Effects of an energy and micronutrient supplement on growth and development in undernourished children in Indonesia: methods.

OBJECTIVES: To describe the methodologies of a clinical trial on the effects of an energy and micronutrient supplement on the growth and development of undernourished children. DESIGN: This trial included two cohorts of children classified as nutritionally-at-risk who were randomly assigned to three treatments (condensed milk + micronutrients (E); skimmed milk + micronutrients (M); skimmed milk (S)). Supplements were given for a period up to 12 months. SETTING: Six tea plantations in Pangalengan, West Java were the site for this study. SUBJECTS: A 12-month-old (N=53) and an 18-month-old (N=83) cohort were recruited from 24 day-care-centers (DCC). Twenty children that received the S supplement were part of the 12- and 18 month-old cohort. Criteria for case inclusion were absence of chronic disease; length-for-age < or = -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization. VARIABLES: Social variables included assessment of health facilities, childcare, housing, income and parental education. Nutrition and growth variables included dietary intake measured over a 24 hr period every 2 months; hemoglobin and three iron indicators measured at baseline, 6 and 12 months; anthropometry measured every 2 months and skeletal maturation measured every 6 months. Cognition and behavior included the assessment of mental and motor development and the behavior of the child under natural conditions. DATA ANALYSIS: An ANOVA was the statistic most frequently used to test inter-group differences and structural equation modeling was used to test the internal validity of the conceptual model of the study.

Nutritional intake of an undernourished infant population receiving an energy and micronutrient supplement in Indonesia.

OBJECTIVES: This paper reports the dietary intake (home, day care centers, supplement and breast milk) of the children in the clinical trial in Pangalengan. DESIGN: Two cohorts of children were randomly assigned to three treatments: E = 1171 kJ + 12 mg iron; M = 209 kJ + 12 mg iron; S = 104 kJ. Supplementation was given for 12 months. SETTING: The sites were six tea plantations in Pangalengan, West Java. SUBJECTS: A 12-month-old (n = 53) and an 18-month-old (n = 83) cohort were recruited from day-care-centers. Twenty children who received S belong to the 12- and 18-month-old cohorts. Inclusion criteria were: no chronic disease; length-for-age < or = -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization. METHODS: E = 1171 kJ + 12 mg iron; M = 209 kJ + 12 mg iron; S = 104 kJ. Supplementation was given for 12 months. Evaluations of intake were made at baseline and every 2 months thereafter. RESULTS: For the 12-month-old cohort the mean increase in daily energy intake approximately 2931 kJ for E, approximately 1675 kJ for M, and approximately 837 kJ increase over the 6 months for the S group. For the 18-month-old cohort the changes were approximately 2512 kJ for E approximately 1675 for the M group and approximately 1047 for the S group.

Effects of an energy and micronutrient supplement on growth and activity, correcting for non-supplemental sources of energy input in undernourished children in Indonesia.

OBJECTIVES: This paper investigates simultaneously the growth and activity of children that received an early energy and micronutrient supplement, adjusting for all non-supplemental energy intakes. Any additional change in growth and activity after this adjustment was then compared across supplements at three points felt to be representative of the study. DESIGN: Two cohorts of children were randomly assigned to three treatments: E = 1171 kJ + 12 mg iron; M = 209 kJ + 12 mg iron; S = 104 kJ. Supplementation was given for 12 months. SETTING: The sites were six tea plantations in Pangalengan, West Java. SUBJECTS: A 12-month-old (n = 53) and an 18-month-old (n = 83) cohort were recruited from day-care-centers. Twenty children that received S belonged to the 12- and 18-month-old cohorts. Inclusion criteria were: no chronic disease; length-for-age < or = -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization. METHODS: Length was measured with a portable measuring board; a Detecto scale with an accuracy of 0.1 kg was used for the measurement of body weight. Arm and head circumferences were measured using similar fiberglass tapes. Motor activity was assessed through continuous 4 h observations at home and at day care centers. Anthropometry and activity were measured every two months over 12 months. RESULTS: After correcting for non-supplemental sources of energy intake, the effects of the supplement on weight and activity were observed at 2 months; effects on length and activity were observed at 6 months; and effects on weight alone were observed at 12 months.

