J. Nutr. 1995 Martorell 1060S 7S

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Supplement: The INCAP Follow-pStudyPatterns of Linear G row th in Rural GuatemalanAdolescents and Children12

REYNALDO MARTORELL 3 DIRK G. SCHROEDER JAN A. RIVERAAND HALEY J. KAPLOW ITZ Depa rtmen t o f In te rn atio na l Hea lth The Rollin s S choo l o f P ub lic Hea lth o f Emory Un iv ersity A tla ntaGA 30322 tC enrod e In ve stig ac io ne s e n Salu d Pb lic a In stitu to Nac io na l d e Salu d Pb lic a 62508Cuernavaca More/os MxicoGenen tech Inc . Sou th San Franc is co CA 94080

ABSTRACT Length and w eight data from a longitudinal study of rural G uatem alan subjects birth to 7 yo f a g e and h eig ht a nd we ig ht d ata from a c ro ss -s ec tio na lstudy of the sam e subjects w hen they w ere 11-24.9 yo ld a re c ompa re d to re fe re nc e d ata fo r t he U SA g en era lp op ula tio n a nd fo r M ex ic an -Americ an s. A t b irth , th em ed ia n le ng th o f G u atema la n c hild re n is a t ~ ~th e 1 6thpercentile of the U SA reference or ~ 2 cm shorter. B y6 m o of age, G uatem alan children are shorter, on average, than the 5th p ercentile of the re ference cu rvesand, in absolute term s, are ~5 cm below the m edian;by 3 y, the difference increases to ~ 10 cm . A s adults,Guatem alans have about the sam e absolute level ofdeficit (-13 cm ) as they did at age 3 y. If the generalUSA popula tio n is u se d fo r c omparis on , Gu atemala nscan be said to grow as expected during adolescence,n either recuperating the grow th retard ation of ea rlyc hild ho od nor fa llin g fu rth er b eh in d in s iz e. If th e Mexic an -Americ an samp le is se le cte d in ste ad , it w ou ld a ppear that som e catch-up in growth occurs in Guatem alan ad olescents. R egardle ss of the choic e of reference p opulation, grow th is m arkedly retard ed only inearly childhood; adolescence is not a period whengrowth is significantly constrained. J. N utr. 125:1 06 0S -1 06 7S , 1 99 5.IN E XIN G K EY W OR Sgrowth anthropometryural Guatemala adolescence

Wh ile much is k nown in d ev elo pin g co un trie s a bo utgrow th in early childhood and the factors that shapeits course, knowledge about growth during laterc hild hood and ado le sc en ce is lim ite d. R ese arc h to d atein dicates th at g row th fa ilu re an d n utrition al stress inp oo r c hild ren from d eve lo pin g co un tries a re g rea testin the first 2-3 y of life (Beaton et al. 1990). G row thd urin g later c hild ho od an d a do lesc en ce in th ese sam e0022-3166 /95 $3 .00 1995 Ameri can Ins ti tu te o f Nutr it ion .

so cie tie s a pp ea rs to b e con sid era bly le ss c on stra in ed ,if at all (M artorell et al. 1994). Som e argue that adolescence is a tim e when the grow th retardation prod uced in ea rly ch ild ho od may b e recu pe ra ted (D elg ad oe t a l. 1 987). However, th e re se arc h to support th e c la imth at c atc h-u p g rowth can o ccu r to a sig nifica nt d eg reedurin g ado le sc en ce is weak (Ma rto re ll e t a l. 1 994). T heobje ctiv e o f th is p ap er is to c ompare p atte rn s o f g row thof poor G uatem alans during childhood and adolesc en ce to both a ra cia lly sim ila r p opula tio n o f Mexic an -Americans and a general U SA reference. Several keyquestions guide the analyses: w hat are the periods inlife in ru ra l Gua temala when sig nific an t g rowth fa ilu reoccurs? Specifically, is adolescence a tim e of constrained grow th or instead, is it a period when som eo f th e g row th fa ilu re o f e arlie r ch ild ho od is o ve rc omeby compen sa to ry g row th ?

M ATERIA LS AND M ETHOD SThe sub ject s included in th is s tudy were part ic ipan tsof a longitudinal study conducted by the Institute ofN utrition of Central America and Panam a (IN CA P)in four villages of eastern G uatem ala. T he study took1Pub lis he d a s a s up pleme nt to T he J ou rn al o f N utritio n. G ue st

ed it or s f or t hi s supp lement al publ icat ion were Reyna ldo Mart or el l,T h e Ro llin s Schoo l o f Pub lic Hea lt h o f Emory Un iv er sity , A tl an ta ,GA , and Nev in Scr im shaw , The Un ite d Nat io ns Un iv ers ity , Bo ston,MA.1 D ata collection and analyses w ere supported by N 1H grantHD2244 0 a nd b y th e In te rn atio na l C en te r fo r R ese arc h o n Women(ICRW), Contrac t IC-75/03.3 T o w hom co rresp on den ce sh ould b e sen t: D epa rtm ent o f Inte rn atio na l H ea lth , T he R ollin s S ch oo l o f P ub lic H ea lth o f EmoryUn iv ers ity , 1 518 C lif to n Road , N .E ., A tla nta , GA 30322 .

