ESPEN LLL Course

Topic 6 Malnutrition in the Community

Screening and Assessment

Module 6.2

Prof. em Rémy Meier MD

University Basel
AMB Gastro- and Nutrition Center
Basel, Switzerland

09.11.2022
 Screening and
Assessment

ESPEN Malnutrition Awareness Week

2022

Prof. em Rémy Meier MD

University Basel
AMB Gastro- and Nutrition Center
Basel, Switzerland

10.2022
Nutritional deficiencies and
malnutrition are a significant
problem in clinical practice.
 Background

• For selecting the patients at risk for

malnutrition it is important to have tools
to define the patients which will benefit
from a nutritional intervention plan
• The process starts with a defined
screening and assessment programme
for making the diagonsis of malnutrition
GLIM consensus paper on
definition of malnutrition
Step 1. Risk screening by a validated screening tool, e.g. NRS2002,
MUST, MNA(SF),
Step 2. Assessement for diagnosis and grading severity

Phenotypic criteria Etiologic criteria

Weight Low BMI Reduced Reduced food Inflammati
loss muscle intake or on
mass assimilation
>5% within past 6 <20 if <70 years, or Reduced by ≤50% of ER >1 week, or any Acute disease/injury or
months, or <22 if >70 years validated body reduction for >2 weeks, or any chronic disease-related
>10% beyond 6 months composition chronic GI condition that
Asia: measuring adversely impacts food
<18.5 if <70 years, or techniques assimilation or absorption
<20 if >70 years

Diagnosis of Malnutrition:
At least 1 phenotypic criterion + 1 etiologic criterion
Cederholm, Clin Nutr 2019, Jensen, JPEN 2019
Diagnosis of
malnutrition by GLIM

Step 1. Risk screening

Step 2. Assessement for

diagnosis
Nutritional screening

Is a tool to rapidly and simply

evaluate whether the patient is at risk
to be or to become malnourished.
Nutritional screening

History:
• Weight loss over time
• Anorexia, nausea
• Food intake
First measurements:
• Body weigth
• Height
BMI (kg/m2)
 GLIM consensus paper on
definition of malnutrition
Step 1. Risk screening by a validated screening tool, e.g. NRS2002,
MUST, MNA(SF),
Step 2. Assessement for diagnosis and grading severity

Phenotypic criteria Etiologic criteria

Weight Low BMI Reduced Reduced food Inflammati
loss muscle intake or on
mass assimilation
>5% within past 6 <20 if <70 years, or Reduced by ≤50% of ER >1 week, or any Acute disease/injury or
months, or <22 if >70 years validated body reduction for >2 weeks, or any chronic disease-related
>10% beyond 6 months composition chronic GI condition that
Asia: measuring adversely impacts food
<18.5 if <70 years, or techniques assimilation or absorption
<20 if >70 years

Diagnosis of Malnutrition:
At least 1 phenotypic criterion + 1 etiologic criterion
Cederholm, Clin Nutr 2019, Jensen, JPEN 2019
True Screening tools

• Malnutrition Universal

ESPEN
Screening Tool (MUST) (1)
• Nutritional Risk Screening
(NRS 2002) (2)

(1) BAPEN: Ferguson et al, Nutrition 1999

(2) Kondrup et al, Clin Nutr 2003

Its main disadvantage is that the recent food intake is not included,
Ferguson et al, Nutrition 1999
Nutritional Risk
Screening (NRS-2002)
Answer
• Is BMI < 20.5? Yes No
• Has the patient lost weight during
the last 3 months? Yes No
• Is the dietary intake reduced in
the last week? Yes No
• Is the patient severely ill ? (e.g. ICU) Yes No

