N utrition G Development, and Maturation: Findings From ...of size, growth rates, and skeletal and...

Ad Hoc Committee To Review the Ten-State Nutrition Survey

306 PEDIATRICS Vol. 56 No. 2 August 1975

N utrition , G , Development, and Maturation:Findings From the Ten-State Nutrition Survey of1968-1970

Stanley M. Garn, Ph.D., and Diane C. Clark, authors for the Committee

The Ten-State Nutrition Survey of 1968-1970,

originally designated as the National NutritionSurvey, was the first and by all means the most

comprehensive attempt to survey the nutritional

status of Americans at all age levels. By way ofillustrative numbers, 86,352 individuals were

contacted; 40,847 participants were studied froman anthropometric, dietary, or biochemical point

of view; and data on nearly 16,000 participants inthe pediatric age group were collected and

analyzed. More than 53 million bits of codedhealth information were acquired on infants,children, and adolescents alone.

By act of Congress, primary attention wasgiven to “the incidence and location of serious

hunger and malnutrition and health problemsincident thereto in the United States.”l Thismeans that the study was to pay particular atten-

lion to the poor, to people in poverty areas, and tothe racial and ethnic groups most likely to be

exposed to the culture of poverty, undernutrition,

and malnutrition. The sample used for study wasprimarily to be drawn from the lower half of the

income spectrum and with the lowest incomesdisproportionately represented.

The history of the Ten-State Nutrition Surveyis a complicated one. It began with the amend-

ments approved by Congress on December 5,1967, but without appropriations. The survey wasthen initiated in several states during 1968, andresponsibility for coordination of data analysiswas transferred to the Nutrition Program, Center

for Disease Control. The Nutrition Program was

abolished in 1972, long before all of the datacould be fully analyzed or even partially re-

ported.

The findings of the Ten-State Nutrition Survey,we find, go far beyond the original expectations.

We worked with original data tapes and reexam-

ined the data state by state and variable byvariable, and we had opportunities for careful

comparisons. We now have three major state-ments to make. First, the Ten-State data (from ten

states and New York City) do not show evidence

of acute Biafra-type malnutrition, even in thelowest (below-poverty) income groupings. Sec-

ond, the data show remarkably consistent socio-

economic effects on size, growth, and develop-ment that have major bearing on the nation’shealth and the national welfare. Third, the find-ings have broad implications for our knowledge ofgrowth and development. The applicability ofmany presently used “norms” are questioned, and

new needs both for information and application

are evident.

THE DIMENSIONS OF POVERTY

Children of the poor grow less, and less well,

than children of those of greater affluence. Basicdata collected in the Survey’ allowed comparisonof size, growth rates, and skeletal and dentalmaturity by various socioeconomic indicators,

including household income, per capita income,and the income-to-needs ratio of Orshansky.Although use of the Orshansky income-to-needs

ratio was an integral part of the Ten-State Nutri-tion Survey, and a ratio of 1.0 designates the

“poverty level,” most workers find per capitaincome more familiar and easier to comprehend.

This latter measure is employed in this report.Taking per capita income from below the

“poverty level” of 1.0 (approximately $800 per

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AMERICAN ACADEMY OF PEDIATRICS 307

capita) through median per capita income for the

years represented ($2,400 per capita and above), a

few generalizations suffice. Low per capita in-comes are systematically associated with smaller

size. Higher per capita incomes are associated

with greater size (Fig. 1). With increasing per

capita income, increasing household income, andincreasing incomes relative to needs, boys (Fig. 2)

and girls are systematically taller and heavier,with greater circumferences (including head

advanced in skeletal maturity, dental develop-ment, and in such derived constants as the fat-freeweight and the skeletal mass). The generalizations

hold, within ethnic and racial groupings, though

at somewhat different levels for blacks, whites,

and Meso-Americans.2

Given these simple relationships between

socioeconomic level and either size or develop-

mental status, it is obvious that the largest propor-

tion of children at the lowest percentiles for size

and the lowest percentiles for skeletal and dentaldevelopment are from the poorest families. Byselection of “standards,” the results can be mademore or less dramatic. If standards such as thoseof the Brush Foundation Studies or the Fels Re-

search Institute Studies are employed, then the

effects of poverty may be shown as even more

growth-limiting than if the Harvard or Iowa

standards are used.

A few examples suffice. The stature difference

between boys and girls of near median per capitaincomes and those of lowest per capita incomes

amounts to perhaps 0.4 SD. Weight differencesand fatness differences between these socioeco-nomic groups amount to perhaps 0.5 to 0.7 SD

(Table I). Indeed, all measurements follow this

pattern: height, weight, head circumference,knee height, and calf, arm, and chest circumfer-

ences. What the Ten-State study has measuredmay be described as the dimensions of poverty,showing the absolute and the relative size differ-

ences within the sample as a whole.

