Utilization and validation of the Global Leadership Initiative on Malnutrition (GLIM): A scoping review

Hidden malnutrition in obesity and knee osteoarthritis: Assessment, overlap with sarcopenic obesity and health outcomes

BACKGROUND & AIMS

Malnutrition may be a hidden but relevant health condition in individuals with obesity and osteoarthritis. The Global Leadership Initiative on Malnutrition (GLIM) consensus includes muscle mass as one of the key phenotypic criteria, potentially enhancing its ability to detect malnutrition in individuals with obesity. We comprehensively profiled the nutritional status of individuals with obesity and advanced knee osteoarthritis and explored associations with health outcomes.

METHODS

Data from the Prevention Of MusclE Loss in Osteoarthritis (POMELO) study was used, which included individuals with knee osteoarthritis and BMI≥35 kg/m2. Nutritional status was evaluated using the GLIM and sarcopenic obesity (SO) criteria. Low muscle mass (dual-energy x-ray absorptiometry), inflammation (C-reactive protein [CRP]), low muscle strength (handgrip/BMI), objective physical function (chair-stand test, 6-min walk test), and self-reported measures (quality of life, arthritis symptoms, and self-efficacy) were evaluated. Linear regressions were performed between GLIM-malnutrition and health outcomes, adjusted by age.

RESULTS

Forty-six individuals (73.9% female, age 64.2 ± 6.7 years, BMI 42.4 ± 4.7 kg/m2) were included. Regarding nutritional status, 26.1% were classified with malnutrition (i.e., defined by the combination of low muscle mass and elevated CRP concentration), 26.1% with SO, and 13% shared both conditions. Individuals with malnutrition presented with worse self-reported physical function (WOMAC function: 38.0 ± 6.6 vs. 32.0 ± 12.5, p = 0.04) and lower arthritis self-efficacy ('other symptoms' component: 5.1 ± 1.9 vs. 6.3 ± 1.7, p = 0.04) compared to those without malnutrition. A trend was identified for lower quality of life (visual analog scale 46.8 ± 12.3 vs. 58.3 ± 20.5, p = 0.06) in those with malnutrition. Poor lipid control (R2 = 0.15, β = 0.76, 95% CI 0.08-1.44, p = 0.030), body fat (R2 = 0.14, β = 5.56, 95% CI 1.01-10.11, p = 0.018), and poor arthritis self-efficacy (R2 = 0.09, β = -1.23, 95% CI -2.39-0.06, p = 0.040) were also associated with malnutrition.

CONCLUSIONS

Participants presented with high malnutrition rates (1 out of 4), and half of them also had SO. Malnutrition was associated with abnormal metabolic parameters, lower arthritis self-efficacy, and worse self-reported physical function. An early nutritional assessment and intervention may be imperative for individuals with osteoarthritis and obesity to mitigate health consequences.

Association between GLIM diagnosed malnutrition and 18-month mortality in hospitalized adults with congestive heart failure: A prospective cohort study

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) criteria have been validated in various clinical settings since 2018, but prospective validation in patients with congestive heart failure (CHF) who are hospitalized remains limited. This study compares the prognostic performance of the GLIM criteria and Mini-Nutritional Assessment (MNA)-defined malnutrition for all-cause mortality in CHF patients and explores the strongest predictive indicator within the GLIM criteria.

METHODS

This single-center prospective cohort study included inpatients with CHF. Agreement between the GLIM criteria and MNA was assessed using Cohen κ coefficient. Survival data were analyzed using Kaplan-Meier curves and adjusted Cox regression analyses.

RESULTS

Among 498 CHF inpatients, 84 (16.9%) died during the 18-month follow-up. Malnutrition prevalence was 47.2% and 50.4% based on the GLIM criteria and MNA, respectively (κ = 0.68; P < 0.001). Malnutrition was independently associated with a higher risk of all-cause mortality (GLIM criteria: hazard ratio, 2.16 [95% confidence interval (CI), 1.13-4.13]; MNA: hazard ratio, 4.28 [95% CI, 1.98-9.22]). Low body mass index was the strongest predictor of all-cause mortality in multivariable analysis (hazard ratio, 5.14; 95% CI, 3.19-8.27).

CONCLUSION

The GLIM criteria showed strong consistency with MNA and effectively predicted all-cause mortality in CHF patients within 18 months.

Criterion validity of the Global Leadership Initiative on Malnutrition criteria for malnutrition diagnosis compared with the Subjective Global Assessment: Results from a large observational study

AIM

The aim of this study was to assess the criterion validity of the Global Leadership Initiative on Malnutrition criteria compared to the subjective global assessment in a diverse inpatient population.

METHODS

This cross-sectional study was a retrospective analysis of point prevalence audit data. The prevalence of malnutrition determined by the Global Leadership Initiative on Malnutrition criteria was compared to the Subjective Global Assessment. Validity statistics were determined using all of the Global Leadership Initiative on Malnutrition criteria concurrently as well as each pair that could be used to diagnose malnutrition. Subgroup analysis was undertaken based on severe malnutrition, treatment group, age and body mass index.

RESULTS

Nine hundred and eighty-one patients were included (65.1 ± 18.6 years, 54.8% male). The prevalence of malnutrition was 36.7% using the Subjective Global Assessment and 36.1% using the Global Leadership Initiative on Malnutrition criteria. More patients were classified as severely malnourished using the Global Leadership Initiative on Malnutrition criteria (9.8% vs. 6.0%), whilst more rehabilitation patients were classified as malnourished using the Subjective Global Assessment (42.2% vs. 33.6%). The criterion validity of the Global Leadership Initiative on Malnutrition criteria was good, with a sensitivity of 92.5% (95% CI 90.9-94.2) and specificity of 96.6% (95% CI 95.5-97.8). There was a downward trend in sensitivity with increasing body mass index and a lower sensitivity in the rehabilitation population. The criterion validity was fair at best when each pair of the Global Leadership Initiative on Malnutrition criteria was considered independently of other criteria.

CONCLUSIONS

When all criteria are considered concurrently, the Global Leadership Initiative on Malnutrition criteria present good criterion validity and can be applied in clinical practice to diagnose malnutrition.

Gastroparesis and its Nutritional Implications

PURPOSE OF REVIEW

To present and discuss recent and previous literature on the nutritional implications and management of gastroparesis. We also briefly review its epidemiology, pathophysiology, and clinical manifestations.

RECENT FINDINGS

- Low viscosity soluble fibers are well-tolerated in patients with mild to moderate gastroparesis symptoms and can thus be used to supplement the diets of these patients. - High-fat liquid meals are reasonably well-tolerated in patients with gastroparesis and can be used to supplement diet as tolerated. - The risk of tardive dyskinesia (TD) with long-term use of metoclopramide is much lower than previously thought. The nutritional status of patients with gastroparesis ranges across a wide spectrum, depending on the severity of their disease. Some patients improve simply with dietary modifications, others respond well to medical therapy, and those with severe, drug-refractory disease often require enteral nutrition or TPN (total parenteral nutrition). Generally, the recommended diet is composed of small particles, low fat, and low fiber; however recent studies showed that low viscosity soluble fibers and high-fat liquid fats can be tolerated. Metoclopramide is the first prokinetic agent of choice, and while the risk of TD is lower than previously thought, long-term use should be avoided in certain patient populations. For those on enteral nutrition, the choice of formula should be based on osmolarity, fat content, and fiber content, in accordance with the patient's tolerance.

Initial calf circumference predicts poor disability outcomes in patients with stroke

BACKGROUND

Calf circumference (CC), which is easy to measure and noninvasive, may be a predictor of functional outcome in patients with acute stroke. However, the association between CC and long-term functional outcome is unclear. The purpose of this study was to investigate whether low CC is associated with functional outcome at 12 months post-stroke.

