UWL: Screening and Assessment Methods (2009)

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

To evaluate the prevalence of undernutrition among patients admitted to a geriatric unit using anthropometric and biochemical parameters in addition to the clinical, social and demographic histories.

Inclusion Criteria:

Admission to the Hospital do Instituto de Previdencia dos Servidores do Estado de Mineas Gerais. 

Exclusion Criteria:

None specified.

Description of Study Protocol:


Recruitment methods were not specified. 


Cross-sectional sample of the hospital population. 

Statistical Analysis:

  • Fisher's and chi-square were used to evaluate the distribution of category variables according to gender
  • Means were compared with Student's T-tests and the Mann-Whitney non-parametric test
  • Logistic regression was used for analysis of factors associated with undernutrition.  


Data Collection Summary:

Timing of Measurements

Measurements were made during the hospital stay.

Dependent Variables

Prevalence of undernutrition based on anthropometric data (weight, height, BMI, calf circumference) and biochemical indicators (total serum cholesterol, serum albumin, lymphocyte count). 

Independent Variables

Social demographic and clinical characteristics such as health problems, functional and cognitive abilities and use of medication collected through medical records or through interviews with subjects or care-givers. 

Description of Actual Data Sample:
  • Initial N: 197 patients
  • Attrition (final N): 197 (57 males)
  • Age: 79.3±8.74 years for males and 81±8.36 years for females.

Other Relevant Demographics

  • 89.3% lived with family, 8.2% lived alone and 2.6% lived in a institution
  • Most were homeowners
  • 31.6% were married and 51% were widowed
  • 63.4% had a maximum of four years of schooling while 18.3% had eleven or more years of schooling
  • Just over 23% were dependent, approximately 26% were partially dependent and 45.8% were independent
  • 63% percent suffered some cognitive impairment and about 60% were depressed
  • Just over 70% were edentulous, with 38.3% having dental prosthesis and 18.3% having an inappropriate dental prosthesis 
  • Only 7.1% had caries but almost 70% had xerostomia. 


Mean weight for males was 54.88±13.58kg and 50.77±6.08kg for women. Mean height for men was 1.63±0.08 meters and 1.49±0.08 meters for women. Mean BMI was 20.51±4.23kg/m2 for men and 22.60±6.55kg/m2 for women.   


Belo Horizonte, Brazil.


Summary of Results:

Anthropometric Data and Biochemical Parameters, Distributed by Gender, of the Elderly Population Treated at the Geriatric Unit of the Hospital do Instituto de Previdencia dos Servidores do Estado de Mineas Gerais, Belo Horizonte, Brazil





  Total   P

BMI (WHO) (kg/m2)




% N %  
≤ 18.49 20 36.4 37 27 57 29.7  

18.5 to 24.99




43.1 84 43.8  
≥25.0 10 18.1 41 29.9 51 26.5  
Total 55 100 37 100 192 100 0.20
BMI (NSI) (kg/m2)              
<22 36 65.4 69 50.4 105 54.7  
22 to 27 15 27.3 41 29.9 56 29.2  
>27 4 7.3 27 19.7 31 16.1  
Total 55 100 137 100 192 100 0.06

Calf circumference (cm)




>31 24 42.9 59 42.8 83 42.8  
 ≤31 32 57.1 79 57.2 111 57.2 0.99
Serum albumin (g per L)              
35 to 50 14 24.6 34 24.5 48 24.5  
28 to 35 23 40.4 71 51.1 94 48  
21 to 27 16 28.1 30 21.6 46 23.5  
<21 4 7.0 4 2.9 8 4.1  
Lymphocyte count (mm-3)              
>1,800 17 29.8 40 28.6 57 28.9 0.99
1,200 to 1,800 19 33.3 47 33.6 66 33.5  
800 to 1,199 12 21.0 29 20.7 41 20.8  
 <800 9 15.8 24 17.1 33 16.8  
Total serum cholesterol (mmol per L)              
<3.36 23 41.1 26 19.0 49 25.4 <0.0001
3.36 to 4.13 17 30.4 23 16.8 40 20.7  
≥4.14 16 28.6 88 64.2 104 53.9  

Other Findings

  • The incidence of undernutrition among subjects was 29.7% with 43.8% well nourished, using the WHO criteria
  • Using the NSI criteria, 54.7% of patients were undernourished with 29.2% well nourished
  • Calf circumference less than 31cm was significantly associated with undernutrition (P<0.0001) irrespective of the classification system used and thus may be a strong marker for undernutrition
  • In contrast, total serum cholesterol level more than 4.14mmol per L was identified as a protective factor against undernutrition (P=0.01).
Author Conclusion:

The prevalence of undernutrition among the hospitalized elderly in Brazil is very high. The measurement of calf circumference is a non-invasive and economical aproach that can facilitate evaluation of the nutritional status of elderly individuals. 

Funding Source:
University/Hospital: Hospital do Instituto de Previdencia dos Servidores do Estado de Minas Gerais
Reviewer Comments:

Inclusion and exclusion criteria and recruitment methods were not specified. The results of screening tools were not measured against any "gold" standard. No intake data were collected.   

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? ???
  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? No
  2.2. Were criteria applied equally to all study groups? ???
  2.3. Were health, demographics, and other characteristics of subjects described? No
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
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? 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? 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? Yes
  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? No
  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? No
  10.2. Was the study free from apparent conflict of interest? Yes