Nutritional diagnosis and screening
Due to lack of definition of malnutrition the health professional face difficulties in diagnosis or grade or malnutrition among patients. A timely and precise diagnosis will help to improve the outcome of treatment and prevent further complications.
Conversely lack of diagnosis will lead to longer stay at hospitals and frequent readmissions. Therefore one undernutrition is diagnosed it has to be treated by the multi-disciplinary sport team of nutritionist according to in initialized care plan.
Nutritional diagnosis is generally carried out by looking at BMI alone or weight loss combined with other BMI or fat free match index. An ideal care plan starts by immediately s upon admission at hospital is followed by through assessment screening patient of nutritional status.
Patient screened at risk undergo appropriate nutritional interventions. Does nutritional screening is the process of identifying individual or groups who are marked restore are vulnerable to malnutrition.
It is 3 and to mention that apart from increasing Healthcare post undernutrition has drastic impact on the tolerance and efficacy of certain treatments for example chemotherapy radiotherapy and antibiotics full stop there for early diagnosis of breast is helpful to prevent onset of Nutrition related problems and design intervention to curb the menace of malnutrition in its infancy.
More oven early detection and treatment are cost-effective and may prevent lifetime complications. Screening is usually Rapid procedure and is carried out prior comprehensive nutritional assessment.
Only patients identified at risk screening is aim to identify risks factors for malnutrition while assessment provides nutritional diagnosis.
| Alternative; A |
| BMI <18.5 KG / m2 |
| Alternative; B |
| Involuntary weight loss >10% indefinite of time, or >5% over |
| the past 3 month. |
| couple with either |
| BMI <20 kg /m2 if <70 years of age , or <22 kg/m2 if> 70 year of age |
| OR |
| FFMI<15 and 17 kg/m2 in women and men , respectively |
Interplay of nutritional screening and assessment:
Nutritional screening:Identify risk factors.
Simple and Quicker.
Can be carried out by the patient or family.
May provide nutritional related outcomes.
Nutritional assessment:
Provide diagnosis.
Relatively Complex and takes long time.
Can be performed by professional dietitian.
Nutrition related outcomes are visible.
Components of nutritional screening:
Dietary intake, protein intake.
BMI or weight loss.
Diseases and their related complications.
Presence of inflammation.
Muscle function.
Nutritional screening tools:
Several screening tools are used to identify characteristics attributed to dietary or nutritional insufficiency and differentiate individuals who are at risk from those who have developed a poor nutritional status. There is a consensus that nutritional screening be formed within the first 24 to 72 hours of hospital admission for all the patients.
Training is the first step in the nutrition care and includes information on dietary history, nutritional intake, anthropometry , biochemical measurements, physiological and clinical parameters, physiological or disease status as well as functional and behavioral aspects.
Screening tools currently suggested by European society for clinical nutrition and metabolism address some of the basic questions including.
Recent weight change;
Recent food intake
Current BMI
Current severity
Guidelines on the use of nutritional screening tools in different settings for example community hospitals and care institutions are based on their reliability and practicability. Following are some of the screening tools recommended by the ESPEN.
Community: malnutrition Universal screening tool MUST.
Hospital: Nutrition screening tool NST.
Elderly: Mini Nutritional assessment MNA.
MUST : a community screening tool:
It was developed by the British Association for antiviral and enteral nutrition and used to detect nutritional problems by secondly BMI weight loss and diseases.
MUST is a simple quick and valid tool for Rapid screening of the community to get an estimate of the grade celebrity of undernutrition.
However it does not account for recent food intake and percentage weight loss. More over BMI calculation may cause problem in some units. MUST is a universally used 5 step tool to identify these and adults or those who are at risk. It relies on three indicators with scores assigned to each grade.
1. BMI score
2. Weight loss score for last 3 to 6 month
3. Acute disease effects score or there has been or likely to be no nutritional intake for more than 5 days.
MUST ( Malnutrition universal screening tool )
Step ;4
Overall risk of malnutrition
Add a score together to calculate overall risk of malnutrition
Score 0 low risk Score 1 medium risk Score 2 or more high risk
Step 5
Management guideline
0 = Low risk routine clinical care
*Repeat screening , Hospital - weekly
Care homes - monthly, Community- annually
for specials groups e.g. those 75 years
1= Medium risk observe
* Document dietary intake for 3days if subject in hospital
or care home.
