ARTICLE IN PRESS

International Journal of Nursing Studies 44 (2007) 1036–1054

www.elsevier.com/locate/ijnurstu
Review
Malnutrition in acute care patients: A narrative review$
Cathy Kubrak, Louise Jensen
Faculty of Nursing, University of Alberta, 3rd Floor Clinical Sciences Bldg., Edmonton, Alta., Canada T6G 2G3
Received 30 April 2006; received in revised form 12 July 2006; accepted 13 July 2006

Abstract

Objectives: This narrative review assesses the current prevalence of malnutrition, the methods for detection of
malnutrition, the factors associated with malnutrition, and the effects of malnutrition in the acute care patients.
Design: A narrative review methodology was employed.
Data sources: CINAHL, Pub Med, and MEDLINE electronic databases were searched from 1996 to 2005, for English
language articles. Search terms of malnutrition, acute care patients, nutrition assessment, and nutrition screening were used.
Review method: The titles and abstracts of 857 articles were examined. Full text of the articles were obtained only when
abstracts described undernutrition, malnutrition, protein-energy malnutrition, nutrition assessment, nutrition screen-
ing, factors contributing to malnutrition, or resultant outcomes of malnutrition in adult acute care patients.
Additionally, a hand search through reference lists of retrieved articles was done. The articles reviewed included
empirical reports (110), reviews (25), commentaries (4), and reports from professional associations (10).
Results: Currently, malnutrition ranges from 13–78% among acute care patients. Different methods of detecting
malnutrition make it difficult to determine the prevalence among acute care patients. Additionally, many nutrition-
screening tools used to detect malnutrition have not undergone rigorous testing for validity, reliability, sensitivity, and
specificity. Numerous personal and organizational factors affect the nutritional status of acute care patients.
Diminished nutritional status contributes to increased use of hospital resources and increased hospital costs.
Conclusion: Malnutrition continues to be a significant problem among acute care patients. The Subjective Global
Assessment tool has the most diagnostic value for acute care patients. Simple measures, like documenting height and
weight on admission, and assessing patient’s nutritional intake, weight status, and medications that alter nutritional
intake could assist in early detection of malnutrition in the acute care patient.
r 2006 Elsevier Ltd. All rights reserved.

Keywords: Malnutrition; Nutrition assessment; Acute care patients; Narrative review

What is already known about the topic?  Various methods of detecting malnutrition are used
to assess/screen the nutrition status of patients in
acute care.
 Malnutrition is a significant issue among acute care  Numerous factors contribute to malnutrition in acute
patients. care patients.
$
Precis: A current review highlights the prevalence, methods What this paper adds
of detection, and effects of malnutrition among acute care
patients.
Corresponding author. Tel.: +1 780 492 9033.  Current prevalence and assessment of malnutrition
E-mail address: ckubrak@ualberta.ca (C. Kubrak). among acute care patients.

0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2006.07.015
 ARTICLE IN PRESS
C. Kubrak, L. Jensen / International Journal of Nursing Studies 44 (2007) 1036–1054
 The extent to which methods of detecting malnutri-
tion are practical, effective, valid, reliable, sensitive,
and specific to patients in acute care.
 The extent to which hospital routines contribute to
malnutrition in patients in acute care.
1. Malnutrition in acute care patients: a narrative review
In 1859, Florence Nightingale described soldiers in the
Crimea hospital starving amongst plenty of food.
Consequently, she suggested methods to ameliorate the
problem, as well as, the importance of nutrition to
patients’ well-being (Nightingale, 1859). Nevertheless,
over 100 years later, 50% of surgical patients (Hill et al.,
1977) and 40% of medical patients (Bistrian et al., 1976)
were reported as malnourished. Early reports estimated
that from 30–55% of patients entering acute care are or
were at risk of becoming malnourished (Bistrian et al.,
1974; Coats et al., 1993; Dempsey and Mullen, 1987;
Detsky et al. 1987a; Hill et al., 1977; McWhirter and
Pennington, 1994). What’s more, Butterworth (1974)
documented a number of practices which contributed to
the decline in nutrition status of acute care patients
including diffusion of responsibility for patient care,
prolonged use of saline or glucose parenteral nutrition,
poor observation and documentation of patients’ diet-
ary intake, failure to recognize malnutrition, and failure
to provide nutrition support. Furthermore, the con-
sequences of malnutrition for acute care patients’
including post-operative complications (Arora and
Rochester, 1982; Buzby et al., 1980; Haydock and Hill,
1986), prolonged hospital stay (Bastow et al., 1983;
Dempsey et al., 1988), and mortality and morbidity have
been identified. In addition, nutrition support was
observed to benefit malnourished surgical patients
(Bastow et al., 1983; Delmi et al., 1990).
In the last 30 years, numerous advances in nutrition
support have been made yet, medical, nursing, and
nutrition journals continue to report that malnutrition is
a significant problem among acute care patients
(Allison, 2000; Hoffer, 2001; Holmes, 2003; Kelly et
al., 2000). If malnutrition remains a significant problem
among acute care patients, what is its current preva-
lence, how is it detected, and what are the contributing
factors and resultant outcomes? Therefore, to obtain a
current perspective on malnutrition in acute care
patients, a review of the literature was undertaken.
The objectives of this narrative review were to assess the
prevalence of malnutrition in the acute care patients,
and to review the methods for detection of malnutrition,
the factors associated with malnutrition, and the effects
of malnutrition.
1037
2. Method
A literature search was conducted using the electronic
databases of CINAHL, Pub Med, and MEDLINE from
1996 to 2005, for English language articles. The following
search terms of malnutrition, acute care patients, nutrition
assessment, and nutrition screening were used. The titles
and abstracts of 857 articles were examined. Full text of
the articles were obtained when abstracts described
undernutrition, malnutrition, protein-energy malnutri-
tion, nutrition assessment, nutrition screening, factors
contributing to malnutrition, or resultant outcomes of
malnutrition in adult acute care patients. Additionally, a
hand search through reference lists of retrieved articles
was done. The articles reviewed included empirical
reports (110), reviews (25), commentaries (4), and reports
from professional associations (10).
3. Prevalence of malnutrition
Malnutrition refers to both over (intakes in excess of
requirements) and under nutrition (intakes of less than
requirements) (Green and Watson, 2005; Holmes, 2003).
For this review, malnutrition was defined as a state of
nutrient insufficiency, as a result of either inadequate
nutrient intake or inability to absorb or use ingested
nutrients (Hoffer, 2001; Jeejeebhoy, 2000). The preva-
lence of malnutrition was similar to that found 10 years
ago, ranging from 13–78% among acute care patients
(Table 1). In England, one in five patients on admission
to one of four hospitals was considered malnourished
(Edington et al., 2000). In Australia, a prospective study
of two Sydney teaching hospitals found 30% of patients
admitted were at risk for malnutrition and 6% were
malnourished (Middleton et al., 2001). Azad et al. (1999)
found that of the elderly patients admitted to a
Canadian tertiary care hospital, 44% of those admitted
were at risk for malnutrition and 15% were malnour-
ished. Of concern with this high rate of malnutrition
among the elderly, is that irrespective of nutritional
status upon admission, nutritional status deteriorates
over the course of hospitalization (Table 2). Further-
more, the estimated prevalence of malnutrition among
specialized patient populations, such as liver transplant
and oncology patients, ranges from 4–90% (Table 3).
Factors associated with this high prevalence of malnu-
trition result from the interplay between disease severity,
degree of disability, complexity of treatment, and health
care practices.
Despite this high prevalence of malnutrition, a lack of
consistent measures for assessment makes it difficult to
compare rates of malnutrition. What’s more, studies
using similar methods to assess nutritional status; (i.e.)
anthropometric measures such as body mass index
(BMI) set different ‘‘end points’’ for defining malnutri-
 ARTICLE IN PRESS
1038 C. Kubrak, L. Jensen / International Journal of Nursing Studies 44 (2007) 1036–1054

