Silvana Paiva Orlandi

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.

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.

The Inflammatory-Nutritional Index: assessing nutritional status and prognosis in gastrointestinal and lung cancer patients

OBJECTIVE To evaluate the prognostic capacity of the Inflammatory-Nutritional Index (INI) in gastrointestinal and lung cancer patients. METHODS Longitudinal study, including patients from a chemotherapy service in Brazil, between July 2008 and May 2010. INI (Albumin/CRP) and nutritional status (by Subjective Global Assessment - SGA) were evaluated. Risk INI was defined as lower than 0.35. The mean follow-up of survival was 1.6 year. Statistical analyses were performed using Stata 11.1™. RESULTS 74 patients participated in the study, mean age 63.4, most of them male (58%) and presenting gastrointestinal cancer (71%). Malnutrition was identified in 87% of the patients (22% severely malnourished). The mean INI was 2.67 and 54% of the patients had INI levels considered as risk. During the follow-up there were 49 deaths (66%). The median survival time for INI risk patients was significantly shorter than for normal INI ones (p = 0,002). It took 0.78 year for the INI risk subsample to decline 50%, while it took 2.78 year for the normal INI subsample. INI risk and severe malnutrition were independent predictors for poor survival. CONCLUSION The INI showed prognostic capacity in this sample and may be a useful tool, based on routinely available blood tests, to assess cancer patients.

Is adductor pollicis muscle thickness a good predictor of lean mass in adults

Summary Background & aims Lean mass (LM) is an important parameter in clinical outcomes, which highlights the necessity of reliable tools for its estimation. The adductor pollicis muscle thickness (APMT) is easily accessible and suffers minimal interference from the adjacent subcutaneous fat tissue. Objective To assess the relationship between the APMT and LM in a sample of Southern Brazilian adults. Methods Participants were adults from the 1982 Pelotas (Brazil) Birth Cohort. LM was measured by dual energy X-ray absorptiometry (DXA). LM and lean mass index (LMI – LM divided by the square of height – kg/m2) were the outcomes. APMT was measured using a skinfold caliper. The mean of three measurements in the non-dominant hand was used in the analyses. APMT was described according to socio-demographic characteristics and nutritional status. The relationship between APMT and both LM and LMI was evaluated by correlation coefficient and linear regression using APMT as a single anthropometric parameter and also in addition to BMI. Results APMT was assessed in 3485 participants. APMT was higher in males, non-whites, less-schooled and obese individuals. APMT was moderately correlated to LM and LMI (ranged from 0.44 to 0.57). Correlation coefficients were higher for LMI as outcome and in females (LM: 0.51 and LMI: 0.57). APMT explained 19% and 26% of the variance in LM in males and females, respectively, whereas it explained 26% and 33% of the variance in LMI. APMT increased the prediction for LM in 3 and 4 percentage points in males and females, in comparison to explained by BMI. BMI explained 48% and 59% of the variance of LMI in males and females whereas APMT increased it to 51% and 62% for both sexes, respectively. Conclusions Results were not good enough to promote the APMT as a single predictor of LM or LMI in epidemiological studies. APMT has a little predictive capacity in estimating LM or LMI when BMI is also considered.

Nutritional and functional factors as prognostic of surgical cancer patients

PurposeWe evaluated phase angle, sarcopenia, and handgrip strength as prognostic factors of postoperative morbimortality in patients with cancer.MethodologyWe conducted a prospective study with 60 oncology patients admitted for elective surgery between November 2015 and May 2016. We calculated the standardized phase angle (SPA) and the skeletal mass index of the subjects based on their bioelectrical impedance tests. Handgrip strength (HGS) was measured using a hydraulic dynamometer. Diagnosis of sarcopenia followed the criteria of the European Working Group on Sarcopenia in Older People. The nutritional status of each subject was evaluated through the Patient-Generated Subjective Global Assessment. Evaluation of postoperative complications followed the Clavien-Dindo classification. We also evaluated the duration of hospital stay. Outcomes were postoperative complications and duration of hospital stay.ResultsThe prevalence of malnutrition was 28.3%, and the prevalence of sarcopenia was 18.6%. The SPA was significantly lower among those who had severe postoperative complications or long hospital stays, while HGS and sarcopenia showed no relationship with these outcomes. Malnutrition was also related to postoperative outcomes.ConclusionSPA can be considered a prognostic factor in postoperative morbimortality for patients with cancer.

Estimation of body fat in adults using a portable A-mode ultrasound.

OBJECTIVE This study aimed to develop and validate equations to estimate body fat based on anthropometric measurements of subcutaneous fat thickness (SFT) and muscle thickness (MT) measured by A-mode ultrasound (BodyMetrix) in Brazilian adults. METHODS Individuals (n = 206) underwent air-displacement plethysmography for body composition assessment. Arm, thigh, and calf circumferences were also obtained. SFT from triceps, biceps, subscapular, abdominal, thigh, and calf regions and MT from triceps, biceps, thigh, and calf regions were measured by BodyMetrix. Prediction equations were developed by stepwise multiple linear regression using the circumferences, weight, height, SFT, and MT. Lins concordance correlation coefficient, mean difference, and 95% limits of agreement (95% LOA) were assessed in apparent and internal validity. RESULTS The prediction equation for whole-body fat for men included thigh circumference, triceps and thigh SFT, biceps MT, weight, and height. The equation for women included age, calf circumference, abdominal and calf SFT, weight, and height. The prediction equation overestimated mens whole-body fat by 0.5 percentual points, in average, and the lower and upper 95% LOA were -6.8% and 7.7%, respectively. For women, the prediction equation overestimated whole-body fat by 0.1 percentual points, in average. Lower and upper 95% LOA were -6.5% and 6.7%, respectively. Optimism-adjusted results using 500 repetitions with same size samples have shown similar results. Body fat extremes did not influence the whole-body fat estimation. CONCLUSIONS BodyMetrix A-mode ultrasound, in association with selected conventional anthropometric measurements, proved to be a reliable tool for the estimation of body fat percentage.

Consumo de carnes por adolescentes do Sul do Brasil

OBJETIVO: Descrever a frequencia de consumo de diferentes tipos de carnes conforme variaveis sociodemograficas e nutricionais, e analisar o consumo, em adolescentes do Sul do Brasil, de dieta rica em gordura conforme os tipos de carne consumidos. METODOS: Estudo transversal realizado com adolescentes pertencentes a coorte de nascimentos de 1993, em Pelotas (RS). A frequencia de consumo de carnes vermelhas, brancas, visceras e embutidos foi avaliada por um Questionario de Frequencia de Consumo Alimentar, adaptado para este estudo. A ingestao de dieta rica em gordura foi avaliada a partir do instrumento proposto por Block. As variaveis independentes foram sexo, cor da pele, nivel socioeconomico, escolaridade materna e estado nutricional. Nas analises estatisticas, foram utilizados testes Qui-quadrado de heterogeneidade e de tendencia linear. RESULTADOS: Foram avaliados 4.325 adolescentes com idade media de 14,7, DP=0,3 anos, dos quais 51,2% eram do sexo feminino. A frequencia de consumo diario de carnes vermelhas foi maior do que a de carnes brancas (43,0% e 9,7%, respectivamente). O consumo de embutidos por mais do que quatro vezes por semana foi referido por 48,5% dos individuos, e 81,4% relataram consumir visceras raramente ou nunca. Adolescentes de maior nivel socioeconomico e filhos de maes com maior escolaridade apresentaram maior consumo de carnes vermelhas e embutidos, enquanto aqueles em situacao oposta apresentaram maior consumo de carnes brancas. Adolescentes que consomem carnes com maior frequencia tambem consomem dieta rica em gordura. CONCLUSAO: As carnes consumidas com maior frequencia pelos adolescentes foram as vermelhas e os embutidos. No entanto, adolescentes de maior nivel socioeconomico consomem carnes vermelhas com maior frequencia, enquanto adolescentes menos favorecidos economicamente consomem mais carnes brancas.

Desenho de um questionário de frequência alimentar digital autoaplicado para avaliar o consumo alimentar de adolescentes e adultos jovens: coortes de nascimentos de Pelotas, Rio Grande do Sul

PURPOSE Methodological paper aiming to describe the development of a digital and self-reported food frequency questionnaire (FFQ), created to the 1982 and 1993 Pelotas Birth Cohorts. METHODS The instrument was created based on FFQs previously applied to subjects belonging to both cohorts in the 2004 and 2008 follow-ups. The FFQ was developed including 88 foods and/or meals where frequencies were clustered from a minimum of never or once/month to a maximum of greater than or equal to 5 times/day. The closed options related to portions were based on a 24-hour recall previously asked to a subsample from the 1993 cohort. Three options for portions were created: equal to, less than or greater than. Equal to portion was described based on the 50 percentile of each food consumed reported in a 24-hour recall. Photographs of portions related to the 50 percentile for each food were also included in the software. RESULTS This digital FFQ included food and meals based on the needs of current researches. The layout of the software was attractive to the staff members as well as to the cohort members. The responding time was 12 minutes and the software allowed several individuals to use it at the same time. Moreover, this instrument dismissed interviewers and double data entry. CONCLUSION It is recommended the use of the same strategy in other studies, adapted to different contexts and situations.Purpose: Methodological paper aiming to describe the development of a digital and self-reported food frequency questionnaire (FFQ), created to the 1982 and 1993 Pelotas Birth Cohorts. Methods: The instrument was created based on FFQs previously applied to subjects belonging to both cohorts in the 2004 and 2008 follow-ups. The FFQ was developed including 88 foods and/or meals where frequencies were clustered from a minimum of never or once/month to a maximum of greater than or equal to 5 times/day. The closed options related to portions were based on a 24-hour recall previously asked to a subsample from the 1993 cohort. Three options for portions were created: equal to, less than or greater than. Equal to portion was described based on the 50 percentile of each food consumed reported in a 24-hour recall. Photographs of portions related to the 50 percentile for each food were also included in the software. Results: This digital FFQ included food and meals based on the needs of current researches. The layout of the software was attractive to the staff members as well as to the cohort members. The responding time was 12 minutes and the software allowed several individuals to use it at the same time. Moreover, this instrument dismissed interviewers and double data entry. Conclusion: It is recommended the use of the same strategy in other studies, adapted to different contexts and situations.

Introduction of an Omega-3 Enriched Oral Supplementation for Cancer Patients Close to the First Chemotherapy: May It Be a Factor for Poor Compliance?

The present study aims to evaluate compliance of cancer patients to EPA-enriched supplementation at the beginning of chemotherapy, and its effects on inflammation. Gastrointestinal and lung cancer patients were randomly assigned to receive nutritional supplement enriched with 2.2 g EPA or standard isocaloric one. Supplements were introduced 72 h before the first chemotherapy and continued for 4 wk. Serum C-reactive protein was measured and its variation was analyzed according to tumor location and treatment group. Compliance was assessed by phone contact and counting of supplement bottles returned after treatment. Sixty-nine patients were assessed, mean aged 65.5 yr old, most of them (59%) men. Gastrointestinal cancer was more prevalent and lung cancer had the highest C-reactive protein values (P = 0.009). Twenty-four patients interrupted treatment (trend for more interruption in EPA group), mainly because of gastrointestinal intolerance. No difference was found in C-reactive protein variation between EPA and control groups after treatment. Lung tumors showed higher inflammation than gastrointestinal ones. A short intervention with EPA was insufficient to reduce inflammation, which may be caused by the frequent abandoning of treatment. The beginning of chemotherapy may not be the optimal time point to initiate EPA supplementation because uncomfortable effects of both treatments may lead to poor adherence.