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Further observations on the relationship between gain in weight and diet in children
1939
PUBLIC HEALTH
FURTHER OBSERVATIONS ON T H E child compared with the standard and an average RELATIONSHIP B E T W E E N G A I N I N obtained for each sample which can be compared with Adamson's standard. The following figures show the WEIGHT AND DIET IN CHILDREN relationship of the average of each school to the A Study of diet and growth in the ehildren of an standard : - Urban Elementary School showing that, as the family increases in size, retardation of growth accompanies GROWTH FIGURESOF RANDOMSAMPLESOF 100 CHILDREN deterioration in diet. FROM RESIDENTIALSCHOOLSCOMPAREDWITH ADAMSON'S STANDARD. By FRASER BROCKINGTON,M.D., D.P.tt.,
Deputy County Medical Officer of Health, Warwickshire. The following analysis of growth results in school children has been designed to determine what, if any, variation in growth follows the deterioration in diet which has been observed to accompany increasing size of family. An analysis of the household budgets of 97 families with children attending an elementary school in West Sussex showed that expenditure per unit upon food declined with increasing size of the family, so that a marked deterioration in diet resulted until such time as the eldest child began remunerative work and augmented the family income.* The question which arises for consideration is whether a corresponding deterioration occurs in the rate of growth among the children of these families. The reader wilt bear in mind that the family diet as recorded may not be an exact measure of the diet of the children within the family owing to variations in appetite or sacrifice by the parents, nor can expenditure upon food be considered an exact indication of food consumption.
Standardlsation of Growth Growth has been standardised by tile method illustrated in PUBLICHEALTrIin April, 1989, namely, by comparison with Adamson's average of 70,000 children, t As has been explained in the above paper, the gain in weight over the year has been compared in the case of each child with the gain which would have occurred on the standard from the child's first age and heigl.t to the new age and height. By this means, it is considered that the effect of varying growth impulses is to some extent eliminated. The method has the disadvantage that gain in weight has sdone to be taken as the factor representing growth. It is important to remember that while Adamson's standard is a gauge by which the rate of growth in children of varied ages and varying growth impulscs can be measured, yet it should not necessarily be looked upon as normal or physiological, since it need not represent the best achievement to be obtained under ideal conditions but no more than the average of a large number of children attending elementary schools in one district. In order to arrive at some idea of the relationship of this standard to physiological growth, random samples of 100 children have been obtained from several good class residential schools, the rate of growth of each * Brockington, F. The Influence of the Growing Family upon the Diet in Urban and Rural Districts. ft. Hyg., 88, 1 (Jan. 1938), I. t Brockington, F. Public Health, 52, 209. This scale appeared in the Annual Report of the M.O.H., Brighton C.B. for 1923.
School. Girls. A
B C D Boys. E F G
Percentage of Standard. 200.0 151-18 161"05 164"85 123.84 121.54 153.43 Average = 153"7"
*Adamson's scale is thus 64 per cent. of the average of residential schools. Since the average rate of growth of these residential schools is considerably higher than the standard, it is fair to assume that Adamson's figures do not represent the physiological. It is hoped that the average of the residential schools sampled may be taken as some indication of the extent to which physiological growth exceeds the standard. In the same way it must be doubted whether 100 per cent. of the B.M.A. (19.q3) diet constitutes the physiological optimum. Unhappily there is no such easy way of checking this standard, but there are indications as those given in a previous paper that the physiological diet is of a somewhat higher standard, particularly in respect of protective foods. As will be seen later in this paper, these figures indicate that the B.M.A. diet falls at least short of 64 per cent. of the physiological.
A Study of the Families arranged in Income Groups In Table I an analysis of the children in the 75 families is made in income groups, and each group is subdivided according to the size of the family in units (cost coefficients). At each family size in each income group, an average is given both of the diet as a proportion of the B.M.A. standard and of the rate of growth of the children in the families as a proportion of Adamson's standard. A study of this table brings out the following points : - -
( l ) A close relationship exists between family expenditure upon food and rate of growth in the children. (a) As the level of income rises, both the diet and the growth resuks improve. The percentage of children reaching Adamson's standard of growth and the B.M.A. standard of diet improves from 14"3 and nil respectively in the group under £'2 to 78-8 and 68-'2 where the income exceeds £5. Similarly, the average growth results in the successive income groups are 78.7, 110.8, 104.4, 122.3 and 143.9 per cent. of Adamson's standard 307
PUBLIC
HEALTH
JULY TABLE I.--INCOME GROUPS~SHILLINGS PER WEEK. PERCENTAGE OF STANDARD.
