Abstract

Aim: To evaluate the association between anemia and some activities of daily living associated with feeding and the difficulty in chewing and swallowing. Methods: Cross-sectional study, which examined 1256 individuals, aged 60 or older who were part of the third collection of the SABE Study (Health, Well-Being and Aging). We classified as anemic men with blood haemoglobin ≤ 13 g/dL and women with values ≤ 12 g/dL. Results: Prevalence of anemia was higher in individuals who reported reduction in food consumption due to chewing and swallowing complaints, in individuals with difficulty to chew and in individuals who reported difficulty to feed themselves due to chewing and swallowing complaints. Anemia was also more prevalent in those with difficulty to feed themselves and to shop for food. In the analyses, the presence of chewing and swallowing complaints was associated with a chance of anemia almost 2 times greater than for individuals without complaints, and the presence of 2 or 3 chewing and swallowing complaints was associated with a 2.7 chance of anemia. Conclusion: The presence of difficulties in chewing and swallowing were associated with higher prevalence of anemia, even after adjustment for other factors, with a dose-response effect, indicating the importance of a multidisciplinary work with older adults.

Key words
Anemia; Older adults; Functionality

Introduction

Anemia is defined as the reduction in the level of hemoglobin circulating in the blood, and it can be triggered by several pathophysiological mechanisms. Values below 12.0 g/dL for women and 13.0 g/dL for men are considered pathologic¹1 World Health Organization (WHO). Iron deficiency anaemia: assessment, prevention and control: a guide for programme managers. Geneva: WHO; 2001..

Anemia is common in older adults and its prevalence is greater with the increase in age²2 Corona LP, Duarte YAO, Lebrão ML. Prevalence of anemia and associated factors in older adults: evidence from the SABE Study. Rev Saude Publica 2014; 48(5):723-731.

3 Costa ED, Soares MC, Oliveira CCD. Prevalência e caracterização da anemia em idosos atendidos em um centro médico no interior de Sergipe. Nutr. Clín. Diet. Hosp. 2016; 36(4):65-72.^-44 Silva CLAD, Lima-Costa MF, Firmo JO, Peixoto SV. Anemia e nível de hemoglobina como fatores prognósticos da mortalidade entre idosos residentes na comunidade: evidências da Coorte de Idosos de Bambuí, Minas Gerais, Brasil. Cad Saude Publica 2013; 29(11):2241-2250.. Previous studies show prevalence varying between 4.5% and 10.2%⁴4 Silva CLAD, Lima-Costa MF, Firmo JO, Peixoto SV. Anemia e nível de hemoglobina como fatores prognósticos da mortalidade entre idosos residentes na comunidade: evidências da Coorte de Idosos de Bambuí, Minas Gerais, Brasil. Cad Saude Publica 2013; 29(11):2241-2250.^,55 Santos IS, Scazufca M, Lotufo PA, Menezes PR, Bensenor IM. Anemia and dementia among the elderly: the São Paulo Ageing & Health Study. Int Psychogeriatr 2012; 24(1):74-81.. Anemia can be a misdiagnosed condition in older adults, seeing as the belief that this condition is inherent to the aging of human beings is still very common among health professionals. However, the condition has been associated with reduction in the performance of activities of daily living, and may increase morbidity and mortality⁶6 Devens LT. Anemia. In: Freitas EVD, Py L, Neri AL, Cançado FAX, Doll J, Gorzoni ML, organizadores. Tratado de geriatria e gerontologia. Rio de Janeiro: Guanabara Koogan; 2011. p. 1179-1190.^,77 Milagres CS, Franceschini SCC, Priore SE, Lima LM, Ribeiro AQ. Prevalência e etiologia da anemia em idosos: uma revisão integral. Medicina (Ribeirao Preto. Online) 2015; 48(1):99-107..

Anemia can have various causes in older adults, as a reflection of an underlying chronic illness, poor diet, blood loss or other possible causes. It is estimated that anemia caused by nutritional deficiency corresponds to one-third of all causes³3 Costa ED, Soares MC, Oliveira CCD. Prevalência e caracterização da anemia em idosos atendidos em um centro médico no interior de Sergipe. Nutr. Clín. Diet. Hosp. 2016; 36(4):65-72.^,77 Milagres CS, Franceschini SCC, Priore SE, Lima LM, Ribeiro AQ. Prevalência e etiologia da anemia em idosos: uma revisão integral. Medicina (Ribeirao Preto. Online) 2015; 48(1):99-107.^,88 Guralnik JM, Eisenstaedt RS, Ferrucci L, Klein HG, Woodman RC. Prevalence of anemia in persons 65 years and older in the United States: evidence for a hight rate of unexplained anemia. Blood 2004; 104(8):2263-2268..

As life expectancy has been increasing in recent years, the evaluation of the functional capacity of older adults is generally carried out through the maintenance of their activities of daily living, which are usually divided into two groups: the basic activities of daily living (BADL) and the instrumental activities of daily living (IADL). The BADL relate to everyday activities associated with the individual’s self-care, such as personal hygiene, feeding, bathing and dressing. The IADL are more complex tasks that are often related with the individual’s social participation, such as: answering phones, shopping, using means of transport, among others⁹9 Pereira EEB, Souza ABFD, Carneiro SR, Sarges EDSNF. Funcionalidade global de idosos hospitalizados. Rev Bras Geriatr Gerontol 2014; 17(1):165-176..

In addition, as the individual ages, their chewing habits change. It is known that dental problems, when associated with speech problems, as well as with aging, may be harmful to health¹⁰10 Ayres A, Teixeira AR, Martins MD, Gonçalvez AK, Olchik MR. Análise das Funções do Sistema Estomatognático em Idosos Usuários de Prótese Dentária. Rev Bras Cien Saúde 2016; 20(2):99-106.. Therefore, these factors can disrupt the individual’s routine, because even if the older adult’s functional capability is in its normal state, chewing and swallowing affect his/her manner of eating and diet, which may be associated with anemia in these individuals.

Thus, considering all the aforementioned factors, it is necessary that health professionals pay special attention to characteristics associated with anemia in older individuals.

However, the Brazilian literature still has very few studies on the topic. So far, there are no articles that have associated the prevalence of anemia with the oral and food functionality of older adults. Therefore, this article seeks to evaluate the association between the occurrence of anemia and some activities of daily living related to feeding, as well as reports on the difficulty in chewing and swallowing of older adults from the city of São Paulo.

Methods

This research uses data from the SABE study (Health, Well-Being and Ageing), a longitudinal research conducted with older adults from the city of São Paulo which carried out four rounds of data collection, the first one having been held in 2000, with a probabilistic sample of 2143 older adults (≥ 60 years of age). The older adults were reassessed in 2006 (n = 1,115) when a new cohort (n = 298), also probabilistic and representative of the urban older population with 60 to 64 years of age from the same municipality, was introduced. Using the same methodology, the third wave of studies was conducted in 2010, within the same location of the 2000 and 2006 cohorts, and including a new cohort, with 60 to 64 years of age (n = 355). More details about the design of the study are described in other publications²2 Corona LP, Duarte YAO, Lebrão ML. Prevalence of anemia and associated factors in older adults: evidence from the SABE Study. Rev Saude Publica 2014; 48(5):723-731.^,1111 Corona LP, Andrade FD, Duarte YAO, Lebrão ML. The relationship between anemia, hemoglobin concentration and frailty in Brazilian older adults. J Nutr Health Aging 2015; 19(9):935-940..

This study is based on data from the third collection, seeing as the inclusion of biochemical tests occurred on this occasion. Thus, the sample used in this study includes 1256 individuals with 60 years of age or older who had valid data related to blood parameters in 2010.

