Randomised controlled trial of qigong in the treatment of mild essential hypertension.

Exercise and relaxation decrease blood pressure. Qigong is a traditional Chinese exercise consisting of breathing and gentle movements. We conducted a randomised controlled trial to study the effect of Guolin qigong on blood pressure. In all, 88 patients with mild essential hypertension were recruited from the community and randomised to Goulin qigong or conventional exercise for 16 weeks. The main outcome measurements were blood pressure, health status (SF-36 scores), Beck Anxiety and Depression Inventory scores. In the qigong group, blood pressure decreased significantly from 146.3+/-7.8/93.0+/-4.1 mmHg at baseline to 135.5+/-10.0/87.1+/-7.7 mmHg at week 16. In the exercise group, blood pressure also decreased significantly from 140.9+/-10.9/93.1+/-3.5 mmHg to 129.7+/-11.1/86.0+/-7.0 mmHg. Heart rate, weight, BMI, waist circumference, total cholesterol, renin and 24 h urinary albumin excretion significantly decreased in both groups after 16 weeks. General health, bodily pain, social functioning and depression also improved in both groups. No significant differences between qigong and conventional exercise were found. In conclusion, Guolin qigong and conventional exercise have similar effects on blood pressure in patients with mild hypertension. While no additional benefits were identified, it is nevertheless an alternative to conventional exercise in the nondrug treatment of hypertension.

Birthweight and psychological distress in adult twins: a longitudinal study.

AIM: To assess the relation between birthweight and psychological distress as measured by the Malaise Inventory in adult twins. METHODS: Data were drawn from the 1958 British birth cohort study, which included twins followed from birth to age 42 y. We examined the relation between birthweight and psychological distress at ages 23, 33 and 42 y measured by the psychological scale of the Malaise Inventory. Analyses were performed both between subjects (n = 282) and within twin pairs (n = 112). The generalized estimating equations approach was used to handle the repeated measurements. RESULTS: Between the 282 twins, the difference in psychological distress score was -0.45 (95% confidence interval -0.74 to -0.15) per Z-score increase in birthweight-for-gestational age. Within twin pairs, the heavier co-twins tended to have a psychological distress score lower than that of their lighter co-twins, the mean difference being -0.35 (-0.78 to 0.09). CONCLUSION: Results from the between-subject analysis agreed with previous findings from adult singletons that psychological health is related to birthweight. The within-pair analysis suggested a similar relation but did not attain statistical significance.

Maternal smoking: an increasing unique risk factor for sudden infant death syndrome in Sweden.

AIM: To assess the change of risk factors that are specific to sudden infant death syndrome (SIDS) after the initialization of a campaign to reduce the risk (RTR) of SIDS compared to non-SIDS postneonatal deaths. METHODS: Data were extracted from the Swedish Medical Birth Registry, 1982-1991 and 1993-1998. 1105 infants died from SIDS during the postneonatal period. 2115 postneonatal deaths were from other causes and 11,050 live birth controls were selected. Risk factors previously identified to be related to SIDS were defined as high parity, prematurity, young maternal age, low Apgar score, birth during the night, single motherhood, multiple births, maternal smoking, male gender, short length standard deviation score (SDS) and small weight-to-length SDS. RESULTS: Non-SIDS deaths were more significantly related to a low 5-min Apgar score, smaller weight-to-length SDS, and/or short length SDS values; while SIDS deaths were more closely related to mothers with higher parity or multiple births, mothers who smoked during pregnancy and single-parent (mother) families. Maternal smoking was even more prominent among SIDS deaths in the post-campaign period. The adjusted odds ratios, compared with non-SIDS deaths, increased from 1.84 (95% CI: 1.48, 2.28) in the pre-campaign period to 4.11 (95% CI: 2.72, 6.21) in the post-campaign period. CONCLUSIONS: Maternal smoking during pregnancy remains the most important modifiable risk factor for SIDS in the post-campaign period in comparison with non-SIDS postneonatal deaths. Other than putting babies in a supine sleeping position, maternal smoking should be the next most important issue to be considered, if there is to be a second campaign.

Refining the Apgar score cut-off point for newborns at risk.

AIM: To evaluate the Apgar score predictive power for mortality during different periods in the first year of life in a population with a very low mortality rate. METHODS: The records of all singleton live births without severe congenital malformations and length of gestation >25 wk (n = 976635) were collected from the Swedish Medical Birth Registry, 1990 to 1998. Receiver operating characteristic (ROC) analysis was utilized. RESULTS: Both the 1-min and the 5-min Apgar scores were shown to be good discriminators for early mortality, with the area under the ROC curve >0.85. For babies at risk of early death, the selected cut-off values for the 1-min Apgar score was <8 for preterm (true-positive (TP) rate: 83.9%; false-positive (FP) rate: 17.7%) and term babies (TP rate: 69.4%; FP rate: 6.7%). At 5 min, the analysis revealed that newborns with an Apgar score <9 were at risk for early death (preterm babies: TP rate: 79.8%; FP rate: 13.3%; term babies: TP rate: 73.8%; FP rate: 3.4%). CONCLUSIONS: Our analysis did not support the common practice in the clinic or in research of grouping infants at risk in Apgar score groups, i.e. a score below 4 or a score below 7. However, the data presented here allow the clinicians and researchers to identify and define a suitable cut-off point in relation to the quality of neonatal care and resources available, rather than adhering to a historical cut-off value that has not been studied in depth.

Do men have a higher case fatality rate of severe acute respiratory syndrome than women do?

Severe acute respiratory syndrome (SARS) has been reported in 30 countries and regions, with a cumulative total of 8,099 probable cases and 774 deaths as of July 31, 2003, according to the World Health Organization. In Hong Kong, People's Republic of China, 1,755 SARS cases and 299 deaths had occurred as of September 22, 2003. The authors analyzed data from the Department of Health, Hong Kong SAR. The data series includes details regarding sex, age, and chronic disease history. Using data from early March to September 22, 2003, the authors found that males had a significantly (p < 0.0001) higher case fatality rate than females did, 21.9% versus 13.2%; the relative risk was 1.66 (95% confidence interval (CI): 1.35, 2.05), and it was 1.62 (95% CI: 1.21, 2.16) after adjustment for age. Subgroup analysis was conducted by excluding health care workers (n = 386) from the analysis. The overall crude relative risk of mortality was 1.41 (95% CI: 1.15, 1.74), and the adjusted relative risk was 1.48 (95% CI: 1.10, 2.00). Thus, among SARS patients, males may be more severely affected by the disease than females are. This finding could be related to a nonuniform case definition of SARS disease, a different treatment regimen, a past smoking history, work-environment factors, or gender-specific immune-defense factors, for instance.

[Longitudinal study on the age at childhood onset in children from Shanghai and its effects on child growth].

OBJECTIVE: The infancy-childhood-puberty (ICP) growth model divides human growth into three additive and partly superimposed phases: infancy, childhood, and puberty reflecting the endocrinology of the growth process. The childhood phase of the ICP model has been assumed to start during the second half-year of life and slowly decelerates, although it continues into puberty until growth ceases. This phase has been taken to mirror the effect of growth hormone (GH). The age at onset of the phase of growth, normally occurring between 6 and 12 months of age is recognized to be an important time event at postnatal human growth. The aims of this study were to study the age at childhood onset in Shanghai children and its effect on child growth, and to compare these results with the results obtained from Swedish longitudinal studies. METHODS: The study population consisted of 1 720 children born between January 1, 1980, and December 31, 1990 in Fenglin Community, Shanghai, who got a continual monitoring at the clinic from birth to six years of age. The age at onset of the 'childhood phase' of growth was determined individually, in units of one month, by visual inspection of the data contained within the individual, computer-generated, ICP-based growth chart for both length and length velocity. T tests, chi(2) tests and multiple linear regression analyses were used in data analysis. RESULTS: There was a significant (P < 0.05) difference in the distribution of the age at onset of the childhood phase of growth between Shanghai and Swedish populations. The mean age of the infants at onset of the 'childhood phase' of growth was 11.2 months in boys and 10.7 months in girls. Compared to their Swedish counterparts, these means occurred 1.3 months later in boys and 1.4 months later in girls. Both age at onset of the 'childhood phase' of growth and length at six months of age significantly (P < 0.05) contributed to the attained height from 12 months of age onward; one month delay in the onset of the 'childhood phase' of growth reduced height, at 5 years of age, by 0.4 cm in boys and 0.56 cm in girls. The mean values of length/height among the four groups of the age of the childhood onset, i.e. 6 m-, 9 m-, 12 m-, >/= 15 m, were found to be significantly (P < 0.05) different from 12 month of age onward. However, a significant (P < 0.05) difference in the mean length/height velocities among the four groups was in principle only found during the following intervals: 3 - 6, 6 - 9, 9 - 12, and 12 - 18 months of age. The mean values of BMI among the four groups of the age of the childhood onset showed significantly (P < 0.05) different only in 9 and 12 months of age. The mean values of BMI velocity among the four groups of the age of the childhood onset were found to be significantly (P < 0.05) different in four age intervals: 3 - 6, 6 - 9, 9 - 12, and 12 - 18 months of age. The age at onset of the 'childhood phase' of growth was negatively associated (P < 0.05) with mid-parental height, though positively related (P < 0.05) to height at six months of age. A simple linear regression was applied to the age at onset of the 'childhood phase' of growth and mid-parental height. It was found that the age at onset of the childhood phase' of growth was 1.5 months later in boys and 1.3 months later in girls, for children with a mid-parent height being -2SD below the mean in comparison to the children of tall parents, i.e. a mid-parental height equals to mean +2SD. CONCLUSIONS: The age at childhood onset is equally important when studying children from Shanghai, as it is with their Swedish counterparts.

