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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 61:935-942 (2006)
© 2006 The Gerontological Society of America

Effect of Family-Style Meals on Energy Intake and Risk of Malnutrition in Dutch Nursing Home Residents: A Randomized Controlled Trial

Kristel A. N. D. Nijs, Cees de Graaf, Els Siebelink, Ybel H. Blauw, Vincent Vanneste, Frans J. Kok and Wija A. van Staveren

1 Division of Human Nutrition, Wageningen University, The Netherlands.
2 Zorgcentrum Tilburg Zuid, Tilburg, The Netherlands.
3 Julius Center for Health Sciences and Care, University Medical Center, Utrecht, The Netherlands.

Address correspondence to: Kristel Nijs, MSc, Wageningen University, Division of Human Nutrition, PO Box 8129, 6700 EV Wageningen, The Netherlands. E-mail: Kristel.Nijs{at}wur.nl


   Abstract
Top
 Abstract
Participants and Methods
 Results
 Discussion
 References
 
Background. Social facilitation and meal ambiance have beneficial effects on food intake in healthy adults. Extrapolation to the nursing home setting may lead to less malnutrition among the residents. Therefore, we investigate the effect of family-style meals on energy intake and the risk of malnutrition in Dutch nursing home residents.

Methods. In 2002 and 2003, a randomized controlled trial was conducted among 178 residents (mean age 77 years) in five Dutch nursing homes. Within each home, two wards were randomized into an intervention (n = 94) and a control group (n = 84). For 6 months, the intervention group received their meals family style, and the control group received the usual individual preplating services. Outcome measures were intakes of energy (kJ), carbohydrates (g), fat (g), and protein (g) and Mini Nutritional Assessment (MNA) score (0–30).

Results. The change in daily energy intake between the control and intervention group differed significantly (991 kJ; 95% confidence interval [CI], 504–1479). The difference in intake of macronutrients was 29.2 g (95% CI, 13.5–44.9) for carbohydrate, 9.1 g (95% CI, 2.9–15.2) for fat, and 8.6 g (95% CI, 3.4–13.6) for protein. The percentage of residents in the intervention group classified by the MNA as malnourished decreased from 17% to 4%, whereas this percentage increased from 11% to 23% in the control group.

Conclusions. Family-style meals stimulate daily energy intake and protect nursing home residents against malnourishment. Therefore, replacement of the preplating meal services with family-style meals in nursing homes is recommended.

IN Western countries, prevalence of malnourishment among elderly persons living in nursing homes ranges from 17% to 65% (1). Malnutrition among elderly persons can be classified into cachexia (involuntary loss of fat-free mass [FFM] without weight loss), wasting (involuntary weight loss), and sarcopenia [loss of muscle mass and strength (2)]. These conditions are determined by a variety of causes, among which are physiological, psychological, medical, social, and environmental factors. Malnutrition has serious negative consequences, such as a higher prevalence of infections, hospitalization, and dysfunctions, and an increased morbidity and mortality (2–5). Prevention of malnutrition has favorable effects on the independence and quality of life of nursing home residents (6,7).

Because malnutrition in nursing home residents has many determinants, this issue has to be addressed with a multifactorial intervention. One important factor that can be modulated easily in a positive way is meal ambiance. Ambiance, defined as the atmosphere of the social and physical environment present with a meal, may stimulate eating behavior. Color, sound, smell, texture, portion size, presentation, and the presence of others may contribute favorably to food consumption (8). Eating with others has shown to lead to an energy intake increase of up to 76% compared to eating alone (9). The concept of improved meal ambiance can be implemented in a nursing home setting through the way food is served, the presence and behavior of nurses, and the organization around the meal.

The results of four previous intervention studies in frail elderly persons on meal ambiance and nutritional status are inconclusive, due to the small sample sizes, limited study duration, or lack of control group (10–12). In two studies, the food delivery system was changed from a preplating service to a more homelike service. In both studies, the intervention resulted in a significant increase in food intake (1400 kJ, standard deviation = 800 kJ, n = 16) (1550 kJ, n = 22); but in neither study did body weight significantly change (13,14). A buffet style program had no effect on either body weight or on the biochemical markers of nutritional status of the residents [n = 40 (11)]. In our 1-year intervention pilot study, residents (n = 22) gained weight (3.3 kg), but no statistically significant increased food intake was reported (15). This negative finding may be attributed to a lack of statistical power (n = 22). Therefore, we conducted a 6-month intervention study in five nursing homes to investigate whether family-style meals increase energy intake sufficiently to improve or maintain energy balance and to decrease the risk of malnutrition of Dutch nursing home residents.


   PARTICIPANTS AND METHODS
Top
 Abstract
 Participants and Methods
Results
 Discussion
 References
 
Recruitment
The nursing homes were recruited by an advertisement in a nationwide journal for nursing homes. In total, 53 nursing homes expressed interest; five of them met our eligibility criteria. The nursing homes had to be medium sized (175–275 beds) with a general nursing home population. There had to be two wards with residents with chronic somatic diseases and long-term care or permanent stay. At the time of admission to the nursing home, the residents were assigned to one of these wards based on vacancy of beds and not based on the main diagnosis of diseases. The eligible wards had to be similar on the following levels: (i) the personnel working on the wards had to be similar in number, discipline, and education; (ii) the wards had to be similar in infrastructure and location; (iii) the residents living on the ward had to have similar day scheme/day activities; and (iv) the nursing homes had to be located in different parts of the country.

Wards were randomly allocated to either the control or intervention ward. The randomization was based on the ward's name. The ward with the name of which the initial letter came first in the alphabet became the intervention ward. We did not visit the wards or have any contact with the staff and residents before allocation. Furthermore, the management of the nursing homes was not aware of the allocation procedure. Only after this procedure did the researchers visit the wards and their personnel.

In total, 282 nursing home residents were invited to participate in a study to examine the effects of a new foodservice system. All residents received an information brochure of the study, and were invited to attend an information meeting. The information brochure stated to which group they were allocated and what the consequences were for them. Written informed consent was obtained by the nurses after the meeting. Residents were excluded when they had a life-threatening disease, had total parenteral feeding, or were not able to give informed consent due to their physical or mental condition. The medical ethical committee of Wageningen University, the client board, and medical ethical committees of the participating nursing homes approved the study protocol.

Family-Style Meal Organization
The 6-month intervention program consisted of five modules: table dressing, food service, staff protocol, residents' protocol, and mealtime protocol (Table 1). Before the start of the meal, tables were set with tablecloths, silverware, and china. The cooked meal was served in dishes, and residents had the opportunity to choose from two kinds of vegetables, two kinds of meat, and potatoes. Breakfast and lunch were also served in family-dinner style.


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  		Table 1. Detailed Intervention Description to Optimize the Meal Ambiance in Dutch Nursing Homes.

 
The control wards maintained the individual preplating service in which the residents had to choose their menus 2 weeks beforehand. At lunchtime, these residents received their tray with their soup, main course, side dish, and dessert. On request, the residents could dine alone or in their rooms. On the tables there were no tablecloths, flowers, or other mealtime attributes. Staff did not sit down with the individual residents, but kept an eye on the group. They distributed the residents' medication or were having private conversations during the residents' meal.

In both groups, residents had breakfast from 7:00 AM until 10:00 AM, lunch at 12:30 PM, and dinner at 5:00 PM. After study implementation, only the duration of the cooked lunch of the intervention group lasted longer (10–15 minutes). Nonparticipating residents were given the same meal services as participating residents in their ward.

Implementation Conditions
In each nursing home, a strictly standardized implementation protocol was followed. The management teams of the nursing homes were contacted and after their consent, the eligible wards were approached for participation. In the intervention wards, project teams were formed and consisted of the head of the ward, the nutrition assistant of the ward, a dietician, the head of the kitchen, and the facility manager of the nursing home. The implementation plan and the intervention were explained to the staff. We emphasized that the cooking staff had to deliver the meals in the intervention ward in dishes instead of on trays. They had to offer the same menu choice in both trial wards. Food availability was kept the same for the intervention and the control group by limiting the amount in the dishes to the sum of the individual portions for the number of residents sitting at the table. To accommodate the increased workload of the staff due to the changes in tasks, the cooked lunchtime meal was changed first, and 1 month later the service of breakfast and dinner was changed.

The control wards were not allowed to implement any food-related changes during the study period. During the 6-month period, the researcher (KN) made unannounced visits to the wards, three times a month, to determine that the nurses made no changes to the meal programs in the intervention or the control ward. Each ward had their own staff; the staff members did not switch from the intervention to the control ward.

Baseline Data
The baseline characteristics sex, age, length of stay, number of drugs, and dietary supplements were collected from the nursing files of the residents. The use of dentures was determined by asking the resident.

