NUTRITION SCREENING

Intended Learning Outcomes

1. Demonstrate understanding if the role of Nutrition Screening in NCP Model
2. Define Nutrition screening in Acute Care settings.
3. Evaluates the appropriateness and validity of nutrition screening tools in
screening nutrition risk.
4. Review and apply recent Advances in Nutrition Screening in Clinical
Settings
Nutrition Assessment
MALNUTRITION
 Definition of Malnutrition
Larana, Inc.

Malnutrition refers to
• deficiencies or excesses in nutrient
intake,
• imbalance of essential nutrients or
• impaired nutrient utilization
(WHO, 2021)
TYPES OF MALNUTRITION

STARVATION-RELATED DISEASE-RELATED
MALNUTRITION MALNUTRITION
• Food and nutrient • Lack of food intake
o
deprivation • With inflammation
• No inflammation
 Definition of Malnutrition

Starvation-related malnutrition is only

diagnosed when protein-energy
malnutrition is caused by food and
nutrient deprivation over a long period of
time in the absence of disease processes
and inflammation (Marshall and Agarwal,
2019).
 Definition of Malnutrition
Larana, Inc.

Disease-related malnutrition with

inflammation is defined as underlying
diseases causing inflammation with a
consecutive lack of food intake or as
uptake with a negative nutrient balance
(Merker et. al, 2020).
THE 3 ETIOLOGY-BASED NUTRITION DIAGNOSES IN ADULTS IN
CLINICAL PRACTICE SETTINGS ARE:
NUTRITION SCREENING
 Nutrition Screening
● Nutrition Screening is the process of identifying
individuals at risk of malnutrition. Various tools are
used to efficiently screen patients, ensuring timely
intervention.
● Nutrition Screening Tools should be:
○ Quick, easy to use, and can be conducted in any
practice setting
○ Valid and reliable
○ Established by RNDs, but can be done by any trained
personnel
 Nutrition Screening
● Screening and rescreening should occur within
appropriate time
● Nutrition screening depends on
○ Setting which its obtained in
○ Life stage or disease type
○ Available data
○ Definition of risk priorities
 Nutrition Screening
Below are three commonly used screening tools:

1. Nutrition Risk Screening (NRS 2002):

2. Mini Nutritional Assessment (MNA):
3. Malnutrition Universal Screening Tool (MUST):
 Nutrition Screening
1. Nutrition Risk Screening (NRS 2002):
The Nutritional Risk Screening 2002 (NRS 2002) identifies
patients at risk of malnutrition.

Nutritional Risk Screening (NRS 2002) has become

particularly well established for the medical inpatient
population.
• Score ≥ 3: the patient is nutritionally at‐risk and a
nutritional care plan is initiated
• Score < 3: weekly rescreening of the patient. If the
patient e.g. is scheduled for a major operation, a
preventive nutritional care plan is considered to avoid
the associated risk status.
 Nutrition Screening
1. Nutrition Risk Screening (NRS 2002):
Sample Case:
Patient Profile:
• Name: Patient X
• Age: 72
• Diagnosis: Severe pneumonia
• Recent History:
⚬ Admitted to the hospital 5 days ago.
⚬ Has experienced a significant decrease in
appetite over the last week.
⚬ Reported weight loss of approximately 6% over
the past two months.
⚬ Current BMI: 19.8
 Nutrition Screening
2. Mini Nutritional Assessment (MNA):
The Mini Nutritional Assessment (MNA) has been designed
and validated to provide a single, rapid assessment of
nutritional status in elderly patients in outpatient clinics,
hospitals, and nursing homes.
The MNA test is composed of simple measurements and
brief questions that can be completed in about 10 min.
The sum of the MNA score distinguishes between elderly
patients with:
1) adequate nutritional status, MNA ≥ 24;
2) protein-calorie malnutrition, MNA < 17;
3) at risk of malnutrition, MNA between 17 and 23.5.
IF BMI IS NOT AVAILABLE PILIPINO VERSION
 Nutrition Screening
3. Malnutrition Universal Screening Tool (MUST):
MUST is a popular screening tool for all types of
hospitalized patients; ESPEN recommends its use at
community level , and its reliability is similar to that of
the MNA in screening for nutritional risk in geriatric
populations.

