Nutrition Screening and

Assessment in Adults
Chanita Unhapipatpong, MD., FRCP(Thailand)
Division of Clinical Nutrition
Internal Medicine Department
Khon Kean Hospital, Ministry of Public Health
Outlines
• Malnutrition diagnosis
• Nutrition screening and assessment tools
• Full nutrition assessment
Outlines
• Malnutrition diagnosis
• Nutrition screening and assessment tools
• Full nutrition assessment
 Complications of Loss of Lean Body Mass
%Loss of total lean body mass Associated mortality, %

10% Impaired immunity, increased infection

10%
20% Decreased healing, weakness, infection, thinning of skin
30%
30% Too weak to sit, pressure sores develop
pneumonia, no healing 50%
40% Death, usually from pneumonia
100%
Eplasty. 2009; 9: e9.
Definition

Malnutrition
BMI for
screening and SARC-F ? Risk, LAB?
screening
assessment

Clinical Nutrition. 2017;36:49-64

Malnutrition/Undernutrition

1 2 3
Esophageal stricture
Stroke
Dementia
Poverty Deprivation of food

Major infection Pancreatic cancer

Burn Rheumatoid arthritis
Trauma Organ failure
Closed head injury COPD
CHF Clinical Nutrition. 2017;36:49-64
Malnutrition Diagnosis: ESPEN
• Fact box: 2 alternative ways to diagnose malnutrition.
• Before diagnosis of malnutrition is considered it is mandatory to fulfil
criteria for being “at risk” of malnutrition by any validated risk screening
tool.
• Alternative 1: BMI <18.5 kg/m2
• Alternative 2:
• Weight loss (unintentional) > 10% indefinite of time, or >5% over the last 3 months
combined with either
• BMI <20 kg/m2 if <70 years of age, or <22 kg/m2 if ≥70 years of age or
• FFMI <15 and 17 kg/m2 in women and men, respectively

*General criteria are intended to be applied independent of clinical setting and aetiology
Clinical Nutrition. 2015;34:335-340
Malnutrition Diagnosis: ASPEN
• At least 2/6 malnutrition criteria are required
1. Low energy intake
2. Weight loss
3. Loss of muscle mass
4. Loss of subcutaneous fat
5. Fluid accumulation
6. Hand grip strength

*General criteria are intended to be applied independent of clinical setting and aetiology
Clinical Nutrition. 2015;34:335-340
ICD-10

Clinical Practice Recommendation for the nutrition management in adult hospitalized patients 2017
ICD-10

Clinical Practice Recommendation for the nutrition management in adult hospitalized patients 2017
Outlines
• Malnutrition diagnosis
• Nutrition screening and assessment tools
• Full nutrition assessment
Nutrition Care Process
Nutrition Screening Nutrition Assessment
Normal

Moderate

Severe

At-risk Malnutrition Malnutrition

Nutrition Intervention
Nutrition screening tools

Nutrition assessment tools

Full nutrition assessment

Difference?

Nutrition Screening Nutrition Assessment

• A process to identify an • Identify any specific nutrition
individual who is risk(s) or clear existence of
malnourished or who is at malnutrition
risk for malnutrition • More specificity
• Within 24-48 hours • More complicated and take
• High sensitivity time
• Easy and less time required

JPEN J Parenter Enteral Nutr. 2011 Jan;35(1):16-24

Full Nutrition Assessment
• A comprehensive approach to diagnosing nutrition problems
that uses a combination of the following:

physical examination laboratory data

nutrition history anthropometric Imaging data

• Provides the basis for a nutrition intervention.

JPEN J Parenter Enteral Nutr. 2011 Jan;35(1):16-24

Difference?

✓
Nutrition Screening
• A process to identify an
individual who is
Nutrition Assessment
• Identify any specific nutrition
risk(s) or clear existence of
malnourished or who is at malnutrition
risk for malnutrition • More specificity
• Within 24-48 hours • More complicated and take
• High sensitivity time
• Easy and less time required

JPEN J Parenter Enteral Nutr. 2011 Jan;35(1):16-24

 Nutrition Screening Tools
Screening Tools Note

Malnutrition Screening Tool(MST) - Outpatient and inpatient setting

- Validated in oncologic patients
Malnutrition Universal Screening tool(MUST) - Good validity for detecting malnourished elderly
- Validated in hospitalized oncologic and COPD patients
Nutrition Risk Screening 2002(NRS2002) - Recommended in critically ill patients
- Validated in hospitalized CKD
Nutrition Risk in the Critically Ill(NUTRIC)score - Recommended in critically ill patients but poor
correlation with nutrition status
Mini Nutritional Assessment-Short Form - High sensitivity for detecting malnourished elderly
- Useful in sarcopenic screening in COPD
SPENT screening tools - Recommend in all hospitalized patients in Thailand

