Nutrition 28 (2012) 271274

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Nutrition
journal homepage: www.nutritionjrnl.com

Applied nutritional investigation

Usefulness of the Malnutrition Screening Tool in patients with pulmonary

tuberculosis
Shigeru Miyata M.D., Ph.D. *, Mikio Tanaka B.S., Daizo Ihaku M.D., Ph.D.
Department of Internal Medicine, Hanna Hospital, Osaka, Japan

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 11 February 2011
Accepted 17 July 2011

Objective: To examine the relation between the Malnutrition Screening Tool (MST) and the
mortality of patients with pulmonary tuberculosis (TB).
Methods: Fifty-two patients with pulmonary TB were analyzed. Nutritional assessment was carried
out using the MST. The MST incorporates three components: presence of weight loss (score 0 or 2),
amount of weight lost (score 14), and poor food intake or poor appetite (score 0 or 1). A score
2
means that the patient is at risk for malnutrition. The Cox proportional hazard model was applied
to assess the ability of the MST to predict prognosis. Receiver operating characteristic curve
analysis was used to assess the MST score as a prognostic indicator in patients with pulmonary TB.
To obtain optimal cutoff values for the MST score for the prognostic assessment in patients with TB,
the maximum Youden index was used.
Results: For predicting the risk of mortality, the optimal cutoff value for the MST score was 2.5.
Univariate and multivariate analyses identied age and a MST score
3 as signicant independent
prognostic factors for survival. The patients with a MST score <3 had a median survival of 453
d and those with a MST score
3 had a median survival of 242 d; the difference was statistically
signicant (P 0.001).
Conclusion: The MST appears to be a reliable tool for the nutritional risk assessment of patients
with pulmonary TB. This risk assessment tool can play a valuable role in quickly identifying
patients at an increased risk of death and providing adequate nutritional support.
2012 Elsevier Inc. All rights reserved.

Keywords:
Malnutrition Screening Tool
Pulmonary tuberculosis
Mortality
Simplicity
Nutritional support

Introduction
Tuberculosis (TB) is a disease with a long history in humans.
TB is also a re-emerging infectious disease that was declared
a global health problem by the World Health Organization in
1993 [1]. There were 9.4 million new TB cases (including 3.3
million women) in 2009, including 1.1 million cases in people
with the human immunodeciency virus. The estimated global
incidence rate decreased to 137 cases per 100 000 people in
2009, after peaking in 2004 at 142 cases per 100 000. The rate is
still decreasing, but too slowly [2]. In Japan, the TB incidence rate
decreased below 20 per 100 000 in 2007 and continued to
decrease, reaching 19.4 in 2008. However, 24 760 patients with
TB were newly identied in 2008. The TB incidence rates in Japan
among the elderly (
65 y) were high; for example, 29.5 per 100
000 in those 64 to 74 y old, 64.2 in those 75 to 84 y old, and 97.3
* Corresponding author. Tel.: 81-72-874-1111; fax: 81-72-874-1114.
E-mail address: smiyata61@hotmail.com (S. Miyata).
0899-9007/$ - see front matter 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.nut.2011.07.013

in those 85 years and older [3]. The aging of the population and
the increased use of immunosuppressive treatments (e.g., cancer
chemotherapy and immunomodulatory agents) highlight the
need for additional strategies to maintain and improve TB
control [4].
Malnutrition is frequently observed in patients with pulmonary TB. Several studies have reported that patients with active
pulmonary TB are malnourished, as indicated by decreases in the
level of visceral proteins, anthropometric indexes, and micronutrient status [5,6]. Nutritional support is necessary for
malnourished patients with TB. Nutritional risk assessment is
important in providing nutritional support.
The Malnutrition Screening Tool (MST) is a simple, quick,
valid, and reliable tool for identifying patients at risk of malnutrition. The tool has only two questions related to weight loss and
decreased appetite. A score of
2 means that the patient is at risk
for malnutrition and warrants further assessment [7].
To the best of our knowledge, no studies have examined the
relation between the MST and the mortality of patients with

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S. Miyata et al. / Nutrition 28 (2012) 271274

pulmonary TB. The objective of this study was to examine the

relation between the MST and the mortality of patients with
pulmonary TB.

Materials and methods

Patients
Fifty-two patients with pulmonary TB were analyzed. The diagnosis of
pulmonary TB was made based on symptoms, chest radiographic inltrates, and
the presence of Mycobacterium tuberculosis on sputum culture. Patients ages
ranged from 17 to 98 y (mean 65.9 y). Patient characteristics are summarized in
Table 1. This study was approved by the institutional review board.

Anti-TB therapy
All patients received anti-TB therapy. All patients were in-patients at the start
of anti-TB therapy. The regimen consisted of isoniazid, rifampicin, ethambutol,
and pyrazinamide daily for 2 mo, followed by isoniazid and rifampicin daily for
the next 4 mo. The dosages of the anti-TB drugs by body weight are listed in Table
2. Pyrazinamide was not administered to patients 80 y or older. The anti-TB
therapy for patients 80 y or older was carried out for 9 mo.

Nutritional assessment
The nutritional risk assessment was carried out using the MST. It incorporates
three components: the presence of weight loss (score 0 or 2), the amount of
weight lost (score 14), and poor food intake or poor appetite (score 0 or 1). The
total score was calculated for each patient. A score of
2 means that the patient is
at risk for malnutrition. The triceps skinfold thickness was measured with a skin
caliper on the posterior upper arm midway between the acromion and olecranon
processes. A skinfold of 4 to 8 mm suggests borderline fat stores, and a thickness
of 3 mm or less indicates severe depletion. The midarm circumference was
measured using a non-stretch plastic tape midway between the acromion and
olecranon of the non-dominant arm. A measurement of 15 cm or less indicates
severe depletion of muscle mass [8]. Laboratory data including albumin and
lymphocyte count were also collected. Clinical variables were compared by the
risk classes yielded by the MST score.

Statistical analysis
Results are expressed as mean  standard deviation. The Cox proportional
hazard model was applied to assess the ability of the MST to predict the
prognosis. Receiver operating characteristic curve analysis was used to assess
the MST score as a prognostic indicator in patients with pulmonary TB. Data
were checked for normality by the ShapiroWilk test and variance homogeneity by the Levene test. Quantitative variables with normal distribution and
homogeneous variances were assessed with the Student t test. Quantitative
variables with normal distribution and inhomogeneous variances were
assessed with the Welch t test. Non-parametric variables were assessed with
the Mann-Whitney U test. Follow-up was measured from the date of the rst
patient visit to the hospital until death or the last date of observation. The
minimum follow-up duration was 90 d. The KaplanMeier method with
the log-rank test was used to calculate survival. P < 0.05 was considered
statistically signicant. Statistical analysis was performed using SPSS 18.0
(SPSS, Inc., Chicago, IL, USA).

Table 2
Dosage of antituberculosis drugs
Body weight
(kg)

Isoniazid
(mg)

Rifampicin
(mg)

Ethambutol
(mg)

Pyrazinamide
(mg)

>3040
>4055
>55

200
300
300

300
450
600

500
750
750

1200
1200
1500

Results
Table 1 presents the demographic and baseline clinical
characteristics of the patients. There were 37 men and 15
women. Their ages ranged from 17 to 98 y (mean  SD, 65.9 
20.0 y). Univariate and multivariate analyses showed that age
was a signicant prognostic factor. In contrast, an MST score
2
was not a signicant prognostic factor (Table 3). A receiver
operating characteristic curve was generated for further analysis
of the prognostic value of the MST score, as presented in Figure 1.
The area under the curve was 0.78 (95% condence interval [CI]
0.6490.911). The MST score was considered to have moderate
prognostic accuracy. To obtain optimal cutoff values for the MST
score for the prognostic assessment in patients with TB, we used
the maximum Youden index. For predicting the risk of mortality,
the optimal cutoff value for an MST score was 2.5. Using a cutoff
value for an MST score of 2.5, the sensitivity was 75.0% and the
specicity was 77.5% for survival. Patients were divided into two
groups based on their MST score (<3 or
3). Based on this cutoff
value, the Cox proportional hazard model was applied to assess
the ability of an MST score
3 to predict the prognosis of patients
with TB. Univariate analysis showed that age and an MST score

