Specificity apparently

Ton Hf Martijn
ABSTRACT widespread indexes assessed used the

of indexes of malnutrition healthy people: the effect

Angelika de Bree, Tjard RJ Schermer, fan

when applied of age13

Brigit Bar, Gerard

to
de Wild, and

Naber, B Katan

Bakkeren,

in rate

Protein-energy hospitalized to assess of false-positive

malnutrition patients. However, malnutrition is diagnoses of

is

thought to the specificity We malnutrition

be these of number

indexes, of of

nutritional postoperative is support. assessing of

intervention complications truly of high these in

has

proven (20-22). nonsurgical might specificity has not developed indexes Maastricht with the surgical validated

to reduce If the also of been patients,

the prevaa benefit

uncertain.

therefore lence

malnutrition percentage

when considerable

patients the

biochemical-anthropometric jects. Nutritional status (aged

74.7

indexes were applied to healthy was assessed in 175 healthy blood in 34

in

sub- from nutritional donors instruments for (aged properly.

Walking lating

However, malnutrition Risk various (23,

current assessed calcupostwas in indexes 50

44.2
3.6

13.4
y)

y) and
participating

highly
the

fit elderly
Nijmegen

volunteers
Four Days

the

The Nutritional association complications by selected of comparing for selected these

Index was nutritional 24). The

by with Index indexes same in

Downloaded from www.ajcn.org by guest on May 14, 2011

March. albumin) Index thyretin, weight)].

We + [20.68 g/L) We

investigated (41.7
-

both present/usual X albumin,

the

Nutritional weight)] g/L) (19.21 lO6IL) 52-64%

Risk and X

Index the serum

[(1.489 Maastricht trans-

operative X developed patients

x
(0.24

objective nutrition elective have for indexes

nutritional minor been

parenteral

(1.86 found

X lymphocytes, previously that

(0.04 X ideal of nonsurgical

in 38 patients hos-(25). Neither In subjects. lence of

procedures healthy in prevanonfalsethe in been

pitalized patients the present study, nutrition according ing to the Maastricht tion in the elderly The rate of < 70 Index; those aged Maastricht a clinically because percentage the

were malnourished 1.9% of the 209 to the Index. volunteers Nutritional

according volunteers Risk

to these indexes. had apparent malIndex and 3.8%

We were protein-energy hospitalized

concerned about malnutrition patients We could therefore

whether that we originate

the high observed from

accord- surgical

The prevalence was 5.9% and diagnoses

false-positive

of apparent malnutri- positive misclassification. 20.6%, respectively. prevalence of apparent was acceptably low whom in the prevalence Risk indexes Index will of and the low. not cause The highSUBJECTS the use of Subjects Nutr The from study the 175 an are at healthy, checkup, AND

investigated

malnutrition in a healthy population, of true malnutrition should have

y with both the Nutritional therefore, the use of these increase in the are not malnourished malnutrition in the to subjects aged 70 y. <

significant patients who of spurious Index

prevalence

malnutrition METHODS

are included. elderly limits Am J C/in

Maastricht

1997;65: 172 1-5. KEY WORDS Nutritional status, validation, biochemistry, Index,

was Committee blood blood

performed for donors donors

after Ethics and give 34

permission and blood Research healthy at

had in elderly least

been people. once or

obtained We In the twice a

Humans.

selected Nu-Netherlands malnu- year as donors checkups pletely

anthropometry, nutritional indexes, trition Index, elderly, Maastricht trition, transthyretin, prealbumin,

Nutritional Risk Index, protein-energy humans

act of charity registered regular according and

without financial and receive medical Only to free their of active volunteers most

compensation. All and laboratory who recent were medical diseases cornand were

intervals.

INTRODUCTION Various energy studies 23% to previous prevalence Index and the Maastricht by workers methods have in been developed to assess

laboratory

or chronic

malnutrition the observed 62%, study of 64% in

similarly named this paper. In

Am J Clin

proteinI From the Departments of Gastrointestinal and Liver Diseases. Clinical 20 published Chemistry, and Physiology, University Hospital Nijmegen, Netherlands: of varied from Blood Bank, Nijmegen, Netherlands: and the Department of Human Nuwith an overall mean of 38% (Table 1). In a trition, Agricultural University Wageningen, Netherlands. in nonsurgical hospitalized patients we found a 2 Supported by Nijmegen University School of Medicine, Nijmegen, malnutrition of 52% using the Nutritional Risk Netherlands. using the Nutrition Index, otherwise known as 3 Address reprint requests to THJ Naber, Department of Gastrointestinal Index (19). The Nutrition Index was developed and Liver Diseases, University Hospital Nijmegen, Geert Groote P1cm Maastricht, Netherlands; to avoid confusion withZuid 8, 6500 HE Nijmegen, Netherlands. indexes we will call it the Maastricht Index in Received May 14, 1996. malnourished surgical patients assessed with Accepted for publication December 17. 1996. hospitalized frequency patients. malnutrition In
Printed in USA. tO 1997 American

Nutr 1997;65:172l-5.

Society

for Clinical

Nutrition

1721

1722 TABLE
Published

NABER 1
figures for the prevalence of malnutrition in random samples

ET

AL

of hospitalized Patients Surgical Postma Pettigrew McWhirter

Bistrian

patients and reference Prevalence % 23 [422]

29 [367]

TABLE 3 Indexes used volunteers

Nutritional

to determine

the nutritional

status 209 healthy of

Risk

x present > 100:

97.5-100: not

Index (23. weightlusual

24) (1.489 = weight)

serum

albumin,

g/L) + 41.7

and

Wesdorp

( 1)

Hall (2)

malnourished

et al (3) and Pennington

et al (5)

(4)

Detsky et at (6) Reilly et al (7) Buzby et al (8) Mean Geriatric Larsson et al (9)
FOllop Constans et al (10) et al ( 1 1) Caner (12)

32 33 40 44 48 41

[198]
[200]

[131] [202] [406]

mild malnourishment 83.5 to < 97.5: moderate malnourishment < 83.5: severe malnourishment Index (25) 20.68 X serum transthyretin, (0.04 X ideal weight)

62 [100]

Maastricht (19.21
-

(0.24 X serum g/L) (1.86

albumin, gIL) lymphocytes,

l06/L)

29 [500]
34 [552] 37 [324] 38 [110]

0: not malnourished > 0: malnourished

Ideal Company

Sullivan and

weight tables

was (26).

determined

by

using

Metropolitan

Life

Insurance

Mean General medicine Larsson et at (13)2 Willard et al (14)2 Coats et al (15) McWhirter and Pennington Weinsier et al (16) Robinson et al (17) Reilly et al (7)
Bistnan et al (18)

33 29 32 38 45 48 56 59
44

[382]
[200]

of

the

hospitalized 2). of used 3). two Risk

patients

whom

we

studied

previously

(19)

Downloaded from www.ajcn.org by guest on May 14, 2011

(Table Assessment We Nutritional (Table albumin weight; Index blood positive

[228]
[300]

(4)

nutritional methods Index (23, and to

status determine 24) Risk and the Index present nutritional Maastricht is based compared status: Index the (25)

[134]
[1001

[365]
[251]

The Nutritional concentrations

on serum with usual

Mean
I
2

44 were also surgical patients.

in brackets. Part of the sample

a value uses serum

100 indicates malnutrition. albumin, serum transthyretin

The Maastricht (prealbumin), ideal ideal weight; Life Insurweight and Tools, was the (26). height New weight in blood before 12.8 kg, of all (Solingen, a

lymphocyte count, and percentage of value indicates malnutrition. Metropolitan to determine with a

selected 13.4 4.1. In blood the y and

for

this their

study. body

Their mass persons index

mean (BMI: 70

SD)

age

was was

44.2 25.6 from

in kg/rn2) y are excluded elderly

ance Company tables were used Current weight was determined Germany) or a Seca (Hamburg, with a Seca CT). or Stanley usual 04-1 weight The by the status; with the

Krupps

Germany) 16 microtoise for blood

balance, (Stanley donors

Netherlands We the in 4

aged

donorship.

therefore Nijmegen volunteers 2). disease, persons. SD) age

approached

people

had completed a sports event each suffering including subjects 24. 1 day for from

1993 which dTable (

Four Days walk 30 excluded thereby The of 74.7 of subjects

Walking km19 miles) the 34

Britain, whoregistered March, nutritional subjects risk

blood bank 6 mo before the usual weight was also The by (75.0 weight the 12.2 recorded similar blood and

the assessment ascertained by 75.4 the bank 6 mo

a questionnaire. weight were

reported

We

elderly persons reducing remaining 3.6

a chronic (

donors and of the assessment

malnourished had a mean 2.3. The age

distribution

elderly respectively). y and a BMI of Laboratory was similar to that

methods concentrations posture (27). subjects in patients in and other Therefore, our clinical analyses are blood sampling position study and in influwas most

TABLE 2 Characteristics of 209 healthy Dutch prevalence of apparent malnutrition Age ran ge (y) Number women of Number men

Blood albumin enced by body volunteers investigated for the performed to that hospitals 2 wk ing on with used

in a semirecumbent people blood was Four Days Walking exclude and to train were on

identical

of

Height
cm

Weight
kg 74.7 12.2

(22). In the elderly after the Nijmegen 5 were

drawn before or March. Trainel-

was performed blood albumin

h/wk. To concentrations asked not

influences of training other analyses, the for2 d before determined by blood spectro-

21-29 30-39 4()-49 50-59 60-69

>

18

17

176 8.5

17
17 19

18
18 16

173 9.6 172 8.4

1698.1

73.1 12.3 77.0 15

79.2 11.8

derly volunteers sampling. Serum albumin

concentrations

16
11

21
21

69

Total 5 SD.

98

111

1699.3 168 8.2 171.2 8.7

74.3

11.4

photometry with bromcresol green lyzer (Hitachi, Tokyo), transthyretin on a Cobas Switzerland)
(DAKO,

a BMlHitachi 747 by immunonephelometry Roche,

ana-

69.1 10.4

74.6 12.2

Fara using

II analyzer (Hoffmann-La a rabbit antihuman transthyretin Transthyretin was

Basel, antiserum against

Copenhagen).

calibrated

SPECIFICITY
+
++ + ++++ +

OF

INDEXES

OF

MALNUTRITION 5

I723

120 x

:l:+++++
++

#
No 110

++

+c+*+4:4.4t*f+
++ +
++

+4
+++++,.

Yes
+

+ ++
+

++9+

+
.

a) V
C
Co

+.i.1:+++++ ?

+r+.,

++

+ ++s. r*4.+

:+4+++
++

iii____ 100
90 Moderate

x a) V
C

S
+

+
+

cc
C 0

No

-C
C-)

-5
*9+ ++

C,)

++

++

80

Severe 70

-10

5
0

1
-15

20
Malnourishment

30

20 30 40 50 60 70 80

40

50

60

70

80

Malnourishment

120

110
>C

++
V

Yes 0

Downloaded from www.ajcn.org by guest on May 14, 2011

0)
V C
Cl)

Not

iii-_

100

x a)
C

cc
90 C 0 Moderate

-C
C) CO

Not

-2

.4

80

Severe

70. 5 0
21.29

-6

I I
30-39

I I
40-49

I I
50-59 60-69

I I
>69

II
FIGURE Index apparently age category from different

-8
21-29 Malnourishment 30-39 40-49 Age Maastricht and in 209 age category apparently 21-29 Index healthy P y, 0.05. < (y) values by age Index (top) 209 in values *Significantly by 50-59 60-69 >69

Malnourishment
FIGURE apparently values nificantly by age 1.Individual healthy category from different Nutritional subjects (bottom) the age and

Age (y)
Risk mean Index ( values SD) by age Nutritional (top)209 in Risk

2. Individual healthy (bottom) the subjects

mean SD) Maastricht ( subjects.

209 in

apparently

category

healthy subjects. 21-29 P < 0.05. y,

*Sig

RESULTS
CRM

(Certified serum The an total automatic of

Reference the number cell Kobe, International of

Material)-470 Federation blood lymphocytes (Sysmex NE

international of was 8000;

ence
istry.

Clinical

referThe Chem- sample determined classified TOA Med- Nutritional three

mean was as of the

( mildly Risk four

SD) Index: were

Nutritional 4.9. Four two aged> 50 1 .9% were malnourished

Risk of the

Index 209 and

value

for

the to of

total were the and 3.8%). shown

1 1. 1

volunteers according two the 95% by age women, Cl: are percentage

(97.5-100) men y. The apparent

with ical

counter Japan).

Electronics,

Statistics We made prevalence malnourished

percentage
CI

malnutrition Mean ( the assumption of malnutrition persons that the was proportion in misclassified. malnourished where SD(p) proportion 1.96. For the
=

was thus SD) Nutritional

(upper limit of Risk Index values

that in a healthy population the is 0%. The observed percentage our sample The was J[p(l therefore upper limit calculated
-

for

in Figure 1. Three of the subjects were classified as malnourtrue ished because of a minor decrease in serum albumin. However, of the weight of these three persons was 100% > of their usual equaled the weight. Their present weight was 171 .2 8.7 kg (Table 2): in of the 95% 52% of the subjects it was lower and in 48% it was higher than as follows: their usual weight. One male weighed 87% of his usual weight (1) is the elderly and Risk ideal was classified as malnourished his to according to the Nutritional than his Cornas The an Index; weight nevertheless, according actual weight Metropolitan the fourth Nutritional of 60-69 ages 21-29 was higher Life Insurance

p + Z0 X SD(p),
where sample subjects, samples program p is size, 95% (28). SAS the and CIs All (29). observed

p)/n]

malnourished, n subgroup

of

were calculated calculations were

by using tables made with the

pany tables (26). This for smallmalnourished according statistical outcome for the age significantly lower

person was to the categories that for

one categorized Risk Index. y > and 69 y was y, indicating

than

1724 increased apparent risk of at a higher in the blood the 95% CI: age. The mean

