Heights of Populations - An Index of Their Nutrition and Socio-Economic Development
Item
- Title
- Heights of Populations - An Index of Their Nutrition and Socio-Economic Development
- Creator
- C Gopalan
- Date
- 1988
- extracted text
-
XIV ANNUAL MEET OF MFC
Background Paper-Ill
HEIGHTS OF POPULATIONS - AN INDEX OF THE1K
NUTRITION AND SOCIO-ECONOMIC DEVELOPMENT.
********************************************
C. Gopalan.
The conventional indices employed by economists and
planners to assess the state of development of a country do not
generally include any index which directly reflects the qqality
of its human resources. Purely economic indicators of national
development such as GNP may, perhaps, suffice in the case of
developed countries of Europe and North America where populati
ons have already attained near-maximal levels of health and .'.-'
nutrition. The major objective of the planning process in the
case of such developed countries, at present, is a further
increase in their economic prosperity, which has already reached
levels more than adequate to meet all their basic human
physiological needs. In the case of less fortunate developing ..
countries like India, however, the primary and major objective
of national planning and 'development* is (or, at least, should
be) the removal of prevailing constraints posed by poverty,
ill-health and undernutrition on human growth and (human). ■
development, and, consequently, on the full expression of the
genetic endowment of the population. Under the circumstances,
it will be appropriate and necessary that the success (or
otherwise) of the planning process in these countries is
assessed by yardsticks which provide a direct measure of its
impact on levels of human growth and human development.
■V.
Reductions in infant mortality rate and increase in
life expectancy - yardsticks generally used to measure plan
achievements - no doubt, do provide a measure of the overall
improviement in health status. However, important and useful
as these indicators are, they are no more than indices of the
"state of survival" of a population. They do not tell us much
about the state of health, nutrition and well-being of the
survivors. What we need for this purpose is a measurement simple, feasible and capable of application on a national
scale, which will provide an indication of the status of the
survivors and of the impact of national developmental
programmes thereon.
....2...
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2
■■
It is in this context that the merits of a continuing
programme of, annual measurements of heights of sufficiently
large and representative population groups across the country
deserve consideration.
-Height measurements have a special place as an index of
socio-economic^development in developing societies'in which
populations have yet to find full expression to their genetic
potential for growth. Quantification of height deficits in
such populations (through comparison of their actual height
with potential height could provide a measure of the degree
of their underdevelopment. Cross-sectional studies among
different segments of the society could indicate differences
in their degrees of underdevelopment. Serial sti dies could
(
provide indications of secular trends and of the''nutritional imp
act of development.
Practical considerations? The facile assumption often
made that "stunting" can be ignored if the subjects happen to
have "appropriate weights for heights" has now been shown
to be unwarranted.
Tanner (Social science History, Vol. 6. 571-581, 1982)
in his remarkable paper on 'The potential of auxoloqical data
for monitoring economic and social well-being1 has provided
a fascinating historical account which highlights the great
value of height measurement as an instrument for monitoring
progress with respect to the state of health, nutrition and
well-being of communities. Steckel (Historical Methods,
16.1.1983) found a close correlation between height and per
capita, income in a study based on there suit of 56 height
studies and per capita income estimates for 20 countries.
When it is recognised that "socio economic" factors and per
capita income could affect height only by mediating changes
in nutritional iraputs, the Importance of height as a
measure ?f nutritional status of a community will. becom ;
obvious.
BIOLOGICAL SIGNIFICANCE OF HEIGHT xIEASbJlEHnjil'S; Why
are height measurements important? We will now brief;y r-jrw
some available evidence relevant to this question.
- 3 Tanner quotes Villerme who wrote as long ago as 1828
that: "Human height becomes greater and growth takes place
more rapidly, other things beingequal in proportion as the
country is richer, comfort more general, houses, clothes
and nourishment better, and labour, fatigue and privations
during infancy and youth less; in other words, circumstances
which accompany poverty delay the age at which complete stature
is reached and stunt adult height."
