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Development and validation of a hospital screening tool for malnutrition: The

Short Nutritional Assessment Questionnaire (SNAQ)

Article  in  Clinical Nutrition · March 2005

DOI: 10.1016/j.clnu.2004.07.015 · Source: PubMed

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 ARTICLE IN PRESS
Clinical Nutrition (2005) 24, 75–82

http://intl.elsevierhealth.com/journals/clnu

ORIGINAL ARTICLE

Development and validation of a hospital screening

tool for malnutrition: the short nutritional
assessment questionnaire (SNAQr)
H.M. Kruizengaa,, J.C. Seidellb, H.C.W. de Vetc, N.J. Wierdsmaa,
M.A.E. van Bokhorst–de van der Schuerena

a
Department of Dietetics,VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam,
The Netherlands
b
Department of Internal Medicine, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
c
EMGO Institute, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands

Received 13 November 2003; accepted 15 July 2004

KEYWORDS Summary Objective: For the early detection and treatment of malnourished
Hospital hospital patients no valid screening instrument for the Dutch language exists.
malnutrition; Calculation of percentage weight loss and body mass index (BMI) by the nurse at
Screening; admission to the hospital appeared to be not feasible. Therefore, the short,
SNAQr; nutritional assessment questionnaire (SNAQr), was developed.
Validation; Research, design and methods: Two hundred and ninety one patients on the mixed
Development internal and surgery/oncology wards of the VU University medical center were
screened on nutritional status and classified as well nourished (o5% weight loss in
the last 6 months and BMI418.5), moderately malnourished (5–10% weight loss in
the last 6 months and BMI418.5) or severely malnourished (410% weight loss in the
last 6 months or 45% in the last month or BMIo18.5). All patients were asked 26
questions related to eating and drinking difficulties, defecation, condition and pain.
Odds ratio, binary and multinomial logistic regression were used to determine the
set of questions that best predicts the nutritional status. Based on the regression
coefficient a score was composed to detect moderately (X2 points) and severely
(X3 points) malnourished patients. The validity, the nurse–nurse reproducibility and
nurse–dietitian reproducibility was tested in another but similar population of 297
patients.
Results: The questions ‘Did you lose weight unintentionally?’. ‘Did you experience
a decreased appetite over the last month?’ and ‘Did you use supplemental drinks or
tube feeding over the last month?’ were most predictive of malnutrition. The
instrument proved to be valid and reproducible.

Corresponding author. Tel.: +31-20-444-3410; fax: +31-20-4444-143.

E-mail address: [email protected] (H.M. Kruizenga).

0261-5614/$ - see front matter r 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.clnu.2004.07.015
 ARTICLE IN PRESS
76 H.M. Kruizenga et al.

Conclusion: SNAQr is an easy, short, valid and reproducible questionnaire for

early detection of hospital malnutrition.
r 2004 Elsevier Ltd. All rights reserved.

Introduction questionnaire divides hospital patients into three

groups: well nourished, moderately malnourished
Malnutrition is a state of nutrition in which a and severely malnourished. Using this question-
deficiency or excess or imbalance of energy, naire, malnourished patients are recognized at
protein and other nutrients, causes measurable admission and referred to dietitian in an early
adverse effects on tissue or body form (body shape, stage. This article describes the process of the
size and composition), function, and clinical out- development of the so called short nutritional
come.1 This broad definition implies that malnutri- assessment questionnaire (SNAQr). In addition, it
tion may arise from a wide range of conditions that reports the results of the diagnostic value and
differ in severity and cause. In Western countries, reproducibility of the SNAQr.
undernutrition is considered to be only a minor
problem compared with that of overweight.
In hospital settings however, there is growing Research design and methods
awareness that undernutrition may play an impor-
tant role in the course of the treatment of patients. The development of the SNAQr is based on the
The body mass index (BMI) (weight/length2) can be results of nutritional status data and characteristics
used to provide an approximate guide to the of 291 patients (population A). The validity of the
probability of chronic undernutrition. One of the SNAQr is tested in a similar population (population
most commonly used cut-off values to define this B) (cross validation). The reproducibility of the
kind of malnutrition is a BMIo18.5.1–4 This index SNAQr is also tested in population B.
does, however, usually not give information about
the unintentional recent weight change that is
often accompanying underlying disease. Several Questionnaire development study
clinical studies have demonstrated that recent (population A)
involuntary weight loss 410% in 6 months is a good
indicator of more acute undernutrition.1,5–8 Subjects
In 2001, the Dutch Dietetic Association con- Two hundred and ninety one patients, admitted to a
ducted a national screening on disease related mixed internal ward (internal medicine, gastro-
malnutrition in 6150 hospital patients at 56 enterology, dermatology, nephrology) and a mixed
different locations.9 Based on the generally accep- surgical ward (general surgery and surgical oncol-
table definitions of malnutrition, disease related ogy) of the VU University medical center in the
malnutrition was defined as 410% involuntary period of April until October 2002, were included in
weight loss 1,5–8 or BMI o18.5.1–3 In this study, the study. Patients who were not able to give
about 25% of the hospital patients appeared to be informed consent, could not be weighed or were
malnourished. Only 50% of the malnourished pa- younger than 18 years of age were excluded from
tients were recognised by the nursing and medical the study. The study-design was approved by the
staff.9 medical ethical commission of the VU University
In an ideal situation the physician or the nurse medical center.
calculates the BMI and the percentage of involun-
tary weight loss over the last months at the first day Nutritional status
of patients’ admission to the hospital. With this On the day of the admission to the hospital, all
information the physician and/or the nurse can patients were weighed on the same calibrated
decide which patients are malnourished and should scale (SECA 880) and their height was asked for.
be referred to a dietitian. In practice nurses or When patients did not know their height, it was
physicians do not have time to calculate indices of measured (SECA 220). Patients were asked whether
nutritional status. Thus, hospital malnutrition often they had lost weight unintentionally over the last
remains unidentified. Therefore, our team devel- month and the last 6 months. Patients were
oped a short questionnaire that can be integrated considered severely malnourished if one or more
in the nurses’ intake of the patient at admission to of the following conditions were present: a BMI
the hospital and costs less than 5 min time. This o18.5,1–4 unintentional weight loss of more than
 ARTICLE IN PRESS
Development and validation of a hospital screening tool for malnutrition: 77

