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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 6  |  Page : 624-629  

Assessment of Agreement between the National (Indian Academy of Pediatrics) and International (Centers for Disease Control and World Health Organization) growth references among tibetan adolescent girls of Kangra District, Himachal Pradesh


Department of Anthropology, University of Delhi, New Delhi, India

Date of Submission20-Jan-2020
Date of Decision24-Jun-2020
Date of Acceptance24-Jun-2020
Date of Web Publication6-Nov-2020

Correspondence Address:
Shweta Singh
Department of Anthropology, University of Delhi, New Delhi-110007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_22_20

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  Abstract 


Context: Various growth assessment references are available to assess nutritional status. The use of body mass index (BMI) in adolescents is well established for clinical and public health applications. It is required to compare national references with the international, to avoid over/underestimation of BMI categories. Aims: The aim of the present study was to quantify differences in the assessment of height/age and BMI/age ratios using national (Indian Academy of Pediatrics [IAP]) and international (Centers for Disease Control and Prevention [CDC], and World Health Organization [WHO]) references. Subjects and Methods: Anthropometric measurements of 276 Tibetan adolescent girls (13–18 years old) were taken. BMI-for-age and height-for-age were measured and compared using three references – IAP 2015, WHO 2007, and CDC 2000. Statistical Analysis Used: Kappa coefficient was done between different references using SPSS version 20 and MS-excel. Results: The prevalence of overweight/obesity was reported highest (23.55%) by IAP references, while stunting was highest (17.26%) with CDC references. A substantial agreement (k = 0.623) was observed in stunting and almost perfect agreement (k = 0.868) was observed for BMI categories between WHO and CDC. The disagreement level was highest in IAP and CDC for stunting and IAP and WHO for BMI categories. Conclusions: Prevalence of malnutrition differs with the application of different references. National references producing higher estimates of obesity than international definition indicates that decisions regarding whether or not to use national BMI references, should always be undertaken with caution.

Keywords: Adolescent girls, body mass index, growth references, stunting


How to cite this article:
Singh S, Singh N, Kshatriya GK. Assessment of Agreement between the National (Indian Academy of Pediatrics) and International (Centers for Disease Control and World Health Organization) growth references among tibetan adolescent girls of Kangra District, Himachal Pradesh. Med J DY Patil Vidyapeeth 2020;13:624-9

How to cite this URL:
Singh S, Singh N, Kshatriya GK. Assessment of Agreement between the National (Indian Academy of Pediatrics) and International (Centers for Disease Control and World Health Organization) growth references among tibetan adolescent girls of Kangra District, Himachal Pradesh. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Dec 5];13:624-9. Available from: https://www.mjdrdypv.org/text.asp?2020/13/6/624/300132




  Introduction Top


Monitoring the growth pattern to obtain collective and individual health information is an important tool for the assessment of adolescent's nutritional status, which allows for earlier interventions when needed.[1],[2] Despite other techniques, anthropometric measures, mainly weight and height, are highly being used for the determination of nutritional status among children and adolescents.[3]

Various growth assessment references are present to assess the nutritional status of children and adolescents. Growth graphs are considered valuable resources to determine different parameters of growth.[4] One such reference was given in 1977, when the National Center for health Statistics (NCHS) and World Health Organization (WHO) disseminated and recommended a weight-for-age, weight-for-height, length-for-height, length-for-age, height-for-age and head circumference-for-age framework for application in the United States to female and male children and adolescents.[5]

These reference curves were used for more than 20 years. Later in 1985, to remove the existing limitations, a review of the reference was done which resulted in the formation of another reference. Thus, the Centers for Disease Control (CDC) published a study in 2000 using the data that had been collected in seven studies, carried out in the United States and Northern Europe.[6] The need to have body mass index (BMI) curves that start at 5 years and allow unrestricted calculation of percentile and z-score curves on age scale from 5 to 19 years resulted in reconstruction of NCHS/WHO reference.[7] As a result, WHO in 2007 gave new references.

Growth patterns differ among different populations of the world as various factors such as nutritional, environmental, genetic, and timing of puberty play a significant role. Hence, it is required to have country-specific growth charts to monitor the growth of children between 5 and 18 years. In 2007, the Indian Academy of Pediatrics (IAP) had published growth monitoring guidelines for Indian children from birth to 18 years based on the then available data from 1989 which is now decades old.[8],[9],[10] The pattern of growth of a population changes with time and hence, it was recommended that references should be updated regularly to reflect current growth patterns and secular trends.[11] Using the statistical approach as suggested by the WHO, in January 2015, the IAP published revised growth charts for 5–18-year-old Indian children to replace earlier IAP charts.[12],[13],[14]

The use of BMI to define underweight, overweight, or obesity in children and adolescents is well established for both clinical and public health applications.[15] It is required to compare national references with the international references, to avoid over/underestimation of BMI categories.[16] Therefore, the aim of the present study was to quantify differences arising in the assessment of height-for-age and BMI-for-age ratios when national (IAP 2015) and international (CDC 2000 and WHO 2007) reference data were used.


