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3Background & aims:
Low muscle mass and -quality on ICU admission, as assessed by muscle area and -density on CT-scanning at lumbar level 3 (L3), are associated with increased mortality. However, CT-scan analysis is not feasible for standard care. Bioelectrical impedance analysis (BIA) assesses body composition by incorporating the raw measurements resistance, reactance, and phase angle in equations. Our purpose was to compare BIA- and CT-derived muscle mass, to determine whether BIA identified the patients with low skeletal muscle area on CT-scan, and to determine the relation between raw BIA and raw CT measurements.
Methods:
This prospective observational study included adult intensive care patients with an abdominal CT-scan. CT-scans were analysed at L3 level for skeletal muscle area (cm2) and skeletal muscle density (Hounsfield Units). Muscle area was converted to muscle mass (kg) using the Shen equation (MMCT). BIA was performed within 72 h of the CT-scan. BIA-derived muscle mass was calculated by three equations: Talluri (MMTalluri), Janssen (MMJanssen), and Kyle (MMKyle). To compare BIA- and CT-derived muscle mass correlations, bias, and limits of agreement were calculated. To test whether BIA identifies low skeletal muscle area on CT-scan, ROC-curves were constructed. Furthermore, raw BIA and CT measurements, were correlated and raw CT-measurements were compared between groups with normal and low phase angle.
Results:
110 patients were included. Mean age 59 ± 17 years, mean APACHE II score 17 (11–25); 68% male. MMTalluri and MMJanssen were significantly higher (36.0 ± 9.9 kg and 31.5 ± 7.8 kg, respectively) and MMKyle significantly lower (25.2 ± 5.6 kg) than MMCT (29.2 ± 6.7 kg). For all BIA-derived muscle mass equations, a proportional bias was apparent with increasing disagreement at higher muscle mass. MMTalluri correlated strongest with CT-derived muscle mass (r = 0.834, p < 0.001) and had good discriminative capacity to identify patients with low skeletal muscle area on CT-scan (AUC: 0.919 for males; 0.912 for females). Of the raw measurements, phase angle and skeletal muscle density correlated best (r = 0.701, p < 0.001). CT-derived skeletal muscle area and -density were significantly lower in patients with low compared to normal phase angle.
Conclusions:
Although correlated, absolute values of BIA- and CT-derived muscle mass disagree, especially in the high muscle mass range. However, BIA and CT identified the same critically ill population with low skeletal muscle area on CT-scan. Furthermore, low phase angle corresponded to low skeletal muscle area and -density.
Trial registration:
ClinicalTrials.gov (NCT02555670).
ARTIKEL
Protein supplementation has shown to improve muscle mass in older adults. However, its effect may be influenced by supplementation dose, frequency and timing. This systematic review aimed to assess the effect of dose, frequency and timing of protein supplementation on muscle mass in older adults. Five databases were systematically searched from inception to 14 March 2023, for randomised controlled trials investigating the effect of protein supplementation on muscle mass in adults aged ≥65 years. Random effects meta-analyses were performed, stratified by population. Subgroups were created for dose (≥30 g, <30 g/day), frequency (once, twice, three times/day) and timing of supplementation (at breakfast, breakfast and lunch, breakfast and dinner, all meals, between meals). Heterogeneity within and between subgroups was assessed using I 2 and Cochran Q statistics respectively. Thirty-eight articles were included describing community-dwelling (28 articles, n=3204, 74.6±3.4 years, 62.8 % female), hospitalised (8 articles, n=590, 77.0±3.7 years, 50.3 % female) and institutionalised populations (2 articles, n=156, 85.7±1.2 years, 71.2 % female). Protein supplementation showed a positive effect on muscle mass in community-dwelling older adults (standardised mean difference 0.116; 95 % confidence interval 0.032–0.200 kg, p=0.007, I 2=15.3 %) but the effect did not differ between subgroups of dose, frequency and timing (Q=0.056, 0.569 and 3.084 respectively, p>0.05). Data including hospitalised and institutionalised populations were limited. Protein supplementation improves muscle mass in community-dwelling older adults, but its dose, frequency or timing does not significantly influence the effect.
OVERZICHTSARTIKEL
Rationale: Sarcopenia is a major problem and is common in community-dwelling elderly. In daily practice, there is need for low cost and easily assessable measurement tools to assess depletion of skeletal muscle (SM) mass, for example as one of the indicators of sarcopenia. Bio-electrical impedance analysis (BIA) is often used to estimate body composition, whereas ultrasound measurement is an upcoming and promising tool, as it is quick, easy to use and inexpensive in comparison with other tools that assess SM mass. Ultrasound could assess site-specific loss of SM mass and determine myoesteatosis. Therefore, in this pilot study we aimed to assess agreement between muscle thickness of rectus femoris (RF) by ultrasound and SM mass by BIA in an older population.
Methods: Twenty-six older adults (mean± standard deviation (SD) age 64 ±5.0 y, 62% women) from the Hanze Health and Ageing Study were included. SM mass by BIA was estimated using the Janssen equation. Muscle thickness of RF was assessed by analyzing ultrasound images from the right leg. Two non-parametric tests were used for analysis. Correlation between ultrasound and BIA was assessed with Spearman Rho. Agreement was determined with Kendall’s coefficient of concordance (Kendall’s W). In both tests a score ≥ 0.7 was considered a strong correlation.
Results: Mean (±SD) RF thickness was 18.9 (±3.8) mm. Median SM mass (Interquartile range) was 23.5 (20.8-34.7) kg. Correlation between RF thickness and SM mass was moderately positive (Spearman r=0.611; P = 0.001), whereas Kendall’s W showed a strong agreement (W= 0.835; P=0.002).
Conclusion: Ultrasound measurement of RF showed an acceptable agreement with skeletal muscle mass assessed by BIA in our sample of older adults. Therefore, ultrasound could be a promising portable tool to estimate muscle size.
POSTER
Background
ICU patients lose muscle mass rapidly and maintenance of muscle mass may contribute to improved survival rates and quality of life. Protein provision may be beneficial for preservation of muscle mass and other clinical outcomes, including survival. Current protein recommendations are expert-based and range from 1.2 to 2.0 g/kg. Thus, we performed a systematic review and meta-analysis on protein provision and all clinically relevant outcomes recorded in the available literature.
Methods
We conducted a systematic review and meta-analyses, including studies of all designs except case control and case studies, with patients aged ≥18 years with an ICU stay of ≥2 days and a mean protein provision group of ≥1.2 g/kg as compared to <1.2 g/kg with a difference of ≥0.2 g/kg between protein provision groups. All clinically relevant outcomes were studied. Meta-analyses were performed for all clinically relevant outcomes that were recorded in ≥3 included studies.
Results
A total of 29 studies published between 2012 and 2022 were included. Outcomes reported in the included studies were ICU, hospital, 28-day, 30-day, 42-day, 60-day, 90-day and 6-month mortality, ICU and hospital length of stay, duration of mechanical ventilation, vomiting, diarrhea, gastric residual volume, pneumonia, overall infections, nitrogen balance, changes in muscle mass, destination at hospital discharge, physical performance and psychological status. Meta-analyses showed differences between groups in favour of high protein provision for 60-day mortality, nitrogen balance and changes in muscle mass.
Conclusion
High protein provision of more than 1.2 g/kg in critically ill patients seemed to improve nitrogen balance and changes in muscle mass on the short-term and likely 60-day mortality. Data on long-term effects on quality of life are urgently needed.
ARTIKEL
OBJECTIVES: Acute hospitalization may lead to a decrease in muscle measures, but limited studies are reporting on the changes after discharge. The aim of this study was to determine longitudinal changes in muscle mass, muscle strength, and physical performance in acutely hospitalized older adults from admission up to 3 months post-discharge.
DESIGN: A prospective observational cohort study was conducted.
SETTING AND PARTICIPANTS: This study included 401 participants aged ≥70 years who were acutely hospitalized in 6 hospitals. All variables were assessed at hospital admission, discharge, and 1 and 3 months post-discharge.
METHODS: Muscle mass in kilograms was assessed by multifrequency Bio-electrical Impedance Analysis (MF-BIA) (Bodystat; Quadscan 4000) and muscle strength by handgrip strength (JAMAR). Chair stand and gait speed test were assessed as part of the Short Physical Performance Battery (SPPB). Norm values were based on the consensus statement of the European Working Group on Sarcopenia in Older People.
