Today’s Wound Clinic (TWC): When most people hear the word “Nestlé,” they probably think of candy. Please discuss how the Nestlé Nutrition Institute (NNI) works to educate clinicians and patients about the role the company plays in promoting proper nutrition through the NNI and the Mini Nutritional Assessment (MNA®).
Nestlé Health Science (NHS): Although sometimes referred to as a “chocolate company,” Nestlé is the world’s largest food and beverage company. We are focused on enhancing lives with science-based nutrition and health solutions for all stages of life and helping consumers care for themselves and their families. In 2010, Nestlé formed NHS, which is engaged in advancing the role of therapeutic nutrition in health management. NHS plays a key role in Nestlé’s ambition to expand the boundaries of nutrition, health, and wellness. NNI shares science-based information and education with healthcare professionals, scientists, nutrition communities, and stakeholders. NNI provides the MNA and other practical tools and training materials designed to improve patient-centered healthcare, build knowledge and clinical competencies, and enable multidisciplinary healthcare professionals.
TWC: When/why was the Nestlé Nutrition Institute (NNI) founded?
NHS: The NNI was founded in 1981. The role of the NNI is to:
- contribute to proper nutrition information and education of healthcare providers;
- partner with the medical and scientific community by providing enhanced access to the latest knowledge in nutritional sciences to enable continual improvement of healthcare for people of all ages; and
- foster the communication of sound nutritional research by helping to connect the scientific community with Nestlé Research.
TWC: How does the NNI operate?
NHS: In addition to being the world’s largest private publisher of nutritional papers and journals, the NNI organizes and hosts internationally acclaimed workshops and symposia, making the findings available worldwide – often leveraging new technology. It provides continuing-education programs for a variety of healthcare professionals including doctors, nurses, and dietitians. Free access to the online educational materials is made available to those who simply register as NNI members (www.nestlenutrition-institute.org).
TWC: What are the goals associated with the NNI?
NHS: The NNI invites healthcare professionals in the area of maternal, infant, clinical, and public health nutrition to a constant exchange of knowledge and nutritional expertise. This communication initiative comprises workshops, publications, educational material, fellowships, and the professional website www.nestlenutrition-institute.org.
TWC: What are the benefits of the NNI to clinicians and their patients?
NHS: The NNI provides the latest updates in nutrition science across the lifespan via its extensive publications library, exclusive videos from leading experts in nutrition from infancy to geriatrics, continuing-education programs, and the latest updates in nutrition science, which clinicians can use in their daily practice.
NHS: The MNA is a validated nutritional screening tool specifically developed to identify individuals ages 65 and older who are malnourished or at risk of malnutrition.
TWC: When/why was the MNA founded?
NHS: The MNA was developed in 1994. It’s the most researched method of nutritional evaluation and a validated nutritional screening tool for the elderly in acute care, long-term care, and community care settings. Originally comprised of 18 questions, the MNA was revised in 2009 and now consists of six questions that streamline the screening process.1 The MNA is available in 35 languages.
TWC: How does the MNA operate?
NHS: The MNA consists of six short questions and:
- takes < 5 minutes to complete;
- is easy to administer in a variety of settings;
- requires no special training;
- requires no blood draws or labs; and
- is available in 35 languages.
TWC: What are the goals associated with the MNA?
- Target the frail, elderly, and at-risk geriatric population.
- Recognize those who are malnourished so intervention can begin immediately.
- Identify at-risk older adults before weight loss occurs and facilitate earlier intervention when response is most successful).
- Include criteria specific to issues of aging (eg, functionality, depression, dementia).
- Identify at-risk older adults before other validated nutrition screening tools do
- Identify those who may respond to treatment.
- Allow healthcare professionals to target interventions to specific causes of malnutrition as identified in the MNA.
- Detect vulnerable older adults at risk for poor outcomes.
TWC: What are the benefits to clinicians and their patients?
NHS: Malnutrition is an addressable condition that affects overall health and impacts patient outcomes. Malnutrition (as measured by the MNA) significantly increases morbidity and mortality. Studies have observed a three-fold higher risk of death among malnourished older adults in an 18-month period after hospitalization.2 Malnutrition may delay recovery (the average stay in rehabilitative care can be up to 18 days longer) and prolong hospitalization (the average period of hospital stay can be up to 14 days longer).2,3 Malnourished patients have higher risks of infection (eg, pneumonia), pressure injury development, injury-related falls, hospital admission, and disability.4-8 Untreated malnutrition poses a huge economic cost to society, and malnutrition is not limited to hospitalized patients. For those living in the community, malnutrition is a risk factor for disease, accidents, and injury. Early detection with a validated screening tool and prompt treatment are essential in preventing the consequences associated with malnutrition.
