I criteri GLIM per la malnutrizione

Rocco Barazzoni

Department of Medical, Surgical and Health Sciences

University of Trieste – Italy

Chairman – European Society for Clinical Nutrition and Metabolism

MALNUTRITION and CLINICAL NUTRITION:

GROWING DEMAND

Malnutrition diagnosis tree

Cederholm et al, Clin Nutr 2017

At risk for malnutrition

Malnutrition/Undernutrition

Disease-related malnutrition (DRM) with inflammation

Acute disease- or trauma-related

malnutrition

Chronic DRM with inflammation

Cancer cachexia and other disease-specific cachexia

Disease-related malnutrition (DRM) without inflammation

Malnutrition/undernutrition without disease

Socioeconomic/ psychologic

related malnutrition

Hunger-related

malnutrition

FOOD RELATEDDISEASE RELATED

20th-21st Century: The “AGING EPIDEMICS”

The OBESITY EPIDEMICS

Clin Nutr 2017

CLINICAL NUTRITIONWORKS

SURVIVAL- CLINICAL OUTCOMES

- ↓Functional status decline

- ↓ 30-day adverse outcome

- ↓Mortality

Lancet 2019

High-Protein + HMB

Clin Nutr 2016

SURVIVAL- CLINICAL OUTCOMES

COST-EFFECTIVENESS (NESG)

Clin Nutr 2017

Clin Nutr 2016

CANCERINDICATIONS: ONS-EN(-PN)

Malnutrition Prevalence 30-70 %

CLINICAL NUTRITION

ROUTINE PATIENTASSESSMENTTREATMENT

IMPLEMENTATION

CLINICAL BARRIERSCOMPLEXITY

- Patient HETEROGENEITY

- Clinical studiesHETEROGENEITY → DESIGN-TARGETS

ONE SIZE DOES NOT FIT ALL

- Evidence GAPS

CLINICAL BARRIERSWHAT IS MALNUTRITION ?

HOW DO YOU DIAGNOSE MALNUTRITION ?

ESPEN (LLL, Blue Book)Pathophysiology

Malnutrition is a subacute or chronic state ofnutrition, in which a combination of varyingdegrees of under- or overnutrition andinflammatory activity has led to changes inbody composition and diminished function

ASPEN/AND consensus statement

Malone et al. Nutr Clin Pract 2013

ICD-WHO

BMI < 18.5 kg/m2

ANEMIA

1) Diagnosis: ↓ Hemoglobin

2) Assessment:

- Hemorragic

- Deficiency

- Hemolitic

- CKD- Other

DIABETES MELLITUS

1) Diagnosis: ↑ Blood Glucose (>126)

↑ HbA1c (>6.5%)

2) Assessment:

- Type 1

- Type 2

- GDM- Secondary

OBESITY

1) Diagnosis: ↑ BMI (>30 kg/m2)

2) Assessment:

ESPEN INITIATIVE 2013-2016:- TERMINOLOGY- DIAGNOSTIC CRITERIA to be

HOW DO YOU DIAGNOSE MALNUTRITION ?

• Simple: used in daily clinical practice

• Simple: minimum number of items

• General: etiology-independent

• Implementation: Consensus

• Implementation: ICD-18

Homeostasis

BODY MASS

What is the core of malnutrition?BASIC DIAGNOSIS: PHENOTYPE

Energy ExpCalorie - Protein

Bone

Fat Mass

Muscle Mass

Other

LBM

Body Protein

FM

Energy ExpCalorie - Protein

BODY COMPOSITION

QUANTITY QUALITY

What is the core of malnutrition?BASIC DIAGNOSIS: PHENOTYPE

ESPEN suggestion for diagnostic criteria for malnutrition

Step 2. Diagnosis is confirmed by

• BMI <18.5 kg/m2

or

• Weight loss >10% (indefinite time)/>5% last 3 mo

combined with either

• BMI <20 (<70 y)/<22 (>70 y) or

• FFMI <15 and 17 kg/m2 in women and men, respect.

