The dengue virus is endemic in many low- and middle-income countries. In Burkina Faso, the proportion of fevers that could be due to dengue is growing. In 2013, a dengue epidemic spread there, followed by other seasonal outbreaks. Dengue is often confused with malaria, and health workers are not trained to distinguish between them. Three training videos using different narrative genres were tested with nursing students from two institutions in Ouagadougou: journalistic, dramatic and animated video. The study aimed to determine if video is an effective knowledge transfer tool, if narrative genre plays a role in knowledge acquisition, and which narrative elements are the most appreciated.A mixed method research design was used. The relative effectiveness of the videos was verified through a quasi-experimental quantitative component with a comparison group and post-test measurements. A qualitative component identified participants’ perceptions regarding the three videos. Data were drawn from a knowledge test (n = 482), three focus groups with health professionals’ students (n = 46), and individual interviews with health professionals (n = 10). Descriptive statistics and single-factor variance analysis were produced. A thematic analysis was used to analyse qualitative data.p <0.05): 12.31% for the journalistic video, 20.58% for the dramatic video, and 18.91% for the animated video. The dramatic and animated videos produced a significantly higher increase in knowledge than did the journalistic video (with respectively 8.27% (p = 0.003) and 6.59% (p = 0.029) and can be considered equivalent with a difference of 1.68% (p = 0.895). Thematic analysis also revealed that these two videos were considered to be better knowledge transfer tools. Four key aspects are important to consider for a video to be effective: 1) transmitting information in a narrative form, 2) choosing good communicators, 3) creating a visual instrument that reinforces the message and 4) adapting the message to the local context.Results showed that all three videos led to significant rates of knowledge improvement when compared with the comparison group  tool to address the training needs of health workers. The ease with which a video can be shared, and its playful nature makes it a particularly attractive tool for reaching and training them and transforming their practices, especially, given their busy schedules. The study addresses the use of video as a KT strategy in relation to the narrative genre, i.e., how information is presented. It contributes to the advancement of knowledge on what motivates the use of video as a KT tool and practice changes in working contexts where professionals need to know how to respond, quickly and appropriately, to health problems such as dengue and other emerging pathologies in Africa. Transferring research evidence into practice is often a slow and complex process. Despite numerous efforts over recent decades, there remains a substantial gap between research evidence production and use , 2. WhenThe question, however, is how best to do this. It has already been established that researchers concerned with knowledge transfer (KT) need to develop strategies to promote knowledge uptake , 7, inclDengue is a mosquito-borne viral infection that has dramatically spread around the world in recent decades, primarily in the tropics and subtropics , 12. EveThe majority of cases are asymptomatic or mild and self-managed and the mortality rate from severe dengue is relatively low. Yet, the economic and resource burden on health services are important in many endemic settings , 18. MorIn Burkina Faso, dengue and other hemorrhagic fevers’ surveillance faces multiple obstacles such as a general lack of knowledge about dengue in the health system, lack of diagnostic means and the limited health workers’ training , 22. AvaFor decades, research has shown that video can improve people's knowledge on health topics, can promote behavior change, can increase self-efficacy and many other advantages . This caMhealth) has gained more and more attention as an innovative technology to promote health by supporting healthcare practices , I wondered how long it would last. I said to myself, I hope it doesn’t go on for an hour.” .The results also reinforce the idea that the absence of an emotional dimension in video 1  handicapped this genre compared to the other two. The objective and emotionless approach of journalism in fact generates a sense of boredom that diverts attention: “it tells the truth”  and because the management of the patient was perceived as being more clearly explained. The actors’ role-playing was considered realistic, which helped with message retention.The results show that the role-playing, which is the backbone of video 2 (dramatic), fosters concentration. This device was recognized as a particularly effective means of transmission because “We’re ‘inside’ the consultation scene, which helped me to concentrate. Your mind retains it better. The day you see a case, it takes you back to the image you saw.” A participant from public school added that the students were able, in this way, to identify with health workers; they felt challenged and involved, which encouraged attentive listening. One nurse  confirmed that this dramatization helped him to identify with the health worker, who became a role model, and to learn how to behave toward the patient. More specifically, it was the alternation between the patient’s questions and the physician’s responses that helped create an engaging story for the viewer. Our results showed that, short of being actively involved, attending a filmed role-playing is equally effective for learning. The effectiveness of the filmed role-playing was largely due to the realism of the scene. For example, according to one public school instructor, the reactions of the patient, who did not contain her astonishment when the doctor insisted on the seriousness of the virus and its mode of transmission, accurately reflected the behaviour of a patient coming for a consultation.How many different dengue serotypes are known?) is a good example. The comparison group obtained a very low score (23%), whereas those who viewed the dramatic and animated videos performed well . In the animated video, the dengue serotypes were presented in the form of four viruses of different colors. The images were considered to be very clear, and it was not surprising that the question achieved a good response. “When you watch the animation, it’s as if it’s all been laid out for you. The information is mapped out and it’s clearer.” The patient’s reactions in the video are not trivial, as they are helpful for effectively transmitting certain data, even of a more technical nature. Question 6 . Yet this information was illustrated by several photos of everyday containers  that were synchronized with the enumeration in the narration, and which should have made it easier to remember.The journalistic video was the only one filmed in a real primary health centre, a choice of setting that was appreciated by some participants for its realism. In fact, one health worker suggested that the journalistic video could be useful for professionals already on the ground, because it conveyed real life The structure of video 2 (dramatic), which involved alternating between scenes of consultation and monologues by the physician, with the inherent breaks in rhythm (stop and restart), was perceived as driving the narrative. Participants indicated that the physician’s comments consolidated the knowledge by providing details on what was observed or explained in the consultation scenes.“It’s good because he [the physician] sums things up for the audience each time. He holds the viewers’ attention… He keeps stopping to address the audience in a serious manner; that’s very important. It’s important because we see he’s doing it to capture the viewers’ attention… and he emphasizes certain key points.” Rather than presenting a continuous narrative, the stratagem of switching between two narrative forms helps maintain the audience’s interest, making it easier for them to understand and assimilate the knowledge.“journalism talks about the problem in a general way” . The narration  imitates the objective tone of journalistic reporting and presents the facts without emotion. No point is emphasized; rather, each one follows on the next, with equal importance and without modulation, hence the feeling of a “comprehensive” approach. One public school instructor said that:In videos 1  and 3 (animated), the narration is off-screen, that is, the narrators are heard but not seen. The conventional and monotone delivery of the journalistic video contributes to the feeling that “The journalistic video was not quite sensational enough. We don’t get much of a feeling, we don’t sense the seriousness [of the situation]. I didn’t like it… It was less moving.”“I think it’s a good thing, because he’s explaining what the viewers saw as an image. At the same time, he’s reinforcing their knowledge at this level.” .In contrast, the narration in video 2 (dramatic), provided by the physician-narrator addressing the audience directly while looking into the camera, appeared to have had a significant impact on message retention. Moreover, the narrator’s role was reinforced by the infographics  that acc“intelligible”, and more “credible”: “The actor can speak more easily and engage people’s attention, which not everyone can do.” Several participants found the nurse interviewed in the journalistic video to be boring. However, using actors to portray the doctor and the patient was considered appropriate by all. Several participants even said the actors could have been more expressive, particularly since patients with dengue fever generally arrive in great pain. “Most [real patients] lie on the table moaning. The woman [actor] didn’t appear sick enough, her pain didn’t come across in her physique.” . Finally, the vast majority of participants said the Burkinabè nationality of the actors enhanced the credibility of the dramatic video. One public school instructor noted that “if it’s a black man, people will say to themselves that this really is the situation in our country.”In the journalistic video, some explanations were given by a nurse, who was quite naturally credible due to his professional status. One might wonder whether having these explanations conveyed by actors would detract from the credibility of the message. On the contrary, said one public school instructor; an actor can make the message clearer, more “everyone sees and understands the same thing”. A public school instructor noted that the animated video had “no images that were not informative and that all the images were focused on information.” Some of the students clearly summarized this perception of the animation video: “The visual and verbal seem to be better combined. In the other videos, there’s just the verbal.” .When addressing the theme of what images are the most appropriate or considered most attractive, the animated video stood out markedly from the other two. One nurse asserted that images were more precise because conveying the maximum information” . The phrase “we are shown”, which recurred in the interviews, revealed that the visual dimension left its mark on people’s minds. This close association between visual and audio freed the viewers from having to make the connection themselves and gave them the impression that the information, thus schematized, was more accessible and easier to remember.One might wonder whether superposition of the moving image and sound would produce an undesirable duplication effect, but that was not the case. Combining audio and visual gave greater consistency to the message, which was described as ““briefing on the problem” and, as such, not geared toward an audience of health professionals. The participants concluded that the journalistic video did not clearly convey information on dengue fever. Yet the narrated text in that video was identical to that of the animated video. The general visual elements of the journalistic video did not sufficiently concretize the information being transmitted verbally, leaving viewers with a nebulous impression of what was actually being communicated.In addition, a visual method that is too general makes the message less clear and can become an obstacle to knowledge transfer. The journalistic video was cited as an example of this. One public school instructor described it as being only a p = 0.241), whereas the improvement was statistically significant for both the animated (p <0.001) and dramatic (p = 0.015) videos. In both cases, the information was accentuated by striking visuals. In the dramatic video, the physician’s explanations were illustrated by the negative RDT sign as it is generally inscribed by the health worker in the patient’s medical record .