Social Network Factors Affect Nutrition Risk in Middle-Aged and Older Adults: Results from the Canadian Longitudinal Study on Aging.

OBJECTIVES: To determine which social network, demographic, and health-indicator variables are associated with SCREEN-8 (nutrition risk) scores at two time points, three years apart, using data from the Canadian Longitudinal Study on Aging. DESIGN: A retrospective cross-sectional study. SETTING AND PARTICIPANTS: 17051 Canadians aged 45 years and older with data from baseline and first follow-up of the Canadian Longitudinal Study on Aging. MEASUREMENTS: Nutrition risk was measured using SCREEN-8. Social network factors included social network size, frequency of contact with social network members, social participation, social support, self-rated social standing, and household income. Demographic variables included age, sex assigned at birth, marital status, educational attainment, and living situation (alone or with others). Health-indicator variables included depression, disability, and self-rated general health, mental health, healthy aging, and oral health. Multivariable linear regression was used to analyze the relationship between the social network, demographic, and health-indicator variables and SCREEN-8 scores at two time points, three years apart. RESULTS: Among the social network variables, individuals with higher social participation, self-rated social standing, and social support had higher SCREEN-8 scores at baseline and follow-up. Among the demographic variables, individuals who were single or widowed, compared to married or partnered, had lower SCREEN-8 scores at both time points. For the health-indicator variables, individuals who screened negative for depression, and those with higher self-rated general health, healthy aging, and oral health had higher SCREEN-8 scores at both time points. At baseline, as age increased, SCREEN-8 scores also increased. CONCLUSION: Individuals with low social participation, low social standing, and low social support may be at increased nutrition risk and should be proactively screened by healthcare professionals. Interventions and community programs designed to increase levels of social participation and foster social support may help to reduce the prevalence of nutrition risk.

Reliability Testing of the Team Member Mealtime Experience Questionnaire.

Team members influence the mealtime experience of residents. Their perspectives on their ability to provide resident- and relationship-centred care during mealtimes is limited. The aim of this study was to describe the development and determine the factor structure and internal and test-retest reliability of the Team member Mealtime Experience Questionnaire (TMEQ). A 23-item questionnaire was developed through several steps. A Likert scale of strongly disagree (score= 1) to strongly agree (score= 5) was used. A total of 137 team members from five diverse homes participated. Time and task-focused items had lower scores (indicating more negative perceptions), whereas knowledge and capability of how to provide resident- and relationship-centred mealtime care had higher scores. Exploratory factor analysis identified three factors; four items were eliminated based on this analysis. Test-retest reliability was completed with 103 participants. Intraclass correlation (ICC) for the total score and three subscales ranged from 0.72 -0.85 while Chronbach's alpha ranged from 0.81-0.92. The 19-item TMEQ is considered reliable for use in research and practice.

Modified Texture Food Use is Associated with Malnutrition in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project.

OBJECTIVE: Modified texture food (MTF), especially pureed is associated with a high prevalence of under-nutrition and weight loss among older adults in long term care (LTC); however, this may be confounded by other factors such as dependence in eating. This study examined if the prescription of MTF as compared to regular texture food is associated with malnutrition risk in residents of LTC homes when diverse relevant resident and home-level covariates are considered. DESIGN: Making the Most of Mealtimes (M3) is a cross-sectional multi-site study. SETTING: 32 LTC homes in four Canadian provinces. PARTICIPANTS: Regular (n= 337) and modified texture food consumers (minced n= 139; pureed n= 68). MEASUREMENTS: Malnutrition risk was determined using the Mini Nutritional Assessment short-form (MNA-SF) score. The use of MTFs, and resident and site characteristics were identified from health records, observations, and standardized assessments. Hierarchical linear regression analyses, accounting for clustering, were performed to determine if the prescription of MTFs is associated with malnutrition risk while controlling for important covariates, such as eating assistance. RESULTS: Prescription of minced food [F(1, 382)=5.01, p=0.03], as well as pureed food [F(1, 279)=4.95, p=0.03], were both significantly associated with malnutrition risk among residents. After adjusting for age and sex, other significant covariates were: use of oral nutritional supplements, eating challenges (e.g., spitting food out of mouth), poor oral health, and cognitive impairment. CONCLUSIONS: Prescription of minced or pureed foods was significantly associated with the risk of malnutrition among residents living in LTC facilities while adjusting for other covariates. Further work needs to consider improving the nutrient density and sensory appeal of MTFs and target modifiable covariates.

Validity and reliability of the new Canadian Nutrition Screening Tool in the 'real-world' hospital setting.

BACKGROUND/OBJECTIVES: Nutrition screening should be initiated on hospital admission by non-dietitians. This research aimed to validate and assess the reliability of the Canadian Nutrition Screening Tool (CNST) in the 'real-world' hospital setting. SUBJECTS/METHODS: Adult patients were admitted to surgical and medical wards only (no palliative patients). Study 1--Nutrition Care in Canadian Hospitals (n=1014): development of the CNST (3 items: weight loss, decrease food intake, body mass index (BMI)) and exploratory assessment of its criterion and predictive validity. Study 2--Inter-rater reliability and criterion validity assessment of the tool completed by untrained nursing personnel or diet technician (DT) (n=150). Subjective Global Assessment performed by site coordinators was used as a gold standard for comparison. RESULTS: Study 1: The CNST completed by site coordinators showed good sensitivity (91.7%) and specificity (74.8%). Study 2: In the subsample of untrained personnel (160 nurses; one DT), tool's reliability was excellent (Kappa=0.88), sensitivity was good (>90%) but specificity was low (47.8%). However, using a two-item ('yes' on both weight change and food intake) version of the tool improved the specificity (85.9%). BMI was thus removed to promote feasibility. The final two-item tool (study 1 sample) has a good predictive validity: length of stay (P<0.001), 30-day readmission (P=0.02; X(2) 5.92) and mortality (P<0.001). CONCLUSIONS: The simple and reliable CNST shows good sensitivity and specificity and significantly predicts adverse outcomes. Completion by several untrained nursing personnel confirms its utility in the nursing admission assessment.

Providing quality nutrition care in acute care hospitals: perspectives of nutrition care personnel.

BACKGROUND: Malnutrition is common in acute care hospitals worldwide and nutritional status can deteriorate during hospitalisation. The aim of the present qualitative study was to identify enablers and challenges and, specifically, the activities, processes and resources, from the perspective of nutrition care personnel, required to provide quality nutrition care. METHODS: Eight hospitals participating in the Nutrition Care in Canadian Hospitals study provided focus group data (n = 8 focus groups; 91 participants; dietitians, dietetic interns, diet technicians and menu clerks), which were analysed thematically. RESULTS: Five themes emerged from the data: (i) developing a nutrition culture, where nutrition practice is considered important to recovery of patients and teams work together to achieve nutrition goals; (ii) using effective tools, such as screening, evidence-based protocols, quality, timely and accurate patient information, and appropriate and quality food; (iii) creating effective systems to support delivery of care, such as communications, food production and delivery; (iv) being responsive to care needs, via flexible food systems, appropriate menus and meal supplements, up to date clinical care and including patient and family in the care processes; and (v) uniting the right person with the right task, by delineating roles, training staff, providing sufficient time to undertake these important tasks and holding staff accountable for their care. CONCLUSIONS: The findings of the present study are consistent with other work and provide guidance towards improving the nutrition culture in hospitals. Further empirical work on how to support successful implementation of nutrition care processes is needed.

Nutrition Screening Tool for Every Preschooler (NutriSTEP): validation and test-retest reliability of a parent-administered questionnaire assessing nutrition risk of preschoolers.

OBJECTIVES: Study 1: To establish the validity of scores on Nutrition Screening Tool for Every Preschooler (NutriSTEP), a community-based parent-administered screening tool for assessing nutrition risk, by comparing scores to an expert rating. Study 2: To demonstrate test-retest reliability of NutriSTEP. SUBJECTS/METHODS: Study 1: Parents of 269 preschoolers (of 294 parents recruited from the community), completed the NutriSTEP questionnaire; a registered dietitian (RD) assessed the nutritional status (based on medical and nutritional history, 3 days of dietary recall and anthropometric measurements) of these preschoolers and rated their nutritional risk (1 (low) to 10 (high risk)). Receiver operating characteristic (ROC) curves were used to establish validity and determine appropriate cut points based on sensitivity and specificity. Study 2: Parents of 140 preschoolers (of 161 recruited) completed NutriSTEP on two occasions. Intraclass correlation (ICC) and kappa were used to assess reliability. RESULTS: Study 1: Scores on NutriSTEP and the RD rating were correlated (r=0.48, P=0.01). Area under the ROC curve for the high risk RD rating (score 8+) and the moderate risk rating (score 5+) were 81.5 and 73.8%, respectively. A moderate risk cut point of >20 and high risk cut point of >25 were identified for the NutriSTEP scores. Study 2: The NutriSTEP score was reliable between administrations (ICC=0.89, F=16.7, P<0.001). Most items on the questionnaire had adequate (kappa>0.5) or excellent (kappa>0.75) agreement. CONCLUSIONS: The NutriSTEP questionnaire is both valid and reliable for determining nutritional risk in preschoolers.

