Domain 2 of 12

Nutrition

Eating and drinking safely, weight maintenance, and dysphagia management.

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What this domain measures

The Nutrition (food and drink) domain captures the ability to eat and drink safely, maintain weight, and manage any swallowing difficulties (dysphagia). The descriptor table has 5 levels (N/L/M/H/S). Severe is reached where PEG/RIG feeding requires 24-hour skilled professional intervention or where intervention is inappropriate or impossible — a routine under-scoring battleground because assessors often treat 'non-problematic' enteral feeding as Moderate even when the regime is complex.

How it's scored (Annex C wording)

DST scoring levels for the Nutrition domain, with verbatim Annex C descriptors.
Level	DST descriptor
No needs	Able to take adequate food and drink by mouth to meet all nutritional requirements.
Low	Needs supervision, prompting with meals, or may need feeding and/or a special diet (for example to manage food intolerances/allergies). OR Able to take food and drink by mouth but requires additional/supplementary feeding.
Moderate	Needs feeding to ensure adequate intake of food and takes a long time (half an hour or more), including liquidised feed. OR Unable to take any food and drink by mouth, but all nutritional requirements are being adequately maintained by artificial means, for example via a non-problematic PEG.
High	Dysphagia requiring skilled intervention to ensure adequate nutrition/hydration and minimise the risk of choking and aspiration to maintain airway. OR Subcutaneous fluids that are managed by the individual or specifically trained carers or care workers. OR Nutritional status 'at risk' and may be associated with unintended, significant weight loss. OR Significant weight loss or gain due to identified eating disorder. OR Problems relating to a feeding device (for example PEG) that require skilled assessment and review.
Severe	Unable to take food and drink by mouth. All nutritional requirements taken by artificial means requiring on-going skilled professional intervention or monitoring over a 24 hour period to ensure nutrition/hydration, for example I.V. fluids/total parenteral nutrition (TPN). OR Unable to take food and drink by mouth, intervention inappropriate or impossible.

Evidence that moves the score up

SALT swallowing assessment with current diet and fluid recommendations (IDDSI levels)
MUST (Malnutrition Universal Screening Tool) scores trended over time
Weight chart over the last 6 months
Food and fluid intake records — quantity and any refusal pattern
PEG / RIG / NG feeding plan including pump rate, top-ups, flushes, and complications log
Hospital admissions for aspiration pneumonia or feeding-related complications
Dietitian reports and any oral nutritional supplement (ONS) prescription
Mealtime support plan describing positioning, pace, and trained-staff requirements

How ICBs commonly under-score this domain

Pattern: Assessor scored Moderate because PEG feeding is 'non-problematic'.

Rebuttal: The Moderate descriptor does cover 'non-problematic PEG' explicitly. The score elevates to High if there are 'Problems relating to a feeding device (for example PEG) that require skilled assessment and review' — and to Severe when all nutritional requirements require on-going skilled professional intervention or monitoring over a 24-hour period. Argue High or Severe with evidence of PEG-related problems, complex regimes, or 24-hour skilled monitoring.

Source: DST Annex C Nutrition Moderate, High, and Severe descriptors

Pattern: Assessor scored Moderate where dysphagia requires modified texture diet and thickened fluids.

Rebuttal: The High descriptor turns on dysphagia requiring skilled intervention to ensure adequate nutrition/hydration and minimise the risk of choking and aspiration. Modified-texture + thickened fluids regimes where trained staff must oversee every meal to prevent aspiration typically meet this.

Source: DST Annex C Nutrition High descriptor

Pattern: Assessor scored Low because weight is 'stable'.

Rebuttal: Stable weight is evidence the nutritional intervention is working — fortified diet, ONS prescription, or enteral top-ups. Per paras 162–166, score the present-day need including the regime, not the maintained outcome. The High descriptor includes 'Nutritional status at risk' and 'Significant weight loss or gain due to identified eating disorder' — both still apply where the regime is keeping the person stable.

Source: para 162-166 + DST Annex C Nutrition High descriptor

4-line rebuttal template

I disagree with the [LEVEL] score for Nutrition. The evidence shows [SPECIFIC PATTERN — dysphagia, PEG/RIG problems, aspiration risk, weight loss, 24-hour skilled monitoring] which meets the [HIGHER LEVEL] descriptor. On [DATE/PERIOD], the nutritional regime was [DESCRIBE: SALT recommendation, IDDSI levels, MUST score, weight trajectory, enteral feeding details, staff time per meal]. Per the well-managed needs principle (National Framework paras 162–166), the [modified diet / thickened fluids / PEG regime] is the intervention, not the absence of need. If [SUPPORT] were withdrawn, the present-day risk would be [DESCRIBE: aspiration, malnutrition, dehydration]. I therefore request the Nutrition domain be re-scored to [HIGHER LEVEL] with reference to the [SPECIFIC EVIDENCE: SALT report, MUST chart, weight log, PEG plan, dietitian letter].

Nutrition rarely secures eligibility on its own

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