Maria Cristina Gonzalez

Obesity paradox in cancer: new insights provided by body composition

BACKGROUND Obesity, defined by body mass index (BMI), appears to have a paradoxical protective effect in several chronic diseases. OBJECTIVE We investigated the obesity paradox in cancer patients by using body composition. DESIGN The study was an observational study of 175 cancer patients assessed before chemotherapy. Obesity was defined as BMI (in kg/m(2)) ≥30 or fat mass index (FMI; fat mass divided by the square of height) ≥5.2 (men) and ≥8.2 (women) measured by using a bioelectrical impedance analysis. Low muscle mass (sarcopenia) was defined as fat-free mass index (fat-free mass divided by the square of height) <17.5 (men) and <15.1 (women). RESULTS Most patients were women (65.7%) and had a mean (±SD) age of 56.9 ± 12.8 y. According to BMI criteria, 60% of patients were overweight or obese. The median survival time for overweight (2.64 y; range: 0.23-3.16 y) and obese (2.61 y; range: 0.26-3.20 y) patients was significantly higher than for patients with a normal (2.04 y; range: 0.06-3.05 y) or low (0.52 y; range: 0.19-0.98 y) BMI (P < 0.001). Sarcopenic patients had shorter survival, regardless of their FMI. Obesity predicted higher survival rates only when sarcopenia was absent. In a multivariate Cox regression model, sarcopenia was an independent predictor of higher mortality (HR: 5.19; 95% CI: 2.58, 10.43) after we controlled for BMI, age, and tumor stage. CONCLUSIONS The obesity paradox is present in cancer patients only when obesity is defined by BMI. Patients with sarcopenic obesity had the poorest prognosis. Cancer patients with high mortality risk can be identified by a body-composition assessment.

Comparison of nutritional risk screening tools for predicting clinical outcomes in hospitalized patients

OBJECTIVE International nutritional screening tools are recommended for screening hospitalized patients for nutritional risk, but no tool has been specifically evaluated in the Brazilian population. The aim of this study was to identify the most appropriate nutritional screening tool for predicting unfavorable clinical outcomes in patients admitted to a Brazilian public university hospital. METHODS The Nutritional Risk Screening 2002 (NRS 2002), Mini-Nutritional Assessment-Short Form (MNA-SF), and Malnutrition Universal Screening Tool (MUST) were administered to 705 patients within 48 h of hospital admission. Tool performance in predicting complications, very long length of hospital stay (LOS), and death was analyzed using receiver operating characteristic curves. RESULTS NRS 2002, MUST, and MNA-SF identified nutritional risk in 27.9%, 39.6%, and 73.2% of the patients, respectively. NRS 2002 (complications: 0.6531; very long LOS: 0.6508; death: 0.7948) and MNA-SF (complications: 0.6495; very long LOS: 0.6197; death: 0.7583) had largest areas under the ROC curve compared to MUST (complications: 0.6036; very long LOS: 0.6109; death: 0.6363). For elderly patients, NRS 2002 was not significantly different than MNA-SF (P>0.05) for predicting outcomes. CONCLUSION Considering current criteria for nutritional risk, NRS 2002 and MNA-SF have similar performance to predict outcomes but NRS 2002 seems to provide a best yield.

Complementarity of Subjective Global Assessment (SGA) and Nutritional Risk Screening 2002 (NRS 2002) for predicting poor clinical outcomes in hospitalized patients

BACKGROUND & AIMS We evaluated the ability of Nutritional Risk Screening 2002 (NRS 2002) and Subjective Global Assessment (SGA) to predict malnutrition related to poor clinical outcomes. METHODS We assessed 705 patients at a public university hospital within 48 h of admission. Logistic regression and number needed to screen (NNS) were calculated to test the complementarity between the tools and their ability to predict very long length of hospital stay (VLLOS), complications, and death. RESULTS Of the patients screened, 27.9% were at nutritional risk (NRS+) and 38.9% were malnourished (SGA B or C). Compared to those patients not at nutritional risk, NRS+, SGA B or C patients were at increased risk for complications (p=0.03, 0.02, and 0.003, respectively). NRS+ patients had an increased risk of death (p=0.03), and SGA B and C patients had an increased likelihood of VLLOS (p=0.008 and p<0.0001, respectively). Patients who were both NRS+ and SGA C had lower estimates of NNS than patients who were NRS+ or SGA C only, though their confidence intervals did overlap. CONCLUSIONS The concurrent application of SGA in NRS+ patients might enhance the ability to predict poor clinical outcomes in hospitalized patients in Brazil.

