Hábitos alimentares e peso corporal no envelhecimento:um estudo em idosos europeus

Hábitos alimentares e peso corporal no envelhecimento: um estudo em idosos europeus Eating habits and weight status in old age: a study of european elderly Cláudia Isabel Pontes Neves Afonso 2011 Dissertação para obtenção de grau de Doutor em Ciências do Consumo Alimentar e Nutrição apresentada à Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto Orientadora: Maria Daniel Vaz de Almeida Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto Co-Orientadora: Carla Maria de Moura Lopes Faculdade de Medicina da Universidade do Porto 1 Í ndice Agradecimentos Resumo 5 Abstract 9 1. Introdução 11 2. Objetivos 51 3. População e Métodos 55 4. Resultados 4.1 ǀ Food related perceived goals among European elderly 67 4.2 ǀ Adherence to Mediterranean food pattern in Portuguese elderly 83 4.3 ǀ The use of meal providers by European elderly 103 4.4 ǀ Prevalence and sociodemographic determinants of obesity in European elderly 119 5. Conclusão 135 6. Bibliografia 145 2 3 A gradecimentos Gostaria de expressar o meu profundo agradecimento a todos os que de alguma forma me apoiaram e auxiliaram durante o período de elaboração deste trabalho. Com especial estima e consideração… À Professora Doutora Maria Daniel Vaz de Almeida, Por toda a vivência partilhada, pelos valiosos ensinamentos e pela referência profissional e humana. À Prof. Doutora Carla Lopes, Agradeço a forma pertinente e rigorosa com que me orientou e pela amizade sincera. Aos estatistas Rui Poínhos e Bruno Oliveira, Que simplificaram o incompreensível de forma generosa e amiga. Às amigas (por ordem alfabética…), Ada, Bela, Meibel (Dr.ª), Patrícia, Rosa Maria e Sara. Pelo suporte e companheirismo. Aos colegas do coração da FCNAUP, Pela boa disposição e encorajamento constantes. Às jovens colegas, Cecília e Margarida, Pelo prestimoso contributo direto e indireto neste projeto. E por fim, mas não menos importante, Aos queridos idosos que pela sua autenticidade e generosidade muito contribuíram para o meu crescimento pessoal e profissional. À minha família por estar sempre presente e também aqueles que já não estão presentes. Muito obrigada! 4 5 R esumo O envelhecimento crescente da população é uma das características mais relevantes da última metade do século XX das sociedades desenvolvidas, fenómeno que tem originado um elevado número de estudos tendo em vista o seu melhor conhecimento e a identificação de fatores de risco modificáveis para o seu não desenvolvimento. A alimentação e a nutrição, assim como outros fatores ambientes têm um enorme impacto na saúde e bem-estar, condicionante da qualidade de vida dos idosos. A alimentação não só é determinante para o estado de saúde mas também para a qualidade de vida numa perspetiva holística: cultural, social e psicológica e a adesão a estilos de vida saudáveis pode desempenhar um papel mais importante que a própria genética do envelhecimento. A presente tese insere-se maioritariamente no Projeto Europeu Food in Later Life, choosing foods, eating meals: sustaining independence and quality of life, “Alimentação em Idade Senior, escolha de alimentos e refeições para manter a independência e qualidade de vida”, nomeadamente do seu Work Package 7 (WP7), designado – avaliar a qualidade de vida relacionada com a alimentação. É finalidade desta investigação contribuir para um melhor conhecimento das expetativas em relação à alimentação, dos recursos alimentares disponíveis e do estado nutricional da população idosa, identificando as suas principais determinantes. A população alvo deste estudo foram idosos Europeus residentes dos seguintes países Dinamarca, Alemanha, Itália, Polónia, Portugal, Espanha, Suécia e Reino Unido com idade igual ou superior a 65 anos. Foram inquiridos cerca de 400 indivíduos por país a viverem nos seus domicílios, constituindo uma amostra comunitária representativa da população Europeia atendendo à diversidade sociodemográfica de cada país (nível de educação e rendimento, urbanização) e colhida em pelo menos três localizações geográficas distintas. A recolha desta informação decorreu no Outono de 2005, tendo sido inquiridos 3291 idosos no total. Mediante os objetivos propostos pelo WP7 do Projeto Food in Later Life procedeu-se à elaboração de um questionário estruturado de administração indireta, com perguntas de 6 resposta simples ou múltipla, em língua Inglesa. Posteriormente, cada país, adaptou-o à sua língua de origem. Os idosos Europeus elencam como tendo maior relevância para a sua alimentação aspetos relacionados com a saúde e com aspetos sensoriais, do que aspetos sociais e económicos. Os idosos com maiores níveis de escolaridade tendem a enfatizar em maior proporção os primeiros aspetos e os idosos com menores rendimentos, os segundos. Idosos mais satisfeitos dão mais importância aos objetivos de saúde e sensoriais e os com mais comprometimentos físicos e mentais, objetivos sociais e económicos. A adesão ao padrão alimentar Mediterrânico foi superior à média do índice, porém aquém do esperado pelas particularidades geográficas que caracterizam Portugal sendo que se identificou grupos de risco de uma baixa adesão: idosos de baixo rendimentos, com condicionantes de saúde, fumadores, a residirem no Norte do país e que recorrem à aquisição de refeições fora dos seus domicílios. Estes idosos provenientes da comunidade recorriam em maior proporção a suportes informais (família) para obter a sua alimentação do que a suportes formais, sendo que as mulheres e os mais idosos se destacam pelo seu não uso e os idosos de maior escolaridade e maiores rendimentos, os que mais recorriam a alimentação fora de casa. A prevalência de obesidade foi superior no Reino Unido (20%) e na Polónia (15.8%) nos idosos e também na Polónia (26.7%) e Alemanha (25.3%) para as idosas. Resultados desta investigação permitem identificar os grupos de risco de intervenção para a prevenção da obesidade idosos com menor escolaridade e idosas com menores rendimentos. Sendo o envelhecimento populacional uma realidade em todo mundo, deverá este facto constituir simultaneamente desafio e oportunidade. Pretende o presente estudo contribuir à sustentação da evidência acerca da relevância da alimentação num contexto de promoção de uma sociedade inclusiva na realidade Europeia. O parlamento Europeu, escolheu 2012 como o Ano Europeu dedicado ao Envelhecimento Ativo, com o objetivo geral de incentivar e apoiar esforços dos Estados-Membros, das autoridades, dos parceiros sociais e da sociedade civil no sentido de promover o envelhecimento ativo usufruindo do potencial desta população, reforçando e preservando desta forma a solidariedade entre gerações (Comissão Europeia, 2010). Esperamos de alguma 7 forma ter contribuído para o melhor conhecimento dos aspetos relacionados com a alimentação no contexto Europeu. 8 15 Evidências epidemiológicas demonstraram, de forma segura, que o risco de inúmeras patologias associadas ao envelhecimento pode ser minimizado por uma intervenção adequada ao nível dos estilos de vida nomeadamente da alimentação/nutrição e atividade física 3; 4 . O crescimento cessa na idade adulta pelo que no idoso, a nutrição contribui para o metabolismo do organismo e exerce funções reparadoras, capazes de retardar o envelhecimento. Fisiologicamente, com o avançar da idade, há uma diminuição dos mecanismos de ingestão, digestão, absorção, transporte e excreção de substâncias, o que se traduz em necessidades nutricionais particulares neste estádio do ciclo de vida 3 . Por outro lado, situações patológicas relacionadas com o envelhecimento podem afetar também as necessidades alimentares/nutricionais. Também a interação fármaconutrimentos, problemas sociais e culturais deverão ser tidos em consideração ao analisar os determinantes do estado nutricional deste grupo etário 5 . Na impossibilidade de modificar a situação biológica do envelhecimento, nomeadamente as limitações devidas a incapacidades e condicionalismos de saúde, é fundamental otimizar a maximização dos recursos associados aos estilos de vida não esquecendo a dimensão familiar e sociocultural, de forma a promover a qualidade de vida e o bem-estar psicológico, de forma a manter um desempenho físico, intelectual e social máximo 6; 7 . Em 2002, na II Assembleia Mundial sobre o Envelhecimento, foi definido um Plano de Ação que visa assegurar que todos possam envelhecer com segurança e dignidade continuando a participar ativamente na sociedade. Todas as orientações traçadas têm como objetivo a criação de uma sociedade inclusiva, em que a população mais velha possa gozar plenamente de todos os seus direitos (civis, políticos, económicos, sociais, culturais), combatendo a discriminação 8 . 16 As recomendações do Programa Nacional para a Saúde das Pessoas Idosas centram-se na necessidade de formar os cidadãos mais velhos sobre estilos de vida nos quais se destacam a atividade física e a alimentação, promovendo como estratégia a identificação dos determinantes da saúde e estilos de vida bem como as principais barreiras de acesso à “saúde” 9 . 1.1 ǀ Determinantes do estado nutricional e qualidade de vida em idosos A alimentação e a nutrição, assim como outros fatores ambientes têm um enorme impacto na saúde e bem-estar, condicionante da qualidade de vida dos idosos 3; 7 . A qualidade de vida associada ao envelhecimento é descrita pela Organização Mundial de Saúde como um “conceito amplo e subjetivo que inclui de forma complexa a saúde física da pessoa, o seu estado psicológico, o nível de independência, as relações sociais, as crenças e convicções pessoais e a sua relação com aspetos importantes do meio ambiente” 8 . Para esta entidade o conceito de envelhecimento ativo é o processo de otimização das oportunidades para a saúde, participação e segurança para melhorar a qualidade de vida das pessoas que envelhecem. Baseia-se fundamentalmente em três pilares: diminuição do risco de doença e/ou incapacidade, promoção do estado de saúde mental e uma perfeita integração na sociedade 7 . Nesta perspetiva, a alimentação não só é determinante para o estado de saúde mas também para a qualidade de vida numa perspetiva holística: cultural, social e psicológica e a adesão a estilos de vida saudáveis pode desempenhar um papel mais importante que a própria genética do envelhecimento 7 . Apesar desta orientação, pouco tem sido investigado de forma a suportar esta evidência 10 . Se a escolha alimentar afeta de forma decisiva o envelhecimento, não é menos verdade que o envelhecimento determina a escolha de alimentos assim condicionando o padrão alimentar 11 . Com o avançar da idade as condições de vida sofrem transformações; por exemplo a reforma pode ocasionar uma diminuição do nível de vida e a rede social de 17 contatos poderá diminuir; com o aparecimento de incapacidades o acesso a determinados estabelecimentos poderá estar condicionado; a perda do cônjuge ou a saída de casa dos filhos, e pode ocasionar perda de interesse e afetar também as circunstâncias em que cozinham e se alimentam. Além do mais o significado das refeições e dos alimentos altera-se com a idade 12; 13 . É o caso das mulheres que ao longo do ciclo de vida passam de prestadoras a usufrutuárias de cuidados alimentares 14 . As expetativas e objetivos pretendidos com a alimentação a par dos recursos disponíveis para a sua concretização alteram-se com o envelhecimento. Em simultâneo, fatores condicionantes da saúde, incapacidades, existência (ou não) de redes sociais de suporte e até alteração de competências para desempenhar tarefas como as de adquirir e preparar refeições, poderão condicionar os consumos alimentares e, por sua vez, influenciando o estado nutricional 10 . Os fatores sociais e económicos são decisivos para a satisfação com a vida e consequentemente da adequação do comportamento alimentar/nutricional. Promover pretextos para um maior convívio em torno da mesa e de refeições nutricionalmente adequadas, em ambiente agradável, pela promoção de sentimentos de pertença a um grupo ou comunidade, parece ser melhor estratégia para promover adequado estado nutricional de idosos, e consequentemente, da sua qualidade de vida 15;16 . Está descrito que idosos que consomem as suas refeições na companhia de amigos e família têm melhor qualidade de vida e são mais felizes 10 . Em idosos, o isolamento social é um aspeto preocupante 14 , não só pela privação de contatos humanos como também pelo seu efeito no estado nutricional. Esta associação não condiciona diretamente situações de malnutrição, mas leva a um desinteresse pelos alimentos e refeições. No entanto, a partilha de refeições aquando de uma doença ou incapacidade em contexto de internamento, poderá ter exatamente o mesmo efeito negativo. 18 Outro aspeto pertinente é o papel do género nas tarefas relacionadas com a preparação das refeições. Em diversas culturas a mulher relega para segundo plano as suas preferências alimentares em detrimento da família (marido, filhos) tomando iniciativa e responsabilidades na alimentação, pelo que numa situação de viuvez deixa de ter motivação para a preparação de refeições. Por outro lado, para os homens idosos que ficaram sós, estas tarefas são tidas como um desafio que necessita de ser incorporado na sua identidade. Destes, um grupo aceita o desafio como se se tratasse de um novo trabalho, outros há que tentam encontrar alguém para fazer estas tarefas, certificando-se que os papéis sociais se mantêm. Mas os idosos do sexo masculino que sempre viveram sozinhos já interiorizaram esta tarefa 17 . O número crescente de idosos na população tem levado ao desenvolvimento redes formais de prestação de cuidados a idosos, nos quais se incluem os alimentares. Estes serviços podem atuar de per si ou como suporte aos cuidadores informais, contribuindo assim para a manutenção do estado funcional e de independência dos idosos 18 . 1.1.1ǀ Idosos, alimentação e saúde A escolha alimentar é influenciada por aspetos biológicos (como a fome, o apetite, o sabor), por condicionantes económicas (custo dos alimentos, rendimento, disponibilidade), determinantes estruturais (acesso, educação, competências e recursos culinários, tempo), características sociais (cultura, família, relações sociais, padrões alimentares) atitudes, crenças e conhecimentos sobre alimentos e alimentação 19 . Em 2001 um projeto Europeu multicêntrico, identificou, as atitudes de idosos europeus (n=1843) em relação à alimentação, nutrição e saúde. Entre os fatores identificados por esta população como tendo influência na sua escolha alimentar destacam-se aspetos relacionados com a qualidade e frescura (54%), seguido da tentativa de comer de forma saudável em simultâneo com a preocupação com o preço dos alimentos (8%). Para estes idosos a alimentação saudável era definida como tendo "menos 19 gordura" (37%) "mais hortícolas e frutas frescas" (34%), e incluindo "alimentos naturais" (11%). Manterem saudáveis (36%), evitarem doenças (26%) e promoverem a qualidade de vida (10%) foram os principais benefícios associados à alimentação saudável referidos por estes idosos. No entanto a adoção de uma alimentação saudável enfrenta diversos obstáculos, nomeadamente a dificuldade de autocontrole (27%), a resistência à mudança (23%) e o preço atribuído à alimentação saudável (15%). De salientar no entanto que 86% dos idosos Europeus acreditavam não precisar de mudar seus hábitos alimentares pois já comia de forma saudável 20 . Em idosos Ingleses, Locher e colaboradores 21 identificam aspetos sensoriais, de conveniência e preço como determinantes importantes para a seleção de alimentos. Neste estudo, as preocupações emocionais (humor) e o uso de produtos naturais desempenhavam uma menor relevância do que os primeiros. A conveniência na preparação da refeição é considerada como um importante determinante da escolha alimentar descrito por Scholderer e Grunert. 2005 22 , contudo Saba e colaboradores 23 , mostraram que idosos Europeus não parecem ver benefícios no consumo de alimentos de conveniência e também nem têm intenção de consumir esses produtos 23 . Manter a independência foi a prioridade de vida mencionada por idosos escoceses que consideravam os alimentos como um fator que contribuía para manter a saúde reduzindo assim a dependência de outros. Outra preocupação assinalada por aqueles idosos era evitar o isolamento social, assumindo como primordial importância manter a ida às compras diárias e de deslocação a cafés ou a outros locais de forma a fazerem as suas refeições 24 . Noutro estudo britânico, os contatos sociais são indicados como os principais componentes de uma boa qualidade de vida 25 . Locher 26; 27 mostrou a preocupação dos idosos em consumir refeições em ambiente confortável e seguro. Um estudo Europeu mostra que preocupações económicas com as refeições principalmente salientadas pelos idosos Portugueses e Polacos 28 . 