Global Leadership Initiative in Malnutrition (GLIM): Global Consensus on Malnutrition Diagnostic Criteria Harriët Jager-Wittenaar, PhD, MD

Transcription

1 Global Leadership Initiative in Malnutrition (GLIM): Global Consensus on Malnutrition Diagnostic Criteria Harriët Jager-Wittenaar, PhD, MD Professor (Lector) of Malnutrition and Healthy Ageing

2 Global Leadership Initiative in Malnutrition (GLIM): Global Consensus on Malnutrition Diagnostic Criteria Harriët Jager-Wittenaar, PhD, RD Professor of Malnutrition and Healthy Ageing Hanze University of Applied Sciences

3 Malnutrition Diagnostic Criteria The path to consensus by the Global Leadership Initiative in Malnutrition (GLIM) The way to consensus Professor Tommy Cederholm, Sweden The GLIM Criteria for Malnutrition Professor Gordon L Jensen, USA

4 Malnutrition ESPEN conceptual definition A state resulting from lack of intake or uptake of nutrition that leads to altered body composition (decreased fat free mass) and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease Cederholm et al., Clin Nutr

5 Nutrition-related disorders Nutrition disorders and nutrition-related disorders Malnutrition/ Undernutrition Sarcopenia and Frailty Overweight and Obesity Micronutrient abnormalities Refeeding syndrome Cederholm et al., Clin Nutr

6 Types of malnutrition At risk for malnutrition * DRM = diseaserelated malnutrition Malnutrition/Undernutrition DRM* with inflammation Acute diseaserelated or injuryrelated malnutrition Chronic DRM with inflammation DRM without inflammation Malnutrition/ undernutrition without disease Socioeconomic or psychologicrelated malnutrition Hunger-related malnutrition Diseasespecific cachexia Cederholm et al., Clin Nutr

7 Operational definition (criteria) for malnutrition diagnosis Alternative 1: BMI <18.5 kg/m Alternative 2: Weight loss (unintentional) > 10% indefinite of time, or >5% over the last 3 months, combined with either BMI <20 kg/m2 if <70 years, or <22 kg/m2 if 70 years or FFMI <15 and 17 kg/m2 in women and men, resp. Energy intake Weight loss Loss of subcutaneous fat Muscle mass Fluid accumulation Reduced hand grip strength à 2 out of 6 criteria is recommended for diagnosis of malnutrition Cederholm et al White et al. 2012

8 Previous attempts have not captured global acceptance Too elaborate Overly restrictive Body composition measurement techniques not available Lack of criteria indicating etiology Not accounting ethnicity.

9

10 Joint action by ASPEN, ESPEN, FELANPE, PENSA Global Leadership Initiative on Malnutrition (GLIM) The GLIM process spanning 3-years CNW/Austin Jan 2016 ESPEN/Copenhagen Sept 2016 CNW/Orlando Feb 2017 ESPEN/the Hague Sept 2017 CNW/Las Vegas Jan 2018 ESPEN/Madrid Sept 2018

11 Global Leadership Initiative in Malnutrition Core committee GL Jensen / Compher C ASPEN Cederholm T / Van Gossum A ESPEN Correia I / Gonzalez MC FELANPE Fukushima R / Higashiguchi T PENSA Working group Baptista G, Barazzoni R, Blaauw R, Coats AJS, Crivelli A, Evans DC, Gramlich L, Fuchs V, Keller H, Llido L, Malone A, Mogensen KM, Morley JE, Muscaritoli M, Nyulasi I, Pirlich M, Pisprasert V, de van der Schueren MAE, Siltharm S, Singer P, Tappenden K, Velasco N, Waitzberg D, Yamwong P, Yu J

12 Objectives of GLIM Consensus development of evidence-based criteria suitable to diverse clinical settings Global dissemination of consensus criteria Priority to seek adoption by leading diagnosis classification and coding entities across the globe Desired approach to malnutrition diagnosis should be: - simple - include clinically relevant diagnostic criteria appropriate for application by all healthcare professionals - using methods that are widely available To promote global use of consensus criteria that can be readily used with other approaches and additional criteria for regional preference

