Learning Objectives. BMI vs. Body Composition. Assessment. Screening. Prado Draft Presentation

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Nutritional Science @UofANutrition Learning Objectives Identify commonly used techniques to assess body composition in clinical settings Describe the importance of body composition assessment across

1 BODY COMPOSITION ASSESSMENT: A NEW ERA FOR NUTRITIONAL ASSESSMENT AND INTERVENTION Dr. Carla Prado, PhD, RD Assistant Professor & Campus Alberta Innovates Program (CAIP) Chair in Nutrition, Food & Health Director, Human Nutrition Research Unit Department of Agricultural, Food and Nutritional Learning Objectives Identify commonly used techniques to assess body composition in clinical settings Describe the importance of body composition assessment across the continuum of care Discuss the impact of nutrition interventions to optimize body composition All patients Screening Is the patient at nutritional risk? Quick, inexpensive and practical Assessment More intensive and through Needs intervention/follow-up Must include detailed measurements Longer time, more measurements, cost may be higher, in depth information BMI vs. Body Composition BMI is an easy, simple assessment Generally accepted as an overall predictor of morbidity and mortality Its main limitation is due to differences in body composition Adapted from Jyothi Prasad & Charney. Nutrition in Clinical Practice v.23, 2008: 366 Curr Opin Clin Nutr Metab Care Sep;20(5): Summary BMI, as the traditional tool for assessing malnutrition and obesity, is not appropriate to accurately differentiate between important body weight components and therefore should not be used for making clinically important decisions at the individual patient level. 1

2 BMI Limitations Same Body Weight Person A Person B Person C Lean Mass Fat Mass Prado et al. Curr Opin Nutr Metab Care. 2015;18: Different Body Weight, same Lean Mass LOW LEAN MASS Who is at Risk? Lean Mass Fat Mass Carneiro et al. Curr Oncol Rep. 18(10):62, 2016 Obesity Diabetes Aging HIV/AIDS Hospitalized Patients Rheumatoid Arthritis LOW LEAN MASS Cancer Chronic Obstructive Pulmonary Disease Cardiovascular Conditions Count (N) Body mass index (kg/m 2 ) Prevalence sarcopenia (%) Prado et al. Proc Nut Soc v.75(2):188 2

LEAN MASS: MUSCLE FUNCTION In individuals identified by screening as at risk of malnutrition,

5 kg/m 2 ), OR - combined finding of weight loss together with either reduced BMI

2 or more: Insufficient energy intake Weight loss Loss of lean mass Loss of subcutaneous fat

functional status as measured by handgrip strength Strength & Power Posture & Balance Mobility

immunity éinfection Physical impairment No wound healing 30% Loss 20% Loss Weakness êhealing

Small radiation - Accessible - Low cost & burden - Portable - Phase angle - Useful for

- Accessibility - Weight > 450lbs (idxa only) - Extreme hydration changes -Assumes constant

3 LEAN MASS: MUSCLE FUNCTION In individuals identified by screening as at risk of malnutrition, the diagnosis of malnutrition should be based on either: - a low BMI (<18.5 kg/m 2 ), OR - combined finding of weight loss together with either reduced BMI (age-specific) or a low lean mass using sexspecific cut-offs. 2 or more: Insufficient energy intake Weight loss Loss of lean mass Loss of subcutaneous fat Localized or generalized fluid accumulation that may sometimes mask weight loss Diminished functional status as measured by handgrip strength Strength & Power Posture & Balance Mobility Regulates Blood Glucose Stores Proteins Loss of Lean Mass - Trajectory 10% Loss Impaired immunity éinfection Physical impairment No wound healing 30% Loss 20% Loss Weakness êhealing BODY COMPOSITION ASSESSMENT Death 40% Loss - Quick - 3 compartments - Appendicular muscle - Small radiation - Accessible - Low cost & burden - Portable - Phase angle - Useful for longitudinal changes - Portable - Less costly - Quicker - No radiation - Separate VAT and SAT - Accessibility - Weight > 450lbs (idxa only) - Extreme hydration changes -Assumes constant hydration factor -Not accurate in extreme BMIs (<16 or > 34 kg/m 2 ) - Nine anatomical sites needed for the analysis. - Sensitive to severe altered water balance - Protocol - Precise - Tissue analysis - Cancer & others: COPD, HIV, CVD, Kidney disease, Cirrhosis - Radiation - Opportunistic only 3

