Context: In this article authors have opined on the debate of the pros and cons of shifting from World Health Organization child growth standards to a nationally compiled standard.
Background on Child Undernutrition in India
Child undernutrition is a significant and persistent issue in India, influenced by multiple determinants such as food intake, dietary diversity, health, sanitation, women’s status, and poverty. The primary anthropometric standards used to measure childhood undernutrition are height-for-age (stunting/chronic undernutrition) and weight-for-height (wasting/acute undernutrition).
Multicentre Growth Reference Study (MGRS)
The MGRS takes a prescriptive approach with the specific aim of setting growth ‘standards’ i.e. how children ought to grow, provided they have a healthy environment and not growth ‘references’ i.e. how children of the reference group grow.
World Health Organisation uses following indicators for the study
- Length/Height for age
- Weight for age
- Weight for length/Height
- Body Mass Index for Age
- Head circumference for Age
- Arm circumference for Age
- Subscapular skin fold for age
- Triceps skinfold for age
- Motor development milestones
- Weight velocity
- length velocity
- Head circumference velocity
Issues in using Multicentre Growth Reference Study as a base:
Data pool
- The sample for India in the MGRS was drawn from a set of privileged households living in South Delhi, of children who met all the eligibility criteria for the study, like having a ‘favourable’ growth environment, being breastfed and having non-smoking mothers etc.
- Indian researchers contest the idea with an argument that such pool set overestimates the undernutrition.
- However, such comparisons with other large datasets would only be valid if these could provide samples that meet all the criteria of a favourable environment for growth, as defined by the MGRS. For ex. even among children (six23 months) in households of the highest quintile in National Family Health Survey (NFHS)5 (201921), only 12.7% meet the requirements of a ‘minimum acceptable diet’ as defined by WHO. Secondly, While almost all mothers in the MGRS sample had completed more than 15 years of education (in 200001), 54.7% of women in NFHS5 had completed 12 or more years of schooling.
Genetic Growth Potential and Maternal Height
- Another issue lies in MGRS missing out to capture the difference in genetic growth potential of Indians vis-a-vis other countries along with lacking in capturing influence of maternal height on child growth.
- However, researchers contest these narrative by stating that a number of countries with similar or even poorer economic conditions, including those in the South Asian region, have shown higher improvements in stunting prevalence using the same WHOMGRS standards.
Implications of High Standards
- There is concern that high standards might lead to overfeeding children misclassified as undernourished, contributing to obesity. However, given dietary gaps and the quality of government nutrition programs, these concerns may be unfounded.
Way Ahead
- Multi-Sectoral Interventions and Development Goals
- Improving diets alone is not sufficient; interventions in sanitation, healthcare, childcare, and women’s empowerment are crucial for better nutritional outcomes. These interventions are tied to the country’s overall development and equitable resource distribution.
- Role of WHO Standards and National Growth Charts
- While it is understood that children grow uniquely, WHO standards are important for understanding population trends and making international comparisons. The Indian Council of Medical Research has considered revising growth references for India to reflect national trends accurately.
In conclusion, India faces challenges in accurately measuring child undernutrition due to multiple factors. While there is a debate on the suitability of WHO growth standards for India, considering genetic potential and environmental influences, the WHO-MGRS standards are still seen as a useful tool for international and intra-country comparisons.