Association between the Prognostic Nutritional Index and Dietary Intake in Community-Dwelling Older Adults with Heart Failure: Findings from NHANES III

Natriuretic peptides and C-reactive protein in in heart failure and malnutrition: a systematic review and meta-analysis

BACKGROUND

Heart failure (HF) and malnutrition exhibit overlapping risk factors, characterized by increased levels of natriuretic peptides and an inflammatory profile. The aim of this study was to compare the differences in plasma brain natriuretic peptide (BNP), N-terminal-pro B-type natriuretic peptide (NT-proBNP), and C-reactive protein (CRP) in patients with HF and malnutrition versus normal nutrition.

METHODS

From inception until July 2023, the databases, PubMed, Scopus, Web of Science, and Cochrane Library were searched. To examine the association among malnutrition [controlling nutritional status (CONUT) score ≥2; Geriatric Nutritional Risk Index (GNRI) score <92] with BNP, NT-proBNP and CRP in patients with HF, a meta-analysis using a random-effects model was conducted (CRD42023445076).

RESULTS

A significant association of GNRI with increased levels of BNP were demonstrated [mean difference (MD): 204.99, 95% confidence interval (CI) (101.02, 308.96, I2 = 88%, P < 0.01)], albeit no statistically significant findings were shown using CONUT [MD: 158.51, 95% CI (-1.78 to 318.79, I2 = 92%, P = 0.05)]. GNRI [MD: 1885.14, 95% CI (1428.76-2341.52, I2 = 0%, P < 0.01)] and CONUT [MD: 1160.05, 95% CI (701.04-1619.07, I2 = 0%, P < 0.01)] were associated with significantly higher levels of NT-proBNP. Patients with normal GNRI scores had significantly lower levels of CRP [MD: 0.50, 95% CI (0.12-0.88, I2 = 87%, P = 0.01)] whereas significantly higher levels of CRP were observed in those with higher CONUT [MD: 0.40, 95% CI (0.08-0.72, I2 = 88%, P = 0.01)]. Employing meta-regression, age was deemed a potential moderator between CRP and GNRI.

CONCLUSIONS

Normal nutrition scores in patients with HF are linked to lower BNP, NT-proBNP, and CRP levels compared with malnourished counterparts. Despite the significant link between CRP and malnutrition, their relationship may be influenced in older groups considering the sensitivity of GNRI due to ageing factors.

Predicting depression in patients with heart failure based on a stacking model

BACKGROUND

There is a lack of literature discussing the utilization of the stacking ensemble algorithm for predicting depression in patients with heart failure (HF).

AIM

To create a stacking model for predicting depression in patients with HF.

METHODS

This study analyzed data on 1084 HF patients from the National Health and Nutrition Examination Survey database spanning from 2005 to 2018. Through univariate analysis and the use of an artificial neural network algorithm, predictors significantly linked to depression were identified. These predictors were utilized to create a stacking model employing tree-based learners. The performances of both the individual models and the stacking model were assessed by using the test dataset. Furthermore, the SHapley additive exPlanations (SHAP) model was applied to interpret the stacking model.

RESULTS

The models included five predictors. Among these models, the stacking model demonstrated the highest performance, achieving an area under the curve of 0.77 (95%CI: 0.71-0.84), a sensitivity of 0.71, and a specificity of 0.68. The calibration curve supported the reliability of the models, and decision curve analysis confirmed their clinical value. The SHAP plot demonstrated that age had the most significant impact on the stacking model's output.

CONCLUSION

The stacking model demonstrated strong predictive performance. Clinicians can utilize this model to identify high-risk depression patients with HF, thus enabling early provision of psychological interventions.

