The cities, home of opportunities, are fast becoming less than ideal nurturing spaces for kids, if the statistical evidence of children’s growth patterns presented by a study led by Imperial College, London, is anything to go by.
The study analysed growth trends among children and adolescents (five years to 19 years) over a span of 30 years (1990 to 2020). A team of almost 1500 researchers collected data from 200 countries and territories, measuring the height and body mass index (BMI) of successive cohorts of children in urban and rural areas. The inferences, published as an article in the journal, Nature, show that over the past 30 years, the difference in the two growth markers in urban and rural children has narrowed. In 1990 and prior, urban children were recorded to have a higher average height and BMI.
At the outset, the study seems to bust the notion that cities provide a conducive environment for children to develop into healthy adults. However, variables and factors affecting the health of children are myriad and varied. So, the inferences of the study need to be looked at through a nuanced and localised lens.
Children’s growth in Asian cities
The study shows that the gap between average height and the mean BMI of successive cohorts of children in urban and rural areas of high-income nations has narrowed, almost to the point of being negligible.
This has been attributed to the better infrastructure, including healthcare and education, in the rural areas of these countries, coupled with easy and relatively affordable access to natural sources of nutritious food. In sub-Saharan Africa and low-income countries of Latin America and Asia, where the reach of development in rural locales is less, the gap remains static or has even increased.
The urban-rural gulf has closed in the middle-income countries in Asia, Latin America and certain parts of Africa as well. That includes India and China, who mirror the trend in high-income countries, albeit at a slower rate. The reasons for it are different for these countries.
Nutrition, the lack of it, especially in lower-income migrant population in cities, have been attributed as a major factor that has triggered the stalling of growth indices in countries including China and India. Less-than-ideal living conditions and the escalating cost of maintaining a nutritious diet are major deterrents. In rural areas, quite the opposite has been seen with increased access to better healthcare and infrastructure due to the implementation of development programmes, and the relatively easier access to fresh and nutritious food tilting the scales.
However, food and its effect on nutritional status is not the same for everyone, says Dr Rebecca Kuriyan Raj, professor and head, division of nutrition, St John’s Research Institute, Bengaluru.
“In rural India, diets are rich in carbs with low protein and other micro minerals, which could influence BMI and more importantly body composition, leading to less-than-ideal muscle/fat ratio [body composition]. Not quite a healthy weight gain,” adds Dr Raj.
How pollution affects child growth
Nutrition is just one of the many factors that play a role in the growth of children.
Air and water pollution, a bane in most cities in developing nations, including metros in India and China, is known to have a negative impact on children’s development.
“Clear air to breathe and water to drink are important for our wellbeing,” says Dr Rajat Chauhan, musculoskeletal and sports medicine specialist from New Delhi. “The long-term physical impact of pollution on children is well studied. And our cities have been reeling under extreme levels of pollution. It naturally will have a say in the growth rate.”
This is magnified among children in the lower-income strata in the cities, where, living in cramped quarters, or slums, they get the worst of everything.
“That’s the irony,” says Dr Chauhan. “They come to cities seeking better education and way of life. They get the worst of both worlds. They lose the green spaces which rural areas offer, for play or sport, while in cities they are exposed to pollution and pathogens because of the unclean, polluted and less-than-ideal living conditions they face.”
Repeated infections, common among children in cities, hamper growth, with their immunity taking a beating as well.
Walkability in cities and health
Physical activity – playing or performing exercises – is known to have a bearing on growth. And villages, with their open spaces, and recreational choices which involve actual play and not online or electronic games, has the potential to trigger changes in growth pattern. However, the choice of recreation is similar in both urban and rural areas with the influx of technology.
“Kids and their pattern of play have changed in rural areas too,” says Dr Chauhan. “Kids in villages also play on their mobile. Last two or three years, tech and the internet have made inroads into rural areas. More and more children prefer playing in virtual fields. So, there is no real difference between being in a village or a city in this regard.”
However, it is not just about avenues to play sports or exercise. ‘Walkability’ makes a difference, says Dr Raj who conducted a pilot study on it in Bengaluru, India. The research paper, authored by Dr Deepa Puttaswamy, Dr Santu Ghosh and Dr Raj, observed an association between urban walkability and obesity indices among children (5-15 years) in the city.
“Movement itself requires a conducive environment,” says Dr Raj. “And cities do not provide that. In villages, walking to a neighbourhood store, school or nearby office is a common practice. In cities, people tend to walk less and use vehicles. Cities themselves are not built to facilitate walking. That has a bearing on children’s health and thereby their growth. It was shown in our study, but it requires further longitudinal studies to understand how built environment affects health and body composition of children in India and other low-middle income countries.”
BMI not perfect children’s growth marker
The numbers, as indicative as they are, do not provide the full picture when it comes to health, say experts.
BMI is often used as an indicator of physical growth, but it is not always an accurate measure.
A healthy BMI is not just hitting a specific number. The body composition matters in assessing the health of the individual, says Dr Raj of St John’s Research Institute.
This is even more valid in countries such as India.
“BMI alone may not be ideal for the Indian population, because Indian children and adults have shown to be of the ‘thin-yet-fat phenotype’, having normal BMI but increased body fat,” says Dr Raj. “Additionally, a recent analysis of the [Comprehensive National Nutrition Survey in India] CNNS data revealed that even in normal/thin/stunted children, about 50 per cent had either high cholesterol or high blood sugars.”
Dr Raj cites a paper by HS Sachdev et. al, published in the European Journal of Clinical Nutrition, which analyses the latest CNNS data to illustrate this BMI paradox among Indian children.
“Metabolic obesity biomarker(s) exists in over half of anthropometrically undernourished and normal-weight Indian children and adolescents (5-19 years),” concludes the paper. “Nutritional status should be characterized through additional reliable biomarkers, instead of anthropometry [analysis of physical markers] alone.”
Dr Raj adds: “So, while urban-rural differences in BMI may have become small, it is important to look to see if body fat has increased, reinforcing the importance of measuring body composition rather than just BMI.”
The Imperial College study, which covered a larger demography involving a global analysis had its own challenges. Measuring other markers of children’s health and their body composition might have not been feasible.
Localised approach to health
Rural lifestyle choices are attributed to better growth indices in the study. However, recent observations suggest that the tendency of rural communities across the world is to ape or aspire to mimic urban lifestyles. That tendency reflects in dietary choices (junk food influx has increased in small towns and rural areas in India), recreational activities in children and daily routines in general.
So, rural areas may be getting close to cities in children’s health indices, at least the two factors (height and BMI) shown in the study. Along with that, poor lifestyle choices and other ills of city life are reaching the villages too.
The factors affecting children’s health vary from country to country, city to city even. Anything and everything from air quality to mental health, avenues to play and move about, socio-economic conditions and gender disparity, and the ready and affordable availability of nutritious food has a say in it.
So, are cities bad for children? Are villages good? Neither the answer, nor the solution, is simple. The solution, however, is feasible provided we stop thinking of a global formula and start formulating a viable and localized understanding of health. That could lead to better implementation of the development agenda and in the planning of the spaces we live in – rural or urban notwithstanding.
