Unintended Weight Loss in Older Adults

UWL: Food, Appetite and Environment (2009)


Westergren A, Karlsson S, Andersson P, Ohlsson O, Hallberg IR. Eating difficulties, need for assisted eating, nutritional status and pressure ulcers in patients admitted for stroke rehabilitation. J Clin Nursing. 2001; 10: 257-269.

PubMed ID: 11820347
Study Design:
Observational study of eating difficulties of patients in a stroke rehabilitation facility
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
  • The aim of the study was to describe and compare patients without a need for assisted eating and those with such a need regarding the types and extent of eating difficulties, nutritional status and pressure ulcers when admittted for rehabilitation after a stroke
  • A further aim was to analyze the relationship between eating difficulties and nutritional status and subsequent pressure ulcer development.
Inclusion Criteria:

Patients consecutively admitted to a stroke rehabilitation facility from November 1996 to November 1997.

Exclusion Criteria:

None reported.

Description of Study Protocol:
  • Recruitment: Not described
  • Design: Observational study of eating difficulties in a stroke rehabilitation facility
  • Blinding used: None
  • Intervention: None.

Statistical Analysis

  • Parametric or non-parametric tests were used for the analysis of differences between patients needing or not needing assisted eating
  • Age and BMI were compared using the T-test
  • Mann-Whitney U-test was used for comparing the number of prescribed drugs. The Katz-ADL index, number of eating difficulties, nutritional status and pressure ulcers.
  • Chi-square tests were used to compare cohabitation, level of independent living, clinical signs and eating difficulties
  • Multiple logistic regression was performed to determine the risk factors for undernourishment
  • Analyses of the predictive risk of nutritional status for having pressure ulcers were made.
Data Collection Summary:

Timing of Measurements

Not stated.

Dependent Variables

  • Nutrition status
  • Number of pressure ulcers.

Independent Variables

Eating difficulties.

Control Variables

Not applicable.

Description of Actual Data Sample:
  • Initial N: 162 patients with stroke
  • Attrition (final N): 162; 74 men, 88 women
  • Age: 78.62 years
  • Ethnicity: Not mentioned
  • Location: Sweden.
Summary of Results:

Nutritional Status Assessed with a Subjective Global Assessment in the Total Sample (N=162) and the Presence and Nature of Pressure Ulcers Among Patients with Dependency in at Least One Activity of Daily Living (Katz ADL Index Not Equal to A; N=123), in Patients Admitted for Stroke Rehabilitation



Independent Eating

Dependent Eating


Nutritional Status











Well-nourished, but at risk of being malnourished




Malnourished Suspected of being malnourished
Severely malnourished
Grade of Pressure Ulcers (N=123) (N=38) (N=85)  
Persistent discoloration
Epithelial damage
Damage to full thickness without cavity
Damage to the full thickness of the skin with cavity

Logistic Regression Analysis of Eating Difficulties as Predictors of Nutritional Status in Patients Admitted for Stroke Rehabilitation

  Odds Ratio 95% CI for OR P-Value


Swallowing Difficulties
Amount of Food Eaten
Eating Speed
  • Hosmer and Lemshow goodness-of-fit test
  • X2 2.89
  • DF 4
  • *P<0.58
  • Factors without significant influence were "sitting position," "manipulating food on the plate," "transport of food to the mouth," "open and/or close the mouth," "manipulating food in the mouth."
Author Conclusion:
  • Eating difficulties among patients with stroke were complex and existed among those who required feeding assistance and those who did not
  • The most common eating difficulties were those related to the phase before the food reaches the mouth
  • Some eating difficulties showed significant predictive ability for under-nourishment, which in turn increased the likelihood of having pressure ulcers.
Funding Source:
Reviewer Comments:
  • These patients are the same ones in a similar study reported by Westergren A, Ohlsson O, Hallberg IR, in Disability and Rehabilitation in 2002
  • The researchers used an unvalidated modification of the Subjective Global Assessment form, which has an unknown impact on their 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) 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? N/A
3. Were study groups comparable? Yes
  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? Yes
  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? Yes
  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? N/A
  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%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? N/A
  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? 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.) 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? 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? No
  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? 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? No
  7.2. Were nutrition measures appropriate to question and outcomes of concern? No
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? ???
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? No
  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? 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)? Yes
  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? ???
  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? ???
  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? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes