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Nutritional Assessment for an Individual
A nutritional assessment identifies protein-energy malnutrition (PEM) and micronutrient deficits that are not readily visible but carry significant clinical consequences. No single parameter is sufficiently sensitive or specific on its own - these tools are most effective when used in combination.
Step 1 - Nutritional History
Weight History
Weight change is the single most practical predictor of clinically significant PEM. Quantify loss over the preceding 6 months:
| Degree of Loss | % Body Weight Lost (6 months) |
|---|---|
| Mild | < 5% |
| Moderate | 5% - 10% |
| Severe | > 10% |
- A loss of >10% typically correlates with a 15-20% decrease in total body protein - the threshold associated with impaired physiology and poor clinical outcomes.
- Change in the past 2 weeks also matters: gaining, stable, or still declining?
- Note: Edema and ascites can mask true weight loss.
Dietary Intake History
Ask about:
- Changes in habitual meal pattern (number, size, content of meals)
- Reason for any change: reduced appetite, dysphagia, dental problems, mood, GI symptoms, ability to prepare food
- Specific foods and amounts eaten over several days (food log or 24-hour recall)
- Type of diet currently consumed: normal solid diet, suboptimal solid, full liquid, hypocaloric liquid, or near starvation
Gastrointestinal Symptoms (>2 weeks duration)
Screen for: nausea, vomiting, diarrhea, anorexia - all of which impair intake or absorption.
Evidence of Malabsorption
Signs/symptoms of fat malabsorption (steatorrhea, oily stools), carbohydrate malabsorption, or protein-losing enteropathy.
Functional Status
- Can the patient shop, cook, and prepare meals?
- Have finances limited food access?
- Are there limitations from disease, frailty, or cognitive impairment?
Medical/Social/Psychological History
- Comorbidities associated with poor nutrition: chronic lung, liver, cardiac, renal disease, cancer, HIV
- Medications that suppress appetite, block nutrient metabolism, or cause malabsorption
- Social factors: living alone, depression, isolation, poverty, immobility, poor dentition, GERD
- Alcohol use
Step 2 - Physical Examination
General Inspection
Look for visible signs of tissue wasting: well-defined bony outlines, prominent veins, sunken temples.
| Finding | What to Assess |
|---|---|
| Subcutaneous fat loss | Orbital hollowing, flat or concave cheeks, thin triceps, visible ribs |
| Muscle wasting | Temples, clavicles, shoulders, interosseous muscles, scapula, quadriceps, calves |
| Edema/Ascites | Pedal/pretibial pitting edema, ascites, scrotal/vulvar edema - may mask weight loss |
| Hydration status | Hypotension, tachycardia, dry mucous membranes |
Micronutrient Deficiency Signs
| Deficiency | Physical Signs |
|---|---|
| Vitamin C | Perifollicular hemorrhage, gum bleeding |
| Vitamin D | Bone tenderness, proximal muscle weakness |
| B12/Folate | Glossitis, pallor, neurological changes |
| Iron | Koilonychia, pallor, angular stomatitis |
| Zinc | Skin rash (acrodermatitis), poor wound healing |
| Protein | Pitting edema, thin/brittle hair, flaky dermatitis |
Step 3 - Anthropometric Measurements
Body Mass Index (BMI)
BMI = Weight (kg) / Height (m²)
| BMI (kg/m²) | Nutritional Status |
|---|---|
| < 16.0 | Severely underweight / Grade III thinness |
| 16.0 - 16.9 | Moderately underweight / Grade II thinness |
| 17.0 - 18.4 | Mildly underweight / Grade I thinness |
| 18.5 - 24.9 | Normal |
| 25.0 - 29.9 | Overweight |
| ≥ 30.0 | Obese |
- A BMI < 18.5 kg/m² prompts referral for full nutritional assessment.
- Caveat: BMI is misleading when fluid overload is present (body cell mass is lower than implied) or in highly muscular individuals (high BMI does not indicate excess fat).
Skinfold Thickness (Fat Mass)
- Triceps and subscapular skinfolds measured with calipers
- Values compared to age- and sex-adjusted normative percentiles
- The sum of triceps + subscapular skinfolds is a proxy for total body fat
Mid-Arm Circumference and Upper Arm Muscle Area
- Mid-arm muscle area estimates skeletal muscle mass
- Values compared against normative 5th percentile tables (age- and sex-adjusted)
Advanced Body Composition (research or specialized settings)
| Technique | What It Measures |
|---|---|
| Dual-energy X-ray absorptiometry (DEXA) | Absolute fat mass, lean mass, bone density |
| Bioelectrical impedance analysis (BIA) | Fat-free mass, body water |
| CT/MRI | Regional fat and muscle (e.g., psoas at L3) |
| Underwater (hydrostatic) weighing | Fat vs. lean mass proportions |
Step 4 - Laboratory Tests
| Test | What It Detects | Key Values |
|---|---|---|
| Serum albumin | Chronic protein depletion; also a negative acute-phase reactant | < 3.0 g/dL suggests moderate-severe PEM; half-life 14-20 days |
| Prealbumin (transthyretin) | More sensitive to recent change due to shorter half-life (2-3 days) | More useful for monitoring short-term change; elevated in CKD |
| Transferrin | Protein status (affected by iron stores) | Half-life 8-9 days |
| C-reactive protein (CRP) | Inflammation (confounds protein markers) | High CRP invalidates albumin/prealbumin as nutritional markers |
| Hemoglobin/CBC | Nutritional anemia (iron, B12, folate), lymphocyte count | Low absolute lymphocyte count correlates with PEM severity |
| Serum creatinine | Skeletal muscle mass proxy (when renal function is normal) | Decreased in muscle wasting |
| 24-hour urine creatinine (Creatinine-Height Index) | Total skeletal muscle mass | Values >20% below normative standards = moderate-severe PEM |
| Blood urea nitrogen (BUN) | Protein catabolism | |
| Serum cholesterol | Decreases with malnutrition | |
| Blood glucose, HbA1c | Metabolic status | |
| Micronutrients (as indicated) | Vitamin D, B12, iron studies, folate, zinc | Based on clinical suspicion |
| Renal and liver function | Affect protein metabolism and drug handling |
Note from ASPEN: Serum albumin and prealbumin reflect severity of the inflammatory response more than true nutritional status. They should not be used as sole metrics in acutely ill patients.
