Nutritional status in hospitalized patients: prevalence, déterminants and impact on hospital stay, mortality and costs

Undernutrition is a frequent condition among hospitalized patients, leading to increased morbidity, mortality, length of hospital stay, and health costs. However, few studies have reported undernutrition prevalence and its management in Switzerland. Indeed, very little information exists for Switzerland regarding the factors associated with undernutrition and its impact on health outcomes and health costs. This project thus aimed to better characterize the prevalence, determinants, management, and consequences of undernutrition among hospitalized patients in Switzerland. To achieve this, five studies were conducted: one literature review, two cross-sectional studies, one diagnostic accuracy study, and one trend analysis. The initial literature review showed that in Europe, undernutrition represents a considerable economic burden, representing as much as 10% of total national health expenditures. The first cross-sectional study was conducted in the Lausanne university hospital and showed that three out of five hospitalized patients are ‘at-risk’ of undernutrition, but only half of them were nutritionally managed; the study also showed that nutritionally ‘at-risk’ patients had higher in- hospital mortality and costs, while their reimbursement rates were lower. Further, the diagnostic accuracy study showed that, despite a good specificity (87%), undernutrition-related codes in hospital discharge data had low sensitivity (43%) and positive predictive values (28%), thus precluding adequate evaluation of prevalence rates of undernutrition. The second cross-sectional analysis focused on hospital discharge data for whole Switzerland; it showed considerable regional variations regarding the reporting of undernutrition and its management, highlighting the absence of standardized procedures for the whole country. Analysis of hospital discharge data for whole Switzerland for the period 1998-2014 showed a several-fold increase in the prevalence of reported undernutrition-related codes (e.g. from 0.18% to 2.13% in Ticino and from 0.23% to 5.63% in Mittelland). Nevertheless, in 2014, still 40% of hospitalizations with an undernutrition-related code had no indication of nutritional management. Overall, this project provided some important information regarding the prevalence, determinants, and impact of undernutrition in Swiss hospitals. The results will hopefully serve as reference for future intervention studies. -- La dénutrition est une condition fréquente parmi les patients hospitalisés, augmentant la morbi-mortalité, la durée du sàjour, et les coûts de la santé. Peu d’études se sont intéressées à la prévalence de la dénutrition et sa prise en charge en Suisse. En fait, il existe très peu d’information concernant les déterminants de la dénutrition et ses conséquences sur la santé et les coûts. L’objectif de ce travail était de mieux caractériser la prévalence, les déterminants, la prise en charge et les conséquences de la dénutrition parmi les patients hospitalisés en Suisse. Pour ce faire, cinq études ont été conduites : une revue de la littérature, deux études transversales, une étude diagnostique et une analyse temporelle. La revue de la littérature a montré qu’en Europe la dénutrition représente un coût financier considérable, pouvant aller jusqu’à 10% des dépenses nationales de santé. La première étude transversale a été conduite à l’hôpital universitaire de Lausanne et a montré que trois patients sur cinq étaient à risque de dénutrition, mais que seulement la moitié bénéficiait d’une prise en charge. Cette étude a également montré que les patients à risque avaient une plus grande mortalité intra-hospitalière et coûtaient plus cher, alors que les taux de remboursement étaient moindres. Par ailleurs, l’étude diagnostique a montré que le codage de la dénutrition avait une bonne spécificité (87%) mais une mauvaise sensibilité (43%) et une valeur prédictive positive faible (28%), ce qui limite l’estimation de la prévalence de la dénutrition par l’utilisation des codes. La seconde étude transversale a porté sur les données de la statistique hospitalière suisse ; elle a montré de grandes disparités régionales concernant le codage et la prise en charge de la dénutrition, dues à l’absence de recommandations au niveau national. Finalement, l’analyse temporelle de la statistique hospitalière suisse pour la période 1998-2014 a montré une augmentation considérable de la fréquence des codes de dénutrition (de 0.18% à 2.13% au Tessin et de 0.23% a 5.63% an Mittelland). Néanmoins, en 2014, encore 40% des hospitalisations ayant un code de dénutrition n’avaient pas de code associé à une intervention nutritionnelle. Dans l’ensemble, ce travail a permis d’obtenir des données concernant la prévalence, les déterminants et l’impact de la dénutrition dans les hôpitaux suisses. Nous espérons que ces résultats pourront servir de référence pour de futures études d’intervention

Prospective association between adherence to the Mediterranean diet and hepatic steatosis: the Swiss CoLaus cohort study