Reference values for change in body mass index from birth to 18 years of age.

UNLABELLED: Body mass index (BMI) has become the measure of choice for determination of nutritional status during the paediatric years, as in adults. Recently, several cross-sectional BMI childhood reference values standards have been published. In order precisely to evaluate childhood nutritional interventions, reference values allowing for the evaluation of changes in BMI values are also needed. For the first time, such reference values can be presented based on 3650 longitudinally followed healthy Swedish children born full term. The reference values for the change in BMI are given as the change in BMI standard deviation scores. The reference values are given as means of mathematical functions adjusting for gender, age of the child and the length of the interval between two measurements for interval lengths of 0.25 to 1.0 y before 2 y of age and of 1 to 5 y between birth and 18 y. The usefulness of the reference values is proved by a graph that forms a part of a clinical computer program; the -2 to +2 standard deviation range of the predicted change in BMI can be computed for an individual child and drawn in the graph as an extended support for clinical decision-making. CONCLUSION: For the first time this communication gives access to BMI growth rate values that can be used both in research and in the clinic to evaluate various interventions, be they nutritional, surgical or therapeutic.

Birthweight distribution in southern Chinese infants with symptomatic congenital heart disease.

OBJECTIVE: Western infants with congenital heart disease have frequently been reported to have a low birthweight for gestational age. Studies in Asian infants seem to be lacking in this area. This is the first extensive study presenting the birthweight distribution of Chinese newborns with symptomatic congenital heart disease. METHODS: The birth data of 454, mainly southern-Chinese infants with symptomatic cardiovascular defects, born between 1990 and 1995 and admitted to Grantham Hospital, Hong Kong in 1994 and 1995, were analysed retrospectively. Infants with (non)-genetic syndromes or other major extracardiac malformations were excluded. RESULTS: Fifteen per cent of all newborns had a birthweight below the reference mean of - 2 Z-score. After correction for length of gestation, no significant difference could be detected in birthweight between the cyanotic and acyanotic groups, nor between the different haemodynamic disturbances. Infants with atrial or ventricular septal defects, tetralogy of Fallot, pulmonary atresia with ventricular septal defect, heart with univentricular atrio-ventricular connection or double outlet right ventricle showed significant birthweight deficits. Transposition of the great arteries was not related to being small for gestational age. CONCLUSIONS: Similar to Western infants, prenatal growth impairment was a common feature in Chinese infants with symptomatic congenital heart disease. The birthweight distribution in Chinese might be comparable to that in Western populations. Exceptions are possibly the high frequency of low birthweight in Chinese newborns with atrial septal defect or a single-ventricle abnormality. Further studies on fetal anthropometry and haemodynamics are necessary to provide insight into the relation between cardiovascular malformations and being small for gestational age.

Benn Index at birth is associated with postnatal linear growth.

