Assessment of Malnutrition

At present, malnutrition has become a non-negligible complication in COVID-19 patients, especially in severe patients. For COVID-19 patients, the causes of malnutrition include insufficient intake and increased demand. Malnutrition caused by insufficient intake of nutrients can be corrected through nutritional support; however, in the period of enhanced disease catabolism, the negative energy balance and negative nitrogen balance cannot be corrected by nutritional support alone, even if a large amount of nutrients are taken in, they cannot be corrected. Only when the primary disease is effectively controlled, the infection is controlled, the inflammatory response subsides, and the human tissue enters the anabolic stage can the body’s nutritional status be effectively improved and obtain good clinical outcomes. Scientific and reasonable nutritional support can effectively improve the nutritional status of COVID-19 patients, reduce complications, enhance immunity, and improve patients’ prognosis. Through nutritional assessment, patients suffering from malnutrition or at potential risk of malnutrition can be identified in time to provide timely nutritional support. Therefore, early and systematic nutritional assessment is particularly important to guide individualized nutritional support treatment.

The purpose of nutritional assessment is to:

  • 1) Determine whether the patient is at risk of malnutrition or potential malnutrition.
  • 2) Assess the severity of malnutrition.
  • 3) Provide the basis for nutritional support treatment.

The first nutritional assessment is nutritional screening, which is the most basic step. Patients at risk of malnutrition after screening need further nutritional assessment to make an accurate diagnosis of malnutrition.

Nutrition Risk Screening

Nutrition risk screening begins with the patient’s medical history, such as weight loss and food intake. For the screening of the risk of malnutrition in patients with COVID-19, Nutrition Risk Screening-2002 (NRS-2002) scoring scale is commonly used in clinical practice.

Hie NRS-2002 rating scale is a scale used to screen adult hospitalized patients for nutritional assessment launched at the European Society of Parenteral and Enteral Nutrition in 2002. The scale is divided into a preliminary screening table and a final screening table. The assessment contents are shown in Table 11.1.

NRS-2002 Assessment Scale for Reduced Nutritional Status Score and Its Definition

  • 1) 0 score: Definition - normal nutritional status.
  • 2) Mild (1 score): 5% weight loss within 3 months or 50%-75% of normal requirements for food intake.
  • 3) Moderate (2 scores): 5% weight loss within 2 months or 25%-50% of normal food intake requirements in the previous week.
  • 4) Severe (3 scores): 5% weight loss within 1 month (15% weight loss within 3 months) or BMI < 18.5 or 0%-25% of normal requirements for food intake in the previous week.

Note: If only one of the three problems is consistent, the degree of severity will be evaluated according to its score, and if several problems are evaluated according to the highest score.

NRS-2002 Assessment Scale for the Severity of Disease and Its Definition

  • 1) 1 score: Patients with chronic diseases who have been hospitalized due to complications. The patient is weak but does not need to stay in bed. Oral supplements to compensate for a slight increase in protein requirements.
  • 2) 2 scores: Patients who need to stay in bed. For example, after major abdominal surgery, the protein requirements increase correspondingly, but most of them can still recover through parenteral or enteral nutrition support.
  • 3) 3 scores: The patient is supported by mechanical ventilation in the intensive ward, and the increased protein requirements cannot be compensated by parenteral or enteral nutrition support; however, protein decomposition and nitrogen loss can be significantly reduced through parenteral or enteral nutrition support.

Relationship between the NRS-2002 Assessment Scale Score Results and Nutrition Risk

1) The total score of > 3 (or pleural fluid, ascites, edema, and serum protein < 35 g/L) indicates that the patient is malnourished or at risk of nutrition, so nutritional support should be used.


Evaluation Index


If “yes”, please tick“V”

Disease States

Patients with pelvic fractures or chronic diseases with the following diseases: liver cirrhosis, chronic obstructive pulmonary disease, long-term hemodialysis, diabetes, and tumors.


Major abdominal surgery, stroke, severe pneumonia, or blood system tumor.


Patients with craniocerebral injury, bone marrow suppression, or ICU (APACHE II score > 10 scores)



Nutritional Status

Normal nutritional status


Weight loss > 5% within 3 months or food intake in the last week (compared to the required amount) reduced by 20%-50 %.


Weight loss > 5% within 2 months, BMI 18.5-20.5 kg/m2, or food intake in the last week (compared to the required amount) reduced by 50%-75%.


Weight loss > 5% within 1 month (or >15% loss within 3 months), BMI < 18.5 kg/m2 (or human serum albumin < 35 g/L), or food intake in the last week (compared to the required amount) reduced by 70%-100%




> 70 years old


Evaluation: The total score of the above three parts is less than 3 points, there is no nutritional risk;

3-5 < scores, there is nutritional risk; >5 points, there is high nutritional risk.

Note: NRS-2002 score refers to nutrition risk screening 2002 score; ICU is the intensive care unit; APACHE II score is the acute physiological and chronic health evaluation score; BMI is body mass index.

  • 2) The total score of < 3 indicates that nutrition should be evaluated weekly. If the result of the subsequent review is > 3 scores, the patient will enter the nutrition support program.
  • 3) If the patient plans to undergo major abdominal surgery, the new score (2 scores) will be scored at the first assessment, and the new total score will be used to determine whether nutritional support is required (> 3 scores).

One of the advantages of NRS-2002 rating scale is that it can predict the potential risk of malnutrition and dynamically judge the changes in patients’ nutritional status. Additionally, doctors and nurses can operate this scale in the clinic, which is easy to operate and easy for patients to accept.

NRS-2002 Score Significance for COVID-19 Patients

If the NRS-2002 score is > 3 scores, it indicates that patients have malnutrition risk, and nutrition intervention is required; if the NRs-2002 score is > 5 scores, it indicates that patients are a high malnutrition risk, and nutrition treatment should be given as soon as possible; malnutrition risk assessment should be performed for all severe COVID-19 patients in ICU as early as possible.

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