In Japan, between 1957 and 1977, average mature height
increased by ^.3 cm in males and 2.7 cm in females; age ;at
maximum increment dropped by 0.97 years in males and 0.53
years in females. Practically all the height increase was
due to increase in leglength, not in sitting height, with
the result that within 20 years of economic advancement, the
entire body proportions of the Japanese had changed. This
is perhaps the most striking and spectacular evidence of the
importance of height measurements as an index of the nutrit
ional status of a population which parallels economic
advancement; and shows that height measurement is an indicator
of as much importance to the developmental economist and
planner as it is the health/nutrition scientist.
There is a large body of evidence pointing to a relation
ship between height and mental function. Indeed, as early as
1893, William Porter (quoted by Tanner) had shown in the
schools of St. Louis that pupils who were academically
advanced for their age were also taller. There, have been
qqite a few similar observations in recent years pointing to
a correlation between height and IQ.
Tanner also quotes that in Norway, in a massive study
in which hgight measurements were recorded in 1.8 million
subjects over 15 years of age, it was found that mortality
in those of heights 185-189 cm was half the rate with those
of height 150-155 cm. A similar lower mortality among taller
children less than five years old in Ghana has also been
reported by BUbewiez et al (Annals of Human Biology, 3>393,
1982).
...A...
i
- 14- -
Reviewing all the available evidence on height
measurements and attempting an answer to the questions "Is
being taller better?", Tanner concludes: "It does look,
therefore, as though height indeed can be a proxy for health
and for the attainment of biological potential. This is true,
of course, only when comparing groups, not in comparing
isolated individuals, the variation between whom is overwhel
mingly due to genetic causes. But between social classes, urban
and rural dwellers, the educated and uneducated, height is a
useful proxy for ’aisanco de vie' ",
. Height measurements will not ony be helpful in monito
ring secular trends in nutrition and economic status? they
will also be useful in interregional and interclass compari
sons of nutritional status. Height measurements could help
to being out glaring socio-economic in equalities and the
consequent disparties in nutritional status among classes
within countries. Bielicki et al (Human Biol. 53- 5'+3“556,
1981) showed that the sons of Polish peasants raised in
villages in families containing four children were distinctly
shorter than sons of professional men with small families
working in large cities. Goldstein (Human Biol. >4-3.91-Hl,
1971) reported a similar phenomenon in the U.K.on the basis
of a national sample survey of heights of seven-year-olds in
1971. '
In the United Kingdom difference between the average
heights of non-manual classes (class III) and labouring
classes (class IV and V) has been reported by Clements and
Picket in 1957 (quoted by Tanner)5 strangely enough, the
data of the office of Population Censuses and Surveys of 1980
show that this difference still persists.
It is only with respect to Scandinavian countries.-...
Sweden and Norway - that there is, today, convincing published
evidence of absence of significant differences with respect to
height as between occupational classes. The attainment of
such a situation of equality and distributive justice wherein
there are no striking differences with respect to nutritional
status as between different occupational and income groups,
must be considered as the hallmark of truly successful socio
economic development5 in such a situation, even the groups
with the lowest income levels are apparently able to achieve
an optimal level of nutrition. Unfortunately, most developing
countries are apparently still far away from this goal.
- 5 ••
Net only is the general level of health and nutrition in their
populations low, there are also apprarcntly far greater
evidences of disparties among populations. Evidence of differences
in height as between different occupation groups in India
are un-fortunately quite striking as observations that follow
will show.
INDIAN STliDIESi Three Indian studies covering fairly
large numbers of subjects indicate the value of height as
a measure of nutritional status. In these studies, height
measurements (along with weight measurements) have been carried
out in subjects of different socio-economic groups; it has
been presumed that the dietary intake would largely parallel
the socio-economic status, and in any case, as was pointed out
earlier, there is no way by which socio-economic or occupat
ional status can exert a direct metabolic effect. on the body
in order to influence height except through its effect on
nutritional inputs. So it will be justifiable to view the
observed relationahip in these studies between height and
e ,'onomic status as in fact a relationship between height and
nutritional status.
Shanti Ghosh and her colleagues (Paper to be published)
carried out an extensive Longitudinal study on growth and
development of children of different socio-economic groups,
followed from birth for periods extending now to nearly
15 years. Nearly 8,200 children were covered in the study.
The communities in vestigated ranged from the poorest (less
than Rs.50 per head per month -1969 level) of the middle
class (more than Rs. 200 per head per month - 1969 level).
The longitudinal data from children belonging to those two
income groups (Figure )show a. clear relationship between
socio-economic status and heights and weights of children,
K, Satyanarayana and colleagues (Ann. Hum.Biology 7,
359-365, 1980) at the National Institute of Nutrition,
Hyderabad, have assembled data from longitudinal observations
on the heights and weights of children of different socio
economic groups in rural Hyderabad observed over a 15-year
period (five to 20 years). The children belonging to their
group I with heights between M and M-2 SD of Boston Standard,
mostly came from families of affluent landlords owning more
6
6-
than five acres of fertile and 5 those of their Group HI were
from the poorest rural households owning no land of own, with
adults being illiterate and eking out their living from seasonal
agricultural wage labour. In Table 1 some of their observations
have been set out. The same table also shows data on heights
and weights of children of the most affluent Indian communities
as observed and reported by D. Hanumantha Rao and Gowrinath
Sastry (Ind. -Tour. Med. Res. 66. 950-956, 1977) of the same
Institute, on thebasis of their cross-sectional studies. The
striking differences between the different socio-economic
groups will again be obvious.
The National Nutrition Monitoring Bureau in Hyderabad,
India has recently completed a study of the dietary, nutritional
and.anthropometic status 6f32,332 subjects (12, 92? adults and
the rest children) drawn from 15 ma. or cities of India (National
Nutrition Monitoring Bureau Report on Urban Populations -1975-79°’
National Institute of Nutrition publication, 1980). The sample
households were classified into five major socio-economic
categories.
The high income group (HIG) and the slum labour (SL)
represented thetwo extreme ends of the economic spectrum,
with the other three groups lying in between. The SL was the
group subject to the greatest socio-economic deprivation poor, largely illiterate or semi-literate, living in highly
overcrowded and unhygienic conditions and having to depend
mostly on unskilled manual labour to eke out a precarious
livelihood. Their diets were decidedly lower in energy
content and their children showed a higher prevalence of signs
of vitamin deficiency.
The heights and weights of children and ad Its
faithfully reflected the socio-economic gradient with the
HIG at one end and SL at the other and the other groups
falling in between. For the sake of convenience only part
of the data from the two groups at the exteme ends (HIG
and SL) have been set out in Tables 2 and 3.
.....7..
- 7 I A B L E - 1
Longitudinal Studies of Growth of Indian Children
of Different Socio-economic Groups.
Group.
Initial (5 yrs.age)
Final (20yrs.age)
Ht.(cm)
Ht.(cm) Wt(kg)
Wt (kg.)
1. Mostly from families
IOI4-.7
of well-to-do landlords* (2.90)
(owning about 5 acres
of fertile land)
15.3
(1.1+)
167.8
(6.26)
51.5
III. Mostly from failles of- 89.2
agricultural labourers* (1+.02)
on seasonal daily wages
11.5
(1.08)
157.8
(6.09)
I4-I4-. 0
18.3
171.8
59-6
Affluent**
108.0
(6.6)
(3.91)
Based on *K.Satyanarayana? Int. Cong.of Nutrition, Brighton,1985
** D. Hanumantha Rao and <1 .Gowrinath Sastry? ind.Jour.
.of Med. Hes. 66.950. 956.
T a B L E - 2
Heights and 'weights of Children.
Age(years)
Sex
Height - cum
HIG -.. Slum
Weight - kg
HIG......... Slum
5
Boys
Girls
110.L107.6
99.8
■ 98.7
18.2 - 16.2, .
13.9
13-6
12.
Boys
Girls
W+.2
132 • 6
133.7
30.8
29.9
25.1
11+0.1+
Boys
Girls
I6I4-.5
156.2
155-.7
11+8.6
I4-6.2
38.6
39.1
16.
^3.1
26.8-■
Source? NNMB Report on urban populations 1975-1979(1980), National Institute of Nutrition, Hyderabad.
T A B L E• - 3
Heights and Weights of Adults
Age group.
Heights (cm)
HIG .
20-25 years M
20-25 years F
166.1+
.
