The research team examined the behavioral impacts of exposure to twelve substances suspected or known to be endocrine disruptors during pregnancy (illustrative image). © Adobe Stock

A study by Inserm, in collaboration with the CNRS, the University of Grenoble Alpes (UGA), the Grenoble Alpes University Hospital (CHU), and the Barcelona Institute for Global Health (ISGlobal), published on December 9 in the The Lancet Planetary Health journal, suggests there may be an association between exposure in the third trimester of pregnancy to two synthetic phenols, methylparaben and bisphenol S, commonly found in everyday products (food, cosmetics, plastics, etc.), and questionnaire scores that could suggest behavioral disorders in children. Further studies will be needed to confirm these results and better understand the mechanisms involved.

With neurodevelopmental disorder diagnose in children on the rise, the role of environmental factors is increasingly being examined. These include chemicals such as endocrine disruptors found in many everyday products, such as certain phenolic compounds and parabens. However, establishing a causal relationship for each substance remains complex and the mechanisms underlying these effects are still poorly understood.

A study bringing together researchers from Inserm, in collaboration with the CNRS, the University of Grenoble Alpes (UGA),  the Grenoble Alpes University Hospital (CHU), and the Barcelona Institute for Global Health (ISGlobal)[1], published on December 9 in The Lancet Planetary Health journal, suggests a potential  association between questionnaire scores that could suggest behavioral disorders in children and prenatal exposure to two chemicals : bisphenol S, a known endocrine disruptor, and methylparaben (a preservative used in cosmetics and food products, among other things), which is under assessment as endocrine disrupting by the European Chemicals Agency..

“This is particularly worrying because bisphenol S is used as a substitute for bisphenol A, which has been banned for certain uses, such as food containers. However, more and more studies suggest adverse health effects, even as we are increasingly exposed to this substance,” explains Claire Philippat, a researcher at Inserm and the last author of this study.

These results are based on two key cohorts for studying the effect of chemical pollutants on children’s health: the first, consisting of 1,080 mothers and their children recruited in Barcelona  between 2018 and 2021, and the second, consisting of 484 mothers and their children recruited in the Grenoble region between 2014 and 2017.

The research team looked at the consequences of exposure to 12 substances suspected or recognized as endocrine disruptors by health authorities during pregnancy: bisphenols, parabens, and other phenolic compounds such as triclosan, measured via repeated urine samples.

“This is one of the strengths of these cohorts: the women collected up to 42 samples during pregnancy, whereas previous studies had a maximum of three. This allows for a real improvement in the measurement of exposure to these substances,” explains the researcher.

After birth, the children’s behavior was assessed between 18 months and two years of age using the Child Behavior Checklist (CBCL), a questionnaire completed by one of the parents to screen for possible behavioral disorders, such as attention difficulties or anxious, depressive, or aggressive behaviors.

The results suggestthat exposure to methylparaben in the third trimester of pregnancy was associated with higher scores on this questionnaire, suggesting possible behavioral disorders in children. Similarly, exposure to bisphenol S, a known endocrine disruptor, during the same period was linked to high scores, but only in boys. However, no cocktail effect resulting from the mixture of different phenols was observed.

To understand the mechanisms by which these compounds could affect children’s behavior, the researchers explored the hypothesis that the hypothalamic-pituitary-adrenal (HPA) axis, whose role is, among other things, to regulate the body’s response to stress, might be involved. They measured the concentrations of several key hormones in this system (cortisol, cortisone, dehydrocorticosterone) in hair samples taken from mothers at the end of pregnancy. However, the hormonal variations observed did not explain the link between prenatal exposure to pollutants and behavioral disorders in children.

“Our results are not sufficient to rule out this hypothesis, as there are still very few studies on the subject. But it is possible that other biological mechanisms, such as disruption of the thyroid or estrogen axis, may be involved” explains the researcher.

Further research will be needed to better understand the mechanisms at play. “Although several studies suggest a link between exposure to endocrine disruptors and behavioral disorders, little research has focused on bisphenol S and methylparaben, the latter of which is not officially recognized as an endocrine disruptor, but only suspected. It is therefore essential to continue conducting studies on large cohorts, with rigorous measurements of exposure to pollutants, in order to better understand these effects,” concludes the last author.

