Review

Nutrition in Clinical Practice

Volume 0 Number 0
Evaluation of Nutrition Status Using the Subjective Global xxx 2020 1–15
© 2020 American Society for
Assessment: Malnutrition, Cachexia, and Sarcopenia Parenteral and Enteral Nutrition
DOI: 10.1002/ncp.10613
wileyonlinelibrary.com

Donald R. Duerksen, MD, FRCPC1 ; Manon Laporte, RD, MSc, CNSC2 ;

and Khursheed Jeejeebhoy, PhD, MBBS, FRCPC3

Abstract
The subjective global assessment (SGA) is a nutrition assessment tool that refers to an overall evaluation of a patient’s history and
physical examination and uses structured clinical parameters to diagnose malnutrition. The SGA is known to be a reliable and valid
tool that predicts morbidity and mortality associated with malnutrition. The objective of SGA is to identify patients likely to benefit
from nutrition intervention and therefore to identify persons in whom inadequate nutrition intake or absorption explain features
of malnutrition, including body wasting. There are other conditions that cause weight loss, muscle wasting, and fat loss, including
cachexia and sarcopenia. Acknowledging that these 2 last conditions differ in their mechanism of body wasting and consequently
in the outcomes of nutrition intervention, the practitioner needs a tool to identify when malnutrition is the dominating factor to
explain body wasting. The SGA form has been revised to clearly reflect the key concepts behind the diagnosis of malnutrition
and help to distinguish this condition from other wasting conditions. This review presents the revised SGA form and guidance
document. Using case studies, it illustrates the 3 wasting conditions, their overlap, and how the SGA identifies malnutrition as a
dominating factor of body wasting and thus individuals who require nutrition intervention. (Nutr Clin Pract. 2020;0:1–15)

Keywords
cachexia; malnutrition; nutrition assessment; sarcopenia; subjective global assessment

Subjective Global Assessment
The subjective global assessment (SGA) was developed
in 1982 and is a nutrition assessment tool that has been
validated by predicting patient outcome 1 and by con-
trolled clinical studies that show SGA identifies patients
who respond to nutrition intervention.2,3 These are unique
aspects of this nutrition evaluation tool. This tool consists
of 5 nutritionally relevant features of the clinical history,
including decreased nutrient intake, unintentional weight
loss, symptoms affecting oral intake, functional capacity,
and metabolic demand. In addition, it includes a physical
examination that focuses on subcutaneous fat loss, mus-
cle wasting, and fluid accumulation. The SGA classifies
individuals as well nourished (SGA A), mildly/moderately
malnourished (SGA B), or severely malnourished (SGA
C). The SGA was initially validated in 59 consecutive
surgical patients admitted to a tertiary care hospital. This
classification predicted length of stay and development
of complications and was found to be reproducible when
performed independently by 2 different practitioners.1 Since
this original description, the SGA has been validated in
different disease states and clinical conditions, including
chronic renal failure, cancer, geriatrics, critically ill patients,
and hospitalized general medical patients.4–7 A recent large
Canadian study showed that SGA predicts the length of stay
in hospitalized medical and surgical patients.8 The SGA is
recognized as the most highly validated tool as a measure
of malnutrition for many populations9 and a semi–gold
standard10 for the diagnosis of malnutrition responsive to
nutrition support based on 2 controlled trials.2,3
Although the SGA has been used in clinical practice for
>30 years, there are several reasons why a review of its
interpretation and use is needed.
Malnutrition in hospitalized patients has a high preva-
lence worldwide, and its identification and management
has received much attention in the past several years.11
From the 1 Max Rady College of Medicine, University of Manitoba,
Winnipeg, Manitoba, Canada 2 Réseau de Santé Vitalité Health
Network, Campbellton, New Brunswick, Canada; and the
3 Department of Medicine St Michael Hospital, University of
Toronto, Toronto, Ontario, Canada.
Financial disclosures: None declared.
Conflicts of interest: None declared.
Corresponding author:
Donald R Duerksen, MD, FRCPC, Max Rady College of Medicine,
University of Manitoba, C5-120 – 409 Tache Avenue, Winnipeg,
Manitoba, Canada R2H 2A6.
Email: dduerkse@sbgh.mb.ca
2 Nutrition in Clinical Practice 0(0)
Groups such as the Canadian Malnutrition Task Force
(CMTF) have confirmed a high prevalence of malnutrition
in hospitals (45%) and have demonstrated that malnutri-
tion identified with SGA is associated with an increased
length of hospital stay.8 The CMTF has incorporated
the use of the SGA into an algorithm, the Integrated
Nutrition Pathway for Acute Care12 for the detection and
management of malnutrition in Canadian hospitals. A
recent analysis on the perception of using SGA in regular
practice reveals its ability to identify malnourished patients
sooner and improve overall efficiency in delivery of nutrition
care.13
Individuals with experience using and teaching SGA
have identified common difficulties in interpreting SGA,
such as determining causes of muscle wasting, that are
not well addressed with current guides. In fact, as the
physical examination is now an integral part of the nutrition
evaluation, the clinician is regularly called on to identify
patients with loss of muscle mass. This naturally leads to
an evaluation as to whether these losses are associated with
inadequate nutrition intake or are due to other conditions.
For example, how do you classify individuals with evidence
of body compositional change but whose nutrient intake has
recently been adequate? There is an increasing awareness
and recognition of cachexia and sarcopenia as important
clinical entities in which inadequate nutrition intake is not
the dominating cause of muscle wasting but rather may be
contributing to the condition and, consequently, does not
respond as well to nutrition management. How does the
SGA help in the differentiation of cachexia and sarcopenia
from malnutrition?
The purpose of this review is to detail the appropriate
use and interpretation of the SGA as a nutrition assessment
tool and demonstrate how it identifies malnutrition in the
context of muscle wasting associated with sarcopenia and
cachexia.
Identification of Malnutrition
Nutrition health is maintained when there is a state of
equilibrium between nutrient intake and requirements.
Malnutrition occurs when net nutrient intake (nutrient
intake corrected for malabsorption) is less than
requirements. Malnutrition has been defined as follows:
“Malnutrition includes both the deficiency or excess (or
imbalance) of energy, protein, and other nutrients. In
practice, undernutrition or inadequate intake of energy,
protein, and nutrients is the focus.”14 Undernutrition or
malnutrition of protein, carbohydrate, and fat leads to a
variety of metabolic abnormalities, physiological changes,
reduced organ and tissue function, and ultimately, loss of
body mass. Concurrent stress, such as trauma, sepsis, and
burns, create an inflammatory state that accelerates the loss
of tissue mass and impairs function. This is also known as
disease-related malnutrition with inflammation.15 With the
critical loss of body mass and function, there is delayed
wound healing, increased susceptibility to infection, and
ultimately, death results. Traditionally, features such
as reduced weight, muscle wasting, loss of body fat,
reduced plasma proteins, and immune dysfunction defined
malnutrition.1 However, it is important to understand
the purpose of identifying malnutrition: it is to identify
persons who will benefit from nutrition therapy that
improves clinical outcomes by reducing complications and
mortality.16
The simple, traditional paradigm of recognition of the
features given above to define malnutrition has several pit-
falls. First, there is a wide range of normal weights, muscle
mass, and fat mass among the population and sexes, making
it difficult to define the early stages of abnormal deficiencies.
Second, if we use the presence of this phenotype to start
nutrition care, then we fail to prevent malnutrition because
we will not recognize it before it becomes extreme nor
will we recognize persons who would ultimately develop
the complications of malnutrition before they occur. Third,
there are conditions, such as cachexia17 and sarcopenia,18
in which the same phenotype (loss of weight, muscle mass,
or strength and fat mass) occurs without significant lack
of nutrition and consequently cannot be fully reversed by
conventional nutrition therapy.
It is clear from the pitfalls listed above that the use
of traditional parameters does not identify patients at the
early stage of malnutrition, has large errors of measurement
especially in a busy clinical service, has a wide range of
normal values, and is influenced by disease. Moreover,
the predictive outcomes of the traditional nutrition as-
sessment methods are unknown. Even, low body mass
index (BMI) as a single parameter to diagnose malnu-
trition failed to predict the negative outcomes.19,20 In a
critical assessment of various techniques traditionally used
to measure nutrition status, it was concluded that these
techniques were inadequate,21 and an alternative method,
which identifies the interacting clinical factors that resulted
in malnutrition, would have to be used. In fact, diagno-
sis of malnutrition requires an integrative interpretation
of history and physical examination using good clinical
judgment.9
Recently, an international group of experts, the Global
Leadership Initiative on Malnutrition (GLIM), has de-
veloped criteria for the diagnosis of malnutrition using
consensus methodology.22 This definition includes pheno-
typic criteria related to weight loss, BMI, and reduced
muscle mass, as well as etiologic criteria, including reduced
food intake/reduced assimilation and inflammation. There
is overlap between these criteria and the components of
the SGA. A recent study demonstrated fair sensitivity
and specificity of the GLIM criteria for the diagnosis of
malnutrition when SGA was used as the comparator.23
Duerksen et al.
Interpretation and Classification of Nutrition
Status Using the SGA
The specifics of the SGA have been published in detail
previously.24 25 See Figure 1 for a data collection form
that summarizes the important aspects of the SGA and
the classification into well nourished, mild/moderately
malnourished, and severely malnourished. This data
collection form is available on the CMTF website at
https://nutritioncareincanada.ca/sites/default/uploads/files/
SGA%20Tool%20EN%20colour_2017(1).pdf (August
2020). This form was developed through consensus by an
interdisciplinary group of experts that included nutrition
support physicians, dietitians and scientists, and 1 of the
originators of the SGA, with feedback from practicing
clinical dietitians.
The following are specific factors to consider when
completing the SGA.
Nutrient Intake
Because malnutrition results when nutrient intake is insuffi-
cient to meet nutrient requirements, assessment of nutrient
intake is an essential part of the SGA. Reduced intake
usually includes reduction in both energy and protein, and
this part of the SGA estimates the degree of decreased
intake compared with an individual’s usual intake, the du-
ration that it has been deceased, and the trend in the past 2
weeks. All sources of intake need to be considered, including
oral nutrition supplements, enteral nutrition, parenteral
nutrition, and sources such as propofol infusions.
Weight
Weight loss results when energy intake is insufficient to
meet nutrition needs and can be stratified into involuntary
weight loss that is not considered significant (<5% of usual
body weight),25 moderate weight loss (5%–10% of usual
body weight), and severe weight loss (>10% of usual body
weight). The time period that weight loss is assessed is over
the past 6 months, although many patients have significant
weight loss over a much shorter period of time. The SGA
is a valid assessment tool that considers the persistence of
continued weight loss over 2 weeks and 6 months rather
than an interpretation of weight according to a comparison
with standard weights. SGA can then be conducted under
circumstances in which the actual weight is not known.19
Symptoms
There are many gastrointestinal symptoms that result in
decreased oral intake or suggest possible malabsorption
(see the data collection sheet in Figure 1). These symptoms
usually coincide with the period of weight loss, and their
resolution leads to normalization of nutrient intake and
3
categorization of nutrition status as SGA A. The duration
of these symptoms is important, as is the trend. If gas-
trointestinal symptoms have normalized over the 2 weeks
prior to the assessment, it is likely that nutrition status has
improved/normalized.
Functional Capacity
Severely malnourished individuals usually have a significant
loss of lean body mass, which may impair their ability
to function at their accustomed level. Initially, this may
result in an inability to perform strenuous tasks but, as it
progresses, may result in affecting activities of daily living.
However, loss of functional capacity and/or body wasting
due to underlying disease processes must be distinguished
from that due to lack of nutrient intake. For example,
neurologic disorders may impair the use of limbs and
therefore affect functional capacity. It is also important to
note that if functional status impairment due to underlying
disease results in limited mobility, lean body mass loss is
likely to be accelerated because of disuse.
Metabolic Requirement
Disease conditions, such as burns, head trauma, systemic
inflammatory response syndrome, and thyrotoxicosis, are
associated with increased metabolic demand and thus re-
quire provision of increased nutrients to maintain metabolic
balance. This must be accounted for when assessing for
nutrition adequacy in patients with these conditions. In
most common clinical conditions, the mild metabolic stress
that is related to the underlying disease does not significantly
increase nutrient needs,26,27 and, therefore, no adjustment
needs to be made.
Physical Examination
Clinical assessment of body composition, including muscle
bulk and fat stores, is an important aspect of the SGA.
Reduced fat stores are an indication of negative energy
balance. Fat stores are best assessed by noting sunken eyes
and by palpating the triceps area as well as the lateral aspect
of the rib area and lower back (see Figure 1).
To assess muscle mass, the area around the shoulder,
including the deltoids, biceps, triceps, pectoralis, supras-
capular, and infrascapular muscles, is particularly important
to examine for muscle bulk (see Figure 1). Unlike loss of
fat mass, muscle wasting occurs with causes other than
malnutrition. These include sarcopenia of aging, cachexia,
and muscle wasting related to disuse. Individuals who
restrict their usual activities but continue to ambulate may
have relatively preserved muscle mass of their lower limbs
compared with their upper limbs. Individuals who have
significant body compositional change, including loss of
body fat and muscle wasting and a history of decreased
4 Nutrition in Clinical Practice 0(0)

