2328 LETTERS TO THE EDITOR ccps skinfold thickness However by ebj19239


									2328                                                                   LETTERS                TO       THE         EDITOR

ccps       skinfold           thickness.             However,             the      mid-ascaris        infection             and      human            nutrition           is un-
arm      circumference                  remained             unchanged,              sig-
                                                                                        certain.         In a recent                study        (3),      it was          found
nifying         that     the body             muscle         mass       decreased; that           2 monthly              piperazinc            administration                   for
this     leads         one       to the          impossible             conclusion an year                was        not       different           from         placebo            as
that      antiascaris             treatment-induced               a state       of regards               effect         on growth.                It may             be      men-
negative           nitrogen           balance.                                          tioncd       that in the recent                  international                seminar
     4) Authors              did      not       monitor           height        along on         “Control             of parasites               in prevention                     of
with      weight.         There          is evidence           to suggest           thatmalnutrition”                 (Tokyo,          December                 1-5,      1980),
height         is a better             index        of nutritional               statusit was         unanimously                   agreed          that       there        is no
than      weight         (2). In a recent               longitudinal             study clear       cut      evidence             of a significant                    effect        of
in Guatemala                    (3),       height         was       found         to ascanasis
                                                                                          be               on nutrition               and it was stressed                     that
more         sensitive          than         weight         as a measure                  of
                                                                                        further        research            in this area            is needed.
growth          over      a period            of 1 yr.                                                                         Mahesh           C. Gupta,              M.D.
     5)  Use         of two          of the          indices         (percentage
weight            for      age         and         percentage               expected Assistant             Professor
weight         gain)       might          have        been      erratic       in case   Human            Nutrition            Unit
of children             aged       54 to 60 months                    at the onsetAll-India                 Institute          of Medical              Sciences
of this 6-month                   study.        This       is because          differ-  Ansari        Nagar,           New        Delhi
                                                                                 up India           110029

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ent     standards              were         used       for children                       to
and        more          than         60 months                of age.           Thus          the
% weight              for age for a child                        aged         57 months
initially          would           be determined                     from         the Har- 1. Stephenson                         LS,       Crompton                 DWT,            Latham            MC,
yard       standards                at the onset               of the study                  and Schulpen                  TWJ,          Nesheim              MC         et al.       Relationship
from         the       Iowa          standards               at the           end        of the between                 Ascaris         infection            and       growth         of malnour-
                                                                                                     ished       preschool            children           in Kenya             AM       J Clin       Nutr
study.         Use of different                      scales        to compare                 the l980;33:l 165-72.
growth           of the           same          child       is liable           to reduce 2. Mata                  L. The         nature         of nutrition              problem.            In: “Nu-
the comparability                          of growth              in different                pe- trition           Planning.           The       state       of the Art”.              L. Joy       (ed).
riods.                                                                                               IPC      science         and     Technology                Press      Ltd.,     Surrey.        Eng-
                                                                                                     land,       1978:91-9.
     6) Authors              found          that growth               changes             were
                                                                                                  3. Gupta           MC,        Urrutia          iJ.     Efecto         del tratamiento                qui-
most        marked             in relation             to skinfold              thickness            mioterapeutico               periodico              de     parasitos           intestinales,
than       in the case               of the three               criteria         based          on sobre          el crecimiento                de nifios          preescolares.               INCAP,
body          weight.            This          observation                  is certainly             Guatemala:                INCAP/UNU                      publication             no 5, 1980.
                                                                                                  4. Garn         SM,       Rosen         NN,        McCann             MB.      Relative         values
unusual              for       the        following              two         reasons:a)
                                                                                                     of different              fat folds          in a nutritional                  survey.        Am        i
Triceps           skinfold             is not a reliable                   indicator            of Chin Nutr               197 1;24:1380-1.
body        fat stores             (4, 5); also,             various           sources           of Crook
                                                                                                  5.                GH,       Bennett          CA,       Norwood             D and          Mahaffey
error        in measuring                     triceps         skinfold             arc well JA. Evaluation                          ofskinfold              measurements                and weight
known           (6). b) Tricpes               skinfold           remains            rather           chart       to measure             body         fat. J Am            Med       Ass      1966;198:
constant,              in the             age       group          studied             by the
                                                                                                  6. Ruiz        L, Colley           JRT,       Hamilton              PJS.     Measurement                of
authors            (7) and             its measurement                        is not         rec- triceps              skinfold            thickness.               An        investigation                of
ommcndcd                   in the preschool                     children             (8).            sources          of variation.               Brit      i Prey         Soc      Med         197 l;25:
     7) Age and sex distribution                                     in the control                   165-67.
and       study           groups            are      not      given;           one        hopes 7. Jelliffe          DB. The           Assessment              ofthe        Nutritional           Status
                                                                                                     of the Community.                        WHO.               Monograph                 Series      No.
they       were         comparable.                                                                  53. Geneva:            World         Health          Organization.                 1966:227.
     Clarification                 of above              points          is important             8. ICNND.               Manual          for nutrition              surveys.         Washington,
because             the       nature            of interactions                    between           DC:       US Govt             Printing          Office         1963.