Outcome Measures
Energy intake.-- Trained project dieticians measured food intake with the observation and weighing-back method during three working-days before and after the intervention (16). In general, these days were independent of each other. An observation day started at 6:00 AM and ended at 10:00 PM. All food and drink consumed by the residents for 3 days were recorded. One day prior to the dietary assessment, the content of household equipment (e.g., spoons, cups), portion sizes, and recipes of the meals were measured three times; the mean was used as a standard portion. Energy intake during bread-based meals and snacks between meals were measured by observation using the computed standard portions of the involved nursing home. The portion sizes of each meal component of the cooked meals were weighed for three standard meals of each day. These measures, combined with the individual ordered menu of the resident, gave the amount of food that the residents received. After the meal, the leftovers of all meal components of each resident were weighed back. Due to the change in the cooked meal services in the intervention group from individual plates to serving dishes, the observation and weighing-back method had to be adapted for the end measurement. Before serving, the content of the serving dishes was weighed, and a trained dietician carried out the task of the table nurse while she observed how many household units the residents took. Afterwards, the leftovers of the individual plates and serving dishes were weighed. During the night, nurses noted if a resident consumed some food and drinks. The obtained dietary data were converted into macronutrients by using a VBS food calculation system (BAS nutrition software; Wageningen, The Netherlands), a computerized version of the Dutch Food Composition Table 2001 (17).

Mini Nutritional Assessment.-- We used the Mini Nutritional Assessment (MNA) as a tool to identify residents at risk of malnutrition (18,19). The assessment questionnaire consists of 18 questions, which can be classified as: (a) anthropometric assessment (weight loss over past 3 months, body mass index [BMI], mid upper arm circumference, and calf circumference); (b) general assessment (six questions related to lifestyle, medication, and mobility); (c) dietary assessment (eight questions related to number of meals, food and fluid intake, and autonomy of feeding); and (d) subjective assessment (self-perception of health and nutrition). The maximum score of the MNA is 30 points. A total score of 17–23.5 indicates risk of malnutrition, a score of < 17 indicates existing malnutrition, and a score of > 23.5 indicates a satisfactory nutritional status. The MNA assessment was performed as indicated by the MNA clinical practice user guide and performed the day after energy intake measurements.

Body weight.-- We used mechanical sitting weighing scales (to the nearest 0.2 kg; Seca, Hamburg, Germany) a digital sitting scale (to the nearest 0.1 kg; Cormier Romainville, France), and digital lifts with a weighing device (to the nearest 0.1 kg; UWE, Taipei Hsien, Taiwan; ARJO, Tiel, The Netherlands; TR-Care, Ochten, The Netherlands) to measure body weight. All weighing scales were calibrated 1 hour before measuring by putting 60 kg on the scales. Body weight was corrected when scales were deviant. The nurses measured the body weight of the residents in the presence of the researcher (KN). Body weight was measured between 2:00 PM and 4:00 PM and after voiding. The residents were wearing normal clothing without cardigan and shoes. Body weight and body composition were measured on the same day 1 week before energy intake measurements.

Body composition.-- Body composition was measured at 7 AM before breakfast and after voiding. The residents wore their nightclothes and were still lying in their hospital bed. Two adhesive electrodes with a surface area of 5 cm2 were placed on the left hand and two on the left foot. Impedance resistance was measured at 50 kHz using a Xitron 4000 bioimpedance analyzer (Xitron Technologies, San Diego, CA). Total body water was calculated for women as 0.2715 x Height2/Z50 + 0.1087 x body weight + 11.9 (20) and for men as 0.3228 x Height2/Z50 + 0.1652 x body weight + 8.3 (20). FFM was calculated as total body water/0.732 (21). Fat mass was calculated as body weight – FFM.

Arm and calf circumferences.-- Mid upper arm and calf circumference were measured as indicated by the MNA clinical practice user guide. The mid arm circumference was measured at the nondominant arm. The resident had to bend the arm at the elbow at a right angle with the palm up. The distance between acromial surface of the scapula and the olecranon process of the elbow on the back of the arm was measured, and the midpoint was marked. After that, the resident let the arm hang loosely, and the circumference was recorded with a tape measure to the nearest 0.1 cm.

The calf circumference was measured while the resident was sitting with the leg hanging loosely. The tape measure was wrapped around the calf at the widest part. Additional measurements above and below the widest point were taken to ensure that the first measurement was the largest. Calf circumference was measured to the nearest 0.1 cm.

