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Reduced muscle mass represents one of the top ranked phenotypic criteria for malnutrition proposed by the Global Leadership Initiative on Malnutrition. Although height-indexed fat-free mass (FFMI) thresholds have been proposed as useful surrogate measures of reduced muscle mass, the independent prognostic value of BIA-derived FFMI by bioelectric impedance analysis (BIA) in patients with cancer still needs to be fully explored.Data on body mass index (BMI), 6-month percentage of weight loss (%WL), FFMI by BIA and quality of life (QoL by EORTC Quality of Life Questionnaire [EORTC QLQ-C30]) of Italian and German patients observed prospectively until death or censoring were used (N = 1217). Patients were stratified in 5 risk categories according to a robustly validated scoring system based on BMI and %WL. Low FFMI was defined as follows: men,17 kg/mReduced FFMI was found in 234 patients (19.2%). After a median follow-up of 57 months [25th-75th, 31-60], 620 patients (50.9%) had died. The study detected differences in survival between patients presenting with and without reduced FFMI (14.0 months vs. 45.1 months; P 0.001). The fully-adjusted hazard ratio of mortality for low FFMI was 1.46 [95%CI, 1.18-1.81] (P 0.001). Low FFMI was also independently associated with reduced QoL: fully-adjusted odds ratio, 1.50 [95%CI, 1.00-2.25] (P = 0.050).Reduced FFMI by BIA independently predicted survival and was associated with impaired QoL. Altered body composition should always be considered in all patients with cancer as additional phenotypic criterion of poor prognosis and BIA offers the possibility of multiple, noninvasive bedside assessments.

Objectives: sarcopenia is common especially in hospitalised older populations. The aim of this study was to assess the prevalence of sarcopenia, defined as low skeletal mass and muscle strength, and its impact on 1-year mortality in older patients with cancer. Methods: skeletal muscle mass was estimated using bioelectric impedance analysis and related to height2 (SMI; Janssen et al. 2002). Grip strength was measured with the JAMAR dynamometer and the cut-offs suggested by the European Sarcopenia and 1-year mortality in cancer 413 Downloaded from https://academic.oup.com/ageing/article-abstract/48/3/413/5272750 by Université de Genève user on 26 November 2019 Working Group on Sarcopenia in Older People (EWGSOP) were applied. One-year mortality was assessed by telephone follow-up and the local cancer death registry. Results: of the 439 consecutively recruited cancer patients (60–95 years; 43.5% women), 119 (27.1%) had sarcopenia. Of the patients with sarcopenia, 62 (52.5%) died within 1 year after study entry compared to 108 (35.1%) patients who did not have sarcopenia (P = 0.001). In a stepwise, forward Cox proportional hazards analysis, sarcopenia (HR = 1.53; 95% CI: 1.034–2.250; P < 0.05), advanced disease (HR = 1.87; 95% CI: 1.228–2.847; P < 0.05), number of drugs/day (HR = 1.11; 95% CI: 1.057–1.170; P < 0.001), tumour diagnosis (overall P < 0.05) and Karnofsky index (HR = 0.98, 95% CI: 0.963–0.995; P < 0.05) associated with 1-year mortality risk. The factors sex, age, co-morbidities and involuntary 6-month weight loss ≥5% were insignificant. Conclusions: sarcopenia was present in 27.1% of older patients with cancer and was independently associated with 1-year mortality. The fact that sarcopenia was nearly as predictive for 1-year mortality as an advanced disease stage underlines the importance of preservation of muscle mass and function as a potential target of intervention in older patients with cancer.

Background & AimsWeight loss is associated with an improvement of insulin sensitivity. Both, a negative energy balance and changes of body composition are integrative components of weight loss interventions. However, the individual impact of these two components on insulin sensitivity and energy metabolism is unclear.MethodsWe performed a randomized controlled trial including 80 overweight or obese post-menopausal women. Participants randomly assigned to the intervention group underwent an 800 kcal/d liquid diet for 2 months followed by four weeks in which the formula diet was substituted by a calorie reduced healthy diet to facilitate further weight loss. This weight loss phase was followed by a 4-week weight maintenance phase, where weight stability was achieved by individualized daily caloric intake without negative energy balance. Volunteers of the control group were instructed to keep their weight stable during the entire period of 4 months. Metabolic phenotyping was performed in both groups at baseline (M0), after weight loss (M3) and after the maintenance period (M4). Additional phenotyping was performed during follow-up at 12 (M12) and 24 months (M24). Primary outcomes were changes of lean body mass (LBM) and changes of insulin sensitivity (ISIClamp) between baseline and M3 and M4. Estimates of energy metabolism were secondary endpoints.ResultsNo significant changes of body weight or LBM were found in the control group between any time points. A significant reduction of body weight, fat mass (FM) and LBM was found in the intervention group between M0 and M3, while no further change was seen between M3 and M4. Only subjects of the intervention group were characterized by an improvement of the second primary outcome ISIClamp at M3, which was preserved until M4. Notably, a lower resting energy expenditure per LBM (REELBM) at M3 as well as the individual difference of REELBM between M3 and M4 significantly predicted a stronger regain of fat mass during follow-up.ConclusionsIn summary, our data demonstrate that modulation of LBM and insulin sensitivity during weight loss is predominantly driven by changes in body weight and body composition, rather than an individual effect of negative energy balance. However, the variance in energy expenditure during negative and steady energy balance indicates a thrifty phenotype, which is highly susceptible to future regain of fat mass.

Summary Background & aims Estimation errors associated with bioelectric impedance evaluation may affect the accuracy of body composition and its prognostic value. We evaluated the prognostic value of a new body composition parameter (Nutrigram®) obtained from bioimpedance vectorial analysis-derived body cell mass and its association with nutritional and functional status. Design Data of Italian and German cancer patients observed prospectively until death were used. Multivariable models (adjusted for age, gender, hydration status, performance status, and disease's stage) were built in both cohorts to assess the association between body composition outcome parameters (low fat-free mass [FFM], Results Low Nutrigram® was independently associated with mortality in both Italian (HR = 1.84 [95%CI, 1.18–2.86]; P = 0.007) and German cohorts (HR = 1.52 [95%CI, 1.17–2.07]; P = 0.008). Low FFMI and low SPA did not predict survival in the German cohort. In patients with low Nutrigram®, worse nutritional and functional status were observed in both study populations. Performance of models addressing the study endpoints showed substantial consistency with both cohorts, particularly of those including low Nutrigram®. Conclusions We validated a new prognostic body composition parameter, which is easier to interpret than standard nutritional parameters and may be useful for identifying cancer patients at nutritional risk, requiring early nutritional support.

Cancer patients, in general, suffer from anorexia hence diminished nutritional intake. In a prospective observational study, we investigated the impact of recent energy and protein intake on cancer-related fatigue and 6-month mortality in patients undergoing chemotherapy. Recent protein and energy intake was assessed by 24-h recall in 285 patients. Cancer-related fatigue was determined by Brief Fatigue Inventory, and fat free mass index (FFMI) was assessed with bioelectrical impedance analysis. Symptoms with the validated German version of European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (30 questions) and 6-month mortality was documented. Risk factors of cancer-related fatigue and predictors of mortality were investigated with logistic regression analysis and stepwise Cox regression analysis, respectively. Low protein intake (

Calculation of cytostatic dose is typically based on body surface area (BSA) regardless of body composition. The aim of this study was to assess the discrepancy between BSA and low fat-free mass (FFM) by investigating the prevalence of low FFM with regard to BSA in 630 cancer patients. First, BSA was calculated according to DuBois and DuBois. Patients were divided into 6 categories with respect to their BSA. Each BSA category was further divided into 3 groups according to FFM: low (-1 SD of mean FFM), normal (-0.99 and 0.99 SD of mean FFM) or high (1 SD of mean FFM), which was derived through bioelectric impedance analysis. FFM was reduced in 15.7% of patients, 69% had normal and 15.2% had high FFM. In patients with low FFM (i.e., more than-1 SD lower than the mean FFM within their BSA group), body mass index and fatigue were higher whereas functional status was reduced. Moreover, in the subcohort of patients receiving chemotherapy, absolute FFM [Hazard ratio (HR) = 0.970, P = 0.026] as well as the allocation to the low FFM group (HR = 1.644, P = 0.025) emerged as predictors of increased 1-yr mortality. In conclusion, there was a large discrepancy between FFM and BSA. Particularly women were affected by low FFM.

Hintergrund: Ausreichende physische Aktivitat und adaquate Proteinaufnahme sind wesentliche Faktoren in der Pravention einer Sarkopenie, insbesondere in der Rekonvaleszenz nach Krankheit mit Bettruhe oder Traumata. Ziel: Das Ziel der vorliegenden Studie war es, die Verfugbarkeit und Art von 1) Ernahrungsberatung und 2) Trinknahrung bzw. Nahrungssupplemente in ambulanten orthopadischen Rehabilitationszentren zu erfassen. Design: Erhebung in deutschen ambulanten orthopadischen Rehabilitationszentren mittels eines per Post verschickten Fragebogens. Zwischen Mai und September 2009 nahmen 82 der 155 angeschriebenen ambulanten orthopadischen Rehabilitationszentren in Deutschland an der Umfrage teil. Der Fragebogen konzentrierte sich auf behandelte Patientengruppen, Verfugbarkeit und Art einer Ernahrungsberatung und das Angebot von Trinknahrung bzw. Nahrungssupplemente. Auserdem wurden demografische Angaben der Zentren erfragt. Ergebnisse: 69 (84,1 %) der ambulanten orthopadischen Rehabilitationszentren gaben an, eine Ernahrungsberatung anzubieten, wovon die Mehrheit auf eine Gewichtsreduktion ausgelegt war; 57,3 % boten eine Standardernahrungsberatung an und nur 23,2 % gaben an, eine Ernahrungsberatung zur Pravention bzw. Behandlung einer Sarkopenie durchzufuhren. 14,6 % der Zentren boten Trinknahrung bzw. Nahrungssupplemente an. Schlussfolgerung: Die in den Zentren angebotene Ernahrungsberatung konzentriert sich auf Gewichtsreduktion, obwohl fast die Halfte der Patienten uber 60 Jahre alt war. Unseren Ergebnissen zufolge konnte das Wissen um die Bedeutung der Ernahrung zur Pravention einer Sarkopenie in den ambulanten orthopadischen Rehabilitationszentren unzureichend sein, obwohl eine Vielzahl der Zentren eine Ernahrungsberatung anbieten.

In obese subjects, reduced muscle mass and strength are associated with impaired functional and metabolic capacity. We therefore investigated the association between abdominal fat distribution, fat mass index and maximum muscle strength of upper and lower extremities in obese patients.One hundred and fifty five outpatients with a body mass index (BMI)⩾30 kg/mBMI did not correlate with hand grip or knee extension strength. The regression model confirmed a positive effect of higher weight on strength parameters; however, increased FMI was shown to have a negative effect on strength in both sexes (women, knee: β: -1.495, confidence interval (CI): -2.075 to -0.0914, P0.0001; women, hand: β: -0.714, CI: -1.156 to -0.273, P=0.002; men, hand: β:-1.448, CI: -2.618 to -0.278, P=0.016). Although increased WHR positively influenced knee extension strength (β: 24.286, CI: 0.728-47.844, P0.043), it did not affect grip strength in women. This association was not seen in men.Body fat distribution rather than BMI alone needs to be considered when evaluating strength parameters in obesity. As the relationship between obesity and strength of the upper versus lower extremities differs, grip strength cannot be considered an indicator of whole body strength in obese individuals.

Background Reduced muscle strength is a cardinal feature in cachexia. We investigated whether weight loss is associated differently with muscle strength in men and women in a large cohort of hospitalized patients. Methods One thousand five hundred hospitalized patients (whereof 718 men, mean age 57.6 ± 16.0 years, mean body mass index (BMI) 24.6 ± 4.8 kg/m²) were included in the study. Non-edematous involuntary weight loss was determined with Subjective Global Assessment; isometric maximal muscle strength was evaluated by hand grip strength. Mid-upper arm circumference and triceps skinfold were used to calculate arm muscle area. Interrelationship between sex and weight loss was evaluated by regression analysis performed with the general linear model (GLM) allowing adjustment for continuous and categorical variables and corrected for age, arm muscle area (AMA), BMI, and diagnosis category (benign/malignant disease) as potentially confounding covariates. Results Both men and women exhibited a significant stepwise decrease of hand grip strength with increasing weight loss. Age, sex, moderate and severe weight loss, BMI, and AMA were significant predictors of hand grip strength. The GLM moreover revealed a significant sex × weight loss effect, since grip strength was similarly decreased in moderate weight loss in men and women when compared to control patients without weight loss (8.5% in men and 10.5% in women, not significant (n.s.)), but the further reduction of grip strength in severe weight loss was significantly different between men and women (10.6% vs. 4.1%, P = 0.033). Conclusions Our findings indicate sex-specific differences in muscle strength response to weight loss.

Phase angle (PhA), a parameter of bioelectrical impedance analysis, is a well-known predictor of morbidity and mortality in various diseases. The causes of decreased PhA are, however, not yet completely understood. We therefore investigated determinants of PhA in 777 hospitalised patients in a retrospective analysis. PhA was assessed by bioelectrical impedance analysis at 50 KHz. Subjective global assessment (SGA) was used to evaluate nutritional status. Age, sex, BMI as well as nutritional status (SGA), benign or malignant disease and C-reactive protein (CRP) were investigated as potential determinants of PhA and standardised PhA (SPhA) = (observed PhA − mean PhA of reference values)/standard deviation of reference values in a general linear model regression analysis. Next to age (estimated effect size, 46·6 %; P P P P P P P

Summary Background & aims Among all muscle function tests, measurement of hand grip strength has gained attention as a simple, non-invasive marker of muscle strength of upper extremities, well suitable for clinical use. This review outlines the prognostic relevance of grip strength in various clinical and epidemiologic settings and investigates its suitability as marker of nutritional status in cross-sectional as well as intervention studies. Methods Studies investigating grip strength as prognostic marker or nutritional parameter in cross-sectional or intervention studies were summarized. Results and conclusions Numerous clinical and epidemiological studies have shown the predictive potential of hand grip strength regarding short and long-term mortality and morbidity. In patients, impaired grip strength is an indicator of increased postoperative complications, increased length of hospitalization, higher rehospitalisation rate and decreased physical status. In elderly in particular, loss of grip strength implies loss of independence. Epidemiological studies have moreover demonstrated that low grip strength in healthy adults predicts increased risk of functional limitations and disability in higher age as well as all-cause mortality. As muscle function reacts early to nutritional deprivation, hand grip strength has also become a popular marker of nutritional status and is increasingly being employed as outcome variable in nutritional intervention studies.

Muscle function has gained attention as an indicator of functional as well as nutritional status. Loss of muscle strength is a key phenomenon in disease related malnutrition. However, the decrease in muscle function frequently precedes alterations of body composition. Therefore, muscle function is likely related to further factors than pure muscle mass, such as electrolytes, energy rich phosphates and membrane potential. This sensitivity might account for the prognostic power of muscle function - and hand grip strength in particular - in regard to morbidity and mortality in both acute and long-term settings. The assessment of voluntary hand grip strength with a dynamometer is a feasible and reliable bed side method suitable for the clinical and ambulatory setting. Hand grip strength has been investigated in numerous nutrition intervention studies. Muscle function responds earlier to nutritional deprivation and restoration, and is therefore an early marker of malnutrition as well as a useful tool for monitoring nutritional intervention in adult patients. In the elderly, however, nutritional intervention is not always successful in improving hand grip strength. A systematic and standardized measurement of hand grip strength is necessary in order to obtain valid results. For the evaluation of baseline grip strength values, age and gender specific reference data must be considered.

We investigated the impact of low phase angle (PhA) values on muscle strength, quality of life, symptom severity, and 1-year mortality in older cancer patients.Prospective study with 1-year follow-up.Cancer patients aged60 years.PhA was derived from whole body impedance analysis. The fifth percentile of age-, sex-, and body mass index-stratified reference values were used as cut-off. Quality of life was determined with the European Organization of Research and Treatment in Cancer questionnaire, reflecting both several function scales and symptom severity. Muscle strength was assessed by hand grip strength, knee extension strength, and peak expiratory flow.433 cancer patients, aged 60-95 years, were recruited. Patients with low PhA (n = 197) exhibited decreased muscle strength compared with patients with normal PhA (hand grip strength: 22 ± 8.6 vs 28.9 ± 8.9 kg, knee extension strength: 20.8 ± 11.8 vs 28.1 ± 14.9 kg, and peak expiratory flow: 301.1 ± 118 vs 401.7 ± 142.6 L/min, P.001). Physical function, global health status, and role function from the European Organization of Research and Treatment in Cancer questionnaire were reduced, and most symptoms (fatigue, anorexia, pain, and dyspnea) increased in patients with low PhA (P.001). In a risk-factor adjusted regression analysis, PhA emerged as independent predictor of physical function (ß:-0.538, P = .023), hand grip strength (ß:-4.684, P.0001), knee extension strength (ß:-4.548, P = .035), and peak expiratory flow (ß:-66.836, P.0001). Low PhA moreover predicted 1-year mortality in the Cox proportional hazards regression model, whereas grip strength was no longer significant.PhA below the fifth reference percentile is highly predictive of decreased muscle strength, impaired quality of life, and increased mortality in old patients with cancer and should be evaluated in routine assessment.

We investigated whether C-reactive protein (CRP) as indicator of acute inflammation is associated with maximal isometric handgrip strength in non-critically ill patients.Handgrip strength was measured with Jamar dynamometer in 620 hospitalized patients (56.4±15.9 years old, 52.3% men). CRP was measured with immunoturbidimetric assay. Fat free mass (FFM) was assessed by bioelectrical impedance analysis. A general linear model regression analysis corrected for confounding variables such as age, sex, FFM, body mass index, comorbidity count and diagnosis category (malignant/benign disease) was performed to test the association between elevated levels of CRP and handgrip strength.CRP was an independent predictor of grip strength (CRP: β-coefficient: -0.169, P=0.018) even after adjustment for relevant confounders. All groups with inflammation showed significant reduction in handgrip strength, corresponding to a loss of ∼1.6 kg in mild inflammation, 3.2 kg in moderate inflammation and 2.9 kg in severe inflammation compared with patients without inflammation.Our data demonstrate the independent association between inflammation and handgrip strength in non-critically ill patients. If not corrected, reduced strength may have implications for the patients' functional status and prognosis. Increasing physical activity and resistance training during convalescence are recommended.

Background: Marine-derived n−3 (omega-3) PUFAs may reduce risk of developing colorectal cancer; however, few studies have investigated the association of n−3 PUFA intakes on colorectal polyp risk.

Background & aims The use of phase angle (PhA) and raw parameters of bioelectrical impedance analysis (BIA) has gained attention as alternative to conventional error-prone calculation of body composition in disease. This review investigates the clinical relevance and applicability of PhA and Bioelectrical Impedance Vector Analysis (BIVA) which uses the plot of resistance and reactance normalized per height. Methods A comprehensive literature search was conducted using Medline identifying studies relevant to this review until March 2011. We included studies on the use of PhA or BIVA derived from tetrapolar BIA in out- and in-patient settings or institutionalized elderly. Results Numerous studies have proven the prognostic impact of PhA regarding mortality or postoperative complications in different clinical settings. BIVA has been shown to provide information about hydration and body cell mass and therefore allows assessment of patients in whom calculation of body composition fails due to altered hydration. Reference values exist for PhA and BIVA facilitating interpretation of data. Conclusion PhA, a superior prognostic marker, should be considered as a screening tool for the identification of risk patients with impaired nutritional and functional status, BIVA is recommended for further nutritional assessment and monitoring, in particular when calculation of body composition is not feasible.

Background: The bioelectrical phase angle has shown predictive potential in various diseases, but general cutoffs are lacking in the clinical setting. Objectives: This study evaluated the prognostic value of the fifth percentile of sex-, age-, and body mass index‐stratified phase angle reference values in patients with cancer with respect to nutritional and functional status, quality of life, and 6-mo mortality. In a second step, we also studied the effect of the standardized phase angle (with a z score to determine individual deviations from the population average) on these variables. Design: A total of 399 patients with cancer were studied. Phase angle was obtained with bioelectrical impedance analysis; muscle function was assessed by handgrip strength and peak expiratory flow. Quality of life was determined by the European Organization for Research and Treatment of Cancer questionnaire. Nutritional status was assessed by using Subjective Global Assessment. Survival of patients was documented after 6 mo. Results: Patients with a phase angle of less than the fifth reference percentile had significantly lower nutritional and functional status, impaired quality of life (P , 0.0001), and increased mortality (P , 0.001). The standardized phase angle emerged as a significant predictor for malnutrition and impaired functional status in generalized linear model regression analyses. It was also a stronger indicator of 6-mo survival than were malnutrition and disease severity in the Cox regression model (P , 0.0001) and according to the receiver operating characteristic curve. Conclusions: The standardized phase angle is an independent predictor for impaired nutritional and functional status and survival. The fifth phase angle reference percentile is a simple and prognostically relevant cutoff for detection of patients with cancer at risk for these factors. Am J Clin Nutr 2010;92:612‐9.

Decreased functionality and muscle weakness are prominent features in cancer patients. We investigated determinants of muscle function assessed by hand grip and knee extension strength as well as functional status in cancer patients.189 consecutively admitted cancer patients (age 60.8 ± 12.7 years, 96 male) were recruited. Muscle function was assessed by hand grip and knee extension strength, and percentage of anticipated peak expiratory flow (%PEF). Functional status was determined by the EORTC questionnaire of quality of life. Nutritional status was assessed with Subjective Global Assessment (SGA). Age, gender, SGA, body mass index, clinical variables such as cancer location, presence of distant metastases, tumour burden according to TNM stage, UICC stage, number of drugs per day, number of comorbidities, type of treatment and depression were investigated as potential risk factors for muscle weakness and impaired functional status in a multiple regression analysis.80 patients (39 male) were classified moderately or severely malnourished. Malnutrition also emerged as an independent determinant for hand grip (estimated effect size 11%, p0.01), knee extension strength (estimated effect size 12%, p0.001), and peak expiratory flow (estimated effect size 30%, p0.008) and functional status (estimated effect size 19.4%, p0.001) next to age and gender, which were the strongest predictors. Among the disease parameters, only amount of daily medication exhibited a significant influence on knee extension strength.Malnutrition is a disease independent risk factor for reduced muscle strength and functional status in cancer patients. Treatment of malnutrition might therefore also restore muscle strength.