Nutrition Assessment Guide | GCC Nursing Platform

MUST — Malnutrition Universal Screening Tool

Purpose: The MUST is a validated, 5-step screening tool for identifying adults who are malnourished or at risk of malnutrition. Steps 1–3 generate a score; steps 4–5 guide management.

🔢 MUST Interactive Calculator

1 BMI Score

Weight (kg)

Height (cm)

BMI > 20 kg/m² — Score: 0 BMI 18.5–20 kg/m² — Score: 1 BMI < 18.5 kg/m² — Score: 2

2 Unplanned Weight Loss (past 3–6 months)

Optional: calculate % weight loss

Current Weight (kg)

Usual Weight (kg)

Weight loss < 5% — Score: 0 Weight loss 5–10% — Score: 1 Weight loss > 10% — Score: 2

3 Acute Disease Effect

No acute disease effect — Score: 0 Acutely ill AND likely no nutritional intake > 5 days — Score: 2

MUST TOTAL SCORE

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Mini Nutritional Assessment (MNA) — Short Form

👴 MNA-SF (For Elderly Patients ≥ 65 years)

Screening Score: 12–14 = Normal nutrition status • 8–11 = At risk of malnutrition • 0–7 = Malnourished. Score < 11 indicates malnutrition risk — proceed to full MNA or refer dietitian.

Question	Scoring
A. Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?	0 = severe; 1 = moderate; 2 = no decrease
B. Weight loss during the last 3 months?	0 = >3kg; 1 = unknown; 2 = 1–3kg; 3 = no loss
C. Mobility?	0 = bed/chair-bound; 1 = able to get out but not outside; 2 = goes outside
D. Has the patient suffered psychological stress or acute disease in the past 3 months?	0 = yes; 2 = no
E. Neuropsychological problems?	0 = severe dementia or depression; 1 = mild; 2 = none
F1. BMI (kg/m²)	0 = <19; 1 = 19–21; 2 = 21–23; 3 = ≥23
F2. Calf circumference (if BMI unavailable)	0 = <31cm; 3 = ≥31cm

GLIM Criteria for Malnutrition Diagnosis

📋 Global Leadership Initiative on Malnutrition (GLIM 2018)

Requires at least 1 phenotypic AND 1 aetiologic criterion to diagnose malnutrition.

Phenotypic Criteria

Unintentional weight loss >5% in 6 months or >10% beyond 6 months
Low BMI: <20 kg/m² (age <70) or <22 kg/m² (age ≥70)
Reduced muscle mass (by validated body composition measure)

Aetiologic Criteria

Reduced food intake or assimilation (<50% of requirements for >1 week, or any reduction >2 weeks, or chronic GI impairment)
Disease burden / inflammation (acute injury/disease or chronic disease)

Nutritional History & Physical Examination

💬 History Questions

Appetite: any decrease over the past 1–3 months?
24-hour diet recall: meals, snacks, fluids
Swallowing difficulty (dysphagia): refer SLT if present
GI symptoms: nausea, vomiting, diarrhoea, constipation, abdominal pain
Recent unintentional weight changes
Dietary restrictions: allergies, religious, ethical
Functional ability: able to shop, cook, self-feed?
Social factors: lives alone, food insecurity

🔎 Physical Examination Signs

Muscle Wasting

Temporal muscle: hollowing above zygomatic arch
Deltoid/shoulder: prominent acromion process
Thenar eminence flattening
Quadriceps wasting (squat test)

Subcutaneous Fat Loss

Orbital fat: sunken eyes
Triceps skinfold < 10th percentile

Oedema (masks weight loss)

Pitting oedema of ankles and sacrum
Ascites (hepatic disease)

Energy Requirements

⚡ Simple Weight-Based Estimates

Clinical Situation	Energy Target	Notes
Maintenance (stable, non-stressed)	25–30 kcal/kg/day	Use actual body weight
Nutritional repletion (malnourished)	30–35 kcal/kg/day	Increase gradually to avoid refeeding
Obesity (BMI > 30)	20–25 kcal/kg/day	Use adjusted body weight
ICU (critically ill)	25–30 kcal/kg/day	Avoid overfeeding; indirect calorimetry ideal
ICU early phase (day 1–3)	50–70% of target	Trophic/permissive underfeeding

ICU Note: Indirect calorimetry remains the gold standard for energy measurement in critical illness. Predictive equations have up to 40% error in ICU patients.