SL
161. M(161.0-161+)
15*+. 6 ■
150.1
(1L-9.1+-151.9)
Weights (kg)
HIG
SL
50.14-
1+6.8
1+6.6
(lt-7.2-14-9.8)
1+1.7
(i+i.o-w.2)
66.3
ii-a.i
166.8
1+0.1+5 years M
161.2 - ■
1+1.6
11+9.6
56.0
lt-O-lt-5 years F
153.1
Figures within brackets in cols.3 and 5 are measurements of
corresponding rural groups.
,
,
.
Source? NNMB Report on urban populations 1975-19?9(1985)National
Institute of Nutrition, Hyderabad.
■
.
’
..... ■
--v
,
_
i.-
-,Li
■. '1 '3___________ ____ ________
--
;
20VLRTY, HIP; T-hb, outstanding findlhg-'fn 111' t'-o
.p.jthree Indian studies’ •ci t'dd above is the striking relationship
be tween'-income and'-, ■occupa-tio'ridl; status' on the one hano and
\. .i '
-■physical- stature ’nn 'the .other . It would appear,.thdt-.the more
LiI.oM
...lowly--(using the- expression.. forthe sake . ofy c.orye^iia:.n.cei) the job
_ that ;a-‘ cbmmunity .is -engaged^ in,' they^rejitcf'^the'Wareelof
stunting
in* its. . children and
adults
.IShe'c'a;rtL
;p'ullers?°.the
'
v.
.-v -I--v, t
c[
o b'O ? V/G
.
Is
f ■■■ Cscavebgersi .manual iab^j^'ers') (i'nciijding-i,those engaged fin
strenuous work), .stone-blitters, porters having to carry heavy
loads arid agricultural labourers are apparently the-.ones who
'•'..•'Care most; stunted'-gnd^hay.e the lowest'.iody weights; 'unfortunately,
the se ’are _pre ci. sely._the ..occupation- g-ro-ups- (-not thg-bus ine ss
, , . executive., ^nd academicians )v.whb stan'd' iri ' greatest'need of a
.... - sturdy body-build for optimal productivity and output and for g
..earning, area-sonable -wage- ■• from'their "occupation.
l
■
- ■?. ,-T A. B iK” -' 1+ /'J' l.X.'.L...
-Maternal Height and:'Incidence of Low. Birth Vteight
in Offspring.- ’
— Maternal height (era),
Less
than
cm ■ ...
' _ ... I:-'
' More than -lb-5 cm
- - More than l’-i-5- cm
. .
Income., group
.
.
-Incidence ' of L.B.W.
Less than Rs.50 per,
head'per month
35.5%
-do"i'ore than Rs.200 per
head"per month
' 2^.2%
15.$
Source? Shanti Ghosh et al.
It is unlikely that differences- in height for age of
the order observed in India •(and possibly other .developing
countries) and between different income/occupation groups
within .the country,, will .be seen In developed countries. It
. . is .precisely- for this-reason that height measurement..acquires
. special importance and significance as an indicator of socio
economic development in developing countries.
It is not so much the retardation ofphysical growth
per se and the relatively small body size of the poor that
need bother us. It is the -fact that there is now mounting
evidence, thanks to sophisticated functional tests which
measure physical stamina and work capacity on the one hand
and mental development and learning ability on the other.,
that impairment in physical growth (as assessed by failure
to achieve the full genetic potential for the attainment of
.9W.
- 9 -
physical stature) is accompanied by varying degrees of
functional incompetence, The fascinating work of Spurr et al
in Colombia (Am. Jour. Clin. Nutr. 39- 1+52-1+59, 19SM-; Human
Biology,
553-57^, 1982; Am. Jour. Clin. Nutr. 37-83l+-8i4-7
1983); Chavez et al in Mexico (Growing Up in a Developing
Community. Inst. Nacional Nutricion, Mexico, 1982); Viteri
in Guatemala (Amino-acid Fortification of Protein Foods, ^d.
Scrimshaw & Htschull, M.I.T Press, Cambridge, 350-375, 1971)
and Satyanarayana et al in India (Am. Jour. Clin. Nutr.
30.322-325, 1977) have provded ample evidence of the functional
implications of growth retardation. Indeed there is often a
linear relationship between the degree of growth retardation
and tie degree ofphysical and mental functional impairment.
Measurement of the degree ofgrowth retardation thus could
serve as aproxy for the assessment of functional competence.