Table 1
Prevalence of malnutrition in acute care adult patients

Authors Country n Prevalence (%) Method of assessment

Mears (1996) USA 95 43 Serum pre-albumin, serum albumin

Bruun et al. (1999) Norway 244 39 Body mass index (BMI), weight loss
Braunschweig et al. (2000) USA 404 54 Subjective Global Assessment (SGA)
Kelly et al. (2000) United Kingdom 337 13 BMI, MACa, waist circumference
Middleton et al. (2001) Australia 819 36 SGA
Isabel et al. (2003) Latin America 9348 50.2 SGA
Kyle et al. (2003a, b) Switzerland, 1760 48 BMI, serum albumin, fat-free mass, body fat
Germany
Robinson et al. (2003) USA 320 33 Serum pre-albumin, serum albumin, retinol
binding protein
Th de Kruif and Vos (2003) Netherlands 334 86 Nursing Nutritional Screening Form (NNSF)
RocandioPablo et al. (2003) Spain 60 78.3 SGA, Nutritional Risk Index (NRI), Gassull
classification Instant Nutritional Assessment
(INA)
Corish et al. (2004) Ireland 359 44 NRI
46 Nutrition Risk Score (NRS)
Pichard et al. (2004) Switzerland 952 57.8 SGA, BMI, fat-free mass, Fat-free-mass index,
fat-mass index
Raja et al. (2004) Singapore 681 22.3 Malnutrition Screening Tool
15.4 SGA
Rasmussen et al. (2004) Denmark 590 39.9 BMI, recent weight loss, recent food intake
Stratton et al. (2004) United Kingdom 794 34.8 Malnutrition universal screening tool (MUST)
Sungurtekin et al. (2004a) Turkey 100 44 SGA
61 NRI
Sungurtekin et al. (2004b) Turkey 251 30 SGA
36 NRI
Weekes et al. (2004) United Kingdom 100 20 Nutrition Screening Tool
Kyle et al. (2005) Germany 794 22 SGA
a
Mid-arm muscle circumference.

tion (Table 4). Additionally, studies examining the
elderly or specialized patient populations use indices
where no references for these cohorts parameters
have been determined, such as serum albumin and
anthropometric measures (Covinsky et al., 2002;
Kyle et al., 2003a; Naber et al., 1997a). Finally, many
of the indicators of malnutrition used for specialized
patient populations are compromised by the disease
state or age, and may be measuring severity of illness
or effects of aging rather than nutritional status
(Jeejeebhoy, 2000).
4. Detection of malnutrition
literature (Green and Watson, 2005). Nutrition assess-
ment refers to a comprehensive evaluation of nutritional
status including, medical history, dietary history, phy-
sical examination, anthropometric measurements, and
laboratory data, whereas nutrition screening is the
process of identifying patients at risk for malnutrition
or who are presently malnourished (Corish, 1999; Green
and Watson, 2005). A number of clinical indicators
and nutrition screening tools (NST) are currently used
to determine risk or presence of malnutrition in acute
care patients (Corish, 1999; Jeejeebhoy, 2000; Klein et
al., 1997). However, no ‘‘gold standard’’ exists for
determining nutrition status (American Society of
Parenteral and Enteral Nutrition [A.S.P.E.N.], 2002;
Klein et al., 1997).

The detection of malnutrition is important, given

that the consequences can contribute to increase in
hospital stay, complications, readmission, and mortality
(Giner et al., 1996; Isabel et al., 2003; Liu et al., 2002;
Van Nes et al., 2001). Nutrition assessment and
nutrition screening are used interchangeably in the
4.1. Clinical indicators
Traditionally, nutritional status is evaluated using
clinical and biochemical data, anthropometric data, and
diet history (Campillo et al., 2004; Chertow et al., 2000;
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C. Kubrak, L. Jensen / International Journal of Nursing Studies 44 (2007) 1036–1054
Table 2
Prevalence of malnutrition and risk for malnutrition in acute care elderly patients
Authors n Prevalence (%)
Azad et al. (1999) 152 59
Covinsky et al. (2002) 311 42.4
Persson et al. (2002) 83 63
82
Thomas et al. (2002) 837 91
Thorsdottir et al. (2005) 60 68.3
58.3
a
Triceps skinfold (TSF).
Covinsky et al., 2002; Fuhrman et al., 2004; Gibson, 1990;
Kyle et al., 2003a; Omran and Morley, 2000a, b;
Robinson et al., 2003). The common clinical indicators
used to assess nutrition status are found in Table 5. Body
weight and BMI are most frequently used to determine
nutritional status, however, relying solely on these
measures can be misleading as changes could be due to
dehydration, ascites, edema, disease, and age (Campillo et
al., 2004; Jeejeebhoy, 2000; Klein et al., 1997; Pennington,
1997). Furthermore, with the increased prevalence of
obesity, many patients with a BMI422 kg/m2 would go
undetected for malnutrition. Studies that used BMI to
detect malnutrition used various ‘‘cut off’’ values ranged
from o16 kg/m2 to o29 kg/m2 (See Table 4). With weight
loss, a more sensitive predictor of nutritional status is the
rate and timing of unintentional weight loss, since it has
been demonstrated that weight loss decreases steadily
after age 70 years and may be confounded by patient
recall or intentional weight loss (Corish and Kennedy,
2000; Detsky et al., 1987a, b; Morgan et al., 1980; Naber
et al., 1997a, b; Omran and Morley, 2000a, b; Parekh and
Steiger, 2004).
Biochemical markers such as visceral proteins, total
lymphocyte count, and nitrogen balance studies are also
used to assess nutrition status. Although visceral
proteins markers (serum albumin/pre-albumin level,
and transferrin) and immune competence (total lym-
phocyte count) are associated with mortality and
morbidity and incidence of infection, they are poor
indicators of nutritional status and are not sensitive in
indicating the effectiveness of nutrition therapy (Cher-
tow et al., 2000; Fuhrman et al., 2004; Jeejeebhoy, 2000;
Mears, 1996a, b; Robinson et al., 2003). For example,
serum albumin and transferrin levels are affected by
disease status, medications, and age (Chertow et al.,
2000; Robinson et al., 2003; Spiekerman, 1995). Low
visceral protein levels reflect ‘‘metabolic stress’’ in most
acute care patients (Corish and Kennedy, 2000; Franch-
1039
Method of assessment
Total lymphocyte count, serum albumin, total cholesterol, risk
factors, % energy intake, Body Mass Index (BMI), %
unintentional weight loss
SGA, serum albumin
SGA
Mini Nutritional Assessment (MNA)
MNA, SCALES, BMI, weight loss, serum albumin, serum urea
nitrogen: creatinine
MNA
Full nutrition assessment (FNA), serum albumin, serum pre-
albumin, total lymphocyte count, MAC, TSFa, BMI, unintended
weight loss, loss of appetite
Arcas, 2001; Raguso et al., 2003). Thus, visceral
protein levels inversely correlate with metabolic stress
and have prognostic relevance to patient outcomes, but
not nutritional status, per se (Corish and Kennedy,
2000; Franch-Arcas, 2001; Raguso et al., 2003). Also
problematic is the lack of internationally accepted ‘‘cut
off’’ parameters for clinical indicators used to detect
malnutrition in acute care patients (Corish and Kenne-
dy, 2000). For example, 10 studies listed in Table 4
used serum albumin to detect malnutrition. Unfortu-
nately, each study set different parameters for
serum albumin thereby, hindering the detection of
malnutrition.
Other anthropometric and functional measures such
as triceps skinfold, mid-arm muscle circumference, and
handgrip strength are also used to determine nutritional
status, but these measures can also vary with disease
status and age (Jeejeebhoy, 2000; Klein et al., 1997;
Omran and Morley, 2000a). For example, triceps
skinfold measurement may be less valid for the elderly
compared to that of younger adults because body fat is
redistributed with age (Jeejeebhoy, 2000; Klein et al.,
1997; Omran and Morley, 2000a). Furthermore, many
anthropometric reference measures do not exist for
various cohorts such as the elderly or specialized patient
populations (Campillo et al., 2004; Jeejeebhoy, 2000;
Omran and Morley, 2000a; Naber et al., 1997a, b;
Pennington, 1997; Persson et al., 2002).
Using a single indicator such as serum albumin,
weight, or triceps skinfold thickness to determine a
patient’s nutritional status fails to recognize the multi-
tude of factors that influence nutritional status (Fuhr-
man et al., 2004; Jeejeebhoy, 2000; Klein et al., 1997).
Therefore, to overcome the limitations of a single
indicator it has been recommended that more than two
indicators of nutrition status be used to detect malnutri-
tion in acute care patients (Arrowsmith, 1999; Klein
et al., 1997). Additionally, agreement on the ‘‘cut off’’
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1040 C. Kubrak, L. Jensen / International Journal of Nursing Studies 44 (2007) 1036–1054