“In Africa, the mosquito is the enemy. When we see bleeding, the color red, we know it means danger.” The red cross that appears on the medications to warn against self-medication was also identified as a danger symbol due to its color.One student  noted that the colors helped him integrate the notion of danger: “the message came across better with the dramatization because the words they used were easier to understand”. Questioned about understanding the message, a nurse explained:The results indicated that the tone and the language used by the actors contributed to a better understanding of the message. One nurse  noted that “About the way of speaking: if it’s among ourselves, we understand each other. But if it’s you, your way of speaking, there are others who don’t easily understand.”p <0.001), the journalistic video (43.04%) (p = 0.012) and the animated video group (41.98%) (p = 0.007). This was also the question on which the students who viewed the animated video obtained the lowest score; it should be noted that the animated video was narrated by a male voice with a European accent. Another possible explanation was that the actor playing the physician in the dramatic video modified the text slightly, replacing the words “dawn” and “dusk”, which were used in the journalistic and animated videos, with “sunrise” and “sunset”.Both the intonations used by the actors, reflecting the local accent, and their vocabulary were more adapted to the target audience. In this regard, question 1 of the knowledge test was interesting. This question concerned the times of the day when dengue mosquitoes are most likely to bite humans, that is, at dawn and dusk. Students who viewed the dramatic video scored significantly higher (65.82%) on this question than both the comparison group (25.51%) .“purely scientific”. It might therefore have been expected that, within the same context—that of health professionals in Burkina Faso—humor would be decoded in much the same way by all participants. However, the satiric nature of the caricatures presented in the animated video was not grasped by everyone. Some only saw the pictures without noticing their humorous nature. This was surprising, given that the caricatures were drawn by the illustrator of Journal du jeudi, a satirical Burkinabè newspaper that was very successful and had become a major societal phenomenon [Here it should be mentioned that the notion that dengue can be fatal came up only in the discussions around the animated video, even though that information was contained in all three videos. This suggests the humor that characterized the animated video did not minimize the seriousness of the message. It was surprising to see, however, that even though all participants agreed that humor facilitates message transmission, their perceptions of what was humorous varied. While some identified the animated video as the most humorous, others preferred the dramatic video. One public school instructor even said he found the tone of the animated video to be enomenon .This study contributes to the advancement of knowledge on what motivates the use of video as a KT tool and practice changes in working contexts where professionals need to know how to respond, quickly and appropriately, to health problems such as dengue and other emerging pathologies in Africa. Given the increasing prevalence of dengue fever and the lack of training among health workers in Burkina Faso , there iThe first research question asked whether the videos were an effective KT tool for transmitting research evidence on dengue to health workers in Burkina Faso. Because the groups that viewed the videos learned significantly more than did the comparison group, the present study showed that viewing videos can lead to significant knowledge improvement, as previously shown in the literature , 53–55. Moreover, this study provides an additional contribution to the literature that examines video as a KT tool. Our study argues that the narrative genre of the video influences the interest of participants—a sine qua non condition for the success of a KT exercise. The second research question asked whether participants’ learning varied depending on which video they viewed. In this experiment, results showed that the groups who viewed the dramatic and animated genres increased their knowledge scores significantly more than did the group who viewed the journalistic video. This suggests that the narrative genre of the video influences the viewer’s capacity to retain information, and that some narrative elements foster knowledge transfer more than others.On that point, the third research question asked what narrative elements  make a video a more effective KT tool. Therefore, this study identified the importance of four key aspects to consider for a video to be effective: 1) Transmitting information in a narrative form, 2) Choosing good communicators, 3) Creating a visual instrument that reinforces the message and finally, 4) Adapting the message to the local context. As we will see, the different appreciated narrative aspects by the participants are mostly supported by scientific literature. A summary of key elements to consider in producing a video is presented in The narrative is a communication technique in which stories, metaphors, and comparisons are used to enhance the audience’s emotional connection to the information being communicated or to the targeted behaviour . Narratiin situ are considered to provide the most effective learning environments [when the video is racially, ethnically, linguistically, and/or culturally concordant with the target population” [The results also showed that the “storytelling” sequences in the dramatic video–dialogue between a physician and a patient—enabled participants to be present where they would not normally be, and as such, were particularly effective . For exaronments , role-plronments . Hoeken ronments  identifiulation” . Howeverulation” . As suchAnother effective narrative aspect of the dramatic video is supported by studies: that is varying the rhythm. Based on a literature review, Berk , describon screen (as opposed to an off-screen voice) fosters knowledge transfer.Studies  previousWhen producing a dramatic video, this study also highlights the importance of mobilizing actors from the target country. This reflects the idea that theatre has the power to give society a representation of itself. In theatre, the public seeks a mirror that will highlight certain aspects of the society to elicit a cognitive or emotional reaction . TheatreIt is also important to ensure that they perform energetically and with emphasis. Regarding the dramatic video, a more dramatic performance by the actors would have amplified the message, in keeping with the notion that, to ensure that spectators grasp the actor’s performance, the latter needs to align his overall expression  with the text . Also, tA video is a better KT tool when it includes visual elements—infographics or animations—that illustrate the ideas being presented. These results, confirming that effective understanding of scientific explanations requires mapping between words and images, are consistent with the theory of double coding , 74, whiAnother important result of this study is the attractiveness of the colors used in the animated video. This was a significative result because it confirms that, for a KT activity to be successful, the information being conveyed needs to be attractive, which requires a good understanding of users’ preferences . This prVideo that adopts a humorous tone is considered more captivating than a didactic document and contributes to better retention of content. Yet humor is a fundamentally cultural phenomenon . Some stMoreover, the language and intonation used should be adapted to the local context. In this study, word choice was not the only factor that influenced understanding. Certainly, language can influence knowledge transfer in various ways because it represents an essential aspect of culture . Even thIn interpreting the results of the present study, certain limitations should be kept in mind. First, even though the sample can be considered sufficient, it is nevertheless a small sample. Also, as the conditions for video projection differed from one class to another, it would be advisable to set up a projection device to avoid such irregularities. Along the same lines, it would have been preferable not to have the experimental groups interacting with each other outside the classroom between projections , to avoiThe measurement instrument developed for this study—that is, the knowledge test—could be improved. It would have been preferable to validate it beforehand with Burkinabè nurses and instructors. It could also be made more precise by replacing the true-or-false questions with multiple-choice questions. We could also have measured other socio-demographic variables in the questionnaire such as having already been diagnosed with dengue fever or not. Moreover, a right-after-training knowledge test was used in this research to evaluate the effectiveness of video as a KT tool. It would be helpful if future studies could measure actual changes in behavior that occur during medical consultation. It is quite possible that participants may forget some knowledge about the diagnosis of dengue in the absence of appropriate reinforcement because transferring learning to behavior is an important issue in professional training. To improve the sustainability of our initiative, a modified version of the video used in this study is available online and can be downloaded so that the professionals can access it at any times .The focus groups and individual interviews were led by the first author of this article. This may have introduced a situational bias among participants and influenced their perceptions of the usefulness of video as a KT tool. Moreover, the virulence of the dengue fever epidemic that had erupted several months before the study and the threat of a new epidemic may have influenced participants’ motivation and enthusiasm for the video tool. Also, given that the first author of this article has worked in the field of documentary cinema, her attraction to video may have influenced her interpretation of the qualitative results.Lastly, the quantitative data were obtained from students, whereas the video is intended for nurses in the professional setting, and it is possible that there is a gap between these two populations. That being said, however, the impressions that emerged in the individual interviews with health professionals overlapped on several points with those of the student focus groups. This suggests that the results regarding the strengths and weaknesses of each video might be generalizable to health professionals. Finally, the extent to which the results of this study in Burkina Faso would be applicable to other countries is uncertain, given that cultural context plays a large role in how the videos are received and perceived. Despite the above-mentioned limitations, every effort was made throughout the study to ensure scientific rigour.This innovative study concludes that a video's narrative genre significantly influences the subsequent knowledge acquisition. This study also identified the narrative elements that allow a video to be as effective as possible according to Burkinabè healthcare providers. We therefore recommend that more video-based tools should be developed to transfer knowledge to health professionals. New videos could be created to fill certain knowledge gaps or even simply to update knowledge. Further studies should be conducted to better understand what knowledge is actually retained and applied over the longer term, and whether the interest generated for this type of training can be sustained. This would make it possible to develop KT video tools that are better adapted to the needs of health workers and to ensure their wide dissemination. Especially in the context of constant circulation of new diseases, such as COVID-19, it is even more important to support and train public health professionals because they need to know how to respond, quickly and appropriately. In conclusion, if you consider using video as a KT tool, we also recommend having recourse to video professionals in order to ensure their quality and effectiveness.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.


