GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community

Development of a New Malnutrition Screening Tool for Patients: Human Key Tool of Nutrition

Background and aims

Malnutrition is related to increased mortality and poor outcome. Therefore, early diagnosis and intervention of malnutrition are recommended. However, the optimal nutrition screening tool for diagnosing malnutrition remains undetermined. This study aimed to verify the discrimination and difficulty of nutrition screening items through item response theory (IRT) analysis and develop a simpler malnutrition screening tool.

Methods

This study enrolled 10,375 patients aged ≥18 years who were admitted at Tokushima University Hospital. Patients who were pregnant had short-term hospitalization (≤3 days), were hospitalized only in the weekend, could not hear clearly, and were hospitalized merely for examination were excluded. A skilled dietitian performed the Subjective Global Assessment, rating a good nutritional status as A, moderate malnutrition as B, and severe malnutrition as C.

Results

According to Subjective Global Assessment, we classified 7119 patients as A, 2892 as B, and 364 as C. Between these classes, the total number of application items was significantly lower in class A but significantly higher in class C. In the discrimination of each item calculated by IRT analysis, the highest discrimination item was "Has your food intake been less than usual?", followed by "Have you had anorexia?", "Have you had vomiting?", "Have you had nausea?", "Have you had dehydration?", and "Have you lost weight?".

Conclusions

Human Key Tool of Nutrition, which is based on the IRT analysis results, is a new simple nutrition screening tool developed by us. Human Key Tool of Nutrition can contribute to the widespread use of nutrition screening.

Complementarity of nutrition risk screening tools with malnutrition diagnosis in patients with cancer: A 12-month follow-up study assessing accuracy metrics and mortality

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) criteria for diagnosing malnutrition were established to provide a standardized approach for diagnosing malnutrition in clinical practice using a nutrition screening tool (NST) as the first step for this process. This study aimed to compare the complementarity of NSTs with the GLIM criteria for malnutrition diagnosis in patients with cancer.

METHODS

Hospitalized patients with different cancer types were evaluated in a prospective cohort study in which they were initially screened using the Patient-Generated Subjective Global Assessment (PG-SGA), Protocol for Nutritional Risk in Oncology (PRONTO), Malnutrition Universal Screening Tool, Nutritional Risk Screening 2002, Malnutrition Screening Tool, and NutriScore for nutrition risk. Malnutrition diagnosis involved phenotypic and etiological criteria as proposed by the GLIM. Complementarity of NST to GLIM criteria was evaluated by calculating accuracy metrics and investigating association with 12-month mortality.

RESULTS

Nutrition risk ranged from 14.8% (NutriScore) to 82.8% (PRONTO) and frequency of malnutrition from 13.8% (with NutriScore) to 88.9% (with PG-SGA). NutriScore presented the lowest negative predictive value (25.1%) whereas PG-SGA presented the highest (58.32%). Regardless of the NST applied, the risk of malnutrition and diagnosis of malnutrition according to the GLIM criteria, combined or isolated, increased the risk of 12-month mortality.

CONCLUSION

All NSTs presented low negative predictive value when their complementarity to GLIM criteria for malnutrition diagnosis was tested. Indeed, patients "at risk" presented similar increased risk of 12-month after discharge mortality in comparison with those at risk and malnourished by the GLIM criteria when all NSTs were applied.

Hand Grip Strength and Body Composition According to the Sarcopenic Obesity Guidelines: Impact on Postoperative Complications in Patients With Gastric Cancer

BACKGROUND

The diagnosis of sarcopenic obesity (SO) in patients with gastric cancer has been inconsistent among studies examining postoperative complications because diagnostic methods have not been standardized. This study aimed to clarify the differences in the prevalence of obesity with and without low hand grip strength (HGS) according to the diagnostic criteria proposed using the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO) and identify the optimal model for predicting postoperative complications.

METHODS

Patients who underwent radical gastrectomy for gastric cancer between April 2015 and March 2023 were included. According to the ESPEN/EASO diagnostic criteria, patients with a body mass index ≥ 25 kg/m2 who met the screening criteria were assessed for percent body fat (PBF) and skeletal muscle mass (SMM) adjusted by weight (SMM/W) and HGS. Depending on the respective cutoff values, six models of low SMM-obesity without HGS and six models of low HGS-obesity with HGS were set. The incidence of postoperative complication with the Clavien-Dindo classification grade 2 or higher was compared across models. Multivariate logistic regression analysis was performed to determine the risk model for postoperative complications, with significance set at p < 0.05.

RESULTS

The analysis included 1762 patients with a median age of 67.0 years; 1123 were men (63.7%). The prevalence of low SMM-obesity was significantly higher (5.4%-17.3%) than that of low HGS-obesity (1.2%-2.3%). Among those with low SMM-obesity, PBF > 20.2% for men and > 31.7% for women as well as SMM/W ≤ 42.9% for men and ≤ 35.6% for women had the highest postoperative complication incidence number of cases. This model was an independent risk factor for postoperative complications in the multivariate analysis (odds ratio: 1.671, 95% confidence interval: 1.204-2.299, and p = 0.002).

CONCLUSIONS

In obese patients with gastric cancer, the preoperative prevalence of low HGS-obesity or low SMM-obesity differed significantly. One of the low SMM-obesity model was associated with postoperative complication after gastrectomy.

The GLIM consensus approach to diagnosis of malnutrition: A 5-year update

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) introduced an approach for malnutrition diagnosis in 2019 comprised of screening followed by assessment of three phenotypic criteria: weight loss, low BMI, and low muscle mass, and two etiologic criteria: reduced food intake/assimilation, and inflammation/disease burden. This planned update reconsiders the GLIM framework based on published knowledge and experience over the past five years.

METHODS

A GLIM working group (n = 43 members) conducted a literature search spanning 2019-2024 using the keywords "Global Leadership Initiative on Malnutrition or GLIM". Prior GLIM activities providing guidance for use of the criteria on muscle mass and inflammation were reviewed. Successive rounds of review and revision were used to achieve consensus.

RESULTS

More than 400 scientific reports are published in peer-reviewed journals, forming the basis of 10 systematic reviews, some including meta-analyses of GLIM validity that indicate strong construct and predictive validity. Limitations and future priorities are discussed. Working group findings suggest that assessment of low muscle mass should be guided by experience and available technological resources. Clinical judgement may suffice to evaluate the inflammation/disease burden etiologic criterion. No revisions of the weight loss, low BMI, or reduced food intake/assimilation criteria are suggested. Following two rounds of review and revision, the working group secured 100 % agreement with the conclusions reported in the 5-year update.

CONCLUSION

Ongoing initiatives target priorities that include malnutrition risk screening procedures, GLIM adaptation to the intensive care setting, assessment in support of the reduced food intake/assimilation criterion, and determination of malnutrition in obesity.

Nutritional status and gastroenteropancreatic neuroendocrine neoplasms: lights and shadows with a clinical guide from the NIKE Group

Neuroendocrine neoplasms (NENs) originating in the gastroenteropancreatic (GEP) tract are rare tumors often associated with significant metabolic disturbances and nutritional challenges. This review explores the intricate relationship between nutritional status and the development, progression, and prognosis of GEP-NENs. Through an extensive literature search encompassing studies up to April 2024, we examined various factors, including obesity, malnutrition, metabolic syndrome and type 2 diabetes mellitus, and their roles in the development and progression of GEP-NENs. The review highlights the dual role of obesity, both as a risk factor and a potential prognostic indicator, drawing attention to the 'obesity paradox' observed in cancer research. Additionally, we discuss the impact of malnutrition on patient outcomes and emphasize the need for comprehensive nutritional assessments beyond BMI. This analysis highlights the importance of incorporating nutritional interventions into preventive and therapeutic strategies for GEP-NEN patients. Future research should further clarify these associations and develop personalized nutritional management protocols to improve patient prognosis and quality of life. Acronyms adopted in the text and tables: AOR: adjusted odd ratio, BIA: Bioelectrical Impedance Analysis, BMI: Body Mass Index, CI: confidence interval, CLARINET: Controlled Study of Lanreotide Antiproliferative Response in Neuroendocrine Tumor, FLI: fatty liver index, GEP: gastroenteropancreatic, GLIM: global leadership into malnutrition, HR: hazard ratio, MS: metabolic syndrome, MUST: malabsorption universal screening tool, NEC: neuroendocrine carcinoma, NENs: Neuroendocrine neoplasms, NETs: Neuroendocrine tumors, NRS: Nutritional Risk Screening, OR: odd ratio, OS: overall survival, PFS: progression-free survival, RR: risk ratio, SGA: Subjective Global Assessment, T2DM: type 2 diabetes mellitus, VAI: visceral adiposity index, WD: well-differentiated.

Prevalence and impact of sarcopenia in patients with inflammatory bowel diseases: A prospective cohort study

BACKGROUND

Inflammatory bowel disease (IBD) patients with sarcopenia are at increased morbidity risk. The aim of this study was to assess the prevalence of sarcopenia in IBD outpatients using both morphological and functional criteria.

METHODS

In this prospective cohort study, all IBD patients admitted to the day hospital unit between March 01 and 31, 2023 were included. Muscle mass and function were evaluated using bioelectrical impedance analysis and handgrip strength measurement, respectively. Probable sarcopenia was defined as reduced handgrip strength (<16-27 kg). Myopenia was defined by a low appendicular muscle mass index (<5.5-7 kg/m²). Sarcopenia was diagnosed based on the coexistence of reduced muscle strength and muscle mass. Disease activity, therapeutic changes, hospitalizations, and IBD-related surgeries were assessed at month 6.

RESULTS

Sixty patients with either Crohn's disease (CD, 52 %) or ulcerative colitis (48 %), with a median age of 37 years (interquartile range [IQR]: 28-54), were included. Fifty-five percent were women. Most patients were in remission (67 %, n = 40). In CD patients, the involvement was ileocolic (48 %), ileal (35 %), or colonic (16 %). A history of IBD-related digestive surgery was noted in 30 % of cases. The median body mass index [BMI] was 24 (IQR: 21-27). The prevalence of sarcopenia, probable sarcopenia, and myopenia was 10 %, 18 %, and 20 %, respectively. Sarcopenic patients were significantly older (59 vs 36 years, p = 0.01), had a longer disease duration (20 vs 8 years, p = 0.003), were more likely to have associated joint inflammation (27 % vs 6 %, p = 0.01) and CD (80 % vs 49 %, p = 0.36). Myopenia was significantly associated with a history of surgery (67 % vs 21 %, p = 0.004) and a lower BMI (21 vs 24, p = 0.001).

CONCLUSION

In this prospective cohort of IBD outpatients, 10 % and 20 % of patients had sarcopenia and myopenia, respectively. Screening for sarcopenia therefore seems essential in this population, including in stable outpatients in remission who do not meet malnutrition criteria and in overweight patients, as according to the literature, sarcopenia is associated with poorer clinical outcomes and increased postoperative complications. Interventional studies are needed to assess the impact of multidisciplinary treatment of sarcopenia on quality of life and disease progression.

Recognizing malnutrition in adults with critical illness: Guidance statements from the Global Leadership Initiative on Malnutrition

BACKGROUND

Patients with critical illness may present with disease-related malnutrition upon intensive care unit (ICU) admission. They are at risk of development and progression of malnutrition over the disease trajectory because of inflammation, dysregulated metabolism, and challenges with feeding.

METHODS

The Global Leadership Initiative on Malnutrition (GLIM) convened a panel of 36 clinical nutrition experts to develop consensus-based guidance statements addressing the diagnosis of malnutrition during critical illness using a modified Delphi approach with a requirement of ≥75% agreement.

RESULTS

(1) To identify pre-existing malnutrition, we suggest evaluation within 48 h of ICU admission when feasible (100% agreement) or within 4 days (94% agreement). (2) To identify the development and progression of malnutrition, we suggest re-evaluation of all patients every 7-10 days (97% agreement). (3) To identify progressive loss of muscle mass, we suggest evaluation of muscle mass as soon as feasible (92% agreement) and again after 7-10 days (89% agreement). (4) To identify the development and progression of malnutrition before and after ICU discharge, we suggest re-evaluating nutrition status before ICU discharge and during clinical visits that follow (100% agreement).

CONCLUSION

Research using consistent etiologic and phenotypic variables offers great potential to assess the efficacy of nutrition interventions for critically ill patients with malnutrition. Assessment of these variables during and beyond the ICU stay will clarify the trajectory of malnutrition and enable exploration of impactful treatment modalities at each juncture. GLIM offers a diagnostic approach that can be used to identify malnutrition in critically ill patients.

Dietary intake in healthy older individuals is associated with lipopolysaccharide binding protein a biomarker of gut function: an exploratory cross-sectional study

Diet, physical function and gut health are important modifiable factors in ageing. However, it is unclear how ageing affects various domains of gut function. Aims of this cross-sectional study were to explore relationships between nutrient intake, physical function, and biomarkers of gut function in older individuals. Healthy participants (n = 94, mean age 71.1 years SD 5.10, 56% female) were recruited to investigate the relationship between nutrient intake (protein, fibre, carbohydrate, fat), physical function (chair rise time, handgrip strength) and lipopolysaccharide (LPS) binding protein (LBP); a marker of gut permeability. Linear regression models, adjusted for age, fat mass/fat free mass ratio, weight and gender, reported LBP changed by; -161.9 ng/mL (95% CI -323.0, -0.8) for every 1 g increase in daily fibre/1,000 kilocalories; 80.5 ng/mL (6.7, 154.2) for 1% increase in daily energy intake as fat; and -88.1 ng/mL (-146.7, -29.6) for 1% increase in daily energy as carbohydrates. When further adjusted for C-reactive protein (CRP), a marker of inflammation, LBP decreased by an additional 6.9 ng/mL for fibre, increased by an additional 4.0 ng/mL for fat and decreased by an additional 3.7 ng/mL for carbohydrate. These findings suggest that in healthy older adults' nutrient intake is associated with LBP, and CRP appears to slightly modify these associations. There were no associations between LBP and handgrip strength or chair rise time. Results suggest that fibre, fat, and carbohydrates are important for maintaining gut function, potentially mediated by inflammation in older adults, although further research is needed to explore the implications for physical function and CRP as a mediator.

Recognizing malnutrition in adults with critical illness: Guidance statements from the Global Leadership Initiative on Malnutrition

BACKGROUND

Patients with critical illness may present with disease-related malnutrition upon intensive care unit (ICU) admission. They are at risk of development and progression of malnutrition over the disease trajectory because of inflammation, dysregulated metabolism, and challenges with feeding.

METHODS

The Global Leadership Initiative on Malnutrition (GLIM) convened a panel of 36 clinical nutrition experts to develop consensus-based guidance statements addressing the diagnosis of malnutrition during critical illness, using a modified Delphi approach with a requirement of ≥75% agreement.

RESULTS

CONCLUSION: Research using consistent etiologic and phenotypic variables offers great potential to assess the efficacy of nutrition interventions for critically ill patients with malnutrition. Assessment of these variables at during and beyond the ICU stay will clarify the trajectory of malnutrition and enable exploration of impactful treatment modalities at each juncture. GLIM offers a diagnostic approach that can be used to identify malnutrition in critically ill patients.

The nutritional impact of 7 versus 21 home-delivered medically tailored meals in patients with heart failure and malnutrition risk: a random order crossover feeding trial (MEDIMEALS)

BACKGROUND

Heart failure (HF) is frequently associated with malnutrition or malnutrition risk. The delivery of medically tailored meals (MTM) to the homes of patients with HF and malnutrition risk or malnutrition after hospital discharge holds promise for improving outcomes. However, the number of MTM needed to provide benefit is not established.

METHODS

A random order crossover study was designed to compare the delivery of 7 versus 21 MTM for four weeks each to patients discharged from the hospital with HF and malnutrition risk. Telephone surveys were conducted at baseline, 30, and 60 days post-discharge to evaluate change in malnutrition risk, American Heart Association (AHA) diet goals, sarcopenia risk, and 30-day readmissions.

RESULTS

Forty-six patients were enrolled. Patients had reduced odds of having malnutrition risk relative to the baseline score at one and two months (OR 0.18, 95% CI 0.04-0.74 and OR 0.21, 95% CI 0.05-0.99, respectively). The AHA diet score improved over time from baseline by 0.73 ± 0.22 units at one month (p = 0.0014), and by 0.48 ± 0.23 units at two months (p = 0.0430), regardless of the number of MTM provided. Sarcopenia risk improved over time (p = 0.01), decreasing by 0.43 ± 0.2 units by one (p = 0.03) and 0.59 ± 0.21 units by two months (p = 0.007) regardless of the number of MTM provided. Readmissions by 30 days were not significantly different based on the number of MTM provided (9% for 21 MTM vs 12.5% for 7 MTM), but well below national data at 23%.

CONCLUSION

The provision of at least seven MTM per week in the early window after hospital discharge to patients with HF and malnutrition or malnutrition risk is a promising strategy to improve malnutrition and sarcopenia risk and diet adherence, while keeping readmissions below national averages.

TRIAL REGISTRATION

Clinicaltrials.gov NCT06142903, registered 11/23/2023.

European Consensus on Malabsorption-UEG & SIGE, LGA, SPG, SRGH, CGS, ESPCG, EAGEN, ESPEN, and ESPGHAN: Part 2: Screening, Special Populations, Nutritional Goals, Supportive Care, Primary Care Perspective

Malabsorption is a complex and multifaceted condition characterised by the defective passage of nutrients into the blood and lymphatic streams. Several congenital or acquired disorders may cause either selective or global malabsorption in both children and adults, such as cystic fibrosis, exocrine pancreatic insufficiency (EPI), coeliac disease (CD) and other enteropathies, lactase deficiency, small intestinal bacterial overgrowth (SIBO), autoimmune atrophic gastritis, Crohn's disease, and gastric or small bowel resections. Early recognition of malabsorption is key for tailoring a proper diagnostic work-up for identifying the cause of malabsorption. Patient's medical and pharmacological history are essential for identifying risk factors. Several examinations like endoscopy with small intestinal biopsies, non-invasive functional tests, and radiologic imaging are useful in diagnosing malabsorption. Due to its high prevalence, CD should always be looked for in case of malabsorption with no other obvious explanations and in high-risk individuals. Nutritional support is key in management of patients with malabsorption; different options are available, including oral supplements, enteral or parenteral nutrition. In patients with short bowel syndrome, teduglutide proved effective in reducing the need for parenteral nutrition, thus improving the quality of life of these patients. Primary care physicians have a central role in early detection of malabsorption and should be involved into multidisciplinary teams for improving the overall management of these patients. In this European consensus, involving 10 scientific societies and several experts, we have dissected all the issues around malabsorption, including the definitions and diagnostic testing (Part 1), high-risk categories and special populations, nutritional assessment and management, and primary care perspective (Part 2).

Survival and parenteral nutrition dependence in patients aged 65 y and older with short bowel syndrome: a retrospective observational cohort study

BACKGROUND

Home parenteral support (PS) is the standard treatment of chronic intestinal failure (CIF) with short bowel syndrome (SBS) as the leading cause. However, outcomes of PS in older patients remain poorly studied.

METHODS

This retrospective observational study evaluated patients with newly diagnosed SBS-CIF initiating PS between 2015 and 2020 at a national French CIF referral center. Patients were stratified into 2 groups: 65 y or older (older group) and younger than 65 y (younger group). Multivariate Cox regression identified predictors of mortality and PS dependence in older patients.

