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Methods o f Assessing
the Physical Fitness o f Children
Bureau Publication No. 263
UNITED STATES DEPARTMENT OF LABOR
CHILDREN’S BUREAU
?
LIBRARY
Agricultural & Mechanical College of Texa§
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College Station, Texas.
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UNITED STATES DEPARTMENT OF LABOR
F r a n c e s P e r k in s ,
Secretary
CHILDREN’S BUREAU • K a t h a r i n e F.
L enroot,
Chief
Methods of Assessing
the Physical Fitness of Children
A study of certain methods based on anthro
pometric, clinical, and socioeconomic obser
vations made of 713 7-year-old white boys
and girls in New Haven, Conn., over a
period of 19 or 20 months during 1934-36
By
RACHEL M. JENSS, Sc. D.
and
SUSAN P. SOUTHER, M. D.
Bureau Publication No. 263
United States
Government Printing Office
Washington : 1940
For sale by the Superintendent o f Documents, Washington, D . C.
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C O N T E N T S
P age
Letter of transmittal______*_________ ______ ___________________________
Introduction_____________________________________________________
Methods of assessing physical fitness____________________________________
The clinical examination_______________________
Biochemical tests for specific nutritional deficiencies_________ ._______
Functional tests__________ ■__ _______________ _____________ __________
Dietary inquiry________________ _____ ____ _________________________
Socioeconomic inquiry___________________________________
Anthropometric measures of body build_____________________________
Indices of body build as a method of assessment of physical fitness______
The four indices of body build included in the study_________________ ___
Description of each index of body build_____________________________
The Baldwin-Wood Tables_____________________________________
The ACH (Arm-Chest-Hip) Index. ___________________________
The Nutritional Status Indices_________________________________
The Pryor Width-Weight Tables__________
Limitations of the four indices of body build________________________
Previous studies____________________________ ____ __________________
Material and methods___________________________ J____________ _ ________
A description of the boys and girls included in the study___________
Age----------------------------------------------------------------------------------Nationality_______ ___ —____________________________ _____ ____ _
Homes__________________________________________
Location___________________i_______________________________
Type of dwelling_____________________________._____________ ,
Presence of parents in the home___________________________
Number of persons in household_______________________ *__ _
Number of persons per room__________________________
Number of additional persons sleeping in the child’s bedroom.
Economic status of their families________________
Assistance____________
Principal source of income_________________________________
Employment of mother___________________
Anthropometric measurements_________________________________
Height------------------------------------------------------------------------------Weight____________________________________________________
Diets----------------------------------------------------------------------------Health________________________________________________________
Pediatrician’s assessment of general nutritional status______
Diagnoses made at annual physical examinations__________
Number and duration of reportable school absences________
Medical and dental care__<_______ :_________________________
Summary______________________
The observations made of these children__________________
Techniques employed_______________
Clinical assessment____________
Anthropometric m easurements--__________________________
in
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IV
CONTENTS
Material and methods— Continued.
The observations made of these children— Continued.
Accuracy of the techniques employed-------------i ------------------------Clinical assessment- _ ------- - ------------ - ------------------- ------ - - Anthropometric measurements------ L® ----------------------------Socioeconomic and related data-----------------------------------------Summary of material and methods--------------- — -------------- --------------Results_________________________________________________ _______________
Indices of body build_ ^--------------------------------------------- --------------------The problem of testing the indices---------------------------------- - ------Criteria for testing the indices--------------- ---------------------------------Observations used in deriving criteria------ ----------------- --------Description of the criteria-------------------------------------------------Number of children selected by the criteria-----------------------Evaluation of the criteria---------— ------------------------------------Testing the indices-----------------------------------------------------------------The Baldwin-Wood Tables------------------------------------------------The ACH Index------------------------------------------------- -------------The Nutritional Status Indices------------------------------------------The Pryor Width-Weight Tables---------------------------------------Summary--------------- ------------------- rS-Ju----------------- *----------- •
--------Clinical j udgment---------------- -------------------------------- ------------- ----------The experimental data--------------------- — ------ ^
- ------------------Review of the literature------------------------------------ -%-------------------Variability of clinical judgment in the present study-----------------Stability of clinical judgment in the present study------------------- Opinions and recommendations of others------- --------------------------The need for improving clinical judgment---------------------------------Summary________ £------------ - - »■§- - - - i - ----- - - ---------------- — g-------- 'M * ~
Appendix I -------------------------------------------------------------------------------------------Statistical methods-------------------------------------------------------------------------Supplementary tables------------------------------------------------------^- ----------Appendix I I ________________________ 1----------------------------------------------------List of references----------------------------- - - - - - ----------------------------------------
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ILLUSTRATIONS
Map.— Location of the homes of the children--------- _______ — ------------Graph.— Weight of Italian boy, A. R., observed at frequent intervals from
72.7 to 92.8 months of age_--n«=n^ ======-~ -----------------------------------------
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99
Letter o f Transmittal
U
n it e d
States D
epartm ent
C
of
L
abor,
h il d r e n ’s
B
ureau,
Washington, August 15, 1940.
M a d a m : There is transmitted herewith Methods of Assessing the
Physical Fitness of Children, a study based on observations made in
New Haven, Conn.
The problem of finding an efficient, economical, and simple method
of assessing physical fitness has occupied the attention of workers in
the field of child health and growth for many years. Recently a
number of methods have been recommended, especially those based
on anthropometric measurements of the child. Some of these pro
cedures have been in more or less widespread use but few attempts have
been made to evaluate the different methods as applied to the same
group of children and to compare the relative effectiveness of these
methods in identifying boys and girls who are physically unfit.
Several years ago it was decided to make such an evaluation of
several methods of assessment, including (1) indices of body build
and (2) clinical judgment of general nutritional status.
The study began in 1934. It was a cooperative undertaking of
Yale University through the Institute of Human Relations and the
department of pediatrics of the School of Medicine and of the Chil
dren’s Bureau of the United States Department of Labor, in coopera
tion with the Department of Health and the Board of Education,
New Haven, Conn.
The study was proposed by Frank K. Shuttleworth, Ph. D., of the
Institute of Human Relations, who participated in outlining the original
schedules and who made preliminary statistical analyses of the data.
It was carried out under the direction of the following members of
the respective staffs: Mark A. May, Ph. D., Director of the Institute;
Grover F. Powers, M. D., Professor of Pediatrics, the Yale University
School of Medicine; and Martha M. Eliot, M. D., Assistant Chief
of the Children’s Bureau.
The general supervision of the field work and the physical examina
tions were carried out and a preliminary report of the clinical aspects
of the study was prepared by Susan P. Souther, M. D., now of the
Connecticut State Department of Health and formerly on the staff of
the Children’s Bureau; the anthropometric measurements were taken
by Mary E. Parker, R. N. Assistance in some of the clinical and
anthropometric aspects of the study was given by Ethel C. Dunham,
M. D., and Clara E. Hayes, M . D., of the Children’s Bureau, and
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VI
LETTER OF TRANSMITTAL
Sander E. Lachman, M. D., then on the staff of the Institute of Human
Relations, Yale University.
After the observations were collected, the analysis was directed and
the final report prepared by Rachel M. Jenss, Sc. D., statistician in
charge of studies of child health and growth, Division of Statistical
Research, Children’s Bureau.
The study has been confined to the problem of evaluating several
methods of assessing physical fitness which have been in more or less
widespread use in this country during recent years. It has not at
tempted to ascertain why certain methods fail nor has it undertaken
the problem of developing new methods of assessment.
It is hoped that the report will resolve some of the difficulties and
confusion which have existed concerning the more generally accepted
methods of assessment of physical fitness, and that later a more
constructive approach can be made to the problem of assessing the
physical fitness of school children.
Acknowledgment is made to Robert J. Myers, Ph.D., Director of
the Division of Statistical Research, and to the following members of
the section on child growth and development, Division of Statistical
Research, for assistance given in the analysis and preparation of the
report: Marie G. Fullam, Mollie Orshansky, Helen R. Robinson, and
Lois F. Smith.
Respectfully submitted.
K a t h a r i n e F . L e n r o o t , Chief.
Hon. F r a n c e s P e r k i n s ,
Secretary of Labor.
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METHODS OF ASSESSING THE PHYSICAL
FITNESS OF CHILDREN
Introduction
The importance of safeguarding the child’s health and physical
fitness, not only for his own sake but also for the welfare of society,
is axiomatic. It follows directly that if his health is to be protected,
the child must be observed at regular intervals in order to ascertain
his physical condition and to determine whether he needs medical
attention or nutritional advice and assistance. How is such an as
sessment to be made? Various methods are available. Some of
them are elaborate, others are more simple; some are based on clinical
examination, others depend on exacting laboratory techniques or are
derived from anthropometric measurements of the child. It is
important to know the relative value of these procedures. Which
of the various methods of assessment in use in this country at the
present time may be both easy and inexpensive to apply, and produc
tive of results?
This question forms the basis for a study of the physical fitness of
7-year-old white boys and girls 1 living in New Haven, Conn., from
September 1934 through May 1936.2 The investigation was under
taken by the Children’s Bureau of the United States Department of
Labor, the Institute of Human Relations of Yale University, and the
Department of Pediatrics of the Yale University School of Medicine,
in cooperation with the Board of Education and the Department of
Health of New Haven.
Before describing the materials and methods of this study, it may
be well to define the term “ physical fitness” and to outline each of the
methods of assessment. Physical fitness is a comprehensive term
which is broader than either health or nutrition. It includes the
child’s general nutritional status and the presence or absence of
organic defects, both considered in relation to his general physical
condition evaluated in terms of his own previous growth and develop
ment. Unfortunately, it is rather elusive of definition and difficult
1 Age is defined in completed years on the last birthday.
3 The children were examined for the first time when they were 6 years old, but the report is based on the
observations made when the boys and girls were 7 years of age, amplified and interpreted in relation to the
earlier findings.
1
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2
A S S E S S IN G
THE
P H Y S IC A L
F IT N E S S
OF
C H IL D R E N
to determine because of the fact that it evaluates the child’s present
condition as a junctional state which is partly the result of previous
growth and which, in turn, will affect his future health and well-being.
The child’s physical fitness is related to a large number of factors,
both endogenous and exogenous. Perhaps most intimately asso
ciated with his physical well-being are the child’s present health and
nutrition as well as his psychological state, each judged in relation to
his heredity, his general disease history, and his previous growth and
development. But equally and sometimes even more important is
the child’s socioeconomic background, because it is safe to assume
that if the family’s income is below a certain level, the child runs the
risk of being physically unfit as a result of unsatisfactory living con
ditions 3 and of a suboptimal intake of the proper dietary constituents.
Although it is difficult, if not impossible, to point out all the factors 4
which may play a role in affecting the child’s physical fitness, it may
be said in summary that the child’s well-being is dependent not only
on his present condition but also on his previous history (familial,
antenatal, and postnatal). Together they determine his ability to
compensate for or overcome his present defects and handicaps, and
his future incapacities as well.
It is obviously impossible at present to appraise correctly a child’s
physical fitness. Not all the factors that affect a child’s well-being
nor their interrelationships are known; no satisfactory methods of
measuring some of these factors are available; and many procedures
which are satisfactory for judging specific aspects of a child’s condition
are too elaborate for widespread application, or the cost involved pro
hibits their inclusion in a school health program or a community
survey.
3 The term “ unsatisfactory living conditions” is used to include such factors as overcrowding; short hours
of sleep or lack of conditions for sound, restful sleep; poor ventilation; and lack of sunlight.
4 Home hygiene, as well as discipline and control both at home and in the school, must also he considered.
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Methods o f Assessing Physical Fitness
Several methods of assessing physical fitness are in use at the present
time. They include the clinical examination, specific biochemical
tests for particular nutritional deficiencies, tests of functional well
being, dietary and socioeconomic surveys, and anthropometric
measures of body build.
The Clinical Examination
The child’s “ apparent” physical condition can be assessed by a
physician. This examination will obviously reveal such conditions as
thinness, faulty posture, flabbiness of muscles, and certain marked
nutritional or organic defects, but at best it gives only an approxi
mate evaluation. There is an increasing realization of the difficulties
of assessing a child’s condition by this method alone.1
In an article on the incidence and assessment of malnutrition
Harris discusses four sources of error.2 They are summarized as
follows:
1. Inadequate clinical methods are used. Examinations are usually
carried out under circumstances which require the inspection of large
numbers of children in a relatively short time. Consequently laboratory techniques or the more refined methods necessary for detecting
the presence of early or slight malnutrition are usually omitted.
2. Debased standards are used. It is commonly known that such
figures as those for the average weights and heights of school children
of a given age and sex have undergone a steady and marked rise during
recent years. Furthermore, the average weights and heights of groups
of children who have been fed on approved dietaries have increased
beyond the weights and heights of comparable groups of children who
were given neither appropriate nor supplemental diets. It is obvious,
therefore, that standards which rely on past averages instead of on
more recent and comparable data are dependent on the use of a
debased norm, and hence, always tend to be underestimates.
3. No standards are known for assessing malnutrition; consequently
no satisfactory way of measuring it exists.
1 See Appendix II: (61) Jones, (60) Lucas et aj., (120) Wilkins. For a more extended discussion, see (121)
Wilkins. The italicized numbers in parentheses refer to the numbered list of references to be found in
Appendix II, pp. 115-121.
2 See Appendix II: (44) Harris, pp. 225-226.
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4
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
4.
The effects of malnutrition are delayed. Of the failure of a
superficial clinical examination to reveal abnormal conditions which
may have a delayed effect, Harris says:
It is obvious that the grosser results of malnutrition can generally be detected
readily enough by the clinical observer * * * . It is rather the earlier
effects, the influence of partial deficiencies, which may pass unobserved if reliance
be placed on cursory clinical examination— and yet these “ milder,” less readily
detected, types of deprivation may none the less have a profound influence,
delayed it may be, on the health and well-being of the subject.3
Biochemical Tests for Specific Nutritional
Deficiencies
Biochemical tests can be made for particular deficiencies including
the vitamins, the inorganic elements such as iron, calcium, phosphate,
and other important dietary constituents. Many of these tests are
complicated and expensive; others, particularly those for the vitamins,
lack specificity or sensitivity; all of them have limited value in assess
ing physical fitness because they measure only particular nutritional
deficiencies.
Functional Tests
Under the general heading of functional tests may be included,
among others, tests of lumbar pull (on a dynamometer), vital capacity,
and basal metabolism.4 Many of these techniques are still in a devel
opmental stage and require further study and application before satis
factory norms are available. But even when such standards have
been developed, giving the tests will require special training or equip
ment and will, therefore, be beyond the reach of the average publichealth officer or school official. Furthermore, they give only a partial
answer to the question “ Is the child physically fit?”
3 See Appendix II: (44) Harris, p. 225.
4 (87) Pryor and Smith give a brief review of the history of strength tests, including the use of the ergograph and Kellogg’s universal dynamometer, and Sargent’s chinning and dipping tests to judge endurance.
Qalton’s tests of reaction time to auditory and visual signals are also mentioned.
For illustration of the use of tests of vital capacity and tests with the spring dynamometer, see Appen
dix II: (19) Cheesman, (118) Warrington [England], reference to Magee in (44) Harris, p. 227, (69) Milligan,
and (128) W oolham and Sparrow. See (118) Warrington [England] for application of the Romberg test
for determining a child’s power of equilibration and coordination and (127) W oolham and H oneybum e,
for pulse and respiratory tests.
For attempts to use standard athletic performances such as the 60-meter race, ball throwing, and jumping
as indications of physical fitness, see (129) W roczynski, p. 673.
Standards based on combinations of various tests of physical performance have also been derived. For
example, a physical-fitness index has been developed b y (92) Rogers. See also (128) W oolham and Sparrow
for a physiological formula developed b y Flack and Woolham.
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METHODS OF ASSESSMENT
5
Dietary Inquiry
A detailed inquiry may be made into the dietary habits and en
vironment of the child in order to estimate his nutritional status.5
Wilkins, pointing out the fundamental importance of this aspect of
the problem, writes:
Workers in animal nutrition know only too well that a diet must be tested,
not only through the whole life of the individual, but through at least three or
four generations before it can be passed as fully adequate. Yet it is customary
to pass children, the most valuable animals of all, as normal in their nutrition,
and, presumably, therefore to pronounce their diets fully adequate in each and
every constituent, without any inquiry into the details of their diets, and with
out even testing the efficiency of a single bodily function. 6
Making detailed dietary inquiries is, however, difficult. They are
also expensive and time-consuming, for they require the services of
well-trained observers and the whole-hearted cooperation of the child
and his family.
Socioeconomic Inquiry
An estimate of the net family income per capita gives a fairly
reliable basis for estimating whether a satisfactory diet is purchasable,
because, as Wilkins has pointed out, “ Enough work has been done
on family budgets and minimum costs of living to enable us to make a
rough estimate of the nutritional possibilities of any family.” 7
On the other hand, although it is inevitable that if the money avail
able for food is inadequate the child’s diet is unsatisfactory and his
health suffers, it should be pointed out, as is stated in an editorial
which appeared in the Journal of the American Medical Association,
that “ malnutrition is no longer considered to be exclusively an out
come of poverty or bad environment.” 8
Anthropometric Measures o f Body Build
Because of the difficulties involved in the application and the
appraisal of the techniques that have been discussed, attempts were
begun to derive indices of body build, based on the interrelations of
4 See Appendix II: (11) Boudreau and Kruse, (44) Harris, (89) Roberts, and (191) Wilkins.
For discussion of what constitutes an adequate diet, see Appendix II: (86) Friend, (4-1) Great Britain M in
istry of Health Advisory Committee on Nutrition, (61) McCarrison, (94) Rose, (108) Sherman, and (109)
Stiebeling and Clark.
6 See Appendix II: (181) Wilkins, p. 145.
7 See Appendix II: (181) Wilkins, p. 146. See also (44) Harris and reference to British Medical Association
Committee on Nutrition in (44) Harris, and (89) Roberts.
8 See Appendix II: (47) Indexes of Nutrition, p. 1286,
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6
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
certain anthropometric measurements.9 These indices are used to
predict a measure of the child’s well-being, such as his weight or arm
girth in terms of his physique or body build. They assess physical
fitness only insofar as it is related to abnormalities in such measures.
Four of these indices, which have received widespread application
in the United States, have been applied to the children included in this
study: 10
(1) The Baldwin-Wood Tables published in 1923.
(2) The A CH (arm-chest-hip) Index developed and published by the
American Child Health Association in 1934.
(3) The Nutritional Status Indices of Franzen published by the American
Child Health Association in 1935.
(4) The Pryor Width-Weight Tables published in 1936.
These indices are based directly or indirectly on statistical techniques
(multiple-regression procedures) which are not always employed in the
development and application of other methods of assessment. For
this reason it is probably advisable to describe in some detail the
fundamental hypotheses on which they have been based, the possible
limitations of this type of approach, and the exact methods of applying
and evaluating each index, and to review critically other studies which
have been made to test the effectiveness of these indices in identifying
children who may be in need of medical care or nutritional advice and
assistance.
9
This type of index is to be distinguished from simple ratios, which have been in use for a great m any
years, although they are not generally applied in the XJnited States at the present time. As early as 1829,
Weight
Bufionreportedsuclranindex or ratio in theform,
It was modified b y Quetelet in 1836, b y Rohrer
in 1908, b y Tuxford in 1917, and b y Bardeen in 1920. Tuxford’s modification was more elaborate than the
others. He proposed the following formulas as a measure of the physical development of school children:
For boys: W ei^tÇ kgQ
Height (cm .)
S Si-age in months
54
During the W orld W ar Pirquet developed a system for assessing nutrition which included a ratio based on
weight and stem length. It is known as the “ pelidisi” index and depends on the relationship
Y WeightXlO
- y / Stem length
Other measurements have also been used in deriving this type of index.
Bernhardt used the following formula for predicting weight:
For example, as early as 1886,
HeightXChest measurement
W eigh t= :
240
and in 1901, Oppenheimer put forth a “ nutritional quotient” defined b y the ratio
M axim um girth of relaxed arm X 100
Chest circumference at end of expiration
Other indices m ay be mentioned which illustrate the use of combinations of tests of physical performance.
One is a physiological formula known as the Flack-W oolham product (1923).' The second is an anatomical
ratio called the Dreyer product (1919).
For a more complete description see Appendix II: (85) Paton and Findlay, pp. 51-57, on which most of
the above discussion is based. See also (57) Dreyer, (89) Roberts, pp. 57-83, (114) Tuxford, and (158) W oolham and Sparrow.
10
See Appendix II: (6) Baldwin and W ood, (85) Franzen and Palmer, (75) Nutritional Status Indices,
and (86) Pryor.
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Indices o f Body Build as a Method o f
Assessment o f Physical Fitness
A number of problems arise in studying these indices of bodybuild.
For example, the question is frequently asked: Can external measure
ments of the human body be used to assess a child’s physical fitness,
especially if there is an early or slight departure from health or if he
is suffering from a mild form of nutritional disorder? Can they
identify the child who is overweight but flabby or the one who is
overdeveloped? It has been pointed out in this connection ihat
such indices attempt only a quantitative evaluation of the child’s
condition and that the qualitative aspects are ignored. To be more
specific: Can an index of body build differentiate between organic
and dietary causes of undernutrition? Does it take inherited or
constitutional factors into account? M ay not long-continued mal
nutrition have interfered with a child’s growth to the extent that
anthropometric measurements cannot be used to evaluate his physical
fitness?
It is also well to bear in mind that recent studies of weight and
weight increments have shown that certain years are “ good growing
years” and others are not.1 Does this phenomenon affect the value
of the indices? Can seasonal variations in the measurements from
which they have been derived be ignored?
Many other questions have been asked. A discussion of their
significance has been omitted, however, since this investigation is
concerned with the identification of children who may be physically
unfit and not with detailed technical problems in methodology.
Nevertheless it may be worth while to indicate the nature of some of
these questions.
For example, a great many statistical problems arise in connection
with the development and application of these indices. Do the basic
data comply with the hypotheses which the mathematical procedures
require; i. e., are the anthropometric measures normally distributed
and is their relationship linear? Are the mathematical procedures
correctly applied? Is the technique equally applicable to both sexes?
To children of different ages? Is the definition of age used in deriving
the indices too broad? Is an index more satisfactory if it is based
on longitudinal instead of cross-sectional data? In other words, if
1 See Appendix II: (77) Palmer, p. 1453, which refers to earlier paper b y same author (80).
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8
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
an index for 6-year-old and also for 7-year-old children is derived
from successive measurements of the same group of boys and girls, is
it more reliable than if it were based on measurements of one group
6 years of age and another group 7 years of age?
In applying these indices the child's observed measure is judged in
relation to the average or expected measurement of his skeletal peers.
For example, the Baldwin-Wood Tables identify as skeletal peers
children who are of the same sex, age, and height. These three
factors are interrelated in such a way as to determine the child's
expected weight, which is in reality the measurement for an average
child of the same sex, age, and build (height). Now, such an average
is dependent on the kind of children whose measurements have been
included. If one assumes that the observations from which such an
index has been developed are also representative of the group to which
it is applied, the question still remains—how far does the average
represent the normal, according to a dictionary definition of the latter
term as applied in the medical and biological sciences—“ conforming
to natural order or law." 2
It should be remembered in this connection that the average anthro
pometric measurements of school children of a given sex and age
have shown a steady increase during the last 15 or 20 years.3 Does
this evident change in physique necessitate the construction of new
indices at certain intervals? Likewise, it has been shown that in
experimental trials the average weight and height of groups of children
who have been fed on improved dietaries have unproved beyond the
weight and height of the controls or of previously comparable aver
ages.4 Do these findings indicate the use of debased standards?
One may also inquire: What are the standards of normal variation?
How much may a child's measure deviate from the average and still
be considered satisfactory? Is this deviation to be expressed in
absolute or relative terms or by means of more elaborate statistical
procedures?
It is essential also to know the kind of children whose measurements
were used for deriving the indices. In other words, what racial,
socioeconomic, and geographic groups do these boys and girls repre
sent, and are they healthy children? In this connection it is inter
esting to note that the White House Conference of 1930 pointed out
that most of the available standards do not represent desirable combi
nations of heritage, history, and home influence, and that further
2 See Appendix II: (88) Gould, p. 961.
2 See Appendix II: (13) Brewer, p. 91, (86) Friend, pp. 27-28, 73, (40) Great Britain Board of Education,
p. 25, (48) Jacob, and (116) Wallsend [England] Education Committee, p. 11. See also references to Rowland
and Stockwell contained in (39) Great Britain Board of Education, p. 23, and see (189) Wroczynski, pp.
595-596, 678, for references to Fessard, Laufer and Laugier, Koch, and W olff.
4 See Appendix II: (44) Harris, p. 226. He refers to studies b y Corry M ann, Leighton and Clark, Orr,
and Scharff and Sinnadorai. See also (69) Loewenthal, (90) Roberts et al., and (106) Simpson and W ood.
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INDICES OF BODY BUILD IN ASSESSING NUTRITION
9
biometric work will be necessary to furnish norms for promoting
useful application of measurement.5
Finally, in evaluating an index it is important to consider the chil
dren whom it fails to identify as well as those whom it selects as
likely to be physically unfit, for although an index may identify some
children who are in need of medical attention or nutritional advice
and assistance, it may fail to select an even larger number of such
children than it identifies. On the other hand, it may select not only
all the children who are physically unfit but also a large number of
healthy boys and girls. In other words, it is important to know just
how efficient such an index is.
The preceding discussion of the limitations of this type of approach,
based on the prediction of one measure of the child’s fitness in terms of
its relation to his physique or body build, has not attempted to review
critically the questions which have been raised, because this study is
not concerned with the more technical aspects of evaluating these
indices as a method of assessing physical fitness.6
5 See Appendix II: (119) W hite House Conference on Child Health and Protection, p. 323.
6 It is suggested that the reader who is interested in the more technical aspects of evaluation consult such
papers as those of (9) Bigwood, pp. 172-173, (34) Pranzen, (49) Jenkins, (50) Jones, (66) Marshall, (78) Palmer,
(95) and (96) Rosenow, and (117) Warner, listed in Appendix H.
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The Four Indices o f Body Build Included
in the Study
Before giving a detailed description of the four indices included in
this study, it may be well to reemphasize the fact that they evaluate
physical fitness only insofar as it is related to abnormalities of certain
measures of the child; for example, his weight or arm girth judged in
relation to his body build.
Description o f Each Index o f Body Build
THE BALDWIN-WOOD TABLES
The index of body build based on the Baldwin-Wood Tables
estimates a boy’s or girl’s weight in terms of his or her height (to the
nearest inch) used as a criterion of body build at a given age (taken at
the nearest birthday). Tables have been derived for ages 5 through
19 for boys and 5 through 18 for girls from which it is possible to de
termine what the child should weigh for his sex, age, and height (used
as a criterion of body build). Then the difference between his
observed and his expected weight is expressed as a percentage of the
expected weight. Baldwin 1 has allowed a deviation of less than 6
percent from the average or expected weight for any height, age
(under 10 years),2 and sex for individual variations. A larger deviation
(6 or more percent) indicates that a child is likely to be in need of
medical attention.3
Measurements of an Italian child, A. R., who was included in the
study, may be used to illustrate the computation of this index. (See
sample schedule of physical measurements.)
It may be seen from this sample schedule that the Italian boy,
A. R., weighed 46 pounds and was 44 inches tall when he was 7 years
of age (7 years, 1 month, 6 days). According to the Baldwin-Wood
Tables the average 7-year-old boy who is as tall as A. R. weighs 44
/46-44\
pounds. In other words, A. R. was 4.5 percent overweight ( —
)
in terms of the Baldwin-Wood standard.
i See Appendix II: (5) Baldwin, p. 4.
2If the child is 10 or more years of age, Baldwin has allowed less thhn 8 percent variation. T he majority
of workers, however, have allowed under 7 or less than 10 percent for children of all ages. See, for example, in
Appendix II: (28) Clark, Sydenstricker, and Collins, (28) Dublin and Gebhart, and (80) Emerson and
M anny.
3
According to Baldwin, “ children who are 15 percent overweight for their height and age m ay also be in
need of medical attention” (see Appendix II: (5) Baldwin, p. 4); but this aspect of the problem of physical
fitness has not been considered in the present report.
10
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FOUR INDICES OF BODY BUILD DESCRIBED
11
PHYSICAL MEASUREMENTS
C h il d r e n ’s B
I n s t it u t e
op
H
um an
R
ureau
U. S.
,
e l a t io n s
U
Name_____ A . R .
Address
—
Date
School
Grade
Age
Weight (lb.)
Height (in.)
Arm girth (cm.)
Flexed
Relaxed
Total
S u b cu ta n eou s
tissue 4
I
II
Total
C h e s t b r e a d th
(cm.)
Inspiration
Expiration
Total
Chest depth
(cm.)
Inspiration
Expiration
Total
Hips (cm.)
Trochanter
Crest
Date
Weight
Race
Main Street
¡/
Boy
and
D
P
epartm ent
e d ia t r ic
D
op
L abor
epartm ent
op
Y
ale
n iv e r s it y
I ta lia n
Examination Number 277
:
"
'
—
Born: Year 28 Month 9 day 4
Girl
1 0 /9 /3 4
Harbor
I
6 /1 / 5
41f
42*
4 /8 /3 5
Harbor
I
6 /7 / 4
43*
42*
1 7 .5
1 6 .3
3 3 .8
1 8 .2
1 6 .5
3 4 .7
1 8 .4
1 6 .6
3 5 .0
II
10*
21*
II
11
22
10*
10*
21
1 8 .1
1 7 .2
3 5 .3
1 8 .1
1 7 .5
3 5 .6
1 8 .5
1 7 .9
3 6 .4
1 3 .6
1 2 .6
2 6 .2
1 3 .7
1 3 .0
2 6 .7
1 4 .5
1 3 .7
2 8 .2
1 9 .9
1 9 .4
1 9 .9
1 9 .6
2 0 .4
2 0 .2
9 /2 5 /3 4
40*
1 /2 3 /3 5
43*
1 0 /1 0 /3 5
Harbor
II
7 /1 /6
46
44
5 /2 7 /3 5 9 /1 8 /3 5 1 /2 3 /3 6
43*
44
47*
5 /2 7 /3 6
48
n e m i i ^ T W w n 'cutTai*e.ous tissu® were made according to the technique described in AparMtrary units Nutntlona Status Indices, pp. 8-10, using a special subcutaneous-tissue caliper which has
THE ACH (ARM-CHEST-HIP) INDEX
The ACH Index was developed by the American Child Health
Association in 1934 and is “ a screening technique constructed to meet
the demand for a practical method of selecting, from a large group,
those children who need a medical examination because they have
extremely small amounts of musculature and subcutaneous tissue.” 6
More specifically, “ when the case is selected he is certain to have an
arm-girth deficiency and very likely to be deficient in subcutaneous
tissue and weight as well.” 6
‘ See Appendix II: (7g) Nutritional Status Indices, p. 1.
• See Appendix II: (35) Franzen and Palmer, p. 11.
239848°— 10----- 2
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,
12
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
Basic tables have been prepared for children of each sex aged from
7 through 12 years (age at last birthday) who have hip widths ranging
from below 20.0 cm. to 29.0 cm. and above. These tables give the
m in im u m difference between arm girth and chest depth7 (AG — CD)
for a given hip width (at the trochanters). If the difference between a
child’s arm girth and his chest depth is exactly equal to or less than
the value given in the table, the boy or girl is identified as in need of
further examination. On the other hand, if the difference is greater
than this minimum, the child is not selected.
The original ACH Index was set to select “ about 10 percent of a
group (in a broad, general sampling). About 60 percent of this selec
tion are extreme-defect cases and over 80 percent are either extreme
defects or those that border on extreme defects. It does miss some
extreme-defect cases and these omissions are deliberately sacrificed in
the interest of speed and simplicity of measurement.” 8 The scale has
also been set to select 14, 20, or 25 percent of a group of boys or girls.9
The 25-percent selection contains nearly all (about 90 percent) of the
extreme-defect cases that can be identified if the more elaborate
Nutritional Status Indices (described on pp. 13-16) had been applied
to the entire group of children in the first place, but it also includes
an appreciable number of children who do not have extreme de
fects. In other words, it is probably advisable to apply the more
refined method, namely, the Nutritional Status Indices, to the pre
liminary ACH 25-percent selection.
Though the index screens out the children with “ extremely small
amounts of soft tissue * * * it does not make individual distinc
tions between the children. Neither does it discriminate, for a given
child, between a deficiency in musculature as opposed to a deficiency
in subcutaneous tissue. * * * The ACH Index was intentionally
so restricted in order that the practical time limits for measurement
in a school or other group situation would not be exceeded.” 10
According to Franzen and Palmer: “ The use that is to be made of
the index depends upon the objectives sought. If we wish to be
sure to identify all extreme-defect cases, then the screen method
[25-percent selection] with the additional measures is indicated. If,
on the other hand, this is not feasible and we are content merely with
knowing that the cases are for the most part severe defects and do
warrant review by a physician, then the simpler * * * method
[10-percent selection] answers the purpose.” The index used in this
way “ is intended both as an aid to the physician and as a mass
7 Both these values represent the sum of two measurements: Chest depth, that is, the measurements for
expiration and inspiration; and arm girth, that is, the measurements of the upper arm, hexed and relaxed.
8 See Appendix II: (86) Franzen and Palmer, p. 5.
See Appendix
(76) Nutritional Status Indices, p. 66.
i° See Appendix
(76) Nutritional Status Indices, p. 2.
8
n:
n:
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FOUR INDICES OF BODY BUILD DESCRIBED
13
selective measure for comparing groups.” 11 If desired, the index
may also be set to identify 14 percent or 20 percent of the children.
The calculation of the ACH Index can also be illustrated for the
Italian boy, A. R. The sample schedule of physical measurements
(see p. 11) shows that at 7 years of age he had an arm-girth measure
ment of 35.0 cm. (sum of 18.4 cm. flexed and 16.6 cm. relaxed) and
a chest-depth measurement of 28.2 cm. (sum of 14.5 cm. inspiration
and 13.7 cm . expiration). The difference between his arm girth and his
chest depth is 6.8 cm. The width of his hips at the trochanters was
20.4 cm. The tables show that for a boy of 7 years with a hip width
between 20.0 cm. and 20.4 cm. the minimum difference between the
arm-girth and chest-depth measurements is 0.0 cm., if 10 percent of
the group of boys are to be identified;12 0.5 cm., if 14 percent;13
1.0 cm., if 20 percent;13 and 1.5 cm., if 25 percent13 of the boys are
to be selected for either further measurement or direct reference to
a physician. As the difference between A. R .’s arm girth and chest
depth (6.8 cm.) is larger than any of these minimum differences, it
follows that he does not fall in the lowest 10, 14, 20, or 25 percent of
the boys in respect to a deficiency in arm girth and probably a de
ficiency in subcutaneous tissue and weight as well.14
THE NUTRITIONAL STATUS INDICES
Tables for the Nutritional Status Indices were developed by
Franzen and his coworkers in the American Child Health Association
in 1935. They may be used to evaluate a child’s condition from 7
through 12 years of age (age at last birthday) in terms of his weight,
muscle size (as indicated by the girth of the upper arm), and the
amount of subcutaneous tissue (measured over the biceps). Each
of these three measures is compared with the weight, arm girth, or
subcutaneous tissue which the average child of the same sex and age
is expected to have for his skeletal build, judged in terms of his
height, the width and depth of his chest, and his bitrochanteric
width.
These comparisons make it possible to determine the child’s stand
ing in weight, arm girth, and subcutaneous tissue in relation to other
children of comparable skeletal build. Thus it is possible to calcu
late the number in 1,000 children of the same sex, age, and skeletal
build who have smaller indices of weight, of arm girth, and of sub
cutaneous tissue than the child examined.
U See Appendix
12 See Appendix
13 See Appendix
ii See Appendix
II:
II:
II:
II:
(SB)
(SB)
(75)
(35)
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Franzen and Palmer, p. 7.
Franzen and Palmer, p. 12.
Nutritional Status Indices, p. 66.
Franzen and Palmer, p. 11.
14
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
This procedure was devised not only to reveal differences in the
nutritional status of children 15 but also to discriminate between a
deficiency in musculature and a deficiency in weight or subcutaneous
tissue, “ a distinction that is important if differential diagnosis of
nutritional status is to be made.” 16 The indices “ are not intended to
supplant the physician in the diagnosing of malnutrition. Rather,
they fu rnish the physician with more adequate evidence for his diag
nosis than he has had in the past. Using these indices, in conjunction
with other clinical signs, the physician can diagnose the condition and
prescribe what shall be done.” 17
The score card for Nutritional Status Indices shows the steps
necessary for the calculation of the three Nutritional Status Indices.
The computations for the weight index may be found on page 16.
The procedures for evaluating the other two— namely, the child’s arm
girth and subcutaneous tissue— are not described because they in
volve similar calculations.
16 Defective nutrition is defined b y Franzen and his coworkers as “ a low amount of arm girth, subcu
taneous tissue and weight, each for skeletal build. Our definition is specific, but it represents a condition
which includes m any other subjective signs.” See Appendix II: (83) Physical Defects; the pathway to
correction, p. 63.
In 1935 Mitchell, who was also associated with this group, added: “ These measurements compared with a
.random 1,000 children of the same skeletal build are not in themselves an evaluation of nutritional status,
but they do give reliable, objective, and valid distinctions in weight, musculature, and adiposity which are
significant in such an appraisal. They are indices of physical signs which should be properly evaluated in
a composite of signs and symptoms. Of course, deviations from an average should not be interpreted
directly as desirable and undesirable signs, but the average provides a convenient reference point which
gives definiteness to the measurements. The use of accurate distinctions in these three physical signs
releases the clinician from the difficulties of individual judgment and gives him greater freedom to apply all
the subtleties of the art of medicine in judging function, growth, and development and all the intricate
factors involved in the nutritional process.”
See Appendix II: (71) Mitchell, p. 319.
16 See Appendix II: (76) Nutritional Status Indices, p. 2.
11 See Appendix II: Ibid., p. 5.
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15
FOUR INDICES OF BODY BUILD DESCRIBED
SCORE CARD FOR NUTRITIONAL STATUS INDICES 1
Name
A .R .
School
H arbor
Sex M
Room
Age 7
Grade I I
Date 10/10/35
M EASUREM ENTS
Arm Girth
Flexed
a
18. 4
Relaxed
b
16. 6
d
10. 5
e
10. 5
Subcutaneous Tissue over the
Biceps
c
3 5 .0
f
2 1 .0
Weight
g _ 4 6 .0
Height
h
4 4 .0
k
3 6 .4
n
2 8 .2
0
2 0 .4
Chest Breadth
Chest Depth
17..9
Expiration
i
Inspiration
j _ 18 .5
Expiration
1
Inspiration
m
13 .7
14 .5
Width of Hips
C O M P U T A T IO N OF IN D IC E S
Arm Girth
+
Value
Value
W eight
Sub. Tissue
+
Value
Measure
9 9 .1
6 2 .2
Height
1 1 .5
1 0 .0
+
Value
Value
Value
1 1 8 .4
8 .2
1 1 .3
1 .8
1 2 .4
Chest Depth
1 4 .3
4 .8
1 1 .7
Hip Width
Adjustments for age
1 6 .2
0
1 8 .3
1 .8
2 2 .4
1 .5
+ 1 1 0 .6 - 4 1 . 8
6 8 .8
+ 7 2 .2 - 2 6 . 7
4 5 .5
+ 1 1 8 .4 - 5 6 .2
6 2 .2
Ch. Breadth
f
Sums
Indices
No. in 1,000 with smaller
indices
964
,309
i This form is presented in (75) Nutritional Status Indices, p. 15 (see Appendix II).
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885
16
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
The detailed steps in the determination of this weight index for the
Italian boy, A. R., are presented at this point. The exact wording
used in the instructions given in the monograph, Nutritional Status
Indices, has been followed as closely as possible.
a. Look up A. R .’s weight under Weight Reading in Table C for 7- to 9-year-old
boys (see p. 24 of the monograph, Nutritional Status Indices) 18 and record the
corresponding table value on the line opposite “ Measure” on the score card (score
card for Nutritional Status Indices) in the plus ( + ) column under “ Weight.”
The table value for A. R .’s weight of 46.0 lb. is 118.4.
b. Look up his height under Height Reading in Table D, p. 25. Opposite the
reading are three values. Select the one for weight and record this value in the
line opposite “ Height” in the section under the proper heading on the score card.
Since the value is negative it is to be entered in the minus (—) column. A. R .’s
height was 44.0 in., which has the following table value for weight: —8.2.
c. Look up his chest-breadth measurement in Table E, p. 26. Record on the
score card the table value given for weight and enter this value opposite “ Chest
Breadth” under the proper index heading in the column with the appropriate sign.
A. R .’s chest breadth of 36.4 cm. has a table value for weight of — 12.4. Since
this is a negative value, enter it in the negative column.
d. Similarly, obtain the values for his chest depth, Table F, p. 27, and for hip
width, Table G, p. 28. The table values for A. R. are written on his score card
(score card for Nutritional Status Indices).
e. Look up his age in Table H. Since A. R. is a 7-year-old boy, 7 but not 8,
the table value for his age to be used for his weight-index calculation is — 1.5.
Enter this value on the line opposite “ Adjustments for Age” under the proper
index heading in the column with the appropriate sign.
/ . Add the figures in the plus column for the weight index and record the total
in the plus column on the line opposite “ Sums.”
Likewise, add the figures in the
minus column and record the total in the minus column on the line opposite
“ Sums.” These two sums for A. R .’s weight index are + 118.4 and —56.2.
g. Subtract the sum of the values in the negative column (56.2) from the sum of
the values in the positive column (118.4) and record the difference (62.2) in the
line opposite “ Indices.” This score, 62.2, is A. R .’s nutritional index for weight
and is strictly comparable with his indices for arm girth and subcutaneous tissue.
By referring this score or index to Table X of the monograph, Nutritional Status
Indices, p. 65, A. R .’s standing in weight relative to others like him in skeletal build
may be obtained. Using Table X , look up 62.2, A. R .’s weight score. The table
value opposite this is 885, the number in 1,000 children of the same sex, age, and
skeletal build who have smaller weight indices (scores) than A. R. In other words,
among a general sampling of 1,000 boys of the same age and skeletal build, 885 in
1,000 weigh less than A. R .19
In order to facilitate comparisons with the other indices included in
this study, Table X of the monograph, Nutritional Status Indices, has
been modified to show the number of children in 100, instead of in
1,000, having less than a given score in one of the Nutritional Status
Indices. When this revised form of Table X is used 88 (88.5) boys in
100 of the same age and skeletal build weigh less than A. R.
18 See Appendix II: Ibid., p. 24.
19 This description of the method of computing the Nutritional Status Index for W eight is based on the
illustration given on pp. 14-18 of the monograph, Nutritional Status Indices. See Appendix II: (75).
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FOUR INDICES OF BODY BUILD DESCRIBED
17
THE PRYOR WIDTH-WEIGHT TABLES
The Pryor Tables estimate the average weight of a boy or girl of a
given age (at nearest birthday) and body build, judged in terms of
his or her height (to the nearest inch) and bi-iliac diameter.
The calculation of this index also may be illustrated for the Italian
boy, A. R .: According to the sample schedule of physical measure
ments (see p. 11), when A. R. was 7 years old his height was 44 in.,
his weight was 46 lb., and “ the width of his iliac crest’ *was 20.2 cm.20
As the Pryor Table for 7-year-old boys does not give the expected or
average weight for a boy who is 44 in. tall and has a crest measure
ment of 20.2 cm., it is necessary to approximate A. R .’s expected
weight. The following method is used: The table gives the average
weight, 42 lb., for a boy of the same height as A. R., who has a bi-iliac
diameter of 19.3 cm. (0.9 cm. less than A. R .’s). It also gives the
expected weight, 46 lb., for a boy of the same height who has a diam
eter of 21.5 cm. In other words, an increase of 2.2 cm. (21.5 cm.
— 19.3 cm.) in the width of the iliac crest— to use one of Pryor’s
terms— corresponds to an increase of 4 lb. in the average weight of a
boy of this age and height. A. R .’s crest measurement is 0.9 cm.
larger than the smaller of these two diameters given in the table and
corresponds approximately to a weight increase of 1.6 lb., which is
added to the average weight, 42 lb., of a boy with a bi-iliac diameter
of 19.3 cm., giving an expected weight of 43.6 lb. for a child who was
weighed with his clothing removed. As the boys and girls included
in this study were weighed wearing their clothing, an allowance of 2
lb. for the weight of the clothing must be made for children who are
more than 40 in. tall.21 Therefore, a 7-year-old boy with the same
height and crest measurements as A. R. weighs, on the average, 45.6
lb. (43.6 lb.+ 2 lb.), compared to A. R., who weighed 46 lb. In other
words, according to this index, A. R. was 0.4 lb. overweight (46-45.6).
As the Pryor Tables do not define the amount of variation in weight
which is within normal limits nor the child’s relative standing in
weight, a procedure has been developed which is comparable to Table
X 22 in the monograph, Nutritional Status Indices.23 It gives the
number in 100 children of the same sex, age, and body build who
weigh less than any individual child. When this method of scoring
is used, 54 boys in 100 of the same sex and build weigh less than A. R.
20 Pryor uses the following terms interchangeably: W idth of iliac crest, bi-iliac diameter, width of pelvic
crest, bicristal diameter, and width of crest of ilium.
21 See Appendix II: (86) Pryor, p. 11.
22 See Appendix II: (76) Nutritional Status Indices, p. 65.
23 The exact method of deriving and using this method of scoring is described in detail in Appendix I,
pp. 97-98. It was approved b y Pryor in a personal communication dated Peb. 3, 1938.
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18
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
Limitations o f the Four Indices o f Body Build
In outlining the limitations of measuring the child’s fitness in terms
of his body build, certain questions which refer either directly or in
directly to the four indices included in this study have been omitted
intentionally from the discussion. For example, Wilkins in an article
entitled “ The Assessment of Nutrition in School Children,” which
appeared in The Medical Officer in 1937, points out a “ subtle error”
in the standard based on the relation of weight to height; namely,
that “ the well-nourished child, while both taller and heavier than the
poorly nourished, is at the same time lighter in relation to its height
than the less well-nourished. In other words, the less well-nourished
child is often heavier in relation to its height than is the betternourished child. This disturbance of the natural relation of weight
to height is, of course, the result of faulty nutrition affecting growth
over a considerable period.” 24
Various workers have also raised questions concerning some of the
measurements used for the Nutritional Status Indices. For example:
Is the amount of subcutaneous tissue which can be picked up asso
ciated with the size of the finger tips? Can one pick up two layers of
the skin of a very fat child, with the calipers set at 30 to standardize
the size of the bite? 25 Are the fat and muscle of the upper arm repre
sentative of the subcutaneous tissue and musculature of the entire
body?
Many other questions arise which one would like to study. For
example: To what extent is an index prognostic as well as diagnostic?
What happens to an index during an acute illness? Is an index related
to a child’s gain in weight or to some other measure of his growth and
development?
24 See Appendix II: (M l) Wilkins, p. 146.
28 The measurements “ are taken with the special subcutaneous-tissue caliper. The examiner stands to
the right of the child and measures the bare right upper arm.
“ Ask the child to extend the bared right arm at right angles to the side of the body, and then to flex the
arm and ‘make a muscle.’ M ark with a pencil the highest point on the biceps muscle. Then have the
child relax and lower his arm. (This highest point on the biceps muscle is the same level at which the girth
of the upper arm is measured and, in actual practice, is marked at the same time the arm-girth measurements
are taken.) Through this ‘biceps point’ draw a short line across the arm. This line furnishes a reference
point for taking the measurements.
“ The size of the ‘bite,’ or the amount of tissue that is grasped, has considerable influence on the accuracy
of this measurement. In order to standardize the amount of tissue grasped, the size of the ‘bite’ is deter
mined b y the caliper itself. Take the caliper in the right hand and open it to a reading of 30. Then, using
the ‘biceps point’ as a center, straddle the blades of the caliper, equally on each side of the ‘biceps point,’
with the lower edges of the blades touching on the horizontal line which has been drawn on the arm. W ith
the left hand above the caliper, place the index finger and the thumb of the left hand in contact with the outer
surface of the caliper blades, remove the caliper, and pinch up the amount of tissue indicated, thus freeing the
tissue from the underlying musculature. Place the blades of the caliper as closely below the index finger
and thum b as possible, release the blades, and measure the thickness of the subcutaneous tissue. Record
the caliper reading.
“ The second measurement is taken in exactly the same w ay as the first, except that to locate the position
of the index finger and the thum b the caliper blades are placed with the upper edges, rather than the lower
edges, touching on the line. The sum of the tw o readings is the Subcutaneous-Tissue measurement.”
See Appendix II: (75) Nutritional Status Indices, pp. 8-10.
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FOUR INDICES OF BODY BUILD DESCRIBED
19
The importance of all these problems is fully recognized, but, on
the other hand, they are necessarily subordinate to the question with
which this study is concerned; namely, do any or all of these indices
satisfactorily measure physical fitness? Warner (1935)26 has sum
marized the criteria which such an index should possess in this manner:
Any satisfactory index of nutritional status (1) must correlate to a
high degree with a clinically acceptable definition of nutrition; (2)
must be objectively determinable; and, finally (3) must be relatively
simple and applicable to the ordinary school health program, and of
such a character that it might be used by persons with only a moderate
amount of training and technical skill.27
The indices included in this study were, of course, designed to
select the child (of a given sex and age) who is physically unfit only
insofar as physical fitness is related to and can be measured by certain
abnormalities of physique. The Baldwin-Wood and Pryor Tables were
developed to identify a boy or girl who is underweight for his or her body
build,28 judged in terms of height or height and bi-iliac diameter; the
Nutritional Status Indices, to identify one who is below his skeletal
peers (children of the same height, chest breadth, chest depth, and hip
width) in subcutaneous tissue, arm girth, or weight; and the ACH
Index, to identify the child who has a small amount of soft tissue in
relation to his build. Therefore, the association between a deficiency in
any one of these measures and the child’s physical fitness determines
the extent to which any of these indices may be expected to identify
the child who is physically unfit.
Previous Studies
A considerable literature is concerned with this subject— the effi
ciency of each of these four indices in identifying children who are
physically unfit. It may be classified conveniently under two headings:
(1) Studies in which the indices have been applied to children belong
ing to another race, to children of a different chronological age, or to
children living in widely separated geographic regions; and (2) studies
in which the children are more or less comparable to the 7-year-old
white boys and girls living in New Haven, Conn., observations of whom
form the basis of this report.
Under the first heading are included such studies as those of Aykroyd
and Rajagopal (4), who tested the ACH Index on a group of children
in South India; Franzen (33) (1934), who studied the ACH Index,
the Baldwin-Wood Tables, and an index of weight for height and hip
width on a group of 11-year-old boys and girls; Le Riche (55), who
26 See Appendix II: (117) Warner, p. 19.
27 Warner defined these criteria for indices of nutrition as distinguished from indices of physical fitness.
28 Baldwin stated that “ children who are 15 percent overweight for their height and age m ay also be in
need of medical attention” (see Appendix II: (5) Baldwin, p .4). Only under weight children, however, are
being considered in this report, as is indicated on p. 10.
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20
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
applied the ACH Index to children living in Pretoria, South Africa;
Jones (51), who tested several indices, including Pryor’s Tables, on
a group of English school boys; and Steggerda and Densen (108), who
applied the Baldwin-Wood standard to Navaho Indian children and
to children of Dutch descent.29
It is unnecessary to review such studies, for the success or failure of
an index applied to children of another race or age or those living in
different geographic regions has no direct bearing on the effectiveness
of an index to identify 7-year-old white children living in New Haven,
Conn., who may be in need of medical care or nutritional advice
and assistance.
On the other hand, it is important to know whether other investi
gators have found a given index a satisfactory method of assessment
when applied to children who are more comparable to those included
in this study. Only a few studies come under this heading:
Clark and his associates (22) tested the Baldwin-Wood Index in
1924 on a group of 506 native white children,30 aged from 6 to 18 years,
inclusive (at nearest birthday), including 32 7-year-old boys and girls.
All these children were without physical defects or evidences of disease
and were judged to be in good or excellent nutritional condition.31
Their findings for 7-year-old boys and girls are given in the following
table:
Nutrition: Good or Excellent1
Percentage deviation from the Baldwin-W ood standard
N um ber of 7-year-old chil
dren who are a given per
cent above or below the
B a ld w in -W o o d standard
weight
Boys
Girls
1
1
__
5
6
2
1
3
—
14
18
1
1
3
4
1
2
1
16 percent or more overweight----------- ----------------------------------------------------------T otal----------- ------------------- ------------- ---------------------- ----------------- -- -
i This table is adapted from table IV of the report discussed which includes figures for children from 6 to
18 years of age, inclusive. Only findings for 7-year-old boys and girls have been used here. See Appendix
II: (22) Clark, Sydenstricker, and Collins, p. 523.
2» gee also Appendix II: (f) Allman, who applied the Baldwin-W ood and A C H Indices; (2) A ykroyd,
(5) A ykroyd, Madhava, and Rajagopal, (16) Buck, (18) Chatterji, (62) McPherson, ( 84) Pinckney, reference
to Clements and Leipoldt in (99) Scantlebury, (122) W ilson, Ahmad, and Mitra, (128) W ilson and Mitra,
who used the A C H Index; (70) and (72) Mitchell, (101) Schlutz, who em ployed the Nutritional Status
Indices; (112) and (118) Turner, for studies using the Baldwin-W ood Tables; (180) Zayaz et al.,for an applica
tion of the Pryor and Baldwin-W ood Tables; and (98) Snyder, St. Paul, M inn., who used the Pryor Tables.
30 Both the parents and the grandparents of these children were b om in the United States. A more
detailed description of the group is given in a study b y the same authors entitled “ Indices of Nutrition.”
These 506 children lived in 4 States: Florida, 130; Georgia, 159; Tennessee, 110; and Utah, 107. There is no
indication as to whether they lived in rural or urban areas. See Appendix II: (21) Clark, Sydenstricker, and
Collins, pp. 1244-1245.
A 5-point scale (“ excellent,” “ good,” “ fair,” “ poor,” or “ very poor” ) was used b y the physicians for
grading nutrition evaluated in terms of general appearance, activity, condition of the skin, amount of sub
cutaneous fat, muscle tone, alertness, and vitality. See Appendix II: (21) Clark, Sydenstricker, and Collins,
pp. 1244-1245.
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FOUR INDICES OF BODY BUILD DESCRIBED
21
It may be seen from this table that 5 of the 14 7-year-old boys
(36 percent) and 6 of the 18 7-year-old girls (33 percent), all of whom
were clinically in good or excellent condition, were 6 or more percent
underweight according to the Baldwin-Wood standard. Although
these results are based on only a small number of children, they
naturally throw some doubt on the Baldwin-Wood method of assess
ment.32
In discussing the significance of their findings Clark and his asso
ciates point out three possible sources of error in the Baldwin-Wood
Tables: (1) They may be based on an unrepresentative group of
children; (2) the limits for normal variation (10 percent) in a child’s
actual weight compared with his expected weight may be too narrow;
these limits may vary with sex or age; 33and, finally, (3) a deviation
from an average weight for sex, height, and age may be an unsatis
factory criterion of physical fitness.34
In 1924 Dublin and Gebhart applied the Baldwin-Wood Tables 35
to a group of 4,047 first-generation Italian children aged from 2 to 10
years, inclusive (age at nearest birthday), living in the Mulberry Dis
trict of New York City. These boys and girls were the apparently
well children coming under the care of the Association for Improving
the Condition of the Poor. They were examined by one well-trained
pediatrician and were diagnosed as either well-nourished or under
nourished. The authors state:
The doctor’s diagnosis of defective nutrition was based on the picture of the
whole child and not on the weight and height alone. Such items as the state of
the musculature, the luster of the eyes, the color and bearing of the children, their
posture, and the relative amount of subcutaneous tissue were all taken into
account in assessing the child’s nutrition. In addition, the physical measure
ments of height and weight were given careful consideration in relation to the
child’s age.36
The accompanying table shows the agreement between the Bald
win-Wood standard and the physician’s judgment, for the 455 7-yearold children included in the study. In this table a 7-percent limit
for underweight has been used. In other words, if the difference
between the child’s observed and his expected weight is less than 7
percent of his expected weight he is not identified by the Baldwin*» Although the authors recognize the fact that no satisfactory standard of physical fitness should include
any large proportion of a group which, judged b y careful medical examination, is found to be in ill health,
they did not study this important aspect of the problem. See Appendix II: (22) Clark, Sydenstricker,
and Collins, p. 519.
33 It is interesting to note that Faber (1925) questioned the validity of Baldwin’s standards (1924), as well
as other generally used standards, of percentage underweight and overweight. H e studied the heights and
weights of about 34,000 San Francisco school children aged 5 through 14 years (age at the nearest birthday),
including 3,421 7-year-old children, and concluded that underweight and overweight standards should
vary with sex and age. See Appendix II: (SI) Faber.
34 See Appendix II: (22) Clark, Sydenstricker, and Collins, p. 521.
33 The W oodbury Tables for boys and girls from birth to school age were used for the very young children.
See Appendix II: (125) W oodbury.
38 See Appendix H : (28) D ublin and Gebhart, p. 4.
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ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
22
Wood standard as being underweight. For example, there were 77
7-year-old boys who, according to the physician’s judgment, were
undernourished. The Baldwin-Wood Tables failed to identify 52
(67.5 percent) of these 77 children as underweight. In other words,
using a 7-percent limit for percentage underweight, the tables selected
only 32.5 percent of the boys whom the physician had diagnosed as
undernourished.
A Comparison of the Selection Made by the Physician’s Diagnosis of Nutrition
and by the Use of the Baldwin-Wood Tables 1
BOYS
U N D E R N O U R IS H E D
W E L L -N O U R IS H E D
Age 4
Doctor’s
diagnosis
W eight table
7 percent
lim it3
Percent
agreement
Doctor’s
diagnosis
W eight table
7 percent
lim it 3
Percent
agreement
130
94. 9
77
25
32. 5
137
7.
GIRLS
U N D E R N O U R IS H E D
W E L L -N O U R IS H E D
Age 4
7.
D octor’s
diagnosis
W eight table
7 percent
lim it 2
142
134
Percent
agreement
Doctor’s
diagnosis
W eight table
7 percent
lim it 3
Percent
agreement
94. 4
99
25
25. 3
1 Adapted from table I, p. 5, in D ublin and Gebhart (28) (See Appendix II).
2 A child is identified as well-nourished if he is less than 7 percent underweight or if his observed weight is
a child is selected as undernourished if he is 7 percent or more underweight according to the standard.
4 Age at nearest birthday.
In discussing these results Dublin and Gebhart conclude: “ A
method which misses three-fourths 37 of all of the children whom a
competent physician, after a thorough examination, would call under
nourished has certainly scant value even as a Tough index for sorting
out the most needy cases.’ ” They attribute the failure of the index
in part to the fact that “ these Italian children are heavier for each
inch of height than the children used in the Wood-Baldwin-Woodbury Table.” 38
In Mitchell’s study (1935) the Baldwin-Wood Tables and the
Nutritional Status Indices were applied to only eight children, in
cluding two 7-year-old boys,39 James and Edward, who had been
referred by their teachers to a physician for special examinations.
James weighed 43 lb. and was, according to the investigator, ob
viously undernourished. He was so unusually low in weight, muscu
lature, and adiposity that he appeared thin and frail and suggested
poor nutrition to the casual observer. The clinical examination also
showed very little flesh over the chest, well-defined winged scapulae,
and soft, flabby muscles. According to the Baldwin-Wood Tables
37 The tables failed to identify three-fourths of the children of all ages (2-10 years, inclusive); two-thirds of
the 7-year-old boys and three-fourths of the 7-year-old girls.
38 See Appendix II: (28) Dublin and Gebhart, p. 8.
3« N o statement is given as to how age was defined, nor an indication of the race, or the location of the
homes of these children.
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FOUR INDICES OF BODY BUILD DESCRIBED
23
he should have weighed 50 lb. and was, therefore, 14 percent under
weight. In terms of the Nutritional Status Indices only 2 in 100
boys with the same skeletal build weigh less than James; 6 have a
smaller arm girth and 20 in 100 have less subcutaneous tissue.40
Edward weighed 47¿4 lb. The investigator described him as of
about average height with average chest breadth and a shallow chest
and narrow hips. Both arms and legs appeared very thin and his
muscles were very soft and flabby. The child was one of nine chil
dren; the family was entirely dependent on public relief; investigation
showed a diet of excess starchy foods which may have accounted
for his adipose tissue. During 6 months' observation he gained only
% lb.41 According to the Baldwin-Wood Tables he was 10.4 percent
underweight. In terms of the Nutritional Status Indices, 7 boys in
100 with the same skeletal build have a lower weight; 9, a smaller
arm girth; and 50, a smaller amount of subcutaneous tissue.
To summarize: The Baldwin-Wood Tables identify both James
and Edward as markedly underweight. According to the Nutritional
Status Indices also, both these children were underweight; they had
exceptionally small arm girths; and James had a deficiency in sub
cutaneous tissue as well. These findings indicate that the Nutritional
Status Indices may be more useful than the Baldwin-Wood Tables
because they evaluate not only the child’s weight but also his muscu
lature and subcutaneous tissue. It should be pointed out, however,
that Mitchell tested the indices on only a small number of children,
and there is no evidence in this study to indicate that the Nutri
tional Status Indices will identify other children who are poorly
nourished.
It is difficult to evaluate and compare these three studies for five
reasons: (1) The indices were applied to groups of children living
under varying conditions; (2) clinical judgment of nutrition was made
by different physicians; (3) there was no attempt to evaluate the
objectivity and stability of clinical judgment nor the accuracy of the
anthropometric measurements; (4) in one study (Clark et ah, 1924)
the indices were tested only on children who were clinically in good
or excellent nutritional condition, in another (Mitchell, 1935), on
children who had been referred by their teacher to the school physi
cian for special examination, in the third (Dublin and Gebhart, 1924),
on boys and girls whom the physician judged to be either well or
poorly nourished; and (5) different selection points were used for test
ing tfie same index.
For example, Clark applied the Baldwin-Wood Tables to children
in excellent or good nutritional condition and, using 6 percent as a
limit for underweight, grouped the children by 5-percent differences
43 See Appendix II: (71) Mitchell, pp. 316-317.
41 See Appendix II: Ibid., pp. 318-319.
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24
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
in the index. Dublin and Gebhart, on the other hand, applied both
7 and 10 percent or more underweight as criteria for selection, classi
fied the children in only two groups, those who were identified as
underweight and those who were not.
Probably a more satisfactory method of testing and comparing such
indices is to apply them to a group of children belonging to the same
nationality,42 of a given sex and age, and living in one community,
who have been under observation for a sufficient period to permit
evaluation of their physical well-being and their socioeconomic status,
and then to compare the effectiveness of each of the indices in select
ing those children who, in terms of each of several carefully defined
criteria, are likely to be in need of medical attention or nutritional
advice and assistance.
The importance of such a study was pointed out by Jones in his
monograph entitled “ Physical Indices and Clinical Assessment of the
Nutrition of School Children,” in which he writes:
Hundreds of physical indices of nutrition have been proposed by writers in
many languages, but it is difficult to discover precisely what these indices will
perform in practice. Though there is an enormous literature, there is no agree
ment among writers as to which index is best. General claims concerning the
value of an index are met more frequently than precise details of performance,
and few attempts have been made to test different indices on the same large
group of children.43
The observations made of the children included in the present study
may be used to test the indices in this way and to evaluate other
methods of assessment, particularly the clinical examination. How
accurate is the physician’s judgment of the child’s general nutritional
status? Is it stable? Is his assessment of the child’s nutrition in
agreement with the judgment of other physicians? To repeat: This
investigation of the physical fitness of New Haven children may be
used to measure the relative efficiency of several methods of assessing
the physical fitness of 7-year-old school children.
This term is used to distinguish broad, ethnic groups.
43 See Appendix II: (61) Jones, pp. 2-3.
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Material and Methods
The observations were made of 713 7-year-old white children2
(365 boys and 348 girls) attending the kindergarten, first grade, or
second grade of the public or parochial schools of New Haven, Conn.,
from September 1934 through May 1936. Of these 713 children 661
(92.7 percent) attended 44 of the 49 public grade schools in New
H aven;3 52 (7.3 percent) of the boys and girls were enrolled in 4 of
the 9 parochial schools.4
Each of these children may be briefly described as follows:
Race______________________
Sex__________________ ___
Nationality 6_______________
Age (in completed years at
first physical examination
in 1934) __....... ....................
Residence___________
School attendance___
Period of observation
White.
Male or female.
Italian, American, or other.6
Six years (only a child who was a single
legitimate birth and was born during
the period from July 1 to December 31,
1928, was eligible for inclusion).
Living with his family or in a foster home.
Attending a public or parochial school in
1928, inclusive, New Haven.
A minimum period of 12 consecutive months
during the school years 1934-35 and 193536. (Most of the children were observed
for either 19 or 20 months.)7
i Included in this section are descriptions of the observations made of these New Haven children. Some
of these data will form the basis for additional studies of child growth and development.
s Age is defined as age at last birthday. As is stated on p. 1, the children included in this study were 6
years old when the first medical examination was made. Periodic weighings were made of some of these
children before they were 6 years old, the age at the first weighing ranging from 5 years 8 months to 6 years
6 months. This report is based on observations made when the boys and girls were 7 years of age, amplified
and interpreted in relation to the earlier findings.
Only children who were single, legitimate births, who were b om during the period from July 1 to D ecem
ber 31,1928, inclusive, and who were living with their families or in foster homes were included in the
study.
3 5 of the public schools were excluded because they served highly specialized groups of children. That is,
one school had a very high percentage of Negroes in attendance; the second was conducted for children living
in an orphanage; the third was used as a training school for teachers and was omitted for administrative
reasons; the fourth had only a small enrollment of 6-year-old children; the fifth was a special school for mental
defectives.
4 These children were included in order to have the different nationality groups in New Haven adequately
represented.
3 “ N ationality” has been defined arbitrarily according to the birthplace of the grandparents. For ex
ample, a child 3 of whose grandparents were born in Italy is classified as “ Italian.” It was necessary to
expand this definition for “ American” children to include boys and girls both of whose parents and 2 of
whose grandparents were born in the United States.
3 A more detailed nationality distribution is given in Appendix I: Supplementary table I, p. 100.
7 A bou t 56 percent of the children were observed for 19 months and about 40 percent for 20 months.
25
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26
ASSESSING T H E PHYSICAL FITNESS OF CHILDREN
The following observations were made of the child during this 19or 20-month period of observation:
Physical examinations:
He was given two annual physical examinations by one pediatrician.
The first examination was made when the child was 6 years old; the second,
1 year later.8 When the first examination was made, most of the child’s
clothing above the waist was removed; at the second examination, written
permission had been obtained from the parents to remove all the clothing
above the waist.
Anthropometric measurements:
He was measured at the same time the annual physical examinations
were made by one observer trained in anthropometry.®
Periodic weighings:
The number of weighings varied: The minimum number was five; the
maximum, nine; the average, eight. The child’s age at the first weighing
ranged from 5 years 8 months to 6 years 6 months; at the last weighing,
from 7 years 2 months to 7 years 10 months. His weight was taken at the
time each of the annual physical examinations was made; 6 months after
the first examination; and at 4-month intervals 10 during the school years
1934-35 and 1935-36.“
Information was also obtained concerning the-following items:
Socioeconomic status:
An economic analyst12 visited his home during each of the 2 school
years (1934-35 and 1935-36) and obtained information from his mother
(or some other responsible adult member of the family if the mother was
absent) concerning the child’s general disease history, his dietary habits
(particularly his consumption of milk and leafy vegetables), and the
economic status of the family. These visits were usually made within a
period 2 to 3 weeks after the physical examinations.
Schooling:
Information concerning school absences— namely, the date, duration,
and reason for each absence of 3 or more days’ duration— was obtained
from the school nurses’ files.13
School progress was also recorded as “ passed” or “ failed.”
