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Background Malnutrition negatively impacts on health, quality of life and disease outcomes in older adults. The reported factors associated with, and determinants of malnutrition, are inconsistent between studies. These factors may vary according to differences in rate of ageing. This review critically examines the evidence for the most frequently reported sociodemographic factors and determinants of malnutrition and identifies differences according to rates of ageing. Methods A systematic search of the PubMed Central and Embase databases was conducted in April 2019 to identify papers on ageing and poor nutritional status. Numerous factors were identified, including factors from demographic, food intake, lifestyle, social, physical functioning, psychological and disease-related domains. Where possible, community-dwelling populations assessed within the included studies ( N  = 68) were categorised according to their ageing rate: ‘successful’, ‘usual’ or ‘accelerated’. Results Low education level and unmarried status appear to be more frequently associated with malnutrition within the successful ageing category. Indicators of declining mobility and function are associated with malnutrition and increase in severity across the ageing categories. Falls and hospitalisation are associated with malnutrition irrespective of rate of ageing. Factors associated with malnutrition from the food intake, social and disease-related domains increase in severity in the accelerated ageing category. Having a cognitive impairment appears to be a determinant of malnutrition in successfully ageing populations whilst dementia is reported to be associated with malnutrition within usual and accelerated ageing populations. Conclusions This review summarises the factors associated with malnutrition and malnutrition risk reported in community-dwelling older adults focusing on differences identified according to rate of ageing. As the rate of ageing speeds up, an increasing number of factors are reported within the food intake, social and disease-related domains; these factors increase in severity in the accelerated ageing category. Knowledge of the specific factors and determinants associated with malnutrition according to older adults’ ageing rate could contribute to the identification and prevention of malnutrition. As most studies included in this review were cross-sectional, longitudinal studies and meta-analyses comprehensively assessing potential contributory factors are required to establish the true determinants of malnutrition.

Genetic studies have to date identified 43 genome wide significant coeliac disease susceptibility (CD) loci comprising over 70 candidate genes. However, how altered regulation of such disease associated genes contributes to CD pathogenesis remains to be elucidated. Recently there has been considerable emphasis on characterising cell type specific and stimulus dependent genetic variants. Therefore in this study we used RNA sequencing to profile over 70 transcriptomes of CD4+ T cells, a cell type crucial for CD pathogenesis, in both stimulated and resting samples from individuals with CD and unaffected controls. We identified extensive transcriptional changes across all conditions, with the previously established CD gene IFNy the most strongly up-regulated gene (log2 fold change 4.6; P(adjusted) = 2.40x10(-11)) in CD4+ T cells from CD patients compared to controls. We show a significant correlation of differentially expressed genes with genetic studies of the disease to date (P(adjusted) = 0.002), and 21 CD candidate susceptibility genes are differentially expressed under one or more of the conditions used in this study. Pathway analysis revealed significant enrichment of immune related processes. Co-expression network analysis identified several modules of coordinately expressed CD genes. Two modules were particularly highly enriched for differentially expressed genes (P<2.2x10(-16)) and highlighted IFNy and the genetically associated transcription factor BACH2 which showed significantly reduced expression in coeliac samples (log2FC -1.75; P(adjusted) = 3.6x10(-3)) as key regulatory genes in CD. Genes regulated by BACH2 were very significantly over-represented among our differentially expressed genes (P<2.2x10(-16)) indicating that reduced expression of this master regulator of T cell differentiation promotes a pro-inflammatory response and strongly corroborates genetic evidence that BACH2 plays an important role in CD pathogenesis.