🔢 Harris-Benedict Equation Calculator

Sex

Age (years)

Weight (kg)

Height (cm)

Activity Factor

Protein Requirements

🥪 Protein by Clinical Condition

Condition	Protein Requirement
Healthy maintenance	0.8 g/kg/day
General hospitalised patient	1.2–1.5 g/kg/day
ICU / Critical illness	1.5–2.0 g/kg/day
Burns / Major trauma	2.0–2.5 g/kg/day
CKD (non-dialysis)	0.6–0.8 g/kg/day
Haemodialysis / CRRT	1.2–1.5 g/kg/day
Peritoneal dialysis	1.2–1.5 g/kg/day
Hepatic failure (compensated)	1.2–1.5 g/kg/day
Post-bariatric surgery	60–80 g/day minimum

Carbohydrate & Fat

🏰 Carbohydrates

50–60% of total daily energy intake
Glucose tolerance impaired in critical illness — monitor blood glucose closely
Maximum IV glucose infusion: 4–5 mg/kg/min
Target blood glucose in ICU: 6–10 mmol/L
Avoid hypoglycaemia (<4 mmol/L) — associated with poor outcome

🧔 Fats

30–35% of total energy intake
Omega-3 fatty acids (EPA/DHA): anti-inflammatory benefit — consider in ARDS, sepsis
MCT/LCT lipid emulsions preferred in PN (Smoflipid, ClinOleic)
Serum triglycerides: <4.5 mmol/L before initiating lipid PN
Monitor triglycerides every 48–72h during PN

Micronutrients — GCC Focus

💊 Key Micronutrient Deficiencies in GCC

Micronutrient	GCC Prevalence	Clinical Relevance	Action
Vitamin D	>90% deficient	Bone health, immunity, muscle function; sun avoidance due to heat/culture	Supplement: 1000–4000 IU/day; check 25-OH-D level
Iron	Common in women	Iron deficiency anaemia; fatigue, reduced immunity	Dietary: dates, red meat, lentils; supplement if Hb <12 g/dL women
Vitamin B12	Vegans, elderly	Megaloblastic anaemia, peripheral neuropathy	1000 mcg IM monthly or oral high-dose if deficient
Zinc	Wound patients	Wound healing, immune function, taste	Zinc sulfate 220 mg oral BD; replace in burns/wounds
Selenium	ICU patients	Antioxidant defence; low in critical illness	IV replacement in ICU: 500–1000 mcg/day (first 2–3 days)
Thiamine (B1)	Refeeding risk	Essential before refeeding malnourished patients	200–300 mg IV before starting nutrition

🏭 GCC Diet Context

Traditional Arabic diet: rice, lamb/chicken, bread, dates, laban (yoghurt), ghee
High refined carbohydrate intake — white rice, white bread, sweets (halwa)
Obesity epidemic: UAE, Saudi Arabia, Kuwait among world's highest obesity rates
T2DM: 15–25% prevalence in GCC adults

Ramadan fasting: 29–30 days; impacts meal timing, hydration, medications
Hospitalised patients: may request exemption — discuss with patient and family sensitively
Tube-fed patients during Ramadan: discuss whether feeds should pause at dawn if culturally important
Sesame allergy: notably prevalent in Middle East — check formula ingredients

Nasogastric (NG) Tube Feeding

💉 Indications for NG Tube Feeding

Dysphagia — swallowing difficulty (stroke, head & neck cancer, neurological disease)
Reduced consciousness / decreased GCS
Failure to meet >60% nutritional requirements orally for >3–5 days
Facial trauma, jaw wiring
Oesophageal obstruction (use post-pyloric route)

🔍 NG Tube Position Verification

NEVER use the blue litmus paper (whoosh) test — it is not safe and is no longer accepted practice. This method has caused patient deaths.

Method	Standard	Notes
pH testing of aspirate	Gold standard (routine)	pH <5.5 confirms gastric placement. If pH ≥6 or no aspirate — do not feed; obtain CXR.
Chest X-ray (CXR)	Required for first insertion	All new NG tube insertions require CXR confirmation before first use. Tube tip should be below diaphragm.
Whoosh / blue litmus paper	NOT acceptable	Do not use — not sensitive or specific for gastric placement.
Capnography	Emerging / specialist	Can detect CO2 if tube in airway — adjunct only.

⏰ Starting & Advancing NG Feeds

Starting Rate

Start at 30–50 mL/hr
Increase by 20–30 mL/hr every 4–8 hours
Reach target rate within 24–48 hours
Target rate: typically 60–80 mL/hr for standard formula
In malnourished: start lower (10–20 mL/hr) to avoid refeeding syndrome

Gastric Residual Volume (GRV)

Check GRV every 4–6 hours
Accept GRV up to 300–500 mL in ICU
Do not routinely stop feeds for GRV <500 mL
If GRV >500 mL: hold feed 1 hour, reassess, consider prokinetics
Elevated GRV does not reliably predict aspiration

Prokinetic Agents for High GRV / Gastroparesis

Drug	Dose	Notes
Metoclopramide	10 mg IV/oral TDS (max 5 days)	First line; risk of extrapyramidal side effects with prolonged use
Erythromycin	250 mg IV/oral TDS × 3–5 days	Low-dose motilin agonist; tachyphylaxis after 5–7 days
Domperidone	10 mg oral TDS	Does not cross BBB; fewer neurological SE; QT prolongation risk

PEG & Post-Pyloric Feeding

🔧 PEG (Percutaneous Endoscopic Gastrostomy)

Indications

Long-term enteral nutrition (>4 weeks anticipated)
Motor neurone disease, stroke, head/neck cancer
Unable to maintain adequate oral intake chronically

Post-PEG Care

First feed: 4–6 hours post-insertion if uncomplicated
Site care: clean daily with saline/water; rotate external disc ±360° daily
Check balloon water: 5–10 mL every 4 weeks (balloon PEG)
Flush: 30 mL water before and after each feed and medication
Watch for: buried bumper syndrome, leakage, granulation tissue, infection

📈 NJ / Post-Pyloric Feeding

Indications

High aspiration risk (recurrent aspiration pneumonia)
Acute pancreatitis (nasojejunal preferred over NG)
Gastroparesis refractory to prokinetics
Gastric outlet obstruction

Key Points

Dobhoff (fine-bore NJ) tube: requires radiological or endoscopic confirmation
No pH check — position must be confirmed by X-ray
Continuous feeding preferred (no large boluses)
Semi-elemental or elemental formulas may be better tolerated

Standard Enteral Feed Formulas

🍼 Common Formula Types

Formula	Energy Density	Features	Use
Jevity 1.0	1.0 kcal/mL	Fibre-containing, low residue	Standard; bowel motility, constipation prevention
Osmolite 1.0	1.0 kcal/mL	Fibre-free, low osmolality	Standard; post-operative, CXR-confirmed NGT
Isosource HN	1.0 kcal/mL	High nitrogen (protein)	Increased protein needs
Jevity 1.5	1.5 kcal/mL	High energy + fibre	Fluid-restricted patients
TwoCal HN	2.0 kcal/mL	Very high energy & protein	Severe fluid restriction, ICU
Peptamen	1.0 kcal/mL	Semi-elemental (peptides)	GI malabsorption, pancreatitis, short bowel
Glucerna	1.0 kcal/mL	Low glycaemic index	Diabetes mellitus, stress hyperglycaemia

