ALLAMA IQBAL OPEN UNIVERSITY, ISLAMABAD

(Department of Environmental Design, Health and Nutrition Sciences)

M.SC PUBLIC NUTRITION

Group:

Abdul hameed (0000251505)

Azeem Dilawar (0000251002)

Uzma naveed (0000247505)

Rozina ismail (0000252289)

Nourin islam (0000251158)

Semester: Autumn, 2022

Assignment No: 2

Course: NUTRITIONAL ASSESSMENT-II

Presented to: MADAM SAMRA JAMIL

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To Develop Your Skills for Correctly
Screening and Assessing the Nutritional
Status of Patients by Using Mini Nutritional
Assessment Tool and Subjective Global
Assessment Tools
(3648)

INTRODUCTION:
Nutrition is a basic requirement for life. Accordingly nutrition plays an important role in
promoting health and preventing disease. Many factors can lead to weight change and
malnutrition. Malnutrition is a condition resulting from a combination of varying degrees of
under- or over nutrition and inflammatory activity, leading to an abnormal body composition and
diminished function. Several classifications of malnutrition have been proposed in the past. Even
now there is still no universally accepted definition. Patients with minor nutritional deficiencies
and those with overt under- or over nutrition are common in clinical practice. The prevalence of
malnutrition (under nutrition) among hospitalized adult patients ranges from 30 to 50%,
depending on the criteria used, and in part whether those at high risk as well as those with
established malnutrition are included.

The Mini Nutritional Assessment (MNA) has recently been designed and validated to provide a
single, rapid assessment of nutritional status in elderly patients in outpatient clinics, hospitals,
and nursing homes. It has been translated into several languages and validated in many clinics
around the world. The MNA test is composed of simple measurements and brief questions that
can be completed in about 10 min. Discriminant analysis was used to compare the findings of the
MNA with the nutritional status determined by physicians, using the standard extensive
nutritional assessment including complete anthropometric, clinical biochemistry, and dietary
parameters. The sum of the MNA score distinguishes between elderly patients with: 1) adequate

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nutritional status, MNA ≥ 24; 2) protein-calorie malnutrition, MNA < 17; 3) at risk of
malnutrition, MNA between 17 and 23.5. With this scoring, sensitivity was found to be 96%,
specificity 98%, and predictive value 97%. The MNA scale was also found to be predictive of
mortality and hospital cost. Most important it is possible to identify people at risk for
malnutrition, scores between 17 and 23.5, before severe changes in weight or albumin levels
occur. These individuals are more likely to have a decrease in caloric intake that can be easily
corrected by nutritional intervention.

The Mini Nutritional Assessment (MNA) is a validated nutritional screening instrument designed
to identify elderly persons who are malnourished or at risk of malnutrition. Developed by Nestlé,
it uses data that are relatively easy to obtain, and it can be administered in clinical settings such
as hospitals or physicians’ offices or in community settings. The MNA is designed to provide
primary care health professionals with a single tool to efficiently identify elderly patients at
nutritional risk who may subsequently need a more extensive nutritional assessment.

It is primarily intended for evaluating the so-called frail elderly—older persons exhibiting some
kind of functional impairment, such as mobility, hearing, or cognitive disorders; those older
persons living in nursing homes; and persons older than 85 living in the community. The
instrument is also effective for screening the hospitalized elderly and those requiring surgery. It
has been shown to be most useful at identifying persons at nutritional risk when included as part
of a comprehensive assessment of an elderly person’s cognition, independence, and mobility.
Factors associated with poor nutritional status are major and minor indicators of poor nutritional
status in older persons Approximately 10 to 15 minutes are needed to complete the full MNA
questionnaire. An abbreviated version of the instrument, the Mini Nutrition Assessment– Short
Form (MNA-SF), comprises questions A through F in the instrument, and can be completed in
less than 5 minutes. The MNA-SF retains the validity of the full MNA but is practical for use in
clinical and community settings because it can be more quickly administered than the full
version. There is also a self- administered version of the instrument, the Self MNA composed of
six questions. Individuals whose scores suggest they are malnourished or at risk of malnutrition
are advised to consult with a health care professional. There are also ―apps‖ for smart phones and
tablets, such as the iPhone and iPad. Most of the information required to complete the full MNA
can be obtained from a physical examination and from a brief interview with the patient or
someone knowledgeable about the patient’s condition and dietary habits. In addition, some
anthropometric data are necessary, including height and weight (for calculating body mass
index), mid-arm circumference, and calf circumference.

The full MNA was developed and thoroughly evaluated by researchers at Toulouse University
Hospital, Toulouse, France; the University of New Mexico, Albuquerque; and the Nestlé
Research Center in Lausanne, Switzerland. The full MNA is completed by assigning points for
each of the 18 items in the instrument, which are then summed to provide a ―malnutrition
indicator score.‖ When the malnutrition indicator score is $ 24, the patient’s nutritional status can
be considered normal, and these patients should be given general dietary and lifestyle
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information about how to remain in good health. A patient whose malnutrition indicator score is
< 17 is likely to be at high risk for protein-energy malnutrition and should be followed up with a
comprehensive nutritional assessment. Those whose malnutrition indicator score is between 17
and 23.5 are at increased risk for malnutrition and should also receive further evaluation of their
nutritional status.

Research shows the full MNA and MNA-SF to be practical, noninvasive, and cost-effective
instruments for identifying elderly persons at risk for malnutrition.

Subjective Global Assessment (SGA) is a clinical technique for assessing the nutritional status
of a patient based on features of the patient’s history and physical examination. 4 Unlike
traditional methods that rely heavily on objective anthropometric and biochemical data, SGA is
based on four elements of the patient’s history (recent loss of body weight, changes in usual diet,
presence of significant gastrointestinal symptoms, and the patient’s functional capacity) and
three elements of the physical examination (loss of subcutaneous fat, muscle wasting, and
presence of edema or ascites). 4 Information obtained from the history and physical examination
can be entered into a form, to arrive at an SGA rating of nutritional status.

