Understanding the Medium Risk Category
When a patient receives a MUST score of 1, they are classified as being at medium risk of malnutrition. The scoring process considers three key parameters: Body Mass Index (BMI), unplanned weight loss over 3-6 months, and the acute disease effect. A score of 1 can result from various combinations, such as a BMI between 18.5-20 kg/m² or a recent 5-10% unintentional weight loss. This medium-risk designation signals the need for observation and first-line dietary advice to prevent further nutritional decline.
The management of a medium-risk score focuses on a 'Food First' approach, which prioritizes using ordinary foods and drinks to boost a patient's nutritional intake. It is a less intensive intervention than the treatment required for high-risk patients but is crucial for reversing the initial signs of nutritional deficiency. Caregivers must understand that a MUST score of 1 is not a static result but a call to action requiring a structured and responsive care plan.
The Observation Phase: Documenting Intake
The first step in managing a MUST score of 1 is a three-day observation period. During this time, a detailed food and fluid intake chart must be maintained. This documentation is crucial for two reasons: it provides a clear picture of the patient's current consumption habits and helps identify potential issues, such as poor appetite, difficulty swallowing, or social factors affecting mealtimes.
After three days, the documented intake is reviewed. If the intake is found to be adequate and there are no further concerns, the patient can revert to routine clinical care, with rescreening scheduled for a later date. If, however, the intake is inadequate or other concerns arise, the care plan must be escalated.
Implementing the 'Food First' Approach
For patients whose intake is deemed inadequate, the 'Food First' strategy is the core of the nutritional care plan. The goal is to increase the daily intake of calories and protein without relying on medical supplements unless necessary.
High-Calorie and High-Protein Foods
- Fortified milk: Add milk powder to whole milk to increase its energy and protein content. This can be used in drinks, sauces, and soups.
- Enriched meals: Fortify main meals by adding butter, cheese, or cream to dishes like mashed potatoes, soups, and casseroles.
- High-energy snacks: Offer nutritious snacks between meals, such as cheese and crackers, yogurt, or nuts.
- Nourishing drinks: Encourage drinks like milkshakes, smoothies, and fruit juice, which provide extra calories and nutrients.
Managing Factors Affecting Intake
- Investigate and address the root cause of poor intake, including nausea, infection, medication side effects, or poor oral health.
- Ensure meals are served in a comfortable, uninterrupted setting with sufficient time for eating.
- Provide necessary assistance with eating and drinking, including adaptive utensils if needed.
- Address social issues that might impact nutrition, such as loneliness or inability to prepare food.
Comparison of Care for Different MUST Scores
| Feature | Low Risk (Score 0) | Medium Risk (Score 1) | High Risk (Score ≥2) |
|---|---|---|---|
| Intervention | Routine clinical care | Observation and 'Food First' | 'Food First' + escalation |
| Monitoring | Re-screen monthly (hospitals) or less frequently (community) | 3-day dietary intake chart; repeat MUST monthly (hospitals/care homes) | Refer to dietitian; weekly monitoring (hospitals) |
| Dietary Focus | Normal, healthy eating | High-calorie, high-protein fortification and snacks | Fortified diet, nourishing drinks, and possibly supplements |
| Referral | N/A | Consider if condition deteriorates or 'Food First' fails | Mandatory referral to dietitian/nutrition support team |
| Care Plan | Standard care plan | Observe intake, start 'Food First', set goals | Set goals, implement intensive nutritional support |
Monitoring and Escalation for a MUST Score of 1
Regular monitoring is a cornerstone of a medium-risk care plan. The frequency of rescreening with the MUST tool varies by care setting:
- Hospitals: Weekly rescreening.
- Care Homes: Monthly rescreening.
- Community: Every 2-3 months.
If the patient's nutritional status improves and their MUST score drops to 0, the 'Food First' care plan should continue until the treatment goals are met. The goal is to stabilize their weight and improve overall nutritional status.
However, it is vital to recognize when the medium-risk plan is not working. If a patient with a MUST score of 1 shows signs of deterioration—such as reducing appetite, further weight loss, or a worsening medical condition—they should be treated as high-risk. This triggers an immediate referral to a dietitian or nutrition support team for specialist intervention.
Conclusion
Identifying a must score of 1 is a critical alert for potential malnutrition, but it is a manageable condition with the right care plan. The combination of thorough intake observation, a proactive 'Food First' dietary strategy, and consistent monitoring empowers healthcare providers and caregivers to effectively address the risk. By focusing on enriched nutrition through everyday foods and managing factors that inhibit eating, most medium-risk patients can regain a healthier nutritional status. The management guidelines provided by BAPEN underscore the importance of this measured yet attentive approach, ensuring that a medium risk does not escalate into a more severe nutritional problem.
BAPEN 'MUST' Explanatory Booklet
What to Do If the MUST Score is 1: Summary
- Understand the Score: A MUST score of 1 indicates a medium risk of malnutrition, requiring observation and nutritional intervention.
- Document Intake: Conduct a three-day dietary intake chart to assess consumption patterns.
- Implement 'Food First': Fortify meals and encourage high-calorie, high-protein snacks and drinks.
- Manage Intake Barriers: Address potential causes of poor appetite, such as medical issues, medication side effects, or social factors.
- Monitor Progress: Regularly rescreen the patient based on their care setting to track improvements or signs of deterioration.
- Know When to Escalate: If the patient's condition worsens, treat as high-risk and refer to a dietitian.
- Create a Care Plan: Work with the healthcare team to develop a clear, documented plan outlining nutritional goals and actions.
What to Do If the MUST Score is 1: FAQ
Q: What is a MUST score of 1? A: A MUST score of 1 signifies that an adult is at a medium risk of malnutrition. It is a result of a screening tool that assesses Body Mass Index, unintentional weight loss, and the effect of acute illness.
Q: What is the first step for a MUST score of 1? A: The initial action is to observe and document the patient's dietary intake for a period of three days to get an accurate record of their nutritional consumption.
Q: What does 'Food First' mean for a score of 1? A: The 'Food First' approach means prioritizing nutritional enhancement using ordinary foods and drinks, rather than immediate reliance on medical supplements. It involves adding high-calorie and high-protein elements to the diet.
Q: How often should a patient with a score of 1 be rescreened? A: The rescreening frequency depends on the care setting. In hospitals, it is typically weekly; in care homes, monthly; and in the community, every 2-3 months.
Q: When should a referral be made for a score of 1? A: A patient with a score of 1 should be referred to a dietitian if their condition deteriorates, for example, if they experience further unintentional weight loss or show no improvement after a month of 'Food First' intervention.
Q: What are examples of 'Food First' strategies? A: Examples include fortifying milk with milk powder, adding butter or cheese to meals, providing nourishing drinks like milkshakes, and offering nutritious snacks between meals.
Q: Can a patient’s score drop from 1 to 0? A: Yes, if the patient's nutritional status improves and their weight stabilizes or increases, their MUST score can decrease to 0. In this case, the 'Food First' approach should continue until treatment goals are met.
