ADA EAL Nutrition Screening Project Victoria Roberts, Dietetic Intern Marywood University

Overview What is the project? Selected topics  Serum albumin  Serum prealbumin  MST tool  MNA-SF tool NSMC nutrition screening

Nutrition Screening Evidence Analysis Project

Selected Topics and Questions Serum albumin/weight loss correlation Serum prealbumin/weight loss correlation MST screening tool MNA-SF screening tool

Serum Albumin Does serum albumin correlate with weight loss in four models of prolonged protein- energy restriction: anorexia nervosa, non- malabsorptive gastric partitioning bariatric surgery, calorie-restricted diets or starvation?

Serum Albumin 190 studies reviewed Exclusions: Burns, trauma, cancer, liver disease with ascited, unmeasured protein loses from dialysis, post-op, refeeding, starvation <5 days, IV Alb administration, Alb reported from urine rather than sera Intervention studies only included if there was a control group that did not receive an intervention. 12 studies included

Serum Albumin Five studies (three cross-sectional, one cohort, one case-control) found that serum albumin does not correlate with weight loss in patients with anorexia nervosa (AN) One cohort study found that serum albumin does not correlate with weight loss in non- malabsorptive gastric partitioning bariatric surgery for obesity. Serum albumin did not respond negatively to protein-calorie deprivation after surgery, suggesting that albumin is not a sensitive indicator of protein status in gastric partitioning patients

Serum Albumin Four studies (One single-group uncontrolled trial, two non-randomized trials and one case-control study) found that serum albumin does not correlate with intentional weight loss in calorie-restricted diets There were no studies identified to meet the inclusion criteria for serum albumin levels in starvation.

Serum Albumin Evidence Strength: Grade II (fair) Limitations  Small sample size  Weak research methodologies in included studies Conclusion: More research needed into the correlation between serum albumin and these four models of prolonged protein- energy restriction.

Serum Prealbumin Does serum prealbumin correlate with weight loss in four models of prolonged protein-energy restriction: Anorexia nervosa, non-malabsorptive gastric partitioning bariatric surgery, calorie- restricted diets or starvation?

Serum Prealbumin 190 studies reviewed Exclusions: Burns, trauma, cancer, liver disease with ascited, unmeasured protein loses from dialysis, post-op, refeeding, starvation <5 days, IV Alb administration, Alb reported from urine rather than sera Intervention studies only included if there was a control group that did not receive an intervention. 12 studies included

Serum Prealbumin One case control, one cross-sectional and one cohort study found that serum prealbumin does not correlate with weight loss in patients with anorexia nervosa (AN) One non-randomized trial and one case series study found that serum prealbumin does not correlate with intentional weight loss associated with calorie-restricted diets

Serum Prealbumin One non-randomized trial found that serum prealbumin does not correlate with weight loss in starvation There were no studies identified to meet the inclusion criteria for serum prealbumin levels in non-malabsorptive gastric partitioning bariatric surgery.

Serum Prealbumin Evidence Strength: Grade III (limited) Limitations  Small sample size  Weak research methodologies in included studies Conclusion: More research needed into the correlation between serum prealbumin and these four models of prolonged protein- energy restriction.

Nutrition Screening Tools What is the validity and reliability of “Nutrition Tool X” in identifying nutrition problems in adult patients in acute care and hospital-based ambulatory care settings?

Nutrition Screening Tools 11 screening tools reviewed for validity and reliability  Grade 1 Evidence (good) Nutritional Risk Screening 2002 (NRS-2002)  Grade II Evidence (fair) Malnutrition Universal Screening Tool (MUST) Mini Nutritional Assessment-Short Form (MNA-SF) * Malnutrition Screening Tool (MST) * Simple Two-part Screening Tool  Grade III Evidence (limited) Nutritional Risk Score (NRS) Seniors in the Community: Risk Evaluation for Eating and Nutrition, Version II Abbreviated (SCREEN II-AB) Tool #1 (Laporte et al, 2001) Rapid Screen tool (Visvanathan et al, 2004) Nutrition Screening Tool (NST)/BAPEN4  Grade V Evidence (not assignable) Short Nutritional Assessment Questionnaire (SNAQ)

Nutrition Screening Tools Based on the available evidence, which nutrition screening tools have been found to be valid and reliable for identifying nutrition problems in adult patients in acute care and hospital-based ambulatory care settings?

Nutrition Screening Tools Considerations for appropriate tools  Quick and easy (<10 minutes to complete)  Grade I or II evidence  Validity (sensitivity and specificity) and reliability measured

Nutrition Screening Tool Validity (all grades)

Nutrition Screening Tool Validity (grades I and II)

MNA-SF Tool 6 questions designed to screen elderly patients (>65 years old) for malnutrition Has not been validated in populations other than the elderly

MNA-SF Tool Evidence Strength: Grade II (fair) Sensitivity >90%; Specificity >90% (1 of 2 studies) Limitations  No data to determine reliability Conclusion: The MNA-SF has been shown to be a valid tool for predicting nutrition problems in geriatric populations in acute inpatient, subacute and ambulatory settings. Care should be taken in settings and populations other than those evaluated. No data was available to determine reliability.

MST Tool

Evidence Strength: Grade II (fair) Sensitivity >90% (3 of 4 studies); Specificity > 90% (2 of 4 studies) Kappa score for reliability:  Kappa range 0-1  Value of 1: perfect agreement  Value of 0: no agreement Conclusion: Shown to be a valid and reliable tool for predicting nutrition problems in acute care and oncology outpatient settings. Care should be taken in settings other than those evaluated. (Grade IV)

Nutrition Screening at NSMC Weight/height -> BMI, ideal weight Diagnosis Albumin Diet order Screening policy

Nutrition Screening at NSMC

References Ferguson M, Capra S, Bauer J, Banks M Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 15(6): Ferguson, M Nutrition Screening Evidence Analysis Project. ADA Evidence Analysis Library. Retrieved June 15, 2011 from