GROWTH MONITORING AND ASSESSMENT

6th Nationwide Anthropological Survey of Children and Adolescents 2001

Bláha P.*, Vignerová J.**

*Faculty of Science, Charles University, Prague

**National Institute of Public Health, Prague

Czech Republic

• Apart from genetic determinants, growth of an individual is to a great extent influenced by external factors (familly backround, socio-economics conditions of the society, health care system, social system etc.).

FENOTYP OF AN INDIVIDUAL =FENOTYP OF AN INDIVIDUAL = GENETIC FACTORS + ENVIRONMENTAL FACTORS +

INTERACTION BETWEEN GENETIC AND ENVIRONMENTAL FACTORS

FAMILYFAMILYENVIRONMENTENVIRONMENT

HEALTH,HEALTH,GROWTHGROWTH

SESSES

PHYSICALPHYSICALENVIRONMENTENVIRONMENT STRESSSTRESS

Flinn M.V., England B.G., American Journal of Physical Anthropology, 1997

Material I.

• 1895: Measurements of 100.000 school children - Czech physician and anthropologist Matiegka (Matiegka J., 1927, Somatology of school children. Nakl. ČSAV a umění, Praha.) – He founded tradition of Nationwide Anthropological Surveys.

• 1800-1809: Mean heights and s.d. in military boarding-school children born between 1800-1809 (in Bohemia and Moravia), recorded in Vienna (Komlos J: Patterns of children’s growth in East-central Europe in the eighteenth century. Annals of Human Biology, 1986, Volume 13, No. 1, pp. 33 - 48.)

Material I: NATIONWIDE ANTHROPOLOGICAL

SURVEYS IN CR

• Every ten years - 1951, 1961, 1971, 1981, 1991, 2001

• Number of children per survey:

80.000 – 100.000 (3 to 5 % of the population of given age)

• Age: 0 to 19 years

Praha

NATIONWIDE ANTHROPOLOGICAL SURVEYS IN CR (1951 to 2001)

• Preschool children: in clinics, by instructed health professionals, mainly paeditricians.

• School children: teachers, provided with detailed written instructions.

• Anthropological measurements: height, body weight, circumferences of the head, arm, waist and hip – Martin Saller method.

• Questionnaires for children: dietary habits, sports activity, TV watching and PC games.

• Questionnaires for parents: parental height, weight, educational level, number of children in the family, breastfeeding and health status of their child.

METHODS

• Original data available from : 1951, 1981, 1991 and 2001.

• For other surveys: sample sizes for each age group, average values and standard deviations are available, for 1895 only average values.

• We have used only these summary values for the growth curves construction.

• Weighted polynomial smoothing spline of 3rd order was used for construction of the growth curves of the height.

• Weights were proportional to sample sizes at the particular time point.

• Its first derivative was then computed to obtain growth velocity.

• 1951 – no data• Since 1975 no

changes• Boys: 50.5 cmBoys: 50.5 cm

3400 g3400 g• Girls: 49.7 cmGirls: 49.7 cm 3270 g3270 g

MEAN BIRTH LENGTH AND WEIGHT

The secular trend of height appears significant from the category of two years olds onwards.

SECULAR TREND OF HEIGHTGrowth curves

Boys

80

100

120

140

160

180

200

4 6 8 10 12 14 16 18Age years

cm

20011991198119711961195118951800-09

Girls

80

100

120

140

160

180

200

4 6 8 10 12 14 16 18Age years

cm

2001199119811971196119511895

-2

-1,5

-1

-0,5

0

0,5

1

1,5

2

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Age years

Z-score

195119711991WHO20011895

-2

-1,5

-1

-0,5

0

0,5

1

1,5

2

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Age years

Z-score

195119711991WHO20021895

BOYS GIRLS

Z-SCORE ACCORDING WHO REFERENCE VALUES

Height

Adult height: 1951 - 172.4 (s.d. 6.6)2001 - 180.4 (s.d. 7.0) dif. 8.0 cm

Adult height: 1951 - 161.0 (s.d. 5.6)2001 - 167.2 (s.d. 6.4) dif. 6.1 cm

• Growth in boys stopped at 21-22 years 100 years ago, nowadays at about 18 years.