Our dependent variable was the presence of anemia. Men with blood haemoglobin lower than 13 g/dL and women with values lower than 12 g/dL were considered anemic, based on the classification proposed by the World Health Organization¹1 World Health Organization (WHO). Iron deficiency anaemia: assessment, prevention and control: a guide for programme managers. Geneva: WHO; 2001..

The independent variables of interest are a) chewing and swallowing complaints; b) indicative features of daily life activities associated with food.

For the evaluation of the chewing and swallowing complaints that affect the social and psychosocial well-being of older adults, we used some questions that are part of the Geriatric Oral Health Assessment Index (GOHAI), developed especially for the older population and which has been validated by several countries ever since it was first proposed¹²12 Carvalho C, Manso AC, Escoval A, Salvado F, Nunes C. Tradução e validação da versão portuguesa do Geriatric Oral Health Assessment Index (GOHAI). Rev. Port. Saúde Publica 2013; 31(2):153-159..

The survey applied consists of 12 questions that relate to the influence that chewing and swallowing complaints can have on older adults, whether physical, psychosocial or related to pain and/or discomfort¹²12 Carvalho C, Manso AC, Escoval A, Salvado F, Nunes C. Tradução e validação da versão portuguesa do Geriatric Oral Health Assessment Index (GOHAI). Rev. Port. Saúde Publica 2013; 31(2):153-159.. The issues that were assessed in this study are: “How many times have you had problems chewing hard foods like meat or apples?”, “How many times were you not able to eat the things you wanted due to problems with your teeth or your dentures?”. The older adults who answered “sometimes”, “rarely” or “never” were considered as having no chewing and swallowing complaints, and the older adults who answered “always” or “often” were considered as having chewing and swallowing complaints. In addition, a question that is part of the questionnaire of the SABE study was used, it being: “Have you been eating less due to digestive problems or have you been experiencing lack of appetite or difficulty chewing or swallowing for the past 3 months?” These questions were condensed to compose the independent variable of the study, named “chewing and swallowing complaints”, with the answers to these questions having been categorized in: no chewing and swallowing complaints; 1 chewing and swallowing complaint; 2 or more chewing and swallowing complaints.

For evaluation of the activities of daily living, the following questions were used: “Do you have trouble eating on your own?”, “Do you have trouble preparing a hot meal?”, and “Do you have trouble purchasing food?” Difficulty was considered when these questions were answered positively.

The control variables used were: gender, age (categorized in: 60 to 69 years old; 70 to 79 years old; ≥ 80 years old), education level (categorized in: elementary school; secondary education; higher education), Body Mass Index (BMI) (categorized in: underweight (< 23 kg/m²); eutrophy (≥ 23 and < 28 kg/m²); overweight (≥ 28 e < 30 kg/m²); obesity (≥ 30 kg/m²), according to the recommendations of the Pan American Health Organization¹³13 Organização Pan-Americana da Saúde (OPAS). Informe preliminar da 36ª Reunión del Comité Asesor de Investigaciones em Salud: Encuesta Multicéntrica-Salud Bienestar y Envejecimento (SABE) em América Latina y el Caribe. Washington: OPAS; 2002., number of referred chronic diseases (including systemic arterial hypertension, diabetes mellitus, cancer, chronic obstructive pulmonary disease, cardiovascular disease, stroke, osteoarthritis), which were categorized in: no disease; one disease; two or more diseases.

For the statistical analysis of the study variables, relative frequency distributions, mean values and standard errors for the continuous variables and, for the categorical variables, proportions, were all estimated. The differences between the groups were estimated using Wald’s generalized test of equality between averages and the χ²2 Corona LP, Duarte YAO, Lebrão ML. Prevalence of anemia and associated factors in older adults: evidence from the SABE Study. Rev Saude Publica 2014; 48(5):723-731. test with Rao-Scott correction, which take into account sampling weights for the estimates with population weighting.

To analyze the association between functionality, chewing and swallowing and anemia, Poisson’s regression analysis was used, with calculation of the unadjusted and adjusted prevalence ratios (PR), in which the dependent variable was the presence of anemia. We kept control variables when they were associated with anemia and that remained significant in the model, or that adjusted any of the variables of interest in at least 10%.

The variables were included in the model in hierarchical steps, namely: model 1 was adjusted for sociodemographic conditions; in model 2, comorbidities were included as proxy for the health conditions; and in model 3, the ADL were included.

All analyses were performed using the Stata® 13 software, by applying the sampling weights to ensure the representativeness of the population of the city of São Paulo. The critical value used was p < 0.05.

Results

Table 1 presents the distribution of older adults according to socioeconomic and health characteristics. The majority of the population was female, aged 60 to 69 years old, with education up to primary school, and with BMI within the normal range. Hypertension was the most prevalent chronic disease (67.56%) and 57.84% of the older adults reported two or more diseases.

Table 2 shows the distribution of anemia in the older adults according to functionality features and chewing and swallowing complaints. The prevalence of anemia was significantly higher in individuals who reported a reduction in food consumption due to chewing and swallowing complaints, as well as in individuals with difficulty to chew and in individuals who reported difficulty to feed themselves due to chewing and swallowing complaints. Anemia was also more prevalent in those with difficulty to feed themselves and to shop for food. However, anemia was less prevalent in individuals with difficulty to prepare a hot meal in relation to those who had no difficulty in doing so.

Figure 1 shows the average hemoglobin in relation to the chewing and swallowing complaints. The average blood concentration of hemoglobin is greater in the older adults who reported having no reduction in food consumption, difficulty chewing and difficulty feeding themselves, when compared with the older adults who did.

Table 3 presents the results of Poisson’s multiple regression analysis. In univariate analyses, the presence of chewing and swallowing complaints was associated with a chance of anemia almost 2 times greater than for individuals without complaints, and the presence of 2 or 3 chewing and swallowing complaints was associated with a 2.7 chance. The presence of difficulties in the ADL associated with feeding was not significant in the gross analysis, but it was maintained to adjust the other variables. In the final model (model 3), the presence of chewing and swallowing complaints remains significant, showing a dose-response effect - association is greater in older adults with two or more complaints when compared to the presence of a single complaint.

Discussion

The results of this study show that the complaints associated with oral health (chewing and swallowing) have association with the presence of anemia. Oral health has been associated with inadequate nutritional status in older individuals¹³13 Organização Pan-Americana da Saúde (OPAS). Informe preliminar da 36ª Reunión del Comité Asesor de Investigaciones em Salud: Encuesta Multicéntrica-Salud Bienestar y Envejecimento (SABE) em América Latina y el Caribe. Washington: OPAS; 2002.

14 Silva DD, Held RBD, Torres SVDS, Souza MDLRD, Neri AL, Antunes JLF. Self-perceived oral health and associated factors among the elderly in Campinas, Southeastern Brazil, 2008-2009. Rev Saude Publica 2011; 45(6):1145-1153.^-1515 Mesas AE, Andrade SMD, Cabrera MAS, Bueno VLRC. Salud oral y déficit nutricional en adultos mayores no institucionalizados en Londrina, Paraná, Brasil. Rev Bras Epidemiol 2010; 13(3):434-445.. Silva et al.¹⁴14 Silva DD, Held RBD, Torres SVDS, Souza MDLRD, Neri AL, Antunes JLF. Self-perceived oral health and associated factors among the elderly in Campinas, Southeastern Brazil, 2008-2009. Rev Saude Publica 2011; 45(6):1145-1153. show that the worst indicators of oral health changes were associated with progressive degrees of biological frailty, as well as with significant increase in the GOHAI index. Mesas et al.¹⁵15 Mesas AE, Andrade SMD, Cabrera MAS, Bueno VLRC. Salud oral y déficit nutricional en adultos mayores no institucionalizados en Londrina, Paraná, Brasil. Rev Bras Epidemiol 2010; 13(3):434-445. show that the negative perception of oral health was associated with nutritional deficit. But this seems to be the first Brazilian study with these results.

Oral health is often cited as an indicator of quality of life, since changes such as dental loss and difficulty chewing influence the life of individuals and may affect feeding¹⁶16 Teixeira MFN, Martins AB, Celeste RK, Hugo FN, Hilgert JB. Associação entre resiliência e qualidade de vida relacionada à saúde bucal em idosos. Rev Bras Epidemiol 2015; 18(1):220-233.^,1717 Nascimento TLH, Liberalesso NA, Balbinot HJ, Neves HF. Association between underweight and overweight/obesity with oral health among independently living Brazilian elderly. Nutrition 2013; 29(1):152-157.. Ayres et al.¹⁰10 Ayres A, Teixeira AR, Martins MD, Gonçalvez AK, Olchik MR. Análise das Funções do Sistema Estomatognático em Idosos Usuários de Prótese Dentária. Rev Bras Cien Saúde 2016; 20(2):99-106. mention that the use of removable dental prosthesis leads to instability in chewing, causing insecurity in the user, who will consequently abstain from eating certain foods.

Despite most older adults not acknowledging lack of teeth as a negative factor in relation to chewing ability¹⁸18 Benedetti TRB, Mello ALSFD, Gonçalves LHT. Idosos de Florianópolis: autopercepção das condições de saúde bucal e utilização de serviços odontológicos. Cien Saude Colet 2007; 12(6):1683-1690., the studies show that older people who had less teeth reported their chewing ability negatively, seeing as chewing and speech skills are indicators of quality of life¹⁴14 Silva DD, Held RBD, Torres SVDS, Souza MDLRD, Neri AL, Antunes JLF. Self-perceived oral health and associated factors among the elderly in Campinas, Southeastern Brazil, 2008-2009. Rev Saude Publica 2011; 45(6):1145-1153.^,1919 Hugo FN, Hilgert JB, Sousa MDLR, Silva DD, Pucca GA. Correlates of partial tooth loss and edentulism in the Brazilian elderly. Community Dent Oral Epidemiol 2007; 35(3):224-232..

In addition, the older people who needed to use complete dentures reported a negative impact in relation to the self-perception of their oral health, especially with regard to the chewing function. One explanation is that the symptoms of pain are easily perceived by older adults as interfering with their daily activities¹⁴14 Silva DD, Held RBD, Torres SVDS, Souza MDLRD, Neri AL, Antunes JLF. Self-perceived oral health and associated factors among the elderly in Campinas, Southeastern Brazil, 2008-2009. Rev Saude Publica 2011; 45(6):1145-1153.^,2020 Nunes CIP, Abegg C. Factors associated with oral health perception in older Brazilians. Gerodontology 2008; 25(1):42-48.^,2121 Gilbert GH, Heft MW, Duncan RP, Ringelberg ML. Perceived need for dental care in dentate older adults. Int Dent J 1994; 44(2):145-152., which is therefore consistent with the results found in this study.

Lamlakar and Parashram²²22 Lamlakar AS, Parashram RM. Oral submucous fibrosis and iron deficiency anemia: A clinical study. J Cont Med A Dent 2016; 4(1):09-16. showed that the deficiencies of B vitamins, iron and other trace elements derived from nutritional depletion may lead to anemia, which can persist due to improper food intake, becoming a vicious cycle.