METHODS

This multicenter retrospective cohort study included patients with acute stroke. Low CC was defined as less than 30 cm for men and 29 cm for women. Poor functional outcome was defined as a modified Rankin Scale (mRS) score of greater than 3 (i.e., 3-6) and the inability to return pre-stroke mRS score at 12 months post-stroke. Multivariate logistic regression analysis was performed with low CC as the independent variable and outcome as the dependent variable.

RESULTS

This study included 445 patients (median age 75 years, 277 men). The prevalence of low CC was 26.7%. Multiple logistic regression analysis showed that low CC was significantly associated with poor functional outcome (OR = 3.036, 95% CI: 1.700-5.422, p < 0.001).

CONCLUSIONS

Low CC at admission in patients with acute stroke is associated with poor functional outcome at 12 months post-stroke. CC, which is easily measured in the acute setting, may serve as a predictor of poor outcomes. Future multicenter prospective interventional studies are needed to clarify the causal relationship between CC and functional outcome.

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.

The association between sarcopenic obesity and malnutrition in community-dwelling older adults

BACKGROUND

The increase in fat tissue and the decrease in muscle mass with advancing age have prompted researchers to explore the coexistence of sarcopenia and obesity, i.e. sarcopenic obesity (SO). SO may lead to malnutrition due to poor diet quality, while malnutrition may contribute to SO by causing further muscle loss and metabolic imbalances.

OBJECTIVES

The aims were to investigate: (i) the prevalence of SO in community-dwelling older adults, (ii) the diagnostic ability of two different malnutrition methods, and (iii) the association between SO and malnutrition.

METHODS

Community-dwelling older adults (≥65 years) were invited to participate. SO assessment was conducted based on the ESPEN/EASO consensus criteria. Malnutrition was evaluated based on both the Global Leadership Initiative on Malnutrition (GLIM) criteria and the Mini-Nutritional Assessment (MNA).

RESULTS

Five hundred and ninety older adults (69.3% women, mean age: 74.31 ± 6.55 years) were included in the study. The overall prevalence of SO was 5.9% (n = 35). The prevalence of malnutrition was 23.9% according to the GLIM criteria, while it was 3.1% according to MNA. The agreement between the two measurements was ĸ = 0.32. There was no association between SO and malnutrition based on either GLIM (P: .06, OR: 1.971, 95% CI: 0.966-4.024) or MNA (P: .948, OR: 1.934, 95% CI: 0.119-7.306).

CONCLUSIONS

Even though the agreement for diagnosing malnutrition between GLIM criteria and MNA was fair, the number of participants diagnosed with malnutrition by GLIM criteria was almost eight times higher than MNA. No association was established between SO and malnutrition defined by GLIM or MNA.

CLINICAL TRIAL NUMBER

NCT05122104.

Malnutrition is associated with clinical outcomes in mechanically ventilated patients with pneumonia and other lung manifestations: A retrospective cohort

BACKGROUND

Malnutrition is a highly prevalent condition in patients who are critically ill that has been previously associated with adverse clinical outcomes. The aims of this study are to describe the prevalence of malnutrition using Global Leadership Initiative on Malnutrition (GLIM) criteria and analyze the associations with clinical outcomes using original criteria or the presence of one phenotypic criterion with inflammation measured by C-reactive protein (CRP) in patients with pneumonia and other lung manifestations who are mechanically ventilated.

METHODS

This retrospective cohort study included patients who are critically ill. Malnutrition was classified using the original GLIM criteria (reduced muscle mass and the assumption of present inflammation because of critical illness) and one phenotypic criterion with severe inflammation (CRP >5 mg/dl). Associations between both groups with clinical outcomes (duration of invasive mechanical ventilation [IMV], length of stay [LOS] on ICU, hospital LOS, ICU mortality, and prolonged ICU LOS) were assessed.

RESULTS

Two hundred and thirty-four patients who were critically ill were included. The prevalence of malnutrition in the established methods GLIM and phenotypic criterion with severe inflammation was 38.4% and 27.7%, respectively. Patients who survived and were diagnosed with malnutrition using inflammation criterion at baseline had longer hospital LOS (31 vs 25 days, P = 0.04). After adjusting for age, clinical diagnosis at admission, and SOFA and APACHE II scores, phenotypic criterion with severe inflammation was associated with duration of IMV (β: 5.7; 95% confidence interval: 0.7-10.7; P = 0.02) and ICU LOS (β: 6.1; 95% CI: 0.8-11.5; P = 0.02).

CONCLUSIONS

Malnutrition considering a phenotypic criterion and CRP >5 mg/dl upon ICU admission was associated with duration of IMV and ICU LOS.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Latin American Study on parenteral and enteral nutritional therapy-ELANPE Study ELANPE Group

OBJECTIVE

We describe the status of medical nutrition therapy in adult patients in several hospitals in Latin America in 2023. with the aim of deepening understanding of its implementation and thus, in turn, contributing to the advancement of future guidelines.

MATERIALS AND METHODS

This is a descriptive, multicenter, cross-sectional study. An electronic questionnaire was applied, containing screening, nutritional therapy, multidisciplinary nutritional support, and monitoring indicators. Descriptive statistics were used in data processing.

RESULTS

A total of 132 hospitals from 14 Latin American countries participated; 68.2% were state-owned with a median of 23,804 patients. In 66% of hospitals (n = 87) nutritional screening is systematically implemented; NRS-2002 (n = 66; 75.9%) applied mostly by dietitians. Median malnutrition at admission was 33% (IQR = 30.8). Median indication for diet therapy was 54.4% (IQR = 44.3); oral supplementation 13.6% (IQR = 18), and enteral and parenteral nutritional support 14.6% (IQR = 10.2). Indication is carried out mostly by dietitians (n = 78; 59.1%). 29.5% (n = 39) of hospitals count on multidisciplinary nutritional support. 75% (n = 99) use industrialized formulas, mostly in closed systems (n = 53; 40.2%). For parenteral nutrition, individually compounded and preprepared solutions are used (n = 71; 53.8%) generally administered by central catheters. Most frequently cited monitoring indicators were hemodynamic instability, metabolic complications, abdominal distension, and gastric residue.

CONCLUSION

There are still low implementation percentages of nutritional screening, formation of nutritional therapy teams, and use of oral supplements. Malnutrition upon admission is within the expected range.

Muscle Biomarkers in Colorectal Cancer Outpatients: Agreement Between Computed Tomography, Bioelectrical Impedance Analysis, and Nutritional Ultrasound

BACKGROUND

Muscle quality and mass in cancer patients have prognostic and diagnostic importance.

OBJECTIVES

The objectives are to analyze agreement between gold-standard and bedside techniques for morphofunctional assessment.

METHODS

This cross-sectional study included 156 consecutive colorectal cancer outpatients that underwent computed tomography (CT) scanning at lumbar level 3 (L3), whole-body bioelectrical impedance analysis (BIA), point-of-care nutritional ultrasound® (US), anthropometry, and handgrip strength in the same day. Measured muscle biomarkers were stratified by sex, age, BMI-defined obesity, and malnutrition using Global Leadership in Malnutrition (GLIM) criteria. Whole-body estimations for muscle mass (MM) and fat-free mass were calculated using two different equations in CT (i.e., Shen, and Mourtzakis) and four different equations for BIA (i.e., Janssen, Talluri, Kanellakis, and Kotler). Muscle cross-sectional area at L3 was estimated using the USVALID equation in US. Different cut-off points for muscle atrophy and myosteatosis were applied. Sarcopenia was defined as muscle atrophy plus dynapenia. Intra-technique and inter-technique agreement were analyzed with Pearson, Lin (ρ), and Cohen (k) coefficients, Bland-Altman analyses, and hypothesis tests for measures of central tendency.

