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1.  Nurses’ views and experiences of caring for malnourished patients in surgical settings in Saudi Arabia – a qualitative study 
BMC Nursing  2014;13:29.
Although the occurrence of malnutrition in hospitals is a growing concern, little is known about how hospital staff understand the care that nurses provide to patients with malnutrition. The purpose of this study was to explore nurses’ views and experiences of caring for malnourished patients in Saudi Arabia (KSA).
Using a qualitative explorative design, fifteen nurses were interviewed as part of a purposive sample hospital staff. The transcripts were analyzed using latent content analysis.
The nurses spontaneously and consistently linked malnutrition with physical inactivity. The two main categories, which emerged, were: ‘Potentials for nurses to provide good nutrition and physical activity’, and ‘Having the ability but not the power to promote proper nutrition and physical activity’. These arose from the subcategories: Good nursing implies providing appropriate health education; Acknowledging the Mourafiq (sitter) as a potential resource for the nursing, but also as a burden; Inadequate control and lack of influence; Cultural diversity and lack of dialog; and Views of women’s weight gain in KSA society.
The nurses felt they have the capacity and passion to further improve the nutrition and activity of their patients, but obstacles in the health care system are impeding these ambitions. The implications for nursing practice could be acknowledgement of the nurses’ views in the clinical practice; culturally adjusted care, improved communication and enhanced language skills.
PMCID: PMC4196725  PMID: 25317076
Malnutrition; Physical activity; Saudi Arabia; Nursing; Nurse’s views
2.  Inter- and intrarater reliability of Minimal Eating Observation and Nutrition Form – version II (MEONF-II) nurse assessments among hospital inpatients 
BMC Nursing  2014;13:18.
The Minimal Eating Observation and Nutrition form – version II (MEONF – II) is a recently developed nursing nutritional screening tool. However, its inter- and intrarater reliability has not been assessed.
Inpatients (n = 24; median age, 69 years; 11 women) were assessed by eight nurses (interrater reliability, two nurses scored each patient independently) using the MEONF-II on two consecutive days (intrarater reliability, each patient was scored by the same nurse day 1 and day 2).
Six patients were at moderate/high undernutrition risk. Inter- and intrarater reliabilities (Gwet’s agreement coefficient) for the MEONF-II 2-category classification (no/low risk versus moderate/high risk) were 0.93 and 0.81; for the 3-category classification (no/low – moderate – high risk) reliabilities (Gwet’s weighted agreement coefficient) were 0.98 and 0.88; and total score inter- and intrarater reliabilities (intraclass correlation) were 0.92 and 0.84.
Reliability of MEONF-II nurse assessments among adult hospital inpatients was supported and the tool can be used in research and clinical practice.
PMCID: PMC4120003  PMID: 25093011
Undernutrition; MEONF-II; Interrater reliability; Intrarater reliability
3.  Primary mesenchymal stem cells in human transplanted lungs are CD90/CD105 perivascularly located tissue-resident cells 
BMJ Open Respiratory Research  2014;1(1):e000027.
Mesenchymal stem cells (MSC) have not only been implicated in the development of lung diseases, but they have also been proposed as a future cell-based therapy for lung diseases. However, the cellular identity of the primary MSC in human lung tissues has not yet been reported. This study therefore aimed to identify and characterise the ‘bona fide’ MSC in human lungs and to investigate if the MSC numbers correlate with the development of bronchiolitis obliterans syndrome in lung-transplanted patients.
Primary lung MSC were directly isolated or culture-derived from central and peripheral transbronchial biopsies of lung-transplanted patients and evaluated using a comprehensive panel of in vitro and in vivo assays.
Primary MSC were enriched in the CD90/CD105 mononuclear cell fraction with mesenchymal progenitor frequencies of up to four colony-forming units, fibroblast/100 cells. In situ staining of lung tissues revealed that CD90/CD105 MSCs were located perivascularly. MSC were tissue-resident and exclusively donor lung-derived even in biopsies obtained from patients as long as 16 years after transplantation. Culture-derived mesenchymal stromal cells showed typical in vitro MSC properties; however, xenotransplantation into non-obese diabetic/severe combined immunodeficient (NOD/SCID) mice showed that lung MSC readily differentiated into adipocytes and stromal tissues, but lacked significant in vivo bone formation.
These data clearly demonstrate that primary MSC in human lung tissues are not only tissue resident but also tissue-specific. The identification and phenotypic characterisation of primary lung MSC is an important first step in identifying the role of MSC in normal lung physiology and pulmonary diseases.