TWC: Where is the MNA utilized?
NHS: The MNA can be used in a variety of settings to detect those ages 65 and older who could benefit from early nutritional intervention. At least 16 clinical practice guidelines recommend use of the MNA. It has a practical use on admission to hospitals or nursing homes and in geriatric clinics, geriatric feeding programs, health screenings and health fairs, geriatric day programs, assisted living sites, home care, dental clinics, dialysis centers, community-based nursing programs, and physician offices. The MNA may be used to re-screen for nutritional risk every three months. The MNA does not require special training and can be completed in 3-5 minutes. The MNA is often administered by physicians, dietitians, and nurses, but it does not have to be completed by a healthcare professional.
TWC: How do clinicians utilize the MNA?
NHS: The MNA allows clinicians to characterize the degree of nutritional issues an individual may be living with to classify nutritional status as either “normal,” “at-risk,” or “malnourished.” Considering the specific items of the MNA that contributed to the individual’s risk or state of malnutrition can help clinicians design a personal nutritional care plan.
TWC: How is the MNA different from other screening tools?
NHS: The MNA remains the most widely studied, used, and accepted tool to screen the elderly for nutritional risk. It has demonstrated validity (good sensitivity and specificity compared to the “gold standard” method) in the relevant patient population.1,9 Compared to other well-known screening methods, the MNA considers some unique factors that are especially important among elderly individuals (eg, recent acute illness/major stress, low muscle mass, and/or mobility problems linked to sarcopenia or frailty risk).
TWC: What purpose does the MNA fulfill as the United States transitions to a quality-based healthcare system?
NHS: The results of cost-effectiveness studies can help decision makers determine best practices in healthcare and is of increasing interest to guide care. Several studies have demonstrated that implementation of a nutritional screening program with a tool such as the MNA for the elderly, along with targeted intervention versus conventional care, helped improve patient outcomes. In one hospital setting, early nutritional screening and intervention supported weight gain among patients (+0.9 kg vs. -0.8 kg for usual care), reduced the incidence of nosocomial infections (35% reduction), and reduced overall cost of nursing care.10 In a community care setting (observing a 12-month follow-up period), early nutritional screening and intervention supported a reduction in healthcare utilization, fewer home-nursing visits, fewer physician and physiotherapist visits, fewer hospital admissions, and shorter length of hospital stay, if hospital admission was necessary. Average medical care costs were less per patient.11 Targeting intervention with oral nutritional supplements (ONS) to those who are malnourished versus conventional care helped to improve patient outcomes:
In a rehabilitation setting, nutritional intervention among malnourished - Improved measures of physical function and walking capacity, and supported discharge to home (versus institutional care).12
Across the continuum of care, starting while in hospital and continuing as outpatient care, a 12-month multi-domain intervention supported better performance in activities of daily living, fewer nursing home admissions (reduced by 84%), and lower risk of death (reduced by 81%).13
TWC: Please discuss the protocol involved with the MNA.
NHS: An algorithm for recommendations, interventions, and practical suggestions to improve nutrition care is provided online (www.mna-elderly.com). These suggested interventions are based on the score of the MNA, which classifies the elderly as “normal nutritional status” (12-14 points), “at risk of malnutrition” (8-11 points), or “Malnourished” (1-7 points). For each category, evidence-based nutritional interventions are suggested, in line with evidence from a Cochrane systematic review.14
TWC: How does the MNA function from the time the patient presents to the provider?
NHS: A typical standard of care is for patients to be appropriately screened for nutritional risk within 48 hours of admission to an acute or long-term care setting. In the outpatient setting, patients should be screened with the MNA on their first visit and, if found to be malnourished or at risk, should be referred to a qualified nutrition professional. The MNA algorithm can help to direct the provider to appropriate nutritional interventions based on the MNA score.
TWC: What are the at-home (or self-care) functions of the MNA?
NHS: Developed in 2012, the Self-MNA is a simple tool to help older adults identify whether or not they have specific nutritional risks or issues. In one study, this new tool was scientifically validated in community-dwelling older adults.15 Older adults may access the Self-MNA on the “Forms” page of www.mna-elderly.com, complete the six questions, and share results with their doctors to help guide a discussion about nutrition and health. The Self-MNA is currently available in English, Spanish, German, Portuguese, and Finnish versions.
TWC: How long does it usually take to administer the MNA?