  Subjects and Methods Top


Study design and population

A cross-sectional survey was conducted among 276 Tibetan adolescent girls (13–18 years) at three schools of Kangra district, Himachal Pradesh, India, during October–November 2018. After obtaining authorized consent from the school management, data were collected using stratified random sampling technique. Ethical permission was taken from the Ethical Committee of the Department of Anthropology (Ref. No./Anth./2018/2893/December 28, dated December 19, 2018). All anthropometric measurements were taken as per the references given by the International Society for the Advancement of Kinanthropometry.[17] Height was measured to the nearest 0.5 cm, using anthropometric rod, while weight was measured to the nearest 0.5 kg, using a floor-type weighing scale. The cutoff points to analyze the nutritional status of children as recommended by the WHO 2007, CDC 2000 and IAP 2015 are given in [Table 1].
Table 1: Cut-off points for nutritional status of adolescents by World Health Organization 2007, Centers for Disease Control 2000, and Indian Academy of Pediatrics 2015

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Statistical analysis

BMI-for-age and height-for-age ratios were calculated for each of the references using SPSS (Statistical Package for Social Sciences) version 20 (IBM Corp. Released 2013. Armonk, New York, United States). and MS-Excel. To assess the child growth agreement coefficient between the BMI-for-age and height-for-age ratios according to the CDC 2000, WHO 2007 and IAP 2015 reference, the Kappa Test was used for nominal variables (height-for-age) and the weighted Kappa coefficient for ordinal variables (BMI-for-age). The k values were estimated with 95% CI and were considered to be in poor agreement if the k< 0.00 “poor,” slight agreement if the values were between 0 and 0.20; fair agreement if the values were between 0.21 and 0.40; moderate agreement when between 0.41 and 0.60; substantial agreement when between 0.61 and 0.80; and almost perfect agreement when between 0.81 and 1.00.[18]


  Results Top


A total of 276 adolescent girls aged 13–18 years were considered for the study. [Table 2] represents the prevalence of BMI categories and stunting among studied population based on different growth references. As per IAP 2015 reference, none of the participants was underweight, while slight difference was reported in case of underweight for WHO 2007 (1.08%) and CDC 2000 (1.81%) reference. Similarly, the prevalence of normal category was high based on CDC 2000 (88.4%) and WHO 2007 (86.95%), while that based on IAP 2015 (76.44%) was lowest among the three references. In case of overweight, the highest prevalence was reported under IAP 2015 (23.55%) reference than WHO 2007 (11.95%) and CDC 2000 (9.78%). Along with this, the prevalence of stunting was found to be highest under CDC 2000 (17.26%) reference while lowest under IAP 2015 (3.62%).
Table 2: Prevalence of body mass index and stunting among Tibetan adolescent girls based on different growth references (n=276)

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[Table 3] shows the BMI-for-age diagnosis of adolescent girls, analyzing the agreement coefficient between the CDC 2000, IAP 2015, and WHO 2007 references. It shows 60% of agreement on the girls considered underweight by CDC 2000 and WHO 2007 references, representing three girls. Among the adolescents classified as normal, we found 238 girls according to the two references, with 97.6% of agreement on this diagnosis. The agreement level on the adolescent girls with overweight was 100% according to both references, which classified 27 girls in this category. The Kappa coefficient estimate of 86.8% showed almost perfect agreement between CDC 2000 and WHO 2007 references on the results of the BMI-for-age diagnosis and shows disagreement in 13.2% of the participants.
Table 3: Distribution of Tibetan adolescent girls, according to Kappa agreement coefficient of body mass index-for-age according to World Health Organization 2007, Centers for Disease Control 2000, and Indian Academy of Pediatrics 2015 references

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The WHO 2007 and IAP 2015 references show 98.6% agreement on the girls considered with normal weight, representing 208 girls. The agreement level on the adolescent girls with overweight was 50.8% according to both references, which classified 33 girls in this category. The Kappa coefficient estimate of 58.7% show moderate agreement between the WHO 2007 and IAP 2015 on the results of the BMI-for-age diagnosis and show disagreement in 41.3% of the participants [Table 3].

The CDC 2000 and IAP 2015 references show 84.4% of agreement on the girls classified as normal, representing 206 adolescent girls. The agreement level on the adolescent girls with overweight was 100% according to both references, which classified 27 girls in this category. The Kappa coefficient estimate of 48.3% shows moderate agreement between CDC 2000 and IAP 2015 on the results of BMI-for-age diagnosis and shows disagreement in 51.7% of participants [Table 3]. [Figure 1] illustrates the BMI-for-age diagnosis of adolescent girls, analyzing the agreement coefficient between the CDC 2000, IAP 2015, and WHO 2007 references.
Figure 1: Kappa agreement coefficient for body mass index-for-age standards

