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Seven-Point Subjective Global Assessment Is

More Time Sensitive Than Conventional
Subjective Global Assessment in Detecting
Nutrition Changes

Article in Journal of Parenteral and Enteral Nutrition April 2015

DOI: 10.1177/0148607115579938 Source: PubMed


0 155

3 authors, including:

Su Lin Lim Lynne Daniels

National University Hospital, Queensland U Queensland University of Technology


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PENXXX10.1177/0148607115579938Journal of Parenteral and Enteral Nutrition X(X)Lim et al

Original Communication
Journal of Parenteral and Enteral
Seven-Point Subjective Global Assessment Is More Time Volume XX Number X
Month 201X 18
Sensitive Than Conventional Subjective Global Assessment 2015 American Society

in Detecting Nutrition Changes for Parenteral and Enteral Nutrition

DOI: 10.1177/0148607115579938
hosted at

Su Lin Lim, PhD1,2; Xiang Hui Lin, MSc1; and Lynne Daniels, PhD2

Background: It is important for nutrition intervention in malnourished patients to be guided by accurate evaluation and detection of
small changes in the patients nutrition status over time. However, the current Subjective Global Assessment (SGA) is not able to detect
changes in a short period. The aim of the study was to determine whether the 7-point SGA is more time sensitive to nutrition changes
than the conventional SGA. Methods: In this prospective study, 67 adult inpatients assessed as malnourished using both the 7-point SGA
and conventional SGA were recruited. Each patient received nutrition intervention and was followed up after discharge. Patients were
reassessed using both tools at 1, 3, and 5 months from baseline assessment. Results: It took significantly shorter time to see a 1-point
change using the 7-point SGA compared with the conventional SGA (median: 1 month vs 3 months, P = .002). The likelihood of at least
a 1-point change is 6.74 times greater in the 7-point SGA compared with the conventional SGA after controlling for age, sex, and medical
specialties (odds ratio, 6.74; 95% confidence interval, 2.8815.80; P < .001). Fifty-six percent of patients who had no change in SGA
score had changes detected using the 7-point SGA. The level of agreement was 100% ( = 1, P < .001) between the 7-point SGA and
3-point SGA and 83% ( = 0.726, P < .001) between 2 blinded assessors for the 7-point SGA. Conclusion: The 7-point SGA is more time
sensitive in its response to nutrition changes than the conventional SGA. It can be used to guide nutrition intervention for patients. (JPEN
J Parenter Enteral Nutr. XXXX;xx:xx-xx)

7-point Subjective Global Assessment; nutrition status; malnutrition; nutrition changes; intervention

Clinical Relevancy Statement (muscle wasting, fat depletion, and nutrition-related edema).6
The final rating of the SGA is a subjective summation of the 8
It is important for nutrition intervention in malnourished components to classify patients into 3 categories: A = well nour-
patients to be guided by accurate evaluation and detection of ished, B = moderately malnourished, and C = severely malnour-
small changes in the patients nutrition status over time. This ished.6 Despite widespread use of the SGA for initial nutrition
study shows that the 7-point Subjective Global Assessment assessment, very few studies have used this tool to assess
(SGA) is more time sensitive in its response to nutrition changes in nutrition status over time.9 In a review article by
changes than the conventional SGA. These findings are clini- Weekes et al,10 which looked at the impact of nutrition interven-
cally relevant to guide dietitians and clinicians in monitoring tion on outcomes, none of the studies cited used the SGA as an
the effectiveness of nutrition intervention and in making timely
changes to improve the outcomes of patients.
From the 1Dietetics Department, National University Hospital,
Singapore; and 2School of Exercise and Nutrition Sciences, Queensland
Introduction University of Technology, Australia.
Malnutrition is prevalent in hospitals and leads to adverse out- Financial disclosure: The study was supported by a grant from the
comes.13 Studies have shown that patient outcomes can be Healthcare Quality Initiative and Innovation Fund (HQI2F), Ministry of
improved with nutrition support.4,5 Nutrition intervention must Health, Singapore.
be guided by accurate evaluation and detection of small changes
Received for publication September 26, 2014; accepted for publication
in the patients nutrition status over time. Subjective Global
March 8, 2015.
Assessment (SGA) is a well-validated tool widely used to assess
nutrition status of patients.68 It involves assessing 5 components Corresponding Author:
Su Lin Lim, PhD, Dietetics Department, National University Hospital,
of medical history (weight and dietary intake changes, gastroin-
5 Lower Kent Ridge Rd, Main Building, Level 1, Singapore 119074,
testinal [GI] symptoms, functional capacity, and metabolic stress Singapore.
from disease) and 3 components of physical examination

