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UWL: Association With Outcomes (2009)

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

To evaluate the dynamics of nutritional health by testing the relative importance of most cited factors including demographics, comorbidities, medication use, functional status, oral health, presence of social support, loneliness and depressive symptoms in predicting nutritional health in a sample of community-dwelling elders, within the context of Roy Adaptation Model.

Inclusion Criteria:

Senior residents who lived in an inner-city public housing complex.

Exclusion Criteria:
  • Younger than 60 years (N=3)
  • Unable to sign a consent form (N=5)
  • Hospitalized (N=7)
  • Did not speak English (N=26)
  • Unable to be located despite multiple attempts (N=7).
Description of Study Protocol:


  • Population-based sample was recruited
  • Every senior resident who lived in an inner-city public housing complex in southern Connecticut was invited by letter to participate; this was followed with personal contact.


Cross-sectional study.

Statistical Analysis

  • Unadjusted odds ratios of each factor to low MNA (less than 24) vs. high MNA (more than 24) scores were computed
  • Factors associated with low MNA scores were then considered in multivariate modeling
  • Hierarchical logistic regression was applied; only variables with the best predictive capacity were contained in the final model
  • A variety of models were examined to rule out order effects prior to specification of the final model.
Data Collection Summary:

Timing of Measurements

  • Cross-sectional community-based survey was conducted
  • A trained geriatric nurse practitioner collected data prospectively and used structured instruments to obtain information
  • All subjects were interviewed in their homes; they were assessed between June and December 2002.

Dependent Variables

  • Nutritional health measured by 18-item, observer-rated Mini Nutritional Assessment
  • Anthropometric measures
    • Weight
    • Knee height
    • Height
    • BMI
    • Mid-arm and calf circumference.

Independent Variables

  • Depressive symptoms measured by a 30-item self-report, dichotomized Geriatric Depression Scale
  • Functional status measured by 10-item, observer-rated Enforced Social Dependency Scale
  • Oral health measured by counting of the remaining natural teeth, examiner-rated Brief Oral Health State Examination (BOHSE) and self-reported Geriatric Oral Health Assessment Index (GOHAI)
  • Demographics
    • Age
    • Gender
    • Marital status
    • Ethnicity
    • Education
    • Living arrangement
    • Income levels
    • Religion
  • Comorbidities assessed through self-reported Comorbidity Checklist
  • Medication use assessed through medication count
  • Presence of social support measured by six-item Social Support Questionnaire Short Form
  • Loneliness measured by 20-item Likert-style University of California at Los Angeles Loneliness scale.

Control Variables

  • Age
  • Gender
  • Ethnicity
  • Religion
  • Income levels
  • Having hypertension
  • Having diabetes
  • Number of morbidities
  • Number of medications
  • GDS scores
  • Loneliness scale
  • ESDS
  • Number of teeth.
Description of Actual Data Sample:

Initial N

  • 310 senior residents who lived in an inner-city public housing complex
  • 262 were eligible after application of exclusion criteria.

Attrition (Final N)

  • 240 subjects were assessed (91.6%), 78.3% female
  • Reasons for nonparticipation included being too busy (N=8), not interested (N=6), not feeling well (N=6) and privacy protection (N=2).


Mean 81.7 years (range 61 years to 98 years).


30.8% were minority (27.1% black, 3.8% other).


Southern Connecticut.


Summary of Results:

The Final Hierarchical Model: Factors Associated with Low MNA Scores (Less than 24)

Associating Factors

Adjusted Odds Ratio (95% Confidence Interval) P-value


1.00 (0.96 to 1.04) 0.929
Male gender reference (---) ---
Female gender 2.14 (0.91 to 5.02) 0.082
White reference (---) ---
Black 0.81 (0.35 to 1.88) 0.631
Other 1.63 (0.33 to 8.09) 0.551
Annual income less than $10,000 (37.1%) reference (---) ---
$10,001 or more (47.1%) 0.40 (0.19 to 0.84) 0.014
No idea or refused to answer (15.8%) 1.01 (0.39 to 2.65) 0.982
Total morbidities 0.99 (0.78 to 1.25) 0.905
Number of medications 0.96 (0.84 to 1.09) 0.509
Depressive symptoms (GDS) 1.12 (1.03 to 1.21) 0.008
Social support (SSQSF) 0.98 (0.94 to 1.01) 0.221
Functional status (ESDS) 1.09 (1.03 to 1.15) 0.005

Self-perceived oral health (GOHAI)

0.87 (0.78 to 0.97)


Other Findings

  • 81 subjects (33.8%) had a BMI less than 22kg/m2 and were classified as underweight
  • 85 subjects (35.4%) had a BMI more than 27kg/m2 and were considered overweight
  • Compared to men, women had a 2.6-fold higher risk of low MNA scores, with 95% confidence interval of 1.32 to 5.12
  • Depressive symptoms were a strong predictor with odds ratio=4.90 (95% confidence interval of 2.27 to 10.58)
  • Age group, loneliness, functional status and examiner-rated oral health revealed strong associations with low MNA scores
  • Annual income of more than $10,000, history of hypertension, presence of social support and better perceived oral health appeared to be preventive for low MNA scores.


Author Conclusion:

This finding lends support to the notion that multidimensional biopsychosocial factors, namely depressive symptoms, functional status, oral health and income, contribute to the dynamics of nutritional health, further supporting the validity of the Roy model.

Funding Source:
Government: NINR/NIH grant F31NR08073
Reviewer Comments:

All subjects were from inner-city public housing complex in Connecticut. Authors note the following limitations:

  • Sample was confined to one site with high percentages of female and Jewish subjects, so the generalizability was limited to these elders
  • Study was cross-sectional, so relationships were more correlational than causal.
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? ???
  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? ???
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? Yes
  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? 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? N/A
  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? N/A
  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? 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