5% in the last month or more than 10% in the last 6 malnourished, a is the constant and b1, b2, b3 and
months. Patients were considered moderately bx represent the regression coefficients of the
malnourished when they had lost 5–10% of their questions x1, x2, x3 and xx.
weight unintentionally in the last 6 months.1,5–8 To make the new questionnaire to a screening
Based on the most commonly accepted standards tool which is practical, the regression coefficients
from the literature, this definition of nutritional associated with the questions were transformed
status was used as the ‘‘objective standard of into a simple score that can be added up to obtain
malnutrition’’ against which the questions from the an aggregate score (in this case: the coefficients of
questionnaire were validated. the model are multiplied by 4/7 and rounded to the
nearest integer, resulting in a score, ranging from 0
Questionnaire to 7 (Table 3). The cut-off points for the scores
On the day of admission to the hospital, all patients belonging to ‘moderately malnourished’ and ‘se-
completed a detailed questionnaire on symptoms verely malnourished’ were determined by reading
and risk factors of malnutrition. The questionnaire the optimal cut-off point in the ROC-curve. All
consisted of 26 nutrition-related questions (Table 2) analyses were performed with the SPSS software
adopted from the quality of life questionnaires package, version 9.0.
EORTC-C30 and EORTC H&N 35,10 and from complex
screening instruments which are too complex and
time-consuming for the daily hospital situation Questionnaire validation study
(Nutricia Nutritional Screening List, Mini Nutritional (population B)
Assessment,11 Subjective Global Assessment).12
The questionnaire was completed with questions For the validation study a new group of 297
of experts (dietitians, nutritionists) who also unan- patients, admitted to the same wards of the VU
imously approved the questionnaire. University medical center in the period of February
until June 2003, was included. Patients who were
Analysis not able to give informed consent, could not be
To select symptoms and risk factors that could be weighed or were younger than 18 years of age were
used to identify subjects with malnutrition, selec- excluded from the study.
tion of questions predictive of malnutrition was Upon admission to the hospital the nurse filled
performed in three phases to finally make up a out the newly developed screening tool, the
short and simple questionnaire, the SNAQr. SNAQr, for every patient. Patients who were
First, the odds ratio was calculated for each classified as moderately or severely malnourished
question of the questionnaire with the presence or following the SNAQr-score (X2 points) received
absence of malnutrition as dependent variable. All energy- and protein-enriched meals and twice a
questions with a statistically significant odds ratio day a nutritious snack. Patients who were classified
(Po0:05) were included in the next phase. as severely malnourished (X3 points) received,
Second, logistic regression was carried out with besides the energy- and protein-enriched meals
the presence or absence of malnutrition as depen- and snacks, treatment by a dietitian (who was
dent variable and with questions with a significant not involved in the study). The dietitian scored
odds ratio as independent variables. The questions the referrals based on the SNAQr-score as
associated with malnutrition at a significance level ‘very necessary’, ‘moderately necessary’ or ‘not
of Po0:05 in a backward stepwise procedure were necessary’.
selected for the next phase of the analysis. The measurements and the definition of the
Third, multinomial logistic regression was carried nutritional status were identical to the procedure
out with severe malnutrition, moderate malnutri- of the first phase of the study.
tion and no malnutrition as the dependent variable The validity of the SNAQr in population B is
and the questions from phase two as the indepen- expressed in the sensitivity, specificity and the
dent variables using Po0:05 as selection criterion. negative and positive predictive value. To measure
This model contained all the finally selected items the cross-validity of the SNAQr a receiver–operator
together. characteristic (ROC) curve was constructed to
The probability of a patient being malnourished present the relationship of the SNAQr-score with
can be predicted by the following regression the definition of malnutrition. ROC curves char-
equation, in which the categorization is based on acterise the relationship between the true positive
a continuous function of P between 0 and 1:P(mal- rate (sensitivity) and the false positive rate (1-
nourished)=1+e–(a+b1x1+b2x2+b3x3+bxxx) 1 where specificity). The specificity of a test is the prob-
P(malnourished) represents the probability of being ability (0–100%) that the SNAQr score is o2 points
 ARTICLE IN PRESS
78 H.M. Kruizenga et al.

Table 1 Characteristics of the well nourished and the moderately/severely malnourished patients of population
A and B.

Population A Population B

Moderately/ Well Whole group Moderately/ Well Whole group

severely nourished severely nourished
malnourished malnourished

N (%) 93 (32%) 198 (68%) 291 98 (33%) 199 (67%) 297

Internal ward/ 62/31 (67%) 99/99 (50%) 161/130 (55%) 63/35 (64%) 79/120 (40%) 144/155 (49%)
surgical and
oncological ward
(N) (% internal)
Sex (men/women) 38/55 (41%) 80/118 (40%) 118/173 (41%) 36/62 (37%) 81/118 (41%) 117/180 (39%)
(% men)
Age (years) 62.2718.3 56.6718.0 58.4718.3 62.2719.0 60.0716.5 60.6717.3
BMI (kg/m2) 22.174.7 26.375.1 25.075.4 22.475.0 25.874.1 24.774.6

