Fat-free Mass Depletion Research Articles

Malnutrition risk screening: New insights in a new era

Twenty years ago, ESPEN published its "Guidelines for nutritional screening 2002", with the note that these guidelines were based on the evidence available until 2002, and that they needed to be updated and adapted to current state of knowledge in the future. Twenty years have passed, and tremendous progress has been made in the field of malnutrition risk screening. Many screening tools have been developed and validated for different patient groups and different health care settings. Some countries even have introduced mandatory screening for malnutrition at admission to hospital. Yet, changes in society and healthcare require a reflection on current practice and policies regarding malnutrition risk screening. In this opinion paper, we share our perspectives on malnutrition risk screening in the twenty-twenties, addressing the changing and varying profile of the malnourished individual, the goals of screening and screening tools (i.e., preventive or reactive), the construct of malnutrition risk (i.e., screening for risk factors or screening for existing malnutrition), and screening alongside a patient's journey.

Arm muscle area for the longitudinal assessment of nutritional status in paediatric patients with cystic fibrosis - A single centre experience

BackgroundIn cystic fibrosis, adequate nutrition contributes to good long-term prognosis. A body mass index (BMI) at or above the 50th percentile for age and sex in all children has been recommended. As researchers have described a depletion of fat-free mass despite normal BMI, longitudinal studies using more sensitive nutritional parameters are warranted. We evaluated anthropometric measurements in an attempt to identify early indicators of deteriorating nutritional status in our paediatric cohort. MethodsWe analysed datasets from children and adolescents between 2 and 17.9 years with at least two entries for triceps skinfold thickness and upper arm circumference in our patient database between January 1995 and December 2018. Arm muscle area (AMA) was calculated, and all values were expressed as z-scores from CDC growth charts. ResultsA total of 4,862 encounters from 161 paediatric patients (78 girls) were available, representing a median number of 28 visits during a median follow-up of 8.1 years per patient. Linear mixed effects models revealed relatively stable courses for weight, height, BMI and skinfold thickness up to adulthood. AMA was the only parameter which declined slightly (r = -0.036), particularly in boys. Kaplan-Meier-analyses showed that AMA was the earliest parameter to decrease below -1 z-score between 6 and 18 years. ConclusionsThe present data suggest that compared with weight or BMI, AMA could serve as an earlier indicator of a deteriorating nutritional status. The benefit of assessing skinfold thickness and arm circumference routinely and calculating AMA from these measurements should be evaluated in large, prospective, multi-centre studies.

The Application of Fat-Free Mass Index for Survival Prediction in Cancer Patients With Normal and High Body Mass Index.

Background: Fat-free mass (FFM) depletion can be masked by a stable body weight or weight gain in the presence of a normal or high body mass index (BMI). This study investigated the prognostic value of low fat-free mass index (FFMI) in cancer patients with normal or high BMI.Methods: This multicenter retrospective cohort study included 1,602 cancer patients with normal/high BMI. The association of FFMI with patients' overall survival (OS) was analyzed by the Kaplan-Meier method and a Cox model.Results: In this analysis, there were 974 (60.8%) females and 628 (39.2%) males. Low FFMI was associated with worse OS when compared with those patients with normal FFMI. After multivariate adjustment, low FFMI was demonstrated to be an independent unfavorable prognostic factor (HR: 1.69; 95% CI: 1.28, 2.23; P < 0.001) in cancer patients with normal/high BMI. For specific tumor type, low FFMI was found to be associated with worse prognosis in patients with lung cancer, breast cancer and upper gastrointestinal cancer. In subgroup analysis, the association of low FFMI with worse survival was significantly modified by weight loss (P for interaction = 0.012), and those patients with concurrent low FFMI and weight loss showed the worst prognosis (HR: 3.53; 95% CI: 2.04, 6.11; P < 0.001).Conclusion: Low FFMI was associated with worse prognosis in cancer patients with normal/high BMI. This study highlights the usefulness of FFMI for prognostic estimation in these patients.

