Clinical Nutrition ESPEN xxx (xxxx) xxx

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Clinical Nutrition ESPEN

journal homepage: http://www.clinicalnutritionespen.com

Original article

Nutritional status in older people e An explorative analysis

Stina Engelheart a, *, Daniela Andre

n b, Dirk Repsilber a, Hele

ne Berte

us Forslund c,
a
Robert Jan Brummer
a €
School of Medical Sciences, Orebro €
University, Orebro, Sweden
b €
School of Business, Orebro €
University, Orebro, Sweden
c
Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

a r t i c l e i n f o s u m m a r y

Article history: Background & aims: The nutritional status is seldom defined in general, but is considered to be important
Received 29 January 2021 throughout life span, especially in times of diseases and disabilities. We previously proposed a theoretical
Accepted 30 August 2021 model of the nutritional status from a functional perspective [1], however without proposing a definition
of the nutritional status. The model comprises four domains that might affect the nutritional and
Keywords: functional status in a bidirectional way. These four domains are: Food and nutrition; Health and somatic
Nutritional status
disorders; Physical function and capacity; and Cognitive, affective, and sensory function. This study
Factor analysis
contributes to the existing literature and knowledge by empirically analysing patterns and relationships
Aged
80 and over
of possible nutritional status indicators within and between the four domains.
Methods: This study is based on a sample of 69 men and women; older than 65 years, receiving home
health care. They were followed up for three years. A broad set of nutritional status indicators in the
participants were assessed in their home yearly. Given the small sample size and large number of var-
iables, we used both correlation and factor analysis to explore patterns of nutritional status indicators
within the four domains and relationships between the four domains suggested by the theoretical model
of nutritional status which we proposed earlier.
Results: At baseline, between 4 and 18 components were extracted from the four domains, separately,
using factor analysis. The first three components of each domain (called main components) were
correlated (p < 0.05) with at least one of the main components of each of the other three domains
(r ¼ 0.34e0.79 at baseline, 0.38e0.74 at year 1, 0.40e0.77 at year 2 and 0.47e0.71 at year 3). At
baseline, these main components explained, respectively, 31%, 52%, 57% and 63% of the sample variation
in the four domains. This remained stable throughout all three years of follow up. In all four domains,
there were statistically significant differences in prevalence of malnutrition, frailty, sarcopenia, and
dehydration (all different inadequate nutritional status) between individuals’ individual component
scores.
Conclusions: This study provides empirical evidence for the relationship between nutritional status in-
dicators within and between the four domains suggested by our theoretical model of nutritional status.
Components in all four domains were associated with inadequate nutritional status, highlighting that a
wide perspective of the nutritional status assessment is necessary to be applied in clinical practice.
© 2021 The Authors. Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and
Metabolism. This is an open access article under the CC BY license (http://creativecommons.org/licenses/
by/4.0/).

1. Introduction traditionally nutrition has not been solidly integrated into health
care systems [3]. However, nutritional status is an important part of
The relationship between food intake, health and quality of life a multifactorial care, in particularly in situations of chronic diseases
are recognized by both researchers [2] and policy makers, but and disabilities, which are common in advanced age. This role of
nutrition is increasingly documented in current literature,
providing consensus of assessment, prevention and treatment of
€
* Corresponding author. School of Medical Sciences, Orebro University, 701 82 inadequate nutritional status such as malnutrition and sarcopenia
€
Orebro, Sweden. [4e6]. However, the literature of how to assess or state an adequate
E-mail address: stina.engelheart@oru.se (S. Engelheart).

https://doi.org/10.1016/j.clnesp.2021.08.036
2405-4577/© 2021 The Authors. Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and Metabolism. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/4.0/).

