global leadership initiative in malnutrition (glim) · mna-sf must espen 2015 aspen/ and2012 sga...
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Harriët Jager-Wittenaar, PhD, MDProfessor (Lector) of Malnutrition and Healthy Ageing
Global Leadership Initiative in Malnutrition (GLIM):
Global Consensus on Malnutrition Diagnostic Criteria
Harriët Jager-Wittenaar, PhD, RDProfessor of Malnutrition and Healthy Ageing
Hanze University of Applied Sciences
Global Leadership Initiative in Malnutrition (GLIM):
Global Consensus on Malnutrition Diagnostic Criteria
Malnutrition Diagnostic CriteriaThe path to consensus by the Global
Leadership Initiative in Malnutrition (GLIM)
The way to consensusProfessor Tommy Cederholm, Sweden
The GLIM Criteria for MalnutritionProfessor Gordon L Jensen, USA
Malnutrition
A state resulting from lack of intake or uptake ofnutrition that leads to altered body composition
(decreased fat free mass) and body cell mass leading to diminished physical and mental function
and impaired clinical outcome from disease
ESPEN conceptual definition
4
“ “
Cederholm et al., Clin Nutr 2017
Nutrition-related disorders
Cederholm et al., Clin Nutr 2017 5
Nutrition disorders and nutrition-related disorders
Malnutrition/ Undernutrition
Sarcopeniaand Frailty
Overweightand Obesity
Micronutrientabnormalities
Refeedingsyndrome
Types of malnutrition
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At risk for malnutrition
Malnutrition/Undernutrition
DRM* withinflammation
Acute disease-related or injury-
relatedmalnutrition
Malnutrition/ undernutrition
without disease
* DRM = disease-related malnutrition
DRM without inflammation
ChronicDRM with
inflammation
Disease-specific
cachexia
Socioeconomicor psychologic-
relatedmalnutrition
Hunger-relatedmalnutrition
Cederholm et al., Clin Nutr 2017
Operational definition (criteria) formalnutrition diagnosis
• Energy intake
• Weight loss
• Loss of subcutaneous fat
• Muscle mass
• Fluid accumulation
• Reduced hand grip strength
à ≥2 out of 6 criteria is
recommended for diagnosis of
malnutrition
Alternative 1:
• BMI <18.5 kg/m
Alternative 2:
• Weight loss (unintentional)
> 10% indefinite of time, or
>5% over the last 3 months,
combined with either
• BMI <20 kg/m2 if <70 years, or
<22 kg/m2 if ≥70 years
or FFMI <15 and 17 kg/m2 in
women and men, resp.
Cederholm et al. 2017 White et al. 2012
Previous attempts have not captured global acceptance• Too elaborate• Overly restrictive• Body composition measurement techniques not
available• Lack of criteria indicating etiology• Not accounting ethnicity• ….
Joint action by ASPEN, ESPEN, FELANPE, PENSA
Global Leadership Initiative on Malnutrition (GLIM)
The GLIM process spanning 3-years• CNW/Austin Jan 2016• ESPEN/Copenhagen Sept 2016• CNW/Orlando Feb 2017• ESPEN/the Hague Sept 2017• CNW/Las Vegas Jan 2018• ESPEN/Madrid Sept 2018
Global Leadership Initiative in Malnutrition Core committee
GL Jensen / Compher C – ASPENCederholm T / Van Gossum A – ESPENCorreia I / Gonzalez MC – FELANPEFukushima R / Higashiguchi T – PENSA
Working groupBaptista G, Barazzoni R, Blaauw R, Coats AJS, Crivelli A, Evans DC, Gramlich L, Fuchs V, Keller H, Llido L, Malone A, Mogensen KM, Morley JE, Muscaritoli M, Nyulasi I, Pirlich M, Pisprasert V, de van der Schueren MAE, Siltharm S, Singer P, Tappenden K, Velasco N, Waitzberg D, Yamwong P, Yu J
Objectives of GLIM• Consensus development of evidence-based criteria suitable
to diverse clinical settings
• Global dissemination of consensus criteria
• Priority to seek adoption by leading diagnosis classification and coding entities across the globe
• Desired approach to malnutrition diagnosis should be:- simple- include clinically relevant diagnostic criteria appropriate for application by all healthcare professionals
- using methods that are widely available
