What is a nutrition screening tool

A limitation of using SGA is that it only classifies subjects into three general groups, and it does not reflect subtle changes in nutritional status. Furthermore, it is subjective, does not account for biochemical values e.

Thus, here we describe the several components that should be part of the nutritional assessment process and interpreted by specialized clinical staff e. Most of these components have limited sensitivity and specificity when used individually; therefore, methods for identifying malnourished patients require the use of several parameters and the clinical judgment of experienced and specialized clinical staff.

Detailed evaluation leads to an understanding of the nature and cause of the nutrition-related problem, and will inform the design of a personalized nutritional care plan [ 30 ]. Body weight, height, and the resulting BMI are important parameters which are relatively easy to obtain from patients with acute as well as chronic diseases.

If height cannot be assessed e. The body weight measurement should be standardized e. The BMI is an indicator of chronic malnutrition. However, the BMI has some limitations. For example, it may be biased by fluid overload and edemas, and does not describe body composition for example, a high BMI can be seen in fat individuals and also in very muscular athletes. Unintentional weight loss is paramount for the assessment of nutritional status, as it points to a catabolic metabolic situation and is associated with higher morbidity and mortality rates.

One of the easiest and lowest-priced non-invasive methods is the measurement of the circumference of a limb e. The subcutaneous fat tissues normally account for half of the entire body fat mass, and the measurement of SFT gives information on the energy stores of the body, mainly fat stores i.

To estimate the total amount of body fat, four skinfolds need to be measured [ 33 ]:. The measurement of SFT requires trained staff and defined conditions.

The high interindividual variability is a clear disadvantage of this method, as age, gender, and ethnicity influence the fat mass.

The decrease in MAMA shows the loss of muscle mass, as a mobilization of the endogenous proteins. This method is not reliable in patients with fluid overload, however, nor does it represent short-term modifications of the nutritional status.

For these reasons, triceps skin fold and MAMA are mostly used for research purposes and not in daily clinical routine, as they give validated data—especially when measurements are performed by the same investigator and repeated in a given time period. Body weight—including weight loss, calculation of the BMI, and measurement of the length, circumference, or thickness of various body parts—is useful for the assessment of nutritional status. Body composition describes the body compartments, such as fat mass, fat-free mass, muscle mass, and bone mineral mass, depending on the body composition model used Figure 1.

Body composition measurements may serve as an early diagnostic tool, as quantification, or as a follow-up method that helps to assess nutritional status [ 34 ]. Body composition may change due to disease, age, physical activity, and starvation. There are several methods available to determinate body composition, more or less invasively, as described in the following section Table 4.

Compartment models of body composition. Modified after [ 40 ]. Bioelectrical impedance analysis BIA is a simple, inexpensive, non-invasive method of estimating body composition. BIA relies on the conduction of an alternating electrical current by the human body. The current passes easily through tissues containing a lot of water and electrolytes like blood and muscles, whereas fat tissues, air, and bone are harder to pass through.

Therefore, the larger the fat-free mass, the greater the capacity of the body to conduct the current. BIA gives good information about total body water, body cell mass, and fat mass when correcting for age, sex, and ethnicity. The newly developed bioelectrical impedance vector analysis BIVA provides information about hydration status, body cell mass, and cell integrity through the vector length and position.

Creatine is metabolized to creatinine at a more or less stable rate, and reflects the amount of muscle mass [ 37 ]. Creatinine excretion correlates with lean body mass and body weight. Urinary creatinine excretion may be influenced by several factors, such as renal insufficiency, meat consumption, physical activity, fever, infections, and trauma.

Additionally, the collection of h urine is challenging in daily practice and further limits the use of this method. DXA is currently considered the gold standard of body composition measurement. It is increasingly used in clinical practice and in research, despite some exposure to radiation. DXA depends on radiological density analysis usually in the hip and spine and is a useful, indirect method of measuring fat mass, fat-free mass, and bone mineral mass.

Magnetic resonance tomography MRT and computed tomography CT allow the quantification of fat mass and fat-free mass, giving information about the fat distribution and enabling an estimation of skeletal muscle mass. These two methods are mainly used in research due to their restricted availability, their cost, and the time expended [ 39 ]. However, it is often possible to obtain nutritional information from scans taken for general diagnostic purposes.

Several other methods are available, mainly for research purposes due to their complexity. These demanding and expensive methods include air displacement plethysmography ADP , dilution methods, the measurement of total body potassium, and in vivo neutron activation analysis [ 40 ].

It is based on the determination of the body volume by means of air displacement having regard to the residual air volume in the lungs and the gastrointestinal tract. Since the density of fat differs from the density of fat free mass, they can both be determined using a two-compartment model. ADP may also be used in ill patients, unlike other densitometry measurement using hydrodensitometry.

