Cutoff percentiles of bioelectrical phase angle predict functionality, quality of life, and mortality in patients with cancer

Phase angle measured by bioelectrical impedance analysis in patients with chronic obstructive pulmonary disease: Associations with physical inactivity and frailty

BACKGROUND

Factors associated with early-stage frailty (pre-frailty) in patients with chronic obstructive pulmonary disease (COPD) remain unestablished. In addition to skeletal muscle quantity, skeletal muscle dysfunction can be estimated using an angular metric from bioelectrical impedance analyzer (BIA), termed the phase angle, that reflects cell membrane reactance representing the structural stability. This study examined whether the phase angle was more closely associated with pre-frailty compared with skeletal muscle quantity in patients with COPD.

METHODS

This cross-sectional analysis included stable smokers with and without COPD whose frailty status was assessed using the Japanese version of the Cardiovascular Health Study criteria. The phase angle and skeletal muscle index (SMI) were measured using BIA, and physical activity over one week was assessed using triaxial accelerometers.

RESULTS

A total of 159 patients were categorized into robust, pre-frail, and frail groups (n = 38, 92, and 29, respectively). The phase angle was significantly smaller in the pre-frail and frail groups than in the robust group after adjusting for age, sex, height, body mass index, smoking history, and lung function. In contrast, SMI did not differ between the robust and pre-frail groups. When combining the pre-frail and frail groups into a non-robust group, 4.8° was determined as the cutoff phase angle value to identify non-robust status. A phase angle <4.8° was associated with shorter durations of moderate-intensity physical activity but not with light physical activity.

CONCLUSIONS

A smaller phase angle was associated with pre-frailty and impaired moderate-intensity physical activity in smokers with and without COPD.

Bioimpedance-derived body composition parameters predict mortality and dose-limiting toxicity: the multicenter ONCO-BIVA study

BACKGROUND

In patients with cancer, lean body mass loss is frequent and associated with worse outcomes, including reduced treatment tolerance and survival. Bioelectrical impedance analysis (BIA) is a popular method for body composition assessment. We evaluated the value of BIA-derived body composition parameters in predicting mortality and, for the first time, dose-limiting toxicity (DLT).

PATIENTS AND METHODS

We conducted a prospective multicenter (n = 12) observational study in adult patients with solid neoplastic disease and receiving primary systemic treatment. We collected information on BIA-derived parameters: phase angle (PhA) <5th percentile of age and gender-specific normative values; standardized PhA (SPA) <-1.65; Nutrigram® <660 mg/24 h/m and <510 mg/24 h/m for males and females, respectively. The primary outcome and the key secondary were 1-year mortality and DLT (any-type severe toxicity requiring a delay in systemic treatment administration or a reduction of its dosage), respectively.

RESULTS

In total, 640 patients were included. At 12 months, death occurred in 286 patients (47.6%). All BIA-derived body composition parameters were independently associated with death: SPA, hazard ratio (HR) = 1.59 [95% confidence interval (CI) 1.30-1.95] (P < 0.001); PhA, HR = 1.38 (95% CI 1.13-1.69) (P = 0.002); Nutrigram®, HR = 1.71 (95% CI 1.42-2.04) (P < 0.001). DLT occurred in 208 patients (32.5%) and body composition parameters were associated with this outcome, particularly SPA: odds ratio = 6.37 (95% CI 2.33-17.44) (P < 0.001).

CONCLUSIONS

The study confirmed that BIA-derived body composition parameters are independently associated not only with survival but also with DLT. Although our findings were limited to patients receiving first-line systemic treatment, the evidence reported may have important practice implications for the improvement of the clinical work-up of cancer patients.

The Role of Combined Muscle Ultrasound and Bioimpedentiometry Parameters for Sarcopenia Diagnosis in a Population of Hospitalized Older Adults

BACKGROUND

For the study of quantitative and qualitative muscle parameters, ultrasound and bioelectric impedance analysis are reliable, non-invasive, and reproducible. The aim of this study was to test the combined role of those techniques for the diagnosis of sarcopenia in a population of hospitalized older males and females.

METHODS

A total of 70 subjects were recruited, including 10 healthy adults and 60 hospitalized elderly patients with a good level of independence and cooperation, with and without sarcopenia. The rectus femoris cross-sectional area (CSA), thickness, echogenicity, and compressibility were measured with ultrasound echography. The phase angles (PhAs) and skeletal muscle mass were calculated by bioimpedence analysis. The muscle quality index (MQI) was calculated as the product of CSA and PhA.

RESULTS

Muscle compressibility was greater and PhA was lower in sarcopenic when compared with non-sarcopenic subjects. The threshold values for sarcopenia diagnosis in both sexes of CSA, of PhA, and of the MQI were identified. The obtained CSA values showed an AUC of 0.852 for women and 0.867 for men, PhA of 0.792 in women and 0.898 in men, while MQI was 0.900 for women and 0.969 for men.

CONCLUSIONS

The newly calculated cut-off values of CSA, PhA, and MQI predicted the presence of sarcopenia with good sensitivity and specificity values. The use of the MQI proved to be more promising than the separate use of CSA and PhA in both male and female subjects.

Assessment of phase angle as a novel indicator for sarcopenic obesity according to the ESPEN/EASO criteria in older adults with diabetes mellitus

BACKGROUND

Sarcopenic obesity (SO) is a clinical condition in which sarcopenia and obesity occur together, and is associated with more poor clinical outcomes, increased mortality, and morbidity than sarcopenia. Phase angle (PhA), a parameter derived from bioimpedance analysis (BIA), provides data on cellular health, membrane integrity, and cellular function. This study aimed to evaluate the relationship between SO and PhA among older adults with type 2 diabetes mellitus (DM).

METHODS

We performed a cross-sectional study in a tertiary hospital, and all participants underwent a comprehensive geriatric assessment, the hand-grip strength test (HGST), the chair stand test (CST) for muscle strength evaluation, the 4-meter walking test, and the timed up-and-go (TUG) test for physical performance assessment. The diagnosis of SO was made according to the ESPEN/EASO criteria. The PhA was determined automatically by the BIA using resistance and reactance at 50 kHz for each participant.

RESULTS

A total of 322 participants were included in the study. The mean age of the participants was 72.5 ±5.8, and 203 (63%) of them were female; 63 (19.6%) of them were sarcopenic obese. In multivariable logistic regression analyses, a significant relationship was found when the model was adjusted for age, female gender, MNA-sf scores, HbA1c level, and CCI scores (OR: 0.53, 95%CI: 0.29-0.98, P = 0.04). In ROC analyses, for PhA in predicting SO diagnosis, the AUC was 0.586 (95%CI: 0.505-0.678, P = 0.033). At the cut-off score 4.4, sensitivity was 57.1% and specificity was 61.4%; positive predictive value (PPV) was 26.5%; negative predictive value (NPV) was 85.5%.

CONCLUSIONS

The study identified a significant relationship between SO and PhA among older adults with type 2 DM. However, larger prospective studies are needed to confirm the potential utility of PhA as a biomarker for SO.

Association between grip strength and electrical properties measured by bioimpedance spectroscopy in women with dementia aged 77 to 97 years living in group homes

Electrical properties estimated from the electrical resistance of the human body can serve as indicators of muscle tissue status and the risk of developing sarcopenia; however, to date, at least to the best of our knowledge, no studies have performed such an assessment in older individuals with advanced dementia. The present study examined the associations between grip strength, body composition and electrical properties using bioimpedance spectroscopy (BIS) in women aged 77-97 years residing in dementia group homes. A total of 33 participants were enrolled with an average age of 88.1±5.2 years; 57.6% of the participants had moderate or severe dementia. The resistance values of the participants were measured in the whole body, upper limbs and lower limbs using BIS, and their body composition, muscle mass index and electrical properties were estimated as indicators of muscle quality. In addition, grip strength was measured and the participants were classified into three groups (high, low and non-measurable) according to their cognitive function. The effect size (partial eta-squared and Cohen's d) was also evaluated. The Shapiro-Wilk test was used to assess the distribution of each variable; variables with non-normal distributions were analyzed following log transformation. Continuous variables were analyzed using a one-way analysis of variance and the Tukey-Kramer post hoc test was used. The post hoc sample size (statistical power: 1-β) analysis revealed a power of ~80% (i.e., 76.1-88.7%), considering the minimum power for sufficient participants. No differences were found in body composition or muscle mass index among the three grip strength groups. As regards the upper limbs, the electrical properties of the characteristic frequencies were significant (P=0.006; effect size, large), and the membrane capacitance (P=0.005; effect size, large) was significantly higher in the high-dose group than in the other groups. A significant association was detected among grip strength, upper limb characteristic frequency and membrane capacitance. Hence, electrical properties may be an indicator of muscle quality in older women identified as needing care for dementia.

Phase angle as a potential tool to evaluate chronic inflammatory state and predict quality of life deterioration in women with breast cancer and obesity: A narrative review

The interaction between lifestyle--defined more specifically in health care as the personal exposome--and its implications on obesity and breast cancer development highlights the critical role of body composition and inflammation in these patients. There is clear evidence that the personal and internal exposome triggers biochemical, inflammatory, and metabolic reprogramming, which might favor ectopic lipid accumulation within the body, such as muscles. Additionally, the presence of excessive adipose tissue exacerbates these alterations in the internal exposome, resulting in cell damage and modifying body composition. Understanding the nexus between these lifestyle-induced exposome modifications, such as inflammation, and the resultant changes in body composition is crucial to assess the association with breast cancer progression and treatment responses. Various techniques can be used to evaluate body composition; one of those most used currently is bioelectrical impedance analysis. This analysis provides parameters, including phase angle (PhA), by which cellular health and metabolic activity can be assessed. In addition, PhA is a potential indicator of nutritional status and disease prognosis, as it has been linked to survival and quality of life in patients with cancer. Therefore, PhA might be used in daily oncology practice to implement an accurate nutritional intervention, reducing side effects and complications of oncology management, and improving quality of life during treatment and survival, even in patients with breast cancer with obesity or overweight. The aim of this review is to analyze the existing information on the current application of PhA in patients with breast cancer and its potential use as a tool to assess inflammatory response, identify malnutrition, and predict the deterioration of quality of life so that it could be proposed as an early indicator for nutritional interventions in this group of patients.

Phase angle and its determinants among adolescents: influence of body composition and physical fitness level

To examine the association between levels of physical fitness, parameters of body composition and phase angle (PhA) amongst adolescents. A total of 152 adolescents (84 girls) aged 11-16 years were included in this study. Weight and height were measured and the body mass index (BMI) was calculated. Bioelectrical impedance analysis (BIA) provided resistance and reactance parameters to calculate fat-free mass (FFM), PhA and fat mass (%FM). The following physical fitness variables were analysed: flexibility, abdominal muscular endurance, upper and lower limb explosive strength, agility, speed and cardiorespiratory fitness. Generalized Linear Models were applied to verify differences across sexes. Stepwise linear regression was used to establish an association between the variables studied. The study established an association between PhA and weight, FFM, BMI, FM, %FM and medicine ball throw (MBT) for girls. As for the boys, an association was verified between PhA and weight, FFM, BMI, standing long jump (SLJ), MBT and the three allometric VO2peak variables analyzed. An association was found between PhA and the boys' 4-m shuttle run test (4SRT) and 20-m sprint test (20SRT). Boys showed a greater phase angle than girls; In girls, BMI and %FM, were determinant of 32.4% (r = 0.57). PhA variability which is influenced by physical fitness, body composition and, therefore, the tissues electrical conductivity. Furthermore, boys' height, FFM, upper limb strength, and agility account for 58.4% (r = 0.76) PhA variability. There was a positive correlation between the physical fitness tests and the PhA.

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.

Predicting the Risk of Morbidity by GLIM-Based Nutritional Assessment and Body Composition Analysis in Oncologic Abdominal Surgery in the Context of Enhanced Recovery Programs : The PHase Angle Value in Abdominal Surgery (PHAVAS) Study

BACKGROUND

Preoperative nutritional status and body structure affect short-term prognosis in patients undergoing major oncologic surgery. Bioimpedance vectorial analysis (BIVA) is a reliable tool to assess body composition. Low BIVA-derived phase angle (PA) indicates a decline of cell membrane integrity and function. The aim was to study the association between perioperative PA variations and postoperative morbidity following major oncologic upper-GI surgery.

PATIENTS AND METHODS

Between 2019 and 2022 we prospectively performed BIVA in patients undergoing surgical resection for pancreatic, hepatic, and gastric malignancies on the day before surgery and on postoperative day (POD) 1. Malnutrition was defined as per the Global Leadership Initiative on Malnutrition criteria. The PA variation (ΔPA) between POD1 and preoperatively was considered as a marker for morbidity. Uni and multivariable logistic regression models were applied.

RESULTS

Overall, 542 patients with a mean age of 64.6 years were analyzed, 279 (51.5%) underwent pancreatic, 201 (37.1%) underwent hepatobiliary, and 62 (11.4%) underwent gastric resections. The prevalence of preoperative malnutrition was 16.6%. The overall morbidity rate was 53.3%, 59% in those with ΔPA < -0.5 versus 46% when ΔPA ≥ -0.5. Age [odds ratio (OR) 1.11; 95% confidence interval (CI) (1.00; 1.22)], pancreatic resections [OR 2.27; 95% CI (1.24; 4.18)], estimated blood loss (OR 1.20; 95% CI (1.03; 1.39)], malnutrition [OR 1.77; 95% CI (1.27; 2.45)], and ΔPA [OR 1.59; 95% CI (1.54; 1.65)] were independently associated with postoperative complications in the multivariate analysis.

CONCLUSIONS

Patients with preoperative malnutrition were significantly more likely to develop postoperative morbidity. Moreover, a decrease in PA on POD1 was independently associated with a 13% increase in the absolute risk of complications. Whether proactive interventions may reduce the downward shift of PA and the complication rate need further investigation.

Association of Phase Angle Dynamics with Sarcopenia and Activities of Daily Living in Osteoporotic Fracture Patients

BACKGROUND

This study aimed to determine whether changes in phase angle during rehabilitation are associated with clinical outcomes such as activities of daily living (ADL), skeletal muscle mass index (SMI), and strength in patients with osteoporotic fractures.

METHODS

This retrospective observational study included patients with osteoporotic fractures admitted to convalescent rehabilitation wards. Changes in phase angle were defined as the difference between the phase angle values at discharge and on admission. The primary outcome was the Functional Independence Measure motor (FIM-motor) score at discharge. The secondary outcomes were SMI and handgrip strength at discharge. We used multivariate analysis to adjust for confounding factors and examine the association between changes in the phase angle and outcomes.

RESULTS

We analyzed a total of 115 patients (97 women, mean age of 81.0±10.0 years), with a median change in phase angle of 0° during hospitalization. We observed increased phase angles in 49 patients (43%), with a median increase of 0.2°. Multiple regression analysis showed that changes in phase angle were independently associated with FIM-motor score at discharge (β=0.238, p=0.027). Changes in phase angle were not significantly associated with SMI (β=0.059, p=0.599) or handgrip strength (β=-0.032, p=0.773) at discharge.

CONCLUSION

An increased phase angle during rehabilitation was positively associated with ADL improvement in patients with osteoporotic fractures. These findings may help clinicians make informed decisions regarding patient care and treatment strategies for better outcomes.

Standardized phase angle: relationship with functionality, muscle mass and postoperative outcomes in surgical cancer patients

To evaluate the association of standardized phase angle (SPA) with nutritional status, functional parameters, and postoperative outcomes in surgical cancer patients. This prospective study includes 59 cancer patients from Pelotas (Brazil) admitted for elective cancer surgery. We obtained the phase angle through Bioelectrical Impedance Analysis (BIA) and standardized it according to the population's reference values. We estimated the muscle mass using BIA for later calculation of the Skeletal Muscle Index (SMI) and performed handgrip strength (HGS) and gait speed (GS) tests. We used the Patient-Generated Subjective Global Assessment (PG-SGA) to assess the nutritional status. Postoperative complications and duration of hospital stay were evaluated as the outcomes. The prevalence of malnutrition in the sample was 28.8%, according to ASG-PPP. SPA was statistically lower in patients with malnutrition, with lower HGS and reduced GS. For postoperative outcomes, patients with severe complications and those with prolonged hospitalization also had lower SPA values. The greater the number of functional alterations in patients, the lower the SPA value, mainly when associated with reduced muscle mass assessed by BIA, suggesting that muscle mass reduction plays an important role in the association between functional alterations and phase angle in patients with cancer. According to the parameters used in this study, low SPA value was associated with impaired nutritional and functional status and negative outcomes in the analyzed sample.

Phase angle as a prognostic indicator in critically ill children: A systematic review

Phase angle (PhA) may reflect the integrity of cellular membranes, hydration status, and total body cell mass. Studies have shown that PhA can be used as a good predictor for evaluation of disease severity in critically ill adults. However, there is a lack of studies assessing the association between PhA and clinical outcomes in critically ill children. This systematic review described the association between PhA at pediatric intensive care unit (PICU) admission with clinical outcomes in critically ill children. The search was conducted using PubMed/Medline, Scopus, Web of Science, EMBASE and LILACS until July 22, 2022. Studies that evaluate the association between PhA at PICU admission in critically ill children and clinical outcomes were eligible. Data regarding population, study design, setting, bioelectrical impedance analysis (BIA) protocol used, PhA classification, and outcome analysis were extracted. Risk of bias was assessed by Newcastle-Ottawa Scale. Among the 4669 articles screened, five prospective studies were included. The studies have shown association between lower values of PhA at PICU admission with longer PICU and hospital length of stay, duration of mechanical ventilation, septic shock, and higher mortality risk. Small sample size, different clinical conditions, and methodological differences of the studies regarding BIA equipment and cutoffs of PhA were observed. Although the studies have limitations, the PhA has a potential role in predicting clinical outcomes in critically ill children. Larger studies with standardized PhA protocols and other relevant clinical outcomes are necessary.

A meta-analysis on the impact of resistance training on phase angle in middle-aged and older individuals

PURPOSE

To determine the impact of resistance training (RT) on phase angle (PhA) in middle-aged and older individuals via meta-analysis, explore effects in subgroups, and identify optimal RT protocol.

MATERIALS AND METHODS

We searched five databases using predefined criteria, assessed literature quality per Cochrane 5.1 Handbook, and used Revman 5.3 for effect size aggregation, bias assessment, sensitivity analysis, and subgroup analysis.

RESULTS

RT improved PhA in middle-aged and older individuals (d = 0.34, 95 % CI: 0.27-0.40, P < 0.05). Effective subgroups included Suspension (d = 0.62, 95 % CI: 0.33-0.90, P < 0.05), free-weights and machine (d = 0.36, 95 % CI: 0.28-0.45, P < 0.05), equipment training (d = 0.24, 95 % CI: 0.13-0.36, P < 0.05), and moderate-intensity RT (d = 0.34, 95 % CI: 0.27-0.42, P < 0.05). RT was conducted 2-3 times/week (d = 0.20, 95 % CI: 0.01-0.38, P < 0.05) or (d = 0.38, 95 % CI: 0.30-0.47, P < 0.05). PhA improved after 8 weeks (d = 0.37, 95 % CI: 0.23-0.51, P < 0.05), 12 weeks (d = 0.35, 95 % CI: 0.26-0.44, P < 0.05), and ≥ 24 weeks (d = 0.26, 95 % CI: 0.11-0.41, P < 0.05) of RT in aged and older individuals. Low- and high-intensity RT, elastic band training, and weekly exercises did not significantly improve PhA.

CONCLUSIONS

RT enhances PhA in middle-aged and older adults. For optimal results, we recommend 2-3 weekly sessions of free weights and machine training lasting at least 8 weeks.

Relationship between the phase angle from bioelectrical impedance analysis and daily physical activity in patients with rheumatoid arthritis

OBJECTIVES

This study aimed to examine the relationship between daily physical activity and the phase angle (PhA) obtained by bioelectrical impedance analysis in rheumatoid arthritis (RA) patients.

METHODS

Data from a prospective cohort study of RA patients who were surveyed every year were analysed. The PhA was assessed by the bioelectrical impedance analysis method, and physical activity was assessed as the amount of time of exercise in metabolic equivalents (METs) per day using a triaxial accelerometer for 7 consecutive days. The association between physical activity and the PhA was evaluated using the isotemporal substitution model in multiple regression analysis.

RESULTS

Seventy-six RA patients were included in the analysis (81% female and age 66.2 ± 13.1 years). On cross-sectional analysis, the isotemporal substitution model in multiple regression analysis showed that the PhA was 0.05 points higher every 10 minutes when activities with intensity of 1 ≤ METs < 2 were replaced by activities with intensity of ≥3 METs (P = .01). Over 1 year, the rate of change in the PhA was 0.69% higher every 10 minutes when activities with intensity of 1 ≤ METs < 2 were replaced by activities with intensity of ≥3 METs (P = .037).

CONCLUSION

The PhA in RA patients may be related to physical activity level.

Association between ICW/TBW ratio and cancer prognosis: Subanalysis of a population-based retrospective multicenter study

BACKGROUND & AIMS

Disease burden is known to alter cellular integrity and water balance. Therefore, the intracellular water/total body water (ICW/TBW) ratio is used as an adjunctive indicator to predict disease severity and prognosis. The ICW/TBW ratio of patients with cancer, who typically present with low muscle mass, poor nutritional status, and high inflammatory response, reportedly differs from that of the healthy population. Herein, we aimed to evaluate the effect of the ICW/TBW ratio on the prognosis of different subgroups of patients with cancer.

METHODS

This multicenter cohort study included 2787 patients with malignancies between June 2014 and December 2018. The association between covariates and overall survival (OS) was assessed using restricted cubic spline models. The multivariate Cox regression model included variables demonstrating a statistical significance in the univariate Cox regression analysis (P < 0.05) without multicollinearity. The generated nomogram used the C-index and calibration curves to validate the predictive accuracy of the scoring system.

RESULTS

The optimal cut-off value for the ICW/TBW ratio was 0.61. The ICW/TBW ratio was an independent prognostic factor (hazard ratio [HR]: 0.621; 95 % confidence interval [CI]: 0.537-0.719, P < 0.001). Moreover, the ICW/TBW ratio had a greater impact on the prognosis of patients receiving chemoradiotherapy than on those receiving chemotherapy alone (chemoradiotherapy: HR = 0.495, P = 0.005 vs. chemotherapy: HR = 0.646, P < 0.001). Multivariate Cox regression analysis showed that sex, age, tumor stage, body mass index, neutrophil-to-lymphocyte ratio (NLR), and ICW/TBW ratio were associated with OS. Subsequently, a nomogram was developed incorporating these variables and yielded a C-index of 0.743.

CONCLUSIONS

The ICW/TBW ratio was associated with muscle mass, nutritional status, and inflammation. A low ICW/TBW ratio is an independent risk factor for poor prognosis in patients with cancer, especially when they are female, have advanced cancer stage, have sarcopenia, and are receiving radiotherapy.

Preoperative Body Composition Correlates with Postoperative Muscle Volume and Degeneration after Total Hip Arthroplasty

Impaired muscle recovery after total hip arthroplasty (THA) may affect gait and activities of daily living. Bioelectrical impedance analysis (BIA) can assess body composition and muscle volume, and computed tomography (CT) can assess muscle volume and the fatty degeneration of muscle. This study aimed to explore the effectiveness of BIA, and the correlation between preoperative body composition and postoperative muscle volume and degeneration after THA using BIA and CT. Thirty-eight patients who underwent THA and had BIA and CT performed pre- and postoperatively were retrospectively assessed. The BIA-derived measurements of preoperative body composition (fat mass index, fat-free mass index, and phase angle) were correlated with the CT-derived measurements (pre- and postoperative muscle volume and gluteus maximus and quadriceps Hounsfield Units of the affected hip). The preoperative fat mass index negatively correlated with the postoperative muscle volume of the gluteus maximus (p = 0.02) and quadriceps (p < 0.001) and the Hounsfield Units of the gluteus maximus (p = 0.03) and quadriceps (p = 0.03). The preoperative fat-free mass index positively correlated with the postoperative muscle volume of the quadriceps (p = 0.02). The preoperative phase angle positively correlated with the postoperative muscle volume of the quadriceps (p = 0.001) and the Hounsfield Units of the gluteus maximus (p = 0.03) and quadriceps (p = 0.001). In patients who underwent THA, preoperative body composition correlated with postoperative muscle volume and the fatty degeneration of the affected lower limb. Preoperative body composition may help predict postoperative muscle volume and fatty degeneration and thus, postoperative recovery.

Physical and autonomic functionality in women with breast cancer pre and post chemotherapy: a case control study

BACKGROUND

Breast cancer (BC) is one of the most incident types of cancer among women in the world. Although chemotherapy is an effective way to treat several types of cancer, it may also cause serious complications, including cardiotoxicity. This study aimed to identify the impact of chemotherapy on functional capacity, muscle strength and autonomic function.

METHODS

Ten breast cancer patients in therapeutic follow-up (TG) and ten women without comorbidities (CG) participated in the study (46±8.87 years old). Both groups were evaluated at two time points, before and 20 weeks after the start of chemotherapy. Functional capacity and muscle strength were assessed by 6-minute walk test (6MWT) and handgrip test, respectively. Autonomic function was assessed by heart rate variability analysis.

RESULTS

TG presented greater reductions in the handgrip test for the non-dominant hand (TG ↓15.2%; CG: ↑1.1%, p<0.05) compared to GC. However, no significant differences were found regarding VO2max (p>0.05) and 6MWT total distance (p>0.05). Regarding the heart rate variability variables before and after follow-up period, rMSSD (CG= 39.15±37.66; TG= 14.89±8.28, p= 0.01) and SDNN (CG= 55.77±40.03; TG= 26.30±10.37, p= 0.02) showed effect in the group and time interaction, whereas the LF/HF ratio presented significant difference only in the time analysis (CG= 2.24±2.30; TG= 2.84±1.82, p= 0.04).

CONCLUSION

Chemotherapy used in the treatment of breast cancer patients resulted in decreased muscle strength and autonomic imbalance. The data suggests that chemotherapy may carry the risk of developing cardiovascular disease.

TRIAL REGISTRATION

Registration not required.

Bioelectrical Impedance Analysis (BIA) for the Assessment of Body Composition in Oncology: A Scoping Review

Bioelectrical Impedance Analysis (BIA) is a reliable, non-invasive, objective, and cost-effective body composition assessment method, with high reproducibility. This scoping review aims to evaluate the current scientific and clinical evidence on BIA for body composition assessment in oncology patients, under active treatment. Literature search was conducted through MEDLINE, CINAHL, Scopus and Web of Science databases, following PRISMA-ScR Guidelines. Inclusion criteria comprised studies reporting the use of BIA for body composition evaluation in adults with cancer diagnosis. Studies including non-cancer pathology or only assessing nutritional status were excluded. This scoping review comprised a total of 36 studies: 25 were original studies including 18 prospective studies, six cross-sectional studies and one retrospective study and 11 were systematic reviews. Population size for the included original articles ranged from 18 to 1217 participants, comprising a total of 3015 patients with cancer with a mean baseline Body Mass Index (BMI) ranging from 20.3 to 30.0 kg/m2 and mean age ranging between 47 and 70 years. Review articles included a total of 273 studies, with a total of 78,350 participants. The current review considered studies reporting patients with head and neck cancer (HNC) (n = 8), breast cancer (BC) (n = 4), esophageal cancer (EC) (n = 2), liver cancer (n = 2), pancreatic cancer (PC) (n = 3), gastric cancer (GC) (n = 3), colorectal cancer (CRC) (n = 8), lung cancer (LC) (n = 1), skin cancer (SK) (n = 1) and multiple cancer types (n = 6). BIA is a suitable and valid method for the assessment of body composition in oncology. BIA-derived measures have shown good potential and relevant clinical value in preoperative risk evaluation, in the reduction of postoperative complications and hospital stay and as an important prognostic indicator in persons with cancer. Future research on the diagnostic value and clinical applications of BIA and BIA-derived phase angle (PhA) should be conducted in order to predict its impact on patient survival and other clinical outcomes.

Phase angle, physical quality of life and functionality in cancer patients undergoing chemotherapy

INTRODUCTION

Nutritional deficiency, especially malnutrition, is frequent in cancer patients and is associated with changes in body composition, such as low muscle mass. Phase angle (PhA) has been used as a prognostic indicator and may be related to nutritional status, functionality, and quality of life in these patients. The objectives of this study were to assess the effect of chemotherapy treatment on PhA values, comparing the PhA variation before and after treatment, and to evaluate the PhA correlation, as a muscle mass surrogate, with the physical domain of quality of life, functionality, and nutritional risk in a sample of patients with cancer.

METHODS

A longitudinal study was conducted in patients with cancer undergoing chemotherapy for the first time. All patients aged 18 years or older, newly diagnosed, and undergoing chemotherapy for the first time were included. To analyze the difference in the PhA means according to the different classification variables, the t-test - or ANOVA - was used. The variation of the final and initial PhA was evaluated through the linear regression test.

RESULTS

A total of 175 patients were analyzed, of which 66.3% were female. The mean PhA of the initial assessment was significantly higher when compared to the final assessment of the patients PhA (p = 0.018). In both the initial and final assessments, PhA was correlated with the physical domain (r = 0.29; p < 0.001 and r = 0.19; p = 0.021) and with the functionality score (r = - 0.32; p < 0.001 and r = - 0.30; p < 0.001) and total PG-SGA (r = - 0.31; p < 0.001 and r = - 0.23; p = 0.006).

CONCLUSION

PhA can be considered a predictor of physical quality of life and functionality in cancer patients receiving chemotherapy treatment.

Do metal implants for total hip arthroplasty affect bioelectrical impedance analysis? A retrospective study

BACKGROUND

Evaluation of body composition after total hip arthroplasty (THA) is essential because it can be used to evaluate muscle and functional recovery. Muscle volume and degeneration are evaluated using computed tomography (CT). However, CT evaluation of muscle volume has several limitations, such as radiation exposure and high medical cost. Bioelectrical impedance analysis (BIA) has gained attention for resolving these limitations of CT. BIA takes advantage of the microelectric current; thus, metal implants may affect the results. Therefore, this study aimed to elucidate the effects of metal implants on BIA after THA.

METHODS

Two groups of patients were assessed (Group 1: 70 patients who underwent unilateral THA and BIA; Group 2: 35 patients who underwent THA and BIA before and after THA). Electric impedance (resistance and reactance) of the operated and non-operated lower limbs was compared in Group 1. The pre- and post-operative impedances of the torso and operated ipsilateral limbs were compared in Group 2.

RESULTS

Regarding electric impedance in Group 1, no significant differences were observed in electrical resistance and reactance between the operated and non-operated lower limbs. Concerning electric impedance in Group 2, postoperative electric resistance of the torso was significantly lower than that preoperatively. However, no significant difference was seen in electric resistance and reactance of the operated ipsilateral limbs preoperatively and postoperatively.

CONCLUSIONS

Electrical resistance and reactance of the limbs did not change significantly after THA. BIA is useful for measuring body composition after THA.

Early prediction of body composition parameters on metabolically unhealthy in the Chinese population via advanced machine learning

Background

Metabolic syndrome (Mets) is considered a global epidemic of the 21st century, predisposing to cardiometabolic diseases. This study aims to describe and compare the body composition profiles between metabolic healthy (MH) and metabolic unhealthy (MU) phenotype in normal and obesity population in China, and to explore the predictive ability of body composition indices to distinguish MU by generating machine learning algorithms.

Methods

A cross-sectional study was conducted and the subjects who came to the hospital to receive a health examination were enrolled. Body composition was assessed using bioelectrical impedance analyser. A model generator with a gradient-boosting tree algorithm (LightGBM) combined with the SHapley Additive exPlanations method was adapted to train and interpret the model. Receiver-operating characteristic curves were used to analyze the predictive value.

Results

We found the significant difference in body composition parameters between the metabolic healthy normal weight (MHNW), metabolic healthy obesity (MHO), metabolic unhealthy normal weight (MUNW) and metabolic unhealthy obesity (MUO) individuals, especially among the MHNW, MUNW and MUO phenotype. MHNW phenotype had significantly lower whole fat mass (FM), trunk FM and trunk free fat mass (FFM), and had significantly lower visceral fat areas compared to MUNW and MUO phenotype, respectively. The bioimpedance phase angle, waist-hip ratio (WHR) and free fat mass index (FFMI) were found to be remarkably lower in MHNW than in MUNW and MUO groups, and lower in MHO than in MUO group. For predictive analysis, the LightGBM-based model identified 32 status-predicting features for MUNW with MHNW group as the reference, MUO with MHO as the reference and MUO with MHNW as the reference, achieved high discriminative power, with area under the curve (AUC) values of 0.842 [0.658, 1.000] for MUNW vs. MHNW, 0.746 [0.599, 0.893] for MUO vs. MHO and 0.968 [0.968, 1.000] for MUO and MHNW, respectively. A 2-variable model was developed for more practical clinical applications. WHR > 0.92 and FFMI > 18.5 kg/m2 predict the increased risk of MU.

Conclusion

Body composition measurement and validation of this model could be a valuable approach for the early management and prevention of MU, whether in obese or normal population.

Phase angle as a marker of outcome in hospitalized pediatric patients. A systematic review of the evidence (GRADE) with meta-analysis

Phase angle (PhA) is a valuable tool for evaluating the nutritional and inflammatory status, which can accompany acute and severe disorders. PhA is a cellular health biomarker, whose value is particularly substantial due to the negative consequences of these situations in the pediatric population. Relevant literature was collected with the aim of comprehensively analysing the evidence on the association between an altered PhA can serve as a predictive-marker for mortality and poor-outcomes in at-risk-pediatric patients. Understanding this relationship could have significant implications for identifying high-risk individuals and implementing timely interventions. A systematic review with meta-analysis was conducted in the primary electronic databases from inception until January 2023. Overall, four studies with a total of 740 patients were eligible for our analysis. Evidence demonstrates that PhA is associated with nutritional status, reflecting undernutrition and changes in body composition related to illness. This review suggests that PhA can indeed be used as an indicator of nutritional status and a tool for predicting prognosis, including mortality and poor-outcomes, in hospitalized pediatric patients. A low PhA was associated with a significant mortality risk [RR:1.51;95%CI (1.22-1.88),p = 0.0002;I2 = 0%,(p = 0.99)] and an increased complications risk [OR:8.17;95%CI (2.44-27.4),p = 0.0007;I2 = 44%,(p = 0.18)]. These findings highlight the importance of taking a comprehensive approach to clinical nutrition, integrating multiple evaluation aspects to establish an accurate diagnosis and personalized therapeutic plans. While PhA emerges as a valuable tool for assessing the risk of malnutrition and as a prognostic-indicator for poor-outcomes in pediatric patients. Further future studies are needed to focus on investigating this relationship in larger and diverse population to strengthen the evidence base.

Association between Phase Angle and Body Composition of Children and Adolescents Diagnosed with HIV Infection

The aim of the study was to investigate how phase angle (PhA) is associated with subtotal and lumbar spine bone mineral density [BMD], lean soft tissue mass [LSTM], total body fat mass, android and gynoid in children and adolescents with HIV according to sex. A cross-sectional study was conducted in Florianópolis, Brazil, involving 64 children and adolescents vertically transmitted with HIV. Resistance and reactance values were obtained using bioelectrical impedance analysis, and PhA was subsequently calculated. Dual emission X-ray absorptiometry was used to assess body composition. Antiretroviral medication, physical activity (accelerometers) and skeletal maturation (wrist-carpal radiography) were used in the adjusted model. In males, PhA was directly associated with subtotal BMD (βadj: 0.65; R²: 0.38, p < 0.01) and lumbar spine BMD (βadj: 0.53; R²: 0.22, p = 0.01), directly associated with LSTM (βadj: 0.76; R²: 0.46, p < 0.01), and inversely associated with gynoid fat (βadj: -0.47; R²: 0.2, p = 0.01), in adjusted models. In females, PhA was directly associated with subtotal BMD (βadj: 0.46; R²: 0.17, p < 0.01) and lumbar spine BMD (βadj: 0.48; R²: 0.19, p < 0.01). It is concluded that PhA was directly associated with subtotal and regional BMD, LSTM, and inversely with gynoid fat in boys with HIV. In girls, PA was directly associated only with subtotal and regional BMD.

A Bioelectrical Impedance Analysis in Adult Subjects: The Relationship between Phase Angle and Body Cell Mass

The correct assessment of body composition is essential for an accurate diagnostic evaluation of nutritional status. The body mass index (BMI) is the most widely adopted indicator for evaluating undernutrition, overweight, and obesity, but it is unsuitable for differentiating changes in body composition. In recent times, bioelectrical impedance analyses (BIA) have been proven as a more accurate procedure for the assessment of body composition. Furthermore, the efficiency of bioelectrical impedance vector analyses, as an indicator of nutritional status and hydration, has been demonstrated. By applying a bioimpedance analysis, it is possible to detect fat mass (FM), fat free mass (FFM), phase angle, and body cell mass (BCM). It is important to point out that phase angle and BCM are strongly associated with health status. The aim of this research was to examine body composition and the association between the phase angle and BCM in 87 subjects (14 males and 73 females), aged between 23 and 54 years, with BMIs ranging from 17.0 to 32.0 kg/m2, according to sex. The BMI results revealed that the majority of the assessed subjects were within the normal range and had a normal percentage of FM. Our data indicate that a direct relation exists between phase angle and cellular health and that these values increase almost linearly. Consequently, a high phase angle may be related to increased BCM values.

An analysis of phase angle and standard phase angle cut-off values and their association with survival in head and neck cancer patients undergoing radiotherapy

OBJECTIVE

The objective of this study is to identify the cutoff values for phase angle (PA) and standard phase angle (SPA) parameters, as determined by bioelectrical impedance analysis (BIA), for predicting malnutrition and investigating their association with overall survival in head and neck cancer (HNC) patients undergoing radiotherapy.

METHODS

In this study, nutritional assessment and follow-up of HNC patients undergoing radiotherapy (RT) between November 2017 and September 2022 were assessed. Nutritional assessment, body composition (BC), and PA results obtained from BIA (Tanita MC-980) were retrospectively evaluated. Statistical Package for Social Sciences (SPSS) version 25.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. The results were evaluated at a confidence interval of 95% and a significance level of p ≤ 0.05.

RESULTS

A total of 53 patients, including 37 (70%) men and 16 (30%) women, with a median age of 60 (23-87 years) were included. The median follow-up time was 51 (range 24-59) months. The mean PA of the patients was calculated as 4.99° (±0.92, 95% CI: 4.74-5.25). The PA of patients with malnutrition (4.66° ± 0.87) was lower than that of well-nourished patients (5.71° ± 0.56) (p < 0.001). As a result of the ROC analysis based on this finding, the ideal PA cut-off point for determining the presence of malnutrition was found to be 5.65, with a sensitivity of 85%, specificity of 79%, accuracy of 83%, and a model discrimination power of excellent level (AUC: 85%, p < 0.001). The median overall survival time of the patients was calculated as 51 months (24-59 months). The mortality rate during the follow-up period was 13%, while the 1-, 3-, and 5-year overall survival rates of the patients were 96.1%, 89.3%, and 86.8%, respectively. Patients with SPA values less than -1.65 had a 5-year overall survival rate of 77.4%, while those with SPA values greater than or equal to -1.65 had a 5-year overall survival rate of 100% (p = 0.030) CONCLUSION: Our study recommends using PA and SPA as standard criteria for detecting malnutrition in HNC patients undergoing RT, with cut-off points of 5.65 and -1.65 respectively, to prevent treatment interruptions and improve outcomes. Further research is needed to validate the SPA cut-off value and its relationship with clinical outcomes, as SPA may be a more effective predictor of malnutrition and overall survival than PA alone.

Phase angle is related to oxidative stress and antioxidant biomarkers in breast cancer patients undergoing chemotherapy

PURPOSE

The study aimed to analyze the influence of chemotherapy on health biomarkers and examine the relationship between phase angle (PhA) and oxidative stress.

METHODS

A prospective study was performed. Women who were starting chemotherapy were recruited. Also, this study included a control group of women without cancer. Bioelectrical impedance multiple-frequency (BIS) analysis, 24h food recall, and blood samples were collected at 2-time points: diagnosis (T0) and after one month of completion of therapy (T1) for the main study group and one-time point for the control group. T-tests or Mann-Whitney Wilcoxon Test was used to compare variables. Linear regression analysis was conducted to test if PhA is related to the dependent variables after adjusting for age and body mass index.

RESULTS

119 women were included (61 with breast cancer and 58 healthy). There was no difference between the groups concerning anthropometrics, fat mass, and fat-free mass. Breast cancer patients had a worsening in PhA (p<0.001) after chemotherapy completion. PhA was positive statistically correlated with extracellular water, albumin, and the antioxidant markers at both times. The linear model showed that PhA was significantly predicted by C reactive protein, 2,2-Diphenyl-1-picrylhydrazyl (DPPH), Malondialdehyde (MDA), total body water/extracellular water, and body mass index fat mass. This model explained 58% of PhA variability (p<0.001).

CONCLUSION

Our findings show that PhA is an easy and affordable tool that correlates oxidative stress markers in breast cancer patients, regardless of age or body mass index.

Phase Angle, Handgrip Strength, and Other Indicators of Nutritional Status in Cancer Patients Undergoing Different Nutritional Strategies: A Systematic Review and Meta-Analysis

Malnutrition in cancer patients is one of the most influential factors in the evolution and mortality of such patients. To reduce the incidence of malnutrition, it is necessary to establish a correct nutritional intervention. For this purpose, precise tools and indicators must be developed to determine the patient’s condition. The main objective of this systematic review and meta-analysis was to analyze the relationship between different nutritional strategies, phase angle (PA), and handgrip strength in patients with cancer, with the secondary objectives being the modification of other indicators of nutritional status, such as weight and body mass index (BMI). A systematic review of randomized clinical trials was carried out in March 2023 in the databases PubMed, Web of Science, Cochrane, and Scopus. As a risk-of-bias tool, RoB 2.0 was utilized. A total of 8 studies with a total of 606 participants were included in the analysis. A significant increase in PA was observed after the different nutritional strategies (SMD: 0.43; 95% CI: 0.10 to 0.77; p = 0.01; I2 = 65.63%), also detecting a significant increase in handgrip strength (SMD: 0.27, 95% CI: 0.08 to 0.47; p = 0.01; I2 = 30.70%). A significant increase in PA and handgrip were observed in cancer patients subjected to different nutritional strategies. These results suggest that these indicators could be used in the nutritional and functional assessment of the patients.

Comparison of bioelectrical impedance analysis-derived phase angle in individuals with different weight status

OBJECTIVE

Obesity is characterized not only by an increase of fat mass but also by alterations in skeletal muscle. Bioimpedance analysis (BIA)-derived phase angle (PhA) may provide specific information on the inherent characteristics of fat-free mass, and is widely used as an index of poor nutritional status. The aim of this study was to describe whether and to what extent PhA varies depending on age, sex, and body mass index (BMI) in individuals with different weight status.

METHODS

We selected 1877 participants for this retrospective study (two weight status groups): 983 individuals with obesity (age 40 ± 13.9 y; BMI 39.5 ± 7.2 kg/m²) and 894 controls (age 40 ± 13.3 y; BMI 24.6 ± 2.7 kg/m²). Anthropometry and PhA at 50 kHz for the whole body were performed in all participants.

RESULTS

PhA was greater in men than in women, although a decline of PhA was observed with age, which was linear in women and occurred in men after 40 y of age. On the other hand, no significant differences were observed with increasing BMI in either sex; lower values might be observed when BMI >50 kg/m².

CONCLUSIONS

A more detailed appraisal of BIA-derived PhA in obesity is reported in the present study, providing basic data that might be taken into consideration in prevention and clinical nutrition. Further studies are needed to explore differences of PhA in individuals with different weight status.

Handgrip strength is correlated with activities of daily living, balance, and body composition in patients with thoracolumbar compression fracture

This study assessed the relationship between handgrip strength (HGS) and activities of daily living, balance, walking speed, calf circumference, body muscle, and body composition in elderly patients with thoracolumbar vertebral compression fracture (VCF). A cross-sectional study in a single hospital was performed with elderly patients diagnosed with VCF. After admission, we evaluated HGS, 10-meter walk test (speed), Barthel Index, Berg Balance Scale (BBS), numerical rating scale of body pain, and calf circumference. We examined skeletal muscle mass, skeletal muscle mass index, total body water (TBW), intracellular water, extracellular water (ECW), and phase angle (PhA) in patients with VCF using multi-frequency direct segmental bioelectrical impedance analysis after admission. A total of 112 patients admitted for VCF were enrolled (26 males, 86 females; mean age 83.3 years). The prevalence of sarcopenia according to the 2019 Asian Working Group for Sarcopenia guideline was 61.6%. HGS was significantly correlated with walking speed (P < .001, R = 0.485), Barthel Index (P < .001, R = 0.430), BBS (P < .001, R = 0.511), calf circumference (P < .001, R = 0.491), skeletal muscle mass index (P < .001, R = 0.629), ECW/TBW (P < .001, r = -0.498), and PhA (P < .001, R = 0.550). HGS was more strongly correlated with walking speed, Barthel Index, BBS, ECW/TBW ratio, and PhA in men than women. In patients with thoracolumbar VCF, HGS is associated with walking speed, muscle mass, activities of daily living measured using the Barthel Index, and balance measured using BBS. The findings suggest that HGS is an important indicator of activities of daily living, balance, and whole-body muscle strength. Furthermore, HGS is related to PhA and ECW/TBW.

Bioelectrical impedance analysis in patients with breast cancer-related lymphedema before and after lymphaticovenular anastomosis

OBJECTIVE

Bioelectrical impedance analysis (BIA) as a measure of lymphedema has been gaining popularity because of its measurement simplicity and noninvasiveness. This study was performed to investigate the effectiveness of BIA for assessment of the outcomes of lymphaticovenular anastomosis (LVA) in patients with breast cancer-related lymphedema.

METHODS

This study involved 25 patients with unilateral breast cancer-related lymphedema who underwent LVA. Segmental multifrequency BIA and conventional circumferential volume measurement were performed preoperatively and 6 months postoperatively from June 2018 to June 2021 at Hiroshima University Hospital International Center for Lymphedema. The patients' clinicopathological data, operative details, and preoperative and postoperative BIA results were investigated.

RESULTS

Segmental multifrequency BIA and circumferential volume measurement were strongly correlated in the lymphedema-affected upper limb both before and after LVA. The interlimb volume, interlimb extracellular water ratio (r = 0.784; P < .001), and interlimb extracellular water/total body water ratio were positively correlated (r = 0.612; P < .01), whereas the phase angle was negatively associated (r = -0.556; P < .01).

CONCLUSIONS

Segmental multifrequency BIA can be a useful tool for assessing the severity of lymphedema and monitoring the outcomes of LVA.

Association of indirect measurement of cell function by bioimpedance analysis with complications in oncologic hepatic surgery

BACKGROUND

Bioelectric impedance vector analysis (BIVA) is a reliable tool to assess body composition. The aim was to study the association of BIVA-derived phase angle (PA) and standardized PA (SPA) values and the occurrence of surgery-related morbidity.

METHODS

Patients undergoing hepatectomy for cancer in two Italian centers were prospectively enrolled. BIVA was performed the morning of surgery. Patients were then stratified for the occurrence or not of postoperative morbidity.

RESULTS

Out of 190 enrolled patients, 76 (40%) experienced postoperative complications. Patients with morbidity had a significant lower PA, SPA, body cell mass, and skeletal muscle mass, and higher extracellular water and fat mass. At the multivariate analysis, presence of cirrhosis (OR 7.145, 95% CI:2.712-18.822, p < 0.001), the Charlson comorbidity index (OR 1.236, 95% CI: 1.009-1.515, p = 0.041), the duration of surgery (OR 1.004, 95% CI:1.001-1.008, p = 0.018), blood loss (OR 1.002. 95% CI: 1.001-1.004, p = 0.004), dehydration (OR 10.182, 95% CI: 1.244-83.314, p = 0.030) and SPA < -1.65 (OR 3.954, 95% CI: 1.699-9.202, p = 0.001) were significantly and independently associated with the risk of complications.

CONCLUSION

Introducing BIVA before hepatic resections may add valuable and independent information on the risk of morbidity.

Phase angle, muscle tissue, and resistance training

The biophysical response of the human body to electric current is widely appreciated as a barometer of fluid distribution and cell function. From distinct raw bioelectrical impedance (BIA) variables assessed in the field of body composition, phase angle (PhA) has been repeatedly indicated as a functional marker of the cell's health and mass. Although resistance training (RT) programs have demonstrated to be effective to improve PhA, with varying degrees of change depending on other raw BIA variables, there is still limited research explaining the biological mechanisms behind these changes. Here, we aim to provide the rationale for the responsiveness of PhA determinants to RT, as well as to summarize all available evidence addressing the effect of varied RT programs on PhA of different age groups. Available data led us to conclude that RT modulates the cell volume by increasing the levels of intracellular glycogen and water, thus triggering structural and functional changes in different cell organelles. These alterations lead, respectively, to shifts in the resistive path of the electric current (resistance, R) and capacitive properties of the human body (reactance, Xc), which ultimately impact PhA, considering that it is the angular transformation of the ratio between Xc and R. Evidence drawn from experimental research suggests that RT is highly effective for enhancing PhA, especially when adopting high-intensity, volume, and duration RT programs combining other types of exercise. Still, additional research exploring the effects of RT on whole-body and regional BIA variables of alternative population groups is recommended for further knowledge development.

The use of phase angle in patients with digestive and liver diseases

Diseases of the liver and the digestive system can lead to malnutrition through an action of reduced food intake or nutrient use, inflammation and impaired metabolism, which result in substantial changes in body composition. Frequently, malnutrition manifests itself with weight loss and reduced muscle mass. However, weight loss and body mass index lack sensitivity to detect the loss of muscle mass and are not informative in distinguishing body water compartments and in characterizing their distribution. This issue is particularly relevant to these two disease models, which are frequently associated with fluid volume imbalances. Phase angle is a useful indicator for cell membrane integrity, water distribution between the intracellular and extracellular spaces and prediction of body cell mass as it is described by measured components of electrical impedance. Malnutrition, inflammation and oxidative stress impair electric tissue properties leading to lower values of PhA. In patients with inflammatory bowel and liver diseases, PhA was consistently found to be related to nutritional status and body composition, particularly the depletion of lean body mass and sarcopenia. It has been associated with prognosis, disease stage and severity and found to be helpful in monitoring fluid shifts and response to interventions.

Utility of the Global Leadership Initiative on Malnutrition criteria for the nutritional assessment of patients with end-stage renal disease receiving chronic hemodialysis

BACKGROUND

Malnutrition is associated with adverse outcomes in patients on chronic haemodialysis. Thus, identifying accurate methods for diagnosing malnutrition is essential. The present retrospective study investigated the utility of the new Global Leadership Initiative on Malnutrition (GLIM) criteria in patients undergoing chronic haemodialysis.

METHODS

Phase angle and fat-free mass index (FFMI) were derived using bioelectrical impedance analysis. Malnutrition was determined when the subjects had at least one phenotypic criterion (weight loss, low body mass index [BMI] or FFMI).

RESULTS

This study included 103 patients undergoing chronic haemodialysis and 46 (44.7%) patients were diagnosed as malnourished. Malnutrition determined using the GLIM criteria was associated with increased risks of all-cause death (hazard ratio = 3.0, p = 0.044) and infection requiring hospitalisation (hazard ratio = 2.4, p = 0.015), independent of age, sex and comorbidities. However, malnutrition was not related to major adverse cardiovascular events (p = 0.908). We further evaluated the longitudinal changes in phenotypic parameters. Subjects with median levels of high-sensitivity C-reactive protein exceeding 5 mg L^-1 exhibited decreased body weight and BMI (p = 0.015 and 0.016, respectively). In addition, body weight, BMI and FFMI were reduced in subjects with a median protein catabolic rate of < 1.0 mg kg^-1 day^-1 , even after adjustment for age, sex and comorbidities (p = 0.026, 0.053 and 0.039, respectively).

CONCLUSIONS

Malnutrition assessed using the GLIM criteria could be a useful predictor of mortality and infection in patients on chronic haemodialysis. To improve nutritional status, approaches for decreasing inflammation and increasing protein intake are needed.

Phase angle in assessment and monitoring treatment of individuals with respiratory disease

Phase angle (PhA) represents a raw variable measured with bioelectrical impedance analysis (BIA) that is used to assess malnutrition in many diseases, including respiratory diseases, mainly chronic obstructive pulmonary disease (COPD). COPD patients with reduced PhA are older, more hypoxic and hypercapnic; patients with more severe COPD have reduced cell mass, evident skeletal muscle depletion, and worsening gas exchange. Malnourished patients with stable COPD in long-term oxygen therapy (LTOT) have more intense dyspnea at rest, greater weight loss over the past 12 months, and more exacerbations per year. Multiple regression analysis highlighted the significance of PhA° in the estimation of muscle strength: hand grip strength (HGS) and in that of respiratory muscles: maximal inspiratory pressure / max. expiratory pressure ratio (MIP/MEP). Furthermore, the relationship between PhA° and all-cause mortality in COPD patients was confirmed with the Cox regression model, Kaplan-Meier test, and log-rank tests. The role of malnutrition in idiopathic pulmonary fibrosis (IPF) is confirmed by the PhA° measurements which, regardless of body weight, is associated with the reduction in muscle mass of these patients, reduces their strength and exercise capacity, and greatly influences the prognosis. In conclusion PhA is a novel biomarker of morbidity and mortality in patients with severe respiratory diseases.

Expert Consensus on Morphofunctional Assessment in Disease-Related Malnutrition. Grade Review and Delphi Study

Disease-related malnutrition (DRM) affects approximately a third of hospitalized patients and is associated with an increased risk of morbimortality. However, DRM is often underdiagnosed and undertreated. Our aim is to evaluate the prognostic value of morphofunctional tools and tests for nutritional assessment in clinical practice. A systematic literature review was conducted to identify studies relating to the morphofunctional assessment of nutritional status and mortality or complications. Evidence was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) method. Twelve GRADE recommendations were made and divided into seven topics: food intake and nutrient assimilation, anthropometry, biochemical analysis, hand grip strength, phase angle, muscle imaging, and functional status and quality of life. From these recommendations, 37 statements were developed and scored in a two-survey Delphi method by 183 experts. A consensus was reached on accepting 26/37 statements. Surveys had high internal consistency and high inter-rater reliability. In conclusion, evidence-based recommendations were made on the prognostic value of morphofunctional assessment tools and tests to assess malnutrition, most of which were found to be feasible in routine clinical practice, according to expert opinions.

Validation of bioelectrical impedance analysis in the evaluation of body composition in patients with breast cancer

BACKGROUND

The evaluation of body composition is an essential parameter for preventing obesity and sarcopenic obesity, which are prognostic factors in breast cancer. This study aims to validate the bioelectrical impedance analysis (BIA) of women who are breast cancer survivors by using the dual-energy x-ray absorptiometry (DXA) measurement method.

METHODS

This validation study included 104 women without metastasis between 32 and 72 years old (mean 47.03 ± 8.59) whose treatment was completed 6 months prior. Body composition analysis was performed sequentially using both measurements and when participants were hungry.

RESULTS

Meaningful differences were found in fat-free mass (FFM) (BIA: 46.57 ± 5.54 kg; DXA: 41.06 ± 5.11 kg), body fat percentage (%BF) (BIA: 34.28% ± 6.24%; DXA: 43.91% ± 5.58%), body fat mass (FM) (BIA: 25.37 ± 8.84 kg; DXA: 31.24 ± 9.09 kg), and lean soft tissue mass (LSTM) (BIA: 4.42 ± 5.66 kg; DXA: 38.75 ± 4.98 kg) (P < 0.001). Powerful associations for body FM and strong associations for other parameters were seen. A constant and/or proportional error was found between the two devices within the direction of strong and solid components. Compared with DXA, the BIA measurement gives a lower estimate of %BF and FM and a higher estimate of LSTM and FFM.

CONCLUSIONS

By the mathematical relationship between the two measurement methods, it seems possible to adapt the body composition parameters obtained from BIA of patients with breast cancer to DXA results. In the future, there will be a need to evaluate these two devices with more extensive studies.

Relationship among Body Composition, Adipocytokines, and Irisin on Exercise Capacity and Quality of Life in COPD: A Pilot Study

Adipose tissue is an endocrine organ that interferes with the severity of chronic obstructive pulmonary disease (COPD). Although inflammatory markers, body composition, and nutritional status have a significant impact on pulmonary function, the real contribution of adipocytokines and myokines in COPD is still controversial. We aimed to evaluate the role played by the body composition, leptin, adiponectin, haptoglobin, and irisin on the functional exercise capacity, respiratory function, and quality of life (QoL) in COPD. In 25 COPD (20% GOLD-1; 60% GOLD-2; 20% GOLD-3) patients and 26 matched control subjects, we find that leptin, total adiponectin and haptoglobin are significantly increased whereas the 6 min walk test (6MWT) and physical functioning scores are significantly decreased in COPD versus controls. A significant positive relationship is found between leptin and fat mass and between 6MWT and the good health indicators of nutritional status. A significant inverse relationship is found between 6MWT and leptin and fat mass, FEV₁ and haptoglobin, and irisin and haptoglobin. Phase angle and leptin level are significant predictors for functional exercise capacity assessed with 6MWT. Taken altogether, the results of this pilot study further support the role played by body composition and adipocytokines on exercise capacity respiratory function and QoL in COPD.

The Role of Standardized Phase Angle in the Assessment of Nutritional Status and Clinical Outcomes in Cancer Patients: A Systematic Review of the Literature

Compared with the phase angle (PA), the predictive ability of the standardized phase angle (SPA) in assessing nutritional status and clinical outcomes in cancer patients remains uncertain. This review aimed to assess (1) the relationship between SPA and nutritional status and clinical outcomes (including complications and survival) in cancer patients; (2) the predictive ability of SPA alone and in comparison with the predictive ability of PA; and (3) the cut-off value of SPA in cancer patients. Studies that addressed the relationship of SPA use to nutritional status, complications, and survival in cancer patients were searched and identified from six electronic databases (PubMed, Medline, CINAHL, Embase, Web of Science, and the Cochrane Library). The included studies were considered to meet the following criteria: English studies with original data that reflected the effects of SPA on nutritional status and clinical outcomes (including complications and survival) and reported a cut-off value of SPA in cancer patients aged ≥18. Thirteen studies that included a total of 2787 participants were evaluated. Five studies assessed the relationship between SPA and nutritional status, and four of them reported a positive relationship between SPA and nutritional status in cancer patients, even considering SPA as a predictor. Twelve studies assessed the relationship between SPA and clinical outcomes in cancer patients. Two-thirds of the studies that evaluated complications reported the predictive ability of SPA; 30% of survival studies reported a positive relationship, 40% reported SPA as a predictor, and 30% reported no relationship. The standard cut-off value for SPA has not yet been determined. Data from the selected studies suggest that SPA might be a predictor of nutritional status. Further studies are needed to determine the value of SPA in predicting nutritional status and clinical outcomes in cancer patients.

Sex differences in the association of phase angle and lung cancer mortality

Background

Lung cancer is a lethal malignant tumor that is common worldwide and is associated with a high incidence of malnutrition. Phase angle (PA) is a simple, objective, and non-invasive indicator of body composition that has increasingly attracted attention as an indicator of the nutritional status and prognosis of patients with malignant tumors. This study aimed to investigate the association between the PA and overall survival in patients with lung cancer.

Methods

This study prospectively analyzed 804 lung cancer patients in the Investigation on Nutrition Status and its Clinical Outcome of Common Cancers (INSCOC) project from 40 hospitals in China. We used a restricted cubic spline to analyze the sex-specific association between PA and mortality in men and women with lung cancer. Cox regression analysis was used to evaluate the independent association between PA and mortality in men and women. Sensitivity analysis was performed. The Kaplan-Meier method was used to evaluate the survival of patients with high and low PA values.

Results

There was an L-shaped association between PA and survival in both men and women with lung cancer (p = 0.019 and p = 0.121, respectively). Kaplan-Meier survival analysis suggested that patients with a high PA showed a better survival than patients with a low PA (p = 0.007 for men and p < 0.001 for women). Multivariate-adjusted Cox regression analysis showed that PA was an independent risk factor for mortality in men (HR = 0.79, 95% CI = 0.65-0.95, p = 0.015), but not in women (HR = 0.83, 95% CI = 0.67-1.04, p = 0.105).

Conclusion

Phase angle is an independent risk factor for the mortality of male lung cancer patients. However, its role in predicting the mortality of female lung cancer patients seems to be limited.

Phase angle derived from bioelectrical impedance analysis as a marker for predicting sarcopenia

Sarcopenia is commonly defined as the age-related loss of muscle mass and function and may be caused by several factors, such as genetics, environmental conditions, lifestyle, drug use, and, in particular, comorbidities. People with pre-existing conditions are more likely to develop sarcopenia and subsequently have a less favorable prognosis. Recently, phase angle (PhA), which is derived from bioelectrical impedance analysis (BIA), has received a great deal of attention, and numerous studies have been carried out to examine the relationship between PhA and sarcopenia in different conditions. Based on these studies, we expect that PhA could be used as a potential marker for sarcopenia in the future.

Phase angle and cellular health: inflammation and oxidative damage

Phase angle is a composite measure that combines two raw bioelectrical impedance analysis measures: resistance and reactance. Phase angle has been considered an indicator of cellular health, integrity, and hydration. As inflammation and oxidative stress can damage cellular structures, phase angle has potential utility in early detecting inflammatory and oxidative status. Herein, we aimed to critically review the current understanding on the determinants of phase angle and its relationship with markers of inflammation and oxidative stress. We also discussed the potential role of phase angle in detecting chronic inflammation and related adverse outcomes. Several factors have been identified as predictors of phase angle, including age, sex, extracellular to intracellular water ratio, and fat-free mass. In addition to these factors, body mass index (BMI) also seems to influence phase angle. Available data also show that lower phase angle values are correlated (negligible to high correlation coefficients) with higher c-reactive protein, tumour necrosis factor-α, interleukin-6, and interleukin-10 in studies involving the general and aging populations, as well as patients with chronic conditions. Although fewer studies have evaluated the relationship between phase angle and markers of oxidative stress, available data also suggest that phase angle has potential to be used as an indicator (for screening) of oxidative damage. Future studies including diverse populations and bioelectrical impedance devices are required to confirm the validity and accuracy of phase angle as a marker of inflammation and oxidative stress for clinical use.

Phase Angle Association with Dietary Habits and Metabolic Syndrome in Diabetic Hypertensive Patients: A Cross-Sectional Study

Phase angle (PhA) levels are often lower than normal because both disease-specific parameters and disease-related inflammatory status, metabolic syndrome (MetS) included, can affect PhA. Therefore, the aim of this cross-sectional study was to compare body composition, metabolic profile and dietary patterns of participants with arterial hypertension (AH), type 2 diabetes mellitus (T2DM) and MetS with regard to PhA values. A total of 208 participants were included, of whom 53.6% were males. For each participant, data about body composition and anthropometric parameters, clinical and laboratory parameters, as well as food frequency questionnaire (FFQ) and Mediterranean Diet Serving Score (MDSS) were obtained. MC-780 Multi Frequency Segmental Body Mass Analyzer (Tanita) was used to assess body composition. Furthermore, waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) were calculated. The results showed that 75 (36.06%) participants had low PhA values and 133 (63.94%) had high PhA values. Participants with higher PhA values had significantly higher body fat percentage (p = 0.04), fat-free mass (kg; p < 0.001), muscle mass (kg; p < 0.001), skeletal muscle mass (% and kg; p < 0.001), sarcopenic index (SMI; p < 0.001) and mid-upper arm circumference (MUAC; p = 0.04), as well as lower fat mass percentage (p = 0.04). Regarding food frequency consumption, significantly higher intakes of red meat (p = 0.003), poultry (p = 0.02) and fast food (p = 0.003) were noticed in participants with higher PhA values. Adherence to the Mediterranean Diet (MeDi) was exceptionally low in both groups of participants, with significantly higher fish intake noticed in participants with high PhA (p = 0.03). In conclusion, our results showed that body composition could be the indicator of PhA in MetS as well as overall low adherence to the MeDi principles. These findings highlight the importance of adequate nutritional strategies and novel approaches to maintaining optimal body composition and adopting proper eating habits within the framework of one’s disease.

Phase Angle as a Predictor for Physical Function in Institutionalized Independent Older Adults

The aim of this study was to investigate the relationship between phase angle (PhA) and physical function in institutionalized, independent older adults. Physical function was evaluated using the Senior Fitness Test Battery. PhA was measured by electrical bioimpedance at 50 khz, and body composition parameters were also registered. Results showed that PhA significantly correlated with all physical fitness tests, except for arm curls. Regarding the results of the multivariate analysis, three models were created: Model 1, formed by a dependent variable "PhA" and two predictor variables "8 ft up-and-go" and "6 min walk"; Model 2, formed by a dependent variable "PhA" and three predictor variables "8 ft up-and-go", "6 min walk" and "30-s chair stand"; and Model 3, formed by a dependent variable "PhA" and four predictor variables "8 ft up-and-go", "6 min walk", "30-s chair stand" and "arm curl". Results showed that predictor variables had a significant influence on the PhA for all three models (Model 1: p = 0.001, 12.5%; Model 2: p = 0.002, 12.9%; and Model 3: p = 0.005, 13.1%). For women, Model 1 showed a significant influence of predictor variables on the PhA (p = 0.030, 9.3%). The results for men in Models 1, 2 and 3 showed significant influences on the PhA (p = 0.002, 31.2%; p = 0.006, 31.6%; and p = 0.016, 31.6%; respectively). This study confirmed previous studies regarding to the relationship between PhA and physical function. It also indicates that PhA could be an excellent predictor of physical function.

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.

Dietary Interventions in Cancer Treatment and Response: A Comprehensive Review

Simple Summary

Chemotherapy and radiotherapy are essential components to the management of most solid malignancies. These modalities exert their effects primarily by mediating the DNA damage of malignant cells; however, healthy cells are also damaged by the same mechanisms and can incur acute and late side effects resulting in both morbidity and mortality. Dietary interventions have been shown to reduce cancer growth, progression, and metastasis in many different solid tumor models and they show promise for improving cancer outcomes in early phase clinical studies. Here, we review preclinical and clinical studies that examine how dietary interventions can impact cancer treatment toxicity and efficacy in patients who were undergoing chemotherapy and/or radiotherapy. This information can help clinicians tailor the dietary regimens to patients based on their treatment methods and promote larger clinical trials to test the dietary effects on cancer treatment safety and efficacy.

Abstract

Chemotherapy and radiotherapy are first-line treatments in the management of advanced solid tumors. Whereas these treatments are directed at eliminating cancer cells, they cause significant adverse effects that can be detrimental to a patient’s quality of life and even life-threatening. Diet is a modifiable risk factor that has been shown to affect cancer risk, recurrence, and treatment toxicity, but little information is known how diet interacts with cancer treatment modalities. Although dietary interventions, such as intermittent fasting and ketogenic diets, have shown promise in pre-clinical studies by reducing the toxicity and increasing the efficacy of chemotherapeutics, there remains a limited number of clinical studies in this space. This review surveys the impact of dietary interventions (caloric restriction, intermittent and short-term fasting, and ketogenic diet) on cancer treatment outcomes in both pre-clinical and clinical studies. Early studies support a complementary role for these dietary interventions in improving patient quality of life across multiple cancer types by reducing toxicity and perhaps a benefit in treatment efficacy. Larger, phase III, randomized clinical trials are ultimately necessary to evaluate the efficacy of these dietary interventions in improving oncologic or quality of life outcomes for patients that are undergoing chemotherapy or radiotherapy.

Phase angle obtained via bioelectrical impedance analysis and objectively measured physical activity or exercise habits

The phase angle (PhA), measured via bioelectrical impedance analysis, is considered an indicator of cellular health, where higher values reflect higher cellularity, cell membrane integrity, and better cell function. This study aimed to examine the relationship between PhA and exercise habits or objectively measured physical activity. We included 115 people aged 32-69 years. The body composition and PhA were measured using a bioelectrical impedance device. Physical activity and sedentary behavior (SB) were assessed using a triaxial accelerometer. Exercise habits were also obtained through structured interviews, and participants were categorized into the no exercise habit (No-Ex), resistance training exercise habit (RT), or aerobic training exercise habit (AT) groups. Objectively measured moderate-to-vigorous physical activity or step count significantly correlated with PhA, independent of age, sex, height, percent body fat, body cell mass, and leg muscle power. In contrast, SB was not significant determinants of PhA. People who exercised regularly (RT or AT) had significantly higher PhA values than did those in the No-Ex group. Furthermore, the PhA was not significantly different between the RT and AT groups. Regularly engaging in exercise with moderate-to-vigorous intensity may improve or maintain muscle cellular health and muscle quality.

Correlation of the Phase Angle with Muscle Ultrasound and Quality of Life in Obese Females

Introduction. Phase angle (PhA) has been suggested to be an indicator of body cell mass and nutritional status. Clinically, the phase angle supposedly reflects body cell mass and cell membrane function, and the higher the phase angle, the better is the cell function. Muscle ultrasound (US) is an emerging nutritional assessment technique. Objective. The aim of this study was to investigate the usefulness and correlation of PhA with muscle US of quadriceps rectus femoris (QRF) in obese female subjects and the relationship with quality of life and physical performance. Material and Methods. In a total of healthy 50 obese female patients, anthropometric data by BIA, muscle mass by ultrasound at the QRF level, analytical determination, blood pressure, and quality of life were measured. Physical performance was assessed, too. Results. In total, 50 female obese patients were included with a mean age of 45.9 ± 2.4 years. The mean body mass index was 32.1 ± 1.6 kg/m2 with a mean weight of 83.5 ± 14.6 kg. Correlation analysis showed a positive correlation of PhA with all US parameters corrected by squared height (anteroposterior muscle thickness, circumference, cross-sectional area, and Echo-intensity). The correlation analysis of biochemical parameters with PhA showed a positive correlation with serum albumin and total protein levels. Physical activity and vitality scores of SF36 were correlated with PhA. Finally, PhA was positive correlated with physical performance, doing push-ups in 30 seconds ( $r$  =0.42; $p$  =0.03) and doing squats in 30 seconds ( $r$  =0.54; $p$  =0.02), without correlation with the time of 1.5 km walk. Conclusion. PhA was correlated with muscle area, muscle circumference, muscle echo intensity, serum protein, quality of life SF-36, and strength physical performance.

Phase Angle, a Cornerstone of Outcome in Head and Neck Cancer

In patients with head and neck cancer, malnutrition is common. Most cases are treated by chemo-radiotherapy and surgery, with adverse effects on the aerodigestive area. Clinical and biochemical characteristics, health-related quality of life, survival, and risk of death were studied. The selected subjects were divided into normal- and low-phase-angle (PA) groups and followed up for at least two years. Mean ages were 67.2 and 59.3 years for low and normal PA, respectively. Patients with PA < 4.42° had significant differences in age, anthropometric and biochemical indicators of malnutrition, and inflammatory status compared to patients with PA > 4.42°. Statistical differences were found in the functional and symptom scales, with lower functional scores and higher symptom scores in patients with low PA. Median survival was 19.8 months for those with PA < 4.42° versus 34.4 months for those with PA > 4.42° (p < 0.001).The relative risk of death was related to low PA (2.6; p < 0.001). The percentage of living patients (41.7%) is almost the same as the percentage of deceased subjects (43.1%; p = 0.002), with high death rates in patients with PA < 4.42°. Phase angle was the most crucial predictor of survival and a risk factor for death in the studied cases.