Nutrition, health and old age – the case of south African urban elderly
Karen E Charlton, MPhil (Epidemiol), MSc, SRD
Nutrition and Dietetics Unit, Department of Medicine, University of Cape Town, Observatory, 7925
email: kc@uctgsh1.uct.ac.za

S A J Clin Nutr 2000 February Vol. 13 No 1.

The southern African region (Botswana, Lesotho, Nambia, South Africa, Swaziland, Mozambique and Zimbabwe) has the continent’s highest percentage of older inhabitants; 6.2% of the population in 1997 was estimated to be 60 years or older. Within southern Africa, South Africa has the highest proportion of older population. The 1996 census data estimate than 2.8 million South Africans are aged 60 years and older, which constitutes 7% of the total population. This percentage is projected to increase to almost 11% of the population over the next 20 years. (Mostert W, Hofmeyr B, Oosthuizen K. Demographic projections for South Africa. Pretoria: Human Sciences Research Council, 1997 – unpublished data.) It is the absolute number of elderly people that determines the need for health and welfare services. In this regard, the number is projected to more than double, to 6.3 million. (Mostert W, Hofmeyr B, Oosthuizen K. Demographic projections for South Africa. Pretoria:Human Sciences Research Council, 1997-unpublished data.)

In terms of life expectancy at birth, differences are seen between the racial groups in South Africa. Life expectancy for white South Africans is currently about 8 - 10 years higher than for the black and coloured populations, and about 5 years higher than for the Asian group. (Mostert W, Hofmeyr B, Oosthuizen K. Demographic projections for South Africa Pretoria: Human Sciences Research Council, 1997 –unpublished data.) In all groups, older women outnumber men. The total population growth rate in South Africa is falling as a result of declining fertility rates. However, as more people reach old age, the growth rate of the 60+ age group has come to exceed that of the total population, and the gap will widen considerably in the future.

Socio-economic considerations regarding the situation of the elderly in southern africa
As a result of the 40 years of apartheid policy, the black, coloured and Asian populations had unequal opportunities and access to the country’s resources and are consequently disadvantaged in most areas of their lives when compared with their white counterparts, particularly with regard to education, income and health status. A countrywide multidimensional survey of a representative sample of 4 400 South Africans aged 60+ years, which was conducted in 1990/91,found that older black South Africans and non-urban dwellers more than urban dwellers were particularly marginalised with regard to educational and socio-economic attainment, provision for old age, indicators of health status and perceived quality of life. Eighty per cent of older blacks in non-urban areas and half in urban areas had received no formal education. About two-thirds of the black and coloured sample reported that they perceived their income to be inadequate in terms of meeting their needs, as compared with only 22% of the white subjects, and a similar trend was seen regarding reported provison for old age.

In most countries in southern Africa, the elderly are more likely than the total population to reside in rural areas. This is a result of the migration of young adults to cities and sometimes the return migration of older adults from urban areas back to rural homes. Following the elimination of the Group Areas Act in 1988, which permitted only male migrant labourers to relocate to urban areas, South Africa has seen a massive movement of persons from non-urban to urban areas, and a resulting proliferation of informal settlements on urban fringes. From available data it is not yet clear if older citizens are being adversely affected by such movement (e.g. being left behind in rural areas with little infrastructure, to raise grandchildren), or whether they are participating in and benefiting from migration through better access to health and pension systems. However, data from the 1996 census indicate that 52% of the 60+ age group now live in urban areas, and that this trend is similar to that of the total population, namely 54% living in urban areas. Secondary analysis of data from the 1995 Western Cape Community Housing Trust (WCCHT) study of African settlements in the metropolitan Cape Town area has provided important information with regard to urbanisation and migration patterns of older subjects. A sample of 920 households was categorised according to households in which there were no members aged 60 and over (‘young’, N = 807), and ‘elderly’ households (N = 113) with at least one older person resident. Elderly households tended to be larger, more prone to experience unemployment, and more likely to be in formal houses rather than informal structures than young households. Dependency ratio* was higher in the elderly households. In terms of income, elderly households were significantly poorer than their younger counterparts. In about half the elderly households, the elderly appeared to be the sole source of income. Large numbers of unemployed kinfolk, particularly the pensioner’s children and grandchildren, clustered around old age pensioners. It was evident that these households would not be viable without the contribution of the pension and it was concluded that social pensioners in urban areas are magnets for economically weaker persons. Further, it was found that contrary to common belief, older citizen have participated in the recent mobility upsurge, both intra-urban and rural-urban migration, although on a somewhat smaller scale than their younger counterparts. Although elderly urban households often form part of an integrated urban/rural link with family members, and visits back and forth are common, the practice of permanent return migration to rural areas in old age appears to be dwindling.

