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I. .. . .4131uunfiu. 11.11:... 1. 3.1.3.1.. .. . 3.16:”? 1101.“ 1 *5 6‘5 1 1.11 1§&£ 1WJ Hr . 1 ‘11. {ow-fl fi0~x 1 o b. 11 .5 “O1 011 .9. 59:19.93"; .9 115. $1 1:1 . 1 1.1“;1W15I.1.. 5.....>.1¢1§.¢1. 53.: go)“. 'rVO. r’I‘1' V. OI Vu‘i‘o .01. _UKI L.l.t1...I..!. 1 Hn:.1.11.... I <\ 3 f \ ABSTRACT GROWTH STATUS OF PRESCHOOL CHILDREN IN THE EXPANDED NUTRITION AND FAMILY PROGRAM by Joan Elizabeth Kazmarek Growth status, defined as a child's accomplishment in height and weight compared to standards for his age, was surveyed in a population of preschool children. Data were obtained as a part of a larger study, namely, an evaluation of the Expanded Nutrition and Family Program (ENFP). The first interview, conducted upon the homemaker's enrollment in the program, consisted of gathering infor- mation of a biological—consumer nature. At this time each child was weighed and measured and urine samples were collected from all available family members. Urine sam- ples were analyzed for thiamin, riboflavin and creatinine. Demographic data on the family and a twenty-four hour food recall on the homemaker, herself, were also Obtained. Nutrition knowledge and attitude toward food and nutrition Joan Elizabeth Kazmarek were Obtained at the second interview conducted with the homemaker. Measurements made on 149 preschool children, aged 15 months to 65 months, were compared to national norms for height and weight. A clustering of values was observed at the lower percentiles. Twenty—five percent of the children measured were below the third percentile for height, according to Stuart and Meredith standards: 13 percent were below the third percentile for weight when analyzed according to the above standards. Analysis of data according to race revealed signifi- cantly (p=.025) more non-Black than Black children at the lower percentiles for both height and weight. The racial difference in growth status was most pronounced for height. Thirty percent of the non-Black children were below the third percentile for height while 13 percent of the Black children fell into this category. Comparison of data from this study with means established by research on racial differences in stature (Garn, 1973) support the conclusion that Black children are taller than non-Black children (p=.003). Stuart and Meredith standards are based on data from children of Northern EurOpean parentage; this set of Joan Elizabeth Kazmarek standards was compiled 30 - 45 years ago. This may preclude the acceptability of these standards for present children. Data obtained from the children in this study were com- pared with standards developed by Rdbson (in press) from the study of low income children in Michigan. A traditional bell-shaped distribution of subjects over a range of values for height and weight according to race and sex resulted. GROWTH STATUS OF PRESCHOOL CHILDREN IN THE EXPANDED NUTRITION AND FAMILY PROGRAM BY Joan Elizabeth Kazmarek A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE Department of Food Science and Human Nutrition 1975 DEDICATION To my Mother and Father ACKNOWLEDGMENT A most sincere thank-you to Dr. Portia Morris for her guidance and patience in the writing of this thesis. The excellent suggestions of Dr. Rachel Schemmel and Dr. Richard Farace for revising this thesis are gratefully acknowledged. Deeply appreciated was the expertise and encouragement given by Dr. Verda Schiefley, Assistant Professor of Statistics, and by Dr. Kathryn Kolasa, Assistant Professor of Food Science and Human Nutrition and Community Medicine. Thank—you to all the "behind-the—scenes" peOple who made this thesis possible. iii TABLE OF CONTENTS Page LIST OF TABLES AND FIGURES. . . . . . . . . . . . . vi Chapter I. INTRODUCTION . . . . . . . . . . . . . . . 1 Objectives . . . . . . . . . . . . . . . 3 II . REVIEW OF LITERATIRE O O O O O O O O O O O 4 Growth Status and Growth Standards . . . 4 Racial Differences in Growth . . . . . . 6 Growth Under Depressed Socio- economic Conditions . . . . . . . . . . 8 Growth and Income 0 O O O O O O O O O O O 10 Growth Status and Food Expenditure . . . 11 Growth Status and Maternal Age . . . . . 12 Growth Status and Educational Level of the Mother . . . . . . . . . . 13 Growth Status, Nutrition Knowledge and Dietary Intake 0 O O O O O O O O O O 14 Growth Status and Nutrient Excretion . . 15 III . METHODOLOGY. 0 O O O O O O O O O O O O O C 17 Sample Selection . . . . . . . . . . . . l7 Instrument . . . . . . . . . . . . . . . 18 Preparation for Data Collection. . . . . 20 Data COlleCtion. O O O O O O O O O O O O 20 Analysis of Data . . . . . . . . . . . . 23 IV . RESULTS 0 O O O O O O O O O O O O O O O O O 2 7 Demographic Data . . . . . . . . . . . . 27 Food Recall Scores, Nutrition Attitude, Nutrition Knowledge and Nutrient Excretion Levels. . . . . . . . . . . . . 28 iv Chapter Page Height and Weight Data . . . . . . . . . 3O Correlations . . . . . . . . . . . . . . 42 V. DISCUSSION 0 O O O O O O O O O O O O O O O 43 Conclusions. . . . . . . . . . . . . . . 49 Suggestions for Future Research. . . . . 50 LIST OF REFERENCES 0 O O O O O O O O O O O O O O O O 5 l APPENDICES A. Biological—Consumer Questionnaire. . . . . 57 B. Nutrition Questionnaires . . . . . . . . . 64 1. Food and Nutrition Attitude Questionnaire . . . . . . . . . . . 64 2. Nutrition Knowledge Questionnaire. . 66 C. Interviewing Procedures 1. Interviewing Procedure for BiOIOgical Data 0 O O O O O O O O O 68 2. Interviewing Procedure for AttitUdinal Data. 0 O O O O O O O 0 70 D. Permission--Proof of Home Call . . . . . . 71 E. Physician Referral Slip. . . . . . . . . . 72 Table LIST OF TABLES AND FIGURES Page Place of Dwelling and Ethnic Background of Project Homemakers. . . . . . . . . . . . 27 Family Size, Monthly Income, Homemaker Age and Educational Level. . . . . . . . . . 28 Food Recall Score, Number of Food Groups Met, Number of Servings Met in Food Groups. . . . . . . . . . . . . . . . . 29 Nutrient Excretion Level, Nutrition Attitude Score and Nutrition Knowledge score 0 O O O O O C C O O O O O O 0 30 Percentages of Subjects in Different Height and Weight Categories According to Stuart and Meredith Standards . . . . . . 31 Percentages of Subjects in Different Height and Weight Categories According to Robson Standards. . . . . . . . . . . . . 32 Percentages of Children, Black and Non- Black in Different Height Categories According to Stuart and Meredith Standards. . . . . . . . . . . . . . . . . . 33 Percentages of Children, Black and Non- Black, in Different Weight Categories According to Stuart and Meredith Standards. . . . . . . . . . . . . . . . . . 34 Percentages of Children, Black and Non- Black in Different Height Categories According to Robson Standards. . . . . . . . 35 vi Table 10. ll. 12. l3. 14. 15. Figures 1. Percentages of Children, Black and Non— Black in Different Weight Categories According to Robson Standards. Investigation of Proportion of in Height Categories According Stuart and Meredith Standards. Investigation of Proportion of in Weight Categories According Stuart and Meredith Standards. Investigation of Proportion of in Height Categories According Robson Standards . . . . . . . Investigation of Proportion of in Weight Categories According Rdbson Standards . . . . . . . Correlation Matrix Between Thirteen Variables. . . . . . . . . . . Food Recall Score of Homemaker Height Category of Child . . . Food Recall Score of Homemaker Weight Category of Child . . . vii Subjects to Subjects to Subjects to Subjects to Page 36 37 38 39 39 42 41 41 CHAPTER I INTRODUCTION The synergism between nature and nurture continues to be of interest. Growth serves as an example of the inter- play between these two forces. "Growth" and "development" are often used interchangeably. "Growth", however, is concerned with increase in size while "develoPment" denotes integration and increasing complexity of function. It is the area of physical growth or increase in size which is of concern here. Environmental factors influence the extent of genetic expression (Garn, 1972). Depressed socioeconomic conditions and the concomitant factors of this situation cannot help but lower the quality of life experienced by the growing child. The Ten State Nutrition Survey (1972) found that decreased growth achievement correlated with decreased income. Growth retardation was more prevalent in low income states and growth was less adequate in low income groups. Larken (1974) listed such correlates of growth failure as: children of lower birthweights, coming from families with 1 2 more siblings and whose parents had higher credit payments, hence, less money for food. Research supports the impor- tant role played by the environment in the growth of the child. In addition to the environmental factors affecting the child's growth status are genetic dispositions for varying degrees of growth. A tremendous range of normal values for a physical characteristic exist. An Eskimo child, for example, would tend toward a shorter, stouter stature. A descendent of the Masai tribe of Africa would be noticeably tall. Other ethnic groups would fall some where between the two extremes. Application of standards for growth based on children of one particular ethnic background of 30 to 45 years ago may be undesireable. A one—to-one contact system maximizes the possibility of the homemaker's exposure to and ad0ption of nutrition messages (Davis, 1968). The Expanded Nutrition and Family Programs (ENFP) were established on such a premise. Home- makers indigenous to the community endeavored to present nutrition information to other homemakers in the community according to the guidelines established by the county extension office. The nutrition aide contacted each enrolled member in her respective home. Reports on the progress of the ENFP were subjective. 3 In 1972, Michigan State University undertook an appraisal of the ENFP utilizing an experimental group in a pre- and post-test design. Change data generated by this research is reported elsewhere (Duff, 1974). The time lapse be- tween the two phases of the study was not considered suf- ficient for significant physical growth to occur, thus, this report is concerned with growth data obtained in the initial phase of the study only. Objectives Specific research questions addressed in this report are: what is the growth status of a population of socio- economically depressed preschool children, do racial dif— ferences occur in the growth status of this same popula— tion; should growth standards be adjusted for the ethnic- background of the child. CHAPTER II LITERATURE REVIEW Growth Status and Growth Standards Growth has long been accepted as an index of nutri- tional status. Growth status, defined as a child's accomplishment in height and weight with respect to standards, will be satisfactory under conditions of Optimum nutrition, barring the existence of any physical dysfunction. Conversely, growth status will most likely be impaired when sub0ptimum nutrition is provided. Dugdale (1972) stated that: Growth achievement...is a reliable guide to the health and nutrition of the child, i.e., those who do not measure up are most likely to be suffering. Rate and quality of growth are important correlates of general health. A child may have attained a height appropriate for his age but be retarded in weight gain. Skeletal deve10pment may be lagging though the weight of the child falls into an acceptable range for his age. Unsatisfactory progress in height and weight for age may 5 indicate unsatisfactory nutrition, according to (Jackson and Kelly, 1945). Driezen £3 31. (1953) examined 2,965 children, aged two years, eleven months to fifteen years, eleven months, from 1942 to 1952 and commented that the children with nutritive failure lagged substantially in height and weight by the third year of life and that that lag increased pro- gressively thereafter. Measurements of height and weight are considered most valid when taken under standard conditions. For height these conditions specify that the child stand, if older than 36 months, barefooted on a floor; the heels, buttocks and shoulders of the child should touch the wall. A right angle should extend from the crown of the head to the wall. Knees should not be flexed nor heels lifted from the floor. Weight is to be measured on a beam or balance scale, cali— brated two to three times each year, with the child naked or in light underclothes. The height and weight of a child less than three years of age is to be measured while the child is in the recumbent state (Committee on Nutrition Advisory, 1974). In order to assess the growth status of a child standards have been developed. The most widely accepted and used standards for height and weight are those of Stuart and Meredith (Lowrey. 