1,2,4,11 , , Helena CANHÃO Helena , 1,4,7 1,2,4,10 , Sara S DIAS 1,4 , Jaime C BRANCO C Jaime , 9 80 , Rute Dinis SOUSA 1,4,5,6 , Pedro Simões COELHO Simões Pedro , 9 ▪ https://doi.org/10.20344/amp.9817 , Maria João GREGÓRIO R e v i s ta C i e n tífi c a d a Or d e m d o s M é d i c o s w w w.a c ta m e d i c a p o r tu g u e s a .c o m 1,2,3,4 , Jorge M MENDES M Jorge , 2,3,8 Assistência à Saúde; Avaliação de Resultados (Cuidados de Saúde); Comorbilidade; Envelhecimento; Portugal; Portuguese adults have a long lifespan, but it is unclear whether they live a healthy life in their final years.We aimed The high prevalence of multimorbidity, combined with unhealthy lifestyle behaviours, suggests that the elderly population elderly the that suggests behaviours, lifestyle unhealthy with combined multimorbidity, of prevalence high The A esperança de vida A está a aumentar em Portugal, contudo desconhece-se o estado de saúde dos idosos. Pretende-se Introduction: Portuguese adults. and other health outcomes among older of multimorbidity and characterize lifestyle to determine the prevalence Material and Methods: We performed a cross-sectional evaluation of 2393 adults, aged 65 and older, during follow-up of the the EpiDoC cohort, a second population-based study involving wave long-term follow-up of of a representative sample of the Portuguese population. Subjects patterns. dietary completed identify to done was analysis a Cluster assessed. were consumption resources structured health and diseases, chronic questionnaire behaviours, during a telephone interview. Socioeconomic, to estimate multimorbidity prevalence and its associated factors. Descriptive and analytic analysis was performed demographic, lifestyle Results: Multimorbidity prevalence among older adults was 78.3%, increased with age strata (72.8% for 65 – 69 years to 83.4% for ≥ 80 years), and Alentejo Azores was The (83.6%). (84.9%) highest most and in common chronic diseases were hypertension (57.3%), rheumatic disease (51.9%), hypercholesterolemia (49.4%), and diabetes (22.7%). Depression symptoms were frequent and (11.8%) highest in the oldest strata. The mean health-related quality of life (EQ-5D-3L) score was 0.59 ± 0.38. Hospitalization in the previous 12 months was reported by 25.8% of individuals. Overall, 66.6% of older adults were physically inactive. ‘Fruit and vegetables dietary pattern’ was followed by 85.4% of individuals; however, regional inequalities were found (69% Azoreans (33%). 22.3% overall and was highest among in Azores). Obesity prevalence was Conclusion: intervention. constitutes a vulnerable group warranting dedicated Portugal; Quality of Life Assessment (Health Care); Aging; Comorbidity; Delivery of Health Care; Outcome Keywords: Introdução: caracterizar estilos de vida e outros fatores relacionados com a saúde dos idosos. determinar a prevalência de multimorbilidade, Material e Métodos: Efetuou-se uma avaliação transversal a 2393 adultos com 65 ou mais anos de idade, da coorte é EpiDoC constituída que por uma amostra representativa da população portuguesa. Os inquiridos responderam a um questionário estruturado através de uma entrevista telefónica, tendo-se recolhido dados socioeconómicos demográficos, estilo de vida, doençasconsumo crónicasde e recursos em saúde. Análise de clusters foi realizada para a identificação de multimorbilidade e fatores associados. descritiva e analítica para estimar a prevalência de padrões alimentares. Efetuou-se análise Resultados: A prevalência de multimorbilidade nos idosos foi de 78,3% (72,8% entre os 65 - 69 anos, 83,4% com 80 + anos) e foi superior nos Açores (84,9%) e no Alentejo (83,6%). As doenças doenças crónicas reumáticas (51,9%), hipercolesterolemia (49,4%) e diabetes mais (22,7%). Os sintomas de foram depressão frequentes, (11,8%) prevalentes foram reportaram idosos dos 25,8% e a 0,38 ± 0,59 de hipertensão média em foi (EQ-5D-3L) vida arterial de qualidade A (57,3%), etários. grupos dos longo ao aumentando ter sido hospitalizados nos 12 meses prévios à entrevista. Cerca de 66,6% dos idosos são fisicamente inativos. O padrão alimentar caracterizado por ‘+ fruta e + foi hortícolas’ reportado por 85,4% dos idosos, contudo foram encontradas iniquidades regionais (69% prevalência de obesidade foi de 22,3%, sendo superior nos açorianos (33%). A para os idosos açorianos). Conclusões: A elevada prevalência de multimorbilidade combinada com estilos de vida pouco saudáveis sugere que a população idosa constitui um grupo vulnerável que requer uma intervenção direcionada. Palavras-chave: Qualidade de Vida ABSTRACT Maria José SANTOS José Maria 1. EpiDoC Unit. Centro de Estudos de Doenças Crónicas. NOVA Medical School. Universidade Nova de Lisboa. Lisboa. Portugal. Medical School. Universidade 1. EpiDoC Unit. Centro de Estudos de Doenças Crónicas. NOVA 2. Sociedade Portuguesa de Reumatologia. Lisboa. Portugal. Lisboa. Portugal. 3. Rheumatology Research Unit. Instituto de Medicina Molecular. Évora. Portugal. Associação Científica. 4. EpiSaúde – Alimentação. Universidade do Porto. Porto. Portugal. 5. Faculdade de Ciências da Nutrição e Alimentação Saudável. Direção-Geral da Saúde. Lisboa. Portugal. 6. Programa Nacional para a Promoção da 7. Unidade de Investigação em Saúde. Escola Superior de Saúde. Instituto Politécnico de Leiria. Leiria. Portugal. Almada. Portugal. 8. Hospital Garcia de Orta. Information Management School. Universidade Nova de Lisboa. Lisboa. Portugal. 9. NOVA 10. Serviço de Reumatologia. Centro Hospitalar Lisboa Ocidental. Hospital Egas Moniz. Lisboa. Portugal. Escola Nacional de Saúde Pública. Universidade Nova de Lisboa. Lisboa. Portugal. 11. Autor correspondente: Helena Canhão. [email protected]  Médicos 2018 Aceite: 08 de janeiro de 2018 | Copyright © Ordem dos Recebido: 18 de outubro de 2017 - RESUMO Coorte EpiDoC Ana Maria RODRIGUES Acta Med Port 2018 Feb;31(2):80-93 Os Desafios do Envelhecimento em Portugal: Dados da em Portugal: Dados do Envelhecimento Os Desafios Cohort Challenges of Ageing in Portugal: Data from the EpiDoC from the EpiDoC Data in Portugal: Ageing of Challenges

ARTIGO ORIGINAL life. of years 10 to 5 last the in life of quality regarding nations between exist differences large yet Europe, across span life the extended have medicine and science in advances such as physical inactivity and unhealthy diets. behaviours, health-related with associated are and clusters eedny fntoa aiiy ad aoaoy results. laboratory and ability, functional third-party dependency, evaluated mainly and old years 55 over aged adults 2672 enrolled 2006, and 2005 in performed study da População Portuguesa The subjects. cohorts older of population-based Some designed to study scarce. health problems consist of a small number are Portugal care. better achieve to policies and strategies new of design the with help will status economic and social and consumption, healthcare situation, clinical An factors, risk approach. of understanding interdisciplinary an require multimorbidity 60 years old per 100 children < 15 years old) is increasing. > people of (number index ageing ageing. Accordingly,the INTRODUCTION will bemorethan65yearsold. Europeans of 20% than more that estimated is it 2025, By oil n fml networks. family and and status, social socioeconomic health, of regarding microdata database containing older panel or 50 aged adults 000 123 approximately cross-national multidisciplinary, (SHARE), Europe a in Retirement and Ageing, Health, of Portugal is one of the 28 participant countries in the Survey h ceitne f w o mr crnc iess t the at time. diseases same chronic more or two of coexistence the as defined been has which concept, multimorbidity the to to multimorbidity. due mainly are life of years 10 to 5 last the with associated as well as the Azores and Madeira islands. the adult of Portuguese population living in mainland Portugal, representative individuals non-institutionalized 661 10 representative ofthePortuguesepopulationarelacking. groups older of data multidimensional and comprehensive hrceiig hi scocnmc characteristics, socioeconomic healthcare and life, of and quality diseases, chronic older lifestyles, their and years 65 characterizing adults of prevalence among the determining multimorbidity by Portugal in ageing of (EpiDoC 2study). of analysis 2015 and 2013 between collected data of wave second the Data cross-sectional a performed. are study were this in collection presented data of waves Three years. six than more for followed been now have subjects disease. rheumatic and diabetes, stroke, cancer, disorders, mental or heart as such diseases, chronic from arising disability and events, drug adverse life, of quality compromised by 3 pdmooia pplto-ae hat dt in data health population-based Epidemiological with adults older in intervention and Assessment is population the countries, other in as Portugal, In In 2011, we established a longitudinal cohort enrolling cohort longitudinal a established we 2011, In The aim of this work was to identify the current challenges In several countries, these later years are accompanied 4 eea o tee hoi dsae ocr in occur diseases chronic these of Several 7-9 niiul scea, n eooi costs economic and societal, Individual, 5,10 Estudo do Perfil de Envelhecimento de Perfil do Estudo Rodrigues AM, etal.ChallengesofageinginPortugal, ica da Ordem dos Médicos www m o c . a s e u g u t r o p a c i d e m a t c a w. w w s o c i d é M s o d m e d r O a d a c fi í t n e i C a t s i v e R (EPEPP) study, a cross-sectional 13 2 ept tee initiatives, these Despite Better living conditions and conditions Betterliving 14 EpiDoC cohort 5,6 This leads 11,12 1

