EAL

UWL: Food, Appetite and Environment (2009)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

This study aimed to address the following two questions:

Do patients who eat in a supervised dining room have an increased nutritional intake when compared with patients eating at their bedside?
Do patients who eat in a supervised dining room have an increased weight gain when compared with patients eating at their bedside?

Inclusion Criteria:

All patients admitted to two medicine for the elderly acute wards at Charing Cross Hospital between February and March 2004
None specifically mentioned.

Exclusion Criteria:

Data for any patient with less than three meals were not included in the study.

Description of Study Protocol:

Recruitment

All patients admitted to two medicine-for-the-elderly acute wards at Charing Cross Hospital between February and March 2004 were considered eligible.

Design

Non-randomized clinical trial: Quasi-experimental study with two comparison groups.

Intervention

Patients on the intervention ward were encouraged to attend a dining room every lunchtime by a trained nursing assistant as part of the rehabilitation process
Patients on the control ward ate only by their bedside
Nursing assistants were available as part of normal ward routine to assist all patients at mealtimes.

Statistical Analysis

Between-group comparisons were performed using a T-test, Mann-Whitney U-test and chi-squared tests as appropriate. Normally distributed data are presented as mean and 95% confidence intervals for the mean, non-parametric data are presented as the median and interquartile range.

Data Collection Summary:

Timing of Measurements

Food intake and weight data were collected over the six-week study period on each patient.

Dependent Variables

Food intake data were collected using standardized Trust food record charts completed by the researchers for a minimum of three lunch meals per patient. Data were collected for an average of six patients in the control group per day and an average of eight patients in the dining room. Mean intake for three lunch meals calculated using nutritional analysis.
Weight was measured weekly using a chair scale.

Independent Variables

Patients on the intervention ward were encouraged to attend a dining room every lunchtime by a trained nursing assistant as part of the rehabilitation process
Patients on the control ward ate only by their bedside.

Description of Actual Data Sample:

Initial N: 48 patients participated, 30 in ward dining room at lunchtime, 18 controls eating at bedside
Attrition (final N): As above
Age: Median age, 84 years
Anthropometrics: No significant differences in age, gender, diagnosis or initial weight between groups at baseline
Location: Charing Cross Hospital, London.

Summary of Results:

Variable

Dining Room Group

Control Group

Statistical Significance of Group Difference

Energy from lunch meal only (kcals)

489 (438 to 554)

360 (289 to 448)

0.013

Protein from lunch meal only (g)

18.9 (16.6 to 21.2)

17.7 (13.2 to 22.2)

0.63

Other Findings

At the lunchtime meal studied, the dining room group had higher intakes of energy compared with controls [489kcal (95% CI, 438 to 554) vs. 360kcal (95% CI, 289 to 448), P<0.013].

Energy intake was 36% (129kcal) greater in the dining room group compared with those eating lunch by their bed.

There was no difference in protein intake between the groups [18.9g (95% CI, 16.6 to 21.2) vs. 17.7g (95% CI, 13.2 to 22.2), P=0.63].

No significant difference in weight gain between the two groups was seen [0.25 kg for controls (95% CI: -1.0 to 1.2) vs. 0.61kg for the dining room group (95% CI: 0.13 - 1.09), P = 0.6].

However, there was a trend towards weight gain in the dining room group (three lost weight and 14 gained) compared to controls (seven lost weight and nine gained, P = 0.12).

Author Conclusion:

Food intake of people on acute elderly medicine wards can be improved by using a supervised dining room. This will potentially lead to weight gain and corresponding improvements in nutritional status and rehabilitation.

Funding Source:

Reviewer Comments:

Recruitment methods and inclusion/exclusion criteria were not well described. Authors note limitations of patients only attending the dining room four times, which could impact weight change, and weighed food intakes would be more accurate than food record charts in estimating energy and protein consumption, as well as the short six-week study period.

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?	???
	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?		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?		No
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	No
	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?	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?		???
	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?	???
	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?	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?	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?		???
	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?	???
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	???
	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?	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?	No
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