3 were signicant prognostic factors (Table 4). Multivariate
analysis identied age (hazard ratio 1.067, 95% CI 1.0151.122, P
0.012) and an MST score
3 (hazard ratio 4.073, 95% CI 1.026
16.178, P 0.046) as signicant independent prognostic factors
for survival. The characteristics of the study population according to the MST score using 2.5 as the cutoff value are presented in
Table 5. The midarm circumference was signicantly larger in the
patients with an MST score <3 (21.9  3.2) than in the patients
with an MST score
3 (18.5  2.3, P < 0.001). Similarly, body
mass index, triceps skinfold thickness, serum albumin, blood
lymphocyte count, and hemoglobin were signicantly higher in
the patients with an MST score <3 than in the patients with an
MST score
3. Higher C-reactive protein concentrations were
observed in the patients with an MST score
3 (Table 5). Figure 2
shows the survival curves for the patients with an MST score <3
and those with an MST score
3. The patients with an MST score
<3 had a median survival of 453 d (95% CI 407499) and those
with an MST score
3 had a median survival of 242 d (95% CI
151332); the difference was statistically signicant (P 0.001).
Discussion

Table 1
Characteristics of 52 patients with pulmonary tuberculosis
Variables

All patients

Men/women
Age (y)
Weight (kg)
Body mass index (kg/m2)
Midarm circumference (cm)
Triceps skinfold thickness (mm)
Serum albumin (g/dL)
Blood lymphocyte count (cells/mL)
Hemoglobin (g/dL)
C-reactive protein (mg/dL)

37/15
65.9 
49.6 
18.7 
20.8 
5.5 
3.0 
979 
11.6 
6.4 

20.0
11.1
3.0
3.3
3.0
0.9
582
2.3
6.1

Tuberculosis is often associated with nutritional deciencies.

A study of 30 patients with pulmonary TB in England reported
Table 3
Cox proportional hazard regression analyses of age and MST score
2 associated
with survival
Variables

Age
MST
2

Univariate analysis

Multivariate analysis

HR

95% CI

HR

95% CI

1.09
7.102

1.0301.154
0.91655.067

0.003
0.061

1.084
3.511

1.0251.147
0.44627.650

0.005
0.233

CI, condence interval; HR, hazard ratio; MST, Malnutrition Screening Tool

S. Miyata et al. / Nutrition 28 (2012) 271274

273

Table 5
Characteristics of the study population by MST score
Variables

Age (y)
Weight (kg)
Body mass index (kg/m2)
Midarm circumference (cm)
Triceps skinfold thickness (mm)
Serum albumin (g/dL)
Blood lymphocyte count (cells/mL)
Hemoglobin (g/dL)
CRP (mg/dL)

MST <3

MST
3

(n 34)

(n 18)

62.6
52.0
19.3
21.9
6.2
3.3
1142
12.2
5.5











20.0
11.8
3.1
3.2
3.1
0.8
641
2.4
6.0

72.2
45.0
17.5
18.5
4.2
2.4
670
10.6
8.5











19.1
7.9
2.7
2.3
2.3
0.5
254
1.5
5.9

0.083
0.043
0.038
<0.001
0.016
<0.001
<0.001
0.019
0.03

CRP, C-reactive protein; MST, Malnutrition Screening Tool

Fig. 1. Receiver operating characteristic curve for the Malnutrition Screening Tool
score (n 52, area under the curve 0.780, 95% condence interval 0.6490.911).