81 function, andmentalhealthinPortugal. physical life, of quality health-related on impact their and diseases musculoskeletal and rheumatic of prevalence the September assessed primarily study between This 2013. December and performed 2011 was which evaluation, respectively). inhabitants, 000 100 ≥ and 999; 99 – 000 20 999; 19 – 000 the population within each locality (< 2000; 2000 - 9999; 10 of size the and (Madeira)], Islands Madeira and (Azores) Islands Azores Algarve, Alentejo, Tejo, do Centro, Vale & (Norte, Lisboa II) [(NUTS Islands units territorial and administrative Mainland by stratified was Portuguese sample study The Azores). and (Madeira the in residences private in living old) years 18 (≥ adults non-institutionalized it atmt a frhr otc aadnd Interviews abandoned. contact further the was after attempt Only sixth attempt. last second the after month one least at was attempt contact last The attempts. six of total a to weekends), and evening, the afternoon, of (morning, days week and day the of times different attempts at made additional were successful, not initial the was When attempt telephone. contact the on individuals all called randomly who team assistant research trained a by 2015 26, March from performed was collection Data 1). (Fig. older) and years (65 adults older were 2393 report, wepresentdatafromEpiDoC2. this In assistants. research trained by conducted telephone interview a during used was questionnaire structured A others. deleting and questions new adding by 1 EpiDoC of centre. care health primary Detailed methodologywaspublishedelsewhere. nearest the two at or later one weeks appointment medical the a across by participants followed 661 country, 10 the of residences the at f .% s ecie elsewhere. described as 0.5% of were prevalence whose conditions related health capture to order adults in performed was calculation size sample EpiDoC 661 Madeira). and 10 Azores mainland, (the enrolled Portugal in residing cohort EpiDoC The research. noncommunicable regarding biomedical and socioeconomic in use for diseases data chronic provide to designed Population anddatacollection:EpiDoCcohort were includedinthecurrentdescriptive/analyticanalysis. older and years 65 were who participants 2 EpiDoC study). 2 EpiDoC the (i.e., Cohort EpiDoC the of follow-up of wave MATERIALMETHODS AND targeted toolderadults. policies public and programs intervention health optimal of goal was to identify key issues to facilitate the development ultimate the process, this Through consumption. resources EpiDoC 1, or EpiReumaPt, was the first cross-sectional first the was EpiReumaPt, or 1, EpiDoC pDC icue 79 aut atcpns o whom of participants, adult 7591 included 2 EpiDoC The EpiDoC 2 study (2013 to 2015) expanded the scope conducted were interviews face-to-face 1, EpiDoC In pDC td i a ainl ouainbsd cohort population-based national a is study EpiDoC second the of evaluation cross-sectional a is study This Acta MedPort2018Feb;31(2):80-93 14,15 h suy included study The 14,15

2013 to July 27, July to 2013 14

ARTIGO ORIGINAL

20 18,19

n = 9023 n = 5653 EpiDoC 3 EpiDoC 3 participants (2015 - 2016) (2015 - 2016) Saúde.Come Saúde.Come Elegible to follow-up Health-related quality of life was 17

(n = 2393) ≥ 65 years old Acta Med Port 2018 Feb;31(2):80-93 Port 2018 Acta Med n = 7591 EpiDoC 2 EpiDoC 2 Health characteristics and healthcare consumption n = 10 153 CoReumaPt CoReumaPt participants (2013 - 2015) (2013 - 2015) for which a higher score corresponds to a of higher life. quality Physical function was evaluated using the Assessment Health Questionnaire (HAQ; ranging from with a higher score representing worse 0 functional ability). to 3, assessed using the European Quality of Life questionnaire with five dimensions and three levels (EQ-5D-3L), activity, sleep activity, habits, frequency of watching television, and frequency of using a computer, video games, or Physical tablets. activity level intake Dietary activity. was physical of frequency weekly reported classified according to self- was assessed through food frequency questions regarding the following foods and beverages: soup, vegetables, fresh fruit, milk, and other dairy products. and costs: In the EpiDoC 1 asked whether they study, had been individuals previously diagnosed were with the following chronic hypertension, rheumatic disease, diseases: allergy, gastrointestinal hypercholesterolemia, thyroid diabetes, disease, cardiac disease, mental disease, or parathyroid disease, pulmonary disease, hyperuricemia, updated was information This disease. neurologic or cancer, defined was Multimorbidity interview. study 2 EpiDoC the in as the coexistence of two or more of these chronic self-reported diseases. Elegible to follow-up 82 Cross sectional analysis (n = 5198) 18 - 64 years old n = 509 ) was calculated and follow-up 2

Subjects from The EpiDoC 2 study to sign consent for 16 EpiReumaPt who refused EpiReumaPt who refused in kg/m 2 R e v i s ta C i e n tífi c a d a Or d e m d o s M é d i c o s w w w.a c ta m e d i c a p o r tu g u e s a .c o m Rodrigues AM, et al. Challenges of ageing in Portugal, in Portugal, of ageing et al. Challenges AM, Rodrigues Information regarding sociodemographic Clinical n = 3886 EpiDoC 1 EpiDoC 1 n = 10 661 participants participants EpiReumaPt (2011 - 2013) (2011 (2011 - 2013) (2011 Appointments Lifestyle characteristics: Self-reported height and Sociodemographic and socioeconomic Sociodemographic categorized according to the World Health (WHO) Organization classification system. weight were collected. Based on these data, body index mass (BMI; weight/height

characteristics: factors (sex, age, ethnicity, years status, of education, marital household Territorial Units for Statistics [NUTS] II region), as well as composition, socioeconomic variables (household income, employment Nomenclature status), was collected in the of EpiDoC 1 study. During EpiDoC the 2 interview, subjects were asked whether any of these characteristics had changed. EpiDoC cohort measurements were performed with the assistance of a computed assisted computed a of assistance the with performed were telephone system. interview Data (CATI) were recorded on by restricted was access database and form, standardized a research each for password and username unique a of use team member. – Flowchart describing the population eligible for this study Figure 1 – Flowchart describing the population eligible included several questions concerning lifestyle habits, such habits, lifestyle concerning questions several included as frequency of alcohol intake, number per week, of smoking habits, frequency alcohol and type units of physical

ARTIGO ORIGINAL Helsinki and revised in 2013 in Fortaleza. in 2013 in revised and Helsinki according to the principles established by the Declaration of principles stated in the Declaration of Helsinki. to, the Guidelines for Good Clinical Practice and the ethical limited not but including, regulations and laws applicable as EpiDoC Committee 1. The study was conducted Ethics in accordance with the same the by and data) personal of tnad eitos T ietf deay atrs we patterns, frequency questions,asdescribedelsewhere. dietary identify food to responses the on based analysis cluster performed To deviations. and standard Continuous values mean weighted variables. by described categorical were variables summarize to used for theEpiDoC1studysample. designed originally weights extrapolation the calibrating by in the subsequent statistical analyses. These were obtained used and computed were weights Extrapolation group. age weights according to stratification by NUT II region, sex, and the adjusted we comparison, this on Based characteristics. status health and socioeconomic, sociodemographic, their to respect with study 2 EpiDoC the of non-participants and population Portuguese participants the the compared first we islands), and to (mainland according sample the of Statistical analysis and homecaresupportwerealsoassessed. assessment therapies, appointments, medical the Hospitalizations, scales. of versions validated Portuguese used We depression. and anxiety of symptoms identify to used pDC b idvdas geig o e olwd and followed be to agreeing participate intheEpiDoC2study. individuals by 1 EpiDoC during signed was consent informed Written staff. EpiDoC All data were kept anonymously and securely by authorized Rheumatology). of Society Portuguese the of headquarters the at (based centre study coordinating the the to from transmitted data separately stored were subject each information for contact and name The participant). each for used was code identification unique a (only database the in identifiers of lack the by safeguarded was confidentiality ecie elsewhere. described were study (EpiReumaPt) 1 EpiDoC the of issues ethical Release 12.CollegeStation, TX: StataCorpLP). Software: Statistical 2011.Stata (StataCorp. 12 version IC (HADS) Scale Depression and Anxiety Hospital The a nme 6/8 Otbr 26 October 67/98, Portuguese number the law with accordance (in Protection Data for all in participate phases ofthestudy. to consent informed provided subjects The Committee. Ethics School Dados NOVAMedical the de by and Proteção de Nacional (Comissão Protection reviewed and approved by the National Committee for Data boue rqece ad egtd rprin were proportions weighted and frequencies Absolute Sample weights: eal of Ethical issuesandpersonalprotection:Details All analyses were weighted and performed using STATA EpiDoC 2 was also approved by the National Committee 14,15,23 o eiy h representativeness the verify To Rodrigues AM, etal.ChallengesofageinginPortugal, ica da Ordem dos Médicos www m o c . a s e u g u t r o p a c i d e m a t c a w. w w s o c i d é M s o d m e d r O a d a c fi í t n e i C a t s i v e R pDC ws performed was 1 EpiDoC th rgrig protection regarding , 24 The study was study The 24 22 Participants’ 21 was ) 83 Anthropometric data but 8.0%wereworkingasdomesticworkers(Table 1). (88.6%), retired were adults older Most group. age oldest the among (35.2%) highest was percentage person the one (24.4%); only with households in proportion lived adults significant older A of month. per euros 500 than less income household a reported older or years 80 individuals incomes were worse among the oldest seniors, as 48.1% of an had income less 32.1% than 500 particular,euros per month. in Similar to education, month; per euros 1000 less than income household a had (77.9%) adults older Most education. of years fewer or four greater,respectively,had or years 80 and years 79 of to 75 aged participants of 80.4% levels Lower education. of education were years found among the oldest seniors: 81.6% and fewer or four had (77.3%) 1850 and widowed, were (25.9%) 705 Caucasian, older adults, 1539 (55.8%) were female, 2372 (98.4%) were 2393 the Of groups. age different to islands). according participants of and characteristics sociodemographic (mainland summarizes 1 population Table Portuguese the of representative were They years). 65 (≥ adults older 2393 seniors ofPortuguese Sociodemographic characteristics RESULTS n Madeira and Azores in found was pattern’) dietary vegetables and (‘fruit pattern dietary However, healthy this 2). to (Table adherence lower strata age across stable remained percentage this adults; older all of 85.4% was vegetables, and fruits of consumption higher by characterized pattern’ Dietary habits Azores (84.6%)and Alentejo (80.1%). in found was inactivity physical of proportion highest The 2). (Table increased age as increased inactive physically were who individuals of proportion the Moreover, (84.5%). of subjects never used a computer, video games, or tablets proportion high Atelevision. watching day per hours three 66.6% of individuals were inactive and 50.9% spent at least Overall, smoked. never 70% almost and alcohol consume beverages not did alcohol 46.9% of total A smokers. of current were 5.2% and intake daily reported individuals Lifestyle characteristics most highest was common amongindividualsin Azores (33%)(Table 4). the Obesity individuals. had overweight regions of prevalence (72%) Madeira and (73.9%), Azores (74.6%), Centro The 2). (Table older or years 80 39.1% for overweight and 15.6% for obesity among seniors seniors: oldest the among less was obesity or overweight of prevalence The obesity). for 22.3% and overweight for The prevalence of overweight or obesity was 68.8% (46.5% The mean BMI of all older adults was 27.3 ± 5.2 kg/m 5.2 ± 27.3 was adults older all of BMI mean The analysed we 2, EpiDoC in participants total 7591 the Of The percentage of individuals adopting a ‘healthy dietary of 33.8% diet, than other habits lifestyle Regarding Acta MedPort2018Feb;31(2):80-93

7.% (i. ) Ide, zrs Madeira, Azores, Indeed, 2). (Fig. (73.9%) (69.0%) 2 .

