Health and Dietary Patterns of the Elderly in Botswana.pdf

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RESEARCH ARTICLE

Health and Dietary Patterns of the Elderly in Botswana

Segametsi Maruapula, PhD; Karen Chapman-Novakofski, PhD, RD, LDN

ABSTRACT

Objective: To describe associations among socioeconomic conditions and dietary patterns of Botswana elderly.

Design: Secondary analysis from a cross-sectional nationwide survey.

Participants: Subjects (N 1086, 60-99 years old) were selected after multistage sampling.

Main Outcome Measures: Dietary patterns were dependent variables; health and socioeconomicvariables were independent variables.

Analysis: Factor analysis with varimax rotation; least squares regression.

Results: The most widely consumed food items were tea (91%), sorghum (82%), and maize-meal(63%). Five dietary patterns emerged: beer; meat/fruit; vegetable/bread; seasonal produce; andmilk/tea/candy patterns. Elderly women, those attending church, and those living with grandchil-

dren were less associated with the Beer Pattern. The Vegetable and Bread Pattern was more commonamong grandparents living with children and those living in towns (urban). Widowed elders wereless likely to consume meat/fruit (P .005). Half had a large family size (6 to 10 children), withabout 30% supporting 1 to 5 children.

Conclusions and Implications: Dietary patterns suggested both food to be emphasized in nutritioneducation programs and those who may benefit most. Nutrition education efforts in Botswana shouldfocus on improving food diversity, with particular targeting of widowed elderly and those in ruralareas, and on increasing vegetable, fruit, meat, and milk intake.

Key Words: elderly, international nutrition, dietary patterns

(J Nutr Educ Behav. 2007;39:311-319)

INTRODUCTION

The proportion of older persons has increased in bothdeveloped and developing countries. It is estimated that afifth of the world’s inhabitants are over 60 years of age, andat the beginning of the new millennium, there were over600 million people over 60 years of age.1,2 Statistics showthat by the year 2050, the population 65 years old and olderwill have doubled in all regions of the world includingsub-Saharan Africa.3

Decreases in birth and death rates resulting in increasedlife expectancies in developing countries have resulted in a

phenomenon called the demographic transition. Statisticsfor Botswana illustrate that the country is in such a demo-graphic transition, although recently life expectancy hasdecreased owing to the impact of the human immunodefi-ciency virus/acquired immunodeficiency syndrome (HIV/AIDS). According to the 2001 Population Census, elderlypeople constitute 5% of the total population of Botswana,a figure that has been constant since 1971.4 The demo-graphic transition is often associated with an epidemiolog-ical transition that reflects a shift toward lower prevalencerates for infectious disease and higher rates for chronicillnesses. Tied closely to both the demographic transition

and epidemiological transition is the nutrition transition,where diets change from “famine-related” to those of a“Westernized” pattern.5

The diet and dietary patterns of older persons are im-portant as contributors to health. An overview of studiesexamining the diet and dietary patterns of older US adultsconcluded that both cross-sectional and longitudinal stud-ies indicate that older persons are more likely to consumefruits and vegetables and less likely to consume red meatand fatty food than younger cohorts.6 In Pennsylvania,older persons were found to have both a higher Fruit andVegetable Pattern and a higher Fat Pattern compared to

younger adults.7

University of Illinois, Urbana, Illinois

Dr. Maruapula is now at the University of Botswana, Gaborone, Botswana.

The second author of this article (Chapman-Novakofski) is on the JNEB staff as

Associate Editor, Research and Reports. Review of this article was handled, exclu-

sively, by the Editor-in-Chief to minimize conflict of interest.

This project was partially funded by the Norwegian Council of Universities/Centre

for International University Cooperation (NUFU), the University of Botswana, and

the Experiment Station, University of Illinois, Urbana-Champaign.

Address for correspondence: Karen Chapman-Novakofski, PhD, RD, LDN, 343

Bevier Hall, 905 S. Goodwin Ave, Urbana, IL 61801; Phone: (217) 244-2852;

E-mail: [email protected].

PUBLISHED BY ELSEVIER INC. ON BEHALF OF THE SOCIETY FOR NUTRITION EDUCATION

doi: 10.1016/j.jneb.2007.07.007

Downloaded from ClinicalKey.com at Universitas Kristen Duta Wacana May 17, 2016.For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.