→ If „No“ to all questions, re-screened at weekly

intervals.
→ If „Yes“ to any question, the final screening is
performed.
Kondrup et al, Clin Nutr 2003
Nutritional Risk Screening
(NRS-2002) Final Screening
(Risk of Malnutrition)
Absent Score 0 Normal nutritional status
Mild Score 1 Wt loss >5% in 3 months
or
Food intake below 50-75% normal requirement in preceding week
Moderate Score 2 Wt loss >5% in 2 months
or
BMI 18.5 – 20.5 + impaired general condition
or
Food intake below 25-50% normal requirement in preceding week
Severe Score 3 Wt loss >5% in 1 mo (>15% in 3 mo)
or
BMI <18.5 + impaired general condition
or
Food intake below 0-25% normal requirement in preceding week
Kondrup et al, Clin Nutr 2003
Nutritional Risk Screening
(NRS-2002) Final Screening
(Severity of disease)

Absent Score 0 Normal nutritional requirements

Mild Score 1 Hip fracture, chronic patients in
particular with acute complications,
cirrhosis, COPD, chronic hemodialysis,
diabetes, oncology
Moderate Score 2 Major abdominal surgery, stroke.
severe pneumonia,
hematologic malignancy
Severe Score 3 Head injury, bone marrow
transplantation, Intensive care patients
(APACHE>10).
Kondrup et al, Clin Nutr 2003
Nutritional risk screening
ESPEN – NRS 2002

• Impaired nutritional status

Weight loss % over time, food intake,
BMI (Score 0-3)
• Severity of disease
Mild to severe (Score 0-3)
• Age over 70 years: add 1 point

If the total score is 3 or more nutritional

support is indicated

Kondrup et al, Clin Nutr 2003

NRS 2002:
4 question and outcome

• The 4 initial questions of the NRS

2002 robustly identify nutritional risk
and are strong predictors of
morbidity and mortality in
hospitalised patients

• These 4 questions are robust

indicators for subsequent poor
outcomes

Tangvik et al, Clin Nutr, 2014

Screening and partial
assessment tools

• MNA (elderly)
• Subjective global assessment (SGA)

Rubenstein et al, J Gerontol 2001

Detsky et al, JPEN, 1984
MNA® Screening Form
(MNA-SF)
1. Has appetite & food intake
declined in past 3 months?
2. Weight loss in past 3 months?
3. Mobility problems?
4. Acute illness or major stress in
last 3 months?
5. Neuropsychological problems:
Dementia or depression?
6. Body mass index
(BMI) (kg/m2)?
If you can not use BMI you can use
the calf circumference (<31cm)!
Rubenstein et al, J Gerontol 2001
Nutritional risk screening
Subjective global assessment
(SGA)

I Patient‘s history
(weight loss, change in dietary intake,
gi-symptoms, functional capacity)
II Physical examination
(muscles, subcutaneous fat, edema, ascites)

Clinician‘s overall judgement

• good nutritional status
• moderate malnutrition
• severe malnutrition

Detsky et al, JPEN, 1984

 Assessment of
Nutritional status

1. Screening

2. Assessment
Nutritional Assessment

Steps to be taken:
• Measure body composition
(body cell mass)
• Measure or evaluate inflammatory activity
and disease activity
• Measure function:
– Muscle strength
– Cognitive function
(mood, concentration, memory etc)
– Immune function
 GLIM consensus paper on
definition of malnutrition
Step 1. Risk screening by a validated screening tool, e.g. NRS2002,
MUST, MNA(SF),
Step 2. Assessement for diagnosis and grading severity
Phenotypic criteria Etiologic criteria
Weight Low BMI Reduced Reduced food Inflammati
loss muscle intake or on
mass assimilation
>5% within past 6 <20 if <70 years, or Reduced by ≤50% of ER >1 week, or any Acute disease/injury or
months, or <22 if >70 years validated body reduction for >2 weeks, or any chronic disease-related
>10% beyond 6 months composition chronic GI condition that
Asia: measuring adversely impacts food
<18.5 if <70 years, or techniques assimilation or absorption
<20 if >70 years

Diagnosis of Malnutrition:
At least 1 phenotypic criterion + 1 etiologic criterion
Cederholm, Clin Nutr 2019, Jensen, JPEN 2019
Muscle mass assessment
• BIA • Calf circumference

• DXA • Mid-upper arm

No circumference
• CT/MRI
• Physical exam
• US

Low muscle mass identified

Evaluation of muscle strengtand function

Compher et al, JEPEN 2022
Function

• Muscle-Strength

• Mobility
CS
Muscle strength
Muscle strength

• Is a good predictor of outcome:

– In chronic situations:
• Aging
• Organ failure (renal failure, COPD,
heart failure….

