1. September, 19th 2016 Liz Hudson MPH, RD
Clinical Nutrition Screening, Subjective Global Assessment, and Intake assessment
September, 19th 2016
Liz Hudson MPH, RD

2. Objectives
Define and discuss the nutrition screening process for hospitalized patients
Describe the steps and goals of a comprehensive nutrition assessment
Subjective global assessment
Review methods to assess dietary intake

3. Nutrition Screening: Differences in definitions
“A process to identify an individual who is malnourished or who is at risk for malnutrition to determine if a detailed nutrition assessment is indicated”
-American Society for Parenteral and Enteral Nutrition (A.S.P.E.N)
“The process of identifying patients, clients, or groups who may have a nutrition diagnosis and benefit from nutrition assessment and intervention by a registered dietitian (RD).”
-Academy of Nutrition and Dietetics (The Academy) Quality Management Committee

4. Key considerations for nutrition screening
Screening may be conducted in any practice setting as appropriate
Tools should be quick, easy to use, valid, and reliable for the patient population or setting
Tools and parameters are established by RDs, but the screening process may be performed by other personnel
dietetic technicians, registered nurse, and other trained personnel
Nutrition screening and re-screening should occur within an appropriate time frame for the setting
The Joint Commission mandates nutrition screening within 24 hours of admission to an acute care center

5. Nutrition Screening
Nutrition screening can be implemented to identify patients or clients with various nutrition diagnoses. 
Most important function is to identify risk for malnutrition. 
By identifying malnutrition risk early through nutrition screening, nutrition intervention can be implemented immediately
Increased potential to improve health outcomes
length of stay, readmission rates, and hospital costs
In the absence of nutrition screening, malnutrition may be overlooked
particularly in patients who fall within the traditional "healthy" weight range or who remain overweight even after losing significant amounts of weight

6. Other Considerations
Complexity: If the tool requires calculations (eg, BMI, percentage weight loss) or is lengthy with many parameters, it is likely to be more time consuming and subject to error.
Can result in a low compliance with screening
Nutrition screening tools that are simple, quick, and easily completed by nonprofessional staff, patients, or family are preferred

7. Other considerations
Patient population: Tools selected for clinical use should have been tested in patient populations similar to the ones where they will be applied
Sensitivity: As screening is only the first step to identify people who require nutrition assessment, a screening tool needs to achieve a high sensitivity (i.e., identifies all at risk), even if this is at the expense of a high specificity (or false positives)
, accurate identification of all patients who are malnourished (sensitivity) takes precedence over misclassifying well-nourished patients (specificity)

8. Other factors to consider…
Who will perform screening?
How can screening be incorporated into current procedures?
What action will be taken for individuals identified as at risk?

9. Commonly Used Nutrition Screening Tools: Malnutrition Screening Tool (MST)
Reliability measures the agreement between the results of the tool when administered by different users (inter-rater) or on different occasions (intra-rater). The Inter-rater reliability was measured by the kappa value, where a value of 0 indicates no agreement and 1 indicates perfect agreement.
Based on the available evidence, the MST was the only tool shown to be both valid and reliable for identifying nutrition problems in acute care and hospital-based ambulatory care settings

11. Commonly Used Nutrition Screening Tools: Malnutrition Universal Screening Tool (MUST)
The MUST was developed by the Malnutrition Advisory Group, a standing committee of the British Association for Parenteral and Enteral Nutrition (BAPEN) in It is a validated, evidence-based tool designed to identify adults who are malnourished or at risk of malnutrition. The tool has face validity, content validity, concurrent validity with a range of other screening tools, and predictive validity. In hospitals, MUST predicts length of hospital stay, discharge destination, and mortality after controlling for age. In community care, it predicts rate of hospital admissions and general practitioner visits, and
shows that appropriate nutrition intervention improves outcome.
The tool is internally consistent and reliable, with good reproducibility between healthcare providers It has been validated across care settings (ie, primary care, home care, acute care, long-term care), which has the benefit of allowing comparable nutrition screening data across care settings.
Three criteria are used by MUST to determine the overall risk of malnutrition: body mass index (BMI), unintentional weight loss, and acute disease effect.

13. Nutrition Assessment First step in the nutrition care process:
Nutrition Diagnosis
Nutrition Intervention 
Nutrition Monitoring & Evaluation
It is defined as “a systematic method for obtaining, verifying, and interpreting data needed to identify nutrition-related problems and their causes and significance” – (JADA 2008)
It is an ongoing, nonlinear, dynamic process that involves initial data collection as well as continual reassessment and analysis of the patient's/client’s status compared with specified criteria

14. Nutrition Assessment
Provides the foundation for the nutrition diagnosis at the next step of the nutrition care process

15. Nutrition Assessment
Nutrition assessment data are obtained from a variety of sources, including:
Screening or referral form
Patient/client interview
Medical or health records
Consultation with other caregivers, including family members
Community-based surveys and focus groups
Statistical reports, administrative data, and epidemiological studies

16. Nutrition Assessment: What data is included
Food and nutrition-related history
Assessment of nutritional adequacy (diet history)
Anthropometric data (height, weight, BMI)
Biochemical data
Medical tests and procedures
Nutrition-related physical examination findings
Patient/client’s history (medical, social)

17. Nutrition Assessment
Goal: Identify any specific nutrition risk(s) or clear existence of malnutrition
1. Identify individuals who require aggressive nutrition support
2. Restore or maintain an individual’s nutrition wellness
3. Identify appropriate medical nutrition therapy