South Africa is the only country in Africa, apart from Namibia, where a non-contributory but means-tested, state old-age pension system exists (R490 per month in 1998). In other African countries the dominant form of social support and care of the elderly remains the responsibility of adult children and the extended family.

Most South African pensioners, whether residing in urban or non-urban areas, live in three-generation households where the social pension contributes a substantial proportion to household budgets. In support of the findings of the WCCHT data cited above, a qualitative study conducted among urban, peri-urban and non-urban female pensioners in KwaZulu-Natal reported that pension monies were used to support kin, primarily to meet the basic needs of the family, especially food, clothing and household utilities. In most cases food was the major expenditure item on the household budget. However, without exception, the pension was reported by subjects to be inadequate for meeting their family’s needs. Nowhere is the sharing ethos (known as u b u n t u) more evident than in the practice of ‘eating f rom the common pot’ in African families. In the peculiar case of South Africa, the social pension affords elderly people independence and respect from younger generations within the household. Møller argues that even in the urban setting, the African extended family appears to be intact; however, the d i rection of remittances (at least financial) within a household unit appears to be from older to younger members. The grandmother is an integral figure in the daily management of the household, not only in terms of providing financially, but also in items of food purchasing, meal preparation and housework. In two studies of pensioners in Cape Town and West Coast towns, women were found to expend more energy per week in activities than men, using a validated physical activity questionnaire which included indices of housework, yardwork, caring, recreation and exercise. In both studies, the differences were attributed to the index of household work, which included shopping. In urban areas, nutrition education activities targeted at this age group may, therefore, impact on the family unit as a whole.

Since the start of the large-scale urbanisation trend in about
1989, studies have been conducted on groups of elderly people in several parts of the country, but predominantly in the Western Cape region. The following stressors were identified as particularly affecting the physical and mental health of the urban elderly. (Ferreira M. The elderly: a high-risk group. Paper presented at the Medical Research Council Workshop on Urban Health Policy for Southern Africa, Johannesburg, March 1995.)

Violence and crime
Violence and a fear of crime were found to inhibit mobility and hence the ability to access health care facilities. Isolation and loneliness may result, with the ‘elderly being prisoners in their own homes’.

Poor access to health services
Identified barriers to health care include lack of knowledge of where to obtain health care, long distances to travel to facilities, inaccessibility of transport, inaffordability of transport or the service itself, and dissatisfaction with health care at State facilities. 3,11-16 New health care policies in South Africa have primarily targeted women, children and youth, with the elderly not regarded as a priority. Although the improvement of community-based care for older clients, together with improved detection and control of risk factors and chronic disease at the primary level were identified as two principal health priorities in the health reconstruction plan, there is scant evidence of any implementation of this policy goal. With the emphasis shift from tertiary and secondary care to primary health care, dedicated geriatric services have fallen by the wayside. The preventive, curative and rehabilitative needs of older clients have for the main part been integrated into general sessions at community clinics at the primary care level. Numerous community nurses have been redeployed from geriatric services, for example, to assist with immunisation programmes for children. As a result, the elderly now have to wait in long queues to receive treatment, together with young mothers, children and everybody else.

A high level of dissatisfaction with health care is not limited to elderly people in urban areas, however. A study of retired people in farming towns in the Western Cape found that even though three-quarters of the subjects reported having ‘financial difficulties’, a quarter of them stated that they chose to consult a private doctor and to pay the doctor’s fee of about R50 - R60, rather than use a government facility where as social pensioners they are entitled to free health care.

Poor health/physical impairment
High percentages of the elderly in newly settled areas rate their health as poor. Chronic diseases such as diabetes and hypertension are either undetected and medically untreated, or in the case of those who do receive treatment, the clinical management of the condition is poor. Currently routine treatment for these conditions at primary care facilities frequently involves little more than the dispensing of medication on a monthly basis; there is little opportunity for patient education regarding lifestyle management.

Lack of knowledge and information
Low literacy and education levels, lack of skills and unfamiliar urban environments inhibit the older person’s ability to access resources and services generally.

Mental health stressors
A high prevalence of depressive symptomatology, especially among urban African women, has been found. Forty-four per cent of older women in the relatively newly urbanised township of Khayelitsha in Cape Town have been found to have symptoms of depression, compared with 27% of women of the same age in Langa, one of the oldest and most established townships in the country. Economic factors, the burden of caregiving and social dislocation and disorganisation were identified as stressors to the mental health of elderly women.

Poor urban environment and infrastructure
In urban areas the elderly are most affected by poor housing infrastructure (inadequate structures, overcrowding, few household conveniences) and transport. As well as potential mutual benefits of living with family members in multigenerational households, family conflict and unsatisfactory living conditions associated with overcrowding may be a stressor for some of the elderly.

Poverty
Despite possibly easier access to pension pay-out centres in urban and peri-urban areas, older people generally report that the pension (R490 per month in 1998) is insufficient to meet their basic needs.

Gender
Older women outnumber men and are more likely to be widowed, poorer and burdened with caregiving and domestic responsibilities.

In the nationwide multidimensional survey in 1991/92, it was found that the most serious problems which older people in urban areas experienced were lack of money, poor health, poor access to health care, depression and a fear of being robbed.

All of the factors listed above will impact on the well-being of an older person and it is evident that those most likely to be at risk are older adults who have recently migrated to the city. In terms of nutritional status, as well as the influence of socio-economic and psychological factors, physiological factors associated with ageing such as impaired digestion, absorption or utilisation of nutrients associated with chronic disease or drug-nutrient interactions, also place the older adult at particular nutritional risk. Available information on the nutritional status and dietary intake of older South Africans is reviewed in the next section.

Dietary habits and nutritional status of older south africans
Information on the nutritional status of community-dwelling South Africans is sparse and is largely limited to data from four studies: a sample of urban blacks in the Free State (N = 400), a sample of urban blacks from the BRISK study in the peri-urban settlements of Cape Town (N = 148), a study of older coloured (mixed ancestry) subjects in Cape Town (N = 200), and a sample of white elderly in Potchefstroom (N = 100). The only published study on the nutritional status of older non-urban South Africans, conducted in a sample of 100 subjects in Pankop, assessed biochemical parameters and anthropometrical measurements (dietary data were not collected) (see Table I). Macronutrient intake and energy profiles Mean energy fell below the RDA for both black and coloured men (1 725 (692) and 1 910 (776) kcal, respectively) and women (1 224 (498) and 1 670 (531), respectively) in urban Cape Town (see Table II). Between 27% and 32% of men, and 36 - 26% of women in these two groups, respectively, had energy intakes below 67% of the RDA. Due to possible methodological biases between the dietary studies of the elderly, it may be more appropriate to consider the energy profiles of the groups. Dietary protein intake was similar across all groups and comprised between 11% and 16% of total energy intake. For urban black men and women in Cape Town and the Free State, percentage energy (%E) from fat contributed about 25% of total energy, compared with 39%E for white elderly, with the coloured sample having an intermediate fat intake of about 32%E. The polyunsaturated/saturated (P/S) ratio was notably higher in the coloured sample (0.8) than for any of the other groups, which is related to their liberal use of plant oils in cooking. Conversely, %E intake from carbohydrate was lowest in the white sample (< 50 %E) than for the other groups (> 56%), which is characteristic of a Western versus cereal - based traditional diet. Mean dietary fibre intake did not meet the prudent dietary recommendation of 30 g/day for any of the groups except for black men in the Free State (31 (28) g/day) The sample of black elderly in Cape Town had fibre intakes which were about half those of the Free State sample (16(11) and 11 (7) g/day for men and women, respectively).