While previous research has suggested that body thinness is related to subsequent linear growth in children, it is unclear whether thinness at birth is related to linear growth in newborns and catch-up growth in small-forgestational age newborns. Drawing on data from a longitudinal growth study of 3,650 full-term Swedish babies, this study examines linear growth from birth to 6 months of age in three groups of newborns with short (< -2 SDS), appropriate (-2 to 2 SDS) and long (> 2 SDS) body length for gestational age. Among infants short at birth, the Benn Index (kg/m2.69) at birth was not related to the odds of short stature (< -2 SDS) at age 6 months (odds ratio = 1.03; p > 0.10). Nonetheless, the Benn Index was positively related to growth velocity in the first 6 months of life in the short (p = 0.060), appropriate (p < 0.05), and tall (p < 0.05) for gestational age newborns. Use of the Ponderal Index (kg/m3) would give similar results. The findings suggest that nutritional status at birth is related to linear growth velocity in newborns.

Association between psychological symptoms in adults and growth in early life: longitudinal follow up study.

OBJECTIVES: To test the hypothesis that birth weight for gestational age and weight gain in early childhood have a long term association with psychological distress in adults. DESIGN: Longitudinal study of 1958 birth cohort followed to age 42 years. SETTING: Population based birth cohort study. PARTICIPANTS: 9731 cohort members with valid perinatal, postnatal, and adult data. MAIN OUTCOME MEASURES: Malaise inventory scores measured at ages 23, 33, and 42 years. Generalised estimating equations approach used to analyse repeated measures. RESULTS: Psychological distress score was inversely related to birthweight z score and weight gain from birth to the age of 7 years. A unit increase in birthweight z score or childhood weight gain was associated with a mean reduction in psychological distress score of 0.10 (95% confidence interval 0.05 to 0.15) and 0.06 (0.02 to 0.10), respectively. Birth weight and weight gain were also inversely related to the odds of having a high level of psychological distress, with odds ratios being 0.90 (0.85 to 0.95) and 0.93 (0.89 to 0.98), respectively. CONCLUSIONS: Psychological health in adults is related to fetal growth and growth in early childhood.

Swedish population-based longitudinal reference values from birth to 18 years of age for height, weight and head circumference.

UNLABELLED: This study aimed to update growth reference values for height, weight and head circumference in order to reflect the changes in body size in the Swedish population during the past two decades. The data came from a large longitudinal growth study on 3650 full-term healthy Swedish children who were born between 1973 and 1975. All of these 1801 girls and 1849 boys had longitudinal data for height and weight from birth to final height. Comparison with previous Swedish growth reference values based on children born between 1955 and 1958 revealed that there have been secular changes in body size. For instance, at 18 y of age, the updated height and weight reference values are 180.4 cm for males and 167.7 cm for females, i.e. 1.9 cm taller and 5.7 kg heavier for males and 2.3 cm taller and 3.4 kg heavier for females compared with the previous reference values. CONCLUSION: These new growth reference values provide current national standards for growth monitoring and evaluation since the year 2000.

Size at birth and neonatal and postneonatal mortality.

UNLABELLED: Birthweight is a crude indicator of size at birth. Some neonatologists and obstetricians have advocated the use of ponderal index and birthlength to characterize size at birth. This paper examines the associations between various size-at-birth indicators and neonatal and postneonatal mortality, with an emphasis on ponderal index and birthlength. Size at birth, gestational age and mortality data for about one million babies born alive in Sweden between 1987 and 1995 were collected from the Swedish Medical Birth Registry. A multinomial logit regression was used to estimate conditional odds ratios. Birthlength and ponderal index were independently associated with neonatal and postneonatal mortality. In the latter period, ponderal index was only weakly associated with mortality. The associations were not sensitive to exclusion of cases of congenital anomalies and adjustment for gestational age. CONCLUSION: Birthlength is strongly associated with both neonatal and postneonatal mortality; ponderal index is strongly associated with neonatal, but weakly with postneonatal mortality. The findings are consistent with previous hypotheses about a transient effect of ponderal index and a persistent effect of birthlength.

Onset of significant GH dependence of serum IGF-I and IGF-binding protein 3 concentrations in early life.

