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Inserm publishes its Collective Expert Review on multiple disabilities

handicap© Julie Borgese

Inserm has published a new Collective Expert Review on the theme of multiple disabilities, commissioned by the French National Solidarity Fund for Autonomy (CNSA). During the 3 years it took to prepare it, a group of 12 experts reviewed over 3400 documents from the international scientific literature available as at the second half of 2023. The conclusions and recommendations of this Collective Expert Review provide useful new elements to improve care and help answer questions regarding the consideration, interactions and integration of people with multiple disabilities.

The term ‘multiple disabilities’ refers to the permanent consequences of a lesion (genetic or accidental) that occurs during the brain’s development and results in severe motor impairment and intellectual disability evaluated as severe to profound. Multiple disabilities are associated not just with extremely restricted communication, autonomy and mobility, but also with comorbidities, sensory impairment and behavioural disorders.

In France, the prevalence of multiple disabilities is currently estimated at around 0.3-0.5 people in every 1000.

 

Complex clinical care

The situations caused by multiple disabilities differ greatly from one person to another, with many disorders that are interlinked. Each must be taken into account when setting up care.

For example, epilepsy, which is very common, presents as a veritable secondary disability. As for respiratory disorders, they constitute the leading cause of mortality and emergency hospitalisation among people with multiple disabilities.

Other disorders that are commonly encountered include:

  • difficulty feeding oneself, digestive and nutritional disorders;
  • due to very limited mobility, bone fragility in children and osteoporosis in adults, excessively weak muscle tone, posture defects and orthopaedic deformities (scoliosis, hip dislocation, etc.);
  • frequent sleep disorders in children (significantly impacting the quality of life of those around them);
  • disruptions to puberty (late or early).

Pain, often multifactorial, is common, sometimes chronic from an early age, and rarely expressed through the usual modes of communication (such as verbal complaints). This makes it difficult to evaluate, leading to the risk of underestimating it. Generally dependent on a third party (healthcare professional or caregiver), such evaluation therefore raises ethical and methodological questions.

The expert group recommends:

  • for motor disorders: rehabilitation via adapted interventions aimed at promoting voluntary movements and motor learning; on a daily basis, prevention of the consequences of impaired motor activity by reducing passive activities (watching television for example) in favour of movement-based activities;
  • for intellectual disability: promotion of interaction-generating environments for people with multiple disabilities and their integration into everyday social spaces, with the appropriate conditions and trained personnel. An appropriate and soothing environment makes it possible to improve the common behavioural disorders (self-aggression, repetitive behaviours, etc.) that are largely linked to living environment;
  • for pain: systematically screen for its presence, evaluate its intensity, frequency and duration using specific validated tools and search for its cause(s) using a detailed examination;

more globally: generalise validated methods for evaluating quality of life, combining different objective approaches in a complementary manner (evaluations by medical staff, parents and other people close to the patient) and self-evaluation.

A French cohort of children and adults with multiple disabilities (Eval-PLH) is ongoing. Future data will make it possible to evaluate, for example, the mortality rate and causes of death of people with multiple disabilities.

 

Support and social integration of people with multiple disabilities

Alongside medical care, multiple disabilities involve lifelong comprehensive and individualised support, in order to offer people a life plan that is appropriate to their various needs and their personal development pathway. Evaluation of the skills, difficulties (medical, psychological, interpersonal) and methods of communication of people with multiple disabilities must be carried out regularly.

This support is crucial in terms of educational and social aspects, particularly for the core subject of being able to communicate, but also for learning, schooling, inclusion and social participation. People with multiple disabilities have the possibility to learn throughout their lives if the right arrangements are made. Some skills, if stimulated in early childhood, improve socialisation and communication over the long term. In addition, people with multiple disabilities can participate in various activities of daily and social life thanks to certain aids, methods and tools that make their environment more suitable.

The expert group recommends:

  • using the severity rating scale for multiple disabilities, validated in French to evaluate individual skills and difficulties;
  • enabling children with multiple disabilities to have access to education tailored to their needs and enabling them to develop their capacities to the fullest;
  • reflecting on the types of learning that benefit children with multiple disabilities in order to build a ‘tailored’ educational pathway within teaching units involving teams from both specialised institutions and ordinary schools;
  • implementing a combination of several modes of communication (voice, touch, gaze, gestures, etc.) and Augmentative and Alternative Communication (AAC) individually adapted to the person’s motor and cognitive abilities and enabling both communication and mutual understanding – this may be a succession of gestures (for example, inspired by sign language) or objects with a precise meaning, but also technological means.

 

The central roles of those close to people with multiple disabilities

Because of their dependence and extreme physical and psychological vulnerability, people with multiple disabilities need a high level of care and attention. The family, other people close to them and professionals are therefore highly impacted on the practical (care, day-to-day organisation) and emotional levels and play a prominent role in support. The evaluation of needs, their coordinated implementation and their adaptation to advancing age demand a multidisciplinary approach and complex coordination between carers.

While the French system (care for people with multiple disabilities, approval of reference and competence centres for multiple disabilities of rare causes) is likely to meet the various life-long needs of the people concerned, the coordination and continuity of the care pathway is not always optimal.

Thus the transition to adulthood, a continuous process that starts between 13 and 15 years of age, remains difficult with medical, social and legal implications for the individual and their family. The severity of multiple disabilities grows with age, consequently increasing the level of dependence. The end of life of people with multiple disabilities also raises many challenges relating to ethics and resources.

Intimacy and affectivity are essential for someone who is in a situation of total physical dependence and without a unified perception of their body. Affection and attention therefore play a decisive role in care and learning.

When it applies to someone whose mental life and psychological and emotional development develop in an atypical way, the question of sexuality finds itself confronted against communication problems and ethical questions.

Finally, in a context where the person is entirely dependent on the interpretations of their communication partners, the high level of vulnerability – physical, psychological and communicational – which characterises multiple disabilities reinforces the risks of abuse (voluntary or involuntary), which can accumulate.

