719669

research-article2017
NCPXXX10.1177/0884533617719669Nutrition in Clinical PracticeCorreia

Invited Review
Nutrition in Clinical Practice
Volume XX Number X
Nutrition Screening vs Nutrition Assessment: Month 201X 1­–10
© 2017 American Society
What’s the Difference? for Parenteral and Enteral Nutrition
DOI: 10.1177/0884533617719669
https://doi.org/10.1177/0884533617719669
journals.sagepub.com/home/ncp

Maria Isabel Toulson Davisson Correia, MD, PhD1,2

Abstract
Screening and assessment imply different processes, with the former indicating risk factors for a deprived nutrition condition and the
latter providing the nutrition diagnosis. Both should be routinely performed at hospital admission according to recommended guidelines;
however, this is not the reality worldwide, and undernutrition remains highly prevalent in the hospital setting. Therefore, the objective of
the current review is to delve into the principles leading to nutrition status deficiencies and how they should be addressed by screening
and assessment. A critical appraisal for the reasons associated with the misunderstanding between screening and assessing is proposed
without further discussing the many available screening tools while approaching some of the assessment instruments. (Nutr Clin Pract.
XXXX;xx:xx-xx)

Keywords
nutrition screening; nutrition assessment; hospitalization; nutritional status; malnutrition

The nutrition status of an individual is a determinant of body subject. The importance of the nutrition status on the overall
composition and functional status. Deficient states negatively well-being of the individual has been documented since the
affect patients’ outcomes, increasing morbimortality, time Minnesota experiments carried out by Ancel Keys in the mid-
spent in the hospital, and readmission rates as well as costs, 1940s.7-14 Nonetheless, nowadays, deficiencies in the nutrition
while decreasing quality of life.1,2 Therefore, screening for risk status—undernutrition—are still the most prevalent conditions
factors associated with deficiencies and, when indicated, in the hospital and outpatient settings in the world, with rates
assessing an individual’s nutrition status should be part of the ranging from 20%–80%, based on the group of patients evalu-
evaluation of a patient. Unfortunately, this is not a worldwide ated or the method used to provide the diagnosis.15-23 Thus, the
mandatory process in most healthcare institutions. question lies on what reasons might justify such abysm between
Professional society guidelines recommend routine nutrition scientific knowledge and the real clinical world.
screening at hospital admission and, if indicated, nutrition Screening and assessment are different processes, which
assessment,3-5 but they differ in how these processes are defined. were extremely well presented and discussed in a paper by
The European Society of Parenteral and Enteral Nutrition5 Charney24 in 2008, who stressed that nutrition screening and
states, “The purpose of nutritional screening is to predict the assessment encompass variables related to identify nutrition
probability of a better or worse outcome due to nutritional fac- problems. According to the author, there is a wide variety of
tors, and whether nutritional treatment is likely to influence tests used by different societies and experts to identify nutrition
this.” The American Society for Parenteral and Enteral Nutrition risk factors. In this regard, the author recommends that such
(ASPEN)3,4 refers to screening as “a process to identify an indi- tools have acceptable reliability and validity while being
vidual who is malnourished or who is at risk for malnutrition to
determine if a detailed nutrition assessment is indicated.”
Furthermore, there is a discrepancy between what expert societ- From the 1School of Medicine, Universidade Federal de Minas Gerais,
Belo Horizonte, Brazil; and 2Nutritional Therapy Team, Instituto Alfa de
ies recommend and what it is practiced in the real world, which
Gastroenterologia, Hospital das Clínicas–Universidade Federal de Minas
is somehow difficult to explain. The Nutrition Care in Canadian Gerais, Belo Horizonte, Brazil.
Hospitals Study reported an absence of a systematic approach
Financial disclosure: None declared.
related to nutrition care in the hospital setting.6 The authors sug-
gest that to improve care processes and strategies and promote Conflicts of interest: None declared.
nutrition care culture, it is of utmost importance to adopt a mul-
Corresponding Author:
tilevel approach in which patients and families, together with
Maria Isabel Toulson Davisson Correia, MD, PhD, School of Medicine,
staff, are part of the whole knowledge translation pathway. Universidade Federal de Minas Gerais, Av Carandaí 246 Apt 902,
This lack of a systematic approach to nutrition screening and Belo Horizonte, MG 30130-060, Brazil.
