Diagnostic and application guidelines for malnutrition in adult patients (2025 edition).

Malnutrition is a crucial factor affecting the prognosis of various diseases, especially among elderly, surgical and critically ill patients. With the implementation of diagnosis related groups (DRGs) and diagnosis-intervention packet (DIP) in China, accurate diagnosis and treatment of malnutrition is essential for enhancing clinical decision-making and patient prognosis. These guidelines were developed by multidisciplinary experts through a systematic review of evidence-based medical literature. They adopt the new international standard for malnutrition diagnosis from the Global Leadership Initiative on Malnutrition (GLIM) proposed by the Global Nutrition Organization and categorize evidence levels, providing recommendations tailored to the Chinese population's data and characteristics. The guidelines cover the entire process of malnutrition diagnosis in adult patients, including definition, epidemiology, nutrition risk screening, multi-level nutrition assessment, and diagnostic procedures. They also propose individualized diagnostic strategies for specific patient groups, such as obese or critically ill patients, and establish a standardized process for malnutrition diagnosis. At last, the guidelines form 27 questions, 38 recommendations, in order to improve the practical capacity of malnutrition diagnosis in China.

Twenty years ago, ESPEN published its "Guidelines for nutritional screening 2002", with the note that these guidelines were based on the evidence available until 2002, and that they needed to be updated and adapted to current state of knowledge in the future. Twenty years have passed, and tremendous progress has been made in the field of malnutrition risk screening. Many screening tools have been developed and validated for different patient groups and different health care settings. Some countries even have introduced mandatory screening for malnutrition at admission to hospital. Yet, changes in society and healthcare require a reflection on current practice and policies regarding malnutrition risk screening. In this opinion paper, we share our perspectives on malnutrition risk screening in the twenty-twenties, addressing the changing and varying profile of the malnourished individual, the goals of screening and screening tools (i.e., preventive or reactive), the construct of malnutrition risk (i.e., screening for risk factors or screening for existing malnutrition), and screening alongside a patient's journey.

Complementarity of nutritional screening tools to GLIM criteria on malnutrition diagnosis in hospitalised patients: A secondary analysis of a longitudinal study

Early recognition of malnutrition is essential to improve the prognosis of older patients with hip fracture. The Nutritional Risk Screening 2002 (NRS-2002), the Short-Form Mini Nutritional Assessment (MNA-SF) and the Global Leadership Initiative on Malnutrition (GLIM) are widely used in malnutrition diagnosis. However, criteria for predicting postoperative hip joint motor function in older patients with hip fractures are still necessary. The objective of this study was to select the most appropriate criteria from the NRS-2002, the MNA-SF and the GLIM in predicting the postoperative hip joint motor function recovery 1 year after surgery. This retrospective observational study included 161 patients aged ≥ 65 years with hip fractures. The nutritional status of patients was determined by the NRS-2002, MNA-SF and GLIM. The Harris hip joint score (HHS), the primary outcome of this study, was used to evaluate hip joint motor function. HHS was classified as excellent (HHS > 75) or non-excellent outcomes (HHS ≤ 75). Logistic regression models for hip joint motor function recovery were constructed. Both the receiver operating characteristic curve and the decision curve analysis were used to select the most predictive criteria. The overall mean age of the 161 patients was 77.90 ± 8.17. As a result, NRS-2002 (OR:0.06, 95%CI [0.01, 0.17]), MNA-SF (OR:0.05, 95%CI [0.00, 0.23]) and GLIM (OR of moderate: 0.03, 95%CI [0.01, 0.11]; OR of severe: 0.02 [0.00, 0.07]) were predictive for recovery of hip joint motor function. Additionally, both the area under curve of the receiver operating characteristic curve (NRS-2002: 81.2 [73.8, 88.6], MNA-SF: 76.3 [68.5, 84.2], GLIM: 86.2 [79.6,92.8]) and the decision curve analysis showed the GLIM was better than others. Compared with NRS-2002 and MNA-SF, GLIM was a more suitable nutritional assessment criteria to predict the postoperative recovery of hip joint motor function for older patients with hip fracture 1 year after surgery.

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. 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 thedirect use of GLIM criteria. 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. 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.

Agreement between the GLIM criteria and PG-SGA in a mixed patient population at a nutrition outpatient clinic

