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Nutrition Across The Lifespan Quiz

Nutrition Across The Lifespan Quiz

Nutrition Across The Lifespan Quiz

Despite being introduced and validated for clinical use about 20 years ago, the MNA has recently received new attention in order to more widely disseminate among healthcare professionals the practice of a systematic nutritional screening and assessment of the old patient. Particularly, the structure has been implemented to face the difficulties in having the patients contributing to the assessment and to reduce further the time required to complete the evaluation. Recent data also confirm that in older populations prevalence of malnutrition by this tool is associated with the level of dependence. The rationale of nutritional assessment is to identify patients candidate to nutritional support. However, the sensitivity of the MNA is still debated because it has been associated with a high-risk ‘overdiagnosis’ and the advantages of a positive screening need to be assessed both in terms of outcome and money saving.


The MNA is a simple and highly sensitive tool for nutritional screening and assessment. The large mass of data collected and the diffusion among healthcare professionals clearly support its use. However, the cost- effectiveness of interventions based on its scoring deserves investigation.


elderly, malnutrition, Mini Nutritional Assessement, Mini Nutritional Assessment Short Form, nutritional screening tools, risk of malnutrition


The Mini Nutritional Assessment (MNA) is the most widespread tool for nutritional screening and assess- ment due to the ease of use and the feasibility in any clinical care setting. Despite being introduced and validated for clinical use about 20 years ago, this tool has recently received new attention and has been the object of reappraisals in order to disseminate more widely the practice of a systematic nutritional screening of the old patient. In this scenario, the aim of this review is to summarize recent evidences and advances on the implementation and the use of this instrument.

Nutrition and Dietetics Service, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy

Correspondence to Emanuele Cereda, MD, PhD, Nutrition and Dietetics Service, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy. Tel: +39 0382 501615; fax: +39 0382 502801; e-mail:

Curr Opin Clin Nutr Metab Care 2012, 15:29–41



Looking at the demographic time trends, the ratio of people aged over 65 years is considerably growing, rising up in the past decade from 18 to 20% of total population (from 2 to 3% for those >85 years old) with a mean lifetime increase of 2 years in both sexes [1].

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Nutritional disorders are of specific relevance for the elderly. Aging is intrinsically associated with a progressive reduction in muscle mass and more widely with a loss of metabolically active com- ponents of the body which in turn result not only in loss of functionality but also in worse outcome [2


,3 &

,4 &&

]. This increased vulnerability to stressors has led experts in to seek for a clinical definition of ‘frailty syndrome’, a condition that is believed to be a continuum situated between normal aging and end-stage disability. In regard to this, no consensus was achieved but an agreement to consider frailty a predisability stage was found [5,6]. The MNA has been proposed as a useful

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� ‘As easy as MNA’ is now considered the business card of the MNA.

� Despite being introduced and validated for clinical use about 20 years ago, time-course improvements in its structure have allowed implementing and disseminating the practice of a systematic nutritional screening of the old patient.

� The MNA is a sensitive tool for nutritional screening and assessement but the risk of ‘overdiagnosing’ nutritional derangements has been the object of debate and the advantages of a positive screening need to be assessed both in terms of outcome and money saving.

Ageing: biology and nutrition

alternative tool to identify frail patients [5] and, interestingly, previous research has shown that in institutionalized patients at risk of malnutrition most of the association between nutritional and functional status (by MNA and Barthel index, respectively) is explained by some of the key features of frailty such as weight loss and sarcopenia [7].

The proneness of aging people to nutritional derangements is likely to be multifactorial and a list of causative factors has been elegantly resumed in the ‘9 Ds’ and the practical acronym ‘MEALS ON WHEELS’ (Table 1) [8,9].

Indeed, the work of international societies and ad-hoc study groups is a timely and rationalized effort to improve the patient’s outcome. Diseases have changed from acute to chronic ones. Similarly, medicine has turned to a preventive approach from a curative one. Accordingly, increased knowledge and awareness, as well as improved practice should

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Table 1. Summary of factors potentially involved in nutriti

The ‘9 Ds’ [8] The acron

Dementia Medicatio

Depression Emotional

Disease (acute and chronic) Anorexia

Dysphagia Late life p

Dysgeusia Swallowin

Diarrhoea Oral facto

Drugs No money

Dentition Wanderin

Dysfunction (functional disability) Hyperthyr

Enteric pro

Eating pro

Low salt, l

Stones, so


theoretically result in early diagnosis of risk con- ditions that, being more likely to be reversible, allow planning of effective interventions.


It is highly recommended that a screening tool fits best to the population object of evaluation [10]. Due to the potentially multifactorial origin of nutritional risk in the elderly it appears that the MNA properly addresses this requirement. Structured in 18 questions grouped in four rubrics (anthropometry, general status, dietary habits, and self-perceived health and nutrition states), the MNA provides a multidimensional assessment of the patient (Table 2) [11,12].

It was initially developed as a one-step evaluation procedure, using as principal reference criteria the physician-rated nutritional status and a full nutri- tional assessment including anthropometric measures, biochemical parameters, dietary intake and functional variables such as cognition (by Mini-Mental State Examination) and activities of daily living (general and instrumental). After its completion, the final score (a maximum of 30 points) allows grading the nutritional status according to clearly defined thresholds: scores above 24, good status; scores 23.5–17, risk of malnutrition; scores below 17, malnutrition. The main features targeted during this phase of design and validation were the reliability, the simplicity, the speed of execution and the acceptability by the patient [11]. Despite the good agreement with the physician’s judgement, which still remains the gold standard of nutritional assessment, the initial researchers

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onal derangements


n effects

problems (especially depression)

nervosa or alcoholism


g disorders

rs such as poorly fitting dentures, caries

g and other dementia related behaviours

oidism or hypothyroidism or hyperparathyroidism or hypoadrenalism


blems (such as inability to feed self)

ow-cholesterol diet

cial problems (such as isolation, inability to obtain preferred foods)

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Table 2. MNA scoring system

Rubrics and questions Score range

Rubric I. Anthropometric assessment (maximum 8 points)

Body weight and height, and related calculation of BMIa 0–3 points

Arm circumference 0–1 points

Calf circumference 0–1 points

3-Month weight lossa 0–3 points

Rubric II. General status assessment (maximum 9 points)

Independence of living 0–1 points

Recent acute events (disease or psychological distress)a 0–2 points

Presence of pressure or skin ulcers 0–1 points

Number of medications taken on 0–1 points

Cognition/depressiona 0–2 points

Mobilitya 0–2 points

Rubric III. Dietary assessment (maximum 9 points)

Eating problems (appetite, swallowing, chewing)a 0–2 points

Number of full meals 0–2 points

Markers of protein intake 0–1 points

Intake of vegetables and fruit 0–1 points

Intake of liquids 0–1 points

Self-sufficiency in eating 0–2 points

Rubric IV. Self-perceived health and nutrition states (maximum 4 points)

Self-perception of nutritional status 0–2 points

Self-perception of health status 0–2 points

MNA, Mini Nutritional Assessment. Data from [12]. aQuestions included in the first version of the MNA–SF.

Mini Nutritional Assessment Cereda

and the scientific community worked hard to bring further improvements and in the following years the tool was the object of different reappraisals. The key passages of this process are summarized in Table 3.

After development and validation, the tool was then implemented as a more practical two-step evalu- ation process. Although the full MNA can be com- pleted in 15–20 min, in cognitively impaired people the assessment may require more time and in some cases answers are difficult to obtain. Moreover, in acute care settings time-consuming procedures may not be performed. A reanalysis of the initial database by Rubenstein et al. [13] allowed a selection of six questions (step 1) to be used as the basic screening procedure [MNA Short Form (MNA-SF)], taking up to 5 min, but that would nevertheless retain the same accuracy of the original tool. To this purpose phys- ician’s clinical rating was again taken as reference standard. However, scoring the patients to a maxi- mum of 14 points, the initial version of MNA-SF allowed identifying only risk of malnutrition (scores <12) so that the completion of full MNA (step 2) is required for confirmation and a diagnosis of malnutrition at risk or overt malnutrition. Moreover, this tool appeared more appropriate for

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the community-dwelling elderly and less efficient than the full version for nursing home residents [12].