RESULTS

We included 175 patients [median age: 61 y (IQR: 46-70 y); 58% female]. Mesenteric ischemia was the primary cause of CIF (32%). Surgical anatomy included jejunostomy (47%), jejunocolic (39%), and ileocolic anastomosis (14%). Older patients [n = 73 (42%); median age: 72 y; IQR: 68-76 y] had higher rates of arterial hypertension, dyslipidemia, cancer, and SBS-CIF caused by radiation enteritis, but fewer cases attributed to Crohn disease. After a median follow-up of 27 mo (95% confidence interval [CI]: 22, 32 mo), the probability of survival was 92% (95% CI: 88%, 97%), and the probability of PS dependence was 68% (95% CI: 60%, 785), with no significant difference between age groups. In older patients, the presence of a jejunostomy (hazard ratios [HR]: 3.4; 95% CI: 1.1, 10.6) was an independent predictor of PS dependence, and BMI of <22 kg/m2 (HR: 10.9; 95% CI: 1.4, 87.4) was an independent predictor of mortality. Fourteen patients (8%) were treated with teduglutide, with no significant difference between age groups.

CONCLUSIONS

Nearly half of patients with SBS-CIF on PS are aged 65 y or older, with PS dependence and survival rates comparable with those of younger patients. These findings suggest that age should not be a barrier to PS initiation.

Global Leadership Initiative on Malnutrition (GLIM) plus Patient- and Nutrition-Derived Outcome Risk Assessment Score (PANDORA) predicts intensive care mortality: A 180-day follow-up study

BACKGROUND AND AIM

Malnutrition is strongly related to mortality in intensive care unit (ICU) patients. The Patient- and Nutrition-Derived Outcome Risk Assessment Score (PANDORA) is a novel mortality prediction tool encompassing nutritional assessment. Since there is limited evidence regarding the power of PANDORA in predicting mortality in critically ill patients, we aimed to evaluate the benefit of adding PANDORA to the Global Leadership Initiative on Malnutrition (GLIM) for mortality prediction in the ICU setting by comparing it with the other valid mortality predictors.

METHODS

A total of 251 ICU patients were enrolled in the study. Malnutrition evaluation tools (i.e., GLIM criteria, The nutritional risk screening 2002, The modified Nutrition Risk in Critically Ill score), and mortality/disease severity tools (PANDORA, The Acute Physiology and Chronic Health Evaluation II score, Sequential Organ Failure Assessment) were performed. Scores ≥43 were defined as high PANDORA score.

RESULTS

The median age (IQR) of participants was 67 (52-78) years, and 47.0% (n = 118) were female. Patients were evaluated according to 30th, 60th, 90th, and 180th-day mortalities. In all groups, patients were older, had a lower body mass index and longer hospitalization time, and were more likely to have malnutrition and higher PANDORA, Acute Physiology and Chronic Health Evaluation II, and Sequential Organ Failure Assessment scores. In the Cox regression analyses, even if adjusted for various confounders, malnutrition according to GLIM criteria and a high PANDORA score had the highest hazard ratio (HR) for mortality (HR: 3.62; 95% confidence interval [CI]: 1.49-8.77; P = 0.004, HR: 3.71; 95% CI: 1.69-8.12; P = 0.001, HR: 3.46; 95% CI: 1.69-7.06; P = 0.001 and HR: 4.00; 95% CI: 1.98-8.09; P = 0.004 for 30th, 60th, 90th, and 180th days, respectively).

CONCLUSIONS

PANDORA is a valid tool for predicting mortality in ICU patients. Furthermore, to our knowledge this is the first study to reveal that integrating GLIM criteria into PANDORA may enhance its power in this setting.

Exocrine pancreatic insufficiency after partial pancreatectomy: impact on primary healthcare utilization and expenditures

INTRODUCTION

We sought to characterize the impact of exocrine pancreatic insufficiency (EPI) on primary healthcare utilization and expenditures following partial pancreatectomy (PP).

METHODS

Patients who underwent PP between 2004 and 2019 were identified using SEER-Medicare. Patients who developed EPI within 6 months following surgery were included in the EPI cohort and were followed for 1-year post-surgery. Differences in post-surgery PCP visit frequency and healthcare expenditures within 1-year were evaluated.

RESULTS

Among 1119 patients, median age was 74 years (IQR: 69-78), about one-half were female (52.5%), and the majority were White (85.2%). Following PP, 22.4% of patients developed EPI. Patients with EPI were more likely to be concomitantly diagnosed with diabetes following PP (EPI: 11.6% vs. no EPI: 3.7%; p < 0.001). On multivariable analyses, EPI was associated with increased PCP visits (Ref. No EPI; percent difference [%diff]: 29.62, 95%CI 15.15-45.90) and higher healthcare costs (Ref. No EPI; total postoperative expenditure: %diff 37.01, 95%CI 12.89-66.29; p < 0.01) within 1-year following PP.

CONCLUSION

Roughly 1 in 4 patients experienced EPI after PP. EPI was associated with increased PCP utilization and higher healthcare expenditures.

Clinical impacts of malnutrition based on the GLIM criteria using the MNA-SF for nutritional screening in patients with acute heart failure

The Global Leadership Initiative on Malnutrition (GLIM) suggested a two-step framework for the assessment of malnutrition based on screening and diagnosis. Malnutrition, as defined by the GLIM criteria, and the risk of malnutrition determined through nutritional screening are associated with adverse outcomes in patients with heart failure (HF). This study investigated the prognostic impact of malnutrition, as defined by the GLIM criteria, compared with the risk of malnutrition determined by the Mini Nutritional Assessment-Short Form (MNA-SF) screening tool among patients hospitalized for acute HF. A total of 446 patients with acute HF who underwent nutritional screening using the MNA-SF and were diagnosed with malnutrition based on the GLIM criteria were include in this study. The primary outcome was the incidence of all-cause death or HF-related readmission after discharge. Patients diagnosed with malnutrition based on both indices had a higher incidence of adverse events within one year post-discharge than patients diagnosed without malnutrition. However, a landmark analysis of years one to three post-discharge found that the incidence of the primary outcome was comparable between patients diagnosed with malnutrition and those that here not. Furthermore, although malnutrition as defined by the GLIM criteria was found to be an independent predictor of the 1 year incidence of all-cause death or rehospitalization for HF even after adjusting for other prognostic indicators (hazard ratio, 1.593; 95% confidence interval, 1.056-2.403; P = 0.026), the risk of malnutrition based on the MNA-SF was not. In conclusion, a diagnosis of malnutrition based on the GLIM criteria provides better prognostic stratification in the first year post-discharge in patients with acute HF as compared with nutritional screening based only on the MNA-SF.

Malnutrition risk, weight loss, and subsequent survival in patients listed for heart transplantation

Background

Higher malnutrition risk is associated with mortality among patients with heart failure and heart transplantation (HT). We investigated which malnutrition risk scores - geriatric nutrition risk index (GNRI), prognostic nutritional index (PNI), or controlling nutritional status (CONUT) - have the strongest mortality association for HT candidates, and whether they are prognostic at the time of HT listing or HT operation.

Methods

We reviewed adults listed for primary HT at a single center 1987-March 2022, with survival follow-up to November 2022. We constructed Cox proportional hazards models and restricted cubic spline curves for each risk score at both HT listing and HT operation and inputted HT operation as a time-varying covariate for models commencing at listing. Risk scores were assessed as continuous and binary variables. Weight change between listing and HT was evaluated similarly.

Results

The 1,024 patients [76% male; median age 55 (46-61) years; HT operation n = 656] had median follow-up of 4.6 (interquartile range 1.6-8.7) years. As a continuous variable, lower GNRI at HT listing (greater malnutrition risk) was independently associated with higher mortality. As binary variables, higher risk GNRI, PNI or CONUT scores at listing were all associated with higher mortality. Conversely, risk scores at time of HT operation were not associated with subsequent mortality. There was a non-significant trend towards higher mortality with greater weight loss between listing and HT operation.

Conclusion

Malnutrition risk scores showed prognostic utility only at time of HT listing. As a continuous variable, GNRI at HT listing was independently associated with subsequent mortality.

Use of parenteral nutrition in the management of enterocutaneous fistula

Nutrition plays an integral role in the management of patients with enterocutaneous fistula (ECF), but practice guidelines are often vague because of limited evidence. As a result, clinicians must rely on expert consensus and sound nutrition principles to guide practice. The initial phase of ECF management involves recognition (eg, fistula location and quantifying output) and stabilization (eg, source control and fluid and electrolyte balance). All patients with ECF should be considered at risk of malnutrition because of malabsorption, high gastrointestinal fluid and nutrient losses, and chronic inflammation. Strict bowel rest in conjunction with parenteral nutrition (PN) is typically warranted on initial presentation, but patients can often transition to oral diet or enteral nutrition if ECF output is low (<500 ml/day) and there is good control of ECF drainage at the skin level. Patients with high-output ECF (>500 ml/day) may require PN to meet fluid, electrolyte, and nutrient requirements to support spontaneous or surgical closure of the ECF. Because the healing process can take months, transfer from the inpatient to home setting should be considered when a patient is medically stable. Preparing for discharge home requires stabilization of fluid and electrolyte balance, achievement of glycemic control, containment of ECF output, and patient and/or caregiver training. A long-term PN treatment plan should be developed that incorporates outpatient monitoring, determination of target weight, and desired PN end point. The purpose of this article is to review the optimal use of PN in adult patients with ECF.

Malnutrition Diagnosed via Global Leadership Initiative on Malnutrition (GLIM) Criteria - Association with Clinical Outcomes and Predictive Value: A Systematic Review of Systematic Reviews

OBJECTIVES

Malnutrition is very common in people with cancer. The Global Leadership Initiative on Malnutrition (GLIM) recommendation on criteria has been proposed as a gold standard for diagnosing malnutrition. The diagnosis of malnutrition includes phenotypic criteria such as unintentional weight loss and etiologic criteria such as reduced food intake. The aim of this review is to summarise the evidence on the GLIM-defined malnutrition association with clinical outcomes and its predictive value.

METHODS

A systematic search was conducted in PubMed, CINAHL, and MEDLINE databases. A total of 6 systematic reviews with and without meta-analysis were identified and included for analysis. Five were systematic reviews with meta-analyses and 1 systematic review without meta-analysis.

