SCREENING

0025-7125/99 $8.00

+ .OO

NUTRITION SCREENING
AND ASSESSMENT
Donald D. Hensrud, MD, MPH

Nutrition can influence the risk for a wide variety of diseases, and,
conversely, malnutrition can result from illness. Nutrition affects various
factors that predispose to medical illness, including immune function,
body composition, and micronutrient status. The three leading causes of
death are related to nutrition: heart disease, cancer, and cerebrovascular
disease.62Nutrition can affect functional status and the ability to carry
out activities of daily living as well as the quality and enjoyment of life.
Identifying abnormalities in nutritional status, mainly deficiencies or in
some cases excesses, through screening is important to decrease morbidity and mortality in the screened population. This article first describes
the types and prevalence estimates of malnutrition. Following this, the
goals of nutrition screening are outlined. Screening and nutrition assessment tools and methods are then covered for ambulatory and hospital
populations. Finally, detailed nutrition assessment is discussed.
Health status can be thought of on a continuous scale ranging from
optimal health on one end to clinical disease on the other, and nutritional
factors can move people either way along this continuum. Nutritional
health promotion activities usually operate on one end of this scale in
such a way so as to move people farther toward optimal health. Nutrition screening has historically been concerned with the other end of the
scale, identifying patients at high risk so that they can then undergo
further nutrition assessment in hopes of preventing or treating clinical
disease. Nutrition screening could also be applied in the context of
health promotion, however. In primary care, for example, it can and
should be part of other health promotion activities.
From the Divisions of Preventive Medicine, Endocrinology & Metabolism, and Internal
Medicine, Mayo Medical School and Mayo Clinic, Rochester, Minnesota

MEDICAL CLINICS OF NORTH AMERICA

VOLUME 83 NUMBER 6 NOVEMBER 1999

1525

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HENSRUD

Nutrition screening is the process of identifying patients at high

nutritional risk so that more extensive nutrition assessment can be performed. Nutrition assessment is a more detailed evaluation and interpretation of multiple parameters and seeks to define the risk of developing
nutrition-related medical complications. It can also be used to monitor
the course of nutritional therapy. Thus, nutrition screening is a brief
evaluation to identify a subset of people at high risk, whereas nutrition
assessment is a more complex process applied to this subset to delineate
further their nutrition status. The distinction between screening and
assessment can be blurred, however. The ultimate goal of both of these
activities is to identify factors in individuals that can be altered through
nutritional support to improve outcome in the screened population.
Because nutrition screening and assessment are inextricably linked, this
overview addresses both of these processes. Nutrition screening may
also influence case finding in clinical practice. For example, a history of
recent weight loss and evidence of malnutrition along with other signs
and symptoms may prompt medical evaluation to search for possible
causes, such as cancer or other conditions.
Another way of influencing nutritional status in a positive manner
is the public health approach, in which education and other efforts are
targeted at all members of the population rather than screening for highrisk individuals. An example is the National Cancer Institutes Five-ADay program, which encourages people to consume at least five servings
of fruits and vegetables per day to decrease the risk of cancer.31The
advantage of the public health approach is targeting and, it is hoped,
influencing most of the population, and therefore it is best used in
situations in which the entire population can potentially benefit, such as
in increasing fruit and vegetable consumption. This approach, however,
would not identify or help high-risk individuals with specific nutritional
problems. For this reason, the public health approach and the screening
approach should be viewed as complementary.
Nutrition screening can be applied to different populations. The
very old are at high risk of nutritional problems. The number of elderly
people in the United States has been increasing and will continue to
increase in the coming years, which will, in turn, increase the number
of people at risk for nutritional problems. Nutrition screening can be
used in the home, ambulatory, institutional, or hospital settings. Nutrition risk and the effectiveness of nutrition screening vary by setting.
Hospitalized patients are at highest risk, and the Joint Commission on
Accreditation of Healthcare Organizations requires nutrition screening
for all patients admitted to the hospital.41The tool and questions used
for screening depend on the characteristics of the population screened
and the goals of the screening program.

TYPES OF MALNUTRITION

Marasmus, commonly known as starvation or severe cachexia, is due

to decreased energy intake relative to energy expenditure and usually

NUTRITION SCREENING AND ASSESSMENT

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develops over a long period of time, often months or longer depending

on energy reserves and the amount of intake. Marasmus can be due to
low energy intake as a primary disorder, or low energy intake can be
secondary to medical illness, such as cancer or chronic renal, liver, or
cardiac (cardiac cachexia) disease. Initially the body attempts to adapt
to decreased energy intake through a number of mechanisms with the
goal of maintaining survival. As the process continues, fuel stores are
depleted, and the individual develops a characteristic wasted appearance. The hallmarks of marasmus are reduced fat and lean tissue stores.
Albumin concentration, immune response, and wound healing are
largely preserved, unless another illness supervenes. Objective criteria
to diagnose marasmus can be based on body mass index (BMI) (BMI weight in kg + height in m2), triceps skinfold thickness, and midarm
muscle circumference. A BMI less than 18.5 is considered ~nderweight.~
For someone 510 tall, underweight would correspond to a weight of
129 lb or less. A triceps skinfold thickness of 3 mm and less or a midarm
muscle circumference of 15 cm or less is consistent with severe depletion
of fat and lean tissue stores.32
Kwashiorkor, sometimes known as hypoalbuminemic malnutrition, develops in the setting of acute illness, such as burns, head injury, severe
trauma, or sepsis. It results from the metabolic response to inflammation
or injury and is mediated by hormones and mono kine^.^^ Kwashiorkor
can develop much more quickly than marasmus, in weeks without
adequate nutritional support. The appearance of patients with kwashiorkor can be deceptive. In contrast to patients with marasmus, they may be
normal weight or even overweight and may not appear malnourished.
Physical signs include edema; easy hair pluckability; and skin breakdown, such as decubiti ulcers or poor wound healing. Laboratory testing
may reveal a low serum albumin; altered trace minerals (decreased
serum iron and zinc and elevated serum copper); and elevated blood
glucose, white blood cell count, urine nitrogen, and serum ferritin or
other acute-phase reactants. Appropriate nutritional treatment in this
setting can help support the individual, but the metabolic state does not
normalize until the illness or injury resolves.
Alterations in micronutrient status are another form of malnutrition
and can be diagnosed by characteristic physical findings and abnormal
laboratory tests in a clinical setting that allows these deficiencies to
develop. Patients who have evidence of marasmus or kwashiorkor are
at increased risk for micronutrient deficiencies.
Historically, nutrition screening has been associated primarily with
deficiencies. In the United States, however, nutritional excesses, both
macronutrient (fat, carbohydrate, protein) and micronutrient (vitamins,
minerals, trace elements), are also important and can contribute to increased morbidity and mortality. Obesity and problems resulting from
dietary supplements are examples.
Overweight is classified as a BMI 25 kg/m2 or greater, and obesity is
classified as a BMI 30 kg/m2 or greater.5 Obesity is associated with an
increased risk for hypertension, diabetes mellitus, dyslipidemia (high

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triglycerides and low high-density lipoprotein cholesterol), certain cancers, cardiovascular disease, gallbladder disease, degenerative arthritis,
respiratory problems including obstructive sleep apnea, and increased
mortality as the degree of obesity increases.34Upper body or abdominal
obesity compared with lower body or peripheral obesity is associated
with insulin resistance and many of these same health risks.64In upper
body obesity, these health risks often appear together in the syndrome
of glucose intolerance, elevated blood pressure, dyslipidemia, and increased risk for cardiovascular disease. In addition, upper body obesity
appears to increase the risk of certain cancers, such as breast and endometrial cancer, and also overall mortality.8,25, 71 The relationships between
upper body obesity and health risks appear to be independent of the
degree of obesity. A waist-to-hip ratio of 1.0 or greater in men and 0.85
or greater in women has been suggested as a cut-off above which health
risks increase, although in reality risk probably rises continuously with
increasing degree of upper body obesity. More recently, the waist measurement alone has correlated just as well with health risks as the waistto-hip ratio.83The National Institutes of Health consensus guidelines
classify a waist measurement of greater than 35 inches in women and
40 inches in men as a marker for increased health
Dietary supplements include vitamins, minerals, herbs, amino acids,
and other substances. Testing for safety or efficacy of dietary supplements before marketing is not required by the Dietary Supplement
Health and Education Act of 1994. Therefore, the potential for adverse
reactions exists. For example, L-tryptophan supplements were linked to
more than 1300 cases of eosinophilia-myalgia syndrome, including at
least 36 deaths in the late 1980s., 77 Another example is ephedra, which
has been linked to more than 800 adverse events, including many deaths.
Limits on the dose of ephedra have been
Interactions with
prescription and nonprescription medications can also occur.57For these
reasons, determination of the use of dietary supplements should be part
of nutrition assessment.
Certain factors predispose to malnutrition and can be divided into
general categories (Table 1). Preexisting disease can affect nutritional
status through a number of different mechanisms. Medications can also
affect nutritional statush6For example, prednisone and tricyclic antidepressants can predispose to weight gain, and isoniazid can predispose
to pyridoxine (vitamin Bh) deficiency. Age can have a large effect on
nutritional status, with the very old at greatest risk. Nutritional status is
affected by certain health habits. Alcohol can affect the absorption,
metabolism, and excretion of many different vitamins and minerals and
is one of the leading causes of malnutrition in the developed world.22
Smokers have been found to have lower levels of vitamin C, selenium,
and carotenoids, which may influence the risk of diseases associated
with smoking.3sSocial factors can also be important. Low income and
social isolation are important factors related to the adequacy of the
diet.lh,