n, D. Repsilber et al., Nutritional status in older people e An explorative analysis, Clinical
Please cite this article as: S. Engelheart, D. Andre
Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2021.08.036
S. Engelheart, D. Andr
en, D. Repsilber et al.
nutritional status in older adults is lacking. What is an adequate or
good nutritional status at old age? Is it possible for an 85 year old in
need of support in activities in daily living to have a good nutri-
tional status? Instead, the measurement of the individual nutri-
tional status is often not focusing on indictors of the status itself,
but in terms of a non-optimal nutritional status, such as malnu-
trition [7e10], frailty [11,12], sarcopenia [13e15] or dehydration [4].
For instance, researchers seldom describe a theoretic definition of
the nutritional status, which is often determined by the way of
measuring a non-optimal nutritional status rather than a theoret-
ical framework. This might explain why there is, to our knowledge,
no standard definition or methodological toolbox for measuring
and define an optimal nutritional status.
Previously, we have proposed a theoretical model of nutritional
status [1], also designed to be used as a mindset to stimulate the
discussion on the interactions between various indicators affecting
both good and bad nutritional status in older people, both in
assessment and in treatment. This theoretical model comprises the
following four domains: Food and nutrition; Health and somatic
disorders; Physical function and capacity; and Cognitive, affective,
and sensory function. These four domains alone or in combination
affect the individual's nutritional status. However, the nutritional
status, in its turn, also affects the domains. The output, or goal, with
the nutritional assessment or treatment is also included in the
theoretical model; an optimal function in an individual perspective.
Previously, the theoretical model has been used as a base to
describe a population of old people receiving home health care [16].
The current study is an explorative statistical analysis of the pat-
terns and relationships of nutritional status indicators (variables)
within and between the four domains. In a first step, this includes a
statistical analysis of how a set of observed variables that all affect
the individual's nutritional status in different ways, contributes to
the domain. In a second step, it includes analysis of the relation-
ships between the observed variables.
The aim of the study was to empirically elucidate patterns and
relationships of nutritional status indicators, within and between
the four domains of a proposed theoretical model of nutritional
status. Furthermore, we aimed to study if and how several observed
indicators of the nutritional status can be reduced to a few main
indicators, for better accessible and manageable implementation
into clinical practice.
2. Material and methods
A sample of 69 men and women above 65 years of age, receiving
home health care were studied with focus on the nutritional status
in a broad sense, including health, function, disease, cognition and
mental status during a follow up period of three years.
In Sweden, home health care is available for patients in need of
regularly health care but with difficulties to visit a local health care
centre. Inclusion criteria for the study were age of 65 years or older,
a need of home health care for more than three months and living
in a geographically defined area in a middle-sized city in Sweden.
Patients in palliative care were excluded. Once a patient was
enrolled to home health care and fulfilled the inclusion criteria, the
patient received written information about the study. For patients
interested in participating in the study, a meeting with the
researcher (SE) was arranged for oral information, clarifications,
answering questions and for obtaining an informed written con-
sent for participation.
From February 2014 to February 2017, all 235 patients who were
enrolled at home health care were offered participation in the
2
Clinical Nutrition ESPEN xxx (xxxx) xxx
study. Most of the patients (n ¼ 217 or 92% of 235) met the inclusion
criteria but only 69 (32%) accepted to participate and were followed
up for three years. See Supplementary Fig. 1.
This empirical study is based on a theoretical model that pre-
sents the nutritional status in a functional perspective by using four
domains: Food and nutrition; Health and somatic disorders;
Physical function and capacity; and Cognitive, affective and sensory
function [1]. Data about the nutritional status and the variables in
the above mentioned four domains, were collected from the par-
ticipants at baseline and followed up for three years.
The study was approved by the Regional Research Ethics Com-
mittee in Uppsala, Sweden (Dnr: 2013/305).
2.1. Methods for data collection
All data collection was performed in the participants' home
environment and the measurements used were nutritional status
indicators (variables within the four domains) with a wide range.
The methods of collecting data were chosen to be suitable to use in
home environment and to be transportable. For instance, bioelec-
trical impedance was used to assess body composition instead of
dual-energy x-ray absorptiometry and 6-min walking test and gait
speed were excluded due to lack of space in participants’ home.
Data collection was performed by registered dietitian/researcher
(SE), and by district nurses or assistant nurses, occupational ther-
apists, and physiotherapists in home health care organisation.
Below, the methods for data collection are described in detail,
categorised in the four domains.
2.2. Food and nutrition
Dietary intake was estimated using a retrospective three-day
food diary, as described in detail elsewhere [16]. Dietary data
were analysed, by using Dietist Net (Kost och Na€ringsdata, Sweden),
based on PC-kost (The Swedish Food Agency). A trained research
dietitian (SE) made all dietary data collection as well as the calcu-
lations to quantify the records. A daily mean of the three-day record
were used and total daily energy intake as well as the following
daily intake of macro- and micronutrients were studied: protein,
total fat, saturated fat, monounsaturated fat, polyunsaturated fat,
carbohydrate, alcohol, dietary fibre, water, calcium, iron and
vitamin C. Energy, protein and water intake were adjusted to body
weight and intake of dietary fibre was adjusted to total energy
intake. Energy percentage (E%) of protein, alcohol, total fat, satu-
rated fat, monounsaturated fat, and polyunsaturated fat was also
included. Finally, meal patterns were analysed by energy and pro-
tein range, for which the lowest daily intake was subtracted from
the highest daily intake in the food diary, but also by number of
eating occasions per day and length of overnight fast, as described
elsewhere [17].
Body weight change and food intake level were used as in-
dicators of energy balance. Information about body weight change
before baseline was retrieved from the Mini Nutritional Assess-
ment, and thereafter measured at each follow up. Food intake level
was calculated as daily energy intake divided by estimated Resting
Energy Rate according to Mifflin-St Jeor [18,19].
2.3. Health and somatic disorders
The following blood and urine samples were analysed:
S-Albumin, P-CRP, B-Haemoglobin, S-Ferritin, S-Cobalamin, S-