Reply                to letter                by Gupta

Dear         Sir:

    We         arc      pleased       to respond                      to Dr. Gupta’s nourished                              Kenyan       preschool        children      (1).
request              for clarifications          on                  our     article    con- 1) Dr.                      Gupta     queries       our statistical        analy-
cerning              Ascaris     infection      and                   growth         of mal-sis, our                    use of intergroup           (rather        than   intra-
                                                                           LETTERS                 TO       THE           EDITOR                                                                         2329

group)                comparisons,                          and           our         reference                 to
                                                                                                              changes            in some                other            anthropometric                           mea-
“seasonal                    factors”               which               may          have           caused sures.            We         did       measure                   height           at the begin-
differences                    in growth                 rate         in all subjects                    overning         and        the end                of the study                      and          reported
time.         We are interested                              to note that Dr. Gupta mean                                     height/age                    and          weight/height                         in our
has now                 discovered                   the paired t test,                  since         in article.             There          was simply                       no point              in repeat-
his own                study, also concluding                               as we did that ing this measurement                                                      a mere              14 wk after                  the
deworming                        can improve                      child          growth             (2), he   first     height           measurement                         was made.
used         only            ax2 test;         whereas                  we used     f         tests,                3) We          agree           with           Dr.         Gupta              that         it was
paired             and           unpaired          t tests,           analysis              of vari- objectionable                              to have                    to use             the          Harvard
ance,          and            multiple              regression                   as required                  standards
                                                                                                                in                   for children                    up to 60 months                           of age
different                 sections            of the data                    analysis.                        and        then          switch             to the              Iowa           standards.                  In
      We are aware                         that        both            groups            of children 1976,                 those          were          the obvious                     choices.              Fortu-
grew           better              in the             second               than           in the            first
                                                                                                              nately           we        now           have             available                the          WHO!
period.               Dr.         Gupta              questions                   “seasonal                 fac-
                                                                                                              NCHS              reference                 data           (5, 6). It is not                           true
tors”           but           in fact               it is clear                     that          seasonal however,                that        we used                the Harvard                     standards
differences                     in growth                 did occur                  in our entire for a 57-month-old                                            child            at the          start         of the
sample                of children.                      The           weight              gain         in studyall           but         switched                  to the              Iowa            standards
children                 (n = 291)             was twice                    as large              in the when                he became                      over            60 months                     old.       For