Table 3
Prevalence of malnutrition in specialized patient populations

Authors Patient Group n Prevalence (%) Method of assessment

Giner et al. (1996) Intensive Care 129 43 Serum albumin, weight: height ratio
Chima et al. (1997) Medical 173 32 Serum albumin, weight: height ratio,
ideal body weight, unintentional weight
loss
Naber et al. (1997a) Non-surgical 155 45 SGAa
57 NRIb
62 Maastricht Index
Stephenson et al. (2001) Liver transplant 109 90.8 SGA, serum albumin, serum creatinine
Bauer et al. (2002) Oncology 71 76 Patient-Generated Subjective Global
Assessment (PG-SGA)
Thoresen et al. (2002) Palliative oncology 46 28 Body Mass Index (BMI), Triceps
skinfold (TSF), mid-arm muscle
circumference (MAC), percentage
weight change from prediagnosis,
serum albumin, serum prealbumin
30 PG-SGA
Campillo et al. (2004) Non-ascites liver cirrhosis 165 18.8 BMI, MAC, (TSF)
Mild ascites liver cirrhosis 124 24.3
Tense ascites liver cirrhosis 107 39.1
Medical cardiovascular disease 81 7.4
Surgical cardiovascular disease 251 4
Stroke 85 4.8
Degenerative neurological 36 5.7
disease
Surgical hip fracture
Palliative cancer 68 25.6
Elderly medical
91 11.8
44 20
Gupta et al. (2004) Colorectal cancer 234 52 SGA
Alvares-de-Silva et al. (2005) Liver cirrhosis 145 28 SGA
18.7 PNIc
63 Handgrip strength (HG)
Dray et al. (2005) Adult cystic Fibrosis 163 49.7 BMI
58.7 CFTR genotype
Zaina et al. (2004) Liver transplant 219
Non-cholestatic 198 2.5 BMI
Cholestatic 21 23.5
Non-cholestatic 198 64.9 Serum albumin
Cholestatic 21 53.9
Non-cholestatic 198 61.6 TSF
Cholestatic 21 56.7
Non-cholestatic 198 50.5 Current body weight /usual body
weight
Cholestatic 21 47.6
a
Subjective Global Assessment.
b
Nutrition Risk Index.
c
Prognostic Nutrition Index.
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C. Kubrak, L. Jensen / International Journal of Nursing Studies 44 (2007) 1036–1054 1041