40
60
I
1
80
Family Size in Cost .A ~, ¢" "' 3 f 3 Co-efficients. Gain. Diet. Gain. Diet. -126 "5 120.1 2-3 83-2 47.9 118.4 96.9 3-4 70.6 48"8 103'3 84.0 4-5 76.9 55'7 88.0 68.6 5--6 . . . . . 6-7 Per cent. of children above AdamNil 48 "2 46 "6 son's standard and B.M.A. diet... 14 -3 78 "7 110 '3 Average gain per cent. of standard... 4 23 Number of families . . . . . . . . . 8 30 Number of children weighed ... Nil 4.3 per cent. Number o f " Leaver " families ...
100
I
1
A
•
150
"
~
f '
Gain. Diet. . . . 97.1 I00.0 96.0 109.6 115"0 98.4 118.7 78"5 48.8
Gain. . 87-5 ~ 128"5 188.8 183.2
57.1
I
. ,,&
~
.,A
f
Diet. Gain. . . 165.0 -115.3 122.6 100.8 139-0 103.2 214.3
66.7
86-7
78.8
3
Diet. 128.0 115.2 94.5 63 -2
104 '4 28
122.3 10
143-9 10
45 46-5 per cent.
15 50 per cent.
19 70 per cent.
o This group contained one child in a family where the proportion of animal protein foods was exceptionally low (b) With incomes below £8 a week (containing 80 per cent. of the children) the relationship m very close. I n the group below £2, both the diet and the growth are markedly defective, the diet being about 50 per cent. and growth about 75 per cent. of standard. There are insufficient children at this level of income to determine any clear influence from increasing size of family. In the group between £2 and £8 a week (containing 25.6 per cent. of the children) as the family gets larger and expenditure upon food declines, the rate of growth declines in proportion. At two to three units of family size, the diet is 120 per cent. of the B.M.A. scale and declines in successive units of family size, 96-8 per cent., 84 per cent. to 68.6 per cent. at five to six units, while the gain in weight declines at corresponding sizes of family from 126.5 per cent. of Adamson's standard, v/a 118.4, 108-8 to 88 per cent. at five to six units. (c) Where the income exceeds £8 a week, growth tends to increase as the family becomes larger although of the family diet declines. It is difficult to see the explanation for this, except in association with the increasing number of " L e a v e r " families. As will be observed in Table II, growth results in " Leaver " families considerably exceed those to be expected of the diet since only 21 per cent. of children failed to reach the standard gain, whereas 50 per cent. fell below the standard diet. Whereas there were no such families in the income group below 40 shillings and only 4.8 per cent. in the group 40 to 60 shillings, in the 80, 100 and TABLE I I . - - A COMPARISONOF GROWTH AND DIET
IN
150 shilling groups, these comprised 46, 50 and 70 per cent. respectively, so that in fact, incomes over £8 a week were largely due to the earnings of elder children. With this in mind, it is difficult to escape the inference that with increase of income by earnings from this source, a greater proportion of the additional food is consumed by the children. This will be more certain to occur if the diet during preceding years has been deficient. (2) Below an income o f ' £ 2 per week the average growth attainment falls short even of Adamson's standard, and it is not until the income exceeds £5 per week that the average growth attainment reaches that of the residential school standard.
(8)
The growth rendts in nearly all instances exceed those which would be expected of the diet.
This suggests that the standard used for measuring the rate of growth is somewhat less below the physiological level than that used for measuring the diet, or in other words, that the B.M.A. (1988) diet is probably more below physiological level than is Adamson's scale. Since Adamson's scale has earlier been shown to be about 64 per cent. of the physiological, the B.M,A. (1938) diet is in all probability less than 64 per cent. of the physiological. (4) Rate of growth in the family declines as the family
increases in size until the eldest child becomes a bread winner. THE
CHILDREN
OF
THE
THREE
GROUPS
OF
FAMILIES.
