Review

Nutrition in Clinical Practice

Volume 00 Number 0
Determination of Nutrition Risk and Status in Critically Ill xxx 2018 1–16

C 2018 American Society for

Patients: What Are Our Considerations? Parenteral and Enteral Nutrition

DOI: 10.1002/ncp.10214
wileyonlinelibrary.com

Zheng-Yii Lee, MSc1,2 ; and Daren K. Heyland, MD, MSc, FRCPC3

Abstract
The stress catabolism state predisposes critically ill patients to a high risk of malnutrition. This, coupled with inadequate or delayed
nutrition provision, will lead to further deterioration of nutrition status. Preexisting malnutrition and iatrogenic underfeeding
are associated with increased risk of adverse complications. Therefore, accurate detection of patients who are malnourished
and/or with high nutrition risk is important for timely and optimal nutrition intervention. Various tools have been developed for
nutrition screening and assessment for hospitalized patients, but not all are studied or validated in critically ill populations. In this
review article, we consider the pathophysiology of malnutrition in critical illness and the currently available literature to develop
recommendations for nutrition screening and assessment. We suggest the use of the (modified) Nutrition Risk in the Critically
Ill (mNUTRIC) for nutrition risk screening and the subjective global assessment (SGA) together with other criteria relevant to
the critically ill patients, such as gastrointestinal function, risk of aspiration, determination of sarcopenia and frailty, and risk
of refeeding syndrome for nutrition assessment. Further research is needed to identify suitable nutrition monitoring indicators to
determine the response to the provision of nutrition. (Nutr Clin Pract. 2018;00:1–16)

Keywords
critical illness; inflammation; malnutrition; nutrition assessment; nutrition status; risk assessment; screening

Introduction Pathophysiology of Malnutrition in Critically

In critically ill patients, nutrition status is closely linked
with clinical outcomes. However, determination of nutrition
status in critically ill patients is not a straightforward
process. Recognizing the role of inflammation in affecting
the nutrition status of a patient, Jensen et al1 proposed
a concept to define malnutrition based on etiologies. This
concept divides malnutrition into the following 2 main eti-
ologies: pure starvation without disease (starvation-related
malnutrition) and disease-related malnutrition associated
with variable degree of inflammation (chronic disease-
related and acute disease or injury-related malnutrition).1
This conceptual model was later adopted by the consensus
Ill Patients
The pathophysiology of malnutrition during critical illness
can be viewed from at least the following 2 main perspec-
tives: stress catabolism and inadequate nutrition intake.
In the early phase of critical illness, catabolic hormones
(such as glucagon, cortisol, and catecholamines) are
From the 1 Department of Nutrition and Dietetics, Faculty of
Medicine and Health Sciences, Universiti Putra Malaysia, Serdang,
Malaysia; 2 Department of Anesthesiology, Faculty of Medicine,
University of Malaya, Kuala Lumpur, Malaysia; and the
3 Department of Critical Care Medicine, Queen’s University and