ARTIGO ORIGINAL n = 509 2 (0.0%) 6 (2.0%) 3 (0.4%) 1 (0.2%) 4.1 ± 4.1 34 (5.5%) 21 (2.9%) 36 (7.9%) 25 (5.2%) 38 (1.6%) 49 (2.0%) 23 (2.5%) 10 (0.2%) 30 (8.3%) 18 (3.4%) 10 (1.8%) 28 (5.2%) 41 (11.2%) ≥ 80 years 87 (23.6%) 39 (12.2%) 55 (10.0%) 74 (16.5%) 116 (20.8%) 116 335 (61.4%) 506 (98.0%) 403 (80.4%) 108 (28.4%) 137 (34.0%) 228 (45.6%) 246 (49.9%) 187 (48.1%) 179 (35.2%) 247 (49.6%) 403 (83.5%) n = 527 1 (0.0%) 9 (1.8%) 6 (1.4%) 6 (3.2%) 3 (0.6%) 1 (0.3%) 4.1 ± 4.2 11 (3.7%) 11 25 (6.1%) 21 (3.7%) 48 (8.6%) 37 (9.7%) 27 (4.0%) 38 (1.6%) 41 (1.5%) 20 (4.0%) 54 (9.2%) 28 (6.4%) 54 (9.4%) 42 (11.8%) 37 (10.1%) 119 (32.0%) 119 336 (57.9%) 523 (99.9%) 422 (81.6%) 161 (35.5%) 104 (15.6%) 321 (64.8%) 174 (27.3%) 175 (44.3%) 103 (26.6%) 153 (27.1%) 292 (57.3%) 441 (90.4%) 75 - 79 years n = 645 0 (0.0%) 8 (1.8%) 6 (1.2%) 5 (1.2%) 4.9 ± 3.6 11 (2.3%) 11 30 (6.6%) 31 (5.2%) 27 (4.1%) 47 (1.6%) 74 (2.2%) 30 (2.9%) 24 (7.5%) 42 (7.9%) 30 (5.7%) 36 (4.4%) 63 (7.1%) 73 (10.8%) 40 (10.7%) 72 (30.2%) 78 (12.1%) 415 (50.4%) 637 (95.4%) 505 (77.4%) 174 (30.0%) 157 (25.0%) 126 (26.3%) 422 (68.2%) 168 (21.4%) 162 (24.1%) 146 (25.5%) 155 (24.1%) 376 (59.4%) 550 (92.9%) 70 - 74 years Acta Med Port 2018 Feb;31(2):80-93 Port 2018 Acta Med n = 712 3 (0.4%) 7 (1.5%) 6 (1.1%) 5.5 ± 3.9 84 54 (7.3%) 52 (7.5%) 26 (4.6%) 78 (2.4%) 73 (1.9%) 46 (5.3%) 34 (6.1%) 22 (5.2%) 14 (2.9%) 45 (5.2%) 56 (11.1%) 36 (3.26%) 82 (18.3%) 75 (14.3%) 117 (13.0%) 117 112 (15.5%) 112 106 (11.5%) 453 (55.5%) 706 (99.3%) 101 (12.9%) 501 (72.3%) 210 (35.7%) 134 (21.2%) 135 (23.1%) 509 (78.0%) 139 (21.2%) 155 (29.4%) 143 (15.6%) 412 (63.8%) 578 (87.6%) 65 - 69 years 6 (0.2%) 4.8 ± 4.0 n = 2393 91 (4.6%) 49 (2.9%) 34 (2.5%) 19 (1.0%) 13 (0.8%) ≥ 65 years 143 (6.5%) 125 (5.1%) 105 (4.5%) 201 (1.9%) 237 (1.9%) 100 (3.1%) 100 (4.9%) 137 (5.2%) 263 (11.1%) 653 (32.6%) 547 (27.1%) 481 (22.0%) 169 (10.1%) 705 (25.9%) 663 (32.1%) 491 (26.5%) 235 (19.3%) 184 (10.4%) 630 (24.4%) 299 (12.1%) 297 (10.8%) 1539 (55.8%) 2372 (98.4%) 1831 (77.3%) 1480 (65.8%) 1327 (58.3%) 1972 (88.8%) R e v i s ta C i e n tífi c a d a Or d e m d o s M é d i c o s w w w.a c ta m e d i c a p o r tu g u e s a .c o m Rodrigues AM, et al. Challenges of ageing in Portugal, in Portugal, of ageing et al. Challenges AM, Rodrigues Caucasian > 12 years 10 - 12 years 5 - 9 years 0 - 4 years Norte Centro Lisboa Alentejo Algarve Azores Madeira Single Married Divorced Widowed Consensual union < 500€ 501€ to 750€ 751€ to 1000€ 1001€ to 1500€ 1501€ to 2000€ 2001€ to 2500€ 2501€ to 3000€ 3001€ to 4000€ > 4000€ 1 person 2 people 3 people ≥ 4 people Sex Female Ethnicity/race Education level Years of education (mean ± SD) of education Years NUTS II region Marital status Household income Household composition Employment status Employed full-time/part-time/domestic Retired/temporary work Sample sizes varied because of missing data: Sex (n = 2393), Ethnicity/race (n = of 2389), education NUTS (n II = (n 2384), = Education Years 2393,) level (n = 2362), Marital status (n = 2391), Household income (n = 1779), Household composition (n = 2393), and Employment status (n = 2276). All percentages and means were weighted to correct for population representativeness. Units for Statistics; SD: standard deviation Territorial NUTS II: Nomenclature of – Sociodemographic characteristics of the older adult Portuguese population Portuguese the older adult of characteristics 1 – Sociodemographic Table

ARTIGO ORIGINAL al itk o vgtbe; n aer, 88 reported 28.8% Madeira, in vegetables; of intake reported 43.3% daily and soup of intake daily reported adults older of 56.4% Azores, In vegetables. and soup of intake Algarve and Table 2–LifestylecharacteristicsandanthropometricdataoftheolderadultPortuguesepopulation(section13) Search timeregardinginformationabouthealth Frequency ofusingcomputer/videogames/tablets Number ofmeals Sleep habits Physical activity Smoking habits Alcohol intake Body massindex Anthropometric data Frequency ofwatchingtelevision Screen time ≥ 5hours/day 3 -4hours/day ≤ 2hours/day < 5hours/week 0 hours/week ≥ 5hours/day 3 -4hours/day ≤ 2hours/day Does notuse 5 ormoremeals/day 4 meals/day 3 meals/day 2 meals/day > 5hours/week ≥ 6hours/day < 6hours/day Active Moderately active Inactive Never Past smoker Current smoker Never Occasionally Daily Obesity Overweight Normal weight Underweight Does notwatch were regions with a lower proportion of daily of proportion lower a with regions were Rodrigues AM, etal.ChallengesofageinginPortugal, ica da Ordem dos Médicos www m o c . a s e u g u t r o p a c i d e m a t c a w. w w s o c i d é M s o d m e d r O a d a c fi í t n e i C a t s i v e R 1294 (83.6%) 1480 (84.5%) 1529 (66.6%) 1691 (69.2%) 1209 (46.9%) 297 (16.3%) 571 (34.6%) 859 (47.2%) 231 (12.6%) 277 (16.8%) 593 (33.1%) 810 (45.3%) 645 (70.4%) 318 (29.6%) 452 (25.5%) 538 (25.6%) 429 (19.3%) 689 (33.8%) 509 (22.3%) 943 (46.5%) 606 (30.4%) 223(14.8%) 155 (7.9%) 101 (5.2%) ≥ 65years 20 (1.4%) 30 (1.5%) 74 (4.8%) 23 (1.6%) 16 (0.8%) 34 (1.9%) n =2393 65 -69years 154 (34.8%) 265 (44.9%) 326 (79.4%) 122 (22.6%) 362 (73.4%) 149 (26.0%) 236 (46.8%) 181 (73.3%) 100 (20.9%) 406 (65.9%) 480 (60.9%) 170 (29.2%) 315 (43.3%) 157 (21.0%) 176 (25.1%) 315 (45.7%) 174 (29.0%) 226(35.8%) 83 (18.4%) 85 (17.6%) 98 (22.6%) 63 (13.2%) 75 (26.7%) 14 (2.4%) 26 (4.6%) 14 (3.0%) 49 (9.9%) 11 (1.7%) 85 1 (0.2%) 8 (1.8%) n =712 and Madeira soup and 42.8% reported daily intake of vegetables. Azores of of intake intake daily reported daily 46.1% Algarve, in and reported vegetables; 36.0% and soup of intake daily Acta MedPort2018Feb;31(2):80-93 70 -74years 154 (33.1%) 236 (52.8%) 347 (81.0%) 390 (84.4%) 153 (32.7%) 202 (41.1%) 171 (77.1%) 398 (74.4%) 456 (71.8%) 139 (22.9%) 337 (48.5%) 108 (19.0%) 166 (25.0%) 266 (50.8%) 143 (23.5%) 180 (32.4%) 65 (12.6%) 63 (18.5%) 88 (18.5%) 78 (18.1%) 69 (22.9%) 58 (11.2%) 10 (1.9%) 20 (7.6%) 36 (7.6%) 32 (5.4%) also had the lowest proportions for daily intake 6 (2.5%) 3 (0.5%) 4 (0.7%) 8 (1.5%) n =645 75 -79years 139 (40.0%) 180 (42.1%) 309 (86.0%) 356 (89.9%) 143 (36.5%) 188 (48.8%) 125 (62.5%) 356 (76.8%) 380 (74.8%) 269 (46.2%) 156 (33.5%) 200 (48.1%) 131 (30.7%) 118 (23.5%) 74 (16.8%) 45 (13.6%) 47 (14.4%) 86 (20.3%) 98 (19.7%) 89 (37.5%) 49 (11.8%) 37 (9.0%) 13 (2.9%) 35 (8.8%) 12 (1.7%) 4 (1.0%) 1 (0.2%) 3 (0.4%) 6 (1.5%) 6 (1.2%) n =527 124 (30.9%) 178 (48.5%) 312 (90.3%) 372 (95.8%) 148 (40.7%) 184 (45.1%) 168 (66.7%) 369 (81.7%) 375 (72.4%) 288 (50.7%) 127 (33.2%) 162 (39.1%) 158 (43.8%) 111 (26.0%) 42 (10.9%) 75 (17.5%) 41 (14.3%) 78 (16.1%) 69 (15.6%) 85 (33.3%) ≥ 80years 12 (3.1%) 14 (3.4%) 30 (7.3%) 15 (3.3%) 21 (4.0%) 2 (0.3%) 2 (0.5%) 3 (2.4%) 8 (7.2%) 5 (1.4%) n =509