Step 5 - Functional Assessment
- Hand grip strength (dynamometry): Measured with a hand-held dynamometer and compared to manufacturer-supplied normative standards. Diminished grip strength is an ASPEN criterion for diagnosing malnutrition.
- Activities of daily living (ADLs): Ability to dress, feed, transfer, toilet.
- Sarcopenia screening: Combined assessment of low muscle mass + low physical performance (relevant in elderly patients).
Step 6 - Validated Screening Tools
Subjective Global Assessment (SGA)
A clinician-rated tool integrating history and physical findings. Assigns one of three categories:
- A - Well nourished
- B - Mildly to moderately malnourished
- C - Severely malnourished
The rating is most strongly influenced by: loss of subcutaneous fat, muscle wasting, and unintentional weight loss. Validated in hospitalized, critically ill, and geriatric patients.
SGA Components:
- Weight change (past 6 months + past 2 weeks)
- Dietary intake change (type and duration)
- GI symptoms for >2 weeks
- Functional impairment (nutritionally related)
- Physical examination: subcutaneous fat loss, muscle wasting, edema, ascites
Mini Nutritional Assessment (MNA)
An 18-item tool particularly validated for elderly patients. Measures:
- BMI
- Weight history
- Cognition and mobility
- Dietary history
- Self-assessment of health/nutritional status
Malnutrition Universal Screening Tool (MUST)
A 3-step tool used in community/hospital settings:
- BMI score
- Unintentional weight loss score
- Acute disease effect score
These sum to give an overall risk category: low, medium, or high.
Step 7 - ASPEN Diagnostic Criteria for Malnutrition
The American Society for Parenteral and Enteral Nutrition (ASPEN) recommends diagnosing malnutrition if 2 or more of the following 6 criteria are present:
| Criterion | Severe Malnutrition Threshold (Chronic Illness) |
|---|---|
| Insufficient energy intake | < 75% of estimated requirement for ≥ 1 month |
| Weight loss | > 5% in 1 month; > 7.5% in 3 months; > 10% in 6 months; > 20% in 1 year |
| Loss of muscle mass | Severe wasting of temples, clavicles, shoulders, interossei, scapula, thigh, calf |
| Loss of subcutaneous fat | Orbital, triceps, or rib fat loss |
| Fluid accumulation | Edema (limbs, genitals) or ascites that masks weight loss |
| Diminished functional status | Reduced hand grip strength vs. normative standards |
Step 8 - Risk Factor Checklist
The following flags should prompt a full nutritional assessment:
- BMI < 18.5 kg/m²
- Serum albumin < 3.0 g/dL (no hepatic or renal explanation)
- Unintentional weight loss > 10-15% in the past 6 months
- Recent hospitalization, surgery, or serious illness
- Chronic disease (cancer, renal failure, cirrhosis, COPD, heart failure)
- Depression, social isolation, cognitive impairment
- Poor dentition or swallowing difficulty
- Polypharmacy (especially appetite suppressants or drugs affecting nutrient metabolism)
- Alcohol misuse
Summary: Components of a Complete Nutritional Assessment
1. Medical + social + psychological history
2. Nutritional history (dietary intake, appetite, GI symptoms)
3. Physical examination (muscle/fat wasting, edema, deficiency signs)
4. Anthropometrics (BMI, skinfolds, mid-arm circumference)
5. Laboratory tests (albumin, prealbumin, CBC, CRP, micronutrients)
6. Functional assessment (hand grip strength, ADLs)
7. Validated screening tool (SGA, MNA, or MUST)
Sources:
- Goldman-Cecil Medicine, 26th Ed. - Nutritional Assessment (p. 2346)
- Sleisenger & Fordtran's GI and Liver Disease - Chapter 5: Nutritional Assessment Techniques (pp. 88-91)
- Schwartz's Principles of Surgery, 11th Ed. - Nutritional Assessment (p. 2079)
- Sabiston Textbook of Surgery - Nutritional Status Assessment
- Textbook of Family Medicine, 9th Ed. - Subjective Global Assessment
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