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2 Journal of Parenteral and Enteral Nutrition XX(X)

outcome measure. Interventional studies using the SGA usually nurses as per hospital protocol. Any patient identified as at risk
showed no significant change between the pre and post results or of malnutrition was referred to the hospital dietitian, who con-
did not report outcomes using this tool.5,11,12 This lack of change firmed the diagnosis of malnutrition using the SGA6 and pro-
may be related to the limited information on the repeatability of vided individualized nutrition intervention and counseling on
the SGA as it is unknown over what time frame the SGA should the ward. Consecutive malnourished adult patients aged 21
be repeated to assess changes in nutrition status. Given the well- years were recruited for the study. Psychiatry patients, mater-
established association between malnutrition and increased risk nity patients, patients receiving palliative care, and patients
of morbidity and mortality,13 monitoring changes in nutrition discharged to a nursing home or community hospital were
status is vital, especially in patients who have already been excluded from the study. The National Healthcare Group
assessed as malnourished or those at risk of further nutrition Domain Specific Review Board approved the study protocol.
deterioration. Informed written consent was obtained from each participant.
One of the disadvantages of the conventional SGA is that
small differences in nutrition status during follow-up cannot be
detected.13,14 To overcome this problem, Churchill et al15
Baseline Assessments
expanded the traditional SGA tool to a 7-point scale to assess For the purpose of this study, nutrition status was reassessed
change in nutrition status among 680 patients starting perito- using the conventional SGA and the 7-point SGA by a study
neal dialysis (CANUSA study). The ratings for nutrition status dietitian no more than 4 days before the patient was discharged
were expanded to range from 1 to 7, in which ratings of 1 to 2 from hospital, and this was considered baseline for tracking the
signify severely malnourished, 3 to 5 signify moderately mal- nutrition status of patients postdischarge. For better standardiza-
nourished, and 6 to 7 signify well nourished.15 Therefore, the tion among assessors, the 7-point SGA (Figure 1) was modified
results of nutrition status as assessed by the 7-point scale will from the one used in the CANUSA study15 to include a selection
always be aligned with the conventional SGA (ie, well nour- of ratings within each component. We tested the validity of this
ished, moderately malnourished, or severely malnourished). modified 7-point SGA against baseline body mass index (BMI)
The CANUSA study showed that 1 unit lower in the 7-point and midarm circumference (MAC), which were measured at the
SGA score was prospectively associated with a 25% increase same sitting. A calibrated digital Seca weighing and height
in the relative risk of death.15 machine (Seca Deutschland, Hamburg, Germany) was used to
Since the CANUSA study, there has been increased use of measure body weight to the nearest 0.1 kg and height to the near-
the 7-point SGA, but this has been limited to renal patients.13,16,17 est 0.01 m. BMI was calculated by dividing body weight in kilo-
No studies have reported on the use of the 7-point SGA in other grams with height in meters squared. Midarm circumference
patient groups. Some authors have speculated that the 7-point was measured on the nondominant arm using a measuring tape
SGA may be more sensitive than the conventional SGA in with the arm hanging relaxed. Measurements were taken mid-
identifying small changes in nutrition status.17,18 Given the way between the point of the acromion and olecranon process 3
broad nature of a 3-point rating in the conventional SGA, a times, and the average was calculated. A Jamar dynamometer
substantial improvement in nutrition status may be required (Sammons Preston Royland, Bolingbrook, Illinois) was used to
before patient transitions from a B (moderately malnour- measure handgrip strength on the dominant hand according to
ished) to an A (well nourished) rating. In contrast, when the procedure recommended by the American Society of Hand
using the 7-point SGA, a moderately malnourished patient Therapists.21 The elbow of the dominant arm was flexed in a 90
may improve from a rating of 3 to 4. In this instance, the patient position with the shoulder and wrist in neutral positions. The
is still classified as moderately malnourished, but smaller handle of the dynamometer was set at the second position. It was
changes in nutrition status are detected. Valid improvements in then placed in the patients hand, and the dietitian would encour-
score within a broad category would suggest improved nutri- age the patient to squeeze as hard as possible. The measurements
tion status, and conversely any deterioration in status can be were taken 3 times with a 2-minute rest in between trials and the
detected and addressed quickly. To date, no studies have been average of the 3 measures was used. Assessment of quality of
published to support this opinion. life was carried out using the European Quality of LifeVisual
The aim of the study was to determine if the 7-point SGA is Analog Scale (EQ-VAS).22 In the EQ-VAS, participants recorded
more time sensitive in its response to nutrition changes than the their current health status on a vertical visual analog scale where
conventional SGA across different patient diagnostic groups. the end points are labeled best imaginable health state and
worst imaginable health state. To assess the reliability of the
7-point SGA, interrater agreement between the 2 study dietitians
Methods was conducted on 37 patients before the commencement of the
study. The first dietitian assessed each patient using the 7-point
Screening and Study Participants SGA, followed by the second dietitian, who repeated the 7-point
All patients were screened for risk of malnutrition on admis- SGA assessment and was blinded to the results of the first
sion using 3-Minute Nutrition Screening19,20 by the ward dietitian.

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Lim et al 3

Weight loss ____ kg in the past 6 months (circle one rating for each category)
Ratings Weight loss
7 0%
6 <3%
5 3<5% 7 6 5 4 3 2 1
4 5<7%
3 7<10%
2 10<15%
1 15%
If weight trend, add 1 point, if weight trend within 1 month, minus 1 point
Dietary Intake (past 2 weeks)
7) Good (Full share of usual meal)
6) Good (> /4 < 1 share of usual meal)
1 3
5) Borderline ( /2 /4 share of usual meal), but increasing
1 3
4) Borderline ( /2 /4 share of usual meal), no change or decreasing 7 6 5 4 3 2 1
3) Poor (< /2 share of usual meal), but increasing
2) Poor (< /2 share of usual meal), no change or decreasing
1) Starvation (< /4 of usual meal)

Gastrointestinal symptoms (that persisted for > 2 weeks)

Nausea: _____ Vomiting: ______ Diarrhea: _______
7) No symptom
6) Very few intermittent symptoms (1x per day) 7 6 5 4 3 2 1
5) Some symptoms (23x per day)improving
4) Some symptoms (23x per day)no change
3) Some symptoms (23x per day)getting worse
12) Some or all symptoms (> 3x per day)

Functional status (nutrition related)

67) Full functional capacity
35) Mild to moderate loss of stamina 7 6 5 4 3 2 1
12) Severe loss of functional ability (bedridden)

Disease state affecting nutritional requirements

6-7) No increase in metabolic demand (no or low stress)
3-5) Mild to moderate increase in metabolic demand (moderate stress) 7 6 5 4 3 2 1
1-2) Drastic increase in metabolic demand (high stress)

Muscle wastage: 67) No depletion in all areas

(at least 3 areas) 35) Mild to moderate depletion 7 6 5 4 3 2 1
12) Severe depletion

Fat stores 67) No depletion in all areas

35) Mild to moderate depletion 7 6 5 4 3 2 1
12) Severe depletion

Edema: 67) No edema

(nutrition related) 35) Mild to moderate edema 7 6 5 4 3 2 1
12) Severe edema

Nutritional Status: Well Nourished / Mildly to Moderately Malnourished / Severely Malnourished

Overall SGA Rating: 7 6 5 4 3 2 1
(circle one)
Figure 1. The 7-point Subjective Global Assessment.

