Understanding the MUST Framework
The Malnutrition Universal Screening Tool (MUST) is a validated, evidence-based assessment designed to help healthcare professionals and other care workers systematically identify malnutrition risk in adults. It is a structured process that combines anthropometric measurements and clinical observations to produce a final score, which then guides management decisions. Following a standardized procedure ensures consistent and reliable results, which is essential for effective nutritional care.
Preparing for the Assessment
Before beginning, ensure you have the necessary equipment and have followed the correct procedures for interacting with the patient. This includes introducing yourself, confirming identity, explaining the procedure, and gaining consent. Necessary equipment typically includes calibrated scales and height measures. Consider any patient-specific factors like mobility, fluid retention, or amputations.
Step 1: Calculating the Body Mass Index (BMI) Score
This first step involves determining the patient's BMI and assigning a corresponding score. BMI is calculated using the formula weight (kg) / height (m)$$^2$$. The score is based on the BMI result: Score 0 for BMI > 20, Score 1 for BMI 18.5–20, and Score 2 for BMI < 18.5. For obese patients, BMI > 30 receives a score of 0.
Using Alternative Measurements
If standard height and weight measurements are not feasible, alternative measurements such as Mid-Upper Arm Circumference (MUAC) or ulna length can be employed to estimate BMI.
Step 2: Determining the Weight Loss Score
Step 2 assesses unplanned weight loss over the previous 3 to 6 months. This calculation uses the formula: [Usual Weight - Current Weight] / Usual Weight * 100. Scores are assigned based on the percentage of weight loss: < 5% receives a score of 0, 5–10% receives a score of 1, and > 10% receives a score of 2.
Step 3: Assessing the Acute Disease Effect Score
This step evaluates the impact of recent or current acute illness on nutritional intake. A score of 2 is given if an acute illness has resulted in, or is likely to result in, little to no nutritional intake for over 5 days. Otherwise, the score is 0.
Step 4: Adding the Scores for Overall Risk
The total MUST score is the sum of the scores from Steps 1, 2, and 3. This total score indicates the overall risk of malnutrition: Score 0 signifies low risk, Score 1 indicates medium risk, and a score of 2 or more denotes high risk.
Step 5: Developing a Management Plan
The final step is to create and implement a management plan tailored to the patient's identified risk level and local care policies.
MUST Risk Level Comparison
| Risk Level | Total MUST Score | Management Recommendation |
|---|---|---|
| Low Risk | 0 | Routine clinical care and regular re-screening. Frequency depends on the setting: annually in the community, monthly in care homes, and weekly in hospitals. |
| Medium Risk | 1 | Observe dietary intake over 3 days. If intake is sufficient, continue routine care and screening. If intake is inadequate, initiate an action plan to boost intake and monitor closely. |
| High Risk | 2 or more | Refer to a dietitian or nutritional support team. Develop a comprehensive plan to enhance nutritional intake and monitor the patient's progress weekly. |
Important Considerations and When to Re-Screen
- Monitoring progress: Regular monitoring of intake and weight is essential for medium- and high-risk patients, with re-screening frequency dependent on the setting and progress.
- Clinical judgement: MUST is a guide; clinical judgement should take precedence for patients with complex needs or in end-of-life care. Adjustments might be needed for conditions like pressure ulcers.
- Documentation: Proper documentation of all steps, scores, and plans is vital for continuity and quality care.
Conclusion
Completing a MUST assessment is a crucial step in identifying and addressing malnutrition and obesity risk in adults. By following the five systematic steps – measuring BMI, quantifying weight loss, assessing acute disease effect, combining scores, and implementing a targeted care plan – healthcare providers can ensure appropriate nutritional support, improving patient outcomes and well-being. For more resources, consult the BAPEN website.
Other Nutritional Assessment Tools
While MUST is widely used, other tools exist, like the Mini Nutritional Assessment (MNA) for older adults. The choice depends on the population and setting, but MUST provides a robust framework. Proficiency in MUST is a core skill for many care professionals.
Alternative Measurement Methods Explained
When direct weight/height aren't possible, alternative methods like ulna length to estimate height and MUAC to estimate BMI provide reliable estimates. These methods are useful for frail or bedridden patients. Proper training is needed for accuracy, and documentation should note when alternative methods are used and why.
