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Clinical applications of physical anthropology.

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Clinical Applications of Physical Anthropology
Department of Pediatrics, Wright State University School of Medicine and the
Children’s Medical Center, Dayton, Ohio 45404
fitness, Sports
Anthropometry, Growth, Nutrition, Dysmorphology, Physical
In recent decades physical anthropology has moved from its more
traditional confines into many areas of clinical interest including growth and
development, nutrition, clinical medicine, dysmorphology, and physical fitness.
The “clinical applications” of physical anthropology is a broad topic, given the
space limitations of a review. Hence, selected clinical applications, emphasizing
anthropometry at the expense of physiology and genetics, are considered. Since
the author is a pediatrician, the review concentrates largely on areas dealing
with children.
In the nineteenth century, physical anthropologists were largely limited to a few
measuring tools: anthropometer, weighing scales, calipers and measuring tapes, and
were handicapped by somewhat primitive statistics. Modern workers have enlarged
their inventory of measuring tools, improved their methodology, and greatly refined
the statistical treatment of data.
Earlier physical anthropologists concentrated on a rather limited group of study
areas: (1)the dimensions of the human body and their variation with age, sex and race,
and, to a lesser extent, with occupation and social class; (2) prehistory and human
evolution; (3) taxonomy of human races; and (4) the relationship between cranial dimensions and intelligence.
Contemporary physical anthropologists continue to study the first two topics. In the
third area, emphasis has changed from “racial” to “ethnic” differences. Racial taxonomies by anthropometric criteria have proved futile. “It is difficult to define races and
the usefulness of this concept, at least as applied to man, is doubtful” (Carmelli and
Cavalli-Sfoma, 1979, p. 41). Genetic affinities between populations are better expressed
in terms of blood group and plasma protein polymorphisms. Interest in the fourth area
waned after Pearson (1906) showed the extremely low correlations between head size
and intelligence, though occasional studies in this area continue to surface (Susanne,
Perhaps a major change in recent decades has been the impressive growth in the
application of physical anthropology to clinical problems. For purposes of this review,
the following areas of clinical application have been selected: (1) growth and development; (2) nutrition and public health; (3) clinical medicine; (4) dysmorphology; and
(5) physical fitness and sports.
The late 1920s saw a rather sudden burst of interest in the causes of individual
differences, both mental and physical. It was hoped that long-term studies of children
0096-848X/82/2501-0169$03.50cc) 1982 Alan R. Liss, Inc.
[Vol. 25, 1982
would supply the elusive answers. Several “longitudinal” studies of the physical growth
and psychological development of normal, white, middle class children were initiated
almost simultaneously in the United States, followed somewhat later by similar programs abroad.
In most of these studies, assessment of skeletal maturation was added to classical
anthropometry, since it had long been known that development of ossification centers
and closure of epiphyses are better indicators of physiological maturity than stature
(Pryor, 1907; Rotch, 1909). Various methods of assessing skeletal maturity have been
devised (Sontag et al., 1939; Greulich and Pyle, 1959; Garn et al., 1964; Tanner et al.,
1975a; Roche et al., 1975). Validity, comparability and reproducibility of the various
methods continue under investigation (Roche et al., 1971; Johnson et al., 1973). The
subject is thoroughly covered in two recent reviews by Roche (1978, 1980a).
The size of the full-term newborn is largely determined by the prenatal environment
(Tanner et al., 1956; Olivier et al., 1978; Robson et al. 1981). It depends more on
maternal than paternal size (Wingerd and Schoen, 19741, as was long ago demonstrated
by the famous Shire horse-Shetland pony crosses of Walton and Hammond (1938).
In the first year of life, length and weight often cross percentile channels (Smith et
al., 1976) and by 3 years of age, the influence of prenatal environment has largely
waned. Thereafter, the genotype of the child becomes dominant, and the effect of paternal stature equals that of maternal stature. From then until puberty, children’s
percentile ranks remain remarkably constant; growth is “channeled.” Even extended
periods of malnutrition or disease result in only temporary declines of growth rates.
