SUBJECTS AND METHODS
Study population and design.
Data come from the CLHNS, acommunity-based cohort study of children born in 1983–1984 inurban and rural communities of Metro Cebu, the most rapidly grow-ing metropolitan area of the Philippines. The CLHNS data providedetailed longitudinal anthropometric, diet, and household SES dataalong with measures of maturational timing and other factors relatingto maternal and child health.Data collection for the ﬁrst round of the CLHNS began during thelast trimester of pregnancy for all participating mothers. All pregnantwomen living in the selected communities during the enrollmentperiod were invited to participate, and
95% enrolled. In the ﬁrstround of the survey (1983–1986), 3080 singleton live births wereincluded. Child data were collected at birth and then bimonthly for2 y. Follow-up surveys took place in 1991 (mean age 8.5 y) with 2264children (74% of the original sample), in 1994 (mean age 11.5 y)with 2192 children (71% of the original sample), in 1998 (mean age15.5 y) with 2089 children (68% of the original sample), and in 2002(mean age 18.5 y) with 2029 children (66% of the original sample).Data were collected in accordance with protocols approved by theInstitutional Review Board of School of Public Health at the Uni-versity of North Carolina at Chapel Hill. Of the 572 subjects whowere lost to follow-up during the initial survey, 155 were lost due todeath (27%), whereas the rest were not found or were no longerliving in Metro Cebu. Of the 244 subjects lost between the end of theinitial survey and the 1991 follow-up, 55 died (23%). The remaininglosses in this and subsequent periods were attributable primarily tomoving outside of the Metro Cebu study area. In the longitudinalmodels described below, these data contribute 4047 observations inboys and 3656 observations in girls.
During the initial study period (frombirth through 2 y of age), recumbent length was measured to thenearest millimeter using a custom-designed length measuring board.During the follow-up surveys, standing height was measured using aportable stadiometer. All measurements were performed in the chil-dren’s homes by trained project personnel using standard techniques.Maternal height was measured at baseline using the same techniques.Height-for-age Z-scores (HAZ) were calculated using the lambda,mu, and sigma parameters (the power transformation, median, andCV, respectively, from the Box-Cox transformation) from the 2000CDC growth reference data (25,26). The new references were chosenbecause they are more appropriate for breast-fed children and becausethey provide reference data past 18 y of age, which is necessary forcalculating HAZ from the 2002 CLHNS follow-up.
Timing of sexual maturation was assessedby questionnaire using age at menarche in girls and pubic hair stagein boys. Girls were asked their age at menarche at each follow-upsurvey from age 11.5 y on. Pubic hair development was self-assessedby having boys compare themselves to line drawings depicting the 5Tanner stages of development (27) at both 15.5 and 18.5 y of age andwas validated against physician assessment in a separate but similarsmall sample that was recruited for that purpose. For ease of analysis,and because there were few subjects at the extremes, pubic hairdevelopment was categorized as early (Tanner stages 4 and 5), aver-age (Tanner stage 3), and late (Tanner stages 1 and 2) based on the1998 survey data at mean age 15.5 y.
The SES index used was developed for the Cebu data,and reﬂected 3 facets of SES, i.e., income, assets, and maternaleducation. One point was awarded for ownership of each of 4 assets:air-conditioning, television (color or black and white), refrigerator, orvehicle (car, bus, truck, or motorized tricycle). Additionally 1, 2, or3 points were awarded in concordance with falling into the lowest,middle, or highest tertile of per capita income, respectively. Last, 1point was awarded if the mother had completed primary school, and2 points were awarded if the mother had any schooling beyondprimary school. Thus, the SES index has a potential range of 0–9points. The outcome data in the longitudinal models used and de-scribed below are height measures at 8.5, 11.5, 15.5, and 18.5 y of age.We used the mean SES index from survey points 2 and 8.5, 8.5 and11.5, 11.5 and 15.5, and 15.5 and 18.5 y of age, respectively, aspredictor variables relating to these outcomes to better describe themean SES inﬂuences experienced by the subjects between surveysand leading up to the outcome measures included.
