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Indian Pediatr 2010;47: 869-872 |
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Growth Performance of Affluent Indian
Preschool Children: A Comparison with the New WHO Growth
Standard |
VV Khadilkar, AV Khadilkar and SA Chiplonkar
From Growth and Pediatric Endocrine Research Unit,
Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital,
Pune 411 001, India.
Correspondence to: Dr Vaman Khadilkar, Consultant
Pediatric Endocrinologist, Hirabai Cowasji Jehangir Medical Research
Institute, Jehangir Hospital, 32, Sassoon Road, Pune 411 001, India.
Email: [email protected]
Received: June 29, 2009;
Initial review: July 20, 2009;
Accepted: October 1, 2009.
Published online: 2010 January 15.
PII: S097475590900451-1
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Abstract
This study was conducted to evaluate the nutritional
status of 2-5 year old affluent, urban children using the new WHO 2006
standards. A cross-sectional, multicentric preschool-based study was
conducted on 1493 children (727 boys). Mean Z scores for height,
weight, body mass index and weight for height (-0.75(1.1), -0.59(1.1),
0.19(1.22) and -0.26(1.18), respectively) were below the WHO standard
median.
Key words: Growth, India, Preschool children, WHO.
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M alnutrition poses a grave risk to
the health of preschool children in developing countries. The relative
magnitude of different measures of nutritional status is affected by the
choice of reference charts used. In April 2006, the World Health
Organization (WHO) released child growth standards for children up to the
age of 5 years, to provide a multiethnic benchmark for breastfed
children(1).
We conducted a multicentric, cross-sectional study to
assess how Indian affluent preschool children (2-5 year) match or diverge
from the WHO 2006 standards. We also compared the percentage of children
who were underweight and stunted according to the WHO 2006 and WHO 1977
(WHO/NCHS) standards(2).
Methods
1493 children (mean age 3.8±0.8 years, 727 boys) 317
(152 boys-North), 325 (150 boys-South), 371 (222 boys-East), 480 (203
boys-West) were studied between June 2007 and January 2008. Eight study
sites were selected. Nutritionally well-off areas (i.e. areas without slum
clusters, low income housing schemes and those with high land prices as
published by Government agencies) were identified and list of schools
catering to children of socio-economically well-off families was prepared
(Yearly fees around Rs 10000 (Indian per capita income 2007-2008, Rs
2021/month)(4). Three schools were selected by generating random numbers.
Based upon reported variance on heights and weights of affluent Indian
children, sample size of 1346 children in 2-5 y age group was determined
with type I error probability of 0.05 and power of the test to be 0.90 to
detect a difference of 0.5 cm in height or 0.5 kg in weight in age-and
sex-groups(5). Therefore a cohort of around 1500 children was selected and
informed consent was obtained from nine schools.
Height was measured using Leicester Height Meter (Child
Growth Foundation, UK, range 60-207cm), weight was measured using portable
electronic weighing scales (Salter, India) (100g). The study was approved
by our Institutional ethics committee. Measurers were tested for height
inter- and intra-observer variability (20 subjects, each observer measured
4 children 4 times), coefficients of variation were < 0.01(1%). Seven
subjects with Z scores exceeding ±5SD and children with major illnesses
were excluded (verified by pediatrician)(6). LMS Growth programme, WHO
Anthro 2005 (WHO homepage (http:// www.who.int/child-growth/software/en/),
EPI_INFO v6.04 and SPSS 11.0 (Chicago, USA, 2001) were used for analysis.
Percentage of children stunted (height for age <-2 SD), underweight
(weight-for-age < -2 SD), wasted (weight for height <-2 SD) and with low
BMI (BMI for age <-2 SD) according to the WHO 2006 and WHO/NCHS standards,
were calculated.
Results
Table I shows smoothened percentile values for
the study population. The 3rd and 50th percentiles for height, weight and
BMI for the study population were lower, and the 97th percentiles for
boys, height, weight and BMI were higher than the WHO standards (data not
presented). The mean Z scores for height, weight, BMI and weight for
height (0.75(1.1), 0.59(1.1), 0.19(1.22) and 0.26(1.18), respectively)
were below the WHO 2006 standard median. Table II shows age
and sex wise distribution of Z scores for height, weight, BMI and weight
for height based on WHO 2006 standards. Percent of children (boys and
girls) stunted, underweight, wasted or having weight for height Z score
<-2 when using the WHO 2006 and the WHO/NCHS cut-offs is illustrated in
Table III.