Effects of an energy and micronutrient supplement on anthropometry in undernourished children in Indonesia.

OBJECTIVES: This paper reports the effects of early supplementary feeding on body weight, length, head circumference and arm circumference among the children in the Pangalengan study. DESIGN: Two cohorts of children were randomly assigned to three treatments: E = 1171 kJ + 12 mg iron; M = 209 kJ + 12 mg iron; S = 104 kJ. Supplementation was given for 12 months. SETTING: The sites were six tea plantations in Pangalengan, West Java. SUBJECTS: A 12-month-old (n = 53) and an 18-month-old (n = 83) cohort were recruited from day-care centers. Twenty children that received S belonged to the 12- and 18-month cohorts. Inclusion criteria were: no chronic disease; length-for-age < or = -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization. METHODS: Length was measured with a portable measuring board; a Detecto scale with an accuracy of 0.1 kg was used for the measurement of body weight. Arm and head circumferences were measured using similar fiberglass tapes. RESULTS: Body weight showed effects on both cohorts at 2, 8 and 12 months; head circumference showed effects at 4 months in the 12-month-old cohort and at 10 months among the females of the 18-month-old cohort; and arm circumference showed effects across cohorts at 2, 8 and 12 months. In general the benefits are clearer for females and for the 12-month-old cohort.

Adequacy of standards for assessment of growth and nutritional status in infancy and early childhood.

BACKGROUND: New "UK 1990" data have been proposed for assessing growth and nutritional status in infancy and childhood. These are still largely untried in clinical practice. There is also doubt about the applicability of more traditional reference data, which are still widely used, in assessing length, weight, skinfold thicknesses, and head circumference. AIMS: To determine the suitability of new and traditional reference data for the assessment of growth and nutritional status in infancy and early childhood. METHODS: 127 infants were recruited at birth and assessed monthly to 6 months of age then at 9, 12, 18, and 24 months. Length, weight, head circumference, and triceps and subscapular skinfold thicknesses were measured. Body mass index (BMI) was calculated. Measurements were expressed as standard deviation scores relative to "revised UK 1990" data for weight, length, head circumference and BMI; relative to Tanner-Whitehouse data for skinfold thicknesses; and relative to Gairdner-Pearson standards for head circumference. Agreement at the extremes of the distribution was assessed by comparison of observed and expected frequencies above the 90th and below the 10th centile. RESULTS: Compared with the revised UK 1990 references small differences were found for weight, length, head circumference, and BMI. Mean head circumference exceeded Gairdner-Pearson standards at all ages. Triceps and subscapular skinfold thicknesses were substantially below Tanner-Whitehouse reference data at all ages and in both sexes. CONCLUSION: Biases in revised UK 1990 reference data are small and not clinically important. The new standards are considerably more appropriate than older reference data. Use of older reference data for head circumference and skinfold thicknesses is inappropriate.

Weaning practice in the Glasgow Longitudinal Infant Growth Study.

AIMS: To assess compliance with Department of Health guidelines on weaning practice in a representative sample of 127 infants from Glasgow, and to identify factors influencing timing of weaning. METHODS: Questionnaires on feeding and weaning were completed during home visits. Ninety eight mothers completed a further questionnaire on attitudes to weaning. RESULTS: Median age at introduction of solid food was 11 weeks (range 4-35 weeks); only 7% of infants had not been weaned before age 4 months. There was no difference in timing of weaning between boys and girls. Younger mothers (< 20 years old), those of lower socioeconomic status, and those who formula fed their infants tended to introduce solids earlier. Infants who were heaviest before weaning were weaned earlier. Seventy three of 98 mothers reported that they weaned their babies because they felt that they required more food. Sources of information influencing time of weaning were previous experience (53/98), books and leaflets (43/98), advice from the health visitor (31/98), and family and friends (15/98). Sixty five of 98 mothers reported receiving formal information on weaning, in most cases (54) this was from the health visitor. Mothers who received formal information tended to wean their infants later. Two per cent of infants had been given cow's milk as a main drink by age 6 months, 17% by 9 months, and 45% by the end of the first year. CONCLUSION: Compliance with recommendations on timing of weaning (not before 4 months), weaning foods, and cow's milk consumption in Glasgow is poor, although no poorer than in many other areas of the UK as found by Office of Population, Censuses and Surveys. Public health messages in relation to weaning may not be reaching their target audience.

Skinfold thicknesses: is there a need to be very precise in their location?

Skinfold thicknesses represent a comparatively simple and reasonably accurate assessment of body fatness which is an important part of the estimation of nutritional state. However, much emphasis is placed on the necessity to be very precise in the exact position of the skinfold being measure and there is frequently concern, also, about the variability of the measurement by different observers using different types of caliper. Fifty-three women and forty-five men had four skinfolds (biceps, triceps, supra-iliac and subscapular) measured first at the standard sites (Tanner, 1953; Edwards et al. 1955), and then at deliberately chosen sites about 20 mm distant from the "correct' ones. The effect on the estimation of body fatness by this manoeuvre resulted in a difference of usually less then 1% and, at a maximum, 3%. In the light of the uncertainty of the basic assumptions which are made in extrapolating from skinfolds (or indeed densitometry, total body water, total body K, and others) to body fatness, these technical errors assume comparatively little importance.

A longitudinal study of changes in body composition and basal metabolism in physically active elderly men.

Ageing in the elderly is usually characterised by loss of fat-free mass (FFM) and reduction in basal metabolic rate (BMR). These age-related changes probably vary in rate, timing and extent between subjects in response to differences in leisure or occupational physical activity, disease and several other factors. Information on rates of change in BMR and FFM is limited by study design (most published work is cross-sectional rather than longitudinal), and possibly by methodology (use of imprecise and/or biased methods for assessment of changes in body composition). In the present study BMR and body composition were first measured in 22 physically active elderly men (mean age 62) in good health and measurements were repeated 6.5 years later. Changes in BMR, FFM and percentage body fat were small and not statistically significant over the time period (paired t, P > 0.05). The study suggests that physically active elderly men in good health in this age range can show very small age-related declines in BMR and FFM.

Ability of biolectric impedance to predict fat-free mass in prepubertal children.

Measurements of body composition are being made increasingly widely in pediatrics. Tetrapolar whole body impedance (BI) is particularly suitable as a method of estimating body composition in children and is therefore the subject of great interest at present. However, the ability of BI to accurately estimate fat-free mass (FFM) in children is unclear, and users of BI are faced with a growing choice of prediction equations for estimation of FFM. Studies in adults have suggested that choice of prediction equation can have a profound effect on the estimate obtained. The aim of the present study was to measure the ability of four published pediatric BI equations to predict FFM in 98 Caucasian prepubertal children (mean age 9.0 y). For three of the published equations, limits of agreement between predicted and reference FFM were wide and distinct biases were apparent. With mean FFM of 25 kg, the equation of L. Cordain et al. overestimated reference FFM (95% CI +2.1 to +3.1 kg), whereas those of P. Deurenberg et al. (95% CI -1.9 to -2.9 kg) and F. Schaefer et al. (95% CI -1.4 to -2.5 kg) systematically underestimated reference FFM. The equation of Houtkooper et al. (95% CI -0.2 to +0.8 kg) predicted FFM with negligible bias and had narrower limits of agreement relative to the reference method than the other three equations tested. We conclude that the ability of BI to predict body composition in children depends on the equation chosen and that the general applicability of BI equations cannot be safely assumed. Cross-validation of BI equations is recommended before they are used routinely for estimation of body composition in children.

Determination of body composition from skinfold thickness: a validation study.