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L INEA R GROW TH IN GUA TEMA LA N A DOLESCENTS 6 Splace betw een 1969 and 1977 in four L adino (i.e.,S pan ish sp eak in g, m ix ed S pan ish /Am erin dian p opulation) v illages. T he objectiv es of the study w ere tote st th e e ff ec ts o f imp ro v ed nutritio n achie v ed th ro ughf oo d su pp lem en tatio n o n p hy sic al g row th an d me ntald ev e lo pmen t. T h e g roup s und er in te nsiv e mon ito rin gw ere pregnant and lactating w om e n and all childrensev en y ears o f ag e an d less. D etails abo ut the m e th od sof this longitudinal study are f ound elsew here (M ar-torell et al. 1995). B rief ly , w eight w as m easured on abeam scale to the nearest 10 g w ith children w earinga lig ht sh if t, th e w e ig ht o f w h ic h w as late r su btracte d.S upine lengths w ere m e asured using a standard m easu ring tab le to th e ne arest 0 .1 cm ; n o stan din g h eig htsw ere tak en on children


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62 S SUPPLEMENTT A BL E

Leng th o r h e ig ht? cm) o f Guatema la n c hildre n, a do le sc en ts a nd young adu lts

A ge (y)Males Females

Median SD Median SD0 0420 250 50 751 01 52 02 53 03 54 05 06 07 011 0 11 9 12 0 12 913 0 13 91 4 0 14 915 0 15 916 0 16

1 Supine length was measured until 7 y of age; 1 cm was subtracted from length values in children a24 m o to approximate height valuesused in the reference population. Standing height w as m easured at 11-25 y. M easurem ent before age 7 y w as at exact ages.2 M easured at 15 days of life.

RESULTSData for length or height, weight and BM I for the

G uatem alan sam ple are given in Tables 1-3, respectively. M edian lengths or heights by age for the G uatemalan and Mexican American popul ations a re p lo ttedtogether w ith the 5th, 50th and 95th percentile valuesfor the U SA reference population in Figures 1 and 2for children 0-36 mo and subjects 11-25 y old, respectively. A t 15 days, the m edian length of G uatem alan m ales is at ~ the 16th percentile of the NCHS/WHO re fe re nce, d ec lin in g to le ss tha n th e 5 th p erce ntile by nine m onths of age and to less than the 3rd percentile by 36 m o. V alues rem ain at the sam e relativeposition at ages 3-7 y of age (not show n). M exican-American boys, on the other hand, are at the 50th perc en tile a t 9 mo (mea su re s a t y oung er a ge s no t a va ila ble ),ma in ta in in g th is le ve l th ro ughout c hild hood .D uring adolescence, the m edian height of G uatem alan m ales rem ains at below the fifth percentile ofthe U SA reference population. The m edian height ofMexic an -Americ an male s is still n ea r th e 50th p erc entile during early adolescence but declines to aroundth e 2 5th p erc en tile in a du lth oo d. P atte rn s are sim ilarfor fem ales at all ages and for both the G uatem alanand Mexican -American popula tions .A bsolute differences in length am ong the populations are shown in Figure 3 for 0- to 36-mo-old

ma le s a nd female s. D iffe re nc es b etween Gua temala nand the NCHS reference (noted as Guat-NCHS inthe legend) are 2.2 cm at 15 days, ~6.5 and 8 cm by12 mo and ~ 10 and 11.5 cm by 36 mo for males andfemale s, resp ective ly . D iffe ren ce s b etw een th e Mexican-American population and the NCHS/W HOreference (noted as Mex-NCHS) are negligiblethroughout young childhood. A t 11 y of age, the difference between the G uatem alan and U SA sam ples(Guat-USA) is at ~12.5 and 13.5 cm for males andfem ales, respectively, only slightly greater than itw as at 3 y (F igure 4). For m ales, differences increasebetween ages 13 and 15, but are at ~ 13 cm again byadulthood for both sexes. D ifferences in height during adolescence and adulthood betw een M exican-American and USA medians (M ex-USA) suggest adifferent pattern (Figure 4). For both m ales and fem ales, differences are minimal at 11 to 13 y of age,b ut in crea se th ere after so th at a t ad ulth oo d Mex ica n-Am ericans are ~6 cm shorter.Patterns of grow th for other anthropom trie dim en sio ns a lso h ave b een ex am ine d. In term s o f sittin gh eig ht an d b on e d iam ete rs, p attern s ge nerally fo llowthose observed for length and height. H ow ever, forb icrista l b re ad th , th ere is sub stan tia l ca tch -u p in la teadolescence, particularly in fem ales. O n the w hole,ru ra l Gua tema la ns h av e sma lle r limb c irc um fe re nc esand reduced skinfold thicknesses than the reference