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second                14 wk of the                        study            compared                   to the  these         children,               the         Harvard                 standards                 were
first        14 wk (see                     Table 1). Less                    than          30%          of extrapolated                    upwards                 assuming                linear          growth
these             children                  were              Ascaris-infected,                 and           in the           few         months                past           60 months                     of age.
only           187           participated                      in the             Ascaris-study,              This        was        a reasonable                        extrapolation                       and,       in
thus        there            was a seasonal                        variation               in growth. any case,                     involved                a very            small          percentage                 of
However,                 in spite ofthat,                      the Ascaris-infected                           the sample.                 The         fact that               dewormed                    children
children                   gained             more              weight              and          skinfold gained               more           weight in kilograms                           compared
than          uninfected                    ones            in the             second             interval to controls                   makes            the concern                     over       standards
after         deworming.                        This             analysis controls                 for         irrelevant.
seasonal                  differences                   in growth,                     which             have 4) Dr.               Gupta              is concerned                         that         the       “age
also         been            noted          in other                  groups            of East              Al-
                                                                                                               and      sex distribution                         in the control                      and         study
rican           children                (3, 4). We                       know            of no pub-           groups            are        not        given;              one         hopes             that        they
lished            data            to show                 that          the       small            dose were     of        comparable.”                       We would                      hope          that       Dr.
lcvamisole                      used         for deworming                              could            haveGupta             would            have           carefully                read         our         paper
caused               this         profound                   seasonal               difference                 before
                                                                                                                in            writing          his letter.                In the first paragraph
weight             gain          and      we have                  addressed                 this point of our                results          section,                we report                the age and
in our               article           (1). Our                  detailed               analyses               do
                                                                                                               sex distribution                     and also state                       that       there         were
still       lead            to the           conclusion                     that         deworming             no statistically                   significant                   associations                   found
was related                      to improved                      growth.                                      between            the Ascans                      and          control            groups            and
      2) We             do agree               that           height           is a good                indi- sex and            age group                   using      f    a test (1).
cator         of chronic                   protein               energy             malnutrition,                   5) Dr.        Gupta              objects              to our            use of triceps
however                     it is not                   sensitive                  to       short-term skinfold                  because               it is “not               a reliable               indicator
changes                  because              the          inherent                 measurement                of body           fat,”        because                 it has “various                        sources
error          is similar                to the actual                        height            increase. of error,”                 because               it “remains                    constant              in the
In         longitudinal                       studies                 of        short            duration age           group            studied,”                  and           because              it is “not
changes                 in height                arc much                    less useful                  thanrecommended                        in preschool                       children.”
                                                                                                                    a) Triceps            skinfo!d               is not a perfect                     indicator
                                                                                                               of body             fat stores,                  but         neither            is the            potas-
TABLE               1                                                                                          sium-40             method                  (7).        Skinfold                thickness                 is,
Seasonal            variation          in children’s                weight        gain                         however,               the       only            commonly                      used           anthro-
                                                                                                               pomctric              field         technique                     that        directly             mea-
      Time    intervals              n      Weight       gain    (kg/yr
                                                 (5 ± SE))                                                     sures        a portion               of body                fat itself.
1st 14 wks                         291       0.90 ± 0.10                         Paired t test                      b) It does             have           “various                 sources           of error,”
    (Dec-Mar)                                                                                                  especially              in the hands                      of untrained                      persons.
2nd       14 wks                   291       2.15 ± 0.10                       p < 0.0009                      So does           every          other           technique                  for assessment
                                                                                                               of nutritional                  status.            Need             we say more?
 2330                                                                          LETTERS                  TO        THE           EDITOR

       c) Triceps             skinfold              thickness              does         “remain”          contributed                    to our               belief             that           malnourished
  fairly        “constant                 in the age group                             studied”f          children            grow             better             without                 worms.
  the children                   are equally                    well-nourished                       over                                                              Lani            S. Stephenson
  time.        The          children                  in our             study           were           not,
  partly          due         to seasonal                     variation                and        partly
  due to treatment                         for Ascaris                  infection.              A ma-Visiting                Assistant                   Professor
  rasmic          child          has a very                   low skinfold,                    and        International
                                                                                                          an                                 Nutrition
 obese         child          has a very                  high         one;        triceps          skin-Division              of Nutritional                            Sciences
  fold      thickness              is related                to effective                   caloric       Cornell            University
 intake          and        to body               energy             stores.                              Ithaca,          NY            14853
      d) The            fact         that         the        ICNND                  manual              (8)
 (1963,          very        useful            but now               out of print)                   does
 not      mandate                   that         triceps            skinfold              thickness
 be measured                     in preschool                    children             can hardly 1. Stephenson                               LS,        Crompton                   DWT,                Latham               MC,
 be taken               as proof                that should it             not be mca-                          Schulpen             TWJ,           Nesheim                MC,          iansen             AAJ.          Rela-
 sured        in this age group.                            It has been                 used               so tionships             between              Ascaris            infection              and        growth            of
                                                                                                                malnourished                   preschool               children               in Kenya.                Am         i
 many          large         scale         surveys              in the United                    States         Chin Nutr             1980;33:1165-72.
 and      elsewhere                   that         we do not                   see any             point 2. Gupta             MC,         Mithal         S. Arara             KL, Tandon                    BN. Effects