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Table 1. CATEGORIES AND CONDITIONS THAT PREDISPOSE TO MALNUTRITION

Decreased intake
Anorexia nervosa
Restrictive diets
Illness
Alcohol abuse
Availability of food and other social factors
Decreased absorption
Malabsorption from inflammatory bowel disease and other causes of diarrhea
Parasites
Drugs, including laxatives, alcohol, antacids
Surgical resection of part of the gastrointestinal tract
Pernicious anemia
Decreased utilization
Drug-nutrient interactions
Genetic conditions
Increased losses
Fistulas, wounds
Alcohol abuse
Blood loss
Hemodialysis
Diarrhea
Nephrotic syndrome
Increased requirements
Pregnancy, lactation, growth
Severe illness, including bums, closed head injury, trauma, sepsis
Fever
Hyperthyroidism
Strenuous physical activity

PREVALENCE OF MALNUTRITION

The prevalence of malnutrition depends on the definition used and

the characteristics of the population under study. Parameters used to
classify malnutrition include body weight or BMI; dietary intake of
macronutrients and micronutrients as a percentage of the Recommended
Dietary Allowance (RDA); and anthropometric data, such as skinfold
thickness and midarm muscle circumference. Population studies looking
at dietary intake data and comparing it to the RDA need to be interpreted carefully. If an intake of a nutrient is below the RDA, it does not
necessarily indicate malnutrition, but it does increase the likelihood
of such.
Estimates vary, but 1%to 15% of free-living elderly have evidence of
I*,
51, ** Data from the Third National Health and Nutrition
maln~trition.'~,
Examination Survey (NHANES 111) indicated that 4.1YO of the population
sometimes or often does not get enough food to eat.'
Surveys of hospitalized and institutionalized patients have shown
much higher prevalence estimates of malnutrition than in ambulatory
populations. Studies dating back to the early 1970s reported malnutrition
in approximately 30% to 50% of medical'2, 85 and surgical hospital
patients", 37 and the institutionalized elderly.45In some of these surveys,

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nutritional status deteriorated during the ho~pitalization.~~,

85 More recent
surveys have shown similar estimates of malnutrition among hospitalized
although in one of these studies the prevalence did not
increase during the hospitalization,61possibly suggesting that nutritional
support was provided. Malnutrition has been correlated with longer
hospital stays, nutrition-related complications, increased mortality during and after hospitalization, and other adverse outcome^.'^, 20, 74-77, 82* 85
In studies evaluating the relationship between malnutrition and outcome, however, it is difficult to separate the effects of underlying disease
from the effects of malnutrition per se.84This difficulty is due to the fact
that many of the parameters in the assessment indices used to classify
nutritional status, including signs, symptoms, and laboratory values
such as serum albumin, are linked to both illness and nutritional factors.
The distinction of whether disease or nutrition is primarily responsible
for the adverse effects associated with malnutrition is moot if nutritional
support results in improved outcome.
Based on current classifications, more than half of the adult population or 97 million Americans are overweight (BMI 2-25 kg/m2).5Almost
one in four adult Americans is obese (BMI 2-30 kg/m2). With prevalence
estimates this high along with serious comorbid conditions, obesity
contributes heavily to increased morbidity and mortality in the U.S.
population.
Until the early 1990s, 40% of the population consumed dietary
supplements.'",49, 58, 73 There have been few data from national surveys
in recent years, but sales of dietary supplements have increased from $3
billion in 1992 to $6.5 billion in 1996. These data, along with data from
suggest that supplement use has been increasing.
small
GOALS OF NUTRITION SCREENING AND
SUPPORT-IMPROVED OUTCOME

At a fundamental level, nutrition is necessary for survival. Theoretically, identifying patients at risk for malnutrition through screening and
further assessment should lead to improved outcome after appropriate
intervention. For ambulatory patients, however, the evidence supporting
improved outcome from screening is scarce.68Of the few data that are
available in the ambulatory elderly, one randomized clinical trial in the
frail elderly failed to show benefit from an oral nutritional ~ u p p l e m e n t . ~ ~
Some screening interventions require the patient to initiate contact
and fill out a questionnaire, such as in the case of an elderly patient
seeing a primary care practitioner. This intefvention requires voluntary
participation from the patient, and those at greater risk of malnutrition
may be less likely to see a physician and participate in screening.
Involving primary care physicians in the screening process and making
them aware of patients who declined to participate may prompt a
brief assessment by the physician even without screening information
suggesting the patient is at high risk. When screening for malnutrition

