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NutriScreen

Nutritional Risk Screening Instruments

Recognised/validated and commonly used screening tools to identify patients with manifest malnutrition or at increased risk of malnutrition

NRS 2002

MNA®-SF

MNA®-LF

PG SGA

MST

MUST

SNAQ 65+

SARC-F

GLIM

DE EN FR IT

Information NutriScreen

NRS-2002 

Recognised/validated and commonly used screening tools to identify patients with manifest malnutrition or at increased risk of malnutrition
Nutrition therapy starts with the identification of patients with an increased risk of malnutrition. There are various "screening tools" recognised in medical practice for this purpose. The European Society for Clinical Nutrition and Metabolism (ESPEN) recommends the use of the Nutritional Risk Screening 2002 (NRS-2002). The treatment team should perform the screening within 24 h after hospital admission. With this application, the NRS-2002 can be easily calculated online 12.
The NRS-2002 quantifies the risk of malnutrition in adults based on nutritional status disorder (BMI, weight loss, food intake), severity of illness and age over 70 years on a scoring scale of 0-7:

NRS ≤2: Currently no risk of malnutrition requiring treatment.
NRS ≥3: Increased risk of malnutrition, initiate the following measures recommended:

  1. Detailed assessment and cause clarification of malnutrition.
  2. Nutritional counselling checks the indication for nutritional therapy in a multiprofessional setting.
  3. Record the diagnosis of malnutrition according to ICD ("International Classification of Diseases") and ensure coding.

  • Sensitivity: 37–96%
  • Specificity: 30–98.1%7

MNA®-SF (Mini Nutritional Assessment Short Form)

The Mini Nutritional Assessment - Short Form was published in 1990 for the assessment of malnutrition risk in geriatric patients* over 65 years of age.5
The assessment consists of six items. It is the first part of the complete Mini Nutritional Assessment (Long Form). It includes two major geriatric syndromes and risk factors for malnutrition, immobility and psychiatric problems.

  • Sensitivity: 35%5
  • Specificity: N/A

MNA®LF (Mini Nutritional Assessment Long Form)

The Mini Nutritional Assessment was published in 1990 for the assessment of malnutrition risk in geriatric patients over 65 years of age5. There is a short version of the assessment with 6 questions. The long full version contains 18 questions. Completion takes 10-15 minutes and should be done by a professional.

  • Sensitivity: 96%5
  • Specificity: 98%5

PG-SGA (Patient-Generated Subjective Global Assessment)

The Patient Generated Subjective Global Assessment (PG-SGA) is based on one of the oldest tools for assessing malnutrition risk. The Subjective Global Assessment was published in 1987. The PG-SGA was developed in 2005. The advantage is that the first part of the assessment can be completed independently by the patient. Scoring is challenging, but can be taught through appropriate training. The tool can be used in the clinical acute setting.6 You can find more information about the PG-SGA here.

MST (Malnutrition Screening Tool)

The Malnutrition Screening Tool was developed in Australia in 1999. It is suitable for hospitalized and ambulatory patients. It is also validated for elderly persons in nursing institutions. It consists of only two questions, one about weight loss and one about food intake, so this tool requires little time8. The MST is well suited to detect intra-individual changes in malnutrition risk7. It should be performed within 24 hours of admission and weekly thereafter. It can be used by healthcare professionals, administrative staff, family, or the patients* themselves6.

  • Sensitivity 41.8%-74.4%5
  • Specificity 82% - 91.8%5

MUST (Malnutrition Universal Screening Tool)

The Malnutrition Universal Screening Tool was published by the British Association for Parenteral and Enteral Nutrition (BAPEN) in 20039. It is intended for screening for malnutrition risk in adults. It is theoretically applicable in all settings (clinic, outpatient, physician offices, nursing homes and homes for the elderly)10. The tool requires data on weight loss, food intake, and disease severity, with consideration of BMI. If BMI cannot be calculated because weight or height cannot be measured, other methods can be used to estimate BMI, such as the circumference of the upper arm.5

  • Sensitivity: 47.9 - 100%7
  • Specificity: 48.9 - 99%7

SNAQ65+ (Short Nutritional Assessment Questionnaire 65+)

The Short Nutritional Assessment Questionnaire (SNAQ) was developed by a team of Dutch nutritionists. This questionnaire does not require any calculation and can be completed in five minutes. The questionnaire collects data on weight loss, upper arm circumference, and appetite and performance. It can be used in both clinical and outpatient settings.7

  • Sensitivity: 75 - 86%5
  • Specificity: 83 - 89%5

Sarc-F

Sarcopenia is the age-related reduction in muscle function and muscle mass. It is associated with falls, functional limitations, and frailty. One of the main risk factors of sarcopenia is malnutrition, specifically protein deficiency1. The International Clinical Practice Guideline for Sarcopenia (ICFSR) recommends annual screening in individuals over 65 years of age2. For this purpose, the Sarc-F questionnaire, which is quick and easy, can be used.  Consisting of five items, the questionnaire can provide a score (range 0 to 19). A score of 4 or higher means a suspicion of sarcopenia. In this case, diagnostics should follow and therapeutic measures should be taken if necessary, such as strength training or protein supplementation.3

  • Sensitivity: 75%4
  • Specificity: 67%4

GLIM11

To diagnose malnutrition, the Global Leadership Initiative on Malnutrition (GLIM) provided a definition in 2018 by global consensus. Prior to diagnosis, risk for malnutrition should be assessed through a validated screening tool. For diagnosis, a phenotypic and an etiologic criterion must be met. One of the following body composition methods is recommended for the determination of reduced muscle mass: DXA (dual X-ray absorptiometry), BIA (bioelectrical impedance analysis), CT or MRI. If these are not available, other methods can be used such as an physical examination or anthropometric measurements such as upper arm circumference or thigh circumference. Handgrip-strength can be determined to assist.