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Quantitative cross-sectional and longitudinal surveyssuch as these provide insights as to dietary quality. Otherresearchers have instead relied on dietary variety as anindicator of dietary quality and nutritional status.8,9 Alongitudinal study of Japanese elderly reported a decline indietary variety in over one third of the participants.10 Thecauses for change in dietary habits are multifactoral, includ-ing sociocultural, demographic, and lifestyle factors. How-

ever, a definitive profile of these factors remains to beexplored in the elderly as well as in other age groups andamong ethnicities.11 Recognized as a valuable tool in thisarea is factor analysis, which may provide more insight intocauses of diet variability than other methods.11,12

Botswana, like many of her African counterparts, haslittle information on the health and nutrition of herpeople.13-20 Whereas some report overall health across agecategories, others report overall nutrition without attentionto age. Clausen et al reported that the diet of older personsin Botswana lacked variety and that determinants of varietyincluded rural residence, number of meals eaten each day,

and economic status. Data included those of the 1998Health and Nutrition of the Elderly in Botswana survey, aswell as a subsample also assessed for medical health.19

Effective National Plans of Action for Botswana, ac-cording to the Food and Agriculture Organization of theUnited Nations, rely on information across the life span f orsuccessful policy development and implementation.21

Given such an information gap, there is a need to elicitadditional information on the health and nutritional situ-ation of the elderly in Botswana. The objective of this studyis to further describe data from the 1998 Health and Nu-trition of the Elderly in Botswana using factor analysis to

define patterns in consumption and to assess the associationof these patterns with health and demographic information.

METHODSStudy Design and Subjects

Data from the 1998 Health and Nutrition of the Elderly inBotswana, conducted by the National Institute of Researchand Documentation of the University of Botswana, and theDepartment of General Practice and Community Medi-cine, Faculty of Medicine, University of Oslo, were ana-

lyzed. The study was a nationally representative householdcross-sectional survey of 1086 elderly persons (52% female,48% male), which represented a 1% sample of this targetpopulation.

To complete a multistage cluster sampling, the countrywas divided into 2 broad strata of urban (towns) and rural(villages). The urban stratum was further divided into 7towns, namely Gaborone, Francistown, Lobatse, Orapa, Jwaneng, Selibe-Phike, and Sowa. A purposive sample wasobtained from 3 towns. Gaborone was selected because it isthe main city, Francistown because it is the oldest town,and Selibe-Phikwe represents the mining towns. The rural

stratum was divided into larger villages (also called urban

villages) and smaller villages (also called rural villages)while ensuring that the disadvantaged western districtswere equally represented. The sampling frame included allolder adults residing in a chosen locality who were eligible.A random selection of the number of respondents requiredwas performed in each locality. Informed consent was ob-tained from each participant, and the study was approvedby the Office of the State President of Botswana.

The food frequency, demographics and health self-assessment questionnaires were prepared by a team of pro-fessionals including demographers, nutritionists, and socialscientists. The food items included in the study were iden-tified through a food frequency questionnaire, which in-cluded the most commonly eaten food items nationally.The food frequency questionnaire was pilot-tested in areasthat were not part of the study, and corrections for clarityor inclusiveness were made prior to the actual study. Par-ticipants were asked to recall how often they ate a food itemfrom a list of 23 predetermined food items, with responsesranging from eating the food item every day to never eating

it.20,22 Data from 2 fruit-related questions were not avail-able for analysis, leaving 21 food items included in thisreport. Questions concerning the numbers of meals andsnacks were included as well as an 8-item question con-cerning changes in the diet since becoming old. The 8items of total intake, variety, meat, fruits, vegetables, fattyfood, alcohol, and sweets had responses of “I eat less,”“more,” “same,” and “never ate.”

Statistical Analyses

Descriptive statistics were used to describe general charac-teristics of the elderly, dietary patterns, perceived changesin the diet, functional ability, and health status. The chi-square test was used to determine associations betweenvariables. Factor analysis, a data reduction method, wasused to identify food patterns. Factor analysis is a multivar-iate statistical technique used to examine underlying pat-terns for a given set of variables. The method of extractionwas principal component analysis (PCA), and varimax wasthe method used to keep rotated factors uncorrelated, usingKaiser Normalization as the method of rotation. The PCAreduces data by formation of linear combinations of the

original observed variables, which groups correlated vari-ables, leading to the identity of underlying dimensions inthe data. Missing data were excluded listwise (all caseslacking data on every variable were excluded). The com-mon eigenvalue of “1” was used as the cutoff point, thusitems with an eigenvalue of 1 or more were retained.23,24

Coefficients that describe linear combinations calledfactor loadings represent correlations of each food itemwith that component. The large factor loading of an itemindicates its high relationship to the factor. In this study,items that had a loading of 0.5 or more on all factors wereretained. Items loading on all factors were eliminated.