FATNESS AND ITS EVALUATION

Prior to the Ten-State Nutrition Survey, com-prehensive, single-source, life-cycle data on outerfatness simply did not exist for the United States

or any other country. In the absence of such data,investigators were presented with a choice of

fatness standards, among them the Rauh-Shumsky

values from Cincinnati,’ composite values corn-

piled by Seltzer and Mayer at Harvard,4’ � andEnglish standards derived from various schoolgroups and institutionalized patients.6 By provid-

ing fatness information from age 1 through adul-

thood and beyond for different socioeconomic

FIG. 1. Stature, weight, and fatfold distributions of low-

income boys (shaded) and median-income boys (unshaded) at10 years of age. As during both earlier and later ages, thelower the per capita income, the shorter the stature, the

lower the weight, and the thinner the outer fat layer. Theneed for medians rather than means is shown by the form of

these distributions.

groupings, the Ten-State data completed the

“missing” ages (Fig. 3) and demonstrated the

compelling need to define fatness standards interms of a socioeconomic reference.


AgeMidpoint

Stature(cm)#{176}

‘�O-$8OO $2,4OO-u�’

Triceps Fatfold (mm)#{176}

0-$800 $2,400-up

2 84.3 84.8

- 3 93.0 94.0

4 100.0 102.3- 5 107.3 108.5

6 111.4 115.5

7 117.6 120.3

8 123.4 127.1

9 129.6 131.7

10 134.5 137.8

11 138.3 142.1

12 145.5 148.5

13 153.1 153.3

14 161.0 162.5

15 163.1 168.6

16 169.8 169.2

17 171.4 173.3

20 174.1 176.2

8.0

8.0

8.0

8.0

8.0

8.0

8.0

8.0

9.0

9.0

10.0

10.0

9.0

8.0

9.0

6.0

10.0

9.0

9.0

8.0

8.0

9.0

8.0

8.0

8.0

10.0

10.0

11.0

11.0

11.0

9.0

7.0

8.0

11.0

2 82.3 84.1

3 91.2 90.7

4 99.0 99.7

- 5 105.1 107.0

6 111.7 113.3- 7 117.5 120.0

8 124.2 124.9

9 128.5 131.9

_______10 134.5 137.5- 11 140.6 143.1

12 146.4 149.3

13 154.6 155.5

14 155.8 160.0

15 159.4 157.6

16 159.9 162.4

17 158.5 160.3

20 159.9 162.2

#{176}Medianvalues for white children. Per capita

(black) boys and girls.

12.2

13.2

15.7

18.1

20.0

22.0

24.0

27.8

33.0

35.1

43.6

47.6

48.8

49.8

56.0

54.0

57.2

relates to size and

10.0

10.0

9.0

10.0

9.0

9.0

10.0

10.0

12.0

11.0

12.0

13.0

16.0

18.0

15.0

14.0

17.0

fatness

9.0

10.0

10.0

10.0

9.0

10.0

10.0

12.0

12.0

13.0

15.0

14.0

14.0

15.0

16.0

17.0

16.0

in American Negro

TABLE I

308 TEN.STATE NUTRITION SURVEY

PER CAPITA INCOME AND GROWTH IN CHILDHOOD AND ADOLESCENCE

_____Weight (kg)#{176}______

� $2,400-up

Boys12.2 12.1

14.2 13.9

15.5 .16.4

18.3 18.3

19.4 20.8

21.0 22.1

24.5 26.1

26.7 27.2

29.2 31.9

32.0 34.7

36.7 37.2

40.7 43.8

49.7 53.3

53.3 56.8

60.2 60.4

56.3 63.6

66.2 71.6

Girls11.5

13.1

15.1

17.6

18.7

21.7

24.4

25.7

29.8

32.5

36.3

43.6

48.8

54.0

53.2

53.0

56.7

income similarly

Fatness values, based on either triceps or standard deviations is necessary.7 No simple trans-

subscapular fatfolds, tend to be skewed in their form (such as the log transform) is adequatedistributions; therefore, the use of medians and because the direction as well as the amount ofpercentiles instead of the conventional means and skewness of fatness varies from age to age. In late


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��3EFIG. 2. Size comparisons of low-income, white, school-age boys (solid lines) and median-income,

white, school-age boys (broken lines) demonstrating the relationships between per capita incomeand growth. As similarly observed in blacks, Meso-Americans, and Puerto-Ricans, boys and girls

below the poverty level ($800 per capita) are size-diminished and become shorter adults.

6

20

l0

170


adolescence and adulthood, triceps and subscapu-

lar fatness values bear a reasonable relationship to

relative weight or percent of standard weight;

but, during infancy and through early adoles-

cence, there appears to be no alternative butmeasuring fatness as fatness8 (Fig. 4).

As shown in the Ten-State data, separately byrace and socioeconomic group, females evidencegreater outer fatness at all ages from childhood

through the ninth decade.9 Adolescence for thefemale is not a period of loss of baby fat, aspopularly believed. Rather, it is a period ofincreasing outer fatness, both in the poor and inthe rich. However, the male does undergo a

transient reduction in outer fatness in earlyadolescence (Fig. 3).