The issue of short time burden has been always considered a mainstay for the design of nutritional screening procedures. In regard to this, the intro- duction of MNA-SF has provided significant advan- ces in the dissemination of nutritional screening as an integral part of routine care. However, research- ers have recently considered that some more could be done to improve the utility and the efficiency of this tool. Performing a laborious and commendable pooled datasets analysis, in 2009 the MNA-Inter- national Group has implemented the MNA-SF [14] in order to allow the identification of three nutri- tional status categories as the case of the full MNA (forms available for free download at: www.mna- To this purpose cut- points of the revised MNA-SF were optimized by comparison with those of full MNA obtaining a sensitivity of 89.3% and a specificity of 94.3% for nutritional risk (score <12) and malnutrition (score <8), respectively. Moreover, the group tested the other anthropometric parameters included in the full version (calf and mid-arm circumferences) to allow the completion independent of the

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ins 31




Table 3. Key passages of MNA implementation history

Historical steps Year Targeted features

MNA development and validation [11]

1994 Reliable scale with clearly defined thresholds; compatibility with assessor’s skills; minimal opportunity of bias in data collection; acceptability by the patient; application in different settings and conditions; low cost

MNA-SF development [13] 2001 Minimal examination time; lowest amount of of ‘don’t know’ answers; wider distribution among general practitioners

MNA-SF revision [14] 2009 Possibility to grade nutritional status in three categories as with the full MNA without increasing the burden of time; independence from body weight and BMI measurement as well as from any anthropometric parameter; wider distribution in any healthcare setting.

MNA, Mini Nutritional Assessment; MNA-SF, Mini Nutritional Assessement Short Form.

Ageing: biology and nutrition

potentially time-consuming and less accessible evaluation of BMI. Accordingly, calf circumference was demonstrated a good substitute of BMI. Particu- larly, it was found that a cut-point of 11 had a sensitivity of 90.2% and a specificity of 76.2% for nutritional risk, whereas a cut-point of 8 had a sensitivity of 88.3% and a specificity of 88.7% for malnutrition [14]. Indeed, these results are promis- ing and looking at the mass of data available for the full MNA and the first version of the MNA-SF there are only a few things that still need to be done to complete the validation. The first is a cross-vali- dation study that reasonably takes into account its application in different healthcare settings, whereas the second is an evaluation of its prognostic value in relation to different outcomes. It could not be excluded that the group is already working on these research issues.


The MNA has been widely used in clinical research and a consistent mass of data is now available. Several investigators all over the world have tested its application and, in regard to this, attention has been primarily focused on the healthcare setting (community, home care/outpatients, acute hospital care, subacute and rehabilitation care, institutions) and the type of patients assessed (e.g. cognitively impaired and/or the frail elderly). Given the multi- dimensional approach, the prevalence picture of nutritional conditions provided by the MNA appears in some measure able to reflect the nutri- tional features (e.g. BMI, weight loss, dietary habits) and the dependence level of the patients assessed across different settings [12,15]. This consideration is a further confirmation of its utility as a tool for grading nutritional derangements.

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In this context, it raises attention towards the recent retrospective pooled analysis of previously published datasets performed by the MNA Inter- national Group [16


] and Soini et al. [17 &&

] in order to provide a perspective of malnutrition frequency in different standards of care.

Extensive reviews of literature on the use of the MNA have been previously performed. The first of these by Guigoz [12] and Vellas et al. [18] date back to 2006 and include all published articles until early 2006. Particularly, in the review by Guigoz [12] an interesting estimation of the prevalence of malnu- trition and risk of malnutrition across the studies according to the different settings was provided. The systematic evaluation of literature was then con- tinued until early 2008 by Bauer et al. [15] but no updated estimation on the prevalence was given. In the present review, literature (English full-text) on the MNA published until June 2011 has been addi- tionally assessed after searching through PubMed and using the MNA Literature Database of the Nestlè Nutrition Institute (available at: www.mna-elderly. com). A detailed description of the articles provid- ing unpublished prevalence data is listed in Table 4 [7,17


