Guidance for the assessment of the dietary intake and gastrointestinal or nutrition impact symptoms etiologic criterion of Global Leadership Initiative on Malnutrition: A modified‐Delphi study

Abstract

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.

INTRODUCTION

The Global Leadership Initiative on Malnutrition (GLIM) provides a basis for a globally accepted understanding of how malnutrition could be consistently diagnosed in clinical settings, especially considering the variability in resources and expertise across care settings and countries. ¹ , ² , ³ , ⁴ The original GLIM approach, ¹ , ² and the update noted in the 5‐year review ³ , ⁴ consists of: (step 1) identifying individuals with risk factors for malnutrition; (step 2) for those with risk factors, collection of data for completion of the five GLIM criteria, with the occurrence of at least one phenotypic and one etiologic criteria being met to diagnose malnutrition, and (step 3) determination of severity of malnutrition using the GLIM phenotypic criteria. The phenotypic criteria of GLIM are non‐volitional weight loss, low body mass index, and low muscle mass, while the etiologic criteria are reduced food intake or assimilation, as well as disease burden/inflammation. ¹ , ² The simplicity of the framework for diagnosing malnutrition has resulted in broad uptake of GLIM. ⁵ , ⁶ Yet, specification of some of the criteria was required after the initial development to enhance operationalization of GLIM in clinical settings. Guidance updates for the muscle mass ⁷ , ⁸ and disease burden/inflammation ⁹ , ¹⁰ criteria have been completed. A remaining criterion for specification was “reduced food intake or assimilation.” ³ , ⁴ The working used the term dietary intake in this guidance to ensure that all forms of intake (e.g., enteral nutrition) are considered. From hereafter this term will be used instead of food intake.

There are multiple causes of poor dietary intake, including anorexia, depression, poor oral health, dysphagia, socioeconomic barriers, gastrointestinal problems, and lack of access to nutrition therapy. ¹ , ² , ¹¹ Assimilation in the form of malabsorptive disorders as well “symptoms of dysphagia, nausea, vomiting, diarrhea, constipation, and abdominal pain” were included in the orginal GLIM guidance (page 6). ¹ , ² Gastrointestinal symptoms were considered “supportive indicators” of reduced dietary intake or impaired assimilation and clinical judgment was noted as important to determine the extent to which intake or assimilation was affected by these symptoms. ¹ , ² The original guidance criterion is “<=50% of energy requirement for >1 week, or any reduction for >2 weeks, or any chronic gastrointestinal (GI) condition that adversely impacts food assimilation or absorption” (Table 3). ¹ , ² Determining if this criterion has been met, especially the assimilation component, could be challenging and a variety of methods have been used in the literature (see Table 1). For example, prior research has used diagnoses of malabsorptive disorders to indicate that this criterion has been met, ¹² , ¹³ while others have used a single sign of diarrhea. ¹⁴ Further, assessment of food intake commonly ignores the determination of a patient's requirement when determining if this criterion is met ¹⁵ , ¹⁶ , ¹⁷ and methods vary from a report food intake from a single question on a screening tool ¹⁶ to proportion of self‐reported food intake consumed over a specified time period. ¹⁷ These operational challenges make it necessary to revise this criterion so that it can be feasibly completed in a consistent manner in clinical practice. The purpose of this work is to provide globally relevant and feasible recommendations on how the GLIM criterion of reduced dietary intake or assimilation should be operationalized to support application in clinical care settings. A modified Delphi was used to build consensus on these recommendations.

Table 3.

Recommendations for assessing GLIM reduced dietary intake, impaired absorption or assimilation criterion.

GLIM reduced dietary intake, absorption, or assimilation recommendations
Dietary intake
1. It is essential to determine the amount consumed for the reduced dietary intake criterion. 2. Clinicians may ask patients to self‐report their diet (vs observed or measured) to determine reduced intake. 3. A comparison of current dietary intake to usual dietary intake can be used to determine if this criterion has been met. 4. Reporting dietary intake for more than one day is required to determine reduced intake. 5. When asking a patient about their dietary intake, ask about the time frame (e.g., last week, last month). It is recommended that clinician expertise be used to determine this time frame for select patients and settings. 6. As an example of a way to assess reduced dietary intake, clinicians can ask one of two questions; a “yes” to either question would indicate the criterion of low dietary intake has been met: 1) “Have you been eating less than your usual amount of food for more than two weeks?” or 2) “Over the last week, did you eat half or less (<=50%) of your usual dietary intake?” 7. A diagram or photograph of a plate or food tray can be used to help patients and staff to determine the amount of consumed. 8. A visual estimation method, for instance, a plate with five options (0, 25%, 50%, 75%, 100%) or the SEFI tool, can be used to determine reduced dietary intake. 9. A qualitative assessment (e.g., poor, fair, good) of either self‐ or staff‐reported food intake is INSUFFICIENT for determining reduced dietary intake. 10. Although appetite is a vital nutrition indicator, self‐ or staff‐reported appetite (e.g., poor, fair, good), is INSUFFICIENT for determining reduced dietary intake.
Absorption/assimilation
11. Gastrointestinal conditions* that result in malabsorption (e.g., diarrhea) OR conditions that impair dietary intake (e.g., dysphagia, chewing problems, nausea, vomiting) can be used to identify this etiologic criterion. *Examples of gastrointestinal conditions include: intestinal failure or insufficiency, radiation enteritis, gastroenteritis, amyloidosis, celiac disease, Zollinger‐Ellison syndrome, GI complications of bariatric or other GI surgery, exocrine pancreatic insufficiency, short‐bowel syndrome, ileo‐ or ileocolonic disease, active flare of Crohn's disease or ulcerative colitis, esophageal strictures, gastroparesis, intestinal (pseudo) obstruction, fistula with high output, ostomy with high output, acute or chronic intestinal dysmotility. 12. The length of time a patient is experiencing gastrointestinal or impaired dietary intake symptoms/signs should be considered when determining whether this criterion has been met. 13. The severity of gastrointestinal or impaired dietary intake symptoms/signs should be considered when identifying if this criterion has been met. 14. To assess the assimilation/absorption component of this criterion, clinicians should ask about severity and duration. A sample question for duration: “Have you experienced swallowing problems, nausea, diarrhea, or vomiting for two weeks or more?” If yes, follow up with a question on severity. A sample question for severity: “How frequent or severe is the swallowing problem, nausea, diarrhea, or vomiting?” If this is at least two times per day for two weeks or more, this is clinically significant and meets the criterion. 15. Clinical judgment should be used to determine if the severity and duration of gastrointestinal or impaired dietary intake symptoms/signs are sufficient to indicate that this criterion has been met.

Abbreviations: GI, gastrointestinal; GLIM, The Global Leadership Initiative on Malnutrition.

Table 1.

Prior research procedures for determining if the GLIM criterion for reduced dietary intake, or impaired absorption, or assimilation was met.

Category	Description
Reduced dietary intake	1) Self‐reported appetite, including items from other questionnaires, e.g., Mini‐Nutrition Assessment‐ Short form (MNA‐SF). 2) Self‐reported reduced dietary intake: a. <50% of usual intake for >5 days; <75% of usual intake for >1 month; 75% of usual intake for >1 month. b. <=50% for >1 week; any reduction for >2 weeks. c. Reduced food intake >2 weeks. d. Based on Nutrition Risk Screen‐2002 question, <50% food intake in last week. e. >75%, <=75%, <=50%, <=25% for 0–4, 5–30 days or >=1 month. f. <50% for 5–30 days; <=75% of usual for >=1 month; or indicates reduced intake but >75% of usual for >=1 month. g. Patient‐Generated Subjective Global Assessment (PG‐SGA) step 2, reduced intake in the past month, score >=1. h. 0, 25%, 50%, 75%, 100% based on past week, month, 3 months and 6 months. i. Responds yes to “eating poorly for a week or more.” j. MNA‐SF question on reduced intake; “Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?” k. Simple Evaluation of Food Intake (SEFI) Tool: two‐sided tool with rating scales: one displays a plate and the proportion of food consumed at the latest meal, and the other features a visual analog scale for current intake, with anchor options of “nothing at all” and “as usual.” l. “How well have you eaten in the week before you were admitted to the hospital?” m. Staff‐reported food intake based on estimated plate waste for single or multiple days.
Chronic gastrointestinal (GI) condition e.g., dysphagia, nausea that adversely affected food intake, assimilation, or absorption	GI symptoms/signs, including dysphagia, nausea, abdominal pain, vomiting, diarrhea or constipation, or malabsorptive disorders like short bowel syndrome or exocrinic pancreatic insufficiency. Any chronic GI condition that adversely impacts food/nutrient assimilation or absorption. Presence of diarrhea based on clinical record. Extensive ileal or ileocolon GI disease, Crohn's disease. Presence of any GI condition registered in the electronic health/medical record. Reduced assimilation, ascites. Malabsorptive GI conditions identified as part of the history interview. Vomiting, severe diarrhea. Box 3 of PG‐SGA score >=1 (>=1 nutrition impact symptom/sign), including dysphagia, nausea, vomiting, diarrhea. Exhibit weight loss as well as malabsorption.

