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UWL: Food, Appetite and Environment (2009)

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

To investigate possible factors that may be associated with nutritional status among people in an early stage of dementia.

Inclusion Criteria:
  • Willingness to sign informed consent
  • Scoring higher than zero on the cognitive part of the Alzheimer's Disease Assessment Scale.
Exclusion Criteria:

None specified.

Description of Study Protocol:


Sixty-nine consecutive individuals who consulted a special dementia unit because of perceived impaired memory were asked to participate


Cross-Sectional Study. Fifty-nine individuals were interviewed with three structured assessment instruments and a number of other structured questions related to nutrition and daily living. The instruments were the Alzheimer's Disease Assessment Scale (ADAS-COG), the Mini Mental State Examination (MMSE) and the Mini Nutritional Assessment (MNA). Twenty-three additional questions were related to nutrition and daily living. Responses were indicated on an ordinal scale of one to five, with the higher numbers indicating worse nutritional condition.  

Statistical Analysis 

Between-group differences were tested with two-sided chi-square on nominal data and two-sided T tests and ANOVA with Bonferroni's post hoc test respectively on interval data. Correlations were computed as the Spearman rank correlation coefficient for ordinal data and as the Pearson's correlation coefficient for interval data. Four stepwise multiple regression analyses were done for association of factors with nutritional status.     


Data Collection Summary:

Timing of Measurements

Subjects were interviewed with three assessment instruments and a number of other structured questions.

Dependent Variables

Nutritional status as determined by the MNA and 23 other structured questions related to nutrition and daily living.

Independent Variables

  • Severity of cognitive and non-cognitive behavioral dysfunctions of individuals with Alzheimer dementia measured by the ADAS-COG
  • Cognitive aspects of mental functions measured by MMSE.

Control Variables

  • Age
  • Sex
  • Civil status.
Description of Actual Data Sample:

Initial N: 59 participants (36 females; 23 males)

Attrition (final N): 59 participants

Age: 74.3 years±7.7 years; (range=52 years-86 years)

Ethnicity: None specified

Other relevant demographics: 22 males and 22 females were married; 18 males and eight females were formerly professional (white collar) workers

Anthropometrics: 10 males and 18 females had lost weight in the last year

Location: Udevalla, Sweden.

Summary of Results:





MNA 17-23.5




P value


Total Mean Score±SD

19.1 ± 6.0

25.8 ± 9.9 27.5 ± 7.4



Total Mean Score±SD

25.0 ± 2.3

23.2 ± 3.9 22.3 ± 2.6


Other Findings

The results showed that predictors for nutritional status were: eating smaller portions, partly lost learned practices and having a dry mouth.

Regression coefficients for predicting nutritional status measured by MNA were smaller portions (beta=-0.51; P=0.000), learned practices (beta=-0.31; P=0.002) and dry mouth (beta=-0.24; P=0.015). The intercorrelations between the obtained predictors were not significant.   

Author Conclusion:

Predictors for nutritional status were eating smaller portions, partly lost learned practices and having a dry mouth. Caring actions for this patient group should focus on support at meals and maintaining oral health. 

Funding Source:
Reviewer Comments:

The author failed to define one of the outcomes ("learned practices"); thus, this term cannot be applied in other situations. 

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? 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? 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? ???
  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? No
  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? 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? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? N/A
  7.6. Were other factors accounted for (measured) that could affect outcomes? ???
  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)? N/A
  8.6. Was clinical significance as well as statistical significance reported? No
  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? ???
  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