[March Edition] Can Muscle Mass Replace Albumin? A Globally Endorsed Tool for Diagnosing Malnutrition |
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Nutritional management for hospitalized and surgical patients is essential for minimizing complications and improving treatment outcomes, and its importance is widely recognized in clinical practice.
In Korea, Serum Albumin is the most commonly used parameter for evaluating nutritional status, and accordingly, it is used as a reimbursement criterion for intensive nutritional therapy under the national healthcare system. Concerns have been raised among international clinical nutrition experts about the appropriateness of relying solely on albumin levels for malnutrition diagnosis (Jensen et al., 2024).
However, the validity of using serum albumin as the sole indicator for diagnosing malnutrition has been questioned by global clinical nutrition experts. (Jensen et al., 2024)
In response, representatives of four major global clinical nutrition societies—ASPEN, ESPEN, FELANPE, and PENSA—collaborated in September 2018 to establish the Global Leadership Initiative on Malnutrition (GLIM) criteria. Numerous recent studies have demonstrated that ㅡMuscle Mass Evaluation is essential for accurate nutritional assessment. In line with this shift, countries such as Japan and France are at the forefront of a growing global trend to use Muscle Mass as a principal marker in nutritional evaluation.
This issue focuses on understanding Muscle Mass Evaluation under the GLIM Guidance and its importance in guiding clinical nutritional decisions. |
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🌎What is Glim Guidance?
The GLIM Guidance is a recently developed global standard for diagnosing malnutrition, created by four major clinical nutrition societies: ASPEN, ESPEN, FELANPE, and PENSA.
Traditional methods of nutritional assessment often relied on subjective clinical judgment, and the lack of standardized criteria across countries has posed challenges for international research and policy development in malnutrition.The GLIM criteria were established to overcome these challenges, and the framework has gained increasing recognition in the academic community, with over 460 publications listed on PubMed as of February 2025.
The GLIM framework follows a standardized three-step process: screening → nutritional assessment → severity grading. Individuals at risk of malnutrition are first identified using screening tools such as MUST or NRS-2002, followed by the application of the five GLIM diagnostic criteria to confirm malnutrition and assess its severity.
GLIM’s diagnostic framework consists of two categories—Phenotypic and Etiologic—and malnutrition is confirmed when at least one criterion from each category is fulfilled. The severity of malnutrition is assessed primarily through phenotypic indicators, allowing for more consistent and systematic clinical management.
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This approach is being increasingly adopted in clinical practice and has been formally implemented in healthcare systems across various countries. A key example is Japan, where GLIM-guided nutritional assessment became mandatory for rehabilitation inpatients at university and tertiary hospitals, following the 2024 revision of medical reimbursement policies. The use of the GLIM criteria is also being encouraged at local hospitals, further illustrating its growing adoption on a global scale. |
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💪Guidelines and Limitations for Muscle Mass Assessment
Following the establishment of the GLIM criteria, more detailed guidance for Muscle Mass Assessment was introduced in 2022.
The publication clearly outlines 1) recommended indicators for Muscle Mass Assessment, 2) appropriate measurement tools, and 3) cutoff values. (Compher et al., 2022).
According to global consensus, Skeletal Muscle Mass is the preferred indicator for muscle assessment, with recommended measurement tools including CT (Computed Tomography), DXA (Dual-Energy X-ray Absorptiometry), and BIA (Bioelectrical Impedance Analysis). Because each tool differs in measurement approach, cutoff values should be tailored to individual factors such as race, sex, age, and disease status.
In particular, the recommended cutoff values for each measurement modality are advised to follow international Sarcopenia Diagnostic Guidelines, such as those from the European Working Group on Sarcopenia and the Asian Working Group on Sarcopenia(Compher et al., 2022).
Also in Sarcopenia Diagnosis, it is recommended to incorporate reference scores such as the young T-score and age-matched Z-score, similar to how they are used in osteoporosis-related bone density tests to ensure more reliable evaluation.
The guidance also highlights known limitations in Muscle Mass Assessment. Since, CT, DXA, and BIA do not directly measure Skeletal Muscle Mass, they may overestimate Muscle Mass in individuals with fluid retention or obesity, where overhydration is a concern.
