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Obesity and healthcare resource utilization: results from Clinical Practice Research Database (CPRD)

C W. le Roux B. ChubbE. Nørtoft A. Borglykke

Acknowledgements: The study was funded by Novo Nordisk. We thank Christiane Lundegaard Haase of Novo Nordisk, for review comments, and Jamie Cozens, MSc, of Watermeadow Medical, an Ashfield Company, for editorial and medical writing services, which were funded by Novo Nordisk.

Declaration of interest: CWlR has been an advisory board member for Fractyl, Herbalife, GI Dynamics, and Novo Nordisk, and has received speaker’s fees from Boehringer Ingelheim, Janssen, Johnson & Johnson, Medtronic, and Sanofi. EN, BC and AB are employees of Novo Nordisk. BC is additionally a shareholder at Novo Nordisk.

Funding: Novo Nordisk, Denmark

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/osp4.291

Summary

Background/Objectives

The economic burden of obesity and type 2 diabetes (T2D) rises with increasing prevalence. This study estimates the association between obesity, healthcare‐resource utilization (HCRU) and associated costs in individuals with/without T2D.

Subjects/Methods

This observational cohort study used the United Kingdom (UK) Clinical Practice Research Datalink (CPRD) data. Between 01 January 2011 and 31 December 2015 total HCRU costs and individual component costs (hospitalizations, GP contacts, prescriptions) were calculated for individuals linked to the Hospital Episodes Statistics database with/without T2D with normal weight, overweight, class I, II, III obesity.

Results

396,091 individuals were included. Increasing BMI was associated with increased HCRU costs. At each BMI category costs were greater for individuals with than without T2D. Relative to normal BMI, increasing BMI was positively associated with increased HCRU costs, with similar magnitude regardless of T2D. The total HCRU cost for an individual with class III obesity was 1.4‐fold (£3695) greater than for normal weight.

Conclusion

In the UK, HCRU costs were positively associated with increasing BMI, irrespective of T2D status. The combination of T2D and obesity was associated with higher HCRU costs compared with individuals of the same BMI, without T2D. These findings suggest that prioritizing weight management programmes focused specifically on individuals with obesity and T2D may be more cost‐effective than for those with obesity alone.

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Identifying malnutrition: From acute care to discharge and beyond

Tyler, Renay D. DNP, RN, ACNP; Guenter, Peggi PhD, RN, FAAN

The Nurse Practitioner: April 16th, 2017 – Volume 42 – Issue 4 – p 18–24

doi: 10.1097/01.NPR.0000513334.61944.8e

Feature: NUTRITION: CE Connection

Abstract: Nutrition assessment and intervention significantly contribute to the well-being of patients. NPs should advocate that patients be appropriately evaluated and implement recommendations as part of a comprehensive care plan to avoid malnutrition in patients while they are in the hospital and when they return home.

In today’s healthcare paradigm, the responsibility of nutrition assessment and patient monitoring typically rests with the dietitian; however, nutrition has long been an important domain of nursing. In the 19th century, Florence Nightingale’s Notes on Nursing stated:

Every careful observer of the sick will agree in this that thousands of patients are annually starved in the midst of plenty, from want of attention to the ways which alone make it possible for them to take food.1

Nightingale elaborated on the importance of nutrition in both acute injury and chronic disease and gave extensive instructions regarding ways to assess patient status and provide nutrition.

Nutrition plays a key role in the disease process; individuals who are malnourished have worse outcomes than those who are well nourished. As members of healthcare teams, NPs have a significant role in facilitating timely and appropriate nutrition assessment and therapies to positively affect clinical outcomes. The NP with enhanced nutrition knowledge can deliver optimal care to acute care patients. Nutrition in medical education curricula and graduate medical education training programs is lacking, and physicians are aware that they might be inadequate in this area.