RESULTS

Intra-technique agreements on muscular atrophy (CT k = 0.134, BIA k = -0.037, US k = 0.127) and myosteatosis (CT k = 0.122) were low, but intra-technique agreement on sarcopenia in CT was fair (k = 0.394). Inter-technique agreement on muscular atrophy and sarcopenia were low. Neither CT and BIA (ρ = 0.468 to 0.772 depending on equation), nor CT and US (ρ = 0.642), were interchangeable. Amongst the BIA equations, MM by Janssen proved the best, with a 1.5 (3.6) kg bias, (-5.6, 8.6) kg LoA, and 9/156 (5.7%) measurements outside the LoA. Muscle biomarkers in all techniques were worse in aged, female, or malnourished participants. Obesity was associated with higher muscle mass or surface biomarkers in all techniques.

CONCLUSIONS

Bedside techniques adequately detected patterns in skeletal muscle biomarkers, but lacked agreement with a reference technique in the study sample using the current methodology.

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.

Two-step GLIM approach using NRS-2002 screening tool vs direct GLIM criteria application in hospital malnutrition diagnosis: A cross-sectional study

BACKGROUND

The two-step Global Leadership Initiative on Malnutrition (GLIM) approach was recently introduced to malnutrition diagnosis in a hospital setting. This study compares the diagnostic performance of this approach that uses the Nutritional Risk Screening-2002 (NRS-2002) as a screening tool and the direct application of GLIM malnutrition diagnostic criteria in hospitalized patients.

METHODS

This cross-sectional study involved 290 adult and older adult patients who were hospitalized. A trained nutritionist implemented the two-step GLIM approach, including NRS-2002 (in the first step) and GLIM criteria (in the second step) for each patient. Then, the accuracy, kappa index, area under the receiver operating characteristic curve (AUC ROC), sensitivity, and specificity of malnutrition diagnostic performance of the two-step GLIM approach and NRS-2002 were evaluated compared to the direct use of GLIM criteria.

RESULTS

The NRS-2002 identified 145 (50.0%) patients as at risk of malnutrition. The prevalence of malnutrition using the two-step GLIM approach and GLIM malnutrition diagnosis criteria were 120 (41.4%) and 141 (48.6%), respectively. The kappa index showed substantial and almost perfect agreement for NRS-2002 (κ = 68%) and the two-step GLIM approach (κ = 85%) with GLIM malnutrition diagnostic criteria, respectively. Furthermore, the AUC ROC (0.926; 95% confidence interval (CI): 0.89-0.96) and accuracy (92.8%) of the two-step GLIM approach compared to the GLIM criteria indicated an acepptable ability to distinguish between malnourished and well-nourished patients.

CONCLUSION

The two-step GLIM approach using NRS-2002 as a screening tool (in step one) had acceptable malnutrition diagnostic performance compared to the direct application of GLIM criteria in hospitalized patients.

Prospective validation of the Global Leadership Initiative on Malnutrition criteria for identifying malnutrition in hospitals: A protocol and feasibility pilot study

BACKGROUND

The aim of this study was to pilot a protocol for prospective validation of the Global Leadership Initiative on Malnutrition (GLIM) criteria in hospital patients and evaluate its feasibility and patient acceptability.

METHODS

The validation protocol follows the GLIM consortium's rigorous methodological guidance. Protocol feasibility was assessed against criteria on recruitment (≥50%) and data collection completion (≥80%); protocol acceptability was assessed via patient satisfaction surveys and interviews. Adult inpatients in a tertiary hospital underwent four nutrition assessments (each by a different assessor); two Subjective Global Assessments (SGAs) and two GLIM assessments. All five GLIM criteria were assessed with bioelectrical impedance analysis used for muscle mass. Interrater reliability, criterion validity, and predictive validity were reported to detect trends.

RESULTS

All primary feasibility criteria were met (consent rate 76%; data for GLIM criterion validity collected on 83% participants). Of predictive outcome data, 100% of hospital-related data, 82% of 6-month mortality data, and 39% of 6-month health-related quality of life data were collected. The mean (SD) age of participants was 61.0 ± 16.2 years, and 51.5% were male. The median (interquartile range) length of stay and body mass index were 7 (4-15) days and 25.6 (24.2-33.0) kg/m2, respectively. GLIM criteria diagnosed 70% of the patients as malnourished vs 55% with SGA. Most patients found the data collection acceptable with minimal burden.

CONCLUSION

The methods outlined in this rigorous GLIM validation protocol are feasible to undertake in hospitals and acceptable to patients. This paper provides practical methodological guidance for future prospective GLIM validation studies.

Global Leadership Initiative on Malnutrition criteria using calf and upper arm circumference as phenotypic criteria for assessing muscle mass demonstrate satisfactory validity for diagnosing malnutrition in hospitalized patients: A prospective cohort study

BACKGROUND

Hospitalized individuals present high rates of malnutrition and loss of muscle mass (MM). Imaging techniques for assessing MM are expensive and scarcely available in hospital practice. The Global Leadership Initiative on Malnutrition (GLIM) proposed a framework for malnutrition diagnosis that includes simple measurements to assess MM, such as calf circumference (CC) and mid-upper arm circumference (MUAC). This study aimed to analyze the validity of the GLIM criteria with CC and MUAC for malnutrition diagnosis, using Subjective Global Assessment (SGA) as the reference standard, in inpatients.

METHODS

A prospective cohort study was conducted on 453 inpatient adults in a university hospital. The presence of malnutrition was assessed within 48 h of hospital admission using SGA and GLIM criteria using CC and MUAC as phenotypic criteria for malnutrition diagnosis. Accuracy, agreement tests, and logistic regression analysis adjusted for confounders were performed to test the validity of the GLIM criteria for malnutrition diagnosis.

RESULTS

The patients were aged 59 (46-68) years, 51.4% were male, and 67.8% had elective surgery. Compared with SGA, the GLIM criteria using the two MM assessment measures showed good accuracy (area under the curve > 0.80) and substantial agreement (κ > 0.60) for diagnosing malnutrition. The highest sensitivity was obtained with GLIMCC (89%), whereas GLIMMUAC showed high specificity (>90%). Also, malnutrition identified by GLIMCC and GLIMMUAC was significantly associated with prolonged hospitalization and in-hospital death.

CONCLUSION

In the absence of imaging techniques to assess MM, the use of CC and MUAC measurements from the GLIM criteria demonstrated satisfactory validity for diagnosing malnutrition in hospitalized patients.

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Development and validation of a novel prognostic prediction system based on GLIM-defined malnutrition for colorectal cancer patients post-radical surgery

Background

Malnutrition often occurs in patients with colorectal cancer. This study aims to develop a predictive model based on GLIM criteria for patients with colorectal cancer who underwent radical surgery.

Methods

From December 2015 to May 2021, patients with colorectal cancer who underwent radical surgery at our center were recruited for this study. We prospectively collected data on GLIM-defined malnutrition and other clinicopathological characteristics. Using Cox regeneration, we developed a novel nomogram for prognostic prediction, which was validated and compared to traditional nutritional factors for predictive accuracy.

Results

Among the 983 patients enrolled in this study, malnutrition was identified in 233 (23.70%) patients. Multivariate analysis indicated that GLIM-defined malnutrition is the independent risk factor for overall survival (HR = 1.793, 95% CI = 1.390-2.313 for moderate malnutrition and HR = 3.485, 95% CI = 2.087-5.818 for severe malnutrition). The novel nomogram based on the GLIM criteria demonstrated a better performance than existing criteria, with AUC of 0.729, 0.703, and 0.683 for 1-year, 3-year, and 5-year OS, respectively, in the validation cohort. In addition, the risk score determined by this system exhibited significantly poorer short-term and long-term clinical outcomes in high-risk groups in both malnourished and well-nourished patients.

Conclusion

Combining handgrip strength, serum albumin level, and TNM stage would help improve the predictive effect of GLIM criteria for colorectal cancer patients post-radical surgery and benefit the individual prognostic prediction of colorectal cancer.

Prevalence and related assessment practices of adult hospital malnutrition in Africa: A scoping review

BACKGROUND AND AIMS

Globally, hospital malnutrition prevalence is estimated at 20-50%, with little known about the situation in African hospitals. The aim of this scoping review was to appraise the current evidence base regarding the prevalence of adult hospital malnutrition and related assessment practices in an African context.

