Paper IV — Nutrition

Appendix — Rapid Revision Grid

Every number, cut-off, criterion, mnemonic and named trial from the five answers, compiled for night-before revision.

A. Diagnostic Criteria and Cut-offs

Item Value to Quote

GLIM — requirement ≥1 phenotypic + ≥1 etiologic criterion GLIM phenotypic Weight loss >5% in 6 mo or >10% beyond 6 mo · Low BMI · Reduced muscle mass GLIM etiologic Reduced intake/assimilation (≤50% requirement >1 wk, any reduction >2 wk, chronic GI disease) · Inflammation/disease burden GLIM BMI — Western <20 if <70 y · <22 if >70 y GLIM BMI — Asian <18.5 if <70 y · <20 if >70 y GLIM Stage 1 (moderate) Loss 5–10% in 6 mo (or 10–20% beyond); BMI <20 (<70 y) / <22 (≥70 y) GLIM Stage 2 (severe) Loss >10% in 6 mo (or >20% beyond); BMI <18.5 (<70 y) / <20 (≥70 y) Significant weight loss 5% in 1 month · 7.5% in 3 months · 10% in 6 months MNA-SF score bands 12–14 normal · 8–11 at risk · 0–7 malnourished MNA performance 96% sensitive, 60% specific; normal MNA → mortality RR 0.35 (0.18–0.66) SNAQ 4 items (appetite, early satiety, taste, meals/day), each 1–5; <14 = significant risk of weight loss Calf circumference <31 cm = low muscle mass (both sexes)

MUAC (2024 validation) <23 cm men · <22 cm women FFMI cut-off <17 kg/m² men · <15 kg/m² women ASMI cut-off <7.0 kg/m² men · <5.4–5.7 kg/m² women CRP inflammation grades <3 mg/L = starvation · medium = cachexia · >100 mg/L = hypercatabolic Mortality-predictive BMI <22 kg/m² → higher 1-y mortality; <15th percentile → 180-day post-hospital mortality Obesity — India Stage 1 (2025) BMI >23 kg/m², no organ/functional effect Obesity — India Stage 2 (2025) BMI >23 + abdominal adiposity (WC or WHtR) + mechanical condition or obesity-associated disease Lancet 2025 obesity Preclinical = excess adiposity, organs preserved · Clinical = excess adiposity + organ dysfunction / functional limitation (1 of 18 conditions)

Dental referral score ≥3 points (dry mouth 2, eating difficulty 1, no dental care 2 y 1, pain 2, food change 1, oral lesions 2)

B. Prevalence Figures

Population / Condition Figure

Malnutrition by MNA — overall 22.8%

By setting (MNA) Rehabilitation 50.5% · Hospital 38.7% · Community 5.8% European meta-analysis LTC 28.7% · Rehab 29.4% · Hospital 22% · Nursing home 17.5% · Community 6% Global malnutrition (2025 meta-analysis, 98 studies) 18.6% (Africa 35.7%; highest by NRS-2002 39.9%) Anorexia of ageing (textbook) 3.3% community → 33% nursing home Anorexia of ageing (2025 pooled, 36 studies) 22.7%; incidence 3.78%; inpatients 34.7% Appetite loss by SNAQ (2025, 62 studies) 29% — community 25%, nursing home 38%, hospital 42% Anorexia in frail/pre-frail 20.5% (vs 11.3% overall); robust → OR 0.37 Involuntary weight loss 5–15% community · 27% frail ≥65 · 8% of adult outpatient visits Sarcopenic obesity (ESPEN/EASO applied) 9% free-living Italian cohort · 13.2% Western China community PEM in institutionalised dementia up to 50% Anorexia in end-stage CHF / dialysis >40% / 30–40% (4-fold mortality)

India — LASI, age ≥60 underweight 28% men · 25% women Nutrition in the Elderly — MD Geriatric Medicine Revision Page 23 of 25 India — LASI, age 45–59 overweight/obese 25% men · 37% women Indian age-specific underweight cut-off (2024) <17.4 (60–74 y) · <13.3 (≥75 y)

C. Physiology Numbers — Anorexia of Ageing

Parameter Figure

Fall in energy intake, age 20→80 ~30%

NHANES III decline 1321 kcal/day men · 629 kcal/day women New Mexico longitudinal −25.1 kcal/day/year men · −19.3 women Swedish cohort (70→76 y) −610 kcal/day men · −440 women Roberts’ underfeeding experiment ~750 kcal/day deficit × 21 days; old men never regained weight CCK-8 IV suppression of intake 31% older vs 15% young (p = 0.02)

Olfactory decline >50% aged 65–80; >75–80% aged ≥80; 46% report appetite/weight change Effect of eating in company Intake rises up to 50% Elders living alone ~29.3% of non-institutionalised Drugs altering taste >250 prescribed drugs Lean mass loss after age 50 up to 3 kg per decade Total body water after 75 falls from 60% to 50% D. Therapeutic Targets Target Value Energy requirement 30–35 kcal/kg/day Protein — healthy elder (ESPEN) 1.0–1.2 g/kg/day Protein — ill/malnourished (ESPEN) 1.2–1.5 g/kg/day Protein — ICMR-NIN RDA 2020 Safe intake 0.83 g/kg/day (EAR 0.66)

Fluid ~1 mL/kcal, about 1.5 L/day

Calcium / Vitamin D after 50 1000–1200 mg / 800 IU (ULs 2000 mg / 4000 IU)

25(OH)D adequacy / deficiency ≥20 ng/mL adequate; treat <10–12 ng/mL ONS dose–duration rule ≥400 kcal/day for ≥35 days in unwell malnourished ≥75 y ONS effect (2009 meta-analysis, 42 trials) 2.3% weight gain; mortality RR 0.74 (0.59–0.92)

Resistance training Progressive, 2–3 times/week

Obesity — energy deficit 500–700 kcal/day (metabolic benefit needs ≥20% reduction) Visceral fat response ~5% weight/fat loss → ≥25% visceral fat reduction Sodium correction rates Hypernatraemia <10 mEq/L/24 h; hyponatraemia 6–8 mEq/L/24 h Folate replacement 1 mg/day Minimum energy for micronutrient adequacy ~1500 kcal/day E. Named Evidence — Trials, Guidelines, Consensus Name What It Says (one line)

GLIM 2019 / 5-year update 2025 Two-step diagnosis; criteria validated and unchanged; any available muscle-mass method acceptable GLIS 2024 Sarcopenia = mass + strength + muscle-specific strength; performance is an outcome ESPEN geriatrics 2022 82 recommendations; screen all; food → ONS → enteral → parenteral; avoid dietary restrictions ESPEN dementia update 2024 Nutrition and hydration guideline specific to dementia EFFORT trial Reaching ≥75% of nutrition goals lowers adverse events and mortality; no legacy effect at 6 months Cochrane IPD-NMA 2026 ONS may reduce 30-day mortality/SAEs in hospitalised elders; certainty low to very low AGS Beers 2023 Avoid megestrol — minimal weight effect, thrombotic risk, possible increased mortality Nutrition in the Elderly — MD Geriatric Medicine Revision Page 24 of 25 Endocrine Society 2024 (vitamin D) Empiric vitamin D at ≥75 years; against routine 25(OH)D testing; daily > intermittent over 50 USPSTF 2024 draft (vitamin D) D grade — no net benefit for falls/fractures in healthy community-dwelling elders Ponsegromab (NEJM 2024) Anti-GDF-15 mAb; up to 2.81 kg weight gain vs placebo in cancer cachexia Anamorelin Oral ghrelin receptor agonist; licensed in Japan 2021; improves lean mass and appetite Mirtazapine Works in NSCLC anorexia (JAMA Oncol 2024); no benefit in hospitalised elders, 6.3% oversedation Look AHEAD Lifestyle intervention improved weight, fitness and risk factors but no reduction in CV events SHEP Weight loss ≥1.6 kg/yr → 4.9× mortality; effect present even at BMI ≥31 Cardiovascular Health Study 5% loss → risk-adjusted mortality 1.67×, irrespective of intentionality Lancet Commission 2025 Clinical vs preclinical obesity; BMI must be paired with a second adiposity measure Misra et al. 2025 (India) Stage 1 / Stage 2 obesity for Asian Indians; BMI >23 threshold ESPEN/EASO 2022 First consensus algorithm for sarcopenic obesity (screen → strength + mass → stage) SURMOUNT-5 / post hoc ≥65 y Tirzepatide > semaglutide; no age interaction for weight or cardiometabolic benefit ICMR-NIN 2024 17 guidelines; “My Plate for the Day”; DIAAS; discourages protein supplements LASI Wave 1 Indian double burden — ~1 in 4 elders underweight, rising urban overweight F. Mnemonics and One-Line Concepts MEALS ON WHEELS — Treatable Causes of Weight Loss Medications · Emotional (depression) · Anorexia tardive / alcoholism · Late-life paranoia · Swallowing disorders · Oral factors · No money · Wandering / dementia · Hyper- and hypothyroidism, hyperparathyroidism, hypoadrenalism