A GLIMmer of insight into lung transplant nutrition: Enhanced detection of malnutrition in lung transplant patients using the GLIM criteria

The Global Leadership Initiative on Malnutrition (GLIM) is a novel framework for diagnosing malnutrition and requires evaluation in wide-ranging clinical settings. This study aimed to assess the prevalence of malnutrition and its phenotypic characteristics among lung transplantation (LTx) candidates comparing GLIM to International Classification of Diseases, 10th Revision (ICD-10) criteria. A retrospective analysis was conducted of all adult patients assessed for LTx in a one-year period. Phenotypic criteria included body mass index (BMI), unintentional loss of weight (LOW) over a 12-month period and fat-free mass index (FFMI) using bioelectrical impedance analysis (BIA). Systemic inflammation associated with severe end-stage lung disease met GLIM's etiological criterion. Diagnosis of malnutrition, and its severity, were classified according to each of GLIM and ICD-10. Of 130 patients, 112 (86%) had all data to classify malnutrition. Malnutrition prevalence according to GLIM was 59%, which was markedly greater than using ICD-10 criteria (26%). Half of the LTx patients were moderately malnourished using GLIM, compared to 19% using ICD-10. A similar proportion were severely malnourished using GLIM (9%) and ICD-10 (7%). Fat-free mass (FFM) depletion (47% of all patients) was a major contributor to GLIM-malnutrition. Over 60% of LTx patients with GLIM-malnutrition were not detected as malnourished using ICD-10 criteria. Malnutrition diagnosis using GLIM was higher than using ICD-10 in LTx patients, primarily attributable to the incorporation of quantitative evaluation of FFM depletion. This highlights the utility of the GLIM framework and the importance of including body composition in malnutrition assessment.

Body composition changes in patients with head and neck cancer under active treatment: a scoping review.

Head and neck cancer patients have the second highest malnutrition prevalence, when compared with other oncological patients. They experience significant weight loss before diagnosis, during and after treatment, and even during the first year of follow-up. However, the prognostic value of weight loss depends on body mass index, and this may be associated with low skeletal muscle mass, masking its loss. Thus, weight loss itself poorly predicts outcome in head and neck cancer patients when compared with depleted skeletal muscle mass, illustrating the inadequacy of body mass index as an accurate method to reflect nutritional status. A synthesis is needed of the body composition changes occurring in head and neck cancer patients during treatment, as well as of the methods to assess it. The aim of this scoping review is to examine and map the body composition changes in head and neck cancer patients under oncological treatment with curative intent. A further objective is to determine which methods are used to assess body composition in these patients. Types of participants: The current review considered head and neck cancer patients, aged 18years or older. This scoping review considered all studies that focused on the body composition changes. This scoping review considered the studies that evaluated the body composition changes in the context of treatment with curative intent. Surgical treatment approach was excluded to avoid excess heterogeneity in the data. Types of sources: This scoping review considered only published studies, with abstract available. A three-step search strategy was undertaken. This review was limited to studies published in English, Spanish, and Portuguese during 2000-2019. The data extracted included author(s)/year of publication, aims and purpose of the study, sample size, study design, type of treatment, measurement points and component(s) of body composition evaluated, body composition assessment methods, and main results/findings. Head and neck cancer patients suffer from serious loss of lean body mass, skeletal muscle, or free fat mass, after treatment compared with baseline. Further, nutritional deterioration is evident and occurs up to 8-12months after treatment. Bioelectrical impedance analysis is one of the body composition assessment tools that has the great advantage for being available on a regular basis for assessment of body composition in head and neck cancer patients. However, it cannot be recommended for clinical decision making until further validation. Head and neck cancer patients experience a significant depletion of lean body mass, fat-free mass, and skeletal muscle, accompanied by body fat mass, while undergoing (chemo)radiotherapy. This can be demonstrated either by triceps skinfold thickness, bioelectrical impedance analysis, dual-energy x-ray absorptiometry, or computed tomography. This loss has a remarkable impact on their survival, on their quality of life, and on the risk for post-operative complications and may result in a reduced response to cancer treatment. Thus, body composition assessment should become an integral component of the care of head and neck cancer patients, beyond weight and body mass index, and should be carried out at different times throughout treatment.

Utility of bioimpedance methods for the assessment of fat-free mass in adult outpatients with inflammatory bowel disease.

Clinically accessible body composition assessment is required to identify fat-free mass (FFM) depletion, which is common in inflammatory bowel disease (IBD) and poorly correlated with body mass index (BMI). The aim of this study was to compare FFM assessed using bioimpedance spectroscopy (BIS) and multifrequency bioelectrical impedance analysis (MFBIA) with dual energy x-ray absorptiometry (DXA) in adult outpatients with IBD. FFM was measured using DXA, BIS, and MFBIA in 40 outpatients with IBD. Paired t tests, Lin and Pearson's correlations, and limits of agreement (LOA) analysis were used to compare FFMDXA with FFMBIS and FFMMFBIA. Participants (26 men, 24 with Crohn's disease) had a median (IQR) age 39 y (32-50 y) and median (IQR) BMI 24.2 kg/m2 (21.9-26.4 kg/m2). Mean FFMDXA was 51.6 ± 12 kg. FFMBIS was highly correlated with FFMDXA (rp=0.97; P < 0.001); however, BIS significantly overestimated FFM compared with DXA by a mean 3.4 ± 2.6 kg (P < 0.001) and showed wide 95% LOA (-1.7 to 8.4 kg). FFMBIS estimations improved when FFM was adjusted for by BMI using Moissl's predictive algorithm, reducing mean bias to 0.1 ± 2 kg (P=0.858; 95% LOA -3.9 to 4 kg). The bias between FFMMFBIA and FFMDXA was 1.3 ± 2 kg (P=0.002) with 95% LOA -2.6 to 5 kg (n=28). Unadjusted BIS overestimated FFM in IBD outpatients compared with DXA with poor agreement at an individual level. Adjusting for BMI ameliorated the overestimation. It is suggested for the estimation of FFM in outpatients with IBD that MFBIA or the Moissl algorithm with BIS be used if DXA is unavailable.

Factors associated with appendicular skeletal muscle mass among male Chinese patients with stable chronic obstructive pulmonary disease: A hospital-based cross-sectional study.

Limbs muscle wasting is a common disorder in patients with chronic obstructive pulmonary disease (COPD) that limits daily activities and exercise intolerance, especially in males. The present study aimed to estimate the prevalence of appendicular skeletal muscle mass (ASM) in male patients with stable COPD. In addition, factors associated with parameters of ASM were also investigated.We recruited 116 male patients with stable COPD from the outpatient clinic between September 2016 and December 2017. For each patient, we obtained demographic characteristics and measured post-bronchodilator forced expiratory volume in 1 second, symptoms, exacerbations history, and ASM. ASM was defined as the sum of the muscle masses of the 4 limbs.Appendicular skeletal muscle mass index (ASMI) in male patients with stable COPD was 8.2 ± 0.9 kg/m2, and the prevalence of low skeletal muscle mass was 7.8% (9 of 116 patients). Multiple linear-regression analysis showed that body mass index, occupation, fat-free mass index, and the modified medical research council scale were significantly correlated with ASMI. Compared with nonexercise group, lower limb muscle mass and ASM were significantly improved in physical exercise group.Underweight, retirement, fat-free mass depletion, and severe dyspnea are all risk factors for ASM in male patients with stable COPD. Our findings also justify the importance of exercise training in improving ASM.

Body Composition Measurement in Bronchiectasis: Comparison between Bioelectrical Impedance Analysis, Skinfold Thickness Measurement, and Dual-Energy X-ray Absorptiometry before and after Pulmonary Rehabilitation

BackgroundIn individuals with bronchiectasis, fat-free mass depletion may be common despite a low prevalence of underweight and is considered a risk factor for increased morbidity and mortality. Techniques to adequately estimate fat-free mass and its changes over time are needed. ObjectiveThe purpose of this study was to assess agreement among values obtained with three different body composition techniques: skinfold thickness measurement (STM), bioelectrical impedance analysis (BIA), and dual-energy x-ray absorptiometry (DXA). DesignThe study was a secondary analysis of data from a randomized controlled trial. Participants/settingA respiratory rehabilitation program was administered for 3 months to individuals with bronchiectasis from the bronchiectasis unit of the Regional University Hospital in Malaga, Spain, from September 2013 to September 2014. Individuals with a body mass index (calculated as kg/m2) >18.5 who were aged 65 years or younger and those with a body mass index >20 who were older than 65 years were included. Main outcome measuresAt baseline and at 3 and 6 months, body composition was determined by DXA and STM. Statistical analyses performedStatistical concordance was assessed with the intraclass correlation coefficient (ICC), kappa coefficient, and the degree of agreement using the Bland Altman method. For comparison of the quantitative variables at baseline vs at 3 months and 6 months, the paired sample t test (or the Wilcoxon test) was used. ResultsThirty participants were included. Strong agreement was observed between body composition values determined by BIA and DXA in fat mass (ICC: 0.92) and fat-free mass (ICC: 0.87). Strong agreement was observed between STM and DXA in the values for fat-free mass (ICC: 0.91) and fat mass (ICC: 0.94), and lower agreement was observed for the longitudinal data and in the regional values. The mean difference between fat-free mass determined by BIA and DXA was + 4.7 with a standard deviation of 2.4 kg in favor of BIA. The mean difference between fat-free mass determined by STM and DXA was +2.3 with a standard deviation of 2.7 kg in favor of STM. Six individuals were classified as having a low fat-free mass index (20%) by DXA vs four by STM (13%; kappa: 0.76) and only two by BIA (6.6%; kappa: 0.44) compared with DXA. ConclusionsDespite good statistical agreement among values obtained with DXA, STM, and BIA, the study findings indicate that STM and BIA, above all, tended to overestimate fat-free mass compared with DXA.

The Influence of Body Composition on Pulmonary Rehabilitation Outcomes in Chronic Obstructive Pulmonary Disease Patients

Alterations in body composition are commonly present in chronic obstructive pulmonary disease (COPD). The hypothesis of this study is that COPD patients would achieve clinical benefits after pulmonary rehabilitation (PR) independent of muscle mass depletion or body weight. We conducted a retrospective cohort study using single-frequency bioelectrical impedance analysis (BIA) for assessment of fat-free mass (FFM) depletion (muscle depletion). Patients were stratified into three categories based on (1) obesity BMI≥30kg/m2, (2) non-obesity BMI<30kg/m2, and (3) combined cachexia (BMI<21kg/m2 and FFM index<16kg/m2) and muscle atrophy (BMI≥21kg/m2 and FFMI<16kg/m2). PR outcomes were defined as the improvement in exercise capacity (maximal exercise capacity, 6-min walk, constant workload cycle exercise duration) and quality of life determined by Chronic Respiratory Questionnaire after PR. We studied 72 patients with available FFM measured by BIA. Patients were predominantly elderly man (N=71; 98%), with a mean age of 72years with COPD GOLD stage I-IV. The groups were balanced in terms of age, comorbidities, baseline FEV1, exercise capacity, and quality of life. The absolute changes in patients with muscle depletion or obesity compared to those without muscle depletion or obesity were not statistically different as was the percentage of patients reaching the minimal clinically important difference (MCID) after PR. A comprehensive PR program in COPD patients improved exercise tolerance and quality of life independent of muscle mass depletion or obesity. Similarly, muscle depletion or obesity had no effect on the percentage of patients achieving the MCID for measures of quality of life and exercise tolerance after PR.

Fat-free mass depletion in patients with COPD in Brazil: development of a new cutoff point and its relation with mortality and extrapulmonary manifestations.

None of the cutoff points for fat-free mass index (FFMI) were tested for the Brazilian population, and it is unknown whether the available ones are able to discriminate extrapulmonary disease manifestations. This cross-sectional study aims to develop and validate a cutoff point for FFM depletion based on Brazilian patients with chronic obstructive pulmonary disease (COPD) and to verify its association and of previously published cutoffs with extrapulmonary manifestations. A new cutoff point was obtained from the best FFMI value for discrimination of preserved exercise capacity in a sample of patients (n=57). The discriminative capacity was assessed in another sample (n=96). The new cutoff point and other previously published ones were tested to discriminate low exercise capacity, physical inactivity, sedentary lifestyle and low quality of life. A receiver operation characteristics curve with area under the curve (AUC) value was plotted and each cutoff points' discriminative capacity was calculated. Cox regression and Kaplan-Meier method assessed the association between the cutoff points and mortality. The new cutoff points for FFMI were 14.65 kg/m2 for women (AUC=0.744; sensitivity (Se)=0.88; specificity (Sp)=0.60) and 20.35 kg/m2 for men (AUC=0.565; Se=0.36; Sp=0.81). The new cutoffs were the best to discriminate poor exercise capacity assessed by walked distance in % predicted and quality of life. Only the new cutoff point was associated with mortality (HR=2.123; 95% CI: 1.03-4.33, P=0.039, log rank P=0.035). Only the new cutoff point was associated with all-cause mortality, and it had the highest discriminating capacity for exercise capacity and quality of life in Brazilian patients with COPD.

Fat mass, fat-free mass, and resting metabolic rate in weight-stable sleeve gastrectomy patients compared with weight-stable nonoperated patients

BackgroundThere is evidence that body composition and resting metabolic rate (RMR) in weight-stable patients after Roux-en-Y gastric bypass and duodenal switch is similar to that of nonoperated individuals within the same body mass index (BMI) interval. Currently, data concerning fat mass (FM), fat-free mass (FFM), and RMR on weight-stable patients after sleeve gastrectomy (SG) are lacking. ObjectivesTo assess FM, FFM, and RMR, in a selected and homogenous population of weight-stable SG patients (WSSG) and compare them with those obtained from healthy normal weight-stable nonoperated (WSNO) volunteers controls of similar sex, age, and BMI. SettingUniversity hospital, Italy. MethodsWe assessed total weight, FM, and FFM by bioelectrical impedance assay, and RMR by indirect calorimetry, in 70 WSSG patients (47 females, 23 males) at a mean follow-up of 3.2 ± 2.1 years after SG and compared them with 70 healthy WSNO volunteers, as controls (47 females, 23 males). ResultsThere was no significant difference between WSSG and WSNO groups concerning total weight (males, 72 ± 2.66 versus 72.8 ± 1.99 kg, P = .0254; females 65.1 ± 2.53 versus 63.7 ± 2.87 kg, P = .0139), FM (males, 17.7 ± 1.53 versus 16.7 ± 1.57 kg, P = .0341; females 19.6 ± 0.50 versus 18.5 ± 2.85 kg, P = .0104), FFM (males, 54.3 ± 3.07 versus 56.1 ± 3.30 kg; P = .049; females 45.5 ± 2.29 versus 45.1 ± 1.13 kg, P = .287), and RMR (males, 1541 ± 121.3 versus 1463 ± 74.4 kcal/d; P = .0118; females 1214 ± 54.9 versus 1250 ± 90.1 kcal/d, P = .0215). ConclusionAt a mean follow-up of 3.2 ± 2.1 years after SG, WSSG patients of both sexes have a FM, FFM, and RMR comparable to that of healthy WSNO individuals within the same age and BMI interval. These findings further support bariatric surgery–induced weight loss as a physiologic process and indicate that young patients, in the setting of an adequate preoperative and postoperative specific diet and moderate physical activity, do not suffer from excessive FFM depletion after SG in the mid-term.

Fat-free mass is not lower 24 months postbariatric surgery than nonoperated matched controls

ObjectiveConcerns about an excessive loss of fat-free mass (FFM) after bariatric surgery prompted this comparison of operated versus matched nonoperated controls regarding FFM. SettingUniversity Hospital and University Research Unit in an urban medical center. MethodsBody composition with bioelectric impedance (Tanita 310, Tanita Corp, Arlington Heights, IL) was measured approximately 2 years after bariatric surgery in weight stable patients and nonoperated weight stable controls matched for body mass index (BMI), gender, and age. t tests provided comparisons. Analysis of variance was used to compare FFM changes for 4 procedures. Levene’s test evaluated variance. ResultsPatients (n = 252; 24.7±15 mo after surgery) and nonoperated controls (n = 252) were matched for gender (71.8% female), age (44.5±11.0 yr), and BMI (32.8±7.0 kg/m2). Patients had different surgical procedures: 107 gastric bypasses (RYGBs), 62 biliopancreatic diversions with duodenal switch (BPD/DSs), 40 adjustable gastric bands (AGBs), and 43 sleeve gastrectomies (LSGs). FFM percentage was significantly higher in the operated patients than controls, 66% versus 62%, P<.0001. For 3 procedures, the FFM was significantly higher; however, AGBs changed only 7.3 BMI units and FFM was not significantly different from their matched controls, 59.8% versus 58.2%. Across surgical groups, FFM percentage differed, P<.0001 (RYGB 66.5±9.2%, BPD/DS 74.0±9.3%, AGB 59.8±7.0%, LSG 59.6±9.3%). Variance was not different (P = .17). ConclusionWeight-reduced bariatric surgery patients have greater FFM compared with nonoperated matched controls. These findings support surgically assisted weight loss as a physiologic process and in general patients do not suffer from excessive FFM depletion after bariatric procedures.

Evaluation of adipokines in children with cystic fibrosis.