for well nourished patients. The sensitivity is the questions showed statistically significant odds
probability (0–100%) that the SNAQr score is X2 ratios. From these, 7 remained in the binary logistic
points for moderately malnourished patients and regression analyses of the second phase. The third
X3 points for severely malnourished patients. The and last phase of multinomial logistic regression,
area under the curve (AUC) quantifies the validity based on a significant Wald-test, resulted in the
of the SNAQr: the greater the area under the final selection of the four questions for the SNAQr
curve, the better the performance of the SNAQr. It (Table 3). These were ‘‘Did you lose weight
varies between 0.5, when the SNAQr is no better unintentionally? More than 6 kg in the last 6 months
than the chance in correctly categorising the two (3 points) or more than 3 kg in the last month’’ (2
groups, and 1.0, when its sensitivity and specificity points), ‘‘Did you experience a decreased appetite
are perfect. over the last month?’’ (1 point), ‘‘Did you use
To measure the inter observer agreement of the supplemental drinks or tube feeding over the last
SNAQr, it was filled out for 47 patient by two month?’’ (1 point).
nurses and for another 47 patients by a nurse and a Patients witho2 points were classified as well
dietitian. The inter observer agreement was tested nourished. Patients with 2 points were classified as
with the kappa (k) and the 95% confidence interval moderately malnourished and patients with X3
(CI) (k71.96 SE).13 points were classified as severely malnourished.

Questionnaire validation study

Results (population B)

Questionnaire development study Following the objective criteria of malnutrition

(population A) (reference standard) in population B (N=297) 78
patients (26%) were severely malnourished and 19
Subjects patients (6%) were moderately malnourished De-
Of the 291 patients that participated in this study, mographic data were similar in population A and B
76 patients (26%) were severely malnourished and (Table 1).
17 patients (6%) were moderately malnourished,
according to the previously described definition of Validity and cross-validity of the SNAQr
malnutrition. The characteristics of population A The validity and the cross-validity of the SNAQr is
and B, including parameters of nutritional status shown in Table 4 for the two cut-off points. In
are presented in Table 1. population B, both sensitivity and specificity proved
to be more than 75% for both cut-off points. The
Selection of the questions for the SNAQr ROC-curve (Fig. 1a) of the moderately and severely
The selection of the SNAQ-questions is described in malnourished patients (cut-off point X2) shows an
Table 2. In the first phase of the selection 17 area under the curve of 0.85 (95% CI 0.79–0.90;
 ARTICLE IN PRESS
Development and validation of a hospital screening tool for malnutrition: 79

Table 2 Selection of the SNAQ-questions.

Over the last month: OR phase 1 (95% CI) Phase 2 Phase 3

(P-value) (P-value)

1. Did you experience difficulty while eating? 4.50 (2.50–8.07) 0.05

2. Did you eat less than normal? 7.36 (3.85–14.07) 0.33
3. Did you experience a decreased appetite? 5.12 (2.86–9.17) 0.02 0.005
4. Did the food taste differently? 1.17 (0.61–2.22)
5. Did you experience nausea? 2.48 (1.44–4.28) 0.38
6. Did you vomit? 1.96 (1.07–3.56) 0.85
7. Did you experience pain while eating? 2.42 (1.27–4.62) 0.92
8. Did you need help with eating and drinking? 4.60 (1.96–10.77) 0.81
9. Did you skip a meal occasionally? 2.45 (1.41–4.27) 0.99
10. Did you often eat alone? 1.48 (0.86–2.54)
11. Do you have false teeth? 2.13 (1.23–3.68) 0.56
12. Did you experience difficulty chewing? 3.47 (1.67–7.18) 0.14
13. Did you experience difficulty swallowing? 2.36 (1.25–4.43) 0.15
14. Did you have diarrhea? 1.93 (1.12–3.33) 0.34
15. Did you have constipation? 1.74 (1.00–3.05)
16. Did you have loss of blood? 1.36 (0.67–2.75)
17. Did you experience burping? 1.18 (0.67–2.09)
18. Do you suffer from a food allergy or are you food 0.44 (0.12–1.54)
intolerant?
19. Did you have to eat an adjusted diet? 1.18 (0.56–2.47)
20. Did you use supplemental drinks or tube feeding? 5.38 (2.62–11.07) 0.03 0.01
21. Did you experience feelings of fatigue or weakness? 4.60 (2.00–10.6) 0.04
22. How often have you been admitted to a hospital during 0.98 (0.57–1.68)
the last year?
23. Did you lose weight unintentionally? 24.73 o0.001
(10.67–57.33)
24. More than 3 kg in the last month? 379 (50–2859) o0.001 o0.001
25. More than 6 kg in the last 6 months? 43 (19–97) o0.001 o0.001
26. Do you have an oncological disease 0.13 (0.88–2.79)

Table 3 Final selection of the questions for the SNAQr.

Regression Regression Scorea OR (95% CI)

coefficient coefficient x 4/7

Constant 4.07
Did you lose weight unintentionally?
More than 6 kg in the last 6 months 5.59 3.19 3 267.0 (30.0–2376.2)
More than 3 kg in the last month 3.63 2.07 2 37.7 (12.5–113.6)
Did you experience a decreased 1.42 0.81 1 4.2 (1.5–11.4)
appetite over the last month?
Did you use supplemental drinks or 1.47 0.84 1 4.3 (1.4–13.9)
tube feeding over the last month?
a
To get round numbers for the SNAQ-scores, the B-coeficients of the logistic regression analyses are multiplied with 4/7 and
rounded of to the nearest integer.

Po0:0001). The area under the curve for the Dietary intervention based on the SNAQr-score
severely malnourished patients (cut-off point X3) One hundred and eleven patients had a SNAQr-
(Fig. 1b) was similar (AUC=0.85; 95% CI 0.79–0.90; score X2 points. They received enriched meals and
Po0:0001). two nutritious snacks per day, by which their daily
 ARTICLE IN PRESS
80 H.M. Kruizenga et al.

Table 4 Validity of the SNAQr in population A and the cross-validity of the SNAQr in population B.

X2 points (moderately and severely X3 points (severely malnourished

malnourished patients) patients)

Population A (%) Population B (%) Population A (%) Population B (%)

Sensitivity 86 79 88 76
Specificity 89 83 91 83
Positive 79 70 78 62
predictive value
Negative 93 89 96 91
predictive value

intake during the hospital stay was increased with effectiveness (clinical outcome) will be reported on
approximately 600 kcal and 10–12 g of protein. in a separate article.
Ninety five patients had a SNAQr-score X3 points The questions with regard to involuntary weight
and were sent to an independent dietitian for loss, loss of appetite and recent use of supple-
further consultation. Six of these patients did not mental drinks or tube feeding appeared to be the
receive additional dietary advise because they best indicators for malnutrition. These items can be
were too ill or had gone home before the dietitian easily scored by the nurse at admission of the
was able to see the patient. Eighty nine patients patient to the hospital. Based on the impact of the
were treated by a dietitian based on the SNAQ- three items on the nutritional status, reflected by
score. In 89% of the cases (79 patients) the dietitian the value of the regression coefficient, a score was
scored the consultation as very necessary, in 7% (6 assigned to each item. Based on this score the
patients) as moderately necessary and in 4% (4 treatment plan was developed.
patients) as not necessary. All patients scored by By using two populations, population A for the
the dietitian as ‘not necessary’ were indeed well development of the SNAQr and population B
nourished following the objective criteria. for the cross-validation of the SNAQr we have
provided insight into the performance of the
questionnaire in clinical practice. Both popu-
Reproducibility of the SNAQr
The kappa (k) of the SNAQr-score, an indicator for lation A and B contained approximately the same
number of severely and moderately malnourished
the nurse–nurse reproducibility in 47 patients, was
patients. The patients were recruited on the
0.69 (95% CI: 0.45–0.94). The k of the SNAQr-score
same medical wards, but recruited in different
in 47 patients by a nurse and a dietitian was 0.91
seasons. Nevertheless, both populations were very
(95% CI:0.80–1.03). From the 47 patients in whom
comparable.
the nurse-nurse reproducibility was tested, 7
The validity and cross-validity of the SNAQr
patients (15%) were classified in different cate-
were good. Of course, the validity of the SNAQr in
gories. In the group of patients in whom the nurse-
dietitian reproducibility was tested, 3 patients (6%) population A was more impressive than the cross-
validity in population B because the logistic
were classified differently.
regression model was build on population A.
However the results of the cross validation in
population B are more meaningful, as they reflect
Discussion the value of the SNAQr in clinical practice. The
area under the curve in population B for both cut-
In August 2003, Kondrup et al. published the ESPEN off points is 0.85. The positive predictive value of
guidelines for nutritional screening.18 One of their the severely malnourished patients (X3 points) was
conclusions was that existing screening tools are 62%. This indicates that 38% patients who were
published with insufficient details regarding their referred to the dietitian based on the SNAQr-
intended use and method of derivation, validation, score, were not severely malnourished, which adds
and with an inadequate assessment of their effec- to the workload of the dietitian. On the other
tiveness. The development of SNAQr does corre- hand, the dietitians scored 89% of the referrals
spond to these requirements. The derivation and based on the SNAQr-score as very necessary.
validation have been described in this article, its Besides on BMI and weight loss, the dietitian
 ARTICLE IN PRESS
Development and validation of a hospital screening tool for malnutrition: 81

ROC Curve population A, these results are an enormous

1.00
improvement to the current clinical situation in
which only half of the malnourished patients is
being recognized, mostly not at admission to the
hospital but in a later stage of hospitalization.
0.75
The reproducibility of the SNAQr was also good.
Training of the nursing staff on the impact of
malnutrition in hospital patients and the need of
Sensitivity

0.50
nutritional screening could result in an even better
nurse-nurse reproducibility.
The SNAQr was validated in a population of
mixed internal, surgical and oncological patients.
0.25 This group of patients is a good reflection of the
nutritionally relevant population of a general
hospital. The results of this study are applicable
to most wards in Dutch hospitals. The SNAQr has
0.00 not been validated for an outpatient population.
0.00 0.25 0.50 0.75 1.00 This will be subject of further study.
(a) 1- Specificity For a more complete insight in the nutritional
ROC Curve status of the study population, body composition
1.00 was measured at admission to the hospital with bio
electrical impedance analyses and upper arm
muscle circumference. The hand grip strength was
measured with handgripdynamometry. Because
0.75 these measurements do not contribute to the
definition of malnutrition which was used to
validate the SNAQr, the results of these measure-
Sensitivity

ments are not reported in this article.

0.50
The true validity of a screening tool can only be
discussed when its impact on clinical outcome has
been proven. To do so, length of hospital stay, care
complexity, weight change during hospital stay and
0.25
costs during hospital stay were recorded to
determine whether the use of the SNAQr and its
treatment plan were cost-effective. Preliminary
0.00 results are promising; we do expect improvement
0.00 0.25 0.50 0.75 1.00 in clinical outcome parameters. However, we have
(b) 1 - Specificity chosen to publish these results in a later stage.
Figure 1 (a)ROC curve of the SNAQr score in the
moderately and severely malnourished patients against
the objective standard of malnutrition for population B. The SNAQr and other short screening
(b) ROC curve of the SNAQr score in the severely instruments
malnourished patients against the objective standard of
malnutrition for population B. Other short screening instruments for hospital
setting are the NRS-2002,14 the MUST,15 the MST16
and the NNSF.17 All instruments are valid and
valuates (subjectively) whether the patient is at suitable for the screening of hospital patients on
risk of becoming malnourished. malnutrition. Our goals in developing the SNAQr
The sensitivity was 76% in the severely malnour- (costs less than 5 min of the nurses time, needs no
ished patients. Six of the 19 patients who were calculating, includes a treatment plan based on the
‘‘missed’’ still scored 2 points and did receive the screeningscore) are only met by the MST. The NNSF
enriched meals and the snacks and the extra is too time-consuming and complicated, the MUST
attention of the nutritional assistant on the ward. needs calculating of the BMI and the percentage of
They lacked the consultation by the dietitian. recent weight loss and the NRS-2002 needs calcu-
Although the sensitivity and the positive predictive lating of the BMI. Both the MST and the SNAQr
value were not as high in population B as in are suitable for screening of hospital patients at
 ARTICLE IN PRESS
82 H.M. Kruizenga et al.

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