Contents - Previous - Next

This is the old United Nations University website. Visit the new site at http://unu.edu

Nutrition policy

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

Abstract

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.

Introduction

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

a. National survey. 1976.

Overnutrition

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.

Acknowledgement

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

References

1. World Bank. Urban policy and economic development: an agenda for the 1990s. Washington, DC: World Bank, 1991.

2. WHO. Strategies for health for all in the face of rapid urbanization: background documents. Geneva: WHO, 1991.

3. Krumdiek CL. The rural-to-urban malnutrition gradient. JAMA 1971;215:1652-54.

4. Basta SS. Nutrition and health in low income urban areas of the third world. Ecol Food Nutr 1977;6:113-24.

5. Wray ID. Child health interventions in urban slums: Are we neglecting the importance of nutrition? Health Pol Plan 1986;(4):299-308.

6. Lipton M. Why poor people stay poor: a study of urban bias in world development. Cambridge, Mass, USA: Temple Smith/Harvard University Press, 1977.

7. Chambers R. Rural development: putting the last first. London: Longman, 1983.

8. Harpham T. Lusty T. Vaughan P. In the shadow of the city. Oxford: Oxford University Press, 1988.

9. Sudharto P. Experiences in the field of primary health care in Jakarta. Report of the Joint UNICEF/WHO Meeting on Primary Health Care in Urban Areas, 2529 July. Geneva: WHO, 1983.

10. Morell S. Morell D. Six slums in Bangkok: problems of life and options for actions. Bangkok: UNICEF, 1972.

11. Austin JE. Confronting urban malnutrition: the design of nutrition programmer. 23rd ed. Washington, DC: World Bank, 1980.

12. Prasada Rao TMV, Gowrinath Sastry J. Vijayaraghaven K. Nutritional status of children in urban slums around Hyderabad city. Ind J Med Res 1974;62(10): 1492-98.

13. Rossi-Espagnet A. Health services and environmental factors in urban slums and shanty towns of the developing world. Food Nutr Bull 1987;9(4):4-20.

14. Clark WF. The rural to urban nutritional gradient: application and interpretation in a developing nation and urban situation. Soc Sci Med 1980;14D:31-36.

15. Graham GG, Maclean WC, Kallman CH, Rabold J. Mellits ED. Urban-rural differences in the growth of Peruvian children. Am J Clin Nutr 1980;33:338-44.

16. Leon ME, Serdula M, Williamson DF, Nieburg P. Sullivan K, Boring JR. Identifying the malnourished within Peru: regional variation in the performance of a nutrition indicator. Int J Epidem 1990;19:214-16.

17. Valverde V, Nieves I, Sloan N et al. Lifestyles and nutritional status of children from different ecological areas of El Salvador. Ecol Food Nutr 1980;9:167-77.

18. Wolfe BL, Behrman JR. Determinants of child mortality, health and nutrition in a developing country. J Dev Econ 1982;11:163-93.

19. IBGE/UNICEF. Perfil estatístico de crianças e mäes no Brasil: situação nutricional. Rio de Janeiro: IBGE, 1982.

20. Pickering H. Lamb WH. Urban and rural differences in seasonal stress in the Gambia. In: Taylor TG, Jenkins NK, eds. Proceedings of 13th International Congress of Nutrition. London: John Libbey, 1986.

21. Nnanyelugo DO. Urbanization and nutrition. Afr Health 1980;2:15-16.

22. Mathe S. Matovu HL, Mossop RT. Nutritional status of an urban community in Zimbabwe. Centr Afr J Med 1985;31:5962.

23. Martins MH de S. Teixeira SG. Hyporiboflavinosis in rural and urban pre-school age children in northeast Brazil. Ecol Food Nutr 1976;5:101-05.

24. Fashakin JB, Oyckanmi MA. Evaluation of some vitamin B complex nutriture in lle-lfe and environs (Nigeria). Int J Nutr Res 1986;56:79-84.

25. Khanjanasthiti P. Wray JD. Early protein-calorie malnutrition in slum areas of Bangkok municipality 19701971. J Med Assoc Thai 1974;57:357-66.

26. Brink EL, Aly HE, Dakroury AM et al. The Egyptian national nutrition survey, 1978. Bull WHO 1983; 61 :853-60.

27. Grimble RF. A study of the pattern of clinical protein energy malnutrition in Accra from 1970 to 1978. J Trop Pediatr 1981;27:12-14.

28. Primhak RA, Chojnowska E, Pongap A. Trends in infant feeding in Port Moresby. Papua New Guinea Med J 1989;32:113-16.

29. Clavano NR. Mode of feeding and its effect on infant mortality and morbidity. J Trop Pediatr 1982;28:28793.

30. Shawqi AM, El Sharif AS, Latif AA, Ruck NF. A study of food habits of mothers and children attending rural and urban health centres in Minya, Egypt. J Trop Pediatr 1985;31:11217.

31. Gross R. Monteiro CA. Urban nutrition in developing countries: some lessons to learn. Food Nutr Bull 1989;11(2):14-20.

32. Crean JTG, Ling SC, Pearson DJ, Shaw SN, Stewart RJ, Wilson JH. Dharavi project, 1985: an investigation into patterns of infant feeding and malnutrition in the urban slum of Dharavi in Bombay. J Trop Pediatr 1987;33(suppl.2).

33. Singhal PK, Mathur GP, Mathur S. Singh YD. Mortality pattems in under six children in ICDS urban slums. Ind Pediatr 1986;23:617-22.

34. Thaver IH, Ebrahim GJ, Richardson R. Infant mortality and undernutrition in the squatter settlements of Karachi. J Trop Pediatr 1990;36:135-40.

35. Flores M, Aranda-Pastor J. Evaluación dietética a nivel nacional en Costa Rica: cambios de una decade. Arch Latinoam Nutr 1980;30:432-50.

36. Van Ginneken. Rural and urban income inequalities. Geneva: ILO, 1976.

37. Jansen GR, Jansen NB, Shigetomi CT, Harper JM. Effect of income and geographic region on the nutritional value of diets in Brazil. Am J Clin Nutr 1977;30:955-64.

38. Homer MR, Dorea JG, Perreira MG, Bezerra VL, Salomon JB. Inquérito dietético com base do consumo familiar: o cave de Ilhéus, Bahia, Brasil em 1979. Arch Latinoam Nutr 1981 ;31 :721-39.

39. Finau SA, Prior JAM, Salmond CE. Hypertension among urban and rural Tongans. Med J Aust 1986;144: 16- 19.

40. Gilbert A, Gugler J. Cities, poverty and development: urbanization in the third world. Oxford: Oxford University Press, 1981.

Contents - Previous - Next