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Overview of ageing, urbanization, and nutrition in developing countries and the development of the reconnaissance project

Abstract
Introduction
Ageing in developing countries
Urbanization in developing countries
Ageing and urbanization: The case of the Philippines
History of the reconnaissance project and the development of CRONOS
The workshop in Wageningen
References

Corazon V. C. Barba and Lucila B. Rabuco

Corazon Barba is affiliated with the Institute of Human Nutrition and Food in the University of the Philippines in Los Baños, and Lucila Rabuco is affiliated with the SEAMEO-TROPMED Philippine National Center in the College of Public Health in the University of the Philippines in Manila.

Abstract

Two of the major demographic trends in the developing and transitional countries are urbanization (the growth of cities and metropolitan populations) and ageing (the increase in the number of persons over 70 years of age, due to extended life expectancy). These two trends are felt to present unresolved challenges regarding health, well-being, and quality of life. These uncertainties gave rise to the multicentre Reconnaissance project carried out in five Asian countries (China, Indonesia, Malaysia, the Philippines, and Thailand) and three Latin American countries (Brazil, Guatemala, and Mexico), in collaboration with institutions in the Netherlands, Germany, and Italy, with financial support from the European Community. The findings, experience, and lessons from the preliminary qualitative (community), and quantitative (individual) surveys were shared among the investigators at a conference held at Wageningen, Netherlands.

Introduction

The declining mortality among infants and children and the increasing life expectancy and longevity in developed and developing countries are changing the structure of the population. The percentage of the population that is elderly, i.e., over 60 years of age, has increased worldwide, and this trend is expected to continue. If not properly addressed, this demographic phenomenon will lead to social and economic problems, due to the associated high risk of disability and morbidity and the need for medical services among the elderly.

In 1980 the United Nations defined 60 years as the age of transition to the elderly segment of the population [1]. This definition was adopted at the World Assembly on Aging convened by the United Nations in Vienna in 1982. Using this definition, it can be calculated that whereas the total world population is increasing at a rate of 1.7% per year, the elderly population is growing at an annual rate of 2.5% [2]. Further, it is estimated that most of this increase will come in developing countries, where the growth rate of the elderly segment of the population will be three times greater than that of the same segment in developed countries.

Ageing in developing countries

The 1989 WHO Expert Committee on the Health of the Elderly reported that by the year 2000, about 67% of the world’s 600 million elderly people will be living in developing countries, compared with about 50% in 1960 [3]. A marked increase is anticipated in the elderly population of Asia, primarily as a result of the rapid increase foreseen in China and India. These two countries alone are projected to have about 270 million more elderly citizens by the year 2020, and it is expected that Indonesia will have 20 million more people over 60 years of age.

By the year 2000, it is estimated that there will be 41 million elderly people in Latin America and the Caribbean [2]. When these projections are extended to the year 2025, the size of the aged population in this region is expected to more than double, to about 93 million. In Brazil and Mexico the increases will amount to 20 and 10 million elderly people, respectively, by the year 2020.

The 1989 WHO Expert Committee also pointed out that the projected increases in elderly populations for the European countries are much smaller than those of some developing countries [3]. Thus, these developing countries will gradually replace some European countries in the ranking of countries with the largest elderly populations. By the year 2020, Indonesia is projected to move to sixth place from tenth place in 1980, just behind Brazil, which had the eleventh place in 1980 but will have moved to fifth in the new millennium. By 2020 Mexico is expected to be in ninth place, ahead of three European countries: Italy, France, and the United Kingdom.

Demographic trends reflect dramatic increases not only in the proportions of older people in the total population but also in life expectancy. These trends will result in changes in the age structure of the workforce. In developing countries, the rates of participation of 60- to 64-year-old men in the workforce tend to be much higher than in industrialized countries [4]. Considering the physiological changes associated with age, it is imperative to study the problem of ageing and work capacity. In addition, many developing countries are experiencing the effects of rapid urbanization and modernization together with related socio-economic and cultural changes. In the migration from rural to urban areas, the elderly are often left behind, and if they move, the elderly are often more likely to encounter difficulties in adapting to the new conditions than their younger counterparts.

Urbanization in developing countries

Urbanization is a process of geographic concentration of the population, although the precise definition of “urban” varies within and among countries. Although the United Nations defines urban populations as “localities with 20,000 or more inhabitants,” Gross and Monteiro [5] report that other factors, such as the level and type of economic activity, may be taken into consideration in classifying or defining urban areas. Nevertheless, it is apparent that the proportion of the world’s largest cities located in developing countries is rapidly rising. In 1975, 10 of the largest metropolitan areas were in developing countries. In the 1980s, 22 of the 35 largest metropolitan areas, containing about 45% of the world’s metropolitan population, were in developing countries. Moreover, it is estimated that by the year 2000, 25 of the largest urban populations, including Mexico City, São Paulo, and Shanghai, will be in developing countries [6].

