Accuracy of the GLIM criteria for diagnosing malnutrition: A systematic review and meta-analysis

Validation of the Global Leadership Initiative on Malnutrition Criteria for Predicting Adverse Outcomes in Acute Pancreatitis

Background and Aim

The Global Leadership Initiative on Malnutrition (GLIM) has proposed criteria for the diagnosis of malnutrition. No studies validated the GLIM criteria in acute pancreatitis (AP). The present study aimed to validate the predictive capacity of GLIM criteria for adverse outcomes in AP patients.

Patients and Methods

Clinical data of 269 patients with AP were analyzed retrospectively. The Nutritional Risk Screening 2002 (NRS2002) was chosen as the screening tool. Multivariate logistic regression analyses evaluated the adverse clinical outcomes in malnourished patients.

Results

Overall, 160 patients (59.5%) were at nutritional risk and 38 (14.1%) were malnourished. Reduced muscle mass/ low body mass index + inflammation combinations contributed most to malnutrition overall and in each subgroup. The malnourished group had lower hemoglobin, neutrophils, albumin, total cholesterol, and triglycerides than the well-nourished group. The malnourished group had higher hospitalization costs (CNY, 11319.34 vs 9258.22, p <0.001) and more local complications (34.2% vs 14.7%, p =0.009) than the well-nourished group. There was an interaction between malnutrition and overweight/obesity on local complications (p for interaction = 0.023). Multivariate logistic regression showed malnutrition was significantly associated with local complications (OR 12.2, 95% CI: 2.51-59.37), infectious complications (OR 9.95, 95% CI: 1.25-79.44) and composite adverse outcome (OR 4.78, 95% CI: 1.05-21.73) in the overweight/obesity subgroup. There was no association between malnutrition and the rate of various adverse outcomes in the non-overweight/obesity subgroup. Additionally, we observed an association between malnutrition and composite adverse outcome (OR 6.75, 95% CI: 1.49-30.68) in patients <70 years only in females.

Conclusion

Malnourished AP patients were more likely to have adverse outcomes than well-nourished patients. Malnutrition was associated with various adverse outcomes only in the overweight/obesity subgroups.

Relationship between malnutrition according to the global leadership initiative on malnutrition criteria and oral health among community-dwelling elderly aged 85 years and older: a cross-sectional study

BACKGROUND

A new diagnostic criterion for malnutrition, the Global Leadership Initiative on Malnutrition (GLIM) criteria, has been proposed. Despite a recognized link between malnutrition and oral health, further clarification is needed regarding this association when using the GLIM criteria. This study examined the association between malnutrition and oral health in community-dwelling older adults aged ≥ 85.

METHODS

This study was conducted using data from the Tokyo Oldest Old Survey on Total Health study, and altogether 519 participants ≥ 85 years were enrolled. Malnutrition was assessed using the GLIM criteria. Oral health information, on the number of teeth, maximum occlusal force (MOF), saliva production, denture-related questions (dissatisfaction and frequency of use), dental visit history in the past year, whether participants enjoyed meals, and oral-related quality of life was assessed using the Geriatric Oral Health Assessment Index (GOHAI) were collected. MOF was assessed the average values of three measurements and lower tertile by sex as decline in MOF. For GOHAI, the score for each items (Q1-Q12) was also evaluated, and further, the decline in each item (score: 1-2 points on a 5-point scale) was assessed as a "problem with each items." Oral health factors differing between those with and without malnutrition were analyzed. For differing items, malnutrition risk was evaluated using Cox regression.

RESULTS

Eighty-nine (17.1%) participants experienced malnutrition. Significant differences were observed in the decline in MOF, enjoyment of meals, individual scores for Q2, Q4, and Q6, and the problem with Q3, Q6, Q7, and Q11. Cox regression analysis showed that decline in MOF (odds ratio [OR]: 1.728, 95% confidence interval [CI]: 1.010-2.959), enjoyment of meals (OR: 0.502, 95% CI: 0.289-0.873), problem with Q3 (OR: 5.474, 95% CI: 1.301-23.028), Q6 (OR: 5.325, 95% CI: 1.026-27.636), and Q7 (OR: 2.867, 95% CI: 1.397-5.882) were associated with ORs of malnutrition.

CONCLUSION

Decline in MOF, enjoyment of meals, swallowing problem (problem with Q3), limit contact due to oral condition (problem with Q6), and esthetics problem (problem with Q7) were associated with malnutrition as assessed using the GLIM criteria.

Implementation of nutritional screening tools, nutritional assessment tools, and diagnostic criteria for malnutrition in convalescent rehabilitation wards: A nationwide survey

BACKGROUND & AIMS

The utilization of recommended nutritional assessment measures in rehabilitation settings remains unclear. This study explored methods for identifying nutritional disorders using data from a nationwide survey conducted in convalescent rehabilitation wards.

METHODS

This cross-sectional study analyzed the annual survey, including methods for identifying malnutrition, the risk of malnutrition, and overnutrition in Kaifukuki (convalescent) rehabilitation wards. Methods identifying malnutrition and risk of malnutrition were grouped into nutritional screening tools (NSTs), nutritional assessment tools (NATs), diagnostic criteria for malnutrition (DCM), and suboptimal methods (e.g., hypoalbuminemia). NSTs, NATs, and DCM were further categorized as "acceptable tools." The association between applying acceptable tools, hospital-based data (e.g., the number of beds), and ward-based data (e.g., assessor for nutritional status) was analyzed by logistic regression analysis with multiple imputations.

RESULTS

In total, 885 hospitals with Kaifukuki rehabilitation wards responded to the survey, and 754 hospitals were included in the analysis. Registered dietitians assessed the nutritional status in 88% of the hospitals, whereas other professionals (e.g., nurses) evaluated the nutritional status in the remainder. NSTs (e.g., Mini Nutritional Assessment Short-Form), NATs (e.g., Subjective Global Assessment), DCM (e.g., Global Leadership Initiative on Malnutrition criteria), and suboptimal tools were used in 13.1%, 5.4%, 4.8%, and 74.6% of cases, respectively. Most hospitals used acceptable measures (e.g., body mass index) for overnutrition (91.2%). Multiple logistic regression analysis showed that assessments by registered dietitians (adjusted odds ratio[OR]: 2.20.95% confidence interval[CI]: 1.09-4.45) and hospital-owned food services, a proxy for limited clinical practice time of dietitians, were associated with a low likelihood of implementing acceptable measures (adjusted OR: 0.64, 95%CI: 0.43-0.97).

CONCLUSIONS

Acceptable malnutrition measures, including the NSTs, NATs, and DCM, have not been widely applied in convalescent rehabilitation settings. The implementation of recommended tools for identifying malnutrition may be promoted when registered dietitians assess the patients' nutritional status.

Investigation of accordance between nutritional assessment tools, and bio-electrical impedance-derived phase angle, with the global leadership initiative on malnutrition criteria in hemodialysis patients

BACKGROUND

Malnutrition (MN) is a major health concern for patients with chronic kidney disease (CKD) who receive maintenance hemodialysis (MHD). These patients are particularly vulnerable to MN due to their compromised health status, which in turn increases the risk of morbidity and mortality. However, there is limited evidence on the use of reliable and effective tools for assessing MN in this population. This lack of sufficient data highlights the crucial need to assess MN within these patients, considering the significant mortality risk it poses. The first aim of this study was to compare the concurrent validity of three nutritional methods: the 7-point Subjective Global Assessment (7p-SGA), the Nutritional Risk Index (NRI), and the Nutritional Risk Screening from 2002 (NRS-2002) with the Global Leadership Initiative on Malnutrition (GLIM) criteria in MHD patients. The second aim was to investigate the advantage of the bio-electrical impedance-derived phase angle (PhA) in predicting MN.

METHODS

one hundred sixty-eight outpatients (31% women) with a mean age of 56.9 ± 14.7 years and a median dialysis vintage of 48 months were included in this retrospective study. Nutritional scores, anthropometric measurements, biological markers, and body composition parameters were collected.

