1. You can’t always tell by looking!
Who is at risk?
You can’t always tell by looking!
You need to use a validated screening tool to assess an individuals risk of malnutrition.
Who is at risk of malnutrition?
You cannot always tell by looking!
However people are great risk of becoming malnourished include:
-infants, young children and the elderly
Those from poor socio-economic groups
Individuals with acute illnesses
Those with chronic disease such as renal disease.

2. ‘MUST’ Malnutrition Universal Screening Tool
MUST is the only validated screening tool.
Not a diagnostic tool – identifies those at risk of malnutrition and highlights change in nutritional status.
This tool should be used on a monthly basis.
MUST is a 5 step process.
Each step gives a score.
The scores are added up to provide you (the professional) with management guidance.
Charts are provided to help assist you to complete each step.
‘People in care settings are screened for the risk of malnutrition using a validated screening tool’
• Not a diagnostic tool but can tell us who is at risk of malnutrition.
• MUST is the only screening tool that is validated for screening malnutrition (by who?)
• Used on a monthly basis.
• Easy to use.
• Highlights improvements as well as deteriorations in nutritional status and weight gain.
• Identify those at risk of malnutrition even if they are healthy or over weight.
Consider underlying cause for poor oral intake or weight loss e.g. dentures, infection, constipation.
SystmOne does have a MUST template which can used by HCPs.

3. ‘MUST’
In terms of time we understand that it may be challenging to complete this within the time frame of appointment, however other HCP can support with this.
ETC.
This flow diagram and charts are free to download from
Further instruction on using MUST is also available from this website.

4. ‘MUST’ management guidelines
Low Risk:
Aim to maintain a healthy weight and follow a balanced diet.
Medium Risk:
Increase oral intake by an extra 500kcal per day.
At least 2 nourishing drinks, snacks or a fortified diet are offered as per the service user’s preference.
High Risk:
Increase oral intake by an extra kcal per day.
At least 2 nourishing drinks, snacks and a fortified diet are offered as per the service user’s preference.
All service users who continue to lose weight after one month of following a fortified diet plan should be referred to the Nutrition & Dietetic service.
The MUST management guidelines detail what to when a persons nutritional risk has been calculated.
Medium risk; Extra 500 calories per day.
High risk; Extra calories per day.
3 ways in which we can acquire more calories for weight gain.
Food fortification
100 calorie boosters
Nourishing drinks.
An extra 500 calories per day = gaining 1lb (0.5kg) per week!

5. Food First Approach Food fortification Nourishing drinks
Adding extra energy and protein to foods/meals without increasing the quantity.
Nourishing drinks
Additional 300kcal and 12g protein (approx.) per serving best consumption in between meals.
100kcal boosters
For a little and often approach, for those with a small appetite.
Apple with Double
cream 32g
Sliced Apple 212g x2
- Food fortification: Adding extra nutrients to food to increase its nutritional and calorie content, without increasing the size of food.
Can help improve the taste and texture of foods. So this can be helpful with those on a soft diet.
We recommend using full fat products as a standard and avoid using the healthy or light versions because they contain more calories.
foods to fortify meals with are:
Sweet foods such as sugar, honey and jam or marmalade.
Dairy such as milk or skimmed milk powder, cream, cheese and butter
Sauces such as mayonnaise, salad cream or dressing, chocolate or strawberry.
This is 100 kcal worth of apple. By adding a table spoon of double cream you only need 3 slices to gain 100 calories.

6. Oral Nutritional Supplements (ONS) - Adults
What are ONS
Oral Nutritional Supplements (ONS) are sterile liquids or powders which provide macro and micro nutrients.
Typically used in addition to the normal diet, when diet alone is insufficient to meet daily nutritional requirements.

7. When to use ONS
It is essential that service users have been screened using a local malnutrition screening tool, e.g. Malnutrition Universal Screening Tool (‘MUST’) and deemed to be at nutritional risk.
Oral Nutritional Supplements (ONS) should only be prescribed to service users who meet the Advisory Committee for Borderline Substances (ACBS) prescribing criteria.
Local prescribing guidelines clearly state:
ALL patients requiring ONS should be referred to the dietitian, preferably before prescribing.
Prescribe for 1 week then review.
Most benefits shown in patients with BMI < 20
Do not use long term unless this is recommended by the dietitian
Avoid commencing for substance misuse patients or where no benefit expected e.g. end of life care.
ACBS indications for ONS
Following total gastrectomy
Disease- related malnutrition
Dysphagia
Intractable malabsorption
Bowel fistulas
Pre-operative preparation of patients who are undernourished
Short bowel syndrome
Proven inflammatory bowel

8. When to use ONS
The aim and expected outcome ONS must be identified and recorded at the beginning of treatment. E.g. increase weight or aid wound healing.
After 3 months, if service users are not progressing toward treatment goals, aims of treatment should be reassessed before continuing with a prescription of oral nutritional supplements.

9. Therapeutic dosage is twice (x2 bottles or sachets) daily.
Encourage service users to be screened monthly using MUST (e.g. by practice nurse) to ensure that ONS continues to be effective
Avoid prescribing ONS for longer than 12 weeks unless advised by a Dietitian.
Therapeutic dosage is twice (x2 bottles or sachets) daily.
Prescribing Guidelines – likely to change in due course with more variety and additional products
If ONS has been prescribed encourage that service users is screened monthly using MUST (e.g. by practice nurse) to ensure continues to be effective.
Limited evidence base that ONS are effective over 3 months. Needs to be reviewed/re-assess.
Prescription amounts, unless stated by a Dietitian volume expected should be 2 serving days. For ready to use compact ONS this would be 56 bottles / 7000ml. Sachets.

10. Which contains more calories and protein?
Home made milkshake
- 200ml whole milk.
- 20g skimmed milk powder.
- 20g milkshake powder.
- 1 tbsp double cream.

11. Taster session

12. Oral Nutritional Supplements In Luton Care Homes
Food First Dietitians manage older people care homes (>10 beds) across Luton and South Bedfordshire.
Open referral process:
Care home staff can refer directly to the team using our new referrals & if they meet the referral criteria.
If there is no evidence of an assessment by a Registered Dietitian & care home are requesting ONS; you can contact for more advice.
Patient identifiable details must be sent via nhs.net (secure portal).
Information needed are service users NHS number, DOB, care home.

13. Top Tips for ONS Prescriptions
Check that service user has been screened using MUST and is deemed to be at risk of malnutrition
Ensure service user’s MUST score is reviewed monthly if they are receiving ONS prescription (e.g. practice nurse, HCA, district nurse, GP)
Check a therapeutic dose is prescribed
56 bottles or sachet (7000ml or 3192g depending on product)
If ONS has been prescribed for >3 months flag to GP
If products not on the prescribing guidelines (e.g. Pro-cal, Calogen, Forticreme, Fortisip Bottle) are prescribed, these should only be prescribed under guidance of a Dietitian
If ONS is requested on hospital TTO without Dietitian letter do not put on repeat and ensure need for prescription is reviewed using MUST.