Midarm Fat Area Research Articles

Human Milk Macronutrients and Bioactive Molecules and Development of Regional Fat Depots in Western Australian Infants during the First 12 Months of Lactation.

We investigated associations between intakes of human milk (HM) components (macronutrients and biologically active molecules) and regional fat depots development in healthy term infants (n = 20) across the first year of lactation. Infant limb (mid-arm and mid-thigh) lean and fat areas were assessed by ultrasound imaging at 2, 5, 9 and 12 months of age. Concentrations of HM total protein, whey protein, casein, adiponectin, leptin, lysozyme, lactoferrin, secretory IGA, total carbohydrates, lactose, HM oligosaccharides (total HMO, calculated) and infant 24-h milk intake were measured, and infant calculated daily intakes (CDI) of HM components were determined. This pilot study shows higher 24-h milk intake was associated with a larger mid-arm fat area (p = 0.024), higher breastfeeding frequency was associated with larger mid-arm (p = 0.008) and mid-thigh (p < 0.001) fat areas. Lysozyme (p = 0.001) and HMO CDI (p = 0.004) were time-dependently associated with the mid-arm fat area. Intakes of HM components and breastfeeding parameters may modulate infant limb fat depots development during the first year of age and potentially promote favorable developmental programming of infant body composition; however, further studies are needed to confirm these findings.

Subjective global nutritional assessment as a nutritional tool in childhood chronic liver disease

Objective of the study was to assess subjective global nutritional assessment (SGNA) in children with chronic liver diseases (CLD). Children aged 3 months to 18 years with CLD were prospectively enrolled (January 2016 to October 2018). SGNA was performed as per validated pro forma for children. Nutritional categories were categorised into three groups: A (well-nourished), B (moderately malnourished) and C (severely malnourished). Agreement between SGNA and anthropometric measures, prediction of morbidity and death or liver transplantation (LT) at 1-year post-enrolment by SGNA and inter-observer reliability of SGNA were assessed. Ninety-two subjects were enrolled, median age 23·5 (3-216) months. SGNA classified 47 patients (51·1 %) in group A, 26 (28·3 %) in group B and 19 (20·6 %) in group C. Kendall coefficients disclosed significant association of SGNA with all anthropometric measurements, greatest with weight for age (r = -0·637), height for age (r = -0·581) and mid-arm fat area (r = -0·449). At 12 months follow-up, twenty children died and four received LT. A significantly higher number of children with malnutrition (groups B and C) had poor outcome (OR 6·74 (95 % CI 2·21, 20·55), P = 0·001), increased risk of hospital readmission (OR 12·2 (95 % CI 4·60, 35·88), P = 0·001), higher rate of infectious complications (OR 22·68 (95 % CI 7·29, 70·53), P < 0·0001) and lower median survival with native liver (Log Rank < 0·001) as compared with group A. Inter-observer agreement in assessment of SGNA was good (90·2 %). SGNA, in contrast to anthropometric measures, is a better nutritional assessment tool. It is reliable, comprehensive and predicts poor outcome in childhood CLD.

Adipopenia Is the Rapid Screening Tool that Best Predicts Mortality in Patients with Decompensated Cirrhosis: Results of a Prospective Study.

Patients with liver cirrhosis (LC) often have malnutrition (MN), which can be associated with decompensation, infection, and death. The aims were to determine: the prevalence of MN in patients with LC and ascites, its impact on mortality, and the relationship between MN and spontaneous bacterial peritonitis (SBP). Nutritional status (NS) was analysed in cirrhotic patients, experiencing their first episode of ascites, who were consecutively admitted at two clinical liver centres between November 2014 and October 2016. The participants underwent diagnostic paracentesis and were followed up to assess their outcomes. 110 participants underwent NS assessment in addition to routine clinical procedures. The prevalence of MN was 30.9% according to corrected body mass index, 67.3% according to upper mid-arm muscle area (UMA) and 40% according to upper mid-arm fat area (UFA). The percentages of the participants remaining alive were 68.1% at 3 months, 59.3% at 6 months, 45.1% at 12 months and 24.2% at the end of the study. Univariate analysis showed that SBP, model for end-stage liver disease (MELD), UFA, UMA and age were significantly associated with mortality. Multivariate analysis showed that only SBP, MELD and UFA (hazard ratio 2.2) were independently associated with mortality. There was a correlation between adipopenia, but not sarcopenia, and SBP. Adipopenia, as assessed by UFA, was present in 40% of the cirrhotic patients, and it was independently associated with mortality.