Higher systemic inflammation response index is associated with increased risk of heart failure in adults: An observational study

Inflammation has been established to play a crucial role in the onset of heart failure (HF) for many years, and the systemic inflammation response index (SIRI) is a new and comprehensive indicator reflecting the inflammation status in human body. The aim of this investigation was to determine the potential relationship between HF and SIRI in adults. For this investigation, we used cross-sectional data from the National Health and Nutrition Examination Survey (NHANES), which was conducted from 2009 to 2018. The study utilized multivariable linear regression models to examine the potential independent relationship between HF and SIRI. Additionally, a subgroup analysis and interaction test were carried out. To illustrate the nonlinear relationship, threshold effect analysis and fitted smoothing curves were also used. 26,303 eligible subjects aged ≥ 20 years were enrolled as the final samples. HF participants exhibited significant higher SIRI compared with non-HF participants [1.89 ± 1.33 vs 1.25 ± 0.95 (1000 cells/μL), P < .0001]. Multivariate logistic regression showed that those in the highest SIRI quartile had a significantly greater risk of HF by 130% (OR = 2.30, 95% CI 1.41-3.76; P < .0001). In addition, nonlinear relationship between HF and SIRI with the inflection point of 2.2 (1000 cells/μL) was observed. According to our research, adult HF prevalence and SIRI are positively correlated. This implies that SIRI could be a valuable biomarker for determining HF risk in the clinic.

Associations between systemic immunity-inflammation index and heart failure: Evidence from the NHANES 1999-2018

BACKGROUND

Heart failure (HF) is a disease closely associated with inflammation, and the systemic immune-inflammation index (SII) is a novel inflammatory marker. Therefore, this study aims to explore the relationship between SII and HF.

METHODS

We used National Health and Nutrition Examination Survey data from 1998 to 2018 to include adults who reported a diagnosis of HF and complete information on the calculation of SII. SII was calculated as platelet count × neutrophil count/lymphocyte count. We used multiple logistic regression models to examine the association between SII and HF and explored possible influencing factors by subgroup analysis. In addition, we performed smoothed curve fitting and threshold effect analysis to describe the nonlinear relationship.

RESULTS

The population-based study involved a total of 48,155 adults ages 20-85. Multivariate logistic regression showed that participants with the highest SII had a statistically significant 32% increased risk of HF prevalence compared to those with the lowest SII (OR = 1.32; 95% CI, 1.06-1.65, P = 0.0144) in a fully adjusted model. Subgroup analysis revealed no significant interactions between SII and specific subgroups (p > 0.05 for all interactions). Furthermore, the association between SII and HF was non-linear; the inflection point was 1104.78 (1000 cells/μl).

CONCLUSIONS

Based on our findings, elevated SII levels were found to be strongly associated with the risk of HF, and SII was nonlinearly associated with HF. To validate these findings, a larger prospective investigation is needed to support the results of this study and investigate potential problems.

Association between dietary copper and cardiovascular disease: A narrative review

Cardiovascular disease (CVD) is a major cause of mortality and morbidity. Several studies have investigated the relationship between trace element status, including copper status, and CVDs in population studies; however, there are controversies about the role of dietary copper and CVD. We aimed to review the association between dietary copper intake with CVD and this association's related factors by reviewing both animal models and human studies. Some animal model studies have reported a strong relationship between dietary copper intake and atherogenesis based on the possible molecular pathways, whilst other studies have not confirmed this relationship. Human studies have not revealed a relationship between CVDs and dietary copper intake, but there is uncertainty about the optimal amount of dietary copper intake in relation reducing the risk of CVDs. These associations may be influenced by ethnicity, gender, underlying co-morbidities and the methods used for its measurement.

Low Sodium Intake, Low Protein Intake, and Excess Mortality in an Older Dutch General Population Cohort: Findings in the Prospective Lifelines-MINUTHE Study