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4 Journal of Parenteral and Enteral Nutrition XX(X)

Follow-up Assessments Table 1. Demographics of the Study Subjects at Baseline

(n = 67).a
Each patient was provided with follow-up appointments at an
outpatient clinic 1 month, 3 months, and 5 months after dis- Characteristic Value
charge from hospital. During these follow-up visits, patients Age, mean SD, y 63.9 14.5 [(27-87]
were reassessed using the 7-point SGA and the conventional Sex
SGA. All patients were given individualized nutrition interven- Male 30 (45)
tion and counseling as appropriate by the study dietitian. Female 37 (55)
Patients who failed to turn up for scheduled outpatient appoint- Ethnicity
ments were home-visited by the study dietitian within 1 week Chinese 52 (78)
of the missed appointments. At the fifth month follow-up, Malay 8 (12)
assessment using the 7-point SGA and the conventional SGA Indian 4 (6)
was carried out by a second dietitian who was blinded to the Other 3 (4)
results of the previous ratings. Patients body weight, handgrip Baseline nutrition statusb
strength, and assessment of quality of life using the EQ-VAS Moderately malnourished 62 (93)
were also measured. Severely malnourished 5(7)
SGA rating: 5 23 (34)
SGA rating: 4 24 (36)
Statistical Analyses SGA rating: 3 15 (22)
All statistical analyses were performed using the Statistical SGA rating: 2 5 (8)
Package for the Social Sciences for Windows (version 21.0; SGA rating: 1 0
SPSS, Inc, Chicago, IL) with statistical significance set at P <
General surgery 19 (28)
.05. The measure of agreement test was used to assess if there
General medicine 15 (22)
was any variability between the 7-point SGA and the conven-
Cardiology 10 (15)
tional SGA as well as the interrater agreement in the measure-
Respiratory 5 (7)
ment of the 7-point SGA between the 2 assessors. Logistic Gastroenterology 4 (6)
regression was used to compare the likelihood of detecting a Oncology 4 (6)
change between the 7-point SGA and the conventional SGA, Endocrinology 3 (5)
controlling for confounding factors such as age, sex, and medi- Geriatrics 3 (5)
cal specialties and presenting the results as odds ratio at 95% Orthopedic 2 (3)
confidence intervals (CIs). The dependent variable in this model Nephrology 2 (3)
was whether there was a change in SGA score, with the refer-
ence category being either the 7-point SGA or the conventional Values are presented as number (%) unless otherwise indicated.
Severity of malnutrition as defined by the 7-point Subjective Global
model. Wilcoxon signed ranks test was performed to determine Assessment (SGA).
the time to see a minimum 1-point change in both the 7-point
SGA and the conventional SGA, and this was reported as a
median value. Time was categorized as 1 month, 3 months, or 5 patients dropped out: 10 patients were discharged to step-down
months to see a change in SGA score for both the 7-point SGA care such as community hospital and/or nursing home, 4
and conventional 3-point SGA. This was because patients were patients returned to their home country, 4 patients had caregiv-
followed up at these intervals after baseline SGA was measured. ers who did not want to continue, 5 patients were discharged to
Spearmans was used to determine the correlation between palliative care, and 3 patients were uncontactable. A total of 67
changes in both SGAs and changes in body weight, handgrip patients completed the study. The average length of stay for the
strength, EQ-VAS, and upper-arm anthropometries. The level of study patients was 9.4 days. The demographic profiles of the
agreement between the 7-point SGA and 3-point SGA and the study subjects and the spread of medical specialties are
interrater agreement between the 2 assessors using the 7-point described in Table 1.
SGA were reported as percent agreement and statistics.
Validity and Reliability
Results The 7-point SGA scale was positively correlated with BMI
( = 0.77, P < .001) and MAC ( = 0.84, P < .001); patients
Participant Demographics
who had a higher SGA score were more likely to have a higher
A total of 105 patients assessed as malnourished were BMI and MAC. The level of agreement between the 7-point
approached to participate in this study. Twelve patients did not SGA and 3-point SGA was 100% ( = 1, P < .001). The inter-
want to participate in the study, citing busyness and not want- rater agreement between 2 assessors for the 7-point SGA was
ing the extra hassle. During the 5-month study, a total of 26 good, at a rate of 83% ( = 0.726, P < .001).