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Point Prevalence of Adult Intestinal Failure in Republic Of Ireland

*A Bell1, *N Conway1, *J Courtney1, *K Kennedy1, *Z Raubenheimer1, N Rice2, D Kevans3, C L Donohoe4, J V Reynolds4*(Equal contribution)

1School of medicine, Trinity College Dublin
2Irish Society for Clinical Nutrition and Metabolism (IrSPEN)
3Dept of Gastroenterology, St James’ Hospital, Dublin 8
4Dept of Surgery, St James’ Hospital, Dublin 8

Parenteral Nutrition (PN) is a life-saving treatment used for patients with Intestinal Failure (IF). PN is complex and demands highly specialised care to avoid serious complications in the home setting. All tertiary centres in the Republic of Ireland (ROI) were contacted to assess the prevalence of IF requiring PN and complications, over a one year period. Sixty-seven patients were treated across 15 centres: a period prevalence of 14.6 and 9.6 patients per million for long-term PN and home PN respectively. Three-quarters of patients experienced at least one major complication with 18% mortality rate over the study period. There were 2.86 admissions per HPN patient, each lasting mean 13.4 days. One-third experienced catheter-related infections. There was a reduced length of stay during emergency re-admissions in high volume centres (mean 31 v 43 days, p=0.17). The establishment of a National Centre for IF/HPN in ROI is integral to reducing PN-associated complications.

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Computed tomography diagnosed cachexia and sarcopenia in 725 oncology patients: is nutritional screening capturing hidden malnutrition?

Éadaoin B. Ní Bhuachalla, Louise E. Daly, Derek G. Power, Samantha J. Cushen, Peter MacEneaney, Aoife M. Ryan

Abstract

Background

Nutrition screening on admission to hospital is mandated in many countries, but to date, there is no consensus on which tool is optimal in the oncology setting. Wasting conditions such as cancer cachexia (CC) and sarcopenia are common in cancer patients and negatively impact on outcomes; however, they are often masked by excessive adiposity. This study aimed to inform the application of screening in cancer populations by investigating whether commonly used nutritional screening tools are adequately capturing nutritionally vulnerable patients, including those with abnormal body composition phenotypes (CC, sarcopenia, and myosteatosis).

Methods

A prospective study of ambulatory oncology outpatients presenting for chemotherapy was performed. A detailed survey incorporating clinical, nutritional, biochemical, and quality of life data was administered. Participants were screened for malnutrition using the Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), and the Nutritional Risk Index (NRI). Computed tomography (CT) assessment of body composition was performed to diagnose CC, sarcopenia, and myosteatosis according to consensus criteria.

Results

A total of 725 patients (60% male, median age 64 years) with solid tumours participated (45% metastatic disease). The majority were overweight/obese (57%). However, 67% were losing weight, and CT analysis revealed CC in 42%, sarcopenia in 41%, and myosteatosis in 46%. Among patients with CT-identified CC, the MUST, MST, and NRI tools categorized 27%, 35%, and 7% of them as ‘low nutritional risk’, respectively. The percentage of patients with CT-identified sarcopenia and myosteatosis that were categorised as ‘low nutritional risk’ by MUST, MST and NRI were 55%, 61%, and 14% and 52%, 50%, and 11%, respectively. Among these tools, the NRI was most sensitive, with scores <97.5 detecting 85.8%, 88.6%, and 92.9% of sarcopenia, myosteatosis, and CC cases, respectively. Using multivariate Cox proportional hazards models, NRI score < 97.5 predicted greater mortality risk (hazard ratio 1.8, confidence interval: 1.2–2.8, P = 0.007).

Conclusions

High numbers of nutritionally vulnerable patients, with demonstrated abnormal body composition phenotypes on CT analysis, were misclassified by MUST and MST. Caution should be exercised when categorizing the nutritional risk of oncology patients using these tools. NRI detected the majority of abnormal body composition phenotypes and independently predicted survival. Of the tools examined, the NRI yielded the most valuable information from screening and demonstrated usefulness as an initial nutritional risk grading system in ambulatory oncology patients.

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 A survey of bolus feeding practices in the UK home enteral feeding population

Simons, S. White, S. Topen, L. Snell, C. Murphy, R. Collins, J. Davies, A. Owen, J. Barker, L. Green, Patel, J. Ridgway, J. Lenchner, J. Faerber, L. Pearce, H. Meanwell, N. Kominek, L. Janik, H. Best, T. Stevens, G.P. Hubbard, R.J. Stratton

OC14 DOI: http://dx.doi.org/10.1016/j.clnesp.2017.07.019

The British Artificial Nutrition Survey (2011) suggests that over 26,600 adult patients receive home enteral tube feeding (HETF) in the UK [1], and that this population is a mix of those who are bed bound/sedentary and those who are very active. Anecdotal evidence from clinicians suggests that the use of bolus feeding regimens is increasing compared to continuous/overnight feeding, allowing feeding to fit in with patient and carer lifestyles, however there is very little published evidence and understanding of this growing practice in HETF in the UK. Therefore a preliminary survey to investigate and characterise the numbers and types of adult HETF patients receiving a bolus feeding regimen was undertaken.

