FROM THE ACADEMY

Position Paper

Position of the Academy of Nutrition and

Dietetics: Malnutrition (Undernutrition)
Screening Tools for All Adults
ABSTRACT POSITION STATEMENT
It is the position of the Academy of Nutrition and Dietetics that, based upon current It is the position of the Academy of Nutrition
evidence, the Malnutrition Screening Tool should be used to screen adults for malnu- and Dietetics that, based upon current evi-
dence, the Malnutrition Screening Tool
trition (undernutrition) regardless of their age, medical history, or setting. Malnutrition should be used to screen adults for malnu-
(undernutrition) screening is a simple process intended to quickly recognize individuals trition (undernutrition) regardless of their
who may have a malnutrition diagnosis. While numerous malnutrition screening tools age, medical history, or setting.
are in use, their levels of validity, agreement, reliability, and generalizability vary. The
Academy of Nutrition and Dietetics reviewed the body of evidence supporting malnu-
trition screening tools and determined a single tool for identifying adults in all settings
who may have malnutrition, regardless of their age or medical history. The Nutrition
Screening for Adults Workgroup conducted a systematic review of the most robust
evidence to promote using the highest-quality malnutrition screening tool available.
J Acad Nutr Diet. 2020;120(4):709-713.

M
ALNUTRITION (UNDER- malnutrition screening tools increases malnourished regardless of age, acute
nutrition) among adults the likelihood that individuals referred and chronic medical conditions, or
aged 19 years through old to an RDN for assessment will have a settings where care is received.
age is a common nutrition malnutrition diagnosis. Conversely, us-
problem.1 Because not all individuals ing valid and reliable tools avoids unnec-
with malnutrition have direct access to essary referrals of people who do not Position Statement Development
registered dietitian nutritionists (RDNs), have malnutrition. Process
screening to identify those who may The Academy’s Nutrition Screening for
have malnutrition or be at risk for Adults Workgroup systematically
malnutrition is a routine part of the POSITION FOCUS reviewed validation studies for
intake or admission process in commu- Malnutrition occurs in health care malnutrition screening tools published
nity and health care settings. Nutrition settings, and in communities where in the peer-reviewed literature from
screening, as described in the Nutrition people suffer from food insecurity and January 1997 through July 2017 and
Care Process, is separate and distinct hunger. Thus, this position applies in all used the results as a basis for this po-
from nutrition assessment,2,3 and is per- settings where food assistance and sition.4,5 The Workgroup included tools
formed by nurses; medical assistants; nutrition services are available. This that met the Academy’s 2011 definition
and nutrition and dietetics technicians, position is based on a comprehensive of nutrition screening (Figure 1), which
registered. Based on a predetermined systematic review4,5 and is intended to was created for an earlier version of
score, patients or clients are referred to provide RDNs and all other health this project.13 As in the earlier sys-
an RDN for nutrition assessment, an in- professionals with validity, agreement, tematic review, the Workgroup sought
depth process that is a licensed function reliability, and generalizability data quick and easy screening tools, defined
in many states. Nutrition assessment for six malnutrition screening tools as requiring fewer than 10 minutes to
may involve verifying some of the infor- supported by the largest number complete. For the current position, the
mation obtained during screening and of studies (Malnutrition Screening requirement for robust data necessi-
then obtaining additional information Tool [MST],6 Malnutrition Universal tated inclusion of tools with adequate
necessary for a malnutrition diagnosis.3 Screening Tool,7 Mini Nutritional supporting evidence, defined as greater
Widespread use of valid and reliable AssessmenteShort Form,8,9 Short than four validation studies. The
Nutritional Assessment Question- Workgroup considered the overall val-
naire,10 Mini Nutritional Assessmente idity, agreement, and reliability results
2212-2672/Copyright ª 2020 by the
Short Form Body Mass Index,11 and and grades of supporting evidence for
Academy of Nutrition and Dietetics.
Nutrition Risk Screening 2002).12 This each tool, then generalizability of each
https://doi.org/10.1016/j.jand.2019.09.011
position supports using a single tool to the widest variety of medical
Available online 19 December 2019
tool to identify adults who may be diagnoses or age groups and settings

ª 2020 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 709
FROM THE ACADEMY

Definition: Nutrition screening is 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 nutritionist (RDN).