,19–26,27 &

,28–56,57 &

,58–67,68 &

,69– 121]. Therefore, data extracted were analysed together with those already reviewed in order to pro- vide an updated picture of malnutrition prevalence. Only those observational studies providing setting- specific data on elderly patients according to three categories of nutritional status (either by full or revised short-form MNA) were considered. The atten- tion was focused on the following settings: acute care (hospital); subacute/rehabilitation care; institutions (nursing home, long-term care and sheltered hous- ing); outpatients/home-care; community. Accord- ingly, prevalence of malnutrition and its risk were

(1) a


cute care (69 studies, n¼17 775 elderly), 23.4% (range 0–68%) and 49.4% (range 8 –93%);

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Table 4. Prevalence of malnutrition and risk of malnutrition according to the MNA (literature review from early 2008 through mid-2011)

Author Pub year Country Setting Population

(N) Malnutrition

(%) Malnutrition at risk (%)

Alhamdan and Alsaif [19] 2011 Saudi Arabia Hospital 100 36.5 50.6

Bahat et al. [20] 2011 Turkey Nursing home 254 22.8 9.8

Battaglia et al. [21] 2011 Italy Outpatients (stable COPD) 460 3.7 27

Borges et al. [22] 2011 Brazil Outpatients 16 0 43.7

Boström et al. [23] 2011 Canada Long-term care 120 31 58

Brain et al. [24] 2011 France Outpatients (breast cancer undergoing chemotherapy)

40 0 6

De La Montana and Miguez [25]

2011 Spain Community 728 12.5 57.5

Ferreira et al. [26] 2011 Brazil Community 1170 2.4 25.6

Gioulbasanis et al. [27 &

] 2011 Greece Hospital (lung cancer patients) 115 25.2 51.3

Gioulbasanis et al. [28] 2011 Greece Hospital (lung cancer patients) 171 26 46.2

Kaburagi et al. [29] 2011 Japan Community 130 2.3 19.2

Khater and Abouelezz [30] 2011 Egypt Nursing home 120 10.8 40.8

Leandro-Merhi et al. [31] 2011 Brazil Hospital 109 8.3 30.3

Nip et al. [32] 2011 UK Hospital (stroke patients) 100 7 66

O’Leary et al. [33] 2011 Australia Rehabilitation hospital 52 5.8 53.8

Ribeiro et al. [34] 2011 Brazil Community 236 1.3 25

Santomauro et al. [35] 2011 Italy Nursing home 463 22.5 58.3

Soderhamn et al. [36] 2011 Norway Hospital 158 17 43.8

Tsai and Chang [37] 2011 Taiwan Hospital (haemodialysis patients) 152 32.2 24.3

Tsai et al. [38] 2011 Taiwan Hospital (liver cancer patients) 300 1.7 47.3

Tsai et al. [39] 2011 Taiwan Hospital (psychiatric patients) 120 5.8 23.3

Velasco et al. [40] 2011 Spain Hospital 400 14.5 44

Vikstedt et al. [41] 2011 Finland Service house residents 375 21 65

Wyka et al. [42] 2011 Poland Community 238 0 16

Yang et al. [43] 2011 USA Home care 198 12 51

Aaldriks et al. [44] 2010 Netherlands Outpatients (undergoing chemotherapy for cancer)

202 5 30

Amirkalali et al. [45] 2010 Iran Outpatients 179 3.4 41.3

Amirkalali et al. [46] 2010 Iran Community 221 3.2 43.4

Bahat et al. [47] 2010 Turkey Nursing home 157 8.9 22.9

Buffa et al. [48] 2010 Italy Home care (Alzheimer’s disease patients)

83 5 27

Buffa et al. [49] 2010 Italy Community 200 1.2 35.9

Cabre et al. [50] 2010 Spain Hospital (pneumonia) 134 27.5 54.7

Cereda et al. [51] 2010 Italy Long-term care 266 18.8 49.6

Chang et al. [52] 2010 Taiwan Hospital 1008 29.3 50.2

Charton et al. [53] 2010 Australia Rehabilitation hospital 2076 33 51.1

Chen et al. [54] 2010 Taiwan Community 156 0 17.9

De Oliveira and Leandro-Merhi [55]

2010 Brazil Hospital 240 29.1 37.1

Drescher et al. [56] 2010 Switzerland Hospital 104 22.1 48

Ferdous et al. [57 &

] 2010 Bangladesh Community 457 26 62

Hafsteinsdóttir et al. [58] 2010 Netherlands Hospital (neurology and neurosurgery)