US Video When the US beam encounters tissue with different acoustical impedance, a part of the sound is reflected and the brighter region in the US image

, Age & Ageing 2010;39:412-23 Grip Strength Calf Circumference - It is important that the position of the subject is standardized: sitting, shoulders

, Age & Ageing 2010;39:412-23 The Jamar hydraulic dynamometer presents higher intra and inter-individual reliability http://www.prohealthcareproducts.

4 US Video When the US beam encounters tissue with different acoustical impedance, a part of the sound is reflected and the brighter region in the US image is created. EWGSOP-suggested algorithm for sarcopenia case finding in older individuals Cruz-Jentoft et al., Age & Ageing 2010;39: Grip Strength Calf Circumference - It is important that the position of the subject is standardized: sitting, shoulders relaxed, the elbow in a 90-degree angle, the upper arm not touching the body. Cruz-Jentoft et al., Age & Ageing 2010;39: The Jamar hydraulic dynamometer presents higher intra and inter-individual reliability times; two times for each leg - Flexible tape - The tape measure is placed around the calf without compressing the subcutaneous tissue - The tape is moved along the length of the calf to obtain the maximal circumference. 4

Calf Circumference CLINICAL CONSEQUENCES <33 for males and females: Bahat Clin Nutr. 2016 Dec; 35(6):1557-1563. <34 cm for males and females: Kawakami et al. Geriatr Gerontol Int.

Inversely correlated with mortality Low circumference à indicator of malnutrition among elderly people Validity lower for women Low Lean Mass in a Cohort of People Seeking Obesity Treatment N=120 Age

5 Calf Circumference CLINICAL CONSEQUENCES <33 for males and females: Bahat Clin Nutr Dec; 35(6): <34 cm for males and females: Kawakami et al. Geriatr Gerontol Int Aug;15(8): <31 cm for females: greater frailty and impaired physical function: Rolland et al J Am Geriatr Soc Aug;51(8): Inversely correlated with mortality Low circumference à indicator of malnutrition among elderly people Validity lower for women Low Lean Mass in a Cohort of People Seeking Obesity Treatment N=120 Age = 46 ±11 years BMI = 44.7 ± 6.3 kg/m 2 Lean Mass (kg) Variable Lean Mass Females Male Body Mass Index (kg/m 2 ) Johnson Stoklossa et al., 2017 J Nutr Metab. Article ID Difficulty with activities of daily living 1. Transfers 2. Falls 3. Wash body 4. Skin problem 5. Wipe self 6. Dress self 7. Tired- housework 8. Tired-leisure 9. Excess skin 10. Access rooms 11. Footwear Multivariate Analysis 3 items of difficulty of ADL Low LM: OR=5.4, p=.003, independent of age, sex and multimorbidity Johnson Stoklossa et al. Current Developments in Nutrition, V2(3). 2018, nzx008 Low Lean Mass in Cancer Low Lean Mass Normal Lean Mass BMI = 30.3 kg/m 2 and BSA = 2.07 m 2 Prado et al. Curr Opin Nutr Metab Care 2015, v. 18, 2015 Lean Mass Fat Mass 5

DOSE LIMITING TOXICITY Incidence of dose-limiting toxicity is increased in people with low LM Low Lean Mass Grades 1 Mild 2

Dose Limiting Toxicity % of patients with dose-limiting toxicity 100 90 80 70 60 50 40 30 20 10 0 5FU Capecitabine Adjuvant FEC

2016; 75:188-198 Normal Lean Mass Glomerular Filtration Rate Cardiac Output Low Lean Mass Renal Blood Flow u 995 consecutive

Flow u Patients were measured in the emergency room within 3h after admission BMI 20 17.