20 Em Portugal, a alimentação é identificada pelos seus idosos como um dos principais determinantes da saúde, seguida de check-up médicos regulares e redução dos hábitos tabágicos. Alinhada com esta perceção encontra-se a preocupação em fazer uma “alimentação saudável” e o preço dos alimentos como principais determinantes da escolha alimentar 29 . A identificação do custo dos alimentos distinguia-nos dos idosos de outros países da União Europeia 20 . Mais recentemente, em 2009, o estudo Estilos de Vida da população Portuguesa incluiu também portugueses com mais de 65 anos (712 indivíduos) e revelou as perceções dos diferentes grupos etários em relação a vários aspetos da sua vida. Em comparação com os mais novos, os portugueses mais velhos consideram o apoio da família e amigos, o meio ambiente e o peso como determinantes da saúde, assim como identificam o preço dos alimentos, aspetos culturais, religiosos ou étnicos e ainda a dieta aconselhada pelo médico como determinantes major da escolha alimentar. Este mesmo estudo encontrou uma proporção de idosos com atividade física reduzida, sendo esta baixa adesão mais prevalente nas idosas (49.7%) 30 . Na sequência da realização de entrevistas em profundidade c , obtivemos uma riqueza de informação qualitativa que nos permite compreender a complexidade dos fatores que interferem com a ingestão alimentar e nutricional dos idosos (Europeus em geral e Portugueses, em particular). Uma conjugação de diferentes fatores confere aos idosos Portugueses características específicas: escolaridade e rendimentos reduzidos, problemas de visão e de saúde oral e atividade física reduzida. Em termos de saúde geral referiam problemas cardíacos, gastrointestinais, nos membros inferiores, reumatismo, tonturas, insónias, dores de cabeça, entre outros problemas. Todos sofriam de pelo menos uma doença crónica: diabetes mellitus tipo 2, dislipidemias e hipertensão arterial (HTA). Consequentemente, mais de 50% dos c Informação colhida no âmbito do Projecto Europeu Food in Later Life (WP3-6), que decorreu em 9 instituições de ensino e investigação da UE em que a Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto (FCNAUP) foi a representante Portuguesa. 21 idosos tomava mais do que três medicamentos por dia. No entanto, a toma de suplementos não era frequente e só as mulheres referiam a ingestão de cálcio 31 . As condicionantes socioculturais, escolaridade e rendimento, bem como o relato de um passado de fome, mostraram ser alguns dos motivos pelos quais os intervenientes se mostraram relutantes em aceitar novidades e a experimentar novos alimentos. Perante este cenário, retratam-se os idosos Portugueses como muito tradicionais, não só no seu modo de vida em geral, mas também no que se refere às suas refeições. Havia uma rotina muito rígida com as refeições, consumidas na sua maior parte no domicílio, sendo que comer fora de casa, por rotina, só com a família e ao fim de semana 32 . Os conselhos alimentares veiculados pelo médico assistente levam a que os idosos alterem a sua alimentação, quer excluindo, quer incluindo determinados alimentos. Tristeza e, por vezes, depressão além de sentimentos de marginalização e solidão, foram visíveis principalmente em idosos a viverem sós, relacionados com a perda de conjugue ou outros, revelavam-se num marcado desinteresse pela alimentação. O passado era então lembrado com saudade, nostalgia e mágoa. Convidar familiares ou outros para comer em casa deixou de ser um prazer devido a problemas de saúde. No entanto, algumas idosas ainda tinham a cargo a alimentação dos netos e/ou filhos, bem como ainda convidam a família a fazerem as suas refeições ao fim de semana 32 . Os homens idosos, principalmente os que viviam sós, recorriam aos suportes formais de aquisição de refeições como aos centros de dia, bares, cafés, restaurantes, clubes sociais e/ou aos informais como a casa dos filhos, principalmente para o jantar 31 . Quando comparavam a alimentação atual com a de tempos passados, embora referissem maiores disponibilidades no presente, consideravam os alimentos mais saborosos e puros no passado 31 . 22 A aquisição de géneros alimentícios para as suas refeições era efetuada maioritariamente no comércio de proximidade: padarias, frutarias, peixarias, talhos e/ou supermercados e de baixo custo. Por vezes a família auxiliava em compras de maior vulto com uma periodicidade mensal e/ou quinzenal. No entanto, os idosos relatavam problemas físicos (dores de costas, joelhos, pés, dificuldade em andar, cansaço, falta de força, patologias crónicas como osteoporose, reumatismo, perda de equilíbrio...) que impediam ou condicionavam a ida às compras ou ao seu transporte para o domicílio 33 . Outros, porém, referiram a não existência de estabelecimentos na vizinhança assim como a fraca acessibilidade, a impossibilidade de deslocação a pé, além da escassez de transportes. Estavam, muitos deles, condicionados ao que os familiares lhes cediam 33 . Independentemente de todas as condicionantes relatadas, notou-se uma enorme preocupação com a aquisição de géneros a baixo custo e a necessidade de recorrerem a lojas onde se sentiam familiarizados com os circuitos e onde já conheciam as/os funcionárias/os que por vezes os auxiliavam nas dúvidas quanto a preços, promoções e localização dos produtos desejados 33 . Quanto à preparação e confeção de alimentos verificou-se que apesar de se sentir algumas limitações no manuseamento de alguns utensílios, como por exemplo facas, a forma de preparar e cozinhar não sofreu grandes alterações ao longo dos anos e mantém-se de modo tradicional, mencionando sempre os ensinamentos das respetivas progenitoras. Apesar da disponibilidade de equipamento facilitador da preparação/confeção de alimentos, como o microondas (usualmente em 2º mão, cedido pelos filhos), os idosos recusavam-se a utilizá-lo que não para aquecer alimentos ou bebidas 33 . As idosas Portuguesas assumem que à medida que o seu estado de saúde se vai degradando, a forma de preparar e/ou confecionar as refeições se altera e identificam uma maior dificuldade e morosidade em todas as tarefas, bem como um perda de confiança nas suas capacidades. O que, de certa forma, justifica os padrões alimentares em que o almoço é a 23 refeição mais elaborada e o jantar algo mais leve, composto por exemplo por sopa, sandes e fruta. Quando os condicionalismos de saúde se acentuam, sentem a necessidade de recorrer à ajuda de redes de suporte disponíveis 33 . A forma de cozinhar destes idosos, era a tradicional Portuguesa, porém algumas idosas referem alterações nos procedimentos culinários de forma a se ajustarem às circunstâncias da sua saúde e assim referem preparar as suas refeições com menos sal e gordura e recorrem principalmente ao método de confeção grelhado 33 . Muitos dos idosos do sexo masculino aprenderam e principiaram a cozinhar nesta fase da vida, por necessidade (incapacidade ou morte da esposa ou devido à inexistência de suporte informal). Geralmente preparam refeições simples; alguns apenas sabem preparar merendas; é um grupo mais heterogéneo que o das mulheres, no que se refere às aptidões culinárias 33 . De uma forma conclusiva este estudo destaca o facto que os determinantes da aquisição, preparação dos géneros, sua confeção e consumo eram marcadamente determinados por características socioeconómicas (preço, disponibilidade de locais e géneros, hábitos alimentares, tradições, presença de suportes formais ou informais) a par de condicionantes físicas e de saúde (condicionalismos inerentes ao próprio processo de envelhecimento, presença de patologia crónica e consequentes modificação de hábitos alimentares) e realçase a importância dos fatores psicológicos (solidão, perda do conjugue), que era absolutamente condicionante da forma de expressar a ausência de qualidade de vida relacionada com a alimentação. 1.2 ǀ Ingestão alimentar/nutricional Informação proveniente do European Nutrition and Health Report 2009 34 para idosos Europeus, mostra uma ingestão diária de energia entre 1696 kcal (Espanha) e 3105 kcal 24 (Roménia) nos homens idosos e entre 1385 kcal e 2003 Kcal nas mulheres dos mesmos países respetivamente. A ingestão de proteínas oscilou entre 13.6-19,0% do valor energético total (VET) nos homens e 13.2% (Polónia) a 20.0% (Espanha) do VET nas mulheres, superiores em alguns países às recomendações da Organização Mundial de Saúde (OMS), 2003 que ditam valores deste nutriente a oscilar entre 10 a 15% do VET). Quanto à ingestão de hidratos de carbono e assumindo as recomendações da OMS 35; 36 de 50-75% do VET, verifica-se que este valor só foi atingido por idosos da Noruega (51.0% em homens e 52.0% em mulheres) e da Polónia (50.0% em homens e 52.6% em mulheres), bem como por mulheres idosas da Finlândia (51.2%) e da Irlanda (50.0%). A proporção proveniente dos lípidos oscilou entre 26.7% (Portugal) a 43.9% (Grécia) no sexo masculino e entre 28,0% a 45,3% em idosos do sexo feminino provenientes exatamente dos mesmos países e, portanto, em geral acima das recomendações (15 a 30% do VET) 36 . De uma forma geral verificaram-se ingestões abaixo das recomendações para a vitamina D, α-tocoferol, folatos, cálcio, magnésio e ferro (apenas mulheres). Os resultados mais abrangentes sobre a situação alimentar de idosos na Europa é proveniente do estudo longitudinal Survey in Europe on Nutrition and Elderly, a Concerted Action (SENECA) 37; 38 . Teve o seu inicio em 1988 em 19 cidades Europeias (definidas com tendo ente 10000-30000 habitantes) em: Hamme (Bélgica), Roskilde (Dinamarca), Pádua (Itália), Culemborg (Holanda), Vila Franca de Xira e Coimbra (Portugal), Betanzos (Espanha) e Yverdon, Burgdorf e Bellinzona (Suíça) Marki (Polónia), B-L- Portstewart (Irlanda). O número de participantes foi de 2586 indivíduos nascidos entre 1913 e 1918. No primeiro follow up em 1993, participaram cerca de 1125 indivíduos, sendo que no final, em 1999 cerca de um quarto dos participantes 627, foi reavaliado. A este estudo presidiu com objetivo geral a melhoria do conhecimento do estado nutricional e das suas consequências numa população idosa, com idades compreendidas entre os 70 e os 75 anos a residir no seu domicílio, bem como o impacto da alimentação sobre a evolução 31 Quadro 4ǀ Recomendações nutricionais para Idosos 48 . Vitamina A (µg) Vitamina C (mg) Vitamina D (µg) Vitamina E (mg) Vitamina K (mg) Tiamina (mg) Riboflavina (mg) Niacina (mg) Vitamina B6 (mg) Folato (µg) Idade 51-70 Masculino 900 90 10 15 120 1.2 1.3 16 1.7 400 Feminino 700 75 10 15 90 1.1 1.1 14 1.5 400 Idade 70+ Masculino 900 90 15 15 120 1.2 1.3 16 1.7 400 Feminino 700 75 15 15 90 1.1 1.1 14 1.5 400 Idade 51-70 Masculino 3000 2000 50 1000 ND ND ND 35 100 1000 Feminino 3000 2000 50 1000 ND ND ND 35 100 1000 Idade 70+ Masculino 3000 2000 50 1000 ND ND ND 35 100 1000 Feminino 3000 2000 50 1000 ND ND ND 35 100 1000 Vitamina B12 (µg) Ácido Pantoténico (mg) Biotina (µg) Colina (mg) Boro (µg) Cálcio (mg) Crómio (µg) Cobre (µg) Flúor (mg) Iodo (µg) Idade 51-70 Masculino 2.4 5 30 550 ND 1200 30 900 4 150 Feminino 2.4 5 30 425 ND 1200 20 900 3 150 Idade 70+ Masculino 2.4 5 30 550 ND 1200 30 900 4 150 Feminino 2.4 5 30 425 ND 1200 20 900 3 150 Idade 51-70 Masculino ND ND ND 3500 20 2500 ND 10000 10 1100 Feminino ND ND ND 3500 20 2500 ND 10000 10 1100 Idade 70+ Masculino ND ND ND 3500 20 2500 ND 10000 10 1100 Feminino ND ND ND 3500 20 2500 ND 10000 10 1100 RDA ou AI RDA ou AI Níveis Superiores de Ingestão Toleráveis Níveis Superiores de Ingestão Toleráveis Vitaminas e Minerais 32 Quadro 4ǀ Recomendações nutricionais para Idosos 48 (continuação) Ferro Magnésio Manganésio Molibdénio Níquel Fósforo (mg) Selénio Vanádio Zinco (mg) (mg) (mg) (mg) (mg) (µg) (mg) (mg) Idade 51-70 Masculino 8 420 2.3 45 ND 700 55 ND 11 Feminino 8 320 1.8 45 ND 700 55 ND 8 Idade ≥ 70 Masculino 8 420 2.3 45 ND 700 55 ND 11 Feminino 8 320 1.8 45 ND 700 55 ND 8 Idade 51-70 Masculino 45 350 11 2000 1 4000 400 1.8 40 Feminino 45 350 11 2000 1 4000 400 1.8 40 Idade ≥ 70 Masculino 45 350 11 2000 1 3000 400 1.8 40 Feminino 45 350 11 2000 1 3000 400 1.8 40 Energia (kcal) Proteína (g) Hidratos de carbono (%) Gordura total (%) Gordura saturada (%) Colesterol (mg) Sódio (mg) Fibra (mg) Masculino 2300 63 >55 <30 <10 <300 dia <2400 dia 20-35 Feminino 1900 50 >55 <30 <10 <300 dia <2400 dia 20-35 RDA ou AI RDA’s de 1989 - Idade ≥ 51 Níveis Superiores de Ingestão Toleráveis Minerais e Macronutrientes Em 2002, um painel de Peritos em Nutrição em Geriatria identificou os micronutrimentos aos quais se deverá dar especial atenção em idosos: a vitamina D em combinação com cálcio, a vitamina B12 e o ácido fólico. Estes autores reforçam a necessidade de adequar as recomendações ao estado nutricional real dos idosos. Mais do que tentar cumprir as indicações nutricionais, deverá colocar-se como desafio para o profissional de saúde, identificar e monitorizar as necessidades individuais, bem como encontrar formas de intervir adequadas 3 . Atendendo que as RDA foram estabelecidas para suprir as necessidades nutricionais de idosos saudáveis é importante que se estabeleçam recomendações para subgrupos de idosos tendo em consideração o seu estado de saúde e funcional bem como as suas características genéticas 3 . 33 1.4 ǀ Avaliação do estado nutricional Em 2003 a British Association for Parenteral and Enteral Nutrition (BAPEN), 51 e a European Society for Clinical Nutrition and Metabolism 52 (ESPEN), alertaram para a necessidade de identificar a população idosa em risco de desnutrição, por excesso ou por carência, pelas consequências negativas daí advindas sobre a capacidade imunológica, a redução da força muscular e a capacidade respiratória, com fadiga, desregulação dos mecanismos de termorregulação e, consequentemente, hipotermia. Apatia, estados depressivos e negligência em relação a si próprio, podem também ser consequência da malnutrição. Estas situações aumentam o risco de doença e o recurso à hospitalização ou à institucionalização 5; 51; 52; 53 . A malnutrição tem elevados custos de saúde para os países, mas a investigação desta temática na velhice centra-se essencialmente apenas já em ambiente hospitalar. Porém, a raiz do problema encontra-se na comunidade, altura em que seria possível e vantajoso evitar o seu agravamento 54 52; 55; 56 . Na Europa e nos Estados Unidos, cerca de 25 a 60% dos idosos hospitalizados e 10 a 85% dos idosos institucionalizados sofrem de malnutrição com diferentes graus de severidade 2 . Em Portugal, em 2005 identificou-se através do instrumento de rastreio malnutrition universal screening tool (MUST) que 9% de idosos do sexo masculino e 15% do sexo feminino a viver na comunidade estavam em risco médio ou alto de malnutrição 57 . Torna-se assim fulcral estabelecer os parâmetros a utilizar na identificação de desnutrição, por deficiência ou por excesso, de modo a fazer-se um diagnóstico precoce, proceder à intervenção individualizada, controlar e reverter a situação 58; 59 . A avaliação do estado nutricional em idosos tem como objetivos primordiais 60; 61 . - Determinar a adequação da ingestão alimentar/nutricional às necessidades individuais; 34 - Identificar fatores de risco de desnutrição; - Diagnosticar situações de malnutrição; - Identificar a etiologia dos défices nutricionais; - Elaborar e aplicar estratégias terapêuticas e; - Avaliar a efetividade da estratégia aplicada. De acordo com Enzi e colaboradores 62 , na 3ª idade a malnutrição pode ser devida à diminuição da ingestão alimentar/nutricional, ao aumento das perdas nutricionais, à alteração do metabolismo dos nutrimentos e ao aumento das necessidades nutricionais (Quadro 5). Quadro 5ǀ Eventuais condicionantes de alterações nutricionais 62 . ↓ Ingestão ↑ ↑↑ ↑ Perdas A l teração do metabolismo dos nutrimentos ↑ ↑↑ ↑ Necessidades nutricionais anorexia hipogeusia disfagia atrofia gástrica polimedicação demência depressão patologias neurológicas artroses pobreza isolamento social … vómitos, diarreia malabsorção fistulas úlceras de pressão síndrome nefrótica glicosúria diálise… interacção com fármacos diabetes hiperuricemia hipertiroidismo hepatopatias … traumatismos queimaduras intervenções cirúrgicas febre úlceras de pressão patologias múltiplas medicação … A avaliação do estado nutricional pode ser feita a quatro grandes níveis: 1. Avaliação clínica e funcional; 2. Avaliação da ingestão alimentar; 3. Avaliação antropométrica e da composição corporal; 4. Avaliação bioquímica e imunológica. 