The growth rates of urban populations vary across regions. Thus, in Africa, the world’s most rapidly urbanizing region, the annual urban population growth rate reached as high as 5.5% during the period from 1985 to 1990. It is expected that this rate will decline slowly, but by 2025 it will still be around 3% Alternatively, in Latin America, the average urban population growth rate declined from 3.9% between 1970 and 1975 to 2.9% between 1985 and 1990; it may only be 1.45% by 2025. In 1990 Latin America was the most urbanized region in the developing world, with 72% of its people living in urban areas. For instance, one of the highest rates of urbanization in the world is found in Brazil, where more than 30 million people live in the three largest cities, São Paulo, Rio de Janeiro, and Belo Horizonte. These three cities are expected to have more than 50 million inhabitants by the year 2000 [7].

In Asia, the annual rate of urbanization was 3.1% during the period from 1985 to 1990. This rate is expected to decline to 2.2% during the period from 1995 to 2000 and 1.1% during the period from 2020 to 2025. However, three of the world’s most populous countries-China, India, and Indonesia-are located in the region, and each has a sizeable urban population [6].

There are three main causes of the rise in urban population in developing countries: rapid overall population growth by natural increase, rural-to-urban migration, and reclassification of rural areas as urban areas [5]. Natural increase within urban areas, along with reclassification, accounts for an average of 61% of urban population growth in developing countries, and rural-to-urban migration accounts for the other 39%. However, regional differences in urban population growth exist. For example, in Latin America, where the urbanization level is already high, natural increase will likely dominate urban population growth [8]. In contrast, there is a high level of rural-to-urban migration, as well as a rapid urban growth rate in sub-Saharan Africa and parts of Asia.

With rapid urban expansion, pressure is exerted on housing, water and sewage facilities, transportation, and distribution of basic commodities. In addition, this creates health and nutrition problems, particularly among those who have recently migrated and are living in slums and shanty towns. In some cities, 30% to 80% of the urban population live under such conditions (table 1).

With the incidence of urban poverty still rising, malnutrition and disease are critical problems in poor urban communities. This particularly affects women, children, the elderly, the disabled, and industrial workers-the groups most vulnerable to health risks. The nutritional situation in some Asian cities was described during the First Asian Workshop on Nutrition in Metropolitan Areas in 1991 [10-15].

Ageing and urbanization: The case of the Philippines

Like many developing countries, the Philippines is experiencing both rapid urbanization and an increasing number of elderly people. The census projected the median age to increase to 19.5 years and life expectancy to increase to 63 years by the year 2000 [16]. About 2.2 million people (3% of the population) are over 65, and the United Nations Economic and Social Commission for Asia and the Pacific has projected that this number will increase to 2.8 million by the year 2000. As the elderly population increases, particularly in the urban poor sector, there are several implications in regard to the country’s response to their needs. Paguio [17] has pointed out inadequate provisions for meeting the needs of the elderly, including inadequacies in health facilities, specialized training of health personnel to manage the sick elderly, geriatric clinics in urban centres, homes for the abandoned elderly, social security provisions, implementation of social regulations for the elderly, and recreational facilities.

Region and city		Year	City population (thousands)	Slum dwellers and squatters (thousands)	% of city population who were slum dwellers or squatters
Africa
	Addis Ababa	1981	2,000	948	47
	Nairobi	1970	535	177	33
	Dakar	1969	500	150	30
Latin America
	Bogota	1969	2,294	1,376	60
	Lima	1970	2,877	1,148	40
	Rio de Janeiro	1970	4,855	1,456	30
South Asia
	Calcutta	1971	8,000	5,328	67
	Bombay	1971	6,000	2,475	41
	Delhi	1970	3,877	1,400	36
East Asia
	Manila	1972	4,400	1,540	35
	Jakarta	1972	4,576	1,190	26
	Bangkok/Thonburi	1970	3,041	600	20

Source: ref. 9

History of the reconnaissance project and the development of CRONOS

Among the industrially developed countries, studies on the nutrition, diet, and health of older persons have been conducted in recent years in the Netherlands [19], the United States (Boston, Massachusetts) [20], and 12 countries of Europe [21]. Additional multicountry research that deals with industrialized, transitional, and deprived populations of the elderly was undertaken in the southern Pacific region [22] and is in progress [23]. However, there are still major descriptive gaps in our knowledge of the patterns of the dietary and nutrient intake and of the state of nutrition and health of the elderly in developing countries. In addition, the effects of urbanization and modernization in developing countries on the socio-economic and cultural life of the people, particularly the elderly, need to be studied.

