Global Leadership Initiative on Malnutrition (GLIM): Guidance on validation of the operational criteria for the diagnosis of protein-energy malnutrition in adults.

BACKGROUND: The Global Leadership Initiative on Malnutrition (GLIM) created a consensus-based framework consisting of phenotypic and etiologic criteria to record the occurrence of malnutrition in adults. This is a minimum set of practicable indicators for use in characterizing a patient/client as malnourished, considering the global variations in screening and nutrition assessment, and to be used across different health care settings. As with other consensus-based frameworks for diagnosing disease states, these operational criteria require validation and reliability testing as they are currently based solely on expert opinion. METHODS: Several forms of validation and reliability are reviewed in the context of GLIM, providing guidance on how to conduct retrospective and prospective studies for criterion and construct validity. FINDINGS: There are some aspects of GLIM criteria which require refinement; research using large data bases can be employed to reach this goal. Machine learning is also introduced as a potential method to support identification of the best cut-points and combinations of operational criteria for use with the different forms of malnutrition, which the GLIM criteria were created to denote. It is noted as well that the validation and reliability testing need to occur in a variety of sectors, populations and with diverse persons completing the criteria. CONCLUSION: The guidance presented supports the conduct and publication of quality validation and reliability studies for GLIM.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community.

RATIONALE: This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. METHODS: In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications. RESULTS: A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories. 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, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community.

RATIONALE: This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. METHODS: In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications. RESULTS: A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories. 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, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

ESPEN guidelines on definitions and terminology of clinical nutrition.

BACKGROUND: A lack of agreement on definitions and terminology used for nutrition-related concepts and procedures limits the development of clinical nutrition practice and research. OBJECTIVE: This initiative aimed to reach a consensus for terminology for core nutritional concepts and procedures. METHODS: The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed a consensus group of clinical scientists to perform a modified Delphi process that encompassed e-mail communication, face-to-face meetings, in-group ballots and an electronic ESPEN membership Delphi round. RESULTS: Five key areas related to clinical nutrition were identified: concepts; procedures; organisation; delivery; and products. One core concept of clinical nutrition is malnutrition/undernutrition, which includes disease-related malnutrition (DRM) with (eq. cachexia) and without inflammation, and malnutrition/undernutrition without disease, e.g. hunger-related malnutrition. Over-nutrition (overweight and obesity) is another core concept. Sarcopenia and frailty were agreed to be separate conditions often associated with malnutrition. Examples of nutritional procedures identified include screening for subjects at nutritional risk followed by a complete nutritional assessment. Hospital and care facility catering are the basic organizational forms for providing nutrition. Oral nutritional supplementation is the preferred way of nutrition therapy but if inadequate then other forms of medical nutrition therapy, i.e. enteral tube feeding and parenteral (intravenous) nutrition, becomes the major way of nutrient delivery. CONCLUSION: An agreement of basic nutritional terminology to be used in clinical practice, research, and the ESPEN guideline developments has been established. This terminology consensus may help to support future global consensus efforts and updates of classification systems such as the International Classification of Disease (ICD). The continuous growth of knowledge in all areas addressed in this statement will provide the foundation for future revisions.

The associations between diet quality, Body Mass Index (BMI) and Health and Activity Limitation Index (HALex) in the Geisinger Rural Aging Study (GRAS).

OBJECTIVES: To determine the associations between diet quality, body mass index (BMI), and health-related quality of life (HRQOL) as assessed by the health and activity limitation index (HALex) in older adults. DESIGN: Multivariate linear regression models were used to analyze associations between Dietary Screening Tool (DST) scores, BMI and HALex score, after controlling for gender, age, education, living situation, smoking, disease burden and self-vs. proxy reporting. SETTING: Geisinger Rural Aging Study, Pennsylvania. PARTICIPANTS: 5,993 GRAS participants were mailed HRQOL and DST questionnaires with 4,009 (1,722 male, 2,287 female; mean age 81.5 ± 4.4) providing complete data. RESULTS: HALex scores were significantly lower for participants with dietary intakes categorized as unhealthy (<60) (0.70, 95% CI 0.69, 0.72, p<0.05) or borderline (60-75) (0.71, 95% CI 0.70, 0.73, p<0.05) compared to those scoring in the healthy range (>75) (0.75, 95% CI 0.73, 0.77) based on DST scores. HALex scores were significantly lower for underweight (0.67, 95% CI 0.63, 0.72, p<0.05), obese class II (0.68, 95% CI 0.66, 0.71, p<0.05) and class III participants (0.62 95% CI 0.57, 0.67, p<0.05) compared to those with BMI 18.5-24.9. CONCLUSIONS: Poor diet quality, as assessed by the DST, is associated with lower HRQOL in adults ≥ 74 years of age.

