UWL: Food, Appetite and Environment (2009)

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

To evaluate the nutritional and clinical consequences of changing from a centralized food delivery system to decentralized bulk food portioning, a system in which meal portioning occurs on residents' floors of a nursing home.

Inclusion Criteria:

None specifically mentioned.

Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:


Study took place on one floor of a home for elderly persons with dementia. Of the 34 residents, 22 participated. Recruitment methods were not described.


Before-after study. 


10 weeks of decentralized bulk food portioning: A system in which meal portioning occurs on residents' floors of the nursing home.

Statistical Analysis

Paired T-tests adjusted by a Bonferroni correction assessed differences between values measured before and after introduction of the new food distribution system.

Data Collection Summary:

Timing of Measurements

Nutritional status verified by food intake estimates and anthropometric measurements before and after 10 weeks of implementation of the new food distribution system.

Dependent Variables

  • Food intake data collected for three non-consecutive days by trained dietitians
  • Anthropometric measurements: Height, weight, BMI, triceps skinfold thickness, mid-upper-arm circumference
  • Biochemical parameters: Albumin, lymphocytes, glucose, sodium, potassium, transferrin, vitamin B12, folate, hemoglobin

Independent Variables

10 weeks of decentralized bulk food portioning.

Control Variables

Sociodemographic and medical data obtained from medical files.

Description of Actual Data Sample:
  • Initial N: 34 residents were invited; 25 agreed to participate.
  • Attrition (final N): 22 residents; one man, 21 women. Two residents withdrew due to illness, one died.
  • Age: Mean age 82 years (range 55 to 94 years)
  • Other relevant demographics: 70% were cognitively impaired, most due to Alzheimer's disease
  • Anthropometrics: Mean body weight was 54kg; mean BMI, 24
  • Location: Montreal, Canada. 
Summary of Results:



Week Zero

Week 10

Statistical Significance of Group Difference

Energy (kcal) 1,555±322 1,924±373


Protein (g)




Fat (g)




Carbohydrates (g) 210±46 260±55 P<0.01

Other Findings

Average food consumption increased substantially and significantly after introduction of the bulk food portioning system.

Mean energy intakes rose from 1,555 to 1,924kcal per day and most other nutrients also increased significantly.

There were no changes in anthropometric values or biochemical parameters, except for albumin level, which decreased to the lower normal limit (35±4g per L to 33±3g per L). 

Author Conclusion:

A decentralized food portioning system in a nursing home led to greater food consumption by residents, but it had no impact on the nutritional status parameters evaluated.

Serving food from the bulk food cart in the dining room can offer elderly residents with dementia positive stimulation arising from the organoleptic properties of the foods themselves, such as enticing odor or from being served foods at the appropriate temperature. The activity surrounding preparation of residents' plates, and the presence of additional people in the dining room, can simulate a more domestic atmosphere and have positive consequences for dietary adequacy and residents nutritional status.

In the long-term care setting, dietitians are responsible for the nutritional, therapeutic and sensory quality of meals served to the elderly; they also must teach, supervise, and motivate food service employees. In a centralized food service system in a nursing home, the dietitian's role is of critical importance, as the elderly constitute a vulnerable population group at high risk for nutritional problems.

Funding Source:
Reviewer Comments:

Inclusion/exclusion criteria and recruitment methods are not well defined. Study involved only one nursing home.

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? No
  2.2. Were criteria applied equally to all study groups? No
  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? 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? 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? 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? 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? Yes
  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? 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)? Yes
  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