TSH, S-Thyroxin, S-25-OH-Vitamin-D, S-Sodium, S-Potassium, S-
S. Engelheart, D. Andr
en, D. Repsilber et al.
Osmolality, S-Creatinine, S-Cystatin C, P-Glucose, S-Insulin, U-
Osmolality and U-sodium. Glomerular filtration rate (GFR) was
estimated based on Cystatin C [20] and Creatinine [21], used as
separate variables and also as their average. Blood pressure and
heart frequency were measured with the participant sitting down.
Present symptoms were recorded by Pharmacotherapeutic
Symptom Evaluation in 20 questions (Phase-20) [22], including the
following symptoms: dizziness, tiredness or exhaustion; poor sleep
pattern or nightmares; abdominal pain or chest pain; headache;
low mood; worries or anxiety; irritability; forgetfulness; poor
appetite; dry mouth; nausea or vomiting; diarrhoea; constipation;
palpitations (rapid or irregular heartbeat); swollen legs or ankles;
shortness of breath; frequent urination or being incontinent of
urine; itching or rash. Each symptom was subjectively categorised
by the degree of problem; none, mild, moderate, or severe. The
number of severe symptoms was summed up to indicate a possible
effect on daily life.
Dehydration were estimated by a quotient of extracellular and
intracellular water (measured by Body Composition Monitor, Fresenius
Medical Care), but also defined as S-Osmolality >300 mmol/L [4].
Morbidity was estimated by the number of prescribed contin-
uously and occasionally prescribed medications. Health related
quality of life was estimated by EQ-5D [7], including five questions
and thereafter computer calculated to a total weighted score from 1
(full degree of health) to 1 (“dead”).
Malnutrition was defined by Mini Nutritional Assessment [8]
and by the GLIM criteria [9]. Frailty was defined by Fried [10], and
sarcopenia was diagnosed according to EWGSOP2, without
defining severity of sarcopenia [11]. Mini Nutritional Assessment
was used as a continuous variable, but malnutrition (by GLIM),
frailty, and sarcopenia were used as binary variables.
2.4. Physical function and capacity
Activity of daily living (ADL) was categorised according to ADL
Taxonomy [23], including both iADL (cleaning, cooking, shopping,
transportation and washing) and pADL (communication and
grooming). The remaining areas in the ADL Taxonomy (dressing,
going to the toilet, hygiene, eat and drink and mobility) were
excluded from further analysis due to similar results in all
participants.
Physical function was measured by handgrip strength [24],
chair stand test [25], timed up and go test [26] and Peak expiratory
flow [27].
Physical activity was self-estimated, using two different ques-
tionnaires. In the International Physical Activity Questionnaire
modified for the elderly, IPAQ-E [28], the number of days of walking
and days of strenuous activities the previous week was noted. In
the Fra €ndineGrimby Scale of physical activity [29], the physical
activity was estimated in categories from 1 to 6, where 1 ¼ hardly
any or none at all; 2 ¼ mostly sedentary, with occasional light ac-
tivity; 3 ¼ light physical activity 2e4 h per week; 4 ¼ exercise 1e2 h
a week; 5 ¼ exercise 3 h a week; or 6 ¼ hard or very hard exercise
several times a week.
Body weight (measured in a digital portable scale, MS-4203,
Corina Medical) and body height (measured using a mobile stadi-
ometer for height measurement, Seca 217) were measured. They
were used as separate variables, as well as combined for calculation
of body mass index (BMI).
Further anthropometrical measures were demispan as well as
circumference of waist, hip and mid arm [30]. Waist/hip-ratio was
calculated. Body composition and hydration were measured using a
Body Composition Monitor (Fresenius Medical Care), estimating
body cell mass, fat free mass and fat mass (in kg and %), total body
water and intra- and extracellular water.
3
Clinical Nutrition ESPEN xxx (xxxx) xxx
2.5. Cognitive, affective, and sensory function
The Mini Mental State Examination [31] was used to indicate
cognitive function, where the maximum score of 30 indicates no
decline. The Geriatric Depression Scale [32] was used for assessment
of the presence of affective disorder, where score less than six (of
maximum 20) indicates that depression is unlikely. Self-estimated
sense of appetite, smell and taste were estimated using a VAS,
from 0 to 10, where zero corresponds to very decreased appetite/
smell/taste and ten corresponds to very good appetite/smell/taste.
The final dataset included 69 participants and 103 variables
within the four domains.
2.6. Statistical analysis
Descriptive statistics of mean and 95% confidence interval
(95% CI) were performed to provide a brief presentation of the
main characteristics of the participants and their nutritional
status.
To identify possible patterns (named components) in each of
the four domains of the theoretical model of nutritional status and
to identify those variables explaining most of the variation in the
study cohort, factor analysis was applied. This approach was also
used to analyse possible dimensional reduction in each domain to
be able to describe its most important characteristics by a few
variables. Eigenvalues larger than one (1.0) were used to select the
relevant components within the domains. Components 1 to 3 in
each domain were considered to be main components and are
reported. Furthermore, the most important variables for a
component are called main determinants, also described in Fig. 1.
Variables in each of the four domains were analysed separately,
but variables of age, BMI and sex were included in all domain
factor analysis.
Furthermore, to analyse if the participants form clusters ac-
cording to the components within each domain, score plots of the
individual participants’ scores according to the components, were
produced and visually analysed. Score plots were also labelled with
colours by sex, malnutrition, frailty, sarcopenia, and dehydration
respectively.
In order to elucidate the relationship between the components
and participants’ nutritional status (defined as malnutrition, frailty,
sarcopenia and dehydration), the participants were divided into
three groups (tertials) due to the individual component score for
the main components in each domain (low e medium e high). The
participants with low score at baseline were compared (with
ManneWhitney U test) to those with high score with regard to
prevalence of malnutrition, frailty, sarcopenia, and dehydration at
baseline and at three year follow up.
Bivariate Pearson correlation was used to test whether there is a
statistically significant linear relationship between the components
within and between the domains, and to determine the strength
and direction of the associations. If p < 0.05, the correlation was
considered statistically significant.
Prior to factor analysis all variables were standardised. For all
statistical analysis we used IBM SPSS Statistics 26.
2.7. Missing data
For various reasons the full data collection was not totally
complete for all participants at baseline and follow up. In these
cases, participants with >70% missing variable data were excluded.
For the remaining participants, missing data was imputed using the
mean value for the variable in question for the subgroup of par-
ticipants matching the participant for which missing data should be
imputed. Primary, subgroups were defined by sex (male or female)
S. Engelheart, D. Andr
en, D. Repsilber et al. Clinical Nutrition ESPEN xxx (xxxx) xxx

Fig. 1. Description of the factor analysis process.

and presence of malnutrition by GLIM criteria (yes or no). If missing
values still was present, secondary subgroups were defined by sex
(male or female) and BMI category (<20, 20e25, 26e30 or >30).
3. Results
This study focused on underlying factors related to nutritional
status associated with the four domains of the proposed model of
nutritional status [1]. A few descriptive statistics of the main
characteristics of the cohort are briefly shown in Table 1 and are
presented in detail elsewhere [16]. At baseline, 69 participants (25
men and 44 women) with mean age of 82 years were included in
the study. For the factor analysis, six participants (9%) were
excluded due to missing data >70% at baseline. At follow up after 1,
2 and 3 years, 5 (9%), 1 (2%) and 2 (6%) individuals, respectively,
were excluded for the same reason (see Supplemental Fig. 1).

Table 1
Characteristics of the population at baseline and follow up at year 1, 2 and 3, by the four domains. Mean and 95% confidence interval are reported within parentheses.

Baseline Year 1 Year 2 Year 3

(n ¼ 42e69) (n ¼ 27e56) (n ¼ 20e41) (n ¼ 13e34)

Sex female 64% 64% 66% 71%

Age years 82 (80e84) 83 (81e85) 84 (82e86) 84 (82e86)
Food and nutrition
Total energy intake kcal 1624 (1495e1754) 1606 (1449e1762) 1570 (1409e1731) 1621 (1456e1788)
Energy intake kcal/kg bw 24 (22e27) 25 (22e27) 23 (20e26) 24 (20e28)
Food intake level quotient 1.3 (1.2e1.4) 1.3 (1.2e1.4) 1.2 (1.1e1.4) 1.3 (1.2e1.5)
Protein intake gram/kg bw 0.9 (0.8e1.0) 0.9 (0.8e1.0) 0.8 (0.7e0.9) 0.9 (0.7e1.0)
Water intake ml/kg bw 26 (23e29) 26 (23e29) 25 (21e29) 26 (21e32)
Vitamin C mg 86 (67e105) 83 (64e103) 87 (63e111) 88 (68e108)
Iron mg 8.0 (7.0e9.0) 7.2 (6.2e8.3) 6.7 (5.9e7.4) 7.6 (6.0e9.1)
Health and somatic disease
EQ-5D score (1 – -1) 0.438 (0.350e0.525) 0.470 (0.377e0.562) 0.381 (0.272e0.490) 0.410 (0.292e0.528)
Medications number/day 7.6 (6.7e8.5) 7.9 (6.8e8.9) 7.8 (6.3e9.4) 9.3 (7.4e11.2)
Severe symptoms number 1.5 (1e2) 1.3 (1e2) 1.1 (1e1) 1.0 (0e1)
Physical function and capacity
Body Mass Index kg/m2 27 (25e29) 28 (26e30) 27 (25e29) 28 (26e31)
Fat free mass kg 44 (41e47) 43 (41e45) 43 (40e46) 44 (40e47)
Fat mass % 38 (35e41) 40 (38e43) 41 (38e45) 43 (39e46)
Chair stand raises/30 s 6.8 (4e7) 7.6 (6e9) 7.9 (6e10) 6.8 (4e9)
Timed up and go seconds 25 (19e30) 21 (17e25) 25 (13e37) 26 (14e38)
Physical activitya category 1-6 2.1 (2e2) 2.3 (2e3) 2.3 (2e3) 2.1 (2e2)
Cognitive, affective and sensory function
Mini Mental State Examination score (0e30) 25 (24e26) 25 (23e26) 24 (22e26) 25 (23e27)
Geriatric depression scale score (0e20) 6.1 (5e7) 5.8 (5e7) 5.2 (4e6) 6.6 (5e8)
a
Category of physical activity from 1 (hardly any or none) to 6 (hard or very hard exercise several times a week).

4
S. Engelheart, D. Andr
en, D. Repsilber et al. Clinical Nutrition ESPEN xxx (xxxx) xxx

Below, the results are presented by each of the four domains.

components (component (all components) components (component (all components) components (component (all components) components (component (all components)
Component 1, 2 and 3, named ‘main components’ (patterns), are

Number of cumulative % cumulative %

presented for each domain. The most important determinants in
each component are named ‘main determinants’.

88%
89%

87%

73%
3.1. Food and nutrition

Total number of components extracted for each analysis are presented, as well as the cumulative percentage of explanation of the sample, in component 1e3 as well as for all extracted components.
Low energy intake (<25 kcal/kg body weight) was present in 25
participants (57%). Compared to the Nordic nutrition recommen-

1e3)

62%
36%

54%

73%
dations [33], eight men and three women had an iron intake below
‘lower intake level’ (7 and 5 mg/day respectively), but none had an
intake of vitamin C below ‘lower intake level’ (10 mg/day), indi-

n ¼ 32
Year 3
cating that most participants had very low probability of an inad-

16
equate intake of those nutrients despite a low energy intake. The

3
inter-individual range of number of eating occasions were large,

Number of cumulative % cumulative %

from three to six occasions per day.
At baseline, nine components were extracted in the domain,
including 30 variables. The main components together explained

87%
86%

82%

57%
52% of the variance among the participants (Table 2). The main
determinants were energy intake (in component 1), fat intake
(component 2) and sex, body size and alcohol intake (component
3), presented in Table 3a. At baseline, component 3 in the domain

1e3)

56%
35%

56%
was strongly correlated (r > 0.7, p < 0.01) with component 2 in the

e
domain Physical function and capacity, characterised by body
composition and sex (presented in Supplemental Table 4a). Also, at

(n ¼ 40)
Year 2
baseline, the main components in the domain were significantly
correlated with eight of the main components in the other

16
8

2
domains.
The results indicate that the energy intake, food intake level and

Number of cumulative % cumulative %

E% fat (within the domain Food and nutrition) should be prioritised
in the nutritional status assessment.