RESULTS

According to GLIM standards, MN was identified in 80% of these patients. Using logistic regression (LR) analysis, all nutritional scores were significantly associated with GLIM criteria, with optimal sensitivity (94.4%) and specificity (85.7%) for 7p-SGA and NRI, respectively. For discriminating the nutritional risk, the GLIM criteria demonstrated a good agreement with 7p-SGA (Kappa concordance coefficient (κ) = 0.677, p-value<0.001) with a good level of accuracy (Area Under the Curve (AUC) = 0.841; 95% Confidence Interval (CI) = 0.705-0.977; p-value <0.001) when compared to the NRI and NRS-2002 (κ = 0.522, p-value<0.001 and κ = 0.411, p-value = 0.006, respectively). An excellent accuracy was found between PhA and the GLIM-defined MN, with an optimal cut-off value of 5.5° for males and 4.5° for females. The LR showed that arm circumference is the parameter that most influences the decrease of PhA (odds ratio 2.710, 95% CI = 1.597-4.597, p-value <0.001).

CONCLUSION

Based on the results of the present study, 7p-SGA is the most sensitive score in identifying MN diagnosed by GLIM criteria. Nonetheless, NRI exhibits greater specificity. PhA is a valuable marker for MN in MHD patients.

GLIM Achieves Best Diagnostic Performance in Non-Cancer Patients with Low BMI: A Hierarchical Bayesian Latent-Class Meta-Analysis

CONTEXT

Global Leadership Initiative on Malnutrition (GLIM) and Patient-Generated Subjective Global Assessment (PG-SGA) are commonly used nutrition assessment tools, whose performance does not reach a consensus due to different and imperfect reference standards.

OBJECTIVE

This study aimed to evaluate and compare the diagnostic accuracy of GLIM and PG-SGA, using a hierarchical Bayesian latent class model, in the absence of a gold standard.

DATA SOURCES

A systematic search was undertaken in PubMed, Embase, and Web of Science from inception to October 2022. Diagnostic test studies comparing (1) the GLIM and/or (2) PG-SGA with "semi-gold" standard assessment tools for malnutrition were included.

DATA EXTRACTION

Two authors independently extracted data on sensitivity, specificity, and other key characteristics. The methodological quality of each included study was appraised according to the criteria in the Quality Assessment of Diagnostic Accuracy Studies-2.

DATA ANALYSIS

A total of 45 studies, comprising 20 876 individuals evaluated for GLIM and 11 575 for PG-SGA, were included. The pooled sensitivity was 0.833 (95% CI 0.744 to 0.896) for GLIM and 0.874 (0.797 to 0.925) for PG-SGA, while the pooled specificity was 0.837 (0.780 to 0.882) for GLIM and 0.778 (0.707 to 0.836) for PG-SGA. GLIM showed slightly better performance than PG-SGA, with a higher diagnostic odds ratio (25.791 vs 24.396). The diagnostic performance of GLIM was most effective in non-cancer patients with an average body mass index (BMI) of <24 kg/m2, followed by non-cancer patients with an average age of ≥60 years. PG-SGA was most powerful in cancer patients with an average age of <60 years, followed by cancer patients with an average BMI of <24 kg/m2.

CONCLUSION

Both GLIM and PG-SGA had moderately high diagnostic capabilities. GLIM was most effective in non-cancer patients with a low BMI, while PG-SGA was more applicable in cancer patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration No. CRD42022380409.

Performance of anthropometry-based and bio-electrical impedance-based muscle-mass indicators in the Global Leadership Initiative on Malnutrition criteria for predicting prognosis in patients with cancer

BACKGROUND

Reduced muscle mass is a criterion for diagnosing malnutrition using the Global Leadership Initiative on Malnutrition (GLIM) criteria; however, the choice of muscle-mass indicators within the GLIM criteria remains contentious. This study aimed to establish muscle-measurement-based GLIM criteria using data from bio-electrical impedance analysis (BIA) and anthropometric evaluations and evaluate their ability to predict overall survival (OS), short-term outcomes, and healthcare burden in patients with cancer.

METHODS

This was a multicenter, prospective study that commenced in 2013 and enrolled participants from various clinical centers across China. We constructed GLIM criteria based on various muscle measurements, including fat-free mass index (FFMI), skeletal muscle index (SMI), calf circumference (CC), midarm circumference (MAC), midarm muscle circumference (MAMC), and midarm muscle area (MAMA). Survival was estimated using the Kaplan-Meier method and survival curves were compared using the log-rank test. Cox proportional hazards regression was used to assess the independent association between the GLIM criteria and OS. The discriminatory performance of different muscle-measurement-based GLIM criteria for mortality was evaluated using Harrell's concordance index (C-index). Logistic regression was used to evaluate the association of the GLIM criteria with short-term outcomes and healthcare burden.

RESULTS

A total of 4769 patients were included in the analysis, of whom 1659 (34.8%) died during the study period. The Kaplan-Meier curves demonstrated that all muscle-measurement-based GLIM criteria significantly predicted survival in patients with cancer (all p < 0.001). The survival rate of malnourished patients was approximately 10% lower than that of non-malnourished patients. Cox proportional hazards regression showed that all the muscle-measurement-based GLIM could independently predict the OS of patients (all p < 0.001). The prognostic discrimination was as follows: MAMC (Chi-square: 79.61) > MAMA (Chi-square: 79.10) > MAC (Chi-square: 64.09) > FFMI (Chi-square: 62.33) > CC (Chi-square: 58.62) > ASMI (Chi-square: 57.29). In comparison to the FFMI-based GLIM criteria, the ASMI-based criteria (-0.002, 95% CI: -0.006 to 0.002, p = 0.334) and CC-based criteria (-0.003, 95% CI: -0.007 to 0.002, p = 0.227) did not exhibit a significant advantage. However, the MAC-based criteria (0.001, 95% CI: -0.003 to 0.004, p = 0.776), MAMA-based criteria (0.004, 95% CI: 0.000-0.007, p = 0.035), and MAMC-based criteria (0.005, 95% CI: 0.000-0.007, p = 0.030) outperformed the FFMI-based GLIM criteria. Logistic regression showed that muscle measurement-based GLIM criteria predicted short-term outcomes and length of hospital stay in patients with cancer.

CONCLUSION

All muscle measurement-based GLIM criteria can effectively predict OS, short-term outcomes, and healthcare burden in patients with cancer. Anthropometric measurement-based GLIM criteria have potential for clinical application as an alternative to BIA-based measurement.

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.

Identifying malnutrition risk in hospitalized patients: an analysis of five tools in the light of GLIM criteria

BACKGROUND

The prompt identification of malnutrition among hospitalized patients using the appropriate screening tool is paramount. The objective of our study is to compare the most recommended screening tools concerning the new GLIM criteria for malnutrition in hospitalized patients.

METHODS

In this cross-sectional study, we analyzed the data on 1,397 patients receiving inpatient treatment at Bandırma Training and Research Hospital between August 2022 and May 2023 to assess and compare malnutrition in them. Patients who received inpatient treatment in the internal and surgical clinics of Bandırma Training and Research Hospital. In addition to the GLIM criteria, we used nutritional screening and assessment tools such as NRS-2002, MST, GMS, MUST, and SNAQ. The GLIM criteria were considered the gold standard for the evaluation of sensitivity and specificity. Receiver operating characteristic (ROC) curves for the five screening tools were also used to assess the ability to distinguish malnutrition-risk patients accurately.

RESULTS

The comparison of the performances of different screening tools in detecting malnutrition demonstrated that while the GMS had the highest sensitivity (87.40%), the NRS-2002 had the highest specificity (91.70%). The area under the Curve (AUC) value indicated that the predictive values of the NRS-2002, MST, GMS, and SNAQ were excellent, and the predictive value of the MUST was good (p < 0.001). While the GLIM criteria in particular appear to be an effective tool for detecting malnutrition in hospitalized individuals, other screening tools are also useful in assessing their malnutrition risk.