18. A, B, C, D’s of Nutrition Assessment
Anthropometric data
Biochemical parameters
Clinical/physical assessment
Dietary history/assessment
The above pieces comprise the ABCD’s of assessment

19. Tools for Assessment of Nutritional Status
Subjective Global Assessment (SGA) validated nutrition assessment tool that correlates well with nutrition risk indices and other assessment data in hospitalized patients
Mini Nutritional Assessment (MNA): reliable and quick method for evaluating nutritional status in older adults, >65 years old
Evaluates independence, medication therapy, pressure ulcers, number of full meals consumed per day, protein intake, fruit and vegetable intake, fluid intake, mode of feeding, self-view of nutritional status, comparison with peers, mid-arm and calf circumferences

20. Assessment of Medical/Health History
Medical History Usually includes the following information:
These histories shed light on nutritional concerns
Chief complaint
Present or past illness
Current health
Allergies
Past or recent surgeries
Family history of disease
Psychosocial data
Review of problems by body system from the patient’s perspective
Alcohol and drug use
Increased metabolic needs
Increased nutrient losses
Chronic disease
Recent major surgery or illness
Disease or surgery of GI tract
Recent significant weight loss

21. Medication History
Important because food and drugs can interact in many ways that affect nutrition status and drug therapy effectiveness
Important to any nutrition assessment

22. Social History SES Ability to purchase food – then prepare it!
Living alone
Physical or mental handicaps
Smoking, drugs, alcohol
Lack of socialization at meals
Unsuitable or unstable housing
Maybe you need to teach them to count carbs and they cannot read!

23. Assessment of Dietary Intake
The book states that balance between nutrient intake and nutrient requirements = nutrition status
Infection, disease, fever, physiologic stress
Nutrition Requirements
Nutrient Intake
FOOD INTAKE: Disease, SES, behavior, emotions, cultural pressures
Growth
Psychologic stress
ABSORPTION: disease, physiologic stress, mechanical problems
Body maintenance and well-being

24. Assessment of Dietary Intake
Individual food intake is influenced by:
Economic situation
Eating behavior
Emotional climate
Cultural influences
Effects of disease states on appetite
Ability to acquire and absorb nutrients

25. Methods to Assessment Dietary Intake
Diet History: one of the best means of obtaining dietary information reviews of an individuals usual patterns of food intake and the food selection variables that dictate food intake
Specific information is important: see box 4-2 in book

26. Diet History Information
Allergies, intolerances, food avoidances: gather information on foods being avoided, why they are being avoided, how long they have been avoided
Appetite: Assess if good, poor, any changes
Factors that affect appetitenot hungry? Early satiety? Taste changes?
Attitude toward eating: Disinterest in eating? Irrational ideas about food, eating, body image

27. Diet History Information
Chronic disease: Treatments, length of treatment time
Dietary modifications: self-imposed or physician prescribed, date of modification
Past nutrition and diet education: compliance, barriers to compliance
Dental and oral health: problems with chewing, dry mouth, pain with eating
Gastrointestinal Factors: frequency of problems, avoidance of specific foods
swallowing difficulty, choking or food sticking
Heartburn, gas, bloating
Problems with nausea, vomiting, diarrhea, constipation: certain foods make it worse?

28. Diet History Information
Home Life and Meal Patterns
Who does the shopping, cooking?
Ability to prepare foods?
Socialization during meals

29. Assessment of Dietary Intake: Methods
Retrospective:
24-hour recall
Food Frequency Questionnaire (FFQ)
Prospective/concurrent:
Food Diary
Calorie count (Nutrient Intake Analysis)

30. Retrospective Methods
24-hr recall
Obtain information on the specific foods and amounts of foods consumed within the past 24 hours
What are the pros and cons?
Food Frequency Questionnaire
Retrospective review of intake frequency (i.e. food consumed per day, per week, per month)
Mostly utilized in research studies
Not always practical in the inpatient setting
Pros and cons?
Pros: quick, easily done at the bedside
Cons: inability to recall foods, may not be indicitive of typical intake or patterns, people might exaggerate low intakes and underreport high intakes of foods

31. Prospective/Concurrent
Food Diary
Documenting dietary intake as it occurs, often used in outpatient settings (3 days  2 weekday, 1 weekend day)
Calorie Count
Inpatient setting: information about actual intake is collected through direct observation or an inventory of foods eaten based on what remains on a patient’s tray (nurse, family, or dietetic tech record)
Usually 3 days
Nutritional supplements, snacks, or any supplemental nutrition support (EN or PN) should also be included
Not easy to do, and should only be used in situations where nutrition support is being considered (starting or stopping)

32. Nutrition Assessment Components
Review dietary intake for factors that affect health conditions and nutrition risk
Evaluate health and disease condition for nutrition-related consequences
Evaluate psychological, functional, and behavioral factors related to food access, selection, preparation, physical activity, and understanding of health condition

33. Nutrition Assessment Components
Evaluate patient’s knowledge, readiness to learn, and potential for changing behaviors
Identify the standards by which data will be compared
Identify possible problem areas for making nutrition diagnoses

34. Critical Thinking in the Nutrition Assessment
Observing for nonverbal and verbal cues that can guide and prompt effect interviewing methods
Distinguishing between important and unimportant data

35. SGA video and handout