NUTRITION SCREENING AND ASSESSMENT

1531

in any setting, including primary care, an intervention strategy should

be in place. It does little good to identify nutritionally high-risk patients
if there are no interventions to help them. Nutrition counseling could be
one part of the intervention in primary care. Most physicians, however,
have not had formal education and training in nutrition and may not
feel adequately prepared to counsel patients in this area. Involving
dietitians and other health care personnel can help with this function.
Despite the lack of evidence, screening for risk factors associated
with malnutrition may cost little and potentially have beneficial effects
if done in the context of other medical care. More information is needed
on the effectiveness of nutrition screening in the ambulatory population,
particularly the elderly.
As stated previously, hospitalized patients classified as malnourished experience increased rates of nutrition-related complications and
poorer outcomes. Some groups of patients have experienced improved
56, 60,
Routine
outcome and less complications with nutritional
use of postoperative nutrition without preoperative nutrition, however,
may increase complications by up to
possibly because the complications of parenteral nutrition, such as infections, outweigh any benefits
in adequately nourished subjects. Consistent with this, the Veterans
Affairs Cooperative Study showed the benefit from perioperative nutrition was confined to those who were severely malnourished as defined
by the Nutrition Risk Index or Subjective Global Assessment.81Subjects
with borderline or mild malnutrition had a worse outcome because of
infectious complications. In another study, the Prognostic Nutrition Index was used to identify patients at high risk, who then received parenteral nutrition. These patients had fewer complications and decreased
mortality compared with a control group.60Therefore, it appears that in
hospitalized patients, nutrition assessment indices can identify patients
at high risk of complications, and nutritional support can be beneficial
in improving outcome in high-risk patients, regardless of the underlying
predisposing conditions or mechanisms. In the institutionalized population, elderly residents in nursing homes who were provided nutrition
supplements experienced improvements in nutritional parameter^.^^ Further studies are required to evaluate the impact of screening programs
in this setting.
SCREENING TOOLS AND METHODS

Screening for malnutrition should meet the criteria outlined in the

article by Nielson and Lang. There should be a relatively high prevalence
o j disease, a suitable screening test, and an effective treatment and a
treatment for screen-detected disease that is more effective than treatment for symptom-detected disease. The screening instrument should
also meet criteria for validity, reliability, sensitivity, specificity, and positive predictive value. There are few brief screening tools that fit all
the criteria, and there is overlap between screening and the nutrition

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HENSRUD

assessment tools. The specific instrument used depends on the setting

and the population screened.
Ambulatory Population

The Nutrition Screening Initiative (NSI)was developed as a partnership among representatives of government, professional organizations,
and private
As part of its goals, a self-assessment checklist,
DETERMINE Your Nutritional Health, was developed to use as a screening tool in the ambulatory, elderly population (Table 2).78This checklist
takes only a few minutes to complete and briefly assesses different areas
that can affect nutritional status, including medications, alcohol use,
illness, and physical or social impairment. Six or more points on this
checklist indicate a high risk for nutritional problems and should prompt
further investigation and evaluation of nutritional status and related
factors. Also developed by the NSI are the level 1 and 2 screening
questionnaires. These tools can be used by health care professionals to
delineate nutritional status further. They include questions on items
known to be associated with nutritional status, such as weight, dietary
intake, living environment, and functional status. The level 1 screen can
be completed by a social service or health care professional. The level 2
screen can be filled out after referral to a physician or qualified health

Table 2. NUTRITION SCREENING INITIATIVE CHECKLIST FOR NUTRITIONAL RISK

Yes
I have an illness or condition that made me change the kmd and/or amount of
food I eat.
I eat fewer than 2 meals per day.
I eat few fruits or vegetables or milk products.
I have 3 or more drinks of beer, liquor, or wine almost every day
I have tooth or mouth problems that make it hard for me to eat.
I do not always have enough money to buy the food I need.
I eat alone most of the time.
I take 3 or more different prescribed or over-the-counter drugs a day.
Without wanting to, I have lost or gained 10 lb in the last 6 months.
I am not always physically able to shop, cook, or feed myself.

2
3

2
2
2
4
1
1

2
2
~

Total
0-2 Good. Recheck your nutritional score in 6 months.
3-5 You are at moderate nutritional risk. See what can be done to improve your eating
habits and lifestyle. Your office on aging, senior nutrition program, senior citizens
center, or health department can help. Recheck your nutritional score in 3 months.
6 or more You are at high nutritional risk. Bring this checklist the next time you see your
doctor, dietitian, or other qualified health or social service professional. Talk with them
about any problems you may have. Ask for help to improve your nutritional health.
Adopted from The Nutrition Screening Initiative: Determine Your Nutritional Health. Washington,
DC, Nutrition Screening Initiative, 1992; with permission.