[1] This study was funded by ANSES, the Fondation de France, and the European ATHLETE (Advancing Tools for Human Early Lifecourse Exposome Research and Translation) fund, which aims to better understand and prevent health effects of numerous environmental hazards and their mixtures, starting from the earliest stages of life.

© Adobe Stock

Two researchers from Inserm and one researcher from INRAE contributed to a series of three articles published on 19 November in The Lancet on the health consequences of consuming ultra-processed foods. The 43 international scientists who signed this series of articles propose the implementation of public health measures to limit the use of ultra-processed foods and improve nutrition worldwide. The scientific literature shows that this improvement requires the implementation of coordinated public policies aimed at reducing the production, marketing and consumption of ultra-processed foods, alongside measures to limit sugar, salt and saturated fat intake and improve access to healthy food.

Ultra-processed foods (UPFs) account for around 35% of our calorie intake in France (and up to 60% in the United States). Studies from around the world show that consumption of these products is associated with an increase in certain chronic diseases such as cardiovascular disease and type 2 diabetes. Limiting consumption of these products is a public health challenge that requires coordinated policies and action at the international level, according to this new series of three articles written by 43 global experts and published in The Lancet. The authors present a roadmap for moving towards effective regulation and healthier, more accessible and affordable diets.

Evidence of the harmful effects of ultra-processed foods is mounting

Ultra-processed foods, according to the NOVA classification, are products that have undergone significant processing (chemical, physical, biological), which are generally formulated from industrial ingredients such as hydrogenated oils, protein isolates or glucose/fructose syrup, and “cosmetic” food additives ‘ food additives (colourings, artificial sweeteners, emulsifiers, etc.).

The data examined in the first article in the series show that diets rich in ultra-processed foods are associated with overall overeating, poor nutritional quality (too much sugar and unhealthy fats, too little fibre and protein) and higher exposure to chemicals and additives that may be harmful to health. In addition, a systematic review of the scientific literature, covering 104 long-term studies, found that 92 of them reported a higher incidence of one or more chronic diseases associated with the consumption of ultra-processed foods, with meta-analyses showing significant associations for 12 health problems, including obesity, type 2 diabetes, cardiovascular disease, depression and premature mortality from all causes. The French NutriNet-Santé cohort, led by the Cress-Eren team (Inserm/INRAE/Cnam/Université Sorbonne Paris Nord/Université Paris Cité), has made it possible to publish some of these pioneering studies. The cohort now makes it possible to go further by providing information on the potential factors at play (food additives, contaminants linked to processing and packaging, etc.).

According to Mathilde Touvier, Inserm research director and coordinator of the NutriNet-Santé cohort, and her colleague Bernard Srour, INRAE researcher, who contributed to the first article in the series: “More and more studies show that a diet rich in ultra-processed foods is harmful to health. While a debate on ultra-processed foods within the scientific community is welcome in order to strengthen the level of available evidence, particularly on the mechanisms and factors involved, it should be distinguished from attempts by special interest groups to discredit current scientific evidence and slow down public health policies.”

Policies to combat ultra-processed foods while improving access to healthy alternatives

The second article in the series presents solutions aimed at regulating and reducing the production, marketing and consumption of UFPs, in order to make manufacturers accountable for their role in promoting ultra-processed foods.

The article explains how improving nutrition globally requires specific policies to complement existing legislation to reduce the saturated fat, salt and added sugar content of foods. Although measures need to be put in place at the consumer level (labelling, education, recommendations), the main focus is on fundamentally transforming the ultra-processed food system. In terms of labelling, for example, this would involve indicating the ultra-processed nature of products so that consumers can easily identify them, as has been proposed and tested with an advanced version of the Nutri-Score that incorporates the dimension of ultra-processing.

The authors also propose stricter trade restrictions, particularly for advertising aimed at children, in digital media and at brand level, as well as a ban on ultra-processed foods in public instiatutions such as schools and hospitals, and restrictions on their sale and shelf space in supermarkets, as is already the case in several countries.

A coordinated global response to combat the lobbying strategies of the ultra-processed food industry

The authors of the third and final article in the series – to which Melissa Mialon, researcher and holder of the Inserm Research Chair in Health Services, contributed – explain the relationship between the strategies of the agri-food industry and the rise of ultra-processed food products: the use of cheap ingredients, industrial methods to reduce costs, intensive marketing and attractive designs to stimulate consumption. With annual global sales of $1.9 trillion, ultra-processed foods are the most profitable food sector.