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Lim et al 5

Table 2. Change in Overall Nutrition Assessment Rating study shows that even though there appears to be no change in
Between Baseline and the Fifth Month Using the 7-Point SGA classification using the conventional SGA, changes in score
and the Conventional SGA (n = 67). within the traditional categories using the 7-point SGA were
Change in Rating Between 7-Point SGA, Conventional observed in 56% of these patients. This is important as repeated
Baseline and Fifth Month No. (%) SGA, No. (%) measures of nutrition assessment over time yield valuable
information that might help guide the nature of the nutrition
0 point [no change] 17 (25) 39 (58)
advice or intervention given. From this current study, we are
1 point 30 (45) 28 (42)
able to show that the 7-point SGA is a useful nutrition assess-
2 points 15 (22) 0
ment tool in detecting nutrition changes over relatively shorter
3 points 5 (8) NA
periods of time compared with the conventional SGA.
Total patients with a 50 (75) 28 (42)
change in score Consequently, nutrition intervention can be adjusted or fine-
tuned earlier if the patient does not respond to the nutrition
NA, not applicable; SGA, Subjective Global Assessment. treatment.
Up until today, no study has provided an evidence base for
the time sensitivity of the 7-point SGA, and many dietitians
Time Sensitivity
and clinicians especially outside of renal specialty are not
Table 2 shows the frequency of the overall change in SGA aware of the usefulness of the 7-point SGA due to a lack of
score using the 7-point SGA and the conventional SGA. Of the published evidence. Although the SGA has been a widely vali-
39 patients who had no change in their score using the conven- dated and well-accepted tool to determine the nutrition status
tional SGA, 22 (56%) had a change in their score within the of patients,7,8 it has not been used in many studies to report
same nutrition status category using the 7-point SGA. changes in nutrition outcomes.10 Even studies that use the SGA
It took significantly shorter time to see a 1-point change initially do not report outcomes using this tool.5,12 Instead,
using the 7-point SGA compared with the conventional SGA changes in body weight are most commonly cited in studies
(median: 1 month vs 3 months, P = .002). The likelihood of at that span over 3 months to determine changes in nutrition sta-
least a 1-point change over a 5-month period was 6.74 times tus of patients.4,23,24 This is probably due to the limitation of the
greater using the 7-point SGA compared with the conven- conventional SGA, which is often not able to detect change in
tional SGA after controlling the results for age, sex, and medi- nutrition status in a shorter period of time even when weight
cal specialties (adjusted odds ratio, 6.74; 95% CI, 2.8815.80; change is present. However, there are limitations to using
P < .001). weight change alone to monitor nutrition status, since changes
in body weight may be confounded by alterations in body com-
position and fluid retention commonly associated with ill-
ness.25,26 In addition, weight measurements pose challenges in
Table 3 compares the correlation between changes in both the patients who are bed bound or old and frail. In an audit of 526
7-point and the conventional SGA and changes in body hospital admissions, only 67% of the population had informa-
weight, handgrip strength, EQ-VAS, and upper-arm anthro- tion on weight.27 Even in the clinical research context, there are
pometries. There was a moderate positive linear correlation difficulties in obtaining complete weight and height data.28,29
between changes in the 7-point SGA and weight gain ( = In clinical practice, unavailable weight records can be as high
0.681, P < .001) and a mild positive linear correlation between as 74%-85%.2830
changes in the 7-point SGA and increase in handgrip strength Malnutrition has been shown to have numerous detrimental
( = 0.346, P = .007), as well as improvement in the quality- effects on health and quality of life.13 To ensure appropriate
of-life scale using the EQ-VAS ( = 0.369, P = .006). The nutrition care is provided, an in-depth assessment of a patients
correlation between changes in the conventional SGA and nutrition status is needed, and the SGA has been developed for
weight change was mild ( = 0.589, P < .001), and only weak this purpose.6 However, once nutrition intervention is imple-
correlation was found between changes in the conventional mented, tracking changes in nutrition status is required to eval-
SGA and handgrip strength ( = 0.210, P = .111) and EQ-VAS uate the effectiveness of the chosen intervention and to prompt
( = 0.124, P = .366). changes in the treatment plan as required. The benefit of the
7-point SGA is that it can potentially detect comparatively
small changes within the broader categories of nutrition status.
A study by Campbell et al17 on patients with chronic kidney
The current study has shown for the first time that the 7-point disease showed a difference in body composition between the
SGA is able to detect response to nutrition intervention faster rating points of the 7-point SGA (3, 4, and 5) within the same
than the conventional SGA in adult malnourished patients. It category of nutrition status (SGA B). Using total body potas-
took significantly shorter time to see a 1-point change using the sium, a gold-standard measure for body cell mass, a linear
7-point SGA in comparison to the conventional SGA. Our increase in mean body cell mass from ratings 3 to 5 in the