The association between anemia and oral health can also reside in the fact that iron, which is the nutrient responsible for great part of nutritional anemias⁸8 Guralnik JM, Eisenstaedt RS, Ferrucci L, Klein HG, Woodman RC. Prevalence of anemia in persons 65 years and older in the United States: evidence for a hight rate of unexplained anemia. Blood 2004; 104(8):2263-2268.^,2323 Bianchi VE. Anemia in the Elderly Population. J Hematol 2015; 3(4):95-106., has red meats as major sources, which require great chewing and swallowing efforts. Thus, an individual who has difficulty with these functionalities can begin restricting firmer foods, preferring those with softer consistency, thus compromising the nutritional quality of their meals.

Red meats, in addition to being more fibrous, are more expensive and therefore less accessible, having their consumption limited in older adults with poor socio-economic conditions²⁴24 Levy-Costa RB, Sichieri R, Pontes NS, Monteiro CA. Disponibilidade domiciliar de alimentos no Brasil: distribuição e evolução (1974-2003). Rev Saude Publica 2005; 39(4):530-540.. In the same way, access to health and dental services can be compromised in less-favored populations²⁵25 Lima-Costa MF, Barreto S, Giatti L, Uchôa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica 2003; 19(3):745-757., which could be an aggravating factor in this association. This is due to the fact that older adults do not see the need for oral treatment, a lower education level being associated with lower frequency of use of dental health services²⁵25 Lima-Costa MF, Barreto S, Giatti L, Uchôa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica 2003; 19(3):745-757.^,2626 Moreira RS, Nico LS, Tomita NE, Ruiz T. A saúde bucal do idoso brasileiro: revisão sistemática sobre o quadro epidemiológico e acesso aos serviços de saúde bucal. Cad Saude Publica 2005; 21(6):1665-1675..

Just like the human body, the swallowing mechanism also experiences a normal aging process. This occurs due to the deterioration of the nerve function and to the decrease in the muscle mass of the brain-dependent region, which affects the swallowing mechanism negatively. It is clear that age is a factor that affects this mechanism over time²⁷27 Aslam M, Vaezi MF. Dysphagia in the Elderly. Gastroenterol Hepatol 2013; 9(12):784-795..

Characterized as a condition of difficulty in swallowing food, dysphagia, from the Greek dys (difficulty) and phagia (to eat), is the feeling that food cannot be moved from the mouth to the stomach. However, despite the physiological changes in the mechanism of swallowing caused by the aging process, dysphagia should not be attributed in an isolated manner to normal aging, and its presence suggests that there should be an investigation to identify potentially treatable causes²⁷27 Aslam M, Vaezi MF. Dysphagia in the Elderly. Gastroenterol Hepatol 2013; 9(12):784-795..

Among these causes, it is possible to list some diseases, such as stroke, amyotrophic lateral sclerosis, Parkinson’s disease, among others - all of them feature an increase in prevalence with aging²⁷27 Aslam M, Vaezi MF. Dysphagia in the Elderly. Gastroenterol Hepatol 2013; 9(12):784-795.^,2828 Khan A, Carmona R, Traube M. Dysphagia in the elderly. Clin Geriatr Med 2014; 30(1):43-53.. With the rapid growth of population aging, dysphagia is increasingly recognized as an important national health issue, being associated with high costs to health²⁷27 Aslam M, Vaezi MF. Dysphagia in the Elderly. Gastroenterol Hepatol 2013; 9(12):784-795..

Another factor that can cause dysphagia is the use of some medications. It is known that with the individual’s aging, his/her health problems tend to increase, thereby increasing the intake of medicines throughout the day²⁷27 Aslam M, Vaezi MF. Dysphagia in the Elderly. Gastroenterol Hepatol 2013; 9(12):784-795.. Drugs can interfere with the swallowing function in different ways, damaging the transit of food through the esophagus, increasing the incidence and severity of dysphagia. In addition, drugs that cause xerostomia may affect the ability to chew food, interfering with the swallowing process. Finally, some drugs have an increased risk of mouth infections, causing the patients to develop difficulty in retaining their dentures, interfering in food chewing and swallowing²⁷27 Aslam M, Vaezi MF. Dysphagia in the Elderly. Gastroenterol Hepatol 2013; 9(12):784-795..

