UWL: Association With Outcomes (2009)

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

To describe nutritional risk in community-dwelling elderly people (65 years and older) and discuss issues associated with this problem.

Inclusion Criteria:
  • Community dwelling older adults
  • Under the care of a health care provider
  • Age 65 years and older
  • Identified as having a risk factor for poor nutritional status BMI less than 24kg/m2.


Exclusion Criteria:
  • Diagnosis of dementia (Folstein Mini-Mental Examination score of 23 or less)
  • Congestive heart failure
  • Cancer
  • Bedridden or unable to stand for measurement of height
  • Currently hospitalized
  • Hospitalized in the past 30 days
  • Residing in a skilled nursing facility
  • Non-English speaking.


Description of Study Protocol:


Letters were sent to health care providers in three VA outpatient clinics. A flyer was posted in the clinical and medical offices as well as areas frequented by older adults, such as senior centers.  


Cross-sectional, descriptive Study. 

A single interview lasting one to 1.5 hours was conducted in the participant's house. The interview included sociodemographic factors (age, sex, ethnicity, conjugal status, education, religion, yearly income, social support and type of residence); current lifestyle (current smoking status, use of alcoholic drinks and physical activity); health indicators (number of medical diagnoses and medications); health service indicators (doctor visits and hospitalizations in the last 12 months); Geriatric Depression Scale (GDS); DETERMINE Your Nutritional Health Checklist and Nutrition Screening Initiative (NSI) Levels I and II (eating habits, living environment, functional status and clinical features); anthropometric measurement (weight, height, midarm circumference, triceps skinfold and BMI); and a semistructured interview.  

Statistical Analysis

  • Descriptive statistics characterized the study sample 
  • A logistic regression analysis estimated the independent association of self-report of having an illness or condition that changed the kind and amount of food eaten; having lost 10 lb., without wanting to, in the last six months.


Data Collection Summary:

Timing of Measurements

A single interview was conducted in the patient's home at a convenient time after consent was obtained. 

Dependent Variables

  • Nutritional risk
  • Low weight.

Independent Variables

  • Depression and mental state
  • Nutrition.

Control Variables

Demographic data.

Description of Actual Data Sample:
  • Initial N: 130 (71 females)
  • Attrition (final N): 130
  • Age: 78±2.3 years
  • Ethnicity: 84% white.

Other Relevant Demographics

  • Married: N=54
  • Home owner: N=86
  • Greater than high school education: N=55
  • Lives on income of less than $6,000 a year: N=12.


  • Height (mean ± SD): 66.56±3.65
  • Weight (mean ± SD): 134.37±21.57
  • BMI (mean ± SD): 21.2±2.3; BMI less than 19, N=15.


Outpatient Veteran's Administration clinics in counties in the western United States. 


Summary of Results:


Demographic, Social and Medical Characteristics of the Subjects (N=130)


Percent (N)

Standard Deviation


56 (71)


Age (range, 65 to 93 years)



BMI (range, 14 to 23kg/m2)



BMI less than 19kg/m2 15 19
Married 54 (70)  
Home owner 86 (112)  
Greater than high school education 55 (71)  
Veteran community (referral by VA) 42 (54)  
Ethnicity, white 64 (109)  
Lives on income of less than $6,000 per year 12 (13)  
Lives alone 36 (47)  
Current smoker 12 (15)  
Has more than one alcoholic drink per day (for women); more than two per day (for men). 10 (13)  
Exercises a minimum of three times per week for 20 minutes 46 (60)  
Number of medications (range, one to 15) 5.96 3.0
Number of medical diagnoses (range, one to 12) 4.81 2.4
Months since last seen by health care professional (range, one to 18) 3.51 3.5
Seen at office visit by physician (not by nurse practitioner or physician assistant) 95 (124)  
Weighed during medical office visit 100 (130)  

NSID score


  Moderate risk

  High risk


23 (30)

49 (63)

29 (37)

Depression Score (GDS) (range, zero to 20) 4.48 3.78
Depressed (more than score of five) 27 (35)  
Lost 10 lb in six months, unintentional 35 (45)  
Midarm muscle circumference less than 10% 5 (7)  
Triceps skinfold less than 10% 19 (25)  


NSI DETERMINE Checklist Scores



Mean ± (Standard Deviation)

Mean Checklist Score



4.65 (3.13)

Nutritional Screening Level 1 Score



6.12 (3.53)