Table 4
Clinical indicator parameters used in prevalence studies of malnutrition

Clinical indicator ‘‘Cut off’’ parameters Malnutrition study

Weight (wt) 1 week 42% wt loss Chima et al. (1997) Z10% wt loss
1 month 45–10% wt loss Bruun et al. (1999) mild 5–10%; moderate 10–20%; severe- more than 20%
3 months 47.5% wt loss Thoresen et al. (2002) 45% during last month
6 months 410% wt loss Rasmussen et al. (2004) mild 3 months 5–10%; moderate 3 months 10–15%;
severe 415%
Azad et al. (1999) moderate 3 month, 1–7.5%; severe 47.5%
Thomas et al. (2002) 42% in 1 month or 47.5% in 6 months
Thorsdottir et al. (2005) unintended weight loss: Yes or No
Body Mass Index (BMI) Range o16.0 –o29.0 kg/m2 Azad et al. (1999) mild 24–29; moderate 20–23; severe o20
Bruun et al. (1999) mild 18–20; moderate 16–18; severeo16
Kelly et al. (2000) malnutritiono18.5
Thomas et al. (2002) malnutritiono19–22
Thoresen et al. (2002) malnutritiono20
Kyle et al. (2003a, b) malnutritiono20
Campillo et al. (2004) malnutrition o20
Pichard et al. (2004) malnutritiono20
Rasmussen et al. (2004) moderate 18.54BMIo20.5; severe o18.5
Thorsdottir et al. (2005) malnutrition 18.2–27.6
Dray et al. (2005) malnutrition o18.5
Mid-arm circumference Range 17.3 –26.9 cm Kelly et al. (2000) malnutrition o22.25
(MAC)
Thoresen et al. (2002) r5th percentile
Thorsdottir et al. (2005) malnutrition 17.3 –25.9
Campillo et al. (2004) malnutrition 18.5 –26.9
Triceps skinfold (TSF) Range 2.2–22.4 mm Thoresen et al. (2002) r5th percentile
Campillo et al. (2004) malnutrition 2.2–22.1
Thorsdottir et al. (2005) malnutrition 11.6 –22.4
Serum albumin Range o24.9–51.0 g/l Mears (1996) moderate 25 –32; severe o25
Giner et al. (1996) malnutrition o35
Chima et al. (1997) malnutrition o30
Azad et al. (1999) mild 28 –34; severe o28
Stephenson et al. (2001) mild o45; moderate o34; severe o38
Covinsky et al. (2002) malnutrition o30 –40
Thomas et al. (2002) malnutrition o40
Thoresen et al. (2002) r30 percentile
Kyle et al. (2003a, b) malnutrition o35
Robinson et al. (2003) malnutrition o40
Thorsdottir et al. (2005) malnutrition 31–51
Serum pre-albumin Range o10 –p450 mg/dl Mears (1996) moderate 10 –17, severe o10
Thoresen et al. (2002) r21 percentile
Robinson et al. (2003) malnutrition o20
Thorsdottir et al. (2005) malnutrition 180 –450
Retinol binding protein Range o3 ng/ml Robinson et al. (2003) malnutrition o3 ng/ml
Serum creatinine Range 0.6 –1.6 mg/dl Stephenson et al. (2001) mild 0.6 –1.0, moderate 0.65 –1.05, severe 0.6 –1.6
Serum urea nitrogen Range 8.3 –40.8 mg/dl Thomas et al. (2002) malnutrition 8.3 –40.8
Total lymphocyte count Range Azad et al. (1999) malnutrition o1.2
0.93  109–2.09  109 l
Thorsdottir et al. (2005) malnutrition 0.93 –2.09
 ARTICLE IN PRESS
1042 C. Kubrak, L. Jensen / International Journal of Nursing Studies 44 (2007) 1036–1054
Table 5
Common indicators used to assess nutrition status
Indicator
Weight (wt), unintentional wt loss, percentage of wt loss
Body Mass Index (BMI)
Serum albumin
Serum transferring
Serum prealbumin
Retinol-binding protein
Total lymphocyte count
Creatinine: height index
Skinfold measures—triceps, biceps, subscapular, and
suprailliac
Functional status—handgrip strength, respiratory function
parameters of clinical indicators within various popula-
tions may assist in the identification of malnutrition.
4.2. Nutrition screening tools (NST)
NST help to identify patients who are malnourished
or ‘‘at risk’’ of malnutrition (Arrowsmith, 1999; Green
and Watson, 2005), so that they can be referred to a
dietician for nutrition assessment and appropriate
nutrition support (Klein et al., 1997). Since physicians
and nurses currently assess patients on admission to
hospital, it has been suggested that they are in an ideal
position to screen patients for malnutrition (Arrow-
smith, 1999; Green and Watson, 2005).
Generally, the indicators of malnutrition used in NST
include weight, height, weight history, symptoms,
functional status, and primary diagnosis to determine
risk or presence of malnutrition (Green and Watson,
2005; Huhmann and Cunningham, 2005). In order to be
useful to clinicians, NST must be flexible, easy to use
and interpret, valid, and reliable in various acute care
patient populations (Green and Watson, 2005; Jones,
2002). NST should direct clinicians in a plan for
Use of information and limitations
Wt loss is considered significant when there is a X5% in 1
month, X7.5% in 3 months, 10% in 6 months. Poor recall of
weight and lack or recording
BMIo18.5 indicates health risk due to undernutrition,
18.5–24.5 indicates normal range, low risk of illness, X25
indicates increased risk for health problems. Increased
prevalence of obesity
p30 mg/dl indicates protein depletion. Values affected by
hydration status, albumin administration, and acute stress.
Half-life of 20 days
p150 mg/dl indicates nutritional depletion. Values affected by
iron deficiency anemia, hemorrhage, dehydration, liver disease,
and chronic infection. Half-life of 8–10 days
p17 mg/dl indicates protein depletion. Values affected by
hydration status, hyperthyroidism, renal failure, metabolic
stress and severe liver disease. Half-life of 2–3 days
p4.5 mg/dl indicates nutrition depletion. Values affected by
injury and metabolic stress. Half-life 12 h
p1500/mm3 indicates malnutrition. Can be affected by drugs
and disease state
p60% indicates severe nutritional deficiency, and skeletal
muscle depletion. Requires accurate 24 h urine collection and
can be affected by meat intake, renal function, drugs and age
Measurements p5th percentile is considered an indicator of
fat and protein depletion. Variability between assessors and
population groups like the elderly
The relationship between muscle function and nutrition status
has not been established
nutrition care (A.S.P.E.N., 2002; Corish 1999). What’s
more, NST should demonstrate its benefits in terms of
cost-effectiveness and clinical outcomes (Arrowsmith,
1999). NST that are recommended for use in acute care
settings by clinical practice groups such as A.S.P.E.N.,
British Society for Parenteral and Enteral Nutrition
(B.A.P.E.N.), and European Society for Parenteral and
Enteral Nutrition (E.S.P.E.N.) are listed in Table 6.
On review of recommended NST, the Malnutrition
Universal Screening Tool (MUST) and Nutrition Risk
Index (NRI) have limited testing for validity, reliability,
specificity, and sensitivity (see Table 6). The NRI,
Prognostic Nutrition Index (PNI), and Prognostic
Inflammatory and Nutritional Index (PINI) are imprac-
tical for clinicians to use, since they would have to wait
for lab results before completing nutrition screening.
Furthermore, the insensitivity and ambiguity of lab
values makes these NRI, PNI, and PINI problematic.
The Mini-Nutritional Assessment (MNA) is only valid
for elderly patients, therefore, its practicality for acute
care practice is questionable. Additionally, the MNA,
NRI, PNI, and PINI have not established inter-rater
reliability for nurses. The Subjective Global Assessment
Table 6
Nutrition screening tools (NST)
Screening tool Tool description
Malnutrition Universal Assess Body Mass Index
Screening Tool (MUST) (BMI), weight (wt) loss, and
(Bapen, 2003) acute disease effect Scoring:
‘‘0’’ ¼ low risk; ‘‘1’’ ¼
medium risk; p2 ¼ high risk
Mini Nutritional First section assess food
Assessment (MNA) intake, weight loss, mobility,
(Vellas et al., 1999) presence of stress or acute
disease, neuropsychological
problems, and BMI. Scoring:
X12 ¼ no risk, p11 ¼ risk
and continued assessment of
12 additional items in second
section. Scoring: 17–23.5 ¼ at
risk; and o17 ¼ malnutrition
Nutrition Risk Index Formula uses serum albumin, Surgical patients Inter-rater reliability not
(NRI) (Veterans Affairs percentage of weight loss to
Total Parenteral calculate NRI score. Scoring:
Nutrition Cooperative 100 ¼ no
Study Group, 1991) risk;497.5–100 ¼ borderline
nutrition risk;
83.5–97.5 ¼ mild nutrition
risk; and o83.5 ¼ severe
nutrition risk
Nutrition Risk Screening Assess BMI, weight loss,
(NRS 2002) (Kondrup et dietary intake, illness severity.
al., 2003) An answer of yes to any
question directs clinicians to
further screening. The second
screening cumulative
scoring:o3 ¼ need for weekly
screening; and
X3 ¼ nutritional risk and
need for nutritional support
Population tested Reliability
Outpatients, and Inter-rater reliability
Inpatients completed with nurses,
(medical, doctors, and dieticians
surgical, and (k ¼ 0:80921:0)
elderly patients) Predictive of mortality
and length of stay in
elderly patients
Elderly only Inter-rater reliability not
completed with nurses.
Other reliability between
observers not specific
(k ¼ 0:51)
reported Predictive of
mortality and morbidity
in surgical patients
Various medical Inter-rater reliability
and surgical between nurse, physician, validity
inpatient and dietician (k ¼ 0:67) (po0:000)
populations
Validity Sensitivity and specificity Clinical practicality
Assessed against Not reported Fast and easy to use
other NSTs but Practical in clinical setting
agreement varied Directs clinicians in a plan
C. Kubrak, L. Jensen / International Journal of Nursing Studies 44 (2007) 1036–1054
from poor to for nutrition care
excellent
(k ¼ 0:4020:75)
Assessed against Reported for 18 items Updated version easy to
weight loss, from MNA, Poor complete Early version
percent weight sensitivity with o3 meals/ required training to
change and other day (0.122) Best complete Updated version
NST sensitivity with acute directs clinicians in a plan
ARTICLE IN PRESS
(p ¼ o0:000) illness (0.910) Poor for nutrition care
specificity with living
conditions (0.604) Best
specificity with mid-arm
circumference and
o2 vegetables/day
Not reported Not reported Clinical practicality not
reported but blood draws
needed for completion
Does not direct clinicians
in a plan for nutrition care
Predictive Sensitivity and specificity Easy and quick to use
range 75–88% and Directs clinicians in a plan
21–59%, respectively for nutrition care
1043
 1044
Table 6 (continued )