Elements of the History

The first of the four elements of the SGA history is the percent and pattern of weight loss within
6 months prior to examination. A weight loss < 5% is considered small. A 5% to 10% weight
loss is considered potentially significant. A weight loss > 10% is considered definitely
significant. The pattern of weight loss is also important. A patient who has lost 12% of his or her
weight in the past 6 months but has recently gained 6% of it back is considered better nourished
than a patient who has lost 6% of his or her weight in the past 6 months and continues to lose
weight. Information about the patient’s maximum weight and what it was 6 months ago can be
compared with the patient’s current weight. Questions about changes in the way clothing fits
may confirm reports of weight change. Information about changes in body weight in the past 2
weeks (increase, no change, decrease) should be elicited as well. These data can be entered or
noted in the appropriate places in Dietary intake, the second element of the history, is classified
as either normal (i.e., what the patient usually eats) or abnormal (i.e., a change from the patient’s
usual diet). If intake is abnormal, the duration in weeks is entered, and the appropriate box is
checked to indicate the type of dietary intake abnormality (i.e., increased intake, suboptimal
solid, full-liquid, IV or hypocaloric liquids, or starvation). The patient can be asked if the amount
of food consumed has changed and, if so, by how much and why. If the patient is eating less, it
would be valuable to know what happens when he or she tries to eat more. Ask for a description
of a typical breakfast, lunch, and dinner and how that compares with what the patient typically
ate 6 or 12 months ago.

Information about any gastrointestinal symptoms persisting more than 2 weeks (the third history
element) should be elicited and noted on the form. Diarrhea or occasional vomiting lasting only a

4
few days is not considered significant. The presence or absence of any dysfunction in the
patient’s ability to attend to activities of daily living (the last history element) should also be
noted on the form. If a dysfunction is present, its duration and type should be noted.

Elements of the Physical Examination

The first of the three elements of the physical examination is loss of subcutaneous fat. The four
anatomic areas (shoulders, triceps, chest, and hands) should be checked for loss of fullness or
loose-fitting skin, although the latter may appear in older persons who are not malnourished.
Illustrations of subcutaneous fat loss in the arm, chest wall, and hands. Loss of subcutaneous fat
should be noted as normal (0), mild loss (1 1 ), moderate loss (2 1 ), or severe loss (3 1
According to Detsky, the presence of muscle wasting (the second element of the physical
examination) is best assessed by examining the deltoid muscles (located at the sides of the
shoulders) and the quadriceps femoris muscles (the muscles of the anterior thigh). 4 Loss of
subcutaneous fat in the shoulders and deltoid muscle wasting gives the shoulders a squared-off
appearance, similar to that These areas can be assessed as being normal or mildly, moderately,
or severely wasted. The presence of edema at the ankle or sacrum can also be assessed as absent,
mild, moderate, or severe. The presence of ―pitting‖ edema can be checked by momentarily
pressing the area with a finger and then looking for a persistent depression (more than 5 seconds)
where the finger was. Ankle edema and ascites can be assessed as absent, mild, moderate, or
severe. When considerable edema or ascites are present, weight loss is a less important variable.

The final step in SGA is arriving at a rating of nutritional assessment. Instead of an explicit
numerical weighting scheme SGA depends on the clinician’s subjectively combining the various
elements to arrive at an overall, or global, assessment. Patients with weight loss > 10% that is
continuing, poor dietary intake, and severe loss of subcutaneous fat and muscle wasting fall
within the severely malnourished category (class C rank). Patients with at least a 5% weight loss,
reduced dietary intake, and mild to moderate loss of subcutaneous fat and muscle wasting fall
within the moderately malnourished category (class B rank). Patients are generally ranked as
well-nourished when they have had a recent improvement in appetite or the other historical
features of SGA. A class A rank would be given to patients having a recent increase in weight
(that is not fluid retention), even if their net loss for the past 6 months was between 5% and 10%.
Using this approach, very few well-nourished patients are classified as malnourished, but some
patients with mild malnutrition may be missed. 4 Despite this subjective nature, clinicians
(nurses and residents)

trained to use SGA were shown to have arrived at very similar rankings when comparing their
evaluations of a series of 109 patients. 4 The method has also been shown to be a powerful
predictor of postoperative complications. 4 , 5 SGA has been shown to be a simple, safe,
effective, and inexpensive tool for clinicians to identify patients who are malnourished or at risk

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of malnutrition. It is regarded by many as the most reliable and efficient method to assess
nutritional status at the bedside and is considered the gold standard for bedside assessment tools.

Objectives:

• To assess the nutritional status of elderly population by using MNA Tool.

• To analyze the nutrition loss and screening malnourishment in hospitalized patient using
SGA.

Methodology:

Tools or materials needed

Mini nutrition assessment fom

Mini nutrition assessment form is extracted from the link university provided. This form is
further used to assess the nutrition status of patients older than 70

Subjective global assessment form

• Subjective global assessment form is extracted from the link university provided.

The forms are used to assess nutrition status of hospitalized patients and how diseases can affect
the nutrition of patients.

The data was collected from Iqra homeopathic clinic Rawalpindi. The criteria to collect the data
is

• MNA was collected from the clinic. The form was filled from elderly people of age more
than 70 years. It took 10 to 15 minutes to complete a single MNA forms. Other than that patients
have been asked general questions about their health situation and how they carry out life with
everything.

• SGA was also collected from the clinic and it was,. This form is filled by the patients of
the clinic different medical situations have been asked. Patients have been asked of their weight,
their current weight, their weight fluctuations, different symptoms of diseases are also asked.
Patients are asked if they show symptoms of other illnesses that can lead to the malnutrition.

1- MNA analysis by AZEEM DILAWAR

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2- MNA analysis by Abdul hameed:

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3- MNA analysis by Rozina ismail:

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4- MNA analysis by Uzma naveed:

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5- MNA analysis by Nourin:

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Case study #1

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First case study is of a lady of 80 years old. According to the screening done in the
MNA forms the patient in the consideration is has shown symptoms of risk of
malnutrition as the patient eats two proper meals of the day. Other than that the
patient has no proper intake of fruits, milk and milk products. As patient lives in
under privileged area it is hard for the patient to get access to the proper food
choices or dietary guidelines needed in old age. The risk of malnutrition is
basically because of not eating properly and not considering healthy dietary
choices

Case study #2

2nd case study is also a female patient of age 87. According to the screening done
in the MNA for it is evaluated that the patient does not has any mobility issues.
Patient’s weight fluctuates in between intervals but most of the time it stays same.
According to the assessment form it is clear that the patient does not take her fruit
servings regularly and patient also does not take milk and milk products regularly.
The meat or poultry consumption is also reduced. It is concluded from the patients’
health condition that patient is at the risk of malnourished.