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 in clarifying                  this       further.                                                            of periodic               deworming                  on nutritional                      status As- of
      6) We cannot                      quickly             obtain            a copy           of Dr.          cans-infested                  preschool               children               receiving              supple-
                                                                                                                mentary          food.         Lancet            1977;l:108-9.
 Gupta’s             second            study           ofAscaris               infection             and
                                                                                                            3. Robson              iRK.            Seasonal               influence                on       height            and
 growth            (9) and             so arc unable                       to comment                    on weight           increments                 of boys            and       girls        in Tanganyika.
 its design,              statistical               analysis,             and         results.                 i Trop         Med          Hyg        1964;67:46-9.
       7) We fmd Dr. Gupta’s                                      verbal           report         from 4. Longhurst                     R, Payne           P. Seasonal                  aspects           of nutrition:
 the recent               international                      seminar              on “Control                  review        of evidence                 and        policy          implications.                   Discus-
                                                                                                               sion     paper.           Brighton,               England:              Institute             for Devel-
 of Parasites                   in Prevention                         of Malnutrition”                         opment           Studies,              University                of Sussex,                  November,
 (Tokyo,              Japan,             December,                     1980)          very       inter-         1979.
esting.           Dr. Gupta                   reports             that       “it was unani- 5. World                         Health            Organization.                   A growth                  chart        for in-
 mously              agreed             that          there           was         no clear               cut ternational                 use      in maternal                   and         child         health          care:
                                                                                                               guidelines              for      primary             health            care         personnel.               Ge-
evidence                of      asignificant                  effect         of ascariasis
                                                                                                               neva:      WHO,              1978.
on nutrition                   (SIC).”              However                 a recent            report 6. National                 Center           for Health               Statistics.            NCHS             growth
we obtained                       (10)        states           that       “the         assembled               curves         for       children            birth-l8               years.           United             States.
agreed           that the relationship                               between              infection            Hyattsville,              MD:         National              Center            for Health               Statis-
with       soil-transmitted                          hclminths                 and nutrition                   tics,     1977.        (Vital         and       health           statistics.            ser.       11: Data
                                                                                                               from       the       national            health           survey.            no.        165)       (DHEW
dcfmitcly                exists          but         the        extent           of its contri-
                                                                                                               publ.      no. (PHS)78-1650.)
bution             to the             general                problem                 is not           well7. Dugdale               AL,        Griffiths            M. Estimating                  body mass
understood.”                      For        nearly            30 yr numerous                         iso- from anthropometric                               data.         Am        J Chin          Nutr          1979;32:
lated,         mainly              clinical,             studies           have          appeared              2400-3.
                                                                                                           8. ICNND.               Manual             for nutrition                 surveys.            Washington,
to prove              that         Ascaris             infection             and        malnutri-
                                                                                                               US Government                        Printing            Office,            1963.
tion      are related.                   Our          study         was an attempt                        to Gupta
                                                                                                           9.                 MC,          Urrutia           ii.      Efecto           del tratamiento                      qui-
quantfy            the relationship                          between               Ascaris           in-       mio-terapeutico                 periodico              de parasitos                    intestinales,
fection            and         malnutrition                       in a rural                 African           sobre       el crecimiento                  de niiios              preescolares.                   INCAP,
community.                      We          agree           wholeheartedly                          with       Guatemala:                 INCAP/UNU                         publ.         no. 5, 1980.
                                                                                                          10. Experts,          administrators                     affirm         parasite-nutrition            link
Dr. Gupta                  that         “further               research              in this area
                                                                                                               at Tokyo            seminar.            JOICFP                News           (newspaper                 of the
is needed.”                    However                    we also               feel       that        our Japanese               organization                  for international                      co-operation
study         in Kenya,                  and           his work              in India,              have       in family           planning)              no. 79 Jan                 198l:3(ool               1).

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