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Nutrition policy

Urban-rural comparisons of nutrition status in the third world - Sarah J. Atkinson


Debate continues on development priorities between urban and rural populations in emerging nations. A review of 33 papers on nutrition status and dietary intakes from different continents and countries found comparisons of poor urban and rural populations inconclusive. It is proposed that the two populations can never be truly comparable, and that urban-rural competition for resources is not useful. Several kinds of health and nutrition surveys could be useful for identifying priority groups and issues within the urban context.


Urban poverty and urban health in emerging nations are receiving increasing attention as development issues. The World Bank has highlighted urban poverty as the major challenge facing the next decade [l]. WHO held an international meeting in May 1991 devoted to technical discussions on strategies for health for all in the face of rapid urbanization [2]; however, little information was presented on nutrition.

Conventional wisdom has suggested that there is less malnutrition in urban than in rural populations in developing countries [3], but the figures show great variation in the cities such that averages can mask the low nutrition status of certain poorer communities [4, 5]. It is implied, though not stated explicitly, in the literature that greater variation is found in urban than in rural populations. This has been related to similarly wide variations in incomes, degree of adaptation to the environment, and food and health practices compared with rural populations [4]. Indeed nutrition status can be seen as a general indicator of both health and economic welfare.

It has been claimed that health and welfare programmes are biased in favour of urban populations, who have less need of such services [6, 7]. The counter-argument has been that, although more services may be available in the cities, the urban poor have little access to them and are thus as much in need of development attention as rural dwellers [8]. This argument continually recurs over priorities for development policy orientation and resource allocation.

We reviewed 33 papers that specifically compare poor urban and rural populations in developing countries with regard to nutrition status and dietary intakes. Drawing together results from many different countries can indicate whether there is any clear pattern in differences between them. The question then arises as to whether this traditional comparison provides a useful approach in setting development priorities.

Urban and rural nutrition

Anthropometry and biochemical status

Nutrition status is most often assessed through nutritional anthropometry in children under five years of age; information on other age groups is sparse. Biochemical status and the prevalence of overt deficiencies of specific nutrients are also sometimes examined.

Little has been found comparing rural and urban populations. Nutrition status was reported to be worse in poor areas of cities than in rural areas in Indonesia [9], Thailand [10, 11], India [12], Costa Rica, Guatemala, and El Salvador [13], and Tonga [14]. On the other hand, nutrition status was better in poor urban populations in Peru [15, 16], El Salvador [17], Nicaragua [18], Brazil [19], Gambia [20], Nigeria [21], and Zimbabwe [22].

Biochemical and dietary measures of riboflavin intakes in Recife, Brazil, showed children under five years old living in urban slums to have better status than children of cane cutters in the surrounding countryside, and this was related to the amount of milk drunk [23]. Low thiamin status was present in both rural and urban Nigerian samples of all ages, with the prevalence higher in the former. However, the prevalence of low riboflavin levels was greater in the urban sample. Both groups had good niacin intake [24].

Growth patterns and breast-feeding

Studies that go beyond describing rates of undernutrition and look at growth patterns may be more informative about differences between rural and urban risks. The growth of poor urban children faltered earlier than that of poor country-dwelling children in Thailand [25], Egypt [26], and Ghana [27].

Urban populations showed a trend toward less breastfeeding and earlier weaning than rural populations in Thailand [25], Papua New Guinea [28], the Philippines [29], and Egypt [30]. In Brazil, the downward trend in breastfeeding started to reverse in the better-off sectors of cities [31]. The earlier onset of growth faltering in urban populations was related to decreased breast-feeding in El Salvador [5], Thailand [25], India [32, 33], Papua New Guinea [28], and Pakistan [34]. By contrast, growth faltering of height in a Brazilian urban community did not start until 10 to 12 months later and was not as closely related to the cessation of breast-feeding and intake of supplementary and weaning foods as is typical in rural populations [31].

Dietary intakes

Dietary-intake studies often are undertaken as a first step in elucidating causes of poor nutrition status. Such studies have indicated that urban diets provide a more adequate energy and nutrient supply overall than rural diets in Costa Rica [35] and Tunisia [36]. A review of all available surveys in Brazil concluded that intake was more affected by low income than by urban or rural residence, although the two worst dietary patterns were in the low-income communities of Sao Paulo and Belo Horizonte. Riboflavin and calcium intakes in Brazil were lower than recommended daily allowances in low-income groups, both rural and urban, but more so in the cities. Thiamin intake was marginal in the urban samples at all income levels [37]. Urban dietary intakes were also of poorer overall quality than rural in Sao Paulo state [38].