between the Academy of Nutrition & Dietetics (AND) and
the American Society for Parenteral and Enteral Nutri-
tion (ASPEN) for the diagnosis of malnutrition (AND-
ASPEN Consensus).2 The discussion of this article will
focus on the definition of acute disease or injury-related
malnutrition. Based on the pathophysiology of malnutri-
tion in critical illness and the current available studies,
considerations for nutrition screening and assessment of
critically ill patients are discussed and suitable tools are
suggested.
Clinical Evaluation Research Unit, Kingston General Hospital,
Kingston, Ontario, Canada.
Financial disclosures: None declared.
Conflicts of interest: None declared.
This article originally appeared online on xxxx 0, 2018.
Corresponding Author:
Zheng-Yii Lee, MSc, Department of Nutrition and Dietetics, Faculty
of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang,
Malaysia.
Email: zheng_yii@hotmail.com
2 Nutrition in Clinical Practice 00(0)
secreted to mobilize body nutrition reserves (muscle and
adipose tissue) for the generation of endogenous energy
substrate (glucose, amino acids, and free-fatty acids) and
to prioritize the delivery of these energy substrates to vital
organs such as the brain or the heart.3,4 At the same time,
proinflammatory cytokines such as Interleukin (IL)-1, IL-6
and tumor necrosis factor-α are also secreted in response
to the body’s acute insult and further exaggerate the
catabolism process.4 During such inflammatory states, the
provision of nutrition is not able to completely reverse the
loss of body cell mass.3 Such conditions predispose critically
ill patients to a high risk of malnutrition (loss of body
cell mass to a critical level), and the risk of complications
is significantly increased if malnutrition ensues.5 At this
stage, the priority is to provide nutrition support to support
vital organ system functions and preserve appropriate host
responses while the underlying disease is treated.6
Although the disease process has tremendous impact on
the nutrition status of critically ill patients, depending on
the patients’ history, the patients may already have features
of malnutrition with a reduced or restricted food intake
long before intensive care unit (ICU) admission due to the
underlying chronic conditions (such as chronic obstructive
pulmonary disease, cancer, or chronic renal failure) or
have reduced intake from a hospital stay prior to ICU
adminssion.6,7 Moreover, in the ICU, the patients may
continue to have restricted nutrition intake and thus they
may experience prolonged fasting or frequent feeding inter-
ruptions due to various ICU procedures.8 These 2 factors,
preexisting malnutrition and iatrogenic underfeeding, may
further complicate the nutrition status and worsen clinical
outcomes.
Nutrition Risk Screening
ASPEN defined nutrition screening as “a process to identify
an individual who is malnourished or who is at risk for mal-
nutrition to determine if a detailed nutrition assessment is
indicated.”9 In the critically ill patient, the stress catabolism
process associated with the degree of inflammation (which
is closely linked with disease severity) requires nutrition
screening that considers nutrition risk in the context of
disease severity and clinical outcomes.5 Nutrition screening
in this context therefore “refers to the risk of acquiring
complications and other forms of adverse outcome that
might have been prevented by timely and adequate nutrition
support.”5 The nutrition risk screening tool must be able
to identify the patients who are most likely to benefit from
more adequate nutrition provision.10,11 Because the patho-
physiology of malnutrition is closely linked with the under-
lying inflammatory status, the scoring system must include
variables related to the metabolic state and disease severity.5
The following 2 nutrition risk screening tools in the litera-
ture have such characteristics: the Nutrition Risk Screening
2002 (NRS-2002)10 and the Nutrition Risk in the Critically
Ill (NUTRIC;11 Appendixes 1 and 2).
The NRS-2002 was developed from an analysis of con-
trolled trials and included recent dietary intake, weight
loss, disease severity, and age to identify patients’ nutrition
risks.10 A score of 3 is considered to be high nutrition risk.
It has been shown to have good predictive validity in various
hospitalized patients,12,13 but not in critically ill patients.
Furthermore, the automatic classification of patients with
an Acute Physiology and Chronic Health Evaluation II
score of 10 to high nutrition risk render most ICU
patients to be classified as high risk. Furthermore, the utility
of variables such as recent food intake and weight change
may be limited due to data unavailability or inaccuracy.
The NUTRIC score was developed in studies of critically
ill patient populations and has been validated in many
observational studies from different countries.11,14-23 As
IL-6 is not routinely performed in most ICUs in the world,
the modified-NUTRIC (mNUTRIC) score without IL-6
was proposed and revalidated.14 However, one of the major
limitations of the NUTRIC/mNUTRIC score is the absence
of classical nutrition variables such as recent food intake
and weight change.
The ASPEN/Society of Critical Care Medicine
guidelines suggest the use of either the NRS-2002 or
NUTRIC/mNUTRIC for the nutrition screening of a
critically ill patient.24 However, the NUTRIC/mNUTRIC
score may be a more suitable nutrition risk screening tool
than the NRS-2002 based on the following reasons:
1. The NUTRIC/mNUTRIC score was developed in
the critically ill patient population with a clear
conceptual model based on the etiology-based mal-
nutrition definition proposed by the AND-ASPEN
consensus and considered variables for starva-
tion (acute and chronic), inflammation (acute
and chronic), age, disease severity, and organ
dysfunction.11
2. The absence of classical nutrition variables such as
weight change and recent food intake was due to
the difficulty in obtaining such variables in ICU
patients. During the initial development study of
the NUTRIC score, >70% of the data from these
variables were unable to be obtained. Moreover, the
inclusion of the available data from these variables
were not predictive of the outcome (28-day mor-
tality), and therefore they were eliminated from the
final statistical model.11 Even if these variables were
obtained, the accuracy of this information may not
be verifiable.
3. The variables in the final model of the NUTRIC/
mNUTRIC score correlate well with the pathophysi-
ology of malnutrition presented previously, whereby
the degree of inflammation is a more determining
Lee and Heyland
factor of nutrition risk especially during the acute
phase of critical illness and hence the use of the dis-
ease severity (Acute Physiology and Chronic Health
Evaluation II) and organ failure scoring (sequential
organ failure assessment) is reasonable.
4. The variables “number of comorbidities” considered
chronic inflammation and “days from hospital to
ICU admission” considered iatrogenic reduced or
restricted food intake that occurred before ICU
admission. In our opinion, both of these variables
are more objective and include the possibility of
long-term and short-term reduced food intake and
recent weight loss.
5. The NUTRIC/mNUTRIC score has been shown in
various critically ill populations to have good predic-
tive validity for clinical outcomes, although the dis-
criminative ability is of fair level (Table 1).11,14-16,20-23
Various observational studies in different popula-
tions have also shown that clinical outcomes are
modified by nutrition adequacy depending on the
risk status of the patients (Table 1).11,14,16-19
The NUTRIC/mNUTRIC score remains to be prospec-
tively tested in a randomized controlled trial. There have
been inconsistent results from post hoc analyses of prospec-
tive randomized trials. In one trial, similar clinical outcomes
were demonstrated between patients with high and low
nutrition risk regardless of the nutrition provision.25 Al-
though the subgroup analysis of another pilot randomized
trial demonstrated a trend toward lower ICU and hospital
mortality among patients with mNUTRIC 5 who received
greater energy and protein delivery by supplemental par-
enteral nutrition (albeit not significant, P = .19), such a
trend was not observed in patients with mNUTRIC <5.26
Future trials that focus on enrolling patients with high nutri-
tion risk may be able to provide a more definitive answer on
whether the mNUTRIC score can modify the relationship
between nutrition adequacy and clinical outcomes.
Nutrition Assessment
Nutrition assessment has a different role from nutrition
screening. As discussed previously, nutrition screening de-
termines the nutrition risk of a patient, and in this context,
the risk of acquiring complications as a consequence of
failure of optimal nutrition provision. In contrast, nutrition
assessment is a formal evaluation of patient nutrition status
by a trained healthcare professional, usually a dietitian, and
results in a nutrition-related diagnosis.27
The AND-ASPEN consensus statement proposes the
characteristics and criteria for the diagnosis of malnutrition
(undernutrition), which are the following: energy intake,
weight change over time, subcutaneous fat loss, muscle loss,
fluid accumulation, and handgrip strength.2 A minimum of
3
2 of the 6 characteristics is recommended for the diagnosis
of malnutrition.2 The criteria to diagnose moderate or
severe malnutrition in the context of acute illness or injury
is shown in Appendix 3. One recent prospective study in
critically ill patients has found that patients who were mal-
nourished as determined by the AND-ASPEN consensus
criteria had 2.5 times higher hospital mortality risk than
their nonmalnourished counterparts.28
Besides the AND-ASPEN consensus criteria, another
potential nutrition assessment tool is the subjective global
assessment (SGA), initially developed to predict postoper-
ative outcomes.29 The SGA incorporated weight change,
recent food intake, gastrointestinal (GI) symptoms, func-
tional capacity, subcutaneous fat loss, muscle loss, and fluid
status for the diagnosis of moderate (SGA class B) or
severe malnutrition (SGA class C; Appendix 4). In fact, the
criteria used for assessment between the SGA and the AND-
ASPEN consensus are notably similar.
Nevertheless, the SGA has been widely studied in the
critical care setting. A recent systematic review has iden-
tified at least 10 studies that used the SGA in critically
ill patients.30 Among the 5 studies rated as high quality,
SGA class B or C when compared with SGA class A
were associated with increased hospital mortality, longer
ICU length of stay, increased risk of new infection and
ICU readmission, and increased percentage of patients
discharged to nursing home.30 Therefore, the SGA may be
more favorable than the AND-ASPEN consensus criteria
for the nutrition assessment of critically ill patients.
However, both the SGA and the AND-ASPEN consen-
sus criteria have at least the following limitations:
1. They were not developed in critically ill populations
and therefore lack variables relevant for critically ill
patients.
2. They have failed to incorporate the severity of
acute illness and criteria associated with stress
metabolism.31
3. They are not “responsive enough” to changes within
a relatively shorter time duration and thus are not
helpful in assessing whether nutrition provided is
optimal, hindering effective nutrition monitoring
and evaluation.32
4. Critically ill patients are often unconscious and
therefore weight and food history are either not avail-
able or obtained from family member.11 Although
1 feasibility study reported that weight and food
history can be obtained in 54.5% and 76.4% of
the ICU patients, respectively,33 the accuracy of the
information provided (especially by proxy) may not
be verifiable.
5. Required subjective clinical interpretation and
therefore training is needed especially among
nonexperts.27
4
Table 1. NUTRIC/mNUTRIC: Discriminative Performance and Whether Nutrition Interventions Modify the Association Between Risk Score and Clinical Outcomes.