Growth.
No Families.
Diet. .... Proportion of Children above the B.M.A. Standard.
(a) Proportion of Children above Adamson's Standard.
Proportion of Children above Residential School Standard.
Average Growth per cent. of Adamson's Standard.
Entrant ... Middle ... Leaver
15 33 27
93.7 53'3 50 "0
71-8 35"6 78 -6
23.5 12.7 35.9
111.6 111.6 138.3
Total ...
75
48"6
56"4
21.0
119.8
Type of Family.
308
(b)
(c)
1939
PUBLIC
From Table I progress of an imaginary family of five children both as regards expenditure on food and rate of growth may be followed over a period of 18 years from the anniversary of the birth of the first child until two children have begun to earn substantially. Graph I shows this progress : GRAPH 1. HYPOTHETICAL FAMILY OF FIVE CHILDREN SHOWING ALTERATIONS IN GROWTH AND DIET FROM BIRTH OF FIRST CHILD UNTIL Two CHILDREN ARF EARNING.
/ leva o~ ~ /
,,,
~c
/ # m
&
so
;5
6o
YeARs Table 4 sets out the data from which the Graphs have been constructed. Throughout the period of school life, the physical progress is seen to be at its lowest level in conformity with the insufficiency in diet. It will be observed that growth fails to attain the average level of residential schools until two children are earning substantially.
Further E x a m i n a t i o n o | in T h r e e Groups
Families
The influence of the growing family upon the diet and the rate of growth may be further studied by examining the families in three groups : - (a) " Entrant "--having no child older than 7 years. (b) " Middle "--those in the period of school life which elapses between the first child reaching the age of 7 years and the date when he begins to earn. (c) " Leaver "--having a child earning in excess of en shillings.
HEALTH
These groups are designed to emphasise the very varying periods of family life, particularly the middle period before the eldest child becomes a bread winner, when the greatest burden of the growing family has to be borne, and the Ieaver period, totally different from a dietetic standpoint, when relative affluence results from additional earnings. It will be realised that although only 58 per cent. of children fall within the zone among the families investigated here, all families must pass through this period which corresponds to that in Graph I from 1943 to 1951. In Table II can be seen the proportion of children in each group falling below the standards for diet and growth and the average attainment of each group. It will be seen that of the children of " Middle " type familie~ only 35.6 per cent. attain the level of Adamson's standard and no more than 12.7 reach the level of residential schools. Among " Entrants " the figures are 71-8 and 23.5 and among " Leavers " 78.6 and 35.9. The average attainment of " Entrant " and " Middle " families are the same (111.6) and that of " Leavers " considerably higher at 138.3 just below the level of the residential schools. It is, therefore, clear that on the whole the growth progress during the year has been considerably retarded in " Middle " families and somewhat less so in " Entrants " and that both are in marked contrast with that of " Leavers." Growth approximates to physiological standards with considerably greater frequency among the children of " Leaver "families whose income, at one time restricted, has suddenly benefited from the earnings of the eldest children. This would appear to suggest very strongly that the working class wage requires augmentation before a standard of diet can be achieved capable of producing physiological growth in children. In Table I I I (a and b) the " Middle " type families have been further subdivided. The proportions of children falling below the standards for both diet and growth increase in proportion with the size of the family. Where, for example, there are five or six children, 75 per cent. fall below the standard diet and 83 below the standard gain; where there are three or four children, 74 per cent. fall below the standard diet and 78 below the standard gain; with two children, 85 and 58 respectively, and with one child, 25 and nil respectively. In Table I I I (b) the average attainment in " Middle " families is shown per cent. of Adamson's standard (according to the number of children at school). The average is seen to decline from 121 where there is one child at school to 75 where there are 4. In conclusion, the above evidence may be taken as confirming the observations previously made by budgetary analysis of the influence of the growing family on the diet in working-class families. The growth of children in families with incomes below 60 shillings (i.e., for all practical purposes those living on a simple working class wage unaugmented by earnings of elder children) is seen to be increasingly retarded in proportion as the family grows in size, until with the first earnings of the eldest child, the diet improves and soon becomes profoundly altered. Where this occurs and the resulting multiple income approaches 3O9
PUBLIC HEALTH
FURTHER OBSERVATIONS ON T H E child compared with the standard and an average RELATIONSHIP B E T W E E N G A I N I N obtained for each sample which can be compared with Adamson's standard. The following figures show the WEIGHT AND DIET IN CHILDREN relationship of the average of each school to the A Study of diet and growth in the ehildren of an standard : - Urban Elementary School showing that, as the family increases in size, retardation of growth accompanies GROWTH FIGURESOF RANDOMSAMPLESOF 100 CHILDREN deterioration in diet. FROM RESIDENTIALSCHOOLSCOMPAREDWITH ADAMSON'S STANDARD. By FRASER BROCKINGTON,M.D., D.P.tt.,
Deputy County Medical Officer of Health, Warwickshire. The following analysis of growth results in school children has been designed to determine what, if any, variation in growth follows the deterioration in diet which has been observed to accompany increasing size of family. An analysis of the household budgets of 97 families with children attending an elementary school in West Sussex showed that expenditure per unit upon food declined with increasing size of the family, so that a marked deterioration in diet resulted until such time as the eldest child began remunerative work and augmented the family income.* The question which arises for consideration is whether a corresponding deterioration occurs in the rate of growth among the children of these families. The reader wilt bear in mind that the family diet as recorded may not be an exact measure of the diet of the children within the family owing to variations in appetite or sacrifice by the parents, nor can expenditure upon food be considered an exact indication of food consumption.
Standardlsation of Growth Growth has been standardised by tile method illustrated in PUBLICHEALTrIin April, 1989, namely, by comparison with Adamson's average of 70,000 children, t As has been explained in the above paper, the gain in weight over the year has been compared in the case of each child with the gain which would have occurred on the standard from the child's first age and heigl.t to the new age and height. By this means, it is considered that the effect of varying growth impulses is to some extent eliminated. The method has the disadvantage that gain in weight has sdone to be taken as the factor representing growth. It is important to remember that while Adamson's standard is a gauge by which the rate of growth in children of varied ages and varying growth impulscs can be measured, yet it should not necessarily be looked upon as normal or physiological, since it need not represent the best achievement to be obtained under ideal conditions but no more than the average of a large number of children attending elementary schools in one district. In order to arrive at some idea of the relationship of this standard to physiological growth, random samples of 100 children have been obtained from several good class residential schools, the rate of growth of each * Brockington, F. The Influence of the Growing Family upon the Diet in Urban and Rural Districts. ft. Hyg., 88, 1 (Jan. 1938), I. t Brockington, F. Public Health, 52, 209. This scale appeared in the Annual Report of the M.O.H., Brighton C.B. for 1923.
School. Girls. A
B C D Boys. E F G
Percentage of Standard. 200.0 151-18 161"05 164"85 123.84 121.54 153.43 Average = 153"7"
*Adamson's scale is thus 64 per cent. of the average of residential schools. Since the average rate of growth of these residential schools is considerably higher than the standard, it is fair to assume that Adamson's figures do not represent the physiological. It is hoped that the average of the residential schools sampled may be taken as some indication of the extent to which physiological growth exceeds the standard. In the same way it must be doubted whether 100 per cent. of the B.M.A. (19.q3) diet constitutes the physiological optimum. Unhappily there is no such easy way of checking this standard, but there are indications as those given in a previous paper that the physiological diet is of a somewhat higher standard, particularly in respect of protective foods. As will be seen later in this paper, these figures indicate that the B.M.A. diet falls at least short of 64 per cent. of the physiological.
A Study of the Families arranged in Income Groups In Table I an analysis of the children in the 75 families is made in income groups, and each group is subdivided according to the size of the family in units (cost coefficients). At each family size in each income group, an average is given both of the diet as a proportion of the B.M.A. standard and of the rate of growth of the children in the families as a proportion of Adamson's standard. A study of this table brings out the following points : - -
( l ) A close relationship exists between family expenditure upon food and rate of growth in the children. (a) As the level of income rises, both the diet and the growth resuks improve. The percentage of children reaching Adamson's standard of growth and the B.M.A. standard of diet improves from 14"3 and nil respectively in the group under £'2 to 78-8 and 68-'2 where the income exceeds £5. Similarly, the average growth results in the successive income groups are 78.7, 110.8, 104.4, 122.3 and 143.9 per cent. of Adamson's standard 307
PUBLIC
HEALTH
JULY TABLE I.--INCOME GROUPS~SHILLINGS PER WEEK. PERCENTAGE OF STANDARD.
