1. Overweight or Obesity, Gender, and Age Influence on High School Students of the City of Toluca’s Physical Fitness. The stature was measured with a model 206 SECA® stadiometer, with their heels, buttocks, and back against the wall in relation to the Frankfort plane. A Harpenden® skinfold caliper was used for the measures, by duplicate.
2. Background and rationale The measurement of stature. The stadiometer produced by Holtain Ltd. Home of the Harpenden Skinfold Caliper. The Harpenden Skinfold Caliper is a precision instrument designed for use in the performance of skinfold thickness measurements. Harpenden Stadiometer Manual High School.

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High adherence rate promising strong data to elucidate the interaction between genomics and the. 24 months) by Harpenden stadiometer (Holtain Ltd. Cal School, 1990. 22 Wijnhoven TM, de Onis M, Onyango. Assessment of gross motor development in the WHO Multicentre. Growth Reference Study.

This is the old United Nations University website. Visit the new site atMuch of the following material is for the benefit of thoseplanning anthropometric surveys. Emphasis is on large-scale,cross-sectional surveys, and issues regarding the collection ofserial data on individual children are not discussed.Personnel Selection and TrainingThe personnel selected to be trained in anthropometry shouldread and write with ease and have good notions of arithmetic. Ifat all possible, one should aim for persons with some secondaryschool education. While some less-educated individuals mayperform adequately, measurement errors will be less of a problemwith, for example, high school graduates who can also be involvedwith quality control procedures.

On the other hand, more highlyeducated personnel (e.g., physicians) may find the task ofmaintaining constant measurement procedures boring and may forthis reason not be as reliable.Women are preferred, for it may not be proper in some culturesfor men to measure women, and children may be more relaxed ifexamined by women.To train anthropometrists, one obviously needs a person withexperience in measuring to demonstrate the proper techniques. Inaddition, a manual or handbook describing all procedures, ideallyincluding simple illustrations, should be available duringtraining.The period of training should last as long as it takes toachieve acceptable levels of reliability and accuracy.' Reliability' can be understood as the degree to whichthe measurer is able to reproduce measurements, while'accuracy' refers to the degree to which themeasurement approximates 'true' values.

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Habicht (13)has devised simple procedures for training personnel. (Theseprocedures are recommended by WHO in a manual for use indeveloping countries 191.) Typically, subjects are measured twiceby each student and by the supervisor. From these data, the errorvariance of each student is estimated and compared to that of thesupervisor to monitor reliability; and systematic differencesamong students and between each student and the supervisor areused to monitor accuracy. At specified levels of performance assuggested by Habicht, students are judged to be ready for datacollection.

The widespread availability of inexpensive electroniccalculators should make these simple computations even easier.Concern with measurement error should continue throughout theduration of the study and should involve three types ofexercises. At periodic intervals, the supervisor and theanthropometrists should meet to discuss problems encountered inthe field, to review measurement procedures, to calibrateinstruments and to repeat the initial training exercises in orderto monitor reliability and accuracy.

Secondly, replicate measuresby each anthropometrist should also be carried out under fieldconditions. The actual measurement process, particularly if theexamination only includes five measures as recommended in thischapter, takes very little time; it is getting to the subject orgetting the subject to come to the measurement centre which isgenerally time-consuming.

Thus it is highly recommended that eachsubject be measured twice by the anthropometrists. As suggestedin figure 3.2 (see FIG. Anthropometry Form),the first set of measurements should go on the front of the formand the second on the reverse side in order to maximize theindependence of each set of observations. If possible, other data(e.g. Clinical signs) could be collected in between each set ofvalues to further improve measurement independence. Doublemeasurements provide ongoing reliability estimates under fieldconditions and, as explained later in the quality controlsection, result in better data. Finally, the supervisor will needto visit periodically the various anthromometrists at theirworking sites.

On such occasions, the supervisor should alsomeasure a small number of subjects (i.e. Five subjects). At theend of the survey, a sufficient number of cases (i.e., 50subjects) would be available to determine accuracy under fieldconditions for each anthropometrists.Table 3.3. (see TABLE 3.3 Measurement ErrorStandard Deviation in an INCAP Longitudinal Study (PreschoolChildren)) shows measurement error data from an INCAPlongitudinal study for the five variables recommended in thischapter.