Subjecve Global Assessment Form

MEDICAL HISTORY

Paent name: _________________________________ Date: _______ / _______ / _______

NUTRIENT INTAKE
1. No change; adequate
2. Inadequate; duration of inadequate intake ________________
Suboptimal solid diet Full fluids or only oral nutrition supplements Minimal intake, clear fluids or starvation
3. Nutrient Intake in past 2 weeks*
Adequate Improved but not adequate No improvement or inadequate

WEIGHT Usual weight ____________ Current weight ____________

1. Non fluid weight change past 6 months Weight loss (kg) ________
<5% loss or weight stability 5-10% loss without stabilization or increase >10% loss and ongoing
If above not known, has there been a subjective loss of weight during the past six months?
None or mild Moderate Severe
2. Weight change past 2 weeks* Amount (if known) __________
Increased No change Decreased

SYMPTOMS (Experiencing symptoms affecting oral intake)

1. Pain on eating Anorexia Vomiting Nausea Dysphagia
Diarrhea Dental problems Feels full quickly Constipation
2. None Intermittent/mild/few Constant/severe/multiple
3. Symptoms in the past 2 weeks*
Resolution of symptoms Improving No changeor worsened

FUNCTIONAL CAPACITY (Fatigue and progressive loss of function)

1.No dysfunction
2.Reduced capacity; duration of change ________________
Difficulty with ambulation/normal activities Bed/chair-ridden
3.Functional Capacity in the past 2 weeks*
Improved No change Decrease

METABOLIC REQUIREMENT
High metabolic requirement  No  Yes
PHYSICAL EXAMINATION

Loss of body fat No Mild/Moderate Severe

Loss of muscle mass No Mild/Moderate Severe
Presence of edema/ascites No Mild/Moderate Severe
SGA RATING
A Well-nourished B Mildly/moderately malnourished  C Severely malnourished
Normal Some progressive nutri tional loss Evidence of wasti ng and progressive symptoms
CONTRIBUTING FACTOR
CACHEXIA(fat and muscle wasting due to disease and inflammation)
SARCOPENIA(reduced muscle mass and strength)

Figure 1. Subjective Global Assessment Form and Guidance For Body Composition. This data collection form is reprinted with
permission from the Canadian Malnutrition Task Force and is available at
https://nutritioncareincanada.ca/sites/default/uploads/files/SGA%20Tool%20EN%20colour_2017(1).pdf (August 2020).
Duerksen et al. 5

Subjecve Global Assessment Guidance For Body Composion

SUBCUTANEOUS FAT
Physical examinaon Normal
Under the eyes Slightlybulging area
Triceps Large spacebetweenfingers
Ribs, lower back, sides of Chest is full; ribs do not show.
trunk Slight to no protrusion of the
iliac crest
Mild/Moderate
Somewhat hollow look,
Slightly dark circles
Some depth to fat tissue, but
not ample. Loose fitting skin.
Ribs obvious, but indentations
are not marked. Iliac Crest
somewhat prominent
Severe
Hollowed look, depression,
dark circles
Very little space between
fingers or fingers touch, loose
fitting skin
Indentation between ribs very
obvious. Iliac crest very
prominent

MUSCLE WASTING
Physical examinaon Normal Mild/Moderate Severe
Temple Well-defined muscle Slight depression Hollowing, depression
Clavicle Not visible in males; may be Some protrusion; may not be Protruding/prominent bone
visible but not prominent in all the way along
females
Shoulder Rounded No square look; acromion Square look; bones prominent
process may protrude slightly
Scapula/ribs Bones not prominent; no Mild depressions or bone may Bones prominent; significant
significant depressions show slightly; not all areas depressions
Quadriceps Well defined Depre ssion/atrophy medially Prominent k nee, Severe
depression medially
Interosseous muscle between Muscles protrudes; could be Slightly depressed Flat or depressed area
thumb and forefinger (back of flat in females
hand)**

FLUID RETENTION
Physical examinaon Normal Mild/Moderate Severe
Edema None Pitting edema of extremities / Pitting beyond knees, sacral
pitting to knees, possible edema if bedridden, may also
sacral edema if bedridden have generalized edema
Ascites Absent Present (may only be present on imaging)

A - Well-nourishedno decrease in food/nutrient intake; < 5% weight loss; no/minimal symptoms affecting food intake;
no deficit in function; no de ficit in fat or muscle massOR *an individual with some criteria for SGA B or C but with
recent adequate food intake; non-fluid weight gain; significant recent improvement in symptoms allowing adequate
oral intake; significant recent improvement in function; and ch ronic deficit in fat and mu scle mass but with recent
clinical improvement in function
B - Mildly/moderately malnourisheddefinite decrease in food/nutrient intake; 5% - 10% weight loss without
stabilization or gain; mild/some symptoms affecting food intake; moderate functional deficit or recent deterioration;
mild/moderate loss of fa t and/or muscle massOR *an individual meeting some criteria for SGA C but with
improvement (but not adequate) of oral intake, recent stabilization of weight, decrease in symptoms affecting oral
intake, and stabilization of functional status.
C - Severely malnourished severe deficit in food/nutrient i ntake; > 10% weight loss whichis ongoing; significant
symptoms affecting food/nutrient i ntake; severe functional deficit OR *recent significant deterioration; obvious signs
of fat and/or muscle loss.
Cachexia - If there is an underlying predisposing disorder (e.g. malignancy) and there is evidence of reduced muscle
and fat and no or limited improvement with optimal nutrient intake, this is consistent with cachexia.
Sarcopenia – If there is an underlying disorder (e.g. agi ng) and there is evidence of reduced mu scle and strength
and no or limited improvement wi th optimal nutrient intake.
**In the elderly prominent tendons and hollowing is the result of aging and may not reflect malnutrion

Figure 1. Continued
6 Nutrition in Clinical Practice 0(0)
intake (with or without gastrointestinal symptoms), are
considered malnourished.
Edema and Ascites
Edema is commonly associated with conditions such as
heart failure, renal failure, liver cirrhosis, and venous insuf-
ficiency. Ascites is a common manifestation of portal hyper-
tension. This accumulation of fluid results in falsely elevated
body weight, which needs to be taken into consideration
by the nutrition clinician. For example, if an individual has
pitting edema to their knees and reports that their weight
is unchanged from the usual body weight, it is likely that
there has been a loss of body mass. In rare circumstances,
edema and ascites may be manifestations of malnutrition,
particularly in states of severe hypoalbuminemia.
Phenotype of Cachexia, Sarcopenia, and
Malnutrition
The common feature of cachexia, sarcopenia, and mal-
nutrition is the phenotype of muscle wasting and loss of
lean body mass. However, there are significant differences
between these conditions.
Cachexia is a “complex medical syndrome associated
with underlying illness and characterized by loss of muscle
mass with or without loss of fat mass”17 that is variably
but incompletely treated by conventional nutrition support.
There are numerous potential causes of cachexia, including
(1) malignancy (usually metastatic with an extensive tumor
burden); (2) chronic inflammatory disorders (eg, chronic in-
fections, inflammatory bowel disease, and collagen vascular
disorders); and (3) organ failure (eg, cardiac, pulmonary
[chronic obstructive pulmonary disease], and renal). In
cancer cachexia, the syndrome is a continuum that may
progress to refractory cachexia, in which there is no response
to treatment.28
Sarcopenia is a syndrome characterized by a progressive
and generalized muscle disorder that is associated with
increased likelihood of adverse outcomes, such as falls,
fractures, physical disability, and mortality. Primary sar-
copenia is age-related loss of skeletal muscle mass and is
defined when no other cause is evident but aging itself.
Sarcopenia may be considered secondary when other causes
are evident.18
There are 5 basic mechanisms that contribute to the
phenotype of muscle wasting and subcutaneous fat loss
in malnutrition, cachexia, and sarcopenia29 : (1) insufficient
energy intake to meet energy requirements; (2) increased
cytokine activity, leading to skeletal muscle catabolism;
(3) reduced muscle loading (muscles require loading and
stress to maintain strength and mass); (4) hormonal action
(corticosteroids, catecholamines, and sympathetic activa-
tion increase skeletal muscle catabolism while testosterone
decreases with aging and reduces muscle mass in males); and
(5 )neuromuscular atrophy (muscle disorders and diseases
affecting peripheral nerves cause muscle atrophy). All of
these mechanisms operate to a variable extent, with 1 or
2 dominating in each of these 3 wasting conditions. In
protein-energy malnutrition, the intake and requirement
mismatch is the dominant mechanism leading to subcuta-
neous fat loss and muscle wasting, and there are minimal
contributions from factors such as cytokines, hormone
activation, or neuromuscular atrophy. In cachexia, the dom-
inating factors that drive muscle wasting and subcutaneous
fat loss are the activated cytokines and the hormonal actions
induced by the underlying malignancy or inflammatory
disorder, whereas energy intake may be much less affected in
this group of disorders. Finally, in sarcopenia, the reduction
in the rate of myofibrillar protein synthesis and reduced
activity are the primary contributors to the muscle wasting
phenotype, and unlike the mechanisms in malnutrition,
there is minimal contribution related to insufficient energy
intake.29
As described above, there is an overlap in the clinical
presentation of these conditions that is reflected in the
criteria proposed to diagnose it. For example, the diagnosis
of cachexia is based on the presence of weight loss of
≥5% of body weight or BMI <20 (calculated as weight
in kg divided by height in meters squared) in the absence
of simple starvation and includes the criteria of decreased
muscle strength, anorexia, and low fat-free mass index
(<7.26 in men and <5.45 in women) (calculated as fat
free mass in kg divided by height in meters squared).17
In regard to sarcopenia, the European Working Group
on Sarcopenia in Older People 2 refers to low muscle
strength as the primary criterion for probable sarcopenia.
The diagnosis of sarcopenia is confirmed by the presence
of low muscle mass (quantity and quality), and when a
low physical performance is also detected, sarcopenia is
considered severe.18 In clinical practice, anthropometry is
the more accessible method proposed to measure muscle
mass. The handgrip strength (HGS) and the usual gait
speed, or get-up-and-go test, are the techniques that can be
used to assess muscle strength and physical performance,
