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UWL: Screening and Assessment Methods (2009)

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

To examine the linkages among food insecurity, nutrition risk factors, indicators of nutritional risk and unintended weight change.

Inclusion Criteria:
  • Homebound elders (aged 60 years and older) receiving Older Americans Act Nutrition Program home-delivered meals
  • Texas Lower Rio Grande Valley (Cameron, Hidalgo, and Willacy counties).
Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:


Chart review conducted in March 2003 and April 2003 of all 908 homebound elders who received OAANP home-delivered meals in the Texas Lower Rio Grande Valley provided the cross-sectional data for this analysis.


Cross-sectional study. 

Statistical Analysis

  • Demographic and nutritional health characteristics were calculated for all homebound elders
  • Proportional differences were assessed with contingency tables using the chi-square statistics
  • Multivariable logistic regression analysis (controlling for demographic characteristics) was used to examine the independent association between food insecurity and each of the nutrition risk factors and indicators of nutritional risk
  • In order to evaluate the interrelationship of food insecurity, nutritional health risk factors and indicators of nutritional risk, path analysis was performed.
Data Collection Summary:

Timing of Measurements

Complete information on demographics and nutritional health was routinely collected in October 2002 through a standardized questionnaire administered by meals program staff as part of OAANP requirements.

Dependent Variables

Nutritional risk: Assessed from a self-reported Nutritional Health Screen, which was a modified version of the NSI DETERMINE Checklist, which uses the following six risk factors for poor nutritional health, including health condition that altered the kind or amount of food (Illness); condition that makes it hard to eat (Oral); not always having enough money to buy needed food (Food Insecurity); eat alone most of the time (Alone); take at least three different prescribed drugs a day (Medications); and not always physically able to shop, cook and feed oneself (Physical Limitations).

Independent Variables

There were three indicators of nutritional risk: Eat two or fewer meals per day (Meals); eat few servings of fruit, vegetables or milk products (Servings); and experienced an unintentional weight change of 10 pounds in last six months (Weight).

Control Variables


Description of Actual Data Sample:
  • Initial N: 908 homebound elders
  • Attrition (final N): 908 elders, 62% female
  • Age: Mean 78 years (range 60 to 104 years)
  • Ethnicity: Almost 77% of participants were minority (99% Mexican American)
  • Other relevant demographics: Of 750 participants with income data, almost 68% reported a poverty-level income
  • Location: Cameron, Hidalgo and Willacy Counties, Texas.
Summary of Results:



Food Secure (N=384) Food Insecure (N=524)


Aged 60 to 74 years

30.7% 35.3% NS
Aged 75 to 84 years 43.7% 42.7% NS
Aged 85 or more years 25.5% 21.9% NS
Female 60.2% 63.7% NS
Mexican American 66.7% 82.8% <0.001
Not married 50.0% 53.0% NS
Rural 16.7% 16.4% NS
Poverty 46.3% 63.0% <0.001
Illness (illness or condition that caused a change kind or amount of food eaten) 27.6% 38.4% <0.001
Medications (takes at least three prescribed drugs per day) 81.5% 85.9% NS
Oral (condition that makes it hard to eat) 19.8% 32.8% <0.001
Alone (eat alone most of the time) 45.8% 57.1% <0.001
Physical (physically unable to shop, cook or feed oneself) 91.4% 94.8% <0.05
Meals (eat two or fewer meals per day) 29.9% 52.1% <0.001
Servings (eat few servings of fruit, milk or vegetables each day) 44.0% 65.6% <0.001

Weight (weight changed at least 10 lbs in past six months)




Other Findings

  • Almost 58% were considered food insecure
  • Almost 34% reported a change in the amount or kind of food eaten as a result of illness or health condition
  • 84% took at least three prescribed medications each day
  • 27% reported oral problems that made it hard to eat
  • 52% ate alone most of the time
  • Over 90% were physically unable to shop, cook or feed themselves
  • Almost 43% consumed two or fewer meals per day
  • Few servings (vegetables, fruit or milk) were consumed by 56% of the sample
  • Over 43% reported an unintended weight change of 10 pounds in the last six months
  • Bivariate and multivariate analyses show that homebound elders who report food insecurity are more vulnerable to poor nutritional health
  • The good fit of the model revealed that specific nutrition risk factors and indicators of nutritional risk were directly and indirectly associated with meal frequency and unintended weight change
  • In this study, unintended weight change was a function of illness, medication use, oral problems and consuming two or fewer meals each day
  • Food insecurity was directly associated with the number of meals consumed and indirectly linked through meal consumption with an unintended weight change.  
Author Conclusion:

With the heightened vulnerability for poor nutritional health among homebound elders who report food insecurity, policymakers and service providers should strengthen efforts to target individual components of nutrition risk rather than aggregate scores or categorical measures.

Funding Source:
Other: Not reported
Reviewer Comments:

All subjects from three counties in Texas. Authors note the following limitations:

  • Cross-sectional research limits the ability to determine temporality and infer causality
  • Limited by the required OAANP data: It would have been helpful to have data on duration and frequency of food insecurity; occurrence of absence of food in the house and being forced to make scarce resource decisions; and presence of depressive symptoms, loss of appetite, burden of illness, nutrition-related functional limitations and self-coping strategies.  
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? N/A
  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%.) 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? ???
  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? N/A
  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? No
  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)? 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? 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