Error estimates derived from standardization exercisesare, as expected, less than those encountered under fieldconditions. Comparisons of the field measurement error varianceto the population variance for each variable shows that the fivemeasures chosen have high reliability. The error variance forother measurements such as chest circumference, for example,represents over 50 per cent of the population variance. FRONT SIDEIdentificationCard numberSubject numberSexFamily or householdnumberFamily status: father,mother, second child, etc.Location: village, area, etcBirth date: day, month, yearExam date: day, month, yearFirst set of measurementsLength (cm)-Weight (kg)-Arm circumference (cm)-Triceps (mm)-Subscapular (mm)-REVERSE SIDESecond set of measurementsLength (cm)Weight (kg)-Arm circumference (cm)-Triceps (mm)-Subscapular (mm)-FIG.

Anthropometry FormTABLE 3.3 Measurement Error Standard Deviation in anINCAP Longitudinal Study (Preschool Children) MeasureStandardizationexercisesField conditionreplicates (one week apart)Field error varianceas per cent of population varianceTotal body length0 34 cm0.42 cm1. 1%Weight0 02 kg0 29 kg5 6%Arm circumference018 cm0.24 cm5.8%Triceps skinfold047 mm0.59 mm12.8%Subscapular0.27 mm031 mm7.3%The measurement error standard deviation was estimated by S (a - b)²1/2 / 2n where a and b are firstand second observations, respectively, and n is the number ofsubjects measured.Source: Martorell et.

(14)Measurement TechniquesThe most widely-accepted techniques of measurement are thoseproposed by the International Biological Programme (10, pp.8-12), as follows:1. Stature (measured with astadiometer or anthropometer; used for children two years old orolder). The subject should stand on a platform with his heelstogether, stretching upward to the fullest extent, aided bygentle traction by the measurer on the mastoid processes. Thesubject's back should be as straight as possible, which may beachieved by rounding or relaxing the shoulders and manipulatingthe posture.

The marked Frankfort plane must be horizontal.Either the horizontal arm of an anthropometer, or acounter-weighted board, is brought down on the subject's head. Ifan anthropometer is used, one measurer should hold the instrumentvertical with the horizontal arm in contact with the subject'shead, while another applies the gentle traction. The subject'sheels must be watched to make sure they do not leave the ground.2. Supine length (measured with aninfant measuring table; used for children younger than two yearsof age). With the infant lying supine, one measurer holds theinfant's head in the Frankfort plane and applies gentle tractionto bring the top of his head into contact with the fixedheadboard.

A second measurer holds the infant's feet, toespointing directly upward, and also applying gentle traction.brings the movable footboard to rest firmly against the infant'sheels.3. Upper arm circumference (measuredwith a tape). The subject's arm hangs relaxed, just away from hisside, and the circumference is taken horizontally at the markedlevel. (The horizontal mark on the left arm is measured half waybetween the inferior border of the acromion process and the tipof the olecranon process.)4. Skinfold thick-nesses (measuredwith skinfold caliper). The skinfold is picked up between thumband forefinger and the caliper jaws applied at exactly the levelmarked. The measurement is read two seconds after the fullpressure of the caliper jaws is applied to the skinfold; if alonger interval is allowed the jaws may 'creep' and thereading will be inaccurate.

Two measurements are used:- Over triceps. The skinfold is picked up at theback of the arm about 1 cm above the level marked on the skinfor the arm circumference and directly in line with the pointof the elbow, or olecranon process.- Subscapular. The skinfold is picked up under theangle of the left scapula. The fold should be vertical, orpointing slightly downwards and outwards.5. Weight (measured with a scale).Weighing should preferably be done with the subject in the nudeor clothed only in lightweight shorts (which may be provided bythe investigator). In the latter circumstance the measurement canbe corrected accordingly by adjusting the machine to read zerowhen a sample garment is placed on it.

In all othercircumstances, including when trousers are worn, the weight of arepresentative garment should be entered on the form, forsubtraction later. The presence of visible oedema should berecorded.Knowing the correct age is essential for interpretinganthropometric data. In its absence, for example, indicators ofstunting cannot be generated. Age data are easy to obtain whenrecords are available, or when mothers recall birth datesreliably. In such cases, the date of birth and the date ofexamination should be recorded; hasty calculations of age in thefield should be avoided.It would be a serious mistake to exclude systematically allchildren of unconfirmed ages, as they most likely will be inpoorer nutritional status. However, the problem of estimating agein such cases is a difficult one. Some options are available ifthe child is yew, young, as Jelliffe notes:Sometimes, the mother may not know the child's age, butmay be able to recite the month of birth, and occasionallythe day as well.