The expert group recommends:

  • conducting early identification and diagnosis of multiple disabilities in children, involving families from the outset and providing adequate support;
  • offering early interventions while promoting care in inclusive early childhood environments in partnership with specialised services;
  • to prevent institutional abuse, the establishment of practice analysis groups, solid ongoing training, a culture of well-treatment and a monitoring unit in institutions and departments. However, the experts warn that these measures cannot replace sufficient human resources with the appropriate equipment;
  • to prevent parental abuse, take into account the psychological suffering of parents and encourage pair work and group- and multidisciplinary exchanges. Patient organisations and social media discussion groups are ways of limiting the effects of social exclusion, especially for parents forced to give up work;
  • to guard against forms of involuntary or passive abuse (laissez-faire, negligence, lack of knowledge, etc.) that may be linked to inappropriate care, interpersonal habits likely to intensify communicational vulnerability, or even an underestimation of the person’s cognitive abilities that may lead to a negation of their psychological life;
  • to recognise and take into account the person’s manifestations of sexuality, to question what the modes of this sexuality may be; to not neglect emotional life by clearly distinguishing it from the questions of sexuality.
For more information: the summary of the Multiple Disabilities Collective Expert Review will be published on 11 June on the dedicated page of the Inserm website. This will be followed by the full version of the Collective Expert Review on 12 June.

To consult them: inserm.fr/expertise-collective

The Inserm Collective Expert Reviews

Developed by Inserm since 1993, the Collective Expert Reviews constitute an approach to evaluating and summarising scientific knowledge on public health themes.

These Collective Expert Reviews respond to the requests from institutions wishing to have recent research data at their disposal. Their objective is to share knowledge and provide independent scientific insights into specific health questions, to aid public decision-making in the field of population health.

The scientific framework, bibliographic support, coordination and promotion of the Collective Expert Reviews are ensured by the Inserm Collective Expert Review Unit.

Health of children born after medically assisted reproduction: no increased overall cancer risk, but a slightly increased leukaemia risk has not been ruled out

Embryon obtenu après une fécondation in vitroEmbryo obtained after in vitro fertilisation (five days after in vitro fertilisation and culture). © Prof. P. Fauque, Dijon University Hospital

Inserm scientists from the Epidemiology of Childhood and Adolescent Cancers team (EPICEA – Inserm JRU 1153)[1] and the EPI-PHARE scientific interest group (ANSM/Cnam), together with experts in medically assisted reproduction (MAR), have published in JAMA Network Open the findings of a large-scale study aimed at comparing the risk of cancer in children conceived by MAR with that of children conceived naturally. Involving over 8.5 million children born in France between 2010 and 2021, this is one of the largest studies conducted to date on the risk of cancer in children conceived by MAR.

Although the study does not show an increased overall risk of cancer among children born after MAR, it does suggest a very slight increase in their risk of leukaemia.

MAR concerns approximately 1 in 30 births in France (see box). The available data, which remain limited and heterogeneous, have suggested increased risks of certain health conditions, including cancers, among children conceived through it. Large-scale evaluation of the cancer risk is essential and constitutes a priority research objective, as a recent report from the French National Academy of Medicine shows[2].

Scientists from Inserm and EPI-PHARE, in conjunction with specialists in MAR, evaluated this cancer risk in one of the world’s largest cohorts of children born after MAR.

They used data from the French National Health Data System (SNDS)[3] to identify children conceived by MAR (artificial insemination, conventional in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI)) and to detect the onset of cancer in children conceived with or without the use of MAR.

All in all, the study concerned the 8 526 306 children born in France between 2010 and 2021, of whom 260 236 (3%) were conceived by MAR, and followed them up to a median age of 6.7 years.

During this follow-up, 9 256 children, including 292 conceived by MAR, developed cancer. The overall risk of cancer was no higher in the children conceived by MAR than in those conceived naturally.

However, a slight increase in leukaemia risk was observed in the children conceived by IVF or ICSI. This increase is very small – representing one additional case per 5 000 newborns conceived by IVF or ICSI having reached 10 years of age – and requires confirmation.

While the absence of an increased overall risk of cancer is reassuring, the epidemiological monitoring will be continued in order to better evaluate the cancer risk over the longer term. It is also necessary to continue research efforts in order to understand which mechanisms related to MAR techniques or parental fertility disorders could induce the increased risk of leukaemia, should this be confirmed.

Medically assisted reproduction (MAR) helps couples to conceive when doing so naturally would be difficult or impossible. The techniques most frequently used are artificial insemination,  conventional in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) with the transfer of fresh or frozen embryos.

In this cohort, 60 106 of the children were born after artificial insemination, 133 965 after fresh embryo transfer and 66 165 after frozen embryo transfer following ICSI or conventional IVF.

For more information on these techniques, visit the websites of Inserm or the French Agency of Biomedicine.

This study received funding from the ANSM.

 

[1] The team is based at the Centre for Research in Epidemiology and Statistics – CRESS (Inserm/Université Paris Cité).

[2] Jouannet P, Claris O, Le Bouc Y. Rapport 23-07. Santé à moyen et à long terme des enfants conçus par fécondation in vitro (FIV). Bull Acad Ntle Med 2023; 207: 695-705.

[3] The SNDS, which groups France’s main existing public health databases, aims to improve knowledge of medical care and broaden the scope of research, studies and evaluations in the field of health.

The consumption of certain food additive emulsifiers could be associated with the risk of developing type 2 diabetes

cornets de glaceEmulsifiers are among the most commonly used additives. They are often added to processed and packaged foods such as certain industrial cakes, biscuits and desserts, as well as yoghurts, ice creams… © Kenta Kikuchi sur Unsplash

Emulsifiers are among the additives most widely used by the food industry, helping to improve the texture of food products and extend their shelf life. Researchers from Inserm, INRAE, Université Sorbonne Paris Nord, Université Paris Cité and Cnam, as part of the Nutritional Epidemiology Research Team (CRESS-EREN), studied the possible links between the dietary intake of food additive emulsifiers and the onset of type 2 diabetes between 2009 and 2023. They analysed the dietary and health data of 104 139 adults participating in the French NutriNet-Santé cohort study, specifically evaluating their consumption of this type of food additive using dietary surveys conducted every six months. The findings suggest an association between the chronic consumption of certain emulsifier additives and a higher risk of diabetes. The study is published in Lancet Diabetes & Endocrinology.

In Europe and North America, 30 to 60% of dietary energy intake in adults comes from ultra-processed foods. An increasing number of epidemiological studies suggest a link between higher consumption levels of ultra-processed foods with higher risks of diabetes and other metabolic disorders.