Key considerations:

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 RDNs, but the screening process may be carried out by nutrition and dietetics
technician, registered and other trained personnel

Nutrition screening and rescreening should occur within an appropriate time frame for the setting.
Figure 1. The Academy of Nutrition and Dietetics’ definition and key considerations for nutrition screening. (Reprinted with
permission from Skipper and colleagues13; ª 2012 American Society for Parenteral and Enteral Nutrition.)

and ranked the tools accordingly adults who may have malnutrition. In-
Abandon all unvalidated malnu-
(Figure 2). The position paper was stitutions and programs that implement trition screening tools (eg,
posted for public comment before the MST should have data available to pressure injury and illness
publication. consistently compare the populations severity tools), including tools
screened for malnutrition, predict the that were validated, then
POSITION resources for needed treatment, and modified without rigorous re-
support research. validation against a standard
It is the position of the Academy of
Based upon the best available evi- definition of malnutrition.
Nutrition and Dietetics that, based
dence,4,5 the Academy advocates that
Discourage strongly the devel-
upon current evidence, the MST should
RDNs: opment of new screening tools
be used to screen adults for malnu-
in favor of further validating
trition (undernutrition) regardless of

Assume a strong leadership role in existing tools,13 especially in
their age, medical history, or setting.
implementing the MST. A benefit adults between the ages of 19
Ferguson and colleagues6 developed
to society occurs if individuals and 49 years, over age 90 years,
the MST to detect malnutrition or risk
who may have malnutrition and in community and long-
for malnutrition. Between 1999 and
obtain nutrition assessment and term care settings.
2017, the MST was validated in acute,

intervention services from an Research the costs and outcomes
long-term, rehabilitation, and ambula-
RDN. This benefit is not without of the malnutrition screening
tory care and oncology clinics in at
cost because of the time required procedure. Minimal data exist on
least nine different countries.15-33
for an RDN to complete a nutrition the financial implications of the
These studies revealed that the MST
assessment. Thus, the impact of proper identification of patients
exhibited a moderate degree of val-
changes to screening procedures who do or do not have malnutri-
idity, a moderate degree of agreement,
affects the amount of RDN time tion or the costs of the screening
and a moderate degree of inter-rater
available to provide other required procedure.4,5 Obtaining these
reliability in identifying malnutrition
nutrition services and provides data could enable the projection
risk in adults (Figure 2). The strength of
justification for RDNs to select of malnutrition assessment and
evidence for the MST is Grade I, good/
and oversee implementation of intervention cost and should be a
strong with good generalizability.4,5,14
malnutrition screening tools. research priority.
Some of the other tools also had high


Implement the MST without Research the minimum level of
or moderate validity, agreement, or reli-
changes to the wording of the education and training needed
ability, but were not supported by Grade
questions or the scoring system to accurately administer the MST
I evidence or good generalizability.4,5
for referrals as originally pre- and develop education and
sented.6 Adding items, modifying training materials to facilitate
IMPLICATION FOR PRACTITIONERS questions, or interpreting scores consistency among users.
While disease-, age-, or setting-specific differently than intended by the
Develop partnerships with pa-
malnutrition screening tools exist, authors of the tool should be tient advocacy groups, other
most organizations where malnutrition avoided, as these changes invali- health care professional organi-
screening occurs have clients or pa- date the MST. Individual patients zations, and policy makers to
tients of different ages with one or or clients with an MST score of 2 implement the MST.
more medical problems and provide should achieve the greatest
nutrition care in a variety of settings. benefit from an RDN referral.
The value of using different screening
Provide ongoing training to para- CONCLUSIONS
tools for individuals with different professionals who administer the The amount and quality of evidence for
personal characteristics is unclear, and MST and monitor the impact of validated malnutrition screening tools
subject to practical limitations. It is the screening and referral process has grown considerably since an earlier
appropriate to implement the screening by summarizing data from in- review of the topic. This additional
tool that will most accurately identify dividuals with malnutrition. evidence supports using a single tool,

710 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS April 2020 Volume 120 Number 4
April 2020 Volume 120 Number 4