• In girls growth stopps earlier, currently at about 17 years.

• 18 years old boys reach an average height of 180.1 cm (12 cm increase compared to 1895)

• 18 years old girls reach and average height of 167.2 cm (10 cm increase compared to1895).

6 8 10 12 14 16

34

56

7

boysgirls

11,15

Age years

13,327,16

7,87

cm • A comparison of a study from 90s with one from 70s shows shift of growth spurt towards younger age categories: 4 months4 months in girls and in girls and 3 months3 months in boysin boys

1975 1995

Girls 11.5 11.1

Boys 13.6 13.3

• The time shift between boys and girls in the onset of adolescent growth spurt is almost 2 years.

GROWTH VELOCITY OF THE HEIGHT(cm per year)

Longitudinal studies

00.10.20.30.40.50.60.70.80.9

1

10 11 12 13 14 15 16 17

Age years

Pro

bal

ity

Girls

Boys

Number: GIRLS: 12.837 BOYS: 9.645

Mean age of menarche:

(50 % YES, 50 % NO)1991: 13.00 years2001: 13.01 years

Mean age of voice-breaking:

1991: 14.50 years2001: 13.84 years

Corresponds with shifting of secular trend of height

AGE OF MENARCHE AND VOICE-BREAKING1991, 2001

Logistic regression

0.01 y.

0.66 y.

BOYS GIRLS

-2

-1,5

-1

-0,5

0

0,5

1

1,5

2

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Age years

Z-score

195119711991WHO20011895

-2

-1,5

-1

-0,5

0

0,5

1

1,5

2

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Age years

Z-score

195119711991WHO20011895

Z-SCORE ACCORDING WHO REFERENCE VALUES

Weight

0102030405060708090

100 110 120 130 140 150 160 170

cm

kg

97

75

50

25

3

BOYS

0102030405060708090

100 110 120 130 140 150 160 170

cm

kg

97

75

50

25

3

GIRLS

WEIGHT-HEIGHT RATIO Empirical percentile charts

1951, 2001

BMI EMPIRICAL CENTILE CHARTS1951, 1991

10

12

14

16

18

20

22

24

26

28

30

2 4 6 8 10 12 14 16 18

Age years

kg/m2

97.perc.

90.perc.

50.perc.

10.perc.

3perc.

1951-97 p.

1951-90 p.

1951-50 p.

1951-10 p.

1951-3 p.

10

12

14

16

18

20

22

24

26

28

30

2 4 6 8 10 12 14 16 18

Age years

kg/m2

97. perc.

90. perc.

50. perc.

10. perc.

3. perc.

1951-97 p.

1951-90 p.

1951-50 p.

1951-10 p.

1951-3 p.

BOYS GIRLS

BMI EMPIRICAL PERCENTILE CHARTS1951, 1991

Adiposity rebound: in 1951 - 1.5 year later

CONSTRUCTION OF BMI PERCENTILE CHARTS

• The number of overweight and obese children is increasing.

• Construction of charts based on current sample (2001) means shifting the cut-off values to higher positions (and thus soften the norm)Solution: Use the norms from 1991

CHLAPCI

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

2 4 6 8 10 12 14 16 18

Věk (roky)

kg/m2

97

50

25

10

3

90

Percentil

© Grant IGA MZ ČR NJ/6792-3/2001, SZÚ

Charts for: weight, weight for height, head circumference, waist circumference, arm circumference, skin fold thickness, etc.