This study aims to assess the association of cigarette smoking, including e-cigarette use, with level of binge drinking, especially high-intensity and extreme high-intensity binge drinking, among a nationally representative sample of middle-aged US adults.Data were derived from the 2017 Behavioral Risk Factor Surveillance System (BRFSS). The final sample consisted of 162748 respondents aged 40–64 years . Weighted distributions of sample characteristics were estimated by intensity of binge drinking. Pearson chi-squared tests were used to compare groups. Bivariate and multivariate logistic regressions were used to estimate crude and adjusted odds ratios to indicate the strength of the association between independent variables and each level of binge drinking.In all, 2.3% and 0.7% of the sample reported high-intensity and extreme high-intensity binge drinking, respectively. Past-month high-intensity and extreme high-intensity binge drinking were reported in 36.3% and 45.0% of smokers, respectively. Mental distress was positively associated with both levels of high-intensity binge drinking; having multiple chronic health conditions was negatively associated with past-month high-intensity binge drinking. Smokers had 3.27 (95% CI: 2.69–3.98) and 4.14 (95% CI: 3.12–5.49) times greater odds of reporting past-month high-intensity and extreme high-intensity binge drinking, respectively. E-cigarette users had 1.56 (95% CI: 1.01–2.42) times increased odds of reporting past-month high-intensity binge drinking, but not extreme high-intensity binge drinking. The largest odds were seen among dual users reporting extreme high-intensity binge drinking  in the past month.Cigarette smoking and e-cigarette use were potentially strong risk factors for high-intensity binge drinking, with cigarette smoking associated with extreme high-intensity binge drinking. Binge drinking differs from heavy drinking in that it typically raises the blood alcohol concentration (BAC) to 0.08 per cent or higher1. Binge drinking can place a heavy burden on society, and is considered as the most common, costly, and deadly pattern of excessive alcohol consumption, contributing to over half of the deaths and three-fourths of the economic costs incurred by excessive drinking3. However, evidence suggests that young people are increasingly consuming alcohol at two (8+/10+) or three (12+/15+) times the traditional (4+/5+) binge drinking threshold4, known as high-intensity binge drinking. For example, national surveys found 10.3–13.0% of those aged 18–26 years consumed 10+ drinks, and 4–5% consumed 15+ drinks, with 9.5 drinks as the average number of drinks consumed in one sitting6. In recent years, high-intensity binge drinking has not decreased in the same way that traditional binge drinking has7. Given the link between binge drinking and adverse outcomes, those who engage in high-intensity binge drinking may be at increased risk for acute health problems such as alcohol intoxication or poisoning, and long-term health problems such as alcohol use disorder8.Excessive alcohol consumption mainly refers to binge drinking  and heaving drinking 9, while smokers may be at elevated risk of engaging in heavy drinking compared with non-smokers10. Heavier alcohol consumption combined with cigarette smoking is linked to a markedly greater risk of smoking-related diseases such as oral, pharyngeal, laryngeal, and esophageal cancers, and worsened brain morphology and functions12. A 30-year cohort study found men who smoked and consumed 15+ drinks per week had the highest all-cause mortality13. However, the majority of these studies measured alcohol use as the average number of drinks consumed per week or month, level of binge drinking was not directly assessed. A few studies examined the co-occurrence of binge drinking and smoking among the adolescent population, for example, Johnson et al.14 analyzed data from 4000 adolescents aged 13–18 years and found adolescent smokers likely to be binge drinkers (5+ drinks on the same occasion) and vice versa, highlighting the need for a dual focus in prevention and early intervention. In another study, Weitzman and Chen15 analyzed data from 10924 students across 120 colleges and found first-year students, especially female students, who picked up binge drinking (4+ for women and 5+ in a drinking occasion for men) in college had higher odds of smoking, again stressing the need to identify co-occurring smoking and binge drinking prevention and treatment models. However, research examining binge drinking and cigarette smoking has rarely extended to include high-intensity binge drinking, furthermore, such research is scarce among older populations.Worldwide, drinking and cigarette smoking are both leading risk factors for morbidity and premature mortality, and they commonly co-occur. Research within the adolescent and young adult population has consistently found drinking associated with the initiation and escalation of cigarette smoking16. Compared with adolescents and young adults, middle-aged adults often carry diverse responsibilities ranging from family-related to work-related domains, and binge drinking may place middle-aged adults at increased risk for adverse consequences or exacerbate age-related physiological changes. For example, an analysis of the 2010–2012 National Vital Statistics System revealed that an overwhelming 75.7% of alcohol-poisoning deaths involved adults aged 35–64 years17. A study found US adults aged ≥50 years and who binged more than 2 days per week had 64% greater odds of experiencing insomnia18. A longitudinal study assessing patterns of binge drinking (<6 versus ≥6 drinks per session) and progression of carotid atherosclerosis during a period of 11 years among Finnish middle-aged adults (mean age: 51.7±6.7 versus 49.7±6.8 years) found binge drinking of ≥6 drinks per session was significantly associated with increased atherosclerosis progression, even after controlling for demographic covariates and total alcohol consumption19. However, the majority of these studies on binge drinking by the middle-aged adult population have focused on the traditional binge drinking threshold, high-intensity binge drinking among this age group is understudied. Recent calls for research on high-intensity binge drinking suggest to examine its prevalence and associated characteristics within, as well as outside, the college environment8. Therefore, it is important to examine the phenomenon among the middle-aged adult population.According to the 2011–2017 Behavioral Risk Factor Surveillance System (BRFSS), the largest increase in the total number of binge drinks per US adult who reported binge drinking was observed among those aged 35–44 years (+26.7%) and 45–64 years (+23.1%), while a decrease was observed among those aged 18–24 years (-12.0%) and 25–34 years (-3.4%)20. Cigarette smoking was linked to poorer general intelligence, visuospatial learning, memory, and fine motor dexterity among middle-aged adults21, which may exacerbate aging-related changes in health. Electronic cigarette usage and correlates among adolescents and young adults have been extensively studied since its growth in popularity. However, recent statistics indicate a significant increase in current e-cigarette use among middle-aged adults, recreationally or as smoking cessation aids23. Yet, the health-related impact of e-cigarettes is not yet well-understood24, nor is its association with binge drinking, or high-intensity binge drinking, well-studied among middle-aged adults.Compared with young (18–24 years) and older adults (≥65 years), middle-aged US adults also seem to have higher rates of cigarette smoking. According to the 2018 National Health Interview Survey (NHIS), 16.3% adults aged 44–64 years currently smoked cigarettes, while only 7.8% of those aged 18–24 years currently smoked cigarettes, and 8.4% of those aged ≥65 years currently smoked cigarettesTherefore, we attempted to fill this gap in the literature through examining the link between levels of binge drinking, especially high-intensity binge drinking, and cigarette smoking and e-cigarette use among nationally representative US adults aged 40–64 years. The aim of the current study was to shed light on the prevalence of high-intensity binge drinking among middle-aged adults, and to examine its association with a key risk factor of morbidity and mortality – cigarette smoking in this population. Findings of this study will have important implications for treatment and intervention strategies.25. All 50 states as well as the District of Columbia, Guam, and Puerto Rico assessed alcohol consumption and use of tobacco products (including e-cigarettes) in 2017. For the purpose of the current investigation, we restricted our sample to middle-aged respondents aged 40–64 years that also had non-missing responses to items assessing levels of binge drinking. A total of 174196 respondents fell into this age group in the 2017 BRFSS.Data for this study were from the 2017 Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is a telephone-based (combined landlines and mobile phones) survey that collects data among a nationally representative sample of non-institutionalized adults (≥18 years) in the US. It is developed and conducted annually by the CDC in conjunction with state health departments in all 50 states as well as the District of Columbia and US territories. The BRFSS utilizes a complex multistage cluster sampling design to adjust for non-response and selection bias, and a weighting method called iterative proportional fitting or raking was used to weight the data4. Extreme high-intensity binge drinking was defined as 12+ drinks for women and 15+ drinks for men in one sitting4.Level of binge drinking was assessed by two questions: ‘During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, malt beverage, or liquor?’ and ‘During the past 30 days, what is the largest number of drinks you had on any occasion?’. Responses were coded to reflect level of binge drinking for men and women, respectively. Participants who reported no drinks during the past 30 days were coded as having 0 drinks. Light drinking was defined as 1–3 drinks for women and 1–4 drinks for men in one sitting. Traditional standard binge drinking was defined as 4+ drinks for women and 5+ drinks for men in one sitting1. High-intensity binge drinking was defined as 8+ drinks for women and 10+ drinks for men in one sittingCurrent smoking and e-cigarette use were assessed by combining responses to two items: ‘adults who are current smokers (Yes or No)’ and ‘adults who are current e-cigarette users ’. Responses to the two items were summed and coded to reflect four combinations: non-user, smoker only, e-cigarette user only, and dual user.27. Responses ranged from ‘none’ to ‘30 days’. To better present its estimated prevalence, we grouped responses into three categories: 0, 1–13 and 14–30 days/month.Mental distress was assessed by the item: ‘Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?’. We controlled for mental distress in the analysis because it was found to be associated with traditional standard binge drinking and smoking among adults aged ≥50 years28. It was assessed by asking respondents whether they were ever told by a doctor, nurse or other health professional that they had the following nine chronic health conditions: a heart attack , angina or chronic heart disease, a stroke, asthma, any type of cancer, chronic obstructive pulmonary disease (COPD) or emphysema or chronic bronchitis, arthritis, kidney disease, and diabetes. Answer options included ‘yes’ or ‘no’ for each of the conditions, and a new variable was created by summing responses across these nine conditions. We grouped the summed responses into 0, 1, 2, and 3–9 types.Presence of chronic health conditions was also included in the analysis because existing research indicates that older adults (≥50 years) in good health were more likely to binge drink than those with multimorbidityWe also controlled for demographic covariates that were commonly associated with binge drinking, which included age in five-year groups , gender , race and ethnicity , education , marital status , and employment status . For prevalence estimates, age was analyzed in its original five-year groups; in the subsequent logistic regression analysis, age was analyzed as a continuous variable. We coded those that reported ‘Out of work for 1 year or more’ or ‘Out of work for less than 1 year’ as unemployed, those reporting ‘employed for wages’ or ‘self-employed’ as employed, and those reporting to be ‘a homemaker’, ‘a student’, ‘retired’, or ‘unable to work’ as inactive.All statistical analyses were performed using SAS Version 9.4 . A total of 174196 respondents aged 40–64 years with non-missing responses to level of binge drinking were included initially. Percentage of non-eligible responses  was 0.20% for education, 1.48% for race and ethnicity, 0.36% for marital status, 0.63% for employment status, 1.23% for mental distress, 3.55% for chronic health conditions, and 0.01% for smoking and e-cigarette use. With non-eligible responses excluded from analysis, the final sample consisted of 162748 unique cases. Because the BRFSS employs complex survey designs, SAS survey procedures (e.g. SURVEYFREQ and SURVEYLOGISTIC) were used to account for weighting, clustering, and stratification of the sample. Weighted distributions of sample characteristics were calculated for the total sample as well as by level of binge drinking intensity. Pearson’s chi-squared test was used to determine if there was a difference between two or more groups of categorical independent variables. Crude and adjusted odds ratios and their corresponding 95% confidence intervals (CIs) were calculated to indicate the strength of the association between independent variables and level of binge drinking intensity.Compared with lower drinking levels, prevalence of high-intensity binge drinking was higher among those who were 40–44 years of age (29.7%), male (80.8%), high school graduates or below (52.3%), single (14.3%) or divorced/widowed/separated (26.5%), employed (78.5%), mentally distressed for 1–13 days (24.8%) or 14–30 days (16.1%) during the past 30 days, without chronic health conditions (59.5%), smokers only (36.3%) or dual users (5.0%).Compared with lower drinking levels, excluding high-intensity binge drinking, prevalence of extreme high-intensity binge drinking was higher among those who were 40–44 years of age (30.1%), male (77.3%), high school graduates or below (60.9%), single (16.9%) or divorced/widowed/separated (33.8%), currently unemployed (9.5%), mentally distressed for 14 days or more (25.8%) during the past 30 days, e-cigarette users (1.9%), smokers (45.0%) or dual and users (8.2%).In the bivariate analysis, smoking alone as well as smoking with concurrent e-cigarette use was associated with decreased odds of light drinking, but these odds were no longer significant in the multivariate analysis. E-cigarette use was associated with higher odds of all three levels of binge drinking in the bivariate analysis, but its association with extreme high-intensity binge drinking was no longer significant in the multivariate analysis.After adjusting for all confounding factors, smokers had a higher likelihood of reporting binge drinking , high-intensity binge drinking  and extreme high-intensity binge drinking . The largest odds of past-month high-intensity  and extreme high-intensity binge drinking  were seen among dual tobacco and e-cigarette users. However, neither smoking nor dual use was associated with past-month light drinking. Compared with smokers, the odds of past-month high-intensity binge drinking were smaller for e-cigarette only users .In the bivariate analysis, moderate level of mental distress (1–13 days/month) was associated with increased odds of binge drinking and high-intensity binge drinking, but it was associated with increased odds of extreme high-intensity binge drinking only in the multivariate analysis. Higher level of mental distress (≥14 days/month) was associated with lower odds of binge drinking in the bivariate analysis, but the association became positive in the multivariate analysis, suggesting underlying interaction effects with one or more variables. Those with higher level of mental distress (≥14 days/month) during the past month had twice  increased odds of reporting extreme high-intensity binge drinking.Having at least 1 chronic health condition was associated with lower odds of standard binge drinking and high-intensity binge drinking in the bivariate as well as multivariate analyses. Those with 3–9 types of chronic health conditions were 61% (95% CI: 0.34–0.46) and 50% (95% CI: 0.34–0.72) less likely to report traditional standard binge drinking and high-intensity binge drinking, respectively.Age was associated with lower odds of all three levels of binge drinking in both bivariate and multivariate analyses; the odds of traditional standard binge drinking, high-intensity binge drinking, and extreme high-intensity binge drinking decreased by 8% (95% CI: 0.90–0.95), 24% (95% CI: 0.72–0.80), and 26% (95% CI: 0.67–0.82), respectively, as age increased. Compared with females, males had 1.98 times (95% CI: 1.84–2.13), 5.26 times (95% CI: 4.33–6.38) and 4.26 times (95% CI: 3.18–5.72) greater odds of reporting high-intensity and extreme high-intensity binge drinking, respectively. Compared with non-Hispanic Whites, all other races/ethnicities had lower odds of reporting binge drinking and high-intensity binge drinking, with the largest decreased odds seen among those of non-Hispanic other race. Non-Hispanic Blacks also reported 69% (95% CI: 0.21–0.47) lower odds of reporting extreme-high intensity binge drinking. Being single or divorced/widowed/separated was associated with lower odds of binge drinking but higher odds of extreme high-intensity binge drinking in the bivariate analysis. However, the association between being single and reporting extreme high-intensity binge drinking was no longer statistically significant in the multivariate analysis; only being divorced/widowed/separated had 1.54 (95% CI: 1.18–2.02) times increased odds of reporting extreme high-intensity binge drinking.To our knowledge, the current investigation is the first to examine prevalence of high-intensity and extreme high-intensity binge drinking and its relation with cigarette smoking and e-cigarette use among a nationally representative sample of middle-aged US adults. We found the percentage of smokers increased with an increment in levels of binge drinking, while 21.6% of those reporting traditional standard binge drinking were smoking, this percentage increased to 36.3% among those reporting high-intensity binge drinking, and to 45.0% among those reporting extreme high-intensity binge drinking, higher than the percentage of smokers among non-drinkers (16.0%) and light drinkers (11.8%). Furthermore, after adjusting for confounding factors, those who were smoking and co-using e-cigarettes had significantly larger odds of reporting all three levels of binge drinking but not light drinking, with the largest odds observed among dual users reporting extreme high-intensity binge drinking. Meanwhile, e-cigarette only users had relatively smaller increased odds of reporting traditional standard binge drinking and high-intensity binge drinking, but not extreme high-intensity binge drinking. Our main finding implies that cigarette smoking rather than e-cigarette use may be a stronger risk factor for high and extremely high-intensity binge drinking for middle-aged adults.29. An estimated 80% to 95% of alcoholics were smokers, while smokers had 4 to 10 times increased odds of developing alcohol use disorders30. The close association between drinking and smoking has meaningful implications for treatment and intervention. Some studies found alcohol use or binge drinking decreased following smoke cessation for most smokers, however, those who were consuming large amounts of alcohol prior to smoke cessation were most likely to continue heavy alcohol use even after smoke cessation32. Some studies found standard binge drinking could impede smoking cessation. Kahler et al.33 reported that compared with moderate non-binge drinking, standard binge drinking doubled smoking lapse. In another study, Kahler et al.33 analyzed data on smokers from four countries and found those who binge drank had low rates of quitting smoking, furthermore, sustained smoking cessation did not lead to significant reductions in drinking, suggesting that smoking cessation interventions alone were unlikely to affect hazardous drinking34. However, findings on concurrent treatment have been inconclusive. For example, Joseph et al.35 found concurrent smoking cessation intervention did not benefit intensive treatment for alcohol dependence or abuse. A broad assessment of the effects of concurrent treatment of drinking and smoking may be out of scope of the current investigation, nonetheless, our finding that smoking was significantly correlated with higher levels of binge drinking among middle-aged adults may propel the need to call for future research examining their synergistic effects and the corresponding influence on treatment or intervention outcomes.Alcohol consumption often co-occurs with cigarette smoking, as their association has long been documented in both clinical and non-clinical samples36 found binge consuming 5 drinks or more was associated with increased odds of ever tried e-cigarettes among 631 students at a northeastern University. Littlefield et al.37 found odds of standard binge drinking increased among traditional cigarette users, e-cigarette users, and dual users at a state college. Yet, research assessing binge drinking in relation to e-cigarette use among the adult population is scarce, though evidence suggests that e-cigarette use may be a risk factor of problematic drinking38. Our finding that e-cigarette use alone was positively associated with binge drinking and high-intensity binge drinking among middle-aged adults extends similar findings in the younger population to the middle-aged population. Our finding further indicates that e-cigarette use alone could be a strong risk factor of higher levels of binge drinking among middle-aged adults, thus, use of e-cigarettes should be included in future studies on binge drinking to improve our understanding of its impact. Further research is also needed to clarify how e-cigarette use could add to the effect of smoking on levels of binge drinking, as we found dual users had the largest odds of reporting all levels of binge drinking than users of either substance alone.A few studies examined e-cigarette use in relation to standard binge drinking among US adolescents and young adults. For example, Hefner et al.39, the definition and assessment of mental distress varied, and thus warrants further validation. In regard to the item in the 2017 BRFSS that assesses mental distress and describes symptoms in broad terms that include stress, depression, and problems with emotions, our finding confirms its association with binge drinking and extends this association to higher levels of binge drinking among the middle-aged population, as the largest odds were seen among those having mental distress for 14 days or more during the past month and reporting extreme high-intensity binge drinking. Experiencing mental distress may prompt people to seek relief in alcohol consumption, but heavy alcohol consumption may also lead to mental distress and risks of suicide40. Further studies are needed to confirm the temporal sequence of binge drinking and mental distress measured using similar items. Heavy alcohol consumption is the major cause for a variety of chronic diseases, and a component cause for more than 200 other diseases conditions41. Although we were not able to derive causality from cross-sectional data, our finding demonstrated that binge drinking was less likely to occur among people with multiple chronic health conditions, which is consistent with existing research42, perhaps because some people may decide to cease binge drinking once they develop alcohol-related chronic health conditions42.The association between alcohol use and certain mental disorders such as depression has been more extensively studied than its association with mental distress per se. Although a positive association between mental distress and binge drinking has been tentatively documented among the older populationThe current study has several limitations. First, the self-report nature of the data may lead to social desirability bias, where participants answer in a more socially acceptable way. Second, the cross-sectional nature of the data limits our ability to derive any direction of causality between smoking and high levels of binge drinking. Further longitudinal research is needed to clarify such directions. Nonetheless, the representativeness of the BRFSS data allows us to examine the link between smoking and high levels of binge drinking in the general middle-aged US adult population, so as to potentially strengthen the generalizability of our findings.The findings of the current study suggest that cigarette smoking could be a strong risk factor for high-intensity and extreme high-intensity binge drinking among middle-aged US adults. Further research is needed to confirm our finding that e-cigarette use alone could be an independent risk factor for binge drinking and high-intensity binge drinking, and to examine how dual use can add to the impact of cigarette smoking on levels of binge drinking.


The origin of malnutrition in older age is multifactorial and risk factors may vary according to health and living situation. The present study aimed to identify setting-specific risk profiles of malnutrition in older adults and to investigate the association of the number of individual risk factors with malnutrition.2 and/or weight loss of >3 kg in the previous 3–6 months. Associations between factors of six domains , the number of individual risk factors and malnutrition were analysed using logistic regression.Data of four cross-sectional studies were harmonized and uniformly analysed. Malnutrition was defined as BMI < 20 kg/mCommunity (CD), geriatric day hospital (GDH), home care (HC), nursing home (NH).n 1073), GDH patients (n 180), HC receivers (n 335) and NH residents (n 197), all ≥65 years.CD older adults  than in the other settings (16–19 %). In the The study indicates a varying relevance of certain risk factors of malnutrition in different settings. However, the relationship of the number of individual risk factors with malnutrition in all settings implies comprehensive approaches to identify persons at risk of malnutrition early. In a recently published meta-analysis including 240 studies with 113 967 older adults from different settings, prevalence of malnutrition according to the Mini Nutritional Assessment was described to be 3 % in community-dwelling adults, 6 % in older outpatients, 9 % in older adults receiving home care and 18 % in nursing home residents. However, published prevalence data on malnutrition varies widely between studies, even within specific settings(–), probably due to different sampling characteristics and diagnostic criteria being used.Malnutrition is widespread in the older population and leads, if it is untreated, to numerous negative clinical consequences such as functional decline, in-hospital complications, increased mortality and reduced quality of life–4. I(–). However, studies investigating individual risk factors of malnutrition showed inconsistent results(–). These inconsistencies may be partly due to different definitions of malnutrition, diverse assessment methods and different sets of investigated risk factors. Furthermore, due to different health, functional and living conditions, risk profiles of malnutrition in older adults may also vary depending on the investigated setting. Studies systematically comparing malnutrition risk profiles of older adults from different settings are scarce. Meijers et al. compared hospital, home care and nursing home settings and focused primarily on the question of which disease-related factors are associated with malnutrition. In the home care setting, cancer, not having diabetes and gastrointestinal diseases were identified as risk factors; in the nursing home setting, female gender and dementia; and in the hospital setting, infection, cancer, dementia, blood diseases, chronic obstructive pulmonary disease and gastrointestinal diseases. Shatenstein et al. compared community-dwelling older adults and institutionalized older people (not further specified) by investigating risk factors of malnutrition from different domains. Loss of appetite as well as loss of interest in life were identified as risk factors of malnutrition in community-dwelling older people and loss in interest in life as well as frailty in institutionalized older people. Such approaches including older adults from different settings and covering multiple domains of potential risk factors could help to identify setting-specific differences in malnutrition risk profiles of older people and could contribute to the development of differentiated and targeted prevention and intervention concepts.Age-related physiological changes, limitations in physical and mental function, health and social aspects are discussed to be relevant individual factors in the aetiology of malnutrition in older people–11. , older people are usually affected by several risk factors of malnutrition. However, studies focus mainly on the identification of specific risk factors of malnutrition(–) but do not consider that the simultaneous occurrence of several risk factors may aggravate the risk of malnutrition.As the origin of malnutrition is multifactorial,10, The primary aim of the present study, a secondary data analysis, was to identify setting-specific risk profiles of malnutrition in community-dwelling older adults, patients of a geriatric day hospital, receivers of home care and nursing home residents by applying uniform definitions of malnutrition and potential individual risk factors from the domains of demographics, health, mental and physical functioning, dietary intake-related problems and dietary behaviour. A secondary aim was to investigate the association between the number of individual risk factors and the presence of malnutrition in these four settings.enable research cluster (http://www.enable-cluster.de/) and focused on four German cross-sectional studies with older adults at least 65 years of age from four different settings, conducted by the Institute for Biomedicine of Aging (Nuremberg) or the Helmholtz Zentrum München. The studies were selected because of similar inclusion and exclusion criteria as well as identical or comparable assessment methods.The current secondary data analysis was a sub-project within the n 1079) living in the region of Augsburg and having German citizenship . The data used in the current secondary data analysis refer to the baseline examination in 2009.The first study was based on a sex- and age-stratified random sample of older community-dwelling adults 17. Thn 198) and was performed in Nuremberg in 2012. Exclusion criteria were discharge within the first 2 d after admission to the GDH and inability to communicate due to severe cognitive impairment, psychological problems, or language or hearing problems.The second study comprised patients of a geriatric day hospital  in three German cities  in 2010. Participants lived in a private household, were allocated to a care level according to the German nursing insurance system and had no terminal illness.The third study  investigated older adults receiving home care  in 201019. Pan 200) in Nuremberg in 2007. Participants with terminal illness, with acute diseases associated with hospital stays and with