ARTIGO ORIGINAL n = 509 6 (1.4%) 6 (2.0%) 8 (1.3%) 6 (1.3%) 3 (0.9%) 7 (0.1%) 3 (0.9%) 9 (2.6%) 20 (3.7%) 19 (8.2%) 15 (4.4%) 14 (4.3%) 16 (3.5%) 38 (7.3%) 13 (3.6%) 18 (4.0%) 18 (4.2%) 12 (2.8%) 29 (6.8%) 19 (4.4%) 19 (4.2%) 24 (4.1%) 34 (11.2%) ≥ 80 years 78 (19.3%) 67 (19.7%) 60 (18.0%) 31 (64.2%) 90 (20.6%) 254 (63.0%) 216 (55.5%) 318 (85.8%) 107 (29.6%) 176 (42.0%) 128 (35.7%) 162 (38.4%) 289 (78.1%) n = 527 5 (1.2%) 2 (0.4%) 9 (1.9%) 5 (0.5%) 6 (1.3%) 5 (1.1%) 5 (1.1%) 19 (5.3%) 30 (7.7%) 17 (3.4%) 34 (6.4%) 14 (4.3%) 37 (9.3%) 20 (4.5%) 30 (6.6%) 14 (2.4%) 16 (3.7%) 16 (3.8%) 19 (3.9%) 12 (2.4%) 29 (6.1%) 18 (4.6%) 21 (8.8%) 20 (4.1%) 81 (19.8%) 65 (17.2%) 66 (17.3%) 73 (18.0%) 244 (62.6%) 235 (61.5%) 316 (83.5%) 133 (35.2%) 154 (38.7%) 154 (44.7%) 130 (30.5%) 300 (75.2%) 75 - 79 years n = 645 3 (0.4%) 3 (0.4%) 4 (0.6%) 3 (0.4%) 9 (1.3%) 11 (1.9%) 11 30 (5.5%) 51 (8.7%) 23 (8.8%) 47 (8.3%) 10 (1.9%) 12 (2.2%) 40 (6.0%) 32 (5.6%) 17 (7.2%) 22 (4.8%) 16 (3.0%) 17 (3.4%) 13 (1.7%) 43 (7.4%) 17 (2.5%) 22 (4.8%) 86 (16.1%) 10 (12.6%) 98 (20.9%) 80 (20.8%) 21 (12.7%) 82 (20.8%) 262 (58.9%) 281 (62.7%) 390 (83.3%) 163 (37.0%) 157 (33.6%) 175 (41.0%) 169 (32.8%) 351 (71.4%) 70 - 74 years Acta Med Port 2018 Feb;31(2):80-93 Port 2018 Acta Med per week. Of note, only 18.4% of older adults drank more 2). than seven glasses of water each day (Table n = 712 6 (0.6%) 4 (0.7%) 9 (1.1%) 2 (3.3%) 4 (3.8%) 2 (3.3%) 9 (1.2%) 86 21 (3.3%) 25 (3.7%) 15 (2.7%) 36 (6.3%) 32 (4.4%) 12 (2.2%) 48 (7.7%) 22 (2.4%) 15 (2.4%) 21 (3.2%) 14 (2.5%) 42 (7.5%) 36 (4.5%) 19 (3.0%) 19 (2.4%) 34 (11.1%) 57 (13.7%) 261 (51.8%) 131 (24.9%) 305 (59.4%) 414 (83.3%) 107 (21.1%) 169 (34.0%) 177 (27.5%) 106 (21.6%) 200 (40.7%) 162 (28.7%) 383 (81.4%) 125 (28.6%) 65 - 69 years n = 2393 90 (4.4%) 80 (5.2%) 37 (1.9%) 15 (0.8%) 44 (2.5%) 58 (2.7%) 61 (3.5%) 36 (1.6%) 13 (1.5%) 85 (6.3%) 65 (3.2%) 21 (1.9%) 75 (3.6%) 51 (2.3%) 13 (1.6%) 32 (1.5%) 81 (5.0%) 84 (6.0%) ≥ 65 years 157 (9.9%) 148 (6.9%) 148 (6.8%) 143 (7.0%) 243 (3.9%) 143 (7.3%) 376 (20.2%) 337 (19.9%) 572 (34.2%) 664 (34.5%) 312 (19.8%) 657 (40.6%) 623 (32.2%) 370 (22.6%) 1021 (58.4%) 1037 (59.9%) 1438 (83.8%) 1323 (76.6%) R e v i s ta C i e n tífi c a d a Or d e m d o s M é d i c o s w w w.a c ta m e d i c a p o r tu g u e s a .c o m Rodrigues AM, et al. Challenges of ageing in Portugal, in Portugal, of ageing et al. Challenges AM, Rodrigues Every day 6 times/week 3 - 5 times/week 1 - 2 times/week Rarely Never Every day 6 times/week Never Rarely Everyday 6 times/week 3 - 5 times/week 1 - 2 times/week Rarely Never 10 - 14 meals/week 7 - 10 meals/week 4 - 6 meals/week 1 - 3 meals/week Rarely Never 10 - 14 meals/week 7 - 10 meals/week 4 - 6 meals/week 1 - 3 meals/week Rarely Never Every day 6 times/week 3 - 5 times/week 1 - 2 times/week Rarely Never 3 - 5 times/week 1 - 2 times/week Frequency of soup consumption Frequency Frequency of vegetables consumption Frequency of vegetables Frequency of fresh fruit consumption Frequency of meat consumption Frequency of fish consumption Frequency of milk/dairy products consumption of fruits: 67.8% in Azores and 73.2% in Madeira 4). (Table Overall, 26.2% of participants ate meat more than seven times per week and 40.6% consumed fish in 4 to 6 meals – Lifestyle characteristics and anthropometric data of the older adult Portuguese population (section 2 of 3) 2 of (section population adult Portuguese of the older data anthropometric and characteristics 2 – Lifestyle Table

ARTIGO ORIGINAL standard deviation. SD: Health questionnaire; HAQ: Assessment scale; Depression Hospital and HADS: Anxiety levels; three and dimensions five with questionnaire Life of Quality European EQ-5D-3L: All percentagesandmeanswereweightedto correctforpopulationrepresentativeness. (n =1545). Anxiety score (n = 1680), HADS Depression score (n = 1680), Hospitalization (n = 2366), Home care HADS (n 2236), = = 1018), (n Medical 3) appointment - (n (0 = score 1783), and HAQ 2211),Number function = of Physical (n medical EQ-5D-3Lappointments score 2278), = (n disease Rheumatic 2267), = (n Hyperuricemia 2268), = (n Hypogonadism 2328), = (n 2322), Gastrointestinal disease (n = 2334), Neurologic disease (n = 2322), Allergy (n = 2339), Mental disease = (n (n = 2330), disease Neoplastic Cardiac disease (n 2325), = = 2333), (n Thyroid disease or parathyroid Pulmonary disease 2334), = (n Hypercholesterolemia 2312), = (n Diabetes 2348), = (n Hypertension data: missing of because varied sizes Sample Table 3–HealthcharacteristicsoftheolderadultPortuguesepopulation All percentagesandmeanswereweightedtocorrectforpopulationrepresentativeness. dietary pattern(n=1708). vegetables and Fruit and 1743), = (n intake water Daily 1753), = (n consumption products milk/dairy of Frequency 1731), = (n consumption fish of Frequency 1744), = (n consumption meat of Frequency 1754), = (n consumption fruit fresh of Frequency 1757), = (n consumption vegetables of Frequency 1761), = (n consumption soup of Frequency 1754), = (n meals of Number 1540), = (n health about information for searching Timespent 1761), = (n games/tablets computer/video using of Frequency 1761), = (n television watching of Frequency 963), = (n habits Sleep 2136), = (n activity Physical 2330), = (n habits Smoking 2074), 2327), = = (n (n index intake mass Alcohol Body data: missing of because varied sizes Sample Table 2–LifestylecharacteristicsandanthropometricdataoftheolderadultPortuguesepopulation(section33) ‘Fruit andvegetablesdietarypattern’ Daily waterintake Noncommunicable chronicdiseases(self-reported) diseases (self-reported)(mean±SD) Number ofnoncommunicablechronic Anxiety symptoms(HADSscore≥11) Anxiety anddepressionsymptoms Hospitalized Healthcare resourcesconsumption HAQscore(0 Physical function EQ-5D-3L score(mean±SD) Quality oflife Homecareinprevious12months previous12months(mean±SD) Numberofmedicalappointmentsin Depressionsymptoms(HADSscore≥11) Medicalappointmentinprevious12months Hypertension > 7glasses/day 1 -2glasses/day 5 -7glasses/day 3 -4glasses/day Hypercholesterolemia Diabetes Cardiac disease Pulmonary disease Gastrointestinal disease Neurologic disease Allergy Hyperuricemia Thyroid orparathyroiddisease Neoplastic disease Rheumatic disease Multimorbidity inprevious12months -3)(mean±SD) Rodrigues AM, etal.ChallengesofageinginPortugal, ica da Ordem dos Médicos www m o c . a s e u g u t r o p a c i d e m a t c a w. w w s o c i d é M s o d m e d r O a d a c fi í t n e i C a t s i v e R 1408 (85.4%) 315 (18.4%) 315 (17.2%) 569 (32.6%) 544 (31.9%) ≥ 65years n =2393 1401 (57.3%) 1225 (49.4%) 1280 (51.9%) 1624 (78.3%) 1718 (96.0%) 8.11 ±10.74 545 (22.7%) 651 (27.3%) 689 (30.3%) 568 (23.9%) 295 (13.3%) 524 (25.8%) 255 (11.1%) 321 (11.7%) 241 (11.8%) 3.26 ±2.53 0.76 ±0.87 0.59 ±0.38 180 (7.3%) 203 (7.8%) 176 (9.6%) ≥ 65years 86 (7.5%) n =2393 65 -69years 409 (83.7%) 177 (33.3%) 145 (26.8%) 98 (24.2%) 84 (15.7%) 87 n =712 65 -69years 8.01 ±10.86 385 (53.7%) 147 (20.8%) 362 (48.5%) 122 (17.3%) 175 (27.0%) 161 (25.8%) 346 (46.3%) 472 (72.8%) 127 (22.3%) 489 (96.3%) 2.92 ±1.19 0.55 ±0.69 0.64 ±0.35 60 (10.6%) 70 (10.2%) 52 (12.4%) 98 (11.0%) 48 (7.9%) 57 (7.7%) 44 (7.3%) 8 (2.0%) n =712 Acta MedPort2018Feb;31(2):80-93 70 -74years 382 (87.8%) 154 (32.6%) 135 (32.3%) 91 (17.1%) 80 (18.0%) n =645 70 -74years 401 (62.0%) 159 (25.1%) 369 (50.3%) 169 (26.3%) 191 (31.9%) 105 (14.5%) 161 (22.7%) 359 (50.2%) 459 (78.2%) 145 (28.1%) 462 (98.1%) 3.39 ±1.51 0.72 ±0.83 0.61 ±0.37 7.82 ±8.73 94 (15.1%) 76 (11.1%) 65 (11.3%) 47 (6.4%) 62 (8.3%) 45 (7.9%) 16 (4.2%) n =645 75 -79years 306 (83.7%) 135 (32.9%) 118 (33.3%) 73 (16.8%) 67 (17.0%) n =527 75 -79years 314 (58.4%) 270 (51.6%) 169 (34.7%) 178 (35.4%) 125 (23.5%) 299 (57.2%) 360 (81.9%) 127 (26.4%) 393 (98.2%) 116 (21.0%) 3.49 ±1.31 0.89 ±0.96 0.54 ±0.42 7.82 ±7.94 64 (12.4%) 68 (15.2%) 65 (11.6%) 68 (11.8%) 50 (8.4%) 50 (8.2%) 47 (9.0%) 24 (9.6%) n =527 120 (30.5%) 129 (37.9%) 311 (86.6%) 53 (13.0%) 84 (18.5%) ≥ 80years 9.04 ±15.27 123 (24.2%) 301 (55.2%) 224 (46.9%) 191 (36.1%) 145 (27.9%) 121 (23.1%) 276 (57.2%) 333 (83.4%) 125 (27.4%) 374 (90.4%) 3.34 ±1.49 0.98 ± 0.53 ±0.39 67 (16.4%) 64 (15.5%) 38 (14.7%) ≥ 80years 54 (11.3%) n =509 35 (6.5%) 50 (8.8%) 34 (6.7%) 32 (8.5%) n =509

