Unintended Weight Loss in Older Adults

UWL: Food, Appetite and Environment (2009)


Simmons SF, Garcia ET, Cadogan MP, Al-Samarrai NR, Levy-Storms LF, Osterweil D, Schnelle JF. The minimum data set weight-loss quality indicator: Does it reflect differences in care processes related to weight loss? Journal of the American Gerontological Society 2003; 51: 1,410-1,418.


PubMed ID: 14511161
Study Design:
Cross-Sectional Study
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

To determine whether nursing homes that score differently on prevalence of weight loss according to a Minimum Data Set quality indicator also provide different processes of care related to weight loss. 

Inclusion Criteria:

All residents in 16 Southern California nursing homes were invited to participate.   

Exclusion Criteria:

Residents housed in a transitional care unit.

Description of Study Protocol:


16 nursing homes volunteered to participate after being recruited from a sample of 46 Southern California nursing homes in the lower (23 homes) or upper (22 homes) quartile on prevalence of weight loss according to MDS data for 2000 


Cross sectional study of MDS data for nutritional status, feeding assistance and cognitive functioning  

Blinding used

Not applicable


Not applicable

Statistical Analysis

Chi square test was used for categorical variables between residents from nursing homes in the upper and lower percentiles 


Data Collection Summary:

Timing of Measurements

Resident interviews were conducted and staff implementation of 16 care processed were observed on three consecutive 12-hour days (7AM to 7PM) 

Dependent Variables

Processes of care related to weight loss

Independent Variables

Prevalence of weight loss

Control Variables


Description of Actual Data Sample:

Initial N

513 residents provided consent

Attrition (final N)

464 residents, 49 did not complete the project because of discharge, hospitalization or death


78±14 years (SD) in lowest quartile homes and 81±11 years (±SD) in highest quartile homes


238 of 400 were white

Other relevant demographics

  • Mean (±SD) length of residence was 16± years for the lowest quartile homes and 21± eight years for highest quartile homes
  • MediCal payment status was 74% for lowest quartile homes and 68% for highest quartile homes
  • MDS eating dependency (zero to four), mean + SD was 1.0±1.2 for lowest quartile homes and 1.1±1.5 for highest quartile homes.


Not reported 


Southern California


Summary of Results:


Accuracy of MDS weight loss indicator and oral intake documentation

Measure Lowest Quartile Group
(11 homes)
Highest Quartile Group
(5 homes)
Consented samples-MDS data  N=262  N=138
5% pr 10% weight loss percentage*†§  2  16
Proportion with a nutrition RAP-MDS§  82  82
Low oral intake (less than 75%)**, percentage  20  50
Medical record review sub-samples  N=180  N=72
Prevalence of 5%, 10% weight loss*§  3  11
Prevalence of 5% weight loss *§ during a 12-month period  24  48
Prevalence of 10% weight loss *§ during a 12-month period  5  22
Proportion with a nutrition RAP-MDS, percentage §  81  87
Proportion at risk, N (percentage) ** 115 (64)  62 (86)
Low oral intake (less than 75%), percentage **  46  73
Independent assessments-observation  N=262  N=138
Total eaten ± SD (0% to 100%), all meals, percentage*  63±26  55±24
Proportion who ate less than 75% both meals,
percentage **
 38  57
Proportion who ate less than 50% both meals,
percentage **
 11  24
Eats less than 50% and chart shows less than 60%, percentage pass*  27  44

† Weight loss quality indicator

‡ Groups of homes: Based on lower quartile, (i.e. homes with low prevalence of weight loss) or higher quartile (i.e. homes with high prevalence of weight loss) on Minimum Data set (MDS) weight loss quality indicator (Year 2000).

§ Prevalence of weight loss was based on the most recent MDS assessment and monthly weight data documented in the medical record for the 1– (loss of  5% of body weight in last 30 days) to six-month (loss of 10% of body weight in 180 days) period immediately before the date of the MDS assessment for the weight loss quality indicator prevalence rates. 

Prevalence of weight loss meeting the same criteria (equaling 5% in 30 days; equaling 10% in 180 days was limited in both calculations to participants whose length of stay was equal to six months at the time of the study.

