Nutrition and must

1. Malnutrition is a common problem in the UK;
however, it is frequently undetected (Elia
et al, 2005). Screening people for risk of
malnutrition is an important step in the identification of
malnutrition and forms the first stage of the nutritional
care pathway.This pathway includes screening, assessment,
implementation of a care plan, monitoring and review.
Nutrition screening tools have become a commonly
used method of identifying malnutrition. A range of
nutrition screening tools have been developed, measuring
a variety of nutrition parameters. Tools include the
Malnutrition Universal Screening Tool (MUST), Mini
Nutritional Assessment (MNA), Nutrition Risk Screening
(NRS) and many local nutrition screening tools (Nestlé,
1991; Elia, 2003; Kondrup et al, 2003; Stratton et al, 2004).
The National Institute for Health and Clinical Excellence
(NICE) has suggested that a nutrition screening tool
should be used in both hospitals and the community, and
that it should incorporate measures of body mass index
(BMI), percentage weight loss, presence of acute disease,
and the time frame over which weight loss has occurred
(NICE, 2006). Subsequently, MUST has been suggested
as a good nutritional screening tool to use (NICE, 2006).
In order to define how prevalent malnutrition is across
care settings, a common nutrition screening tool needs to
be used. During the development of MUST by the British
Association of Parenteral and Enteral Nutrition (BAPEN),
the tool was validated for use in both hospitals and the
community. Its validity was tested against other nutrition
screening tools that were already in use, including the
MNA and NRS. MUST was recorded as being quick and
easy to complete in a short period of time (Stratton et al,
2004). It has good concurrent validity with other nutrition
screening tools, and with its ability to be used in different
care settings,the tool is able to track individuals’nutritional
journey between care settings.
This paper discusses the prevalence of malnutrition
according to MUST screening in different settings, its
association with deprivation, healthcare outcomes and
cost, and the role of training in improving nutritional care
provision.
Prevalence of malnutrition in
hospitals and the community
MUST has been used to describe the prevalence of
malnutrition risk in a variety of care settings in the UK.
Notably, BAPEN’s Nutrition Screening Week surveys
reported the prevalence of malnutrition risk in hospitals,
care homes and mental health units in 2007, 2008 and
2010, with the final survey taking place in April 2011.
The number of centres that have taken part in the surveys
indicates the scale of adoption of MUST into a range
of healthcare settings in the UK, with 490 hospitals and
396 care homes participating over the course of the three
surveys. The results of the surveys have led to reports
that malnutrition may affect over 3 million people in the
UK, with the majority of malnutrition occurring in the
community (Elia et al, 2010).
Hospitals
The Nutrition Screening Week Surveys have reported that
approximately 28% of patients in UK hospitals are at risk
of malnutrition, with risk varying according to age and
diagnosis (Elia et al, 2008). From the results of national
surveys and other studies, older people and those with
cancer or gastrointestinal problems have been identified
as being at higher risk of malnutrition (Stratton et al,
2006; Elia et al, 2008). With hospital admission episodes
Nutritional care and the Malnutrition
Universal Screening Tool (MUST)
Emma Parsons
Research Fellow, Department of Nutrition and Dietetics, King’s College London Email: emma.l.parsons@kcl.ac.uk
Abstract
Malnutrition is a common and costly problem in the UK. Prevalence varies
according to setting, from 5% in GP surgeries to 42% in care homes;
however, malnutrition is frequently undetected. A variety of nutrition
screening tools have been produced, measuring a range of nutritional
parameters. Guidance from the National Institute for Health and Clinical
Excellence (NICE) recommends the use of a tool such as the Malnutrition
Universal Screening Tool (MUST) to screen for malnutrition risk in both
hospitals and the community. This article discusses the prevalence of
malnutrition according to MUST both in hospitals and the community. It also
considers the association between malnutrition and deprivation, healthcare
outcomes and cost, and the role of training in increasing nutritional
screening use and appropriate care plans. There is a need to ensure that
all people accessing healthcare services are screened for malnutrition, and
that nutritional care plans and interventions are initiated, monitored and
reviewed in order to improve health outcomes for malnourished people in
the UK.
