Osteoporos Int DOI 10.1007/s00198-015-3121-2
ORIGINAL ARTICLE
Poor nutritional status is associated with a higher risk of falling and fracture in elderly people living at home in France: the Three-City cohort study M. J. Torres 1,2,3 & C. Féart 1,2 & C. Samieri 1,2 & B. Dorigny 3 & Y. Luiking 4 & C. Berr 5,6 & P. Barberger-Gateau 1,2 & L. Letenneur 1,2
Received: 15 October 2014 / Accepted: 24 March 2015 # International Osteoporosis Foundation and National Osteoporosis Foundation 2015
Abstract Summary Falling and fractures are a public health problem in elderly people. The aim of our study was to investigate whether nutritional status is associated with the risk of falling or fracture in community-dwelling elderly. Poor nutritional status was significantly associated with a higher risk of both falling and fractures. Introduction Nutrition could play a role to prevent falls and fractures. The purpose of this study is to investigate whether a poor nutritional status is associated with the risk of falling and of fracture in community dwelling elderly. Methods Baseline nutritional status of participants was assessed using the Mini Nutritional Assessment (MNA). After a follow-up of 12 years, 6040 individuals with available data for falls and 6839 for fracture were included. People who presented the outcomes at baseline were excluded. Cox
models were used to evaluate the associations between nutritional status and the risks of fall or fracture. Results The frequency of poor nutritional status (MNA≤ 23.5), at baseline, was respectively 12.0 % in the Bfall study sample^ and 12.8 % in the Bfracture study sample.^ Incident fall and fracture over 12 years were reported in 55.8 and 18.5 % of the respective samples, respectively. In multivariate models controlled for sociodemographic data and several baseline health indicators, poor nutritional status was significantly associated with a higher risk of falling (hazard ratio (HR)=1.66, 95 % confidence interval (95 % CI) 1.35–2.04 in men and HR=1.20, 95 % CI 1.07–1.34 in women) and with a higher risk of fracture (HR=1.28, 95 % CI 1.09–1.49). Conclusion Poor nutritional status was associated with a higher risk of both falling and fractures in French elderly community-dwellers. Early screening and management of the nutritional status may be useful to reduce the frequency of these events in older people.
* M. J. Torres
[email protected]
Keywords Aged . Community-dwellers . Epidemiology . Fall . Fracture . Nutritional status
1
2
Univ. Bordeaux, ISPED, Centre INSERM U897-EpidemiologieBiostatistique, F-33000 Bordeaux, France INSERM, ISPED, Centre INSERM U897-EpidemiologieBiostatistique, F-33000 Bordeaux, France
3
NUTRICIA Advanced Medical Nutrition, Danone Research, 93400 Saint Ouen, France
4
Nutricia Research, Nutricia Advanced Medical Nutrition, Utrecht, The Netherlands
5
CMRR Languedoc Roussillon, CHU Montpellier, 34000 Montpellier, France
6
INSERM, U1061, Neuropsychiatrie: Recherche Épidémiologique et Clinique, Université Montpellier I, Hôpital La Colombière, 34000 Montpellier, France
Introduction Falling and fractures are an important public health challenge for elderly population whose proportion is growing worldwide. In older population, falling and fractures are important determinants of functional decline and disability [1, 2], increase the mortality rate, and lead to dramatic medical costs to society [3]. It is estimated that about 30 % of elderly people living at home fall at least once each year [4, 5]. The risk and severity of injuries after a fall are important, and falling appears to be a key determinant of fracture risk [6]. In elderly people, some body sites of fractures, such as the hip, the wrist,
Osteoporos Int
or the spine, are a clinical manifestation of osteoporosis [7]. Other bones common to fracture in older people are the arms or legs. The prevention of falling could decrease the occurrence of fractures. Among modifiable risk factors for falls and fractures, malnutrition could play a role through its impact on muscle and bone health [8]. Adequate protein intake is recommended for optimal muscle function with aging and to maintain strength and physical endurance [9], while the role of protein intake on bone health is more controversial [10]. A low protein intake has been associated with a decrease of bone mineral density [11] and with higher risk of bone fractures in women [12]. Among other nutrients, adequate calcium and vitamin D intake have been consistently associated with preserved bone health [13, 14]. We have previously shown that a nutrient pattern with higher intakes of calcium, phosphorus, vitamins B12, proteins, unsaturated fats, and moderate alcohol was associated with a lower risk of fracture [15]. Furthermore, malnutrition has been associated with lower bone mineral density [16] that could have an effect on fracture. Taken altogether, these findings suggest that global malnutrition could be a risk factor for both falling and fracture. Malnutrition, as evaluated by the Mini Nutritional Assessment (MNA), is present in 4 to 10 % of seniors living at home [17]. The MNA, sign of energy and multiple nutrient deficiencies and particularly of a low intake of protein, has been validated specifically in older persons to identify people with a poor nutritional status [18]. Malnutrition has been associated with poor muscle strength [19] and impaired balance [20], two conditions that could lead to falling. Saka et al. have shown that 43 % of people with a poor nutritional status experience one or more falls in the next year, which is significantly higher when compared to 31 % of people with a satisfying MNA score (p=0.02) [21]. Other studies have shown an association between malnutrition and the risk of falling [22–26], but most of them examined subjects living in hospitals or in nursing homes and during a short follow-up. At our knowledge, no study has explored the association between the nutritional status assessed by the MNA and the occurrence of fracture. The aim of this study was to determine whether nutritional status (evaluated by the MNA) is associated with the overall and fracture site-specific (i.e., the hip, wrist, spine, upper and lower limbs) risk of falling and fracture in communitydwelling older people.