Do nutrition intervention
modify the association
Discriminative between risk score and
Author Country N Population Score Performance clinical outcomes?

Observational studies
Heyland et al, Canada 597 - Age 18 Total: 1–10 - aROC for 28-day Yes. High risk: ↑ nutrition
201111 - Stay 24 hours in - Low risk: 0–5 mortality: 0.783 adequacy was a/w ↓ 28-day
the ICU - High risk: 6–10 mortality (P = .01)

Rahman et al, 40 ICU in 1199 - Age 18 and MV Total: 1–9 - aROC for 28-day Yes. High risk: each 25% ↑ in %
201514 Europe & - Multiorgan failure - Low risk: 0–5 mortality: 0.648 of energy received was a/w ↓
North - Expected ICU LOS - High risk: 6–9 6-month mortality by 18%
America >5 days (P < .05)

Mukhopa-dhyay Singapore 401 - Medical ICU Total: 1–9 - aROC for 28-day Yes. High risk: ↑ nutrition
et al, 201616 - Age 18 - Low risk: 0–4 mortality: 0.71 adequacy was a/w ↓ 28-d
- MV 48 - High risk: 5–9 - Se & Sp: 72% & 63% mortality (P < .001)
hours (n = 273)
- Stay 24 hours in
the ICU

Compher et al, Worldwide 202 2853 - Age 18 and MV Total: 1–9 – Yes. High risk: ↑ E & protein was
201717 ICU - Stay in ICU 4 days - Low risk: 0–4 a/w ↓ 60-day mortality & time
(n = 2853), 12 days - High risk: 5–9 to discharge alive
(n = 1605)

Lee et al, 201718 Malaysia 154 - Age 18 Total: 1–9 – Yes. Low risk: E & protein
- MV within 48 hours - Low risk: 0–5 adequacy 2/3 of requirement
of ICU admission - High risk: 6–9 was a/w ↑ 60-day mortality by
- Stay 72 hours in about 6 times
the ICU

Hsu et al, 201819 Taiwan 190 - Age 65 Total: 1–9 – Yes. High risk: energy adequacy
- MV 48 hours - Low risk: 0–4 of 80% was
- High risk: 5–9 a/w ↓ ICU and hospital
mortality than <80%;; protein
adequacy of 80% was a/w ↓
hospital mortality than <80%
Moretti et al, Argentina 368 - Adult Total: 1–9 / 1–10 (use - aROC for mortality: –
201420 - MV >24 hours CRP for IL-6) 0.671
- Low risk: 0–4/0-5 - If substitute IL-6 with
- High risk: 5–9/6-10 CRP, aROC: 0.679

(continued)
 Table 1. (continued)

Do nutrition intervention
modify the association
Discriminative between risk score and
Author Country N Population Score Performance clinical outcomes?

Mendes et al, Portugal 1143 - Adult Total: 1–9 - aROC for 28-day –
201721 - ICU LOS >72 hours - Low risk: 0–4 mortality: 0.718
- High risk: 5–9

Lew et al, 201722 Singapore 439 - Adult 18 Total: 1–9 - aROC for hospital –
- ICU LOS 24 hours - Low risk: 0–4 mortality: 0.66
- High risk: 5–9

Kalaiselvan et al, India 678 - Adult Total: 1–9 - aROC for mortality: –
201723 - Required MV for - Low risk: 0–4 0.642
>48 hours - High risk: 5–9 - PPV, NPV, Se & Sp for
mortality: 47.4%,
68.9%, 41.5%, 73.8%,
respectively

de Vries et al, Netherlands 475 - Age 18 Total: 1–9 - aROC for 28-day –
201815 - MV within 24 hours - Low risk: 0–4 mortality: 0.768
of ICU - High risk: 5–9 - aROC for MV >2
days: 0.666

Randomized controlled trial

Arabi et al, 201725 Saudi Arabia 894 - Age 18 Total: 1–9 – No. Similar outcomes between
& Canada - Start EN within - Low risk: 0–4 higher and lower energy
48 hours - High risk: 5–9 delivery regardless of
- Expected to stay NUTRIC score
72 hours in the
ICU

Wischmeyer Canada, 125 - Age >18 Total: 1–9 Yes. High risk: ↑ nutrition
et al, 201826 United - Acute respiratory - Low risk: 0–4 adequacy by SPN was a/w a
States, failure - High risk: 5–9 not significant trend toward
Belgium, and - Start EN within reduced ICU and hospital
France 48 hours mortality (P = .19)
- BMI <25 or >35

↑ = increased, ↓ = decreased/reduced. a/w, associated with; aROC, area under the receiver operating characteristics curve; BMI, body mass index; CRP, C-reactive protein; E, energy; EN,
enteral nutrition; ICU, intensive care unit; IL-6, Interleukin-6; LOS, length of stay; MV, mechanically ventilated; mNUTRIC, Modified-NUTRIC; NPV, negative predictive value; NUTRIC,
Nutrition Risk in the Critically Ill; PPV, positive predictive value; Se, sensitivity; Sp, specificity; SPN; supplemental parenteral nutrition.