Common Complications & Management

⚠ Enteral Feeding Complications

Complication	Causes	Management
Diarrhoea	Antibiotic-associated, formula intolerance (osmolality, rate), C. difficile, medications (sorbitol-based)	Check C. diff; switch to fibre-containing formula; reduce rate; review medications; probiotics (clinical guidance)
Constipation	Low fibre, dehydration, opioids, immobility	Increase water flushes; switch to fibre formula; laxatives; mobilise
Nausea / Vomiting	High GRV, infection, medications	Reduce rate; check GRV; prokinetics; consider post-pyloric feeding
Aspiration	HOB flat, high GRV, impaired airway protection	HOB 30–45°; confirm tube position; reduce rate; consider PEG or NJ
Tube blockage	Inadequate flushing, crushed medications	Flush 30 mL water every 4h and after meds; use pancreatic enzyme/Coke flush; replace tube if blocked
Refeeding syndrome	Malnourished patient; see Tab 4	Start low, go slow; thiamine; electrolyte monitoring

HOB reminder: Always maintain Head-of-Bed elevation at 30–45° during and for 30 minutes after enteral feeding to reduce aspiration risk.

💊 Drug Administration via NG Tube

Flush with 30 mL water before and after each medication
Never crush: modified-release tablets (SR/MR/XL), enteric-coated tablets, gelatin capsules
Acceptable to crush: immediate-release tablets (confirm with pharmacist)
Omeprazole: use dispersible tablet or oral suspension — do not crush standard capsule
Phenytoin: significant NG feed interaction — hold feeds 1–2 hours before and after
Warfarin, levothyroxine: absorption affected by feeds — time carefully
Always consult pharmacist for any NG medication queries

Parenteral Nutrition (PN)

💰 When to Use PN

Enteral nutrition is always preferred when the GI tract is functional. Use PN only when enteral route is not available, not tolerated, or contraindicated for >3 days.

PN Indications

GI obstruction, paralytic ileus
Severe short bowel syndrome
High-output fistula (enteral not tolerated)
Severe malabsorption (mesenteric ischaemia)
Enteral nutrition contraindicated (>3 days)
Post-op: complex GI surgery, anastomotic leak

PN Contraindications / Caution

Functional GI tract available — use EN
Expected PN duration <5 days (risk > benefit)
Terminal illness where nutrition will not benefit quality of life
Untreated severe electrolyte abnormalities

💋 TPN vs Peripheral PN

Feature	Total PN (TPN)	Peripheral PN (PPN)
Route	Central venous catheter (CVC), PICC	Peripheral IV cannula
Osmolality	Up to 3000 mOsm/L	<900 mOsm/L (risk of phlebitis)
Duration	Short or long-term	Short-term only (typically <10–14 days)
Energy provision	Full nutritional requirements	Partial — cannot provide full needs
Dedicated lumen	Required — no other drugs via PN lumen	Dedicated cannula required

📋 PN Components

Component	Purpose	Notes
Dextrose (glucose)	Energy (3.4 kcal/g)	Max infusion rate 4–5 mg/kg/min; hyperglycaemia common
Amino acids	Protein substrate (4 kcal/g)	Standard 15% solution; glutamine may be added in ICU
Lipid emulsion	Energy + essential fatty acids (9 kcal/g)	Smoflipid, ClinOleic preferred; check TGs <4.5 before starting
Water-soluble vitamins	B vitamins, vitamin C	Add daily; Cernevit or Soluvit
Fat-soluble vitamins	A, D, E, K	Add daily to lipid phase; Vitalipid
Trace elements	Zinc, selenium, copper, iodine, manganese	Add daily; Additrace or Tracutil
Electrolytes	Na, K, Ca, Mg, Phosphate	Added according to daily monitoring results

