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Unintended Weight Loss in Older Adults

UWL: Food, Appetite and Environment (2009)


Westergren A, Unosson M, Ohlsson O, Lorefalt B, Hallberg IR. Eating difficulties, assisted eating and nutritional status in elderly (>65 years) patients in hospital rehabilitation. International Journal of Nursing Studies, 2002; 39: 341-351.

PubMed ID: 11864657
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 investigate the occurrence of eating difficulties in hospitalized patients 65 years or older in rehabilitation care and to analyze the association between eating difficulties, assisted eating and nutritional status, taking possible confounders into account.
Inclusion Criteria:
Patients admitted to specified units (stroke, heart-lung, orthopedic or general elderly care) within an urban or university hospital in Sweden between 1996 and 1998. 
Exclusion Criteria:
Patients who could not take anything orally.
Description of Study Protocol:


  • Methods not described
  • Patients admitted to specified units (stroke, heart-lung, orthopedic or general elderly care) within an urban or university hospital in Sweden between 1996 and 1998.


  • Cross-sectional study
  • Activities of daily living, including food intake, were assessed using the Katz ADL index
  • Eating difficulties were assessed by a trained observer
  • Nutrition status was assessed using Subjective Global Assessment.

Statistical Analysis

  • Differences between patients from more than one group were analyzed with Chi-square test or Fisher's exact test
  • ANOVA with Bonferroni correction for was used for continuous data and post-hoc analysis, respectively
  • Kruskal Wallis was used for ordinal data
  • Between-group analysis was conducted with Mann-Whitney U-test
  • Principle component analysis was used with varimax (orthagonal) rotation was performed based on a correlation matrix with phi coefficients
  • Kaiser-Meyer Olkin measure of sampling adequacy was used
  • Logistic regression was used to analyze eating assistanct with Subjective Global Assessment as the dependent variable
  • Goodness of fit tests were performed
  • Analysis was designed to control for diagnosis and care settings being possible confounders
  • P-values below 0.05 were considered statistically significant.
Data Collection Summary:

Timing of Measurements

  • Measurements made at the same time
  • Activities of daily living, including food intake, were assessed using the Katz ADL index
  • Eating difficulties were assessed by a trained observer
  • Nutrition status was assessed using Subjective Global Assessment.

Dependent Variables

Nutrition status, based on Subjective Global Assessment score (B-D), indicating malnutrition. 

Independent Variables

  • Eating difficulties assessed by trained observer
  • Activities of daily living, including food intake, were assessed using the Katz ADL index.
Description of Actual Data Sample:
  • Initial N: Unknown; 550 was the target
  • Attrition (final N): 520 (60% were women)
  • Age: 81.0 years
  • Ethnicity: Unstated; the study was completed in Sweden
  • Location: Lund, Sweden.
Summary of Results:
  • Patients admitted to rehabilitation wards (N=520)
  • Principal component analysis with varimax rotations for eating difficulties and Cronbach’s alpha for the components (N=520)

Mean Values for Components and Differences Between Those with Assisted Eating and Those Without (Mann-Whitney U-Test) and Between Wards [Kruskal-Wallis Test (four wards) and Mann Whitney U-Test (two wards)]

Eating Difficulties
Manipulating Food on the Plate
Transport of Food to the Mouth
Sitting Position
Opening or Closing the Mouth
Manipulate Food in the Mouth
Aberrant Eating Time
Eating ≤3/4 of Food Served
Eigen Values After Rotation
Percent of Explained Variance
Crohnbach's Alpha
Mean (95% CI; Possible Values Range from 0 to 3)
Not assisted eating (N=335)
Assisted eating (N=1,851)

Eating Difficulties, Advanced Age and Diagnosis Categories Significantly Associated with Malnutrition in Patients Admitted for Rehabilitationa

Odds Ratio
(95% Confidence Interval for OR)

Total sample
Assisted eating
Non-assisted eating
Diseases of the Digestive System (520 579)
Eating Difficulties Regarding Energy
Symptoms, Signs and Ill-Defined Conditions (780 799)
Neoplasms (140 239)
Diseases of the Nervous System and Sense Organs (320 389)
Advanced Age

a: For total sample: Hosmer and Lemeshow goodness of fit test, chi-square =1.80, DF=8, P=0.986.

Variables without significant association with malnutrition were eating difficulties regarding:

  • Ingestion and deglutition, gender, advanced age, infectious and parasitic diseases (001 139)
  • Endocrine, nutritional and metabolid diseases and immunity disorders (240 279)
  • Diseases of the blood and blood forming organs (280 289)
  • Mental disorders (290 319)
  • Diseases of the circulatory system (390 459)
  • Diseases of the respiratory system (460 519)
  • Diseases of the skin and subcutaneous tissue (680 709)
  • Musculoskeletal system and connective tissue (710-739)
  • Injury and poisoning (800 999).
Author Conclusion:
  • Findings from the study indicated no significant association between deglutition and malnutrition when difficulties regarding energy were taken into account
  • Priority needs to be placed on the early detection of eating difficulties, especially within the component energy and the cause of these difficulties in order to implement intervention strategies to prevent sequels such as malnutrition
  • Structured observations of eating difficulties, including energy, seem to have a potential for planning and providing suitable nursing interventions to maintain or improve nutritional status.
Funding Source:
Reviewer Comments:
  • Nutritional status was assessed using the Subjective Global Assessment tool
  • Patients were assigned to groups based on the Katz activities of daily living instrument
  • Four groups were different at baseline for age, gender, Katz activities of daily living score for total dependence, BMI, SGA score and length of stay
  • Authors note that the instrument used for the structured observations was not tested for inter-rater reliability.   
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? Yes
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) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? No
  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? ???
  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? N/A
  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? ???
  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? 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? 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? 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? Yes
  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? Yes
  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)? Yes
  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