UWL: Screening and Assessment Methods (2009)

Study Design:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:
  • To study the energy and nutrient intake of elderly nursing home residents with multiple diagnoses and make a comparison with the Swedish Nutrition Recommendations
  • To follow the intake of these elderly individuals over time through repeated assessments of food intake
  • To compare energy intake with the patients' body-weight development during the study
  • To correlate two-year mortality after the study to parameters measured during the time of the study:
    • Age
    • Sex
    • Body weight
    • Fat-free mass
    • Energy intake
    • Activities of daily living.
  • To test whether individual nutritional intervention can help nursing home residents with nutritional problems. 
Inclusion Criteria:

None specifically mentioned.

Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:
  • Recruitment: 76 elderly nursing home residents with multiple diagnoses from April 2000 to October 2001 were studied. Recruitment methods were not described.
  • Design: Longitudinal study.  


  • Information about a risk situation and the need for awareness, along with encouragement to the resident and the ward staff regarding the importance of a proper diet
  • Fortification of the normal diet
  • Oral fluid supplements
  • Adjustment of food consistency
  • Energy-reduced diet.

Statistical Analysis

  • Comparisons between groups were done using Student's T-test, as were longitudinal comparisons within groups
  • Cox proportional hazards model was fitted to investigate how mortality was affected by age, gender, body weight, fat-free mass, energy intake and ADLs
  • A mixed linear model was used to investigate if weight and energy intake were correlated on an individual level
  • Energy intake and weight were measured on three occasions for each individual and therefore a longitudinal model could be used to model this relationship
  • A model with random intercept and random slope was fitted.
Data Collection Summary:

Timing of Measurements

  • Weighed assessment of food intake repeated three times during 1.5 years
  • Analysis of body composition at baseline
  • Recording of body weight every three months
  • Analysis of two-year mortality.

Dependent Variables

  • Energy and nutrient intake determined by weighed food intake analysis on five consecutive weekdays carried out by a nutritionist with the assistance of the nursing home staff
  • Body composition measured through skinfold thickness (biceps, triceps, subscapular and iliac crest)
  • Body weight measured on digital chair scale
  • Resting metabolic rate measured with indirect calorimetry using Delta Trac metabolic monitor
  • Activities of daily living examined according to the Katz Index.

Independent Variables

  • Information about a risk situation and the need for awareness, along with encouragement to the resident and the ward staff regarding the importance of a proper diet
  • Fortification of the normal diet
  • Oral fluid supplements
  • Adjustment of food consistency
  • Energy-reduced diet.


Description of Actual Data Sample:
  • Initial N: 76 residents
  • Attrition (final N): 52 residents had three complete dietary assessments, 79% female
  • Age: Mean age 84±7 years 
  • Other relevant demographics: Mean body weight stable at 61kg
  • Location: Sweden. 
Summary of Results:



Survivors (N=25) Non-Survivors (N=27)

Statistical Significance of Group Difference

Age (Years)

Time in Nursing Home (Months)
ADL Score (Katz)
Weight (kg)
Fat-Free Mass (kg)
Fat-Free Mass (%)
Fat Mass (kg)
Fat Mass (%)

Energy Intake, RMR




Other Findings

  • Mean energy intake at baseline was 1,501kcal per day (25kcal per kg per day) and mean protein intake was 53g per day (0.9g per kg per day)
  • Mean intake of vitamin D, vitamin E, folic acid, selenium and dietary fiber was less than 60% of recommended
  • At the second assessment intake of energy and many nutrients was higher than at baseline, but at the third assessment intake had decreased
  • There was no correlation between energy intake and body weight over time
  • Two-year mortality was 52%
  • Male gender and low body weight constituted an increased risk of mortality
  • Comparing survivors and non-survivors showed that the mean body weight was 9kg higher in the survivors throughout the study (57kg vs. 66kg, P=0.04)
  • This group had a relatively lower fat-free mass and higher-fat mass than the non-survivors (P<0.01)
  • The difference in body composition was only seen in females, possibly due to the low number of males
  • The survivors had higher intakes of most nutrients but this reached significance only for a few of them
  • The non-survivors had significantly higher intakes of sucrose.
Author Conclusion:
  • From this study, we can conclude that intake of energy and nutrients is low in many nursing home residents and this could partially explain the high prevalence of malnutrition in this group
  • More research is needed regarding reasons for the low intake
  • In this study, it was not caused by a poor supply of food. Possible explanations for the low intake could be quality and choice of food, meal time frequency, effects of disease and medications on appetite and energy metabolism and social, psychological and environmental factors.
Funding Source:
Other: Not mentioned
Reviewer Comments:
  • Inclusion criteria and exclusion criteria and recruitment methods were not described
  • Incomplete data for many subjects.
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? No
  2.2. Were criteria applied equally to all study groups? ???
  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? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  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? 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? N/A
  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? Yes
  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? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  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? Yes
  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? Yes
  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? Yes
  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? 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? 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