DOI: 10.1111/ggi.

14072

ORIGINAL ARTICLE
EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH

Comparison between the Global Leadership Initiative on

Malnutrition and the European Society for Clinical Nutrition
and Metabolism definitions for the prevalence of malnutrition
in geriatric rehabilitation care
Akio Shimizu,1,2 Keisuke Maeda,2,3 Toshiki Honda,4 Yuria Ishida,5 Junko Ueshima,2,6
Shinsuke Nagami,7 Ayano Nagano,8 Tatsuro Inoue,9 Kenta Murotani,10 Jun Kayashita,11
Ichiro Fujishima12 and Naoharu Mori2
1
Department of Nutrition, Hamamatsu City Aim: The recently proposed Global Leadership Initiative on Malnutrition (GLIM) criteria
Rehabilitation Hospital, Hamamatsu, Japan may accurately reflect the nutritional status of older adults because they use information such
2
Department of Palliative and Supportive as reduced muscle mass and chronic and acute disease to diagnose malnutrition. This study
Medicine, Graduate School of Medicine, aimed to determine the prevalence and characteristics of malnutrition in older adults assessed
Aichi Medical University, Nagakute, Japan by the GLIM and the European Society for Clinical Nutrition and Metabolism (ESPEN) diag-
3
Department of Geriatric Medicine, National nostic criteria for malnutrition (DCM) in post-acute geriatric care.
Center for Geriatrics and Gerontology, Obu,
Japan Methods: This cross-sectional study included older patients admitted to rehabilitation care
4
Department of Rehabilitation, Hamamatsu units. Malnutrition was evaluated using GLIM-DCM and ESPEN-DCM using a two-step
City Rehabilitation Hospital, Hamamatsu, Japan process (initial screening and subsequent steps). The prevalence and differences observed
5
Department of Nutrition, Aichi Medical between GLIM-DCM and ESPEN-DCM were reported, and the determinants of each crite-
University Hospital, Nagakute, Japan rion were identified.
6
Department of Clinical Nutrition and Food
Service, NTT Medical Center Tokyo, Results: This study included 335 older patients (mean  SD, age 80.0  7.5 years; 54.0%
Shinagawa, Japan women). The prevalence of older patients diagnosed with GLIM-DCM and ESPEN-DCM
7
Faculty of Health Science and Technology, was 66.9% and 59.1%, respectively, and the agreement between ESPEN-DCM and GLIM-
Kawasaki University of Medical Welfare, DCM was 80.9%. The results of multivariate analyses showed that all items of the phenotypic
Kurashiki, Japan and etiologic criteria were independent determinants for GLIM-DCM, whereas disease bur-
8
Department of Nursing, Nishinomiya den/inflammation (P = 0.996), included in the etiologic criteria of GLIM-DCM, were not
Kyoritsu Neurosurgical Hospital, determinants of ESPEN-DCM.
Nishinomiya, Japan
9
Department of Physical Therapy, Niigata Conclusion: This study reported the prevalence of malnutrition according to GLIM-DCM
University of Health and Welfare, Niigata, Japan and the differences in the characteristics of patients diagnosed with malnutrition based on
10
Biostatistics Center, Kurume University, GLIM-DCM and those diagnosed based on ESPEN-DCM in geriatric rehabilitation care
Kurume, Japan units. Further studies are required to investigate the prevalence of malnutrition in different
11
Department of Health Sciences, Faculty of care settings. Geriatr Gerontol Int 2020; ••: ••–••.
Human Culture and Science, Prefectural
University of Hiroshima, Hiroshima, Japan Keywords: malnourished, older adults, post-acute care.
12
Department of Rehabilitation Medicine,
Hamamatsu City Rehabilitation Hospital,
Hamamatsu, Japan

Correspondence
Keisuke Maeda, MD, PhD,
Department of Geriatric Medicine,
National Center for Geriatrics and
Gerontology, 7-430 Morioka, Obu,
Aichi, 474-8511, Japan.
Email: kskmaeda1701@gmail.com

Received: 18 June 2020

Revised: 29 August 2020
Accepted: 9 October 2020

[Correction added on 3 November 2020, after first online publication: The 6th author’s name has been corrected from ‘Sinsuke Nagami’
to ‘Shinsuke Nagami’.]