Once the cause of the growth failure is removed, accelerated or “catch-up” growth
(Prader et al., 1963; Tanner, 1981)puts the child back into its pre-illness channel. Even
catch-up growth of the brain seems possible, a t least in infancy (Marks et al., 1978;
Roche, 1980b).After 10 to 12 years of age, catch-up growth is less predictable and often
incomplete. Protein-calorie malnutrition (and probably other disorders) have a stronger
inhibiting effect on stature than on skeletal maturation (Martorell et al., 1979). Catchup growth after renal transplantation has been extensively studied (Potter et al., 1970;
Grushkin and Fine, 1973; Saenger et al., 1974; Hoda et al., 1975; Chesney et al., 1978).
However, interpretation of available data is difficult since most patients required longterm corticosteroid therapy to prevent transplant rejection. Alternate-day steroid therapy seems to permit better catch-up growth.
The channeling of growth allows prediction of adult stature from age, current stature,
and skeletal maturity (Bayley and Pinneau, 1952). Prediction has been somewhat
refined by accounting for midparental stature (Tanner et al., 1970, 1975b; Roche et al.,
1975). Prediction methods have recently been reviewed by Roche (1980~).
Interest in the accurate prediction of adult stature heightened when it was shown
that the acceleration of puberty by estrogen therapy would limit the growth of excessively tall girls (Whitelaw et al., 1965; Roche and Wettenhall, 1969). Testosterone
therapy has a comparable effect upon the stature of boys (Zachman et al., 1976). Fear
of late side effects has made most United States physicians hesitant to use estrogen
therapy for tall girls (Conference on Estrogen Treatment, 1978), though long-term
studies of treated women by Wettenhall et al. (1975) fail to show disturbances of the
menstrual cycle or impairment of fertility.
The availability of stature prediction has been very helpful to the practicing pediatrician. The ability to predict, within relatively narrow limits, the onset of puberty and
adult stature has reassured countless short children with constitutional delay of maturation (Gallagher, 1975) and has undoubtedly prevented a good deal of inappropriate
endocrine therapy.
It should be emphasized that methods for predicting adult stature should not be
applied to children with skeletal dysplasias, other dwarfing syndromes, or chromosomal
aberrations. Each of these disorders has its own growth and skeletal maturation pattern.
Growth curves for several skeletal dysplasias have recently been published by Horton
et al. (1978,19811,while those for children with the Russel-Silver syndrome have been
reported by Tanner et al. (1975~).Patterns of growth and maturation in Down’s syndrome have been evaluated by Roche (1964, 1965); Rarick and Seefeldt (1974); Cronk
(1978) and others, while Brook et al. (1974) have published growth curves for the XO
(Turner) syndrome.
The growth of the fetus has become an area of considerable clinical importance (see
also the section “Clinical Medicine”). Fetal measurement and the growth of low-birthweight infants have recently been reviewed by Southgate (1978) and Brandt (1978).
The standards of fetal length, weight, and head circumference by Lubchenco et al.
(1963, 1966) are used in most hospital nurseries to decide whether infants are small
for gestational age (intrauterine growth retardation), average, or large for gestational
age (e.g., infants of diabetic mothers). Proper classification has an important bearing
on management and prognosis. The Lubchenco data were derived from a racially mixed
neonatal population in Denver, Colorado (altitude 1600 m). Subsequent reference data
and growth charts (Usher and McLean, 1969; Babson et al., 1970; Babson and Benda,
1976)are more representative for the majority of United States and Canadian neonates.
However, they have not been widely used in clinical pediatrics. Usher and McLean
(1969) have also offered reference data for several additional fetal measurements. Norms
for some other dimensions of premature and term neonates have had to be developed
for various aspects of therapy, such as placement of gastric and duodenal feeding tubes
and insertion of umbilical artery catheters (Dunn, 1966; Rosenfeld et al., 1980). The
measurement of short-term neonatal growth in length has been facilitated by use of
the Holtain neonatometer (Davies and Holding, 1972).