CONCLUSIONS

We emphasized MST's alignment with GLIM criteria, underscoring the importance of a multidisciplinary approach for early malnutrition diagnosis. Patients at risk of malnutrition can be diagnosed more quickly and accurately with appropriate screening tools and the effectiveness of treatments can be increased.

Calcium deficiency is associated with malnutrition risk in patients with inflammatory bowel disease

BACKGROUND AND AIM

Patients with inflammatory bowel disease (IBD) often have the condition of malnutrition, which can be presented as sarcopenia, micronutrient deficiencies, etc. Trace elements (magnesium, calcium, iron, copper, zinc, plumbum and manganese) belonging to micronutrients, are greatly vital for the assessment of nutritional status in humans. Trace element deficiencies are also the main manifestation of malnutrition. Calcium (Ca) has been proved to play an important part in maintaining body homeostasis and regulating cellular function. However, there are still a lack of studies on the association between malnutrition and Ca deficiency in IBD. This research aimed to investigate the role of Ca for malnutrition in IBD patients.

METHODS

We prospectively collected blood samples from 149 patients and utilized inductively coupled plasma mass spectrometry to examine their venous serum trace element concentrations. Logistic regression analyses were used to investigate the association between Ca and malnutrition. Receiver operating characteristic (ROC) curves were generated to calculate the cutoffs for determination of Ca deficiency.

RESULTS

Except Ca, the concentrations of the other six trace elements presented no statistical significance between non-malnutrition and malnutrition group. In comparison with the non-malnutrition group, the serum concentration of Ca decreased in the malnutrition group (89.36 vs 87.03 mg/L, p = 0.023). With regard to ROC curve, Ca < 87.21 mg/L showed the best discriminative capability with an area of 0.624 (95% CI: 0.520, 0.727, p = 0.023). Multivariate analyses demonstrated that Ca < 87.21 mg/L (OR = 3.393, 95% CI: 1.524, 7.554, p = 0.003) and age (OR = 0.958, 95% CI: 0.926, 0.990, p = 0.011) were associated with malnutrition risk. Serum Ca levels were significantly lower in the malnutrition group than those in the non-malnutrition group among UC patients, those with severe disease state or the female group.

CONCLUSIONS

In patients with IBD, Ca deficiency is an independent factor for high malnutrition risk.

Validity of nutrition screening tools for risk of malnutrition among hospitalized adult patients: A systematic review and meta-analysis

BACKGROUNDS & AIMS

Malnutrition is prevalent among hospitalized patients in developed countries, contributing to negative health outcomes and increased healthcare costs. Timely identification and management of malnutrition are crucial. The lack of a universally accepted definition and standardized diagnostic criteria for malnutrition has led to the development of various screening tools, each with varying validity. This complicates early identification of malnutrition, hindering effective intervention strategies. This systematic review and meta-analysis aimed to identify the most valid and reliable nutritional screening tool for assessing the risk of malnutrition in hospitalized adults.

METHODS

A systematic literature search was conducted to identify validation studies published from inception to November 2023, in the Pubmed/MEDLINE, Embase, and CINAHL databases. This systematic review was registered in INPLASY (INPLASY202090028). The risk of bias and quality of included studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies version 2 (QUADAS-2). Meta-analyses were performed for screening tools accuracy using the symmetric hierarchical summary receiver operative characteristics models.

RESULTS

Of the 1646 articles retrieved, 60 met the inclusion criteria and were included in the systematic review, and 21 were included in the meta-analysis. A total of 51 malnutrition risk screening tools and 9 reference standards were identified. The meta-analyses assessed four common malnutrition risk screening tools against two reference standards (Subjective Global Assessment [SGA] and European Society for Clinical Nutrition and Metabolism [ESPEN] criteria). The Malnutrition Universal Screening Tool (MUST) vs SGA had a sensitivity (95% Confidence Interval) of 0.84 (0.73-0.91), and specificity of 0.85 (0.75-0.91). The MUST vs ESPEN had a sensitivity of 0.97 (0.53-0.99) and specificity of 0.80 (0.50-0.94). The Malnutrition Screening Tool (MST) vs SGA had a sensitivity of 0.81 (0.67-0.90) and specificity of 0.79 (0.72-0.74). The Mini Nutritional Assessment-Short Form (MNA-SF) vs ESPEN had a sensitivity of 0.99 (0.41-0.99) and specificity of 0.60 (0.45-0.73). The Nutrition Universal Screening Tool-2002 (NRS-2002) vs SGA had a sensitivity of 0.76 (0.58-0.87) and specificity of 0.86 (0.76-0.93).

CONCLUSIONS

The MUST demonstrated high accuracy in detecting malnutrition risk in hospitalized adults. However, the quality of the studies included varied greatly, possibly introducing bias in the results. Future research should compare tools within a specific patient population using a valid and universal gold standard to ensure improved patient care and outcomes.

Managing fluid balance and nutritional status in a short bowel syndrome patient awaiting intestinal transplant: a case report

BACKGROUND

Despite being a long-term therapy for patients with short bowel syndrome (SBS), subcutaneous injections of teduglutide promote the regeneration of the gastrointestinal tract. Such cases are particularly concerning for patients with residual small bowel.

METHODS

In this report, we present a case of an SBS patient with only 5 cm of remaining small bowel and a high-output duodenal stoma, who was treated with teduglutide.

RESULTS

The initiation of teduglutide injections in our patient resulted in a reduction of stoma output, improvement in the patient's nutritional status, regulation of fluid balance, and stabilization of their clinical condition.

CONCLUSIONS

This case suggests that subcutaneous injections of teduglutide, when combined with appropriate nutritional care, can effectively treat high-output stomas, even in cases where the small bowel is nearly absent.

Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach

BACKGROUND & AIMS

The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation in support of the etiologic criterion for inflammation.

METHODS

A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified-Delphi review. A multi-round review and revision process served to develop seven guidance statements.

RESULTS

The final round of review was highly favorable with 99 % overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (mg/dL or mg/L) for the clinical laboratory that is being used.

CONCLUSION

Confirmation of inflammation should be guided by clinical judgement based upon underlying diagnosis or condition, clinical signs, or CRP.

Impact of preoperative prealbumin levels on long-term prognosis in patients with gastric cancer after gastrectomy: a retrospective cohort study

BACKGROUND

The relationship between preoperative prealbumin levels and long-term prognoses in patients with gastric cancer after gastrectomy has not been fully investigated. This study clarified the effect of preoperative prealbumin levels on the long-term prognosis of patients with gastric cancer after gastrectomy.

METHODS

This retrospective cohort study included consecutive patients who underwent radical gastrectomy for primary pStage I-III gastric cancer and whose preoperative prealbumin levels were measured between May 2006 and March 2017. Participants were categorized according to their preoperative prealbumin levels into high (≥22 mg/dL), moderate (15-22 mg/dL), and low (<15 mg/dL) groups. The overall survival (OS) in the three groups was compared using the log-rank test, and prognostic factors were identified using Cox proportional hazards regression analysis.

RESULTS

The median follow-up duration was 66 months. Of 4732 patients, 3649 (77.2%) were classified as high, 925 (19.6%) as moderate, and 158 (3.3%) as low. Lower prealbumin levels were associated with poorer prognoses (P < 0.001). Multivariate analysis showed that prealbumin levels of 15-22 mg/dL [hazard ratio (HR): 1.576, 95% confidence interval (CI): 1.353-1.835, P < 0.001] and <15 mg/dL (HR: 1.769, 95% CI: 1.376-2.276, P < 0.001) were independent poor prognostic factors for OS. When analyzed according to the cause of death, prealbumin levels were associated with other-cause survival, but not cancer-specific survival.

CONCLUSIONS

Preoperative prealbumin levels correlated with OS in patients with gastric cancer after gastrectomy; the lower the prealbumin level, the worse is the prognosis. Prealbumin levels may be associated with other-cause survival.