Background: Several studies have found a U-shaped association between sodium intake and mortality. The increased mortality risk of low sodium intake has raised debates and hampers widespread acceptance of public health campaigns and dietary guidelines on reducing sodium intake. Whether the excess risk can be attributed to low sodium intake alone or concomitant inadequate intake of other relevant nutrients is unknown. Objective: We investigated whether concomitant low protein intake could explain the lower part of the U-shaped association of sodium intake with all-cause mortality. Methods: We included 1603 individuals aged between 60 and 75 years old from the gender- and socioeconomic status-balanced prospective Lifelines-MINUTHE cohort study. Using multivariable Cox regression analyses, we investigated the association of sodium intake (24 h urinary sodium excretion) with all-cause mortality, including the interaction with protein intake calculated from the Maroni formula. Results: Mean intakes of sodium and protein were 3.9 ± 1.6 g/day and 1.1 ± 0.3 g/kg/day, respectively. After a median follow-up of 8.9 years, 125 individuals (7.8%) had died. The proportion of participants with insufficient protein intake (<0.8 g/kg/day) was inversely related to sodium intake (i.e., 23.3% in Q1 versus 2.8% in Q4, p < 0.001). We found an increased risk for mortality in both the highest quartile (Q4, >4.7 g/day; hazard ratio (HR) 1.74 (95% confidence interval (CI) 1.03−2.95)) and the lowest two quartiles of sodium intake (Q1, 0.7−2.8 g/day; 2.05 (1.16−3.62); p = 0.01 and Q2, 2.8−3.6 g/day; 1.85 (1.08−3.20); p = 0.03), compared with the third quartile of sodium intake (Q3, 3.6−4.7 g/day). This U-shaped association was significantly modified by protein intake (Pinteraction = 0.006), with the increased mortality risk of low sodium intake being reversed to the lowest mortality risk with concomitant high protein intake. In contrast, the increased mortality risk of low sodium intake was magnified by concomitant low protein intake. Conclusions: We found that a higher protein intake counteracts the increased mortality risk observed in subjects with a low sodium intake. In contrast, a joint low intake of sodium and protein is associated with an increased mortality risk, allegedly due to poor nutritional status. These findings support the guidelines that advocate a lower sodium intake, while highlighting the importance of recognizing overall nutritional status among older adults.

Malnutrition and infection lead to poor prognosis and heavy financial burden of patients with chronic heart failure

Background

Chronic heart failure (CHF) is a major public health concern, as it is associated with poor prognosis and heavy financial burden. In recent years, there has been increasing interest in medications for CHF in China, but few studies pay attention to the effects of nutrition and infection.

Methods and results

This was a retrospective study collected patients with CHF admitted to the Department of Cardiology of Qilu Hospital of Shandong University from January 2017 to May 2018. Patients were classified according to the prognosis and the financial burden. Through comparison and regression analysis, we found that the factor associated with worse prognosis were decreased heart rate, albumin and prealbumin; β-blockers and mineralocorticoid receptor antagonism (MRA) were the factor improved the prognosis of patients with CHF; the factor overburdening financial condition were infection, decreased prealbumin, high Alanine aminotransferase (ALT), usage of recombinant human brain natriuretic peptide (rhBNP) and Levosimendan; aspirin and Sacubitril/Valsartan were the factor releasing financial burden of patients with CHF. Then, we grouped by Controlling Nutritional Status (CONUT) score, which enabled evaluation of the patient's protein reserve and immune defenses. Patients in the malnutrition group had higher infection ratios, longer hospital stays, and greater hospital expenses than the normal group. The improvement ratios of therapeutic outcomes in the moderate or severe malnutrition group were lower than in the normal and mild malnutrition group.

Conclusion

Malnutrition and infection caused poor prognosis and increased financial burden of patients with CHF. The high CONUT score indicated the CHF patient's unfavorable prognosis and heavy financial burden.

An Inverse Correlation between the Atherogenic Index of Plasma and Heart Failure: An Analysis of the National Health and Nutrition Examination Survey 2017-March 2020 Pre-Pandemic Data

Aims: The atherogenic index of plasma (AIP) is associated with cardiovascular diseases. Nevertheless, limited studies have investigated the association between AIP and the risk of heart failure (HF) in the general population. This study aimed to explore the association between AIP and HF risk using a large-scale population dataset from the National Health and Nutrition Examination Survey (NHANES) 2017−March 2020 Pre-pandemic data. Methods: A total of 5598 individuals were included in the analysis of the association between AIP and HF from the NHANES database. The relationship between AIP and HF was examined using multivariate logistic regression and smooth curve fitting. An association between the two was detected based on the odds ratios (ORs) and 95% confidence intervals (CIs). Results: The overall prevalence of HF among the 5598 participants analyzed was 3.21%. Compared with individuals in the lowest quartile of AIP, participants in the higher quartiles showed a significantly reduced probability of HF. Smooth curve fitting analysis revealed a linear association between AIP and HF. Compared with individuals in Q1 of the AIP, participants in Q2 (OR = 0.38, 95% CI = 0.2−0.72, p = 0.0033), Q3 (OR = 0.24, 95% CI = 0.12−0.48, p < 0.0001), and Q4 (OR = 0.32, 95% CI = 0.14−0.74, p = 0.0075) had a significantly decreased risk of HF after adjusting for other risk factors. Analysis of subgroup strata revealed that AIP may interact with age and statin use (p for interaction = 0.012 and 0.0022, respectively). Conclusion: Our results suggest that a high AIP value is negatively correlated with HF prevalence. The AIP may be an effective method for identifying individuals at a high risk of HF.

