In the UK over 3 million adults are malnourished.

Over 30% of adults admitted to the hospital are malnourished. This figure rises to 35% for people residing in care settings. 

From 2011-2012 19.2 billion pounds was spent on malnutrition across health and social care. 


What is Malnutrition?

Malnutrition is a state of nutrient deficiency, which has a significant impact on body function and clinical outcomes (NICE, 2012). 

Nutrients include energy, protein, minerals and vitamins. 


Causes of Malnutrition 

There are many reasons that a person can become malnourished.

These range from the obvious, such as being at the end of life, to the less obvious, such as poverty or self-neglect.


Other factors that can contribute to malnutrition include:

  • Poor manual dexterity
  • Mental illness such as anxiety or depression
  • Breathing problems, such as COPD or heart failure 
  • Stroke
  • Cancer, or other diseases that increase energy requirements
  • Wounds
  • Oral problems, including lack of teeth or poorly fitting dentures
  • Malabsorption, having an ileostomy for example
  • The dining experience and presentation of food and drink
  • Dementia
  • Poor vision
  • Poor mobility
  • Dysphagia
  • Nausea/Vomiting
  • A poor diet
  • Lack of care and support
  • Chronic pain
  • Side effects of medication


Determining whether someone is Malnourished or Underweight

The two most commonly used tools are the BMI (Body Mass Index) and subsequently, the MUST score (Malnutrition Universal Screening Tool).

The body mass index (BMI) is a measurement tool that uses height and weight to work out if a person's weight is healthy. 

The BMI calculation divides an adult's weight in kilograms by their height in metres squared.

For most adults, an ideal BMI is in the 18.5 to 24.9 range.

The MUST score uses the BMI as part of the assessment to work out a person's risk of malnutrition.


The MUST is a five-step tool and includes management guidelines, which can be used to develop a care plan.

Step One

Measure height and weight to get a BMI score.

If this is not possible, there are other techniques such as measuring ulna length to estimate height, so that the BMI can be calculated.

Assessors can measure the mid-upper arm circumference (MUAC) to estimate BMI category.

Step Two

Review percentage of unplanned weight loss.

Step Three

Evaluate if the person is acutely ill and unlikely to be taking any nutrition for > 5 days.

Step Four

Scores from steps 1-3 are added together to calculate the overall risk of malnutrition.

Identifying malnutrition using MUST

Treatment of Malnutrition

Although nutritional supplements have a place in the treatment of malnutrition, they can be very costly.

They are also not particularly well received by patients, particularly older people.

The first line treatment is to offer the person a fortified diet.

A fortified diet is simply adding extra calories to everyday meals that people already eat.

There are many ways that staff can fortify someone's diety and add many extra calories without them having to take supplementary drinks or eat extra meals.

It is preferable to have three fortified meals and two high energy snacks.

Ways to fortify foods are as follows: 

Fortifying foods to treat malnutrition

Big meals can be daunting to people with a reduced appetite or struggle to eat well. 

It is easy to add 1000 calories a day without too many changes.

To increase intake by 1000 calories add:

  • 4oz cheddar
  • 2oz butter
  • 2 luxury biscuits, shortbread or chocolate
  • 1 level teaspoon of sugar

It is important to add high-energy calorific foods as these can be taken in smaller quantities and still provide the extra intake that is needed.


Goal Setting

When people are malnourished it is important to set goals in their care plan and to remember that these are unique to each person.

For some, it may be taking extra calories and protein in order to try to heal a wound.

For others, they may be receiving end-of-life care and the goal may be to support good nutrition but not to try to gain weight.

If a fortified diet is not enabling someone to meet their goals then oral nutritional supplements may be prescribed. 

A referral to the dietician should be made for further advice and support, and always if the person has a MUST score of two or more.