UWL: Association With Outcomes (2009)

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

To describe the influence of protein-calorie malnutrition on quality of life in nursing homes, using archived data from the Minimum Data Set.

Inclusion Criteria:

None specified.

Exclusion Criteria:

None specified.

Description of Study Protocol:
  • Recruitment: Convenience sample of nursing home residents was recruited from three nursing homes in eastern Washington. Recruitment methods were not described.
  • Design: Cross-sectional analysis of Minimum Data Set assessment data. The study was guided by the Quality Nutrition Outcomes Long-Term Care Model. 
  • Statistical analysis: Descriptive statistics and correlational analyses using the Pearson R coefficient were used in the analyses.
Data Collection Summary:

Timing of Measurements

MDS assessment data were collected from each resident's medical record by researchers. The number of MDS assessments depended on the length of time each resident was living in the nursing home (two to six assessment periods; up to 12 months).

Dependent Variables

  • Quality of life
  • Functional status
  • Depression
  • Psychosocial well-being.

Independent Variables

Protein-calorie malnutrition as measured by BMI.

Description of Actual Data Sample:
  • Initial N: 311 nursing home residents
  • Attrition (final N): 311 residents (102 male, 207 female)
  • Age: Aged 65 years or older. 14.5% were considered young-old (65 to 74 years), 42.1% were old (75 to 84 years ), 43.4% were old-old (85 years or more).
  • Location: Eastern Washington.
Summary of Results:

Relationship Between BMI and Select MDS Indicators of Quality of Life

MDS Item

Measuring Point R P

Functional Status: Eating



Three months
Six months
Functional Status: Personal Hygiene Admission
Three months

Six months



Functional Status: Toilet Use (Independence) Admission
Three months
Six months
Depression Admission
Three months
Six months
At Ease Doing Self-Initiated Activities Admission
Three months
Six months
Pursues Involvement in Facility Life Admission
Three months

Six months

Unhappy with Roommate Admission
Three months
Six months
Unhappy with Residents Other than Roommate Admission
Three months
Six months
Recent Loss of Close Family Member or Friend Admission
Three months
Six months
Strong Identification with Past Roles and Life Status Admission
Three months
Six months

Other Findings

  • Of the 311 participants, 38.6% were malnourished (N=120; BMI less than 22)
  • Protein-calorie malnutrition (as measured by BMI) influenced quality of life for these residents in that there was a significant relationship between BMI and functional status (eating, personal hygiene and toilet use) and BMI and psycho-social well-being (initiative or involvement, unsettled relationships and past roles)
  • 40% were diagnosed with depression, but depression was not a significant indicator of low BMI in these nursing home residents
  • Several measures of psycho-social well-being were indicators of low BMI, especially when measured six months post-admission.
Author Conclusion:

In conclusion, understanding the relationship between nutritional status and quality of life as depicted in the Quality Nutrition Outcomes Long-Term Care Model could lead to improved quality of life for older adults in nursing homes and guide future innovative intervention studies aimed at preventing protein-calorie malnutrition.

Funding Source:
University/Hospital: University of Arizona, Office of the Vice President for Research and Graduate Studies
Reviewer Comments:
  • Inclusion and exclusion criteria and recruitment methods were not specified
  • Measurement of variables were not described
  • The Quality Nutrition Outcomes Long-Term Care Model was used to guide the study, but morbidity, health care utilization, serum albumin and prealbumin were not measured.
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? No
  2.2. Were criteria applied equally to all study groups? N/A
  2.3. Were health, demographics, and other characteristics of subjects described? ???
  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? ???
  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.) ???
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? ???
  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? 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? N/A
  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? ???
  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)? ???
  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? No
  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