Diversity of foods among older people in northern communities of Thailand: Ways to promote health and wellness

Abstract

Purpose

Due to the increasing population and diverse lifestyles of aging people in Thailand, close examination of their needs and health care problems is required. Availability and accessibility of food affects the health and well-being of aging people in the community; therefore, to enhance their quality of life, community nurses and health care personnel must understand the variety of foods in their diet, in order to provide suitable and culturally acceptable nutrition for the elderly. The purpose of this paper is to explore the diversity of foods eaten by older people and the social, economic, environmental, and cultural contexts in which they live in the Northern region of Thailand. This is a part of a larger research project of community food management systems for the care of older people.

Design/methodology/approach

Critical ethnographic research was employed during the study. The data were collected from 41 primary elderly informants and family members. The researcher collected data by conducting individual in-depth interviews, observation of activities, and focus group discussions. The text data were analyzed by content analysis.

Findings

Information gathered from this research reveal nine categories of food which older people are associated with and which include: favorite foods; food provided by others; foodstuffs which should be eaten due to chronic diseases (recommended by doctor); foods to be avoided; snacks; food eaten with others (eating when socializing); food for festivals and cultural traditions; food offered for making merit; and food donated to others.

Originality/value

Utilization of health data, specifically regarding individual dietary diversity, can guide community nurses and health care personnel to provide and promote health that will suit individuals and their families. Community nurses and health care personnel should be aware of the variety of older persons’ diets and the importance of being able to manage and sustain their own nutritional needs. Appropriate nutrition, which is one of the social determinants of health, could improve the quality of the well-being of aging members in the community.

Citation

Bubpa, N. and Nuntaboot, K. (2018), "Diversity of foods among older people in northern communities of Thailand: Ways to promote health and wellness", Journal of Health Research, Vol. 32 No. 1, pp. 95-104. https://doi.org/10.1108/JHR-01-2018-028

Introduction

The United Nations has assessed that 2001-2100 will be the Century of Aging where more than 10 percent of the global population will be aged 60 years and over. It is very likely that the majority of these elderly persons will have low incomes. This social and economic challenge will require that each country must prepare their own unique plan to overcome barriers to food security and nutrition of aging members in their community[1].

This prediction applies to all ASEAN nations, as well as Thailand[2]. Thailand is now an aging society, and it is expected that the proportion of the population aged 60 years and over will increase to 20 percent of the country’s population in the years 2024-2025. This percentage of the aged in a population is considered “an aged society.”

In addition, about one in four of the present Thai population will be regarded as “aging people” in the next 20 years[3-5].

The elderly has various problems and needs that affect their nutrition, including health status, disabilities, vision impairment, problems of chewing, swallowing, restrictions of motion, chronic diseases like diabetes, high blood pressure, obesity, and malnutrition[5-8]. For the social situation, the survey on older people reveals different living styles, such as living with children, living with a spouse, living alone, and other types of living as of 56.5, 17.6, 10, and 14.5 percent, respectively. Moreover, family members often have insufficient time to take care of their elderly relations and often lack health care knowledge and skills to care for them adequately[9, 10]. With regard to economics, elderly people are often dependent on others because they have no income, or their income may have significantly decreased. Prices of goods and foodstuffs are becoming increasingly more expensive. According to forecasts of dependent older people in Thailand, in 2009, there were 140,000 severely dependent older persons, and the number is expected to double to 280,000 people in 2024[11]. With regard to environmental aspects, food may often be contaminated with chemicals and must be washed prior to consumption. There is often a shortage of water resources, and there are no areas or supplies of agricultural raw materials for planting or raising animals in order to obtain quality foods. Food production is also often far from homes. Older persons may have physical limitations which may lead to difficulties to buy or prepare food adequately. With regard to cultural aspects, food culture is changing with an increase in consumption of fast foods, change in eating habits, marketing of food, delivery of prepared meals, food processing, and preservation[11-13].

Food and nutrition are important factors of a good life, and food is one of the social determinants of health. Nutrition, or the lack of it, affects the health of older people[14, 15]. Food security is increasingly important to the global community. Institutions have predicted that in the next ten years, there will be a phenomenon of rising costs for many types of foods, and this will have a negative effect on the poor, who may not be able to acquire adequate amounts or nutritious food. The agricultural structure is changing – the labor force is decreasing and the younger generation often prefers to work in cities rather than on farms. Chemicals are used to increase productivity, which often make food products less healthy or even reduces nutrition levels. With haste in everyday life, people often eat out instead of cooking at home. Alternately, they buy pre-cooked or semi-finished food products. The prepared food business is growing. Most food products are now prepared in factories; agri-business is replacing agri-culture. These food products are sold in supermarkets and convenience stores located within the community, but often scattered widely and farther from homes. For elderly with travel and mobility limitations, this may be problematic[16-18].