Dietary patterns and relationship to obesity-related health outcomes and mortality in adults 75 years of age or greater.

BACKGROUND: The prevalence of obesity-related adverse health outcomes is increasing among older adults. Because it is thought that nutrition plays an important role in successful aging, there has been considerable interest in the association between dietary patterns of older adults and obesity-related health outcomes. OBJECTIVE: This study examined the association between dietary patterns and mortality and prevalence of obesity-related health outcomes, namely cardiovascular disease (CVD), type 2 diabetes mellitus, hypertension, and metabolic syndrome (MetSyn), over a 5-year follow-up period in adults aged 75 years or greater. DESIGN: A longitudinal observational study with cross-sectional dietary assessment. SETTING: Rural Central Pennsylvania. PARTICIPANTS: Community-dwelling older adults (N = 449; 76.5 years old; 57% female). MEASUREMENTS: Multiple, unannounced, 24-hour dietary recalls were used to collect dietary intake. Cluster analysis was used to derive dietary patterns. Prevalence of CVD, diabetes mellitus, hypertension, and MetSyn was extracted from outpatient electronic medical records. Logistic regression was used to examine the associations between dietary patterns and health outcomes and mortality. RESULTS: 'Sweets and Dairy', 'Health-Conscious' and 'Western' dietary patterns were identified. Compared to the 'Health-Conscious' pattern, those in the 'Sweets and Dairy' pattern had increased odds of hypertension over the follow-up period; adjusted odds ratio (95% CI) was 2.18 (1.11-4.30). No significant associations were found for CVD, diabetes mellitus, MetSyn or mortality with dietary patterns. CONCLUSIONS: These findings support the potential value of healthy dietary patterns in the management of hypertension in older adults. We did not observe any other strong associations between dietary patterns and health outcomes or mortality in persons ≥ 75 years of age; thus failing to support the use of overly restrictive diet prescriptions for older persons, especially where food intake may be inadequate.

Dietary patterns and diet quality among diverse older adults: the University of Alabama at Birmingham Study of Aging.

OBJECTIVES: To characterize dietary patterns among a diverse sample of older adults (≥ 65 years). DESIGN: Cross-sectional. SETTING: Five counties in west central Alabama. PARTICIPANTS: Community-dwelling Medicare beneficiaries (N=416; 76.8 ± 5.2 years, 56% female, 39% African American) in the University of Alabama at Birmingham (UAB) Study of Aging. MEASUREMENTS: Dietary data collected via three, unannounced 24-hour dietary recalls was used to identify dietary patterns. Foods were aggregated into 13 groups. Finite mixture modeling (FMM) was used to classify individuals into three dietary patterns. Differences across dietary patterns for nutrient intakes, sociodemographic, and anthropometric measurements were examined using chi-square and general linear models. RESULTS: Three dietary patterns were derived. A "more healthful" dietary pattern, with relatively higher intakes of fruit, vegetables, whole grains, eggs, nuts, legumes and dairy, was associated with lower energy density, higher quality diets as determined by healthy eating index (HEI)-2005 scores and higher intakes of fiber, folate, vitamins C and B6, calcium, iron, magnesium, and zinc. The "western-like" pattern was defined by an intake of starchy vegetables, refined grains, meats, fried poultry and fish, oils and fats and was associated with lower HEI-2005 scores. The "low produce, high sweets" pattern was characterized by high saturated fat, and low dietary fiber and vitamin C intakes. The strongest predictors of better diet quality were female gender and non-Hispanic white race. CONCLUSION: The dietary patterns identified may provide a useful basis on which to base dietary interventions targeted at older adults. Examination of nutrient intakes regardless of the dietary pattern suggests that older adults are not meeting nutrient recommendations and should continue to be encouraged to choose high quality diets.

Relative validity of the Geisinger Rural Aging Study food frequency questionnaire.

OBJECTIVE: To determine the relative validity of a population specific food frequency questionnaire (FFQ) and evaluate the effectiveness of the instrument for assessing nutritional risk in older adults. DESIGN: A cross-over design with participants completing two different dietary assessment instruments in random order. SETTING: The Geisinger Rural Aging Study (GRAS), a longitudinal study of over 20,000 adults living in the central, northern and eastern counties of Pennsylvania. PARTICIPANTS: A subset of GRAS consisting of 245 older adults (60% women) ranging in age from 70 to 95 years. MEASUREMENTS: Energy and nutrient intakes were assessed from two instruments: a population specific food frequency questionnaire (FFQ) and four 24-hour dietary recalls conducted over a two week period. RESULTS: Pearson correlation coefficients between the FFQ and dietary recalls for most nutrients were 0.5 or higher which suggests that the FFQ provided relatively valid estimates of macro and micronutrient intakes examined. Bland-Altman plots were generated to examine the agreement between instruments. Data are shown for energy, folate and zinc with close agreement at lower intakes indicative of risk for folate and zinc. Sensitivity results also showed that the FFQ was able to correctly classify individuals adequately at risk for most nutrients examined. CONCLUSION: This population specific FFQ appears to be a valid instrument for use in in evaluating risk for many nutrients that are of particular concern in older adults residing throughout many predominately rural counties in Pennsylvania.

Obesity among older persons: Screening for risk of adverse outcomes.

A research overview is presented that highlights the growing prevalence of obesity among older persons and the associated risks for medical co-morbidity, healthcare resource use, functional decline and homebound status. Findings reveal that even for obese individuals poor diet quality and micronutrient deficiencies are relatively common concerns. Currently available nutrition risk screening instruments lack validity for overweight / obese older persons. Development and preliminary testing of a new Nutrition Health Outcomes Questionnaire (NHOQ) for this application are presented.

Nutrition in the elderly.

Nutrition is a prime concern for the optimal health of older persons. Nutritional requirements for older persons must take into account the physiologic changes that occur with aging. The gastrointestinal tract is the site of key structural and functional changes that affect nutrient intake and assimilation. A working knowledge of nutritional screening, assessment, and interventions can assist the practitioner in providing quality care for the older patient.

Screening for hospitalization and nutritional risks among community-dwelling older persons.

BACKGROUND: The potential for the use of nutritional screening to identify older persons at risk of hospitalization has not been contrasted with the use of tools developed for predicting hospital admissions. OBJECTIVE: Our goal was to compare the associations of items from the Level II Nutrition Screen (LII) and the Probability of Repeated Admissions (P(ra)) questionnaire with the outcome of hospitalization. DESIGN: This was a cohort study of participants in a Medicare managed-risk health plan who completed both the LII and P(ra) (n = 386). All hospitalizations within 1 y of screening were recorded. Hierarchical multivariate logistic regression was used to model associations with hospitalization. RESULTS: P(ra) items that retained significant associations with hospitalization were self-reported health, hospitalization in the past year, and >6 doctor visits in the past year (positive predictive value: 20%; sensitivity: 53.1; specificity: 69.7). LII items that retained significant associations with hospitalization were eating problems and polypharmacy (positive predictive value: 17.9%; sensitivity: 58.0; specificity: 56.3). Those persons designated by the P(ra) score as being at high risk of hospitalization (P(ra) > or = 0.30, 75th percentile) were also more likely to report weight loss, polypharmacy, consumption of a special diet, and functional limitation on the LII. CONCLUSIONS: Retained items from the P(ra) and the LII were comparable in identifying participants at risk of hospitalization. These observations suggest that nutritional risk factors such as eating problems, weight loss, and consumption of special diets should be considered in the management of older persons at risk of hospitalization, irrespective of the screening approach selected.

The relationship between body mass index and self-reported functional limitation among older adults: a gender difference.

OBJECTIVES: To determine whether there is a gender difference in how body mass index (BMI) relates to self-reported functional limitation. Also, to evaluate whether the method of categorizing BMI changes the observed results. DESIGN: Cross-sectional cohort study. SETTING: Rural Pennsylvania. PARTICIPANTS: A total of 7,120 male (n = 3,312) and female (n = 3,808) community-dwelling older adults enrolled in a Medicare managed-risk contract. MEASUREMENTS: All subjects completed a modified Level II Nutrition Risk Screen upon enrollment in the health plan. Height and weight were obtained by nursing personnel during an enrollment clinic visit. Subjects who reported 10 or more pounds weight loss in the previous 6 months were excluded. Logistic regression was used to evaluate the relationship between BMI and self-reported functional limitation separately for each sex, adjusting for age, depression, and polypharmacy. Two schemes were used to categorize BMI: equally distributed sex-specific quintiles and arbitrary division based on National Institutes of Health (NIH) Obesity Guidelines. RESULTS: How BMI relates to functional limitation depends upon both sex and method of categorizing BMI. When BMI was considered in gender-specific quintiles, women in the highest quintile of BMI had increased risk of functional impairment; there was no relationship between BMI and functional limitation for men. When BMI was categorized by the NIH obesity guidelines, both men and women with BMI >40 had significantly increased risk of functional limitation. CONCLUSIONS: The mechanisms behind gender discrepancy in self-reported functional limitation remain unclear. Studies may need to consider men and women separately, because how BMI relates to function depends on gender. Further research is needed to evaluate how changes in weight and body composition during middle and old age affect functional status.

Nutrition in the elderly.

Older people are growing in prevalence and their nutrition-related concerns adversely impact upon health, function, and life quality. Changes in body composition and organ system function alter nutrient requirements. The purpose of this review is to examine changes in nutritional requirements with aging and to highlight practical approaches to nutritional screening, assessment, and intervention. A multidisciplinary approach with individualized care is recommended. Health care providers who work with older people must be attentive to nutrition, because appreciable comorbidity and unfavorable outcomes may accompany either under- or overnutrition.

Responses of older adults to theory-based nutrition newsletters.

OBJECTIVE: To evaluate the effect of a theory-based newsletter on knowledge, attitude, and behavior change in older adults. DESIGN: Pretest-posttest, random assignment, and treatment-control design with 2 treatment groups: 1 that received newsletters only and 1 that received newsletters with follow-up telephone interviews. Control group completed pretest-posttest surveys only. SUBJECTS/SETTING: Four hundred eighty men and women, aged 60 to 74 years, were recruited to participate in a home-based educational intervention using a patient list generated from a rural tertiary care hospital database, Geisinger Medical Center in Danville, Pa. INTERVENTION: Five nutrition newsletters designed using the nutrition communication model and adult learning theory principles were mailed biweekly. Telephone interviews followed each of the 5 newsletters 10 to 14 days after distribution. OUTCOME MEASURES: Nutrition knowledge and interest, food behavior related to dietary fat, and stages of change for dietary fat and fiber. STATISTICAL ANALYSES PERFORMED: Analysis of covariance was used to determine group differences in posttest outcome measures using pretest as covariate. RESULTS: In addition to achieving higher scores than the control group, the treatment groups were significantly different from each other in correct and perceived nutrition knowledge at posttest. Those in the treatment group receiving telephone calls scored higher (mean change = 19.0% for correct and 20.3% for perceived) than those who received the newsletters only (mean change = 12.5% for correct and 14.3% for perceived; P < .05). Treatment groups also rated their interest in nutrition higher than the control group did; there was no between-treatment difference. Treatment groups performed significantly better than the control group for dietary fiber stage of change (P < .05). Those receiving only newsletters scored significantly better than the control for the "avoid fat" food behavior (P < .05). APPLICATIONS/CONCLUSIONS: This study provides an example of the incorporation of a theoretical model in development and evaluation of newsletters. Home-delivered nutrition newsletters based on this model can communicate health and nutrition information to older adults. Consumers today have more opportunities than ever before to access nutrition information quickly and inexpensively. Newsletters can help dietetics professionals filter and limit what consumers must process, saving clients time and improving the accuracy of information obtained. Dietetics professionals in both clinical and community practice are uniquely positioned to provide highly focused and understandable information to consumers via a newsletter format.

