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Undersized Indian children: nutrients-starved or hungry for development?

Summary of research 1

Location: India

What we know: The WHO Multicentre Growth Reference Study (MGRS) growth curves provide a single international reference for population-level comparison for children under five years of age.

What this article adds: The MGRS charts describe the growth of children under ideal conditions; only 5-10% of Indian children fulfil the WHO MGRS eligibility criteria. The prevalence of undersized children is a proxy for overall socioeconomic development, intergenerational factors, biological and environmental determinants, and nutrition. However, interventions to improve child undersize in India focus on food and nutrients-based interventions, despite limited, unstainable benefits and some negative consequences. With the exception of water, sanitation and hygiene (WASH), other broader determinants are not actively targeted. Prevalence of stunting and underweight has declined in India (in tandem with overall national development), while wasting remains stagnant; this anthropometric pattern may reflect nutrition transition. Undersize in Indian children reflects wider societal maldevelopment and inequity and a legacy of considerable intergenerational handicap, necessitating a greater catch-up period. Comprehensive (simultaneously addressing all determinants), patient and equitable (prioritising the deprived) development is the key to progress.

Children under five years of age with body dimensions <-2 standard deviations (SD) of World Health Organization (WHO) Multicentre Growth Reference Study (MGRS) charts are defined as undersized. However, the MGRS charts, designed as a global reference (for comparison), are being used as a standard (target to be achieved). This aspiration should be balanced with realistic expectations. The MGRS charts describe the growth of children who are free from socioeconomic, environmental and biological constraints, and whose care has followed recommended health practices and behaviours associated with healthy outcomes. Thus, MGRS growth curves are expected to provide a single international reference that represents the best description of physiological growth for all children below five years of age; low anthropometric values in MGRS subjects reflect biological variability or additional unmeasured factors, rather than nutrition compromise. Currently, only 5-10% of Indian children meet the WHO MGRS eligibility criteria. In this context, a recent paper examines how nutrition progress can be achieved in the Indian population. 

Considering the stringent MGRS eligibility criteria, the prevalence of undersized children at population level is a crude but convenient proxy for a blend of overall socioeconomic development and intergenerational constraint of maternal undersize. Nutrient deficits, particularly in individuals, may comprise only one contributing factor, yet food and nutrient subsidies or supplementation are typical and often the only strategies used to address population undersize. While there are certain benefits in disaster and famine situations, only some nutrient or food-based interventions, including those during pregnancy, are evidenced to increase anthropometric indices or do so modestly (0.1-0.25 SD or 5%-10% deficit), with unsustainable gains. Undesirable consequences include complacency among stakeholders that everything possible is being done; diversion of public finances and attention from other crucial unattended determinants of undersize; dependence by the beneficiaries on public welfare; and risk of contributing to non-communicable diseases through long-term, food-based supplementation.

Other potential determinants of undersize include water, sanitation and hygiene (WASH); nutrition counselling; maternal characteristics; curative and preventive health care; maternal, household and community resources; literacy; income; women empowerment; safety nets; and genes. These are seldom visualised or actively targeted for improving undersize, although efforts have begun to integrate WASH interventions. Attempts to accelerate the pace of progress must consider inequity (the greater the proportion of the population that is deprived, the higher the burden and slower the improvement); comprehensive interventions; using ‘windows of opportunity’ (such as the first 1,000 days and adolescence); sustainability of interventions, ideally over generations; baselines (populations starting at lower levels will take longer to reach targets); and intergenerational handicap (only a limited improvement is possible within one generation).

In tandem with overall national development, time trends show a gradual decline in the incidence of undersize in children; this trend has hastened in the past decade, even among the underprivileged. This is supported by intergenerational comparison, over the past 30 years, of anthropometric data of children and their parents in the New Delhi Birth Cohort subjects from middle socioeconomic status who were not recipients of food subsidies (Sinha et al, 2017). In comparison to their parents, children were considerably taller (0-5 years 0.99 SD; 5-10 years 1.17 SD) and heavier (0-5 years 0.77 SD; 5-10 years 1.52 SD), while only those aged 5-10 years were broader (had a higher BMI; 1.03 SD). The steady decline in the prevalence of stunting and underweight, with stagnant wasting levels, is observed in neighbouring countries too and appears unrelated to specific determinants. The underlying and proximate factors related to stunting and wasting are similar. A steady improvement in stunting and underweight with stagnant wasting levels is therefore unlikely to be related to non-improvement of specific determinants like food or nutrients, but is probably a reflection of biological thinness (thin-fat infant phenotype) of Indian populations (Yajnik et al, 2003), or the pattern of anthropometric change in stunted populations undergoing nutrition transition. In children under five years old, increase in length (or height) and breadth are two distinct biological processes, which generally do not occur simultaneously. Thus, rapid and simultaneous declines in both stunting and wasting prevalence, as perceived in the Sustainable Development Goals, appear challenging, if not impossible, to achieve.

Politicians, policy makers, other stakeholders and the lay public must realise that there is no magic solution to eliminate undersize in children, which reflects wider societal maldevelopment and inequity. Focusing solely on nutrients and one or two additional determinants (for example, WASH interventions) will yield slow and disappointing results. Irrespective of the benefits on body size, every ingredient of the development process deserves to be in place in its own right; for example, purchasing power; access to education, healthcare, water supply and sanitation services; and nutritional security. A seemingly unclear agenda can be more clearly structured by uniting two to three key indicators each from the above key domains to monitor progress and fine-tune interventions.

The author concludes that undersized Indian children have a legacy of considerable intergenerational handicap, necessitating a greater catch-up period even under the best circumstances. We therefore need to be patient and practical. There has been a gradual improvement, which has sped up in the past decade. A predominant focus on nutrients-based solutions will fail to accelerate progress. Comprehensive and equitable development is the key to success.


Endnote

1Sachdev HPS. (2018) Undersized Indian children: nutrients-starved or hungry for development? Proc Indian Natn Sci Acad 84 No. 4 December 2018 pp. 867-875.


References

Sinha S, Aggarwal AR, Osmond C, Fall CHD, Bhargava SK and Sachdev HS (2017). Intergenerational change in anthropometric indices and their predictors among children in New Delhi Birth Cohort. Indian Pediatr 54 185-192.

Yajnik CS, Fall CHD, Coyaji KJ, Hirve SS, Rao S, Barker DJ P, Joglekar C and Kellingray S (2003). Neonatal anthropometry: the thin-fat Indian baby. The Pune Maternal Nutrition Study Int J Obes Relat Metab Disord 27 173-80.

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Undersized Indian children: nutrients-starved or hungry for development?. Field Exchange 59, January 2019. p41. www.ennonline.net/fex/59/undersizedindianchildren

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