ALLAMA IQBAL OPEN UNIVERSITY, ISLAMABAD

(Department of Environmental Design, Health and Nutrition Sciences)

M.SC PUBLIC NUTRITION

Group:

Abdul hameed (0000251505)

Azeem Dilawar (0000251002)

Uzma naveed (0000247505)

Rozina ismail (0000252289)

Nourin islam (0000251158)

Semester: Autumn, 2022

Assignment No: 2

Course: NUTRITIONAL ASSESSMENT-II

Presented to: MADAM SAMRA JAMIL

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To Develop Your Skills for Correctly
Screening and Assessing the Nutritional
Status of Patients by Using Mini Nutritional
Assessment Tool and Subjective Global
Assessment Tools
(3648)

INTRODUCTION:
Nutrition is a basic requirement for life. Accordingly nutrition plays an important role in
promoting health and preventing disease. Many factors can lead to weight change and
malnutrition. Malnutrition is a condition resulting from a combination of varying degrees of
under- or over nutrition and inflammatory activity, leading to an abnormal body composition and
diminished function. Several classifications of malnutrition have been proposed in the past. Even
now there is still no universally accepted definition. Patients with minor nutritional deficiencies
and those with overt under- or over nutrition are common in clinical practice. The prevalence of
malnutrition (under nutrition) among hospitalized adult patients ranges from 30 to 50%,
depending on the criteria used, and in part whether those at high risk as well as those with
established malnutrition are included.

The Mini Nutritional Assessment (MNA) has recently been designed and validated to provide a
single, rapid assessment of nutritional status in elderly patients in outpatient clinics, hospitals,
and nursing homes. It has been translated into several languages and validated in many clinics
around the world. The MNA test is composed of simple measurements and brief questions that
can be completed in about 10 min. Discriminant analysis was used to compare the findings of the
MNA with the nutritional status determined by physicians, using the standard extensive
nutritional assessment including complete anthropometric, clinical biochemistry, and dietary
parameters. The sum of the MNA score distinguishes between elderly patients with: 1) adequate

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nutritional status, MNA ≥ 24; 2) protein-calorie malnutrition, MNA < 17; 3) at risk of
malnutrition, MNA between 17 and 23.5. With this scoring, sensitivity was found to be 96%,
specificity 98%, and predictive value 97%. The MNA scale was also found to be predictive of
mortality and hospital cost. Most important it is possible to identify people at risk for
malnutrition, scores between 17 and 23.5, before severe changes in weight or albumin levels
occur. These individuals are more likely to have a decrease in caloric intake that can be easily
corrected by nutritional intervention.

The Mini Nutritional Assessment (MNA) is a validated nutritional screening instrument designed
to identify elderly persons who are malnourished or at risk of malnutrition. Developed by Nestlé,
it uses data that are relatively easy to obtain, and it can be administered in clinical settings such
as hospitals or physicians’ offices or in community settings. The MNA is designed to provide
primary care health professionals with a single tool to efficiently identify elderly patients at
nutritional risk who may subsequently need a more extensive nutritional assessment.

It is primarily intended for evaluating the so-called frail elderly—older persons exhibiting some
kind of functional impairment, such as mobility, hearing, or cognitive disorders; those older
persons living in nursing homes; and persons older than 85 living in the community. The
instrument is also effective for screening the hospitalized elderly and those requiring surgery. It
has been shown to be most useful at identifying persons at nutritional risk when included as part
of a comprehensive assessment of an elderly person’s cognition, independence, and mobility.
Factors associated with poor nutritional status are major and minor indicators of poor nutritional
status in older persons Approximately 10 to 15 minutes are needed to complete the full MNA
questionnaire. An abbreviated version of the instrument, the Mini Nutrition Assessment– Short
Form (MNA-SF), comprises questions A through F in the instrument, and can be completed in
less than 5 minutes. The MNA-SF retains the validity of the full MNA but is practical for use in
clinical and community settings because it can be more quickly administered than the full
version. There is also a self- administered version of the instrument, the Self MNA composed of
six questions. Individuals whose scores suggest they are malnourished or at risk of malnutrition
are advised to consult with a health care professional. There are also ―apps‖ for smart phones and
tablets, such as the iPhone and iPad. Most of the information required to complete the full MNA
can be obtained from a physical examination and from a brief interview with the patient or
someone knowledgeable about the patient’s condition and dietary habits. In addition, some
anthropometric data are necessary, including height and weight (for calculating body mass
index), mid-arm circumference, and calf circumference.

