Frequency of Malnutrition in Older Adults: A Multinational

Perspective Using the Mini Nutritional Assessment

Matthias J. Kaiser, MD, Jürgen M. Bauer, MD, Christiane Rämsch, Dipl.-Biomath. (FH),w
Wolfgang Uter, MD,w Yves Guigoz, PhD, z Tommy Cederholm, MD, PhD,§ David R. Thomas, MD, k
Patricia S. Anthony, MS, RD,z Karen E. Charlton, PhD,# Marcello Maggio, MD, PhD,
Alan C. Tsai, PhD,ww Bruno Vellas, MD, PhD, z z and Cornel C. Sieber, MD, for the Mini Nutritional
Assessment International Group

OBJECTIVES: To provide pooled data on the prevalence
of malnutrition in elderly people as evaluated using the
Mini Nutritional Assessment (MNA).
DESIGN: Retrospective pooled analysis of previously pub-
lished datasets.
SETTING: Hospital, rehabilitation, nursing home,
community.
PARTICIPANTS: Four thousand five hundred seven peo-
ple (75.2% female) with a mean age of 82.3.
MEASUREMENTS: The prevalence of malnutrition in the
combined database and in the four settings was examined.
RESULTS: Twenty-four data sets with information on full
MNA classification from researchers from 12 countries
were submitted. In the combined database, the prevalence
of malnutrition was 22.8%, with considerable differences
between the settings (rehabilitation, 50.5%; hospital,
38.7%; nursing home, 13.8%; community, 5.8%). In the
combined database, the ‘‘at risk’’ group had a prevalence of
46.2%. Consequently, approximately two-thirds of study
participants were at nutritional risk or malnourished.
CONCLUSION: The MNA has gained worldwide accep-
tance and shows a high prevalence of malnutrition in differ-
ent settings, except for the community. Because of its
From the Institute for Biomedicine of Aging and wDepartment of Medical
Informatics, Biometry and Epidemiology, Friedrich-Alexander University
Erlangen-Nürnberg, Erlangen, Germany; zNestlé Nutrition/HealthCare Nu-
trition, Gland, Switzerland; §Clinical Nutrition and Metabolism, Department
of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden;
k
Division of Geriatric Medicine, Saint Louis University Health Sciences
Center, St. Louis, Missouri; #School of Health Sciences, Faculty of Health and
Behavioral Sciences, University of Wollongong, Wollongong, Australia;

Department of Internal Medicine and Biomedical Sciences, Section of
Geriatrics, University Hospital of Parma, Parma, Italy; wwGraduate Institute
of Long-Term Care, Department of Healthcare Administration, Asia Uni-
versity, Taiwan, ROC; and zzCHU Toulouse, Inserm U558, Department of
Geriatric Medicine, Toulouse, France.
Address correspondence to Matthias J. Kaiser, Institute for Biomedicine of
Aging, Friedrich-Alexander University Erlangen-Nürnberg, Heimerichstrasse
58, 90419 Nuremberg, Germany. E-mail: dr-kaiser@web.de
DOI: 10.1111/j.1532-5415.2010.03016.x
specific geriatric focus, the MNA should be recommended
as the basis for nutritional evaluation in older people. J Am
Geriatr Soc 58:1734–1738, 2010.
Key words: malnutrition; undernutrition; Mini Nutri-
tional Assessment; elderly; nutritional screening
M alnutrition is one of the most relevant conditions that
negatively affects the health of older people.1 The
prevalence of malnutrition is generally high in older adults,
but it is strongly dependent on the population studied. Pre-
vious publications reported a prevalence of malnutrition
ranging from nonexistent in healthy, community-living
‘‘young old’’ persons2 to as high as 57% in residents of long-
term care institutions.3 In the community, poor nutritional
status is present before disease appears, as is risk of mal-
nutrition.4,5 Therefore, a systematic and structured nutri-
tional screening is recommended for early detection of
malnutrition to counteract the decline of health status
caused by deficiencies in macro- and micronutrients. The
criterion standard for the diagnosis of malnutrition has not
been established, although for older adults, efforts have
been made to create a screening tool that includes factors
associated with physical, social, and cognitive domains of
older individuals. Since the Mini Nutritional Assessment
(MNA) was first published in 1994,6,7 the MNA has been
established as one of the most valid and most frequently
used nutritional screening tools in older persons.8,9 The
MNA is a recommended part of the comprehensive geriatric
assessment and is an important research tool in geriatric
medicine, with more than 400 scientific papers published
about it.10 In addition, the MNA may be useful for teaching
purposes in the context of nutritional care in older per-
sons.11 Unlike many of the existing nutrition screening tools

JAGS 58:1734–1738, 2010

r 2010, Copyright the Authors
Journal compilation r 2010, The American Geriatrics Society 0002-8614/10/$15.00
JAGS SEPTEMBER 2010–VOL. 58, NO. 9
available, the MNA was specifically designed and validated
for use in older persons. It has been shown to perform well
in diverse settings and across populations.12 The aim of the
present study was to pool existing international data on the
MNA from high-quality trials (published in peer-reviewed
journals) in one large database and to provide information
on the prevalence of malnutrition in older persons on a
larger scale. All settings relevant for the care of older per-
sons were included: community, nursing homes, acute care
hospitals, and rehabilitation units.
METHODS
Data Collection and Database Setup
The present study is a retrospective pooled analysis. To
identify eligible studies, a literature search was performed
on PubMed. Because of ongoing changes in population de-
mographics, studies published before 2000 were not in-
cluded. Studies were selected if the MNA (preferably full
form) was used and a clear definition of the setting was
provided. Authors were contacted in writing and asked to
submit their original data sets. All data sets were transmit-
ted electronically in a structured format. Occasionally, data
sets had to be revised before transmission to increase com-
prehensibility (e.g., translation into English) and to meet
advisory board or ethics committee regulations on data
transfer (e.g., deletion of patient names). Two members of
the study group (RC and KMJ) reviewed each data set and
appended it to the database. Setting allocation was made on
the basis of setting description provided by the respective
publications. In some cases, authors were contacted and
asked to describe their patient collective to enable an ad-
equate allocation. Only data from study participants aged
65 and older were entered into the database.
Ethics Approval and Statistical Analysis
The ethics committee of the University of Erlangen-
Nuremberg approved the conceptual design. Statistical
analysis was based on the combined database and on sub-
sets of data, stratified for settings. Statistical analysis was
performed using SAS (version 9.2, SAS Institute, Cary, NC).
RESULTS
Database Content
Investigators from all five continents agreed to participate and
submitted 27 datasets including information on more than
6,000 study participants aged 65 and older. Because of the
unavailability of the full MNA classification in several data-
sets, the effective sample size used in the following analyses
was 4,507 (24 study files from 12 countries). This also in-
cluded data from two theses (otherwise unpublished) and one
previously unpublished study file that were acquired through
personal contacts. Geographically, the data received cover
study participants from all five continents, with a stronger
focus on European populations (80.6% of study data).
The combined database provided information on 1,384
hospitalized patients from Belgium,13 Switzerland,14 Ger-
many,15 Italy (unpublished data, 16), and Sweden.17 Study
files from 1,586 nursing home residents came from Switzer-
land,18 Germany,19–22 Spain,23 France,24 the Netherlands,25
the United States,26 and South Africa.27 Information on 964
FREQUENCY OF MALNUTRITION IN THE ELDERLY 1735
community-dwelling study participants was available from
Switzerland,28 France,29 Japan,30 Sweden,31 and South
Africa.27 Data on 345 patients from geriatric rehabilitation
was available from Australia,32 Italy,33 and the United
States.34 Two hundred twenty-eight cases from Japan re-
mained unclassified with regard to setting but were included
in the prevalence analysis of the combined sample.35
Demographic Characteristics and Prevalence
of Malnutrition
The basic characteristics of the study population stratified
for setting and sex are given in Table 1; 75.2% of study
participants were female. The mean age of the study pop-
ulation was 82.3  7.5. Women were older than men (82.7
vs 81.3). More than 60% of the study population was aged
80 and older. Age distribution differed between the settings.
Nursing home residents were oldest, particularly women.
The youngest population was the community-dwelling
group. The differences in age distribution between acute
care and geriatric rehabilitation were minor. The setting-
specific distribution of MNA categories (well nourished, at
risk, malnourished) in the combined database and the four
examined settings is given in Figure 1. In the combined da-
tabase, more than two-thirds of the study participants were
classified as at risk of malnutrition (46.2%) or overtly mal-
nourished (22.8%). The proportion of well-nourished older
adults was particularly low in convalescent older persons in
geriatric rehabilitation (8.5%) and in hospitalized elderly
patients (14.0%). In those two settings, approximately 90%
of study participants were malnourished or at risk of devel-
oping malnutrition. In the nursing home setting, only 32.9%
of residents were well nourished. Although the level of mal-
nutrition was low in the community setting, 31.9% of com-
munity-living elderly persons were at risk of malnutrition.
DISCUSSION
The database used for the present analysis was compiled
from 24 data sets provided by researchers from all five
continents. This is the largest database of information on
nutrition screening in older adults from a range of residen-
tial settings. The information provides insight into the
prevalence of malnutrition using the well-validated MNA
tool8,9,12 in older populations with various degrees of de-
pendence, from older persons living autonomously in the
community to patients in geriatric hospitals and residents of
long-term care institutions.
Overt malnutrition according to the MNA affected
nearly one-quarter of the examined population, with the
lowest prevalence reported in community-dwelling older
adults and the highest prevalence in rehabilitation units. In
the total sample, as well as in two out of four settings (hos-
pital and nursing home), the largest proportion of older
adults was classified as being at nutritional risk. Nutritional
status deteriorates as dependency and care needs grow, fol-
lowing a sequence from community living to nursing home
and hospital. Similar differences in the prevalence of malnu-
trition across settings have been described previously.9,12,36
Nevertheless, percentages given in original research papers
sometimes differ substantially from one another.8,12 Here,
pooled analyses help to smooth results to gain a clearer pic-
ture on a greater scale. The MNA may be regarded as a
1736 KAISER ET AL. SEPTEMBER 2010–VOL. 58, NO. 9 JAGS

particularly suitable tool for diagnosis of malnutrition be-

82.7  7.4

25.4  5.9
37.8  7.1

17.4  8.9
n 5 3,388

21.5 (7.5)
Women

1.4 (4.0)
Combined Database

20.8
45.6
33.6
cause it offers a multidimensional approach to elderly people
by selection of items that correspond well with relevant fea-
tures of the target population (e.g., dementia, mobility, mode
of feeding, pressure sores). Although tools such as the Mal-

81.3  7.7

24.1  4.8
36.5  7.2

13.0  7.2
n 5 1,063
nutrition Universal Screening Tool (MUST)37 and the Nu-

20.5 (7.5)

1.9 (5.2)
Men

28.0
48.9
23.1
tritional Risk Screening 2002 (NRS)38 are also often used to
assess nutritional status in elderly persons, it is the specific
focus of the MNA that has enhanced acceptance and appli-
cation of this tool in geriatric medicine.10,39 The MUST
82.3  7.5

24.6  6.2
33.6  5.1

11.2  5.3
16.0 (8.0)
Women
n 5 246

53.3 seems limited to use as a brief screening tool, without proper

39.4
7.3

F
Rehabilitation

representation of change in older people’s body shape. The

body mass index (BMI) cutoff in the MUST is a low 18.5 kg/
m2, which many experts regard as too low. In the MNA,
alternatively, subjects begin to lose points for BMI values
80.2  7.6

24.2  5.7
32.9  5.0

8.3  4.7
17.5 (7.5)
n 5 99

below 23.0 kg/m2. The NRS was developed and validated on

Men

40.4
52.5
7.1

F
adults, but not specifically older adults, in the acute care
setting. The NRS indicates the greater risk of elderly persons
of being malnourished by adding 1 point to the risk score if
79.3  6.6

25.6  6.4
38.3  3.4

28.5  9.8
25.5 (5.0)

subjects are aged 70 and older, but by strongly focusing on

Women
n 5 848

29.0
65.7
5.3

acute disease, the NRS seems to be less appropriate for com-

Community

munity-dwelling older people and nursing home residents

because their health is often much stabler than that of their
counterparts in acute care.
20.5  11.4
79.3  7.2

23.1  4.0
39.0  3.6
22.8 (5.3)
n 5 116

There are a number of limitations to the present study.

Men

52.6
37.9
9.5

Despite the large sample size, results may not be generalized

because of the heterogenous and convenience nature of the
database. The four settingsFhospital, nursing home, reha-
bilitation, communityFare not evenly represented in the
85.1  7.4

26.3  5.7
42.3  8.7

18.8  8.0
n 5 1,189

22.0 (5.5)
Women

0.4 (1.0)

combined database, which is dominated by patients in acute

13.5
53.7
32.7
Nursing Home

care and nursing home residents. Particularly the sample

size from the rehabilitation is smaller than those from the
other settings. Ethnic heterogeneity also warrants consid-
eration. Although the present study was designed to include
81.3  8.3

25.1  5.1
38.7  9.8

14.9  6.2
22.0 (6.0)
n 5 397

0.8 (1.3)

a large number of data sets from around the world, its main
Men

14.4
52.4
33.3

focus was on European populations, whereas populations

228 cases were unclassifiable regarding setting; 56 cases were unclassifiable regarding sex.
Table 1. Basic Characteristics of the Study Population (N 5 4,507)

from Australia, Asia, Africa, and the United States consti-

tuted only a minority of the total sample size. Therefore,
82.9  6.9

24.4  5.6
36.4  6.4

14.4  7.9

although it indicates the general magnitude of the problem

18.5 (8.0)
Women
n 5 943

1.6 (4.5)
36.0
49.9
14.1

(malnutrition in older people), the results from the analyses

are not to be regarded as representative with regard to a
Hospital

certain country or continent or the world.