1973. p. 79-80). Meredith 6 weighed and measured children of Northern EurOpean ancestry from a high socioeconomic background in Iowa. Stuart ob— tained his data from a similar group of children in Boston. Compilation of these data resulted in a smooth curve of values for height and weight for age. The data obtained from weighing and measuring one child can be plotted against the curve in order to ascertain the growth status of the child relative to a large group of other children his own age (Falkner, 1962a, 1962b). Racial Differences in Growth Research on the subject of growth and race tends to support a genetic disposition among Black children for greater stature. Barr gt a1. (1972), measured 7,500 children of three colors, ages five to fourteen years. Black children were, on the average, 2.3 cm taller and 2 kg. heavier than White children. Referring to the Ten State Nutrition Survey (1972), the American Academy of Pediatrics (1973) suggested a genetic factor outweighing the influence of economic fac- tors as Blacks were found to be advanced skeletally, tending toward greater size while maintaining less fat when at the same or even lower economic level. In spite of generally retarded growth status in poor families, one 7 and one-half times as many White children as Black were below the fifteenth percentile for height when all children measured were at the same poverty level. Verghese, Scott, Teireira and Ferguson (1969) con- cluded that the Black children of the pOpulation in their study were taller than the White children in the Harvard study of Stuart (1943). These researchers weighed and measured 1,400 Black boys and 1,200 Black girls, aged three months to seventeen years, from low income families in Washington, D.C. In an earlier report by Scott 33 31. (1962) birth weights and lengths were recorded for forty-seven Black boys and sixty—four Black girls. These children were from a lower-middle class background and had birth weights and lengths less than those for white children. The Black infants, however, exhibited greater annual growth velocity. Differences between Black and White children were cited by Owen and Lubin (1973). They stated that Black children are smaller at birth than White children, at equal develOpmental levels as White children at one year of age, and taller and heavier thereafter. Garn (1972) examined American Negro children and American children of European ancestry and found that Black males average .77 cm taller than White males; Black 8 females averaged 1.20 cm taller than White female children. Utilizing data from 10,958 Black and White, low income boys and girls from eight of the ten states in the National Nutrition Survey (NNS, 1972), Garn found Black children to average 2.5 cm taller than White children up to the age of twelve years. Growth Under Depressed Socioeconomic Conditions Retardation in height and weight has been found repeatedly under adverse socioeconomic conditions. Schaefer (1969), commented on the establishment of the National Nutrition Survey, and hypothesized that the greatest prevalence of malnutrition would be among those segments of the pOpulation with the lowest income. Results of the NNS included decreased intakes of vitamin A and vitamin C, inadequate urinary riboflavin, prevalent dental carries, the presence of intestinal parasites and obesity in mature women, most commonly among families whose annual income was less than $5,000. The children in these families were the ones most often at or below the sixteenth percentile for height and weight from birth to six years of age. Data from the Michigan portion of the NNS (1971) revealed that 46.5 percent of children below poverty level were one or more standard deviations from the Stuart and Meredith means for height. Chase 35 31. (1973) examined preschool children of Mexican-American migrant farm workers and found 30 percent of the children to be below the third percentile for weight and 25 percent to be below the third percentile for height. McGanity (1969) reported Texas NNS data and stated that among those families whose incomes fell into the lowest twenty-five percent of the economic scale the curve of the mean values for height and weight of children followed the curve for the sixteenth percentile of the standards of Stuart and Meredith. Meredith (1941) observed the sons of men belonging to "managerial" or "professional" classes. These boys were taller and heavier than boys from lower socioeconomic classes though not by more than three percent for height and six percent for weight. The American Academy of Pediatrics (1973) commenting on growth under depressed socioeconomic conditions stated that "...to a significant degree malnutrition in children appears to be a consequence of both the quality of life and the economic status of the family..." (1973). Sandstead _£.al. (1971) observed 100 preschool children living under adverse socioeconomic conditions. The findings from this study include 24.7 percent of the sample to be 10 below the tenth percentile for height. Another study in which 18 percent of the preschool children were found to be below the third percentile for height was performed by Chase (1971) on the preschool children of Migrant workers. The mean annual income for these families was $1,885; the average family size was 6.6 persons. After collecting heights and weights of preschoolers in a North Central Regional Study and finding heights to be more deviant from the Iowa standards than weights, Fryer and co-workers (1972) commented that perhaps foods eaten by the poor contribute more to weight than to height. Growth and Income Retarded growth status under depressed socioeconomic conditions has been mentioned. Specific studies have been conducted in order to assess the correlation between growth status and income. Fryer t El- (1972) noted that height of preschoolers in a North Central Regional Study was more adversely affected by income than weight. A finding of a study by Furtel t 31. (1971), of Negro preschool children in Mississippi, was a relationship between income per capita and nutritional status: those families possessing incomes above $500/capita/annum had significantly better 11 intakes of calories, protein, calcium, iron, vitamin A and vitamin C. Graham (1972) reported increased stature to be positively correlated with increased disposable income after a study done in a socioeconomically depressed area of Lima, Peru. In an evaluation of the nutritional status of Mississippi preschool children, Owen gt El- (1969) deter- mined a minimum income per person per annum to maintain satisfactory nutritional status to be $500. Sixteen per- cent of the children from families in which the per person per annum income was less than this figure fell below the third percentile for height. Growth Status and Food Expenditure The family income and size are the two most important determinants of the amount of money spent for food (Feaster and Perkins, 1973). The USDA Economic Research Service, evaluating the impact of the Expanded Food and Nutrition Education Program (EFNEP) on low income families, stated that among families earning less than $2,700 per annum, one third of that income was spent on food. Families with an annual income of less than $1,200 had to spend one half of their annual income on food. These figures are based on a family of approximately 5 persons. 12 A study by Sandstead £5 31. (1971) correlated height and average weekly expenditure for food. The United States Department of Agriculture (USDA) average expenditure per person, per week for food at this time was $6.25. About 25 percent of the children for whom this figure averaged $4.05 fell below the tenth percentile for height. An investigation of growth failure by Larkin (1974) at the Ypsilanti Well Child Clinic, Ypsilanti, Michigan, suggested that a decreased amount of money spent for Food and Food Stamps was a correlate of inferior growth status among low income children. Growth Status and Maternal Age Another correlate of poor growth mentioned in Larkin's study was the age of the mother. Larkin noted that older mothers are more likely to have babies of lower birth- weights which may result in children with inferior growth accomplishment. A study of homemakers up to the age of 60 revealed that not only did homemakers under 40 years feed their families better than older homemakers but a negative correlation existed between the age of the homemaker and her use of the milk group (Young g£_al,, 1956). 13 Growth Status and Educational Level of the Mother Inferior growth status among children of older mothers may be the result of decreased educational achievement among older homemakers. Furtell, Kilgore and Windham (1971) examined the nutritional status of preschool children in Mississippi. Among their findings was a posi- tive correlation between the dietary intake of nutrients and the educational level of the mother; daily intakes of calcium, iron, vitamin A and vitamin C parallelled her education. Young, Berresford and Waldner (1956) investigated the nutrition knowledge possessed by the homemaker and showed as the educational level of the homemaker increased so did her utilization of seven food groups, keeping income level stable. One of the conclusions of an analysis of the ENFP (USDA, 1972) was that more educated homemakers from higher income backgrounds had higher food expenditures and gener- ally had better diets. In a study in Peru (Graham, 1972) greater stature was seen among children whose mothers had five or more years of schooling compared with those children whose mothers had less than five years of schooling. 14 Growth Status, Nutrition Knowledge and Dietary_Intake A strong interrelationship exists among the age of the homemaker, her educational achievement, income level, amount spent for food and food stamps, nutrition knowledge, dietary intake and urinary nutrient excretion. YOung 35 El: (1956) noted that the educational level of the homemaker was positively related to nutrition knowledge and that nutrition knowledge does increase the efficiency of the homemaker in feeding her family. Increased nutrient intake would make satisfactory growth status possible. Nutrition knowledge was positively and significantly correlated with education in a study of the homemaker's nutrition knowledge (Bass, 1969). A portion of the North Central Regional Study (1971) assessed the nutrition knowledge of the homemaker in rela- tion to her attitude toward food and nutrition. Mothers of preschool children were requested to keep a three day food intake record for herself and her child. The mother was interviewed regarding meal planning and food preparation practices and permissiveness toward child feeding. The findings of Eppright and co-workers follow. The amount of money spent for food was highly and positively correlated with energy and nutrient intake. Increasing educational level of the homemaker related to increased intakes of 15 calcium, iron, thiamin, roboflavin and vitamin C. The more educated the homemaker, the less permissive her attitude towards child feeding and a high negative correlation was determined between permissiveness and attitude toward nutrition, meal planning and food preparation. Eppright gt 31. (1969) evaluated the eating behavior of preschool children and found that children by the age of three years have deve10ped negative attitudes towards certain foods, especially vegetables, based on the attitude manifested by a mother or a father. Research by Kerry gt 3;. (1968) also supported the concept that the attitude of family members towards food items by young children is important. A negative orientation towards nutrient rich foods can result in decreased nutrient intake with subse- quent decrease in achievement of maximum growth status. Growth Status and Nutrient Excretion Nutritional status is reflected in biochemical as well as dietary and anthrOpometric measures. Urine composition and urinary nutrient excretion can serve to indicate the level of nutrient intake. Kerry gt 3;. (1968) conducted a study in which dietary records of 40 preschool children were kept for three days. Twenty children were of a high socioeconomic background and 20 were from a low socioeconomic 16 background. Biochemical measurements were made; urinary nutrient excretion was found to be higher among the pre- school children of high socioeconomic background whose dietary records were more satisfactory also. Owen _£.