All anthropometric measures were performed in duplicate, and the mean was used. If the two measurements differed by more than 5 mm or 0.5 kg, measurements had to be retaken.

Statistical Analyses
The sample size was calculated on the basis of a 210 kJ/day extra intake, which in a 6-month period would lead to a 1.2 kg weight gain in healthy adults. A sample size of 60 persons in each group was needed to achieve significance difference in energy intake at a level of 5% with 90% statistical power for a two-tailed type I error. Because of an expected mean dropout rate of 50% over a 6-month period, the total number of residents in each group at the start of the study was estimated to be 120 (22).

The randomization took place on the nursing ward level, not on resident level. Therefore, we performed a linear mixed model with random intercept to adjust for clustering effects within wards (23).

Adjustments were made for age, because residents in the intervention group were older (see Table 2) (24). Although baseline sex and length of stay were not significantly different between the control and intervention group, we adjusted the models for these two factors because other studies showed an effect of sex and duration on changes in body weight. In further analyses, the variable nursing home turned out to be a confounder; therefore, all outcome measures were also adjusted for the unmeasured effect of nursing home.


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  		Table 2. Baseline Characteristics of the Intervention and Control Group.

 
The MNA classifications were analyzed with the nonparametric Mann–Whitney U test. Statistical analyses were carried out using the SAS 9.1 system (SAS Institute Inc., Cary, NC).


   RESULTS
Top
 Abstract
 Participants and Methods
 Results
Discussion
 References
 
Residents' Baseline Characteristics
Of the 282 residents invited to participate, 250 were willing to cooperate. We excluded five residents because one was subcomatose, two were declared terminally ill, and two switched over to parenteral nutrition after they gave their consent. During the research period, 34 residents died, 11 moved to another institution or nursing ward, 19 were discharged, and 3 residents withdrew their consent. In total, 178 residents completed the study. Complete data of food intake were available of 94 residents of the intervention group and 84 residents of the control group (see Figure 1). Baseline characteristics are presented in Table 2.


Figure 01
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  		Figure 1. Study flow chart

 
Energy Intake
Mean energy intake of the residents of the intervention group was 5979 kJ at baseline. After the intervention period, this intake increased by 483 kJ (95% confidence interval [CI], 88–878). The control group had a baseline mean energy intake of 6285 kJ, and by the end of the intervention period their mean intake dropped by 420 kJ (95% CI, –713 to –127). The estimated mean of individual changes between control and intervention group differed significantly (992 kJ; 95% CI, 504–1479) (see Table 3).


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  		Table 3. Mean 24-Hour Energy Intake (SE) of Dutch Nursing Home Residents Before and After the Meal Ambiance Intervention, Changes (SE), and Estimated Difference With CI.

 
Macronutrients
Carbohydrate (12.9 g; 95% CI, 0.28–27.1), protein (4 g; 95% CI, 1.4–6.4), and fat (4.5 g; 95% CI, 0.8–8.4) intake within the intervention group increased significantly. Within the control group, the decreases of carbohydrate (–14.9 g; 95% CI, –23.4 to –6.4) and protein (–3.7 g; 95% CI, –6.3 to –1.1) intake were significant, but were not for fat intake (–3.1 g; 95% CI, –7.9 to 1.6). The estimated difference between control and intervention was 29 g (95% CI, 13.5–44.9) for carbohydrate, 9.1 g (95% CI, 2.9–15.2) for fat, and 8.6 g (95% CI, 3.4–13.6) for protein (see Table 3).

MNA and Anthropometric Data
Mean MNA score increased statistically significantly (95% CI, 1.5–3.4) within the intervention group by 2.5 points, whereas it decreased significantly (95% CI, –0.1 to 3.1) within the control group by 1.5 points (Table 4). The estimated difference between control and intervention was 3.9 (95% CI, 2.3–5.6).


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  		Table 4. MNA Score and Mean Anthropometric Data of the Residents Before and After the Meal Ambiance Intervention in Dutch Nursing Homes, Changes (SE), and Estimated Difference With CI.