Emulsifiers are among the most commonly used additives. They are often added to processed and packaged foods such as certain industrial cakes, biscuits and desserts, as well as yoghurts, ice creams, chocolate bars, industrial breads, margarines and ready-to-eat or ready-to-heat meals, in order to improve their appearance, taste and texture and lengthen shelf life. These emulsifiers include for instance mono- and diglycerides of fatty acids, carrageenans, modified starches, lecithins, phosphates, celluloses, gums and pectins.

As with all food additives, the safety of emulsifiers had been previously evaluated by food safety and health agencies based on the scientific evidence that was available at the time of their evaluation. However, some recent studies suggest that emulsifiers may disrupt the gut microbiota and increase the risk of inflammation and metabolic disruption, potentially leading to insulin resistance and the development of diabetes.

For more information: read Inserm’s report on type 2 diabetes

For the first time worldwide, a team of researchers in France has studied the relationships between the dietary intakes of emulsifiers, assessed over a follow-up period of maximum 14 years, and the risk of developing type 2 diabetes in a large study in the general population.

The results are based on the analysis of data from 104 139 adults in France (average age 43 years; 79% women) who participated in the NutriNet-Santé web-cohort study (see box below) between 2009 and 2023.

The participants completed at least two days of dietary records, collecting detailed information on all foods and drinks consumed and their commercial brands (in the case of industrial products). These dietary records were repeated every six months for 14 years, and were matched against databases in order to identify the presence and amount of food additives (including emulsifiers) in the products consumed. Laboratory assays were also performed in order to provide quantitative data. This allowed a measurement of chronic exposure to these emulsifiers over time.

During follow-up, participants reported the development of diabetes (1056 cases diagnosed), and reports were validated using a multi-source strategy (including data on diabetes medication use). Several well-known risk factors for diabetes, including age, sex, weight (BMI), educational level, family history, smoking, alcohol and levels of physical activity, as well as the overall nutritional quality of the diet (including sugar intake) were taken into account in the analysis.

After an average follow-up of seven years, the researchers observed that chronic exposure – evaluated by repeated data – to the following emulsifiers was associated with an increased risk of type 2 diabetes:

  • carrageenans (total carrageenans and E407; 3% increased risk per increment of 100 mg per day)
  • tripotassium phosphate (E340; 15% increased risk per increment of 500 mg per day)
  • mono- and diacetyltartaric acid esters of mono- and diglycerides of fatty acids (E472e; 4% increased risk per increment of 100 mg per day)
  • sodium citrate (E331; 4% increased risk per increment of 500 mg per day)
  • guar gum (E412; 11% increased risk per increment of 500 mg per day)
  • gum arabic (E414; 3% increased risk per increment of 1000 mg per day)
  • xanthan gum (E415; 8% increased risk per increment of 500 mg per day)

This study constitutes an initial exploration of these relationships, and further investigations are now needed to establish causal links. The researchers mentioned several limitations of their study, such as the predominance of women in the sample, a higher level of education than the general population, and generally more health-promoting behaviours among the NutriNet-Santé study participants. Therefore caution is needed when extrapolating the conclusions to the entire French population.

The study is nevertheless based on a large sample size, and the researchers have accounted for a large number of factors that could have led to confounding bias. They also used unique, detailed data on exposure to food additives, down to the commercial brand name of the industrial products consumed. In addition, the results remain consistent through various sensitivity analyses[1], which reinforces their reliability.

These findings are issued from a single observational study for the moment, and cannot be used on their own to establish a causal relationship. They need to be replicated in other epidemiological studies worldwide, and supplemented with toxicological and interventional experimental studies, to further inform the mechanisms linking these food additive emulsifiers and the onset of type 2 diabetes. However, our results represent key elements to enrich the debate on re-evaluating the regulations around the use of additives in the food industry, in order to better protect consumers,’ explain Mathilde Touvier, Research Director at Inserm, and Bernard Srour, Junior Professor at INRAE, lead authors of the study.

Among the next steps, the research team will be looking at variations in certain blood markers and the gut microbiota linked to the consumption of these additives, to better understand the underlying mechanisms. The researchers will also look at the health impact of additive mixtures and their potential ‘cocktail effects.’ They will also work in collaboration with toxicologists to test the impact of these exposures in in vitro and in vivo experiments, to gather more arguments in favour of a causal link.

NutriNet-Santé is a public health study coordinated by the Nutritional Epidemiology Research Team (CRESS-EREN, Inserm/INRAE/Cnam/Université Sorbonne Paris Nord/Université Paris Cité) which, thanks to the commitment and loyalty of over 170 000 participants (known as Nutrinautes), advances research into the links between nutrition (diet, physical activity, nutritional status) and health. Launched in 2009, the study has already given rise to over 270 international scientific publications. In France, a call to recruit new participants is still ongoing in order to continue to further public research into the relationship between nutrition and health.

By devoting a few minutes per month to answering questionnaires on diet, physical activity and health through the secure online platform  etude-nutrinet-sante.fr, the participants contribute to furthering knowledge, towards a healthy and more sustainable diet.

[1] Sensitivity analyses in epidemiology aim to test the robustness of statistical models by varying certain parameters, hypotheses or variables in the model to assess the stability of the associations observed. For example, in this study, additional account was taken of sweetener consumption, weight gain during follow-up and other metabolic diseases.

A study on the pre-COVID-19 health of French citizens to help decision-makers reduce the disease burden

StéthoscopeA new study provides an overview of the health of French citizens just prior to the 2019 pandemic and its evolution from 1990 to 2019 © Unsplash

In order to implement suitable public health policies, it is crucial to know the health status of the population and its evolution over time. This knowledge is all the more important given the severe disruptions caused by the COVID-19 pandemic to healthcare systems worldwide. For the first time, a study by teams from Inserm, Université de Bordeaux and Bordeaux University Hospital in collaboration with Santé publique France, French National Health Insurance (CNAM) and the Global Burden of Disease (GBD) study collaborators, provides an overview of the health of French citizens just prior to the 2019 pandemic, and its evolution from 1990 to 2019. This research also compares the French situation with that of other European countries, resulting in an accurate assessment to guide public decision-making and reflect on the more general impact of COVID-19 on French health. The study findings have been published in The Lancet Regional Health.

