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 socioeconomic
variables 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; and
milk/tea/candy patterns. Elderly women, those attending church, and those living with grandchildren were less associated with the Beer Pattern. The Vegetable and Bread Pattern was more common
among grandparents living with children and those living in towns (urban). Widowed elders were
less likely to consume meat/fruit (P .005). Half had a large family size (6 to 10 children), with
about 30% supporting 1 to 5 children.
Conclusions and Implications: Dietary patterns suggested both food to be emphasized in nutrition
education programs and those who may benefit most. Nutrition education efforts in Botswana should
focus on improving food diversity, with particular targeting of widowed elderly and those in rural
areas, 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 both
developed and developing countries. It is estimated that a
fifth of the worlds inhabitants are over 60 years of age, and
at the beginning of the new millennium, there were over
600 million people over 60 years of age.1,2 Statistics show
that by the year 2050, the population 65 years old and older
will have doubled in all regions of the world including
sub-Saharan Africa.3
Decreases in birth and death rates resulting in increased
life expectancies in developing countries have resulted in a

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, exclusively, 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: kmc@uiuc.edu.

PUBLISHED BY ELSEVIER INC. ON BEHALF OF THE SOCIETY FOR

NUTRITION EDUCATION
doi: 10.1016/j.jneb.2007.07.007

phenomenon called the demographic transition. Statistics

for Botswana illustrate that the country is in such a demographic transition, although recently life expectancy has
decreased owing to the impact of the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/
AIDS). According to the 2001 Population Census, elderly
people constitute 5% of the total population of Botswana,
a figure that has been constant since 1971.4 The demographic transition is often associated with an epidemiological transition that reflects a shift toward lower prevalence
rates for infectious disease and higher rates for chronic
illnesses. 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 important as contributors to health. An overview of studies
examining the diet and dietary patterns of older US adults
concluded that both cross-sectional and longitudinal studies indicate that older persons are more likely to consume
fruits and vegetables and less likely to consume red meat
and fatty food than younger cohorts.6 In Pennsylvania,
older persons were found to have both a higher Fruit and
Vegetable Pattern and a higher Fat Pattern compared to
younger adults.7

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.

312

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

Quantitative cross-sectional and longitudinal surveys

such as these provide insights as to dietary quality. Other
researchers have instead relied on dietary variety as an
indicator of dietary quality and nutritional status.8,9 A
longitudinal study of Japanese elderly reported a decline in
dietary variety in over one third of the participants.10 The
causes for change in dietary habits are multifactoral, including sociocultural, demographic, and lifestyle factors. However, a definitive profile of these factors remains to be
explored in the elderly as well as in other age groups and
among ethnicities.11 Recognized as a valuable tool in this
area is factor analysis, which may provide more insight into
causes of diet variability than other methods.11,12
Botswana, like many of her African counterparts, has
little information on the health and nutrition of her
people.13-20 Whereas some report overall health across age
categories, others report overall nutrition without attention
to age. Clausen et al reported that the diet of older persons
in Botswana lacked variety and that determinants of variety
included rural residence, number of meals eaten each day,
and economic status. Data included those of the 1998
Health and Nutrition of the Elderly in Botswana survey, as
well as a subsample also assessed for medical health.19
Effective National Plans of Action for Botswana, according to the Food and Agriculture Organization of the
United Nations, rely on information across the life span for
successful policy development and implementation.21
Given such an information gap, there is a need to elicit
additional information on the health and nutritional situation of the elderly in Botswana. The objective of this study
is to further describe data from the 1998 Health and Nutrition of the Elderly in Botswana using factor analysis to
define patterns in consumption and to assess the association
of these patterns with health and demographic information.

METHODS
Study Design and Subjects
Data from the 1998 Health and Nutrition of the Elderly in
Botswana, conducted by the National Institute of Research
and Documentation of the University of Botswana, and the
Department of General Practice and Community Medicine, Faculty of Medicine, University of Oslo, were analyzed. The study was a nationally representative household
cross-sectional survey of 1086 elderly persons (52% female,
48% male), which represented a 1% sample of this target
population.
To complete a multistage cluster sampling, the country
was divided into 2 broad strata of urban (towns) and rural
(villages). The urban stratum was further divided into 7
towns, namely Gaborone, Francistown, Lobatse, Orapa,
Jwaneng, Selibe-Phike, and Sowa. A purposive sample was
obtained from 3 towns. Gaborone was selected because it is
the 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 districts
were equally represented. The sampling frame included all
older adults residing in a chosen locality who were eligible.
A random selection of the number of respondents required
was performed in each locality. Informed consent was obtained from each participant, and the study was approved
by the Office of the State President of Botswana.
The food frequency, demographics and health selfassessment questionnaires were prepared by a team of professionals including demographers, nutritionists, and social
scientists. The food items included in the study were identified through a food frequency questionnaire, which included the most commonly eaten food items nationally.
The food frequency questionnaire was pilot-tested in areas
that were not part of the study, and corrections for clarity
or inclusiveness were made prior to the actual study. Participants were asked to recall how often they ate a food item
from a list of 23 predetermined food items, with responses
ranging from eating the food item every day to never eating
it.20,22 Data from 2 fruit-related questions were not available for analysis, leaving 21 food items included in this
report. Questions concerning the numbers of meals and
snacks were included as well as an 8-item question concerning changes in the diet since becoming old. The 8
items of total intake, variety, meat, fruits, vegetables, fatty
food, alcohol, and sweets had responses of I eat less,
more, same, and never ate.

Statistical Analyses
Descriptive statistics were used to describe general characteristics of the elderly, dietary patterns, perceived changes
in the diet, functional ability, and health status. The chisquare test was used to determine associations between
variables. Factor analysis, a data reduction method, was
used to identify food patterns. Factor analysis is a multivariate statistical technique used to examine underlying patterns for a given set of variables. The method of extraction
was principal component analysis (PCA), and varimax was
the method used to keep rotated factors uncorrelated, using
Kaiser Normalization as the method of rotation. The PCA
reduces data by formation of linear combinations of the
original observed variables, which groups correlated variables, leading to the identity of underlying dimensions in
the data. Missing data were excluded listwise (all cases
lacking data on every variable were excluded). The common eigenvalue of 1 was used as the cutoff point, thus
items with an eigenvalue of 1 or more were retained.23,24
Coefficients that describe linear combinations called
factor loadings represent correlations of each food item
with that component. The large factor loading of an item
indicates its high relationship to the factor. In this study,
items that had a loading of 0.5 or more on all factors were
retained. Items loading on all factors were eliminated.
Other studies have used different cutoff points for retaining

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.

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

factors, as low as 0.35.25 The number of components that

best represent the data was chosen based on the point at
which the scree plot levels.24,26
A score was created for each older adult per each
component identified. Scores were calculated by multiplying the factor loading by the corresponding standardized
value 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 and
sociodemographic and lifestyle factors. The potential predictor variables were examined using general linear model
option and the stepwise regression method with the exception of functional abilities and perceived health (SPSS, Inc,
version 12.0, Chicago, IL, 2006).

RESULTS
Demographics 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 attended
school. Of those who had attended some school, most
(88%) had some primary/elementary school education, and
few (6%) had upper-level secondary schooling.
Half of the elderly had a large family size (6 to 10 children), with only 5% having no children. Indeed, the majority
lived with their children or grandchildren (66%), with some

313

living with both their children and grandchildren. Twentyeight percent of the elderly indicated they supported 1 to 5
children, although disposable income was limited.
Some elderly earned their livelihood from farming
(16%) or other employment (12%), but pension was the
main source of income, with 67% indicating a pension of
P110.00 ($25 in 1998). However, the elderly had assets in
the 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% had
been bothered by illness in the past 3 months, and had
sought treatment primarily from various health care providers (75%). Most elderly (60%) indicated they had reduced ability to function, and a further 20% were dependent on others for help. There were no gender differences in
ability to function. However, 60% of those who indicated
they were dependent on others for help also had poor
health. There was no difference in self-health rating, ability
to function, and the need for help between elderly who
were financially supported and those who were not. The
elderly who had never attended school were more likely to
indicate 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

Age (y, mean SD)

Sex (%)
Health (%)
Good
Fair
Poor
Age categories (%)
60-74 years
75-84 years
85 years
Current marital status (%)
Single
Married
Widowed
Cohabiting
Other
Religion (%)
African Spiritual
Catholic
Protestant
Muslim
Other religions
No religion

Men (n 519)
72.3 ( 9.6)
48

Women (n 560)
72.0 ( 9.0)
52

Total Sample (N 1079)

72.2 ( 9.3)
100

18.6
58.9
22.5

12.0
63.5
24.5

15.2
61.3
23.5

51
27.6
23.8

48.6
27.1
21.9

49.7
27.4
22.9

11.9
70.3
13.2
3.6
1.6

21.8
27
48.6
1.1
1

17
47.8
31.6
2.3
1.3

17.4
7.9
21.8
1.2
11.4
40.3

22
12.2
29.6
0.9
13.4
21.9

19.8
10.1
25.8
1.0
12.5
30.8

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.