RESULTS: A total of 343 acute hospitalized older adults were included in the analyses with a mean (SD) age of 79.3 (6.6) years, 49.3% were women. From admission up to 3 months post-discharge, muscle mass (-0.1 kg/m2; P = .03) decreased significantly and muscle strength (-0.5 kg; P = .08) decreased nonsignificantly. The chair stand (+0.7 points; P < .001) and gait speed test (+0.9 points; P < .001) improved significantly up to 3 months post-discharge. At 3 months post-discharge, 80%, 18%, and 43% of the older adults scored below the cutoff points for muscle mass, muscle strength, and physical performance, respectively.
CONCLUSIONS AND IMPLICATIONS: Physical performance improved during and after acute hospitalization, although muscle mass decreased, and muscle strength did not change. At 3 months post-discharge, muscle mass, muscle strength, and physical performance did not reach normative levels on a population level. Further research is needed to examine the role of exercise interventions for improving muscle measures and physical performance after hospitalization.
ARTIKEL
Background and Purpose: Decreased muscle mass and muscle strength are independent predictors of poor postoperative recov- ery in patients with esophageal cancer. If there is an association between muscle mass and muscle strength, physiotherapists are able to measure muscle strength as an early predictor for poor postoperative recovery due to decreased muscle mass. Therefore, in this cross-sectional study, we aimed to investigate the association between muscle mass and muscle strength in predominantly older patients with esophageal cancer awaiting esophagectomy prior to neoadjuvant chemoradiation. Methods: In patients with resectable esophageal cancer eligible for surgery between March 2012 and October 2015, we used computed tomographic scans to assess muscle mass and compared them with muscle strength measures (hand- grip strength, inspiratory and expiratory muscle strength, 30 seconds chair stands test). We calculated Pearson correla- tion coefficients and determined associations by multivariate linear regression analysis. Results and Discussion: A tertiary referral center referred 125 individuals to physiotherapy who were eligible for the study; we finally included 93 individuals for statistical analysis. Mul- tiple backward regression analysis showed that gender (95% confidence interval [CI], 2.05-33.82), weight (95% CI, 0.39- 1.02), age (95% CI, −0.91 to −0.04), left handgrip strength (95% CI, 0.14-1.44), and inspiratory muscle strength (95% CI, 0.08-0.38) were all independently associated with muscle surface area at L3. All these variables together explained 66% of the variability (R2) in muscle surface area at L3 (P < .01). Conclusions: This study shows an independent association between aspects of muscle strength and muscle mass in patients with esophageal cancer awaiting surgery, and phys- iotherapists could use the results to predict muscle mass on the basis of muscle strength in preoperative patients with esophageal cancer.
ARTIKEL
PURPOSE OF REVIEW: The loss of muscle mass in critically ill patients contributes to morbidity and mortality, and results in impaired recovery of physical functioning. The number of publications on the topic is increasing. However, there is a lack of consistent methodology and the most optimal methodology remains unclear, hampering its broad use in clinical practice.
RECENT FINDINGS: There is a large variety of studies recently published on the use of ultrasound for assessment of muscle mass. A selection of studies has been made, focusing on monitoring of muscle mass (repeated measurements), practical aspects, feasibility and possible nutrition and physical therapy interventions. In this review, 14 new small (n = 19-121) studies are categorized and reviewed as individual studies.
SUMMARY: The use of ultrasound in clinical practice is feasible for monitoring muscle mass in critically ill patients. Assessment of muscle mass by ultrasound is clinically relevant and adds value for guiding therapeutic interventions, such as nutritional and physical therapy interventions to maintain muscle mass and promote recovery in critically ill patients.
OVERZICHTSARTIKEL
Background: Weight loss is key to treatment of older adults with obesity and type 2 diabetes, but also a risk for muscle mass loss. This study investigated whether a whey protein drink enriched with leucine and vitamin D could preserve muscle mass and improve glycemic control during combined lifestyle intervention in this population. Methods: 123 older adults with obesity and type 2 diabetes were randomized into a 13-week lifestyle intervention with dietary advice and exercise, receiving either the enriched protein drink (test) or an isocaloric control (control). Muscle mass was assessed with dual-energy X-ray absorptiometry and glycemic control by oral glucose tolerance test. Statistical analyses were performed using a linear mixed model. Results: There was a nonsignificant increase in leg muscle mass (+0.28 kg; 95% CI, −0.01 to 0.56) and a significant increase in appendicular muscle mass (+0.36 kg; 95% CI, 0.005 to 0.71) and total lean mass (+0.92 kg; 95% CI, 0.19 to 1.65) in test vs. control. Insulin sensitivity (Matsuda index) also increased in test vs. control (+0.52; 95% CI, 0.07 to 0.97). Conclusions: Use of an enriched protein drink during combined lifestyle intervention shows beneficial effects on muscle mass and glycemic control in older adults with obesity and type 2 diabetes.