Triceps Skinfold Thickness Is Associated With Lumbar Bone Mineral Density in Peritoneal Dialysis Patients.

Anthropometric measurements, including body mass index (BMI), body weight and total fat mass are associated with the bone mineral density (BMD) in the general population. Compared to that in the general population, BMD was lower in dialysis patients. However, the association between anthropometric measurements and BMD is not well-established among peritoneal dialysis (PD) patients. To study this, we conducted a cross-sectional study in 48 chronic PD patients. Anthropometric parameters, biochemical data, and BMD measured by dual energy X-ray absorptiometry in lumbar vertebrae (L2-L4) were collected. Among these PD patients, eight patients (16.7%) had osteoporosis and 22 patients (45.8%) osteopenia, while 18 patients were normal. Older age, decreased height, lower body weight, BMI, triceps skinfold thickness (TSF), mid-arm fat area (MAFA), and higher adiponectin levels were observed in our patients with lower lumbar T-scores. Height, body weight, waist circumference, BMI, body fat mass, TSF, mid-arm circumference, MAFA, and serum phosphorus levels were positively, while age, adiponectin levels were negatively correlated with lumbar BMD levels. According to our multivariate forward stepwise linear regression analysis, TSF (R2 change = 0.080, P = 0.017) and body weight (R2 change = 0.333, P = 0.002) were both correlated with low lumbar BMD. In conclusion, either TSF or body weight in our chronic PD patients was proved to be an independent predictor for osteolytic bone lesions.

Anthropometric differences and body composition among ethnic minorities in northern Vietnam

Little is known about ethnic differences in body size and composition among minority groups in Vietnam. We used data from an ongoing study (PRECONCEPT) of women of reproductive age (WRA) in Thái Nguyên province, Vietnam to 1) compare selected anthropometric measures and body composition indices across ethnic groups; and 2) evaluate cutoff points for mid‐upper‐arm (MUAC) and calf circumference (CC) for screening undernutrition. A battery of anthropometric measurements (weight, height, MUAC, CC, triceps and subscapular skinfold thickness) was obtained for 4918 WRA. Body mass index (BMI), mid upper arm muscle (MUAMA) and fat area were calculated. The prevalence of underweight (BMI &lt; 18.5 kg/m) and overweight (BMI &gt;; 23 kg/m) were 32% and 5%, respectively. Mean (± SD) MUAC for the largest ethnic group, the Kinh (24.3 ± 2.1) was significantly lower than both Tay (24.6 ± 2.2) and San Chi (24.8 ± 2.2). Similar differences were seen for BMI (Kinh: 19.4 ±1.9; Tay :19.6 ±1.9, and San Chi:19.9 ± 2.0). The differences in BMI and MUAMA remained significant after adjusting for age, socioeconomic status, energy intakes, education and food insecurity. ROC analysis showed high predictive strength of MUAC and calf circumference in screening underweight women. Further studies are needed to explain differences in body composition among ethnic minority subpopulations.Funding: The Mathile Inst. and the Micronutrient Initiative

Ocena stanu odżywienia i składu ciała pacjentów z mukowiscydozą

IntroductionCystic fibrosis (CF) is a chronić multiorgan disease inherited in an autosomal recessive manner. It is mainly characterized by respiratory failure and maldigestion. The exocrine insufficiency of pancreas manifests itself in steatorrhea and leads to malnutrition and growth retardation. AimThe airm of this study was to evaluate retrospectively the physical development and the body composition of patients with CF using noninvasive methods: anthropometric traits and densitometry. Material and methodsThe examined group comprised 25 patients with cystic fibrosis (17 girls, 8 boys) aged from 15-months to 18-years-old (mean age 10 years, SD ± 67 months). Basic anthropometric traits were measured and 3 skin-folds, Mid Arm Fat Area (MAFA) also Mid Arm Muscle Area (MAMA) and Body Mass lndex were calculated. By using dual-energy X-ray absorptiometry (DXA) the Lean Body Mass (LBM) as well as bonę minerał content of total skeleton and lean body mass ratio (TBBMC/LBM) were calculated. 23 healthy children (17 boys, 6 girls) were the control group. Data standardization was madę by using computer programme ‘gimAntropometry’. For the statistical calculations nonparametric tests were used which are available in the STATISTICA application. Results40% of patients with CF were below the 10 centile for body weight (4.34% in control's group, p=0.003). The skinfold thickness of triceps in 52% of children was below norm (vs 8.69%). Lowered index (TBBMC/LBM) was in 31% of patients with CF. The values of MAMA and LBM were reduced in respectively 31.8% and 42.1% patients with cystic fibrosis (p=0.02; p=0.001). The obtained results pointed the delayed height age in relation to calendar age in both groups, however, it was significantly bigger in CF group. Within MAFA, chest circumference and other skinfolds there was no statistic difference. ConclusionsThe deficiency of body weight, height and reduced skinfold thickness of triceps confirmed a problem of malnutrition in the disease unit. The non-invasive methods of assessment of physical development allow to estimate the progress of disease and the presumptive modification of dietary treatment.

Hyperleptinemia positively correlated with metabolic syndrome in renal transplant recipients

Our aim was to evaluate the relationship between metabolic syndrome and fasting serum leptin concentration in renal transplant recipients. Fasting blood samples were obtained from 55 renal transplant recipients. Metabolic syndrome and its components were defined using the diagnostic criteria of the International Diabetes Federation. Thirteen patients (23.6%) had metabolic syndrome. Fasting leptin concentrations were positively correlated with metabolic syndrome (p=0.003). Univariate linear regression analysis indicated fasting serum leptin values were positively correlated with waist circumference (r=0.284; p=0.036), body mass index (r=0.358; p=0.007), body fat mass (r=0.610; p<0.001), triglycerides (r=0.268; p=0.048), high-sensitivity C-reactive protein (hs-CRP) (r=0.377; p=0.005), triceps skinfold (r=0.335; p=0.012), and mid-arm fat area (r=0.351; p=0.009). Multivariate forward stepwise linear regression analysis of the significant variables revealed that body fat mass (R2 change=0.373; p<0.001) and hs-CRP (R2 change=0.045; p=0.049) were the independent predictors of fasting serum leptin concentration. Serum leptin concentration correlates positively with metabolic syndrome in renal transplant recipients.

Excess Weight and Adiposity in Children and Adolescents in Havana, Cuba: Prevalence and Trends, 1972 to 2005

Rising prevalence of excess weight in children and adolescents is a serious public health problem in both developed and developing countries, associated with a growing burden of chronic non-communicable diseases in youth and adults. In Cuba, population-based growth and development surveys have been conducted since the 1970s, the latest in 2005. Estimate prevalence of overweight, obesity and high adiposity in children and adolescents aged -19 years in Havana, Cuba, in 1972, 1993 and 2005, and describe secular trends in these conditions in the periods observed. A retrospective, descriptive study examined data from growth and development surveys conducted in Havana in 1972, 1993 and 2005, which obtained Body Mass Index (BMI) and left mid-arm fat area (MAFA) in the population aged < or =19 years using probabilistic sampling and comparable methods of anthropometric measurement and data verification, processing and analysis. Age- and sex-specific percentiles were used as cutoff points for diagnosing overweight, obesity and high adiposity in 3 age groups (early childhood: <5 years; childhood: 5-9 years; and adolescence: 10-19 years). Descriptive statistics were used to calculate prevalence, expressed as a percentage of the population surveyed in each nutritional status category, by sex, age group and survey year. Trends were established by comparing prevalence in 3 periods: 1972-1993, 1993-2005 and 1972-2005. Statistical significance of the percentage differences between survey years in each period was calculated using 95% confidence intervals (CI). Prevalence of excess weight (overweight + obesity) in the study population was 15.3% in 1972, 9.6% in 1993, and 16.4% in 2005, and was more frequent in males but varied by age group and survey year. Prevalence of high adiposity decreased from 13.3% in 1972 to 12.7% in 1993, increasing significantly to 28.8% in 2005. High adiposity was more frequent in males and decreased as age increased, except in children aged <5 years, who had lowest adiposity in 1972. While excess weight predominated over high adiposity in 1972 (15.3% and 13.3%, respectively), this relationship was reversed in 1993 (9.6% excess weight vs 12.7% high adiposity) and continued as a growing trend in 2005 (16.4% excess weight vs 28.8% high adiposity). Prevalence of excess weight and high adiposity generally declined during economic crisis and scarcity, and rose as the economy improved. Continued monitoring is required to detect sustained or rising prevalence of these conditions and to develop interventions to reduce health risks.