Community organized food and nutrition education: participation, attitudes and nutritional risk in seniors.

UNLABELLED: Evergreen Action Nutrition (EAN) is a health promotion program designed to facilitate relatively healthy members of a seniors recreation center to maintain their nutritional health as they age. A main goal of this project was to demonstrate the feasibility and relevance of using the community organization approach to develop a nutrition education program for seniors. METHODS: Using the current membership list, seniors were randomly selected to receive a mailed baseline (n=247) questionnaire. A follow-up survey (n=251) was sent out to randomly selected members three years later to determine participation in EAN and reported behavior change. Although not the same individuals, responses were compared to baseline to determine changes in nutritional risk. Items from the Diet and Health Knowledge survey were compared by EAN participation. RESULTS: The program had a large reach with 162 survey respondents (64.5%) reporting some level of participation and 51% reporting "frequent" participation. Use of informal forms of education predominated (e.g. displays). Significant differences were found between baseline and follow-up for risk attributed to low intake of fruits and vegetables and frequency of eating, with EAN participants having reduced risk of low fruit and vegetable intake. Those participating in formal education (e.g. food workshops) reported more frequent changes in food practices than those participating in informal activities. EAN participants appear to have more healthy nutrition attitudes/beliefs. CONCLUSION: The community organization approach to program planning and delivery leads to the development of diverse and appropriate nutrition education activities for seniors. Informal and formal health promotion activities can be successfully implemented in recreation centers.

Body Mass Index (BMI), BMI change and mortality in community-dwelling seniors without dementia.

UNLABELLED: Recently Canada adopted the World Health Organization's (WHO)Weight Classification system for Body Mass Index (BMI). To date, there has been minimal investigation on the predictive ability of BMI on mortality in seniors. This study investigates the predictive ability of the BMI categories identified in this Weight Classification System and change in BMI on mortality in Canadian seniors. METHODS: Canadian Study of Health and Aging (CSHA) participants who completed clinical examination (including body weight measurements) in 1991 (CSHA1) and 1996 (CSHA2) were included (n = 539). BMI change (CSHA1 to CSHA2) was categorized as no change/mild increase (0 to < 2.0 units), mild decrease (-0.1 to < -2.0 units), or significant increase/decrease (> or = +/-2.0 units). The outcome was subsequent 5-year-mortality, i.e. death between CSHA2 and CSHA3 (2001). Logistic regression controlled for age, gender, education level, marital status, smoking and cognitive status. RESULTS: BMI at CSHA1 was not a significant predictor of all-cause mortality between CSHA2 and CSHA3. A significant decrease in BMI regardless of BMI category predicted death (OR 2.10 95% CI 1.17, 3.80). Other factors predictive of death were age and cognitive impairment without dementia. CONCLUSION: A static measure of BMI is a less useful measure of mortality risk than weight change in older adults. Weight change, especially weight loss resulting in a BMI change of at least 2.0 units, is predictive of mortality and should be considered a warning sign.

Validity and reliability of SCREEN II (Seniors in the community: risk evaluation for eating and nutrition, Version II).

BACKGROUND: Nutrition risk screening for community-living seniors is of great interest in the health arena. However, to be useful, nutrition risk indices need to be valid and reliable. The following three studies describe construct validation, test-retest and inter-rater reliability of SCREEN II. METHODS: Study (1) seniors were recruited from the general community and from a geriatrician's clinic to complete a nutritional assessment and SCREEN II. 193 older adults provided medical and nutritional history, 3 days of dietary recall and anthropometric measurements. A dietitian reviewed all information collected and ranked seniors on risk: 1 (low) to 10 (high risk). Receiver operating characteristic curves were completed. An abbreviated SCREEN II was developed through statistical analysis and expert ranking of the 17 items. Studies (2) and (3) seniors were recruited from the community to self-administer (n = 149) or be interviewed (n = 97) using SCREEN II twice within 2 weeks. For self-administration one index was completed via mail. Interviewer administration was completed via telephone with two interviewers. Intra-class correlations were calculated. RESULTS: (1) Total and abbreviated SCREEN II have increased sensitivity and specificity as compared to SCREEN I in identifying seniors at nutritional risk. (2) Test-retest reliability was adequate (intra-class correlation (ICC) = 0.83). (3) Inter-rater reliability was adequate (ICC = 0.83). CONCLUSIONS: SCREEN II appears to be a valid and reliable tool for the identification of risk for impaired nutritional states in community-living older adults, and is an improvement over SCREEN I.

