Nutrition and Cancer

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Comparison of MUST and Nutriscore for the

Screening of Malnutrition in Hospitalized Oncology
Patients

Alfonso Vidal-Casariego , Emilio Amigo-Otero , Francisco Pita-Gutiérrez ,

Gloria Lugo-Rodríguez , Carmen Almeida-Seoane & Teresa Martínez-
Ramonde

To cite this article: Alfonso Vidal-Casariego , Emilio Amigo-Otero , Francisco Pita-Gutiérrez ,

Gloria Lugo-Rodríguez , Carmen Almeida-Seoane & Teresa Martínez-Ramonde (2020):
Comparison of MUST and Nutriscore for the Screening of Malnutrition in Hospitalized Oncology
Patients, Nutrition and Cancer, DOI: 10.1080/01635581.2020.1817952

To link to this article: https://doi.org/10.1080/01635581.2020.1817952

Published online: 08 Sep 2020.

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NUTRITION AND CANCER
https://doi.org/10.1080/01635581.2020.1817952

Comparison of MUST and Nutriscore for the Screening of Malnutrition in

Hospitalized Oncology Patients
Alfonso Vidal-Casariego, Emilio Amigo-Otero, Francisco Pita-Guti
errez , Gloria Lugo-Rodr
ıguez, Carmen
Almeida-Seoane, and Teresa Mart
ınez-Ramonde
~a, A Corun
Department of Endocrinology and Nutrition, University Hospital of A Corun ~a, Spain

ABSTRACT ARTICLE HISTORY

Introduction: Nutriscore is a malnutrition screening tool designed specifically for cancer Received 14 February 2020
patients. Our objective was to assess its performance in hospitalized cancer patients. Accepted 21 August 2020
Patients and methods: Adult patients diagnosed with any solid neoplasm hospitalized in
Medical Oncology were included. In the first 24–48 h, of admission they were screened with
Nutriscore and Malnutrition universal screening tool (MUST). Both tests were compared
using chi-square, kappa index and ROC curve. Nutriscore sensitivity (S), specificity (Sp) and
predictive values (PV) were calculated using MUST as a reference.
Results: A total of 93 patients were included. The most frequent tumors were lung (36.6%),
colorectal (24.8%) and breast (8.6%). MUST identified 69.9% of the patients at nutritional
risk, and Nutriscore 44.1% (p < 0.001), with a low kappa index [k ¼ 0.38 (95% CI 0.23 to
0.54)]. The AUC of the ROC curve for Nutriscore with respect to the MUST was 0.739.
Nutriscore showed S ¼ 58.6 (95% CI 45.7 to 71.2), Sp ¼ 89.3% (95% CI 76.0 to 100.0%), VP
þ ¼ 92.7% (95% CI 83.5 at 100.0%) and VP- ¼ 48.1% (95% CI 33.5 to 62.6).
Conclusions: Nutriscore did not provided better screening results in hospitalized cancer
patients than a validated tool such as MUST.

Introduction multifactorial syndrome that is characterized by a

Cancer is a process of uncontrolled growth and dis-
semination of cells, which can appear virtually any-
where in the body. The tumor usually invades the
surrounding tissue and can cause metastases in distant
points of the organism. Cancer is a growing epidemio-
logical problem globally. According to the
GLOBOCAN project the number of tumors continues
to grow, having increased from the estimated 14 mil-
lion cases in the world in 2012 to 18.1 million in
2018 (1).
Malnutrition is a common condition in patients
with cancer, triggered by different clinical situations
that determine insufficient food intake, altered diges-
tion and absorption of nutrients, and catabolism. The
prevalence of significant weight loss at the time of
diagnosis range between 15 and 40% depending on
the type of cancer. At hospital admission 33.9% of
oncology patients are malnourished, and the preva-
lence rises to 36.4% at discharge (2). However, the
prevalence of malnutrition increases to 80% as the
disease progresses (3). Cancer cachexia is defined as a
continuous loss of skeletal muscle mass (with or with-
out loss of fat mass) that cannot be fully reversed by
conventional nutritional support and that leads to
progressive functional impairment (4). The molecular
mechanisms involved in the development of cancer
cachexia are complex and not fully known. Certain
molecules increased in cancer have been described as
inducers of anorexia, mainly cytokines (IL-1b, IL-8
and TNF-a) but also neuropeptides (serotonin, NPY
and CRF) and peptide hormones (glucagon). In add-
ition of the metabolic changes induced by the tumor,
its localization at any point of the digestive tract or in
the head and neck area can produce mechanical or
functional alterations that can limit oral feeding.
Surgery, chemotherapy, and radiotherapy, especially
when combined, can impair nutritional status in these
patients by different mechanisms (5).
Nutritional screening is a standardized procedure
that allows the identification of malnourished individu-
als or those at risk of malnutrition that can benefit
from proper nutritional care. Nutritional screening