On a world-wide basis, malnutrition is the most prevalent health problem of children.
Keppel(1968) estimated that 70% of all children under 6 years of age suffer from some
degree of protein-calorie malnutrition. In the third world, malnutrition is also a common problem of childbearing women, especially the multiparous (Jelliffe, 1966). Malnourished women are also a t a substantially higher risk of producing low birthweight
infants, and these low birthweights are due mainly to prematurity with its attending
hazards (Falkner, 1981).
Anthropometry is a rapid, inexpensive, noninvasive and sensitive method of assessing
and monitoring the nutritional status of child populations (Jelliffe, 1966; Waterlow,
1972; Waterlow et al., 1977; Nichaman and Lane, 1979; Gebr6-Medhin, 1979), while
chemical tests on blood or urine are more useful for detecting deficiencies of specific
nutrients (iron, zinc, vitamins, etc.) than for assessing general health and overall
nutritional status. Ideally, growth norms for children should be derived from a socioeconomically elite group of comparable genetic background (Garn, 1965; Walker and
Richardson, 1973; Neuman, 1979). Such height and weight reference data have been
developed for many populations, and comparisons have confirmed the existence of some
racial differences in stature and body proportions (Greulich, 1957;Malina, 1969; Robson
et al., 1975; Garn and Clark, 1976b; Eveleth and Tanner, 1976). Nevertheless, studies
have also shown that the growth curves of well nourished infants and preschool children
of different racial backgrounds are remarkably similar, so that reference growth data
for United States children have not been as inappropriate for other populations as was
once thought (Guzman, 1968; Habicht et al., 1974). Similarly, differences in mean
menarcheal ages seem to reflect nutritional status more than genetic constitution (Frisch
and Revelle, 1971; Tanner, 1973; Eveleth and Tanner, 1976). Nutrition also seems, to
a large extent, to be responsible for “racial” differences in adult stature. This has been
amply demonstrated by the secular increases of stature in populations that were once
disadvantaged (Greulich, 1957; Meredith, 1976; Malina, 1979; Roche, 1979; Higman,
1979). The reverse has also been observed, i.e., socioeconomicallyadvantaged groups,
such as Harvard and Wellesley college freshmen, have shown no significant increase
of stature in recent decades (Bawkin and McLaughlin, 1964; Damon, 1974). Once populations have reached socioeconomicallyadvantaged status, true ‘%acial”(genetic) differences become apparent. Japanese in Japan and in California now seem to have
attained their genetic potential for stature (Eveleth, 1979).
In field studies of disadvantaged child populations, one needs simple anthropometric
dimensions and indices to determine the prevalence of malnutrition and to select chil-
(Vol. 25, 1982
dren who are in urgent need of intervention. Currently, the most popular indices of
malnutrition are percentage of mean body weight for age and percentage of mean body
weight for stature (Gomez et al., 1955; Jelliffe, 1966; Waterlow, 1972). A somewhat
better understanding of nutritional status may be gained by adding estimates of body
composition, especially of fat and muscle, which indicate calorie and protein reserves.
In field studies, fat is generally estimated from skinfold measurements. Age- and
sex-specific norms for triceps and subscapular skinfolds are available for several populations (Johnston et al., 1972,1974; Tanner and Whitehouse, 1975; Frisancho, 1981).
Skinfold measurements may be combined with certain circumference measurements
for estimates of relative body fatness (Behnke and Wilmore, 1974; Weltman and Katch,
1978). Correlations between skinfold measurements and the more precise laboratory
estimates of fatness (e.g., underwater weighing, total body water) have been reasonably
good (Forbes, 1964; Wilmore and Behnke, 1969; Frerichs et al., 1979; Boulton, 1981).
