A critical analysis of the methodological processes applied in the studies using the Global Leadership Initiative on Malnutrition

FONSECA, Ana Luísa Ferreira; FERREIRA, Lívia Garcia

doi:10.1590/1678-9865202134e210072

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Sumário

REVIEW • Rev Nutr 34 • 2021 • https://doi.org/10.1590/1678-9865202134e210072 copy

A critical analysis of the methodological processes applied in the studies using the Global Leadership Initiative on Malnutrition

Global Leadership Initiative on Malnutrition: uma análise crítica de estudos a respeito dos processos metodológicos utilizando a ferramenta

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Although hospital malnutrition is highly prevalent worldwide, it is difficult to compare the data due to the different nutritional assessment tools used. The Global Leadership Initiative on Malnutrition, which aims to operationalize malnutrition diagnosis, consists of five criteria: three phenotypic and two etiological criteria. Many researchers have studied the applicability and clinical relevance of Global Leadership Initiative on Malnutrition, and methodological standards have been established by the Global Leadership Initiative on Malnutrition commission for the application and possible validation of the tool. This study aimed to analyze the methodological processes of the studies that compared the Global Leadership Initiative on Malnutrition with a test tool. A literature review was conducted by the Portal Periódicos from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior between November 2020 and January 2021. This review included articles published in English between 2016 and 2021 that compared the Global Leadership Initiative on Malnutrition with another tool used for diagnosing malnutrition. The sample had 13 articles, of which 11 did not adequately describe how the Global Leadership Initiative on Malnutrition criteria were applied. Only two studies utilized a combination of the phenotypic and etiological criteria. Some studies differed from the methodological recommendations of the Global Leadership Initiative on Malnutrition commission. Thus, it seems that applying the Global Leadership Initiative on Malnutrition in a manner different from the original framework elicited limited results regarding the applicability and reliability of the tool. Therefore, more studies should be conducted on the application of the GLIM Global Leadership Initiative on Malnutrition in different populations and contexts as per the patterns suggested to determine its actual applicability and reliability.

Keywords
Malnutrition; Nutritional assessment; Nutritional status

Search terms Portal Periódicos from Capes
#1 “Malnutrition”
#2 “Nutritional assessment”
#3 “Nutritional status”
#4 “GLIM”
#5 “Global Leadership Initiative on Malnutrition”
#6 “Validation”
#7 “Protein-energy malnutrition”
#8 “GLIM criteria”
#9 “Nutritional assessment tool”
#10 “Subjective Global Assessment”
#11 “Malnutrition” AND “nutritional assessment”
#12 “Malnutrition” AND “nutritional assessment” OR “nutritional status”
#13 “Malnutrition” AND “Global Leadership Initiative on Malnutrition” OR “GLIM”
#14 “Malnutrition” AND “nutritional assessment” AND “GLIM”
#15 “Malnutrition” AND “GLIM” OR “validation”
#16 “Malnutrition” AND “GLIM” OR “GLIM criteria”
#17 “Nutritional assessment” OR “nutritional status” AND “GLIM”
#18 “Nutritional assessment” AND “validation” AND “GLIM”
#19 “Protein-energy malnutrition” AND “GLIM”
#20 “Protein-energy malnutrition” AND “nutritional assessment”
#21 “Nutritional assessment tool” AND “validation”
#22 “Nutritional assessment tool” AND “validation” AND “GLIM”
#23 “Subjective Global Assessment” AND “GLIM”
#24 “Subjective Global Assessment” AND “GLIM” OR “validation”
#25 “Subjective Global Assessment” AND “nutritional assessment” AND “validation”

Authors	Study design	Sample	Tools used	Methods	Main findings
Allard et al. [²³23 Allard JP, Keller H, Gramlich L, Jeejeebhoy KN, Laporte M, Duerksen DR. GLIM criteria has fair sensitivity and specificity for diagnosing malnutrition when using SGA as comparator. Clin Nutr. 2020;39(9):2771-7. https://doi.org/10.1016/j.clnu.2019.12.004 https://doi.org/10.1016/j.clnu.2019.12.0... ]	Retrospective prospective cohort analysis	N=784 adults	SGA, CNST, and GLIM	The minimum criteria of GLIM were used for the diagnosis (at least 1 phenotypic criterion + 1 etiological criterion). Four combinations of phenotypic and etiological criteria were made, and each combination was compared to the SGA.	SGA malnutrition prevalence = 45.2% GLIM malnutrition prevalence = 33.3% The GLIM that combined weight loss or low BMI as the phenotypic criteria and low food intake or CRP as the etiological criteria (A, B, C, and D) showed poor sensitivity (61.3%) and fair specificity (89.8%) as compared to the SGA.
Bellanti et al. [²⁸28 Bellanti F, Lo Buglio A, Quiete S, Pellegrino G, Dobrakowski M, Kasperczyk A, et al. Comparison of three nutritional screening tools with the new glim criteria for malnutrition and association with sarcopenia in hospitalized older patients. J Clin Med. 2020;9(6):1898.]	Prospective	N=152 elderly patients	SGA, GLIM, MUST, and NRS2002	The minimum criteria of GLIM were used for the diagnosis (at least 1 phenotypic criterion + 1 etiological criterion). There was no mention of utilizing combinations of the GLIM criteria.	Malnutrition according to GLIM = 46% MUST showed greater agreement with the GLIM in detection of malnutrition in this population. Sensitivity was 64%, 96%, and 47% and specificity was 82%, 15%, and 76% with MUST, SGA, and NRS2002, respectively.
Boulhosa et al. [²⁴24 Boulhosa RSSB, Lourenço RP, Côrtes DM, Oliveira LPM, Lyra AC, Jesus RP. Comparison between criteria for diagnosing malnutrition in patients with advanced chronic liver disease: GLIM group proposal versus different nutritional screening tools. J Hum Nutr Diet. 2020;33(6):862-8.]	Prospective cross	N=166 chronic liver disease patients	GLIM, NRS2002, and RFH-NPT	The minimum criteria of GLIM were used for the diagnosis (at least 1 phenotypic criterion + 1 etiological criterion). There was no mention of utilizing combinations of the GLIM criteria.	The nutritional risk identified by RFH-NPT showed greater sensitivity and greater agreement with the malnutrition diagnosis made using the GLIM. According to the GLIM, 42.80% were classified as nourished and 57.20% as malnourished. None of the screening tools reported such a significant number of individuals at nutritional risk. It was noted that 45.26% and 20% of patients at a low risk according to the NRS2002 and RFH-NPT, respectively, were malnourished by the GLIM.
Clark et al. [³⁵35 Clark AB, Reijnierse EM, Kwang W, Maier AB. Prevalence of malnutrition comparing the GLIM criteria, ESPEN definition and MST malnutrition risk in geriatric rehabilitation patients: RESORT. Clin Nutr. 2020;39(11):3504-11. https://doi.org/10.1016/j.clnu.2020.03.015 https://doi.org/10.1016/j.clnu.2020.03.0... ]	Retrospective analysis of prospective cohort	N=693 elderly patients	ESPEN, GLIM, and MST	Different phenotypes were created based on 3 different tools (ESPEN, GLIM, and MST), and the characteristics were compared between 8 phenotypes: GLIM, GLIM/ESPEN, GLIM/MST, GLIM/ESPEN/MST, ESPEN, ESPEN/MST, MST, and not malnourished according to all 3 tools. The minimum criteria of GLIM were used for the diagnosis (at least 1 phenotypic criterion + 1 etiological criterion). There was no mention of utilizing combinations of the GLIM criteria.	Only a small proportion of patients were identified as malnourished or at risk of malnutrition by all the tools (7.2%). There was slight agreement regarding the prevalence and risk of malnutrition between the GLIM, ESPEN (k=0.30), and MST (k=0.26). The accuracy of the MST was low as compared to the GLIM and ESPEN criteria. The 91.0% of patients considered malnourished by the ESPEN were similarly diagnosed by the GLIM. The malnutrition prevalence determined by GLIM was 52.0%. According to the ESPEN and MST, 44.4% of patients were at nutritional risk.
Fierini, Madill [³³33 Fierini D, Madill J. Malnutrition in an academic health sciences centre: applying results from nutritionDay 2011 to the proposed Global Leadership Initiative on Malnutrition approach to diagnosing malnutrition. Clin Nutr Exp. 2020;32:1-10. https://doi.org/10.1016/j.yclnex.2020.06.001 https://doi.org/10.1016/j.yclnex.2020.06... ]	Retrospective analysis of prospective cohort	N=264 hospitalized patients	CNST and GLIM	Patients were screened by CNST, and those at risk were evaluated using the GLIM. The minimum criteria of GLIM were used for the diagnosis (at least 1 phenotypic criterion + 1 etiological criterion). There was no mention of utilizing combinations of the GLIM criteria.	According to the CNST, 38% of patients were at malnutrition risk, and 25% of patients at risk were considered malnourished by the GLIM.
Groot et al. [²⁵25 Groot LM, Lee G, Ackerie A, van der Meij BS. Malnutrition screening and assessment in the cancer care ambulatory setting: mortality predictability and validity of the patient-generated subjective global assessment short form (PG-SGA SF) and the GLIM criteria. Nutrients. 2020;12(8):1-13.]	Prospective cross	N=246 adults with CA	GLIM, MST, PG-SGA, and PG-SGA-SF	The minimum criteria of GLIM were used for the diagnosis (at least 1 phenotypic criterion + 1 etiological criterion). There was no mention of utilizing combinations of the GLIM criteria. The data reported by the GLIM and PG-SGA-SF were compared to the PG-SGA data.	The GLIM assessment showed a higher percentage of malnutrition as compared to the PG-SGA assessment (35% vs. 16%). Compared to PG-SGA, malnutrition diagnosis by GLIM had a sensitivity of 76%, specificity of 73%, and poor agreement (k=0.323).
Henrique et al. [²⁶26 Henrique JR, Pereira RG, Ferreira RS, Keller H, de van der Schueren M, Gonzalez MC, et al. Pilot study GLIM criteria for categorization of a malnutrition diagnosis of patients undergoing elective gastrointestinal operations: a pilot study of applicability and validation. Nutrition. 2020;79-80:e110961.]	Prospective cross	N=206 adults with GID admitted for surgery	SGA and GLIM	A combination of a phenotypic criterion and an etiological criterion of the GLIM was used to categorize the patients as malnourished. Ten different combinations of phenotypic and etiological criteria were made, and each combination was compared to the SGA.	The several combinations of GLIM criteria provided different malnutrition rates. GLIM 1 (weight loss % and low food intake) and 6 (weight loss % and inflammation) showed greater agreement with SGA as compared to the other combinations. Malnutrition prevalence: SGA=50.0%, GLIM 1=31.6%, and GLIM 6=41.3%.
Matsumoto et al. [²⁹29 Matsumoto Y, Iwai K, Namikawa N, Matsuda S, Wakano C, Heya H, et al. The relationship between existing nutritional indicators and Global Leadership Initiative on Malnutrition (GLIM) criteria: a one-institution cross-sectional analysis. Clin Nutr. 2020;39(10):3099-104. https://doi.org/10.1016/j.clnu.2020.01.016 https://doi.org/10.1016/j.clnu.2020.01.0... ]	Prospective cross	N=490 hospitalized patients	GLIM and MNA-SF	The minimum criteria of GLIM were used for the diagnosis (at least 1 phenotypic criterion + 1 etiological criterion). There was no mention of utilizing combinations of the GLIM criteria.	About 33% of patients were considered malnourished by the GLIM. The GLIM criteria for malnutrition were fulfilled by 98% of patients screened for risk by MNA-SF.
Rigler et al. [²⁷27 Rigler M, Kagan I, Bendavid I, Theilla M. Validation of GLIM Malnutrition Criteria with SGA and FFMI Measurement in 150 Hospitalized Patients. Clin Nutr. 2019;38(2019):S40. https://doi.org/10.1016/S0261-5614(19)32557-9 https://doi.org/10.1016/S0261-5614(19)32... ]	Prospective cross	N=150 hospitalized patients	SGA and GLIM	The minimum criteria of GLIM were used for the diagnosis (at least 1 phenotypic criterion + 1 etiological criterion). There was no mention of utilizing combinations of the GLIM criteria.	There was a significant correlation between the GLIM and SGA assessment of the malnutrition diagnosis (R=0.353).
Steer et al. [³²32 Steer B, Loeliger J, Edbrooke L, Deftereos I, Laing E, Kiss N. Malnutrition prevalence according to the GLIM criteria in head and neck cancer patients undergoing cancer treatment. Nutrients. 2020;12(11):3493.]	Retrospective analysis of prospective cohort	N=188 HNC patients	GLIM and MST	The minimum criteria of GLIM were used for the diagnosis (at least 1 phenotypic criterion + 1 etiological criterion). Subsequently, the malnutrition diagnosis was determined without metastatic disease (inflammation) as an etiological criterion. There was no mention of utilizing combinations of the GLIM criteria.	The GLIM determined that 20.0% of HNC patients undergoing treatment were malnourished and 42.0% were considered at nutritional risk. The malnutrition prevalence determined by the GLIM was 22.6%.
Theila et al. [³⁴34 Theilla M, Rattanachaiwong S, Kagan I, Rigler M, Bendavid I, Singer P. Validation of GLIM malnutrition criteria for diagnosis of malnutrition in ICU patients. Clin Nutr. 2019;38(2019):S4. https://doi.org/10.1016/S0261-5614(19)32125-9 https://doi.org/10.1016/S0261-5614(19)32... ]	Prospective cross	N=84 critical patients	SGA, PA, GLIM, FFMI, and PANDORA	The minimum criteria of GLIM were used for the diagnosis (at least 1 phenotypic criterion + 1 etiological criterion). All patients were defined as having an acute disease. There was no mention of utilizing combinations of the GLIM criteria.	There was a high correlation between PA, FFMI, and PANDORA and the GLIM in this population. The SGA validated the GLIM criteria combined with two diagnostic criteria (PA and FFMI) for diagnosing malnutrition with a high level of accuracy. The GLIM malnutrition assessment appears to be acceptable in the ICU setting. Sensitivity was 85% and specificity 79% for the GLIM stratified by the SGA results.
Xu et al. [³¹31 Xu JY, Zhu MW, Zhang H, Li L, Tang PX, Chen W, et al. A Cross-sectional study of glim-defined malnutrition based on new validated calf circumference cut-off values and different screening tools in hospitalised patients over 70 years old. J Nutr Heal Aging. 2020;24(8):832-8.]	Prospective cross	N=6519 hospitalized elderly patients	GLIM, MNA-SF, MUST, and NRS2002	Nutritional risk patients underwent nutritional assessment by the GLIM. The minimum criteria of GLIM were used for the diagnosis (at least 1 phenotypic criterion + 1 etiological criterion). There was no mention of utilizing combinations of the GLIM criteria.	The GLIM associated with the MNA-SF seems to be the first choice for the malnutrition diagnosis, as they detected a greater number of malnourished patients than the other tools did. Malnutrition prevalence by GLIM = 35.0%; Malnutrition prevalence by GLIM and MNA-SF = 32.6%
Xu et al. [³⁰30 Xu JY, Zhang XN, Jiang ZM, Jie B, Wang Y, Li W, et al. Nutritional support therapy after GLIM criteria may neglect the benefit of reducing infection complications compared with NRS2002: a reanalysis of a cohort study. Nutrition. 2020;79-80:e110802.]	Retrospective analysis of prospective cohort	N=1831 hospitalized patients	GLIM and NRS2002	Patients at nutritional risk underwent nutritional assessment by the GLIM. The minimum criteria of GLIM were used for the diagnosis (at least 1 phenotypic criterion + 1 etiological criterion). Patients were divided into 4 groups: negative NRS2002 (NRS-), positive NRS2002 (NRS+), malnutrition (NRS+/GLIM+), and positive NRS2002 but no malnutrition (NRS+/GLIM-). There was no mention of utilizing combinations of the GLIM criteria.	Malnutrition prevalence: (NRS+/ GLIM+) = 21.40% NRS+ = 45.17% NRS+/GLIM- = 33.40% About 47% of the NRS+ patients were neglected by the GLIM. Nutritional risk determined by the NRS2002 seems to be a better indicator for starting nutritional support than malnutrition diagnosis.

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[1] Correspondence to: L.G. FERREIRA. E-mail: livia.ferreira@ufla.br.