Pn Noor Fathiyah Che Kasim

Dietitian
UKM Medical Centre
Nutrition Support Team October 2010, PPUKM
Nutrition Support Team

12/08/21 Fathiyah/NST/24/01/11 1
Objectives of presentation
 Malnutrition
 Explain the purpose of nutritional screening
 Explain the difference between screening
and assessment
 Describe the different screening tools
available for detecting risk of malnutrition
 Describe the different nutrition assessment
methods and tool available

PPUKM Nutrition Support Team

12/08/21 Fathiyah/NST/24/01/11 2
 Malnutrition: How many in the world?
 The most recent estimate
by FAO says that 925
million people are
undernourished
 This is 13.6% of the
estimated world
population of 6.8 billion
 Most of undernourished
are in developing
countries
PPUKM Nutrition Support Team
3
 Malnourished: How about hospitalized
patients?
 Protein-energy malnutrition
- Long term care: 19-27%
- Acute care: 33-58%
 Local data:
- As high as 70% depending on
criteria used

Ref: Dwyer et al 1991. Nutrition Screening Initiative

Suzana et al MJN 2002.

PPUKM Nutrition Support Team

12/08/21 Fathiyah/NST/24/01/11 4
 Sub-clinical nutrient deficiency
Optimal level
 Malnutrition develops
slowly
Impaired biochemical function:
 Becomes apparent only tissues stores body fluid
in the late stages of Plasma level may be
disease normal
Functional deficiency
 Early detection is critical -metabolic -cognition
 Sensitive screening -Immunological - work capacity

tools needed
Clinical deficiency

Death

PPUKM Nutrition Support Team

12/08/21 Fathiyah/NST/24/01/11 5
 Why early detection of
malnutrition is important?
 To prevent progression of malnutrition to a
severe stage
 To identify nutrition problems early so that
effective intervention can be plan and
implemented early.
 For better outcome after intervention

PPUKM Nutrition Support Team

12/08/21 Fathiyah/NST/24/01/11 6
 Nutrition Screening
 Purpose: to quickly identify
 To identify:
- who have poor nutritional status
- who are at risk / high risk for nutritional problem
- who are in good nutritional status
 Test should be
- non invasive
- not expensive
- quickly available result

PPUKM Nutrition Support Team

12/08/21 Fathiyah/NST/24/01/11 7
 Screening VS Assessment: What is the
difference?
Screening
 Identify individual who is
- malnourished
- at risk of malnutrition
 Objectives:
- predict probability of
outcome due to nutritional
factor
- predict if nutritional
intervention will be beneficial
PPUKM Nutrition Support Team
Assessment
 Comprehensive approach
to define nutrition status:
A, B, C, D
 Objectives:
- Determine nutrition status
- Formulate an appropriate
nutrition care plan
8
Nutrition Screening- who & how
 Done by admitting staff (nurses) or community health care
team
 Identify:
1. Pt not at risk: repeat if necessary
2. Pt at risk: give standard nutrition plan
eg; indent high protein diet
3. Pt at risk but medical condition prevent
a standard care plan Refer dietitian
for detail
eg; multiple organ failure nutritional
4. There is doubt whether pt is at risk assessment

eg; early stage skin cancer but well nourished

PPUKM Nutrition Support Team

12/08/21 Fathiyah/NST/24/01/11 9
Nutrition Screening- who & how
 Generally ward staff perform screening: inpatient &
outpatient
 Usually done upon admission for inpatient
- Form scored & referrals made by medical staff
- Form handed to dietitian
 Referral must be made if pt is classified at risk
 Dietitian may be keep and store screening forms but
it will need to be in permanent medical record
 Dietitian needs to do full assessment after screening
found at risk & implement nutrition care plans

PPUKM Nutrition Support Team

10
 Available Tools for Screening
 Mini Nutritional Assessmant (MNA)-Nestle
 Nutrition Screening Initiative
- DETERMINE checklist
 MUST (Malnutrition Universal Screening Tool)
 MST (Malnutrition Screening Tool)
 Nutrition Risk Screening

PPUKM Nutrition Support Team

11
 Screening Tools
 Allow quick survey of large numbers of
patients
 Typically validated for specific
populations (eg: oncology, renal,
surgical)
 SHOULD not be used without
considering target population of a
particular stool-result may not be valid