IntroductionApproximately 34%-65% of people with multiple sclerosis (pwMS) develop cognitive impair- ment (CI). CI often encompasses information processing speed, memory problems, difficulty concentrat- ing, and problems using executive functions effectively. This study explores the perception of the presence of CI from the perspectives of pwMS and neurologists.MethodsUS, UK and EU retrospective data analysis from the 2011-2019 Adelphi Multiple Sclerosis Disease- Specific Programme (MS-DSP). The MS-DSP is a database where neurologists provide data on the next 10 pwMS to have a consultation, patient record form (PRF), integrated with pwMS self-reported data, patient self-completion form (PSC). Neurologists and pwMS were asked about the presence of problems concentrating.Results25,374 pwMS had a PRF. 11,220 pwMS had a PRF and PSC, of these 4294 answered the cognition section, with 62% (n=2,643) reporting CI (mild 36.8%, moderate 18.6, or extreme 6.1% problems concen- trating) in the past two weeks. For the same pwMS, neurologists reported 27% (n=1,158) currently having CI (mild 19.9%, moderate 6.8%, or severe 0.3% problems concentrating).ConclusionsA clear discordance is observed between neurologists and pwMS on their perception of the presence and severity of CI with neurologists clearly underestimating the existence. Funding: Novartis Pharma AG, Basel, Switzerland.

Background and purpose Cognitive impairment is a common symptom of multiple sclerosis (MS) and occurs in more than 40% of people living with MS (plwMS). No real‐world study has assessed the perception of neurologists and plwMS on cognitive issues. Methods Using data from the 2011–2019 Adelphi MS Disease Specific Programme database, this real‐world, retrospective, cross‐sectional multi‐cohort study included people aged ≥18 years with relapsing–remitting MS and secondary progressive MS from the United States, UK and the EU. Neurologists provided data on the patient record form for plwMS, with the same plwMS invited to voluntarily complete a patient self‐completion form: a questionnaire about their experiences with MS. Results Of 25,374 plwMS, 4817 who provided information on cognitive and mood symptoms were included in the analysis. Of the plwMS, 68% and 59% reported feeling ‘mentally fatigued’ and having ‘difficulty concentrating’, respectively. Neurologists reported only 27% of plwMS as having ‘difficulty concentrating’ and 15% of plwMS as having ‘short‐/long‐term memory problems’. Neurologists reported cognitive or mood symptoms as ‘not experienced’ by a higher percentage of participants with relapsing–remitting MS than secondary progressive MS. Of the plwMS who experienced ‘difficulty concentrating’, most had a concomitant feeling of being ‘mentally fatigued’ (52%), followed by ‘feeling anxious or tense’ (49%) and ‘feeling depressed’ (44%). In plwMS, caregivers reported ‘difficulty concentrating’ (16%) as the most common cognitive issue. Conclusion A clear discordance was observed between neurologists and plwMS regarding the perception of the cognitive and neuropsychiatric issues. These results underline the under‐perception of cognitive and emotional affective symptoms in plwMS during neurological consultations. Graphical representation of study outline, main results and conclusion.

ObjectiveTo evaluate the contribution of MRI activity and relapses in defining disease activity in Secondary progressive multiple sclerosis (SPMS) patients by analysing real-world data from Adelphi real-world MS Disease Specific Programme (Adelphi-MS-DSP) and to understand whether active SPMS (aSPMS) and non-active SPMC (naSPMS) are mutually exclusive groups in EXPAND.MethodsAdelphi-MS-DSP was a non-interventional, multinational real-world study (N=37,318). Patients were categorised into aSPMS (⩾1 new lesion on the most recent MRI and/or ⩾1 relapse in the last 12-months) and naSPMS groups. In EXPAND, disease activity was defined as relapses in the 2-years before screening and with/without ⩾1 gadolinium-enhancing (Gd+) T1 lesion at baseline. Demographics, MRI and relapse status were analysed descriptively.ResultsSPMS from the Adelphi-MS-DSP were categorised as aSPMS (n=1889) and naSPMS (n=665). Disease activity for aSPMS was based on MRI lesions (59.1%), relapses (12.6%), and both (28.3%). In EXPAND, 52.6% of patients (n/N=866/1645) who had no relapse in the 2-years prior to screening and no Gd+ T1 lesions at baseline were categorised under naSPMS; of these who were on placebo, 52.7% experienced on-study relapse and/or MRI activity.ConclusionsIn both real-world and clinical studies, MRI activity appears to be a more sensitive measure of disease activity versus relapses. Funding: Novartis Pharma AG, Basel, Switzerland.

Early nutrition plays a pivotal role in long-term health. The World Health Organization (WHO) recommends exclusive breastfeeding during the first six months of life, with the gradual introduction of solids after this period. However, studies in the Republic of Ireland (ROI) have shown poor compliance with guidelines. The ROI continues to have one of the lowest breastfeeding rates worldwide. Our objective was to analyse differences in breastfeeding and complimentary feeding behaviours between Irish and non-Irish mothers residing in the ROI, as well as the role of acculturation on these behaviours, using the national longitudinal study, Growing Up in Ireland (GUI). Mothers (n = 11,134) residing in the ROI were interviewed when their infants were nine months of age. The percentage of Irish mothers who initiated breastfeeding was 49.5%, as opposed to 88.1% among the non-Irish cohort (p < 0.001). Breastfeeding initiation reduced from 89.4% of non-Irish mothers who had arrived within the last year to five years ago to 67.5% for those who had arrived 11 to >20 years ago (p < 0.001). Our results indicate that cultural differences are an important factor in shaping patterns of infant feeding in the ROI. Reviewing existing support and education policies for parents is required to achieve the implementation of desirable infant feeding practices.

When treating malnutrition, oral nutritional supplements (ONSs) are advised when optimising the diet is insufficient; however, ONS usage and user characteristics have not been previously analysed. A retrospective secondary analysis was performed on dispensed pharmacy claim data for 14,282 anonymised adult patients in primary care in Ireland in 2018. Patient sex, age, residential status, ONS volume (units) and ONS cost (EUR) were analysed. The categories of ‘Moderate’ (<75th centile), ‘High’ (75th–89th centile) and ‘Very High’ ONS users (≥90th centile) were created. The analyses among groups utilised t-tests, Mann–Whitney U tests and chi-squared tests. This cohort was 58.2% female, median age was 76 years, with 18.7% in residential care. The most frequently dispensed ONS type was very-high-energy sip feeds (45% of cohort). Younger males were dispensed more ONSs than females (<65 years: median units, 136 vs. 90; p < 0.01). Patients living independently were dispensed half the volume of those in residential care (112 vs. 240 units; p < 0.01). ‘Moderate’ ONS users were dispensed a yearly median of 84 ONS units (median cost, EUR 153), ‘High’ users were dispensed 420 units (EUR 806) and ‘Very High’ users 892 yearly units (EUR 2402; p < 0.01). Further analyses should focus on elucidating the reasons for high ONS usage in residential care patients and younger males.

Early complementary feeding has been shown to increase the risk of overweight, obesity and chronic diseases later in life. Poor compliance with current guidelines on complementary feeding has been reported by Irish studies. The aim of the present paper is to identify predictors of early complementary feeding in order to help health professionals target population groups in greater need of dietary intervention as well as to provide effective advice. Cross-sectional analysis of the national, longitudinal Growing Up in Ireland study. Data were derived from the first wave (2007-2008) of the Growing Up in Ireland infant cohort. A cohort of mothers (n 11 134) from the Republic of Ireland, interviewed when their infants were 9 months of age. Of the infants, 1469 (13·5 %) had been regularly taking solids in the period between 12 and 16 weeks; this percentage increased to 47·0 % of the sample in the period between 16 and 20 weeks. Timing of formula feeding commencement, high maternal BMI and choosing a relative as the infant's minder were strongly associated with early introduction of solids both in bivariate and multivariate analysis. Those infants who started formula feeding at >4 months were 88·4% less likely to be introduced to solids early compared with those who started at <2 months (OR = 0·116; 95% CI 0·072, 0·186; P < 0·001). The results demonstrate that biological, social and behavioural aspects exert an important role in infant feeding practices. These findings are relevant to the design of policies and intervention programmes aimed at educating parents.