Other studies have used different cutoff points for retaining

312 Maruapula & Chapman-Novakofski/HEALTH AND DIETARY PATTERNS OF THE ELDERLY IN BOTSWANA



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factors, as low as 0.35.25 The number of components thatbest represent the data was chosen based on the point atwhich the scree plot levels.24,26

A score was created for each older adult per eachcomponent identified. Scores were calculated by multiply-ing the factor loading by the corresponding standardizedvalue for each food and summing across the food types.Scores identified were considered as outcome variables and

were used to determine associations between the score andsociodemographic and lifestyle factors. The potential pre-dictor variables were examined using general linear modeloption and the stepwise regression method with the excep-tion of functional abilities and perceived health (SPSS, Inc,version 12.0, Chicago, IL, 2006).

RESULTSDemographics and Health Perceptions

Demographic characteristics of the elderly are presented in

Table 1. Most elderly were in the 60-74 age category(49.7%), were married (48%), and practiced Christianity(55%). The majority of the elderly (53%) had not attendedschool. Of those who had attended some school, most(88%) had some primary/elementary school education, andfew (6%) had upper-level secondary schooling.

Half of the elderly had a large family size (6 to 10 chil-dren), with only 5% having no children. Indeed, the majoritylived with their children or grandchildren (66%), with some

living with both their children and grandchildren. Twenty-eight percent of the elderly indicated they supported 1 to 5children, although disposable income was limited.

Some elderly earned their livelihood from farming(16%) or other employment (12%), but pension was themain source of income, with 67% indicating a pension of P110.00 ($25 in 1998). However, the elderly had assets inthe form of land and livestock, with 80% owning a house,

68% arable land, 41% small animal stock (goats and sheep),and 33% owning cattle.

Most elderly (61%) rated their health as fair; 96% hadbeen bothered by illness in the past 3 months, and hadsought treatment primarily from various health care pro-viders (75%). Most elderly (60%) indicated they had re-duced ability to function, and a further 20% were depen-dent on others for help. There were no gender differences inability to function. However, 60% of those who indicatedthey were dependent on others for help also had poorhealth. There was no difference in self-health rating, abilityto function, and the need for help between elderly who

were financially supported and those who were not. Theelderly who had never attended school were more likely toindicate they needed help (P .01), were dependent (P .001), and had poor health (P .001).

Dietary Patterns

The most widely consumed food items were tea (91%),sorghum (82%), and maize-meal (63%). These items were

Table 1. Demographic Characteristics of the Elderly in Botswana

Men (n 519) Women (n 560) Total Sample (N 1079)Age (y, mean SD) 72.3 ( 9.6) 72.0 ( 9.0) 72.2 ( 9.3)

Sex (%) 48 52 100Health (%)

Good 18.6 12.0 15.2Fair 58.9 63.5 61.3

Poor 22.5 24.5 23.5Age categories (%)

60-74 years 51 48.6 49.775-84 years 27.6 27.1 27.4

85 years 23.8 21.9 22.9Current marital status (%)

Single 11.9 21.8 17Married 70.3 27 47.8

Widowed 13.2 48.6 31.6

Cohabiting 3.6 1.1 2.3Other 1.6 1 1.3

Religion (%)African Spiritual 17.4 22 19.8

Catholic 7.9 12.2 10.1Protestant 21.8 29.6 25.8

Muslim 1.2 0.9 1.0Other religions 11.4 13.4 12.5

No religion 40.3 21.9 30.8

Journal of Nutrition Education and Behavior ● Volume 39, Number 6, November/December 2007 313



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followed by milk (39%) and bread (34%). Only about aquarter of the elderly consumed green vegetables (25%),meat (23%), rice (22%), and other vegetables (20%).Chicken, melon, canned beef, traditional beer, canned fish,pumpkin, khadi (traditional distilled beer), juice, and softdrinks were consumed by less than 20% of the surveyedelderly on 3 or more days per week (Figure 1).

