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Child mortality

The mortality of children one to four years old in underdeveloped countries is more directly an expression of inadequate nutrition during and after weaning, with all its consequences, including infection-nutrition synergistic damage. Moreover, the ratio of mortality in infants to that in children one to four years old is a sensitive indicator of nutritional status land socioeconomic development). Excellent direct correlations on a country-to-country level have been found between this index and the United Nations Development index [50]. Separate data on urban and rural mortality rates for children in this age group are available from various UN Demographic Yearbooks from ten less-developed countries, seven countries with centralized economies and intermediate development, and nine developed countries.

For this age group as for infants, the differences in mortality rates between the less-developed and other countries are striking, as are the urban-rural differences in the less-developed countries. In urban areas the median value is 13 to 20 times as large as for the other countries; in rural areas it is 27 to 33 times as large.

Protein-energy deficiency

It can be argued that nutritional deficiencies are the most important determinant of poor health and mortality in the urban setting [40, 51] and that their eradication would have profound effects on the health and development of city dwellers. The generally used criteria for the diagnosis of protein-energy deficiency (PED) at the population level are estimations of the magnitude of energy deficiency, protein and specific nutrient intakes, and the prevalence of children below five of six years of age with inadequate growth defined by anthropometric measurements. This analysis is based on anthropometric criteria.

The diagnosis of chronic PED is based essentially on height-for-age deficits (below 2 SD of the median, below the fifth centile of the distribution, or 10% or greater deficit from the fiftieth centile) That of acute PED is based on weight-for-height deficits (below 2 SD of the median, below the fifth centile of the distribution, or 15% or greater deficit from the fiftieth centile). Acute PED is superimposed on chronic PED when both deficits coincide in the same child.

Relatively few sources of data report urban and rural prevalences of anthropometric deficits on a comparative basis. Table 8 presents data derived from country reports of the Office Nutrition of USAID [31-34, 52-59] tabulated in terms of percentage prevalence of chronic and acute PED, respectively, for children below five or six years of age by site of residence, and by either socio-economic condition (urban poor or total urban sample) of type of agriculture ( subsistence or cash).

In terms of chronic PED, the rural populations are either slightly or clearly worse off than their urban counterparts. The variability of its prevalence is quite striking: ranging from 8% to 60.8%, or a 7.6-fold difference, for the urban samples and from 15.6% to 72.2%, or a 4.6-fold difference, for the rural samples. The range of differences of chronic PED between urban and rural areas within any one country or region is no greater than twofold. With respect to acute PED also, the rural populations are generally worse off.

Tanner and Eveleth [60] referred to a series of studies on growth in urban and rural populations. In every case the urban population was taller and heavier than the rural. They expanded on the study of the city of Nowa Huta, Poland, where all the population had migrated from neighbouring rural or small urban towns when the city was established, 15 years before the study. The city dwellers under 15 years old were significantly taller and heavier than the children who had remained in the rural areas from which migration originated. Moreover, the children whose families had migrated from small towns were taller than those who had migrated from rural areas (fig. 2).

Growth patterns in stature for urban and rural samples from Greece, Romania, Finland, Costa Rica, and Jamaica were also analysed; all showed a progressive advantage for urban boys up to 14 to 16 years of age (fig. 3), the maximum difference being near ten inches in the case of Jamaica. The difference tended to decrease slightly by 18 years of age, since the urban boys reached maximal stature close to that age, while rural boys were still growing. In terms of relative heights among countries, Finnish boys were between three and six inches taller than other boys at age 18. Adult heights differed little between urban and rural samples from the same country, although urban adults tended to be taller than rural adults. For women, the study in Jamaica showed a stature advantage for girls up to 16 years old; after that age, rural and urban women attained the same height. In Costa Rica the urban sample remained about two inches taller at final heights Age 18).

FIG. 2. Mean heights of boys whose families migrated from towns and whose families migrated from villages, in the new town of Nowa Huta, Poland, 1967, compared with those of boys from Little Poland ( the origin of 78% of Nowa Huta immigrants ) 9-14 years old and from the rural villages of Kurpie and Suwalki at other ages (Source: Ref. 60.)

FIG. 3. Mean heights of boys in urban and rural areas in Greece, Romania, and Finland ( Source: Ref. 60.)