KEY WORDS
w MUST w Nutritional screening w Deprivation w Cost
w Malnutrition prevalence w Nurse training
CLINICAL REVIEW
S16 Nutrition, May 2011

2. in England totalling 14.7 million per year (Department of
Health (DH), 2011), it provides an opportunity to identify
those at risk of malnutrition and initiate a nutritional care
package that could be continued in the community.
Outpatient clinics
Between November 2009 and October 2010 approximately
68.9 million people attended outpatient clinic appointments
in England (DH, 2011), and research into the prevalence
of malnutrition within people accessing this service is
growing. Given the large number of people that attend
outpatient clinics, they provide an ideal opportunity to
assess people’s nutritional risk in the community.
Two observational studies of malnutrition risk in
outpatients services in Southampton have reported
malnutrition risk to range from 16–21% (Rust et al, 2010;
Collins et al, 2010a). The first survey screened people
attending a range of outpatients clinics (n=321), with
the mean prevalence of malnutrition risk being 16%
(11% medium risk and 5% high risk) (Rust et al, 2010).
The prevalence of malnutrition increased with age, and
was more prevalent in women and those presenting to
gastroenterology clinics. Rust et al also found that the
majority of people were at risk due to weight loss rather
than low BMI.A further study by Collins et al, found that
21% of outpatients with chronic obstructive pulmonary
disease (COPD) were at risk of malnutrition (7% medium
risk, 14% high risk, n=425) (Collins et al, 2010a).The risk
was significantly higher in those with very severe COPD
(moderate 11%, severe 17%, very severe 36%; χ2=0.001).
Sheltered housing
With a growing number of people living in sheltered
housing, surveys to estimate malnutrition risk in this
population are emerging.Two recent observational studies
of varying size and location indicated that the prevalence
of malnutrition risk ranged from 10–12% (Harris et al,
2008; Ralph et al, 2010a).
In 2007, a small-scale observational study of 100 people
living in sheltered housing in Wales used the MUST to
assess risk of malnutrition.The study found that 10% were
at risk of malnutrition (Harris et al,2008).A similar finding
of 12% was reported by a larger study of 1053 people living
in sheltered housing in Wiltshire and Somerset in 2008
(Ralph et al, 2010a).They found that malnutrition risk was
higher in those aged greater than 80 years, compared with
younger people (Ralph et al, 2010a).The study by Ralph
et al (2010a) suggested that applying the figure of 12%
prevalence of malnutrition to the entire sheltered housing
population in the UK would equate to more than 67,000
people being at risk of malnutrition.
Care homes
BAPEN’s Nutrition Screening Week surveys represent
the largest national survey of nutritional screening in UK
care homes, with a combined total of approximately 3000
care home residents, who were screened in the 2007,
2008 and 2010 surveys (Russell and Elia, 2008; Russell
and Elia, 2009; Russell and Elia, 2011).The prevalence of
malnutrition ranged from 30% to 42%,with the prevalence
of malnutrition found to be higher in winter than summer
(Russell and Elia, 2008; Russell and Elia, 2009).
BAPEN has reported trends in malnutrition risk
according to increasing age, type of care home and
the presence of disease (Elia et al, 2008). It is, however,
important to note that the survey only included residents
admitted in 6 months prior to the surveys, and excluded
those already receiving nutritional interventions.
Other smaller surveys have taken place in care homes,
reporting the prevalence of malnutrition to range from
32% in care homes in Peterborough (n=703) (Cawood
et al, 2008) to 37% in Hampshire (n=1322) (Parsons
et al, 2010a) and 40% in Dorset (n=688) (Ralph et al,
2010b), which echo the figures reported by BAPEN.The
Hampshire and Dorset surveys both indicated trends in
malnutrition risk according to age and gender but no
differences according to length of stay.
Malnutrition screening in GP
surgeries
Currently, data on nutritional screening in GP surgeries is
limited.A recent survey of 54 GPs reported that only 10%
used a nutrition screening tool, with 90% of those who
used a tool using MUST (Cook et al, 2011).When asked
what they thought the prevalence of malnutrition was
among their patients, the mean prevalence of malnutrition
was reported to be 4.8% in this setting; however, responses
to the question ranged from 0–50% of people at risk,
clearly highlighting that further work is needed in order to
assess this patient group (Cook et al, 2011).