respectively.18 In practice, there is a wide premorbid range
of normal muscle grip strength, depending on muscle mass,
occupation, sex, and age, limiting the accuracy of the HGS
measurement.
Many of the criteria of sarcopenia and cachexia are also
present in individuals with malnutrition. The overlap in
these criteria presents a challenge for the clinician seeking to
define nutrition status and determines the need for nutrition
care intervention. When it is time to diagnose malnutrition,
a fundamental key concept needs to be considered: is inad-
equate nutrient intake (and/or absorption) the dominating
mechanism explaining the loss of muscle mass. If so, a
response to feeding should be expected. A synthesis of the
Duerksen et al.
5 criteria used by the SGA allows the clinician to evaluate
the dominant cause of the phenotype called malnutrition
in any patient, thus allowing the differentiation of primary
lack of nutrition from cachexia and sarcopenia. In many
cases, particularly when patients present to the hospital
and have an underlying medical disorder, their wasting
phenotype may result from multiple factors—for example,
malnutrition and cachexia or malnutrition and sarcopenia.
SGA and Evaluation of Malnutrition,
Cachexia, and Sarcopenia
The SGA provides an overall assessment of a patient’s
nutrition status and distinguishes individuals who have body
wasting due primarily to lack of nutrition (malnutrition)
from conditions such as cachexia and sarcopenia. For
example, a patient with metastatic ovarian cancer may lose
substantial amounts of weight and present with severe
muscle wasting. If the initial assessment confirms a ma-
jor decrease in oral intake and/or evidence of significant
malabsorption, this patient would likely be classified as
severely malnourished, SGA C. Given the large tumor
burden and associated nausea, it is possible that cachexia
is also contributing to the muscle wasting. Frequently,
malnutrition and cachexia or sarcopenia may each con-
tribute to the phenotype of muscle wasting, particularly on
initial presentation to the healthcare professional. If the
patient with metastatic ovarian cancer classified as SGA C
is given full nutrition support (meeting her requirements for
a significant period of time), and there is no significant im-
provement in weight, functional capacity, or body compo-
sition, a subsequent evaluation could reclassify her as being
cachexic, and her nutrition status would be SGA A. The
muscle wasting that this individual would continue to have
would be consistent with cachexia. Cachexia is considered a
contributing factor when there is discordance between the
body compositional assessment and that nutrition intake
obtained on history. Individuals with cachexia demonstrate
weight loss, loss of muscle mass, and subcutaneous fat loss
but are close to meeting their nutrition needs when nutrient
intake is assessed. Particularly at presentation, it is possible
to have a mixed diagnosis of malnutrition and cachexia—
many individuals with cachexia also have decreased oral
intake. Once nutrient intake has been optimized through
supplementation or specialized nutrition support, ongoing
loss of lean body mass is attributed to cachexia.
As part of the aging process, muscle wasting may not
be due to an energy/nutrient deficit but to sarcopenia.
Sarcopenia can be partially, but incompletely, treated by
supplying higher amounts of protein.30 If the nutrient in-
take is assessed as appropriate for an elderly individual, and
on further evaluation there is no evidence of malabsorption,
but there is evidence of low muscle strength and mass,
this final assessment would conclude that this is sarcopenia
7
of aging. Many elderly patients have evidence of mild to
moderate muscle loss in addition to low muscle strength
although there has not been a major change in their oral
intake. This is the typical feature of sarcopenia.
The differentiation of cachexia or sarcopenia from mal-
nutrition is made by making an overall assessment as to
whether the intake of nutrients, as well as gastrointestinal
function (eg, appetite, swallowing, and bowel function),
allows for adequate intake and absorption or whether it is
is impaired sufficiently, to fully or in part account for the
muscle and fat wasting and weight loss. In addition, when
considering cachexia, an underlying inflammatory disorder
or malignant condition or major organ failure should be
present. Prior to giving the final rating, the clinician must
assess whether changes in body weight and composition are
dominated by malnutrition (insufficient intake relative to
energy expenditure) or by the cachexia/sarcopenia.
SGA and Nutrition Status Change
The SGA considers the relevant nutrition factors at a
specific point in time, and a classification of nutrition status
is made based on this information. Nutrition status may
change based on changes in clinical status and optimization
of nutrient intake. The SGA factors in these changes, and,
therefore, the classification may change based on this assess-
ment. Thus, SGA is considered a dynamic assessment. For
example, consider the case of a man aged 67 years who has
dysphagia and is diagnosed with achalasia (an esophageal
motility disorder characterized by failure of relaxation of
the lower esophageal sphincter and aperistalsis). He has
lost 14% of his usual body weight (because of his inability
to eat due to dysphagia), has severe muscle wasting in
his upper and lower extremities, and has decreased fat
stores and, therefore, would be classified as SGA C. After
successful surgery, he is able to meet his nutrition needs
with a texture-modified diet and nutrition supplements. A
nutrition reassessment after a period of recovery would
conclude that his dysphagia has resolved and his oral intake
has normalized to meet his nutrition requirements. He
would still have evidence of body compositional change
(with fat loss and muscle wasting), as this would take time
to improve, but a reclassification would consider him to be
in the SGA A category. The SGA considers the trajectory
of symptoms and oral intake over a 2 week period, and if
symptoms have resolved and nutrient intake has normalized
to meet energy expenditure (and there is improvement
in weight and functional capacity), the individual would
no longer be considered malnourished even though there
are persistent body compositional changes.24 The latter
are likely to take considerable time to replete, particularly
lean body mass. If there has been improvement in the
symptoms and intake but not fully, the nutrition classifi-
cation may improve but would not be considered to have
8 Nutrition in Clinical Practice 0(0)