Nutrition and health-related quality of life in frail older adults.

BACKGROUND: Frail older adults are at risk for poor nutrition and frequently experience declining healthrelated quality of life (HR-QOL). The relationship between nutritional risk and HR-QOL although intuitive, has been rarely studied. OBJECTIVE: To determine the independent association of nutritional risk with HR-QOL in frail older adults. DESIGN: Cross-sectional survey. Data were collected by interviewer-administered questionnaire. Nutritional risk was measured by SCREEN (Seniors in the Community: Risk Evaluation for Eating and Nutrition) and HR-QOL by perceived health status and report of number of days in the past month where physical or mental health was not good, or where activities were limited. Frail (n=367) seniors were recruited from 23 community service providers. A wide variety of covariates were also measured. Multivariate modeling based on a conceptual model was used to identify factors associated with HR-QOL. RESULTS: Nutritional risk appears to be a significant and important factor associated with HR-QOL. Other significant covariates were: falls, social supports, social activity, health behaviours, pain and medication use. CONCLUSION: Nutritional risk as measured by SCREEN appears to be a significant covariate in explaining differences in HRQOL among frail older adults. Further work should determine if nutritional risk predicts changes in HR-QOL over time.

Nutritional risk and time to death; predictive validity of SCREEN (Seniors in the Community Risk Evaluation for Eating and Nutrition).

BACKGROUND: Undernutrition in community-living seniors is common and has the potential to adversely influence health outcomes. Nutritional risk screening tools can help identify seniors at risk, but few have predicted health outcomes. METHODS: Seniors were recruited from 23 community service providers. The 8-item abbreviated version SCREEN (Seniors in the Community Risk Evaluation for Eating and Nutrition) was used to identify nutritional risk in 367 seniors; demographics, health, activities of daily living, and psychosocial variables were included in a baseline assessment. The seniors were followed-up by telephone for 18 months to determine the occurrence of health outcomes, including death. Cox regression was used to identify predictors of survival time. RESULTS: During the 18-month follow-up there were 27 deaths (approximately 7%). Using the abbreviated tool, nutritional risk was common (42.2%). This low rate of death limited the modeling to only a few key covariates, which were based on bivariate analyses. Nutritional risk was significantly associated with time to death. Gender was also associated with time to death, with men more likely to die sooner than women. Increasing age was also significantly associated with shorter survival times. CONCLUSIONS: Nutritional risk as measured by SCREEN was predictive of time to death. This simple tool may be useful for future epidemiological research on health outcomes of seniors. Further work should confirm these results, as the low event rate influenced the modeling strategy.

Construct validation and test-retest reliability of the seniors in the community: risk evaluation for eating and nutrition questionnaire.

BACKGROUND: We performed two studies. Study 1 was a construct validation of Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN), a 15-item questionnaire for assessing nutritional risk. In Study 2, we examined the test-retest reliability of SCREEN. METHODS: Study 1 was a cross-sectional study, and Study 2 was a cohort study. For Study 1, ten diverse community sites were used to recruit participants. A total of 128 older adults attended a clinic to provide medical and nutritional history and anthropometric measurements. A dietitian interviewed each participant. Dietitians used clinical judgment to rate the probability of nutritional risk from 1 (low risk) to 10 (high risk). Spearman's rho correlation and receiver operating characteristic curves were completed. An abbreviated SCREEN was developed through multiple linear regression analysis. In Study 2, SCREEN was randomly distributed to members of a seniors' recreation center where a self-selected sample (n = 124) completed two mailed SCREENs, 4 weeks apart. The test-retest reliability was estimated through paired correlations of total scores and individual items. RESULTS: In Study 1, total and abbreviated SCREEN scores were significantly associated with the dietitian nutritional risk rating (rho = -.47 and rho = -.60, respectively). Study 2 revealed that the test-retest reliability of SCREEN was adequate. CONCLUSIONS: SCREEN appears to be a valid and reliable tool for identifying community-dwelling older adults at risk for impaired nutritional states.