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[Table 4] shows the height-for-age diagnosis of adolescent girls, analyzing the agreement coefficient between the CDC 2000, IAP 2015, and WHO 2007 references. It was found that 24 girls were diagnosed as stunted, according to CDC 2000 and WHO 2007 references, representing a 50% agreement level on this diagnosis, against 100% of agreement in girls considered as nonstunted. According to the Kappa coefficient, these two references show substantial agreement of 62.3% between CDC 2000 and WHO 2007 on the results of the height-for-age diagnosis and shows disagreement in 37.7% of the participants.
Table 4: Distribution of Tibetan adolescent girls, according to Kappa agreement coefficient of height-for-age according to World Health Organization 2007, Centers for Disease Control 2000, and Indian Academy of Pediatrics 2015 references

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The WHO 2007 and IAP 2015 references show 100% agreement on girls considered as stunted against 94.7% of agreement in girls classified as nonstunted. According to Kappa coefficient, these two references show moderate agreement of 56.6% between WHO 2007 and IAP 2015 on the results of the height-for-age diagnosis and show disagreement in 43.4% of the participants [Table 4].

The CDC 2000 and IAP 2015 references shows 100% agreement on girls considered as stunted against 85.7% of agreement in girls classified as nonstunted. According to Kappa coefficient, these two references show fair agreement of 30.4% between CDC 2000 and IAP 2015 on the results of the height-for-age diagnosis while show substantial disagreement in 69.6% of the participants [Table 4]. [Figure 2] illustrates the height-for-age diagnosis of adolescent girls, analyzing the agreement coefficient between the CDC 2000, IAP 2015, and WHO 2007 references.
Figure 2: Kappa agreement coefficient for height-for-age standards

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  Discussion Top


This study compared the ability of a national IAP 2015 BMI-for-age and height-for-age reference for estimating malnutrition in adolescents with the two frequently employed international references, the WHO 2007 and CDC 2000, and demonstrated that there was mostly a moderate agreement between these three classifications.

This study illustrates that the percentage of adolescents classified as underweight, overweight, and stunted varies considerably depending on the cutoff points of BMI used. The prevalence of overweight/obesity as measured by CDC 2000 (9.78%) was very low than those measured by IAP 2015 (23.55%) and WHO 2007 (11.95%) standards, indicating that CDC 2000 standards underestimate the obesity among adolescents in India. Similar findings were observed by different studies from India in recent years.[19],[20],[21] On the other hand, the prevalence rates of stunting as per CDC 2000 references (17.26%) were higher than WHO 2007 (8.69%) and IAP 2015 (3.62%) references. Overweight and obesity prevalence reported among the present study was higher than reported by different studies of India using the similar classifications.[19],[20],[22],[23],[24],[25],[26]

The reasons for the differences observed between the classifications of BMI-for-age and height-for-age can be explained because of the different population, different references used and the methods used to construct them. These differences affect the level of cutoff points affecting the results.[27] The choice of what would be normal weight in the reference population can vary substantially between countries, and many countries have their own growth charts for children.[28]

The comparison between the three references through the statistical test to assess the agreement coefficient showed that, in the height-for-age assessment, 62.3% of agreement between CDC 2000 and WHO 2007, 56.6% between IAP 2015 and WHO 2007, and 30.4% between IAP 2015 and CDC 2000 exists. For the BMI-for-age, agreement levels amounted to 86.8% between WHO 2007 and CDC 2000, 58.7% between IAP 2015 and WHO 2007, and 48.3% between IAP 2015 and CDC 2000. Hence, the highest agreement for both height-for-age and BMI-for-age was obtained between WHO 2007 and CDC 2000 criteria. This indicates that both the references can be used to estimate the prevalence of obesity, overweight, normal weight, and thinness among school children and adolescents in India.[29] Also, a substantial agreement (κ = 0.66) was observed between IAP 2015 and WHO 2007 references in other studies as well.[30]

There is still a dilemma for using national or international reference data for the assessment of nutritional status.[31],[32] Further studies are required to use a larger sample size at national level in order to define the best criteria for assessing BMI status. The differences observed can have important implications in public health, such as surveillance of nutritional status, identifying secular trends and evaluating the impact of interventional programmes.[33]


  Conclusions Top


Prevalence of malnutrition differs with the application of different references. It is required to choose suitable reference carefully to avoid any potential misclassification of adolescents. This study shows that high prevalence of obesity/overweight was reported with IAP 2015 references than CDC 2000 and WHO 2007, while for stunting, high prevalence was reported with CDC 2000 than WHO 2007 and IAP 2015. The agreement level was highest between WHO 2007 and CDC 2000 for both height-for-age and for BMI-for-age. The fact that national definition of obesity (IAP 2015) produced higher estimates of obesity prevalence than the international definition is a clear indication that public health decisions regarding whether or not to use national BMI reference for the assessment of nutritional status should be undertaken with caution.

Acknowledgment

The authors duly acknowledge all the participants and school authorities for their willing cooperation. We also acknowledge the Department of Anthropology for providing technical support.

Financial support and sponsorship

We thank the UGC NET JRF for all their financial help.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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