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6 Journal of Parenteral and Enteral Nutrition XX(X)

Table 3. Correlation Between Changes in the 7-Point SGA and the Conventional SGA and Changes in Body Weight, Handgrip
Strength, Quality of Life, and Upper-Arm Anthropometries in 5 Months.

Changes in 7-Point SGA Changes in Conventional SGA

Changes Observed Between Baseline and
Fifth Month n Correlation () P Value Correlation () P Value
Weight change 67 0.681a <.001 0.589b .001
Changes in handgrip strength 59c 0.346b .007 0.210d .111
Changes in quality of life (EQ-VAS) 55c 0.369b .006 0.124d .366
Changes in midarm circumference 63c 0.473b <.001 0.475b <.001
Changes in triceps skinfold thickness 63c 0.395b <.001 0.483b <.001
Changes in midarm muscle circumference 63c 0.415b <.001 0.364b .003

EQ-VAS, Euro-Quality of LifeVisual Analog Scale; SGA, Subjective Global Assessment.

Moderate correlation.
Mild correlation.
Missing data due to refusal or inability of patients to be measured.
Weak correlation.

7-point SGA was detected. This suggests that nutrition change highly correlated with other nutrition parameters (BMI and
took place even though patients would still have been consid- MAC) and therefore provides evidence based on its validity
ered moderately malnourished (rating B) within the broad cat- and use in specialties besides renal patients.
egories of the conventional SGA.17 The study also shows that changes in the 7-point SGA cor-
The subjectivity of the conventional SGA tool has been relate better with changes in body weight, handgrip strength,
raised in many studies and is one of the major limitations of midarm muscle circumference, and quality of life (QoL) mea-
this tool.14,31 The expanded scale and detailed response options sures than the conventional SGA. Body weight, handgrip
in the 7-point SGA have their advantages in overcoming this strength, midarm anthropometries, and QoL are commonly
limitation. They enable standardized scoring and objectivity of used as outcome measures for nutrition intervention in mal-
the assessors within each item in the 7-point SGA. This may nourished patients.4,5 However, since each of these parameters
partly explain the good interrater reliability of the 7-point SGA on its own cannot be used as a sole indicator of malnutrition,
between dietitians, despite the tool having 7 ratings of nutrition the ability of the 7-point SGA to diagnose malnutrition as well
status. Previous studies on SGA have shown interrater reliabil- as to monitor the nutrition progress of patients is notable.
ity of 79% and 81%.7,8 The ambiguity in the conventional SGA There are several strengths in this study. This is the first
is addressed in the 7-point SGA, whereby the expanded items study to show that the 7-point SGA can be used to detect nutri-
in each component are specified clearly (Figure 1), thus facili- tion changes faster than the conventional SGA. This facilitates
tating greater standardization between assessors. The clarity of earlier evaluation of the impact of any nutrition intervention
the 7-point SGA is enhanced by clear instruction that func- and provides critical guidance to the healthcare professional in
tional status should be nutrition related and not the conse- making decisions regarding medical nutrition therapy. Another
quence of a debilitating medical condition such as stroke and strength of this study is the use of a blinded assessor method to
that at least 3 muscle areas need to be examined. test the interrater reliability of the 7-point SGA.
Similar to the conventional SGA, the final rating in the In addition, this study was carried out across a range of
7-point SGA is based on the subjective weighting of the com- medical conditions. In contrast, the 7-point scale SGA intro-
ponents to classify patients into 3 categories: well nourished, duced in the CANUSA study15 has been studied only in renal
moderately malnourished, and severely malnourished. Hence, patients.13,16,17 The inclusion of a range of medical conditions
the 7-point SGA can always be converted to the conventional is advantageous since patients usually present with multiple
SGA rating (but not vice versa). This was clearly demonstrated comorbidities. Furthermore, it is not practical to switch from
by the excellent level of agreement between the 7-point SGA one tool to another for different medical conditions. The aim is
and 3-point SGA in this study. With this, the prognostic valid- to minimize confusion among staff, standardize practice, and
ity of the 7-point SGA remains the same as the conventional conserve resources in training staff when they transfer from
SGA, which has been shown to have good prognostic value for one ward to another.
a range of clinical outcomes such as mortality, length of hospi- This study was conducted on a small sample size, with the
tal stay, and readmission.1,3 Previous studies have found the majority being Asians, which limits the generalizability of the
7-point SGA to be a valid and reliable tool to assess patients findings. In addition, using BMI and MAC may not be accurate
nutrition status. However, these studies were conducted on surrogates for body composition. Future studies on non-Asians
renal patients.13,16 This current study, conducted on multidisci- and validating the 7-point SGA with more accurate surrogates
plinary medical specialties, shows that the 7-point SGA is for body composition such as dual-energy X-ray absorptiometry