9% Low BMI: 73% Normal BMI: 31% LOW LEAN MASS AND SURVIVAL Population: Kaiser Permanente of Northern California Cancer Registry

6 DOSE LIMITING TOXICITY Incidence of dose-limiting toxicity is increased in people with low LM Low Lean Mass Grades 1 Mild 2 Moderate 3 Severe 4 Life threatening 5 Fatal - Dose delays - Dose reductions - Treatment termination - Hospitalization - Death Dose Limiting Toxicity % of patients with dose-limiting toxicity FU Capecitabine Adjuvant FEC Sorafenib Sorafenib Sunitinib Vandetanib Fluoropyrimidine Imatinib ECX & CF Prado et al. Proc Nut Soc. 2016; 75: Normal Lean Mass Glomerular Filtration Rate Cardiac Output Low Lean Mass Renal Blood Flow u 995 consecutive patients u Patients admitted to the emergency centre for medical or surgical reasons and subsequently hospitalized Hepatic Blood Flow u Patients were measured in the emergency room within 3h after admission BMI % Low Lean Mass FFM 10 th P 31% Serum Albumin 35 g/l 14.9% Low BMI: 73% Normal BMI: 31% LOW LEAN MASS AND SURVIVAL Population: Kaiser Permanente of Northern California Cancer Registry and Electronic Medical Records, N=3276, stage I III CRC, ages BMI and albumin significantly underestimated the prevalence of malnutrition in patients at hospital admission Optimal nutritional assessment should therefore include objective measurements of body composition 6

Cancer Epidemiol Biomarkers Prev. 2017; 26:1008-1015 #At risk: Survivor Function Estimate 1 0.9 0.8 0.7 0.6 0.5 Overall log-rank p=0.01 0 2 4 6 8 10 No.

surgery Infection ICD-10 code ( 1) recorded (n%) Inpatient rehabilitation care code ( 1) recorded (n%) Normal Low LM P- value 5 (8.8) 16 (29.6) 0.005 8 (5.6) 13 (14.3) 0.024 Mean LOS (days) 13.1 ± 8.

008 Length of Hospital Stay, Complications & Readmissions Patients with low lean mass are significantly more expensive to care for Mean adjusted payer cost for major general elective surgery by lean

7 Cancer Epidemiol Biomarkers Prev. 2017; 26: #At risk: Survivor Function Estimate Overall log-rank p= No. of years since diagnosis Normal Not Normal Sarcopenic Low Lean Sarcopenic Mass Low LM is association with postoperative infection and delayed recovery from CRC resection surgery Infection ICD-10 code ( 1) recorded (n%) Inpatient rehabilitation care code ( 1) recorded (n%) Normal Low LM P- value 5 (8.8) 16 (29.6) (5.6) 13 (14.3) Mean LOS (days) 13.1 ± ± Length of Hospital Stay, Complications & Readmissions Patients with low lean mass are significantly more expensive to care for Mean adjusted payer cost for major general elective surgery by lean mass Xiao et al. Unpublished results Percentile of LM Jeffrey Friedman et al. Nutr Clin Pract 2015;30:175 Low Lean Mass & mortality in older people living in a nursing home 44% patients with low LM died vs. 15% patients with normal LM Nursing home residents - BIA - Handgrip strength - Gait speed Mortality assessed at the end of 2 years European Working Group on Sarcopenia in Older People criteria Low LM: 29% Severe LM depletion: 25.4% Geriatrics & Gerontology International GGI R2, 20 JUL 2016 DOI: /ggi Controlled for age, sex, BMI, DM, COPD, dementia, CVD, calf circumference, osteoarthritis, ADL, MMSE 7