RESULTS

GLIM-defined malnutrition is associated with decreased survival, disease-free survival, increased post-operative complications, increased overall complications, and prolonged length of stay. It has predictive value for worsening clinical outcomes.

CONCLUSION

The results support the use of GLIM criteria and indicate their predictive value for clinical outcomes. There is robust evidence indicating the association and predictive value of GLIM-defined malnutrition for clinical outcomes in people with cancer to recommend its use in clinical practice. Thus, the GLIM criteria depend on prior screening tools used and the consistency of muscle mass assessment.

IMPLICATIONS FOR NURSING PRACTICE

Nutrition care is a fundamental aspect of cancer nursing practice and nurses need to be aware of the signs of malnutrition. The GLIM criteria are relevant to be used also in cancer nursing practice for the early detection of malnutrition among people with cancer.

Prevalence of malnutrition among adult inpatients in China: a nationwide cross-sectional study

Malnutrition substantially contributes to adverse clinical outcomes. However, no national survey has been conducted to characterize its epidemiology in hospital settings in China. We conducted the China Nutrition Fundamental Data 2020 project among a multistage stratified cluster sample of adult inpatients from 291 study sites across 30 provinces, autonomous regions and municipalities (except for Hong Kong, Macao, Taiwan Province, and the Xizang Autonomous Region, please see MATERIALS AND METHODS for details of the causes) of China to generate reliable data on the prevalence of malnutrition and explore the associated risk factors. We collected information on participants' sociodemographic characteristics, physical examinations, and laboratory test results. Malnutrition was defined according to the Global Leadership Initiative on Malnutrition (GLIM) criteria. The standardized prevalence of malnutrition was calculated, and factors associated with malnutrition were examined using logistic regression analyses. We included 54,652 individuals with seven systemic diseases who completed all the survey documents in the final analysis. The overall prevalence of malnutrition was 12.5%, representing 7.6 million adult inpatients in China. The prevalence of malnutrition was higher in men, individuals aged ⩾ 60 years, residents of central and western regions, people from lower economic areas, and those with lower education levels than in women, individuals aged <60 years, residents of eastern regions, individuals from higher economic areas, and those with higher education levels. Patients with higher disease severity scores, infectious diseases, and neoplasms had a higher tendency for malnutrition than those without such conditions. Sex, age, region, economic level, education level, disease severity score, infectious diseases, and neoplasms were independently associated with malnutrition. In conclusion, malnutrition is prevalent among Chinese adult inpatients, necessitating national- and hospital-level interventions. This survey provides several avenues to begin addressing the burden of malnutrition in China.

Development and external validation of Global Leadership Initiative on Malnutrition-dictated nomograms predicting long-term mortality in hospitalized patients with cirrhosis

OBJECTIVES

Global Leadership Initiative on Malnutrition (GLIM) criteria have gradually accounted for the mainstay evaluating nutritional status. We sought to establish GLIM-dictated nomograms with other prognostic factors influencing long-term mortality and externally validate their predictive performance in decompensated cirrhosis.

METHODS

The derivation cohort comprised 301 patients presenting with cirrhosis-associated acute insults, while the validation cohort encompassed 101 subjects from another tertiary hospital. Two nomograms were constructed to predict the 1-year all-cause mortality by integrating the GLIM criteria. The study population was stratified into low-, moderate- and high-risk mortality groups according to aforesaid proposed models.

RESULTS

Adjusting Child-Turcotte-Pugh classification (Nomo#1) or Model for End-stage Liver Disease-Sodium score (Nomo#2) separately, the GLIM criteria were independently associated with 1-year mortality in the multivariate Cox regression analysis (Nomo#1 hazard ratio (HR) = 3.139, p < 0.001; Nomo#2 HR = 3.456, p < 0.001). The C-index and time AUC for Nomo#1 and Nomo#2 performed significantly better than those of the GLIM criteria or conventional scoring systems alone. The survival rate of the low-risk group was significantly higher than those of the moderate- or high-risk groups (Nomo#1: 95% vs 65.8% vs 33.3%, p < 0.001; Nomo#2: 94.3% vs 64.5% vs 25%, p < 0.001). Furthermore, our proposed models exhibited moderate prediction accuracy and may identify malnourished patients with poor survival conditions in the external validation cohort.

CONCLUSION

GLIM criteria-defined malnutrition negatively impacted long-term mortality in the context of decompensated cirrhosis. Our established nomograms may predict survival status with sufficient discriminatory ability, alongside good consistency and clinical benefits, supporting their effectiveness in daily practice.

Nutritional Status in a Group of Patients with Wounds Due to Diabetic Foot Disease and Chronic Venous Insufficiency

Background: Wound healing is a complex physiological process that begins immediately upon injury. Nutritional status significantly affects the course of regenerative processes. Malnutrition can prolong the inflammatory phase, limit collagen synthesis, and increase the risk of new wound formation. The issue of malnutrition is becoming increasingly prevalent and remains a significant concern, particularly among older adults dealing with chronic conditions. Methods: The study was conducted at the Wound Treatment Clinic of the Specialist Hospital at the Podkarpackie Oncology Center in Brzozów, Poland, over 12 months (31 December 2022 to 31 December 2023). A prospective assessment was carried out on 106 patients with chronic wounds. The sample selection was purposeful, based on the following criteria: individuals with hard-to-heal vascular wounds related to diabetic foot disease or venous insufficiency, who provided informed consent to participate after reviewing the study concept. The assessment included a questionnaire and biochemical blood analysis. Further evaluations covered wound characteristics and classification based on clinical scales. The morphotic and biochemical blood parameter assessment included albumin concentration, hemoglobin, C-reactive protein (CRP), and the nutritional risk index (NRI). Results: A larger wound area was associated with lower morphotic values in both groups. Exudate levels and severity in chronic venous insufficiency (CVI) patients and diabetic foot disease (DFD) were associated with lower hemoglobin, albumin, and NRI values. At the same time, the depth of tissue structure damage correlated with the measured biochemical parameters. Conclusions: NRI values and morphotic blood parameters, along with albumin, hemoglobin, and CRP levels, are closely associated with wound characteristics, including surface area, exudate level, and the severity of tissue destruction. The greater the destruction of tissue structures, the higher the risk of malnutrition and wound infection, as indicated by biochemical assessment.

Geriatric nutritional risk index as a predictor of major postoperative complications in emergency femoral hernia patients

BACKGROUND

To evaluate the prognostic values of GNRI for major postoperative complications in emergency femoral hernia patients.

METHODS

In this cross-sectional study, we enrolled 105 emergency femoral hernia patients. GNRI was calculated using preoperative body weight, height, and serum albumin. The primary outcome was a composite of major postoperative complications. Univariable and multivariable logistic regression analyses were used to examine the association between GNRI and major complications. The ability of GNRI in detecting major complications was assessed by area under the curve (AUC).

RESULTS

The prevalence of low, moderate, and severe nutritional risk was 18.1%, 25.7%, and 10.5%. Five patients (4.8%) had major postoperative complications. Higher GNRI was associated with lower risk of major complications after adjusting for age and sex (aOR = 0.90, 95% CI: 0.81-1.00, P = 0.044). The AUC for GNRI identifying major complications was 0.812 (95% CI: 0.640-0.984, P = 0.019), and the optimal cut-point value was 90.96 (sensitivity: 80.0%; specificity: 72.0%).

CONCLUSIONS

GNRI is significantly associated with major postoperative complications. It is a simple and useful prognostic tool for femoral hernia patients in emergency settings.

Prevalence and Prognostic Significance of Malnutrition in Patients with Non-Alcoholic Fatty Liver Disease (NAFLD)

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) has become the primary cause of chronic liver disease. Although malnutrition is a common late-stage clinical consequence during the course of organ dysfunction and death in critical patients, it has not received sufficient attention in the context of NAFLD. The aim of this study was to explore the prevalence and prognostic significance of malnutrition in patients with NAFLD using three simple tools for nutrition assessment.

METHODS

Participants (n = 3908) in the National Health and Nutrition Examination Survey (NHANES) database were divided into NAFLD (n = 1737) and non-NAFLD (n = 2171) groups. The controlling nutritional status (CONUT) score, prognostic nutrition index (PNI), and nutrition risk index (NRI) were applied to investigate the association between malnutrition and mortality among NAFLD patients.

RESULTS

The median age of participants was 54.0 years, with females accounting for 52.2% of the study cohort. A majority of elderly male participants had NAFLD, and up to 18% of NAFLD patients suffered from malnutrition. During the average period of follow-up (24.4 ± 7.2 months), 36 all-cause deaths occurred in the NAFLD group. Multivariate analysis revealed that malnutrition was associated with significantly higher mortality compared with normal nutrition. The adjusted hazard ratio (HR) for PNI was 4.44 (95% CI: 2.07-9.53, p < 0.001), and for NRI it was 6.98 (95% CI: 1.47-33.11, p = 0.014). The CONUT score also showed a trend for association with higher mortality.

CONCLUSION

Malnutrition is a common comorbidity in NAFLD patients and is closely associated with poor prognosis and higher mortality. The three nutrition assessment tools employed in this study could be used to improve the predictive ability of nutritional status for mortality among NAFLD patients.