Less than half (44%) of the elderly ate 3 or more meals

per day. In assessing the number of meals eaten the previousday, 60% had eaten 2 meals or less per day, and 40% hadconsumed 3 meals or more per day. Breakfast was eaten by95% of the elderly. When asked to state the dietary changesthat had occurred since becoming old, 53% of the elderlysaid they were consuming less food in total, 43% had a lessvaried diet, 63% were eating less fatty food, 37% wereeating less meat, and 32% ate less fruit. Vegetables were theonly food items whose consumption had increased, as 33%indicated increased consumption.

Dietary Components IdentifiedExploratory factor analysis was completed on the 21 items(Table 2). The Kaiser-Meyer-Olkin (KMO), which mea-sures sampling adequacy and should be greater than 0.5 fora satisfactory factor analysis, was 0.814, indicating thatfactor analysis was appropriate. Bartlett’s test of sphericity,which means that the correlation matrix was not an iden-

tity matrix, had a chi-square of 4979 (df 210) and wassignificant (P .001).

The results of factor analysis indicated that tea andsorghum, with means of 5.59 and 5.36, respectively, werethe 2 most important variables influencing dietary patternsof the elderly. Five dietary components emerged which bestdescribed the dietary patterns of older adults. These werechosen using the scree plot, which leveled off from factor 5(Figure 2).

Table 3 shows in bold factor loadings of 0.5 or higherobtained for each of the components identified. The firstcomponent/factor was labeled the Beer Pattern, with all

types of beers, both traditionally and commercially pro-duced, loaded highly. The second component was the Meatand Fruit Pattern, composed of items from both red andwhite meat. The third pattern was labeled the Vegetableand Bread Pattern, as it includes both the green leafyvegetables and other vegetables and the bread group. TheSeasonal Produce group was so named because of the sea-sonality of the food items contained in this dietary pattern(pumpkin, melon, and watermelon). The final pattern ob-tained was the Milk, Tea, and Candy Pattern, which in-

Table 2. Description of Food Items Used in Factor Analysis of Food Patterns

for the Elderly in Botswana

Bojalwa: traditional beerChibuku: commercially brewed, traditional beer

Khadi: distilled traditional beerCanned beer: commercially brewed beer

Chicken: all types of chicken (boiled, fried, or grilled)Meat: any red meat (beef, mutton, goat, or wild game)

cooked in various ways Juice: any type of fruit juice

Canned fish: various types, eg, sardines or fish in tomatosauce

Soft drink: pop or soda (fizzy drinks)Rice: cooked rice

Sorghum meal: milled grain cooked as soft or thickporridge

Vegetables (other): other vegetables, not green

Green leafy vegetables: green vegetablesBread: any type of bread

Melon: non-sweet melonWatermelon: sweet melon

Pumpkin: any type of squashMilk: any type of milk, fresh or fermented

Sweets/candy: assorted forms of candyTea: hot tea

Maize-meal: milled grain cooked as soft or thick porridge

89

82

63

39

34

25

23

22

20

14

12

0 20 40 60 80 100

Percent consuming food thrice a week

Tea

Sorghum

Maize

Milk

Bread

Green Vegetables

Meat

Rice

Other Vegetables

Beer

Cola drinks

F o o

d

I t e m s

Figure 1. Percentage of older adults in Botswana consuming food items at

least 3 times a week.

Scree Plot

Component Number

21191715131197531

E i g e n v a l u e

5

4

3

2

1

0

Figure 2. Scree plot showing percentage of variance explained by each

component.




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cluded only these food items. The naming of the 5 factorswas subjective based on the predominant food componentsthat loaded on a factor, referred to as “patterns.”

Association With Sociodemographic andLifestyle Variables

The Beer Pattern was negatively associated with the femalegender (P .001), having grandchildren (P .006), prot-

estant church affiliation (P .001), spiritual church affil-iation (P .010), and the senior or higher education level(P .040). Belonging to any one of the mentioned groupswas associated with less consumption of beer (Table 4).There was no significant association of the Beer Patternwith health perception.

The Meat and Fruit Pattern was positively associatedwith a religious affiliation to protestant churches (P .001), and consuming snacks (P .028). Widowed olderadults were less likely to consume meat and fruit juicecompared to those who were married (P .005) (Table 4).The Meat and Fruit Pattern was negatively associated with

poor health (P

.001).

