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To identify the rate of unintentional weight loss in adults following their admission into residential healthcare facilities, assess the effectiveness of a new medical nutrition therapy protocol for the prevention and treatment of unintentional weight loss and describe nutrition assessment and intervention activities of dietitians.

Inclusion criteria for dietitians not described. Dietitians were instructed to sequentially invite all adults (21 and older), up to a maximum of 20, who were admitted to their healthcare facilities during a three-month recruitment period. 

Exclusion criteria for dietitians not described. Adults entering hospice, respite care program or those expected to have a short-term stay of less than 30 days were excluded.

Recruitment

Volunteer dietitians were recruited via announcement in CD-HCF publications and at national and state meetings. Interested dietitians were mailed a study overview, study expectations and consent forms. Enrollment was from November 1998 to June 1999. 

Design

Randomized clinical trial. Volunteer dietitians were randomly assigned to usual nutrition care or MNT protocol care groups using a random numbers table.

Intervention

• Usual nutrition care, using existing definition for significant weight loss
• MNT protocol care: Emphasized assessment; intervention (including weighing frequency); communication with staff, medical doctor, family and resident; and reassessment, using weight loss criteria defined in the protocol. 

Statistical Analysis

• Desired sample size to detect significant differences in unintentional weight loss was 400 residents
• Dietitian and facility characteristics were compared between groups using the chi-square test
• Descriptive statistics were used to describe residents, characterize nutrition care and resident outcomes and make comparisons between groups
• Discharge from the facility and missing data led to varying numbers in the analyses
• Resident characteristics were compared between groups using an independent T-test and chi-square test
• Chi-square and independent T-tests were used to test differences between groups, and repeated measures ANOVA was used to test the effect of nutrition care group on weight change while controlling for gender
• Multivariate analysis using the general linear model was used to explore the association of oral and nutritional risks and health conditions on weight outcomes.

Timing of Measurements

Dietitians recruited newly admitted residents and tracked their weights for up to six months. Weighing was expected at admission and 90 days later. If residents were identified with significant unintended weight loss within the first 90 days post-admission, their weight was tracked for an additional 90 days following identification.

Dependent Variables

• Rate of unintentional weight loss
• Weight status 90 days after admission
• Weight status 90 days after identification of unintentional weight loss
• Weights were taken from medical or other records
• Due to weighing schedules within facilities, weights were accepted if they were within a 14-day window
• Medical record audit forms including age, gender, admitting diet, disease information and MDS data collected for each enrolled resident
• Documented nutrition care activities related to assessment, intervention and staff involvement were noted using a checklist.

Independent Variables

• Usual nutrition care
• MNT protocol care
• Compliance with study procedures ascertained through midpoint dietitian feedback survey.

Control Variables

Demographic information regarding gender, race, higher education, number of years working in residential healthcare facilities and information about the facility collected through dietitian questionnaire.

• Initial N: 96 dietitians volunteered and received the recruitment packet, and 36 completed the consent form and dietitian questionnaire and were randomized (20 MNT, 16 usual care)
• Attrition (final N): 31 dietitians from 29 facilities completed the field test (16 MNT, 13 usual care). Medical record data were available for 394 residents (223 MNT, 171 usual care) and complete weight trend data were available for 364 residents (200 MNT, 164 usual care). Reasons for dietitian withdrawal not mentioned. 11 dietitians in the MNT group and 13 dietitians in the usual care group returned the midpoint dietitian survey.
• Age: Dietitian age was not mentioned. Resident age ranged from 38 to 100 years (mean 81.7±9.2 years).
• Anthropometrics: There were no significant differences between MNT and usual care groups
• Location: United States. 

Other Findings

• 14 of 364 residents (4%) were admitted with significant pre-existing weight loss, which was successfully treated in eight residents during the first 90 days
• Substantial unintentional weight loss (more than 5% in any 30 days) developed in 78 residents (21%)
• Women developed significant weight loss more often than men (24% vs. 16.7%) and unintended weight loss was more likely to go unidentified in women than men (6.0% vs. 1.9%).
• Factors found to be associated with weight change from admission to 90 days were the following: Gender (female, 91.022, P=0.000), Alzheimer's disease (female, 4.144, P=0.043) and on a therapeutic diet (female, 5.153, P=0.024)
• MNT-protocol care dietitians were more likely to identify unintentional weight loss
• When unintentional weight loss was identified, and after providing nutrition care to these residents for an additional 90 days, 32 of 61 residents (52%) maintained or gained weight
• Dietitians in usual care and MNT-protocol care groups were equally successful in treating pre-existing or post-admission unintentional weight loss when it was identified
• Differences were found in nutrition care activities. MNT-protocol care dietitians reported more nutrition assessment activities, whereas usual care dietitians reported more intervention activities.
• For residents with weight loss problems, usual care dietitians more frequently talked with and instructed staff, educated resident or family members, talked with MDs and recommended alternative feeding routes
• MNT dietitians tended to recommend diet modification, appetite enhancers, and increased weighing frequency for residents with weight loss problems; in contrast, usual care dietitians recommended feeding assistance and supplements for residents with or without weight-loss problems. 

Nutrition care protocols with standardized weighing procedures can increase the identification of unintentional weight loss in the residential healthcare environment. Improved identification supports the additional assessment activities used by MNT-protocol care dietitians. Similar outcomes for usual care and MNT-protocol care groups when unintentional weight loss was identified indicate that usual nutrition care was already a high standard of care for intervention.

Other:

None reported

Inclusion and exclusion criteria for dietitians not described. Weights were accepted if within a 14-day window. Usual care interventions were not necessarily similar enough for comparison. Discharge from the facility and missing data led to varying numbers in the analyses. Authors note the following limitations:

• Dietitians were self-selected and may not be representative of other dietitians in residential healthcare facilities
• Sample size of 394 came close to calculated sample size of 400, but weight data were incomplete for 12% of the sample
• MNT and usual care groups differed in the extent of residents' oral and nutritional problems, diagnoses and health conditions
• Lacked control over actual weighing and therefore precision and reliability of weights
• Volunteer dietitians had responsibility for data collection at their own facilities, raising the potential of bias and possible inconsistency between sites.