Nutrition Status and Health-Related Quality of Life Among Outpatients With Advanced Head and Neck Cancer.

This pilot study evaluated nutrition status and health-related quality of life (HRQOL) outcomes among outpatients with head and neck cancer (HNC). Data were collected from 19 patients (18 males, 1 female) during 3 time points: once before chemoradiotherapy (CRT) initiation and 1 and 3 months after CRT. Nutrition status was evaluated using the Scored Patient-Generated Subjective Global Assessment (PG-SGA). Malnutrition was defined as PG-SGA stage B (moderate/suspected malnutrition) or stage C (severely malnourished). HRQOL was assessed through the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its HNC-specific module (QLQ-H&N35). We found that well-nourished patients reported having fewer issues with pain, fatigue, appetite loss, chewing, sticky saliva, coughing, and social eating than those categorized as malnourished (P < .05). The association between the global quality-of-life score and PG-SGA score was statistically significant but weak in strength (r = -0.37, P = .012). Although PG-SGA identified 70% as either moderately or severely malnourished before treatment initiation, the mean body mass index was in the overweight category (29 ± 5 kg/m2 ). Compared with pretreatment, patients reported more severe problems with chewing, swallowing, sticky saliva, dry mouth, speech, social eating, and taste and smell sensations at 1-month follow-up, although issues with dry mouth persisted 3 months post treatment (P = .003). In conclusion, malnourished patients reported having worse HRQOL symptoms compared with well-nourished patients. Routine nutrition and psychosocial assessment through PG-SGA and EORTC tools might help identify patients in need of nutrition and psychosocial care.

Impact of Software Selection and ImageJ Tutorial Corrigendum on Skeletal Muscle Measures at the Third Lumbar Vertebra on Computed Tomography Scans in Clinical Populations.

BACKGROUND: There is growing interest in computed tomography (CT) measures of skeletal muscle cross-sectional area (CSA) for nutrition assessment. Multiple software programs are available, but little work has been done comparing programs. We aimed to determine if CT-derived measures of skeletal muscle CSA at the level of the L3 are influenced by the software program used. We also demonstrate the importance of the ImageJ corrigendum published in this journal. METHODS: Two software programs, National Institutes of Health ImageJ and Tomovision sliceOmatic, were compared. ImageJ measures were obtained using both the original tutorial and corrigendum instructions. Skeletal muscle CSA at the level of the L3 was measured in advanced heart failure and head and neck cancer populations by 3 different investigators. Intraclass correlation coefficients were used to calculate intrarater and interrater reliability. Bland-Altman analysis was used to assess agreement. RESULTS: Both software programs yielded excellent intrarater and interrater reliability scores (intraclass correlation coefficients, 0.985-1.000). The overall mean difference (ImageJ tutorial with corrigendum - sliceOmatic) for the entire sample (N = 51) was found to be 1.53 cm2 (95% CI, 0.59-2.47 cm2 ). The overall mean difference (ImageJ corrected - original) for the entire sample (N = 51) was found to be -11.35 cm2 (95% CI, -12.75 to -9.95 cm2 ). CONCLUSION: Measures of skeletal muscle CSA at the L3 were found to be ∼1.53 cm2 higher with ImageJ than sliceOmatic. This difference was not found to affect interpretation against a published cut point. The importance of accounting for the ImageJ tutorial corrigendum was shown to be clinically significant when applied to published cut points.

Protein in the Hospital: Gaining Perspective and Moving Forward.

Provision of adequate protein is crucial for optimizing outcomes in hospitalized patients. However, the methodologies upon which current recommendations are based have limitations, and little is known about true requirements in any clinical population. In this tutorial, we aim to give clinicians an understanding of how current protein recommendations were developed, an appreciation for the limitations of these recommendations, and an overview of more sophisticated approaches that can be applied to better define protein requirements. A broader perspective of the challenges and opportunities in determining clinical protein requirements can help clinicians think critically about the individualized nutrition care they provide to their patients with the goal of administering adequate protein to optimize outcomes.

Malnutrition Identified by the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition Consensus Criteria and Other Bedside Tools Is Highly Prevalent in a Sample of Individuals Undergoing Treatment for Head and Neck Cancer.

