Newly Released Criteria Strives for a Global Consensus of Malnutrition

New criteria could be incorporated in ICD-11.

Malnutrition is a terrible problem worldwide, even more so in third-world countries than here in the U.S. Historically, it was due to starvation and famine, born of poverty, war, and nature, but malnutrition due to disease and inflammation is a major factor now, especially in developed countries.

In our sphere, a fundamental lack of consensus on diagnostic criteria for malnutrition has opened the door for denials.

In January 2016, the Global Leadership Initiative on Malnutrition, or GLIM, convened with the intent to establish global consensus criteria so that prevalence, interventions, and outcomes can be compared worldwide. The core leadership committee included the American Society for Parenteral and Enteral Nutrition, or ASPEN, as the representative of the United States.

I am going to offer a summary, with the disclaimer that although the criteria are newly released, they have not been universally adopted yet.

The committee settled on a two-step model for risk screening via use of any validated screening tool – including the ASPEN criteria, which many of your organizations no doubt utilize – followed by a secondary diagnosis assessment.

There are three phenotypic criteria. A phenotype is the visible character of an organism, or the way genes or genotypes and the environment combine to express physical characteristics.

All existing malnutrition tools recognize nonvolitional weight loss as being an indicator, and as such, this constitutes the first phenotypic criterion. This refers to unintentional loss of weight, and the committee noted that many patients may have lost the weight prior to presentation to healthcare professionals.

There was significant variation in the use of low body mass index (BMI) as a criterion for malnutrition. Having obesity coincident with malnutrition is a first-world problem. Low BMI is more typical in other regions of the world.

The last phenotypic criterion is reduced muscle mass, also known as sarcopenia. There was no consensus as how to best measure and judge diminished muscle mass, but as reduced muscle function generally accompanies loss of muscle mass, decreased hand grip strength can be used as a proxy.

The next step was determining etiology. The two categories identified were decreased nutrition and disease burden/inflammation. 

Reduced food intake from decreased appetite, depression, medication side effects, or availability and malabsorption, or decreased assimilation from processes such as short bowel syndrome, bariatric surgery, and persistent vomiting constitute the first etiologic criterion.

The alternative etiologic criterion comprises severe, chronic, or frequently recurrent inflammation, such as major infections, burns, trauma, and chronic diseases such as heart failure, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), liver disease, and cancer. This is subdivided into chronic disease with and without inflammation, acute disease or injury with severe inflammation, and starvation associated with socioeconomic or environmental factors.

To diagnose malnutrition, there needs to be at least one phenotypic criterion and one etiologic criterion. GLIM went on to offer severity grading criteria. Only moderate and severe malnutrition are recognized, which is likely to cause us problems if providers diagnose mild malnutrition.

The committee also noted that cachexia, or wasting disease, due to a chronic disease such as AIDS or cancer fits into the category of malnutrition related to chronic disease with inflammation, but noted that there are some distinctive features. The GLIM criteria are to be applied in parallel. Epidemiologically, if one were to code R64 for cachexia with the appropriate malnutrition code, you could identify these cases. The excludes 1 are for abnormal weight loss and nutritional marasmus.

GLIM plans to validate the criteria and reevaluate every three to five years. The committee also hopes to have the World Health Organization (WHO) embrace them and incorporate them into ICD-11.

I am going to guess that we are going to see organizations and societies adopt these criteria, and our dietitians are going to transition as well. Let’s hope the third-party payers and auditors follow suit.

Program Note:

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