NHS: The MNA and Self-MNA can be completed in 3-5 minutes. In a recent study, clinicians completed MNA screening of elderly individuals in about 90 seconds (an average of 1.2 ± 0.5 minutes).16
TWC: Is any training required among healthcare staff in order to be able to administer and follow care planning through the MNA? If so, how can training be accomplished?
NHS: Use of the MNA and Self-MNA does not require specialized medical education or certification. Practical training, with supporting materials freely accessible on the MNA website (www.mna-elderly.com), may be helpful.
TWC: Please describe the educational materials available for providers through the NNI.
NHS: The following information can be found on the MNA website (www.mna-elderly.com):
An overview section includes a link to the MNA literature database, information for incorporating the MNA into electronic health records (EHRs), and a link to download the MNA app for the iPhone or iPad.
The MNA users’ guide can be found in the “Tools for Clinicians” section and provides step-by-step directions for completing the MNA. The guide includes explanations for each MNA question and suggestions for training others to use the MNA.
The MNA video demonstrates step-by-step directions for using the MNA in clinical practice and includes alternate ways to measure height using demispan, arm span, or knee height, as well as how to measure calf circumference for patients when height and weight are not available.
TWC: Where can providers access educational tools about the MNA?
NHS: Comprehensive information on the MNA and malnutrition in the elderly can be found online at www.mna-elderly.com and www.nestlenutrition-institute.org.
TWC: What is the impact of the MNA specifically as it relates to patients living with chronic wounds?
NHS: Malnutrition and low body weight are associated with chronic wounds. The MNA offers patient’s healthcare providers and patients living with chronic wounds a quick and easy way to determine if they are malnourished or at risk for malnutrition and could benefit from nutritional intervention to facilitate wound management. If the MNA identifies nutrition risk, the algorithm offers intervention options, including ONS that patients can use to increase protein and calorie intake, which are essential for wound management.
TWC: Why did NHS support a quality measure on nutritional screening of patients who are living with chronic wounds?
NHS: While numerous studies have reported associations between poor nutrition and wounds, a 2013 study showed the MNA performed better than the Braden Scale and other measures in predicting pressure injury development in the elderly.5 This study, and other evidence, led the U.S. Wound Registry (USWR) to recommend the MNA as the validated nutritional screening tool of choice for wound care. The USWR went on to develop a quality measure for nutritional screening of patients who are living with chronic wounds. As part of the development of the quality measure, the plan is for the MNA to be translated into standardized clinical terminology to allow the electronic exchange of clinical health information. This step will facilitate the incorporation of the MNA into any approved U.S. EHR and advance the goal of nutritional screening (using a validated tool) in all older adults, including those living with chronic wounds. Recognizing the gap that exists between recommendations to routinely screen all older adults for nutrition risk and actual practice, NHS provided a grant to the USWR for development of the quality measure to promote use of the MNA to increase healthcare provider awareness and treatment of poor nutritional status among at-risk older adults to improve patient outcomes.
TWC: What are the specific benefits the MNA offers to clinicians and patients in the outpatient wound clinic setting?
NHS: For clinicians, the MNA provides a simple way to report and comply with one of the 13 quality measures in the Physician Quality Reporting System (PQRS) and avoid penalties. The MNA meets the PQRS requirement for a validated nutrition screening tool* and nutritional recommendations, and it is quick and easy for staff members to use and administer. For patients, the MNA identifies malnutrition and risk for malnutrition so that interventions can be implemented earlier, when it is most effective and facilitates wound healing.
*While the MNA is specifically validated for those ages 65 and older, with clinical judgment and expertise as provided by healthcare professionals who treat patients living with wounds, the MNA may be deemed appropriate for those younger than 65 who are treated in wound care clinics. This decision was also supported by a 2013 study that showed the MNA performed better than the Braden Scale and other measures in predicting pressure injury development.5
TWC: How does the MNA specifically function in the wound clinic setting as opposed to other healthcare settings? Are there differences?
NHS: The MNA functions much the same in the wound clinic setting as in other healthcare settings. Patients should be screened for nutritional risk on admission to the wound clinic and at regular intervals. Those found to be malnourished or at risk for malnutrition should be referred to a qualified nutrition professional for a complete nutritional assessment and appropriate intervention plan. Wound clinics without a registered dietitian nutritionist (RDN) on staff may refer patients to local hospital outpatient nutrition departments or locate an RDN through the Academy of Nutrition and Dietetics (www.eatright.org/find-an-expert). Until the client sees the RDN, the MNA algorithm can guide clinicians in providing general nutritional treatment, monitoring, or rescreening recommendations. Patients at risk for malnutrition with an MNA score of 8-11 and documented weight loss should be offered interventions (eg, diet enhancement and ONS providing an additional 400 kcal/day), close weight monitoring, and a more in-depth nutritional assessment. Malnourished patients with scores of 0-7 should be offered a similar intervention, but with ONS providing 400-600 kcal/day.