§1. (1969) suggested a relationship among not only nutrient intake, nutrient excretion and growth achieve- ment but also intestinal parasites and poverty in the inter- playing factors combining to reduce possibilities for optimum growth status. McGanity (1969) reported that in the Texas portion of the NSS, unacceptable levels for thiamin and riboflavin excretion were found to be twice as prevalent among the poor as for the pOpulation in general. The NNS in Michigan found unacceptable thiamin excretion levels in 6 percent of the population being investigated; 14 percent of this same low income population demonstrated riboflavin excretion levels unacceptable according to standards set by the Interdepartmental Committee on Nutrition for National Defense (ICNND, 1963). Data from the entire Ten State Nutrition Survey (1972) reveal riboflavin excretion levels to be inadequate according to ICNND standards particularly for children under seventeen years and for some Blacks: thiamin excretion was not indicative of any significant health problem. CHAPTER III METHODOLOGY Weight, in pounds, and height, in inches, were the criteria utilized to assess the growth status of the pre- school children in this study. Sample selection, instru— ment design, data collection and analysis procedures will be discussed in this chapter. Sample Selection Data on 149 preschool children were collected from selected counties in Michigan: Jackson, Kent, Lenawee, Saginaw, St. Joseph and Wayne. Randomization of the sample was performed by the establishment of a quota of homemakers for each county equal to six times the number of full—time Expanded Nutrition and Family Program (ENFP)!aides. Each family consecutively enrolled, within certain time con- straints, was deemed randomly selected for the purpose of this study. Commencement of data collection by the research team in a particular county and the enrollment of the last of the quota of homemakers for that county constituted the 17 18 the time constraints. A portion of the sample was also derived from Ingham county, Michigan. The sample selection in Ingham county was carried out by requesting participation of families who had children in the Head Start program. Other low income families also participated. Project families from Jackson, Kent, Lenawee, Saginaw, St. Joseph and Wayne counties belonged to the ENFP: Ingham county families did not. This established a treatment and control group for the purpose of generating change data according to the pre- and post-test design. All preschoolers at the beginning of the study were considered experimentally similar. Data will be presented on the entire group of preschool children. From the seven counties, data were Obtained on 149 preschool children from 108 families. "Preschool" is defined in age as 15 months to 65 months. Instrument The research instrument was divided into two parts. Upon initial contact with the homemaker, the ENFP aide routinely collects information regarding family residence, size, monthly income, assistance received by the family, educational level of the homemaker and food consumption by the homemaker within the last twenty-four hours. The 19 research team copied this information from the aide's enrollment form in order to avoid needless repetition of questioning the homemaker. The interviewer requested information from the homemaker regarding family character- istics in addition to those obtained from the aide's enrollment form. This interview also consisted of collect- ing urine samples from all willing and able family members and weighing and measuring all available children. These data were recorded on the biological-consumer question- naire (Appendix A). The second interview required the homemaker's response to various statements pertaining to four categories: food and nutrition attitudes, child rearing attitudes, general social and educational attitudes and nutrition knowledge. Only parts I and IV are apprOpriate to this study (Appendices B-1 and B-2). Prior to actual data collection the questionnaires were pretested on a group of low income homemakers. The instrument was translated into Spanish due to the large number of homemakers of this particular ethnic background in the study. 20 Preparation for Data Collection Interviewing technique employed by the research team was standardized (Appendix C). The county extension offices were visited by the research team prior to data collection to acquaint the staff with the procedures to be utilized. Role playing involving the county Home Economist and aides facilitated in-depth explanation of the project methods. Nutrition aides were requested to enroll the study families in the regular manner and, in addition, to ascer- tain whether the homemaker would agree to an additional person upon the occasion of the aide's next visit. The aide was instructed not to explain details of the evalua- tion project and to minimize contact with the homemaker between her enrollment and the arrival of the first member of the research team. Data Collection Collection of data from the seven counties continued from November, 1972 to August, 1973. The member of the research team administering the biological—consumer questionnaire accompanied the nutrition aide on her second visit to the homemaker. The researcher explained the evaluation project to her at this time and requested her co-Operation. The homemaker