Nutrition 29 (2013) 993999

Contents lists available at ScienceDirect

Nutrition
journal homepage: www.nutritionjrnl.com

Applied nutritional investigation

Ability of different screening tools to predict positive effect on nutritional

intervention among the elderly in primary health care
Anne Marie Beck Ph.D. a *, Tina Beermann M.Sc. (Clin. Nutr.) b, Stine Kjr c,
Henrik Hjgaard Rasmussen Prof. d
a

Research Unit for Nutrition (EFFECT), Herlev University Hospital, Herlev, Denmark
Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Faculty of Health, Aalborg University, Denmark
Medical Department, Frederiksberg Hospital, Denmark
d
Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Faculty of Health, Aalborg University, Denmark
b
c

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 7 November 2012
Accepted 24 January 2013

Objective: Routine identication of nutritional risk screening is paramount as the rst stage in nutritional treatment of the elderly. The major focus of former validation studies of screening tools has been
on the ability to predict undernutrition. The aim of this study was to validate Mini Nutritional
AssessmentShort Form (MNASF), the Malnutrition Universal Screening Tool (MUST), the Nutritional
Risk Screening 2002 (NRS2002), Body Mass Index (BMI) <24, and the Eating Validation Scheme (EVS),
using published randomized controlled trials of nutritional intervention among old people in primary
health care, in order to evaluate whether they were capable of distinguishing those with a positive
benet from those that showed no benet of nutritional intervention.
Methods: The methods used were a literature search; classication of participants with respect to
nutritional risk according to the different nutritional screening tools; and validation (i.e., evaluation of whether the different tools were capable of distinguishing those with a positive benet
from those that showed no benet of nutritional intervention by assessing the positive [PPV] and
negative [NPV] predictive values).
Results: MNASF, NRS2002, BMI <24 and EVS had the highest PPV (0.75) and EVS the highest NPV
(0.74) with regard to functiondthe primary clinical outcome.
Conclusion: Overall EVS seemed most capable of distinguishing those clients and residents with
a positive benet from those that showed no benet of nutritional intervention. The ndings
should be conrmed in further validation and intervention studies.
2013 Elsevier Inc. All rights reserved.

Keywords:
Nutritional screening tools
Validation
Clinical outcome
Frail elderly

Introduction
In Denmark as many as 50% of elderly people in primary
health care suffer from unintended weight loss and approximately 16% have a body mass index (BMI) below 18.5 kg/m2 [1,2].
Many studies highlight the extent of undernutrition among
these groups of old people. Weight loss and low BMI have been
associated with increased risk for morbidity and mortality;
impaired cognitive, physical, and social function and hence
reduced quality of life; and increased health care costs [3].
All authors participated in the conception and design and carried out the data
collection. AB carried out the data analysis and interpretation of data. AB and SK
drafted the manuscript; TB and HHR revised it critically for important intellectual content. All authors read and approved the nal manuscript to be
submitted.
* Corresponding author: Tel.: 45 3868 9393; fax: 45 38 68 34 49.
E-mail address: Anne.Marie.Beck@regionh.dk (A. M. Beck).
0899-9007/$ - see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.nut.2013.01.016

Routine identication of nutritional risk by screening is

paramount as the rst stage in nutritional treatment of this
population. The usefulness of screening tools can be evaluated by
various methods. The predictive value is of major importance; for
example, that the individual identied to be at risk by the
method is likely to obtain a health benet from the intervention
arising from the results of the screening. Benets from nutritional treatment may be assessed in a number of ways: reduced
number or severity of complications of disease and its treatment;
accelerated recovery from disease; reduced consumption of
resources; and improvement or at least prevention of deterioration in physical, cognitive, and social function [4]. Although the
last one mentioned in our opinion seems to be the most relevant,
the major focus of former validation studies of screening tools
has been on ability to predict undernutrition [4,5].
In Denmark, a BMI <24 often is used as a screening tool. In
other countries, frequently used nutritional screening tools in the