*If improve or adequate intake - little clinical concern;
If no improvement -clinical concern -follow local policy
*Repeat screening
Hospital- weekly , Care home-at least monthly, community
at least 2-3 month.
2= Or more high risk treat
*Refer to dietitian, nutritional support team or implement
local policy.
*Improve and increase overall nutritional intake .
*Monitor and review care plan hospital- weekly
care home - monthly , community-monthly
*Unless detrimental or no benefit is expected from
nutritional support e.g. imminent death
All risk categories;
*Treat underlying condition and provide help and advice
on food choice, eating and drinking when necessary.
*Record malnutrition risk category.
*Record need for special diets and follow local policy.
b. NRS-2002 (nutritional risk screening) :
NRS-2002 is a simple and well validated nutritional screening tool used to identify patients who are severely malnourished and need increased dietary requirements.
Nrs 2002 to start with 4 basic questions about BMI weight loss dietary intake and disease severity. If the answer of any of the questions is yes indicating a deviation from normal.
Screening questions Yes/No
1 ) Is BMI < 20.5?
2) Has the patients lose weight within the last 3 months?
3)the patient had a reduced dietary intake in the last week?
4)Is the patient severely ill? ( e.g. in intensive therapy)
Yes; If the answer is ' yes ' to any question , the final screening is performed.
| Impaired nutritional status | Sererity of disease(=increase in |
| requirement) | |
| Absen; score 0 | Normal nutrition status | Absent ;scoeo | Normal nutrition requirement |
| Mild | weight loss >5%in 3 month | Mild | Hip fracture chronic patient, |
| OR | | particular with acute |
| Score 0 | Food intake below 50-75% of | Score 1 | complication; |
| normal requirements in | | cirhosis, COFD chronic |
| preceding week | | hemodialysis,diabetes,oncology |
| Moderate | Weight loss >5%in 2 months | Moderate | Major abdominal surgery, stroke, |
| OR | | server pneumonia, hematologic |
| Score 2 | BMI 18.5- 20.5% impaired | | malignancy |
| general condition | Score 2 | |
| OR | | |
| Food intake 25-50% of normal | | |
| requirement preceding week | | |
| Sever | weight loss >5%in 1 months | Severe | Head injury, bone marrow |
| Score 3 | (>15% in 3 months) | | transplantation, intensive care |
| OR | | patients. |
| BMI <18.5 + impaired general | Score 3 | (APACHE>10) |
| condition | | |
| OR | | |
| Food intake 0-25% of normal | | |
| requirement in preceding week. | |
Age if > 70 years ; add to total score above = age adjusted total score;
Score >3 ; The patient is nutritionally at risk and a nutritional care plan has to be initiated.
Score>3; Weekly re-screening of the patient. If the patient is scheduled for a major operation, a preventative nutritional care plan is considered in avoid the associated risk.
Score Nutritional status
0-2 Well nourished
3-4 Medium risk
5-6 Nutritional status
Elderly; MNA (Mini malnutritional assessment)
It is validated, highly specific and sensitive tool to identify patients at risk of malnutrition. its development started in 1989 at International Association of geriatrics and gerontology (IAG).
It comprises of 18 parameters including weight loss, anorexia, anthropometric measurements, during situation cognitive and mood disorders, acute diseases, dietary and subjective assessment, drug intake and mobility etc.
More over, it is important to educate Health Care professional about the practices of MNA for development of early intervention.
Mini nutrition assessment(MNA) -Screening adapted from MNA Société des proudest Nestle".
A
| screening question with score and severity | Score assigned |
| Has food intake declined over the past 3 month due to loss of appetite | |
| digestive problems, chewing or swallowing difficulties? | |
| 0= Sever loss of appetite | |
| 1= Moderate loss of appetite | |
| 2= No loss of appetite |
B
| Weight loss during last month |
| 0= Weight loss greater than 3Kg |
| 1= Does not know |
| 2= Weight loss between 1 and 3 Kg |
| 3= No weight loss |
c
| Mobility? |
| 0= Bed or chair bound |
| 1= Able to get out of bed/ chair but does not go out |
2= Goes out
|
D
| Has suffered physical stress or a cute diseases in the past 3 month? |
| 0= YES |
| 1= NO |
E
| Neuropsychological problems? |
| 0= Severe dementia or depression |
| 1= Mild dementia |
| 2=No psychological problem |
F
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