The full MNA was developed and thoroughly evaluated by researchers at Toulouse University
Hospital, Toulouse, France; the University of New Mexico, Albuquerque; and the Nestlé
Research Center in Lausanne, Switzerland. The full MNA is completed by assigning points for
each of the 18 items in the instrument, which are then summed to provide a ―malnutrition
indicator score.‖ When the malnutrition indicator score is $ 24, the patient’s nutritional status can
be considered normal, and these patients should be given general dietary and lifestyle
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information about how to remain in good health. A patient whose malnutrition indicator score is
< 17 is likely to be at high risk for protein-energy malnutrition and should be followed up with a
comprehensive nutritional assessment. Those whose malnutrition indicator score is between 17
and 23.5 are at increased risk for malnutrition and should also receive further evaluation of their
nutritional status.

Research shows the full MNA and MNA-SF to be practical, noninvasive, and cost-effective
instruments for identifying elderly persons at risk for malnutrition.

Subjective Global Assessment (SGA) is a clinical technique for assessing the nutritional status
of a patient based on features of the patient’s history and physical examination. 4 Unlike
traditional methods that rely heavily on objective anthropometric and biochemical data, SGA is
based on four elements of the patient’s history (recent loss of body weight, changes in usual diet,
presence of significant gastrointestinal symptoms, and the patient’s functional capacity) and
three elements of the physical examination (loss of subcutaneous fat, muscle wasting, and
presence of edema or ascites). 4 Information obtained from the history and physical examination
can be entered into a form, to arrive at an SGA rating of nutritional status.

Elements of the History

The first of the four elements of the SGA history is the percent and pattern of weight loss within
6 months prior to examination. A weight loss < 5% is considered small. A 5% to 10% weight
loss is considered potentially significant. A weight loss > 10% is considered definitely
significant. The pattern of weight loss is also important. A patient who has lost 12% of his or her
weight in the past 6 months but has recently gained 6% of it back is considered better nourished
than a patient who has lost 6% of his or her weight in the past 6 months and continues to lose
weight. Information about the patient’s maximum weight and what it was 6 months ago can be
compared with the patient’s current weight. Questions about changes in the way clothing fits
may confirm reports of weight change. Information about changes in body weight in the past 2
weeks (increase, no change, decrease) should be elicited as well. These data can be entered or
noted in the appropriate places in Dietary intake, the second element of the history, is classified
as either normal (i.e., what the patient usually eats) or abnormal (i.e., a change from the patient’s
usual diet). If intake is abnormal, the duration in weeks is entered, and the appropriate box is
checked to indicate the type of dietary intake abnormality (i.e., increased intake, suboptimal
solid, full-liquid, IV or hypocaloric liquids, or starvation). The patient can be asked if the amount
of food consumed has changed and, if so, by how much and why. If the patient is eating less, it
would be valuable to know what happens when he or she tries to eat more. Ask for a description
of a typical breakfast, lunch, and dinner and how that compares with what the patient typically
ate 6 or 12 months ago.

Information about any gastrointestinal symptoms persisting more than 2 weeks (the third history
element) should be elicited and noted on the form. Diarrhea or occasional vomiting lasting only a

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few days is not considered significant. The presence or absence of any dysfunction in the
patient’s ability to attend to activities of daily living (the last history element) should also be
noted on the form. If a dysfunction is present, its duration and type should be noted.