994

A. M. Beck et al. / Nutrition 29 (2013) 993999

older population are the Mini Nutritional Assessment (MNA) and

its short form (MNASF), the Malnutrition Universal Screening
Tool (MUST), and the Nutritional Risk Screening (NRS2002) [6].
These also are the screening tools recommended by the European
Society for Clinical Nutrition and Metabolism (ESPEN) [4].
These screening tools have been designed for different aims,
applications, and processes [5,7]. However, apparently none of
these tools have been designed to predict benets of nutritional
intervention among the elderly in primary health care. As part of
the project called The Good Meal we therefore designed a new
screening tool, the Eating Validation Scheme (EVS) for this
purpose. The content of the EVS is based on, respectively, the
results of our former validation studies [8,9], and studies
regarding the signicance of different nutritional risk factors and
weight loss [10,11]. EVS is depicted in Figure 1.
The objective of this study was to validate EVS, MNASF,
MUST, NRS2002, and BMI<24 using published randomized
controlled trials (RCT) of nutritional intervention among old
people in primary health care, in order to evaluate whether they
were capable of distinguishing those with a positive benet from
those that showed no benet of nutritional intervention.
Methods
The method used is based on that used for validation of the NRS2002 among
patients [12].
1. Literature search to identify RCTs of nutritional intervention among old
people in primary health care;
2. Classication of participants with respect to nutritional risk according to
recommended nutritional screening tools;
3. Validation (i.e., evaluation of whether the different tools were capable of
distinguishing those with a positive clinical outcome from those that
showed no benet of nutritional intervention).
Literature search
The studies included in the Cochrane review [13], which assessed functional
outcome among old people in primary health care were selected for further
reading. Additionally, the list of references to studies excluded from the Cochrane
review was hand-searched to identify other relevant studies. Also, the publication status of on-going studies mentioned in the review was identied.
Second, an update of the search performed in the Cochrane review was
performed in November 2009 (last search in the Cochrane review was performed
in December 2007) [13].
The references of all retrieved studies were searched for additional trials.
Related citations of identied trials were checked.
One author (AB) carried out the search by scanning the titles and abstract
sections. Full articles were then retrieved for further assessment if the information given suggested that the study:





Used random allocation to the comparison groups

Compared oral nutritional intervention with no intervention or a placebo
Involved old people in primary health care, who were aged 65 y old
Assessed nutritional and functional outcomes

Oral nutritional interventions included individual dietary advice by a dietitian, industrial and homemade supplements, other milk-based supplements,
fortication of normal food sources, and changed meal service.
The primary outcomes of interest were functional; physical (e.g., activities of
daily living measures, falls, balance, walking speed); cognitive (e.g., Mini Mental
State Examination or cognitive performance measures), and social (e.g., measures
of social engagement). The secondary outcome of interest was nutritional;
change in weight, and change in energy intake.
Based on the full articles, it was decided whether the effect on the outcomes
should be considered positive or no effect. Studies that claimed a positive
effect that could not be conrmed by their published data were categorized as
showing no effect.
Nutritional screening tools
The nutritional screening tools MUST, MNASF, and NRS2002, recommended by ESPEN [4], were used in the validation study.

Fig. 1. Eating Validation Scheme (EVS).

MUST is primarily developed for use in the community and includes a BMI
score, a weight loss score, and an acute disease score. MUST is designed to
identify need for nutritional treatment as well as establishing nutritional risk on
the basis of knowledge about the association between impaired nutritional status
and impaired function [4,5,7].
MNA is designed to detect the presence of undernutrition and the risk for
developing undernutrition among the elderly in home-care programs, nursing
homes, and hospitals. MNASF includes six parts, evaluating decline in food
intake, weight loss, mobility, physiological stress or acute disease, cognitive
condition, and BMI [4].
NRS2002 is designed to predict clinical effects of nutritional treatment in
hospital settings. NRS2002 level 1 contains BMI status, weight loss history,
nutritional intake, and severity of disease. Level 2 contains the same factors, but
includes a grading of their severity (mild [score 1], moderate [score 2], severe
[score 3]). NRS2002 evolved from a preexisting tool by adding a score component for people aged at least 70 years [4,5,7].
Furthermore, the recently developed nutritional screening tool EVS, was
validated. EVS consist of a combination of formerly validated tools [8,9], and is
designed for use among nursing home residents and home-care clients. EVS
(depicted in Fig. 1) contains information about eating habits, recent unintended
weight loss, and the presence or absence of nutritional risk factors (eating
dependency, chewing and swallowing problems, acute disease, or acute change
in chronic disease). The information is combined to give a total number of points;
0 (no risk); 1 (at risk), and 2 (intervention).
Finally, we used a BMI <24 for classication of nutritional risk because this tool
often is used in practice in Denmark (based on recommendations from ref. 14).
Details about the items included in the different tools and their cut-off points
for nutritional risk can be found in Table 1.