Evaluation of weight in the percentile chart

Percentile range Evaluation

97 < obese

90 – 97 overweight

75 – 90 robust

25 – 75adequate

weight

10 – 25 slim

3 – 10low weight

< 3 thin1

3

5

7

9

11

13

0 1 2 3 4 5 6 7 8 9 10 11 12věk (měsíce)

kgHMOTNOST, dívky

Percentil

97

50

3

90

75

25

10

CUT-OFF VALUES FOR OVERWEIGHT AND OBESITY

• CR- 5th Nationwide Anthropol. Survey 1991 overweight BMI > 90. p., obesity BMI > 97 p.

• WHO 2007 Growth Reference forchildren (5-19 y.) overweight BMI > +2SD, obesity BMI > +3SD

• CDC 2000 - 5 surveys in USA (1963-1994) overweight BMI > 85. p., obesity BMI> 95. p.

• IOTF 2000 - 6 national representative studies (Brazil, Great Britain, Hong Kong, Netherlands, Singapur, USA) overweight in 18 years BMI = 25, obesity BMI = 30

BMI HIGHER THAN 2 and 3 SD - according to WHO standards 2006

Age 24 - 59 monthsFor gender and country (project HOPE)

4,4

4,7

4,2

4,1

5,7

8,6

7,5

8,2

10,4

12,2

1

1,3

2,2

2,9

2,6

1,5

2,2

3,3

4

4,4

3,7

3,3

5,7

6,0

5,9

5,7

9,8

5,5

10,2

9,6

1,4

1,8

2,1

5,0

4,1

3,0

2,5

5,5

3,9

8,8

25 20 15 10 5 0 5 10 15 20 25

Czech R., 2001

Cyprus, 2004

Romania, 2004

Netherlands 2002-06

Italy, 2005

Scotland, 2003

England, 2002

Poland, 2000

Greece, 2003-04

Spain, 2006

Males % Females

>2SD ≤3SD >3 SD >2SD ≤3SD >3 SD

A. Cattaneo, L. Monasta, E. Stamatakis, S. Lioret, K. Castetbon, F. Frenken, Y. Manios, G. Moschonis, S. Savva, A. Zaborskis, A. I. Rito, M. Nanu, J. Vignerová, M. Caroli, J. Ludvigsson, F. S. Koch, L. Serra-Majem, L. Szponar, F. van Lenthe and J. Brug: Overweight and obesity in infantsand pre-school children in the European Union: a review of xisting data. Obesity reviews. doi: 10.1111/j.1467-789X.2009.00639.

PERCENTAGE OF OVERWEIGHT AND OBESE CHILDREN

Reference data: WHO and IOTF recommendationsAge 7 – 11 years

0

5

10

15

20

25

30

35

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

%

USAEuropeCzech Rep.

Report of the International Obesity Task Force, 2004

PREVALENCE OF OVERWEIGHT ANF OBESITY IN 7 YEARS OLD BOYS 2008

COSI study (WHO 2007)

0%

20%

40%

60%

80%

100%

1951 1981 1991 2001 2008

Obezita

Nadváha

Normální

PREVALENCE OF OVERWEIGHT AND OBESITY IN 7 YEARS OLD GIRLS 2008,

COSI study (WHO 2007)

0%

20%

40%

60%

80%

100%

1951 1981 1991 2001 2008

Obezita

Nadváha

Normál

PERCENTAGE OF OVERWEIGHT AND OBESE CHILDREN

IOTF (Cole 2000) 5 – 17 years

International Obesity Task Force, 2004

32

19

1113

0

5

10

15

20

25

30

35

USA Europe Czech Rep. 1991 Czech Rep. 2001

%

CONCLUSION

• The development of physical characteristics, in particular height and weight of children and adolescents, is a sensitive indicator for socio-economic conditions in which the children grow up and mature.

• Throughout the period of the 20th century - in line with improvements in socio-economic conditions - the physical height was increasing in all age categories.

• A shift in onset and peak of the growth spurt occured towards lower age categories.

• The shift in growth spurt is linked with shift in the timing of onset of the sexual maturity.

• The proportion of children and adolescents with overweight and obesity is also increasing in CR, although to a lesser degree than in other developed countries.