Assessment of nutritional status – basic measurement tools Fergus N Doubal November 2006.

Assessment of nutritional status Assessment of nutritional status – basic measurement tools– basic measurement tools

Fergus N DoubalFergus N Doubal

November 2006November 2006

DefinitionsDefinitions

Nutrition – the process of taking in and Nutrition – the process of taking in and assimilating nutrientsassimilating nutrients

Malnutrition – lack of proper nutritionMalnutrition – lack of proper nutrition

Dietician – an expert on diet and nutritionDietician – an expert on diet and nutrition

Nutritional state – very complexNutritional state – very complex

? Percentage make up/ measurable ? Percentage make up/ measurable things/ deleterious effectsthings/ deleterious effects

Who is at risk?Who is at risk?

EverybodyEverybody

The illThe ill

The elderlyThe elderly

The youngThe young

Those with chronic/debilitating diseaseThose with chronic/debilitating disease

Those who cannot retain/absorb nutrientsThose who cannot retain/absorb nutrients

Assessment is a dynamic processAssessment is a dynamic process

How do we measure nutritional How do we measure nutritional status?status?

1 - Questionnaire - appetite, mood, what 1 - Questionnaire - appetite, mood, what the patients normal diet is, have they lost the patients normal diet is, have they lost weight unintentionally, do they have weight unintentionally, do they have physical trouble eating, past and current physical trouble eating, past and current medical historymedical history

2. Bedside measurements2. Bedside measurements– WeightWeight– Height (ulnar length/ mid arm span)Height (ulnar length/ mid arm span)– Mid arm circumferenceMid arm circumference– Triceps skinfold thicknessTriceps skinfold thickness

3. Laboratory measurements3. Laboratory measurements– AlbuminAlbumin– PrealbuminPrealbumin– White blood cells and lymphocytesWhite blood cells and lymphocytes

– Which reference ranges to use.Which reference ranges to use.

Why do we need a screening tool? Why do we need a screening tool? (and how do they differ from nutritional assessment tools)(and how do they differ from nutritional assessment tools)

Screening tool screens for patients who Screening tool screens for patients who might be at risk of malnourishment and might be at risk of malnourishment and determines who should be further referred determines who should be further referred on for specialist interventionon for specialist intervention

Nutritional assessment tools are used to Nutritional assessment tools are used to assess current state of nutritionassess current state of nutrition

The two techniques overlapThe two techniques overlap

Why do we need a screening tool?Why do we need a screening tool?

Not all patients will need specialist Not all patients will need specialist nutritional input.nutritional input.

Malnourishment is however common and Malnourishment is however common and treatable with benefits to both the patient treatable with benefits to both the patient and the NHSand the NHS

There is a finite number of dieticiansThere is a finite number of dieticians

The LiteratureThe Literature

ConfusingConfusing

Each hospital seems to have their own Each hospital seems to have their own tooltool

No gold standard so huge variation in what No gold standard so huge variation in what is used as the reference standardis used as the reference standard

Many tools have not been validated which Many tools have not been validated which in itself is a hugely complicated businessin itself is a hugely complicated business

How many tools are there?How many tools are there?

Nursing nutritional screening tool,nutritional risk assessment tool,seniors in the community: risk evaluation for eating and nutrition,simple screening tools 1 and 2,Ayreshire nutrition screening tool,nursing nutritional assessment,nutritional assessment checklist,nutritional risk assessment scale,scales,nutritional screening tool,nursing nutritional screening tool,nutrition assessment chart,nutrition risk of older adults risk score,nutritional form for the elderly,five question nutritional screening tool,nutritional risk index,nutritional screening tool,australian nutrition screening initiative,mini nutritional assessment,determine,Level 1 screen.

All of the above are for the elderly

There are over 50 published toolsMost take between 2-30 minutes to complete

Mini nutritional assessment seemed to be coming out top (needed a which report) although it is backed by Nestle.

