UWL: Screening and Assessment Methods (2009)

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

To assess which factors contribute to the high level of nutritional risk detected by the Mini Nutritional Assessment (MNA) test in institutionalized older women, through complete nutritional assessment.

Inclusion Criteria:

All older women living at two private nursing homes were asked to participate.

Exclusion Criteria:

Presence of an acute illness at the beginning of the study.

Description of Study Protocol:


  • Older women living in two private nursing homes in Granada, Spain
  • All women were asked to participate in the study, so participation was voluntary.


Cross-sectional study. 

Statistical Analysis

  • Kolmogorov-Smirnov and the Levene tests were used to check the normal distribution of variables and the homogeneity of variances
  • Statistical analyses of the data were performed by ANOVA or the Kruskal-Wallis test
  • Pearson's or Spearman's correlation coefficients were used to measure the association between variables.
Data Collection Summary:

Timing of Measurements

One-time measurements.

Dependent Variables

High level of nutritional risk.

Independent Variables

  • Spanish version of Mini Nutritional Assessment was used as an assessment tool to detect nutritional risk
  • Anthropometric measurements
    • Weight and height measured with precision scale and stadiometer
    • Body mass index
    • Triceps and subscapular skinfold thicknesses measured with calipers
    • Mid-arm and calf circumferences measured with measuring tape.
  • Quantification of dietary intake (seven-day weighed food records analyzed with nutritional software)
  • Clinical and functional evaluations
    • Number of drugs
    • Katz index
    • Red Cross cognitive scale.
  • Biological markers (fasting blood samples analyzed for albumin, prealbumin, transferrin, and lymphocyte counts).
Description of Actual Data Sample:
  • Initial N: 107 women were interested
  • Attrition (final N): 89 older women completed the study; five had acute illness, three died and 10 did not participate for personal motives
  • Age: Range, 72 years to 98 years
  • Ethnicity: Not mentioned.
  • Other relevant demographics
    • All subjects had low to medium socioeconomic status (81.1% had monthly incomes equal to or lower than the minimum wage)
    • 80.9% had no schooling but could read and write
    • Only 2.2% had higher education.
  • Location: Granada, Spain.
Summary of Results:

Significant Differences Between Classifications of Older Women (P<0.05)


Total (N=89) Malnourished by MNA (N=5) At Risk of Malnutrition by MNA (N=56) Well-Nourished by MNA (N=28)

Mid-Arm Circumference (cm)


Red Cross Cognitive Score





Energy Intake (kcal)
Fat Intake (g)

Other Findings

  • Mean MNA score was 21.6±3.2
  • 7.9% (N=5) of the older women were malnourished (MNA score, 14.5±1.4), 61.8% (N=56) were at risk of malnutrition (MNA score, 20.6±2.1) and 30.3% (N=28) were well-nourished (MNA score, 25.0±1.1) according to the MNA test
  • The mean values of the anthropometric parameters were acceptable for an older Spanish population and the presence of severe malnutrition was low: 10.1% according to the BMI (under 21kg per m2) and between 3.4% and 6.7%, if triceps skinfold thickness (under 11mm), subscapular skinfolds (under 8.7mm) and mid-arm circumference (under 21.5cm) are considered
  • 100% of the women had normal serum albumin (over 3.5mg per dL), 22.4% had low serum transferrin (under 250mg per dL), 24.7% had low serum prealbumin (under 18mg per dL) and 11.2% had a lymphocyte count lower than 1,200 per mcL
  • Mean energy intake was 1,597±197kcal per day, representing 93.9% of the Spanish recommendation for older women
  • The caloric profile of the diet was adequate (14% protein, 31% lipids, 55% carbohydrates), as was the protein supply according to body weight, however a high percentage of the women had deficient intakes (less than 66% of the recommended dietary intakes for Spanish people) of vitamin B6 (33%), folate (28%), vitamin E (89%), magnesium (53%), iron (13%) and zinc (91%).
Author Conclusion:
  • The MNA test is a useful instrument to identify older people at risk of malnutrition in an institutionalized setting with a health status considered to be acceptable
  • The main factors determining nutritional risk are related to risk situations (global evaluation) and self-perception of health (subjective assessment). However, dietary intake showed that even though subjects had adequate calorie profiles, diets with low energy content had important nutritional deficiencies in zinc (91%), magnesium (53%), iron (13%), vitamin E (89%), vitamin B6 (33%) and folate (28%), all of which are micronutrients involved in the state of health of the elderly.
  • Although the MNA test was designed to detect protein-energy malnutrition, in an institutionalized population with an adequate nutrition status according to anthropometric and biochemical parameters, it is important to develop a diet that includes more of the necessary micronutrients
  • Development of malnutrition is a continuous process that begins with inadequate food intakes and continues with changes in biochemical indices and body composition and proper nutrition may contribute to the health and well-being of the elderly and to their ability to recover from illness.
Funding Source:
Other: Not reported
Reviewer Comments:

Women from only two nursing homes in Spain.

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? 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? 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? Yes
  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? 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? N/A
  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? 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)? 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? No
9. Are conclusions supported by results with biases and limitations taken into consideration? ???
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? No
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