Clinical Research

Nutrition in Clinical Practice

Volume 33 Number 6
Risk of Malnutrition Evaluated by Mini Nutritional December 2018 879–886

C 2018 American Society for

Assessment and Sarcopenia in Noninstitutionalized Parenteral and Enteral Nutrition

DOI: 10.1002/ncp.10022
Elderly People wileyonlinelibrary.com

Ilaria Liguori, MD1 ; Francesco Curcio, MD1 ; Gennaro Russo, MD1 ;

Michele Cellurale, MD1 ; Luisa Aran, MD1 ; Giulia Bulli, MD1 ;
David Della-Morte, MD, PhD2,3 ; Gaetano Gargiulo, MD4 ; Gianluca Testa, MD,
PhD1,5 ; Francesco Cacciatore, MD, PhD1,6 ; Domenico Bonaduce, MD1 ;
and Pasquale Abete, MD, PhD1

Abstract
Background: Malnutrition indices and muscle mass and strength in the elderly are poorly investigated. Moreover, malnutrition seems
to be 1 of the more important factors in the cause of sarcopenia. The presence of sarcopenia and its relationship with malnutrition
indices were studied in noninstitutionalized elderly people who underwent Comprehensive Geriatric Assessment (CGA). Methods:
A total of 473 elderly subjects (mean age, 80.9 ± 6.6 years) admitted to CGA were studied. Malnutrition risk was evaluated with
Mini Nutritional Assessment (MNA) score, whereas muscle mass and muscle strength were evaluated by bioimpedentiometry and
hand grip, respectively. Sarcopenia was assessed as indicated in the European Working Group on Sarcopenia in Older People
(EWGSOP) consensus. Results: Overall prevalence of sarcopenia was 13.1%, and it increased from 6.1% to 31.4% as MNA
decreased (P < .001). MNA score was lower in elderly subjects with sarcopenia (15.4 ± 4.2) than without sarcopenia (22.0 ±
4.0) (P = .024). Linear regression analysis showed that MNA score is linearly related both with muscle mass (r = 0.72; P < .001)
and strength (r = 0.42; P < .001). Multivariate analysis, adjusted for several confounding variables including comorbidity and
disability, confirmed these results. Conclusions: MNA score is low in noninstitutionalized elderly subjects with sarcopenia, and it
is linearly related to muscle mass and muscle strength. These data indicate that MNA score, when evaluated with muscle mass and
strength, may recognize elderly subjects with sarcopenia. (Nutr Clin Pract. 2018;33:879–886)

Keywords
aged; elderly; malnutrition; muscle strength; nutrition assessment; nutritional status; sarcopenia