• To promote global use of consensus criteria that can be readily used with other approaches and additional criteria for regional preference
Strong Support for a two Step Approach to Malnutrition Diagnosis
Step 1 – screening for malnutrition risk usingavailable standard validated approaches
Step 2 – assessment to diagnose malnutrition and tostage severity
Survey of existing approaches screening and assessment of malnutrition and cachexia
NRS-
2002
MNA-
SF
MUST ESPEN
2015
ASPEN/
AND 2012
SGA Evans
2008
PEW
2008
Fearon
2011
Etiologies
Reduced food intake X X X X X X X XDisease burden/
inflammationX X X X X X X X X
Symptoms
Anorexia X X X XWeakness X X XSigns/Phenotype
Weight loss X X X X X X X X XBody mass index X X X X X X XLean/fat free/muscle mass X X X X X X XFat mass X X XFluid retention/ascites X XMuscle function; e.g. grip
strengthX X X
Biochemistry X X
Selected criteria by GLIM working group ballot
NRS-2002
MNA-SF
MUST ESPEN2015
ASPEN/ AND 2012
SGA Evans2008
PEW2008
Fearon2011
Etiologies
Reduced food intake X X X X X X X X
Disease burden/ inflammation
X X X X X X X X X
Signs/Phenotype
Weight loss X X X X X X X X X
Body mass index X X X X X X X
Lean/fat free/muscle mass
X X X X X X X
Consensus phenotypic and etiologic criteria cut-offs for the diagnosis of malnutrition
Phenotypic Criteria Etiologic Criteria
Weight loss (%)
Low body mass index (kg/m2)
Reduced muscle mass
Reduced food intake or assimilation
Inflammation
>5% within past 6 months, or>10% beyond 6 months
<20 if <70 years, or<22 if >70 years
Reduced by validated body composition measuring techniqueSupportive measure: muscle strength
≤50% of energy requirements >1 week, or any reduction for >2 weeks, or any chronic GI condition that adversely impacts food assimilation or absorptionSupportive indicators: gastrointestinal symptoms
Acute disease/ injuryor chronic disease-relatedSupportive proxy measures: CRP, albumin, pre-albumin
Asia:<18.5 if <70 years, or<20 if >70 years
Thresholds for severity grading of malnutrition into Stage 1 (moderate) and Stage 2 (severe) malnutrition
Phenotypic Criteria
Weight loss (%) Low body mass index (kg/m2)
Reduced muscle mass
Stage 1Moderate Malnutrition(Requires 1 phenotypic criterion that meets this grade)
5-10% within the past 6 months, or 10-20% beyond
6 months
<20 if <70 years, <22 if ≥70 years
Mild to moderate deficit (per validated
assessment method)
Stage 2Severe Malnutrition(Requires 1 phenotypic criterion that meets this grade)
>10% within the past 6 months, or
>20% beyond 6 months
<18.5 if <70 years,
<20 if ≥70 years
Severe deficit (per validated assessment
method)
At risk for malnutrition• Use validated screening tools
Assessment criteria• Phenotypic
- Non-volitional weight loss- Low body mass index- Reduced muscle mass
• Etiologic- Reduced food intake or assimilation- Disease burden/inflammatory condition
Meets criteria for malnutrition diagnosis• Requires at least 1 Phenotypic criterion and
1 Etiologic criterion
Determine severity of malnutrition • Severity determined based on Phenotypic
criterion
GLIM diagnostic scheme for screening, assessment, diagnosis and grading of malnutrition
Risk screening
DiagnosticAssessment
Diagnosis
SeverityGrading
Conclusion
• A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed
• Next steps are:- to secure further collaboration and endorsements from leading nutrition professional societies, to identifyoverlaps with syndromes like cachexia and sarcopenia
- WHO à ICD-11- to promote dissemination, validation studies, and feedback
• The diagnostic construct should be re-consideredevery 3-5 years
Free access to consensus paper
https://doi.org/10.1016/j.clnu.2018.08002
https://doi.org/10.1002/jpen.1440
Discussion
• What is the predictive validity of these criteria?• How do these criteria distinguish between the
subtypes of malnutrition?• How to implement these criteria?• Opportunity for dietitians?!
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