Growth pattern of primary schoolchildren in Benghazi, Libya 45 ABSTRACT. Objective : To fi nd the growth trends in a sample of schoolchildren in Benghazi (Libya), and to compare it with interna- tional and other local growth charts, as a step for setting the national curves. Method: From 25th February to 31st October 1993, a sample of 2,022 pupils (1,160 boys and 862 girls) were randomly selected from three public primary schools in three different socio-economic areas in Benghazi. A questionnaire consisting of social and scholastic items was distributed to teachers a few days before the examina- tion. The height and weight of all the pupils were measured according to the standards of Jellife, Gorstein, WHO, and de Onis. Data were analysed and compared with both the reference standard of the United States National Center for Health Statistics (NCHS-USA), and the local standards of Tripoli-1986. Results : The boys and girls in the lowest age-group had a pattern similar to that of the reference popu- lation for both height/age and weight/age, but it dropped sharply from mid-school years. The Benghazi curves were consistently higher than those of Tripoli, particularly for height/age. Conclusion: The nutritional status of these children, which was good before the begin- ning of schooling, was negatively affected during the school years. This could be attributed either to births in the family and consequent neglect, or to the school’s negative effects on the child, such as lack of appetite created by anxiety or other factors. Further studies from dif ferent regions of the country are needed to set national growth curves. Key Words : anthtropometric measurements, child, growth, nutrition, Benghazi, Libya, NCHS-USA. I t h as been long r ecognized that environ mental infl uences – especially nutrition and socio-economic status – are more important than genetics in determin- ing the somatic growth of children, particularly during the early childhood when growth is rapid.1 This is supported by recent community-based researches on child growth in UK,8 Hong Kong,9 Argentina,10 USA11–14 and other countries.15 Therefore, the growth pattern of children is a good indicator of their nutritional status, health and socio- economic level. Nutritional anthropometric measurements are useful for measuring such growth patterns. Their simplicity belies their ability to refl ect the pattern of physical growth and development of a population.16,17 In spite of the tediousness in the preparation of growth charts,1,18 it is advisable to have local charts developed in the community itself, as the charts pertaining to the well-nourished children in deve- loped countries may not be quite valid in developing ones.1,3 Charts developed using local data are valuable not only for assessing the current nutritional status but also for detect- ing future changes, such as improved nutritional awareness, better health status by implementation of health education programmes, prevention and effective treatment of diseases, vaccination programmes etc., or a downslide, as in famine, epidemics or war. Ideally both cross-sectional and longitudinal serial squ journal for scientific research: medical sciences 2001, 1, 45–49 ©sultan qaboos university Growth pattern of primary schoolchildren in Benghazi, Libya *Mar wan M. Al-Sharbati1, Ameer A. Younan2, Omar H. Sudani3 1Department of Behavioural Medicine College of Medicine, Sultan Qaboos University P.O. Box 35, Al-Khod 123, Muscat, Sultanate of Oman. 2Department of Nutrition, College of Public Health Al-Arab Medical University, Benghazi, Libya. 3Dean, College of Public Health, Al-Arab Medical University, Benghazi, Libya. *To whom correspondence should be addressed. E-mail: marwan@squ.edu.om a l - s h a r b a t i e t a l46 measurements are needed for growth assessment of chil- dren, However, only cross-sectional measurements were practical for this study, as they were quickly obtained, gave information on the prevailing state of nutrition, and did achieve the general objectives.1,3 Although many countries have charted their growth reference standards,19–22 in Libya, such studies were few. Prior to us, only two studies had been performed: (1) in 1979 in Benghazi on preschoolers,23,24 and (2) in 1986 in Tripoli on schoolchildren.7 Lack of growth data for children in Benghazi, an important port city in north- eastern Libya and the second biggest city in Libya after Tripoli, obliged us to conduct this study. The study aimed to prepare local growth curves (weight/age and height/age) for a representative sample of Benghazi schoolchildren, till a countrywide study could be performed for a larger, repre- sentative sample of both urban and rural pupils, to set the national curves. M E T H O D This cross-sectional study was conducted between 25th Feb- ruary and 31st October 1993 by taking physical measure- ments of 2,022 pupils (1,160 boys and 862 girls) aged 6–12 years, living in Benghazi. Public primary schools in three areas of the city of different socio-economic levels: Al- Fwehat Al-Sharqiya (high class area), Al-Slawi (middle class area) and Al-Mheshi (lower class area)25 were listed, and one school was randomly selected from each area: School-H from the high class area, School-M from the middle class area, and School-L from the lower class area. We excluded private schools because their children comprised a small fraction of the total population of school- children, and because of the possibility that their inclusion in the sample might create bias. All the pupils were examined in the School-H and School-M, but systematic sampling was done in School-L due to the large number of classes there. Using this method we examined 3–4 classes in every grade, in every school. p r o c e d u r e The internists who worked under our supervision were fully instructed about the aim and the procedure of the research, and were frequently changed to prevent possible bias.3 The administrations of the schools, teachers and the children were also clearly informed about the nature and objectives of the research. We distributed a questionnaire (which sought infor- mation social variables related to each child, such as the date of birth, parents’ education level and occupation, family size, etc.) to teachers a few days before the physical exami- nation of the children. In most cases the schools were able to obtain this information from the pupils’ fi les; wherever such information was lacking it was obtained from the child’s parents by sending a slip of paper with the child, to be returned the next day. m e a s u r e m e n t s For each child we measured height to the nearest 0.1cm, and weight to the last 100 g. For measuring height, we fi xed a calibrated ruler to the wall. As the child stood barefoot with his/her heel, back and head touching the wall with the head in the Frankfurt plane, a thin wooden plate was placed above the head perpendicular to the ruler and paral- lel to the ground to measure the height accurately. Weight was measured using a portable weighing machine3 that was standardized regularly, the child being barefoot and wear- ing light clothes. All the anthropometric measurements were carried out as stipulated by Jellife et al,1 Gorstein et al,2 W HO 3,4 and de Onis et al.5 The data were analysed statistically using Harvard Graphics statistical package. The results were compared with the reference NCHS-USA standards and with the local standards of Tripoli (1986).6,7 R E S U L T S Table 1 shows the composition of the sample according to age, sex and school. A total of 2,022 pupils (1,160 boys and 862 girls) were examined, among whom 855 pupils were from School-H (473 boys and 382 girls), 524 pupils from School-M (281 boys and 243 girls), and 643 pupils from School-M (406 boys and 237 girls). Figure 1 shows the Benghazi boys’ height percentiles compared with the boys’ medians of height (of the same age) for both the reference population of NCHS-USA standards,6 and the standards of Tripoli.7 The median of height for Benghazi boys starts off at the same level as the reference median during the younger ages. However, by the age of nine, differences start to appear, when the Beng- hazi median starts defl ecting downward. Indeed, at the age of 12, the reference median curve approaches the 75th percentile curve of Benghazi. However, median height of Benghazi boys remains consistently higher than the Tripoli median throughout the school years. In fact, the latter reaches only the 25th percentile of Benghazi boys’ height. Figure 2 shows the weight/age of Benghazi boys com- pared with the NCHS-USA reference and the Tripoli curves. Here the median weight for Benghazi boys, which, at the age of 6 years remains just below but very close to the reference median, starts declining by the age of 9 and by the end of school age the reference median approaches the 75th percentile. As for Tripoli median, it remains slightly lower than the Benghazi median throughout. Girls’ height percentiles are plotted with the median g r o w t h pa t t e r n o f s c h o o l c h i l d r e n 47 height of both NCHS -USA reference and Tripoli medians in Figure 3. Here also, the difference between Benghazi girls’ median height and reference population is minimal during the early years of the school, but it starts to appear at the age of eight years, and the curve goes down sharply at the age of 11. The reference median height actually crosses the 75th percentile of that of Benghazi girls at the highest age. Tripoli median for girls’ height remains lower than that of Benghazi, and it corresponds to the 25th percentile during the school years. Weight/age for Benghazi girls is shown in Figure 4, compared with the medians of both the reference popula- tion and Tripoli girls of comparable age. Here also Benghazi girls’ median weight simulates that of the reference median of NCHS-USA at the age of six years, but deviates down in mid-school age. The Tripoli girls’ median weight, how- ever, is similar with that of Benghazi at the beginning of the school age, but dips down between the ages of 8–11 years, to again rise to the level of Benghazi at 12 years. D I S C U S S I O N This study demonstrates that the growth pattern (height/ age and weight/age) of