Note: The concept of reduced food intake or assimilation in the original guidance has been expanded to include absorption, and the term “dietary intake” is used to be more inclusive of intake overall.

METHODS

Delphi design

A modified Delphi approach ¹⁸ was chosen to develop consensus. This method has been used previously by the GLIM working groups to develop this diagnostic approach, ¹ , ² as well as to develop guidance for inflammation, ⁹ , ¹⁰ muscle mass reduction, ⁷ , ⁸ and nutrition assessment in critically ill patients ¹⁹ , ²⁰ as well as the the 5‐year update. ³ , ⁴ Ethics review was completed at the University of Waterloo, Canada (ORE# 46718) for the modified Delphi process.

Participants

A working group recommended by the GLIM core group was established and included: MdvdS and GB (Europe), CL (Asia), NK (Australia), KH, CC, AM (United States), CMM (Central America), as well as the co‐leads RB (South Africa) and HK (Canada). A research associate (CMMills) supported the Delphi process, and a nurse practitioner (NS) was included to promote representation of this discipline. International membership promoted the inclusion of diverse expertise and practices. The working group identified a further 28 clinical experts (2–3 per member) from their region, who were subsequently invited to also participate. To be eligible, participants had to have clinical experience in conducting dietary assessment in a variety of clinical situations as part of a nutrition assessment. This extended working group was invited to each round of the Delphi and were anonymous to each other until completion of the guidance.

Delphi process

The scope of work was clarified that the guidance created would be easy to use, feasible for clinical application, and could be completed by individuals who are neither a nutritionist or dietitian. A PubMed search was conducted to identify papers published between 2019 and 2024 that included a reduced dietary intake, absorption, or assimilation component to their GLIM diagnostic process for patients/participants. The working group listed and reviewed the criteria used to identify pertinent statements and clarifications required for inclusion in the first survey (Table 1). The lack of clarity and consistency in determining the reduced dietary intake, absorption or assimilation criterion was notable from this brief review, reinforcing the need for a Delphi process to establish consensus‐based guidance. The working group also completed a scoping review of valid and reliable measures for determining reduced dietary intake in clinical settings. ²¹ This information was collectively used to develop the first Delphi survey.

HK, RB, and CMMills created each Delphi survey, which the working group reviewed before release. An invitation email was sent from HK that included the study information letter; consent was obtained at the start of the online questionnaire. The extended working group had approximately three weeks to complete each round (October 2024, February 2025, May 2025). Each survey began with an introduction, reminding participants of the scope and purpose of the Delphi study, the current GLIM criterion for reduced dietary intake, absorption, or assimilation, and how to complete the survey. The surveys concluded with demographic questions (age group, role, region, professional background, and current work setting) and asked about prior involvement in any GLIM consensus activities. The working group met to review and make decisions on new questions following Rounds 1 and 2. To promote participation in the third round, working group members emailed their two or three invited colleagues to remind them of the study and its importance. Two reminder emails were sent by HK, and authorship on the guidance was offered. A meeting of the working group after Round 3 confirmed recommendations.

Consensus thresholds

As per standard operating procedures for ESPEN guidelines, an agreement greater than 75% was used to determine consensus. ²²

Delphi survey content

Surveys consisted of rating questions on agreement as well as open‐text boxes for comments. Round 1 had 28 questions in addition to the demographic items (Supplemental file). The extended working group rated their agreement with each item on a 7‐point scale (1 = Disagree, 7 = Agree) and provided comments. Round 2 included 10 recommendations on which consensus had been achieved in Round 1 (File S1). Participants revised the wording and provided further comments on guidance statements. The remainder of the survey (n = 14 items) consisted of questions that did not reach consensus or new items that resulted from Round 1. Participants rated their agreement (Disagree = 1, Agree = 7) and had the opportunity to provide further input or comment for these new and revised statements.