TABLE 1. Summary of findings of papers comparing rural and urban nutrition status




Nutritional anthropometry

Urban worse than rural

Urban better than rural

Costa Rica,
El Salvador

El Salvador

10, 11


15, 16

Thiamin (Be) and riboflavin (B2) status

Urban better than rural
B1 and B2 (< 5 yrs)

Urban worse than rural





Growth patterns and breast-feeding

Urban faltering earlier
than rural

Urban weaning earlier
than rural

Faltering and weaning
related (urban)

Faltering and weaning
not related (urban)


Papua New

El Salvador
Papua New








Dietary intake

Urban better than rural

Urban worse than rural

Costa Rica





Urban greater than rural



a. National survey. 1976.


Malnutrition encompasses all aspects of poor diet, and city dwellers are expected to be more obese and to have excess intakes of fats and salt, typical of the Western diet. Obesity is more prevalent in urban populations, particularly in the richer socio-economic groups [31]. In a dormitory town of Bulawayo, Zimbabwe, where the population was not rich, living conditions were good with respect to sanitation and water. Even there, however, 50% of the adults were obese as measured by mid-upper-arm circumference. Obesity was also common in preschool children and to a lesser extent in school-age children [22]. In Maseru, Lesotho, 40% of urban women were obese according to a 1976 survey.

In Tonga the prevalence of hypertension in males and of high systolic blood pressure, which may be influenced by dietary habits, in both sexes was greater in the urban than in the rural population [39].

A critique of rural-urban comparisons

Collation of the findings of the 33 papers reviewed comparing poor rural and urban populations (table 1) shows mixed results, and statistical comparisons of the rural and urban communities are not valid.

First, the identification of rural and urban communities with comparable economic status is always open to disagreement because of the very different subsistence activities in each [40]. Second, the distribution of malnutrition is likely to be different. In a rural population, although some areas will be poorer than others, it is likely that in any one area the cases of malnutrition will be distributed across villages rather than concentrated in one or two, since most villages include a range of income levels.

By contrast, in cities the settlement pattern tends to be specifically by income, and the differences in environmental health between sections are also marked. If cluster surveys are made, greater variation between subpopulations reflects different settlement patterns rather than a difference in total malnutrition rates. What this means is that the bulk of the undernourished can be more easily found and targeted in the city. Comparisons of rates of undernutrition can be made fairly only between averages for the whole of each population, and it still remains true that in all such national surveys the rural areas show lower nutrition status (Centre for Human Nutrition, personal communication).

Given these different patterns of malnutrition distribution, it must be asked whether comparisons are useful at all. The usual rationale is that resources will be channelled toward the problem area. However, it does not seem useful to set up rural and urban populations as competitors for resources. There are poorer rural social and sometimes geographic groups, and there are poorer urban households almost always in identifiable geographic areas of a city. Both should be the focus of interventions and policies. If resources are scarce, the target groups need to be defined more specifically and cost-effective strategies identified, rather than creating an artificial divide.

The historical argument for focusing more on urban nutrition has been that city populations are growing disproportionately fast, particularly the poorer part. Figures show such an increase in both absolute and relative terms, together with an increasing absolute and relative population of slum dwellers [18~. The relative increase of the urban poor may represent migration of the rural poor to the city, and this is an additional argument in favour of addressing urban issues [40].

Support for this argument requires figures that show increasing rates of malnutrition together with models predicting future trends if preventive action is not taken to ensure access to food for the swelling urban population. Few such statistics are available, but one study along these lines indicated deteriorating health and nutrition status in Thailand [25]. Unfortunately, longitudinal studies are costly and seldom undertaken. A more practical approach is to initiate research that examines intra-urban differentials in health and nutrition indicators, together with associated social and economic factors. This approach both assists development planners to identify populations that are particularly deprived and calls attention to the degree of inequality that can exist in cities in terms of health, nutrition, and general welfare.


Dr. Atkinson is currently supported by the British ODA through the Urban Health Programme at the London School of Hygiene and Tropical Medicine.


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