Identifying Malnutrition

Criteria and tools for nutrition screening and assessment in pediatric and adult patients are described.

Definition of malnutrition

Historically, there has been no clear consensus on how malnutrition should be defined.1–3 Multiple definitions for adult malnutrition syndromes are found in the nutrition and medical literature. This can lead to confusion among practitioners and investigators alike. Recent evidence suggests that inflammation plays a key role in the pathophysiology of disease-related malnutrition. The inflammatory component has both diagnostic and therapeutic implications.2 The American Society of Parenteral and Enteral Nutrition (ASPEN) states that malnutrition represents "an acute, subacute or chronic state of nutrition, in which a combination of varying degrees of overnutrition or undernutrition with or without inflammatory activity have led to a change in body composition and diminished function".4

Diagnosis of malnutrition
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An International Guideline Committee attended a series of meetings at the ASPEN and European Society for Parenteral and Enteral Nutrition (ESPEN) Congresses. Subsequently, a Consensus Statement from the Academy of Nutrition and Dietetics/ASPEN "Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition)" proposed an etiology-based approach to the diagnosis of adult malnutrition in clinical settings, as shown in Figure 1.5

Figure 1. Etiology-based malnutrition definitions5


Reproduced from J Acad Nutr Diet, 112, White JV, Guenter P, Jensen G, et al., Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition), pp. 730–738, Copyright (2012), with permission from American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics.


This group identified six continuous, rather than discrete, characteristics to standardize the clinician's approach to the diagnosis and documentation of adult malnutrition.4 These characteristics, as shown in Table 1, distinguish between severe and non-severe malnutrition, and should be assessed routinely on admission and at frequent intervals throughout the patient's stay in an acute, chronic, or transitional care setting.5

Table 1. Clinical characteristics recommended by Academy of Nutrition and Dietetics/ASPEN to support diagnosis of malnutrition5

Clinical Characteristic: Energy intake Malnutrition is the result of inadequate food and nutrient intake or assimilation; thus, recent intake compared to estimated requirements is a primary criterion defining malnutrition. The clinician may obtain or review the food and nutrition history, estimate optimum energy needs, compare them with estimates of energy consumed and report inadequate intake as a percentage of estimated energy requirements over time.
  Malnutrition in the context of acute Illness or injury Malnutrition in the context of chronic illness Malnutrition in the context of social or environmental circumstances
  Non-severe (moderate) malnutrition Severe malnutrition Non-severe (moderate) malnutrition Severe malnutrition Non-severe (moderate) malnutrition Severe malnutrition
  <75 % of estimated energy requirement for >7 days ≤50% of estimated energy requirement for ≥5 days <75 % of estimated energy requirement for ≥1 month <75 % of estimated energy requirement for ≥1 month <75 % of estimated energy requirement for ≥3 month ≤50% of estimated energy requirement for ≥1 month
Clinical Characteristic:
Interpretation
of weight loss
The clinician may evaluate weight in light of other clinical findings including the
presence of under- or over-hydration. The clinician may assess weight change over time reported as a percentage of weight lost from baseline
  Time      % Time      % Time      % Time      % Time      % Time      %
  1 week   1-2 1 week   >2 1 month   5 1 month   >5 1 month   5 1 month   >5
  1 month   5 1 month   >5 3 month   7.5 3 month   >7.5 3 month   7.5 3 month   >7.5
  3 month   7.5 3 month   >7.5 6 month   10 6 month   >10 6 month   10 6 month   >10
      1 year      20 1 year      >20 1 year      20 1 year      >20
Malnutrition typically results in changes to the physical exam. The clinician may perform a physical exam and document any one of the physical exam findings below as an indicator of malnutrition.


Physical characteristic Malnutrition in the context of acute Illness or injury Malnutrition in the context of chronic illness Malnutrition in the context of social or environmental circumstances
Non-severe (moderate) malnutrition Severe malnutrition Non-severe (moderate) malnutrition Severe malnutrition Non-severe (moderate) malnutrition Severe malnutrition
Body Fat Loss of subcutaneous fat (e.g. orbital, triceps, fat overlying the ribs)
  Mild Moderate Mild Severe Mild Severe
Muscle mass Muscle loss (e.g. wasting of the temples [temporalis muscle]; clavicles [pectoralis and deltoids]; shoulders [deltoids]; interosseous muscles; scapula [latissimus dorsi, trapezius, deltoids]; theigh [quadriceps] and calf [gastrocnemius]).
  Mild Moderate Mild Severe Mild Severe
Fluid accumulation The clinician may evaluate generalized or localized fluid accumulation evident on exam (extremities; vulvar/scrotal edema or ascites). Weight loss is often masked by generalized fluid retention (edema) and weight gain may be observed.
  Mild Moderate Mild Severe Mild Severe
Reduced grip strength Consult normative standards supplied by the manufacturer of the measurement device.
  Mild Moderate Mild Severe Mild Severe