A survey of adult (≥18 years) tube fed patients (total n=1833), who were receiving part or all of their tube feeding via a bolus feeding regimen, was undertaken across 10 HETF services in the UK between November 2015 and May 2016. A standardised questionnaire, which included patient demographics (age, gender, primary diagnosis, residential status, working status, activity level), tube type and feeding regimen details (type of feed, method, duration) and reasons for bolus feeding, was completed for each patient from their dietetic notes.

Patients with bolus tube feeding regimens represented 33% (n=609) of the total HETF population surveyed. Bolus fed patients (mean age 58 years (SD 20, range 18–97), 59% male), had an average time on tube feeding of 4 years 1 month (SD 4 years 6 months, range 2 months–23 years 7 months) and an average time on a bolus feeding regimen of 3 years 6 months (SD 3 years 11 months, range 26 days–20 years 4 months). The majority of patients (73%) were fed via percutaneous endoscopic gastrostomy (PEG), resided in their own/family homes (70%) or in nursing homes (23%), and most patients were either bed/chair bound or very sedentary (69%), with the majority of patients not working (61%) or being retired (34%). Only 2% of patients were working. The most common primary diagnosis was head and neck cancer (21%), followed by stroke (16%) and cerebral palsy (12%). The head and neck cancer population were found to be much more active (78%) than the rest of the bolus fed population (30%), (seated work – moderate exercise). Of the patients surveyed, the large majority (74%) were using bolus feeding as their primary method of tube feeding either via syringe (51%) or by gravity feeding (40%). The most common reasons for choosing a bolus feeding regimen were: to top up the oral diet (20%), to mimic meal times (16%), easy (15%) and quick (12%) to use. The most commonly used feeds for bolus feeding were oral nutritional supplements (59%), with the highest proportion of these (51%) being 2.4 kcal/ml compact-style supplements.

We understand this to be the largest survey of its kind specifically assessing the demographics and feeding practices of adult bolus fed patients in the UK, and showing that 1/3 of HETF patients are bolus fed. This survey largely demonstrates similarities between the demographics of those on bolus feeding regimens and the total HETF population as reported in BANS [1], although there does appear to be a dominant subgroup of head and neck cancer patients, who may be bolus feeding for different reasons. Further research is required to understand this patient group, possibly with the inclusion of specific questions regarding bolus feeding being included in future BANS surveys.

Reference

[1] Smith T, Micklewright A, Hirst A, Stratton RJ, Baxter J. Annual BANS Report 2011. Artificial Nutrition Support in the UK 2000–2010. BAPEN.

Costs of Malnutrition in Institutionalized and Community-Dwelling Older Adults: A Systematic Review

Pedro Abizanda, MD, PhD, Alan Sinclair, MD, FRCP, Núria Barcons, RDN, Luis Lizán, MD, Leocadio Rodríguez-Mañas, MD, PhD

Objectives

The aim of this study was to assess health economics evidence published to date on malnutrition costs in institutionalized or community-dwelling older adults.

Design

A systematic search of the literature published until December 2013 was performed using standard literature, international and national electronic databases, including MedLine/PubMed, Cochrane Library, ISI WOK, SCOPUS, MEDES, IBECS, and Google Scholar. Publications identified referred to the economic burden and use of medical resources associated with malnutrition (or risk of malnutrition) in institutionalized or community-dwelling older adults, written in either English or Spanish. Costs were updated to 2014 (€).

