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Nutrition assessment

Why nutrition assessment is important 

Nutrition assessment is different from nutrition screening in that it:

Determines the presence of malnutrition (diagnosis) and other nutrition disorders
Determines the severity and causes of malnutrition
Is used to stratify and plan nutrition interventions¹.

Who can assess 

Nutrition assessment should be completed by a qualified/accredited dietitian.

Who should receive a nutrition assessment

It is recommended that individuals with a cancer treatment plan known to lead to high risk of malnutrition or other nutrition disorder such as sarcopenia or cachexia, should also be referred to the dietitian to have a comprehensive nutrition assessment². This includes those undergoing major surgery to the gastrointestinal tract.

All individuals screened as ‘at risk’ of malnutrition should be referred to the dietitian for a comprehensive nutrition assessment.

What and how to assess

Comprehensive nutrition assessment

In order to effectively stratify and plan individual nutrition interventions, a comprehensive nutrition assessment is needed to determine the presence of malnutrition (diagnosis), as well as the severity and causes of malnutrition and other inter-related nutrition disorders such as sarcopenia and cachexia^1,3-5.

A comprehensive nutrition assessment involves an evaluation of the following elements^3-5:

The Patient-Generated Subjective Global Assessment (PG-SGA) is an assessment tool used to diagnose the presence of malnutrition, which also incorporates a number of the elements required in undertaking a comprehensive nutrition assessment, to determine the causes and severity of malnutrition^4,8,9, such as:

nutrition impact symptoms
reduced food intake
functional status assessment to determine muscle strength and function
nutrition-focused physical examination (fat mass, muscle mass and oedema).

Malnutrition diagnosis

The most important part of a comprehensive assessment is diagnosing if the individual is clinically malnourished and the severity of malnutrition. This allows the individual to be stratified into receiving targeted or specialist nutritional care by the dietitian, which determines the intensity of the nutrition intervention.

A diagnosis of malnutrition can be made using different validated tools and/or criteria (see Resources section below for more details):

Patient-Generated Subjective Global Assessment (PG-SGA)⁹
Global Leadership initiative on Malnutrition (GLIM)¹⁰
Subjective Global Assessment (SGA)¹¹.

Assessment measures

Comprehensive nutrition assessment and malnutrition diagnosis with PG-SGA (including how to incorporate GLIM)

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The scored Patient-Generated Subjective Global Assessment (PG-SGA) has been validated for use in cancer patients and is internationally recognised as the preferred assessment tool to diagnose the presence of malnutrition, and also to determine the severity and causes of malnutrition^4,8,9.

It can be performed by a dietitian or other clinician who is specifically trained in completing the PG-SGA.

The PG-SGA incorporates the core phenotypic and etiologic criteria to diagnose malnutrition, as per the Global Leadership Initiative on Malnutrition (GLIM) guidelines¹⁰:

Phenotypic	Etiologic
BMI <20 (if <70years) or <22 (if >70years)	Reduced food intake
Unintentional loss of weight >5%	Presence of inflammation
Reduced muscle mass at 4 sites

It also incorporates a number of the elements required in undertaking a comprehensive nutrition assessment, in order to determine the causes and severity of malnutrition, such as:

nutrition impact symptoms
reduced food intake
functional status assessment to determine muscle strength and function
nutrition-focused physical examination (fat mass, muscle mass and oedema).

The PG-SGA produces a global nutrition status category of A, B or C, which can be used to stratify nutrition interventions in the prehabilitation setting into universal (well nourished, PG-SGA A), targeted (moderate/suspected malnutrition, PG-SGA B) or specialised (severely malnourished, PG-SGA C). It also produces an additive numerical score, which can be used for triage recommendations and to monitor nutritional status over time. See table 1 for more detailed information.

Table 1, details of PG-SGA

The PG-SGA consists of 7 items, each covering an nutrition-related aspect that impacts nutritional status. The first 4 items are designed to be completed by the patient (weight, food intake, symptoms, activities and function). The remaining 3 are completed by a dietitian/suitably trained clinician (disease status, metabolic demand, physical exam).

Number of items	Time to complete	Cut offs for risk stratification	Minimal clinically important difference (MCID)	Can be completed by any clinician?	Can be completed by patient?	Can be completed remotely?	Freely available?	Equipment / resources required
7	10 mins	PG-SGA A = well nourished (universal), PG-SGA B = moderate / suspected malnutrition (targeted) or PG-SGA C = severe malnutrition (specialised)	Change in PG-SGA category A, B or C *	Dietitian or clinician specifically trained in completing PG-SGA	First 4 sections only (screening component only)	Yes	Yes	Nil

* There is no published minimum clinically significant difference for the PG-SGA numerical score¹⁵

Assessment of muscle mass

Functional assessment of muscle strength and function

Biochemical assessment

Resources

Prado C, Laviano A, Gillis C, Sung A, Gardner M, Yalcin S, Dixon S, Newman S, Bastasch M, Sauer A, Hegazi R, Chasen M. Examining guidelines and new evidence in oncology nutrition: a position paper on gaps and opportunities in multimodal approaches to improve patient care. Support Care Cancer. 2022;30:3073-3083.
Kiss N, Loeliger J, Findlay M, et al. Clinical Oncology Society of Australia: position statement on cancer-related malnutrition and sarcopenia. Nutr Diet. 2020;77:416–425.
Gillis C, Hasil L, Kasvis P, Bibby N, Davies SJ, Prado C, West MA, Shaw C. Nutrition Care Process Model Approach to Surgical Prehabilitation in Oncology. Front Nutr. 2021;24(8):644706.
Ford K, Prado C, Weimann A, Schuetz P, Lobo D. Unresolved issues in perioperative nutrition: A narrative Review. Clin Nutr. 2022;41:1578-1590.
Prado C, Landi F, Chew STH, Atherton PJ, Molinger J, Ruck T, Gonzalez MC. Advances in muscle health and nutrition: A toolkit for healthcare professionals. Clin Nutr. 2022;41:2244-2263.
Fischer A, JeVenn A, Hipskind P. Evaluation of muscle and fat loss as diagnostic criteria for malnutrition. Nutr Clin Pract. 2015:30(2):239-248.
Russell MK. Functional assessment of nutrition status. Nutr Clin Pract. 2015 Apr;30(2):211-8.
Jager-Wittenaar H, Ottery FD. Assessing nutritional status in cancer. Curr Opin Clin Nutr Metab Care. 2017;20:322-329.
Bauer J, Capra S, Ferguson M. Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer. Eur J Clin Nutr. 2002;56:779-785.
Cederholm T, Jensen GL, Correia M, Gonzalez MC, Fukushima R, Higashiguchi T, et al. GLIM criteria for the diagnosis of malnutrition- a consensus report from the global clinical nutrition community. Clin Nutr. 2019;38:1e9.
Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker A, Mendelson RA, Jeejeebhoy KN. What is subjective global assessment of nutritional status? J Parenter Enteral Nutr. 1987;11(1):8-13.
Weimann A, Braga M, Carli F, Higashiguchi T, Hubner M, Klek S, Laviano A, et al. ESPEN practical guideline: clinical nutrition in surgery. Clin Nutr. 2021;40:4745-4761.
Bharadwaj S, Ginoya S, Tandon P, Gohel TD, Guirguis J, Vallabh H, et al. Malnutrition: laboratory markers vs nutritional assessment. Gastroenterol Rep. 2016;4:272-80.
Lacy M, Roesch J, Langsjoen J. Things we do for no reason: prealbumin testing to diagnose malnutrition in the hospitalized patient. J Hosp Med. 2019;14:239-41.

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Acknowledgements

Co-Principal Investigators:

A/Prof Alicia Martin – Director of Allied Health, Peter MacCallum Cancer Centre
Jenelle Loeliger – Manager Nutrition and Speech Pathology, Peter MacCallum Cancer Centre

Project Manager:

Dr Christina Prickett – Clinical Psychologist, Peter MacCallum Cancer Centre

Project team:

Dr Rajib Ahmed – Consultant Anaesthetist, Peter MacCallum Cancer Centre
Professor Linda Denehy – Head of Allied Health Research, Peter MacCallum Cancer Centre
Ben de Zoete – Manager Physiotherapy & Occupational Therapy, Peter MacCallum Cancer Centre
Dr Lara Edbrooke – Allied Health Research Development Lead, Peter MacCallum Cancer Centre
Dr Maria Ftanou – Director of Psychosocial Oncology, Peter MacCallum Cancer Centre
A/Prof Hilmy Ismail – Anaesthetist, Peter MacCallum Cancer Centre
Professor Berhard Riedel – Director of Anaesthetics, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre
Catherine Sinton – Clinical Nurse Consultant, Peter MacCallum Cancer Centre
Anya Traill – Manager Physiotherapy & Occupational Therapy, Peter MacCallum Cancer Centre

Communications Advisor:

Maddison Gray – Communications & Media Specialist, Western & Central Melbourne Integrated Cancer Services (WCMICS)

Clinical content leads:

Dr Raj Ahmed – Consultant Anaesthetist, Peter MacCallum Cancer Centre
Anna Beaumont – Dietitian, Peter MacCallum Cancer Centre
Jess Crowe – Physiotherapist, Peter MacCallum Cancer Centre
Dr Fiona Lynch – Clinical Psychologist, Peter MacCallum Cancer Centre
Lisa Nguyen – Physiotherapist, Peter MacCallum Cancer Centre
Catherine Sinton – Clinical Nurse Consultant, Peter MacCallum Cancer Centre

Steering committee members:

Dr Rajib Ahmed – Consultant Anaesthetist, Peter MacCallum Cancer Centre
Michael Barton – Deputy Manager, Western & Central Melbourne Integrated Cancer Services (WCMICS)
Hollie Bevans – Senior Dietitian, Western Health
Professor Linda Denehy – Head of Allied Health Research, Peter MacCallum Cancer Centre
Janelle Devereux and Bianca Bell – Executive Director, Health Systems Integration, North West Melbourne Primary Health Network (NWMPHN)
Ben de Zoete – Manager Physiotherapy & Occupational Therapy, Peter MacCallum Cancer Centre
Dr Lara Edbrooke – Allied Health Research Development Lead, Peter MacCallum Cancer Centre
Dr Maria Ftanou – Director of Psychosocial Oncology, Peter MacCallum Cancer Centre
Mr Michael Hii – Deputy Director, HPB and Upper GI Surgery, St Vincent’s Hospital Melbourne
A/Prof Hilmy Ismail – Anaesthetist, Peter MacCallum Cancer Centre
Drew Kenneady – Consumer Representative
Mainak Majumdar – Director, Critical Care, Mercy Health
A/Prof Alicia Martin - Director of Allied Health, Peter MacCallum Cancer Centre
Sharyn McGowan – Allied Health Team Leader, Bendigo Health
Fiona McKinnon – Director of Allied Health, St Vincent’s Hospital Melbourne
Orla McNally – Surgeon, The Royal Women’s Hospital
Jenelle Loeliger – Manager Nutrition and Speech Pathology, Peter MacCallum Cancer Centre
Denise Mitchell – Consumer Representative
Kathryn Pierce – Western Health Allied Health Representative, Western Health
Amanda Piper – Head of Cancer Strategy, Cancer Council Victoria (CCV)
Dr Christina Prickett – Clinical Psychologist, Peter MacCallum Cancer Centre
Professor Berhard Riedel – Director of Anaesthetics, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre
Catherine Sinton – Clinical Nurse Consultant, Peter MacCallum Cancer Centre
Anya Traill – Manager Physiotherapy & Occupational Therapy, Peter MacCallum Cancer Centre
Chris White – Director, Cancer Centre, Bendigo Health

Contributions to content:

Shaza Abo – Physiotherapist, Peter MacCallum Cancer Centre
Dr Diva Baggio – Haematology Laboratory Registrar, Peter MacCallum Cancer Centre
A/Prof Cherie Chiang – Endocrinologist & Internal Medicine Consultant Physician, Peter MacCallum Cancer Centre
Professor Linda Denehy – Head of Allied Health Research, Peter MacCallum Cancer Centre
Dr. Amy Dennett – Physiotherapist, La Trobe University
A/Prof Helena Frawley – Principal Research Fellow, Allied Health, University of Melbourne
Dr Margaret He – Consultant Anaesthetist, Tauranga Hospital, New Zealand
Dr Nicolette Holt – Respiratory, Sleep & Perioperative Consultant Physician, Peter MacCallum Cancer Centre
A/Prof Hilmy Ismail – Consultant Anaesthetist, Peter MacCallum Cancer Centre
Ms Alana Jones – Enhanced Recovery after Surgery Nurse Coordinator, Royal Melbourne Hospital
Erin Laing – Dietitian, Peter MacCallum Cancer Centre
Dr Debra Leung – Consultant Anaesthetist, Peter MacCallum Cancer Centre
Tennille Lewin – Centre for Health Services Research, Peter MacCallum Cancer Centre
Celia Marsten – Occupational Therapist, Peter MacCallum Cancer Centre
Dr Walston Martis – Consultant Anaesthetist, Peter MacCallum Cancer Centre
Dr Mark Nolan – Consultant Cardiologist, Peter MacCallum Cancer Centre
Dr Chad Oughton – Consultant Anaesthetist, Peter MacCallum Cancer Centre
Ella Sexton – Clinical Psychologist, Peter MacCallum Cancer Centre
Dr Emma Tyson – Consultant Anaesthetist, Peter MacCallum Cancer Centre
A/Prof David Westerman – Consultant Haematologist, Peter MacCallum Cancer Centre
A/Prof Jamie Young – Pain & Rehabilitation Consultant Physician, Peter MacCallum Cancer Centre

The project team sincerely thanks all participants from various stages of this project:

The consumers, health professionals and other experts who participated in the co-design workshops
The health professionals and patients from the three implementation sites including Western Health, Bendigo Health and St Vincents Hospital Melbourne.

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Contact

For questions or comments related to this website, please email prehabtoolkit@petermac.org

Nutrition assessment

Why nutrition assessment is important

Who can assess

Who should receive a nutrition assessment

What and how to assess

Comprehensive nutrition assessment

Malnutrition diagnosis

Assessment measures

Table 1, details of PG-SGA

Resources

Patient-Generated Subjective Global Assessment:

Global Leadership Initiative on Malnutrition (GLIM):

Subjective Global Assessment (SGA):

COSA Cancer-related Malnutrition and Sarcopenia Implementation Toolkit:

Privacy Policy

Information for statistical purposes

Third party sites

Cookies

Disclaimer

Acknowledgements

Co-Principal Investigators:

Project Manager: ​

Project team:​

Communications Advisor:

Clinical content leads: ​

Steering committee members:

Contributions to content:

The project team sincerely thanks all participants from various stages of this project:

Contact

Why nutrition assessment is important 

Who can assess 

Project Manager:

Project team:

Clinical content leads: