Charles Chin Han Lew

Background: This article presents the results of the modified Delphi study conducted by the GLIM Risk of Malnutrition Working Group to develop a consensus‐based conceptual definition of “risk of malnutrition”, as first step in revising the GLIM screening procedure. Methods: Focus groups with nutritional care experts and patient/older adult representatives, and a literature exploration informed 46 statements on risk of malnutrition. Malnutrition experts ( n = 112) evaluated these statements, using a five‐point Likert scale. Statements with ≥75% agreement were accepted; those with ≥75% disagreement and/or neutrality were rejected. Remaining statements were marked “undecided” and re‐evaluated in later rounds. Results: In three questionnaire rounds (response rates 63%, 59%, and 54%), 26 statements were ultimately accepted to shape the conceptual definition of “risk of malnutrition”. The GLIM Working Group and patient/older adult representatives reviewed the pre‐final professional and layperson versions. Risk of malnutrition was defined as: A dynamic state, with or without unintentional weight loss, in which an individual has one or more risk factors, that is, nutrition impact symptoms, and/or disease‐related, physical, psychological, social, demographic, and economic risk factors, that may result in malnutrition and may negatively impact clinical outcomes. In the layperson version, sentences were simplified to aid comprehension. Conclusion: GLIM has developed the first global (professional and layperson) conceptual definition of risk of malnutrition. This definition will guide future nutritional screening recommendations and a more preventive malnutrition approach. It also implies that screening tools covering “risk of malnutrition” should no longer be validated against signs or the diagnosis of malnutrition.

Background and Aims: Within the original GLIM procedure (2019), the step on nutritional screening was not further elaborated. A new GLIM Risk of Malnutrition Working Group has recently developed a consensus‐based conceptual definition of “risk of malnutrition.” The present study aimed to operationalize this definition. Methods: This study consisted of: (1) a literature search to identify risk factors for malnutrition, and (2) a two‐round online modified Delphi study. International professional experts ( n = 113) in the field of malnutrition were invited to rate the importance of identified risk factors using a 9‐point Likert scale. In questionnaire round 1, risk factors were rated “critically important” if ≥70% of the participants rated them 7–9, or “not important” if >30% rated them 1–3. The remaining risk factors were categorized as “undecided.” In questionnaire round 2, undecided risk factors were classified as “critically important” or “important, but not critical,” based on the same threshold. Results: The literature search revealed 64 risk factors that were included in the Delphi questionnaires. Of 113 invited experts, 57 responded to Delphi Round 1, and 46 responded to Delphi Round 2. Twenty‐nine risk factors (from the overarching risk categories unintentional weight loss, nutrition impact symptoms, disease‐related factors, physical factors, psychological factors, decreased food intake, food assimilation, and poor diet) were deemed “critically important,” 10 “important, but not critical,” and 19 “substantially important.” Conclusion: In this study, we identified which risk factors are considered critical to operationalize “risk of malnutrition.” Screening for risk of malnutrition should take these relevant risk factors into account.

The GLIM malnutrition diagnostic framework includes the etiologic criterion for reduced dietary intake or assimilation (i.e., digestion or absorption). This criterion required further specification to support consistent use in clinical practice. Three rounds of a modified Delphi was undertaken to develop consensus on guidance to support identification of this criterion. A working group ( n = 10) developed surveys iteratively. Invited global experts with diverse disciplines and practice contexts ( n = 30) fully completed surveys; consensus was determined at 75% agreement. Three surveys and rounds of voting resulted in 15 guidance statements. Notable points include: (a) using usual intake as the comparator for reduced dietary intake rather than energy requirement, (b) use of gastrointestinal symptoms and nutrition impact symptoms to determine challenges with absorption or assimilation, rather than solely gastrointestinal conditions, and (c) using clinical judgment to determine severity of these symptoms. The final criterion is “less than or equal to 50% dietary intake in the last week or any reduction in intake greater than 2 weeks OR severe gastrointestinal or nutrition impact symptoms (e.g., dysphagia, nausea, vomiting, diarrhea) as a result of an acute or chronic condition or therapy.” Future work should confirm the feasibility of this criterion in clinical practice and its criterion validity within the GLIM framework.

Background: Better understanding the impact of dietetic services on nutrition practices seems required as it may represent an opportunity for optimization in post–cardiac surgery patients. The present study aims to evaluate and compare nutrition practices and clinical outcomes in post–cardiac surgery intensive care unit (ICU) patients with and without dietetic services.Methods: This is a secondary analysis of a multinational prospective observational study in patients (n = 237) with >72 h of post–cardiac surgical ICU stay with and without dietetic services describing nutrition practices and outcomes up to 12 days after ICU admission.Results: Dietetic services were available in 61.5% (8 of 13) ICUs (1.0 ± 0.5 full‐time equivalents/10 beds). Enteral nutrition was initiated <48 h from ICU admission in 49.6% and 59.1% of patients at sites with vs without dietetic services, respectively. Parenteral nutrition was started within 118.3 ± 56.5 and 131.5 ± 69.2 h at sites with vs without dietetic services, respectively. Energy target (23.7 ± 4.8 vs 24.6 ± 4.8 kcal/kg body weight/day) and actual supply (10.5 ± 6.7 vs 10.3 ± 6.2 kcal/kg body weight/day) did not differ between the groups. Protein targets (1.4 ± 0.4 vs 1.1 ± 1.3 g/kg body weight/day) and actual protein provision (0.6 ± 0.4 vs 0.4 ± 0.3 g/kg body weight/day) were higher in patients at sites with vs without dietetic services.Conclusion: Improvements in medical nutrition therapy practices in patients after cardiac surgery are needed in ICUs with and without dietetic services. Appropriately staffed dietetic services as essential members of the medical care team may be crucial to transfer knowledge on adequate medical nutrition therapy strategies into practice.

Context: There is a common belief that adult critically ill patients diagnosed with or at risk of malnutrition would benefit from higher energy delivery. Objective: This systematic review and meta-analysis aimed to evaluate the association between energy delivery and mortality in adult critically ill patients diagnosed with or at risk of malnutrition. Data Sources: Databases including Medline, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central, and Google Scholar were searched from inception to November 20, 2023. Data Extraction: Randomized controlled trials (RCTs) and observational studies that (1) included critically ill patients (aged ≥18 years) diagnosed with or at risk of malnutrition using validated tools following intensive care unit (ICU) admission, (2) had at least 20% energy difference between intervention and comparison groups, and (3) reported mortality outcomes were included. The random-effects model was used to pool the data. Data Analysis: Two RCTs (4681 at-risk patients) and 5 observational studies (1587 at-risk patients [including 389 high-risk patients]) were included. The pooled mean energy delivered during the first 7–14 days of ICU admission in higher vs lower energy groups was 25.6 ± 5.9 vs 9.7 ± 5.6 kcal/kg per day (P = .004) in RCTs and 21.0 ± 5.2 vs 13.3 ± 5.3 kcal/kg per day (P < .001) in observational studies. No mortality difference was found between higher vs lower energy groups in at-risk patients (risk ratio: 0.99; 95% CI: 0.85, 1.17; P = .94) in RCTs and high-risk patients (adjusted odds ratio: 1.37; 95% CI: 0.43, 4.32; P = .59) in observational studies. Trial sequential analysis was performed and 31 232 patients were required to show a potential treatment effect. Conclusion: These data do not support the prevailing belief that higher energy delivery improves survival in adult critically ill patients diagnosed with or at risk of malnutrition. Systematic Review Registration: PROSPERO registration no. CRD42021274378.