Table I
Height, Weight and BMI Percentile Values for Boys and Girls
Age (in years) |
Gender |
Height Percentile (in cm) |
|
|
3 |
10 |
25 |
50 |
75 |
90 |
97 |
2 |
Boys |
- |
79.3 |
81.9 |
84.8 |
87.8 |
90.9 |
- |
|
Girls |
77.6 |
80 |
82.5 |
85.3 |
88.2 |
91.3 |
94.7 |
2.5 |
Boys |
80.3 |
83 |
85.8 |
88.7 |
91.8 |
95.1 |
98.5 |
|
Girls |
80.7 |
83.2 |
85.9 |
88.7 |
91.8 |
95 |
98.5 |
3 |
Boys |
83.9 |
86.7 |
89.6 |
92.6 |
95.8 |
99.2 |
102.8 |
|
Girls |
83.8 |
86.5 |
89.3 |
92.2 |
95.4 |
98.7 |
102.2 |
3.5 |
Boys |
87.5 |
90.4 |
93.4 |
96.6 |
99.9 |
103.3 |
106.9 |
|
Girls |
90 |
92.9 |
96 |
99.2 |
102.5 |
106 |
109.6 |
4 |
Boys |
91 |
94 |
97.2 |
100.4 |
103.8 |
107.4 |
111.1 |
|
Girls |
90 |
92.9 |
96 |
99.2 |
102.5 |
106 |
109.6 |
4.5 |
Boys |
94.4 |
97.6 |
100.8 |
104.2 |
107.7 |
111.3 |
115.1 |
|
Girls |
- |
96.1 |
99.3 |
102.6 |
106 |
109.6 |
- |
5 |
Boys |
97.8 |
101 |
104.4 |
107.9 |
111.4 |
115.1 |
119 |
|
Girls |
96.1 |
99.3 |
102.6 |
106 |
109.6 |
113.2 |
117 |
Weight Percentile (in Kg) |
|
|
3 |
10 |
25 |
50 |
75 |
90 |
97 |
2 |
Boys |
- |
9 |
9.7 |
10.6 |
11.8 |
13.3 |
- |
|
Girls |
8.6 |
9.2 |
9.8 |
10.6 |
11.4 |
12.4 |
13.6 |
2.5 |
Boys |
9.1 |
9.8 |
10.7 |
11.7 |
13 |
14.7 |
17.1 |
|
Girls |
9.3 |
9.9 |
10.7 |
11.5 |
12.5 |
13.7 |
15.2 |
3 |
Boys |
9.9 |
10.7 |
11.7 |
12.8 |
14.3 |
16.3 |
18.9 |
|
Girls |
9.9 |
10.7 |
11.5 |
12.5 |
13.7 |
15.1 |
16.7 |
3.5 |
Boys |
10.7 |
11.6 |
12.7 |
14 |
15.6 |
17.8 |
20.8 |
|
Girls |
10.6 |
11.4 |
12.4 |
13.5 |
14.8 |
16.4 |
18.4 |
4 |
Boys |
11.5 |
12.5 |
13.6 |
15.1 |
17 |
19.4 |
22.8 |
|
Girls |
11.2 |
12.1 |
13.2 |
14.5 |
16 |
17.8 |
20.1 |
4.5 |
Boys |
12.2 |
13.3 |
14.6 |
16.2 |
18.3 |
21 |
24.8 |
|
Girls |
- |
12.9 |
14.1 |
15.5 |
17.2 |
19.3 |
- |
5 |
Boys |
13 |
14.2 |
15.6 |
17.4 |
19.7 |
22.7 |
26.9 |
|
Girls |
12.5 |
13.6 |
14.9 |
16.5 |
18.4 |
20.8 |
23.8 |
BMI Percentile (in Kg/m2) |
|
|
3 |
10 |
25 |
50 |
75 |
85 |
95 |
2 |
Boys |
- |
13 |
13.8 |
14.7 |
15.9 |
16.6 |
- |
|
Girls |
11.8 |
12.5 |
13.3 |
14.4 |
15.6 |
16.4 |
17.8 |
2.5 |
Boys |
12.4 |
13 |
13.8 |
14.8 |
16 |
16.7 |
18.1 |
|
Girls |
11.8 |
12.5 |
13.4 |
14.4 |
15.7 |
16.5 |
18 |
3 |
Boys |
12.3 |
13 |
13.8 |
14.8 |
16.1 |
16.8 |
18.4 |
|
Girls |
11.8 |
12.6 |
13.4 |
14.5 |
15.8 |
16.6 |
18.2 |
3.5 |
Boys |
12.3 |
13 |
13.8 |
14.9 |
16.2 |
17 |
18.6 |
|
Girls |
11.9 |
12.6 |
13.5 |
14.6 |
15.9 |
16.7 |
18.3 |
4 |
Boys |
12.3 |
13 |
13.8 |
14.9 |
16.3 |
17.1 |
18.8 |
|
Girls |
11.9 |
12.6 |
13.5 |
14.6 |
16 |
16.9 |
18.5 |
4.5 |
Boys |
12.3 |
13 |
13.9 |
15 |
16.4 |
17.2 |
19 |
|
Girls |
- |
12.6 |
13.5 |
14.7 |
16.1 |
17 |
- |
5 |
Boys |
12.3 |
13 |
13.9 |
15 |
16.5 |
17.4 |
19.3 |
|
Girls |
11.9 |
12.6 |
13.6 |
14.7 |
16.2 |
17.1 |
18.9 |
Table II
Height, Weight and BMI Z Scores Based on WHO 2006 Standards
Parameter |
Age Interval |
Boys |
Girls |
|
(yr) |
Z score |
Z score |
Height |
2-3 |
1.0 |
0.8 |
|
3-4 |
0.4 |
0.7 |
|
4-5 |
0.6 |
0.9 |
Weight |
2-3 |
0.8 |
0.3 |
|
3-4 |
0.4 |
0.4 |
|
4-5 |
0.4 |
0.7 |
BMI |
2-3 |
0.2 |
0.3 |
|
3-4 |
0.2 |
0.3 |
|
4-5 |
0.0 |
0.3 |
Weight for Height |
2-3 |
0.3 |
0.3 |
|
3-4 |
0.3 |
0.3 |
|
4-5 |
0.1 |
0.3 |
* BMI: Body mass index. |
Table III
Percentage of Children with Z Score Below -2 and Above +2 for Height, Weight, BMI and Weight
for Height Using the WHO 2006 and WHO/NCHS (1977) Standards
Parameter |
Boys (%) |
Girls (%) |
|
WHO 2006 |
WHO/NCHS |
WHO 2006 |
WHO/NCHS |
Stunting
(Z score < -2) |
13.6 |
11.2 |
11.2 |
6.7 |
Underweight (Z score < -2) |
8.5 |
10.7 |
10.4 |
10.6 |