confirmed her 21 intent to be included in the project by her signature on a consent form (Appendix D). Urine samples were collected in individual plastic cups provided by the researcher. Specimens were checked immediately for hemoglobin, ketones, glucose, albumin and pH by using Labstix Reagent Strips, from the Ames Company, a division of Miles Laboratories. Results were recorded. When abnormal results were Obtained researchers provided slips indicating the specific results which the homemaker could take to her physician (Appendix E). This routine check was performed in part as a service to the family and also to encourage participation from all possible family members by providing immediate feedback. Storage of the specimens in individual brown bottles and acidification with 1 N HCl at 5 mls. HCl per 50 mls. urine stabilized vitamin content. Upon returning to the university, researchers deposited the specimens in a freezing unit where they remained until analysis. The researcher questioned the homemaker concerning resources available in the home for food preparation, shOpping practices, use of vitamin supplements by family members, availability and participation in the School Lunch Program, when applicable. Demographic data per— taining to the family were Obtained from the aide's 22 enrollment form. As part of the biological-consumer interview the researcher weighed and measured all available children of the homemaker. Weight was measured on a portable bathroom scale with the child in light indoor clothing, no shoes, and recorded to the nearest half pound. Height was mea- sured by having the child stand in stocking feet on a bare floor with shoulders and heels in contact with a flat, vertical surface, such as a wall, and a right angle extend- ing from the crown of the child's head to the wall. The measurement was taken in inches and recorded to the nearest quarter inch. The first interview was concluded by setting up an appointment with the homemaker approximately one week later for the second interviewer's visit to the homemaker. The second interview consisted of presenting the home- maker with a set of statements pertaining to four categories: food and nutrition attitudes, child rearing attitudes, general social and educational attitudes and nutrition knowledge. The statements were read to the homemaker by the interviewer and the homemaker was requested to give her response verbally, either mild or strong agreement or mild or strong disagreement. The researcher circled the given response on her COpy of the questionnaire. 23 Analysis of Data Height and weight data from 149 preschool children were analyzed. A ceiling age of 55 months, rather than 65 months for a particular set of standards caused a variation of the number of subjects in one analysis. Demographic characteristics obtained from the families included residence, urban, farm, or rural-non-farm; ethnic background of the family: family size: family income per month; financial assistance received by the family; ages of family members and educational level achieved by the homemaker. Recipients of the Graduate Equivalent Diploma (GED) were credited with a twelfth grade education. Con- sumer oriented data were as follows: food preparation equipment available in the home, shOpping habits of the homemaker, reasons for food purchases in the market and vitamin supplements taken by family members. The adequacy of the homemaker's diet was analyzed with reference to the Basic Four Food Groups. For adults this standard specifies two servings each from the meat and milk group and four servings from each of the breads and cereals group and fruits and vegetables group. Each of the four food groups was assigned a maximum value of four. Every serving met in the meat or milk group had a potential value of two while each component of the breads 24 and cereals and fruits and vegetables groups was awarded one point. The score on a particular homemaker's food recall, then, could range from zero for no items met in any of the groups of the Basic Four to sixteen for all items met in all of the groups. No points were awarded for servings above the requirement in any of the groups. Urinalyses were performed by a Michigan State Univer— sity technician who utilized the Technicon Auto-Analyser. Creatinine determination employed Technicon Auto-Analyser method n—llb I/II. Thiamin analysis was carried out by the method developed by Leveille (1972) and automated by Romsos and Kirk (1973). Riboflavin content of the sample was assessed according to the method of Kirk (1973). Thiamin and riboflavin were eXpressed as micrograms of vitamin per gram of creatinine. In order to categorize results, excretion data were classified according to age and compared to standards established by the ICNND (1963). Evaluation of growth status consisted of a comparison on the child's achievements in height and weight for his age and sex to standards. Eight categories were generated for both height and weight by the standards established by Stuart and Meredith (Lowrey, 1973, p. 79-80) first category included those subjects falling below the third percentile for height or weight, the second category consisted of the 25 subjects ranging from the third to the tenth percentiles for height or weight and so on. The frequency and per- centage of subjects falling into each of the categories were analyzed. Standards resulting from the research of RObson (in press) enabled the division of the sample into four categories for height and four for weight. Research conducted by Garn (1973) on stature of low income children of different ethnic backgrounds provided arithmetic means from which were computed deviations for this study sample. In addition to the evaluation for height and weight in regards to age, racial differences were assessed. The prOportion of the sample in each category was observed for Black and non-Black children. Analysis of nutrition attitude resulted in a score reflecting a continuum for laissez—faire to planning. The response indicating the most extensive planning was given a value of four, the response indicating the next most extensive planning was given a value of three and so on for the remaining two reSponses. The sum was then divided by the number of questions to determine a score ranging from four to one indicating a homemaker who favored careful control of nutrient intake and meal planning (four) to one who took for granted that her family would be getting suf— ficient nutrients from the foods they ate (one). 26 Nutrition knowledge was analyzed in a similar manner. The most appropriate response, determined by a group of professional nutritionists and graduate students, was given a value of four. Decreasing values were given to decreas- ingly apprOpriate responses. A correlation matrix was devised from all possible combinations of the following variables: height and weight mean height, urinary thiamin excretion, urinary riboflavin excretion, homemaker's attitude towards food and nutrition homemaker's nutrition knowledge, twenty-four food recall of the homemaker, family income and age and educational level of the homemaker. A scattergram was constructed from height and weight scores of the child and the mother's food recall score. Analyses were run on the Control Data Corporation (CDC) 6500 model computer. Multianalysis of variance (Schiefley and Schmidt, 1973) was used to test the rela- tionship between growth status and race: correlation testing was used on the relationship between growth status and the other parameters investigated. CHAPTER IV RESULTS Demographic Data Urban dwellers comprised 81.5 percent of the sample in this study. Homemakers classified as rural-non-farm dwellers were 18.5 percent of the population. Ethnic distribution consisted of 54.6 percent. White homemakers, 32.4 percent. Black homemakers and 12.0 percent Spanish American. TABLE 1 PLACE OF DWELLING.AND ETHNIC BACKGROUND OF PROJECT HOMEMAKERS (N=108) Place of Dwelling Percent of Homemakers Urban 81.5 Rural-Non-Farm 18.5 Ethnic Background Percent of Homemakers White 54.6 Black 32.4 Spanish American 12.0 27 28 Families ranged in size from two to sixteen members. The mean family size was 4.7 persons with a standard deviation of 1.9 persons. The monthly income for project families ranged from $20 to $990 with a mean Of $370 and a standard deviation of $144. The average homemaker was 27.4 years of age and had completed 10.2 years of school. TABLE 2 FAMILY SIZE, MONTHLY INCOME, HOMEMAKER AGE AND EDUCATIONAL LEVEL (N=108) Mean S.D. Range Family Size 4.7 1.9 2-16 Monthly Income 370.4 144.2 20-990 Homemaker Age 27.4 6.4 18-59 Homemaker Education 10.2 2.7 0-Be ond High Sc ool Food Recall Scores, Nutrition Attitude, Nutrition Knowledge and Nutrient Excretion Levels Adequacy of food intake was measured by the homemaker's 24 hour food recall. A detailed eXplanation of the scoring system is found in Chapter III. The mean food recall score was 9J1food items, out of a possible score of 16 food items. Of the Four Food Groups, homemakers met, on the average, 1.3 food groups each day. The average homemaker consumed 29 2.0 servings each day from the meat group, 2.7 servings from the breads and cereals group, 1.7 servings of fruits and vegetables and 1.0 servings of milk. TABLE 3 FOOD RECALL SCORE, NUMBER OF FOOD GROUPS MET, NUMBER OF SERVINGS MET IN FOOD GROUPS (N=108) Mean S.D. Range Food Recall Score 9.1 3.2 2.0—16.0 Number of Food Groups Met 1.3 1.1 0.0-4.0 Number of Servings Met in Food Groups Meat 2.0 1.0 0.0-2.0 Breads/Cereals 2.7 1.7 0.0-4.0 Fruits/Vegetables 1.7 1.3 0.0-4.0 Milk 1.0 1.1 0.0-2.0 Nutrient excretion levels were classified according to ICNND standards (1963). A mean score for thiamin excre— tion and standard deviation were 3.8 and 0.5. Riboflavin excretion averaged 2.9 i .8. l: j 1": l 30 TABLE 4 NUTRIENT EXCRETION LEVEL, NUTRITION ATTITUDE SCORE AND NUTRITION KNOWLEDGE SCORE (N=108) Mean S.D. Range Nutrient Excretion Level Thiamin 3.8 0.5 1.0-4.0 Riboflavin 2.9 0.8 1.0—4.0 Nutrition Attitude Score 3.2 0.4 1.0-4.0 Nutrition Knowledge Score 2.8 0.4 1.0-4.0 The homemaker's attitude toward food and nutrition, reflected in a score ranging from one, laissez-faire, to four, planning, averaged 3.2 t0.4. Nutrition knowledge possessed by the homemaker, also expressed on the basis of four appropriate responses indicating incorrect to correct knowledge averaged 2.8:t0.4. Height and Weight Data Data from height and weight measurements made on 149 preschool children were compared to standards established by Stuart and Meredith (Lowrey, 1973) and also to standards resulting from research on stature (RObson, in press). Means for stature resulting from research by Garn (1973) were utilized to assess growth status. 31 Stuart and Meredith (Lowrey, 1973) data were divided into eight categories for both height and weight. The mean height category attained by the preschool children in this study was 3.2; the mean weight category: 3.7. Height and weight means both had standard deviations of 1.8. TABLE 5 PERCENTAGES OF SUBJECTS IN DIFFERENT HEIGHT AND WEIGHT CATEGORIES ACCORDING TO STUART AND MEREDITH STANDARDS (N=149) Height Weight Percentile Category N % N % <3 1 37 12.8 19 12.8 3-10 2 17 11.4 23 15.4 11-25 3 32 21.5 30 20.1 26-50 4 28 18.8 30 20.1 51-75 5 19 12.8 20 13.4 76—90 6 8 5.4 15 10.0 91—97 7 4 2.7 8 5.4 >97 8 4 2.7 4 2.7 Mean Category 3.2 3.7 S.D. 1.8 1.8 Four categories resulted from research by Robson (in press). According to Robson's standards the preschool children attained a mean height category of 2.5 (S.D. = 0.6) while mean weight category was 2.4 (S.D. = 0.6). 32 TABLE 6 PERCENTAGES OF SUBJECTS IN DIFFERENT HEIGHT AND WEIGHT CATEGORIES ACCORDING TO ROBSON STANDARDS (N=121) Height Weight Percentile Category N %. N ‘% <3 1 2 1.7 2 1.7 3-50 2 60 50.0 73 60.3 51-97 3 52 43.0 42 34 7 >97 4 7 5.8 4 3 3 Mean Category 2.5 2.4 S.D. 0.6 0.6 The data were analyzed for racial differences in growth status. According to Stuart and Meredith (Lowrey, 1973) the mean height category for Black children was 3.9 i 2.0 while the value of this parameter for non-Black children was 2.9 i 1.7. Chi square testing showed that Ho may be rejected at the .025 level of confidence. 