Measurement of body composition is proving increasingly important in clinical nutrition and research. Skinfold thickness is a simple means of estimating body composition which is widely used in children, but there is little information on its validity. There has been a proliferation of equations for estimation of body composition from skinfolds, but some doubt as to their general applicability. The aim of the present study was to validate five currently used equations for this purpose in a sample of 98 healthy prepubertal children (64 boys, 34 girls), mean (SD) age 9.1 (1.7) years by comparison of estimates from each equation with measurements of fatness derived from hydrodensitometry. Differences between methods were determined by calculation of biases and limits of agreement. Limits of agreement between predicted and measured fatness were wide, particularly in the girls, and some distinct biases were apparent. Choice of prediction equation therefore has a substantial influence on the estimate of fatness obtained when using skinfolds in children. The existing published equations are associated with large random errors or significant systematic errors. For the time being skinfolds might best be regarded as indices (rather than measures) of body fatness in individuals, or means of estimating body fatness of groups. Estimating the total body fatness of individual prepubertal children using skinfolds, on the basis of this evidence, is not advisable at present.

Social, psychological, and behavioural factors related to body size in adult men and women: A comparison of methods.

Some of the difficulties with obesity research concern inconsistencies in the definition of the construct, the methods by which it has been assessed, and the samples that have been employed. The purpose of the present study was to investigate whether there were significant differences in the nature of the simultaneous relationships between a number of variables previously associated with obesity and body size when assessments were made by body mass index (BMI) or an estimation of fatness from skinfold thicknesses. In addition, comparisons were made when subjects were classified into obese and non-obese categories. Appropriate multiple regression and logistic regression analyses were used to analyze these data for a group of adult men and women sampled from the general population. These procedures allowed a comparison of results when the dependent variables were in their continuous versus their dichotomous form. Approximately 250 adult men and women participated in the study. Percent body fat was associated with less frequent leisure time exercise participation, slower walking speed, reduced levels of trait anxiety, and a greater tendency to diet. Among women, but not men, lower socioeconomic status was also related to fatness. However, several of these relationships were absent when BMI served as the measure of body size, and to a greater extent, when subjects were classified into obesity categories. The findings of this study underscore the importance of measurement techniques and classification procedures in determining the outcome of psychosocial and behavioural data in the area of obesity research.

Appropriate technology in body composition: a brief review.

This paper attempts to link the particular method to be used for body composition measurements to the objectives of the study. There is often inadequate attention paid to the real requirement for different degrees of precision, and excessive amounts of time and labour are spent on quite unnecessary minutiae of technology. Special attention is paid to bio-electrical impedance, skinfold thicknesses, stable isotope techniques, and methods for assessing fat distribution.

Low body mass index, physical work capacity and physical activity levels.

In a normal population the distribution of body mass index (BMI) is such that a certain proportion of the population is likely to be at low values without necessarily being malnourished. However, although they may have low BMIs without being malnourished, they could certainly be physiologically and physically disadvantaged. An attempt is made to dissect out the probability of work capacity and physical activity being influenced by changes occurring in the human body with diminishing BMI. The conclusion reached is therefore that before physical activity is affected, the BMI would probably have to be 17 or less, although it is possible that work capacity might be reduced before this level is reached. In any case, work requiring the use of the body mass - such as carrying loads, digging or shovelling earth or coal, pulling or cycling a rickshaw, stone splitting etc.- would impose a greater stress on people of low BMI.

Prediction of body density from skinfold thickness in elderly subjects: are the existing equations valid?

In 33 healthy elderly subjects, body density was measured using hydrodensitometry and predicted from the sum of four skinfold thicknesses. In the men, mean measured density was 1.045 kg/l and mean predicted density 1.041 kg/l, with bias and limits of agreement 0.004 (+/- 0.016) kg/l and 95% confidence interval (CI) for the difference 0.001-0.008 kg/l. In the women, mean measured density was 1.012 kg/l and mean predicted density 1.020 kg/l, and 95% CI for the difference was -0.016-0.000 kg/l. The bias was therefore in the opposite direction in women than men, and limits of agreement were wider (-0.008 +/- 0.030 kg/l) in the women. Biases in prediction of density lead to systematic error in estimation of body fatness in elderly subjects, and this systematic error is more likely to be of practical significance in women than men.