Nutritional Status and Dietary Pattern of the Elderly in Tshiulungoma and Maniini Village of Thulamela Municipality, Vhembe District.

Introduction: Dietary patterns provide a comprehensive information about the food consumption habits within a population. Dietary patterns of every individual changes as we grow older. Dietary pattern of elderly is essential to the evaluation of their nutritional status. This study aimed to describe the nutritional status and dietary pattern of the elderly. Methods: This was a cross sectional study involving elderly people aged 60 years and above. Socio demographic information was obtained from elderly people through a questionnaire. Dietary information was assessed using a questionnaire and dietary diversity score. Data on dietary intake were collected using Food Frequency Questionnaire (FFQ). Height and weight were measured. BMI were determined and classi�ed using BMI category. Results: A total of 300 elderly people had participated in the study, 150 from Maniini village and 150 from Tshiulungoma village. The prevalence of underweight, overweight and obesity was 2%, 34% and 17% respectively. Most (66%) of the participants ate three meals per day. It was found that 13.7% of the elderly skipped breakfast every day. About 19.6% of elderly ate supper sometimes while 13.7% did not eat supper. Conclusion: The �ndings of study reveals that most of the participants ate three main meals a day, with minority skipping either breakfast or dinner or eat in- between meals. Obesity was more prevalent in female as compared to the male counterparts. Improving nutritional status of elderly should follow an integrated approach tackling both malnutrition at the same time considering behavioural approach.

Appropriate nutrition is vital for elderly people because of the physiological changes that occur as one is aging (Agbozo et al., 2018). Loss of muscle mass, metabolic abnormalities and reduced immune function is the results of functional limitations and poor diet in most elderly people (Vellas et al.,2000). Good nutritional status and proper diet during aging is critical for boosting immune system and infection resistance (Pae, Meydani & Wu, 2012). Eating variety of food to meet their nutritional need of their changing physiological state is very rare (Donini et al., 2013). Past experiences of food during childhood and earlier adulthood may in uence attitudes concerning food and meals in later life (Edfors & Westergren, 2012). However, Dietary pattern are not static and may change as the individual is aging.
South Africa like many developing countries is undergoing nutrition transition which promote and exacerbate weight gain in age groups. Even though dietary changes caused by these nutrition transition occur, undernutrition among elderly people still prevails especially in rural areas. In 2008 the prevalence of malnutrition in the sub-Saharan Africa varied according the country with Cameron (6%), Ghana (48%),

Materials And Methods
A cross sectional study was carried out in 300 elderly people aged 60 years and above in Tshiulungoma and Maniini village of Thulamela Municipality, Vhembe District. Thulamela local municipality is the smallest municipality of four in the district, making up 10% of its geographical area. It is the largest municipality in the province in terms of population. The name Thulamela is a Karanga word meaning 'the place of giving birth. Data was collected during a three-month period (August to October 2019).
Simple random sampling was used to select Thulamela municipality from the four municipalities in the Vhembe District, Maniini and Tshiulungoma from 186 villages in Vhembe district. Convenience sampling was used to select study participants. A meeting with the elderly people was arranged at the chief's kraal.
The researcher provided explanation on the aim, objectives and procedure of the study. Furthermore, the elderly people were given consent form to sign before data collection. All elderly people who agreed to participate were included, while those with cognitive de cits who were unable to respond to the interview were excluded. Furthermore, the study excluded elderly people who were in wheelchairs due to lack of equipment to measure their weight and height.
Data were collected by a team of trained health professionals (nutritionists and Biokineticists). Data was collected using a questionnaire and pilot tested to check for anything that could impede the instrument's ability to collect data in economical and systematic fashion. To ensure that the study participants recall food item consumed in the past given their age, food models were used. The following variables such as demographic data, dietary patterns, dietary diversity score as well as anthropometrics were measured. An expert from the Department of Linguistics at the University of Venda translated the questionnaire into the local language used in Thulamela Municipality which is Tshivenda to ensure that participants clearly understood the questions. Anthropometric assessments were performed according to standard procedure. The following measurements were taken in duplicate using calibrated equipment with the adult wearing light clothing and no shoes: standing height and weight. Height was measured to the nearest 0.1 cm using a calibrated portable Seca solar scale (Seca-model 0213, Hammer Steindamm, Hamburg, Germany) and weight was measured to the nearest 0.01 kg on a portable Seca solar scale (model 0213) (Seca, Hammer Steindamm, Hamburg, Germany). The solar scale and stadiometer were calibrated before measurements using a calibration weight and steel tape respectively (Lee & Nieman, 2010).