The COVID-19 pandemic has disrupted the organisation of healthcare systems and exacerbated problems that many countries, including France, were already facing, such as inequalities in healthcare access, hospital pressures and shortages of healthcare professionals. In order to address these challenges beyond the usual surveillance systems, it is essential to make a more accurate diagnosis of the health of French citizens prior to the COVID-19 crisis, particularly in an attempt to analyse its specific impact on different health indicators.

This is the proposal of a new study by teams from Inserm, Université de Bordeaux and Bordeaux University Hospital, in collaboration with Santé publique France and French National Health Insurance (CNAM). This study evaluated several French health indicators in 2019 prior to the pandemic, as well as their evolution from 1990 to 2019, and offers a comparison of France’s situation with that of other Western European countries over the same period.

The added value of GBD data

The Global Burden of Disease (GBD) study, coordinated by the Institute for Health Metrics and Evaluation, has been conducted since 1990 by a global network of 5,647 employees across 152 countries and territories. The 2019 study analyses 286 causes of death, 369 diseases and injuries, and 87 risk factors in 204 countries and territories. GBD has been used to inform health policies in many nations and local jurisdictions, as well as by international organisations such as the World Bank and World Health Organization.

However, this wealth of data had never previously been used and presented specifically for France to describe the health evolution of its citizens through indicators reflecting sociodemographic status, life expectancy, healthy life expectancy and years lived with disability.

Some definitions

Life expectancy: this is the life expectancy at birth, which represents the average life expectancy of a fictitious generation subject to the age-specific mortality conditions prevailing that year.

Healthy life expectancy: this is the average life in good health, i.e. without irreversible limitation of activity in daily life or disability – of a fictitious generation subject to the conditions of mortality and morbidity prevailing that year.

Years of life lost: this is an indicator of premature mortality. It represents the number of life years lost due to a disease having caused premature death in relation to the life expectancy of the population.

Years lived with disability: this is an indicator used to estimate morbidity – i.e. the ‘weight of a disease’ in terms of disability – in years lived with the disability for a given disease. This number of years is weighted according to the nature of the disability.

Disability-adjusted life-years (DALYs): this is the number of years of healthy life years ‘lost’ due to illness, disability or death and is the sum of the two previous indicators (Years of life lost + Years lived with disability).

Improved life expectancy and healthy life expectancy

The results of the analysis confirm that over the period considered (1990 to 2019), life expectancy at birth in France had improved over time, from 77.2 years in 1990 to 82.9 years in 2019, ranking it seventh in terms of life expectancy among the 23 western European countries studied. What is more, the French live longer in good health on average, with their healthy life expectancy having also increased – this time from 67 to 71.5 years, and placing the country in fourth position.

The increase in healthy life expectancy makes it possible to hypothesise on the improvements made in certain areas, such as better care or more appropriate prevention, thereby limiting the development of diseases. This study thus makes it possible to estimate the burden of diseases according to their impact on the various GBD indicators.

Compared to other European countries, cardiovascular diseases play a smaller role in morbidity and mortality in France.

‘We have observed that the stroke and ischaemic heart disease burden is lower in France than in other Western European countries. This finding, which has been seen in the past, could be explained by a lower prevalence of many cardiovascular risk factors (hypertension, diabetes) and a healthier lifestyle (exercise, diet) in France. Efforts must continue to be made to prevent and treat these diseases, whose prevalence nevertheless continues to remain high,’ explain the authors.

It is also important to provide better care for mental health disorders (particularly depressive- and anxiety disorders) and musculoskeletal disorders (particularly low back pain) which represent the main reasons for years lived with disability.

The study also highlights the progress that needs to be made in preventing cancer, particularly by continuing efforts to combat smoking. In France, as in other European countries, cancer is still the leading cause of mortality.

‘Overall, these findings highlight a marked trend towards the improvement of health in France. They should encourage decision-makers to design intervention strategies to reduce the burden of morbidity and mortality, paying particular attention to causes such as cancer, cardiovascular diseases, mental health and musculoskeletal disorders,’ the authors point out.

This study is therefore a valuable resource, complementing the regular epidemiological surveillance conducted by Santé publique France in particular, to guide public policies and implement relevant measures to improve prevention initiatives and access to healthcare. It is also an important first step towards improving our understanding of the impact of the COVID-19 pandemic on the health of French people. The same study will now have to be carried out with the data collected at the end of the health crisis on these same key indicators, in order to highlight any changes in the population’s health.

The consumption of certain food additive emulsifiers may increase the risk of cancer

© Mathilde Touvier/Inserm

Emulsifiers are among the additives most widely used by the food industry, helping to improve the texture of food and extend its shelf life. Researchers from Inserm, INRAE, Université Sorbonne Paris Nord, Université Paris Cité and Cnam, as part of the Nutritional Epidemiology Research Team (CRESS-EREN), have undertaken to study the possible links between the dietary intake of food additive emulsifiers and the development of cancer. They analysed the health data of 92 000 adults participating in the French NutriNet-Santé cohort study, specifically evaluating their consumption of this type of food additive. The results of this research, published in PLoS Medicine, suggest an association between the intake of certain emulsifiers and an increased risk of cancer – particularly of the breast and prostate.

In Europe and North America, 30 to 60% of dietary energy intake in adults comes from ultra-processed foods. An increasing number of epidemiological studies suggest a link between high intakes of ultra-processed foods with higher risks of obesity, cardiometabolic diseases and certain forms of cancer.

Emulsifiers are among the most commonly used additives in these foods. They are often added to processed and packaged foods such as certain industrial cakes, biscuits and desserts, as well as ice creams, chocolate bars, breads, margarines and ready meals, in order to improve their appearance, taste and texture and lengthen shelf life. These include mono- and diglycerides of fatty acids, carrageenans, modified starches, lecithins, phosphates, celluloses, gums and pectins.

As with all food additives, the safety of emulsifiers had already been evaluated based on the scientific evidence available at the time. However, some recent studies suggest that emulsifiers may disrupt the gut microbiota and increase the risk of inflammation, potentially increasing susceptibility to some types of cancer. For the first time at an international level, a team of French researchers has studied the relationships between the dietary intake of emulsifiers and the risk of several forms of cancer in a large study in the general population.