In a general way, and within each racial and

ethnic group represented in sufficient numbersfor realistic comparison, the poor are leaner (lessfat) and those at median incomes are fatter. This

generalization holds for males at all ages (withsome early exceptions), and it applies to females

40

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through early adolescence. However, during

adolescence, females with lower incomes end upfatter and those of higher incomes end up leaner.Indeed, during the adult years, fatness is posi-

tively (upwardly) related to socioeconomic statusin the male, but negatively (downwardly) related

to socioeconomic status in the female. Moreover,

the “reversal” of relative fatness in the female

during adolescence and beyond serves to chal-lenge the contention that the level of fatness

attained in infancy predicts or predetermines

relative fatness through to adulthood.’�There is considerable evidence from studies of

obese children and longitudinal studies thatfatness is au.xogenic (growth-promoting)-that

fatter boys and girls are taller, have a largerskeletal mass, mature earlier, and so forth.’#{176} “

New data from the Ten-State Nutrition Survey

document this evidence to perfection. Year after

year, fatter children are taller and definitely more

advanced in development than leaner boys andgirls. By 12 years of age, the lean boys and girls


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FEMALES

2 3 4 56 810AGE

20 30 40 60 80 100

FIG. 3. Life cycle comparison of fatfold trends in 8,437 white females (broken line) and 6,823white males (solid line). There is a tendency for the female to be fatter at all ages. Data from the

Ten-State Nutrition Survey confirm the existence of a prepubertal fat gain in both sexes, but an

adolescent loss in the male coincident with a notable adolescent fat gain in the female.

310 TEN�STATE NUTRITION SURVEY

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are about 6 cm shorter than those who are fat8 12

(Fig. 5).

Furthermore, fatter individuals showed higherhemoglobins and consistently higher hematocrits(Fig. 6) during infancy, childhood, and adoles-

cence, as well as throughout the life span. Thisfinding is important to understanding differentialmortality of anemic individuals’3 and in pre-

senting hemoglobin and hematocrit “norms.”If the Ten-State Nutrition Survey showed

nothing else, it clearly documents the systematic

relationship between the level of fatness and therate of growth. Apart from such other variables asnutrient densities, parental supervision of energy

expenditure, and standards of medical care, thelevel of size and the level of growth attainmentmay be manipulated by altering the caloric

balance.

ThE PREVALENCE AND CONCOMITANTSOF OBESITY

Although the Ten-State Nutrition Survey wasauthorized by Congress to undertake an investiga-

tion into the prevalence of undernutrition in theUnited States, it was obvious from the beginning

that the broader question of malnutrition (includ-ing both undernutrition and overnutrition) was of

national concern.

Many investigators on the American socialscene have put overnutrition and obesity as

parallel problems; obesity is no less morbidogenicthan undernutrition and contributes more toadulthood mortality. The problem was to investi-

gate overnutrition and obesity in a populationsample without clear definitions as to exactly how

“obesity” was to be described. Preliminarystudies with the fatfold and weight data from the


WHITE FEMALESN2480

140

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OBESEBY TRICEPS FATFOLD

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2 3 4 6 810ACE


20 30 40 60 80100

FIG. 4. Relative weight (percent standard weight) of white females categorized as “obese” by

fatfold measurements in the Ten-State Nutrition Survey. The conventional 20% overweightstandard reasonably corresponds to the direct measurement of obesity in adult women; obese

children are less than 20% overweight, and obese adolescent girls considerably exceed theconventional overweight standard. Fatness and not overweight is a far more useful measure in

children.’

Ten-State Nutrition Survey showed that the

“20%” weight definition of obesity commonly

used for adults was both an inappropriate andunacceptable definition for infants and children.8

Further studies revealed that socioeconomic and

population differences in the level of fatness madea definition of obesity suitable for one group butunsuitable for another. Defining “obesity” as theupper 15% of fatness (i.e., above the 85th percent-ile),7 and taking the Ten-State Survey data as awhole, different propdrtions of children were

“obese” in different socioeconomic groupings.

Beyond infancy, for simplicity, the “obese” were

systematically those of greater affluence in bothAmerican Negro (black) and white children.

Conversely, the percent defined as “obese” wasnecessarily less in the poor and below-povertyboys and girls. The upper reaches of fatness in

infants, children, and adolescents were more

likely to be achieved by middle income boys andgirls.

Concomitants of “obesity” thus defined were

found to be numerous. As may be expected fromthe previous section on fatness, the obese boys

and girls were developmentally and size

advanced; they were taller, heavier, and further

along in ossification; and they had larger skeletalmasses and considerably greater mineral mass.Although generally the obese boys and girls did

not differ particularly in reported nutrient densi-

ties, the obese of all ages and both sexes hadsystematically higher hemoglobins and hemato-

crits.

A separate category of super-obese boys andgirls, the upper 5% in fatness, resembled the obesein certain respects and carried the dimensional

and developmental extremes further. The super

obese were taller and more advanced skeletally;

they had larger skeletons, a still larger fat-free

weight, and a larger mineral mass. But, they were

not notably middle-income as were the simply

obese, and, in other socioeconomic respects, they

did not share backgrounds with the simple

obese.The exact definition of obesity remains an

equivocable one. From the extensive data onhand, ranging from the lowest to the highestlevels of fatness, there is not a discontinuity in the

fatness distribution representing a separate area

of “obesity,” nor is there bimodality to indicatewho the obese inherently are. Rather, the obese

display, in size and development, the characteris-


WHITE FEMALES WHITE MALES150-

145 -

140 -

135-

130-

125 -

155- 155-

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ACEFIG. 5. The relationship between level of fatness and growth in size in boys (left) and girls (right). Fatter children are

systematically taller than leaner children, and the statural difference may be 12 cm and more.’’2 These findings show the need tointerpret body size in conjunction with fatness data throughout childhood.

