UWL: Association With Outcomes (2009)
Saletti A, Johansson L, Yifter-Lindgren E, Wissing U, Osterberg K, Cederholm T. Nutritional status and a 3-year follow-up in elderly receiving support at home. Gerontology, 2005; 51 (3): 192-198.PubMed ID: 15832047
- To evaluate nutritional status, including meal patterns and meal-related problems, in elderly people living at home
- Moreover, the nutritional status was related to long-term mortality through re-examination of a sub-sample of the participants after three years.
- Subjects receiving home care in five Swedish municipalities (one rural community, one small city and three larger cities)
- Over age 65 years.
None specifically mentioned.
- Recruitment: Investigation took place in five Swedish municipalities. In each community, one to three home service areas (a total of 10) were selected with a total of 100 subjects from each participating municipality.
- Design: Cross-sectional study and cohort study
- Blinding used: Observers were directly involved in the care of the study subjects which may have biased the assessments.
- In the evaluation of differences between MNA categories, ANOVA or the Kruskal-Wallis test was used, in accordance with the distribution of the tested variable
- For statistical analysis of the Katz ADL index, the letters A through G were given the numbers zero through six
- In the three-year follow-up analyses, Student's paired T-tests or Wilcoxon's matched pairs tests were used in accordance with the distribution of the variables
- Survival analyses (including Kaplan-Meier curves and log-rank tests) and logistic regression analyses were performed in order to evaluate the relationship between nutritional status and long-term outcome.
Timing of Measurements
Subjects were interviewed. Mortality was evaluated after a three-year period.
Mortality follow-up was performed by consulting Swedish population records (data from one municipality not available).
- Nutritional status assessed by means of the Mini-Nutritional Assessment
- Weight, height, BMI
- Mid-arm circumference and calf circumference were measured
- Recent weight change
- Intake of medication
- Acute diseases (including psychological stress)
- Neuropsychological problems
- Pressure sores or skin ulcers
- Assessment of dietary intake: How many full meals were eaten, food choice, fluid intake per day, how much help was required during the meals and appetite
- Self-assessment of nutritional status
- Self-perceived health status
- Assessment of mood
- Activities of daily living assessed according to the ADL index of Katz.
507 eligible subjects.
Attrition (Final N)
- 353 subjects examined, 64% females
- 154 subjects were not examined: 108 refrained from participation, six were terminally ill and 40 were not suitable due to hospitalization, a recent move to institutional care or other infirmities
- Mortality was evaluated in 224 study participants after a three-year period
- 31 of 64 elderly were reexamined after three years.
Mean, 82±7 years among participants, 82±8 years among non-participants.
Other Relevant Demographics
26% needed personal care once a day, 19% twice a day and 6% needed personal care around the clock.
- Participants and non-participants were similar
- Mean age in the study populations varied among the five municipalities (from 80.4±7 years to 83.6±6 years, P<0.05), whereas gender, civil status, MNA score and BMI were not significantly different.
Odds Ratios and 95% Confidence Intervals for Death Within Three Years
95% Confidence Interval
- 8% and 41% of the elderly were assessed as malnourished or at risk of malnutrition, respectively
- BMIs under 20 and under 23 were found in 12% and 31% of the subjects, respectively
- 6% of the study participants reported a weight loss over three kg during the last three months and 12% had lost one kg to three kg
- From the self-assessed appetite, 2% reported no appetite, 18% a reduced appetite, 37% an acceptable appetite and 43% a good appetite
- The subjects who scored low in MNA often reported a decreased appetite and the subjects who scored high in MNA often had a good appetite (P<0.001)
- Chewing and swallowing problems and reduced appetite were more often reported by those at risk of being malnourished, compared with the well-nourished study participants (P<0.001)
- Meals-on-wheels services were given to one-third, of whom 66% used one portion for several meals
- The three-year mortality was 50% for those who were malnourished, 40% for those at risk of malnutrition and 28% for the well-nourished group (P<0.05)
- The corresponding mortality was 50% for subjects with a BMI under 20, 35% for those with BMIs ranging from 20 to 28 and 27% for those with BMI over 28 (P=0.05)
- The median MNA score had decreased from 22 (range, 20.5 to 26) to 19.5 (range, 17 to 23.5; P<0.001) in the 31 subjects re-examined after three years
- After three years, a weight loss of 4.0±5.8kg was registered (P<0.001).
- About half of the home-living elderly with public support were malnourished or were at risk for malnutrition
- The malnourished subjects often had problems during mealtimes and seldom ate full meals
- Elderly people with BMI above 28 displayed the lowest risk of death within three years.
|Government:||Swedish National Board of Health and Welfare|
- Data from one municipality was not available for mortality follow-up
- Only 31 of 64 were re-examined after three years
- Authors note the following sources of uncertainty in the study:
- Large number of observers
- Observers were directly involved in the care of the study subjects which may have biased the assessments.
Quality Criteria Checklist: Primary Research
|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|
|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?||Yes|
|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?||???|
|3.||Were study groups comparable?||Yes|
|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?||Yes|
|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?||Yes|
|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?||???|
|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?||???|
|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?||No|
|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.)||No|
|5.3.||In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?||No|
|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?||Yes|
|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?||Yes|
|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?||Yes|
|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)?||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|