A CONSENSUS REPORT

GLIM: GLOBAL FROM THE GLOBAL

LEADERSHIP INITIATIVE CLINICAL NUTRITION
ON MALNUTRITION COMMUNITY

LEAH GRAMLICH, MD, FRCP

Professor of Medicine
University of Alberta
Edmonton, Alberta, Canada

US-ENS-2100004
DISCLOSURES

 The content of this program has met the continuing education criteria
of being evidence-based, fair and balanced, and non-promotional
 This educational event is supported by Abbott Nutrition Health Institute,
Abbott Nutrition
 Leah Gramlich is the Chair of the Canadian Malnutrition Task Force
 Leah Gramlich has received an honorarium for this presentation
 Leah Gramlich has received honoraria from Baxter, Takeda, Fresenius
Kabi, Abbott; She has received research support from Baxter, Fresenius
Kabi, Takeda, Abbott. She has received education support from Nestle.
OBJECTIVES

→ Explain the definition, prevalence and impact of malnutrition in

adult patients
→ Review expert group recommendations/consensus/guidelines on
malnutrition diagnosis, including the new GLIM consensus
→ Summarize next steps for the GLIM consensus and how
clinicians can utilize the consensus within their practice
MALNUTRITION:
DEFINITION, PREVALENCE, AND IMPACT
 • Malnutrition is a state resulting
from lack of intake or uptake
of nutrition that leads to altered
body composition
• This can result in diminished physical and
mental function

Cederholm T, et al. Clin Nutr. 2017;36(1):49-64.

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 MALNUTRITION IS CAUSED BY MULTIPLE,
OFTEN OVERLAPPING RISK FACTORS

Disease/ Cognitive Psychological Physical Socioeconomic

Inflammation impairment challenges impairment status
Lack of Multiple Inadequate
medical awareness comorbidities Polypharmacy food & fluid intake

MALNUTRITION
Fuhrman MP. Nutr Clin Pract. 2009;24(2):196-205.

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 MALNUTRITION NEGATIVELY IMPACTS CLINICAL OUTCOMES
AND COST OF CARE

M A L N U T R I T I O N

 Hospital readmissions
 Wound healing
 Infections  Mortality

 Other complications  Treatment

 Convalescence
 Length of stay (LOS) in hospital

 COST
 QUALITY OF LIFE

1. Norman K, et al. Clin Nutr. 2008;27(1):5-15.

2. Allaudeen N, et al. J Hosp Med. 2011;6(2):54-60.

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 MALNUTRITION IMPOSES A SIGNIFICANT ECONOMIC BURDEN

$157B per year

without diabetes $338B per year with
diabetes/prediabetes

Depression $42.2

Musculoskeletal Disorders $10.2

Dementia $22.3

COPD $43.2

Coronary Heart Disease $23.9

Colorectal Cancer $3.3

Breast Cancer $3.2

Stroke $8.4

$0.0 $5.0 $10.0 $15.0 $20.0 $25.0 $30.0 $35.0 $40.0 $45.0 $50.0

2010 USD (billions) per year

Snider JT, et al. JPEN J Parenter Enteral Nutr. 2014;38(2 Suppl):77S-85S. COPD- Chronic Obstructive Pulmonary Disease

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NUTRITIONAL STATUS IS PROGRESSIVELY COMPROMISED
OVER THE CONTINUUM OF CARE

HOSPITAL ADMISSION HOSPITAL STAY POST-DISCHARGE

30%–50% of patients Many patients with Weight loss and

are malnourished normal nutrition status loss of muscle increase
upon admission prior to admission risk of hospital
Sriram K, et al. JPEN J Parenter Enteral Nutr. experience a decline readmissions
2017;41(3):384-391; Gariballa S, Alessa A. Clin
Nutr. 2013;32(5):772-776; Allaudeen N, et al. J during hospitalization
Hosp Med. 2011;6(2):54-60.

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 HOSPITAL MALNUTRITION IN NORTH AMERICA

43% - 69% N O RT H A M E R I C A
Hospitalized patients in Canada
with moderate/severe malnutrition

33%
Prevalence of malnutrition risk
among hospitalized patients in the US

Keller H, et al. Eur J Clin Nutr. 2017;71(6):766-772.

Sauer AC, et al. JPEN J Parenter Enteral Nutr. 2019;43(7):918-926.

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 HOSPITAL MALNUTRITION IN LATIN AMERICA

L AT I N A M E R I C A

40%–60%
Prevalence of malnutrition
at the time of admission

Correia MITD. Clin Nutr. 2017;36(4):958-967.

