Module 3: Nutrition

Urban nutritional problems result in a spectrum of outcomes, from obesity to malnourishment.  Cities are unique in that these extremes appear side by side.  Studies of South African cities revealed the coexistence of malnourished children and obese adults in the same household.(1)  While obesity and malnutrition have been traditionally separated as health issues, evidence of their coexistence within homes and among similar groups should motivate policymakers to consider addressing them together. 

Overweight and Obesity

A much higher level of obesity exists in urban areas than in rural areas for a number of reasons, including the types of foods available and the amount of physical activity involved in an urban lifestyle.  Urban diets tend to include foods containing more energy and fat density, which can contribute to chronic health problems.  As compared to rural diets, urban diets tend to include more animal products, fat, sugar, pre-prepared and processed foods, and milled and polished superior grains, such as rice or wheat (rather than corn or millet).(2) A recent study of rural-to-urban migrants in India found that migration to cities often results in a higher intake of energy and fat as well as vegetables, dairy products, sugars, and macronutrients.(3)  In developing countries around the world, urban areas are becoming more globalized and diverse, shifting to what are often termed, “western diets,” which include more meat, oils, fats, and refined carbohydrates, and are lower in fiber than more traditional diets.  For example, in China, the traditional low fat diet is quickly losing popularity, especially in urban areas.  More of the Chinese are now consuming over 30% of their energy from fat; though this is more drastic in higher income groups, there have been increases in all income populations in the country.(4)  

For many of the poor, a lack of food is not the core issue; the deficiencies stem from the lack of nutrients found in many cheap foods.  People make choices about what foods to eat that are often detrimental to their health.  However, the people making these choices do not always have the full freedom that the word “choice” connotes.  Many people must buy cheap food to keep themselves and their families from hunger, opting for lower quality foods that can be bought at low prices.  A study in Los Angeles found that many homeless people do not have access to cooking facilities or food storage.  Further, many of these individuals depend on soup kitchens that do not necessarily have a variety of nutritious options from which to choose.  The same study found that obesity and cardiovascular disease were related to nutrition quality.(5) These “costs” of poor nutrition contribute to even higher health care costs, creating a dangerous downward spiral.  Additionally, education can be an indicator of obesity.  In a study conducted in Brazil, both education and access to information were independently related to being overweight, demonstrating that the educated are less likely to be obese.(6) For many communities, though the choice is present, the information is not. 

Problems with weight in urban communities are not caused solely by food choice.  Calorie intake and the amount of energy expended daily both contribute to an individual’s health.  Compared to residents of rural areas, city dwellers lead more sedentary lives.  Industrialization and urbanization reduce the need for human energy in production, shifting work patterns in urban areas to more sedentary service and commercial work.  In China, urban residents in all in socioeconomic strata showed an increase in sedentary activity patterns from 1989 to 1993, while those in rural areas showed an increase in high physical activity patterns.(7)  This activity shift among urbanites exacerbates the nutritional issues of obesity and being overweight.  

Malnutrition

For a city’s poorest residents, malnutrition is a tremendous concern and a dire health issue, particularly for slum inhabitants.  In adults, malnutrition limits working capacity and leaves the afflicted more vulnerable to disease, environmental harm, and the physical demands of pregnancy and lactation.  As Dr. Carlos L. Krumdiek from the University of Alabama Medical Center explains, “only when a reasonably good level of nutrition has been attained, can the slum dweller concern himself with the secondary matters of improving his surroundings.”(8) 

However, malnourished individuals experience these effects in conjunction with various other challenges.  Some slum residents have reported that they economize on food so that they can pay their ever-increasing rent.(9)  In a study of seven countries, household wealth contributed to malnutrition at levels ranging from 30% to 76%.(10)  When struggling to secure the necessities, low quality food can satisfy hunger and make it possible to accomplish daily tasks and pay for other goods, though simultaneously sacrificing long-term health.  

Case Study: Household Food Insecurity in Delhi, India

A study that was done in Delhi, India to determine the relationship between household food insecurity and undernutrition found that 54% of children under five years old suffered from chronic undernutrition and 38% of women were severely undernourished.  Household food security was assessed by anthropometry, dietary recall, and self-reported food insecurity factors such as uncertain supply, limited quality and quantity, and going to bed hungry.  Results demonstrated that household food insecurity is a key component of undernutrition, and unemployment plays a substantial role as well.  Of the households in the study, 51% are food insecure, due, at least in part, to their low monthly income, suggesting that community leaders should learn and promote coping mechanisms and other positive practices to reduce food insecurity. (11)

Major Nutritional Deficiencies Affecting Urban Dwellers

There are several nutritional deficiencies that are common in poor areas around the world, but that are found in particularly high levels in urban slums.  These include:

• Protein energy malnutrition – This is the most common deficiency in children. It is associated with infection and child mortality, and can have long-term effects such as low weight and stunted growth. Cheap “fast foods” and ready-to-eat “convenience” foods are more common in poor households as parents work long hours, but these foods typically lack in nutritional value.

• Vitamin A deficiency – This is caused by low intake of leafy vegetables, dairy, meat, fish, and fruits. In India, about 73% of children aged 12-71 months were able to consume foods that were rich in vitamin A more than three times per week. Families tended to consume these foods more during the winter, which could suggest that seasonal cost fluctuations influenced purchasing ability.

• Iron deficiency anemia – This can lead to the impairment of cognitive performance, motor and language development, and coordination. Iron deficiency also raises the risk of morbidity from infectious diseases. It is a result of low iron intake, poor quality weaning, and over-reliance on milk.

• Iodine deficiency disorders – While this endures as a problem of malnutrition, universal salt iodization has improved the situation. (12)

Unique Issues in Childhood Malnutrition

Malnutrition causes one-third of all childhood deaths.  Select studies have concluded that for children under five years old, malnutrition is most prevalent in rural areas.(13)  However, disaggregated research shows that slum children are at a higher risk of malnourishment than their rural counterparts are.(14) Averages juxtaposing children in 41 low- and middle-income countries demonstrate that stunting is three times more prevalent among the poorest urban children than among the richest.(15)  In India, more than 50% of children in the urban poor population are stunted or underweight; in the majority of the country, nutrition problems are more concentrated in urban areas.(16)

There are innumerable causes of malnutrition for urban slum children.  In broad terms, they can be categorized as follows:

• Inadequate food intake – improper family feeding practices including unequal distribution of food, or lack of nutrient-rich food

• Illness – diarrhea and other health problems caused by low-quality living and sanitation conditions

• Deleterious caring practices – lack of caregivers who are informed and educated, particularly regarding nutrition

• Service issues - limited connection to health and social services (17)

Infant feeding practices, a component of the first category above, is especially unique in urban settings.  Women in cities tend to work outside their homes, as opposed to rural women who often work inside the house.  Most urban women work in factories, shops, or as unskilled laborers and servants, and are typically unprotected by labor laws that regulate working hours or allow for maternity leave.  This can reduce the time a woman spends on breastfeeding and raising her child, and care of the infants is often left to older siblings.  Though breastfeeding is common, exclusive breastfeeding is not, and feeding bottles, animal milk, and commercial milk formula are frequently diluted, leading to nutrient deficiencies.  Moreover, studies from three cities in India found that in the slums, most children that fed from bottles had only one bottle with one nipple, which was rarely cleaned properly.  These early life practices can create long-term detriments in children’s health.(18)

Over time, childhood malnutrition can harm development in both the body and the brain.  This can take the form of stunting, poor cognition, or a host of other chronic health and developmental issues.(19) Additionally, malnourished children lose educational opportunities due to early brain damage, frequent illness, or because they spend their time in school suffering “in the lethargy of the undernourished.”(20)

Interventions

Whether it is a result of a dearth of food or an abundance of unhealthy food, malnutrition creates long-term chronic health conditions that require serious medical care.  Fortunately, there are campaigns to improve awareness of nutritional values and ways to conserve and cook foods in more nutrient-preserving ways.  A report by UN-HABITAT and WHO outlines several examples of actions that promote food security and quality:

• Promote in-city food production – Use public spaces to grow foods, thereby increasing nutrient content, education, and outdoor activity.

• Ensure schools support healthy food choices – Implement programs that help schools serve healthier foods, and teach students and parents about nutrition.

• Provide older adults with healthy food as part of home-delivered meal services – Help the elderly obtain nutritious foods by eliminating issues of transportation and physical activity that may be impossible.

• Regulate food production and marketing – Create policies and campaigns to increase nutritional awareness, or even limit unhealthy practices.(21)

With further exploration of evidence-based interventions, these approaches can be applied to raise the health status of an entire population gradient, and have the potential to decrease problems of obesity and malnutrition.

Footnotes

(1) Harpham, T. (2009). Urban health in developing countries: What do we know and where do we go? Health & Place 15: 107–116. 

(2) Popkin, B. M. (1999). Urbanization, lifestyle changes and the nutrition transition. World development, 27(11), 1905-1916.

(3) Bowen, L., Ebrahim, S., De Stavola, B., Ness, A., Kinra, S., Bharathi, A. V., ... & Reddy, K. S. (2011). Dietary intake and rural-urban migration in India: a cross-sectional study. PloS one, 6(6), e14822.

(4) Popkin, B. M. (1999). Urbanization, lifestyle changes and the nutrition transition. World development, 27(11), 1905-1916.

(5) Langnäse, K., & Müller, M. J. (2001). Nutrition and health in an adult urban homeless population in Germany. Public health nutrition, 4(3), 805-811.

(6) Popkin, B. M. (1999). Urbanization, lifestyle changes and the nutrition transition. World development, 27(11), 1905-1916.

(7) Ibid.

(8) Krumdiek, C. (1971). The Rural-to-Urban Malnutrition Gradient: A Key Factor in the Pathogenesis of Urban Slums. JAMA 215: 1652-1654.

(9) Harpham, T. (2009). Urban health in developing countries: What do we know and where do we go? Health & Place 15: 107–116. 

(10) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.

(11) Gupta, P., Jha, M., Agnihotri, A., Kaushik, S., Patra, P., Dethi, V., & Agarwal, A. (2008). Levels and Determinants of Household Food Insecurity in Delhi Slums. In A paper presented in 40th Annual Conference of Nutrition Society of India.

(12) Ghosh, S., & Shah, D. (2004). Nutritional Problems in Urban Slum Children. Indian Pediatrics 41: 682-696.

(13) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.

(14) Shetty, P. (2011). Health Care for Urban Poor Falls Through the Gap. The Lancet 377: 627-628. 

(15) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.

(16) Agarwal, S., Satyavada, A., Kaushik, S., & Kumar, R. (2007). Urbanization, urban poverty and health of the urban poor: status, challenges and the way forward. Demography India, 36(1).

(17) Ghosh, S., & Shah, D. (2004).  Nutritional Problems in Urban Slum Children.  Indian Pediatrics 41: 682-696. 

(18) Ibid.

(19) Ibid.

(20) Krumdiek, C. (1971). The Rural-to-Urban Malnutrition Gradient: A Key Factor in the Pathogenesis of Urban Slums. JAMA 215: 1652-1654.

(21) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.