Original Communication

Journal of Parenteral and Enteral

Nutrition
Nutrition Screening Tools: An Analysis of the Evidence Volume 36 Number 3
May 2012 292-298
© 2012 American Society
for Parenteral and Enteral Nutrition
DOI: 10.1177/0148607111414023
Annalynn Skipper, PhD, RD, FADA1; Maree Ferguson, PhD, MBA, RD2; http://jpen.sagepub.com
hosted at
Kyle Thompson, MS, RD3; Victoria H. Castellanos, PhD, RD4; and http://online.sagepub.com
Judy Porcari, MBA, MS, RD5

Abstract
In response to questions about tools for nutrition screening, an evidence analysis project was developed to identify the most valid and
reliable nutrition screening tools for use in acute care and hospital-based ambulatory care settings. An oversight group defined nutrition
screening and literature search criteria. A trained analyst conducted structured searches of the literature for studies of nutrition screening
tools according to predetermined criteria. Eleven nutrition screening tools designed to detect undernutrition in patients in acute care and
hospital-based ambulatory care were identified. Trained analysts evaluated articles for quality using criteria specified by the American
Dietetic Association’s Evidence Analysis Library. Members of the oversight group assigned quality grades to the tools based on the quality
of the supporting evidence, including reliability and validity data. One tool, the NRS-2002, received a grade I, and 4 tools—the Simple
Two-Part Tool, the Mini-Nutritional Assessment–Short Form (MNA-SF), the Malnutrition Screening Tool (MST), and Malnutrition
Universal Screening Tool (MUST)—received a grade II. The MST was the only tool shown to be both valid and reliable for identifying
undernutrition in the settings studied. Thus, validated nutrition screening tools that are simple and easy to use are available for application
in acute care and hospital-based ambulatory care settings. (JPEN J Parenter Enteral Nutr. 2012;36:292-298)

Keywords
administration; adult; geriatrics; home nutrition support; nutrition assessment; outcomes research/quality