The series examines the mechanisms that contribute to avoiding regulation, steering scientific research and influencing public opinion despite knowledge of the health impacts.

The authors call for a coordinated global public health response and argue that ‘there is now a need for a bold and coordinated global response to establish food systems that prioritise the health and well-being of populations.’

© Photo Jannis Brandt/ Unsplash

Consumption of plant-based products is associated with better cardiovascular health, provided they are of good nutritional quality and not or minimally processed. This is the finding of a research team from INRAE, Inserm, Sorbonne Paris Nord University and Cnam, based on analysis of health data from a cohort of 63,835 adults. The results are published in The Lancet Regional Health – Europe.

Previous studies have reported that a high consumption of so-called ultra-processed foods[1] is associated with an increased risk of developing cardiovascular disease, while other studies[2] have shown that a diet including a high proportion of plant products, when nutritionally balanced, reduces the risk of developing these diseases.

To study the links between nutrition and cardiovascular health, a research team from INRAE, Inserm, Sorbonne Paris Nord University and Cnam went beyond the distinction between a food’s plant or animal origin, by integrating nutritional quality, such as carbohydrate, lipid or antioxidant vitamin and mineral content, as well as the degree of food processing.

The research team analyzed health data from 63,835 adults participating in the French NutriNet-Santé cohort. The average follow-up period was 9.1 years, and up to 15 years for the first participants. Dietary intakes, i.e. foods and beverages consumed over at least 3 days, were collected using online questionnaires.

Nutritional quality and degree of processing

It has been shown that adults with a diet richer in plant products of higher nutritional quality (lower in fat, sugar and salt) and with little or no industrial processing, had a 40% lower risk of cardiovascular disease than those with a diet lower in plant products and richer in animal products[3].

Adults who ate a diet richer in vegetable products of higher nutritional quality, but ultra-processed such as industrial wholemeal breads, commercial soups, pasta-based ready meals or commercially seasoned salads (compared to people who ate a diet lower in these products and richer in animal products), did not have a lower risk of cardiovascular disease.

The risk of cardiovascular disease was around 40% higher for adults who consumed a high proportion of low-nutritional-quality, ultra-processed plant products (potato potato chips, sweetened fruit drinks or plant extract sodas, sweetened chocolate products or confectionery, sweetened breakfast cereals, salted cookies, etc.) than for people with a diet richer in plant products of good nutritional quality and little or no industrial processing.

These results underline the need to consider both nutritional quality and the degree of processing and formulation of foods, in addition to the plant-animal balance in the diet, to better assess the links between nutrition and cardiovascular health. They provide new arguments to encourage public health and nutrition policies to promote plant-based foods that are both of good nutritional quality and little or unprocessed (good-quality fresh, frozen or canned fruit and vegetables, for example, with no added fat, salt, sugar or additives).

France’s most deprived municipalities have the highest newborn death rates according to the study’s social deprivation index adjusted for the perinatal period (illustration) © Adobestock

With neonatal mortality on the increase in France, a new study by Inserm, Paris Cité University, Inrae, Paris Nord University and APHP, published on 16 September in BMJ Medicine, shows that it could be linked to socioeconomic inequalities. Using their social deprivation index adjusted for the perinatal period, the researchers observed that the risk of neonatal death is higher for mothers living in deprived municipalities. These findings emphasise the importance of conducting perinatal care audits across France, according to the researchers.

Women living in socioeconomically disadvantaged municipalities are more likely to see their child die in the first few days after birth. This is the finding of a new study published by a research team from Inserm, Paris Cité University, Inrae, Paris Nord University and APHP in BMJ Medicine on 16 September 2025.

A study from 2022[1] had already revealed a significant increase in infant mortality (death before one year of age) in France since 2012. While this study had identified neonatal mortality (death within the first 28 days of life) as the main component in the increase in infant mortality, it did not make it possible to know the areas and populations most affected.

To remedy this, a scientific team has developed a social deprivation index adjusted for the perinatal period for each municipality in mainland France[2], resulting from the analysis of various factors associated with the health of newborns in previous studies: unemployment rate, percentage of immigrants in the sector, that of tenants, single-parent families, and median household income. The scientists then cross-referenced this indicator with the neonatal mortality rate over two periods: 2001-2008 and 2015-2020, using the French National Health Data System (SNDS).