Sarcopenia has been defined as a phenomenon character-
ized by an age-related loss of muscle mass and strength
particularly evident in older people aged >75 years.1-3
Sarcopenia is related to an increased risk for morbidity
and mortality in elderly people,4-6 especially in institution-
alized elderly nursing home residents.7 This pathological
condition is defined as a geriatric syndrome characterized
by a loss of independence, a higher risk for falls, a reduc-
tion of the quality of life, and an increase in healthcare
cost.1-3 From the pathophysiological point of view, several
factors may be involved in the pathogenesis of sarcope-
nia including hormonal, metabolic, inflammatory state,
physical inactivity, and more importantly, malnutrition
state.8
Muscle protein loss at advancing age depends on a
discrepancy between muscle protein synthesis and muscle
protein breakdown; in fact, muscle protein synthesis rates
are reduced in the older population with age-related decline
at a rate of 3.5% per decade from age 20–90 years.9-11 It
is well known that protein-energy-malnutrition prevalence
in the acute care setting ranges between 23% and 60% of
elderly patients, and 22%–28% in this setting are at nutrition
risk.12 However, data on the prevalence of malnutrition in
From the 1 Department of Translational Medical Sciences, University
of Naples “Federico II”, Naples, Italy; 2 Department of Systems
Medicine, University of Rome Tor Vergata, Rome, Italy; 3 IRCCS San
Raffaele Pisana, Rome, Italy; 4 Division of Internal Medicine, AOU
San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy; 5 Department
of Medicine and Health Sciences, University of Molise, Campobasso,
Italy; and 6 Azienda Ospedaliera dei Colli, Monaldi Hospital, Heart
Transplantation Unit, Naples, Italy.
Financial disclosure: None declared.
Conflicts of interest: None declared.
[This article was modified on 2018-06-05 after initial online
publication to correct reference 17.]
This article originally appeared online on February 13, 2018.
Corresponding Author:
Pasquale Abete, MD, PhD, Associate Professor of Geriatrics,
Dipartimento di Scienze Mediche Traslazionali, Università di Napoli
Federico II, Via S. Pansini, 80131 Naples, Italy.
Email: p.abete@unina.it
880
community-dwelling older adults are poor, although some
reports indicate a range of 5%–30%.12
Moreover, malnutrition and sarcopenia often coexist in
a clinical syndrome characterized by a combination of
decreased nutrient intake and decreased body weight, along
with a decrease in muscle mass, strength, and/or physical
function (ie, malnutrition-sarcopenia syndrome [MSS]).13
Malnutrition and sarcopenia, taken together, are associated
with negative health outcomes. Thus, it is extremely impor-
tant to assess malnutrition status, and more importantly,
nutrition assessment should be integrated with sarcopenia
screening.13
Several malnutrition tools have been used with different
results.14 Mini Nutritional Assessment (MNA) represents
1 of the more specific tool to assess malnutrition state in
geriatric settings.15 However, this approach, together with
sarcopenia screening, is not well investigated in outpatient
older adults.
Thus, in this study, we aimed to investigate the rela-
tionship between muscle mass and strength and malnutri-
tion evaluated by MNA in outpatients older adults who
underwent Comprehensive Geriatric Assessment (CGA),
including several clinical and biochemical parameters.
Methods
Study Population
The study enrolled 473 consecutive elderly outpatients (ࣙ65
years) admitted to a CGA center. The study received
full ethical approval from research ethics committees in
accordance with the ethical standards laid down in the
1964 Declaration of Helsinki and its later amendments. All
participants signed an informed consent form, and the insti-
tutional review boards approved the study. Anthropometric
measurements including age, sex, body mass index (BMI),
and waist circumference (WC) were performed.16,17
Comprehensive Geriatric Assessment
Elderly participants underwent a comprehensive geri-
atric multidimensional evaluation that included cognitive
function evaluation with Mini-Mental State Examination
(MMSE)18 ; depressive symptoms with Geriatric Depression
Scale (GDS)19 ; comorbidity and comorbidity severity with