ARTIKEL
Rationale: Lean body mass, including muscle, is known to decrease with age, which may contribute to loss of physical function, an indicator of frailty. Moreover, low muscle thickness is considered an indicator of frailty in critically ill patients. However, little is known about the relationship between muscle thickness and frailty in community dwelling adults. Therefore, we studied the association between frailty and whole body lean body mass index (LBMi) and muscle thickness of the rectus femoris (RF) in community dwelling older adults. Methods: In older adults aged ≥55y, who participated in the Hanze Health and Ageing Study, frailty status was assessed with a multidimensional instrument, measuring frailty on a cognitive, psychosocial en physical level, i.e., the Groningen Frailty Indicator (GFI), using ≥4 as cut-off score for frailty. LBMi (kg/m2) was estimated with BIA (Quadscan 4000©, Bodystat), using the build-in equation. Muscle thickness (mm) of the RF was measured with ultrasound, using the Bodymetrix© (Intelametrix). Univariate and multivariate binary logistic regression analyses were performed for LBMi and for RF thickness. Multivariate analysis corrected for age, sex, body mass index (kg/m2), and handgrip strength (handgrip dynamometer; kg). A p-level of <0.05 was considered significant and Odds Ratios (OR; [95% CI]) were presented. Results: 93 participants (age 65.2±7.7 years; male 46 %; LBMi 17.2±2.6 kg/m2; RF 14.6±4.4 mm; median GFI =1 (interquartile range=0-3; frail: n=18) were included in the analysis. In both the univariate and multivariate analysis, LBMi (p=0.082, OR=0.82 [0.66-1.03]; p=0.077, OR=0.55 [0.28-1.07] respectively) and muscle thickness of RF (p=0.436, OR=0.95 [0.84-1.08]; p=0.796, OR= 1.02 [0.88-1.18] respectively) were not significantly associated with frailty. None of the co-variables were significantly associated with frailty either. Conclusion: In this sample of older adults aged ≥55 years, LBMi and RF thickness are not associated with frailty. However, frail participants scored at cut-off or just above, and measurements in a population with higher scores for frailty may provide further insight in the association between lean body mass and muscle thickness and frailty.
POSTER
Background: The diagnosis of sarcopenia is essential for early treatment of sarcopenia in older adults, for which assessment of appendicular lean mass (ALM) is needed. Multi-frequency bio-electrical impedance analysis (MF-BIA) may be a valid assessment tool to assess ALM in older adults, but the evidences are limited. Therefore, we validated the BIA to diagnose low ALM in older adults.
Methods: ALM was assessed by a standing-posture 8 electrode MF-BIA (Tanita MC-780) in 202 community-dwelling older adults (age ≥ 55 years), and compared with dual-energy X-ray absorptiometry (DXA) (Hologic Inc., Marlborough, MA, United States; DXA). The validity for assessing the absolute values of ALM was evaluated by: (1) bias (mean difference), (2) percentage of accurate predictions (within 5% of DXA values), (3) the mean absolute error (MAE), and (4) limits of agreement (Bland-Altman analysis). The lowest quintile of ALM by DXA was used as proxy for low ALM (< 22.8 kg for men, < 16.1 kg for women). Sensitivity and specificity of diagnosing low ALM by BIA were assessed.
Results: The mean age of the subjects was 72.1 ± 6.4 years, with a BMI of 25.4 ± 3.6 kg/m2, and 71% were women. BIA slightly underestimated ALM compared to DXA with a mean bias of -0.6 ± 1.2 kg. The percentage of accurate predictions was 54% with a MAE of 1.1 kg, and limits of agreement were -3.0 to + 1.8 kg. The sensitivity for ALM was 80%, indicating that 80% of subjects who were diagnosed as low ALM according to DXA were also diagnosed low ALM by BIA. The specificity was 90%, indicating that 90% of subjects who were diagnosed as normal ALM by DXA were also diagnosed as normal ALM by the BIA.
Conclusion: This comparison showed a poor validity of MF-BIA to assess the absolute values of ALM, but a reasonable sensitivity and specificity to recognize the community-dwelling older adults with the lowest muscle mass.
ARTIKEL