Elements of the Physical Examination

The first of the three elements of the physical examination is loss of subcutaneous fat. The four
anatomic areas (shoulders, triceps, chest, and hands) should be checked for loss of fullness or
loose-fitting skin, although the latter may appear in older persons who are not malnourished.
Illustrations of subcutaneous fat loss in the arm, chest wall, and hands. Loss of subcutaneous fat
should be noted as normal (0), mild loss (1 1 ), moderate loss (2 1 ), or severe loss (3 1
According to Detsky, the presence of muscle wasting (the second element of the physical
examination) is best assessed by examining the deltoid muscles (located at the sides of the
shoulders) and the quadriceps femoris muscles (the muscles of the anterior thigh). 4 Loss of
subcutaneous fat in the shoulders and deltoid muscle wasting gives the shoulders a squared-off
appearance, similar to that These areas can be assessed as being normal or mildly, moderately,
or severely wasted. The presence of edema at the ankle or sacrum can also be assessed as absent,
mild, moderate, or severe. The presence of ―pitting‖ edema can be checked by momentarily
pressing the area with a finger and then looking for a persistent depression (more than 5 seconds)
where the finger was. Ankle edema and ascites can be assessed as absent, mild, moderate, or
severe. When considerable edema or ascites are present, weight loss is a less important variable.

The final step in SGA is arriving at a rating of nutritional assessment. Instead of an explicit
numerical weighting scheme SGA depends on the clinician’s subjectively combining the various
elements to arrive at an overall, or global, assessment. Patients with weight loss > 10% that is
continuing, poor dietary intake, and severe loss of subcutaneous fat and muscle wasting fall
within the severely malnourished category (class C rank). Patients with at least a 5% weight loss,
reduced dietary intake, and mild to moderate loss of subcutaneous fat and muscle wasting fall
within the moderately malnourished category (class B rank). Patients are generally ranked as
well-nourished when they have had a recent improvement in appetite or the other historical
features of SGA. A class A rank would be given to patients having a recent increase in weight
(that is not fluid retention), even if their net loss for the past 6 months was between 5% and 10%.
Using this approach, very few well-nourished patients are classified as malnourished, but some
patients with mild malnutrition may be missed. 4 Despite this subjective nature, clinicians
(nurses and residents)

trained to use SGA were shown to have arrived at very similar rankings when comparing their
evaluations of a series of 109 patients. 4 The method has also been shown to be a powerful
predictor of postoperative complications. 4 , 5 SGA has been shown to be a simple, safe,
effective, and inexpensive tool for clinicians to identify patients who are malnourished or at risk

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of malnutrition. It is regarded by many as the most reliable and efficient method to assess
nutritional status at the bedside and is considered the gold standard for bedside assessment tools.

Objectives:

• To assess the nutritional status of elderly population by using MNA Tool.

• To analyze the nutrition loss and screening malnourishment in hospitalized patient using
SGA.

Methodology:

Tools or materials needed

Mini nutrition assessment fom

Mini nutrition assessment form is extracted from the link university provided. This form is
further used to assess the nutrition status of patients older than 70

Subjective global assessment form

• Subjective global assessment form is extracted from the link university provided.

The forms are used to assess nutrition status of hospitalized patients and how diseases can affect
the nutrition of patients.

The data was collected from Iqra homeopathic clinic Rawalpindi. The criteria to collect the data
is

• MNA was collected from the clinic. The form was filled from elderly people of age more
than 70 years. It took 10 to 15 minutes to complete a single MNA forms. Other than that patients
have been asked general questions about their health situation and how they carry out life with
everything.

• SGA was also collected from the clinic and it was,. This form is filled by the patients of
the clinic different medical situations have been asked. Patients have been asked of their weight,
their current weight, their weight fluctuations, different symptoms of diseases are also asked.
Patients are asked if they show symptoms of other illnesses that can lead to the malnutrition.