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Lim et al 7

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The impact of nutrition intervention on a reliable morbidity and mortal-
significantly shorter time to see a 1-point change using the ity indicator: the hemodialysis-prognostic nutrition index. J Ren Nutr.
7-point SGA (1 month) compared with the conventional SGA 2003;13:186-190.
(3 months). It would be useful to know the minimum amount 12. Norman K, Kirchner H, Freudenreich M, Ockenga J, Lochs H, Pirlich
of time over which the 7-point method can detect change. If M. Three month intervention with protein and energy rich supplements
this method can be validated over a series of shorter time inter- improve muscle function and quality of life in malnourished patients with
non-neoplastic gastrointestinal diseasea randomized controlled trial.
vals between patient visits, it may provide invaluable informa- Clin Nutr. 2008;27:48-56.
tion to track the effectiveness of nutrition interventions to 13. Visser R, Dekker FW, Boeschoten EW, Stevens P, Krediet RT. Reliability
make timely changes in improving the clinical outcomes of of the 7-point subjective global assessment scale in assessing nutritional
patients. Future studies to assess the ability of the method to status of dialysis patients. Adv Perit Dial. 1999;15:222-225.
detect important clinical outcomes such as mortality and read- 14. Kalantar-Zadeh K, Kleiner M, Dunne E, Lee GH, Luft FC. A modified
quantitative subjective global assessment of nutrition for dialysis patients.
mission rates with each point change in the scoring are also Nephrol Dial Transplant. 1999;14:1732-1738.
warranted. 15. Churchill DN, Taylor DW, Keshaviah PR. Adequacy of dialysis and nutri-
tion in continuous peritoneal dialysis: association with clinical outcomes.
Canada-USA (CANUSA) Peritoneal Dialysis Study Group. J Am Soc
Conclusions Nephrol. 1996;7:198-207.
The 7-point SGA is more time sensitive in its response to nutri- 16. Steiber A, Leon JB, Secker D, et al. Multicenter study of the validity and
reliability of subjective global assessment in the hemodialysis population.
tion changes than the conventional SGA. It can be used in a J Ren Nutr. 2007;17:336-342.
range of medical conditions and adult age groups to assess and 17. Campbell KL, Ash S, Bauer JD, Davies PS. Evaluation of nutrition assess-
monitor the progress of nutrition status in patients. More ment tools compared with body cell mass for the assessment of malnutri-
important, it can be used to guide nutrition intervention for tion in chronic kidney disease. J Ren Nutr. 2007;17:189-195.
patients. 18. Jones CH, Wolfenden RC, Wells LM. Is subjective global assessment
a reliable measure of nutritional status in hemodialysis? J Ren Nutr.
Acknowledgments 19. Lim SL, Tong CY, Ang E, et al. Development and validation of 3-Minute
We are very grateful to Linda McCann for providing advice and Nutrition Screening (3-MinNS) tool for acute hospital patients in
initial training on the 7-point Subjective Global Assessment. Singapore. Asia Pac J Clin Nutr. 2009;18:395-403.
20. Lim SL, Ang E, Foo YL, et al. Validity and reliability of nutrition screen-
ing administered by nurses. Nutr Clin Pract 2013;28:730-736.
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