Patients with CF present numerous pathological conditions such as malnutrition, depletion of fat-free mass, metabolic disturbances (abnormal glucose metabolism, increased insulin resistance, chronic energy deficit, local and chronic inflammation), which could affect or be associated with altered adipokines concentration Material and Methods: We aimed in this study to investigate the levels of selected adipokines such as resistin, apelin, adiponectin to demonstrate their application as possible markers of inflammation. Serum level of resistin was higher (p < 0.001) and adiponectin - lower (p=0.02) in CF children than in healthy children. There was no difference in serum apelin level between two examined groups. However, values of adiponectin/BMI and apelin/BMI ratios in CF did not differ significantly from controls. Higher values of resistin/BMI ratio in CF in comparison to controls were observed Serum resistin/adiponectin ratio was significantly higher in CF patients than in controls (p < 0.0001). Resistin/BMI ratio correlated negatively with FEV1 (R:-48,p < 0.043). Serum resistin/adiponectin ratio correlated negatively with FEV1/FVC (R:-49, p=0.04), Adipokines showed no correlation with BMI and BMI-SDS, glucose, total cholesterol, and LDL-, HDL-cholesterol, triglyceride serum levels. Spirometric parameters FEV1, FVC, VC correlated negatively with serum glucose levels (R: -0.55, p < 0.018; R: -0.65 p < 0.0025; R:-0.76, p < 0.0008 respectively). FEV1 and FVC correlated positively with BMI-SDS (R:0.58, p < 0.01; R:0.5, p < 0.036, respectively). A significant increase in resistin concentration expressed also as resistin/BMI, and resistin/adiponectin ratios, observed in children with CF may suggests that this adipokine is involved in the inflammatory process underlying the disease and is related to worse spirometric parameters describing airways obstruction.

Dietary intake of patients with moderate to severe COPD in relation to fat-free mass index: a cross-sectional study.

BackgroundFat-free mass (FFM) depletion has been shown to be a better predictor of mortality than BMI in chronic obstructive pulmonary disease (COPD) patients. The specific aim of the current study was to assess the nutritional status of stable COPD patients in relation to fat free mass index profiles.MethodsWe investigated 65 male moderate-to-severe stable COPD patients. A self-reported questionnaire was applied about general characteristics and smoking history. Nutritional intake was assessed by using a 54–item quantitative food frequency questionnaire. Weight, height, mid-upper arm circumference (MUAC), waist circumference (WC), handgrip strength and body composition measurements were taken by a trained dietitian. The data were analyzed with SPSS 15.0 software.ResultsThe mean age of the patients was 62.1 ± 8.9 years. Among all of the patients 13.8% was underweight (BMI < 21 kg/m2) and 18.5% had a low fat-free mass index (FFMI < 16 kg/m2). The percentages of the patients who did not meet the daily recommended intakes (RNI) were highest for magnesium (93.8%) and calcium (92.3%). Mean daily consumptions of milk-yogurt, red meat and fruits were significantly low in the low FFMI group compared to normal FFMI group (for all; p < 0.05). Patients with normal FFMI had significantly higher weight, height, WC, MUAC, handgrip strength, fat and fat-free mass than the patients with low FFMI (for all; p < 0.05).ConclusionsDieticians should be aware of COPD patients with low FFMI in order to evaluate the nutritional intake and therefore plan nutritional strategies to improve prognosis of the disease.

How dieting makes the lean fatter: from a perspective of body composition autoregulation through adipostats and proteinstats awaiting discovery.

Whether dieting makes people fatter has been a subject of considerable controversy over the past 30 years. More recent analysis of several prospective studies suggest, however, that it is dieting to lose weight in people who are in the healthy normal range of body weight, rather than in those who are overweight or obese, that most strongly and consistently predict future weight gain. This paper analyses the ongoing arguments in the debate about whether repeated dieting to lose weight in normal-weight people represents unsuccessful attempts to counter genetic and familial predispositions to obesity, a psychosocial reaction to the fear of fatness or that dieting per se confers risks for fatness and hence a contributing factor to the obesity epidemic. In addressing the biological plausibility that dieting predisposes the lean (rather than the overweight or obese) to regaining more body fat than what had been lost (i.e. fat overshooting), it integrates the results derived from the re-analysis of body composition data on fat mass and fat-free mass (FFM) losses and recoveries from human studies of experimental energy restriction and refeeding. These suggest that feedback signals from the depletion of both fat mass (i.e. adipostats) and FFM (i.e. proteinstats) contribute to weight regain through the modulation of energy intake and adaptive thermogenesis, and that a faster rate of fat recovery relative to FFM recovery (i.e. preferential catch-up fat) is a central outcome of body composition autoregulation in lean individuals. Such a temporal desynchronization in the restoration of the body's fat vs. FFM results in a state of hyperphagia that persists beyond complete recovery of fat mass and interestingly until FFM is fully recovered. However, as this completion of FFM recovery is also accompanied by fat deposition, excess fat accumulates. In other words, fat overshooting is a prerequisite to allow complete recovery of FFM. This confers biological plausibility for post-dieting fat overshooting - which through repeated dieting and weight cycling would increase the risks for trajectories from leanness to fatness. Given the increasing prevalence of dieting in normal-weight female and male among young adults, adolescents and even children who perceive themselves as too fat (due to media, family and societal pressures), together with the high prevalence of dieting for optimizing performance among athletes in weight-sensitive sports, the notion that dieting and weight cycling may be predisposing a substantial proportion of the population to weight gain and obesity deserves greater scientific scrutiny.

