India moves to develop its own growth standards for kids

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The Indian government, for the first time, has initiated moves to develop country-specific growth standards for children amid concerns that the weight and height references recommended by the World Health Organization may not be suitable in the Indian context.

Paediatricians chart the weight and height of kids from birth, which is then expressed in percentiles to assess whether a child is growing well and how she fares vis a vis other kids her age.

These measurements, which include weight, height, weight for height and body mass index, are also taken into account in several surveys and studies, including the ones carried out by governments, to gauge the parameters associated with malnutrition among kids.

The health ministry has directed the Indian Council of Medical Research to develop standards for kids aged 0-18. The ICMR has constituted a 14-member committee under senior paediatrician and researcher Dr HPS Sachdev.

Other panel members include paediatricians, nutrition experts, biostatisticians and representatives from ministries and the government think tank Niti Aayog.

“The move comes following an understanding through several studies that growth patterns in kids are influenced by genetics as well as environmental factors,” said a senior health ministry official.

The official added that adopting WHO charts on Indian kids may not have been appropriate as it has been developed mainly taking environmental factors into account rather than genetics.

Sachdeva told Moneycontrol that while the panel has had several meetings over the past few months, the project was still in the works.

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Charting growth the WHO way

The 2006 WHO growth standard is based on the Multi Growth Reference Study (MGRS), which is considered a universal standard for healthy height and weight in children.

Substantial deviation from this growth standard is used to define three important indicators: stunting (low height for age), wasting (low weight for height), and underweight (low weight).

These three indicators are most often used to assess the prevalence of different forms of undernutrition in a population. They are used in international targets such as Sustainable Development Goals and India, too, uses these reference points in its POSHAN Abhiyan or nutrition programme.

Major concerns

The MGRS, carried out between July 1997 and December 2003, was a population-based study conducted in the US, Oman, Norway, Brazil, Ghana and India.

“The study involved a small population group in affluent South Delhi, and as such, was not representative of the whole of India,” Sachdeva said.

According to Sachdeva, apart from genetics, factors such as low haemoglobin levels, gestational restrictions and zinc serum in Indian women also play a key role in determining the height and weight of kids.

He noted that several countries, including the US, have their own growth references.

Dr Anuradha Khadilkar, deputy director and consultant paediatrician with Hirabai Cowasji Jehangir Medical Research Institute in Pune, said that using WHO standards in the Indian context has two major issues.

“While at the public health level, it may not be representing the real picture of nutrition — at the individual level, it means that children below the WHO standards are sometimes subjected to unnecessary tests and diagnoses and mothers feel a lot of pressure due to the stigmatisation involved,” she said.

Khadilkar, along with researchers from Harvard University, recently wrote a paper titled ‘Should India adopt a country-specific growth reference to measure undernutrition among its children?’ which was published in The Lancet.

Another research project, by Khadilkar and others, on affluent Indian children under 5 years of age, had shown a significant percentage of stunting and underweight but relatively less wasting and preserved BMI based on WHO growth charts. The study highlighted that nearly a third of Indian children were still not at par with WHO standards.

An analysis of four rounds of the National Family Health Survey (1992-2016) for assessment of change in nutritional status in under-five Indian children using WHO standards (NFHS 1&2 used International Growth References by the National Centre for Health Statistics, US) also showed that despite improvements in stunting and underweightedness, wasting has actually worsened over 4 rounds of surveys due to greater improvement in height as compared to weight.

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Guarded steps

According to Khadilkar, India needs to “think about using WHO growth standards for Indian kids” but caution should be taken not to undermine the problem of malnutrition.

A member of the expert panel said that the way ahead for the country includes using altered cut-offs with WHO charts based on health outcome data from the Comprehensive National Nutrition Survey (CNNS), or to create standards from existing data.

But not everyone is enthused with the idea of new growth standards for India.

Nutrition activist Dr Arun Gupta, who is a paediatrician by training, suspected that the development may just be aimed at moving targets, given India’s huge malnutrition burden.

“I do not know very well the arguments being used in favour of such a move. But the fact remains that nearly 30 percent of India’s kids under 5 are malnourished, and by measuring it against the new standards, the government may show it to be just about 15-20 percent. But the crisis remains,” he said.