In the process of allocation of collected data to one of
81.2  7.1

23.8  4.3
36.1  6.4

11.0  6.1
17.5 (8.5)
n 5 385

2.1 (5.4)

the aforementioned settings, the authors applied great care,

Men

45.2
41.0
13.8

but in some cases, the inclusion of the respective data was

possible only after consultation with the respective authors
to clarify characteristics of the study population with regard
SD 5 standard deviation; IQR 5 interquartile range.

to disease status, therapeutic measures, and duration of

C-reactive protein, mg/dL, median (IQR), n 5 1,425
Body mass index, kg/m2, mean  SD n 5 3,348

stay. Nevertheless, the characteristics of rehabilitation,

Mini Nutritional Assessment score, median (IQR)

Triceps skin fold, mm, mean  SD, n 5 1,913

long-term care, and acute care setting may vary between

countries and continents. Therefore, misinterpretations
leading to wrong setting allocation cannot be completely
Albumin, g/L, mean  SD, n 5 1,550

excluded.
Characteristic

CONCLUSION
The MNA has been established as a nutritional screening
Well nourished, %
Age, mean  SD

Malnourished, %

tool for use in various care settings for older persons and as
such has been used globally as a component of comprehen-
At risk, %

sive geriatric assessment. According to MNA classification,

the proportion of older people who are overtly malnour-
ished or at risk of becoming malnourished is high in all
JAGS SEPTEMBER 2010–VOL. 58, NO. 9
80%
70%
53.4%
60%
47.3%
38.7%
50%
32.9%
40%
30%
14.0%
13.8%
20%
10%
0%
Hospital (n=1,384) Nursing home
(n=1,586)
Well nourished
Figure 1. Setting-specific distribution of Mini Nutritional Assessment classification (combined sample includes 228 cases unclassified
for setting).
examined settings except for the community. Even though
no tool, neither the MNA nor any other tool in use, can be
regarded as the criterion standard for nutritional screening
of older persons, MNA items specifically address relevant
features of the aging population that allow for early detec-
tion of malnutrition risk and enable assessors to take im-
mediate action. Therefore, performing the MNA as a
screening test is strongly recommended as the basis for nu-
tritional evaluation.
ACKNOWLEDGMENTS
The authors wish to acknowledge all colleagues from the
MNA International Group who submitted original data
and participated in discussions on the project’s progress.
The authors are indebted to Marcello Maggio, who pro-
vided a previously unpublished dataset. Part of this work
was presented as a poster and oral communication at the
2009 International Association of Gerontology and Geri-
atrics Congress, Paris, France, and the 2009 European So-
ciety for Clinical Nutrition and Metabolism Congress,
Vienna, Austria.
Conflict of Interest: All authors are members of the
MNA International Group and attended a workshop in
Lausanne, Switzerland, in October 2008 that was fully
funded by Nestlé. Kaiser has been supported by a research
grant from Nestlé Nutrition, Vevey, Switzerland. Bauer is a
consultant to Nutricia and has received research grants
from Nestlé and Nutricia. He has received honoraria for
giving talks in collaboration with Nestlé, Abbott, and
Fresenius. Sieber and Vellas are consultants to Nestlé and
have received honoraria for giving talks in collaboration
with Nestlé. Anthony is an employee of Nestec Ltd. Guigoz
is an external advisor to Nestec Ltd.
The study has been supported through a research grant
by Nestlé Nutrition (Vevey, Switzerland) to Matthias J.
Kaiser.
Author Contributions: Matthias J. Kaiser: conception,
data collection, analysis, and interpretation; preparation of
manuscript. Jürgen M. Bauer and Cornel C. Sieber: con-
ception, data collection and interpretation, preparation of
FREQUENCY OF MALNUTRITION IN THE ELDERLY 1737
62.4%
50.5%
46.2%
41.2%
31.9%
31.0%
22.8%
8.5%
5.8%
Community (n=964) Rehabilitation Combined (n=4,507)
(n=345)
At risk Malnourished
manuscript. Christiane Rämsch and Wolfgang Uter: data
analysis and interpretation, preparation of manuscript.
Yves Guigoz: conception, data analysis and interpretation,
preparation of manuscript. Tommy Cederholm and David
R. Thomas: conception, data interpretation, preparation of
manuscript. Patricia S. Anthony: conception, data collec-
tion and interpretation. Karen E. Charlton: data interpre-
tation, preparation of manuscript. Marcello Maggio:
conception, data interpretation. Alan C. Tsai: data inter-
pretation. Bruno Vellas: conception, data interpretation.
Sponsor’s Role: None.
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