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Nutrición Hospitalaria

versión On-line ISSN 1699-5198versión impresa ISSN 0212-1611

Nutr. Hosp. vol.26 no.6 Madrid nov./dic. 2011




Evaluation of the mini-nutritional assessment short-form (MNA-SF) among institutionalized older patients in Spain

Evaluación del test corto de valoración nutricional (MNA-SF) en ancianos institucionalizados en España



D. A. De Luis1, R. López Mongil2, M. González Sagrado1, J. A. López Trigo3, P. F. Mora4, J. Castrodeza Sanz5 and Group NOVOMET

1Institute of Endocrinology and Nutrition. Medicine School and Unit of Investigation. Hospital Rio Hortega. University of Valladolid.
2Assistential Center Dr. Villacian. Valladolid.
3Elderly Municipal Center. Malaga.
4Internal Medicine. University of Dallas. Texas. USA.
5Dept. of Public Health. University of Valladolid. Spain.





Introduction: In the present study, we evaluated a short form version of MNA test in a multicenter study and the relationship of different biochemical markers with MNASF scores.
Material and methods: This was a cross-sectional survey covering a sample of representative of the older institutionalized Spanish population aged above 65 years (n = 873). A Mini nutritional assessment short form test (MNA-SF) was used.
Results: The number of patients classified as well nouri shed (42.1%) was larger in the 65-74 (52.6%) range than in the 75-84 (40.2%), 85-94 (43.8%) and > 95 (24%) age ranges. Risk of undernutrition occurred in a total of 506 patients (57.9%), risk of undernutrition was larger in > 95 (76%) range than in 65-74 (47.4%), 75-84 (59.8%) and 85-94 range (56.2%). No differences were detected between males and females at risk of undernutrition (odds ratio: 0.85 CI 95%: 0.64-1.12).
Conclusion: In this multicenter study, institutionalized patients have a high prevalence of at risk of malnutrition assessed by MNA-SF test.

Key words: Institutionalized patients. Malnutrition. Nutrition evaluation.


Introducción: En el presente estudio, se evaluó una versión corta del test MNA en un estudio multicéntrico y se valoro la relación de los marcadores bioquímicos con el test MNA-SF.
Material y métodos: Se realizó un estudio transversal de una muestra representativa de la población anciana institucionalizada española de más de 65 años (n = 873). Se utilizó en todos los pacientes el test de valoración nutricional en su versión corta (MNA-SF).
Resultados: El número de pacientes clasificados como bien nutridos (42,1%) fue mayor en los ancianos de 65-74 años (52,6%) que en el rango de edad entre 75 a 84 (40,2%), 85-94 años (43,8%) y > 95 años (24%). La situación de riesgo de desnutrición se produjo en un total de 506 pacientes (57,9%), este riesgo de desnutrición fue mayor en los ancianos mayores de 95 años (76%) que en el rango de edad de 65 a 74 años (47,4%), de 75 a 84 años (59,8%) y de 85-94 años (56,2%). No se detectaron diferencias entre hombres y mujeres en riesgo de desnutrición (OR: 0,85 IC 95% : 0.64-1.12).
Conclusión: En este estudio multicéntrico, los pacientes ancianos institucionalizados tienen una alta prevalencia de riesgo de desnutrición evaluada por el test MNA-SF.

Palabras clave: Paciente institucionalizado. Malnutrición. Evaluación nutricional.



Malnutrition is a prevalent problem in hospitalized and institutionalized patients.1-2 Data produced from studies involving different Hospitals designed to study malnutrition in terms of patient outcome, hospital stance or costs confirm the high prevalence of malnutrition. 3 The Council of Europe has published the resolution "Food and nutritional care in hospitals: How to prevent under nutrition. Report and recommendations". 4 This is an important position document in this matter.

Malnutrition is often unrecognised and subsequently goes untreated. Anthropometry measurements are generally considered as the single most easily obtainable and non-invasive method by which to assess nutritional state. Biochemical measurements such as serum albumin and lymphocyte count are also well known as markers for the malnutrition and are the most commonly used laboratory tests.5 The evaluation of nutritional conditions in the elderly population demands the utilization of easy, precise and fast methods. The Mini-Nutritional Assessment (MNA) test, that attributes scores based on dietetic, anthropometric, subjective and global assessments,6 congregates those advantages and has been evaluated in geriatric patients.7-8 However, its length impedes its use as a brief screening tool. Several questions require special training (e.g., anthropometrics) or subjective judgements. The MNA takes approximately 10 to 15 minutes to administer. This is a reasonable length for a diagnostic test but is perhaps too long for a screener in a primary care setting. A short form of MNA (MNA-SF) could be a good tool to screen malnutrition in these patients.9

In this study, we evaluated a short form version of MNA test in a multicenter study to assess malnutrition in an institutionalized elderly population.


