EAL

UWL: Screening and Assessment Methods (2009)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To examine the extent of poor health status and nutritional risk among Australians age 65 years and older, as determined by the Australian Nutrition Screening Initiative.

Inclusion Criteria:

Older Australians, age 65 years to 98 years.

Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:

Recruitment

In 2001 the questionnaire was posted to a proportionally random selection of 2,457 older Australians stratified by state and territory from the 2000 Australian Electoral Commission roll. Completed surveys were returned by 1,263 individuals between the ages of 65 and 98 years.

Design

Cross-sectional study.

Statistical Analysis

Chi-square tests were used to determine the relationship between each Australian Nutrition Screening Initiative (ANSI) statement and sex and the risk group (low risk, moderate risk and high risk) scores, self-perceived health status (poor to fair, good or very good to excellent) and sex
Binary logistic analyses were done to provide estimates of the probability of positive responses to specific statements.

Data Collection Summary:

Timing of Measurements: The 12 statements that comprise the ANSI were incorporated in a comprehensive, self-administered national postal survey designed to elicit information on the health and lifestyle practices of older Australians

Dependent variable: Nutritional risk

Independent variable: Australian Nutrition Screening Initiative.

Description of Actual Data Sample:

Initial N: Questionnaire sent to 2,457 older Australians

Attrition (final N): 1,263 individuals (641 males, 622 females). 62% response rate after allowing for confirmed non-deliveries.

Age: Age ranged from 65 to 98 years for males, 65 to 95 years for females

Ethnicity: Not mentioned

Other relevant demographics: Demographic and health features of the sample were consistent with the general population of older Australians in terms of ethnicity, living conditions, self-perceived health status, smoking status, weight status and for a range of health conditions

Location: Australia.

Summary of Results:

Statements	% Yes	% Yes - Males	% Yes - Females	Significance
I have an illness or condition that made me change the kind and/or amount of food I eat	34	34	35	0.584
I eat at least three meals per day	91	89	93	0.02
I eat fruit or vegetables most days	95	94	96	0.04
I eat dairy products most days	82	81	84	0.064
I have teeth, mouth or swallowing problems that make it hard for me to eat	6	7	6	0.44
I have three or more drinks of beer, liquor or wine almost every day	18	28	9	0.000
I have six to eight cups of fluids most days	89	86	91	0.006
I am always able to shop, cook and/or feed myself	87	87	88	0.64
I take three or more prescribed or over-the-counter drugs every day	44	42	45	0.35
I always have enough money to buy food	95	94	95	0.81
Without wanting to, I have lost or gained five kg in the last 6/12	15	14	19	0.049
I eat alone most of the time	28	19	37	0.000

Other Findings

According to the ANSI, 59% (n=747) of the sample was at risk of poor nutritional status as well as poor health status.

36% (n=454) of the sample was at high nutritional risk, 23% (n=293) were at moderate nutritional risk and 41% (n=516) were at low nutritional risk.

There was no significant difference in the proportion of nutritional risk among males and females (P=0.190).

The most frequently occurring risk factors were: taking three or more different prescription or over-the-counter drugs each day (44%), having an illness that led to changes to the kind and/or amount of food consumed (34%), eating alone most of the time (28%), not eating dairy products most days (18%), consuming three or more alcoholic beverages each day (18%) and unintentional weight change of five kilograms in the last six months (15%).

Approximately 9% did not eat three meals per day, 5% did not eat fruit or vegetables most days and 5% reported having insufficient funds to buy food.

Sex differences were observed for several ANSI statements.

Author Conclusion:

In conclusion, the ANSI identified that the majority (59%) of this sample of elderly Australians were at nutritional risk. Checks of internal reliability, using other survey questions, revealed inconsistencies in responses obtained using the ANSI checklist. The underlying assumption that agreement with risk factor statements leads to increased nutritional risk appears to be a major flaw in the design of this tool. The ANSI is of limited value as a screening tool for the detection of nutritionally at-risk older Australians. However, as an unweighted checklist it could be used as an educational tool to assist health professionals evaluate the impact of individual risk factors on nutritional adequacy and overall well-being.

Funding Source:

University/Hospital:

Australian Centre for Complementary Medicine Education and Research, University of Queensland and Southern Cross University

Reviewer Comments:

Large representative sample. Authors note that the ANSI fails to discriminate between drugs that can adversely affect nutritional status and those that might improve nutritional status. Screening based on self-reported data, primarily yes/no answers.

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)	Yes
	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)	Yes

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?		Yes
	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?	Yes
	2.4.	Were the subjects/patients a representative sample of the relevant population?	Yes
3.	Were study groups comparable?		N/A
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	N/A
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	N/A
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	N/A
	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?	N/A
	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.)	N/A
	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?		Yes
	4.1.	Were follow-up methods described and the same for all groups?	Yes
	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%.)	Yes
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	Yes
	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?		N/A
	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.)	N/A
	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?	???
	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?	???
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	???
	7.7.	Were the measurements conducted consistently across groups?	N/A
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)?	N/A
	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?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes