glim: the new malnutrition clinical criteria and …...glim: the new malnutrition clinical criteria...

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GLIM: The New Malnutrition Clinical Criteria and Implications for the CDI Profession

Charlene Compher, PhD, RD, CNSC, FADA, FASPENProfessor of Nutrition ScienceUniversity of PennsylvaniaSchool of NursingPhiladelphia, PA

Richard Pinson, MD, FACP, CCSPrincipal/Medical DirectorPinson & Tang, LLCHouston, TX

2019 Copyright, HCPro, a division of Simplify Compliance LLC, and/or session presenter(s). All rights reserved. These materials may not be copied without written permission.

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Explain the purpose of the GLIM criteria– Discuss the next steps in the validation of GLIM criteria– Contrast AND‐ASPEN consensus criteria with GLIM criteria– Identify patients who meet GLIM criteria using current cut points


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What Is the Global Leadership Initiative on Malnutrition (GLIM)?

• Diversity of approach in recognizing malnutrition – Limits understanding of condition, effective treatment approaches– Limits comparability of research findings– May limit appropriate coding and payment for care– Physicians desire simple, single approach to enable broad implementation

• In 2016, thought leaders of continental nutrition societies began discussion of best approaches for standardization of malnutrition diagnosis in clinical settings– U.S.: Gordon Jensen, Charlene Compher– Europe: Tommy Cederholm, Andre Van Gossum– Asia: Takashi Higashiguchi, Ryoji Fukushima– Latin America: Isabel Correia, Cristina Gonzales


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Comparison of Approaches Used to Diagnose MalnutritionAND‐ASPEN

(United States)Subjective Global

Assessment(Canada, S. America)

European Society for Clinical Nutrition &

Metabolism

NRS‐2002(Europe, Asia)

Etiology

Reduced food intake √ √ √ √

Disease/inflammation √ √ √ √

Symptoms

Anorexia √

Weakness √

Signs

Weight loss √ √ √ √

Body mass index √ √

Loss of lean mass √ √ √

Loss of fat mass √

Fluid retention √ √

Muscle function √


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Overall Framework of GLIM

At risk for malnutrition

Malnutrition/Undernutrition

Disease‐related malnutrition (DRM) with inflammation

Acute disease‐ or injury‐related malnutrition

Chronic DRM with inflammation

Cancer cachexia and other disease‐specific cachexia

Disease‐related malnutrition (DRM) without inflammation

Malnutrition/undernutrition without disease

Socioeconomic‐ or psychologic‐related

malnutrition

Hunger‐related malnutrition

Cederholm, Jensen. Clinical Nutrition 2017; 36:7‐10.

Used with permission.


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GLIM Diagnostic Scheme

Jensen, JPEN J Parenter Enteral Nutr. 2018 Sep 2. doi: 10.1002/jpen.1440. PMID: 30175461

Used with permission.


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GLIM Phenotypic and Etiologic Criteria

1 Phenotypic Criterion From This List 1 Etiologic Criterion

Weight Loss Low BMI Reduced Muscle Mass Reduced Food Intake or Assimilation

Inflammation

5%–10% within 6 months or10%–20% beyond6 months

< 20 if age < 70 years or< 22 if age ≥ 70 years

By validated body composition deviceOrBy physical exam

≤ 50% of needs for > 1 week OrAny reduction for > 2 weeks

Acute or chronic disease‐related

> 10% in within 6 months or> 20% beyond 6 months

< 18.5 if age < 70 yearsor< 20 if age ≥ 70 years

By validated body composition deviceOrBy physical exam

Chronic GI condition that limits absorption

Jensen et al, JPEN 2018: 1‐9. doi: 10.1002/jpen.1440


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GLIM Phenotypic Criteria to Determine Severity of Malnutrition

Phenotypic Criterion From This List

Weight Loss Low BMI Reduced Muscle Mass

Moderate Malnutrition

5%–10% within 6 months or10%–20% beyond 6 months

< 20 if age < 70 years or < 22 if age ≥ 70 years

Mild to moderate deficit by device or physical exam

Severe Malnutrition

> 10% within 6 months or> 20% beyond 6 months

< 18.5 if age < 70 years or< 20 if age ≥ 70 years

Severe deficit by device or physical exam

Jensen et al, JPEN 2018: 1‐9, DOI: 10.1002/jpen.1440 2019 Copyright, HCPro, a division of Simplify Compliance LLC, and/or session presenter(s). All rights reserved. These materials may not be copied without written permission.