PPUKM Nutrition Support Team

12
 Mini Nutritional Assessment
(Nestle)
 Developed in 1990
 Validated for ages 65+
 Simple, reliable, non invasive and quick
 Validated in hospital and community
setting

PPUKM Nutrition Support Team

13
 Mini Nutritional Assessment
(Nestle)

 Form divided into 2 parts:

1) Screening
2) Assessment

PPUKM Nutrition Support Team

14
 Mini Nutritional Assessment
(Nestle)- Screening part
- BMI (kg/m2)
- Weight loss in past 3 months
- Acute illness or major stress in past 3
months
- Mobility
- Dementia or depression
- Has appetite & food intake decreased
in past 3 months

PPUKM Nutrition Support Team

15
 Mini Nutritional Assessment
(Nestle)- Screening part
 Screening score
1) 12 points or greater – normal
- not at risk
- no need to complete
assessment
2) 11 points or below – possible malnutrition
- cont assessment

PPUKM Nutrition Support Team

16
PPUKM Nutrition Support Team
17
 Mini Nutritional Assessment
(Nestle)
 Scoring system
Full MNA - > 24 : normal nutrition
- < 24 : Further assessment
and intervention
 Limitations:
- Not capable of covering special aspects of malnutrition
(eg; insufficient micronutrient intake)
- Not suitable for pt receiving enteral tube feeding &
no oral foods
- Not suitable for all ages groups and disease states.

PPUKM Nutrition Support Team

18
 Nutrition Screening Initiative-
DETERMINE

12/08/21 Fathiyah/NST/24/01/11 19
 Nutrition Screening Initiative-
DETERMINE
 Disease
 Eating poorly
 Tooth Loss/ Mouth Pain
 Economic hardship
 Reduce social contact
 Multiple medicines
 Involuntary wt loss/gain
 Need assistance in Self-care
 Elder year above age 80
PPUKM Nutrition Support Team
12/08/21 Fathiyah/NST/24/01/11 20
 Nutrition Screening Initiative-
DETERMINE
 Design to increase community dwelling
elders awareness about health and nutrition
 Self-administered checklist determines need
for referral to a health care professional
 Not clinically validated
 Suitable for community / out patient

PPUKM Nutrition Support Team

21
 Nutrition Screening Initiative-
DETERMINE
 Scoring system:
0-2 : Good! Rechecked nutritional score in 6
months.
3-5 : You are at moderate nutritional risk
Rechecked nutritional score in 3 months
> 6 : You are at high nutritional risk
Bring this checklist when you see health
care professionals and ask for help to
improve your nutritional health.

PPUKM Nutrition Support Team

22
 Malnutrition Universal Screening
Tools (MUST)
 Developed by BAPEN, UK
 A practical, reliable, validated tool for
nutrition screening
 Allows comparable nutritional screening
across different care settings by different
health professionals
- primary care, home, acute care, long term
care (suitable both out-pt and in hospital
setting)
PPUKM Nutrition Support Team
23
Malnutrition Universal Screening Tools (MUST)

PPUKM Nutrition Support Team

24
 MUST Recommended Management
Guidelines
0= Low risk: Routine 1= Medium risk: >2= High risk:
Care Observe Treat
repeat screening
- hospital: - hospital: refer
- hospital: weekly
document diet & to dietitian/
- care homes:
fluid intake 3dys implement local
monthly
- care homes: policies.
- community:
annually for special (as for hospital) - care homes:
group eg; >75yr - community: (as for hospital)
repeat - community:
screening (2-3 (as for hospital)
monthly)

PPUKM Nutrition Support Team

25
 Malnutrition Screening Tools (MST)
 Developed by Australian group
(Ferguson et al. 1999)
 A simple and quick tool that has been
validated for use in Australian hospitals
to identify malnutrition risk for patients.