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

Dietary Components Identified

Exploratory factor analysis was completed on the 21 items
(Table 2). The Kaiser-Meyer-Olkin (KMO), which measures sampling adequacy and should be greater than 0.5 for
a satisfactory factor analysis, was 0.814, indicating that
factor analysis was appropriate. Bartletts test of sphericity,
which means that the correlation matrix was not an iden-

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

for the Elderly in Botswana

Bojalwa: traditional beer

Chibuku: commercially brewed, traditional beer
Khadi: distilled traditional beer
Canned 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 tomato
sauce
Soft drink: pop or soda (fizzy drinks)
Rice: cooked rice
Sorghum meal: milled grain cooked as soft or thick
porridge
Vegetables (other): other vegetables, not green
Green leafy vegetables: green vegetables
Bread: any type of bread
Melon: non-sweet melon
Watermelon: sweet melon
Pumpkin: any type of squash
Milk: any type of milk, fresh or fermented
Sweets/candy: assorted forms of candy
Tea: hot tea
Maize-meal: milled grain cooked as soft or thick porridge

Cola drinks

12

Beer

14

Other Vegetables

20

Items

Rice

22

Meat

23

Green Vegetables

Food

followed by milk (39%) and bread (34%). Only about a

quarter 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 soft
drinks were consumed by less than 20% of the surveyed
elderly 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 previous
day, 60% had eaten 2 meals or less per day, and 40% had
consumed 3 meals or more per day. Breakfast was eaten by
95% of the elderly. When asked to state the dietary changes
that had occurred since becoming old, 53% of the elderly
said they were consuming less food in total, 43% had a less
varied diet, 63% were eating less fatty food, 37% were
eating less meat, and 32% ate less fruit. Vegetables were the
only food items whose consumption had increased, as 33%
indicated increased consumption.

25

Bread

34

Milk

39

Maize

63

Sorghum

82

Tea

89

20

40

60

80

100

Percent consum ing food thrice a week

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

least 3 times a week.

tity matrix, had a chi-square of 4979 (df 210) and was

significant (P .001).
The results of factor analysis indicated that tea and
sorghum, with means of 5.59 and 5.36, respectively, were
the 2 most important variables influencing dietary patterns
of the elderly. Five dietary components emerged which best
described the dietary patterns of older adults. These were
chosen using the scree plot, which leveled off from factor 5
(Figure 2).
Table 3 shows in bold factor loadings of 0.5 or higher
obtained for each of the components identified. The first
component/factor was labeled the Beer Pattern, with all
types of beers, both traditionally and commercially produced, loaded highly. The second component was the Meat
and Fruit Pattern, composed of items from both red and
white meat. The third pattern was labeled the Vegetable
and Bread Pattern, as it includes both the green leafy
vegetables and other vegetables and the bread group. The
Seasonal Produce group was so named because of the seasonality of the food items contained in this dietary pattern
(pumpkin, melon, and watermelon). The final pattern obtained was the Milk, Tea, and Candy Pattern, which in-

Scree Plot
5

Eigenvalue

314

0
1

11

13

15

17

19

21

Component Number

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

component.

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.

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

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

Factor Components and Factor Loadings

Food Item
Bojalwa
Chibuku
Canned beer
Khadi
Chicken
Meat
Juice
Canned fish
Soft drink
Rice
Sorghum
Vegetables
(other)
Green leafy
vegetables
Bread
Melon
Watermelon
Pumpkin
Milk
Sweets/candy
Tea
Maize-meal

1
2
3
.881
.012 .023
.868 .001
.024
.788
.162
.016
.649 .003
.010
.001
.719
.145
.177
.566
.209
.112
.529
.207
.130
.505
.036
.095
.481
.246
.033
.456
.263
.050 .426
.257
.002
.218
.818
.006

.088

.043
.015
.070
.018
.027
.103
.007
.260

.384
.132
.134
.390
.014
.303
.042
.002

4
.026
.055
.010
.032
.204
.075
.149
.136
.148
.227
.047
.007

5
.007
.018
.006
.037
.009
.185
.196
080
.440
.303
.322
.050

.152

.032

.534
.127
.103
.838
.018
.798
.204
.579
.065
.227
.006
.088
.024 .062
.263 .156

.171
.030
.030
.036
.641
.545
.500
.432

.796

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

cluded only these food items. The naming of the 5 factors

was subjective based on the predominant food components
that loaded on a factor, referred to as patterns.

