★ PSPEN Consensus · GLIM Criteria 2018
PAKISTAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION
GLIM Criteria — Global Leadership Initiative on Malnutrition
Global consensus diagnostic criteria for malnutrition in adults — Two-step: Risk screening + Assessment (Phenotypic + Etiologic) + Severity grading.
📖 About GLIM — Why Global Consensus?
The Global Leadership Initiative on Malnutrition (GLIM) was launched in 2016 and published in 2019 by leading clinical nutrition societies worldwide to create one universal diagnostic approach for adult malnutrition, usable across all settings and regions — including South Asia / Pakistan.
- Two-step workflow: (1) Screen for risk with validated tool → (2) Assess for diagnosis
- Diagnosis requires: At least 1 phenotypic (weight loss / low BMI / low muscle mass) + 1 etiologic (reduced intake/assimilation OR inflammation/disease burden)
- Severity grading: Based on severity of phenotypic criteria — Stage 1 Moderate and Stage 2 Severe
- Muscle mass included as core criterion — acknowledges sarcopenia component
- Endorsed by PSPEN for hospital and community practice in Pakistan with Asian BMI adaptation
2
Steps: Screen + Assess
5
Criteria: 3P + 2E
1+1
Required for Diagnosis
2
Severity Stages
2018
Consensus Year
Interactive Calculator
⚡ GLIM Diagnosis & Severity Calculator
Enter patient data — GLIM phenotypic, etiologic, diagnosis and severity stage are calculated automatically.
👆 Fill patient data — initial risk, phenotypic, etiologic, diagnosis and severity stage will appear here
📋 GLIM Clinical Flowchart — Two-Step Diagnostic Process
Step 1: Screen for risk → Step 2: Assess 3 phenotypic + 2 etiologic → Diagnosis = 1 phenotypic + 1 etiologic → Severity grading
1
Step 1 — Risk Screening (Use Validated Tool)
Any validated hospital/community tool: NRS-2002, MUST, MNA-SF, SGA, MST, etc.
NRS-2002Hospitalized adults · Score ≥3 = At risk
MUSTCommunity + Hospital · Score ≥1 = Observe, ≥2 = Treat
MNA-SFElderly ≥65y · Score 0–7 at risk
Any Local ToolValidated for Pakistan setting
If NOT at risk →Re-screen per schedule (hospital weekly). No GLIM assessment required now.
If AT RISK →Proceed to Step 2: GLIM Assessment for diagnosis and severity grading.
If at risk → Step 2: GLIM Assessment
2
Step 2 — Assessment for Diagnosis (3 Phenotypic + 2 Etiologic)
Diagnosis requires AT LEAST 1 phenotypic criterion + AT LEAST 1 etiologic criterion
🧬 Phenotypic Criteria (3) — Need ≥13 criteria
1
Non-volitional Weight LossWithin past 6 months: >5% · Beyond 6 months: >10% · Thresholds guide severity (see below)
2
Low Body Mass IndexGlobal: <20 kg/m² if <70y, <22 if ≥70y · Asia (incl. Pakistan): <18.5 if <70y, <20 if ≥70y for diagnosis; lower thresholds define severity
3
Reduced Muscle MassReduction confirmed by validated body composition (BIA, DXA, CT), anthropometry (calf/MUAC), or functional surrogate (handgrip as supportive)
🔥 Etiologic Criteria (2) — Need ≥12 criteria
A
Reduced Food Intake or Assimilation≤50% of energy requirements >1 week OR any reduction >2 weeks OR any chronic GI condition impairing assimilation/malabsorption (dysphagia, nausea, vomiting, diarrhea, obstruction)
B
Inflammation / Disease BurdenAcute disease / injury-related: major infection, burns, trauma, closed head injury · Chronic disease-related: malignant, COPD, CHF, CKD, chronic infection, inflammation (CRP, fever, inflammatory markers)
0
No PhenotypicNo weight loss, BMI normal, muscle mass preserved → No phenotypic → No GLIM malnutrition
0
No EtiologicNo reduced intake, no GI issue, no inflammation/disease burden → No etiologic → No GLIM malnutrition
✓
Diagnosis: 1 Phenotypic + 1 EtiologicMEETS GLIM: At least 1 from each group → Malnutrition diagnosed → Proceed to severity grading
Diagnosis = 1 Phenotypic + 1 Etiologic → Severity Grading
3
Step 3 — Severity Grading (Based on Phenotypic Criteria)
Stage 1 Moderate malnutrition vs Stage 2 Severe malnutrition — Use most severe phenotypic indicator
Stage 1 · Moderate Moderate Malnutrition
- Weight loss: 5–10% within past 6 months OR 10–20% beyond 6 months
- BMI: Global: <20 if <70y, <22 if ≥70y · Asia: <18.5 if <70y, <20 if ≥70y
- Muscle mass: Mild to moderate deficit (e.g., calf circumference mildly low, SMI moderate reduction)
Stage 2 · Severe Severe Malnutrition
- Weight loss: >10% within past 6 months OR >20% beyond 6 months
- BMI: Global: <18.5 if <70y, <20 if ≥70y · Asia: <17 if <70y, <17.5 if ≥70y (some use <17.5/<18)
- Muscle mass: Severe deficit (marked loss on exam, imaging or anthropometry)
How to assign severity:If any phenotypic meets severe threshold → classify as Stage 2 Severe, even if other phenotypic are moderate. Otherwise if all phenotypic at least moderate → Stage 1 Moderate.
Clinical implication:Severity guides intensity of nutrition support, monitoring frequency, and need for specialist referral. Severe = higher priority for dietitian + EN/PN assessment.
⚠️ Important: GLIM diagnosis does not replace clinical judgement. Always assess functional status, comorbidities, and patient goals. Muscle mass may be difficult to measure — use calf circumference (<31 cm presumptive), MUAC, or validated clinical assessment if BIA/DXA/CT unavailable. Inflammation may be inferred from disease, fever, elevated CRP/procalcitonin, low albumin (not specific). Re-assess every 3–6 months or after clinical change.
★ PAKISTAN SOCIETY FOR PARENTERAL & ENTERAL NUTRITION ★
GLIM Criteria endorsed for Pakistan practice by PSPEN — Based on Cederholm et al. Clinical Nutrition 2019 consensusFor educational & clinical use by qualified professionals. © PSPEN · 2025
Reference Tables
📊 GLIM Phenotypic Thresholds — Detailed
Use for severity grading — Global thresholds and Asian adaptation for Pakistan.
← Swipe to see all columns →
| Phenotypic Criterion | Moderate Malnutrition (Stage 1) | Severe Malnutrition (Stage 2) | Asian (Pakistan) Moderate | Asian Severe |
|---|---|---|---|---|
| Weight loss within 6mo | 5–10% | >10% | 5–10% | >10% |
| Weight loss beyond 6mo | 10–20% | >20% | 10–20% | >20% |
| BMI if <70y | <20 kg/m² | <18.5 kg/m² | <18.5 kg/m² | <17.0 kg/m² |
| BMI if ≥70y | <22 kg/m² | <20 kg/m² | <20 kg/m² | <17.5 kg/m² |
| Reduced Muscle Mass | Mild to moderate deficit | Severe deficit | Mild-mod deficit (CC <34M/<33F) | Severe deficit (CC <31 / low SMI) |
Reference Tables
🔥 Etiologic Criteria & Muscle Assessment Methods
← Swipe table →
| Category | Criteria | Examples / Tools |
|---|---|---|
| Reduced Intake | ≤50% of ER >1 week OR any reduction >2 weeks OR chronic GI condition | Anorexia, dysphagia, nausea, vomiting, diarrhea, obstruction, malabsorption, IBD, short bowel, pancreatic insufficiency |
| Inflammation: Acute | Acute disease / injury with inflammatory response | Major infection, burns, trauma, closed head injury, major surgery — CRP >10 mg/L, fever, elevated WBC |
| Inflammation: Chronic | Chronic disease-related with persistent mild-moderate inflammation | Malignancy, COPD, CHF, CKD, chronic infection, rheumatoid arthritis — CRP mildly elevated, low albumin (supportive) |
| Muscle: BIA | Fat-free mass index, skeletal muscle index (SMI) | FFMI <17 M / <15 F kg/m² low; SMI cut-offs by device/population |
| Muscle: Anthropometry | Calf circumference (CC), mid-upper arm circumference (MUAC) | CC <31 cm = low; MUAC <23 cm undernutrition, <19 severe — rapid bedside |
| Muscle: Imaging | DXA, CT at L3 | CT L3 SMI <52.4 M / <38.5 F cm²/m² = low (cancer); DXA appendicular SMI |
Best Practice
💡 PSPEN — How to Implement GLIM in Pakistan
🏥 In Hospitals
1. Screen all admissions within 24h with NRS-2002 or MUST. 2. If at risk → perform GLIM assessment within 48h. 3. Document phenotypic + etiologic + severity stage in notes. 4. Refer Stage 1 to ward dietitian, Stage 2 to senior dietitian/nutrition team urgently.