87%
83%

82%

63%
3.2. Health and somatic disorders

Polypharmacy (>5 continuously prescribed medications) was

1e3)

58%
37%

56%

63%
present in 39 participants (77%), and 28 (56%) had one or more
severe symptoms.
The domain included 55 variables whereof 18 components were
(n ¼ 51)

extracted. The main components together explained 31% of the of

Year 1
Results of factor analysis at baseline and follow up at year 1, 2 and 3, by the four domains.

the sample variance (Table 2). The main determinants of the main
16
8

components were appetite, symptoms of heart failure and forget-

fulness (in component 1), s-osmolality and kidney function (in
Number of cumulative % cumulative %

component 2) and BMI and malnutrition (in component 3), see

Table 3b.
The main components in the domain were closely correlated
85%
83%

94%

71%

with the main components in domain Physical function and ca-

pacity at baseline, as a total of seven statistical correlations out of
nine possible (presented in Supplemental Table 4b).
1e3)

The results indicated that the nutritional status assessment

52%
31%

63%

57%

should prioritise the following six variables within domain Health

and somatic disorders: subjective symptoms of having poor appe-
of variables (n ¼ 63)
Baseline

tite, having shortness of breath, having swollen legs or ankles, or

feeling forgetful in combination of s-osmolality and GFR.
18
9

3.3. Physical function and capacity

Number

Mean BMI was 26.8, and 14 (23%) subjects were obese (BMI
30
55

31

>30). The majority of the subjects (n ¼ 44, 79%) had >30% body fat.
Cognitive, affective and
Physical function and

Self-estimated physical activity level was low, in median the

Health and somatic

sensory function
Food and nutrition

category “mostly sedentary, with occasional light activity” (cate-

gory 2).
disorders

capacity

The domain included 31 variables and eight components were

extracted, where the main components together explained 63% of
Table 2

the sample variance (Table 2). The main determinants in the

domain were body size (in component 1), body composition and
5
S. Engelheart, D. Andr
en, D. Repsilber et al. Clinical Nutrition ESPEN xxx (xxxx) xxx

Table 3a
Loadings for the main determinants and their cumulative explanatory value at baseline and follow up at year 1, 2 and 3, by components. Domain Food and nutrition.

Baseline Year 1 Year 2 Year 3

Variable Loading Variable Loading Variable Loading Variable Loading

Domain: Food Component 1 27% 36% 30% 32%

and nutrition Energy intake 0.881 Fat intake 0.951 Fat intake 0.944 Intake of 0.921
monounsaturated fat
Food Intake Level 0.852 Intake of 0.935 Food Intake Level 0.839 Fat intake 0.893
monounsaturated fat
Fat intake 0.799 Food Intake Level 0.922 Intake of monounsaturated fat 0.833 Energy intake/kg bw 0.855
Energy intake/kg bw 0.779 Intake of saturated fat0.871 Intake of polyunsaturated fat 0.821 Food Intake Level 0.841
Component 2 14% 12% 16% 18%
E% Fat 0.877 Carbohydrate intake 0.780 Carbohydrate intake 0.875 Sex 0.813
E% Monounsaturated fat 0.853 E% Fat 0.678 Sex 0.691 E% Saturated fat 0.748
E% Polyunsaturated fat 0.686 E% Monounsaturated fat 0.610 Alcohol intake 0.636 E% Polyunsaturated fat 0.741
E% Saturated fat 0.672 E% Polyunsaturated fat 0.606 Energy intake 0.613 Intake of saturated fat 0.721
Component 3 10% 10% 10% 12%
Sex 0.660 Water intake 0.748 Fibre intake/MJ 0.647 E% Protein 0.801
Body mass index 0.563 Body mass index 0.652 Calcium intake 0.641 Protein intake 0.682
Alcohol intake 0.546 E% Protein 0.633 E% Protein 0.612 Protein intake range 0.663
E% Alcohol 0.508 Fibre intake/MJ 0.508 Protein intake 0.477 Alcohol intake 0.573

Table 3b
Loadings for the main determinants and their cumulative explanatory value at baseline and follow up at year 1, 2 and 3, by components. Domain Health and somatic disease.

Baseline Year 1 Year 2 Year 3

Variable Loading Variable Loading Variable Loading Variable Loading

Domain: Health Component 1 12% 16% 18% 16%

and somatic disease Having poor appetite 0.714 Abdominal pain or 0.812 S-osmolality 0.763 Being short of breath 0.792
chest pain
Being short of breath 0.714 Number of severe 0.805 GFR (mean crea/CysC) 0.734 S-osmolality 0.750
symptoms
Swollen legs or ankles 0.713 Having worries or being 0.795 P-creatinine 0.710 Cystatin C 0.749
anxious
Feeling forgetful 0.713 Having poor appetite 0.770 Having worries or 0.681 Frailty 0.690
being anxious
Component 2 11% 13% 10% 11%
S-osmolality 0.810 Cystatin C 0.802 Feeling tired or 0.747 Having a low mood 0.762
exhausted
P-creatinine 0.724 GFR (mean crea/CysC) 0.763 Number of severe 0.614 Being irritable 0.654
symptoms
GFR (mean crea/CysC) 0.716 GFR (cysC) 0.740 Headache 0.547 Having worries or being 0.649
anxious
Cystatin C 0.711 B-hb 0.678 Poor sleep or 0.508 Number of severe 0.585
nightmares symptoms
Component 3 8% 8% 8% 9%
P-albumine 0.582 Body mass index 0.721 B-hb 0.571 P-potassium 0.637
B-hb 0.560 S-cobalamin 0.610 Age 0.570 Palpitations 0.627
Body mass index 0.543 P-sodium 0.456 P-potassium (mmol/L) 0.527 GFR (crea) 0.571
Malnutrition (MNA) 0.487 S-thyroxin. free 0.450 S-cobalamin (pmol/L) 0.467 Having poor appetite 0.537