Case study #3

3rd case study is also taken from a female of age 75. The patient has a sever
decrease in food intake thus making it difficult for the weight to be stable at a
specific point. BMI is also less than 19. The patient eats 2 regular meals per day.
There is a very less intake of fruit servings per day. Ilk and products are also taken
in a very less amount. Poultry and chicken or meat is also taken in a very less
amount and thus the patient is at the risk of malnutrition.

Case study #4

The 4th case study is a lady of 90 years old. There is no severe decrease in food
intake in the patient. Patient also shows some symptoms of decreased mobility as
the patient does come out of the bed or chair but does not go out and stays at home
doing daily routine work. The patient has a BMI in the normal range that is in
between 19 to 21. The patient also shows some symptoms of neuropsychological
symptoms. The patient takes in 2 meals per day. Protein intake is also much
decreased as there is a very little to less consumption of milk and milk products

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other than milk products poultry and meat is also taken in much decreased amount.
According to MNA screening the patient has a malnourished profile thus a full
MNA can be performed on the patients.

Case study #5

The fifth case study is of a male patient of the age 70. According to the screening
performed on Abdul Rasheed. The patient is experiencing a sever decrease in the
food intake. The weight loss is also accompanied with the decrease in food intake.
The patient eats only one meal of the day. Because of the decreased amount of
food taken in, the patient also takes a very less amount of the fruits servings. Milk
and milk products are also not consumed properly. Same is the case with proteins
and meat eaten. Because of such low amounts of food taken the patient is
malnourished and should go for a further screening.

1- SGA analysis by Azeem Dilawar

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2- SGA analysis by Abdul hameed:
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3- SGA analysis by Rozina ismail:

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4- SGA analysis by Uzma naveed:

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 5- SGA analysis by Nourin:

Case study #1

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The first case study is a male patient with almost no change in nutrient. Nutrient
supply is adequate. And the nutrient intake of the patient is mostly of solids.
Weight fluctuation is noticed in the data but the fluctuation is less than 5 percent
thus there is no noticeable change in the nutrition of the person. However the
symptoms of the patient disease are much more to be ignored. The symptoms
include anorexia, constipation and feeling full quickly. The patient is given SGA
ranking B which is mild or moderately malnourished.

Case study #2

2nd case study is of a male patient with weight 70 that is not changed over the
course of months, the food intake is adequate solid food. As there are no changes
in the weight, there are also no symptoms in the illnesses in the body that can
evaluate to the medical condition of the patient. As there are also no metabolic
disruptions the patient is well nourished thus given SGA ranking of A.

Case study # 3

In the 3rd case study there is a female patient with the symptoms of intermittent
where they stay empty stomach for most of the time as the symptoms are not
improving. Metabolic requirement of the patient is also not much high. The
physiological functions are also not much interrupted by the few symptoms patient
is showing. Thus a SGA ranking of B is given to the patient because of the
symptoms of mild intermittent hunger and because of no improvement of the
symptoms. According to the ranking B of the patient the patient is mild or
moderately malnourished.

Case study #4

The 4th case study is of a male patient with the weight of 60kg. There is no change
in the weight of the patients as the weight remains constant. The patient shows
symptoms of nausea but these symptoms are improving. Nutrient intake of the
patient is adequate and the there is no decrease in metabolic rate or physiological
functions thus the patient is given SGA ranking A this shows that the patient is
well nourished and can combat the disease easily.

Case study # 5

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The 5th case study is of a female patient with symptoms of diarrhea. The
symptoms are improving and there is an improvement in the intake of food and
retention of it in the body. The patient shows mild or moderate changes in the
physiological functions with almost no changes in the metabolic requirement. The
functional capacity of the patient is also of no change. The food intake is adequate
and more solid foods are given to the patient to help her with improving.
According to the assessments conducted it is advised that the SGA ranking is A
and the patient is well nourished with adequate amount of food intake.

Result and discussion of MNA:

Result:

The Mini Nutritional Assessment (MNA) is a validated tool used to assess the
nutritional status of older adults. The MNA consists of 18 questions and provides a
score ranging from 0 to 30. The MNA result and discussion can provide valuable
insights into an individual's nutritional status and inform the development of
personalized care plans to address their needs.

The MNA result is typically presented as a score, where a score of 24 or higher

indicates a normal nutritional status, a score between 17 and 23.5 indicates a risk
of malnutrition, and a score below 17 indicates malnutrition. Based on the MNA
score, healthcare professionals can develop a personalized care plan to address the
individual's specific nutritional needs.

In the discussion, the MNA results are interpreted based on the individual's
responses to the 18 questions. The discussion can provide insights into the possible
causes of malnutrition, such as poor appetite, recent weight loss, and mobility
limitations.

Discussion:

The MNA result and discussion can also highlight the potential consequences of
malnutrition, such as increased risk of falls, hospitalization, and mortality.

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Therefore, the MNA can help identify individuals who are at risk of malnutrition
and develop strategies to prevent or treat malnutrition.

Additionally, the MNA result and discussion can be used to monitor progress and
assess the effectiveness of the care plan. Regular MNA assessments can track
changes in the individual's nutritional status and identify any gaps or challenges in
the care plan.

Conclusion:

In conclusion, the MNA is a useful tool for assessing the nutritional status of older
adults, identifying those at risk of malnutrition, and developing personalized care
plans to address their specific needs. The MNA result and discussion can provide
valuable insights into the possible causes of malnutrition and potential
consequences. Regular MNA assessments can monitor progress and assess the
effectiveness of the care plan.

Result and discussion of SGA:

Result:

SGA forms are the questionnaire that is used to evaluate nutritional status of
hospitalized patients that are going through some medication or procedures for
treatment of their diseases.

The result and discussion of Subjective Global Assessment (SGA) can provide
valuable insights into an individual's nutritional status and inform the development
of personalized care plans to address their needs.

