Several studies have reported poorer diet quality among those in low socioeconomic groups and resource-constrained settings, particularly elderly people in rural areas, than among those in high socioeconomic groups (Irz et al., 2014; Power et al., 2014). Low socioeconomic status leads to reduced accessibility to food variety, poor food choice, and increased poor coping strategies such as skipping meals or overconsumption of poor-quality food (Kamphuis et al., 2015). In addition, it also causes low consumption of high-quality protein and micronutrients, leading to reduced immunity, high mortality and infections in adults (Best & Papies, 2019). (Bhurosy & Jeewon, 2014; Psaltopoulou et al., 2017).
Studies have shown that an increase in the variety of food consumed is related to increased quality of macro- and micronutrient nutrients in the diet of different age groups (Tsubota-Utsugi et al., 2015; Bandoh & Kenu, 2017). Dietary diversity (DD) has been recognized worldwide as a major element of high-quality diets (Rizzo et al., 2013; Zhao et al., 2017).
The demographic and epidemiologic characteristics of Uganda, a low-income country, are changing, with a decrease in mortality and overall life expectancy of 63.7 years (UBOS, 2017), implying that the number of elderly individuals will continue to increase (Wandera et al., 2017). The country had 1.1 million people aged ≥60 years in 2002, and this number gradually increased to 1.3 million in 2010. According to the national population census conducted in 2014, 4% of Ugandans were 60 years of age or older (UBOS, 2017). This number is projected to reach 5.4 million by 2050 (HAI & UNFPA, 2012).
As the population of elderly people continues to increase with a high level of vulnerability, governments need to develop policies to address the problems that affect older persons, including those related to social protection (Devereux, 2015), for their empowerment (Barrientos et al., 2012). The government of Uganda piloted and is implementing a social assistant grant for empowerment (SAGE) programme as an instrument for unconditional cash transfer (UCT) specifically targeting elderly people (Merttens et al., 2016). However, the contribution of SAGE to the dietary quality and nutrient intake adequacy of elderly people in remote rural areas of northern Uganda has not been well studied.
The Uganda Demographic and Health Survey (UBOS) (2016) revealed that 19% of Ugandans were underweight, but there are no precise data on the elderly population. The literature on the quality of the diet consumed by elderly people is limited (Schramm et al., 2016). The literature shows that the prevalence of underweight adults is high and is associated with older age (>55 years) and being divorced/separated in the Gulu district of northern Uganda (Schramm et al., 2016). Despite the fact that evaluation findings confirmed that SAGE has enhanced elderly people's food intake and nutrition (Merttens et al., 2016), limited literature still exists on diet quality among these elderly people.
The major types of social protection in Africa include social assistance, social insurance and social fairness (Devereux, 2015). In Uganda, social assistance is the major element of social protection offered and includes the Karamoja Cash Transfer Pilot Program, the World Food Program (WFP) (KWFP-CT), the Antenatal Care Utilization Study (ACUS) CCT and the SAGE (Owusu-Addo et al., 2018)
The grant recipients receive approximately $7 (25,000 Ugandan Shillings) every month. All older people are eligible for this stipend, although it is mainly intended for individuals who do not work in formal capacity. The SAGE program is overseen by the Expanding Social Protection (ESP) within the Ministry of Gender, Labour, and Social Development. Senior Citizen Grants (SCGs) and Vulnerable Families Grants (VFGs) are the two components of SAGE.
Nutrition and cash transfer
Cash transfer and nutrition are strongly linked because income and poverty are the most important root causes of malnutrition (Devereux, 2015). Cash transfers can address the causes of malnutrition; they also increase resilience, social inclusion, and psychological wellbeing.