Table I. Dietary surveys of older South Africans

Table II. Comparison of the mean (SD) energy distribution, P/S ratio, cholesterol and fibre intakes of older South Africans

Micronutrient intake
In both men and women, mean intake did not meet the RDA for the following micronutrients across all of the groups: vitamin D, calcium and zinc (Table III). The black Cape Town sample generally had the lowest mean micronutrient intakes compared with the other samples, which is in line with their lower energy intakes.

Table III. Mean daily micronutrient intake of older urbanised South Africans (mean (SD))

Anthropometric status
For both men and women the sample of older white South Africans appeared to be between 5 and 10 cm taller in stature than the other groups, which may be indicative of early chronic malnutrition (Table IV). Mean BMI was highest for urban black women in Cape Town at 30.3 (6.9) and lowest for non-urban black women in the areas of Pankop (25 (5.2)). For men, mean BMI fell below 25, except for the black sample in Cape Town and the white sample in Potchefstroom. The prevalence of obesity, indicated by a BMI of 30 and above, was fourfold higher in urban black women in Cape Town than in women in non-urban Pankop. A low prevalence of obesity was found in urban black men and no cases were seen in non-urban black men.

Table IV. Comparison of anthropometric data in samples of older South Africans (means (SD))

Health status of older south africans
It is to be expected that the nutrition transition associated with increasing urbanisation trends in present and future cohorts of older Africans will be accompanied by an increase in chronic diseases of lifestyle (CDL), such as coronary heart disease, cerebrovascular disease and diabetes. However, the link between diet, urbanisation and the manifestation of chronic disease is not clear. The older black Xhosa population living in urban Cape Town has been shown to have markedly lower rates of hypertension (30.3%) than their Sesotho-speaking counterparts of the same age in either urban (Manguang, 70.6%) or non-urban (QwaQwa, 56.7%) Free State. This finding has also been reported for the younger black population of Cape Town, as well as in a group of Xhosa-speaking lead factory workers in the Eastern Cape. Urban exposure (a categorical variable, described as 40% or more of life spent in a city) was identified as an independent risk factor for diabetes in the black population of Cape Town by Levitt et al. The age-adjusted prevalence of 8% is higher than any previously reported for Africans in South Africa or the rest of Africa.

The cardiovascular risk factor profile of older South Africans in urban and non-urban areas is shown in Table V. Older white, coloured and Asian South Africans have been shown to be already at high risk for chronic diseases. The older coloured population in Cape Town has been shown to have a high prevalence of diabetes (28.7%, 95% CI = 21.7% - 35.7%), which is among the highest reported for this age group worldwide, accompanied by a high prevalence of hypertension (71.7%, 95% CI=68.5 - 74.9&). A sample of white South Africans aged 55 - 69 years in Durban has been shown to have the least favourable serum cholesterol levels compared with other groups of a similar age (53% had a high-risk value > 6.5 mmol/l); however, obesity was surprisingly uncommon (12%) in the same group. The proportion of people with protective high-density lipoprotein (HDL)/total cholesterol ratios (i.e. > 20%) in the sample was low (12%) and was similar to that found in a sample of Indian people of the same age in Durban.