Malnutrition, arising from a deficiency of energy and protein intake, occurs commonly among community-dwelling individuals. Oral nutritional supplements (ONS) are an effective method of managing malnutrition if prescribed for patients who are malnourished or at risk of malnutrition. However, previous research indicates that inappropriate prescribing of ONS occurs frequently in the community setting (30–70% prevalence). Moreover, it has been previously shown that the management of patients ‘at risk’ of malnutrition in the primary care/community setting in Ireland is sub-optimal, with low awareness of the condition and its management among non-dietetic health care professionals (HCPs). In Ireland, general practitioners (GPs) are the main prescribers of ONS in primary care. They are also on many occasions the first point of contact for individuals in the community who are malnourished or at risk of malnutrition. Therefore, exploring their experiences and perceptions can provide insight into the complexities of managing malnutrition and ONS prescribing in the community. The aim of this qualitative study was to explore GPs’ experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland. Semi-structured interviews were conducted with nine GPs. The interview explored among others the following domains; Barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded interviews were transcribed and analysed using inductive thematic analysis. Three main themes were identified; i) Malnutrition a secondary concern, encapsulating the idea that malnutrition is not something that GPs screen for in isolation ii) Resources and support for managing malnutrition are needed in the community iii) Reluctance to prescribe ONS. GPs reported not screening for malnutrition, but viewed it as a consequence of other conditions and social factors. According to the GPs, they should not have sole responsibility for malnutrition management and more dietitians and trained community nurses would be desirable to support them to deal with malnutrition in the community. A preference to avoid supplementation and implement dietary changes first was expressed by GPs. As main prescribers, GPs thought that they should receive further independent trainingon the different ONS available in the market as currently they did not feel confident prescribing a range of them. Awareness of ONS cost and its misuse by certain patients were reported as reasons that made GPs reluctant to prescribe them, potentially leading to under prescribing.

Protein-energy malnutrition, or undernutrition, arising from a deficiency of energy and protein intake, can occur in developed countries both in hospitalised patients and in the primary care/community setting. Oral nutritional supplements (ONS) are an effective method of managing malnutrition if prescribed for patients who are malnourished or at risk of malnutrition. Pooled data of older adults at risk of malnutrition indicate that ONS combined with dietary counselling is the most effective intervention. Previous Irish research has demonstrated that management of patients ‘at risk’ of malnutrition in the primary care/community setting is sub-optimal, with low awareness of the condition and its management among non-dietetic health care professionals. Therefore, the aim of this qualitative study is to explore community nurses’ and dietitians’ experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland. Three focus groups were conducted with primary care dietitians (n = 17) and one focus group with community nurses (n = 5), one of the nurses had prescribing rights. The focus groups explored the following domains; the term malnutrition and patient population presenting as malnourished or at risk of malnutrition, barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded focus groups were transcribed and analysed using inductive thematic analysis. Both professional groups showed similar perspectives, and three preliminary main themes were identified; i) Malnutrition is a misunderstood term, ii) Delayed treatment of malnutrition, iii) Challenges with ONS prescription in the primary care/community setting. Both dietitians and community nurses agreed that the term malnutrition had negative connotations for patients and preferred not to use it with them. Dietitians identified the need for a multidisciplinary approach to manage patients at risk of malnutrition in the community, and community nurses agreed on their pivotal role identifying the risk of malnutrition and providing first line advice to clients. However, community nurses expressed the urgent need for training to provide first line advice to patients to improve their nutritional status to prevent malnutrition. Both groups also agreed on the need for access to more dietitians in the community, and suggested that giving dietitians prescribing rights would improve appropriate ONS prescribing. Community nurses identified a gap in their knowledge of the different ONS products, and the need to receive independent generic education on nutritional supplements.