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  8. How to assess nutritional state

How to assess nutritional state

This section provides structured guidance on how to do a brief but effective nutritional assessment for malnutrition and obesity (metabolic syndrome risk). We encourage you to follow and use locally developed and agreed guidance and pathways for identifying and managing malnutrition. This should include advice on when to refer to a dietitian for detailed nutritional assessment.

Assessment should establish the causes and duration of any nutritional issues.

In the first instance, we advise you to use the Patients Association Nutrition Checklist [PDF]. Note that section B can be adapted for local use and section A is already validated.

For a comprehensive assessment as well as for monitoring progress, you can follow the ABCDEF process (Anthropometric, Biochemical, Clinical, Dietary Information, Economic and social status, Function) adapted for COVID-19 recovery here. It includes a list of factors to consider when assessing patients and tools or techniques to assess these. Some techniques require training to be undertaken reliably.

ABCDEF assessment

Anthropometric

Neuro-inflammatory responses can perpetuate inflammation and wasting, as well as weight loss in vulnerable populations. Regain of weight needs to be monitored through body composition assessment using anthropometric measurements (Di Filippo et al., 2021). Anthropometry is one technique to help identify loss of muscle and/or strength, changes in body size and composition.

  • Calculate per cent weight loss over time, usually the last 3-6 months if you have a previous weight - use the online Malnutrition Universal Screening Tool calculator or weight loss score charts [PDF]
  • Measure height and weight to calculate body mass index (BMI)
  • Mid upper arm circumference (MUAC) (Lawrence et al., 2021) indicates overall body size and is useful if you cannot weigh the patient. It can also be used as a surrogate measure for BMI. Information on how to measure MUAC [PDF] is available through BAPEN
    • MUAC of less than 23.5cms suggests a BMI less than 20kg/m2
    • MUAC of more than 32.0cm suggests a BMI of more than 30kg/m2 (obesity)
  • Hand grip strength (you will need a dynamometer) will indicate muscle strength. It is quick and easy to do with a dynamometer and can be repeated easily over time to monitor changes. Regaining any lost muscle strength is important for recovery and function
  • The six-minute walk test (Barazzoni et al., 2020; Cawood et al., 2020) is an alternative method to hand grip strength to judge physical abilities or performance. It is particularly useful in those with respiratory illnesses and helps determine the degree of functional impairment (Matos Casano, Ahmed and Anjum, 2025)
  • Triceps skin-fold thickness (TSF) and arm muscle circumference (AMC) indicate levels of fat and muscle, but these are specialist measures only

Biochemical

Biochemistry is vital for nutritional care during critical illness and helpful for some people with chronic illnesses. A dietitian is trained to identify the types of blood tests needed to help in nutritional assessment.

  • Despite an ongoing narrative around albumin and nutritional state, serum albumin and prealbumin levels are not indicators of nutritional state (Evans et al. 2020)
    • Albumin and prealbumin in chronic and critical illness are significantly affected by inflammatory processes
    • Raised inflammatory markers such as C-reactive protein (CRP) are associated with reduced albumin and pre-albumin levels. This is because of the hepatic reprioritisation of protein synthesis during critical and chronic illness and increased permeability of capillaries, resulting in redistribution of serum proteins (Evans et al. 2020)
  • Assessment for anaemia, which may be nutrition-related, can be made through various biochemical tests, including full blood count, which includes haemoglobin, ferritin, iron, B12 and folate levels
  • Urea and electrolyte levels can be helpful in assessing hydration and renal function
  • Blood tests for some micronutrients are possible. However, such tests only provide serum levels of the micronutrient and do not reflect total body levels, are expensive and not routinely indicated in most patients at risk of malnutrition

Clinical

There is a range of factors to consider, including:

  • Post-hospitalisation significant gastrointestinal symptoms (vomiting, gastric retention, diarrhoea, abdominal distention, and hyperglycaemia)
  • Presence of PICS (post-intensive care syndrome)
  • Hyper-inflammation 
  • Frailty and weight management issues, soft tissue pressure sores, cognitive decline, depressive symptoms and dependency care, delirium, breathlessness (Lawrence et al., 2021)
  • Fatigue is a key symptom of COVID-19 and can be assessed using the Analogue Scale of Fatigue (for 18-55 year olds) [PDF]
  • There are some tests that can be conducted with patients or by themselves to assess their taste or smell loss guided by scientific research and best practice 

Dietary

  • Food intake (measured using food and fluid charts, food frequency, diet history, recalls) (Barazzoni et al., 2020; Cawood et al., 2020)
  • Reduced desire to eat and appetite (Barazzoni et al., 2020; Cawood et al., 2020)
  • Other symptoms to ask about include: anosmia, diarrhoea, nausea, and vomiting. Address swallowing issues and dysphagia (which can appear after the infection and last for 21 days–4 months) (Lawrence et al., 2021). These can be assessed using the Eating Assessment Tool (EAT-10). Available to view and download from the Melbourne Ent Group [PDF]
  • There is a list of procedures utilised by the multidisciplinary team when assessing dysphagia that have been categorised according to their risk of COVID-19 transmission in Miles et al., 2020. Other considerations for the use of telehealth when assessing and monitoring dysphagia have been proposed (Miles et al., 2020)
  • Check compliance with any dietary advice received (Malnutrition Pathway, 2020)

Economic and Social

Function