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Evidence Behind GLIM Proposed Phenotypic Criteria


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Weight Loss

• A basic indicator of surgical risk in patients with chronic peptic ulcer– Studley, JAMA 106:458, 1936

Weight loss < 20%

Mortality 3.5%

Weight loss > 20%

Mortality 33.3%


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European Weight Loss Data:390 Swedish Esophageal Cancer Patients: Greater Mortality if > 20% Postop Weight Loss

Hynes, Euro J Surg Oncology, 2017; 43:1559‐1565

IMAGE


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Asian Weight Loss Data:1,311 Japanese Lung Cancer Patients: Lower Survival if > 3.7% Weight Loss

Nakagawa, Interactive Cardiovascular & Thoracic Surgery 2016; 23:560-566

IMAGE


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Asian BMI Data:1,311 Japanese Postop Lung Cancer Patients: Lower 3‐Year Survival if BMI < 18.5

Nakagawa, Interactive Cardiovascular & Thoracic Surgery, 2016; 23:560-566

IMAGE


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Asian BMI Data: 2,521 Elderly Taiwanese: Increased Need for Care if BMI < 18 or Calf Circumference < 29/27

Cut points for BMI: BMI < 18; BMI < 20; BMI ≥ 20Cut points for calf circumference: CC < 29 (M)/< 27 (F); CC < 33 (M)/< 31 (F)

Hsu, Clin Nutr 2016; 35:735‐740

IMAGE


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Asian BMI Data:211 S. Korean Gastric Cancer Patients: Lower 5‐Year Survival if BMI < 23

Jun, Nutr & Cancer 2016; 68:1296-1300

IMAGE


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Asian BMI Data:484 Taiwanese Liver Cancer Patients: Lower 1, 3, 5‐Year Survival if BMI < 25

Lee, Oncotarget 2016; 16:22948-22959

IMAGE


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Asian BMI Data:104 Taiwanese COPD Patients, 3‐Year Mortality: Lower Survival if BMI < 21 or Calf Circumference < 30

Ho, Intl J COPD, 2016; 11:2075‐2080

IMAGE


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European BMI Data:4,330 Danish Women With Endometrial Cancer: Lower Survival if BMI < 18.5

Type I = estrogen sensitive cancer; Kristensen, Intl J Gynecol Cancer, 2017; 27:281‐288

IMAGE


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European BMI Data:390 Swedish Esophageal Cancer Patients: Greater Mortality if BMI ≤ 19.9 at 6 Months Postop

Hynes, Euro J Surg Oncol, 2017; 43:1559‐1565

IMAGE


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European BMI Data:31,985 Norwegian Adults, 20‐Year Follow‐Up: Lower Survival if BMI < 18.5, < 22.9

Lorem, Health & Quality of Life Outcomes, 2017; 15:191‐205

IMAGE


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U.S. Low BMI Data:51,898 Elderly Patients Followed 1 & 17 Years After MI: Increased Mortality if BMI < 18.5 (5,678, 9.8%)

Bucholz, PLoS Med, 2016; 13(4):e1001998

IMAGE


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What Proportion of the U.S. Hospital Population Has Low BMI?

• Nutrition Day point‐prevalence survey of U.S. hospitalized patients in 2009–2015– Median age 74 (IQR 52–76) in 9,902 US patients

– Mean BMI 29.19 ± 8.15• < 18.5 = 4.8%• 18.5–25 = 29%• 26–29.9 = 27.5%• 30–34.9 = 18.8%• > 35 = 20%

• 33% had nutrition risk by malnutrition screening tool

• 32% ate ¼ of their meal or less• Hospital mortality increased 3.24‐fold in those eating < ¼ of their meal

• In patients NPO, mortality increased 6‐fold – Sauer et al, JPEN in press 2018


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Asian Versus Western ICU Patients Mortality Increased if BMI < 18.5

Figure 1. Hospital Mortality in Western ICU patients Figure 2. Hospital Mortality in Asian ICU Patients

Compher, J Parent Enteral Nutr 2017; Epub ahead of print June 1; PMID: 2864492552019 Copyright, HCPro, a division of Simplify Compliance LLC, and/or session presenter(s). All rights reserved. These materials may not be copied without written permission.

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Data to Support BMI < 20 in Hospital Patients

• In 9,125 German cardiac surgery patients age 69 years, 3% had BMI < 20 – 1‐year mortality increased 2‐fold if BMI < 20

• In 1,268 Italian STEMI patients age < 75 years, 2% had BMI < 20 and 5% if age > 75 years– ICU mortality increased 3.5‐fold if BMI < 20

• In 2,772 global ICU patients with mean age 60 years, 5% had BMI < 20– 60‐day mortality greatest (36%) with BMI < 20

• Compher, JPEN 2017; Jun 1:148607117713182 Epub ahead of print; PMID: 28644925


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Support for Risk With BMI < 20 in Hospital Patients

• In analysis of International Nutrition Survey of ICU Patients data, we compared 4,274 Western to 1,375 Asian patients