Effectiveness of Global Leadership Initiative on Malnutrition and Subjective Global Assessment for diagnosing malnutrition and predicting wound healing in patients with diabetic foot ulcers

Malnutrition significantly hampers wound healing processes. This study aimed to compare the effectiveness of the Global Leadership Initiative on Malnutrition (GLIM) and Subjective Global Assessment (SGA) in diagnosing malnutrition and predicting wound healing in patients with diabetic foot ulcers (DFU). GLIM criteria were evaluated for sensitivity (SE), specificity (SP), positive predictive value, negative predictive value and kappa (κ) against SGA as the reference. Modified Poisson regression model and the DeLong test investigated the association between malnutrition and non-healing ulcers over 6 months. This retrospective cohort study included 398 patients with DFU, with a mean age of 66·3 ± 11·9 years. According to SGA and GLIM criteria, malnutrition rates were 50·8 % and 42·7 %, respectively. GLIM criteria showed a SE of 67·3 % (95 % CI 60·4 %, 73·7 %) and SP of 82·7 % (95 % CI 76·6 %, 87·7 %) in identifying malnutrition, with a positive predictive value of 80·0 % and a negative predictive value of 71·1 % (κ = 0·50) compared with SGA. Multivariate analysis demonstrated that malnutrition, as assessed by SGA, was an independent risk factor for non-healing (relative risk (RR) 1·84, 95 % CI 1·45, 2·34), whereas GLIM criteria were associated with poorer ulcer healing in patients with estimated glomerular filtration rate ≥ 60 ml/min/1·73m2 (RR: 1·46, 95 % CI 1·10, 1·94). SGA demonstrated a superior area under the receiver's operating characteristic curve for predicting non-healing compared with GLIM criteria (0·70 (0·65-0·75) v. 0·63 (0·58-0·65), P < 0·01). These findings suggest that both nutritional assessment tools effectively identify patients with DFU at increased risk, with SGA showing superior performance in predicting non-healing ulcers.

Prevalence of Malnutrition in a Group of Institutionalized Psychogeriatric Patients Using Different Diagnostic Criteria

Malnutrition (MN) is a highly prevalent condition in the elderly. It is associated with functional impairment, disability, frailty, and sarcopenia. The aim was to analyze the capacity of GLIM and ESPEN criteria to diagnose MN in a sample of institutionalized psychogeriatric patients. Clinical and anthropometric data were collected in a cross-sectional study. Patients' frailty, dependence, functional capacity, MNA, hand-grip strength (HS), and sarcopenia were evaluated. Body composition (BC) was estimated by conventional bioimpedance analysis. MN diagnosis was established using the ESPEN and the GLIM criteria based on fat-free mass index (GLIM-FFMI), appendicular skeletal muscle mass index (GLIM-ASMMI), skeletal muscle mass index (GLIM-SMMI), and HS (mGLIM). Ninety-two patients (57.6% men; mean age: 79.4 years) were studied. Depending on the diagnosis criteria, MN prevalence was between 25% (ESPEN) and 41.3% (GLIM-SMMI). Agreement between ESPEN and all GLIM criteria was poor, but it was excellent between all GLIM criteria (kappa > 0.8). Phenotypic criteria carried more weight in the diagnosis of MN than etiological ones. Depending on the parameter used, the prevalence of reduced muscle mass was notably different. Differences in BMI, BC, inflammation, and albumin are detected by the GLIM-FFMI criteria in the MN and non-MN subjects. Also, this criterion is the only one that identified differences in phase angle (PhA) between these groups. In the elderly, PhA can be very useful to monitor nutritional status.

Global Leadership Initiative on Malnutrition (GLIM) for the diagnosis of malnutrition - a framework for consistent dietetic practice

Malnutrition is an alarming and ongoing healthcare problem globally. Malnutrition has a negative impact on the individual patient, leading to poorer clinical outcomes and increased mortality, but also poses an economic burden on society. Proper identification and diagnostics are prerequisites for initiation of treatment. In 2019, the Global Leadership Initiative on Malnutrition, a consensus-based global framework to uniformly diagnose malnutrition across populations, healthcare settings, and countries was published. Identifying and treating malnutrition is an interdisciplinary team effort. Nonetheless, the nutrition and dietetics profession is specifically trained for diagnosing and treating nutrition(-related) conditions, and therefore has a key role in the interdisciplinary team in implementing the GLIM framework in clinical practice. For the nutrition and dietetics profession, GLIM offers a great opportunity for moving both the scientific and clinical knowledge of malnutrition management forward. While the GLIM framework has been extensively studied since its launch, various knowledge gaps still remain. For the nutrition and dietetics profession, these knowledge gaps mainly relate to the GLIM implementation process, to the role of GLIM in relation to the nutrition care process, and to treatment strategies for various nutrition-related conditions. In this opinion paper, we aimed to describe the rationale for implementing the GLIM framework in clinical dietetic practice, and propose a research agenda based on knowledge gaps regarding GLIM in relation to nutrition care from a dietetic point of view.

Validity of the GLIM criteria for the diagnosis of malnutrition in patients with colorectal cancer: A multicenter study on the diagnostic performance of different indicators of reduced muscle mass and disease severity

OBJECTIVES

To assess the concurrent and predictive validity of different combinations of Global Leadership Initiative on Malnutrition (GLIM) criteria in patients with colorectal cancer considering different indicators of reduced muscle mass (MM) and the effects of the disease.

METHODS

A secondary analysis with patients with colorectal cancer. The reduced MM was assessed by arm muscle area, arm muscle circumference, calf circumference, fat-free mass index, skeletal muscle index (SMI) and skeletal muscle. Cancer diagnosis or disease staging (TNM) was considered for the etiologic criterion referred to as the effect of the disease. The other phenotypic and etiologic criteria were also evaluated, and we analyzed 13 GLIM combinations. Concurrent validity between GLIM criteria and Patient-Generated Subjective Global Assessment was evaluated. Logistic and Cox regression were used in the predictive validation.

RESULTS

For concurrent validity (n = 208), most GLIM combinations (n = 6; 54.5%) presented a moderate agreement with Patient-Generated Subjective Global Assessment and none showed satisfactory sensitivity and specificity (>80%). Reduced MM evaluated by SMI and SMI were present in the GLIM combinations associated with postoperative complications (odds ratio, ≥2.0), independent of other phenotypic and etiologic criteria. The combinations with reduced MM considering any method and fixed phenotypic criteria and TNM were associated with mortality (hazard ratio, ≥2.0).

CONCLUSIONS

Satisfactory concurrent validity was not verified. The GLIM diagnosis of malnutrition was associated with postoperative complications and mortality.

Bayesian diagnostic test evaluation and true prevalence estimation of malnutrition in gastric cancer patients

BACKGROUND & AIMS

Malnutrition is prevalent among gastric cancer (GC) patients, necessitating early assessment of nutritional status to guide monitoring and interventions for improved outcomes. We aim to evaluate the accuracy and prognostic capability of three nutritional tools in GC patients, providing insights for clinical implementation.

METHODS

The present study is an analysis of data from 1308 adult GC patients recruited in a multicenter from July 2013 to July 2018. Nutritional status was assessed using Nutritional Risk Screening 2002 (NRS-2002), Patient-Generated Subjective Global Assessment (PG-SGA) and Global Leadership Initiative on Malnutrition (GLIM) criteria. Bayesian latent class model (LCM) estimated the malnutrition prevalence of GC patients, sensitivity and specificity of nutritional tools. Cox regression model analyzed the relationship between nutritional status and overall survival (OS) in GC patients.

RESULTS

Among 1308 GC patients, NRS-2002, PG-SGA, and GLIM identified 50.46%, 76.76%, and 68.81% as positive, respectively. Bayesian LCM analysis revealed that PG-SGA had the highest sensitivity (0.96) for malnutrition assessment, followed by GLIM criteria (0.78) and NRS-2002 (0.65). Malnutrition or being at risk of malnutrition were identified as independent prognostic factors for OS. Use any of these tools improved survival prediction in TNM staging system.

CONCLUSION

PG-SGA is the most reliable tool for diagnosing malnutrition in GC patients, whereas NRS-2002 is suitable for nutritional screening in busy clinical practice. Given the lower sensitivity of NRS-2002, direct utilization of GLIM for nutritional assessment may be necessary. Each nutritional tool should be associated with a specific course of action, although further research is needed.

Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation, and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation.

METHODS

A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified Delphi review. A multiround review and revision process served to develop seven guidance statements.

RESULTS

The final round of review was highly favorable, with 99% overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection, or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (milligrams per deciliter or milligram per liter) for the clinical laboratory that is being used.

CONCLUSION

Confirmation of inflammation should be guided by clinical judgment based on underlying diagnosis or condition, clinical signs, or CRP.

Validity and applicability of the global leadership initiative on malnutrition criteria in non-dialysis patients with chronic kidney disease

Introduction

There are no standardized assessment criteria for selecting nutritional risk screening tools or indicators to assess reduced muscle mass (RMM) in the Global Leadership Initiative on Malnutrition (GLIM) criteria. We aimed to compare the consistency of different GLIM criteria with Subjective Global Assessment (SGA) and protein-energy wasting (PEW).

Methods

In this study, nutritional risk screening 2002 first four questions (NRS-2002-4Q), Nutritional Risk Screening 2002 (NRS-2002), Malnutrition Universal Screening Tool (MUST), and Mini-Nutritional Assessment Short-Form (MNA-SF) tools were used as the first step of nutritional risk screening for the GLIM. The RMM is expressed using different metrics. The SGA and PEW were used to diagnose patients and classify them as malnourished and non-malnourished. Kappa (κ) tests were used to compare the concordance between the SGA, PEW, and GLIM of each combination of screening tools.

Results

A total of 157 patients were included. Patients with Chronic kidney disease (CKD) stage 1-3 accounted for a large proportion (79.0%). The prevalence rates of malnutrition diagnosed using the SGA and PEW were 18.5% and 19.7%, respectively. The prevalence of GLIM-diagnosed malnutrition ranges from 5.1% to 37.6%, depending on the different screening methods for nutritional risk and the different indicators denoting RMM. The SGA was moderately consistent with the PEW (κ = 0.423, p < 0.001). The consistency among the GLIM, SGA, and PEW was generally low. Using the NRS-2002-4Q to screen for nutritional risk, GLIM had the best agreement with SGA and PEW when skeletal muscle index (SMI), fat-free mass index (FFMI), and hand grip strength (HGS) indicated a reduction in muscle mass (SGA: κ = 0.464, 95% CI 0.28-0.65; PEW: κ = 0.306, 95% CI 0.12-0.49).

Conclusion

The concordance between the GLIM criteria and the SGA and PEW depended on the screening tool used in the GLIM process. The inclusion of RMM in the GLIM framework is important. The addition of HGS could further improve the performance of the GLIM standard compared to the use of body composition measurements.

Application of Global Leadership Initiative on Malnutrition criteria in patients with liver cirrhosis

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) criteria were published to build a global consensus on nutritional diagnosis. Reduced muscle mass is a phenotypic criterion with strong evidence to support its inclusion in the GLIM consensus criteria. However, there is no consensus regarding how to accurately measure and define reduced muscle mass in clinical settings. This study aimed to investigate the optimal reference values of skeletal muscle mass index for diagnosing sarcopenia and GLIM-defined malnutrition, as well as the prevalence of GLIM-defined malnutrition in hospitalized cirrhotic patients.

METHODS

This retrospective study was conducted on 1002 adult patients with liver cirrhosis between January 1, 2018, and February 28, 2022, at Beijing You-An Hospital, Capital Medical University. Adult patients with a clinical diagnosis of liver cirrhosis and who underwent an abdominal computed tomography (CT) examination during hospitalization were included in the study. These patients were randomly divided into a modeling group (cohort 1, 667 patients) and a validation group (cohort 2, 335 patients). In cohort 1, optimal cut-off values of skeletal muscle index at the third lumbar skeletal muscle index (L3-SMI) were determined using receiver operating characteristic analyses against in-hospital mortality in different gender groups. Next, patients in cohort 2 were screened for nutritional risk using the Nutritional Risk Screening 2002 (NRS-2002), and malnutrition was diagnosed by GLIM criteria. Additionally, the reference values of reduced muscle mass in GLIM criteria were derived from the L3-SMI values from cohort 1. Multivariate logistic regression analysis was used to analyze the association between GLIM-defined malnutrition and clinical outcomes.

RESULTS

The optimal cut-off values of L3-SMI were 39.50 cm 2 /m 2 for male patients and 33.06 cm 2 /m 2 for female patients. Based on the cut-off values, 31.63% (68/215) of the male patients and 23.3% (28/120) of the female patients had CT-determined sarcopenia in cohort 2. The prevalence of GLIM-defined malnutrition in cirrhotic patients was 34.3% (115/335) and GLIM-defined malnutrition was an independent risk factor for in-hospital mortality in patients with liver cirrhosis ( Wald = 6.347, P  = 0.012).

CONCLUSIONS

This study provided reference values for skeletal muscle mass index and the prevalence of GLIM-defined malnutrition in hospitalized patients with liver cirrhosis. These reference values will contribute to applying the GLIM criteria in cirrhotic patients.

Malnutrition Screening Tools Are Not Sensitive Enough to Identify Older Hospital Patients with Malnutrition

This study evaluates the concurrent validity of five malnutrition screening tools to identify older hospitalized patients against the Global Leadership Initiative on Malnutrition (GLIM) diagnostic criteria as limited evidence is available. The screening tools Short Nutritional Assessment Questionnaire (SNAQ), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), Mini Nutritional Assessment-Short Form (MNA-SF), and the Patient-Generated Subjective Global Assessment-Short Form (PG-SGA-SF) with cut-offs for both malnutrition (conservative) and moderate malnutrition or risk of malnutrition (liberal) were used. The concurrent validity was determined by the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the level of agreement by Cohen's kappa. In total, 356 patients were included in the analyses (median age 70 y (IQR 63-77); 54% male). The prevalence of malnutrition according to the GLIM criteria without prior screening was 42%. The conservative cut-offs showed a low-to-moderate sensitivity (32-68%) and moderate-to-high specificity (61-98%). The PPV and NPV ranged from 59 to 94% and 67-86%, respectively. The Cohen's kappa showed poor agreement (k = 0.21-0.59). The liberal cut-offs displayed a moderate-to-high sensitivity (66-89%) and a low-to-high specificity (46-95%). The agreement was fair to good (k = 0.33-0.75). The currently used screening tools vary in their capacity to identify hospitalized older patients with malnutrition. The screening process in the GLIM framework requires further consideration.

Protocol for a prospective cohort study on the feasibility of application of nutritional ultrasound in the diagnosis and follow-up of patients with nutritional risk at hospital discharge: study on body composition and function (DRECO)

INTRODUCTION

Nutritional ultrasound (US) is an emerging technique in clinical nutrition for the morphological and structural study of muscle mass. Currently, all definitions of malnutrition include the measurement of muscle mass; however, there is no single way to assess it. It is necessary to develop new techniques to identify muscle involvement in malnutrition that are valid, standardised, reliable, accurate and profitable.

OBJECTIVE

To value the new muscle US techniques aimed to measure muscle and functional status, to make a more accurate diagnosis and a better prediction of complications and morbidity and mortality in patients at nutritional risk.

PRIMARY OUTCOME

to assess the feasibility of US or muscle US techniques in both nutritional diagnosis and follow-up in a nutritional intervention programme.

METHODS AND ANALYSIS

Disease-Related caloric-protein malnutrition EChOgraphy (DRECO) is a prospective, multicentre (25 Spanish hospitals), uncontrolled clinical study in standard clinical practice to value the usefulness of nutritional US (muscle US) in the nutritional diagnosis and follow-up, over 3-6 months, after standard nutritional clinical practice intervention and physical activity, to control their disease-related malnutrition. 1000 patients are expected to be included in.

DISCUSSION

This study will standardise nutritional US measures. It will validate and define specific cut-off values for nutritional US and correlate it with already well-known nutritional tools such as Subjective Global Assessment or Global Leadership Initiative on Malnutrition criteria. Thus, muscle US will become not only a tool to diagnose malnutrition, but it will also be integrated in the daily practice to evaluate nutritional interventions.

ETHICS AND DISSEMINATION

All DRECO study materials have been approved by each of the IRB/IEC of all the sites enrolled (either approval of the own IRB/IEC or validating the approval of the IRB/IEC of another hospital). The study has been registered with ClinicalTrials.gov, on 27 June 2022. The results from this study will be presented at scientific conferences and in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT05433831.

Improving the assessment of malnutrition in cancer: Using systemic inflammation markers as a supplement to the inflammation items of the GLIM criteria

BACKGROUND & AIMS

Systemic inflammation is a key pathogenic criterion for diagnosing malnutrition using the Global Leadership Initiative on Malnutrition (GLIM) criteria. Although cancer is commonly considered as a chronic inflammation-related disease, the inflammatory burden may vary depending on the type and stage of cancer. Therefore, a more precise definition of inflammation criteria could facilitate the identification of malnutrition in cancer.

METHODS

This prospective multicenter study included 1683 cancer patients screened via NRS2002 for malnutrition risk. The inflammatory burden index (IBI), C-reactive protein (CRP) level, neutrophil-to-lymphocyte ratio (NLR), and albumin (ALB) level were used to assess the inflammatory burden. Kaplan-Meier and Cox regression analyses were used to determine the relationship between the GLIM criteria and overall survival. Harrell's concordance index (C-index) was used to compare the discriminative performance of the original, IBI-based, CRP-based, NLR-based, and ALB-based GLIM criteria for survival. Logistic regression models were used to assess the association between GLIM criteria and short-term outcomes, length of hospital stay, and hospitalization costs.

RESULTS

Compared to the original GLIM criteria, the IBI/CRP/NLR/ALB-based GLIM criteria better predicted the long-term outcomes of patients with cancer (chi-square: 1.316 vs. 78.321 vs. 74.740 vs. 88.719 vs. 100.921). The C-index revealed that the inflammation marker-based GLIM criteria showed significantly better prognostic accuracy than the original GLIM criteria. The ALB-based GLIM criteria exhibited the best prognostic accuracy. The inflammation marker-based GLIM criteria were independent predictive factors for the long-term prognosis of cancer. Patients with malnutrition had a 45% higher risk of adverse long-term prognoses than those without malnutrition. The inflammation marker-based GLIM criteria had good prognostic ability to predict outcomes at 3, 6, and 12 months. The stepwise effect of the grading of severity via the IBI-based GLIM criteria and CRP-based GLIM criteria was notable. The inflammation marker-based GLIM criteria are useful for predicting short-term outcomes, length of hospitalization, and hospitalization costs.

CONCLUSION

The inflammation marker-based GLIM criteria have a stronger predictive value than the original GLIM criteria in evaluating both the short- and long-term prognoses of cancer patients. It is recommended to use the inflammation marker-based GLIM criteria for nutritional evaluation of cancer patients.

Glycaemic and insulinaemic impact of a diabetes-specific oral nutritional supplement with extra-virgin olive oil in patients with type 2 diabetes mellitus at nutritional risk: a randomized, double-blind, crossover, multicentre clinical trial (DIACARE)

Introduction

Introduction: there is controversy about the usefulness of specific enteral nutrition formulas in malnourished patients with diabetes. The effects on blood glucose and other aspects of metabolic control are not fully understood in the scientific literature. Objective: the aim of the study was to compare the glycaemic and insulinaemic response of patients with type 2 diabetes at risk of malnutrition after oral feed between a diabetes-specific formula with AOVE (DSF) and a standard one (STF). Methods: A randomized, double-blind, crossover, multicentre clinical trial was conducted in patients with type 2 diabetes at risk of malnutrition (SGA). The patients were randomized to receive either DSF or STF, a week apart. A glycaemia and insulinaemia curve was made at times 0 minutes, 30 min, 60 min, 90 min, 120 min, and 180 min after the patients drank 200 ml of the oral nutritional supplement (ONS). The principal variables were the area under the curve (AUC0-t) of glucose and insulin. Results: 29 patients (51 % women) were included, who were on average 68.84 (SD 11.37) years old. Regarding the degree of malnutrition, 86.2 % presented moderate malnutrition (B) and 13.8 % severe (C). When the patients received the DSF, they had a lower mean of glucose AUC0-t (-3,325.34 mg/min/dl [95 % CI: -4,3608.34 to -2,290.07]; p = 0.016) and also a lower mean of insulin AUC0-t (-451.14 uU/min/ml [95 % CI: -875,10 to -27.17]; p = 0.038). There were no differences in the degree of malnutrition. Conclusion: compared with STF, DSF with AOVE showed a better glycaemic and insulinaemic response in patients with type 2 diabetes at risk of malnutrition.

Prevalence of malnutrition based on global leadership initiative in malnutrition criteria for completeness of diagnosis and future risk of malnutrition based on current malnutrition diagnosis: systematic review and meta-analysis

Background

The proposal of the global leadership initiative in malnutrition (GLIM) criteria has received great attention from clinicians. The criteria are mainly used in the research environment and have the potential to be widely used in the clinic in the future. However, the prevalence of malnutrition and risk of future malnutrition based on a current diagnosis of malnutrition are worth exploring.

Methods

A systematic search of PubMed, Embase, and the Cochrane Library was performed from the earliest available date to 1 February 2023. According to the diagnostic criteria of the GLIM, we analysed the prevalence of malnutrition by directly adopting the GLIM criteria for diagnosis without a previous nutritional risk screening (one-step approach) and by adopting the GLIM criteria for diagnosis after a nutritional risk screening (two-step approach). The main outcome was the prevalence of malnutrition based on the one-and two-step approaches. Secondary outcomes were the future risk of malnutrition based on the GLIM diagnosis, including mortality within and beyond 1 year. primary outcomes were pooled using random-effects models, and secondary outcomes are presented as hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

A total of 64 articles were included in the study, including a total of 47,654 adult hospitalized patients and 15,089 malnourished patients based on the GLIM criteria. Malnutrition was diagnosed by the one-step approach in 18 studies and by the two-step approach in 46 studies. The prevalence of malnutrition diagnosed by the one-and two-step approaches was 53% (95% CI, 42%-64%) and 39% (95% CI, 0.35%-0.43%), respectively. The prevalence of malnutrition diagnosed by the GLIM criteria after a nutritional risk screening was quite different; the prevalence of malnutrition diagnosed by the Nutritional Risk Screening 2002 (NRS2002) GLIM tool was 35% (95% CI, 29%-40%); however, the prevalence of malnutrition diagnosed by the Mini Nutrition Assessment (MNA) GLIM tool was 48% (95% CI, 35%-62%). Among the disease types, the prevalence of malnutrition in cancer patients was 44% (95% CI, 36%-52%), while that in acute and critically ill patients was 44% (95% CI, 33%-56%). The prevalence in patients in internal medicine wards was 40% (95% CI, 34%-45%), while that in patients in surgical wards was 47% (95% CI, 30%-64%). In addition, the mortality risk within 1 year (HR, 2.62; 95% CI, 1.95-3.52; I² = 77.1%) and beyond 1 year (HR, 2.04; 95% CI, 1.70-2.45; I² = 59.9%) of patients diagnosed with malnutrition by the GLIM criteria was double that of patients with normal nutrition.