a Cumulative Illness Rating Scale (CIRS-Comorbidity and
CIRS-Severity)20 and drug number; disability with basic
and instrumental activities of daily living (BADLs and
IADLs, respectively); physical performance with 4-m gait
speed (cutoff < 0.8 m/s)21 ; physical activity with Physical
Activity Scale for the Elderly (PASE)22 ; social support eval-
uation with Social Support Assessment (SSA) scored from
17 (participants with the lowest support) to 0 (participants
with the highest support)23 and Tinetti Mobility Test or
Performance-Oriented Mobility Assessment (TMT).
Nutrition in Clinical Practice 33(6)
Frailty status was assessed by the Italian Frailty Index
derived by Rockwood’s frailty methods, recently validated
in an Italian cohort of elderly subjects.24 Fried’s frailty
methods were also assessed according to the Cardiovascular
Health Study Collaborative Research Group.25
Assessment of Nutrition Status
Nutrition status was assessed by MNA. The MNA test
is composed of simple measurements and brief questions
that can be completed in <10 minutes: (1) anthropometric
measurements (weight, height, and weight loss); (2) global
assessment (6 questions related to lifestyle, medication, and
mobility); (3) dietary questionnaire (8 questions, related to
number of meals, food and fluid intake, and autonomy of
feeding); and (4) subjective assessment (self-perception of
health and nutrition). The sum of the MNA score distin-
guishes between elderly patients: (1) with adequate nutrition
status (MNA ࣙ 24), (2) with protein-calorie malnutrition
(MNA >17), and (3) at risk for malnutrition (MNA between
17 and 23.5). With this scoring, sensitivity was found to be
96%, specificity 98%, and predictive value 97%.26
Assessment of Muscle Mass and Strength
Muscle mass was measured by bioelectrical impedance
analysis (BIA) using a Quantum/S Bioelectrical Body Com-
position Analyzer (Akern Srl, Florence, Italy). Whole-body
BIA measurements were taken between the right wrist and
ankle with the subject in a supine position. Muscle mass
was calculated using the following BIA equation of Janssen
and colleagues.27 Skeletal muscle mass (kg) = ([height2 /BIA
resistance × 0.401] + [gender × 3.825] + [age × −0.71])
+ 5.102, where height is measured in centimeters; BIA
resistance is measured in ohms; for gender, men = 1 and
women = 0; and age is measured in years. Absolute skeletal
muscle mass (kg) was converted to skeletal muscle index
standardizing by meters squared (kg/m2 ). Muscle strength
was assessed by grip strength, measured using a hand-grip
dynamometer (Mecmesin Advanced Force Gauge 500N;
GDM, Corsico (MI), Italy). The participant squeezed the
dynamometer with maximum effort for at least 5 seconds.
Hand-grip strength was tested 3 times with a minimum of
60 seconds rest provided for recovery between each attempt.
Maximum grip strength was recorded as the highest value of
3 trials. The maximum value was used rather than the mean
of 3 trials allowing for a measure that was independent
of fatigue, which may have been possible in some of the
participants. BMI-adjusted values were used as a cutoff
point to classify low muscle strength (BMI ࣘ24, 24.1–28,
<28 was 29, ࣘ30, and ࣘ32 kg for men; BMI ࣘ23, 23.1–
26, 26.1–29, and <29 was 17, ࣘ17.3, ࣘ18, and ࣘ21 kg for
women, respectively).25 Using the cutoff points indicated
in the European Working Group on Sarcopenia in Older
Liguori et al
People (EWGSOP) consensus, subjects with a low grip
strength presenting low muscle mass (skeletal muscle index
<8.87 and 6.42 kg/m2 in men and women, respectively) were
classified as “sarcopenia.”28
Biochemical Parameters
Hemoglobin (normal values: 12.0–17.5 g/dL in men and
12.0–16.0 g/dL in women), lymphocytes (normal values:
1.0–4.8 × 103 ), serum albumin level (normal values: 3.6–
5.2 g/dL), total iron binding capacity (normal values: 218–
411 μg/dL), C-reactive protein (CRP; normal values: <5
mg/dL), and butyryl-cholinesterase (b-CHE; normal values:
5.400–13.200 U/L) were routinely obtained.
Statistical Analysis
Baseline characteristics of the sample are expressed as
mean ± standard deviation. Participants were stratified
by the presence or absence of sarcopenia and stratified
by categories of MNA (<17, 17–23.5, ࣙ24). Categorical
variables were analyzed using χ 2 testing, continuous vari-
