F., Wong W. W., Hopkinson J. M., Heinz C. J., Mehta N. R., O’Brian Smith E. Energy requirements derived from total energy expenditure and energy deposition during the first 2 years of life. Am. J. Clin. Nutr. 2000;72:1558-1569
2. Eveleth P. B., Tanner J. M. Worldwide Variation in Human Growth 2nd ed. 1990 Cambridge University Press Cambridge, U.K.
3. Frisancho A. R. Anthropometric Standards for the Assessment of Growth and Nutritional Status 1990 The University of Michigan Press Ann Arbor, Michigan.
4. Johnston F. E., Bogin B., McVean R. B., Newman B. C. A comparison of international standards versus local reference data for the triceps and subscapular skinfolds of Guatemalan children and youth. Hum. Bio. 1984;56:157-171
5. Kaplowitz H., Martorell R., Mendoza F. S. Fatness and fat distribution in Mexican-American children and youths from the Hispanic Health and Nutrition Examination Survey. Am. J. Hum. Bio. 1989;1:631-648
6. Malina R. M., Habicht J-P., Yarbrought C., Martorell R., Klein R. E. Skinfold thicknesses at seven sites in rural Guatemalan ladino children birth through seven years of age. Hum. Bio. 1974;46:453-469
7.
Malina R. M., Habicht J-P., Martorell R., Lechtig A., Yarbrough C., Klein R. E. Head and chest circumference in rural Guatemalan Ladino children, birth to seven years of age. Am. J. Clin. Nutr. 1975;28:1061-1070
8. Martorell, R.(1999) The short- and long-term effects of improving nutrition in early childhood. In: Human Growth in Context (Johnston, F.E., Zemel, B. & Eveleth, P.B., eds.), chp. 29, pp. 331–345, Smith-Gordon, London, U.K.
9.
Martorell R., Kettel Khan L., Hughes M. L., Grummer-Strawn L. M. Obesity in Latin American women and children. J. Nutr. 1998;128:1464-1473
10.
Martorell R., Leslie J., Moock P. R. Characteristics and determinants of child nutritional status in Nepal. Am. J. Clin. Nutr. 1984;39:74-86
11. Measham A. R., Chatterjee M. Wasting Away. The Crisis of Malnutrition in India 1999 The World Bank Washington, D.C.
12. Schroeder D. G., Brown K. H. Nutritional status as a predictor of child survival: summarizing the association and quantifying its global impact. Bull. World Hlth. Org. 1994;72:569-579
13. Tanner J. M., Hayashi T., Preece M. A., Cameron N. Increase in length of leg relative to trunk in Japanese children and adults from 1957 to 1977: comparison with British and with Japanese Americans. Ann. Hum. Biol. 1982;9:411-424[Medline]
14. Victora C.G. The association between wasting and stunting: an international perspective. J. Nutr. 1992;122:1105-1110
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