40
60
I
1
80
Family Size in Cost .A ~, ¢" "' 3 f 3 Co-efficients. Gain. Diet. Gain. Diet. -126 "5 120.1 2-3 83-2 47.9 118.4 96.9 3-4 70.6 48"8 103'3 84.0 4-5 76.9 55'7 88.0 68.6 5--6 . . . . . 6-7 Per cent. of children above AdamNil 48 "2 46 "6 son's standard and B.M.A. diet... 14 -3 78 "7 110 '3 Average gain per cent. of standard... 4 23 Number of families . . . . . . . . . 8 30 Number of children weighed ... Nil 4.3 per cent. Number o f " Leaver " families ...
100
I
1
A
•
150
"
~
f '
Gain. Diet. . . . 97.1 I00.0 96.0 109.6 115"0 98.4 118.7 78"5 48.8
Gain. . 87-5 ~ 128"5 188.8 183.2
57.1
I
. ,,&
~
.,A
f
Diet. Gain. . . 165.0 -115.3 122.6 100.8 139-0 103.2 214.3
66.7
86-7
78.8
3
Diet. 128.0 115.2 94.5 63 -2
104 '4 28
122.3 10
143-9 10
45 46-5 per cent.
15 50 per cent.
19 70 per cent.
o This group contained one child in a family where the proportion of animal protein foods was exceptionally low (b) With incomes below £8 a week (containing 80 per cent. of the children) the relationship m very close. I n the group below £2, both the diet and the growth are markedly defective, the diet being about 50 per cent. and growth about 75 per cent. of standard. There are insufficient children at this level of income to determine any clear influence from increasing size of family. In the group between £2 and £8 a week (containing 25.6 per cent. of the children) as the family gets larger and expenditure upon food declines, the rate of growth declines in proportion. At two to three units of family size, the diet is 120 per cent. of the B.M.A. scale and declines in successive units of family size, 96-8 per cent., 84 per cent. to 68.6 per cent. at five to six units, while the gain in weight declines at corresponding sizes of family from 126.5 per cent. of Adamson's standard, v/a 118.4, 108-8 to 88 per cent. at five to six units. (c) Where the income exceeds £8 a week, growth tends to increase as the family becomes larger although of the family diet declines. It is difficult to see the explanation for this, except in association with the increasing number of " L e a v e r " families. As will be observed in Table II, growth results in " Leaver " families considerably exceed those to be expected of the diet since only 21 per cent. of children failed to reach the standard gain, whereas 50 per cent. fell below the standard diet. Whereas there were no such families in the income group below 40 shillings and only 4.8 per cent. in the group 40 to 60 shillings, in the 80, 100 and TABLE I I . - - A COMPARISONOF GROWTH AND DIET
IN
150 shilling groups, these comprised 46, 50 and 70 per cent. respectively, so that in fact, incomes over £8 a week were largely due to the earnings of elder children. With this in mind, it is difficult to escape the inference that with increase of income by earnings from this source, a greater proportion of the additional food is consumed by the children. This will be more certain to occur if the diet during preceding years has been deficient. (2) Below an income o f ' £ 2 per week the average growth attainment falls short even of Adamson's standard, and it is not until the income exceeds £5 per week that the average growth attainment reaches that of the residential school standard.
(8)
The growth rendts in nearly all instances exceed those which would be expected of the diet.
This suggests that the standard used for measuring the rate of growth is somewhat less below the physiological level than that used for measuring the diet, or in other words, that the B.M.A. (1988) diet is probably more below physiological level than is Adamson's scale. Since Adamson's scale has earlier been shown to be about 64 per cent. of the physiological, the B.M,A. (1938) diet is in all probability less than 64 per cent. of the physiological. (4) Rate of growth in the family declines as the family
increases in size until the eldest child becomes a bread winner. THE
CHILDREN
OF
THE
THREE
GROUPS
OF
FAMILIES.