Nutritional status of patients with biliary atresia and autoimmune hepatitis related to serum levels of vitamins A, D and E

Chronic liver disease may induce to malabsorption of lipids and fat-soluble vitamins, leading to injury of nutritional status. To evaluate the nutritional status of pediatric-age patients with autoimmune hepatitis and biliary atresia related to serum levels of vitamins A, D and E and the disease severity. This controlled transverse study, evaluated the patients with autoimmune hepatitis and biliary atresia and a reference group paired by sex and age. The patients underwent anthropometric evaluation, alimentary inquiry and determination of serum levels of vitamins A, D and E by high performance liquid chromatography. The Mann-Whitney test, Spearman correlation coefficients and variance analysis (ANOVA) were utilized for data treatment, regarding significant difference if P<0.05. The highest nutritional deficit was observed in patients with biliary atresia, mainly with cholestasis. The serum levels of vitamins A and E for the reference group changed as a function of age. The serum levels of vitamins A, D and E were higher in reference group than in patients with biliary atresia and autoimmune hepatitis together or separately. There were not difference in the serum levels of vitamins A, D and E between biliary atresia groups with cholestasis and without cholestasis. It was verified correlation between weight/age, triceps skinfold thickness, subscapular skinfold thickness, midarm circumference, midarm fat area values and vitamin A serum levels, as well as between all anthropometric indicators and vitamin E in patients with autoimmune hepatitis and biliary atresia. The patients with biliary atresia and cholestasis presented the highest nutritional injury. The patients with biliary atresia and autoimmune hepatitis presented lower serum levels of vitamins A, D and E that in control group. There is a directly proportional correlation between vitamin serum levels, mainly vitamin E, and all anthropometric variables of biliary atresia and autoimmune hepatitis groups.

Validation of Percent Body Fat Indicators in Pediatric Oncology Nutrition Assessment

Given the high prevalence of malnutrition and potential impact nutritional status can have on a child undergoing treatment for cancer, it is vital that oncology centers regularly assess nutritional status. It is important that simple noninvasive anthropometric nutrition assessment measures correlate to more accurate body composition measures. The aim of this study was to determine the relationship between anthropometric measures and percent body fat determined via air displacement plethysmography in the children being treated in a pediatric oncology and hematology department. This cross-sectional study measured height, weight, percent ideal body weight (%IBW), mid arm circumference, triceps skinfolds, and mid upper arm fat area in 23 children. These anthropometric variables were compared against the reference measure of percent body fat via air displacement plethysmography. Correlational analysis and general linear models showed that there was a significant statistical relationship between percent body fat and body mass index Z score, %IBW, mid arm circumference, triceps skinfolds, and arm fat area. Simple anthropometric measurements of %IBW and triceps skinfolds are good indicators of percent body fat and should be incorporated into regular nutrition assessment of the pediatric oncology patient.