NUTRITION SCREENING AND ASSESSMENT

1533

care professional and includes additional questions on laboratory and

anthropometric data, medication use, and depression.
The NSI checklist was able to predict nutrition-related complications
In addition to screening, it
in retrospective&,70 and prospective
may also provide education and increased awareness of nutrition issues
among the elderly.70The NSI materials have been distributed widely,
but formal evaluation of the effect of the program has not been completed. Some have criticized the NSI checklist as not having gone
through appropriate testing and evaluation before widespread implementation to make sure it meets the criteria for screening and is efficacious.68The purpose of the checklist, however, is as an initial screen and
educational tool that can lead to more extensive nutrition assessment, if
indicated.86There is little risk, and it takes little time to complete.
When seeing patients in an ambulatory clinical setting, brief nutrition screening can be part of a periodic examination. Particular attention
should be given to weight and weight changes. Medical illnesses that
affect nutritional status should be noted. As a brief dietary screen, the
clinician can ask about usual intake during meals and snacks (e.g., what
do you eat in a typical day for breakfast, lunch, dinner, and snacks?).
Although validity of inquiring about diet habits in this manner may be
questionable, it provides a quick snapshot into a patients dietary habits
that can be obtained in a brief amount of time. This information can
then be used to provide nutritional health promotion advice. If any
clinically significant problems are encountered, more detailed nutrition
assessment can be performed.
Screening for obesity is straightforward. Using the new classification
scheme and guidelines from the National Institutes of Health, all that is
required is height and weight to determine BMI. Waist measurement
should be obtained because upper body obesity confers additional health
risks, which may influence the aggressiveness of nutrition interventions.
Further assessment and treatment are dictated by initial classification.
Dietary supplement use can be screened for in a medical encounter
at the same time medications are assessed. This screening can be done
using a written questionnaire. To assess dietary supplement use adequately, however, patients should be asked directly what supplements
they take because substantial underreporting may occur using a written
q~estionnaire.~~
There are other areas related to nutrition in which screening in the
general population may be prudent. Of the elderly, 15% may have
For this reason, checking serum vitamin B,,
vitamin B,, defi~iency.~~
concentrations periodically and, if necessary, methylmalonic acid after
the age of 60 may be prudent. Dietary intervention is part of first-line
treatment for hypertension and hyperlipidemia, conditions in which
national detection and treatment programs exist. Further details regarding these programs and their nutritional components can be found
elsewhere.3,

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Hospitalized Population

Nutrition screening for hospitalized patients is required within 24

hours of admission by the Joint Commission on Accreditation of Healthcare organization^.^^ Nurses, dietitians, or other personnel can perform
this screen. Because of the number of patients hospitalized and shorter
hospital stays, this screen needs to be brief. One way to do this is to
focus the screen on main areas (e.g., recent weight loss, ability to consume adequate oral dietary intake, and the presence of any disease
process or other factor that is likely to affect nutritional intake during
the hospitalization). If there is concern in any of these areas, the patient
can then be referred for more detailed nutrition assessment.
NUTRITION ASSESSMENT TOOLS
Ambulatory Population

The Mini Nutritional Assessment (MNA) is an 18-item checklist

targeted for the frail elderly and organized in four main areas: diet
intake, anthropometrics, general assessment, and self (patient) assessment.2yBased on this information, the MNA places patients into one of
three categories: well-nourished (224 points), at risk for malnutrition
(17 to 23 points), or malnourished (516 points). This classification
scheme was validated in different settings using clinical assessment of
nutritional status as the standard. In one setting, 90 of 115 (78%) subjects
were classified
The MNA can be used for screening in some
populations and therefore straddles the line between screening and
assessment.
The Nutritional fisk Index (distinct from the Nutrition Risk Index
discussed later) uses 16 items in five areas to assess nutritional risk.
These items were based, in part, on questions in the NHANES I survey.
Reliability and validity for this tool have been evaluated and were fair.91
Hospitalized Population

Subjective Global Assessment is used primarily by clinicians to

assess nutritional status in hospitalized patients. It uses physical findings
and four areas of the medical history: change in weight over the past 2
weeks and 6 months, change in dietary intake, gastrointestinal symptoms, and functional capacity (Table 3).21This information is used to
classify patients into one of three categories of nutritional status: well
nourished, moderately malnourished, or severely malnourished. This
technique has good interrater agreement2'; has good sensitivity and
specificity7,Iy; and predicts nutrition-related complications in certain populations, including surgical patients, patients with human immunodefi-

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Table 3. FEATURES OF SUBJECTIVE GLOBAL ASSESSMENT

History
1. Weight change and height:
Current height
cm; weight
kg
Overall loss in past 6 mo:
kgr
Yo
Change in past 2 weeks (use
or -):
kg,
Y"
2. Dietary intake change (relative to usual intake) or no change
Duration =
days
Type: Suboptimal solid diet
Hypocaloric liquids
Starvation
Supplement: (circle) nil, vitamin, minerals
3. Gastrointestinal symptoms that persisted for >2 wk
None
Nausea
Vomiting
Diarrhea
Pain At rest On eating
4. Functional capacity
No dysfunction
days
Dysfunction Duration =
Type: Working suboptimally
Ambulatory but not working
Bedridden
Disease and its relation to nutritional requirements
Primary diagnosis:
Metabolic demand (stress)
No stress
Moderate stress
High stress (burns, sepsis, severe trauma)
Physical Status
(for each trait, specify: 0 = normal, 1 = mild deficit, 2 = established deficit)
Loss of subcutaneous fat
Muscle wasting
Edema
Ascites
Mucosal lesions
Cutaneous and hair changes

Strbjective global assessment grade

From Jeejeebhoy KN: Nutritional Assessment. Gastroenterol Clin North Am 27:361, 1998; with
permission.

