Unintended Weight Loss in Older Adults

UWL: Screening and Assessment Methods (2009)

Citation:

Woo J, Chumlea WC, Sun SS, Kwok T, Lui HH, Hui E, Fang NY, Fan YP. Development of the Chinese Nutrition Screen (CNS) for use in institutional settings. J Nutr Health Aging. 2005; 9(4): 203-210.

PubMed ID: 15980920
 
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 develop and validate a Chinese nutrition screening tool for elderly Chinese subjects in the institutional setting.

Inclusion Criteria:

Age greater than 65 years.

Exclusion Criteria:

Receiving parenteral and enteral nutrition.

Description of Study Protocol:

Recruitment

Participants were recruited from hospitals and old age homes for the reliability study.

Design

Cross-sectional study.

A 14-question survey was developed by the investigators and tested for reliability using the test-retest method in a population of 200 men and 200 women at two different sites. A modified tool containing 16 questions was developed and validated in a group of 867 participants from two different sites. 

Statistical Analysis

  • Reliability: Intra-class correlation coefficient and Kappa coefficients
  • Validity: Degree of concordance between three groups of scores using Kappa coefficients and Cronbach's alpha to evaluate CNS scores with physician nutrition assessment. 

 

Data Collection Summary:

Timing of Measurements

  • The CNS was administered twice to each subject and each subject had their nutritional status assessed twice by one of two physicians
  • The CNS was administered independent of the physician assessments and these second tests occurred within 24 hours to one week after the first
  • These repeated observations determined the reliability of the CNS and the physician assessments.  

Dependent Variables

  • Nutritional risk
  • Physician assessment for comparison.

Independent Variables

  • Age
  • Chinese health care system, diet, food customs and culture.

 

Description of Actual Data Sample:
  • Initial N: The screening tool was developed using a sample of 200 men and 200 women; the validation sample consisted of 340 men and 527 women 
  • Attrition (final N): As above
  • Age: Men had a mean of 77±7.2 years; women had a mean of 79.2±8.2 years
  • Ethnicity: Chinese
  • Anthropometrics: The Shanghai group was younger and heavier than the Hong Kong group
  • Location: Hong Kong and Shanghai, China.
Summary of Results:

 

Characteristics of the Subjects

 
 
N
Mean (SD)
 
 
Male
Female
Male
Female
Age (year)***
Hong Kong
168
360
78.5 (7.7)+++
81.9 (7.7)+++
 
Shanghai
172
167
75.6 (6.5)
73.4 (5.7)
 
Total
340
527
77.0 (7.2)
79.2 (8.2)
Weight (kg)***
Hong Kong
168
360
57.9 (11.3)++
49.8 (10.4) +++
 
Shanghai
172
167
61.5 (11.4)
54.6 (9.7)
 
Total
340
527
59.7 (11.5)
51.3 (10.5)
Height (cm)***
Hong Kong
168
360
161.1 (7.3)+++
148.5 (6.7)+++
 
Shanghai
172
167
165.9 (7.3)
154.6 (5.4)
 
Total
340
527
163.6 (7.6)
150.4 (6.9)
BMI (kg/m2)
Hong Kong
168
360
22.3 (4.2)
22.5 (4.4)
 
Shanghai
172
167
22.3 (3.9)
22.8 (3.8)
 
Total
340
527
22.3 (4.1)
22.6 (4.2)
Hemoglobin (g per L)
Hong Kong
39
45
12.1 (2.3)
12.0 (2.0)++
 
Shanghai
171
167
12.0 (2.3)***
11.2 (2.0)
 
Total
210
212
12.1 (2.3)
11.4 (2.2)
Albumin (g per L)
Hong Kong
 39
 45
31.3 (6.7)*
34.6 (6.2)
 
Shanghai
170
167
39.1 (9.8)
37.5 (5.8)
 
Total
209
219
37.6 (9.8)
36.9 (6.0)

SD: Standard deviation; P<0.001***, P<0.01**, P<0.05* by T-test, comparing between sex, same country; P<0.001+++, P<0.01++, by T-test comparing between country, same sex.
Descriptive Statistics of Chinese Nutrition Scores Grouped by Physician’s Classification by Center and Gender

Center
Sex
Nutritional Status
N
Mean
SD
Hong Kong
 
 
 
 
 
 
Men
Overall
168
22.7
3.7
 
 
Malnourished
22
17.9
3.4
 
 
At Risk
39
21.9
3.9
 
 
Normal
107
23.9
2.7
 
Women
Overall
360
22.9
3.5
 
 
Malnourished
42
21.0
3.8
 
 
At Risk
63
21.9
4.1
 
 
Normal
255
23.5
3.0
Shanghai
 
 
 
 
 
 
Men
Overall
172
20.5
3.7
 
 
Malnourished
12
14.3
2.6
 
 
At Risk
51
17.7
2.1
 
 
Normal
109
22.5
2.6
 
Women
Overall
167
19.6
4.3
 
 
Malnourished
12
13.8
2.1
 
 
At Risk
71
17.9
1.9
 
 
Normal
84
21.9
2.6
 
Women
Overall
867
21.8
3.8
 
 
Malnourished
88
18.4
4.4
 
 
At Risk
224
19.7
3.7
 
 
Normal
555
23.1
2.9

Other Findings
  • A BMI cut-off score of 18.5 was found to have a sensitivity of 0.84 and specificity of 0.79 for detecting malnutrition
  • The CNS were compared with physician assessments based on two groups, normal or at risk with less than normal nutritional status, had kappa coefficients of 0.5 overall and were as high as 0.8 in Shanghai
  • CNS was able to identify about 90% of all persons with normal nutritional status and had about a 60% chance of correctly identifying a person at risk with a less than normal nutritional status. 
Author Conclusion:

The CNS can be used in a two-group classification to identify those who have a normal nutritional status (CNS of 21 or higher). Those who do not fall into this group should have their nutritional status evaluated in greater detail (CNS score 20 or less). 

Funding Source:
Industry:
Nestec Ltd, Switzerland
Pharmaceutical/Dietary Supplement Company:
Reviewer Comments:

The study would have been stronger if inter-rater reliability between sites were demonstrated. Authors note the limitation of biochemical measurements not being included in the CNS. 

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? Yes
  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? ???
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) ???
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? ???
  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? No
  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.) No
  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? N/A
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? ???
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? N/A
  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? ???
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)? No
  8.6. Was clinical significance as well as statistical significance reported? ???
  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? ???
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? ???