Vitamin-mineral supplementation and use of herbal preparations among community-living older adults.

Basic information on seniors' use of supplements is lacking. In this study, a convenience sample of community-living older adults (n = 128) was recruited from 10 sites to determine the prevalence, frequency, duration and type of supplement use. Use information, demographics and medical/nutritional history were collected with an interview-administered questionnaire. Supplement use included both vitamin-mineral and/or herbal preparations. Average age of participants was 76 years and 73% were female. Users comprised 79.9% of the sample. Vitamin E was the most common vitamin-mineral and herbal teas were the most popular herbal preparations. The predominant reason for use was to "improve one's health". Initial results suggest that older adults are learning about, using and purchasing these supplements from a variety of sources. With this common use and the concerns over interactions with prescription medications, further work is required to determine if these findings are consistent in a more diverse, randomly selected older Canadian population.

Do nutrition indicators predict death in elderly Canadians with cognitive impairment?

This study describes the independent association between nutritional risk and death in older adults diagnosed with cognitive impairment. Canadian Study of Health and Aging participants who completed a clinical exam and were diagnosed with cognitive impairment and had complete data for regression analyses were included (n = 735). Nutritional risk was defined as the presence of at least one abnormal nutrition indicator identified during the clinical exam (history of weight loss, abnormal serum albumin, poor appetite, body mass index < 20). Other covariates believed to influence mortality were modelled with nutritional risk using logistic regression. There were 373 deaths during the five-year follow-up period in this sample. Nutritional risk was found to independently increase the likelihood of death (OR = 1.6, 95% CI 1.1, 2.2) in these older adults suffering from cognitive impairment. Further work is required to determine if interventions can improve nutritional status and quality of life of these older adults.

A decade of doctoral research in nutrition.

OBJECTIVE: To describe North American dissertation research in human nutrition from 1986 through 1995. DESIGN: A census collection. SUBJECTS/SETTING: The unit of observation was the dissertation abstract submitted to Dissertation Abstracts International for the years 1986 through 1995. Only dissertations written in English with a human nutrition subject code (0570) that lead to a PhD, DrPH, EdD, or ScD at a North American university were included (N = 2,044). Abstracts were reviewed by 2 raters who extracted pertinent data on variables describing the dissertation research (e.g., topic of dissertation, type of sample). ANALYSES: Analyses were descriptive. RESULTS: The majority (n = 1,147) of doctoral dissertations were completed by female students. Male students were more likely to study in vitro samples than female students (11% vs 4%) and female students were more likely to study human subjects (64%). Male students tended to have male advisers, although overall male advisers appeared to predominate (34% men, 24% women, 42% unknown or missing). Topic areas for dissertation work reflected gender differences. Popular topics for dissertation research have changed over time; biochemical-, micronutrient-, and obesity-related research decreased and research in development of theoretical constructs and examination of dietary habits of selected groups increased. CONCLUSIONS: From 1986 through 1995 there was an increase in the proportion of female doctoral students. Female and male students varied in the type of sample studied, gender of advisers, age group of human subjects, and topics of their dissertations. Universities emphasized different topic areas and methodologies. There appears to have been an increase in areas of applied research (e.g., dietary habits) and a decrease in basic science topic areas (e.g., micronutrients) over the 10-year period examined.

Predictors of dietary intake in Ontario seniors.

This study determined the independent association of 24 risk factors with dietary intake in community-living seniors. The study sample was 5,073 seniors for whom complete data were available from the 1990 Ontario Health Survey. Risk factors were items completed on an interviewer-administered health questionnaire. Diet Score, Mean Adequacy Ratio and energy were the diet outcomes derived from a self-administered food frequency questionnaire. The independent association of risk factors with these diet outcomes was assessed with multiple linear regression analyses. Factors that were consistently and positively associated with diet outcomes included: education, income, social support, perceived health status, belief in the nutrition/health link, dependence in walking and vision. Factors that were consistently and negatively associated with diet outcomes included: chewing status, dentition, hearing, level of happiness and body mass index. These results provide a basis for the development of a screening tool for the identification of "at risk" subgroups of seniors.

Resolution, EPC-syntheses, absolute stereochemistry, and pharmacology of the (S)-(+)- and (R)-(-)-isomers of the MAO-A inhibitor tetrindole hydrochloride.