Growth.
No Families.
Diet. .... Proportion of Children above the B.M.A. Standard.
(a) Proportion of Children above Adamson's Standard.
Proportion of Children above Residential School Standard.
Average Growth per cent. of Adamson's Standard.
Entrant ... Middle ... Leaver
15 33 27
93.7 53'3 50 "0
71-8 35"6 78 -6
23.5 12.7 35.9
111.6 111.6 138.3
Total ...
75
48"6
56"4
21.0
119.8
Type of Family.
308
(b)
(c)
1939
PUBLIC
From Table I progress of an imaginary family of five children both as regards expenditure on food and rate of growth may be followed over a period of 18 years from the anniversary of the birth of the first child until two children have begun to earn substantially. Graph I shows this progress : GRAPH 1. HYPOTHETICAL FAMILY OF FIVE CHILDREN SHOWING ALTERATIONS IN GROWTH AND DIET FROM BIRTH OF FIRST CHILD UNTIL Two CHILDREN ARF EARNING.
/ leva o~ ~ /
,,,
~c
/ # m
&
so
;5
6o
YeARs Table 4 sets out the data from which the Graphs have been constructed. Throughout the period of school life, the physical progress is seen to be at its lowest level in conformity with the insufficiency in diet. It will be observed that growth fails to attain the average level of residential schools until two children are earning substantially.
Further E x a m i n a t i o n o | in T h r e e Groups
Families
The influence of the growing family upon the diet and the rate of growth may be further studied by examining the families in three groups : - (a) " Entrant "--having no child older than 7 years. (b) " Middle "--those in the period of school life which elapses between the first child reaching the age of 7 years and the date when he begins to earn. (c) " Leaver "--having a child earning in excess of en shillings.
HEALTH
These groups are designed to emphasise the very varying periods of family life, particularly the middle period before the eldest child becomes a bread winner, when the greatest burden of the growing family has to be borne, and the Ieaver period, totally different from a dietetic standpoint, when relative affluence results from additional earnings. It will be realised that although only 58 per cent. of children fall within the zone among the families investigated here, all families must pass through this period which corresponds to that in Graph I from 1943 to 1951. In Table II can be seen the proportion of children in each group falling below the standards for diet and growth and the average attainment of each group. It will be seen that of the children of " Middle " type familie~ only 35.6 per cent. attain the level of Adamson's standard and no more than 12.7 reach the level of residential schools. Among " Entrants " the figures are 71-8 and 23.5 and among " Leavers " 78.6 and 35.9. The average attainment of " Entrant " and " Middle " families are the same (111.6) and that of " Leavers " considerably higher at 138.3 just below the level of the residential schools. It is, therefore, clear that on the whole the growth progress during the year has been considerably retarded in " Middle " families and somewhat less so in " Entrants " and that both are in marked contrast with that of " Leavers." Growth approximates to physiological standards with considerably greater frequency among the children of " Leaver "families whose income, at one time restricted, has suddenly benefited from the earnings of the eldest children. This would appear to suggest very strongly that the working class wage requires augmentation before a standard of diet can be achieved capable of producing physiological growth in children. In Table I I I (a and b) the " Middle " type families have been further subdivided. The proportions of children falling below the standards for both diet and growth increase in proportion with the size of the family. Where, for example, there are five or six children, 75 per cent. fall below the standard diet and 83 below the standard gain; where there are three or four children, 74 per cent. fall below the standard diet and 78 below the standard gain; with two children, 85 and 58 respectively, and with one child, 25 and nil respectively. In Table I I I (b) the average attainment in " Middle " families is shown per cent. of Adamson's standard (according to the number of children at school). The average is seen to decline from 121 where there is one child at school to 75 where there are 4. In conclusion, the above evidence may be taken as confirming the observations previously made by budgetary analysis of the influence of the growing family on the diet in working-class families. The growth of children in families with incomes below 60 shillings (i.e., for all practical purposes those living on a simple working class wage unaugmented by earnings of elder children) is seen to be increasingly retarded in proportion as the family grows in size, until with the first earnings of the eldest child, the diet improves and soon becomes profoundly altered. Where this occurs and the resulting multiple income approaches 3O9