Specialist Dietitian Nayran Muniz-Owen assesses the impact of unknown clinical and social histories on dietetic assessment in acute adult inpatient mental health settings.
In acute mental health settings, dietitians frequently encounter patients with incomplete or unknown clinical and social histories, including missing weight trajectories, unclear dietary intake patterns, and limited knowledge of social and cultural context.
These unknowns can significantly hinder accurate nutritional assessment, risk stratification and the formulation of effective treatment plans.
This article explores the implications of these unknowns for dietary care, emphasising the challenges in conducting nutritional assessments, identifying malnutrition and addressing therapeutic goals.
It is essential to improve interdisciplinary information sharing, develop targeted assessment tools and provide enhanced training to manage uncertainty in dietetic practice.
Acute adult mental health units are characterised by clinical complexity, fluctuating patient engagement and, often, significant barriers to obtaining a comprehensive history.
Dietitians play a vital role in assessing nutritional risk, interpreting limited or fragmented information, and supporting patients’ nutritional recovery within challenging and dynamic settings.
However, the effectiveness of dietary assessment is often hindered by the lack of essential patient data.
This includes missing weight history, unclear diet history, and fragmented or unavailable social and cultural background information.
These gaps may arise from factors such as chronic homelessness, avoidance of medical care over long periods, self-isolation and severe self-neglect, which are common in severe mental illness. These ‘unknowns’, or incomplete histories, create uncertainty, raise clinical risk and may negatively impact care outcomes.
Challenges in nutritional assessment
1. Unknown weight history
The documentation of weight history – including baseline weight, weight trends and recent or current weight – is vital for diagnosing malnutrition and assessing nutritional risks in individuals with eating disorders and severe mental illnesses.
When such information is incomplete or unavailable, or the patient cannot report it themselves, dietitians working in acute inpatient mental health settings typically obtain additional details from GPs, next of kin, carers or family members.
However, in cases where these sources are inaccessible or cannot be contacted, dietitians may have no choice but to rely on a single weight measurement, which can be misleading and insufficient for accurate assessment.
Malnutrition diagnosis often depends on assessment tools such as the Malnutrition Universal Screening Tool (MUST), which is not validated for use within acute mental health environments (Stratton et al., 2004), or SANSI, a tool validated solely for forensic mental health settings.
Alternatively, diagnostic criteria such as the Global Leadership Initiative on Malnutrition (GLIM) prioritise nonvolitional weight loss over time as a primary indicator (Cederholm et al., 2019).
The evaluation of refeeding risk is similarly compromised by the lack of baseline anthropometric data.
National Institute for Health and Care Excellence (NICE) guidelines for preventing refeeding syndrome heavily rely on knowledge of recent weight loss and diminished nutritional intake (NICE, 2006).
In acute mental health facilities, patients often exhibit limited medical engagement or lack documented care histories, especially at the outset of treatment, rendering these data difficult or impossible to obtain.
Moreover, patients experiencing acute psychiatric symptoms – such as psychosis, mania or catatonia – are frequently unable to provide coherent or accurate dietary or weight histories at the time of admission.
As their mental state improves with treatment, they may later recall critical information, such as prolonged fasting, significant weight loss or severe dietary restrictions.
Nevertheless, by the time they are capable of disclosing such details, crucial windows for early diagnosis and prevention of complications such as refeeding syndrome may have already passed.
Research indicates that electrolyte shifts and refeeding complications may occur within two to five days of nutritional rehabilitation, particularly among high-risk patients.
Consequently, delays in obtaining essential historical information because of psychiatric instability can directly result in an underestimation of refeeding risk and delayed intervention, thereby increasing morbidity and extending hospital stays.
2. Gaps in dietary history
A patient’s usual intake, food preferences, restrictions and disordered eating behaviours are critical to assessment and care planning. However, patients in acute mental health crises may be unable or unwilling to provide reliable dietary information because of:
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Psychosis, disordered thinking, catatonia or cognitive impairment
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Distrust, shame or fear of repercussions
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Lack of insight into their eating behaviours
Rocks et al. (2022) reported that dietitians working in psychiatric settings found it very challenging to gather accurate dietary recalls from patients with active psychosis or mood disorders.
These situations hinder the use of standard tools such as 24-hour recalls or food frequency questionnaires, which depend on patient insight and cooperation.
Nevertheless, despite notable differences in intervention components and outcomes, individually delivered and dietitian-led interventions were recognised as the most effective for addressing nutritional problems.
3. Incomplete social and cultural history
Social determinants such as housing stability, food access, immigration status and cultural or religious dietary practices are often poorly documented, completely unknown or not sufficiently considered.
It is important to emphasise that these factors are crucial for dietetic interventions, especially in mental health acute settings.
When unaddressed during admission, these gaps can lead to discharge into food-insecure environments, undermining the effectiveness of dietetic measures, or to dietary recommendations that are unsuitable or culturally insensitive, reducing adherence.
The World Health Organization highlights the importance of cultural competence in providing safe and effective nutrition care.
This is particularly vital in mental health settings, where patients may face additional barriers, including stigma, language and speech difficulties, and social exclusion, which further complicate the assessment of social and cultural needs.
Clinical consequences of unknowns
Risk of misdiagnosis or delayed diagnosis
Without longitudinal weight data, conditions such as undernutrition or restrictive eating disorders may remain unnoticed.
For instance, atypical anorexia nervosa, where BMI stays within the normal or higher range at the beginning, can be significantly under-recognised without considering historical weight information.
Suboptimal or inappropriate interventions
Inadequate dietary histories can lead to overestimation or underestimation of nutritional status.
For instance, starting a high-calorie diet in a refeeding-sensitive patient because of unrecognised prior nutritional depletion may cause serious complications, such as electrolyte shifts, oedema and cardiac failure.
Conversely, underestimating requirements because of missing historical information can delay nutritional rehabilitation, impair recovery and prolong hospital stay.
Strengthening structured risk-screening processes, interdisciplinary information sharing and cautious, phased care planning can help reduce these risks and support safer nutritional practice.
Heightened ethical and professional responsibility
Dietitians are frequently required to make clinical decisions in acute mental health settings under considerable uncertainty.
Balancing patient autonomy with safety and ethical obligations demands a high degree of professional judgement and MDT discussions.
In these cases, thorough documentation of clinical reasoning is essential for quality assurance and legal protection.
Strategies for managing unknowns
Risk-based frameworks
Employ risk-stratified models, with heightened vigilance, when key information is missing.
Some eating disorder protocols treat ‘unknown weight history’ as a clinical red flag, warranting enhanced monitoring and cautious refeeding when other signs are showing its risk.
Interdisciplinary collaboration
Collaborate with nursing, psychiatry, occupational therapy, medical teams in community or acute settings and social work to help reconstruct missing histories.
When appropriate and ethically feasible, input from carers or family members can provide valuable insights into a person’s preadmission status.
Enhanced screening tools
Use screening tools that are validated for mental health settings.
Currently, there is no malnutrition screening tool validated specifically for acute mental health environments in the UK.
The SANSI screening tool is validated only for secure psychiatric settings (forensics).
Other tools are currently being developed for implementation in the UK.
Training and supervision
Invest in training dietitians to manage clinical uncertainty, apply trauma-informed care principles and enhance mental health literacy.
Implementing structured supervision and reflective practice can mitigate moral distress and diminish the risk of clinical burnout.
Discussion
Unknown clinical and social histories in acute mental health dietetics are not simply documentation gaps – they represent direct clinical risks.
Addressing these challenges requires a systemic response, including strengthened communication across health services, standardised protocols for documenting unknown information and assessment frameworks that explicitly account for uncertainty.
Improving the tracking, continuity and visibility of key clinical information across the care pathway must be embedded within dietetic education, clinical governance and professional standards to support safe and effective practice.
Conclusion
Unknown weight history, diet patterns and social histories are common, yet critical barriers to effective dietetic assessment in acute mental health settings.
These unknowns necessitate careful clinical reasoning, interdisciplinary collaboration and risk-sensitive practice.
Future research should focus on the development and validation of tools tailored to mental health contexts, and the design of protocols that enable safe, patient-centred care amid uncertainty.
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