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1476-56407592021SepEuropean journal of clinical nutritionEur J Clin NutrMalnutrition screening on hospital admission: impact of overweight and obesity on comparative performance of MUST and PG-SGA SF.139814061398-140610.1038/s41430-020-00848-4Traditional malnutrition screening instruments, including the Malnutrition Universal Screening Tool (MUST), strongly rely on low body mass index (BMI) and weight loss. In overweight/obese patients, this may result in underdetection of malnutrition risk. Alternative instruments, like the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF), include characteristics and risk factors irrespective of BMI. Therefore, we aimed to compare performance of MUST and PG-SGA SF in malnutrition risk evaluation in overweight/obese hospitalized patients.We assessed malnutrition risk using MUST (≥1 = increased risk) and PG-SGA SF (≥4 = increased risk) in adult patients at hospital admission in a university hospital. We compared results for patients with BMI < 25 kg/m2 vs. BMI ≥ 25 kg/m2.Of 430 patients analyzed (58 ± 16 years, 53% male, BMI 26.9 ± 5.5 kg/m2), 35% were overweight and 25% obese. Malnutrition risk was present in 16% according to MUST and 42% according to PG-SGA SF. In patients with BMI < 25 kg/m2, MUST identified 31% as at risk vs. 52% by PG-SGA SF. In patients with BMI ≥ 25 kg/m2, MUST identified 5% as at risk vs. 36% by PG-SGA SF. Agreement between MUST and PG-SGA SF was low (к = 0.143). Of the overweight/obese patients at risk according to PG-SGA SF, 83/92 (90%) were categorized as low risk by MUST.More than one-third of overweight/obese patients is at risk for malnutrition at hospital admission according to PG-SGA SF. Most of them are not identified by MUST. Awareness of BMI-dependency of malnutrition screening instruments and potential underestimation of malnutrition risk in overweight/obese patients by using these instruments is warranted.© 2021. The Author(s), under exclusive licence to Springer Nature Limited part of Springer Nature.van VlietIris M YIMY0000-0001-8601-9850Department of Dietetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. i.m.y.van.vliet@umcg.nl.Gomes-NetoAntonio WAW0000-0002-4398-4877Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.de JongMargriet F CMFC0000-0001-7347-4344Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.BakkerStephan J LSJL0000-0003-3356-6791Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.Jager-WittenaarHarriëtHDepartment of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands.NavisGerjan JGJDepartment of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.engJournal ArticleResearch Support, Non-U.S. Gov't20210215
EnglandEur J Clin Nutr88040700954-3007IMAdultBody Mass IndexFemaleHospitalsHumansMaleMalnutritiondiagnosisepidemiologyetiologyNutrition AssessmentNutritional StatusObesitycomplicationsOverweightcomplicationsAWGN received research support from Danone Nutricia for contributing to this research. HJW was co-developer of the Pt-Global app/web tool. Other authors declare no conflict of interest.20204920201214202012112021217602022726602021216692021215ppublish33589809PMC841665610.1038/s41430-020-00848-410.1038/s41430-020-00848-4McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ. 1994;308:945–8. doi: 10.1136/bmj.308.6934.945.10.1136/bmj.308.6934.945PMC25397998173401Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clin Nutr. 2008;27:5–15. doi: 10.1016/j.clnu.2007.10.007.10.1016/j.clnu.2007.10.00718061312Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health. 