ables using a 1-way analysis of variance, and nonparametric
variables (ie, PASE score and lymphocyte number) using
Wilcoxon-Mann-Whitney. Univariate regression analysis
was used to test a correlation among muscle mass and
strength, and MNA score with other variables such as
age, BMI, WC, MMSE, GDS, CIRS-Comorbidity, CIRS-
Severity, drug number, BADLs, IADLs, PASE, 4-m walking
speed, TMT, and social support score. Statistically signifi-
cant variables were included into a multivariate regression
model as potential confounders. All statistical analyses
were performed with SPSS software (version 15.0; SPSS,
Chicago, IL). A P value <.05 was considered statistically
significant.
Results
A total of 473 elderly subjects with a mean age of 80.9
± 6.6 years was studied. Table 1 lists the anthropometric
measurements, CGA, and biochemical assessment stratified
in sarcopenia and nonsarcopenia according to EWGSOP
definition and diagnostic algorithm. The prevalence rate
of sarcopenia was 13.1%. CIRS comorbidity and severity
score, drug number, and CRP were higher, whereas 4-minute
gait speed, Tinetti score, and b-CHE were lower in elderly
subjects with sarcopenia. In addition, MNA score together
with muscle mass and grip strength were lower in elderly
subjects with sarcopenia with respect to elderly subjects
without sarcopenia (Table 1).
Table 2 lists the same parameters stratified for different
levels of MNA score (ࣙ24, 17–23.5, and <17). Prevalence
of sarcopenia progressively increased as MNA decreased
(from 6.1% to 31.4%; P < .001). Elderly subjects were
progressively older, and MMSE and Tinetti score and
881
4-m gait speed decreased as MNA score decreased. GDS
score, BADLs and IADLs lost, and low social support
increase as MNA score decreased. Similarly, both frailty
by Fried’s score and Rockwood’s score increased as MNA
score decreased. Among biomarkers, lymphocytes and b-
CHE decreased, whereas CRP increased as MNA score
decreased.
Figure 1 shows the relationship among skeletal muscle
mass and strength stratified by MNA score in nonin-
stitutionalized elderly people. Muscle mass progressively
decreased (from 17.6 ± 3.0 to 10.0 ± 2.9 kg/m2 ), as well as
muscle strength (from 41.2 ± 10.2 to 27.7 ± 8.3 kg), as MNA
score decreased.
At univariate analysis, age, CIRS-severity score, number
of drugs, BADLs lost, and CRP were negatively correlated
with skeletal muscle mass, whereas Tinetti score, 4-m gait
speed, PASE score, serum albumin level, hemoglobin, b-
CHE, and, more importantly, MNA score were positively
correlated with skeletal muscle mass. Multivariate analysis
confirms this correlation except for serum albumin level and
CRP (Table 3). The positive linear relation between skeletal
muscle mass and MNA score is shown in Figure 2A (y =
0.65x + 2.2; r = 0.72; P < .001).
Univariate and multivariate linear regression analysis on
muscle strength is shown in Table 3. Age, CIRS comorbidity
and severity, number of drugs, BADLs lost, and CRP were
negatively correlated with muscle strength, whereas Tinetti
score, 4-m gait speed, PASE score, hemoglobin, b-CHE, and
MNA score were positively correlated with muscle strength.
Except for CRP, all linear relationships were confirmed at
multivariate analysis. The positive linear relation between
muscle strength and MNA score is shown in Figure 2B
(y = 1.1x + 14.2; r = 0.46; P < .001).
Discussion
Our data show that MNA score, 1 of the most specific
tools for the assessment of malnutrition, is lower in non-
institutionalized older adults with sarcopenia than in those
without sarcopenia. Interestingly, MNA score is strongly
related to muscle mass and strength both at univariate and
multivariate analyses. This evidence suggests that malnutri-
tion state is frequently associated with a reduction of muscle
mass and strength; therefore, it should be investigated,
especially in the presence of sarcopenia in noninstitution-
alized older adults.
Sarcopenia
Age-related muscle mass decline is defined “sarcopenia,”
and it is primarily due to the progressive atrophy and
loss of type II muscle fibers and motor neurons.29 This
phenomenon tends to be reduced at a rate of 1%–2% per
year after the age of 50 years.1-3 Sarcopenia is characterized
by fibrosis and infiltration of adipose tissue determining a
882 Nutrition in Clinical Practice 33(6)