Association With Sociodemographic and

Lifestyle Variables
The Beer Pattern was negatively associated with the female
gender (P .001), having grandchildren (P .006), protestant church affiliation (P .001), spiritual church affiliation (P .010), and the senior or higher education level
(P .040). Belonging to any one of the mentioned groups
was associated with less consumption of beer (Table 4).
There was no significant association of the Beer Pattern
with health perception.
The Meat and Fruit Pattern was positively associated
with a religious affiliation to protestant churches (P
.001), and consuming snacks (P .028). Widowed older
adults were less likely to consume meat and fruit juice
compared to those who were married (P .005) (Table 4).
The Meat and Fruit Pattern was negatively associated with
poor health (P .001).

315

The Vegetable and Bread Pattern was positively associated with living with grandchildren, but negatively associated with living in villages, small or larger (P .001), or
snacking (P .005). Older adults living with 6 to 10
dependents (P .001) and those who consumed snacks
were positively associated with the Seasonal Produce Pattern (Table 4). There was no association between either the
Vegetable and Bread or the Seasonal Produce Pattern and
perceived health.
The Milk, Tea, and Candy Pattern was negatively associated with older adults who had fewer than 5 grandchildren (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 adults
planted something last season on their farms (P .011),
usually planted something on the farm (P .04), and
belonged to a protestant church, these items had a positive
association 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 analyzing the data from the 1998 Health and Nutrition of the
Elderly in Botswana survey, using 5 food groups to determine frequency. Whereas the previous report used once
weekly or more for data analysis, the present study used at
least 3 days per week consumption for food frequency
analysis. Both studies found tea, sorghum, and maize-meal
most 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 analyses
for milk, bread, and vegetables. In both analyses, meat
ranks lower than the former food items. The limited number of food items included in the 1998 Health and Nutrition of the Elderly in Botswana survey may be a limitation
of any analysis of this data. However, although the questionnaire used had many fewer food items than eaten in the
United States, others have found far fewer number of food
items eaten in African communities. For instance, Savy et
al reported a mean of 8 food items eaten per day.27 Nevertheless, any fortification policy should be cognizant of the
role 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 both
cross-sectional and longitudinal data for US elderly, which
also report decreases in caloric intake with age.6
Differences with dietary assessment methods as well as
sampling and statistical analyses make comparison with
other dietary pattern studies of limited value. Nevertheless,
this study identified 5 dietary patterns, whereas most studies
of dietary patterns completed in the US and Europe have
identified 2 to 3 patterns on average.28,29 The fact that the
Beer Pattern explains most of the variance in the factors is
probably because there are 4 different types of beer listed in
the food frequency questionnaire, whereas only 1 food item

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.

316

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

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

Beer Pattern
Intercept/constant
Female
Any grandchildren
Protestant churches
Spiritual churches
Senior education
Meat/Fruit Pattern
Intercept/constant
Protestant churches
Widowed elderly
Any snack
Vegetable and Bread Pattern
Intercept/constant
Rural smaller village
Rural larger village
Any snack
Any grandchildren
Seasonal Produce Pattern
Intercept/constant
Dependents fewer than 10
Any snack
Milk, Tea and Candy Pattern
Intercept/constant
Grandchildren fewer than 5
Planted last season
Total meals yesterday
Support adequate
Protestant churches
Usually plant something

Coefficient ()