Effects of HIV Infection on Body Composition Changes Among Men of Different Racial/Ethnic Origins

Purpose: To compare racial/ethnic differences and effects of HIV on body composition among antiretroviral (ART)-naïve HIV seropositive (HIV+) men to a representative sample of HIV seronegative (HIV-) men. We hypothesized that the effect of HIV infection will be uniform across all racial/ethnic groups. Method: A cross-sectional analysis was performed comparing HIV- (NHANES 1999-2002) and ART-naïve HIV+ men (CPCRA 061). Regional subcutaneous fat area was estimated by skinfold caliper. Total body fat (TBF), fat-free mass (FFM), and body fat index (BFI) were derived by Durnin-Womersley formula (TBF-DW, FFM-DW, BFI [TBF-DW/height2]). Bioelectric impedance analyses (BIA) was used to assess TBF-BIA, FFM-BIA, and body cell mass (BCM). Multivariate regression modeling adjusted for age, smoking, and hepatitis C for each measurement was performed. Results: HIV+ men (n = 321) were older and more likely to be smokers than HIV- men (n = 1,996). The HIV- men were heavier in weight (+17.8 kg, p < .001) and had higher BMI (+4.3 kg/m2, p < .001), BCM (+2.4 kg, p = .02), FFM (+5.9 kg, p < .001), TBF-DW (+5.95 kg, p < .001), BFI (+1.6 kg/m2, p < .001), and regional fat mass than the HIV+ men. In the multivariate model, there were significant percentage differences between HIV− and HIV+ African American men for all body composition measurements (weight +15.3%; BMI +14.5%; BCM +5.2%; TBF-DW +15%; BFI 13.9%; FFM-DW 7.9%) and all circumference and skinfold measurements; all ps < .05. For Caucasian men, the following differences were significant between HIV- and HIV+: weight +14.4%; BMI +14.0%; BCM +6.0%; TBF-DW +17.7%; BFI 17.1%; FFM-DW 8.7%; and all circumference and skinfold measurements. Similarly, among Latino men the following differences were significant: weight +10.1%; BMI +12.3%; FFM-DW +7.7%; and arm, waist, and thigh circumferences and mid-arm skinfold fat area. The interaction terms for race/ethnicity were not significant across the three racial groups for weight, BMI, BCM, TBF-BIA, and BFI. Conclusion: Compared to HIV uninfected men, among HIV-infected ART-naïve men there was a significant effect of HIV infection itself on body composition among all racial/ethnic groups.

Serum Prealbumin and Albumin Concentrations do not Reflect Nutritional State in Children with Cerebral Palsy

Serum prealbumin concentration (PALB) and albumin concentration (ALB) were evaluated as markers of undernutrition in 107 children with cerebral palsy (CP) age 2 to 18 years. PALB and ALB were rarely below the normal reference ranges and showed little to no correlation with anthropometric measures (eg, skinfolds, midarm fat area), growth (height), severity of CP (eg, feeding dysfunction, motor impairment), or general health.

Grip Strength as an Index for Assessment of Nutritional Status of Children Aged 6-10 Years

The purpose of this study was to evaluate the use of grip strength as an index of nutritional status in 6-10 y old children. Seven hundred and eighty seven children (364 boys and 423 girls) in the age group of 6 to 10 y were selected from private and municipal schools, orphanages and slums in the cities of Mumbai and Pune, India. Grip strength was measured using the dominant hand. Height, weight, mid-arm circumference and triceps skinfold were also measured in all subjects. A significantly high correlation (p<0.01) was observed between grip strength and age for both sexes. Boys had a higher grip strength than girls at all ages. Grip strength was significantly correlated with height, weight, mid arm circumference, triceps skinfold, arm fat and arm muscle areas (p<0.01). Stepwise multiple regression analyses showed height, weight, triceps skinfold and age to be independent variables influencing grip strength. Grip strength was found to be a specific measure of lean body mass (75 to 94%), but sensitivity was quite low (about 25%). The positive predictive value was variable, ranging from 54.6 to 21.5%. The specificity, sensitivity and positive predictive values were very high when compared with arm muscle area. Grip strength may have a potential value as an additional test for nutritional assessment in field situations and clinical settings.