sex (in component 2) and physical strength, activity and waist/hip
ratio (component 3); see Table 3c. At baseline, component 1 in the
domain was strongly correlated (r > 0.7, p < 0.01) with component
3 in the domain Health and somatic disorders (characterised by
inflammation, blood counts and body size) as well as with
component 3 in domain Cognitive, affective and sensory function
(characterised by age, body size, sex and depression), where all
three components included body size as a main determinant
(showed in Supplemental Table 4c). The main components in the
domain were significantly correlated with six of the main com-
ponents in the other domains, at baseline (see Supplemental
Table 4c).
The results indicated that BMI, hip and waist circumference,
body cell mass, intracellular water, fat free mass and timed up and
go test should be prioritised in the nutritional status assessment
(within the Physical function and capacity).
3.4. Cognitive, affective, and sensory function
Mean score of Mini Mental State Examination was 25, which
should be regarded as normal in a population of þ80 years old
people with disabilities [34]. Depression symptoms were com-
mon, and the results in 20 participants (36%) indicated possible
presence of depression.
The eight variables in this domain were extracted to four
components. The main components together explained 57% of the
variance in the participants, shown in Table 2. The main compo-
nents’ main determinants were taste, smell, and appetite (in
component 1), sex, appetite, smell, and body size (in component
2) and age, body size, sex, and depression symptoms (in compo-
nent 3), see Table 3d. The main components in the domain were
significantly correlated with nine of the main components in the
other domains, at baseline (see Supplemental Table 4d).

6
S. Engelheart, D. Andr
en, D. Repsilber et al. Clinical Nutrition ESPEN xxx (xxxx) xxx

Table 3c
Loadings for the main determinants and their cumulative explanatory value at baseline and follow up at year 1, 2 and 3, by components. Domain Physical function and capacity.

Baseline Year 1 Year 2 Year 3

Variable Loading Variable Loading Variable Loading Variable Loading

Domain: Physical Component 1 29% 29% 29% 32%

function and capacity Body weight 0.917 Body weight 0.918 Body weight 0.898 Waist circumference 0.943
Body water 0.917 Waist circumference 0.915 Fat free mass 0.856 Body weight 0.941
Fat free mass 0.892 Total body water 0.889 Waist circumference 0.840 Total body water 0.864
Waist circumference 0.874 Fat free mass 0.876 Total body water 0.832 Body mass index 0.838
Component 2 21% 15% 14% 13%
Fat mass (%) 0.817 iADL: Cooking 0.620 Hip circumference 0.712 iADL: Cooking 0.811
Fat mass (kg) 0.752 Chair stand test 0.593 Fat mass (kg) 0.705 iADL: Washing 0.707
Hip circumference 0.566 Physical activity) 0.578 Body cell mass 0.608 Handgrip strenght 0.597
Body cell mass 0.513 Fat mass (%) 0.567 Mid arm circumference 0.598 iADL: Shopping 0.611
Component 3 12% 13% 13% 9%
iADL: Shopping 0.736 Handgrip strenght 0.585 Physical activity 0.709 Body cell mass 0.738
iADL: Cleaning 0.697 Body height 0.546 iADL: Cooking 0.679 Days of walking 0.487
Physical activity 0.587 Timed up and go 0.541 Chair stand test 0.640 Intracellular water 0.450
iADL: Cooking 0.563 Body cell mass 0.521 iADL: Transportation 0.571 iADL: Shopping 0.424

Table 3d
Loadings for the main determinants and their cumulative explanatory value at baseline and follow up at year 1, 2 and 3, by components. Domain Affective and sensory function.

Baseline Year 1 Year 2 Year 3

Variable Loading Variable Loading Variable Loading Variable Loading

Domain: Cognitive. Component 1 24% 30% 41% 38%

affective and sensory function Sense of taste 0.784 Sense of taste 0.865 Sense of taste 0.900 Sense of appetite 0.918
Sense of smell 0.674 Sense of smell 0.818 Body mass index 0.694 Sense of taste 0.856
Sense of appetite 0.586 Sense of appetite 0.701 Sense of smell 0.671 Sense of smell 0.845
Body mass index 0.670 Depression score 0.597
Component 2 18% 19% 16% 19%
Sex 0.612 Depression score 0.676 Sense of taste 0.912 Sex 0.645
Sense of appetite 0.576 Age 0.616 Sense of appetite 0.899 Mini Mental State 0.597
Examination
Body mass index 0.495 Mini Mental State 0.593 Depression score 0.684 Age 0.546
Examination
Sense of smell 0.448 Body mass index 0.661 Sense of taste 0.426
Component 3 15% 14% 16%
Age 0.622 Sex 0.683 Body mass index 0.636
Body mass index 0.506 Body mass index 0.545 Age 0.619
Sex 0.475 Mini Mental State Examination 0.503
Depression score 0.403 Depression score 0.488