Objective: The Mediterranean diet has been promoted as a healthy dietary pattern, but whether the Mediterranean diet may help to prevent hepatic steatosis is not clear. This study aimed to evaluate the prospective association between adherence to the Mediterranean diet and risk of hepatic steatosis. Design: Population-based prospective cohort study. Setting: The Swiss CoLaus Study. Participants: We evaluated 2288 adults (65.4% women, aged 55.8±10.0 years) without hepatic steatosis at first follow-up in 2009–2012. Adherence to the Mediterranean diet was scaled as the Mediterranean diet score (MDS) based on the Mediterranean diet pyramid ascertained with responses to Food Frequency Questionnaires. Outcome measures: New onset of hepatic steatosis was ascertained by two indices separately: the Fatty Liver Index (FLI, ≥60 points) and the non-alcoholic fatty liver disease (NAFLD) score (≥−0.640 points). Prospective associations between adherence to the Mediterranean diet and risk of hepatic steatosis were quantified using Poisson regression. Results: During a mean 5.3 years of follow-up, hepatic steatosis was ascertained in 153 (6.7%) participants by FLI criteria and in 208 (9.1%) by NAFLD score. After multivariable adjustment, higher adherence to MDS was associated with lower risk of hepatic steatosis based on FLI: risk ratio 0.84 (95% CI 0.73 to 0.96) per 1 SD of MDS; 0.85 (0.73 to 0.99) adjusted for BMI; and 0.85 (0.71 to 1.02) adjusted for both BMI and waist circumference. When using NAFLD score, no significant association was found between MDS and risk of hepatic steatosis (0.95 (0.83 to 1.09)). Conclusion: A potential role of the Mediterranean diet in the prevention of hepatic steatosis is suggested by the inverse association observed between adherence to the Mediterranean diet and incidence of hepatic steatosis based on the FLI. The inconsistency of this association when hepatic steatosis was assessed by NAFLD score points to the need for accurate population-level assessment of fatty liver and its physiological markers

Description of Ultra-Processed Food Intake in a Swiss Population-Based Sample of Adults Aged 18 to 75 Years.

Ultra-processed foods (UPFs) are associated with lower diet quality and several non-communicable diseases. Their consumption varies between countries/regions of the world. We aimed to describe the consumption of UPFs in adults aged 18-75 years living in Switzerland. We analysed data from the national food consumption survey conducted among 2085 participants aged 18 to 75 years. Foods and beverages resulting from two 24-h recalls were classified as UPFs or non-UPFs according to the NOVA classification, categorized into 18 food groups, and linked to the Swiss Food Composition Database. Overall, the median energy intake [P25-P75] from UPFs was 587 kcal/day [364-885] or 28.7% [19.9-38.9] of the total energy intake (TEI). The median intake of UPFs relative to TEI was higher among young participants (<30 years, p = 0.001) and those living in the German-speaking part of Switzerland (p = 0.002). The food groups providing the most ultra-processed calories were confectionary, cakes & biscuits (39.5% of total UPF kcal); meat, fish & eggs (14.9%); cereal products, legumes & potatoes (12.5%), and juices & soft drinks (8.0%). UPFs provided a large proportion of sugars (39.3% of total sugar intake), saturated fatty acids (32.8%), and total fats (31.8%) while providing less than 20% of dietary fibre. Consumption of UPFs accounted for nearly a third of the total calories consumed in Switzerland. Public health strategies to reduce UPF consumption should target sugary foods/beverages and processed meat

Causal and associational language in observational health research: a systematic evaluation

We estimated the degree to which language used in the high profile medical/public health/epidemiology literature implied causality using language linking exposures to outcomes and action recommendations; examined disconnects between language and recommendations; identified the most common linking phrases; and estimated how strongly linking phrases imply causality. We searched and screened for 1,170 articles from 18 high-profile journals (65 per journal) published from 2010-2019. Based on written framing and systematic guidance, three reviewers rated the degree of causality implied in abstracts and full text for exposure/outcome linking language and action recommendations. Reviewers rated the causal implication of exposure/outcome linking language as None (no causal implication) in 13.8%, Weak 34.2%, Moderate 33.2%, and Strong 18.7% of abstracts. The implied causality of action recommendations was higher than the implied causality of linking sentences for 44.5% or commensurate for 40.3% of articles. The most common linking word in abstracts was “associate” (45.7%). Reviewer’s ratings of linking word roots were highly heterogeneous; over half of reviewers rated “association” as having at least some causal implication. This research undercuts the assumption that avoiding “causal” words leads to clarity of interpretation in medical research

Effects of ground flaxseed supplementation on cardiovascular disease among hemodialysis patients at a goverment hospital, in Tehran, Iran