Avaliação do estado nutricional de crianças e adolescentes com insuficiência renal crônica

the purpose of this study is to evaluate the nutritional status of children and teenagers with chronic renal (CRF) failure using anthropometric measurements. 41 children and adolescents with (CRF) (creatinine "clearance" < 50 ml/min/1,73m(2)) followed at the Pediatric Nephrology Unit (HC-UNICAMP), between January 1995 and November 1996, were evaluated by the assessment of anthropometric measurements, mid upper arm circunference (MUAC) and triceps skinfold (TSF). With these measurements, mid arm fat area (MUAFA) and arm muscle area (AMA) were calculated and its z-scores. These measurements were performed twice at least, ranging from 0.21 to 1.3 years (0.88 +/- 0.04). all the z-scores (MUAC, TSF, MUAFA and AMA) were very low, and only the AMA z-score was statistically significant (p= 0,03 Wilcoxon test). The patients were divided in to groups, according to their treatment, and the MAC z-score for the renal transplantation group was statistically significant (p= 0,02 Wilcoxon test). these data demonstrate a compromised nutritional status from both muscle and fat stores, with an improvement in muscle stores.

Long-term nutritional and neurodevelopmental outcome of liver transplantation in infants aged less than 12 months.

Liver transplantation is established treatment for children with end-stage liver disease and has a 5-year survival rate of 80% to 85%, even in infants under 12 months. Long-term outcome in nutritional rehabilitation and normal development is unknown. This study aimed to prospectively evaluate growth and psychoneurologic performance of children who undergo liver transplantation in infancy. Twenty-five infants (18 girls, 7 boys) who underwent liver transplantation at less than 12 months of age (median age, 9 months) were evaluated for 4 years. Growth measurements were expressed as standard deviation scores (SDSs; mean +/- SEM), and psychoneurologic performance was assessed with the unrevised Griffiths Mental Ability Scales (normal range, 80-120). Four children died during the study (4-year survival, 84%). The children were malnourished before transplantation (SDSs: weight, -1.9 +/- 0.2; midarm muscle area, -0.93 +/- 0.3; midarm fat area, -1.52 +/- 0.3; and height, -0.95 +/- 0.3). Nutritional rehabilitation for all parameters occurred within 12 to 24 months after transplantation, which was most significant for weight (-1.1 +/- 0.2, P = 0.001), midarm muscle area (0.74 +/- 0.3, P = 0.001), and midarm fat area (-0.44 +/- 0.3, P = 0.01). There was some improvement in height (-0.72 +/- 0.3, P = 0.14), which was not significant, although infants who were severely stunted before transplantation (mean height standard deviation score [SDS] -2.46) showed significant catch-up at 1 year after transplantation (mean height SDS -1.2, P = 0.003). Psychoneurologic scores were within normal limits before transplantation and were maintained for the 4-year follow-up period, although individual scores varied during this period. Improved nutritional status was associated with increased muscle bulk and subsequent improvement in motor scores from 90.6 at initial assessment to 97.3 at 4 years (P = 0.28). There was a temporary reduction in social skills and eye-hand coordination in the first year, which may have been an effect of the hospital environment or cyclosporine immunosuppression. Language abilities also regressed during the first year, possibly related to the effect of nasogastric tube feeding in delaying normal speech development. Liver transplantation in infancy has not only a successful outcome but is also associated with long-term catch-up growth and nutrition and maintenance of normal development.

Does malnutrition affect survival in cirrhosis?

