UWL: Screening and Assessment Methods (2009)
Citation:
Study Design:
Class:
- 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:
Recruitment
- Older women living in two private nursing homes in Granada, Spain
- All women were asked to participate in the study, so participation was voluntary.
Design
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)
Variables |
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) |
28.4±4.4
|
23.2±6.9
|
27.9±3.9
|
30.1±4.9
|
Red Cross Cognitive Score |
1.1±0.9 |
1.2±0.8
|
1.3±1.0 |
0.75±0.8 |
Energy Intake (kcal) |
1,597±197
|
1,388±345
|
1,610±181
|
1,607±181
|
Fat Intake (g) |
58±12
|
46±18
|
58±11
|
60±10
|
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
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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) | 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 | |