196 7 34

Hsieh et al. [59] 2010 Taiwan Community (solitary elderly) 120 5 39.2

Community (nonsolitary elderly) 240 0 6.7

Mini Nutritional Assessment Cereda

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Table 4 (Continued)

Author Pub year Country Setting Population

(N) Malnutrition

(%) Malnutrition at risk (%)

Kim et al. [60] 2010 Korea Hospital (cancer patients undergoing chemotherapy)

65 19 60

Mesas et al. [61] 2010 Brazil Community 267 1.9 19.6

Niedźwiedzka and Wądołowska [62]

2010 Poland Community 390 1 22

Saka et al. [63] 2010 Turkey Outpatients 413 13 31

Tsai et al. [64] 2010 Taiwan Long-term care 208 22.6 56.7

Tsai et al. [65] 2010 Taiwan Outpatients (haemodialysis) 192 5 36

Tsai et al. [66] 2010 Taiwan Community 301 0.7 12

Vanderwee et al. [67] 2010 Belgium Hospital 2329 33 43

Vedantam et al. [68&] 2010 India Community 227 13.7 37

Vischer et al. [69] 2010 Switzerland Outpatients (diabetic) 146 13.9 75

Volkert et al. [70] 2010 Germany Hospital 205 30.2 69.8

Wang et al. [71] 2010 China Outpatients (Parkinson’s disease)

117 1.7 19.7

Amer et al. [72] 2009 Egypt Nursing home 100 9 45

Bernabeu-Wittel et al. [73] 2009 Spain Hospital 812 10.3 52.6

Buffa et al. [74] 2009 Italy Community 170 1.2 35.9

Cansado et al. [75] 2009 Portugal Hospital 531 32.4 60.8

Cereda et al. [76] 2009 Italy Long-term care 241 12.8 39

Correa et al. [77] 2009 Brazil Home care 34 38.2 61.8

Elkan et al. [78] 2009 Sweden Outpatients (rheumatoid arthritis)

80 1.3 32.5

Essed et al. [79] 2009 Netherlands Nursing home 86 2.4 15.1

Ghasemi et al. [80] 2009 Iran Institutions 1100 35.9 60.9

Gillioz et al. [81] 2009 France Home care (Alzheimer’s disease patients)

126 12.6 55.9

Grieger et al. [82] 2009 Australia Long-term care 74 16 37

Guerra and Amaral [83] 2009 Portugal Retirement home and social day care

55 3.6 23.6

Han et al. [84] 2009 China Community 162 8 36.4

Hengstermann et al. [85] 2009 Germany Hospital 189 14.5 69.6

Johansson et al. [86] 2009 Sweden Community 258 0.4 16

Kaiser et al. [87&&] 2009 Germany Nursing home (according to the nursing staff)

138 8.7 54.3

Lei et al. [88] 2009 China Hospital 184 19.6 53.2

O’Dwyer et al. [89] 2009 Ireland Home care (meals-on-wheels patients)

63 9.5 27

Oliveira et al. [90] 2009 Brazil Hospital 240 29.1 37.1

Orsitto et al. [91] 2009 Italy Hospital 623 18 58

Salva et al. [92] 2009 Spain Outpatients (dementia; 80% Alzheimer’s disease)

946 5 32

Serra-Prat et al. [93] 2009 Spain Long-term care 25 12 44

Smoliner et al. [94] 2009 Germany Nursing home 114 22.8 57.9

Soini et al. [17&&] 2009 Finland Service housing 1475 13.4 64.6

Tsai et al. [95] 2009 Taiwan Community 501 0.5 13.6

Tsai et al. [96] 2009 Taiwan Hospital (neuropsychiatric patients)

105 7.6 21.9

Tsai et al. [97] 2009 Taiwan Long-term care 208 22.1 61.1

Tsai and Shih [98] 2009 Taiwan Long-term care (poststroke) rehabilitation

74 13.5 63.5

Ageing: biology and nutrition

34 Volume 15 � Number 1 � January 2012



Table 4 (Continued)

Author Pub year Country Setting Population

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