The results are based on the analysis of data from 92 000 adults in France (average age 45 years; 79% women) who participated in the NutriNet-Santé cohort study (see box below) between 2009 and 2021.

The participants completed at least 3 days of online dietary records of all food and drink consumed and their brand (for industrial products), with the possibility of updating their dietary intake data every 6 months. These records were matched against databases in order to identify the presence and level of food additives (including emulsifiers) in the products consumed. Laboratory assays were also performed in order to provide quantitative data.

During the follow-up, the participants reported the onset of any cancer (2 604 cases diagnosed), which was validated by a medical committee following examination of their medical records. Several well-known risk factors for cancer, including age, sex, weight (BMI), educational level, family history, smoking, alcohol and levels of physical activity, as well as the overall nutritional quality of the diet (e.g. sugar, salt, energy intakes) and menopausal status were taken into account.

After an average follow-up of 7 years, the researchers found that higher intakes of mono- and diglycerides of fatty acids (E471) were associated with increased risks of cancer overall (a 15% higher risk among those consuming the most – 3rd tertile – compared with those consuming the least – 1st tertile), breast cancer (a 24% higher risk), and prostate cancer (a 46% higher risk). On the other hand, women with higher carrageenan intakes (E407 and E407a) had a 32% higher risk of developing breast cancer, compared with the group with lower intakes.

Given that this is the first observational study in this area, it cannot establish causality on its own, and the authors acknowledge it to have certain limitations. For example, the high proportion of women, the higher average level of education and the generally more health-conscious behaviours among the NutriNet-Santé study participants compared with the general French population, which may limit the generalisation of the results

That being said, the study sample was large and the authors were able to consider a wide range of potentially confounding factors, while using detailed and unique data on exposures to food additives, down to the brand of the products consumed. In addition, the results remained unchanged after multiple sensitivity analyses, thereby strengthening their robustness.

‘While these findings need to be replicated in other studies worldwide, they bring new key knowledge to the debate on re-evaluating the regulations around the use of additives in the food industry, in order to better protect consumers,’ explains Mathilde Touvier, Research Director at Inserm, and Bernard Srour, Junior Professor at INRAE, lead authors of the study.

 

NutriNet-Santé is a public health study coordinated by the Nutritional Epidemiology Research Team (CRESS-EREN, Inserm/INRAE/Cnam/Université Sorbonne Paris Nord/Université Paris Cité) which, thanks to the commitment and loyalty of over 170 000 participants (known as Nutrinautes), advances research into the links between nutrition (diet, physical activity, nutritional status) and health. Launched in 2009, the study has already given rise to over 270 international scientific publications. In France, a drive to recruit new participants is still ongoing in order to continue to further public research into the relationship between nutrition and health.

By devoting a few minutes per month to answering questionnaires on diet, physical activity and health through the secure online platform etude-nutrinet-sante.fr, the participants contribute to furthering knowledge, towards a healthy and more sustainable diet.

Eating meals early could reduce cardiovascular risk

© Freepik

A study led by scientists from INRAE, the Barcelona Institute for Global Health, Inserm, and the Université Sorbonne Paris Nord, has revealed that the time at which we eat could influence our risk of developing cardiovascular disease. This study, carried out on a sample of over 100,000 people from the NutriNet-Santé cohort, followed between 2009 and 2022, suggests that eating a late first or last meal is associated with a higher risk of cardiovascular disease. It also appears that a longer night-time fasting duration is associated with a reduced risk of cerebrovascular disease such as stroke. The findings, published in Nature Communications, suggest the importance of daily meal timing and rhythm in reducing cardiovascular disease risk.

Cardiovascular diseases are the leading cause of death in the world according to the Global Burden of Disease study, with 18.6 million annual deaths in 2019, of which around 7.9 are attributable to diet. This means that diet plays a major role in the development and progression of these diseases. The modern lifestyle of Western societies has led to specific eating habits such as eating dinner late or skipping breakfast. In addition to light, the daily cycle of food intake (meals, snacks, etc.) alternating with periods of fasting synchronizes the peripheral clocks, or circadian rhythms, of the body’s various organs, thus influencing cardiometabolic functions such as blood pressure regulation. Chrononutrition is emerging as an important new field for understanding the relationship between the timing of food intake, circadian rhythms and health.

Scientists used data from 103,389 participants in the NutriNet-Santé cohort (79% of whom were women, with an average age of 42) to study the associations between food intake patterns and cardiovascular disease. To reduce the risk of possible bias, the researchers accounted for a large number of confounding factors, especially sociodemographic factors (age, sex, family situation, etc.), diet nutritional quality, lifestyle and sleep cycle.

The results show that having a first meal later in the day (such as when skipping breakfast), is associated with a higher risk of cardiovascular disease, with a 6% increase in risk per hour delay. For example, a person who eats for the first time at 9 a.m. is 6% more likely to develop cardiovascular disease than someone who eats at 8 a.m. When it comes to the last meal of the day, eating late (after 9 p.m.) is associated with a 28% increase in the risk of cerebrovascular disease such as stroke compared with eating before 8 p.m., particularly in women. Finally, a longer duration of night-time fasting – the time between the last meal of the day and the first meal of the following day – is associated with a reduced risk of cerebrovascular disease, supporting the idea of eating one’s first and last meals earlier in the day.

These findings, which need to be replicated in other cohorts and through additional scientific studies with different designs, highlight a potential role for meal timing in preventing cardiovascular disease. They suggest that adopting the habit of eating earlier first and last meals with a longer period of night-time fasting could help to prevent the risk of cardiovascular disease.

The NutriNet-Santé study is a public health study coordinated by the Nutritional Epidemiology Research Team (EREN-CRESS, Inserm/INRAE/Cnam/Université Sorbonne Paris Nord/Université Paris Cité), which, thanks to the commitment and support of over 175,000 study participants, is advancing research into the links between nutrition (diet, physical activity, nutritional status) and health. The study was launched in 2009 and has already resulted in over 270 international scientific publications. There is still a call for new study participants living in France to continue advancing research into the relationship between nutrition and health.

By spending a few minutes a month responding via the etude-nutrinet-sante.fr secure online platform, participants help to advance knowledge of the relationship between diet and health.

