Protein calorie malnutrition increases morbidity and mortality risk in patients. For this reason, assessment of nutritional status is an important component of good medical care. Unfortunately, assessing patient nutritional status is difficult, and many techniques have been used with varying degrees of success. The available methods of nutritional assessment and their shortcomings are anthropometric measurements, which only provide a snapshot in time and do not predict the future plasma protein measurements which are altered by non nutritional factors such as inflammation, clinical methods, such as nutritional Risk Screening, or NRS, and the mini nutritional assessment. These methods depend upon body mass index, exact weight changes, or percentage changes in food intake, since BMI has not been shown to correlate with that outcome these methods are unreliable. The objectives for this instructional video are first to explain the value of a composite approach to nutritional assessment, in which trends rather than exact figures are used to evaluate status.

It is called subjective global assessment or SGA. Second to provide instruction on the proper procedure for conducting SGA SGA fulfills the requirements of a desirable system of nutritional assessment in that it is able to identify malnutrition, distinguish it from a disease state, predict outcome and identify patients in whom nutritional therapy will alter outcome. subjective global assessment was developed at the University of Toronto by Dr. Khurshid, Gigi boy in an effort to improve upon current methods of nutritional assessment This procedure is easy to learn and simple to implement. SGA requires no additional laboratory testing or capital outlay. SGA has been validated in a variety of settings internationally and in a variety of patient populations, including patients with HIV, cancer, cardiac disease, chronic renal insufficiency in the elderly and in children. The results of SGA have been found to be highly predictive of nutritional status.

In the German hospital nutrition study published in 2016 SGA identified patients with a longer hospital stay whereas BMI was not predictive. subjective global assessment has been validated to correlate strongly with outcome in a 2005 study conducted in India using SGA as a screening tool. The SGA score was strongly correlated to 30 day mortality, adverse events, prolonged length of stay, and other outcome measures in a population in which exact weight changes could not be obtained. SGA basis its evaluation of nutritional status on clinical criteria, routine history and physical examination. SGA classifies patients as a well nourished, be mildly malnourished or suspected of malnutrition, which is indicated by signs that reflect a progression of nutrition deterioration and see severely malnourished, which is characterized by the presence of progressive nutrition related symptoms and evidence of wasting the first SGA component the medical history involves asking questions and evaluating the patient's responses in four areas.

Weight change dietary intake, gastrointestinal symptoms and functional impairment. The first question is what is the patient's weight change over the past six months. Examining the degree of weight change over this time period alerts the assessor to the potential severity of the clinical situation. Most patients will be unable to identify the percent of weight loss that they have experienced. However, they usually know if they are wasting that is losing muscle mass or subcutaneous fat. Record the patient's weight loss on the SGA form.

Try to determine the extent of the patient's weight loss. If the percentage weight change is known, then a 5% or less weight decline reflects a normal weight fluctuation of five to 10% loss is considered potentially significant. Losing 10% or more of one's body weight is considered a significant loss and places the patient in the malnourished category. If the patient does not know the percent weight loss, the clinician should compare the patient's measured weight at the time of the examination to the patient's last documented weight for estimated gain or loss. A continuous weight is significant. In contrast, weight stability after weight loss suggests a milder degree of malnutrition.

The pattern of weight loss is also very important. Ask the patient how weight has changed over the past two weeks. Record the patient's weight change over the past two weeks on the SGA form. If the patient has gained weight in the past two weeks, the patient could be rated in the nourished category, even if he or she has experienced a significant weight loss over the preceding six months. If the patient's weight has stabilized over the past two weeks, the changes are equivocal. If the patient experienced continuing wasting or weight loss over the past two weeks, he or she is at ongoing risk for malnutrition.

The second question is has the patient's dietary intake changed? The patient's dietary intake is classified into one of four categories normal, reduced intake, sub optimal solid or liquid diet, and the most severe category, very poor intake or starvation. A change in diet and whether or not it persists suggests the likelihood of subsequent change in nutritional status. Ask the patient whether his or her appetite or food intake is the same as it was six months ago. If either appetite or intake has changed. Ask how it is also asked how long the change has been present.

If the change is recent, documented on the chart for follow up investigation later. Next, record how the diet has changed. reduction in quality and variety of food or low intake diets lasting for weeks, placed the patient at risk for malnutrition. Ask the patient if he or she has been placed on a new diet from another healthcare professional. If there is a new diet, it should be evaluated to ensure nutritional requirements are met. The third question assesses the presence of persistent gi symptoms.

A persistent gi symptoms are defined as those experienced on a daily basis for longer than two weeks. Short term or intermittent symptoms are not considered in SGA. The type and severity of gastrointestinal symptoms will dictate Turman how long the individuals inability to eat will continue. Patients with significant and persistent gi symptoms will be at increased risk without nutrition therapy. Record the patient's gi symptoms on the SGA form. The most important symptoms to consider are pain on eating, nausea, vomiting, and diarrhea, because they significantly affect the amount of nutrients ingested and retained for utilization by the body.

The more persistent and severe the symptoms, the more likely it is that the patient is or will become severely malnourished. Question four rates the patient's functional impairment. Nutritional deficits and underlying disease can both cause fatigue and progressive loss of function, even before weight loss or physical signs of wasting the change in functional capacity It alerts the clinician to both subclinical and progressive compromised in nutritional status. When evaluating a patient using SGA consider only the loss of functional capacity related to malnutrition. The duration of the functional incapacity, if any should be noted, greet the patient in one of three categories. They are in increasing severity as follows normal, reduce capacity and unable to work.

Note whether or not the patient is ambulatory or bedridden, and record all answers. The isolated loss of muscle strength such as difficulty and rising from a sitting position may indicate moderate or severe malnutrition, but it should be distinguished from muscle disused a common problem in elderly patients. Other causes of activity dysfunction should not be considered evidence of malnutrition. For instance, a diabetic whose fingers have been amputated has activity dysfunction. However, this would not affect the SGA score, because the dysfunction is related to a disease entity itself and not to malnutrition. After the history is complete, the healthcare professional conducts a physical examination of the patient.

While conducting the physical exam, obtain a global perspective of the patient's physical condition. clinical signs to watch for include loss of subcutaneous fat, muscle wasting, a deema, and a slight ease. Examine areas for subcutaneous fat loss. The fewer reserves of fat, the greater the likelihood of a poor outcome due to malnutrition. subcutaneous fat loss can be seen as a loss of fullness in an area or skin fitting lose sleep over the deeper tissues. A prime area to look for subcutaneous fat loss is over the biceps and under the triceps.

Using the skinfold measurement technique, pinch the areas below the triceps or above the biceps. If fingers meet when the skinfold is pinched, the loss is severe. Once you have completed the physical assessment for subcutaneous fat loss, the clinician places the patient in one of three categories. No loss, yes, some loss or severe loss. Examine several muscle groups for muscle wasting. The greater the loss of muscle The higher the likelihood of a poor outcome.

Prominent bone structure and flat or hollow areas suggests muscle wasting. muscle wasting is often best visualized In the muscles of the upper body, peripheral muscles of the upper body are not examined in SGA. Following up the temporalis muscle near the temple is an optimal location to examine for muscle wasting. Look along the line of the clavicle. The smaller the muscle mass, the more prominent the bone. Examine the shoulder for squaring as a sign of malnutrition.

Rather than the round look of normal patients. The ribs should be examined. They are visible in malnourished patients. lower body muscle groups for instance, the quadriceps and the muscles around the knee and the calf should not be examined as part of SGA. These muscle groups are not specific indicators for malnutrition, because wasting can occur due to muscle inactivity. Once you have completed the physical assessment for muscle, wasting the condition places the patient in one of three categories.

No wasting, yes some wasting or severe wasting. malnutrition may give rise to a Dema. Loss of fluid from the intravascular into the extra vascular space is manifested as a deema. This can be best assessed in the sacrum and ankles. Record your findings in one of three categories, no edema, yes, some edema, or severe edema. apply these can arise from malnutrition.

This occurs because of abnormal physiologic pressure relationships and fluid dynamics within the abdominal cavity, resulting in an abnormal collection of fluid within the abdominal cavity. If a patient exhibits society's clinicians must ensure that the excess fluid weight is not incorporated into the weight measurement, since that will overstate the patient's true body weight placed the patient in one of three categories, no societies, yes some societies or severe societies. On the basis of these findings, the clinic observer assigns an SGA rating which corresponds to his or her subjective opinion of the patient's nutritional status. The rating is a composite of the medical history and the physical assessment, which when compiled predicts risk of mild or progressive malnutrition. The severely malnourished rating is given whenever a patient has a high risk medical history, such as low intake or gastrointestinal problems that hamper nutrient utilization, physical signs of malnutrition, such as severe loss of sub Qt taneous fat, or muscle wasting may or may not be evident.

Severely malnourished patients will be ranked in the malnourished or severe categories in most sections of the SGA form. mildly or moderately malnourished patients may have a ranking in all rating categories. This can make the category be patients more difficult to classify. If the severe rating is not clearly indicated, assign the patient to the moderate malnutrition classification. If there is weight stability, minimal but some gastrointestinal symptoms or restricted but not markedly reduced intake. A patient with obvious physical signs of malnutrition should be rated as mild or moderate malnutrition or SGA classification be if the patient has no dietary difficulties, Or gi symptoms, which might predispose to malnutrition, and no physical signs of malnutrition.

The patient should be assigned to the well nourished or a category. If a malnourished patients appetite shows marked improvement, and the patient has recently gained weight, he or she may be assessed the a rating despite previous loss of fat and muscle. Now, let's examine several patients using the subjective global assessment technique. Let's start with a severely malnourished patient. This patient is considered a severely malnourished patient or category C. A review of this severely malnourished patients history provides the following clinical presentation. This patient has suffered from severe muscle wasting and subcutaneous fat loss over the past six months.

He currently weighs about 41 kilograms, which is significantly below his weight only six months ago. Record the patient's weight on the form. Place a check in the yes box for weight loss over the past six months. Since we do not know the actual weight loss or the percent of weight loss, leave these areas of the form blank. The patient reports his weight has continued to decrease over the last two weeks suggestive of continuing deterioration of his nutritional status. Place a checkmark in the continued last box.

Next, evaluate the patient's dietary intake. It has changed during the past four weeks shifting to a sub optimal solid diet. Check the box titled semi solid or liquid diet on the SGA form. The patient indicates that he is experienced Seeing nausea and diarrhea persistently. Since these gi symptoms occur multiple times during the day, place a check in the severe category for these two symptoms. Check the no box for pain on eating and vomiting.

Asking the patient about his activity level reveals that he is able to sit up and stand but can only walk a short distance. record this activity as reduced capacity and also as ambulatory on the SGA form. Start the physical exam by assessing the patient's fat stores to determine the degree of fat stores, then the patient's arm and pinch the patient's skin where the triceps are located. Be careful not to pinch the muscle mass since you are trying to determine the amount of fat stores directly underneath the skin. If you can feel Your fingers touching there is little or no fat stored. Examine the biceps.

Pinching this patient's skin reveals that there is only a small amount of fat stores remaining. In this case, the fingers are not touching. Although you can see there is very little space between the fingers, indicating severe loss of fat stores. After you have completed your examination of these areas, evaluate your impressions and rate the patient's degree of subcutaneous fat loss. This patient shows signs of severe subcutaneous fat loss. Place a checkmark in the severe subcutaneous fat loss box.

The next step of the SGA physical assessment is to examine the patient's muscle mass for signs of wasting. Examine the temple nor The temporalis muscle prominently extends along this area. If the area appears flat, there is no evidence of muscle wasting. This patient actually has the depression. Notice the prominent temporal bone. In this patient, the clavicle is quite prominent, indicative of severe muscle loss.

To examine the shoulders, position the patient's arms down at his sides. Normal shoulders are curved, especially at the shoulder joint. This patient's shoulders aren't quite squared. squared shoulders are assigned often observed in severely malnourished patients. Notice that the acromion protrusion is quite prominent. Notice how prominent the ribs of this patient are a sign of severe muscle wasting.

Now evaluate yourself pression and rate the patient's degree of muscle wasting. This patient shows signs of severe muscle wasting. Place a checkmark in the severe muscle wasting category on the FDA form. The next step of the SGA physical examination is to look for signs of edema. An easy area to examine is the patient's ankle. Pressing the patient's ankle shows this patient has no sign of ankle edema.

Record this finding as no edema on the SGA form. Examine the patient for signs of societies. This patient shows no sign of society. record this finding as no societies because this patient's medical history shows a progression of signs that lead to malnutrition and a physical exam. A nation showing substantial muscle wasting and subcutaneous fat loss. He would be rated a category c severely malnourished.

Next, let's examine a patient who is a category A well nourished. This patient has not experienced any weight loss over the past six months. Mark no on the form for both weight loss over the past six months, and weight change. dietary intake has been sufficient and remain stable, which should be recorded as normal intake. She has experienced no gi symptoms recorded as no for each of the four categories. She actively participates in daily activities, which should be recorded as normal.

Assess the patient's degree of subcutaneous fat loss. A pinch of the skin near her triceps and biceps reveals normal amount of subcutaneous fat. You can rate this patient's degree of subcutaneous fat stores, as no examination of the temple shows no sign of wasting. There is no depression between the hairline and the eye socket. The clavicle can be seen as is common with females, but does not protrude. This patient's shoulders are well rounded.

There is a normal amount of muscle tissue at the shoulder joint. The ribs cannot be seen. examination of these key parameters of muscle wasting indicate this patient's muscle mass is normal. record her muscle wasting as No. examination of the ankle reveals no signs of edema records record this finding as no on the SGA score sheet. Because the patient's medical history suggests no predisposition to malnutrition, and her examination indicates no wasting or other physical signs of malnutrition.

This patient is classified as a category A well nourished, moderately malnourished patients are often the most difficult patients to classify. However, inconsistent results are typical of mildly or moderately malnourished patients. Therefore, if a patient is not clearly well nourished or severely malnourished, he or she probably is a moderately malnourished patient. We will examine two different patients, each of whom would be classified as moderately malnourished. Although this patient does not appear wasted, he reports having lost approximately nine kilograms over the past six months, which represents Almost 9% of his current body weight. While some of this weight loss may have been desirable, record weight loss over the past six months as Yes, record the patient's weight loss and the percentage weight loss on the SGA form.

He has continued to lose weight over the past two weeks. Although he does not think he's losing weight as quickly as before record a yes in the weight change category. The patient's dietary intake has changed during this time, and he is currently consuming a sub optimal solid diet. This should be marked as semi solid or liquid diet on the SGA form. The patient has experienced mild diarrhea and nausea please a yes for these symptoms and a no for the other symptoms. The patient reports no physical impairments except he becomes more Easily tired when performing his normal daily activities.

This should be classified as reduced capacity and ambulatory on the SGA form. Start the physical examination for loss of subcutaneous fat. When pinching the upper arms, the fingers never touch, exhibiting significant subcutaneous fat surrounding both the triceps and biceps. Since this patient exhibits no signs of subcutaneous fat loss, a checkmark should be placed in the no box. An examination of the temple shows a slight depression where the temporalis muscle is located. The degree of muscle wasting his flight but definite, the patient's clavicle is not readily apparent, indicating that there is no muscle loss in this area.

The shoulders appear to be well rounded And the shoulder joint contains appropriate muscle mass. The ribs cannot be seen a sign that there is no muscle wasting in this area. There is little evidence of muscle wasting in most areas, but there is evidence in one area. muscle loss should be recorded as yes on the SGA form. examination of the ankle shows no signs of edema. record this finding as no on the SGA score sheet.

Examine the patient for signs of asylees this patient shows no sign of a sighting. record this finding as No. This patient's assessment pattern is ambiguous. The medical history is highly suggestive of malnutrition. Therefore, despite the near absence of physical signs, this patient is classified as a moderately malnourished patient. Category B.

The second moderately malnourished patient has lost a noticeable amount of weight over the past six months a yes rating. This patient reports that over the past two weeks, she has continued to lose weight. So the weight change field should be marked as a yes. Her dietary intake has declined which should be marked on the SGA form as reduced intake. She has no gi symptoms and a normal functional capacity. record these findings on the SGA form.

When assessing her triceps for subcutaneous fat loss, the fingers never touch. The biceps have much smaller amounts of fat, a possible sign of malnutrition. Since this patient shows signs of subcutaneous fat loss in one area, a checkmark should be placed in the yes box, even though fat loss is not evident in other areas. An examination of the temple shows that this patient has a deep depression of the temporalis muscle. The patient's clavicle is readily apparent, indicating that there is some muscle loss in this area. The shoulders appear to be rounded except one a chromium protrusion is prominent, indicating a lack of muscle bulk.

There are two slight depressions around the ribs, a sign of muscle wasting. Most of the muscle groups examined here show evidence of muscle wasting. Therefore the patient's muscle wasting should be classified as Yes. examination of this patient's ankle shows no signs of edema. record this finding as no on the SGA score sheet. As with the previous patient, a review of the SGA Form shows inconsistent ratings.

For this reason the patient is classified as a moderately malnourished patient for Category B. This training program is intended to provide a detailed explanation of the subjective global assessment nutritional assessment technique. Performing SGA will help you identify patients that are at risk of poor outcome because of their nutritional status. We have provided several unclassified patients on another portion of this instructional video to give you the opportunity to test your understanding of the SGA technique.