Round 3 included 15 recommendations where experts were asked to confirm their agreement or disagreement (binary items/yes or no) with guidance statements that had been refined and simplified after Round 2 (File S2). Three items that still lacked consensus were asked with the seven‐point scale (Disagree = 1, Agree = 7). These were examples of questions used to assess reduced dietary and specifically protein intake (asked separately), and the relevance of calculating patient's energy requirement to determine reduced intake.

RESULTS

Table 2 provides the participant demographics. Round 3 had the most participants (n = 30) with complete demographic data, with 19 indicating they had participated in Round 1 and 20 in Round 2. The following results are the final 15 recommendations that achieved consensus (Table 3). Recommendations are presented in a deliberate sequence, with earlier statements implicitly informing those that follow.

Table 2.

Characteristics of Delphi participants.

	Round 1 N = 21 n (%)	Round 2 N = 18 n (%)	Round 3 N = 30 n (%)
Age group (years)
26–39	1 (4.8)	2 (11.1)	1 (3.3)
40–55	12 (57.1)	7 (38.9)	15 (50.0)
56+	8 (38.0)	8 (44.4)	13 (43.4)
Prefer not to answer	0	1 (5.6)	1 (3.3)
Region
North America	9 (42.8)	7 (38.8)	12 (40.0)
Central America	1 (4.8)	1 (5.6)	2 (6.7)
Caribbean	0	0	1 (3.3)
Southeast Asia	2 (9.5)	2 (11.1)	3 (10.0)
Australia/Oceania	4 (19.0)	3 (16.7)	4 (13.3)
Europe	4 (19.0)	4 (22.2)	5 (16.7)
Africa	1 (4.8)	1 (5.6)	3 (10.0)
Role *
Academic	6 (28.5)	2 (11.1)	10 (33.3)
Clinician	7 (33.3)	7 (38.8)	13 (43.3)
Clinician researcher	11 (52.3)	11 (61.1)	13 (43.3)
Other (e.g., educator, administration)	2 (9.5)	2 (11.1)	0
Profession
Physician	3 (14.2)	3 (16.7)	6 (20.0)
Dietitian	16 (76.1)	14 (77.7)	21 (70.1)
Nurse practitioner	2 (9.5)	0	1 (3.3)
Nurse	0	1 (5.6)	1 (3.3)
Pharmacist	0	0	1 (3.3)
Sector (work or research) *
Hospital	16 (76.2)	16 (88.8)	28 (93.3)
Outpatient speciality clinic	6 (28.5)	5 (27.8)	8 (26.7)
Primary care	2 (9.5)	4 (22.2)	2 (6.7)
Long‐term care/nursing home	2 (9.5)	4 (22.2)	4 (13.3)
University (unspecified area of research)	4 (19.0)	0	1 (3.3)
Provincial	1 (4.8)	0	0
Previously participated in GLIM (yes)	8 (38.1)	12 (66.7)	17 (56.7)

^*Could provide more than one answer. Missing Demographic Data: Delphi 1 n = 1; Delphi 2 n = 1; Delphi 3 n = 4

Abbreviation: GLIM, The Global Leadership Initiative on Malnutrition.

Recommendation #1: It is important to determine the amount consumed to meet the reduced dietary intake criterion. 96.7% agreement.

Almost all of the extended working group (94%) agreed with this statement in Round 1. Fluid was considered as part of this recommendation in Round 2, but dropped after comments that fluid is often non‐nutritive and less relevant than food intake. It was also noted by participants that a reduction in dietary intake should not trigger this criterion if the reduction was intentional for the purpose of weight loss.

Recommendation #2: Clinicians may ask patients, to self‐report diet (vs observed or measured) to determine reduced intake. 100% agreement.

Prior research (Table 1) has tended to use a self‐report mechanism for determining reduced intake. It was recognized that impaired cognition would affect patients’ capacity to self‐report, and clinicians should use their judgment to assess cognitive capacity when reporting on diet, referring to other informants as necessary. If a dietary intake assessment is completed with recorded food intake, these data could also be used to determine this criterion.

Recommendation #3: A comparison of current dietary intake to usual dietary intake can be used to determine if this criterion has been met. 96.7% agreement.

Comparison to “usual intake” is commonly used rather than the estimated energy requirement (Table 1). Proportion of food intake was dropped from the original version of this statement in Round 2 and use of compartor of “usual” intake achieved consensus. Patients who are chronic low consumers may already have a usual intake that is low. It was suggested that clinicians can help specify that a usual dietary intake promotes weight stability, regardless of the starting weight.

Recommendation #4: Reporting dietary intake for more than one day is required to determine reduced intake. 100% agreement .

Early statements considered setting (e.g., hospital, primary care) and the minimum amount of time (e.g., 1 day, 1 week, 1 month) required to determine reduced intake as compared to the “usual”, but these did not achieve consensus (also see recommendation #5). What was clear and achieved consensus was that more than one day was needed to determine the reduction in dietary intake.

Recommendation #5: When asking a patient about their dietary intake, ask about the time frame (e.g., last week, last month). It is recommended that clinician expertise be used to determine this time frame for select patients and settings. 96.7% agreement.

Due to challenges in achieving consensus on a minimum time frame for reduced dietary intake, this statement was written. Time frame would be dependent on the setting and the patient population, requiring clinical expertise to determine the best comparator. It was noted that having two time points to understand a trend in food intake is needed, especially for patients with chronic malnutrition.

Recommendation #6: As an example of a way to assess reduced dietary intake, clinicians can ask one of two questions; a “yes” to either question would indicate the criterion of low dietary intake has been met. 93.3% agreement.

Question #1: “Have you eaten less than your usual amount of food for more than two weeks?”

Question #2: “Over the last week, did you eat half or less (<=50%) of your usual dietary intake?”

A suggestion was made in Round 1 to provide scripted questions for clinicians to use for this criterion. The cut point of <=50% was chosen to be consistent with the original criterion and this achieved consensus. In Round 3, a few participants indicated that two weeks was too long for the first question in this recommendation. A shorter time frame, such as one week, could be used for those with a recent crisis or concerns about patient memory.

Recommendation #7: A diagram or photo of a plate or food tray can be used to help patients and staff determine the amount consumed. 93.3% agreement.

Several aids were considered in Round 1 and participants were asked to make suggesions on appropriate aids; however, only visual aids such as a diagram or photograph achieved consensus. When using visual aids, it is recommended that clinicians remind patients to report their intake beyond a single meal. It was also noted that in some cultures, other visuals (e.g., a bowl) that are specific to the local context should be used.

Recommendation #8: A visual estimation method, such as a plate with five options (0, 25%, 50%, 75%, 100%) or the Simple Evaluation of Food Intake (SEFI) tool can be used to determine reduced dietary intake. 93.3% agreement.

A simple diagram of plates with propotions consumed, the Rate‐a‐Plate visual ²³ and the Simple Evaluation of Food Intake (SEFI) Tool ²⁴ , ²⁵ were shown to participants as examples of visual aids. The Simple Evaluation for Food Intake (SEFI) includes two sides; one side displays a plate and the proportion of food consumed at the latest meal, and the other features a visual analog scale for current intake, with anchor options of “nothing at all” and “as usual.” Rate‐a‐Plate was thought to be too complex and dropped from the recommendation. Both the Simple Evaluation of Food intake (SEFI) ²⁴ , ²⁵ and a plate with five intake options (0, 25%, 50%, 75%, 100%) ²⁶ , ²⁷ have been validated in prior research. It was noted throughout the Delphi process that these diagrams are often used in reference to a single meal, which is insufficient for determining reduced intake and is in contradiction to Recommendation #4. As noted in Recommendation #7, clinicians can use these tools with patients, but they must ensure that the patient reports their current intake relative to their usual intake, beyond a single meal.

Recommendation #9: A qualitative assessment (e.g., poor, fair, good) of either self‐ or staff‐reported dietary intake is INSUFFICIENT for determining reduced dietary intake. 86.7% agreement.

It was clear from the first Delphi round that a qualitative evaluation of intake would not be sufficient for this criterion, as only 18% were in agreement with the use of qualitative terms such as “fair” or “poor” intake. This recommendation was not assessed in further rounds of the Delphi.

Recommendation #10: Although appetite is a vital nutrition indicator, self‐ or staff‐reported appetite (e.g., poor, fair, good) is INSUFFICIENT for determining reduced dietary intake. 90% agreement.

Similar to Recommendation #9, this statement was asked in the first round and had no consensus (6% agreement). It was further noted by participants that reduced appetite does not always equate to reduced dietary intake. An assessment of appetite is important in a nutritional assessment; however, intake can supplant hunger or appetite for food.

Dietary intake components that did not achieve consensus

Consensus on intake as compared to energy requirements, as recommended in the original guidance, ¹ , ² did not achieve consensus. Notably, our brief review of the literature revealed that researchers and clinicians do not determine energy requirements when using GLIM (Table 1). Similarly, the adequacy of total protein as part of the reduced dietary intake was its own statement but did not achieve consensus. Participants raised concerns about challenges in determining protein requirements, especially when patients have concurrent inflammation and non‐specialist clinicians are involved in this determination. As GLIM is intended to be a quick tool for use in various settings, quantifying energy and protein intake was considered beyond the scope, and this recommendation was not included in the guidance.

Recommendation #11: Gastrointestinal conditions* that result in malabsorption (e.g., diarrhea) OR conditions that impair dietary intake (e.g., dysphagia, chewing problems, nausea, vomiting) can be used to identify this etiologic criterion. 93.3% agreement.

*Examples of gastrointestinal conditions include: intestinal failure or insufficiency, radiation enteritis, gastroenteritis, amyloidosis, celiac disease, Zollinger‐Ellison syndrome, GI complications of bariatric or other GI surgery, exocrine pancreatic insufficiency, short‐bowel syndrome, ileo‐ or ileocolonic disease, active flare of Crohn's disease or ulcerative colitis, esophageal strictures, gastroparesis, intestinal (pseudo) obstruction, fistula with high output, ostomy with high output, acute or chronic intestinal dysmotility.

Participants noted that it was also relevant to ask about symptoms/signs that impair dietary intake rather than solely the presence of a condition that could be malabsorbing as seen in prior research (Table 1). It was emphasized in Round 1 that symptoms/signs had to be present in addition to the conditions that cause malabsorption or impair intake, although malabsorption may occur with or without symptoms. Clinical judgment should determine whether conditions and their associated malabsorption or impaired intake warrant triggering this criterion. It is important to note that the examples provided are not exhaustive.

Recommendation #12: The length of time a patient is experiencing gastrointestinal or impaired dietary intake symptoms/signs should be considered when identifying if this criterion has been met. 100% agreement.

Time frame is an important consideration for symptoms and signs of impaired absorption and intake. However, the diverse patient experience is not amenable to a single “rule” around this point, as noted by the several suggestions participants provided. The time frame will depend on the severity of the symptoms/signs. It was noted that these symptoms needed to be of a chronic nature, rather than short‐term, but this could vary by setting. It was also noted that this criterion should be used to diagnose malnutrition in patients with permanent or severe GI dysfunction with ongoing symptoms.

Recommendation #13: The severity of gastrointestinal or impaired dietary intake symptoms/signs should be considered when identifying if this criterion has been met. 96.7% agreement.

Although severity and duration are linked when considering malabsorption or symptoms/signs that impair intake, they are not the same, and thus the two separate reocmmendations. Presence of a gastrointestinal condition in a patient's history does not indicate malabsorption or food intake symptoms, but that the duration (Recommendation #12) and severity of these issues must be assessed for this criterion to be met. Participants noted that frequency and volume, as well as stool consistency, would be part of a clinician's assessment of severity.

Recommendation #14: To assess the assimilation/absorption component of this criterion, clinicians should ask about duration and severity. A sample question for duration: “Have you experienced swallowing problems, nausea, diarrhea, or vomiting for two weeks or more?” If “yes,” follow up with a question on severity. A sample question for severity: “How frequent or severe is the swallowing problem, nausea, diarrhea, or vomiting?” If this is at least two times per day for two weeks or more, this is clinically significant and meets the criterion. 93.3% agreement.

As noted above in Recommendation #12, the time frame for determining if this criterion has been met in these sample questions will need to be adjusted based on the setting and patient context. Some of the extended working group believed that two weeks was too long for a malnourished patient to be experiencing these symptoms/signs. Furthermore, it was also noted that it is important to understand the context of feeding for all of the reduced absorption or assimilation recommendations.

Recommendation #15: Clinical judgment should be used to determine if the severity and duration of gastrointestinal or impaired dietary intake symptoms/signs are sufficient to indicate that this criterion has been met. 90% agreement.

This recommendation was first introduced in Round 2, to emphasize the importance of clinical judgement to determine if assimilation was affected and thus the criterion triggered. The assimilation component of this criterion was noted by the working group to especially require clinical expertise for determination.

Nutrition specialist assessment

It was noted across the three survey rounds that a nutrition specialist assessment was considered a preferred approach to determine the reduced dietary intake or assimilation criterion. However, the GLIM framework is intended for use by any trained healthcare professional involved in patient assessment. As noted in the 5‐year review, a nutrition assessment is not always feasible due to limited availability of trained clinicians. ³ , ⁴ As a result, these recommendations have considered all healthcare scenarios for the use of GLIM, including when a nutrition assessment is not available prior to GLIM criteria application. Nutrition assessment should always be carried out post the completion of GLIM, in accordance with current circumstances and available resources, to provide interventions to improve patient nutritional status.