In our study, the prevalence of anemia was higher in older adults with older age and in those with low education level. Bianchi²³23 Bianchi VE. Anemia in the Elderly Population. J Hematol 2015; 3(4):95-106. noted, in his study, an association between the prevalence of anemia in relation to gender and older ages, that is, 85 years or older. Older age and lower education level may also be associated with the increased reports of chewing and swallowing complaints, as described by Cardoso et al.²⁹29 Cardoso SV, Olchik MR, Teixeira AR. Alimentação de idosos institucionalizados: correlação entre queixas e características sociodemográficas. Distúrbios Comun 2016; 28(2):278-285.. Therefore, these two groups seem to have higher chances for both conditions - anemia and oral problems.

This study shows higher prevalence of anemia in older people with difficulties in some activities of daily living, however, this association did not remain significant in the regression analysis. Milagres et al.⁷7 Milagres CS, Franceschini SCC, Priore SE, Lima LM, Ribeiro AQ. Prevalência e etiologia da anemia em idosos: uma revisão integral. Medicina (Ribeirao Preto. Online) 2015; 48(1):99-107. also report having found no significant association between functional capacity and anemia. On the other hand, Bosco et al.³⁰30 Bosco RM, Assis EPS, Pinheiro RR, Queiroz LCV, Pereira LSM, Antunes CMF. Anemia and functional capacity in elderly Brazilian hospitalized patients. Cad Saude Publica 2013; 29(7):1322-1332. reported significant association between the presence of anemia and reduced functional capacity. The authors also concluded that older adults who live alone have greater functional capacity in relation to those who live with family members. This is due to the fact that older adults with low functional capacity need third-party assistance in their daily activities.

The results of this research should be interpreted with caution, since this is a cross-sectional study, that is, a cause-and-effect relationship between chewing and swallowing complaints and anemia cannot be established. The use of hemoglobin levels as an indicator of anemia can also be indicated as limitation, since the literature has studies that show natural reduction in hemoglobin levels as inherent to the ageing process³¹31 Salive ME, Cornoni-Huntley J, Guralnik JM, Phillips CL, Wallace RB, Ostfeld AM, Cohen HJ. Anemia and hemoglobin levels in older persons: relationship with age, gender, and health status. J Am Geriatr Soc 1992; 40(5):489-496.^,3232 Schaan MDA, Schwanke CH, Bauer M, Luz C, Cruz IM. Hematological and nutritional parameters in apparently healthy elderly individuals. Revista Brasileira de Hematologia e Hemoterapia 2007; 29(2):136-143.. On the other hand, there are few longitudinal studies that deal with this subject, thus, there are no consolidated opinions about this aspect of aging³²32 Schaan MDA, Schwanke CH, Bauer M, Luz C, Cruz IM. Hematological and nutritional parameters in apparently healthy elderly individuals. Revista Brasileira de Hematologia e Hemoterapia 2007; 29(2):136-143., and, in addition, the World Health Organization’s definition of hemoglobin-based anemia is currently still in force.

This study also has strong points, such as the fact of it including a large probabilistic sample originated from the largest Brazilian city, and therefore, the results presented here should be taken into consideration in subsequent studies, as they may guide the actions in health and nutrition for the older population.

In conclusion, the importance of a multidisciplinary work with older adults, involving nutritionists, dentists and audiologists, becomes clear, due to the association between anemia and chewing and swallowing problems, to support the process of recovery from anemia of these individuals, as well as improve their quality of life and diet.

Acknowledgments

The authors thank Prof. Maria Lucia Lebrão (in memory) for her valuable work in the coordination of the SABE Study, the Foundation of Support to Research of the State of São Paulo (FAPESP) for financing the Study, and the Fund of Support to Teaching, Research and Extension (FAEPEX) of Unicamp for financing the research initiation scholarship.

References

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