A new study sheds light on the link between childhood ADHD symptoms and physical health conditions

TDAH ADHD manifests as high levels of inattention and/or hyperactivity and impulsivity. © Adobe Stock

Attention-deficit hyperactivity disorder (ADHD) affects many children and is often accompanied by other conditions, such as metabolic disorders, asthma and dental caries. However, uncertainties remain as to the chronology of onset of such conditions, particularly when it comes to knowing which are linked with ADHD over time or, on the other hand, which increase the risk of developing ADHD symptoms. Scientists from Inserm and Université de Bordeaux at the Bordeaux Population Health Center in collaboration with teams in the UK, Sweden and Canada have conducted the most comprehensive analysis to date by evaluating temporal links between ADHD symptoms and a wide range of medical conditions. Their findings, published in Lancet Child and Adolescent Health, highlight the importance of the multidisciplinary management of ADHD patients, based on enhanced collaboration between physical and mental healthcare professionals.

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that begins in childhood and is characterised by high levels of inattention and/or hyperactivity and impulsivity. In addition to the difficulties it causes at school and in professional and social life, research has shown that ADHD is associated with various medical comorbidities (metabolic disorders, asthma, obesity, addictions, etc.) and an increased risk of accidental injury.

Nevertheless, the studies published so far in this area presented methodological limitations. With their small patient samples and lack of long-term health follow-up, they were unable to determine the direction of the links observed and the chronology of their onset. In addition, confounding factors such as social health inequalities or medication use were often insufficiently taken into account.

This made it difficult for scientists to answer a certain number of questions: do comorbidities appear before or after the development of ADHD? Are they directly related to it or caused by other factors? Can ADHD be promoted by previous medical conditions? Yet it is understanding the temporal sequences of these different associations that is essential in order to develop appropriate care and prevention strategies for patients.

The team of Cédric Galera, researcher at the Bordeaux Population Health Center (Inserm/Université de Bordeaux) and child psychiatrist, working with UK, Swedish and Canadian teams, therefore decided to analyse the data of more than 2,000 children from the large-scale Quebec Longitudinal Study of Child Development cohort. The children were followed from 5 months to 17 years of age. They were seen multiple times in early childhood (5 months to 5 years of age), middle childhood (6 to 12 years of age) and in adolescence (13 to 17 years of age).

 

ADHD and other disorders

On these occasions, the children were evaluated on the severity of any ADHD symptoms they had as well as their physical condition (general health, any illnesses, etc.). These data were reported to the researchers by the person who knew the child best in early childhood, by teachers in middle childhood, and by the child itself in adolescence.

Based on these data and taking into account multiple confounding factors, the scientists carried out statistical analyses to measure the associations between presenting ADHD symptoms and developing certain subsequent physical disorders, and conversely, between presenting physical problems in childhood and then developing subsequent ADHD symptoms.

‘This is the most comprehensive analysis evaluating the temporal links between ADHD symptoms and a wide range of medical conditions, including skin problems, infections, injuries, sleep disorders and other chronic diseases. We sought to evaluate the possible longitudinal associations between ADHD symptoms and a wide range of physical conditions, taking into account several confounding factors,’ explains Galera, who is also the first author of the study.

The scientists showed that having ADHD symptoms in early childhood was associated with a high BMI in middle childhood and adolescence, as well as unintentional injuries in adolescence. Conversely, having presented with unintentional injuries in early childhood was associated with subsequent onset of ADHD symptoms in middle childhood and adolescence. Finally, restless legs syndrome in early childhood also increased the risk of ADHD in middle childhood.

‘By shedding light on the links between ADHD and various comorbidities, as well as the timescale at which they occur, our study reinforces the idea that physical and mental health problems are intertwined, and highlights the need for healthcare professionals of all disciplines to work together in a better way. For example, physicians should be able to refer patients to other disciplinary fields as needed. The earlier we intervene, the more we prevent the evolving risks associated with ADHD,’ emphasises Galera.

To go further, the team will continue to focus on these links by studying data collected on young adults between the ages of 20 and 25. In addition, the scientists would also like to carry out similar work using French data, based on the large cohorts set up in the country, such as the French Longitudinal Study of Children (Elfe).

Diaper Packaging Conveys Pictures Inconsistent With Recommendations for Preventing Sudden Infant Death Syndrome

Image conforme aux recommandations de couchage des nourrissons Sleeping in prone position was identified as the major risk factor for sudden infant death syndrome (SIDS) in the early 1990s.  Royalty-free image – Association Naître et Vivre and ANCReMIN

In several European countries where the incidence rates of sudden infant death syndrome (SIDS) are high, a high frequency of unsafe parental sleep practices has also been observed. In addition, it is known that pictures conveying implicit or explicit health messages can lead to the modification of health practices. Researchers from Inserm, Université Paris Cité and HEC Paris, in collaboration with the Greater Paris University Hospitals (AP-HP), Nantes University Hospital and other European research structures, studied images shown on baby diaper packaging in 11 European countries, including France. The team showed that a very high proportion of pictures were inconsistent with safe infant sleep recommendations – with many images depicting babies sleeping on their stomach (prone position) or on their side, on loose bedding or surrounded by objects, or sharing a sleep surface with another person. These findings highlight the discrepancy between the pictures used on diaper packaging and safe infant sleep recommendations. They should encourage manufacturers and the legislator to take steps to ensure that these products – and more generally all commercial and official photographs – are consistent with the recommendations for the prevention of SIDS. The study has been published in The Journal of Pediatrics.

Sudden infant death syndrome (SIDS) is the unexpected death of a baby under the age of one year old[1], which remains unexplained after a full investigation, including a review of the medical history, investigation of the scene of death, and an autopsy. Putting a baby to sleep in the prone position was identified as the major risk factor for SIDS in the early 1990s. Other risk factors related to the sleep environment were then identified, particularly loose bedding or soft objects (pillows, pillow-like toys, stuffed toys, quilts, comforters, sheepskins, blankets, non-fitted sheet, or bumper pads) and sharing the sleep surface with another person (parent, brother, sister, etc.).