A. M. Beck et al. / Nutrition 29 (2013) 993999

995

Results
Literature search
Eighteen RCTs that had assessed the effect of nutritional
intervention on the participants physical, cognitive, or social
function were identied. Two of these were excluded, due to lack
of a no-intervention group [16,17]. In addition to the studies
included in the Cochrane review [13], another four studies were
identied (published in six papers) [1823]. One of these studies
included a multifaceted intervention comprising nutrition,
exercise, and oral care [20,21]. Details of the 16 included RCTs
[1835] and are presented in Table 3.
Classication of participants with respect to nutritional risk
according to different nutritional screening tools

Fig. 1. (continued).

Classication of participants with respect to nutritional risk according to different

nutritional screening tools
As a rst step, all the authors met, discussed, and agreed on what to do with
studies that had incomplete information on key issues (e.g., if the extent of
weight loss before the study was not stated it was decided to look at the reported
energy intake and compare it with the estimated requirement).
Then each of the authors (AB, TB, and SK) read all papers blind to the views of
the others and classied the participant groups with respect to nutritional risk
according to the different screening tools. Specically with regard to NRS2002,
the classication was according to levels 1 and 2.
The judgments were made according to the mean results of nutritional
status, unless specic screening tools were used. In all studies, it was assumed
that participants with acute disease had been excluded. This item, therefore
always obtained a score of 0.
After the rst evaluation, studies where the three authors disagreed were
submitted to the fourth author (HHR) for independent evaluation (i.e., without
knowing the scores given by the other authors). The nal scores were those on
which the majority agreed.
Validation
The evaluation of whether the different tools were capable of distinguishing
those with a positive outcome from those that showed no benet of nutritional
intervention was assessed by calculating the sensitivity, specicity, and positive
and negative predictive values (PPV and NPV) [15], with regard to the outcomes;
energy intake, weight, and function (see Table 2 for further details).
Data presented in the original articles were used to perform the calculations.
No further information was obtained from the authors of the studies. The analysis
was not censored according to the quality of the studies.

From the data in the 16 RCTs [1835], the participants were

classied by means of the items included in the different tools
and their cut-off points for nutritional risk (see Table 1). All
studies provided information regarding BMI and the presence of
nutritional risk factors. Some studies [20,21,24,27,30,33,34], did
not provide information about recent weight loss. However,
except for one study [27], they all provided information about
dietary intake. Hence, if this intake was low compared with
estimated requirement, the participants were considered as
having a recent weight loss. In the last study [27], a weight loss in
the control group was reported during the intervention, and
therefore it was judged that this group also had lost weight before
start. AB, TB, and SK agreed on the classication with regard to
the cut-off of all studies with MNASF and BMI<24. AB, TB, and
SK agreed on the classication with regard to the cut-off of 14
studies with MUST, NRS2002 level 1, NRS2002 level 2, and EVS.
The studies [2023,27,3032] on which the three authors disagreed were submitted to the fourth author (HHR) for independent evaluation. In each case, HHR agreed with the majority of
the other authors (i.e., three of four agreed on the classication).
The nal scores can be found in Table 4. The participant groups
varied with respect to their nutritional risk in the 16 studies
depending on the screening methods used. However, identical
results were obtained with regard to the scoring by means of,
respectively, MNASF and BMI<24 (see Table 4).
Validation
Not all 16 studies contained information about change in
energy intake and weight: Four of 16 had found a positive effect
of the nutritional intervention on the participants function

Table 1
Items included in the nutritional screening tools used in the validation study

MUST
MNASF
NRS2002
Level 1
NRS2002
Level 2
BMI<24
EVS

BMI

Weight loss

Appetite loss/reduced
dietary intake

Acute disease

X
X
X

X
X
X

X
X

X
X
X

Nutritional risk f
actors
X

X
X

Score

Cut-off values
nutritional risk

06
014
04*

2
11
1*

07

3

01y
02

1y
2

BMI, body mass index; EVS, Eating Validation Scheme; MNASF, Mini Nutritional Assessment Short Form; MUST, Malnutrition Universal Screening Tool; NRS2002,
Nutrition Risk Screening 2002
* Level 1 consists of four questions, if just one is answered with a yes, it means that NRS2002 level 2, should be performed.
y
No proper score, just an evaluation of whether or not the BMI is <24. If it is, the score is 1.