The Predictive Role of Preoperative Malnutrition Assessment in Postoperative Outcomes of Patients Undergoing Surgery Due to Gastrointestinal Cancer: A Cross-Sectional Observational Study

Background: Malnutrition affects patients undergoing surgery for gastrointestinal cancers and contributes to poor postoperative outcomes, including increased complication rates, longer hospital stays, and higher mortality. Despite the availability of several malnutrition screening tools and prognostic scores, their effectiveness in predicting postoperative outcomes remains unclear. This study aimed to compare the predictive accuracy of Patient-Generated Subjective Global Assessment (PG-SGA), Global Leadership Initiative on Malnutrition (GLIM), Geriatric Nutritional Risk Index (GNRI), and Controlling Nutritional Status (CONUT) score for postoperative outcomes in patients undergoing surgery for colorectal, hepato-pancreato-biliary and upper gastrointestinal cancers. Methods: A cross-sectional observational study from March 2022 to October 2023 was conducted in two university surgical departments, after registration on ClinicalTrials database (NCT05795374). Patient characteristics, preoperative nutritional status and postoperative outcomes were analyzed. Results: In total, 480 patients were enrolled. CONUT and GNRI demonstrated high specificity (over 90% and 80%, respectively) for predicting overall complications, major complications, prolonged hospital stay, mortality, and advanced disease stage across all cancer types. Notably, CONUT showed a specificity over 97% and GNRI over 89.7% for colorectal and upper gastrointestinal cancer patients, respectively, despite their lower sensitivity. On the contrary, PG-SGA and GLIM presented better sensitivity (up to 50%), but slightly lower specificity (up to 86.4%). Conclusions: CONUT and GNRI are valuable for ruling out non-at-risk patients for adverse postoperative outcomes, while PG-SGA and GLIM provide better sensitivity. A step-up approach-initial screening with PG-SGA and GLIM, followed by detailed evaluation with CONUT or GNRI- should be validated in future studies across diverse clinical settings.

Health policy to address disease-related malnutrition: a scoping review

ABSTRACT

Background

Health policies promote optimal care, yet policies that address disease-related malnutrition (DRM) are lacking. The purpose of this study was to conduct a scoping review to identify literature on existing and planned policy to address DRM in children or adults and explore the settings, contexts and actors of DRM policy.

Methods

A search strategy comprising DRM and policy keywords was applied to eight databases on 24 February 2023. Articles that addressed DRM and policy were selected for inclusion after two independent reviews. The health policy triangle (HPT) framework (ie, actors, content, contexts and processes considerations for policy) guided data extraction and thematic analysis.

Results

A total of 67 articles were included out of the 37 196 identified. Some articles (n=14) explored established policies at the local level related to food and mealtime, nutrition care practices, oral nutritional supplement prescribing or reimbursement. Other articles gave direction or rationale for DRM policy. As part of the HPT, actors included researchers, advocacy groups and DRM champions while content pertained to standard processes for nutrition care such as screening, assessment, intervention and monitoring. Contexts included acute care and care home settings with a focus on paediatrics, adults, older adults. Processes identified were varied and influenced by the type of policy (eg, local, national, international) and its goal (eg, advocating, developing, implementing).

Discussion

There is a paucity of global DRM policy. Nutrition screening, assessment, intervention and monitoring are consistently identified as important to DRM policy. Decision makers are important actors and should consider context, content and processes to develop and mobilise DRM policy to improve nutrition care. Future efforts need to prioritise the development and implementation of policies addressing DRM.

Exploring the intersections of frailty, sarcopenia, and cachexia with malnutrition

This review examines our current understanding of consensus definitions for frailty, sarcopenia, and cachexia and their perceived overlap with malnutrition. Patients with these syndromes will often meet the criteria for malnutrition. It is common for these overlap syndromes to be misapplied by practitioners, and confusion has been further exacerbated by the lack of a common malnutrition language. To address the latter concern, we recommend using either the standalone Global Leadership Initiative in Malnutrition (GLIM) framework or the GLIM consensus criteria integrated with other accepted approaches as dictated by preference and available resources. Established care standards should guide the recognition and treatment of malnutrition to promote optimal clinical outcomes and quality of life. The effectiveness of nutrition interventions may be reduced in settings of severe acute inflammation and in end-stage disease that is associated with cachexia. However, such interventions may still assist patients to tolerate treatments that target the underlying etiology for an overlap syndrome, and they may help to improve select clinical outcomes and quality of life. Recent, large, well-designed randomized controlled trials have demonstrated the compelling positive clinical effects of medical nutrition therapy. The application of concurrent malnutrition risk screening and assessment is therefore a high priority. The necessity to deliver specific interventions that target the underlying mechanisms of these overlap syndromes and also diagnose and address malnutrition is paramount. It must be highlighted that securing beneficial outcomes for frailty, sarcopenia, and cachexia will also require nonnutrition interventions, like comprehensive care plans, pharmacologic agents, and prescribed exercise.

Malnutrition in patients with obesity: An overview perspective

Malnutrition in patients with obesity presents a complex and often overlooked clinical challenge. Although obesity is traditionally associated with overnutrition and excessive caloric intake, it can also coincide with varying degrees of malnutrition. The etiopathogenesis of obesity is multifaceted and may arise from several factors such as poor diet quality, nutrient deficiencies despite excess calorie consumption, genetics, and metabolic abnormalities affecting nutrient absorption and utilization. Moreover, a chronic low-grade inflammatory state resulting from excess adipose tissue, commonly observed in obesity, can further exacerbate malnutrition by altering nutrient metabolism and increasing metabolic demands. The dual burden of obesity and malnutrition poses significant risks, including immune dysfunction, delayed wound healing, anemia, metabolic disturbances, and deficiencies in micronutrients such as vitamin D, iron, magnesium, and zinc, among others. Malnutrition is often neglected or not given enough attention in individuals with obesity undergoing rapid weight loss through aggressive caloric restriction, pharmacological therapies, and/or surgical interventions. These factors often exacerbate vulnerability to nutrition deficiencies. We advocate for healthcare practitioners to prioritize nutrition assessment and initiate medical intervention strategies tailored to address both excessive caloric intake and insufficient consumption of essential nutrients. Raising awareness among healthcare professionals and the general population about the critical role of adequate nutrition in caring for patients with obesity is vital for mitigating the adverse health effects associated with malnutrition in this population.

Implementing the Global Leadership Initiative on Malnutrition (GLIM) criteria in Crohn's disease: Prevalence of malnutrition and association with clinical outcomes

BACKGROUND & AIMS

Limited data exist regarding the implementation of the Global Leadership Initiative on Malnutrition (GLIM) criteria for diagnosing malnutrition in Crohn's disease (CD), and its association with CD prognosis. In the present study eighteen GLIM combinations and a combined one were implemented to identify differences in the prevalence of malnutrition and to investigate potential associations with clinical outcomes at 6 months.

METHODS

Different methodologies to diagnose malnutrition were used at baseline, namely the Subjective Global Assessment (SGA), eighteen different combinations of phenotypic and etiologic GLIM criteria and a combined version based on all GLIM combinations (GLIMcv) to test differences in the estimated prevalence and outcomes' prognosis. At 6 months, data for clinical outcomes were collected (i.e. hospitalization, antibiotics use, intensification/change of biologic agent, initiation of biologic agent/corticosteroids, surgery, disease activity), and an overall adverse clinical outcome index was created.

RESULTS

250 people with CD (54.8 % males, mean age 41.2 ± 14.1 years, 37.2 % with active disease) were enrolled. Prevalence of malnutrition based on SGA and GLIMcv was 23 % and 52 %, respectively, and 5.8-63 % based on different GLIM combinations. Malnutrition diagnosed with GLIMcv was associated with an increased likelihood of intensification/change of biologic agent [Odds ratio (OR): 1.82, 95 % Confidence interval (CI): 1.00-3.42, p = 0.05] and an overall adverse clinical outcome (OR: 2.18, 95 % CI: 1.23-3.87, p = 0.008) at 6 months, after adjustment for age, sex, disease location and duration. Malnutrition diagnosed through SGA was not associated with clinical outcomes at 6 months.

CONCLUSIONS

Based on GLIMcv, half of the sample was diagnosed with malnutrition. Malnutrition significantly increased the likelihood of uncontrolled disease requiring treatment upgrading and leading to an overall adverse clinical outcome short term.

Effects of high-protein supplementation during cancer therapy: a systematic review and meta-analysis

BACKGROUND

Establishing the effectiveness of high-protein supplementation in reducing cancer-related side effects is crucial.

OBJECTIVE

The study aimed to assess the effectiveness and safety of high-protein supplementation on clinical outcomes of patients undergoing cancer therapy.

METHODS

Systematic searches were conducted on Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Central Register of Controlled Trials, and Scopus from inception until July 2023. Randomized controlled trials administering supplements with ≥10 g protein/serving, given to 20+ adult patients undergoing cancer therapy were included. Random-effects meta-analyses were used to estimate the effects of high-protein supplementation on the primary outcomes of body weight and health-related quality of life (HRQoL). We employed a vote-counting approach based on effect direction for secondary outcomes (that is, body composition, muscle function, hospitalization, response to cancer therapy/toxicity, survival, and systemic inflammation). Risk-of-bias (ROB) was assessed.

RESULTS

Thirty-five studies involving 3701 patients with diverse cancer types were included. Patients who received high-protein supplementation lost less body weight than controls (mean difference = 1.45 kg; 95% CI: 0.42, 2.48 kg; P = 0.006; I2 = 80%). No differences in HRQoL were observed; all studies assessing HRQoL were rated as high ROB. A beneficial effect on muscle mass was found in 11 of 13 studies, although most had a high ROB due to assessment techniques. When considering higher quality studies, evidence of a beneficial effect was found in 5 of 5 studies for muscle strength, and 3 of 4 for hospitalization rate. Effects on other secondary outcomes were inconsistent or limited. No serious adverse effects were reported.

CONCLUSIONS

High-protein supplementation mitigates weight loss, improves muscle strength, and lowers hospitalization rates in patients undergoing cancer therapy. These positive clinical outcomes, along with a favorable safety profile, suggest that high-protein supplementation may be a valuable addition to medical practice. However, given the need for more robust trials and the high ROB observed in the existing studies, these conclusions should be interpreted with caution. This review was prospectively registered with PROSPERO under the registration number CRD42021237372.

Evaluation of different screening tools for detection of malnutrition in hospitalised patients

AIMS AND OBJECTIVES

To assess the prevalence of malnutrition in hospitalised adult patients, and to evaluate the accuracy of the most commonly used nutritional screening tools for identifying individuals at risk of malnutrition.

METHODS

A prospective cross-sectional study was conducted on a total of 248 hospitalised patients in internal medicine wards (mean age: 75.2 years; 39.5% females). Nutritional screening was performed within 48 h of admission using the following tools: Malnutrition Universal Screening Tool (MUST), Nutrition Risk Screening Tool (NRS-2002), Malnutrition Screening Tool (MST), Short Nutritional Assessment Questionnaire (SNAQ), and Mini Nutritional Assessment Short Form (MNA-SF). The criteria of the European Society for Clinical Nutrition and Metabolism (ESPEN) were used as the gold standard for defining malnutrition. Patients were also evaluated using the Subjective Global Assessment (SGA) and the Global Leadership Initiative on Malnutrition (GLIM) criteria. Accuracy was determined by examining sensitivity, specificity, and positive and negative predictive values, and diagnostic agreement was determined by calculation of Cohen's kappa (κ). The study is reported as per the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

RESULTS

The ESPEN criteria classified 20.2% of the hospitalised patients as malnourished. Overall, the MUST had the highest sensitivity (80.0%), specificity (74.7%) and positive predictive value (44.4%). For the subgroup of patients aged >65 years, the MNA-SF had high sensitivity (94.4%) but low specificity (39.0%). Based on Cohen's κ, the SGA and GLIM criteria showed low agreement with the ESPEN criteria.

CONCLUSION

The MUST was the most accurate nutritional screening tool, through the MST is more easily applied in many clinical settings. A comprehensive assessment of malnutrition that considers muscle mass is crucial for the reliable diagnosis of malnutrition.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The present findings underscore the importance of accurate assessment of the malnutrition status of hospitalised patients and the need for a reliable screening tool. No patient or public contribution.

GLIM-defined malnutrition in patients with acute abdomen associated with poor prognosis and increased economic burden: A cross-sectional study

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) criteria have rapidly developed into a principal methodological framework for nutrition diagnosis. However, the applicability of the GLIM criteria in patients with acute abdomen has not been validated.

METHODS

This is a cross-sectional study conducted on patients diagnosed with acute abdomen and admitted to a tertiary hospital in southwest China. Nutrition risk screening was conducted using the Nutrition Risk Screening 2002, and patients identified with nutrition risk were assessed for malnutrition based on the GLIM criteria.

RESULTS

We enrolled a total of 440 patients with acute abdomen. The top three diagnoses of acute abdomen were intestinal obstruction (47.2%), acute appendicitis (23.1%), and digestive system perforation (8.8%). The prevalence of nutrition risk was 46.5%, with a malnutrition rate of 32.5% based on the GLIM. Patients with malnutrition according to the GLIM showed significantly higher rates of intensive care unit (ICU) admission (13.28% vs 7.07%; P = 0.003), increased hospitalization costs (median: 3315USD [interquartile range (IQR): 978-7852] vs 1641 [IQR: 816-3523] USD; P < 0.001), and longer length of hospital stay (LOS) (median: 8 [IQR: 5-13] vs 6 [IQR: 4-8] days; P < 0.001) compared with patients without malnutrition. Multivariate analysis indicated that GLIM-defined malnutrition was an independent predictor of hospitalization costs, and severe malnutrition was an independent predictor of ICU admission.

CONCLUSION

GLIM criteria are applicable for diagnosing malnutrition in patients with acute abdomen. The prevalence of malnutrition was high in patients with acute abdomen. Malnutrition was associated with increased ICU admission and LOS, along with higher economic burden.

Development of a local nomogram-based scoring system for predicting overall survival in idiopathic pulmonary fibrosis: A rural appalachian experience

Background

Accurate staging systems are essential for assessing the severity of idiopathic pulmonary fibrosis (IPF) and guiding clinical management. This study aimed to evaluate the prognostic value of pulmonary comorbidities and body mass index (BMI) in IPF, develop a nomogram predicting overall survival (OS), and create a nomogram-based survival prediction model.

Methods

Patients with IPF were identified from electronic medical records of the West Virginia hospital system. Least Absolute Shrinkage and Selection Operator (LASSO) Cox regression analysis was used for variable selection, and a nomogram was constructed. Risk groups were defined based on the nomogram's probability tertiles. The performance of the nomogram-based model was evaluated using Harrell's concordance index (C-index) and the Hosmer-Lemeshow test.

Results

The study included 152 patients with IPF. The majority of the patients were elderly, male, and had a BMI above 24 kg/m2. The median survival duration was 7.6 years. The survival rates were 91% at 1 year, 78% at 3 years, and 68% at 5 years. LASSO regression selected carbon monoxide lung diffusion capacity percentage predicted (DLco%), BMI, pulmonary hypertension, pulmonary embolism, and sleep apnea as independent predictive variables. The nomogram demonstrated good discrimination (C-index = 0.71) and calibration.

Conclusions

Pulmonary comorbidities and BMI have significant prognostic value in IPF, emphasizing the necessity for consistent screening, assessment, and management of these factors in IPF care. Furthermore, the nomogram-based staging system showed promising performance in predicting OS and represents an actionable staging system that could potentially improve clinical management in IPF. Further validation of the nomogram is warranted to confirm its utility in clinical practice.

Ultrasound-measured Quadriceps Muscle Thickness and Mortality in Older Patients With Heart Failure

BACKGROUND

Ultrasound might be helpful for muscle mass assessment in patients with heart failure (HF). We aimed to determine the feasibility and prognostic implications of ultrasound-measured quadriceps muscle thickness (QMT) in older patients with HF.

METHODS

This was a post hoc analysis of a multicentre prospective cohort study including patients hospitalized for HF aged 65 years and older. QMT at rest and during isometric contractions using ultrasound was measured with the patient in the supine position before discharge.

RESULTS

The interobserver agreement for measuring QMT was excellent, with intraclass correlation coefficients of 0.979 (95% confidence interval [CI], 0.963-0.988) at rest and 0.997 (95% CI, 0.994-0.998) during isometric contraction. The intraobserver reproducibility was also excellent (intraclass correlation coefficient > 0.92). Of the 595 patients (median age, 81 years; 56% male), median QMT at rest and during contraction were 18.9 mm and 24.9 mm, respectively. The patients were grouped according to sex-specific tertiles of height-adjusted QMT. During the median follow-up of 735 days, 157 deaths occurred, and Kaplan-Meier curve analysis showed that the lowest tertile of the height-adjusted QMT was associated with a higher mortality. Cox proportional hazard analysis revealed that thinner height-adjusted QMT was independently associated with higher mortality, even after adjusting for conventional risk factors (per 1 mm/m increase: hazard ratio, 0.94; 95% CI, 0.89-0.99; P = 0.030 [at rest] and hazard ratio, 0.94; 95% CI, 0.90-0.99; P = 0.015 [during isometric contraction]).

CONCLUSIONS

Ultrasound-measured QMT in older patients with HF is feasible, and thinner height-adjusted QMT at rest and during isometric contraction was independently associated with higher mortality.

Using 3D facial information to predict malnutrition and consequent complications

BACKGROUND

Phase angle (PhA) correlates with body composition and could predict the nutrition status of patients and disease prognosis. We aimed to explore the feasibility of predicting PhA-diagnosed malnutrition using facial image information based on deep learning (DL).

METHODS

From August 2021 to April 2022, inpatients were enrolled from surgery, gastroenterology, and oncology departments in a tertiary hospital. Subjective global assessment was used as the gold standard of malnutrition diagnosis. The highest Youden index value was selected as the PhA cutoff point. We developed a multimodal DL framework to automatically analyze the three-dimensional (3D) facial data and accurately determine patients' PhA categories. The framework was trained and validated using a cross-validation approach and tested on an independent dataset.

RESULTS

Four hundred eighty-two patients were included in the final dataset, including 176 with malnourishment. In male patients, the PhA value with the highest Youden index was 5.55°, and the area under the receiver operating characteristic curve (AUC) = 0.68; in female patients, the PhA value with the highest Youden index was 4.88°, and AUC = 0.69. Inpatients with low PhA had higher incidence of infectious complications during the hospital stay (P = 0.003). The DL model trained with 4096 points extracted from 3D facial data had the best performance. The algorithm showed fair performance in predicting PhA, with an AUC of 0.77 and an accuracy of 0.74.

CONCLUSION

Predicting the PhA of inpatients from facial images is feasible and can be used for malnutrition assessment and prognostic prediction.

2024 Peggi Guenter excellence in clinical practice lectureship: From curiosity and eagerness to passion: Moving the malnutrition needle

Most every new clinician practicing in nutrition support enters their practice environment with wide open eyes and a sense of curiosity as they encounter new patient and clinical experiences. As clinicians expand their expertise, they often identify challenges they are eager to address. Eagerness turns to passion as the desire to affect change grows. Malnutrition has sparked curiosity and interest in many, and, in some, it has become a passion. As a result, many major achievements have occurred both in the United States and globally that have the capability of moving the needle favorably to achieve better outcomes for our patients. This lecture will highlight how curiosity, eagerness, and passion have led to successes in addressing aspects of malnutrition. These successes offer the structure to continue our efforts to move the needle forward. Our patients deserve nothing more.

Validity of the Global Leadership Initiative on Malnutrition criteria in East Asian patients with gastric cancer: a comprehensive narrative review

Background

Malnutrition is a significant public health issue for patients with gastric cancer, particularly in East Asia, the region most affected globally. In response to the absence of adequate tools for assessing nutritional status, the Global Leadership Initiative on Malnutrition (GLIM) criteria were established in 2018, aiming to standardize the diagnosis of malnutrition. However, there is no consensus on the value of GLIM criteria for evaluating the nutritional status of patients with gastric cancer in East Asia. Given these facts, our study aimed to assess the validity of the GLIM criteria in East Asian patients with gastric cancer.

Methods

We conducted a rapid critical review of available literature, summarizing the existing problems in GLIM applications and possible improvement directions. After systematically summarizing the literature published in PubMed, Web of Science, and Cochrane Library, a total of 13 articles involving 7,679 cases were included in this study.

