NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update Primary Care

Medicines Update Primary Care March 2017

Identifying and Treating Malnutrition

MUST, MUST Care Pathways and the Role of Oral Nutritional Supplements (ONS)

Key Points:

  • Malnutrition is under-recognised and a larger problem than often thought.
  • Food, Fluid and Nutritional care standards are driving improvements in the identification and treatment of malnutrition in NHSGG&C.
  • Those at risk of malnutrition should be screened using MUST (link below).
  • NHSGG&C have an agreed care pathway (link below) which provides guidance on the treatment of malnutrition based on MUST score and local policy and processes.
  • Dietary advice is the first line of treatment for those at risk of malnutrition – downloadable advice leaflets that can be provided to patients and carers are available via Staffnet (links below).
  • If ONS are to be considered this should be after trialling dietary change and taking into account the patients MUST score (i.e. level of malnutrition risk).
  • Over the counter ONS and home-made nourishing drinks are often appropriate and should be encouraged.
  • If ONS are to be prescribed, ACBS standard indications must be taken into account.
  • Ensure® Shake is now the preferred first line prescribable ONS product. Mixing Instructions
  • Treatment aim, goals and monitoring should be agreed, particularly where prescribed ONS are used.
  • For further learning, a Learnpro module on MUST is available to NHSGG&C staff.


Is malnutrition really a problem?                                             

Under nutrition (also referred to as malnutrition) results from a deficit of energy, protein and other nutrients leading to adverse effects on health, body function and clinical outcome.  In individuals who are malnourished there is a greater risk of ill health, hospital admission and a longer recovery time potentially resulting in an increased hospital stay.  In Scotland, 24% of patients admitted to hospital are at risk of malnutrition.

The size of the problem is often under-estimated.  Malnutrition affects over 3 million people in the UK, of which 1.3 million are over the age of 65.  Ninety eight percent of people affected by malnutrition live in the community.  In Scotland, over the next 10 years, the proportion of over 75s will increase by over 25%.  This age group are the highest users of NHS services.  The current UK cost of malnutrition is estimated to be £19.6 billion per year and as older adults are at higher risk of malnutrition, the cost of managing it is expected to increase. 

Identifying malnutrition – what is MUST?

Healthcare Improvement Scotland’s Food, Fluid and Nutritional (FFN) Care Standards (click here)   highlight the importance of both identifying individuals who are at risk of malnutrition and managing that risk.  Locally, these standards have driven improvements to nutritional care across a variety of care settings in NHSGG&C resulting in a greater number of people than ever before being identified as at risk of malnutrition and receiving treatment.  Nutritional screening is now carried out in acute, community and care home settings.  For this, NHSGG&C have adopted a national validated tool called MUST (Malnutrition Universal Screening Tool). This tool supports staff to identify an individual’s level of malnutrition risk by calculating a ‘score’ using a few simple steps.  An online calculator which simplifies the process further is also now available HERE


I have a MUST score for my patient, what should I do now?

NHSGG&C have developed a MUST care pathway that supports clinical decision making in relation to the level of risk identified in line with local policy and processes. 


  • To aid self-management, NHSGG&C have also developed a leaflet called Eating To Feel Better, which provides first line dietary advice to help patients who are identified as medium or high risk to improve their nutritional intake.  As per the MUST care pathway, patients at risk of malnutrition, or their carers, should be provided with this leaflet and encouraged to implement dietary change for at least 4 weeks. The importance of dietary change is often under-estimated but is the cornerstone of treatment of malnutrition; the simple addition of a slice of toast with peanut butter and a glass of full cream milk, or an individual sponge pudding can increase nutritional intake by around 400 calories.  More high calorie snack ideas for patients are available in the downloadable leaflet HERE
  • If, after 4 weeks of implementing dietary changes, patients continue to have concerns about their nutritional intake or weight, they should be encouraged to return for review. 

Key points for consideration at review include;

  • re-assessment of MUST,
  • changes in health status / social circumstances and
  • exploration of any barriers to improved nutritional intake.


As per the MUST pathway, if there has been deterioration at this stage, it may be appropriate to refer the patient to community dietetics; ideally via SCI-referral, however if this is not possible a referral form is available.   It may also be appropriate to consider oral nutritional supplements (ONS) at this stage. 


If Oral Nutritional Supplements (ONS) are to be introduced:

1. The use of OTC (over the counter) ONS products e.g. Meritene®, Complan® and Aymes® (retail) is often appropriate and should be encouraged.

Alternatively, patients / carers may wish to try home-made nourishing drinks and recipes  are available to provide to patients. These OTC and home-made products have a similar nutritional content to prescribable ONS and promote self-management and patient choice.  OTC products are available for purchase from supermarkets, health food shops, and some community pharmacies and online.

2. If prescribable ONS are to be initiated, in addition to the patient’s risk of malnutrition (i.e. MUST score) the patient must also have one of the standard ACBS indications* for prescribing.

* Disease-related malnutrition, intractable malabsorption, pre-operative preparation of malnourished patients, dysphagia, proven inflammatory bowel disease, following total gastrectomy, short-bowel syndrome, bowel fistula.


For any agreed treatment, but in particular where ONS are prescribed, the aim of treatment, clear treatment goals, defined treatment period and a plan for longer term monitoring should be agreed with patients and carers.  The typical effective dose / treatment for prescribed ONS is 1 sachet / bottle per day for a period of 2-3 months.  Ensure® Shake is now the preferred, first line choice for prescribable ONS which, if made with whole milk, is equivalent to 389 calories per sachet.  


The NHSGG&C adult oral nutrition formulary and prescribing guidance for ONS are currently being updated  

Keep an eye on future editions of Medicines Update for further information.