BACKGROUND: Using the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition (Academy/ASPEN) Consensus malnutrition definition, we estimated malnutrition prevalence in a sample of individuals with head and neck cancer (HNC) and compared it with the Patient-Generated Subjective Global Assessment (PG-SGA). We also investigated the utility of the 50-kHz phase angle (PA) and 200-kHz/5-kHz impedance ratio (IR) to identify malnutrition. MATERIALS AND METHODS: Nineteen individuals (18 males, 1 female) scheduled to undergo chemoradiotherapy were seen at 5 time points during and up to 3 months after treatment completion. Multiple-frequency bioelectrical impedance analysis, PG-SGA, nutrition-focused physical examination, anthropometry, dietary intake, and handgrip strength data were collected. RESULTS: Using the Consensus, 67% were found to be malnourished before treatment initiation; these criteria diagnosed malnutrition with overall good sensitivity (94%) and moderate specificity (43%) compared with PG-SGA. Over all pooled observations, "malnourished" (by Consensus but not PG-SGA category) had a lower mean PA (5.2 vs 5.9; P = .03) and higher IR (0.82 vs 0.79; P = .03) than "well-nourished" categorizations, although the clinical relevance of these findings is unclear. PA and IR were correlated with higher PG-SGA score (r = -0.35, r = 0.36; P < .01) and handgrip strength (r = 0.48, r = -0.47; P < .01). CONCLUSION: The Academy/ASPEN Consensus and the PG-SGA were in good agreement. It is unclear whether PA and IR can be used as surrogate markers of nutrition status or muscle loss.

Phase Angle and Impedance Ratio: Reference Cut-Points From the United States National Health and Nutrition Examination Survey 1999-2004 From Bioimpedance Spectroscopy Data.

BACKGROUND: Raw bioimpedance parameters (eg, 50-kHz phase angle [PA] and 200-kHz/5-kHz impedance ratio [IR]) have been investigated as predictors of nutrition status and/or clinical outcomes. However, their validity as prognostic measures depends on the availability of appropriate reference data. Using a large and ethnically diverse data set, we aimed to determine if ethnicity influences these measures and provide expanded bioimpedance reference data for the U.S. METHODS: The National Health and Nutrition Examination Survey (NHANES) is an ongoing compilation of studies conducted by the U.S. Centers for Disease Control and Prevention designed to monitor nutrition status of the U.S. POPULATION: The NHANES data sets analyzed were from the years 1999-2000, 2001-2002, and 2003-2004. RESULTS: Multivariate analysis showed that PA and IR differed by body mass index (BMI), age, sex, and ethnicity (n = 6237; R2 = 41.2%, P < .0001). Suggested reference cut-points for PA stratified by age decade, ethnicity, and sex are provided. CONCLUSION: Ethnicity is an important variable that should be accounted for when determining population reference values for PA and IR. We have provided sex-, ethnicity-, and age decade-specific reference values from PA for use by future studies in U.S. POPULATIONS: Interdevice differences are likely to be important contributors to variability across published population-specific reference data and, where possible, should be evaluated in future research. Ultimately, further validation with physiologically relevant reference measures (eg, dual-energy x-ray absorptiometry) is necessary to determine if PA/IR are appropriate bedside tools for the assessment of nutrition status in a clinical population.

Evaluation of Advanced Bioimpedance Spectroscopy Models for Measuring Body Composition in Healthy Adults (NHANES 1999-2004) and Those Undergoing Massive Weight Loss Following Roux-en-Y Gastric Bypass Surgery.

INTRODUCTION: Bioimpedance spectroscopy (BIS) devices utilize biophysical modeling to generate body composition data. The addition of body mass index (BMI) to modified Xitron-Hanai-based mixture equations improved BIS estimates of intracellular water (ICW), particularly at the extremes of BMI. A 3-compartment model for distinguishing excess fluid (ExF) from normally hydrated lean (NHLT) and adipose tissue may further improve BIS estimates. OBJECTIVE: We aimed to validate a BIS approach based on the Chamney model for determining fat mass (FM) in healthy individuals (NHANES) and for measuring FM changes in individuals undergoing massive weight loss. METHODS: Using adult NHANES 1999-2004 (2821 female, 3063 male) and longitudinal pre-to-post-RYGB (15F) data, we compared dual-energy-X-ray absorptiometry (DXA) and BIS for FM. We applied BIS adiposity-corrected values to Chamney equations for normally hydrated lean and adipose tissue (NHLT, NHAT) and FM. Method agreement was evaluated by correlations, paired t-tests, root mean square error (RMSE), Bland-Altman (B-A) analysis, and concordance correlation coefficients (CCC). RESULTS: Method agreement between BIS and DXAFM was good in healthy adults (r=0.96, CCC=0.93, p<.0001), and pre-to-post-RYGB (r=0.93-0.98, CCC=0.81-0.86, p<.001). Although cross-sectional FM measures differed, FM change measures post-RYGB did not (35.6±8.9 vs. 35.2±9.2 kg, BIS vs. DXA) and agreed well (r=0.84, p<.0001). The 15 subjects with follow-up measurements at 1 year lost 11.5±9.8 kg FFM by DXA, but only 1.3±2.5 kg of NHLT by BIS, suggesting that the FFM loss may have been mostly adipose tissue water. CONCLUSIONS: Incorporation of the Chamney model into BIS algorithms is a major conceptual advancement for assessing and monitoring body composition. Its ability to differentiate ICW and extracellular water (ECW) in NHLT and NHAT, as well as excess ECW is promising, and would facilitate lean tissue monitoring in obesity and acute/chronic disease.

INTRODUÇÃO: Os dispositivos de espectroscopia de bioimpedância (DEB) utilizam modelagem biofísica para gerar dados de composição corporal. A adição do índice de massa corporal (IMC) às equações de mistura modificadas com Xitron-Hanai modificadas melhorou as estimativas de DEB de água intracelular (AI), particularmente nos casos extremos do IMC. Um modelo de 3 compartimentos para distinguir o excesso de fluido (ExF) de magro normalmente hidratado (NHLT) e tecido adiposo pode ainda melhorar as estimativas do DEB. OBJETIVO: Pretendemos validar uma abordagem do DEB com base no modelo de Chamney para determinar a massa de gordura (MG) em indivíduos saudáveis (NHANES) e para medir mudanças de MG em indivíduos submetidos à perda de peso maciça. MÉTODO: Usando o NHANES adulto 1999­2004 (2821 mulheres, 3063 homens) e dados longitudinais pré-pós-RYGB (15 F), comparamos a absorção de raios-X de dupla energia (DXA) e DEB para MG. Aplicamos os valores corrigidos de adiposidade do BIS às equações de Chamney para tecidos magros e adiposos normalmente hidratados (NHLT, NHAT) e FM. O acordo de método foi avaliado por correlações, testes t pareados, erro quadrado médio (EQM), análise Bland-Altman (B-A) e coeficientes de correlação de concordância (CCC). RESULTADOS: O acordo de método entre DEB e DXA MG foi bom em adultos saudáveis (r=0,96, CCC=0,93, p<.0001) e pré-pós-RYGB (r=0,93­0,98, CCC=0,81­0,86, p<0,001). Embora as medidas de MG transversais diferissem, as medidas de mudança de MG pós-RYGB não (35,6±8,9 vs. 35,2±9,2 kg, DEBvs. DXA) e concordaram bem (r=0,84, p<.0001). Os 15 sujeitos com medidas de seguimento ao 1 ano perderam 11,5±9,8 kg FFM por DXA, mas apenas 1,3±2,5 kg de NHLT pelo DEB, sugerindo que a perda de FFM pode ter sido principalmente água do tecido adiposo. CONCLUSÕES: A incorporação do modelo de Chamney em algoritmos DEB é um grande avanço conceitual para avaliar e monitorar a composição corporal. A sua capacidade de diferenciar AI e água extracelular (AE) no NHLT e NHAT, bem como o excesso de AE é promissor e facilitará a monitorização do tecido magro na obesidade e doença aguda/crônica.

Bioimpedance at the bedside: current applications, limitations, and opportunities.

The loss of muscle mass is a defining characteristic of malnutrition, and there is ongoing interest in the assessment of lean tissue at the bedside. Globally, bioimpedance techniques have been widely appreciated for their noninvasiveness, safety, ease of use, portability, and relatively low cost compared with other clinically available methods. In this brief update, we review the 3 primary types of commercially available bioimpedance devices (single- and multiple-frequency and spectroscopy) and differentiate the underlying theory and current applications of each. We also address limitations and potential opportunities for using these devices at the bedside for clinical assessment. Mixed reports in the validation literature for all bioimpedance approaches have raised questions about absolute accuracy to estimate whole body composition in clinical populations, particularly those with abnormal fluid status and/or body geometry in whom underlying method assumptions may be violated. Careful selection of equations can improve whole body estimates by single- and multiple-frequency techniques; however, not all devices will allow for this approach. Research is increasing on the use of bioimpedance variables including phase angle and impedance ratio as potential markers of nutrition status and/or clinical outcomes; consensus on reference cut-points for interpreting these markers has yet to be established. Novel developments in the bioimpedance spectroscopy approach are allowing for improved fluid management in individuals receiving dialysis; these developments have implications for the clinical management of other conditions associated with fluid overload and may also provide enhanced whole body estimates of lean tissue through new modeling procedures.

Avaliação de modelos avançados de espectroscopia de bioimpedância para medir a composição do corpo em adultos saudáveis (NHANES 1999-2004) e aqueles que sofrem perda de peso em massa após a cirurgia de bypass gástrico Roux-en-Y / Evaluation of Advanced Bioimpedance Spectroscopy Models for Measuring Body Composition in Healthy Adults (NHANES 19992004) and Those Undergoing Massive Weight Loss Following Roux-en-Y Gastric Bypass Surgery

Introduction: Bioimpedance spectroscopy (BIS) devices utilize biophysical modeling to generate body composition data. The addition of body mass index (BMI) to modified Xitron-Hanai-based mixture equations improved BIS estimates of intracellular water (ICW), particularly at the extremes of BMI. A 3-compartment model for distinguishing excess fluid (ExF) from normally hydrated lean (NHLT) and adipose tissue may further improve BIS estimates. Objective:We aimed to validate a BIS approach based on the Chamney model for determining fat mass (FM) in healthy individuals (NHANES) and for measuring FM changes in individuals undergoing massive weight loss. Methods: Using adult NHANES 1999-2004 (2821 female, 3063 male) and longitudinal pre-topost-RYGB (15F) data, we compared dual-energy-X-ray absorptiometry (DXA) and BIS for FM. We applied BIS adiposity-corrected values to Chamney equations for normally hydrated lean and adipose tissue (NHLT, NHAT) and FM. Method agreement was evaluated by correlations, paired t-tests, root mean square error (RMSE), BlandAltman (B-A) analysis, and concordance correlation coefficients (CCC). Results: Method agreement between BIS and DXAFM was good in healthy adults (r=0.96, CCC=0.93, p<.0001), and pre-to-post-RYGB (r=0.93-0.98, CCC=0.81-0.86, p<.001). Although cross-sectional FM measures differed, FM change measures post-RYGB did not (35.6±8.9 vs. 35.2±9.2 kg, BIS vs. DXA) and agreed well (r=0.84, p<.0001). The 15 subjects with follow-up measurements at 1 year lost 11.5±9.8 kg FFM by DXA, but only 1.3±2.5 kg of NHLT by BIS, suggesting that the FFM loss may have been mostly adipose tissue water. Conclusions: Incorporation of the Chamney model into BIS algorithms is a major conceptual advancement for assessing and monitoring body composition. Its ability to differentiate ICW and extracellular water (ECW) in NHLT and NHAT, as well as excess ECW is promising, and would facilitate lean tissue monitoring in obesity and acute/chronic disease.(AU)

Introdução: Os dispositivos de espectroscopia de bioimpedância (DEB) utilizam modelagem biofísica para gerar dados de composição corporal. A adição do índice de massa corporal (IMC) às equações de mistura modificadas com Xitron-Hanai modificadas melhorou as estimativas de DEB de água intracelular (AI), particularmente nos casos extremos do IMC. Um modelo de 3 compartimentos para distinguir o excesso de fluido (ExF) de magro normalmente hidratado (NHLT) e tecido adiposo pode ainda melhorar as estimativas do DEB. Objetivo: Pretendemos validar uma abordagem do DEB com base no modelo de Chamney para determinar a massa de gordura (MG) em indivíduos saudáveis (NHANES) e para medir mudanças de MG em indivíduos submetidos à perda de peso maciça. Método: Usando o NHANES adulto 1999-2004 (2821 mulheres, 3063 homens) e dados longitudinais pré-pós-RYGB (15 F), comparamos a absorção de raios-X de dupla energia (DXA) e DEB para MG. Aplicamos os valores corrigidos de adiposidade do BIS às equações de Chamney para tecidos magros e adiposos normalmente hidratados (NHLT, NHAT) e FM. O acordo de método foi avaliado por correlações, testes t pareados, erro quadrado médio (EQM), análise Bland-Altman (B-A) e coeficientes de correlação de concordância (CCC). Resultados: O acordo de método entre DEB e DXA MG foi bom em adultos saudáveis (r=0,96, CCC=0,93, p<.0001) e pré-pós-RYGB (r=0,93-0,98, CCC=0,81-0,86, p<0,001). Embora as medidas de MG transversais diferissem, as medidas de mudança de MG pós-RYGB não (35,6±8,9 vs. 35,2±9,2 kg, DEBvs. DXA) e concordaram bem (r=0,84, p<.0001). Os 15 sujeitos com medidas de seguimento ao 1 ano perderam 11,5±9,8 kg FFM por DXA, mas apenas 1,3±2,5 kg de NHLT pelo DEB, sugerindo que a perda de FFM pode ter sido principalmente água do tecido adiposo. Conclusões: A incorporação do modelo de Chamney em algoritmos DEB é um grande avanço conceitual para avaliar e monitorar a composição corporal. A sua capacidade de diferenciar AI e água extracelular (AE) no NHLT e NHAT, bem como o excesso de AE é promissor e facilitará a monitorização do tecido magro na obesidade e doença aguda/crônica.(AU)