EAL

UWL: Association With Outcomes (2009)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To determine the nutritional status of elderly persons in Taiwan
To compare the nutritional status of elderly persons who are dependent in at least one activity of daily living (ADL) with the nutritional status of elderly persons who are independent in ADLs
To determine the relationship between functional status and nutritional assessment indices in the elderly.

Inclusion Criteria:

Non-institutionalized
65 years or older
Resident of Taichung, Taiwan
Participant in Taichung community and senior citizen centers.

Exclusion Criteria:

Presence of edema or dehydration as ascertained through examination by a physician.

Description of Study Protocol:

Recruitment

Subjects were recruited from local community and senior citizen centers.

Design

Cross-sectional studies.

Blinding Used

None reported.

Statistical Analysis

Sigma Stat software, version 1.0, was used. Student T-tests were used to determine the difference in subjects' anthropometric measurements to compare the two groups. Some data was skewed rather than normally distributed; therefore, a Mann-Whitney rank test was used to examine differences in hematological, biochemical and nutrient intake between the two groups. For categorical response variables, chi-square or Fischer exact test were used. Multiple regression was used to examine relationships between functional status and nutritional status.

Data Collection Summary:

Timing of Measurements

Functional status interview as demographic and health questionnaires, body weight, height, triceps skinfold thickness (TSF) and mid-arm circumference (MAC) were obtained on enrollment
24-hour diet recall and food frequency questionnaire was obtained
Following dietary intake survey completion, fasting venous blood samples were obtained to assess hemoglobin, hematocrit, mean corpuscular volume (MCV), red blood cell (RBC), white blood cell (WBC), albumin, total cholesterol and triglycerides.

Dependent Variables

Functional status: Dependence (responding yes to needing help to perform one or more of the following ADLs: Bathing, dressing, grooming, toileting, walking or moving about, feeding, shopping, food preparation and traveling outside the home)
Nutritional Risk Index (NRI) malnutrition score: NRI [(15.9 x albumin grams per Liter) +41.7(present weight divided by usual weight)]. NRI is more than 100, no malnutrition; 97.5 to 100, mild malnutrition; 83.5 to less than 97.5, moderate malnutrition; less than 83.5, severe malnutrition.

Independent Variables

Age
Marital status
Education
Living situation
Smoking status
Alcohol drinking
Drug use
Chronic disease
Body mass index
TSF, MAC, MAMC, AMA
Hgb, HCT, MCV, RBC, WBC, albumin, cholesterol, triglycerides
Dietary intake of energy, carbohydrate, fat, protein, vitamin A, vitamin C, thiamin, riboflavin, niacin, calcium, iron, sodium and fiber.

Description of Actual Data Sample:

Initial N: 96 (40 males and 56 females)
Attrition (final N): 96
Age: 65 to 80 years; mean age of 70.5±4.1 years for functionally dependent and 69±3.6 years for non-functionally dependent
Ethnicity: Taiwanese (assumed)
Location: Taichung, Taiwan. Data collection site was not specified.

Demographics and Health Characteristics of Subjects

No statistically significant differences between groups in the characteristics below were reported, i.e., groups were similar in the characteristics below.

Characteristic	Functionally Dependent (N=42) 13 Men, 29 Women	Without Fx Dependence (N=54) 27 Men, 27 Women
Single	0	1
Married	27 (64.3%)	42 (77.8%)
Widowed/separated/divorced	15 (35.7%)	11 (20.4%)
No education	14 (33.3%)	16 (29.6%)
Elementary education	12 (28.6%)	19 (35.2%)
Junior high or more	14 (33.4%)	19 (35.2%)

Live alone	5 (11.9%)	3 (5.6%)
Live with couple only	9 (21.4%)	8 (14.8%)
Live with family	27 (64.3%)	41 (75.9%)
Other living situation	1 (1.9%)	2 (3.7%)