CONTACT Francisco Pita Gutierrez Francisco.Pita.Gutierrez@sergas.es ~a.

Department of Endocrinology and Nutrition, University Hospital of A Corun
~a, Spain.
As Xubias 84, 15006, A Corun
ß 2020 Taylor & Francis Group, LLC
2 A. VIDAL-CASARIEGO ET AL.
methods must be valid, reliable, reproducible, practical
and associated with specific protocols for action. The
guidelines of the European Society for Clinical
Nutrition and Metabolism (ESPEN) recommend the
periodical screening of malnutrition in cancer patients
with a validated tool that include dietary intake,
changes in weight and body mass index (BMI) (6).
There are numerous validated screening tools for the
detection of malnutrition such as Malnutrition
Screening tool (MUST), Nutrition Risk Screening 2002
(NRS-2002), and Mini Nutritional Assessment (MNA).
MUST was developed by the British Association for
Parenteral and Enteral Nutrition (BAPEN) (7). It ana-
lyzes BMI, weight loss in the last 3–6 mo, and the effect
of acute disease on food intake. Each parameter scores
0–1 or two points and patients are classified as low (0),
medium (1) and high risk (2). NRS 2002 was devel-
oped by Kondup et al. and analyzes BMI, reduced
intake during the last week, weight loss and the severity
of the illness (8). Each parameter is evaluated individu-
ally with a score of 1–3 points, and one point is added
to patients > 70 years. Patients are classified as “at
nutritional risk” if the score is> 3. MNA was designed
for the assessment of elderly and has a full and a
reduced version. It analyzes the BMI (which can be
replaced by the circumference of the arm in those cases
in which the BMI is not available), the reduction of
dietary intake and weight loss the last 3 mo, mobility,
psychological stress or acute illness, and the presence
of neurological problems. Each parameter has a vari-
able score and the sum of them classifies the patient in
normal nutritional status (12–14 pts.), at risk of malnu-
trition (8–11 pts.), or malnourished (<8 pts.) (9). All
these tools have been successfully used for nutrition
screening in cancer patients (2, 10,11).
Recently, a new tool for malnutrition screening has
been specifically designed for cancer patients.
Nutriscore evaluates involuntary loss of weight in the
last 3 mo, a reduction in food intake during the last
7 day, and a specific score depending on the type of
neoplasia and the antineoplastic treatments received
(12). It has been validated in outpatients, but it has
not been tested in hospitalized patients. The aim of
this study was to assess the validity of the Nutriscore
and concordance with MUST as well asseses its pre-
dictive value for complications (mortality, mean stay)
in hospitalized oncological patients.
Patients and Methods
A cross-sectional study was designed including
patients from the hospitalization ward of the
Department of Oncology, located in the University
Hospital A Coru~ na. This is a teaching hospital with
1,415 beds installed, a reference population of 505,797
people and 7,613 professionals. In 2017, the
Department of Oncology received a total of 1,022
admissions with an average stay of 8.6 day. Among
the most frequent causes of admission were secondary
neoplasms of respiratory and digestive organs, lung
neoplasms, digestive toxicity of treatments and neu-
tropenias. The study was designed according the
applicable ethical and legal norms, in particular the
Declaration of Strength (Brazil), and followed the
standards of good practices in research in human
beings. The Ethics and Clinical Research Committee
of the hospital approved the study protocol, and
patient anonymity was preserved.
Patients were included if they were older than
18 year, had a histologically confirmed diagnosis of
any solid malignancy, and were admitted to the
Oncology ward of the University Hospital A Coru~ na.
Exclusion criteria were diagnosis of hematologic
malignancies, hospital admission of less than 24 h,
patients admitted to the Oncology hospitalization
ward but in charge of other hospital departments, and
terminal illness in which death is expected in the fol-
lowing hours.
A sample size of 93 patients was estimated, based
on a population of 340 patients admitted during the
study period, an estimated prevalence of malnutrition
(according to previous studies) of 36%, a level of con-
fidence (1  a) of 90% and an accuracy of 7% (2).
Patients were recruited consecutively, the next day
after hospital admission and upon request of consent.
Patients admitted during the weekend or non-working
days were recruited the next working day (maximum
48 h, after admission). Patient recruitment took place
between November 2018 and April 2019.
Researchers obtained anthropometric measures of
the patient (usual weight, current weight and height).
When it was not possible to weigh, the weight
referred by the patient was collected. When the height
could not be measured, it was estimated from the
length of the ulna according to the instructions of
MUST. MUST and Nutriscore scores were obtained
by the researchers after a personal interview with the
patient. Other data were extracted from the medical
records: date of birth, admission date, discharge date,
diagnosis, cause of admission, nutritional support dur-
ing hospitalization (oral nutritional supplements,
enteral nutrition, parenteral nutrition), mortality dur-
ing admission and readmissions 30 day
after discharge.