Realizing the need to focus on the growing population of the elderly, and cognizant of the important role that nutrition plays in health and functional ability, representatives from five Asian countries (China, Indonesia, Malaysia, the Philippines, and Thailand) and three Latin American countries (Brazil, Guatemala, and Mexico), together with three European countries (Germany, Italy, and the Netherlands), decided to undertake a new cross-cultural research study of nutrition and the elderly. The aim of this multicentre, multicultural study was to describe the food habits and the health and nutritional status of the elderly as well as to generate and test hypotheses by examining the relationships between nutritional and non-nutritional variables.

The cross-cultural study was initiated and supported by the South-East Asian Ministries of Education Organization (SEAMED) with the assistance of its four training centres in Tropical Medicine (TROPMED). SEAMEO-TROPMED receives technical and advisory support from the Ministry of Economic Cooperation of the Federal Republic of Germany through GTZ (Deutsche Gesellschaft fur Technische Zusammenarbeit). The International Union of Nutritional Sciences (IONS) extended technical assistance to the research, and financial support for the Reconnaissance phase of the study was provided by the European Community (EC).

Before conducting a full-scale cross-cultural study of nutrition and the elderly, the participating research centres decided to undertake a Reconnaissance study, an exploratory pilot survey for initial assessment of the specific nutritional situation of the population group living within a defined geographic area. In particular, this involved:

· assessment of the overall conditions at the national, provincial, and district levels relevant to the nutritional situation of the elderly;

· definition of the geographic location of the urban and rural study sites;

· collection of preliminary information on the nature and importance of nutritional problems and their possible causes at the study sites;

· acquisition of the opinion of the target groups on the type, scope, and importance of nutritional problems and their possible causes, and the supply of resources in their general surroundings;

· construction of a causal model, built on the information obtained, to define important variables that might be included in the final research protocol;

· exploration of nutritionally related norms and values in order to give research questions a substantive worth;

· definition of anthropometric and biochemical measurement techniques and equipment.

· standardization of survey methods and techniques that would enable comparison of data and analyses between countries and projects;

· presentation of a valid and reliable appraisal for the definition of a research protocol;

· provision of a useful tool to ensure consistent reporting.

· data on socio-demographics and health, food behaviour, physical activities, and social behaviour, including memory tests;

· anthropometric measurements;

· blood pressure and haemoglobin determinations.

Guided by the revised Reconnaissance manual for the Multicenter Study of Nutrition and the Elderly, which was distributed in November 1992, the participating East Asian and Latin American countries chose rural and urban communities (representative of low- and middle-income households) and collected data from randomly selected men and women from two age groups: elderly people aged 60 to 70 years and adults aged 35 to 40 years.

The workshop in Wageningen

Country experiences as a result of the Reconnaissance project were presented at the workshop of the SEAMEO/EC/IUNS Multicenter Study of Nutrition and the Elderly held on 15-19 March 1993 at the International Agricultural Center and the Wageningen Agricultural University at Wageningen, Netherlands. Findings of the semi-quantitative appraisal of the situation in the communities and of the quantitative measurements taken from a minimum of 24 respondents, according to a matrix of age, sex, economic level, and geographic location, as specified in the Reconnaissance, were reported by the representative(s) of each participating country. Issues and concerns encountered during the Reconnaissance were discussed. Representatives from the IONS [23] and the EURONUT-SENECA [21] studies and other interested observers from Costa Rica, Canada, and the World Health Organization (WHO) in Switzerland also shared their experiences.

The participants, facilitators, and observers were divided into five groups to review the variables and methods used to meet the specified objectives. Each group tackled a specific concern and reported their recommendations during the plenary session. The group leaders incorporated the suggestions emanating from the discussions and rendered group reports to the project coordinator, as described by Gross and Hage [24]. These were incorporated in the revised protocol and procedures manual to be used for the full studies.

During the workshop, the representatives from the eight countries signified their willingness and commitment to be part of the multicentre process and to proceed in carrying out a full study on the Nutritional and Food Security Situation of Rural and Urban Elderly from Selected East Asian and Latin American Developing Countries. The workshop was highlighted by the birth of CRONOS (Cross-Cultural Research on the Nutrition of Older Subjects).