A relatively recent addition to the field of nutritional anthropometry is the midarm
circumference, a simple measure of muscle (i.e., protein) reserves (Jelliffe and Jelliffe,
1969; Shakir and Morley, 1974). Reference data have been published by Robinow and
Jelliffe (1969), Burgess and Burgess (19691, and Frisancho (1981). The insertion tape
(Zerfass, 1975) has contributed to measurement accuracy and reproducibility. Arm
circumference for stature as read from the “QUAC stick” (Arnhold, 19691, has been
recommended for the rapid detection of severe protein-calorie malnutrition, but Margo
(1977) has questioned the value of this index.
Correction of arm circumference for the thickness of the subcutaneous fat layer, as
measured by the biceps and triceps skin folds, provides an estimate of mid-arm muscle
mass (Jelliffe, 1966; Jelliffe and Jelliffe, 1969). Norms for this “arm muscle” circumference have been published by Frisancho (1981).
Malnutrition occurs not only in the third world. It is a common problem in hospital
patients of all ages and social strata, especially in those suffering from malabsorption,
extensive burns, or advanced cancer. This long neglected area has received more attention since the introduction of “hyperalimentation,” i.e., complete intravenous nutrition (Dudrick et al., 1968). Unfortunately, anthropometry is not as finely tuned a
tool for assessing the nutritional status of individuals or for monitoring short-term
changes of hospital patients (Collins et al., 1979) as for monitoring child populations.
Overnutrition, i.e. obesity is a problem primarily in the affluent world. While slim
figures remain fashionable in the upper social strata, obesity in children and adults
has become more prevalent in all the developed and in some underdeveloped countries
(Neuman, 1979).The roles of heredity and environment in the genesis of obesity remain
under investigation (Forbes, 1977; Garn and Clark, 1976a).The technique of measuring
fat cell (adipocyte) size and number in the living (Hirsch and Gallian, 1968; Hirsch,
1975) and monitoring their changes with age promise to be a major advance in understanding the development and persistence of obesity (Knittle, 1972; Knittle et al.,
1977).However, doubts about the validity of the technique and the conclusions based
on the technique have been voiced by Widdowson and Shaw (19731,Ashwell and Garrow
(1973), and others. Roche (1981) recently reviewed the adipocyte-number hypothesis
and concluded that i t was untenable.
Skeletal mineral is a n important component of the body. It accounts for about 10%
of lean body weight (Behnke and Wilmore, 1974). Anthropometric methods for estimating bone mineral in the living are of relatively recent origin. Current methodologies
are reviewed in a recent monograph edited by Cohn (1981). The contributing authors
cover the basic principles and clinical applications of radiogrammetry, densitometry,
photon absorptiometry, Compton scattering, computerized axial tomography, and neutron activation.
Much has been learned of changes in skeletal mineral with age. Body mineral increases with growth through childhood. During puberty, sex hormones cause a striking
endosteal and periosteal apposition of new bone in each sex. This gain is followed by
a gradual loss, beginning a t 35 to 50 years of age (Garn, 1970; Trotter and Hixon,
1974). Bone loss is generally more rapid in females than in males. The bone loss of
later years shows a great deal of individual variation, which is still poorly understood.
The new methods are capable of detecting changes in cortical and cancellous bone long
before they become visible in standard roentgenograms. In severe, generalized bone
loss, the mineral content of a single metacarpal or phalanx is highly correlated with
the mineral content of the entire skeleton, while in some other conditions bone loss is
more regional and assessment of a single bone may not be representative (Meema and
Meema, 1981). The newer methods of estimating skeletal mineral have been used to
study skeletal changes and monitor therapy in hyperparathyroidism, renal disease,
rickets, postmenopausal osteoporosis, osteogenesis irnperfecta, and so on.