996

A. M. Beck et al. / Nutrition 29 (2013) 993999

Table 2
Sensitivity, specicity, positive and negative predictive values, and prevalence
[15]
Diagnosis
based on test

Condition status
positive negative

Positive
Negative
Sum

B
b
Bb

Sum
n
N
Nn

Bn
bN
BbnN

Sensitivity B/(B b), Specicity N/(n N)

Positive predictive value (PPV) B/(B n), Negative predictive value (NPV)
N/(b N)
Prevalence (B b)/(B b n N)
B true-positive, N true-negative, b false-negative, n false-positive

(physical, mental, or social); 4 of 10 had found a positive effect on

energy intake; and 11 of 14 had found a positive effect on weight
(see Table 3). Some of the studies also had examined the effect on
morbidity and mortalitydthe effect was in general limited (data
not shown).
The results of the calculation of the sensitivity, specicity, PPV
and NPV with regard to the primary and secondary clinical
outcomes are shown in Table 5.
Due to the identical results obtained with regard to the
scoring by means of, respectively, MNASF and BMI<24, the
validation results also were identical.
MNASF, NRS2002, and EVS had the highest PPV (0.75)
and EVS the highest NPV (0.74) with regard to functiondthe
primary outcome. With regard to weightdthe secondary outcomedMNASF and BMI<24 had the highest PPV (0.91), with
the exception of EVS, all methods had a low NPV (0). With regard

to energy intakedthe other secondary outcomedMNASF, NRS

2002, and BMI<24 had the highest PPV (1), but again low NPV
(respectively, 0.33 and 0).
Overall EVS seemed most capable of distinguishing those
participants with a positive benet from those that showed no
benet of nutritional intervention.

Discussion
From a validation based on 16 RCTs [1835], it appears that
EVS is the most suitable tool for predicting a positive effect of
nutritional intervention among old people in primary health care
on function, weight, and energy intake.
To our knowledge, none of the screening tools included in this
study (see Table 1) were previously studied for their ability to
predict positive benets of nutritional intervention among this
group. One explanation is that they have been designed for
different aims and applications (see previously).
We included NRS2002 in the validation study despite this
tool being intended for hospital use, because we believe it will be
of great value to have a common tool for all care settings.
Additionally, NRS2002 (level 2) is the only screening tool
developed to predict positive benets of nutritional intervention
and has been validated according to this in hospitalized patients
[12]. That study found a sensitivity of 0.75 and a specicity of
0.55 [13], but PPV and NPV are not specied. For comparison, the
sensitivity and specicity of EVS, in relation to functional
capacity, are respectively 0.43 and 0.98 (see Table 3).

Table 3
Randomized controlled studies, which had assessed the effect of nutritional intervention on the participants physical, cognitive, or social function and that are used in
the validation study
Reference

Setting

Age (mean [SD]) (I/C)

Duration
(wk)

Nutritional
Intervention

Screening

Effect
energy
intake

Effect
weight

Effect
physical
function

[18]*,y

Home care

83 (4.5)/82.9 (4)

ID

No

No

Nursing home
Nursing home
Nursing home

No
Positive
Positive

No
Positive
Positive

Nursing home
Home-care

Milk powder
Meal ambience
Chocolate, hONS,
exercise, oral care
Fortied food hONS
iONS ID

No
Positive
Positive

[19]*
[25]

81.2 (9.5)/79.7 (10.5)

78 (11)/75 (10)
87 (8490)/86 (8487)
(95%CI)
82.2 (9.5)/84 (9.5)
76 (7)/79 (8)

Yes (weight
loss, BMI)
Yes (BMI)
No
No

No

[24]
[22,23]*
[20,21]*,y

12 24
follow-up
7
24
11 27
follow-up
12
12

No
No

No
Positive

No
Positive

[26]

Home-care

81.6 (7.5)/76.6 (6.1)

16

iONS ID

Positive

No

Home for the elderly

83 (7392)/83 (7191)
(range)
84.6 (5.5)/84.7 (5.5)
83 (6)/85.6 (7)

24

iONS

Yes (MNA)
Yes (weight
loss, BMI)
Yes (weight
loss BMI)
Yes (MNA)

Positive

No

8
12 24
follow-up
10

iONS
iONS

Yes (MNA)
No

Positive

Positive

No
No

iONS

No

No

Positive

No

12

iONS

Yes (BMI)

Positive

No

83 (1)/83 (1)

12 and 36

iONS

No

Positive

84 (6.3)/81 (7)

24

iONS

Yes (BMI)