1. Avaliação Clínica e Funcional História Clínica Pela recolha da história clínica deverão obter-se antecedentes pessoais e familiares; rotinas de atividades diárias; prática de atividade física, capacidade de mastigação, insalivação e 35 deglutição; medicação; alterações de peso; problemas gastrointestinais; dependências e patologias crónicas 58; 60; 61; 63 . Exame Físico Frequentemente os sinais clínicos de desnutrição são subvalorizados por serem confundidos com alterações físicas do envelhecimento. Assim, um exame físico meticuloso ao nível da face, cabelo, mucosas, pele, membros inferiores e superiores, tórax e abdómen permitirá diagnosticar desnutrição e identificar os nutrimentos que lhe estarão associados (Quadro 6). Deve pesquisar-se a perda de gordura subcutânea (a nível bicipital, tricipital, nas regiões suborbitais, tórax...), a perda de massa muscular (nas têmporas, ombros, clavícula, escápula, costelas, músculo do dorso da mão, joelho, barriga da perna...) e eventual presença de edema e ascite 60; 61; 63 (Quadro 6). Quadro 6ǀ Sinais clínicos de desnutrição e nutrimentos associados 61 Sinais Clínicos de Desnutrição Nutrimentos a ssociados Face Despigmentação difusa Dermatite seborreica nasolabial Niacina, vitaminas B2 e B6 Cabelo Seco, frágil, opaco, sem brilho e despigmentado Proteínas, vitaminas B6 e B12, biotina, ferro, zinco Olhos Conjuntiva pálida e seca. Cegueira nocturna. Xeroftalmia Vitaminas A e B6, niacina Unhas Em forma de colher e frágeis Ferro, vitamina B12 Pele Xerose cutânea, dermatite, palidez Niacina, vitaminas A e B6, biotina, proteínas e zinco Lábios Estomatite angular, queilose Vitaminas B2 e B12 Língua G lossite, fissuras, atrofia das papilas, aspecto liso e vermelho vivo Vitaminas B6, B2 e B12, ácido fólico Gengivas Hemorragias Vitamina C Estado neurológico Alterações da sensibilidade vibratória e postural Demência, depressão Vitamina B12, ácido fólico, cálcio Aspeto geral Letargia, apatia, irritabilidade, desorientação, transtornos do padrão do sono Ferro, vitaminas B1 e B12 36 Para avaliar a capacidade funcional dos idosos foram desenvolvidos e validados índices de actividade de vida diária como o Activities of Daily Living (ADL) e o Instrumental Activities of Daily Living (IADL) e, a capacidade cognitiva pode ser apreciada através do Mini Mental State Examination (MMSE) e da Geriatric Depression Scale (GDS) 60; 61; 63 . Força muscular A redução da força muscular que ocorre com a idade poderá comprometer a execução das atividades diárias normais e/ou reduzir a intensidade dessas atividades. A força muscular da mão, medida através de dinamometria, representa um índice concreto da funcionalidade dos membros superiores, pode ser utilizada na monitorização da função motora e é indicadora do estado de saúde e nutricional. A utilidade da dinamometria como componente da avaliação nutricional da população idosa comprovada por Guerra e Amaral 64 , mostra um elevado valor preditivo de morbilidade, aumento de risco de complicações e mortalidade. 2. Avaliação da Ingestão Alimentar Para a seleção do método a utilizar para a avaliação da ingestão alimentar em idosos deve ter-se em consideração as respetivas capacidades intelectuais, literacia e a motivação para colaborar de forma a obtermos informação válida. Independentemente do método a selecionar é fundamental que seja aplicado por profissionais treinados para o efeito, de forma a obter-se a precisão desejada 65; 66 . No caso dos idosos a informação colhida através dos diversos métodos pode apresentar limitações devidas ao comprometimento da memória recente o que dificulta uma correta identificação do alimento consumido e a respetiva quantidade. A identificação da quantidade consumida é difícil no caso dos idosos que não preparam as suas refeições nem se servem. Para a população idosa em Portugal esta condicionante poderá ser ainda mais evidente nos homens do que nas mulheres 65; 66 . 37 As limitações das capacidades visuais e auditivas poderão também dificultar, por exemplo, a aplicação de métodos que necessitem de recorrer a entrevista. Na presença de alterações cognitivas a informação deverá ser colhida através de um prestador de cuidados conhecedor do idoso 65 . Resumidamente apresentam-se os diversos métodos de avaliação da ingestão alimentar: Registo/diário alimentar 66 : método em que cada indivíduo é ensinado a descrever criteriosamente, tudo o que come e bebe durante um período de tempo definido. Este método está descrito como apropriado para pessoas motivadas e com elevada literacia. Inquérito às 24 horas anteriores 66 : o inquirido é convidado, através de uma série sistemática de questões (abertas/estruturadas) a recordar e a descrever todos os alimentos e bebidas que consumiu nas 24 horas anteriores à entrevista. O facto de apelar à memória recente que poderá estar comprometida nesta faixa etária, poderá condicionar a validade da informação obtida. Frequência de consumo alimentar 66 : este método consiste na aplicação de um inquérito que consta de uma lista de alimentos e bebidas previamente elaborada de acordo com os hábitos alimentares da população em causa. Os inquiridos têm que ter a capacidade de estimar a frequência de consumo habitual de cada alimento da lista num determinado período de tempo. Apesar de estar descrito que os idosos apresentam uma boa memória referente a factos passados a memória pode também ser uma limitação à escolha deste método. História alimentar 66 : O inquirido é convidado, através de uma entrevista estruturada, a descrever o seu padrão habitual de consumo alimentar, incluindo o seu dia-a-dia e também as variações à rotina (fins-de-semana, férias, estações do ano, turnos de trabalho…). De uma forma geral, o tempo máximo descrito para a obtenção de informação válida é de um ano. Mais uma vez, o recurso à memória é o condicionante para este grupo. 38 Independentemente do método selecionado este deverá ser adaptado ao grupo de idosos a inquirir avaliando previamente as suas capacidades de memória e o facto do tempo da sua atenção estar limitado, a presença de doenças crónicas e mentais, condições socioeconómicas além de alterações fisiológicas. No entanto, os idosos têm, em geral, hábitos alimentares muito rígidos e monótonos, o que facilita a colheita deste tipo de informação 65 . 3. Avaliação Antropométrica e da Composição Corporal A avaliação antropométrica é considerada não invasiva, segura, de fácil execução e baixo custo operacional, e permite objetivamente identificar populações em risco nutricional. Na população mais velha as alterações fisiológicas do envelhecimento e as condicionantes patológicas, de estilos de vida e fatores socioeconómicos, poderão comprometer a informação obtida 60; 63 . As limitações ao uso da antropometria em idosos podem ser devidas a: - Falta de cooperação do indivíduo; - Inexperiência do examinador (das técnicas e da população em causa); - Equipamento mal calibrado; - Padrões de referência desajustados. Assim, é essencial o recurso a equipamentos calibrados e precisos e a aplicação de técnicas já validadas. Das limitações de ordem técnica que poderão condicionar este tipo de avaliação destacam-se dificuldades de deslocação, manter o equilíbrio postural durante o tempo necessário para a avaliação ou dificuldades de posicionamento. De entre as dificuldades fisiológicas, destacamse fatores inerentes ao próprio processo de envelhecimento como a redução da massa muscular e óssea, diminuição da estatura, alterações na quantidade e distribuição do tecido adiposo subcutâneo, alterações da compressão e elasticidade dos tecidos assim como 39 estreitamento das cartilagens intervertebrais. Todos estes fatores poderão afetar a precisão da medição e a interpretação das medidas antropométricas. Sugere-se, assim, precaução no uso e interpretação das estimativas da composição corporal em idosos para evitar erro de classificação 59; 60; 63; 67 . Estatura Esta medida é discutível na prática geriátrica atendendo às limitações na sua interpretação devido a condicionantes fisiológicas do envelhecimento como: o achatamento das vértebras, a redução dos discos intervertebrais, deformidades como a acentuação da cifose dorsal, escoliose, entre outras deformidades da coluna e arqueamento dos membros inferiores. Em alternativa à medição da altura, podem ser medidos outros parâmetros como altura do joelho (distância joelho-calcanhar), extensão e semi extensão do braço, altura deitado e altura sentado. A altura joelho-calcanhar apresenta-se como a mais válida na prática geriátrica e, recorrendo às fórmulas de Chumlea 68 pode-se inferir a altura real vertebral 58; 60; 63; 67 . Peso É a medida base e um indicador do estado de saúde que permite a monitorização com facilidade. Perdas de 5% de peso em menos de 1 mês ou 10% ou mais em 6 meses, poderão ser consideradas um sinal de malnutrição nos idosos 2; 58 . No entanto esta medida não permite distinguir os diversos componentes do peso. Para pesar idosos poderá ser necessário adquirir uma balança estável, grande ou eventualmente uma balança cadeira ou que se aplique a uma cama, para idosos dependentes ou mesmo acamados. Na impossibilidade de realizar esta medição Chumlea 69 estabeleceram fórmulas que estimam o peso através de medições alternativas como o perímetro da barriga da perna, altura do joelho e prega cutânea sub escapular. 40 De uma forma geral, a partir dos 65 anos, poderá ocorrer redução da água corporal, do peso visceral, do tecido muscular e uma estrutura óssea mais leve, e, consequentemente redução do peso corporal 65 . Índice de massa corporal (IMC) Calculado através da relação entre o peso (em kg) e o quadrado da altura (em m), é um indicador muito utilizado e recomendado na avaliação do estado nutricional em todas as faixas etárias. No entanto como não reflete a distribuição da gordura, deve ser associado a outras medidas como por exemplo a prega cutânea tricipital 60 . Há dúvidas quanto aos critérios ou pontos de classificação do IMC em idosos. De acordo com Hajjar e colaboradores 70 , o IMC desejável é 24-29 kg e um IMC abaixo de 24 kg/m2 é considerado pelo autor como um indicador de malnutrição 70 . No quadro abaixo pode observar-se os diferentes pontos de corte sugeridos por diferentes autores para classificação do IMC em idosos (Quadro 7). Quadro 7ǀ Diferentes pontes de corte de IMC considerados para avaliação do estado nutricional de idosos. Classificação IMC (kg/m 2 ) Referências Baixo peso Peso normal Excesso de peso CDC,1991 71 - - >27.3 (mulheres) >27.8 (homens) WHO, 2000 72 (= à população adulta) <18.5 18.5 a 24.9 25 a 29.9 (sobrecarga ponderal) ≥ 30 (obesidade) Lipchitz, 1994 73 <22 22 a 27 >27 Hajjar e colaboradores, 2004 70 <24 24 a 29 >29 47 6. Nutritional Risk Screening (NRS) 52 : é o instrumento de rastreio sugerido pela ESPEN para rastreio em meio hospitalar. Avalia o IMC, perda de peso, alteração da ingestão alimentar e presença de doença crónica 7. Malnutrition Universal Screening Tool (MUST) 51 inclui o IMC, perda de peso e questões do foro alimentar, é recomendado para ser utilizado na comunidade. 1.5 ǀ Promoção do estado nutricional do idoso Para responder ao desafio demográfico da Europa, é imperativo promover ativamente estilos de vida saudáveis, a fim de reduzir a prevalência das maiores causas de morte e incapacidade que assentam os seus fatores de risco em variáveis relacionadas com estilos de vida. Promover estilos de vida saudáveis significa: a) fornecer os meios necessários para permitir a todos, incluindo aos idosos uma participação ativa e independente na sociedade; b) promover uma abordagem positiva e integrada para a saúde que promova variedade de atividades sociais, económicas, de infraestruturas, planeamento, transporte e outras políticas relevantes e; c) criar um ambiente propício para promover um estilo de vida saudável 78 . Promover a saúde através da promoção de hábitos alimentares obriga assim a uma intervenção delineada de forma a atingir objetivos assentes nos principais eixos estruturantes do seu comportamento, gostos, expetativas, preferências, de matriz cultural que definem o individuo como membro de uma determinada comunidade tendo em consideração as características sociais 79 . Programas/formas de auxílio alimentar/nutricional, deverão ser assim concebidos tendo como base uma identificação das reais necessidades nutricionais dos diferentes grupos de idosos e adequados sob ponto de vista gastronómico e cultural 56; 61 . Mais do que atenuar as incapacidades causadas pelo envelhecimento, os serviços de saúde deverão procurar monitorizar o estado de saúde e nutricional dos idosos de modo a evitar 48 que este se degrade, propiciando assim a sua manutenção e autonomia na comunidade e fomentando a sua qualidade de vida 56 . Os profissionais de saúde deverão ser proativos adotando uma postura holística face ao envelhecimento, demonstrando abertura e compreensão não só para questões alimentares/nutricionais, mas também tendo em consideração o suporte emocional, tentando preservar ao máximo a integração deste grupo tão válido na sociedade e consequentemente a sua independência 7; 56 . 1.6 ǀ O Projeto Europeu Food in Later Life, choosing foods, eating meals: sustaining independence and quality of life , A maior parte do presente trabalho insere-se no Projeto Europeu Food in later life, choosing foods, eating meals: sustaining independence and quality of life, “Alimentação em Idade Senior, escolha de alimentos e refeições para manter a independência e qualidade de vida” 15; 80 , nomeadamente do seu Work Package 7 (WP7), designado - determinar a qualidade de vida relacionada com a alimentação. Decorreu em oito países da União Europeia (Dinamarca, Alemanha, Itália, Polónia, Portugal, Espanha, Suécia e Reino Unido), e foi coordenado pelo Reino Unido pela Professora Margaret Lumbers da Universidade de Surrey. Os objetivos gerais do projeto Food in Later Life foram: (1) estudar a relação entre a ingestão alimentar, estado nutricional, saúde e qualidade de vida e; (2) compreender os fatores que determinam a escolha alimentar em pessoas idosas e estabelecer comparações entre diferentes países, faixas etárias, sexos e circunstâncias de vida. 49 Genericamente este projeto visa suportar de forma científica, ferramentas de intervenção aos vários prestadores de cuidados formas e informais de idosos. Especificamente o WP7 teve como objetivo geral o desenvolvimento e validação de um questionário que permitisse determinar a qualidade de vida relacionada com a alimentação em idosos. 50 51 2 ǀ O bjetivos 52 53 2 ǀ O bjetivos 2.1 | O bjetivo G eral É finalidade desta investigação contribuir para um melhor conhecimento das expetativas em relação à alimentação, recursos alimentares disponíveis e estado nutricional da população idosa, identificando os seus principais determinantes. 2.2 | O bjetivos E specíficos São objetivos específicos desta investigação, atendendo às desigualdades sociais, económicas, culturais e condições de vida dos idosos: - Conhecer as principais expetativas em relação à alimentação e seus determinantes; - Avaliar hábitos e padrões de consumo alimentares explorando a sua relação com os seus estilos de vida e saúde; - Reconhecer os principais fornecedores de refeições fora do domicílio e identificar os seus determinantes; - Identificar a prevalência de inadequação do estado nutricional por excesso e sua relação com determinantes sociodemográficas. 54 55 3 ǀ P opulação e M étodos 56 63 Face às recomendações da OMS 36 , em ambos os sexos verificou-se que a ingestão ligeiramente aumentada do consumo de lípidos totais, de proteínas e de cloreto de sódio. Aumentada também de ácidos gordos da série n-3 e açúcares simples. Relativamente aos hidratos de carbono e fibras alimentares a proporção encontrada foi abaixo da recomendada. Quadro 12ǀ Ingestão nutricional dos idosos Portugueses (por género) e respetiva comparação com as recomendações da OMS Objetivos 36 (% do valor energético total exceto quando referido) Ingestão nutricional Homens (mediana da % do valor energético total exceto quando referido) Mulheres (mediana da % do valor energético total exceto quando referido) Gordura total 15 - 30% 31.21 32.99 Gordura saturada <10% 9.02 9.25 Acidos gordos polinsaturados (PUFAs) 6 - 10% 5.46 5.73 n-6 (PUFAs) 5 - 8% 4.09 4.21 n-3 (PUFAs) 1 - 2% 5.46 5.73 Acidos gordos trans <1% 0.38 0.40 Hidratos de carbono totais 55 - 75% 44.26 48.21 Açucares simples <10% 16.07 17.80 Proteína 10 - 15% 17.91 19.17 Colesterol <300 mg por dia 266.77mg 250.84mg Cloreto de sódio (sodio) <5 g por dia 15.56g 14.15g Fibra > 25g 20.97 19.66 Energia Media (desvio padrão) Mediana 25 th percentil 75 th percentil 1930.05±751.06 1852.08 1424.62 2285.44 1809.57±788.19 1747.07 1227.95 2270.46 Os parâmetros antropométricos aferidos permitem-nos traçar o perfil antropométrico da população idosa Portuguesa descrito no quadro abaixo (Quadro 13). 64 Quadro 13ǀ Perfil antropométrico dos idosos Portugueses Homens Altura (cm) Peso (kg) IMC (kg/m 2 ) Circunferência da Barriga da Perna (cm) Perímetro da Cintura (cm) Perímetro do Braço (cm) P5 153.00 57.00 21.03 28.05 68.00 24.00 P25 161.00 68.63 24.44 34.00 92.00 28.00 P50 167.00 74.25 27.44 37.00 99.00 30.00 P75 170.00 81.00 29.51 41.00 106.00 33.00 P95 176.00 94.99 33.29 52.95 117.00 38.00 Mulheres P5 143.50 48.50 20.87 23.77 56.00 21.95 P25 150.00 60.00 24.61 32.00 87.50 27.00 P50 154.00 65.00 27.73 36.00 96.00 30.00 P75 158.00 73.00 30.34 41.10 103.00 32.13 P95 168.00 87.00 35.44 51.05 118.00 38.00 65 4 ǀ R esultados 4.1 ǀ Food related perceived goals among European elderly 66 67 FOOD RELATED PERCEIVED GOALS AMONG EUROPEAN ELDERLY AFONSO C 1 , LOPES C 2 ,DE MORAIS C 1 , POINHOS R 1 , OLIVEIRA BMPM 1,3 , RAATS M 4 , LUMBERS M 4 , GRUNERT K 5 , DE ALMEIDA MDV 1 , FOOD IN LATER LIFE TEAM id 1 Universidade do Porto, Faculdade de Ciências da Faculty of Nutrition and Food Sciences of - Rua Dr. Roberto Frias 4200 – 465 Porto - Portugal ([email protected]) 2 Universidade do Porto, Medical School, Department of Clinical Epidemiology, Predictive Medicine and Public Health – Portugal, Universidade do Porto, Institute of Public Health 3 LAID – INESC, Porto, LA, 4 University of Surrey, UNIS, School of Management – UK 5 The Mapp Centre; The Aarhus School of Business – Denmark [SUBMITED FOR PUBLICATION] Abstract Objectives: To identify in a free-living European elderly population, the main food related perceived goals and the sociodemographic and health determinants associated to them. Design: A structured questionnaire was performed to identify food related goals, using two five points’ scales. To ascertain if the items associated with food related goals, could be aggregated in different subdomains, factor analysis was carried out. General Linear Model was performed to obtain adjusted mean and 95% CI as well as to compare the main effects, and all twoway interactions of the independent variables on both scales. Linear regression was used to estimate the association between scores, satisfaction with food-related life, physical and mental health as measured by the SF8 Health Survey. Participants: Within the European Project “Food in Later Life” 3290 European citizens aged 65+ years from 8 EU countries (Denmark, Germany, Italy Poland, Portugal, Spain, Sweden and the UK) were interviewed with a structured questionnaire in a face-to-face situation. Results: The five most important foodrelated goals in the elderly were: ‘to choose foods that they enjoy eating (3.87±0.831), followed by ‘to try to eat healthier’ (3.77±0.93), Overall, Portuguese and Spanish elderly highlighted the ambiance when eating, as well as the need to keep food expenditures low. On the other side, for Danish and Swedish seniors, expenditures revealed to be less important. Factor analysis identifies two subdomains related to health and sensorial aspects of food (Health/Sensorial) and another, associated with socialization and economics (Social/Economic). In general, European elderly gave more emphasis to goals related to health and sensorial items (64.0±16.8) than to social and economic matters (55.5±18.7). Health/Sensorial aspects were more selected by more educated elders and A Ac ck kn no ow wl le ed dg ge em me en nt ts s T Th he e d da at ta a u us se ed d i in n t th hi is s a ar rt ti ic cl le e b be el lo on ng g t to o t th he e E Eu ur ro op pe ea an n R Re es se ea ar rc ch h P Pr ro oj je ec ct t F Fo oo od d i in n L La at te er r L Li if fe e. . C Ch ho oo os si in ng g f fo oo od ds s, , e ea at ti in ng g m me ea al ls s: : s su us st ta ai in ni in ng g i in nd de ep pe en nd de en nc ce e a an nd d q qu ua al li it ty y o of f l li if fe e ( (2 20 00 04 4– –2 20 00 05 5) ) c co oo or rd di in na at te ed d b by y D Dr r. . M Ma ar rg ga ar re et t L Lu um mb be er rs s a an nd d D Dr r. . M Mo on ni iq qu ue e R Ra aa at ts s f fr ro om m t th he e U Un ni iv ve er rs si it ty y o of f S Su ur rr re ey y ( (U Un ni it te ed d K Ki in ng gd do om m) ) a an nd d f fi in na an nc ce ed d b by y t th he e E Eu ur ro op pe ea an n C Co om mm mi is ss si io on n ( (Q QL LK K1 1C CT T2 20 00 02 20 02 24 44 47 7) ). . 5 Food in Later Life Team: Denmark: Klaus Grunert, Niels Asger Nielsen Germany: Ulrich Oltersdorf, Birgit Schuhmacher,Cornelie Pfau Italy: Anna Saba; Aida Turrini, Laura D’Addezio, Fabrizia Maccati Poland: Katarzyna Kozłowska, Wojciech Roszkowski, Anna Szczecińska, Marzena Danowska-Oziewicz, Lidia Wądolowska, Bozenna Kozikowska, Roman Cichon, Ewa Szymelfejnik, Anna Waluś, Magdalena Kozikowska, Dariusz Słowiński Portugal: Cecilia de Morais, Cláudia Afonso, Maria Daniel Vaz de Almeida Spain: Jesús Contreras, Silvia Bofill, Yolanda Lacasta Sweden: Per-Olow Sjödén, Christina Fjellström, Margaretha Nydahl, Jenny Ekblad United Kingdom: Sara Arber, Kate Davidson, Monique Raats, Margaret Lumbers, Wendy Hunter, Anita Eves, Richard Shepherd 68 Social/Economic by those with lower education level and a monthly income between 433 and 1078€. Conclusion: This study showed a very heterogeneous picture of food related goals according to country of residence and other sociodemographic aspects. More educated elderly referred mostly Health/Sensorial aspects and lower educated ones tended to emphasize Social/Economic matters. In general, more satisfied elder were more likely to emphasise health/sensorial aspects and those with physical and mental constrains emphasized social/economic aspects. Keywords: Elderly, food-related goals, sociodemographic, health determinants. Introduction The dynamics of demographic changes, namely the greying of the world’s population require the identification of the main determinants of healthy ageing, a concept understood by the WHO “a process of optimising opportunities for physical, social and mental health to enable older people to take an active part in society without discrimination and to enjoy an independent and good quality of life 1 it constitutes a challenge for societies aiming to contribute to the elderly’s health and quality of life maintenance 2 . In order to promote Healthy Ageing it is crucial to recognize that “the elderly” do not constitute a homogeneous group, neither biologically, nor psychologically or socially. Their values, attitudes, motivations and behaviours differ and these change across the life stages 3; 4 . Scientific evidence increasingly supports that a good nutrition is essential to health and selfsufficiency, being considered one of the major determinants of successful ageing 5; 6; 7 . Epidemiological research has shown that healthy behaviours such as healthy eating, physical activity and not smoking play a more important role than genetic factors in helping individuals to avoid the decline that occurs with ageing 6 . Dietary habits may change with aging but the causes of these various changes are still under debate. If physiological changes affect eating behaviour, what is eaten also affects physiological functions 8 . Any efforts to change eating behaviours, namely by community-based interventions involving self-management approaches, must take into account the individuals’ self-perceived motivations and barriers to food selection 9; 10 . The European diversity also occurs amongst the elderly populations in what their concepts, benefits and barriers to healthy eating are concerned. Previous research showed that the European elderly population (EU-15) identified quality and freshness, trying to eat healthy and price as the most important factors influencing 69 their food choice. Healthy eating was viewed as eating “less fat”, “more fresh vegetables and fruit” and “natural foods”. Healthy eating was also perceived to have several benefits, namely to stay healthy, to prevent disease and to promote quality of life. However, self-control, resistance to change and price, were recognised as barriers to the adoption of healthy eating. Moreover, the majority believed their diet to be already healthy and therefore did not perceive the need to change their eating habits 11 . Locher et al, identified sensory appeal (i.e., tastes good), convenience, and price as important motivations for food selection in the elderly whereas ethical concerns, mood and natural content played a less important role 10 . Eating is not an involuntary process; on the contrary, as a bio-social and cultural phenomenon, the promotion of healthy ageing through healthy eating is more likely to be effective if based on the understanding of the main determinants of food choice as well as the motivations, expectations and perceived food related goals. Contrary to the study of the determinants of food choice, food related perceived goals as well as food expectations have never been studied in a cross cultural situation in which elderly from eight European countries were investigated. Objectives To identify in a free-living European elderly population, the main food related perceived goals and the sociodemographic and health determinants associated to them. Participants and procedures 3291 elderly above 65 years of age and living independently in their own homes in 8 EU countries (Denmark, Germany, Italy Poland, Portugal, Spain, Sweden and the United Kingdom) participated in the Project Food in Later Life 12 . In each country, the sample (around 400 people) was quota controlled according to three sampling characteristics: gender, age (65 to 74 years and over 75 years) and living circumstances (living alone versus living with others). In addition, the sample should reflect the diversity of each national population based on education level, income and urbanization of living environment (urban/suburban/rural) and was drawn from at least three geographical regions in each participant country. 70 The information was collected in a face-to-face situation by trained interviewers from marketing research companies, using a structured questionnaire designed by the Food in Later Life team according to the previously defined objectives. The questionnaire was developed in English, translated to each national language and back-translated before it was piloted in each country. Respondents were asked to provide information about: - Highest level of education achieved (no formal education; first level or basic: less than primary school/primary school completed; secondary: secondary school completed; tertiary: college/university completed/postgraduate degree completed); - Total income in euros, into 13 categories (less than 366€; 366-433€; 434-646€; 647-864€; 865-1078€; 1079-1291€; 1292-1622€; 1623-1942€; 1943-2161€; 2162-2481€; 2482-2793€; 2794-3578€; more than 3578€). Due to a low frequency of some categories, this measure was subsequently re-coded into four categories: less than 433€ per month, 433 to 1078 €/month, 1079 to 1943 €/month and above 1943€/month; - Marital status (married/cohabiting, widow/separated or single). Participants were asked to provide information about the importance attributed to eleven foodrelated perceived goals, scoring from 1 (not important) to 5 (extremely important), developed in a previous qualitative research 13 . Satisfaction with food related life was measured by the 5 item satisfaction with food related life (SWFL) scale developed by Grunert et al, 2007 and physical (PCS8) and mental health (MCS8) were measured by the SF8 Health Survey 14 . Overall subjective life satisfaction was also assessed using a 1 (completely unsatisfied) to 10 (completely satisfied) point scale. Statistical analysis Data were stored and analysed using SPSSWIN 17.0. Mean and standard deviation (S.D.) were used to describe continuous variables. To ascertain if the items associated with food related goals, could be aggregated in different subdomains, factor analysis was performed. The principal component analysis was done to estimate the number of factors emerging and to assess the appropriateness of the correlation 71 matrices for factor analysis. The criteria of eingenvalue ≥ 1 were used to identify the number of factors to be retained in a first phase. Subsequently, Cattell’s method was used and two principal components were extracted 15 . The interpretation of the factor loadings was carried out after Varimax rotation. Internal consistency was also analysed through item-total correlations and Cronbach’s alfa coefficients. The cut off points for the total item correlations and alpha values were considered satisfactory if equal to or greater than 0.30 or 0.60, respectively. After achieving the two scales, mean and 95% Confidence Intervals (95% CI) were used to describe sociodemographic and health variables associated to them. Univariate analysis from a General Linear Model was performed to compare the main effects as well as all two-way interactions of the independent variables on each of the two scales and to obtain the adjusted mean and 95% CI. Linear regression was used to estimate the association between scores, satisfaction with foodrelated life, physical and mental health as measured by the SF8 Health Survey. Results In this free-living European elderly, the main food related perceived goals were associated to pleasure (enjoy eating) and to eat a healthy diet, with mean levels of importance, on a 1 to 5 point scale, of 3.87±0.831 and 3.77±0.93, respectively. To choose food products and dishes that are quick and easy to prepare (2.71±1.251) and to be able to cook meals for others (2.72±1.327), were the goals considered less important to these elderly. According to country of residence, different goals had different levels of importance. Compared to the European average, elderly from Portugal (4.15±0.664) and Spain (4.15±0.644) gave more importance to eating surroundings, which constituted their main food related perceived goal. Polish elderly highlight the importance of being self-sufficient (e.g. not requiring help from others) as their main food related goal (3.73±1.122). To keep expenditures low, was an important goal to Spanish (4.00±0.887), Portuguese (3.77 ±0.858) and Polish (3.67±1.235) elderly, but less important to elderly from Denmark (2.35 ±1.115) and Sweden (2.42 ±1.084) (Table 1). 72 Table 1. Mean and standard deviation of food related perceived goal importance by European elderly 8 country mean (SD) 3291 1. T o choose food products and dishes that enjoy eating 3.87 (0.831) 3.75 (0.848) 4.11 (0.772) 3.86 (0.812) 3.61 (0.975) 3.94 (0.701) 3.94 (0.656) 3.53 (0.915) 4.18 (0.690) 2. T o eat an healthy diet 3.77 (0.93) 3.65 (0.954) 4.03 (0.776) 3.70 (0.952) 3.48 (1.109) 4.08 (0.652) 3.97 (0.747) 3.32 (1.030) 3.90 (0.842) 3. T o vary menu and have a wide range of food and dishes 3.65 (0.908) 3.43 (0.982) 3.97 (0.812) 3.62 (0.908) 3.62 (0.906) 3.74 (0.808) 3.89 (0.752) 3.27 (0.944) 3.68 (0.936) 5. T o arranje shopping and preparation of meals that don’t need help from others 3.41 (1.256) 2.85 (1.471) 3.78 (1.141) 3.23 (1.218) 3.73 (1.122) 3.83 (0.832) 3.59 (1.029) 3.01 (1.372) 3.13 (1.387) 6. To keep expenditures on food as low as possible 3.22 (1.213) 2.35 (1.115) 3.29 (1.032) 3.48 (1.030) 3.67 (1.235) 3.77 (0.858) 4.00 (0.887) 2.42 (1.084) 2.79 (1.200) 7. T o eat meals in the company of other people 3.15 (1.298) 2.66 (1.304) 3.35 (1.270) 3.50 (1.032) 3.16 (1.302) 3.68 (0.983) 3.83 (0.994) 2.63 (1.282) 2.38 (1.355) 8. To maintain the cultural traditions of country or region in relation to food and meals 3.09 (1.307) 2.16 (1.215) 3.03 (1.300) 3.42 (1.142) 3.60 (1.129) 3.57 (0.852) 3.77 (1.035) 2.31 (1.241) 2.82 (1.434) 9. T o control weight 2.95 (1.259) 2.72 (1.324) 3.09 (1.242) 3.06 (1.177) 2.65 (1.349) 3.56 (0.885) 3.28 (1.121) 2.35 (1.235) 2.89 (1.270) 11. T o choose food products and dishes that are quick and easy to prepare 2.71 (1.251) 2.37 (1.177) 3.00 (1.48) 2.44 (1.226) 2.51 (1.306) 3.53 (0.929) 3.04 (1.173) 2.02 (1.102) 2.74 (1.270) 2.78 (1.267) 2.58 (1.256) 2.41 (1.367)2.48 (1.283) 2.68 (1.385) 3.10 (1.278) 2.61 (1.417) 3.12 (1.160) Spain 3.36 (1.081) 10. To be able to cook meals for others Sweden UK 4. T o eat daily meals in nice surroundings 3.64 (0.970) 3.45 (0.968) 3.62 (1.025) 3.64 (0.972) 3.57 (1.052) 4.15 (0.644) 3.40 (0.952)4.15 (0,664) 2.72 (1.327) Denmark Germany Italy Poland Portugal Scale: 1 (low importance) to 5 (high importance) Factor analysis was performed to evaluate if the food related perceived goals, could be aggregated in different subdomains. Firstly, the principal component analysis identified a three component solution that accounted for 50.6% of total variance. However from these 11 items, one of them (to choose food products and dishes that are quick and easy to prepare) did not fit with any of the components. After it’s exclusion, a solution of two fixed components, explained 42.2% of the total variance. This solution presents two components with an alpha of Cronbach's coeficient of 0.660 for the first component and 0.608 for the second (Table 2). 79 7. American Dietetic Association (2000) Position of the American Dietetic Association: nutrition, aging and the continuum of care. J Am Diet Assoc 100, 580-595. 8. Elsner RJF (2002) Changes in eating behavior during the aging process. Eat Behav 3, 15- 43. 9. Herne S (1995) Research on food choice and nutritional status in elderly people: a review. British Food Journal 97, 17 10. Locher JL, Ritchie CS, Roth DL et al. (2009) Food choice among homebound older adults: motivations and perceived barriers. J Nutr Health Aging 13, 659-664. 11. de Almeida MDV, Graça P, Afonso C et al. 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Silverman P, Hecht L & Mcmillin JD (2002) Social support and dietary change among older adults. Ageing & Society 22, 29-59. 26. Howarth G (1993) Food consumption, social roles and personal identity. In Ageing, Independence and the Life Couse, [ASaE M, editor]. London: Jessica Kingsley. 27. Brownie S (2006) Why are elderly individuals at risk of nutritional deficiency? Int J Nurs Pract 12, 110-118. 28. Ramic E, Pranjic N, Batic-Mujanovic O et al. (2011) The effect of loneliness on malnutrition in elderly population. Med Arh. 65, 3. 29. Mathey MF, Zandstra EH, de Graaf C et al. (2000) Social and physiological factors affecting food intake in elderly subjects: an experimental comparative study. Food Qual Prefer 11, 397-403. 80 30. Steptoe A, Pollard TM & Wardle J (1995) Development of a measure of the motives underlying the selection of food: the food choice questionnaire. Appetite 25, 267-284. 31. Bryant LL, Corbett KK & Kutner JS (2001) In their own words: a model of healthy aging. 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Revue canadienne de sante publique 96 Suppl 3, S27-31, S30-35. 81 4 ǀ R esultados 4.2 ǀ Adherence to Mediterranean food pattern in Portuguese elderly 82 83 Adherence to Mediterranean food pattern among Portuguese Elderly Afonso C 1 , Lopes C 2 , de Morais C 1 , Poinhos R 1 , Oliveira BMPM 1,3 , de Almeida MDV 1 1 Universidade do Porto, Faculdade de Ciências da Nutrição e Alimentação - Rua Dr. Roberto Frias 4200 – 465 Porto - Portugal ([email protected]) 2 Universidade do Porto, Faculdade de Medicina, Departamento de Epidemiologia Clínica, Medicina Preditiva e Saúde Pública – Portugal, Universidade do Porto, Instituto de Saúde Pública 3 LAID – INESC, Porto. [SUBMITED FOR PUBLICATION] Abstract Objective: To identify in a free-living population the adherence and main determinants of the Mediterranean food pattern (MDP) among Portuguese Elderly. Design: Cross-sectional study to evaluate the adherence to the Mediterranean food pattern (MDP), the diet index developed by González, et al 1 , was computed. Descriptive analysis consisted on computing for each gender, the median, 25th percentile and 75th percentile of consumption for each type of food included in the index (vegetables and garden products, fruits, pulses, cereals, red meat, fish, olive oil, milk and milk products and wine) adjusted for sociodemographics, age, education, living circumstances and geographical area of residence. General Linear Model was performed to compare the main effects as well as all two-way interactions of the independent variables on MDP in addition to obtain the adjusted mean and 95% CI. Multiple linear regression was used to estimate the association between MDP scores, satisfaction with food-related life, physical and mental health as measured by the SF8 Health Survey. Means were adjusted by gender, age, education and living circumstances. Setting: Free living elderly from all Portuguese regions. Subjects: 400 Portuguese aged 65+ years, were interviewed with a structured questionnaire in a face-to-face situation. Results: Adherence to the MDP was above the mean among the free-living Portuguese elderly (mean 22.2±3.9 points), from a maximum of 36 points. 83% of the participants were above the mean. Those with higher scores were more frequently men [mean 22.3 (95%CI 21.8;22.9)], old elderly [mean 22.2 (95%CI 21.7;22.8)] and with a higher educational level [mean 22.13 (95%CI 22.1;23.4)]. Elderly with significant lower adherence to the MDP were more likely to have a lower monthly income [mean 21.52 (95%CI 22.7-22.4)], tend to live in the North [mean 21.1 (95%CI 20.4;21.8)], being smokers [mean 20.5 (95%CI 19.1;21.9)] and use family and restaurants to obtain their meals. The MDP score increased significantly with better self-perceived physical health (SF-8). 84 Conclusion: The results of this study enables the identification of groups with lower adherence of MDP: lower income elderly, with health constrains, smokers, living in the North and which obtained their meals away from their own home. Keywords: Portuguese, Mediterranean patterns, sociodemographic, health determinants . Introduction Globally, the number of older adults is growing rapidly, namely in European countries which are considered to have an “aged population”. In Europe every seventh person is aged 65 years or more, and this proportion is growing while the proportion of children is declining. The ageing process is more advanced in countries like Portugal, than in other western parts of Europe 2 . At the same time, health risks are in transition: populations are ageing due to successes against infectious diseases; and patterns of physical activity and food, alcohol and tobacco consumption are also changing 3 The maintenance of good health, functionality and quality of life is crucial in the ageing process and research has shown that healthy behaviours such as having a healthy diet, being physically active, and not using tobacco are more influential than genetic factors in helping individuals to minimize further risk of ill-health and to maximize their prospects for healthy ageing 4; 5 . It is clear that a wide variety of food cultures and cuisines have the ability to promote healthy ageing. The nutrient-based approach to recommend intakes have limitations as it does not consider the environmental, socioeconomic and lifestyle context of eating 4 . Dietary patterns, such as the Mediterranean diet, characterized by a high consumption of plant foods with protective factors as a high consumption of raw and cooked vegetables, fresh fruits, legumes and non-refined cereals including bread, high olive oil consumption, moderate milk consumption and dairy products, especially in the form of cheese, low consumption of meat and moderate consumption of alcohol, especially in the form of wine, appear to be relevant even in old age 1; 6; 7 . Fish intake is also a desirable characteristic of a Mediterranean diet, but intake depends on the proximity to the sea 6 . A systematic review of cohort studies that have analysed the relationship between adherence to a Mediterranean diet, mortality, and incidence of chronic diseases in a primary prevention setting, showed that greater adherence to a Mediterranean diet is associated with a significant 85 improvement in health status, as seen by a significant reduction in overall mortality (9%), mortality from cardiovascular diseases (9%), incidence of or mortality from cancer (6%), and incidence of Parkinson’s and Alzheimer’s disease (13%). These results seem to be relevant for public health, in particular to encourage a Mediterranean-like dietary pattern for primary prevention of major chronic diseases 8 . The update of the previous meta-analysis confirms, in a large number of subjects and studies, the significant and consistent protection provided by adherence to the Mediterranean diet in relation to the occurrence of major chronic degenerative diseases 9 . Recently, results from a Spanish cohort of the European Prospective Investigation into Cancer (EPIC) showed that Mediterranean diet was associated with a 6% decreased risk of all-cause mortality to which a high olive oil intake and moderate alcohol consumption contributed mostly 10 . Previous studies found smaller mortality inequalities in Southern Europe than in other European populations. According to Regidor (2011), mortality inequalities in Spanish older adults are small. The presence of social networks and the general adherence to the Mediterranean diet may account for this finding 11 . Results from the HALE study (Healthy aging—a longitudinal study in Europe), based on nutrition and lifestyle data from about 2,300 European elders, aged 70 to 90 years from 11 countries for 10 years, showed that lifestyle factors including Mediterranean diet, being physically active, moderate alcohol use and not smoking, significantly reduced the risk of allcause mortality. All factors together resulted in a risk reduction compared to those elderly without or with only one of the above-mentioned positive lifestyle factors. This relationship also holds true for cause-specific mortality like CVD mortality, cancer mortality and mortality from other causes. About 60% of the mortality in this population could be explained by lifestyle factors 12 . Analogous results arose from the EPIC in which 74,000 older than 60 years from nine European countries were followed for seven years. The outcome of the studies indicated that healthy lifestyle choices result in important reductions in morbidity and mortality 13 . A recent investigation by Tognon et al 14 explored the association of a dietary pattern close to the Mediterranean diet with total mortality in population-based cohorts of 70-year old samples of Swedish from the Gerontological and Geriatric Population Studies in Gothenburg. It concluded that a higher adherence to a Mediterranean diet pattern, especially by consuming 86 wholegrain cereals, foods rich in polyunsaturated fatty acids, and a limited amount of alcohol, predicts increased longevity in the elderly. In that study, single food groups were not always found to be associated either inversely or directly with mortality risk. This fact suggests that the use of scores in nutritional epidemiology is indeed an advantageous approach for investigation. Portugal, situated by the Atlantic is under the influence of the Mediterranean sea and has been considered Mediterranean by nature and climate as well as for cultural and social practices 15 including food patterns 16; 17; 18; 19; 20 . However recent data showed that the adherence to a Mediterranean diet was poor in all Portuguese regions; and that it had decreased over time in the North, Centre, Lisbon and Tejo valley. The investigators concluded that between 1990 and 2000, the decreasing adherence to a Mediterranean food pattern and the diminishing compliance with World Health Organization dietary goals suggest that Portuguese households have reduced their diet quality 21 . One of the recommendations for healthy ageing based on results from the HALE project, highlight the importance of Mediterranean type of diet as a key component of nutrition education, even in later life 22 . Ensuring that older persons continue to contribute productively to society as workers and providers instead of being only recipients of care and services enhances their social and economic involvement and overall well-being 4 Many studies investigate the adherence to Mediterranean patterns, but the relationship with satisfaction with life, food related quality of life, health variables (physical and mental), as well as food-related perceived goals, constrains related to food acquisition and preparation and the use of meal providers has scarcely been investigated. Eating patterns are not isolated phenomena, free-living people eat combinations of foods and these arrangements reflect individual food preferences modulated by a mixture of genetic, cultural, social, health, environmental, lifestyle, and economic determinants. Understanding this behaviour in a broad sense is essential to community intervention 23 . Objectives To identify in a free-living population the adherence and main determinants of the Mediterranean food pattern (MDP) among Portuguese Elderly. 87 Methods Participants 400 elderly above 65 years of age and living in their own homes were selected. The sample was quota controlled according to three sampling characteristics: gender, age (65 to 74 years and over 75 years) and living circumstances (living alone versus living with others). The sample reflects the diversity of the national population based on education level, income and urbanization of living environment (urban/suburban/rural). The trained interviewers collected information in a face-to-face situation, using a structured questionnaire previously piloted. Data collection The questionnaire was structured to obtain data on social, demographic and behavioural (food consumption, physical activity, smoking and alcohol intake) characteristics. Respondents were asked to provide information about: - Highest level of education achieved (no formal education; first level or basic: less than primary school/primary school completed; secondary: secondary school completed; tertiary: college/university completed/postgraduate degree completed) later recoded into 3 categories: without any educational level, less than primary and above primary level, due to the low frequency in some categories); - Total monthly income in euros, into 13 categories. Due to low frequency of some categories, this measure was subsequently re-coded into four: less than 366€ per month, 366 to 433 €/month, 433 to 865 €/month and above 866€/month; - Food expenditure per person in euros into four categories: less than 14€/week, 15 to 28€/week, 29 to 35€/week, more than 36€/week. Due to a low frequency of some categories, this measure was subsequently re-coded into three categories in which the two last categories were grouped. - Marital status (married/cohabiting, widow/separated or single). 88 Mediterranean diet index Food consumption was assessed using a semi-quantitative food-frequency questionnaire previously validated for the Portuguese population 24 . Food consumption was converted in total energy intake with the software Food Processor Plus (ESHA Research, Salem, OR), which has been updated with traditional Portuguese foods. To evaluate the adherence to the Mediterranean food pattern (MDP), the diet index developed by González, et al 1 , was computed. This index comprises 9 food groups: vegetables and garden products, fruit, pulses, cereals, red meat, fish, olive oil, milk and milk products and wine. For fruit, vegetables, fish, pulses, cereals and olive oil, 4 to 1 points are assigned to the following intakes: more than 75 th percentile (75P), 50P to 75P; 25P to 50P; less 25P. For red meat, milk and milk products, reverse scores are assigned. For wine (men/women), 1 point is assigned to consumptions above 40/20 g of ethanol; 4 points to consumption between 1 and 100/200 ml wine; 3 points to consumptions more than 100/200 ml of wine, but less than 20/40 g ethanol; 0 points to nil consumption of wine or alcohol. The final index ranges between 9 points (lower adherence) to 36 points (higher adherence). Lifestyles, health, satisfaction with life and food, food acquisition and preparation, meal providers (family and restaurants), food related perceived goals Physical activity was evaluated by self-reported information according to the items: - walking (time/week) and/or; - regular physical exercise (kind of exercise, time/week). These variables were subsequently transformed into dichotomous variables (if a person did or not exercise and/or usually walk). Smoking habits were recorded and subjects were classified, as never-smokers, current smokers (at least one cigarette a day) and ex-smokers (quit smoking for at least 6 months). Satisfaction with food related life was measured by the 5 item satisfaction with food related life (SWFL) scale developed by 25 and physical (PCS8) and mental health (MCS8) was measured by the SF8 Health Survey 26 . Overall subjective life satisfaction was also assessed with a 10 point scale, from 1 (completely unsatisfied) to 10 (completely satisfied). 