Nutritional Screening Level 2  Score



3.96 (1.61)
NSI Level 1 Screen      
Height in inches (60 to 75)     66.56 (3.65)
Weight (range, 84 to 185)     134.37 (21.57)
BMI (range, 14 to 23)     21.24 (2.27)
BMI less than 24 100 130  
10-lb weight loss in six months? 34.6 45  
Eating habits      
Does not have enough food each day 100 130   
Eats alone 41.5 54   
Does not eat anything for one or more days per month 2.3  
Has poor appetite 30.8 40  
Is on special diet 53.8 70  
Eats vegetables two or fewer times daily 35.4 46  
Eats milk or milk products once or not at all daily 47.7 62   
Eats fruit or drinks fruit juice once a day or not at all 32.3 42  

Eats bread, cereals, pasta, rice or other grains five or fewer times daily


More than one alcoholic drink per day (for women) and more than two alcoholic drinks per day (for men) 10 13  
Has pain in mouth, teeth or gums 13.1 17  
Difficulty chewing 14.6 19  
Difficulty swallowing 9.2 12  
Living environment      
Lives on an income of less than $6,000 per person in household per year 11.5 15  
Lives alone 36.2 47  
Is homebound 4.6 6  
Is concerned about home security 3.8 5  
Lives in a home with inadequate heating or cooling 3.1 4  
Does not have a stove or refrigerator 0.8 1  
Is unable or prefers not to spend money on food 2.3 3  
Functional status       
Usually or always needs assistance with      
   Bathing 6.9 9  
   Dressing 6.9 9  


6.9 9  
   Toileting 3.8 5  
   Eating 3.1 4  
  Walking or moving about 20 26  
   Traveling (outside the home) 21.5 28  
   Preparing food  14.6 19  
   Shopping for food or other necessities 16.9 22  
Level II Screen Scores      
  Midarm circumference (range, 15 to 40)     26.49 (3.46)
  Triceps skinfold (range, five to 30)     16.23 (5.77)
  Midarm muscle circumference less than 10% 5.4 7  
   Triceps skinfold less than 10% 19.2 25  
Drug use      
   Number of medications (range one to 15)     5.96 (3.04)
  More than one alcoholic drink per day (for women); more than two per day (for men) 10 13  
Clinical features      
  Has pain in mouth, teeth or gums 13.1 17  
  Difficulty chewing 14.6 19  
  Difficulty swallowing 9.2 12  
  Angular stomatitis 0.0 0  
  Glossitis 0.0 0  
  Bone pain 23.8 31  
  Bone fracture 40.0 52  
  Skin changes 6.9 9  
Mental and cognitive status      
  Depression Scale (GDS Score)     4.48 (3.78)
  Cognitive level (Mini-Mental Status Examination)     29.12 (1.24)
Laboratory Data (N=58)      
  Serum albumin (less than 3.5g per dL) 3.1 4  
  Serum cholesterol (less than 160mg per dL) 13.8 18  

Other Findings

In a multivariate logistic regression analysis, three variables had statistically significant independent associations with severe underweight:

  • An illness or condition that changed the kind and amount of food eaten [odds ratio (OR), 4.7; 95% confidence interval (95% CI), 1.6, 13.1]
  • Unintentional weight loss of 10 pounds in six months (OR, 4.0; 95% CI, 1.5, 10.7)
  • Usually or always needs assistance with traveling outside the home (OR, 4.0; 95% CI, 1.4,11.3).


Author Conclusion:

In summary, weight loss is a sentinel event with devastating consequences among community-living elders. The goal is to modify nutritional risk factors to assure independent living, to delay institutionalization and to decrease the risk of morbidity and mortality. This study reported that older adults who were more likely to be severely underweight were those who self-reported having an illness or condition that changed the kind and amount of food eaten, unintentionally lost 10 lb in the last six months and reported needing assistance with traveling. Our knowledge of nutritional status of older adults is far from complete. There is a need for replication of our study and for further research with a larger, ethnically diverse sample to increase our understanding of the factors that contribute to unintentional weight loss and low weight and for the development of appropriate preventive and treatment strategies to improve the health of the older adult.

Funding Source:
Other: None acknowleged
Reviewer Comments:

Authors note the following limitations:

  • Lack of diversity in ethnicity and functional and socioeconomic generalizability, limiting generalizability
  • All elderly including obese, average weight and underweight were not studied
  • Study design limits causal inference.
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? 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? 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%.) N/A
  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? 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? No
  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? ???
  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)? 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? 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? No
  10.2. Was the study free from apparent conflict of interest? Yes