Is MUST still a must for identifying malnutrition?

Malnutrition continues to be a common and costly problem in the UK

A recent report by BAPEN¹ (British Association of Parenteral and Enteral Nutrition) estimates that in England, the cost of malnutrition, identified using the Malnutrition Universal Screening Tool (MUST), is estimated to be an astonishing £19.6 billion. This represents approximately 15% of the total expenditure on health and social care and therefore presents itself as a significant public health problem. The report goes on to explain that although the high costs associated with malnutrition stem from institutionalised care, ‘since more than 90% of malnutrition originates and exists outside these institutions, preventive measures should be undertaken in the community to reduce the clinical and economic burden of malnutrition.’

Exactly what is malnutrition and what are the signs and symptoms of malnutrition?

Malnutrition (in this case defined as undernutrition,) is a state of nutrition in which a lack of energy, protein and other nutrients causes measurable adverse effects on body composition, size, shape, function and clinical outcome². Malnutrition can be found across all care settings, disease categories and individuals of all ages; although the prevalence is higher in hospitals (29% at risk) and nursing homes (41% at risk) and in adults over the age of 65 years (33% at risk vs. 25%³.)

Some of the signs and symptoms of malnutrition may include²:

• Loss of appetite
• Unplanned weight loss (clothes, rings, dentures may become loose)
• Tiredness and loss of energy
• Reduced physical strength and ability (such as not being able to walk as far or perform tasks as usual)
• Lethargy and depression
• Poor concentration

How can it be identified?

Screening for malnutrition is recommended by NICE Clinical Guideline 32 – Nutrition Support for Adults (NICE CG32⁴) and forms the basis of Quality Standard 24 (QS24⁵) which recommends that malnutrition screening should be carried out by healthcare professionals with appropriate skills and training and recommends the frequency of screening dependent on the care setting. The Malnutrition Advisory Group of BAPEN – a multi-disciplinary group of health professionals and patients – developed ‘MUST,’ a simple 5 step validated screening tool to detect undernutrition in adults of different ages and diagnoses in different healthcare settings.

The benefits of using the MUST Tool

MUST is easy to use and validated for the majority of patient groups and healthcare settings. MUST assesses three measures of increased risk:

• Body Mass Index (BMI) – calculated from a person’s weight and height. A BMI of less than 18.5kg/m² suggests a significant risk of malnutrition.
• Unplanned weight loss – the loss of more than 10% of normal body weight in the past 3 to 6 months suggests a greater risk of malnutrition.
• Acute disease effect – being acutely ill and unable to eat for more than five days.

From these three factors, the overall risk of malnutrition is determined; low, medium or high risk of malnutrition. It also guides the user to develop individualised care plans for dietary treatment as required and initiates further monitoring.

There is the potential for CCGs to make significant savings in healthcare costs if in every patient contact ‘MUST’ was a ‘must’ as this would increase the likelihood of earlier identification and management of malnutrition.

Indeed, ‘The Malnutrition Pathway⁶’, developed by a multi professional expert panel and endorsed by a range of professional bodies uses ‘MUST’ and acts as a practical guide to support GP’s and community healthcare professionals to identify and manage individuals at risk of malnutrition. It also includes guidance on prescribing, monitoring and stopping oral nutritional supplements.

What are the consequences of malnutrition?

The evidence is clear, malnutrition continues to go undetected and therefore untreated in many community settings. Malnutrition has adverse consequences for both individuals and the wider healthcare economy¹. For individuals it affects every system in the body always resulting in increased vulnerability to illness impacting on the wider healthcare economy through increasing healthcare use. There is strong evidence to suggest that those at risk of malnutrition have poorer clinical outcomes such as increased risk of infections and wound healing and greater healthcare use such as more hospital admissions, longer length of stays and more GP visits⁷. Therefore, preventive measures, such as MUST screening should be undertaken in the community to reduce the clinical and economic burden of malnutrition.

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References:

(1) NIHR & BAPEN: The cost of malnutrition in England and potential cost savings from nutritional interventions (2015.) https://www.bapen.org.uk/pdfs/economic-report-full.pdf

(2) BAPEN: Introducing ‘MUST’ http://www.bapen.org.uk/screening-and-must/must/introducing-must

(3) BAPEN: Managing malnutrition to improve lives and save money (2018.) https://www.bapen.org.uk/pdfs/reports/mag/managing-malnutrition.pdf

(4) NICE CG32 Nutrition support in adults (2006.) https://www.nice.org.uk/guidance/cg32

(5) NICE QS24 Nutrition support in adults (2012.) https://www.nice.org.uk/guidance/QS24

(6) Managing adult malnutrition (2012.) www.malnutritionpathway.co.uk

(7) Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: An evidence-based approach to treatment. Oxford: CABI Publishing; 2003