South Africa is failing to address malnutrition in its older people

Thenjiwe Madzinga sits with her grandson Thina Gxotelwa in the small room they share in a shack in Cape Town’s Khayelitsha township. Madzinga cares for her five grandchildren, including four who were orphaned when her daughter died from AIDS in 2002. Finbarr O'Reilly/Reuters

The traditional extended family system has eroded in much of sub-Saharan Africa, leaving many older people who traditionally depended on this support vulnerable. In rural households, young people often migrate to cities in search of employment. International emigration and the pandemic of HIV/AIDS have also taken their toll.

The effect is that older people lack the financial and other resources to take care of themselves. As a result, many find it difficult to meet their nutrient requirements.

South Africa has the highest percentage of older people on the continent. Around 4.1 million people, or 8% of the population, are aged 60 or older and classified as pensioners. This is projected to nearly double to seven million (9.3% of the population) by 2030.

The health care needs of older people tend to be marginalised because South Africa’s health policy is focused on children, youth and maternal care. In particular, the nutritional needs of this age cohort is not being addressed with major implications for their overall health. Apart from lunch clubs at senior citizens’ centres and meals-on-wheels services, nutrition programmes for older people are sparse. So what can be done?

Why the over 60s are more at risk

South Africa’s health care services are not keeping up with the needs presented by older people who are more prone to a range of ailments and health challenges. These include:

  • Hypertension, heart disease and stroke, all of which are on the rise.

  • A decline in physical and mental function. These may include dementia, depression, delirium, vision problems, poor oral health and disease – either acute or chronic. Social factors that contribute to these are isolation and loneliness, poverty and lack of access to an adequate food supply, and, in some cases – particularly in bereaved widowers – inadequate knowledge about food preparation.

  • The way the body digests and absorbs nutrients changes with age. This results in an increased need for calcium, vitamin D and some B vitamins.

  • More frequent falls and fractures. Falling can have devastating effects on functional ability. A Cape Town survey found that 26% of older people had fallen in the 12 months before the study. Another 14% sustained a fracture. Almost half of those who fell did not return to their previous level of independence.

The heavy burden of poverty

Widespread poverty places older people at a high risk of malnutrition. As in other sub-Saharan countries, the majority of older South Africans have been disadvantaged for their whole lives. They have had poor access to health care and lifelong diets that were inadequate in both quantity and quality.

Malnutrition results in impaired immune function, poor wound healing, loss of muscle mass, strength and function, increased infections, and ultimately an increase in morbidity and mortality.

A survey of 283 people over the age of 60 in impoverished areas surrounding Cape Town found that half of them were at risk of malnutrition. Another 5% were malnourished.

The participants who had nutritional risk were more likely to have impaired mental functions than those who were well-nourished. The research could not determine whether the impaired mental functioning contributed to poor nutrition because of confusion about food preparation or forgetfulness to eat, or if it was a consequence of malnutrition. Many nutrients have functions in the brain, including omega-3 fatty acids, iodine, polyphenols and thiamine.

Our research showed that household food poverty is highest in households headed by older people. This may be related to the country’s social security payments system. Poorer South Africans over the age of 60 are eligible for a monthly government pension. This money acts as a magnet for younger, unemployed family members and often feeds the extended family, including grandchildren and unemployed adult children.

Although this is good news for poverty alleviation it does not provide the safety net to ensure adequate food intake.

What can be done?

Innovative strategies have been tested elsewhere. In Australia, frail and malnourished people who used the meals-on-wheels services were given a nutritious between-meal snacks in addition to their usual meal orders. This resulted in an increase in weight over four-weeks.

In the Netherlands, providing family style meals with attractive table settings and music during meals to residents in old age homes improved their quality of life, physical performance and their body weight over six months.

Malnutrition in older people is often not recognised and may be masked by excess body weight. For this reason, it has been suggested that nutrition screening should occur during routine patient interactions at primary care clinics.

Rapid nutrition screening tools have been tested in South Africa and have shown to be valid and reliable.

In 2000, an urgent need for more attention to be paid to the nutritional status of older people in South Africa was highlighted. Applied research on nutrition problems and the development and evaluation of appropriate nutrition interventions was sparse.

Fifteen years on, not much has changed and the number of older people is growing. Early recognition and management of malnutrition is still needed because it has an impact on overall health and quality of life in older people – and must be given the priority it deserves.