SE

.769
.645
.354
.424
.346
.850

0.133
0.108
0.127
0.124
0.133
0.411

5.769
5.981
2.790
3.413
2.606
2.067

.001
.000
.006
.001
.010
.040

.157
.481
.348
.425

0.078
0.125
0.121
0.192

2.005
3.849
2.867
2.213

.046
.001
.006
.028

.369
.646
.573
.309
.160

0.082
0.107
0.079
0.110
0.073

4.492
6.035
7.240
2.804
2.184

.001
.001
.001
.005
.029

.130
1.186
.515

0.065
0.220
0.202

2.013
5.394
2.555

.045
.001
.011

.530
.353
.323
.415
.320
.281
.523

0.266
0.120
0.125
0.126
0.136
0.133
0.253

1.994
2.927
2.579
3.297
2.344
2.118
2.068

.047
.004
.011
.001
.020
.035
.040

SE indicates standard error

represents the red meat group. Also, green leafy vegetables

are not disaggregated into various food items. This probable
bias should support a change in the national health and
nutrition questionnaires used in Botswana in future years.
Alcohol use, including but not limited to beer, has been
reported to include 34% of this target population, in contrast to the reported use in the present study of beer 3 times
per week or more by 14% of Botswana elders.30 Information
that was not included in the 1998 Health and Nutrition of
the Elderly in Botswana was pattern of consumption. For
instance, Matsha et al report a beer consumption pattern
where a 5-liter container is filled with beer and shared
within a group, being refilled as needed.31 Quantification of
this type of consumption is difficult. Although women are
traditionally the ones who brew beer in Botswana society,32
females are negatively associated with the Beer Pattern
compared to males. This association is not surprising, as in
most societies, women are usually less likely to drink alcohol 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 abstain

from alcohol and other drugs.35,37,38 The elderly living with
grandchildren were also less likely to indulge in alcohol,
probably because of the need to save money to buy food for
the children instead of using it for their own pleasure. The
negative association of consuming alcohol and increased
education has also been documented in other studies.39,40
Heavy drinking was associated with the male gender, being
single, having less than a high school education, having
annual income below the median, and smoking.39
Vegetable and bread consumption was more common
among grandparents who lived with children, and also
more prevalent in towns (urban) than villages (rural). This
finding is consistent with previous findings that adults, and
specifically the elderly in urban areas, consume more vegetables than those in rural areas.41,42 Environmental influences on fruit and vegetable consumption have included
income as well as access to fruits and vegetables.43 In arid
countries where vegetables and fruits need to be imported,
urban areas are likely to have more produce than rural. A

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.

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

review by Stloukal indicates aging associated with poverty

in many developing countries is a rural phenomenon.44
Rural elderly have been found to have nutritional inadequacies, 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 the
effect of residence be considered when determining the
quality of the diet of older persons. That vegetable and
bread consumption was more common in elderly living
with children suggests that the influence of children on
elders intake, and vice-versa, requires additional study. The
important role of the extended family in raising children is
typical of sub-Saharan Africa. The orphan population continues to grow in Botswana because of the high incidence of
HIV. Throughout sub-Saharan Africa, most orphaned children live with extended families.47
The association of single/widowed status of women with
poor 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 associated with a decreased body mass index (BMI) and decreased vegetable intake in both men and women,48-50
others have found no effect of marital status on the dietary
pattern of US elders.46
Most (76%) elderly Batswanans perception of their
health as either fair or poor is similar to that of 78% of
elderly Malawians, who reported their health to be somewhat reduced or poor.51 The elderly of Mankgodi, a village
in southern Botswana, had analogous results for the perception of their health, as 81% said they had reduced or poor
health.15 Poor self-reported health status has been associated with musculoskeletal pain, depression, incontinence,
dermatological problems, and dental problems in this population.15 However, in the United States, only a third of
African American elderly rated their health as fair to
poor.52 Indeed, most elderly Americans (72%) rated their
health as good, very good, or excellent.53 Older adults in
Botswana and Malawi rated their health as poor more often
than older adults in the United States, including those of
African American descent. The lack of association of perceived health with 3 of the dietary patterns and a negative
association 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 more
detailed analysis of this population was completed with a
subset medical survey.19 The medical survey (N 393)
identified having only 1 or 2 meals a day, having no formal
education, not owning cattle, and living in a rural area as
being associated with a low food variety. In the present
analysis of the larger survey, more elderly had small animal
stock (goats and sheep) rather than cattle, a surprising
finding, given that in Botswana cattle outnumber people.
The low percentage of elderly involved in farming (16%) is

317

comparable to findings by a study by Gobotswang et al,

which documented that households headed by elderly older
than 65 years were 3 times more likely to have no harvest
compared to those 45 years and below.54 Less engagement
of the elderly in agricultural production may predispose
them to food insecurity and nutritional vulnerability.
Although this study asked about pensions, it did not ask
about 2 additional assistance programs: the World War
Veterans Scheme and the Destitution Program. Through
the pension scheme (known locally as Tandabala or Motauduje), older persons aged 65 years and above are given
monthly payments without any means test. Furthermore,
male elderly are eligible for a monthly payment if they are
veterans of either the First or the Second World War. An
older person could also be a recipient of government assistance through the Destitution Program according to the
criteria stipulated by the Revised National Policy on Destitution. As a destitute, one receives food rations on a
monthly basis to meet food requirements.55 Participation in
this program by the elders should be evaluated.
Limitations of this study primarily reflect secondary data
analysis research: the food frequency questionnaire is the
sole record of food intake; 2 fruit item results were not
available, which may modestly change the results; and
conclusions may reflect the cohort itself and not changes as
a result of aging.