decreases in body mass index, triceps skinfold thickness, arm

muscle circumference, and serum albumin [6].
Patients with TB very frequently develop deciencies of
nutrients, such as vitamins A, B complex, C, and E and selenium,
which are fundamental to the integrity of the immune response
[911]. Four studies found lower levels of serum vitamin D in
patients with TB compared with those in controls [1215].
In addition to the central role of lipid storage, the adipose
tissue has major endocrine functions and releases a variety of
proinammatory and anti-inammatory factors, including adipocytokines, such as leptin, adiponectin and resistin, and cytokines and chemokines. Altered levels of different adipocytokines
have been observed in a variety of inammatory conditions, and,
in particular, the role of leptin in immune responses and
inammation recently has become increasingly evident [16]. An
altered leptin production during infection and inammation
strongly suggests that leptin is a part of the cytokine cascade,
which organizes the innate immune response and host-defense
mechanisms [17]. Active TB is associated with cachexia, weight
loss, and low serum concentrations of leptin [18,19]. Moreover,
leptin-decient mice are more susceptible to M. tuberculosis than
are wild-type mice, and T-cell numbers, including those
producing interferon-g, are decreased in infected lungs, suggesting that leptin contributes to the protection against TB [20].
However, a causative correlation between the severity of TB and
leptin has not been fully established, and leptin concentrations
do not predict wasting in human TB [19]. Nutrition and infection
interact with each other synergistically. Recurrent infections lead
to a loss of body nitrogen and worsen nutritional status; the
resulting malnutrition in turn produces a greater susceptibility to
infection.
Malnutrition in hospitalized children is still very prevalent,
especially in children with underlying disease and clinical

conditions [21]. Hulst et al. [22] developed a simple tool of

assessing nutritional risk in children. This tool, STRONGkids, was
tested during a nationwide survey in the Netherlands. It consists
of four key items, i.e., risk of disease, intake, weight loss, and the
Subjective Global Assessment (SGA). The four questions in this
tool can be completed just after admission and are not timeconsuming. Using this tool, a signicant relation was found
among having a high risk score, a negative SD score in weight
for height, and a prolonged hospital stay [22].
Malnutrition is also a common and often under-recognized
problem in patients with chronic obstructive pulmonary
disease [23]. Survival studies have consistently shown signicantly higher mortality rates in underweight patients than in
overweight patients with chronic obstructive pulmonary
disease [24].
The SGA is one comprehensive assessment technique that has
been shown to be a valid screening tool for the prevention and
treatment of malnutrition in various patient populations. The
MST is a simple tool that can be used to identify patients at risk of
malnutrition. The sensitivity and specicity of the MST at predicting the SGA were 93% [7]. The MST was developed for
hospital use in adult patients with an acute illness. It has also
been validated for use in patients undergoing cancer treatments
(radiotherapy, chemotherapy) and older patients presenting to
an emergency department [2527]. Recently, Isenring et al. [28]

Table 4
Cox proportional hazard regression analyses of age and MST score
3 associated
with survival
Variables

Age
MST
3

Univariate analysis

Multivariate analysis

HR

95% CI

HR

95% CI

1.09
6.504

1.0301.154
1.75524.104

0.003
0.005

1.067
4.073

1.0151.122
1.02616.178

0.012
0.046

CI, condence interval; HR, hazard ratio; MST, Malnutrition Screening Tool

Fig. 2. Survival curves for the patients with an MST score <3 and those with an
MST score
3. Censored patients were those who reached the end of their followup without dying (P 0.001, log-rank test). MST, Malnutrition Screening Tool.

274

S. Miyata et al. / Nutrition 28 (2012) 271274

suggested the valuable role of the MST in quickly identifying the

risk of malnutrition in a residential care setting. Several methods
are available for assessing nutritional status. Nutritional assessment methods such as the SGA or the mini-nutritional assessment are too detailed and take a long time to complete for use
with all patients admitted to a hospital. The MST has the
advantage of being very quick and simple to use, with no
calculations. The adoption of a cutoff value of 2.5 improves the
predictive ability of the MST score as a prognostic indicator in
patients with pulmonary TB. The MST will be used in future
studies of nutritional support in patients with TB.
One of the limitations in this study is the short duration of
follow-up. The minimum follow-up duration was 90 d. Other
limitations of this study are the small sample and the unusual
balance of male/female ratio. For these reasons, it cannot be
regarded as representative of the pulmonary TB population.
Conclusion
The MST appears to be a reliable tool for nutritional risk
assessment of patients with pulmonary TB. This risk assessment
tool can play a valuable role in quickly identifying patients at an
increased risk of death and providing adequate nutritional
support.
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