Screening tool Tool description Population tested Reliability Validity Sensitivity and specificity Clinical practicality

Prognostic Nutritional Formula uses serum albumin, Surgical and Inter-rater reliability not Predictive Sensitivity—86%, Clinical practicality not
Index (PNI) (Mullen et serum transferrin, triceps skin medical patients reported Predictive of validity Specificity—69% reported, but blood draws
al., 1980; Buzby et al., fold thickness, delayed mortality and morbidity (po0:000) needed for completion
1980) cutaneous hypersensitivity in surgical patients Does not direct clinicians

C. Kubrak, L. Jensen / International Journal of Nursing Studies 44 (2007) 1036–1054

reactivity to calculate PNI
score. Scoring:o40% ¼ low
risk; 40–49% ¼ moderate risk;
and 450% ¼ high risk
Prognostic Inflammatory Formula uses a 1 acid
and Nutritional Index glycoprotein, C-reactive
(PINI) (Ingenbleek and protein, albumin, and
Carpentier, 1985) prealbumin to calculate PINI
score. Scoring:430 ¼ life risk;
in a plan for nutrition care
In-patients Inter-rater reliability not Predictive Not reported Simple and easy to use
reported validity once blood draws are
(po0:000) complete therefore maybe
impractical for use Does
not direct clinicians in a

ARTICLE IN PRESS
21–30 ¼ high risk; plan for nutrition care
11–20 ¼ medium risk;
1–10 ¼ low risk; and
o1 ¼ minimal risk
Subjective Global Assess weight loss, dietary Outpatients, and Inter-rater reliability Assessed against Sensitivity—82%, Requires training to use
Assessment (SGA) Detsky intake, gastrointestinal inpatients established with nurses, clinical Specificity—72%, Directs clinicians in a plan
et al. (1987a) symptoms, disease state, and (medical, physicians, and indicators for nutrition care
functional capacity; Subjective surgical, and dieticians—81%, (po0:001) and
physical assessment. Rating: specialized predictive of mortality, other NST,
A ¼ well nourished; patient morbidity, post-operative considered a
B ¼ moderately populations) infections validated NST
malnourished; and
C ¼ severely malnourished
 ARTICLE IN PRESS
C. Kubrak, L. Jensen / International Journal of Nursing Studies 44 (2007) 1036–1054
(SGA) has undergone rigorous testing for validity,
reliability, specificity, and sensitivity. Additional advan-
tages to using the SGA include an established inter-rater
reliability with nurses, validation with a variety of acute
care populations, and cost-effectiveness (Detsky et al.
1987a). Drawbacks to using the SGA include the time
commitment required for training and assessment. Of
the recommended NST for use in acute care settings, the
SGA has the most diagnostic value for acute care
patients.
Arrowsmith (1999) evaluated six NST developed for
use by nurses in hospital or community settings. The
NRI and MNA were found to be impractical or time
consuming for nurses to use in clinical practice. For
example, the MNA requires the measuring of mid-arm
and calf circumferences which may be difficult to assess
in frail elderly patients admitted to an emergency or
orthopedic setting. Only the MNA, had undergone re-
testing for reliability, validity, sensitivity and specificity
testing. The other NST including NRI, Nutritional Risk
Score, Nursing Nutrition Screening Tool (NNST),
Screening in Practice (SIP), and Nursing Nutritional
Assessment Tool (NNAT) required testing for reliabil-
ity, validity, sensitivity, or specificity. Additionally, none
of the NST directed a plan for further nutrition care or
therapy. Finally, none of the NST had undergone testing
to determine the effects on clinical outcomes. Jones
(2002) critically reviewed 44 NST for use in acute, long-
term, and community settings by a variety of health care
professions. Only 39% of the NST had both reliability
and validity evaluated. Green and Watson (2005)
reviewed 35 NST for use by nurses in various clinical
settings. Their review supported the findings of the
others (Arrowsmith, 1999; Jones, 2002) that very few of
the NST in use by nurses had undergone rigorous
testing. Green and Watson (2005) also highlighted
that the lack of validity and reliability of screening
tools in use may have negative economic consequences
to healthcare systems that are already stretching
sparse resources. None of the authors who evaluated
Table 7
Factors contributing to malnutrition in acute care patients
Personal
Age
Apathy/depression
Disease (cancer, diabetes, cardiac, G.I.a)
Drug therapy
Inability to buy, cook, consume
Inability to chew or swallow
Limited mobility (arthritis/tremors, obesity)
Sensory loss (taste/smell)
Treatment (ventilation, surgery, drainage tubes)
a
Gastrointestinal (G.I.).
1045
the NST recommended any one NST for use in the acute
care setting.
These critical reviews demonstrated that many NST in
use in acute care settings have not been subjected to
rigorous testing for validity, reliability, specificity, and
sensitivity (Arrowsmith, 1999; Green and Watson, 2005;
Jones, 2002). Additionally, some NST are ineffective in
clinical practice because they are: (a) difficult or
impractical to implement, (b) not universal in various
patient populations, (c) not able to direct a plan for
nutrition care, and (d) not proven to be cost-effective or
of benefit to clinical outcomes (Arrowsmith, 1999;
Green and Watson, 2005; Jones, 2002).
5. Factors associated with malnutrition
The development of malnutrition among acute care
patients is influenced by other factors that are indepen-
dent of disease status. Current reported factors attrib-
uted to malnutrition fall into two main categories:
personal and organizational (Table 7). Personal ele-
ments can be further sub-divided into physical and
social causes (Allison and Kinney, 2001; Holmes, 2003;
Reid, 2004; Rosenthal, 2004; Thomas et al., 2002).
Unfortunately, many of the current factors attributed to
malnutrition in acute care patients are not different from
those documented over 30 years ago by Butterworth
(1974).
The physical factors for malnutrition among acute
care patients are attributable to disease, age, and
treatment (Allison, 2000; Anker and Sharma, 2002;
Brandi et al., 1999; Braunschweig et al., 2000; Ro-
senthal, 2004). Diseases, like cancer and diabetes, as well
as, cardiac or gastrointestinal disorders affect a patient’s
ability to ingest, digest, absorb, transport, utilize, and
excrete nutrients in the body (Anker and Coats, 1999;
Barber et al., 1999; Bozzetti et al., 2000; Braga et al.,
2002; McClave et al., 1999; Roberts et al., 2003;
Organizational
Failure to recognize malnutrition
Lack of nutritional screening or assessment
Lack of nutritional training
Confusion regarding nutritional responsibility
Failure to record height and weight
Failure to record patient intake
Lack of adequate intake
Lack of staff to assist with serving and feeding
Importance of nutrition unrecognized
 ARTICLE IN PRESS
1046 C. Kubrak, L. Jensen / International Journal of Nursing Studies 44 (2007) 1036–1054
Woodcock et al., 2001). Age, disease, and treatment
factors associated with malnutrition include difficulty
chewing and swallowing, sensory losses of taste and
smell, tremors and reduced dexterity, and poor mobili-
zation (Allison and Kinney, 2001; Elmstahl et al., 1997;
Grobbelaar et al., 2004; Liu et al., 2002; Rosenthal,
2004; Sullivan et al., 1999). Treatment factors associated
with changes to energy expenditure leading to malnutri-
tion include surgery, mechanical ventilation, drugs,
drainage tubes, and ostomies (Brandi et al., 1999;
Cheever, 1999; Fearon and Luff, 2003; Giner et al.,
1996; Kyle et al., 2005; Reid, 2004). Social circumstances
such as reduced ability to buy, cook, or consume food
contribute to impaired nutritional status. This is
especially true among the elderly and chronically ill,
who because of physical, psychological, or financial
factors are at increased risk for malnutrition (Nelson et
al., 1998; Rosenthal, 2004; Sullivan et al., 1999).
Organizational factors identified to be associated with
malnutrition include lack of nutrition screening or
assessment and documentation, inadequate training of
medical and nursing staff, confusion regarding nutri-
tional responsibility, increased nursing workload, and
lack of adequate nutritional intake (Campbell et al.,
2002; Friedmann et al., 1997; Holmes, 2003; McWhirter
and Pennington, 1994; Pedersen, 2005; Perry, 1997b;
Rasmussen et al., 1999). Lennard-Jones et al. (1995)
interviewed 454 nurses and 319 junior doctors in 70
hospitals in the United Kingdom and found that among
nurses only 52% recorded patient’s weight and 69%
recorded patient’s height on hospital admission. Rea-
sons given for not recording weight and height included
no available measure or scale, patients were too ill, and
weight and height measures were not considered to be
important. Sixty-five percent of the nurses asked
patients about food intake and 63% of nurses stated
the reason for not asking about nutrition was that these
questions were unimportant. Perry’s (1997b) survey of
110 nurses in a Welsh hospital found 48% of the nurses
carried out nutritional assessment on their patients of
whom 26% used only the patient’s weight as an
indicator of nutritional status rather than percentage
of weight loss over 6 months or unintentional weight
loss. A review of 141 patient charts showed that 69% of
the charts had a recorded weight but less than 51% of
the charts had a recorded height (Perry, 1997b). Bruun
et al.’s (1999) reviewed 240 patient charts in Norway and
found that 59% of the charts had a recorded weight and
51% had a recorded height for surgical patients.
Campbell et al.’s (2002) review of 600 patient charts in
acute hospitals in Scotland found that 67% of the charts
had a recorded weight but only 41% had both weight
and height recorded despite recommendations made in
1992 by the King’s Fund for routine monitoring of
patient’s height and weight. Similar studies of nurse’s
recording practices of patient’s height and weight in the
United States and Canada were not found. Thus, basic
clinical practices such as recording of height and
weight are not being completed. Furthermore, without
baseline data it is difficult to detect a decline or change
in a patient’s nutritional status. These findings also
underscore that there has been little change to the
clinical practice of recording a patient’s height and
weight, over the last 10 years, despite recommendations
for recording height and weight especially on admission
to acute care.
In assessing health care professional knowledge of
nutrition, Stotts et al. (1987) surveyed 142 under-
graduate nursing programs in the United States and