The Reconnaissance and workshop provided each participant not only with additional knowledge of the nutritional situation of the elderly in eight developing countries, but, more importantly, with experience in the process of developing and organizing a multicentre, multicultural study. It is hoped that through this publication we can share with others the wealth of experience from the lessons learned in networking to address problems of nutrition and the elderly in the third world.

References

1. United Nations. Problems of the elderly and the aged. Draft programme and arrangements for the World Assembly on the elderly: Report of the Secretary General. New York: United Nations, 1980.

2. Chelala CA. Health of the elderly: a concern for all. Washington, DC: Pan American Health Organization, 1992.

3. World Health Organization. Health of the elderly: report of a WHO expert committee. WHO Tech Rep Ser 779. Geneva: WHO, 1989.

4. World Health Organization. Aging and working capacity: report of a WHO study group. WHO Tech Rep Ser 835. Geneva: WHO, 1993.

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

6. Cepede M. Nutrition and urbanization. Food Nutr Bull 1984;10:43-51.

7. Gross R. Urbanization and nutrition in Brazil. In: Pongpaew P. Sastroamidjojo S. Prayurahong B. Migasena P. Rasad A, eds. Human nutrition. Better nutrition in nation building. Proceedings of 2nd SEAMEO-TROPMED seminar on nutrition. Bangkok: SEAMEO-TROPMED, 1990:31-6.

8. Rossi-Espagnot A. Primary health care in urban areas: reaching the urban poor in developing countries. A state of the art report. UNICEF/WHO Rep No. SHS844. Geneva: World Health Organization, 1984.

9. Donahue JJ. Some facts and figures on urbanization in the developing world. Assignment Children 1982;57/58:21-42.

10. Matulessy P. Asumi R. Thamrin MR, Husaini, Angeles IT, Karyadi D. Nutrition situation in metropolitan Jakarta. Southeast Asian J Trop Med Pub Health 1992;23(suppl 3):3-16.

11. Lin KG. The nutritional situation in metropolitan Kuala Lumpur, with focus on squatters. Southeast Asian J Trop Med Pub Health 1992;23(suppl 3):17-30.

12. Florentino RF, Villavieja GM, Boquecosa JP, Bacos FF. Nutrition situation in Metro Manila. Southeast Asian J Trop Med Pub Health 1992;23(suppl 3):3145.

13. Migasena P. Choopanya K. Nutrition and the environment situation in Bangkok. Southeast Asian J Trop Med Pub Health 1992;23(suppl 3):46-53.

14. Shetty PS. City studies in nutrition: Bangalore, India. Southeast Asian J Trop Med Pub Health 1992; 23(suppl 3):54-58.

15. Ahmed F. Nutritional situation in Dhaka. Southeast Asian J Trop Med Pub Health 1992;23(suppl 3):5964.

16. National Census and Statistics Office (NCSO). Population and population projection of the Philippines. Manila: NCSO, 1988.

17. Paguio B. Republic of the Philippines lacks health care for elderly. Manila Bulletin, 17 October 1991.

18. Food and Nutrition Research Institute (FNRI). Third national nutrition survey, Philippines. Manila: FNRI, Department of Science and Technology, 1989.

19. Lowik MRH, Schrijver J, Odink J, van der Berg H, Wedel M, Hermus RJJ. Nutrition and aging: nutritional status of “apparently healthy” elderly (Dutch Nutrition Surveillance System). J Am Coll Nutr 1990; 9:18-27.

20. Hartz SC, Russell RM, Rosenberg IH, eds. Nutrition in the elderly: the Boston nutritional status survey. London: Smith-Gordon, 1992.

21. de Groot LCPGM, van Staveren WA, Hautvast JGAJ, eds. EURONUT-SENECA. Nutrition and the elderly in Europe. Eur J Clin Nutr. 1991;45(suppl 3):1-196.

22. Andrews GR. Health and ageing in the developing world. In: Evered D, Whelan J. eds. Research and the ageing population. Ciba Foundation Symposium 134. Chichester, UK: John Wiley & Sons, 1988:17-37.

23. Wahlqvist ML, Davies L, Hsu-Hage BH-H, Kouris-Blazos A, Scrimshaw NS, Steen B. van Staveren WA, eds. Food habits in later life: descriptions of elderly communities and lessons learned. Jointly published on CD-ROM by the United Nations University Press, Tokyo, and the Asia Pacific Journal of Clinical Nutrition, 1996.

24. Gross R. Hsu-Hage BH-H. The process of revision of the protocol. Food Nutr Bull 1997;18:264-6.