UWL: Association With Outcomes (2009)

Study Design:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:
  • To investigate nutritional status and its relationship to cognitive function, well-being, functional ability and energy intake in frail elderly assisted living residents with regular need for care and assistance
  • In a sub-group of original sample, to study changes in nutritional status, cognitive function, well-being, functional ability and energy intake over a one-year period.
Inclusion Criteria:
  • Resident of one of two service flats (municipality funded assisted living apartments for elderly persons) in Southern greater Stockholm, Sweden.
  • Requires regular assistance from buildings' care personnel
  • Agreement to participate in study.


Exclusion Criteria:
  • Free-living senior citizens
  • Service flat residents who do not require any help for buildings' care personnel.
Description of Study Protocol:
  • Recruitment: Of a total 198 residents in the two buildings, 130 residents had regular assistance and were therefore eligible to participate in the study. 80 out of the 130 eligible residents were willing to participate in the study. 
  • Design: Cross-sectional, involving examinations to determine nutritional status, well-being, cognitive function, activities of daily living and energy intake. The examinations were performed in residents' apartments.
  • Blinding used: None. Two of the examiners (data collectors) were study authors.
  • Intervention: Not applicable.

Statistical Analysis

  • Non-parametric descriptive statistics
  • Kruskal Wallis Test for differences between MNA groups
  • Mann Whitney U-test for post-hoc tests
  • Spearman rank order for correlation analyses
  • Wilcoxon's signed rank test to evaluate changes over time in the one-year follow-up.
Data Collection Summary:

Timing of Measurements

  • One collection time
  • For 44% of subjects, repeat measurements were taken at one year.

Dependent Variables

  • Nutritional status: Mini Nutritional Assessment (MNA). Part of the MNA is Body Mass Index.
  • Subjects were weighed using a Seca 882 electronic scale or a Tamita BWB 660 electronic wheel chair scale
  • Height was measured from standing or if unable to stand, length was taken from subject in a stretched lying position.

Independent Variables

  • Energy intake: Two methods used. A 24-hour recall and residents kept a one-day food record. 21 individuals kept four-day dietary records. A coefficient of variation from day-to-day was calculated from the four-day records.
  • Energy requirements: Predicted using the WHO equation (1985) and multiplied by a physical activity level (PAL) factor. The PAL factor for bedridden or wheelchair transported subjects was 1.2 and ambulatory subjects had a PAL factor of 1.5.
  • Cognitive function: Short Portable Mental Status Questionnaire (SPMSQ); 10 questions (date, day of week, person's location, address, age, date of birth, current and past prime minister names, mother's name, subtract three from 20 and so forth). Maximum score is 10; a score of less than seven indicates impairment.
  • Well-being: Health index questionnaire. Nine questions concerning energy, temper, fatigue, loneliness, sleep, vertigo, bowel function, pain and mobility. Each question has four response categories (very poor, rather poor, rather good and very good). Only individuals who scored six or more on the SPMSQ were asked these questions.
  • Functional ability: Barthel Index Questionnaire 
  • Level of care: Graded from one to seven
    • One to two: Assistance once or twice per week
    • Three: Assistance more than twice per week
    • Four to five: Assistance every day
    • Six: Assistance every day and sometimes at night
    • Seven: 24-hour care.  

Control Variables

Not applicable.

Description of Actual Data Sample:

Initial N

80 (58 women, 22 Men) 

Attrition (final N)

  • As above
  • Repeated measurements at one year
  • N=35 (29 women, six men).


Median 85.5 years (range, 68 to 96).


Not specified. Assumed Swedish. 

Other Relevant Demographics

None provided.


  • Median BMI was 23.6 (20.3kg/m2 to 27.2kg/m2
  • 20% had a BMI less than 20kg/m2
  • 55% had a BMI less than or equal to 24kg/m2
  • 16% had a BMI more than 30kg/m2.


Southern Stockholm, municipal assisted living apartments.