TWC: Clinicians talk about “gaps in practice” for some interventions that all providers should be doing and should know to do, such as offloading a diabetic foot ulcer. What do officials associated with the NNI/MNA see as the gaps in practice that exist with regard to nutrition or nutritional assessment?
NHS: Nutrition screening is a necessary step in identifying and treating malnutrition, an under-recognized public health issue. National and international organizations recommend routine screening for vulnerable groups should be built into nutrition policies and quality programs. According to João Siffert, MD, NHS chief medical officer, “Given the high prevalence of malnutrition in the elderly, its multifactorial etiology and pathophysiology, and its high impact on various health outcomes, malnutrition should be included among the geriatric syndromes and be systematically screened at least annually.”
TWC: How does NHS help address these gaps?
NHS: NHS is part of public/private partnerships working to identify and reduce malnutrition in older adults by implementing routine nutrition risk screening, increasing public awareness, addressing health policy, improving access to quality care, and educating medical staff. The goal of the MNA is to increase healthcare provider awareness of poor nutritional status among individuals ages 65 and older and to address nutritional deficits if they exist via a simple screening tool and intervention.
- Kaiser MJ, Bauer JM, Ramsch C, et al. Validation of the mini nutritional assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging. 2009;13(9):782-8.
- Charlton K, Nichols C, Bowden S, et al. Poor nutritional status of older subacute patients predicts clinical outcomes and mortality at 18 months of follow-up. Eur J Clin Nutr. 2012;66(11):1224-8.
- Charlton KE, Nichols C, Bowden S, et al. Older rehabilitation patients are at high risk of malnutrition: evidence from a large Australian database. J Nutr Health Aging. 2010;14(8):622-8.
- Kelaiditi E, Demougeot L, Lilamand M, Guyonnet S, Vellas B, Cesari M. Nutritional status and the incidence of pneumonia in nursing home residents: results from the INCUR study. J Am Med Dir Assoc. 2014;15(8):588-92.
- Yatabe MS, Taguchi F, Ishida I, et al. Mini nutritional assessment as a useful method of predicting the development of pressure ulcers in elderly inpatients. J Am Geriatr Soc. 2013;61(10):1698-704.
- Tsai AC, Lai MY. Mini nutritional assessment and short-form mini nutritional assessment can predict the future risk of falling in older adults - results of a national cohort study. Clin Nutr. 2014;33(5):844-9.
- Luscombe-Marsh N, Chapman I, Visvanathan R. Hospital admissions in poorly nourished, compared with well-nourished, older South Australians receiving 'Meals on Wheels': findings from a pilot study. Australas J Ageing. 2014;33(3):164-9.
- Martínez-Reig M, Gómez-Arnedo L, Alfonso-Silguero SA, Juncos-Martínez G, Romero L, Abizanda P. Nutritional risk, nutritional status and incident disability in older adults. The FRADEA study. J Nutr Health Aging. 2014;18(3):270-6.
- Jones JM. The methodology of nutritional screening and assessment tools. J Hum Nutr Diet. 2002;15(1):59-71.
- Rypkema G, Adang E, Dicke H, et al. Cost-effectiveness of an interdisciplinary intervention in geriatric inpatients to prevent malnutrition. J Nutr Health Aging. 2003;8(2):122-7.
- Arnaud-Battandier F, Malvy D, Jeandel C, et al. Use of oral supplements in malnourished elderly patients living in the community: a pharmaco-economic study. Clin Nutr. 2004;23(5):1096-103.
- Rabadi MH, Coar PL, Lukin M, Lesser M, Blass JP. Intensive nutritional supplements can improve outcomes in stroke rehabilitation. Neurology. 2008;71(23):1856-61.
- Singh NA, Quine S, Clemson LM, et al. Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial. J Am Med Dir Assoc. 2012;13(1):24-30.
- Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev. 2009;(2):CD003288.
- Huhmann MB, Perez V, Alexander DD, Thomas DR. A self-completed nutrition screening tool for community-dwelling older adults with high reliability: a comparison study. J Nutr Health Aging. 2013;17(4):339-44.
- Okubo Y. Development and feasibility of the nutrition and functionality assessment (NFA) among Japanese community-dwelling older adults. Talk presented at: World Congress on Active Ageing; July 1, 2016; Melbourne, AU. Accessed online: http://wcaa2016.com.au/download/WCAA2016-program-book.pdf