Ecology of Food and Nutrition

ISSN: 0367-0244 (Print) 1543-5237 (Online) Journal homepage: http://www.tandfonline.com/loi/gefn20

Mini Nutritional Assessment (MNA) is Rather a Reliable and Valid Instrument to Assess Nutritional Status in Iranian Healthy Adults and Elderly with a Chronic Disease Ladan Ghazi, Seyed-Mohammad Fereshtehnejad, Salman Abbasi Fard, Motahhareh Sadeghi, Gholam Ali Shahidi & Johan Lökk To cite this article: Ladan Ghazi, Seyed-Mohammad Fereshtehnejad, Salman Abbasi Fard, Motahhareh Sadeghi, Gholam Ali Shahidi & Johan Lökk (2015) Mini Nutritional Assessment (MNA) is Rather a Reliable and Valid Instrument to Assess Nutritional Status in Iranian Healthy Adults and Elderly with a Chronic Disease, Ecology of Food and Nutrition, 54:4, 342-357, DOI: 10.1080/03670244.2014.994743 To link to this article: http://dx.doi.org/10.1080/03670244.2014.994743

Published online: 25 Feb 2015.

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Date: 06 November 2015, At: 18:58

Ecology of Food and Nutrition, 54:342–357, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0367-0244 print/1543-5237 online DOI: 10.1080/03670244.2014.994743

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Mini Nutritional Assessment (MNA) is Rather a Reliable and Valid Instrument to Assess Nutritional Status in Iranian Healthy Adults and Elderly with a Chronic Disease LADAN GHAZI Department of Nutrition and Dietetics, Monash University, Notting Hill, Victoria, Australia; Department of Biosciences and Nutrition, Karolinska Institutet, Stockholm, Sweden

SEYED-MOHAMMAD FERESHTEHNEJAD Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences, and Society (NVS), Karolinska Institutet, Stockholm, Sweden; Firoozgar Clinical Research Development Center (FCRDC), Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran

SALMAN ABBASI FARD Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran

MOTAHHAREH SADEGHI Student Scientific Research Committee, Tehran University of Medical Sciences, Tehran, Iran

GHOLAM ALI SHAHIDI Department of Neurology, Iran University of Medical Sciences, Tehran, Iran

JOHAN LÖKK Division of Clinical Geriatrics, Department of Neurology, Care Sciences, and Society (NVS), Karolinska Institutet, Stockholm, Sweden; Department of Geriatric Medicine, Karolinska University Hospital, Stockholm, Sweden

This study aimed to evaluate the usefulness of the Mini Nutritional Assessment (MNA) to assess nutritional status of Iranian population and to compare its psychometric properties between patients suffering from a chronic disease, healthy elderly and younger adults. As a group of elderly with a chronic disease, 143 Parkinson’s disease (PD) patients and as the control group, 467 healthy persons were enrolled. The Persian-translated version of MNA was filled-up through interviews together with anthropometric measurements. Address correspondence to Ladan Ghazi, Monash University, Level 1, 264 Ferntree Gully Road, Notting Hill, VIC 3168, Australia. E-mail: [email protected] 342

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Cronbach’s α coefficient of entire MNA was 0.66 and 0.70 in healthy individuals and PD patients, respectively. The total MNA score could significantly discriminate the ones with BMI ≥ 24kg/m2 in both groups. In general, MNA was a valid and reliable tool for nutritional assessment. We acknowledge study limitations including lack of serum measurements and a selection bias towards mild-to-moderate PD. MNA is a more reliable tool in older healthy individuals and rather younger elderly with PD. KEYWORDS elderly, Mini Nutritional nutritional status, reliability, validity

Assessment

(MNA),

Malnutrition is a condition depriving the body of an adequate amount of nutrients. It may lead to higher treatment costs, lowering quality of life and consequently increasing the risk of morbidity and mortality (Barker, Gout, and Crowe 2011). Malnutrition is a frequent and serious problem in geriatric patients. In ill elderly population, it is one of the most common and least-heeded problems in hospitals and nursing homes (de Rijk et al. 1995; Barichella et al. 2008). The prevalence of under-nutrition among older patients in nursing homes and hospitals reaches high levels as 30%–60% (Guigoz, Vellas, and Garry 1996). Currently, about 6.6% of the total Iranian population, which accounts for more than four million people, is above 60 years of age. Thus, the Iranian population is aging rapidly and this figure is expected to double in the next four decades (Ravanipour et al. 2010), which highlights the increasing trend of morbidity and mortality, too. It has been indicated that proper nutritional care and diagnoses of malnutrition in its early stages among the elderly population followed by proper interventions can reduce the prevalence of severe malnutrition and society’s health care costs (Norman et al. 2008). Therefore, there is a need for a valid and reliable instrument to assess nutritional status of the elderly population especially among those suffering from chronic conditions which are even at a higher risk of malnutrition. The Mini Nutritional Assessment (MNA) was developed nearly 20 years ago and it has been designed as a useful comprehensive geriatric assessment instrument. Its purpose is to evaluate the nutritional status among the elderly population in outpatient clinics, hospitals, and nursing homes. MNA provides information about cognition, social status, autonomy, and mobility. Moreover, it can identify if a person is at risk of malnutrition and predict mortality and hospital cost (Vellas et al. 1999). Its usefulness extends as a comprehensive geriatric assessment tool that can help in identifying patients who may benefit from early intervention (Guigoz et al. 1996). It has also been seen as a combined screening and assessment tool (Bauer et al. 2006). The MNA questionnaire has been translated into many languages and is being utilized in several countries. This questionnaire can be completed rapidly and