The results indicated that the following three variables within
the domain Cognitive, affective, and sensory function should be
prioritised in the nutritional status assessment: self-estimated
sense of taste, smell, and appetite.
3.5. Individual component score and its consequences
Score plots with the two main components within each domain
at baseline and at year 1 follow up revealed no clear clusters or
obvious outliers. However, when the plots were coloured by sex,
some clusters appeared, mostly confirming that sex or variables
related to sex differences (i.e. muscle strength) also were main
determinant in a component. If score plots were labelled by pres-
ence of malnutrition, frailty, and sarcopenia, respectively, no clear
clusters appeared for either of the main components in none of the
four domains. However, some clusters appeared if labelled by
dehydration.
The prevalence of inadequate nutritional status (defined as
malnutrition, frailty, sarcopenia, and dehydration respectively) at
baseline and at annual follow up is presented in Supplemental
Table 5. If the individual component scores were allocated to ter-
tials at baseline (presented in Supplemental Table 6) and compared
with respect of the prevalence of malnutrition, a difference be-
tween individual score category in components in all four domains
was found. After three years, no significant difference occurred in
the prevalence of malnutrition according to individual component
score at baseline.
There were differences between individual component scores
according to the prevalence of frailty in main components in all
domains except for the components in the domain Cognitive, af-
fective, and sensory function. After three years, the prevalence of
frailty was still more common in participants with either a high
score in component 3 at baseline in the domain Food and nutrition
(being a male with high BMI and alcohol intake), with high score in
component 1 in the domain Physical function and capacity (high
body weight, large hip and waist circumference), or with high score
in component 2 in the domain Cognitive, affective and sensory
function (being a male with good appetite and high BMI), at
baseline.
Sarcopenia was more prevalent in participants with high score
in main components in domain Physical function and capacity as
well as high score in domain Cognitive, affective, and sensory
function. After three years, sarcopenia was more common in par-
ticipants with low score, compared to those with high score, in
component 1 in the domain Physical function and capacity, at
baseline.
Presence of dehydration, at baseline, differed according to the
tertials of the component scores in one or more main components