ciency virus (HIV) or acquired immunodeficiency syndrome (AIDS),and

hospitalized general medical patients.20,38, 61
Another nutritional assessment approach based on physiologic function as well as the history and physical examination has been developed
for use in hospitalized patients, primarily those who are undergoing
surgery.yoThis method uses weight change along with a brief history
and functional evaluation of various systems (respiratory, muscle, skin
integrity) to determine nutritional status. This method was validated in
preoperative patients and predicted postoperative complications primarily in those with evidence of physiologic impairment.8yA brief algorithm

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HENSRUD

to be used along with this assessment method has been developed to

decide if nutritional intervention is likely to be beneficial. In addition to
nutrition assessment, it considers the degree of metabolic stress and
extent of surgery.
Other indices have been derived using multivariate statistical techniques of nutrition and metabolic stress-associated variables whose purpose is to identify hospitalized patients at risk for nutrition-related
complications. The Prognostic Nutritional Index is one such instrument
and uses triceps skinfold measurement, cutaneous delayed hypersensitivity, and serum albumin and transferrin to classify patients into low,
intermediate, and high risk.13It has predicted complications and mortality in hospitalized patients,I3,s9 but the use of delayed hypersensitivity
limits wide-scale clinical use. The Hospital Prognostic Index also uses
serum albumin, transferrin, and delayed hypersensitivity along with
current diagnosis to predict sepsis and mortality.30Many of the variables
in this tool and the Prognostic Nutritional Index may be related more to
the underlying illness rather than nutritional status.
The Nutrition Risk Index (not to be confused with the Nutritional
Risk Index described earlier) was used in the Veterans Administration
Cooperative Study that evaluated the effect of perioperative nutritional
support.H'This index is a simple equation that uses serum albumin and
recent weight loss. Of note, these two variables are associated with two
different types of patients. Serum albumin may be low because of
kwashiorkor-type malnutrition, whereas weight loss may be a result of
a marasmus-promoting process. Regardless of the underlying pathophysiology, however, patients classified as severely malnourished by the
Nutrition Risk Index who were randomly assigned to parenteral nutrition had improved outcome.
DETAILED NUTRITION ASSESSMENT

As in other areas of medicine, nutrition assessment can be approached in an organized fashion through evaluation of the patient's
history, physical examination, and laboratory assessment. Integration
of these components then leads to rational clinical interpretation of
nutritional status.

History
The two main areas of interest in the history are the patient's
medical history and nutritional history. The medical history should be
reviewed for factors that may influence nutritional status, including any
of the factors in Table 1. Elderly patients may have memory problems
that make it difficult to obtain an accurate history. Family members or
previous medical records, if available, can be helpful in this situation to
provide historical information.

NUTRITION SCREENING AND ASSESSMENT

1537

The following items related to weight should be obtained: usual

weight (in the recent past before any weight loss or illness), current
weight, amount and duration of weight loss, and dry weight if applicable. Alterations in fluid status, particularly among critically ill patients,
such as dehydration, edema, and ascites, should be taken into consideration when interpreting weight changes. For example, if a patient recently underwent an operation and received large quantities of intravenous fluid, the dry weight before the operation would be more reflective
of body mass.
A history of weight loss can be one of the most important pieces of
information in the nutrition screening and assessment process. Although
mean weight in the population decreases slightly after age 60,26,27 invol52
untary weight loss is an ominous sign and should be investigated.2R,
Weight loss of more than 5% in 1 month or 10% in 6 months can be
considered clinically significant. Weight loss of more than 10% in 6
months along with physiologic impairment of two organ systems can
lead to major complications, sepsis, and p n e ~ m o n i a To
. ~ ~estimate the
amount of weight loss, it is assumed that usual weight can be recalled
accurately, which may not always be the case.
Determining dietary intake to a detailed degree of precision may be
useful for nutrition assessment of selected individuals in specific situations but has limited use in clinical or population screening because of
the time and complexity in collecting and analyzing this information
using available tools. A 24-hour dietary recall can be obtained relatively
quickly and provides a quick insight into recent diet intake. Recent
intake may not be representative of usual intake, however. Brief dietary
assessment information can be obtained by asking about usual daily
intake as discussed earlier. Other pieces of information in the nutrition
history, such as food intolerances, aversions, and other habits, should be
obtained if relevant.
More detailed dietary assessment can be obtained using a written
food diary, usually for 3 or 7 days, which can be analyzed by a dietitian
using a computer software program. Scannable forms are also available
that require less time on the part of the dietitian. A food frequency
questionnaire estimates the frequency of intake of foods over a period
of time, often a year. They are most useful for analyzing data from
groups of subjects, such as in epidemiologic studies, and have limited
clinical utility. Calorie counts can be helpful in hospitalized patients,
provided that they are complete and accurate.
Pertinent other historical items may be important. A history of
choking when eating or drinking or a history of repeated pneumonias,
particularly in the lower lobes, suggests recurrent aspiration. A bedside
swallowing evaluation can be done for further assessment and, if necessary, a video swallow can be performed. A history of decreased appetite,
nausea, vomiting, or diarrhea can contribute to nutritional status and
may prompt further medical investigation.
Signs and symptoms of other illnesses may affect food intake. This
category may include physical conditions, such as dysphagia resulting

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HENSRUD

from esophageal cancer, or psychiatric conditions, such as depression.