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 HOSPITAL MALNUTRITION IN EUROPE

27% EUROPE
of patients
diagnosed
43%
with malnutrition of patients aged
70 years were
33% malnourished
gastroenterology
VS

38% 8%
oncology of patients
<30 years
56%
geriatric wards
Pirlich M, et al. Clin Nutr. 2006;25(4):563-572.

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 HOSPITAL MALNUTRITION IN SINGAPORE

Prevalence of malnutrition by specialties

Others (n=32) SINGAPORE
Surgery (n=121)
Orthopaedic (n=88)
Neurosurgery (n=11) n=818
Malnutrition was determined with Subjective Global
Neurology (n=52) Assessment within 48 h of hospital admission

Cardiology (n=90) 25% of patients were

Urology (n=22)
Cardiothoracic Vascular Surgery (n=23)
classified as moderately
General Medicine (n=145) malnourished and 4% as
Gastroenterology (n=60)
Nephrology (n=58) severely malnourished
Respiratory (n=36)
Endocrine (n=25)
Oncology (n=55)
0 20 40 60 80

Prevalence of malnutrition (%)

Lim SL, et al. Clin Nutr. 2012;31(3):345–350.

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 EXPERT GROUP RECOMMENDATIONS/
CONSENSUS/GUIDELINES ON MALNUTRITION
DIAGNOSIS: AND/ASPEN & ESPEN

AND- Academy of Nutrition and Dietetics

ASPEN- American Society for Parenteral and Enteral Nutrition
ESPEN- European Society for Clinical Nutrition and Metabolism
 Over the past decade, many
expert nutrition organizations
have published consensus
statements on malnutrition
diagnosis criteria

GLIM
 MALNUTRITION DIAGNOSIS CRITERIA CONSENSUS
STATEMENTS

2012
Global Leadership Initiative
AND/ASPEN on Malnutrition (GLIM) [ASPEN,
Consensus statement of the Academy of Nutrition and ESPEN, FELANPE, and PENSA]
Dietetics/American Society for Parenteral and Enteral 2019 GLIM criteria for the diagnosis
Nutrition: characteristics recommended for the identification of malnutrition—A consensus
and documentation of adult malnutrition (undernutrition) report from the global clinical
nutrition community
2015
ESPEN
Diagnostic criteria for malnutrition—An ESPEN consensus
statement

White JV, et al. J Acad Nutr Diet;2012;112(5):730-738.

White JV, et al. JPEN J Parenter Enteral Nutr. 2012;36(3):275-283. FELANPE- Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism
Cederholm T, et al. Clin Nutr. 2019;38(1):1-9. PENSA- The Parenteral and Enteral Nutrition Society of Asia

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 2012 AND/ASPEN CONSENSUS STATEMENT:
ADULT MALNUTRITION CHARACTERISTICS

Grip Fluid Muscle Insufficient Body Weight

strength accumulation mass energy intake fat loss CONSENSUS
S TAT E M E N T

A D U LT M A L N U T R I T I O N
( i f ≥ 2 p r e s e n t )

1.White JV, et al. J Acad Nutr Diet;2012;112(5):730-738.

2. White JV, et al. JPEN J Parenter Enteral Nutr. 2012;36(3):275-283.

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 2015 ESPEN CONSENSUS STATEMENT:
DIAGNOSTIC CRITERIA FOR MALNUTRITION

Two ways to diagnose malnutrition

CONSENSUS
S TAT E M E N T
1 BMI <18.5 kg/m2

2 Unintentional weight loss >10% indefinite of time

or >5% over the last 3 months combined with either
• BMI <20 kg/m2 if <70 years of age
• FFMI <15 in women and 17 kg/m2 in men

BMI- Body Mass Index

Cederholm T, et al. Clin Nutr. 2019;38(1):1-9. FFMI- Fat-Free Mass Index

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Assessment tools are used
differently around the globe,
and no single approach
has secured broad
global acceptance

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EXPERT GROUP RECOMMENDATIONS/
CONSENSUS/GUIDELINES ON MALNUTRITION
DIAGNOSIS: GLIM
 The Global Leadership
Initiative on Malnutrition (GLIM)
is focused on building a global
consensus around diagnostic
criteria for malnutrition in adults
in clinical settings

Cederholm T, et al. Clin Nutr. 2019;38(1):1-9.