13 Strong Support for a two Step Approach to Malnutrition Diagnosis Step 1 screening for malnutrition risk using available standard validated approaches Step 2 assessment to diagnose malnutrition and to stage severity

14 Survey of existing approaches screening and assessment of malnutrition and cachexia NRS MNA- SF MUST ESPEN 2015 ASPEN/ AND 2012 SGA Evans 2008 PEW 2008 Fearon 2011 Etiologies Reduced food intake X X X X X X X X Disease burden/ inflammation Symptoms X X X X X X X X X Anorexia X X X X Weakness X X X Signs/Phenotype Weight loss X X X X X X X X X Body mass index X X X X X X X Lean/fat free/muscle mass X X X X X X X Fat mass X X X Fluid retention/ascites X X Muscle function; e.g. grip strength X X X Biochemistry X X

15 Selected criteria by GLIM working group ballot NRS MNA- SF MUST ESPEN 2015 ASPEN/ AND 2012 SGA Evans 2008 PEW 2008 Fearon 2011 Etiologies Reduced food intake X X X X X X X X Disease burden/ inflammation Signs/Phenotype X X X X X X X X X Weight loss X X X X X X X X X Body mass index X X X X X X X Lean/fat free/muscle mass X X X X X X X

16 Consensus phenotypic and etiologic criteria cut-offs for the diagnosis of malnutrition Phenotypic Criteria Etiologic Criteria Weight loss (%) Low body mass index (kg/m 2 ) Reduced muscle mass Reduced food intake or assimilation Inflammation >5% within past 6 months, or >10% beyond 6 months <20 if <70 years, or <22 if >70 years Asia: <18.5 if <70 years, or <20 if >70 years Reduced by validated body composition measuring technique Supportive measure: muscle strength 50% of energy requirements >1 week, or any reduction for >2 weeks, or any chronic GI condition that adversely impacts food assimilation or absorption Acute disease/ injury or chronic disease-related Supportive proxy measures: CRP, albumin, pre-albumin Supportive indicators: gastrointestinal symptoms

17 Thresholds for severity grading of malnutrition into Stage 1 (moderate) and Stage 2 (severe) malnutrition Phenotypic Criteria Weight loss (%) Low body mass index (kg/m 2 ) Reduced muscle mass Stage 1 Moderate Malnutrition (Requires 1 phenotypic criterion that meets this grade) 5-10% within the past 6 months, or 10-20% beyond 6 months <20 if <70 years, <22 if 70 years Mild to moderate deficit (per validated assessment method) Stage 2 Severe Malnutrition (Requires 1 phenotypic criterion that meets this grade) >10% within the past 6 months, or >20% beyond 6 months <18.5 if <70 years, <20 if 70 years Severe deficit (per validated assessment method)

18 GLIM diagnostic scheme for screening, assessment, diagnosis and grading of malnutrition Risk screening At risk for malnutrition Use validated screening tools Diagnostic Assessment Assessment criteria Phenotypic - Non-volitional weight loss - Low body mass index - Reduced muscle mass Etiologic - Reduced food intake or assimilation - Disease burden/inflammatory condition Diagnosis Meets criteria for malnutrition diagnosis Requires at least 1 Phenotypic criterion and 1 Etiologic criterion Severity Grading Determine severity of malnutrition Severity determined based on Phenotypic criterion

19 Conclusion A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed Next steps are: - to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia - WHO à ICD-11 - to promote dissemination, validation studies, and feedback The diagnostic construct should be re-considered every 3-5 years

20 Free access to consensus paper

21 Discussion What is the predictive validity of these criteria? How do these criteria distinguish between the subtypes of malnutrition? How to implement these criteria? Opportunity for dietitians?! 21

22 Thank you! Special thanks to: Prof.dr. T. Cederholm Prof.dr. G. Jensen