Table V. Comparison of the prevalence (%) of cardiovascular risk factors in older South Africans

Geriatric nutrition services
Historically, the care of the elderly in South Africa has been the responsibility of the Department of Welfare. However, poor intersectoral co-operation has meant that geriatric nutrition services have been fragmented and have fallen in the gap between the ministries of Health and Welfare. In the late 1960s the welfare department began to establish service centres, which offer services such as meals and opportunities for social interaction, but no such centres were established for black elders. In the early 1980s the South African Council for the Aged began to establish luncheon clubs for black elderly and today there are over 500 of these clubs throughout the country. The Department of Welfare continues to subsidise some service centres, but not meals. Some voluntary and church-affiliated organisations run schemes that deliver meals to homebound older persons; however, non-governmental organisations (NGOs) face increasing difficulties in sustaining the services owing to insecure funding.37

From 1991 the National Nutrition and Social Development Programme (NNSDP) of the Department of Health made funds available for the elderly through established luncheon clubs. However, this programme was terminated in 1994, and as with the R5 million-a-year protein-energy malnutrition (PEM) scheme which provides dietary supplementation through fortified milk-based drinks and maize meal, resources are now redirected to pregnant and lactating women and children. By and large, geriatric nutrition services have not been evaluated. A single small study investigated the impact of luncheon clubs on the nutritional status of a sample of elderly club members. The study concluded that the average meal provided did not meet a third of the RDAfor many nutrients, but was an important source of nutrition for club members. Information is needed on the effectiveness of various nutrition interventions in this age group.

Conclusions and recommendations

• The ratio of protein, fat and carbohydrate to total energy intake provides an indication of the atherogenicity of the diet and identifies a population’s position in the ‘nutrition transition’. Survey findings suggest that urbanised older black South Africans have a low fat intake (< 30%E), older white South Africans have a high fat intake (> 35%E), while coloured elderly have an intermediate fat intake (32%E). The trend for increasing urbanisation in the country has implications for changing dietary practices.
• Micronutrient intake was low across all the groups, particularly for vitamin D, calcium and zinc, which is consistent with data on older populations in other countries. The particularly low micronutrient values of the sample of black women in Cape Town are probably a function of their inadequate energy intake, which places this group at high risk of micronutrient deficiencies. Regarding the adequacy of vitamin D intake in the comparative South African studies the US Food and Nutrition Board of the Institute of Medicine has recently recommended an even higher adequate daily intake of vitamin D for adults aged 71 years or older than the present RDA, namely 15 µg (600 IU) per day.
  Little is known regarding the bone health of older black South Africans; however, a study conducted almost 30 years ago reported that the prevalence of hip fractures in black South African women was more than tenfold lower than that seen in their black American counterparts, or white American women. The apparently low prevalence of osteoporosis and related conditions in black populations who consume little dietary calcium and vitamin D is puzzling and warrants ongoing investigation.
  Widespread fortification of appropriate basic foodstuffs, such as calcium fortification of bread and vitamin D fortification of milk and dairy products, as occurs in North America and some European countries, may prove successful in the primary prevention of certain nutrient deficiency disorders in older South Africans. However, intervention trials are awaited.
• Regarding anthropometric status, it appears that older black and coloured South Africans are of shorter stature than white South Africans and older Americans, which suggests early chronic malnutrition. It has been suggested that adult lifestyles add to the effects of intra-uterine insult, particularly in the case of development of adult obesity in people who were small at birth and who were undernourished as young children. In this regard, older previously disadvantaged South African populations appear to be at risk of these additive effects, at least in the case of women.
• Older black and coloured men tend towards under-nutrition, while women across all the groups tend towards obesity. The prevalence of obesity was markedly higher (almost fourfold) in urban compared with non-urban black women.
• Further research is required to identify simple, valid measures to screen for malnutrition and overnutrition in the elderly, particularly focusing on poor populations in developing countries, taking into account socio-economic circumstances, cultural practices and living arrangements.
• The provision of nutrition services to elderly people in urban areas is complicated by the apparent double burden of nutrition-related disease. On the one hand, there is evidence of micronutrient under-nutrition in older adults, while on the other hand there is evidence of high risk for chronic diseases of lifestyle in certain groups. Coupled with this complex situation is the current prioritisation of other sectors of the population, namely women and children, for the targeting of nutrition services.
• In conclusion, optimal nutrition for the elderly has implications in terms of improving their health status and general well-being, as well as reducing their utilisation of health care resources. There is an urgent need to develop a geriatric nutrition policy in the country and to implement programmes requiring intersectoral co-operation between the ministries of Health and Welfare.

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Last updated: 17-Feb-2004