Malnutrition is an important consequence of and contributor to chronic disease. It is clearly a complex and multifactorial problem that can be difficult to manage but there are a number of key points to remember for the exam.

NICE defines malnutrition as the following:

• a Body Mass Index (BMI) of less than 18.5; or
• unintentional weight loss greater than 10% within the last 3-6 months; or
• a BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6 months

Around 10% of patients aged over 65 years are malnourished, the vast majority of those living independently, i.e. not in hospital or care/nursing homes.

Screening for malnutrition is mostly done using MUST (Malnutrition Universal Screen Tool). A link is provided to a copy of the MUST score algorithm.

• it should be done on admission to care/nursing homes and hospital, or if there is a concern. For example an elderly, thin patient with pressure sores
• it takes into account BMI, recent weight change and the presence of acute disease
• categorises patients into low, medium and high risk

Management of malnutrition is difficult. NICE recommend the following points:

• dietician support if the patient is at high-risk
• a 'food-first' approach with clear instructions (e.g. 'add full-fat cream to mashed potato'), rather than just prescribing oral nutritional supplements (ONS) such as Ensure
• if ONS are used they should be taken between meals, rather than instead of meals