Synopsis
Detect malnutrition and refeeding risk systematically, identify reversible barriers to eating, and deliver proportionate food-first or oral supplement support with measurable goals and multidisciplinary review.
- Nutritional screening is a repeatable risk-finding process, not a complete dietetic assessment; use a validated tool such as MUST within the setting's agreed timetable.
- MUST combines current body mass index, unplanned weight loss and an acute-disease effect when no intake is expected for more than five days.
- A high body mass index does not protect against malnutrition: oedema obscures weight, and sarcopenia or micronutrient deficiency can coexist with obesity.
- Before prescribing supplements, ask why intake fell: pain, nausea, dysphagia, dental disease, delirium, poverty, restrictive diets, depression, medication and inadequate mealtime assistance are actionable causes.
- Use oral nutrition when swallowing is safe and intake can meet goals; enrich ordinary food, offer preferred snacks and add nutritionally complete supplements when food alone is insufficient.
- Document an explicit goal, product type, frequency and review date because an unexplained supplement on repeat prescription is not a nutrition plan.
- Screen for refeeding risk before substantially increasing energy in a depleted patient; oral drinks and fortified food can precipitate the syndrome just as tube or parenteral feeding can.
- Escalate to dietetics and the multidisciplinary nutrition-support team when risk is high, intake remains inadequate, swallowing is unsafe, needs are complex or artificial nutrition is being considered.
Key red flags
A patient with very low intake, major weight loss, low potassium, phosphate or magnesium, or a very low BMI needs immediate refeeding-risk management before unrestricted supplementation.
Choking, inability to handle secretions, recurrent aspiration or acute neurological dysphagia requires urgent swallowing and airway-safety assessment rather than extra oral drinks.
Hypotension, oliguria, confusion or severe electrolyte disturbance indicates acute physiological compromise requiring medical stabilisation alongside nutrition planning.
Progressive dysphagia, persistent vomiting, gastrointestinal bleeding or unexplained weight loss can signal obstruction or malignancy and needs diagnostic escalation.
Refusal of food in a patient with cognitive impairment, severe mental illness or possible neglect demands capacity, safeguarding and multidisciplinary evaluation without coercive assumptions.
Investigation priorities
Standardise risk identification and trigger the appropriate local care pathway.
Management branches
Validated screening identifies medium or high risk, or clinical concern overrides a low score.
- Confirm weight history, recent intake, acute illness, swallowing safety, symptoms, function and social access to food.
- Assess refeeding risk and immediate medical instability before recommending rapid nutritional escalation.
- Create a tiered plan with food enrichment, assistance, symptom treatment and dietetic referral proportional to risk.
- Specify outcome measures and a review date, then escalate route if oral intake remains unsafe or persistently inadequate.