Resolution of (RS)-tetrindole (3) and enantioselective reductions of the imine 7 yielded (S)-(+)-(4) and (R)-(-)-tetrindole (5). The absolute stereochemistry of 4 was established by X-ray analysis of the corresponding Mosher amide 6. From in vitro as well as in vivo data (MAO-inhibition, levels of monoamines and their respective metabolites in rat brain), 4 was identified as the eutomer.

Weight gain impacts morbidity and mortality in institutionalized older persons.

OBJECTIVE: To determine if a significant weight change in previously undernourished older persons is associated with mortality and morbidity. DESIGN: Retrospective survey. SETTING: A chronic care hospital in Canada. SUBJECTS: Follow-up survey from an original data set (Time 1) on 88 previously diagnosed undernourished and 60 adequately nourished. Average age was 78 years; average length of residence was 40 months. Of the 148 subjects, 120 were male. MEASUREMENTS: Average time to follow-up (Time 2) was 319 days from Time 1. Data was collected on weight change, reported incidence of infection, use of antibiotics, number of falls, and admissions to acute centers, as well as incidence and cause of death. Three-day diet intake records were available on 15% of subjects within 1 month of Time 2. Five nutritional groups existed within this follow-up population: those previously undernourished who gained at least 5% of Time 1 weight (Group 1), those undernourished who lost at least 5% of Time 1 weight (Group 2), those undernourished who maintained their weight (Group 3), those adequately nourished who lost at least 5% of original weight (Group 4), and those who remained adequately nourished (Group 5). RESULTS: Forty-one of the 148 patients died; this was significantly associated with nutrition group (X2 = 11.23, P = 0.02), with fewer deaths in Groups 1, 3, and 5. As well, primary diagnosis (x2 = 32.6, P = 0.001), length of residence (X2 = 25.6, P = 0.01), and time to death (X2 = 26.4, P = 0.009) were significantly associated with nutrition group. Diet intake records indicated an improvement in energy and protein intake in Group 1 during the follow-up. Energy and protein change, whether increased or decreased from the original study, was significantly associated with nutrition group. Total number of feeding impairments and presence of dysphagia were significantly associated with nutrition group. Other morbidity events were not significantly associated with nutrition group, but trends suggest a positive effect of weight gain on incidence of falls, incidence of more than two infections, and incidence of recurring infections. CONCLUSIONS: A weight increase of at least 5% of body weight in previously undernourished patients is associated with a decreased incidence of death and may reduce morbidity events. Feeding impairments may affect ability of patients to gain weight, but dysphagia is associated with weight increase. Other nonnutritional variables of diagnosis, number of medications, and declining medical status also affect mortality and morbidity outcomes.

Malnutrition in institutionalized elderly: how and why?

OBJECTIVE: To determine the prevalence of undernutrition and overnutrition in long-term care elderly patients and the functional, behavioral, environmental, nutritional, and medical variables associated with this prevalence. DESIGN: Cross-sectional, observational. SETTING: Long-term care hospital in Canada. SUBJECTS: Two hundred elderly patients (n = 166 male), average age 78.5 years. MEASUREMENTS: Assessment of nutritional status and presence of specific behavioral, medical, environmental, and functional characteristics known to impact on nutritional status. Nutritional status was determined by weight, % weight loss, BMI, skinfolds, arm circumference, area measurements, and % body fat. Multiple regression analyses were performed to identify the factors associated specifically with undernutrition and overnutrition in this population. RESULTS: Severe undernutrition was present in 18% (n = 36) and severe overnutrition in 10% (n = 20). Mild/moderate undernutrition was present in 27.5% (n = 55) and mild/moderate overnutrition in 18% (n = 36). Overnutrition was positively associated with primary diagnosis and number of medications and negatively associated with poor appetite, number of feeding impairments, protein intake, and mental state. Undernutrition was positively associated with dysphagia, slow eating, low protein intake, poor appetite, presence of a feeding tube, and age and negatively associated with primary diagnosis. CONCLUSIONS: Undernutrition exists at a level that is high (45.5%) but not unusual for this type of institutional setting. Behavioral, environmental, and disease-related factors greatly influence nutritional status. Undernutrition appears to be affected by nutritional factors more than overnutrition. Efforts should be directed toward influencing some of these factors to decrease undernutrition in the institutionalized elderly.