Figure 2. (A) Moderate muscle wasting of pectoralis muscles and deltoids, with squaring of shoulders. (B) Moderate muscle
wasting of scapular muscles. (C) Moderate muscle wasting of interosseous muscles of hands. (D) Mild loss of subcutaneous fat of
triceps and sides of trunk.

normalized—for example, a patient might have been classi-
fied as SGA C and now would be classed as SGA B.
Case Studies
Case 1: Sarcopenia
A man aged 92 years was admitted to the hospital because of
a fall at home while climbing stairs. He has also been treated
for a urinary tract infection. After a short hospital stay in
acute care, the patient was transferred to a residential ward.
His past medical history is also significant for high blood
pressure, abdominal aortic aneurysm (stent 2 years ago),
abdominal hernia repair 17 years ago, and glaucoma. He
is a nonsmoker and has a Mini-Mental State Examination
score of 26.
Regarding his nutrient intake, he reports eating less, as
compared with years ago, but his intake and appetite are
stable and have not changed over the past several years. On
a more detailed dietary intake history, he states that he has
3 meals per day and eats meats and substitutes as well as
fruit, vegetables, starches, and desserts. He tends to finish his
plate on a regular basis and has not noted any decrease in
oral intake. He has had no weight loss in the past 15 months
and, in fact, has had a mild weight gain. His current weight
is 63 kg. Fifteen months ago, his weight was 60.4 kg and 1
year ago was 62.1 kg. When he was younger and working,
he reported weighing as much as 77 kg. His current height is
181 cm and BMI is 19.2. There has been no notable change
in his functional capacity in the past 15 months. He walks
on a daily basis, ∼12 times, 50 steps each time, and 2.5 feet
per step. He also performs 4 different types of exercise with
his arms. His HGS was 21 kg.
On physical examination, he exhibits physical signs of
moderate muscle wasting of his pectoralis muscles and
deltoids (Figure 2A) and subscapular and suprascapular
muscles as well as trapezius (Figure 2B). There is also mod-
erate muscle wasting of his interosseous muscle between
the thumb and forefinger (Figure 2C) and mild loss of
subcutaneous fat (triceps and sides of trunk) (Figure 2D).
Duerksen et al.
According to the SGA (Figure 3), this 92-year-old man
is classified as well nourished (SGA A); the low muscle
strength (HGS < 27 kg) and low muscle mass meet the
criteria for probable sarcopenia.18
Case 2: Malnutrition and Cachexia
A man aged 67 years presents to the hospital with weight
loss and new-onset jaundice and pruritis. His past medical
history is significant for hypertension. He quit smoking
5 years previously and consumes 8–10 beer on most week-
ends. He has no significant past surgical history.
He is admitted to the hospital, where a CT scan of his
abdomen demonstrates a large mass in the head of the
pancreas, multiple enlarged lymph nodes, and several large
lesions in the liver consistent with metastatic pancreatic
cancer.
An ERCP demstrates narrowing of the duodenum from
tumor compression, but it is possible to insert a decompres-
sive biliary stent. This results in resolution of his jaundice
and pruritis.
Regarding his nutrient intake, he states that his oral
intake has decreased in the past 6 weeks. He is nauseated
and becomes full easily, and this limits his oral intake. He
has also lost his appetite. Although he tries to eat 3 meals
per day, he estimates that he eats approximately half of what
he normally does.
He has lost ∼11 kg in the past 2 months. His current
weight is 83 kg. His current height is 179 cm and BMI is
26.
He works as a supervisor at a construction company. His
work is quite sedentary. He has continued to work until
several days before coming to hospital. He does not do
any regular physical exercise but has been doing yard work
around the house. He has definitely noticed more fatigue in
the past several weeks.
On physical examination, he exhibits physical signs of
severe muscle wasting of his pectoralis muscles and deltoids,
as well as his subscapular and suprascapular muscles. There
is also moderate muscle wasting of his interosseous and
temporalis muscles. There is moderate loss of subcutaneous
fat (triceps and sides of trunk).
According to the SGA (see Figure 4), he is classified as
severely malnourished (SGA C); at this assessment point,
he clearly has inadequate oral intake and an imbalance in
this energy intake and expenditure and is therefore con-
sidered malnourished. His energy expenditure is likely not
increased because of the pancreatic cancer.31 He also has an
underlying condition that can be associated with cachexia,
metastatic pancreatic cancer with a large tumor burden, and
it is unclear the degree to which this is contributing to his
phenotype of muscle wasting and subcutaneous fat loss.
Therefore, on the SGA form, there is a question mark beside
the cachexia category (see Figure 4).
9
He is initially started on oral nutrition supplements and
appears to tolerate them well for the first 2–3 weeks.
After about 6 weeks, he begins to have worsening of his
early satiety symptoms, and a repeat computed tomography
scan demonstrates tumor enlargement and evidence of gas-
tric outlet obstruction. A duodenal stent is inserted, with a
marked improvement in his symptoms. He is able to tolerate
a texture-modified diet and oral nutrition supplements. It is
estimated that he is meeting his nutrition requirements with
his oral intake. His weight is 79 kg.
His nutrition status is reevaluated 8 weeks later. Al-
though he still has some mild anorexia, he has no nausea,
emesis, or diarrhea. He has been able to maintain his oral
intake by “pushing himself.” He is walking with his wife
on a daily basis. His weight is stable at 80 kg. On physical
examination, he has muscle wasting that is similar to the
wasting noted on presentation.
On SGA assessment, his oral intake is sufficient to
maintain his weight, and his gastrointestinal symptoms are
much improved. He would be classified as SGA A. Despite
the correction of his energy imbalance, he still has a muscle
wasting phenotype. This is attributed to the cachexia related
to his underlying tumor (see Figure 5).
Case 3: Sarcopenia and Cachexia
A female aged 90 years is admitted for a short hospital
stay (3 days) for pneumonia, requiring an intravenous an-
tibiotic treatment; C-reactive protein at admission is 208.3
mg/L. Her past medical history is significant for chronic
obstructive pulmonary disease stage 2, high blood pressure,
dyslipidemia, and gastroesophageal reflux disease. She is a
nonsmoker.
Regarding her nutrient intake, she reports having a very
good appetite and denies any decrease of her food intake,
even in presence of the lung infection. She explains having
a very stable eating pattern in the past 15 years, eating 6
times a day, and always making sure to have good and well-
balanced meals. An example of recall of her dietary intake
on a typical day is shown below:
Breakfast:
Porridge (200 mL) + honey + flax seeds,
1
2
banana, 2% milk (125 mL), orange juice (200 mL),
and
1 piece of toast (whole wheat bread + jam + mar-
garine)
AM snack: Apple
Lunch:
Homemade soup (rice, chicken, and vegetables)
Baguette (several slices) + margarine
Dessert: Piece of pie, cookies, or muffin and tea
PM Snack: Yogurt
Supper:
Fish/meat/poultry (60 g),
10 Nutrition in Clinical Practice 0(0)

Subjecve Global Assessment Form

MEDICAL HISTORY

Paent name: _________________________________ Date: _______ / _______ / _______

NUTRIENT INTAKE
1. x No change; adequate
2. Inadequate; duration of inadequate intake ______
Suboptimal solid diet Full fluids or only oral nutrition supplements Minimal intake, clear fluids or starvation
3. Nutrient Intake in past 2 weeks*
x Adequate Improved but not adequate No improvement or inadequate