New signs and symptoms should prompt more detailed medical evaluation.
Medications that are used, both prescription and nonprescription,
should be reviewed because they can influence nutritional status in
a number of ways, including drug-nutrient interactions, weight gain,
anorexia, and altered gastrointestinal motility. Alcohol and tobacco use,
past and present, should be determined and quantified.
Social factors can influence nutritional status. Living alone, problems with activities of daily living, low income, lack of transportation,
lack of access to healthy foods, poor sanitation, and lack of a refrigerator
or stove all may contribute to malnutrition, particularly in the elderly.
Physical Examination

General observations of the patient can be useful as a preview to

objective measurements discussed subsequently. This observation can
include brief comments on obesity, body fat distribution, and wasting in
terms of fat and lean tissue reserves. Muscle wasting can often be
observed in the extremities, temples, or interosseous areas.
Body temperature should be measured. Fever can be one manifestation of the metabolic response to injury or illness. Fever raises energy
expenditure up to 13% for each 1C elevation, which may affect nutritional support goals. In hospitalized patients, the presence and location
of drains, feeding tubes, endotracheal tubes, and intravenous lines
should be noted because this may influence nutritional support recommendations.
Detailed physical findings concerning individual micronutrient deficiencies are beyond the scope of this article and can be found in other
reference^.^^ The more common signs relate to the hair, skin, mouth, and
neurologic systems (Table 4).In the right setting (history of weight loss,
alcohol abuse, restricted dietary habits), examination of these areas may

Table 4. COMMON SIGNS OF VITAMIN DEFICIENCIES

Physical Sign

Hair
Corkscrew hairs
Skin
Perifollicular petechiae
Purpura
Mouth and oral cavity
Cheilosis and angular stomatitis
Smooth, red, painful tongue
Neurologic system
Peripheral neuropathy
Ophthalmoplegia, confabulation

Vitamin Deficiency

Vitamin C
Vitamin C
Vitamins C and K
Riboflavin, pyridoxine, niacin
Vitamin B,,, niacin, folate, riboflavin
Thiamine, pyridoxine, vitamin B,,
Thiamine

NUTRITION SCREENING AND ASSESSMENT

1539

reveal signs of vitamin deficiency. As discussed previously, physical

signs of the metabolic response to illness or injury in kwashiorkor that
are sometimes seen in the critical care unit include easy hair pluckability
or hair falling out, edema, and skin breakdown (poor wound healing or
decubiti ulcers).

Anthropometrics
Anthropometrics measures aspects of body composition. Changes
in these parameters take place over a relatively long period of time and
therefore are indicators of long-term nutritional status. Body weight is a
simple and easily obtainable measurement and preferably should be
measured rather than reported. Fluid status should be taken into consideration when interpreting weight. Height should also be measured, and
comparison of actual with ideal body weight from height-weight tables
can be done. If height cannot be obtained because of inability to stand
or amputations, other measures can be used, such as knee height or arm
span. BMI can be calculated from height and weight and has the advantage of greater correlation with body fat and health risks. An accurate
weight or BMI does not reflect the specific compartments of body composition. Individuals may have the same weight or BMI but differ widely
in the percent muscle and fat tissue, which can reflect risk of disease.
Body fat distribution can be estimated by measuring the waist circumference. Measurement of the waist circumference should be obtained at the
level of the iliac crests.80
Triceps and other skinfold thicknesses measure subcutaneous fat
and are an indication of body fat stores. Triceps skinfold can be performed with a skin caliper on the posterior upper arm midway between
the acromion and olecranon processes. A skinfold thickness of 4 to 8
mm or less suggests borderline fat stores, and a thickness of 3 mm or
less indicates severe depletion.32Midarm muscle circumference estimates
muscle mass or lean tissue stores. Midarm muscle circumference can be
calculated from the triceps skinfold and arm circumference as follows:
MAMC

C - (0.314 X TSF)

where M A M C = midarm muscle circumference (cm), C = arm circumference (cm), and TSF = triceps skinfold (mm). A midarm muscle
circumference of 16 to 20 cm is associated with borderline muscle mass,
and 15 cm or less indicates severe depletion of muscle mass.32More
detailed standards are available to use for comparison. Interrater variability can be high when obtaining these measurements. There are many
other more technologically advanced methods to determine body composition, but they have limited utility in clinical nutrition assessment
and none in screening.