Table 1. Baseline Characteristics of the 473 Elderly Patients Enrolled in the Study Stratified for the Presence and Absence of
Sarcopenia.

Sarcopeniaa

All No (86.9%) Yes (13.1%)

Characteristics (N = 473) (n = 411) (n = 62) Pb

Anthropometric data
Age ± SD, y 80.9 ± 6.6 74.3 ± 8.1 80.5 ± 7.6 .145
Female sex, % 60.9 64.5 37.1 .057
BMI ± SD, kg/m2 27.4 ± 5.6 27.2 ± 3.1 24.2 ± 4.0 .064
Waist circumference ± SD, cm 99.7 ± 13.5 99.0 ± 10.8 96.4 ± 11.4 .007
Geriatric evaluation ± SD
Mini-Mental State Examination score 21.5 ± 6.3 23.2 ± 6.4 21.6 ± 4.4 .059
Geriatric Depression Scale score 7.6 ± 4.4 6.7 ± 4.6 8.6 ± 5.4 .187
CIRS-Comorbidity score 3.9 ± 2.2 3.40 ± 1.79 5.12 ± 2.05 .024
CIRS-Severity score 1.9 ± 0.5 1.60 ± 0.22 2.34 ± 0.55 .030
No. of drugs 6.1 ± 3.2 2.0 ± 1.0 4.0 ± 1.0 .020
BADLs lost, n 2.0 ± 1.8 1.4 ± 1.6 2.6 ± 1.8 .212
IADLs lost, n 4.2 ± 2.8 2.8 ± 1.4 4.0 ± 3.2 .321
Tinetti score 17.3 ± 7.8 22.4 ± 4.0 18.2 ± 2.2 .020
MNA score 20.9 ± 4.3 22.0 ± 4.0 15.4 ± 4.2 .024
4-m gait speed, m/s 0.46 ± 0.4 0.91 ± 0.20 0.60 ± 0.30 <.05
PASE score 37.6 ± 51.1 102.0 ± 40.8 38.4 ± 80.2 <.001
Social support score 8.3 ± 4.9 7.0 ± 2.0 9.5 ± 2.0 <.05
Fried’s frailty score 3.5 ± 1.5 2.2 ± 1.2 3.6 ± 1.2 <.05
Rockwood’s frailty score 21.2 ± 8.7 14.6 ± 9.4 28.2 ± 6.2 <.05
Muscle measurements
Grip strength, kg 26.2 ± 7.6 30.4 ± 8.6 21.8 ± 8.4 <.05
Skeletal muscle mass, kg/m2 8.0 ± 1.6 9.0 ± 1.6 6.6 ± 1.4 <.05
Biochemical measurements ± SD
Serum albumin level, g/dL 4.1 ± 0.7 4.0 ± 0.4 3.4 ± 0.8 .560
Total iron binding capacity, μg/dL 325.6 ± 54.6 296.4 ± 68.2 222.8 ± 74.2 .266
Hemoglobin, g/dL 12.9 ± 1.8 13.2 ± 1.4 12.4 ± 2.0 .059
Lymphocytes, n × 103 4.1 ± 8.2 2.2 ± 1.0 1.7 ± 1.7 .112
C-reactive protein, mg/dL 0.8 ± 0.4 0.40 ± 0.28 0.90 ± 0.44 <.05
Butyryl-cholinesterase, U/L 7480 ± 2320 8600 ± 1450 3400 ± 2850 <.05

BADLs, basic activities of daily living; BMI, body mass index; CIRS, Cumulative Index Rating Scale; IADLs, instrumental activities of daily
living; MNA, Mini Nutritional Assessment; PASE, Physical Activity Scale for the Elderly.
a Sarcopenia was defined in subjects with a low muscle strength presenting low muscle mass (skeletal muscle index <8.87 and <6.42 kg/m2 in men

and women, respectively). BMI-adjusted values were used as a cutoff point to classify low muscle strength (BMI ࣘ24, 24.1–28, and <28 was 29,
ࣘ30, and ࣘ32 kg for men; BMI ࣘ23, 23.1–26, 26.1–29, and <29 was 17, ࣘ17.3, ࣘ18, and ࣘ21 kg for women, respectively).
b P = statistical difference between the presence and the absence of sarcopenia.