95 Table 4. Parameter Estimates of MDP by satisfaction with life, SF-8 sub-scales, satisfaction with food life and perceived goals related to food. Sample median MDP score 1 Adjusted MDP score 1, 2 β 95%CI β 95%CI Health perceived status SF-8 Physical health SF-8 Mental health Satisfaction with Life 43.90 39.92 6.00 0.03 -0.027 -0.06 -0.0; 0.7 -0.06;-0.007 -0.77; 0.65 0.05 -0.022 -0.20 0.009;0.90* -0.057;0.13 -0.43;0.023 Satisfaction with food life (SWFL) 3.80 -0.13 -0.35;0.85 -0.17 -0.90;0.55 Perceived goals related to food Health/Sensorial Social/Economics 75.00 66.66 0.52 0.45 0.025;0.07* 0.018;0.07* 0.05 0.05 0.02;0.078* 0.019;0.08* 1 Score ranges between 9 points (lower adherence) and 36 points (higher adherence) 1 2 adjusted by gender, age, education and living circumstances *p<0.05 Discussion The Mediterranean diet has been consistently associated with positive health outcomes and a better quality of life. It is recognized that focusing on single nutrients ignores the important and complex interactions between components of a diet and, more significantly because people do not eat nutrients but they do eat foods and meals. Consequently, dietary scores estimating the adherence to specific food patterns as the Mediterranean diet have been developed 27 To evaluate adherence to Mediterranean food pattern, numerous indexes have been developed, among which the Mediterranean Diet Score (MDS) proposed by 13; 28 is the most extensively employed 29 . In the current study, the MDP proposed by 1 , based on 30 and 28 was chosen as its wide range, between 9 (lower adherence) and 36 points (higher adherence), would enable to identify variability between groups. Firstly the consumption of some food groups was evaluated and subsequently their combination was obtained according to the MDP score 1 In the present study Portuguese elderly, men were found to eat more fish and fish products and wine than women. In EpiPorto study the elderly men appeared to eat more milk and milk products, red meat, fish and fish products, cereals, fruits and wine, than elderly women 31 . 96 Results from the Portuguese National Health Surveys of 1989/1999, from adults plus 65 years old, showed that consumption of meat, fish, potato/rice and vegetables was higher in older men and milk and fruit were more consumed among older female. Older elderly tend to consume more fruit, vegetables, cereals, milk and milk products and olive oil than the younger old. Olive oil also more consumed by older women, as well as fish and fish products. Data from Lopes et al, indicated that with increasing age, the consumption of the majority of food groups decrease: milk and milk products (only for women), red meats, fish and fish products (just for men) and fats and oils, alcoholic beverages (just for women) 31 . This same tendency was shown by Marques Vidal et al with the exception of milk for both genders and fruits for men 32 More educated elder men tend to eat more vegetables, fish and fish products, wine and fruit than lower educated ones. Fruit and pulses are consumed by more educated elderly women than by those with a lower education level. Independently of age, data from the Portuguese National Health Surveys of 1989/1999, revealed that as the education increased, the consumption of meat, fish, vegetables also increased in both genders, and fruit consumption in women 32 . Data collected through the Portuguese Household Budget Surveys (HBS) of 2000/2001 showed that as education level increased, the mean availability in quantity/person per day decreased for cereals, potatoes, pulses, olive oil and the availability of fruits, milk and milk products increased 32 . In the present study, adherence to the MDP was above the mean among the free-living Portuguese elderly (mean 22.23±3.91 points). The same score 1 applied to Spanish adults revealed that the MDP seems to be fairly uniform, around 22.5, similar to present study. In spite of the small, differences, elderly with significant higher adherence to the MDP were more frequently men and old elderly in both studies. The present data suggests that elderly with significant higher adherence to the MDP were more likely to have higher educational level and monthly income and tend to live more frequently in the Centre of Portugal. In the Spanish study no variations were found according to educational level, but adherence was lowest in young adults and women and was slightly higher in the south than in the north of Spain 1 . 97 Our results did not suggest any differences in adherence to the MDP and physical activity probably due the great proportion of inactive elderly neither living circumstances (living alone or with others). Considering smoking habits, non-smokers had more adherence to the MDP than smokers. The above findings are in line with data from the SENECA study, where in the Southern European centres, a high quality diet was not related to physical activity, explained also by the high proportion of inactivity in elderly who live with their children. However men who lived with their children had a higher diet score than men who lived alone 33 . Data collected through the Portuguese Household Budget Surveys using MAI index, showed that the adherence to a Mediterranean diet was poor in all Portuguese regions; the proportion of households adhering to it was lower in the North, Centre, Lisbon and Tejo valley. In households, whose head had secondary or higher education, living in semi-urban or urban areas, from the Azores region, with higher income were more likely to have low-quality diet. On the contrary, households’ with only elderly members were more likely to have a better diet-quality level 34 . Despite the small differences of MDP adherence according to income and education, the present results were in agreement with previous studies where healthier diets are generally associated with higher education and income and/or to higher social class 35; 36 . In the HALE study, which also used the MAI index, lower scores ranging from 1.0 to 1.5 in the Northern Europe, and scores ranging from 2.0 to 3.6 in the Southern Europe were found 37 .As expected, our data from the Portuguese regions are closer to the Southern European than to the Northern ones. Association between MDP index and health status was complex as it increased significantly with physical health (SF-8), but, on the other hand, was negatively associated, although not significant with mental health, subjective satisfaction with life and satisfaction with food life. MDP index was also significantly positively related with both health/sensory and social/economic food goals. People with higher adherence to Mediterranean food pattern are more likely to identify goals related with food either Health/sensorial or Social/economics. 98 In the present study, lower adherence to MDP was associated to the use of formal (as restaurants) or informal (as family) meal providers. In spite of the fact that adherence to the MDP was above the medium range score in this Portuguese elderly, this study results are in line with others reporting the “westernization of Mediterranean countries” food habits even in the old age group 38 21 . A publication 39 from Chen & Marques Vidal, (2007) showed that Portugal is consistently and rapidly moving away from the traditional Mediterranean diet much faster than any other Mediterranean country. It is essential that elderly maintain dietary and lifestyle practices that prevent and manage chronic conditions, thereby maximizing their chances for successful aging. Elderly should be encouraged to eat a healthy diet as varied as possible 40 . Interventions aimed at supporting the individual and promoting healthier environments will often lead to increased independence in older age. Improving multiple healthy behaviours such as eating habits, increasing levels of physical activity and avoid smoking as well as encouraging the extensive social interaction will certainly reduce chronic disease risks of death and disability and, consequently increase longevity and healthy ageing 4 12 . R esults of the present study suggest that the Mediterranean type of diet should be promoted to improve health and wellbeing in older age. The study weaknesses must be pointed out. First, even if the sample reflects the diversity of the national population based on education level, income and urbanization of living environment (urban/suburban/rural) and regions, the number of participants was small. Second its cross-sectional nature does not allow direct assessment of the determinants of MDP. Obtaining reliable data on food consumption is prone to various types of error associated to the instrument used to assess food intake. However the food-frequency questionnaire used has good reproducibility and validity (Lopes, 2000, Lopes et al, 2007), which may have minimized the expected underestimation of intake, frequent in food consumption studies. Conclusion The results of this study enables the identification of groups with lower adherence of MDP: lower income elderly, with health constrains, smokers, living in the North and which obtained their meals away from their own home. The present study illustrates the importance of a lifestyle approach, in which the Mediterranean Diet is included, to promote the elderly’s 99 health and wellbeing. As a consequence, food based dietary recommendations within the Mediterranean Diet should be established for the elderly. References: 1. González CA, Argilaga S, Agudo A et al. (2002) Sociodemographic differences in adherence to the Mediterranean dietary pattern in Spanish populations. Gac Sanit 16, 214-221. 2. 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(2011) Does the Mediterranean diet predict longevity in the elderly? A Swedish perspective. AGE 33, 439-450. 15. Ribeiro O (1998) Portugal, o Mediterrâneo e o Atlântico. 7th ed. Lisboa: Livraria Sá da Costa Editora. 16. Nestle M (1995 ) Mediterranean diets: historical and research overview. Am J Clin Nutr 61, 1313S- 1320S. 17. Willett WC, Sacks F, Trichopoulou A et al. (1995) Mediterranean diet pyramid: a cultural model for healthy eating. Am J Clin Nutr 61, 1402S-1406S. 18. Serra-Majem L, Ferro-Luzzi A, Bellizzi M et al. (1997) Nutrition policies in Mediterranean Europe. Nutr Rev 55, S42-S57. 19. Peres E (1996) Prodigiosa alimentação mediterrânica. Alim Hum 11, 5-7. 20. Assman G, Sacks F, Awad AB et al. (2000) International consensus statement: dietary fat, the Mediterranean diet, and lifelong good health. 100 21. Rodrigues SSP, Caraher M, Trichopoulou A et al. (2007) Portuguese households’ diet quality (adherence to Mediterranean food pattern and compliance with WHO population dietary goals): trends, regional disparities and socioeconomic determinants). Eur J Clin Nutr, 1-10. 22. Bogers RP, Tijhuis M, van Gelder BM et al. (2005) Final report of the HALE (Healthy Ageing: a longitudinal study in europe). 23. Ashima K K (2004) Dietary patterns and health outcomes. J Am Diet Assoc 104, 615-635. 24. Lopes C, Aro A, Azevedo A et al. (2007) Intake and adipose tissue composition of fatty acids and risk of myocardial infarction in a male Portuguese community sample. J Am Diet Assoc 107, 276-286. 25. Grunert KG, Dean M, Raats MM et al. (2007) A measure of satisfaction with food-related life. Appetite 49, 486-493. 26. Ware JE, Kosinski M, Dewey JE et al. (2001) How to score and interpret single-item health status measures: A manual for users of the SF-8TM health survey. 27. Sofi F (2009) The Mediterranean diet revisited: evidence of its effectiveness grows. Curr Opin Cardiol 24, 442-446 410.1097/HCO.1090b1013e32832f32056e. 28. Trichopoulou A, Kouris-Blazos A, Wahlqvist MK et al. (1995) Diet and overall survival in elderly people. BMJ 311, 1457-1460. 29. Bach A, Serra-Majem L, Carrasco JL et al. (2006) The use of indexes evaluating the adherence to the Mediterranean diet in epidemiological studies: a review. Public Health Nutr 9, 132-146. 30. Osler M & Schroll M (1997) Diet and mortality in a cohort of elderly people in a north European community. Int J Epidemiol 26, 155-159. 31. Lopes C, Oliveira A, Santos A-C et al. (2006) Consumo alimentar no Porto. Porto: Faculdade de Medicina da Universidade do Porto,. 32. Marques-Vidal P, Ravasco P, Dias CM et al. (2006) Trends of food intake in Portugal, 1987-1999: results from the National Health Surveys. Eur J Clin Nutr 60, 1414-1422. 33. Haveman-Nies A TK, de Groot LC, Wilson PW, van Staveren WA, (2001) Evaluation of dietary quality in relationship to nutritional and lifestyle factors in elderly people of the US Framingham Heart Study and the European SENECA study. Eur J Clin Nutr 55, 870-880. 34. Rodrigues SSP, Caraher M, Trichopoulou A et al. (2007) Portuguese households/' diet quality (adherence to Mediterranean food pattern and compliance with WHO population dietary goals): trends, regional disparities and socioeconomic determinants. Eur J Clin Nutr 62, 1263-1272. 35. Moreira P & Padrão P (2006) Educational, economic and dietary determinants of obesity in Portuguese adults: A cross-sectional study. Eat Behav 7, 220-228. 36. Marmot MG & Wilkinson RG (2006) Social determinants of health. 2sd ed. New York: Oxford University Press. 37. Knoops KTB, Groot de LC, Fidanza F et al. (2006) Comparison of three different dietary scores in relation to 10-year mortality in elderly European subjects: the HALE project. Eur J Clin Nutr 60, 746- 755. 38. Trichopoulos D & Lagiou P (2004) Mediterranean diet and overall mortality differences in the European Union. Public Health Nutr 7, 949-951. 39. Chen Q & Marques-Vidal P (2007) Trends in food availability in Portugal in 1966–2003. Eur J Nutr 46, 418-427. 40. Niedert KC & American Dietetic Association (2005) Position paper of the American Dietetic Association: nutrition across the spectrum of aging. J Am Diet Assoc 105, 616-633. 101 4 ǀ R esultados 4.3 ǀ The use of meal providers by European elderly 102 103 The use of meal providers by European elderly Cláudia Afonso 1 , Cecília Morais 1 , Carla Lopes 2 , Monique Raats 3 , Margaret Lumbers M 3 , Klaus Grunert 4 , Maria Daniel Vaz de Almeida MDV 1 , Food in Later Life team iiiii 1 Universidade do Porto, Faculdade de Ciências da Nutrição e Alimentação - Rua Dr. Roberto Frias 4200 – 465 Porto - Portugal ([email protected]) 2 Universidade do Porto, Faculdade de Medicina, Departamento de Epidemiologia Clínica, Medicina Preditiva e Saúde Pública – Portugal, Universidade do Porto, Instituto de Saúde Pública 3 University of Surrey, UNIS, School of Management – UK 4 The Mapp Centre; The Aarhus School of Business – Denmark [SUBMITED FOR PUBLICATION] Abstract The aim of the present study was to evaluate the use of meal providers and the main sociodemographic determinants associated to this use in free-living European elderly. Within the European Project “Food in Later Life 3290 European citizens aged 65+ years from 8 EU countries (Denmark, Germany, Italy Poland, Portugal, Spain, Sweden and the UK) were interviewed with a structured face-to-face questionnaire. To estimate the magnitude of the association between the use of meal provider and socio demographic factors, adjusted odds ratio (OR) and 95% confidence intervals (95%CI) were computed using logistic regression. These European elderly obtained their provide meals from a variety of sources with an average of 0.81 times a week in Portuguese elderly to 1.71 times a week, from 3 times a week in Italian elderly. Nearly half of the Portuguese elderly never used any kind of meal provider (46.8%) in contrast to most Danish and Italians who rely on outside providers to obtain their meals. With the exception of Sweden the main meal providers used by the European elderly, were the family (70.9%), followed by restaurants (47.4%), cafés (28.8%), bar (28.6%) and take away (26.5%). Men were more likely than women to obtain meals from all kinds of meal providers with exception of the family (71.4%) and cafés (31.5%) that were mainly selected by women. The oldest groups obtain their meals generally from family (71.1%) and luncheon clubs (13.4%). The remaining types of meal providers were selected by the younger group. As expected, as education and income increased, more elderly obtained their meals from providers. Conclusion: European elderly relied more on the informal network (family) than in the formal sector (be it restaurants and alike, or day care centers and meals on wheels) to obtain their meals. The present study showed that women and the older ones were those who referred less frequently use meal providers. Living circumstances did not seem to be a strong determinant of meal procurement. The relationship between education attainment and income were straightforward concerning the use of almost all kinds of meal providers. Keywords: Elderly, meal providers, sociodemographic determinants, Europe. Introduction Food habits are determined by a variety of factors, which include internal and external ones like psychological, biological, cultural, economic, political, environmental, religious and social. These influences contribute to the development, maintenance or modification of dietary patterns across the life cycle 1,2 . 