JPEN J Parenter Enteral Nutr. 2011 Jan;35(1):16-24

 Malnutrition Screening Tools(MST)

Weight
A score of 0 – 1indicates a low risk of malnutrition
A score of 2 indicates a moderate risk of malnutrition
A score of 3 – 5 indicates a high risk of malnutrition

Intake

Ferguson et al. 53
Malnutrition Universal Screening Tools(MST)
BMI Intake

Weight Patient’s condition

Clinical medicine (London, England). 4. 405-7.

 Nutrition Risk Screening 2002
Initial screening

BMI

Weight

Intake

Patient’s condition

≥ 1 score

Clinical Nutrition (2003) 22(4): 415–421

Nutrition Risk Screening 2002
Final screening
Weight Intake Patient’s condition

Age

Clinical Nutrition (2003) 22(4): 415–421

Modified NUTRIC Score

https://www.criticalcarenutrition.com/
Modified NUTRIC Score

Clinical Nutrition 35 (2016) 158-162

Modified NUTRIC Score

Clinical Nutrition 35 (2016) 158-162

 Modified NUTRIC Score
A1. Based on expert consensus, we suggest a
determination of nutrition risk (eg, nutritional
risk screening [NRS 2002], NUTRIC score) be
performed on all ICU patients whom intake is
anticipated to be insufficient.

High nutrition risk identifies those patients

most likely to benefit from early EN
therapy(JPEN 2016)
• NUTRIC score has explained only 1.1%
of the variance of phase angle.
• NUTRIC score has a limited prediction to
the urgency of aggressive nutrition
therapy within the early period of ICU
admission

(Nutr Clin Pract. 2019;0:1–8)

Lancet Respir Med 2023; 11: 602–12
 All patients treated with invasive mechanical ventilation
and vasoactive drugs for shock within 24 hours after ICU admission

Randomisation was stratified by centre

using permutation blocks of variable sizes

6 kcal/kg per day and 0·2–0·4 g/kg per day 25 kcal/kg per day and 1·0–1·3 g/kg per day
On day 8, the targets were changed to 30 kcal/kg per day for calories and 1·2–2·0 g/kg per d
Baseline Characteristic

The Lancet Respiratory medicine 2023;11(7):602-12.

Mini Nutrition Assessment-Short Form

https://mna-elderly.com/forms/MNA_thai-052021.pdf
 SPENT Screening Tool

Weight
Intake ≥2 points
Patient’s condition

SPENT Guideline in Adult Hospitalized Patients. 2017

SPENT Guideline

Within 24-48 hours Within 1 week

SPENT Screening Tools

≥2 points <2 points

NAF/NT

NAF A NAF B NAF C

SPENT Guideline in Adult Hospitalized Patients. 2017

Nutrition Screening Tools

MST MUST NRS2002

SPENT
NUTRIC MNA-SF screening
tool
Difference?

Nutrition Screening
• A process to identify an
individual who is
✓ Nutrition Assessment
• Identify any specific nutrition
risk(s) or clear existence of
malnourished or who is at malnutrition
risk for malnutrition • More specificity
• Within 24-48 hours • More complicated and take
• High sensitivity time
• Easy and less time required

JPEN J Parenter Enteral Nutr. 2011 Jan;35(1):16-24

 Nutrition Assessment Tools
Assessment Tools Note

Subjective Global Assessment(SGA) - Validated and familiar tools in many setting

- Associated with mortality and length of stay
Patient-Generated Subjective Global - More extensive tools consisting of patient-generated section
Assessment(PG-SGA) identify symptoms
- Validated in cancer patients
Mini Nutritional Assessment(MNA) - Validated in geriatric patients

Malnutrition-Inflammation Score(MIS) - Validated in dialysis patients and associated with hospitalization

and mortality
Global Leadership Initiative on - Consensus-based approach and worldwide accepted criteria
Malnutrition(GLIM) - Provide a globally accepted starting point to identifying
malnutrition
Nutrition Alert Form(NAF) - Recommended in all hospitalized patients and validated in cancer

Nutrition Triage(NT) - Recommended in all hospitalized patients

SGA
Weight

Intake

GI symptoms

Function

Physical examination
Journal of renal nutrition. 14. 191-200.
MNA
MIS
GLIM Criteria
Global Leadership Initiative on Malnutrition

1
≥ 1 in 3 points
+
2
≥ 1 in 2 points

Malnutrition

Clinical Nutrition. 2019;38(1):1-9.