found that only half of the programs required a basic
nutrition course and 61% had integrated nutrition
content into the curriculum. Nutrition training ranged
from 0–100 h. Additionally, no standard nutrition
course or method for integrating nutrition content was
used in the nursing programs. Weigley (1997) surveyed
342 new nursing graduates to determine the nutritional
knowledge required for competent practice. New grad-
uates stated their undergraduate nutrition curriculum
focused primarily on fluid, electrolyte and acid-base
balance, followed by diet therapy for diabetics. Other
topic areas covered included macronutrients, nutrition
through the life-cycle, enteral and parenteral nutrition,
and nutrition in hypertension, surgery, trauma and
sepsis. Lindseth (1997) tested 129 graduating nurses in
the midwestern United States on their nutritional
knowledge using a 50 item multiple-choice exam. The
mean score on the exam was 60.25%. Nutritional
content areas nurses scored the lowest included nutrition
in the life cycle, cultural nutrition, and role of diet and
disease (Lindseth, 1997). Perry (1997b) tested 110 nurses
in the United Kingdom on their nutritional knowledge
through a multiple choice test and found that 79% had
grades below C. Kowanko et al.(1999) interviewed seven
nurses working on a medical unit in an Australian
hospital and found that while nurses believed nutritional
care was important they perceived they lacked the
knowledge (such as, macronutrients) needed to give
nutritional care to patients. Moreover, nutrition care
was considered inadequate due to confusion about
nutrition responsibilities, a lack of time, and a shortage
of nurses available to feed patients. Nightingale and
Reeves (1999) tested doctors (n ¼ 29), medical students
(n ¼ 65), nurses (n ¼ 45), pharmacists (n ¼ 11), and
dietitians (n ¼ 11) in the United Kingdom on their
knowledge of assessment and management of malnutri-
tion with a 20 question multiple-choice exam. Among
the 45 nurses in study, the average score on the exam
was 35%, which was significantly less than other groups.
Rasmussen et al.’s (1999) survey of 395 doctors and 462
nurses working in a Danish hospital found that 77% of
the respondents believed that nutritional assessment
should be done on admission, but 42% stated that
 ARTICLE IN PRESS
C. Kubrak, L. Jensen / International Journal of Nursing Studies 44 (2007) 1036–1054
nutritional assessment was not routinely performed.
Reasons for not performing nutritional assessments
included lack of a nutritional screening tool, difficulty
identifying at risk patients, lack of clinical nutrition
knowledge, and confusion about nutritional responsi-
bilities between health care professionals. These studies
demonstrate that knowledge of nutrition among nurses
is poor. All researchers concluded that nutrition
education is essential for healthcare professionals.
Additionally, confusion about nutritional responsibil-
ities, lack of time, and lack of nurses to assist with
feeding existed in acute care settings.
In assessing the nutritional intake of acute care
patients, Barton et al. (2000b) measured the wastage
and food intake on four specialty wards (medical,
surgical, orthopedic, and elderly) for 28 days in an
acute care hospital in the United Kingdom. They found
that more than 40% of the food was wasted and that the
average protein and energy intake was less than 80% of
the recommended daily requirements, despite providing
over 2000 kcal/day. Kowanko et al. (2001) examined 585
meals of medical patients in an Australian hospital and
found that despite providing adequate energy and
nutrients, about one-third of the patients had low
energy intake. They suggested that with a low energy
intake, patients are unlikely to meet the necessary basal
metabolic needs. Hamilton et al.’s (2002) audit of the
nutrition intake of elderly patients in community
hospitals in the United Kingdom found meals lacked
adequate protein, fiber, and vitamin D. Additionally,
lack of time, limited nursing staff to assist with feeding,
and lack of energy dense snacks were associated with
poor energy intake among the elderly. Dupertuis et al.
(2003) audited the food wastage and intake of 1707
patients in a Swiss hospital and found that despite
providing approximately 2000 kcal/day, two-thirds of
the patients did not eat all the food served. Moreover,
30% of the protein intake was not consumed. Reasons
for not eating the food included lack of taste, early
timing of meals, no menu choice, poor cooking, and
unacceptable menu. Wright et al. (2004) analyzed the
meals at one academic medical center and at one large
metropolitan Veterans Affairs Medical Center for 2
weeks and found that meals, especially the restricted
diets, were deficient in vitamins (such as Vitamin C and
D) and minerals (such as calcium and folate). Food
wastage and limited intake by acute care patients
indicates that nutrient intake is poor during hospital
stay. Furthermore, critical nutrients such as proteins,
vitamins, and minerals are not eaten. Suggested
strategies to reduce food wastage and improve nutrient
intake include documentation of patient intake, improv-
ing the quality of the food service (taste, menu choice,
and cooking style), provision of an energy dense snack,
and improving the serving and feeding of patients
(Barton et al., 2000a).
1047
A review of the factors associated with malnutrition
highlights the interaction between disease, disability,
medications, and the organization in contributing to
malnutrition. Furthermore, it underscores the difficulty
in establishing a clear cause and effect relationship
between disease, disability, or drugs, and malnutrition.
Many studies reviewing organizational factors stressed
the need for healthcare professionals to change current
practices regarding nutritional assessment and screening
of patients on admission, as well as the need to establish
clinical standards that include measuring height and
weight on admission and monitoring weight throughout
hospitalization (Campbell et al., 2002; Lennard-Jones et
al., 1995; Perry, 1997a, b). Because researchers failed to
provide data on the percentage of patients at nutritional
risk, adequacy of nutritional intake during hospitaliza-
tion, percentage of patients that received nutritional
therapy, or percentage of weight change during hospi-
talization, it is difficult to determine if any change to
patient outcomes occurred (Campbell et al., 2002;
Lennard-Jones et al., 1995; Perry, 1997a). Further
nutritional training, especially knowledge and identifica-
tion of malnutrition was recommended (Kowanko et al.,
1999; Lindseth, 1997; Rasmussen et al., 1999; Night-
ingale and Reeves, 1999). Studies examining food
wastage and intake in hospital suggest that inadequate
nutrient intake may contribute to the decline in weight
and nutritional status in acute care patients. Unfortu-
nately, many of the studies assessing food wastage and
intake did not explore reasons for the inadequate
nutrient intake therefore, it is difficult to determine if
disease state or organizations factors contributed to
poor food intake (Barton et al., 2000b; Kowanko et al.,
2001; Wright et al., 2004). However, the need for
documentation of patient intake, adequate staffing to
serve and assist with feeding, nutrient dense snacks to
ensure that recommended daily requirements are met,
and serving food that is appealing to the sick is
supported (Dupertuis et al., 2003; Hamilton et al.,
2002; Kowanko et al., 2001; Wright et al., 2004).
6. Effects of malnutrition
The physical consequences of malnutrition include
loss of lean tissue, reduced respiratory muscle and
cardiac function, decreased intestinal absorption (espe-
cially of macro–micronutrients like calcium and zinc),
increased thromboembolism, and impaired renal func-
tion (Arora and Rochester, 1982; Chandra, 1997;
Christou, 1990; Giner et al., 1996; Hoffer, 2001;
Mazolewski et al., 1999; McKibbin et al., 2003; Naber,
2004; Pichard et al., 2004). Also, malnutrition adversely
affects psychological responses, leading to fatigue or
apathy, which delays recovery and can exacerbate
anorexia (Barton et al., 2000b; Campbell et al., 2004;
 ARTICLE IN PRESS
1048 C. Kubrak, L. Jensen / International Journal of Nursing Studies 44 (2007) 1036–1054
Rosenthal, 2004). Impaired immunity can lead to
increased complications such as pressure ulcers, delayed
wound healing, and increased risk of infections (Allison
and Kinney, 2000; Baldwin and Parson, 2004; Collins et
al. 2005; Fearon and Luff, 2003; Heslin and Brennan,
2000; Mechanick, 2004; Naber et al., 1997a, b).
The adverse consequences of malnutrition can affect
all patients but they are especially hazardous for those
with sepsis, trauma, burns, and who are immuno-
compromised or elderly (Allison et al., 2000; Allison et
al., 2004; Brandi et al., 1999; DiMaria-Ghalili, 2002;
Hoffer, 2001; Naber et al., 1997a, b; Roberts et al., 2003;
Van Nes et al., 2001). Furthermore, the interaction
between illness state and nutrition can exacerbate the
effects of malnutrition (Corish and Kennedy, 2000;
Jeejeebhoy, 2000). For example, infection increases
energy expenditure and may also result in reduced
ability to absorb nutrients leading to a continuous cycle
of infection and malnutrition (Mechanick, 2004).
Reduced mobilization often results in muscle weakness