Positive
(BMI)
Positive

84 (6)/81 (7)

24

iONS

Yes (BMI)

79.5 (6)/78.1 (5)

12 24
follow-up

iONS

Yes (MNA)

[27]

[28]
[29]y

Nursing home
Residential care

[30]y

Nursing home

[31]

Psycho-geriatric
nursing home
Retirement home

[32]y
[33]
[34]
[35]

Sheltered housing/
Home for the elderly
Sheltered housing/
home for the elderly
Day care centers/
geriatric wards (AD)

85.7 (1.2)/89.2 (0.8)

(SEM)
85.3 (8.4)/78.7 (8.8)

No

Positive

Positive

Effect
cognitive
function

Effect
social
function

No
No

Positive

No

No

No

No

No

No

AD, Alzheimers disease; BMI, body mass index; CI, condence interval; hONS, homemade oral nutritional supplements; I/C, intervention and control; iONS, industrial
oral nutritional supplements; ID, individual dietary advice by a dietitian; MNA, Mini Nutritional Assessment
* Not included in reference 13.
y
Studies with a combined intervention (e.g., nutrition and/or exercise). Data presented are from those who only received the nutritional intervention (except for the
study by Beck and co-workers [20,21] where a multifaceted intervention was provided).
z
Included in reference 13 as a Ph.D. thesis.

A. M. Beck et al. / Nutrition 29 (2013) 993999

Table 4
The classication of the participant groups with respect to nutritional risk
according to the different screening tools in different randomized controlled
trials of nutritional intervention*
Reference

MUST

MNASF

NRS2002
Level 1

NRS2002
Level 2

BMI <24

EVS

[18]
[24]
[22,23]
[20,21]
[19]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]

2
2
01
01
2
2
2
01
01
01
01
2
01
01
01
2

11
11
11
11
11
11
11
11
11
11
11
11
12
11
11
11

1
1
1
1
1
1
1
0
1
1
0
1
0
0
0
1

3
3
12
3
3
3
3
12
3
3
12
3
12
12
12
3

1
1
1
1
1
1
1
1
1
1
1
1
0
1
1
1

2
1
2
2
2
2
2
1
1
1
1
1
1
1
1
2

BMI, body mass index; EVS, Eating Validation Scheme; MNASF, Mini Nutritional
Assessment Short Form; MUST, Malnutrition Universal Screening Tool; NRS
2002, Nutrition Risk Screening 2002
* See Table 1 for explanation of scores.

EVS is the only nutritional screening tool that does not

include BMI, see Table 1.
In recent years there has been some debate as to whether BMI
is a useful parameter to assess nutritional status in the elderly
[36,37]. The debate is due to a change in body composition in the
form of an increased content of fat and a loss of muscle mass and
therefore loss of muscle strength and function (sarcopenia). The
reasons are many, including aging, physical inactivity, and
inadequate intake of protein [38]. Elderly people with high BMI
therefore can suffer from sarcopenic obesity, where the
combination of obesity and sarcopenia presumably may enhance
Table 5
Results of the validation study*
Primary clinical outcome: function

Sensitivity
Specicity
PPV
NPV

MUST

MNASF

NRS2002
Level 1

NRS2002
Level 2

BMI <24

EVS

0.14
0.67
0.25
0.5

0.2
0
0.75
0

0.27
0.80
0.75
0.33

0.2
0.67
0.5
0.33

0.2
0
0.75
0

0.43
0.89
0.75
0.74

Secondary clinical outcome: energy intake

Sensitivity
Specicity
PPV
NPV

MUST

MNASF

NRS2002
Level 1

NRS2002
Level 2

BMI <24

EVS

0.2
0.4
0.25
0.33

0.4
0
1
0

0.5
1
1
0.33

0.43
0.67
0.75
0.33

0.4
0
1
0

0.5
0.75
0.75
0.5

Secondary clinical outcome: weight

Sensitivity
Specicity
PPV
NPV

MUST

MNASF

NRS2002
Level 1

NRS2002
Level 2

BMI <24

EVS

0.57
0
0.36
0

0.77
0
0.91
0

0.7
0
0.64
0

0.67
0
0.55
0

0.77
0
0.91
0

0.71
0.14
0.46
0.33

BMI, body mass index; EVS, Eating Validation Scheme; MNASF, Mini Nutritional
Assessment Short Form; MUST, Malnutrition Universal Screening Tool; NRS
2002, Nutrition Risk Screening 2002; NPV, negative predictive value; PPV,
positive predictive value
* Whether the different tools were capable of distinguishing those with
a positive clinical outcome from those that shoved no benet of nutritional
intervention.