Results

The results indicated a lack of sufficient data on sensitivity and specificity to fully validate the GLIM criteria for diagnosing malnutrition in East Asian patients with gastric cancer. Additionally, some studies have reported moderate agreement between the GLIM and the PG-SGA. Furthermore, malnutrition defined by GLIM is a risk factor for short and long-term outcomes in East Asian patients with gastric cancer. However, the prognostic effect of moderate malnutrition on these patients remains controversial.

Conclusion

Despite being in the early application stages, GLIM has shown promising potential in diagnosing and predicting the prognosis of malnutrition. However, future research should incorporate more comprehensive validity parameters, including sensitivity, specificity, and PPV/NPV, to achieve a more thorough understanding of GLIM's diagnostic efficacy. Furthermore, further optimization of GLIM is necessary to address the needs of more diverse populations and situations.

Protocol for a pilot study: Feasibility of a web-based platform to improve nutrition, mindfulness, and physical function in people living with Post COVID-19 condition (BLEND)

Individuals with Post COVID-19 condition (PCC), or long COVID, experience symptoms such as fatigue, muscle weakness, and psychological distress, including anxiety, depression, or sleep disorders that persist after recovery from COVID-19. These ongoing symptoms significantly compromise quality of life and diminish functional capacity and independence. Multimodal digital interventions targeting behavioural factors such as nutrition and mindfulness have shown promise in improving health outcomes of people with chronic health conditions and may be beneficial for those with PCC. The BLEND study (weB-based pLatform to improve nutrition, mindfulnEss, and physical function, in patients with loNg COVID) study is an 8-week pilot randomized controlled trial evaluating the feasibility of a digital wellness platform compared to usual care among individuals with PCC. The web-based wellness platform employed in this study, My Viva Plan (MVP)®, integrates a holistic, multicomponent approach to promote wellness. The intervention group receives access to the digital health platform for 8 weeks with encouragement for frequent interactions to improve dietary intake and mindfulness. The control group receives general content focusing on improvements in dietary intake and mindfulness. Assessments are conducted at baseline and week 8. The primary outcome is the feasibility of platform use. Secondary and exploratory outcomes include a between-group comparison of changes in body composition, nutritional status, quality of life, mindfulness, physical activity, and physical performance after 8 weeks. Findings of this study will inform the development of effective web-based wellness programs tailored for individuals with PCC to promote sustainable behavioural changes and improved health outcomes.

Malnutrition defined by global leadership initiative on malnutrition criteria impedes home discharge in acute care hospital admissions

BACKGROUND & AIMS

Limited evidence exists on the association between malnutrition diagnosis using the Global Leadership Initiative on Malnutrition (GLIM) criteria in hospitalized acute care patients and their outcomes; several aspects still require clarification. This study aimed to evaluate the relationship between malnutrition, as defined by the GLIM criteria, at the time of acute hospital admission and discharge to home.

METHODS

This retrospective observational study was conducted at a hospital that provides acute care in Japan. Adult patients admitted between July 2023 and April 2024 were included in this study. The primary outcome was the number of patients discharged to home, with in-hospital mortality as the secondary outcome. To ensure the reliability of the cohort-wide results, background factors were adjusted using propensity score matching. The two groups were compared based on the presence or absence of malnutrition, as defined by the GLIM criteria at admission. Furthermore, multiple logistic regression analysis was conducted, with the outcome as the dependent variable and malnutrition, diagnosed using the GLIM criteria, as the explanatory variable, adjusting for covariates.

RESULTS

A total of 1007 patients were included in the final analysis, of whom 492 (49 %) were diagnosed without malnutrition, while 515 (51 %) were diagnosed with malnutrition according to the GLIM criteria. In the multivariate logistic regression analysis after matching, malnutrition defined by the GLIM criteria emerged as an independent factor associated with discharge to home (odds ratio [OR] = 0.37, 95 % confidence interval = 0.25-0.56, P < 0.001) when adjusting for age, sex, and various comorbidities. Among the GLIM sub-criteria, reduced muscle mass, reduced food intake or assimilation, and disease burden or inflammation were independently associated with discharge to home. Notably, disease burden/inflammation exhibited the lowest OR among the GLIM sub-criteria for discharge.

CONCLUSION

Malnutrition diagnosed using the GLIM criteria upon admission in patients admitted to a regional hospital providing acute care was associated with decreased rates of discharge to home and increased in-hospital mortality. Specifically, attention should be paid to the criteria for reduced muscle mass and disease burden or inflammation within the GLIM framework.

Peripheral parenteral nutrition: A retrospective observational study to evaluate utility and complications

BACKGROUND

Peripheral parenteral nutrition (PPN) provides an alternative nutrition support strategy to centrally administered PN for specific patients requiring short-term PN. Previous studies have demonstrated limited use of PPN and variable complication rates. This study aimed to evaluate PPN complications and usage at this center.

METHODS

This was a single-center retrospective observational study of all adult patients who received at least 1 day of PPN from June 2018 to December 2023. Demographic and clinical data were collected, including complications, indications for PN and reason for PPN, duration of therapy, reason for cessation of PPN, nutrition status, energy and protein provision, and central line insertion rates.

RESULTS

381 patients were included, the median age was 62 (interquartile range = 28-74) years, and 235 were men (61.7%). The most common indication for PN was ileus (n = 153, 40%) followed by gastrointestinal obstruction (n = 93, 24%). The median time receiving PPN was 3 (2-4) days. Patients received a median of 65% (55%-75%) of energy and 58% (50%-69%) of protein requirements with PPN. Malnutrition was diagnosed in 47.5% (n = 181) of this cohort. Total complication rates were 8.7% (n = 33), with cannula infiltration being the most common complication (6.6%, n = 25). 213 (56%) patients proceeded to central line insertion.

CONCLUSION

PPN proved to be a safe and effective therapy for short-term PN when managed by a nutrition support team. PPN has the potential to attenuate short-term nutrition deficits and prevent central venous access device insertion in selected patients, making it a valuable nutrition support therapy.

Photobiomodulation therapy to prevent oral mucositis and functional impairment in adult patients with haematological cancer undergoing haematopoietic stem cell transplantation: randomised trial protocol

INTRODUCTION

Oral mucositis is a highly prevalent condition in individuals treated for haematological neoplasms, primarily during haematopoietic stem cell transplantation (HSCT). The condition is known to delay recovery processes, increasing the risk of infection, the number of interventions and the length of hospital stays. The proposed Photobiomodulation Therapy for Oral Mucositis and Functional Impairment Transplantation Trial aims to assess the effectiveness and acceptability of using photobiomodulation in the oral cavity to prevent oral mucositis and functional impairment in adult patients undergoing HSCT.

METHODS AND ANALYSIS

This is an assessor-blinded and statistician-blinded, parallel-group randomised controlled clinical trial (photobiomodulation vs control group).

PARTICIPANTS AND SETTING

30 patients, aged 18-65 years, with haematological neoplasms undergoing HSCT at the Clínica Dávila Oncology and Bone Marrow Transplant Unit.

PRIMARY OUTCOME MEASURES

oral mucositis will be assessed daily using the WHO grading scale, beginning on the day of transplant through day 20 post-transplant. Researchers will assess functional capacity using a 2 min step test, handgrip strength with the Jamar digital dynamometer, lower limb strength using a 30' sit-to-stand test and quality of life with the Functional Assessment of Cancer Therapy-Bone Marrow Transplantation Questionnaire. Acceptability will be assessed by logging treatment adherence and using a Visual Analogue Scale. Assessments will occur at two time points (1): on admission to the transplant unit, before starting the conditioning regimen and (2) on the day of discharge.

INTERVENTION

three times per week photobiomodulation therapy using a diode laser device will begin the first day of conditioning and continue through day 3 post-transplant.

ETHICS AND DISSEMINATION

The Clínica Dávila and Universidad del Desarrollo Clinical Research Ethics Committees approved this study in accordance with the Helsinki Declaration. Patients' informed consent will be required. The dissemination strategy includes publication in scientific journals as well as presentations in the media and at conferences.

TRIAL REGISTRATION NUMBER

NCT06260111.

Mediterranean Diet and Lifestyle in Persons with Mild to Moderate Alzheimer's Disease

Due to the continuous aging of the population and consequent increase in dementia, focus on its prevention is of growing importance for public health. Since effective pharmacological treatments are not yet available, other determinants of cognitive decline have become fundamental. Several studies have indicated that the Mediterranean diet (MedDiet) is associated with reduced incident cognitive decline and dementia, but few studies have been conducted in persons already diagnosed with Alzheimer's disease (AD). We age-matched 73 patients with mild-moderate AD with 73 controls (mean age for the whole group = 76.5 ± 6.5; 67.5% women). The cases had a significantly lower adherence to the MedDiet and lower physical activity vs. controls, where only one participant (1.4%) had a high adherence to the MedDiet among cases compared to 5.5% among controls, while 52.5% of the cases had a moderate adherence to the MedDiet vs. 82.2% in controls. In multivariate analysis, only the presence of AD was significantly associated with a lower adherence to the MedDiet vs. controls. Other factors examined (gender, age, physical activity level, multimorbidity, and polypharmacy) were not significantly associated with adherence to the MedDiet. Thus, AD patients had a low adherence to the MedDiet and very low physical activity. Public health strategies aimed at promoting the Mediterranean diet and physical activity for older people should be a priority.

Nutritional Status and Inflammation as Mediators of Physical Performance and Delirium in Elderly Community-Acquired Pneumonia Patients: A Retrospective Cohort Study

Purpose

This study proposes a multiple mediation model to evaluate the association among diminished physical performance, malnutrition, inflammation, and delirium in seniors with community-acquired pneumonia.

Patients and Methods

This retrospective cohort study included elderly patients hospitalized for community-acquired pneumonia at the Geriatrics Department of the Second People's Hospital of Lianyungang from January 1, 2020, to January 1, 2024. Logistic regression analysis was conducted to examine the associations among physical performance, nutritional status, C-reactive protein (CRP) levels, and delirium. Mediation models assessed the effects of nutritional status and CRP on the relationship between physical performance and delirium, with subgroup analyses based on diabetes status.