ARTIGO ORIGINAL (14.88) a 79.5% 90.7% 87.1% 87.6% 2.0% in those aged 65 to 70 years (Table (Table years 70 to 65 aged those in 2.0% - our data show that many individuals 25 vs. 93.0% Acta Med Port 2018 Feb;31(2):80-93 Port 2018 Acta Med In the present study, we determined the prevalence Despite positive results obtained for life expectancy in participants reflected their health status. In the 12 months before the EpiDoC 2 interview, 1718 older attended at adults least one medical (96%) appointment, and the mean number of appointments was ± 8.11 10.74. In the previous 12 months, 25.8% of older adults were hospitalized, and 86 (7.5%) received home care utilization during assistance. the previous 12 Home months was care particularly individuals among 14.7% group: age oldest the among high years 80 ≥ aged 5). The percentages of patients hospitalized (31.4%) and attending at least one medical appointment (99.3%) during the previous 12 months were highest in Lisboa; however, the number of medical appointments Madeir and in (16.57) Azores in highest were the months previous 12 4). (Table DISCUSSION of multimorbidity and analysed the prevalence of chronic diseases, lifestyle from data using factors, adults, older among consumption resources quality of life, a national cohort representative sample of the Portuguese and health population. between years 81.3 to 78.2 from increased which - Portugal 2005 and 2015 65 years and older are living in poor health conditions. 88 73.9% Madeira 69.0% R e v i s ta C i e n tífi c a d a Or d e m d o s M é d i c o s w w w.a c ta m e d i c a p o r tu g u e s a .c o m Rodrigues AM, et al. Challenges of ageing in Portugal, in Portugal, of ageing et al. Challenges AM, Rodrigues Azores > 73.8% 73.8% - 78.6% 78.6% - 83.4% 83.4% - 88.2% ≥ 88.2% The overall prevalence of multimorbidity among older adults; older all in 0.38 ± 0.59 was EQ-5D-3L mean The study in resources care health of consumption high The Health characteristics strata, age across increased it and (78.3%), high was adults ranging from 72.8% for individuals aged 65 to 69 years to 83.4% among adults ≥ 80 years (Table 3). Multimorbidity prevalence was higher in Azores 4). The (83.6%) mean (Table number of noncommunicable (84.9%) and Alentejo chronic diseases was 3.3 reported ± chronic 2.5. diseases The were rheumatic most frequently hypertension disease (57.3%), (51.9%), (49.4%). and Depression hypercholesterolemia symptoms older adults were and (11.8%) were most common in the oldest frequent among individuals, with a frequency of 15.5% in those ≥ 80 years old. Cardiac disease was more common in participants 80 years and older (36.1%) than in those aged 65 to 69 years (17.3%) 3). (Table Azores was the region with the highest prevalence of hypertension (61.2%) and cardiac disease gastrointestinal and (53.0%) hypercholesterolemia (34.8%); disease (34.9%) were most prevalent in the Norte region 4). (Table this quality of life score remained stable across age strata (Table 3). Regarding physical disability, the score mean was HAQ 0.76 ± 0.87 for adults among 0.98 ± 0.98 of score a with strata, age across all individuals and increased 80 years and older. – Distribution of ‘fruit and vegetables dietary pattern’ by region among Portuguese seniors according to NUTS II by region among Portuguese seniors pattern’ Figure 2 – Distribution of ‘fruit and vegetables dietary Units for Statistics Territorial NUTS II: Nomenclature of

ARTIGO ORIGINAL Table 4–LifestylecharacteristicsoftheolderadultPortuguesepopulationaccordingtoNUTSIIregion(section13) dcto ad eotd lw oshl icm (32.1% income household low a reported and education of years fewer or four had older and years 65 individuals of majority the Indeed, behaviours. lifestyle unhealthy and vulnerable group in terms of poor socioeconomic conditions a are adults Portuguese older that observed we process, ageing the of consequences health known the from Apart Currentsmoker Smokinghabits Obesity Overweight Normalweight Underweight Active Moderatelyactive Inactive Physicalactivity Never Occasionally Daily Alcohol intake Never Pastsmoker Doesnotwatch Frequencyofwatchingtelevision Screen time Bodymassindex(kg/m Anthropometric data 3 ≤2hours/day 6times/week Everyday Frequency ofsoupconsumption >5hours/week <5hours/week 0hours/week Search timeregardinginformationabouthealth ≥5hours/day ≥5hours/day 3 ≤2hours/day Doesnotuse Frequency ofusingcomputer/videogames/tablets 3 1 Rarely Never -4hours/day -4hours/day -5times/week -2times/week 2 ) Rodrigues AM, etal.ChallengesofageinginPortugal, ica da Ordem dos Médicos www m o c . a s e u g u t r o p a c i d e m a t c a w. w w s o c i d é M s o d m e d r O a d a c fi í t n e i C a t s i v e R 133 (19.0%) 261 (44.2%) 169 (36.2%) 421 (69.7%) 260 (36.2%) 258 (40.4%) 462 (69.1%) 144 (23.9%) 184 (34.4%) 280 (50.2%) 341 (57.1%) 434 (85.3%) 494 (88.6%) 118 (23.4%) 111 (19.4%) 82 (19.9%) 48 (10.4%) 80 (13.4%) 89 (13.9%) 45 (12.8%) 30 (7.1%) 12 (1.6%) 23 (3.6%) 10 (1.5%) 53 (9.0%) 29 (4.8%) 17 (2.4%) n =653 4 (0.6%) 7 (1.3%) 6 (1.0%) Norte 213 (46.1%) 129 (27.9%) 360 (75.7%) 277 (49.0%) 177 (35.7%) 416 (76.6%) 107 (21.5%) 151 (34.5%) 223 (48.0%) 275 (59.3%) 334 (83.8%) 403 (89.6%) 114 (24.6%) 78 (15.3%) 65 (15.9%) 60 (14.4%) 65 (15.0%) 95 (22.7%) 10 (1.9%) 36 (8.5%) 10 (2.4%) 23 (4.9%) 38 (9.0%) 29 (7.5%) 16 (3.5%) n =547 7 (1.5%) 7 (1.8%) 0 (0.0%) 6 (1.4%) 9 (2.1%) Centro 208 (52.5%) 132 (25.2%) 271 (72.7%) 237 (51.1%) 131 (31.4%) 296 (61.7%) 138 (32.3%) 159 (42.7%) 206 (63.2%) 235 (79.1%) 235 (73.1%) 94 (22.1%) 93 (17.6%) 58 (18.1%) 95 (34.4%) 42 (18.0%) 73 (21.5%) 79 (20.7%) 63 (17.3%) 27 (6.0%) 41 (9.2%) 10 (2.2%) 29 (7.2%) 17 (9.6%) 11 (1.9%) n =481 1 (0.2%) 6 (1.5%) 7 (2.9%) 9 (4.0%) 5 (0.8%) Lisboa 89 ae aog le aut i rcn yas pvry rates poverty years, recent in adults older among rates poverty improving generally poverty.Despite of risk higher osset ih h rsls f rvos tde i our in studies previous of country results the are data with These consistent alone. lived one-quarter Furthermore, approximately month). per euros 500 below incomes had Acta MedPort2018Feb;31(2):80-93 26 109 (80.1%) 103 (58.2%) 125 (70.4%) 38 (28.2%) 57 (41.0%) 44 (29.5%) 32 (21.0%) 29 (20.9%) 30 (22.1%) 16 (14.7%) 50 (45.8%) 36 (33.2%) 66 (60.9%) 75 (83.0%) 14 (17.0%) 18 (17.8%) 98 (85.6%) 23 (21.0%) 11 (12.4%) Alentejo 10 (7.5%) 6 (18.3%) suggesting that people 65 years and older had a had older and years 65 people that suggesting n =169 2 (2.4%) 6 (5.4%) 4 (3.2%) 0 (0.0%) 1 (0.8%) 1 (1.2%) 9 (8.8%) 5 (2.3%) 1 (4.4%) 13 (16.4%) 41 (49.4%) 31 (33.6%) 15 (16.3%) 18 (26.5%) 24 (37.6%) 70 (78.6%) 68 (57.2%) 75 (59.4%) 28 (41.2%) 20 (41.7%) 33 (46.1%) 43 (88.5%) 14 (17.1%) 10 (24.4%) 51 (73.6%) 10 (18.3%) 11 (21.0%) 9 (14.7%) 6 (11.6%) Algarve n =105 1 (0.7%) 3 (3.0%) 6 (6.8%) 0 (0.0%) 0 (0.0%) 1 (2.0%) 0 (0.0%) 4 (7.9%) 2 (2.3%) 2 (4.4%) 132 (84.6%) 130 (61.8%) 131 (61.6%) 63 (33.7%) 73 (40.2%) 49 (26.2%) 31 (16.9%) 38 (21.3%) 53 (29.4%) 15 (12.6%) 41 (42.1%) 38 (41.3%) 55 (56.4%) 54 (84.9%) 15 (16.6%) 21 (22.5%) 71 (75.3%) 22 (24.1%) 15 (9.0%) 9 (15.2%) n =201 Azores 0 (0.0%) 7 (6.0%) 0 (0.0%) 0 (0.0%) 1 (1.1%) 1 (1.1%) 7 (8.7%) 9 (9.8%) 1 (1.0%) 0 (0.0%) 166 (73.8%) 134 (53.5%) 186 (74.0%) 128 (82.8%) 119 (89.3%) 54 (24.3%) 90 (47.7%) 52 (30.4%) 38 (20.1%) 42 (22.6%) 21 (17.4%) 78 (53.8%) 47 (30.2%) 45 (28.8%) 23 (14.5%) 19 (14.7%) 51 (34.9%) 29 (22.2%) 12 (9.2%) 13 (7.0%) 10 (5.5%) Madeira 6226.4%) 11 (8.8%) n =237 1 (0.8%) 6 (3.4%) 2 (1.5%) 2 (1.6%) 2 (1.0%) 2 (1.4%) 3 (1.6%)