The dilution methods aim to determinate the total body water by means of dilution of non-radioactive isotopes e. Such tracers are given orally or parenterally, and their concentrations in urine and blood are measured after a defined time. Extracellular water can then be determined using bromide or sulfate, allowing the definition of intracellular water. Since potassium is mostly found intracellularly and the natural isotope K 40 is present in constant fraction, the measurement of the potassium allows the calculation of the body cell mass and thus enables the very accurate determination of the body cell mass.

With the in vivo neutron activation, the body is irradiated with neutron radiation, inducing the emission of a characteristic spectrum of gamma-radiations.

This expensive method allows the quantification of single elements such as nitrogen, calcium, sodium, etc. There is no single parameter that can thoroughly assess nutritional status or monitor nutritional therapy. However, a set of laboratory parameters in the clinical routine e. Laboratory values—particularly in chronically malnourished patients—may help to detect deficiencies in vitamins C, D, E, K, thiamine, B6, B12, and folic acid and trace elements zinc, selenium, and iron and help to monitor current substitution therapies.

In the early phase of refeeding, potassium, phosphate, and magnesium deficiencies may occur, potentially leading to severe complications e. Laboratory values to detect malnutrition and monitor nutritional status [ 41 ]. Laboratory values are mostly delayed and costly, and largely dependent on the analytic method and the analyzing laboratory.

Additionally, numerous non-nutrition-related factors may influence the laboratory parameters e. Thus, laboratory values must always be interpreted within the clinical context. It is the starting point of the nutritional assessment. Factors leading to malnutrition such as pain, gastrointestinal symptoms e. Physical examination is an objective method of detecting clinical signs and symptoms of nutritional deficiencies of vitamins and minerals e.

Some clinical signs are specific to a specific disease or nutrient deficiency. Others are non-specific and need further tests to elucidate their etiology Table 6. Physical examination includes the control of vital parameters, the inspection and palpation for water retention edema and ascites , and a rough assessment of muscle mass and subcutaneous fat stores.

Clinical signs and symptoms of micronutrient deficiencies [ 40 , 42 ]. Functional measurements are increasingly important in nutritional assessment. Indeed, muscle strength and cognitive functions all influence quality of life. Energy deficiency diminishes muscle strength and power, as well as overall physical condition. It is therefore very relevant to have information about muscle function and strength in the clinical setting. Muscle function tests are very sensitive to nutritional deficiencies, and therefore also to nutritional interventions.

Changes can therefore be noticed much earlier than through body composition tests, for example. Hand dynamometry has been validated as a nutritional marker, correlates very well with the nutritional status, and is simultaneously a good predictor of surgical outcome, increased hospital length of stay, higher re-hospitalization rates, and decreased physical status.

It is additionally a good predictor for short- and long-term mortality [ 43 ]. Other possible measurements are knee extension, hip flexion strength, or peak expiratory flow. Measurement of the distance walked in a given time e. Fluid and alcohol intake should also be recorded. The quantification of food intake is one of the key approaches to assessing nutritional risk in individual patients. The assessment of macronutrients fat, carbohydrates, and proteins is as important as the assessment of micronutrients vitamins, trace elements.

There are numerous standardized methods of measuring food intake, such as 24 h food recall, food frequency questionnaires, and direct observation food records are frequently used by nurses for institutionalized patients. These provide semi- quantitative information.

The accurate assessment of food intake is difficult and error-prone. There is a growing need for more accurate dietary assessment methods. High-quality data are essential for research on the association between diet and health, for an understanding of dietary patterns, and for the identification of nutrition-related health problems [ 45 ].

Innovative technologies that improve dietary assessment have been proposed recently, and can be classified into four principal groups according to the technological features that each of them incorporate [ 46 , 47 , 48 , 49 , 50 ]:.

Systems that incorporate some degree of automation. These either use bar-code readers in order to automatically recognize packaged food labels [ 50 ], or utilize smartphone applications that integrate the automatic recognition of food items.

In this case, the user takes photos of the food and the system recognizes the type of food. Systems that are completely based on artificial intelligence. In a typical scenario, the user takes photo s of the food and then the system automatically and in real-time identifies the different food items identification , recognizes the type of each of them labeling , and creates a 3D model of each of them 3D reconstruction [ 54 , 55 , 56 , 57 , 58 ].

Supported by food composition databases, food images are translated into nutrient values such as grams of macronutrients or calories [ 54 , 56 ]. These new technologies have several advantages.

Additionally, these technologies offer portability and greater social acceptability than paper-based methods [ 59 ]. However, there are also some limitations for each group. The manual dietary assessment methods provide all the disadvantages of paper-based methods except for expenditures related to paper usage. Body sensor monitoring provides no input about the type or quality of the food that is captured [ 50 ].

