EAL

UWL: Association With Outcomes (2009)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To assess the prevalence of "reduced appetite" and to study the relationship between reduced appetite and nutritional status.

Inclusion Criteria:

Only subjects with adequate cognitive function (assessed by using a Geriatric Mental Test), not terminally diseased, were included.

Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:

Recruitment

Randomized population survey among elderly
One group recruited from patients recently admitted for acute disease or exacerbation of disease
One group recruited from their homes, selected randomly by The Central Bureau of Statistics.

Design

Cross-sectional analysis of a prospective cohort study of hospital and community-dwelling older people.

Statistical Analysis

Student's T-test for comparison of means between the groups
Fisher exact test for comparison between two categories of qualitative data.

Data Collection Summary:

Timing of Measurements

All one-time measurements were made in the hospital.

Dependent Variables

Nutritional status was assessed through the registration of body weight and height, BMI, triceps skinfold, midarm circumference and serum albumin
Muscle strength
Blood samples were analyzed for serum calcium, cholesterol, hemoglobin, ascorbic acid, calcidiol and zinc.

Independent Variables

Appetite was measured through a structured interview asking seven questions related to digestive problems: Presence of reduced appetite, constipation, nausea, dyspepsia, heartburn, diarrhea and swallowing problems.

Description of Actual Data Sample:

Initial N

Authors mention 346 aged patients: 311 subjects living independently in their homes, admitted to Aker University Hospital for an acute disease or exacerbation of chronic disease; 106 subjects (54 men, 52 women) living in the same area as the Hospital Group (417 subjects).

Attrition (Final N)

Authors mention 346 patients. Tables describe 248 patients in the Hospital Group and 103 in the Home Living Group (351 patients).

Age

Range: 70 to 94 years
Mean age: 78.8 years in the Hospital Group; 79.3 years in Home Living Group.

Ethnicity

Not mentioned.

Anthropometrics

Hospital and Home Living Groups were not compared in terms of demographics.

Location

Norway.

Summary of Results:

Variables	Undernourished	Well-Nourished	Total
Reduced Appetite	76	31	107
Not Reduced Appetite	62	79	140

Other Findings

Reduced appetite was present in 43% of the Hospital Group, compared to 15% in the Home Living Group
71% of those with reduced appetite were undernourished, while 44% with normal appetite were undernourished
Reduced appetite was present in all diagnostic groups in the Hospital Group, but most common in patients with lung disease (P=0.05) and least common in patients with heart disease (P=0.028)
Patients with reduced appetite had a significantly reduced body weight, BMI (P=0.0000 in males, P=0.0003 in females), triceps skinfold (P=0.0065 in males, P=0.0013 in females), arm-muscle circumference (P=0.0000 in males, P=0.0055 in females), muscle strength (P=0.0000 in males, NS in females), serum albumin (P=0.0002), hemoglobin (P=0.0036), calcidiol (NS in males, P=0.0038 in females), cholesterol (P=0.0014) and zinc (P=0.0208
The sensitivity for malnutrition was 0.55, while the positive predictive value was 0.71.

Author Conclusion:

In this study, those with reduced appetite had a significantly reduced nutritional status
Reduced appetite is common among aged people in hospital and is a predictor for undernutrition.

Funding Source:

Other:

Not reported

Reviewer Comments:

The numbers of subjects do not add up correctly between tables and the article narrative
Groups were not compared for similarity
Authors note that they did not address the effects of depression, social isolation, cognitive impairment, aging, medications, disease with cytokines production and reduced metabolic rate, on appetite.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	N/A
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	N/A

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		???
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	Yes
	2.2.	Were criteria applied equally to all study groups?	N/A
	2.3.	Were health, demographics, and other characteristics of subjects described?	???
	2.4.	Were the subjects/patients a representative sample of the relevant population?	???
3.	Were study groups comparable?		???
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	Yes
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	???
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	Yes
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	???
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	???
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		???
	4.1.	Were follow-up methods described and the same for all groups?	???
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	???
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	???
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		Yes
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	N/A
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	Yes
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	N/A
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	N/A
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	Yes
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	N/A
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	N/A
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	N/A
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	N/A
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		???
	7.1.	Were primary and secondary endpoints described and relevant to the question?	N/A
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	N/A
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	???
	7.5.	Was the measurement of effect at an appropriate level of precision?	Yes
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	No
	7.7.	Were the measurements conducted consistently across groups?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	No
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	No
	10.2.	Was the study free from apparent conflict of interest?	Yes