GLIM
2019 A TWO-STEP APPROACH FOR MALNUTRITION
GLIM DIAGNOSIS

Screening to identify at-risk

1 status using any validated tool
 At least 1 phenotypic criterion and
1 etiologic criterion should be present

 Etiologic criteria should be used to guide

Assessment for diagnosis and
2 grading the severity of malnutrition
intervention and anticipated outcomes
 Recommended approach supports
classification of malnutrition into
etiology-related diagnosis categories

Cederholm T, et al. Clin Nutr. 2019;38(1):1-9.

GLIM
2019 PHENOTYPIC AND ETIOLOGIC CRITERIA FOR THE
GLIM DIAGNOSIS OF MALNUTRITION

Phenotypic Criteria Etiologic Criteria

>5% within past 6 months, Reduced ≤50% of ER >1 week, or any reduction for
Weight loss (%)
or >10% beyond 6 months food intake or >2 weeks, or any chronic GI condition
assimilation that adversely impacts food assimilation
or absorption
<20 if <70 years, or <22 if >70 years
Low body mass
index (kg/m2) Asia:
<18.5 if <70 years, or <20 if >70 years
Inflammation Acute disease/injury or
Reduced Reduced by validated body composition chronic disease-related
muscle mass measuring techniques

GI = Gastrointestinal
Cederholm T, et al. Clin Nutr. 2019;38(1):1-9. ER = Energy Requirements

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2019 DIAGNOSTIC SCHEME FOR SCREENING,
GLIM ASSESSMENT, DIAGNOSIS, AND GRADING

Risk screening Diagnostic assessment Diagnosis Severity grading

At risk for Assessment Meets criteria Determine severity

malnutrition criteria
• Use validated • Phenotypic
screening tools − Non-volitional
weight loss
− Low body mass index
− Reduced muscle mass
for malnutrition
diagnosis
• Requires at least
1 phenotypic criterion
and 1 etiologic criterion
of malnutrition
• Severity determined based
on phenotypic criterion

• Etiologic
− Reduced food intake
or assimilation
− Disease burden/
inflammatory condition

Cederholm T, et al. Clin Nutr. 2019;38(1):1-9.

GLIM
2019 THRESHOLDS FOR SEVERITY GRADING
GLIM OF MALNUTRITION

Phenotypic Criteria
Low Body Mass Reduced
Weight Loss (%)
Index (kg/m2) Muscle Mass

STAGE 1
5%-10% within the past Mild-to-moderate deficit
MODERATE MALNUTRITION 6 months, or 10%-20%
<20 if <70 years,
(per validated assessment
(requires 1 phenotypic criterion <22 if ≥70 years
beyond 6 months methods)
that meets this grade)

STAGE 2
SEVERE MALNUTRITION
(requires 1 phenotypic criterion
that meets this grade)
>10% within the past <18.5 if <70 years, Severe deficit (per
6 months, or <20 if ≥70 years validated assessment
>20% beyond 6 months methods)

Cederholm T, et al. Clin Nutr. 2019;38(1):1-9.

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2019 NEXT STEPS
GLIM

 GLIM consensus selected criteria already in use

throughout the world, making global adoption
more likely

 Global databases can be used to support the

development of global standards of care to
promote improved outcomes

 GLIM will be shared with the WHO in the

context of the ICD-11 revision process

 GLIM will be reassessed every 3–5 years

WHO- World Health Organization

Cederholm T, et al. Clin Nutr. 2019;38(1):1-9. ICD- International Classification of Disease

GLIM
 Several forms of validation and reliability
Review were reviewed in the context of GLIM
• Research using large databases and
GLIM: Guidance on machine learning can be employed
to refine GLIM
validation of the operational
criteria for the diagnosis • Validation and reliability testing need
of protein‐energy to occur in a variety of sectors and
populations and with diverse patients
malnutrition in adults using GLIM criteria
• The guidance presented supports the
GLIM criteria
publication of quality validation and
requires validation and reliability studies for GLIM
reliability testing

Keller H, et al. JPEN J Parenter Enter Nutr. 2020;44(6):992-1003.

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STUDIES UTILIZING THE NEW GLIM
MALNUTRITION DIAGNOSIS CRITERIA
 A number of studies have been
conducted to investigate the
validity of GLIM criteria and
assess performance

GLIM
 Since the publication of GLIM criteria in 2018,
more than 500 articles have been published
mentioning the GLIM criteria and approach

 There is a real appetite for a common,

simple framework for diagnosing malnutrition

 Given that GLIM is based solely on expert

opinion, it requires a validation process to
support the criterion and construct validity

GLIM
 STUDY Data from 1,660 older community-living
adults in the Toledo Study on Healthy
Malnutrition prevalence Ageing were analyzed using GLIM criteria
and burden in healthcare • 12.6% of patients were malnourished
resource use among
• Being at-risk/malnourished was associated
Spanish community-living
with greater medication utilization, higher
older adults rates of hospital admission and longer
stays, and higher hospitalization costs
• Such findings suggest that malnutrition
risk-screening for older adults could
15% of patients found to
be at risk of malnutrition
improve health and lower cost of care

Rodríguez-Sánchez B, et al. Clinicoecon Outcomes Res. 2020;12:355-367.

GLIM
 Review A review of recent studies on techniques
and tools for screening and diagnosis of
Diagnosis of malnutrition in gastrointestinal disease in
the light of GLIM concluded that:
malnutrition in patients
with GI disease • GLIM criteria for the diagnosis of
malnutrition are feasible for IBD, liver,
and pancreas diseases
• Pending studies expect to provide data
on the clinical relevance to diagnose
GLIM criteria are
malnutrition by the GLIM concept
feasible for IBD, liver,
and pancreas diseases

Cederholm T, et al. Cur Opin Clin Nutr Metab Care. 2020;23(5):361-366. IBD- Inflammatory Bowel Disease

GLIM
 STUDY
In a prospective observational study,
GLIM criteria for adult 1,015 patients admitted to the Hospital
malnutrition and its San Ángel Inn Universidad were
relationship with adverse assessed using GLIM criteria
outcomes • Malnutrition according to the GLIM
criteria was strongly associated with
mortality and unplanned transfer to
critical care areas

prevalence of
18.9% malnutrition at hospital
admission

Galindo Martín CA, et al. Clin Nutr ESPEN. 2020;38:67-73.

GLIM
 STUDY
In a longitudinal study, 41 older
Impact of malnutrition hospitalized patients were assessed
on acute muscle using GLIM criteria for changes in thigh
wasting in frail older muscle mass and muscle strength
hospitalized patients • Malnourished patients lost
- 10% of handgrip strength and
- 12% of knee extension strength
• Malnutrition according to the
Mean thigh muscle GLIM criteria was associated with
declined by 9% in acute muscle wasting in frail older
malnourished patients patients during 2-week hospitalization

Pourhassan M, et al. Nutrients. 2020;12(5):1387.

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  There is a need to understand not only how,
but which GLIM etiologic and phenotypic
criteria are being used in both theory and in
clinical practice, along with their potential
impact on malnutrition literature

 With experts in the field applying the GLIM

criteria to these types of studies, we can
better assess the validation methods
described in these studies, while more
effectively describing malnutrition
prevalence and outcomes

GLIM
CALL TO ACTION: NUTRITION SCREENING AND
INTERVENTION FOR AT-RISK PATIENTS
 Using GLIM criteria to diagnose
malnutrition in at-risk patients can
allow clinicians to recommend
early nutritional intervention to
improve outcomes

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 WHAT CAN YOU DO?
SCREENING AND INTERVENTION

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SCREENING AND INTERVENTION

Follow the GLIM two-step approach Recommend nutrition intervention for patients
for malnutrition diagnosis at risk for malnutrition and with malnutrition

 Use GLIM etiologic criteria

to guide intervention
1 Screening to identify at-risk
status using any validated tool  Recommend increased protein,
to ensure patients maintain muscle
mass and strength
Assessment for diagnosis and grading
2 the severity of malnutrition  Consider oral nutrition supplements
and beta-hydroxy-beta-methylbutyrate
(HMB) supplementation
Cederholm T, et al. Clin Nutr. 2019;38(1):1-9.
Woo J. et al. Curr Opin Clin Nutr Metab Care. 2018;21(1):19-23.

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SUMMARY

→ Malnutrition is common in adult patients across the healthcare

continuum globally
→ Malnutrition leads to poorer outcomes for patients and the
healthcare system
→ Multiple expert groups have published malnutrition criteria and
diagnosis consensus statements over the past decade
→ The GLIM consensus was published in 2018 to help provide
a global consensus on malnutrition identification and diagnosis
→ Multiple studies have assessed the validity of GLIM criteria
→ Clinicians can screen patients to identify those at risk for malnutrition
and recommend early nutritional intervention to improve outcomes
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