UWL: Association With Outcomes (2009)
- 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.
Statistical Analysis
- 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.
Dependent Variables
Mortality follow-up was performed by consulting Swedish population records (data from one municipality not available).
Independent Variables
- 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)
- Mobility
- 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.
Initial N
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.
Age
Mean, 82±7 years among participants, 82±8 years among non-participants.
Ethnicity
Not mentioned.
Other Relevant Demographics
26% needed personal care once a day, 19% twice a day and 6% needed personal care around the clock.
Anthropometrics
- 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.
Location
Sweden.
Odds Ratios and 95% Confidence Intervals for Death Within Three Years
Variables |
Odds Ratio |
95% Confidence Interval |
P-Value |
MNA |
1.89
|
1.18-3.01
|
0.007
|
Age |
1.33 |
1.01-1.74 |
0.04 |
Male Gender |
1.60
|
0.86-2.99
|
0.14
|
Other Findings
- 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 | ||
Industry: |
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Not-for-profit |
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- 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
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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? | 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 | |