Program B-4 Evaluating Physical Development and Nutrition

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3 I. The Importance of Body Measurement Body measurements are one way we measure a student's physical development. We can evaluate health, whether the student suffers from any diseases or illnesses, or his or her nutritional state. Furthermore, once we have take measurements, we can adjust desks and chairs to fit the student's body to create a more comfortable and productive learning environment. Just as each person's face is different, body types and pace of development differ from child to child. However, there are general patterns of development, and significant divergence from these patterns are rare. When significant difference occur, it may indicate illness, malnourishment, or problems with a student's home life. Body measurements are an invaluable tool to confirm normal developmental or detect problems. Unfortunately, in most developing countries, physical development standard values are not available. Body measurement is crucial to calculating these standard values. II. Differences in Physical Development by Generation, Region, and Ethnicity Lifestyle and environment have a large influence on an individual's physical development. It follows that development will also vary depending on where a person lives, the generation they belong to, or their ethnicity. Generational Differences During the period of rapid economic growth in Japan after the Second World War, the average height of a Japanese person increased dramatically. In 1960, the average adult Japanese male was 163cm. By 1980, this figure had risen to 170cm, and is still gradually increasing. The change was not only in height; the pace of physical development also increased significantly. In our own research, we have found that the average male height of an urban-dwelling Thai person increased approximately 6cm from 1980 to 2000, a period of marked economic growth. Regional Differences When comparing cities and rural areas, people living in cities tend to be physically larger. This could be explained by a difference in lifestyle. While in Japan there is little difference between the lifestyle of people living in the city or rural areas, in developing countries, rural areas continue to be economically disadvantaged. Ethnic Differences Depending on genetic factors and lifestyle patterns characteristic of an ethnic group, body size also differs. For this reason, we cannot take standard values for physical development for one ethnic group and use them to evaluate members of a different ethnic group. For example, if we compare the average height of People A and People B, and find that People B has a smaller average height, we may mistakenly conclude that People B are not developing properly. Because there are differences in physical development depending on region and ethnicity, conducting body measurements in both urban and rural areas, and for each ethnic group, is clearly important. 33

III. Taking Body Measurements 1 Who to Measure All students should be measured. If it is not possible to measure the entire school at once, measurements can be made for each class separately.

3 Body Measurement Teams Body measurement is done by a two people-- the person measuring and the person recording the measurements.

4 III. Taking Body Measurements 1 Who to Measure All students should be measured. If it is not possible to measure the entire school at once, measurements can be made for each class separately. 2 When to Measure Measurements should be made once or twice a year, at a fixed date or interval. Another option is to measure daily as a regular morning activity. 3 Body Measurement Teams Body measurement is done by a two people-- the person measuring and the person recording the measurements. Measurements can be roughly divided into 1) bone length 2) muscles 3) body fat. One pair is assigned to each measurement, so a body measurement team would typically consist of 6 people. However, a larger school could have a larger team, and a smaller school a smaller team as necessary. 4 Team Member Roles, Measurement Process 1) The Measurer measures each body proportion/characteristic using the specific method. The Recorder can also help with measurement along with accurately recording values. 2) The Measurer announces the measurement verbally. The Recorder repeats the value out loud while writing it down on the record sheet. 3) The Measurer confirms or corrects the Recorder if he or she has made a mistake. 5 Body Measurement Priorities We have prioritized body measurements by considering the diagnostic effectiveness, manpower requirements, and equipment needed. Priority 1 is most important, having the greatest utility and simplicity. Priority 1 Priority 2 height, weight, (body evaluation) sitting height, chest circumference Priority 3 upper arm circumference, thigh circumference, skin-fold thickness of upper arm, below shoulder blade, upper hipbone Priority 4 minimum torso circumference, buttocks circumference, skin-fold thickness for the stomach and flank (side of torso) Begin with high priority measurements and work your way down. Decide what measurements are possible and appropriate given the conditions at your school. Figure 1. Body Measurement Area 34

6 Body Measurement Equipment 1) tape measure for height 2) tape measure for sitting height 3) tape measure for circumference of body parts 4) caliper for measuring skin-fold thickness 5) weight scale

5 6 Body Measurement Equipment 1) tape measure for height 2) tape measure for sitting height 3) tape measure for circumference of body parts 4) caliper for measuring skin-fold thickness 5) weight scale 6) record sheet for student's body measurements (form 1) 7) long-term record sheet for student's body measurements (form 2) 8) physical development survey sheet (form 3) Find out the living conditions of students before they enter school by conducting a lifestyle survey at the time of body measurement. The student's parent or guardian can answer the questions in this survey. 7 Body Measurement Items & Methods Standing/Sitting Height Preparations for Measuring Standing Height Set up measuring tape (Figure 2) Wall Tape Measure 1) Measurement area must have a concrete or wooden floor. 2) Measurement area floor must be level 3) Measurement area must have a wall, at least 2m tall and perpendicular to the floor. 4) Measuring tape must fall directly to the floor while affixed to the wall; the 0 of the measuring tape begins at floor level. Floor Set up triangle (Figure 3) 1) The triangle, which is placed on top of the student's head, should be made of wood or plastic Figure 2. Set-up for Measuring Height 2) The side of the triangle that touches the student's head should be approximately 20cm. The side of the triangle placed against the measuring tape/wall should be 10-15cm. These two sides should be perpendicular to each other (a right triangle). Figure 3. Triangle for Measuring Standing/Sitting Height 35

How to Measure Standing Height: 1) The student stands against the measuring tape in bare feet with back, buttocks, and heels pressed against the wall.

The bottom of the measuring tape is centered between the student's heels. 2) The measurer positions the student's head so that their eye-ear plane is horizontal.

6 How to Measure Standing Height: 1) The student stands against the measuring tape in bare feet with back, buttocks, and heels pressed against the wall. The student stands with a natural posture, both arms relaxed at their side. Heels are touching, with feet open about 60 degrees apart. The bottom of the measuring tape is centered between the student's heels. 2) The measurer positions the student's head so that their eye-ear plane is horizontal. The eyeear plane is defined by the tragus of the left and right ear, and the bottom of the left eye socket (Figure 4). The measurer places the triangle on top of the student's head (Figure5). Measurements are taken to the nearest millimeter. Figure 4. Horizontal Eye-Ear Plane Figure 5. How To Measure Standing Height Sitting Height Preparations for Measuring Sitting Height 1) Prepare a place for the student to sit, such as a chair or desk (Figure 6) Tape Measure Set up measuring tape 1) In the same way as the height measurement, attach the measuring tape to the wall. In this case, align the 0 of the measuring tape to the top of the chair or desk (Figure 7). Set up triangle 1) Use the same triangle as used in height measurement. Figure 6. Seat for Measuring Sitting Height Wall Floor Figure 7. Set-up to Measure Sitting Height 36

7 How to Measure Sitting Height: 1) The student sits on the chair or table. If the chair or table is not deep enough, causing the student to slide forward, provide a block or platform for the students feet to keep their thighs parallel to the ground. The student sits tall, with buttocks and back touching the wall behind them, and arms hanging at their sides. 2) The measurer positions the student's head so that their eye-ear plane is horizontal, and places the triangle on top of the student's head (Figure 8). Measurements should be taken to the nearest millimeter. Figure 8. How to Measure Sitting Height Weight Necessary equipment: body weight scale How to Measure Weight: 1) The child being measured should wear as little clothing as possible. If the child's weight is measured while clothed, the weight of the clothing should be estimated, and the scale should be adjusted that amount before weighing the child. 37

Skin-fold Thickness Measurement The same method is used for all areas of the

9). If necessary, a marker pen can be used to clearly mark the target area on

How to Measure Skin-fold Thickness: 1) The measurer uses their left thumb and

right hand while the left hand holds the skin-fold.

