UWL: Screening and Assessment Methods (2009)

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

The aims of the study were to:

1.  estimate the intake of key nutrients consumed from meals on 1 day in residents receiving high level care (nursing home residents) and lower level care (hostel residents)

2.  assess any differences in key nutrients in residents with and without eating impairments, and between 3 major texture modification groups:  full, soft/minced and pureed

Inclusion Criteria:
  • Every resident in each ward or group was included, provided they were present for the 3 meals
Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:


14 eating sites (wards or dining rooms) from residential care institutions, which were recruited to a larger study investigating prevention of hip fractures with vitamin D supplementation, were invited and agreed to participate in this study.  Sites and wards were chosen to include a sample of residents being served the 3 common diet texture modifications (full diet, soft/minced and pureed) and to include both high level care and lower level care (nursing homes and hostels).

Design:  Cross-Sectional Study

Blinding used (if applicable):  not applicable

Intervention (if applicable)

Individual plate waste was estimated at 3 meals on 1 day.

Statistical Analysis

Student t tests and ANOVA and Tukey's honestly significant difference post hoc tests were used to test differences between groups.

Data Collection Summary:

Timing of Measurements

Individual plate waste was estimated at 3 meals on 1 day.

Dependent Variables

  • Food intake assessed through visual estimation of plate waste, 1 plate waste observer per site, nutrient intakes calculated using software and recipes were used when available from the institution
  • Intake of food beverages served between meals was not assessed 

Independent Variables

  • Level of care:  nursing home or hostel

Control Variables

  • Staff provided information on age (from medical records) and were asked whether each resident's eating was impaired by eyesight loss, problems of the arms or hands, dentures, swallowing problems or dementia
  • Staff also assessed residents as being partially or fully fed by staff or as self-feeding
Description of Actual Data Sample:

Initial N:  152 nursing home residents, 13 not present for all 3 meals on sampling day.  95 hostel residents, 19 not present for all 3 meals on sampling day.  75 had been included in the previous study validating the visual plate waste assessment method. 

Attrition (final N):  212 residents, 56 males and 156 females; 139 lived in nursing homes and 76 in hostels

Age:  mean age 82.9 ± 9.5 years

Ethnicity:  not mentioned

Other relevant demographics:

Anthropometrics:  There were no differences in age between residents of the 2 types of facilities or between the consumers of the 3 different diet texture types.

Location:  Australia


Summary of Results:

 Mean Nutrient Intakes from Meals

  All (n=215) Nursing Home (n=139) Hostel (n=76) Full Diet (n=114) Soft Diet (n=48) Pureed Diet (n=53)
Energy (MJ) 4.3 3.9, P < 0.001 5.2 4.7 3.9, P < 0.001 3.8, P < 0.001

% Energy Eaten


74.2, P < 0.001 87.7 82.2



Protein (g) 46.7 44.6, P < 0.01 50.5 48.9 46.8 41.7
Calcium (mg) 401 359.0, P < 0.001 480.5 437.9 366.1 356.8
Fibre (g) 17.2 14.6 22.0 19.2 15.3 14.6, P < 0.01
Vitamin D (µg) 1.0 1.0 1.0 1.0 0.8 1.9
Protein/Energy 11.0 11.7, P < 0.001 9.8 10.5 12.0 11.2



98.8 94.4 95.3



Fibre/Energy 4.0 3.8 4.2 4.0 4.0 3.9

Other Findings

Mean total energy served from meals was 5.3 MJ/day, (95% confidence interval:  5.1 to 5.6 MJ/day) in nursing homes which was lower than in hostels, 5.9 MJ/day (95% confidence interval:  5.6 to 6.2 MJ/day, P = 0.007).

The percent of energy consumed of that served was 14% lower in nursing homes compared to hostels.

Protein and calcium intakes were also lower in nursing homes:  44.5 g protein (95% confidence interval:  41.5 to 47.5 g) vs 50.5 g protein (95% confidence interval:  46.6 to 54.3 g) and 359.0 mg calcium (95% confidence interval:  333.2 to 384.8 mg) vs 480.5 mg calcium (95% confidence interval:  444.3 to 516.7 mg), both P < 0.001.

There was no difference in nutrient/energy ratios, except for protein/energy, which was higher in nursing homes (11.7, 95% confidence interval: 11.3 to 12.2) than in hostels (9.8, 95% confidence interval: 9.4 to 10.3, P < 0.001).

Ability to self-feed had no significant effect on nutrient intakes in nursing homes.

Of those in nursing homes classified as eating impaired, 36% received no assistance with feeding and had lower intakes of protein (37.8 g, 95% confidence interval: 33.0 to 42.1) compared to those receiving some assistance (46.1 g, 95% confidence interval: 41.3 to 50.9, P = 0.026).


Author Conclusion:

This study confirmed that those residents in higher-level care facilities, such as nursing homes, were served less energy, calcium and fibre in 1 day at the 3 meals and consequently had lower intakes of energy, calcium and fibre.  The proportion of food eaten from that served for the day was lower in nursing homes, with nursing home residents consuming 74% of the energy served and hostel residents consuming 88%.  Strategies to effectively monitor nutrient intakes and to identify those with eating impairment are required in order to ensure adequate nutritrion of residents in nursing homes and hostels. 

Funding Source:
Food Company:
University/Hospital: joint society of Dutch Univesity
Reviewer Comments:

Authors note that institutions were not randomly selected and therefore may not be representative of all nursing homes and hostels.  Inclusion/exclusion criteria not well defined.  Authors note limited accuracy with 1 day food intake measurements, as compared to longer time periods.  75 had been included in the previous study validating the visual plate waste assessment method.  Intake of food beverages served between meals was not assessed.

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? ???
  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? 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.) 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? Yes
  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? Yes
  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? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  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? 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? ???
  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? 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? 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)? N/A
  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