In Africa, cash transfers are becoming more popular following the tangible evidence that consistent transfers have a greater impact on lowering poverty, vulnerability and social risks and improving dietary quality (Owusu-addo et al., 2018). For instance, the effect of CTs on food security and dietary diversity was examined in nine programs. The overall effect was consistently positive across all studies. In the Zambia CGP programme (Bonilla et al., 2017), the Ghana LEAP programme (Owusu-addo et al., 2018), the Malawi SCTP programme (Brugh et al., 2018) and the Lesotho CGP programme (Bhalla et al., 2018; Tiwari et al., 2016)
Cash given in time and a known time interval increases the quantity and quality of food consumed in beneficiaries households. However, a smaller and more irregular cash transfer has no beneficial effects on food security (Tiwari et al., 2016).
Nutrition in elderly persons
Biological changes in the digestive system of healthy older people strongly affect food and nutrient intake(Garcia, 2012). Many hormones, such as cholecystokinin, insulin, ghrelin, and leptin, affect nutrient intake and are regulated by the hypothalamus hunger–satiety control centre. Changes in internal body control that occur with aging cause negative changes in the gastrointestinal tract, affecting the hormones that control nutrient intake (Chapman, 2004)
In elderly people with high levels of glucose intolerance and insulin, insulin is a satiety hormone that supports leptin signalling to the hypothalamus and inhibits gherlin use to stimulate appetite (Convit et al., 2002) and changes in the intestinal microbiota
Macronutrient requirements
The Food and Nutrition Board of the Institute of Medicine of the National Academies released the macronutrient guidelines, which recommend a fat intake of 20% to 35% of the total energy with emphasis on the consumption of less cholesterol, saturated fat, and trans-fat (Foote el al., 2000). Additionally, an older adult’s diet has to include 45% to 65% carbohydrates, preferably complex carbohydrates in the form of fibres. Furthermore, on average, 10% to 35% of the daily protein intake should come from total calories. Moreover, dietary protein consumption may be advantageous for elderly people's physical function (Isanejad et al., 2016; Landi et al., 2016).
Micronutrient requirements
Deficits in some micronutrients play a role in a number of age-related diseases. For instance, low consumption of vitamin- and mineral-rich food was linked to all-cause cardiovascular disease mortality among elderly people (Chen et al.,2019). This implies that information with regard to the RDA of elderly people is of paramount importance if the disease burden is to be addressed.
Table 1: Requirements for micronutrients (vitamins) for older adults (>50 years)
Nutrient
|
Men
|
Women
|
Vitamin
|
|
|
Vitamin E
|
15 mg (22.5 IU)/day
|
15 mg (22.5 IU)/day
|
Vitamin D (51-70 years)
|
15 μg (600 IU)/day
|
15 μg (600 IU)/day
|
Niacin
|
14 mg NE/day
|
16 mg NE*/day
|
Vitamin D (>70 years)
|
20 μg (800 IU)/day
|
20 μg (800 IU)/day
|
Vitamin A
|
700 μg (2,333 IU)/day
|
900 μg (3,000 IU)/day
|
Thiamin
|
1.1 mg/day
|
1.2 mg/day
|
Riboflavin
|
1.1 mg/day
|
1.3 mg/day
|
Vitamin B6
|
1.5 mg/day
|
1.7 mg/day
|
Vitamin B12
|
2.4 μg/day#
|
2.4 μg/day#
|
Pantothenic acid
|
5 mg/day (AI)
|
5 mg/day (AI)
|
Biotin
|
30 μg/day (AI)
|
30 μg/day (AI)
|
Vitamin C
|
75 mg/day
|
90 mg/day
|
Vitamin K
|
90 μg/day (AI)
|
120 μg/day (AI)
|
Folate
|
400 μg/day
|
400 μg/day
|
Source: Food and Nutrition Board recommendations (RDAs except where otherwise noted)
Niacin equivalent, or *NE: 1 mg NE = 60 mg tryptophan = 1 mg niacin
#Due to the age-related increase in malabsorption, vitamin B12 consumption should come from supplements or meals fortified with the vitamin
RDA is the recommended Dietary Allowance; AL stands for Adequate Intake; µg stands for microgram; mg for milligram; g for gram; and IU for international unit.
