On September 2, 2018, the Global Leadership Initiative on Malnutrition (GLIM) published in the Journal of Parenteral and Enteral Nutrition a consensus recommendation “GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community.”

Leaders of the initiative included representatives from the American Society for Parenteral and Enteral Nutrition (ASPEN), European Society for Clinical Nutrition and Metabolism, Latin American Nutritional Federation, Parenteral and Enteral Nutrition Society of Asia.

The purpose of GLIM is to reach a global consensus on the identification and endorsement of criteria for the diagnosis of malnutrition in clinical settings.

The GLIM definition of malnutrition is based on 5 diagnostic criteria: 3 phenotypic (clinical findings) and 2 etiologic (causes).

The diagnosis of malnutrition requires at least 1 phenotypic criterion and 1 etiologic criterion.

GLIM Malnutrition criteria

Phenotypic Criteria
1.  Weight loss % (unintended)5% < 6 months, or
10% > 6 months
2.  Low BMI< 20 if < 70 yrs, or < 22 if > 70 yrs
3.  Reduced Muscle MassReduced by objective measures and/or physical exam

 

Etiologic Criteria
1.  Reduced Nutritional Intake< 50% of requirement > 1 week, or
Any reduction > 2 weeks, or
Chronic GI disorders with adverse nutrition impact
2.  InflammationChronic disease, or
Acute disease/injury with severe systemic inflammation, or
Socioeconomic/environmental starvation

 Severity of malnutrition is based on phenotypic criteria only, and requires 1 phenotypic criteria that meets these thresholds:

Moderate (stage 1) malnutrition
1.  Weight loss %
(unintended)
5%─10% < 6 months, or
10%─20% > 6 months
2.  Low BMI< 20 if < 70 yrs, or < 22 if > 70 yrs
3.  Reduced Muscle MassMild-to-moderate deficit (per validated assessment methods*)

 

Severe (stage 2) malnutrition
1.  Weight loss %
(unintended)
> 10% < 6 months, or
> 20% > 6 months
2.  Low BMI< 18.5 if < 70 yrs, or
< 20 if > 70 yrs
3.  Reduced Muscle MassSevere deficit (per validated assessment methods*)

*To measure muscle mass, GLIM recommends use of DEXA, bio-electrical impedence analysis (BIA), ultrasound, CT or MRI, but these are costly and impractical.  As an alternative, calf or arm circumference and physical exam findings may be used along with calibrated hand-grip strength which is correlated with muscle mass.

The GLIM criteria offer some advantages over the 2012 ASPEN Malnutrition Consensus criteria.  While the ASPEN criteria is effective for diagnosing malnutrition, it was less so for defining severe malnutrition.  The GLIM criteria are less subjective, more clinically intuitive and include weight loss, muscle mass, and BMI parameters that are more consistent with the traditional concepts of non-severe and severe malnutrition.

For example, muscle mass assessment is much more robust than in ASPEN recommending calf/arm circumference, physical findings and measurement of hand grip strength. More stringent criteria for severe malnutrition reduces over-diagnosis and compliance exposure.

In addition, the GLIM Etiology criteria for acute disease/injury includes confirmation of severe systemic inflammation (in contrast to ASPEN).  This is a much-needed provision that incorporates recent research showing the central role systemic inflammation plays in the development of malnutrition.  Biomarkers are recommended to confirm chronic or severe systemic inflammation. C-reactive protein (CRP) is preferred but low albumin/prealbumin are also included.  While not specifically mentioned by GLIM, SIRS criteria could also be used to identify systemic inflammation.

It is important to note that applying the GLIM BMI criteria in the United States could be problematic.  A sizeable proportion of the population is obese to begin with, so some patients with malnutrition can be expected to have a BMI above 22.  A BMI < 20─22 may be unacceptable for malnutrition when the CDC definition of normal is 18.5 to 24.9.  A facility should consider modifying the GLIM BMI criteria for moderate (stage 1) malnutrition to < 18.5 and severe (stage 2) to < 16 to be more consistent with clinical expectations and for compliance purposes.

From a coding perspective, GLIM identifies only moderate and severe malnutrition. Malnutrition stage is not an indexed term so if stage 1 is documented, code E46 (unspecified malnutrition) may be used. If only stage 2 is documented, it must be clarified as severe for correct coding of E43 (severe malnutrition).