Table 1. Characteristics of the patients.
Sample size
Sex- Female (%-n)
Age (yr)
Usual weight (kg)
Current weight at admission (kg)
Height (m)
BMI (kg/m2)
Death during hospitalization (%-n)
30-day rehospitalization (%-n)
Causes for admission
Gastrointestinal toxicity or symptoms
Pneumological complications(not infections)
Diagnostic or therapeutic procedures
Fever or infection
Neurological complications (not infections)
Others
Categorical variables are expressed as percentage (%) and absolute num-
ber (n); quantitative variables are summarized as mean and stand-
ard deviation.
BMI: Body Mass Index.
Statistical Analysis
Qualitative data were summarized as percentages. The
normal distribution of quantitative data was verified
with the Shapiro-Wilk test, and they were summarized
by means and standard deviation (or median and
interquartile range). Qualitative variables were com-
pared using chi-square, and continuous quantitative
variables were compared using Student’s t for inde-
pendent measures (or Mann-Whitney U). Odds ratio
(OR) for the prevalence malnutrition was calculated
with a 95% confidence interval (CI). The data
obtained with Nutriscore were compared with those
obtained with MUST using the kappa test and the
COR curve. Sensitivity (S), specificity (Sp), positive
predictive value (PPV) and negative predictive value
(NPV) of the Nutriscore tool were calculated using
MUST as the reference tool. A value of p less than
0.05 was considered significant.
Results
A total of 93 patients were included in the study, their
characteristics are summarized in Table 1. The study
population included patients diagnosed with different
solid tumors, the most frequent lung (36.6%), colo-
rectal (24.7%), breast (8.6%) and pancreas (6.5%). Of
these, 18.3% had a tumor stage I-II and 81.8% stage
III-IV.
According to Nutriscore 41 (44.1%) patients were
at malnutrition risk, and according MUST they were
65 (69.9%), the difference was significant (p < 0.001).
From the 65 patients at nutritional risk according to
MUST, 38 had also a positive result in Nutriscore. Of
the 28 patients normally nourished according to
MUST, 25 were classified equally by Nutriscore and 3
as at nutritional risk (Table 2). The level of
NUTRITION AND CANCER 3
Table 2. Contingency table with the results of MUST
93 and NUTRISCORE.
52.7 (49) MUST
65.1 (15,3)
76.7 (13.5) POSITIVE (n) NEGATIVE (n)
69.7 (13.6) NUTRISCORE POSITIVE (n) 38 3
1.66 (0.08) NEGATIVE (n) 27 25
25.3 (4.6)
14,1 (13) MUST: Malnutrition Universal Screening Tool.
24,7 (23)
concordance measured with the kappa index was low
28.0%
15.0% [ƙ ¼ 0.38 (95% CI 0.23 to 0.54). When MUST was
14.0% used as the reference screening method, Nutriscore
9.7%
6.2% sensitivity was 58.6% (95% CI 45.7 to 71.2), specificity
27.1% 89.3% (95% CI 76.0 to 100.0), positive predictive value
92.7% (95% CI 83.5 to 100.0) and negative predictive
value 48.1% (95% CI 33.5 to 62.6). The COR curve
based on these results showed an area under the curve
of 0.739 (Figure 1).
Among patients with a positive screening with
MUST the length of hospital stay was significantly
longer compared to patients with a negative screening
[11.9 (12.0) days vs. 6.7 (6.9); p ¼ 0.038]. There were
not significant differences in mortality (18.7% vs. 3.7;
p ¼ 0.064) nor 30-day readmission (28.8% vs. 11.5%;
p ¼ 0.087). Nutriscore also showed no significant dif-
ferences between the two groups with respect to mor-
tality (17.1% vs. 11.8%, p ¼ 0.468) and readmission
(27.3% vs. 20.0%; p ¼ 0.451). The hospital stay, as
with MUST, was significantly longer in patients at
risk according to Nutriscore [13.3 (13.8) days vs. 7.9
(7.3); p ¼ 0.027].
Discussion
This is the first published study that analyzed the per-
formance of Nutriscore for the detection of risk of
malnutrition in hospitalized oncology patients. This
tools had been previously validated for outpatients set-
ting, showing good results when compared with
Patient generated -Subjective Global Assessment (PG-
SGA).1 In our study MUST detected more patients at
risk of malnutrition at admission in the oncology
ward, and Nutriscore presented a low concordance
with this tool.
The prevalence of risk of malnutrition in our study
was higher, with both MUST and Nutriscore, than the
reported in previous studies such PREDyCES (33.9%)
and the study by Leiva Badosa et al. (17.5%) (13).
Although in the first NRS-2002 was used for screen-