Integration with EMR — Add GLIM checklist to admission form
📏 Muscle Mass Practical Tips
In low-resource setting, use calf circumference (best single anthropometric predictor) + subjective assessment of temporalis, interosseous, quadriceps wasting. Handgrip strength as supportive functional measure (<27kg M, <16kg F low).
Training nurses to measure CC correctly at maximum calf girth
🔬 Inflammation - How to Assess
Acute inflammation = fever, elevated CRP >10 mg/L, procalcitonin, WBC, wound infection. Chronic = underlying chronic disease + CRP 3–10 mg/L persistently, low prealbumin trend. Clinical judgement if labs unavailable.
CRP most practical inflammatory marker across Pakistan
🍽️ Intervention by Stage
Stage 1 Moderate: Food-first, fortify local foods (daal, egg, milk, nuts, ghee), dietitian counseling, weekly monitoring.
Stage 2 Severe: Intensive support — ONS, consider EN/PN, daily monitoring, treat underlying cause, correct micronutrients.
Energy 25–30 kcal/kg, protein 1.0–1.5 g/kg (higher in severe / catabolic)
FAQ
❓ GLIM — Frequently Asked Questions
Q1. How is GLIM different from MUST or NRS-2002?
MUST/NRS-2002 = Screening tools to identify at-risk patients. GLIM = Diagnostic criteria to confirm malnutrition diagnosis and grade severity. GLIM Step 1 says you must first screen with a validated tool like MUST/NRS. So they are complementary — screen with MUST/NRS, then diagnose with GLIM.
Q2. Do I need to measure muscle mass to diagnose GLIM malnutrition?
Not necessarily. GLIM has 3 phenotypic criteria — you need only 1 of them. If patient has clear weight loss >5% or low BMI, you can diagnose without muscle mass measurement. Muscle mass adds sensitivity, especially when weight loss/BMI are not obvious (e.g., edema, obesity). If BIA/DXA unavailable, use calf circumference or clinical assessment of muscle wasting.
Q3. What Asian BMI thresholds should I use for Pakistan?
GLIM original global thresholds are <20 (<70y) and <22 (≥70y) for moderate, <18.5 and <20 for severe. For Asian populations including Pakistan, GLIM suggests lower thresholds may be appropriate: many Pakistani studies use <18.5 (<70y) and <20 (≥70y) as moderate, and <17 (<70y) and <17.5 (≥70y) as severe. Our calculator notes Asian option — use clinical judgement and local validation.
Q4. If patient has 2 phenotypic criteria (one moderate, one severe) — what severity stage?
GLIM severity is determined by the most severe phenotypic indicator. If any phenotypic meets severe threshold, classify as Stage 2 Severe malnutrition, even if other phenotypic are only moderate. Document all phenotypic present.
Q5. Patient is obese but has weight loss and low muscle mass — can they be malnourished by GLIM?
Yes. This is sarcopenic obesity. An obese patient (BMI >30) with weight loss >10%, reduced muscle mass and inflammation/reduced intake can be diagnosed as malnourished by GLIM. Do not exclude obese patients — assess muscle mass and weight loss.
Q6. Is low albumin an etiologic criterion?
No. GLIM explicitly states albumin is NOT a nutritional marker but reflects inflammation. Hypoalbuminemia can be supportive of inflammation but is not itself a diagnostic criterion. Use CRP, clinical disease burden, and intake data instead.
Q7. How often should I re-assess GLIM?
Initial GLIM diagnosis at admission if at risk. Re-assess every 3–6 months in community, weekly during acute hospitalization, or whenever clinical condition changes significantly (surgery, infection, deterioration).