ABSTRACT
OBJECTIVE: We aimed to develop anthropometric growth references for Indian children and adolescents, based on available 'healthy' child data from multiple national surveys. METHODOLOGY: Data on 'healthy' children, defined by comparable WHO's Multicentre Growth Reference Study (MGRS) selection criteria, were extracted from four Indian surveys over the last 2 decades, viz, NFHS-3, 4, and 5 and Comprehensive National Nutrition Survey (CNNS). Reference distributions of height-for-age for children up to 19 years, weight-for-age for children up to 9y, weight-for-height for children less than 5 years and BMI for age for children between 5-19 y were estimated by GAMLSS with Box-Cox Power Exponential (BCPE) family. The national prevalence of growth faltering was also estimated by the NFHS-5 and CNNS data. RESULTS: The distributions of the new proposed Indian growth references are consistently lower than the WHO global standard, except in the first 6 months of age. Based on these references, growth faltering in Indian children and adolescents reduced > 50% in comparison with the WHO standard. CONCLUSION: The study findings revealed that the WHO one-standard-fits-all approach may lead to inflated estimates of under nutrition in India and could be a driver of misdirected policy and public health expenditure in the Indian context. However, these findings need validation through prospective and focussed studies for more robust evidence base.
Subject(s)
Anthropometry , Body Height , Body Weight , Humans , India/epidemiology , Adolescent , Child , Child, Preschool , Infant , Male , Female , Body Height/physiology , Reference Values , Body Weight/physiology , Infant, Newborn , Young Adult , Growth Charts , Child Development/physiologyABSTRACT
OBJECTIVE: To examine the accuracy of World Health Organization (WHO) growth standard in under-5 year Indian children, and identify a method to contextualize the WHO standard for India. PARTICIPANTS: Data of Healthy children, defined by WHO selection criteria, extracted from nationally representative Indian surveys (National Family Health Surveys, NFHS-3, NFHS-4, NFHS-5 and Comprehensive National Nutrition Survey, CNNS). DESIGN: Height for age z score (HAZ) and weight for age z score (WAZ) and weight for height z score (WHZ) distributions in healthy sample were compared against the standard normal. If deviant, age-specific correction factors for z scores were estimated by hierarchical linear mixed effects mean and variance polynomial models. A new term, excess mean risk of growth faltering (EMRGF), was introduced to describe growth faltering. MAIN OUTCOME: Measure of deviation of HAZ, WAZ and WHZ from standard normal distribution. Correction of WHO growth standards for India leading to accurate prevalence of stunting, underweight and wasting in Indian children using NFHS-5 data. RESULTS: Data on 10,384 healthy under-5 year children were extracted, of which 5377 were boys. Across surveys and metrics, the mean z scores were significantly lower than zero (-0.52 to -0.79). HAZ and WHZ variability (1.16, 1.07) were significantly higher than 1. Derived age-specific corrections reduced the NFHS-5 prevalence of growth faltering by 50%. The national EMRGF (after applying the age-specific correction) for height for age was 15.5% (95%CI:15.3-15.8), and weight for age was 15.0% (95%CI:14.8-15.3), respectively, in NFHS-5. CONCLUSION: The WHO growth standards need contextual customization for accurate estimation of the burden of growth faltering in under-5 year children in India. When corrected, the burden of growth faltering is lower, by half or more, in all the three indices.