Associations between malnutrition
risk, deprivation and outcomes
In addition to data on the prevalence of malnutrition in
different care settings,the association between malnutrition
risk and deprivation and prediction of health outcomes has
been investigated.
The association between malnutrition and deprivation
varies according to setting. The Index of Multiple
Deprivation (Noble et al, 2008; NHS Executive, 2000)
has been used to measure deprivation in such studies.
It incorporates scores for income, employment, health
deprivation, education, housing and access to services.
Studies of hospital inpatients (Stratton and Elia, 2006)
and outpatients with COPD (Collins et al, 2010b) have
reported significant associations between malnutrition risk
and deprivation, with those at risk of malnutrition being
more likely to live in more deprived areas than those at low
risk of malnutrition.
Conversely, care home residents living in more
deprived areas were not at a significantly different risk
of malnutrition than those living in less deprived areas
(Parsons et al, 2010b).
CLINICAL REVIEW
S18 Nutrition, May 2011

3. Health outcomes and cost
The majority of the literature related to MUST and health
outcomes has taken place in hospitals, with reports that
MUST can predict mortality and length of hospital stay
(Stratton et al, 2006). There is evidence to suggest that
malnourished people have more infections and pressure
ulcers and visit their GP more often (Elia et al, 2005;
Stratton et al, 2006).
A survey of people screened for malnutrition risk in
outpatients clinics found that those at risk of malnutrition
experienced more hospital admissions (both planned and
emergency) over a 6 month period post MUST screening.
People at risk of malnutrition also had significantly longer
hospital stays,with the use of healthcare resources increasing
with level of malnutrition risk (Cawood et al, 2011).
Furthermore, a survey of malnourished people with
COPD attending outpatient appointments found that they
experienced twice the number of hospital admissions and
were three times more likely to die within the 6-month
period following screening for malnutrition risk, compared
to those at low risk of malnutrition (Collins et al, 2010c).
In both surveys the results for healthcare use and mortality
remained significant when adjusted for age.
With evidence linking malnutrition with increased use of
Nutrition, May 2011 S19
CLINICAL REVIEW
healthcare, it is clear that malnutrition is a costly problem.
It was thought that public expenditure on malnutrition in
the UK cost in excess of £13 billion in 2007 (Elia, 2010).
The evidence highlights the vast numbers of people at risk
of malnutrition, and without detection and treatment, the
consequences of the condition will remain costly, both
in terms of the health and quality of life of those with
malnutrition and to the healthcare system.
Nutritional care provision
Training the workforce
National guidance has highlighted the need to ensure
that nutritional screening takes place, and ensure that
appropriate care plans are put in place and monitored
(NICE, 2006; Care Quality Commission (CQC), 2010).
Reports have suggested that nutritional knowledge of
nurses in both hospitals and nursing homes and GPs is
variable and that further nutritional training is required
(Leung et al, 2011, O’Mahony et al, 2011).
Recent research has suggested that training nurses can
improve standards of nutritional care provided in hospitals
and care homes (Leung et al, 2011; O’Mahony et al, 2011;
Molyneux et al, 2011). Surveys of nurses in both Scotland
and Ireland have reported that providing nutritional training

4. fortification (addition of energy-dense foods or snacks)
or the use of oral nutritional supplementation (ONS)
(ready-made products containing energy, protein, vitamins
and minerals). For any person at risk of malnutrition, it
is important that a more in-depth assessment of their
nutritional status occurs post nutritional screening to
ensure the correct management plan is put in place (NICE,
2006; CQC, 2010; DH, 2010). Any form of nutritional
intervention should be monitored, and its effectiveness
reviewed at regular intervals.
Food fortification is normally provided as the first line
treatment of malnutrition;however,the evidence to support
its use is limited (Baldwin et al, 2007), and further research
is necessary in this area. There is a wealth of information
to support the use of ONS in malnourished people,
providing benefits to a range of clinical and healthcare
outcomes, particularly in the hospital setting (Stratton,
2005). However, ONS prescription varies according to
local prescription policy. Further research is required in the
community to determine the clinical benefits of providing
malnourished people with ONS.