The SGA result is typically presented as a score, ranging from A to C, where A

represents a well-nourished individual, B represents a moderately malnourished
individual, and C represents a severely malnourished individual. Based on the SGA
score, healthcare professionals can develop a personalized care plan to address the
individual's specific nutritional needs.

Discussion:
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In the discussion, the SGA results are interpreted based on the individual's medical
history, physical examination, and dietary intake. The discussion can provide
insights into the possible causes of malnutrition, such as underlying medical
conditions, functional limitations, or poor dietary intake.

The SGA result and discussion can also highlight the potential consequences of
malnutrition, such as impaired wound healing, increased risk of infections, and
reduced quality of life. Therefore, the SGA can help identify individuals who are at
risk of malnutrition and develop strategies to prevent or treat malnutrition.

Additionally, the SGA result and discussion can be used to monitor progress and
assess the effectiveness of the care plan. Regular SGA assessments can track
changes in the individual's nutritional status and identify any gaps or challenges in
the care plan.

Conclusion:

In conclusion, the SGA is a useful tool for assessing an individual's nutritional

status, identifying those at risk of malnutrition, and developing personalized care
plans to address their specific needs. The SGA result and discussion can provide
valuable insights into the individual's medical history, physical examination, and
dietary intake, as well as potential consequences of malnutrition. Regular SGA
assessments can monitor progress and assess the effectiveness of the care plan.

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TOPIC

Develop your skills to assess the nutritional status of

patients by using Mini Nutritional Assessment and
Subjective Global Assessment tools

Abstract

Protein-energy malnutrition (PEM) is a common condition among patients admitted

to hospitals, and it is associated with a worse prognosis and increased mortality.
Although several screening systems have been developed, PEM is still poorly
recognized, and there is no consensus on which test is more reliable and feasible in
clinical practice. Prealbumin (PAB) is a potential useful PEM marker because its
serum concentrations are closely related to early changes in nutritional status.

Objective of the study :

A study was undertaken to determine which nutritional assessment tool would be better in
assessing changes in nutritional status over time in hospitalised older patients. The two tools
used were the Mini Nutritional Assessment (MNA) and the Subjective Global Assessment
(SGA). To evaluate the clinical assessment of nutritional status and mortality in geriatric
patient. The main objective of this study is to evaluate the clinical assessment of nutritional
status and mortality in geriatric patients. 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 aims of the
study were to evaluate the nutritional status of the hospitalised elderly patients, to estimate the
prevalence and distribution of malnutrition among them and to value the correlation of the
Mini Nutritional Assessment (MNA) with nutritional biochemical and anthropometric
parameters.

Key Words

Key words: Nutritional status, Mini Nutritional Assessment, Subjective Global Assessment,
older person, aging.

INTRODUCTION

It is well established that the older person (greater than 65 years of age) generally experiences
higher rates of undernutrition and are more prone to malnutrition than the general population
(1-5). This has major implications for clinical care as those older persons who experience
undernutrition have slower wound healing, compromised immunity, increased risk of
infections, longer hospital stays, more frequent hospital re-admissions and ultimately increased
cost of care . The accurate detection of malnutrition in the older person therefore represents a
growing nutritional responsibility. If undetected, undernutrition may result in more rapid
deterioration of health and early death . In 1998 the authors were involved in a routine
malnutrition screening initiative introduced in three regional hospitals in the Illawarra Area
Health Service (IAHS), New South Wales, Australia . The main purpose being to flag those
patients at risk of malnutrition and commence early nutrition intervention. It was proposed
those repeat assessments would enable the measurement of nutritional changes over time and
provide an indication of the impact of that nutrition intervention. Those identified as “at risk”
of malnutrition were then assessed using the Subjective Global Assessment (SGA) . However,
the dietitians assessing older clients expressed concerns that the SGA did not appear to be
highly sensitive in this population. The sensitivity was questioned when serial SGA
measurements were taken over time. Dietitians noted improvements in nutritional status but
these changes were too small to elicit shifts in the SGA categories. This concern prompted a
closer examination of the use of the SGA in the older person. A review of the literature
showed the inter-rater agreement of the SGA was less when used in older clients and there
were discrepancies in reporting of malnutrition rates. The SGA is a nutritional assessment tool
validated for use in all hospitalised patients. The Mini Nutritional Assessment (MNA)
 however, was specifically designed and validated in the older population for integration into
geriatric assessment programmes. A review of the area showed an absence of literature directly
comparing the SGA with the MNA in the detection of malnutrition in the older population.
This prompted us to compare the SGA with the MNA, for clients greater than 65 years of age.

The Importance of Identifying Malnutrition

Nutrition is a basic requirement for life. Accordingly nutrition plays an important role in
promoting health and preventing disease. Many factors can lead to weight change and
malnutrition. Malnutrition is a condition resulting from a combination of varying
degrees of under- or overnutrition and inflammatory activity, leading to an abnormal
bodycomposition and diminished function
(1). Several classifications of malnutrition have been proposed in the past. Even now
there is still no universally accepted definition.
Patients with minor nutritional deficiencies and those with overt under- or
overnutrition are common in clinical practice. The prevalence of malnutrition
(undernutrition) among hospitalized adult patients ranges from 30 to 50%, depending
on the criteria used, and in part whether those at high risk as well as those with
established malnutrition are included .
(4). Undernutrition should be seen as an additional disease, as well as an important
component of comorbidity. The underlying condition and inadequate provision of
nutrients (particularly energy and protein) are the main reasons for developing
undernutrition. Many patients are already undernourished before they reach the
hospital. Those at highest risk for undernutrition are older people who are hospitalized
or living in care homes, people on low incomes or who are socially isolated, people
with chronic disorders, and those recovering from a serious illness or condition,
particularly a condition that affects their ability to eat. In addition, hospitalized
patients often show further deterioration in their nutritional status. One large survey
showed that four out of five patients do not consume enough to cover their energy or
protein needs
(5). There are many known reasons to explain this. The underlying disease may
directly impair nutrition (as, for example, in the case of an oesophageal stricture) and
can induce metabolic and/or psychological disorders which increase the nutritional
needs or decrease food intake. In addition, the fasting periods before many
examinations and interventions lead to further inadequate food intake. Hospital
undernutrition can also become aggravated because of inappropriate meal services,
inadequate quality and flexibility of the hospital catering, and insufficient aid provided
by the care staff.
The consequences of undernutrition are well-known. A poor nutritional status leads to
an increase in complications, a longer length of stay, higher mortality, higher costs
and more re-admissions. The EuroOOPS study, for example, found significant
increases in complications, length of stay and mortality in patients at risk for
undernutrition. Undernutrition also influences the efficacy or tolerance of several key
treatments, such as antibiotic therapy, chemotherapy, radiotherapy or surgery.
Furthermore, it is now clearly demonstrated that undernutrition significantly increases
overall health care costs.
Undernutrition is undoubtedly a major burden for patients and health care
professionals, and routinely should be actively sought. When undernutrition is
diagnosed, it should be treated in accordance with an individual nutritional care plan.
The best outcomes are seen when there is supervision by a multidisciplinary
nutritional support team.