Phase angle and its determinants in healthy subjects: influence of body composition

BACKGROUND The phase angle (PA) has been used as a prognostic marker in several clinical situations. Nevertheless, its biological meaning is not completely understood. OBJECTIVE We verified how body-composition components could explain the PA. DESIGN The trial was a cross-sectional study involving 1442 participants (women: 58.5%; Caucasian: 40.2%) from body-composition studies. Labeled tritium dilution and total-body potassium were used to estimate total-body water (TBW) and intracellular water (ICW), respectively. Extracellular water (ECW) and the ECW:ICW ratio were estimated from the difference and the ratio of these values. Fat-free mass (FFM) and fat mass (FM) were estimated with the use of dual-energy X-ray absorptiometry, underwater weighing (UWW), and TBW. The PA was estimated with the use of a single-frequency bioelectrical impedance analysis system. Correlations between the PA and all body-composition variables were evaluated. A multivariate linear regression analysis was performed to adjust for the effects of body-composition variables on the PA variability. All analyses were performed separately by sex. RESULTS Compared with men, women exhibited significantly larger ECW:ICW ratios and FM. The highest positive correlation was shown between the PA and FFM obtained with the use of UWW (both sexes). The highest negative correlation was shown between the PA and ECW:ICW ratios for both sexes. Age, race, height, ECW:ICW, and FFM from UWW were significant PA determinants in a multivariate linear regression model. Even after adjustment for all significant covariates, the explained PA variance was low (adjusted R(2) = 0.539 and 0.421 in men and women, respectively). The greatest impact on the total PA prediction in both men and women were age, FFM, and height. CONCLUSIONS Age is the most significant PA predictor in men and women followed by FFM and height. The ECW:ICW contribution may explain the association of the PA observed in the clinical setting and in people who are obese.

Prevalence of sarcopenia among community-dwelling elderly of a medium-sized South American city: results of the COMO VAI? study

There is insufficient data concerning sarcopenia prevalence in South America. The aim of this study was to estimate sarcopenia prevalence and its clinical subgroups in a Southern Brazilian city.

Body composition phenotypes and obesity paradox.

Purpose of reviewThe obesity paradox is a highly controversial concept that may be attributed to methodological limitations related to its identification. One of the primary concerns is the use of BMI to define obesity. This index does not differentiate lean versus adipose tissue compartments (i.e. body composition) confounding health consequences for morbidity and mortality, especially in clinical populations. This review will describe the past years evidence on the obesity paradox phenomenon, primarily focusing on the role of abnormal body composition phenotypes in explaining the controversies observed in the literature. Recent findingsIn spite of the substantial number of articles investigating the obesity paradox phenomenon, less than 10% used a direct measure of body composition and when included, it was not fully explored (only adipose tissue compartment evaluated). When lean tissue or muscle mass is taken into account, the general finding is that a high BMI has no protective effect in the presence of low muscle mass and that it is the latter that associates with poor prognosis. SummaryIn view of the body composition variability of patients with identical BMI, it is unreasonable to rely solely on this index to identify obesity. The consequences of a potential insubstantial obesity paradox are mixed messages related to patient-related prognostication.

Applicability of nutritional screening methods in hospitalized patients

The prevalence of energy-protein malnutrition in hospitals varies from 20 to 50% depending on the criteria used. Nutritional risk refers to increased morbidity and mortality risk resulting from the nutritional status. Nutritional screening identifies malnourished or at risk of malnourishment individuals, aiming to determine if there is nutritional risk and if a more thorough nutritional assessment is necessary. Meanwhile, nutritional assessment, besides detecting malnutrition, classifies its degree and allows the collection of information that helps to correct it. The nutritional assessment tools most often cited in current literature were reviewed. Nutritional assessment articles were obtained from scientific websites. Among the cited tools, the Nutritional Risk Screening 2002 stands out. It can be used for all inpatients regardless of their disease or age, does not have additional costs to the service and can be performed by different professionals. It is up to each professional to develop a critical sense and determine his or her preferred technique.The prevalence of energy-protein malnutrition in hospitals varies from 20 to 50% depending on the criteria used. Nutritional risk refers to increased morbidity and mortality risk resulting from the nutritional status. 554 | M. RASLAN et al. Rev. Nutr., Campinas, 21(5):553-561, set./out., 2008 Revista de Nutrição Nutritional screening identifies malnourished or at risk of malnourishment individuals, aiming to determine if there is nutritional risk and if a more thorough nutritional assessment is necessary. Meanwhile, nutritional assessment, besides detecting malnutrition, classifies its degree and allows the collection of information that helps to correct it. The nutritional assessment tools most often cited in current literature were reviewed. Nutritional assessment articles were obtained from scientific websites. Among the cited tools, the Nutritional Risk Screening 2002 stands out. It can be used for all inpatients regardless of their disease or age, does not have additional costs to the service and can be performed by different professionals. It is up to each professional to develop a critical sense and determine his or her preferred technique. Indexing terms: Hospital care. Malnutrition. Mass screening. Triage.