Clinical Relevancy Statement
The finding that valid and reliable nutrition screening tools are
available is expected to result in accurate identification of
nutrition problems. If these tools are quick and easy to use, it is
possible that they will reduce the amount of time required for
nutrition screening. If accurate nutrition screening can be com-
pleted with fewer criteria and in less time, resources saved may
be reallocated toward higher priority nutrition activities.
Introduction
Screening for nutrition problems is a Medicare Condition of
Participation and therefore a requirement for accreditation or
certification of U.S. healthcare facilities.1 Nutrition screening
is also a primary mechanism for patients to be referred to a
registered dietitian (RD) for further nutrition assessment, diag-
nosis, and intervention.2 Thus, valid and reliable nutrition
screening tools are needed to ensure that referrals are appropri-
ate. RDs are responsible for developing nutrition screening
criteria and supervising the nutrition screening process. How-
ever, nutrition screening is typically conducted by others.
Nutrition screening has become increasingly complex since
it was first described by Seltzer and colleagues in 1979.3 These
authors describe the process of using albumin and total lympho-
cyte count to identify patients on hospital admission who require
nutrition repletion as instant nutrition assessment; it resembles
the process we now term nutrition screening. Potosnak and
Chudnow4 added laboratory data and information about appetite
and weight change over time to the first screening tool by Seltzer
et al. The Nutrition Screening Initiative developed tools that
have not been independently validated.5,6 In 1994, the American
Dietetic Association (ADA) recommended more than 60 nutri-
tion screening criteria that were derived from selected litera-
ture.7 The ADA recommendations did not specify how these
criteria were to be used or whether they were valid indicators of
nutrition problems. In many U.S. hospitals, dietitians recom-
mend lengthy nutrition screening tools, which have not been
tested for reliability, validity, or accuracy.8 However, outside the
United States, accurate, streamlined nutrition screening tools
that have been validated against a complete nutrition assessment
are widely used.9 During a nutrition screening workshop in
2006, RDs from the United States, Europe, Australia, and the
From 1Annalynn Skipper and Associates, Oak Park, Illinois; 2Princess
Alexandra Hospital, Brisbane, Australia; 3Appalachian State University,
Boone, North Carolina; 4Florida International University, Miami, Florida;
and 5North Shore University Hospital, Manhasset, NY.
Financial disclosure: none declared.
Received for publication December 31, 2010; accepted for publication
March 23, 2011.
Corresponding Author: Annalynn Skipper, PhD, RD, FADA, Annalynn
Skipper and Associates, PO Box 45, Oak Park, IL 60303; e-mail:
Annalynn_Skipper@comcast.net.
Nutrition Screening Tools / Skipper et al 293
Table 1.  Definition and Key Considerations in Nutrition
Screening
Definition:
Nutrition screening is the process of identifying patients,
clients, or groups who may have a nutrition diagnosis and
benefit from nutrition assessment and intervention by a
registered dietitian (RD).
Key considerations:
May be conducted in any practice setting as appropriate
Tools should be quick, easy to use, valid, and reliable for the
patient population or setting
Tools and parameters are established by RDs, but the screening
process may be carried out by registered dietetic technicians
and other trained personnel
Nutrition screening and rescreening should occur within an
appropriate time frame for the setting
Middle East began to discuss how to identify and implement
efficient, valid, and reliable nutrition screening tools.10 This
group proposed an evidence analysis project to identify the most
reliable and valid tools for nutrition screening in acute care and
hospital-based ambulatory care settings.
Methods
A workgroup of RDs with expertise in research, clinical nutri-
tion management, and clinical practice provided oversight to
the project. The workgroup began by establishing definitions
to be used in the project. Workgroup members viewed nutrition
screening as separate and distinct from nutrition assessment,
although the terms are often used interchangeably in the litera-
ture and in practice. The workgroup also wanted to focus spe-
cifically on nutrition screening and developed the definition of
nutrition screening in Table 1, which was subsequently
approved for use by the ADA’s Quality Management Commit-
tee.11 Because screening tools must identify a nutrition prob-
lem to be valid, the workgroup also defined undernutrition as
the nutrition problem.
Articles describing specific screening tools were included if
the tools were (1) simple and reports indicated a completion
time of less than 10 minutes, (2) administered by a healthcare
professional, (3) tested against an acceptable reference stan-
dard for validity, (4) tested on adults older than age 18, (5)
tested in an acute or hospital-based ambulatory care setting,
and (6) if the authors reported the validity and reliability of the
nutrition screening tool or sufficient data for reliability and
validity to be calculated. Articles were excluded if they
reported the results of trials with ≤20 participants.
The definition of the nutrition problem, undernutrition, was
defined as a measure of body composition at a given time and
change in body composition over time as described by van
Venrooij et al.12 Thus, acceptable reference standards for vali-
dating a nutrition screening tool were the Subjective Global
Assessment (SGA), the Patient-Generated Subjective Global
Assessment (PG-SGA), the Mini-Nutritional Assessment
(MNA), and dietitian assessments that included a measure of
body composition and change in that measure over time.13-15
Literature Search
A trained and experienced lead analyst searched the English lit-
erature using the PubMed search engine as specified by the
workgroup. The dates of the literature search for nutrition
screening tools were 1997 to 2007. The search included acute
care, community-based care, community dwelling, and the
names of specific nutrition screening tools: MNA, MUST,
DETERMINE checklist, Short Nutritional Assessment Ques-
tionnaire (SNAQ), meals on wheels, nutrition screening tools/
instruments, SGA, prognostic nutrition index (PNI), nutritional
risk index (NRI), prognostic inflammatory and nutritional index
(PINI), nutrition screening questionnaire, nursing nutrition
screen, mass nutrition screening, nutrition scoring system, nurs-
ing nutritional screening tool, nutrition assessment tool,
SCREEN II, sensitivity and specificity, diet surveys, and nutri-
tion surveys. The reference lists of review articles obtained were
searched by hand for additional articles, and workgroup mem-
bers also searched their personal files. A total of 168 articles
describing 11 nutrition screening tools were identified.
Articles were reviewed by the workgroup, and those that
met the inclusion criteria were graded for quality (positive,
negative, neutral) by trained analysts using criteria specified
by the ADA’s Evidence Analysis Library.16 The work of ana-
lysts was reviewed by the lead analyst, and agreement was
negotiated in situations where the analyst and lead analyst dis-
agreed on quality rankings. The workgroup graded the evi-
dence supporting the tools on a scale of I to IV, where I = good,
II = fair, III = limited, IV = expert opinion, and V = grade not
assignable. Articles describing studies of tools that received
grades of I and II were then reviewed by the workgroup for
validity and reliability data.18 Validity was determined by mea-
suring sensitivity and specificity. Sensitivity is the percentage
of undernourished individuals correctly identified by the
screening tool as being at risk (true positive/true positive +
false negative). Specificity is the percentage of well-nourished
individuals correctly identified by the screening tool as being
not at risk (true negative/true negative + false positive).
Reliability was measured by the κ value, a measure of interra-
ter agreement, with a value of 0 indicating no agreement and 1
indicating perfect agreement.
Results and Discussion
Eleven nutrition screening tools were evaluated for their valid-
ity and reliability to identify nutrition problems of patients in
294
Table 2.  Results of Evidence Analysis of Nutrition Screening Tools