Summary of Results:
Variables Treatment Group
Measures and Confidence Intervals
Statistical Significance of Group Difference
Nutritional Status

30% malnourished (N=24)

59% at risk for malnutrition (N=47)

11% well-nourished (N=9)

Median MNA score was 19.5 (15.5-22.5)

Malnourished subjects had a lower body weight and BMI than at-risk or well nourished subjects (P<0.001)

  • 52kg vs. 69.3kg and 69.7kg, respectively
  • 19.8kg/m2 vs. 25.6kg/m2 and 24.2kg/m2, respectively.

In the malnourished and at risk groups, men weighed more than women; 64.8kg vs. 47.9kg (P<0.05) and 73.7kg vs. 62.5kg (P<0.01), respectively

Energy Intake Median intake: 1,546kcal (1,243-1,798) per day

In malnourished group, intake (1,410kcal) was lower than requirements (1,615kcal) P<0.05

In at risk for malnutrition group, intake (1,573 calories) was lower than requirements (1,812 calories) P<0.01

Energy Requirements

1,792 (1,626-2,035) kcal per day

Only 30% reached daily estimated requirements

Coefficient of variation for 21 individuals with four-day food records was 17%

Malnourished subjects had lower energy requirements than at risk or well nourished subjects (P<0.001)
Cognitive Function

70% of subjects had a score of 8 or greater on SPMSQ

Median score was 8 (7-9)

Malnourished subjects had worse cognitive function that two other groups, 7 vs. 9 (P<0.001)
Well-being Median Health Index Score was 24 (22-29) Health Index was lower for malnourished subjects 21 vs. 25.5 (at risk) and 27 (well nourished) P<0.05)
Functional Ability Median Barthel score was 75 (55-85) and ranged from 30-100 The Barthel Index was lower for malnourished subjects compared with other two groups ( 62.5 vs. 80 and 85) P<0.01

Other Findings

  • The level of care differed for the malnourished group compared to the other two groups: 5.0 vs. 4.0 and 2.0 (P<0.001)    
  • Level of care correlated inversely to 
    • MNA, R=-0.53 (P<0.001)
    • SPMSQ, R=-0.26 (P<0.02) 
    • Barthel Index, R=-0.61 (P<0.001).

One-Year Follow-Up (N=35)

  • For subjects who agreed to be examined again after one year, there was no difference between this group and the non-re-examined group in terms of age, gender, nutritional status and care level (data not shown)
  • The five subjects who were classified as malnourished at baseline declined in weight from 47kg to 36kg (P<0.05) over the follow-up period. Those subjects at risk or well-nourished did not experience a weight change. 
  • No differences in scores were seen in MNA, well-being or cognitive function either within groups or between groups.
Author Conclusion:
  • One-third of the frail residents were malnourished
  • One in 10 residents were well-nourished
  • Malnourished residents had significantly worse cognitive function, well-being, functional ability and had a greater need for daily assistance
  • Subjects classified as malnourished at baseline had a marked weight loss during the subsequent year
  • This indicates that community assisted housing (in Stockholm) is not able to prevent nutritional deterioration or improve status in those who are malnourished.
Funding Source:
Reviewer Comments:
  • Median values are reported followed by sigma spread. No mean values are reported. This may have been an error in translation and what is reported as a median is actually a mean with the ±1 standard deviation spread.
  • No socio-economic statistics were provided other than age and sex
  • For number six on the checklist, is marked unclear because for the 35 individuals who had the one-year follow-up measurements, the authors did not report whether these individuals had any hospitalizations or medical treatments in the intervening period
  • No multivariate analysis for confounding factors was performed. Some of the factors that could have been assessed and compared between groups include recent hospitalizations, number of medications, income and level of education.  
  • For number nine on the quality criteria checklist, some study limitations are discussed by the authors, but not the lack of measurement and analysis of potential confounding factors.
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? No
  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? No
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
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? N/A
  4.1. Were follow-up methods described and the same for all groups? N/A
  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%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? N/A
  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? 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? ???
  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? ???
  6.6. Were extra or unplanned treatments described? ???
  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? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? ???
  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? No
  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? ???
  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)? No
  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? No
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