Prognostic utility of the prognostic nutritional index combined with serum sodium level in patients with heart failure

BACKGROUND AND AIMS

Both malnutrition and hyponatremia (serum sodium <135 mmol/L) can be induced by the impaired absorption function of the edematous intestinal wall caused by heart failure (HF) and are prognostic factors of mortality in HF. However, little is known about the interrelationship of nutritional status and hyponatremia in mortality risk prediction in HF.

METHODS AND RESULTS

This study enrolled 2882 HF patients admitted to the HF care unit of Fuwai Hospital, Beijing, China from 2008 to 2018; 71.3% were male and the mean age was 56.64 ± 15.96 years. Nutritional status was assessed by prognostic nutritional index (PNI), calculated as serum albumin (g/L) + 5 × total lymphocyte count (10⁹/L). Lower PNI indicates worse nutritional status. Patients were divided into 8 groups based on baseline PNI quartiles (Q1: <43.6, Q2: 43.6-48.55, Q3: 48.55-63.25, Q4: >63.25) and sodium level (normal sodium and hyponatremia). After adjustment, patients in the PNI Q1 associated with hyponatremia had a 2.12-fold higher risk of all-cause death (95% confidence interval [CI]: 1.67-2.70) compared with those in the PNI Q4 with normal sodium. A refinement in risk prediction was observed after adding PNI quartile and serum sodium category to the original model (ΔC-statistic = 0.018, 95% CI: 0.007-0.025; net re-classification index = 0.459, 95% CI: 0.371-0.548; integrated discrimination improvement = 0.025, 95% CI: 0.018-0.032).

CONCLUSION

HF patients with both the lowest PNI quartile and hyponatremia are at higher risk of all-cause mortality. The combination of PNI and serum sodium level enhanced the predictive value for all-cause mortality in hospitalized HF patients.

CLINICAL TRIAL REGISTRATION

URL: ClinicalTrials.gov; Unique Identifier: NCT02664818.

Periodontitis Is Associated With Heart Failure: A Population-Based Study (NHANES III)

Objectives: The aim of this study was to investigate the relationship between periodontitis and heart failure using the Third National Health and Nutrition Examination Survey (NHANES III). Methods: Participants who had received a periodontal examination were included and investigated for the occurrence of heart failure. The included participants were divided into no/mild periodontitis and moderate/severe periodontitis groups according to their periodontal status. Weighted prevalence of heart failure was calculated, and weighted logistic regressions models were used to explore the association between periodontitis and heart failure. Possible influencing factors were then explored through subgroup analysis. Results: Compared with that of the no/mild periodontitis group, the incidence of heart failure in participants with moderate/severe periodontitis was 5.72 times higher (95% CI: 3.76-8.72, p < 0.001). After adjusting for gender, age, race, body mass index, poverty income ratio, education, marital status, smoking status, drinking status, hypertension, diabetes, stroke, and asthma, the results showed that the incidence of heart failure in the moderate/severe group was 3.03 times higher (95% CI: 1.29-7.13, p = 0.012). Subgroup analysis showed that criteria, namely, male, 40-60 years old, non-Hispanic white, body mass index >30, poverty income ratio ≥1, not more than 12 years of education, currently drinking, stroke but no diabetes, or asthma supported moderate/severe periodontitis as a risk factor for heart failure (p < 0.05). Conclusion: According to data from this nationally representative sample from the United States, periodontitis is associated with an increased risk of heart failure.