assessment is certainly not due to a lack of information on the Email: isabel_correia@uol.com.br
2 Nutrition in Clinical Practice XX(X)

cost-effective and providing rapid results. However, assessment underdiagnosed, mostly as a consequence of the worldwide
allows the clinician to gather more information and conduct a pandemic of obesity.34
nutrition-focused examination to determine if there is truly a In the early stages of undernutrition, muscle is protected, as
nutrition derangement, to name it, and to indicate the severity of energy and protein requirements are met by use (and, therefore,
this problem. However, despite the long time that has gone by, loss) of liver glycogen and body fat associated with the mobi-
the doubt still seems to exist, and societies have tried to address lization of labile protein stores from the viscera. It is in this
this, as well as the definition of other practiced important termi- phase that functional alterations occur while body composition
nologies in the practice of clinical nutrition.25 changes might not yet be identified.33 As time progresses, loss
The objective of the current review is to delve into the prin- in muscle and fat compartments increases, leading to severe
ciples leading to nutrition status condition and how they undernutrition. Simultaneous imbalance of micronutrients also
should be addressed by screening and assessment. The rea- occurs. Although terms such as “protein-energy” and “protein-
sons associated with the misunderstanding between screening caloric” malnutrition/undernutrition are recognized by the
and assessing are proposed without further discussing the International Classification of Diseases, “overall” undernutri-
many available screening tools while approaching some of the tion encompasses micronutrients.
assessment instruments. In fact, it would almost be an impos- The many available terms in the medical literature encom-
sible task to cover all of them, given that there are >200 articles passing nutrition derangements have led an international com-
in PubMed referring to “nutrition screening” in adults, 63 in the mittee of experts to propose the following nomenclature for
last 5 years, and >5000 when the search phrase is “nutrition undernutrition diagnoses: “starvation-related malnutrition,”
assessment,” 1865 in the last 5 years. when there is chronic starvation without inflammation;
“chronic disease-related malnutrition,” when inflammation is
chronic and of mild to moderate degree; and “acute disease or
Nutrition Status injury-related malnutrition,” when inflammation is acute and
Nutrition status is the balance between an organism’s demands of severe degree.35 Inflammation and the nutrition status are
for physiologic functioning and its intake and use of nutrients. directly linked since the increased production and/or expres-
If for any reason, mostly as a consequence of famines or dis- sion of proinflammatory mediators leads to protein breakdown
ease states, there is an inadequacy of nutrients to meet needs, and increased resting metabolic rate, while protein require-
then undernutrition/malnutrition develops. ments are increased to produce acute phase proteins.
There have been many definitions for the undernutrition/ Other terms have been used to define alterations in the
malnutrition syndrome. According to Jellife,26 it is “a morbid nutrition status, such as cachexia and sarcopenia. Cachexia
state secondary to a deficiency or excess, relative or absolute, derives from the Greek words kakos and hexis, which mean
of >1 essential nutrients.” However, in clinical practice— “bad condition,” and it has often been considered an advanced
whether discussing children, adults, or the elderly—malnutri- undernutrition state, especially in patients with cancer.
tion has mostly been used to characterize a deficient nutrition However, cachexia affects not only those with neoplastic dis-
status condition. Because of its many terminologies, the search eases but also patients with wasting diseases, such as chronic
for an ideal, clear, and adequate definition has led several obstructive pulmonary disease, cardiac failure, and AIDS,
experts and various associations to try to better characterize the among others. According to experts, the syndrome is a conse-
status of those with nutrition derangements.25,27-32 In fact, quence of negative protein and energy balance driven by the
undernutrition may be a better term than malnutrition to define combination of reduced food intake and abnormal metabo-
a deficient nutrition status (the prefix under meaning “less, lism.32 The term sarcopenia has been differently defined by the
lower”), as malnutrition also encompasses obesity (the prefix various societies and authors.36-38 It is derived from the Greek
mal meaning “bad, wrongful”). words sarx (flesh) and penia (poverty). The Society of
Undernutrition is a consequence of insufficient intake, Sarcopenia, Cachexia and Wasting Disorders36 coined it as “a
increased demand for nutrients, or a disorder in the absorption/ person with muscle loss whose walking speed is ≤ 1 m/s or
use of nutrients. Unintentional loss of body weight is the basic who walks < 400 m during a 6-minute walk, and who has a
characteristic of undernutrition, which is usually caused by lean appendicular mass corrected for height squared of 2 stan-
decreased food intake resulting from lack of appetite, alone or dard deviations or more below the mean of healthy persons
with inadequate utilization of nutrients or increased losses as between 20 and 30 years of age of the same ethnic group.”