The urban-rural difference in growth disappeared in a United States sample when income levels were paired, except for the low-income rural group, which remained smaller than all the others. This was also the case for urban and rural populations in Bombay. In Nigeria and Costa Rica, urban slum dwellers had the same heights as rural rwellers. Finally, in Tokyo, the well-known secular increases in height has been greater in the rural population ( who were smaller before). To quote Tanner and Eveleth [60]:

In the economically impoverished urban areas of Asia, Africa, and South America the shanty-town slum dwellers are mostly not larger than their rural counterparts, though children living in the middle-class areas of the cities are. In general urban-rural differences mirror the differences seen between children in different social classes, whether in the urban or rural population.

However it does have to be borne in mind that outbreeding is greater in towns than in rural villages and that if heterosis for stature occurs in man, as it may, then this in itself would cause the adult height (though not the rate of maturation} to be greater in the towns. In addition those people who migrate from the villages to settle in towns are usually not a random sample of the village population, but may be taller and heavier than average. Thus some part of the greater adult stature of the urban population, where it occurs, may be due to these selective genetical mechanisms. Thus it seems highly probable that most, if not all, urban-rural differences are due to the economic differential between town and country dwellers, resulting in the better feeding of the well-off.

Table 9 compares data from urban and rural populations in seven Latin American countries and Jamaica [61, 42]. Urban populations are "better nourished" than their rural counterparts, but in some cities the prevalence of PED is as high as in poor rural areas. No clear predominance of early PED in the urban populations was observed [42]. Others, however, have reported early malnutrition as typical of the urban setting because of early weaning and introduction of the milk-formula bottle with all its consequences [62, 63, 50]. Earlier PED in the urban setting has also been reported in Bangkok [64]; Accra, Ghana [65]; Harere and Chitungwiza, Zimbabwe; and Togo [66]. In Bangkok marked growth retardation, wasting, and small head circumference occurred early, before six months of age, and persisted in the urban environment even though older children (after about 18 months of age) grew in height better than their rural counterparts. In Togo more wasting (marasmus and marasmus-kwashiorkor) is reported in the urban setting. In Accra the type of PED is no different in urban and rural settings; it just appears earlier in the former.

TABLE 9. Percentages of children under five years old with weight-for-age deficits, classified by the Gomez scale, in selected urban and rural populations

  Grade I

Grades II-III

Chaco Province city
Rural departments
San Juan Province city
Rural departments
15.9 4.4 0 4.5 6.5 4.5
27.0 8.4 4.8 8.6 13.0 7.3
9.7 0.6 0 0 2.9 0
20.5 3.7 4.3 8.3 5.2 2.1
19.4 3.0 0 13.3 4.7 1.5
La Paz, urban 35.5 16.4 8.3 15.3 24.4 15.4
Ribeirão Prêto city
Rural city
Recife, urban
São Paulo, urban
24.4 5.6 0 3.5 4.2 7.2
24.1 5.3 3.3 3.6 7.3 5.3
31.0 5.9 5.7 0 2.3 7.4
35.9 11.9 5.3 15.6 12.1 12.2
29.7 5.5 0.6 2.9 4.0 7.3
29.2 3.9 1.5 4.2 4.6 3.9
36.3 9.4 0 18.5 8.9 9.6
Cali, urban
Cartagena, urban
Medellín, urban
37.0 11.7 2.0 12.1 12.5 12.7
39.7 14.3 2.6 8.9 13.3 16.9
39.7 15.7 6.8 12.9 12.1 18.6
El Salvador  
San Salvador
Rural municipios
28.2 5.1 1.1 2.4 5.4 6.2
46.3 15.8 10.5 6.2 20.9 16.1
Metropolitan Kingston
Rural St. Andrews
33.0 7.2 1.6 3.3 13.2 6.9
37.5 9.8 9.1 10.0 20.8 7.6
Monterrey, urban 31.3 6.1 3.0 3.7 8.2 6.2

Source: Ref. 42.

The process of acculturation, urbanism, and modernism to which poor rural immigrants are subjected in the slums and their nutritional repercussions on children were studied in Beirut 167]. Families carefully matched for income, composition, education, and so on demonstrated a progressive improvement in nutritional status, food practices, and general life-style as time elapsed living in the urban slum.

Although PED is found in the urban environment, that setting is more conducive to better nutrition even though these advantages tend to disappear among new immigrants (who actually bring their rural habits and problems to the city for some time) and among the urban poor.