reduction of functional capacity, an increase of disability
and mortality, and therefore an increase of healthcare
costs.3-5,30 Many mechanisms have been hypothesized to
explain the origin of age-related decline in muscle strength
and mass, including inflammation, physical inactivity, and
malnutrition.31,32
Malnutrition and Sarcopenia
Therefore, elderly adults may lose muscle mass and
strength.33 Accordingly, older adults usually eat less protein
than younger adults.31 In fact, community-dwelling older
adults (ࣈ10%) and those living in care homes (ࣈ30%) do not
consume the estimated average requirement for daily protein
intake (0.7 g/kg body weight/day),34,35 which represents the
minimum intake level to maintain muscle integrity for older
adults.36,37

The relationship between malnutrition and sarcopenia is
not well established, especially in elderly outpatients.29 A
disproportion between protein intake and protein needs may
determine a loss of skeletal muscle mass because of im-
balance between muscle protein synthesis and degradation.
Mini Nutritional Assessment as Tool
for Malnutrition Detection
Because malnutrition in the elderly is multifactorial, several
measures of malnutrition in geriatric people have been
Liguori et al 883

Table 2. Baseline Characteristics of the 473 Older Adult Participants Enrolled in the Study stratified for Mini Nutritional
Assessment.

Mini Nutritional Assessment score

ࣙ24 (51.0%) 17-23.5 (34.2%) <17 (14.8%) P

Characteristics (n = 241) (n = 162) (n = 70) for Trend

Anthropometric data
Age ± SD, y 79.7 ± 6.5a 81.3 ± 6.7 81.8 ± 6.3 .001
Female sex, % 27.4 46.3 26.3 .432
Body mass index, kg/m2 28.1 ± 5.0a 27.6 ± 6.2 26.1 ± 5.0 <.05
Waist circumference, cm 100.3 ± 9.4a 98.5 ± 11.2 98.2 ± 10.1 <.05
Geriatric evaluation ± SD
Mini-Mental State Examination score 24.3 ± 4.9a 21.0 ± 6.3 18.5 ± 6.8 <.001
Geriatric Depression Scale score 4.8 ± 3.6a 8.3 ± 4.0 10.1 ± 4.1 <.001
CIRS-Comorbidity score 3.1 ± 2.1 4.1 ± 2.2 4.4 ± 2.0 .456
CIRS-Severity score 1.7 ± 0.4 1.9 ± 0.5 2.0 ± 0.4 .455
No. of drugs 5.2 ± 3.3 6.5 ± 3.0 6.6 ± 3.2 .184
BADLs lost, n 1.0 ± 1.5 2.1 ± 1.8 3.2 ± 1.8 <.05
IADLs lost, n 2.5 ± 2.6 4.5 ± 2.6 5.9 ± 2.2 <.05
Tinetti score 21.9 ± 6.0 16.2 ± 7.5 12.8 ± 7.1 <.05
MNA score 25.8 ± 1.5a 20.6 ± 1.8 14.5 ± 2.2 <.001
4-m gait speed, m/s 0.66 ± 0.47 0.46 ± 0.5 0.33 ± 0.5 <.05
PASE score 65.4 ± 60.8a 28.9 ± 43.8 16.1 ± 28.7 <.05
Social support score 5.4 ± 3.9 8.9 ± 4.6 11.4 ± 4.2 <.05
Fried’s frailty score 2.6 ± 1.5 3.6 ± 1.4 4.5 ± 1.3 <.001
Rockwood’s frailty score 15.7 ± 8.0 22.2 ± 7.4 27.2 ± 7.1 <.001
Sarcopenia, n (%) 15 (6.2) 25 (15.4) 22 (31.4) <.001
Muscle measurements ± SD
Grip strength, kg 41.2 ± 10.2 38.1 ± 9.3 27.7 ± 10.3 <.001
Skeletal muscle mass, kg/m2 17.6 ± 1.5 16.8 ± 2.1 10.0 ± 2.9 <.001
Biochemical measurements ± SD
Serum albumin level, g/dL 4.2 ± 0.5 4.2 ± 0.9 3.9 ± 0.4 .052
Total iron binding capacity, μg/dL 350.4 ± 50.4 341.0 ± 60.2 265.0 ± 80.2 .163
Hemoglobin, g/dL 13.2 ± 1.8 13.0 ± 1.7 12.0 ± 1.9 .420
Lymphocytes, n × 103 5.0 ± 9.8 4.9 ± 9.3 1.2 ± 0.6 <.05
C-reactive protein, mg/dL 0.50 ± 0.42a 0.64 ± 0.50 0.95 ± 0.30 .048
Butyryl-cholinesterase, U/L 7950 ± 2150 7650 ± 2300 7000 ± 2100 .042

BADLs, basic activities of daily living; CIRS, Cumulative Index Rating Scale; IADLs, instrumental activities of daily living; MNA, Mini
Nutritional Assessment; PASE, Physical Activity Scale for the Elderly.
a P < .01 vs MNA score <17.

developed. Biochemical and clinical indices are investi-
gated by Nutritional Risk Index38 and Geriatric Nutri-
tional Risk Index39 ; anthropometry, mobility, cognitive
state, self-perceived health, and nutrition by Short Form
MNA,40 by Malnutrition Universal Screening Tool,41 and
by unintentional weight loss and poor intake (MST)42 ; and
medical history and clinical and subjective evaluation by
Nutrition Risk Screening 2002 (NRS-2002).43 In contrast
with nutrition screening tools, nutrition assessment methods
are more comprehensive and are frequently used by geria-
tricians. In particular, the Subjective Global Assessment44
and MNA45 are largely used to perform a nutrition di-
agnosis and begin nutrition management in older adult
patients.46
Sarcopenia and Mini Nutritional Assessment
Score
In our noninstitutionalized older adults, MNA score pro-
gressively decreases as muscle mass and strength are
reducing in both univariate (r = 0.72 and r = 0.46, respec-
tively) and multivariate (r = 0.62 and r = 0.40, respectively)
analyses. Interestingly, MNA score is significantly lower in
subjects with sarcopenia vs without sarcopenia (15.4 ± 4.2
vs 22.0 ± 4.0; P < .024). Some reports have investigated the
relationship between MNA and sarcopenia. However, this
relationship in noninstitutionalized older adults is poorly
investigated. In contrast, among acute geriatric patients,
malnutrition evaluated with MNA was associated to 30%
884 Nutrition in Clinical Practice 33(6)

Figure 1. Muscle mass and strength stratified by Mini

Nutritional Assessment score (ࣙ24, 17–23.5, <17) in
noninstitutionalized elderly people; P for trend = .001 for
both muscle mass (*P < .05 for <17 vs 17–23.5 and ࣙ24) and
strength (*P < .05 for <17 vs 17–23.5 and ࣙ24).

of the patients with sarcopenia.47 In addition, among male

residents in a nursing home, MNA scores were significantly
lower in residents having low compared with having normal
skeletal muscle mass (17.1 ± 3.4 vs 19.6 ± 2.5; P = .005).48
More importantly, in a prospective study, subjects with
malnutrition risk and sarcopenia have a risk for mortality 4
times higher than subjects without sarcopenia with normal
nutrition.49 Therefore, Vandewoude et al13 recently indi-
cated the MSS to depict the clinical scenario characterized
by both malnutrition and sarcopenia. Finally, it should
be emphasized that malnutrition plays a key role in the
pathogenesis of both frailty and sarcopenia.8 Malnutrition Figure 2. Regression linear relationship among muscle mass
and sarcopenia are frequently present in older adults with (A) and muscle strength (B) and Mini Nutritional Assessment
diabetes and chronic obstructive pulmonary disease that are score for noninstitutionalized elderly people.
characterized by a high degree of frailty.50,51 Interestingly,
the “frailty score” identified by Fried’s and Rockwood’s
methods was 2.6 ± 1.5 and 15.7 ± 8.0 at the highest status should be always evaluated to address therapeutical
MNA and 4.5 ± 1.3 and 27.2 ± 7.1 at the lowest MNA, interventions and lifestyle modifications (ie, increase of
respectively. protein intake and physical activity).3 Thus, it is mandatory
for clinician researchers to develop a reliable and valid
Evaluation of Nutrition Status in Patients With diagnostic algorithm to identify elderly subjects with both
Sarcopenia: Clinical Implications malnutrition and sarcopenia.

