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Malnutrition & Oral Nutritional Supplements

Checked: 23-04-2022 by Vicky Ryan Next Review: 23-04-2023

Overview

Malnutrition can happen very gradually, which can make it very difficult to spot in the early stages. NICE guidelines (CG32) recommend screening using MUST on initial registration at GP surgery, when there is clinical concern and to monitor weight at annual reviews for long term conditions.

Some of the symptoms and signs to watch out for include:

Loss of appetite
Weight loss – clothes, rings, jewellery, dentures may become loose
Tiredness
Reduced ability to perform normal tasks
Reduced physical performance – e.g. not being able to walk as far or as fast as usual
Altered mood – malnutrition can be associated with lethargy and depression
Poor concentration
Problems with skin integrity- delayed wound healing

Calculate the MUST score

MUST (Malnutrition Universal Screening Tool) has been developed by BAPEN (November 2003) and recommended by NICE CG32 Nutrition support in adults (February 2006).

MUST is a five-step screening tool to identify adults, who are at low, medium or high risk of malnutrition.

It includes management guidelines which can be used to develop a care plan.

An electronic MUST Calculator is available at: http://www.bapen.org.uk/screening-for-malnutrition/must-calculator

For Full Detailed BAPEN Guidance see: http://www.bapen.org.uk/pdfs/must/must-full.pdf

An alternative MDCalc MUST score calculator is available here: Malnutrition Universal Screening Tool (MUST) - MDCalc

Patients can self-screen for unexplained weight loss using the BAPEN Malnutrition Self-Screening website: https://www.malnutritionselfscreening.org/

Management

Low Risk - ‘MUST’ score = 0.

This is a normal score so observation/monitoring only is required

Repeat screening annually for at risk groups e.g. COPD, those >75 years of age or based on clinical concern.

Medium Risk- ‘MUST’ score = 1 or 2

Implement food first advice and consider the use of over the counter (OTC) supplements (e.g. meritene, complan, nurishment, Aymes etc)

Food First advice should be trialed for 2 - 4 weeks. If goals are not achieved, consider prescribing Oral Nutritional Supplements (ONS) twice daily, supported by a planned review process.

For patients with disease-related malnutrition, please refer to the Pathway for prescribing Oral Nutritional Supplements (ONS) in BNSSG for disease-related malnutrition (DRM) for further information.

Please see the BNSSG Formulary for full details on initiating and choice of First Line ONS in community settings.

Manage in primary care with advice & guidance (A&G) support from Sirona Nutrition Specialist Service A&G via email: sirona.dieteticsadvice@nhs.net

Diagnosed Learning Disability with ‘MUST’= 1
Diagnosed dysphagia by Speech and Language Therapy (SaLT) assessment alongside a neurology diagnosis (e.g. MND)
‘MUST’ score = 2 with no improvement after a 4 week implementation of food first advice
Review of suitability of current ONS prescription

Please see Sirona care & health - Nutrition and Dietetics referral pathway for adults within BNSSG for full details which is on the Nutrition & Dietetics Local Services page of Remedy

Refer

Please see Nutrition & Dietetics Local Services for referral options if a patient is in one or more of the following categories:

Diagnosed Learning Disability with ‘MUST’ > 2
Diagnosed dysphagia by SaLT alongside a neurology diagnosis (e.g. MND) and no improvement after a 4 week implementation of food first advice and first line ONS
‘MUST’ score = 2 with no improvement after a 4 week implementation of food first advice and first line ONS
More than 15% unintentional body weight loss in the last three months
‘MUST’ >3

Resources

Sirona Leaflet Library - Nutrition & Dietetics - Malnutrition

Sirona Leaflet Library - Nutrition & Dietetics - Nutrition & Hydration

Sirona Leaflet Library - Nutrition & Dietetics - Easy Read Information

Sirona information for Professionals including Nutrition Care Plans

BNSSG Formulary - Nutrition Chapter including useful links to Malnutrition resources

Managing Adult Malnutrition https://www.malnutritionpathway.co.uk/

Resources for health care professionals https://www.malnutritionpathway.co.uk/healthcare-index

Managing malnutrition in COPD Managing Malnutrition: COPD (malnutritionpathway.co.uk)

Videos with dietitians making up fortified foods:

Fortified Custard (youtube.com)

Fortified Milk (youtube.com)

Fortified Soup (youtube.com)

Fortified Porridge (youtube.com)

Fortified Dairy-free Milk (youtube.com)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.