If this is so, the mother will often recalldetails of the youngest child only, not those of oldersiblings. (16)The examiner in the above situations can estimate the year ofbirth confidently if the child is an infant or toddler.The use of dental eruption data as an aid in estimating age inthe first two years of life has also been proposed. However,there is considerable variability in eruption times and normativedata are not available for many groups.Estimating the age of children older than two years is thedifficult aspect of the problem. Jelliffe offers some advice:Often the only practicable method may be to construct alocally relevant calendar.

Based on events in the precedingyears, including agricultural, climatic and politicaloccurrences, as well as natural or man-made disasters. However,such a calendar takes weeks to prepare and pre-test in the field,while its use in survey circumstances is laborious,time-consuming, and least satisfactory with the unsophisticatedcommunities for which it is intended. Calendars will plainly haveto be specific for different communities. (16)All other data should be collected even when age provesimpossible to estimate. Assessments of wasting, as noted earlier,do not require that age be known.EquipmentThe Ninth Handbook of the International Biological. Programme(15) as well as Zerfas (17) discuss the selection of equipmentand list the addresses of some instrument distributors.The lightest and least expensive piece of equipment will bethe tape needed for measuring arm circumference. Cloth and papertapes are not recommended because they wear out and stretcheasily.

Fiberglass or steel tapes are preferable.A number of calipers are available for measuring fat folds.The two most widely used are the Lange (US made) and theHarpenden (British-made) models, either of which is suitable.These two calipers possess rectangular jaws and exert a constantpressure of 10 gm/mm2 Prices range between US $150 and US $200for most calipers.The measurement of weight, height, and supine length presentsspecial problems. If subjects are to be measured in their homes,the equipment chosen should be light and sturdy. Where subjectsare asked to come to a central station or designated location,the bulk and weight of the equipment is of less concern. The mostwidely used scales suitable for fixed locations are the Detectobaby (up to 16 kg) and adult (up to 140 kg) scales (beambalance).

Suitable for use in house-to-house surveys is theBritish-made Salter scale (spring scale; up to 25 or 50 kg),which can be hung from a tree branch or a house beam. This scalehas been used successfully in surveys such as those conducted bythe US Center for Disease Control (CDC) in El Salvador.Currently, the portable weighingmodel 235 sells for £21. Field-worthy but heavier scales (i.e.,19 pounds) are available for measuring adults (15). Commonbathroom scales are not reliable and are not recommended forweighing infants and young children, though they are suitable forcross-sectional surveys in adults.Precise, sturdy instruments formeasuring stature in fixed locales include the HarpendenStadiometer (US $694 per unit). This instrument is impractical(100 pounds in weight) for the type of survey research that isgenerally carried out in developing countries. Some weightscales, such as the Detecto scales, have built-in stadiometers;but again, they are not suitable for house-to-house surveys Aportable stadiometer, suitable for house-to-house surveys, isavailable in the Harpenden line of instruments (Harpenden PocketStadiometer.

Model 98-605, $46). Where reasonably straight wallsare found in homes, a scale (e.g.

Fibre-glass tape) can be tapedto the wall, and, with the use of a flat board to press againstthe top of the head after positioning the individual correctly,height can be measured with surprising accuracy.Length in children can be easilymeasured with portable boards, usually made out of wood.Inexpensive models have been developed by UCLA and the CDC (17),WHO (9). And by INCAP; they can easily be replicated by localcarpenters. Infants' boards have a fixed vertical end againstwhich the child's head is positioned and a movable end which ispositioned against the soles of the feet. A fiberglass tape isattached along the flat board.

Sturdy infant measuring tables arealso available commercially; these are, however, more expensive,very bulky and more appropriate for fixed locales. For example,the Harpenden infant measuring table weights 20 pounds and costsUS $658.