Diagnostic radiology is one of the corner stones of modern medicine. Diagnostic
radiologists lean heavily on a great variety of skeletal and soft tissue dimensions, and
new standards continue to be developed in response to clinical needs. For that reason,
the work has been accomplished mainly by radiologists and clinicians rather than by
physical anthropologists. Most of the reference data are scattered through the radiologic
literature, but some have been collated in monographs (Lusted and Keats, 1967).
Computerized axial tomography (CAT) provides a new means of viewing the interior
of the body. Its introduction in 1972 has ushered in a new era for diagnostic medicine.
Ultrasonography has made equally spectacular strides in the past decade. The regions
once least accessible, i.e., the heart, brain and pregnant uterus, are now open to noninvasive visualization and measurement. Meanwhile, radiation exposure per study has
been substantially reduced (CAT) or completely eliminated (ultrasonography).
The diagnosis of acquired and congenital heart disease by ultrasonography has required the establishment of a great number of new norms for such dimensions as
thickness of ventricular walls, size of cardiac chambers, diameter of valve rings, aortic
and pulmonary artery roots, and so on (Feigenbaum, 1973; Epstein et al., 1975; Henry
et al., 1975; Goldberg et al., 1980). Ultrasonography also permits better timing and
more precise measurement of the functional capacity of the cardiac chambers.
Until recently, the brain could be visualized only by invasive and potentially dangerous methods, such as pneumoencephalography or cerebral angiography. Now it can
be seen in remarkable detail in CAT scans. In infants with open anterior fontanelles,
ultrasonography yields similar structural detail. In the study of neonates, ultrasonography has great advantages since the equipment is portable and relatively inexpensive. The procedure does not require sedation or anesthesia as does CAT scanning.
Ultrasound is thus particularly useful for repeated bedside studies.
Interpretation of the new brain images has required new sets of norms for intracerebral dimensions (Haber et al., 1980; Sauerbrei et al., 1981, Babcock and Han, 1981).
Comparisons of CAT %lices” with anatomical brain sections have been useful in identifying anatomic landmarks (Matsui and Hirano, 1979).
Recent studies by Galaburda et al. (1978) and Geschwind (1979) have greatly advanced our knowledge of cortical localization of various intellectual skills and have
demonstrated remarkable asymmetry of cortical organization. Functional localization
is a developmental process (Trevarthen, 1979). Unilateral cortical insults in infancy
permit a shift of some functions, e.g., speech, to the intact contralateral hemisphere.
Although newer techniques (Editorial, Lancet, 1979; Brownell et al., 1982) permit
visualization of regional cortical blood flow and metabolism during various motor,
perceptual and mental activities, clinical applications have been delayed by technical
problems, equipment cost, and, in the case of positron emission tomography (PET), the
limited availability of the short-lived positron-emitting isotopes.
Detailed study of the fetus and placenta is a completely new area, which has proved
to be of great clinical importance. The improvement of ultrasonic equipment in the
past five years (,,gray scale” and “real time” imaging) has greatly expanded its use in
prenatal diagnosis and has opened a new field for applied anthropometry. Ultrasonic
measurement of biparietal diameter (Campbell, 1968; Levi and Smets, 1971) and
crown-rump length (Campbell and Dewhurst, 1971) permit estimation of fetal age
within narrow limits, far more reliably than the time elapsed since the last menstrual
period. Knowledge of fetal age is particularly important if amniocentesis is to be per-
[Vol. 25, 1982
formed for the detection of genetic defects. The optimal time is 13 to 14 weeks after
conception. Ultrasonography also provides information on the dimensions of the placenta, another field for normative study (Hellman et al., 19701, and the location of the
placenta, which is important for the physician performing amniocentesis.