Results

A total of 9 studies of 46 initially retrieved met the preestablished criteria and were submitted to thorough scrutiny. All publications reviewed involved studies conducted in Europe, and the results regarding the contents of all the studies showed that total costs associated with malnutrition in institutionalized and community-dwelling older adults were considerably higher than those of well-nourished ones, mainly due to a higher use of health care resources (GP consultations, hospitalizations, health care monitoring, and treatments). Interventions to reduce the prevalence of malnutrition, such as the use of oral nutritional supplements, showed an important decrease in-hospital admissions and medical visits.

Conclusion

Malnutrition is associated with higher health care costs in institutionalized or community-dwelling older adults. The adoption of nutritional interventions, such as oral nutritional supplements, may have an important impact in reducing annual health care costs per patient.

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A Healthy Weight for Ireland: Obesity Policy and Action Plan 2016 – 2025

Department of Health

This Obesity Policy and Action Plan is the result of the Government’s desire to assist its people to achieve better health and in particular to
reduce the levels of overweight and obesity.

It also acknowledges that the solutions are multiple and that every sector has a role in reducing the burden of this condition.

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Lack of sleep as a contributor to obesity in adolescents: impacts on eating and activity behaviors.

Chaput JP, Dutil C

Sleep is an important contributor to physical and mental health; however, chronic sleep deprivation has become common in adolescents, especially on weekdays. Adolescents aged 14-17 years are recommended to sleep between 8 and 10 h per night to maximize overall health and well-being. Although sleep needs may vary between individuals, sleep duration recommendations are important for surveillance and help inform policies, interventions, and the population of healthy sleep behaviors. Long sleepers are very rare among teenagers and sleeping too much is not a problem per se; only insufficient sleep is associated with adverse health outcomes in the pediatric population. Causes of insufficient sleep are numerous and chronic sleep deprivation poses a serious threat to the academic success, health and safety of adolescents. This article focuses on the link between insufficient sleep and obesity in adolescents.

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Sarcopenia in daily practice: assessment and management

BMC GeriatricsBMC series

Sarcopenia is increasingly recognized as a correlate of ageing and is associated with increased likelihood of adverse outcomes including falls, fractures, frailty and mortality. Several tools have been recommended to assess muscle mass, muscle strength and physical performance in clinical trials. Whilst these tools have proven to be accurate and reliable in investigational settings, many are not easily applied to daily practice.

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Interaction of obesity and inflammatory bowel disease

Jason W Harper and Timothy L Zisman

Inflammatory bowel disease (IBD) is a chronic inflammatory condition of unknown etiology that is thought to result from a combination of genetic, immunologic and environmental factors. The incidence of IBD has been increasing in recent decades, especially in developing and developed nations, and this is hypothesized to be in part related to the change in dietary and lifestyle factors associated with modernization. The prevalence of obesity has risen in parallel with the rise in IBD, suggesting a possible shared environmental link between these two conditions. Studies have shown that obesity impacts disease development and response to therapy in patients with IBD and other autoimmune conditions. The observation that adipose tissue produces pro-inflammatory adipokines provides a potential mechanism for the observed epidemiologic links between obesity and IBD, and this has developed into an active area of investigative inquiry. Additionally, emerging evidence highlights a role for the intestinal microbiota in the development of both obesity and IBD, representing another potential mechanistic connection between the two conditions. In this review we discuss the epidemiology of obesity and IBD, possible pathophysiologic links, and the clinical impact of obesity on IBD disease course and implications for management.

 

Effect of anaemia on hand grip strength, walking speed, functionality and 1 year mortality in older hospitalized patients

Etienne Joosten Elke Detroyer Koen Milisen

Anaemia is a common problem in hospitalized older patients and is recognized as a risk factor for a significant number of adverse outcomes. Data of the effect of anaemia on functional status during hospitalization and mortality after discharge are limited. Aim of the study is to examine whether there is an association between anaemia, hand grip strength, gait speed and basic activities of daily living (ADL) during hospitalization and mortality 1 year after discharge in geriatric patients.

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New ESPEN guidelines on nutrition in cancer patients

As survival and quality of life of patients with cancer dramatically improved over the last few years, the management of medical nutrition became critically important for these patients. The tolerance and safety of all modalities of anti-cancer treatment are indeed conditioned by the nutritional status. Hence, the clinicians involved in the care of these patients need a pragmatic review of the currently available evidence in the area of oncology/hematology more than in any other chronic condition. These evidence based ESPEN guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative.

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