Table 2: Micronutrient (mineral) requirements for older adults (>50 years)
Nutrient
|
Men
|
Women
|
Minerals
|
|
|
Sodium
|
1.5 g/day (AI)
|
1.5 g/day (AI)
|
Manganese
|
1.8 mg/day (AI)
|
2.3 mg/day (AI)
|
Potassium
|
2.6 g/day (AI)
|
3.4 g/day (AI)
|
Fluoride
|
3 mg/day (AI)
|
4 mg/day (AI)
|
Iron
|
8 mg/day
|
8 mg/day
|
Zinc
|
8 mg/day
|
11 mg/day
|
Chromium
|
20 μg/day (AI)
|
30 μg/day (AI)
|
Molybdenum
|
45 μg/day
|
45 μg/day
|
Selenium
|
55 μg/day
|
55 μg/day
|
Iodine
|
150 μg/day
|
150 μg/day
|
Magnesium
|
320 mg/day
|
420 mg/day
|
Phosphorus
|
700 mg/day
|
700 mg/day
|
Copper
|
900 μg/day
|
900 μg/day
|
Calcium (51-70 years)
|
1,200 mg/day
|
1,000 mg/day
|
Calcium (>70 years)
|
1,200 mg/day
|
1,200 mg/day
|
Source: Food and Nutrition Board recommendations (RDAs except where otherwise noted)
* Microgram (µg), milligram (mg), gram (g), international unit (IU), recommended dietary allowance (RDA), and adequate intake (AL) are some examples of abbreviations.
Dietary quality
Because the elements that meet healthy nutritional requirements are not often found in a single food item but are instead present in a variety of food groups and variations, nutrition guidelines generally indicate that the healthiest and highest-quality diets are the ones with the greatest diversity(Castro-Quezada et al., 2014).
In Uganda and other developing nations, energy intake is the most significant predictor of food security, but northern Uganda has seriously low dietary diversity and quality with a low intake of energy (WFP, 2013). A study in urban and rural areas in Ghana reported that 28.8% of women who met the minimum dietary diversity for women (MDD-W) had a mean dietary diversity score (DDS) of 3.81 ± 0.7, and the majority of the women had inadequate intake of minerals and vitamin A (Ayensu et al., 2020). Another study conducted among Thai community-dwelling older people revealed an average DDS of 18.4 ± 3.9 out of 32 food frequencies (Chalermsri et al., 2022). Furthermore, the majority of the examined elderly individuals in Nigeria, both male (36.4%) and female (48.6%), were found to have a minimum score for dietary diversity (Adepoju & Coker, 2018). Another study on the dietary intake of Chinese elderly individuals reported high consumption of tea, salt, tubers, fruits, fish, soybeans, cereal, vegetables, and meat (Yin et al., 2019).
Determinants of dietary intake among elderly persons
In a similar vein, Tsubota-Utsugi et al. (2015) and Chalermsri et al.,(2022) asserts that living situation also affects dietary DQ, in which elderly people living alone in a family have poor dietary intake. In another study, dietary variety scores and sociodemographic factors such as sex, age, marital status, and expected monthly income were found to be significantly correlated (Adepoju & Coker., 2018). In addition, younger and older people from lower social classes, as well as those with lower levels of education, are known to have poorer diets more frequently (Bloom et al.,2017).
Against this background, the current study determined dietary intake and associated factors among elderly beneficiaries and nonbeneficiaries of SAGE residing in rural areas of northern Uganda.
This study was conceived after the realization that the population of elderly people is increasing and that their vulnerability to food production and socioeconomic access to food are now real, which poses threats to elderly people’s dietary quality and nutrient intake adequacy.
This study provides information for rational decision making by policy makers on the design and implementation of cash transfer programs such as the SAGE. The study findings also provide a basis for future research.