As discussed earlier, malnutrition and sarcopenia are con-

ditions frequently found in older adults that lead to nega-
tive outcomes including increased morbidity and mortality
and increased healthcare costs and rehospitalizations.8,13,49
Usually, these conditions have been separately screened,
but rarely are both conditions simultaneously assessed.8,13
Moreover, many patients concurrently show malnutrition
and sarcopenia; therefore, patient’s nutrition and functional
Conclusions
MNA score, 1 of the most accepted instruments for the
assessment of malnutrition, is lower in noninstitutionalized
older adults with sarcopenia. Thus, the presence of mal-
nutrition is strongly related to muscle mass and strength.
These findings support that low MNA score is frequently
associated to elderly outpatients with sarcopenia.
Liguori et al 885

Table 3. Univariate and Multivariate Linear Regression Analyses on Skeletal Muscle Mass and Muscle Strength.

Muscle Mass Muscle Strength

Univariate Multivariate Univariate Multivariate

Variables r P r P r P r P

Age −0.14 <.05 −0.15 <.05 −0.18 <.05 −0.16 <.05

Body mass index 0.06 .204 0.04 .220
Waist circumference 0.12 .340 0.06 .320
Mini-Mental State Examination 0.08 .120 0.08 .102
Geriatric Depression Scale −0.14 .347 −0.10 .300
CIRS-Comorbidity −0.10 .340 −0.10 <.05 −0.08 <.05
CIRS-Severity −0.07 .032 −0.06 <.05 −0.10 <.01 −0.09 <.01
No. of drugs −0.08 .030 −0.07 <.01 −0.04 .042 −0.04 <.05
BADLs −0.14 <.05 −0.12 <.05 −0.14 <.05 −0.12 <.05
IADLs −0.08 .342 −0.04 .442
Mini Nutritional Assessment 0.72 <.01 0.62 <.05 0.46 <.01 0.40 <.05
Tinetti score 0.65 <.01 0.051 .03 0.44 <.01 0.39 <.05
4-m gait speed 0.30 <.05 0.29 <.05 0.32 .05 0.28 <.05
PASE 0.57 <.05 0.30 .04 0.41 .001 0.29 <.05
Social support −0.04 .282 −0.07 .541
Serum albumin level 0.18 .022 0.14 .084 0.12 .064
Total iron binding capacity 0.14 .112 0.14 .122
Hemoglobin 0.24 <.04 0.20 <.05 0.30 <.05 0.26 .020
Lymphocytes 0.14 .114 0.15 .75
C-reactive protein −0.24 <.05 −0.08 .421 −0.20 <.05 −0.18 .325
Butyryl-cholinesterase 0.35 <.01 0.30 <.01 0.44 <.01 0.40 .036

BADLs, basic activities of daily living; CIRS, Cumulative Index Rating Scale; IADLs, instrumental activities of daily living; PASE, Physical
Activity Scale for the Elderly.

Acknowledgments 5. Iannuzzi-Sucich M, Prestwood KM, Kenny AM. Prevalence of sar-

Funding source: Fondazione Roma NCDS-2013-00000331 –
Sarcopenia and Insulin Resistance in the Elderly; Age-
Associated Inflammation as a Shared Pathogenic Mechanism
and Potential Therapeutic Target (DDM), Rome, ITALY.
Statement of Authorship
I. Liguori, F. Cacciatore, D. Bonaduce and P. Abete contributed
to conception and design; D. Della-Morte, G. Gargiulo and
G. Testa contributed to analysis and interpretation of data;
F. Curcio, G. Russo, M. Cellurale L. Aran and G. Bulli
contributed to acquisition of data.
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