well as requirements. The main risk factors leading to undernu- Muscle and functionality loss is also related to the nutrition
trition include any disease state per se (chronic or acute), alone status, as undernourished individuals present with decreased
or in conjunction with social segregation (eg, elderly individu- body compartments, of which the muscle is mostly affected in
als, those with psychological diseases), low economic status, the acute inflamed patient.
lack of medical awareness, and longer hospitalizations. On the other extreme of undernutrition lies obesity, an
Functional decline, which is often linked with undernutrition,33 unhealthy accumulation of fat mass, defined as a body mass
may precede body composition alterations, which are often index (BMI) >30 kg/m2. Obesity is a global pandemic that is
Correia 3

Nutrition Screening
The etymology of the word screen seems to date from medi-
eval Europe: Escren, from Old North French; Escran, from
Old French, “a screen against heat”; Scherm, either from
Middle Dutch or Frankish, “screen, cover”; Skrank, whose ori-
gins are unattested to a written source, “barrier.”50 The word
was initially a noun, meaning a physical object of protection
(apparently, against fire), and only in the late 15th century did
it seem to evolve to a verb with a complementary meaning as a
“contrivance for warding off the heat of a fire or a draught of
air.” Thus, as a verb, “to screen” has associations to the physi-
cal act of protection. According to Bravo,50 “screen as a verb
cannot be defined without first defining screen as a noun.
Because of the dual nature of the word screen it becomes a
complicated word to define. Yet screen, be it noun or verb, is
always a medium with a message.” The latter definition cer-
tainly applies to its role in terms of nutrition screening, being
then the act of identifying risk factors against the integrity of
the nutrition status of an individual.
There are many nutrition screening tools currently being
used in the hospital and the community, some more sophisti-
cated and others simpler,5,51-57 encompassing the general patient
or more specific disease-related populations5,54,56-61 and sup-
Figure 1.  Nutrition screening versus assessment. Most people ported by clinical nutrition societies.3,5,62 In thesis, the ideal
can carry it out, including the patient and family. screening tool should be easy and quick to use and have high
sensitivity and specificity, with good accuracy in detecting the
nutrition risk while identifying nutrition-related outcomes.
also associated with increased morbimortality with diminished
However, statisticians have shown that to reach high sensitivity
quality and length of life while dramatically increasing indi-
and specificity with accuracy is almost impossible.63-65 In this
vidual, national, and global health costs.39 It is important to
regard, the majority of the techniques used to put together most
stress the fact that many obese individuals may often present
of the nutrition screening tools seem not to have utilized either
with deficits of their nutrition status and that sarcopenia—sar-
copenic obesity—per se is associated with adverse effects,34,40 uniform or adequate methods aiming at this purpose. However,
placing them at higher risk of complications when sick.41,42 those constructed under these principles should be used.
Therefore, it is of utmost importance to raise awareness to the The attribution of a score to each question related as a risk
fact that sick obese individuals are, as well as the other patients, factor to undernutrition has often been utilized, and the final
at higher risk of undernutrition. However, this condition fre- addition of all these indicates the risk of a deficient nutrition
quently goes underdiagnosed43,44 due to the lack of routine status or poor outcome.66 This approach could represent a bias
nutrition screening and assessment. by prejudging the effect of a variable over the other and thus
In summary, several terms have been used to characterize negatively affecting the adequacy of the tool. Few screening
the nutrition status of an individual, and a call for unanimity tools have been adequately evaluated by employing multivari-
has been raised by different experts from nutrition societies.45 ate statistical models. These models are alternative approaches
Nonetheless, there is no doubt that unintentional weight loss that take into account the relevance and impact of independent
and decreased food intake, with disease, which may further variables related to the risk of the outcome variable—in this
affect nutrient absorption and utilization, lead to a decline in case, undernutrition—therefore validating the adequacy of the
overall body function, placing the individual at risk of increased instrument.67
morbimortality.1,46-49 Thus, the importance of identifying risk Van Bokhorst-de van der Schueren et al68 carried out a sys-
factors for undernutrition (screening) and, when indicated, fur- tematic review to assess the validity and predictive validity of
ther assessing the nutrition status (assessment) is fundamental nutrition screening tools, in different languages, for the general
to the best holistic approach of any sick individual. The disease hospital population. They identified 83 studies (32 screening
per se may lead to undernutrition, and undernutrition alone tools), in which 42 presented data on construct or criterion
affects disease outcomes in a vicious circle. So, screening and validity versus a reference method and 51 evaluated the tools
assessment—2 different processes to identify the nutrition sta- based on predictive validity on outcomes such as length of
tus (Figure 1)—should be routine in healthcare. stay, mortality, and complications. According to the authors,
4 Nutrition in Clinical Practice XX(X)

“none of the tools performed consistently well to establish the the most difficult aspect, since there is an intertwined relation
patients’ nutrition status.” The same authors evaluated, in between nutrition status and disease, which hampers the cur-
another study, those tools being used among the elderly popu- rent tools to evaluate the role of each in the patient’s outcome.