tube-feeding were excluded.The fourth study was conducted in two municipal nursing homes  were included. Participants with >20 % missing values within a defined set of risk factors of malnutrition (see below) were excluded. The final samples included 1073 CD older adults, 180 2 and/or reported weight loss of >3 kg in the previous 3 to 6 months, following the German guidelines for clinical nutrition in geriatrics.The analyses focused on protein–energy malnutrition which was defined as BMI < 20 kg/meriatrics22.GDH patients and HC receivers . In NH residents, weight was assessed with a calibrated weigh chair scale . Height was measured by a conventional or an ultrasound stadiometer . In participants unable to stand upright , knee height was measured by a sliding calliper and height was calculated by the formulas of Chumlea et al.. If measurements were not feasible data were taken from medical records. BMI was calculated as [weight (kg)]/[height (m)]2. Self-reported weight loss was assessed within the previous 6 months ; GDH: study-specific question) or the previous 3 months ).Weight was measured with calibrated standing scales in CD older adults , ea et al.23. IfS1.Information on participants’ characteristics and potential risk factors of malnutrition were obtained by standardized questionnaires in all studies. In cases of severe cognitive impairment or inability to communicate, questions were addressed to the participants’ primary caregiver (HC) or the nursing staff (NH). Twenty-three potential risk factors were assessed identically or similarly in all four studies. When necessary, variable coding was harmonized after discussion and consent within the working group . An overview on the harmonization of variable coding can be found in the online supplementary material, Supplemental Table v. with others) was considered in CD older adults, GDH patients and HC receivers, but not in NH residents.Demographics are represented by age, gender and living situation. Living situation , multimorbidity (≥2 diagnosed chronic diseases) and the diagnosis of eight specific chronic diseases, namely diabetes mellitus, heart diseases, stroke, cancer, respiratory diseases, gastrointestinal diseases, renal diseases and arthropathy. score of <24 points in the GDH, HC and NH studies and as Telephone Interview for Cognitive Status–modified (TICS-m) score of ≤31 points in the CD study. Emotional status was assessed by the Geriatric Depression Scale (GDS) in all four studies. Scores >5 points indicated depressive symptoms.Mental function was evaluated by two variables. Cognitive impairment was categorized as Mini Mental State Examination (MMSE)26 sco in the GDH, HC and NH studies and the German version of the Health Assessment Questionnaire (HAQ) in the CD study. Items of both instruments were dichotomized .Physical function was defined by having mobility limitations and eating difficulties using the respective items of the Barthel Index for activities of daily living29 in  (CD) or study-specific questions  were used. All variables were dichotomized .Dietary intake-related problems were defined as having poor appetite, nausea, chewing problems and swallowing problems. Nausea and chewing problems were assessed by study-specific questions. For poor appetite and swallowing problems, items from SCREEN II24 .Dietary behaviour was represented by two variables on low fruit and vegetable intake (<2 servings/d) and low fluid intake (<3 glasses/d). To build these variables the respective items of the MNA25 werHC and NH participants due to the high number of missing values because of inability to communicate or severe cognitive deficits (test not feasible). Results are presented for each setting . Participants’ characteristics are given as mean and sd or as median and interquartile range for continuous variables and as relative frequencies for binary variables. Differences between studies were tested by the Kruskal–Wallis test followed by pairwise comparisons with Bonferroni correction for continuous variables and the χ2 test followed by the z test with Bonferroni correction for nominal variables. Results were considered statistically significant when P values were <0·05 (two-sided). Univariate logistic regression analyses were performed for all twenty-three variables to identify factors associated with malnutrition in each of the four studies. Factors showing P < 0·10 were considered for the multivariable logistic regression models, which were built based on a command for stepwise forward inclusion of variables (likelihood ratio). Multicollinearity between variables significantly associated with malnutrition in the univariate approach was checked by calculating the variance inflation factor. As the variance inflation factor values were all about 1, multicollinearity was not assumed. Goodness-of-fit was evaluated by the Hosmer–Lemeshow test and explained variance was based on Nagelkerke’s R2. In addition, the association between the number of potential individual risk factors and malnutrition was investigated by logistic regression analyses for each setting. The number of individual risk factors was calculated based on the twenty potential risk factors from the domains of health status, mental function, physical function, dietary intake-related problems and dietary behaviour. Demographics were not considered as living alone was not assessed in all four studies and age and gender were used as adjustment variables in the regression models. Statistical analysis was performed with the statistical software package IBM SPSS Statistics version 24.Missing data of eleven potential risk factors of malnutrition ranging from 0·1 to 6·3 % were imputed for each study separately using the interactive Markov chain Monte Carlo method. Twenty imputation models were created and in each model all variables were considered as both dependent and predictive variable. Regarding depressive symptoms, missing values were modelled as a separate category in CD sample compared with the three other settings. Across all settings participants were predominantly identified as malnourished due to weight loss; only in the NH sample was a distinct part of the participants (7·6 %) categorized as malnourished solely due to BMI < 20 kg/m2.The prevalence of malnutrition was 11·0 % in CD older adults, 18·9 % in GDH patients, 15·8 % in older adults receiving HC and 17·2 % in NH residents  than in the other samples. Significantly more GDH patients lived alone compared with CD older adults and HC receivers.Mean age of participants was 76·0 years in CD older adults, 79·3 years in CD sample and in more than 80 % of the GDH, HC and NH samples. Accordingly, the prevalence of most single chronic diseases was also lower in the CD sample than in the other samples.Polypharmacy and multimorbidity were identified in about 50 % of the GDH patients (10 %) and was about four and six times higher in HC and NH participants, respectively. Depressive symptoms were observed in about 11 % of CD older adults and did not differ between the other three studies with proportions above 30 %. Due to severe cognitive impairment, administration of the GDS was not feasible in 13 and 23 % of HC receivers and NH residents, respectively.The prevalence of cognitive impairment was lowest in HC) and 60 % (NH) were affected.The prevalence of mobility limitations was lowest in CD older adults (17 %) and highest in NH residents with two-thirds of the participants affected. Difficulties with eating were a minor problem in the CD and GDH samples (<10 %), while in the samples depending on care 44 % ) varied between settings and was higher in the HC (7 (6–9)) and NH studies (7 (5–9)) than in the GDH study (6 (4–7)) and the CD study (3 2–5)), where it was lowest Table . In all –5), wherThe present study highlights risk profiles of malnutrition in older people from different settings and shows that the rate of older people being malnourished is increasing with the number of individual risk factors.. The age of NH residents was on average 10 years older than that of CD older adults. This difference is also described by other studies conducted in the respective settings. Differences between the settings are also stressed by the varying number of potential individual risk factors of malnutrition. While the median number was only three in the CD sample, it was more than doubled in the HC and the NH samples.The four groups of participants included reflect the heterogeneity of the older population with respect to health and functional states Table . Even th31. Thet al. used the MNA to define malnutrition in their meta-analysis. Using BMI and weight loss we identified higher prevalence for CD older adults, GDH patients and HC receivers, while the prevalence for NH residents was found to be similar. An explanation for these different malnutrition rates might be the fact that the MNA considers, in addition to anthropometric measures, health and functional aspects. A Dutch study, using also low BMI and weight loss as parts of the definition of malnutrition, but with deviating cut-offs from our study, reported a slightly higher prevalence in receivers of HC (22 %) and NH residents (19 %) compared with our data  within the former study can be explained by not specifying a cut-off for a lower limit of weight loss. Regarding the criteria used to define malnutrition in our samples weight loss played the major role, while a low BMI became relevant only with increasing need of care, especially in the NH setting. However, compared with reviews reporting prevalence rates for BMI < 20 kg/m2 of between 9 and 40 % in NH residents, the number found in our study (8 %) was low. The differences might be due to sampling characteristics.The prevalence of malnutrition varied likewise between the settings and was significantly lower in CD older adults than in the other three settings. However, as the majority of older people live independently in the community, this is a very relevant group regarding the prevention and treatment of malnutrition. Cereda -analysis5. Usiesidents 9 % compaThe stepwise logistic regression analyses identified the most relevant factors associated with malnutrition in each setting. The setting-specific risk profiles represent only small sets of variables (two to four) and do not cover all domains of investigated risk factors. Generally, the factors subsumed under the domains mental function and dietary behaviour seemed to be of minor importance for the occurrence of malnutrition in all four settings. The CD setting presented the most diverse set of risk factors covering all remaining domains but demographics. In the GDH setting