 GLIM Criteria

1 % weight loss Low body mass index Reduce muscle mass

2 Reduced food intake or assimilation Inflammation

Clinical Nutrition. 2019;38(1):1-9.

GLIM Criteria: Severity

Limitation in Asia!

Clinical Nutrition. 2019;38(1):1-9.

Nutrition Alert Form

✓
✓

SPENT Guideline in Adult Hospitalized Patients. 2017

Nutrition Alert Form

SPENT Guideline in Adult Hospitalized Patients. 2017

Nutrition Alert Form

Limitation!
SPENT Guideline in Adult Hospitalized Patients. 2017
Nutrition Alert Form

NAF A 0-5 points NAF B 6-10 points NAF C ≥ 11 points

15

Normal Moderate malnutrition Severe malnutrition

Re-evaluate Nutrition Support Nutrition Support

within 1 week within 3 days within 24 hours

SPENT Guideline in Adult Hospitalized Patients. 2017

Nutrition Alert Form
Nutrition Alert Form
จ่ายตามค่า
กลาง
การเบิกจ่ายค่าชดเชยทางการแพทย์ ดังนี้ DRGs

✓ โรงพยาบาลใช้ทรัพยากรสาหรับรักษาพยาบาลผู้ปว่ ยเป็นการล่วงหน้า
✓ โรงพยาบาลเรียกเก็บค่าชดเชยบริการทางการแพทย์จากกองทุนสุขภาพ
(ข้าราชการ ประกันสังค หลักประกันสุขภาพ)
✓ กองทุนสุขภาพใช้อตั ราการจ่ายตา ระบบกลุ่ กลุ่ วินิจฉัยโรคร่ว (DRGs)
สาหรับการให้บริการผู้ป่วยใน
เรียกเก็บจาก จ่ายตาม
รพ.รักษาก่อน
กองทุน RW--- DRGs
 Nutrition Alert Form

• หลักเกณฑ์ ในสรุปต้ องมีข้อมูลสนับสนุน ดังนี้

• 1.มีการคัดกรอง (screening)และการประเมิน (assessment) ภาวะโภชนาการของผูป้ ่ วย
ได้แก่ Nutrion trige(NT) หรื อ แบบฟอร์ม nutrition alert form (NAF) เพื่อใช้จาแนกระดับ
ความรุ นแรงของภาวะทุพโภชนาการ
• 2. ให้เลือกภาวะทุพโภชนาการที่รุนแรงที่สุดของการรับไว้ใน รพ. คราวนั้นเป็ นวินิจฉัย
• 3. โรงพยาบาลควรจัดตั้งทีมโภชนบาบัด (nutrition support team) แบบสหสาขา เพื่อให้
การดูแลรักษาผูป้ ่ วยที่มีภาวะทุพโภชนาการได้อย่ทีา่มางต่ อเนื่อง
: คู่มือแนวทางปฏิบตั ิในการตรวจสอบเอกสารหลักฐานการเรี ยกเก็บค่าใช้จ่าย เพื่อบริ การ
สาธารณสุ ขของหน่วยบริ การในระบบหลักประกันสุ ขภาพแห่งชาติ ปี 2562
 คุณกนกร ัตน์ ไสยเลิศ
หัวหน้างานเวชระเบียนผูป้ ่ วยใน
กลุม
่ งานสารสนเทศทางการแพทย ์
โรงพยาบาลขอนแก่น
สถิตจิ านวนสรุปวินิจฉัย Malnutrition (E40-E46)

ปี 2560 = 169 ราย ปี 2564 = 923 ราย

ปี 2561 = 130 ราย ปี 2565 = 799 ราย
ปี 2562 = 213 ราย ปี 2566 = 655ราย
ปี 2563 = 162 ราย

ก่อนพัฒนา หลังพัฒนา
ที่มา : งานข้อมูลและสถิติ กลุม่ งานสารสนเทศทางการแพทย์, ข้อมูล ณ วันที่ 10 มกราคม 2567
 สถิติการวินิจฉัยโรค malnutrition ที่ ีผลต่อค่า DRGs
ปี งบประมาณ (ราย)
ที่ ICD 10 คาวินิจฉัย
2560 2561 2562 2563 2564 2565 2566 รวม

