On the Issues with the WHO Growth Standards – Growth charts

Source: This post on the Issues with the WHO Growth Standards has been created based on the article “Growth charts – WHO standards versus India crafted” published in “The Hindu” on 28^th December 2023.

UPSC Syllabus Topic: GS Paper 2 Social Justice – Issues related to Health.

News: The article discusses the various issues with the WHO Growth Standards, which are used in calculating undernutrition levels in India.

High levels of child undernutrition have been a persistent problem in India.

What are the determinants of undernutrition?

1. food intake, b. dietary diversity, c. health, d. sanitation, e. women’s status, f. poverty.

How do we measure undernutrition?

The most common measures of childhood undernutrition are based on anthropometric standards such as:

1. Height-for-age (stunting/chronic undernutrition).
2. Weight-for-height (wasting/acute undernutrition).

India, like most other countries, uses the globally accepted WHO Growth Standards to measure malnutrition. However, there is a growing debate related to the use of these growth standards in India.

What are the WHO Growth Standards based on?

They are based on a Multicentre Growth Reference Study (MGRS) that was conducted in 6 countries between 1997 and 2003 (Brazil, Ghana, India, Norway, Oman and the United States).

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 including having a ‘favourable’ growth environment, being breast-fed and having non-smoking mothers.

What is the issue with the WHO Growth Standards?

Some issues raised vis-à-vis the MGRS methodology are as follows:

1) Some researchers who have analysed data from other surveys for India suggest that these standards overestimate undernutrition.

2) Such comparisons could also be misleading because the study norms of the WHO-MGRS are different from Indian studies. For example, the MGRS included a component of counselling to ensure appropriate feeding practices, which is missing in the NFHS or Comprehensive National Nutrition Survey.

3) Does not consider Genetic Differences: Another important set of issues with regard to 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.
Low average maternal heights reflect intergenerational transmission of poverty and poor status of women. An appropriate indicator needs to capture this deprivation as well.
However, various countries with poorer economic conditions, including those in the South Asian region, have shown higher improvements in stunting using the same standards. It also needs to be considered that gene pools also shift at the population level with greater socio-economic development —  demonstrated by the growing average heights of countries such as Japan, refuting that genetic differences are that big a concern.

4) Inappropriately High Standards: Another serious concern is related to inappropriately high standards leading to a misreading of the nutrition situation in India.
This might result in a potential overfeeding of misclassified children under programmes of the government introduced to address undernutrition, thereby resulting in an increase in overweight and obesity.

What additional steps need to be taken to address undernutrition?

1. The quality of the meals under nutrition schemes must be improved to ensure that they are not cereal-heavy, include all nutrients, and contribute to dietary diversity.
2. Recommendations such as including eggs in meals for children and pulses in the Public Distribution System must be acted upon urgently.
3. Along with this, multiple interventions such as better sanitation, access to health care, childcare services and so on are required for better nutritional outcomes.
4. Ensuring better livelihoods and lowering poverty, access to education and women’s empowerment are also important steps.

In light of these issues, the Indian Council of Medical Research has constituted a committee to revise the growth references for India. However, using the WHO standards is important for international comparisons and intra-country trends — an advantage that would be lost with any new country-specific standard.

Question for practice:

Measuring undernutrition in a sound manner, keeping in mind the conditions of India, are an important first step in tackling the problem. Discuss in the context of the issues with the WHO Growth Standards.