These 713 white children form a selected group. They were 6 years
old at the first physical examination, they were of single, legitimate
8There was a minimum interval of 11 months 16 days, and a maximum of 1 year 14 days, between the 2
physical examinations.
9 A few observations were made during the first year of the study b y another trained observer who
repeatedly checked her observations against those made b y the anthropometrist.
10 These weighings were made for the most part during the last weeks of September 1934; January, M ay,
and September, 1935; and January and M a y 1936.
“ T he weights were secured for the most part within a 3-day interval, and were taken b y the anthropom
etrist, the pediatrician, and the office clerk. A few weighings were also made b y the economic analysts
who collected the socioeconomic data.
The socioeconomic data were collected from October through M arch or April of each year of the study.
6 economic analysts were em ployed during the first year, and 2 new agents collected the data during the
second year of the study.
is in the case of absences which occurred prior to the second home visit these data were supplemented b y
information obtained from the mother at this visit. In appropriate instances additional inquiries were
made about absences which occurred subsequently.
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MATERIAL AND METHODS
27
birth, their nationality was known, they were living in their own or
foster homes, they were attending school in New Haven, and most of
them were under observation for a 19- or 20-month period.
Conversely, boys and girls were excluded or discharged from the
study for any of the following reasons: Multiple birth; illegitimacy;
incorrect age; unknown or incorrectly stated race or nationality;
residence in an orphanage or other institution; attendance at a
private school (other than parochial) or nonenrollment at school;14
omission of certain anthropometric measurements or of either of the
physical examinations; interval of more than 1 year and 14 days, or
less than 11 months and 16 days between the two annual physical
examinations; establishment of residence in another city; death during
the period of observation; or age outside limits established for testing
the indices.15 It is, of course, difficult to estimate the effect of
excluding these children from the study, and no attempt has been
made to do so.
A Description o f the Boys and Girls Included in the
Study
A description of the age and nationality groups represented, the
kind of homes the children came from, and the general physical condi
tion of the 713 boys and girls included in the study may be helpful
in interpreting the results.
AGE
The ages (in completed years and months) of the children when
the second annual physical examinations were made are given in
table 1. None of these 713 boys and girls were less than 7 years
0 months of age. Approximately 72 percent were less than 7 years
4 months, and none of them were more than 7 years 7 months of age.
In other words, there is relatively very little variation in the ages of
the boys and girls included in the study.
This somewhat unusual age distribution is probably the result of
the following circumstances: Only children bom during the period
from July 1 to December 31, 1928, inclusive, were eligible for inclu
sion; the annual physical examinations were made from October of
one year through March of the next; and no child was retained in the
study who was less than 6 years of age at the time of his first medical
examination or less than 7 years old at the second examination, which
was made approximately 1 year later.
There were 2 reasons for nonenrollment: (1) Children were not required to attend school until they
were 7 years of age; (2) they were physically incapacitated and unable to attend school.
16
A t the beginning of the study, age was defined as age at nearest birthday. Later, it was changed to
age at last birthday in order to permit testing of the Nutritional Status and A C H Indices on all the children
included.
2 3 9 8 4 8 °— 40------ 3
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28
T
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
able
1 . — Age
of the boys and girls at the time of the second physical examination
B oth sexes
B oys
Girls
Age*
N um ber
Percent
Number
Percent
Num ber
713
100.0
365
100.0
348
100.0
74
151
150
137
91
70
33
7
10.4
21.2
21.0
19.2
12.8
9.8
4.6
1.0
36
78
67
74
46
39
20
5
9.8
21.4
18.3
20.3
12.6
10.7
5.5
1.4
38
73
83
63
45
31
13
2
10.9
21.0
23.9
18.1
12.9
8.9
3.7
.6
T otal________ ____ _______ _ ______
7 years 0 m onths_____________ . . . . . . .
7 years 1 m onth__________________________
7 years 2 m onths_________________________
7 years 3 m onths_______________________ .
7 years 4 m onths_________________________
7 years 5 m onths____________ ____ _______
7 years 6 m onths_____________________ . . .
7 years 7 m onths------------ ------- ------------------
Percent
l A ge is given in completed years and months.
NATIONALITY
The nationalities to which the children belong are shown in table
2.16 About 46 percent of the children were classified as “ Italian”
and approximately 18 percent as “ American.” The remaining 36
percent, representing various geographic groups, were classified as
“ Russians,” “ Polish,” “ Irish,” and “ All others.” The fact that so
large a number of Italian children were included in the study is of
particular significance because, on the average, the Italian boys and
girls were shorter and tended to weigh less than the other children.17
Is this difference in their body build likely to affect the efficiency of
the indices?
T
able
2 . — Nationality
of the boys and girls
B oth sexes
Boys
Girls
N ation a lity1
T otal__________________________
Italian____________________________ ______
American______________ ____________ .
Russian______________________ __________
P olish___________________________________
Irish_____________________________________
A ll others............................................ ............
Num ber
Percent
Number
Percent
N um ber
713
100.0
365
100.0
348
100.0
330
130
66
35
34
118
46.3
18.2
9.3
4.9
4.8
16.5
166
65
34
19
17
64
45.5
17.8
9.3
5.2
4.7
17.5
164
65
32
16
17
54
47.1
18.7
9.2
4.6
4.9
15.5
Percent
1
Classification was based on the birthplace of 3 of the child’s grandparents. T he classification “ American”
includes not only children 3 of whose grandparents were born in the United States but also children
whose parents and 2 of whose grandparents were b om here.
HOMES
Location.
The location of these children's homes is shown on the map on
p. 29.
i« For the definition of “ nationality” used in the study see page 25.
17
See tables 11 and 12, which give the heights and weights of the boys and girls belonging in each nation
ality group. See also M eredith’s discussion of this problem: Appendix II: (68) Meredith, p. 344.
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MATERIAL AND METHODS
29
The various sections of the city were all fairly well represented, but
the majority (62.7 percent) of the boys and girls lived in the outlying
regions, especially in the eastern (19.1 percent) and western (25.0
percent) parts of New Haven.
Type of dwelling.
Only about 12 percent of the boys and girls were living in one-family
dwellings; all the others, approximately 88 percent, lived in flats or
apartments. (Table 3.) The fact that so few of the children lived
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30
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
in one-family houses can be attributed in part to the relatively small
number of such dwellings which exist in New Haven.18
T
able
3 .—
Type of dwelling occupied by the families of the boys and girls 1
Girls
Boys
Both sexes
T yp e of dw elling3
Number
T otal______________________________
3 695
One-family dwelling_____________________
Flat or apartm ent.------------- ---------------------
84
611
Percent
100.0
12.1
87.9
Num ber
Percent
Number
3 358
100.0
3 337
100.0
37
321
10.3
89.7
47
290
13.9
86.1
Percent
i Data based on observations made when the children were 6 years of age.
aA 1-family dwelling is a residence adapted to the use of only 1 family. It m ay be connected with a store
or it m ay be one of a series of houses with adjoining walls. A flat or apartment is a 1-family unit in a building
adapted to 2 or more families. These definitions are adapted from Appendix II: (26) Dreis, p. 9.
3 T yp e of dwelling was unknown for 7 boys and 11 girls.
Presence of parents in the home.
Most of these children (90.3 percent) were residing with both their
parents. Less than 10 percent (9.0 percent) lived with only one
parent; and very few boys and girls (0.7 percent) resided in foster
homes. (Table 4.)
T
able
4 . — Presence
of parents in the homes of the boys and girls
Both sexes
Boys
Girls
Parents living in the home
N um ber
Percent
100.0
365
100.0
348
100.0
90.3
9.0
.7
339
24
2
92.9
6.6
.5
305
40
3
87.6
11.5
.9
Num ber
Percent
T o t a l-.- ________ __________________
713
Both parents____________________________
One parent_________________________ ____
Neither parent1---------------------------------------
644
64
5
Num ber
Percent
1 Oases of children living in foster homes.
Number of persons in household.
The number of persons in the household included not only the mem
bers of the child’s immediate family but also any relatives, friends,
roomers, and servants living under the same roof.19 Nearly threefifths (58.6 percent) of the children lived in households including four,
five, or six members. A few (4.7 percent) lived in homes containing as
many as 11 or more persons. (Table 5.)
18
The Southern N ew England Telephone Co. M arket Survey of 1931 indicated that less than one-fifth of
all the occupied dwellings in N ew Haven were 1-family residences. See Appendix II: (26) Dreis, pp. 9,11.
i* Boarders were excluded.
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MATERIAL, AND METHODS
T
able
5 .—
Number of persons in the households in which the boys and girls lived1
B oys
B o t h sexes
G ir ls
N u m b e r o f p e r s o n s in h o u s e h o ld 2
T o t a l ____________________________________
N um ber
P ercen t
N um ber
P ercen t
N um ber
3 709
100 .0
3 364
100 .0
3 345
100.0
3
65
140
149
127
77
58
34
23
16
11
3
0 .4
9 .2
1 9 .7
2 1 .0
17.9
10.9
8 .2
4 .8
3 .2
2 .3
1 .6
.4
0
36
76
74
55
42
29
20
13
10
5
3
0 .0
9 .9
2 0 .9
2 0 .3
15.1
1 1 .5
8 .0
5 .5
3 .6
2 .7
1 .4
.8
3
29
64
75
72
35
29
14
10
6
6
0
0 .9
8 .4
1 8 .6
2 1 .7
2 0 .9
1 0 .1
8 .4
4 .1
2 .9
1 .7
1 .7
3
.4
1
.3
2
2.............................................- .............................. ...........
3________________________________________________
4 ________________________________________________
5________________________________________________
6 ________________________________________________
7________________________________________________
8 ________________________________________________
9 ________________________________________________
10________________________________________________
11__________________________ _____ _______________
12___ _____ ______________________ _____________13_____________________ ________ _________________
14_______________________________ ____ ____
P ercen t
.0
.6
1 Data based on observations made when the children were 6 years of age.
2 Num ber of persons in household included the child’s immediate family, relatives, roomers, friends, and
servants living under the same roof.
2 Num ber of persons in household was unknown for 1 b oy and 3 girls.
Number of persons per room.
If crowding is defined arbitrarily as one and one-half or more per
sons per room,20 it may be seen from table 6 that approximately 32
percent of the children included in this study were living in homes
where overcrowding was a serious problem, although in about 43
percent of the households there were from one to less than one and
one-half persons per room, and about 25 percent of the children were
living in homes with less than one person per room.
T
able
6 . — Number
of persons per room in the households in which the boys and
girls lived 1
Boys
Both sexes
Girls
Persons per r o o m 2
Number
Percent
Number
Percent
Number
Total______________________________
3 707
100.0
3 363
100.0
3 344
100.0
Less than )4 ........ ....................... ....................
)4, less than 1________________ _________
1, less than 1)4___________________________
1)4, less than 2___________________________
2, less than 2)4______________________ ____
2)4, less than 3____________________ ______
3, less than 3)4______________________ ____
3)4, less than 4___________________________
2
174
302
145
59
22
2
1
0.3
24.6
42.7
20.5
8.4
3.1
.3
.1
0
94
147
81
30
10
0
1
0.0
25.9
40.5
22.3
8.3
2.7
.0
.3
2
80
155
64
29
12
2
0
0.6
23.2
45.1
18.6
8.4
3.5
.6
.0
Percent
1 Data based on observations made when the children were 6 years of age.
2 The number of persons in the household included the child’s immediate family, relatives, roomers,
friends, and servants living under the same roof. The number of rooms excluded bathrooms and hall
ways.
3 Num ber of persons per room was unknown for 2 boys and 4 girls.
20
It is recognized that any arbitrary standard of crowding has limitations. In this connection R ollo H.
Britten, of the National Institute of Health, has pointed out that “ a reasonable index should depend not
only on persons per room but also on such factors as age and sex make-up of the family, size of rooms, whether
the dwelling unit is in a house or apartment, geographic location, etc.” See Appendix II: (16) Britten.
It should be remembered, however, that the nature of the present investigation has automatically re
stricted the type of family under consideration. E very child in this study comes from a household con
sisting of at least 2 persons, a 6-year-old child and an adult. A standard of crowding applied to a group of
these families is probably a more reliable index of socioeconomic status than if it is applied to a less rigorously
defined group.
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32
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
Number of additional persons sleeping in the child’s bedroom.
Another and perhaps a more sensitive index of crowding is the
number of persons occupying one bedroom. About 43 percent of
the children included in this study slept in a room occupied by two
or more additional persons, and approximately 44 percent slept in a
room occupied by one other person. Only about 13 percent had their
own bedrooms. (Table 7.)
T
able
7 . — Number
of additional 'persons sleeping in the child’s bedroom 1
G ir ls
B oys
B o t h sexes
A d d it i o n a l p e r s o n s o c c u p y i n g c h ild 's
room
T o t a l __________________ _________________
0 _________________________________________________
1_______ _____ ___________________________________
2 .......................................... ............................................—
3 . . ................ .............- ............... — .................................
4 _________________________________________________
5............................................................................. .............
6 .............................................. ........ ............... ...............
7____________ ____________________ _______ -
N um ber
P ercen t
N um ber
3 707
100 .0
3 363
93
307
204
74
22
6
0
1
1 3 .2
4 3 .4
2 8 .9
10 .5
3 .1
.8
.0
.1
53
158
107
34
10
1
0
0
P ercen t
N um ber
100 .0
3 344
100 .0
1 4 .6
4 3 .5
2 9 .5
9 .4
2 .7
.3
.0
.0
40
149
97
40
12
5
0
1
1 1 .6
4 3 .3
2 8 .2
1 1 .6
3 .5
1 .5
.0
.3
*
P ercen t
1 Data based on observations made when the children were 6 years of age.
2 Number of additional persons occupying same sleeping room as child was unknown for 2 boys and 4
girls.
ECONOMIC STATUS OF THEIR FAMILIES
Assistance.
With such conditions existing in the children’s homes, it is reason
able to expect that a considerable number of families were in poor
economic circumstances. If assistance from public or private agen
cies or both21 is used as a criterion, it may be seen from table 8 that
this is so. Almost 24 percent of these boys’ and girls’ families re
ceived assistance during the year prior to the home visit made when
the child was 6 years old and again when the child was 7 years of age,
compared with 70 percent that received no assistance at any time
during the period of observation. A few families (4.5 percent)
received assistance during the first year only and a still smaller num
ber (1.8 percent) during only the second year of the study. In other
words, nearly one-fourth of the children’s families received assistance
from public or private agencies or both during the years prior to both
home visits; most of the remaining families received no assistance
either year.
21
This information was obtained b y the economic analysts at the home visits, was cleared through the
Social Service Exchange, and was checked with the records of the public and private agencies giving direct
and work relief in N ew Haven. In addition, families reporting an income of less than $1,000 a year, those
with a history of severe illness, and all other families whose income statements appeared inaccurate were
cleared through the Social Service Exchange.
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33
MATERIAL AND METHODS
T
able
8 . — Assistance from public, private, or public and private agencies given the
families of the boys and girls during the year preceding each home visit
Both sexes
Boys
Girls
Assistance1
Number
Percent
Number
Percent
Num ber
__________
713
100.0
365
100.0
348
100.0
First year only_____________________ ____
Second year on ly_______________________
Both years___________________ __________
Neither year.. ____________ ____________
32
13
169
499
4.5
1.8
23.7
70.0
16
10
92
247
4.4
2.7
25.2
67.7
16
3
77
252
4.6
.9
22.1
72.4
T otal_________ ____ _
Percent
1 Assistance given at any time during the 12 months preceding the home visit. This assistance took the
form of direct relief, work relief, or direct and work relief from any public or private agency.
Principal source of income.
What was the principal or major source of income of these boys’
and girls’ families during the year preceding the second home visit?
Table 9 shows it to be the father’s earnings in slightly more than twothirds (68.8 percent) of the homes; the mother’s earnings, in about 4
percent; assistance from public or private agencies or both, in 17
percent; and other sources, in about 10 percent.
T
able
9 . — Principal
source of income of the families of the boys and girls during the
year preceding the second home visit
Both sexes
Boys
Girls
Principal source of in com e1
T otal. _________________ ______
W ork of father3_______________________
W ork of m oth er3. . . . . _____________
Other sources 4_______ _________ ____ _
Assistance3_____ _ _______________
Number
Percent
Number
Percent
Num ber
2 689
100.0
2 348
100.0
2 341
100.0
474
26
72
117
68.8
3.8
10.4
17.0
236
9
36
67
67.8
2.6
10.3
19.3
238
17
36
50
69.8
5.0
10.5
14.7
Percent
1 That source which contributed the major portion of the family income.
2 The source of income was unknown for 17 boys and 7 girls.
3 D id not include work relief.
4 “ Other sources” included income from work of children, from relatives, savings, unemployment and
other types of compensation, insurance, and rent. It did not include income from work relief.
3 “ Assistance” included both work relief and direct relief from public and private agencies.
Employment of mother. 22
In about 18 percent of the households the mother was gainfully
employed, mostly outside the home. (Table 10.)
22
In cases where the child was not living with his own mother, the information pertained to the woman
in charge of the household.
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34
T
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
able
1 0 . — Employment
status of the mothers of the boys and girls during the year
preceding the second home visit1
B oth sexes
Boys
Girls
Em ploym ent status
Num ber
Percent
Number
Percent
Num ber
Percent
T otal_____________ ____ _______ ___
713
100.0
365
100.0
348
100.0
M other not em ployed___________________
M other em ployed____. __________________
584
129
81.9
18.1
302
63
82.7
17.3
282
66
81.0
19.0
Inside hom e__ _____________ __ _ ___
Outside home________________________
Unknown whether em ployed inside
or outside hom e____________________
12
105
1.7
14.7
6
49
1.7
13.4
6
56
1.7
16.1
12
1.7
8
2.2
4
1.2
1 In cases where the child was not living with his own mother, the information pertained to the wom an
in charge of the household.
ANTHROPOMETRIC MEASUREMENTS
Height.
The heights of these children are given in table 11. As would be
expected, there was considerable variation in the averages of the
American and Italian boys and girls, the American child being taller
on the average than the Italian. No comparison has been made
between the children grouped under the heading “ Other” and the
American or Italian boys and girls, as the first-mentioned group of
children represent so many nationalities that comparisons are not
warranted.
T
able
1 1 . — Heights
of the boys and girls
Boys
Girls
Height (in inches)
Total
Italian1 A m erican2 O ther3 Total
Italian 1 A m erican2 O ther3
T ota l................ ..........
365
166
65
134
348
164
65
119
41.0-41.9-...............................
42.0-42.9,................... ..........
43.0-43.9-_______ ________
44.0-44.9. ...........................
45.0-45.9-_____ _____ _____
46.0-46.9...... ...................... 47.0-47.9........ .......... .............
48.0-48.9-..............................
49.0-49.9........................ .........
50.0-50.9-_____ ___________
51.0-51.9______ ___________
52.0-52.9...................... ..........
53.0-53.9_____ ____ _______
54.0-54.9,............... ................
1
8
9
34
41
57
75
54
32
29
17
6
2
0
1
6
7
25
25
29
39
20
7
5
2
0
0
0
0
1
1
2
6
12
8
13
9
6
3
4
0
0
0
1
1
7
10
16
28
21
16
18
12
2
2
0
0
4
9
36
55
59
71
60
25
22
4
1
1
1
0
3
7
28
36
26
27
28
5
4
0
0
0
0
0
0
0
3
5
15
11
15
9
6
0
1
0
0
0
1
2
5
14
18
33
17
11
12
4
0
1
1
M ea n ________ ___________
Standard deviation_______
47.5
2.25
46.5
1.93
48.1
2.21
48.3
2.17
47.1
1.96
46.4
1.76
47.8
1.68
47.8
2.02
1 3 of the child’s grandparents were horn in Italy.
a 3 of the child’s grandparents or 2 of his grandparents and both his parents were born in the United States.
3 These children did not meet the definitions outlined in footnotes 1 and 2.
Weight.
The weights of the children are given in table 12.23 Here, as in
height, there appear to be differences between the children classified
33 For the frequency distributions of bitrochanteric width see supplementary table II, Appendix I, p. 100.
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MATERIAL AND METHODS
35
as Italian and as American, the Italian tending to weigh less than the
American boys and girls.
T
able
12.— Weights of the boys and girls
Boys
Girls
Weight (in pounds)
Total
Total_____________
34.0-37.9........ ................__ _
38.0-41.9_______________
42.0-45.9____ .
46.0-49.9________ .
50.0-53.9_______________
54.0-57.9___........................
58.0-61.9_____________
62.0-65.9__________
66.0-69.9___________
70.0-73.9______________
74.0-77.9_____________
78.0-81.9_______ _____
82.0-85.9_______
86.0-89.9________ .
90.0-93.9________________
94.0-97.9___________
98.0-101.9______________
102.0-105.9______________ ...
M ean___________________
Standard deviation_______
Italian i American3 O ther3 Total
Italian 1 American3 Other3
365
166
65
134
348
164
65
119
2
14
38
89
85
65
40
13
11
3
1
3
0
1
0
0
0
0
1
9
22
56
37
22
14
4
1
2
7
14
10
16
6
3
2
2
1
1
0
0
0
0
0
0
0
3
9
19
38
27
20
' 6
9
1
0
1
0
1
0
0
0
0
4
15
78
87
71
40
20
11
9
3
6
1
1
0
1
0
0
1
3
9
47
49
27
13
9
0
5
0
1
0
1
0
0
0
0
0
0
3
12
18
18
6
2
4
0
1
0
0
0
0
0
0
0
1
1
3
19
20
26
21
9
7
4
2
5
1
0
0
1
0
0
0
54.9
7.52
51.2
8.63
49.1
7.06
51.3
9.08
54.1
9.49
52.7
7.39
0
0
0
1
0
0
0
0
0
0
50.5
' 6.06
53.8
8.54
i 3 of the child’s grandparents were born in Italy.
* 3 of the child’s grandparents or 2 of his grandparents and both his parents were born in the United States.
3These children did not meet the definitions outlined in footnotes 1 and 2.
Such nationality differences are important because, as has been
mentioned (see p. 28), they may affect the efficiency of the indices in
identifying boys and girls in need of medical attention or nutritional
advice or assistance. The indices depend on estimates of body build
(based on anthropometric measurements) for judging a child’s physical
fitness (insofar as physical fitness is related to abnormalities in certain
measures such as weight or arm girth) when the expected or average
measure for children of the same sex, age, and build is used as a stand
ard. Such a standard may vary with the nationality of the children
from whose measurements it was derived and may, therefore, be most
efficient in judging the fitness of children of the same nationality as the
boys and girls whose measurements were used in developing the index
or standard.
DIETS
As information concerning the dietary habits of these children is not
very satisfactory, only the data on milk consumption have been
analyzed.24 (Table 13.) Although 56.5 percent of the boys and girls
24 The estimates of m ilk consumption are obviously inaccurate and in addition are based on a cup which is
smaller than the standard measure.
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36
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
drank an “ adequate” amount (2, 3, or 4 cups per day) of milk at 7
years of age,25 only 28.3 percent consumed an “ optimum” amount
(5 cups or more). On the other hand, a considerable proportion of
these children (13.9 percent at the age of 7) had an inadequate amount
(less than 2 cups per day) of milk in their diet, and a very small num
ber of the boys and girls (1.3 percent at the age of 7) did not drink
any milk.
T
able
13.— Adequacy of the amount of milk consumed daily hy the boys and girls
Girls
Boys
Both sexes
Adequacy of milk consumed per day
Number
N o milk:
Inadequate:2
A dequate:3
O p tim u m :4
Percent1 Num ber
Percent1 Num ber
Percent1
9
0
1.3
.0
3
0
0.8
.0
6
0
1.7
.0
99
39
13.9
6.4
55
86
15.1
6.9
44
14
12.7
4.1
402
308
56.5
48.6
200
147
55.0
40.4
202
156
58.2
44-7
201
60
28.3
7.0
106
S3
29.1
9.1
95
17
27.4
4.9
1 The percentages in each case were based on the total number of children for whom information at both
6 and 7 years of age was available: For both sexes, 711; for boys, 364; and for girls, 347. (The amount of
m ilk consumed daily was unknown for 1 b oy and 1 girl at 7 years of age.)
2 “ Inadequate” was defined as less than 2 cups per day.
2 “ Adequate” was defined as 2 up to but not including 5 cups per day. T he absolute standard of 3 cups
a day has not been adopted because the estimates of milk consumption are subject to error.
1 “ Optimum ” was defined as 5 or more cups per day.
HEALTH
Pediatrician9s assessment of general nutritional status.
As has been stated, all the children were examined both years of the
study by one pediatrician, who judged their nutritional status to be
“ excellent,” “ good,” “ borderline,” “ poor,” or “ very poor.” These
estimates were based on careful physical examinations which were
made according to detailed written instructions.26
On the basis of these examinations the percentage of children in
each nutritional class was as follows:
(1)
More than half the boys and girls were judged to be in a border
line condition at 7 years of age. Some of them were probably fairly
well nourished; others were in a nutritional condition that bordered
on poor. Nevertheless, all these children constitute a health problem,
22 The standard of 3 cups per day as adequate and 4 cups as optim um has not been applied. (See Appendix
II: (109) Sherman and Hawley.) Instead, 2up to but not including 6 cups a day (an average of 3)^ cups) has
been considered adequate; less than 2 cups, inadequate; and 5 cups or more, an optim um amount. This
grouping has been made in order primarily to identify 2 of the 3 groups of children: (1) Those who had a
definitely un satisfactory amount of milk in their diets as compared with (2) those who had an optimum
Amount.
26 A detailed evaluation of both the objectivity and the stability of the pediatrician’s judgment occurs
on pp. 82-87.
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MATERIAL AND METHODS
37
as they are difficult to identify and their condition may grow progres
sively worse if they do not receive proper care and treatment.
(2) About 34 percent of the boys and girls were judged to be in
good or excellent nutritional condition (30.2 percent good and 3.4
percent excellent) at 7 years of age.
(3) Necessarily, if about 57 percent of the children were rated as
in borderline and about 34 percent in good or excellent nutritional
condition, only a small percentage (9.5 percent) could have been
judged by the physician to be poorly or very poorly nourished at 7
years. All these children, 28 out of 365 boys and 40 out of 348 girls,
were classified as poorly nourished; none of them as very poorly
nourished.
It is also interesting to note (table 14) that, according to this
pediatrician’s judgment, about 5 percent of the children were poorly
nourished during both years of the study, compared with about 9
percent at 7 years of age.
T
able
1 4 . — Pediatrician’s
assessment of nutritional status of the boys and girls
Both sexes
Boys
Girls
Nutritional status
Num ber
Excellent:
A t 7 years_________
A t both 6 and 7 years_ .
Good:
A t 7 years___
A t both 6 and 7 years .
Borderline:
A t 7 years.........
A t both 6 and 7 years__
Poor:
A t 7 years______
-4f both 6 and 7 years____
V ery poor:
A t 7 years_________
A t both 6 and 7 years. . .
Percent1 Number
24
U
3.4
Z.O
215
101
30.2
HZ
406
pm
41.1
68
89
6.4
0
0
.0
.0
Percent1 Number
Percent *
3.0
1-4
13
3.7
%.6
32.9
95
64
27.3
16.6
56.4
41-4
200
14%
¿ 0.8
16
7.7
4-4
40
11.5
6.6
0
.0
.0
0
0
.0
.0
47
nt\n
57.5
i The percentages in each case were based on the total number of children for whom information at both
6 and 7 years of age was available: For both sexes, 713; for boys, 365; and for girls, 348 mrormatlon at Dotil
Diagnoses made at annual physical examinations.27
The diagnoses made at the examinations given when the children
were 6 and again when they were 7 years of age are shown in table 15.
At 7 years of age 53 percent of the boys and girls were found to be
suffering from various ailments, mostly of the respiratory tract.
Under nonrespiratory infections only one case of rheumatic heart
disease was included, and under the heading “ Other positive diag
noses, three congenital heart conditions. With few exceptions, the
rest of the diagnoses were of minor importance. This is not sur
prising, for all the children were well enough to attend school and to
be under observation for approximately a 2-year period.
27
If more than 1 diagnosis was made at a given examination, that which the pediatrician considered most
important clinically was recorded.
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38
T
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
15.— Diagnoses made at the annual physical examinations of the boys and girls
able
Diagnosis
A t 6 years
Girls
Boys
Both sexes
A t 6 years
A t 7 years
A t 6 years
A t 7 years
A t 7 years
Per
N um Per N um Per N um Per Num Per N um Per N um
cent
cent ber
cent ber
cent ber
cent ber
cent ber
ber
365 100.0
713 100.0
348 100.0
348
100.0
146
202
42.0
58.0
183
165
52.6
47.4
57.8
201
57.7
163
46.8
37.3
20.5
.6
110
91
1
31.6
26.1
.3
96
67
2
27.6
19.2
.6
365 100.0
Total ..........................
713 100.0
N o disease----------------------D isease1------------ ------- ------
265
448
37.2
62.8
335
378
47.0
53.0
119
246
32.6
67.4
152
2Î3
41.6
58.4
Infectious disease-------
444
62.3
374
52.5
243
66.6
211
Respiratory--------N onrespiratory.. O th er2______________
273
171
4
38.3
24.0
.5
232
142
4
32.6
19.9
.5
163
80
3
44.7
21.9
.8
136
75
2
i If more than 1 diagnosis was made at a given examination, that which the pediatrician considered the
most important clinically was recorded.
3 “ Other” included asthma and congenital heart conditions.
Two other items may be useful in indicating the general physical
condition of the boys and girls included in this study: (1) School
absences; and (2) the physician’s judgment of the child’s need for
medical or dental care.
Number and duration of reportable school absences•
Only absences of 3 or more school days’ duration are reportable in
New Haven. The school nurse’s files show the number of such
absences, the total number of school days which they represent, and
the reasons for the absences. Only absences due to illness have been
recorded, and the material has been analyzed in terms'of the associa
tion between the duration of reportable absenes cand the number of
such absences. (Table 16.)
T
able
16.— Association between the number of reportable absences during the school
year and the duration of these absences 1
Duration of reportable absences
Total
Num ber of reportable absences2
0
o
3-4
5-9
10-14
15-19
20-29
30 or
more
__________ _____________
186
0
0
0
0
0
102
0
0
0
0
107
49
1
0
0
20
54
22
3
0
5
17
20
4
0
7
22
19
12
0
8
8
7
19
186
249
150
69
38
Total____ ____________________
186
102
157
99
46
60
42
3 692
1 The data on school absences have not been presented separately for boys and girls, because analysis
failed to reveal any sex difference in either the number or the duration of reportable absences.
2 A reportable absence is an absence of 3 or more school days.
3 Information on school absences was lacking for 8 boys and 13 girls.
During 1935-36, when the children were 7 years of age, approxi
mately 27 percent of the boys and girls had no reportable school
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MATERIAL AND METHODS
39
absences.28 It should be remembered, however, that these children
may have been absent any number of days during the year if each
absence were of less than 3 school days’ duration. It is unfortunate
that such boys and girls have not been differentiated from the children
who had no absences, for a sickly child who is able to attend school
except for absences of a day or two should be distinguished from a
healthy boy or girl who never misses school. On the other hand,
none of these children had any protracted illnesses during the school
year, although it may well be that some of the boys and girls frequently
suffered from minor ailments which undermined their health but did
not materially affect their attendance at school.
Most of the other boys and girls (36.0 percent of all the children)
had only one reportable absence. This absence usually lasted from
3 to 9 school days (41.0 percent, 3 or 4 days, and 43.0 percent,-5 to 9
days); there were a few boys and girls (10.0 percent) absent from 10
to 19 days, and an even smaller number (6.0 percent) absent 20 days
or more.
About 22 percent of all the children were absent twice for periods
of 3 school days or more. About one-third of these boys and girls
were out less than 10 days; a somewhat larger proportion (36.0 percent),
10 to 14 days; and the others (31.3 percent), 15 days or longer.
Finally, a considerable number of the children (more than 15 per
cent of the total) were reported as having had three or more absences
at 7 years. These boys and girls were usually absent for long periods.
Twenty-nine percent of them were not at school for 20 to 29 days,
and nearly one-fourth of these children had reportable absences total
ing 30 school days or more.29
Medical and dental care.
When the pediatrician examined the children each year she indi
cated whether they needed medical care or dental care or both (table
17). Analysis of her findings shows that nearly 60 percent of the boys
and girls were in need of both medical and dental care at 7 years of
age, and that slightly more than 40 percent needed such care at both
6 and 7 years. In other words, nearly half the children were in need
of medical and dental care during both years of the study. Even
more significant, perhaps, is the fact that only about 2 percent of the
boys and girls needed neither medical nor dental care at 7 years of
age and that only 1 percent of the children needed neither type of
care at 6 or at 7 years of age.
28
The data on school absences have not been presented separately for boys and girls, because analysis
failed to reveal any sex differences in either the number or the duration of reportable absences.
28 A larger percentage of the children had reportable absences totaling 10 school days or more at 6 than
at 7 years, but there appears to be little association between the duration of reportable absences at 6 and at
7 years except for the boys and girls who had absences totaling 15 days or more. Consequently, findings at
the earlier age have been omitted from the discussion.
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40
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
In interpreting these findings it should be remembered, however,
that need for medical care refers to observation as well as treatment;
undoubtedly many of the children needed observation only, because
of a reported history of colds, perhaps; or such conditions as dull ear
drums; mouth breathing; or moderately enlarged tonsils.
T
able
17.— Recommendation of the pediatrician on the need of the hoys and girls for
medical and dental care
B oth sexes
Boys
Girls
T yp e of care needed
Num ber
M edical and dental care:
A t 7 years_______ _________
A t both 6 and 7 years___
Medical care only:
A t 7 years______
A t both 6 and 7 years
Dental care only:
A t 7 years______________
A t both 6 and 7 years______
N o care:
A t 7 years______________
A t both 6 and 7 years______
422
P ercent1 Number
59.2
Percent '
Num ber
P ercent1
42.0
fiQ fi
41. e
215
ISO
58.9
41.1
207
146
s
7
1.0
■4
3
2
.8
.5
4
1
.3
271
m
38.0
17.2
143
66
39.2
18.1
128
67
3fi 8
16.4
13
8
1.8
1.1
4
1
1.1
.3
9
7
2.0
m
'T h e percentages in each case were based on the total number of children for whom information at both
6 and 7 years of age was available: For both sexes, 713; for boys, 365; and for girls, 348.