PPUKM Nutrition Support Team

26
 Malnutrition Screening Tools (MST)
MALNUTRITION SCREENING TOOL
1. Have you lost weight recently without trying?
No 0
Unsure 2
If yes, how much weight (kg) have you lost?
1-5 1
6-10 2
11- 15 3
> 15 4
Unsure 2
2. Have you been eating poorly because of a decreased appetite?
No 0
Yes 1
Total
Score of 2 or more = patient at risk of malnutrition

PPUKM Nutrition Support Team

27
 Malnutrition Screening Tools (MST)

PPUKM Nutrition Support Team

28
 Nutrition Risk Screening 2002
 Developed by Kondrup et al –ESPEN
 Used retrospective analysis of RCT (adults)

Based on concept of:

Indications for nutrition support are
a) the severity of undernutrition
b) the increase of nutritional requirements
from the disease
 Screen includes measures of current
potential under nutrition and disease severity
PPUKM Nutrition Support Team
29
 Nutrition Risk Screening 2002

PPUKM Nutrition Support Team

30
 Nutrition Risk Screening 2002
 Scoring system
Score (0-3) for impaired nutritional status (only
one: choose the variable with highest score)
Score for severity of disease
Add the two scores ( total score)
if age > 70 years: add 1 to the total score
to correct for frailty of elderly
If age-corrected total > 3: start nutritional
support

PPUKM Nutrition Support Team

31
 Nutrition Risk Screening 2002
 Strengths:
Proven to be a practical tool in the hospital setting
Can be facilitated by a range of healthcare
workers
It meant to cover all possible pt categories in a
hospital
 Limitation:
May not effectively screen for deficiencies or
toxicities of certain micronutrients

PPUKM Nutrition Support Team

32
Modified Nutrition Risk Screening 2002
Has been used in general surgery ward in
PPUKM –trial run basis

PPUKM Nutrition Support Team

33
 Screening VS Assessment
Screening Assessment
 Immediate  Longer time
 Minimum  More measurements
measurements  More expense
 Least expense  In – depth information
 Concise information  Requires greater
 Can be facilitated by expertise in its
any member of health facilitation
care team

PPUKM Nutrition Support Team

34
 Nutritional Assessment

 2nd Step after nutrition screening

 Definition: A process of collecting and

assessing data of anthropometry,
biochemical, clinical condition and patient’s
dietary intake.

PPUKM Nutrition Support Team

35
 Nutritional Assessment
An assessment leads to a nutrition care
plan that includes:
- nutrition intervention
- nutrition education
- frequency of monitoring

PPUKM Nutrition Support Team

36
 Nutritional Assessment Method
 Anthropometry
1) Body weight:
- History - BMI
- Actual - Weight change over a time
- Goal wt
2) Body composition:
- Adipose store; triceps or subscapular
skin fold thickness
- Lean body mass; MAMC, MAMA

PPUKM Nutrition Support Team

37
 Nutritional Assessment Method
 Biochemical data
- visceral protein stores
- somatic protein stores
- micronutrients
- fluid, electrolytes and acid-base balance
- lipid status

PPUKM Nutrition Support Team

38
 Nutritional Assessment Method
 Clinical data:
- physical exam
- medical history
- psychosocial history
- demographic
- physical activity level
- current medical/surgical issues

PPUKM Nutrition Support Team

39
 Nutritional Assessment Method
 Diet intake:
- diet history
- appetite assessment
- quantitative food intake
- qualitative food intake
- food habits and pattern
- fluid intake/balance

PPUKM Nutrition Support Team

40
 Nutritional Assessment Tool
 Subjective Global Assessment (SGA)

PPUKM Nutrition Support Team

41
 Subjective Global Assessment (SGA)
1. Wt history
2. Review of dietary intake
Medical History 3. GI symptoms
(60%) 4. Functional status &
activity level
5. Assess metabolic •No laboratory
demands indices are
included
Physical Loss of fat stores, muscle
Examination wasting, edema, ascites •Documented in
(40%) rating form
SGA1 (Class A):normal or
well nourished
SGA 2 (Class B): mild to
Nutritional moderate malnutrition
Status Rating SGA 3 (Class C): severe
malnutrition

PPUKM Nutrition Support Team

42
Subjective Global Assessment (SGA)
 Physical examination (Part 2)

PPUKM Nutrition Support Team

43
 Nutrition Support Team

12/08/21 Fathiyah/NST/24/01/11 44