VALIDITYa
Positive Negative EVIDENCE
Predictive Predictive OVERALL GRADE,
TOOL Sensitivity Specificity Value Value VALIDITYb AGREEMENTa RELIABILITYa GENERALIZABILITYc STRENGTHd
MSTe Moderate Moderate Moderate Moderate MODERATE MODERATE MODERATE Good I, Good/strong
f
MUST Moderate Moderate Moderate High HIGH MODERATE MODERATE Fair II, Fair
g
MNA-SF Moderate Moderate Low Moderate MODERATE LOW MODERATE Fair II, Fair
SNAQh Moderate High Low High MODERATE — MODERATE Fair II, Fair
MNA-SF-BMI i
Moderate Moderate Moderate High HIGH MODERATE — Limited II, Fair
NRS-2002 j
Moderate High Moderate Moderate MODERATE MODERATE — Limited II, Fair
a
Sensitivity, specificity, positive predictive value, negative predictive value cutoffs: High: 90% to 100%, moderate: 80% to 89%, low: 79%; agreement and reliability k
cutoffs: High: 0.8 to 1; moderate: 0.6 to 7.9; low: 5.9.
b
See Figure 3 in Skipper and colleagues4 for the algorithm to determine the overall validity.
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

c
The Workgroup determined generalizability based on usefulness of each tool across the broadest array of adult age groups, locations, diseases, and treatments according to
evidence.
d
Elements considered in the evidence grade include quality of the evidence, consistency of results across studies, quantity of studies, and number of subjects, clinical impact
of outcomes, and generalizability to population of interest.14
e
MST¼Malnutrition Screening Tool.
f
MUST¼Malnutrition Universal Screening Tool.

FROM THE ACADEMY

g
MNA-SF¼Mini Nutritional AssessmenteShort Form.
h
SNAQ¼Short Nutritional Assessment Questionnaire.
i
MNA-SF-BMI¼Mini Nutritional AssessmenteShort Form Body Mass Index.
j
NRS-2002¼Nutrition Risk Screening 2002.
Figure 2. Validity, agreement, reliability, generalizability, and strength of evidence of adult malnutrition (undernutrition) screening tools.
711
FROM THE ACADEMY

the MST, to screen all adults for 10. Kruizenga HM, Seidellb JC, de Vetc HCW, Appropriate methods to guide nutrition
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712 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS April 2020 Volume 120 Number 4
 FROM THE ACADEMY

AUTHOR INFORMATION
The Academy of Nutrition and Dietetics develops position papers to assist in promoting the public’s optimal nutrition, health and well-being. This
position was adopted by the Council on Research on August 6, 2019. This position is in effect until December 31, 2023. All requests to use
portions of the position or republish in its entirety must be directed to the Academy at [email protected].
Authors: Annalynn Skipper, PhD, RD (American Medical Association, Chicago, IL); Anne Coltman, MS, RD, LDN, CNSC (Trinity Health, Melrose Park,
IL); Jennifer Tomesko, DCN, RD, CNSC (Rutgers University, School of Health Professions, Newark, NJ); Pamela Charney, PhD, RD (University of
North Georgia, Dahlonega, GA); Judith Porcari, MBA, MS, RD (Lehman College, Bronx, NY); Tami A. Piemonte, MS, RDN, LD/N (Academy of
Nutrition and Dietetics, Evidence Analysis Center, Chicago, IL); Deepa Handu, PhD, RD, LDN (Academy of Nutrition and Dietetics, Evidence
Analysis Center, Chicago, IL); Feon W. Cheng, PhD, MPH, RDN, CHTS-CP (Academy of Nutrition and Dietetics, Evidence Analysis Center,
Chicago, IL).
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
The authors of the paper have no conflicts to disclose. A. Skipper is an employee of the American Medical Association (AMA), but the ideas
expressed in this position are those of the Academy of Nutrition and Dietetics and do not reflect AMA policy.
FUNDING/SUPPORT
There is no funding to disclose.
Reviewers: Constantina Papoutsakis, PhD, RDN (Academy of Nutrition and Dietetics, Chicago, IL); Jason Switt (Academy of Nutrition and Dietetics,
Chicago, IL); Jill Bala Kohn, MS, RDN, LDN (Academy of Nutrition and Dietetics, Chicago, IL); Sharon M. McCauley, MS, MBA, RDN, LDN, FADA,
FAND (Academy of Nutrition and Dietetics, Chicago, IL); Marsha Schofield, MS, RD, LD, FAND (Academy of Nutrition and Dietetics, Chicago, IL).
This position paper was made available for Academy member feedback.
Systematic Review Workgroup: The authors would like to thank Erin Pover, MS, RDN, CSOWM, LDN (Workgroup member from 2016 to March
2018), Kathy Hoy, EdD, RDN (lead analyst from 2016 and July 2017), and Margaret Foster, MS, MPH, AHIP (librarian) for their contributions to this
project. A full listing of the systematic review project team is available on www.andeal.org/nsa.
ACKNOWLEDGEMENTS
The authors thank the reviewers for their many constructive comments and suggestions. The reviewers were not asked to endorse this position
or the supporting paper.

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