IS THERE AGREEMENT BETWEEN THE GLIM AND THE NRS CRITERIA IN THE NUTRITIONAL DIAGNOSIS OF HOSPITALIZED SURGICAL PATIENTS? PILOT STUDY

Existe concordância entre os critérios GLIM e NRS no diagnóstico nutricional de pacientes cirúrgicos hospitalizados? Estudo piloto

ABSTRACT

Background:  There is no consensus on which nutritional diagnosis methods are most relevant in the hospital clinical practice.

Objective:  This study investigated the agreement between the global leadership initiative on malnutrition (GLIM) criterion and the nutritional risk screening (NRS) instrument for the nutritional diagnosis of in-patients.

Methods:  Cross-sectional study with 95 hospitalized surgical patients. Clinical data, nutritional risk using the NRS and malnutrition using the GLIM criteria were evaluated. The data were analyzed using the chi-square, Mann-Whitney, McNemar and Kappa coefficient tests.

Results:  There was good agreement between the two methods (Kappa=0.6067). Patients who were malnourished according to the GLIM or at nutritional risk by NRS were older (P=0.0461 by GLIM and P=0.0200 by NRS) and had a higher diagnosis rate of neoplasms (38.5%, P=0.0006 by GLIM and 32.7%, P=0.0030 by NRS). The GLIM criterion identified a lower percentage of patients with malnutrition (41.05%) in relation to the NRS regarding patients with nutritional risk (54.7%).

Conclusion:  The GLIM criteria and the NRS instrument are concordant methods for diagnosing malnutrition and nutritional risk in hospitalized surgical patients respectively.

Keywords: Hospitalized surgical patients; global leadership initiative on malnutrition; nutritional risk screening; criteria

HIGHLIGHTS

•This study suggests the use of the NRS and the GLIM criteria for the nutritional diagnosis of hospitalized surgical patients, especially patients with vascular diseases and digestive neoplasms.

•The two methods are concordant for the result of nutritional risk or malnutrition.

•The GLIM criterion identified a lower percentage of patients with malnutrition in relation to the diagnosis of malnutrition by the NRS.

INTRODUCTION

There is still no consensus on which nutritional method or indicator should be considered the gold standard in hospitalized patients’ nutritional screening and the association between nutritional status and unfavorable clinical outcomes is already known^1-4. This evidence indicates that more studies are required to understand the main differences in nutritional diagnosis assessed by different methods^1-4.

Among the existing methods, the global leadership initiative on malnutrition (GLIM) criteria^3-5 and the nutritional risk screening (NRS)^6,7 are validated and are recommended methods for diagnosing malnutrition and nutritional risk, respectively.

Therefore, this preliminary study investigated the agreement between the GLIM criteria and the NRS for the nutritional diagnosis of in-patients.

METHODS

Study design, participant characteristics, inclusion and exclusion criteria

This is a preliminary, cross-sectional study, part of a larger investigation that assesses different nutritional diagnosis methodologies and muscle strength in hospitalized surgical patients in a reference hospital that serves a representative population of a large metropolitan region of the country This study was approved by of the Pontifical Catholic University of Campinas, São Paulo, Brazil (reference number: 5.728.982). The procedures used in this study adhere to the tenets of the Declaration of Helsinki ethics and research committee and the patients who participated in the survey signed the free and informed consent form (FICF).

Inclusion criteria: patients whose medical records were entered with information regarding diagnosis, type of disease and complications; non-terminal patients; patients over 18 years of age, with more than 24 hours hospital stay, able to understand and respond to questions, with preserved motor and cognitive function and who had signed the FICF. Exclusion criteria: patients with edema or ascites, hospitalized in isolation, who were in terminal conditions and who had any kind of dementia, Alzheimer’s or Parkinson’s disease. After screening according to these criteria, the study population consisted of 95 (n=95) in-patients, admitted for different clinical conditions.

Methodological procedures and variables studied

Data collection was performed at bedside. Demographic and clinical data were retrieved from the medical records (age, gender, comorbidities, type of disease, occurrence of complications and surgery, length of hospital stay, hospital discharge or death). Nutritional status was assessed using the GLIM criteria^3-5 and the NRS^6,7, and the agreement between the two methods was subsequently investigated.

Global Leadership Initiative on Malnutrition (GLIM) criteria: the GLIM criterion was determined from the nutritional screening that indicated the presence of at least one phenotypic criterion (unintentional weight loss or low body mass index or reduction in muscle mass by arm circumference or calf circumference) and one etiological criterion (reduction in food consumption or disease severity)^3-5.

NRS: the NRS was used to determine nutritional risk, taking into account weight loss, reduction in food consumption, body mass index and severity of the disease, with an adjustment factor being added for patients aged ≥70 years. The total NRS score allowed the patient to be classified using a numerical score: at nutritional risk (score ≥3) and without nutritional risk (score <3)^6,7.

Statistical analysis

Data were expressed with frequency (n) and percentage (%) values for categorical variables and descriptive measures (mean, standard deviation and median) for quantitative variables. To compare proportions, the chi-square or Fisher’s exact test was used, when necessary, and to compare continuous measurements between two groups, the Mann-Whitney test was applied. To evaluate the agreement between the methods (GLIM criteria and NRS instrument) the Kappa coefficient was used. To compare classifications, the McNemar test was used. The significance level adopted was 5%.

RESULTS

Our sample included 95 patients and was mainly composed of patients with vascular diseases (55.8%, n=53), digestive neoplasms (20%, n=19) and other diseases (24.2%, n=23). The mean age was 59.36±15.91 years (median=60 years). As to gender 67.4% (n=64) of the participants were male and 32.6% (n=31) female. The length of hospital stay was 17.01±24.27 days (median=10 days); 93.7% (n=89) patients had comorbidities; 61.1% (n=58) underwent surgical procedures; 26.6% (n=25) had complications during hospitalization and 2.1% (n=2) died.

Regarding nutritional status, the majority of patients presented nutritional risk according to the NRS (54.7%, n=52) and the classification of malnutrition was observed in 41.1% (n=39) of patients according to the GLIM criteria.

Figure 1 and Table 1 illustrate the agreement analysis between the GLIM criterion and the NRS; good agreement was observed between the two methods (Kappa=0.6067). It was found that compared to the NRS, the GLIM criterion identified a lower percentage of patients with malnutrition (NRS=54.7% with nutritional risk versus GLIM criterion=41.05% of malnourished patients).

FIGURE 1
Agreement analysis between the two methods: GLIM and NRS criteria.

TABLE 1
Analysis of agreement between the GLIM criterion and the NRS.

Global Leadership Initiative on Malnutrition (GLIM)	Nutritional Risk Screening (NRS)		Total
	With nutritional risk	Without nutritional risk
Malnourished	37.89% (n=36)	3.16% (n=3)	41.05% (n=39)
Not malnourished	16.84% (n=16)	42.11% (n=40)	58.95% (n=56)
Total	54.74% (n=52)	45.26% (n=43)	100% (n=95)

• Simple Kappa=0.6067; 95%CI (0.4542; 0.7592), good agreement P=0.0029 (McNemar).

In the descriptive analysis and comparison of the variables between the GLIM malnutrition criteria classification, and the NRS with nutritional risk, it was found that age and diagnosis showed a significant difference. Patients who were malnourished according to the GLIM criteria or were at nutritional risk according to the NRS, had a higher mean or median age (P=0.0461 according to the GLIM criterion and p=0.0200 according to the NRS) and a higher rate in the diagnosis of digestive neoplasms (38.5%, P=0.0006 according to the GLIM criterion and 32.7%, P=0.0030 by NRS) (Table 2). And in the classification of non-malnourished using the GLIM criterion and without nutritional risk by the NRS, more patients with vascular disease were observed (67.9%, n=38 by GLIM and 67.4%, n=29 by the NRS) (Table 2).

TABLE 2
Descriptive analysis and comparison of variables between the GLIM and NRS criteria classification (N=95).

Variables Studied	Category	GLIM= malnourished (N=39)	GLIM= not malnourished (N=56)	P -value	NRS= with nutritional risk (N=52)	NRS = without nutritional risk (N=43)	P-value
Age (years)	Mean ± SD	63.36±17.54	56.57±14.17	0.04611	62.63±16.90	55.40±13.80	0.02001
	Median	65.00	57.00		64.50	57.00
LS (days)	Mean ± SD	15.90±16.99	17.79±28.39	0.94561	18.90±27.07	14.72±20.47	0.54171
	Median	9.00	10.00		10.00	10.00
Gender	Female	9 (23.1%)	22 (39.3%)	0.09742	16 (30.8%)	15 (34.9%)	0.67032
	Male	30 (76.9%)	34 (60.7%)		36 (69.2%)	28 (65.1%)
Disease	Vascular dis	15 (38.5%)	38 (67.9%)	0.00062	24 (46.2%)	29 (67.4%)	0.00302
	Neoplasms	15 (38.5%)	4 (7.1%)		17 (32.7%)	2 (4.7%)
	Others	9 (23.1%)	14 (25.0%)		11 (21.2%)	12 (27.9%)
Death	No	37 (94.9%)	56 (100.0%)	-	50 (96.2%)	43 (100.0%)	-
	Yes	2 (5.1%)	0 (0.0%)		2 (3.8%)	0 (0.0%)
Complications	No	30 (76.9%)	39 (70.9%)	0.51562	38 (73.1%)	31 (73.8%)	0.93632
	Yes	9 (23.1%)	16 (29.1%)		14 (26.9%)	11 (26.2%)
Surgery	No	14 (35.9%)	23 (41.1%)	0.61092	21 (40.4%)	16 (37.2%)	0.75212
	Yes	25 (64.1%)	33 (58.9%)		31 (59.6%)	27 (62.8%)
Comorbidities	No	1 (2.6%)	5 (8.9%)	0.39543	2 (3.8%)	4 (9.3%)	0.40493
	Yes	38 (97.4%)	51 (91.1%)		50 (96.2%)	39 (90.7%)

• GLIM: global leadership initiative on malnutrition; NRS: nutritional risk screening; LS: length of stay; DIS: disease. ¹ Mann-Whitney test; ² Chi-square test; ³ Fisher’s exact test.

The other study variables, such as length of hospital stay, gender, occurrence of complications, surgical procedure, presence of comorbidities and death, did not show a significant association when comparing the two methods (Table 2).

And the age and diagnosis were different in relation to the classification by the two methods. Older patients with digestive neoplasms presented nutritional risk according to the NRS or malnutrition according to the GLIM criteria.

DISCUSSION

This study comprised a population of 95 patients, the majority of whom were patients with vascular diseases and digestive neoplasms. Two nutritional diagnosis methods were compared and there were more patients with digestive neoplasms who were malnourished based on the GLIM criteria and at nutritional risk according to the NRS when these patients were compared with patients with vascular diseases. Findings of malnutrition among patients with neoplasms are in line with other reports in the literature^8,9. Unlike the nutritional diagnosis among patients with digestive neoplasms, the findings here indicated that the condition of not being malnourished and without nutritional risk was more frequent in patients with vascular diseases.

The impact of malnutrition according to the GLIM criterion, stratified by renal function in hospitalized patients with heart failure, could predict ninety-day mortality, as reported in a recently conducted retrospective study¹⁰. Such findings may suggest the relevance of using this criterion in routine hospital clinical practice. In another investigation, the authors showed that the reduction in the geriatric nutritional risk index was independently related to the increased risk of major adverse cardiovascular events, all-cause mortality and any revascularization in patients with ischemic heart failure undergoing percutaneous coronary intervention¹¹. A systematic review and meta-analysis¹² that investigated the association between malnutrition and mortality in patients with stroke, showed the validity of using nutritional indices during hospital admission, due to the association observed between malnutrition, survival and functional outcomes. This review also suggested that further prospective studies be performed, in order to validate the findings of the meta-analysis¹².

The findings of the present study showed 54.7% of patients with nutritional risk according to the NRS and 41% of patients with malnutrition according to the GLIM criteria; different results from another recent study showed 31.2% of nutritional risk according to the NRS and 35.6% of malnutrition according to the GLIM criteria, also in hospitalized patients¹³.

Prevalence of 46% malnourished patients according to the GLIM criteria and agreement of 89% with the malnutrition universal screening tool, 53% with the subjective global assessment and 62% with the NRS, were observed in an investigation that compared nutritional screening instruments with this criterion in hospitalized patients⁴. And all instruments showed a moderate malnutrition level, according to that paper⁴.

In other studies, low agreement between GLIM and the patient’s subjective global assessment was observed¹⁴ and GLIM appeared as a predictor of mortality¹⁴. The use of this criterion has already been recommended for the assessment of malnutrition in hospitalized patients¹³.

Finally, the findings of this study suggest that both instruments could be used in the assessment of hospitalized surgical patients in the routine nutritional clinical practice.

CONCLUSION

The NRS and the GLIM criteria are concordant methods for diagnosing nutritional risk and malnutrition in hospitalized surgical patients. This study suggests the use of both methods for nutritional investigations in hospitalized surgical patients in different clinical conditions.

ACKNOWLEDGMENTS

The authors are grateful to the patients who participated in the study and to the Pontifical Catholic University of Campinas, SP-Brazil.

REFERENCES

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• Disclosure of funding:
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• Declaration of use of artificial intelligence:
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Publication Dates

• Publication in this collection
  25 Nov 2024
• Date of issue
  2024

History

• Received
  20 July 2024
• Accepted
  20 Aug 2024