Effect of physical training on fat-free mass in patients with chronic obstructive pulmonary disease (COPD)

Background. Weight loss and depletion of fat-free mass are common problems in patients with chronic obstructive pulmonary disease (COPD) and are related to muscular weakness and exercise intolerance. Physical training of COPD patients has good effect on exercise tolerance and quality of life. The aim of this study was to examine factors that affect change in fat-free mass after physical training, in patients with COPD.Patients. Patients were examined before and after a 4-month exercise period. Weight and height were measured, and bioelectrical impedance was performed. Fat-free mass (FFM) was calculated, by a three-compartment model, and fat-free mass index (FFMI) was calculated as FFM kg/m2 and body mass index (BMI) as kg/m2. A symptom-limited ramp ergometer test and 12-minute walk test (12MWT) were performed. Dyspnoea score of daily activities was determined by Chronic Respiratory Disease Questionnaire (CRDQ). Blood was taken for analyses of C-reactive protein (CRP) and fibrinogen. Patients with a BMI <21 kg/m2 were given nutritional support during the training period.Results. A total of 27 patients completed the training (64 years, FEV1 31% of predicted). Patients with low FFMI gained 1.2 kg, whereas those with normal FFMI lost 0.7 kg (p = 0.04). In multivariate analyses high age (p = 0.03), low FEV1 (p = 0.02), and a high level of dyspnoea (p = 0.01) at baseline were found to be negative predictors for increase in FFM.Conclusions. Difficulties in increasing the fat-free mass in COPD patients by physical training seem to be associated with dyspnoea in daily life and impaired lung function (FEV1).

Nutrition impact symptoms and body composition in patients with COPD.

Anorexia or lack of appetite is common in chronic obstructive pulmonary disease (COPD) and may be caused or augmented by several symptoms affecting appetite and eating. We aimed to investigate and quantify the extent of nutrition impact symptoms (NIS) in patients with COPD and to explore relationships between NIS and fat-free mass depletion. The results in this cross-sectional study are based on 169 COPD patients (62% female subjects). Body composition was assessed using bioelectrical impedance spectroscopy and the patients reported NIS by two newly developed questionnaires: the Eating Symptoms Questionnaire (ESQ) and the Disease-Related Appetite Questionnaire (DRAQ). Symptoms with the highest prevalence were dry mouth (71%), stomach ache (39%), pain or aches affecting appetite (36%) and constipation (35%). Problems with diarrhoea and feeling affected by smells were more severe among women compared with men (P<0.05). Thirty-six percent of the patients were depleted (fat-free mass index (FFMI) <15 kg/m2 for women and FFMI<16 kg/m2 for men). Depleted patients had more NIS (P<0.05) and also rated appetite and taste of food as worse compared with non-depleted patients (P<0.05). NIS are common in patients with COPD, and depleted patients have more severe symptoms. To investigate how these symptoms are best prevented and/or managed and whether NIS prevention/treatment can affect development of malnutrition in patients with COPD is a challenge for the future.

Fat-Free Mass Depletion Is Associated With Poor Exercise Capacity Irrespective of Dynamic Hyperinflation in COPD Patients