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L INEA R GROW TH IN GUA TEMA LA N A DOLESCENTS 1063ST ABL E 2

Weight kg) o f Guatemalan ch ildren , ado le scentsand young adu ltsMalesAge(y)0.04'0.250.50.751.01.52.02.53.03.54.05.06.07.011.0-11.912.0-12.913.0-13.914.0-14.915.0-15.916.0-16.917.0-17.918.0-24.9Median3.45.77.07.7

1Me as ure d at 1 5 d ay s o f lif e.

populations, particularly in m ales. M edian BM I v aluesby age are show n for adolescent and adult M ex ican-A m ericans and Guatem alans relativ e to US A percen-tiles in Figure 5 and 6 for m ales and fem ales, respectiv ely . T he G uatem alan population, particularly in thecase of m ales, is the leanest. Guatem alan m ales hav ev alues that are betw een the 50th and 5th percentiles.O lder Guatem alan fem ale adolescents and y oungw om en, on the other hand, hav e BM I v alues w hichare near the 50th percentile of the US population.M ex ican-A m ericans of both sex es hav e v alues w hichare at or slightly abov e the 50th percentile.

DISCUSSIONA m ajor con sideration in any discussion of the resu ltspresented abov e is the choice of ref erence population.T he ideal population to use w ould be one w ith sim ilargrow th potential as the G uatem alan population but living in an env ironm ent that does not constrain grow th.W hether the M ex ican-A m erican population is the appropriate choice is not entirely clear. Just as G uatem alan s, Me x ic an -Am e ric an s are o f S pan is h-In dian an ce stry ,

though dif ferences m ay ex ist in the proportions of adm ix ture. M ex ican-A m ericans are one of the tallest Hispan ic po pulations reported in the lite rature (M artorell

et al. 19 89) and are as tall as w e ll-to-do pop ulations f romGuatem ala (Johnston et al. 1973, Johnston et al. 1976)and M ex ico C ity (R am os-G alv n 1975). B ef ore adolescenc e, M e xican-Am e ricans are as tall as the general U SApopulation suggesting unconstrained grow th but important dif ferences are observ ed during adolescence(Figure 2). O ne ex planation m ight be that dif ferences aredue to genetic factors that lead to a faster grow th tem poin M e xican-Am e ricans and, hence , to a shorter durationof the adolescent grow th phase. On the other hand, sexual m aturation data for M ex ican-A mericans fromHHANE S do not suggest precociousness relativ e to patterns observ ed in European longitudinal studies (V illa-real et al. 1989). B ut, data of this ty pe are notoriouslyd if f ic ult to c olle ct re liab ly an d c ro ss-stu dy c om p aris on sm ay be f law ed. A lso, the lack of US A reference data forsex ual m aturation is a serious lim itation .T w o of the sets of reference data (i.e., N CH S/W H O,Frisancho) used in this report are deriv ed from cross-sectional data and are subject to biases introduced bycohort ef fects. Periodic surv ey s rev eal that av erageheights in the general US population hav e not changedfor som e tim e and hence these biases are unlik ely tobe im portant in the US data of Frisancho (1990). In thecase of M ex ican-A m e ricans, m ark ed changes in staturehav e occurred ov er tim e (M artorell et al. 1989). It isnot c lear w hether future national surv ey s w ill rev ealdif f erences w ith respect to HHA N ES data, now 8-10

T ABL E 3Body mas s index kg /m1 o f Gua tema lan children,

ado le sc en ts and young adu ltsM ales Fem ales

A ge (y ) M edian SD Median SDBirth0.250.50.751.01.52.02.53.03.54.05.06.07.011.0-11.912.0-12.913.

:.4.8.8.6.5.3.1.2.2.2.1.1.0.0.41.31.61.113.316.217.016.716.416.016M e asu red at 1 5 d ay s o f lif e.


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64 S SUPPLEMENT110-106-100-95 -90 -858076 -7065 -60 -55 -50

J. Nutr. 1995 Martorell 1060S 7S

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