ing, in the last the selected tool was also MUST, so
the difference in the prevalence of malnutrition could
be attributed to differences in the population rather
than in the screening tool. When patients admitted to
the oncology ward were screened using Subjective
4 A. VIDAL-CASARIEGO ET AL.
Global Assessment (SGA) a prevalence of risk of mal-
nutrition of 75% was found, a figure closer to that
found in our study using MUST (14). In the current
study, only patients admitted to the oncology ward
were recruited, most of them with a very high risk of
malnutrition due to the advanced stage of the tumor
and the concurrence of acute complications (mainly
gastrointestinal) (Table 3). In the earlier studies a sub-
group of patients with the diagnosis of cancer from
the general population of the hospital was analyzed,
probably hospitalized for the diagnosis of the tumor
or for other health problems with a lower risk of mal-
nutrition. Our hospital is located in northwest of
Spain, where the Mediterranean diet is a typical diet
pattern. This means that the data on the prevalence of
cancer and its types may differ if the study was car-
ried out in northern Europe or the USA, given the
data on the protective role of the Mediterranean diet
against cancer, particularly those of digestive tract. On
the other hand, the association between diet and
Figure 1. ROC curve comparing Nutriscore with MUST. The
blue line delimits the area under the curve of the dianostic
accuracy of Nutriscore using MUST as the reference method.
The green one represents the reference line.
Table 3. Comparison of the main characteristics according each screening tool.
MUST
Positive Negative
Age (yr) 65.0 (17.0) 63.3 (10.9)
Female % (n) 58.5 (38/65) 39.3 (11/28)
Stage III-IV % (n) 96.2 (51/53) 100.0 (25/25)
% Weight loss 12.1 (9.2) 1.6 (7.6)
BMI (kg/m2) 24,9 (4,9) 26.3 (3.7)
Categorical variables are expressed as percentage (%) and absolute number (n); quantitative variables are summarized as mean and
standard deviation.
MUST: Malnutrition Universal Screening Tool. BMI: Body Mass Index.
cancer has been well established, especially for some
type of cancer (15–17).
MUST has been validated in patients with cancer,
showing a good performance when compared to refer-
ence methods like PG-SGA. In the study by Bol
eo-
Tom
e et al. the sensitivity and specificity of MUST
were 0.80 and 0.89, respectively, when compared with
PG-SGA (15). The study by Hettiarachchi et al.
showed even better results, with a good concordance
(k ¼ 0.81), and a higher sensitivity (86.7%) and speci-
ficity (94.5%) (18). In view of these results we decided
to use MUST as a reference tool, since the most com-
mon used (SGA or PG-SGA) are more complex, con-
sume more time, and incorporate a relevant degree of
subjectivity. When MUST has been compared with
other usual screening tools in hospitalized patients
such as NRS-2002, MNA, MST, and SGA also showed
the best results, which probably makes this tool the
best for the detection of patients at risk of malnutri-
tion in the hospital (19–21). Beyond its discriminatory
capacity, MUST can even be performed by the patient
himself using a paper or electronic version, with a
response time lower than 5 mins (22).
The main difference between the two tools ana-
lyzed in this study lies, beyond the different score
given to anthropometric measurements, that MUST
scores the nutritional risk of acute disease, while
Nutriscore rate the nutritional risk of cancer and its
treatment. Cancer of head and neck, upper digestive
tract and digestive system lymphomas have the high-
est rate in Nutriscore, highlighting the link between
malnutrition and these types of cancer. From the
results of this study it is inferred that the effect of
acute disease has more weight than the diagnosis or
cancer treatment in nutritional risk. These results sug-
gest Nutriscore might be a better screening tool in
outpatient cancer.
Nutritional risk determined with both tools was
associated with a longer hospital stay, but we did not
found differences in mortality or in the readmission
rate. MUST results at hospital admission have been
previously related to mortality (13). The main
NUTRISCORE
p Positive Negative p
0.930 68.0 (10.4) 62.9 (18.1) 0.929
0.089 63.4 (26/41) 44.2 (23/52) 0.066
0.325 97.0 (32/33) 97.8 (44/45) 0.823
<0.001 17.7 (7.9) 5.2 (9.9) <0.001
0.173 24.5 (5.1) 25.9 (4.2) 0.132

