UWL: Food, Appetite and Environment (2009)

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

To describe and compare eating difficulties from admission to discharge, with regard to length of stay (LOS) and discharge to institutional care, as well as in relation to gender. 

Inclusion Criteria:

Admission to a stroke unit for rehabilitation during November 1996 to November 1997.

Exclusion Criteria:
  • Age: Under 65 years
  • No eating difficulties on admission.
Description of Study Protocol:
  • Recruitment: All patients admitted for stroke rehabilitation from an inpatient stroke unit
  • Design: Before-after study; observational study of patients aged 65 or older, admitted for stroke rehabilitation and having at least one eating difficulty, were observed on admission and discharge
  • Blinding used: None
  • Intervention: None.

Statistical Analysis

  • Dependent-groups: McNamar test for nominal data, Wilcoxon signed rank test for ordinal data and paired T-test for interval data that were normally distributed
  • Independent groups: Chi-square test and Fisher's exact test for nominal data with a Mann-Whitney U-test for ordinal data and T-test for interval data that were normally distributed
  • Linear regression was performed with LOS as the dependent variable and independent variables were gender, age, cohabitation, living alone, deglutition difficulties and low energy on admission and at discharge
  • Logistic regression analysis was performed with discharge destination as the dependent variable. Independent variables were gender, age cohabitation, BMI, ingestion and deglutition difficulties and low energy on admission and at discharge.
Data Collection Summary:

Timing of Measurements

Eating assessments were done at admission and discharge.

Dependent Variables

  • Length of stay
  • Discharge destination.

Independent Variables

  • Gender
  • Age
  • Cohabitation
  • BMI
  • Ingestion
  • Living alone
  • Deglutition difficulties
  • Low energy on admission and at discharge.

Control Variables

Not applicable.

Description of Actual Data Sample:
  • Initial N: 162 patients with stroke. Three were aged under 65 years, 40 had no eating difficulties.
  • Attrition (final N): 108 (56 men, 52 women). Eight had not been observed at discharge, three died.
  • Age: 77.6 years (±6.7) for men and 80.6 (plus or minus) for women
  • Ethnicity: Not noted; the study was conducted in Sweden
  • Anthropometrics: Mean BMI was 23.7±4.2 for men and 22.5±4.7 for women
  • Location: Lund, Sweden.
Summary of Results:

Table Two: Eating Difficulties Among Patients (Aged ≥65 Years) for Rehabilitation with Stroke After Eating Difficulties, Differences Between Admission and Discharge (N=108)

Eating Difficulties
Patients with Eating Difficulties
On admission
At discharge
Ingestion, m (SD)
1.6 (1.1)
1.0 (1.1)
Sitting Position
Manipulating Food of the Plate
Transport of Food to the Mouth
Deglutition, m (SD)
0.8 (1.0)
0.5 (0.8)
Opening or Closing the Mouth
Manipulating Food in the Mouth
Swallowing Difficulties
Energy, m (SD)
1.2 (0.8)
0.9 (0.8)
Eating <75% of Food
Reduced Alertness
Aberrant Eating Time
Number of Difficulties, m (SD)
3.6 (2.2)
2.5 (2.1)

Other Findings

  • On admission, among patients discharged later, the mean number of low energy problems was higher among women (1.67) than among men (1.18, P<0.030) and among those with shorter LOS
  • At discharge, in patients with longer LOS, the mean number of low-energy problems was higher and low food intake more common among women (1.27 and N=18, 82%) than men (0.81, P<0.048 and N=16, 50%, P<0.018)
  • Further, in patients discharged to institutional care, low food intake at the time of discharge, was more common among women (N=25, 83%) than among men (N=20, 59%).
Author Conclusion:
  • Ingestion difficulties on admission indicate a longer in-hospital stay and decrease to a greater extent than other types of eating difficulties
  • If these difficulties persist at the time of discharge, the patients are more likely to need institutional care
  • It is important to assess and take systematic measures for each of the three variants of eating difficulties, i.e., ingestion, deglutition and energy to improve eating abilities
  • Women in particular need attention with regard to low food intake.
Funding Source:
Reviewer Comments:

Authors note limitation of not controlling for measures taken during the rehabilitation to improve eating ability, as well as having to wait for an available bed in a particular facility may have affected LOS.

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) ???
  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? N/A
  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? 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? N/A
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? 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.) No
  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? 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? No
  6.6. Were extra or unplanned treatments described? No
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? ???
  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? No
  7.2. Were nutrition measures appropriate to question and outcomes of concern? N/A
  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? 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)? ???
  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? No
10. Is bias due to study's funding or sponsorship unlikely? No
  10.1. Were sources of funding and investigators' affiliations described? No
  10.2. Was the study free from apparent conflict of interest? Yes