Unintended Weight Loss in Older Adults

UWL: Food, Appetite and Environment (2009)


Xia C, McCutcheon H. Mealtimes in hospital: Who does what? Journal of Clinical Nursing. 2006; 15: 1,221-1,227.

PubMed ID: 16968426
Study Design:
Descriptive Study
D - Click here for explanation of classification scheme.
Quality Rating:
Negative NEGATIVE: See Quality Criteria Checklist below.
Research Purpose:

The purpose of this study was to establish what nurses do at mealtimes in relation to the eating practices of elderly patients in two medical wards of an acute care facility.   

Inclusion Criteria:

None described.

Exclusion Criteria:

None described.

Description of Study Protocol:


None described.


Guided observation of mealtime activities (meal delivery, nurses' help with position change and bed table adjustment, time of access to the meal and reason for delayed access, patients' eating difficulty and nurses' assistance, interruptions and social interaction, checking food intake and documentation) 12 times during a week (four times for breakfast, four times for lunch and four times for dinner). 

Statistical Analysis

Data were analyzed using descriptive statistics and thematic analysis.

Data Collection Summary:

Timing of Measurements

Each ward was observed 12 times during a week (four times for breakfast, four times for lunch, and four times for dinner).

Dependent Variables

  • Meal delivery
  • Nurses' help with position change
  • Bed table adjustment
  • Times of access of meal
  • Reason for delayed access
  • Patients' eating difficulty
  • Nurses' assistance
  • Interruption and social interaction
  • Checking food intake
  • Documentation.

Independent Variables

  • One ward had changed staff meal break times so that nurses did not have their breaks when patients were eating their meals
  • One ward allowed staff meal breaks while patients were eating their meals.
Description of Actual Data Sample:
  • Initial N: Two wards
  • Attrition (final N): Two wards (50 nurses: 26 from Ward One and 24 from Ward Two; 47 patients)
  • Age: Patients aged 65 years or older
  • Location: A hospital in South Australia.
Summary of Results:

Table 1. Type of Eating Difficulty

Type of Eating Difficulty Frequency Percent
Opening food 12 54.5
Using cutlery 8 36.5
Adding seasoning 7 31.8
Food too far away 5 22.7
Uncomfortable eating position 4 18.2
Pouring a drink 4 18.2
Cutting food 1 4.5
Spreading butter 1 4.5
Opening denture box 1 4.5

Table 2. Type of Assistance Nurses Provided When Patients Begin Eating

Type of Help Frequency Percent
Opened food 18 78.3
Described meal 14 60.9
Helped to sit comfortably 9 39.1
Helped to use cutlery 7 30.4
Added seasoning 7 30.4
Encouragement 6 26.1
Poured drink 6 26.1
Cut 4 17.4
Spread butter 4 17.4
Feeding 4 17.4
Asked about the food 1 4.3
Provided other food 1 4.3
Gave glasses 1 4.3

Table 3. Type of Assistance Nurses Provided During Patients’ Eating Practice

 Type of Help with Eating Frequency Percent 
Opened food 41.2 
Encouragement 7 41.2 
Talked  35.5 
Described food 23.5 
Added seasoning  17.6 
Poured drink 17.6 
Feeding  17.6 
Provided other food 17.6 
Asked about the food 11.8 
Helped to sit comfortably 1 5.9
Helped to use cutlery 1 5.6
Cut 1 5.9
Spread butter 0 0

Other Findings

  • Older patients did not receive enough assistance during mealtimes
  • Interruptions happened frequently and social interaction was neglected
  • About one-third of patients observed left more than two-thirds of their meals. 
Author Conclusion:

Nutrition issues appeared to receive less priority in the ward than other nursing care activities and nurses' assistance was generally insufficient and not provided in a timely manner. In order to improve nurses' practice at meal times, simply increasing staff numbers may not be enough; we may need to consider education to change or refocus nurses' attitudes and perceptions about the importance of nutrition. Meal delivery should be undertaken or supervised by nursing staff. During mealtimes, nurses need to spend more time assisting patients with eating rather than attending to other tasks. Providing enough assistance with opening, describing the meal and giving encouragement to eat are important, and help should be given in a timely manner. Interruption should be avoided during eating and social interaction should be emphasized.


Funding Source:
Reviewer Comments:
  • The authors did not address the original objective, which was to describe differences in feeding practices between one ward where nurses took breaks during patient mealtimes and one ward where they did not take breaks during patient mealtimes
  • Authors note limitations of the small sample size for observation and limited ability to generalize findings.


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? ???
  2.3. Were health, demographics, and other characteristics of subjects described? No
  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) Yes
  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.) ???
  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? No
  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%.) No
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? ???
  4.4. Were reasons for withdrawals similar across groups? ???
  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? ???
  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? 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? 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? ???
  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? No
  7.1. Were primary and secondary endpoints described and relevant to the question? No
  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? ???
  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? ???
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? ???
  8.2. Were correct statistical tests used and assumptions of test not violated? No
  8.3. Were statistics reported with levels of significance and/or confidence intervals? No
  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? ???
  10.1. Were sources of funding and investigators' affiliations described? No
  10.2. Was the study free from apparent conflict of interest? Yes