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Measuring and recording a patient’s nutritional status/risk of malnutrition and calculating a malnutrition universal screening tool (MUST) score can appear in OSCEs. You’ll be expected to correctly record your findings and accurately calculate a MUST score.
Malnutrition is a state in which a lack of nutrition causes measurable adverse effects on health. It can be both a cause and an effect of ill health. Adverse social factors can also increase the risk of an individual becoming malnourished.1-2 Despite a high prevalence, people with or at risk of developing malnutrition are often not identified and remain untreated.3
Due to the high prevalence of malnutrition, its adverse health effects, and frequent failure to identify and treat, MUST is an important screening tool. Developed by the British Association for Parenteral and Enteral Nutrition (BAPEN), it aims to provide healthcare professionals with a standardised approach to identifying and managing malnutrition.4
Indications
Patients should be screened opportunistically in the community, such as during a routine health check, then a minimum of annually if deemed to be at low risk.3, 5
In primary care, individuals should be screened following admission to a new care setting, such as a care home, then a minimum of monthly if low risk.3, 5
In secondary care, individuals should be screened on admission, and then at least weekly if low risk.5
MUST screening should also be completed whenever there is a clinical concern of malnutrition, including, but not limited to:3
- Unplanned weight loss
- Reduced appetite
- Difficulty swallowing
- Altered bowel habits
Gather equipment
Gather the relevant equipment required for the MUST:
- Height stick (stadiometer)
- Tape measure
- Weighing scales
- MUST documentation toolkit
Introduction
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Briefly explain what the procedure will involve using patient-friendly language.
Gain consent to proceed with recording MUST.
Ask if the patient has any pain before proceeding.
Malnutrition universal screening tool (MUST)
The MUST is an assessment of a patient’s nutritional status that aims to identify individuals who are malnourished or at risk of malnutrition, as well as obesity. The MUST assessment comprises five steps. Steps 1-3 gather important information about the patient’s current nutritional status, and steps 4-5 categorise the patient based on risk and provide guidance on subsequent management.
- Step 1: body mass index (BMI) score
- Step 2: weight loss score
- Step 3: acute disease effect score
- Step 4: combines the scores of steps 1-3 to give a MUST score
- Step 5: management guidelines are directed based on risk of malnutrition5
Step 1: BMI score
BMI is calculated by dividing an individual’s weight in kilograms by the square of their height in centimetres:
Height measurements should be taken using a height stick (stadiometer) where possible. Ensure it is correctly positioned, with the patient standing upright, shoes removed, feet flat, and heels against the height stick or wall. Ask the patient to look straight ahead and lower the head plate until it gently touches the top of the head.
Weight measurement should be taken with clinical scales where possible, ensuring scales are set to zero before taking a reading. Ensure the patient has removed their shoes and is wearing light clothing.
Once height and weight have been measured, calculate the BMI using the BMI chart. This also provides imperial measurements (stones, pounds, feet, and inches).5
Based on the patient’s BMI measurement, a score is assigned for step 1:
- >20 kg/m2 (>30 Obese), score 0
- 5 – 20 kg/m2, score 1
- <18.5 kg/m2, score 2
Alternative measurements and considerations
If the patient’s height or weight cannot be measured accurately, use a recently recorded measurement or a measurement reported by the patient if it is deemed reliable and realistic.
Alternatively, height can be estimated by measuring the length of the patient’s ulna from the elbow (olecranon process) to the wrist (styloid process). Ideally, the left arm is used.
Step 2: weight loss score
Step 2 specifically aims to assess unplanned weight loss in the last 3-6 months. This information can be obtained from either the patient or from recent weight measurements recorded in the patient’s medical records.
The amount of unplanned weight loss is calculated as a percentage of total body weight.5
Based on the percentage measurement, a score is assigned for step 2:
- <5%, score 0
- 5-10%, score 1
- <10%, score 2
If height, weight or unplanned weight loss measurements cannot be obtained, then subjective criteria must instead be used.5
Subjective criteria
The subjective criteria aim to establish a clinical impression of the patient’s risk of malnutrition when objective forms of measurement are not obtainable. The assessor no longer uses the scoring system in steps 1, 2 and 3. Instead, clinical judgement is used to establish an overall low, medium or high malnutrition risk based on subjective criteria.5
BMI
- Clinical impression – thin, acceptable weight, overweight. Obvious wasting (very thin) and obesity (very overweight) can also be noted.
- Mid upper arm circumference (MUAC) may be used to estimate BMI category in order to support your overall impression of the subject’s nutritional risk.
Unplanned weight loss
- Clothes and/or jewellery have become loose fitting (weight loss).
- History of decreased food intake, reduced appetite or swallowing problems over 3-6 months and underlying disease or psycho-social/physical disabilities likely to cause weight loss.
Acute disease effect
-
Acutely ill and no nutritional intake or likelihood of no intake for more than 5 days.
Step 3: acute disease effect score
If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days, there is an increased risk of malnutrition associated with acute illness. Both must be present to score as ‘yes’.
- If no, score 0
- If yes, score 2
It is unlikely that patients will score in community or outpatient clinic settings.5
Summary of MUST criteria (steps 1-3)
| Step | Criteria | Score |
| Step 1: BMI score | >20 (>30 obese) | 0 |
| 18.5-20 | 1 | |
| <18.5 | 2 | |
| Step 2: weight loss score | <5% | 0 |
| 5-10% | 1 | |
| >10% | 2 | |
| Step 3: acute disease effect score | No acute illness present or unlikely to receive no nutrition for >5 days | 0 |
| Acute illness and no nutrition or likely no nutrition >5 days | 2 |
Step 4: overall risk of malnutrition
Scores for steps 1-3 are combined to give an overall MUST score. Patients may score a minimum of 0 and a maximum of 6. Based on this score, an overall risk of malnutrition is given:5
- Score 0: low risk of malnutrition
- Score 1: medium risk of malnutrition
- Score 2 or more: high risk of malnutrition
Step 5: management guidelines
Based on the overall risk of malnutrition, step 5 provides guidance for ongoing patient management.5
For all patients, ensure that the category is recorded alongside any need for special diets (local policy should be followed in relation to special diets). The MUST also recommends recording the presence of obesity. However, treating any underlying clinical conditions will generally take priority over treating obesity.5
Low risk
Patients at low risk of malnutrition should undergo routine clinical care and be appropriately rescreened using the MUST; the frequency of rescreening is dependent on the clinical setting and patient group:
- Hospital: weekly
- Care home: monthly
- Community (specific groups only): annually
Medium risk
Patients at medium risk of malnutrition should be initially observed by documenting dietary intake over 3 days.
If intake is deemed to be adequate and there are no other nutritional concerns, the patient will revert to routine clinical care and defined rescreening.
If intake is deemed inadequate, clinical concerns should be raised, and local policy should be followed. Generally, local policy should plan, monitor, and review goals to improve and increase nutritional intake.
High risk
Patients at a high risk of malnutrition should be treated following local policy; this may include appropriate escalation to a dietitian or nutritional support team. Again, in general, local policy should look to plan, monitor and review goals to improve and increase nutritional intake.5
To complete the assessment…
Explain to the patient that the assessment is now complete.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your findings and MUST score.
References
- National Institute of Health and Care Excellence (NICE). Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. NICE guideline [CG32]. 2017. Available from: [LINK]
- British Association for Parenteral and Enteral Nutrition (BAPEN). Available from: [LINK]
- National Institute of Health and Care Excellence (NICE). Adult malnutrition. 2024. Available from: [LINK]
- British Association for Parenteral and Enteral Nutrition (BAPEN). ‘MUST’ & Self-Screening. Available from: [LINK]
- British Association for Parenteral and Enteral Nutrition (BAPEN). THE ‘MUST’ EXPLANATORY BOOKLET: A Guide to the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for Adults. 2011. Available from: [LINK]
Figure references
- Figure 1-4. British Association for Parenteral and Enteral Nutrition (BAPEN). ‘MUST’ & Self-Screening. Available from: [LINK]
Malnutrition universal screening tool
A copy of the full ‘MUST’ screening tool and the explanatory booklet are available to download.
‘MUST’ is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). For further information on ‘MUST’ see www.bapen.org.uk Copyright © BAPEN 2012 (licence number LIC2206)
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