5
6 Nutrition in Clinical Practice 00(0)
Table 2. Gastrointestinal Symptoms That May Be Indicative
of Gastrointestinal Dysfunction.
Gastrointestinal
Symptom Definition
High GRV Maximum GRV >500 mL at least once
Vomiting/ Visible vomiting or regurgitation in any
regurgitation amount
Diarrhea Loose or liquid stool 3 or more times per
day (diagnosis may also be based on the
King’s Stool Charta )
Bowel distension Suspected or radiologically confirmed
bowel dilatation in any bowel segment
GI bleeding Visible appearance of blood in vomits,
nasogastric aspirate, or stool
Intra-abdominal Mean intra-abdominal pressure of the day
hypertension 12 mmHg
Abdominal Mean intra-abdominal pressure 20 mmHg
compartment with new organ dysfunction or failure,
syndrome with intra-abdominal pressure
measured in the supine position with
zero-point at mid axillary line with a
maximal instillation volume of 25 mL
GRV, gastric residual volume. Adapted from Reintam Blaser A, Poeze
M, Malbrain ML, Bjorck M, Oudemans-van Straaten HM, Starkopf
J. Gastrointestinal symptoms during the first week of intensive care
are associated with poor outcome: a prospective multicentre study.
Intensive Care Med. 2013;39(5):899-909. https://doi.org/10.1007/
s00134-013-2831-1.34
a Whelan K, Judd PA, Preedy VR, Taylor MA. Covert assessment of
concurrent and construct validity of a chart to characterize fecal
output and diarrhea in patients receiving enteral nutrition. JPEN J
Parenter Enteral Nutr. 2008;32(2):160-168. https://doi.org/10.1177/
0148607108314769
Besides the use of the SGA or the AND-ASPEN con-
sensus criteria for nutrition assessment, there are many
other criteria relevant to ICU patients that a dietitian
needs to consider during the nutrition assessment process.
The ASPEN/Society of Critical Care Medicine guidelines
suggest an evaluation of comorbid conditions, function of
the GI tract, and risk of aspiration as part of nutrition
assessment.24 However, no further explanation or more spe-
cific variables were provided. It is indeed useful to consider
the current diagnosis as well as the comorbid conditions
of the patients to evaluate the degree and duration of
inflammation as well as the possible duration of inadequate
nutrition intake. In fact, the NUTRIC/mNUTRIC score
has the number of comorbidities as one of its variables.
The variables to evaluate GI tract function may be
adopted from the study of Reintam Blaser et al.34 This
prospective multicenter observational study found that GI
symptoms including high gastric residual volume, vomiting
or regurgitation, diarrhea, bowel distension, GI bleeding,
and abdominal compartment syndrome (Table 2) were pre-
dictive of 28-day mortality, and the occurrence of 3 or more
coincident GI symptoms was associated with higher 28-day
mortality.34 In critically ill patients with enteral nutrition,
the risk factors of aspiration include a documented previ-
ous episode of aspiration, reduced level of consciousness
(continuous infusion of sedatives or increased intracra-
nial pressure), vomiting, persistently high gastric residual
volume, and being fed in supine position and/or having
increased risk of delayed gastric emptying (hyperglycemia,
electrolyte abnormalities, use of drugs known to reduce
gastric emptying).35
The potential use of various technologies for the assess-
ment of body composition such as computed tomography
(CT), ultrasound, and bioelectrical impedance analysis has
been explored in various studies in recent years.36 Skeletal
muscle quality revealed by CT scan at the third lum-
bar vertebra was associated with mortality in critically ill
patients.37-39 However, CT scans are costly, require transfer
to a radiology unit, and involve a dose of radiation that
limits its usage to patients for whom CT is ordered for other
clinical reasons. The measurement of quadricep muscle
layer thickness by ultrasound in the ICU also showed
promising results.40,41 Serial ultrasound measurement of the
rectus femoris cross-sectional area has shown that muscle
mass decreases continuously from ICU admission to almost
one-fifth of baseline at day 10 of an ICU stay.42 Low fat-
free mass as indicated by low phase angle or high impedance
ratio obtained by bioelectrical impedance analysis measure-
ment has also been shown to be associated with mortality
and time-discharge alive among the critically ill patients.43,44
However, the routine use of such body composition anal-
ysis techniques may be impractical in the mechanically
ventilated critically ill population. Fluid and electrolyte
abnormalities commonly seen in critically ill patients will
influenced the accuracy of bioelectrical impedance analysis,
and further research is needed to define the optimal way to
conduct ultrasound measurement for a better reliability and
validity in the ICU.36
Because low skeletal muscle mass is associated with
poor clinical outcomes in the ICU and traditional imaging
methods are impractical or not yet validated, alternative
measures to diagnosing low skeletal muscle mass may be
needed.37-39 The SARC-F is a simple and validated ques-
tionnaire used to determine sarcopenia (Appendix 5).45,46
As the main feature of sarcopenia is the loss of muscle mass
(and strength),47 the SARC-F may be useful to identify pa-
tients with low skeletal muscle mass before ICU admission.
As sarcopenia is commonly associated with frailty,48 frailty
can also be measured by using the Clinical Frailty Scale
(Appendix 6).49 In a systematic review and meta-analysis,
7 of the 10 included studies used the Clinical Frailty Scale
to measure frailty. The presence of frailty in the ICU was
found to be associated with increased mortality and reduced
likelihood to be discharged home.50 It is most likely that
sarcopenic and frail patients had poor nutrition status and
warrant a more attentive nutrition intervention.47,50
Lee and Heyland 7

Table 3. Comparison of Variables Used by Nutrition Risk Screening and Assessment Tools.