Forty-eight normal full-term Chinese babies (25 boys and 23 girls) were followed up every 2 mo in the first year and every 3 mo during the second year of life for anthropometric measurements. Blood samples were taken at birth and at 6, 10, 12, and 18 mo after birth for serum GH-binding protein, IGF-I, and IGF-binding protein 3 analysis. Onset of the childhood phase of growth in the infants was determined from the growth data plotted on Infancy-Childhood-Puberty growth charts. The serum GH-binding protein concentrations were low in cord blood but rose significantly at 6 mo, with slower rises in late infancy and early childhood. However, a significant rise in serum IGF-I and IGF-binding protein 3 levels was only observed from 10 mo of life onward. The change in IGF-I between birth and 6 mo was significantly correlated with length gain (r(2) = 0.35, p < 0.05) and body mass index gain (r(2) = 0.41, p < 0.01) during the same period. The 34 infants with onset of childhood phase of growth between 6 and 10 mo had a higher mean serum IGF-I value at 10 mo (8.8 +/- 5.8 nM versus 4.9 +/- 3.1 nM; p < 0.05) and higher length velocity between 10 and 12 mo (16.3 +/- 4.7 cm/y versus 8.8 +/- 4.3 cm/y; p < 0.001) compared with the 14 infants with a later onset after 10 mo of age. A significant correlation between a change in serum IGF-I and IGF-binding protein 3 levels was observed during the three 6-mo periods between birth and 18 mo, but a significant correlation between a change in serum GH-binding protein and a change in serum IGF-I or IGF-binding protein 3 levels was only seen between 12 and 18 mo of age. The multiple regression analysis (r(2) = 0.43, p = 0.0002) revealed that the change in serum GH-binding protein and IGF-I concentrations between 6 and 12 mo of age and the age of onset of childhood phase of growth could explain 43% of the length gain between 6 and 12 mo of age in our babies. The results of our study support the hypothesis that the onset of the childhood phase of growth is associated with the onset of significant GH action on growth.

Timing of birth and infant and early neonatal mortality in Sweden 1973-95: longitudinal birth register study.

OBJECTIVE: To assess the impact of time of birth on infant mortality and early neonatal mortality in full term and preterm births. DESIGN: Analysis of data from the Swedish birth register, 1973-95. PARTICIPANTS: 2 102 324 spontaneous live births of infants without congenital malformation. OUTCOME MEASUREMENTS: Absolute and relative risk of infant mortality, early neonatal mortality, and early neonatal mortality related to asphyxia. RESULTS: Infant mortality, early neonatal mortality, and early neonatal mortality related to asphyxia were higher in infants who were born during the night (9 pm to 9 am) compared with those born during the day for 1973-9, 1980-9, and 1990-5. The difference was more dramatic for preterm infants. The largest difference was observed during 1990-5, when there was a 30% increase in early neonatal mortality (relative risk 1.31, 95% confidence interval 1.10 to 1.57) and a 70% increase in early neonatal mortality related to asphyxia (1.70, 1.22 to 2.38) in preterm infants born during the night compared with rates for preterm infants born during the day. A detailed analysis over 24 hours revealed two "high risk" periods: between 5 pm and 1 am and around 9 am. CONCLUSIONS: Infants born during the night have a greater risk of infant and early neonatal mortality and early neonatal mortality related to asphyxia than those born during the day. There has been no improvement over the past two decades. The problem is more serious for preterm births and was even worse in the 1990s. Shift changes and the hours immediately after such changes are high risk periods for neonatal care.

Modelling variation of lower leg length growth in early life.

We consider the estimation of sources of variation for panel data with repeated measurements. With no repeated measurements and known measurement error, models for variation decomposition have been proposed when there are one or more types of measurements. Estimation was performed using the EM algorithm accompanied by model augmentation that demands more computational efforts. In this article we extend previous variation models and modify the estimation methods in order to estimate various variation components after eliminating the unknown effects of measurement error. Specifically, methods that dispense with model augmentation and estimation of time-dependent covariates are considered. A set of lower leg length data from Chinese infants is analysed by using the proposed model. Interestingly, our results are consistent with the well-accepted three-phase (infancy-childhood-puberty) growth transition proposition for human growth. Moreover, gender effect is found to be time-varying.

Parametric modelling of neonatal mortality in relation to size at birth.

We use a richly parameterized model to analyse the effects of shortness and thinness at birth on neonatal mortality in Swedish live-born singletons. The model captures the hazard of neonatal mortality according to the function alpha x exp(-gamma x t) + delta, where t represents age. Covariates are allowed to simultaneously influence the initial excess hazard, the rate of decay, and the long-term hazard. Among term newborns, birth length for gestational age had a stronger effect on the long-term hazard and a weaker effect on the initial excess hazard than the Ponderal index. The initial excess hazard associated with a low Ponderal index tended to decay quickly. Among preterm newborns, a higher birth length for gestational age was associated with lower initial and long-term hazards, and with a faster rate of decay of the initial excess hazard. In contrast, the Ponderal index was not associated with the long-term hazard. We discuss the interpretability of the model and its potential use in neonatology and medical demography. We also compare the model to a Cox model with time-dependent covariates.

Seasonality of growth in Shanghai infants (n=4128) born in 11 consecutive years.

OBJECTIVE: To describe the seasonal growth patterns in Shanghai infants, to explore seasonal time lag between weight gain and length gain, and to investigate the long-term effect of birth season on early postnatal growth. DESIGN: Community-based longitudinal study. SETTING: Shanghai, People's Republic of China. METHOD: Children were followed up monthly from 1 to 6 months, 3 monthly from 6 to 12 months, and 6 monthly from 12 to 24 months. SUBJECTS: A total of 6018 children born between 1 January 1980 and 31 December 1990. MAIN OUTCOME MEASURES: Weight gain, length gain and change in body mass index (BMI) over the seasons of the year. RESULTS: The infants tended to grow faster in height in spring and summer, and faster in weight and BMI in autumn and winter. The seasonal effect on weight gain and length gain is largely independent. The mean length value at 1 month of age was about 2.0 cm higher in infants born in May to July than in those born in November to February. At 24 months of age this difference was reduced to about 0.7 cm. CONCLUSIONS: There is a clear and consistent seasonality in growth in Shanghai infants. The seasonality seems to act independently on weight and length. Birth month has some association with attained size, but this is reduced during the first 2 y of life.

Critical growth phases for adult shortness in Hong Kong Chinese.

OBJECTIVES: This study was designed to explore whether the influence of subnormal growth in fetal, infancy, childhood and pubertal phases on adult short stature was the same when comparing privileged and underprivileged populations. METHODS: Data came from two longitudinal growth studies: 1) Hong Kong Chinese children who were born in 1967 (n = 132), and 2) the comparatively more privileged Swedish children who were born in 1973-1975 (n = 2,850). RESULTS: 68% of Hong Kong Chinese children had two or more growth phases subnormal, much higher than the 12.4% for Swedish children. 42.4% of Hong Kong Chinese were short at final height, much higher than the 2.2% for Swedish children. Subnormal growth in any growth phase was associated with an increased risk of adult short stature in both series (p<0.01). After adjustment for mid-parental height, the place of residence (Hong Kong/Sweden) was not significant for adult shortness (p>0.05) in the pooled data. CONCLUSIONS: The impact of subnormal growth in any phase on adult shortness is similar in privileged and underprivileged populations. The much higher prevalence of subnormal growth and consequently adult short stature in developing countries is likely mainly attributable to adverse extrinsic or environmental influences.

Fetal growth, early postnatal growth and motor development in Pakistani infants.

BACKGROUND: Studies have often compared the postnatal motor development of 'small' versus 'normal' newborns. Not much is known about the associations between a broad spectrum of size at birth and motor development. The effect of early postnatal growth on motor development is little researched. Growth failure in terms of shortness and thinness should be differentiated, but not many studies have the data for this analysis. METHODS: This is a longitudinal study of infants born in Lahore, Pakistan, between 1984 and 1987. Age at commencement of independent walking and age at 'building a 3-cube tower' were taken as indicators of gross and fine motor development, respectively. Size at birth was captured by length and thinness as continuous variables; postnatal growth from birth to 6 months of age was measured by changes in length and thinness. Adjustment for covariates and handling of censored cases were performed by generalized log gamma regression. RESULTS: Thinness at birth and postnatal stunting and wasting had a linear, inverse association with gross motor development (each P < 0.05). Birth length had a non-linear, inverse association with this outcome (P < 0.05). Birth length, thinness at birth and postnatal wasting had a linear, inverse association with fine motor development (each P < 0.05). CONCLUSION: Both fetal and early postnatal growth over a broad spectrum may affect infants' motor development. It is not just the babies who were very small at birth that suffered. Birth length appeared to be more influential than other anthropometric indicators.