METHODS

A comprehensive and exhaustive search strategy was undertaken to search seven electronic bibliographic databases (including Africa-specific databases) from inception until August 2022 for articles/resources reporting on the prevalence of adult hospital malnutrition in an African setting. Two reviewers independently reviewed abstracts and full-text articles and data extraction was undertaken in duplicate.

RESULTS

We screened the titles and abstracts of 7537 records and included 28 studies. Most of the included studies were conducted in the East African region (n = 12), with ten studies from South Africa. Most studies were single-centre studies (n = 22; 79%), including 23 to 2126 participants across all studies. A variety of study populations were investigated with most described as medical and surgical populations (n = 14; 50%). Malnutrition risk prevalence was reported to be between 23% and 74%, using a variety of nutritional screening tools (including MNA-SF/LF, NRS-2002, MUST, NRI, GNRI). Malnutrition prevalence was reported to be between 8% and 85%, using a variety of tools and parameters, including ASPEN and ESPEN guidelines, SGA, MNA-SF/LF, anthropometric and biochemical indices, with one study using the GLIM criteria to diagnose malnutrition.

CONCLUSIONS

Both malnutrition risk and malnutrition prevalence are alarmingly high in African adult hospitalised patients. The prevalence of malnutrition differs significantly among studies, owing in part to the variety of tools used and variability in cut-offs for measurements, underscoring the importance of adopting a standardised approach. Realities in the African context include limited nutritional screening and assessment, poor referral practices, and a unique disease burden. General awareness is needed, and routine nutritional screening practices with appropriate nutrition support action should be implemented as a matter of urgency in African hospitals.

Advancements in nutritional diagnosis and support strategies during the perioperative period for patients with liver cancer

Liver cancer represents a grave hepatic condition and constitutes a significant global health concern. Surgical resection remains the principal therapeutic modality for liver cancer. Nevertheless, perioperative malnutrition exerts a notable impact on patients with liver cancer, emerging as an independent risk factor for disease mortality and adverse outcomes. Hence, precise nutritional diagnosis and timely nutritional support hold the potential to enhance therapeutic efficacy and quality of life for liver cancer patients. This study represents a meticulous foray into the literature, extracting data from PubMed, Web of Science, and EMBASE databases, with a focus on the past 5 years. It scrutinizes the impact of malnutrition on patients undergoing liver cancer surgery, the etiological underpinnings of malnutrition within this patient cohort, the critical assessment of perioperative nutritional status, and the strategic approaches to nutritional support. Utilizing rigorous inclusion and exclusion criteria, the amassed scholarly works are meticulously synthesized, methodically organized, and categorically elaborated upon. Ultimately, the authors propose the incorporation of a multidisciplinary nutrition management team during the perioperative period, comprising nutritionists, pharmacists, physicians, nurses, psychologists, and rehabilitation therapists, among other specialized professionals. Together, they collaborate to devise and implement personalized nutritional support plans, monitor patients' nutritional status, and make necessary adjustments as required. Through comprehensive management and intervention, improvements in the nutritional status of liver cancer patients can be achieved, thereby enhancing surgical success rates and facilitating postoperative recovery. It is believed that this manuscript will offer valuable insights to advance the nutritional management during the perioperative phase of liver cancer, aiding in ameliorating patients' nutritional status and treatment outcomes.

Global, regional and national burdens of nutritional deficiencies, from 1990 to 2019

The epidemiological and burden characteristics of nutritional deficiencies (ND) have been evolving, and it is crucial to identify geographical disparities and emerging trends. This study aimed to analyse the global, regional and national trends in the burden of ND over the past 30 years. Data were obtained from the Global Burden of Disease (GBD) 2019 database for the period 1990-2019. The study examined the incidence rates and disability-adjusted life years (DALY) of ND at various levels. Globally, the incidence rate of ND decreased from 2226·2 per 100 000 in 2019 to 2096·3 per 100 000 in the same year, indicating a decline of 5·8 %. The average annual percentage change (AAPC) was -0·21 (-0·31, -0·11). Similarly, DALY, prevalence and mortality rates of ND exhibited significant declines (AAPC = -3·21 (-3·45, -2·96), AAPC = -0·53 (-0·55, -0·51) and AAPC = -4·97 (-5·75, -4·19), respectively). The incidence rate of ND varied based on age group, sex, cause and geographical area. Moreover, a negative association was observed between incidence and the sociodemographic index. At the regional level, the South Asia and sub-Saharan Africa regions had the highest incidence rates of ND. In conclusion, the global incidence rate of ND showed a mixed pattern, while the DALY rate consistently declined. Additionally, prevalence and mortality rates of ND decreased between 1990 and 2019.

Albumin-dNLR score could be an etiological criterion to determine inflammation burden for GLIM in medical inpatients over 70 years old: A multicenter retrospective study

Aim

To validate the role of the albumin-derived neutrophil-to-lymphocyte (ALB-dNLR) score in diagnosing malnutrition in medical inpatients over 70 years old.

Methods

This is a retrospective cross-sectional study involving 7 departments from 14 Chinese hospitals. The ALB-dNLR score was calculated, and outcomes between groups with positive and negative ALB-dNLR scores were compared after propensity score matching (PSM). Afterwards, the outcomes were compared between the groups receiving nutrition support and those not receiving support among malnourished patients diagnosed using the Global Leadership Initiative Malnutrition (GLIM) criteria after PSM.

Results

Out of 10,184 cases, 6165 were eligible. 2200 cases were in the positive ALB-dNLR score group. After PSM, 1458 pairs were analyzed, showing lower in-hospital mortality (0.8 % vs. 2.1 %, p = 0.005) and a lower nosocomial infection rate (5.9 % vs. 11.0 %, p < 0.001) in the negative ALB-dNLR score group. In malnourished patients, 259 pairs were analyzed after PSM. It showed better outcomes in mortality (0.8 % vs. 3.5 %, p = 0.033), nosocomial infection rate (5.4 % vs. 15.4 %, p < 0.001), length of stay (LOS) (13.8 ± 10.3 vs. 18.4 ± 14.1, p < 0.001), and total hospital cost (3315.3 ± 2946.4 vs. 4795.3 ± 4198.2, p < 0.001) in the support group. In malnourished patients with ALB-dNLR score as the sole etiological criterion, 94 pairs were calculated. It showed better outcomes in mortality (0.0 % vs. 6.4 %, p = 0.029), nosocomial infection rate (7.4 % vs. 18.1 %, p = 0.029), LOS (13.7 ± 8.3 vs. 19.8 ± 15.2, p = 0.001), and total hospital cost (3379.3 ± 2955.6 vs. 4471.2 ± 4782.4, p = 0.029) in the support group.

Conclusions

The ALB-dNLR score was validated to predict in-hospital mortality in medical inpatients over 70 years old. Malnutrition patients diagnosed by the GLIM criteria and using the ALB-dNLR score might benefit from nutrition support.

A Cross-Sectional Validation Study of Camry EH101 versus JAMAR Plus Handheld Dynamometers in Colorectal Cancer Patients and Their Correlations with Bioelectrical Impedance and Nutritional Status

BACKGROUND

Reduced muscle strength (dynapenia) and mass (atrophy) are prognostic factors in oncology. Measuring maximal handgrip strength with dynamometers is feasible but limited by the cost of the reference device (JAMAR).

METHODS

A cross-sectional study was conducted on colorectal cancer outpatients treated with chemotherapy or under active surveillance in our center from September 2022 to July 2023. Accuracy, reliability, and concordance were compared for two handheld dynamometers: the JAMAR Plus (the gold-standard device) and the Camry EH101 (a low-cost index device). A simultaneous nutritional diagnosis with GLIM criteria and bioelectrical impedance analysis (BIA) was carried out.

RESULTS

A total of 134 participants were included. The median of maximal strength for the JAMAR Plus had a non-significant difference of 1.4 kg from the Camry EH101. The accuracy and reliability of the devices were high. Bland-Altman analysis showed a 0.8 kg bias and -4.1 to 5.6 kg limits of agreement (LoA); a 0.1 kg bias and -5.3 to 5.4 kg LoA in men; a 1.5 kg bias and -2.2 to 5.3 kg LoA in women. In total, 29.85% of the participants were malnourished. Prevalence of dynapenia increased from 3.67% with the JAMAR Plus to 5.14% with the Camry EH101. Both devices had a moderate and significant correlation with BIA-estimated muscle mass.

CONCLUSIONS

The Camry EH101 was a cost-effective alternative to JAMAR Plus in our sample.

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.

Prevalence of nutritional risk and malnutrition in hospitalized patients: a retrospective, cross-sectional study of single-day screening

Hospital malnutrition remains a significant public health issue, particularly in developing countries. The Global Leadership Initiative on Malnutrition (GLIM) proposed homogenizing criteria to standardize malnutrition diagnosis. This study aimed to retrospectively determine the prevalence of nutritional risk and malnutrition diagnoses among hospitalized patients using the Nutritional Risk Screening (NRS)-2002 screening instrument and the GLIM criteria, respectively. We conducted a retrospective, cross-sectional study from nutritional records of patients hospitalized in a single centre 2021. Nutrition data from records included medical diagnosis, gender, length of stay, age, weight, height, body mass index, weight loss, calf circumference, and middle upper arm circumference. Nutritional risk and malnutrition were evaluated using NRS-2002 and GLIM criteria. Its concordance was further evaluated by using a Kappa test. The study included 616 records of patients; 52.3% (n = 322) of the population were male. The prevalence of nutritional risk, according to NRS-2002, was 69.5% (n = 428). Nutritional risk as well as malnutrition diagnosis according to GLIM criteria was observed in 87.8% (n = 374) of patienttritional risk and malnutrition were evaluated using NRS-2002 and GLIM criteria. Its concordance was further evaluated by using a Kappa test. Ws. Tools showed a strong concordance (κ= 0.732). All anthropometric data, except for height, were found to be significantly different between patients with moderate and severe malnutrition (p < 0.05). Our findings highlight a high prevalence of malnutrition in this group of hospitalized patients in Mexico. NRS-2002 demonstrated good agreement with the diagnosis of malnutrition according to GLIM criteria and could be considered part of the straightforward two-step approach for malnutrition; however, further studies are needed.

Malnutrition and cachexia may affect death but not functional improvement in patients with sarcopenic dysphagia

PURPOSE

To investigate whether two factors, malnutrition and cachexia, affect swallowing function, activities of daily living (ADL), and death in sarcopenic dysphagia.

METHODS

Of 467 patients enrolled in the Japanese Sarcopenic Dysphagia Database, 271 met the study eligibility criteria in a retrospective cohort study. Patients were divided into four groups based on whether they had cachexia according to the Asian Working Group for Cachexia (AWGC) criteria and malnutrition according to the Global Leadership Initiative on Malnutrition (GLIM) criteria. Multivariate analyses were performed to investigate the differences in changes in the Food Intake LEVEL Scale (FILS) and Barthel Index (BI) and death after follow-up between the malnutrition and cachexia group and the other groups.

RESULTS

The mean age was 83.7 ± 8.3 years, 119 (44%) were men and 152 (56%) were women. The median FILS at baseline was 7 and the median BI was 25. A total of 120 (44%) had malnutrition only, 54 (20%) had neither cachexia nor malnutrition, 12 (4%) had cachexia only, and 85 (31%) had both cachexia and malnutrition. Multivariate analyses showed no significant difference between the change in BI (P = 0.688) and the change in FILS (P = 0.928) between the malnutrition and cachexia group and the other groups; however, death increased significantly (P = 0.010).

CONCLUSION

Some patients diagnosed with cachexia were not malnourished, although many patients with cachexia were malnourished. While patients with both cachexia and malnutrition did not show significant improvement in ADL and swallowing function compared with patients without both conditions, the number of deaths increased significantly.

Re-assessing the role of peri-operative nutritional therapy in patients with pancreatic cancer undergoing surgery: a narrative review

Pancreatic cancer is the most common medical condition that requires pancreatic resection. Over the last three decades, significant improvements have been made in the conditions and procedures related to pancreatic surgery, resulting in mortality rates lower than 5%. However, it is important to note that the morbidity in pancreatic surgery remains r latively high, with a percentage range of 30-60%. Pre-operative malnutrition is considered to be an independent risk factor for post-operative complications in pancreatic surgery, such as impaired wound healing, higher infection rates, prolonged hospital stay, hospital readmission, poor prognosis, and increased morbidity and mortality. Regarding the post-operative period, it is crucial to provide the best possible management of gastrointestinal dysfunction and to handle the consequences of alterations in food digestion and nutrient absorption for those undergoing pancreatic surgery. The European Society for Clinical Nutrition and Metabolism (ESPEN) suggests that early oral feeding should be the preferred way to initiate nourishing surgical patients as it is associated with lower rates of complications. However, there is ongoing debate about the optimal post-operative feeding approach. Several studies have shown that enteral nutrition is associated with a shorter time to recovery, superior clinical outcomes and biomarkers. On the other hand, recent data suggest that nutritional goals are better achieved with parenteral feeding, either exclusively or as a supplement. The current review highlights recommendations from existing evidence, including nutritional screening and assessment and pre/post-operative nutrition support fundamentals to improve patient outcomes. Key areas for improvement and opportunities to enhance guideline implementation are also highlighted.

A Prognostic Model Based on Nutritional Indexes for Patients With Pan-Cancer: A Real-World Cohort Study

BACKGROUND

The aim was to identify the nutritional indexes, construct a prognostic model, and develop a nomogram for predicting individual survival probability in pan-cancers.

METHODS

Nutritional indicators, clinicopathological characteristics, and previous major treatment details of the patients were collected. The enrolled patients were randomly divided into training and validation cohorts. Least absolute shrinkage and selection operator (Lasso) regression cross-validation was used to determine the variables to include in the cox regression model. The training cohort was used to build the prediction model, and the validation cohort was used to further verify the discrimination, calibration, and clinical effectiveness of the model.

RESULTS

A total of 2020 patients were included. The median OS was 56.50 months (95% CI, 50.36-62.65 months). In the training cohort of 1425 patients, through Lasso regression cross-validation, 13 characteristics were included in the model. Cox proportional hazards model was developed and visualized as a nomogram. The C-indexes of the model for predicting 1-, 3-, 5-, and 10-year OS were 0.848, 0.826, 0.814, and 0.799 in the training cohort and 0.851, 0.819, 0.814, and 0.801 in the validation cohort. The model showed great calibration in the two cohorts. Patients with a score of less than 274.29 had a better prognosis (training cohort: HR, 6.932; 95% CI, 5.723-8.397; log-rank p < 0.001; validation cohort: HR, 8.429; 95% CI, 6.180-11.497; log-rank p < 0.001).

CONCLUSION

The prognostic model based on the nutritional indexes of pan-cancer can divide patients into different survival risk groups and performed well in the validation cohort.