This epidemiological work led to the development and dissemination of international safe infant sleep recommendations. The implementation of these recommendations from the 1990s has helped reduce the incidence of SIDS in France by 80%, which currently stands at between 250 and 350 deaths per year. However, in several European countries, including France, the incidence rates of SIDS are no longer decreasing (or only very slowly), and a high frequency of unsafe parenting practices has been noted.

According to the scientific literature, we know that images can convey implicit or explicit health messages, which has been effective in modifying many health practices (alcohol consumption during pregnancy, breast-feeding, etc.). We also know that while advertising images have historically been important tools for persuasion, they have also always been a source of information for consumers.

Studies have analyzed pictures of sleeping babies in parenting magazines, newspapers, brochures, commercial photo bank websites and on Instagram® and have reported alarming rates of inconsistency with safe infant sleep recommendations ranging from 35% to 93% depending on the medium.

In this context, researchers from Inserm, Université Paris Cité, HEC Paris, Greater Paris University Hospitals (AP-HP), Nantes University Hospital in collaboration with other European research structures, decided to study pictures on diaper packaging in Europe – a product which young parents frequently use.

The scientists systematically searched the internet for the packaging of diapers sold in 11 European countries for babies weighing less than 5 kg, as they are the most at risk of SIDS.

For each packaging identified, they extracted the following data: was there a picture depicting a baby, was the baby sleeping and, if so, was the baby sleeping in accordance with 3 of the 7[1] recommendations for the prevention of SIDS that can be easily evaluated on the images? Statistical analyses (known as “meta-analyses”) were then carried out using the data obtained in each country to evaluate whether there was any inconsistency with sleeping recommendations.

The research team identified 631 diaper packaging for babies weighing less than 5 kg. On 49 % of them, there was a picture with a sleeping baby. The analyses indicated that 79% of packages depicting a sleeping baby, i.e. 34% of all of the packages, were inconsistent with at least one recommendation for the prevention of SIDS.

For example, a baby was depicted in prone position or on the side on 45% of these packs, with soft objects or loose bedding (pillows, pillow-like toys, stuffed toys, quilts, comforters, sheepskins, blankets, non-fitted sheet, or bumper pads) on 51% of them, or sharing the sleep surface with another person on 10% of them.

Examples of diaper packaging for babies in France and Europe with an image that is inconsistent with the recommendations for the prevention of SIDS: baby not sleeping on their back (A, C); baby sleeping with loose bedding or a soft object (pillow, blanket, toy) (A, B, C, D); baby sharing the sleep surface with another person (D)

 

The researchers also conducted a search, this time non-systematic, on the websites of health agencies or scientific societies and once again found images inconsistent with the prevention of SIDS.

“Our findings highlight a discrepancy between the messages conveyed on these everyday products or on institutional sites, to which many parents are highly exposed, and the recommendations for the prevention of SIDS. These findings suggest the need for action with manufacturers and legislators addressing this issue. We need to reduce exposure to commercial or official images that are inconsistent with the recommendations for the prevention of SIDS in order to prevent unsafe sleep practices. In doing so, manufacturers and legislators would fully contribute to accurate health information,” concludes Martin Chalumeau, last author of the study, epidemiologist at Inserm, professor at Université Paris Cité and pediatrician at AP-HP.

[1] S de Visme et al., J Pediatr 2020 Nov; 226:179-185.e4. doi : 10.1016/j.jpeds.2020.06.052

[2] The 7 recommendations of the American Academy of Pediatrics: (1) back to sleep for every sleep, (2) on a firm sleep surface in (3) a safety crib (crib, bassinet, portable crib, play yard), (4) in the parents’ room, (5) without any soft objects or loose bedding on, under, beside (pillows, pillow-like toys, stuffed toys, quilts, comforters, sheepskins, blankets, non-fitted sheet, or bumper pads), (6) without sharing the sleep surface with another person, and (7) offering a pacifier.

Improving Your Sleep Can Protect Your Cardiovascular Health

Scientists have studied the risk of incident cardiovascular disease in relation to five sleep dimensions. © Adobe Stock

The association between sleep disorders and cardiovascular risk is already well documented. Apnea, sleep deficit, and insomnia are linked to an increased risk of cardiovascular diseases and stroke. A new study published in European Heart Journal has now explored this association in much greater depth. Led by Inserm research director Jean-Philippe Empana and his team at the Paris Cardiovascular Research Center (Inserm/Université Paris Cité) in collaboration with the Centre hospitalier universitaire vaudois (CHUV, Lausanne), the study shows that five aspects of sleep  are almost each equally important to explain the association between sleep and the risk of coronary events and stroke.Improving one of these aspects over time can bring significant benefit. These five aspects are nighttime sleep duration, chronotype (being a morning or evening person), frequency of insomnia, excessive daytime sleepiness, and sleep apnea.

Sleep is essential to health and well-being, and several physiological mechanisms explain this. Poor sleep quality or quantity is therefore associated with a deterioration in health: mood problems, depression, weight gain, infections, diabetes, hypertension, etc. A link has also been established with cardiovascular risk – an issue which Jean-Philippe Empana’s Inserm team at the Paris Cardiovascular Research Center decided to explore further.

To do this, the team studied the risk of cardiovascular accidents (acute coronary syndrome or stroke) in relation to five aspects of sleep: nighttime sleep duration, chronotype (being a morning or evening person), frequency of insomnia, excessive daytime sleepiness, and sleep apnea.

Usually, studies focus on a single sleep dimension, mainly sleep duration or the presence of sleep apnea, but good or healthy sleep encompasses several dimensions,” clarifies Aboubakari Nambiema, first author of this publication and postdoctoral researcher at Inserm.

The researchers incorporated these five patterns of sleep into a single score in order to account for the multifactorial nature of sleep. Each of these patterns was evaluated using a specific questionnaire validated by the scientific community and appropriate for large studies (Pittsburgh sleep quality index-PSQI, Berlin questionnaire or Epworth Sleepiness Scale) and counts for 1 point when it is optimal and 0 points when it is not. The overall score therefore varies from 0 (worst score) to 5 (optimal score corresponding to: 7 to 8 hours of sleep per night, being a morning person, not having insomnia, apnea, or excessive daytime sleepiness).

 

Monitoring over time

This score was used in two population surveys that study the determinants of cardiovascular health.

