High levels of child undernutrition have been a persistent problem in India. It is well recognised that the determinants of undernutrition are multiple, and include food intake, dietary diversity, health, sanitation, women’s status and the over-arching context of poverty. The most common measures of childhood undernutrition are based on anthropometric standards such as height-for-age (stunting/chronic undernutrition) and weight-for-height (wasting/acute undernutrition). Monitoring these is key to tracking progress in terms of actual outcomes. India, like most other countries, uses the globally accepted World Health Organization (WHO) Growth Standards to measure malnutrition. However, there is an emergent debate on a number of issues related to the use of these growth standards in India, some of which are discussed below.
On using the MGRS as the base
The WHO standards are based on a Multicentre Growth Reference Study (MGRS) that was conducted in six countries between 1997 and 2003 (Brazil, Ghana, India, Norway, Oman and the United States). The purpose was to determine the pattern of growth (from birth to five years) of children who did not face any known deficiencies in their environments. The references that were previously used (WHO-National Center for Health Statistics references) were based on children only from the U.S., many of whom were not breastfed but formula-fed. The MGRS took a prescriptive approach, with the specific aim of setting growth ‘standards’ (how children ought to grow, provided they have a healthy environment) and not growth ‘references’ (how children of the reference group grow). 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.