Nature of the evidence base and approaches to guide nutrition interventions for individuals: a position paper from the Academy of Nutrition Sciences

This Position Paper from the Academy of Nutrition Sciences is the third in a series which describe the nature of the scientific evidence and frameworks that underpin nutrition recommendations for health. This paper focuses on evidence which guides the application of dietary recommendations for individuals. In some situations, modified nutrient intake becomes essential to prevent deficiency, optimise development and health, or manage symptoms and disease progression. Disease and its treatment can also affect taste, appetite and ability to access and prepare foods, with associated financial impacts. Therefore, the practice of nutrition and dietetics must integrate and apply the sciences of food, nutrition, biology, physiology, behaviour, management, communication and society to achieve and maintain human health. Thus, there is huge complexity in delivering evidence-based nutrition interventions to individuals. This paper examines available frameworks for appraising the quality and certainty of nutrition research evidence, the development nutrition practice guidelines to support evidence implementation in practice and the influence of other sources of nutrition information and misinformation. The paper also considers major challenges in applying research evidence to an individual and suggests consensus recommendations to begin to address these challenges in the future. Our recommendations target three groups; those who deliver nutrition interventions to individuals, those funding, commissioning or undertaking research aimed at delivering evidence-based nutrition practice, and those disseminating nutritional information to individuals.

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.

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.

Challenges in identifying malnutrition in obesity; An overview of the state of the art and directions for future research

(Protein-energy) malnutrition in individuals living with obesity presents complex diagnostic challenges due to the distinctive physiological characteristics of obesity. This narrative review critically examines the identification of malnutrition within the population with obesity, distinguishing malnutrition in obesity from related conditions such as sarcopenic obesity. While noting some shared features, the review highlights key differences between these conditions. The review also highlights the limitations of current malnutrition screening tools, which are not designed for individuals living with obesity. These tools primarily rely on anthropometric measurements, neglecting (among others) nutrient intake assessment, which hinders accurate malnutrition detection. Additionally, this review discusses limitations in existing diagnostic criteria, including the Global Leadership Initiative on Malnutrition (GLIM) criteria, when applied to individuals living with obesity. Challenges include the identification of appropriate cut-off values for phenotypic criteria (unintentional weight loss, low body mass index and muscle mass) and aetiological criteria such as reduced food intake and inflammation for the population with obesity. Overall, this review emphasises the need for modified screening tools and diagnostic criteria to recognise and assess malnutrition in obesity, leading to improved clinical outcomes and overall wellbeing.

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.

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.

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.

Exploring the use of the GLIM criteria to diagnose malnutrition in cancer inpatients

OBJECTIVES

The Global Leadership Initiative on Malnutrition (GLIM) criteria establish a diagnosis of malnutrition based on the presence of at least one phenotypic and one etiologic criterion. This study aimed to assess the concurrent and predictive validity of the GLIM criteria in hospitalized cancer patients.

METHODS

This is an observational retrospective study, including 885 cancer patients, ages >18 y, admitted to a medical oncology inpatient unit between 2019 and 2020. All patients at risk for malnutrition according to the Nutritional Risk Screening 2002 score were assessed by the subjective global assessment (SGA) and 14 different combinations of the GLIM criteria. The SGA was considered the gold standard for assessing the concurrent validity of the GLIM combinations. For a subsample of patients with data available on inflammatory markers (n = 198), the serum albumin and C-reactive protein were included in the combinations as etiologic criteria. The predictive validity of the different combinations was tested using the occurrence of surgical complications as the clinical outcome. The sensitivity and specificity values were calculated to assess the concurrent validity, univariate and multivariate logistic regression models were used to test predictive validity. Adequate concurrent and predictive validity were determined as sensitivity and specificity values >80% and odds ratio values ≥2.0, respectively.

RESULTS

The median age of the patients was 61.0 y (interquartile range = 51.0-70.0). Head and neck cancer was the prevailing diagnosis and 375 patients were at nutritional risk. According to the SGA, 173 (26.1%) patients were malnourished (SGA categories B or C) and the prevalence of malnutrition ranged from 3.9% to 30.0%, according to the GLIM combinations. None of the tested combinations reached adequate concurrent validity; however, the presence of malnutrition according to four combinations independently predicted surgical complications.

CONCLUSIONS

The predictive validity of the GLIM was satisfactory in surgical cancer patients.

Definition of malnutrition from routinely-collected data for orthopedic surgery research: the global leadership initiative on malnutrition (GLIM) tool and others

The correct identification of malnourished patients in the context of hip, knee, or spine surgery research would enhance the quality of analytical studies investigating the prediction potential of preoperative nutritional disorders on postoperative recovery. However, accurate malnutrition screening and diagnostic assessment rely on parameters that were not routinely collected in routine practice until a few years ago. The authors of this article present substitute literature-based equations that can be built up using historical routinely collected data to classify patients that had been at risk of malnutrition or malnourished. For what concerns the risk screening, several methods are available to identify patients at risk of over- or undernutrition, encompassing the BWd (body weight difference from the ideal weight), GNRI (geriatric nutritional risk index), INA (instant nutritional assessment), LxA (combination of lymphocyte count and albumin), PMA (protein malnutrition with acute inflammation), PMAC (protein malnutrition with acute and chronic inflammation), IDM (iron deficit malnutrition), and VBD (vitamin B deficit malnutrition). Conversely, the GLIM (global leadership initiative on malnutrition) criteria can be used to assess malnutrition and diagnose subclasses of undernutrition. Rational use of these tools can facilitate the conduction of efficient prospective studies in the future, as well as bespoke retrospective cohort studies and database research.

Skeletal muscle-focused guideline development: hierarchical model incorporating muscle form, function, and clinical outcomes

Sarcopenia, sarcopenic obesity, malnutrition, and cachexia clinical guidelines were created by expert consensus over the past decade. These pathological states all share in common deficits in skeletal muscle mass, and in some cases muscle function, which adversely impact patient outcomes. Early identification is key as some detrimental outcomes are potentially preventable with available treatments. The four guidelines share common design features: patients suspected of having the condition are first screened with a focused clinical history; if positive, the next step is evaluation with either a measure of body "form" (e.g., mass, shape, and composition) or function (e.g., mechanical, endurance, and metabolic); combined form and functional criteria are also recognized. The form and functional "gateway" nodes establish whether or not to proceed with further evaluations and treatments. Intensive discussions among experts focus on selection of these gateway nodes and the final choice is made when consensus is reached. Form and functional measures are often treated as equivalent alternatives when framed in the context of "outcomes" for which they are intended to predict. Here we adapt a classic biological concept stating that "function follows form" to show that pathophysiological links are present between these two different muscle qualities and clinical outcomes. We argue that a hierarchy exists such that outcomes closely follow functions that, in turn, follow form…the OFF rule. The OFF rule explains why functional measures often show stronger associations with outcomes than those quantifying form, helps to frame debates on how to structure the gateway nodes used to identify patients for further evaluation and treatment, and sets out a pathophysiological structure for developing future outcome prediction models.

Cross-sectional assessment of body composition and detection of malnutrition risk in participants with low body mass index and eating disorders using 3D optical surface scans

BACKGROUND

New recommendations for the assessment of malnutrition and sarcopenia include body composition, specifically reduced muscle mass. Three-dimensional optical imaging (3DO) is a validated, accessible, and affordable alternative to dual X-ray absorptiometry (DXA).

OBJECTIVE

Identify strengths and weaknesses of 3DO for identification of malnutrition in participants with low body mass index (BMI) and eating disorders.

DESIGN

Participants were enrolled in the cross-sectional Shape Up! Adults and Kids studies of body shape, metabolic risk, and functional assessment and had BMI of <20 kg/m2 in adults or <85% of median BMI (mBMI) in children and adolescents. A subset was referred for eating disorders evaluation. Anthropometrics, scans, strength testing, and questionnaires were completed in clinical research centers. Lin's Concordance Correlation Coefficient (CCC) assessed agreement between 3DO and DXA; multivariate linear regression analysis examined associations between weight history and body composition.

RESULTS

Among 95 participants, mean ± SD BMI was 18.3 ± 1.4 kg/m2 in adult women (N = 56), 19.0 ± 0.6 in men (N = 14), and 84.2% ± 4.1% mBMI in children (N = 25). Concordance was excellent for fat-free mass (FFM, CCC = 0.97) and strong for appendicular lean mass (ALM, CCC = 0.86) and fat mass (FM, CCC = 0.87). By DXA, 80% of adults met the low FFM index criterion for malnutrition, and 44% met low ALM for sarcopenia; 52% of children and adolescents were <-2 z-score for FM. 3DO identified 95% of these cases. In the subset, greater weight loss predicted lower FFM, FM, and ALM by both methods; a greater percentage of weight regained predicted a higher percentage of body fat.