Number (%) of smokers	4 (9.5%)	5 (9.3%)
Alcohol consumers (%)	6 (14.3%)	13 (24.1%)
Users of prescription or OTC medications	25 (59.5%)	21 (38.9%)
Reported chronic disease (%)
Osteoporosis	19 (45.2)	24 (44.4)
Hypertension	17 (40.5)	21 (38.9)
Heart disease	13 (31)	7 (13)
Stroke	1 (1.9)	0
Diabetes mellitus	5 (11.9)	5 (9.3)
Anemia	7 (16.7)	10 (18.5)
Lung disease	2 (4.8)	4 (7.4)
Renal disease	5 (11.9)	3 (5.6)
Two or more chronic diseases	7 (16.7)	5 (9.3)

Height (cm)	155.4±8.1	158.4±6.8
Weight (kg)	59.6±9.0	60.0±8.8
BMI (kg/m²)	24.7±3.2	23.9±2.9
TSF (mm)	17.4±6.2	15.5±6.9
MAC (cm)	27.9±2.6	28.2±2.9
MAMC (cm)	22.4±2	23.5±3.1
AMA	40.4±7.3	43.9±10.0

No significant differences between groups in measured hematological and biochemical parameters with the exception of triglycerides. The functionally dependent subjects had significantly (P=0.0037) higher serum triglycerides than non-dependent subjects (148.8±88.9 vs. 105.6± 58.6).

Summary of Results:

Other Findings

No statistically significant differences in nutrient intake between the two groups. However, the elderly in both groups had signficantly less mean energy intake (1,589kcal and 1,700kcal for dependent and independent groups, respectively) than the RDNA for Taiwan of 1,800kcal per day for men and 1,600kcal per day for women.

All subjects in the functionally dependent group were independent in bathing, dressing, grooming, toileting and feeding.

Subjects reporting less than 75% of recommended iron intake were more likely to be functionally dependent (P=0.0409).

Functionally dependent subjects tend to use more medications (P=0.0421) and have higher serum triglycerides (P=0.0093) than non-dependent subjects.

Functional status was significantly and negatively correlated with chronic disease (R=-0.244, P=0.016).

No significant difference in NRI score or prevalence of malnutrition per NRI was seen between the dependent and independent groups.

No significant relationship was found between NRI and any of the independent variables with the exception of hematocrit.

NRI was positively correlated with hematocrit (R=0.22, P=0.034).

No correlation was observed between albumin level and functional status.

Author Conclusion:

Although the subjects with functional dependence exhibited poorer nutritional status on the basis of the anthropometric, hematological, biochemical, nutrient intake and NRI than functionally independent subjects, these differences were not statistically significant. Functionally dependent elderly were at greater risk for inadequate iron intake and abnormal serum triglycerides. They were also at greater risk for chronic diseases and had a greater need for medications.

Funding Source:

Other:

Reviewer Comments:

Subject recruitment was not described in detail. This is why Number Two in the quality checklist received a "No".

One of the researchers, a RD, may have helped to collect 24-hour recall food records and food frequency questionnaire

Researchers describe the study participants as highly illiterate with large variation in reported nutrient intake (e.g., 573kcal per day to 3,191.9kcal per day). There is a potential for recall bias in this population due to high probability of health illiteracy.

Functional dependence was not precisely defined. Poor appetite, difficulty swallowing, chewing, mouth and tooth problems were included in the ADL interview. It's unclear from Table One, p. 136, which of these problems qualified as "dependence" in ADL.

There was no mention of withdrawals from the study. For Number Four on quality checklist, the assumption is made that 96 subjects enrolled in the study and all 96 completed the study.

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?	N/A
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	???
2.	Was the selection of study subjects/patients free from bias?		No
	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?		Yes
	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?	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?	Yes
	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.)	Yes
	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?	N/A
	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%.)	???
	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?		No
	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?	No
	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?	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?	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?	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?	N/A
	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)?	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