The muscle-related indicator is removed from Global Leadership Initiative on Malnutrition (GLIM) criteria implemented in China for many reasons. Patients with hematopoietic stem cell transplants are at nutrition risk and can enter into the second step of GLIM; thus, they are suitable for learning the diagnosing malnutrition significance between primary GLIM and GLIM-China criteria. This article aims to explore the role of muscle mass in the diagnostic criteria of malnutrition and the effects of GLIM-China for diagnosing malnutrition. A total of 98 inpatients with hematopoietic stem cell transplants (HSCT) were recruited. Nutrition risk was assessed by using the Nutritional Risk Screening 2002 (NRS-2002). Appendicular skeletal muscle mass (ASMI) and fat-free mass index (FFMI) were determined using the bioelectrical impedance analysis (BIA) method. Malnutrition is defined by GLIM-China, GLIM, and PG-SGA. We use erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to assess inflammation in GLIM and GLIM-China. The correlation or consistency among ASMI, FFMI, ESR, CRP, GLIM-China, GLIM, and PG-SGA was evaluated, respectively. One hundred percent instead of the patients had nutritional risk. The magnitude of malnutrition using PG-SGA, GLIM, and GLIM-China was 75.5, 80.6, and 64.3%, respectively. GLIM-China and PG-SGA showed the same performance (p = 0.052 vs. 1.00) and agreement (kappa = 0.404 vs. 0.433, p < 0.0001) with the FFMI. Consistency was noted between ASMI and PG-SGA in the assessment of malnutrition (p = 0.664) with a good agreement (kappa = 0.562, p = 0.084). ASMI and FFMI could determine muscle mass reduction, which could not be determined by BMI, albumin (ALB), and pre-albumin (pre-ALB); 34% of GLIM-China (-) patients were with low ASMI, and 40% with low FFMI; 30.0% of patients with PG-SGA (<4) still have low ASMI, and 38.2% have low FFMI. If only the PG-SGA scale is used as a diagnostic criterion for evaluating malnutrition, a large proportion of patients with reduced muscle mass will be missed, but more patients with muscle loss will be missed via GLIM-China. Muscle-related indicators will help diagnose malnutrition.

To review recent reports on techniques and tools for screening and diagnosis of malnutrition in gastrointestinal disease, in the light of the newly published definition of malnutrition by the Global Leadership Initiative on Malnutrition (GLIM). In 2019, the GLIM concept of malnutrition was published advocating a two-step procedure; first, screening, and second confirmation of the diagnosis that requires a combination of phenotypic and etiologic criteria. Three studies in patients with gastrointestinal disorders so far published utilize the GLIM criteria. Otherwise, traditional tools, as Nutrition Risk Screening-2002, Malnutrition Universal Screening Tool or Subjective Global Assessment are used, and confirm that malnutrition is observed in a substantial number of patients with inflammatory bowel diseases (IBDs), serious liver disorders and various forms of pancreatitis. Common for these disorders is an extensive loss of muscle mass, which is one of the GLIM phenotypic criteria. Such patients often undergo abdominal computed tomography scans that enable psoas muscle mass at L3 or L4 level to be calculated. The 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 malnutrition by the GLIM concept.

Objective: this study aimed to explore the agreements between the Global Leadership Initiative on Malnutrition (GLIM) using left calf circumference (CC) as criterion for reduced muscle mass and the Patient-Generated Subjective Global Assessment (PG-SGA), or GLIM using appendicular skeletal muscle index (ASMI) for the diagnosis of malnutrition in gastric cancer patients. Methods: the Nutritional Risk Screening 2002 (NRS 2002) was used as nutritional risk screening. PG-SGA and GLIM were applied for malnutrition diagnosis. Agreements were evaluated by Kappa, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and area under the curve (AUC). Results: a total of 405 gastric cancer patients were included. The values of Kappa, sensitivity, specificity, PPV, NPV, accuracy and AUC were 0.463, 67.9 %, 87.3 %, 92.9 %, 52.8 %, 73.6 % and 0.776, and 0.496, 76.7 %, 78.0 %, 89.4 %, 57.9 %, 77.0 % and 0.773, respectively, between GLIM using CC with or without NRS 2002 and PG-SGA. All values of agreement were higher than 0.800 or 80.0 % between GLIM using left CC and GLIM using ASMI. Conclusion: the agreements were both acceptable between GLIM using left CC and PG-SGA, and GLIM using ASMI. Left calf circumference can be one of the credible references indicating a reduced muscle mass in patients with gastric cancer.

The performance of three nutritional tools varied in colorectal cancer patients: a retrospective analysis

ObjectiveTo investigate and compare the predictive efficacy of the Nutritional Risk Screening 2002 (NRS2002) and the Global Leadership Initiative on Malnutrition (GLIM) criteria for postoperative complications in patients with gastrointestinal malignancies.MethodsThis prospective cohort study enrolled patients with gastrointestinal malignancies scheduled for surgical resection at our institution from December 2019 to December 2024. Nutritional risk and status were assessed using NRS2002 and GLIM criteria within 24 h of admission. Data on postoperative complications, hospitalization expenses, length of hospital stay, and unplanned 30-day and 60-day readmissions were meticulously collected and analyzed using logistic regression and ROC curve analysis.ResultsA total of 471 patients were included. Nutritional risk (NRS2002 ≥ 3) was identified in 45.01% (n = 212) of patients. According to GLIM criteria, 43.10% (n = 203) were diagnosed with malnutrition. Multivariable logistic regression analysis revealed that nutritional risk (adjusted OR 7.58, 95%CI: 4.75–12.05, p < 0.001), GLIM-defined malnutrition (adjusted OR 5.62, 95%CI: 3.59–8.76, p < 0.001), moderate malnutrition (adjusted OR 4.78, 95%CI: 2.78–8.17, p < 0.001), and severe malnutrition (adjusted OR 6.71, 95%CI: 3.82–11.78, p < 0.001) were independent risk factors for postoperative complications. The Area Under the Curve (AUC) for NRS2002 in predicting complications was 0.735, which was significantly greater than the AUC for GLIM diagnosis (0.706; p = 0.003). No significant difference in AUC was observed between NRS2002 and GLIM severity grading (0.712; p = 0.215). Neither NRS2002 nor GLIM assessments were significantly associated with unplanned readmissions in adjusted models.ConclusionBoth NRS2002-defined nutritional risk and GLIM-defined malnutrition are significant independent predictors of postoperative complications in patients with gastrointestinal malignancies. The NRS2002 demonstrated slightly superior predictive ability for postoperative complications compared to the dichotomous GLIM diagnosis. These findings support the routine use of both tools for preoperative risk stratification to guide targeted nutritional interventions.

