ADOPTION OF NEW WHO GROWTH STANDARDS – ISSUES AND IMPLICATIONS PREMA RAMACHANDRAN DIRECTOR, NUTRITON FOUNDATION OF INDIA

Rationale for change to new WHO standards What are the differences between the NCHS, new WHO and IAP standards Assessing prevalence of under-nutrition NCHS and new WHO standards IAP and new WHO standards using BMI for age as per new WHO standards Summary of issues and implications

Rationale for change to new WHO standards Corrects the historical fallacy of using formula fed children from single ethnic group in one country as global standard for assessment of nutritional status of preschool children and consequent problems in interpretation of data.

What are the differences between the NCHS and new WHO standards

Comparison between NCHS& New WHO Standards The New WHO standards show that breast fed infants in the first six months are taller as compared to bottle fed infants in NCHS standards

Comparison between NCHS& New WHO Standards The New WHO standards show that breast fed infants in the first six months are heavier as compared to bottle fed infants in NCHS standards

Assessing prevalence of undernutrition: use of new WHO standards instead of NCHS standards

DLHS data base on weight for age in preschool children was used for this analysis DLHS data including data on nutritional status was made available by IIPS Mumbai Data analysis plan was prepared through collaboration between NFI and NIHFW Data analysis was done at NIHFW

Median of the DLHS data is just below the 3 rd centile of WHO standards after the third month.

Under-weight rates in 0-6 month as assessed by the NCHS standards ( % ) is unrealistically low in view of 30% low birth-weight rate in the country. With new WHO standards, prevalence of under- weight in first three months is 30% suggesting that breast feeding in the first three months prevents deterioration in nutritional status

Computed under-nutrition rates in the critical 0-6 month age group with new WHO standard are higher as compared to under -nutrition rates derived from NCHS/WHO standards This should be viewed as a correction of a historical fallacy and not as alarming rise in under weight rates in 0-6 age group

After 3 months underweight rate rises –? due to early introduction of milk supplements Between 6 and 11 months underweight rate further rises to 45 % -?due to inadequate complementary feeding Analysis of data using new WHO norms clearly brings out importance of wrong infant feeding habits as determinants of underweight in infancy New WHO norms can be used to bring home the critical importance of nutrition education for improving infant feeding practices and nutritional status of infant.

Progressive increase in the underweight rates in 12 to 24 months of age – ?attributable to inadequate intake of family food due to poor child feeding practices. Nutrition education that children have small stomach capacity, and should be fed 5-6 times to provide them adequate food may help in improving the dietary intake and nutritional status of children in this age group.

In the 1-5 year age group the computed undernutrition rates using the new WHO standards are substantially lower as compared to those computed from NCHS standards. This should not be allowed to generate a sense of complacency that undernutrition rates are falling

Assessing prevalence of undernutrition using IAP & new WHO standards

DLHS median is above Harvard median till four months and becomes below Harvard 80% median by 12 months. DLHS 3 rd centile is more or less similar to 50 % of Harvard median.

If the new WHO standards are used instead of NCHS standards in surveys and ICDS continues to use IAP standards, there will be substantial differences in the reported prevalence of underweight between surveys and ICDS service reporting; unlike surveys ICDS will continue to report gender differences in prevalence of undernutrition.

NFI studies and WHO standards

NFI had initiated studies in Anganwadis in North West Delhi in August 2006 Information on infant and child feeding practices, morbidity during 15 days prior to visit and health and nutrition care seeking behavior was collected Anthropometric indices were measured

Exclusively breastfed infants grow well in the first six months. Infants who are exclusive breastfed beyond six months weigh less than those who receive complementary feeds and breast milk.

The median weight for age for boys from Delhi anganwadis is comparable to 3rd centile of WHO standards;97thcentile weight for age of children are more or less similar to median of WHO standards

The median height for age for boys from Delhi anganwadis is below the 3rd centile of WHO standards; 97thcentile height for age of children are more or less similar to median of WHO standards

Unlike height & weight for age, 3 rd centile, median & 97 th centile BMI for age are just below corresponding values of WHO standards

The question which of the three indices - weight for age, height for age and BMI for age is the most appropriate for assessment of nutritional status in an era when both under and overnutrition are public health problems has to be answered through research studies

To sum up

Use of new WHO growth standards: Corrects the historical fallacy of using formula fed children from single ethnic group in one country as global standard and consequent problems in interpretation of data. Computed under-nutrition rates in the critical 0-6 month age group with new WHO standard are higher as compared to under -nutrition rates derived from NCHS/WHO standards – this should not be viewed with alarm Computed under-nutrition rates in 1-5 year age with new WHO standard are lower as compared to under -nutrition rates derived from NCHS/WHO standards – this should not lead to complacency

Use of new WHO growth standards can make an important contribution in clearly bringing into focus the importance of nutrition and health education in improving infant and young child feeding and caring practices and reducing the under-nutrition in preschool children

Low birth-weight rate in India is 30% Prevalence of under-weight in first three months is 30% suggesting that breast feeding in the first three months prevents deterioration in nutritional status After 3 months underweight rate rises –? due to early introduction of milk supplements Between 6 and 11 months underweight rate further rises to 45 % -?due to inadequate complementary feeding Analysis of data using new WHO norms clearly brings out importance of wrong infant feeding habits as determinants of underweight in infancy and emphasises importance of nutrition education to correct them.

Progressive increase in the underweight rates in 12 to 24 months of age – ?attributable to inadequate intake of family food due to poor child feeding practices. Need for nutrition education to correct these faulty habits. With the availability of new WHO standards for weight for age, height for age and BMI for age clinicians and research workers can assess which of the three indices is the most a appropriate index for assessment of functional de-compensation in the era when both under and overnutrition are public health problems