Non-fasting bioelectrical impedance analysis in cystic fibrosis: Implications for clinical practice and research

Remote endpoints for clinical trials in cystic fibrosis: Report from the U.S. CF foundation remote endpoints task force

The COVID-19 pandemic necessitated a rapid shift in clinical research to perform virtual visits and remote endpoint assessments, providing a key opportunity to optimize the use of remote endpoints for clinical trials in cystic fibrosis. The use of remote endpoints could allow more diverse participation in clinical trials while minimizing participant burden but must be robustly evaluated to ensure adequate performance and feasibility. In response, the Cystic Fibrosis Foundation convened the Remote Endpoint Task Force (Supplemental Table 1), a multidisciplinary group of CF researchers with remote endpoint expertise and community members tasked to better understand the current and future use of remote endpoints for clinical research. Here, we describe the current use of remote endpoints in CF clinical research, address key unanswered questions regarding their use and feasibility, and discuss the next steps to determine clinical trial readiness.

ESPEN-ESPGHAN-ECFS guideline on nutrition care for cystic fibrosis

BACKGROUND

Nutritional status is paramount in Cystic Fibrosis (CF) and is directly correlated with morbidity and mortality. The first ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with CF were published in 2016. An update to these guidelines is presented.

METHODS

The study was developed by an international multidisciplinary working group in accordance with officially accepted standards. Literature since 2016 was reviewed, PICO questions were discussed and the GRADE system was utilized. Statements were discussed and submitted for on-line voting by the Working Group and by all ESPEN members.

RESULTS

The Working Group updated the nutritional guidelines including assessment and management at all ages. Supplementation of vitamins and pancreatic enzymes remains largely the same. There are expanded chapters on pregnancy, CF-related liver disease, and CF-related diabetes, bone disease, nutritional and mineral supplements, and probiotics. There are new chapters on nutrition with highly effective modulator therapies and nutrition after organ transplantation.

Having breakfast has no clinically relevant effect on bioelectrical impedance measurements in healthy adults

BACKGROUND

Bioelectrical impedance analysis (BIA) is commonly used to evaluate body composition as part of nutritional assessment. Current guidelines recommend performing BIA measurements in a fasting state of at least 2 h in a clinical setting and 8 h in a research setting. However, since asking patients with malnutrition or sarcopenia to fast is not desirable and literature to support the strategy in the guidelines is lacking, this study aimed to assess the impact of breakfast on BIA measurements.

METHODS

We performed an explorative, prospective study in healthy volunteers aged between 18 and 70 years, with a normal fluid balance and a body mass index between 18.5 and 30 kg/m2. BIA measurements were performed according to the standard operating procedure in the fasting state, and 1, 2, 3, and 4 h after ingesting a standardized breakfast meal of about 400 kcal with a 150 mL drink, using the hand-to-food single-frequency BIA (Bodystat500 ®). The Kyle formula was used to calculate the primary outcome, i.e. fat-free mass (FFM, kg). A linear mixed model was used to compare baseline values with other time points. A difference of 1 kg in FFM was considered clinically relevant.

RESULTS

Thirty-nine (85% female) volunteers were included, with a median age of 28 years (IQR 24-38). In 90% of the participants, having breakfast had no clinically relevant impact on the estimated FFM. For the group, the most pronounced mean difference, a statistically but not clinically significant higher value of 0.2 kg (0.4%), was observed after 3 h of fasting compared to baseline. No statistically significant differences were found at the other time points.

CONCLUSION

Eating affects single-frequency BIA measurements, but differences in FFM remain below clinical relevance for most participants when using a standardized breakfast. Thus, the current study suggests performing a BIA measurement in a fasting state is not required.