Community nurses and health care personnel must be aware of both the increasing aging population and changes in the community’s food security. It is, therefore, necessary to understand the perspectives of older people and their families concerning foodstuffs consumed by the elderly. This knowledge will help community nurses and health care personnel to design clearer and more comprehensive “care for older persons” and prepare the community to be involved by producing sufficient and quality foods to meet the demands, and which can be purchased and used for health purposes[19]. This will help to promote the well-being and improve the quality of life of older members of society. Based on a review of literature and related research studies, such knowledge has not been found. Awareness of this lack of knowledge led to this present study. It is part of a research project on community food management systems for the care of older people. The objective of this study was to explore the variety of foods of older people under their social, economic, environmental, and cultural contexts in the northern communities of Thailand.

Methods

This critical ethnographic research aims to examine culture, knowledge, and action. Critical ethnographers, seeking something more, attempt to connect the meanings to broader structures of social power and control[20]. This research focuses on understanding the views and behaviors including the acquisition of older people and their families concerning food. The research was carried out thoroughly and comprehensively in order to lead to proposals to community nurses and health care personnel for creating guidelines for the development of a community food management system for improving the care of its aging members.

Key informants

In order to reflect the variety of views of older persons and their families, key informants were reached by the gate keeper (the community health team) and then they were sought out by using the purposive sampling method, and were selected according to the qualifications set by the snowballing technique. A total of 41 older persons and their families were selected who had different living standards, health, and self-help abilities and included older people taken care of by family members (18 people); older people living as a couple and whose partner was around the same age (10 people); older people who lived alone (8 people); and family members buying and/or preparing food and/or feeding food to older people who were immobile or bed ridden (5 people).

This study was approved by the Khon Kaen University Ethics Committee in Human Research (HE 582209). Older persons are considered vulnerable people. The researcher protected the rights of the informants by providing information about the study and each participant signed a consent form. The privacy of the informants and their decision making was respected. It is hoped the results of this study will benefit older members of the community and protection of their equal rights will be taken into account.

Instruments

The main questions for the older persons and the families were as follows: What are the “foods” you like to eat? Do they meet your needs? Where and how do you get these foods? What do you think of as “foods for older persons”? And what are they? The interview guideline was developed by the researcher and reviewed by three experts on elderly care and food security before application.

Data collection

The study was performed at one sub-district of Lamphun Province, Northern Thailand during September 2015 to November 2016. The researcher collected data including individual in-depth interviews, observation, and focus group discussions. Observational data were collected by observing food-related activities of older persons in numerous sites including their home, in a Health Promoting Hospital, at temples, older people’s school, during community activities, or during traditional activities which included traditional customs. In-depth interviews were administered for 45-60 minutes for each elderly and their families and six to seven older people were included in the hour-long focus group discussions. Field notes and an audio tape recording were used for each interview and discussion.

Data analysis

The text data were analyzed by field note analysis, content analysis as well as the analysis of similarities and differences from various sources, typological analysis, matrix table analysis, and the systematic classification process of coding, categories and identifying themes. The researcher performed the analysis along with the data collection and reviewed it with the informants[21].

Results

The results of the study reveal nine categories of “food” based on the perspectives of older people and their families and also observed during the elderly’s life activities. These categories outline the eating habits of the elderly, beliefs of older persons regarding food and nutrition, sources of foods for the elderly and the culture of food sharing in their community including.

Favorite food

This refers to food(s) that the older persons most love to eat. If they could choose, they would cook their favorite food themselves. There are many ways to get the foods they like. First, cooking by themselves: aging people choose foodstuffs and cook what they like. Foods are mostly local dishes such as pork soup with bitter gourd, agasta curry, Chinese cabbage curry, chili paste, steamed fish, and blanched vegetables, which are considered to be easy to digest and good for health. The food they cook themselves could often be eaten for several meals, for example, they cook in the evening and it is kept in the refrigerator and warm for eating the following morning and at noon. Ingredients for these dishes can be found easily in the community and older people enjoy eating them. Second, planting vegetables for consuming in the household: older people plant vegetables they like to eat, which can also save money and is easy to find when require. It was “planting what you want to eat, and eating what you plant.” They also share these vegetables with neighbors, or sell them. This planting demonstrate ways of saving money and contributing to their income. Third, buying food themselves: if they do not want to cook themselves, they would buy it ready cook or buy the ingredients they want to cook from the market. Fourth, older people request family members to buy meals or ask mobile venders to deliver food to them at home. Mobile venders often pass elders’ houses everyday, therefore older people can ask venders to bring additional foods from the market when passing next or on the following day. Fifth, their family members cook or buy favorite foods for the older person. Family members, who know what kind of foods older people like, will cook or buy their favorite food. Sixth, if it were their favorite food, even when they are sick, they will cook or go to buy it themselves. However, favorite foods are often not the best food for their nutrition or health, and may even be rather unhealthy, such as raw spicy minced pork, or salted pork rind:

I cook by myself. I cook it in the evening and also eat it in the morning. I have no teeth. I can walk or ride a bike to the market. I grow vegetables to eat myself. I use a Charcoal stove. I do everything myself. I do not want to ask my daughter-in-law to cook for me, because she is tired and she must take care of her husband

(An 85-year-old man who had high blood pressure and lived with his son).

My most favorite foods are curry and chili paste like Chinese cabbage curry and boiled Chinese cabbage. Curry must not be spicy. I cook chili paste myself. I do not buy it because food cooked by me is more delicious than buying. My teeth are not strong. So, I have to grind all food into a paste before eating. For example, I have to grind pork rind before eating. I eat it sometimes. I make chili paste from eggplants and eat it with pork rind and steamed rice. Sometimes, I share food with my sister who lives near me

(A 75-year-old woman who had no illness and lived alone).

Food provide by others

This refers to food given to older persons by others, i.e. the older persons do not prepare it themselves. They have no choice, cannot refuse, accepting it even if they do not like the taste or smell. The sources of the food are as follows. First, their children bring it for them and the older persons please their children by telling them that they can eat everything (even when they do not like what is given to them). This is because the older persons cannot cook by themselves, are unwell or they may not want to ask for anything from their children. Second, their relatives or neighbors bring it for them, or third, other people bring it for them, such as volunteers including health care volunteers who take foods during home visits. The village headman often acquire foods from the temple to give to older people especially those who live with a partner of the same age or to those living alone, who are unable to care for themselves. The older persons eat what they are given without complaint:

My daughter cooks for me before going out to sell food at the industrial estate. She runs a restaurant. In the morning, she will prepare food for me. In the evening, she cooks at her restaurant and brings it for me to eat at home. Sometimes, she asks me what I want to eat. I am very considerate. I can eat anything she cooks

(A 68-year-old woman with diabetes and living with her daughter).

Foodstuffs which should be eaten because of chronic diseases (recommended by a doctor)

This refers to food that is suitable or should be avoided for certain health conditions or diseases. For example, the doctor may have recommended that they should either avoid these foods (as it may make the disease worse or more difficult to manage), or may have recommended them to eat certain foods such as more steamed or boiled vegetables or fish, as it may be beneficial to the patient’s condition. Sometimes doctor advices that food should be seen as medicine or eating certain bitter herbs can help to cure diseases:

I had breast cancer and got an operation in 1993, and I got chemotherapy 28 times. On the last visit, the doctor told me that I no longer had cancer but I should eat food that is easy to digest. I have to eat steamed vegetables and steamed fish. They are delicious. I do not eat spicy or salty food. I have knowledge about herbs, so I plant them for eating. I plant andrographis paniculata, justicia gangetica, ivy gourd, pumpkin, and baby jackfruit. I cannot eat all of them because we are only two people living together

(A 74-year-old woman who used to have breast cancer and lived with her 74-year-old husband who had high blood pressure).

Foods to be avoided

Foods to be avoided include the foods that individual elderly persons have reactions such as abnormal and uncomfortable feelings. These sensations occur every time they eat such food, causing a feeling of dizziness or drunkenness, or breaking out in a rash after eating. The older persons who have allergic experiences are careful with food and they inform their children not to prepare or provide that food:

I can eat all kinds of food. Sometimes, I eat fried food or curry with local vegetables, such as boiled pork, boiled bitter gourd, agasta curry, spicy minced pork, green chili dip and steamed vegetables. But, I cannot eat Siamese neem tree. When I eat it, tears come to my eyes because it is so bitter. So I eat other vegetables instead. My children also know this problem. They eat it, but I do not eat it

(A 72 -year-old woman without chronic disease living with her children and grandchildren).

Snacks

Older people eat snacks to relieve stress or just to relax when they get bored, when being alone, or if friends visit. Sometimes, they eat snacks alone, but at other times they eat with children in the house, or with neighbors, or people visiting their home. This kind of food can be categorized as follows: first, snacks such as boiled peas, boiled sweet potatoes, crackers, glutinous rice roasted in bamboo, and fruits. Second, snacks during rituals and ceremonies prepare by the host, such as candy and sunflower seeds for welcoming guests at a funeral ceremony:

Crackers are snacks for older persons. They are crispy and not sweet. They are also good for health because they are mixed with sesame. I like it. It is easy to buy. They are sold at Village No. 1

(A 76-year-old woman without chronic disease living with grandchildren).

