Date : 29/12/2023

Relevance: GS Paper 2- Social Justice - Health

Keywords: World Health Organization (WHO), Multicentre Growth Reference Study (MGRS), National Family Health Survey (NFHS).

Context-

Child undernutrition remains a persistent challenge in India, with multifaceted determinants such as food intake, dietary diversity, health, sanitation, women's status, and the overarching context of poverty. While India currently relies on the globally accepted World Health Organization (WHO) Growth Standards, there is an ongoing debate on several issues related to their application within the Indian context. Here we explore the intricacies of using WHO standards and look into the emerging discourse surrounding the development of nationally crafted growth charts.

Determinants of undernutrition encompass various factors, including:

1. Food intake
2. Dietary diversity
3. Health
4. Sanitation
5. Women’s status
6. Poverty

The measurement of undernutrition commonly relies on anthropometric standards, specifically:

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

In India and many other nations, the globally accepted WHO Growth Standards serve as the basis for assessing malnutrition. However, there is an ongoing discussion regarding the suitability of these growth standards in the Indian context.

Using the MGRS as the Base: Debates and Divergence

The WHO Growth Standards are rooted in the Multicentre Growth Reference Study (MGRS), conducted across six countries between 1997 and 2003. However, the sample for India in the MGRS was drawn from privileged households in South Delhi, raising questions about the representativeness of the data. Some researchers argue that these standards might overestimate undernutrition in India, but valid comparisons require datasets meeting MGRS criteria, a challenging task given the vast socio-economic disparities.
While the MGRS aimed to set growth standards, its prescriptive approach and distinct study norms, including counseling for appropriate feeding practices, differ significantly from prevalence studies like the National Family Health Survey (NFHS). Understanding the purpose and methodological nuances of the MGRS is crucial for contextualizing the debates surrounding its application in India.

Genetic Growth and Maternal Heights: Unravelling Complexity

The genetic growth potential of Indians, coupled with the influence of maternal heights on child growth, adds a layer of complexity to the debate. Maternal height, a non-modifiable factor at an individual level, reflects the intergenerational transmission of poverty and the status of women. While improvements in maternal height might be challenging within a generation, it serves as a proxy for the environment of deprivation. Regional variations within India, along with shifts in gene pools due to socio-economic development, challenge the notion of the immutability of genetic potential. The concern about misdiagnosis due to inappropriately high standards leading to potential overfeeding undernutrition-program beneficiaries underscores the delicate balance required in crafting growth standards reflective of India's diverse contexts.

Challenges and Opportunities in Program Implementation

Concerns about potential misclassification leading to overfeeding highlight the need for improvements in program implementation. Despite fears of an increase in overweight and obesity, the inadequacy of current programs, such as mid-day meals and supplementary nutrition in anganwadis, suggests that dietary gaps persist. Urgent actions, including improving the quality of meals, diversifying diets, and incorporating nutrient-rich foods like eggs and pulses into distribution systems, are imperative. The broader determinants of stunting, including livelihoods, poverty, access to education, and women's empowerment, underscore the interconnectedness of nutrition with overall development. While anthropometric indicators offer summary insights, addressing the distal determinants requires a comprehensive approach, aligning with India's developmental goals.

ICMR Recommendation:

In response to these debates, the Indian Council of Medical Research (ICMR) has constituted a committee to revisit growth references for India. The committee's recommendation for a detailed, rigorous study across the country to examine child growth signals a proactive approach. The ultimate goal is to potentially devise national growth charts, aligning with India's high aspirations for development.
While the pursuit of more precise information on child growth is commendable, there remains a logical argument to adhere to the aspirationally high yet achievable standards set by the WHO-MGRS. Striking a balance between national specificity and international comparability is essential for informed policy decisions and effective interventions.

Addressing undernutrition requires several additional measures:

1. Enhance Meal Quality: Improve the nutritional content of meals in undernutrition schemes by moving away from cereal-heavy options. Ensure that meals are well-balanced, providing all essential nutrients to promote dietary diversity.
2. Implement Urgent Recommendations: Act promptly on recommendations such as the inclusion of eggs in children's meals and the incorporation of pulses into the Public Distribution System to enhance nutritional value.
3. Comprehensive Interventions: Implement a range of interventions, including improved sanitation, increased access to healthcare, and enhanced childcare services, to achieve more favorable nutritional outcomes.
4. Holistic Approach: Adopt a holistic approach that involves addressing livelihoods, reducing poverty, promoting access to education, and empowering women, as these factors play crucial roles in combating undernutrition.
5. Revision of Growth References: Recognizing the significance of the issue, the Indian Council of Medical Research has formed a committee to revise growth references for India. However, it is essential to continue using WHO standards for international comparisons and tracking intra-country trends, as adopting a new country-specific standard could compromise these advantages.

Conclusion

Child undernutrition in India demands a nuanced approach to growth standards, considering the intricacies of socio-economic diversity, genetic factors, and program implementation challenges. The ongoing debate between using WHO standards and crafting national growth charts reflects the complexity of addressing undernutrition comprehensively. The ICMR's proactive stance in revisiting growth references indicates a commitment to evidence-based policymaking.

As India navigates the path forward, the dialogue should not only focus on growth standards but also on improving the broader determinants of child nutrition. Balancing the need for specificity with the advantages of international comparability is pivotal for shaping policies that not only address undernutrition but also contribute to holistic development. Ultimately, the quest for optimal child nutrition requires a collaborative effort, informed by a deep understanding of India's diverse contexts and the evolving landscape of global health standards.

Source- The Hindu