This study investigated a 3-step procedure of nutritional risk screening, evaluation, and Global Leadership Initiative on Malnutrition (GLIM) diagnosis for Chinese elderly inpatients. Nutritional risk screening was performed as the first step using the Nutritional Risk Screening 2002 (NRS2002). Nutritional status evaluation was performed as the second step using the Mini-Nutritional Assessment Short Form (MNA-SF). Malnutrition diagnosis was performed as the third step using the GLIM criteria. The consistency of these tools and the validity of the GLIM criteria were proven. Fewer patients met the GLIM criteria compared with the NRS2002. Good correlations between malnutrition and frailty or sarcopenia were discovered.

Background/Objectives: Malnutrition frequently occurs following bariatric surgery and can lead to higher morbidity rates, hospitalizations, and extended hospital stays. Nutritional assessment tools such as the Global Leadership Initiative on Malnutrition (GLIM) are not validated for diagnosis of malnutrition following bariatric surgery. This study aimed to assess the validity of GLIM criteria in evaluating the nutritional status of post-sleeve gastrectomy patients compared to the Subjective Global Assessment (SGA). Methods: A total of 47 adult patients who underwent sleeve gastrectomy (SG) from 6 months to 2 years prior were evaluated using the GLIM and SGA. Additionally, multiple pass 24 h recall was collected for two days, and macronutrient analyses were conducted using ESHA software (version 11.11.x). Agreement between both tools was determined using Kappa (κ) statistics, and the Receiver Operating Characteristics (ROC) curve was used to establish sensitivity and specificity. Results: The study found that malnutrition was diagnosed in 48.9% and 42.6% of patients according to the GLIM and SGA criteria, respectively. The GLIM criteria exhibited inadequate accuracy (AUC = 0.533; 95% CI, 0.38-0.72) with a sensitivity and specificity of 55.0% and 55.6%, respectively. The agreement between both tools was determined to be poor (κ = 0.104). Conclusions: GLIM did not show sufficient agreement with SGA. Consequently, the criteria of GLIM may need revision for better diagnosis of malnutrition in post-sleeve gastrectomy patients.

There are no standardized assessment criteria for selecting nutritional risk screening tools or indicators to assess reduced muscle mass (RMM) in the Global Leadership Initiative on Malnutrition (GLIM) criteria. We aimed to compare the consistency of different GLIM criteria with Subjective Global Assessment (SGA) and protein-energy wasting (PEW). In this study, nutritional risk screening 2002 first four questions (NRS-2002-4Q), Nutritional Risk Screening 2002 (NRS-2002), Malnutrition Universal Screening Tool (MUST), and Mini-Nutritional Assessment Short-Form (MNA-SF) tools were used as the first step of nutritional risk screening for the GLIM. The RMM is expressed using different metrics. The SGA and PEW were used to diagnose patients and classify them as malnourished and non-malnourished. Kappa (κ) tests were used to compare the concordance between the SGA, PEW, and GLIM of each combination of screening tools. A total of 157 patients were included. Patients with Chronic kidney disease (CKD) stage 1-3 accounted for a large proportion (79.0%). The prevalence rates of malnutrition diagnosed using the SGA and PEW were 18.5% and 19.7%, respectively. The prevalence of GLIM-diagnosed malnutrition ranges from 5.1% to 37.6%, depending on the different screening methods for nutritional risk and the different indicators denoting RMM. The SGA was moderately consistent with the PEW (κ = 0.423, p < 0.001). The consistency among the GLIM, SGA, and PEW was generally low. Using the NRS-2002-4Q to screen for nutritional risk, GLIM had the best agreement with SGA and PEW when skeletal muscle index (SMI), fat-free mass index (FFMI), and hand grip strength (HGS) indicated a reduction in muscle mass (SGA: κ = 0.464, 95% CI 0.28-0.65; PEW: κ = 0.306, 95% CI 0.12-0.49). The concordance between the GLIM criteria and the SGA and PEW depended on the screening tool used in the GLIM process. The inclusion of RMM in the GLIM framework is important. The addition of HGS could further improve the performance of the GLIM standard compared to the use of body composition measurements.

Simple muscle assessment improves GLIM-based malnutrition detection and prognostic stratification in hospitalized patients:A nationwide study.