Food for eating together (eating when socializing)

This refers to food prepare when enjoying a social occasion with friends, and food is bring to eat together at an appointed place. There are three types of occasions. First, eating together in a small group: it is an informal gathering amongst a group of friends and acquaintances. The meeting helds at one of the houses of the group members who may have a special event such as a birthday party, house warming party or want to celebrate something special. The food is often a favorite food of the group members and it may be food that group members ask other members to cook, or food that members volunteer to cook for others. Second, semi-formal appointment: the municipality helds meetings in the village in order to listen to opinions of the village leader groups, asking questions to the village headman, or the assistance of the village headman and group leaders. Budgets for food are often around 1,500-2,000 baht and food is prepare by women of the village who prepare food to eat together. Third, formal appointment: the host of the event organize an event with a clear purpose. There are participants and there are also those who prepare food, such as a Khan-tok banquet or a Chinese banquet. Traditional or general food can be served:

Usually I am in a group and we eat together. If we are free, we will eat together. Mostly, we eat at my house. There are about 5-6 people in my group who like to eat together. We will assign those who will make the food. One of my friends can cook delicious food, so she likes to cook it for us. Most of them are single or their children are grown up. So, we are not lonely. We also have a “Line Group” to talk to and make an appointment

(A 65-year-old woman living alone and a member of “Kin Horm Torm Muan, Enjoy Eating Group”).

Food for festivals and cultural traditions

This refers to types of food regularly eaten during festivals and other cultural traditional ceremonies. There are four main types, including: first, food for annual festivals: there is the festival for the preservation of the culture of Ping-Hang-Sai-Ua (Northern Thai spicy sausage) which is organized to promote tourism and another festival identifying the different tastes and identity of the area – Sai-Ua (Northern Thai spicy sausage). In this festival, other foods such as glutinous rice roasted in bamboo, roasted fish, sticky rice, green chili dip, and pork rind are also introduced:

The host prepared booths for the stores from other districts for selling Sai-Ua and other foods, such as roasted omelet served on a banana leaf, steamed curried pork, steamed curried fish, Northeastern food, papaya salad, grilled fish, rice vermicelli, meat balls, noodles, or rice roasted in bamboo and honey. There were also some fruits such as mangos and oranges. The local foods such as grilled climbing perch, rice noodles in fish curry sauce, rice noodles with spicy pork sauce, spicy curry, fish curry, bird curry, crocodile curry, and minced fish spicy salad were also sold. Healthy food, vegetarian food and Sai-Ua were sold. The women gathered to cook healthy food to sell. The people in the community and the older persons as well as their families went to buy food in the evening

(From the field note record of food for the annual festival).

Second, food for fun festivals: “Fun Festivals” refers to the annual traditional festivals of the province and the people in the North, such as the Songkran Festival (April). People in the area also prepare foods in a basket called “Chut Dam Hua” for the watering ceremony for elder persons. Foods in the baskets consist of garlic, dried chili, red onion, Ovaltine, and coffee. There are also other festivals, including Phra That Luang eight Peng in May, or Buddhist Lent Day in July, the end of Buddhist Lent Day in September, Yi Peng in November, and Salak Yom Ceremony at Phra That Luang. Foods such as sweets and bananas with sticky rice prepare for merit making and eating in the family:

During the New Year Festival, it was very fun. I felt that I was blessed and I was happy. I helped others wrap desserts and cook. If I was at home, my grandchildren would give me “Chut Dam Hua” which was a basket filled with white or red onions. In the basket, there were garlic, dried chili, white and red onions, Ovaltine and coffee. The main things that cannot be missed were turmeric juice and Som Poi […]

(A 76-year-old woman living with children and grandchildren).

Third, food for serious festivals: this refers to food prepare for those who attend solemn rituals, such as a funeral ceremony which is alcohol free. Single dish food and one to two local foods such as sticky rice, jackfruit curry, pork in brown sauce, or fried pork and fried vegetables are served in order to save costs of the ceremony. Fourth, food based on beliefs: this is the food that older persons believe should not be cooked on some occasions. For example, for a funeral ceremony, noodles, rice vermicelli, and vermicelli should not be cooked because it is believed to cause consecutive deaths. Spicy salad such as spicy vermicelli salad or Yum Yai Salad must be served because it is believed to cause harmony. Also, jackfruit curry must be cooked during the New Year in every household because it is believed to create support for the next year. Food made from duck and river snails, such as spicy minced duck, boiled duck, and river snail curry, would not be served or shared with friends or relatives because it is believed to cause boredom.