Discussion
Malnutrition is under-detected and under-treated across
care settings in the UK. Since the development of MUST
almost a decade ago, it has become widely adopted by
the healthcare community. The tool has been used to
identify the scale of malnutrition risk in a variety of
settings. MUST has also been used to demonstrate the
association between malnutrition and the decline in health
of malnourished people, and the subsequent increase in the
cost of treating the consequences of malnutrition.Without
providing training to the healthcare workforce in detecting
malnutrition and implementing the appropriate nutritional
interventions, malnutrition will remain a common and
costly problem.
Nutritional screening needs to be recognized as an
important part of routine clinical practice and should be
viewed as the first step in a pathway to improving peoples’
nutritional status.Without ongoing monitoring and review
of people at risk of malnutrition, effecting changes in
nutritional care will be limited. There is also a need to
further explore the roles of nutritional interventions
such as food fortification and ONS in the management
of malnutrition in the hospital and community. Further
research would inform us on how to ensure people receive
interventions that best treat their nutritional status in terms
of improving their quality of life and clinical,functional and
healthcare outcomes.
Conclusion
Screening for malnutrition has indicated that malnutrition
is a significant problem in the UK and adversely effects
people’s health. There is a need to ensure that all people
accessing healthcare services are screened for malnutrition.
Nutritional care plans and appropriate nutritional
interventions can then be initiated,monitored and reviewed
CLINICAL REVIEW
S20 Nutrition, May 2011
to nurses can increase their knowledge, awareness and use
of MUST (Leung et al, 2011; O’Mahony et al, 2011). In
care homes, the provision of education to care home staff
improved the use of MUST, documentation of screening
results and care planning, and the implementation of food
fortification for those residents at risk of malnutrition.
With the introduction of nutritional education, the risk
of malnutrition among their residents declined from 38%
to 12% at medium risk and 35% to 27% at high risk,
with increased detection and implementation of food
fortification (Molyneux et al, 2011).
In order to identify GPs’nutritional training requirements,
their current knowledge of nutrition needs to be assessed.
Provision of nutritional education to doctors at medical
school has been limited. A survey of 54 GPs in southern
England found that many did not have any form of
nutritional training at (78%) or since (77%) medical school
(Chapman and Grimble, 2011). Despite NICE guidance
on nutrition support in adults having been published,
67% of GPs surveyed were unaware of the guidelines,
and 70% of those who were aware of the guidelines
had not implemented them (Cook et al, 2011). With
increasing onus on GPs to identify malnutrition, there is
a clear need to ensure that GPs, and their practice nurses,
receive training on malnutrition. Barriers to nutritional
counselling included lack of time, knowledge and low
patient compliance.The survey reported that the majority
of GPs felt that this could be improved if consultations
were longer, if they had more resources to give out and if
they had better access to dietitians (Chapman and Grimble,
2011).
Self-screening with MUST
In addition to the provision of training, new ways to
use MUST in outpatient clinics are being investigated.
At present MUST is normally completed by health
professionals in all settings; however, given the large
numbers of people accessing healthcare services, this
represents a significant challenge in terms of time and
resource.
Recently, the feasibility of self-screening in outpatients
clinics (n=205 outpatients) was trialled in Southampton
hospitals, and compared with health professionals screening
of the same patients, to check the validity of the results
(Stratton et al, 2011). The study found that self-screening
could be used to predict healthcare use and that there was
excellent agreement between the self-screening and health
professionals’ screening results. With the self-screening
forms, 71% of patients were able to complete the screening
independently in under 5 minutes (Stratton et al, 2011).
Nutritional care plans
Having screened people for malnutrition risk,it is important
for a care plan to be put in place, monitored and reviewed
in all settings.This may range from simply ensuring people
are re-screened at regular intervals, to implementing
nutrition support in the form of dietary counselling, food

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key points
w MUST is a quick, easy and validated screening tool that can be used for
the first stage in the nutrition care pathway
w Malnutrition risk in the community ranges from 4.8% in GP surgeries to up
to 42% in care homes
w Those at risk of malnutrition in the community could be identified using
MUST so that a nutritional care plan can be implemented and monitored
w GPs and nurses awareness of the current nutritional guidelines is variable
and they may require training
w Malnutrition has a clear cost implication as malnourished individuals use
more healthcare resources
Bridgit Dimond
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CLINICAL REVIEW
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