2011;8:514–27. doi: 10.3390/ijerph8020514.10.3390/ijerph8020514PMC308447521556200Freijer K, Tan SS, Koopmanschap MA, Meijers JM, Halfens RJ, Nuijten MJ. The economic costs of disease related malnutrition. Clin Nutr. 2013;32:136–41. doi: 10.1016/j.clnu.2012.06.009.10.1016/j.clnu.2012.06.00922789931Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2017;36:49–64. doi: 10.1016/j.clnu.2016.09.004.10.1016/j.clnu.2016.09.00427642056Cederholm T, Jensen GL, Correia M, Gonzalez MC, Fukushima R, Higashiguchi T, et al. GLIM criteria for the diagnosis of malnutrition—a consensus report from the global clinical nutrition community. Clin Nutr. 2019;38:1–9. doi: 10.1016/j.clnu.2018.08.002.10.1016/j.clnu.2018.08.00230181091Anthony PS. Nutrition screening tools for hospitalized patients. Nutr Clin Pract. 2008;23:373–82. doi: 10.1177/0884533608321130.10.1177/088453360832113018682588Jensen GL, Compher C, Sullivan DH, Mullin GE. Recognizing malnutrition in adults: definitions and characteristics, screening, assessment, and team approach. J Parenter Enter Nutr. 2013;37:802–7. doi: 10.1177/0148607113492338.10.1177/014860711349233823969411Kyle UG, Kossovsky MP, Karsegard VL, Pichard C. Comparison of tools for nutritional assessment and screening at hospital admission: a population study. Clin Nutr. 2006;25:409–17. doi: 10.1016/j.clnu.2005.11.001.10.1016/j.clnu.2005.11.00116356595Guerra RS, Sousa AS, Fonseca I, Pichel F, Restivo MT, Ferreira S, et al. Comparative analysis of undernutrition screening and diagnostic tools as predictors of hospitalisation costs. J Hum Nutr Diet. 2016;29:165–73. doi: 10.1111/jhn.12288.10.1111/jhn.1228825532556Rabito EI, Marcadenti A, da Silva Fink J, Figueira L, Silva FM. Nutritional Risk Screening 2002, Short Nutritional Assessment Questionnaire, malnutrition screening tool, and malnutrition universal screening tool are good predictors of nutrition risk in an emergency service. Nutr Clin Pract. 2017;32:526–32. doi: 10.1177/0884533617692527.10.1177/088453361769252728199797van Bokhorst-de van der Schueren MA, Guaitoli PR, Jansma EP, de Vet HC. Nutrition screening tools: does one size fit all? A systematic review of screening tools for the hospital setting. Clin Nutr. 2014;33:39–58. doi: 10.1016/j.clnu.2013.04.008.10.1016/j.clnu.2013.04.00823688831Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:766–81. doi: 10.1016/S0140-6736(14)60460-8.10.1016/S0140-6736(14)60460-8PMC462426424880830Davidson I, Smith S. Nutritional screening: pitfalls of nutritional screening in the injured obese patient. Proc Nutr Soc. 2007;63:421–5. doi: 10.1079/PNS2004371.10.1079/PNS200437115373952Ng WL, Collins PF, Hickling DF, Bell JJ. Evaluating the concurrent validity of body mass index (BMI) in the identification of malnutrition in older hospital inpatients. Clin Nutr. 2019;38:2417–22. doi: 10.1016/j.clnu.2018.10.025.10.1016/j.clnu.2018.10.02530501917Agarwal E, Ferguson M, Banks M, Vivanti A, Batterham M, Bauer J, et al. Malnutrition, poor food intake, and adverse healthcare outcomes in non-critically ill obese acute care hospital patients. Clin Nutr. 2019;38:759–66. doi: 10.1016/j.clnu.2018.02.033.10.1016/j.clnu.2018.02.03329559233Leibovitz E, Giryes S, Makhline R, Zikri Ditch M, Berlovitz Y, Boaz M. Malnutrition risk in newly hospitalized overweight and obese individuals: Mr NOI. Eur J Clin Nutr. 2013;67:620–4. doi: 10.1038/ejcn.2013.45.10.1038/ejcn.2013.4523549203Ness SJ, Hickling DF, Bell JJ, Collins PF. The pressures of obesity: the relationship between obesity, malnutrition and pressure injuries in hospital inpatients. Clin Nutr. 2018;37:1569–74. doi: 10.1016/j.clnu.2017.08.014.10.1016/j.clnu.2017.08.01428890276Jager-Wittenaar H, Ottery FD. Assessing nutritional status in cancer: role of the Patient-Generated Subjective Global Assessment. Curr Opin Clin Nutr Metab Care. 2017;20:322–9. doi: 10.1097/MCO.0000000000000389.10.1097/MCO.000000000000038928562490Bauer J, Capra S, Ferguson M. Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer. Eur J Clin Nutr. 2002;56:779–85. doi: 10.1038/sj.ejcn.1601412.10.1038/sj.ejcn.160141212122555Gabrielson DK, Scaffidi D, Leung E, Stoyanoff L, Robinson J, Nisenbaum R, et al. Use of an abridged scored Patient-Generated Subjective Global Assessment (abPG-SGA) as a nutritional screening tool for cancer patients in an outpatient setting. Nutr Cancer. 2013;65:234–9. doi: 10.1080/01635581.2013.755554.10.1080/01635581.2013.75555423441610Vigano AL, di Tomasso J, Kilgour RD, Trutschnigg B, Lucar E, Morais JA, et al. The abridged patient-generated subjective global assessment is a useful tool for early detection and characterization of cancer cachexia. J Acad Nutr Diet. 2014;114:1088–98. doi: 10.1016/j.jand.2013.09.027.10.1016/j.jand.2013.09.02724462323Abbott J, Teleni L, McKavanagh D, Watson J, McCarthy AL, Isenring E. Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) is a valid screening tool in chemotherapy outpatients. Support Care Cancer. 2016;24:3883–7. doi: 10.1007/s00520-016-3196-0.10.1007/s00520-016-3196-027095352Beek LT, Banning LBD, Visser L, Roodenburg JLN, Krijnen WP, van der Schans CP, et al. Risk for malnutrition in patients prior to vascular surgery. Am J Surg. 2018;216:534–9. doi: 10.1016/j.amjsurg.2017.11.038.10.1016/j.amjsurg.2017.11.03829258651Kosters CM, van den Berg MGA, van Hamersvelt HW. Sensitive and practical screening instrument for malnutrition in patients with chronic kidney disease. Nutrition. 2019;72:110643. doi: 10.1016/j.nut.2019.110643.10.1016/j.nut.2019.11064331926378Banning LBD, Beek LT, El Moumni M, Visser L, Zeebregts CJ, Jager-Wittenaar H, et al. Vascular surgery patients at risk for malnutrition are at an increased risk of developing post-operative complications. Ann Vasc Surg. 2019;64:213–20. doi: 10.1016/j.avsg.2019.10.037.10.1016/j.avsg.2019.10.03731634605De Groot LM, Lee G, Ackerie A, van der Meij BS. Malnutrition Screening and Assessment in the Cancer Care Ambulatory Setting: mortality predictability and validity of the Patient-Generated Subjective Global Assessment Short form (PG-SGA SF) and the GLIM criteria. Nutrients. 2020;12:2287. 10.3390/nu12082287.PMC746897632751724van Vliet IMY, Gomes Neto AW, de Jong MFC, Jager-Wittenaar H, Navis GJ. High prevalence of malnutrition both on hospital admission and pre-discharge. Nutrition. 2020;77:110814. 10.1016/j.nut.2020.110814.32442829Gomes Neto AW, van Vliet IMY, de Jong MFC, Jager-Wittenaar H, Navis GJ. Predictive validity of malnutrition screening (MUST) vs nutritional assessment (PG-SGA) Clin Nutr. 2018;37(Suppl 1):S105. doi: 10.1016/j.clnu.2018.06.1403.10.1016/j.clnu.2018.06.1403Gomes Neto AW, van Vliet IMY, Oste MCJ, de Jong MFC, Bakker SJL, Jager-Wittenaar H, et al. Malnutrition screening and prediction of hospital outcomes—comparison of two screening tools. Submitted for publication.Elia M. The ‘MUST’ report. Nutritional screening of adults: a multidisciplinary responsibility. BAPEN, (MAG) MAG; 2003. https://www.bapen.org.uk/pdfs/must/must-report.pdf.Kruizenga H, Beijer S, Huisman-de Waal G, Jonkers-Schuitema C, Klos M, Remeijnse-Meester W, et al. Richtlijn Ondervoeding: herkenning, diagnosestelling en behandeling van ondervoeding bij volwassenen. Stuurgroep Ondervoeding; 2017. https://www.stuurgroepondervoeding.nl/wp-content/uploads/2019/02/SoV01-Richtlijn-Ondervoeding-losse-paginas-210x297februari-2019.pdf.Kruizenga H, van Keeken S, Weijs P, Bastiaanse L, Beijer S, Huisman-de Waal G, et al. Undernutrition screening survey in 564,063 patients: patients with a positive undernutrition screening score stay in hospital 1.4 d longer. Am J Clin Nutr. 2016;103:1026–32. doi: 10.3945/ajcn.115.126615.10.3945/ajcn.115.12661526961930Ottery FD. Definition of standardized nutritional assessment and interventional pathways in oncology. Nutrition. 