Wasting
(Z score < -2) |
4.3 |
12.9 |
9.4 |
17.5 |
Wt For
Ht* (Z score < -2) |
6.4 |
3.9 |
8.1 |
6.7 |
Tall (Z
score >2) |
1.4 |
5.2 |
1 |
10.5 |
Overweight (Z score >2) |
3.6 |
4.9 |
0.6 |
2.7 |
BMI >95th
percentile |
7.3 |
5.5 |
3.8 |
2.2 |
Wt For
Ht* (Z score >2) |
5.5 |
4.5 |
3 |
1.6 |
* Weight for height; BMI: Body mass index |
Discussion
Our study shows that as a group, the mean Z
scores for height, weight, BMI and weight for height for the study
population were below the WHO 2006 standard median. From the age of 2
years until 5 years, the mean Z score for height, weight and BMI
showed consistent improvement when compared with the WHO 2006 standards.
Interestingly, the BMI did not differ much from the WHO 2006 standards,
suggesting relatively small body size. Using the WHO 2006 cut-offs, a
higher percentage of boys and girls were classified as being stunted and
wasted, lower percentage of boys were classified as being underweight, a
similar number of girls were classified as being underweight using both
cut-offs and a lower percentage were classified as having BMI<-2SD.
The WHO 2006 standards have placed the breastfed child
as the norm for growth and have set a lower standard for weight gain as
compared to the WHO/NCHS charts(7). This would reduce the threshold for
diagnosis of overweight and obesity, thus helping to curb the global
epidemic of obesity. At present, charts published by Agarwal, et al.
for Indian children under 5 years of age are in use(8). However,
implementing the use of the WHO standards by all caregivers of children
under 5 years would reduce the confusion resulting from the use of
multiple charts; this is particularly relevant in todays era of migration
and global traffic.
Our data suggest that change to WHO 2006 standards may
have some impact on nutritional indicators in clinical practice and on
National statistics used to measure the success of government initiatives.
Using the new standards could give the impression of deterioration in
nutritional status if previous data are not re-analyzed. Healthcare
professionals looking after children thus need to be trained before the
new charts are adopted.
Our study has several shortcomings. The study is
cross-sectional and due to logistic reasons we have not measured children
<2 years or recorded birth, parental or feeding history. It is possible
that the relationship to the standards may vary according to age and our
results may have been affected to some extent as the 0-2 age group could
not be represented.
Conributors: The study was planned by AVK, VVK and
SAC. AVK organized the data collection. Data were analyzed and the
manuscript was prepared by all authors. VVK will act as guarantor of the
study.
Funding: Unconditional Grant from Eli Lilly India
and the HCJMRI Jehangir Hospital, Pune.
Competing interests: None stated.
Annexure-I
Participating Investigators
Sanwar Agrawal, Ekta Institute of Child Health,
Raipur; Archana Dayal Arya, Sir Ganga Ram Hospital, New Delhi;
Anil Bhansali, PGIMER, Chandigarh; Shaila Bhattacharya,
Manipal Hospital, Bangalore; Rajesh Chokhani, Health care for
children, Mumbai; Subhankar Chowdhury, IPGME&R and SSKM Hospital,
Kolkata; Vaishali Ghelani, Girgaon, Mumbai; Jayashree Gopal,
Apollo Hospitals, Chennai; Jayanthy Ramesh, Hyderabad; and
Mona Shah, Baroda.
What This Study Adds?
The growth performance of affluent Indian preschool children
was suboptimal compared with the new WHO growth standard.
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