SUMMARY
Most of the boys and girls were between 7 and 7% years of age when
the indices were tested. Nearly half of them were Italian, and nearly
20 percent were American children; the others represented various
smaller nationality groups.
The different sections of New Haven were all fairly well repre
sented. Most of the children lived in flats or apartments with both
their parents; and there were generally four, five, or six persons living
in their homes. Considerable overcrowding existed; about 32 per
cent of the boys and girls lived in households where there were one
and one-half or more persons per room and in about 43 percent of the
homes at least two people were occupying the same bedroom with
the child who was included in this study. Some of these boys and
girls were in extremely poor economic circumstances; about 24 per
cent of their families received assistance (from public, private, or
both public and private sources) during the year prior to each of the
home visits. Even more significant is the fact that 17 percent of the
families were dependent on such assistance for the principal part of
their income during the second year of the study.
There were marked differences in the body build of these boys and
girls. For example, the Italian children were shorter and tended to
weigh less, on the average, than the American children.
The diets, judged in terms of the number of cups of milk consumed
per day, were often inadequate. At 7 years of age, only about 28 per-
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MATERIAL AND METHODS
41
cent of the boys and girls drank an optimum amount (five or more
cups); about 15 percent of the children had less than two cups per day.
If the physician’s judgment is used as a criterion of general nutri
tional status, about 34 percent of the boys and girls were in good or
excellent nutritional condition at the time the indices were applied
(at 7 years); almost 57 percent were in a borderline condition, and
approximately 9 percent were judged to be poorly nourished.
Other evidence which gives some indication of the health of these
children includes: (1) The specific clinical findings at the physical
examinations; (2) absence from school; and (3) the physician’s judg
ment of the boys’ and girls’ need for medical and dental care.
(1) At the time the second physical examinations were made, the
physician found more than half the boys and girls suffering from
various ailments, mostly respiratory-tract infections.
(2) Of the boys and girls with reportable school absences (i. e.,
absences of 3 school days or more) at 7 years of age, 36.0 percent were
absent only once, 21.7 percent, twice, and 15.4 percent, three or more
times. A large proportion (53.3 percent) of those who had been out
three or more times were out of school for as much as 20 school days
or longer.
(3) According to the physician’s judgment, nearly 60 percent of the
children were in need of both medical and dental care at 7 years, and
slightly more than 40 percent at both 6 and 7 years of age. A child
in need of medical attention was almost always in need of dental care,
although the reverse was not generally true.
All these findings— medical, dental, and socioeconomic—indicate
that without doubt there must be boys and girls included in this study
who were likely to be undernourished and to be in need of medical
care or nutritional advice and assistance.
The Observations Made o f These Children
TECHNIQUES EMPLOYED
Every attempt was made to have the observations of these boys
and girls as accurate as possible. In order to accomplish this purpose,
uniform methods of collecting the material and editing the schedules
were used.
No attempt will be made to describe each of the observations.30
On the other hand, the most important items— namely, clinical judg
ment of the child’s nutrition and anthropometric measurements— will
be described in some detail.
30 Instructions for making the physical examinations, for taking the anthropometric measurements, and
for obtaining socioeconomic data, together with the schedules for recording these observations m ay be
obtained upon request from the Children’s Bureau, U. S. Department of Labor.
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42
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
Clinical assessment.
For many years clinical judgment has been the accepted method of
assessing a child’s physical fitness. With increasing knowledge,
improvements have been made in the procedures used in the examina
tion and in the method of arriving at a final judgment of the child’s
general nutritional status. But the physical examination which forms
a part of the usual school health program does not always include
these techniques, because they may require specially trained personnel
or new equipment or both, and because some of them consume con
siderable time in the examining room or in the laboratory. In other
words, such tests are costly, and most school budgets have not ex
panded sufficiently to support so expensive a program. These more
elaborate procedures31 were excluded, therefore, from the present
study in order to have the physical examinations comparable to the
examinations included in the ordinary school health program.
There were two other reasons which made it advisable to exclude
these specialized tests. First, they present many administrative and
technical problems. Thus specific permission must be obtained from
parents or guardians of the children before some of the procedures
may be applied. Second, some of the tests have not been standardized
sufficiently to permit accurate interpretation.
But even if these considerations could have been eliminated, the
first reason still remained; namely, the advantage of having the physi
cal examinations of the boys and girls in this study comparable to
examinations which it is administratively practical to employ in a
school health program today. If the physical examinations are made
in this way, the four indices included in the study can then be com
pared with the type of examination which they would ordinarily be
used to supplement or replace. Furthermore, a study of the objec
tivity of clinical judgment of general nutritional status based on this
type of examination might furnish some clues as to how to improve
the physical examination without the addition of elaborate and ex
pensive tests. In short, it was considered more important to use
carefully a method which the average school physician can and must
employ than to set up an elaborate and costly procedure which it is
not at present practical to adopt in examining large groups of school
children.
In order to make the examination as objective and accurate as
possible, detailed written instructions were prepared for the pediatri
cian’s use concerning the number of items to be included in the exami
nation and the method of evaluating each item. In addition, a 5point scale was devised for judging the child’s general nutritional status
(see chart entitled “ Grading of General Nutritional Status” p. 43).
si Except for hemoglobin and red-blood-cell determinations made on the first day of the check-up examina
tions on 133 children (70 boys and 63 girls) who were included in the study.
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GRADING OF GENERAL NUTRITIONAL STATUS
1. Excellent.
2. Good.
3. Borderline.
4. Poor.
Good color.
Excellent muscle.
Thin fat.
Good color.
Excellent muscle.
Very thin fat.
Good color.
Flabby muscle.
Thin fat.
Good color.
Excellent muscle.
Satisfactory fat.
Good color.
Firm muscle.
Fair fat.
Good color.
Firm muscle.
Thin fat.
Good color.
Flabby muscle.
Very thin fat.
Good color.
Excellent muscle.
Fair fat.
Good color.
Flabby muscle.
Excellent fat.
Good color.
Firm muscle.
Very thin fat.
Pale color.
Excellent muscle.
Thin fat.
Good color.
Excellent muscle.
Excessive fat.
Good color.
Flabby muscle.
Satisfactory fat.
Pale color.
Excellent muscle.
Very thin fat.
Good color.
Firm muscle.
Excellent fat.
Good color.
Flabby muscle.
Fair fat.
Pale color.
Firm muscle.
Thin fat.
Good color.
Firm muscle.
Satisfactory fat.
Pale color.
Excellent muscle.
Fair fat.
Pale color.
Firm muscle.
Very thin fat.
Pale color.
Firm muscle.
Satisfactory fat.
Pale color.
Flabby muscle.
Thin fat.
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Pale color.
Flabby muscle.
Very thin fat.
MATERIAL AND METHODS
Good color.
Excellent muscle.
Excellent fat.
5. Very poor.
00
44
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
This scale was based on (1) color of mucous membranes,32 (2) quality of
muscle,33and (3) amount of fat,34 and was used as a guide in evaluating
nutrition. Other items, including posture, condition of the skin and
hair, and general development, were given consideration in arriving at
a final clinical judgment of the child’s general nutritional status.36
Anthropometric measurements.
The anthropometric measurements necessary for determining the
Baldwin-Wood, Nutritional Status, ACH, and Pryor Indices were
made according to the methods recommended by the investigators 36
with the following exceptions:
Weight.— After his shoes, sweater, and coat were removed, the child
was weighed on a balance scale located in the school and his weight
was recorded to the nearest quarter of a pound. This is the pro
cedure used for the Baldwin-Wood, the ACH, and the Nutritional
Status Indices. In calculating the Pryor Index, there is a correction
to allow for clothing if weight is not taken in the nude. This adjust
ment has been made for each boy and girl included in the present study.
Iliac crests.— When the children were 7 years old the crest measure
ments were taken next to the skin, according to the prescribed tech
niques, with a sliding wooden caliper. However, during the first 3
months of the study (October through December 1934), the bi-iliac
diameter was taken over the clothing with an obstetric metal caliper.
This difference in technique will not affect the indices, because the
incorrect technique was used only in the first 3 of the 5 months during
which the examinations of the 6-year-old children were made, whereas
the indices were derived from measurements made when these children
were 7 years of age.
The instruments used in taking the measurements were checked
frequently; that is, the steel tape equipped with a Gulick spring
handle, used in making the Franzen and ACH measurements, and the
subcutaneous-tissue calipers for the Franzen Indices, were compared
at weekly intervals with standardized instruments. About every 2
months they were returned to the factory for replacement of springs
or for calibration. In addition, the scales located in each of the
schools were balanced at frequent intervals.
3* Color of mucous membranes was assessed as “ good” or “ definitely pale.”
83 Clinical judgment of muscle which was graded as “ excellent,” “ firm ,” or “ flabby,” was based on a
combination of muscle pull and muscle tone.
34 Clinical judgment of fat which was graded as “ excessive,” “ excellent,” “ satisfactory,” “ fair,” “ thin,”
or “ very thin,” was based on an average of the amount of arm and abdomen fat.
35 Diagnoses based on physical examinations were not used in arriving at a judgment of the child’s general
nutritional status except insofar as they affected the clinical items entering into the assessment. Neverthe
less, such diagnoses m ay have influenced the pediatrician unconsciously, although every effort was made
to base the assessment wholly on the items specified in the instructions.
36 For a detailed description of the methods of taking the anthropometric measurements necessary for com
puting each index, see the following references given in Appendix II: Baldwin-W ood Tables— (5) Baldwin,
p. 1; A C H Index— (35) Franzen and Palmer, pp. 9-11; Nutritional Status Indices— (75) Nutritional Status
Indices, pp. 7-12; and Pryor W idth-W eight Tables— (88) Pryor and Stolz, p. 3, and (86) Pryor, p. 8.
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MATERIAL AND METHODS
45
ACCURACY OF THE TECHNIQUES EMPLOYED
Clinical assessment.
It will be remembered that all the physical examinations were made
during both years of the study by one pediatrician, who used detailed
written instructions as an aid in arriving at her assessment of the
children. Since her judgment of general nutritional status has been
used both as a method of assessment and as a criterion for evaluating
the four indices of body build, it is important to determine both its
objectivity and its stability. In order to study these two problems,
check-up examinations were made of some of the children after the
physical examinations were completed in March 1936. They con
sisted of two parts: (1) An initial and repeat examination of some of
the children (51 boys and 52 girls) by the same pediatrician who
made all the physical examinations during both years of the study, in
order to check the stability of her judgment; and (2) examinations of
these same children and of 105 others (56 boys and 49 girls) by the
same physician and by two additional pediatricians, in order to de
termine the extent of agreement in judgment among the three physi
cians. The findings are presented in a later section of this report.
(See pp. 82-87.)
Anthropometric measurements.
At the same time that the check-up examinations were made, the
accuracy of the anthropometric measures was studied in this manner:37
One hundred children (50 boys and 50 girls) were measured twice by
anthropometrist D, who made all the measurements during both years
of the study, and between D ’s initial and repeat observations were
measured, by another anthropometrist, E.
In order to study the variability of the anthropometric data, the
initial measurements of each anthropometric characteristic made by
anthropometrist D have been compared with the measurements of the
other observer, E. This comparison has been made in terms of the
means and standard deviations of the two distributions; that is, if
D and E measured the children with an equal degree of accuracy, the
means as well as the standard deviations of the distributions should
coincide. Conversely, if the two observers’ measurements were not
made with the same precision, the means or the standard deviations
or both will not be identical. Usually, however, the means coincide,
and under these circumstances the anthropometrist whose measure-'
ments have the smaller standard deviation is the more accurate of
the two.
37
For evidence concerning the variability and consistency of anthropometric measurements see Appendix
II: (IB) Boyd, ( 46) Hejinian and Hatt, (55) Lincoln, (66) Marshall, and (67) Meredith.
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46
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
To illustrate this method the reader is reminded that D and E
each measured the bitrochanteric width of 50 7-year-old boys. Analy
sis shows that the average or mean bitrochanteric width for D ’s
observations is 21.9 cm. (table 18); and their dispersion, measured in
terms of the standard deviation, is 1.36 cm. If this value is added
to and subtracted from the mean, the limits obtained, 20.5 and 23.3
cm., define an interval that includes slightly more than two-thirds of
D ’s measurements.
T
able
1 8 . — Means
and standard deviations of anthropometric measurements made
by observers D and E on 50 boys and 50 girls
Girls
Boys
Mean
Standard
deviation
Mean
Standard
deviation
Observer—
Observer—
Observer—
Observer—
Anthropometric measurement
Arm girth 1 (cm .)------ ---------- -----------Bi-iliac crests (width) (cm .)------------Bitrochanteric width (cm .)-------------Chest breadth 1 (cm .)----------------------Chest d e p th 1 (cm .)------------Height (in .)______________ _________
Subcutaneous tissue1_______________
W eight 0 b .)......... - ________________
D
E
D
E
D
E
D
35.4
20.0
21.9
38.9
28.3
47.3
23.5
52.9
35.1
19.6
21.8
39.3
28.8
47.3
24.3
53.0
3.45
1.20
1.36
1.86
1.63
2.19
3.39
8.73
3.37
1.22
1.42
2.03
1.94
2.18
3.32
8.68
35.4
19.9
22.1
38.4
27.8
47.6
26.0
52.9
35.1
19.8
22.1
38.9
28.5
47.7
27.7
53.0
3.61
1.02
1.20
2.21
1.91
2.00
4.41
8.12
i This anthropometric characteristic is the sum of 2 measurements.
Status Indices, pp. 7-12, for a description of this measure.
E
3.42
1.12
1.22
2.28
1.91
1.98
4.84
8.04
See Appendix II: (76) Nutritional
A similar analysis made of E ’s observations shows that the mean is
21.8 cm., and the standard deviation, 1.42 cm., compared with 21.9
and 1.36 cm. for D ’s measurements. (Table 18.) Now, if this stand
ard deviation, 1.42 cm., is added to and subtracted from the mean,
21.8 cm., the limits obtained, 20.4 and 23.2 cm., are about the same
as those for D ’s observations (20.5 and 23.3). These findings indi
cate that there is excellent agreement between the two anthropometrists’ measurements of the bitrochanteric width of 7-year-old boys.
The data for the 50 girls included in these anthropometric examina
tions also show close agreement between the two observers. (Table 18.)
Similar analyses of the other anthropometric characteristics of
these boys and girls are shown in table 18. It may be seen upon
examination of this table that the largest errors for the boys were
made in measuring chest depth, chest breadth, and arm girth, in the
order named, and for girls, in subcutaneous tissue, arm girth, and width
of the iliac crests. As a whole, however, the observations of D and
E were in very close agreement.38
38
For any given anthropometric characteristic the error of the measurement has been assumed to be
directly proportional to the difference between the number of scale units within the interval defined b y the
mean, plus and minus 1 standard deviation, for the measurements made b y each of the observers, D and E .
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47
MATERIAL AND METHODS
The stability of D ’s measurements has been studied in terms of
the error involved in making repeat measurements of each anthropome
tric characteristic (except weight and height) on the 50 boys and the
50 girls included in the anthropometric check-up observations.
If it is assumed that each of these two measurements, the first and
repeat observations, contains chance, uncorrelated errors, the stability
of D ’s measurements may be tested in terms of a statistical constant,
which estimates their dispersion or variability. This constant,
known as the standard deviation of a difference (<r dlff ), may be used
to estimate the standard deviation of the error of measurement.39
More specifically, if D makes no errors in measuring an anthropometric
characteristic, her first and repeat measurements are equal and the
difference between them is zero; but if she makes chance errors
only, her initial measurement may be larger or smaller than the repeat
observation, and the difference between them will vary both in direc
tion and size. As a result, the average or mean difference between the
initial and repeat measurements of any given anthropometric char
acteristic will be zero, and the dispersion of the errors can be esti
mated in terms of the standard deviation of the error of measurement.
This standard deviation of the error of measurement can then be
added to and subtracted from the average or mean error, zero, to
indicate the limits between which slightly more than two-thirds of
D ’s errors are likely to occur. If this standard error is added to and
subtracted from any single observation, the resulting scale values
give the limits within which the true value of the observation is
likely to occur.
Table 19 gives this estimate of the standard deviation of the error
of measurement for each anthropometric characteristic except weight
and height. It may be seen that subcutaneous tissue is the most
unstable, then the chest measurements and the arm girth; but the
maximum standard deviation of the error of measurement for any
of these six anthropometric characteristics is less than 0.5 cm.
T
able
19.— Standard deviations of the error of measurement of six anthropometric
measurements of 50 boys and 50 girls (observer D)
Anthropometric measurement
Standard deviation of
the error of measure
ment
Boys
A rm girth * (cm .)____ ______________ _____ _______________
Bi-iliac crests (width) (cm .)______ ____________ ____ _______
B¡trochanteric w idth (cm .)______________________________________
Chest breadth i (cm .)................................................ .....................
Chest depth i (cm .)_____________________________________________
Subcutaneous tissue1______ ______________________________
. i This anthropometric characteristic is the sum of 2 measurements.
Status Indices, pp. 7-12, for a description of this measure.
0.189
.0725
.135
.248
.257
.265
Girls
0.170
.0962
.116
.196
.295
.365
See Appendix II: (75) Nutritional
39 For a description of the m ethod of estimating the standard deviation of the error of measurement, see
Appendix II: (79) Palmer, pp. 227-228,
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48
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
This analysis indicates that D ’s measurements are unusually stable.
This finding, together with the fact that her measurements agree well
with those of the other observer, E, furnishes convincing evidence that
D is an extremely careful and accurate worker and that her measure
ments are a satisfactory basis for deriving the indices included in this
study.
Socioeconomic and related data.
The socioeconomic data were checked and verified by different
methods, depending on the type of material and the sources available.
For example, statements about illnesses were checked against hospital
and clinic reports, the files of the Visiting Nurses’ Association, and the
records of the Divisions of Tuberculosis and Venereal Diseases of the
New Haven Department of Health.
Data on income and assistance could be verified only for families
who reported that they had received assistance during the year
preceding each home visit or who were known to public or private
agencies in New Haven giving direct or work relief. During the
course of the study all the families with an income under $1,000,
those reporting relief assistance, families with members suffering from
severe illness, and those whose income estimates appeared to be
grossly inaccurate were cleared through the Social Service Exchange
of New Haven. This means that the source and amount of income
of these families, the number of persons living on the income, and the
type and amount of assistance were checked against the records of the
social agencies, both public and private, administering any form of
assistance in New Haven.
School absences and progress were verified from school records.
The office clerk also checked relevant data against one another
and against the files of the health and welfare agencies of the city.
For example, wherever possible the birth date of the child as well as
his legitimacy and the age of his parents were compared with the
records of the Bureau of Vital Statistics of the City Health Depart
ment; other facts about the parents, with the files of the school
nurses and agencies granting assistance.
Data obtained at the first home visit which did not tally with
information derived from other sources were checked by the eco
nomic analysts at the second home visit.
In general, the socioeconomic data are fairly reliable and accurate.
Such inaccuracies as occur are due for the most part to the failure of
the mother to remember the child’s history or to the fact that, as the
child had previously lived in another city, records for checking were
not available. Some inaccuracies have also resulted from the em
ployment of several economic analysts for collecting thé data, Inso-
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m aterial and methods
49
far as possible, however, the observations were checked against one
another and against the records of public and private agencies in
New Haven.
Summary o f Material and Methods
In the preceding pages an attempt has been made to outline the
purpose of the study and the method of collecting the observations
as well as the procedures used in checking the material and editing
the schedules.
Before proceeding to ah analysis of these observations it may be
well to review the plan and objectives of the investigation: The plan
was to observe a group of 713 children living in New Haven, Conn.,
from September 1934 through May 1936, \yho were 7 years of age
at the time of the second annual physical examination and were
attending the public or parochial schools of the city. The purpose
was to study the efficiency of each of several methods of assessing
physical fitness (clinical judgment and four indices of body build) in
identifying children who at 7 years of age were likely to be in poor
physical condition.
The evaluation of these methods of assessing the child's well-being
has been made in terms of the findings when the children were 7
years old for two reasons. First, the indices of body build have
been computed from measurements of the boys and girls taken at
the age of 7 years, as the Nutritional Status Indices and the ACH
Index apply to 7-year-old children and not to boys and girls 6 years
of age.40 Second, if the various methods of assessment are tested on
the boys and girls at 7 years of age, a whole series of clinical, anthro
pometric, and socioeconomic data, based on observations made over
a period of 20 months, are available for evaluating the physical
fitness of the children.
40 In <>ther words, these 2 methods are probably most efficient in testing children of the same age as the
boys and girls from whose measurements the indices have been derived.
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Results
Indices o f Body Build
THE PROBLEM OF TESTING THE INDICES
Two serious difficulties stand in the way of any attempt to test the
four indices of body build included in this study. The first, discussed
in detail in the early part of the report, is based on the fact that none
of these indices attempts to identify every child who is in poor physical
condition. In fact, they measure the child’s physical fitness only
insofar as it is related to such characteristics as his weight, subcuta
neous tissue, or arm girth. Consequently, if the indices are to be
given a fair but rigorous test, it is necessary to apply them to a large
group of children. The success or failure of the indices can then be
measured by comparing the children they identify with the boys and
girls who are likely to be in very poor physical condition.
The selection of such a group constitutes the second difficulty in
studying these indices. It is apparent that some standard is needed
for identifying children on whom the indices are to be tested, but
unfortunately, as has been indicated, such a standard of physical
fitness is lacking. In fact, it is this very need for a reliable measure
which meets both the statistical requirements of objectivity and
reliability, and the practical requirements of unprohibitive cost, ease
of application, and expediency that the indices now being studied
were designed to meet. In the true sense, then, the solution to the
problem of the efficiency of these indices is indeterminate, since no
entirely satisfactory criterion of reference is at hand.
CRITERIA FOR TESTING THE INDICES
Nevertheless, many of the factors which go to make up this com
plex state are known and can be measured. They can be used for
deriving approximations to the true standard of physical fitness
which may serve as criteria for testing the indices. Such a proced
ure— namely, setting up several arbitrary but well-defined criteria
for identifying children who are likely to be physically unfit—has
been adopted in this investigation.
Observations used in deriving criteria.
Before defining the specific criteria which have been used in this
study, it may be well to restate the material and methods and to
describe some of the estimates of growth and development which
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RESULTS
51
have been used in deriving these criteria. It will be remembered (1)
that during a 19- or 20-month period of observation beginning Sep
tember 1934 one pediatrician examined 713 school children at 6 and
again at 7 years of age; (2) that the physician described each child’s
general nutritional status as “ excellent,” “ good,” borderline,”
“ poor,” or “ very poor” ; (3) that at each physical examination the
pediatrician indicated whether the child was in need of medical care,
dental care, or both; (4) that an anthropometrist took eight measure
ments when the two annual physical examinations were made; (5)
that each child was weighed at frequent intervals during the 19- or
20-month period of observation.
The anthropometric measurements have been used to derive the
following growth estimates:
1. The absolute increase or decrease in each anthropometric characteristic.
For example, if a boy’s arm girth was 33.2 cm.1 at the age of 6 and 34.3 cm. at the
age of 7, his arm girth increased approximately 1.1 cm. during the 12-month
period.
2. The relative percentage increase or decrease in each of these anthropometric
characteristics. Thus, the arm girth of this same child increased about 3.3
percent in a year (1.1 cm./33.2 cm.).2
3. A more refined estimate of gain in weight. In order to determine each
child’s average percentage gain in weight per month,3 an equation has been fitted
to his successive weighings made at frequent intervals during the 19- or 20-month
period of observation.* This equation measures the child’s relative gain in weight
much more accurately than an estimate derived from the two weighings made at
the annual physical examinations because it is based on a larger number of meas
urements (five to nine) made at more frequent intervals.
Some of these data, both the clinical observations and the growth
estimates, have been used to derive provisional criteria of physical
fitness which will make it possible to appraise the effectiveness of the
four indices of body build used in this study—namely, the BaldwinWood Height-Weight-Age Tables, the ACH Index, the Nutritional
Status Indices, and the Pryor Width-Weight Tables.
Description of the criteria.
Five empirical criteria of physical fitness have been established.
Criterion I is based on clinical judgment of the child’s general nu
tritional status. Any boy or girl found by the examining physician
to be in poor or very poor general nutritional condition at 7 years of
age was “ selected” by this criterion. Only the boys and girls who
were poorly or very poorly nourished as distinguished from those who
1 The sum of 2 measurements made according to the Franzen technique.
tional Status Indices, pp. 7-8.
T 2
See Appendix II : (75) Nutri
distributio11 of percentage change in arm girth per year, see supplementary table IV , Appendix
3 For a distribution of average percentage gain in weight per month, see supplementary table III, Apnen
dix l , p. 101.
* See Appendix I, pp. 98-99, for a description of the method used in fitting the exponential equation to
the consecutive weighings of each child.
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52
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
were in a borderline state of nutrition have been used for testing the
indices, on the assumption that if an index fails to select obvious
cases— that is, children who are in poor physical condition—it will
also fail to identify children who are in borderline physical condition.
Unfortunately, it is these very “ borderline” children who constitute
the major problem in assessing physical fitness, but until the ade
quacy of an index in selecting poorly nourished children is established
there is no reason for testing it on a child who is in borderline nutri
tional condition. “ Selected,” as used here and as it will be used in
describing the results of testing the indices, means that on the basis
of a given method of evaluating physical fitness— in this case, general
nutritional status at 7 years of age— a child is found to be physically
unfit and is, therefore, in need of medical attention or nutritional
advice and assistance.
Criterion I I is a refinement of Criterion I. Any child who was
found by the examining physician to be in a state of poor or very
poor nutrition at 6 and at 7 years of age was selected by Criterion II.
Criteria I I I and I V are based on the child’s average percentage
weight gain and percentage change in arm girth. Although estimates
were made of the increase or decrease in each of seven anthropometric
characteristics of these boys and girls, only weight and arm girth
have been used in deriving criteria of physical fitness. Weight has
been used because it is a measurement which is easy to make accur
ately and because it has been carefully studied, although it has the
limitation of being a three-dimensional or volumetric characteristic,
which may be more closely related to the child’s skeletal development
than to his physical fitness. Arm girth has been selected not only,
because it is easily measured and the error of measurement is relatively
small (table 19) but also because it reflects the child’s increase in
musculature and in subcutaneous tissue as well as his skeletal develop
ment. It has another advantage in its large relative variation. Next
to weight and subcutaneous tissue, arm girth has the largest coefficient
of variation of any of the eight anthropometric measurements included
in this study.6 In other words, there is considerable variation in the
5 T he coefficients of variation for the measurements made when the boys and girls were 7 years of age are
as follows:
Coefficient
Measurement
Boys
W eight
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............. - _______________________ ______-
8.39
5.39
5.30
4.77
5.70
4.73
13.30
14.02
Girls
10.23
5.59
6.20
5.43
6.27
4.16
14.81
16.85
RESULTS
53
arm girth of the boys and girls which may have biological as well as
clinical significance.
According to Criterion I I I children have been selected who exhibited
an “ unsatisfactory” gain in weight. If a child’s average percentage
increase in weight per month is exceeded by at least 90 percent of the
boys or the girls included in this study,6 his weight gain has been
arbitrarily defined as unsatisfactory.7 In other words, only about
10 percent of the children exhibited an average percentage increase
in weight as small as or smaller than that of the child in question.
This definition is empirical and open to criticism, but, on the other
hand, it seems reasonable to assume that a child of this age who
exhibits so small a gain in weight is not in good physical condition.8
Criterion I V is based on percentage change in arm girth. Any
child whose percentage change in arm girth between 6 and 7 years of
age was in the lowest 10 percent9 of the group of boys or girls included
in the study is selected by Criterion IV. All the children identified
by this criterion exhibited a percentage decrease in arm girth.
Criterion V is the most restricted of the five criteria. It is a modi
fication of two of the others and involves both clinical judgment and
growth estimates. Any child who was found by the pediatrician to
be in poor or very poor nutritional condition (Criterion I) and in
need of medical and dental care when examined at the age of 7 years,
and who exhibited an unsatisfactory percentage change in arm girth,
as in Criterion IV, is selected by Criterion V.
Number of children selected by the criteria.
The numbers of boys and of girls identified by these five criteria
vary considerably. (Table 20.) Criterion III (average relative
monthly gain in weight) selects the largest number of boys, 37 (10.1
percent), and girls, 37 (10.6 percent); Criterion V, based on clinical
judgment of general nutritional status, need for medical and dental
care at 7 years, and percentage change in arm girth, selects the
smallest number of children, 4 boys (1.1 percent) and 5 girls (1.4
percent).
* Theoretically, the lowest 10 percent of the children of each sex were to be selected. This would mean
identifying 37 boys find 35 girls. However, it was necessary to select 37 instead of 35 girls because of the
limitations resulting from grouping the material. All the boys who were selected showed an average per
centage gain in weight per month of 0.657 or less; the girls, of 0.672 or less.
7 This estimate of percentage weight gain is a more refined measure than the one used in the preliminary
report of this study. See Appendix II: (106) Souther, Eliot, and Jenss, p. 437.
» Although it m ay well be that an exceptionally rapid percentage gain in weight is as significant as an
exceptionally small gain, a child whose weight gain is exceeded b y approximately 90 percent of the boys or
girls included in the study is not likely to be in very good health.
* Theoretically the lowest 10 percent of the children of each sex were to be selected. This would mean
identifying 37 boys and 35 girls. However, it was necessary to select 32 instead of 35 girls because of the
limitations resulting from grouping the data. All the children who were selected showed a percentage
decrease in arm girth: 1.3 or more for boys, 0.7 or more for girls.
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54
T
able
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
2 0 . — Number
and 'percent of the 365 boys and 348 girls selected by each of
five criteria of physical fitness
Girls
Boys
Criterion
I. Clinical estimate of poor or very poor nutritional status at
II. Clinical estimate of poor or very poor nutritional status at
III. “ Unsatisfactory” 1 average percentage gain in weight per
IV . “ Unsatisfactory” s percentage change in arm girth per year.
V . Clinical estimate of poor or very poor nutritional status at
7 years of age, need of both medical and dental care at 7
years of age, and “ unsatisfactory” 1 percentage change in
Percent
N um ber
Percent
N um ber
28
7.7
40
11.5
18
4.9
23
6.6
37
10.1
37
10.6
37
10.1
32
9.2
4
1.1
5
1.4
i T he lowest 10 percent of the group of boys and girls included in the study have been considered selected
b y this criterion. This w ould mean identifying 37 boys and 35 girls. However, it was necessary to select
37 instead of 35 girls because of the limitations resulting from grouping the data.
A ll the boys who were selected showed an average percentage gam in weight per m onth of 0.657 or less;
The^owesiflO percent of the group of boys and girls included in the study have been considered selected
b y this criterion. This w ould mean identifying 37 boys and 35 girls. However, it was necessary to select
32 instead of 35 girls because of the limitations resulting from grouping the material.
A ll the children who were selected showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7
or more for girls.
Evaluation of the criteria.
None of these criteria is a very satisfactory measure of the child’s
physical fitness, although each has certain relative advantages and dis
advantages. For example, the clinical examination might identify a
child with flabby muscles who probably would not be selected by a
growth estimate such as percentage gain in weight. On the other
hand, clinical judgment does not measure dynamic aspects of the
child’s growth and development so accurately as growth measures
based on seriatim observations of the child.
As none of these criteria is ideal and there is no valid measure to be
used as a standard, the reader is left to choose for himself the criterion
or criteria which he is willing to accept as a more or less satisfactory
measure of physical fitness. He may, of course, find himself unwilling
to accept unreservedly any one of these criteria. In that case, how
ever, he will certainly not reject all five as without some value, since
the factors on which they are based are generally known to be closely
related to physical fitness. In other words, although the failure of an
index to agree with any particular criterion may not prove that the
index is inefficient, the reader will probably concede that its failure to
agree to a considerable extent with all five methods of assessing a
child’s well-being justifies the conclusion that the index is not efficient
in identifying children who may be in need of medical attention or
nutritional advice and assistance.
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RESULTS
55
TESTING THE INDICES
Because the several indices measure different aspects of physical
fitness and use different methods of identifying children who are in
poor physical condition (pp. 10-17), it will be necessary to describe
the association between each index and the five criteria separately.
The Baldwin-Wood Tables.
It will be remembered that the Baldwin-Wood Tables give the child’s
expected weight in terms of his height for his age and sex; that the
child’s actual weight is compared with his expected weight and the
difference between them is expressed as a percentage of the expected
measurement; 10 and that if the observed weight is 6 or more percent
less than the expected, the child is selected by this index as being
underweight.
Methods of analysis.—Before evaluating the efficiency of this index in
selecting children identified by each of the five criteria, it may be well
to digress for a moment for the purpose of outlining the methods used
in presenting the results. The data were first analyzed in the form of
“ fourfold” tables (table 21), which are useful in presenting observa
tions when the frequencies of each of the four possible combinations of
two attributes are known in respect to presence or absence. To cite
an example based on the Baldwin-Wood Tables:
The girls included in this study have been classified into two groups on the basis
of clinical judgment of nutrition at 7 years of age— namely, girls who were poorly
or very poorly nourished (clinical judgment) and girls who were not. They have
also been classified, according to the Baldwin-Wood Index, into two other inde
pendent groups consisting of girls selected by the index as underweight, and girls
who were not. These two classifications (based on clinical judgment of general
nutritional status and on the Baldwin-Wood Index) can be further refined and
interrelated to determine the number of girls who were in poor or very poor nutri
tional condition who were also selected by the Baldwin-Wood Index; the number
of girls who were identified by the criterion (clinical judgment) but not selected
by the index; those identified by the index and not selected by the criterion; and,
finally, the girls selected by neither the index nor the criterion. This type of
analysis is illustrated in table 21.
According to this table the criterion classifies only 40 of the 347 girls 11 as poorly
or very poorly nourished at 7 years of age; the index identifies 25 (62.5 percent)
of these 40 children as underweight for their height and age, although it selects 52
other girls as underweight whom the physician did not consider poorly or very
poorly nourished. In other words, although the index selects nearly twice as
many children as the criterion 12 it fails to identify 15 (37.5 percent) of the 40
girls whom the physician judged to be poorly or very poorly nourished.