Review the factors associated with dietary sodium adherence in patients with heart failure from selected research-based literatures

Background

Low-sodium dietary is an important measure to avoid heart failure patient’s body fluid volume overload. There are still more than 50% of heart failure patients who are incapable of complying low-sodium dietary. This study utilized the systematic literature review method, with the purpose to understand the related factors towards the compliance behavior of low-sodium dietary of patients with heart failure.

Methods

This study typed keywords (congestive heart failure, adherence, compliance, low sodium diet, low salt diet, dietary sodium restriction) from computer databases (CINAHL, Cochrane, Medline, ProQuest Nursing Allied Health, PubMed, and ScienceDirect) and according to inclusion criteria were as follows: (1) Research objects were adult patients admitted to HF, (2) Research content were related to sodium diet compliance behavior. (3) Non-intervention research. Exclusion criteria were as follows: (1) participants who was pregnant women, (2) qualitative research, (3) studies on development of tool, (4) poster. Select needed 14 articles that meet the purposes of this study. In addition, the study also collected 4 more studies with the same purpose from the references that were included in the retrieved articles, and finally a total of 18 studies were included in the analysis of this study. Data analysis uses descriptive statistics (percentage, frequency distribution) and content analysis method.

Results

This study use a systematic literature review method, it was found that the results of the studies use nonintervention method, which explored the relevant factors of low-sodium dietary compliance in heart failure patients over the past 20 years, could be summarized in 4 dimensions as social and economic conditions, patient conditions, disease conditions and therapy conditions.

Conclusions

Heart failure patients’ compliance behavior toward low-sodium dietary is multi-dimensional. Therefore, this study recommends when the health care providers evaluating patients’ compliance behavior of low-sodium dietary, it is necessary to consider more different aspects.

The Association Between Dietary Antioxidant Micronutrients and Cardiovascular Disease in Adults in the United States: A Cross-Sectional Study

Background: Antioxidant micronutrients represent an important therapeutic option for the treatment of oxidative stress-associated cardiovascular diseases (CVDs). However, few studies have evaluated the relationship between the levels of multiple dietary antioxidants and CVDs.

Objective: The study therefore aimed to evaluate associations between dietary antioxidants and total and specific CVDs among a nationally representative sample of adults in the US.

Design: In total, 39,757 adults (>20 years) were included in this cross-sectional study from the 2005–2018 National Health and Nutrition Examination Survey. We analyzed dietary recall of 11 antioxidant micronutrients in this population. Multivariate logistic and weighted quantile sum (WQS) regression were both applied to examine the relationships between these antioxidants, alone and in combination, with the prevalence of all CVDs and specific CVDs. The linearity of these correlations was also explored using restricted cubic spline (RCS) regression.

Results: Multivariate logistic models showed that, compared with the lowest quartile, the levels of 11 antioxidants in the highest quartile were independently associated with decreased total CVD (all P < 0.05). The WQS index showed that, when considered together, the 11 micronutrients were negatively correlated with total CVD (P < 0.001) and five specific CVDs (all P < 0.05), and selenium had the strongest association (weight = 0.219) with total CVD. Moreover, the RCS model demonstrated that iron, zinc and copper were all negatively and non-linearly correlated with total CVD, while the eight other micronutrients had non-significant, linear, negative relationships with total CVD (P for non-linearity >0.05). A piecewise binary logistic regression analysis showed that the inflection points in the relationships between CVD and iron, zinc and copper were 7.71, 6.61, and 0.74 mg/day, respectively.

Conclusions: Our findings suggested that high levels of combined dietary antioxidant micronutrients are associated with decreased prevalence of CVDs, and that selenium has the greatest contribution to this association.

Concentrations of Mg, Ca, Fe, Cu, Zn, P and anthropometric and biochemical parameters in adults with chronic heart failure

Background

The study investigated the relationship between the concentrations of Mg, Ca, Fe, Cu, Zn, P and anthropometric and biochemical parameters in the blood serum of patients with heart failure (HF) and the potential influence on the development and progression of HF.

Material & methods

The study included 214 patients (155 men and 59 women), aged 40–87 years, presenting symptoms or signs typical of HF (according to the NYHA functional classification). Serum concentrations were determined for Mg, Ca, Fe, Cu, Zn, P, C-reactive protein (CRP), creatinine, urea, triglyceride levels (TG), total cholesterol (CH), high density protein (HDL), low density protein (LDL). The levels of macro-and microminerals were analysed using inductively coupled serum optical emission spectrometry (ICP-OES).

Results

Our study confirmed the role of known risk factors in the development of heart failure, including: overweight, diabetes, hypertension, high triglycerides (TG), high total cholesterol (CH), high levels of low density protein (LDL) and reduced levels of high density protein (HDL), high CRP, high creatinine. Moreover, deficient serum concentrations of Mg (47% of the studied men and 54% of the women) and Cu (in 44% of men and more than 30% of women) were observed, as well as subnormal serum Fe (2% of women) and Zn (1% of men). Elevated serum Ca was found in 50% of men and 49% of women. In 44% of the studied men and 52% of the studied women, P levels in serum were also above-average. The study revealed a significant positive correlation between serum levels of Ca and Mg, and also Ca and Cu in women. In men, serum Cu was positively correlated with Mg and Ca concentrations. In patients from group 1 (NYHA I–II), Mg content was positively correlated with Ca and Cu. In this patient group, Ca was also positively associated with Cu content in serum. In group 2 (NYHA III-IV), serum Mg concentration was significantly positively correlated with that of Cu and Ca.

Conclusions

Changes in the serum concentrations of macro-and microminerals may significantly affect the severity of HF in Polish patients.

Association Between the Prognostic Nutritional Index and Cognitive Function Among Older Adults in the United States: A Population-Based Study

BACKGROUND

Nutritional status has been recognized as an important factor influencing cognitive function-related diseases, but few comprehensive nutrition indicators are available to assess the risk of cognitive decline.

OBJECTIVE

This study aimed to investigate the relationship between the prognostic nutritional index (PNI) and cognitive function in an elderly population, and the differences in nutrient intake between different levels of nutritional risk.

METHODS

Based on cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) 2011-2014, we included 2,564 older participants. The lower quartile of each of the four cognitive tests was considered to have cognitive function impairment (CFI). Binary and multivariate logistic regression models were used to estimate the relationship between the PNI and the odds ratio of CFI.

RESULTS

After adjustment for confounding variables, we found that the odds of CFI were significantly lower for participants with normal PNI levels than for those with low PNI levels. In a comparison of global cognitive impairment scores, participants with a normal PNI had lower ratios of poor cognitive performance than those with a low PNI. By comparing the nutrient intake at different PNI levels, we found a reduction in the intake of protein, dietary fiber, total saturated fatty acids, and multiple micronutrients in the low PNI group.

CONCLUSION

Our study shows that the PNI can be a good predictor of the odds of CFI in the elderly population and that it is a convenient indicator of reduced intake of nutrients which may be important to brain health.

Relationship between Nutritional Status and Clinical and Biochemical Parameters in Hospitalized Patients with Heart Failure with Reduced Ejection Fraction, with 1-year Follow-Up

Heart Failure (HF) is a cardiovascular disease with continually increasing morbidity and high mortality. The purpose of this study was to analyze nutritional status in patients diagnosed with HF with reduced ejection fraction (HFrEF) and evaluate the impact of malnutrition on their prognosis. The Polish version of MNA form (Mini Nutritional Assessment) was used to assess the patients’ nutritional status. The New York Heart Association (NYHA) class, exacerbation of HF, chosen echocardiographic and biochemical parameters, e.g., natriuretic peptides or serum albumin, were also analyzed. Among the 120 consecutive patients, 47 (39%) had a normal nutritional status, 62 (52%) were at risk of malnutrition and 11 (9%) were malnourished. The patients with malnutrition more frequently presented with HF exacerbation in comparison to those with normal nutritional status (82% vs. 30% respectively, p = 0.004). There were no significant differences between the investigated groups as to natriuretic peptides; however, both the malnourished patients and those at risk of malnutrition tend to show higher B-type natriuretic peptide (BNP) and NT-proBNP concentrations. During the average 344 days of follow-up 19 patients died and 25 were hospitalized due to decompensated HF. Malnutrition or being at risk of malnutrition seems to be associated with both worse outcomes and clinical status in HFrEF patients.