A total of 1,053 cirrhotic patients were included in a prospective study to determine whether malnutrition is a risk factor for mortality in cirrhotic patients. Child-Pugh classification as well as clinical and biochemical variables were used to assess the severity of cirrhosis. Nutritional status was evaluated both by anthropometric and clinical measurements. Patients were defined as malnourished when midarm muscle area (MAMA) and/or midarm fat area (MAFA) were below the 5th percentile of an age- and sex-matched population. During follow-up, 419 patients died. The estimated survival rate was 82.7% at 1 year, 65.1% at 3 years, and 50.7% at 5 years. The presence of muscle depletion and/or of a steep reduction in fat deposits was associated with a higher risk of mortality (midarm muscle area, < 5th percentile, relative risk = 1.79; midarm fat area, < 5th percentile, relative risk = 1.35). When patients were stratified according to the Child-Pugh classification, cumulative survival was lower in patients with a reduction in muscle mass in Child-Pugh classes A and B (log rank: P = .027; P = .022, respectively) but not in class C. Conversely, a significant reduction in adipose tissue deposits appeared to have no independent impact on survival in any Child-Pugh class. When examined using a multivariate Cox proportional hazard analysis, age, sex, bilirubin, cholinesterase, ascites, and esophageal varices were selected, whereas the parameters of nutritional status were not. This suggests that malnutrition, while strongly associated with the deterioration of liver function, cannot be considered an independent risk factor for mortality in a general population of cirrhotic patients.

Does malnutrition affect survival in cirrhosis?

A total of 1,053 cirrhotic patients were included in a prospective study to determine whether malnutrition is a risk factor for mortality in cirrhotic patients. Child-Pugh classification as well as clinical and biochemical variables were used to assess the severity of cirrhosis. Nutritional status was evaluated both by anthropometric and clinical measurements. Patients were defined as malnourished when midarm muscle area (MAMA) and/or midarm fat area (MAFA) were below the 5th percentile of an age- and sex-matched population. During follow-up, 419 patients died. The estimated survival rate was 82.7% at 1 year, 65.1% at 3 years, and 50.7% at 5 years. The presence of muscle depletion and/or of a steep reduction in fat deposits was associated with a higher risk of mortality (midarm muscle area, < 5th percentile, relative risk = 1.79; midarm fat area, < 5th percentile, relative risk = 1.35). When patients were stratified according to the Child-Pugh classification, cumulative survival was lower in patients with a reduction in muscle mass in Child-Pugh classes A and B (log rank: P = .027; P = .022, respectively) but not in class C. Conversely, a significant reduction in adipose tissue deposits appeared to have no independent impact on survival in any Child-Pugh class. When examined using a multivariate Cox proportional hazard analysis, age, sex, bilirubin, cholinesterase, ascites, and esophageal varices were selected, whereas the parameters of nutritional status were not. This suggests that malnutrition, while strongly associated with the deterioration of liver function, cannot be considered an independent risk factor for mortality in a general population of cirrhotic patients. (Hepatology 1996 May;23(5):1041-6)

Nutritional status in cirrhosis

Malnutrition frequently occurs in patients with chronic liver disease and may represent a risk factor influencing both short- and long-term survival in these patients. Previously published studies have tended to be confined to alcoholic patients and there are few data on the prevalence of nutritional abnormalities in patients with cirrhosis not of alcoholic origin. Anthropometric measurements and a clinical evaluation of the nutritional status of 1402 patients with cirrhosis (883 males and 519 females) were recorded between january 1988 and 1989 by the Italian Multicentre Cooperative project on Nutrition in Liver Cirrhosis. The origin of liver disease was alcohol-related in 37% of patients. Child-Pugh criteria were used to establish the severity of the liver disease. Patients with cirrhosis exhibited a wide range of nutritional abnormalities. While 29% of females and 18% of males appeared to be overnourished, a significant reduction in fat stores, as estimated by the mid-arm fat area, and/or muscle mass, as estimated by mid-arm muscle area, was observed in 30% of patients with cirrhosis. The prevalence of signs of nutritional depletion increased in both sexes as liver function deteriorated. Mean values for mid-arm fat area decreased by 30% in males and by 40% in females with moderate to severe liver failure (Child-Pugh Classes B and C). The reduction in mid-arm muscle area was more evident in males (17% decrease) than in females (9% decrease). Patients with alcohol-related cirrhosis showed a higher prevalence of malnutrition and had more frequent severe liver impairment (Child-Pugh Classes B and C). Overall, the clinical judgement differed from the anthropometric assessment in 23% of patients, suggesting the need to introduce some simple anthropometric measurements in the evaluation of the nutritional status in patients with cirrhosis. Malnutrition frequently occurs in patients with chronic liver disease and may represent a risk factor influencing both short- and long-term survival in these patients. Previously published studies have tended to be confined to alcoholic patients and there are few data on the prevalence of nutritional abnormalities in patients with cirrhosis not of alcoholic origin. Anthropometric measurements and a clinical evaluation of the nutritional status of 1402 patients with cirrhosis (883 males and 519 females) were recorded between january 1988 and 1989 by the Italian Multicentre Cooperative project on Nutrition in Liver Cirrhosis. The origin of liver disease was alcohol-related in 37% of patients. Child-Pugh criteria were used to establish the severity of the liver disease. Patients with cirrhosis exhibited a wide range of nutritional abnormalities. While 29% of females and 18% of males appeared to be overnourished, a significant reduction in fat stores, as estimated by the mid-arm fat area, and/or muscle mass, as estimated by mid-arm muscle area, was observed in 30% of patients with cirrhosis. The prevalence of signs of nutritional depletion increased in both sexes as liver function deteriorated. Mean values for mid-arm fat area decreased by 30% in males and by 40% in females with moderate to severe liver failure (Child-Pugh Classes B and C). The reduction in mid-arm muscle area was more evident in males (17% decrease) than in females (9% decrease). Patients with alcohol-related cirrhosis showed a higher prevalence of malnutrition and had more frequent severe liver impairment (Child-Pugh Classes B and C). Overall, the clinical judgement differed from the anthropometric assessment in 23% of patients, suggesting the need to introduce some simple anthropometric measurements in the evaluation of the nutritional status in patients with cirrhosis.