Positive Negative
Screening Reference Sample Sensitivity, Specificity, Predictive Predictive
Tool Grade Population Mean Age, y Standard Size % % Reliability Value, % Value, % Agreement
18
NRS-2002 I Medical-surgi- LOS 1–10 days: 50.5 ± SGA 995 62 93 NA 85* 79* κ = 0.48 (agree-
cal hospital- 21.9; >11 days: 65.4 ± ment among
ized 18.7; LOS unknown: methods)
44.4 ± 17.0
NRS-200219 Acute hospital- 80.2 ± 7.7 MNA 80 39 83 NA 85 37 84.6%
ized
NRS-200219 Acute hospital- 80.2 ± 7.7 SGA 120 70 85 NA 79 78 79.2%
ized
MNA-SF20 II Ambulatory 72 (range, 60–98) MNA 408 100 69.5 NA 92.8 78.5 NA
MNA-SF21 Subacute and France: 78.3 MNA 904 97.9 100 NA 98.7 NA NA
ambulatory Spain: 75.8
New Mexico: 76.8
MST22 II Acute hospital- 54.3 ± 14.8 SGA 2211 74 76 NA 27.9 96 NA
ized
MST23 Acute hospital- 57.7 ± 16.5 (range, SGA 408 93 93 κ = 0.84–0.93 98 73 NA
ized 19–74) (P < .01)
MST24 Oncology out- 59.1 ± 13.8 PG-SGA 50 100 92 κ = 0.83– 80 100 NA
patients 0.88;
N = 20
MST9 Oncology out- 59.9 ± 13.5 (range, SGA 106 100 81 NA 40 100 NA
patients 15–89)
MUST25 II Medical 45 ± 13.9 SGA 50 NA NA NA NA NA 92% (κ = 0.783)
MUST18 Medical-surgi- LOS 1–10 days: 50.5 ± SGA 995 61 76 NA 65 76 κ = 0.26 (agree-
cal hospital- 21.9; >11 days: 65.4 ± ment between
ized 18.7; LOS unknown: methods)
44.4 ± 17.0
NST/BAPEN26 II Acute hospital- 59.6 ± 19.4 (study 1); Dietitian as- 166 86* 95* κ = 0.66 80* 96* Pilot phase:
ized 59.6 ± 16 (study 2); sessment κ = 0.72 (CI,
59.6 ± 16.9 (study 3) 0.59–0.84)
Simple Two- II Acute hospital- 54.3 ± 14.8 SGA 2211 63 97 NA 70.2 95.5 NA
Part Tool22 ized
NRS27 III Acute care, 55.9 (range, 8.5 mo to Dietitian as- 153 NA NA 74% NA NA 93%
medical- 92 y) sessment
surgical

(continued)
 Table 2.  (Continued)

Positive Negative
Screening Reference Sample Sensitivity, Specificity, Predictive Predictive
Tool Grade Population Mean Age, y Standard Size % % Reliability Value, % Value, % Agreement
SCREEN-II III Seniors in com- Elderly; 98% >64 y Dietitian as- 193 84 58 Study 2, (N = 83 59 NA
AB28 munity and sessment 149); test-
geriatrician’s retest reli-
clinic ability ICC
= 0.84,
95% CI
Study 3 (N
= 97) inter-
rater ICC =
0.79; intra-
rater ICC =
0.85
Rapid Screen29 III Subacute care >65 Standardized 65 78.6 97.3 NA 95.7* 85.7* 35.4% malnour-
(rehabilitation nutrition ished; 64.6%
center) assessment nourished
Tool #130 III ACE; LTCE ACE: 78.9 ± 7.1; LTCE: Dietitian as- ACE: 72; ACE: 75; ACE: 75; IRR diet NA NA NA
79.5 ± 7.1 sessment LTCE: 70; LTCE: LTCE: tech and
total: 142 63; total 63; total RN: 85%
sample: 70 sample: 70 ACE; 80%
LTCE; all
sample κ
= 0.60 ±
0.07; test-
retest 78%
ACE; 82%
LTCE;
overall κ
= 0.60 ±
0.07

ACE, elderly in acute care; CI, confidence interval; ICC, intraclass correlation coefficient; IRR, interrater reliability; LTCE, elderly in long-term care; LOS, length of stay; MNA,
Mini-Nutritional Assessment; MNA-SF, Mini-Nutritional Assessment–Short Form; MST, Malnutrition Screening Tool; MUST, Malnutrition Universal Screening Tool; NA, not
available; NRS, Nutritional Risk Screening; NST/BAPEN4, Nutrition Screening Tool/British Association of Parenteral and Enteral Nutrition; PG-SGA, Patient-Generated
Subjective Global Assessment; RN, registered nurse; SCREEN-II AB, Seniors in the Community: Risk Evaluation for Eating and Nutrition, Version II, abbreviated version; SOA,
subjective global assessment.
*Values calculated by a work group member.

