FNCE 2023
Session 357. Providing MNT for the Pediatric Type 1 Diabetes Population: What Does the Evidence Show?
Monday, October 9, 8:30 AM - 9:30 AM

See session information ♦ See EAL review results

UWL: Screening and Assessment Methods (2009)

Study Design:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

This study aimed to:

  • Examine the interrelationship between hunger and aversion and respective contribution to food intake
  • Determine how each relate to other health-related contemporaneous subjective states preceding the meal (good physical health, positive mood, pain)
  • Explore clinical variables as moderators of the drives-intake relationships to identify population segments for which these relationships are the strongest.
Inclusion Criteria:
  • Age older than 65 years
  • No or light cognitive impairment [Mini-Mental State Examination (MMSE)>23]
  • Eat hospital food almost exclusively
  • Eat meals in unit's dining room.
Exclusion Criteria:
  • Dementia
  • Depression [Geriatric Depression Scale-15 (GDS-15) more than 10]
  • Malabsorption syndrome
  • Rheumatoid arthritis
  • Neoplasia
  • Severe liver disease
  • Severe renal insufficiency
  • Severe chronic obstructive pulmonary disease
  • Participants for whom information for a variable was missing, or meals for which data were missing for a meal-level variable.
Description of Study Protocol:


All patients newly admitted to the rehabilitation unit of the Institut Universitaire de Geriatrie de Montreal between December 1999 and June 2001 were screened for eligibility.


Time series study. 

Statistical Analysis

  • The distinctive contribution of hunger and aversion to intake were tested using random coefficient analysis
  • Partial correlations were computed between the two drives (hunger and aversion), between each drive and other subjective contemporaneous states (physical health, mood, and pain), and between each drive and intakes (energy and protein)
  • The same set of correlations were calculated separately for subgroups presenting low and high values of each moderator
  • Subgroup correlation coefficients were compared using Fisher's Z transformation
  • Results with P<0.10 are also presented.
Data Collection Summary:

Timing of Measurements

Patients were observed during repeated meals in a geriatric rehabilitation unit for a total of 1,477 meals. For each participant, meal-level measures were obtained for all three main meals, every other day of the hospital stay until discharge, for a maximum of six weeks.

Dependent Variables

Food intake: protein and energy consumption were calculated from plate leftovers. Meal-level nutritional needs were calculated using Harris-Benedict equation with an activity factor of 1.3.

Independent Variables

  • Perceived hunger, aversion, and contemporaneous subjective states were reported five to 10 minutes before each meal, using five visual analog scales
  • Individual, psychological, and clinical measures obtained from participants' medical charts:  age, sex, body mass index
  • Cognitive status evaluated using MMSE
  • Depression evaluated using GDS
  • Self-reported appetite
  • Nutritional status evaluated using Thomas' Protein-Energy Malnutrition Index (PEMI)
  • Functional status evaluated using Functional Independence Measure (FIM)
  • Severity of impairment evaluated using Cumulative Illness Rating Scale (CIRS)
  • Use of multiple medications.
Description of Actual Data Sample:

Initial N: Of 355 newly admitted geriatric patients, 188 were excluded. Of 167 eligible patients, 84 were not invited. 83 patients were invited to participate and 46 declined. 37 were recruited. 

Attrition (final N): 32 patients (21 women, 11 men). Five withdrew from the study (one death).

Age: Range, 65 to 92 years; mean 78.8 years±6.5 years.

Ethnicity: Not mentioned

Location: Canada.


Summary of Results:



Aversion-Energy Relationship

Partial r

Aversion-Energy Relationship

P value

Aversion-Protein Relationship

Partial r

Aversion-Protein Relationship

P value

Female (N=934)

0.01 0.004 -0.02 0.019
Male (N=496) -0.15 --- -0.15 ---
Age 65 to 79  years (N=766) -0.05 1.000 -0.08 0.704
Age>80 years (N=664) -0.05 --- -0.06 ---
BMI<23 (N=699) -0.09 0.134 -0.07 1.000
BMI>24 (N=719) -0.01 --- -0.07 ---
MMSE 23 to 27 (N=659) -0.09 0.030 -0.12 0.011
MMSE>27.5 (N=651) 0.03 --- 0.02 ---
GDS 0 to 4 (N=518) 0.02 0.337 -0.01 0.150
GDS 5 to 9 (N=501) -0.04 ---  -0.09 ---
Poor appetite (N=614) -0.03 0.592 0.01 0.067
Good appetite (N=740) -0.06 --- -0.10 ---
PEMI 0 to 2 (N=871) -0.06 0.140 -0.11 0.027
PEMI 3 to 7 (N=559) 0.02 --- 0.01 ---
FIM<87 (N=703) 0.02 0.036 -0.04 0.294
FIM>88 (N=542)  -0.10 --- -0.10 ---
CIRS<10 (N=619) -0.13 0.009 -0.14 0.024
CIRS>11 (N=811) 0.01 --- -0.02 ---
Polypharmacy<6 (N=593) -0.08 0.263 -0.11 0.190

Polypharmacy>7 (N=837)





Other Findings

The hunger-aversion relationship had a low inverse correlation (r=-0.113, P=0.001), with each uniquely contributing to protein intake (positive and negative effects, respectively, all P < 0.05).

Hunger was positively associated with the perception of physical health (r=0.21) and with mood (r=0.26, both P=0.001).

Aversion was associated with pain (r=0.17, P=0.001).

Furthermore, aversion-intake relationships were influenced by moderators, whereas hunger-intake relationships remained constant. 

Aversion was more strongly inversely related to both intakes in men, in participants with lower cognitive status and in those with lower impairment.

The more functionally independent participants showed a stronger aversion-energy relation, with directionally consistent results for protein intake.

The aversion-protein relation was stronger in those with normal or good appetite and better nutritional status. 

Author Conclusion:

Our results underscore the need to enrich current nutrition practice in treating malnutrition in hospitalized geriatric patients with a more systematic consideration of interventions that aim to modulate hunger and aversion as an intrinsic part of nutritional care. Because drives are influenced by the quality of the immediate subjective experience, careful design of sensorial, environmental, and social components surrounding the meal are likely to improve food intake. Indeed, results from recent studies of the influence of specific interventions on food intake in elderly people are consistent with this notion. We hope that our findings will foster further practice and research development in this direction.

Funding Source:
Government: Canadian Institutes of Health Research
Danone Institute of Canada
Food Company:
Reviewer Comments:
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? 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? 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? 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? 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? Yes
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  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? Yes
  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? Yes
  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? Yes
  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)? Yes
  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? No
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