What are the diagnostic criteria for severe protein calorie malnutrition?

Diagnostic Criteria for Severe Protein Calorie Malnutrition

Severe protein calorie malnutrition requires meeting at least one phenotypic criterion AND one etiologic criterion from the ESPEN GLIM framework, with specific thresholds that distinguish it from moderate malnutrition. 1

Phenotypic Criteria (Need at least ONE)

Weight Loss:

• >10% weight loss within the past 6 months, or 1, 2
• >20% weight loss beyond 6 months 1

Body Mass Index:

• <18.5 kg/m² if patient is <70 years old, or 1, 2
• <20 kg/m² if patient is ≥70 years old 1, 2
• For Asian populations, thresholds are lower: <18.5 kg/m² if <70 years, <20 kg/m² if ≥70 years 1

Muscle Mass:

• Severe deficit in muscle mass assessed by validated methods including: 1, 2
  • Fat-free mass index (FFMI) by dual-energy absorptiometry 1
  • Bioelectrical impedance analysis (BIA) 1
  • CT or MRI imaging 1
  • Mid-arm muscle circumference or calf circumference when advanced methods unavailable 1
  • Hand-grip strength as supportive functional measure 1, 2

Etiologic Criteria (Need at least ONE)

Reduced Food Intake or Assimilation:

• ≤50% of energy requirements for >1 week, or 1, 2
• Severe malabsorption or severe gastrointestinal symptoms (severe dysphagia, nausea, vomiting, diarrhea, constipation, or abdominal pain) 1

Disease Burden/Inflammation:

• Acute disease/injury-related with severe inflammation (major infection, burns, trauma, closed head injury), or 1
• Chronic disease-related with chronic or recurrent inflammation (malignancy, COPD, heart failure, chronic kidney disease) 1
• CRP may be used as supportive laboratory measure 1

Additional Clinical Indicators of Severe Nutritional Risk

While not part of the formal GLIM criteria, these indicators suggest severe nutritional risk requiring immediate intervention:

• NRS 2002 score >5, or 1
• Subjective Global Assessment (SGA) grade C, or 1
• Serum albumin <30 g/L in absence of hepatic or renal dysfunction 1

Critical Implementation Points

The two-step diagnostic approach is essential: First screen using validated tools (NRS-2002 for inpatients, MUST for community, MNA-SF for elderly), then assess using GLIM criteria if screening is positive. 2

Common pitfalls to avoid:

• Do not rely on BMI alone in fluid-overloaded patients (especially those with kidney or liver disease), as this underestimates malnutrition severity 1, 2
• Do not use single parameters like albumin alone, as it reflects inflammation and hydration status, not just nutritional state 1
• Thresholds must be adapted for race and age—Asian populations have different BMI cutoffs 1

Functional assessment strengthens diagnosis: Document functional status using WHO or Karnofsky scales, as severe malnutrition correlates with diminished functional capacity. 2

In children, different criteria apply: Severe acute malnutrition is defined as weight-for-height <70% of median (or <-3 SD), bilateral pitting edema, or mid-upper-arm circumference <110 mm in ages 1-5 years. 3