The Effect of Fasting on Body Composition Assessment in Hospitalized Cancer Patients

Guidelines for bioelectrical impedance analysis (BIA) recommend fasting before measurements, but how it affects the outcomes is unclear. This descriptive, before-and-after study examines the effect of fasting on BIA results and its impact on the diagnosis of malnutrition in hospitalized cancer patients. Fifty-three oncology patients (admitted in January-March 2020) were consecutively enrolled regardless of their nutritional status. Patients were assessed by the same dietician 24-48 h after admission, following the usual clinical practice. The measurements were taken after 12-h fasting (fasting state) and 60-90 min after breakfast (non-fasting state). Bioimpedance parameters (resistance [R], reactance [Xc], phase angle [PA]) and body composition indices (free-fat mass index [FFMI] and appendicular skeletal muscle index [ASMI]) were calculated. On average, R values did not significantly differ between fasting and non-fasting states (mean difference: +1.82 Ω; p = 0.64). The non-fasting Xc and PA were reduced (mean differences: -1.55 Ω, p = 0.93 and 0.09°, p = 0.82, respectively). Fasting and non-fasting FFMI and ASMI were similar (mean differences: -0.13 kg/m2 (p = 0.5) and -0.10 kg/m2 (p not calculated)). These results suggest that BIA does not require fasting, facilitating its routine use in hospitalized cancer patients.

Cystic fibrosis year in review 2019: Section 3 multisystem-based care and research

During the year 2019, numerous research studies and other reports were published that are interesting and instructive to professionals who care for people with cystic fibrosis (CF) and their families.  This report is the third of 3 CF year in review articles and focuses on the multisystem manifestations of CF care. Previous articles have addressed cystic fibrosis transmembrane regulator modulators and reports on CF pulmonary disease and airway infections. It is an exciting time to be involved in care and research that aims to improve care for people with CF and their families.

Consuming a low-calorie amount of routine food and drink does not affect bioimpedance body fat percentage in healthy individuals

OBJECTIVES

Bioimpedance analysis is a simple, safe, and relatively inexpensive method to assess body composition. The bioimpedance guidelines recommend that the test be performed after fasting and avoiding the consumption of liquids. Studies have verified the effects of consuming liquids and food on bioimpedance; however, these studies used preestablished meals and hydration. The aim of the present study is to identify whether ad libitum food and liquid intake interfere with body composition parameters estimated via bioimpedance.

METHODS

The evaluations were carried out over 2 d. On the first d, the hydration protocol was applied and on the second d, the food protocol. In both cases, bioimpedance was performed after an 8-h overnight fast. The test was repeated 30 min after the intake of liquids or food depending on the protocol. The reproducibility between the pre- and posttest evaluations was assessed using the Bland-Altman method. We considered deviations of up to 5% in the limits of agreement to be clinically acceptable.

RESULTS

In the hydration protocol, the mean difference in fat percentage (FP) was -0.50 (P = 0.05), the lower limit of agreement was -3.60%, and the upper limit of agreement was 2.61%. In the food protocol, the mean difference in FP was 0.002 (P = 0.99), the lower limit of agreement was -3.20%, and the upper limit of agreement was 3.20%.

CONCLUSIONS

Our study shows that ad libitum food and liquid intake do not cause a change above clinically acceptable levels in the FP estimated by bioimpedance.

Circulating Biomarkers of Accelerated Sarcopenia in Respiratory Diseases

Skeletal muscle dysfunction is a critical finding in many respiratory diseases. However, a definitive biomarker to assess muscle decline in respiratory diseases is not known. We analyzed the association of plasma levels of glycoprotein Dickkopf-3 (Dkk-3), c-terminal agrin fragment-22 (CAF22) and microRNAs miR-21, miR-134a, miR-133 and miR-206 with hand-grip strength (HGS) and appendicular skeletal mass index (ASMI) in male, 54-73-year-old patients with chronic obstructive pulmonary diseases (COPD), asthma or pulmonary TB (n = 83-101/group). Patients with respiratory diseases showed a reduction in HGS and gait speed, while a reduction in ASMI was only found in patients with pulmonary TB. Among the sarcopenia indexes, HGS showed the strongest correlation with plasma CAF22, miR-21 and miR-206 levels while ASMI showed the strongest correlation with Dkk-3 and miR-133 in respiratory diseases. We found a modest-to-significant increase in the plasma markers of inflammation, oxidative stress and muscle damage, which had varying degrees of correlations with Dkk-3, CAF22 and selected micro RNAs (miRs) in respiratory diseases. Taken together, our data show that plasma levels of Dkk-3, CAF22 and selected miRs can be useful tools to assess accelerated sarcopenia phenotype in the elderly with respiratory diseases.