The Vegetable and Bread Pattern was positively asso-ciated with living with grandchildren, but negatively asso-ciated with living in villages, small or larger (P .001), orsnacking (P .005). Older adults living with 6 to 10dependents (P .001) and those who consumed snackswere positively associated with the Seasonal Produce Pat-tern (Table 4). There was no association between either theVegetable and Bread or the Seasonal Produce Pattern and

perceived health.The Milk, Tea, and Candy Pattern was negatively as-

sociated with older adults who had fewer than 5 grandchil-dren (P .004), who were in perceived poor health (P .001), and who indicated inadequate support from friends,relatives, and the government (P .02). But if older adultsplanted something last season on their farms (P .011),usually planted something on the farm (P .04), andbelonged to a protestant church, these items had a positiveassociation with the Milk, Tea, and Candy Pattern (Table 4).

DISCUSSION

Food intake variety was very limited, as has been reported.19

Clausen et al developed a Diet Diversity Score when ana-lyzing the data from the 1998 Health and Nutrition of theElderly in Botswana survey, using 5 food groups to deter-mine frequency. Whereas the previous report used “onceweekly or more” for data analysis, the present study used atleast 3 days per week consumption for food frequencyanalysis. Both studies found tea, sorghum, and maize-mealmost often consumed and low intake of fruits, vegetables,and dairy. The order of food item consumption relative to

frequency of intake differs slightly between the 2 analysesfor milk, bread, and vegetables. In both analyses, meatranks lower than the former food items. The limited num-ber of food items included in the 1998 Health and Nutri-tion of the Elderly in Botswana survey may be a limitationof any analysis of this data. However, although the ques-tionnaire used had many fewer food items than eaten in theUnited States, others have found far fewer number of fooditems eaten in African communities. For instance, Savy etal reported a mean of 8 food items eaten per day.27 Never-theless, any fortification policy should be cognizant of therole these food items play in the diet of elders. The elders’

perceptions of eating less food in general with less variety,less meat, and fewer fatty food items is comparable to bothcross-sectional and longitudinal data for US elderly, whichalso report decreases in caloric intake with age.6

Differences with dietary assessment methods as well assampling and statistical analyses make comparison withother dietary pattern studies of limited value. Nevertheless,this study identified 5 dietary patterns, whereas most studiesof dietary patterns completed in the US and Europe haveidentified 2 to 3 patterns on average.28,29 The fact that theBeer Pattern explains most of the variance in the factors isprobably because there are 4 different types of beer listed in

the food frequency questionnaire, whereas only 1 food item

Table 3. Factor Loading for 5 Dietary Patterns of the Diet Consumed by the

Elderly in Botswana

Food Item

Factor Components and Factor Loadings

1 2 3 4 5

Bojalwa .881 .012 .023 .026 .007

Chibuku .868 .001 .024 .055 .018Canned beer .788 .162 .016 .010 .006

Khadi .649 .003 .010 .032 .037Chicken .001 .719 .145 .204 .009

Meat .177 .566 .209 .075 .185 Juice .112 .529 .207 .149 .196

Canned fish .130 .505 .036 .136 080Soft drink .095 .481 .246 .148 .440

Rice .033 .456 .263 .227 .303

Sorghum .050 .426 .257 .047 .322Vegetables

(other)

.002 .218 .818 .007 .050

Green leafy

vegetables

.006 .088 .796 .152 .032

Bread .043 .384 .534 .127 .171Melon .015 .132 .103 .838 .030Watermelon .070 .134 .018 .798 .030

Pumpkin .018 .390 .204 .579 .036Milk .027 .014 .065 .227 .641

Sweets/candy .103 .303 .006 .088 .545

Tea .007 .042 .024 .062 .500

Maize-meal .260 .002 .263 .156 .432

Factor Component 1 indicates Beer Pattern; Factor Component 2, Meat

and Fruit Pattern; Factor Component 3, Vegetable and Bread Pattern; Factor

Component 4, Seasonal Produce Pattern; Factor Component 5, Milk, Tea

and Candy Pattern




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represents the red meat group. Also, green leafy vegetablesare not disaggregated into various food items. This probablebias should support a change in the national health andnutrition questionnaires used in Botswana in future years.

