Unintended Weight Loss in Older Adults

UWL: Food, Appetite and Environment (2009)


Simmons SF, Levy-Storms L. The effect of dining location on nutritional care quality in nursing homes. Journal of Nutrition Health and Aging. 2005; 9: 434-439. 

PubMed ID: 16395515
Study Design:
A cross-sectional study in 34 nursing homes to describe the effect of dining location on indicators of nutritional care quality in nursing home residents.
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

The purpose of the study was to address these questions:

  • What is the effect of dining location on four nutritional care processes, after adjusting for staffing level and resident characteristics?
  • What are the implications of these findings for improving nutritional care quality for residents at risk for unintentional weight loss? 
Inclusion Criteria:

Nursing homes in California.

Exclusion Criteria:
  • Nursing home administrator declined to participate
  • Residents were covered by Medicare.
Description of Study Protocol:


761 residents were asked individually to participate from 34 nursing homes. 


A single observation was made of four nutrition-related behaviors on the part of staff or residents. Results of the observation were compared with facility-level observations. 

Statistical Analysis

Logistic regression analyses were used to determine the independent effects of dining location on nutrition care quality. Bivariate analyses were conducted to identify independent variables (resident demographic and functional characteristics, staffing level and dining location) that were significantly correlated with each of the four outcome variables. 


Data Collection Summary:

Timing of Measurements

Two direct observations of nursing home residents on two consecutive days (typically breakfast or lunch).

Dependent Variables

  • Total percent food eaten 
  • Meal assistance in minutes
  • Ability to get substitute foods.

Independent Variables

Dining location.

Control Variables

Controlled for nursing home level effects.

Description of Actual Data Sample:
  • Initial N: 761 study participants
  • Attrition (final N): 761; 419 were missing MDS data
  • Age: 81±12.6 years
  • Ethnicity: 65% Caucasian
  • Other relevant demographics: 67% female; mean length of stay, 31.3 months; mean MDS recall score, 2.5; proportion of residents with minimum data set (MDS) recall less than two, 64%; MDS eating dependency scale score, 1.1; proportion of residents with MDS eating dependency score less than one, 28% 
  • Location: California nursing homes.
Summary of Results:



Indicator 1

Eats Less than 50% and Chart Less than 60%

(nm=397; N=383)g

-2.0 Log Likelihood

Odds Ratios (CI)

Indicator 2

Eats Less than 50% and Assistance More than One Minute

(nm=397; N=383)g

-2 Log Likelihood

Odds Ratios (CI)

Indicator 3

Needs Assistance and Assistance More than Five Minutes

(nm=392; N=197)h

-2 Log Likelihood

Odds Ratios (CI)

Indicator 4

Able to Get Substitute


-2 Log Likelihood

Odds Ratios (CI)

Resident Level





MDS recallh

0.87 (0.73 to 1.03)

0.75** (0.62 to 0.91)

0.64** (0.54 to 0.76)

1.91** (1.33 to 2.74)
MDS eating dependencyc 1.07 (0.9 to 1.28) 1.92** (1.56 to 2.436) 1.79* (1.05 to -3.06) 1.64 (0.83 to 3.21)

Dining locationd

2.01** (1.22 to 3.31)

0.81 (0.44 to 1.48)

1.79* (1.05 to 3.06)

1.64 (0.83 to 3.21)
Facility Level        
Staff levele 0.85 (0.41 to 1.68) 1.40 (0.61 to 3.20) 3.99** (1.70 to 9.36) 7.46 (0.86 to 64.5)
Proportion in dining roomf 1.34 (0.65 to 2.76) 1.02 (0.43 to 2.40) 0.41* (0.19 to 0.89) 1.24 (0.38 to 4.03)

CI = 95% confidence intervals; nm = number of resident-meals; N=number of residents; *P<0.05; **P<0.01; ***P<0.001.

a Refers to observation and resident interview protocols for definitions and scoring of care process outcome measures one through four. Each of the four indicators were scored pass (zero, event) or fail (one, reference group). Indicators one to three were scored at the resident-meal level; while indicator four was scored at the resident level.  

b Minimum Data Set Recall Score (MDS Section B. Cognitive patterns, item three). Memory/Recall ability (a to d): Able to accurately recall (a) current season, (b) location of own room, (c) staff names or faces, (d) the patient is in a nursing home. Zero, unable to recall any of the four items (in the last seven days) to four (able to recall all four items).

c Minimum Data Set Eating Dependency Score (MDS) Section (Physical Functioning, item one-h) rated:

  • Zero: Independent
  • One: Supervision
  • Two: Limited assistance
  • Three: Extensive assistance
  • Four: Total dependence.

d Dining locations: In room (zero, reference group) vs. dining room (one) for meal.

e Staff level: Low [Zero, less than 4.1 total hours (licensed nurses plus nurses aides) per resident day (HPRD)] vs. high (one, equal to or greater than 4.1 total HPRD).

f Proportion (0% to 100%) of study sample within each facility directly observed to eat at least one meal in the dining room categorized into less than 75% (zero) vs. equal to or greater than 75% (one).

g 419 residents (431 resident meals) were excluded from analysis due to missing MDS data. 399 of 487 residents with an MDS recall score of two or greater were scored; the remaining 88 residents replied "don't know" or failed to respond at all to the interview question.   

Other Findings

Nutritional care quality was significantly better according to two to four indicators if a resident ate meals in the dining room compared to their rooms.

Residents who were rated by nursing home staff as requiring assistance to eat were more likely to receive assistance in the dining room compared to their rooms.

Nursing home staff medical record documentation of oral food and fluid consumption was more accurate when residents ate in the dining room. 

Author Conclusion:

Nursing home residents at risk for unintentional weight loss should eat their meals in a common area, such as the dining room, to promote adequate feeding assistance care provision and accurate medical record documentation of oral food and fluid consumption. Residents' presence in the dining room also increases staff-time efficiency for the delivery of assistance and feasibility for the encouragement of residents' self-feeding capabilities and oral food and fluid consumption through the provision of verbal cueing and social stimulation. A pleasant dining location that accomodates most residents within a facility may represent a fundamental rule of quality nutritional care.

Funding Source:
Reviewer Comments:
  • The quality of this study is limited by the number of subjects (419 of 761) with missing MDS data
  • Authors note limitations of study being limited to one geographic region (California) and the consent rate for both facilities (39%) and study participants (37%) was low, primarily due to a restricted two-week time period for recruitment
  • Authors also note that there were multiple nutritional care quality indicators validated in previous studies that were not included in the current study. In particular, two indicators related to the quality of feeding assistance (nursing home staff provision of verbal cueing in the context of physical feeding assistance and social stimulation during meals).
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? ???
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? ???
  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%.) ???
  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? No
  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? Yes
  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? 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? 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? 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? No
  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? 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? 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