Context

• High levels of child undernutrition have been a persistent problem in India.
• India, like most other countries, uses the globally accepted World Health Organization (WHO) Growth Standards to measure malnutrition.
• However, there is an emergent debate on several issues related to the use of these growth standards in India.

WHO Growth Standards

• The WHO standards are based on a Multicentre Growth Reference Study (MGRS) that was conducted in six countries between 1997 and 2003 (Brazil, Ghana, India, Norway, Oman, and the United States).
• The purpose was to determine the pattern of growth (from birth to five years) of children who did not face any known deficiencies in their environments.
• The references that were previously used (WHO-National Centre for Health Statistics references) were based on children only from the U.S., many of whom were not breastfed but formula-fed. 

Debate on WHO Growth Standards

• The Prescriptive Approach of MGRS
  • The MGRS took a prescriptive approach, with the specific aim of setting growth standards which means how children ought to grow, provided they have a healthy environment and.
  • It did not provide growth references which means how children of the reference group grow.
• Sampling Concerns
  • The sample for India in the MGRS was drawn from a set of privileged households living in South Delhi.
  • These children met all the eligibility criteria for the study including having a favourable growth environment.
• Potential Overestimation of Undernutrition in India: There are concerns about potential overestimation of undernutrition when comparing MGRS standards with other datasets due to differences in sampling criteria and methodologies.
• Concerns Around Genetic Growth
  • Another important set of issues about using the MGRS standards is the difference in genetic growth potential of Indians with respect to others and the influence of maternal heights on child growth.
  • At an individual level, maternal height is undeniably a non-modifiable factor for the growth of her child.
  • Therefore, there is a question of how much improvement is possible in one generation.
  • However, low average maternal heights are themselves a reflection of the intergenerational transmission of poverty and poor status of women.
  • Therefore, a measure of an environment of deprivation, an appropriate indicator of a deficient environment, such as stunting, needs to capture this deprivation as well.
• Misdiagnosis and Overfeeding
  • WHO standards raise concerns about inappropriately high standards leading to misdiagnosis and potential overfeeding of children under government programs targeting undernutrition.
  • This is a worry, given the increasing burden of non-communicable diseases (NCDs) in India.

Challenges in Comparing WHO Standards with Large Scale Indian Surveys (NFHS)

• Sample Representation
  • Equivalent samples meeting all criteria for a favourable growth environment, as defined by the MGRS, are challenging to find in large-scale surveys in India.
  • This difficulty is attributed to high levels of inequality and the underrepresentation of the rich section in these datasets.
  • For instance, even among children (six-23 months) in households of the highest quintile in National Family Health Survey (NFHS)-5 (2019-21), only 12.7% meet the requirements of a ‘minimum acceptable diet’ as defined by WHO.
  • While almost all mothers in the MGRS sample had completed more than 15 years of education (in 2000-01), 54.7% of women in NFHS-5 had completed 12 or more years of schooling.
• Methodological Differences
  • There are methodological differences between the WHO-MGRS and other prevalence studies which implies that the MGRS included a counselling component to ensure appropriate feeding practices.
  • This component was missing in surveys like NFHS or Comprehensive National Nutrition Survey, potentially affecting the comparability of the data.
• Prescriptive Standards vs. Prevalence Studies:
  • Understanding the purpose of the MGRS sample, which was to set prescriptive standards, can help resolve many sampling concerns.
  • This implies that the MGRS was designed with a different objective compared to prevalence studies like NFHS.
• Absence of Data Collection Make It Difficult to Make a Comparison
  • Importance of considering the context and purpose of the data collection is necessary when making comparisons.
  • It means that comparing standards without recognising the differences in study norms may lead to misleading conclusions.

Are WHO Standards Still Useful in Indian Context?

• Yes, WHO Standards Have Been Useful in Many Countries
  • Several 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 WHO-MGRS standards.
  • Regional differences within India, both in the prevalence of stunting as well as increases in adult heights, also indicate that some States such as Odisha, Chhattisgarh, Tamil Nadu, and Kerala are achieving much faster reductions than others.
• Unique Growth Trajectories and Interpretation
  • What these standards are used for are mainly to understand population trends.
  • Using the appropriate standards is also important for international comparisons and intra-country trends, an advantage that would be lost with any new country-specific standard.

ICMR recommendation

• Amid these discussions, the Indian Council of Medical Research has constituted a committee to revise the growth references for India.
• This committee has recommended a detailed rigorous study to be conducted across the country to examine child growth with the purpose of devising national growth charts, if necessary.

Conclusion

• Acquiring newer, and more precise information on child growth is a welcome move considering India’s high aspirations of reaching development to every person by 2047.
• At the same time, it seems logical to stick to the aspirationally high but achievable standards suggested by the WHO-MGRS, considering the gaps in Indian large-scale surveys and standards.