1540

HENSRUD

Laboratory Tests

Albumin is commonly thought of as a good marker of nutritional

status and visceral protein stores. A number of studies have demonstrated that low serum albumin concentrations correlate with longer
hospital stay, medical complications, and increased mortality.*,6, 23, 36, 65, 67
Albumin levels, however, are primarily affected by illness. There is
increased Catabolism; decreased synthesis, and particularly redistribution into the extravascular space of albumin as part of the metabolic
response to injury or illness. This response can occur acutely within 24
to 48 hours. In contrast, in anorexia nervosa, a condition with obvious
nutritional compromise, normal albumin levels are relatively preserved
until late in the course. Albumin synthesis can decrease slightly in
marasmus, but this effect is small compared with the effect of medical
stress. For these reasons, albumin should be thought of primarily as a
marker of stress, rather than nutritional status per se.46Adequate nutritional support may help to lessen the nadir of the decrease in serum
albumin during illness and help eventually to restore normal levels, but
this occurs mainly because of improvement in the metabolic stress and
can take weeks or even months.
Other serum proteins that have been used in nutrition assessment
are transferrin, prealbumin, and retinol binding protein. These proteins
are also affected by illness and injury, similar to albumin, and so offer
little advantage over albumin in nutrition assessment. The half-life of
transferrin is 8 days, and that of prealbumin 2 days compared with 18
to 21 days for serum albumin. Because levels can change more quickly
than albumin, they have been used to monitor the response to nutritional
therapy. This monitoring is often primarily for interests sake, however,
because changes in nutritional support are rarely indicated based on
changes in serum proteins.
A 24-hour urinary total or urea nitrogen can be interpreted as
corresponding to the degree of protein catabolism and therefore protein
requirements. Many factors can affect this measurement, including adequacy of collection, diuretics, renal function, and protein intake, and so
this test needs to be interpreted carefully. In addition, attempting to
obtain positive nitrogen balance can be a frustrating and fruitless exercise at times in critically ill patients. Administering more protein can
increase urine nitrogen and result in a vicious cycle of further increases
in protein without ever obtaining positive nitrogen balance.
Creatinine is produced from muscle metabolism, and urinary values
reflect muscle mass. Dietary intake and renal function also influence
urinary creatinine. The creatinine height index can be used to compare
24-hour urinary creatinine with standard values. In clinical practice, use
is limited because of the need to obtain a 24-hour urine collection and
the lack of influence on nutritional support recommendations.
Markers of immune function have been used in nutrition assessment. Delayed cutaneous hypersensitivity and total lymphocyte count
72
have been used, and impairment correlates with poorer

NUTRITION SCREENING AND ASSESSMENT

1541

Many other factors, including illness, infection, and injury, can affect
these parameters, and currently they are not used widely in nutrition
assessment.
Individual micronutrients can be measured if there is suspicion of
deficiency based on the clinical setting and results of nutrition assessment. For example, hospitalized patients and the elderly who are institutionalized, live in northern climates, or spend little time outdoors may
be at increased risk for vitamin D deficiency.3y,7y In these situations,
measurement of vitamin D levels is prudent. In the hospitalized patient,
interpretation can sometimes be difficult because of the effect of concurrent illness. For example, low serum zinc and iron concentrations and
increased serum copper can be present in critically ill patients without
true defi~iency.~~
In primary care, relatively few laboratory tests are required to assess
malnutrition. Most of the information needed to determine treatment
recommendations can be obtained from the history and physical examination. With kwashiorkor and marasmus, it is reasonable to check serum
albumin and white blood cell count. In obesity, fasting blood glucose,
thyroid-stimulating hormone, and a serum lipid screen (total cholesterol,
triglycerides, high-density lipoprotein cholesterol, and calculated lowdensity lipoprotein cholesterol) should be checked. If there is any evidence of micronutrient deficiencies, appropriate testing should be obtained.

Functional Assessment

Functional testing, such as grip strength and respiratory muscle

strength, can be a useful component of nutrition assessment. Changes
in metabolism and function can occur long before alterations in body
composition detected by anthropometrics. Electrical stimulation of muscle has the advantage that it does not depend on voluntary effort. Muscle
function has correlated with postoperative complications better than
other nutritional parameter^.^^, 4x, xy, y2 Muscle function can also respond
more quickly than other nutrition parameters to nutritional support.
Improvement in physiologic function can occur in 4 to 7 days after
6y
starting parenteral nutrition before any increases in body pr~tein.'~,

Synthesis of Information

It is necessary to take into consideration all of the available information from the nutrition assessment before making nutrition recommendations. Integrating information from the nutritional and medical history,
physical examination, and appropriate laboratory studies requires clinical judgment and experience. In addition, information regarding the
disease process and future likelihood of need for nutritional support

1542

HENSRUD

should be considered when formulating a specific and appropriate nutritional plan.

SUMMARY

Both undernutrition and overnutrition contribute to increased risk

of morbidity and mortality. Marasmus, kwashiorkor, and decreased micronutrient status are types of nutritional deficiencies, whereas obesity
and problems resulting from dietary supplements are examples of overnutrition. Screening for malnutrition can be performed in the ambulatory, hospital, and institutional populations, each with methods appropriate for the target population. For patients determined to be at high
risk, further nutrition assessment can be performed to help arrive at
specific nutritional treatment goals. Identifying and treating malnutrition
can potentially have an important impact on decreasing morbidity and
mortality in the population.

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Donald D. Hensrud MD, MPH
Division of Preventive Medicine, W12B
Mayo Clinic
200 1st Street SW
Rochester, MN 55905