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easily (about 10 minutes). It consists of brief questions and simple measurements which may be conducted by physicians or healthcare professionals. In a study by Vellas and colleagues on diagnostic values of the MNA, the sensitivity of the questionnaire was found to be 96% with 98% specificity and 97% predictive value to distinguish malnourished cases. In the same study, the MNA scale was also found to be predictive of mortality and hospital cost (Vellas et al. 1999). According to one study evaluating the Persian-translated version of the MNA used for Iranian elderly population, the sensitivity, specificity, positive and negative predictive values were 88%, 62%, 57%, and 89%, respectively. In the same study, it has been found that the MNA with its established cut-off points may not be appropriate for Asian population, including Iranian individuals (Amirkalali et al. 2010). Small numbers of participants, selection of the study subjects only from patient groups or specific age-ranges in other investigations, have made the previous results less reliable and non-generalizable to other populations (Barichella et al. 2008; Wang et al. 2010). Moreover, there is not enough study comparing the psychometric properties of the MNA in elderly with and without a chronic health condition. Since even many healthy individuals with different age groups might be at risk of malnutrition, which is not diagnosed prior to serious symptoms, it is then of utmost importance to also study the validity and reliability of a user-friendly tool such as MNA in adults with no previous symptoms of malnutrition. To cover these issues, we conducted this research evaluating the validity and reliability of the Persian-translated MNA among Iranian population with different range of age comparing between healthy participants and a group of patients suffering from a chronic illness. For this purpose, we choose Parkinson’s disease (PD) with a global prevalence rate of 72 to 258.8 per 100,000 persons mainly elderly, representing the second most common progressive neurodegenerative disease globally (Ravanipour et al. 2010; Sheard et al. 2011; WHO 2006).

METHODS Participants The cross-sectional study was performed in Iran, during 2011–2012. Participants were 610 patients, including 143 with PD, recruited from one referral movement disorder clinic in Tehran; and 467 healthy controls, recruited from the medical staff and the patients’ relatives in Alzahra hospital in Isfahan and Sina and Imam Khomeini hospitals in Tehran, two large cities of Iran. The exclusion criteria were moderate to severe dementia and current or previous chronic comorbidities such as hypertension and diabetes mellitus; those who were following special diets or suffering from nutritionrelated disorders were also excluded from the study. The same criteria were used for all the participants including the healthy controls and for the patients with chronic illness (PD).

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All the patients were entered after they had been diagnosed clinically by a neurologist specialized in movement disorders. Participation in this study was voluntary and informed consent was obtained verbally. Data collection was performed through face to face interviews by the staff including physicians, nutritionists, neurology residents, and neurologists specialized in movement disorders. This study was a collaboration project between Karolinska Institutet, Stockholm, Sweden, and Iran University of Medical Sciences, Tehran, Iran. The study protocol was approved by the Ethics Committee of the Firoozgar Clinical Research Development Center (FCRDC) affiliated with the Iran University of Medical Sciences in Tehran, Iran.

The MNA Questionnaire The full form MNA questionnaire consists of 18 items grouped into 2 subtitles: 6 screening questions in section I and 12 assessment questions in section II. The MNA includes body mass index (BMI), weight loss, arm and calf circumference, appetite, medication, general and cognitive health, dietary matters, autonomy of feeding, self-perception of health and nutrition, as well as subjective judgment of malnutrition. The maximum score in the MNA test is 30 points; where 16 points is obtained by screening questions and 14 points is related to assessment questions. Based on the final scores, subjects could be classified into three groups: score 17–23.5 (at risk for malnutrition), score less than 17 (with malnutrition), and score 24–30 (with normal nutritional status). In this study, we have used the full MNA form translated into Persian language. It is provided by Nestlé Nutrition Institute and it is available online on the Nestlé website (Durrieu et al. 1992).

Anthropometric Measurements As part of MNA questionnaire, each participant underwent a clinical examination including measurement of mid arm circumference (MAC), calf circumference (CC), weight and height. Body weight was recorded in a standardized manner using calibrated floor scales to the nearest 0.1 kg. The standing height was measured to the nearest 0.1 cm using a stadiometer at head level, with the subject’s bare feet close together, lightly dressed, back and heels against the wall, standing erect and looking straight ahead. Body mass index was calculated as body weight (kg) divided by squared height (m2 ), according to the study conducted by Quetelet and colleagues (Eknoyan 2008). MAC was measured with the flexible inextensible tape that should be applied snugly around the maximum girth of the proximal part of forearm while the subject’s arm was hanging down freely along their trunk at their sides. For CC, the maximal circumference between the ankle and the knee was measured with a flexible tape that was applied horizontally around the

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maximum girth of the calf while the subject was standing with their weight evenly distributed on both feet. The measurements were manipulated to maintain close contact with the skin without compression of underlying tissues on the non-dominant arm and leg to the nearest 0.1 cm (Nozaki et al. 1999). All anthropometric measurements were performed by trained personnel.

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Statistical Analysis Data were analyzed using SPSS software version 17 (Chicago, IL., USA). To describe quantitative and categorical variables mean (standard deviation; SD) and frequency (%) were reported. Chi square statistic and Fisher’s exact test were performed to compare relative frequency of qualitative variables between the two study groups wherever appropriate. In order to compare the mean value of quantitative variables between the patient group and healthy controls, independent samples t-test was used. The univariate relationship between different pairs of numerical measurements (including MNA score, age, disease duration and the scores of different questionnaires) was assessed by means of either Spearman or Pearson correlation test and correlation coefficient (r) was reported. RELIABILITY

ANALYSIS

Internal consistency of the Persian version of MNA questionnaire was assessed using item-total Spearman correlation statistic where the score of each item of the MNA was correlated with the total MNA score. Moreover, Cronbach’s α coefficient was calculated within each of the two domains of the MNA questionnaire and for the whole questionnaire as well. For all of these reliability coefficients, either the p value or 95% or confidence interval (CI) were reported. VALIDITY

ANALYSIS

To check the criterion validity, correlation between the MNA scores and other representatives of nutritional status namely the anthropometric measurements were evaluated using the Pearson correlation test. In addition, receiver operating characteristics (ROC) curve analysis was performed for assessing the accuracy of MNA score in discriminating patients or healthy individuals who were overweight or obese. For this purpose, one condition was defined as the binary discriminated outcome, meaning BMI ≥ 24 kg/m2 versus BMI < 24 kg/m2 . In addition to area under curve (AUC), the best cut-off point for total MNA score was calculated to discriminate the subjects with a BMI < 24 kg/m2 regarding the Youden’s index corresponding to each

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cut-off value. Sensitivity and specificity were also calculated for that cut-off value of the MNA questionnaire. A two-tailed p value of less than .05 was considered to show a statistical significance difference or correlation in all analytical procedures.

RESULTS

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Demographics and Anthropometric Characteristics Baseline and anthropometric characteristics of the two groups are summarized in table 1. Healthy individuals consisted of 151 (32.3%) females and 316 (67.7%) males with a mean age of 49.86 years (SD = 14.04) ranging between 21 to 84 years. The enrolled PD patients were 47 (32.9%) females and 96 (67.1%) males with a mean age of 61.44 years (SD = 10.47) which ranged between 35 to 91 years. Among anthropometric measurements, the mean of mid-arm circumference (MAC) was significantly higher in PD patients cm, 28.13 (SD = 4.93) versus 26.74 cm (SD = 5.31), p = .004; while calf-circumference (CC) was significantly lower in the PD patient group, 34.92 cm (SD = 3.83) versus 35.81 cm (SD = 4.39), p = .022.

Reliability In item-total correlation analysis and as shown in Table 2, the first item, “changes in dietary intake,” (Spearman r = .564, p < .001) and item number TABLE 1 Baseline and Anthropometric Characteristics of Parkinson’s Disease Patients and All Healthy Controls (Non-Matched)

Characteristics Age (y) Gender N (%) Female Male Level of education N (%) Illiterate Primary and/or secondary High school/diploma College and/or university Weight (kg) Height (cm) Body mass index (BMI) (kg/m2 ) Mid-arm circumference (MAC) (cm) Calf circumference (CC) (cm) ∗

All healthy controls (n = 467) Mean (SD)

Parkinson’s Disease patients (n = 143) Mean (SD)

49.86 (14.04)

61.44 (10.47)

151 (32.33) 316 (67.67) 41 200 76 150 69.85 165.44 25.48

(8.8) (42.8) (16.3) (32.1) (13.06) (9.59) (4.17)

13 35 39 54 71.93 166.66 25.86

(9.2) (24.8) (27.7) (38.3) (13.77) (8.93) (4.30)

Mini Nutritional Assessment (MNA) is Rather a Reliable and Valid Instrument to Assess Nutritional Status in Iranian Healthy Adults and Elderly with a Chronic Disease.

This study aimed to evaluate the usefulness of the Mini Nutritional Assessment (MNA) to assess nutritional status of Iranian population and to compare...
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