Results

A total of 379 patients were included, with a mean age of 80.0±7.4 years, and 51.7% were male. The incidence of delirium during hospitalization was 28.5% (n=108). Subgroup analyses revealed significant correlations between physical performance, nutritional status, and CRP (P<0.001), regardless of diabetes status. After adjusting for confounding variables, CRP was positively associated with delirium, while MNA-SF and SPPB scores showed negative correlations with delirium risk (OR=0.852, 95% CI: 0.730-0.995; OR=0.580, 95% CI: 0.464-0.727, P<0.05). Mediation analyses indicated that MNA-SF scores and CRP significantly mediated the association between SPPB and delirium. Specifically, pathways "SPPB→ MNA-SF→ delirium", "SPPB→ CRP→ delirium", and "SPPB→ MNA-SF→ CRP→ delirium" demonstrated significant mediating effects in patients without diabetes, while only the pathway "SPPB→ MNA-SF→ CRP→ delirium" was significant in those with diabetes.

Conclusion

Older patients with community-acquired pneumonia and poor physical performance are more susceptible to delirium, with nutritional status and inflammation as key mediators.

Impact of Malnutrition on the Length of Stay for Hospitalized Chimeric Antigen Receptor T-cell (CAR-T) Therapy Patients in the United States (2020)

Background Chimeric antigen receptor T-cell (CAR-T) therapy offers a promising treatment for certain malignancies but can be associated with complications. Malnutrition and cachexia are common in cancer patients and may worsen outcomes. This study investigated the impact of malnutrition on the length of hospital stay (LOS) in patients with hematologic malignancies undergoing CAR-T therapy. The analysis focused on different subpopulations, including those with acute lymphoblastic leukemia (ALL), multiple myeloma (MM), diffuse large B-cell lymphoma (DLBCL), and non-Hodgkin lymphoma (NHL) excluding DLBCL. Methods Utilizing the 2020 National Inpatient Sample (NIS) data, we performed survey-based mean estimation analyses for LOS across various subpopulations of CAR-T therapy patients. These subpopulations were defined by specific diagnoses: ALL, myeloma, DLBCL, and NHL excluding DLBCL. We compared the LOS between patients with and without malnutrition using STATA accounting for the complex survey design. Cachexia was included as disease-induced malnutrition. Results The total CAR-T population used for analyses included 439 patients, and malnutrition was present in 50 (11.39%). The overall CAR-T population demonstrated a significantly longer LOS for patients with malnutrition (30.92 days, 95% CI: 24.30 to 37.54) compared to those without malnutrition (17.97 days, 95% CI: 15.48 to 20.46, p = 0.0002). This trend held true across subgroups. Specifically, the ALL population had a significantly longer LOS with malnutrition (45.25 days, 95% CI: 35.46 to 55.04) compared to non-malnourished patients (27.58 days, 95% CI: 16.74 to 38.42, p = 0.0279). For the DLBCL population, the mean LOS was 24.47 days (95% CI: 19.22 to 29.71) with malnutrition and 17.17 days (95% CI: 13.29 to 21.04, p = 0.0161) without malnutrition. The NHL population excluding DLBCL exhibited a mean LOS of 33.86 days (95% CI: 22.66 to 45.07) for malnourished patients and 17.44 days (95% CI: 14.76 to 20.11, p = 0.0055) for non-malnourished patients. The myeloma population showed a similar trend although not statistically significant, with a mean LOS of 39.00 days (95% CI: -3.54 to 81.54) for malnourished patients and 18.03 days (95% CI: 15.02 to 21.03, p = 0.3337) for non-malnourished patients. These findings highlight significant variations in LOS across different CAR-T-treated cancer subtypes, emphasizing the impact of malnutrition on healthcare resource utilization in oncology. Conclusion Malnutrition is associated with a significantly longer hospital stay among patients undergoing CAR-T therapy. This trend is consistent across various subpopulations, including those with ALL, DLBCL, and NHL (excluding DLBCL). While the impact of malnutrition on LOS was not statistically significant in the myeloma population, this could potentially be attributed to the smaller sample size in this group. Overall, these findings underscore the critical role of nutritional status in managing patients undergoing CAR-T therapy. Future studies should investigate the most effective methods for identifying and treating malnutrition in this patient population to reduce hospital stays and optimize overall patient care.

Health economic evaluation of an artificial intelligence (AI)-based rapid nutritional diagnostic system for hospitalised patients: A multicentre, randomised controlled trial

BACKGROUND & AIMS

Malnutrition is prevalent among hospitalised patients, and increases the morbidity, mortality, and medical costs; yet nutritional assessments on admission are not routine. This study assessed the clinical and economic benefits of using an artificial intelligence (AI)-based rapid nutritional diagnostic system for routine nutritional screening of hospitalised patients.

METHODS

A nationwide multicentre randomised controlled trial was conducted at 11 centres in 10 provinces. Hospitalised patients were randomised to either receive an assessment using an AI-based rapid nutritional diagnostic system as part of routine care (experimental group), or not (control group). The overall medical resource costs were calculated for each participant and a decision-tree was generated based on an intention-to-treat analysis to analyse the cost-effectiveness of various treatment modalities. Subgroup analyses were performed according to clinical characteristics and a probabilistic sensitivity analysis was performed to evaluate the influence of parameter variations on the incremental cost-effectiveness ratio (ICER).

RESULTS

In total, 5763 patients participated in the study, 2830 in the experimental arm and 2933 in the control arm. The experimental arm had a significantly higher cure rate than the control arm (23.24% versus 20.18%; p = 0.005). The experimental arm incurred an incremental cost of 276.52 CNY, leading to an additional 3.06 cures, yielding an ICER of 90.37 CNY. Sensitivity analysis revealed that the decision-tree model was relatively stable.

CONCLUSION

The integration of the AI-based rapid nutritional diagnostic system into routine inpatient care substantially enhanced the cure rate among hospitalised patients and was cost-effective.

REGISTRATION

NCT04776070 (https://clinicaltrials.gov/study/NCT04776070).

Impact of withholding early parenteral nutrition on 2-year mortality and functional outcome in critically ill adults

PURPOSE

In critically ill adults, withholding parenteral nutrition until 1 week after intensive care admission (Late-PN) facilitated recovery as compared with early supplementation of insufficient enteral nutrition with parenteral nutrition (Early-PN). However, the impact on long-term mortality and functional outcome, in relation to the estimated nutritional risk, remains unclear.

METHODS

In this prospective follow-up study of the multicenter EPaNIC randomized controlled trial, we investigated the impact of Late-PN on 2-year mortality (N = 4640) and physical functioning, assessed by the 36-Item Short Form Health Survey (SF-36; in 3292 survivors, responding 819 [738-1058] days post-randomization). To account for missing data, we repeated the analyses in two imputed models. To identify potential heterogeneity of treatment effects, we investigated the impact of Late-PN in different nutritional risk subgroups as defined by Nutritional Risk Screening-2002-score, modified NUTrition Risk in the Critically Ill-score, and age (above/below 70 years), and we evaluated whether there was statistically significant interaction between classification to a nutritional risk subgroup and the effect of the randomized intervention. Secondary outcomes were SF-36-derived physical and mental component scores (PCS & MCS).

RESULTS

Two-year mortality (20.5% in Late-PN, 19.8% in Early-PN; P = 0.54) and physical functioning (70 [40-90] in both study-arms; P = 0.99) were similar in both groups, also after imputation of missing physical functioning data. Likewise, Late-PN had no impact on 2-year mortality and physical functioning in any nutritional risk subgroup. PCS and MCS were similar in both groups.

CONCLUSION

Late-PN did not alter 2-year survival and physical functioning in adult critically ill patients, independent of anticipated nutritional risk.

Global Leadership Initiative on Malnutrition-defined malnutrition coexisting with visceral adiposity predicted worse long-term all-cause mortality among inpatients with decompensated cirrhosis

BACKGROUND/OBJECTIVES

Malnutrition coexisting with abdominal adipose tissue accumulation bring a double burden on prognosis. More recently, the Global Leadership Initiative on Malnutrition (GLIM) has reached a novel consensus concerning the diagnostic criteria, that is, a two-step modality combining nutritional risk screening and subsequent phenotypic/etiologic parameters for comprehensive evaluation in hopes of harmonizing the malnutrition diagnosis. We aimed to elucidate their synergistic impact among inpatients with decompensated cirrhosis concerning long-term mortality.

SUBJECTS/METHODS

Malnutrition, visceral obesity, and visceral adiposity were defined by the Global Leadership Initiative on Malnutrition (GLIM), visceral fat area (VFA), and visceral to subcutaneous adipose tissue area ratio (VSR) on computed tomography, respectively. Accordingly, the patients were categorized into different groups given their nutritional status and visceral obesity/adiposity. Multivariate Cox regression was performed to identify independent risk factors associated with 1-year all-cause mortality. Kaplan-Meier curves with log-rank tests were compared among distinct groups.

RESULTS

Totally, 295 patients were recruited. GLIM, VFA, and VSR identified 131 (44.4%), 158 (53.6%), and 59 (20%) patients with malnutrition, visceral obesity and visceral adiposity, respectively. Malnutrition coexisted with visceral obesity in 55 (MO group) relative to visceral adiposity in 40 patients (MA group). Multivariate Cox analysis showed that MA (hazard ratio: 2.48; 95% confidence interval: 1.06, 5.79; P = 0.036) was independently associated with dire outcome rather than MO. Moreover, patients with cirrhosis in the MA group had the worst survival status when compared with other groups (log-rank test: P < 0.001).

CONCLUSIONS

The current study indicated that coexisting GLIM-defined malnutrition and VSR-defined visceral adiposity were in relation to worse long-term mortality among inpatients. It is imperative to delicately manage nutritional status and provide personalized treatment in this vulnerable subgroup for achieving better prognosis.