What is MUST and Why is it Necessary?
The Malnutrition Universal Screening Tool (MUST) is a simple, quick, and validated nutritional screening method developed by the British Association for Parenteral and Enteral Nutrition (BAPEN). It is designed for use by all care workers in various healthcare settings, including hospitals, community care, and care homes. The tool's primary purpose is to identify adults who are malnourished, at risk of malnutrition, or obese, allowing for the development of a suitable care plan. The necessity of MUST arises from the high prevalence of malnutrition and its adverse health consequences, which often go undetected. Regular and systematic screening, especially upon admission to a new care setting, is vital for early intervention.
The Five-Step MUST Screening Process
The MUST screening process is structured into five distinct steps. It is important to complete all steps sequentially to arrive at an accurate overall risk score and subsequent management plan.
Step 1: Calculate the BMI Score
Body Mass Index (BMI) is the first parameter measured. BMI is calculated by dividing an individual's weight in kilograms by the square of their height in meters.
- Score 0: BMI >20 kg/m² (>30 kg/m² is obese).
- Score 1: BMI 18.5–20 kg/m².
- Score 2: BMI <18.5 kg/m².
If height and weight cannot be reliably measured, alternative methods, such as using ulna length or mid-upper arm circumference (MUAC), can be used to estimate BMI category.
Step 2: Determine the Weight Loss Score
This step assesses the degree of unintentional weight loss over the past 3 to 6 months. Information can be gathered from patient records or by self-reporting.
- Score 0: Unintentional weight loss <5%.
- Score 1: Unintentional weight loss 5–10%.
- Score 2: Unintentional weight loss >10%.
Step 3: Assess the Acute Disease Effect Score
This step is crucial for hospitalized or acutely ill patients. A score is assigned if the patient is acutely ill and there has been, or is likely to be, no nutritional intake for more than 5 days.
- Score 0: No acute illness or unlikely to have no nutritional intake for >5 days.
- Score 2: Acute illness present with likely no nutritional intake for >5 days.
Step 4: Calculate the Overall Risk Score
To determine the overall risk of malnutrition, the scores from Steps 1, 2, and 3 are added together.
- Score 0: Low risk of malnutrition.
- Score 1: Medium risk of malnutrition.
- Score 2 or more: High risk of malnutrition.
Step 5: Develop a Management Plan
Based on the overall risk score, management guidelines are implemented. For all risk categories, the underlying condition should be treated, and help and advice on food choices should be provided.
- Low Risk: Routine clinical care and appropriate rescreening.
- Medium Risk: Observe and document dietary intake for 3 days. If intake is inadequate, follow local policy for improving nutritional intake.
- High Risk: Initiate local policy for nutritional support, which may involve referral to a dietitian or nutritional support team.
MUST vs. Other Nutritional Screening Tools
| Feature | Malnutrition Universal Screening Tool (MUST) | Nutritional Risk Screening 2002 (NRS-2002) | Mini Nutritional Assessment-Short Form (MNA-SF) |
|---|---|---|---|
| Target Population | General adult population in all care settings. | Hospitalized patients, as recommended by ESPEN. | Elderly patients, as recommended by ESPEN. |
| Key Parameters | BMI, unplanned weight loss, acute disease effect. | BMI, weight loss, food intake, disease severity. | Food intake, weight loss, mobility, acute disease, neuropsychological stress, BMI. |
| Number of Steps | 5 steps. | Initial screening questions, followed by a more detailed assessment. | 6-item questionnaire. |
| Ease of Use | Considered fast, easy, and user-friendly for all care staff. | Requires slightly more detailed patient information. | Quick to perform and validated specifically for older adults. |
| Detection | Identifies undernutrition and obesity. | Primarily focuses on undernutrition risk in hospitalized patients. | Specifically targets malnutrition risk in the elderly. |
Case Study: Implementing MUST in a Care Home
Consider a 78-year-old resident, Mrs. Davison, who has been in a care home for three months. Her MUST screening is performed by a care assistant during a routine health check.
- Step 1: Her BMI is 19.1 kg/m², which falls into the 18.5-20 kg/m² category. This gives her a score of 1.
- Step 2: Her weight records show an unplanned weight loss of 6% over the last six months. This results in a score of 1.
- Step 3: She is not acutely ill and has had consistent nutritional intake. Her score is 0.
- Step 4: The total MUST score is 1 + 1 + 0 = 2. This categorizes her as high risk of malnutrition.
- Step 5: The care home's policy for a high-risk score dictates a referral to a dietitian. The care plan includes monitoring dietary intake, food fortification, and a review of her nutritional progress.
This example demonstrates how MUST allows for early identification and tailored intervention, preventing Mrs. Davison's condition from worsening.
The Role of MUST in Modern Healthcare
The implementation of MUST is vital for modern healthcare systems to combat the widespread issue of malnutrition. Its universal applicability across different settings and its simplicity make it a cornerstone of nutritional care. By providing a standardized approach, MUST ensures that all healthcare professionals, regardless of their background, can effectively screen for malnutrition risk. Regular rescreening, as guided by the MUST management plan, ensures ongoing monitoring and adjustment of care, which is particularly important for patients with fluctuating clinical conditions. However, it is crucial to remember that MUST is a screening tool, not a diagnostic one. A high-risk score necessitates a more comprehensive nutritional assessment by a qualified professional, such as a dietitian.
Conclusion
In conclusion, the Malnutrition Universal Screening Tool (MUST) is an essential, easy-to-use five-step method for identifying adults at risk of malnutrition, undernutrition, or obesity across various care settings. By assessing BMI, unintentional weight loss, and acute disease effect, it provides a clear risk score that guides immediate and appropriate management plans. Its widespread use in the UK and recommendation by international bodies like ESPEN highlights its importance in enabling early intervention, improving patient outcomes, and standardizing nutritional care. While a powerful tool, it should always be used in conjunction with clinical judgment to ensure comprehensive and compassionate patient care.
Outbound link: Learn more about BAPEN and MUST
