Unintended Weight Loss in Older Adults

UWL: Screening and Assessment Methods (2009)

Citation:

Andersson JC, Gustafsson K, Fjellstrom C, Sidenvall B, Nydahl M. Meals and energy intake among elderly women - an analysis of qualitative and quantitative dietary assessment methods. J Hum Nutr Diet. 2001;14 (6): 467-476.

PubMed ID: 11906589
 
Study Design:
Cross-sectional study
Class:
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

To analyze whether a qualitative method, in relation to traditional dietary assessment methods, was adequate to establish sufficient energy intake and energy content in separate meals in a population of elderly women.

Inclusion Criteria:
  • Elderly women age 63 years to 88 years
  • Living at home
  • Healthy according to their own definitions
  • Non-disabled regarding the meal situation
  • Have proper time orientation and mentally able based on telephone conversation.
Exclusion Criteria:

Excluded if did not meet inclusion criteria.

Description of Study Protocol:

Recruitment

Elderly women participating in the MENEW study (Meals, Eating Habits and Nutrient Intake among Elderly Women). Subject selection was conducted systematically and randomized from the Swedish population register.

Design

Cross-sectional study.

Statistical Analysis

  • Main results are presented as means with standard deviations
  • Paired T-tests were used to compare energy from quick-prepared and prepared meals.
Data Collection Summary:

Timing of Measurements

Dietary assessment using qualitative and quantitative methods. 24-hour recall performed during home visit. Three-day food diary mailed in afterwards. Repeated 24-hour recall conducted by telephone one week after the first visit.   

Dependent Variables

  • Height, weight, BMI
  • Qualitative: Food-Based Classification of Eating Episodes model was used to describe and analyze meals, based on seven different food groups
  • Quantitative: Combination of repeated 24-hour recall and a three-day estimated food diary.

Independent Variable

Age.

 

Description of Actual Data Sample:

Initial N: 570 women were invited to participate. 171 did not fulfill inclusion criteria. Of 399 remaining women, 240 refused to participate due to old age, tiredness or illness. 159 were visited by MENEW investigators. 

Attrition (final N): 135 elderly women. 24 excluded due to incomplete data.

Age: 63 years to 88 years; mean, 75.9 years±8.0 years

Ethnicity: Not mentioned

Anthropometrics: Mean BMI=25.9±4.1

Location: Three communities in mid-eastern Sweden.

 

Summary of Results:

 

Variables

Mean±SD

1997 Swedish Nutrition Recommendations

Energy, MJ

6.8±1.9

8.3 for women ≤75 years

8.2 for women ≥76 years

Protein, g 62±18  
Protein, % 16±2 10-15
Fat, g 61±21  
Fat, % 33±5 ≤30
Carbohydrate, g 200±60  
Carbohydrate, % 50±6 55-60
Alcohol, g 3±7  

Alcohol, %

1±3

≤5

Other Findings

The mean intake of energy estimated by the five-day registration was 6.8MJ±1.9MJ.

The total number of eating events was 5.22±1.04 per day.

Of all eating events, 57.4% were classified as meals and 42.6% as snacks.

Quick-prepared incomplete meals were the most common meal (22.4%), followed by quick-prepared complete meals (14.5%).

Prepared complete meals contributed the most energy during the day (28.9%), followed by quick-prepared incomplete meals (23.8%) and quick-prepared complete meals (19.3%).

On a group level, the Food-Based Classification of Eating Episodes model was useful to describe the diet among a group of elderly women; however, on an individual level, some complete meals were low or very low in energy due to small portion sizes. 

Author Conclusion:

The main conclusion of this study was that a qualitative method, such as the Food-Based Classification of Eating Episodes model, must be supplemented with a dietary assessment method giving the energy intake to ensure that it is sufficient, especially when studying groups at risk for malnutrition. This method can be used to evaluate the diet among a group of elderly women; however, looking at separate meals, some had low energy content, which depended on small portion sizes. In several cases, the women consuming meals with a low energy content also had a low total daily energy intake that might constitute a risk for poor nutritional intake. It can be concluded, therefore, that in this elderly population there is no guarantee that this qualitative method can adequately predict sufficient energy intake in individuals who could be seen as problematic cases.

Funding Source:
Government: Swedish Council for Social Research, Swedish Council for Forestry and Agricultural Research
Reviewer Comments:
  • 135 women may not be representative of the original 570 asked to participate; authors note that the women actually participating might be healthier and more inclined to reflect on food and cooking than those who refused to participate or were excluded
  • Authors note that they question the classification of "complete meals" in this population and that the problem with the method is that it does not consider amounts of food consumed.
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? No
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? 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? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? No
  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? No
  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? 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? Yes
  10.2. Was the study free from apparent conflict of interest? Yes