Alcohol use, including but not limited to beer, has beenreported to include 34% of this target population, in con-trast to the reported use in the present study of beer 3 times

per week or more by 14% of Botswana elders.30

Informationthat was not included in the 1998 Health and Nutrition of the Elderly in Botswana was pattern of consumption. Forinstance, Matsha et al report a beer consumption patternwhere a 5-liter container is filled with beer and sharedwithin a group, being refilled as needed.31 Quantification of this type of consumption is difficult. Although women aretraditionally the ones who brew beer in Botswana society,32

females are negatively associated with the Beer Patterncompared to males. This association is not surprising, as inmost societies, women are usually less likely to drink alco-hol than males.33-36 The elderly who attended church were

also negatively associated with the Beer Pattern, most prob-

ably because church attendees are more likely to abstainfrom alcohol and other drugs.35,37,38 The elderly living withgrandchildren were also less likely to indulge in alcohol,probably because of the need to save money to buy food forthe children instead of using it for their own pleasure. Thenegative association of consuming alcohol and increasededucation has also been documented in other studies.39,40

Heavy drinking was associated with the male gender, beingsingle, having less than a high school education, havingannual income below the median, and smoking.39

Vegetable and bread consumption was more commonamong grandparents who lived with children, and alsomore prevalent in towns (urban) than villages (rural). Thisfinding is consistent with previous findings that adults, andspecifically the elderly in urban areas, consume more veg-etables than those in rural areas.41,42 Environmental influ-ences on fruit and vegetable consumption have includedincome as well as access to fruits and vegetables.43 In aridcountries where vegetables and fruits need to be imported,

urban areas are likely to have more produce than rural. A

Table 4. Results of Ordinary Least Squares Regression for Food Patterns of the Elderly in Botswana

Coefficient () SE t P

Beer Pattern

Intercept/constant .769 0.133 5.769 .001

Female .645 0.108 5.981 .000Any grandchildren .354 0.127 2.790 .006

Protestant churches .424 0.124 3.413 .001

Spiritual churches .346 0.133 2.606 .010Senior education .850 0.411 2.067 .040

Meat/Fruit Pattern

Intercept/constant .157 0.078 2.005 .046

Protestant churches .481 0.125 3.849 .001Widowed elderly .348 0.121 2.867 .006

Any snack .425 0.192 2.213 .028Vegetable and Bread Pattern

Intercept/constant .369 0.082 4.492 .001Rural smaller village .646 0.107 6.035 .001

Rural larger village .573 0.079 7.240 .001Any snack .309 0.110 2.804 .005

Any grandchildren .160 0.073 2.184 .029 Seasonal Produce Pattern

Intercept/constant .130 0.065 2.013 .045Dependents fewer than 10 1.186 0.220 5.394 .001

Any snack .515 0.202 2.555 .011Milk, Tea and Candy Pattern

Intercept/constant .530 0.266 1.994 .047Grandchildren fewer than 5 .353 0.120 2.927 .004

Planted last season .323 0.125 2.579 .011Total meals yesterday .415 0.126 3.297 .001

Support adequate .320 0.136 2.344 .020Protestant churches .281 0.133 2.118 .035

Usually plant something .523 0.253 2.068 .040

SE indicates standard error




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review by Stloukal indicates aging associated with povertyin many developing countries is a rural phenomenon.44

Rural elderly have been found to have nutritional inade-quacies, probably owing to social and geographic isolation,limited access to transportation, and limited availability of nutrition programs and services.45,46 It is vital that theeffect of residence be considered when determining thequality of the diet of older persons. That vegetable and

bread consumption was more common in elderly livingwith children suggests that the influence of children onelders’ intake, and vice-versa, requires additional study. Theimportant role of the extended family in raising children istypical of sub-Saharan Africa. The orphan population con-tinues to grow in Botswana because of the high incidence of HIV. Throughout sub-Saharan Africa, most orphaned chil-dren live with extended families.47

The association of single/widowed status of women withpoor consumption of meats and juice is not surprising.Widowhood usually results in decreased economic power,rendering a widowed elder unable to purchase these food

items, which are usually expensive components of the diet.Whereas some studies have found that widowhood is asso-ciated with a decreased body mass index (BMI) and de-creased vegetable intake in both men and women,48-50

others have found no ef fect of marital status on the dietarypattern of US elders.46

Most (76%) elderly Batswanans’ perception of theirhealth as either fair or poor is similar to that of 78% of elderly Malawians, who reported their health to be some-what reduced or poor.51 The elderly of Mankgodi, a villagein southern Botswana, had analogous results for the percep-tion of their health, as 81% said they had reduced or poor

health.15

Poor self-reported health status has been associ-ated with musculoskeletal pain, depression, incontinence,dermatological problems, and dental problems in this pop-ulation.15 However, in the United States, only a third of African American elderly rated their health as fair topoor.52 Indeed, most elderly Americans (72%) rated theirhealth as good, very good, or excellent.53 Older adults inBotswana and Malawi rated their health as poor more oftenthan older adults in the United States, including those of African American descent. The lack of association of per-ceived health with 3 of the dietary patterns and a negativeassociation with 2 patterns (vegetarian and milk/tea/candy)

is difficult to interpret but does highlight the complexity of the diet–health relationship.