 
Similar trends were seen for the variables mid upper arm and calf circumference, but the estimated differences between groups (0.52 cm and 0.53 cm) were not statistically significant (95% CI, –0.2 to 1.3 and 95% CI, –0.06 to 1.1). In contrast, the decrease (–1.1 kg) of body weight in the control group and the estimated difference (1.5 kg; 95% CI, 0.4–2.7) between the groups were statistically significant. In both groups, the FFM of the residents decreased. The estimated difference between both groups for FFM was 1.3 kg (95% CI, 0.12–2.4). The variable fat mass had a trend similar to that observed for body weight (0.5 kg; 95% CI, –1.4 to 2.2).

MNA Classification
At baseline, the MNA classification of both groups was similar (p =.15), but at the end of the study, MNA classification of the groups was statistically significantly different (p <.0001). After the 6 months, the group with a satisfactory nutritional status among the intervention group increased from 20% to 51%, whereas this percentage decreased from 25% to 17% in the control group. The percentage of residents with risk of malnutrition in the intervention group decreased from 63% to 45%, whereas this percentage remained stable in the control group. The percentage of the residents who were malnourished according to the MNA decreased from 17% to 4% in the intervention group, whereas this percentage increased from 11% to 23% in the control group. The changes within groups were statistically significantly different (z = –4.5, p <.001) (See Figure 2).


Figure 02
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  		Figure 2. The differences in percentages of classification in the Mini Nutritional Assessment of Dutch nursing home residents after the meal ambiance intervention. Note that the end classification between groups was statistically significant (z = –5.1, p <.0001)

 

   DISCUSSION
Top
 Abstract
 Participants and Methods
 Results
 Discussion
References
 
This intervention study of Dutch nursing home residents demonstrated that changing the meal services from individual preplating services to family-style meals has a beneficial effect on the food intake (energy and macronutrients), body weight, and body composition of the residents. The percentage of residents in the intervention group classified by the MNA as malnourished decreased from 17% to 4%, whereas this percentage increased from 11% to 23% in the control group. Family-style meals decrease the risk that nursing home residents will become malnourished.

In this study 89% of the invited residents agreed to participate. A total of 28% of the residents who started the study did not complete it for various reasons (e.g., deceased or discharged). These residents had similar characteristics as the residents who completed the study, except for length of stay (z = –5.36, p <.0001). The characteristics of the noncompleters of the control and intervention groups were also similar. Moreover, considering the low nonresponse (11%) and the general inclusion criteria, we conclude that the study population was representative of Dutch nursing home residents with a chronic somatic disorder.

To observe potential effects of the intervention on energy intake and nutritional status, accurate measurement of food intake and anthropometry are of major importance. Therefore, we used the observation and weighing-back method instead of self reports to assess daily energy intake (16). Calculating the mean daily intake for 3 days of each resident reduced the effect of the day-to-day variation of energy intake (16). Within each nursing home the same dieticians performed the energy intake observation for the control and intervention group. The dieticians were trained for 2 days in weighing and estimating amounts of food and in how to code the obtained data. To lower the influence of observation on the normal eating behavior of the residents, measurements of the content of all used household units were performed 1 day prior to the energy intake observation. The dieticians were presented as researchers to the residents to prevent residents from feeling restricted in their eating behavior. After changing the meal service, dieticians had to sit down with the residents of the intervention group to observe their intake. Therefore, the dieticians could not be blinded for the intervention. During the rest of the day, the energy intake observation method stayed the same. In conclusion, we hold the view that the chosen strategy for food intake recording was reliable and valid, and that this type of intervention within this population is the most feasible, with minor burden to the residents.

BMI is not a very reliable parameter in frail elderly persons. It does not take into account the changes in stature and body composition (25). Therefore, a more accurate indicator of the nutritional status was needed. The MNA was developed and validated especially to evaluate the risk of malnutrition, and takes into account different predictors of malnutrition: anthropometric (weight, height, and weight loss), global, dietary, and subjective data (26). Based on the MNA, 14% of our study population was malnourished and 65% was at risk. These numbers were more realistic than were the results based on the BMI classification.

Family-style meals were defined in a fixed protocol that in each intervention ward had to be implemented without major changes. The meals were presented differently to the control and intervention residents, but the meal components themselves came from the same cooking units. Nutrition assistants in the intervention group were trained to order the same amounts of food they ordered before the intervention. In this way, the residents were offered meals which were similar with respect to weight and nutrient content. The only two differences were the presentation of the food and the moment of choice. The fact that both groups had the same food as well the same available amount implies that the effects of the current intervention cannot be attributed to differences in food availability or food composition.

The potential confounding effect of factor of attention is minimized by an intervention period of 6 months. At the end (month 8), the ambiance project was seen as a normal procedure, and most residents could not remember the old individually preplating services. After such a long period, the effect of attention should be similar in both groups.

An important factor to explain the observed effect is the process of social facilitation (the enhancement of a behavior due to the sheer presence of others). The sights and sounds of others doing the same thing augment ongoing responses (27). Family-style meals could encourage the feeling of having the meal in the company of others; therefore, residents ate more than they did when having their meals in individual preplating services. Social facilitation of meal size is not only related to the number of others present, but also to the extension of meal duration and the more social atmosphere (28). Besides the number of residents, specific company (such as family, friends, and nurses) may enhance energy intake (29). The social interaction during these meals increased by the extra attention residents received from the nurses who were sitting at the tables and who were instructed to stimulate conversations. In this study we cannot say which part of the intervention protocol had the most impact on the residents. The protocol we used has to be considered as one package; other models, such as restaurant, meals prepared by the residents, and wait-staff service, could have the same effect (13,30).

In addition to the group effect and the social atmosphere, family-style meals allow residents to choose their food during dinner and no longer have to order their food 2 weeks ahead. In this way, the residents experienced a larger variety of food choice, which stimulated their appetite (31,32). In combination with the social atmosphere and the group setting, this might have led to a further increase of food intake.

Baseline energy intake (6.1 MJ/day) of the residents is in accordance with earlier observations (5.4 MJ/day and 6.1 MJ/day, 5.8 MJ/day) (10,15). The outcome of the interventions differed, however. In our study, energy intake increased by 483 kJ, which is smaller than the observed increases of Mathey (767 kJ) and Elmståhl (1400 kJ). Moreover, in both studies body weight did not statistically differ. A third study, in which a buffet-style program was implemented, had no effect on either body weight (p =.638) or on the biochemical markers of nutritional status of the residents (n = 40). Unfortunately, in that study food intake was not measured (21). These differences in observations might be due to methodological problems of the latter studies, that is, absence of control group, no adjustment for group effect, lack of statistical power (n = 22), or short intervention period. Our study results are based on a 6-month randomized controlled trial in 10 wards, in which adjustments of potential confounding effects of ward, nursing home, or resident characteristics are addressed.

Other studies tried to improve nutritional status with specially designed diets, supplements, or exercise programs (1–4). All of these were also successful. The advantage of our intervention is that we did not create a new task for the staff, it was already embedded in the daily activity pattern. During mealtimes, the residents were given choices as to what to eat and they were stimulated to perform normal meal activities. They did not have to eat specially designed supplements or diets.

In general, the management and nursing staff were enthusiastic about the project. In all five nursing homes, the project was continued in the intervention ward and was implemented in the control and other wards. The project was also successfully implemented in closed psychogeriatric wards after minor adaptations. This suggests that the implementation of family-style meal service is not limited to our study population and that residents with dementia benefit as well. This benefit has to be confirmed, however, by a long-term controlled intervention study.

Because the organizational structures of meal services in Europe and the United States are quite similar to the Dutch setting, it is worthwhile to change the individual preplating services to family-style meals. Considering that family-style meals stimulate energy intake and prevent malnutrition in nursing home residents (without a negative influence on staff satisfaction, workload, and cost) we recommend replacement of the preplating meal services with family-style meals in nursing homes.


   Acknowledgments
Top
 Abstract
 Participants and Methods
 Results
 Discussion
 References
 
This project was entirely funded by The Netherlands Organization for Health Research and Development (ZonMw) project number 2420.0021.

Kristel Nijs conducted fieldwork, data analyses, interpretation, and drafting of the manuscript. Wija van Staveren, Frans Kok, and Cees de Graaf supervised, revised, designed, and provided the funding of the study. All investigators contributed to the writing of the paper. The principal investigators, K. Nijs, MSc and Prof C. de Graaf, had full access to all the data in the study, took responsibility for the integrity of the data and the accuracy of the data analysis, and had final responsibility for the decision to submit the manuscript for publication.

We thank all the staff and residents in the participating nursing homes.


   Footnotes
Top
 Abstract
 Participants and Methods
 Results
 Discussion
 References
 
Decision Editor: Luigi Ferrucci, MD, PhD

Received October 11, 2005

Accepted March 5, 2006


   References
Top
 Abstract
 Participants and Methods
 Results
 Discussion
 References
 

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