997

the risk for loss of function, disease, and death [38]. Therefore, it
is suggested that the ideal BMI for the elderly is higher than for
younger people (i.e., between 24 and 29 kg/m2) and BMI <24
indicates nutritional risk [14]. However, our results suggest that
the use of BMI <24 alone is not a sufcient nutritional screening
tool to assess whether old people in home care and nursing
homes may benet from nutritional intervention.
Both MNASF and EVS includes various nutritional risk factors
in the nutrition screening. The MNASF factors are cognition
and mobility. In EVS the factors are chewing and swallowing
problems, eating dependency, and disease state. The intention
in both tools is that there must be an effort to address the nutritional risk factors, too (e.g., offer physiotherapy or dental care).
Although participants in the included studies had a high incidence of various risk factors, interventions rarely have been targeted against these. It may be some of the explanation to the
relatively limited effect of an initiated nutritional intervention [13].
Our study suffers from some weaknesses. Most studies had
information on key issues that made it possible to score the
participants with the different tools. However, the judgments
often were made according to the mean results of nutritional
status, which mean that some of the participants did not full
the criteria. This might have inuenced our ndings.
A screening tool may be wrongly categorized on account of
a type 2 error (i.e., studies may not be adequately powered to
detect certain outcome variables). Indeed many of the variables
included in the analyses were secondary outcome variables and it is
not clear if the studies were adequately powered to examine them.
Some of the included studies have involved multiple interventions in one group for comparison with a control group (no
intervention). It can be difcult to ascribe any benets to the
nutritional component of the intervention when it might have
been due to exercise or other type of intervention. Therefore,
nutrition screening tools may be assessed on the wrong premises.
We did not perform a proper systematic review and a more
systematic search may have identied more studies and may
have changed our ndings.
Only a few of the 16 studies had data on quality of life and
morbidity, and therefore it was not possible to assess the validity
of the different tools in relation to these topics. Moreover it was
not possible to assess the validity compared to the effect on
survival because none of the studies found a positive effect of
nutritional intervention.
From the available data in the studies used for the validation it
was not possible to assess the part of EVS that concerns recent food
intake (i.e., whether the elderly person leaves  25% on the plate).
However, a former study has found this screening tool reliable [9].
The strength of our study is that there only was minor
disagreement between the classications made by AB, TB, and
SK, and in all cases the fourth author (HHR) agreed with the
majority of the other authors.
Furthermore, in contrast to former validation studies of
screening tools [6,39], our focus was on whether they were
capable of distinguishing those with a positive benet from
those that showed no benet of nutritional intervention.
Choosing a screening tool requires a consideration of a wide
range of issues, including the intended purpose of the tool, its
reliability and validity (i.e., content, construct, responsiveness),
and practical issues associated with its implementation (ease of
use and time taken to complete tool) [57,39]. All of these aspects
still lack consideration with regard to the newly developed EVS.
The major focus of our study compared with former validation
studies, was the predictive values (e.g., how many of those who
could actually benet from an intervention) that the tools