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BWA: A Response to GLIM’s Limitations in Muscle Assessment
InBody measures Muscle Mass using Bioelectrical Impedance Analysis (BIA). One of the key advantages of BIA is that, unlike CT or DXA, it does not involve radiation and allows for safe, repeated monitoring through the use of a small alternating current. These characteristics make BIA a practical and effective tool for situations that require regular nutritional assessment.
The Body Water Analyzer (BWA), InBody’s most advanced medical device, compensates for the limitations of existing Muscle Mass Assessment methods and provides a range of indicators useful for determining cutoff values.
1) How BWA Overcame the Limitations Pointed Out in the GLIM Guidance
BWA is the first device to implement 3MHz high-frequency current, which enables precise distinction between Extracellular and Intracellular Water. It also provides Z₀ and Z∞, which are valuable for research purposes. This helps provide a more precise evaluation of the overhydration status in patients with edema, ultimately enhancing the accuracy of Muscle Mass Measurements. Furthermore, based on over 130 million InBody measurement data globally, age-specific evaluation results are provided, including the recommended T-score and age-matched Z-score.
Furthermore, BWA, specialized in body fluid analysis, plays an important role in essential medical fields, such as fluid monitoring, sarcopenia diagnosis, and cellular nutrition assessment. It can measure patients in a supine position, making it suitable for immobile patients such as those in intensive care, rehabilitation, and amputees, and is actively used in various medical fields including dialysis, rehabilitation, and cancer immunology.
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2) BWA: A Promising Tool for Sarcopenia Diagnosis
Another strength of the BWA is its use as a Sarcopenia Diagnostic tool in primary care settings and university hospitals. Since 2021, Sarcopenia has been officially recognized as a medical condition in Korea. Following this, body composition analysis using multi-frequency impedance has passed the New Medical Technology Assessment, and the use of InBody for non-reimbursed Sarcopenia Diagnosis is now being widely conducted.
Additionally, the GLIM Guidance states that malnutrition can be a cause of Sarcopenia and recommends diagnosing malnutrition in patients with Sarcopenia. Consequently, the application of BWA in Sarcopenia research is growing, and it is being recognized as a more accurate and reliable tool for assessment.
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Thus, Muscle Mass Assessment has gained recognition as a crucial indicator in malnutrition diagnosis, with widespread agreement from global experts, and its use in clinical practice continues to rise. Especially in the current healthcare environment where nutritional management is prioritized, more precise and reliable muscle evaluation has become an essential factor in improving patient treatment effectiveness and prognosis.
As a result, it is crucial for clinical practice to acknowledge these changes and actively implement Muscle Mass Assessment techniques that incorporate the most recent guidelines and research developments. |
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📜References
1. Jensen GL, Cederholm T, Ballesteros-Pomar MD, Blaauw R, Isabel M, Cuerda C, et al. Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach. Journal of Parenteral and Enteral Nutrition. 2024 Jan 15;
Available from: https://pubmed.ncbi.nlm.nih.gov/38221842/
2. Compher C, Cederholm T, Correia MITD, Gonzalez MC, Higashiguch T, Shi HP, et al. Guidance for assessment of the muscle mass phenotypic criterion for the Global Leadership Initiative on Malnutrition diagnosis of malnutrition. JPEN Journal of parenteral and enteral nutrition [Internet]. 2022 Apr 19;48(1). Available from: https://pubmed.ncbi.nlm.nih.gov/35437785/
3. Jensen GL, Cederholm T, Correia MITD, Gonzalez MC, Fukushima R, Higashiguchi T, et al. GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community. Journal of Parenteral and Enteral Nutrition. 2018 Sep 2;43(1):32–40.
Available from: https://pubmed.ncbi.nlm.nih.gov/30181091/
4. Baek JY, Jung HW, Kim KM, Kim M, Park CY, Lee KP, et al. Korean Working Group on Sarcopenia Guideline: Expert Consensus on Sarcopenia Screening and Diagnosis by the Korean Society of Sarcopenia, the Korean Society for Bone and Mineral Research, and the Korean Geriatrics Society. Annals of Geriatric Medicine and Research [Internet]. 2023 Mar 1 [cited 2023 Nov 24];27(1):9–21.
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