PMCID: PMC4212711  PMID: 25478178
Lung Transplantation
4.  Female University Students’ Physical Activity Levels and Associated Factors—A Cross-Sectional Study in Southwestern Saudi Arabia 
Background: The high prevalence of physical inactivity in Saudi Arabia is a growing challenge to public health. This study aimed to examine the prevalence of physical activity (PA) and associated factors among female university students. Methods: This cross-sectional study involved 663 randomly selected female university students who completed the Arab Teens Life Style questionnaire. Data included measurements of anthropometric, socioeconomic and environmental factors, as well as self-reported PA. Ordinal regression was used to identify associated factors with low, moderate and high PA levels. Results: The mean age of participants was 20.4 years (SD 1.5). Mean BMI of the students in relation to PA were 23.0, 22.9, 22.1 for high, moderate and low levels of activity, respectively. The analysis revealed significantly higher PA levels among married students, those with high educated mothers, and those who lived far from parks, and lower activity levels among underweight students. Conclusions: This study raises four important determinants for female university students’ PA levels. These factors could be of great importance in the endeavor to prevent the health-threatening increase in physical inactivity patterns and thus non-communicable diseases and obesity where the focus should be on the specific situation and needs of women in Saudi Arabia.
PMCID: PMC3774451  PMID: 23939387
epidemiologic methods; Middle East; women’s health; Saudi Arabia; physical activity; female university students; cross-sectional studies; socioeconomic factors
5.  Home-Living Elderly People's Views on Food and Meals 
Journal of Aging Research  2012;2012:761291.
Background. The aim of the study was to describe home-living elderly people's views on the importance of food and meals. Methods. Semistructured interviews with twelve elderly people. The interviews were analysed using qualitative content analysis. Results. Respondents described how their past influenced their present experiences and views on food and meals. Increased reliance on and need of support with food and meals frequently arose in connection with major changes in their life situations. Sudden events meant a breaking point with a transition from independence to dependence and a need for assistance from relatives and/or the community. With the perspective from the past and in the context of dependency, respondents described meals during the day, quality of food, buying, transporting, cooking, and eating food. Conclusions. Meeting the need for optimal nutritional status for older people living at home requires knowledge of individual preferences and habits, from both their earlier and current lives. It is important to pay attention to risk factors that could compromise an individual's ability to independently manage their diet, such as major life events and hospitalisation. Individual needs for self-determination and involvement should be considered in planning and development efforts for elderly people related to food and meals.
PMCID: PMC3443996  PMID: 22991667
6.  Action-Oriented Study Circles Facilitate Efforts in Nursing Homes to “Go from Feeding to Serving”: Conceptual Perspectives on Knowledge Translation and Workplace Learning 
Journal of Aging Research  2012;2012:627371.
Background. Action-oriented study circles (AOSC) have been found to improve nutrition in 24 nursing homes in Sweden. Little, however, is known about the conceptual use of knowledge (changes in staffs' knowledge and behaviours). Methods. Qualitative and quantitative methods, structured questionnaires for evaluating participants' (working in nursing homes) experiences from study circles (n = 592, 71 AOSC) and for comparisons between AOSC participants (n = 74) and nonparticipants (n = 115). Finally, a focus group interview was conducted with AOSC participants (in total n = 12). Statistical, conventional, and directed content analyses were used. Results. Participants experienced a statistically significant increase in their knowledge about eating and nutrition, when retrospectively comparing before participating and after, as well as in comparison to non-participants, and they felt that the management was engaged in and took care of ideas regarding food and mealtimes to a significantly greater extent than non-participants. The use of AOSC was successful judging from how staff members had changed their attitudes and behaviours toward feeding residents. Conclusions. AOSC facilitates professional development, better system performance, and, as shown in previous studies, better patient outcome. Based on a collaborative learning perspective, AOSC manages to integrate evidence, context, and facilitation in the efforts to achieve knowledge translation in a learning organisation. This study has implications also for other care settings implementing AOSC.
PMCID: PMC3443610  PMID: 22991666
7.  Diagnostic performance of the Minimal Eating Observation and Nutrition Form - Version II (MEONF-II) and Nutritional Risk Screening 2002 (NRS 2002) among hospital inpatients - a cross-sectional study 
BMC Nursing  2011;10:24.
The usefulness of the nutritional screening tool Minimal Eating Observation and Nutrition Form - Version II (MEONF-II) relative to Nutritional Risk Screening 2002 (NRS 2002) remains untested. Here we attempted to fill this gap by testing the diagnostic performance and user-friendliness of the MEONF-II and the NRS 2002 in relation to the Mini Nutritional Assessment (MNA) among hospital inpatients.
Eighty seven hospital inpatients were assessed for nutritional status with the 18-item MNA (considered as the gold standard), and screened with the NRS 2002 and the MEONF-II.
The MEONF-II sensitivity (0.61), specificity (0.79), and accuracy (0.68) were acceptable. The corresponding figures for NRS 2002 were 0.37, 0.82 and 0.55, respectively. MEONF-II and NRS 2002 took five minutes each to complete. Assessors considered MEONF-II instructions and items to be easy to understand and complete (96-99%), and the items to be relevant (87%). For NRS 2002, the corresponding figures were 75-93% and 79%, respectively.
The MEONF-II is an easy to use, relatively quick and sensitive screening tool to assess risk of undernutrition among hospital inpatients. With respect to user-friendliness and sensitivity the MEONF-II seems to perform better than the NRS 2002, although larger studies are needed for firm conclusions. The different scoring systems for undernutrition appear to identify overlapping but not identical patient groups. A potential limitation with the study is that the MNA was used as gold standard among patients younger than 65 years.
PMCID: PMC3305676  PMID: 22185436
8.  Cut-off scores for the Minimal Eating Observation and Nutrition Form – Version II (MEONF-II) among hospital inpatients 
Food & Nutrition Research  2011;55:10.3402/fnr.v55i0.7289.
Background and objective
The newly developed Minimal Eating Observation and Nutrition Form – Version II (MEONF-II) has shown promising sensitivity and specificity in relation to the Mini Nutritional Assessment (MNA). However, the suggested MEONF-II cut-off scores for deciding low/moderate and high risk for undernutrition (UN) (>2 and >4, respectively) have not been decided based on statistical criteria but on clinical reasoning. The objective of this study was to identify the optimal cut-off scores for the MEONF-II in relation to the well-established MNA based on statistical criteria.
Cross-sectional study.
The study included 187 patients (mean age, 77.5 years) assessed for nutritional status with the MNA (full version), and screened with the MEONF-II. The MEONF-II includes assessments of involuntary weight loss, Body Mass Index (BMI) (or calf circumference), eating difficulties, and presence of clinical signs ofUN. MEONF-II data were analysed by Receiver Operating Characteristics (ROC) curves and the area under the curve (AUC); optimal cut-offs were identified by the Youden index (J=sensitivity+specificity–1).
According to the MEONF-II, 41% were at moderate or high UN risk and according to the MNA, 50% were at risk or already undernourished. The suggested cut-off scores were supported by the Youden indices. The lower cut-off for MEONF-II, used to identify any level of risk for UN (>2; J=0.52) gave an overall accuracy of 76% and the AUC was 80%. The higher cut-off for identifying those with high risk for UN (>4; J=0.33) had an accuracy of 63% and the AUC was 70%.
The suggested MEONF-II cut-off scores were statistically supported. This improves the confidence of its clinical use.
PMCID: PMC3149411  PMID: 21814520
cut-off scores; MEOF; MNA; MEONF; nutritional screening; ROC-curve
9.  Validity and user-friendliness of the minimal eating observation and nutrition form – version II (MEONF – II) for undernutrition risk screening 
Food & Nutrition Research  2011;55:10.3402/fnr.v55i0.5801.
To analyze the criterion-related validity and user-friendliness of the Minimal Eating Observation and Nutrition Form – Version II (MEONF – II) and Malnutrition Universal Screening Tool (MUST) in relation to the Mini Nutritional Assessment (MNA). In addition, the effect of substituting body mass index (BMI) with calf circumference (CC) was explored for the MEONF-II.
The study included 100 patients who were assessed for nutritional status with the MNA (full version), considered here to be the gold standard, and screened with the MUST and the MEONF-II. The MEONF-II includes assessments of involuntary weight loss, BMI (or calf circumference), eating difficulties, and presence of clinical signs of undernutrition.
The MEONF-II sensitivity (0.73) and specificity (0.88) were acceptable. Sensitivity and specificity for the MUST were 0.57 and 0.93, respectively. Replacing the BMI with CC in the MEONF-II gave similar results (sensitivity 0.68, specificity 0.90). Assessors considered MEONF-II instructions and items to be relevant, easy to understand and complete (100%), and the questions to be relevant (98%). MEONF-II and MUST took 8.8 and 4.7 minutes to complete, respectively, and both were considered relevant and easy to finish. In addition, MEONF-II was thought to reveal problems that allows for nursing interventions.
The MEONF-II is an easy to use, relatively quick, and sensitive screening tool to assess risk of undernutrition among hospital inpatients, which allows for substituting BMI with CC in situations where measures of patient height and weight cannot be easily obtained. High sensitivity is of primary concern in nutritional screening and the MEONF-II outperforms the MUST in this regard.
PMCID: PMC3021369  PMID: 21246022
undernutrition; screening; criterion-related validity; acceptability; MEOF; MNA; MUST; MEONF
10.  Do study circles and a nutritional care policy improve nutritional care in a short- and long-term perspective in special accommodations? 
Food & Nutrition Research  2010;54:10.3402/fnr.v54i0.5402.
Disease-related malnutrition is a major health problem in the elderly population and management issues are under-explored.
What is the prevalence of undernutrition-risk (UN-risk), underweight, and overweight in special accommodations (SAs)? Do study circles and a nutritional care policy (NCP) improve the precision in nutritional care (NC) and decrease the prevalence of under- and overweight in a short- and/or long-term perspective?
Quasi-experimental pre- and post-intervention design with three experimental groups and one control group (CG).
In 2005 (Time 1 – T1), 1726 (90.4%) residents agreed to participate; in 2007 (Time 2 – T2), 1,526 (81.8%); and in 2009 (Time 3 – T3), 1,459 (81.3%) residents participated.
Experimental groups: between T1 and T2 the first period of study circles was conducted in one municipality; between T2 and T3 a second period of study circles in another municipality was conducted; after T1 a NCP was implemented in one municipality. CG: residents in three municipalities.
Under- and overweight were defined based on BMI. Risk of undernutrition was defined as involving any of: involuntary weight loss, low BMI, and/or eating difficulties. The ‘precision in NC’ describes the relationship between nutritional treatment (protein- and energy-enriched food (PE-food) and/or oral supplements) and UN-risk.
The prevalence of UN-risk varied between 64 and 66%, underweight between 25 and 30%, and overweight between 30 and 33% in T1–T3. At T2 the prevalence of underweight was significantly lower in the first period study circle municipality, and at T3 in the second period study circle municipality compared to in the CG. The precision in NC was higher in a short-term perspective in the study circle municipalities and both in a short- and long-term perspective in the NCP municipality. At T3 between 54 and 70% of residents at UN-risk did not receive PE-food or oral supplements.
Study circles give positive short-term effects and a NCP gives positive short- and long-term effects on NC. Whether a combination of study circles and the implementation of a NCP can give even better results is an area for future studies.
PMCID: PMC2946866  PMID: 20877587
education; policy; undernutrition; overweight; prevalence; special accommodation; quality improvement
11.  Uncovering Indicators of the International Classification of Functioning, Disability, and Health from the 39-Item Parkinson's Disease Questionnaire  
Parkinson's Disease  2010;2010:984673.
The 39-item Parkinson's disease questionnaire (PDQ-39) is the most widely used patient-reported rating scale in Parkinson's disease (PD). However, recent studies have questioned its validity and it is unclear what scores represent. This study explored the possibility of regrouping PDQ-39 items into scales representing the International Classification of Functioning, Disability, and Health (ICF) components of Body Functions and Structures (BF), Activities and Participation (AP), and Environmental (E) factors. An iterative process using Rasch analysis produced five new items sets, two each for the BF and AP components and one representing E. Four of these were found to represent clinically meaningful variables: Emotional Impairment (BF), Gross Motor Disability (AP), Fine Motor Disability (AP), and Socioattitudinal Environment (E) with acceptable reliability (0.73–0.96) and fit to the Rasch model (total item-trait chi-square, 8.28–33.2; P > .05). These new ICF-based scales offer a means to reanalyze PDQ-39 data from an ICF perspective and to study its health components using a widely available health status questionnaire for people with PD.
PMCID: PMC2957468  PMID: 20976013
12.  Study circles improve the precision in nutritional care in special accommodations 
Food & Nutrition Research  2009;53:10.3402/fnr.v53i0.1950.
Disease-related malnutrition is a major health problem in the elderly population, but it has until recently received very little attention, especially are management issues under-explored. By identifying residents at the risk of undernutrition (UN), appropriate nutritional care can be provided.
To investigate if study circles and policy documents improve the precision in nutritional care and decrease the prevalence of low or high body mass index (BMI).
Pre and post-intervention study.
Special accommodations (nursing homes) within six municipalities were involved.
In 2005, 1,726 (90.4%) of 1,910 residents agreed to participate and in 2007, 1,526 (81.8%) of 1,866 residents participated.
Study circles in one municipality, having a policy document in one municipality and no intervention in four municipalities.
Risk of UN was defined as involving any of: involuntary weight loss; low BMI; and/or eating difficulties. Overweight was defined as high BMI.
In 2005 and 2007, 64% and 66% of residents, respectively, were at the risk of UN. In 2007, significantly more patients in the study circle municipality were accurately provided protein and energy enriched food (PE-food) compared to the no intervention municipalities. There was a decrease between 2005 and 2007 in the prevalence of low BMI in the study circle municipality, but the prevalence of overweight increased in the policy document municipality.
Study circles improve the provision of PE-food for residents at the risk of UN and can possibly decrease the prevalence of low BMI. It is likely that a combination of study circles and implementation of a policy document focusing on screening and on actions to take if the resident is at UN risk can give even better results.
PMCID: PMC2754113  PMID: 19798421
education; malnutrition; undernutrition; overweight; special accommodation; quality improvement
13.  Malnutrition prevalence and precision in nutritional care differed in relation to hospital volume – a cross-sectional survey 
Nutrition Journal  2009;8:20.
To explore the point prevalence of the risk of malnutrition and the targeting of nutritional interventions in relation to undernutrition risk and hospital volume.
A cross-sectional survey performed in nine hospitals including 2 170 (82.8%) patients that agreed to participate. The hospitals were divided into large, middle, and small sized hospitals. Undernutrition risk and overweight (including obesity) were assessed.
The point prevalence of moderate/high undernutrition risk was 34%, 26% and 22% in large, middle and small sized hospitals respectively. The corresponding figures for overweight were 38%, 43% and 42%. The targeting of nutritional interventions in relation to moderate/high undernutrition risk was, depending on hospital size, that 7–17% got Protein- and Energy Enriched food (PE-food), 43–54% got oral supplements, 8–22% got artificial nutrition, and 14–20% received eating assistance. Eating assistance was provided to a greater extent and artificial feeding to a lesser extent in small compared to in middle and large sized hospitals.
The prevalence of malnutrition risk and the precision in provision of nutritional care differed significantly depending on hospital volume, i.e. case mix. It can be recommended that greater efforts should be taken to increase the use of PE-food and oral supplements for patients with eating problems in order to prevent or treat undernutrition. A great effort needs to be taken in order to also decrease the occurrence of overweight.
PMCID: PMC2687453  PMID: 19422727
14.  Nutrition and its Relation to Mealtime Preparation, Eating, Fatigue and Mood Among Stroke Survivors After Discharge from Hospital - A Pilot Study 
The Open Nursing Journal  2008;2:15-20.
Eating difficulties and nutritional deficits are common among persons with acute stroke and during rehabilitation. Little is known about such problems after discharge from hospital. In addition the relationship between fatigue and nutritional status among stroke survivors living in the community remains to be explored. The aim of this pilot study was to describe mealtime preparation, eating, fatigue, mood and nutritional status among persons with stroke six months after discharge from hospital and to explore associations between these factors. Patients were interviewed six months poststroke. Standardised questions and methods were used. The mean age of the 89 respondents was 77.2 (SD 6.6) years, 44 were women and 45 men. Difficulties with swallowing, ingestion and energy to eat occurred among 27%, 20% and 7% respectively. Difficulties with cooking and buying food occurred among 57% and 56% respectively and 41% were at nutritional risk. Feeling full of energy less than some of the time was experienced by 61% while 15% had felt gloomy and sad at least some of the time during the previous four weeks. Considering activities of daily living (ADL), having a less favourable nutritional status was significantly predicted by difficulties with buying food, difficulties with ingestion and being a woman. Considering psychological state (mood and energy), having a less favourable nutritional status was significantly predicted by a lack of energy and high age. This study supports the occurrence of a nutritionally related fatigue by means of “lack of energy”. The associations between poor nutritional status and fatigue can work in both directions. Thus persons with fatigue are more prone to have poor nutritional status and those with poor nutritional status are at greater risk of fatigue. Besides fatigue also difficulties with buying food and ingestion are associated with nutritional risk. As nutritional deficits occur a long time after stroke onset it is important to assess aspects of mealtime preparation and the eating process and when necessary provide food delivery service and eating assistance in order to prevent a vicious circle of undernourishment and fatigue to develop.
PMCID: PMC2582825  PMID: 19319216
Fatigue; mood; mealtime preparation; eating; nutrition; stroke.

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