1- MNA analysis by AZEEM DILAWAR

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2- MNA analysis by Abdul hameed:

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3- MNA analysis by Rozina ismail:

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4- MNA analysis by Uzma naveed:

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5- MNA analysis by Nourin:

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Case study #1

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First case study is of a lady of 80 years old. According to the screening done in the
MNA forms the patient in the consideration is has shown symptoms of risk of
malnutrition as the patient eats two proper meals of the day. Other than that the
patient has no proper intake of fruits, milk and milk products. As patient lives in
under privileged area it is hard for the patient to get access to the proper food
choices or dietary guidelines needed in old age. The risk of malnutrition is
basically because of not eating properly and not considering healthy dietary
choices

Case study #2

2nd case study is also a female patient of age 87. According to the screening done
in the MNA for it is evaluated that the patient does not has any mobility issues.
Patient’s weight fluctuates in between intervals but most of the time it stays same.
According to the assessment form it is clear that the patient does not take her fruit
servings regularly and patient also does not take milk and milk products regularly.
The meat or poultry consumption is also reduced. It is concluded from the patients’
health condition that patient is at the risk of malnourished.

Case study #3

3rd case study is also taken from a female of age 75. The patient has a sever
decrease in food intake thus making it difficult for the weight to be stable at a
specific point. BMI is also less than 19. The patient eats 2 regular meals per day.
There is a very less intake of fruit servings per day. Ilk and products are also taken
in a very less amount. Poultry and chicken or meat is also taken in a very less
amount and thus the patient is at the risk of malnutrition.

Case study #4

The 4th case study is a lady of 90 years old. There is no severe decrease in food
intake in the patient. Patient also shows some symptoms of decreased mobility as
the patient does come out of the bed or chair but does not go out and stays at home
doing daily routine work. The patient has a BMI in the normal range that is in
between 19 to 21. The patient also shows some symptoms of neuropsychological
symptoms. The patient takes in 2 meals per day. Protein intake is also much
decreased as there is a very little to less consumption of milk and milk products

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other than milk products poultry and meat is also taken in much decreased amount.
According to MNA screening the patient has a malnourished profile thus a full
MNA can be performed on the patients.

Case study #5

The fifth case study is of a male patient of the age 70. According to the screening
performed on Abdul Rasheed. The patient is experiencing a sever decrease in the
food intake. The weight loss is also accompanied with the decrease in food intake.
The patient eats only one meal of the day. Because of the decreased amount of
food taken in, the patient also takes a very less amount of the fruits servings. Milk
and milk products are also not consumed properly. Same is the case with proteins
and meat eaten. Because of such low amounts of food taken the patient is
malnourished and should go for a further screening.

1- SGA analysis by Azeem Dilawar

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2- SGA analysis by Abdul hameed:
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3- SGA analysis by Rozina ismail:

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4- SGA analysis by Uzma naveed:

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 5- SGA analysis by Nourin:

Case study #1

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The first case study is a male patient with almost no change in nutrient. Nutrient
supply is adequate. And the nutrient intake of the patient is mostly of solids.
Weight fluctuation is noticed in the data but the fluctuation is less than 5 percent
thus there is no noticeable change in the nutrition of the person. However the
symptoms of the patient disease are much more to be ignored. The symptoms
include anorexia, constipation and feeling full quickly. The patient is given SGA
ranking B which is mild or moderately malnourished.

Case study #2

2nd case study is of a male patient with weight 70 that is not changed over the
course of months, the food intake is adequate solid food. As there are no changes
in the weight, there are also no symptoms in the illnesses in the body that can
evaluate to the medical condition of the patient. As there are also no metabolic
disruptions the patient is well nourished thus given SGA ranking of A.

Case study # 3

In the 3rd case study there is a female patient with the symptoms of intermittent
where they stay empty stomach for most of the time as the symptoms are not
improving. Metabolic requirement of the patient is also not much high. The
physiological functions are also not much interrupted by the few symptoms patient
is showing. Thus a SGA ranking of B is given to the patient because of the
symptoms of mild intermittent hunger and because of no improvement of the
symptoms. According to the ranking B of the patient the patient is mild or
moderately malnourished.

Case study #4

The 4th case study is of a male patient with the weight of 60kg. There is no change
in the weight of the patients as the weight remains constant. The patient shows
symptoms of nausea but these symptoms are improving. Nutrient intake of the
patient is adequate and the there is no decrease in metabolic rate or physiological
functions thus the patient is given SGA ranking A this shows that the patient is
well nourished and can combat the disease easily.