IMPLICATIONS FOR RESEARCH AND

PRACTICE
The heavy reliance on 3 food items, tea, sorghum, and
maize-meal, suggests poor nutritional status. The medical
survey previously published included evaluation of BMI and
anemia status. Most elderly were not anemic (88%) and of
normal BMI status (65%). Equal percentages had low BMI
or were classified as obese (17.5%).20 However, further
investigation with additional nutrition-related biochemical
data as well as anthropometric data will not only provide
additional characterization of elders but also point to possible solutions in terms of nutrition education needs, crop
diversification, fortification, and supplementation. It appears that protein sources may be inadequate for many
elders, which could be addressed by nutrition educators
familiar with local resources. The need for additional investigation as to the role of beer in social and health
perspectives of the elders is supported by this study. The
contribution of beer to the nutritional profile is not known.
As noted previously, the large family size of the Botswana elderly, with many elders caring for several children,
suggests another important aspect for future research and
nutrition education. Knowledge of childrens nutritional
needs and ability to provide those food items have not yet
been 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

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.

318

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

needed on the specific health problems that the elderly

have and the extent of their inability to function. Although
the ages of his patients are not included, 1 recent neurology
medical resident visiting Botswana noted that over 20% of
the patients he treated had ischemic stroke. This finding
has ramifications for the need to prevent cardiovascular
disease and also for the functional disability likely to result
after cardiovascular incident.56 Although most elderly ate
breakfast and did not eat alone, more than half ate 2 or
fewer meals per day and did not snack. The elderly indicated they had undergone certain dietary changes, like
eating less food and consuming a less varied diet. Assessment of the economic and physical reasons for these
changes would be necessary prior to designing any national
intervention. In addition, health and diet beliefs of this
population should be further investigated relative to life
experiences before national recommendations are developed. However, nutrition education efforts may focus on
improving food diversity, with particular targeting of widowed elderly and those in rural areas.

12.

13.

14.
15.

16.

17.

18.

19.

ACKNOWLEDGMENTS
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.

20.

REFERENCES

22.

1. Solomons NW. Demographic and nutritional trends among the elderly in developed and developing regions. Eur J Clin Nutr. 2000;
54(suppl 3):S2S14.
2. Cohen JE. World Population in 2050: assessing the projections. Conference Series-Federal Reserve Bank of Boston. 2001;46:83-113.
3. Kinsella K, Phillips DR. Global aging: the challenge of success. Popul Bull.
2005;60:1-44. Available at: http://www.prb.org/pdf05/60.1GlobalAging.
pdf. Accessed January 5, 2007.
4. Central Statistics Organization, Republic of Botswana. Central Statistics Office. 2001. Housing and Population Census. Available at:
http://www.cso.gov.bw/html/census/census_2k.html. Accessed January 6, 2007.
5. Popkin BM, Gorden-Larsen P. The nutrition transition: worldwide
obesity dynamics and their determinants. Int J Obes. 2004;28:S2-S9.
6. Wakimoto P, Block G. Dietary intake, dietary patterns, and changes
with age: an epidemiologic perspective. J Gerontol A Biol Sci Med Sci.
2001; 56 Spec No 2:65-80.
7. Ledikwe JH, Smiciklas-Wright H, Mitchell DC, Miller CK, Jensen
GL. Dietary patterns of rural older adults are associated with weight
and nutritional status. J Am Geriatr Soc. 2004;52:589-595.
8. Bernstein MA, Tucker KR, Ryan ND, et al. Higher dietary variety is
associated with better nutritional status in frail elderly people. J Am
Diet Assoc. 2002;102:1096-1104.
9. Marshall TA, Stumbo PJ, Warren JJ, Xie XJ. Inadequate nutrition
intakes are common and are associated with low diet variety in rural,
community-dwelling elderly. J Nutr. 2001;131:2191-2196.
10. Kwon J, Suzuki T, Kumagai S, Shinkai S, Yukawa H. Risk factors for
dietary variety decline among Japanese elderly in a rural community:
an 8-year follow-up study from TMIG-LISA. Eur J Clin Nutr. 2006;
60:305-311.
11. Park SY, Murphy SP, Wilkens LR, et al. Dietary patterns using the

21.

23.
24.
25.

26.

27.

28.