Nutrition Risk Screening

Tools NA Tools
NA
Components Variables NUTRIC NRS-2002 SGA AND-ASPEN
√ √ √
FH Recent food intake √
FH GI symptoms (nausea, vomiting,
diarrhea, anorexia) √
FH Days in hospital before ICU
admission (acute starvation) √
AD Current weight √ √ √
AD Weight change √b
BD IL-6 or CRPa (acute inflammation) √ √
PD Subcutaneous fat loss √ √
PD Muscle loss √ √
PD Fluid status √
PD Muscle strength (handgrip) √
PD Functional capacity √
CH Number of comorbidities (chronic
inflammation) √ √
CH Age √ √
Clinical APACHE II (disease severity) √
Clinical SOFA (organ dysfunction)

AD, anthropometric data; AND-ASPEN, Academy of Nutrition and Dietetics-American Society of Parenteral and Enteral Nutrition criteria;
APACHE II, acute physiology and chronic health evaluation II; BD, biochemical data, medical test and procedures; CH; client history; CRP,
C-reactive protein; FH, food and nutrition-related history; GI, gastrointestinal; ICU, intensive care unit; IL-6, Interleukin-6; NA, nutrition
assessment; NRS-2002, Nutrition Risk Screening-2002; NUTRIC; Nutrition Risk in the Critically Ill; PD, nutrition-focused physical findings;
SGA, Subjective Global Assessment; SOFA, sequential organ failure assessment.
a Moretti et al, 2014.20
b Not required in modified-NUTRIC.