• BMI significantly lower in Asians– 28 vs. 23, p < 0.0001

• Age significantly older in Asians– 63.5 years vs. 59 years, p < 0.0001

• BMI < 20 associated with 1.30 ORmortality (1.07–1.57)

• Greater protein/energy reduces mortality in high‐risk patients with low BMI Compher et al, JPEN 2018; 00:1‐7, PMID 2995985


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Next Steps in GLIM Criteria Validation

• Current GLIM cut points represent best estimates based on published data • Intense effort by global nutritionists to use existing data sets to refine these cut points toward greater precision

• Validation study underway by Academy of Nutrition and Dietetics to validate the AND‐ASPEN criteria in large sample concurrent with measurement of GLIM criteria


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GLIM Comparison to AND‐ASPEN

• GLIM is congruent with AND‐ASPEN approach, though specific criteria differ somewhat

• Physicians using GLIM can easily obtain the needed information from the dietitian’s assessment


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Comparison of GLIM and AND‐ASPEN CriteriaMalnutrition Weight Loss Low BMI Reduced Muscle Mass

GLIM AND‐ASPEN GLIM AND‐ASPEN GLIM and AND‐ASPEN

Moderate 5%–10% within 6 months or10%–20% beyond 6 months

2% in 1 weekor5% in 1 month or 7.5% in 3 monthsor10% in 6 monthsor 20% in 1 year

< 20 if age < 70 years or < 22 if age ≥ 70 years

Mild to moderate deficit by device or physical exam

Severe > 10% within 6 months or> 20% beyond 6 months

> 2% in 1 weekor> 5% in 1 monthor> 7.5% in 3 monthsor> 10% in 6 monthsor > 20% in 1 year

< 18.5 if age < 70 years or< 20 if age ≥ 70 years

Severe deficit by device or physical exam


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Case Examples

• 40‐year‐old man with Crohn’s disease has usual weight of 140 lb (63.6 kg), BMI = 25. No evidence of muscle mass loss.

• Presents to GI clinic with weight of 130 lb (59 kg), saying he has lost this weight over past 30 days– Weight loss is 8% in 1 month– BMI = 23.3

• Is he malnourished by GLIM criteria? – Phenotypic: Weight loss 5%–10% within 6 months (moderate malnutrition) – Etiologic: Malabsorption due to Crohn’s disease

• Is he malnourished by AND‐ASPEN criteria?– Yes; moderate malnutrition by weight loss and inadequate food intake, in context of

chronic inflammation


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Case Examples

• 80‐year‐old woman comes to emergency department after a fall she reports is due to her severe arthritis

• Her BMI is 20 kg/m2

• Further evaluation documents < 50% of her energy needs for the past 10 days because she could not manage her stairs for shopping

• Is she malnourished by GLIM criteria?– Phenotypic: Age > 70, BMI < 22 (moderate malnutrition)– Etiologic: Food intake < 50% for > 1 week

• Is she malnourished by AND‐ASPEN criteria?– Need more information about her weight history and physical exam


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Case Examples

• 25‐year‐old man admitted to ICU after gunshot wound to abdomen, undergoes multiple surgical repairs to small and large intestine and multiple days NPO for the OR

• At admission to ICU, his BMI was 23• One week later, his BMI is 20, weight loss 13% in 1 week• Is he malnourished by GLIM criteria?

– Phenotypic: Weight loss > 10% in 6 months (severe malnutrition)– Etiologic: Severe inflammatory response with injury

• Is he malnourished by AND‐ASPEN criteria?– Yes; severe malnutrition, by weight loss, inadequate intake, and severe injury‐associated

inflammation• This patient will require expensive medical care, including tube feedings or

parenteral nutrition


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Case Examples

• 55‐year‐old woman goes to her physician because she has unexpected weight loss. She weighed 160 lb (BMI 32) at a visit with her gynecologist 6 months ago. Today her weight is 135 lb, a 15% weight loss. Her BMI is 27. She has not noticed a change in her diet or appetite.

• Is she malnourished by GLIM criteria?– Phenotypic: Weight loss > 10% in 6 months – Etiologic: MD will look for occult oncologic diagnosis

• Is she malnourished by AND‐ASPEN criteria?– Severe weight loss, but would need to evaluate food intake carefully – Not likely to see loss of muscle mass by exam in this patient


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Summary

• The GLIM approach to diagnosing malnutrition is a work in progress• Designed to standardize and simplify the diagnosis of malnutrition, further work is needed to refine the specific cut points used to classify severity of malnutrition

• Based on long history of nutrition research and congruent with all commonly used nutrition assessment strategies, the approach appears sound


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Thank you. Questions?

[email protected]@pinsonandtang.com

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glim: the new malnutrition clinical criteria and …...glim: the new malnutrition clinical criteria...

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