What is more, dietician-supported assessment is labor-intense and expensive to analyze [ 50 ]. Moreover, with the AI-based systems, it is not possible to capture all the basic nutrient information including cooking methods with one single image [ 45 ], and the majority of the existing apps are manual or semi-automatic in terms of food logging, and non-automatic in portion size estimation.

Individuals tend to estimate portion size inaccurately [ 62 ]; almost half of the errors found in food records are attributed to such faulty estimations [ 63 ]. Other possible disadvantages are under-reporting due to either poor image quality or user negligence in taking an adequate number of pictures before and after food and drink consumption [ 64 ].

In addition, some food types such as mixed foods or liquids are difficult to analyze with automated image analysis [ 58 ]. Tools that include only some AI components are usually non-validated; they include a limited number of food categories, and questions relating to the used nutrient databases arise [ 50 ]. The most important limitation of the majority of these technologies is the need for a tech-savvy user [ 45 ].

Several studies have compared dietary assessment by traditional methods versus innovative technologies. Some of them conclude that electronic records would be a useful tool, both for large-scale epidemiological studies and in the clinical context [ 61 ].

Others conclude that apps could replace the traditional h recall and serve as feasible tools for dieticians investigating dietary intake at a population level [ 65 ].

The longer the app recording periods are, the better the correlation between the traditional and the innovative methods seems to be [ 66 ]. However, novel technologies for dietary assessment appear valid at the population level rather than for individualized support [ 67 , 68 , 69 ]. Even though there are an increasing number of studies in the domain of innovative technologies, sample sizes are relatively low, and duration is usually short.

Therefore, there is a need for well-designed long-term studies to explore and analyze the combination of traditional methods and state-of-the-art technological tools which characterizes the new era of nutritional assessment. Energy requirements are calculated from the basal energy requirement multiplied by an activity factor.

They can be calculated with formulae e. These formulae cannot be used in special situations e. The protein requirement may be estimated by using 1. The specific macronutrient requirements are described in Table 7.

Indirect calorimetry remains the gold standard for the assessment of energy requirements, but in many clinical settings this option is not available, as indirect calorimeters may not be easy to operate and may not be portable or affordable.

Several conditions may impair food intake and should be taken into account as well. Additionally, cognitive changes affecting appetite and ability to feed oneself, and physiological changes that affect the desire to eat, may negatively impact the dietary intake.

The assessment of quality of life is a more subjective parameter that is being increasingly included in nutritional assessment. It reflects the current health status, and may be used as an outcome parameter to monitor nutritional therapy. It is based on the perception of wellbeing in different domains—for example, symptoms pain , physical mobility, strength , psychological anxiety, depression , and social isolation , all potentially having an effect on eating.

There are many questionnaires available, but there is no established consensus on which should optimally be used. Malnutrition is a frequent threat in hospitals, and is associated with negative outcomes. However, it remains a mostly treatable condition when there is adequate nutritional management. It is crucial to identify patients who are at nutritional risk or malnourished as early as possible, allowing the start of timely and effective nutritional support.

Identifying patients at risk of malnutrition is the first step in the nutritional care process within a multimodal care system. Nutritional risk screening with simple and rapid tools should be performed systematically in each patient at hospital admission to detect patients who are nutritionally at risk or malnourished. Comprehensive detailed nutritional assessment should be performed thereafter in those patients identified as at risk of malnutrition or who are malnourished.

This screening should be performed by a specialist e. New assessment methods may be very helpful, as they are accurate and quick. Systematic nutritional risk screening and standardized nutritional management may also contribute to reduced healthcare costs. Conceptualization, E. National Center for Biotechnology Information , U. Journal List J Clin Med v.

J Clin Med. Published online Jul Vasiloglou , 3 Philipp Schuetz , 4, 5 and Zeno Stanga 1. Maria F. Author information Article notes Copyright and License information Disclaimer. Received May 30; Accepted Jul 9. This article has been cited by other articles in PMC.

Keywords: nutritional risk screening, nutritional assessment, malnutrition. Introduction Nutrition is a basic need of life and thus plays an important role in health promotion and disease prevention. Screening Nutritional risk screening tools are very helpful in the daily routine to detect potential or manifest malnutrition in a timely manner. Table 1 Nutritional Risk Screening Yes Is the patient critically ill? Yes If yes to one of those questions, proceed to screening.

If no for all answers, the patient should be re-screened weekly. Open in a separate window. If adequate: little concern and repeat screening hospital weekly, care home at least monthly, community at least every 2—3 months. If inadequate: clinical concern. Follow local policy, set goals, improve and increase overall nutritional intake, monitor and review care plan regularly. Set goals, improve and increase overall nutritional intake. Monitor and review care plan hospital weekly, care home monthly, community monthly.