At least two of six characteristics are recommended for diagnosis. The National Center for Health Statistics defines 'chronic' as a condition/disease lasting ≥ 3 months.5

Nutrition screening in children
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Infants and children are particularly susceptible to the effects of starvation; small preterm infants, for example, may only survive 4 days of starvation due to their low non-protein caloric reserve. Preterm infants are considered to be at nutritional risk and should undergo screening to identify those who require formal nutrition assessment with development of a nutrition care plan.6,7


Due to the absence of evidence-based criteria and the lack of a simple and properly validated screening tool, routine nutrition screening in pediatric patients is, unfortunately, only rarely carried out in Europe.8 As malnutrition in hospitalized children is a relevant risk factor for unfavorable outcome and increased care needs, prolonged stay in hospital, and increased health-care costs,9 the implementation of a simple and reliable nutrition screening tool has been suggested as highly desirable. The screening tools developed for adults are not validated for use in children. Major reasons for this include the difficulty of assessing improper growth and different disease pathologies compared with adults.8


Several nutrition screening tools have been developed in the last years to identify the risk of malnutrition in hospitalized children (Table 2). However, these tools have not yet been validated in larger patient cohorts and proof of their overall benefit is still lacking.8 Thus, inclusion into routine clinical practice is not expected in the near future. An ongoing, multicenter study involving over 2,400 pediatric in-patients in Europe will presumably shed light on this issue. The systematic collection of anthropometric measurements and interviews, together with outcomes data, will help to establish appropriate screening parameters.8

Table 2. Nutrition screening tools for hospitalized pediatric patients8

Screening tool Setting
Pediatric nutritional risk score Medical/surgical
Subjective Global Nutrition Assessment Medical/surgical
STAMP Medical/surgical
PYMS Medical/surgical
STRONGkids Academic/general

PYMS: Pediatric Yorkhill Malnutrition Score; STAMP: Screening Tool for the Assessment of Malnutrition in Pediatrics; STRONGkids: Screening Tool Risk on Nutritional status and Grow.

Permission pending


Nutrition screening and assessment in adults
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Nutrition care comprises nutrition screening, assessment and intervention in malnourished patients. The recommended algorithm is shown in Figure 2.10


Whereas nutrition screening is a process used to identify individuals who are malnourished or are at risk of malnutrition, nutrition assessment represents a "comprehensive approach to diagnosing nutrition problems that uses a combination of the following: medical, nutrition and medication histories, physical examination, anthropometric measurements (such as age, weight, height and gender), and laboratory data."4 This information provides the basis for the development of an individual Nutrition Care Plan. As illustrated in Figure 2, clinical assessment is a continuous process that includes periodic rescreening and reassessment.10

Figure 2. Nutrition care algorithm10


Reproduced with permission from Mueller C, et al. JPEN J Parenter Enteral Nutr 2011;35:16–24.


The currently available and most frequently applied nutrition screening and assessment tools for adults are summarized in Table 3. Parameters assessed are grouped according to anthropometry and diet, disease relation, or other variables.10 Detailed nutrition assessment should be performed by nutritionists.10

Table 3. The currently available and most frequently applied nutrition screening and assessment tools for adults10

Instrument Anthropometry and/or diet-related Severity of illness Other (physical, psychological variables or symptoms)
Screening tools
Birmingham Nutrition Risk Score Weight loss
BMI
Appetite
Ability to eat
Stress factor (severity of diagnosis)
Malnutrition Screening Tool Appetite
Unintentional weight loss
Malnutrition Universal Screening Tool BMI
Change in weight
Presence of acute disease
Maastricht Index Percentage ideal body weight Albumin
Prealbumin
Lymphocyte count
Nutrition Risk Classification Weight loss
Percentage ideal body weight
Dietary intake
Gastrointestinal function
Nutritional Risk Index Present and usual body weight Albumin
Nutrition Risk Screening 2002 Weight loss
BMI
Food intake
Diagnosis (severity)
Prognostic Inflammatory and Nutritional Index Albumin
Prealbumin
C-reactive protein
α1-acid glycoprotein
Prognostic Nutritional Index Triceps skin fold Albumin
Transferrin
Skin sensitivity
Simple Screening Tool BMI
Percentage weight loss
Albumin
Short Nutrition Assessment Questionnaire Recent weight history
Appetite
Use of oral supplement or tube feeding
Nutrition assessment tools
Mini Nutritional Assessment Weight data
Height
Mid-arm circumference
Calf circumference
Diet history
Appetite
Feeding mode
Albumin
Prealbumin
Cholesterol
Lymphocyte count
Self-perception of nutrition and health status
Subjective Global Assessment Weight history
Diet history
Primary diagnosis Stress level Physical symptoms (subcutaneous fat, muscle wasting, ankle edema, sacral edema, ascites)
Functional capacity
Gastrointestinal symptoms