¶ At risk defined as MDS or medical record documentation of weight loss (equaling 5% in 30 days, equaling 10% in 180 days), low oral intake (less than 75%), serum albumin less than 3.5, or a diagnosis of malnutrition.

*P<0.050; **P<0.010

SD=standard deviation

Other Findings

Clinical indicators and group comparisons for nursing home (NH) care processes related to weight loss that showed no significant differences

Clinical Indicator and Data Source Percentage Pass
(n or nm)*

All NH residents should be weighed  monthly, and these
weights should be documented in the medical record

100 (n=179) 100 (n-71)

IF the MDS nutrition RAP has been triggered for a NH
resident†, THEN the PCP should document the presence or
absence of malnutrition (or related disorder) in the medical record‡

66 (n=150) 56 (n=64) 

IF a NH resident shows a more than 25% decrease in oral intake for three consecutive days, THEN an evaluation of the reasons for the decrease in oral intake should be initiated within two weeks–medical record.

90 (n=50) 82 (n=39) 

IF a NH resident has documented involuntary weight loss§
or hypoalbuminemia (less than 3.5g/dL), THEN he or she should receive an evaluation from a licensed provider of relevant co-morbid conditions within one month–medical record.

66 (n=79)  78 (n=36)

All NH residents should receive an annual examination
of the oral cavity-medical record

91 (n=181) 93 (n=71) 
If MDS Section G Physical Functioning, Item one hour:
Eating rated by NH staff as requiring physical assistance
(limited to total),? THEN the resident should receive verbal notification or cueing before the assistance is given–direct observation
54 (nm=39)  31 (nm=26) 
IF a vulnerable elder is admitted to a NH, THEN within 
two weeks, the resident’s preferences for daily life activities
related to meals should be assessed and documented
in the medical record
91 (n=178)  94 (n=71) 

IF a resident eats less than 50% at any meal (resident is at risk
for weight loss due to low oral intake), THEN he or she should
receive more than one minute of staff assistance at that meal
–direct observations

34 (nm=140) 25 (nm=80)
ALL residents should be permitted to substitute appropriate food
items on the menu-interview
81 (N=150)  85 (N=80)

*Groups of homes: Based on lower quartile, (i.e. homes with low prevalence of weight loss) or higher quartile (i.e. homes with high prevalence of weight loss) on Minimum Data set (MDS) weight loss quality indicator (Year 2000).

 Nutrition Resident Assessment Protocol (RAP) is triggered on the MDS if one or more of the following conditions is present: (K3a) weight loss, (K4a) complaints about taste of many foods, (K4c) leaves =25% of food uneaten at most meals, (K5a) parenteral or intravenous feeding, (K5c) mechanically altered diet, (K5d) syringe feeding, (K5e) therapeutic diet, or (M2a) pressure ulcer.


Primary care nurse or nurse practitioner


§ Involuntary weight loss of 5% in 30 days or =10% in 90 days


? MDS eating dependency (MDS section G. Physical Functioning, items 1b, h): 0=independent, 1=supervision, 2=limited assistance, 3=extensive assistance, 4=total dependence. Denominator includes participants who were rated as level 2, 3, or 4.


n=number of participants scored pass + fail: nm=number of meals 

Author Conclusion:

The MDS weight-loss quality indicator reflects differences in the prevalence of weight loss between NHs. NHs with a lower prevalence of weight loss have fewer residents at risk for weight loss and staff who provide verbal prompting and social interaction to more residents during meals, but the adequacy and quality of feeding assistance care needs improvement in all NHs. 

Funding Source:
Reviewer Comments:

Authors note limitations of study being conducted in one geographical region and time delay between identification of nursing homes as being in the upper or lower quartile (2000-2001) and the independent assessment of care-process implementation (2001-2002). Sample sizes for scoring some indicators were small due to eligibility criteria. Some important care processes may not have been captured in indicators measured, and weights not independently measured at time of study. 

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? N/A
  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? N/A
  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? No
  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? No
  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? 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? ???
  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? ???
  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? ???
  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)? N/A
  8.6. Was clinical significance as well as statistical significance reported? No
  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