A stunted child may also be underweight or wasted. Another may be overweight despite being stunted, while some children experience several forms of malnutrition simultaneously. Counting each condition separately can lead to double counting, making it hard to determine the actual number of children affected.
Researchers and public health experts in Maharashtra developed a tool to address this challenge by offering a more comprehensive assessment of children's nutritional status. The Double Burden Index of Malnutrition (DBI-PNGR) classifies children into nine distinct, non-overlapping categories, ensuring that each child is counted only once.
Developed by a team associated with the United Nations Children's Fund (UNICEF) and other public health experts, the method is described in a paper published in the International Journal of Community Medicine and Public Health. Its objective is to provide a clearer picture of the multiple nutritional challenges children face, helping health workers estimate how many children have normal growth and how many experience one or more forms of malnutrition.
The nine categories range from children with normal growth to those who are stunted, wasted, underweight or affected by combinations of these conditions. The index also accounts for children who are overweight or obese, including those who may simultaneously be stunted or underweight.
“The same child can be both wasted and stunted. This makes assessment and treatment more complex because the management of a wasted child differs from that of a stunted child. An obese child, too, needs a different diagnosis,” said Dr Mrudula Phadke, senior adviser to the National Health Mission and UNICEF, who primarily devised the method along with Rajlakshmi Nair and other researchers.
Malnutrition encompasses stunting, wasting and being underweight, as well as deficiencies of essential vitamins and minerals, overweight and obesity. These conditions can coexist in the same child, making it difficult to estimate the overall burden by simply adding figures for individual indicators.
The new classification seeks to address this gap by assigning every child to a single category, even when multiple nutritional conditions overlap. This could help health workers move beyond individual measurements and develop a more accurate understanding of the extent and nature of malnutrition.
Anganwadi workers monitor children's growth by recording their age, weight and height and comparing the measurements with World Health Organisation standards. These assessments help identify children who may require nutritional support or medical attention. Accounting for overlapping conditions could further help frontline workers plan more targeted interventions.
Data from the National Family Health Surveys (NFHS-4 and NFHS-5), along with other surveys, have shown differing trends across nutritional indicators. According to NFHS-6 figures cited by the researchers, 19.9 per cent of children are stunted, 29.5 per cent are wasted, 31.4 per cent are underweight, and 1.5 per cent are obese. The DBI-PNGR classifies children into mutually exclusive categories labelled A to I, covering children with normal growth and those who are wasted, underweight or stunted, including combinations of these conditions, as well as those who are stunted and overweight or obese. Each child is assigned to one category.
Dr Uday Bodhankar, former national president of the Indian Academy of Paediatrics, who helped develop the module, said early identification of nutritional problems could support timely intervention.
By providing a framework that accounts for overlapping nutritional conditions, the DBI-PNGR could help public health workers and policymakers assess the burden of child malnutrition more comprehensively and design interventions that respond to children's differing nutritional needs.
