UWL: Food, Appetite and Environment (2009)
- The aim of the study was to describe and compare patients without a need for assisted eating and those with such a need regarding the types and extent of eating difficulties, nutritional status and pressure ulcers when admittted for rehabilitation after a stroke
- A further aim was to analyze the relationship between eating difficulties and nutritional status and subsequent pressure ulcer development.
Patients consecutively admitted to a stroke rehabilitation facility from November 1996 to November 1997.
None reported.
- Recruitment: Not described
- Design: Observational study of eating difficulties in a stroke rehabilitation facility
- Blinding used: None
- Intervention: None.
Statistical Analysis
- Parametric or non-parametric tests were used for the analysis of differences between patients needing or not needing assisted eating
- Age and BMI were compared using the T-test
- Mann-Whitney U-test was used for comparing the number of prescribed drugs. The Katz-ADL index, number of eating difficulties, nutritional status and pressure ulcers.
- Chi-square tests were used to compare cohabitation, level of independent living, clinical signs and eating difficulties
- Multiple logistic regression was performed to determine the risk factors for undernourishment
- Analyses of the predictive risk of nutritional status for having pressure ulcers were made.
Timing of Measurements
Not stated.
Dependent Variables
- Nutrition status
- Number of pressure ulcers.
Independent Variables
Eating difficulties.
Control Variables
Not applicable.
- Initial N: 162 patients with stroke
- Attrition (final N): 162; 74 men, 88 women
- Age: 78.62 years
- Ethnicity: Not mentioned
- Location: Sweden.
Nutritional Status Assessed with a Subjective Global Assessment in the Total Sample (N=162) and the Presence and Nature of Pressure Ulcers Among Patients with Dependency in at Least One Activity of Daily Living (Katz ADL Index Not Equal to A; N=123), in Patients Admitted for Stroke Rehabilitation
|
Total |
Independent Eating |
Dependent Eating |
P-Value | |
Nutritional Status |
(N=162) |
(N=77) |
(N=85) |
||
|
Well-nourished |
110 |
67 |
43 |
|
Well-nourished, but at risk of being malnourished |
32 |
1 |
31 |
||
Malnourished | Suspected of being malnourished |
17
|
7
|
10
|
|
Severely malnourished |
3
|
2
|
1
|
<0.0005 | |
Grade of Pressure Ulcers | (N=123) | (N=38) | (N=85) | ||
None |
105
|
36
|
69
|
||
Persistent discoloration |
5
|
0
|
5
|
||
Epithelial damage |
6
|
1
|
5
|
||
Damage to full thickness without cavity |
4
|
0
|
4
|
||
Damage to the full thickness of the skin with cavity |
3
|
1
|
2
|
<0.06 |
Logistic Regression Analysis of Eating Difficulties as Predictors of Nutritional Status in Patients Admitted for Stroke Rehabilitation
Odds Ratio | 95% CI for OR | P-Value | |
Alertness |
5.4
|
1.1-25.9
|
P<0.04 |
Swallowing Difficulties |
4.6
|
1.6-13.2
|
P<0.006 |
Amount of Food Eaten |
3.1
|
1.1-8.7
|
P<0.03 |
Eating Speed |
3.0
|
1.1-7.8
|
P<0.03 |
- Hosmer and Lemshow goodness-of-fit test
- X2 2.89
- DF 4
- *P<0.58
- Factors without significant influence were "sitting position," "manipulating food on the plate," "transport of food to the mouth," "open and/or close the mouth," "manipulating food in the mouth."
- Eating difficulties among patients with stroke were complex and existed among those who required feeding assistance and those who did not
- The most common eating difficulties were those related to the phase before the food reaches the mouth
- Some eating difficulties showed significant predictive ability for under-nourishment, which in turn increased the likelihood of having pressure ulcers.
- These patients are the same ones in a similar study reported by Westergren A, Ohlsson O, Hallberg IR, in Disability and Rehabilitation in 2002
- The researchers used an unvalidated modification of the Subjective Global Assessment form, which has an unknown impact on their findings.
Quality Criteria Checklist: Primary Research
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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? | Yes | |
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? | Yes | |
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? | N/A | |
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) | N/A | |
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.) | 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.) | 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? | No | |
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%.) | N/A | |
4.3. | Were all enrolled subjects/patients (in the original sample) accounted for? | N/A | |
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.) | N/A | |
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? | 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? | ??? | |
6.4. | Was the amount of exposure and, if relevant, subject/patient compliance measured? | No | |
6.5. | Were co-interventions (e.g., ancillary treatments, other therapies) described? | No | |
6.6. | Were extra or unplanned treatments described? | No | |
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? | No | |
7.2. | Were nutrition measures appropriate to question and outcomes of concern? | No | |
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? | 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? | 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)? | Yes | |
8.5. | Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? | ??? | |
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? | ??? | |
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? | Yes | |
10.2. | Was the study free from apparent conflict of interest? | Yes | |