the public primary schoolchildren aged six to twelve years in Benghazi in the year 1993 was similar to the international standards at early school years for both sexes (which is different from other studies)21,22 but it dropped down with the advance of the age, (which is in accordance with other studies).7,26,27 The picture is clear enough for boys, where the relative decline started from the age of nine, while in girls it began at the age of eight or even earlier. The minimal differences in height and weight between Benghazi schoolchildren and the reference popula- tion at the start of the school indicates the satisfactory nutri- tional status of the former at preschool age. That state of good nutrition has been possibly affected negatively at mid- school period, possibly either by reduced attention from mother as it diverted toward newborns or younger chil- dren in the family, or by the pressures of school life affect- ing health and nutrition. We must also keep in mind the here ditary and environmental factors that affect the growth spurt in both sexes. This may be responsible for the big dif- ference between Benghazi children and the reference popu- lation at mid-school age; the Americans possibly started their adolescent growth spurt earlier than the Libyans. The higher curves of growth seen in our group com- pared to that of Tripoli for both boys and girls, specially for height, indicates better nutritional status in the fi rst few years of schooling in Benghazi than in Tripoli, as it is well known that the height is a good indicator of nutrition in the past.17 The difference in weight curves in favour of Beng- hazi, although less marked than the height, perhaps indi- cates improved nutrition in 1993 compared to 1986, when Table 1. The composition of the sample of school children examined for growth pattern according to age and sex, Benghazi (1993) School-H (High class neighbourhood) School-M (Middle class neighbourhood) School-L (Lower class neighbourhood) Grand Total Age (y) Boys Girls Total Boys Girls Total Boys Girls Total Boys Girls Total 6 74 55 129 45 23 68 50 36 86 169 114 283 7 83 56 139 26 39 65 58 53 111 167 148 315 8 69 68 137 47 29 76 58 39 97 174 136 310 9 89 56 145 39 42 81 76 35 111 204 133 337 10 63 70 133 36 36 72 47 13 60 146 119 265 11 69 66 135 42 50 92 57 19 76 168 135 303 12 17 6 23 23 19 42 36 25 61 76 50 126 13 5 5 10 16 3 19 15 11 26 36 19 55 14+ 4 4 7 2 9 9 6 15 20 8 28 Total 473 382 855 281 243 524 406 237 643 1160 862 2022* *2088 questionnaire sheets were distributed; however, 66 pupils were absent during the physical examination. The age-groups 13 and 14+ are not considered in the charts because their numbers were very small. a l - s h a r b a t i e t a l48 the Tripoli curves were drawn. The improvement of the socio-economic status, earlier diagnosis and treatment of diseases, and better awareness of people regarding nutrition probably achieved this result. This emphasises the impor- tance of reviewing and updating growth charts periodically, especially in developing countries to assess the effi cacy of national health programs.21,28,29 Though our study had limitations, the present charts Figure 3. Benghazi girls' height percentiles (cm) according to age, compared with NCHS-USA and Tripoli medians Figure 4. Benghazi girls' weight percentiles (kg) according to age, compared NCHS-USA and Tripoli medians 100 110 120 130 140 150 160 6 7 8 9 10 11 12 Age (years) He ig ht (c m ) Bengh 25th Bengh 50th Bengh 75th US 50th Tripoli 50th 15 25 35 45 6 7 8 9 10 11 12 Age (years) W eig ht (k g) Bengh 25th Bengh 50th Bengh 75th US 50th Tripoli 50th Figure 1. Benghazi boys' height percentiles (cm) according to age, compared with NCHS-USA and Tripoli medians Figure 2. Benghazi boys' weight percentiles (kg) according to age, compared NCHS-USA and Tripoli medians 100 110 120 130 140 150 160 6 7 8 9 10 11 12 Age (years) He ig ht (c m ) Bengh 25th Bengh 50th Bengh 75th US 50th Tripoli 50th 15 25 35 45 6 7 8 9 10 11 12 Age (years) W eig ht (k g) Bengh 25th Bengh 50th Bengh 75th US 50th Tripoli 50th g r o w t h pa t t e r n o f s c h o o l c h i l d r e n 49 are more suited for local use, instead of foreign ones. How- ever, further studies on larger samples representing school- children of the whole country (urban and rural) are needed on a nation-wide level, to set up the fi nal national Libyan growth charts. C O N C L U S I O N This study has shown that Benghazi public primary school- children had more or less a similar pattern of growth with the reference population at the start of the school, but it dropped below that during the school years. On the other hand, Benghazi children’s growth pattern is higher than that of Tripoli children as measured in 1986, especially the height curves, which is probably an indication of better nutritional status of school-children of Benghazi in their preschool period compared to the Tripoli schoolchildren. a c k n ow l e d g e m e n t We are grateful to the Ministry of Education, Government of Libya for permitting us to do this research. 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