Scoring:
0: Low Risk
1: Medium Risk
2 or more: High Risk
 Nutrition Screening
3. Malnutrition Universal Screening Tool (MUST):
How to screen using ‘MUST’ There are five steps to
follow:
Step 1: Body mass index (BMI) (kg/m2 )
• Take the subject’s height and weight to calculate BMI
• If weight and height are not available, self reported
height and weight, if realistic and reliable, may be
appropriate.
• Height may be estimated using ulna length, knee
height or demi span if the reported height is
unreliable.
 Nutrition Screening
3. Malnutrition Universal Screening Tool (MUST):
Step 2: Unplanned weight loss
• Unplanned weight loss over 3 to 6 months is a more
acute risk factor for malnutrition than BMI

< 5% weight loss = within normal variation (score 0)

5-10% weight loss = early indicator of increased risk (score
1)
>10% weight loss = clinically significant (score 2)

● To establish the subject’s weight loss score, ask if

there has been any weight loss in the last 3 to 6
months, and if so how much (or look in their records).
 Nutrition Screening
3. Malnutrition Universal Screening Tool (MUST):
Step 3: Acute disease can affect risk of
malnutrition
If the patient is currently affected by an acute
patho-physiological or psychological condition, and
there has been no nutritional intake for 5 or more
days, they are at nutritional risk. Such patients include
those who are critically ill, have swallowing difficulties
(e.g. after stroke), post head injuries or are undergoing
gastrointestinal surgery. Add a score of 2 for these
patients.
 Nutrition Screening
3. Malnutrition Universal Screening Tool (MUST):
Step 4: Overall risk of malnutrition
Establish overall risk of malnutrition after considering
all relevant factors. Add scores together from Steps 1,
2 and 3 to calculate overall risk of malnutrition.

0 = Low risk
1 = Medium risk
2 or more = High risk
 Nutrition Screening
Other nutrition screening tools:
1. Simplified Nutritional Appetite Questionnaire
(SNAQ)
This tool was developed in the Netherlands. It consists
of three questions: if there has been weight loss (more
than 6 kg in the last 6 months, or more than 3 kg in the
last month), loss of appetite, and if the patient required
nutritional supplementation in the last month.
The responses to each question are reported on a scale
ranging from “very bad” to “very good”, with a final score
of 1 to 5. A score of 2 indicates moderate malnutrition,
and 3 or more points denote severe malnutrition.
 Nutrition Screening
Other nutrition screening tools:
2. Malnutrition Screening Tool (MST)
• Developed in 1999 by Ferguson et al., this is a quick
and easy screening tool that includes questions
about appetite, nutritional intake, and recent
weight loss. A score of equal to or greater than 2,
out of a total of 7, suggests the need for a
nutritional assessment and/or intervention.
• It is recommended for hospitalized, outpatient, and
institutionalized adult patients.
 Nutrition Screening
Other nutrition screening tools:
3. Nutrition Risk in the Critically Ill (NUTRIC Score)
This model was developed by Heyland et al., in 2011 to
identify critically ill patients who are likely to benefit
from an intensive nutritional intervention. The model
seeks to integrate the absence of food intake, whether
acute or chronic (recent reduction in food intake and
hospital stay), inflammation (by means of interleukin-6,
and the presence of comorbidities), nutritional status,
and outcomes. It also includes the values of the
Sequential Organ Failure Assessment (SOFA) and the
Acute Physiology and Chronic Health Evaluation
(APACHE II)
 Nutrition Screening
Other nutrition screening tools:
4. Nutritional Risk Index (NRI)
The NRI is the oldest screening tool, and was initially described by Buzby et al., to examine the
association between malnutrition and surgical outcomes.
It uses the following formula:
Outcome = (0.363 × albumin) + (1.27 × (% weight loss)) + 0.119

A result of less than 2.71 is considered abnormal, and is associated with a complication rate of
27.5% and mortality of 22%, whereas patients with a higher value present rates of 14.6% and
2.8%, respectively.
 Nutrition Screening
Other nutrition screening tools:
5. Geriatric Nutritional Risk Index (GNRI)
This corresponds to a modification of the Nutritional Risk Index, adapted to geriatric patients. It
is regarded as an index of risk of morbidity and mortality associated with malnutrition, rather
than as an index for the classification of malnutrition.
The prediction formula is:
GNRI = (1.489 × albumin (g/L)) + (41.7 × (weight/ideal weight))