10 For a distribution of these relative differences see supplementary table X I V , Appendix I, p. i l l .
» The Baldwin-W ood Index could not be applied to 1 of the 348 girls included in the study as her height
exceeded the measurements given in the Baldwin-W ood Table,
i* The index selected 77 girls; the criterion, 40.
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56
T
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
able
21.— Association between clinical estimate of nutritional status and the Bald
win-Wood Tables for 347 1 7-year-old girls 2
Baldwin-W ood Tables
Clinical estimate of nutritional status
O ther4________________
_________________ _________________ _______
T otal____________ _____ ________________
_____________________
Selected as
under
weight 3
N ot se
lected
25
52
15
255
77
270
i 348 girls were included in the study, but the index could not be tested on 1 girl whose height exceeded
the measurements in the table.
3 F or the Baldwin-W ood Tables age at nearest birthday was used; at the physical examinations age was
defined in completed years.
3 6 percent or more underweight.
4 “ Other” included children whose nutritional status was estimated as excellent, good, or borderline.
This method of analyzing the data (in the form of fourfold tables)
may be condensed 13for inclusion in the table which gives the results of
testing the index (table 22) to show the number of children selected by
each of the five criteria, the number identified by the index, and the
number selected by both the criterion and the index. This table also
gives the children identified by both the criterion and the index as a
percentage of those selected by the criterion and shows the percentage
of the boys or girls included in the study who must be screened by the
index to include all the boys or girls identified by each of the criteria.
In interpreting the results of testing this or any other index, it
should be remembered that to be effective as a method of assessment,
an index must have both specificity and sensitivity. If an index is
specific, every child who is selected is in poor physical condition but
not every child who is in poor physical condition is necessarily
selected. On the other hand, if the index is sensitive, it will identify
all the children who are in poor physical condition, but not every
child it selects is necessarily physically unfit. To put it in another
way, there are two requirements which a satisfactory index must
fulfill. When applied to a group of children, it must pick out all or
nearly all the children who are in poor physical condition, and in
addition it must reject all or nearly all the children who are physi
cally fit. Does the Baldwin-Wood Index meet these requirements?
This question will be answered for each of the 5 criteria.
13 It is important to point out that the original fourfold table used in testing the index can be derived from
the summary tables. For example, according to table 22 there were 347 girls on whom the index was tested.
Criterion I selected 40 girls;, the index identified 77; 25 girls were selected b y both the criterion and the index,
and 15 girls identified b y the criterion were not selected b y the index. Similarly, 52 girls identified b y the
index were not selected b y the criterion. N ow , if the index identified 77 girls and it was tested on 347, it
necessarily follows that the iudex did not select 270 girls. Similarly, if the criterion identified 40 girls it failed
to select 307; and finally, if 307 were rejected b y the criterion of whom 52 were selected b y the index, 255 were
rejected b y both the criterion and the index. These observations form all the necessary data for completing
the fourfold table which shows the association between Criterion I and the Baldwin-W ood Index.
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Comparison o / each of Jive criteria 0} physical fitness and the Baldwin-Wood Tables applied to 7-year-oli children,1
_____________________________________________ S47 girls2 (6 'percent selection by the index)2
T able 22.
N um ber of children identified b y —
Criterion
Criterion
Boys
Girls
Index
Boys
Criterion and index
Girls
Boys
I. Clinical estimate of poor or very poor nutri
tional status at 7 years of age_______________
Clinical estimate of poor or very poor nutri
tional status at both 6 and 7 years of age_____
IH.
“ Unsatisfactory’ ’ * average percentage gain in
weight per m onth____ ________ _________
IV.
“ Unsatisfactory” ® percentage change in arm
girth per year._________________________
V . Clinical estimate of poor or very poor nutri
tional status at 7 years of age, need of both
medical and dental care at 7 years of age, and
unsatisfactory” { percentage change in arm
girth per year_________________
Boys
boys and
Children screened b y the index in order
to include all the children identified b y
the criterion
Girls
Boys
Girls
53.6
62.5
Num ber
276
Percent
75.6
Num ber
276
Percent
79.5
55.6
60.9
236
64.7
276
79.5
21.6
24.3
352
96.4
337
97.1
16.2
25.0
352
96.4
333
96.0
25.0
60.0
185
50.7
208
59.9
RESULTS
II.
Girls
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
See
l Age at nearest birthday.
8According6to th i^ n d ex a^chifd^seiected if he Is 6 p e r c e n f o ^ m o ^
an ^ e ^ s e ^ e r c e n t^ e ^ a in T ^ w e ig h t^ r n a o n th o Y o . e ^ o r ^
showedPaper™ntage decreasein a m g h t h : l!j}*or m o r T f o i ^ b ^ 0.7 or more t o girl °
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DOt b ® t6Sted on 1 ^
whose height exceeded the measurements given in the table,
have been eonsidered selected b y this criterion.
A ll the boys who were selected showed
StUdy haV6 been considered selected b y this criterion.
A ll the children who were selected
Ol
<1
58
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
Criterion I .— It may be seen from table 22 that the Baldwin-Wood
Index identified as 6 or more percent underweight 77 of the 347 girls
on whom it was tested; that Criterion I (clinical judgment) selected
40 girls as poorly nourished and that only 25 girls were identified by
both the criterion and the index. In other words, of the 40 girls
whom a competent physician judged to be poorly nourished at 7
years of age, 25, or approximately 62 percent, were identified by the
Baldwin-Wood Index as being 6 or more percent underweight. It
follows that 52, or approximately 68 percent, of the 77 girls identified
by the Baldwin-Wood Index were not poorly nourished according to
the physician’s judgment and that 15, or approximately 38 percent,
of the 40 girls who were selected by the physician were rejected by the
index.
In interpreting these results it is appropriate to refer to a question
asked by A. Bradford Hill in discussing R. Huws Jones’ paper,
“ Physical Indices and Clinical Assessment of the Nutrition of School
Children,” read before the Royal Statistical Society in London on
November 16, 1937. Hill asked: “ If the test fails to pick out
certain boys clinically assessed as bad or picks out certain others
clinically assessed as good, is it because the test is bad or the clinical
assessment is bad?” 14
In order to minimize the errors inherent in clinical judgment, all
the physical examinations of the children included in this study were
made by one well-trained pediatrician and included the evaluation of
many factors commonly agreed upon to be basic elements in physical
fitness. Furthermore, the stability and reliability of her clinical
findings have been investigated and found to be as objective as can
reasonably be expected.15 If, then, her judgment is accepted as a
more or less satisfactory criterion of physical fitness, one may con
clude that (1) the Baldwin-Wood Index failed to identify nearly 40
percent of the girls who were poorly nourished, and (2) more than
two-thirds of the girls it selected were not physically unfit according
to the physician’s judgment.
The index was even less efficient in identifying boys selected by
this criterion (clinical judgment). Only 15, or about 54 percent, of
the 28 boys whom the pediatrician judged to be poorly nourished were
identified by the index; while 50, or approximately 77 percent, of the
65 boys who were selected by the index were not identified by the
criterion. In other words, the Baldwin-Wood Tables are not an
efficient index if clinical judgment is used as a standard of physical
fitness.
m
15
See Appendix II: {61) Jones, p. 35.
A detailed discussion of the stability and reliability of the pediatrician’s judgment is presented on
pp. 82-87.
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■
RESULTS
59
The Baldwin-Wood Tables have been tested in another way by
determining the number and percentage of the boys or girls who must
be screened by the index in order to identify all the children selected
by the criterion. For example, according to Criterion I, 40 girls were
identified as poorly nourished (by clinical judgment) at 7 years of
age. If, as has been pointed out, the Baldwin-Wood Index is set to
identify girls who are 6 or more percent underweight, it selects only
25, or about 62 percent, of these 40 girls. On the other hand, if the
index is required to select all the 40 children whom the pediatrician
judged to be physically unfit, it will also identify 236 girls whom the
pediatrician did not select, a ratio of about 1 to 6. If a similar test is
made for the 365 boys included in the study, the ratio is approximately
1 boy who was poorly nourished to every 10 who were not. This
evidence confirms the previous findings and demonstrates even more
clearly the low sensitivity of the index in identifying the group of
New Haven children included in this study, if it is tested in terms of
clinical judgment.
Criterion I I .— Children identified by Criterion II were judged by
the pediatrician to be in poor or very poor nutritional condition at 6
and also at 7 years of age. This criterion is theoretically a more
rigorous test than Criterion I, for although they are both based on
clinical judgment of general nutritional status, Criterion II refers to
both physical examinations (that is, the examinations made at 6 and
again at 7 years of age) while Criterion I applies only to the findings
at 7 years (table 22). According to this table the Baldwin-Wood
Index identified about 56 percent of the 18 boys and about 61 percent
of the 23 girls selected by the criterion. In other words, it failed to
identify nearly half the children selected by the criterion as poorly or
very poorly nourished at both 6 and 7 years of age. If one considers
the additional fact that 63, or about 82 percent, of the girls and 55,
or about 85 percent, of the boys who were identified by the index
were not selected by the criterion, it is quite clear that the BaldwinWood Tables are neither a selective nor a sensitive measure of the
physical fitness of the boys and girls included in the study, if clinical
judgment at both 6 and 7 years of age is used as a criterion.
Criterion I I I .— The Baldwin-Wood Index identified only about 24
percent of the 37 girls and about 22 percent of the 37 boys whose
weight gain was unsatisfactory (Criterion III).16 In interpreting
these results it should be remembered that (1) the weight-gain esti
mates are exceptionally accurate, for they are based on an average
of eight weighings made over approximately a 2-year period; (2) about
is These estimates of average relative gain in weight per month are probably more accurate than the
estimates of percentage gain in weight per year used in the preliminary report (see Appendix I I : (108) Souther,
Eliot, and Jenss, p. 437). Consequently the results of testing the indices in terms of these 2 forms of the
criterion are not strictly comparable.
239848°— 40-
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-5
60
ASSESSING TH E PHYSICAL FITNESS OE CHILDREN
90 percent of the boys and of the girls included in the study exhibited
a larger average percentage increase in weight per month during the
19- or 20-month period of observation than the boys and girls selected
by the criterion; and (3) these children were probably in poorer
physical condition than the boys and girls whose weight gain was
more satisfactory, although not all children who are in poor physical
condition necessarily exhibit a small weight gain. As has been pointed
out, however, the Baldwin-Wood Tables identified only about 20 to
25 percent of the boys and girls selected by this criterion. If the
index is set to identify all the boys and girls who exhibited an unsatis
factory weight gain, it would identify about 96 percent of the boys
and about 97 percent of the girls included in the study. In other
words, practically all the children would have to be selected by the
index if it is to identify the small number whose weight gain was
unsatisfactory.
Criterion I V .— This criterion, percentage change in arm girth,17 has
none of the virtues which result from widespread application and
study such as the weight-gain estimates have. It has been used in
this investigation, however, because it has the probable advantage, in
comparison with weight-gain estimates, of not being influenced to the
same extent by the child’s skeletal development. In addition, the
percentage change in the arm girth of these children varied consid
erably. The range for boys was from a decrease of 6.3 percent per
year to an increase of 21.6 percent, with a mean increase of 3.12
percent and a standard deviation of 3.58 percent. Corresponding
figures for the girls are as follows:
Percent
Range__ T:______________________________ —9. 1 to + 19. 5
Mean__________________ _______________
3. 63
Standard deviation_____________________
3. 64
In other words, the variation in this growth estimate is large enough
to assume biological and perhaps clinical significance, for there are
some indications that marked changes in a child’s physical well-being
are often reflected in his arm girth. It is for these reasons that per
centage change in arm girth has been used, as Criterion IV, for iden
tifying boys and girls who are likely to be in need of medical attention
or nutritional advice and assistance.
For the application of this criterion, the boys and girls were each
grouped in order of percentage change in arm girth per year. Then
the children who were in approximately the lowest 10 percent of each
group were arbitrarily selected, as showing an unsatisfactory per
centage change in arm girth (a decrease of 1.3 or more percent for
boys and 0.7 percent or more for girls) between 6 and 7 years of age.
17 The sum of 2 measurements according to the technique described in A ppendix II: (75) Nutritional
Status Indices, pp. 7-8.
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RESULTS
61
The Baldwin-Wood Index identified only about 16 percent of these
37 boys and 25 percent of the 32 girls who were selected by the cri
terion. If the index is required to select all these children who showed
an unsatisfactory change in arm girth, it must identify about 96 per
cent of the boys and the same percentage of the girls included in the
study.
Criterion V .— The limitations of each of the four criteria which
have been studied are well recognized. Two of these criteria are
entirely dependent on clinical judgment; the other two are dependent
on growth estimates. It was, therefore, decided to employ a criterion
(Criterion V) which involves both clinical judgment and estimates
of growth, and, in addition, includes the physician’s judgment of the
child’s need for medical and dental care. In order to make the test
very rigorous, the following requirements for selection by the cri
terion were made: (1) The child’s general nutritional status was
judged by the pediatrician to be poor or very poor at 7 years of age;
(2) the child needed both medical and dental care at the age of 7
years when the pediatrician made the physical examinations; and (3)
each child was in approximately the lowest 10 percent of the group
of boys or girls included in the study with respect to percentage change
in arm girth between 6 and 7 years of age.
As would be expected, only a small number of children— 4 of the
365 boys and 5 of the 347 girls— on whom the index was tested, were
selected by this criterion. Examination of their anthropometric
schedules, physical examinations, medical histories, and socioeconomic
schedules indicates that these 9 children were in very poor physical
condition. Yet the index failed to identify 3 of the 4 boys and 2 of
the 5 girls. If it does not select these children who are extreme cases,
will it identify other boys and girls who are physically unfit?
The ACH Index.
The next index to be tested is the ACH Index. It is based on an
empirical procedure developed by the American Child Health Associ
ation for identifying children with a small amount of musculature and
subcutaneous tissue relative to body build: According to this pro
cedure a child may be selected as falling in the lowest 10, 14, 20, or
25 percent of a group of boys or girls of the same age and hip width.
Such selection is dependent on the difference between the child’s arm
girth and his chest depth relative to his hip width. In order to make
the results of testing this index roughly comparable to the findings
which pertain to the Nutritional Status Indices and to the Pryor
Tables, each o f which has been arbitrarily set to identify the lowest
15 percent of a large group o f boys and girls, the ACH Index has been
set to select the lowest 14 percent of a group of children of the same
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62
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
sex, age, and hip width.18 At this level only 9 of the 712 children19
on whom the index was tested, 4 boys (1.1 percent) and 5 girls (1.4
percent), were identified by the index.
According to table 23 the ACH Index does not agree very well with
any of the five criteria. When the index was tested on the girls, there
was maximum agreement (10.0 percent) with clinical judgment of
nutritional status at 7 years (Criterion I). On the other hand, for
three of the criteria—namely, unsatisfactory weight gain (Criterion
III), unsatisfactory change in arm girth (Criterion IV), and Criterion
V, based on clinical judgment and need for medical and dental care at
7 years of age as well as unsatisfactory change in arm girth—none of
the girls selected by the criterion were identified by the ACH Index.
It was somewhat more efficient in identifying boys, but the maximum
agreement was only 25 percent (Criterion V ).20 In other words,
evidence derived from this study indicates that the index is not suf
ficiently sensitive because it identified so small a number of children.
In terms of the five criteria used in this study, it is also not a highly
selective procedure.
The Nutritional Status Indices.
The three Nutritional Status Indices utilize the principle of com
paring (1) weight; (2) muscle size as indicated by the girth of the
upper arm; and (3) amount of subcutaneous tissue over the biceps
with the child’s expected weight, arm girth, or subcutaneous tissue
judged in relation to his sex, age, and body build measured in terms
of his height, chest depth, chest breadth, and hip width. The method
of computing and evaluating the child’s relative standing, or “ score,”
in any one of these three anthropometric measures is described in the
monograph, Nutritional Status Indices.21 Table X of that publication
gives the child’s score and his relative standing in a group of his
skeletal peers of the same sex and age,22 but the authors do not give
instructions for interpreting the significance of the child’s standing in
terms of his physical fitness. Neither is there a definite statement
in the monograph concerning the relative value of each of the three
indices. In order, therefore, to test the indices in terms of their
agreement with the five criteria, it was necessary to make the following
is Supplementary table V, Appendix I, p. 102, tests the index set to select 20 instead of 14 percent of the
children. It m ay be seen upon examination of this table that the results agree in general with those pre
sented in table 23.
i®713 children were included in the study, but the index could not be tested on 1 b o y whose bitrochanteric
width was unknown.
M The A C H Index does not permit analysis to determine the percentages of the children screened b y the
index in order to select all the children identified b y a criterion.
a See Appendix II: (75) Nutritional Status Indices, pp. 14-18.
2®The Nutritional Status Indices were constructed to show the number of children in 1,000, but in this
monograph the number of children in 100 is used in order to present the results in percentage form.
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T
able
2 3 . — Comparison
of each of five criteria of physical fitness and the ACH Index applied to 7-year-old children,1 364 boys and 348 girls2
(14 percent selection by the index) 8
N um ber of children identified b y—
Criterion
Criterion
B oys
I. Clinical estimate of poor or very poor nutritional status at 7 years of age
I I . Clinical estimate of poor or very poor nutritional status at both 6 and 7 years of age
III. “ Unsatisfactory” 4 average percentage gain in weight per m o n t h ___
___
I V . “ Unsatisfactory” * percentage change in arm girth per year__
B oys
Girls
B oys
Girls
B oys
Girls
28
40
4
5
3
4
10.7
10.0
18
23
4
5
2
2
11.1
8.7
37
37
4
5
0
0
.0
.0
37
32
4
5
1
0
2.7
.0
4
5
4
5
1
0
25.0
.0
1 Age in com pleted years.
3 713 children, 365 boys and 348 girls, were included in the study, but the index could not be tested on 1 b oy whose bitrochanteric w idth was unknown
'dth CC° rdm g t0 thlS mdeX a child is selected if the difference between his arm girth and chest depth falls in the lowest 14 percent of a group of boys or girls of the same age and hip
4Approxim ately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the boys who were selected showed
an average percentage gain in weight per month of 0.657 or less; the girls, of 0.672 or less.
* Approxim ately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the children who were selected
showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7 or m ore for girls.
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RESULTS
V . Clinical estimate of poor or very poor nutritional status at 7 years of age, need of both medical and dental care at 7 years of age, and “ unsatisfactory” * percentage change in arm
girth per year___________________________ __
Criterion and
index
Index
Girls
Children identified
by criterion and
index as percent
of those identified
b y criterion
I
64
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
arbitrary decisions about both the child’s score and the three Nutri
tional Status Indices:
1. A child has been considered selected by any one of these three
indices if his score shows him to be in the lowest 15 percent of a group
of his skeletal peers of the same sex and age as shown in Table X of the
monograph, Nutritional Status Indices.23
2. Each index and every possible combination of the three indices
have been used in comparing the Nutritional Status Indices with the
criteria, (a) The weight index; (b) the index for arm girth; (c) the
index for subcutaneous tissue; (d) the indices for weight and subcuta
neous tissue; (e) the indices for weight and arm girth; (/) the indices for
arm girth and subcutaneous tissue; and (g) the indices for weight, arm
girth, and subcutaneous tissue have been compared with each of the
five criteria.
The results of testing these indices are given in tables 24 to 30,
inclusive.
1 See pp. 14-16 for method of computing score.
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T
able
24.— Comparison of each of five criteria of physical fitness and the Nutritional Status Index for Weight applied to 7-year-old children,1
364 boys and 347 girls 2 (16 percent selection by the index)*
N um ber of children identified b y —
Criterion
Criterion
Boys
Index
Girls
Boys
Criterion and index
Girls
Boys
Girls
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
Boys
Girls
Children screened b y the index in order
to include all the children identified b y
the criterion
Boys
Girls
28
40
4
1
0
1
0.0
2.5
Number
357
Percent
98.1
Num ber
309
Percent
89.0
II. Clinical estimate of poor or very poor nutri
tional status at both 6 and 7 years o f age_____
18
23
4
1
0
0
.0
.0
357
98.1
309
89.0
III. “ Unsatisfactory” 4 average percentage gain in
weight per m onth____________________________
37
37
4
1
0
0
.0
.0
357
98.1
342
98.6
IV . “ Unsatisfactory” 3 percentage change in arm
girth per year_____ ___________________ ______
37
32
4
1
0
0
.0
.0
357
98.1
337
97.1
V . Clinical estimate of poor or very poor nutri
tional status at 7 years of age, need of both
medical and dental care at 7 years of age, and
“ unsatisfactory” 3 percentage change in arm
girth per year__________________
__________
4
5
4
1
0
0
.0
.0
357
98.1
309
89.0
1 Age in com pleted years.
2 713 children, 365 boys and 348 girls, were included in the study, b u t the index could not be tested on 1 b oy whose bitrochanteric w idth was unknown and on 1 girl whose chest
breadth was less than the measurements given in the table.
3 A child has been considered selected b y this index if his score shows him to be in the lowest 15 percent of a group of his skeletal peers of the same sex and age.
4 Approximately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the boys who were selected showed
an average percentage gain in weight per m onth of 0.657 of less; the girls, of 0.672 or less.
3 Approximately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the children who were selected
showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7 or more for girls.
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RESULTS
I. Clinical estimate of poor or very poor nutri
tional status at 7 years of age________ _____
T
able
25.-C om parison of each of five criteria of physical fitness and the Nutritional Status Index for Arm Girth applied to 7-year-old children,'
GO!
nnnA 0 / 7
rtrnr-7o
/1
2
rr\£>nr/*£>'nt spl.p.ri/l.nvi. nil the, 'ItTldeXI ®
Num ber of children identified b y —
Children screened b y the index in order
to include all the children identified b y
the criterion
Girls
Bo ys
Girls
a s s e s s in g
Boys
Girls
Boys
Girls
Boys
Girls
Boys
Criterion and index
Index
Criterion
Criterion
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
05
05
28
40
4
2
2
2
7.1
5.0
Number
202
Percent
55.5
Num ber
292
Percent
84.1
II. Clinical estimate of poor or very poor nutri
tional status at both 6 and 7 years of age--------
18
23
4
2
1
2
5.6
8.7
202
55.5
292
84.1
III. “ Unsatisfactory” * average percentage gain in
weight per m onth__________________ _________
37
37
4
2
0
0
.0
.0
352
96.7
347
100.0
IV . “ Unsatisfactory” « percentage change in arm
girth per year--------- --------------------------------------
37
32
4
2
1
1
2.7
3.1
352
96.7
332
95.7
V . Clinical estimate of poor or very poor nutri
tional status at 7 years of age, need of both
medical and dental care at 7 years of age, and
“ unsatisfactory” * percentage change in arm
girth per year........ ................................w-............
4
5
4
2
1
1
25.0
20.0
134
36.8
110
31.7
f it n e s s
348 girls, were included in the study, but the index could not be tested on 1 b o y whose bitrochanteric width was unknown and on 1 girl whose chest
of
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selected b y this criterion.
All the children who were s e le c t*
c h il d r e n
“
®
t a < K d ” l i t t e s tu d , have b « n e o n «
showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7 or more for girls.
p h y s ic a l
l
brea^ ? p ^ 1^ 1w tb eentc o n ^ d e r ^ esdecteci by^his index^fChis score shows him to be in the lowest 15 percent of a group of his skeletal peers of the same sex and age.
i^ApCS o x i S t d y t t S Z S f f i S S S ofth egrou p of boys or girls included in the study have been considered selected b y this criterion. A ll the boys who were selected showed
the
I. Clinical estimate of poor or very poor nutri
tional status at 7 years of age.......................... .
T
able
26.- -Comparison of each of five criteria of physical fitness and the Nutritional Status Index for Subcutaneous Tissue applied to 7-year-old
children,1 864 boys and 847 girls2 (15 percent selection by the index)*
N um ber of children identified b y—
Criterion
Criterion
Boys
I.
II.
Index
Girls
Boys
Criterion and index
Giils
Boys
Girls
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
Boys
Children screened b y the index in order
to include all the children identified b y
the criterion
Girls
Boys
Girls
Clinical estimate of poor or very poor nutritional
status at 7 years of age________ ;___________
28
40
24
25
1
2
3.6
5.0
Number
341
Percent
93.7
Num ber
323
Percent
93.1
C linical estimate of poor or very poor nutritional
status at both 6 and 7 years of age________ ___
23
24
25
0
1
.0
4.3
341
93.7
323
93.1.
37
37
24
25
2
3
5.4
8.1
358
98.4
332
95.7
IV . “ Unsatisfactory” 8 percentage change in arm
girth per year.......... ............ ..... ..................... .
37
32
24
25
5
1
13.5
3.1
336
92.3
323
93.1
4
5
24
25
1
0
25.0
.0
326
89.6
315
90.8
V.
Clinical estimate of poor or very poor nutritional
status at 7 years of age, need of both medical
and dental care at 7 years of age, and “ unsat
isfactory” 8percentage change in arm girth per
y e a r................ ........................................................
1 Age in com pleted years.
.
2 713 children 365 boys and 348 girls, were included in the study, but the index could not be tested on 1 b oy whose bitrochanteric width was
breadth was less than the measurements given in the table.
8 A child has been considered selected b y this index if his score shows him to be in the lowest 15 percent of a group of his skeletal peers of the
4 Approxim ately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll
an average percentage gam in weight per m onth of 0.657 or less; the girls, of 0.672 or less.
8 Approxim ately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion.
showed a percentage decrease m arm girth: 1.3 or more for boys, 0.7 or more for girls.
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unknown and on 1 girl whose chest
u
w
same sex and age
the bovs who were selected showed
All the children who were selected
RESULTS
18
III. “ Unsatisfactory” 4 average percentage gain in
weight per m o n t h ....___________ ___________
T
able
27.— Comparison of each of five criteria of physical fitness and the Nutritional Status Indices for Weight and Arm Girth applied to 7-year-old
children,1 864 boys and 847 girls2 (15 percent selection by the index)2
N um ber of children identified b y —
Girls
Boys
I. Clinical estimate of poor or very poor nutritional
II. Clinical estimate of poor or very poor nutritional
V . Clinical estimate of poor or very poor nutritional
status at 7 years of age, need of both medical
and dental care at 7 years of age, and “ unsatis
factory” 3 percentage change in arm girth per
Boys
Girls
Boys
Girls
Boys
Girls
Girls
Boys
28
40
0
0
0
0
0.0
0.0
Number
202
Percent
55.5
Num ber
281
Percent
81.0
18
23
0
0
0
0
.0
.0
202
55.5
281
81.0
37
37
0
0
0
0
.0
.0
349
95.9
342
98.6
37
32
0
0
0
0
.0
.0
349
95.9
329
94.8
4
5
0
0
0
0
.0
.0
134
36.8
110
31.7
III. “ Unsatisfactory” 3 average percentage gain in
IV . “ Unsatisfactory” 5 percentage change in arm
Criterion and index
Index
Criterion
Children screened b y the index in order
to include all the children identified b y
the criterion
1 Age in com pleted years.
„
.
,
. ,
, ,
,
,
.
, . . .
,
2 713 children, 365 boys and 348 girls, were included in the study, but the index could not be tested on 1 b o y whose bitrocbantenc width was unknown and on 1 girl whose chest
breadth was less than the measurements given in the table.
. . .
, ,
...
A,
...
.
3 A child has been considered selected b y both these indices if his scores show him to be in the lowest 15 percent of a group of his skeletal peers of the same sex and age.
4 Approxim ately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the boys w ho were selected showed
an average percentage gain in weight per m onth of 0.657 or less; the girls, of 0.672 or less.
...
. ,,
3 Approximately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the children who were selected
showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7 or more for girls.
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ASSESSING T H E PHYSICAL FITNESS OF CHILDREN
Criterion
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
C&
T
able
2 8 .—
Comparison of each of five criteria of physical fitness and the Nutritional Status Indices for Weight and Subcutaneous Tissue applied
to 7-year-old children,1 36J) boys and 31ft girls 2 (15 percent selection by the index) 3
Num ber of children identified b y —
Criterion
Criterion
Girls
Boys
Criterion and index
Index
Girls
Boys
Girls
Boys
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
Boys
Girls
Children screened b y the index in order
to include all the children identified b y
the criterion
Boys
Girls
28
40
2
0
0
0
0.0
0.0
Number
339
Percent
93.1
Num ber
294
Percent
84.7
II. Clinical estimate of poor or very poor nutri
tional status at both 6 and 7 years of age____
18
23
2
0
0
0
.0
.0
339
93.1
294
84.7
III. “ Unsatisfactory” 4 average percentage gain in
weight per m onth _. ________ _______________
37
37
2
Q
0
0
.0
.0
353
97.0
327
94.2
IV . “ Unsatisfactory” s percentage change in arm
girth per year________________________________
37
32
2
0
0
0
.0
.0
334
91.8
314
90.5
V . Clinical estimate of poor or very poor nutri
tional status at 7 years of age, need of both
medical and dental care at 7 years of age, and
“ unsatisfactory” 6 percentage change in arm
girth per year________________________________
4
5
2
0
0
0
.0
.0
324
89.0
289
83.3
RESULTS
I. Clinical estimate of poor or very poor nutri
tional status at 7 years of age_________ _____
1 Age in com pleted years.
.
,
_
,
. . .
.
2 713 children, 365 boys and 348 girls, were included in the study, but the index could not be tested on 1 b o y whose bitrochanteric width was unknown and on 1 girl whose chest
breadth was less than the measurements given in the table.
a A child has been considered selected b y both these indices if his scores show him to be in the lowest 15 percent of a group of his skeletal peers of the same sex and age.
4 Approximately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the boys who were selected showed
an average percentage gain in weight per month of 0.657 or less; the girls, of 0.672 or less.
5 Approximately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. All the children who were selected
showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7 or more for girls.
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05
ZD
T
able
29.— Comparison of each of five criteria of physical fitness and the Nutritional Status Indices for Arm Girth and Subcutaneous Tissue
applied to 7-year-old children,1 364 boys and 347 girls 2 (15 percent selection by the index)3
N um ber of children identified b y —
Criterion
Girls
Boys
Criterion and index
Index
Girls
Boys
Boys
Girls
Boys
Girls
Children screened b y the index in order
to include all the children identified b y
the criterion
Girls
Boys
I. Clinical estimate of poor or very poor nutri
tional status at 7 years o f age______ __________
28
40
2
0
1
0
3.6
0.0
Number
198
Percent
54.4
Number
280
Percent
80.7
II. Clinical estimate o f poor or very poor nutri
tional status at both 6 and 7 years o f age_____
18
23
2
0
0
0
.0
.0
198
54.4
280
80.7
III. “ Unsatisfactory” 4 average percentage gain in
weight per m onth..................................................
37
37
2
0
0
0
.0
.0
349
95.9
332
95.7
IV . “ Unsatisfactory” 8 percentage change in arm
girth per year........... ..............................................
37
32
2
0
1
0
2.7
.0
332
91.2
314
90.5
V . Clinical estimate o f poor or very poor nutri
tional status at 7 years of age, need of both
medical and dental care at 7 years of age, and
“ unsatisfactory” 8 percentage change in arm
girth per year________________________________
4
5
2
0
1
0
25.0
.0
128
35.2
109
31.4
ASSESSING T H E PHYSICAL FITNESS OF CHILDREN
Criterion
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
O
1Age in completed years.
5
713 children, 365 boys and 348 girls, were included in the study, but the index could not be tested on 1 boy whose bitrochanteric width was unknown and on 1 girl whose chest
breadth was less than the measurements given in the table.
3 A child has been considered selected b y both these indices if his scores show him to be in the lowest 15 percent of a group of his skeletal peers of the same sexand age.
4 Approximately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. All the boys who were selected showed
an average percentage gain in weight per month of 0.657 or less; the girls, of 0.672 or less.
3 Approximately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the children who were selected
showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7 or more for girls.
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T
able
3 0 .-
-Comparison of each of five criteria of physical fitness and the Nutritional Status Indices for Weight, Arm Girth, and Subcutaneous
1 issue applied to 7-year-old children,1 364 boys and Sift girls 2 (15 percent selection by the index) 3
N um ber of children identified b y—
Criterion
Criterion
Boys
Index
Girls
Boys
Criterion and index
Girls
Boys
28
40
0
II . Clinical estimate of poor or very poor nutri
tional status at both 6 and 7years ofage
18
23
0
III. “ Unsatisfactory” 4 average percentage gain in
weight per month _____
37
37
0
IV . “ Unsatisfactory” 8 percentage change in arm
girth per year___________________
37
32
0
V . Clinical estimate o f poor or very poor nutri
tional status at 7 years of age, need of both
medical and dental care at 7 years of age, and
“ unsatisfactory” 8 percentage change in arm
girth per y e a r . ............................
4
5
0
0
0
Boys
Boys
Girls
0.0
Num ber
198
Percent
54.4
Num ber
270
Percent
77.8
.0
198
54.4
270
77.8
.0
.0
346
95.1
327
94.2
0
.0
.0
331
90.9
312
89.9
0
.0
.0
128
35.2
109
31.4
0
0
0
0
0
Girls
Children screened b y the index in order
to include all the children identified b y
the criterion
0.0
1 Age in com pleted years.
b r e a S S S S
4
g T S 'S K l * , " “ ^
b “ ‘ *heIna“
"*
“
1* *
b i t e o d b m « » width was «n ltn ow « and on 1 g t t whoao cheat
has been considered selected b y all 3 of the indices if his scores show him to be in the lowest 15 percent of a group of his skeletal peers of the same sex and aee
an avera ge°p e™ en t^ e^ a in ^ w e ig h tie r month
p?E
L ? g r £ p f o K
S ^
^
showedPaper™ntage decmaJeln K g W h : l f s i r m S b o y l f 0°7 m m om lor g h l i th<5 StUdy ^
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been considered selected b? this criterio11- A11 the boys who were selected showed
be6n C° nsMered seIected ^
this criterion- AU the ^ « d r e n who were selected
RESULTS
I. Clinical estimate of poor or very poor nutri
tional status at 7 years of age _
Girls
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
72
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
Examination of these tables permits the following broad generaliza
tions: (1) There is some variation (from zero to 7.2 percent) in the
number and percentage of boys and girls who were identified by each
of the Nutritional Status Indices or by any combination of these
indices:
Num ber of children
selected b y the index
Nutritional Status Index
Boys
4
4
24
None
12
12
None
Girls
1
2
25
N one
None
None
None
i T he 2 children identified b y both weight and subcutaneous-tissue indices were not identified b y the armgirth and subcutaneous-tissue indices.