312 TEN-STATE NUTRITION SURVEY

=

tics of the continuum. They are fatter, fromhigher income levels, are bigger and more devel-

oped, and they have a higher fat-free weight and alarger skeletal mass.8 The super obese share these

developmental concomitants, but super obesity

cannot easily be related to income. The anteced-ents leading to super obesity may be different

from those that lead to simple statistical obesity,per Se.

FAMILY-LINE ASPECTS OF FATNESS

Since families and entire households wereincluded in the Ten-State Survey, new opportuni-ties existed for the family-line analysis of develop-mental data. Complete family-line analysis of

fatness (comparing parents and their children,and siblings to each other) were undertaken. Thiswas a formidable statistical task because of the

thousands of pairings involved; there were 8,000white families alone.

The results showed clearcut parent-child simi-larities in fatness and sizable sibling similarities in

fatness. When the parents were categorized aslean, medium, or obese (based on their fatness

percentiles) and the various parental combina-lions were compared, the results were impressive.When both parents were lean, the children

tended to be lean. When both parents were obese,the children tended to be obese. The parentalcombinations, obese + lean and obese + medi-urn, yielded nearly textbook results (Table II).

To avoid having the sibling similarities infatness and the remarkably consistent parent-child resemblances in fatness taken as simpleproof of the genetic hypothesis, there are consid-

erable similarities in fatness between spouses(husband-wife); these increase through the fourthdecade.’4 Taken together, these findings suggest

that the level of fatness may be more acquired

because of family eating and exercising habitsthan genetically inherited. These findings attest,


AGE

20 30 40 60 80 tOO

TABLE II

PARENTAL FATNESS COMBINATIONS AND

RELATIVE FATNESS OF THEIR CHILDREN#{176}


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FIG. 6. Median hemoglobin levels in obese individuals (solid line) and lean individuals (broken

line) show systematically higher hemoglobin levels in obese individuals from childhood throughthe ninth decade. These fatness-related differences repeat themselves in American Negro (black)

individuals, but at lower levels of hemoglobin. Therefore, there is a need to reconsider themeaning of hemoglobin standards at all ages.

moreover, to the wisdom of investigating nutri-

tion in the family and household context, and thevalue of investigating survey data for more than

simple description.Complete analysis of family-line aspects of

fatness will be given in a later report. Forexample, by age 17 the children of obese parentsare three times as fat as the children of lean

parents!

RACE DIFFERENCES IN GROWN ANDDEVELOPMENT

Prior to the Ten-State Nutrition Survey of

1968-1970, there was insufficient data on race

differences in growth and development to suggestor reject a need for race-specific standards for sizeduring growth. However, with the nearly equalsample of American Negro (black) and Americanwhite boys and girls in the survey and the detailed

socioeconomic information, the magnitude of

race differences could be established with confi-

dence. Though initially smaller than white neo-nates and infants, American Negro (black) boys

and girls grew more rapidly, and from the secondyear of life through early adolescence they were

systematically taller by about 2 cm. This finding,

Father Mother

Relative Fa tness of

Sons�

N Z

Daughters�

N Z

Lean

Lean

Lean

MediumMedium

MediumObese

ObeseObese

Lean

Medium

Obese

LeanMedium

Obese

Lean

Medium

Obese

51 -0.63

160 -0.36

24 -0.08

155 -0.37816 +0.02

164 +0.3029 +0.10

146 +0.53

105 +0.57

45 -0.95

122 -0.2923 -0.05

114 -0.29566 -0.07115 +0.17

24 +0.38

100 +0.62

80 +0.54

#{176}Parental fatness based on triceps percentiles for ageand sex. Fatness values for the children are expressed

as normalized Z scores relative to the median for ageand sex. By the late teens, the children of lean + lean

and obese + obese parents are even more dramatically

different.

reported in the American Journal of DLseases of

Children,’5 proved to be in accordance with

Owen and Lubin’s findings from the PreschoolNutrition Survey’6 and recent findings from the

National Collaborative Survey of the National


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FIG. 7. Averaged from infancy through early adolescence,

stature differences between American Negro (black) boysand girls and their white age-peers. Though smaller at birth,

boys and girls of largely African ancestry tend to exceedwhite children between the 2nd and the 14th year.”’8 This

suggests a need for race-specific stature standards,IC� � wellas ossification timing and dental development.

Institute of Neurological Diseases and Stroke.’7Furthermore, these comparative findings fromthe Ten-State Survey are compatible with corn-

parisons from the Kaiser-Permanente Health Planin California’8 and similar comparisons from theNational Health Examination.’9 Both with andwithout correction for socioeconomic status,American Negro (black) boys and girls tend to be

taller from infancy through to adolescence (Fig.

