Anthropometric midarm measurements can detect systemic fat-free mass depletion in patients with chronic obstructive pulmonary disease

Individual changes in anthropometric measures after age 60 years: a 15-year longitudinal population-based study

BACKGROUND

weight loss is commonly observed with ageing. We explored the trajectory of body mass index (BMI) and two proxies of muscle mass-calf circumference (CC) and mid-arm circumference (MAC)-and identified their determinants.

METHODS

within the SNAC-K cohort, 2,155 dementia-free participants aged ≥60 years were followed over 15 years. BMI, CC and MAC were measured at baseline and follow-ups. Baseline sociodemographic and lifestyle factors were collected through interviews. Diabetes and vascular disorders were diagnosed by physicians through clinical examination and medical records. Data were analysed using linear mixed-effect models stratified by age (younger-old [<78 years] vs. older-old [≥78 years]).

RESULTS

over the 15-year follow-up, BMI remained stable among participants aged 60 years at baseline (βslope = 0.009 [95% confidence interval -0.006 to 0.024], P = 0.234) and declined significantly among those aged ≥66 years, while CC and MAC declined significantly across all age groups. The decline over 15 years in BMI, CC and MAC separately was 0.435 kg/m2, 1.110 cm and 1.455 cm in the younger-old and was 3.480 kg/m2, 3.405 cm and 3.390 cm in the older-old. In younger-old adults, higher education was associated with slower declines in all three measures, while vascular disorders and diabetes were associated with faster declines. In older-old adults, vigorous physical activity slowed declines in BMI and CC, while vascular disorders accelerated declines in BMI and MAC.

CONCLUSIONS

CC and MAC declined earlier and more steeply than BMI. Cardiometabolic disorders accelerated such declines, while higher education and physical activity could counteract those declines.

Chronic obstructive pulmonary disease - diagnosis and management of stable disease; a personalized approach to care, using the treatable traits concept based on clinical phenotypes. Position paper of the Czech Pneumological and Phthisiological Society

This position paper has been drafted by experts from the Czech national board of diseases with bronchial obstruction, of the Czech Pneumological and Phthisiological Society. The statements and recommendations are based on both the results of randomized controlled trials and data from cross-sectional and prospective real-life studies to ensure they are as close as possible to the context of daily clinical practice and the current health care system of the Czech Republic. Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable heterogeneous syndrome with a number of pulmonary and extrapulmonary clinical features and concomitant chronic diseases. The disease is associated with significant mortality, morbidity and reduced quality of life. The main characteristics include persistent respiratory symptoms and only partially reversible airflow obstruction developing due to an abnormal inflammatory response of the lungs to noxious particles and gases. Oxidative stress, protease-antiprotease imbalance and increased numbers of pro-inflammatory cells (mainly neutrophils) are the main drivers of primarily non-infectious inflammation in COPD. Besides smoking, household air pollution, occupational exposure, low birth weight, frequent respiratory infections during childhood and also genetic factors are important risk factors of COPD development. Progressive airflow limitation and airway remodelling leads to air trapping, static and dynamic hyperinflation, gas exchange abnormalities and decreased exercise capacity. Various features of the disease are expressed unequally in individual patients, resulting in various types of disease presentation, emerging as the "clinical phenotypes" (for specific clinical characteristics) and "treatable traits" (for treatable characteristics) concept. The estimated prevalence of COPD in Czechia is around 6.7% with 3,200-3,500 deaths reported annually. The elementary requirements for diagnosis of COPD are spirometric confirmation of post-bronchodilator airflow obstruction (post-BD FEV₁/VCmax <70%) and respiratory symptoms assessement (dyspnoea, exercise limitation, cough and/or sputum production. In order to establish definite COPD diagnosis, a five-step evaluation should be performed, including: 1/ inhalation risk assessment, 2/ symptoms evaluation, 3/ lung function tests, 4/ laboratory tests and 5/ imaging. At the same time, all alternative diagnoses should be excluded. For disease classification, this position paper uses both GOLD stages (1 to 4), GOLD groups (A to D) and evaluation of clinical phenotype(s). Prognosis assessment should be done in each patient. For this purpose, we recommend the use of the BODE or the CADOT index. Six elementary clinical phenotypes are recognized, including chronic bronchitis, frequent exacerbator, emphysematous, asthma/COPD overlap (ACO), bronchiectases with COPD overlap (BCO) and pulmonary cachexia. In our concept, all of these clinical phenotypes are also considered independent treatable traits. For each treatable trait, specific pharmacological and non-pharmacological therapies are defined in this document. The coincidence of two or more clinical phenotypes (i.e., treatable traits) may occur in a single individual, giving the opportunity of fully individualized, phenotype-specific treatment. Treatment of COPD should reflect the complexity and heterogeneity of the disease and be tailored to individual patients. Major goals of COPD treatment are symptom reduction and decreased exacerbation risk. Treatment strategy is divided into five strata: risk elimination, basic treatment, phenotype-specific treatment, treatment of respiratory failure and palliative care, and treatment of comorbidities. Risk elimination includes interventions against tobacco smoking and environmental/occupational exposures. Basic treatment is based on bronchodilator therapy, pulmonary rehabilitation, vaccination, care for appropriate nutrition, inhalation training, education and psychosocial support. Adequate phenotype-specific treatment varies phenotype by phenotype, including more than ten different pharmacological and non-pharmacological strategies. If more than one clinical phenotype is present, treatment strategy should follow the expression of each phenotypic label separately. In such patients, multicomponental therapeutic regimens are needed, resulting in fully individualized care. In the future, stronger measures against smoking, improvements in occupational and environmental health, early diagnosis strategies, as well as biomarker identification for patients responsive to specific treatments are warranted. New classes of treatment (inhaled PDE3/4 inhibitors, single molecule dual bronchodilators, anti-inflammatory drugs, gene editing molecules or new bronchoscopic procedures) are expected to enter the clinical practice in a very few years.

Loop diuretic use is associated with skeletal muscle wasting in patients with heart failure

BACKGROUND

Loop diuretics are widely used for the management of fluid retention in patients with heart failure (HF). Sarcopenia, defined as decreased skeletal muscle mass, is frequently present in patients with HF and is associated with poor prognosis. The effects of loop diuretics on skeletal muscle in HF patients have not been fully elucidated. Here, we investigated the impact of loop diuretics on the skeletal muscle mass in patients with HF.

METHODS

We conducted a subanalysis of a cross-sectional study from 10 hospitals evaluating 155 patients with HF (age 67 ± 13 yrs, 69% men).

RESULTS

We compared the HF patients who were treated with loop diuretics (n = 120) with the patients who were not (n = 35). The thigh and arm circumferences were significantly small in the group treated with loop diuretics compared to those not so treated (39.9 ± 4.8 vs. 43.5 ± 6.9 cm, p < 0.001 and 26.7 ± 3.5 vs. 28.9 ± 6.2 cm, p < 0.001, respectively). In a univariate analysis, higher age, lower body mass index, lower hemoglobin, and loop diuretic use were significantly associated with smaller thigh circumference. In a multivariable analysis, the use of loop diuretics was independently associated with smaller thigh circumference (β = -0.51, 95% confidence interval -0.98 to -0.046, p = 0.032).

CONCLUSION

Loop diuretics are associated with decreased thigh and arm circumferences in patients with HF, independent of the severity of HF. Our findings revealed for the first time the adverse effects of loop diuretics on skeletal muscle wasting. These findings will have a significant impact in clinical practice regarding the frequent use of loop diuretics in HF patients.

Muscle Dysfunction in Smokers and Patients With Mild COPD: A SYSTEMATIC REVIEW

PURPOSE

To describe and discuss the available evidence in the literature concerning muscle function and the association between smoking and muscle dysfunction in smokers and patients with mild chronic obstructive pulmonary disease (COPD).

METHODS

The literature search involved the following databases: PubMed, Pedro, CINAHL, Cochrane Library, Lilacs, and EMBASE. Studies were included if they investigated muscle strength and/or endurance and/or cross-sectional area (CSA) in smokers and/or patients with COPD classified as Global Initiative for Obstructive Lung Disease (GOLD) I and without lung cancer. Two authors screened and identified the studies for inclusion.

RESULTS

Eighteen studies were identified. Some studies found lower values in a variety of muscle strength variables in smokers compared with nonsmoking controls, whereas others found similar values between these groups. When comparing patients with COPD classified as GOLD I with smokers, COPD patients showed lower muscle strength. Two studies found no differences in muscle CSA between smokers compared with nonsmoking controls. Some preliminary evidence also shows that patients with COPD classified as GOLD I had lower CSA in comparison with smokers.

CONCLUSION

Results concerning muscle dysfunction in smokers are divergent, since some studies have shown worse results in a variety of muscle strength variables in smokers compared with nonsmoking controls, whereas other studies have not. Moreover, there is rather preliminary evidence indicating worse muscle dysfunction and lower CSA in patients with mild COPD in comparison with healthy (or non-COPD) smokers.

Prognostic usefulness of arm circumference and nutritional screening tools in older patients with cardiovascular disease

BACKGROUND AND AIM

Arm circumference (AC) and nutritional screening tools have been shown to have prognostic capability in patients with cardiovascular disease (CVD). This study aimed to compare the prognostic predictive capabilities of AC and nutritional screening tools in older patients with CVD.

METHODS AND RESULTS

The study population consisted of 949 admitted patients ≥60 years old with CVD. Patients underwent AC measurement and nutritional screening before hospital discharge. We used the controlling nutritional status index (CONUT), the geriatric nutritional risk index (GNRI), and the prognostic nutritional index (PNI) as nutritional screening tools. The end point of the study was all-cause mortality. The mean age of the study population was 72.3 ± 7.2 years, and 68.2% of the patients were male. A total of 130 deaths occurred over a median follow-up period of 2.2 years (interquartile range, 1.1-3.8 years). After adjusting for other prognostic factors, AC (hazard ratio [HR]: 0.59; p < 0.001), CONUT (HR: 0.82; p = 0.016), GNRI (HR: 0.77; p = 0.040), and PNI (HR: 0.80; p = 0.014) were significant predictors of mortality. However, adding AC to the multivariate-adjusted model (0.739 vs. 0.714, respectively; p = 0.037), but not CONUT, GNRI, or PNI (0.724, 0.717, and 0.723 vs. 0.714; p = 0.072, p = 0.306, and p = 0.127, respectively), significantly increased the area under the curve on receiver operating characteristic curve.

CONCLUSIONS

AC, but not nutritional screening tools, plays a complementary role to preexisting prognostic factors for predicting prognosis in older patients with CVD.

Association of Anthropometric Indexes With Disease Severity in Male Patients With Chronic Obstructive Pulmonary Disease in Qazvin, Iran

Malnutrition is one of the most important factors that lead to lower quality of life in patients suffering from chronic obstructive pulmonary disease (COPD). There are several methods for assessing malnutrition including anthropometric indexes. The aim of this study was to determine the association of anthropometric indexes with disease severity in male patients with COPD in Qazvin, Iran. This cross-sectional study was conducted on 72 male patients with COPD in Qazvin, Iran, from May to December 2014. Spirometry was performed for all participants. Disease severity was determined using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline. Body mass index (BMI), mid-arm muscle circumference (MAMC), and triceps skinfold thickness (TSF) were measured. MAMC and TSF were categorized into three subgroups as <25^th P, between 25^th P and 75^th P, and >75^th P (Where P is the abbreviation for percentile.). Data were analyzed using ANOVA and logistic regression analysis. Mean age was 60.23 ± 11.39 years. Mean BMI was 23.23 ± 4.42 Kg/m², mean MAMC was 28.34 ± 3.72 cm², and mean TSF was 10.15 ± 6.03 mm. Mean BMI and MAMC in the GOLD stage IV were significantly lower than other stages. Of 72, 18.1% were underweight while 6.9% were obese. The GOLD stage IV was associated with 16 times increased risk of underweight and nine times increased risk of MAMC < 25^th P. Disease severity was associated with BMI and MAMC as indexes of malnutrition in patients with COPD in the present study. The GOLD stage IV was associated with increased risk of underweight and low MAMC.

Thoracic muscle cross-sectional area is associated with hospital length of stay post lung transplantation: a retrospective cohort study

Low muscle mass is common in lung transplant (LTx) candidates; however, the clinical implications have not been well described. The study aims were to compare skeletal muscle mass in LTx candidates with controls using thoracic muscle cross-sectional area (CSA) from computed tomography and assess the association with pre- and post-transplant clinical outcomes. This was a retrospective, single-center cohort study of 527 LTx candidates [median age: 55 IQR (42-62) years; 54% male]. Thoracic muscle CSA was compared to an age- and sex-matched control group. Associations between muscle CSA and pre-transplant six-minute walk distance (6MWD), health-related quality of life (HRQL), delisting/mortality, and post-transplant hospital outcomes and one-year mortality were evaluated using multivariable regression analysis. Muscle CSA for LTx candidates was about 10% lower than controls (n = 38). Muscle CSA was associated with pre-transplant 6MWD, but not HRQL, delisting or pre- or post-transplant mortality. Muscle CSA (per 10 cm² difference) was associated with shorter hospital stay [0.7 median days 95% CI (0.2-1.3)], independent of 6MWD. In conclusion, thoracic muscle CSA is a simple, readily available estimate of skeletal muscle mass predictive of hospital length of stay, but further study is needed to evaluate the relative contribution of muscle mass versus functional deficits in LTx candidates.

Prognostic Usefulness of Arm and Calf Circumference in Patients ≥65 Years of Age With Cardiovascular Disease

Current diagnostic criteria for sarcopenia require measurement of muscle function (MF) and muscle mass. Mid upper arm circumference (AC) and calf circumference (CC) are currently used as metrics of muscle mass. This study was performed to compare the prognostic predictive capabilities of AC and CC in older patients with cardiovascular disease (CVD). The study population consisted of 599 admitted patients aged ≥65 years (74.8 ± 6.3 years, 392 men) with CVD. We measured MF (gait speed and grip strength), AC, and CC before hospital discharge. The end point was all-cause mortality. During follow-up (median 1.63 years, interquartile range 2.09 years), 72 deaths occurred. Both high AC and high CC were associated with better outcome; however, only AC (adjusted hazard ratio per SD increase 0.56, p = 0.023), but not CC (adjusted hazard ratio per SD increase 0.91, p = 0.696), showed significant independent prognostic capability after adjusting for other prognostic factors. Moreover, adding AC to MF (0.71 vs 0.62, p = 0.005) but not CC to MF (0.67 vs 0.62, p = 0.188) significantly increased the area under the curve on receiver operating characteristic curve. In conclusion, a high AC, but not CC, was an independent predictor of survival and could be a readily available and simple metric for risk stratification in older patients with CVD.

The relationship between anthropometric indicators and walking distance in patients with chronic obstructive pulmonary disease

Background

Exercise intolerance is a major issue affecting many people with COPD. Six-minute walking distance (6MWD) is a widely used indicator of exercise capacity in patients with COPD. The process is strenuous and time-consuming, especially for patients who have muscle wasting. Anthropometric indicators that reflect body lean mass, such as body mass index (BMI), mid-arm circumference (MAC), and calf circumference (CC), may have value in predicting exercise intolerance.

Purpose

This study attempted to determine the abilities of simple anthropometric indicators including BMI, MAC, and CC in reflecting the exercise intolerance of COPD patients.

Methods

We recruited 136 nonhospitalized ambulatory COPD patients without acute conditions from a general hospital in Taiwan. Each subject’s BMI, MAC, and CC were measured, and they were examined with pulmonary function tests and a 6-minute walk test.

Results

Among the three anthropometric indicators examined, CC showed the strongest correlation with the 6MWD, followed by MAC and BMI. CC was also strongly associated with functional capacity, followed by MAC, according to the receiver operating characteristic curves. CC and MAC, but not BMI, were significantly associated with exercise intolerance according to logistic regression models that controlled for potential confounders.

Conclusion

Among the three variables examined, CC and walking distance may have the strongest association in COPD patients. CC may have value in serving as an adjunct to 6MWD in evaluating exercise intolerance of patients with COPD.

Leucine supplementation improves acquired growth hormone resistance in rats with protein-energy malnutrition

Background

Protein-energy malnutrition (PEM) can lead to growth hormone (GH) resistance. Leucine supplementation diets have been shown to increase protein synthesis in muscles. Our study aimed at investigating if long-term leucine supplementation could modulate GH-insulin-like growth factor (IGF)-1 system function and mammalian target of rapamycin (mTOR)-related signal transduction in skeletal muscles in a rat model of severe malnutrition.

Methodology/Principal Findings

Male Sprague-Dawley rats (n = 50; weight, 302 ± 5 g) were divided into 5 treatment groups, including 2 control groups (a normal control group that was fed chow and ad libitum water [CON, n = 10] and a malnourished control group [MC, n = 10] that was fed a 50% chow diet). After undergoing a weight loss stage for 4 weeks, rats received either the chow diet (MC-CON, n = 10), the chow diet supplemented with low-dose leucine (MC-L, n = 10), or the chow diet supplemented with high-dose leucine (MC-H, n = 10) for 2 weeks. The muscle masses of the gastrocnemius, soleus, and extensor digitorum longus were significantly reduced in the MC group. Re-feeding increased muscle mass, especially in the MC-L and MC-H groups. In the MC group, serum IGF-1, IGF-binding protein (IGFBP)-3, and hepatic growth hormone receptor (GHR) levels were significantly decreased and phosphorylation of the downstream anabolic signaling effectors protein kinase B (Akt), mTOR, and ribosomal protein S6 kinase 1 (S6K1) were significantly lower than in other groups. However, serum IGF-1 and IGF binding protein (IGFBP)-3 concentrations and hepatic growth hormone receptor (GHR) levels were significantly higher in the MC-L and MC-H groups than in the MC-CON group, and serum IGFBP-1 levels was significantly reduced in the MC-L and MC-H groups. These changes were consistent with those observed for hepatic mRNA expression levels. Phosphorylation of the downstream anabolic signaling effectors Akt, mTOR, and S6K1 were also significantly higher in the MC-L and MC-H groups than in the MC-CON group.

Conclusion/Significance

Our data are the first to demonstrate that long-term supplementation with leucine improved acquired growth hormone resistance in rats with protein-energy malnutrition. Leucine might promote skeletal muscle protein synthesis by regulating downstream anabolic signaling transduction.

Clinical outcome of protein-energy malnourished patients in a Brazilian university hospital

Protein-energy malnutrition (PEM) is a treatable disease with high prevalence among hospitalized patients. It can cause significant increases in the duration of hospitalization and costs. PEM is especially important for health systems since malnourished patients present higher morbidity and mortality. The objective of the present study was to assess the evolution of nutritional status (NS) and the effect of malnutrition on clinical outcome of patients at a public university hospital of high complexity in Brazil. Patients hospitalized in internal medicine (n = 54), oncology (n = 43), and infectious diseases (n = 12) wards were included. NS was evaluated using subjective global assessment up to 48 h after admission, and thereafter at intervals of 4-6 days. On admission, patients (n = 109) were classified as well-nourished (n = 73), moderately malnourished or at risk of malnutrition (n = 28), and severely malnourished (n = 8). During hospitalization, malnutrition developed or worsened in 11 patients. Malnutrition was included in the clinical diagnosis of only 5/36 records (13.9% of the cases, P = 0.000). Nutritional therapy was administered to only 22/36 of the malnourished patients; however, unexpectedly, 6/73 well-nourished patients also received commercial enteral diets. Complications were diagnosed in 28/36 malnourished and 9/73 well-nourished patients (P = 0.000). Death occurred in 12/36 malnourished and 3/73 well-nourished patients (P = 0.001). A total of 24/36 malnourished patients were discharged regardless of NS. In summary, malnutrition remains a real problem, often unrecognized, unappreciated, and only sporadically treated, even though its effects can be detrimental to the clinical course and prognosis of patients. The amount of public and private funds unnecessarily dispersed because of hospital malnutrition is significant.

Nutritional status in patients with chronic pancreatitis

OBJECTIVE

Chronic pancreatitis (CP) patients have an increased risk of malnutrition. Information about nutritional status of CP outpatients is scarce, and simple, sensitive methods to identify patients at risk are lacking. This explorative cross-sectional study was performed to survey the nutritional status of CP outpatients.

SUBJECTS

Fifty patients with chronic or recurrent acute pancreatitis (RAP) had a nutritional assessment performed. Scores on nutritional screening tools and a quality of life questionnaire were assessed. General observations and relations between parameters were described.

RESULTS

Thirty-nine patients had CP and eleven patients had RAP. According to the nutritional screening tools, 28-50% of the patients had a moderate or high risk of malnutrition. All domains of the Short Form Health Survey were significantly lowered in CP patients (all P0.001) compared with the Dutch norm values. A considerable number of patients scored below the 5th percentile on anthropometric measures. Mini Nutritional Assessment could not identify all patients with very low anthropometric scores. Substantial weight loss was not a sensitive indicator for functional impairment.

CONCLUSION

CP outpatients are at risk of malnutrition. Currently used screening methods (for example, weight loss) are likely to be not sensitive enough to identify all patients with impaired body composition and restricted function. Therefore, some patients with objective decline in nutritional status will remain unidentified. An extended nutritional assessment is recommendable in CP patients.

Chronic Obstructive Pulmonary Disease: official diagnosis and treatment guidelines of the Czech Pneumological and Phthisiological Society; a novel phenotypic approach to COPD with patient-oriented care

BACKGROUND

COPD is a global concern. Currently, several sets of guidelines, statements and strategies to managing COPD exist around the world.

METHODS

The Czech Pneumological and Phthisiological Society (CPPS) has commissioned an Expert group to draft recommended guidelines for the management of stable COPD. Subsequent revisions were further discussed at the National Consensus Conference (NCC). Reviewers' comments contributed to the establishment of the document's final version.

DIAGNOSIS

The hallmark of the novel approach to COPD is the integrated evaluation of the patient's lung functions, symptoms, exacerbations and identifications of clinical phenotype(s). The CPPS defines 6 clinically relevant phenotypes: frequent exacerbator, COPD-asthma overlap, COPD-bronchiectasis overlap, emphysematic phenotype, bronchitic phenotype and pulmonary cachexia phenotype.

TREATMENT

Treatment recommendations can be divided into four steps. 1(st) step = Risk exposure elimination: reduction of smoking and environmental tobacco smoke (ETS), decrease of home and occupational exposure risks. 2(nd) step = Standard treatment: inhaled bronchodilators, regular physical activity, pulmonary rehabilitation, education, inhalation training, comorbidity treatment, vaccination. 3(rd) step = Phenotype-specific therapy: PDE4i, ICS+LABA, LVRS, BVR, AAT augmentation, physiotherapy, mucolytic, ABT. 4(th) step = Care for respiratory insufficiency and terminal COPD: LTOT, lung transplantation, high intensity-NIV and palliative care.

CONCLUSION

Optimal treatment of COPD patients requires an individualised, multidisciplinary approach to the patient's symptoms, clinical phenotypes, needs and wishes. The new Czech COPD guideline reflects and covers these requirements.