limitation of the study is a small sample size, suffi-
cient to compare the tools but not to detect differen-
ces in mortality or reentry.
In conclusion, our study shows a high prevalence
of malnutrition in patients admitted to the oncology
plant, and that malnutrition is related to longer hos-
pital stays. MUST has a better ability to detect
patients at risk of malnutrition than Nutriscore in this
setting. The establishment of a screening continues to
be one of the pillars in the fight against high impact
diseases, such as malnutrition. At present, we have
multiple validated tools but, beyond that, it is neces-
sary to cut the barriers that hinder their use and
explore the usefulness of innovative technologies for
their effective implementation.
Author Contribution Statement
Conception or desing of the work: Alfonso Vidal-Casariego,
Emilio Amigo-Otero. Data collection: Emilio Amigo-Otero.
Data analysis and interpretation: Alfonso Vidal-Casariego,
Emilio Amigo-Otero. Drafting the article: Alfonso Vidal-
Casariego, Emilio Amigo-Otero. Critical revision fo the art-
icle: Francisco Pita-Guti
errez, Gloria Lugo-Rodr
ıguez,
Carmen Almeida-Seoane, Teresa Mart
ınez-Ramonde. Final
approval of the version to be published: Alfonso Vidal-
Casariego, Emilio Amigo-Otero, Francisco Pita-Guti
errez,
Gloria Lugo-Rodr
ıguez, Carmen Almeida-Seoane, Teresa
Mart
ınez-Ramonde.
Disclosure Statement
None of the authors have any conflicts of interest
to declare.
ORCID
Francisco Pita-Guti
errez http://orcid.org/0000-0003-
2317-9376
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