Conclusion

The prevalence of malnutrition diagnosed by the GLIM criteria after a nutritional risk screening was significantly lower than the prevalence of malnutrition diagnosed directly by the GLIM criteria. In addition, the mortality risk was significantly greater among malnourished patients assessed by the GLIM criteria.Systematic review registration: identifier CRD42023398454.

Nutritional issues concerning general medical ward patients: feeding patients recovering from critical illness

PURPOSE OF REVIEW

ICU survivors often spend long periods of time in general wards following transfer from ICU in which they are still nutritionally compromised. This brief review will focus on the feeding of patients recovering from critical illness, as no formal recommendations or guidelines on nutrition management are available for this specific situation.

RECENT FINDINGS

While feeding should start in the ICU, it is important to continue and adapt nutritional plans on the ward to support individuals recovering from critical illness. This process is highly complex - suboptimal feeding may contribute significantly to higher morbidity and mortality, and seriously hinder recovery from illness. Recently, consensus diagnostic criteria for malnutrition have been defined and large-scale trials have advanced our understanding of the pathophysiological pathways underlying malnutrition. They have also helped further develop treatment algorithms. However, we must continue to identify specific clinical parameters and blood biomarkers to further personalize therapy for malnourished patients. Better understanding of such factors may help us adapt nutritional plans more efficiently.

SUMMARY

Adequate nutrition is a vigorous component of treatment in the post-ICU period and can enhance recovery and improve clinical outcome. To better personalize nutritional treatment because not every patient benefits from support in the same manner, it is important to further investigate biomarkers with a possible prognostic value.

Impact of malnutrition as defined by the GLIM criteria on treatment outcomes in patients with cancer: A systematic review and meta-analysis

BACKGROUND & AIMS

Malnutrition has been reported to lead to poor postoperative outcomes. The Global Leadership Initiative on Malnutrition (GLIM) criteria were published in 2019 as a global consensus on the criteria for diagnosing malnutrition. However, the relationship between GLIM-defined malnutrition and treatment outcomes in patients with cancer has not been fully investigated. Therefore, this study aimed to clarify the impact of GLIM-defined malnutrition on the treatment outcomes of patients with cancer.

METHODS

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, the World Health Organization International Clinical Trials Platform Search Portal, and ClinicalTrials.gov and identified observational studies published from inception to January 17, 2022. We conducted a systematic review and random-effects meta-analysis studies that included patients with cancer aged >18 years who received any kind of treatment and whose nutritional status was assessed using GLIM criteria. We independently assessed the risk of bias and quality of evidence using Quality In Prognosis Studies and Grading of Recommendations, Assessment, Development, and Evaluation approach. The primary outcomes were overall survival (OS) and postoperative complications. Hazard ratios and 95% confidence intervals (CIs) for OS and relative risk ratios and 95% CIs for postoperative complications were pooled. The protocol was published by PROSPERO (CRD42022304004).

RESULTS

Of 67 studies after screening, ten studies (n = 11,700) reported the impact of GLIM-defined malnutrition on postoperative outcomes. Compared with no malnutrition, GLIM-defined malnutrition may worsen OS (hazard ratio, 1.56; 95% CI, 1.38-1.75; I² = 37%) and increase postoperative complications (relative risk ratio, 1.82; 95% CI, 1.28-2.60; I² = 87%). The risk of bias in each study was either moderate or high. The certainty of the evidence was low because of publication bias and a moderate or high risk of bias.

CONCLUSIONS

GLIM-defined malnutrition may worsen OS and increase the risk of postoperative complications in patients with cancer undergoing treatment. Further studies are needed to confirm these findings and mitigate this risk.

Multidisciplinary Assessment and Individualized Nutritional Management of Dysphagia in Older Outpatients

INTRODUCTION

The evidence on the efficacy of nutrition therapy to prevent complications of dysphagia is based on observational studies that used different tools for nutritional and dysphagia assessment, and different scales for the definition of diet textures, rendering their results incomparable and the knowledge on dysphagia management inconclusive.

METHODS

This retrospective observational study was performed in 267 older outpatients who were assessed for dysphagia and nutritional status by a multidisciplinary team at the Clinical Nutrition Unit of IRCCS INRCA geriatric research hospital (Ancona, Italy) from 2018 to 2021. GUSS test and ASHA-NOMS measurement systems were used for dysphagia assessment, GLIM criteria for the assessment of nutritional status, and the IDDSI framework to describe the texture-modified diets. Descriptive statistics were used to summarize the characteristics of the subjects evaluated. Sociodemographic, functional and clinical parameters were compared between patients with and without BMI improvement overtime by an unpaired Student's t test, Mann-Whitney U test or Chi square test, as appropriate.

RESULTS

Dysphagia was diagnosed in more than 96.0% of subjects; 22.1% (n = 59) of dysphagic subjects were also malnourished. Dysphagia was treated exclusively by nutrition therapy, prevalently by individualized texture-modified diets (77.4%). For the classification of diet texture, the IDDSI framework was used. The follow-up visit was attended by 63.7% (n = 102) of subjects. Aspiration pneumonia was registered only in one patient (less than 1%), and BMI improved in 13 of 19 malnourished subjects (68.4%). The improvement of nutritional status was primarily reached in subjects whose energy intake was increased and texture of solids modified, in younger subjects, and in those taking less drugs and not reporting any weight loss before the first assessment.

CONCLUSIONS

The nutritional management of dysphagia must guarantee both an adequate consistency and energy-protein intake. Evaluations and outcomes should be described with universal scales, in order to allow for comparison between studies and contribute to the collection of a critical mass of evidence on the efficacy of texture-modified diets in the management of dysphagia and its complications.

GLIM Criteria for Assessment of Malnutrition in Saudi Patients with Type 2 Diabetes

The Global Leadership Initiative on Malnutrition (GLIM) is a new approach established for the assessment of malnutrition. This study aimed to validate the GLIM for the diagnosis of malnutrition in patients with type 2 diabetes mellitus (T2DM) in Saudi Arabia, using the Subjective Global Assessment (SGA) as a reference. In addition, the association between the GLIM criteria and vascular complications in those patients was examined. A cross-sectional study was conducted on 101 patients with T2DM. The level of agreement between the GLIM and SGA tools was calculated using the kappa coefficient (κ). A receiver operating characteristic curve was used to determine the sensitivity and specificity of the GLIM. In addition, binary logistic regression was performed to investigate the association between each GLIM criterion and T2DM vascular complications. According to both the GLIM and the SGA, malnutrition was found in 15.8% and 17.8% of patients, respectively. The GLIM criteria achieved a very good level of accuracy (AUC = 0.877). The agreement between the tools was substantial (κ = 0.778). The 'disease/inflammation' criterion of the GLIM was significantly associated with macrovascular complications. To conclude, the GLIM criteria for diagnosis of malnutrition presented satisfactory levels of validity, and as such are acceptable for assessing the nutritional status of patients with T2DM.

Validity and feasibility of the global leadership initiative on malnutrition diagnostic concept in older people: a literature review from August 2021 to August 2022

PURPOSE OF REVIEW

Early 2019, the Global Leadership Initiative on Malnutrition (GLIM) concept offered a clinically applicable and objective procedure for diagnosing malnutrition. This review summarizes 40 publications from August 2021 to August 2022 that applied the GLIM criteria in older populations from various clinical settings for criterion and predictive validation.

RECENT FINDINGS

Criterion validity studies, by comparing the GLIM construct with various semi-gold standards such as SGA, PG-SGA, MNA-FF/SF and ESPEN criteria, indicate by sensitivity, specificity and agreement that GLIM performs at least as well as the other tools to capture malnutrition. One meta-analysis of 20 studies with various comparators reports high accuracy for distinguishing malnutrition. GLIM-malnutrition prevalence figures vary with screening tool. Predictive validity of GLIM for mortality, and other outcomes, is good in all settings reported. Sarcopenia and GLIM show some expected overlapping.