WEIGHT Usual weight ____________ Current weight ___63 kg___

1.Non fluid weight change past 6 months Weight loss (kg) ________
x<5% loss or weight stability 5-10% loss without stabilization or increase >10% loss and ongoing
If above not known, has there been a subjective loss of weight during the past six months?
x None or mild Moderate Severe
2. Weight change past 2 weeks* Amount (if known) __________
Increased x No change Decreased

SYMPTOMS (Experiencing symptoms affecting oral intake)

1.Pain on eating Anorexia Vomiting Nausea Dysphagia Diarrhea
Dental problems Feels full quickly Constipation
2. x None Intermittent/mild/few Constant/severe/multiple
Symptoms in the past 2 weeks*
x Resolution of symptoms Improving No changeor worsened

FUNCTIONAL CAPACITY (Fatigue and progressive loss of function)

1.No dysfunction x
2.Reduced capacity; duration of change ________________
Difficulty with ambulation/normal activities Bed/chair-ridden
3.Functional Capacity in the past 2 weeks*
Improved x No change Decrease

METABOLIC REQUIREMENT
High metabolic requirement x No  Yes
PHYSICAL EXAMINATION
Loss of body fat No x Mild/Moderate Severe
Loss of muscle mass No x Mild/Moderate Severe
Presence of edema/ascites x No Mild/Moderate Severe

SGA RATING
x A Well-nourished B Mildly/moderately malnourished  C Severely malnourished
Normal Some progressive nutri tional loss Evidence of wastin g and progressive
symptoms
CONTRIBUTING FACTOR
CACHEXIA(fat and muscle wasting due to disease and inflammation)
X SARCOPENIA(reduced muscle mass and strength)

Figure 3. SGA form from Case 1. SGA classification of well nourished (rating A), with associated probable sarcopenia.
Duerksen et al. 11

Subjecve Global Assessment Form

MEDICAL HISTORY

Paent name: _________________________________ Date: _______ / _______ / _______

NUTRIENT INTAKE
1. No change; adequate
2. Inadequate; duration of inadequate intake: 6 weeks
Suboptimal solid diet x Full flui ds or only oral nutrition supplements Minimal intake, clear fluids or starvation
3. Nutrient Intake in past 2 weeks*
Adequate Improved but not adequate x No improvement or inadequate

WEIGHT Usual weight94 kg Current weight 83 kg

1.Non fluid weight change past 6 months Weight loss (kg) 11 kg
<5% loss or weight stability 5-10% loss without stabilization or increase x>10% loss and ongoing
If above not known, has there been a subjective loss of weight during the past six months?
None or mild Moderate Severe
2. Weight change past 2 weeks* Amount (if known) __________
Increased No change xDecreased

SYMPTOMS (Experiencing symptoms affecting oral intake)

1. Pain on eating xAnorexia Vomiting xNausea Dysphagia
Diarrhea Dental problems x Feels full quickly Constipation
2. None Intermittent/mild/few Constant/severe/multiple
3. Symptoms in the past 2 weeks*
Resolution of symptoms Improving x No changeor worsened

FUNCTIONAL CAPACITY (Fatigue and progressive loss of function)

1.No dysfunction: No major dysfunction
2.Reduced capacity; duration of change ________________
Difficulty with ambulation/normal activities Bed/chair-ridden
3.Functional Capacity in the past 2 weeks*
Improved x No change Decrease

METABOLIC REQUIREMENT
High metabolic requirement x No  Yes
PHYSICAL EXAMINATION

Loss of body fat No x Mild/Moderate Severe

Loss of muscle mass No Mild/Moderate x Severe
Presence of edema/ascites x No Mild/Moderate Severe
SGA RATING
A Well-nourished B Mildly/moderately malnourished x C Severely malnourished
Normal Some progressive nutri tional loss Evidence of wasti ng and progressive
symptoms
CONTRIBUTING FACTOR
? CACHEXIA(fat and muscle wasting due to disease and inflammation)
SARCOPENIA(reduced muscle mass and strength)

Figure 4. SGA form from Case 2. The patient is considered severely malnourished (rating C). Although cachexia could be a
contributing factor, there is a definite imbalance between nutrient intake and energy requirements. SGA, subjective global
assessment.
12 Nutrition in Clinical Practice 0(0)

Subjecve Global Assessment Form

MEDICAL HISTORY

Paent name: _________________________________ Date: _______ / _______ / _______

NUTRIENT INTAKE
1. x No change; adequate
2. Inadequate; duration of inadequate intake ______
Suboptimal solid diet x Full flui ds or only oral nutrition supplements Minimal intake, clear fluids or starvation
3. Nutrient Intake in past 2 weeks*
x Adequate Improved but not adequate x No improvement or inadequate

WEIGHT Usual weight ____________ Current weight ___80___

Non fluid weight change past 6 months(in this case 2 months) Weight loss (kg) none
x<5% loss or weight stability 5-10% loss without stabilization or increase >10% loss and ongoing
If above not known, has there been a subjective loss of weight during the past six months?
x None or mild Moderate Severe
2. Weight change past 2 weeks* Amount (if known) __________
Increased x No change Decreased

SYMPTOMS (Experiencing symptoms affecting oral intake)

1. Pain on eating x Anorexia Vomiting Nausea Dysphagia
Diarrhea Dental problems Feels full quickly Constipation
2. None x Intermittent/mild/few Constant/severe/multiple
Symptoms in the past 2 weeks*
Resolution of symptoms x Improving No changeor worsened

FUNCTIONAL CAPACITY (Fatigue and progressive loss of function)

1.No dysfunction: yes
2.Reduced capacity; duration of change ________________
Difficulty with ambulation/normal activities Bed/chair-ridden
3.Functional Capacity in the past 2 weeks*
Improved x No change Decrease

METABOLIC REQUIREMENT
High metabolic requirement x No  Yes
PHYSICAL EXAMINATION
Loss of body fat No x Mild/Moderate Severe
Loss of muscle mass No Mild/Moderate x Severe
Presence of edema/ascites x No Mild/Moderate Severe

