Patient in own home Community Malnutrition Screening Tool (Adults) based on the Malnutrition Universal Screening Tool ( MUST )

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1 Step 1 (Use page 2/3 for BMI score) BMI kg/m 2 Great Western Hospitals Patient in own home Community Malnutrition Screening Tool (Adults) based on the Malnutrition Universal Screening Tool ( MUST ) + Step 2 + More than score = 0 (More than = Obese).5 - score = 1 Less than.5 score = 2 (Use page 5 for score) Unplanned % in past 3-6 months Less than 5% score = % score = 1 More than 10% score = 2 NHS Foundation Trust Step 4 Overall risk of malnutrition Add scores together to give overall risk of malnutrition and complete FOOD is a MUST screening record Step 5 Management guidelines for each score Step 3* Acute disease effect score If patient is acutely ill and there has been or is likely to be no nutritional intake for more than 5 days Score 2* * Rarely needed in the community Note specific concerns Re-feeding Risk: Those who have eaten little or nothing for 5 days or more should have nutritional support introduced gradually and be monitored closely. Those at high risk of malnutrition on MUST may be at risk of re-feeding syndrome. Refer to page of CG Nutrition support in adults: quick reference guide on for further information. Dysphagia: Individuals with signs of dysphagia require further investigation, refer to Speech and Language Therapy. = Low Risk Record aims of treatment and actions on FOOD is a MUST screening record Consider healthy diet information For printable information on healthy eating or, go to: uk.com/foodfacts Score 1 = Medium Risk = FOOD FIRST Record aims of treatment and actions on FOOD is a MUST screening record** Complete FOOD is a MUST care plan Manage factors which affect food intake*** Follow the FOOD FIRST approach for improving nutrition (see page 6): Provide Food First advice for improving nutrition leaflet Encourage fortified food and 2 nourishing drinks and 2 nourishing snacks daily between meals Advise a daily multivitamin and mineral Score 2 or more = High Risk = FOOD FIRST Record aims of treatment and actions on FOOD is a MUST screening record** Complete FOOD is a MUST care plan Manage factors which affect food intake*** Follow the FOOD FIRST approach for improving nutrition (see page 6): Provide Food First advice for improving nutrition leaflet Encourage fortified food and 2 nourishing drinks and 2 nourishing snacks daily between meals Advise a daily multivitamin and mineral If patient cannot implement Food First advice, consider following Score 2 or more on review box Repeat MUST Monthly on REVIEW Reduce then discontinue ONS. Return to normal, balanced diet. If still concerned about adequacy of nutritional intake Continue multivitamin and mineral. Score 1 on REVIEW Continue with FOOD FIRST approach and complete review on FOOD is a MUST care plan, repeat MUST monthly. If deteriorating or ongoing concerns Consider treating as high risk (see Score 2 or more on review box). Score 2 or more on REVIEW**** If weight stable or increased in the last month Continue with FOOD FIRST approach and complete review on FOOD is a MUST care plan, repeat MUST monthly. If weight decreased in the last month or unable to implement FOOD FIRST advice Contact GP to request a review. Ask GP to start 2 x first line oral nutritional supplements (ONS) daily. Trial for 2 weeks, check acceptability and try other types and flavours if necessary before issuing a monthly prescription# If weight decreasing after 1 month on ONS Ask GP to refer to Dietitian for further advice**** ** Aims of treatment could include weight maintenance or gain, improved nutritional intake, wound healing, pressure area care, improvements in psychological health and improvements in physical health. *** Factors which may affect appetite include nausea and/or vomiting, constipation or diarrhoea, medication, alcohol and drug use, social concerns (ability to shop, cook and eat) and availability of suitable meals. **** Unless detrimental or no benefit expected from nutritional support, e.g. terminal stage of illness. # Guideline for Prescribing Oral Nutritional Supplements (ONS) for Adults in the Community The Malnutrition Universal Screening Tool ( MUST ) is adapted and reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). For further information on MUST see 1

(kg) (kg) Step 1 BMI score (& BMI) Height (feet and inches) 4'9½ 4'9½ 4'10½ 4'11 5'0 5'0½ 5'1½ 5'2 5'3 5'4 5'4½ 5'5½ 5'6 5'7 5'7½ 5'8½ 5'9½ 5'10 5'11 5'11½ 6'0½ 6'1 6'2 6'3 6'3½ 6'4½ 100 100 47 47 46

2 (kg) (kg) Step 1 BMI score (& BMI) Height (feet and inches) 4'9½ 4'9½ 4'10½ 4'11 5'0 5'0½ 5'1½ 5'2 5'3 5'4 5'4½ 5'5½ 5'6 5'7 5'7½ 5'8½ 5'9½ 5'10 5'11 5'11½ 6'0½ 6'1 6'2 6'3 6'3½ 6'4½ Height BAPEN Height BAPEN Note : The black lines denote the exact cut off points (, and.5 kg/m 2 ), figures on the chart have been rounded to the nearest whole number. (obese) (obese) Score 1 Score 1 Score 2 Score 2 Note : The black lines denote the exact cut off points (, and.5 kg/m 2 ), figures on the chart have been rounded to the nearest whole number. 2 (stones (stones and and pounds) pounds) BMI chart reproduced with the kind permission of BAPEN

3 (kg) (kg) Step 1 BMI score (& BMI) Height (feet and inches) 4'9½ 4'10½ 4'11 5'0 5'0½ 5'1½ 5'2 5'3 5'4 5'4½ 5'5½ 5'6 5'7 5'7½ 5'8½ 5'9½ 5'10 5'11 5'11½ 6'0½ 6'1 6'2 6'3 6'3½ 6'4½ Height (feet and inches) '9½ 4'10½ 4'11 5'0 5'0½ 5'1½ 5'2 5'3 5'4 5'4½ 5'5½ 5'6 5'7 5'7½ 5'8½ 5'9½ 5'10 5'11 5'11½ 6'0½ 6'1 6'2 6'3 6'3½ 6'4½ Height BAPEN 15 BAPEN Note : The black lines denote the exact cut off points (, and.5 kg/m 2 ), figures on the chart have been rounded to the nearest whole BAPEN number. BAPEN Score (obese) 0 (obese) Height Note : The black lines denote the exact cut off points (, and.5 kg/m 3 2 ), figures on the chart have been rounded to the nearest whole number. (stones (stones and pounds) and pounds) BMI chart reproduced with the kind permission of BAPEN

4 Alternative Measurements If height cannot be measured use recently documented or self-reported height (if reliable and realistic) OR use ulna length to estimate height (see below). If height and weight cannot be obtained use mid upper arm circumference (MUAC) measurement to estimate BMI category (see below). MUAC is not designed to generate a score. If recent cannot be calculated use self-reported (if deemed reliable and realistic). Estimating height from ulna length Men (less than 65 years) Men (more than 65 years) Ulna length (cm) Women (less than 65 years) Women (more than 65 years) Measure between the point of the elbow (olecranon process) and the midpoint of the prominent bone of the wrist (styloid process) (left side if possible). Decontaminate tape measure after use. Mid upper arm circumference (MUAC) measurement to estimate BMI category Subjective Criteria Men (less than 65 years) Men (more than 65 years) Ulna length (cm) Women (less than 65 years) Women (more than 65 years) Bend the patient s left arm at the elbow at a 90 degree angle with the upper arm held parallel to the side of the body. Measure the distance between the bony protrusion on the shoulder (acromion) and the point of the elbow (olecranon process). Mark the mid-point. With the patient s left arm hanging loose, measure around the upper arm at the marked mid-point. Ensure that the tape measure is snug, but not tight. Decontaminate tape measure after use. If MUAC is less than.5cm, BMI is likely to be less than kg/m 2. If MUAC is greater than.0cm, BMI is likely to be greater than kg/m 2. These can be used if standard or alternative measurements cannot be obtained. Subjective criteria should be used together to aid the professional s judgement of the individual s overall malnutrition risk category (low, medium or high). These can be used if standard or alternative measurements cannot be obtained. 1. BMI: If the patient is thin or has protruding bones, malnutrition is possible. If the patient is of acceptable weight or over weight, malnutrition is unlikely. 2. loss: the presence of the following are suggestive of some degree of : Loose clothing, jewellery (e.g. wedding band, wrist watch). 3-6 month history of decreased food intake/appetite or swallowing problems and/or underlying disease likely to cause. 3. Acute disease effect: malnutrition risk is possible if the patient is acutely ill and has had no nutritional intake for more than 5 days. The Malnutrition Universal Screening Tool ( MUST ) is adapted and reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). For further information on MUST see 4

5 Step 2 loss score Start with person s CURRENT weight then read across to find where their PREVIOUS weight fits this weight gives the score. Current kg Previous kg (3-6 months ago) SCORE 0 Less than 5% SCORE 1 Between 5-10% SCORE 2 More than 10% kg less than more than.3 kg less than more than.4 kg less than more than.6 kg less than more than.7 kg less than more than.8 kg less than more than.9 kg less than more than.0 kg less than more than.1 kg less than more than 42.2 kg less than more than 43.3 kg less than more than 44.4 kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than 84.4 Current kg Previous kg (3-6 months ago) SCORE 0 Less than 5% SCORE 1 Between 5-10% SCORE 2 More than 10% 77 kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than 1.7 Current kg Previous kg (3-6 months ago) SCORE 0 Less than 5% SCORE 1 Between 5-10% SCORE 2 More than 10% 1 kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than kg less than more than 8.9 5

6 Great Western Hospitals Food First Advice for Improving Nutrition NHS Foundation Trust Food First is an approach to treating poor dietary intake and unintentional using every day nourishing foods and drinks. Please see below for suggested ideas to help improve the nutritional intake of an individual with a small appetite. Food First advice for Improving Nutrition patient information booklet is available to print from GWH intranet ( Small frequent meals and snacks Nourishing snacks or nourishing drinks between meals Recommend full fat or high energy options (if appropriate to medical conditions i.e. diabetes) Recommend the use of frozen or ready-made meals and snacks if food preparation is tiring Recommend food fortification to increase the nourishment from foods and drinks Ideas for Food Fortification Add butter to potatoes and vegetables Thickly spread butter on bread or toast Add grated cheese to mashed potato, soups, sauces and scrambled eggs Add sugar, honey or syrup to hot drinks, porridge, cereals and into puddings Add milk or cream to soups and sauces Use mayonnaise or dressing on salad or sandwiches Make hot drinks with fortified milk Nourishing Drink Ideas Hot or cold milky drink (0-450kcal) 0ml whole milk (full cream or full fat) 4 heaped tablespoons (tbsp) milk powder (or 2 heaped tbsp milk powder and 2 tbsp cream) 1-2 tbsp milkshake powder or syrup, instant coffee, hot chocolate or malted drink Nourishing instant soup (0kcal) 0ml whole milk 2 heaped tbsp milk powder 1 individual packet soup Created by Registered Dietitians The Nutrition and Dietetic Departments; (Salisbury District Hospital, Royal United Hospital, St Martins Hospital, Chippenham Hospital and The Great Western Hospital) Nourishing Snack Ideas Try eating one nourishing snack between each meal (mid-morning, mid-afternoon, before bed) Sweet options Milky puddings (rice pudding, custard, mousse) Whole milk yoghurts (full cream or full fat) Chocolate, biscuits, cakes, pastries Cereal or breakfast bars Dried fruit Tea cakes, scones, malt loaf, crumpets spread with butter and jam Breakfast cereal with fortified milk Savoury options Toast, crumpets, muffins, bread, bagel (with butter, cheese, ham, pate) Pork pie, sausage roll, scotch egg Cheese on toast, beans on toast Crisps, cheese and crackers Slice of pizza or quiche Nuts / Peanut butter How to make Fortified Milk Add 4-5 tablespoons of milk powder to 1 pint of whole milk Fortified milk can be used for milky drinks, milky puddings, porridge, cereal CS156 NHS Creative January 14 6

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