Suggestions for Nutrition Screening and
Assessment for Critically Ill Patients
The AND has developed the Nutrition Care Process, which
includes nutrition assessment, nutrition diagnosis, nutri-
tion intervention, and nutrition monitoring and evalua-
tion to guide and standardize dietetic practice.51 In the
Nutrition Care Process, nutrition assessment consists of 5
components, which are food and nutrition-related history;
anthropometric data; biochemical data, medical test, and
procedures; nutrition-focused physical findings; and client
history.51
The variables used by the NUTRIC, NRS-2002, SGA,
and AND-ASPEN as part of the components of nutrition
assessment are summarized in Table 3. As severity of disease
plays a major role in the pathophysiology of malnutrition,
a clinical component is added to the 5 original components.
From the table, it is observed that the variables for the NU-
TRIC score and the SGA are mutually exclusive (variables
used by the NUTRIC are not used by the SGA and vice
versa). Therefore, both tools complement each other well for
the nutrition risk screening and assessment of critically ill
patients. A recent study in 439 critically ill patients showed
that the discriminative ability of a combination of tools on
hospital mortality is better (area under the receiver oper-
ating characteristics curve [aROC], 0.70) when compared
with either a single tool (aROC for mNUTRIC, 0.66; aROC
for SGA, 0.61).22 When compared with patients who had
low nutrition risk or were not malnourished, an mNUTRIC
score of 5 and SGA classification of B or C increased hos-
pital mortality by 14.4 times, whereas hospital mortality was
increased by 5.3 times and 4.3 times if only the mNUTRIC
or SGA were used alone, respectively.22 Another study also
found that patients who were classified as high nutrition
risk (by the mNUTRIC) and malnourished (SGA) had the
longest hospital and ICU length of stay and were more likely
to require additional rehabilitation after discharge from
the ICU.52 The improvement of discriminative ability for
28-day mortality cannot be demonstrated when the mNU-
TRIC was used in combination with the Malnutrition
Universal Screening Tool, whereas the aROC used in com-
bination resulted in a lower discriminative ability and was
lower than when the mNUTRIC was used alone (0.679 vs
0.768).15
Therefore, a complete nutrition evaluation for a critically
ill patient may include the use of the NUTRIC/mNUTRIC
score for nutrition risk screening and the SGA and other
relevant criteria for ICU patients (such as GI tract function
8 Nutrition in Clinical Practice 00(0)
and risk of aspiration) for nutrition assessment. The use of
AND-ASPEN consensus criteria may also be feasible given
the almost similar criteria with the SGA. However, the SGA
is more favorable as it is well studied in the critically ill pop-
ulation. In addition, the SGA does not require a handgrip
dynamometer, which may not be available in a resource-
limited setting. ICU patients may also be unconscious or
too weak to perform test for handgrip strength. In addition,
the cut off values of the variables were defined arbitrarily.
More studies are needed before a stronger recommendation
for its use in the critically ill patients can be made. The incor-
poration of body composition analysis for nutrition assess-
ment is an added advantage if feasible. The use of simple
questionnaires to identify patients with sarcopenia and/or
frailty before ICU admission may also help to determine
potential patients with low skeletal muscle mass and poor
nutrition status. The monitoring of the response to nutrition
intervention may be a more difficult task as most of the nu-
trition variables are not responsive enough to assess whether
nutrition provided is optimal.32 However, electrolyte level
(such as phosphorus and potassium) need to be monitored
frequently during the initial stage of nutrition provision
to detect potential occurrence of refeeding syndrome so
that calorie intake can be adjusted accordingly.53 Future
studies may monitor the clinical response to treatment such
as level of inotropes, dose of insulin needed for glycemic
control, ventilator setting, wound healing, and physical
functioning as potential indicators for optimal nutrition
therapy. Ferrie and Tsang54 suggested the use of fatigue
scoring and functional tests (such as handgrip strength and
forced expiratory volume in 1 second) in conscious patients
and the use of bedside ultrasound for unconscious patients
as potential nutrition monitoring indicators in the ICU,
which remains to be tested in a prospective randomized trial.
It must be noted that currently there is no gold standard for
the diagnosis of malnutrition, and therefore it is necessary to
exercise appropriate clinical judgment based on individual
patient responses for the determination of optimal nutrition
provision.
Conclusion
The detection of nutrition risk and diagnosis of
malnutrition in critically ill patients are not a simple
and straightforward processes. They involve consideration
of the pathophysiology of malnutrition and the use
of accurate and responsive indicators to measure
nutrition status. Despite their inherent limitations, the
NUTRIC/mNUTRIC score and SGA may be the current
best available tools for the evaluation of nutrition risk and
diagnosis of malnutrition, respectively. Other assessment
criteria relevant to ICU patients such as GI function, risk
of aspiration, and the determination of sarcopenia and
frailty may also be useful for a more complete assessment.
Monitoring of serum phosphorus and potassium level
after the commencement of nutrition support is needed
for early detection of potential refeeding syndrome. A
validated nutrition monitoring indicator that is responsive
to short-term nutrition therapy is still lacking in the critical
care setting, and further research is warranted.
Statement of Authorship
Z.-Y. Lee contributed to conception/design of the research;
Z.-Y. Lee and D. K. Heyland contributed to acquisition,
analysis, or interpretation of the data; Z.-Y. Lee drafted
the manuscript; Z.-Y. Lee and D. K. Heyland critically
revised the manuscript; and Z.-Y. Lee and D. K. Heyland
agree to be fully accountable for ensuring the integrity and
accuracy of the work. All authors read and approved the
final manuscript.
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Lee and Heyland 11

APPENDIX

1) NRS-2002

(a) Simple screening:

i. Is BMI <20.5?
ii. Has intake been reduced during the last week?
iii. Has there been a recent weight loss?
iv. Is the patient severely ill?

If the answer is yes to any of these four questions, the formal screening in the table is carried out

Impaired nutritional status Severity of Illness (stress metabolism)

Absent Score 0 Normal nutritional status Absent Score 0 Normal nutritional requirements

Mild Score 1 • Weight loss >5% in 3 months Mild Score 1 • Hip fracture
or • Chronic patients in particular
• Food intake below 50–75% of normal with acute complications:
requirement in preceding week cirrhosis, COPD
• Chronic haemodialysis
• Diabetes
• Oncology
Moderate Score 2 • Weight loss >5% in 2 months Moderate Score 2 • Major abdominal surgery.
or • Stroke
• BMI 18.5 – 20.5 + impaired general • Severe pneumonia
condition • Hematologic malignancy
or
• Food intake below 25 – 50% of normal
requirement in preceding week
Severe Score 3 • Weight loss >5% in 1 month Severe Score 3 • Head injury
( > 15% in 3 months) • Bone marrow transplantation
or • Intensive care patients
• BMI <18.5 + impaired general (APACHE 10)
condition
or
• Food intake below 0 – 25% of normal
requirement in preceding week
Score Score
Total Score

(b) Calculate the total score:

i. Find score (0–3) for Impaired nutritional status (only one: choose the variable with highest score) and Severity of
disease (stress metabolism, i.e. increase in nutritional requirements).
ii. Add the two scores (→ total score)
iii. If age 70 years: add 1 to the total score to correct for frailty of elderly
iv. If age-corrected total 3: start nutritional support
12 Nutrition in Clinical Practice 00(0)