104 The external factors influencing food choice differ across the life span and these changes affect food habits in different ways. Internal, personal factors are also influenced by age. In the past decades, research has identified negative changes such as loss of cognition, disease and disruption of the social network to have a large influence in dietary patterns. It is also considered that the magnitude of age-related decline in very old people is a risk for adaptation problems, since most of the domains of living are affected 3 . It is important to identify adaptation strategies that people use to fulfill alone some of their basic necessities, they are no longer able to manage due to modifications of their life situation (loss of partner, loneliness, among others), health status or other kind of situations that interfere with their autonomy. The increasing number of old people in the population has led to the development of longterm services to meet the needs of older people, with minor or major disabilities. These services can act as a support to informal caregivers, or as a unique source of support for some elders, and contributes to their maintenance, as independent living person 4 . When many of the usual domestic tasks become a burden for the older people and informal networks cannot provide the required support, one of the most common alternatives is the search of formal network services, such as meal/food service providers. Many of the food providers are directed towards a frail older population, while others target the older population, in general. Search and use of food services by the elderly might be affected by many living conditions, including to the expectations people have in their living context 5 . Scientific evidence supports that good nutrition is one of the major determinants of successful ageing not only by a physiological perspective but also by the contribute to social, cultural and psychological quality of life 6 , benefitting both the individual and the society: health is improved, dependence is decreased and the utilization of health care resources is contained 7 . The US Administration on ageing focuses on the need to improve the access to safe and adequate food in communities emphasizing the importance of food assistance programs to help to reduce the cost of use of nursing homes by the elder. As computed 1 month in a nursing home equals that of providing mid-day meals, 5 days a week, for about 7 years 8 . Investigation to identify where the elderly get their meals and to understand the relative importance of this provision to their nutritional wellbeing is of the highest importance since efficient policies are needed to enable older populations to maintain their independence in the society. 111 In this study, the profile of European elderly who use meal providers across countries showed a very heterogeneous picture. Free-living elderly from countries like Denmark, Italy and Germany tended to obtain more frequently their meals out of the home, but, on the contrary, in Portugal far less elderly mentioned to obtain meals from meal providers. This fact can be related to sociodemographic characteristics of Portuguese elderly, namely low education level and low income 11 . Across 7 of the 8 countries (Sweden being the exception) the informal network (family) is identified as more important than the formal sector (be it restaurants and alike, or day care centers and meals on wheels) to provide meals to the elderly. Traditionally, family is recognized as vital informal caregivers and health resource. The caregiving role involves providing personal care to older adults for the activities of daily living such as bathing and tasks related to food acquisition, preparation and consumption 8,5, 12, 13 . Nevertheless the role of non-kin carers, as informal caregivers can also be significant in supporting older people 14 . This was shown by Turrini 15 in relation to food shopping in this same European sample. In Canada, as in the United States, day care centers have assumed an important role in the continuum of long-term care services. In addition to allowing older persons to remain in their homes, adult day care programs provide support and relief to informal caregivers 4 . In the current study, only a small proportion of the elderly use day center to obtain their meals. A Swedish study found that social networks seemed to prevent low quality of life, which should be taken into account by professional helpers, especially in collaboration with relatives with regard to planning and providing care 16 . In our study Swedish elderly were also found to be less likely to require support from the family than other Europeans which may be due to the fact that in Northern European countries the formal networks are usually widely available and active. On the contrary, in Italy where multi-generational households occur, the family, relatives or friends are the main caregiver 15 in agreement with our findings. 112 Roy & Payette evaluating the effect of meals on wheels on dietary intakes of frail Canadian elderly showed the improvement of dietary intakes of recipients of this program 17 . Contrary to what we expected, this type of provider was the least used by European elderly (2.6% EU average), except in the case of Denmark (7.4%). Large socio-demographic differences amongst older Europeans can influence the procurement of other strategies of food supply outside home. The current study showed that women and the older elderly were less likely to ever use any type of meal providers The opposite was shown in an WHO report, in which a vast majority of cases, as ageing proceeds, women are more likely to be both caregivers and care recipients 18 . It is worth noticing that we did not find living circumstances to be strong determinants of meal procurement but the relationship between education attainment and income were straightforward concerning the use of almost all kinds of meal providers. Several studies have described differences in food choice by gender, as women have been found to have healthier food choices than men, due to more knowledge and beliefs about the importance of nutrition care to health 19 . Our findings may be explained by the fact that more traditional women may associate eating out or ask for meal from outside sources as less healthy choices. Also, in similar living conditions, women are usually more independent than men concerning for example their cooking skills. Engler-Stringer reviewed studies focusing on cooking practices and their contribution to health and suggested that the relationship between home cooking and dietary quality should be a matter for more investigation (Engler- Striger, 2010). In young adults, Larson 20 , found a higher quality of diet in those who cooked their meals. Another possible explanation to this difference according to gender is because women are more economically disadvantaged in the old age, have less access to transportation, and are more likely to spend part of their retirement living alone. In a study performed by Garry, 10% of men and 45% in women eat diner alone 21,22 . Social support and material circumstances still play an important role in independence in old age 23 . Studies carried out in different populations found higher income and education associated with large social networks 24,25 . On the other hand, lower income elderly were found to face physiological and social obstacles to obtain healthy diets 26 . 113 The literature indicates that social determinants as eating without company can profoundly influence the nutritional practices, mainly of men 27 and Ramic 28 et al revealed that loneliness is a significant predictor of the risk of malnutrition. The SOLINUT study, analyzed the interaction between loneliness and nutrition, highlighted the extreme importance of preventive intervention, which could avoid a decline of nutritional status 29 . The findings from the HALE project, showed that having few social contacts was associated with a higher mortality risk in women 30 . In Scotland, a free living older group stated that their main priority was to remain in their own homes and to maintain a good nutritional status. These elderly highlight the importance to give attention to food shopping and preparation as key dimensions of what they define as ‘independent living'. These elderly developed strategies to avoid loneliness, the most important of which was shopping on a daily basis just to see people, followed by being involved in “social eating” through going to local cafes/lunch clubs 31 . Eating with others may increase social interaction and food consumption, and women tend to eat more 13% when men are present and, the couple consume more 23% when dining with family or friends 32 . However our data did not show significant differences in living circumstances (living or not alone) or marital status on the use of meal providers. Nutritional status of the older people is more likely to be determined by education, income, marital status and socioeconomic status rather than chronological age 9,33 . In a position paper from ADA it is stated that the social aspects of eating are important pleasures of life that persist throughout life. In the UK, increasing age, not owing a car, being a widow(er) and worse self-reported overall health were associated with greater use of both statutory and private home care services. Other conditions, such as older age on leaving full-time education were also associated with the use of private services 5 . Our findings, suggest that it is important to improve interventions involving informal networks to provide adequate meals (families, relatives…) and formal providers (restaurants, take-away, bars…), that help older persons to have an independent and healthier life in the community for 114 a long period (ADA, 2010). In the line of the present study it is essential, first of all, to identify those who use the providers, which are the main meal providers, as well as to understand the main determinants to select them to promote a healthy service through food meals. Understanding the social determinants of eating behavior are so important, or sometimes more important, than to treat physical disability or disease 34,35,36. Eating in a social, comfortable, safe and familiar environment enhances not only food intake but also health-related quality of life 37,38 . The access in the community independently of the existence of food and nutrition assistance by formal sectors should be promoted 9 . Caregivers (formal or informal) should be aware of the nutrition needs of older people, should apply national guidelines/codes of practice and should be proactive, establishing reflective feed-back suggestions and compliance about foods and meals 9 . Community meal providers should encourage training for food service providers to produce more nutritionally adequate, tasty and safe menus tailored to the elderly, employing friendly staff to increase social interaction and sense of community belonging 35 . Conclusion In the present study, most European elderly living in the community relied mainly on the informal network (family) than in the formal sector (be it restaurants and alike, day care centers and meals on wheels) to obtain their meals. Contrary to what was expected living circumstances did not influence the use of meal providers but educational level and income were strongly related to the use of meal providers and to obtain meals out. An ageing population brings new challenges to policy-makers and planners to promote health related quality of life. Appropriate and coordinated care from meal providers should be available, understanding through investigation the socio demographic determinants of the major meal providers, to adequate nutrition programs interventions trough the life course 10 . References 1. Eertmans A, Baeyens F & Van den Bergh O (2001) Food likes and their relative importance in human eating behavior: review and preliminary suggestions for health promotion. Health Educ Res 16, 443-456. 2. Fieldhouse P (1995) Food and nutrition. Customs and culture. London. 115 3. Jopp D & Rott C (2006) Adaptation in very old age: Exploring the role of resources, beliefs, and attitudes for centenarians' happiness. . Psychol Aging 21, 266-280. 4. Baumgarten M, Lebel P, Leclerc C et al. (2002) Adult day care for the frail elderly: outcomes, satisfaction and cost. J Aging Health 14, 237-259. 5. Stoddart H, Whitley E, Harvey I et al. (2002) What determines the use of home care services by elderly people? 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Nutrition 20, 821- 838. 117 4 ǀ R esultados 4.4 ǀ Prevalence and sociodemographic determinants of obesity in European elderly 118 119 PREVALENCE AND SOCIODEMOGRAPHIC DETERMINANTS OF OBESITY IN EUROPEAN ELDERLY AFONSO C 1 , LOPES C 2 , DE MORAIS C 1 , RAATS M 3 , LUMBERS M 3 , GRUNERT K 4 , DE ALMEIDA MDV 1 AND THE FOOD IN LATER LIFE TEAM 5 1 Universidade do Porto, Faculdade de Ciências da Nutrição e Alimentação - Rua Dr. Roberto Frias 4200 – 465 Porto - Portugal (claud[email protected]) 2 Universidade do Porto, Faculdade de Medicina, Departamento de Epidemiologia Clínica, Medicina Preditiva e Saúde Pública – Portugal, Universidade do Porto, Instituto de Saúde Pública 3 University of Surrey, UNIS, School of Management – UK 4 The Mapp Centre; The Aarhus School of Business – Denmark [SUBMITED FOR PUBLICATION] Abstract Objective: To evaluate the prevalence of obesity and its sociodemographic determinants in European seniors. Design and participants: This study includes 3291 free-living European citizens aged 65 years and plus, from 8 EU countries (Denmark, Germany, Italy Poland, Portugal, Spain, Sweden and the UK). Data was collected in 2005, by a structured questionnaire in a face-to-face interview. Body mass index (BMI) was calculated by a self-reported weight and height and classified according to World Health Organization’s criteria. Adjusted odds ratio (OR) and confidence intervals (95%CI) were computed using logistic regression models. Results: The prevalence of overweight and obesity was 49.8% and 13.3%, in men and 39.5% and 17.8% in women, respectively. Independently of gender, BMI decreased with age, nevertheless this tendency is not similar across countries. The higher obesity prevalence was observed for English (20.5%) and Polish (15.8%) men and Polish (26.7%) and German women (25.3%). Obesity was higher among younger (OR=0.60 and 95%CI: 0.44-0.81) and in less educated men (OR=0.35 and 95%CI: 0.19-0.62). In women, obesity was lower in the older group (OR=0.53 and 95%CI: 0.40-0.69) and in those with higher monthly income (OR=0.50 and 95%CI: 0.25-0.99). Conclusions: This study supports that obesity in elderly people is a public health concern in Europe. The younger elderly and those with low socioeconomic status should be considered as target groups for weight management programs. Keywords: Elderly, Obesity, Sociodemographic determinants, Europe. Introduction Worldwide the proportion of older people defined as 60 years and over, has risen from 8% in 1950 to 11% in 2007 and is expected to reach 22% in 2050 1; 2 . In European Union during the last 10 years, life expectancy at birth increased by nearly 3 years and the percentage of those aged 65 years and older represented about 17% of the population in 2003 3 . 