Recommended thresholds for determining reduced muscle mass:

Men Women
Appendicular Skeletal Muscle Index (ASMI, kg/m2) <7.26 <5.25
ASMI, kg/m2 (a) <7 <6
ASMI, kg/m2 (b)
DXA <7 <5.4
BIA <7 <5.7
Fat free mass index (FFMI, kg/m2) <17 <15
Appendicular lean mass (ALM, kg) <21.4 <14.1
Appendicular lean mass adjusted for BMI = ALM/BMI <0.725 <0.591

DXA = dual energy x-ray absorptiometry, BIA ¼ bioelectrical impedance analysis.
BMI = body mass index.
a Recommendations from European Working Group on Sarcopenia in Older People 2 (EWGSOP2); personal communication Alfonso Cruz- Jentoft.
b Recommendations from Asian Working Group for Sarcopenia (AWGS) for Asians.

References

  1. Schaupp, A., Martini, S., Schmidmaier, R. & Drey, M. (2021). Diagnostisches und therapeutisches Vorgehen bei Sarkopenie [Diagnostic and therapeutic approach to sarcopenia]. Zeitschrift fur Gerontologie und Geriatrie, 54(7), 717–724. https://doi.org/10.1007/s00391-021-01968-7
  2. Dent, E., Morley, J. E [J. E.], Cruz-Jentoft, A. J., Arai, H., Kritchevsky, S. B., Guralnik, J., Bauer, J. M., Pahor, M., Clark, B. C., Cesari, M., Ruiz, J., Sieber, C. C., Aubertin-Leheudre, M., Waters, D. L., Visvanathan, R., Landi, F., Villareal, D. T., Fielding, R., Won, C. W., . . . Vellas, B. (2018). International Clinical Practice Guidelines for Sarcopenia (ICFSR): Screening, Diagnosis and Management. The journal of nutrition, health & aging, 22(10), 1148–1161. https://doi.org/10.1007/s12603-018-1139-9
  3. Malmstrom, T. K. & Morley, J. E [John E.] (2013). SARC-F: a simple questionnaire to rapidly diagnose sarcopenia. Journal of the American Medical Directors Association, 14(8), 531–532. https://doi.org/10.1016/j.jamda.2013.05.018
  4. Drey, M., Ferrari, U., Schraml, M., Kemmler, W., Schoene, D., Franke, A., Freiberger, E., Kob, R. & Sieber, C. (2020). German Version of SARC-F: Translation, Adaption, and Validation. Journal of the American Medical Directors Association, 21(6), 747-751.e1. https://doi.org/10.1016/j.jamda.2019.12.011
  5. Chrástecká, M., Blanař, V. & Pospíchal, J. (2022). Risk of malnutrition assessment in hospitalised adults: A scoping review of existing instruments. Journal of clinical nursing. Vorab-Onlinepublikation. https://doi.org/10.1111/jocn.16470
  6. NEMO. (May 2017). Validated Malnutrition Screening and Assessment Tools: Comparison Guide. The State of Queensland 1995–2023.
  7. Skipper, A., Coltman, A., Tomesko, J., Charney, P., Porcari, J., Piemonte, T. A., Handu, D. & Cheng, F. W. (2020). Adult Malnutrition (Undernutrition) Screening: An Evidence Analysis Center Systematic Review. Journal of the Academy of Nutrition and Dietetics, 120(4), 669–708. https://doi.org/10.1016/j.jand.2019.09.010
  8. Ferguson, M., Capra, S., Bauer, J. & Banks, M. (1999). Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition (Burbank, Los Angeles County, Calif.), 15(6), 458–464. https://doi.org/10.1016/s0899-9007(99)00084-2
  9. Todorovic, V., Russell, C. & Elia, M. (2011). The ‘MUST’ Explanatory Booklet: A Guide to the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for Adults. BAPEN. https://www.bapen.org.uk/pdfs/must/must_explan.pdf
  10. Sharma, Y., Avina, P., Ross, E., Horwood, Hakendorf, P. & Thompson, C. (2022). Validity of the Malnutrition Universal Screening Tool for Evaluation of Frailty Status in Older Hospitalised Patients. Gerontology & Geriatric Medicine. Vorab-Onlinepublikation. https://doi.org/10.1177/23337214221107817
  11. Cederholm, T., Jensen, G. L., Correia, M. I. T. D., Gonzalez, M. C., Fukushima, R., Higashiguchi, T., Baptista, G., Barazzoni, R., Blaauw, R., Coats, A., Crivelli, A., Evans, D. C., Gramlich, L., Fuchs-Tarlovsky, V., Keller, H., Llido, L., Malone, A., Mogensen, K. M., Morley, J. E [J. E.], . . . Compher, C. (2019). GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. Clinical nutrition (Edinburgh, Scotland), 38(1), 1–9. https://doi.org/10.1016/j.clnu.2018.08.002
  12. Kondrup J, et al. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr. 2003;22(3):321-36.

List of abbreviations

BMI Body Mass Index
ESPEN  European Society for Clinical Nutrition and Metabolism
ICD International Statistical Classification of Diseases and Related Health Problems
NRS Nutritional Risk Screening



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