2) The NUTRIC and the Modified NUTRIC Score

Variable Range Points

Age (year) <50 0

50 – 74 1
75 2
Acute physiology and chronic health evaluation II (APACHE II) <15 0
15 – 19 1
20 – 28 2
28 3
Sequential organ-failure assessment (SOFA) <6 0
6–9 1
10 2
Number of Comorbidities 0–1 0
2 1
Days from hospital to ICU admission 0 – <1 0
1 1
Interleukin-6 (IL-6) (pg/ml) 0 – <400 0
400 1

NUTRIC Score Scoring System (With IL-6)

Sum of points Category Explanation

6 – 10 High Score • Associated with worse clinical outcome (mortality, ventilation)

• These patients are the most likely to benefit from aggressive nutrition therapy
0–5 Low Score • These patients have a low malnutrition risk

Modified-NUTRIC Score Scoring System (Without IL-6)

Sum of points Category Explanation

5–9 High Score • Associated with worse clinical outcome (mortality, ventilation)
• These patients are the most likely to benefit from aggressive nutrition therapy
0–4 Low Score • These patients have a low malnutrition risk

(Adapted from http://www.criticalcarenutrition.com/resources/nutric-score. Accessed on 1st April, 2018)

Lee and Heyland 13

3) The Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition (AND-ASPEN)
Consensus for the Diagnosis of Malnutrition in the Context of Acute Illness or Injury

Clinical Characteristics Moderate Severe

<75% of estimated ER for 50% of estimated ER for

1) Energy Intake >7days 5 days
2) Weight change over time (note for under- or % Time % Time
overhydration) 1–2 1 week >2 1 week
*Usual weight should be used as the baseline weight 5 1 month >5 1 month
7.5 3 months >7.5 3 months
3) Loss of subcutaneous fat (eg, orbital, triceps, fat Mild Moderate
overlying the ribs)
4) Muscle Loss (eg, wasting of the temples [temporalis Mild Moderate
muscle], clavicles [pectoralis and deltoids], shoulders
[deltoids], interosseous muscles, scapula [latissimus
dorsi, trapezious, deltoids], thigh [quadriceps], and
calf [gastrocnemius])
5) Fluid Accumulation (Generalized or localized Mild Moderate to Severe
[extremities, vulvar/scrotal edema, or ascites])
6) Reduced grip strength (Refer normative standard by NA Measurably reduced
the device manufacturer)

A minimum of 2 of the 6 characteristics above is recommended for diagnosis of either severe or nonsevere malnutrition
14 Nutrition in Clinical Practice 00(0)

4) Subjective Global Assessment (SGA)

A. History

1. Weight change
Overall loss in past 6 months: Amount = kg
% loss = kg
Change in past 2 weeks: Increase
No change
Decrease
2 Dietary Intake change (relative to normal)
No Change
Change
Duration
Weeks =
Type
Suboptimal solid diet
Hypocaloric liquids
Full liquid
Starvation
3 Gastrointestinal symptoms (that persisted for >2 weeks)
None
Nausea
Vomiting
Diarrhea
Anorexia
4 Functional Capacity
No Dysfunction
Dysfunction
Duration
Weeks =
Type
Working suboptimally
Ambulatory
Bedridden
5 Disease and its relation to nutritional requirements
Primary Diagnosis (Specify):
Metabolic Demand (Stress)
No stress
Low stress
Moderate stress
High stress

B. Physical (for each trait specify: 0 = normal, 1+ = mild 2+ = moderate, 3+ = severe)

Loss of subcutaneous fat (triceps, biceps, under the eyes)
Muscle wasting (temple, clavicle, shoulder, scapula/ribs, quadriceps, calf, knee, interosseous muscle)
Ankle edema
Sacral edema
Ascites

C. SGA rating (select one)

Well Nourished (A)
Moderately (or suspected of being) malnourished (B)
Severely Malnourished (C)
Lee and Heyland 15

5) SARC-F

Component Question Scoring

Strength How much difficulty do you have in lifting and carrying 10 pounds None = 0
(4.5 kilogram) ? Some = 1
A lot or unable = 2
Assistance in walking How much difficulty do you have walking across a room? None = 0
Some = 1
A lot, use aids, or unable = 2
Rise from a chair How much difficulty do you have transferring from a chair or bed? None = 0
Some = 1
A lot or unable without help = 2
Climb stairs How much difficulty do you have climbing a flight of 10 stairs? None = 0
Some = 1
A lot or unable = 2
Falls How many times have you fallen in the past year? None = 0
1–3 falls = 1
4 or more falls = 2
16 Nutrition in Clinical Practice 00(0)

6) Clinical Frailty Scale

Please consider the participant’s overall condition 2 weeks prior to this admission to hospital.
How fit or frail was s/he at that time point? Check one response only.
If you have trouble deciding between two options, choose the higher functioning level.