Growth and body composition of periurban Guatemalan children in relation to zinc status: a cross-sectional study

In a study of periurban Guatemalan school-children (89 males, 73 females) aged 81.5 +/- 7.0 mo (mean +/- SD), height, weight, arm circumference, and triceps-skinfold-thickness (TSF) measurements were examined in relation to plasma and hair zinc concentrations, plasma and red blood cell alkaline phosphatase activities, recognition thresholds for salt (RTS), delayed-cutaneous hypersensitivity response to seven recall skin test antigens, and cognitive measures. Children were stunted [median height-for-age (HA) Z score -1.49] but not wasted [median weight-for-height (WH) Z score 0.20], with median midarm muscle area (MAMA) and midarm-fat area (MAFA) Z scores of -0.57 and -0.35, respectively. Of the children, 63.5% of males and 44.1% of females had hair zinc < 1.68 mumol/g (P < 0.05); 12.3% of males and 1.5% of females had plasma zinc < 10.71 mumol/L (P < 0.05). Children with hair zinc < 1.68 mumol/g had higher (P < 0.05) medians for WA Z and WH Z scores, RTS, and phytic acid intake than did those with hair zinc > or = 1.68 mumol/g. Zinc status explained some of the variance in growth (HA, WA, and WH Z scores), body composition (MAFA Z scores), and taste acuity. Suboptimal zinc status arose partly from diets low in readily available zinc.

Use of Internal Validity in the Construct of an Index of Undernutrition

An index of undernutrition (IOU) has been developed from a crosssectional study of 200 general surgical patients. The IOU was constructed using a ranking method based upon the relative values of anthropometric measurements (weight loss, mid-arm muscle area, mid-arm fat area) and serum protein concentrations (albumin, transferrin). The IOU was derived without reference to the incidence of adverse clinical events and took the form of a boolean cluster. A subsequent prospective longitudinal study evaluated the IOU in 367 general surgical patients at the time of admission to hospital. The results of this study supported the validity of the IOU. There was no association between gender and IOU scores. However, patients with high scores were more likely to be elderly (p less than 0.02), have cancer (p less than 0.001), stay in hospital longer (p less than 0.001), or experience an adverse clinical event after surgery (p less than 0.001). In accord with other published indices of undernutrition, the association between the extent of undernutrition and the incidence of adverse clinical events was only of moderate diagnostic potential (overall accuracy 68%). This study demonstrates that it is possible to derive an index of protein-energy undernutrition that is independent of the incidence of adverse clinical events.