Growth charts — WHO standards versus India-crafted 

Child undernutrition in India has persistently been a significant challenge, with multiple determinants recognized, including food intake, dietary diversity, health, sanitation, women's status, and the overarching context of poverty. Common measures of childhood undernutrition, such as stunting (chronic undernutrition) and wasting (acute undernutrition), rely on anthropometric standards like height-for-age and weight-for-height. Monitoring these indicators is crucial for assessing actual progress. While India adopts the globally accepted World Health Organization (WHO) Growth Standards for measuring malnutrition, there is an emerging debate on various issues related to their applicability in the Indian context. Some of these issues are explored below.

• The World Health Organization (WHO) standards, utilized as the basis for assessing child growth, derive from the Multicentre Growth Reference Study (MGRS) conducted across six countries from 1997 to 2003 (Brazil, Ghana, India, Norway, Oman, and the United States).
• This study aimed to establish growth "standards," outlining how children should ideally grow under healthy conditions, as opposed to "references" based solely on the growth patterns of a reference group.
• The MGRS sample in India was drawn from privileged households in South Delhi, representing children meeting specific eligibility criteria, including a favourable growth environment, breastfeeding, and non-smoking mothers.
• Critics analyzing data from alternative surveys in India argue that these WHO standards may overestimate undernutrition.
• However, valid comparisons would require datasets meeting all the MGRS criteria for a favourable growth environment, which is challenging due to high inequality and underrepresentation of the affluent in large-scale surveys.
• For instance, even among children in the highest quintile households in the National Family Health Survey (NFHS)-5, only a small percentage meet the WHO-defined "minimum acceptable diet." Disparities in maternal education levels between the MGRS sample and NFHS-5 further complicate comparisons.
• Comparisons may be misleading since the MGRS study norms differed significantly from prevalence studies.
• The MGRS incorporated counselling to ensure proper feeding practices, a component absent in surveys like NFHS or the Comprehensive National Nutrition Survey.
• Recognizing that the MGRS aimed to establish prescriptive standards helps address most sampling concerns. Additional issues related to MGRS methodology, such as the pooling of data from different countries, have been thoroughly discussed in the study reports.

The Multicentre Growth Reference Study (MGRS) was a landmark research project conducted between 1997 and 2003 by the World Health Organization (WHO). It aimed to establish new growth standards for infants and young children from birth to five years old.

Objectives

• Develop prescriptive standards for child growth, outlining how children should grow under ideal conditions, rather than simply reflecting existing growth patterns.
• Gather data from diverse populations to create culturally sensitive and globally applicable standards.
• Address limitations of previous growth standards based primarily on Western populations.

Methodology

• Conducted in six countries: Brazil, Ghana, India, Norway, Oman, and the United States.
• Included a longitudinal component following 1743 mother-infant pairs from birth to 24 months and a cross-sectional component measuring 7728 children aged 18 to 71 months.
• Focused on children from favourable environments – breastfeeding, non-smoking mothers, adequate diets, and access to healthcare.
• Collected data on height, weight, head circumference, and other anthropometric measurements.

Outcomes

• Developed new WHO Child Growth Standards based on the MGRS data, including growth charts and associated software for interpretation.
• Improved understanding of child growth patterns in diverse populations.
• Contributed to global efforts to monitor and improve child health and nutrition.

Criticisms

• Limited sample size: The study included a relatively small number of children compared to large national surveys.
• Focus on "ideal" environments: Critics argue that the focus on favourable conditions may not reflect the realities faced by most children, potentially overestimating undernutrition prevalence.
• Generalizability: Concerns exist about the applicability of standards based on six diverse populations to specific countries or regions.

The National Family Health Survey (NFHS) is a large-scale, multi-round survey conducted in India by the Ministry of Health and Family Welfare, Government of India. With the International Institute for Population Sciences (IIPS) serving as the nodal agency, the NFHS provides state and national information on various aspects of population, health, and family welfare.

Objectives

• Gather data on fertility, infant and child mortality, family planning practices, maternal and child health, reproductive health, nutrition, anaemia, and utilization of health services.
• Track progress in achieving national health and family welfare goals.
• Identify disparities in health indicators across different states, districts, and socioeconomic groups.
• Inform policy and program decisions related to population and health.

Methodology

• Conducted in rounds every four to five years. Five rounds have been completed so far, with the latest being NFHS-5 conducted in 2019-21.
• Employs a representative sample of households, ensuring the findings accurately reflect the national and state populations.
• Uses a combination of interviews and anthropometric measurements to collect data from women, men, and children.
• Data is collected through household questionnaires, individual interviews with women and men, and biological assays (blood tests, etc.).

Key Findings

• NFHS reports provide a wealth of data on various indicators, including:
  • Fertility rates: Birth rates, child mortality, family planning practices.
  • Maternal and child health: Maternal and neonatal mortality, immunization coverage, nutritional status.
  • Reproductive health: Awareness and use of contraception, sexually transmitted infections.
  • Nutrition: Anaemia prevalence, dietary diversity, child stunting and wasting.
  • Utilization of health services: Access to antenatal care, deliveries in health facilities, utilization of family planning services.

Importance

• NFHS data is crucial for policy formulation and program implementation in areas like maternal and child health, family planning, and nutrition.
• It helps monitor progress towards achieving national health goals outlined in documents like the National Health Mission.
• The data is also used by researchers and academics to study population trends, health disparities, and the effectiveness of interventions.

Limitations

• As with any large-scale survey, NFHS data may have some limitations, such as sampling biases and measurement errors.
• The long time gap between rounds can make it difficult to track rapid changes in certain health indicators.