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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.62 Nutrition 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. Nutri- tion 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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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 high- risk individuals. An example is the National Cancer Institute’s Five-A- Day program, which encourages people to consume at least five servings of fruits and vegetables per day to decrease the risk of cancer.31 The 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. Nutri- tion 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.41 The 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

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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 5’10 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.34 Upper body or abdominal obesity compared with lower body or peripheral obesity is associated with insulin resistance and many of these same health risks.64 In 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 endo- metrial 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 waist- to-hip ratio.83 The 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.57 For 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 statush6 For example, prednisone and tricyclic antide- pressants 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.3s Social factors can also be important. Low income and social isolation are important factors related to the adequacy of the diet.lh,


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

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

Decreased absorption

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 maln~trition.'~, I*, 51, ** Data from the Third National Health and Nutrition Examination Survey (NHANES 111) indicated that 4.1 YO 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.45 In 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,61 possibly 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.84 This 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).5 Almost 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 small suggest that supplement use has been increasing.

GOALS OF NUTRITION SCREENING AND SUPPORT-IMPROVED OUTCOME

At a fundamental level, nutrition is necessary for survival. Theoreti- cally, 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.68 Of 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 ~upplement .~~

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


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 outcome and less complications with nutritional 56, 60, Routine 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.81 Subjects with borderline or mild malnutrition had a worse outcome because of infectious complications. In another study, the Prognostic Nutrition In- dex 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.60 Therefore, 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^.^^ Fur- ther 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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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 partner- ship 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).78 This 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

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.

food I eat. of 2

3 2 2 2 4 1 1 2 2

~

Total

0-2 3-5

Good. Recheck your nutritional score in 6 months. 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.

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.

6 or more You are at high nutritional risk. Bring this checklist the next time you see your

Adopted from The Nutrition Screening Initiative: Determine Your Nutritional Health. Washington, DC, Nutrition Screening Initiative, 1992; with permission.


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 retrospective&, 70 and prospective In addition to screening, it may also provide education and increased awareness of nutrition issues among the elderly.70 The 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 effica- cious.68 The purpose of the checklist, however, is as an initial screen and educational tool that can lead to more extensive nutrition assessment, if indicated.86 There 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 patient’s 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 vitamin B,, defi~iency.~~ For this reason, checking serum vitamin B,, 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 Health- care 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.2y Based 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).21 This 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-


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

No dysfunction Dysfunction Duration = days Type: Working suboptimally

Ambulatory but not working Bedridden

Primary diagnosis:

No stress Moderate stress High stress (burns, sepsis, severe trauma)

4. Functional capacity

Disease and its relation to nutritional requirements

Metabolic demand (stress)

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.yo This 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.8y A brief algorithm

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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.13 It 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.30 Many 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 ap- proached 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.


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 applica- ble. 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 involuntary weight loss is an ominous sign and should be investigated.2R, 52

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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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 manifesta- tion of the metabolic response to injury or illness. Fever raises energy expenditure up to 13% for each 1°C 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 Vitamin Deficiency

Hair

Skin Corkscrew hairs

Perifollicular petechiae Purpura

Cheilosis and angular stomatitis Smooth, red, painful tongue

Peripheral neuropathy Ophthalmoplegia, confabulation

Mouth and oral cavity

Neurologic system

Vitamin C

Vitamin C Vitamins C and K

Riboflavin, pyridoxine, niacin Vitamin B,,, niacin, folate, riboflavin

Thiamine, pyridoxine, vitamin B,, Thiamine


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.32 Midarm 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 MAMC = 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.32 More detailed standards are available to use for comparison. Interrater vari- ability 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.

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Laboratory Tests

Albumin is commonly thought of as a good marker of nutritional status and visceral protein stores. A number of studies have demon- strated 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 redistribu- tion 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.46 Adequate 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 interest’s 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 have been used, and impairment correlates with poorer 72


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 concur- rent 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 low- density 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 starting parenteral nutrition before any increases in body pr~tein. '~, 6y

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

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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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