1996;12:S15–9. doi: 10.1016/0899-9007(95)00067-4.10.1016/0899-9007(95)00067-48850213Sealy MJ, Hass U, Ottery FD, van der Schans CP, Roodenburg JLN, Jager-Wittenaar H. Translation and cultural adaptation of the Scored Patient-generated Subjective Global Assessment: an interdisciplinary nutritional instrument appropriate for Dutch cancer patients. Cancer Nurs. 2018;41:450–62. doi: 10.1097/NCC.0000000000000505.10.1097/NCC.000000000000050528538001Balstad TR, Bye A, Jenssen CR, Solheim TS, Thoresen L, Sand K. Patient interpretation of the Patient-Generated Subjective Global Assessment (PG-SGA) Short Form. Patient Prefer Adherence. 2019;13:1391–400. doi: 10.2147/PPA.S204188.10.2147/PPA.S204188PMC670161531496666Jager-Wittenaar H, de Bats HF, Welink-Lamberts BJ, Gort-van Dijk D, van der Laan B, Ottery FD, et al. Self-completion of the Patient-Generated Subjective Global Assessment short form is feasible and is associated with increased awareness on malnutrition risk in patients with head and neck cancer. Nutr Clin Pract. 2020;35:353–62. doi: 10.1002/ncp.10313.10.1002/ncp.10313PMC707895431134665WHO. Body Mass Index (BMI) classification 2017. http://apps.who.int/bmi/index.jsp?introPage=intro_3.html. Accessed 12 Feb 2020.Landis JR, Koch GG. The measurement of oberver agreement for categorical data. Biometrics. 1977;33:159–74. doi: 10.2307/2529310.10.2307/2529310843571de Pinho NB, Martucci RB, Rodrigues VD, D’Almeida CA, Thuler LCS, Saunders C, et al. Malnutrition associated with nutrition impact symptoms and localization of the disease: results of a multicentric research on oncological nutrition. Clin Nutr. 2019;38:1274–9. doi: 10.1016/j.clnu.2018.05.010.10.1016/j.clnu.2018.05.01029853223Kubrak C, Olson K, Jha N, Jensen L, McCargar L, Seikaly H, et al. Nutrition impact symptoms: key determinants of reduced dietary intake, weight loss, and reduced functional capacity of patients with head and neck cancer before treatment. Head Neck. 2010;32:290–300.19626639Lindqvist C, Slinde F, Majeed A, Bottai M, Wahlin S. Nutrition impact symptoms are related to malnutrition and quality of life—a cross-sectional study of patients with chronic liver disease. Clin Nutr. 2020;39:1840–8. 10.1016/j.clnu.2019.07.024.31427181Gonzalez MC, Correia M, Heymsfield SB. A requiem for BMI in the clinical setting. Curr Opin Clin Nutr Metab Care. 2017;20:314–21. doi: 10.1097/MCO.0000000000000395.10.1097/MCO.000000000000039528768291Kyle UG, Morabia A, Slosman DO, Mensi N, Unger P, Pichard C. Contribution of body composition to nutritional assessment at hospital admission in 995 patients: a controlled population study. Br J Nutr. 2007;86:725–31. doi: 10.1079/BJN2001470.10.1079/BJN200147011749682Chan M, Kelly J, Batterham M, Tapsell L. Malnutrition (subjective global assessment) scores and serum albumin levels, but not body mass index values, at initiation of dialysis are independent predictors of mortality: a 10-year clinical cohort study. J Ren Nutr. 2012;22:547–57. doi: 10.1053/j.jrn.2011.11.002.10.1053/j.jrn.2011.11.00222406122Raad S, Smith C, Allen K. Nutrition status and chronic obstructive pulmonary disease: can we move beyond the body mass index? Nutr Clin Pract. 