Methods Study population The Three-City (3C) study is an observational cohort study of vascular risk factors for dementia; the methodology has been described elsewhere [27]. In 1999–2001, 9294 communitydwellers aged 65 years and over were randomly recruited from
electoral rolls of three French cities: Bordeaux (n=2104), Dijon (n=4931), and Montpellier (n=2259). The study was approved by the Ethics Committee of the Kremlin-Bicêtre Hospital. Written consent was provided by all participants. At baseline, psychologists collected sociodemographic and medical history of participants by a questionnaire. To date, five follow-up examinations were performed at about 2, 4, 7, 10, and 12 years after inclusion. Two subsamples were analyzed. For the falling subsample, from the 7464 participants with no recent falls at baseline, we included 6040 individuals with available nutritional status information at baseline, who were followed at least once during the 12 years of follow-up, and had no missing data in the covariates. We employed the same selection criteria for the fracture subsample: from the 8560 participants with no recent fractures at baseline, 6839 subjects were included. Outcomes Self-reported history of falling was provided by participants at baseline and at each follow-up visit (except at the 7 years follow-up). Self-reported history of fractures and information about the body sites of the fractures (the hip, wrist, spine, upper limb (arm, shoulder, collarbone, excluding wrist), lower limb (excluding hip), and other site) were collected at baseline and at each follow-up visit. The two main outcomes of interest in this analysis were the occurrences of a first fall and of a first fracture. In secondary analyses, we studied fractures for each site separately. Nutritional status assessment MNA is a questionnaire identifying elderly people who are at risk of malnutrition or malnourished [18]. It is composed of 18 items grouped into four parts (anthropometric measurements, a global assessment, a dietary questionnaire, and a selfassessment) and provides a total score on 30 points. A score superior to 23.5 indicates a good nutritional status, inferior or equal to 23.5 a risk of malnutrition, and inferior to 17 indicates malnutrition. In the present study, the MNA was not strictly administered but similar questions from the baseline survey allowed us to build an equivalent from proxy items. This form has shown a good agreement with the standard form in a previous study [28]. In 3C, the proportion of malnourished individuals was only small; therefore, these malnourished were grouped with those at risk of malnutrition representing people in a Bpoor nutritional status^ opposed to a Bgood nutritional status.^ Other variables Whatever the outcome studied, i.e., risk of falling or risk of fracture, a set of common adjustment variables, including
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gender; study center (Bordeaux, Dijon, or Montpellier); marital status (married, widowed, or other); education level (defined as high for subjects with at least a high school diploma vs the others); smoking status (never smoker, former smoker, or current smoker); cognitive function evaluated by the Mini Mental State Examination (MMSE) [29]; using more than five drugs, hypertension (defined as having systolic blood pressure >160 mmHg or diastolic blood pressure >95 mmHg or use of antihypertensive drugs); and the presence of dyspnea, arteritis, and heart failure were considered. Regarding the risk of fracture, treatments for osteoporosis (bisphosphonates, raloxifene, strontium ranelate, teriparatide, and calcitonin) and supplementation with calcium and/or vitamin D were considered in addition to the abovementioned common covariates.
Over 12 years, 1264 subjects (18.5 %) had at least one incident fracture at any site. Among this sample, 2.3 % had a hip fracture, 1.8 % a spinal fracture, 4.6 % a wrist fracture, 4.6 % a lower limb fracture, 3.6 % an upper limb fracture, and 5.5 % a fracture at other body sites as first fracture. The incidence rate for fracture at any site was 2.6/100 PY (95 % CI 2.5–2.7), without significant differences between men and women. People with an incident fracture were significantly older, more often female, widowed, and never smokers. They also reported more often supplementation with vitamin D and/or calcium and medication for osteoporosis than those without experience of fracture.
Statistical analyses
The results of the Cox proportional hazards model analyses of the association between nutritional status and the incidence of falling are presented in Table 3. As the interaction between nutritional status and gender was statistically significant (p5 drugs, N (%) MMSE, mean (SD) Dyspnea, N (%) Heart failure, N (%) Arteritis, N (%) Hypertension, N (%) Nutritional status (MNA), N (%) Normal At risk of malnutrition Malnourished
p valuea
Incident falling Yes (n=3369, 55.8 %)
No (n=2671, 44.2 %)
73.5 (5.2) 2528 (41.9)
73.8 (5.2) 1149 (34.1)
73.2 (5.2) 1379 (51.6)
1340 (22.2) 3275 (54.2) 1425 (23.6) 1177 (19.5)
783 (23.2) 1770 (52.5) 816 (24.2) 665 (19.7)
557 (20.9) 1505 (56.3) 609 (22.8) 512 (19.2)
3765 (62.3) 1451 (24.0) 824 (13.7)
1925 (57.1) 941 (27.9) 503 (14.9)
1840 (68.9) 510 (19.1) 321 (12.0)
3638 (60.2) 2075 (34.4) 327 (5.4) 1665 (27.6) 27.4 (2.0) 114 (1.9) 274 (4.5) 183 (3.0) 3603 (59.7)
2151 (63.9) 1055 (31.3) 163 (4.8) 1013 (30.1) 27.5 (2.0) 67 (2.0) 171 (5.1) 100 (3.0) 1990 (59.1)
1487 (55.7) 1020 (38.2) 164 (6.1) 652 (24.4) 27.3 (2.0) 47 (1.8) 103 (3.9) 83 (3.1) 1613 (60.4)
5315 (88.0) 708 (11.7) 17 (0.3)
2896 (86.0) 460 (13.6) 13 (0.4)
2419 (90.6) 248 (9.3) 4 (0.1)