29.
30.

31.

32.
33.

Food Guide Pyramid groups are associated with sociodemographic and

lifestyle factors: the multiethnic cohort study. J Nutr.
2005;135:843-849.
Schulze MB, Hoffmann K, Kroke A, Boeing H. Dietary patterns and
their association with food and nutrient intake in the European
Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam
study. Br J Nutr. 2001;85:363-373. Erratum in: Br J Nutr 2002;87:279.
Grivetti LE. Dietary Resources and Social Aspects of Food Use in a
Tswana Tribe [dissertation]. Department of Geography, University of
California at Davis; 1976.
Maruapula SD. Micronutrient Malnutrition in Botswana. Gaborone:
Government Printers; 1996.
Clausen F, Sandberg E, Ingstad BHP. Morbidity and health care
utilization among elderly people in Mmankgodi village, Botswana. J
Epidemiol Commun Health. 2000;54:58-63.
Fry CL. Culture, age, and subjective well-being: health, functionality,
and the infrastructure of eldercare in comparative perspective. J Fam
Issues. 2000;21:751-776.
Shaibu S, Wallhagen MI. Family caregiving of the elderly in Botswana:
boundaries of culturally acceptable options and resources. J Cross Cult
Gerontol. 2002;17:139-154.
Clausen T, Romoren TI, Ferreira M, Kristensen P, Ingstad B,
Holmboe-Ottesen G. Chronic diseases and health inequalities in
older persons in Botswana (southern Africa): a national survey. J Nutr
Health Aging. 2005;9:455-461.
Clausen T, Charlton KE, Gobotswang KS, Holmboe-Ottesen G. Predictors of food variety and dietary diversity among older persons in
Botswana. Nutrition. 2005;21:86-95.
Holmboe-Ottesen G. Nutrition and food security in Letlhakeng village, Kweneng district, Botswana. Interim report, University of Oslo/
Gaborone: University of Botswana; 1991.
Agriculture and Consumer Protection Department, Food and Agriculture Organization of the United Nations. National Plans of Action
for Food Security and Nutrition. Available at: http://www.fao.org/ag/
agn/nutrition/national_npafsn_en.stm#. Accessed May 15, 2007.
Holmboe-Ottesen G. Nutrition and food security in Letlhakeng village. In: Mugabe M, Gobotswang K, Holmboe-Ottesen G, eds. From
Food Security to Nutrition Security in Botswana. Gaborone, Botswana:
Lentswe La Lesedi; 1998.
Cattell RB. The scree test for the number of factors. Multiv Behav Res.
1966;1:245-276.
Field A. Discovering Statistics Using SPSS. London: Sage Publications;
2005.
Balder HF, Virtanen M, Brants HA, et al. Common and countryspecific dietary patterns in four European cohort studies. J Nutr.
2003;133:4246-4251.
Grimm L, Yarnold P, eds. Reading and Understanding More Multivariate
Statistics. Washington, DC: American Psychological Association;
2005.
Savy M, Martin-Prevel Y, Sawadogo P, Kameli Y, Delpeuch F. Use of
variety/diversity scores for diet quality measurement: relation with
nutritional status of women in a rural area in Burkina Faso. Eur J Clin
Nutr. 2005;59:703-716.
Newby PK, Muller D, Hallfrisch J, Andres R, Tucker KL. Food
patterns measured by factor analysis and anthropometric changes in
adults. Am J Clin Nutr. 2004;80:504-513.
Yang E, Kerver M, Song WO. Dietary patterns of Korean Americans
described by factor analysis. J Am Coll Nutr. 2005;24:115-121.
Clausen T, Charlton KE, Holmboe-Ottesen G. Nutritional status,
tobacco use and alcohol consumption of older persons in Botswana. J
Nutr Health Aging. 2006;10:104-110.
Matsha T, Brink L, van Rensburg S, Hon D, Lombard C, Erasmus R.
Traditional home-brewed beer consumption and iron status in patients with esophageal cancer and healthy control subjects from Transkei, South Africa. Nutr Cancer. 2006;56:67-73.
McCall M. Rural brewing, exclusion and development policymaking.
Gend Devel 1998;4:9-38.
Kraus L, Bloomfield K, Augustin R, Reese A. Prevalence of alcohol

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.

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

34.

35.

36.

37.

38.
39.

40.

41.

42.
43.