Abnormal liver functions as a result of total parenteral nutrition in a patient with short-bowel syndrome.

The pathogenesis of total parenteral nutrition (TPN)-induced liver cholestasis is poorly understood. Cholestasis generally occurs late in TPN therapy in association with elevated serum alkaline phosphatase and total bilirubin concentrations. Such factors as preexisting medical conditions, excessive nutrient infusion, amino-acid deficiency, absence of enteral stimulation, protracted duration of therapy, continuous infusion schedule, and hypoalbuminemia have all been suggested as possible etiologies. Various treatments have been proposed for the correction of TPN-induced cholestasis including administration of bile salt and antimicrobial therapies. To avoid potential hepatic complications associated with TPN, certain preventive measures can be considered. Administration of energy substrates should not be excessive. A mixed-fuel system that includes lipids should be implemented. TPN should be cycled if it will be used long term, and initiation of enteral nutrition should begin as soon as possible.

Evaluation of a food label nutrition intervention for women with type 2 diabetes mellitus.

OBJECTIVE: To evaluate an educational intervention about the food label designed specifically for women with type 2 diabetes mellitus. DESIGN: A pretest-posttest control group design. Participants received random group assignment. SUBJECTS/SETTING: Forty-three women aged 40 to 60 years with type 2 diabetes living in a rural community in Pennsylvania participated. Forty participants (93%) completed the program. INTERVENTION: Nine weekly group sessions were developed on the basis of findings from previous research among this sample. Principles from Ausubel's learning theory were also incorporated into program design and evaluation. MAIN OUTCOME MEASURES: The effectiveness of the food label education program on participants' knowledge was determined using a multiple-choice test designed to measure declarative and procedural knowledge. A skills inventory assessed participants' perceived confidence in using the food label. The validity and reliability of the instruments had been established previously. STATISTICAL ANALYSES: Analysis of variance was performed to compare groups. Paired t tests compared pretest and posttest results. RESULTS: The experimental group showed a greater gain than the control group in total knowledge (P < .001), declarative knowledge (P < .001), and procedural knowledge (P < .01) at posttest. Posttest data showed a significant increase (P < .01) in experimental participants' perceived confidence in using the food label. CONCLUSIONS: Women with diabetes need more education about the food label. This intervention is an effective outpatient education program. Participant knowledge and perceived confidence in using the food label improved significantly as a result of the intervention. Future research should assess retention of knowledge gained and the impact of the intervention on metabolic measures of diabetes management and control.

Obesity in older persons.

The prevalence of obesity among older persons is growing. This trend has adverse medical, functional, psychosocial, and health care resource consequences. Many obese older persons were obese middle-aged adults. A sedentary lifestyle may be the dominant contributing factor. Intervention should focus on moderate weight reduction through the modification of diet, exercise, and behavior. Improvements in health and quality of life can be achieved with moderate weight reduction. Strategies tailored to the older population will facilitate successful interventions. Dietitians must be key participants in the effort to raise awareness of obesity as a serious health concern for older persons. The focus must be on achieving a more healthful weight.

Clinical nutrition: opportunity in a changing health care environment.

This article summarizes presentations from a satellite symposium, "Clinical Nutrition: Opportunity in a Changing Health Care Environment," held July 26, 1997, at the 37th annual meeting of the American Society for Clinical Nutrition in Montreal. The symposium was cosponsored by the American Society for Clinical Nutrition and the American Society for Parenteral and Enteral Nutrition. The diverse topics served as a practical forum for sharing information on innovative responses, concerns, and impediments in the rapidly evolving practice environment.