© 2020 Japan Geriatrics Society | 1

 A Shimizu et al.
Introduction
Malnutrition is associated with important issues of older adults,
including prevalence of frailty and sarcopenia, incidence of falls, pro-
longed hospital stay and mortality.1–4 In particular, malnutrition has
been reported to affect functional outcomes adversely, such as the
activity of daily living (ADL) and improved swallowing function in
older inpatients requiring rehabilitation.5,6 Therefore, early identifi-
cation and intervention of malnutrition may contribute to positive
clinical outcomes for malnourished older adults. Indeed, the identifi-
cation of nutritional risk and the performance of nutritional therapy
have been shown to improve functional outcome, reduce mortality,
hospital readmission rates and healthcare cost.7,8
In 2015, the European Society for Clinical Nutrition and
Metabolism (ESPEN) diagnostic criteria for malnutrition (DCM)
defined malnutrition using validated nutritional screening tools
for initial screening, with a focus on weight change and body
composition.9 However, ESPEN-DCM does not include factors
associated with reduced food intake, digestive tract problems,
inflammation and diseases, which are the etiologies of malnutri-
tion. Digestive tract problems, inflammation and diseases are cau-
ses of anorexia of aging in older adults.10 Furthermore, anorexia
of aging is considered a cause of malnutrition and sarcopenia.10
Therefore, etiologies such as reduced food intake, digestive tract
problems and inflammation are considered key components in the
diagnosis of malnutrition in the older population.
Recently, to define universal criteria for malnutrition, four aca-
demic societies for clinical nutrition organized the Global Leadership
Initiative on Malnutrition (GLIM) and proposed new malnutrition
diagnostic criteria.11 The GLIM criteria consist of phenotype criteria,
including weight loss, low body mass index (BMI), reduced muscle
mass and etiologic criteria, including reduced food intake or assimila-
tion and disease burden/inflammation.11 Thus, the GLIM criteria
include important factors related to prognostic and functional out-
comes for older adults. Furthermore, the GLIM criteria have been
developed to compare the prevalence, interventions and outcomes of
malnutrition worldwide.11 Therefore, nutritional assessment using
the GLIM criteria may be desirable to develop better nutritional inter-
ventions. However, only few studies have investigated the prevalence
of malnutrition based on GLIM-DCM in rehabilitation care units.12
In addition, only few studies have investigated the differences in
patients diagnosed with malnutrition using the ESPEN-DCM defini-
tion and those diagnosed using the GLIM-DCM definition.12
Therefore, this study aimed to report the prevalence of malnu-
trition according to GLIM-DCM in older inpatients in rehabilita-
tion care units in Japan, and to summarize the differences
between GLIM-DCM and ESPEN-DCM of the prevalence of
malnutrition.
Methods
Study design and setting
This retrospective cross-sectional study was conducted in rehabili-
tation care units in the Hamamatsu Rehabilitation Hospital in
Hamamatsu, Shizuoka, Japan, between April and November 2018.
The hospital has 135 beds to provide post-acute rehabilitative care
for individuals who require rehabilitative training based on the
Japanese health insurance system in a city with a population of
approximately 800 000, of which 26.1% were aged ≥65 years.
This study was conducted with the approval of the Hamama-
tsu Rehabilitation Hospital Ethics Committee (Trial ID: 18–50).
Because of the retrospective study design, patients could withdraw
2 |
from the study at any time using the opt-out procedure. The par-
ticipants were assured of the right to withdraw from the study
using a notification opt-out measure on the website or hospital
bulletin board.
Participants
Hospitalized older adult patients aged ≥65 years whose primary
diseases were orthopedic diseases, stroke and hospital-associated
deconditioning, were enrolled during the study period. The Japa-
nese health insurance system supports hospital rehabilitative train-
ing for patients with the abovementioned three conditions. The
study excluded patients who had missing admission values such
as calf circumference (CC), weight changes, or amount of food
intake from further analyses.
Data collection
Demographic and clinical data (e.g., age, sex, primary diagnosis,
comorbidity, height, weight, serum albumin level, C-reactive pro-
tein level, nutritional status and anthropometric data) were
extracted from the patients’ medical records. The Charlson
Comorbidity Index was used to evaluate comorbidities,13 with
higher Charlson Comorbidity Index scores indicating higher
severity of comorbidities and risk of mortality. The oral condition
was assessed using the Oral Health Assessment Tool14 by trained
attending nurses. The Oral Health Assessment Tool consists of
eight categories of oral health, and evaluates each item as follows:
0 = healthy, 1 = changes or 2 = unhealthy. ADL were evaluated by
physical or occupational therapists using the Functional Indepen-
dence Measure.15 The Functional Independence Measure is an
indicator of ADL, with scores ranging from 0 to 126, which con-
sists of 13 motor items and five cognitive items. Swallowing ability
was evaluated using the International Dysphagia Diet Initiative
Standardization Functional Diet Scale (IDDSI-FDS),16 and
patients with an IDDSI-FDS score ≤4 were likely to have
dysphagia.6,16
Nutritional status
BMI was calculated as body weight (kg) divided by height squared
(m2). Changes in body weight during the past 3–6 months, food
intake observed before hospital admission and food intake 7 days
after hospital admission were obtained from the patients’ medical
charts. The amount of dietary intake was assessed by nurses using
a visual estimation method, and further estimation of the amount
of nutritional intake was conducted by registered dietitians. The
CC of the patients was measured by registered dietitians on admis-
sion in a non-dominant limb, with the patients assuming a supine
position with 90 of knee flexion. Fat-free mass (FFM) was calcu-
lated using the formula,17 and the FFM index was calculated as
FFM (kg) divided by height squared (m2). FFM was obtained using
an estimated 24-h urine creatinine excretion rate (eCER) and is
calculated as follows: FFM = 13.0 + 0.03 × eCER; eCER
(mg/day) = 879.89 + 12.51 × weight (kg) − 6.19 × age (years)
(−379.42 for women).17 All patients underwent nutritional risk
screening using the Mini Nutritional Assessment Short Form
(MNA-SF)18 within 24 h of admission, as assessed by registered
dietitians. The MNA-SF is a validated nutritional risk screening
tool consisting of six items, with scores ranging from 0 to 14 points
and a score of ≤11 is considered a risk factor for malnutrition.18
© 2020 Japan Geriatrics Society
 Table 1 Characteristics of the study participants according to the Global Leadership Initiative on Malnutrition (GLIM) and European Society for Clinical Nutrition and Metabolism
(ESPEN) definitions

© 2020 Japan Geriatrics Society

All GLIM criteria ESPEN criteria
Malnutrition Non-malnutrition P-value Malnutrition Non-malnutrition P-value
(n = 335) (n = 224) (n = 111) (n = 198) (n = 137)
Age (years) 80.0  7.5 80.8  7.5 78.3  7.3 0.010 81.4  7.3 78.0  7.4 <0.001
Sex, female, n (%) 181 (54.0) 119 (53.1) 62 (55.9) 0.637 119 (60.1) 62 (45.3) 0.007
Primary diseases for rehabilitation, n (%) 0.880 0.347
Orthopedic diseases 118 (35.2) 77 (34.4) 41 (36.9) 76 (38.4) 42 (30.7)
Stroke 153 (45.7) 103 (46.0) 50 (45.0) 86 (43.4) 67 (48.9)
Hospital-associated deconditioning 64 (19.1) 44 (19.6) 20 (18.0) 36 (18.2) 28 (20.4)
Charlson Comorbidity Index, points 1 (0–2) 2 (0–2) 0 (0–2) <0.001 2 (0–2) 0 (0–0) 0.069
OHAT, points 0 (0–2) 0 (0–2) 0 (0–1) 0.005 0 (0–2) 0 (0–0) 0.007
Body mass index (kg/m2) 20.6  3.7 19.2  3.0 23.2  3.4 <0.001 18.4  2.3 23.6  3.0 <0.001
Serum albumin level (g/dL) 3.5  0.4 3.4  0.4 3.7  0.3 <0.001 3.4  0.4 3.6  0.4 <0.001
C-reactive protein level (mg/dL) 0.7  1.5 1.6  0.1 1.2  0.1 0.045 1.5  0.1 1.5  0.1 0.854
Calf circumference (cm)
Male 30.9  4.0 29.4  3.2 34.1  3.5 <0.001 28.5  2.8 33.5  3.3 <0.001
Female 29.1  3.9 27.6  3.5 32.1  2.8 <0.001 27.5  3.4 32.2  3.0 <0.001
Fat-free mass index (kg/m2)
Comparison of two malnutrition criteria