7). Race-appropriate norms and standards may

well be recommended, at least for American

Negro (black) and American white boys andgirls.’9

In similar fashion, American Negro (black)

children proved systematically advanced in toothemergence or, specifically, the age-at-emergencefor each of 28 permanent teeth.2#{176}Tooth by tooth,American Negro (black) boys and girls had earlier

tooth emergence than their white age-peers, arace difference further increased when appro-

priate correction was made for socioeconomic

status.20’ 21

Postnatal ossification also showed systematicevidence of a difference between blacks andwhites as indicated from median ages at ossifica-

tion of postnatal centers of the hand and wrist.22These findings show a systematic advancement in

skeletal development in blacks. They are inmarked contrast to findings reported from various

countries in Africa (where the black children tend

toward skeletal retardation beyond the first orsecond year of life). These new findings indicate

that, given any reasonable level of economicequality, separate standards for ossification

timing are indeed appropriate when evaluatinghand radiographs or making “bone-age” assess-

ments in blacks and whites.

In addition to the systematic differences in

length or stature, in permanent tooth emergence,

and in postnatal ossification, systematic racedifferences were also found in metacarpal

lengths,23 computed rates of subperiosteal apposi-

lion and endosteal surface resorption, and relativerates of bone formation and bone loss. The net

effect, as calculated from radiogrammetric mea-surements, is to produce a larger skeletal mass in

children and adults of largely African ancestry.24

Therefore, evidence for greater skeletal mass atall ages bears on basic problems of both caloric

and mineral nutrition. If stature is greater inAmerican Negro (black) boys and girls and if the

skeletal mass attained is considerably greater in

children and adolescents of largely African ances-try, it is reasonable to suggest greater caloric

requirements, larger allowances for calcium and

phosphorous, and (possibly) greater requirements

for vitamin D.In one area the question of true race differences

remains partially equivocable-the area of fatness.

Considering the sample as a whole, AmericanNegro (black) boys and girls are leaner (through

adolescence) than their white counterparts.

However, this difference in fatness has some

socioeconomic basis because higher-income

American Negro boys and girls are fatter thantheir counterparts at and below the poverty level.

Moreover, though American Negro (black) girlsare systematically leaner than their white coun-terparts through to adolescence and after, the

adult black female is fatter at all ages through theninth decade. Accordingly, we are not inclined toregard the lesser fatness of American Negro(black) boys and girls as necessarily or exclusively

genetic; we tend to see this difference as asocioeconomic and subcultural manifestationaltered in adulthood by differential expectancies

of fatness, differences in body image, and

different levels of access to calories.The Ten-State Nutrition Survey showed the

existence and reality of certain race differences,even after correction for socioeconomic status,


Fi;. 8. Examples of the tnquetrolunate fusion (arrows) in

posteroanterior hand radiographs of American Negro (black)individuals. Hand-wrist radiographs taken in the Ten-StateNutrition Survey provide new population data on the

frequency of this trait, and they further confirm the validityof the race assignments.2627

FIG. 9. Radiograph showing brachymesophalangia of themiddle segment of the fifth digit and a cone-shaped or “peg”

epiphysis. Radiographs taken in the Ten-State Surveyprovide new population frequencies for this trait, which is

especially common in Meso-Americans, Chinese, and Japa-nese,272’ and showed that affected individuals tend to be

shorter than their unaffected siblings.3’



THE INFLUENCE OF PER CAPITA INCOME ON

BONE DEVELOPMENT, BONE FORMATION,

AND THE SKELETAL M�ss

Variable � Description

Ossification timing

Outer bone growth

Bone resorption

Net bone formation

Skeletal mass

TABLE III


Advanced (earlier) ossification

timing of postnatal hand-wristcenters

Increased metacarpal diameters,

areas, and length at all age?’

Increased bone resorption asshown by wider medullary widths

and area?’

Increased net bone formation

(total bone formation minus total

bone resorption)’�

Increased skeletal mass at allage?’

and (with the exception of fatness) in directionsopposite to those suggested by the economic

differences. After socioeconomic correction, and

even before it, black boys and girls tended to be

taller, had a larger skeletal mass, had a greater

bone density, and had skeletal and dental ad-vancement. All these findings were to a degreewhich indicates the need for appropriate race

standards in future nutritional surveys and din-

ical evaluations.

RADIOGRAPHIC FINDINGS

The Ten-State Nutrition Survey of 1968-1970

followed the example of the Central AmericanNutrition Survey by including posteroanterior

hand-wrist radiographs of a majority of individ-uals studied.25 As a result, we have much new andvaluable information on the effects of nutritional

status on ossification timing, bone remodeling andbone lengths, and proportions during growth. Wealso have important baseline “normative” data onmany developmental variants never beforesampled in such depth.

Within the Ten-State sample, virtually all

examples of the triquetrolunate fusion wereobserved in participants designated as black in

the survey (Fig. 8); this is a useful and importantindependent test of the accuracy of the race

assignments.26’ 27 Brachymesophalangia V wasdisproportionately observed in participants of

Meso-American and American Indian ancestry27;

again, this confirms the accuracy of the assign-ments. We now have useful, normative frequen-cies for the triquetrolunate fusion, brachymeso-

phalangia V, and cone-shaped epiphyses, and we

can show that cone-epiphyses are not a necessaryprelude to brachymesophalangia29 (Fig. 9). Radio-graphs from the Ten-State Survey have resolved

many outstanding problems.Analysis of individuals with brachymesopha-

langia V show them to be stature-reduced for age,sex, and race, and even stature-reduced compared

with their own siblings.30 Therefore, this radio-

graphic “sign” must now be considered as morethan a simple skeletal variant, one with majorimplications to growth and development.