8 Skin-fold Thickness Measurement The same method is used for all areas of the body. It is important to accurately measure the designated body areas (Figure 9). If necessary, a marker pen can be used to clearly mark the target area on the body before measurement. How to Measure Skin-fold Thickness: 1) The measurer uses their left thumb and pointer finger to pinch (gently) the area 1-2cm on each side of the measurement target area. Make sure that the skin held between the fingers is completely separated from the muscle underneath. 2) The measurer holds the calipers perpendicular to the skin-fold with the right hand while the left hand holds the skin-fold. The caliper reading (indicated by the arrow) is read and recorded to the nearest mm (Figure 10). Figure 10. How to Use Calipers Figure 9. Places to Measure Skinfold Figure 11. Measuring on top of clothing: measure skin-fold with clothing, then clothing thickness 38

Detailed Methods Upper Arm (Figure 9, 1) The student relaxes shoulders and arms and lets them fall to their sides.

How to Measure Skinfold Thickness, Back of Upper Arm Below Shoulder Blade (Figure 9, 2) The student relaxes shoulders and arms and lets them fall to their sides.

The skinfold is held 1cm above the measurement target, and runs along the bottom of the shoulder blade at a 45 degree angle to the backbone (Figure 13). Figure 13.

9 Detailed Methods Upper Arm (Figure 9, 1) The student relaxes shoulders and arms and lets them fall to their sides. The measurer comes behind the student, vertically pinches and measures the skin-fold midway between the top of the right shoulder-joint and the elbow (Figure 12). Figure 12. How to Measure Skinfold Thickness, Back of Upper Arm Below Shoulder Blade (Figure 9, 2) The student relaxes shoulders and arms and lets them fall to their sides. The measurer comes behind the student, pinches and measures the skinfold 1-2cm below the right shoulder blade. The skinfold is held 1cm above the measurement target, and runs along the bottom of the shoulder blade at a 45 degree angle to the backbone (Figure 13). Figure 13. How to Measure Skinfold Thickness, Below Shoulder Blade Above Hipbone (Figure 9, 3) The measurer measures the area a few centimeters above the most protruding part of the right hipbone. The skin-fold runs at a degree angle, and is held 1cm in front of the measurement target (Figure 14) Figure 14. How to Measure Skinfold Thickness, Above Hipbone 39

How to Measure Skinfold Thickness, Stomach Lower Leg (Figure 9, Part 5) The measurer stands in front of the student and finds the

10 Stomach (Figure 9, 4) The measurer measures the area 2-3cm to the right of the midline. The skin-fold is held 1cm above the measurement target, and does not include the bellybutton (Figure 15). Figure 15. How to Measure Skinfold Thickness, Stomach Lower Leg (Figure 9, Part 5) The measurer stands in front of the student and finds the fleshiest part of the widest section of the lower leg. The skin-fold runs vertically and is held 1cm above the measurement target (Figure 16) Figure 16. How to Measure Skinfold Thickness, Lower Leg 40

Body circumference (all measurements to nearest mm) Chest Circumference (Figure 17) 1) The student relaxes shoulders and arms and lets them fall to their sides.

The measuring tape often sags in back, so it is helpful to have an assistant make sure it stays taut.

3) Take the measurement while the student is breathing normally, after the student has exhaled and before they take their next breath. Figure 17.

11 Body circumference (all measurements to nearest mm) Chest Circumference (Figure 17) 1) The student relaxes shoulders and arms and lets them fall to their sides. 2) The measurer wraps the measuring tape around the body horizontally, at the level of the nipples. The measuring tape often sags in back, so it is helpful to have an assistant make sure it stays taut. When it is difficult to determine the position of female students nipples because of underwear, measure at the most protruding point of the breasts. 3) Take the measurement while the student is breathing normally, after the student has exhaled and before they take their next breath. Figure 17. How to Measure Chest Circumference Minimum Torso Circumference (Figure 18) 1) The student relaxes shoulders and arms and lets them fall to their sides. 2) Standing in front of the student, the measurer wraps the measuring tape around the body horizontally at the level of the narrowest part of the torso. 3) Take the measurement while the student is breathing normally, after the student has exhaled and before they take their next breath. Buttocks Circumference (Figure 19) 1) The student relaxes shoulders and arms and lets them fall to their sides. 2) The measurer wraps the measuring tape around the hips at the level of where the buttocks protrude most in back. Figure 18. How to Measure Minimum Torso Circumference Figure 19. How to Measure Buttocks Circumference 41