One was conducted in Paris and included 10 157 adults aged 50 to 75 years (Paris Prospective Study III, PPS3) and the other in Lausanne, Switzerland, brought together 6 733 participants aged over 35 years (CoLaus|PsyCoLaus study).

The score was calculated at the point of inclusion and then two to five years later. The occurrence of cardiovascular events was then monitored for approximately eight to 10 years.

Although the use of a composite score to study sleep habits had already been tested in the past, this is the first time to our knowledge that a study has investigated its evolution over time and its potential association with cardiovascular diseases,” explains Jean-Philippe Empana.

By combining the data from the two surveys, an initial analysis confirms that the higher the initial (baseline) score, the lower the risk of incident cardiovascular disease. Compared to the participants with a score of 0-1 (10% of the participants), the risk of cardiovascular disease is reduced by 10% for those with a score of 2 (21% of the participants), by 19% for those with a score of 3 (32% or the majority of the participants), by 38% for a score of 4 (27% of the participants) and by 63% for those with the best score of 5 (10% of the participants).

“In other words, almost 60% of incident cardiovascular disease could potentially be avoided if all individuals had an optimal sleep score (score of 5), thus highlighting the potential public health implications of the results,” clarifies Jean-Philippe Empana.

A second analysis that took an unprecedented look at the change in sleep score over time showed that sleep improved in 8% of the participants, deteriorated in 11% and remained stable in the majority of the participants (2/3 of them remained with a score equal to or greater than 3). Importantly, these changes are associated with the occurrence of cardiovascular disease. In particular, this risk decreased by 16% per one point increase in the score over time, regardless of which dimension of the score was improved. “They each seem to be of equal importance,” specifies Nambiema.

The researchers now hope that healthcare professionals and the general population will take advantage of this tool: “the ease and speed of use of the questionnaires as well as the simplicity of calculating the sleep score should encourage their understanding and good adherence,” they predict.

Screens and Child Cognitive Development: Exposure Time is Not the Only Factor to Consider

Enfant déjeunant en regardant l'écran d'un ordinateur portableTo what extent does early or excessive screen exposure affect children’s cognitive development? © AdobeStock

To what extent does early or excessive screen exposure affect children’s cognitive development? This is a question that is currently dividing scientists. A team led by Inserm researcher Jonathan Bernard at the Center for Research in Epidemiology and Statistics (Inserm/INRAE/Université Paris Cité/Université Sorbonne Paris Nord) studied the data of nearly 14,000 children from the French Elfe cohort[1] for each child from the age of 2 to 5.5 years. While this is not the first study to show a negative relationship between exposure time and development, it also highlights that this relationship is not true for all domains of cognition and is much weaker when the family context is properly taken into account. Its findings also confirm[2] a non-negligible negative relationship between exposure to television during family meals and early language development. This research, published in The Journal of Child Psychology and Psychiatry, suggests that while screen time is important, the context of exposure also matters.

In the face of rapid changes in the use of screens and their growing place in everyday life, one question continues to divide scientists: to what extent does too early and/or excessive exposure to screens influence child development? With the majority of studies having focused on language development, less attention has been paid to other cognitive domains. The same applies to the potential influence of the family environment, as well as the child’s daily activities.

The team led by Inserm researcher Jonathan Bernard at the Center for Research in Epidemiology and Statistics (Inserm/INRAE/Université Paris Cité/Université Sorbonne Paris Nord) sought to evaluate the associations between screen use and cognitive development in early childhood, taking into account factors related to social, perinatal, family, and lifestyle conditions. To do this, it looked at data from nearly 14,000 children from the French cohort Elfe, collected for each child from the age of 2 to 5.5 years, between 2013 and 2017.

The parents reported their children’s daily screen time at ages 2, 3.5 and 5.5 years. They were also asked to report whether they had the television on during family meals in their children’s second year. Many factors related to the children’s lifestyle and daily activities also had to be specified. Finally, various cognitive domains were evaluated: language development at age 2, non-verbal reasoning at age 3.5 and overall cognitive development at ages 3.5 and 5.5.

The research team observed that at ages 3.5 and 5.5, screen exposure was associated with lower overall cognitive development scores, particularly in the areas of fine motor, language and autonomy. However, when lifestyle factors likely to influence cognitive development were taken into account in the statistical models, the negative relationship decreased and became of small magnitude.

The results of the study also show that, regardless of exposure time, having the television on during family meals at age 2 (which concerned 41% of children) was associated with lower language development scores at the same age. These children also had poorer overall cognitive development at age 3.5.

“This could be explained by the fact that television, by capturing the attention of family members, interferes with the quality and quantity of interactions between parents and child. Yet such interaction is crucial at this age for the acquisition of language,” explains Shuai Yang, PhD student and first author of the study. He continues: In addition, television adds background noise to family discussions that makes it difficult for the child to decipher sounds and limits verbal understanding and expression. “

These findings suggest that screen time is not the only factor to consider: the context in which screen use takes place could also be an important factor. It is also suggested that not all areas of cognition would be affected in a similar way.

“The first years of life are decisive, not just for cognitive development but also for the establishment of lifestyle habits, adds Bernard. When a child uses a screen excessively, they do so at the expense of other social activities or interactions that are essential for their development. “

The robustness of this study is due to the large number of participants, but also the consideration of factors related to the social profile of the families and the activities of the children.

“While our findings suggest that the harmful effects of screen use in early childhood have a low impact on cognitive development at the individual level and can be compensated for in the years that follow, they do however justify remaining vigilant at population level. When it comes to public health, these little things all add up,” explains Bernard. He added that more long-term studies are needed to evaluate the cumulative impact of these effects from early childhood to adolescence.

The research by his team is continuing through the follow-up of the children in the Elfe cohort in order to answer these questions.

 

[1]Elfe is France’s first national, longitudinal study dedicated to the follow-up of children from birth to adulthood. More than 18,000 children born in metropolitan France in 2011 were enrolled in it (i.e. one in every 50 children born in 2011). Since the first contact with the families during the maternity stay, the participating parents are regularly interviewed in order to better understand how the environment, family setting and living conditions influence the development, health and socialization of the children. The ELFE study mobilizes around 150 researchers from a variety of scientific disciplines.

[2]See our press release from June 8, 2021: Television During Meals Linked to Poorer Language Development in Young Children

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