Low lean mass is a powerful and independent predictor of poorer prognosis Shorter survival Physical impairment/ disability Greater length of hospital stay CAN NUTRITION PREVENT/ REVERSE LEAN MASS

Post-operative complications Low Lean Mass Age related Sex hormones Apoptosis Mitochondrial dysfunction Endocrine Corticosteroids, GH, IGF-1, IR, abnormal thryroid function Neurological Motor neuron

8 Low lean mass is a powerful and independent predictor of poorer prognosis Shorter survival Physical impairment/ disability Greater length of hospital stay CAN NUTRITION PREVENT/ REVERSE LEAN MASS LOSS? Low Lean Mass Poorer quality of life Need for rehabilitation Disease progression JPEN 2014; 38:940 Proc Nutr Soc. 2016;75:188. Post-operative complications Low Lean Mass Age related Sex hormones Apoptosis Mitochondrial dysfunction Endocrine Corticosteroids, GH, IGF-1, IR, abnormal thryroid function Neurological Motor neuron loss Inadequate nutrition Nutrients under consideration for treatment of low lean mass Disuse Immobility Lack of physical activity Treatment/ Surgery Adapted from: Cruz-Jentoft et al., Age & Ageing 2010;39: Prado & Purcell. In Preparation POSITIVE FUTURE FOR NUTRITION INTERVENTION Lean mass can be changed. Anabolism is similar to healthy young adults. Deutz et al. Clin Nutr 2011;30:759 Low LM is reversible even in older adults with deconditioning, inflammation and concurrent comorbid conditions. Current Opinion Critical Care 2016, v. 22, p279. 8

Nutritional Screening Monitoring and Evaluation

Body composition evaluation should be integrated

Allow objective, systematic, and early screening

early initiation of optimal nutritional support,

malnutrition-induced morbidity, mortality,

condition: indication for treatment Enable

ICD-10 Code for Sarcopenia (Low LM) Basis for

to influence public health & health policy

Mario Siervo Dr. Sunita Gosh Dr. Arya Sharma Dr.

Camila Pinto Carlene Johnson Stoklossa Camila

9 Nutritional Screening Monitoring and Evaluation Nutritional Assessment Nutritional Intervention Nutritional Diagnosis Ann Nutr Metab. 2012;60(1):6-16. Body composition evaluation should be integrated into routine clinical practice for the initial assessment and sequential follow-up of nutritional status. Allow objective, systematic, and early screening of malnutrition and promote the rational and early initiation of optimal nutritional support, thereby contributing to reducing malnutrition-induced morbidity, mortality, worsening of the quality of life, and global health care costs. ñawareness and attention Acceptance as a condition: indication for treatment Enable storage and retrieval of diagnostic information ICD-10 Code for Sarcopenia (Low LM) Basis for reimbursement and resource allocation Potential to influence public health & health policy ACKNOWLEDGMENTS COLLEAGUES: Dr. Cristina Gonzalez Dr. Bette Caan Dr. Nicolaas Deutz Dr. Marielle Engelen Dr. Mario Siervo Dr. Sunita Gosh Dr. Arya Sharma Dr. Michael Sawyer Stephanie Ramage PRADO S LAB Camila Pinto Carlene Johnson Stoklossa Camila Orsso Leticia Pereira Camila Pinto Sarah Purcell Amanda Purkiss Claire Trottier Jingjie Xiao Alena Frankish Adapted from: S. Studenski. Implications of a Sarcopenia ICD-10 Code for Further Research and Physicians in Practice (aginginmotion.org) & Aging In Motion Press Release 9

Clinical Nutrition in the 21st Century Malnutrition, sarcopenia and cachexia

Clinical Nutrition in the 21st Century Malnutrition, sarcopenia and cachexia Stéphane M. Schneider, MD, PhD, FEBGH Professor of Nutrition and ESPEN ECPC Chair In proto-indo-european, Latin and Greek Under