ADOPTION OF NEW WHO GROWTH STANDARDS ISSUES AND IMPLICATIONS

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ADOPTION OF NEW WHO GROWTH STANDARDS ISSUES
AND IMPLICATIONS PREMA RAMACHANDRAN DIRECT
OR, NUTRITON FOUNDATION OF INDIA
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• 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

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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 .
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What are the differences between the NCHS and
new WHO standards
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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
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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
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Assessing prevalence of undernutrition use of
new WHO standards instead of NCHS standards
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• 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

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Median of the DLHS data is just below the 3 rd
centile of WHO standards after the third month.
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Under-weight rates in 0-6 month as assessed
by the NCHS standards ( 10-15 ) 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
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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
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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 .
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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.
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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
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Assessing prevalence of undernutrition using IAP
new WHO standards
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DLHS median is above Harvard median till four
months and becomes below Harvard 80 median by 12
months. DLHS 3rd centile is more or less similar
to 50 of Harvard median.
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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 .
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NFI studies and WHO standards
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• 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

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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.
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The median weight for age for boys from Delhi
anganwadis is comparable to 3rd centile of WHO
standards97thcentile weight for age of children
are more or less similar to median of WHO
standards
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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
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Unlike height weight for age, 3rd centile,
median 97thcentile BMI for age are just below
corresponding values of WHO standards
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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

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To sum up
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• 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

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• 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

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• 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.

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• 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

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THANK YOU