7
S. Engelheart, D. Andr
en, D. Repsilber et al.
in all four domains. However, after three years the prevalence of
dehydration was not significantly different between high or low
individual component score in any domain at baseline.
4. Discussion
This study is an explorative statistical analysis of a compre-
hensive set of indicators of nutritional status, in order to reveal
patterns and relationships within and between four domains of a
theoretical model of nutritional status. The results provided sta-
tistically significant empirical evidence for the existence of patterns
as well as relationships within and between the four domains. We
present, separately for each domain, patterns and a reduced (i.e.
simplified) set of main indicators. Most importantly, our result
confirmed that the four domains include patterns that were
dependent on each other. Hence, the domains statistically inter-
acted with each other, and with the nutritional and the functional
status. The relationships between the four domains in this sample
might be partly explained by inflammation, as it is affecting all
domains [35,36]. Inflammation could be both a cause and an effect
of diseases and is negatively affecting the anabolic processes and
could decrease appetite and food intake. The theory of inflam-
maging [35] includes presence of chronic low-grade inflammation,
that is proposed to contribute to age-associated morbidity and
mortality. However, in our sample inflammation (P-CRP >5 mmol/
L) was only present in 38% of the participants at baseline [16]. A
larger sample size and an experimental design that allows eluci-
dations of causal effects may provide more robust analysis of the
nutritional status.
The theoretical model of nutritional status used in this study is
based on a wide spectrum of comorbidity in an unspecific way.
Minor adaptations might be valuable when using in patients with
specific clinical syndromes or diseases.
The factor analysis indicated that the following 19 measure-
ments should be prioritised in the nutritional status assessment:
energy intake, food intake level and E% fat; subjective symptoms
of appetite, shortness of breath, swollen legs or ankles or forget-
fulness in combination with s-osmolality and GFR; BMI, hip and
waist circumference, body cell mass, intracellular water, fat free
mass and timed up and go test; and self-estimated sense of taste,
smell and appetite. All these determinants are, to some extent,
intuitive or already known risk factors of the nutritional status of
malnutrition [37,38].
The participants in this study, comprising old men and women
receiving home health care because of their health status, have low
energy intake but not deficient nutrient intake, although not
optimal according to the Nordic Nutrition Recommendations [33].
Polypharmacy was common and physical activity was very low, in
line with earlier findings [39,40]. Cognitive function was within
normal level for this age group, and depression symptoms sug-
gested that one third of the participants might be clinically
depressed. In another study [16], we reported that the prevalence
of inadequate nutritional status in the same cohort, was high: 83%
had malnutrition, 45% was dehydrated, 44% had sarcopenia, and
34% was frail. During the three year follow up the prevalence of
inadequate nutritional status decreased, except for dehydration,
that increased. These results together indicate and articulate that
old people receiving home health care are fragile and are at risk of
nutritional problems. However, our results also help to better
define and understand nutritional problems in terms of the un-
derlying domains, as to easy clinical assessment of such problems.
The number of extracted components within each domain
suggested a high covariance in a few specific patterns. In all four
domains there was a high cumulative percentage of explanation of
the variation of the data in the first three components. This
8
Clinical Nutrition ESPEN xxx (xxxx) xxx
indicated clear patterns and strong relationships within the do-
mains. For instance, at baseline, the main components in domain
Physical function and capacity explained 63% of the variance in this
study cohort. Albeit not explaining the total (100%) of the data
variance, no variable was totally unnecessary to grasp the entire
picture, but our results provided a good indication of where to start
the nutritional assessment.
For variables within the domain Food and nutrition, most of the
sample variance was explained by energy and fat intake, and that
component itself explained about a third of the variation, making it
a major component of the variation of the sample, in this domain.
This was expected, as intake of macro- and micronutrients is
known to depend on the total energy intake [41]. The fat intake and
food intake level were main determinants of component 1 in this
domain also at follow up at year 1, 2 and 3. This indicated that these
variables, as indicators of Food and nutrition domain, are important
to record and evaluate in health care praxis.
In the domain Health and somatic disorders, renal function
seemed to be important as it appeared in the first three compo-
nents at baseline as well as in follow up. At baseline, poor appetite
was one of the main determinants explaining the sample variation
in the first component, supporting that loss of appetite is an
important indicator of nutritional status and health outcome [16].
Appetite was also a main determinant of component 1 in the
domain Cognitive, affective, and sensory function.
In the domain Physical function and capacity, a body size-
related pattern was observed in component 1, which remained
stable at follow up at 1, 2 and 3 years. The body size and its relation
to physical function has also been studied by Al Snih et al. [42]
suggesting different BMI cut off values in older people depending
on the chosen outcome; a lower BMI (about 24) was suggested
being optimal for preserved functionality, but a higher BMI (about
27) was suggested being optimal analysing seven year mortality.
The same component, completed with fat free mass, were the
variables that most European nutrition experts agreed upon as
important for the definition of malnutrition according to
consensus-based diagnostic criteria [8].
The factor analysis of this sample did not provide any statistical
evidence for the importance of age for the nutritional status and the
four domains. Also, either sex or BMI clearly stood out to be the
over-all explaining variables of the nutritional status, as might be
hypnotised. The nutritional status is far more complicated than
that.
In this study we found empirical evidence for the theoretical
expectations of the proposed nutritional status model, in the sense
that the domains, presented in the model as gears that connect to
each other in an ongoing machinery, indeed interacted and were
not independent of each other. We also found that the prevalence of
the nutritional status of malnutrition, frailty, sarcopenia, and
dehydration were associated with the individual component score
in the first three components in each domain. The individual
component score is an indicator of how each participant was
ranked with respect to that component and to all other participants
in the study. A high component score indicated that the participant
is highly ranked with respect to the component by his/her score in
the specific component (example in high BMI, high body weight
and high hip and waist circumference). A low component score
indicated the opposite (low BMI, low body weight etc.). However,
an individual component score close to zero indicated that the
participant are intermediate ranked with respect to the specific
component and the other participants.
Main determinants, of the components associated with higher
prevalence of dehydration were; being male with high BMI and
high alcohol intake; high s-osmolality and low GFR; low albumin,
haemoglobin, BMI and malnutrition score; high body weight, waist
S. Engelheart, D. Andr
en, D. Repsilber et al.
and hip circumference; being a male with good appetite and high
BMI, but decreased sense of smell. Some of these determinants
confirmed previously presented risk factors by Wotton et al. [43],
but with one opposite result: In our study being a male was found
to be a main determinant for dehydration (in combination with
BMI, and sense of appetite and smell), contradictory to Wotton et al.
who found that being a female was a risk factor for dehydration.
Prevalence of frailty or sarcopenia was not associated with
components in all four domains, but in three and two respectively.
Interestingly, prevalence of sarcopenia was not associated with any
of the main components in the domain Food and nutrition. How-
ever, it is still unknown how and to what extent diet contributes to
the development of sarcopenia, as reports are contradictory [44,45].
In this study, the multidimensionality of variables was a strength,
with a total of more than 100 variables measured in each participant.
However, a weakness of the study was the limited number of par-
ticipants (n ¼ 69), which makes deeper analysis impossible due to a
very low number of degrees of freedom. Additionally, the very low
participation rate (32%) requires special statistical methods to
eliminate the potential of selection bias. Nonetheless, collecting
data, both the number of study participants followed for three years
and performing the measurements in the participants homes was a
major effort. Hence, performing larger studies with a larger sample
requires more resources and to some extent other methods (e.g.
digital devices). Unfortunately, we do not have any information
about patients who declined participation in our study. Therefore,
the results and conclusions should be interpreted keeping in mind
that the results are based on participants that agreed to participate.
Given these technical limitations of our data, we provided results in
line with the major aim of this study, which was to perform an
explorative empirical analysis of the nutritional status with a sta-
tistical approach that allowed to identify and test the relationships
between the components of each of the four domains.
To our knowledge, there are only two previous studies, origi-
nating from the 1970s, that empirically analysed indicators of the
nutritional status using factor analysis [46,47]. However, these
studies comprised a much lower number of variables and focussed
on preschool children respectively adolescents and adults. In the
study of the preschool children, a total of 32 variables (in four do-
mains) were reduced to 10 components. In the adolescents and
adult study, a total of 28 variables (in three dimensions) were
reduced to eight variables, with no reduction in diagnostic potential.
Further studies are needed in populations similar to this (fragile
old people) but also in other populations, e.g. community dwelling
older adults, different age cohorts or in populations specified by
illness, e.g. dementia, cardiovascular diseases, osteoporosis.
5. Conclusion
This study explored the nutritional status with a statistical
approach, using a wide range of variables that might have a role in
describing nutritional status. Results confirmed a close interrela-
tion between the four domains presented in the theoretical model
of nutritional status; Food and nutrition; Health and somatic dis-
orders; Physical function and capacity; and Cognitive, affective, and
sensory function. We suggested that the 103 included variables
may be reduced to 19 in a first analysis of nutritional status in old
people. We concluded that all previously determined domains in
fact are associated with nutritional status in old men and women
receiving home health care.
Funding statement
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
9
Clinical Nutrition ESPEN xxx (xxxx) xxx
Author contribution
All five authors have been engaged in the conceptualization and
methodology of the study as well as in writing, reviewing and
editing the manuscript. All five authors have final approved the
submitted version of the article.
Declaration of competing interest
All authors declare that there is no conflict of interest’.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.clnesp.2021.08.036.
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