Clinical applications of fetal studies are many. Intrauterine growth retardation can
now be determined prenatally by estimating fetal weight from measurements of fetal
abdominal circumference (Campbell and Wilkins, 1975)or intrauterine volume (Gohari
et al., 1977). The ventricular system of the fetal brain is well visualized by ultrasonography (Headlock et al., 198l), and reference data for fetal ventricular dimensions
have been established (Denkhaus and Winsberg, 1979). Hydrocephalus is easily diagnosed prenatally. Finally, fetal age, as estimated from fetal dimensions, is important
for choosing the best time for the induction of labor or for caesarean section, if such
intervention is necessary. Current knowledge of prenatal growth and development, as
studied by ultrasound, is reviewed in a recent monograph (Hobbins, 1979).
Dysmorphology and teratology are relatively new disciplines that have been expanding rapidly during the past two decades (Warkany, 1971; Smith, 1976; Gorlin et
al., 1976). Various body dimensions and proportions, not commonly used in anthropometry or clinical medicine, have become important for the delineation of malformation syndromes and for therapeutic intervention, i.e., orthodontia, plastic, and craniofacial surgery. Age-specific reference data for several measurements, for example,
ear length and width, intercanthal and interpupillary distances, palpebral fissure width,
philtrum length, mouth width, and a number of facial proportions have been developed
(Cervenka, 1969; Feingold and Bossert, 1974; Jones et al., 1978; Farkas, 1979; Miller
et al., 1980; MBhes, 1981). However, more remains to be done in this vast, almost
uncharted area of dysmorphology, and joint exploration by clinicians and physical
anthropologists is indicated. New investigative techniques (e.g., Rabey, 1977) should
help to provide age-, sex-, and race-specific norms for many facial features. Factor
analysis should also prove useful in exploring the complex interrelationships.
Age- and sex-specificnorms for length of the major limb bones, their ratios to stature
(Maresh, 1970) and to each other (Robinow and Chumlea, 1982), and standards for
metacarpal and phalangeal lengths (Garnet al., 1972)have proved useful in delineating
disorders of disproportionate growth (skeletal dysplasias, etc.).
Physical fitness is determined by a combination of physiologic and anthropometric
parameters. In physiologic terms, fitness is “aerobic work capacity” or VOZ max, the
maximum oxygen uptake per minute. Values vary with sex, age, stature, and weight
(Astrand, 1960; Astrand and Rodahl, 1977). VOz max can be improved by training and,
since it is related to body weight, by reduction of body fat (Davies et al., 1972). The
reduced fitness of advancing years is, to some .extent, due to lack of exercise and to
changes in body composition (loss of lean body mass, gain of fat). It is thus partly
preventable and treatable (van HUSS,1979).
Aerobic capacity, its measurement and determinants, and the concept of trainability
during growth and adulthood have been comprehensively reviewed in the preceding
volume of the Yearbook by Bouchard et al. (1981).Of clinical significance is the concept
of “functional aerobic impairment,” the percentage difference between the measured
VOz max and that predicted from age, sex, and activity status (Bruce et al., 1973).
Physical anthropologists and human biologists have contributed significantly to several areas of sports medicine. Contributions range from the study of physique (e.g.,
Tanner, 1964; de Garay et al., 1974; Kunze et al., 1976), body composition (Novak et
al., 1976; Wilmore and Bergfeld, 19791, and physiological function and performance of
elite athletes (Shephard et al., 1974; Shephard, 1978; Houston and Green, 1976; Ward
et al., 1979). Growth and maturity characteristics of young athletes and the effects of
physical activity have been reviewed by Malina (1980, 1982).
The announcement of the demise of physical anthropology (Symposium “Physical
Anthropolgy Is Dead,” 1975) is premature. Applied physical anthropology is thriving
and its future looks bright. Physicians will probably continue to take the lead in
developing norms that are medically relevant and statistically not too complex. Physical
anthropologists will make their greatest contributions in solving problems involving
multiple variables and requiring more sophisticated statistical treatment, and in projects involving large populations and elaborate study designs.
Drs. R. M. Malina and A. F. Roche made many helpful suggestions which are gratefully acknowledged.
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