Food survey
Food Frequency questionnaire was used to assess the dietary intake of elderly people. The adequacy of nutrients intake was compared with the recommended dietary intake for elderly people (Food and Nutrition Board, 2011). The dietary diversity score was interpreted using the WHO recommended cut-off point.

De nition of underweight, Normal, Overweight and Obesity
The BMI (Kg/m 2 ) was selected to estimate the prevalence of underweight, overweight and obesity according to WHO references values. Underweight was de ned as less (<) 18.5, normal weight: 18.5 to 25, Overweight: 25-29.5 and Obesity: >30 kg/m 2 (WHO, 1995).

Statistical Analysis
Statistical package of social sciences (IBM SPSS Statistics., Armonk, NY version 25) was used to analyze categorical and descriptive data such as mean, standard deviation, frequencies and percentages. Chisquare test for categorical data and Pearson's correlation were performed to assess the relationship between socio-demographic characteristics and nutritional status. A p ≤ 0.01 and p ≤ 0.05 was considered statistically signi cant. Food nder was used to analyze dietary intake of the study participants. The dietary diversity score was interpreted using the WHO recommended cut-off point.

Results
The socio demographic information of the study participants is summarized in Table 1. Half of the study participants had ages within 60-69 years. The mean (standard deviation (SD)) of the male participants was 70.04 (6.65) while that of female was 70.04 (6.65). Majority of the participants attended school. Of all those who attended school, 38.6% attended primary while 28.1% attended secondary school. Half of the participants were married. Almost all participants were receiving social grants. Most of the participants were Venda speaking while minority were Sepedi speaking.  (11) The prevalence of underweight, overweight and obesity was 2%, 34% and 16.7% respectively. The prevalence of overweight and obesity was high in females (18.7% and 11.7%) as compared to their male counterparts (15.3% and 5%). Sixty percent of the participants had medium dietary diversity score while 38% of the participants had the highest dietary diversity score. However, minority of the participants had the lowest dietary diversity score. This nding was not statistically signi cant (p = 0.064) ( Table 2).   Half of the participants did meet their energy intake while 49.8% did not meet their energy intake (p = 0.023). The mean intake of energy was 2345 ± 942.35. Of all the participants, 62.5% did not met their protein intake while 56.4% while 37.5% did meet their protein intake. The mean intake of protein was 45.3 ± 19.4 while that of iron was 8.4 ± 7.5 and that of zinc was 11.2 ± 10.8. Almost sixty percent of the participants did not meet their vitamin B2 intake while only 40.2% did meet their vitamin B2 intake (Table 5). no exception, obesity rates are greater among those ages 65 to 74 than among those ages 75 and over and over and obesity is associated with increase in mortality and contribute to many chronic diseases.
Prevalence of obesity and overweight could be due to the fact that aging is associated with a decrease in total energy expenditure, and if this coincides with a maintained or increased energy intake, overweight/obesity may develop (Edfors & Westergren, 2012). However, the socioeconomic disparities, poor nutritional qualities of traditional diets in many rural communities could not be ruled as they might have contributed to malnutrition among elderly people. Under and overnutrition among elderly coexist in the current study like many Sub-Saharan countries (Alao, Akinola & Ojofeitimie, 2015; Maila, Audain & Marinda, 2019). The prevalence of obesity was high among 13% female as compared to their male 4% counterparts (Mittal & Srivastava, 2006). This may be due to the fact that women are heavier than males while males are taller than females and in South Africa overweight and obesity is associated with "wealth and healthy" but the perception has drastically changed on the basis that overweight and obesity are associated with many non-communicable diseases (Motadi et al., 2015) The nutrition and health of the elderly is often neglected. Most nutritional intervention programs are directed toward infants, young children, adolescents, and pregnant and lactating mothers (Agarwalla, Saikia & Baruah, 2015). Every community has its own pattern and practices, with ideas as to which foods are good for the people at different ages and which one are not. What people think about food is also affected by what is available. Most of the elderly people know the nutritional values of the foods they eat.