and loss of nutrients like calcium, and combined, they
can lead to falls resulting in fractures and other traumas,
and further malnutrition (Reid, 2004; Rosenthal, 2004).
Prolonged periods of fasting in combination with pain
can also result in diminished nutrient intake and
worsening malnutrition (Lewis et al., 2001; Ljungqvist
and Soreide, 2003).
In addition to the physical and psychological effects of
malnutrition, malnourished patients have longer hospital
stays that increase the cost of hospitalization (Braunsch-
weig et al., 2000; Funk and Ayton, 1995; Isabel et al.,
2003; Neumayer et al., 2001; Robinson et al., 1987;
Rypkema et al., 2004). Hospital costs and use of
resources increase in malnourished patients because
complications like infections and thrombosis delay
recovery from illness (Braunschweig et al., 2000; Chima
et al., 1997; Isabel et al., 2003; Raja et al., 2004; Senkal et
al., 1997; Smedley et al., 2004). In the elderly surgical
population, complications often result in re-admission to
hospital (Allison and Kinney, 2001; Campbell et al., 2004;
Friedmann et al., 1997; McClave et al., 1999; Sullivan and
Walls, 1998; Sullivan et al., 2002; Tucker and Miguel,
1996). Braunschweig et al.’s (2000) study of 404 adult
patients found that hospital costs increased by 60% in
malnourished patients compared to well-nourished pa-
tients. The increased costs were directly attributed to
longer hospital stays and complications, such as infec-
tions. Neumayer et al. (2001) studied 1007 patients
undergoing intestinal surgery, 183 of whom received
nutrition support. They concluded that patients who
received early and sufficient nutrition stayed on average
3.5 days less and had $5000 less in hospital costs
compared to patients who received sufficient nutrition
(60% of protein and caloric needs). These studies confirm
results from earlier work which demonstrated that
hospital charges are 30–50% greater in the malnourished
patients compared to well-nourished patients and that
these costs are directly attributable to increased hospital
stay and increased use of hospital resources (Senkal et al.,
1997; Smedley et al., 2004; Robinson et al., 1987; Reilly et
al., 1988; Tucker and Miguel, 1996). Thus, patients at risk
for malnutrition or are malnourished have longer hospital
stays after adjusting for severity of illness. However, none
of the studies reported on long-term (6 months–1 year)
outcomes.
7. Implications
Given that the prevalence of malnutrition is particu-
larly high among special cohort patient populations like
the elderly and cancer patients, these patient populations
should be targeted for nutritional screening on admis-
sion. The consequences of malnutrition can adversely
affect length of hospital stay, rate of complications, and
quality of life among acute care patients. Therefore,
many clinical practice groups currently recommend
nutrition screening of acute care patients either prior
to admission or within 24–48 h of admission
(A.S.P.E.N., 2002; B.A.P.E.N., 2003; Kondrup et al.,
2003; Weekes et al., 2004). Since there is no ‘‘gold
standard’’ for nutritional assessment or screening, it is
important to use tools which incorporate both subjective
and objective measures such as unintentional weight
loss, disease status, and functional status to facilitate
detection of at risk and malnourished acute care
patients. Additionally, since clinical indicators used to
detect malnutrition may be confounded by other factors,
it is recommended that a combination of clinical
indicators be used to assess risk for and presence of
malnutrition (A.S.P.E.N., 2002; Kondrup et al., 2003).
Since nurses typically assess patients on admission to an
acute care setting, they are in an ideal position to do
nutrition screening of acute care patients (Arrowsmith,
1999; Corish and Kennedy, 2000). Nutrition screening
of acute care patients should include documentation of
height and weight since this information is necessary
during hospitalization to detect changes to a patient’s
nutrition status. Acute care patients identified as at risk
for malnutrition or are malnourished also require
further nutrition assessment and a nutrition care plan.
Also, any nutrition care plan requires ongoing evalua-
tion.
Although numerous NST are recommended, the SGA
(Detsky et al., 1987a) is one of the few NST that has
demonstrated reliability and validity among various
acute care patient populations and a high measure of
sensitivity and specificity, therefore it could be consid-
ered for use in practice. Kruizenga et al. (2005) reported
on the impact of early nutrition screening by nurses and
treatment of malnourished patients, which found that
mean length of hospital stay was reduced by 1 day and
 ARTICLE IN PRESS
C. Kubrak, L. Jensen / International Journal of Nursing Studies 44 (2007) 1036–1054
resulted in a cost saving of h35.4 (approximately $40.00
U.S). Further research into the effectiveness of NST,
nutritional assessments, nutritional therapy, and nutri-
tional protocols in changing patient outcomes is needed
to demonstrate the benefits and cost-effectiveness of
nutrition care (Arrowsmith, 1999; Klein et al, 1997).
Additionally, there is a need for universally accepted
‘‘cut off’’ parameters to direct or regulate how clinical
nutrition indicators like anthropometric, biochemical,
and functional measures be used in various patient
populations (Corish and Kennedy, 2000; Corish et al.,
2004; Covinsky et al., 2002; Klein et al., 1997). Future
studies also need to derive reference data for various
populations, such as the elderly and specialized patient
populations, so that it is known how indices like serum
albumin and weight should be interpreted within a
specific population.
Future studies are needed to understand the barriers
to nutritional care within acute care settings. This
research would explore the knowledge, responsibilities,
and workloads that prevent nutrition care. Studies into
nursing workloads which prevent nurses from screening
or assessing nutrition status and serving and assisting
with nutritional care could provide evidence needed to
change workloads so nutrition care of patients has
greater priority (Elmstahl et al., 1997; Holmes, 2003;
Kowanko et al., 2001). In view of the evidence indicating
a lack of adequate nutrient intake during hospitaliza-
tion, there is first, a need for documentation of nutrient
intake. Furthermore, there is a need for nurses to find
the time to assist with serving and feeding of food,
especially patients such as the elderly who are at greater
risk for malnutrition. Future studies must also confirm
the long-term effects and cost-effectiveness of nutritional
supplementation on patient outcomes.
Despite evidence which demonstrates that malnutri-
tion adversely affects patient outcomes and health care
costs, malnutrition continues to be unrecognized in
clinical practice. A.S.P.E.N. (2002) has recommended
nutritional training of undergraduate students and
further specialized training for physicians in clinical
nutrition. Since nutrition education which includes
nutrition screening and assessment may not always be
a part of nursing education it is likely that nurses will
require additional training and education of nutrition
(Arrowsmith, 1999; Holmes 2003; Lindseth, 1997;
Weigley, 1997). Additionally, nutrition education should
include information on the nutrition status in acute care
patients, and care planning required for nutrition
support.
8. Conclusion
Malnutrition is not a new clinical issue but continues
to be a significant problem in acute care patients. While
1049
there is debate about best method of detecting malnu-
trition, and discussions continue about the factors
attributable to malnutrition, a significant number of
acute care patients are at risk for or are malnourished on
admission and whose nutritional status continues to
deteriorate during hospitalization. As a result of
malnutrition, patients have increased complications
such as wound infections and pneumonia which in turn
increases hospital stay and health care costs. Due to the
high prevalence of malnutrition among acute care
patients, it has been suggested that nurses are in an
ideal position to complete nutrition screening. Of the
recommended NST, the SGA has the most diagnostic
value for acute care patients. Additionally, it has been
suggested that education in nutrition could improve the
detection of at risk and malnourished patients. In the
interim, simple measures that could be employed are to
document height and weight on admission, assess
patient’s nutritional intake, assess patient’s weight over
the course of hospitalization, and assess medications
that could alter nutritional intake. Moreover, a con-
certed effort could be made to assist with feeding to
ensure adequate nutrient intake. Future research is
needed on the prevalence of malnutrition, especially
among vulnerable patient populations. Future studies
are also needed on the cost of malnutrition to
healthcare, as well as the cost-effectiveness of nutritional
therapy. The solutions to improve the nutritional status
in acute care patients may not be highly technical but it
is often the straightforward measures that Florence
Nightingale reinforced, like diet which make significant
differences to a patient’s health.
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