How to Measure Upper Arm Circumference Lower Leg Circumference (Figure 21) 1) The student stands normally, with legs slightly spread, weight evenly distributed between the

12 Upper Arm Circumference (Figure 20) 1) The student relaxes shoulders and arms and lets them fall to their sides. Arm muscles are not be contracted. 2) The measurer wraps the measuring tape around the arm horizontally, at the level of the widest part of the upper arm as seen from the side. Figure 20. How to Measure Upper Arm Circumference Lower Leg Circumference (Figure 21) 1) The student stands normally, with legs slightly spread, weight evenly distributed between the left and right feet. 2) The measurer wraps the measuring tape around the lower leg horizontally, at the level of the widest part of the lower leg as seen from the front. Figure 21. How to Measure Lower Leg Circumference 42

13 8 Body Indices The following formulas are used to evaluate how overweight or underweight a person is. 1) BMI (Body Mass Index) = (weight in kg/height in mm^2) x 10^4 Appropriate for evaluating infants and adult. For elementary and middle school-age students, this index exhibits large variation, and is therefore less meaningful. 2) Rohrer's Index = (weight in kg/height in mm^3) x 10^7 Appropriate for elementary and middle school students. Values are comparatively stable during this stage of development. 3) Degree of Overweightness (%) = [(weight of subject) - (average weight of person of same height as subject)] (average weight of person of same height as subject) x 100 *(average weight of a person of same height as subject) can be calculated as: (height of the subject in cm - 100) x.9 The Degree of Overweightness can be generally evaluated in the following way: 20%~ slightly overweight, 30%~ very overweight -10%~ slightly underweight, -20%~ underweight Figure 22. Thai Male Standard Physical Development Curve for Height (reference: unpublished study by S. Ohsawa, et al.) 9 Calculation and Uses of Physical Development Standard Values Standard values for physical development are statistical calculations based on height, weight, and body index values grouped by age and sex. These values can be expressed in graphs such as Figure 22, which shows average height values and percentiles calculated from body measurements we conducted in Thailand. However, it would be difficult to evaluate a Thai boy's physical development by simply taking one height measurement and comparing it to this graph. It is necessary to take several measurements at regular intervals and plot these data points to determine a pattern of growth. Here are a few things to be aware of when using a Physical Development Standard Value Graph to evaluate development of a student: 43

1) If a student's falls below the 5th percentile curve on the height or weight graph, it is likely that the student is not developing properly due to poor nutrition or other factors.

14 1) If a student's falls below the 5th percentile curve on the height or weight graph, it is likely that the student is not developing properly due to poor nutrition or other factors. If the student is above the 95th percentile curve (Figure 23), especially in weight, it is likely the student is developing abnormally. Figure 23. Incidence of Low Body Weight (reference: unpublished study by S. Ohsawa, et al.) 2) If a students height and weight values fall or rise suddenly in relationship to the graph (Figure 24), it is possible that the student is suffering from an illness, or that there is some problem in their home environment. 3) If a student's weight is above the 95th percentile, they are very overweight. Students below the 5th percentile (Figure 25) are very underweight. In both cases, it is possible that there are problems with eating habits or the home environment, or the student may be suffering from an illness. Figure 24. Abnormal Physical Development (reference: unpublished study by S. Ohsawa, et al.) Figure 25. Standard Height - Body Weight Curve for Thai Boys (reference: unpublished study by S. Ohsawa, et al.) 10 Using Height Measurements to Adjust Desks and Chairs Based on student height, it is possible to make set a generally appropriate height for chairs and desks. Please refer to Form 5 in Program D: Improving School Environmental Quality. 44

Review Supplement Info Waist-to hip Ratio, Gurth Measurements & Skin Fold

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