Case study # 5

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The 5th case study is of a female patient with symptoms of diarrhea. The
symptoms are improving and there is an improvement in the intake of food and
retention of it in the body. The patient shows mild or moderate changes in the
physiological functions with almost no changes in the metabolic requirement. The
functional capacity of the patient is also of no change. The food intake is adequate
and more solid foods are given to the patient to help her with improving.
According to the assessments conducted it is advised that the SGA ranking is A
and the patient is well nourished with adequate amount of food intake.

Result and discussion of MNA:

Result:

The Mini Nutritional Assessment (MNA) is a validated tool used to assess the
nutritional status of older adults. The MNA consists of 18 questions and provides a
score ranging from 0 to 30. The MNA result and discussion can provide valuable
insights into an individual's nutritional status and inform the development of
personalized care plans to address their needs.

The MNA result is typically presented as a score, where a score of 24 or higher

indicates a normal nutritional status, a score between 17 and 23.5 indicates a risk
of malnutrition, and a score below 17 indicates malnutrition. Based on the MNA
score, healthcare professionals can develop a personalized care plan to address the
individual's specific nutritional needs.

In the discussion, the MNA results are interpreted based on the individual's
responses to the 18 questions. The discussion can provide insights into the possible
causes of malnutrition, such as poor appetite, recent weight loss, and mobility
limitations.

Discussion:

The MNA result and discussion can also highlight the potential consequences of
malnutrition, such as increased risk of falls, hospitalization, and mortality.

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Therefore, the MNA can help identify individuals who are at risk of malnutrition
and develop strategies to prevent or treat malnutrition.

Additionally, the MNA result and discussion can be used to monitor progress and
assess the effectiveness of the care plan. Regular MNA assessments can track
changes in the individual's nutritional status and identify any gaps or challenges in
the care plan.

Conclusion:

In conclusion, the MNA is a useful tool for assessing the nutritional status of older
adults, identifying those at risk of malnutrition, and developing personalized care
plans to address their specific needs. The MNA result and discussion can provide
valuable insights into the possible causes of malnutrition and potential
consequences. Regular MNA assessments can monitor progress and assess the
effectiveness of the care plan.

Result and discussion of SGA:

Result:

SGA forms are the questionnaire that is used to evaluate nutritional status of
hospitalized patients that are going through some medication or procedures for
treatment of their diseases.

The result and discussion of Subjective Global Assessment (SGA) can provide
valuable insights into an individual's nutritional status and inform the development
of personalized care plans to address their needs.

The SGA result is typically presented as a score, ranging from A to C, where A

represents a well-nourished individual, B represents a moderately malnourished
individual, and C represents a severely malnourished individual. Based on the SGA
score, healthcare professionals can develop a personalized care plan to address the
individual's specific nutritional needs.

Discussion:
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In the discussion, the SGA results are interpreted based on the individual's medical
history, physical examination, and dietary intake. The discussion can provide
insights into the possible causes of malnutrition, such as underlying medical
conditions, functional limitations, or poor dietary intake.

The SGA result and discussion can also highlight the potential consequences of
malnutrition, such as impaired wound healing, increased risk of infections, and
reduced quality of life. Therefore, the SGA can help identify individuals who are at
risk of malnutrition and develop strategies to prevent or treat malnutrition.

Additionally, the SGA result and discussion can be used to monitor progress and
assess the effectiveness of the care plan. Regular SGA assessments can track
changes in the individual's nutritional status and identify any gaps or challenges in
the care plan.

Conclusion:

In conclusion, the SGA is a useful tool for assessing an individual's nutritional

status, identifying those at risk of malnutrition, and developing personalized care
plans to address their specific needs. The SGA result and discussion can provide
valuable insights into the individual's medical history, physical examination, and
dietary intake, as well as potential consequences of malnutrition. Regular SGA
assessments can monitor progress and assess the effectiveness of the care plan.

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