Bioelectrical Impedance Analysis and Mid-Upper Arm Muscle Circumference Can Be Used to Detect Low Muscle Mass in Clinical Practice

Standardising and simplifying the Global Leadership Initiative on Malnutrition (GLIM) for its more general application

BACKGROUND

Malnutrition is present in 20-50% of hospital patients but its recognition is often neither timely nor complete. The Global Leadership Initiative on Malnutrition (GLIM) aims to improve this, but its successful implementation may be compromised by its dependence on (a choice of) prior screening tools and difficulties in consistent assessment of muscle mass.

AIMS

To explore different approaches to screening and muscle assessment in GLIM and to offer simpler choices for its more widespread application.

METHODS

(1) Data from 300 consenting in-patients provided Nutritional Risk Screening (NRS-2002), Malnutrition Universal Screening Tool (MUST), and Subjective Global Assessment (SGA) scores. GLIM scoring was preceded by NRS-2002 or MUST (using threshold scores of 1 or 2 for MUST), or no prior screening. The results of GLIM scoring preceded by different screening approaches were compared with those of SGA. (2) The literature on mid-upper arm circumference (MUAC) and calf circumference (CC) as simple, non-invasive, objective methods of muscle assessment methods was reviewed (3) The cumulative times taken to obtain GLIM scores were measured and corrected for the different screening strategies.

RESULTS

(1) Participants' mean age was 60 years, 157 (52%) were female and mean BMI was 27.8 kg/m2. In comparison with SGA, GLIM with no prior screening had the highest sensitivity (65%) and negative predictive value (NPV) (76%), but the lowest specificity (90%) and positive predictive value (PPV) (84%). The equivalent figures for GLIM with prior MUST "1" were 62%, 75%, 93% and 88%; with prior NRS-2002, 55%∗, 73%, 98%∗ and 95%∗; and with prior MUST "2", 44%∗, 69%∗, 98%∗, 95%∗. The area under an ROC curve was the highest (0.78) when GLIM was performed without screening or with prior MUST "1". (2) Being less affected by oedema and gender differences than calf circumference, MUAC could serve as a standard globally accessible muscle mass assessment method which can be supplemented by technical approaches if available and deemed necessary. (3) The overall per-capita time requirement of GLIM was 240-245 s without prior screening, and was increased by 2-3% with prior MUST "1", by 27-29% with prior NRS-2002 and decreased by 8-9% with prior MUST "2".

CONCLUSIONS

Preceding GLIM by screening can decrease its sensitivity and increase overall time utilisation; "gold standard" muscle assessment is not globally accessible. Our results therefore support considering using GLIM as a combined screening and assessment tool, with MUAC as the method of muscle assessment which can be supplemented by technical approaches if available and deemed necessary. This could potentially both simplify the use of GLIM and improve the early detection of malnutrition. ∗Indicates statistically significant difference from use of GLIM without prior screening.

A Cross-Sectional Validation Study of Camry EH101 versus JAMAR Plus Handheld Dynamometers in Colorectal Cancer Patients and Their Correlations with Bioelectrical Impedance and Nutritional Status

BACKGROUND

Reduced muscle strength (dynapenia) and mass (atrophy) are prognostic factors in oncology. Measuring maximal handgrip strength with dynamometers is feasible but limited by the cost of the reference device (JAMAR).

METHODS

A cross-sectional study was conducted on colorectal cancer outpatients treated with chemotherapy or under active surveillance in our center from September 2022 to July 2023. Accuracy, reliability, and concordance were compared for two handheld dynamometers: the JAMAR Plus (the gold-standard device) and the Camry EH101 (a low-cost index device). A simultaneous nutritional diagnosis with GLIM criteria and bioelectrical impedance analysis (BIA) was carried out.

RESULTS

A total of 134 participants were included. The median of maximal strength for the JAMAR Plus had a non-significant difference of 1.4 kg from the Camry EH101. The accuracy and reliability of the devices were high. Bland-Altman analysis showed a 0.8 kg bias and -4.1 to 5.6 kg limits of agreement (LoA); a 0.1 kg bias and -5.3 to 5.4 kg LoA in men; a 1.5 kg bias and -2.2 to 5.3 kg LoA in women. In total, 29.85% of the participants were malnourished. Prevalence of dynapenia increased from 3.67% with the JAMAR Plus to 5.14% with the Camry EH101. Both devices had a moderate and significant correlation with BIA-estimated muscle mass.

CONCLUSIONS

The Camry EH101 was a cost-effective alternative to JAMAR Plus in our sample.

SARC-F and modified versions using arm and calf circumference: Diagnostic performance for sarcopenia screening and the impact of obesity

AIM

SARC-F is limited by low sensitivity for sarcopenia identification. As surrogates of muscle mass, mid-arm circumference (MAC) and/or calf circumference have been proposed as additions to SARC-F to enhance sarcopenia identification. The aim of this study was to evaluate the diagnostic performance of SARC-F, SARC-CalF, SARC-F + MAC, and SARC-CalF + MAC in sarcopenia detection, and to assess the impact of obesity on their diagnostic performance.

METHODS

We studied 230 healthy non-frail community-dwelling older adults age >50 years. We performed receiver operating characteristic curve analysis for SARC-F, SARC-CalF, SARC-F + MAC and SARC-CalF + MAC against sarcopenia diagnosed by the Asian Working Group for Sarcopenia (AWGS) 2019 as the reference standard. Obesity was defined by high waist circumference (men ≥90 cm, women ≥80 cm). We performed subgroup analysis to compare between obese and non-obese groups.

RESULTS

The prevalence of sarcopenia was 27.0% by AWGS 2019. SARC-CalF + MAC had the best diagnostic performance (area under the curve [AUC] 0.74, 95% confidence interval [CI] 0.67-0.81; sensitivity 66.1%; specificity 69.1%), followed by SARC-CalF (AUC 0.70, 95% CI 0.62-0.78; sensitivity 21.0%; specificity 95.8%). SARC-F (AUC 0.57, 95% CI 0.49-0.66; sensitivity 0%; specificity 100%) performed significantly worsethan its modified versions (P < 0.05). There was higher accuracy of sarcopenia identification in obese compared with non-obese groups for SARC-F + MAC (AUC 0.75, 95% CI 0.65-0.85 vs. 0.58, 95% CI 0.46-0.70) and SARC-CalF + MAC (AUC 0.75, 95% CI 0.66-0.85 vs. 0.70, 95% CI 0.59-0.81).

CONCLUSIONS

The addition of arm circumference to SARC-CalF confers better diagnostic accuracy for sarcopenia identification, especially in the obese group. Thus, MAC may complement SARC-CalF for community screening of sarcopenia amongst healthy community-dwelling older adults by increasing sensitivity for the detection of sarcopenic obesity. Geriatr Gerontol Int 2024; 24: 182-188.

Older adults, appendicular anthropometric measurements, and poor functional performance are predictors of sarcopenia in individuals with head and neck squamous cell carcinoma

OBJECTIVE

To identify predictors of sarcopenia (demographical, anthropometric measurements, tumor-related clinical characteristics, performance status, and serum C-reactive protein (CRP) and albumin levels in individuals with head and neck squamous cell carcinoma (HNSCC).

MATERIAL AND METHODS

This cross-sectional study selected diagnosed with HNSCC (n = 125). Sarcopenia was defined as low muscle strength and low physical performance. Association between sarcopenia and anthropometric assessments (weight, height, body mass index, triceps skinfold, mid-upper arm circumference [MUAC], mid-upper arm muscle circumference, mid-upper arm fat area [UFA], mid-upper arm bone free muscle area, calf circumference, and appendicular skeletal muscle mass and index), tumor clinical characteristics (anatomical site, tumor size, and cervical metastasis), performance status scale (Eastern Cooperative Oncology Group Performance Status [ECOG-PS]), and CRP and albumin levels was analyzed using binary logistic regression models.

RESULTS

The diagnosis of sarcopenia was identified in 28 (22.4%) individuals with HNSCC. Being an older adult increases the odds of association with sarcopenia in individuals with HNSCC (odds ratio [OR] = 1.05). Increments in MUAC measurement reduce the odds of association with sarcopenia (OR = 0.69), while the increase in the UFA measurement increases the odds of association with sarcopenia (OR = 1.33). Poor ECOG-PS scores increase the odds of association with sarcopenia in individuals with HNSCC (OR = 5.54).

CONCLUSION

Early identification of easy-to-perform, cost-effective predictors of sarcopenia tends to favor the implementation of personalized therapeutic and supportive interventions in individuals with HNSCC.

Mid-arm muscle circumference and triceps skinfold thickness associated with cardiometabolic disease in Chinese residents: A prospective cohort study

BACKGROUND AND AIMS

The association of cardiometabolic disease (CMD) with body muscle and fat mass remains unclear. Mid-arm muscle circumference (MAMC) and triceps skinfold (TSF) thickness are easily obtained measuring methods for these two body compositions. This study aimed to investigate the association of CMD with MAMC and TSF thickness among Chinese residents.

METHODS

A total of 9440 eligible participants from the China Health and Nutrition Survey were included in the analysis. Associations of CMD prevalence with MAMC and TSF thickness were estimated using logistic regression models. Multivariable COX proportional-hazards regression models were used to estimate the effect of baseline MAMC and TSF thickness on subsequent CMD.

RESULTS

Positive associations of CMD prevalence with MAMC (odds ratio [OR] = 1.169, 95% confidence interval [CI] 1.110-1.232, P < 0.001) and TSF thickness (OR = 1.313, 95%CI 1.240-1.390, P < 0.001) were observed in the cross-sectional analysis. In the longitudinal study, a 1-SD increase in MAMC was associated with a 13.6% increased risk of CMD incidence (hazard ratio [HR] = 1.136, 95%CI 1.073-1.204, P < 0.001), and a 1-SD increase in TSF thickness had a 17.6% increased risk of CMD incidence (HR = 1.176, 95%CI 1.084-1.276, P < 0.001). For the CMD components, both MAMC and TSF thickness contributed to increased incidences of hypertension (HR = 1.163, 95%CI 1.097-1.233, P < 0.001 in MAMC; HR = 1.218, 95%CI 1.110-1.336, P < 0.001 in TSF thickness) and diabetes mellitus (HR = 1.166, 95%CI 1.028-1.323, P = 0.017 in MAMC; HR = 1.352, 95%CI 1.098-1.664, P = 0.004 in TSF thickness).

CONCLUSIONS

Individuals with higher MAMC and TSF thickness had an increased incidence of CMD, mainly hypertension and diabetes mellitus. This study revealed a seemingly counterintuitive association between body muscle mass and metabolic homeostasis. Although the potential mechanisms require further exploration, the impact of body muscle mass on metabolic health cannot be ignored.

Computed tomography measured epicardial adipose tissue and psoas muscle attenuation: new biomarkers to predict major adverse cardiac events and mortality in patients with heart disease and critically ill patients. Part II: Psoas muscle area and density

Sarcopenia is a syndrome characterised by loss of skeletal muscle mass, loss of muscle quality, and reduced muscle strength, resulting in low performance. Sarcopenia has been associated with increased mortality and complications after medical interventions. In daily clinical practice, sarcopenia is assessed by clinical assessment of muscle strength and performance tests and muscle mass quantification by dual-energy X-ray absorptio-metry (DXA) or bioelectrical impedance analysis (BIA). Assessment of the skeletal muscle quantity and quality obtained by abdominal computed tomography (CT) has gained interest in the medical community, as abdominal CT is performed for various medical reasons, and quantification of the psoas and skeletal muscle can be performed without additional radiation load and dye administration. The definitions of CT-derived skeletal muscle mass quantification are briefly reviewed: psoas muscle area (PMA), skeletal muscle area (SMA), and transverse psoas muscle thickness (TPMT). We explain how CT attenuation coefficient filters are used to determine PMA and SMA, resulting in the psoas muscle index (PMI) and skeletal muscle index (SMI), respectively, after indexation to body habitus. Psoas muscle density (PMD), a biomarker for skeletal muscle quality, can be assessed by measuring the psoas muscle CT attenuation coefficient, expressed in Hounsfield units. The concept of low-density muscle (LDM) is explained. Finally, we review the medical literature on PMI and PMD as predictors of adverse outcomes in patients undergoing trauma or elective major surgery, transplantation, and in patients with cardiovascular and internal disease. PMI and PMD are promising new biomarkers predicting adverse outcomes after medical interventions.

Mid-Arm Muscle Circumference or Body Weight-Standardized Hand Grip Strength in the GLIM Superiorly Predicts Survival in Chinese Colorectal Cancer Patients

Our objective was to identify the optimal method to assess reduced muscle mass (RMM) using the Global Leadership Initiative on Malnutrition (GLIM) approach and investigate the roles of the GLIM approach in nutrition assessment and survival prediction in colorectal cancer (CRC) patients. During a median follow-up period of 4.2 (4.0, 4.4) years, a development cohort of 3612 CRC patients with a mean age of 64.09 ± 12.45 years was observed, as well as an external validation cohort of 875 CRC patients. Kaplan−Meier curves and multivariate Cox regression were adopted to analyze the association between GLIM-diagnosed malnutrition and the overall survival (OS) of CRC patients. A nomogram predicting individualized survival was constructed based on independent prognostic predictors. The concordance index, calibration curve, and decision curve were applied to appraise the discrimination, accuracy, and clinical efficacy of the nomogram, respectively. Patients diagnosed with severe malnutrition based on either the mid-arm muscle circumference (MAMC) or body weight-standardized hand grip strength (HGS/W) method had the highest mortality hazard ratio (HR, 1.51; 95% CI, 1.34−1.70; p < 0.001). GLIM-defined malnutrition was diagnosed in 47.6% of patients. Severe malnutrition was an independent mortality risk factor for OS (HR, 1.25; 95% CI, 1.10−1.42; p < 0.001). The GLIM nomogram showed good performance in predicting the survival of CRC patients and was clinically beneficial. Our findings support the effectiveness of GLIM in diagnosing malnutrition and predicting OS in CRC patients.

Endothelial Damage and Muscle Wasting in Cardiac Surgery Patients

This is a post-hoc analysis to assess the effect of anesthesia, surgical trauma, and extracorporeal circuit on endothelial integrity, microvascular permeability, and extracellular fluid balance, as well as on skeletal muscle catabolism, in patients undergoing elective cardiac surgery. We included 127 well-nourished patients undergoing “on-pump” elective cardiac surgery. One day prior to surgery (D0) and again on postoperative day 7 (POD7), body mass index, body composition assessment, hand-grip strength (HGS), and mid-upper arm muscle circumference (MAMC) were measured. Patients were assigned to early recovery (ER) and late recovery (LR) groups, depending on the duration of ICU stay (cut-off 48 hours). The magnitude of change (Δ) in all parameters studied was assessed in ER versus LR groups, regarding (i) epithelial tissue dysfunction (Δ-Extra-Cellular Water percentage (Δ-ECW%), Δ-Phase Angle (Δ-PhA)), (ii) skeletal muscle mass catabolism (Δ-Skeletal muscle mass reduction%, Δ-Hand Grip Strength (Δ-HGS) and Δ-Mid Upper-Arm Muscle Circumference (Δ-MAMC)). Baseline measurements were similar in both groups. A significant difference was observed in all Δ-parameters studied (Δ-ECW%, Δ-PhA and muscle catabolism, Δ-HGS, Δ-MAMC), the worse results being correlated to the LR group. The results raise the issue that patients with early recovery may silently have pathological conditions, continuing even on the day of discharge - further research should be planned.

Assessing nutritional status in older adults requiring long-term care: Interchangeability of bioelectrical impedance analysis and manual methods for upper arm anthropometric measurements

AIM

In older adults, arm circumference and arm muscle circumference are common nutritional assessment tools. Bioelectrical impedance analysis devices can automatically measure arm circumference and arm muscle circumference. However, the interchangeability of the measurements made by bioelectrical impedance analysis with the actual manual measurements has not been clarified. This study examined the interchangeability of these two measurements and their relationship with sarcopenia.

METHODS

The interchangeability between bioelectrical impedance analysis and manual arm circumference and arm muscle circumference measurements was calculated using Bland-Altman analysis in 112 older adults certified to require long-term care in the Japanese system. Furthermore, multivariate analysis was used to investigate the association between arm circumference and arm muscle circumference obtained using the bioelectrical impedance analysis method and sarcopenia.

RESULTS

The bioelectrical impedance analysis and manual methods were interchangeable, with a percentage error of <15% (arm circumference 13.54% and arm muscle circumference 13.54%) for the upper arm anthropometric measurement. In multivariate analysis, decreased arm muscle circumference was significantly associated with sarcopenia risk.

CONCLUSIONS

Values obtained using the bioelectrical impedance analysis method were interchangeable with the values obtained using manual measurement. This shows that upper arm anthropometric measurement using bioelectrical impedance analysis might be useful as a nutritional assessment tool for older adults requiring long-term care. Geriatr Gerontol Int 2022; ••: ••-••.

Anthropometric Indices as Predictive Screening Tools for Obesity in Adults; The Need to Define Sex-Specific Cut-Off Points for Anthropometric Indices

Due to the lack of full agreement as to the best indicators for obesity diagnosis and type, the aim of this study was to assess the comparative classification capabilities with the use of BIA results and selected anthropometric indices in individuals aged 20–60 years. This was a cross-sectional observational study among 368 Caucasian subjects aged 20–60 years. Body size and four skinfolds measurement were taken. To assess individual body composition, the bioelectrical impedance (BIA) method was applied. The results of fat mass (FM, kg) and fat-free mass (FFM, kg) were taken to calculate FM/FFM, fat mass index (FMI), and fat free mass index (FFMI). Receiver-operating characteristic (ROC) curve analysis was employed to compare the predictive power of different anthropometric indices in differentiating the classification of obesity in adults. The results of this study demonstrated and confirmed the need to change the approach to commonly used indicators such as BMI (body mass index) or WHtR (waist-to-height ratio), which should lead to the establishment of new criteria for the diagnosis of obesity that will also be sex-specific, in the adult population. The measurement of body fat content should become a generally accepted indicator for effective diagnosis, as well as for screening, of obesity.

The Use of Bioelectrical Impedance Analysis Measures for Predicting Clinical Outcomes in Critically Ill Children

Background

The study aimed to investigate the association of bioelectrical impedance analysis (BIA) for predicting clinical outcomes in critically ill children.

Methods

This single-center prospective observational study included patients admitted to a mixed Pediatric Intensive Care Unit (PICU). All patients underwent anthropometric measurement and BIA measurements in the first 24 h of admission. The patients were classified into different groups based on body mass index (BMI) for age. Electronic hospital medical records were reviewed to collect clinical data for each patient. All the obtained data were analyzed by the statistical methods.

Results

There were 231 patients enrolled in our study, of which 31.6% were diagnosed with malnutrition. The phase angle (PhA) of 90-day survivors was significantly higher than that of the non-survivors (4.3° ± 1.1°vs. 3.1° ± 0.9°, P = 0.02). The age-adjusted Spearman partial correlation analysis showed a weak negative correlation between PhA and duration of medical ventilation (r_s = -0.42, P < 0.05). Furthermore, length of stay in PICU has a very weak correlation with ECW/TBW (r_s = 0.29, P < 0.05), and a negative correlation with protein (r_s = -0.27, P < 0.05). Multivariate analysis found that PhA was a significant predictor associated with the 90-day mortality when it was adjusted for PRISM III score (adjusted OR = 1.51, CI: 1.10–2.07, p = 0.01). The area under the ROC (AUROC) of PhA for predicting 90-day mortality was 0.69 (95% CI: 0.53–0.85, p < 0.05), and the cutoff value of PhA was 3.0°, with a sensitivity and specificity of 83 and 53%, respectively.

Conclusion

BIA-derived PhA was found to be an independent predictor of 90-day mortality among critically ill children. A low PhA was associated with a prolonged duration of medical ventilation.

Measurement of Sarcopenia in Head and Neck Cancer Patients and Its Association With Frailty

In head and neck cancer (HNC) there is a need for more personalized treatment based on risk assessment for treatment related adverse events (i.e. toxicities and complications), expected survival and quality of life. Sarcopenia, defined as a condition characterized by loss of skeletal muscle mass and function, can predict adverse outcomes in HNC patients. A review of the literature on the measurement of sarcopenia in head and neck cancer patients and its association with frailty was performed. Skeletal muscle mass (SMM) measurement only is often used to determine if sarcopenia is present or not. SMM is most often assessed by measuring skeletal muscle cross-sectional area on CT or MRI at the level of the third lumbar vertebra. As abdominal scans are not always available in HNC patients, measurement of SMM at the third cervical vertebra has been developed and is frequently used. Frailty is often defined as an age-related cumulative decline across multiple physiologic systems, with impaired homeostatic reserve and a reduced capacity of the organism to withstand stress, leading to increased risk of adverse health outcomes. There is no international standard measure of frailty and there are multiple measures of frailty. Both sarcopenia and frailty can predict adverse outcomes and can be used to identify vulnerable patients, select treatment options, adjust treatments, improve patient counselling, improve preoperative nutritional status and anticipate early on complications, length of hospital stay and discharge. Depending on the definitions used for sarcopenia and frailty, there is more or less overlap between both conditions. However, it has yet to be determined if sarcopenia and frailty can be used interchangeably or that they have additional value and should be used in combination to optimize individualized treatment in HNC patients.

Muscular Ultrasonography in Morphofunctional Assessment of Patients with Oncological Pathology at Risk of Malnutrition

Background: Muscular ultrasonography is a technique that allows assessing the amount and quality of muscle in a specific body region. The aim of the study was to compare the value of muscle ultrasonography in diagnosis of malnutrition with techniques such as anthropometry, handgrip strength and impedanciometry in patients with oncological pathology. Methods: Cross-sectional study in 43 patients with oncological pathology and high nutritional risk. Classical anthropometry (body mass index (BMI), arm circumference (AC), calf circumference (CC) and estimated appendicular muscle mass index (ASMI)) was performed. Body composition was measured with impedanciometry (BIA), phase angle (PA) and fat-free mass index (FFMI) and muscle ultrasonography of quadriceps rectus femoris (muscle area (MARA) and circumference (MCR) in section transverse). Malnutrition was diagnosed using the GLIM criteria and sarcopenia was assessed using EWGSOP2 criteria. Results: The mean age was 68.26 years (±11.88 years). In total, 23/20 of the patients were men/women. The BMI was 23.51 (4.75) kg/m2. The ASMI was 6.40 (1.86) kg/m2. The MARA was 3.31 cm2 in ultrasonography. In impedanciometry, phase angle was 4.91 (0.75)°; the FFMI was 17.01 kg/m2 (±2.65 kg/m2). A positive correlation was observed between the MARA with anthropometric measurements (AC: r = 0.39, p = 0.009; CC: r = 0.44, p < 0.01; ASMI: r = 0.47, p < 0.001); and with BIA (FFMI: r = 0.48, p < 0.01 and PA: r = 0.45, p < 0.001). Differences were observed when comparing the MARA based on the diagnosis of sarcopenia (Sarcopenia: 2.47 cm2 (±0.54 cm2); no sarcopenia: 3.65 cm2 (±1.34 cm2); p = 0.02). Conclusions: Muscle ultrasonography correlates with body composition measurement techniques such as BIA and anthropometry in patients with cancer.

Genetics and Epigenetics of Bone Remodeling and Metabolic Bone Diseases

Bone metabolism consists of a balance between bone formation and bone resorption, which is mediated by osteoblast and osteoclast activity, respectively. In order to ensure bone plasticity, the bone remodeling process needs to function properly. Mesenchymal stem cells differentiate into the osteoblast lineage by activating different signaling pathways, including transforming growth factor β (TGF-β)/bone morphogenic protein (BMP) and the Wingless/Int-1 (Wnt)/β-catenin pathways. Recent data indicate that bone remodeling processes are also epigenetically regulated by DNA methylation, histone post-translational modifications, and non-coding RNA expressions, such as micro-RNAs, long non-coding RNAs, and circular RNAs. Mutations and dysfunctions in pathways regulating the osteoblast differentiation might influence the bone remodeling process, ultimately leading to a large variety of metabolic bone diseases. In this review, we aim to summarize and describe the genetics and epigenetics of the bone remodeling process. Moreover, the current findings behind the genetics of metabolic bone diseases are also reported.