33 TABLE 7 PERCENTAGES OF CHILDREN, BLACK AND NON-BLACK, IN DIFFERENT HEIGHT CATEGORIES ACCORDING TO STUART AND MEREDITH STANDARDS (N=149) Black Non-Black (N=47) ' (N=102) Percentile Category N % N % . <3 1 6 12.8 31 30.4 3-10 2 3 6.4 14 13.7 11-25 3 13 27.7 19 18.6 26-50 4 9 19.2 19 18.6 51-75 5 8 17.0 11 10.8 76-90 6 2 4.3 6 5.9 91-97 7 2 4.3 2 2.0 >97 8 4 8.5 0 0.0 Mean Category 3.9 2.9 S.D. 2.0 1.7 Chi Square 17.2 degrees of freedom = 7 p=.025 Weight data indicate mean categories of 4.3 i 2.0 and 3.4 i 1.2 for Blacks and non-Blacks, respectively. The null hypothesis may be rejected for weight also (p=0.025). 34 TABLE 8 PERCENTAGES OF CHILDREN, BLACK AND NON-BLACK, IN DIFFERENT WEIGHT CATEGORIES ACCORDING TO STUART AND MEREDITH STANDARDS (N=149) Black Non-Black (N=47) y(N=102) Percentile Category N % N '% <3 1 6 12.8 13 12.8 3-10 2 3 6.4 20 19.6 11-25 3 4 8.5 26 25.5 26-50 4 12 25.5 18 17.7 51-75 5 10 12.3 10 9.8 76-90 6 6 12.8 9 8.8 91-97 7 3 6.4 5 4.9 >97 8 3 6.4 l 1.0 Mean Category 4.3 3.4 S.D. 2.0 1.7 Chi Square 16.5 degrees of freedom = 7 p=.025 Analysis of growth data according to standards sup- plied by Robson (in press) showed similar trends. Mean height categories were 2.7 i 0.6 and 2.4 i 0.7 for Black and non-Black children, respectively. (HO rejected at .05 level of confidence.) 35 TABLE 9 PERCENTAGES OF CHILDREN, BLACK AND NON-BLACK, IN DIFFERENT HEIGHT CATEGORIES ACCORDING TO ROBSON STANDARDS (N=121) Black Non-Black (N=39) (N=82) Percentile Category N %. N % <3 1 0 0.0 2 2.4 3-50 2 13 33.3 47 57.3 51-97 3 24 61.5 28 34.2 >97 4 2 5.1 5 6 1 Mean Category 2.7 2.4 S.D. 0.6 0.7 Chi Square 10.2 degrees of freedom = 3 p=.025 Weight means were 2.6 i 0.6 and 2.3 i 0.5 for Black and non-Black preschool children, respectively. The null hypothesis for weight can be rejected at the .025 level of confidence. 36 TABLE 10 PERCENTAGES OF CHILDREN, BLACK AND NON-BLACK, IN DIFFERENT WEIGHT CATEGORIES ACCORDING TO ROBSON STANDARDS (N=121) Black Non—Black (N=39) (N=82) Percentile Category N’ % N '% <3 1 0 0.0 2 2.4 3-50 2 17 43.6 56 68.3 51-97 3 19 48.7 23 28.1 >97 4 3 7.7 1 1 2 Mean Category 2.6 2.3 S.D. 0.6 0.5 Chi Square 10.2 degrees of freedom = 3 p=.025 An investigation of the proportion of subjects in each category was carried out to determine at exactly which percentiles racial differences in growth were signifi- cant. Expected and observed values for each category for height and weight were compared. A significant racial difference in height was Observed in the first category only when comparisons were made according to Stuart and Meredith standards (Lowrey, 1973). 37 TABLE 11 INVESTIGATION OF PROPORTION OF SUBJECTS IN HEIGHT CATEGORIES ACCORDING TO STUART AND MEREDITH STANDARDS (N=149) Black Non—Black (N=47) (N=102) Percen- Cate- Ex- Ob- Ex- Ob- Signifi- tile gory pected served pected served cance <3 1 11.7 6 25.3 31 .025 3-10 2 5.4 3 11.6 14 0 11-25 3 10.1 13 21.9 19 0 26-50 4 8.8 9 19.2 19 0 51-75 5 6.0 8 13.0 11 8 76-90 6 2.5 2 5.5 6 B 91-97 7 1.3 2 2.7 2 0 > 97 8 1.3 4 2.7 0 fl Significant weight differences between Black and non- Black preschool children were seen in the second and third categories. 38 TABLE 12 INVESTIGATION OF PROPORTION OF SUBJECTS IN WEIGHT CATEGORIES ACCORDING TO STUART AND MEREDITH STANDARDS (N=149) Black Non-Black (N=47) (N=102) Percen- Cate- Ex- Ob- Ex- Ob- Signifi- tile gory pected served pected served cance (3 l 6.0 6 13.0 13 0 3-10 2 7.3 3 15.7 20 .025 11-25 3 9.5 4 20.5 26 .025 26-50 4 9.5 12 20.5 18 0 51-75 5 6.3 10 13.7 10 2 76-90 6 4.7 6 10.3 9 8 91-97 7 2.5 3 5.5 5 fl >97 8 1.3 3 2.7 1 fl Analysis of height data according to Robson's stand- ards (in press) revealed a significant difference between expected and Observed values in the second and third cate- gories for height. 39 TABLE 13 INVESTIGATION OF PROPORTION OF SUBJECTS IN HEIGHT CATEGORIES ACCORDING TO ROBSON STANDARDS (N=121) Black Non-Black (N=39) (N=82) Percen- Cate- Ex- Ob- Ex- Ob- Signifi- tile gory pected served pected served cance <3 1 .6 0 1.4 2 G 3-50 2 19.3 13 40.7 47 .05 51-97 3 16 8 24 35.2 28 .05 > 97 4 2 4 2 4.7 5 fl Weight data was significantly different between blacks and non-Blacks in the second category only. TABLE 14 INVESTIGATION OF PROPORTION OF SUBJECTS IN WEIGHT CATEGORIES ACCORDING TO ROBSON STANDARDS (N=121) Black Non-Black (N=39) (N=82) Percen- Cate- Ex- Ob- Ex- Ob- Signifi- tile gory pected served pected served cance <3 1 .6 0 1.4 2 0 3-50 2 23.6 17 49.5 56 .025 51-97 3 13.5 19 28.5 23 0 >97 4 1.3 3 2.7 l 0 40 Garn (1973) computed means for stature with reference to age and race from children in the Ten State Nutrition Survey (1972). These means were used to evaluate racial differences in the growth status of the preschool children in this study. A grand mean of zero was formed from Garn's means. The height mean for Black children in this study was greater than the grand mean by 0.8 t 1.9 cm. The dif- ference between the grand mean and the mean for non-Black children was 0.3 i 1.7 cm. Analysis of variance testing of these two values revealed a significant racial differ- ence in stature (p20.003) . Relationships were observed among various parameters in the correlation matrix. Heights and weights correlated at the 0.01 level. Positive correlations (p.50.01) were observed between the age of the homemaker and family in- come; between riboflavin and thiamin excretion: between the educational level of the homemaker, her nutrition attitude and nutrition knowledge; between her nutrition knowledge and food recall. Positive correlations at the .05 level were Observed for some growth status parameters: Home- makers age and height and weight according to Stuart and Meredith standards (Lowrey, 1973) and nutrition knowledge of the homemaker and weight according to Robson standards (in press) and height according to Stuart and Meredith standards (Lowrey, 41 1973). A scattergram constructed from the height and weight score of the child and the mother's food recall score revealed no consistent pattern. Height Category Weight Category I—‘Nw-PU'IOAQCD FIGURE 1 FOOD RECALL SCORE OF HOMEMAKER - HEIGHT CATEGORY OF CHILD .- ’3}: :0: z... 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