92338

2013
PENXXX10.1177/0148607113492338Journal of Parenteral and Enteral Nutrition / Vol. XX, No. X, Month XXXXJensen et al

Malnutrition Forum Report

Journal of Parenteral and Enteral
Nutrition
Recognizing Malnutrition in Adults: Definitions and Volume 37 Number 6
November 2013 802­–807
Characteristics, Screening, Assessment, and Team © 2013 American Society

Approach for Parenteral and Enteral Nutrition

DOI: 10.1177/0148607113492338
jpen.sagepub.com
hosted at
online.sagepub.com

Gordon L. Jensen, MD, PhD1; Charlene Compher, PhD, RD, CNSC, LDN, FADA2;
Dennis H. Sullivan, MD3; and Gerard E. Mullin, MD4

Abstract
Appropriate recognition of malnutrition in adults requires knowledge of screening and assessment methodologies. An appreciation for
the contributions of inflammation has resulted in a new etiology-based approach to defining malnutrition syndromes. The Academy of
Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) have published a consensus document
that extends this approach to describe characteristics for the identification and documentation of malnutrition in adults. Nutrition
screening tools are used to identify patients at nutrition risk and those who are likely to benefit from further assessment and intervention.
Nutrition assessment serves to guide appropriate intervention. A systematic approach to nutrition assessment that supports the new
diagnostic scheme and criteria from the Academy and A.S.P.E.N. has recently been presented. Since screening delays and failures in the
diagnosis and management of malnutrition are all too common, a multidisciplinary team approach is recommended to promote improved
communication and quality of care. (JPEN J Parenter Enteral Nutr. 2013;37:802-807)

Keywords
malnutrition; screening; assessment; team approach

Definitions and Characteristics
The estimated prevalence of malnutrition (undernutrition) among
hospitalized adults in modern healthcare is typically in the 30%–
50% range depending on the setting and criteria that are used.
Widespread confusion among healthcare practitioners has
resulted from the use of historic definitions for malnutrition syn-
dromes that employ diagnostic criteria that suffer notable limita-
tions in sensitivity, specificity, and interobserver reliability.1 A
new approach to defining malnutrition syndromes has recently
been proposed that builds on current insights regarding the con-
tributions of inflammatory response.2 There is now appreciation
that acute and chronic inflammation are important etiologic fac-
tors in the pathogenesis of malnutrition in disease or injury states
due to associated metabolic alterations and anorexia.3
An International Guidelines Committee, convened under
the auspices of the American Society for Parenteral and
Enteral Nutrition (A.S.P.E.N.) and the European Society for
Clinical Nutrition and Metabolism, recommends consider-
ation of malnutrition syndromes that include chronic starva-
tion without inflammation (eg, anorexia nervosa or major
depression with lack of interest in eating); chronic disease-
associated malnutrition, when inflammation is chronic and of
mild to moderate degree (eg, organ failure, pancreatic cancer,
rheumatoid arthritis, or sarcopenic obesity); and acute disease
or injury-associated malnutrition, when inflammation is acute
and of severe degree (eg, major infection, burns, trauma, or
closed head injury) (Figure 1).2 Patients may be appropriately
assigned to 1 or more of these syndromes or may transition
from one to another. This construct also readily accommo-
dates overweight or obese individuals with malnutrition con-
cerns. Heightened concern is warranted when starvation is
superimposed upon acute or chronic inflammatory conditions
or when a new acute inflammatory insult is superimposed
upon underlying starvation or chronic disease–related malnu-
trition. Such patients require close follow-up and intervention
From 1Department of Nutritional Sciences, Pennsylvania State
University, University Park; 2University of Pennsylvania School of
Nursing, Philadelphia; 3Department of Medicine, University of Arkansas
for Medical Sciences, Little Rock; and 4Department of Gastroenterology
and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland.
Financial disclosure: The Malnutrition Forum was sponsored by Abbott
Nutrition. This article, which summarizes the authors’ presentations at the
forum, was written solely by the authors.
Received for publication March 27, 2013; accepted for publication May
8, 2013.
This article originally appeared online on August 22, 2013.
Corresponding Author:
Gordon L. Jensen, MD, PhD, The Pennsylvania State University, 110
Chandlee Lab, University Park, PA 16802, USA.
Email: glj1@psu.edu.
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Jensen et al 803
Nutrional risk
idenfied:
Low food intake or loss
of lean body mass
Inflammaon
present?
NO YES, mild-to-moderate
Starvaon-related Chronic disease-related
Acute disease-related
malnutrion malnutrion
e.g., chronic starvaon, e.g., CKD, cancer, rheumatoid
anorexia nervosa arthris, sarcopenic obesity
e.g., sepsis, burn, trauma
Figure 1.  Etiology-based definition of malnutrition risk. The
role of inflammation in disease-related malnutrition is recognized
in this classification system.4,5 CKD, chronic kidney disease.
to prevent development of severe malnutrition. Although criti-
cally ill patients may not necessarily be malnourished acutely,
they have metabolic dysregulation and associated catabolism
that warrant early assessment and intervention.6
The Academy of Nutrition and Dietetics (the Academy; for-
merly the American Dietetic Association) and A.S.P.E.N. have
extended this diagnostic construct with a recent consensus
document highlighting characteristics recommended for the
identification and documentation of malnutrition in adults.4,5
The proposed criteria are:
•• Insufficient energy intake: % nutrients consumed/
administered vs requirement
•• Unintended weight loss: can occur at any body mass
index
•• Physical examination
|| Loss of muscle mass
|| Loss of subcutaneous fat
|| Evidence of fluid accumulation (localized or gen-
eralized)
•• Diminished physical function
|| Hand grip strength
|| SPPB (Short Physical Performance Battery) for
elderly patients
|| Other
Positive finding in any 2 characteristics indicates malnutrition.
Thresholds are suggested for assignment to categories of mal-
nutrition in the context of social or environmental circum-
stances, chronic illness, or acute illness or injury, which
correspond to the malnutrition syndromes described above. It
is recognized that the proposed approach to adult malnutrition
definitions and characteristics is a work in progress. Educational
programs are slated by the Academy and A.S.P.E.N. to pro-
mote their use by skilled nutrition practitioners. The criteria
developed in support of these diagnoses will require further
development and testing. The translation of this construct to
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routine clinical practice will warrant validation. Feasibility tri-
als are currently ongoing, and further refinement is anticipated
moving forward. An approach to pediatric malnutrition syn-
dromes is also currently in development.
Screening
YES, severe
Nutrition screening is a process employed to identify patients
who are at nutrition risk and who would be served by further
malnutrion nutrition assessment and intervention. Since it is not feasible to
conduct a complete nutrition assessment of every patient due
to limited staffing levels of nutrition providers and to the rapid
movement of patients through clinical sites, nutrition screening
tools have evolved as a method of identifying the subset of
patients who require a more thorough nutrition assessment. To
be most useful, these tools should have acceptable validity, be
simple to administer, have broad applicability across multiple
clinical settings and patient conditions, and use commonly
available information.
Screening tools have variable components and most often
have been compared with the gold standard of the Subjective
Global Assessment (SGA) for validity. The SGA enters the
domain of assessment and requires a physical examination for
evidence of muscle and fat mass wasting and edema, in addi-
tion to history of weight loss and reduced physical function.
Although the SGA is predictive of morbidity and mortality in
many types of hospitalized patients, the skilled professional
time required to administer it is somewhat more than other
approaches. In a recent comparison of 10 screening tools,7 the
Malnutrition Screening Tool (MST), a tool that uses uninten-
tional weight loss and reduced appetite to screen for malnutri-
tion, had greatest validity and reliability. The Nutrition Risk
Screening (NRS)–2002, which uses unintentional weight loss,
low body mass index (BMI), disease severity, age >70 years,
and impaired condition, also had acceptable sensitivity and
specificity. The Malnutrition Universal Screening Tool (MUST)
uses unintentional weight loss, BMI, disease severity, and
problems with food intake to classify malnutrition risk, with
good sensitivity and specificity. The Subjective Nutrition
Assessment Questionnaire (SNAQ) requires unintentional
weight loss, appetite loss, and use of nutrition supplements or
tube feeding. In a comparison of screening tools with an inpa-
tient sample, the MST and SNAQ were most useful due to
adequate availability of screening components (Table 1).8
Patients who screen as at nutrition risk have worse clinical
outcomes than those who are at low risk, including more
frequent hospital readmissions,13-15 longer length of hospi-
tal stay,14-16 and greater mortality.14,15,17-19 Moreover, when
patients at nutrition risk receive appropriate individualized
nutrition care, outcomes are improved, including reduced read-
missions,20,21 shorter length of stay,20 and lower mortality.22,23
The screening tools to date have 3 primary limitations.
Most have been evaluated in adults in hospital settings, with
804 Journal of Parenteral and Enteral Nutrition 37(6)