CONCLUSIONS

3DO can accurately estimate body composition in participants with low BMI and identify criteria for malnutrition and sarcopenia. In a subset, 3DO detected changes in body composition expected with weight loss and regain secondary to eating disorders. These findings support the utility of 3DO for body composition assessment in patients with low BMI, including those with eating disorders. This trial was registered at clinicaltrials.gov as NCT03637855.

GLIM criteria to identify malnutrition in patients in hospital settings: A systematic review

Malnutrition is recognized as one of the main public health problems in hospitals. The Global Leadership Initiative on Malnutrition (GLIM) has established a global consensus on the criteria for diagnosing malnutrition in adults in hospital settings. This study aimed to evaluate the ability of the GLIM criteria as a tool to identify malnutrition in hospital settings and to compare the prevalence of malnutrition identified by GLIM criteria with that identified by other screening and/or nutrition assessment methods. This was a systematic review. Searches were performed using MEDLINE/PubMed, Scopus, and Virtual Health Library, based on established descriptors. The included studies were observational and used screening and/or nutrition assessment tools to compare the prevalence of malnutrition and predictive capacity identified by GLIM criteria in patients aged >18 years in hospital settings. Twelve studies were included in this systematic review. A total of 4066 individuals with different pathologies and clinical conditions participated in the included studies. The prevalence of malnutrition, according to the GLIM criteria, ranged from 16% to 80%. In four studies, the prevalence of malnutrition based on GLIM was higher than that based on the other indicators. Six studies that evaluated the predictive ability of GLIM criteria identified satisfactory sensitivity and specificity. Four studies found low to high agreement between GLIM and the other methods. GLIM criteria can identify malnutrition and find a high prevalence and severity of malnutrition in the hospital setting, proving them to be a sensitive and specific instrument, with good agreement between screening and nutrition assessment methods.

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.

Underutilized legumes: nutrient status and advanced breeding approaches for qualitative and quantitative enhancement

Underutilized/orphan legumes provide food and nutritional security to resource-poor rural populations during periods of drought and extreme hunger, thus, saving millions of lives. The Leguminaceae, which is the third largest flowering plant family, has approximately 650 genera and 20,000 species and are distributed globally. There are various protein-rich accessible and edible legumes, such as soybean, cowpea, and others; nevertheless, their consumption rate is far higher than production, owing to ever-increasing demand. The growing global urge to switch from an animal-based protein diet to a vegetarian-based protein diet has also accelerated their demand. In this context, underutilized legumes offer significant potential for food security, nutritional requirements, and agricultural development. Many of the known legumes like Mucuna spp., Canavalia spp., Sesbania spp., Phaseolus spp., and others are reported to contain comparable amounts of protein, essential amino acids, polyunsaturated fatty acids (PUFAs), dietary fiber, essential minerals and vitamins along with other bioactive compounds. Keeping this in mind, the current review focuses on the potential of discovering underutilized legumes as a source of food, feed and pharmaceutically valuable chemicals, in order to provide baseline data for addressing malnutrition-related problems and sustaining pulse needs across the globe. There is a scarcity of information about underutilized legumes and is restricted to specific geographical zones with local or traditional significance. Around 700 genera and 20,000 species remain for domestication, improvement, and mainstreaming. Significant efforts in research, breeding, and development are required to transform existing local landraces of carefully selected, promising crops into types with broad adaptability and economic viability. Different breeding efforts and the use of biotechnological methods such as micro-propagation, molecular markers research and genetic transformation for the development of underutilized crops are offered to popularize lesser-known legume crops and help farmers diversify their agricultural systems and boost their profitability.

Analysis of predictors of malnutrition in adult hospitalized patients: social determinants and food security

Background

Malnutrition in hospitalized patients is becoming a priority during the patient care process due to its implications for worsening health outcomes. It can be the result of numerous social factors beyond clinical ones. This study aimed to evaluate the link between these various risk factors considered social determinants of health, food security levels, and malnutrition and to identify potential predictors.

Methods

A cross-sectional observational study was conducted on a random sample of adult patients in five different hospitals in Lebanon. Malnutrition was assessed using the Global Leadership Initiative on Malnutrition (GLIM) criteria. Patients were interviewed to collect social and economic characteristics and were categorized into four criteria: (1) area of residence (urbanization level), (2) level of education, (3) employment status, and (4) source of health coverage. The food security level was screened by a validated two-question tool, adapted from the US Department of Agriculture Household Food Security Survey, targeting both quantity and quality.

Results

In a random sample of 343 patients, the prevalence of malnutrition according to the GLIM criteria was 35.6%. Patients with low levels of food security, mainly low quality of food, had higher odds of being malnourished (OR = 2.93). Unemployed or retired patients and those who have only completed only elementary school had higher odds of being diagnosed with malnutrition as compared to those who were employed or had university degrees, respectively (OR = 4.11 and OR = 2.33, respectively). Employment status, education level, and type of health coverage were identified as predictors of malnutrition in the multiple regression model. Household location (urban vs. rural) was not associated with malnutrition.

Conclusion

The social determinants of health identified in our study, mainly the level of education and income level, in addition to food security, were identified as predictors of malnutrition in hospitalized patients. These findings should guide healthcare professionals and national policies to adopt a broader perspective in targeting malnutrition by including social determinants in their nutrition care.

GLIM in chronic kidney disease: What do we need to know?

The lack of consensus on diagnostic criteria for malnutrition has hampered developments in research and clinical practice pertaining to nutrition. This opinion paper describes the applicability and other aspects of using the Global Leadership Initiative on Malnutrition (GLIM) criteria for diagnosing malnutrition in patients with chronic kidney disease (CKD). We examine the purpose of GLIM, the particularities of CKD that can affect the nutritional and metabolic status and the diagnosis of malnutrition. In addition, we make an appraisal of previous studies that used GLIM in the context of CKD and discuss the value and relevance of using the GLIM criteria in patients with CKD.

Association between Malnutrition Assessed by the Global Leadership Initiative on Malnutrition Criteria and Mortality in Older People: A Scoping Review

The Global Leadership Initiative on Malnutrition (GLIM) criteria were introduced in 2018 for the diagnosis of malnutrition in adults. This review was aimed at gathering the evidence about the association between malnutrition according to the GLIM criteria and mortality in older people, an emerging and clinically meaningful topic in the implementation of the GLIM criteria in geriatric healthcare settings. This scoping review considered meta-analyses, systematic reviews, cohort studies, and cross-sectional studies published in PubMed, Scopus, and the Cochrane Database for Systematic Reviews from the development of the GLIM criteria in 2018 to January 2023. Seventeen articles (15 cohort and 2 cross-sectional studies) were included. The association between GLIM criteria and mortality had been assessed in hospitalized (11 over the 17 articles) and community-dwelling older populations, and those in nursing homes. The review found a strong association between malnutrition according to GLIM criteria and mortality in hospitalized (1.2-fold to 7-fold higher mortality) and community-dwelling older people (1.6-fold to 4-fold higher mortality). These findings highlight the prognostic value of the GLIM criteria and support strategies towards the implementation of malnutrition evaluation according to the GLIM, in order to optimize comprehensive geriatric assessment and provide older people with the highest quality of nutritional care. Studies in nursing home populations were very scarce and may be urgently required.

Predictive validity of GLIM malnutrition diagnosis in patients with colorectal cancer

BACKGROUND

Considering that the validation of the Global Leadership Initiative on Malnutrition (GLIM) remains unclear in patients with colorectal cancer, the present study aimed to assess the agreement, accuracy, sensitivity, specificity, and prognostic effect of the GLIM on survival when compared with the Patient-Generated Subjective Global Assessment (PG-SGA).