In a longitudinal study on undernourished boys in India,
Satyanarayana and colleagues (Am. Jour. Clin. Nutr.32.1769 1775, 1979) showed that the wages earned by adolescent boys
employed by farmers in rural areas were significantly
related to body weight and height. Men and women with better
nutritional anthropometry earned 30 percent to 50 percent
additional incentive money (over and above the uniform basic
pay) in factories where individual incentive system based
on work output was inoperation.
A considerable proportion of girls in developing
countries who are stunted and of low body size because
of undernutrition during the crucial years of their growth
and development end up with heights below l>+5 cm when they
entermontherhood. It is now known that there is a direct
relationship between stunting of the mothers and the
occurrence of low birth weights in their offspring, according
to the recommendations of international agencies, maternal
heights below lb-5 cm may be considered indicative of risk
of obstetric complicationsand low birth weight. It will be
seem fromthe data presented in Table U- based on a study by
Shanti Ghosh et al. in Indiathat a distinctly higher propor
tion of offspring a mothers with heights less than l>+5 cm were
of low birth weight. In India, as in many other developing
countries, more than one-third of all infants born alive are
of birth weights below 2,5000 gm. It is now known that both
with respect of hei: ht and weight, infants who start with
the initial handicap of low birth weight apparently never
10 -
fully recover from their initial handicap. Thus low birth
weights in full term infants make a lasting contribution
to stunting.
Stunting is the outstanding- feature of so-called
’adaptation'. It is the feature that ensures that, not just
this generation but the next as well, does not escape from the
poverty trap. Stunted children with impaired learning abilities
and schooling end up as stunted adults with low levels of
productivity, educational attainment and resourcefulness and
earn low incomes and thus continue to be enmeshed in the
poverty trap and so unable to feed their children adequately.
Stunted women beget offspring with low birth weights who start
their lives with an initial handicap from which they never
■fully recover. Thus stunting and poverty with which it is
invariably associated continue from one generation to another.
To view this scenario as "acceptable adaptation" is cruel irony'.
a country 'or community in which large segments of the
population suffer from growth retardation and resultant stunt
ing and small body size,•> is one in which the quality and calibre
of human resources is eroded and is of substandard quality.
A community in which a considerable part of the
population is stunted is usually a community with high infant
and child mortality, high levels of morbidity in children,
high rate of drop-outs from schools. This is also a community
in which children have lost valuable time for learning skills,
mothers have lost considerable part of their daily wages and
health services are so overburdened with a heavy load of
curative work to the point that preventive and promotive
health programmes are relegated to the background.
A PROGRAMME FOR USE OF HEIGHT MEASUREMENTS AS AN INDICATOR
In view of the con siderat tone, di sfnr.f'.cri ab'w, there
would, appear to be a sound case for the institution of a
country-wide programme ofs
*measurements of heights of children six to seven years of age
in our rural schools to be repeated systematically in the
same schools annually; and
* measurements of heights of adults (men and women) belonging
to different occupation ('and income) groups in different parts
of the country to be systematically repeated once in five years.
....11....
- 11 -
The. National Nutrition Monitoring Bureau (NNMB) at the
National Institute of Nutrition, H deraba'd, has been carrying
put height measurements as part of its very useful, though
limited, mctiiuoixng prog?.-mine. The same Institute has also
carried out several ad hoc research studies in which heights
of small population groups in the country have been compared
(some c.f these studies have been referred to in this paper).
But what is envisaged in the present proposal is a much larger
programme of height measurement carried out systematically on
a country wide scale. If height measurements have.to serve
as a meaningful in dicator of changing trends with respect to
nutritional status of communities across the country, such
measurements may have to be organised somewhat differently and
conducted on a much wider scale. Such a study could very well
become part of'an expanded programme of operations of the
National Nutrition Monitoring Bureau. It is, however, not
the purpose of this paper to discuss the statistical design,
and the organisational and operational details of such a study.
I.
The most appropriate and. convenient age group that
could, be immediately captured, for large scale height surveys
would be schooD. children of the six to seven year age group i.e. those be longing to the 1st or 2nd standard (the stage at
which drop-outs are few.) he have a ready-ijiade institutional
infrastructure for this purpose. According to the AH-India
Education Survey of 1982., there were nearly J.6 lakh rural
schools in the country, a school within a radius of 1 km of
practically every village in the country. Of the estimated
55 tc 60 million chiBren in rural schools, probably between
one-fourth to one-third may fall in the six to seven year
age category. It is certainly not being suggested here that
we should launch as ambitious a programme as that of Japan,
in which all school children between five and 17 years have
been measured for height annually for nearly h-0 years now.
