Comparison of Nutritional Status of Under-Five Indian Children (NFHS 4 Data) Using WHO 2006 Charts and 2019 Indian Synthetic Charts

Comparison of Nutritional Status of Healthy Under-Five Indian Children Using Composite Index of Anthropometric Failure on WHO 2006 versus 2019 Indian Synthetic Growth Charts

OBJECTIVES

To assess nutritional status of apparently-healthy under-five Indian children using Composite Index of Anthropometric Failure (CIAF) and to compare anthropometric failure prevalence using conventional indices and CIAF on World Health Organization (WHO) vs. synthetic Indian growth charts.

METHODS

This observational study was conducted over 2 y. The inclusion criteria was apparently-healthy children (0-60 mo) and the exclusion criteria were acute/chronic illness and small for gestational age.

RESULTS

A total of 1557 children (762 girls) were included in the study. The mean age of the subjects was 21 mo. The Z-scores for height, weight, body mass index (BMI) for age and weight for height in children were lower on WHO vs. synthetic charts (p = 0.0001). Significantly higher proportion of children were moderately and severely underweight, stunted and wasted on WHO charts. Synthetic charts identified significantly higher proportion as normal for weight, height, BMI for age, weight for height, overweight (overall), and a higher prevalence of severe stunting, and severe acute malnutrition (SAM) was noted among girls compared to boys. Using CIAF, 54.1% children were normal on WHO charts vs. 78.0% on synthetic (p = 0.0001). Larger proportion of girls (8.8%) were stunted+underweight (category-E) vs. boys (4.3%) on synthetic charts (p = 0.0003). Significantly higher proportion of children demonstrated failure (single/dual/multiple) on WHO charts except category-Y (higher proportion of underweight on synthetic charts). Maximum difference in CIAF (WHO vs. synthetic) was observed between 0-24 mo age. Of 1215 children normal on synthetic charts, 837 (68.9%) were normal on WHO charts. Of 116 underweight children (category-Y) on synthetic charts, 20 (17.2%) were underweight on WHO charts; remaining had compound failure (wasting+underweight = 49.1%, wasting+stunting+underweight = 14.7%, stunting+underweight = 12.1%) on WHO charts. Among those stunted+underweight (category-E) on synthetic charts, WHO charts classified 1/4th as wasted+stunted+underweight (category-D).

CONCLUSIONS

Synthetic references are more representative of Indian growth patterns, and seem more appropriate for monitoring growth of Indian children to avoid mislabelling as malnourished.

Association of Child Growth Failure Indicators With Household Sanitation Practices in India (1998-2021): Spatiotemporal Observational Study

BACKGROUND

Undernutrition among children younger than 5 years is a subtle indicator of a country's health and economic status. Despite substantial macroeconomic progress in India, undernutrition remains a significant burden with geographical variations, compounded by poor access to water, sanitation, and hygiene services.

OBJECTIVE

This study aimed to explore the spatial trends of child growth failure (CGF) indicators and their association with household sanitation practices in India.

METHODS

We used data from the Indian Demographic and Health Surveys spanning 1998-2021. District-level CGF indicators (stunting, wasting, and underweight) were cross-referenced with sanitation and sociodemographic characteristics. Global Moran I and Local Indicator of Spatial Association were used to detect spatial clustering of the indicators. Spatial regression models were used to evaluate the significant determinants of CGF indicators.

RESULTS

Our study showed a decreasing trend in stunting (44.9%-38.4%) and underweight (46.7%-35.7%) but an increasing prevalence of wasting (15.7%-21.0%) over 15 years. The positive values of Moran I between 1998 and 2021 indicate the presence of spatial autocorrelation. Geographic clustering was consistently observed in the states of Madhya Pradesh, Jharkhand, Odisha, Uttar Pradesh, Chhattisgarh, West Bengal, Rajasthan, Bihar, and Gujarat. Improved sanitation facilities, a higher wealth index, and advanced maternal education status showed a significant association in reducing stunting. Relative risk maps identified hotspots of CGF health outcomes, which could be targeted for future interventions.

CONCLUSIONS

Despite numerous policies and programs, malnutrition remains a concern. Its multifaceted causes demand coordinated and sustained interventions that go above and beyond the usual. Identifying hotspot locations will aid in developing control methods for achieving objectives in target areas.

Global relevance of MGRS growth standards: the case of India

The most common measures of childhood undernutrition are based on anthropometric measures such as height-for-age (stunting/chronic undernutrition) and weight-for-height (wasting/acute undernutrition). It is well recognised that the determinants of undernutrition are multiple, including food intake, dietary diversity, health, sanitation and women's status. Currently, most countries across the world including India use the globally accepted WHO-Multicentre Growth Reference Study (MGRS) growth standards (2006) for the purposes of measurement as well as for evaluating progress on these metrics. However, there is some discussion on the universal relevance of these standards, and in the Indian context, whether these standards overestimate the prevalence of stunting, considering differences in genetic potential for growth. This is especially relevant in the context of increasing burden of obesity and non-communicable diseases in India. Based on a detailed review of literature, policy documents and expert inputs, this review paper discusses the relevance of the WHO growth standards for height/stunting, in the context of India. Issues discussed related to the MGRS methodology include pooling of data and intersite and intrasite variability, opting for standards as opposed to references, and external validity. Other issues related to plasticity of stunting and the influence of maternal heights are also discussed, in the context of analysing the appropriateness of using universal growth standards. Based on the review, it is recommended that the current standards may continue to be used until a newer global standard is established through a similar study.

Comparison of WHO 2006 Growth Standards and Synthetic Indian References in Assessing Growth in Normal Children and Children with Growth-Related Disorders

Introduction

A good screening tool, such as a growth chart, should distinguish between children with normal growth and those with perturbed growth. Suitability of synthetic Indian growth references for diagnosing growth-related disorders for under-five children has not been evaluated. To assess the validity of World Health Organization (WHO) 2006 standards vs synthetic Indian references (2019) (by comparing weight, height, body mass index (BMI), standard deviation scores (SDS) and the composite index of anthropometric failure (CIAF)) in differentiating normal children and children with growth-related disorders.

Methods

Records of 2188 children (0-60 months) attending a tertiary centre paediatric outpatient department (OPD) were retrospectively studied; 1854 children were healthy and 334 were diagnosed with growth-related disorders as per the European Society for Paediatric Endocrinology (ESPE) classification. The anthropometric parameters converted to Z-scores for weight-for-age (WAZ), height-for-age (HAZ), BMI-for-age (BAZ) and a CIAF were computed using WHO and synthetic charts; Student's t-test was used for assessing differences and Youden's index for validity.

Results

Disease status of children and anthropometric failure on WAZ, HAZ, BAZ and CIAF on both WHO and synthetic charts had a significant association (P-value <0.05). WAZ, HAZ on both charts and CIAF on synthetic chart had a fair to moderate agreement (Kappa statistics) with disease status as per diagnosis (P-value <0.05). The sensitivity and negative predictive value for all anthropometric parameters were higher for synthetic charts.

Conclusion

Indian charts were more sensitive for diagnosing growth-related disorders from birth to 60 months of age when compared to WHO growth standards.

Growth Prediction of Under-5 Children Using Statistical Models for Eastern Region of India

Background

Percentile curves are often used to assess variances in children's growth pattern. This study is aimed at explaining effect of the respondents' sociodemographic characteristics on under-5 children's birth weight and identifying most suitable models, out of 11 statistical models reviewed, for estimating children's growth in terms of height and weight of a given birth-weight category and obtain estimated growth curves.

Material and Methods

The study used National Family Health Survey (NFHS)-4 data from four Eastern States of India, consisting of 54,075 under-5 children. Estimated growth curves were obtained, using best-fit models.

Results

Birth weight was found to be associated with children's age, gender, birth order, body mass index, mother's education, living place and wealth index. Two models - Cubic Model and Power Model - showed best fit to the height and weight measurements. We obtained estimated growth curves of boys and girls for a given birth-weight category.

Conclusions

All socio-demographic factors studied, except respondent's occupation, were associated with children's birth weight. Cubic and Power Models were most suitable for assessing growth in terms of height and weight of boys and girls, belonging to a given birth-weight category.

Growth Estimation of Under-Five Children Using Statistical Models in Central Region of India

BACKGROUND AND AIMS

To determine the suitability of 11 basic statistical models for estimating child-growth of under-five children and to bring-forth estimated growth curves for mean height & mean weight by their selected birth-weight categories for Central Region of India.

METHODS

The study used fourth round of National Family Health Survey-4 (NFHS-4) data of India, consisting of 75,645 under-five children, belonging to 3 Indian States - Chhattisgarh, Madhya Pradesh & Uttar Pradesh. The children of the Region were first divided into 4 sub categories according to their birth-weight: (i) < 2000 gm, (ii) 2000-2499 gm, (iii) 2500-2999 gm (iv) 3000+gm, growth curve for mean height and mean weight were estimated for two sexes.

RESULTS

The significant association of 7 socio-demographic factors studied, namely - age & sex of child, birth-order, BMI, mother's highest level of education, place of residence and wealth index. Further, Cubic Model and Power Model, demonstrated best-fit to height & weight data of under-five children, belonging to different birth-weight categories, for estimating growth of boys & girls separately. These models enabled us to estimate mean height and mean weight, with 95% CI, for boys and girls separately by different birth-weight categories.

CONCLUSIONS

Study concluded that 7 socio-demographic factors were significantly associated with birth-weight. Further, Cubic Model and Power Model were most suitable for estimating child growth in terms of mean height & mean weight for boys and girls - considering specific birth-weight categories.