– In acute situations:
• Surgery or trauma
• Second hit (superimposed infection
when already subject to inflammatory
activity)
Handgrip strength
and outcome

Lower handgrip strength at hospital

Admission is associated with:
- Longer hospitalisation time
- No difference in men and women
- No difference in surgical and medical
patients

Mendes et al, JPEN 2014

Laboratory testing

Is useful for acute disease/injury

or chronic disease-related conditions
for
• Assessment of inflammation and severity of
disease
- CRP (sensitive but not specific)
- Hb (sensitive but not specific)
- Albumin (sensitive, specific and
quantitative)
- Lymphocytes (sensitive, specific but not
quantitative)
Limitations of serum
proteins
• These proteins are manufactured by
the liver; hepatic insufficiency may
affect their production (not true in
stable cirrhosis)
• Serum concentrations of visceral
proteins decline due to disease
related increases in distribution space
(eg. ECW/EVS) and possibly due to
increased breakdown independent of
nutritional status
Infectious complications
and albumin

Kudsk et al, JPEN 2003

Serum albumin reflects
disease severity and is a
good predictor of outcome
but is not a very good
indicator of nutritional status
Measurement
immune function

• Lymphopenia and DHR are not good

parameters for the nutritional
assessment

• They are not recommended to be

assessed, because the data are very
controversial
Measurement
cognitive function
• To be developed
• No consensus
• No easy method
• Clinical impression
• Quality of life determined by:
– Muscle function
– Immune function
– Cognitive function
GLIM consensus paper on
definition of malnutrition
Step 1. Risk screening by a validated screening tool, e.g. NRS2002,
MUST, MNA(SF),
Step 2. Assessement for diagnosis and grading severity

Phenotypic criteria Etiologic criteria

Weight Low BMI Reduced Reduced food Inflammati
loss muscle intake or on
mass assimilation
>5% within past 6 <20 if <70 years, or Reduced by ≤50% of ER >1 week, or any Acute disease/injury or
months, or <22 if >70 years validated body reduction for >2 weeks, or any chronic disease-related
>10% beyond 6 months composition chronic GI condition that
Asia: measuring adversely impacts food
<18.5 if <70 years, or techniques assimilation or absorption
<20 if >70 years

Diagnosis of Malnutrition:
At least 1 phenotypic criterion + 1 etiologic criterion
Cederholm, Clin Nutr 2019, Jensen, JPEN 2019
 Severity
Phenotypic Criteria
Weight loss (%) Low body mass Reduced muscle mass
index (kg/m2)

Stage 1 5-10% within <20 if <70 yr, Mild to moderate deficit

(per validated
Moderate past 6 mo, or <22 if ≥70 yr assessment methods)
Malnutrition 10-20%
(Requires 1 beyond 6 mo
phenotypic
criterion that
meets this
grade)

Stage 2 >10% within <18.5 if <70 yr, Severe deficit (per

validated assessment
Severe past 6 mo, or <20 if ≥70 yr methods)
Malnutrition >20% beyond
(Requires 1 6 mo
phenotypic
criterion that
meets this
grade)
Conclusion
• For screening consensus has been reached
regarding stepwise evaluation of the risk to become
or to be malnourished
• Assessment of nutritional state consists of three
defined steps:
– Measurement of body composition
(fat free mass/body cell mass)
– Assessment of inflammatory activity
– Measurement of function
• Muscle force
• (Immune function)
• (Cognitive function)
• Treatment should be targeted to treat the specific
risk problem of the patient
– Nutrition
– Inflammation
– Training of muscle function