Male 17.1  1.7 16.6  1.5 18.2  1.6 <0.001 16.0  1.1 18.2  1.5 <0.001
Female 13.4  1.7 12.9  1.4 14.5  1.5 <0.001 12.7  1.2 14.9  1.5 <0.001
MNA-SF (points) 6 (4–8) 5 (3–6) 8 (7–10) <0.001 5 (3–6) 8 (6–8) <0.001
FIM (points) 74 (48–90) 64 (39–83) 85 (70.5–98) <0.001 64.5 (41.3–84) 80 (64–80) <0.001
IDDSI Functional Diet Scale (points) 7 (3–8) 7 (3–7) 7 (7–8) <0.001 7 (3–7) 7 (4–7) <0.001
FIM, Functional Independence Measure; IDDSI, International Dysphagia Diet Standardization Initiative; MNA-SF, Mini Nutritional Assessment Short Form; OHAT, Oral Health Assessment Tool.
Data are mean  SD, n (%) and median (interquartile range).

|
3
 A Shimizu et al.

Figure 1 Prevalence of malnutrition as

assessed by the GLIM and ESPEN
diagnostic criteria for malnutrition. ESPEN,
European Society of Clinical Nutrition and
Metabolism; GLIM, Global Leadership
Initiative on Malnutrition.

Global Leadership Initiative on Malnutrition diagnostic
criteria for malnutrition
The GLIM-DCM includes nutritional risk screening and diagnos-
tic processes in the criteria and is composed of three phenotypic
and two etiologic components to diagnose malnutrition.11 The
first step is to identify the patients at risk of malnutrition during
the initial nutritional screening, and the second step is to assess
the phenotypic and etiologic components. The diagnosis of mal-
nutrition requires at least one criterion from each component.
The phenotypic criteria included weight loss (>5% within the past
6 months or >10% beyond 6 months), low BMI (<18.5 kg/m2 for
patients aged <70 years or BMI <20 kg/m2 for patients aged
>70 years) and reduced muscle mass. The GLIM recommends
measurement by validated body composition measures, such as
dual-energy absorptiometry and bioelectrical impedance; however,
standard anthropometric measurements for defining reduced
muscle mass, such as the mid-arm muscle or CC, are accept-
able.11 In this study, the CC was used to evaluate reduced muscle
mass, and the CC cut-off value (CC ≤30 cm in men and ≤29 cm in
women) that reflected reduced muscle mass in Japanese hospital-
ized patients was adapted.19 The etiologic criteria included
reduced food intake (≤50% of energy requirements for >1 week,
or any reduction for >2 weeks) or presence of underlying condi-
tions that negatively affected assimilation, such as dysphagia; nau-
sea; and disease burden, such as injury and acute/chronic disease-
related inflammation. In this study, the presence of disease bur-
den/inflammation was determined based on “chronic disease with

Table 2 Comparisons of the Global Leadership Initiative on Malnutrition (GLIM) and European Society for Clinical Nutrition and
Metabolism (ESPEN) criteria-related items

GLIM criteria ESPEN criteria

All Malnutrition Non-malnutrition P-value Malnutrition Non-malnutrition P-value
(n = 335) (n = 224) (n = 111) (n = 198) (n = 137)
Phenotypic criteria
of GLIM, n (%)
Weight loss 212 (63.3) 188 (83.9) 24 (21.6) <0.001 176 (88.9) 36 (26.3) <0.001
Low BMI† 166 (49.6) 151 (67.4) 15 (13.5) <0.001 151 (76.3) 15 (10.9) <0.001
Reduced muscle mass 160 (47.8) 145 (64.7) 15 (13.5) <0.001 140 (70.7) 20 (14.6) <0.001
Etiologic criteria of GLIM, n (%)
Reduced food intake or 168 (50.1) 201 (90.5) 21 (18.9) <0.001 170 (85.8) 52 (37.9) <0.001
assimilation
Disease 96 (28.6) 81 (36.1) 15 (13.5) <0.001 63 (31.8) 33 (24.0) 0.344
burden/inflammation
ESPEN criteria, n (%)
BMI <18.5 kg/m2 109 (32.5) 101 (45.1) 8 (7.2) <0.001 109 (55.0) 0 (0.0) <0.001
Weight loss 212 (63.3) 177 (79.0) 35 (31.5) <0.001 176 (88.9) 36 (26.3) <0.001
Low BMI‡ 217 (64.8) 182 (81.3) 35 (31.5) <0.001 182 (91.9) 35 (25.6) <0.001
Low FFMI 227 (67.7) 178 (79.4) 49 (44.1) <0.001 182 (91.9) 45 (32.8) <0.001
BMI, body mass index; FFMI, fat-free mass index.
†
Cut-off value for low BMI is <18.5 kg/m2 for patients aged <70 years or <20.0 kg/m2 for patients aged >70 years.
‡
Cut-off value for low BMI is <20.0 kg/m2 for patients aged <70 years or <22.0 kg/m2 for patients aged >70 years.

4 | © 2020 Japan Geriatrics Society

 Comparison of two malnutrition criteria

Table 3 Nutritional characteristics based on the Global Leadership Initiative on Malnutrition (GLIM) components in patients with and
without malnutrition according to the two definitions

GLIM-defined malnutrition Negative Positive P-value Positive Negative P-value

ESPEN-defined malnutrition Negative Negative Positive Positive
Age (years) 78.0  7.5 77.7  7.0 0.020 81.6  7.4 79.1  5.5 0.155
Sex, female, n (%) 48 (52.2) 14 (31.1) 0.676 105 (58.7) 14 (73.7) 0.204
Phenotypic criteria
Weight loss 8 (8.7) 28 (62.2) <0.001 160 (89.4) 16 (84.2) 0.495
Low BMI by GLIM 5 (5.4) 10 (22.2) 0.003 140 (78.2) 10 (52.6) 0.013
Reduced muscle mass 5 (5.4) 15 (33.3) <0.001 130 (72.6) 10 (52.6) 0.069
Etiologic criteria, n (%)
Reduced food intake or assimilation 20 (21.7) 32 (71.1) <0.001 169 (94.4) 10 (52.6) <0.001
Disease burden/inflammation 17 (18.5) 20 (44.4) 0.001 63 (35.2) 0 (0.0) 0.002
BMI, body mass index; ESPEN, European Society of Clinical Nutrition and Metabolism.

inflammation,” “chronic disease with little or no inflammation,” forced input method, and age, sex and diagnostic items for the
or “severe acute disease with inflammation,” according to GLIM GLIM and ESPEN criteria were used in the analysis. P < 0.05 was
criteria.11 considered statistically significant. Statistical analyses were per-
formed using SPSS version 21.0 (IBM Japan, Tokyo, Japan).

European Society for Clinical Nutrition and Metabolism

diagnostic criteria for malnutrition
The ESPEN-DCM has two alternatives for diagnosing malnutri-
tion after initial nutritional screening with a validated screening
tool.9 One is to diagnose malnutrition if the BMI is <18.5 kg/m2,
and the other is a combination of unintentional weight loss
(>10% of habitual weight indefinitely or >5% over 3 months),
reduced BMI (<20 kg/m2 for patients aged <70 years, or < 22 kg/
m2 for patients aged >70 years), or low FFM index (<17 kg/m2 in
men and <15 kg/m2 in women).
Statistical analysis
Categorical variables are expressed as the number of patients (per-
centage). Continuous variables are presented as mean  standard
deviation or median (interquartile range) for parametric or non-
parametric distributions based on histograms, respectively. Differ-
ences between groups were examined using the χ2 test and Mann–
Whitney U-test for categorical and quantitative variables, respec-
tively. Agreement between the GLIM-DCM and ESPEN-DCM
definitions of malnutrition prevalence was assessed using the χ2
test. A logistic regression analysis was performed using the GLIM-
and ESPEN-defined malnutrition as dependent variables to clarify
the influence of etiologic and phenotypic factors on the presence
of malnutrition. A multivariate analysis was performed using the
Results
In total, 351 patients admitted to the rehabilitation care units dur-
ing the study period were enrolled; 16 patients with missing data
were excluded. Finally, 335 older patients (mean  SD, age
80.0  7.5 years; 54.0% women) admitted to the rehabilitation
care units were analyzed, and all the patients were identified to be
at risk of malnutrition (MNA-SF scores ≤11).
Table 1 shows the results of comparisons between patients
with and without malnutrition according to GLIM-DCM and
ESPEN-DCM. For both criteria, patients with malnutrition were
characterized by their older age and low ADL and swallowing
function. Malnourished patients showed high C-reactive protein
levels only in GLIM-DCM (P = 0.045). The prevalence of malnu-
trition according to GLIM-DCM and ESPEN-DCM was 64.7%
(95% confidence interval, 61.5–71.9) and 56.0% (95% confidence
interval, 53.6–64.4) (P < 0.001), respectively (Fig. 1).
Table 2 shows the comparison of malnutrition-related items
involved in GLIM-DCM or ESPEN-DCM. Patients diagnosed
with malnutrition according to GLIM-DCM had a significantly
higher prevalence of all items involved in the phenotypic criteria
and of those involved in the ESPEN criteria, compared with
patients without malnutrition. Similarly, patients diagnosed with
malnutrition as per ESPEN-DCM had a significantly higher