SUMMARY

In populations more than 60 years old, the GLIM construct appears to have well acceptable criterion validity as well as predictive validity. The continuous implementation of the GLIM concept is justified.

A scoping review on the GLIM criteria for malnutrition diagnosis: Understanding how and for which purpose it has been applied in studies on hospital settings

AIMS

This scoping review aimed to identify and map the literature on malnutrition diagnosis made using the GLIM criteria in hospitalized patients.

METHODS

The scoping review was conducted using the Joanna Briggs Institute's methodology. We searched PubMed, Embase, Scopus, and Web of Science (until 16 April 2022) to identify studies based on the 'population' (adults or elderly patients), 'concept' (malnutrition diagnosis by the GLIM criteria), and 'context' (hospital settings) framework. Titles/abstracts were screened, and two independent reviewers extracted data from eligible studies.

RESULTS

Ninety-six studies were eligible (35.4% from China, 30.2% involving oncological patients, and 30.5% with prospective data collection), 32 followed the two-step GLIM approach, and 50 applied all the criteria. All the studies evaluated body mass index (BMI), while 92.7% evaluated weight loss; 77.1%, muscle mass; 93.8%, inflammation; and 70.8%, energy intake. A lack of details on the methods adopted for criterion evaluation was observed in five (muscle mass evaluation) to 40 studies (energy intake evaluation). The frequency of the use of the GLIM criteria ranged from 22.2% (frequency of low BMI) to 84.7% (frequency of inflammation), and the malnutrition prevalence ranged from 0.96% to 87.9%. Less than 30% of studies aimed to assess the GLIM criterion validity, eight studies cited the guidance on validation of the GLIM criteria, and a minority implemented it.

CONCLUSIONS

This map of studies on the GLIM criteria in hospital settings demonstrated that they are applied in a heterogeneous manner, with a wide range of malnutrition prevalence. Almost 50% of the studies applied all the criteria, while one-third followed the straightforward two-step approach. The recommendations of the guidance on validation of the criteria were scarcely adhered to. The gaps that need to be explored in future studies have been highlighted.

Impact of malnutrition as defined by the global leadership initiative on malnutrition criteria on the long-term prognosis in older patients with gastric cancer after gastrectomy

PURPOSE

This study investigated whether or not the impact of malnutrition, as defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria, on the long-term prognosis after gastrectomy differed between older and young patients with advanced gastric cancer.

METHODS

This study included patients with primary stage I-III gastric cancer who underwent gastrectomy between April 2008 and June 2018. Patients were divided into normal, moderate, and severe malnutrition groups according to the GLIM criteria for the body mass index (BMI) and body weight loss (BWL). The primary endpoint was the overall survival (OS).

RESULTS

Of the 512 patients, 274 (53.5%) were included in the younger group (< 70 years old) and 238 (46.5%) in the older group (≥ 70 years old). The prevalence of moderate and severe malnutrition was significantly higher in the older group than in the younger group (P < 0.001 and P = 0.001, respectively). A multivariate analysis showed that moderate malnutrition [hazard ratio (HR) 1.793, P = 0.028] and severe malnutrition (HR 2.374, P = 0.002) were independent prognostic factors in the older group but not in the younger group.

CONCLUSION

GLIM criteria-defined malnutrition did not correlate with the prognosis in the younger group, whereas moderate and severe malnutrition were independent poor prognostic factors for the OS in the older group.

Validation of GLIM criteria on malnutrition in older Chinese inpatients

Objective

Malnutrition is a nutritional disorder and common syndrome that has a high incidence and is easily ignored in hospitalized older patients. It can lead to multiple poor prognoses, such as frailty. Early identification and correct evaluation of possible malnutrition and frailty are essential to improve clinical outcomes in older patients. Therefore, our objective was to explore the applicability and effectiveness of the Global Leadership Initiative on Malnutrition (GLIM) criteria for identifying malnutrition in older patients.

Methods

In total, 223 participants aged ≥60 years were involved. Nutrition was evaluated using the Mini Nutritional Assessment-Full Form (MNA-FF) and GLIM criteria, which adopt a two-step procedure. The first step was to use three different methods for the screening of nutritional risk: the Nutrition Risk Screening 2002, the Mini Nutritional Assessment Short Form (MNA-SF), and the Malnutrition Universal Screening Tool. The second step was to link a combination of at least one phenotypical criterion and one etiological criterion to diagnose malnutrition. The Clinical Frailty Scale was used to assess frailty. Sensitivity, specificity, Youden index, kappa values, and positive and negative predictive values were used to evaluate the validity of the GLIM criteria. Logistic regression models were used to assess whether there was a correlation between malnutrition, as defined by the GLIM criteria, and frailty.

Results

We found that 32.3–49.8% of our patient sample were at risk of malnutrition based on the GLIM diagnosis and using the three different screening tools; 19.3–27.8% of the patients were malnourished. GLIM criteria with MNA-SF as a diagnostic validation and MNA-FF as a reference showed high consistency (K = 0.629; p &lt; 0.001), sensitivity (90.5%), and specificity (86.4%). Logistic regression analysis showed that malnutrition, using MNA-SF with the GLIM criteria, was relevant for a higher likelihood of frailty (OR = 1.887; 95% CI 1.184–2.589).

Conclusions

The incidence of GLIM-defined malnutrition was 19.3–27.8% using different screening tools. The consistency between the GLIM criteria using the MNA-SF and the MNA methods was high. Malnutrition, as diagnosed by the GLIM criteria with MNA-SF, was significantly correlated with frailty. GLIM criteria with MNA-SF may be a more reliable malnutrition assessment process in older inpatients.

Machine Learning-Based Prediction of In-Hospital Complications in Elderly Patients Using GLIM-, SGA-, and ESPEN 2015-Diagnosed Malnutrition as a Factor

Background: Malnutrition is prevalent in elderly inpatients and is associated with various adverse outcomes during their hospital stay, but the diagnosis of malnutrition still lacks widely applicable criteria. This study aimed to investigate the association of malnutrition diagnosed with the SGA, ESPEN 2015, and GLIM criteria, respectively, with in-hospital complications in elderly patients. Method: Hospitalized patients over 65 years old who had been assessed with the SGA guideline for malnutrition at admission were retrospectively recruited from a large observational cohort study conducted in 34 level-A tertiary hospitals in 18 cities in China from June to September 2014. Malnutrition was then retrospectively diagnosed using the GLIM and ESPEN 2015 criteria, respectively, for comparison with the results of the SGA scale. The risk factors for malnutrition were analyzed using logistic regression, and the value of the three diagnostic criteria in predicting the in-hospital complications was subsequently explored using multivariate regression and the random forest machine learning algorithm. Results: A total of 2526 subjects who met the inclusion and exclusion criteria of the study were selected from the 7122 patients in the dataset, with an average age of 74.63 ± 7.12 years, 59.2% male, and 94.2% married. According to the GLIM, SGA, and ESPEN 2015 criteria, the detection rates of malnutrition were 37.8% (956 subjects), 32.8% (829 subjects), and 17.0% (429 subjects), respectively. The diagnostic consistency between the GLIM and the SGA criteria is better than that between the ESPEN 2015 and the SGA criteria (Kappa statistics, 0.890 vs. 0.590). Logistic regression showed that the risk of developing complications in the GLIM-defined malnutrition patients is 2.414 times higher than that of normal patients, higher than those of the ESPEN 2015 and SGA criteria (1.786 and 1.745 times, respectively). The random forest classifications show that the GLIM criteria have a higher ability to predict complications in these elderly patients than the SGA and ESPEN 2015 criteria with a mean decrease in accuracy of 12.929, 10.251, and 5.819, respectively, and a mean decrease in Gini of 2.055, 1.817, and 1.614, respectively. Conclusion: The prevalence of malnutrition diagnosed with the GLIM criteria is higher than that of the SGA and the ESPEN 2015 criteria. The GLIM criteria are better than the SGA and the ESPEN 2015 criteria for predicting in-hospital complications in elderly patients.