Nutritional anaemias

The available evidence [33, 32, 55, 59, 53] indicates that, in general, the prevalence of nutritional anaemias is lower for urban children and mothers than for their rural counterparts; however, with the exception of Yemen, the differences between the two populations are minimal. The range of prevalences within each setting is several times greater than the urban rural differences, again with the exception of Yemen. There is no apparent reason for this susceptibility of the Yemenite populations.

There is often a higher prevalence of anaemia and of deficiency of erythropoietic factors (particularly iron) among migrants to Western industrial cities than among established urbanites. The migrants initially have the anaemia and iron status of the population in the area from which they came. Often, as acculturation proceeds, the diet becomes more varied, parasite loads decline, and the haematological status improves [68].

A gradient has been observed in the iron reserves of Guatemalan women of reproductive age according to their residence: urban middle-class women in Guatemala City (in the highlands) had higher reserves than rural highland women, who in turn were better off than their lowland counterparts. This gradient was independent of parity in the sample studied.

Other vitamin and mineral deficiencies

Few studies have specifically addressed urban-rural differences in vitamin and mineral deficiencies. Vitamin-A deficiency affects populations in both areas, particularly children suffering from malnutrition, diarrhoea, and infectious diseases [69-71], although mild deficiency may occur in non-malnourished, non-infected children [72]. Actual prevalence and incidence vary both in urban and rural settings by country, season, and method of diagnosis, reported prevalences being as high as 45% in the total populations [73].

The decline in breast-feeding, which is predominantly an urban phenomenon, aggravates the situation in infancy [71, 74]. On the other hand, the previously discussed greater variety of foods and more opportune complementary feedings in urban settings serve as protective practices. The concomitant increase in frequency of infection in non-breast-fed infants certainly is an aggravating factor. Several studies on the liver vitamin-A reserves of healthy victims of accidental death have been done in less-developed nations, all showing some degree of deficiency [75-79].

In Thailand, levels of vitamin A in both serum and liver were lowest among the poor, particularly farmers and unskilled labourers, suggesting more similarity by socio-economic group than by urban-rural location. About one-third of migrant children of Mexican-American origin among Colorado farm workers have been shown to have low vitamin-A serum concentrations (and low zinc levels by serum and hair analysis), compard to only 7.5% among the healthy stable population in the same region [80, 81]. Thus even in developed countries, vitamin-A deficiency (and also general undernutrition) occurs in at-risk populations, such as poor migrants.

TABLE 10. Prevalence of non-insulin-dependent diabetes mellitus among Indians, Melanesians, and Polynesians in rural and urban settings

Country and ethnic
Setting Prevalence
Cook Islands  
Polynesian 20 + rural 2.4
urban 5.7
Indian 20 + rural 13.0
urban 15.0
Indian 15 + rural 1 .2
urban 2.0
New Caledonia  
Melanesian 20 + rural 1.7
urban 6.9
Polynesian 20 + rural 2.0
urban 13.0
Indian 20 + rural 13.3
urban 14.8
Papua New Guinea  
Melanesian 18 + rural 5.5
urban 22.0
Western Samoa  
Polynesian 20 + rural 2.7
urban 7.0

Sources: Refs. 82-84.

Chronic nutrition-related diseases

Modernization, westernization, and urbanism play a decisive role in modifying life-styles and diet, which in turn contribute significantly to the development of obesity, non-insulin-dependent diabetes mellitus ( see table 10), and cardiovascular disease (fig. 4). It is also apparent that the Western diet and obesity added to environmental factors determine the prevalence of certain cancers. Consequently, the epidemiological pattern of chronic nutrition-related diseases could be interpreted as reflecting the degree of westernization of a society.

At some risk of over-simplification, we may say that the degree of westernization and urbanism in the process of urbanization in less-developed Countries in contrast to the traditional rural way of life, and the level of cultural transition in the urban setting, appear to be closely associated with the epidemiology of nutrition-related diseases. Recent poor migrants to urban areas who are traditional in their diet and lifestyle exhibit nutrition-related pathologies that are more characteristic of rural culture (deficiency diseases and infectious processes being prominent}, while those whose social and economic evolution lead to modernism and acculturation to a Western diet and lifestyle tend to exhibit the disease patterns associated with this new culture. The process of rapid urbanization characteristic of many countries in transition also leads to an epidemiological transitional state in which both types of pathology co-exist [87-89], together with other indications of transition, including changes in birth and mortality rates and patterns.

FIG. 4. Age-related dynamics of atherosclerosis plaques in selected populations from developed and developing nations, derived from autopsy studies. X = prevalence rate at age 20. ( Source: Ref. 85.)


Special appreciation is expressed to Dr. A. Horwitz,R. Trowbridge, B. Popkin, J. Mason, and J. D. Wray for their advice and encouragement, to Robert Giometti, Julie Long, and Gina de Trejo for their help in the preparation of this paper, and to Adelina F. Viteri and J. Katona-Apte for their patience.


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Urbanization and hunger in the cities

Anwar M. Hussain and Paul Lunven

Urbanization is an inevitable consequence of socioeconomic development and industrialization. In developing countries it is proceeding at such a fast rate that it is outpacing the growth of services and employment. The result is teeming slums in city centres and shanty towns on their peripheries. Many of their inhabitants are compelled to live in a state of intense deprivation, and thus disproportionately bear the brunt of hunger and malnutrition in the cities.

Naturally, such unprecedented growth of urban populations has consequences for hunger and malnutrition. To put the issue into proper perspective, it is necessary to understand the magnitude of and trends in urbanization, as well as the characteristics of settlements themselves, and the direct and indirect effects of hunger on the persons who inhabit them. The greater the knowledge of these aspects, the more successfully vulnerable groups will be identified and measures and policies to combat urban hunger implemented.

Magnitude of and trends in urbanization

Developing countries constituted 75% of the world population in 1980. It is projected that they will be the source of all net additions to the world rural population and 84% of the net additions to the world urban population between 1980 and 2000. During this period it is likely that the urban population in developing countries will rise from about 31% of the total to 44% (table 1) [1]. Two of three urban residents and nine of ten rural residents of the world will be in the developing countries by 2000. This projected rate of urban growth is particularly striking be cause there is no historical precedent for the sheer numbers of people being added to the urban sectors in these countries [21.

Not only is the world becoming increasingly urbanized, but United Nations projections show that by 2000 a large part of the population will be concentrated in major urban centres of growth called "primate cities." By 1980 at least one in four of the population of Argentina, Iraq, Peru, Chile, Egypt, the Republic of Korea, Mexico, and Venezuela lived in a primate city. It is projected that by 2000 there will be 79 such cities in the world with populations greater than 4 million. Of these, 59 will be in the developing countries and will account for one-fourth of the population of these nations [1].

Large differences exist in the degree of urbanization in the various regions of the developing world, but these are likely to decrease by the year 2000. Some differences will persist, however, particularly between other regions and Latin America, which has almost reached the level of urbanization in developed countries. By the year 2000 three of four persons in Latin America and two of five in Asia and Africa will live in urban areas.

Characteristics of urban settlements in developing countries

Physical characteristics

In contrast to the planned cities of the developed countries, rapid growth of population in the developing world has overloaded the existing physical facilities in large cities [3]. The resultant pattern comprises four distinct physical parts:

-an old central area of the city, mostly decaying, with a heavy concentration of people and outdated services;
-a planned middle-class area with reasonably adequate services;
-a prosperous elite area with all modern amenities;
-a periurban area, unplanned, unserviced, and extremely densely populated (four to five times higher than the average in some cities for which statistics are available, e.g. Calcutta and Manila).

It is mainly the periurban areas and decaying city centres that attract most of the new migrants and become the geographical location of hunger in the cities.

TABLE 1. Projected urban and rural population growth by region, 1980-2000

  Population (millions)a Average annual
growth rate (%)
1980 2000
Total Urban Rural Total Urban Rural Total Urban Rural
Africa 470 136 (29) 334(71) 853 362 (42) 491 (58) 3.0 5.0 1.9
East Asia 1,058 294 (28) 765 (72) 1,346 557 (41) 789 (59) 1.2 3.2 0.2
South Asia 1,404 348 (25) 1,056 (75) 2,075 770 (37) 1,305 (63) 2.0 4.1 1.1
Latin America 364 238 (65) 126(35) 566 428 (76) 138 (24) 2.2 3.0 0.5
All developing regionsb 3,301 1,016 (31) 2,285(69) 4,847 2,121(44) 2,725 (56) 1.9 3.7 0.9
All developed regions 1,131 806 (71) 325 (29) 1,272 1,011 (79) 262 (21) 0.6 1.1 -1.1
World 4,432 1,822 (41) 2,610 (59) 6,119 3,132 (51) 2,987 (49) 1.6 2.7 0.7

a. Figures in parentheses are percentages.
b. Includes Melanesia, Micronesia, and Polynesia.

Source: Ref. 1


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