(2) Probably the only index that identifies a sufficient number of
children to justify a detailed comparison with any of the five criteria
is the Nutritional Status Index for Subcutaneous Tissue, which selects
24 boys and 25 girls out of the 364 boys and 347 girls on whom the
index was tested. It is surprising that so few children were selected
by the other six indices. Although no attempt has been made to
determine the reasons why the indices failed to identify more children,
there is some evidence that the Nutritional Status Index for Weight
and the Index for Arm Girth do not satisfactorily describe New Haven
boys and girls. According to Table X of the monograph, Nutritional
Status Indices, the scores of any large group of children tested by
either of these two indices should be distributed according to the
normal probability curve, with a mean or average -score of 50.0 and a
standard deviation of 10.0.
If a frequency distribution is made of the weight or arm-girth scores
of the boys and girls included in this study, the distribution is not
normal, the mean is not 50.0, and the spread of the scores, as measured
in terms of their standard deviation, is not 10.0.24 In fact, the whole
curve is shifted to the right and is skew in the positive direction.25
The reason for these differences is not known because the Nutri
tional Status monograph does not describe the 7-year-old children
whose measurements were used in deriving the indices. It may be
m T he mean and the standard deviation can be translated into x]a values of 0 and 1, respectively. See
supplementary tables X V , X V I , and X V I I , Appendix I, pp. 111-112, which give the observed values of the
mean and the standard deviation of the distributions of the Nutritional Status Indices for the N ew Haven
children included in this study.
25
A personal communication from Dr. C. E . Palmer, U . S. Public Health Service, states that the Nutri
tional Status scores for Hagerstown school children also fail to approximate the normal error curve. See
Appendix II: (81) Palmer.
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RESULTS
73
said, however, that the New Haven children included in this study form
a selected group 26 and that the majority represent two quite distinct
nationality groups. About 46 percent of the children were Italian,27
and approximately 18 percent were American boys and girls. This
large proportion of Italian children may partly explain the failure of
the indices to identify 7-year-old New Haven boys and girls, but,
whatever the reason, the number of boys and girls selected by the
weight or the arm-girth index is so small that the value of the index
is immediately subject to question.
In table 26, which presents the results of testing the Nutritional
Status Index for Subcutaneous Tissue, it is found that although this
index identified 24 boys and 25 girls, it selected only a small per
centage of the children identified by any of the five criteria. Indeed,
the maximum agreement between this index and the criteria was
only 25 percent. When the index is tested in terms of the percentage
of the boys or girls who must be screened in order to identify all the
children selected by a criterion, the minimum is almost 90 percent.
In other words, there can be little doubt concerning the low selectivity
and sensitivity of the Nutritional Status Index for Subcutaneous
Tissue in assessing the nutrition of these New Haven boys and girls.
To summarize:
1. The Nutritional Status Indices, either singly or in combination,
failed to select most of the children identified by any of the five criteria.
2. The maximum agreement is 25 percent for Criterion V.
3. The maximum agreement for any of the other four criteria is
only about 14 percent.
4. In 50 (71.4 percent) of the 70 tests (five criteria for each of the
seven Nutritional Status Indices for the two sexes) in which the
children identified by the Nutritional Status Indices (tables 24-30,
inclusive) were compared with the boys and girls selected by the five
criteria, the index failed to identify a single child who was selected
by a criterion.
5. If any of these indices is set to select all the children identified
by any one of the criteria, the minimum number of children which the
index must select in order to include all the children identified by
any of the criteria is about 31 percent; the maximum, 100 percent;
and the average, about 81 percent. In other words, there is con
siderable evidence that the Nutritional Status Indices are neither
selective nor sensitive if any one of the five criteria used in this study
is accepted as an approximate standard of physical fitness.28
26 See pp. 27fl. for description of the children included in this study.
27 For definition see p. 25.
28 These indices have also been tested b y using a criterion which selects the lowest 20 instead of the lowest
15 percent of the boys and of the girls. See supplementary tables V I -X I I , Appendix I, pp. 103-109. In
general these tables confirm the findings based on the selection of the lowest 15 percent of the children.
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74
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
The Pryor W idth-Weight Tables.
The Pryor Tables are logically an elaboration of the Baldwin-Wood
Tables which estimate a child’s weight for his sex, age, and height.
The Pryor Tables take one more variable into account in evaluating a
c hild’s expected weight; namely, his bi-iliac diameter. In other
words, they use two variables (height and width of the iliac crests)
instead of only one (height) in judging weight.
Although the instructions for using these tables do not prescribe
a method of selecting boys or girls who may be underweight or of
comparing a child with other boys and girls of the same age, sex, and
body build, Pryor has approved the use of a procedure which
approximates the one used by Franzen and his coworkers in deriving
the Nutritional Status Indices. It utilizes the principle of sub
tracting the child’s expected weight from his observed weight and
expressing this difference in terms of the standard deviation of the
regression equation for weight on height and width of the iliac crests.29
It has been arbitrarily decided that a child is selected by the Pryor
Index if his relative standing or score by this method of scoring shows
bfm to be in the lowest 15 percent of a group of his skeletal peers of
the same sex and age.30
With this selection point in use, the Pryor Tables have been com
pared with each of the five criteria. (Table 31.) It may be seen
from this table that there was not a close agreement between the
index and any of the criteria. The maximum agreement was 32.1
percent; the minimum, 10.8 percent. If the index is set to include
all the children selected by the criteria, the minimum percentage
identified by the index is 67.7 percent; the maximum, 97.5 percent.
One would expect this index to be as satisfactory as the BaldwinW ood Tables, but it must be remembered that (1) the New Haven
children on whom the index was tested may include a larger percentage
of Italian boys and girls than the children whose measurements were
used in deriving the Pryor Tables; and (2) these tables are an elabora
tion of the Baldwin-Wood standard, in terms of the widths of the
iliac crests of a group of California boys and girls who may not be
comparable to the children included in the Baldwin-Wood Tables.
But whatever the reason or reasons, the Pryor Index is not an entirely
satisfactory method of identifying New Haven children of this age
who may be physically unfit.
29
see Appendix I, pp. 97-98, for a detailed description of this method. See also supplementary table
X V I I I , Appendix I, p. 112, for a distribution of the x/<r values of the Pryor Index for the boys and girls
included in this study.
so T he index has also been §et
the lowest j » percept of tjie clpldreg.
supplpjneptary tpj)lp
^nnj, Appen^Xj!, p. ljg.
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T
able
31
— Comparison of each of five criteria of physical fitness and the Pryor Index applied to 7-year-old childrenf S65 boys and 8A7 airls*
_239848
N um ber of children identified b y —
Criterion
Criterion
Boys
Index
Girls
Boys
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
Criterion and index
Girls
B oys'
Girls
Boys
Girls
Children screened b y the index in order
to include all the children identified b y
the criterion
Boys
Girls
I.
Clinical estimate of poor or very poor nutri
tional status at 7 years of age________________
28
40
54
31
9
11
32.1
27.5
Number
306
Percent
83.8
Num ber
284
Percent
81.8
II.
Clinical estimate of poor or very poor nutri
tional status at both 6 and 7 years of age_____
23
54
31
5
7
27.8
30.4
251
68.8
284
81.8
37
37
54
31
7
4
18.9
10.8
346
94.8
338
97.4
IV . “ Unsatisfactory” * percentage change in arm
girth per year______________________
37
32
54
31
4
4
10.8
12.5
356
97.5
334
96.3
4
5
54
31
1
1
25.0
20.0
251
68.8
235
67.7
V.
Clinical estimate of poor or very poor nutri
tional status at 7 years of age, need of both
medical and dental care at 7 years of age, and
“ unsatisfactory” 5 percentage change in arm
girth per year______ ______________________
RESULTS
18
III. “ Unsatisfactory” 4 average percentage gain in
weight per m onth____ ______________________
i Age at nearest birthday.
Bn ave,S]k i S
S
showed^apercentafee K T f n
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b *v* b“ n < # ■ “ ■
%
Ì l w
S
Ì S
“ “ StUdr
b“ “
«
*
W *“ »
bi “
" 1 t h , b o y , who w er. 'started showed
A" “ “
" b°
§& *>
Cn
76
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
SUMMARY
Although the four indices included in this study— namely, the
Baldwin-Wood, the ACH, the Nutritional Status, and the Pryor
Indices— differ so markedly in type that it would be manifestly unfair
to compare their performance, one fact emerges clearly from the
study: There is little agreement between these four indices and any
of the five criteria. None of these criteria is an entirely satisfactory
standard, but the failure of the indices to identify a considerable
proportion of the children selected by all five criteria together with
the identification by the indices of an even larger number of boys and
girls who were rejected by the criteria means that the indices are
probably neither a selective nor a sensitive method of assessing the
physical fitness of the 7-year-old New Haven children included in
this study.
Clinical Judgment
THE EXPERIMENTAL DATA
As has been stated (p. 45), it is important to determine both the
objectivity and the stability of the clinical judgment of the pediatrician
designated as “ A ” who made all the physical examinations during
both years of the study. In order to investigate this problem, 208
children (107 boys and 101 girls)31were included in a series of check-up
examinations which were made in March and April 1936 after the
tests and examinations of the children at the age of 7 years were
completed.
These check-up examinations may be discussed under two headings:
(1) Examinations of each of the 208 children by three pediatricians,
A, B, and C, in order to study the variability of clinical judgment of
general nutritional status; and (2) reexamination of 103 (51 boys and
52 girls) of these 208 children by pediatrician A in order to measure
the stability of her judgment.
To make these tests comparable with the annual physical examina
tions the following precautions were taken: (1) The distribution of the
nationality of the 208 children included in the check-up examinations
corresponded roughly to the nationality of the 713 boys and girls on
whom the indices were tested (table 32); (2) the three pediatricians
(two women, A and B, and one man, C) who made the examinations
were exceptionally well qualified for the task, having had similar
training and experience, especially in examining New Haven children—
a factor of considerable importance in studying the variability of
their clinical judgment; (3) each physician was provided with the
set of instructions used by pediatrician A in completing the annual
si A few of these 208 children, 21 boys and 18 girls, were not included in the group on which the indices
were tested.
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RESULTS
77
physical examinations; (4) the importance of following the instruc
tions in arriving at a judgment of general nutritional status was
stressed, although the physicians did not work together before begin
ning the check-up examinations to test their interpretations of the
instructions or to compare their methods of assessment; and finally,
(5) no tune limit was set for completing an examination.
T
able
32.
Nationality of 107 boys and 101 girls included in the check-up
examinations
Both sexes
B oys
Girls
N ationality1
T o t a l . ..........
Italian___
American___
Russian___
Polish_____
Irish_____
All others___
N um ber
Percent
N um ber
Percent
Number
208
100.0
107
100.0
101
100.0
90
44
18
8
13
35
43.3
21.2
8.7
3.8
-6 .2
16.8
47
22
9
5
6
18
43.9
20.6
8.4
4.7
5.6
16.8
43
22
9
3
7
17
42.6
21.8
8.9
3.0
6.9
16.8
Percent
/w » l» fe fw ? ai ion.waSi ba?e.<?.on
birthplace of 3 of the child's grandparents. T he classification “ Americhildren 3 of whose grandparents were born in the United States but also children
whose parents and 2 of whose grandparents were born here.
euuuren
The routine adopted for making the observations was as follows:
On the first day of observation the child was examined by pediatrician
A. 32 On the following day he was to be examined by B, and also by C.
Unfortunately, it was administratively impossible to have A*s reexami
nation made immediately after the three physical examinations by A,
B, and C. An interval of 13 days elapsed, on the average, before A
reexamined the children. Table 33 shows the number and percentage
of these children according to the interval between A*s original and
repeat examinations.
T
able
3 3 . — Interval
between the initial and repeat check-up examinations of 51
boys and 52 girls made by pediatrician A
Both sexes
B oys
Girls
Interval (in days)
N um ber
Percent
103
100.0
N um ber
Percent
N um ber
100.0
52
100.0
13.7
5.9
.0
5.9
3.9
19.6
.0
7.8
31.4
9.8
2.0
3
3
0
4
6
6
0
4
20
2
4
5.8
5.8
.0
7.7
11.5
11.5
.0
7.7
38.5
3.8
7.7
**0 n tlle same day some of these children were also measured b y anthropometrists D and E .
See p. 45.
T otal_______
7..
8_____________
9____________
10.........................
11______________
12_____________
13_______________
14_____________
15....... .....................
16______________
17____ ____________
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10
0
0
8
16
0
8
36
0
Percent
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
78
It would have been more satisfactory, of course, if the repeat
examinations had been made earlier. Only a few of the children,
however, were ill during the interval between examinations, none of
them seriously enough to produce a clinically recognizable change in
their general physical condition.
Although this routine was carefully followed, it was impossible to
make all the examinations as planned. Made during school hours,
they had to be fitted into the teaching program. Likewise, children
who were examined on Friday by physician A could not be examined
by B and C until Monday. In addition, one of the pediatricians, C,
became ill and was unable to examine 52 boys and 53 girls until A
made her reexaminations. The resulting maximum interval of time
between A ’s first examination and the examination made by one of
the other two physicians is given in table 34.
T
34.— Maximum interval between initial check-up examination of 107 boys
and 101 girls by pediatrician A and examination by pediatrician B or C
a b l e
G ir ls
B oys
B o t h sexes
I n t e r v a l (in d a y s )
N um ber
208
T ota l -
P ercen t
100.0
38.0
.0
11.5
1„
2„
N um ber
107
P ercen t
100.0
41.1
.0
Number
101
P ercen t
100.0
34.5
.0
12.9
.0
10.3
.0
.0
!?::
; 8-
5.3
2.9
7.5
2.8
3.0
3.0
10-
3.4
3.8
7.7
.0
3.8
17.3
3.4
2.4
.0
2.8
1.9
9.3
3.7
15.0
4.7
.9
.0
4.0
5.9
5.9
.0
4.0
19.8
.0
.0
.0
.0
.0
1.0
345-
.0
.0
.0
9„
111
12.
1314.
15..
1617.
18.
19.
20.
21.
22.
.0
.0
.0
.5
.0
.0
.0
.0
.0
.0
.0
2.0
4.0
.0
.0
.0
From this table it may be seen that, on the average, a period of 7
days elapsed between the physical examinations of A and B, or A and E
C, although about 50 percent of the children were examined within 3 }
days and 38 percent during a 1-day period.
REVIEW OF THE LITERATURE
Before turning to a discussion of the variability of these findings, it
may be well to review rather briefly some of the studies bearing on this
point which have appeared recently in the literature of the subject.
One study is described in an article by Mayhew Derryberry (25)
entitled “ Reliability of Medical Judgments on Malnutrition,” pub
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RESULTS
79
listed in Public Health Reports (U. S. Public Health Service) for
February 18, 1938. The article may be summarized, in part, as
follows :
Six experienced pediatricians examined, independently, 108 11-year-old boys who
represented the entire 11-year-old population— both resident and nonresident—
of an institution in New York City. There was no time limit for making thèse
examinations; the boys were usually stripped to the waist, and their nutrition was
graded according to the Dunfermline scale 33 as “ excellent,” “ good,” “ fair ”
or “ poor.” The physicians who made these examinations differed markedly in
the number of children they found to be poorly nourished. The number each
physician selected was as follows: 2, 6, 7, 10, 12, and 15.
“ But even more confusing was the fact,” writes Derryberry, “ that children
classed as malnourished by one physician frequently were not the same children
that were rated malnourished by another physician * * * In all there were
25 of the 108 boys rated ‘poor’ by at least one of the physicians but only 1 who was
so rated by the entire group of doctors * * * Two of the cases were given
every rating in the scale.” 3i Derryberry confirmed these findings 38 by the analy
sis of a similar series of examinations made by five women physicians on 113
girls 38 attending an institution in New Jersey.
In summarizing tbe results of this study Derryberry concludes that
whether or not a boy or girl is rated as malnourished depends more
on the physician who is the examiner than it does on the actual con
dition of the child.
Another study, made by R. Huws Jones (51) and reported in the
Journal of the Royal Statistical Society, Part Ï, 1938, is also con
cerned, among other subjects, with the variability of clinical judgment.
Pertinent sections of this report may be summarized as follows:
The observations were made in three localities, Liverpool, Manchester, and
Prescot. In Liverpool 142 white boys 37 who were attending two schools in a
poor district were examined by four experienced male members of the Medical
Department of the Liverpool Education Committee. These physicians were
asked to assess nutrition as they would in ordinary routine examinations and to
place a child in one of eight nutrition grades: 5, 4 + (excellent); 4, 4— (normal);
3 + , 3 (subnormal); and 3—, 2 + (bad). Although they discussed the definitions
and points of procedure before making the examinations, their judgment varied
considerably.
The results of these examinations may be summarized as follows: Although all
four physicians agreed on 34 percent of the children, most of them were normal in
nutrition; the number of cases of excellent nutrition ranged from 1 to 17 and of
subnormal or had nutrition from 8 to 23; for 12 of the 142 boys there was a differ
ence of three or mère grades in the physicians’ assessments, and for one child, a
difference of five grades. Of 30 boys whose nutrition was graded as subnormal
or bad by one or more of the four physicians, only 3 were there by agreement of
all four.
33 See Appendix II: (US) Derryberry, p. 265.
33Id.
33There was more uniformity in the proportion of children classified as poor than in the previous experi
ment, but the disagreement in the ratings of different physicians was even more striking.
33Age unknown.
37Age unknown.
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80
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
The second series of observations were made at Manchester, where four assistant
school medical officers— two men and two women— examined 168 boys,38 the
entire population of the senior boys’ department of a Manchester school. These
physicians classified nutrition in only one of four grades instead of eight as in
Liverpool: A, excellent; B, normal; C, slightly subnormal; D, bad. One of them
was unable to place certain boys in any but two grades and classified them as
either good or poor. Nevertheless, the Manchester inquiry in general confirms
the Liverpool findings.
The third test was made at a school in Prescot, where four male medical officers,
one from the staff of each of the four local authorities cooperating in the study,
examined 155 b o y s ,39 using the Board of Education’s classification of four nutri
tional grades. It is interesting to note that although these physicians came from
four areas, they agreed somewhat better than the physicians in Liverpool and
Manchester.
This same English study contains also an evaluation of the con
sistency or stability of clinical judgment. This part of Jones report
may be summarized as follows:
Five of the members of the school medical staff of the Cheshire County Council—
two men and three women— examined twice each of 193 boys attending two
schools in Norwich, one in a good district and the other in a poor district. There
was an interval of a week between the first and repeat examinations made by each
physician.
Some of the results of this study are pertinent to the present discussion. In the
second examination every one of these physicians found a greater percentage of
boys in excellent nutritional condition, and four out of five found a smaller per
centage whose nutrition was subnormal. This difference may be due to the fact
that at the initial examinations the children attending the school in the good
district were examined first, but when the repeat examinations were made the
procedure was reversed.
In other words, it is possible that after examining the boys from the poor
district the physicians were all the more impressed by the condition of the children
in the other school. Thus, the second physician, when he reexamined the same
children, decreased by about one-half the number of boys whose nutrition he
judged to be subnormal.
The analyses of these data also show that one of the five physicians changed his
assessment in 20 percent of the cases, and the other four, in 27 to 31 percent.
This means that, on the average, they placed one boy in four in a different grade at
the second examination. One of the physicians even changed a “ slightly sub
normal” diagnosis into a diagnosis of “ excellent” and another an “ excellent into
a diagnosis of “ slightly subnormal.” Further analysis shows that for children
found to be malnourished by one or more physicians, consistency of judgment
varied from 8 percent for the first physician to 70 percent for the fourth.
These findings were verified by the results of a second experiment undertaken
at Bolton, where two local school medical officers and three others (three women
and two men physicians) from Leigh, Southport, and Wigan conducted the ex
aminations of 200 boys 40 under conditions which were similar to those at Norwich,
with the exception of the fact that the differences between the boys from the
good and the poor districts were not so great.
The results of this study confirm in general the investigation made at Norwich,
although the consistency of clinical judgment at Bolton was greater, owing in part
38Age, race, and socioeconomic status unknown.
3®Age, race, and socioeconomic status unknown.
<oAge unknown.
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RESULTS
81
to the fact that a larger percentage of the boys in Bolton were normal in nutrition.
Thus, three of the physicians were consistent in 50 percent of the cases of sub
normal nutrition, the others in 70 and 76 percent, but one physician changed a
child two grades— from “ bad” to “ normal.”
In this article Jones summarizes his findings on the subject of clinical
judgment, in these words:
Perhaps the most important part of the work reported in this paper is that
concerned with the reliability of clinical assessments. It has been shown that the
distribution of nutrition found in a given population, and the number and identity
of the boys assessed subnormal, are largely dependent upon the particular doctor
who makes the assessments. The doctors compared in this inquiry were, with one
exception, persons of long experience, and all were urged to take as much time as
they wanted over the assessment of each boy. Nevertheless, these doctors show
important disagreements not only with each other but also with their own assess
ments of the same population after a short time interval. The present criticism is
directed against the method, not against the doctors concerned; in fact, the care
these doctors would take, knowing the purpose of the inquiry, leads one to fear
that the results set out in the previous pages may show the position in an unduly
favorable light. * * *
As a result of this inquiry, one may venture to claim that the method of assess
ing nutrition at present followed by school medical officers, on the direction of the
Board of Education, is unreliable. The results obtained by that method are, to
say the least, of doubtful value.41
Investigations by Betenson (8) and Herd (46) confirm these find
ings. Betenson writes:
The experiment of mine which he [Harris 42] was good enough to mention was,
I think, the first of this nature to demonstrate what faulty conclusions can be
arrived at by various doctors using a classification which had no scientific basis
at all. I expect you know that our Board of Education in London about 3 years
ago wished us to classify all our school children into four categories called (A)
excellent, (B) normal, (C) slightly subnormal, and (D) bad, and it was on pur
pose to find out how a definite area in South Wales was responding to this classi
fication that I suggested that three medical men, one from each county, and the
same of medical women should meet together in one of my schools. The meet
ing accordingly took place, the children were selected unknown to any of us by
a school nurse, and these children passed in turn before all six of us, who were
spaced quite a considerable distance apart from one another in a fairly large
room, the object being that we should not have any discussion at all on any
of the children or see one another’s classifications until all the 100 had been seen.
When these examinations were completed, the average agreement
between any pair of observers was found to be as low as two out of
five.43
The other investigation reported by Herd (46) showed clinical
assessment by medical officers to be “ absolutely fallacious.” Thus,
in one test in which 36 children were graded as excellent, only 3 were
« See Appendix II: (61) Jones, p. 33.
See Appendix II: (4 4 ) Harris, p. 226.
43 See Appendix II : (4 4 ) Harris, p. 226.
42
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82
ASSESSING TH E PHYSICAL FITNESS ÖF CHILDREN
agreed upon by all the medical officers, and the variability was even
greater in the normal and slightly subnormal nutritional groups.44
Each of these studies has certain limitations. For example, the
interval between the physical examinations was too long in the
Cheshire County experiment; Derryberry did not indicate the length
of time which intervened between the examinations made in New
York City; and different numbers of nutritional grades were used in
Liverpool and in Manchester, so that the findings for these two cities
are not directly comparable. Similarly, no information is available
concerning the socioeconomic status of the children examined in the
study reported by Herd. Even more important is the fact that in
some instances, so far as is known, there were no detailed instructions
for making the physical examinations; this seems to be the case in
Jones' investigations. Nevertheless, in spite of these shortcomings,
the studies all indicated that clinical judgment is liable to considerable
error and that as a result it is not always a satisfactory criterion of
physical fitness.
Do the check-up examinations made on some of the boys and girls
included in this study confirm these findings?
VARIABILITY OF CLINICAL JUDGMENT IN THE PRESENT
STUDY
In answering the question asked in the preceding section it should
be borne in mind that pediatrician A made all the annual physical
examinations during both years of the study. Consequently, it is
important to know how her clinical judgment of nutrition compares
with the judgment of the other pediatricians, B and C. This problem
is, of course, somewhat different from the one in which Jones, Derry
berry, Herd, and others were interested, because they were concerned
with the variability and reliability of clinical judgment as such,
rather than with the accuracy of one pediatrician's judgment.
It will be remembered in this connection that A, B, and C each
examined 208 7-year-old children— 107 boys and 101 girls— and that
they graded nutrition as excellent, good, borderline, poor, or very
poor (See p. 36).
Table 35 shows the results of these examinations. In evaluating
this table it is well to keep in mind the fact that if clinical judgment is
to be used as a criterion of physical fitness for identifying children in
need of medical attention or nutritional assistance, it is especially
important to consider the number of boys and girls each physician
judged to be in poor or very poor nutritional conditon. This table
indicates that the pediatricians disagreed concerning the number of
« This statement is contained in a discussion of a paper b y W oolham.
p. 260.
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See Appendix II: {1S6) W oolham ,
RESULTS
§3
children, especially boys, whom they placed in these two nutrition
grades. A selected 8; B, 41; C, 22 of the 107 boys as poorly or very
poorly nourished. (Corresponding figures for the girls are A 13B, 22; and C, 18.) 46
T a b l e 35.
Nutritional status of 107 boys and 101 girls as estimated by pediatri__________Mans A, B, and C at the check-up examinations
Boys
Girls
Pediatrician—
Pediatrician— y
Nutritional status
k
B
O
'
A
B
C
N um Per N um Per N um Per N um Per N um Per N um
Per
ber
cent
ber cent
ber
cent
ber
cent
ber
cent
ber cent
T otal_____
Excellent____
G ood ______
Borderline_____
Poor__________
V ery p oor_____
107
1 0 0 .0
107
1 0 0 .0
107
1 0 0 .0
101
1 0 0 .0
2
1.9
27.1
63.5
7.5
3
19
44
40
2 .8
4
13
3.7
3
34
51
13
3.0
33.6
50.5
12.9
29
68
8
0
.0
1
17.8
41.1
37.4
.9
68
22
0
1 2 .1
63.6
2 0 .6
.0
0
.0
101
4
20
55
20
2
1 0 0 .0
101
1 0 0 .0
4.0
19.8
54.4
19.8
10
14
59
18
9.9
13.9
58.4
17.8
2 .0
0
.0
These findings should be interpreted cautiously, for they do not
indicate how frequently the three pediatricians agreed on any one
child's nutritional status. For example, it is impossible to determine
from the preceding table whether the eight boys selected by A were
also selected by B or by C. Table 36 46 answers these questions for
45 A and C did not select any children as very poorly nourished; B identified 2 girls and 1 boy.
One m ay
infer from these figures either that the physicians agreed that very few of the children were very poorly
nourished or that they were classifying the children into 4 instead of 5 nutritional grades.
46 Tbis table has been derived from a large number of more detailed tabulations. It m ay be used to derive
additional information concerning the check-up examinations. For example, it is possible to determine the
number of boys A classified as poorly or very poorly nourished whom B placed in one of the other nutri
tional grades, and the number of boys B classified as poorly or very poorly nourished whom A placed in one
of the other grades. It is also possible to ascertain the total number of boys B graded as in borderline, good,
and excellent nutritional condition, as well as the number A placed in these 3 grades. Thus, A classified 8
boys as poorly or very poorly nourished; 5 of these 8 boys were also judged to be poorly or very poorly
nourished b y pediatrician B . In other words, B placed 3 of these 8 boys in one of the other 3 nutritional
grades; likewise, the 36 out of 41 boys B graded as poorly or very poorly nourished, A placed in one of the
other nutritional grades. Similarly, if A judged 8 boys to be poorly or very poorly nourished and she exam ■
ined 107 boys, she must have placed 99 boys in the other nutritional grades, and so forth. These figures
form the necessary data for making fourfold tables of the following type:
Association between the estimates made by pediatricians A and B of the
nutritional status of 107 boys at the check-up examinations
Estimates b y pediatrician B
Estimates b y pediatrician A
Poor or
very poor
Other
1
Total
Poor or very p oor..
O ther 1__________
T otal. _______
41
bordOThne ” included ebildren whose nutritional status was estimated as excellent, good, or
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ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
84
only two grades, poor and very poor nutrition.47 For example, it
shows that both A and B selected 5 boys as poorly or very poorly
nourished, although A classified a total of 8 and B, 41 boys in this
grade; C selected 22 boys but agreed with A on only 3 as being in poor
or very poor nutritional condition. Similarly, A and B and A and C
also identified 9 girls as poorly or very poorly nourished, although A
placed 13, B, 22, and C, 18 in these nutritional classes.
T
3 6 — Agreement among pediatricians A, B, and C in their estimates of poor
or very p o o f nutritional status among the 107 hoys and 101 girls at the check-up
examinations
------------ —-------------- -------
a b le s
Girls
Boys
Pediatricians
Percent
Num ber
13
12.9
2 1 .8
18
17.8
16.8
9
14
2 .8
8
8.9
13.9
7.9
7.5
38.3
22
2 0 .6
4.7
5
3
18
3
Percent
22
41
8
Num ber
2 .8
—
It is clear from these tables that A was the most conservative and B
the least conservative of the three pediatricians, and that variability of
clinical judgment appears to be considerably greater for the boys than
for the girls.
. f .
. ,
.
It is interesting to reexamine this material also m terms oi tne
amount of disagreement between the nutritional ratings made by two
pairs of observers—namely, A and B, and A and C—without taking
into account either the nutritional grades or the direction of the differ
ences; that is, whether B or C graded a child as better or more
poorly nourished than A.
According to tables 37 and 38, if the pediatricians disagreed, their
judgment usually differed by only one grade. It should be remem
bered, however, that a difference of one grade may determine whether
a child is or is not selected as poorly or very poorly nourished and in
need of medical attention or nutritional advice and assistance.
T
able
37—
Difference between the estimates made by pediatricians A and B of the
jj
__
, ini « 7 ± n . rbprlc.-un exarmncit'ious
Girls
Boys
Difference in estimates
Percent
Num ber
107
44
62
1
1 0 0 .0
41.1
58.0
.9
Num ber
101
57
Percent
1 0 0 .0
56.4
— \--------- —
« See supplementary tables X I X - X X I V , Appendix I, pp. 112-114: for a more detailed analysis of the phy
sicians’ ratings.
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SESULTS
T
85
3 8 .— Difference between the estimates made by pediatricians A and C of the
nutritional status of 107 boys and 101 girls at the check-up examinations
able
Boys
Girls
Difference in estimates
N um ber
Percent
Number
Percent
T otal_______
107
1 0 0 .0
101
1 0 0 .0
N one____________
1 grade_____________
2 grades............__................
63
44
58.9
41.1
64
37
63.4
36.6
0
.0
0
.0
At this point in the discussion it may be well to ask, in summary,
how frequently these three physicians agreed concerning a child’s
nutritional status. Table 39 shows that they agreed on 31 of the 107
boys and 46 of the 101 girls, blit 22 of these 31 boys and 32 of the 46
girls were in borderline nutrition. To express these findings somewhat
differently: The agreement between the three pediatricians was least
satisfactory for children who deviated markedly from the average;
namely, those who were judged to be good or excellent in nutrition
and those whose nutritional status was poor or very poor. All this
evidence confirms the findings of Jones, Derryberry, Betenson, and
others 48 that clinical judgment of nutrition is subject to considerable
variation and is not always consistent.
T
able
3 9 .— Extent of agreement among pediatricians A, B, and C in their estimates
of nutritional status of the boys and girls at the check-up examinations 1
Children on whom 3 pediatricians agreed
Estimates of nutritional status
Boys
Num ber
T otal_________
Excellent_______
G ood______________
Borderline.. _______
P o o r .________________
Very poor_______________
Girls
Percent
Num ber
31
29.0
46
0
0 .0
6.5
0
8
2 0 .6
32
7
22
2
0
1.9
.0
6
0
Percent
45.5
0 .0
7.9
31.7
5.9
.0
‘ T he 3 pediatricians agreed on the ratings of 31 of the 107 boys and 46 of the 101 girls included in the check
up examinations.
STABILITY OF CLINICAL JUDGMENT IN THE PRESENT
STUDY
Although A often disagreed with B or C, her own judgment was rela
tively stable. The findings at her first and repeat physical examina
tions of 103 children, 51 boys and 52 girls, are shown in table 40.
This table indicates that at each examination A classified about the
same number of boys in good and borderline nutritional condition, but
did not identify the same number as likely to be poorly nourished.
48
See Appendix II : 191) Roberts. Stone, and Bowler.
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See also references given on pp.
8 6 ff.
86
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
The table also shows that A ’s judgment was probably less consistent
for girls than for boys.49
T
able
4 0 . — Estimates
made by pediatrician A of the nutritional status of 51 boys
and 52 girls at the initial and repeat check-up examinations
Girls
B oys
Nutritional status
T o t a l ________
Initial examination Repeat examination Initial examination
Repeat examination
Percent
N um ber
Percent
N um ber
Percent
N um ber
Percent
N um ber
51
1 0 0 .0
51
1 0 0 .0
52
1 0 0 .0
52
1 0 0 .0
0
0 .0
0
0 .0
2
2
13
34
4
25.5
66.7
7.8
14
35
27.5
6 8 .6
16
28
3.8
26.9
65.5
3.8
0
- .0
3.9
2
0
.0
6
0
3.8
30.8
53.9
11.5
.0
14
34
2
0
.0
The association between the nutritional ratings made qf each child
at the examinations designed to check the stability of the pediatrician s
judgment is shown in tables 41 and 42. These tables indicate that
A ’s judgment was most stable for boys and girls in a borderline nutri
tional condition and least stable for those who were likely to be poorly
nourished.
If these tables are examined in terms of the number of boys or girls
who were placed in the same nutritional grade at both initial and
repeat physical examinations, expressed as a percentage of the number
who were placed in this grade at the initial examination, it may be seen
that at the repeat examination A gave a borderline nutritional rating
to about 88 percent of the boys whom she placed in this same grade
at the initial examination; a good rating to about 77 percent and a
poor nutritional rating to only 50 percent of the boys classified in this
grade at the initial examination. Corresponding figures for the girls
were about 89 percent, 69 percent, and 33 percent, respectively. In
other words, there is considerable evidence that A ’s judgment was
least stable for the children whom it was most important to identify;
namely, those who were likely to be in poor nutritional condition.