ConsiderationsConsiderations

Who is the tool forWho is the tool forAnd in which countryAnd in which countryIs it easy – do the nurses like it?Is it easy – do the nurses like it?Do the patients like it?Do the patients like it?Has it been validated by somebody who Has it been validated by somebody who did not invent it?did not invent it?Why is a new tool being made?Why is a new tool being made?MuddleMuddle

I asked the dieticians and nursesI asked the dieticians and nurses

What we use now is the Falkirk scoreWhat we use now is the Falkirk scoreTaken from FalkirkTaken from FalkirkBased upon scores re BMI, weight history, ability to eat, Based upon scores re BMI, weight history, ability to eat, appetite/intake, mental state, disease state, clinical appetite/intake, mental state, disease state, clinical condition, skin, agecondition, skin, ageGuidelines at bottom – monitor/frequency/refer and food Guidelines at bottom – monitor/frequency/refer and food chartchartEasy – nurses liked itEasy – nurses liked itOn Stroke Unit WGH all patients had form and all On Stroke Unit WGH all patients had form and all weighedweighedFeatures in the NHS Scotland best practice guidelinesFeatures in the NHS Scotland best practice guidelinesNo evidence published and then whamNo evidence published and then wham

MalnutritionUniversalScreening

Tool

This is the new NHS Lothian tool to be used by all Healthcare teams(Apart from Theatres, Children, Maternity and Renal services)

Launch – week beginning 30th OctoberCD Rom will be on the intranet

Clinical areas will have a resource pack & cardsRoad shows from 12m.d – 2p.m.

Come along and see the resource packs, get your pocket guide and chat to Dietitians & CPPD staffMonday 30th REH Dining room Tuesday 31st AAH Dining room

Wednesday 1st St Johns Dining roomThursday 2nd RIE Foyer

Friday 3rd WGH Dining room

MUSTMUST

Developed by the MAG which is a Developed by the MAG which is a standing committee of BAPEN which was standing committee of BAPEN which was set up to promote good nutrition in 1992set up to promote good nutrition in 1992Published in 1994Published in 1994BAPEN says that it has good internal and BAPEN says that it has good internal and external and all sorts of other validity and external and all sorts of other validity and is a good predictor of outcome and is is a good predictor of outcome and is fantastic in every way – no references fantastic in every way – no references obviousobvious

EvidenceEvidence

I looked but could not find much I looked but could not find much Two studies published by members of the Two studies published by members of the MAG linking MUST with LOS and medical MAG linking MUST with LOS and medical outcomoutcomAnother study compared MUST with SGA Another study compared MUST with SGA and NRI and NRS 2002 and concluded and NRI and NRS 2002 and concluded that all can be used although NRS 2002 that all can be used although NRS 2002 had higher sens and spec than the others had higher sens and spec than the others but they used SGA as a referencebut they used SGA as a reference

So the MUST scoreSo the MUST score

Five step screening tool for adultsFive step screening tool for adults

Includes management guidelinesIncludes management guidelines

Will be gradually implemented in Lothian Will be gradually implemented in Lothian over the next wee whileover the next wee while

Nice and glossyNice and glossy

Good charity backingGood charity backing

StepsSteps

Measure BMIMeasure BMI

Note percentage unplanned weight lossNote percentage unplanned weight loss

Establish acute disease scoreEstablish acute disease score

Add scores together to calculate overall Add scores together to calculate overall riskrisk

Use management guidelines to develop Use management guidelines to develop care plancare plan

Good pointsGood points

Co-ordinated approachCo-ordinated approach

Just one toolJust one tool

Charity backedCharity backed

Easy to useEasy to use

QuickQuick

Appears to relate to clinical outcomes – Appears to relate to clinical outcomes – destination, LOS but only adjusted for agedestination, LOS but only adjusted for age

Bad pointsBad points

Not a huge amount of easily found Not a huge amount of easily found independently published validity testingindependently published validity testing

May not apply to subgroups of patients ie May not apply to subgroups of patients ie those with cancer and may result in too those with cancer and may result in too many patients being referred to the many patients being referred to the dieticians ie all acutely unwell patients dieticians ie all acutely unwell patients score 2 pointsscore 2 points

Future?Future?

Useful of oral mucosal epithelial cell Useful of oral mucosal epithelial cell apoptosis rate in nutritional assessment.apoptosis rate in nutritional assessment.

Nutrition 22 (2006) in pressNutrition 22 (2006) in press

Malnourished patients had lower rates of Malnourished patients had lower rates of apoptosis (?conserving energy)apoptosis (?conserving energy)

Take home messagesTake home messages

Use MUSTUse MUST

Complex AreaComplex Area

Use tools to assist rather than replace Use tools to assist rather than replace clinical judgementclinical judgement

Think of malnourishmentThink of malnourishment