Malnutrition, often understood as ‘poor nutrition’, occurs when an individual’s diet lacks sufficient energy and nutrients, leading to measurable adverse effects on their body’s composition or function.1 While malnutrition can technically encompass overnutrition, it is more commonly associated with undernutrition, particularly in cases of being underweight. In the UK, it’s estimated that around 3 million people are affected by malnutrition or are at risk, with a significant majority (93%) living within communities.2 Malnutrition is not just a health issue; it’s both a cause and a consequence of various illnesses, representing a widespread clinical and public health challenge that often goes unnoticed in primary care settings.3,4 This oversight may stem from a predominant focus on the opposite end of the spectrum – overeating and obesity – when addressing weight management and nutritional well-being.
The detrimental impact of malnutrition is profound, affecting disease risk, progression, and prognosis, while also increasing post-injury complications and delaying recovery from illness. This condition escalates healthcare demands within communities, leading to more frequent GP visits and increased needs for home care. Recent estimates indicate that the financial burden of malnutrition on health and social care in England alone surpasses £19 billion annually, with half of this cost attributed to individuals over 65 years of age.3 Alarmingly, treating a malnourished patient costs over three times more than treating a well-nourished patient. With an aging population and the escalating costs of health and social care, these figures are only projected to rise, underscoring the urgent need for effective strategies like the Must Tool Care Plan.
The Imperative to Screen and Treat with a MUST Tool Care Plan
Older patients are particularly vulnerable to malnutrition, a risk often wrongly dismissed as an inevitable part of aging. Malnutrition accelerates the age-related decline in muscle mass and strength, leading to sarcopenia, a key contributor to frailty.5 Early detection and intervention through a structured MUST tool care plan are crucial in mitigating the clinical risks associated with malnutrition, including increased susceptibility to illness, clinical complications, and mortality. Given that most cases of malnutrition originate in community settings, primary care is the ideal setting for proactive identification and management using a MUST tool care plan.
Guidelines from the National Institute for Health and Care Excellence (NICE) advocate for GPs to screen patients upon registration and whenever clinical concerns arise.6,7 Screening should also be conducted opportunistically during routine health checks, flu vaccinations, and for residents in care homes. NICE specifically recommends weighing patients, calculating their Body Mass Index (BMI), and employing a validated screening tool such as the Malnutrition Universal Screening Tool (MUST) as part of a comprehensive MUST tool care plan.2
The MUST tool, developed by the multidisciplinary Malnutrition Advisory Group of the British Association for Parenteral and Enteral Nutrition (BAPEN), is central to an effective care plan.2,8 It utilizes three independent criteria for risk assessment:
- Current weight status, assessed using BMI.
- Evidence of unintentional weight loss, as even a 5–10% weight loss can significantly impact body function.2
- Presence of acute disease likely to result in nil nutritional intake for more than 5 days.
Each criterion is scored on a scale of 0–2. The cumulative score categorizes patients into low (0), medium (1), or high (≥2) risk groups for malnutrition. For those identified at medium or high risk, a nutrition management care plan based on the malnutrition pathway, often referred to as a MUST tool care plan, is essential.9 This pathway guides healthcare providers in determining the necessity for specialist dietary advice, meal assistance, food-first approaches, or prescriptions for oral nutritional supplements (ONS). While local guidelines may differ, GPs should be able to access protocols from their community dieticians to effectively implement a MUST tool care plan. For instance, Dorset provides a clear referral pathway.10 A robust MUST tool care plan includes setting clear, reviewable goals for patients identified at medium or high risk, ensuring ongoing monitoring of their nutritional status.
Gaps in Primary Care Implementation of MUST Tool Care Plans
Despite clear recommendations and the availability of the MUST tool care plan, malnutrition continues to be a neglected area in primary care. Routine screening using validated tools like MUST is not consistently integrated into care planning, especially for individuals over 75. Several factors contribute to this gap, including insufficient knowledge and training within primary care settings, an overwhelming focus on obesity and overeating as primary health concerns, a lack of clear leadership or ownership among GPs who may delegate this responsibility to practice nurses or dieticians, resource constraints, funding limitations, and an already stretched clinical agenda.3
A retrospective review conducted within a small GP surgery in Dorset, serving a significant older population (14.2% of patients over 75), highlights these challenges. Although the practice was recognized as ‘Dementia Friendly’ and boasted high patient satisfaction and Quality and Outcomes Framework ratings, the review revealed shortcomings in malnutrition screening. Out of 539 patients over 75, 411 (76%) had a BMI recorded in the past two years, and only 12 (3%) were underweight (BMI under 18.5 kg/m2). Among these underweight patients, a concerningly low number – only one (8%) – had a documented MUST score. While some received dietary advice (33%) and referrals to a dietician (25%), and were prescribed ONS (33%), these interventions were not consistently applied. This patient group also exhibited high rates of primary care consultations, averaging 12 nurse contacts per year, largely due to pressure sores and ulcers, conditions often linked to poor nutrition. These findings corroborate broader evidence suggesting inadequate screening for malnutrition using validated tools like MUST and indicate room for improvement in clinical management through consistent application of MUST tool care plans.
Conclusion: Embracing MUST Tool Care Plans for Better Patient Outcomes
Systematic screening and effective management of malnutrition through MUST tool care plans are critical clinical imperatives that have been largely overlooked in primary care. Relying solely on BMI measurement is insufficient; the adoption of validated malnutrition screening tools like MUST is essential. Implementing MUST tool care plans will significantly enhance nutritional care, facilitate the identification of at-risk individuals, and guide decisions regarding nutritional supplements and professional dietary advice. There is an urgent need to raise awareness about malnutrition within communities, emphasize its impact on patient outcomes, and highlight its substantial economic burden on healthcare systems. To facilitate this, GPs require access to specialized training, primary care teams need to establish clear leadership roles for managing patient nutritional needs (whether GPs, nurses, or dieticians take the lead), and healthcare commissioners must consider implementing incentives,11 developing local protocols, and allocating adequate resources to support MUST tool care plans. As healthcare models evolve, there’s a valuable opportunity to more fully integrate community dieticians into primary healthcare teams, enhancing the effectiveness of MUST tool care plans.
Ongoing initiatives are actively addressing malnutrition, such as the Malnutrition Task Force (http://www.malnutritiontaskforce.org.uk/) and BAPEN (http://www.bapen.org.uk/). Furthermore, the Nutrition in Older People Programme by the Wessex Academic Health Science Network is evaluating integrated strategies for malnutrition identification and treatment in communities, offering resources like the Older People’s Essential Nutrition (OPEN) toolkit, with materials available for free download.12 These resources are invaluable in supporting the widespread adoption and effective implementation of MUST tool care plans in primary care.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
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