T
able
4 1 . — Association between the estimates made by pediatrician A of the nutri
tional status of 51 boys at the initial and repeat check-up examinations
Estimates at repeat examination
Total
Estimates at initial examination
Excellent
Excellent__________ ______ ________
Borderline______________ _________
P oor_______________________________
V ery poor---------------------------------------T o t a l . - ----------- --------------------4o The
0
0
0
0
0
0
Borderline
Good
V ery poor
Poor
4
3
30
0
0
2
0
0
0
0
2
0
14
35
2
0
10
0
0
0
0
0
0
0
13
34
4
0
51
0
number of boys find girls classified as poorly nourished is small and the results must be interpreted
cautiously.
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87
RESULTS
T
able
4 2 .— Association between the estimates made by pediatrician A of the nutri
tional status of 52 girls at the initial and repeat check-up examinations
Estimates at repeat examination
Estimates at initial examination
Total
Excellent
Excellent_________
G ood ________________
Borderline_____________
P oor______________ ______
V ery poor_____________
T otal______ __________
Good
Borderline
2
0
0
0
0
0
11
2
14
3
0
0
0
Poor
V ery poor
0
0
0
0
2
0
0
0
0
0
0
34
2
0
5
25
4
2
16
28
6
0
52
In interpreting these findings it is well to bear in mind that the
pediatrician who made all the examinations in this study was excep
tionally well-trained and had had considerable experience in examin
ing school children, particularly boys and girls living in New Haven.
Certainly her clinical judgment is as satisfactory as that of many
other physicians. It is also well to point out that even if her judg
ment was not always consistent and objective, it is probably a more
satisfactory criterion than the individual judgments of several phy
sicians would have been. A real advantage exists, therefore, in having
had the clinical data for this study collected by one observer.
Nevertheless, the evidence indicates that A ’s judgment was liable
to considerable error and should be followed with reservations as a
criterion for evaluating indices of physical fitness or nutrition.
OPINIONS AND RECOMMENDATIONS OF OTHERS
To sum up this discussion of clinical judgment, it is illuminating
to survey the opinions and recommendations of other investigators.
Various writers have pointed out the necessity for improving the
clinical examination. Lishman states it this way:
We have tended in the past to rely too much when making our assessment
upon “ general impressions,” and the more striking skeletal defects arising from
insufficient food, as distinct from imperfect functioning of the many processes
involved in nutrition, to the exclusion of specific signs of probable nutritional
deficiency revealed after questioning the parent or teacher and examining the
child.50
Brewer is more specific in his criticism. He points out that the
average physician has been taught in medical school to diagnose
pathological conditions and has had limited experience in examining
healthy children. Brewer continues: “ * * * though we have
hundreds of specialists in children’s diseases, we have few in children’s
health and these few are not counted as specialists unless they approach
their function through pathology.” 51
50
51
See Appendix I I : (¿>8) Lishman, p. 3 4 1 .
See Appendix II: (18) Brewer, p. 93.
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A
88
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
The White House Conference of 1930 has pointed out the necessity
for making seriatim examinations and appraising the individual child
in terms of the progress made between examinations. Improvement
in his condition, the Conference reported, is often of far greater signifi
cance than status at the moment.62
The Lancet takes a less conservative attitude in an editorial on the
variability of clinical judgment of nutrition. This editorial interprets
the problem as an “ indictment of a system, not of the medical assessor,
of whom the impossible, it seems, is being asked.” 63
Stuart, in a more detailed discussion, writes:
The clinician is constantly comparing one child with a composite picture of
children of similar age. This picture includes a wide range of variations which he
has come to expect on the basis of experience. The way any one physician will
interpret a child will depend both upon the accuracy of his observations and upon
the extent and type of his personal experience.64
Eliot illustrates this aspect of the discussion in writing of the phys
ical examinations made of Puerto Kican children by physicians ac
customed to judging the nutritional status of New Haven, Conn.,
school children:
That the usual standard of gauging the physical condition of the children was not
adhered to (because of the preponderance of poorly nourished children), but that
a standard based on the range within the group itself was unintentionally sub
stituted, will be shown later. * * *
It was without question the intention of the physicians who made the examina
tions in Puerto Rico to use the same standards for estimating subcutaneous fat as
they had used in similar studies in New Haven, and so to have comparable data
from the two places. However, in the face of the preponderance of poorly nour
ished children and the scarcity of really well-nourished ones, the judgment of the
physicians with regard to estimating amounts of subcutaneous fat rapidly became
warped, and unintentionally there occurred, in conformity with the variations
within the group, a definite readjustment in their whole scale of values, as has been
pointed out. Children who in New Haven would have been considered to have a
“ fair” amount of subcutaneous fat, were, because of this unconscious readjustment
of standards, reported as having a “ good” amount, and those who in New Haven
would have been considered to have a “ poor” amount were reported as having a
“ fair” amount. There is little doubt that the ratings of the fat of these Puerto
Rican children are high as compared with the ratings given in New Haven by the
same physicians.55
In discussing the situation in England, Herd expressed the same
point of view:
All children inspected in the routine age groups are assessed by the medical
officers in regard to their state of nutrition * * *. This assessment is an
attempt to gauge the general physical condition of the child, as apart from specific
m See A ppen dix'll: (119) White House Conference on Child Health and Protection, Part IV , pp. 296,
300-301.
53 See Appendix II: (107) State of nutrition, p. 1258.
54 See Appendix II: (111) Stuart, p. 195.
85 See Appendix II: (116) U. S. Children’s Bureau, Publication No. 217, p. 25.
See also Green (43) for
discussion of this same subject.
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RESULTS
89
defects. Some defects would count little or not at all in such an assessment, e. g.,
defects of the senses; on the other hand, the presence of a generalized defect like
anemia would naturally place a child in a low grade nutritionally. Assessment
is made partly by static qualities— stature, bulk, skin, color, muscle tone, etc.—
partly by dynamic qualities— alertness, general liveliness, and activity. These
qualities are not measurable, except stature and bulk, and it is even questionable
whether such measurable quantities should be given much weight in the decision,
especially stature, which is so eminently a hereditary quality. Assessment there
fore has to be decided by individual judgment, based upon past experience. There
is room therefore for considerable difference in the assessments made by individual
medical officers and of this a good deal of evidence has been found.56
In other words, according to Cathcart:
There is no reliable objective measure of the state of nutrition. The physical
measurements of the child do not give much help and the other generally accepted
signs are in the main subjective, the gloss of the hair, the bloom of the skin, the
brightness of the eye, the alertness of response, and so on. Each doctor forms his
own mental standard and judges the children by this subjective measure. All
subjective measures are liable to great distortion. They seem, no doubt, to the
individual to be fixed and sure, but are indeed fluid. His judgment is warped by
his immediately preceding stimulus. If he has examined a group of children who
are fit and well and the next group is less satisfactory, he ranks the second group
lower than he would have done had the first group been only very moderate. Until
some objective standard can be devised it is quite impossible to expect any uni
formity in assessment of nutrition in a wide area. Too often, as Bacon has said,
the eye of the examiner “ is bedewed with human passion.” 57
An interesting discussion of this aspect of the problem is also con
tained in a book entitled “ National Fitness/’ edited by F. Le Gros
Clark. In this report the author discusses the clinical significance of
the term “ normal nutrition” in these words:
We arranged for a letter to be sent to a number of school medical officers,
asking them to explain to us how they and their assistants interpreted the term
“ normal” in their reports. Did the term imply that the children so classified
reached a fair average standard for the district considered, or did it imply in
their minds that the children approximated to a certain ideal standard? * * *
Fourteen of the officers * * * seemed * * * to mean by normal no more
than a fair average for their area. One from a midland borough says: “ Normal
nutrition implies a fair average for the child population of the elementary schools
of the area; it does not imply that the child so classified reaches any ideal standard
of fitness.” His colleague in a northern borough says much the same: “ M y own
impression is that, in the absence of any accepted standard for the assessment of
nutritional conditions, one is bound to be influenced by the general average
standards of the children examined.” A third from a southern borough gives his
opinion that the word normal as used in the service clearly means average or
that usually seen.” But even those who suggest that normal means to them the
approximation to some ideal, frequently qualify their statements. Thus a doctor
from a southern county remarks: “ Normal nutrition * * * implies that the
medical officer reviewing the child is satisfied that the child’s condition is satis
factory in regard to nourishment, taking all the factors into consideration.”
56 S ee A p p e n d i x
87 S e e A p p e n d i x
II: ( 64 ) M a n c h e s t e r [E n g la n d ] E d u c a t io n C o m m i t t e e , p . 11.
II: (17) C a t h c a r t , p . 18.
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90
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
“ Normal,” says a northern borough officer, “ is interpreted as apparently satis
factory, i. e., not showing any apparent evidence of malnutrition.”
Actually, out of the 24 replies which were unambiguous, 4 seemed to define
normal as in some respect “ corresponding to an ideal in the mind of the officer
examining.” The remainder of the replies either qualify their statements or
imply that the normal is at best the average for the child population of today,
which is scarcely a high average; it has been described by many as a debased
average.
We invite the reader’s attention to further quotations from these same letters,
if he would ponder the absolute confusion under which the whole problem is
submerged. “ I disapprove of the whole system of notation, particularly in its
use of the word ‘excellent.’ The idea of supernormal nutrition repels me, for
I don’t believe it can exist” (northern borough). “ The whole question of mal
nutrition depends upon the medical examiner” (northern borough). “ I am in
clined to think that the quality [i. e., of the term nutrition] is so indefinite as to
make it impossible to obtain a precise standard in any way applicable” (southern
county). “ I don’t know what normal as applied to nutrition means. I wish I
did” (northern borough).
[The author continues] * * * if the whole idea of this “ nutrition assessment”
creates such discomfort among its many officers, why on earth has the board
insisted with such regularity on wasting their time in a valueless survey? 58
Koberts emphasizes another aspect of the problem.
She writes:
The physician’s rating is the only one that attempts to recognize qualitative as
well as quantitative aspects, and this is too subjective a method to be of value in
situations where such rating scales are most desired. 59
Wilkins is even more forceful in his criticism:
We may well ask whether anyone is justified in professing to be able to assess
such a multiple functional complex during a few minutes’ inspection of a child.
In my opinion it amounts to little more than guesswork. * * * I contend that
* * * the anatomical standards of the art student are an infinitely truer guide to
nutritional normality than those of practitioners and medical officers who rely
on the presence or absence of the usually accepted pathological signs.60
The periodical, The Medical Officer, in a recent editorial, raises
the same question.
There is every justification for the author’s [R. Huws Jones]61 finding that “ the
method of assessing nutrition at present followed by school medical officers is
unreliable. * * * ” He leaves his readers with a fundamental question.
Is the state of nutrition an entity capable of valid measurement? Many of us will
answer this question with an emphatic “ No.” He does not believe that our in
spectors are wanting in skill but he does believe that knowledge has not yet ad
vanced far enough to provide us with a reliable yardstick which will give reason
ably consistent results when accurately applied.62
58 See Appendix II:
69 See Appendix II:
so See Appendix II:
si See Appendix II:
82 See Appendix II :
(90) Clark, p. 127-134.
(89) Roberts, p. 71.
(191) W ilkins, pp. 145,147.
(51) Jones.
(74) Nutrition of school children, p. 64.
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RESULTS
91
Dunstan expresses the same opinion when he writes:
These returns, being based on qualitative estimates, can never be more than
measures of the variability of the personal equation.*« * * * It is clear that
some mensurational yardstick will need to be devised which will record and
classify the physical status of the children by quantitative means.64
In summary, a passage from the report of the Chief Medical Officer
of the Ministry of Health of Great Britain gives weight to the findings
of this study of New Haven children. The Chief Medical Officer
writes:
The assessment of the state of nutrition by clinical examination is beset with
many difficulties because this method of evaluation involves reliance not on
objective data but on subjective impressions and on the personal competence of the
investigator. The standards of the examiner, as well as the results which he
obtains, are mental concepts and therefore incapable of precise objective meas
urement. While different physicians will probably be in general agreement con
cerning children who are either very healthy or grossly malnourished, slight
differences are likely to occur with children less clearly differentiated. The
decision given will depend on the skill, experience, and judgment of the physician.
If his conceptual standards remain reasonably constant consistent results will be
obtained. But the constancy of the criteria of different clinicians is variable.
They are liable to vary with the opinion of the physician, with the influence of
his surroundings, and with his most recent clinical experience.65
The practical importance of this whole topic is outlined by the
Committee Against Malnutrition:
In discussing the nutrition and health of school children, we have first to ask
by what standard they are being judged. What is the optimum physique and
health of a normal child? It is clear that, until we know this, we are comparing
our children with a standard that may be “ debased;” i. e., well below the optimum.
Meanwhile, it has been pointed out (1) that the conception of “ malnutrition”
as laid down for the school medical service is very unsatisfactory to the scientific
mind; (2) that, however strenuously the officers may work, the school medical
examinations are not adequate for assessing how far the children are actually
undernourished; and (3) that there is grave cause for suspecting that the figures
returned in different areas for “ malnutrition” depend greatly on the subjective
and personal impressions of the officers and have very little objective and scientific
validity. * * * If our findings are correct, then it is clear that official figures,
whatever else they may reveal, do not supply an answer to the vital q u e s tio n how far are the children of this country underfed and malnourished? 66
63 Returns from 34 classified areas exhibited widespread variation and a disconcerting degree of variability
m assessment o f nutrition. See reference to Memorandum of Committee Against Malnutrition, Oct 1936,
contained in Appendix II : (29) Dunstan, p. 5 5 .
84 See Appendix II: (29) Dunstan, p. 55.
65 See A ppendix II: ( 42) Great Britain M inistry of Health, Annual Report of the Chief Medical Officer
pp. 164-165.
88 See Appendix II: (73) Nutrition of School Children, Committee Against Malnutrition, p. 28.
239848°—40-----7
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92
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
THE NEED FOR IMPROVING CLINICAL JUDGMENT
If, as the preceding discussion indicates, the clinical examination
as it is usually made does not satisfactorily assess the child’s physical
fitness, how can it be improved? 67 How can the examination be made
more objective and stable? Can its value be increased without the
addition of a number of expensive or elaborate laboratory procedures?
What items in the physical examination are most accurate? Which
ones are most likely to influence the pediatrician’s judgment?
In order to answer these and related questions, analyses were made
not only of the variability and stability of clinical judgment of gen
eral nutritional status but also of the specific clinical items which
went to make up the physical examination. The interrelationships
between these items have also been studied, as well as their correla
tion with the physician’s judgment of the child’s nutritional status.
A subsequent report will incorporate findings on these points and
will attempt to point out which clinical findings are most reliable and
which ones are most likely to influence the pediatrician’s judgment
of the child’s fitness. Does the physician agree with other physicians
concerning such findings as the condition of a child’s tonsils, his
musculature, his subcutaneous tissue, the condition of his mouth and
skin? Are his own findings stable? Wliat value or weight does he
give each one of these items in arriving at a final judgment of the
child’s fitness? Is he influenced by the child’s size, by the color
of his skin, by his posture, or by the child’s attitude or his mental
alertness?
A study of such questions as these may prove of value in indicating
some of the problems of assessing physical fitness. As has been pointed
out editorially in the Lancet (see p. 88), it is not the clinician who is
at fault but the method which he is asked to use and the conditions
under which he must work.
Is it not possible to develop more objective standards? For ex
ample, what is meant by enlarged tonsils? Wliat is a satisfactory
amount of subcutaneous tissue for a 7-year-old child? D o boys of
this age have less subcutaneous fat than girls? Such questions as
these must be answered either by establishing new norms or by de
riving and employing better techniques, if the clinical examination
is to be improved and the child’s fitness is to be more satisfactorily
assessed.
67 Recent attempts to improve the clinical examination include such studies as those of Lishman in
England and Glazier in Boston. See A ppendix II: (57) Lishman and (57) Glazier. Efforts are also being
made to em ploy more specific and elaborate tests and thus make the clinical examination more detailed as
well as more objective. See A ppendix II: (10) Boone and Ciocco, (55a) Kruse, Palmer, Schmidt, and W ieh l.
and (102) Schmidt.
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RESULTS
93
On the other hand, even if such tools—new norms and better tech
niques— are available, they may be exacting and expensive to apply,
requiring, as they do, elaborate, costly equipment. In addition, the
expense involved in making satisfactory periodic examinations of a
large group of boys and girls is prohibitive for most communities at
the present time. For these reasons indices of body build and other
preliminary screens have been developed.
The four screening methods tested in this monograph have not
proved efficient. Some other procedures must be found.
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Summary
Two methods of evaluating physical fitness: (1) Indices of body
build, as exemplified by the Baldwin-Wood Weight-Height-Age Tables,
the ACH Index of Nutritional Status, the Nutritional Status Indices,
and the Pryor Width-Weight Tables; and (2) clinical judgment of
general nutritional status have been tested in order to determine
both their sensitivity and their selectivity.
The observations were made of 713 7-year-old children (365 boys
and 348 girls) who were attending the public or parochial schools of
New Haven, Conn., from September 1934 through M ay 1936. The
boys and girls were first examined when they were 6 years of age.
The observations included a physical examination made by one welltrained pediatrician, anthropometric measurements taken by one
anthropometrist, and socioeconomic data obtained at home visits
made by economic analysts. A second set of examinations were
made a year later by the same pediatrician and anthropometrist, and
by another group of economic analysts. In addition, the boys and
girls were weighed at frequent intervals during the course of the
study. Toward the end of the observational period, the objectivity
and stability of (1) the pediatrician’s judgment of general nutritional
status and (2) the anthropometric measurements were studied.
The indices have been tested when the child was 7 years of age by
comparison with five criteria, which involve clinical judgment of
general nutritional status, need of medical and dental care, and an
estimate of the child’s gain in weight and change in arm girth. These
criteria have been based on observations made of the children at
both 6 and 7 years of age and on periodic weighings made at frequent
intervals during a 19- or 20-month period of observation.
The results of the study may be summarized as follows:
1. In terms of any of these five more or less satisfactory criteria of
physical fitness, none of the four indices of body build (the BaldwinW ood Index, the ACH Index, the Nutritional Status Indices, and
the Pryor Index) proves an efficient method of identifying children
included in this study who, according to the criteria, are likely to be
physically unfit. The indices are neither selective nor sensitive, as
they fail to identify a considerable number of boys or girls whom
a given criterion selects as likely to be in need of medical care or
nutritional advice and assistance, and, in addition, they often identify
children who were not selected by the criterion.
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SU M M ARY
*>
95
2. The clinical judgment of the pediatrician who made the examina
tions was liable to considerable error, in terms of both the variability
and the stability of her judgment. This evidence confirms other
studies and points to the necessity of improving the physical examina
tion, particularly if need for medical care is to remain an objective of
child-health programs. The importance of some measure of the
child’s growth, such as periodic weighings, is emphasized and the
fundamental importance of the child’s dietary habits is stressed.
Any evaluation of physical fitness must include as a minimum these
three aspects of the child’s well-being—namely, his physical condition
as found at clinical examination, his growth and development, and
his dietary habits if a more satisfactory assessment of physical fitness
is to be made.
If this result is to be achieved, constant interchange of information
and close cooperation of specialized skills are needed between pro
fessional workers who are in a position to contribute to the appraisal
of the physical fitness of children.
Orr, director of the Imperial Bureau of Animal Nutrition, Rowett
Institute, Aberdeen, emphasized this need in one of the Harben
lectures he delivered recently at the institute. He said:
The problems we have been discussing will not be solved until the laboratory
worker, the expert clinician, skilled in detecting the earliest deviations from health,
and the school medical officer, who has to deal with large numbers of children, thé
majority of whom are “ border-line” cases of malnutrition, cooperate and pool
their knowledge and experience.68
68 See Appendix II:
(76a) Orr, p. 23.
k
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Appendix I
Statistical Methods
PROCEDURE USED IN DETERMINING A CHILD’ S STAND
ING OR SCORE FOR THE PRYOR WIDTH-WEIGHT
INDEX
The procedure used in determining the child’s standing or score for the Pryor
Width-Weight Index corresponds approximately to the procedure employed by
Franzen in deriving the Nutritional Status Indices scores except that the standard
deviation of the multiple-regression equation for weight on height and width of
the bi-iliac crests is unknown. It has, therefore, been approximated by deter
mining the differences between the observed weights and the theoretical or ex
pected weights of all the children of each sex included in this Children’s Bureau
study, squaring these differences, and dividing by the number of boys or girls.1
It would have been preferable to derive this statistical constant from the differ
ences between the observed weights and the expected weights of the children
from whose measurements the Pryor Index was derived or, better still, from
the formula for the standard deviation of the regression surface, had the necessary
data been available. Although this procedure necessarily introduces a certain
amount of error, it furnishes a method for classifying the children according to
the Pryor Index.2
In applying this method, it was necessary to calculate four such standard
deviations, since the Pryor Tables define age at the nearest birthday, instead of
age at the last birthday as in this study.
The computed standard deviations and the number of children on whose meas
urements they have been based are as follows:
Sex
M ales______________ _______
Females_________________________
Age (at nearest birthday)
7 years____
8 years_________ ____________
8 years______________________
Standard
deviation
N um ber of children
whose observations
were used in com
puting the stand
ard deviation i
4.20
6.13
5.19
5.36
360
26
»349
16
i Observations of 39 children (21 boys and 18 girls) who were included in the check-up physical and anthro
pometric examinations but who were excluded from the group of 713 children on whom the 4 indices were
tested, were included in making these estimates. This fact explains the difference between the number of
children on whom the indices were tested and the number whose measurements were used in calculating the
standard deviation.
* 1 girl whose height exceeded the measurements given in the table wag excluded.
1 T he number of degrees of freedom was taken into account in calculating the standard deviations.
* This procedure has been approved b y Dr. Pryor in a personal communication, dated February 3,1938.
97
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98
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
These standard deviations were used to derive each child’s score: The diflerence
between his observed weight and his theoretical weight was divided by the appro
priate standard deviation to determine his score, or x jc value, from which his
standing or score relative to other children of the same sex, age, and skeletal
build (judged in terms of height and width of the iliac crests) may be determined.
For example, the Italian boy, A. R ., weighed 46 pounds at 7 years 1 month of
age. According to the Pryor Tables, his expected weight was 45.6 pounds.
The difference between these two weights is 0.4 pounds. When this number is
divided by the appropriate standard deviation, 4.20 pounds, A. R .’s x/cr score
is 0.1. According to the integral table for the normal-error curve, 54 boys in
100 of the same age and body build (height and width at the bi-iliac crests) would
weigh less than A. R. This method corresponds basically to the one used by
Franzen in setting up Table X , shown on p. 65 of the monograph, Nutritional
Status Indices. It is based on the assumption that the distribution of the x[<r
values follows the normal curve of error.
METHOD OF ESTIMATING EACH CHILD’ S AVERAGE PER
CENTAGE GAIN IN WEIGHT PER MONTH
Successive weighings of a child between the ages of 6 and 8 years exhibit a trend
which, within the variability of the measurements, is approximately exponential
in form. As a result, an estimate of the weight gain of each child included in
this study may be made by fitting the exponential equation, y*=aeb* to his 8
weighings, made at stated intervals3 during a 19- or 20-month period of
observation, beginning September 1934.4
In this equation y is the theoretical (as distinguished from the observed)
weight in pounds and x is the child’s age (measured in units of 1 month) when
the weighing was made.
The parameters a and e b have the following meaning: a is the value of y when
x equals 0.0; e b= y ( n+ i ) / y n • In this problem the parameter eb may be considered
an arithmetic estimate of the child’s weight at any given age expressed as a pro
portion of his weight the preceding month. If the child exhibits a continuous
weight gain from month to month, eb is greater than 1.0; the larger eb, the more
rapidly the child is gaining. If eb equals 1.0, the child’s weight remains about the
same throughout the period of observation. If eb is less than 1.0, the child is
actually losing weight.
Since e is a mathematical constant (2.718), the value of eb is determined by the
value of the exponent, 6, which is the relative instantaneous velocity
In other words, it is an estimate of the child’s average percentage gain or loss in
weight per month during the period of observation. For example, if 6 equals
0.008 (0.0077) or eight-tenths of 1 percent, the child’s weight increased at a rate
of 0.8 percent per month. In other words, if he weighed 50 pounds at 6 years
6 months of age, he probably weighed about 50.4 pounds at 6 years 7 months.
The parameters, b and a, have been determined under a least-squares criterion,
as is illustrated in the following sample calculation and graph based on the ob
servations for A. R., the Italian boy whose measurements have also been used to
illustrate other parts of the text:
3 W eights were taken at 4-month intervals, at the time both annual physical examinations were made,
and about 6 months after the first physical examination.
4 Num ber of weighings, period of observation, and dates are average figures. For more detailed descrip
tion of these observations see pp. 25 and 26.
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99
APPENDIX I
Age in months
(x)
72. 70
73. 17
76. 63
79. 13
80. 77
84. 47
85. 20
88. 63
92. 77
S
(x')*
Weight in
lb ..
(y)
12. 70
13. 17
16. 63
19. 13
20. 77
24. 47
25. 20
28. 63
32. 77
40.
41.
43.
43.
43.
44.
46.
47.
48.
Log y
75
75
50
25
50
00
00
50
00
1. 6101
1. 6207
1. 6385
1. 6360
1. 6385
1. 6435
1. 6628
1. 6767
1. 6812
193. 47
14. 8080
(x ')2
161.
173.
276.
365.
431.
598.
635.
819.
1073.
2900
4489
5569
9569
3929
7809
0400
6769
8729
4536. 0163
x' log y
20.
21.
27.
31.
34.
40.
41.
48.
55.
4483
3446
2483
2967
0316
2164
9026
0039
0929
319. 5853
•An arbitrary x scale (x') has been used, with 60 months equal to 0.
Normal equations:
Solving:
14.8080= 9
319.5853=193.47
and
log a + 193.47
log o + 4536.0163
b log e
6 log e
6 = 0.007711
a = 37.44
y—
3 7 , 4 4 e 0 .00771 i x /
Therefore, during the 20-month period of observation from 72.7 to 92.8 months
of age, A. R. s weight increased on the average 0.77 percent per month.
WEIGHT
IN
POUNOS
Weight of Italian Boy, A . R., Observed at Frequent Intervals From 72.7 to 92.8
Months of A g e
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Supplementary Tables
MATERIAL AND METHODS
Su pplem en tary
table
I .— Nationality of the boys and girls
Girls
Boys
Both sexes
Nationality
1
N um ber
Percent
N um ber
Percent
N um ber
713
1 0 0 .0
365
1 0 0 .0
348
-330
130
66
59
35
34
24
17
9
9
46.3
18.2
9.3
8.3
4.9
4.8
3.4
2.4
166
65
34
34
19
17
1 .2
1 .2
5
7
1 0 0 .0
47.1
18.7
9.2
7.2
4.6
4.9
3.4
3.2
164
65
32
25
16
17
45.5
17.8
9.3
9.3
5.2
4.7
3.3
12
6
Percent
12
11
1 .6
4
1.4
1.9
1 .1
.6
2
1
Classification was based on the birthplace of 3 of the child’s grandparents. The classification “ A.merican” includes not only children 3 of whose grandparents were born in the United States but also children
whose parents and 2 of whose grandparents were b om here,
a D id not have 3 grandparents from any 1 country.
* 3 grandparents from various N orth European countries.
< 3 grandparents from 1 N orth European country.
* 3 grandparents from 1 Central European country.
6 3 grandparents from 1 South European country.
Su p p l e m e n t a r y
II.— Bitrochanteric widths of the boys and girls
table
Girls
Boys
Bitrochanteric width
(in centimeters)
Total Italian
Total__________________ -- <364
___________________
18.0-18.4
18.5-18.9_______________________
19.0-19.4
_____________________
19.5-19.9_______________________
20.0-20.4 _____ _________________
20.5-20.9
___________________
21.6-21.4_______________________
___________________
21.5-21.9
22.6-22.4 _______________________
22.5-22.9________ _______________
23.0-23.4_______ _________________
23.5-23.9________ _______________
24.0-24.4 _______________________
24.5-24.9.,________ ______________
25.0-25.4____ _________ _________
25.5-25.9._______ _______________
26.0-26.4 _______________________
26.5-26.9 _______________________
27.6-27.4 _____ _________________
27.5-27.9 _______________________
0
1
3
11
31
31
51
78
62
40
24
15
1
166
64
134
348
164
0
1
2
0
0
1
0
0
0
2
0
1
5
15
19
24
41
27
13
3
7
5
3
9
7
17
25
25
24
9
17
25
53
51
56
47
33
27
1
0
1
10
11
0
1
1
0
0
0
0
6
6
2
1
0
0
0
0
0
21.9
1.35
2 2 .1
1 .1 1
1
0
0
0
0
10
6
1
1
1
0
0
0
0
0
21.9
1.16
21.7
1.08
10
3
3
Americans Other 3 Total Italian 1 Americans Other 3
10
12
10
3
5
3
3
14
32
28
26
. 17
10
11
6
0
0
0
2
8
11
11
8
9
. 7
5
1
0
0
5
3
10
12
22
21
16
11
3
0
0
2
1
0
0
0
0
0
0
1
1.25
21.7
1.30
22.3
1.42
5
14
3
1
1
1
0
2
3
1
0
1
1
21.9
1.36
119
65
0
2 1 .6
8
2
1
2
1
0
1
0
13 of the child’s grandparents were born in Italy.
/
a 3 of the child’s grandparents or 2 of his grandparents and both his parents were born in the Umted states,
a These children did not meet the definitions outlined in footnotes 1 and 2.
4 Bitrochanteric width was unknown for 1 boy.
100
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101
APPENDIX I
RESULTS
,
Growth estim ates used in deriving Criteria III IV, and V.
Supplem
entary
table
II I .— Average percentage gain in weight per month of the
hoys and girls
Average percentage gain
Boys
Girls
T otal...................................................
0.20-0.39.....................................................
0.40-0.59_________________________________
0.60-0.79___ ____________ ________________ ____
0.80-0.99___________________________________
1.00-1.19_______________________________
1.20-1.39— ................................ ..............
1.40-1.59_______________ __________________
1.60-1.79.____________ _____________ ____ _
1.80-1.99___________________________________
2.00-2.19-............. ............................... ......................
2.20-2.39..................................... ................................
Supplem entary
table
0
IV .— Percentage change in arm girth per year o f the boys
and girls
Percentage change
Boys
Girls
Total__________________ , -1 0 .0 t o -0 8 .1 ................................. .
-0 8 .0 to -0 6 .1 ___________________
-0 6 .0 t o -0 4 .1 — ............. ..........................
-0 4 .0 to -0 2 .1 .................................................
-0 2 .0 to -0 0 .1 ........... .......... ..........................
00.0 to 01.9_______ ______________________
02.0 to 03.9................ ...................................
04.0 to 05.9-.......................... ...........
06.0 to 07.9......... .......... ...............................
08.0 to 09.9_____ ____ _____________
10.0 to 11.9_____________________________
12.0 to 13.9_________________________
14.0 to 15.9_________________________
16.0 to 17.9______________________________
18.0 to 19.9___________________________________
20.0 to 21.9_______________________________
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348
______________
...............
.......................
1
17
63
Indices o f body build.
Supplem entary
table
V . — Comparison of each of five criteria of physical fitness and the ACH Index applied to 7-year-old children,1 364
hoys and 348 girls 2 (20 percent selection by the index) 3
Criterion
Criterion
B oys
Criterion and
index
Index
Girls
B oys
Children identified
b y criterion and
index as percent
of those identified
b y criterion
Boys
Girls
Girls
B oys
Girls
28
40
6
8
4
5
14.3
12.5
II. Clinical estimate of poor or very poor nutritional status at both 6 and 7 years of age______
18
23
6
8
3
3
16.7
13.0
III. “ Unsatisfactory” 4 average percentage gain in weight per month____________________ ____
37
37
6
8
0
1
.0
2.7
IV . “ Unsatisfactory” 3 percentage change in arm girth per year___ ___________________________
37
32
6
8
1
0
2,7
.0
V . Clinical estimate of poor or very poor nutritional status at 7 years of age, need of both medi
cal and dental care at 7 years of age, and “ unsatisfactory” 5 percentage change in arm
girth per year____________ ____ ____________________________________________ _____
___
4
5
6
8
1
0
.25.0
.0
I. Clinical estimate of poor or very poor nutritional status at 7 years of age_____ _____ _______
1 Age in completed years.
2 713 children, 365 boys and 348 girls, were included in the study, but the index could not be tested on 1 b oy whose bitrochanteric w idth was unknown.
3 According to this index a child is selected if the difference between his arm girth and chest depth falls in the lowest 20 percent of a group of boys or girls of the same age and hip
width.
4Approxim ately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the boys who were selected showed
an average percentage gain in weight per m onth of 0.657 or less; the girls, of 0.672 or less.
5 Approxim ately the lowest 10 percent of the group of boys or girls included in the stu dy have been considered selected b y this criterion. A ll the children w ho were selected
showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7 or more for girls.
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Federal Reserve Bank of St. Louis
%
ASSESSING T H E PHYSICAL FITNESS OF CHILDEEN
N um ber of children identified b y —
Supplem entary
table
V I.— Comparison of each of five criteria of physical fitness and the Nutritional Status Index for Weight applied to 7-yearold children,1 364 hoys and 347 girls2 (20 percent selection by the index) 3
N um ber of children identified b y —
Criterion
Criterion
Boys
I.
II.
Criterion and
index
Index
Girls
Boys
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
Girls
Boys
Girls
Boys
Clinical estimate of poor or very poor nutri
tional status at 7 years of age________________
28
40
11
4
2
1
Clinical estimate of poor or very poor nutri
tional status at both 6 and 7 years of age_____
Girls
Children screened b y the index in order
to include all the children identified b y
the criterion
Boys
Girls
7.1
2.5
Number
357
Percent
98.1
Number
309
Percent
89.0
11.1
.0
357
98.1
309
89.0
23
11
4
2
0
37
37
11
4
0
2
.0
5.4
357
98.1
342
98.6
IV . “ Unsatisfactory” » percentage change in arm
girth per y e a r .,_____________________________
37
32
11
4
0
0
.0
.0
357
98.1
337
97.1
4
5
11
4
0
0
.0
.0
357
98.1
309
89.0
V.