DISCUSSION

Fifteen consensus‐based recommendations emerged from this consensus process conducted over nine months with 30 global clinician experts. Ten recommendations focused on reduced dietary intake, while five recommendations were used to elaborate on how the assimilation component of this criterion should be assessed, including the concepts of severity and duration of symptoms and signs. A significant departure from the original GLIM criterion is the omission of determining a patient's energy requirement, a concept thought infeasible for most non‐specialist clinicians. As a result of this Delphi process, the following is recommended for determining this criterion: 50% or less of usual dietary intake in the last week or any reduction in dietary intake for at least 2 weeks OR severe gastrointestinal or nutrition impact symptoms/signs (e.g., dysphagia, nausea, vomiting) as a result of an acute or chronic condition or therapy.

Reduced dietary intake, impaired absorption, or assimilation – the minimum

The reduced dietary intake component of this criterion requires understanding the amount of current intake relative to usual intake, over a specified time frame that is greater than one day. Visual aids can support this estimation. A plate‐based diagram showing proportions of intake (see Figure 1) can be used to help patients determine their current intake relative to their usual intake.

Figure 1.

Example of plate diagram to determine dietary intake. The figure graphically depicts a visual estimation method (VEM) based on plate‐model pictures. In this example five plate options are used with 0% (no food was consumed), 25% (a quarter of food was consumed), 50% (half of food was consumed), 75% (three‐quarters of food was consumed) and 100% (all food was consumed). The gray shaded area indicates food left on the plate and the white area indicates food consumed.

However, clinicians should ensure that patients are not reporting on a single meal when using such a diagram. Self‐report of dietary intake by patients is sufficient for this determination, but observed or measured intake is also appropriate.

The minimum requirement for achieving the reduced assimilation component of this criterion includes determining the duration and severity of symptoms and signs (e.g., diarrhea) that indicate malabsorption or can impact dietary intake (e.g., dysphagia, vomiting). The presence of the gastrointestinal condition alone is not sufficient—there must also be an evaluation of symptoms/signs more broadly. ¹¹ The 2025 GLIM update noted that the original guidance did not address these concepts, although it recognised that severity and duration were relevant. ³ , ⁴ Further, it was noted by participants that symptoms and signs of nausea and vomiting noted in the original guidance ¹ , ² were not problems resulting in malabsorption, but rather consumption, resulting in the expansion in these recommendation to include symptoms and signs of dysphagia, nausea and vomiting, and others (e.g., dry mouth) that can impact dietary intake.

A place for clinical judgement

A single “rule” for the time frame for reduced dietary intake; what usual intake was (and if it was sufficient to stabilize weight); and the combination of severity and duration of symptoms and signs that impact intake and assimilation results in the need for clinical judgment. Although the two‐step questions provided in the recommendations suggest a “rule” for each component of the criterion, these questions will not be sufficient in all contexts. For example, chronically low consumers may report consuming more than 50% of their usual intake. However, this “usual intake” may be relatively low. A patient in the hospital setting may have severe diarrhea for less than a week that is impacting their absorption of food and based on clinical judgement, this should meet the criterion. It is important for the clinician to consider the context of the patient's past history when using their judgment on whether or not this criterion applies for the determination of malnutrition. The recommendation to use clinical judgement for this criterion is consistent with the confirmed guidance on the inflammation criterion. ² , ⁴

Strengths and limitations

As a result of virtual administration, this modified Delphi process was developed and completed by an extended working group of nutrition experts with diverse clinical experience across several regions of the world, where different conventions, resources, and capacities exist for determining malnutrition. Final recommendations were agreed upon by 30 of 38 invited participants who provided complete data including demographics, as well as the GLIM core group who are authors. Sufficient time between rounds provided for careful review and reworking of statements.