To improve the overall outcomes from nutritional treatment it is necessary to

select patients with overt undernutrition/malnutrition, and those at most risk of
developing nutritional deficiencies during their hospitalization. An ideal care plan
should start by screening all patients when they are admitted, proceeding to a detailed
assessment of nutritional status in those found to be at increased risk. In patients who
are identified to be malnourished or at high risk, an appropriate nutritional intervention
should follow. Unfortunately, although this process is well-known and forms part of
several national and international guidelines, it is not carried out everywhere. It
remains necessary to raise awareness of undernutrition and to improve the outcomes
of patients’ treatments by nutritional measures.
 Literature Review

The Mini Nutritional Assessment

The Mini Nutritional Assessment (MNA) has recently been designed and validated to provide a
single, rapid assessment of nutritional status in elderly patients in outpatient clinics, hospitals,
and nursing homes. It has been translated into several languages and validated in many clinics
around the world. The MNA test is composed of simple measurements and brief questions that
can be completed in about 10 min. Discriminant analysis was used to compare the findings of the
MNA with the nutritional status determined by physicians, using the standard extensive
nutritional assessment including complete anthropometric, clinical biochemistry, and dietary
parameters.

In the past two decades, a number of geriatric assessment instruments have been developed to
diagnose and treat high-risk elderly patients. However, too little attention has been given to
identifying those elderly patients who would benefit from early detection of malnutrition. There
are many changes in physiologic function, nutritional status, and diet with aging. It is not clear
whether these changes are inherent to the aging process or whether they reflect changes in
physical activities, diet, body composition, or chronic illness. Assessing the nutritional status of
older population requires clinical studies to identify physical signs of nutritional health or
disease, dietary studies to evaluate nutrient intakes by accepted standards, and laboratory
investigations to provide data about the quantities of particular nutrients in the body or to
measure certain biochemical functions that depend on an adequate supply of particular nutrients.

Nutrition is a multifactorial entity which determines the health of an individual. Malnutrition can
be defined as a state of imbalance in protein, energy, and other entities of nutrition. Malnutrition
though affects both pediatric and geriatric age group, malnutrition in geriatric age group is
always underdiagnosed. The prevalence of malnutrition is increasing in this population, and this
has a negative influence on elderly people’s health and quality of life,
Nutrition is a basic need of life and thus plays an important role in health promotion and disease
prevention. Nutritional intake and its controlling mechanisms (e.g., appetite, satiety) are highly
complex physiological processes. These processes have a strong influence on nutritional status,
which in turn depends on nutritional intake, its balanced supply of macro and micronutrients, and
fluid intake. For various reasons, ill people may struggle to meet their nutritional and hydration
requirements, and as a consequence, 20–50% of patients are malnourished or at high risk of
malnutrition upon hospital admission . One in five patients does not consume enough food to
cover their energy or protein needs. The underlying disease may directly impair nutritional intake
and may induce metabolic and/or psychological disorders, which increase the nutritional needs
or decrease food intake. Frequent problems such as chewing and swallowing issues, immobility,
and side effects of drugs and polypharmacy should not be underestimated in this regard. A
protracted decline in nutritional status results in a catabolic metabolism and chronic low-grade
inflammation, potentially leading to several harmful consequences, such as loss of fat-free mass,
immune dysfunction, higher complications and mortality rates, reduced quality of life, and
prolonged hospital stays. Malnutrition also influences the efficacy or tolerance of several
treatments, such as antibiotic therapy, chemotherapy, radiotherapy, and surgery. The increased
metabolism due to the stress of eventual surgical procedures further aggravates the nutritional
metabolic risk, and is characterized by activation of the sympathetic nervous system, endocrine
responses, and immunological and hematological changes—all leading to a hypermetabolic state,
which may further increase patients’ nutritional needs. In addition, the fasting periods before
many examinations and interventions, as well as inappropriate meal services, inadequate quality
and flexibility of hospital catering, and insufficient assistance provided by the health care staff to
the most vulnerable patients, lead to further inadequate food intake and deterioration of patients’
nutritional status A systematic and standardized approach to identifying this condition is needed,
and that is where nutritional screening tools play an important role. When malnutrition is
diagnosed, an individual nutritional care plan should be established by a nutrition specialist (e.g.,
dietitian, expert clinician) in consultation with a multidisciplinary team, and monitored regularly
throughout the hospital stay. To improve the overall outcomes from nutritional treatment it is
necessary to select patients with overt malnutrition, and those at most risk of developing
nutritional deficiencies during their hospitalization. A systematic approach to addressing
malnutrition in hospitals should start with the screening of all patients on admission, proceeding
to a detailed assessment of nutritional status in those found to be at increased risk. In patients
who are identified as malnourished or at nutritional risk, an appropriate nutritional intervention
tailored to the individual patient’s needs should follow. Unfortunately, although the need for this
process is well-recognized and forms part of several national and international guidelines, it is
not carried out everywhere. In the well-known cross-sectional “NutriDay” survey conducted in
2007–2008, 21,007 patients from 325 hospitals in 25 European countries were included. Results
showed that a screening routine existed in only half (53%) of the hospitals in the different
regions, mostly performed with locally developed methods. While the routine screening of
patients for malnutrition on hospital admission existed for 93% of units in the United Kingdom,
less than 33% of units had this practice in Austria, Germany, and the South Eastern region. In
addition, more than a quarter of all patients (27%) were considered to be at risk of malnutrition, and
energy goals were not met in almost half (43%) of the surveyed population. It remains necessary to raise
awareness of malnutrition and to improve the outcomes of patients’ nutritional treatments.