Step 1. Risk screening by a validated instrument , e.g. NRS-2002, MUST, MNA(-SF), SNAQ, ...i.e. BMI, Weight loss, Reduced food intake, Disease severity

Cederholm et al Clin Nutr 2015

Clin Nutr 2016

Validation studies (n=426 total cites)

CRITICISM(OPPORTUNITIES TO INCREASE CONSENSUS)

• Cut-offs

– Low prevalence figures

• Body Composition

• Pathophysiology Criteria

• Global DISCUSSION-FEEDBACK

GLOBAL LEADERSHIP INITIATIVE ON MALNUTRITION 2016-:

HOW DO YOU DIAGNOSE MALNUTRITION ?

2-STEP Approach: strong consensus

• Step 1 – SCREENING

– (RISK: available standard validated approaches).

• Step 2 – ASSESSMENT

– DIAGNOSIS

– ETIOLOGY

CORE COMMITTEE + WORKING GROUP: Ballott• The top 5 ranked criteria:

PHENOTYPE

– WEIGHT LOSS

– ↓BMI (underweight)

– ↓ LEAN - FAT-FREE - MUSCLE MASS

ETIOLOGY

– ↓ FOOD INTAKE

– ↑ Disease burden - ↑ INFLAMMATION

ALGORYTHM FOR MALNUTRITION DIAGNOSIS

PHENOTYPIC CRITERIA!!

SEVERITY GRADING: yes

GLIM Consensus – SUMMARY• Diagnosis: 2-step process

– Step 1: Screening for malnutrition risk

– Step 2: Diagnosis > Assessment

• CRITERIA:

3 PHENOTYPE + 2 ETIOLOGY– 1 phenotype + 1 etiology criteria are required for diagnosis

• SEVERITY STAGING– Stage 1: Moderate

– Stage 2: Severe

• PERIODIC RE-EVALUATION + UPDATES

– EVERY 3-5 years

GLIM

GLIM MALNUTRITION DIAGNOSTIC CRITERIA:

• A set of simple consensus criteria intended forglobal application by professionals

– Moderate training needed

• Readily available assessment tools and methods

– Physical examination and standard anthropometricmeasures may be acceptable (MUSCLE MASS)

• Possible use with additional approaches andcriteria (REGIONAL preference)

GLIM

GLIM MALNUTRITION DIAGNOSTIC CRITERIA:

• Comprehensive assessment should follow diagnosis(ETIOLOGY of malnutrition)

• Consultation of skilled nutrition specialist-practitioner

• Repeated measures over time recommended

– Trajectories of decline, maintenance, and improvementmay be identified

GLIM – WHAT NEXT ?

DISSEMINATIONIMPLEMENTATION

VALIDATION

PERSPECTIVE

DISSEMINATION

–CLINICAL AND SCIENTIFIC SOCIETIES

–REGULATORY AGENCIES

–NEW PARTNERS

+

CLINICAL

PROBLEM DIAGNOSIS TREATMENT

MALNUTRITION

↑ ↑ comorbidities

↑ ↑ care

↑ ↑ cost

↓ ↓ outcome GLIM

GUIDELINEDELIVERY

Non-Nutrition Specialists

SPECIALTY-specific ISSUES

+

CLINICAL

PROBLEM DIAGNOSIS TREATMENT

MALNUTRITION

↑ ↑ comorbidities

↑ ↑ care

↑ ↑ cost

↓ ↓ outcome GLIM

GUIDELINEDELIVERY

EDUCATIONAL TOOLS

PROMOTE COOPERATION

The OBESITY EPIDEMICS

+

A PERFECT MUSCLE METABOLIC STORM

INFLAMMATION

INSULIN RESISTANCE

OX STRESS

+

OBESITY per se

MASSFUNCTION

PROTEIN DEGRADATION

+

A PERFECT MUSCLE METABOLIC STORM

INFLAMMATION

INSULIN RESISTANCE

OX STRESS

+

COMPLICATED OBESITY

MASSFUNCTION

PROTEIN DEGRADATION

METABOLIC SYNDROME DIABETES

MASSFUNCTION

PROTEIN DEGRADATION

THERAPEUTIC WEIGHT LOSS BARIATRIC SURGERY

The (SARCOPENIC) OBESITY EPIDEMICS?

Tangvik et al, Clin Nutr 2014

HOSPITAL At-Risk Population: DiseaseAgeObese

GLIM ALGORYTHM FOR MALNUTRITION DIAGNOSIS

At risk for Malnutrition Use validated screening tools

Assessment Criteria

Phenotype

o Weight losso ↓BMI (underweight)

o ↓ Muscle Mass Etiology

o ↓ Food intake (or absorption)

o ↑ Inflammation - Disease

AT LEAST 1 Phenotype Criterion

AND

1 Etiology Criterion

Screening

Diagnosis

YES

↑ OBESE AND MALNOURISHED!!

PERSPECTIVE

DISSEMINATION–CLINICAL AND SCIENTIFIC SOCIETIES

–REGULATORY AGENCIES•ICD

•WHO–NEW PARTNERS

WHO

Moscow Dec 16 WHO-ESPEN meeting

PATIENT VIDEOS!!

NON-Nutritionist HealthCare Professionals

Patients

Public

NEW PARTNERSto increase demand for clinical nutrition

FAMILY MEDICINE

January 2020 ESPEN Winter meeting

PERSPECTIVE

IMPLEMENTATION

–NATIONAL ENDORSEMENT – COMMITMENT

• NATIONAL POLICYMAKERS

–STRATEGIC GOALS:

• Body weight ROUTINE MEASUREMENT

• Body composition ROUTINE MEASUREMENT

ADDITIONAL RECOMMENDATIONS

Cut-Offs and SURROGATES:

•↓ MUSCLE MASSE.G: fat free mass index (FFMI, kg/m2) by DEXA or BIA, CT, MRI.Ethnicity adaptation NEEDEDALTERNATIVES: when not available or by regional preference:- physical exam- standard anthropometric measures- functional assessments (e.g. hand-grip strength) may be

considered as a SUPPORTIVE measure.

PERSPECTIVE

PERSPECTIVE

ADDITIONAL RECOMMENDATIONS

Cut-Offs and SURROGATES:

•DISEASE - INFLAMMATION- Acute disease/injury-related with severe inflammation.E.G: major infection, burns, trauma or closed head injury

- Chronic disease-related with chronic or recurrent mild tomoderate inflammation.E.G:: malignant disease, COPD, CHF, CKD or any diseasewith chronic or recurrent Inflammation.

C-reactive protein may be used as laboratory measure: → CUT-OFFS

PERSPECTIVE

VALIDATION: Validation teamManuscript in press Clin Nutr 2019

- CRITERIA- Predictive – Prognostic value

- METHODOLOGY- Comparable results – Databases

- Required by AGENCIES

1) The GLIM diagnostic criteria represent a historicachievement in the field of clinical nutrition since theyallow for simple, accessible and accepted identification ofmalnutrition at global level

2) Such strength should be used to advance clinical, scientificand political recognition of malnutrition and the clinicalnutrition field at large

3) The process has started and should continue withcoordinated global efforts to maximize momentum andimpact in dissemination, implementation and validationinitiatives

Conclusions

LET’S GET TO WORK!!

Can we go global with the proposed approach to malnutrition diagnosis?THINK GLOBALLY – ACT LOCALLY!!

SEPTEMBER 19-22, 2020

Acknowledgements:

Tommy Cederholm

ESPEN EDU working group

GLIM working group

Thank you for your attention