We include a DV score in our models because manymicronutrients are important for supporting linear growth, yet intakesof micronutrients are highly correlated, making it difﬁcult to examinetheir independent effects. The literature shows that DV is associatedwith overall nutrient adequacy, making it a useful measure of dietquality (28–30).Because several nutrients important for growth (such as zinc)cannot be isolated from the Cebu data because they are not includedin the Philippine food composition tables (31), we used a foodgroup–based DV index, a common approach (28–30,32–34), ratherthan a nutrient-based index. We based our score on a DV scorecreated previously for the Cebu population (35) in which 1 point wasawarded for having eaten at least 1 food from each of several cate-gories: ﬁsh, animal source foods, staple cereals, other starches, vege-tables, fruits, beans and nuts, and dairy.A variety of dietary assessment tools were used during the Cebustudy. An FFQ covering a recall period of 1 y was administered at8.5 y of age, one 24-h recall was administered at 11.5 y of age, and two24-h recalls were administered on nonconsecutive days at each of thesurvey points thereafter. Portion sizes for both the FFQ and the 24-hrecalls were ascertained using the same set of ﬁeld-tested food modelsat each survey point. Mothers or guardians were the respondents forthe children through age 11.5 y, whereas the subjects responded forthemselves thereafter. The differences between the dietary assessmenttools used imposed some difﬁculties in creating comparable measuresof dietary variety over time. The FFQ is preferable for representingusual intake (36), but because it reports intakes based on a compre-hensive list of 77 foods, it is likely to show greater dietary variety thanthe 24-h recalls. For the 24-h recall data, greater variety would likelybe reﬂected through the use of data from two 24-h periods (at ages25.5 and 18.5 y) than from one 24-h period (at age 11.5 y). Inaddition, 24-h recalls may not represent usual intake patterns (37).An additional independent set of questions was administered inthe same way at each time point, listing what foods were usually eatenfor breakfast, lunch, dinner, and snacks. Thus, we used the responsesfrom these “usual intake” questions to construct a comparable DVscore at 8.5, 11.5, 15.5, and 18.5 y of age with a possible range of 0to 8 points. Mendez (35) demonstrated the validity of this methodwithin the Cebu data by validating the DV score constructed fromthese additional “usual intake” questions against the nutrient intakedata from the more standard 24-h recall data at 11.5 y of age, andfound that the DV score was strongly associated with nutrient ade-quacy for a variety micronutrients such as iron, calcium, and vitaminA (35).
We use kilocalories (kcal)
per day as calculatedfrom the FFQ at 8.5 y of age and from the 24-h recalls at the latersurvey points, recognizing that the energy intakes are likely to besomewhat inﬂated at 8.5 y of age but that the association betweenincreases in intake and increases in height is assumed to be the same.The use of energy tertiles (to overcome the differences due to thediscrepancies in methods) did not substantively change our ﬁndings;thus we used the continuous measure energy intake from 8.5, 11.5,15.5, and 18.5 y of age.
Frequencies and percentages for matura-tional timing in boys, and means and SD for height, HAZ, SES index,DV score, and energy intake for each survey point from which theheight outcome measures are taken (ages 8.5, 11.5, 15.5, and 18.5 yof age) were determined. Means and SD for height and HAZ at 2 yof age were also calculated because height at 2 y is included in ourmodels as a control. Although the HAZ data were not used in ourmodels, they are provided to show the extent of linear growthretardation in the Cebu population.We ﬁt a longitudinal model using Generalized Estimating Equa-tions (GEE) predicting height (using outcome data from 8.5, 11.5,15.5, and 18.5 y of age). We selected this type of “population average”regression model because we were not interested in estimating sub-ject-speciﬁc parameters. GEE models also account for correlations of
DIET AND HEIGHT IN FILIPINO YOUTH
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