the two identified risk factors from the health and the dietary intake-related problems domains, namely respiratory diseases and poor appetite, overlap with the risk profile of the CD older adults. In the HC setting dietary intake-related problems were of primary importance and in the NH setting, besides age, physical functional aspects played the major role.et al. reporting strong evidence for an association between poor appetite and malnutrition in CD older adults. Also studies within the NH setting reported an association between poor appetite and malnutrition, while a study in HC receivers did not. Poor appetite seems to be an important trigger for reduced dietary intake in older people and is a consequence of age-related physiological changes, diseases, depression, medication use, lower physical activity and social isolation. Nausea was the second dietary intake-related problem found to be associated with malnutrition; however, in the multivariate analyses the association remained significant only in HC receivers. The relevance of nausea in the HC setting is supported by its prevalence and by a Dutch study in older adults receiving HC also observing an association with (risk of) malnutrition.From the domain of dietary intake-related problems, poor appetite was identified as a major factor related to malnutrition in our study with especially high OR in the GDH setting. This result is in accordance with the systematic review of van der Pols-Vijlbrief er adults12. Al(–). There are few other studies using similar statistical approaches showing an association of gastrointestinal diseases with malnutrition in different community settings. However, in a systematic review no conclusions for an association of both respiratory and gastrointestinal diseases with malnutrition were drawn due to limited studies. In all four settings polypharmacy and multimorbidity were not found to be associated with malnutrition in the multivariate statistical models. This is in line with the results of several other studies from different settings(–). The lack of association might be due to little variation in these variables as up to 87 % of the participants were affected. Only in the CD setting, in which the prevalence was lower (50 %), was a tendency towards an association visible in the univariate approach. The health factors diabetes mellitus, heart diseases and stroke were consistently not associated with malnutrition in all statistical models indicating a low relevance of these factors in the respective settings. The results are in line with those of the several other investigations showing no or inverse associations between these diseases and malnutrition. Stroke as a potential risk factor of malnutrition might be more relevant in acute and post-acute settings; and furthermore, stroke patients dependent on tube-feeding, and therefore potentially at higher risk of malnutrition, might be under-represented in investigations.From the health domain, respiratory diseases were associated with malnutrition in CD older adults as well as in GDH patients and gastrointestinal diseases in CD older adults. Both diseases are linked to inflammation, increased energy demands and wasting conditions in severe disease stages, which possibly explains the link to malnutrition–42. . The association between mobility limitations and malnutrition seems to be moderated by the factor setting in our analyses. Mobility limitations were identified as a factor related to malnutrition only in the NH study, while in the CD setting as well as in the combined sample the univariate association was attenuated in the multivariate analyses. It is surprising that mobility limitations seem to be a less relevant risk factor of malnutrition in the GDH and HC samples, as it could be expected that mobility limitations impede shopping and cooking and therefore the supply of foods. This could be a sign for an adequate support by family members and caregivers regarding shopping and meal preparation in these samples. In other studies mobility limitations were found to be associated with different surrogates of malnutrition in CD, HC and NH samples. The conflicting results might be partly due to different assessment methods of mobility and a more detailed assessment of the mobility status might be needed to show an association with malnutrition. Regarding mental function, cognitive impairment and depressive symptoms were univariately related to malnutrition in the CD and the HC samples (only depressive symptoms) but the effects were attenuated in the multivariable models. Previous results from other studies are inconsistent. In a recent multi-cohort meta-analysis in CD older adults both aspects were not associated with incident malnutrition. In the review of van der Pols-Vijlbrief et al., also focusing on CD adults, moderate evidence for no association between depression and malnutrition and inconclusive results for cognitive status were reported, while the review of Tamura et al. in NH residents found both depression and cognitive limitations to be associated with malnutrition.In the functional domains only physical but not mental functional factors were related to malnutrition in our study. Although difficulties with eating were distinctly more prevalent in the samples dependent on care , they were identified as a risk factor of malnutrition only in CD older adults. A reason could be that in the HC setting caregivers are aware of the problems and provide adequate help, while CD older adults have presumably no or less support from caregivers and cannot cope with the problems. In several other studies using different definitions of malnutrition, eating dependency was also reported as a risk factor in older adults living in the community, sheltered housing and nursing homes,,46. Also in line with our findings Tamura et al. reported higher age to be a risk factor of malnutrition in NH residents, and van der Pols-Vijlbrief et al. found moderate evidence for no association between age and malnutrition in CD older adults. An explanation for these discrepancies could be that usually with increasing age also chronic diseases and functional impairments occur more often, which might lead to nursing home admission. Consequently, those ‘older olds’ in need of care, who remain home-dwelling, might represent a specific less morbid group with lower risk of malnutrition. Moreover, the HC sample might be influenced by ‘younger olds’ being dependent on care because of lifelong or accident-related disabilities and not due to age-associated functional decline and chronic diseases.From the demographic domain, only age was identified as a factor associated with malnutrition in HC receivers and NH residents but not in CD older adults and GDH patients. The direction of the association differed between the two settings. In HC receivers higher age paradoxically reduces the likelihood of malnutrition, which is consistent with a Dutch study in older HC receivers47. Al. However, other aspects of dietary behaviour, like protein intake, which could not be addressed in our study, have been shown to be related to malnutrition.The factors of the domain dietary behaviour were not found to be related to malnutrition in all four settings. In a recently published study in CD older adults, diet quality according to the Healthy Eating Index was not associated with incident malnutrition51. HoOur results indicate that within all four settings the likelihood of being malnourished increased with the number of potential individual risk factors. The simultaneous occurrence of potential risk factors from the same or from different domains may aggravate the gap between (increased) energy and protein requirements and (reduced) intake, which is causal for the development of malnutrition.v. proxy report) was partly different between studies. Fourth, to define weight loss we used the respective question from the applied malnutrition screening tools. As these questions do not specifically ask for unintentional weight loss, we cannot completely rule out that some participants lost weight intentionally. Moreover, it needs to be considered that we used weight loss in kilograms to define malnutrition, while guidelines suggest using percentage weight loss. Regarding the generalizability of our results it needs to be considered that populations referring to the four investigated settings might vary between countries because of different health-care systems.Covering a broad age, health and functional spectrum, using a large set of potential risk factors, applying uniform definitions of malnutrition and risk factors to the four studies in different settings, and using the same statistical approach are strengths of the current secondary data analysis. However, some limitations need to be addressed. First, the analysis was based on cross-sectional data only, not allowing the assumption of any causal relationships, and the sample sizes of some studies were small resulting in a lower power of the analyses which could be responsible for some of the differences found between studies. Second, the analysis is limited to the exploration of potentially individual risk factors that were assessed in all four studies similarly. Therefore, some further potentially important factors addressing the individual level, like income or loneliness, as well as interpersonal or environmental levels might be missing. Third, when harmonizing the data of the four studies, a reduction of scale levels was necessary for some variables to achieve comparability, which leads to a loss of information. In addition, the type of assessment (e.g. self- ight loss52. ReThe results of the present study stress differences in the prevalence of malnutrition and its potential risk factors between four geriatric settings and indicate a varying relevance of specific factors associated with malnutrition in the four settings. The relationship between the number of individual risk factors and malnutrition in all settings implies comprehensive assessment approaches for clinical practice, considering not only single risk factors but also their combination to identify persons at risk of malnutrition early. To better understand the complex aetiology of malnutrition in older adults, the prognostic value of the identified factors regarding the development of malnutrition should be the subject of future longitudinal studies in the different settings. In addition, research needs to be further aligned by establishing uniform diagnostic criteria of malnutrition and by defining a minimum data set covering all relevant domains of risk factors, which are assessed in a standardized way.