METHODS

Patients with colorectal cancer who were scheduled to undergo a routine abdominal computed tomography (CT) scan were recruited. Using the GLIM two-step approach, the patients were first screened for malnutrition by using the PG-SGA Short Form (score ≥3). The malnutrition diagnosis was based on the etiologic (disease burden [cancer] or reduced food intake) and phenotypic GLIM criteria, including weight loss, body mass index, and skeletal muscle index at the third lumbar vertebra when using the CT scans. The food intake was assessed by the PG-SGA.

RESULTS

This study included 191 patients (age, 60.5 ± 11.3 years; 57% men), and 23% and 32% were malnourished according to the GLIM and the PG-SGA, respectively. The GLIM revealed fair sensitivity (64%), good agreement (kappa = 0.65), specificity (96%), and diagnostic accuracy for detecting malnutrition (area under the receiver operating characteristic curve = 0.80; 95% CI, 0.72-0.88) when compared with the PG-SGA. The malnutrition value according to the GLIM and the PG-SGA was associated with short-term survival. However, only the PG-SGA was associated with long-term survival.

CONCLUSIONS

Although showing fair sensitivity, the GLIM had good agreement, specificity, and diagnostic accuracy for malnutrition detection and was an independent predictor of short-term survival in patients with colorectal cancer.

Metabolic and histomorphological changes of adipose tissue in cachexia

PURPOSE OF REVIEW

To describe the role of the main changes occurring in adipose tissue during cachexia and how these affects patient's outcomes, with a specific focus on cancer.

RECENT FINDINGS

In cachexia, the changes within the adipose tissue have been recently described as the presence of inflammatory infiltration (T-lymphocytes and macrophages), enhanced fibrosis, and the occurrence of beige adipocytes (i.e., browning). The latter one is a process driving cachexia enhancing thermogenesis, primarily via modulation of uncoupling protein 1. Also, increased lipolysis of white adipose tissue, especially in cancer, via higher expression of hormone sensible and adipose tissue triglyceride lipases, was detected in experimental models and in human adipose tissue. Other systemic metabolic alterations occur in association with changes in adiposity, including insulin resistance and increased inflammation, all conditions associated with a worse outcome. Moreover, these profound metabolic alterations were shown to be implicated in several consequences, including extreme and progressive unvoluntary body weight loss.

SUMMARY

Alterations in adiposity occur early during cachexia. Adipose tissue atrophy, as well as metabolic changes of white adipose tissues were observed to be pivotal in cachexia, and to be implicated in several clinical complications and poor prognosis.Further research is necessary to clarify the mechanisms underlying the loss of adiposity and therefore to identify novel therapeutic options to counteract this phenomenon in cachexia.

Prognostic implications of the global leadership initiative on malnutrition criteria as a routine assessment modality for malnutrition in hospitalized patients at a university hospital

BACKGROUND & AIMS

Few studies have examined the association between mortality and malnutrition diagnosed using the Global Leadership Initiative on Malnutrition (GLIM) criteria for routine nutritional assessment; thus, this association is not well known. We aimed to clarify the association between GLIM-defined malnutrition and mortality in a large population of hospitalized patients.

METHODS

In this retrospective cohort study, we enrolled adult patients admitted to Aichi Medical University Hospital between April 2019 and March 2021, who underwent nutritional assessment using the GLIM criteria. In November 2021, we collected the following data from electronic medical records: demographic, clinical, and laboratory data upon admission; nutritional data assessed using GLIM criteria; and data on final patient outcomes.

RESULTS

In this study, we included 9372 hospitalized patients who were identified to be at risk by the validated nutritional screening tools (50.6% men, median age 75.0 [67.0-82.0] years, 69.2% patients aged ≥70 years). The number of patients with no, moderate, and severe GLIM-defined malnutrition was 4145 (44.2%), 2799 (29.9%), and 2428 (25.9%), respectively. Kaplan-Meier survival curve analysis showed a significant increase in mortality with worsening nutritional status (log-rank test, P < 0.001). After adjusting for age and sex, multivariable Cox regression analysis revealed that both moderate (Hazard ratio [HR] 2.0, 95% confidence interval [CI] 1.79-2.23, P < 0.001) and severe malnutrition (HR 3.06, 95% CI 2.74-3.40, P < 0.001) were independent risk factors for mortality. Moreover, multivariable analysis showed that four of the five GLIM sub-criteria (except low body mass index) were independently associated with prognosis.

CONCLUSION

Malnutrition and its severity, routinely assessed using the GLIM criteria, are associated with high mortality in hospitalized patients at nutritional risk. Further research is needed to evaluate the usefulness of the GLIM sub-criteria, including low body mass index, in these patients.

The global leadership initiative on malnutrition criteria for the diagnosis of malnutrition in patients admitted to the intensive care unit: A systematic review and meta-analysis

BACKGROUND

Malnutrition is associated with a high risk of morbidity and mortality in patients with critical illness. The nutrition status of patients in the intensive care unit (ICU) is challenging to assess. The Global Leadership Initiative on Malnutrition (GLIM) is a novel framework used for the diagnosis of malnutrition. However, its efficacy in patients with critical illness in the ICU has not been validated.

AIM

To investigate the use and validity of the GLIM criteria in adult patients admitted to the ICU.

METHODS

A systematic review and meta-analysis were performed, and seven databases were searched for relevant studies. The selection criteria included studies that used the GLIM in adult patients admitted to the ICU. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

RESULTS

Five studies were included in the analysis. Approximately 15%-68% of patients were diagnosed with malnutrition using the GLIM criteria. Meanwhile, 48%-75% of patients with malnutrition were identified with the Subjective Global Assessment (SGA). The inflammation criterion was easily adjudicated due to critical status, and three studies compared the GLIM and the SGA. According to the QUADAS-2 tool, the nutritional assessment process was not explicit in the studies. The meta-analysis had an overall sensitivity of 65.3% (95% CI: 34.9%-86.9%) and an overall specificity of 88.8% (95% CI: 58.1%-97.8%). In the prospective validation, malnutrition assessed by the GLIM criteria, and the SGA was associated with mortality. However, the association between length of hospital stay and mechanical ventilation was unclear.

CONCLUSIONS

The use and validity of the GLIM criteria among patients admitted to the ICU is still limited. Moreover, some concurrent and predictive validation studies have methodological limitations. Further studies must be performed to validate the use of the GLIM criteria in the ICU.

Nascent to novel methods to evaluate malnutrition and frailty in the surgical patient

Preoperative nutrition status is an important determinant of surgical outcomes, yet malnutrition assessment is not integrated into all surgical pathways. Given its importance and the high prevalence of malnutrition in patients undergoing surgical procedures, preoperative nutrition screening, assessment, and intervention are needed to improve postoperative outcomes. This narrative review discusses novel methods to assess malnutrition and frailty in the surgical patient. The Global Leadership Initiative for Malnutrition (GLIM) criteria are increasingly used in surgical settings although further spread and implementation are strongly encouraged to help standardize the diagnosis of malnutrition. The use of body composition (ie, reduced muscle mass) as a phenotypic criterion in GLIM may lead to a greater number of patients identified as having malnutrition, which may otherwise be undetected if screened by other diagnostic tools. Skeletal muscle loss is a defining criterion of malnutrition and frailty. Novel direct and indirect approaches to assess muscle mass in clinical settings may facilitate the identification of patients with or at risk for malnutrition. Selected imaging techniques have the additional advantage of identifying myosteatosis (an independent predictor of morbidity and mortality for surgical patients). Feasible pathways for screening and assessing frailty exist and may determine the cost/benefit of surgery, long-term independence and productivity, and the value of undertaking targeted interventions. Finally, the evaluation of nutrition risk and status is essential to predict and mitigate surgical outcomes. Nascent to novel approaches are the future of objectively identifying patients at perioperative nutrition risk and guiding therapy toward optimal perioperative standards of care.