In patients with COPD, we investigated the effect of the fat-free mass (FFM) on maximal exercise capacity and the relationship with changes in operational lung volumes during exercise. In a cross-sectional study 57 patients (16 females; age 65 ± 8 y) were consecutively assessed by resting lung function, symptom-limited cardiopulmonary exercise test, and body composition by means of bioelectrical impedance analysis to measure the FFM index (FFMI; in kilograms per square meter). Patients were categorized as depleted (n = 14) or nondepleted (n = 43) according to FFMI. No significant difference in gender, age, and resting lung function was found between depleted and nondepleted patients. When compared with nondepleted COPD patients, the depleted COPD patients had a significantly lower O2 uptake at the peak of exercise and at anaerobic threshold as well as at peak oxygen pulse, oxygen uptake efficiency slope (OUES), and heart rate recovery (HRR) (P < .05 for all comparisons), but similar inspiratory capacity/total lung capacity at the peak of exercise. Moreover, they also reported significantly higher leg fatigue (P < .05), but not dyspnea on exertion. In all patients, significant correlations (P < .01) were found between FFMI and peak oxygen pulse, OUES, HRR, and leg fatigue. This study shows that FFM depletion plays a part in the reduction of exercise capacity in COPD patients, regardless of dynamic hyperinflation, and is strictly associated with poor cardiovascular response to exercise and to leg fatigue, but not with dyspnea.

Hepatic encephalopathy is related to anemia and fat-free mass depletion in liver transplant candidates with cirrhosis

Background. Although muscle wasting may lead to decreased ammonia detoxification in cirrhosis, the potential role of lean mass depletion in hepatic encephalopathy (HE) has not been explored. Anemia, hormonal abnormalities, and psychological distress may contribute to cognitive dysfunction, but data on their potential relation to HE are limited. Methods. Data on 108 cirrhotic liver transplant candidates enrolled in a prospective study on fatigue were retrospectively analyzed. HE was assessed clinically and with the number connection tests (NCT) A and B. Psychosocial distress was assessed with a validated questionnaire. Fasting serum glucose, insulin, ammonia, and the glomerular filtration rate (GFR) were measured. Fat and fat-free mass was evaluated with dual-energy X-ray absorptiometry. Serum cortisol, testosterone, dehydroepiandrosterone, thyroid function tests, interleukin-6, and tumor necrosis factor-α (TNF-α) were measured in a subgroup of 80 patients. Results. A total of 28% of patients had (overt or minimal) HE. Anemia was present in 59%, diabetes in 29%, renal impairment in 16%, and fat-free mass depletion in 14%. In multivariate analysis, fat-free mass depletion was an independent predictor of HE and NCT-A; renal impairment of NCT-A and -B; and anemia of NCT-B (p < 0.05 for all). HE was also independently related to international normalized ratio and TNF-α (p < 0.05 for both), but not to other hormonal abnormalities or psychological distress. Plasma ammonia was independently associated to anemia (beta = 15.24, p = 0.049), fasting insulin (beta = 0.26, p < 0.05), and GFR (beta = -0.43, p = 0.003). Conclusions. Anemia and fat-free mass depletion are predictors of HE in cirrhotic liver transplant candidates along with liver failure, renal impairment, and systemic inflammation.

Effectiveness of Pulmonary Rehabilitation in Exercise Capacity and Quality of Life in Chronic Obstructive Pulmonary Disease Patients With and Without Global Fat-Free Mass Depletion

ObjectiveTo investigate the effectiveness of pulmonary rehabilitation (PR) in exercise capacity and quality of life in patients with chronic obstructive pulmonary disease (COPD) with and without global fat-free mass (FFM) depletion. DesignRetrospective case-control. SettingOutpatient clinic, university center. ParticipantsCOPD patients (N=102) that completed PR were initially evaluated. InterventionPR including whole-body and weight training for 12 weeks, 3 times per week. Main Outcome MeasuresSt. George Respiratory Questionnaire (SGRQ), 6-minute walk distance (6MWD), and FFM evaluation applied before and after PR. ResultsPatients were stratified according to their FFM status measured by bioelectric impedance. They were considered depleted if the FFM index was ≤15kg/m2 in women and ≤16kg/m2 in men. From the initial sample, all depleted patients (n=31) composed the FFM depleted group. It was composed predominantly by women (68%) with a mean age ± SD of 64.4±7.3 years and a forced expiratory volume in 1 second of 33.6%=−13.2% predicted. Paired for sex and age, 31 nondepleted patients were selected from the initial sample to compose the nondepleted group. Improvement in the 6MWD was similar in these 2 groups after PR. Both groups improved SGRQ scores, although the observed power was small and did not allow adequate comparison between depleted and nondepleted patients. There was no difference between groups in weight change, whereas FFM tended to be greater in depleted patients. This increase had no correlation with the 6MWD or the SGRQ. ConclusionsBenefits of PR to exercise capacity were similar comparing FFM depleted and nondepleted COPD patients. Although FFM change tended to be greater in depleted patients, this increase had no definite relation with clinical outcomes.