295
296
Table 3.  Data Required to Complete Nutrition Screening Tools Evaluated in the Nutrition Screening Evidence Analysis Project

Tools

NST/ Simple Two- SCREEN-II Rapid

Criteria NRS-200219 MNA-SF20 MST22 BAPEN426 MUST24 Part Tool22 NRS27 AB29 Screen29 Tool #130

Recent unintentional weight loss x x x x x x x x x

Appetite x x x x x
Body mass index x x x x x
Disease severity x x x x
Age >70 y x
Weight x
Height x
Weight gain or loss x
Subcutaneous fat loss x
Impaired general condition x
Housebound x
Meal preparation habits and eating alone x
Dementia or depression x
Food intake or eating problem; skipping meals x x x x
Ability to eat and retain food x
Intake of fluid/fruits and vegetables x

MNA-SF, Mini-Nutritional Assessment–Short Form; MST, Malnutrition Screening Tool; MUST, Malnutrition Universal Screening Tool; NRS, Nutritional Risk Screening; NST/
BAPEN4, Nutrition Screening Tool/British Association of Parenteral and Enteral Nutrition; SCREEN-II AB, Seniors in the Community: Risk Evaluation for Eating and Nutrition,
Version II, abbreviated version.
Nutrition Screening Tools / Skipper et al 297
acute care and hospital-based ambulatory care settings. Results
of the analysis of the evidence supporting these 11 tools are
summarized in Table 2. A single tool, the NRS-2002, received
a grade I, 4 tools received a grade II, and the remainder received
a grade III. The SNAQ tool was not evaluated against an
acceptable reference standard to determine validity and was
given a grade V. Tools with grade I and II evidence in the high-
est quartile for sensitivity (>83%) and specificity (>90%) were
the MNA–Short Form (SF), which had a sensitivity and speci-
ficity greater than >90% in 1 of 2 studies, and the MST, with a
sensitivity >90% in 3 of 4 studies and a specificity >90% in 2
of 4 studies.20,23 The MST had a κ score of 0.83–0.88. No data
were available to evaluate the reliability of the MNA-SF. Thus,
the MST was the only tool shown to be both valid and reliable
for identifying nutrition problems in the settings studied.
Further Research
Some studies reviewed and excluded were limited by small sam-
ple size and the use of weak research methodologies. A major
issue in validating nutrition screening tools is clear identification
of an acceptable reference standard for nutrition problems. Stan-
dard definitions of nutrition problems are available in the Inter-
national Dietetics and Nutrition Terminology, and an
international workgroup is working to further refine the specific
criteria for malnutrition.31,32 Future studies validating nutrition
screening tools should incorporate these standard definitions.
The ideal screening tool would be 100% sensitive and specific.
As this is generally not achievable, and there is almost always
some misclassification, the need to correctly classify all patients
who are malnourished (sensitivity) takes precedence over mis-
classifying well-nourished patients (specificity). Reliability
should also be determined to ensure there is consistency in the
use of the tool between raters. Future studies should adhere to
international guidelines for reporting research to facilitate com-
parison of findings from this study with new studies.33
Application and Conclusions
Clearly, simple nutrition screening tools are valid identifiers of
nutrition problems of patients in acute care and hospital-based
ambulatory care. Reliability testing for nutrition screening tools
is needed as only the MST and British Association for Parenteral
and Enteral Nutrition (BAPEN)–II were tested for reliability.
Also, there are opportunities for researchers to test nutrition
screening tools in settings such as rehabilitation facilities, long-
term acute care, and long-term care facilities. The MNA-SF was
developed in elderly populations, and further testing for reliabil-
ity and validity in younger populations is recommended. The
most reliable and valid tools could be tested in the pediatric
population where valid and reliable nutrition screening tools
have not been developed. Given the number of nutrition screen-
ing tools described in the literature, further research directed
toward developing new screening tools is not recommended.
Clinicians selecting screening tools may wish to consider
the availability and quality of evidence supporting a particular
screening tool as well as the availability of data required to use
the tool. Table 3 contains the data needed for each of the tools
evaluated. Tools that are simple, quick, and easily completed
by nonprofessionally trained staff such as administration staff,
patients, or family members are preferred over tools requiring
calculations such as body mass index and percentage weight
loss. Also, tools selected for clinical use should have been
tested in patient populations similar to the ones where they will
be applied (Table 2). Reliable and valid nutrition screening
tools have been developed and should be further tested in a
broader range of patients. When the results of further studies
are made available, the grades of evidence supporting each of
the tools evaluated may change. In the interim, selection of
simple tools that are reliable and valid may improve compli-
ance in completing nutrition screening and may also free up
time that may be reallocated toward nutrition intervention.
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