The results highlight significant inequalities in neonatal mortality.

“Regardless of the period studied, our social deprivation index adjusted for the perinatal period shows more deaths occurring in newborns whose mothers live in the most deprived municipalities,” observes Jennifer Zeitlin, epidemiologist and research director at Inserm, and last author of the study.

When analysing the data in more detail, the scientists saw that over the 2015-2020 period, the 20% of children born to mothers living in the most deprived municipalities (according to the social deprivation index adjusted for the perinatal period) had a death rate in the 28 days following birth of 3.34 per 1 000 live births, i.e. a risk around 1.7 times that of the 20% of children from the most least deprived areas (1.95 deaths per 1 000 births). The more mothers come from deprived areas, the greater the risk of neonatal death.

“If the entire population had the same risk of neonatal mortality as the 20% least deprived, it is estimated that around a quarter of deaths, i.e. 2 496 newborn deaths, could have been avoided in the 2015-2020 period alone”, says Victor Sartorius, the first author.

The comparison between the periods 2001-2008 and 2015-2020 confirms the increase in neonatal mortality in mainland France. But “the increase observed is concentrated only in deprived areas, while mortality has remained stable in the rest of the country”, observes Zeitlin.

Title: Neonatal mortality rates in mainland France between 2015 and 2020 and 2001 and 2008 according to social deprivation groups

Caption: To analyse the link between neonatal mortality and social deprivation, the statisticians divided births into five equal groups called “quintiles”, according to the social deprivation index adjusted for the mothers’ perinatal period, over two periods: between 2001 and 2008, and between 2015 and 2020. The first quintile (group 1) corresponds to the 20% of children born to mothers living in the least deprived municipalities, and the last quintile (group 5) to the 20% of children born to mothers living in the most deprived municipalities. When comparing the 2001-2008 period with that of 2015-2020, the researchers observed that the neonatal mortality rate remained stable in the least deprived groups (1 and 2) and the median group (3). However, they observed an increase in the mortality rate between these two periods, which is concentrated exclusively in the most deprived groups (4 and 5). This distribution highlights inequalities in relation to neonatal mortality according to the social deprivation of the mothers.

Several hypotheses can be put forward to explain the association between the level of social deprivation and neonatal mortality. For example, characteristics that have been linked to socioeconomic level, such as overweight, smoking and exposure to pollution, lead to a higher risk of prematurity or low birth weight in the baby, which are themselves risk factors for neonatal death. There are also ethical and personal considerations such as the decision whether or not to terminate the pregnancy due to certain foetal diseases.

“We also need to mention the organisation of our healthcare system; we know that access to healthcare and the ability of residents to use the healthcare system is reduced in deprived areas, adds Sartorius. In addition, high occupancy rates in units that care for critically ill newborns together with under-staffing could also be a hypothesis among the causes to be explored.”

“According to a recent analysis by the French National Authority for Health (HAS), 57% of serious adverse events related to care in newborns, such as deaths, could have been avoided[3], reiterates Zeitlin. The question is therefore how to improve the organisation of healthcare provision and the conditions for patient care, particularly in the most fragile areas according to our social and perinatal deprivation index. This could include more staff, better training of healthcare workers and appropriate infrastructure.”

To mitigate the risks, the research team suggests conducting audits of perinatal care provision in each area, like the one whose conclusions were made public in 2015 in Seine-Saint-Denis[4].

“Our study shows the extent to which deprived populations are at the forefront of neonatal mortality and highlights the urgency of implementing targeted public health measures in the high-risk areas that we’ve identified”, concludes the last author.

[1]https://doi.org/10.1016/j.lanepe.2022.100339

[2]Except for municipalities with fewer than 50 households, for which the data were not available.

[3]evenements_indesirables_graves_associes_aux_soins_eigs_survenus_chez_les_nouveau-nes.pdf

[4]Fresh insight into the causes of infant and perinatal mortality in the Seine-Saint-Denis district – Inserm press room

© Mathilde Touvier

Food additive mixtures are an everyday feature of our diets, especially through ultra-processed foods. Until recently, safety evaluations of these additives have been conducted substance by substance due to a lack of data on the effect of them ingested together. In a new study, researchers from Inserm, INRAE, Sorbonne Paris Nord University, Paris Cité University and Cnam, as part of the Nutritional Epidemiology Research Team (CRESS-EREN), examined the possible links between exposure to mixtures of commonly consumed food additives and the onset of type 2 diabetes. They analysed the health data of over 100 000 adults participating in the French NutriNet-Santé cohort. Two out of the five mixtures tested were found to be associated with a higher incidence of type 2 diabetes, particularly one mixture containing different emulsifiers such as carrageenans, modified starches and other additives (found in stocks, milky desserts, fats and sauces, etc.), and another containing sweeteners, colourings and acidifiers (characteristic of artificially-sweetened drinks and sodas). Their findings have been published in Plos Medicine.

Widely used by the agri-food industry, food additives are mainly found in the ultra-processed products sold in our supermarkets. The scientific literature now provides information on the potential harmful effects of consuming several of these substances, which have been associated with the development of metabolic disorders, chronic inflammation and gut microbiome imbalance. Recent studies from the NutriNet-Santé cohort have also revealed an association between the consumption of some of these additives and an increased risk of type 2 diabetes, cancer and cardiovascular diseases.

Although these studies provide insights into the individual effect of each of these substances, no study had yet looked at the possible impact of their combined consumption. And this is despite ultra-processed foods often containing mixtures of food additives, each with its specific properties (preservatives, flavour enhancers, colourants, texture agents, etc.).

To measure the consequences of exposure to these mixtures, a research team led by Mathilde Touvier, Inserm research director and study coordinator, analysed the health data of 108 643 adults in the NutriNet-Santé cohort over an average follow-up period of 7.7 years.

The participants completed at least two days (up to 15 days) of online dietary records of all food and drink consumed and their brands.

In order to obtain a reliable estimate of the exposure to additives and to focus on those with a potentially significant health impact, only those additives consumed by at least 5% of the cohort were included in mixture modelling. The presence or absence of each additive in each food was determined by cross-referencing several databases, taking into account the date of consumption (to incorporate any reformulations over time), as well as some laboratory assays of quantitative levels of additives in the food.

Five main mixtures of additives were identified, representing groups of substances frequently ingested together (due to their joint presence in industrially processed products or resulting from the co-ingestion of foods often consumed together).

The results show two of these mixtures to be associated with a higher incidence of type 2 diabetes, regardless of the nutritional quality of the diet (intake of sugar, calories, fibre, saturated fat, etc.) and sociodemographic and lifestyle factors. No associations were found for the other three mixtures.

The first mixture incriminated was primarily composed of several emulsifiers (modified starches, pectin, guar gum, carrageenans, polyphosphates, xanthan gum), a preservative (potassium sorbate) and a colouring agent (curcumin). These additives are typically found in a variety of ultra-processed foods, such as stocks, milky desserts, fats and sauces.

The other mixture implicated was primarily composed of additives found in artificially-sweetened drinks and sodas. It contained acidifiers and acidity regulators (citric acid, sodium citrates, phosphoric acid, malic acid), colouring agents (sulphite ammonia caramel, anthocyanins, paprika extract), sweeteners (acesulfame-K, aspartame, sucralose), emulsifiers (gum arabic, pectin, guar gum) and a coating agent (carnauba wax).

In this study, interactions between the additives of these mixtures were detected suggesting that some could interact with each other, either by enhancing their effects (synergy) or by attenuating them (antagonism).

“This study is the first to estimate exposure to food additive mixtures in a large cohort of the general population and to analyse their link to the incidence of type 2 diabetes. The findings suggest that several emblematic additives present in many products are often consumed together and that certain mixtures are associated with a higher risk of this disease. These substances may therefore represent a modifiable risk factor, paving the way for strategies to prevent type 2 diabetes,” explains Marie Payen de la Garanderie, PhD student at Inserm and first author of this research.

“Further studies are needed to elucidate the underlying mechanisms and deepen the understanding of the potential synergies and antagonisms between these substances. This observational study alone is not sufficient to establish a causal link. However, our findings are in line with recent in vitro experimental work suggesting possible cocktail effects[1]. They indicate that the evaluation of additives should take into account their interactions and support public health recommendations that advise limiting non-essential food additives,” explains Dr Touvier.