lation in nursing homes, and they identified 24 papers using 20 Maybe the first big challenge lies exactly on the ideal defini-
instruments.69 Seventeen studies reported on criterion validity tion for undernutrition, as previously discussed. Nonetheless,
and 9 on predictive validity. Four of the tools had been designed several nutrition assessment tools have been well associated
for use in long-term settings. None of them, not even those with prognosis, mortality, and costs—in particular, Subjective
designed for the nursing home environment, performed (on Global Assessment (SGA),1,42,47,48,71 which should be consid-
average) better than “fair” in providing the “residents’ nutrition ered when choosing a tool for use in any institution.
status” or in predicting inadequate nutrition status–related out- Anthropometry is still the most used criterion, in particular
comes. This led the authors to conclude that “not one single by dietitians. No doubt, body weight is a simple measure of
screening or assessment tool is capable of adequate nutrition total body mass, which—when compared with previous weight
screening as well as predicting poor nutrition related outcome. (usual weight) or ideal weight (based on the weight of healthy
Development of new tools seems redundant and will most populations)—provides insights into the patient’s nutrition sta-
probably not lead to new insights.” tus. Weight loss >10% of usual body weight is strongly indica-
Given all the above drawbacks, as well as the principle of tive of undernutrition and is related to higher morbidity and
screening, which is to identify risk factors other than provide a mortality.71-73 A loss of more than one-third of the original
diagnosis, it seems reasonable that the best tool to use should weight was linked with imminent death in a classic study by
preferentially be easy enough to be applied by anyone in the Nightingale et al, who combined 3 methods to detect undernu-
healthcare system or even answered by the patient or a member trition: percentage weight loss, mid arm muscle circumference,
of the family. In this regard, most of the screening tools have in and BMI. According to the authors, for those who cannot be
common 2 queries: (1) unintentional recent weight loss, usu- weighed or have edema, mid arm muscle circumference could
ally around 5%–10%, and (2) inadequate food intake in the last help improve the diagnosis.74 Also, weight loss might be diffi-
1 or 2 weeks (these cutoffs have been a matter of discussion cult to determine in some individuals due to lack of informa-
among experts).70 A positive answer to any of them should tion, illiteracy, or mental disorientation. Morgan et al75 showed
indicate a need for further and deeper evaluation. This should that weight loss accuracy by patient report was 0.67 and its
be performed by a trained healthcare professional (dietitian, power of prediction was 0.75. These data indicate that 33% of
doctor, nurse) using whatever tool is the protocol in the institu- those patients who had lost weight would have been missed
tion. This certainly would favor against time constraint–related and 25% of those with stable weights would have been diag-
problems faced by most healthcare providers in the different nosed as having lost weight. This scenario may even be worse,
settings, who are overloaded with tasks, while providing the such that weight loss could be perceived positively by the phy-
attending physician the indication for the need to evaluate the sicians, the patients, and the families, in particular in the cur-
nutrition status of the sick individual. In summary, making rent obesity pandemic, thus declining clinicians’ sensitivity to
screening easy would probably help increase overall aware- it. Also, weight change alone may not have any nutrition sig-
ness to the nutrition condition. nificance, since it is influenced by confounding factors, mainly
related to the hydration status.
Weight and height provide the BMI, which, according to
Nutrition Assessment population studies, has been shown to be associated with signifi-
Nutrition assessment differs from nutrition screening in the cant mortality rates when values are between 14 and 15 kg/m2.76
depth of the information obtained by the individual in relation Nonetheless, with the obesity pandemic, it has become extremely
to his or her nutrition conditions, which will allow the clinician difficult to rely solely on BMI as a prognostic tool for declined
to formulate a diagnosis. Thus, by nutritionally assessing a per- nutrition status. A Canadian group recently published a classifi-
son, one is going to be able to confer if there is undernutrition cation system incorporating the prognostic significance of BMI
or not and determine the severity of the condition to better plan and percentage of weight loss for patients with cancer, showing
the most appropriate intervention and mostly follow up the that those with lower BMI and a higher percentage of weight
effectiveness of the feeding therapy regimen. loss had decreased survival.76
Several methods for nutrition assessment have been used Skin folds and arm circumferences are body compartment
throughout time. While some techniques are very sophisticated measurements of muscle and adipose tissue, which suffer from
and expensive, others are less complicated and available in the interference of obesity and edematous states and which are
most hospitals. Each has clinical advantages and disadvan- influenced by intraobserver and interobserver errors.
tages. However, the gold standard tool should (1) be sensitive Furthermore, the patients’ measures are compared with those
and specific enough to predict outcomes related to nutrition in tables derived from healthy populations. Jellife’s26 and
status and (2) be able to show changes in the status of the indi- Frisancho’s77 standard tables for triceps skinfold and mid arm
vidual after any nutrition intervention. The latter is certainly muscle circumference are the most commonly used in clinical
Correia 5

practice. Both of these are questionable in regard to the used acute stress situations, such as those related to infection, sur-
methods. Jellife collected data by measuring European male gery, and polytrauma, serum albumin levels are generally very
military personnel in service in Greece and low-income low as a consequence of decreased synthesis, increased degra-
American women. Frisancho derived tables from measure- dation, transcapillary losses, and fluid replacement,89 which are
ments of white men and women who had participated in the undoubtedly also risk factors for the deterioration of the nutri-
1971–1974 U.S. Health and Nutrition Survey. Thuluvath and tion status. Therefore, serum albumin level might be altered due
Triger critically assessed these tables and indicated that 20%– to factors other than undernutrition, as in hepatic disorders, pro-
30% of healthy controls would be diagnosed as malnourished tein losses (in fistula, peritonitis, nephrotic syndromes, etc), and
based on the standards of these tables.78 Furthermore, these acute infection or inflammation—once again, risk factors for a
authors found an inadequate correlation between the Jellife and deprived nutrition status.
Frisancho standards. Thus, these measures are certainly rather In the same way that serum albumin level is influenced by
controversial to be routinely used in clinical practice, in par- the above-mentioned phenomena, so are the other hepatic pro-
ticular alone. teins, which confer them as questionable markers of nutrition
Currently, more sophisticated body composition methods status when used alone. Similar acute conditions may also
have been used as nutrition assessment tools for healthy and affect the creatinine height index. This is obtained by measur-
sick populations as well as athletes, in the clinical setting and ing a 24-hour urinary creatinine excretion, and the results are
in research. Tools such as computed tomography (CT), ultra- compared with standard values for a given height. Any other
sound, nuclear magnetic resonance, whole body conductance factor that might interfere with creatinine excretion, such as
and impedance, dual-energy x-ray absorptiometry, neutron age, renal disease, stress, and diet, may affect its interpreta-
activation, hydrodensitometry, and others are good examples tion.90 The same applies to nitrogen balance.
of these instruments. However, many of them are difficult to As a consequence, nutrition indexes using the aforementioned
use in the hospital setting, especially with the bedridden markers/tools are doomed to imply serious diagnostic bias, as
severely ill patient; they also expose the individual to high each measurement has its own restrictions. However, when they
radiation (CT) and are rather expensive. Nonetheless, CT and were put together to assess surgical populations, it was possible
ultrasound have been shown to indicate important losses of to predict with increased sensitivity major morbidity.82,91
muscle mass and subcutaneous tissue, as well as the presence Other relevant assessment tools—such as handgrip dyna-
of intermuscular adipose tissue. All of these findings are asso- mometry and exercise testing for heart rate variability, as well
ciated with loss of functionality and increased risk of adverse as respiratory muscle strength, fiber quality, and functional-
outcomes in patients with cancer as well as those with other ity—may be ways to detect earlier muscle loss and provide a
diseases.40-42,79-81 However, it is of utmost importance to bear better evaluation of nutrition repletion. They have not been
in mind that CT is an examination of convenience; that is, fully given their importance in the clinical setting, probably
nobody will demand such assessment only for body composi- because of their difficulty in assessing severe acutely ill
tion purposes. patients. Handgrip dynamometry, ergometer workup with heart
Biochemical hepatic markers, such as serum albumin level, rate changes during maximal exercise, as well as respiratory
transferrin, retinol binding protein, and prealbumin, have been muscle strength seem to earlier detect muscle loss, fiber qual-
used by physicians to provide the nutrition diagnosis. When ity, and functionality while providing a better evaluation of
low, serum albumin level (one of the most extensively studied nutrition repletion after therapy.92-97 As multiple elements of
proteins) has been associated with increased morbidity and lean tissue (water, minerals, nitrogen, and glycogen) are incor-
mortality.82-86 However, serum albumin level represents an porated after feeding, intracellular potassium is increased, and
equilibrium among hepatic synthesis, serum albumin level deg- membrane potential is enhanced. This suggests that cell ion
radation, and losses from the body. In fact, serum albumin level uptake happens earlier than protein synthesis during nutrition
reflects the balance between intravascular/extravascular com- therapy.94,95 Thus, muscle and cell energetics are closely asso-
partments and water distribution. Two-thirds of the serum albu- ciated, and the nutrition status may be rapidly impaired in the
min level pool are in the extravascular compartment and presence of sepsis, trauma, renal failure, and drug administra-
one-third in the intravascular. The half-life of serum albumin tion by direct impact on skeletal muscle function. However, for
level, when released into the plasma, is about 21 days. A total of dynamometry—the most practical of all the functional tests—
10.5–14.0 g (200 mg/kg) of serum albumin level is synthesized the absence of standardized equipment and protocols has lim-
and degraded every day in a steady state. Therefore, a deficient ited its usage. Also, this tool is not feasible for patients in the
nutrition status will hinder serum albumin level production as a intensive care unit, owing to their clinical conditions (eg, intu-
consequence of the lack of nutrients that are essential to its syn- bation, hypercapnia, hypoxia, intrinsic muscle disorders) as
thesis. However, in chronic malnutrition states, the plasma well as the use of muscle relaxants and other drugs. However,
serum albumin level concentration is often normal because of muscle functionality could be assessed by the contraction of
the compensatory effect (lower degradation and a shift from the the adductor pollicis muscle in response to an electrical stimu-
extracellular compartment to the intracellular).87,88 However, in lus of the ulnar nerve at the wrist. This tool could be used for
6 Nutrition in Clinical Practice XX(X)

the assessment of nutrition status and as an indicator of nutri- Furthermore, SGA was developed to provide the diagnosis
tion improvement under these conditions.98 In this regard, within 48 hours after hospital admission, but it has also been
another method that could help assess nutrition repletion is used at different time frames, still with good prognostic
calorimetry, which measures energy expenditure. The latter is results.1,101,102,112 Nonetheless, its useful to assess nutrition sta-
dependent on muscle mass, as this is the metabolically active tus evolution and interventions has been questionable.
tissue and major determinant of energy expenditure.99,100 However, a new study from the Canadian group,73 whose
However, the metabolic status of the individual, the presence objective was to assess factors associated with nutrition decline
of fever, changes in ambient temperature, and the thermic in medical and surgical wards, used SGA at admission and dis-
effect of food and activity may influence calorimetry, hamper- charge. It showed that 37% of the patients had in-hospital
ing its use alone to provide the nutrition diagnosis. Furthermore, changes in SGA: 19.6% deteriorated and 17.4% improved.
a steady state is mandatory for accurate calorimetry results, Thus, the SGA role as a marker of adequate nutrition repletion
and throughout the day, at least 3–5 measurements should be should further be tested in other studies, since, as previously
done to achieve more precise data, in severely ill patients in stated, nutrition status changes usually occur at molecular and
particular. cellular levels before reaching functional or body composition
In routine clinical practice, the use of most of the above- improvements.94,95 Variations of SGA, such as Patient-
discussed instruments alone may be hampered as related to the Generated Subjective Global Assessment113,114 or Scored
drawbacks of each, the costs, and the availability. Therefore, it Global Assessment,115 have been described and used in cancer
is of utmost importance to rely on clinical judgment supported populations with good outcome associations.110,116
by assessment tools, especially among critically ill patients. Considering the similarity of SGA and the AND/ASPEN
SGA, as described by Detsky et al,101,102 and the instrument tool, with the former having potential drawbacks, in particular
detailed in the Academy of Nutrition and Dietetics/ASPEN among nonexperts—that is, it relies on clinician interpreta-
(AND/ASPEN)103,104 statements are very similar clinical tools tion, while the latter is more objective—it would certainly be
of assessing the nutrition status of patients, which individually important to adopt widespread use of the AND/ASPEN
include nutrition risk variables. They cover various aspects of instrument.