BMI, body mass index


Adapted with permission from Mueller C, et al. JPEN J Parenter Enteral Nutr 2011;35:16–24.
ESPEN guidelines suggest that all patients should be screened on admission to hospital or other medical institutions. If the patient is at risk of malnutrition, but metabolic or functional problems prevent a standard plan from being carried out, or if there is doubt as to whether the patient is at risk, a referral should be made to an expert for a more detailed assessment.11

Body composition assessment
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A specific assessment of lean and adipose tissue is often crucial for malnutrition diagnosis. In patients with breast cancer, skeletal muscle loss has been shown to be an independent predictor of poor survival.12 A study of 21 cancer patients has demonstrated that accurate prediction of whole-body composition can be achieved by dual-energy x-ray absorptiometry (DEXA) and computed tomography (CT).13 The advantages of CT images over DEXA scans are that they provide detailed information about specific muscles, adipose tissues, and organs, and that they are routinely taken in cancer patients.14 As such, they can be used during routine clinical practice to characterize weight loss in cancer patients, thereby facilitating therapeutic decisions.


The relation between fat-free mass (FFM) loss and clinical course is shown in patients with sarcopenic obesity. As the sensitivity of body mass index (BMI) for detecting FFM loss is strongly reduced, body composition evaluation should be considered to detect undernutrition in routine practice.14

Nutrition screening in adult critically ill patients
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ASPEN guidelines for adult critically ill patients note that traditional nutrition assessment tools (albumin, prealbumin and anthropometry) are not validated in critical care. Before initiation of feeding an assessment should be conducted that includes evaluation of weight loss and nutrient intake prior to admission, level of disease severity, comorbid conditions, and function of the gastrointestinal tract. (Evidence grade E; non-randomized cohorts with historical controls and/or case series, uncontrolled studies, expert opinions). They also recommend the use of indirect calorimetry to measure energy requirements when possible.15

Nutrition screening in patients with cancer
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The ASPEN guidelines state that patients with cancer are nutritionally at risk, and should receive nutrition screening (Grade D recommendation; supported by at least one non-randomized cohort with contemporaneous controls) to identify those patients who require formal nutrition assessment and development of a nutrition care plan.16 The patient-generated subjective global assessment, the subjective global assessment , and the nutrition risk index are some of the tools that can be used for the screening process to identify malnourished cancer patients.16

Nutrition screening in adult patients with acute and chronic renal failure
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The ASPEN guidelines recommend that patients with acute and chronic renal failure should undergo a formal nutrition assessment, including evaluation of inflammation (Grade D recommendation). They suggest that evaluation of the serum protein status (serum albumin) together with a marker of inflammation, such as C-reactive protein, may help to identify patients at high risk of mortality, and for whom nutrition support should be considered. They also recommend the use of indirect calorimetry to measure energy requirements when possible.17

Nutrition screening in the elderly
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Malnutrition in hospitalized, elderly patients has been shown to be common.18 It often goes unrecognized and has been associated with higher mortality and delayed functional recovery .7,19 Few of the standard measures of nutrition status have reference values for adults >60 years of age. As a result, these tools will not sufficiently detect undernutrition in all older patients.


For older adults, nutrition assessment should include evaluation of physical status, biochemical assessment, oral health status and medication review. It should also include functional status, including activities of daily living and instrumental activities of daily living, cognitive and psychological function, and socio-economic factors.7,11


The Mini Nutritional Assessment (MNA®) tool was specifically developed and validated for identification of elderly patients who are malnourished or at risk of malnutrition. This tool is intended for use in out-patient clinics, hospitals, and nursing homes, and includes physical and mental measures of parameters such as functionality, depression, and dementia, as well as a dietary questionnaire.20 The use of the MNA tool was demonstrated in several clinical studies, and its sensitivity, specificity, and predictive value were found to be 96%, 98%, and 97%, respectively.21 Thus, MNA is recommended by national and international expert panels as the preferred method for nutrition screening in the elderly.11,22

Useful links
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References
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  2. Jensen GL, Bistrian B, Roubenoff R, Heimburger DC. Malnutrition syndromes: a conundrum vs continuum. JPEN J Parenter Enteral Nutr 2009;33:710–716.
  3. Roubenoff R, Heymsfield SB, Kehayias JJ, Cannon JG, Rosenberg IH. Standardization of nomenclature of body composition in weight loss. Am J Clin Nutr 1997;66:192–196.
  4. American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors and Clinical Practice Committee. Definition of terms, style, and conventions used in A.S.P.E.N. Board of Directors-approved documents. May 2012 [accessed June 7, 2013]. Available at: http://www.nutritioncare.org/Library.aspx
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  20. Guigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly: The Mini Nutritional Assessment as part of the geriatric evaluation. Nutr Rev 1996;54:S59–S65.
  21. Vellas B, Guigoz Y, Garry PJ, et al. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 1999;15:116–122.
  22. Salva A, Corman B, Andrieu S, et al. Minimum data set for nutritional intervention studies in elderly people. J Gerontol A Biol Sci Med Sci 2004;59:724–729.