UWL: Food, Appetite and Environment (2009)

Study Design:
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Quality Rating:
Research Purpose:

To determine the effects of dysphagia on selected social and psychological aspects of the quality of life of patients and to explore the relationship between the psychological handicaps of the condition and the frequency of diagnosis and treatment.

Inclusion Criteria:

Patients were included only if they were able to understand and answer questions and regularly experienced one or more of the following subjective dysphagia-related symptoms:

  • food sticking in the throat and/or choking on food
  • persistent cough or sore throat
  • inability to swallow liquids
  • loss of appetite
  • mild throat discomfort
  • pain when swallowing
  • heartburn and/or acid regurgitation
Exclusion Criteria:
  • Any respondent suffering from only loss of appetite or mild throat discomfort was excluded
  • Any respondent who was suffering from severe dementia was excluded on the basis that they were unable to answer questions reliably
Description of Study Protocol:


European nursing homes and clinics were located through directories and databases on the Internet, with the assistance of local healthcare professionals, public servants, and a network of regional physicians from the European Study Group on Dysphagia.  Between July and August 1999, patients with dysphagia were selected from 37 nursing homes and clinics in Europe.

  • The UK group was drawn from nursing homes and clinics/hospitals in the Manchester area
  • The French group was drawn from nursing homes and hospitals in the region of Toulouse and Maine-et-Loire
  • The German group was drawn from nursing homes in the Munich area
  • The Spanish group was drawn from nursing homes around Madrid 

Design:  Cross-Sectional Study 

Blinding used (if applicable):  not applicable 

Intervention (if applicable)

  • Patients with dysphagia were interviewed using an established questionnaire developed by Gustafsson and Tibbling
  • Qualitative interviews with a total of 28 health professionals were conducted to improve understanding of the patients data in the context of that country 

Statistical Analysis

Data is presented quantitatively.  No formal statistical comparisons were made.

Data Collection Summary:

Timing of Measurements

Subjects completed questionnaire and healthcare professionals completed qualitative interviews.

Dependent Variables

  • Eating habits
  • Personal feelings and importance
  • Seeking help
  • Medical status

Independent Variables

  • Dysphagia

Control Variables

  • Background information
Description of Actual Data Sample:

Initial N: 360 patients with dysphagia met inclusion criteria, approximately 90 per country

Attrition (final N):  360 subjects, 33% male, 67% female


  • 7.3% were aged 55 - 59
  • 7.8% were aged 60 - 64
  • 12.6% were aged 65 - 69
  • 16.5% were aged 70 - 74
  • 20.4% were aged 75 - 79
  • 33.9% were aged 80+

Ethnicity:  not mentioned

Other relevant demographics:

Anthropometrics:  there were differences among the patients from the 4 countries, but statistical analysis of differences between countries not completed

Location:  Nursing homes and clinics in Germany, France, Spain and the United Kingdom 


Summary of Results:


Responses Percentage
Food sticking in the throat/choking of food


Persistent cough or sore throat


Mild throat discomfort 41%
Inability to swallow liquids 40%
Loss of appetite 36%
Pain when swallowing 35%
Heartburn/acid regurgitation 27%
Unable to eat certain foods - Yes 55%
Unable to eat certain foods - No 35%
Unable to eat certain foods - Don't know 10%
Need personal assistance when eating 33%
Eating less 50%
Eat and swallow more slowly 32%
Take sips of liquid in between bites of food 27%
Chew food longer before swallowing 19%
Other 22%

Eating should be an enjoyable experience


Eating is an enjoyable experience 45%
Difference between "should" and "is" 39%
Avoid eating with others because of swallowing problems 36%
Feel embarrassed at mealtimes because of swallowing problems 37%
Experience anxiety or panic during mealtimes because of swallowing problems 41%
Swallowing problems make life less enjoyable 55%

Other Findings

Over 50% of patients (range 42% - 60%) claimed that they were "eating less" with 44% (range 36% - 49%) reporting weight loss during the preceding 12 months.

40% of patients acknowledged receiving a confirmed diagnosis of dysphagia; only 32% acknowledged receiving professional treatment for it.

Most people with dysphagia believe their condition to be untreatable, only 39% of the sufferers believed that their swallowing difficulties could be treated.

84% of patients felt that eating should be an enjoyable experience but only 45% actually found it so.

41% of patients stated that they experienced anxiety or panic during mealtimes.

Over 1/3 (36%) of patients reported that they avoided eating with others because of their dysphagia. 

1/3 of patients needed personal assistance while eating.

Author Conclusion:

In a large elderly population that might accept dysphagia as an untreatable part of the aging process, clinicians need to be aware of the adverse effects of dysphagia on self-esteem, socialization, and enjoyment of life.  Careful questioning should assess the impact of the condition on each patient's life, and patients should be educated on their choices for treatment in the context of any coexisting illness.  Awareness of the condition, diagnostic procedures and treatment options must be increased in society and among the medical profession.

In conclusion, the social and psychological impact of dysphagia is severe and the condition is underdiagnosed in European hospitals and clinics.  Increased recognition by health care professionals in all countries to the possibility of dysphagia in patients and an understanding of treatment options in the context of comorbid conditions will relieve suffering and improve quality of life in many patients.  The authors recommend that healthcare resources be allocated to the training of healthcare professionals and to providing management and treatment options.

Funding Source:
Novartis Consumer Health
Pharmaceutical/Dietary Supplement Company:
Reviewer Comments:
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? Yes
  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? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  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? Yes
  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.) Yes
  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? N/A
  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.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  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? N/A
  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? N/A
  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? Yes
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? N/A
  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)? N/A
  8.6. Was clinical significance as well as statistical significance reported? N/A
  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? 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