Despite the fact that many studies have focused on harm from others' drinking, there is a lack of knowledge regarding severe forms of these harms. This study aimed to assess sex differences in the prevalence of severe harm from others' drinking and sex‐specific associations with one's own drinking.n = 15 576). Adjusted odds ratios of self‐reported experiences of severe harm (harmed ‘a lot’) from others' drinking were calculated using logistic regression models. Additive interactions were used to determine sex‐specific associations between own drinking and harm.The data originated from a Swedish cross‐sectional population survey  than men . Alcohol dependence predicted such harm for both sexes. No association with severe harm from known drinkers was found for male drinkers and binge drinkers, whereas female drinkers and binge drinkers reported more experiences of such harm. These differences indicated a supper‐additive interaction (RERI: 0.92–1.47) and signs of having alcohol dependence among women indicated an even higher interaction (RERI: 5.37).Women suffer more frequently from severe harm from others' drinking. Men and women report different experiences of severe harm from known people's drinking conditioning on their drinking behaviour. Sex‐specific longitudinal studies are warranted to examine the relation between different behaviours and these harms. Whether these findings hold in settings with different drinking cultures and social norms should be explored. Recent surveys on the epidemiology of alcohol‐related problems have increasingly emphasised the detrimental consequences for parties other than the drinker, that is, problems denoted as alcohol's harm to others (AHTO) , 2, 3. TA limitation with previous research is that few studies have focused on severe harms from others' drinking, that is harms that are likely to have significant implications for health and social well‐being of the victim . ConsequIn addition to a research gap in the extent own drinking and alcohol problems elevate the risk of severe AHTO, little is known of sex differences in this respect, that is if being a heavy drinker involves different risks of AHTO for men and women. More specifically, there is lack of studies assessing whether the combined effect of sex and own drinking behaviours exceeds the likelihood of harm from each factor considered individually . PreviouThe aims of the present study were to assess sex differences in the prevalence of severe harm from other people's drinking and to explore sex‐specific associations between one's own drinking habits  and severe harm. Using data from a large Swedish population sample, the following research questions will be addressed:Is the self‐reported prevalence of severe harm from other people's drinking higher among women than men?To what extent is the association between own drinking habits and severe harm from other people's drinking modified by sex?As AHTO may occur either due to known people's drinking  or due to the behaviour of unknown drinkers , the anaA cross‐sectional survey was conducted in Sweden between February and May 2013. The original sample included 27 000 individuals aged 17–84 years  and randomly selected from the Swedish population register, which includes all residents in the country. Participants were asked to complete a paper‐and‐pencil questionnaire or an identical web‐based questionnaire. A total of three reminders were sent to non‐responders. A voucher of 100 SEK (approximately 10 Euro) was offered to the participants. In cases where respondents answered the questionnaire more than once, duplicates were removed and the first registered questionnaire was included in the data file. A total of 15 576 (57.7%) individuals completed the survey. The number of respondents unable to participate due to illness, emigration, language problems and death was 222, and 521 addresses were incorrect. The study was approved by the Central Ethical Review Board in Stockholm (reference number 2012/1740‐31/5).The respondent's own drinking habits were assessed as: (i) frequency of drinking during the past 12 months; and (ii) frequency of binge drinking during the past 12 months, defined as having approximately six units of alcohol  or more on the same drinking occasion. For both variables, participants were grouped into the following categories: non‐(binge) drinkers, up to three times a month and one time or more a week.Alcohol dependence  was assessed by study‐specific questions based on the Swedish version of the Mini International Neuropsychiatric Interview version 6 , which cThe study‐specific questions on self‐reported AHTO were derived from the World Health Organization–ThaiHealth protocol . Before 2.Descriptive information about the study sample is presented as proportions, and differences in the distribution between men and women were examined using Pearson's χWe estimated the self‐reported past‐year prevalence of harm and corresponding 95% confidence intervals (CI) for men and women overall as well as within subgroups for different drinking behaviour. The past‐year prevalence of severe harm was considered as differing between groups if the 95% CIs did not overlap.The association between own drinking habits, sex and severe harm were estimated by calculating odds ratios (OR) and corresponding 95% CIs using binary logistic regression, after adjustment for covariates that could represent potential confounders; age in intervals  , level oFirst, single effects were estimated for sex and drinking habits. The single effect refers to the estimate of sex without stratifying on drinking habits, or the reverse. Next, to assess whether the association between own drinking habits and severe harm from others' drinking was modified by sex, we estimated joint effects for sex and each indicator of own drinking habits  separately using a common reference category for the two factors. The references categories were as follows: non‐drinking men, non‐binge drinking men and men without signs of alcohol dependence. Separate models for every single exposure and joint exposures were fitted.11 − OR10 − OR01 + 1). This measure estimates whether the combined OR of the two factors together (OR11) is larger  than the sum of the ORs of the two factors considered individually . In addition, the attributable proportion (AP) to interaction (RERI/OR11) was calculated to estimate the proportion of the combined effect that is due to interaction. CIs for RERI were calculated using the delta method [Interactions on the additive scale were then calculated using Rothman's  formula a method  as recoma method .In order to assess if the included joint effect variables statistically and significantly contributed with improvements of the model fit, Wald tests were calculated for different categories of each joint variable of sex and own drinking habits. As an example, the Wald test was calculated for improvement of model fit when including the categories of men and women, respectively, drinking weekly in comparison to the reference category of non‐drinking men.The data were weighted to reproduce the sex and age composition of the Swedish population in the 2013 census. Data analyses were carried out using the Stata Statistical Software version 16 . RespondThe characteristics of the analytical sample are presented in Table The past‐year prevalence of severe AHTO was higher among women than men, in particular regarding known drinkers .When sex and own drinking habits were considered jointly in the adjusted models, the results showed that the association between one's own drinking habits and severe harm from known people's drinking was modified by sex Table . That isConversely, for severe harm from strangers' drinking, we found no joint effect between own drinking habits and sex. Still, it should be noted that male drinkers had decreased odds of being severely harmed by strangers' drinking compared to male non‐drinkers.Relative to men without alcohol dependence, women with signs of alcohol dependence had ORs of 11.41 and 4.68 for severe harm from known people's drinking and strangers' drinking, respectively. This corresponded to a statistically significant superadditive interaction of RERI 5.37 and AP of 47% for harm from known people's drinking, while no statistically significant RERI estimate was found for harm from strangers' drinking.The aim of the present study was to assess sex differences in severe harm from others' drinking, as earlier studies have only used broader measures of AHTO also including less severe harms. Sex differences were assessed in terms of prevalence and the extent own drinking habits and problems are associated with this form of harm.The prevalence of severe AHTO was significantly higher among women than among men, both regarding harm from known drinkers and from strangers' drinking. This sex difference was more pronounced for severe harm from known people's drinking, which was reported more than twice as often among women, whereas the prevalence of harm from strangers' drinking was about 50% higher.Higher estimates of AHTO among women are in accordance with previous studies where severe and less severe harm have been mixed in the same measure , 8, 13. One possible explanation for the higher prevalence of severe AHTO among women is that women are more aware of others' behaviour than men and, therefore, report problems more frequently in surveys. This interpretation is supported by studies based on register data showing that the same proportions of boys and girls have a parent with an alcohol‐related hospitalisation , whereasWe also found a statistically significant joint effect of own alcohol habits and sex in relation to severe harm from known people's drinking, with a higher risk of harm associated with own drinking, binge drinking and signs of having alcohol dependence among women. Conversely, in relation to severe harm from stranger's drinking, no association between own drinking habits and such harm was found among women.The positive association between own drinking and severe AHTO from known people among women is in line with previous studies based on data from the International Gender and Alcohol's Harm to Others project. One study from this project found that women who drink excessively are more likely to have a heavy‐drinking partner , with a Previous studies from Scandinavian countries offer support for sex‐specific patterns of harm in terms of own drinking habits. For instance, a Swedish population study based on data from 2002 showed that the association between own drinking habits and experiencing a minimum of two of the four specific types of AHTO was stronger among women than men. In the study, Hradilova Selin  revealedOne possible explanation for this sex difference is that, while under the influence of alcohol, women are more susceptible and at a higher risk of victimisation than men are. It was not possible to address this hypothesis in the present study, but previous studies suggest that intoxicated women are considered by others to be more vulnerable and more sexually available , 30.' drinking, own drinking frequency was negatively associated with harm, although in the joint effect models, the results indicated that this only was statistically significant for male drinkers and not among females. Explanations for this finding are so far speculative; it may be related to higher tolerance towards strangers' alcohol‐related misbehaviour with a higher own drinking frequency, or to a tendency to attribute a strangers' problem behaviour to other causes than alcohol. In fact, an Australian study showed decreased support for policies controlling hazardous alcohol‐behaviour among men experiencing abuse from others' drinking [It should be noted that, in relation to severe harm from strangersdrinking . This reHaving signs of alcohol dependence was associated with an elevated risk of severe harm from others' drinking among both men and women. This may be explained by the fact that these individuals spend a lot of time in social contexts where alcohol problems are a shared experience, and likewise the occurrence of harm. There are no data in the current study to confirm this notion but a previous study showed that individuals' drinking increases with the number of heavy drinkers in their social networks . It shouThe major strength of the current study is the large sample size, which allows for a focus on the less prevalent severe forms of AHTO, but those entailing substantial risks for the health and the social well‐being of those exposed . It shouThere are also some limitations that need to be acknowledged, such as the cross‐sectional design implying limited possibilities to draw any conclusions of causality. Another limitation is the broad definition of ‘severe’ harm which does not include information on types of harms and how often they have occurred.Women in Sweden suffer from severe harm from others' drinking to a higher extent than men and have a higher susceptibility to be harmed from known people's drinking in relation to own drinking behaviour. Severe alcohol problems such as alcohol dependence increase the risk of being severely harmed by others' drinking for both men and women.Table S1. Wording of study‐specific items of alcohol dependence and response alternatives.Click here for additional data file.