The radiographic findings demonstrated a rela-tionship between family income and postnatal

ossification of the hand,3’ within each race, sepa-rately considered. We now have median values at

age-at-ossification of 30 hand centers-from thecapitate and hamate to the distal ulna and the

adductor sesamoid of the thumb-for differentsocioeconomic groups.22’ 31, 32 Radiogrammetricmeasurements have shown that subperosteal

apposition is greatest in those of greater affluenceand less in those at and below the povertyline2�’ 32, 33 (Table III). The excess of bone forma-

lion over bone resorption clearly follows aneconomic gradient-at least through median per

capita income-to the extent that the skeletal

mass is a partial reflection of economic status.

Extrapolated to kilograms of bone or grams ofcalcium or phosphorous incorporated into bone,the advantages of affluence may be described as a5% greater skeletal mass or mineral mass and a 5%greater rate of bone formation.24

Comparison of skeletal development in blacksand white proved especially impressive. Evenwithout correction for economic status, black

boys and girls had earlier ossification timing22’ 32

than white boys and girls, through to the appear-ance of the adductor sesamoid. Black boys andgirls evidenced greater metacarpal diameters,

longer metacarpal lengths, greater cortical thick-ness, and larger cortical volumes and calculated

bone volumes2�’ 32 (Fig. 10).The radiographic findings from the Ten-State

Nutrition Survey yielded a variety of substantivefindings on the effects of race and nutritional

status on ossification timing, bone remodeling,and bone loss; and it provided new and normative

information on ossification sequence timing,remodeling rates, maturation, and completion.New norms for these parameters,22’ 31, 32 on the

carpal angle,33 and on dimensions, proportions,and ratios of clinical and diagnostic value3438make the radiographic findings from the Ten-State Survey of greater pediatric value than was

originally anticipated.


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SOME “MONDAY MORNING”

REFLECTIONS

Because we were not involved in the original

design of the Ten-State Survey, we are not ego-involved in defending the sampling procedure.

We explored the data in depth. From what we

know now, we would have preferred a consider-

ably larger survey, the inclusion of a largernumber of states, and the deliberate inclusion of

larger numbers of Puerto Ricans, Mexican-Amer-icans, and a useful sample of Cuban migrants.Although 400 boys or 400 girls of an age is a

respectable sample by conventional experience,

when subdivided into race groupings and socioe-

conomic groupings, it is difficult to extract a

usefully large sample of minority groups atdifferent economic levels. In retrospect, wewould also have preferred the use of a single

survey team which moved from state to state,

central procurement of supplies, and a controllaboratory, rather than the decentralized state-

by-state teams that Congressional action dictated.But this would have required more time than

Congress allowed, and the results may not have

been significantly different.Certain design features may be highly

commended. The sample provides nearly equalnumbers of American Negro (black) and white

boys and girls. There were reasonably comparable

numbers of white children in both the low andmedian income groupings. Although the samples

of Mexican-American and Puerto Rican boys andgirls are smaller than we might like, they are still

larger samples than previously studied. Subcod-

ings and geographic separation allowed division

of that government rubric SPAM (for Spanish-

American surnames) into useful Meso-American

and Puerto Rican subgroupings. All Spanish-

speaking persons do not share the same genes orthe same dietary practices.

In these “Monday morning” reflections, we arealso aware of the need for reasonably promptanswers, which precluded a ten-year survey, with

dangers of built-in obsolescence. We havebecomj� aware of the tremendous size of the dataaccumulation, which taxes the limits of the IBM

360 computer, and the problems of merging somany tapes with so much data on them. We have

also discovered that the sheer writing-up of thefindings is a taxing problem, especially since

appropriations have ceased to exist.

There are many other parts of the Ten-StateSurvey, relating to serum and urinary biochemis-tries, caloric and nutrient intakes, and problems

of pregnancy and lactation. These still have to be

I I �1.ll

2 3 456810 20 30 501090

FIG. 10 Cortical area of the second metacarpal at midshaft ofAmerican Negro (black) individuals (solid circles) and Amer-

ican white individuals (open circles), calculated from meta-carpal widths at midshaft. These and other radiogrammetric

measurements of more than 25,000 individuals confirmgreater skeletal masses in individuals of largely African

ancestry, and point to greater mineral-protein needs for

skeletal growth.2�32

summarized and reported. We are aware thatthere are complaints that the survey did not findrampant malnutrition, or that the survey-withintentional concentration on the poor-seemingly

overreported growth retardation and size diminu-lion for the United States as a whole.

We feel that we have reasonably reported what

was found of primary scientific value, and

without attempt to sensationalize. The basic find-

ings on growth and development reported here

are numerous enough and important enough toobviate any need now to concentrate on theproportion of children below arbitrary levels of

size or growth performance. Indeed, we urgefuture workers to concentrate on differenceswithin the sample they have surveyed, withoutrecourse to external “norms.”



CONCLUSIONS

The Ten-State Nutrition Survey of 1968-1970

contributed far more information on nutrition

and growth than was originally anticipated. Inaddition to quantification of the relationshipbetween economic level and size and growthprogress and demonstrating the concomitants of

obesity and the effects of leanness, the results

pointed out major gaps in our knowledge andprovided a new body of substantive important

information.