1 C00 - C97 Malignant neoplasms 18 14 28 29 518 595 428 1630

2 J120 - J189 Pneumonia 30 24 20 22 108 126 162 492
3 I500 Congestive heart failure 2 1 0 0 17 20 7 47
4 N185 Chronic kidney disease, stage 5 0 0 0 3 8 4 9 24
5 L891 Bedsore Stage II 2 1 0 1 7 0 5 16
6 N10 Acute tubulo-interstitial nephritis 1 1 1 0 8 1 0 12
7 E110 DM with coma 1 1 0 0 1 0 2 5
รวม 54 42 49 55 667 746 613 2226
 เปรียบเทยบค่าประมาณการ Hospital reimbursement of Malnutrition
Diagnosis Severe & moderate malnutrition ปี งบประมาณ 2565
ที่่ ICD 10 กลุ่มโรค ปี งบประมาณ 2565

Adj.RW ไม่ Adj.RW ผลต่าง 1 จานวน(ราย) ประมาณการณ์ทงั้ หมด

มี มี adj.RW
malnutrition malnutritio /1 ราย
n
1 C00 - C97 Malignant neoplasms 0.8905 2.067 1.1765 10,588.50 595 6,300,158
2 J120 - J189 pneumonia 0.5661 0.9877 0.4216 3,794.40 126 478,094
3 I500 Congestive heart failure 0.8915 1.6921 0.8006 7,205.40 20 144,108
4 N185 Chronic kidney disease, stage 5 0.5767 1.1205 0.5438 4,894.20 4 19,577
5 L891 Bedsore Stage II 1.4164 2.4689 1.0525 9,472.50 0 0
6 N10 Acute tubulo-interstitial nephritis 0.6181 1.6079 0.9898 8,908.20 1 8,908
7 E110 DM with coma 0.4723 0.9551 0.4828 4,345.20 0 0

รวม 6,950,845
 ตัวอย่าง DRGs ค่า Adj.RW โรค Pneumonia
No malnutrition Severe malnutrition
 Nutrition Triage 2013
Physical examination

Intake

Function

Weight
 Nutrition Triage 2013
Comorbidity
 SPENT Guideline

• คำแนะนำ ที่ ๑.๕ การวินิจฉัยความเสี่ ยงต่อภาวะทุพโภชนาการ ควรมีการ

ระบุเป็ นเอกสารแนบในแฟ้มผูป้ ่ วยหรื อ ระบบสารสนเทศของโรงพยาบาล
เพื่อใช้ในการติดตามผูป้ ่ วยหลังจากจาหน่ายหรื อเพื่อใช้ในการตรวจสอบและ
การเบิกจ่ายตามระดับ diagnosis-related group (DRG)

SPENT Guideline in Adult Hospitalized Patients. 2017

ICD-Code
• Severe malnutrition
E43 • BMI < 16 kg/m2 , NAF C, NT 4

• Moderate malnutrition
E44.0 • BMI 16-16.99 kg/m 2 , NAF B, NT 3

• Mild malnutrition
E44.1 • BMI 17-18.49 kg/m2 , NT 2

SPENT Guideline in Adult Hospitalized Patients. 2017

Nutrition Assessment Tools

SGA PG-SGA GLIM

MNA MIS NAF/NT

Outlines
• Malnutrition diagnosis
• Nutrition screening and assessment tools
• Full nutrition assessment
Nutrition Assessment
Full Nutrition Assessment
• Anthropometric assessment
• Mid arm muscle circumference, tricep skin fold, weight , height
• Biochemical assessment and body composition
• Anemia, albumin, prealbumin, transferrin
• Bioelectrical impedance analysis, CT scan, DEXA, ultrasound muscle mass
• Clinical data and physical examination
• Hand grip, performance test, sign of macro/micronutrient deficiency, sign of secondary
cause of obesity
• Diet assessment
• Quantity and quality
• Economy
• Fortified diet, oral nutritional supplement, commercial product, blenderized diet
History Taking: Malnutrition

• Dietary recall
Dietary
intake • Ability to assess
food

• Severity
Weight
• Increase/decrease

GI • Appetite
symptoms • GI loss
Physical Examination: Malnutrition

Sign of macronutrient deficiency

Sign of micronutrient deficiency

Macronutrient Deficiency
• Weight
Weight • Height BMI = weight(kg) ÷ height(m)2
• BMI

• Mid-arm
Muscle muscle
circumference

• Triceps
• Biceps
Fat
• Subscapular
• Suprailiac

https://mucomplex.mahidol.ac.th/
SGA

PG-SGA

NT
Subcutaneous fat

Muscle

Edema
Mid Arm Circumference

Acromion

Olecranon

Wikihow.com
Triceps Skinfold Thickness

Acromion

Olecranon

Wikihow.com
Triceps Skinfold Thickness

https://med.mahidol.ac.th/med/
Mid Arm Muscle Circumference
MAMC = MAC – π (TSF)

