Unintended Weight Loss in Older Adults

Healthy Non-Obese Older Adults (2010-2012)


Gariballa S, Forster S.  Energy expenditure of acutely ill hospitalized patients.  Nutr J 2006;5:9.

PubMed ID: 16569253
Study Design:
Cohort Study
B - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

To measure energy expenditure of acutely ill elderly patients in hospital and following discharge in the community.

Inclusion Criteria:
  • Hospitalized acutely ill elderly patients
Exclusion Criteria:
  • Patients suffering from severe medical or psychiatric illness, morbid obesity, moderate to severe dementia or difficulty with swallowing
Description of Study Protocol:


Consecutive hospitalized acutely ill elderly patients were recruited.  This study was conducted over an 8 month period.

Design:  Cohort Study

Blinding used (if applicable):  not applicable 

Intervention (if applicable):  Energy expenditure measured in hospital and after discharge. 

Statistical Analysis

Repeated measures ANOVA was used to test within and between subject differences.  Differences between groups at baseline were adjusted for history of drug intake, severity of acute illness, smoking and alcohol consumption and chronic illness.  Mann-Whitney U test, Partial and Spearman's rank correlation were also used.  Forward stepwise multiple regression analysis was performed to determine the predictive importance of baseline variables (age, gender, body weight, BMI, drugs and CRP concentration) for measured energy expenditure.

Data Collection Summary:

Timing of Measurements

35 had energy expenditure studied in the hospital on 2 occasions (within 72 hours of admission and 5 days later), and 20 had energy expenditure measured in hospital and at 6 weeks in the community.

Dependent Variables

  • BMR measured by indirect calorimetry
  • TEE calculated as 1.3 x BMR + 10% for thermic effect of food
  • Height, weight, BMI 
  • Triceps skinfold thickness
  • Mid-upper arm circumference
  • C-reactive protein concentration measured by modified latex-enhanced immuno-turbidimetric assay

Independent Variables

  • Hospitalization or discharged to community

Control Variables

  • Age
  • Gender
  • BMI
  • History of drug intake
  • Severity of acute illness
  • Smoking and alcohol consumption
  • Chronic illness
Description of Actual Data Sample:

Initial N: 63 hospitalized patients.  8 were used to study the indirect calorimeter.  35 had energy expenditure studied in the hospital on 2 occasions (within 72 hours of admission and 5 days later), and 20 had energy expenditure measured in hospital and at 6 weeks in the community.

Attrition (final N):  as above

Age: mean age 76 +/- 9 years

Ethnicity: not mentioned

Other relevant demographics:

Anthropometrics:  baseline differences between groups not reported

Location:  South Yorkshire, United Kingdom


Summary of Results:


  Baseline (n=55) Day 5 (n=32)

6 weeks in the community (n=17)

Age 76 +/- 9 --


Gender, female (%) 8 (40%) -- --
Chronic disease/patient 1.5 -- --
Drug/patient 2.1 -- 2.1
Body weight (kg) 70 +/- 13 -- 72 +/- 12
BMI 26.3 +/- 5.5 -- 26.4 +/- 5.5
MUAC (cm) 29.3 +/- 2.9 -- 29.7 +/- 1.9
TSF (mm) 19 +/- 7.8 -- 16.3 +/- 4.4
Thyroid stimulating hormone (normal 0.38 - 4.7 mu/L) 1.6 +/- 0.75  -- 3.3 +/- 6.9

C-reactive proteins (normal <6 mg/L)

22 +/- 28

12 +/- 18

5 +/- 7

Energy expenditure (BMR, kcal/day)

1403 +/- 346

1317 +/- 446

1159 +/- 445

Other Findings

Men had higher basal energy expenditure values compared to women however the difference was not statistically significant (1405 +/- 321 kcal for men, 1238 +/- 322 kcal for women, mean difference 166 kcal, 95% CI:  -17 to 531, p = 0.075). 

After adjusting for age, gender and BMI both medication and C-reactive protein concentrations showed significant correlation with measured energy expenditure in the hospital (r = -0.36 and r = -0.29, both p < 0.05).

However, in a multivariate analysis for all 63 subjects combined CRP explained most of the variance in BMR in hospital.

The Harris-Benedict equation predicted within +/- 10% measured BMR in only 47% of individuals in hospital.

Author Conclusion:

In conclusion, this study showed that acute inflammation and medications during acute illness might affect energy expenditure of hospitalized older people.  Further studies on the impact of acute illness on the timing, macronutrient balance and energy provision of nutritional support of older people is long overdue.

Funding Source:
University/Hospital: University Sheffield (UK), United Arab Emerates University
Reviewer Comments:

Determination of those measured in hospital vs community not described, not clear if these groups were similar at baseline.  Total energy expenditure calculated, not measured.

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? 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? ???
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) No
  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? ???
  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? Yes
  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.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? Yes
  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? 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? 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? ???
  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