Table 1.  Comparison of Malnutrition Risk Screening Tools.

Malnutrition Risk Screening Tools Description Parameters Used

9
Malnutrition Screening Tool (MST) MST is a simple, quick-to-administer, Unintentional weight lossa
  2-question tool. Appetitea

Nutritional Risk Screening–2002 Developed by ESPEN, this is a preferred tool Unintentional weight lossa
(NRS-2002)10 to screen for malnutrition in European BMIa
  hospital settings. Disease severity
Age
Impaired general condition

Malnutrition Universal Screening Tool Developed for screening in the community, Unintentional weight lossa
(MUST)11 MUST is widely used in the United Kingdom BMIa
  and Europe. Disease severity
Food intakea

Short Nutritional Assessment Questionnaire A simple, easy-to-administer, 3-question Unintentional weight lossa
(SNAQ)12 screening tool developed in the Netherlands Appetitea
for hospital screening. Use of oral supplement or tube feeding

BMI, body mass index; ESPEN, European Society for Clinical Nutrition and Metabolism.
a
Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition diagnostic characteristic.

only a few in outpatient clinics or longer-term care facilities,
but none have been systematically examined across the con-
tinuum of care. Since malnutrition may develop gradually over
time, the availability of tools that detect the disorder in the
early phases at primary care medical or community settings
would provide a clear clinical advantage for early intervention.
The second major limitation is the lack of tools that address the
nutrition risk of patients with obesity. Although obesity is
highly prevalent and associated with comorbid conditions that
complicate clinical outcomes, obese patients in clinical set-
tings are not noted to be at risk with any of the currently avail-
able nutrition screening tools. Finally, the best nutrition
screening tool will have limited applicability if the components
used are not readily available.
As it is not feasible to conduct a full nutrition assessment on
every admission to a healthcare facility, the development of
valid nutrition screening tools that can be used in any clinical
setting, across the life span, and that detect nutrition risk in
obese as well as undernourished patients is a high-priority goal
for the near future. To enable optimal staffing to conduct
evidence-based approaches to nutrition care, these screening
tools must be used as an initial step in a pathway of nutrition
assessment and intervention, so that cost-effective care can be
provided.
Assessment
The assessment of a patient’s nutrition status is the crucial next
step following the identification of risk by screening so that
appropriate intervention can be implemented. However, such
an assessment can be difficult to perform. Since there is no
“gold standard” by which nutrition status can be defined or
measured, the clinician must rely on a wide array of surrogate
measures and possess knowledge of how each can best be
used. No one surrogate measure is optimal for assessing nutri-
tion status for all patients in all clinical situations; the sensitiv-
ity, specificity, and overall validity of each measure as a
nutrition marker vary dramatically depending on the clinical
situation.24 The cost, availability, and acceptability to a patient
may also limit the use of many of these putative nutrition indi-
cators. For these reasons, assessment of nutrition status needs
to involve a multicomponent evaluation that is comprehensive
enough to allow the assessing clinician to interpret each
measure in context. Nutrition status cannot be assessed in
isolation.
Since nutrient intake is an important determinant of body
composition and physiologic function, the ultimate goal of the
nutrition assessment is to determine whether nutrient intake
has been and continues to be adequate to maintain or attain
body composition and physiologic function that is optimal for
the health and long-term survival of the individual. To make
such assessments possible, techniques used for measuring
body composition or some aspect of physiologic function are
often used as surrogate markers of nutrition status. Such sur-
rogate markers can provide valuable information. However,
gauging the adequacy of an individual’s nutrition status based
on measures of body composition or physiologic function has
its limitations. As shown in Figure 2, nutrition is only one of
many factors that decisively affect body composition and
physiologic function. The integrity of the central and periph-
eral nervous system, the individual’s level of physical activity,
multiple hormones, and inflammation are also important deter-
minants. It is also important to recognize that an adequate
nutrient intake is necessary, but not sufficient, to maintain body
mass and normal physiologic function and that additional
intake is required to replete established deficits. Energy,

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Jensen et al 805

protein, and micronutrient requirements are in turn influenced

by a wide array of factors, including activity level, environ-
ment, disease states, medications, and relative intake of other
nutrients.
Multiple surrogate measures have been promoted for use in
assessing the adequacy of an individual’s nutrition status. Each
measure has its advantages and limitations and must be inter-
preted in the context of the individual’s clinical status. For
example, a onetime or serial assessment of body weight is eas-
ily obtained, inexpensive, acceptable to the patient, and highly
reliable given the wide availability of precision scales in homes
and healthcare institutions. However, certain disease states
such heart, kidney, or liver failure can cause large fluctuations
in total body water, which has the effect of significantly alter-
ing the sensitivity and specificity of weight as a marker of
nutrition status. Consequently, it may be difficult to determine
the nutrition significance of a weight in many clinical situa-
tions. Use of advanced technologies such as magnetic reso-
nance imaging or dual-energy x-ray absorptiometry can
Figure 2.  Major determinants of body composition and
provide estimates of the size of specific body compartments physiologic function.
such as muscle or lean mass, which may help in interpreting
the weight data.25,26 However, these techniques are costly, less
readily available, and often contraindicated, and they have not A systematic approach to adult nutrition assessment that
been sufficiently validated in all clinical settings. supports the new diagnostic construct from the Academy and
Some of the putative nutrition indicators widely used in the A.S.P.E.N. presented above has recently been proposed.30 The
past are now considered to have limited applicability in the assessment incorporates history and clinical diagnosis, clinical
clinical assessment of nutrition status. This is particularly true signs and physical examination, anthropometric data, labora-
for the serum secretory proteins, including serum albumin, pre- tory indicators, dietary assessment, and functional outcomes.
albumin, and transferrin.27 It is now recognized that their serum Additional details can be found in the third edition of the
concentrations are probably much more strongly affected by A.S.P.E.N. Adult Nutrition Support Core Curriculum.31
many disease states, particularly those that produce an inflam-
matory response, than by nutrient intake.28,29 In such settings,
Team Approach
they may have greater utility as proxy indicators of inflamma-
tory status and related disease outcomes. Even in healthy indi- A multidisciplinary team approach is important to promote
viduals, they are relatively insensitive to changes in nutrient appropriate recognition and management of malnutrition. The
intake, although this is less a concern with prealbumin and the prompt recognition of malnutrition upon admission requires
other serum proteins with short half-lives.29 education of the nursing and physician staff, the implementa-
Primary clinical outcomes such as survival, rate of recovery tion of valid screening tools, and the creation of a reliable
from illness, and physical performance are probably the most channel of communication among nursing, pharmacy, medical,
important indicators of the adequacy of an individual’s nutri- and nutrition disciplines. Swift recognition of individuals with
tion status. However, their sensitivity and specificity as nutri- malnutrition and those who are at risk is a critical component
tion markers are also strongly affected by the interaction of to patient care in the hospital setting. Screening delays and fail-
multiple other factors, including the severity of any underlying ures circumvent good nutrition care.
disease or injury. As with all other putative indicators of nutri- Unfortunately, many hospitals do not prioritize malnutrition
tion status, each outcome must be assessed in context of the risk screening. For instance, the results from the Nutrition Care
individual’s overall clinical situation. Day Survey 2010 showed that a large number of acute care
Given the critical importance of nutrition to health and the hospital wards in Australia and New Zealand do not comply
limitations of currently available nutrition assessment method- with evidence-based practice guidelines for nutrition screening
ologies, it is important that a multicomponent evaluation be of malnourished patients. Indeed, malnutrition screening was
used in assessing an individual’s nutrient needs. The evaluation reported in only 64% (n = 234) of the medical wards.32 In the
needs to be comprehensive enough to allow the assessing clini- United States, The Joint Commission requires that nutrition
cian to interpret the results in the context of the patient’s over- screening be conducted within 24 hours of admission to the
all clinical situation. Only by so doing will the clinician have hospital with full nutrition assessment to follow if the patient is
any indication of the sensitivity and specificity of each assess- at malnutrition risk.33 Despite these standards, screening delays
ment parameter as a nutrition indicator in that setting. and failures are common. A Dutch study found that about half

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806 Journal of Parenteral and Enteral Nutrition 37(6)
of those patients categorized as moderately or severely mal-
nourished were seen by a dietitian.34 Nutrition screening is
not prioritized secondary to barriers that include the use of
improper and invalid screening tools, the lack of automated
triggers for nutrition consultation, and the insufficient staffing
of registered nurses (RNs). In addition, limited nutrition educa-
tion of RNs and medical doctors results in variability in the
recognition of malnutrition.
A root cause analysis to improve malnutrition screening at
Johns Hopkins35 led to the formation a multidisciplinary team
that resulted in a 47% reduction in screening failures, a 2-day
reduction in the time to nutrition consultation, and a reduc-
tion in length of stay for those who were malnourished.
Implementation of early screening of malnutrition was also
associated with improved healthcare economics.35 Key stake-
holders should be engaged in forming hospital policies on mal-
nutrition screening, assessment, and intervention. To promote
optimal outcomes, it is imperative that leadership from medi-
cine, pharmacy, nursing, dietary, informatics, legal, risk man-
agement, quality assurance, and hospital administration should
collaborate on improving nutrition care practices in the hospi-
tal setting.
Summary
A new approach to defining malnutrition syndromes builds on
the current understanding of the key contributions of inflam-
matory response. The Academy and A.S.P.E.N. have extended
this approach with a recent consensus document highlighting
characteristics recommended for the identification and docu-
mentation of malnutrition in adults.4,5 These characteristics are
a work in progress and will be subject to further testing to vali-
date their use for routine clinical practice.
Nutrition screening is used to identify patients who are at
nutrition risk and who are likely to benefit from further nutri-
tion assessment and intervention. The ideal screening tool
should have acceptable validity, be simple to administer, have
broad applicability across multiple clinical settings and patient
conditions, and use commonly available information. The
practitioner should review the strengths and limitations of cur-
rently available screening tools to aid in appropriate tool
selection.
Once a patient has been identified at nutrition risk by
screening, then nutrition assessment is the key next step so that
appropriate intervention can be delivered. Since there is no
“gold standard” by which nutrition status can be defined or
measured, the practitioner must rely on a multicomponent
array of surrogate measures and possess knowledge of how
each can best be used and interpreted. Each assessment mea-
sure has its own advantages and limitations and must be inter-
preted in the context of the individual patient’s clinical status.
A systematic approach to adult nutrition assessment that sup-
ports the new diagnostic scheme and criteria from the Academy
and A.S.P.E.N. has recently been proposed.30,31
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Screening delays and failures in the diagnosis and manage-
ment of malnutrition are unfortunately common. Priorities to
address these lapses in care include education of the nursing
and physician staff, the implementation of valid screening
tools, and the creation of a reliable channel of communication
between nursing, medical, and nutrition disciplines. A multi-
disciplinary team approach is recommended to promote
improved patient outcomes.
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