ARTIGO ORIGINAL 3 (9.3%) 1 (0.5%) 9 (5.1%) 2 (1.0%) 6 (4.7%) 8 (5.0%) 4 (2.3%) 1 (0.5%) 9 (6.5%) 6 (3.8%) 1 (0.6%) n = 237 Madeira 13 (1.5%) 51 (8.6%) 29 (7.3%) 10 (7.3%) 12 (7.2%) 12 (6.7%) 17 (11.5%) 41 (26.1%) 18 (13.9%) 44 (29.0%) 46 (31.0%) 45 (76.6%) 77 (51.9%) 34 (24.3%) 16 (12.4%) 23 (15.2%) 43 (32.9%) 63 (39.3%) 22 (15.3%) 49 (30.9%) 22 (13.5%) 51 (36.0%) 109 (73.2%) Furthermore, 30 7 (1.2%) 9 (7.1%) 1 (5.1%) 0 (4.0%) 4 (4.0%) 1 (1.1%) 3 (2.9%) 1 (1.1%) 1 (1.5%) 3 (3.7%) 1 (1.1%) 3 (2.8%) 2 (2.4%) 9 (9.8%) Azores n = 201 9 (10.8%) 11 (11.9%) 11 11 (14.1%) 11 27 (27.6%) 17 (17.7%) 30 (32.6%) 22 (13.6%) 20 (22.1%) 55 (69.1%) 27 (30.7%) 17 (16.2%) 12 (12.5%) 33 (35.5%) 19 (20.2%) 17 (19.5%) 45 (45.6%) 67 (67.8%) 12 (12.7%) 25 (29.0%) 43 (43.3%) 4 (2.3%) 2 (0.9%) 2 (2.0%) 1 (0.9%) 0 (0.0%) 3 (3.3%) 2 (1.9%) 2 (1.9%) 1 (0.8%) 6 (9.7%) 0 (0.0%) 0 (0.0%) 1 (1.3%) 1 (0.9%) 5 (5.3%) n = 105 Algarve 7 (10.5%) 10 (2.0%) 7 (13.5%) 4 (10.2%) 11 (13.3%) 11 11 (15.9%) 11 21 (38.3%) 23 (35.3%) 10 (16.0%) 33 (79.5%) 20 (35.4%) 15 (23.2%) 18 (27.0%) 13 (25.1%) 28 (43.7%) 52 (87.6%) 17 (31.8%) 10 (17.9%) 28 (42.8%) Poor socioeconomic conditions in later in conditions socioeconomic Poor 29 9 (0.0%) 6 (2.6%) 5 (5.4%) 1 (2.3%) 3 (2.5%) 0 (0.0%) 4 (3.5%) 0 (0.0%) 7 (6.2%) 1 (0.8%) 3 (2.9%) 8 (6.2%) 1 (0.8%) 0 (0.0%) 8 (8.1%) 6 (4.8%) 1 (0.5%) 5 (6.2%) 8 (6.5%) n = 169 23 (7.6%) Alentejo 20 (20.0%) 36 (33.1%) 31 (27.2%) 21 (19.7%) 66 (82.1%) 42 (38.6%) 23 (23.1%) 30 (29.6%) 25 (24.7%) 31 (30.1%) 39 (33.6%) 98 (89.3%) 32 (27.4%) 59 (54.6%) Acta Med Port 2018 Feb;31(2):80-93 Port 2018 Acta Med with adverse health outcomes, both in terms health. mental and of physical life should receive particular attention, since it is one of the main determinants of poor health status. deterioration in health status accompanying process the is associated ageing with additional needs in terms of 90

27 Lisboa 5 (8.6%) 4 (0.8%) 0 (0.0%) 6 (6.5%) 6 (6.9%) 8 (1.7%) 6 (1.4%) 0 (0.0%) 4 (1.1%) 3 (1.6%) n = 481 11 (0.3%) 11 11 (2.2%) 11 63 (5.5%) 29 (1.8%) 17 (4.9%) 13 (3.8%) 18 (3.5%) 10 (2.5%) 23 (4.7%) 21 (4.4%) 75 (22.2%) 95 (26.0%) 44 (15.8%) 89 (21.2%) 60 (27.7%) 56 (19.6%) 59 (21.3%) 114 (36.0%) 114 206 (78.9%) 161 (46.5%) 109 (30.0%) 135 (39.2%) 292 (86.5%) 219 (66.9%) Centro 9 (2.6%) 2 (0.4%) 7 (1.2%) 8 (1.6%) 7 (1.4%) 2 (0.4%) 2 (0.5%) n = 547 95 (5.8%) 29 (5.0%) 16 (4.1%) 23 (2.6%) 10 (2.5%) 17 (3.8%) 31 (6.6%) 14 (3.8%) 19 (4.8%) 16 (3.4%) 13 (3.0%) 24 (5.8%) 44 (9.6%) 82 (17.7%) 58 (13.2%) 83 (18.0%) 72 (16.4%) 79 (17.5%) Several studies 165 (38.0%) 137 (31.2%) 275 (80.0%) 194 (46.0%) 137 (29.3%) 155 (36.5%) 178 (37.2%) 381 (86.5%) 284 (63.8%) 28 Norte 9 (4.0%) 3 (0.4%) 8 (1.1%) 9 (3.9%) 5 (0.7%) n = 653 11 (2.5%) 11 45 (4.6%) 29 (5.9%) 17 (8.3%) 23 (1.6%) 17 (2.9%) 25 (3.5%) 58 (8.2%) 15 (2.2%) 31 (9.4%) 16 (2.3%) 17 (2.7%) 52 (9.9%) 34 (4.7%) 111 (7.8%) 111 96 (17.4%) 116 (19.9%) 116 165 (26.1%) 184 (36.6%) 341 (71.8%) 102 (16.3%) 187 (37.9%) 231 (37.8%) 131 (22.4%) 204 (37.0%) 176 (28.6%) 439 (79.5%) 109 (24.5%) 353 (57.7%) R e v i s ta C i e n tífi c a d a Or d e m d o s M é d i c o s w w w.a c ta m e d i c a p o r tu g u e s a .c o m Rodrigues AM, et al. Challenges of ageing in Portugal, in Portugal, of ageing et al. Challenges AM, Rodrigues - 7 glasses/day - 5 times/week - 2 times/week - 4 glasses/day - 2 glasses/day - 10 meals/week - 6 meals/week - 3 meals/week - 2 times/week - 5 times/week - 10 meals/week - 6 meals/week - 3 meals/week - 2 times/week - 5 times/week > 7 glasses/day 5 3 1 3 Rarely Never Daily water intake 1 Never Frequency of milk/dairy products consumption Every day 6 times/week Rarely Never Frequency of fish consumption 10 - 14 meals/week 7 4 1 1 3 Rarely Never Frequency of meat consumption 10 - 14 meals/week 7 4 1 Rarely Never consumption Frequency of fresh fruit Every day 6 times/week Rarely 1 3 Frequency of vegetables consumption Frequency of Every day 6 times/week have suggested that loneliness in older adults is associated is adults older in loneliness that suggested have According to European Union statistics on income and living and income on statistics Union European to According conditions (EU-SILC) for 2014, 31.4% of individuals aged 65 and over lived alone in EU-28, and 24.7% lived alone in Portugal, a percentage similar to ours. increased from 14.6% to 17% between 2013 and 2014. – Lifestyle characteristics of the older adult Portuguese population according to NUTS II region (section 2 of 3) (section 2 II region to NUTS according population Portuguese the older adult of characteristics 4 – Lifestyle Table

ARTIGO ORIGINAL n vrl peaec o 6% o mliobdt ad a and multimorbidity for 67% of prevalence overall an found which Salive, by review systematic a of results the with consistent are results These with adults. older among age increases multimorbidity that suggested results our Moreover, adults. older of Portuguese among (78.3%) of multimorbidity proportion number high a (mean with diseases), problems chronic 3.3 health chronic multiple of presence the revealed findings Our increases. expectancy older the population. in self-management health for capacity less to stressed, poor socioeconomic status is quite closely related situation. by Chen socioeconomic As poor a with people older obtain to difficult be may which utilization, healthcare II: Nomenclatureof Territorial UnitsforStatistics;SD:standarddeviation. EQ-5D-3L: European Quality of Life questionnaire with five dimensions and three levels; HADS: Hospital Anxiety and Depression scale; HAQ: Health Assessment questionnaire; NUTS All percentagesandmeanswereweightedtocorrectforpopulationrepresentativeness. Medical appointment(n=1783),andNumberofmedicalappointments1545). 2268), Hyperuricemia (n = 2267), Rheumatic disease (n = 2278), HADS Anxiety score (n = 1680), HADS Depression score (n = 1680), Hospitalized (n = 2366), Home care (n = 1018), (n = 2334), Neurologic disease (n = 2322), Allergy (n = 2339), Mental disease (n = 2330), Neoplastic disease (n = 2333), Thyroid or parathyroid disease (n = 2328), Hypogonadism (n = pattern (n = 1708), Hypertension (n=2,348), Diabetes (n = 2312), Hypercholesterolemia (n = 2334), Pulmonary disease (n = 2325), Cardiac disease (n = 2322), Gastrointestinal disease consumption (n = 1744), Frequency of fish consumption (n = 1731), Frequency of milk/dairy products consumption (n = 1753), Daily water intake (n =meat of Frequency 1754), 1743),= (n consumption fruit Fruitfresh of Frequency 1757), = and(n consumption vegetables vegetablesof Frequency 1761), = dietary (n consumption soup of Frequency 1754), = (n meals of Number 1540), = (n health about information for searching Timespent 1761), = (n games/tablets computer/video using of Frequency 1761), = (n television watching of Frequency 963), = (n habits Sleep 2136), = (n activity Physical 2330), = (n habits Smoking 2074), 2327), = = (n (n index intake mass Alcohol Body data: missing of because varied sizes Sample Table 4–LifestylecharacteristicsoftheolderadultPortuguesepopulationaccordingtoNUTSIIregion(section33) Noncommunicable chronicdiseases(self-reported) (HADSscore≥11) Anxiety symptoms Anxiety anddepressionsymptoms (HADSscore≥11) Depressionsymptoms months Homecareinprevious12 months Hospitalized Healthcare resourcesconsumption previous12months Medicalappointmentin months (mean±SD) appointments inprevious12 Number ofmedical Thyroid or parathyroid disease Diabetes Hypertension Cardiac disease Pulmonary disease Hypercholesterolemia Hyperuricemia Neurologic disease Gastrointestinal disease Neoplastic disease Allergy utmriiy s eoig oe omn s life as common more becoming is Multimorbidity Multimorbidity Rheumatic disease 31 inprevious12

Rodrigues AM, etal.ChallengesofageinginPortugal, ica da Ordem dos Médicos www m o c . a s e u g u t r o p a c i d e m a t c a w. w w s o c i d é M s o d m e d r O a d a c fi í t n e i C a t s i v e R 152 (21.8%) 394 (57.7%) 189 (29.9%) 361 (53.0%) 434 (77.2%) 342 (53.3%) 207 (34.9%) 135 (20.5%) 150 (23.7%) 548 (94.5%) 6.69 ±7.82 92 (13.0%) 89 (12.3%) 88 (12.6%) 67 (10.1%) 80 (12.2%) 48 (6.3%) 27 (6.5%) 55 (7.0%) n =653 Norte 8.27 ±10.88 124 (22.7%) 308 (58.5%) 152 (30.2%) 274 (50.5%) 355 (79.2%) 287 (53.0%) 150 (26.1%) 131 (26.3%) 435 (96.8%) 115 (23.0%) 78 (13.4%) 80 (15.8%) 49 (10.1%) 67 (14.6%) 62 (11.6%) 31 (5.3%) 21 (8.3%) 38 (7.3%) n =547 Centro 10.88 ±13.30 280 (56.9%) 239 (45.0%) 336 (76.1%) 254 (47.7%) 149 (32.7%) 150 (29.8%) 123 (31.4%) 348 (99.3%) 114 (20.9%) 92 (22.8%) 66 (10.8%) 49 (11.1%) 48 (7.4%) 59 (7.9%) 23 (9.4%) 33 (6.4%) 14 (9.9%) 55 (9.5%) n =481 Lisboa 91 countries. NorthAmerican and the European in other to similar reported findings are which diabetes, and disease, cardiac disease, rheumatic gastrointestinal hypertension, hypercholesterolemia, were disease, population study our in In the Netherlands, quality of life expressed as the mean the as expressed countries. life of other quality Netherlands, from the In adults with compared when ± 0.38, 0.59 of score EQ-5D-3L mean a by reflected as life, of hrceitc, oieooi, utrl atr, and factors, cultural inequities. social population socioeconomic, in differ differences multimorbidity characteristics, of of because countries patterns across and prevalence The rvlne f 15 fr niiul ≥ 5 er old. years 85 ≥ individuals for 81.5% of prevalence Portuguese older adults reported lower levels of quality of levels lower reported adults older Portuguese Acta MedPort2018Feb;31(2):80-93 101 (58.8%) 123 (83.6%) 143 (23.9%) 106 (93.1%) 7.41 ±5.38 85 (47.1%) 33 (21.3%) 94 (54.3%) 21 (14.1%) 26 (12.9%) 42 (24.3%) 45 (27.5%) 17 (12.8%) 39 (23.9%) Alentejo 13 (8.0%) 17 (8.9%) 13 (7.3%) 11 (7.9%) n =169 5 (5.5%) 5,34-36 33 h ms peaet hoi diseases chronic prevalent most The 6.32 ±6.19 50 (43.2%) 49 (43.3%) 27 (28.8%) 56 (47.9%) 16 (20.1%) 70 (79.3%) 24 (25.9%) 36 (30.8%) 25 (17.9%) 10 (13.1%) 23 (26.5%) 62 (94.7%) 10 (8.2%) Algarve n =105 8 (5.6%) 3 (6.9%) 5 (3.7%) 2 (3.5%) 9 (9.1%) 149(84.9%) 6.34 ±16.57 124 (61.2%) 117 (58.9%) 98 (50.2%) 56 (19.9%) 28 (13.4%) 72 (34.8%) 60 (30.0%) 41 (21.2%) 24 (13.3%) 81 (92.2%) 11 (12.2%) 18 (8.6%) 17 (8.8%) 15 (7.5%) 11 (5.8%) n =201 Azores 7 (7.0%) 2 (5.9%) 6.68 ±14.88 144 (58.0%) 130 (52.8%) 157 (74.6%) 138 (92.3%) 119 (47.0%) 24 (10.1%) 61 (26.0%) 28 (10.3%) 58 (25.7%) 44 (18.1%) 57 (23.8%) 23 (14.4%) 34 (14.7%) 15 (11.9%) 16 (9.0%) 13 (6.3%) 18 (6.9%) Madeira n =237 6 (2.7%) 32

ARTIGO ORIGINAL 45 44 Acta Med Port 2018 Feb;31(2):80-93 Port 2018 Acta Med The ageing process, in combination with unhealthy The considered. be should study our of limitations Some In conclusion, Portuguese older adults represent a The authors declare that the procedures were followed use in protocols the followed having declare authors The All authors report no conflict of interest. The present project was granted by the Public Health lifestyle behaviours and the healthcare presence of utilization of increased in multiple results problems, chronic health services and high costs for the health system. Our study showed high healthcare resources increased. age as increased which adults, consumption older Portuguese among Regional differences were also Azores, Lisboa, of regions the with consumption, resources observed in healthcare and Madeira exhibiting the highest healthcare utilization. Several factors a can person’s socioeconomic influence coverage and accessibility. and healthcare system’s health utilization, status especially and the sample used in this study did not include institutionalized particularly this to apply not may results our so adults, older susceptible group. Moreover, dietary intake was assessed with food frequency questions in EpiDoC 2, as there is no validated questionnaire for telephone use regarding dietary intake. In addition, data from noncommunicable diseases were based on self-reported data. Nonetheless, this study was performed in a national representative sample, with a of participants. robust study design and a high number vulnerable group, with poor unhealthy socioeconomic conditions, lifestyle Our results behaviours, suggest that design and there and implement is interventions an to lifestyle multimorbidity. promote behaviours, urgent healthy improve need health literacy, to and life. noncommunicable chronic diseases in later control PROTECTION OF AND ANIMALS HUMANS according to the regulations established Research by the and Clinical Ethics Association. Medical Declaration of the World Committee and to the Helsinki CONFIDENTIALITY DATA at their working center regarding data patients’ publication. Informed consent was duly obtained from the patient. CONFLICTS OF INTEREST FUNDING SOURCES Initiatives Programme (PT06), financed byFinancial Mechanism 2009-2014. EEA Grants the general adult population. However, when we analysed overweight prevalence to due across be different may This age increased. groups, age there as trend decreasing a was individuals. elderly in common quite is which undernutrition, Poor appetite, loss of taste and smell, dental deterioration, dysphagia, and limited access to food because of disease lead and individuals older among frequent are disability and to decreased food intake. 92

43 41 22 39,41 vs 33% of men). These trends were 37 39 Other studies found similar In our Portuguese older adults, 40 38 R e v i s ta C i e n tífi c a d a Or d e m d o s M é d i c o s w w w.a c ta m e d i c a p o r tu g u e s a .c o m Rodrigues AM, et al. Challenges of ageing in Portugal, in Portugal, of ageing et al. Challenges AM, Rodrigues 42 39 Similar findings have been observed in other 22 By contrast, older Norwegians have a more active more a have Norwegians older contrast, By 39 Our study suggests the need for lifestyle characterization lifestyle for need the suggests study Our Furthermore, older individuals in Portugal have a high Regarding dietary habits, a high proportion of Portuguese of proportion high a habits, dietary Regarding Our results showed that several unhealthy lifestyle Regarding other lifestyle habits, a high proportion quality of life remained stable across age strata. remained stable quality of life and 65 individuals aged Among adults. older Portuguese of above, alcohol abstinence was high, but 33.8% reported daily alcohol the Additionally, intake. majority of individuals (69.2%) reported never smoking. The Survey in Europe on Nutrition and the Elderly: a Concerted Action (SENECA) study, which included participants from several European countries, showed that alcohol and smoking habits varied strongly across European countries, alcohol consumption with in France highest and Italy daily (58% and respectively). 78%, also observed for older Australians: the mean EQ-5D-3L score was 0.87 between 65 and 74 years of age and 0.83 at age 75 years or older). results. suggesting a much higher prevalence when compared with The SENECA study showed significant variations in levels of physical activity among older adults across countries European southern with 32%, to 4% from ranging countries, having the lowest levels of activity. In a previous study based on EpiDoC 2 data but including all adult age groups, an ‘unhealthy’ associated with other unhealthy dietary behaviours, such as being pattern was currently sedentary, smoking, and consuming alcohol on a daily basis. prevalence (69%) of overweight or obesity. This prevalence This obesity. or overweight of (69%) prevalence is consistent with findings of previous studies in Portugal,

older adults reported daily intake of fruit and vegetables; however, the majority had inadequate water intake. These countries. European other of those to similar are findings behaviours appear to be more common in some regions of the Portugal (especially Azores and Madeira), suggesting that a combination of these modifiable risk factors might be present within specific groups of the population. Although we performed simple descriptive analysis in study, the previous current data including Portuguese ages suggested adults that some of unhealthy lifestyle all behaviours appear to be clustered in the same population groups.

