Malnutrition Universal Screening Tool (MUST)

★ Clinical Nutrition Tool · Adult Screening

PAKISTAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION

MUST — Malnutrition Universal Screening Tool

A complete 5-step evidence-based screening tool to identify malnourished adults, those at nutritional risk, or obese — for hospitals, clinics, communities & care settings across Pakistan.

📖 About the MUST Tool

The Malnutrition Universal Screening Tool (MUST) is a validated, evidence-based five-step screening framework developed for adults. It enables healthcare professionals to consistently identify patients who are malnourished, at risk of malnutrition, or obese — and to start the right care plan immediately.

• Validated & widely adopted across hospitals, community care and primary care globally
• Quick to use — typically under 3–5 minutes per patient
• Three objective components: BMI, recent weight loss, and acute disease effect
• Produces a clear risk category (Low / Medium / High) and recommended care pathway

5

Screening Steps

3

Risk Categories

0–6

Score Range

<5m

Time per Patient

Interactive Calculator

⚡ Calculate MUST Score Instantly

Enter patient details — BMI score, weight-loss score, and overall MUST risk are calculated automatically.

Weight (kg)

Height (cm)

BMI Score (manual override) — auto from weight/height — BMI > 20 → Score 0 BMI 18.5–20 → Score 1 BMI < 18.5 → Score 2

Previous weight 3–6 months ago (kg)

Weight Loss % (manual override) — auto from above — < 5% → Score 0 5–10% → Score 1 > 10% → Score 2

Acute Disease Effect No acute effect → Score 0 Acutely ill + no/likely no intake >5 days → Score 2

👆 Fill in the fields above — MUST score and risk level will appear here

Pakistan Society for Parenteral & Enteral Nutrition

MUST — Malnutrition Universal Screening Tool

Complete 5-step clinical flowchart with management guidelines · PSPEN Pakistan

📋 The 5-Step MUST Flowchart

Step 1 Score + Step 2 Score + Step 3 Score = Total MUST Score → Risk Level → Care Plan

1

BMI Score

Body Mass Index · kg ÷ m²

BMI > 20(if >30 = Obese)

0

BMI 18.5 – 20Underweight range

1

BMI < 18.5Severely underweight

2

Formula: BMI = weight (kg) ÷ height² (m²)
If height cannot be measured: use ulna length, knee height, or demi-span equivalent tables.

+

2

Weight Loss Score

Unplanned loss in past 3–6 months

< 5% lossMinor / no concern

0

5 – 10% lossModerate concern

1

> 10% lossSevere / significant

2

Formula: % loss = (previous weight − current weight) ÷ previous weight × 100
Use clinical records; verify with patient & family if uncertain.

+

3

Acute Disease Effect

No / likely no nutritional intake

Not acutely illor intake likely adequate

0

Acutely ill AND no/likely no intake > 5 days

2

Applies to: acutely ill patients where nutritional intake has been, or is expected to be, absent for >5 days. Not for chronic conditions alone.

Step 4 — Add all three scores together

4

Overall Risk of Malnutrition

Step 1 + Step 2 + Step 3 — Determine the category

0

LOW RISK Total score = 0 Routine clinical care; document and re-screen per policy

1

MEDIUM RISK Total score = 1 Observe · record intake · monitor closely

≥2

HIGH RISK Total score = 2 or more Treat · refer · develop active care plan

Step 5 — Use management guidelines to develop a care plan

5

Management Plan

Based on overall MUST score & local clinical policy

0 · Low Risk Routine Care

• Continue normal clinical care
• Document nutritional status in patient notes
• Re-screen: inpatients weekly, hospital outpatients monthly, community patients at least annually (or sooner if clinical concern)
• For obese patients: manage according to local obesity policy (score 0 still applies)

1 · Medium Risk Observe & Document

• Record dietary intake for 3 days using food charts
• If intake adequate — little clinical concern; continue routine care but monitor closely
• If intake inadequate — set nutritional goals, increase overall intake (food first approach), monitor & review care plan
• Re-screen: hospital weekly · care homes monthly · community monthly to 3-monthly

2+ · High Risk Treat & Refer

• Refer to registered dietitian / clinical nutrition team immediately
• Set clear nutritional goals & improve overall intake
• Consider oral nutritional supplements (ONS) if oral diet insufficient
• Consider enteral / parenteral nutrition if GI tract is non-functional
• Re-screen & monitor: hospital weekly · care home monthly · community monthly

📅 Re-screening Schedule by Setting

← Swipe to see more →

Setting	Low Risk	Medium Risk	High Risk
Hospital (inpatient)	Weekly	Weekly	Weekly
Hospital (outpatient)	Monthly	Monthly	2–4 weekly
Care Home	Monthly	Monthly	Monthly
Community	Annually (minimum)	Monthly–3 monthly	Monthly
GP Clinic	Annually	3 monthly	1–3 monthly

⚠️ Important Clinical Notes:
• MUST screens adults only (≥18 years). Not validated for children, adolescents, or pregnant/lactating women without specialist input.
• If weight or height cannot be measured, use alternative measurements (ulna length, knee height, mid-upper arm circumference — MUAC, or subjective global assessment).
• Patients with fluid disturbances (oedema, ascites), plaster casts, or amputations need special interpretation — adjust calculations accordingly.
• Reassess whenever there is clinical concern, regardless of the routine schedule.

★ PAKISTAN SOCIETY FOR PARENTERAL & ENTERAL NUTRITION ★

Developed & endorsed for clinical use by PSPEN Pakistan
This screening tool is intended for educational and clinical use by qualified healthcare professionals.
Always combine MUST findings with clinical judgement and local protocols. © PSPEN · 2025 · For healthcare use across Pakistan.

Reference Chart

📊 WHO BMI Classification for Adults

Standard BMI categories used internationally and in Pakistan to interpret MUST Step 1.

← Swipe to see all columns →

BMI (kg/m²)	WHO Classification	Health Risk	MUST Score
< 16.0	Severe Underweight	Very high risk of malnutrition	2
16.0 – 16.9	Moderate Underweight	High risk of malnutrition	2
17.0 – 18.4	Mild Underweight	Risk of malnutrition	2
18.5 – 20.0	Normal – Low	Acceptable but monitor	1
20.0 – 24.9	Normal	Healthy range	0
25.0 – 29.9	Overweight	Increased metabolic risk	0
30.0 – 34.9	Obese Class I	Moderate health risk	0
35.0 – 39.9	Obese Class II	Severe health risk	0
≥ 40.0	Obese Class III	Very severe health risk	0

* Asian populations (including Pakistanis) have elevated metabolic risk at lower BMIs. Some Pakistani guidelines consider BMI 23–27.5 as overweight. Always interpret in clinical context.

Alternative Methods

📏 When Weight or Height Cannot Be Measured

Use these alternative anthropometric methods when direct measurement is not possible (bedridden, immobile, amputee, etc.).

🦴 Ulna Length

Measure from the point of the elbow (olecranon) to the midpoint of the styloid process of the wrist. Use the ulna-length-to-height conversion table to estimate height, then calculate BMI.

Best for: bedridden or wheelchair-bound patients · quick & reproducible

🦵 Knee Height

Measure from the heel to the front of the thigh, just above the patella, with knee bent at 90°. Use gender & age-specific equations to estimate standing height.

Best for: elderly, immobile adults · validated in older populations

📐 Mid-Upper Arm Circumference (MUAC)

Measure circumference at the midpoint between the acromion and olecranon. MUAC < 23 cm suggests undernutrition; < 19 cm suggests severe undernutrition.

Best for: rapid community screening, pregnant women, children 6–59 months

📋 Subjective Global Assessment (SGA)

Clinical assessment based on weight history, dietary intake, GI symptoms, functional capacity, and physical examination. Classifies patients as well-nourished, moderately malnourished, or severely malnourished.

Best for: comprehensive bedside nutritional assessment

Clinical Pathways

🏥 When to Refer to a Dietitian / Nutrition Team

PSPEN recommends timely referral for any patient identified as medium or high risk, or showing clinical signs of nutritional decline.

🚨 Immediate Referral (within 24–48 hours)

• MUST score ≥ 2 (High Risk)
• BMI < 18.5 with active medical condition
• Unintentional weight loss > 10% in 3–6 months
• Patient unable to maintain oral intake for > 5 days
• Severe dysphagia, swallowing difficulties, or aspiration risk
• Active oncology, surgical, or critical care patients with poor intake
• Unhealed pressure ulcers or chronic wounds with malnutrition

📅 Routine Referral (within 1–2 weeks)

• MUST score 1 (Medium Risk) with inadequate intake
• BMI 18.5–20 with chronic disease (COPD, CKD, CHF, diabetes)
• 5–10% unintentional weight loss in 3–6 months
• Post-bariatric or post-surgical patients with poor intake
• Elderly with reduced appetite, mobility, or cognitive decline
• Pregnant/lactating women with nutritional concerns (specialist pathway)
• Patients on long-term modified diets needing review

Best Practice

💡 PSPEN Clinical Pearls & Implementation Tips

Practical guidance for healthcare professionals integrating MUST into routine practice in Pakistan.

🏥

For Hospitals

• Screen all admissions within 24 hours of admission
• Include MUST score in nursing admission documentation
• Place high-risk patients on a nutritional care pathway immediately
• Reassess weekly during inpatient stay
• Document MUST score in discharge summary for continuity

👨‍⚕️

For GPs & Clinics

• Screen at first registration and at least annually
• Screen all elderly patients at every visit if > 75 years
• Screen patients with chronic diseases at routine review
• Combine MUST with medication review (polypharmacy affects appetite)
• Use local language (Urdu/Sindhi/Punjabi/Pashto) for patient education

🏡

For Community & Home Care

• Train LHWs, nurses, and family caregivers in MUST use
• Screen all elderly home-bound patients at first visit
• Reassess monthly or after any acute illness/hospitalization
• Educate families on food-first approach and high-protein local foods
• Consider telephone follow-up for rural & remote patients

🍽️

Nutrition Intervention

• Food first: enrich local meals with daal, dairy, eggs, nuts, ghee
• Offer small frequent meals (5–6/day) for poor appetite
• Consider oral nutritional supplements (ONS) if diet alone insufficient
• Manage treatable causes: nausea, pain, dental issues, depression
• Provide caregiver education on feeding techniques & food hygiene

FAQ

❓ Frequently Asked Questions

Common questions about MUST screening in Pakistani clinical practice.

Q1. How often should I re-screen a patient?

Frequency depends on the setting and the patient's risk category. As a rule: inpatients weekly, outpatients monthly, care home residents monthly, and community patients at least annually. Always re-screen earlier if there is any clinical concern, change in condition, or after acute illness/hospitalization.

Q2. Can MUST be used for children or pregnant women?

MUST is validated for adults (≥18 years) only. For children, use WHO growth charts or paediatric nutrition screening tools. For pregnant and lactating women, MUST is not directly applicable — use specialist antenatal nutritional assessment and BMI cut-offs appropriate for pregnancy.

Q3. What if a patient has oedema or ascites?

Fluid retention (oedema, ascites) can mask weight loss and falsely elevate BMI. In such cases: (a) document the clinical condition, (b) use clinical judgement alongside MUST, (c) consider MUAC or SGA as alternatives, and (d) use estimated dry weight when calculating BMI if fluid status is known.

Q4. How do I handle patients with amputations?

Adjust measured body weight using standard amputation correction factors (e.g. subtract 1.8% for below-knee, 4.9% for above-knee, etc. — refer to PSPEN resource library for full table). Calculate BMI using the adjusted estimated weight.

Q5. Is MUST applicable in ICU / critical care?

MUST has limitations in critically ill patients due to fluid shifts, mechanical ventilation, and inability to obtain reliable weight/height. In ICU, use MUST in combination with NRS-2002 or NUTRIC score, and rely heavily on clinical judgement, biochemistry, and SGA.

Q6. What if the patient or family cannot recall previous weight?

Use multiple sources: (a) clinical records, (b) previous prescriptions, (c) reported weight at prior visits, (d) family/caregiver recall, (e) well-fitting clothes or belt notches. If completely unavailable, document as "unknown" and use MUAC + SGA for assessment.

Q7. Is training required to use MUST?

Yes. While MUST is simple, formal training ensures consistency and accuracy. PSPEN recommends a 2–3 hour training session covering all 5 steps, alternative measurements, and documentation. Training materials are available from PSPEN for hospitals, GP clinics, and community health teams.

Q8. How does MUST apply to obese patients in Pakistan?

Obese adults (BMI > 30) automatically score 0 on MUST but should be managed according to local obesity guidelines (diet, lifestyle, medical/surgical options). MUST's primary focus is undernutrition; obesity management follows a separate pathway but should be integrated into overall care.