The frequency of malnutrition in older adults depends on population, geography, age, socioeconomic status, and the screening tools used. The frequency of malnutrition was determined in 33.6% of our study group according to the MNA. GLIM criteria are currently used to determine malnutrition. To determine malnutrition according to these criteria, outpatients are generally questioned about weight loss, nutritional intake, and inflammation status. However, there are many validated techniques in GLIM criteria that can determine low muscle mass. We compared these methods to determine which techniques could be more meaningful, reliable, and valuable.
Our study found that when evaluated with the MAMC, CC, FFMI, HGS, and without using reduced muscle mass, GLIM resulted in an age increase with malnutrition development in outpatients. Outpatients, who develop malnutrition with the advancement of age, decrease their BMI values. Studies have found that age was an independent risk factor for malnutrition (19).
As far as we know, our study is the first study on GLIM criteria created by evaluating different muscle masses in older adult outpatients. Based on the results of this study, we considered which of the phenotypic criteria used in GLIM studies in the literature should be given in detail in the method section. Our study detected malnutrition as 26.9% when using MAMC, 28.1% when using CC, 31.5% when using FFMI, and 31.9% when using HGS to determine muscle strength, which was taken as one of the phenotypic criteria. When GLIM-2F+2E was evaluated, the frequency of malnutrition was lower (21.4%), and approximately 10% of outpatients were missed when reduced muscle mass was not in use.
In our study, 24-hour food consumption records, which we consider a strength of our study, were not found in the literature. Patients with malnutrition according to GLIM, which was determined using different muscle mass evaluation methods, were compared. According to the protein requirement of the European Parenteral and Enteral Nutrition Association (ESPEN) guidelines, 55% of males and 58% of females reached their target protein at the end of the day in our study. Morris et al. conducted a study to describe the protein intake of older adults. According to the ESPEN guidelines (20), less than 15% of the participants reached 1.2 g/kg/day intake levels. Sixty-seven percent of males and 77% of females reached the 25-g protein target in the middle of the day.(21) Calorie and carbohydrate intake were lower in both genders, especially in males diagnosed with MN using the GLIM-MAMC.
Handgrip strength has been a superior outcome marker for healthy people and patients, especially in older adults. FFMI found by BIA measurement is the only method recommended and validated by GLIM, so we used it as a reference. In our study, when handgrip was included in GLIM criteria, the rate of malnutrition was 31.9% in older adults. The MN ratio found by the GLIM-HGS method gave the closest value to the MN ratio in the reference method. Therefore, even if HGS is used instead of FFMI in clinics without BIA, MN will not be ignored. HGS assessment gives the closest rate to malnutrition in patients scanned with the MNA. Some studies have emphasized low handgrip strength was consistent with the possibility of early death, early disability, increased risk of complications, length of hospitalization, or prolonged stay after surgery.(22) Bolivar et al. conducted a prospective study to determine the prevalence of malnutrition in cancer patients. They evaluated the most compatible malnutrition rates by taking Subjective Global Assessment (SGA) and some anthropometric measurements of the patients. SGA and GLIM criteria (especially with HGS) were found to be the most valuable tools in the diagnosis of malnutrition and evaluation of six-month mortality.(10)
In our study, the CC was the best indicator of the number of malnourished older adults after the HGS and FFMI. Bonnefoy et al. studied 911 geriatric patients to determine nutritional status. The study investigated the method that gives the best correlation value between biochemical methods (albumin, transthyretin, transferrin, retinol-binding protein, and a1-acid glycoprotein) and anthropometric methods (upper-middle arm circumference, calf circumference, and skinfold thickness). The anthropometric method that determined the best nutritional status in the study showed that the CC was the best.(23) In a study by Drescher et al., the MNA and Nutritional Risk Screening (NRS) scores were high in geriatric patients with low CC (24).
In our study, GLIM-MAMC, malnutrition was found at 26.9%, while the mean MAMC of malnourished female outpatients was 18.8±1.9 cm, and the mean of malnourished male outpatients was 18.6±1.3 cm. In a study by Bolivar et al., GLIM-MAMC evaluation of cancer patients was followed. In the SGA evaluation of the patients, 25.5% had moderate MN, and 56.1% had severe MN. In GLIM-MAMC evaluation, they found MN in 72.2% of the patients. This is the most similar study to ours, and the reason for higher MN rates is that the patient group had cancer. Our patient group consisted of outpatients from general society.
A study comparing GLIM criteria with reduced food intake, one of the malnutrition evaluation parameters, could not be identified in the literature. Hanisah et al., in their study, assessed malnutrition using SGA and anthropometric measurements, and food intake was measured using the Dietary History Questionnaire. While 50.4% of the patients were moderately malnourished, 11% were found to be severely malnourished. According to MN-MAMC, rates were found to be 10.9% in males and 3% in females. According to MN-CC, rates were found as 34.8% in males and 20.2% in females.(25) In our study, when according to MN-MAMC, the rate was found as 7.6% (7.8% in males and 7.4% in females). When according to MN-CC was determined, the rate was found as 10.9% (10% in males and 11.5% in females). However, when malnutrition was evaluated using the GLIM-MAMC, the rate of MN increased to 20% in males and 31.1% in females. Likewise, when malnutrition was evaluated using the GLIM-CC, the rate of MN increased to 22.2% in males and 31.8% in females. In other words, when MN is evaluated by only looking at the MN-MAMC or MN-CC values of the patients, MN rates are low; this can mislead us. According to GLIM-MAMC and GLIM-CC, food consumption records taken from patients are a valid etiological criterion in showing the malnutrition levels of the patients. Thus, we can prevent patients who need MN treatment from being overlooked.
In our study, calorie intake was 1188 ± 544 kcal in males, while it was 1080 ± 522 kcal in females. The percentage of males not reaching their target calories was 36.7%, while females not reaching their target calories was 34.5%. This MN ratio was found close to according to GLIM-MAMC, GLIM-CC, GLIM-FFMI, and GLIM-HGS evaluation.
In our study, we calculated the energy received by the patients with a 24-hour food consumption record, and we evaluated those with below 50% of the energy they should receive according to GLIM criteria as having a reduced food intake. As a result, the MN ratio was determined as 21.4% with the GLIM-2F+2E. Although this study was conducted as a more objective evaluation, according to the evaluation made by taking the muscle mass into account, MN rates were found to be 5-10% missing. In other words, no matter how objective the 24-hour food consumption record is, which is one of the strengths of our study, it will always give better results when evaluated with muscle mass. In this case, when MN is evaluated GLIM-2F+2E instead of GLIM with muscle mass, results show that we overlook sarcopenic elderly individuals, a concept intertwined with malnutrition.
The strength of our study is that it was performed in an outpatient patient group with a higher incidence of more specific malnutrition. By taking a 24-hour food record, we evaluated the decrease in the food received by the patient with a more objective method. The fact that C-Reactive Protein determination was not routinely performed in every patient to evaluate the acute inflammation, which is one of the etiological criteria, can be considered a disadvantage of our study.
Clinically, the fastest, most practical, and cost-effective determination of malnutrition in geriatric outpatients is vital for both patients and healthcare professionals. GLIM is the most up-to-date method that includes many criteria to diagnose MN. According to our study, compared to other malnutrition diagnostic methods, GLIM better detects elderly patients with malnutrition that may be overlooked. A more objective assessment will be made when GLIM criteria are combined with the 24-hour food consumption record. In our study, "GLIM-HGS" was the validated technique that showed the most meaning after MNA in screening malnutrition status of outpatients. However, while the MNA determines the risk of malnutrition in older adults, GLIM shows the malnutrition status. Therefore, "GLIM- HGS" can be used instead of the MNA in outpatients.
In conclusion, when GLIM-2F+2E assessment was made by taking food consumption records, GLIM-MAMC was the most meaningful method for MN evaluation. Still, GLIM-HGS was the most meaningful and practical evaluation of muscle mass assessment in the clinic. With this method, it is easier to determine the malnutrition status of the outpatients, and it will not be overlooked.