The leading cause of death in patients with chronic kidney disease including dialysis patients is cardiovascular disease (CVD). Approximately 50% of deaths in these patients are related to CVD. Among patients undergoing hemodialysis (HD), one of the major risk factors for CVD is lipid abnormalities. Besides, low level of serum albumin and high concentration of serum systemic inflammation markers, especially C-reactive protein (CRP) are important risk factors for CVD among patients undergoing HD. The present study was conducted to investigate the effects of flaxseed supplementation on cardiovascular risk factors among patients undergoing HD. This was a randomized interventional study involving 38 patients on maintenance HD (20 males, 18 females) with lipid abnormalities (Triglyceride > 2.26 mmol/L and/or high density lipoprotein-cholesterol < 1.1 mmol/L) in the age range of 23 to 77 years. Patients enrolled in the study did not have diabetes, inflammatory diseases, or infection disease, and none of them received omega-3 fatty acid supplement and lipid lowering drugs. They were randomly assigned to either a flaxseed or control group (n=19). Subjects in the flaxseed group received 40 g/d ground flaxseed for 8 weeks, whereas subjects in the control group consumed their usual diet, without any flaxseed supplementation. The outcomes of the study were evaluated at baseline, week 4 and 8. The primary outcomes were serum lipid profile, serum CRP and serum albumin levels. The secondary outcome measures were anthropometric measurements and dietary intake (assessed by 2- day record and one day food recall). In this study, serum concentrations of triglyceride (TG; p < 0.001), total cholesterol (TC; p < 0.01), and low density lipoprotein-cholesterol (LDL-C; p < 0.01) decreased significantly within the flaxseed group over time by 30%, 14% and 17%, respectively. There were significant increases in serum concentrations of TG, TC, and LDL-C within the control group by 21%, 15% and 8%, respectively. The mean changes in serum TG, TC, and LDL-C were statistically significant from baseline to week 4 (p < 0.05) and 8 (p < 0.001) between the two groups. Serum high density lipoprotein-cholesterol (HDL-C) and serum albumin increased significantly by 16% and 9%, respectively within the flaxseed group over time (p < 0.01). There was significant reduction in serum HDL-C and albumin level within the control group over time by 10% and 5%, respectively. Serum CRP concentration reduced significantly by 31% within the flaxseed group over time (p < 0.05), whereas no significant change was observed in the control group. The mean changes in serum CRP was significant difference between the two groups (p < 0.05). Baseline dietary intakes data were comparable with the exception of the control group having higher intake of dietary fiber than the flaxseed group (p < 0.05). At baseline, mean intakes of energy, protein, carbohydrate and dietary fiber in a large percentage of the subjects in both groups were lower than the recommended intakes. At week 8, subjects in the flaxseed group achieved the recommendation for energy (30.5 ± 9 kcal/ kg body weight/day), protein (1.2 ± 0.36 g/kg body weight/day) and dietary fiber (25 ± 4 g/d). In conclusion, 40 g/d flaxseed supplementation for 8 weeks improved lipid profiles and serum albumin level and reduces systemic inflammation in patients on maintenance HD with lipid abnormalities in addition to an overall dietary improvement

Evaluating and rethinking public health for the 21st century ::toward vulnerable population interventions

Public health preventive interventions aim to improve population health through two main approaches. Firstly, individual-centered interventions seek to change knowledge and behaviors of individuals identified as at high risk of disease. Secondly, population-centered interventions are delivered across the whole population, without prior detection of individuals at increased risk of disease (1). Population-centered interventions can address three types of health determinants: (i) the personal behaviors (e.g., mass media campaigns to improve diet), (ii) the physical environment (e.g., clean air and water policies), and (iii) the social and economic environment (e.g., safe housing provision). Despite the significant role of both individual- and populationcentered approaches in improving population health during the last decades, health inequities between socially, culturally, or financially disadvantaged groups within populations are increasing, at least for some health outcomes (2). This is partly due to shortcomings of both individual- and population-centered approaches. Learning from modern public health history and given the health emergencies such as the COVID-19 pandemic, this commentary argues that 21st-century public health should mainly invest in vulnerable population interventions. This approach aims to decrease health inequities between socially defined groups and is a necessary complement to population-centered interventions

Importance of collecting data on socioeconomic determinants from the early stage of the COVID-19 outbreak onwards

International audienceDisadvantaged socioeconomic position (SEP) is widely associated with disease and mortality, and there is no reason to think this will not be the case for the newly emerged coronavirus disease 2019 (COVID-19) that has reached a pandemic level. Individuals with a more disadvantaged SEP are more likely to be affected by most of the known risk factors of COVID-19. SEP has been previously established as a potential determinant of infectious diseases in general. We hypothesise that SEP plays an important role in the COVID-19 pandemic either directly or indirectly via occupation, living conditions, health-related behaviours, presence of comorbidities and immune functioning. However, the influence of socioeconomic factors on COVID-19 transmission, severity and outcomes is not yet known and is subject to scrutiny and investigation. Here we briefly review the extent to which SEP has been considered as one of the potential risk factors of COVID-19. From 29 eligible studies that reported the characteristics of patients with COVID-19 and their potential risk factors, only one study reported the occupational position of patients with mild or severe disease. This brief overview of the literature highlights that important socioeconomic characteristics are being overlooked when data are collected. As COVID-19 spreads worldwide, it is crucial to collect and report data on socioeconomic determinants as well as race/ethnicity to identify high-risk populations. A systematic recording of socioeconomic characteristics of patients with COVID-19 will be beneficial to identify most vulnerable groups, to identify how SEP relates to COVID-19 and to develop equitable public health prevention measures, guidelines and interventions