(66.6%) of Portuguese older inactive. These adults results are consistent was with data classified from Reasons for the Geographic as and Racial Differences in Stroke (REGARDS) study from middle-aged the and older adults United spend 77.4% States, of in their time in sedentary which behaviours.

EQ-5D-3L score was 0.94 for EQ-5D-3L adults 65 to 69 years old and 0.86 for individuals 85 years or older. countries as well. lifestyle, when compared with the Portuguese population. proportion high a population, Norwegian the among Indeed, physical daily of more or minutes 30 reported participants of activity, with women achieving this level of commonly activity than men more (38.7% of women

ARTIGO ORIGINAL 6. 5. 4. 3. 2. 1. REFERENCES 23. 22. 21. 20. 19. 18. 17. 16. 15. 14. 13. 12. 11. 10. 9. 8. 7. health activity, musculoskeletal physical maintaining in nutrition between adequate and time, interactions sedentary The population: older the for prescription Exercise JL. Thompson LJ, Loon van G, Wallis BJ, Shad adult the BMJ Open.2015;5:e009287. in multimorbidity study. cross-sectional a Portugal: of in care primary attending Prevalence population L. Santiago F, Prazeres Health JP. Health. 2009;99:540-8. Mackenbach Europeans of that J, with poor Americans the and rich of of health comparison a years: Banks 74 to 50 aged MM, adults US in disadvantage Glymour Gynaecol. M, Obstet Avendano Clin Res Pract 2013;27:643-59. Best strategies. preventive and world ageing an of consequences P.clinical Stratton The B, Lunenfeld population ageing população global of da acceleration coming The S. Scherbov W, Sanderson W, Lutz Envelhecimento Estatística. residente emPortugalenaUniãoEuropeia.Lisboa:INE;2015. de Nacional Instituto F e a. pRuat hw o efr a ainl ouain based population national a perform to how EpiReumaPt: al. et AF, Gouveia N, Rodrigues AM, Ramiro S, Machado P, da Costa LP, Mourao Front Nutr. 2017;4:25. symptoms. depression are and styles consumption life unhealthy meat other with high associated by characterized patterns Dietary al. et B, Andre S, Dias RD, Sousa M, Eusebio AM, Rodrigues MJ, Gregorio aiain td o a otgee eso o te optlAxey and Anxiety Depression Scale Hospital the of M. version Baltar Portuguese R, a of Meneses study A, Validation Martins T, Ferreira I, Silva J, Pais-Ribeiro patient of Measurement outcome inarthritis HR. Holman RG, Kraines P, Spitz JF, Fries 5D inPortugal EQ- the of valuation M. The Oppe LN, Pereira PL, Ferreira LN, Ferreira Portuguese EQ-5D M. Oppe LN, population norms Pereira PL, Ferreira LN, multimorbidity Ferreira existing on review systematic índices. JGerontol.2011;66A:301-11. multiple a of – measurement The diseases DB. chronic Bartels K, Berger C, Diederichs Report Series854.Geneve:WHO;1995. TechnicalWHO Committee. Expert WHO a of report anthropometry of interpretation and use the status: Physical Organization. Health World RMD Open.2016;2:e000166. survey. health national a EpiReumaPt- from results Portugal: in health their impact on health-related quality of life, physical function and mental and diseases musculoskeletal and rheumatic of Prevalence al. et PM, Machado S, Ramiro Rodrigues M, JC, Eusebio Branco N, Gouveia AM, Port. 2015;40:110-24. musculoskeletal and rheumatic of diseases study in Portugal: a detailed view the of the methodology - EpiReumaPt al. et P, Rodrigues AM, Gouveia N, da Costa LP, Eusebio M, Ramiro S , Machado - Supportingpoliciesforaninclusivesociety. 2015. Börsch-Supan A, Kneip T, Litwin H, Myck M, Weber G. Ageing in Europe the EPEPP study. Arch GerontolGeriatr. 2011;52:304-8. al. et Apopulation: Portuguese the in aging of study socio-demographic Mota-Pinto A, Rodrigues V, Botelho A, Verissimo MT, Morais A, Alves C, orge V Mt-it A d Sua , oeh A Avs , de C, Alves component analysis A, Botelho B, principal Sousa a population: Portuguese the of profile aging The CR. Oliveira de A, Mota-Pinto V, Rodrigues and Med. 2002;162:2269–76. expenditures, elderly G.Prevalence, the in conditions chronic multiple of Anderson complications B, Starfield JL, in Wolff co-morbidity of classification chronic disease pre-therapeutic The AR. indices Feinstein multimorbidity existing on review Journals Gerontol-Ser A BiolSciMedSci.2011;66A:301-11. systematic A - diseases Diederichs C, Berger K, Bartels D. The measurement of multiple chronic disease Feinstein A. inchronic ofco-morbidity classification The pre-therapeutic . Maturitas.2016;93:78-82. . JChronicDis.1970;23:455–68. . QualLifeRes.2014;23:413-23. . JChronicDis.1970;23:455-68. . QualLifeRes.2014;23:425-30. . PsycholHealthMed.2007;12:225-35. . Nature.2008;451:716-9. . Arthritis Rheum.1980;23:137-45. . JCommunityHealth.2014;39:747-52. Rodrigues AM, etal.ChallengesofageinginPortugal, ica da Ordem dos Médicos www m o c . a s e u g u t r o p a c i d e m a t c a w. w w s o c i d é M s o d m e d r O a d a c fi í t n e i C a t s i v e R . Acta Reumatol Am J Public J . Am Arch Intern Arch . . 93 25. 24. 40. 39. 38. 37. 36. 35. 34. 33. 32. 31. 30. 29. 28. 27. 26. 42. 41. 45. 44. 43. e ia nseç: oa e o sx - uoa [accessed Europa. - sexo from: por Available e 20]. Esperan total Sep nascença: 2017 à vida Esperança Contemporrâneo. de Portugal Dados de Base - PORDATA human involving research medical subjects. JAMA.2013;310:2191–4. for declaration principles association ethical medical Helsinki of World Association. Medical World study -apracticalguide older adults. A nationalcohortstudy al. Patterns of sedentary behavior and mortality in U.S. middle-aged and et VenaMM, SaffordN, JE, Colabianchi B, Hutto VJ, Howard KM, Diaz J Gerontol A BiolSciMedSci.2004;59:1277-84. across Europe: a review of the longitudinal results of the SENECApeople elderly study. in mortality and health, status, nutritional Lifestyle, WA. Staveren van M, Schroll S, Henauw de MW,Verheijden LC, Groot de population Australian South EQ-5D–5L: norms. HealthQualLifeOutcomes.2016;14:133. the using measured life of McCaffrey N, Kaambwa B, Currow DC, Ratcliffe J. Health-related quality by measured EQ-5D-3L. HealthQualLifeOutcomes.2017;15:3. elderly Dutch community-dwelling in life of Quality GA. Mangen MJ, Bolkenbaas M, Huijts SM, Werkhoven CH, Bonten MJ, Wit ageing healthy for framework policy a health: and ageing on report World The Beard JR, Officer A, de Carvalho IA, Sadana R, Pot AM, Michel JP, et al. 2016 Study Disease Lancet. 2017;390:1151-210. of Burden Global the and for analysis regional, systematic a Global, Collaborators. Death 1980-2016: death, of causes 264 for mortality specific age-sex national of Causes 2016 GBD in Trends B. Egan P,Hypertension. 2017;70:275-84. Muntner L, Chen L, 1999–2012 adults US in factors risk hypertension and prehypertension Zhang J, Li JN, Booth Equity Health.2014;13:74. J Int Country. Basque the of case the Europe: Southern in expectancy life disability-free in inequalities social in Changes S. Esnaola U, Martín 83. Rev.2013;35:75- Epidemiol adults. older in Multimordbidity ME. Salive elderly the 2014;1:410-5. in self-management socioeconomic health between and correlation The status SX. Li LN, Feng CX, Chen community a in participates senior mealprogram(1026.4) that population elderly socioeconomic low a of status Health MY. Hong M, Piwowarski JW, Min H, Tsunoda J GeriatrPsychiatry. 2008;23:1213-21. live?” we do people older of health the and Loneliness BA. Lawlor CO, Luanaigh how and we are who Luxembourg: Eurostat;2015. EU: the in people publication“ flagship the “of elderly the on focus — EUROSTAT.society ageing An 92. noughties the in poor less became adults Portuguese older how poverty: and Ageing I. CF,Andrade Rodrigues Luxembourg: 2008. Eurostat PressOffice;2010. in conditions Living release: News EUROSTAT. and otherhealthrelatedlifestylecharacteristics intake nutrient with Germany—associations in adolescents of patterns Richter A, Heidemann C, Schulze MB, Roosen ST, Mensink GB. Dietary Appetite. 2017;110:108-15. and older? and patterns years 65 food ages inhabitants Norway’s between among satisfaction life association an there Is al. et C, Nguyen MJ, Gregorio Rodrigues AM, Ferreira GA, Espnes H, Canhao B, Andre 0009.2005.00428.x. care utilization in the United States. Milbank Q. 2005;83:10.1111/j.1468- Andersen R, Newman JF. Societal and individual determinants of medical Hickson M.Malnutritionandageing - RelatórioParteII.Porto:UniversidadedoPorto; 2015-2016) (IAN-AF Física de Atividade e Nacional Inquérito Alimentar al. et S, V,Guiomar Alarcão M, Severo A, Oliveira TorresD, C, Lopes Acta MedPort2018Feb;31(2):80-93 . Lancet.2016;387:2145-54. ça+de+vida+à+nascença+total+e+por+sexo-1260. . Acta ReumatolPort.2015;40:128-36. . The FASEB Journal.2014;28. . PostgradMedJ.2006;82:2-8. . Ann InternMed.2017;167:465-75. https://www.pordata.pt/Europa/ Eur J Ageing. 2014;11:285- Ageing. J Eur . . BMCPediatr. 2012;12. 2017. n J us Sci. Nurs J Int . Int . . . .

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