The survey did not find pot-bellied, spider-

limbed malnutrition of the starvation level. It didnot suggest the prevalence of “hunger” of a kind

widely advertised in a 1967 television spectacu-lar. What it did show was that the dimensions of

poverty could be spelled out in smaller size andlesser growth. It also showed interactionsbetween economic level and size and growth

performance in blacks and whites.Among the novel and serendipitous findings

were those showing dimensional, developmental,

and temporal differences between black andwhite children who were carefully matched for

economic level. The study showed the simple

effect of level of fatness on both tempo andamount of growth. It demonstrated the anteced-ents of obesity in socioeconomic context. And it

showed the differing participation of differentorgan systems and measures of somatic and skel-etal development.

The Ten-State Nutrition Survey has been criti-

cized first for directing attention to the poor, and

second because it was not exclusively a survey ofthe poor. Yet, we now have data that never before

existed. These data show the exact dimensionaland developmental comparisons, both of the chil-dren of the poor and those of median incomes.

The survey has been criticized for limited geo-graphical representation; it excluded both the

Western states and the Plains states. Apart fromthe logistics, it is questionable whether the inclu-

sion of Montana, Idaho, Nebraska, and Wyoming

would have appreciably altered the results. The

survey, empowered by Congress but with noinitial appropriation, did not return completeresults in a mere six months. With budgets now

cut off, some � of the findings may never berevealed. Yet, the nature and the direction of thefindings greatly amplify our knowledge of growthand development. What we have learned about

fatness, socioeconomic effects, or racial differ-ences in growth will long influence growthappraisal and nutritional assessment. There is a

clear need to keep a continuing eye on the

growth, development, and nutritional status ofAmericans, at least once each decade. We should

not wait until the millenium to learn whether our

present measures of appraisal are obsolete.

COMMITI’EE To REvn�wTHE TEN-STATE NixrRITIoN SURVEY

Cii�iu�s U. LOWE, M.D., Chairman

GILBERT Foiu�Es, M.D.STANLEY � Ph.D.

GEORGE M. OWEN, M.D.NATHAN J. SMITH, M.D.WILLIAM B. WElL, JR., M.D.

Liaison Representative

MILTON Z. NICHAMAN, M.D.

Consultants

ERLING JOHANSEN, D.D.S.

NATHANIEL ROWE, D.D.S.

REFERENCES1. U. S. Department of Health, Education, and Welfare:

Ten-State Nutrition Survey 1968-1970: Atlanta:DHEW Publications No. (HSM) 72-8130, Center

for Disease Control, 1972.2. Cam, S. M., and Rosen, N. N.: A Preliminary Analysis of

Anthropometry, Radiographic and Dental Data forthe Ten-State Nutrition Survey. Ann Arbor, Michi-

gan: University of Michigan, Center for HumanGrowth and Development, 1972.

3. Rauh, J. L., and Schumsky, D. A.: An evaluation of

triceps skinfold measures from urban school chil-dren. Hum. Biol., 40:363, 1968.

4. Seltzer, C. C., and Mayer, J.: Body build and obesi-

ty-who are the obese? JAMA, 189:677, 1964.5. Seltzer, C. C., and Mayer, J.: A simple criterion of

obesity. Postgrad. Med., 38:A101, 1965.6. Hammond, W. H.: Measurement and interpretation of

subcutaneous fat, with norms for children and

young adult males. Brit. J. Prey. Soc. Med., 9:201,1955.

7. Garn, S. M.: The measurement of obesity. Ecol. FoodNutr., 1:333, 1972.

8. Gam, S. M., Clark, D. C., and Guire, K. E.: Growth,body composition and development of obese andlean children. In, Winick, M. (ed.): Symposium on

Childhood Obesity, to be published.9. Gam, S. M., and Clark, D. C.: Economics and fatness.

Ecol. Food Nutr., 3:19, 1974.

10. Gain, S. M., and Haskell, J. A.: Fat thickness anddevelopmental status in childhood and adolescence.Am. J. Dis. Child., 99:746, 1960.

11. Wolff, 0. H.: Obesity in childhood: A study of birthweight, the height and onset of puberty. Q. J. Med.,

24:109, 1955.12. Garn, S. M., Clark, D. C., and Guire, K. E.: Level of

fatness and size attainment. Am. J. Phys. Anthrop.,40:447, 1974.

13. Takkunen, H., and Aromaa, A.: Anemia and mortality.Am. J. Clin. Nutr., 27:323, 1974.



14. Gain, S. M., Clark, D. C., and Ullman, B. M.: Doesobesity have a genetic basis in man? Ecol. Food

Nutr., to be published.15. Gam, S. M., Clark, D. C., and Trowbridge, F. L.:

Tendency toward greater stature in AmericanBlack children. Am. J. Dis. Child., 126: 164, 1973.

16. Owen, G. M., and Lubin, A. H.: Anthropometric differ-ences between black and white preschool children.Am. J. Dis. Child., 126:168, 1973.

17. Garn, S. M., Owen, G. M., and Clark, D. C.: Thequestion of race differences in stature norms. Ecol.Food Nptr., 3:319, 1974.