998

A. M. Beck et al. / Nutrition 29 (2013) 993999

identify. Of course the ideal screening tool also has a high

sensitivity and a high specicity [15]. Table 5 shows that the
sensitivity was in general low in all the tools, including the EVS.
Therefore, it might be relevant to consider if EVS could be optimized to achieve a higher sensitivity, for example, by taken
a closer look at the point system and the included risk factors.
Furthermore, it might be relevant to validate EVS among less frail
older people.
Finally, our results need to be conrmed by a proper
randomized nutritional intervention, where the benets of
a multifaceted nutritional intervention aimed at residents and
clients, who are identied by means of EVS, are assessed.
Conclusion
From a validation using 16 RCTs it appears that EVS is most
capable of distinguishing those with a positive clinical outcome
from those that showed no benet of nutritional intervention,
when compared with BMI <24, MNASF, MUST, and NRS2002.
These ndings should be conrmed in further validation and
intervention studies.
Acknowledgment
This study was part of the project called The Good Meal,
which ran from 2008 to 2010. The objectives of the project were
to develop and test a number of tools and methods for the Danish
municipalities to strengthen the quality of their meal service for
senior citizens. The National Board of Social Services had no role
in study design, in the collection, analysis and interpretation of
data, in the writing of the manuscript; or in the decision to
submit the manuscript for publication.
References
[1] Beck A, Ovesen L. Body mass index and energy intake of old Danish nursing
home residents and home-care clients. Scand J Caring Sci 2002;16:8690.
[2] Beck A, Damkjr K. Optimal body mass index in a nursing home population. J Nutr Health Ageing 2008;12:6757.
[3] Arvanitakis M, Beck A, Coppens P, De Man F, Elia M, Hebuterne X, et al.
Nutrition in care homes and home care. How to implement adequate
strategies. Clin Nutr 2008;27:4818.
[4] Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN Guidelines for
Nutrition Screening 2002. Clin Nutr 2003;22:41521.
[5] Elia M, Stratton R. Considerations for screening tool selection and role of
predictive and concurrent validity. Curr Opin Clin Nutr Metab Care
2011;14:42533.
[6] Bauer JM, Kaiser MJ, Sieber CJ. Evaluation of nutritional status in older
persons: nutritional screening and assessment. Curr Opin Clin Nutr
2010;13:813.
[7] Elia M, Stratton R. An analytic appraisal of nutrition screening tools supported by original data with particular reference to age. Nutrition
2012;28:47794.
[8] Beck A, Ovesen L. Modication of the nutrition questionnaire for elderly to
increase its ability to detect elderly people with inadequate intake of
energy, calcium, vitamin C and vitamin D. Eur J Clin Nutr 1999;53:5609.
[9] Beck A, Ovesen L, Schroll M. Validation of the Resident Assessment
Instrument triggers in the detection of undernutrition. Age Ageing
2001;30:1615.
[10] Challa S, Sharkey JR, Chen M, Phillips CD. Association of resident, facility,
and geographic characteristics with chronic undernutrition in a nationally
represented sample of older residents in US nursing homes. J Nutr Health &
Ageing 2007;11:17984.
[11] Mamhidir AG, Ljunggren G, Kihlgren M, Kihlgren A, Wimo A. Underweight,
weight loss and related risk factors among older adults in sheltered
housingda Swedish follow-up study. J Nutr Health & Aging 2006;
10:25562.