The MNA is the screening tool most frequently used in institutionalized geriatric patients (Table
3). It combines screening and assessment features. Unlike the NRS-2002, the MNA includes
diverse components (loss of appetite, altered sense of taste and smell, loss of thirst, frailty,
depression) often relevant for the nutritional status of older people. It also includes
anthropometric measurements, nutritional habits, general condition, and self-evaluation. Both the
MNA (complete form) as well as a short-form MNA (MNA-SF) are available. The complete
MNA includes eighteen items in four domains (Appendix A). The MNA-SF includes only six
items, but is quicker and as effective as the long version. If the total score is 11 points or less, the
patient is considered at risk of malnutrition or malnourished and the full version (assessment)
should be performed. It is important for clinicians to understand how the tools were validated
and for which population and care setting they were developed in order to determine if the tool is
appropriate for use in their institution

Assessment

Nutritional assessment should be performed in patients identified as at nutritional risk according to the
first step (i.e., screening for risk of malnutrition). Assessment allows the clinician to gather more
information and conduct a nutrition-focused physical examination in order to determine if there is truly a
nutrition problem, to name the problem, and to determine the severity of the problem . The data collected
in a nutritional assessment are often similar to data collected in the screening process, but in more depth.
Screening assesses risk whereas assessment actually determines nutritional status. The observation and
documentation of oral nutritional intake, including qualitative and quantitative aspects, and measurement
of energy, protein, and micronutrient intake, is an important part of nutritional assessment. There is a
limited number of tools used for the assessment of nutritional status. The most-used tool is the Subjective
Global Assessment (SGA), which includes information on a medical history (weight loss; dietary intake
change; gastrointestinal and functional impairment) and physical examination (loss of subcutaneous fat;
muscle wasting; ankle edema, sacral edema, and ascites). Each patient is classified as either well
nourished (SGA A), moderately or suspected of being malnourished (SGA B), or severely malnourished
(SGA C). A limitation of using SGA is that it only classifies subjects into three general groups, and it
does not reflect subtle changes in nutritional status. Furthermore, it is subjective, does not account for
biochemical values (e.g., visceral protein levels), and its sensitivity, precision, and reproducibility over
time have not been extensively studied in some patient populations. Thus, here we describe the several
components that should be part of the nutritional assessment process and interpreted by specialized
clinical staff (e.g., dietitians). Most of these components have limited sensitivity and specificity when
used individually; therefore, methods for identifying malnourished patients require the use of several
parameters and the clinical judgment of experienced and specialized clinical staff. Detailed evaluation
leads to an understanding of the nature and cause of the nutrition-related problem, and will inform the
design of a personalized nutritional care plan

Mini nutritional assessment (MNA)

This tool was originally developed in 1990 to assess the nutritional status of elderly patients. The
full form of MNA consists of 18 scored questions that are divided into 4 categories: 1)
anthropometric measurements;

2) global assessment;

3) dietary history and

4) metabolic stress . The MNA generates a total score of 30. The total scores are interpreted as
follows: 24–30 (normal nutritional status); 17–23.5 (at risk of malnutrition); less than 17 points
(malnourished) .
Subjective global assessment (SGA)

This instrument was originally developed by Detsky et al. in 1987 to predict malnutrition in
patients undergoing gastrointestinal surgery . The SGA consists of two assessment features:

1) history and

2) physical examination relevant to malnutrition status . The history part includes patterns of
weight change, dietary history, gastrointestinal signs and symptoms, physical functionality and
underlying inflammatory disease . Additionally, three categories of physical assessment in
relation to malnutrition are used in SGA: loss of subcutaneous fat, muscle wasting and the
presence of fluid retention . After the assessment, the patient is classified as either SGA-A (well-
nourished), SGA-B (moderately malnourished), or SGA-C (severely malnourished).

Patient Generated-subjective global assessment (PG-SGA)

The PG-SGA was originally developed as an extension of the SGA tool to assess the nutritional status of
patients with cancer. The tool includes all SGA components and involves patients to self-report their
nutritional histories . Additionally, there are two new features in this instrument: first, for each
item of the PG-SGA, a score of 0–4 is added, the more severe the symptoms in relation to
malnutrition the higher the assigned value. Second, PG-SGA can generate a numerical score in
addition to summarizing a global rating of A (well-nourished), B (moderately malnourished), and
C (severely malnourished). A total score between 0 and 35 quantitatively informs the severity of
malnutrition and types of intervention needed: 0–1 point indicates no need for any intervention;
2–3 points suggest education needs for the patients and family; 4–8 points indicate the need for a
referral to a dietitian; and a score of 9 or more recommends an action of critical nutritional
intervention.

Furthermore, this review revealed that many recent studies have expanded their interests to
validate the use of the MNA tool for patients other than geriatrics; this has expanded its
popularity for use in patients with complex medical needs. However, the challenge exists in the
applicability of Body Mass Index (BMI) measurements for patients in tertiary-care settings. For
example, there are disagreements in BMI thresholds based on different age-group; body weight
is sensitive to the change in fluid status, which is commonly seen in inpatients; cancer tumors
can also significantly increase the body mass, thus creating bias of BMI interpretation. On the
other hand, MNA contains questions to self-evaluate nutritional and health status, and this may
reduce its applicability in patients with declined cognition or impaired speech capacity. Finally,
questions that address food choices, portion size, and the mode of feeding may not be
appropriate for patients who are nutritionally stable but are receiving enteral feeding as an
alternate route of food intake.

Among the three malnutrition assessment tools studied in this review, SGA was the first tool
developed and validated for use in healthcare. Moreover, it was recommended as an acceptable
assessment tool by the European Society for Clinical Nutrition and Metabolism (ESPEN) .
Compared with MNA and PG-SGA, the portion of patient-reported items is lower in SGA.
However, multifaceted anthropometric measures are added into the assessment to examine the
muscle mass loss, subcutaneous fat loss, and signs of fluid overload in 11 areas of body parts;
these features of SGA were reported to improve the accuracy of malnutrition assessment, and the
tool has been validated for use in a variety of patient populations. However, in the current
review, SGA was not found to have sufficient sensitivity for the identification of severe
malnutrition among patients with renal failure; one explanation about this conflicting finding
could be that fluid overload as a result of end-stage renal disease may mask the sign of
subcutaneous fat loss, which can interfere with clinicians’ subjective judgments on nutritional status.

Aim

The aim of this study was to determine which of the two tools (SGA or MNA) was more accurate at
detecting malnutrition in hospitalised older persons in the IAHS.

In particular: 1. Does the MNA detect a higher number of malnourished patients than the SGA, when
used by dietitians to assess the nutritional status of individuals aged 65 years and over?

2. Is there a difference in the detection of malnutrition at Day 30 and Day 60 after admission, between
the SGA and MNA?

Methods
All patients over 65 years of age admitted to the five hospitals during May 2001 were eligible.
The only exclusions were those patients admitted to palliative care or with severe dementia. Two
dietitians saw each patient. Each dietitian assessed the patient using his or her assigned
nutritional assessment tool either the SGA or the MNA. All dietitians were randomly assigned
the tool at the commencement of the study. They were familiarised with the use of the tool by
participating in a workshop prior to the start of the study.

The study included patients 65 years of age and over admitted to five hospitals within the Layya
City. All new admissions to these sites over a one-month period (between February and March
2023) were eligible for the study; with the exception of palliative care patients and patients with
severe dementia.

Design of study:

This was a prospective single blind study conducted over a 60-day period. A paired sample
was used. Two observations (the SGA and MNA) were done on each participant at baseline
(Day 0), Day 30 and Day 60 after admission. This was a cross-sectional study. Those patients
that were discharged during this period were followed up at home or place of residence.
Results and other relevant data such as social status, and admitting diagnosis (if available)
were recorded on a simple patient data form by each observer for every subject.

SUBJECTS:

There were 43 patients at the commencement of the study, then 28 patientsat day 30 and
20 patients at day 60.

Tools for Assessment

The SGA is a subjective global assessment tool designed for hospitalised patients and the
MNA is specifically developed for the assessment of the nutritional status of the older
person .

Modification of the MNA tool

The MNA was developed in France with collaboration from the Clinical Nutrition Program,
University of New Mexico USA and the Nestle Research Centre, Lausanne Switzerland.
After consultation with the author , the MNA tool was modified as follows to make it more
culturally specific to the older Australian population.

i) Question F Body Mass Index (BMI) (weight in kg)/(height in m)2

The French anthropometric standards are lower than those used for the USA and Australia,
therefore the BMI range was modified to reflect the ranges recommended by the
Dietary Guidelines for Older Australians. For healthy older adults most assessment
standards suggest a range of 22 - 27 (20), therefore Question F in the screening
component was adjusted as illustrated above.
ii) Question K Selected consumption markers for protein intake The original MNA had two
or more servings of legumes or eggs per week. After consultation with the author, this was
modified to one - two servings per week to better match the Australian dietary practices.
Legumes are traditionally consumed in greater quantities in Mediterranean diets. On
average 18g legumes are consumed per day in Mediterranean diets compared with 6g per
day in the Layya City of Pakistan(21,22).
Adjustments to MAC measurements were made based on the American percentile norms for
measurements of MAC in older white subjects (23), which also included gender differences.

Procedure

For the purpose of the study, participating hospitals were grouped into three sites. A total of six dietitian’s
(two from each site) acted as investigators. The investigators worked in pairs, each being randomly
assigned a nutrition assessment tool – either the SGA or MNA. All investigators had been trained in the
use of the SGA and were currently using this tool in their normal clinical practice. To minimise user bias
and familiarise themselves with the MNA tool, all dietitians involved in the study used the MNA over a
trial period of one week prior to the commencement of the study. To maximise inter-rater reliability a
workshop was conducted prior to this trial where the dietitians were trained in the use of the MNA.

Implementation

The SGA and MNA were each conducted on all new (and appropriate) admissions, over a 30-day
period. The first assessment on admission was Day 0 (baseline). The same investigators used the
same assessment tool to reassess each subject at Day 30 and again at Day 60. “Patient data
forms” were completed for each subject at Day 0, 30 and 60, and forwarded on to another
dietitian, independent of the study for collation. If a subject was identified as nutritionally
compromised the site dietitian provided nutrition care throughout their admission as per standard
dietetic practice within the Nutrition Department. Follow-up of the subjects at Day 30 and 60
were arranged closer to the time due. Where subjects were willing, an outpatient clinic
appointment was made, however, the majority of follow-ups were home visits.

Statistics and Ethics

Data are given as mean SD or as median (25th to 75th percentile). Differences between
independent groups were assessed using Student t test, Mann–Whitney U test, analysis of
variance, and Kruskal-Wallis test, depending on the distribution of the analyzed variable.
Pearson and Spearman rank correlation coefficients were calculated accordingly. KaplanMeier
survival curves are presented, and significance levels according to survival between groups
were calculated using log-rank test. Age and the diagnosis of any cardiovascular disorder were
used as potential confounders for mortality in multiple logistic regression analyses together
with SGA and MNA and other possible independent predictors for mortality as identified using
univariate logistic regression analyses. The study conformed to the Helsinki declaration and
was approved by the local Ethics Committee. Before entry, all patients gave their informed
consent. In subjects who had cognitive dysfunction, consent was sought from relatives

Result
: The MNA was able to detect greater numbers of malnourished subjects when compared to the
SGA. This finding was consistent across Day 0, 30 and 60 and statistically significant (p<0.05)
at all time periods

Overall 43 subjects were assessed at baseline using each tool. Table 1 describes the subjects’
characteristics at the three time points. There was no statistical difference in the variables at
each of the three time points measured.