[1] Cynthia Recoules, Mathilde Touvier, Fabrice Pierre, Marc Audebert. Food Chem Toxicol. 2025 Feb:196:115198. doi: 10.1016/j.fct.2024.115198. Epub 2024 Dec 14. Evaluation of the toxic effects of food additives, alone or in mixture, in four human cell models.

© AdobeStock

Human cognitive biases can particularly affect decision-making when speed is of the essence, such as when lives are at stake in a medical emergency. A research team from Inserm and the University of Bordeaux has tested an advanced method of generative artificial intelligence (AI)[1], trained with data from patient records corresponding to 480 000 entries to the Bordeaux University Hospital Emergency Department. Its findings, presented at the Machine Learning for Health symposium in Vancouver, and published in Proceedings of Machine Learning Research, show that the AI tested is likely to reproduce and measure caregiver biases relating to patient gender during triage. These results form a case study of how new generative AI algorithms can be used to identify and understand human cognitive biases.

In emergency care settings that demand rapid decision-making, human cognitive biases, particularly “judgment” biases, can critically impact medical decisions and patient prognosis. These “cognitive shortcuts” occur when people are required to form opinions or make decisions based on incomplete or over-generalized information. Decision-making can therefore be unconsciously affected by these biases (related, for example, to sex/gender, age, ethnicity, etc.), and lead to under or overestimating the severity of a patient’s condition.

So how can we better identify these biases and reduce their impact? One answer could be found in AI and particularly generative AI known as “large language models” (LLMs), which are capable of imitating human decision-making thanks to their mastery of human language (such as ChatGPT). These models are in fact capable of effectively understanding the “free-text”[2] that accounts for a large proportion of the clinical data collected by healthcare staff, particularly in hospital emergency departments.

A team led by Inserm Research Director Emmanuel Lagarde[3] at the Bordeaux Population Health Research Center (Inserm/University of Bordeaux), was interested in the potential of these LLMs to detect and quantify gender bias in a rapid decision-making setting. The context used to evaluate this method was the triage[4] of patients in emergency departments. Accurate triage is critical: underestimating an emergency in which treatment is then delayed could worsen prognosis. However, overestimating the severity of a patient’s condition could lead to the overuse of resources, which can be particularly harmful if many other patients are also requiring attention.

The scientists used an innovative approach in which AI was trained to triage patients based on the texts contained in their medical record, thereby reproducing any cognitive biases of the nursing staff having performed this triage. The data used for this training comprised over 480 000 entries to the Emergency Department of Bordeaux University Hospital between January 2013 and December 2021.

Once trained, the model was capable of assigning a triage score (evaluating the severity of the patient’s condition) based on reading a record, as the nurse would do. The record was then altered in order to change patient gender references in the clinical texts, and a new score was assigned by the model. It was the difference between these two scores, one produced from the original record and the other from the altered record, which made it possible to estimate the cognitive bias.

The results showed the AI to be significantly biased against women. Based on identical clinical records, the severity of their conditions tended to be underestimated compared to those of men (with around 5% classified as “less critical” and 1.81% classified as “more critical”). Conversely, the severity of the men’s conditions tended to be slightly overestimated (with 3.7% deemed “more critical” versus 2.9% deemed “less critical”). This bias increased in line with the level of inexperience of the nursing staff.

“This research shows how large language models can help detect and anticipate human cognitive biases – in this case regarding the goal of fairer and more effective management of medical emergencies,” explains Lagarde. “The method used shows that, in this context, LLMs are able to identify and reproduce the biases that guide human decision-making from the clinical data collected by nursing staff,” adds Ariel Guerra-Adames, doctoral student and first author of this research[5].

The team will now go on to study the evaluation of biases related to other patient characteristics (age, ethnic group). Ultimately, it should also be possible to refine the system with the introduction of non-verbal variables (facial expressions, tone of voice) which, while not necessarily appearing in the written data, could nevertheless be critical in decision-making.

[1] Generative artificial intelligence is an AI system that is able to create content, be it text, images, sounds, videos or other forms of data.

[2] In a medical context, free-text refers to information recorded as unstructured text, i.e. without rigid organization or a predefined format. This includes texts produced directly by healthcare professionals to describe observations, diagnoses, treatments or medical history, often in natural language.

