Govt initiates moves to set ‘Indian’ standards for stunting in children | India News

NEW DELHI: A meeting of experts led by Indian Council of Medical Research (ICMR) director general Dr Rajiv Bahl, and Niti Aayog member Dr VK Paul was held last week to discuss setting indigenous growth standards for children. This is despite several experts saying that this was a futile exercise since India was part of the Multicentric Growth Reference Study (MGRS) of the World Health Organisation (WHO) in 2003, which drew up the growth standards currently being used in India.

The meeting comes in the wake of surveys showing that Indian kids are not achieving the standard height for a particular age, a condition defined as stunting. It was reported in December 2022 that the health ministry had directed the ICMR to develop growth standards for India and that the ICMR had constituted a 14-member committee for the purpose. In March this year, the Economic Advisory Council to the PM (EAC-PM) argued in a working paper that the height that children of a particular age group ought to achieve could be lower for India.
The paper pointed out that though the India sample for WHO’s MGRS study was taken from the affluent pockets of South Delhi, Indian and Omani children were consistently shorter than those from other countries. “In other words, India’s best-fed children were smaller on average than those of other countries,” stated the paper. It argued that this demonstrated how “a blind application by national agencies of a one-size-fits-all global standard presents a misleading picture of an important malnutrition indicator”. The authors sought a revisiting of local anthropometric measurements and “data based on our own benchmarks derived from indigenous characteristics which are better suited to gauge malnutrition in India”.

However, many public health researchers and paediatricians countered the recommendation to lower growth standards stating that it would be a disservice to the cause of child health and nutrition to suggest that Indian children had a low genetic potential to grow and therefore stunting in them would not be amenable to interventions. Within India, there is evidence that the height of different groups of children has increased with time, which indicated the yet-to-be realised potential for growth of Indian children, they argued.
The National Family Health Survey (NFHS) of 2019-21 showed that 36% of children under five years were stunted or had not achieved the standard height for that age cohort. It had come down from 38% in the 2015-16 NFHS, which used the same standard. Since then, some members of the EAC-PM have found fault with the NFHS methodology, sampling etc. However, another survey commissioned by the health ministry along with UNICEF, the Comprehensive National Nutrition Survey (CNNS 2016-18), also showed that 35% of children under five years were stunted. Both surveys estimated stunting using the WHO standards.
The CNNS found a higher prevalence of stunting in under-fives in rural areas (37%) than in urban areas (27%). Also, children in the poorest wealth quintile were more likely to be stunted (49%), as compared to 19% in the richest quintile. The CNNS was the first national survey to measure anthropometry in children aged 5 to 14 years. Overall, 22% of children aged 5 to 9 years were stunted and 6% were severely stunted. According to the UNICEF, a stunted child is too short for his or her age and does not fully develop. Stunting reflects chronic undernutrition during the most critical periods of growth and development in early life. It estimated that India has the highest number of stunted children in the world (40.6 million) representing one-third of the global total of stunted children under the age of five.
If a lower standard of height for a particular age is set for India, the proportion of children who are stunted would come down even without any nutritional or health intervention or efforts to improve the living condition of children. The EAC-PM working paper estimated that by using “indigenous growth charts” the proportion of stunted under-five children could come down from 36% to about 24%. The reason for targeting childhood stunting is hinted at in the working paper, which states that childhood stunting is a “malnutrition indicator that finds its way into the Global Hunger Index and Sustainable Development Goals” (SGDs) and that “it also determines the success of India’s nutrition programs like Poshan Abhiyaan 2.0”. Thus, by lowering the standard, India could look better in the Global Hunger Index and would seem closer to achieving the SDGs.
“Taking cognisance of the diversity of children’s growth, Indonesia, U.K. and the U.S. have developed their own growth charts for reference by medical practitioners,” states the working paper. While Indonesia does have its own standard, the US Centers for Disease Control and Prevention (CDC), the federal agency tasked with promoting public health in the US, actually recommends that health care providers use the WHO growth charts, rather than those it has developed, to monitor growth from birth to age 2.
“They explain this recommendation by saying that the WHO charts track the growth of children who were raised in a healthy environment according to a pre-decided set of nutritional guidelines that are now believed to be better than what was used to create the CDC charts. The big difference between how the children who participated in the WHO and CDC studies were raised is breastfeeding – for many years, most people in the US haven’t followed the WHO’s guidance on breastfeeding. The CDC study, which uses children from 1977, did not require that included babies be breastfed,” explained a population researcher.
“The WHO standards provide a better description of physiological growth in infancy. Clinicians often use the CDC growth charts as standards on how young children should grow. However, the CDC growth charts are references; they identify how typical children in the US did grow during a specific time period. Typical growth patterns may not be ideal growth patterns. The WHO growth charts are standards; they identify how children should grow when provided optimal conditions,” states the CDC on its website.
“Growth standards are prescriptive and define how a population of children should grow given optimal nutrition and health, whereas growth references represent how children are growing rather than how they should be growing. The WHO’s 2006 growth charts for children under five years are examples of growth standards. They delineate how children of the world under the age of five years should grow if most of the controllable variables are kept optimal,” explained paediatricians Rakesh Lodha and Yogesh Jain and public health expert C Sathyamala in their 2013 paper titled Reality of Higher Malnutrition among Indian Children.
Citing another study, they pointed out that from 1971 onwards, the mean heights of affluent boys in Delhi and Varanasi increased by 2.1 cm and 1.5 cm per decade respectively, indicating that there is a definite potential for Indian children to improve their heights. They added that with this slow decadal increment even among elite children, it may take many decades to catch up with the developed world. The Dutch took nearly 150 years to increase their mean heights by 6 inches and now their heights appear to have plateaued off.