SGA RATING
x A Well-nourished B Mildly/moderately malnourished  C Severely malnourished
Normal Some progressive nutri tional loss Evidence of wasti ng and progressive
symptoms
CONTRIBUTING FACTOR
X CACHEXIA(fat and muscle wasting due to disease and inflammation)
SARCOPENIA(reduced muscle mass and strength)

Figure 5. SGA form from Case 2. The patient is considered well nourished (rating A), as caloric and protein intake has
normalized, weight has stabilized, and gastrointestinal symptoms have improved. The patient still has moderately severe muscle
and fat loss and exhibits a wasting phenotype. This is attributed to the cachexia associated with the underlying malignancy. SGA,
subjective global assessment.
Duerksen et al. 13

Figure 6. (A) Mild to moderate muscle wasting of deltoids and pectoralis muscles, with squaring of the shoulders; some
prominence of the acromioclavicular region. (B) Moderate muscle wasting of interosseous muscles of hands, as demonstrated by
prominent tendons. Palpation of the first interosseous muscle would confirm this. (C) Mild muscle wasting of scapular muscles.
(D) Full quadriceps: no notable evidence of wasting.

potatoes (125 mL), carrots (125 mL), and fruit juice
(200 mL)
Dessert: Apple sauce, fruit cake, or pie
HS snack: Cheese and crackers
She does not have any symptoms or barriers limiting her
food intake.
The patient does not think she has lost weight recently, al-
though she never weighs herself. She reports having weighed
up to 57 kg, but that was >10–15 years ago. Her usual
weight now, for the past 10 years, is ∼50 kg. When asked
why she would have lost this weight when compared with
years ago, the patient said, “the age does that!” Some mea-
sured weights have been tracked in the electronic medical
record (at admission, 48.6 kg; 8 months ago, 48.4 kg; and
27 months ago, 50.4 kg). Her current height is 158 cm and
BMI is 19.4.
There has been no change in her functional capacity: she
lives alone in her house and is a very active woman who
is involved in different activities in the community, and she
walks outside daily, gardens, and performs housework. She
has some limitations because of her breathing, and it takes
her longer to perform usual activities of daily living.
On physical examination, she exhibits physical signs
of mild to moderate muscle wasting of her deltoids and
pectoralis (Figure 6A) as well as the interosseous muscles
of her hand (on palpation, there was loss of muscle mass
of the first interosseous muscle) (Figure 6B) and mild loss
on subscapular and suprascapular muscles (Figure 6C).
Her quadriceps do not exhibit any notable sign of muscle
wasting (Figure 6D). She does not really have a dominant
hand, using 1 or the other, depending on the task. The
average of 3 measurements of her HGS on each hand was
14 kg (right hand) and 16 kg (left hand).
According to the SGA (Figure 7), this 90-year-old
female is classified as well nourished (SGA A); the low
muscle strength (HGS < 16 kg) and low muscle mass meet
the criteria for probable sarcopenia.18 Moreover, the BMI
< 20 in absence of simple starvation, in addition to the
decrease of muscle strength and low muscle mass, reach the
criteria for potential diagnosis of cachexia.17 This would be
attributed to her underlying chronic obstructive pulmonary
disease.
14 Nutrition in Clinical Practice 0(0)

Subjecve Global Assessment Form

MEDICAL HISTORY

Paent name: _________________________________ Date: _______ / _______ / _______

NUTRIENT INTAKE
1. x No change; adequate
2. Inadequate; duration of inadequate intake ______
Suboptimal solid diet Full fluids or only oral nutrition supplements Minimal intake, clear fluids or starvation
3. Nutrient Intake in past 2 weeks*
x Adequate Improved but not adequate No improvement or inadequate

WEIGHT Usual weight ____________ Current weight ___48.6 kg___

1.Non fluid weight change past 6 months Weight loss (kg) ________
x<5% loss or weight stability 5-10% loss without stabilization or increase >10% loss and ongoing
If above not known, has there been a subjective loss of weight during the past six months?
x None or mild Moderate Severe
2. Weight change past 2 weeks* Amount (if known) __________
Increased x No change Decreased

SYMPTOMS (Experiencing symptoms affecting oral intake)

1.Pain on eating Anorexia Vomiting Nausea Dysphagia Diarrhea
Dental problems Feels full quickly Constipation
2. x None Intermittent/mild/few Constant/severe/multiple
Symptoms in the past 2 weeks*
x Resolution of symptoms Improving No changeor worsened

FUNCTIONAL CAPACITY (Fatigue and progressive loss of function)

1.No dysfunction x
2.Reduced capacity; duration of change ________________
Difficulty with ambulation/normal activities Bed/chair-ridden
3.Functional Capacity in the past 2 weeks*
Improved x No change Decrease

METABOLIC REQUIREMENT
High metabolic requirement  No x Yes
PHYSICAL EXAMINATION
Loss of body fat No x Mild/Moderate Severe
Loss of muscle mass No x Mild/Moderate Severe
Presence of edema/ascites x No Mild/Moderate Severe

SGA RATING
x A Well-nourished B Mildly/moderately malnourished  C Severely malnourished
Normal Some progressive nutri tional loss Evidence of wastin g and progressive
symptoms
CONTRIBUTING FACTOR
xCACHEXIA(fat and muscle wasting due to disease and inflammation)
xSARCOPENIA(reduced muscle mass and strength)

Figure 7. SGA form from Case 3. SGA classification of well nourished (rating A), with sarcopenia and cachexia as contributing
factors to explain the body wasting. SGA, subjective global assessment.
Duerksen et al.
Conclusion
The SGA allows the clinician to analyze the interaction of
dietary intake, disease, and body activity when evaluating
the role of malnutrition in the observed phenotype of
the patient. In individuals with significant fat and lean
body tissue loss, it identifies those most likely to benefit
from nutrition therapy. Anthropometric measurements or
biochemical changes in isolation do not identify the role
of nutrition in a particular patient illness or phenotype.
In situations in which there is a significant interaction of
reduced intake, immobility, and disease, change in SGA
score with nutrition therapy will help distinguish the role of
malnutrition from other factors that could result in a similar
wasting phenotype.
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