A potential limitation in any Delphi process was the selection of experts ²⁰ , ²⁸ , ²⁹ who were recommended by the working group and may have had similar views on how to assess reduced dietary intake, absorption, or assimilation in clinical settings. ²⁸ However, experts included several disciplines (e.g., dietetics, medicine, nursing) and global representation with anonymous participation. A limitation of a virtual Delphi approach was the lack of discussion among participants in face‐to‐face meetings. ²⁸ , ²⁹ Due to the varied comments provided by participants, the working group decided to develop new statements for voting, rather than providing all comments back to participants for review. This may have curtailed development of guidance, but this approach promoted short surveys promoting participation. Finally, the first two survey rounds had a lower participation rate (e.g., 18/38) than the final round. This could have truncated new ideas to be brought forward in Round 3. The core working group considered wording and other suggestions that developed in this final round, and many of the extended working group are co‐authors of this publication, demonstrating their alignment with these recommendations.

CONCLUSION

The etiologic GLIM criterion to assess malnutrition of reduced dietary intake or assimilation has been revised and further operationalized using a consensus process with international nutrition experts. Key components include the removal of energy requirement and focusing on symptom/sign severity and duration for the assimilation component. It is recommended that this GLIM criterion be revised to: 50% or less of usual dietary intake in the last week or any reduction in dietary intake for at least 2 weeks OR severe gastrointestinal or nutrition impact symptoms/signs (e.g., dysphagia, nausea, vomiting) as a result of an acute or chronic condition or therapy. Future work is needed to confirm this revision. First, clinicians should use this criterion in their diagnosis of malnutrition to evaluate the feasibility of all components. Researchers should determine the predictive and criterion validity of this criterion within GLIM in diverse clinical settings, to demonstrate its robustness for use in clinical practice.

AUTHOR CONTRIBUTIONS

Renée Blaauw: Conceptualization; methodology; data curation; investigation; formal analysis; supervision; project administration; writing—original draft; writing—review and editing. Heather Keller: Conceptualization; methodology; data curation; investigation; formal analysis; supervision; project administration; writing—original draft; writing—review and editing; software. Christine Marie Mills: Software; data curation; formal analysis; project administration; writing—original draft; writing—review and editing. Gert Bischoff: Conceptualization; methodology; investigation; writing—original draft; writing—review and editing. Charlene compher: conceptualization; investigation; writing—original draft; methodology; writing—review and editing. Marian De Van Der Schueren: Conceptualization; investigation; methodology; writing—original draft; writing—review and editing. Krista Haines: Conceptualization; investigation; methodology; writing—original draft; writing—review and editing. Nicole Kiss: Conceptualization; investigation; methodology; writing—original draft; writing—review and editing. Charles Lew: Conceptualization; investigation; methodology; writing—original draft; writing—review and editing. Ainsley Malone: Conceptualization; investigation; methodology; writing—original draft; writing—review and editing. Claudia Maza Moscoso: Conceptualization; investigation; methodology; writing—original draft; writing—review and editing. Nancy Stoner: Conceptualization; investigation; methodology; writing—original draft; writing—review and editing. Rocco Barazzoni: Writing—review and editing. jack j bell: writing—review and editing. Madeleine Coetzee: Writing—review and editing. Ryoji Fukushima: Writing—review and editing. Elena George: Writing—review and editing. Leah Gramlich: Writing—review and editing. Yen Peng Lim: Writing—review and editing. Roseann Nasser: Writing—review and editing. Matthias Pirlich: Writing—review and editing. Terese Scollard: Writing—review and editing. Nicolette Wierdsma: Writing—review and editing. Marion Winkler: Writing—review and editing. Tommy Cederholm: Writing—review and editing.

CONFLICT OF INTEREST STATEMENT

Renée Blaauw – Fresenius Kabi, Nestle Health Sciences – consultancies, speaker honoraria, scientific board. M. Isabel T. D. Correia – Abbott Nutrition, Baxter Nutrition, Fresenius Nutrition, Nestlé Nutrition – lectures and scientific board, Grant funding Fresenius. M. Cristina Gonzalez reported receiving research support from the National Council for Scientific and Technological Development, Brazil, and consulting fees, honoraria for presentations, or travel expenses from Abbott Nutrition, Nutricia, and Nestlé Health Science Brazil. Heather Keller – Abbott Nutrition, Nestle Health Sciences – consultancies, speaker honoraria. The remaining authors declare no conflicts of interest.

Supporting information

Supplemental File Delphi surveys.

Blaauw R, Keller H, Mills CM, et al. Guidance for the assessment of the dietary intake and gastrointestinal or nutrition impact symptoms etiologic criterion of Global Leadership Initiative on Malnutrition: a modified‐Delphi study. J Parenter Enteral Nutr. 2026;50:614‐624. 10.1002/jpen.70073