• MAMC = Mid arm muscle circumference(cm)

• MAC = Mid arm circumference(cm)
•π = 3.14
• TSF = Triceps skin fold(cm)
Mid Arm Muscle Circumference

https://med.mahidol.ac.th/med/
Physical Examination: Malnutrition
Hair and nails Neuro

Skin Abdomen

Eye Bone

Perioral MSK

Tongue
Physical Examination: Malnutrition

Food and nutrition bulletin 2010

Nutrition in Clinical Practice, 34: 490-503
Macronutrient Deficiency
Kwashiorkor
• Enamel paint spots (superficial
desquamation) in mild case to
flaky paint dermatosis (large
areas of erosion)
• Hair: spare, dry, brittle with
reddish tinge, flag sign(bands
of light and dark discoloration)
• Edema

Central Bringing Excellence in Open Access

Macronutrient Deficiency
Essential fatty acid deficiency
• Dry, scaly rash esp.
intertriginous area
• Hair loss
• Hair depigmentation
• Poor wound healing
• Easy infection

Practical Gastroenterology. June 2017

Macronutrient Deficiency

USMLE step 2 Ck
Micronutrient Deficiency
Vitamin B deficiency
• Angular stomatitis
• Cheilosis with fissuring
• Glossitis
• Seborrheic dermatitis like
• Photophobia and
conjunctivitis

Nutrition in Clinical Practice, 34: 490-503

Micronutrient Deficiency
Niacin deficiency
• Dermatitis
• Well defined crusted scaly
keratotic plaque at
photoexposed area
• Gaunlet sign, Casal’s
necklace, gaiter sign,
butterfly at face

Fitzpatrick 9th edition

Nutrition in Clinical Practice, 34: 490-503
Micronutrient Deficiency
Vitamin B2 and B6
deficiency

N ENG J MED. 350; 11

Micronutrient Deficiency
Vitamin C deficiency
• Follicular keratotic plugging
• Corkscrew hairs
• Perifollicular purpura
• Poor wound healing
• Hemorrhagic gingivitis
• Scorbutic rosary

Fitzpatrick 9th edition

Nutrition in Clinical Practice, 34: 490-503
Micronutrient Deficiency
Vitamin A deficiency
• Night blindness
• Xeropthalmia
• Bitot’s spot
• Xerosis
• Perifollicular
hyperkeratosis

Fitzpatrick 9th edition

Nutrition in Clinical Practice, 34: 490-503
Micronutrient Deficiency
Zinc deficiency
• Alopecia
• Acrodermatitis
• Eczematous and erosive
dermatitis

Fitzpatrick 9th edition

Nutrition in Clinical Practice, 34: 490-503
Micronutrient Deficiency
Iron deficiency
• Koilonychia
• Aphthous stomatitis
• Angular stomatitis
• Atrophied tongue papillae

Nutrition in Clinical Practice, 34: 490-503

Handbook of Famine, Starvation, and Nutrient Deprivation. 2017
Micronutrient Deficiency
Copper deficiency
• Kinky hair
• Pili torti, steel wool
• Skin depigmentation

Journal of Clinical Pathology 2006

Functional Assessment
• Muscle strength
• Handgrip strength
• Low if male < 28 kg and female < 18 kg
• Physical performance
• 5-time chair stand test (abn if ≥ 12 s)
• 6-m walk(abn if < 1 m/s)

Asian Working Group for Sarcopenia: 2019

 No single

Laboratory: Nutritional Marker nutritional

marker

Marker Half life Low in conditions Note

Serum albumin 20 days Malnutrition, infection, -Long half life

burns, fluid overload, -Influenced by several
hepatic failure, cancer, factors
nephrotic syndrome
Serum transferrin 10 days Malnutrition but -Responds more
influenced by iron rapidly
status
Prealbumin 2-3 days Malnutrition, infection, -Unaffected by
liver failure hydration status
-False high in renal
failure

J. Clin. Med. 2019, 8, 775

Gastroenterol Rep (Oxf). 2016 Nov; 4(4): 272–280.
Take Home Message
• Nutrition screening which is high sensitivity tool should be
done within 24-48 hours
• Nutrition assessment is for identification of malnutrition and
full nutrition examination should be implemented
• Early detection, prioritize nutrition risk and prompt nutrition
intervention should be considered.
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YOUR ATTENTION
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