📊 PN Monitoring Schedule

Daily Monitoring

Blood glucose (every 4–6 hours initially)
Electrolytes: Na, K, bicarbonate
Phosphate (critical for refeeding)
Magnesium, Calcium
Fluid balance / weight
Line site inspection

2–3× Weekly

LFTs (ALT, AST, ALP, bilirubin)
Triglycerides (if lipid PN)
FBC, clotting
Urea & creatinine
Trace elements (weekly in long-term PN)

⚠ PN Complications

Complication	Prevention / Management
Hyperglycaemia	Target 6–10 mmol/L; insulin infusion titration; reduce glucose rate; avoid overfeeding
Hypertriglyceridaemia	Stop lipid if TG >5 mmol/L; resume at lower rate when TG <4.5
PN-associated liver disease (PNALD)	Use cyclic PN (off 8–12h); minimise duration; use Smoflipid (omega-3 containing); start EN as soon as possible
Line-related bloodstream infection (CRBSI)	Strict aseptic technique; dedicated PN lumen; no blood draws from PN line; change tubing every 24h (with bag change)
Overfeeding	Avoid exceeding 20–25 kcal/kg/day; hypercapnia (excess dextrose); hyperglycaemia; hepatic steatosis
Refeeding syndrome	See section below — applies equally to PN

⚠ Refeeding Syndrome

Refeeding syndrome is a potentially fatal electrolyte and metabolic disturbance occurring in malnourished patients when nutrition is reintroduced. The hallmark is hypophosphataemia caused by massive intracellular shifts of phosphate, potassium, and magnesium.

📋 Pathophysiology

During starvation: body depletes intracellular phosphate, potassium, magnesium — serum levels may appear normal
Refeeding causes insulin surge → glucose uptake → phosphate/K⁺/Mg²⁺ shift into cells
Serum phosphate falls rapidly → ATP depletion → cardiac arrhythmia, respiratory failure, haemolysis
Thiamine (Vitamin B1) depletion is co-pathology → must supplement BEFORE starting feeds

🛑 NICE High-Risk Criteria for Refeeding Syndrome

Patient is at HIGH RISK if they have ONE or more of the following:

BMI < 16 kg/m²

Unintentional weight loss > 15% in the past 3–6 months

Little or no nutritional intake for more than 10 days

Low levels of potassium, phosphate, or magnesium before feeding starts

OR TWO or more of:

BMI < 18.5 kg/m²

Unintentional weight loss > 10% in 3–6 months

Little or no nutritional intake for >5 days

History: alcohol misuse, insulin use, antacids, diuretics, or chemotherapy

High-risk groups: anorexia nervosa, chronic alcoholism, cancer cachexia, post-operative starvation >5 days, homelessness/malnutrition

✅ Refeeding Syndrome Management Protocol

1BEFORE starting nutrition

Give Thiamine (Vitamin B1) 200–300 mg IV immediately before first feed (prevents Wernicke's encephalopathy)
Check baseline electrolytes: phosphate, potassium, magnesium, sodium
Correct any electrolyte deficits before commencing nutrition
B-vitamin complex supplementation (Pabrinex or equivalent)

2Start feeds SLOWLY

Maximum 10 kcal/kg/day for the first 2 days (5 kcal/kg/day if extreme risk)
Increase by 33% every 2 days if electrolytes stable
Reach full target over 4–7 days
Do not restrict sodium — may worsen oedema by causing ADH release

3Daily electrolyte monitoring

Phosphate, potassium, magnesium — daily for first 2 weeks
Replace electrolytes proactively and aggressively:
— Phosphate: IV Phosphate replacement if <0.6 mmol/L
— Potassium: KCl oral/IV per local protocol
— Magnesium: IV magnesium sulphate if severe depletion
Monitor fluid balance, cardiac rhythm
Blood glucose every 4–6 hours

Critical warning: If phosphate falls below 0.32 mmol/L — STOP feeds, inform medical team immediately, commence IV phosphate replacement urgently.

GCC-Specific Nutritional Issues

🌐 Obesity & Diabetes Epidemic

UAE, Saudi Arabia, Kuwait, Qatar among world's highest obesity prevalence
Adult obesity rates: 30–40% in many GCC populations
Type 2 diabetes: 15–25% prevalence (IDF data); highest globally
Medical nutrition therapy (MNT) is a cornerstone of diabetes management
Bariatric surgery increasing: post-op nutritional support critical (B12, iron, Ca, vit D)
Dietitian referral mandatory post-bariatric surgery

🌎 Ramadan Fasting in Hospital

Fasting from dawn (Fajr) to sunset (Maghrib) — typically 12–16 hours
Iftar (break fast at sunset): major meal; Suhoor (pre-dawn): lighter meal
Dehydration risk — especially summer in GCC; monitor fluid balance
DM patients: medication timing must be adjusted (consult physician/pharmacist)
Hospitalised patients: most Islamic scholars permit exemption when unwell — discuss sensitively
Tube-fed patients: if culturally important, discuss pausing feeds during daylight with patient & family
IV fluids: not considered breaking fast by most scholars — continue if clinically needed

☀ Vitamin D Deficiency

>90% of GCC population deficient despite intense sunshine
Reasons: cultural dress, sun avoidance, limited outdoor activity, high melanin content
Deficiency defined as 25-OH-Vitamin D <50 nmol/L (20 ng/mL)
Insufficiency: 50–75 nmol/L
Repletion: loading dose 50,000 IU weekly × 8 weeks; maintenance 1,500–2,000 IU/day
Associated with: osteoporosis, falls, immune dysfunction, depression, T2DM

🩹 Iron Deficiency & Anaemia

Particularly common in women of reproductive age in GCC
Dietary sources: red meat, lamb liver, dates (natural iron in GCC diet), lentils, chickpeas
Vitamin C enhances non-haem iron absorption — advise with meals
Tea and coffee inhibit iron absorption — avoid 1 hour either side of meals
Oral ferrous sulfate 200 mg TDS; take on empty stomach if tolerated
IV iron (Ferinject) for intolerance, poor absorption, or severe anaemia

📌 Dietitian Referral Criteria

MUST score ≥ 2 (high risk)
Pre-operative complex or major surgery
Renal disease (CKD stage 3–5, dialysis)
Hepatic failure or cirrhosis
Inflammatory bowel disease

Eating disorders (anorexia nervosa, bulimia)
Post-bariatric surgery (mandatory)
Diabetes mellitus (MNT)
Oncology — cancer cachexia
Any patient requiring PN (review within 48h)

📌 Quick Reference: MUST Scoring Card

MUST Total	Risk Category	Action
0	Low risk	Routine clinical care; reassess weekly (hospital) / monthly (community)
1	Medium risk	Observe; document 3-day food intake; if inadequate, follow local policy; reassess weekly
≥ 2	High risk	Treat: refer dietitian; initiate nutrition support; set nutrition goals; monitor regularly

📝 Knowledge Quiz — Nutrition Assessment

1. A patient has a BMI of 17.8, unplanned weight loss of 12% over 3 months, and has been acutely ill with no oral intake for 6 days. What is their MUST score?

2. What is the GOLD STANDARD method for confirming NG tube position before FIRST use?

3. Which electrolyte abnormality is the HALLMARK of refeeding syndrome?

4. What protein requirement is recommended for a critically ill ICU patient?

5. What must be given BEFORE starting any nutrition in a patient at high risk of refeeding syndrome?

6. A patient in ICU has a gastric residual volume (GRV) of 350 mL. What is the correct action?

7. Which feature is UNIQUE to post-pyloric (NJ) tube feeding?

8. What is the most prevalent micronutrient deficiency in the GCC population?

9. Which drug should NOT be crushed for administration via NG tube?

10. According to NICE criteria, which patient is at HIGH risk of refeeding syndrome?