Malnutrition: MUST be seen by a Dietitian

Malnutrition – How to MUST?

Malnutrition can be defined as when you get too little or too much of any nutrient which can have a detrimental effect on the body.


MUST: Malnutrition Universal Screening Tool

Malnutrition Universal Screening Tool (MUST) is used in all acute settings across the UK to determine the need for nutritional intervention.

When in the acute setting high priority individuals are those with a MUST score of 2 or above. These patients have a poor nutritional status due to their acute condition, weight loss or low body mass index (BMI). Nurses are to complete this tool as part of the patient’s admission in order for a dietetic referral to be made as soon as possible to improve nutritional status. From experience this task is usually poorly carried out possibly due to limited understanding, inadequate training or time pressures. As a result the patients overall health can continue to deteriorate as nutrition is a key element in recuperation. This post will therefore help to guide you through the process and help you to optimise your patient’s nutritional intake.



Firstly some facts and figures to put malnutrition into perspective. BAPEN estimates that around 3 million individuals within the United Kingdom are suffering from malnutrition. This is costing the National Health Service over a whopping £13 billion each year. Studies suggest that the use of nutritional supplementation in those who are malnourished decreases infections and pressure sores by 70% and reducing death by 40%. NICE have noted that the provision of adequate nutrition and hydration for inpatients and those in care homes would be one of the most effective ways to cut costs in the NHS. Oral nutritional supplements, enteral and parenteral nutrition only amount to 2% of the total bill for malnutrition each year. Taking into account all of the above it can be seen that by screening for malnutrition and diagnosing early can benefit both the patient and the health service.

Clinical Effects of Malnutrition


MUST Process

MUST is a simple 5 step process that should be carried out on admission as accurately as possible.


Step 1: Weight and Height

Weight and height are the main measure that should be recorded initially. A precise weight gives dietitians the ability to estimate requirements accurately for weight maintenance, weight gain or weight loss. Height helps to calculate BMI which is the initial indicator of malnutrition risk.

It can be difficult to obtain weights and heights in an acute setting if patients are very unwell. There are however other options to estimate weights and heights such as mid upper arm circumference and ulna length. These options can be used on those who are bed bound so no excuses. The MUST tool comes with guidance how to complete these measurements. This should be something student nurses are taught during placement in order to retain this information when they are fully qualified. Any nurses who are unfamiliar with these measurements should be retrained. If you are unfamiliar with any of the above measurements it is important to bring this to the attention of your ward sister so that further training can be arranged. Please do not be afraid to ask for help as when you know how to proceed correctly it makes the MUST recording more accurate and will help dietitians to improve nutritional status. It will also speed up the time frame from referral to assessment.


Step 2: Weight Loss

Weight loss is the next determining factor of whether a referral to the dietetic department is appropriate. Note unintentional weight loss is what should be documented. The percentage can be calculated using this equation:


Tables of percentage weight loss are also provided with this tool so you can estimate at a glance. The unfortunate thing about determining weight loss in an acute setting is the issue of unavailable weight histories and majority of times especially in elderly care (those most at risk of malnutrition) the can have poor recall or confusion due to acute illness. This means that most of the time this section receives a score of 0. This could be corrected by obtaining a weight history from GP, nursing home or next of kin. In most cases the doctor/ nurse need to find out medical history, medication list, history of presenting complaint from these sources. Therefore all it would take to obtain an accurate weigh history is ask one extra question at time of admission. Other ways to determine weight loss is if it is extremely difficult to obtain a weight history could be jewellery or clothing are loose, problems with eating, refusing food or any issues that would indicate that getting enough food to maintain weight would be difficult. Remember nutrition is extremely important in overall health and without it healing takes longer.

Causes of Malnutrition


Step 3: Acute Disease Effect

Step number 3 is most likely the simplest of questions as it determines if the acute disease has caused limited nutritional intake for more than 5 days. As nurses are working closely with the patient they will know how ill they are and how much they are able to eat. It is recommended to commence food charts if you believe the patient is at risk as this enables dietitians during assessment to quickly estimate nutritional intake in relation to nutritional requirements and provide adequate nutritional support to improve the dietary situation.


Step 4: Add Scores of Steps 1-3

Finally adding all of the previous steps to get a total. This total will determine the risk. It is indicated on the tool how to interpret results and what to do with each score.


Step 5: Develop Care Plan

It is imperative that if a MUST scores >2 the patient should be referred to appropriate dietitian or nutritional support team as soon as possible. Once the patient has reached this stage they have a low BMI, significant weight loss or are extremely ill.

As a dietitian’s we want to improve quality of life by optimising nutritional intake, maintaining lean body mass and maintaining tissue integrity to prevent hospital stays that can be uncomfortable, unfamiliar and upsetting. In order to do this all health professionals need to recognise the importance of nutrition in health and disease prevention.

We need to eat to live therefore let’s help the population find the right balance. Remember nurses are the gateway for patients to receive the correct support as they know their patient’s better than anyone. This support will only be provided however if the correct referral process is followed as a result getting information right first time will most definitely improve waiting times and promote accurate assessment. All health professionals need to work together to ensure the patient receives all the support they need for optimum health status.


Key Points to take away

  • Accurate weight and heights are a MUST
  • Obtain weight history at admission
  • Ask for training if unsure
  • Refer if appropriate


‘Alone we can do so little together we can do so much.’

‘Excellence is not a skill it is an attitude.’

‘Most of the seven billion people in the world suffer from malnutrition. Half have too little food and the other have too much.’


Publication Information


Rachel Fitzsimons, Registered Dietitian, DT27002