EAL

UWL: Association With Outcomes (2009)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To identify the leading risk factors associated with non-invasive measures of poor nutritional status among elders who are age 80 years or older and still living independently in the community.

Inclusion Criteria:

Age 80 years or older
Cognitive status intact or mild intellectual impairment (four or fewer errors as measured by the Short Portable Mental Status Questionnaire)
Independent-living, community-dwelling elders living alone or with others, including those receiving one daily community meal from services such as Meals on Wheels or the Elderly Nutrition Program Community Meal Centers.

Exclusion Criteria:

Non–English-speaking
Living in nursing homes, community-based residential facilities or assisted living situations in which all meals are supplied on a daily basis as part of a housing contract
Unable to stand for measurement of height and weight.

Description of Study Protocol:

Recruitment

Participants were recruited by 21 parish nurses who had contact with community-dwelling old-old at local churches throughout Dane County, Wisconsin, a mixed rural and urban county. Parish nurses recruited participants by personally contacting them and then calling the researcher with the names and telephone numbers of potential subjects who had agreed to participate, or by distributing flyers with the researcher's phone number for direct contact by interested subjects.

Design

Cross-sectional, descriptive study.

Statistical Analysis

Multinomial logistic regression based on the maximum likelihood method was used
Unintentional weight change was collapsed into two categories: weight loss and no weight loss
All predictor variables were examined for out-of-range values, plausible means, standard deviations and out-of-range.

Data Collection Summary:

Timing of Measurements

One-hour in-home interviews were conducted during the first four months of 2002. Interviews consisted of demographic data, descriptive data, risk factor scales, measured height and weight and open-ended questions about helps and barriers to nutritional health.

Dependent Variables

Poor nutritional status as measured by body mass index (BMI) and unintentional weight loss in previous six months.

Independent Variables

Nutritional risk factors as assessed by five measures:

Social factors [the Lubben Social Network Scale (LSN)]
Physical factors [Instrumental Activities of Daily Living (IADL)]
Mental factors [Yesavage's Geriatric Depression Scale (GDS)]
Economic factors
Individual choice factors (24-hour recall nutritionally analyzed based on the modified Food Guide Pyramid for the elderly).

Description of Actual Data Sample:

Initial N: 74 community-dwelling old-old subjects referred

Attrition (final N): 68 subjects, 17 men (25%). Three refused to participate, two became too ill to be interviewed and one died prior to interview.

Age: mean age, 85.7 years; range, 80 to 102 years

Ethnicity: all were Caucasian

Other relevant demographics: 25% were obese

Location: Wisconsin.

Summary of Results:

Logistic Regression: Prediction of the Likelihood of Poor Nutrition

Variables	P value	Confidence Interval	Odds Ratio
Predicting BMI in underweight or obese categories
LSN	0.46	0.97-1.00	0.97
GDS	0.82	0.78-1.36	1.03
IADL	0.22	0.51-1.17	0.77
Amount spent per week on food	0.25	0.98-1.09	1.03
Number of food groups	0.66	0.56-1.63	0.95
Predicting weight loss
LSN	0.82	0.87-1.12	0.99
GDS	0.02	1.12-2.43	1.65
IADL	0.74	0.70-2.11	1.21
Amount spent per week on food	0.76	0.90-1.06	0.98
Number of food groups	0.22	0.68-3.72	1.59
Weight loss with two predictors
GDS	0.007	0.45-0.88	0.63
Number of food groups	0.40	0.34-1.6-55	0.72

Other Findings

63% prepared all of their own meals on a typical day.

Women had a higher average number of social networks (mean 31.4) than men (mean 28).

For the depression scale, scores of 5 or more indicate depression and the mean of this sample was 2.4.

The dairy group was the worst with only one in five people (22%) getting the three or more recommended servings.

Depression and the food pyramid groups with adequate amounts eaten were predictive of unintentional weight loss in the previous six months (P=0.013) but not of high or low BMI.

Author Conclusion:

In research and practice, valid and sensitive tools for detecting nutritional decline before poor nutrition results in adverse outcomes continue to be a challenge to nurses in community settings. These data suggest that nurses and other health care professionals in the community setting seeking a short, non-invasive way of screening for nutritional decline in independent living old-old may be able to use a 15-item screen for depression and five yes/no questions about food intake to screen for nutritional decline as evidenced by unintentional weight loss. Early detection of depression and poor food intake could point to cost-effective interventions for a rapidly increasing population.

Funding Source:

Not-for-profit

National Institute for Nursing Research (NR07102)

Other non-profit:

Reviewer Comments:

Subjects recruited through personal contact with parish nurses. All subjects were from one county in Wisconsin.

Authors note the following limitations:

Convenience sample may be biased
Subject selection by the parish nurses could have introduced bias
Lack of racial diversity in the sample
24-hour diet recall may not capture variations in intake
Weight loss was by self-report and subject to error.

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?	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?	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?		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?		???
	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?	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?	???
	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)?	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