Clinical estimate of poor or very poor nutri
tional status at 7 years of age, need of both
medical and dental care at 7 years of age, and
“ unsatisfactory” 5 percentage change in arm
girth per y e a r........................ .............................
•
1 Age in completed years.
8 713 children, 365 boys and 348 girls, were included in the study, but the index could not be tested on 1 b oy whose bitrochanteric width was unknown and on 1 girl whose chest
breadth was less than the measurements given in the table.
8 A child has been considered selected b y this index if his score shows him to be in the lowest 20 percent of a group of his skeletal peers of the same sex and age.
4 Approxim ately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the boys who were selected showed
an average percentage gain in weight per month of 0.657 or less; the girls, of 0.672 or less.
8 Approxim ately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the children who were selected
showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7 or more for girls.
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Federal Reserve Bank of St. Louis
APPENDIX
18
III. “ Unsatisfactory” 4 average percentage gain
in weight per m onth________ - _______________
Supplem entary
table
V II.— Comparison of each of five criteria of physical fitness and the Nutritional Status Index for Arm Girth applied to
7-year-old children,1 364 boys and 347 girls 2 (20 percent selection by the index) 3
N um ber of children identified b y —
Criterion
Boys
Criterion and
index
Index
Qirls
Boys
Girls
Boys
Girls
Boys
Girls
Children screened b y the index in order
to include all the children identified b y
the criterion
Boys
Girls
I. Clinical estimate of poor or very poor nutri
tional status at 7 years of age________________
28
40
8
7
.5
5
17.9
12.5
Number
202
Percent
55.5
Num ber
292
Percent
84.1
II. Clinical estimate of poor or very poor nutri
tional status at both 6 and 7 years of age_____
18
23
8
7
4
3
22.2
13.0
202
55.5
292
84.1
III. “ Unsatisfactory” 4 average percentage gain
in weight per m onth_________________________
37
37
8
7
0
0
.0
.0
352
96.7
347
100.0
IV . “ Unsatisfactory” 8 percentage change in arm
girth per year......................... ...............................
37
32
8
7
1
1
2.7
3.1
352
96.7
332
95.7
V . Clinical estimate of poor or very poor nutri
tional status at 7 years of age, need of both
medical and dental care at 7 years of age, and
“ unsatisfactory” 8 percentage change in arm
girth per year_______________________________
4
5
. 8
7
1
1
25.0
20.0
134
36.8
110
31.7
> Age in completed years.
3 713 children, 365 boys and 348 girls, were included in the study, but the index could not be tested on 1 b o y whose bitrochanteric width was unknown and on 1 girl whose chest
breadth was less than the measurements given in the table.
3 A child has been considered selected b y this index if his score shows him to be in the lowest 20 percent of a group of his skeletal peers of the same sex and age.
4 Approximately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the boys who were selected showed
an average percentage gain in weight per month of 0.657 or less; the girls, of 0.672 or less.
8 Approxim ately the lowest 10 percent of the group of boys or girls included in the stu dy have been considered selected b y this criterion. A ll the children who were selected
showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7 or more for girls.
<•
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Federal Reserve Bank of St. Louis
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
Criterion
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
O
Supplem entary
table
V III.— Comparison of each of five criteria of physical fitness and the Nutritional Status Index for Subcutaneous Tissue
applied to 7-year-old children,1 864 boys and 347 girls 2 (20 percent selection by the index) 3
N um ber of children identified b y —
Criterion
Criterion
Boys
Criterion and
index
Index
Girls
Boys
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
Girls
Boys
Girls
Boys
Girls
Children screened b y the index in order
to include all the children identified b y
the criterion
Boys
Girls
28
40
43
42
3
7
10.7
17.5
Num ber
341
Percent
93.7
Num ber
323
Percent
93.1
II. Clinical estimate of poor or very poor nutri
tional status at both 6 and 7 years of age_____
18
23
43
42
1
4
5.6
17.4
341
93.7
323
93.1
H I. “ Unsatisfactory” 4 average percentage gain in
weieht per month
37
37
43
42
2
4
5.4
10.8
358
98.4
332
95.7
IV . “ Unsatisfactory” 3 percentage change in arm
girth per year....................... ............... .................
37
32
43
42
7
3
18.9
9.4
336
92.3
323
93.1
V . Clinical estimate of poor or very poor nutri
tional status at 7 years of age, need of both
medical and dental care at 7 years of age, and
“ unsatisfactory” • percentage change in arm
girth per year________________________________
4
5
43
42
1
2
25.0
40.0
326
89.6
315
90.8
APPENDIX
I. Clinical estimate of poor or very poor nutri
tional status at 7 years of age________________
1 Age in completed years.
3 713 children, 365 boys and 348 girls, were included in the stody, but the index could not be tested on 1 b oy whose bitrochanteric width was unknown and on 1 girl whose chest
breadth was less than the measurements given in the table.
3 A child has been considered selected b y this index if his score shows him to be in the lowest 20 percent of a group of his skeletal peers of the M m c sex and age.
4 Approxim ately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the boys who were selected showed
an average percentage gain in weight per month of 0.657 or less; the girls, of 0.672 or less.
5 Approxim ately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the children who were selected
showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7 or more for girls.
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Federal Reserve Bank of St. Louis
O
On
Su pplem entary
table
I X .— Comparison of each of five criteria of physical fitness and the Nutritional Status Indices for Weight and Arm Girth
applied to 7-year-old children,1 364 boys and 3Ifl girls 2 (20 percent selection by the index) 8
Criterion
Index
Criterion
Boys
Criterion and
index
Girls
Boys
Girls
Girls
Boys
Boys
Children screened b y the index in order
to include all the children identified b y
the criterion
Girls
B oys
Girls
Clinical estimate of poor or very poor nutri
tional status at 7 years of age____________
28
40
4
0
2
0
7.1
0.0
Number
202
Percent
55.5
N um ber
281
Percent
81.0
Clinical estimate of poor or very poor nutri
tional status at both 6 and 7 years of age--------
18
23
4
0
2
0
11.1
.0
202
55.5
281
81.0
“ Unsatisfactory” 4 average percentage gain in
weight per m o n t h ...* _____________ * _______
37
37
4
0
0
0
.0
.0
349
95.9
342
98.6
“ Unsatisfactory” 5 percentage change in arm
girth per year..........................................................
37
32
4
0
0
0
.0
.0
349
95.9
329
94.8
Clinical estimate of poor or very poor nutri
tional status at 7 years of age, need of both
medical and dental care at 7 years of age, and
“ unsatisfactory” 3 percentage change in a rm .
girth per year____________ ____ _______________
4
5
4
0
0
0
.0
.0
134
36.8
110
31.7
1 Age in completed years.
a 713 children, 365 boys and 348 girls, were included in the study, but the index could not be tested on 1 b o y whose bitrochanteric width was unknown and on 1 girl whose chest
breadth was less than the measurements given in the table.
3 A child has been considered selected b y both these indices if his scores show him to be in the lowest 20 percent of a group of his skeletal peers of the same sex and age.
4 Approximately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. All the boys who were selected showed
an average percentage gain in weight per month of 0.657 or less; the girls, of 0.672 or less.
5 Approximately the lowest 10 percent of the group of boys or girls included in the study have been considered selected b y this criterion. A ll the children who were selected
showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7 or more for girls.
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Federal Reserve Bank of St. Louis
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
Num ber of children identified b y —
^
table X .
Comparison of each of five criteria of physical fitness and the Nutritional Status indices for Weiqht and Subcutaneous
__ _______________ Ttssueapphed to 7-year-old c h ild r e n 364 boys and 347 girls* (20 percent selection by th iin d exfi
* ubcuta™™s
Su p p l e m e n t a r y
239848
Num ber of children identified b y—
Criterion
Criterion
Boys
Criterion and
index
Index
Girls
Boys
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
Girls
Boys
Girls
Boys
Children screened b y the index in order
to include all the children identified b y
the criterion
Girls
Boys
Girls
28
40
6
0
0
0
0.0
0.0
N um ber
339
Percent
93.1
Num ber
294
II. Clinical estimate of poor or very poor nutritional
status at both 6 and 7 years of age____________
Percent
84.7
18
23
6
0
0
0
.0
.0
339
93.1
294
III. “ Unsatisfactory” 4 average percentage gain in
weight per m o n th ,_____ _____________________
84.7
37
37
6
0
0
0
.0
.0
353
97.0
327
94.2
37
32
6
0
0
0
.0
.0
334
91.8
314
90.5
4
5
6
0
0
0
.0
.0
324
89.0
289
83.3
IV . “ Unsatisfactory” « percentage change in a r m
girth per year________________________________
V . Clinical estimate o f poor or very poor nutritional
status at 7 years o f age, need of both medical
and dental care at 7 years of age, and “ unsatis
factory” « percentage change in arm girth per
year________________________________ ____
.
J
APPENDIX I
I. Clinical estimate of poor or very poor nutritional
status at 7 years of age_______________________
1 Age in completed years.
breadth was less than the measurements g iv er/h f thcfteW e?16 Study’ but the index could not be tested on 1 b oy whose bitrochanteric width was unknown and on 1 girl whose chest
4 A p p r o x i^ te fy °h e ? o w ^ t 10SperTOnt^if K g r o u p ^ ^ ^
sta K a w b S Z K
nt f ? T X
his -S,ke?etal peers of the ^ m e sex and age.
an average percentage gain in weight per month of 0.657 or less; the girls of 0 672 or less
y
Ve been consldered selected b y this criterion. All the boys who were selected showed
» h o w A ’S S f f i $ £ ¡ ¡ 2
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Federal Reserve Bank of St. Louis
t£ £ £ 3 ? f i
the StUdr ha™ bee" co“ l t e d
b y *“ ■ « “ O'1» ” - A ll the c h il d ,,, who were e le cte d
t a b l e X I — Comparison of each of five criteria of physical fitness and the Nutritional Status Indices fp j Arm Girth and SubcJoneous Tissue applied to 7-year-old children,' 364 boys and 347 girls * (20 percent selection by the index)*
_______
Supplem entary
Num ber of children identified b y —
Boys
Girls
Index
Boys
Girls
Boys
Girls
Boys
Children screened b y the index in order
to include all the children identified b y
the criterion
Girls
B oys
Girls
I. Clinical estimate of poor or very poor nutritional
status at 7 years of age........- ................................
3.6
7.5
Number
198
Percent
54.4
N um ber
280
Percent
80.7
II. Clinical estimate of poor or very poor nutritional
status at both 6 and 7 years of age-................ --
.0
13.0
198
54.4
280
80.7
“ Unsatisfactory” * average percentage gain in
weight per m onth__ ________________________
.0
.0
349
95.9
332
95.7
IV . “ Unsatisfactory” 8 percentage change in arm
girth per year_______________________________
2.7
3.1
332
91.2
314
90.5
20.0
128
35.2
109
31.4
m
V . Clinical estimate of poor or very poor nutritional
status at 7 years of age. need of both medical
and dental care at 7 years of age, and “ unsatis
factory” 8 percentage change in arm girth per
year_________________________________________
i t t S
's K
r a i i d
348 girls, were included in the study, but the index could not be tested on 1 boy whose bitrochanteric width was unknown and on 1 girl whose chest
“
study have b e e » coueldered fle e te d b y this c r l t e t o .
showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7 or more for girls.
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Federal Reserve Bank of St. Louis
»
All the c h i l d » » who were seleeted
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
Criterion
Criterion
Criterion and
index
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
o
OO
N um ber of children identified b y —
Criterion
Criterion
Boys
Girls
Criterion and
index
Index
Boys
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
Girls
B oys
Girls
Boys-
Children screened b y the index in order
to include all the children identified b y
the criterion
Girls
Boys
L Clinical estimate of poor or very poor nutritional
status at 7 years of age_______ _____________
Number
198
II. Clinical estimate of poor or very poor nutritional
status at both 6 and 7 years of age____
Girls
Percent
54.4
Num ber
270
Percent
77.8
H I. “ Unsatisfactory” 1 average percentage gain
in weight per month........... _____________ _
girth per year___________________________
V. Clinical estimate of poor or very poor nutritional
al ^ years of age, need of both medical
and dental care at 7 years of age, and “ unsat
isfactory « percentage change in arm girth
per year.................
________________________________ __________ .
,
0,
,
0,
.0 ,
,
1Age in completed years.
breadth was ten t f f n S m e i ^
128 ,
35.2 ,
HU
109
31.4
study’ but the mdex 00,11(1 not be tested on 1 b oy whose bitrochanteric width was unknown and on 1 girl whose chest
an a
the ¡ J o u V ^ b ^
s ^ S y h S e been conoid 20 d “ w
g^ p ° i his skeletal peers of th e same sex and age.
an average percentage gain in weight per month of 0.657 or less; t h l gW s?of0 672or]e^s d h
b
considered selected b y this criterion. All the boys who were selected showed
sh ow ed a p e r c e n t ^ d ecreased »
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Federal Reserve Bank of St. Louis
S
;
US*©? m orcfo^ b oys! 0.7 w m o ie fo r g h ls ?tbe StUdy h&Ve been considered selected b y this criterion.
A ll the children who were selected
APPENDIX I
IV. “ Unsatisfactory” 5 percentage change in arm
Su pplem en tary
table
X I I I .— Comparison of each of five criteria of physical fitness and the Pryor Index applied to 7-year-old children, 1
865 hoys and 847 girls 2 (20 percent selection by the index) 3
N um ber of children identified b y —
Criterion
Boys
Girls
Index
Boys
Girls
Boys
Girls
B oys
Children screened b y the index in order
to include all the children identified b y
the criterion
Girls
Boys
Girls
I. Clinical estimate of poor or very poor nutritional
status at 7 years of age------------------------------ -------
39.3
27.5
Number
306
Percent
83.8
Num ber
284
Percent
81.8
II. Clinical estimate of poor or very poor nutritional
status at both 6 and 7 years of age----------------------
38.9
30.4
251
68.8
284
81.8
III. “ Unsatisfactory” 4 average percentage gain in
weight per m onth______ ,1 --------------- -------------...
21.6
18.9
346
94.8
338
97.4
IV. ‘Unsatisfactory” 6 percentage change in arm
girth per year----------------------------------------------------
18.9
18.8
356
97.5
334
96.3
25.0
20.0
251
8.8
235
67.7
V. Clinical estimate of poor or very poor nutritional
status at 7 years of age, need of both medical
and dental care at 7 years of age, and “ unsat
isfactory” 8 percentage change in arm girth
per year----------------------- -------------------------------------
2 n fc h i ld r e n t le s b o y t M d 348 girls, were included in the study, but the index could not be tested on 1 girl whose h e i g h t . e x c e e d e d t h < t h e table.
3 A child has been considered selected b y this index if his score shows him to be m the lowest 20 percent of a group ^ ^ s ^ele^al peers of the same sac and age.
]
d h
ed
4 Approxim ately the lowest 10 percent of the group of boys or girls included m the study have been considered selected b y this criterion. All the boys who were selected snow
“
TI'p T r o K M T t S S o S ^ ^ ^
f t . study have 1 » » considered selected b y this criterion.
showed a percentage decrease in arm girth: 1.3 or more for boys, 0.7 or more for girls.
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Federal Reserve Bank of St. Louis
A ll the children who were srieeted
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
Criterion
Criterion and
index
Children identified
b y criterion and
index as percent
of those identi
fied b y criterion
APPENDIX I
Supplem en tary
table
111
X IV .— Baldwin-Wood Index for the boys and girls
Percent underweight or overweight
Boys
Girls
Total.................... .
-2 0 .0 to
-1 5 .0 to
-1 0 .0 to
- 5.0 to
0.0 to
5.0 to
10.0 to
15.0 to
20.0 to
25.0 to
30.0 to
35.0 to
40.0 to
45.0 to
50.0 to
55.0 to
60.0 to
-1 5 .1 ............................
-1 0 .1 ........................
- 5.1........................
- 0.1........... ................
4 .9 .......................
9.9....... ..............
14.9............................
19,9....................
24.9.................
2 9 .9 ...................
34.9________
.
3 9,9 .........................
44.9...............................
49.9...........................
54.9......... ...........................
59.9..........................
64.9............................
1
"
............... .
................... .
................. ...
.................
.................
1
1
0
M ean................. .......................
Standard deviation________
8.70
11.2
»348 girls were included in the study, but the index could not he tested on 1 girl whose
height exceeded the measurements given in the table.
Su pple m e n ta r y
table
X V .— Nutritional Status Index for Weight of the boys and
girls
xt<T !
Boys
T otal.
to
to
to
to
0.0to
0.5 to
1.0 to
1.5 to
2.0 to
2.5 to
3.0 to
-2 .0
- 1 .5
- 1 .0
- 0 .5
s 364
2 347
1
3
18
43
94
95
62
33
10
3
2
0
1
14
38
91
95
56
35
10
2
5
--1 .6 — .
--1 .1
--0 .6 — ,
■-0 .1 —
0.4— ,
0.9—
1.4....
1.9....
2.4 ...
2.9— .
3.4—
M ea n ______________
Standard deviation.
Girls
0.652
0.773
0.715
0.772
index or score according to an arbitrary scale which m ay be expressed in terms of the
abscissa of the normal curve. Table X score=10a:/<j-+50.
2 365 boys and 348 girls were included in the study, but the index could not be tested
on 1 b oy whose bitrochanteric width was unknown and on 1 girl whose chest breadth
was less than the measurements given in the table.
Su pple m e n ta r y
table
X V I.— Nutritional Status Index for Subcutaneous Tissue of
the boys and girls
x/oa
B oys
T o t a l.................. ............
- 2 .0 to
- 1 .5 to
- 1 .0 to
- 0 .5 to
0.0 to
0.5 to
1.0 to
1.5 to
2.0 to
2.5 to
3.0 to
- 1 .6 ................
-1 .1 — ............
- 0 .6 ........................................
—0.1.. ................. .......
0.4__......................
0.9__.....................................
1.4......................
1 .9 -.....................
2.4................
2.9________
..
3.4— .................
M ean________ __
Standard deviation____ _
Girls
2 364
................... ”
............... ... .........................
.......................'
...............
................. '
’
18
82
1
0
0
1
0.678
0. 720
1 See footnote 1, supplementary table X V .
>365 boys and 348 girls were included in the study, b u t the index could not be tested on
l boy whose bitrochanteric width was unknown and on .1 girl whose chest breadth was
less than the measurements given in the table.
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112
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
Su pp le m e n t a r y
X V II.— Nutritional Status Index for Arm Girth of the boys
and girls
table
T o ta l....................................- ....................... - .........................
—1 tn
—1 Oto
1-1
0-6
n n in
Ö k to
IlSf-.n
Jfl|n
n.4
n9
1.4
19
__
Girls
B oys
x/<r 1
-------------------- ------- ------- --------------_______________________________
_______________________________
________________ _______ ____________
_____________________________
________________ ____________ __________
Standard deviation---------------------------- ---------------------- ------------
* 364
* 347
4
8
32
48
79
81
60
33
7
12
2
18
34
86
70
55
46
21
8
7
1.07
0.904
0.838
0.905
i See footnote 1, supplementary table X V .
. . . . . . .
,.
j 365 boys and 348 girls were included in the study, b u t the index could not be tested on
1 b oy whose bitrochanteric width was unknown and on 1 girl whose chest breadth was
less than the measurements given in the table.
Supplem entary
table
X V III.— Pryor Index for the boys and girls
Girls
Boys
x<rll
365
—i n t o
on
0 Kto
1 n to
l ’ fi to
0.9
14
1.9
4*λ to
¿Oto
49
¿4
___________________________________
_
- ________ ____________________
_
___ ________ __________________
____ ____________________________ -
_______________________________________
______________________ ___________ -
Standard deviation---------------------------------------------------------------
ä 347
2
0
3
18
31
56
87
75
47
27
10
4
2
1
0
0
2
0
. 0
0
0
2
5
24
73
96
72
37
16
7
7
3
1
2
1
0
0
1
-0.0404
1.01
0.00216
0.975
1 For procedure followed in computing x/cr values see Appendix I, pp. 97-98.
2 348 girls were included in the study, but the index could not be tested on 1 girl
whose height exceeded the measurements given in the table.
Clinical judgm en t o f general nutritional status.
t a b l e X I X .— Association between the estimates made by pediatri
cians A and B of the nutritional status of 107 boys at the check-up examinations
Su pplem en tary
Estimates b y pediatrician B
Total
Estimates b y pediatrician A
Excellent
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Good
0
2
1
0
0
2
13
4
0
0
3
19
Borderline
Poor
V ery poor
0
14
27
, 3
0
0
0
36
4
0
0
0
0
1
0
2
29
68
8
0
44
.40
1
107
____
APPENDIX I
113
S7tricians
^ W ^ EÏT,t!iTRT^
î ' EnutritionoJ
^ i :T ~ As7sociaiion
between
A and B o f the
stnto/s n-f im
n**ia *the
** estimates
^
__made
__ by
*9. .vedia•
—
Estimates b y pediatrician B
Estimates b y pediatrician A
T otal
Excellent
E xcellent..
G ood______
Borderline
Poor___
Very poor______
Good
Borderline
0
0
1
0
T o t a l ____
Poor
V ery poor
0
16
36
3
0
0
0
13
7
0
0
0
0
2
0
3
34
51
13
0
55
20
2
101
t a b l e XXI.- — Association between the estimates made bv vediatricians A and CJof t,h.p. w.wiwii/i'n.n/ ©//t//w© z/vy
ji .
^
Supplem entary
Estimates b y pediatrician C
Estimates b y pediatrician A
Excellent
Excellent.
G ood______
Borderline___
P oor_______
Very poor____
Total
Good
0
0
T otal_______
Supplem entary
tncians A and
Borderline
Poor
V ery poor
0
16
47
5
0
0
0
19
3
0
0
0
0
0
0
2
29
68
8
0
68
22
0
107
X X II . — Association between the estimates made bv vediaof the nutritional s ta tu s n f m i m V /o
__1. _________ • r
table
C
Estimates b y pediatrician C
Estimates b y pediatrician A
Excellent
E x cellen t...
G o o d . ............
Borderline..
Poor_____
V ery poor_____
Borderline
1
table
tricians B and CJof t.h.p.
Poor
V ery poor
0
0
14
41
4
0
0
0
9
9
0
0
0
0
0
0
3
34
51
13
0
10
59
18
0
101
0
T otal.............
Supplem entary
Total
Good
X X II I. — Association between the estimates made bv vediaotn-faia a/ in*y ^ „ >j h . .1 7
^ ? aia
—Estimates b y pediatrician B
Estimates b y pediatrician C
Excellent
Excellent.
G ood_____
Borderline.
Poor____
Very poor...........
T o t a l............
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1
Good
Total
Borderline
0
1
4
35
0
Poor
V ery poor
4
0
0
0
23
17
0
0
0
0
1
0
4
13
68
22
0
44
40
1
107
114
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
e n t a r y t a b l e X X I V — Association between the estimates made by pedia
tricians B and C of the nutritional status of 101 girls at the check-up examinations
Su pple m
Estimates b y pediatrician B
Total
Estimates b y pediatrician C
Excellent
3
1
0
0
0
4
Borderline
Good
7
9
4
0
0
20
V ery poor
Poor
0
4
47
4
0
0
0
8
12
0
0
0
0
55
20
2
10
14
59
18
0
0
101
—
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Appendix II
List of References1
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(^)
MADHAVA, K. B., and RAJA60PAL, K., Detection of malnutrition
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(10) BOONE, B. R., and CIOCCO, A., Cardiometric studies on children, I. Stethographic patterns of heart sounds, observed in 1,482 children, Milbank
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body, Am. J. Phys. Anthropol. 13: 389-432, Oct.-Dee. ’29
(18) BREWER, D., Development of school medicine, M. Officer 60: 91-93 Aus
27, ’38
’
(14) BRITISH MEDICAL ASSOCIATION, Report of Committee on Nutrition: See
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(15) BRITTEN, R. H., Senior Statistician, National Institute of Health, U. S.
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i This list follows the style of the Quarterly Cumulative Index M edicus published b y the American
Medical Association, Chicago.
115
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116
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
(18) CHATTERJI, A. C., I. M. S., Director of Health for Bengal, Calcutta, India,
Personal communication, dated May 15, ’39, concerning a nutritional
survey in Bengal, India
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(20) CLARE, F. IE GROS, National Fitness; a brief essay on contemporary Britain.
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518-525, Mar. 14, ’ 24
(28) CLEMENTS, F. W .: See reference to study using ACH Index contained in (99)
Scantlebury
(24) CORRY MANN, H. C .: See reference contained in (44) Harris, pp. 261-265,
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(25) DERRYBERRY, M., Reliability of medical judgments on malnutrition, Pub.
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(28) DUBLIN, L. I., and GEBHART, J. C., Do Height and Weight Tables Identify
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(29) DUNSTAN, W. R., Clinical assessment of nutrition, M. Officer 57: 55, Feb. 6,
’37
(80) EMERSON, W. R. P., and MANNY, F. A., Weight and height in relation to mal
nutrition, Arch. Pediat. 37: 468-485, Aug. ’20
(31) FABER, H. K., Variability in weight for height in children of school age, Am. J.
Dis. Child. 30: 328-335, Sept. ’25
(32) FESSARD, A., LAUFER, J., and LAUGIER, H.: See reference contained in (129)
Wroczynski
(88) FRANZEN, R., Selection of malnourished school children, Am. J. Dis. Child.
47: 789-798, April ’34
(84) ----------Validity of comparisons of current methods for estimating physical
status, Child Development 8: 221-222, Sept. ’37
(35) ---------- and PALMER, G. T., The ACH Index of Nutritional Status. Pp. 12.
New York: American Child Health Assn., 1934
(36) FRIEND, G. E., The Schoolboy; a study of his nutrition, physical development
and health. Pp. xii + 128. Cambridge: W. Heifer and Sons, Ltd., 1935
(87) GLAZIER, M. M., Estimation of nutritional state in children, New England
J. Med. 222: 180-184, Feb. 1, ’ 40
(88) GOULD, G. M., Gould’s Medical Dictionary; the words and phrases generally
used in medicine and the allied sciences, with their pronunciation and
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Pp. xviii+l>538. Philadelphia: P. Blakiston’s Son and Co., 1935
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Federal Reserve Bank of St. Louis
APPENDIX II
117
(89) GREAT BRITAIN BOARD OF EDUCATION, The Health of the School Child;
annual report of chief medical officer for the year 1935. Pp. 159. London:
His Majesty’s Stat. Off., 1936
WO) ----------The Health of the School Child; annual report of chief medical
officer for the year 1936. Pp. 136. London: His Majesty’s Stat. Off., 1937
(41) GREAT BRITAIN MINISTRY OF HEALTH, Advisory Committee on Nutrition,
First Report. Pp. 52. London: His Majesty’s Stat. Off., 1937
(42 ) ----------Annual Report of Chief Medical Officer for the year 1933. Pp. 295.
London: His Majesty’s Stat. Off., 1934
(48) GREEN, M. E., Malnutrition Among School Children. (Reprinted from the
Nutrition Report of the British Association for Labour Legislation.)
Pp. 14. London: The Children’s Minimum Council, 1938
(44) HARRIS, I . J., Incidence and assessment of malnutrition; critique and
review, M. Officer 58: 225-229, Nov. 27, ’37; 237-240, Dec. 4, ’37; 249-251,
Dec. 11, ’37; 261-265, Dec. 18, ’37; 273-277, Dec. 25, ’37
(45) HEJINIAN, L. M., and HATT, E., Stem-length; recumbent-length ratio as
index of body type in young children, Am. J. Phys. Anthropol. 13: 287-307,
July-Sept. ’29
(46) HERD, H., Discussion of paper, Assessment of nutrition, by J. G. Woolham,
Pub. Health 50: 258-260, May ’37
(47) [Editorial] Indexes of nutrition. J. A. M. A. 81: 1286-1287, Oct. 13, ’ 23.
(48) JACOB, R., Heights and weights in a girls’ public school. (Letter to the
editor) Nature 142: 436-437, Sept. 3, ’38
(49) JENKINS, R. I., On a distortion embodied in the Pryor-Stolz width-weight
tables, M. Rec. 146: 127-128, Aug. 4, ’37
(50) JONES, R. H., The Nutrition of Liverpool Schoolboys in Relation to Certain
Physical Measurements. Pp. 172. Submitted for the degree of M. A.
in the University of Liverpool, May 1937
(61) ----------Physical indices and clinical assessment of the nutrition of school
children, J. Roy. Statist. Soc. 101: 1-52, Part I, ’38
(52) KOCH, E. W .: See reference contained in (129) Wroczynski
(52a) KRUSE, H. D., PALMER, C. E., SCHMIDT, W., and WIEHL, D. G., Medical
evaluation of nutritional status; methods used in a survey of high school
students, Milbank Memorial Fund Quart. 18: 257-298, July ’40.
(58) LEIGHTON, G., and CLARK, M. L .: See reference contained in (44) Harris,
p. 262, Dec. 18, ’37
(54) LEIPOLDT, C. L., A. C. H. Index as applied to South African boys: See
reference contained in (99) Scantlebury
(55) LE RICHE, H., A. C. H. Index as applied to boys and girls in selected Pretoria
schools, South African J. M. Sc. 3: 60-62, April ’38
(56) LINCOLN, E. A., Reliability of anthropometric measurements, Pedagogical
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(57) LISHMAN, F. J. G., A scheme of clinical assessment of nutrition and a survey
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Houldershaw, Ltd.
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Health 51: 341, Aug. ’38
(59) LOEWENTHAL, L. J. A., Effect of addition of milk to diet of school boys in
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M. C., Growth problems and their relation to zones of normal physiologic
reactions, J. Pediat. 1: 572-592, Nov. ’32
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118
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
(61) McCARRISON, R., Nutrition and national health, J. Roy. Soc. Arts 84:
1047-1107, Aug. 28, ’36
(62) McPHERSON, C. A., The A. C. H. Index and other assessments of the nutri
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27, ’37
(64) MANCHESTER [ENGLAND] EDUCATION COMMITTEE, Annual Report of
the School Medical Officer (Dr. Henry Herd) for 1936. Pp. 96. Man
chester: Education Offices, 1937
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cal status, Child Development 8: 89—92, Mar. ’37
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eight- and nine-year-old white males, Child Development 7: 262-272,
Dec. ’ 36
(68) ----------Stature of Massachusetts children of North European and Italian
ancestry, Am. J. Phys. Anthropol. 24: 301-346, Jan.-Mar. ’39
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(78) [Author unlisted] Nutrition of school children, Committee Against Malnu
trition, Bulletin No. 9 (July 1935), p. 28
(74) [Editorial] Nutrition of school children. M. Officer 59: 64-65, Feb. 12, ’ 38
(75) [Author unlisted] Nutritional Status Indices; method of obtaining measures
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(77) PALMER, C. E., Further studies on growth and the economic depression;
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APPENDIX II
119
(82) PATON, D. N., FINDLAY, L., and others, Poverty, Nutrition and Growth;
studies of child life in cities and rural districts of Scotland. Medical Re
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(83) [Author unlisted] Physical Defects; the pathway to correction. Pp. xvii +
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(84) PINCKNEY, J. M., Director, Office of Nutrition and Health Education Bu
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(87) ----------and SMITH, R. T., Physical strength of adolescent girls, J. Pediat 14610-617, May ’39
(88) ----------and STOLZ, H. R., Determining appropriate weight for bodybuild,
J. Pediat. 3: 608-622, Oct. ’33
(89) ROBERTS, L. J., Nutrition Work with Children, Second edition. Pp. xix-f
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(90)
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(91)
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(96)
Weight and skeletal build; a rejoinder, Am. J. Orthopsychiat
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(97) ROWLAND, S. R .: See reference contained in (39) Great Britain Board of
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(98) ST. PAUL [MINN.] DEPARTMENT OF EDUCATION, Bureau of Schools,
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1938
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Am. J. Pub. Health 30: 165-168, Feb. ’ 40
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Federal Reserve Bank of St. Louis
120
ASSESSING TH E PHYSICAL FITNESS OF CHILDREN
{108) SHERMAN, H. CM Chemistry of Food and Nutrition. Fifth edition. Pp.
vii+640. New York: Macmillan, 1937
(10^) ----------and HAWLEY, E., Calcium and phosphorus metabolism in childhood,
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used in judging physical fitness of school children, Am. J. Pub. Health
29 : 434-438, May ’39
{107) [Editorial] State of nutrition. Lancet 2: 1257-1258, Nov. 2 7 ,’ 37
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homogeneous groups— with particular reference to Navaho Indians and
Dutch whites, Child Development 7: 115-120, June ’36
{109) STIEBELING, H. K., and CLARK, F., Planning for good nutrition in U. S.
Dept, of Agriculture, Yearbook of Agriculture, 1939; food and life.
Pp. 321-340. Washington: Government Printing Office, 1939
{110) STOCKWELL, G. E. S .: See reference contained in {39) Great Britain Board
of Education, p. 23
{111) STUART, H. C., Standards of physical development for reference in clinical
appraisement; suggestions for their presentation and use, J. Pediat. 5:
194-209, Aug. ’34
{112) TURNER, C. E., Precision and reliability of underweight measurement,
Am. J. Pub. Health 19: 969-979, Sept. ’29
{118) ----------Weighing and measuring school children, J. Outdoor Life 28: 377381, June ’31
{114) TUXFORD, A. W., Estimation of physique and nutrition in children, J. Hyg.
39: 203-216, Mar. ’39
{115) U. S. CHILDREN’S BUREAU, Publication No. 217, The Effect of Tropical
Sunlight on the Development of Bones of Children in Puerto Rico, by
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1933
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{118) WARRINGTON [ENGLAND] COUNTY BOROUGH OF WARRINGTON,
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{119) WHITE HOUSE CONFERENCE ON CHILD HEALTH AND PROTECTION,
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APPENDIX II
121
(124) WOLFF, Die Nachwirkung der Kriegshungerperiode auf das Schulkinderwachstum: See reference contained in (129) Wroczynski
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