Reasons for the dropout included subjects withdrawal from the study, subjects uncontactable for follow
up, subjects on holiday over the follow up period, difficulty with time/resource constraints for dietitians
to follow up some subjects who required home visits. Graphs (Figure 1,2 and 3) illustrate the nutritional
status as detected by the SGA and MNA over the 60-day time period. There was not a significant
difference between the numbers identified as undernourished (i.e. at risk and malnourished) with each
tool. The significance however, lies in the degree of malnutrition detected, with the MNA identifying a
greater proportion of malnourished subjects consistently across the time intervals, compared to the
SGA.
The advantage of SGA is its clinical utility. It is simple, quick, inexpensive, and has been widely accepted
as a criterion to validate new tools developed for nutritional screening and assessment. Most interestingly,
SGA was recognized as a nutritional screening tool used to increase the Diagnosis Related Group based
health care reimbursement in Europe and the coding of malnutrition on a casemix-based hospital funding
system in Singapore . However, in addition to the need for on going training and practice to maintain the
high accuracy of malnutrition diagnosis by SGA , this subjective assessment tool lacks responsiveness to
change to detect the changes in nutritional status following intervention. This disadvantage may limit its
use in clinical practice to measure the effect of malnutrition treatment and it may reduce its selection for
use as an outcome measure in future nutritional studies.

It may be concluded that objective nutritional assessment, including body composition measurements,
and the ability to predict long-term mortality support the use of SGA, MNA, and short MNA as nutrition
assessment instruments in geriatric patient care. Whether patients identified using these techniques as
malnourished or at risk for PEM will benefit from nutritional intervention needs to be addressed in future
trials.

Limitations of MNA and SGA

A critical review of the clinical measurement properties of three malnutrition assessment tools
for use with patients in hospitals was performed. A total of 34 studies were eligible for review, of
which 18 were rated to have an acceptable quality of clinical measurement study design. The
reliability and validity of all three tools: SGA, MNA, and PG-SGA were assessed; all of them
were easy to use, non-invasive, and cost-effective for assessing the malnutrition status of
patients. MNA was the most validated for a variety of measurement properties, whereas SGA
was the least studied tool in the last 20 years. Both MNA and PG-SGA possess acceptable test-
retest reliability and internal consistency; moreover, PG-SGA had excellent diagnostic accuracy
for the identification of malnutrition in various patient populations, and one study that properly
examined the responsiveness to change of the MNA tool (MDC = 2.1) was identified. None of
the three tools showed a consistently strong correlation with other nutritional parameters and
health adverse outcomes, and the inter-rater reliability for both SGA and PG-SGA was not
consistently acceptable among the studies identified in this review. Because of the lack of a gold
standard to define malnutrition, this review did not find sufficient evidence to suggest the
criterion (concurrent) validity for these studied tools; however, region-specific malnutrition
criteria selected to identify coding of malnutrition in inpatients which informs hospital
reimbursement funding may be used as a benchmark in such circumstances to validate the tool
use. A future study using sound methodological quality is needed to evaluate the responsiveness
to change of these malnutrition assessment tools for the detection of a change in nutritional
status.

Discussion

The literature cites rates of malnutrition amongst hospitalized older persons as ranging from 20
to 60% (16,24). Similar to the rates identified in this study. The rates of malnutrition and those
at risk of malnutrition identified in this study using the modified MNA reflect similar rates to
those found in other MNA studies. The major finding from this study is that the modified
MNA detected greater numbers of malnourished subjects when compared to the SGA. This
finding was consistent across the three time intervals measured and was statistically significant
(see table 2).
This finding supports the claim by other authors that the SGA cannot be used to monitor
changes in nutritional status because of its subjectivity and non-quantitative data analysis,
whereas the quantitative nature of the MNA allows for easier monitoring of nutritional changes
over time. Other studies using the SGA for nutritional assessment of the older person have
found discrepancies in the detection of malnutrition. This may be explained in part by the
lower inter-rater agreement found with the SGA when used with older patients. The MNA
however, has been found to have good inter-rater reproducibility. One of the advantages of the
MNA for dietitians is that it does not rely on additional measurements that may be difficult for
dietitians to access- such as blood tests. It is a tool that is sensitive enough to detect the small
changes in nutritional status that may occur over time with nutritional support. Further work is
needed to determine the extent to which the MNA can be used as a detector of nutritional
change over time. Questions such as, “At what time interval should a patient have a repeat
nutritional assessment performed to most accurately detect altered nutritional status?” need to
be investigated. Vellas suggests that monthly weight measurements and a repeat MNA at 3
months is an important follow up for nutritionally compromised older patients. A nutrition
intervention study conducted in Nursing Homes in France demonstrated changes in MNA
score at day 60 following oral supplementation. It is also interesting to note that the average
BMI of this study population was 24.5 (within the normal standard range of 22-27). The MNA
(at a score between 17 and 23.5) has demonstrated an ability to assess declining i.e. “at risk”
nutritional status before severe changes in weight (or albumin levels) occurs.
Future Directions for Clinical Practice
The ability of the modified MNA to more accurately identify malnourished older patients
compared to the SGA as demonstrated by these study findings has important implications for
dietetic practice and care of this group. Nutrition intervention is said to be easier and more
effective when implemented in those identified as at risk of malnutrition than in those who are
severely malnourished . Further investigation is warranted to determine if changes in current
dietetic practices, such as more aggressive intervention in nutritional support, are necessary. The
screening component (MNA-SF) could be easily administered by nursing/medical staff on
admission to hospital, with those identified as at risk of malnutrition (MNA screening score 11
points or below) being referred to the dietitian for further assessment and appropriate nutrition
intervention. This would increase staff awareness of the prevalence of malnutrition amongst
older patients and would also allow dietitians to spend more of their clinical time in nutrition
assessment, intervention and follow up of these patients.

Conclusion

This study has shown the MNA to be a more appropriate nutrition assessment tool for older
patients when compared to the SGA. The MNA is better able to identify severely malnourished
patients. This study illustrated the potential use of the MNA as an ongoing monitor of
nutritional status and hence a measure of the impact of nutrition intervention.

In this study, the modified MNA has proved to be a more appropriate nutrition assessment tool
than the SGA in hospitalised older patients. It is better able to identify malnourished patients.
This could potentially impact on dietetic practice, as more aggressive nutritive therapy may be
necessary to improve nutritional outcomes within this patient group.

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