Material and methods


This was a cross-sectional survey covering a sample of representative of the institutionalized Spanish population aged above 65 years. The study was approved by the Clinical Research Ethics Committee of the Medicine School (University of Valladolid). Forty-five centers were selected by means of probabilistic sampling, followed by selections of 20 individuals of each center.

Information was gathered over the course of 2007 through personal interviews. This was followed by a physical examination to measure blood pressure, and anthropometric variables. Interviewers underwent standardized training to administer the questionnaire and anthropometric measurements. The final sample study consisted of 873 patients, 561 females and 312 males.


Blood samples were taken after 12 hour overnight fast. Plasma glucose levels were determined by using an automated glucose oxidase method (Glucose analyser 2, Beckman Instruments, Fullerton, California). Serum total cholesterol and triglyceride concentrations were determined by enzymatic colorimetric assay (Technicon Instruments, Ltd., New York, N.Y., USA). Albumin (3,5-4,5 g/dl) and transferrin (200-400 mg/dl) were measured with an auto analyser (Hitachi, ATM, Mannheim, Ger). Iron (30-300 ng/ml) were analysed with an analyser (Beckman Coulter, Inc, LA, CA).

Anthropometric measurements

Body weight was measured to an accuracy of 0.1 kg and height was measured in centimetres using a stadiometer. Body mass index computed as body weight in kilograms/(height in meters2).

Mini-nutritional assessment short-form test

The standard MNA test is composed of simple measurements and questions that can be completed in about fifteen minutes. The MNA-SF test is composed of 6 questions: anthropometric measurement (body mass index and weight loss), global assessment (motility), dietary question (food intake) and health assessment (acute diseases and neurological problems). The sum of MNA-SF score distinguishes between two groups of patients: a) 12 points or greater (normal, no need for further assessment) and b) 11 points or below (possible malnutrition, continue assessment).10

Statistical analysis

The results were expressed as mean standard deviation. The distribution of variables was analysed with Kolmogorov-Smirnov test. Quantitative variables with normal distribution were analysed with student t-test. Non-parametric variables were analysed using the Mann-Whitney U test. Discrete variables were analysed with the chi-square test, with Yates correction as necessary, and Fisher's test. Correlation analysis was realized with Pearson test. Odds ratios were calculated to compare males and females. A p-value under 0.05 was considered statistically significant.



A total of 873 patients were enrolled, mean age was 82.6 ± 8.3 years, weight 66.1 ± 14.7 kg and BMI 27.2 ± 5.6. The sex distribution of patients was 312 (35.7%) males and 561 (64.3%) females. In males, mean age was 80.1 ± 8.1 years, weight 71.8 ± 14.1 kg and BMI 27.2 ± 4.9. In females, mean age was 84.1 ± 7.9 years, weight 62.8 ± 14.1 kg and BMI 27.1 ± 5.8.

Table I shows the distribution of patients according their gender, age range and nutritional state. The number of patients classified as well nourished (42.1%) was larger in the 65-74 (52.6%) range (n = 72) than in the 75-84 (40.2%) (n = 142) (p < 0,02), 85-94 (43.8%) (n = 135) (p < 0,01) and > 95 (24%) (n = 18) (p < 0,001) age ranges (see table I). Risk of undernutrition occurred in a total of 506 patients (57.9%), risk of under nutrition was larger in > 95 (76%) range than in 65-74 (47.4%) (p < 0,005), 75-84 (59.8%) (p < 0,02) and 85-94 range (56.2%) (p < 0,01), assessed by chi square proportion test. No differences were detected between males and females at risk of undernutrition (odds ratio: 0.85 CI95%:0.64-1.12).

Table II shows the means of the variables in each MNA-SF classification for each gender and for the total group. Statistical differences among MNA-SF classification was detected in age, glucose, albumin and iron. Age was higher in at risk group than well nourished group. Albumin, iron, glucose levels were higher in well nourished group than at risk group. In females were higher age, total cholesterol, and transferrin levels than males. In males were higher iron levels than females.

Table III shows the correlation analysis performed between MNA-SF scores and some parameters. MNASF scores were correlated with haemoglobin, transferrin, iron in total group, males and females. Albumin correlates with MNA-SF score only in total group.



The frequencies of at risk of undernutrition (57.9%) and well nourished (42.1%) in our population were within the range presented in the literature. MNA-SF is associated with biochemical indicators of nutritional status, is an easy-to-use and inexpensive tool in clinical practice, which reinforces its importance in the clinical assessment of institutionalized patients.9,11

Under nutrition is common in this population, can develop or worsen in institutions, and is associated with poor outcomes. Different studies show the scares attention granted to the nutritional state in clinical practice in our area, using parameters as weight, BMI, skinfolds, corporal circumferences, albumin and prealbumin. 12 In clinical practice we have a lot of nutritional assessment variables and these variables vary in their ability to discriminate malnutrition.

Mininutritional Assessment Test (MNA) is a simple screening test for patients. Validation studies have shown that the assessment score is correlated with clinical, anthropometric a biological variables.13 In 32 studies of institutionalized elderly subjects (n = 6,821 elderly) using the MNA, the prevalence of malnutrition was 21% (range 5-71%) and risk for malnutrition was 51% (range 27-70%). The prevalence of well-nourished subjects was 29% (range 4-61%).14 These previous work shows that MNA is an accurate assessment tool for nutritional problems, and is highly correlated with both clinical assessment of nutritional status and objective indicators such as serum albumin and adverse clinical events.15-17

In our study, the MNA-SF has 6 questions instead of 18, eliminates time-consuming and subjective items, and can be administered in approximately 3 minutes. These measures are relatively easy to obtain and are often available in patient records. However, it also has limitations due to this partial approximation to the nutritional assessment. As our data shows, the high rates of at risk of undernutrition was observed in the age > 95. The effect of age is not always observed in malnourished subjects and those at risk of malnutrition, 18,19 but it is expected that older people has more nutritional problems than younger one.

The two MNA-SF categories showed statistically differences among age, glucose, albumin and iron levels. Patients at risk of malnutrition had high age than well-nourished and less iron, glucose and albumin levels well-nourished. The comparison by gender showed statistical significance among age, haemoglobin, transferrin and iron levels. A positive correlation of haemoglobin, transferrin, iron and albumin were verifies with MNA-SF values. Undernutrition starts with an improper intake of nutrients and progresses through a series of functional and biochemical changes such as haemoglobin, transferrin, iron and albumin. In a previous study MNA-SF values had high correlation with albumin levels.9 Other authors11 have demonstrated that MNA-SF is a useful screening tool for hospitalized elders at risk of malnutrition. It is associated with clinical outcomes and is able to predict functional decline. In elderly acute medical patients in general wards, the MNA-SF have a high sensitivity,19 too. This short form test has been proposed to be used as the first step of an efficient preoperative nutritional evaluation of ambulatory elderly patients.10

Taking into account the high prevalence of patients at risk of malnutrition, a rational strategy for nutritional screening in the elderly population is needed. Data presented here suggest that nutritional screening can be performed efficiently using the MNA-SF.

In this multicenter study, institutionalized patients have a high prevalence of at risk of malnutrition assessed by MNA-SF test. MNA-SF presented weak correlation with biochemical marker, we conclude that MNA-SF test must be an important device in the clinical evaluation of institutionalized patients. A major assumption underlying a nutritional screening strategy is that patients discovered to be malnourished or at risk will benefit from being detected, in a high risk population of elderly patients with a lot of co morbidities.


Members of group NOVOMET

José Aspiazu, Nieves Campos, M.a Jesús Carranza Priante, Antonio Castillo Polo, Raúl Cifuentes, Cristina Clemente Soler, Olga Cortizo Suárez, Juan Díaz Melian, Mariano Esbrí Victor, Olga Fernández Duque, Concepción García Alonso, M.a José García Sánchez, Dolores Gaspar Alfonso, José Luis Gascón Gaspar, Beatriz Gil Mombiela, Fernando Goméz Busto, Luis Gongora Yudes, M.a Carmen González Benito, M.a Dolores González, Gerardo Guerrero Ramos, Pedro Herrador Martínez, Andrés Bernabé Herrera Cámara, Rita Hoyos Echevarría, Consuelo Imaz González, M.a Dolores Jiménez Hornos, Raquel Labrador, Rosa López Mongil, Bernardo López Oblare, José Antonio López Trigo, María Lopez Viñas, José Manuel Luján Ortega, M.a Teresa Magdalena Iglesias, Nicolás Maturana Navarrete, José Manuel Marín Carmona, Carlos Navarro Moreno, Francisco Javier Navarro Olivera, Eloy Ortiz Cachero, Javier Pérez Martín, Vicenta T. Nebot Peñarrota, Nicolás Peña Sarabia, Guillermo Pérez Vázquez, M.a Flor Pozuelo Batanero, Roberto Prieto, M.a del Canto Primo Rodríguez, Alfredo Puertas Cantería, Esperanza Ramón Alonso, M.a José Rodríguez Barquero, José Joaquín Roldán Jarreta, Estibaliz Sanchez Castro, Belen Salmon García, Rosa Sanjuan Cuartero, Javier Santana Quilez, Ismael Sobron Monje, José Luis Tobaruela, Blanca Torres Moreno, Olegario Tudela, Juan Pedro Simón Turriarte, Pilar Valenzuela Barranco, Miguel Ángel Vázquez Vázquez, Miguel Ángel Villodres Morales.



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Daniel Antonio de Luis Román.
Hospital Universitario Rio Hortega.
C/ Perales, 16.
47130 Simancas. Valladolid (Spain).

Recibido: 25-III-2011.
Aceptado: 5-IV-2011.

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