In the year 2005-06, the Third Round of National Family Health Survey (NFHS 2005-06) released state and national level estimates on the nutritional status of children under five years of age in India. The report noted that 40.4 per cent of the children in India were reported as underweight. Subsequently in the HUNGaMA Report presented in the year 2011, the indicator for malnutrition remained as high as the previous reports, with 40 per cent of the children underweight and 60 per cent stunted.
In the financial year of 2010-11, the approved budget outlay for expenditure under public health stood at INR 5560 crores while the subsequent budget raised the outlay to INR 5720 crores. The nutritional estimates raised a fundamental question on the efficacy of health interventions at a point of time when India spent nearly 4 per cent of its GDP over public health. It lead the then Prime Minister Manmohan Singh observe that the issue of malnutrition among children was a “national shame”.
However, the reports were far from being universally accepted and were also widely criticized on methodological grounds. In his working paper titled “The Myth of Child Malnutrition in India”, released by IIPS (International Institute of Population Sciences), Arvind Panagariya questioned the use of reference standards for classifying children (under five years of age) as malnourished. Seconding the argument, Panagariya also questioned whether a certain individual suffering from malnutrition can be “pushed” into the safe (adequately nourished zone) within their life time as it takes generations for a population to reach its full nutritional potential.
While the second argument can be more prudently discussed by students and scholars of medical fraternity, much can be said about the first; reference standards. My understanding over the methodological protocol involved while calculating malnutrition majorly stems from the nutritional analysis conducted on the data gathered by Annual Health Survey – Clinical Anthropometric and Biochemical survey (AHS-CAB, 2013-2014). After its release, AHS-CAB shall provide the most recent estimates on malnutrition and non-communicable, life-style oriented diseases for the 9 EAG states in India.
There are presently popular reference standards for calculating malnutrition namely; NCHS (National Centre Health Statistics, U.S.) Standards and the MGRS (Multicenter Growth Study Group, WHO) standards. While the NFHS 2 (National Family Health Survey, Second Round) made use of NCHS standards, subsequently the NFHS 3 made use of MGRS standards. AHS-CAB makes use of the MGRS reference standards 2007, updated by WHO. Both the studies provide a normal growth curve for children under 5 years of age and can be most popularly seen in the growth charts available at Sub-Centres or hospitals in India. While these be the tools, how does one calculate “malnutrition” per se?
The reference standards calculates three constructs namely:
- Weight for Height (Wasting) – Whether the child has adequate weight for his/her present height. The construct may depict rapid loss in weight owing to high incidence of diseases.
- Height for Age (Stunting) – Whether the child has adequate height/length for his/her age.
- Weight for Age (Underweight) – Whether the child has adequate weight for his/her age.
While Wasting represents a rapid loss in weight vis-à-vis the child’s height, stunting represents a long-term undernourishment. Finally, underweight is used as a composite score for both wasting and stunting and is most popularly reported (given the relative stability). The Growth Charts available with the frontline workers also aims to track the indicator of underweight (Weight for Age). Children lying below -2 SD are considered as moderately malnourished, children lying below -3 SD are considered as severely malnourished.
Though the process follows a robust model, the questions arise after calculation of Z-scores for the three constructs. The current MGRS reference standard is based on the data collected across Brazil, Ghana, India, Norway, Oman and U.S) vis-à-vis the NCHS. However, the growth chart follows a logic, as pointed out by Panagariya that, “all differences between the height and weight of population occur due the differences in nutrition”. Therefore, the scores observe that the differences between the sample of a child taken from a well-to-do neighborhood in New Delhi and one residing at a remote village in the state of Chhattisgarh is solely because of the nutritional differences. While this might make statistical sense, in all actuality populations differ based upon their race, ethnicity, cultural practices and genetic make-up. Effectively, one is therefore not comparing apple with an apple by following the standards.
While this can be regarded as one of the several issues plaguing the methodology, a deeper concern arises with the hiatus caused by unquestioned reporting and linear interpretation of the reports. If unexplained and unchecked, the public outcry over malnutrition might cause health practitioners to push infants recording low birth weight above the malnutrition levels through administration of external supplements, a trend not unknown to us currently. If this be a way forward, what happens to the previous argument of longitudinal “catching-up” process? What is the upper limit for the supplement beyond which one risks building obesity? Given the limitations, whether one should make use of reference standards at all?
Such questions need to be addressed while one interprets the survey results. While reference standards are the most convenient and popularly used methods, they should also be interpreted with more care and prudence. India is well placed to develop its own reference standards based upon a more diverse sample that can be regularly updated. While such considerations lie mostly with the policy makers, it is recommended that the underlying concepts of nutrition should be disseminated within the larger populace using simple language. In the words of an anonymous author, “An educated citizenry is a vital requisite for our survival as a free people”.