18. Wingerd, J., Solomon, I. L., and Schoen, E. J.: Parent-specific height standards for preadolescent childrenof three racial groups, with method for rapiddetermination. Pediatrics, 52:556, 1973.

19. Hamill, P. V., Johnston, F. E., and Grams, W.: Heightand weight of children: United States Vital andHealth Statistics, series 11, No. 104, Rockville, Md.:Department of Health Education and Welfare,Public Health Service, 1970.

20. Garn, S. M., Sandusky, S. T., Nagy, J. M., and Trow-bridge, F. L.: Negro-Caucasoid differences inpermanent tooth emergence at a constant incomelevel. Arch. Oral Biol., 18:609, 1973.

21. Garn, S. M., Nagy, J. M., Sandusky, S. T., and Trow-bridge, F.: Economic impact on tooth emergence.Am. J. Phys. Anthrop., 39:233, 1973.

22. Gam, S. M., Sandusky, S. T., Nagy, J. M., and McCann,M. B.: Advanced skeletal development in low-income Negro children. J. Pediatr., 80:965, 1972.

23. Garn, S. M., Miller, R. L., and Larson, K. E.: Standardsfor bone size and mass. In, Jaworski, A. F. G., and

Meema, E. H. (eds.): Workshop on Bone Morphom-et,y. Unpublished manuscript.

24. Garn, S. M.: The course of bone gain and the phases ofbone loss. Orthop. Clin. North Am., 3:503, 1972.

25. Evaluacion Nutricional de la Poblacion De CentroAmerica y Panama: Guatemala. Instituto de Nutri-cion de Centro America y Panama (INCAP).Oficina de Investigaciones Internacionales de losInstitutos Nacionales de Salud (EEUU). Ministeriode Salud Publica y Asistencia Social, 25:8, 1969.

26. Garn, S. M., Frisancho, A. R., Poznanski, A. K.,Schweitzer, J., and McCann, M. B.: Analysis oftriquetral-lunate fusion. Am. J. Phys. Anthropol.,34:431, 1971.

27. Gain, S. M.: Human Races, ed. 3. Springfield, Illinois:Charles C Thomas, 1971.

28. Gain, S. M., Gall, J. C., Jr., and Nagy, J. M.: Brachy-mesophalangia-5 without cone-epiphysis mid-5 inDown’s syndrome. Am. J. Phys. Anthropol., 36:253,1972.

29. Gam, S. M., Poznanski, A. K., Nagy, J. M., and McCann,M. B.: Independence of brachymesophalangia-5from brachymesophalangia-5 with cone mid-5. Am.J. Phys. Anthropol., 36:295, 1972.

30. Gam, S. M., Nagy, J. M., Poznanski, A. K., and McCann,M. B.: Size reduction associated with brachymeso-phalangia-5: A possible selective advantage. Am. J.Phys. Anthropol., 37:267, 1972.

31. Garn, S. M., Sandusky, S. T., Rosen, N. N., and Trow-bridge, F.: Economic impact on postnatal ossifica-tion. Am. J. Phys. Anthropol., 38:1, 1973.

32. Gam, S. M., Miller, R. L., and Larson, K. E.: MetacarpalLengths, Cortical Diameters and Areas From theTen-State Nutrition Survey. Ann Arbor, Michigan:University of Michigan, Center for Human Growthand Development, 1973.

33. Harper, H. A. S., Poznanski, A. K., and Garn, S. M.: Thecarpal angle in American populations. Invest.

Radiol., 9:217, 1974.34. Garn, S. M.: Adult bone loss, fracture epidemiology and

nutritional implications. Nutrition, 27:107, 1973.

35. Garn, S. M., and Poznanski, A. K.: Transient andirreversible bone losses. In, Barzel, U. S. (ed.):Osteoporosis. New York: Grune and Stratton, Inc.,1970.

36. Gam, S. M., Poznanski, A. K., and Nagy, J. M.: Bonemeasurement in the differential diagnosis of osteo-penia and osteoporosis. Radiology, 100:509, 1971.

37. Kuhns, L. R., Poznanski, A. K., Harper, H. A. S., and

Gam, S. M.: Ivory epiphyses of the hands. Radiol-ogy, 109:643, 1973.

38. Poznanski, A. K.: The Hand in Radiologic Diagnosis, ed.2. Philadelphia: W. B. Saunders, 1974.


1975;56;306Pediatrics Nathaniel Rowe

M. Owen, Nathan J. Smith, William B. Weil, Jr., Milton Z. Nichaman, Erling Johansen and Stanley M. Garn, Diane C. Clark, Charles U. Lowe, Gilbert Forbes, Stanley Garn, George

SurveyNutrition Survey of 1968-1970: Ad Hoc Committee To Review the Ten-State Nutrition

Nutrition, Growth, Development, and Maturation: Findings From the Ten-State

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1975;56;306Pediatrics Nathaniel Rowe

M. Owen, Nathan J. Smith, William B. Weil, Jr., Milton Z. Nichaman, Erling Johansen and Stanley M. Garn, Diane C. Clark, Charles U. Lowe, Gilbert Forbes, Stanley Garn, George

SurveyNutrition Survey of 1968-1970: Ad Hoc Committee To Review the Ten-State Nutrition

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