[12] Kondrup J, Rasmussen HH, Hamberg O, Stanga Z. Nutritional risk screening

(NRS 2002): a new method based on an analysis of controlled trials. Clin
Nutr 2003;22:32136.
[13] Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly patients at risk from malnutrition (review). Cochrane
Database of Systematic Reviews; 2009. http://dx.doi.org/10.1002/
14651858.CD003288.pub3. Issue 2 NO.: CD003288.
[14] Beck A, Ovesen L. When should hospitalized elderly patients be considered
at nutritional risk. Clin Nutr 1998;17:1958.
[15] Altman DG. Practical statistics for medical research. London, UK: Chapmann & Hall; 1995.
[16] Wouters-Wesseling W, Slump E, Kleijer CN, de Groot CPGM, van
Staveren WA. Early nutritional supplementation immediately after diagnosis of infectious disease improves body weight in psycho-geriatric
nursing home residents. ACER 2006;18:704.
[17] Zak M, Swine C, Grozicki T. Combined effect of functionally-oriented
exercise regimens and nutritional supplementation on both the institutionalised and free-living frail elderly (double-blind, randomised clinical
trial). BMC Public Health 2009;9:39. http://dx.doi.org/10.1186/1471-24589-39.
[18] Rydwik E, Frndin K, Akner G. Effects of physical training and nutritional
intervention program in frail elderly people regarding habitual physical
activity level and activities of daily living a randomized controlled pilot
study. AGG; 2009. http://dx.doi.org/10.1016/j.archger.2009.12.001.
[19] Smoliner C, Norman K, Scheufele R, Hartig W, Pirlich M, Lochs H. Effects
of food fortication on nutritional and functional status in frail elderly
nursing home residents at risk of malnutrition. Nutrition 2008;24:
113944.
[20] Beck A, Damkjr K, Beyer N. Multifaceted nutritional intervention among
nursing-home residents has a positive inuence on nutrition and function.
Nutrition 2008;24:107380.
[21] Beck A, Damkjr K, Soerby L. Physical and social functional abilities seem
to be maintained by a multifaceted randomised controlled nutritional
intervention among old (65 years) Danish nursing home residents. AGG
2010;50:3515.
[22] Nijs KAND, de Graaf C, Kok FJ, van Staveren WA. Effect of family style
mealtimes on quality of life, physical performance, and body weight of
nursing home residents: cluster randomised controlled trial. BMJ
2006;332:11804.
[23] Nijs KAND, de Graaf C, Siebelink E, Blauw YH, Vanneste V, Kok FJ, et al.
Effect of family-style meals on energy intake and risk of malnutrition in
Dutch nursing home residents: a randomised controlled trial. J Gerontol
2006;61:93542.
[24] Kwok T, Woo J, Kwan M. Does low lactose milk powder improve the
nutritional intake and nutritional status of frail older Chinese people living
in nursing homes? J Nutr Health Ageing 2001;5:1721.
[25] Gray-Donald K, Payette H, Boutier V. Randomised trial of nutritional
supplementation shows little effect on functional status among free-living
frail elderly. J Nutr 1995;125:296571.
[26] Payette H, Boutier V, Coulombe C, Gray-Donald K. Benets of nutritional
supplementation in free-living frail, undernourished elderly people:
a prospective randomised community trial. J Am Diet Assoc 2002;102:
108895.
[27] Manders M, de Groot LCPGM, Hoefnagels WHL, Dhonukshe-Ruten RAM,
Wouters-Wesseling W, Mulders AJMJ, et al. The effect of a nutrient dense
drink on mental and physical function in institutionalised elderly people. J
Nutr Health Ageing 2009;13:7607.
[28] Lauque S, Arnaud-Battandier F, Mansourian R, Guigoz Y, Paintin M,
Nourhashemi F, et al. Protein-energy oral supplementation in malnourished nursing-home residents. A controlled trial. Age Ageing 2000;29:
516.
[29] Rosendahl E, Lindelf N, Littbrand H, Yifter-Lindgren E, Lundin-Olsson L,
H
aglin L, Gustafson Y, et al. High-intensity functional exercise program and
protein-enriched energy supplement for older persons dependent in
activities of daily living: a randomised controlled trial. Aust J Physiotherapy
2006;52:10513.
[30] Fiatarone MA, ONeill EF, Ryan ND, Clements KM, Solares GR, Nelson ME,
et al. Exercise training and nutritional supplementation for physical frailty
in very elderly people. N Engl J Med 1994;330:176975.
[31] Wouters-Wesseling W, Wouters AEJ, Kleijer CN, Bindels JG, de Groot CPGM,
van Staveren WA. Study of the effect of a liquid nutrition supplement on
the nutritional status of psycho-geriatric nursing home patients. Eur J Clin
Nutr 2002;56:24551.
[32] Bonnefoy M, Cornu C, Norman S, Boutitie F, Bugnard F, Rahmani A, et al.
The effects of exercise and protein-energy supplements on body composition and muscle function in frail elderly individuals: a long-term
controlled randomised study. Br J Nutr 2003;89:7318.
[33] Wouters-Wesseling W, van Hooijdonk C, Wagenaar L, Bindels J, de Grott L.
The effect of a liquid nutrition supplement on body composition and
physical functioning in elderly people. Clin Nutr 2003;22:3717.

A. M. Beck et al. / Nutrition 29 (2013) 993999

[34] Wouters-Wesseling W, Wagenaar L, Rozendaal M, Berend Deien J, de
Grott LC, Bindels J, et al. Effect of an enriched drink on cognitive function in
frail elderly persons. J Gerontol 2005;60A:26570.
[35] Lauque S, Arnaud-Battandier F, Gilette S, Plaze J-M, Andrieu S, Cantet C,
et al. Improvement of weight and fat-free mass with oral nutritional
supplementation in patients with Alzheimers disease at risk of malnutrition: a prospective randomised study. J Am Geriatr Soc 2004;52:17027.
[36] Janssen I, Mark AE. Elevated body mass index and mortality risk in the
elderly. Obes Rev 2007;8:4159.

999

 a A, Gonza
lez-Reimers E,
[37] Casas-Vara A, Santolaria F, Fernandez-Bereciartu
Garca-Ochooa A, Martinez-Riera A. The obesity paradox in elderly patients
with heart failure: analysis of nutritional status. Nutrition 2012;28:
61622.
[38] Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al.
Sarcopenia: European consensus on denition and diagnosis. Age Ageing;
2010. http://dx.doi.org/10.1093/ageing/afq034.
[39] Green SM, Watson R. Nutritional screening and assessment tools for older
adults: literature review. J Adv Nurs 2006;54:47790.

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.