44.

use and the association between onset of use and alcohol-related

problems in a general population sample in Germany. Addiction.
2000;95:1389-1401.
Larrieu S, Letenneur L, Berr C, et al. Sociodemographic differences in
dietary habits in a population-based sample of elderly subjects: the 3C
study. J Nutr Health Aging. 2004;8:497-502.
Kerr-Correa F, Igami TZ, Hiroce V, Tucci AM. Patterns of alcohol use
between genders: a cross-cultural evaluation. J Affect Disord. 2007;
102:265-275.
Proude EM, Britt H, Valenti L, Conigrave KM. The relationship
between self-reported alcohol intake and the morbidities managed by
GPs in Australia. BMC Fam Pract. 2006;14:17. Available at: http://
www.biomedcentral.com. Accessed January 5, 2007.
Jones-Webb R. Drinking patterns and problems among AfricanAmericans: recent findings. Alcohol Health Res World. 1998;22:260264.
Stylianou S. The role of religiosity in the opposition to drug use. Int
J Offender Ther Comp Criminol. 2004;48:429-448.
Karlamangla A, Zhou K, Reuben D, Greendale G, Moore A. Longitudinal trajectories of heavy drinking in adults in the US. Addiction.
2006;101:91-99.
Wray LA, Alwin DF, McCammon RJ. Social status and risky health
behaviors: results from the health and retirement study. J Gerontol B
Psychol Sci Soc Sci. 2005;60:85-92.
Ruel MT. Is dietary diversity an indicator of food security or dietary
quality? A review of measurement issues and research needs. Food
Nutr Bull. 2003;24:231-232.
Jaime PC, Monteiro CA. Fruit and vegetable intake by Brazilian
adults, 2003. Cad Saude Publica. 2005;21(Suppl):19-24.
Kamphuis CB, Giskes K, de Bruijn GJ, Wendel-Vos W, Brug J, van
Lenthe FJ. Environmental determinants of fruit and vegetable consumption among adults: a systematic review. Br J Nutr. 2006;96:620635.
Stloukal L. Rural population aging in poorer countries: possible implications
for rural development. Sustainable Development Dimensions. Rome: FAO,
2001. Available at: http://www.fao.org/sd/2001/pe0501a_en.htm. Accessed
January 5, 2007.

319

45. Arcury TA, Quandt SA, Bell RA, McDonald J, Vitolins MZ. Barriers
to nutritional well-being for rural elders: community experts perceptions. Gerontologist. 1998;38:490-498.
46. Ledikwe JH, Smiciklas-Wright H, Mitchell DC, Jensen GL, Friedmann JM, Still CD. Nutritional risk assessment and obesity in rural
older adults: a sex difference. Am J Clin Nutr. 2003;77:551-558.
47. Miller CM, Gruskin S, Subramanian SV, Rajaraman D, Heymann SJ.
Orphan care in Botswanas working households: growing responsibilities in the absence of adequate support. Am J Public Health. 2006;96:
1429-1435.
48. Wilcox S, Evenson KR, Aragaki A, Wassertheil-Smoller S, Mouton
CP, Loevinger BL. The effects of widowhood on physical and mental
health, health behaviors, and health outcomes: The Womens Health
Initiative. Health Psychol. 2003;22:513-522.
49. Eng PM, Kawachi I, Fitzmaurice G, Rimm EB. Effects of marital
transitions on changes in dietary and other health behaviors in US
male health professionals. J Epidemiol Community Health. 2005;59:5662.
50. Lee S, Cho E, Grodstein F, Kawachi I, Hu FB, Colditz GA. Effects of
marital transitions on changes in dietary and other health behaviours
in US women. Int J Epidemiol. 2005; 34:69-78.
51. Chilima D. Assessing nutritional status and functional ability of older
adults in developing countries. Dev Pract. 2000;10:108-113.
52. Paschal AM, Lewis RK, Martin A, Dennis-Shipp D, Simpson DS.
Baseline assessment of the health status and health behaviors of
African Americans participating in the activities-for-life program: a
community-based health intervention program. J Community Health.
2004;29:305-318.
53. Himes C. Elderly Americans. Popul Bull. 2002;56:1-44.
54. Gobotswang KS, Marks GC, ORouke P. Participation in laborintensive public works program: effect on staple crop production in
southeastern Botswana. Food Nutr Bull. 2002;23:413-420.
55. Ministry of Local Government, Botswana. Background paper for sectional programmes and policies on safety nets. Paper presented at: The
Revised National Food Strategy Workshop; 2003.
56. Dahodwala N. Neurology education and global health: my rotation in
Botswana. Neurology. 2007;68:E15-16.

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.