120 In an analogous way, prevalence of overweigh and obesity is increasing in all age groups, including in older people 4; 5; 6; 7; 8; 9; 10 . The recognition of this health problem in the elderly is quite recent and contrasts to the commonly accepted idea that ageing leads to weight loss and malnutrition 11 . The longitudinal and multicentric SENECA study showed higher obesity prevalence in the elderly in European countries, independently of gender 12 . The epidemic of obesity is a major public health problem and a continuum challenge to health professionals. In elderly, obesity can exacerbate the age-related decline in physical function and lead to frailty, doubtless a risk factor for mortality 8; 10; 13; 14 . Controversy remains about the health consequences of overweight in old age, according some investigators this condition does not represent a serious problem in this age group 11; 15; 16; 17; 18 . The ideal BMI has been reported to shift upwards with age, if for adults the BMI with lowest absolute risk of mortality is between 18.5 kg/m 2 and 25 kg/m 2 , for elderly has been reported to be among 24 and 29 kg/m 2 19 . Data from the National Health and Nutrition Examination Survey studies indicated that a BMI of 25–29.9 kg/m 2 was not associated with increased risks of mortality in cohorts in the United States 20 . However, BMI higher than 30 kg/m 2 is certainly, a risk factor for disability, morbidity and mortality 18 . With the increasing prevalence of obesity worldwide and the need for targeted action, numerous studies highlight the relevance between socioeconomic status even in the elderly 18; 21 Socioeconomic differences in the prevalence of overweight and obesity can be a factor through which inequalities in health emerge. In affluent societies, obesity levels tend to be higher in the lower socio-economic classes, especially among 4 . WHO MONICA Project concludes that lower education level were associated to higher BMI in half of the men and almost all women adult population 22 . Obesity is an extremely costly health problem and the solution requires a profound understanding of major determinants that are driving to this condition namely in elderly people 4 . It is important to recognise that elderly people are a very heterogeneous group, not only according to physiological characteristics but also with respect to sociodemographic conditions, and living situations 23 . The aim of this study was to evaluate the prevalence of obesity in free living European Seniors and the sociodemographic variables associated to it. 127 Discussion The obesity epidemic has received considerable attention around the world. Many studies indicate that BMI increases amongst middle-aged elderly people, who are at the greatest risk of health complications 25 . Our findings draw attention to the differences in obesity prevalence across the European countries, with 15.6% (13.3% in men and 17.8% in women) of the elderly being obese, this prevalence ranged from 7.5% (Italy) to 20.5% (UK) in men and 9.6% (Sweden) to 26.7% (Poland) in women. The prevalence of underweight was only present among 0.4% of elderly men and 2.3% of elderly female. Contrary to what has been observed in children a north-south gradient was not found for elderly 26 . Data from SENECA finale, showed ranged from 8% (Italy), similar to our results, to 32% (France) in men; and 10% (Denmark) (a higher prevalence was found in our data) to 46% (Belgium) in women 12 . According to the SHARE study, collected self-report data from individuals aged 50 plus the occurrence of obesity ranged from 13.1% (Switzerland) to 20.2% (Spain) in men, higher than our results, and 12.7%, lower than present data, to 26.9% in women, respectively in the same countries 10 . Results from the Gothenburg cohort in Sweden, presented prevalence of obesity in 11% of men and 16% of women 27 , higher than the present results in both genders, nevertheless in the self-report measures from European Nutrition and Health Report it was found similar results 26 . According to the WHO in 2005, the prevalence of obesity in the UK were among the highest in Europe, and in 2004 in England, 46.8% of elderly and 49.3% of elderly women were obese 28 , data from the last European Nutrition and Health Report showed the same tendency 26 . The present study presented a lower prevalence probably because of our self-reported data, nevertheless the prevalence in this country were above the European average. In an Irish elderly sample, almost one-fifth had a BMI over 30 kg/m 2 (17% of men and 20% of woman) 29 . In a Portuguese study the prevalence of obesity in the oldest groups varied from 17.2% in 60- 69 years old group to 14.1 in the oldest (more than 70) in men, similar results were performed by the present study; and 31.1% in 60-69 years old group to 31.7% in those women with more than 70 years old 30 , a higher proportion than our results from the Portuguese sample. 128 In a free-living elderly Spanish study showed a prevalence of obesity in men of 31.5% and 40.8% for women 31 , these data contrast with our findings regarding this country where the proportions were much more lower. The Italian Longitudinal Study on Ageing found a prevalence of obesity of 15% for men and 28% for women 11; 32 also greater than Italian data from our study. Data from the European Nutrition and Health Report 26 showed similar data from this country to present, due the equal methods of data collection (Table 5). Table 5 Comparison between prevalence of obesity (BMI≥ 30.0kg/m 2 ) in elderly by gender: present study vs. data from other previous European studies. Men Women Men Women Men Women Men Women Men Women Denmark 24 (11.8) 27 (12.7) 14.4 13.8 12 12 16 10 - - Germany 27 (13.2) 57 (25.3) 17.1 17.5 23 29 - - - - Italy 15 (7.5) 25 (12.2) 16.2 18.1 13 13 8 14 15 28 Poland 32 (15.8) 58 (26.7) - - 29 8 - - - - 17.2 (60-69 y) 31.1 (60-69 y) 14.1 (≥70 y) 31.7 (≥70 y) Spain 28 (13.5) 34 (16.5) 20.2 26.9 - - 17 26 31.5 40.8 Sweden 18 (9.0) 19 (9.6) 13.4 15.8 9 11 - - 11 16 31 (65-74 y) 35 (65-74 y) 18 (≥74 y) 27 (≥74 y) Total 211 (13.3) 284 (17.8) 16.5 18.5 - - 20 20 - - 46.8 49.3 21 22 20 UK 40 (20.5) 37 (20.2) - - - - Portugal 27 (15.7) 27 (19.7) - - 18 SENECA finale (de Groot CPGM et al 2002) Other studies (British Nutrition Foundation 2009, Dey DK et al 2001 , Inelman E et al 2003, Perissinotto E et al 2002, Santos AC and Barros H 2003) Self-reported Measured Present SHARE (Peytremann- Bridevaux I and Santos- Eggimann B 2008) European Nutrition and Health Report (Elmadfa I et al 2009) In a recent publication obtained from a national representative sample of US population, the prevalence of obesity was 37.1% in men, aged plus 60 years and 33.6% in women with the same age, 33 , this reported proportion is higher than the mean average of European studies above. 129 The preliminary findings from SABE confirms that Latin American and Caribbean display differences across obesity prevalence varied from the higher prevalence found in Uruguay and Chile to the lower, found in Brazil and Cuba. In this study, 20.3% of elderly men and 41.6% in elderly women in Uruguay were obese, as well as in 26.4% in men and 33.6% in women from Chile. In Brazil and Cuba the obesity prevalence was found in 9.8% and 13.8% of elderly men, and in 25.8% and 28.2% of the older female, respectively 34 . Regarding gender, epidemiological data suggested that the obesity was in general higher in women than in men 11; 27; 29; 30; 31; 32; 35; 36 , as well as observed in the present study, exception to the study performed in the United States, and from some particular countries in the European studies 10; 12; 26; 33; 37 . In both genders the odds favouring obesity significantly decreased with age as well as in other studies across the world 9; 13; 26; 29; 32; 38; 39; 40 In our sample we found differences in obesity prevalence related to education level in men and with income in women. In men, obesity is significantly related with education and in elderly women with monthly income. Older less educated men tend to be more obese and older women with a higher income tend to be less obese. In general the most consistent association previously described in the literature is that the educational level and income is inversely related to physical disability and health status, accompany worse health outcomes in older age 21; 41 . In relation to obesity, many studies have investigated the relationship between socioeconomic status and obesity and in general an inverse association has been observed 18; 22; 30; 36; 42; 43; 44 . This fact could be attributed to food insecurity (limited or uncertain availability to eat nutritional-dense and safety food in a social accepted form), limited medical care access, decreased the opportunities to engage in healthy behaviours like physical activity, and a limited access to community resources 5; 45 . The report compiled by the Working Group of the International Obesity Task Force (IOTF), shows that as the socioeconomic conditions of a country improve, the average weight of the population rises and the number of people who are obese increases. As a transition proceeds, overweight and obesity also begin to increase among the poor, especially among women. In affluent societies, obesity levels tend to be highest in the lower socioeconomic classes, as in the transition countries, mainly among women but in the ethnic minorities population still persist in the affluent women 4 . 130 Prevalence of obesity in SHARE study was strongly related with lower socioeconomic status across countries and gender regarding education level and income, as well as in our findings 9 . Results from the European project ZENITH, also confirm this fact, the results were similar regarding the fact that obesity was more associated with low educational level and low sociodemographic profile 46 . In a Spanish study differences by educational level were seen only in women. The increase of obesity in this population was justified by the authors through socioeconomic conditions in Spain during the years these cohorts were born 31 . Among Portuguese, higher prevalence of obesity in elderly and less educated men has been reported 30 . In the US population, the prevalence of obesity showed significant variation by racial and ethnic groups 33 and in Brazilian elderly the prevalence of obesity was significantly related to income, but in the opposite way, obesity was prevalent in those elderly with higher income 47 and in Bambuí, study education level was significantly related to a low prevalence of obesity 38 . In the present study living alone or with others, marital status and weekly food expenditure per person were not significantly associated to obesity, however some investigators highlight the relevance of marital status to nutritional status among the elderly 48; 49 . Our research is based on a large representative sample of free-living European elderly, but some limitations of this study should be pointed out. The mainly was obviously the fact of BMI was calculated by self-assessed weight and height, which eventually explains the differences in obesity prevalence from other studies that used objective measures. Assuming that self-reported weight and height may be unreliable indicators of body mass, due to the general trend to overestimate height and to underestimate weight, consequently leading to an underestimation of BMI, this occurrence is usual in the elderly. Ramos et al, confirm this fact identifying that the proportion of unawareness was higher not only in women but also in the older 50 . In elderly people, physiological changes due to ageing affect body shape, size and composition, consequently it is common that this fact interfere with self-perception of measures of weight and height 11; 13; 19; 28; 32; 51 In 2007, a reviewed performed by Lin on this subject found a poor validity of self-report measures 52 and some authors agree in considering a poor indicator of risk in elderly 11; 32 . Nevertheless, BMI represents an easier and most frequently used index to identify subjects at 131 risk of under or over nutrition, and it was described as an important indicator of mortality for adults of all ages 39 . In spite of these limitations our findings were in line with other investigations 11; 13; 28; 32 that reveal that obesity is a public health problem around this age group and the true percentage of obesity may therefore be higher than our estimates. The strengths of the present study were that limited studies are available on how obesity patterns differ across countries, using the same methodology, and considered the sociodemographic factors as a determinant of obesity in the free-living elderly. Conclusion In spite of the fact that BMI was calculated by self-reported weight and height we found a high prevalence of obesity across free-living European elderly, and if malnutrition predisposes delays recovery from illness and adversely affects body function, while being obese increases the risk of many chronic diseases and interfere with quality of life in the elderly. Being obese was more prevalent in English (20%) and Polish (15.8%) elderly men, and Polish (26.7%) and German (25.3%) elderly women. 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Nutr Today 42, 263-266. 135 5 ǀ C onclusão 136 143 muitas possam ser as respostas de várias índoles, sem a conotação de instituição de suporte “a incapazes”. O que espera o idoso autónomo? Manter-se com saúde, de forma a manter a sua independência. O que come o idoso Português? Menos bem que o esperado num país com influências Mediterrânicas, em que a ocidentalização dos hábitos alimentares parece estar a chegar às gerações mais velhas. Onde come o idoso? Inserido na comunidade, opta por realizar na maior parte das vezes as suas refeições em casa, escolhendo a família e os restaurantes, nas situações em que não o faz. Como está o idoso? A engordar tal como as demais faixas etárias em Portugal. A nível comunitário deverão ser estabelecidos programas/formas de auxílio alimentar/nutricional, concebidos tendo por base a identificação das necessidades nutricionais reais dos diferentes grupos de idosos e adequados sob o ponto de vista gastronómico e cultural 61;5 . Mais do que atenuar as incapacidades causadas pelo envelhecimento, os programas comunitários deverão procurar monitorizar o estado de saúde e nutricional dos idosos de modo a evitar que este se degrade, propiciando assim a sua manutenção e autonomia na comunidade e fomentando a sua qualidade de vida 5 . Em condições de identificação de enfraquecimento, criando estruturas comunitárias de suporte para vários graus de exigência desde a realização de tarefas simples até níveis mais elevados de dependência. Os profissionais de saúde deverão ser proactivos adotando uma postura holística face ao envelhecimento, demonstrando abertura e compreensão não só para questões alimentares/nutricionais, mas também tendo em consideração o suporte emocional, tentando preservar ao máximo a integração deste grupo tão válido na sociedade e consequentemente a sua independência 5; 56 . 144 O parlamento Europeu, estabeleceu que 2012 será o Ano Europeu dedicado ao Envelhecimento Ativo, com o objetivo geral de incentivar e apoiar esforços dos Estados- Membros, das autoridades, dos parceiros sociais e da sociedade civil no sentido de promover o envelhecimento ativo usufruindo do potencial desta população, reforçando e preservando desta forma a solidariedade entre gerações 94 . Torna-se assim urgente contribuir para a construção de um papel social do cidadão sénior, como alguém útil e imprescindível entre todos nós. Porque o envelhecimento não é uma escolha é um privilégio, e envelhecer bem é uma necessidade. 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Choosing foods, eating meals: sustaining independence and quality of life (2004–2005) coordinated by Dr. Margaret Lumbers and Dr. Monique Raats from the University of Surrey (United Kingdom) and financed by the European Commission (QLK1CT200202447). 5 Food in Later Life Team: Denmark: Klaus Grunert, Niels Asger Nielsen Germany: Ulrich Oltersdorf, Birgit Schuhmacher,Cornelie Pfau Italy: Anna Saba; Aida Turrini, Laura D’Addezio, Fabrizia Maccati Poland: Katarzyna Kozłowska, Wojciech Roszkowski, Anna Szczecińska, Marzena Danowska-Oziewicz, Lidia Wądolowska, Bozenna Kozikowska, Roman Cichon, Ewa Szymelfejnik, Anna Waluś, Magdalena Kozikowska, Dariusz Słowiński Portugal: Cecilia de Morais, Cláudia Afonso, Maria Daniel Vaz de Almeida Spain: Jesús Contreras, Silvia Bofill, Yolanda Lacasta Sweden: Per-Olow Sjödén, Christina Fjellström, Margaretha Nydahl, Jenny Ekblad United Kingdom: Sara Arber, Kate Davidson, Monique Raats, Margaret Lumbers, Wendy Hunter, Anita Eves, Richard Shepherd