Perspective Enterprises (7466 Thrasher Lane, Kalamazoo,Michigan) has, however, developed a lighter (8 pounds) measuringboard for around US $70.Quality ControlAll data collection activitiesshould be monitored by a supervisor. He or she should meetperiodically with the anthropometrists to reread the manuals andto review the measuring techniques; periodic visits to the fledare also recommended.Data flow charts need to beprepared.

Forms must be inspected shortly after collection tomake sure all information is recorded properly. A record of namesand dates or measurements should be kept at the field site, andthe number of forms sent periodically to the central offices fordata-processing should be counted and recorded. After the dataare punched, the original forms should be filed for safekeeping.The punched data should be analysed as soon as possible tomonitor reliability (from duplicate measurements) and to scan foroutliers. A recent book edited by Jelliffe and Jelliffe (18)contains articles by Garn, Zerfas, and Nichaman. These threearticles outline the most common types of errors that lead tooutliers.In scanning for outliers, valuescan be checked against the appropriate age-sex groupdistribution.

For example, a value may be labelled as an outlierif it is more than two or three standard deviations above orbelow the mean. In addition, if two measurements are obtained, asrecommended in this chapter, the differences between pairedvalues can be compared to the measuring standard deviation.Values that differ by three times or more from the measuringstandard deviation would be suspect. Ideally, one shouldremeasure the subjects whose values are questionable. Where thisis not feasible, suspect values should be divided into those thatare clearly impossible and those that are unlikely but plausible.The former should be deleted from the data files. Decisions as towhat to do with unusual but plausible information are alwaysdifficult and arbitrary.

If the quality of data is high, only asmall percent of values (i.e., less than 1 per cent) may beinvolved, and little information will be lost if these values aredeleted. Another strategy is to code suspect but plausibleinformation so as to investigate its effect on key data analyses.Whatever is done, criteria and procedures should be specified andmade available to those using the information.A final note on quality control:To some, the supervision and quality control procedures suggestedhere may appear excessive and time consuming. They are certainlynot.

One impact of quality control procedures is that they fostera careful attitude on the part of field workers. To see 'allthis fuss' devoted to numbers (which may be largelymeaningless to them) develops a sense of pride andresponsibility. Otherwise, workers come to believe one isinterested primarily in numbers, quality not being an issue.The design presented in table3.1. Does not necessarily require the use of a norm or referenceagainst which to compare the data collected. However, there isalways the need to quantify the severity of nutritional problemsand/or ascertain the pace of progress in nutritional status in arelative sense; for these purposes, norms become necessary.The question as to whether growthdata on children of European origin from developed nations areappropriate as norms for developing countries has been heatedlydebated (19; 20; 21). A seemingly obvious solution would be fordata on the well-nourished of each country, or even better foreach ethnic group within a country, to serve as the norm fortheir ethnically appropriate group.

This suggestion is not alwayspractical because high quality data on sufficient numbers of thewell-nourished do not yet exist for all ethnic groups. Moreover,some ethnic groups in some countries are so overwhelmingly poorand malnourished that a 'well-nourished' group may noteven exist.

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What is more interesting is that when data fromwell-nourished, preschool children of diverse ethnic groups arecompared to the European norms, differences are usually rathersmall, particularly when viewed against the yew, largedifferences between the poor and the well-nourished in eachethnic group (19; 21). It would appear therefore, that growthdata derived from European populations are justified as'norms' for developing countries - that is, as roughapproximations and not as targets. (Appropriate to this point arethe remarks of Waterlow et al. 491 ) who in proposingNCHS data as norms for developing countries state: 'If it isfelt that in a particular population even well-nourished childrenare shorter in stature than children of the North Americanreference population, then it might be reasonable to set thetarget for height as 95 per cent of the reference height ratherthan 100 per cent. Decisions of this kind have to be takenlocally, and it is not possible to make internationalrecommendations about them.' ) Finally, the use of a similarnorm by workers in developing countries facilitates thecomparison of published results.The National Center for HealthStatistics (NCHS) has prepared new percentile charts forassessing the growth of children in the United States (23).

Thesedata have been recommended as the norms to use worldwide by ateam of leading scientists from Europe, the United States, andthe World Health Organization (22). Their proposal is likely togain wide acceptance among researchers.The adoption of the NCHS normswill not lead to very different estimates of the magnitude ofmalnutrition.

The cut-off point of 75 per cent weight for age hasbeen used to identify children with second-and third-degreemalnutrition (i.e.