Body weight and fat-free mass changes in a cohort of patients receiving chemotherapy

PurposeMalnutrition is prevalent in cancer patients and it can become even greater during its treatment. The purpose of the present study is to verify changes in the fat-free mass (FFM) and body weight (BW) in cancer patients during chemotherapy treatment and to identify their significant determinants.MethodsIn a longitudinal study of 174 patients starting a chemotherapy protocol, bioelectrical impedance analysis (BIA) was used to estimate FFM and the nutritional assessment by patient-generated subjective global assessment. BW and FFM changes have been calculated and their significant determinants were identified after a multivariate analysis.ResultsMalnutrition was found in 23% of the patients at the admission. After a multivariate analysis, a significant BW change was found during the treatment in patients submitted to previous/adjuvant and palliative chemotherapy (weight gain of 4.15% and 2.23%, respectively, p = 0.05) and a significant FFM loss (7.61%, p < 0.01) in patients with severe malnutrition at admission.ConclusionsOnly the chemotherapy protocol and initial nutritional state had a significant influence in BW and FFM changes during the chemotherapy. BIA may contribute to other methods of nutritional assessment, in order to detect modifications in body composition even in the absence of BW changes.

Association between an inflammatory-nutritional index and nutritional status in cancer patients

INTRODUCTION Cachexia is a multifatorial syndrome characterized by loss of body weight, fat and muscle, increasing morbidity and mortality. The use of an index accounting for both serum albumin and C Reactive Protein levels could make early identification of cachexia easier. OBJECTIVE To evaluate the variation of an inflammatory nutritional index related to nutritional status in cancer patients. METHODS Cross sectional study including patients with gastrointestinal and lung cancer of a public chemotherapy service in Brazil. Serum albumin and C Reactive Protein were measured and the nutritional status was defined by Subjective Global Assessment. Statistical analyses were performed using Stata 9.2(TM). RESULTS A total of 74 patients were evaluated, 58.1% of them were male, mean age 63.4 ± 11.9 years old. Gastrointestinal cancer was the most prevalent type (71.6%). Only 13.7% of the patients were well nourished and 21.9% were severely malnourished. C Reactive Protein significantly increased according to nutritional status decline (p=0.03). When the albumin from patients with systemic inflammation was evaluated, there was no significant variation in relation to nutritional status (p=0.06). The Inflammatory Nutritional Index significantly varied in relation to nutritional status independent of the systemic inflammation (p=0.02). CONCLUSIONS Inflammatory Nutritional Index can be an adjuvant way for biochemical nutritional assessment and follow up in cancer patients with systemic inflammation.

Adductor pollicis muscle: A study about its use as a nutritional parameter in surgical patients

BACKGROUND & AIMS Body composition is important to identify malnutrition, and several anthropometric measurements are used to estimate muscle mass in the clinical practice. This study aimed to assess the adductor pollicis muscle thickness (APMT), its covariates and association with malnutrition in hospitalized surgical patients. METHODS APMT was measured in 361 surgical patients in both dominant (DAPMT) and non-dominant (NDAPMT) sides. APMT values below the 5th percentile of reference values provided by a healthy population were considered as malnourished. Nutritional status was assessed by Subjective Global Assessment (SGA). The difference in APMT values among nutritional status categories was evaluated, and the association between malnutrition by SGA and APMT was estimated using multivariate linear regression. Sensitivity, specificity and positive and negative predictive values were also calculated. RESULTS Most patients were women (60.4%). APMT values were significantly different among SGA categories. Well-nourished patients had APMT values significantly higher compared to the ones with moderate or severe malnutrition by SGA, with no significant difference between APMT values in moderate or severe malnourished patients. Statistically significant associations between both DAPMT and NDAPMT below the 5th percentile and malnutrition and were found (RR = 3.99, CI 95% = 3.19-5.00; p < 0.001; and RR = 3.92; CI 95% = 3.10-4.96; p < 0.001; respectively). Gender, age, estimated weight and nutritional status were considered associated factors for APMT. APMT showed low sensitivity (DAPMT: 34.9%, NDAPMT: 37.7%) but high specificity (DAPMT: 98.7%, NDAPMT: 97.8%) to identify malnutrition. CONCLUSIONS APMT was significantly associated with nutritional status in a sample of surgical patients. The APMT seems to be a simple and useful anthropometric tool to confirm the diagnosis of malnutrition.