The economic influence on the health and nutrition of the elderly in Botswana requires additional study. A moredetailed analysis of this population was completed with asubset medical survey.19 The medical survey (N 393)identified having only 1 or 2 meals a day, having no formaleducation, not owning cattle, and living in a rural area asbeing associated with a low food variety. In the presentanalysis of the larger survey, more elderly had small animalstock (goats and sheep) rather than cattle, a surprisingfinding, given that in Botswana cattle outnumber people.

The low percentage of elderly involved in farming (16%) is

comparable to findings by a study by Gobotswang et al,which documented that households headed by elderly olderthan 65 years were 3 times more likely to have no harvestcompared to those 45 years and below.54 Less engagementof the elderly in agricultural production may predisposethem to food insecurity and nutritional vulnerability.

Although this study asked about pensions, it did not askabout 2 additional assistance programs: the World War

Veterans Scheme and the Destitution Program. Throughthe pension scheme (known locally as Tandabala or Mo-tauduje), older persons aged 65 years and above are givenmonthly payments without any means test. Furthermore,male elderly are eligible for a monthly payment if they areveterans of either the First or the Second World War. Anolder person could also be a recipient of government assis-tance through the Destitution Program according to thecriteria stipulated by the Revised National Policy on Des-titution. As a destitute, one receives food rations on amonthly basis to meet food requirements.55 Participation inthis program by the elders should be evaluated.

Limitations of this study primarily reflect secondary dataanalysis research: the food frequency questionnaire is thesole record of food intake; 2 fruit item results were notavailable, which may modestly change the results; andconclusions may reflect the cohort itself and not changes asa result of aging.

IMPLICATIONS FOR RESEARCH ANDPRACTICE

The heavy reliance on 3 food items, tea, sorghum, and

maize-meal, suggests poor nutritional status. The medicalsurvey previously published included evaluation of BMI andanemia status. Most elderly were not anemic (88%) and of normal BMI status (65%). Equal percentages had low BMIor were classified as obese (17.5%).20 However, furtherinvestigation with additional nutrition-related biochemicaldata as well as anthropometric data will not only provideadditional characterization of elders but also point to pos-sible solutions in terms of nutrition education needs, cropdiversification, fortification, and supplementation. It ap-pears that protein sources may be inadequate for manyelders, which could be addressed by nutrition educators

familiar with local resources. The need for additional in-vestigation as to the role of beer in social and healthperspectives of the elders is supported by this study. Thecontribution of beer to the nutritional profile is not known.

As noted previously, the large family size of the Bo-tswana elderly, with many elders caring for several children,suggests another important aspect for future research andnutrition education. Knowledge of children’s nutritionalneeds and ability to provide those food items have not yetbeen explored.

Few elderly reported their health as good in this study,and the majority of the elderly indicated that they had

reduced ability to function. Further investigations are




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needed on the specific health problems that the elderlyhave and the extent of their inability to function. Althoughthe ages of his patients are not included, 1 recent neurologymedical resident visiting Botswana noted that over 20% of the patients he treated had ischemic stroke. This findinghas ramifications for the need to prevent cardiovasculardisease and also for the functional disability likely to resultafter cardiovascular incident.56 Although most elderly ate

breakfast and did not eat alone, more than half ate 2 orfewer meals per day and did not snack. The elderly indi-cated they had undergone certain dietary changes, likeeating less food and consuming a less varied diet. Assess-ment of the economic and physical reasons for thesechanges would be necessary prior to designing any nationalintervention. In addition, health and diet beliefs of thispopulation should be further investigated relative to lifeexperiences before national recommendations are devel-oped. However, nutrition education efforts may focus onimproving food diversity, with particular targeting of wid-owed elderly and those in rural areas.

ACKNOWLEDGMENTS

This project was partially funded by the Norwegian Council of Universities/Centre for International University Cooperation(NUFU), the University of Botswana, and the ExperimentStation, University of Illinois, Urbana-Champaign.

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