A score under 82 represents a high risk of complications, between 82 and 92 points to a

moderate risk, and above 92, a low risk.
 Nutrition Screening
Other nutrition screening tools:
6. Prognostic Nutritional Index (PNI)
This was developed by Mullen et al., investigating the relationships between nutritional status
and outcomes in surgical patients.
The formula is as follows:
PNI% = 158 − (16.6 × albumin(g/L)) − (0.78 × (TSF)) − (0.20 × (TFN)) − (5.8 × (DH))
where TDF = triceps skinfold, TFN = serum transferrin, and DH = cutaneous delayed
hypersensitivity to antigens.
Patients are classified as high-nutritional-risk with PNI >50%, as moderate between 40% and
49%, and as low-risk below 40%, with a significantly higher rate of complications and mortality
in patients with high-nutritional-risk who do not receive a nutritional intervention in relation to
those who do, or who have a low-nutritional-risk
 Nutrition Screening
Other nutrition screening tools:
7. Prognostic Inflammatory and Nutritional Index (PINI)
Initially applied to critical patients, in whom it proved to be a sensitive and specific marker of
nutritional and inflammatory status, it was later applied to other types of patients, such as
surgical and hemodialysis patients [73].
Calculated as (alpha-1-acid glycoprotein (a1-AG) × C-reactive protein (CRP))/albumin ×
transthyretin. A PINI score = <1 is considered normal. A Score >30 = high life risk, 21–30 = high
risk, 11–20 = medium risk, 1–10 = low risk, and <1 = minimal risk.
Thank you! Any questions?
 ANNOUNCEMENTS

● February 10 and 13 - Laboratory - Collection for Nutrition Screening

(no lecture)
○ By Pairs - 6 people each for NRS, MNA, and MUST (Total of 18
patients)
○ Prioritize people 65 years up for MNA
● February 17 - Quiz on Nutrition Screening and Medical
Abbreviations
 REFERENCES
● Hersberger, L., Bargetzi, L., Bargetzi, A., Tribolet, P., Fehr, R., Baechli, V., ... & Schuetz, P. (2020). Nutritional risk screening (NRS 2002) is a strong and modifiable
predictor risk score for short-term and long-term clinical outcomes: secondary analysis of a prospective randomised trial. Clinical Nutrition, 39(9), 2720-2729.
● Inoue, T., Misu, S., Tanaka, T., Kakehi, T., & Ono, R. (2019). Acute phase nutritional screening tool associated with functional outcomes of hip fracture patients: A
longitudinal study to compare MNA-SF, MUST, NRS-2002 and GNRI. Clinical Nutrition, 38(1), 220-226.
● Irish Nutrition and Dietetics Institute, Ashgrove House, Kill Avenue, Dun Laoghaire,co. Dublin Email: info@[Link]
● Jensen, G. L., Mirtallo, J., Compher, C., Dhaliwal, R., Forbes, A., Grijalba, R. F., ... & Waitzberg, D. (2010). Adult starvation and disease‐related malnutrition: a proposal
for etiology‐based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. Journal of Parenteral and Enteral Nutrition, 34(2),
156-159.
● Kalan, U., Arik, F., Isik, A. T., & Soysal, P. (2020). Nutritional profiles of older adults according the Mini-Nutritional Assessment. Aging Clinical and Experimental
Research, 32, 673-680.
● Marshall, S., & Agarwal, E. (2019). Comparing characteristics of malnutrition, starvation, sarcopenia, and cachexia in older adults. In Handbook of famine, starvation,
and nutrient deprivation: from biology to policy (pp. 785-807). Springer.
● Merker, M., Felder, M., Gueissaz, L., Bolliger, R., Tribolet, P., Kägi-Braun, N., ... & Schuetz, P. (2020). Association of baseline inflammation with effectiveness of
nutritional support among patients with disease-related malnutrition: a secondary analysis of a randomized clinical trial. JAMA network open, 3(3),
e200663-e200663.
● process (15th ed.). St. Louis, Misoouri: Elsevier.
● Raymond, J. & Morrow, K. (2021). Krause and Mahan's food and the nutrition care
● Serón-Arbeloa, C., Labarta-Monzón, L., Puzo-Foncillas, J., Mallor-Bonet, T., Lafita-López, A., Bueno-Vidales, N., & Montoro-Huguet, M. (2022). Malnutrition screening
and assessment. Nutrients, 14(12), 2392.
● WHO. Malnutrition. Geneva: WHO; 2021