In fact, it is these measurements that have provided (and
continue to provide) the most convincing scientific evidence
of the impact of Japan's remarkable economic recover;-' on the
nutritional status of its people. Iu should at least be
possible for us in this country to initiate immediately
a limited programme of annual height measurements in a fair
....12...
- 12 number of representative rural schools in different parts of
the country. For this purpose, representative schools in each
block cf the country must be selected according to a proper
statistical design.
It is extremely important that the persons chosen to
carry out the measurements are property trained. It will be
ideal if the rural school teacher himself could be trained for
this purpose. If the study is going to be limited to just one
annaul measurement of the child and only to six-to seven-yearolds, the time that the teacher needs to spend on this work on
the entire year will be insignificant. He can be trained to
record not only height but the weight of the child. Involving
the teacher in the programme lias its special merits. Apart from
the fact that this willbe an inexpensive arrangement, it is also
most unliekly that we will find (orneed) anybody else in the
village who will be better educated and qualified to do this
job. If the work is entrusted to the teacher, then it will be
possible for him to so arrange the timing of the measurements
that he can carry out this work in his spare time without
encroaching on his teaching hours. However, the entire operation,
if it is not to degenerate into an unreliable exercise, must be
directed, supervised ana monitored by a competent central
institution with adeauate expertise in nutrition, auxology,
epidemiology and bio-statistics. Equipment needed for the
measurement must be provided to each school, periodically
calibrated and promptly replaced wherever necessary.
Data from each school, block, state and the entire
country must be collated, properly analysed and published
annually. This operation world generate a vast amount of
useful data which will throw a groat deal of light on the
status of nutrition of our rural children at the stage when
they have first ended their perilous journey through their
’preschool’ years (zero to five years). These data will also
help us to indirectly evaluate the impact of our MCIl and
ICDS programmes on the nutritional status of our children.
In audition to ’measurements on school children, cross—
sectional measurement of heights in adults (male and female)
of different occupational classes and communities - such as
landless agric Itv.ral labour in different regions of the country,
....13...
- 13 -
white-collar and industrial, labour in urban areas, Harijans
tribals could be undertaken. Such measurements may be repeated
in the same population groups at five-yearly intervals. It is
extremely important that the groups for these measurements ar.
net chosen in an ad hoc fashion but after due consideration of
their significance and importance to the national human resource
base. The group chosen must be sufficiently large and represent
ative .
Such height measurements and quantification of height
deficits through comparison with an international or national
standard and application of the procedure of L scores will help
us identify differences in nutritional status as between
different regions, populations, groups and social classes in
the country and to monitor changes over a period of time.
CONCLUDING COMi'iENTS t
The thoughts expressed in this
paper are by no means new. The importance of height measurements
has long been well-kncwn to paediatricians and health scienti
sts. The central point being made in this paper is that it is
high time that we make effective use of this well-known, simple ?
feasible and relatively no.'.pensive indicator to monitor the
impact of our national programmes on the nutritional status of
curpeople. Inis is an indicator which will prove of as much
use to the d°'--;lv.ocntaL c-'OTiomist and the planner as to the
health/nutrition scientist. Our planners will then be able to
assess their achievements on the basis of easily quantifiable
and verifiable data and need not have to get lost in sterile
debates arising from dubious claims as to how many "thousands I!
did (or did not) cross the "poverty line" ’.
Partly 'based on a paper to be presented at WIDER
( U.N. University) , Helsinki in July 1987.
FOUNDATION
NEWS .
"NUTRITION PROGRAMMES IN ORISSA STATE" - by
x.C. Swaminathan, Shakti Ghosh and C. Gopalan - NFI Scientific
Report 5 - pp. 32. Tliis publication contains a review of
ongoing nutrition programmes- in the State of Orissa.,...India, &
suggestions for a brobdcr'''strateg^/for nubritTonal improvement.
Free copies can be had from the'Foundation on specific, request.
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