Growth charts — WHO standards versus India crafted

Background: Child undernutrition has been a persistent issue in India, and its determinants are diverse, encompassing factors such as food intake, dietary diversity, health, sanitation, women's status, and the overarching context of poverty. The primary measures for childhood undernutrition, including stunting (chronic undernutrition) and wasting (acute undernutrition), rely on anthropometric standards such as height-for-age and weight-for-height. Monitoring these indicators is crucial for assessing actual progress. India, like many other nations, adopts the World Health Organization (WHO) Growth Standards as a global benchmark for measuring malnutrition. However, there is an ongoing debate regarding various aspects of using these growth standards in the Indian context.

Issues:

MGRS as the base

• The MGRS aimed to establish growth standards for children (from birth to five years) in healthy environments, as opposed to growth references based on U.S. children, many of whom were formula-fed.
• The MGRS sample for India was drawn from privileged households in South Delhi, meeting specific criteria like a favorable growth environment, breastfeeding, and non-smoking mothers.
• Some researchers argue that MGRS standards may overestimate undernutrition in India, but valid comparisons require datasets meeting MGRS criteria, challenging due to inequality and underrepresentation of the rich in large-scale surveys.
• Even among children in the highest quintile households, only a small percentage meets the WHO-defined 'minimum acceptable diet.'
• Comparisons with MGRS could be misleading as it involved counseling for appropriate feeding practices, absent in other surveys like NFHS or Comprehensive National Nutrition Survey.

Genetic growth and other concerns

• Issues with MGRS standards include differences in genetic growth potential among Indians and the influence of maternal heights on child growth.
• Maternal height is a non-modifiable factor influencing child growth, reflecting intergenerational transmission of poverty and women's poor status.
• Stunting, as an indicator of a deficient environment, should capture deprivation, but questions arise regarding the plasticity and usefulness of the standard.
• Some countries with similar or poorer economic conditions show higher improvements in stunting prevalence using WHO-MGRS standards.
• Regional differences within India, as well as shifts in gene pools with socioeconomic development, challenge the immutability of genetic potential.
• Concerns about inappropriately high standards leading to misdiagnosis and potential overfeeding under government programs are raised, but improving meal quality can address these fears.
• Dietary gaps, poor coverage of nutritional programs, and the need for diverse interventions like better sanitation, healthcare, and childcare services are emphasized.
• Distal determinants of stunting, such as livelihoods, poverty, education, and women's empowerment, require attention for overall development and equitable Resource distribution.
• Acknowledgment that individual children grow uniquely, and trained health personnel can interpret growth charts for individual care, while population trends are understood using appropriate standards for international and intra-country comparisons.

Recommendations of ICMR

• The Indian Council of Medical Research has formed a committee to update the growth references for India. Reports indicate that this committee proposes a comprehensive and thorough study nationwide to assess child growth, aiming to create national growth charts if deemed necessary.
• While obtaining more accurate and recent data on child growth is a positive step—especially in light of ambitious developmental goals to reach every individual by 2047 and the benefits of comparability—it appears reasonable to adhere to the aspirational yet attainable standards put forth by the WHO-MGRS.
• Therefore, while gathering detailed national data is a positive step, retaining the WHO-MGRS as a temporary reference point seems prudent. This ensures continued focus on ambitious but achievable goals for child health and development, aligning with India's vision for the future.

World Health Organization (WHO)

• The World Health Organization (WHO), established in 1948 as the specialized health agency of the United Nations, has its headquarters located in Geneva, Switzerland.
• With 194 Member States, six regional offices, and 150 country offices, WHO operates as an inter-governmental organization. It collaborates with its member states, typically through their Ministries of Health.
• WHO plays a crucial role in global health by offering leadership, shaping health research priorities, establishing norms and standards, formulating evidence-based policy recommendations, providing technical assistance to countries, and monitoring and evaluating health trends.
• World Health Day, celebrated annually on April 7, marks the commencement of WHO's operations.

Multicentre Growth Reference Study (MGRS)

• The WHO Multicentre Growth Reference Study (MGRS) was undertaken between 1997 and 2003 to generate new growth curves for assessing the growth and development of infants and young children around the world.
• The MGRS collected primary growth data and related information from approximately 8500 children from widely different ethnic backgrounds and cultural settings (Brazil, Ghana, India, Norway, Oman and the USA).
• The new growth curves are expected to provide a single international standard that represents the best description of physiological growth for all children from birth to five years of age and to establish the breastfed infant as the normative model for growth and development.