Food offered for making merit

This is the food that older persons usually prepare to make merit and which will normally be eaten at the same time with others. It can be divided into three types. First, food offer to monks by placing in an alms bowl: the food is offer to monks by spooning food into an alms bowl in the morning in front of the house, on religious occasions or at venues of religious events such as at a house warming ceremony, on New Year’s Day or Father’s Day. Second, food prepare for welcoming persons making merit: food for events organize for raising money to celebrate religious buildings such as churches, temples or pavilions. Each house invites friends and relatives to make merit. The host has to prepare food and drinks to welcome those who, in return, come to make merit. The food prepare by the host mostly include vermicelli eaten with curry, spicy minced pork, sticky rice, and bananas with sticky rice. Third, food for making merit to commemorate deceased ancestors: this involves the preparation of a “money tree” and dry food in a basket which is taken in the basket to the temple to offer to the monks. In the basket, there is often rice, dry or fresh food such as rice, garlic, shallots, salt, fermented fish, dried fish, canned fish, milk, snacks, rice, bananas with sticky rice, fresh vegetables, and fruits.

Food donated to others

This food is for sharing. Older persons prepare according to religious beliefs which is to fulfill their soul and spirit. It is divided into two types. First, food provide to help others: food would be given to the needy, or those who needed help. Also it might be given to animals such as dogs, cats, and birds. It is an expression of sympathy and caring. The food to be donated include rice and other dry food. Or, it may be food permit by the host or owner of the food, taken from religious events and given to older persons, the poor, or the disabled. Second, food provide at almshouses: this is the food that people provide at almshouses during religious events held at temples where there are many participants, such as at the Five Precepts market (Dharma on tour), during the Buddhist Lent Festival (when activities held at ten temples), and also at the Tarn Kuay Sa-Lak Festival. The food to be donated is easy for all ages to eat on site as it is drinks or snacks rather than a sit down meal. Sometimes, participants can take food home to give to older persons at home. The foods include soybean milk, fruit juice, milk, soy custard in ginger syrup, desserts, bananas with sticky rice, deep-fried dough stick, noodles, and braised fish maw in red gravy.

Discussion

The results of this study reveal that there are nine categories of “food” based on the perspectives of older persons and their families: favorite foods; food provide by others; foodstuffs which should be eaten due to chronic diseases (recommended by doctor); foods to be avoided; snacks; food eaten with others (eating when socializing); food for festivals and cultural traditions; food offer for making merit; and food donated to others. These categories demonstrate a wide variety of foods consumed by the elderly. Food is not only eaten as a necessity for human hunger and energy but also as a part of fulfilling their social and spiritual needs[22].

Nowadays, a proper diet for older persons focuses on food for health and chronic diseases, reduction of sweet and salty food and types of food that should/should not be eaten for health or nutrition reasons. In addition to health needs, there is also a need to follow the accustomed lifestyle of older people, such as making merit, traditions, festivals, beliefs or superstitions, attending to traditions, economic considerations, and social events, which complement social and spiritual aspects of life and remain important aspects of complete well-being[22]. These needs are all affecting the culture of food consumption, food production, food creation, and assistance of people in the community. The older community members are both givers and receivers. If community nurses and health care personnel understand the diversity of “food” based on the views of older people and their families, and understand the behavior or actions that are related to the acquisition of food at the household level, they will be able to use health science and arts to design better health promotion activities. By encouraging people to care for older citizens in all community activities, as well as using tools for brainstorming and finding ways in the community to encourage participation in food production that is suitable for older people and can help with their chronic diseases, the health and happiness of the elderly can be maintained or improved. Food should be safe, nutritious, and available for older people and their families to purchase and appropriate to provide or donate to other older persons or for other community purposes. The community should also participate in producing foods by raising poultry, fisheries, planting and preserving vegetables and fruits in order to make foods available, and respond to the needs of as well as solve health problems of the older members in their community[23-25].

Conclusions and recommendations

Community nurses and health care personnel should have skills, knowledge, and cultural sensitivity by understanding the behavior and actions related to the acquisition of food because this will affect food priorities and food choices. This will help to design programs for health and wellness promotion in accordance with the needs of older people based on the context of the area in which they live. This provides an opportunity to work for the improvement of the quality of life for all of the aging members including the social, economic, environmental, and cultural contexts in the community. Community nurses and health care personnel must focus on the changing demographic situation and food security, as well as the varieties of food, which are social factors determining the vital care of older persons.