Table 4 Multiple logistic regression analysis for two malnutrition criteria

Factors GLIM-defined malnutrition ESPEN-defined malnutrition

Odds ratio 95% CI P-value Odds ratio 95% CI P-value
Age (years) 1.0 0.9–1.0 0.746 1.0 0.9–1.1 0.180
Sex (female) 0.5 0.1–1.5 0.224 3.9 1.5–10.3 0.005
Phenotypic criteria
Weight loss 64.0 16.7–245.1 <0.001 287.9 34.9–2369.0 <0.001
Low BMI by GLIM 13.2 3.4–50.9 <0.001 90.1 11.6–695.3 <0.001
Reduced muscle mass 7.2 2.0–25.8 0.002 6.1 2.1–17.4 0.001
Etiologic criteria
Reduced food intake or assimilation 184.8 39.6–861.5 <0.001 2.8 1.1–7.1 0.021
Disease burden/inflammation 49.4 10.0–243.8 <0.001 1.0 0.3–2.6 0.966
BMI, body mass index; CI, confidence interval; ESPEN, European Society of Clinical Nutrition and Metabolism; GLIM, Global Leadership Initiative
on Malnutrition.

© 2020 Japan Geriatrics Society | 5

 A Shimizu et al.
proportion of all items involved in the phenotypic criteria and of
those involved in the ESPEN criteria, compared with patients
without malnutrition. In contrast, the disease burden/inflamma-
tion involved in the etiologic criteria of GLIM-DCM did not differ
between the patients diagnosed with malnutrition with/without
ESPEN-DCM (P = 0.344).
Table 3 shows the characteristics of patients with and without
malnutrition between the two definitions. Although GLIM-DCM
is more likely to identify older patients with malnutrition than
ESPEN-DCM, the ESPEN-DCM is more sensitive than GLIM-
DCM for detecting malnutrition-related items, such as weight
loss, low BMI and reduced muscle mass.
Table 4 shows the factors influencing malnutrition diagnosis
using multivariate analyses. All items in the phenotypic and etio-
logic criteria were independent determinants for GLIM-DCM,
whereas disease burden/inflammation (P = 0.966), involved in the
etiologic criteria of GLIM-DCM, were not determinants of
ESPEN-DCM. In addition, the magnitude of reduction in food
intake in GLIM-DCM (odds ratio, 184.8; P < 0.001) and weight
loss in ESPEN-DCM (odds ratio, 287.9; P < 0.001) were the
highest among all other items.
Discussion
We investigated the prevalence of malnutrition in older Asian
inpatients admitted to rehabilitation care units using the newly
proposed GLIM-DCM. In addition, we applied ESPEN-DCM to
similar patients and summarized the differences in their character-
istics. We found that GLIM-DCM more frequently diagnosed
malnutrition than ESPEN-DCM. To our knowledge, this is the
first study to report the differences between GLIM-DCM and
ESPEN-DCM in post-acute care settings.
The prevalence of GLIM-DCM and ESPEN-DCM was 66.9%
and 59.1%, respectively. The GLIM and ESPEN-DCM frame-
works are similar; both frameworks include a two-step process to
diagnose malnutrition, such as initial screening and the subse-
quent steps. In addition, both diagnostic criteria include loss of
body weight, low BMI and reduced muscle mass. The evident dif-
ferences between GLIM-DCM and ESPEN-DCM are that GLIM-
DCM includes etiologic criteria, such as reduced food intake/
assimilation and disease burden/inflammation.11 Between the
ESPEN-DCM and the Academy of Nutrition and Dietetics/Amer-
ican Society for Parenteral and Enteral Nutrition DCM, previous
studies reported a lower prevalence of malnutrition cases diag-
nosed with ESPEN-DCM compared with those diagnosed with
the Academy of Nutrition and Dietetics/American Society for Par-
enteral and Enteral Nutrition DCM (64.1% vs. 20.2%), subjective
global assessment (SGA) (34.4% vs. 20.3%) and patient-generated
SGA (57.1% vs. 12.1%); the SGA also includes reduced food
intake and disease burden as components of the criteria.12,20,21
Considering these previous findings, the etiology of malnutrition
may affect the detection rate of malnutrition. In this study, GLIM-
DCM was more sensitive than ESPEN-DCM for etiologic items,
such as disease burden/inflammation. Thus, GLIM-DCM, which
includes etiology as a component, could identify malnutrition
more frequently than ESPEN-DCM.
Etiologic criteria, such as reduced food intake or assimilation,
and disease burden/inflammation, were considered more specific
determinants in GLIM-DCM than in ESPEN-DCM. Etiologic
criteria, such as reduced food intake or assimilation, and disease
burden/inflammation, were not included in ESPEN-DCM
because the ESPEN working group failed to reach a consensus.9
In contrast, GLIM-DCM successfully included the etiologic
6 |
criteria because it highlighted the importance of considering vari-
ables that reflect the pathophysiological mechanisms that underlie
malnutrition.11,22 Interestingly, reduced food intake or assimila-
tion was a determinant of malnutrition for both the GLIM-DCM
and ESPEN-DCM criteria in this study. Anorexia of aging,
defined as the loss of appetite and/or decreased food intake in late
life, is considered a cause of malnutrition in older patients.10
Thus, reduced food intake or assimilation is an important factor
for identifying malnutrition in older patients. Furthermore, disease
burden/inflammation was identified as the determinant of malnu-
trition in GLIM-DCM, whereas in ESPEN-DCM, disease burden/
inflammation was not necessarily a determinant of malnutrition in
this study. Disease-related malnutrition, which includes an
inflammatory component, is commonly observed in older persons
and diverse clinical practice settings worldwide.23,24 Therefore,
GLIM-DCM, including the etiology of malnutrition, may be more
appropriate for the diagnosis of malnutrition in older adults than
ESPEN-DCM. The presence of GLIM-DCM has been reported
to be associated with higher mortality rates in community-
dwelling older adults.25 The inclusion of GLIM-DCM in the
Comprehensive Geriatric Assessment may help prevent or
improve poor outcomes in older adults.
This study had some limitations. First, it was a retrospective
single-center study, which may limit the generalizability of the
results to older adults in different care settings. Second, FFM was
calculated using previously reported equations; hence, measure-
ment of FFM using dual-energy X-ray absorptiometry or bioelec-
trical impedance analysis method is required. However, the
estimated FFM was highly associated with the FFM measured
using dual-energy X-ray absorptiometry (r = 0.95).17
In conclusion, this study reported the prevalence of malnutri-
tion according to GLIM-DCM and compared the differences in
characteristics between older patients diagnosed with malnutrition
in post-acute care units based on the GLIM-DCM and ESPEN-
DCM definitions. Studies regarding the prevalence of malnutrition
in different care settings are required in the future.
Disclosure statement
The authors declare no conflict of interest.
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How to cite this article: Shimizu A, Maeda K, Honda T,
et al. Comparison between the Global Leadership Initiative
on Malnutrition and the European Society for Clinical
Nutrition and Metabolism definitions for the prevalence of
malnutrition in geriatric rehabilitation care. Geriatr.
Gerontol. Int. 2020;1–7. https://doi.org/10.1111/ggi.14072
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