The Nutritional Status of Elites in India, Kenya, and Zambia: An appropriate guide for developing reference standards for undernutrition?

Assessments of undernutrition are typically based on comparisons between anthropometric indicators of children and a reference standard from the US. Due to a number of problems associated with this reference standard, WHO is currently engaged in generating a new international reference standard for child growth based on well-to-do populations in a sample of poor and rich countries. The focus on socioeconomic elites is to ensure that the measured growth reflects their genetic potential (and not according their constrained environment). Based on an analysis of the Demographic and Health Surveys from Kenya, India, and Zambia, we identify a number of problems associated with using socioeconomic elites as representative of the genetic potential of a population. First, there are several, non-overlapping ways to identify elites. Second, the anthropometric status of elites appears to depend to a considerable degree on the nutrition and health status of non-elites. Third, there is a danger that the elites are not a random sample of the growth potential of the population. And lastly, it appears that the nutritional status of elites differs substantially between the three countries so that it is unclear how one can combine them to generate one international reference standard.