Some avoid certain foods because of personal dislike, social and cultural practices and religion. The dietary pattern of the participants shows that most of them ate three main meals a day which is necessary for good health. This is similar to ndings from a study carried out among elderly in rural Southern African countries (Lee et al., 1996). As shown by Shahar et al. (2003) the older population tends to continue the more traditional eating pattern of three meals a day. However, minority of them either skip breakfast or eat in-between meals. Minority of the participants sometimes skip breakfast or dinner. Skipping of meals is a very common practice among elderly people in the rural areas (Lee, Templeton & Wang, 1996). Minority of the participants in the current study snacked in between meals possibly to enable them cope with the energy needs of the body as they go about their daily activities. However, Lee et al. (1996) reported low intake of nutrient among elderly people who snacked frequently. The pattern also shows a low intake of snacks, alcohol and tobacco use among them.
The ndings on food consumption revealed that many participants in the current study consumed food from different food groups. However, most of the participants consumed fruits, vegetables and cereals. Protein food sources were rarely consumed except that participants consumed legumes, nuts and seeds usually consumed with green leafy vegetables and a small amount of animal-derived food (Labadarios et al., 2005). The rarely consumption of this animal derived food sources could be due their high cost, limited supply and in some cases, due to religious or cultural practices. Insu cient consumption of these animal food source leads to low intake of important micronutrients among this age group (Roohani et al., 2013).
Our study showed low consumption of milk and milk product among the participants. Perhaps this can be attributed to the fact that milk is perceived as tasteless by most elderly people due to deterioration of taste buds. Between 75 and 85 years, the taste buds' deterioration is 65% reduction of sensitivity to sweet and salty taste. One of the well-established factors that affect food choice is the sensory perceptions to food stimuli. Chemical and physical properties of the food are perceived by the individual in terms of sensory attributes. These sensory attributes of foods can be categorized, in broad terms, as appearance, texture, trigeminal mouth feel, odour and taste (Shepherd, 1999;Alao et al., 2015). The ability to perceive these sensory attributes in addition to liking them determines whether an individual consumes a food (Shepherd, 1999 Furthermore, highest dietary score may be linked to overnutrition observed among study participants as indicated by the prevalence of overweight and obesity. Almost half of the participants didn't meet their energy intake in the current study. Alao et al. (2015) reported that older who may not eat enough to meet energy needs which can results in increases the risk of nutrition related illness. Our study revealed that even though many participants consumed food from different food groups, it is also noticed from the result of the study that participants didn't meet the dietary intake of iron, zinc, calcium, vitamin B1, B2 and vitamin C. These may be attributed to the agerelated alterations to the sense of taste which is closely linked to poor appetite, inappropriate food choices, and lower nutrient intake. This insu cient intake of micronutrients may be due to the fact that the participants reported low intake of protein. Protein share the same food sources with zinc, iron, vitamin B1 and B2 (Mahan & Escott-Stump, 2012).
The limitation of the present study was that the information on dietary intake relied on the ability of the participants to recall, which might have resulted in under and overreporting. The study was conducted in two villages which cannot be generalized to Thulamela municipality.

Conclusion
The study reveals that most of the participants ate three main meals a day, with minority skipping either breakfast or dinner or eat in-between meals. Consumption of food from different food groups ensures balanced nutrition even though very few had highest dietary diversity score. BMI status of the study participants indicate that most of them had a normal weight. This study reveals that even though elderly people are known to be more knowledgeable about the role and importance of nutrition, it does not imply an improvement in dietary intakes. Understanding of dietary patterns of older people is necessary for providing appropriate nutritional guidance. Nutrition education to encourage healthy eating among elderly people should include family support.
Abbreviations WHO: World Health Organization.

BMI: Body Mass Index
Declarations South Africa. A full and adequate oral and written explanation of the study was given to the participants. Participants gave written signed informed consent to participate in the study. The consent form included the participants' right to withdraw from the study and codes were used to ensure con dentiality of the information obtained.

Consent to publication:
The manuscript does not contain any individual person's data in any form.