a patient’s nutrition history, from body weight changes to func-
tional capacity alterations. This information can be provided
by the patient or a relative with good accuracy. SGA provides
Conclusion
the nutrition diagnosis based on gathered information regard- A deficient nutrition status (undernutrition) is still an under-
ing loss of weight, changes in food intake, gastrointestinal diagnosed condition among sick and vulnerable individuals
symptoms/signs (vomiting, diarrhea, anorexia), the stress (particularly the elderly), placing them at higher risk of morbi-
imposed by the disease, and a physical examination that evalu- mortality, increased hospital stay, and readmissions with associ-
ates loss of muscle and fat mass as well as the presence of ated higher costs.2,22,117-119 Nutrition screening and assessment
edema. AND/ASPEN considers that if ≥2 of the following 6 are 2 approaches that utilize risk factors to identify at-risk indi-
characteristics are present, the patient is malnourished: insuf- viduals (the former) and help make a nutrition diagnosis (the
ficient energy intake, weight loss, loss of muscle mass, loss of latter). Nutrition screening should, in general, be a quicker tool
subcutaneous fat, localized or generalized fluid accumulation that any healthcare professional can carry out. However, in
that may sometimes mask weight loss, and diminished func- clinical practice, some screening instruments are rather time
tional status as measured by handgrip strength. In addition, and labor complex.68,120,121 Nonetheless, nutrition assessment
several authors have compared these 2 tools with other used must encompass variables that will not only help provide the
instruments that provide the diagnosis and predict morbidity, nutrition diagnosis but also confer adequate follow-up of the
mortality, length of stay, and costs.17,47,48,71,105-111 patients after nutrition therapy. The latter, unfortunately, is still
Recently, a multicenter cohort study assessed different a more controversial issue, and many tools currently fail to ade-
nutrition indicators to predict outcomes of hospitalization and quately provide such a characteristic.
readmission rates. After controlling for age, sex, and diagnosis, Screening and assessment both predict outcomes related to
severely malnourished patients (by SGA) and those with the nutrition status. Nutrition assessment, a more complex
impaired hand grip strength stayed in the hospital longer and approach, would be expected to perform better. However, this
had increased 30-day readmission.109 A potential advantage of has been a matter of discussion in the literature, with results
AND/ASPEN over SGA is that the former is an objective indicating that both can be used59,110,120,122-124 and with similar
method while the latter relies completely on the interviewer’s predicting capacity.110,120 Therefore, given that strong evi-
capacity to (1) collect information from the patient or members dences have shown the link between risk of nutrition-associ-
of the patient’s family and then (2) interpret these and provide ated factors and increased morbimortality, length of hospital
the patient’s diagnosis based on his or her expertise. It is there- stay, and costs,1,48,73,97,125,126 if in most healthcare settings, for
fore mandatory that all of those willing to perform SGA different reasons, only screening can be carried out, this would
undergo a process of training to decrease the chances of bias. certainly help narrow the gap between what it is recommended
Correia 7

and what it is performed.4,5 However, it is important to stress 5. Kondrup J, Rasmussen HH, Hamberg O, Stanga Z; Ad Hoc ESPEN
that well-structured and scientifically developed tools should Working Group. Nutritional risk screening (NRS 2002): a new
method based on an analysis of controlled clinical trials. Clin Nutr.
be adopted.68,69 2003;22(3):321-336.
Ultimately, enrolling the patient and the families in the pro- 6. Laur C, Keller HH. Implementing best practice in hospital multidisci-
cess of screening the nutrition status might be useful, especially plinary nutritional care: an example of using the knowledge-to-action
in places where the overload of work hampers healthcare pro- process for a research program. J Multidiscip Healthc. 2015;8:463-472.
fessionals to routinely carry out screening or assessment. 7. Keys A. Experimental human starvation; general and metabolic results of
a loss of one fourth the body weight in six months. Fed Proc. 1946;5(1,
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