Unintended Weight Loss in Older Adults

UWL: Food, Appetite and Environment (2009)


Kofod J and Birkemose A. Meals in nursing homes. Scand J Caring Sci. 2004; 18(2): 128-134.

PubMed ID: 15147475
Study Design:
Observational and cross-sectional study.
D - Click here for explanation of classification scheme.
Quality Rating:
Negative NEGATIVE: See Quality Criteria Checklist below.
Research Purpose:

To test the general hypothesis that:

  • Residents appreciate the meal situation in nursing homes with home-like meal situations
  • Nutritional status of the residents is improved in this type of nursing home, through the assessment of the prevalence of residents with a BMI below 20.
Inclusion Criteria:
  • "Stay and living environments" (SLE) for two to five years
  • Residents over age 75 years.
Exclusion Criteria:

Residents with dementia and others not able to communicate were excluded from the study. 

Description of Study Protocol:


Study was conducted from June 2001 to October 2001 as part of a research project focusing on the possible association between improved meal situations and diminishing underweight among nursing home residents. Recruitment methods for the nursing homes were not described. Residents were selected in cooperation with the staff at the nursing homes.


Observational and cross-sectional study.  


  • In the "Stay and Living Environments" (new nursing homes established in 1990s), meals are eaten in small groups of six to 10 residents
  • Residents are asked to take part in meal preparation and have influence on the menu
  • Basic intention is to provide the residents with home-like meal situations and encourage them to use their own resources and influence the daily routines instead of taking a passive position.

Statistical Analysis

  • Interview themes and topics were broken down and reanalyzed into new coherences
  • Interviews were re-analyzed to elaborate on themes found
  • Interpretation was finally checked in the interviews and correlated with BMI.
Data Collection Summary:

Timing of Measurements

Study was conducted between June 2001 and October 2001.

Dependent Variables

Measurement of BMI at two of the four nursing homes; undernutrition defined as BMI below 20. Residents weighed to nearest 100g on a chair weight while height was self-reported.

Independent Variables

Home-like meal situation measured through qualitative interviews with residents and staff and observations at four nursing homes.


Description of Actual Data Sample:
  • Initial N: 19 residents and seven social and health service assistants interviewed
  • Attrition (final N): 19 residents (10 female, nine male) and seven staff. BMI measured in 43 residents
  • Age: Mean age 84 years (range 75 to 93 years)
  • Location: Four Danish nursing homes at various locations in Denmark.
Summary of Results:

Characteristics of Residents at Two Nursing Homes


Nursing Home One

Nursing Home Two
Number of residents 9 34 
Females/males 7/2 28/6 
Weight (kg) 60.5 (55.0 to 73.5) 61.5 (53.0 to 68.0)
Height (m) 1.61 (1.58 to 1.68) 1.61 (1.54 to 1.63) 
BMI (kg/m2) 23.2 (21.1 to 27.8) 25.8 (23.3 to 27.9)
BMI<20 (%) 0

Residents prefer dining in own room


Other Findings

Two general patterns could be outlined according to the way the residents perceived their mutual relations in the meal situation: A general appreciation of eating together and the opposite.

Most of the residents were glad to use their possibility of influencing the meal planning.

In general, residents did not perceive the environment as a home, while from the staff's point of view, the meal situation resembled a home-like setting.

Many residents were unable to participate in the meal preparation due to their physical disabilities.

Author Conclusion:

This study could not confirm the general hypothesis, as a consistent improvement in the meal situation was not found in the nursing homes studied. This underscores that competence is required by the staff to handle the social aspect of the meal situation. However, an indication of improved nutritional status was found in two of the nursing homes where the degree of undernutrition was lower than generally found in Denmark. Furthermore, the study indicated that the staff and residents had different perceptions of the nursing homes.

Funding Source:
Reviewer Comments:

BMI measurements only completed in two of the four nursing homes and height based on self-report. Recruitment of nursing homes or residents was not described. Small sample size. Achievement of home-like meal situation in nursing homes was questionable despite the fact they had been termed "SLE" for two to five years. Authors note that other known nutritional risk factors for elderly people could add to the explanation of the BMI levels: Eating dependency, depression, chewing problems, disease and adverse drug effects.

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) Yes
  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) Yes
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? ???
  2.2. Were criteria applied equally to all study groups? ???
  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? ???
  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? ???
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  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? ???
  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? Yes
  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? No
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? No
  6.6. Were extra or unplanned treatments described? No
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  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? 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? No
  7.5. Was the measurement of effect at an appropriate level of precision? No
  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? 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)? 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? 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