[3] In collaboration with Cédric Gil-Jardiné from the University of Bordeaux Hospital Emergency Department and Marta Avalos from the Inria center at the University of Bordeaux

[4] Triage in medical emergencies consists of classifying patients by the severity of their condition, so as to optimize the order of care and save as many people as possible. It is performed by dedicated nurses who collect various information from each patient (reason for visit, vital signs, medical history, etc.) and assign an “emergency” score according to a validated scale.

[5] Ariel Guerra-Adames received the Best Paper Award when presenting this work at the Machine Learning for Health Symposium in Vancouver.

L’alimentation serait responsable d’environ 30% des décès dus aux maladies cardiovasculaires. © Mathilde Touvier

Cardiovascular diseases are the leading cause of mortality in Western Europe, accounting for 1/3 of deaths in 2019. Diet is thought to be responsible for around 30% of such deaths. Nutrition-related prevention policies therefore constitute a major public health challenge for these diseases.

In an article to be published on 11 September 2024 in Lancet Regional Health – Europe, researchers from the Nutritional Epidemiology Research Team (CRESS-EREN), with members from Inserm, Inrae, Cnam, Université Sorbonne Paris Nord and Université Paris Cité, in collaboration with researchers from the International Agency for Research on Cancer (WHO-IARC), report an increased risk of cardiovascular diseases associated with the consumption of foods that rank less favourably on the Nutri-Score scale (new 2024 version) within the European cohort EPIC. A total of 345,533 participants from the cohort, spread across 7 European countries and followed for 12 years, were included in the analyses.

Officially adopted in France in 2017 (and in 6 other European countries since), the Nutri-Score aims to provide rapid information on the nutritional quality of foods and drinks to help and encourage consumers to compare them and choose those that offer a better nutritional quality. In parallel, it encourages manufacturers to improve the nutritional quality of their products.

The Nutri-Score has 5 categories, ranging from A (dark green – higher nutritional quality) to E (dark orange – lower nutritional quality). An algorithm ranks each product according to its levels – per 100 g – of energy, sugars, saturated fatty acids and salt (to limit) and proteins, fruits, vegetables and pulses (to favour).

A number of studies published in international scientific journals have shown the validity of Nutri-Score in characterising the nutritional quality of foods and its efficacy in guiding consumers towards more nutritious choices (over 140 publications). In particular, links between the consumption of foods with a less favourable Nutri-Score (lower nutritional quality) and an increased risk of cardiovascular diseases have so far been observed in French studies (SU.VI.MAX and NutriNet-Santé cohorts). Studies in France, UK, Spain and Italy have also seen similar associations with an increased risk of various chronic diseases as well as higher mortality.

In this new study, the researchers focused on the latest version of the Nutri-Score algorithm (updated in 2024, see box), linked to the risk of cardiovascular diseases, in a large population spread across 7 European countries, with the aim of providing new scientific evidence for validating the Nutri-Score on a European scale. It follows two studies published in 2018 and 2020 in the same population on cancer risk and mortality.

A total of 345 533 participants from the EPIC (European Prospective Investigation into Cancer and Nutrition) cohort were included in the analyses. During the follow-up (12 years, between 1992 and 2010), 16 214 participants developed a cardiovascular disease (6 565 of whom had myocardial infarction and 6 245 stroke). The findings show that the participants consuming on average more foods with less favourable Nutri-Score, reflecting lower nutritional quality, were at increased risk of cardiovascular diseases, particularly myocardial infarction and stroke. These associations were significant after a large number of sociodemographic and lifestyle factors were taken into account.

‘These findings confirm the relevance of Nutri-Score as a public health tool to guide consumers in their food choices with the goal of preventing chronic diseases’, emphasises Inserm researcher Mélanie Deschasaux-Tanguy.

‘They also provide key elements to support the adoption of Nutri-Score as a mandatory nutritional logo in Europe’, explains Mathilde Touvier, Inserm research director.

 

[1] https://sante.gouv.fr/prevention-en-sante/preserver-sa-sante/nutrition/nutri-score/etudes-et-rapports-scientifiques/

[2] https://theconversation.com/en-2024-le-nutri-score-evolue-pourquoi-et-que-faut-il-en-retenir-221697

To find out more: watch the Inserm program “Nutri-Score, we tell you everything” (french only).

© 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.