2019;34:330–9. doi: 10.1002/ncp.10306.10.1002/ncp.1030630989731Vidot H, Kline K, Cheng R, Finegan L, Lin A, Kempler E, et al. The relationship of obesity, nutritional status and muscle wasting in patients assessed for liver transplantation. Nutrients. 2019;11:2097. doi: 10.3390/nu11092097.10.3390/nu11092097PMC676990031487854Almasaudi AS, McSorley ST, Dolan RD, Edwards CA, McMillan DC. The relation between Malnutrition Universal Screening Tool (MUST), computed tomography-derived body composition, systemic inflammation, and clinical outcomes in patients undergoing surgery for colorectal cancer. Am J Clin Nutr. 2019;110:1327–34. doi: 10.1093/ajcn/nqz230.10.1093/ajcn/nqz23031529042Ni Bhuachalla EB, Daly LE, Power DG, Cushen SJ, MacEneaney P, Ryan AM. Computed tomography diagnosed cachexia and sarcopenia in 725 oncology patients: is nutritional screening capturing hidden malnutrition? J Cachexia Sarcopenia Muscle. 2018;9:295–305. doi: 10.1002/jcsm.12258.10.1002/jcsm.12258PMC587996929271097Elkan AC, Engvall IL, Tengstrand B, Cederholm T, Hafstrom I. Malnutrition in women with rheumatoid arthritis is not revealed by clinical anthropometrical measurements or nutritional evaluation tools. Eur J Clin Nutr. 2008;62:1239–47. doi: 10.1038/sj.ejcn.1602845.10.1038/sj.ejcn.160284517637600Martin L, Gioulbasanis I, Senesse P, Baracos VE. Cancer-associated malnutrition and CT-defined sarcopenia and myosteatosis are endemic in overweight and obese patients. J Parenter Enter Nutr. 2019;44:227–38. doi: 10.1002/jpen.1597.10.1002/jpen.159731012128Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyere O, Cederholm T, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48:16–31. doi: 10.1093/ageing/afy169.10.1093/ageing/afy169PMC632250630312372Ceniccola GD, Castro MG, Piovacari SMF, Horie LM, Correa FG, Barrere APN, et al. Current technologies in body composition assessment: advantages and disadvantages. Nutrition. 2019;62:25–31. doi: 10.1016/j.nut.2018.11.028.10.1016/j.nut.2018.11.02830826596Sizoo D, de Heide LJM, Emous M, van Zutphen T, Navis G, van Beek AP. Measuring muscle mass and strength in obesity: a review of various methods. Obes Surg. 2020. 10.1007/s11695-020-05082-2. Accessed 6 Nov 2020.PMC780898433159294Jensen B, Braun W, Geisler C, Both M, Kluckmann K, Muller MJ, et al. Limitations of fat-free mass for the assessment of muscle mass in obesity. Obes Facts. 2019;12:307–15. doi: 10.1159/000499607.10.1159/000499607PMC669677631132777Nijholt W, Scafoglieri A, Jager-Wittenaar H, Hobbelen JSM, van der Schans CP. The reliability and validity of ultrasound to quantify muscles in older adults: a systematic review. J Cachexia Sarcopenia Muscle. 2017;8:702–12. doi: 10.1002/jcsm.12210.10.1002/jcsm.12210PMC565904828703496Heymsfield SB, Arteaga C, McManus C, Smith J, Moffitt S. Measurement of muscle mass in humans: validity of the 24-hour urinary creatinine method. Am J Clin Nutr. 1983;37:478–94. doi: 10.1093/ajcn/37.3.478.10.1093/ajcn/37.3.4786829490Wang Z, Gallagher D, Nelson ME, Matthews DE, Heymsfield SB. Total-body skeletal muscle mass: evaluation of 24-h urinary creatinine excretion by computerized axial tomography. Am J Clin Nutr. 1996;63:863–9. doi: 10.1093/ajcn/63.6.863.10.1093/ajcn/63.6.8638644679Stam SP, Eisenga MF, Gomes-Neto AW, van Londen M, de Meijer VE, van Beek AP, et al. Muscle mass determined from urinary creatinine excretion rate, and muscle performance in renal transplant recipients. J Cachexia Sarcopenia Muscle. 2019;10:621–9. doi: 10.1002/jcsm.12399.10.1002/jcsm.12399PMC659645530907512