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

Definitions Nutrition – the process of taking in and assimilating nutrients Malnutrition – lack of proper nutrition Dietician – an expert on diet and nutrition Nutritional state – very complex ? Percentage make up/ measurable things/ deleterious effects

Who is at risk? Everybody The ill The elderly The young Those with chronic/debilitating disease Those who cannot retain/absorb nutrients Assessment is a dynamic process

How do we measure nutritional status? 1 - Questionnaire - appetite, mood, what the patients normal diet is, have they lost weight unintentionally, do they have physical trouble eating, past and current medical history

2. Bedside measurements –Weight –Height (ulnar length/ mid arm span) –Mid arm circumference –Triceps skinfold thickness

3. Laboratory measurements –Albumin –Prealbumin –White blood cells and lymphocytes –Which reference ranges to use.

Why do we need a screening tool? (and how do they differ from nutritional assessment tools) Screening tool screens for patients who might be at risk of malnourishment and determines who should be further referred on for specialist intervention Nutritional assessment tools are used to assess current state of nutrition The two techniques overlap

Why do we need a screening tool? Not all patients will need specialist nutritional input. Malnourishment is however common and treatable with benefits to both the patient and the NHS There is a finite number of dieticians

The Literature Confusing Each hospital seems to have their own tool No gold standard so huge variation in what is used as the reference standard Many tools have not been validated which in itself is a hugely complicated business How many tools are there?

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All of the above are for the elderly There are over 50 published tools Most 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.

Considerations Who is the tool for And in which country Is it easy – do the nurses like it? Do the patients like it? Has it been validated by somebody who did not invent it? Why is a new tool being made? Muddle

I asked the dieticians and nurses What we use now is the Falkirk score Taken from Falkirk Based upon scores re BMI, weight history, ability to eat, appetite/intake, mental state, disease state, clinical condition, skin, age Guidelines at bottom – monitor/frequency/refer and food chart Easy – nurses liked it On Stroke Unit WGH all patients had form and all weighed Features in the NHS Scotland best practice guidelines No evidence published and then wham

Malnutrition Universal Screening 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 October CD Rom will be on the intranet Clinical areas will have a resource pack & cards Road shows from 12m.d – 2p.m. Come along and see the resource packs, get your pocket guide and chat to Dietitians & CPPD staff Monday 30th REH Dining room Tuesday 31st AAH Dining room Wednesday 1st St Johns Dining room Thursday 2nd RIE Foyer Friday 3rd WGH Dining room

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

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

So the MUST score Five step screening tool for adults Includes management guidelines Will be gradually implemented in Lothian over the next wee while Nice and glossy Good charity backing

Steps Measure BMI Note percentage unplanned weight loss Establish acute disease score Add scores together to calculate overall risk Use management guidelines to develop care plan

Good points Co-ordinated approach Just one tool Charity backed Easy to use Quick Appears to relate to clinical outcomes – destination, LOS but only adjusted for age

Bad points Not a huge amount of easily found independently published validity testing May not apply to subgroups of patients ie those with cancer and may result in too many patients being referred to the dieticians ie all acutely unwell patients score 2 points

Future? Useful of oral mucosal epithelial cell apoptosis rate in nutritional assessment. Nutrition 22 (2006) in press Malnourished patients had lower rates of apoptosis (?conserving energy)

Take home messages Use MUST Complex Area Use tools to assist rather than replace clinical judgement Think of malnourishment