NABER prevalence

ET

AL apparent could in be frequency prevalence considerable. between of This the malnutrition is illustrated two indexes. in healthy by the The voldisless

Therefore, of unteers y was crepancy to 6%

apparent malnutrition 1. 1% (upper limit (upper were between The -3.63 of the limit of aged > 69

donors 2.7%),

aged 21-69 as opposed elderly were the or total 4.3%

the 95% CI: 20%) in the y. No significant differences Index 2). were Index; 2). The Nine value classified for as

hikers observed sample (upper

favorable values seen who jects might suggest despite nourished was our various individuals.

in our otherwise that some of precautions It could to also

highly fit elderly subthem were malnourished avoid suggest the selection that the of risk malof a of

sexes. mean Maastricht 95% 2.25 CI: (Figure 7.0%),

subjects,

malnourished

limit misdiagnosis accord- On the basis

of malnutrition of the Nutritional in an Index These of

is appreciable Risk Index,

in elderly patients. the percentage aged 20%;

ing to the Maastricht aged > 60 y (Figure according tors in this index compared indicating higher (upper competitors significant age. limit all to the cases. was with a The of

seven were males and reasons for apparent were higher category of 1 .2%) spurious blood in the and in the a combination (ie, poorer) 60-69 of

malnutrition all nine wereapparent 70 y was 6% with malnutrition of score y y, was 38%). using the facthe 95% for clinical againelderly at a apatient 1.1%which The Maastricht CI of 38%. significance subjects. A to receive is expensive two elderly

our highly upper limit it was figures

fit elderly subjects of the 95% CI of

Maastricht Index A significantly seen the in the reference probability prevalence 95% CI: age age

21% with an upper limit raise questions about indexes when applied malnutrition or parenteral complications. as malnourished classified false-positive malnourCoop-

of the to

categories

y> and 69 21-29 malnutrition donors elderly CI:

nutritional of enteral induce categorized Index the

higher mean the

false diagnosis unnecessary and could volunteers

could cause nutrition, on as

walking

it was 20.6% (upper limit of the 95% differences were seen between sexes.

the basis of the Nutritional Risk No mildly malnourished. Obviously, diagnosis is highest ished. The Veterans

were both risk of a as

in subjects classified Affairs Total Parenteral showed in such that penoperative mildly

mildly Nutrition

Downloaded from www.ajcn.org by guest on May 14, 2011

DISCUSSION We sess found clinical however, subjects We was were applied clinical that the two malnutrition rate of of that the biochemical-anthropometric in two apparent groups malnutrition indexes of healthy was low aged active to subjects and < as-

erative trition

Study was

Group ineffective

parenteral patients,

nu-

malnourished

significance 6-21% were assumed

in the group of subjects our group of highly fit, as malnourished. were process laboratory with blood of charity. a regular basis was not It is basis can be of their well of not by volunteers the and

and was effective only in more severely malnourished patients (21). Therefore, the consequence of misclassification of elderly and patients with this index is limited. The Maastricht Index does of no grades of malnutrition and use of this index in 70 not y; include elderly elderly treated patients mistakenly subjects results resulted for in our indicate as except in 21 % of the elderly malnutrition. However, study that the precludes high definitive proportion is when not elderly of due patients the being number conclusions. hospitalized to patients U thank Conic
assay.

classified because of a medical the

of

malnourished. which the examination

plausible selected:

This elderly Our volunteers

no abnormalities, excluded. In donorship socially normal elderly that jects habits, protein cerning diseases tion group cally of in is well body

and volunteers Netherlands an on BMI act had the

chronic donors The income, BMI.

diseases are unpaid, volunteers and In that status, with our different

diagnosed showed patients weremisclassification, involved. and were were of We

malnourished possibly

positive are

seen as adjusted, weight

de Kat

Angelino

for

developing

and

performing

the

transthyretin

group from

of

volunteers,

significantly known health

younger volunteers. not selected on the or lifestyle factors (30) and malnutrition were not malnourished micronutrients. in elderly excluded. elderly

elderly subREFERENCES nutritional regard studies conwith chronic the proporThe

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malnourished previous subjects excluded was 10% <

In most persons, If they persons were

(31).

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volunteers included in their average nutrient

the

One indexes calibrated tion, so

yield normal the outcome

in a normal to normal that are used not calibrated be the

the coefficients value of each

and constants index are fixed

The published reference ranges outcome of the index could be constants used are inappropriate

could erroneous for

inapplicable, if the coefficients population

and

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SPECIFICITY
nostic nutritional index in gastrointestinal surgery.

OF
Am

INDEXES
I Surg

OF

MALNUTRITION support. Nutrition nutrition

Rouflart

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than

their

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