Screening A Has food intake declined over the past 3 months due to loss of appetite, digestive problems, or chewing or swallowing difficulties? Do not answer F2 if F1 is already completed. Assessment Nutritional assessment should be performed in patients identified as at nutritional risk according to the first step i.

Anthropometric Measurements 3. Body Weight and Body Mass Index Body weight, height, and the resulting BMI are important parameters which are relatively easy to obtain from patients with acute as well as chronic diseases. Skinfold Measurements One of the easiest and lowest-priced non-invasive methods is the measurement of the circumference of a limb e. To estimate the total amount of body fat, four skinfolds need to be measured [ 33 ]: — Biceps skinfold front side of the middle upper arm ; — Triceps skinfold back side of the middle upper arm ; — Subscapular skinfold under the lowest point of the shoulder blade ; and — Suprailiac skinfold above the upper bone of the hip.

Body Composition Body weight—including weight loss, calculation of the BMI, and measurement of the length, circumference, or thickness of various body parts—is useful for the assessment of nutritional status. Figure 1. Table 4 Advantages and disadvantages of methods used to assess body composition. Creatinine Height Index CHI Creatine is metabolized to creatinine at a more or less stable rate, and reflects the amount of muscle mass [ 37 ]. Magnetic Resonance Tomography MRT and Computed Tomography CT Magnetic resonance tomography MRT and computed tomography CT allow the quantification of fat mass and fat-free mass, giving information about the fat distribution and enabling an estimation of skeletal muscle mass.

Further Methods Used to Measure Body Composition Several other methods are available, mainly for research purposes due to their complexity. Biochemical Analysis There is no single parameter that can thoroughly assess nutritional status or monitor nutritional therapy. Table 5 Laboratory values to detect malnutrition and monitor nutritional status [ 41 ]. Clinical Evaluation 3. Physical Examination Physical examination is an objective method of detecting clinical signs and symptoms of nutritional deficiencies of vitamins and minerals e.

Table 6 Clinical signs and symptoms of micronutrient deficiencies [ 40 , 42 ]. Physical Function Functional measurements are increasingly important in nutritional assessment.

Innovative technologies that improve dietary assessment have been proposed recently, and can be classified into four principal groups according to the technological features that each of them incorporate [ 46 , 47 , 48 , 49 , 50 ]: — Manual dietary assessment —The user inserts all required data e. This method replaces the paper-based methods of dietary assessment into an electronic form by the use of pictures, video, text, or voice without the inclusion of automatic features.

These data are then analyzed by nutrition experts who use standardized methods e. No automation features are usually incorporated. Table 7 Macronutrient requirements for adults. Quality of Life The assessment of quality of life is a more subjective parameter that is being increasingly included in nutritional assessment.

Conclusions and Outlook Malnutrition is a frequent threat in hospitals, and is associated with negative outcomes. Screening A Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? Author Contributions Conceptualization, E. Conflicts of Interest The authors declare no conflicts of interest.

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Foley N. Which reported estimate of the prevalence of malnutrition after stroke is valid? Bauer J. Evaluation of nutritional status in older persons: Nutritional screening and assessment. Schindler K. How nutritional risk is assessed and managed in European hospitals: A survey of 21, patients findings from the — cross-sectional nutritionDay survey.

This article elaborates dietary , biochemical, and anthropometric measurements as nutritional assessment methods that can be applied in four forms of nutritional assessment system: surveys, surveillance, screening, or interventions.

A comprehensive nutritional assessment includes 1 anthropometric measurements of body composition; 2 biochemical measurements of serum protein, micronutrients, and metabolic parameters; 3 clinical assessment of altered nutritional requirements and social or psychological issues that may preclude adequate intake;.

There are four steps in the process: Nutrition Assessment. Nutrition Diagnosis. Nutrition Intervention. Step 2: Nutrition Diagnosis. Step 3: Nutrition Intervention. Step 4: Nutrition Monitoring and Evaluation. Nutritional screening and assessment Nutritional screening , which is the focus of this report, refers to a rapid, general, often initial evaluation undertaken by nurses, medical or other staff, to detect significant risk of malnutrition and to implement a clear plan of action, such as simple dietary measures or.

Further efforts are warranted to improve nutritional assessment tools for use in vulnerable older adults. What is a nutrition screening tool? Category: healthy living nutrition. Nutrition screening and assessment is an attempt to identify a patient's current nutritional status and related nutrient recommendations and requirements. Screening is a simple process used to discover those who are at risk of being malnourished and are therefore susceptible to diseases. What is a must score? What is nutritional anthropometry?

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What are the four main steps of the nutrition assessment process? NCP Snapshots. Step 1: Nutrition Assessment.