ReviewBody composition: Why, when and for who?☆
Introduction
Undernutrition features loss of variable intensity of fat-free mass (FFM), associated with loss of fat mass whose importance increases with the duration of undernutrition. Its prevalence among elderly subjects, patients with chronic diseases or during the course of the hospital stay is very high1, 2, 3, 4 and likely to increase during the next decade, since the negative impact of undernutrition on the clinical outcome is expected to increase. Indeed, the improvements in medical technology and therapy prolong survival, even in elderly sedentary subjects with pre-existing sarcopenia5 or in patients with chronic diseases. As a consequence, the proportion of patients with low FFM will increase, leading to an impairment of their overall health, functional capacities and quality of life.6, 7 Indeed, FFM loss is unequivocally associated with decreased survival, negative clinical outcome, i.e. increased rate of infections, complications, hospitalizations, lengths of hospital stay and recovery,2 and therapy toxicity in cancer patients,8 which ultimately increase health care costs.2 Therefore, the management of nutritionally at risk patients should integrate a nutritional strategy aiming at reducing the clinical and functional consequences of the disease and/or the hospital stay, in the setting of a cost-effective medico-economic approach.9, 10
This review sustains the hypothesis that the measurement of FFM should be implemented on a regular basis in clinical practice, with the aim of optimizing the early detection, the management and the follow-up of undernutrition.
Section snippets
Why measuring body composition in clinical practice?
The main goal of body composition measurements in clinical practice is the evaluation of nutritional status by measuring FFM and fat mass (FM). The clinical assessment of nutritional status is recommended on a regular basis in hospitalized patients and nutritionally at risk outpatients.11 In some chronic conditions, body mass index (BMI) and the percentage of weight loss do not provide any insight about the respective contributions of FFM and FM in the body mass changes. In chronic obstructive
Overview/conceptualization of methods for body composition measurements
Body compartments, such as FFM, fat mass and body water, can be measured quantitatively. Numerous methods of body composition measurement have been developed through time: anthropometry, including the 4-skinfold method,39 hydrodensitometry,40 the measurements of mid-arm muscle circumference,40 in vivo neutron activation analysis,33, 34, 35 anthropogammametry from total body 40Potassium,41 nuclear magnetic resonance (NMR),42 dual-energy X-ray absorptiometry (DEXA),43, 44 BIA,30, 31, 45 and more
Is body composition correlated with nutritional risk and clinical outcome?
Body composition assessment allows the quantification of FFM loss, i.e. body protein loss. FFM and FFMI (FFM normalized for the body height) were shown to be significantly lower in hospitalized (n = 995) than in age-, height-, and sex-matched controls (n = 995) (FFMI of patients with a 1 to 2-day hospital stay vs. controls: men, 18.5 ± 1.9 vs. 19.5 ± 1.6 kg/m2; women, 15.2 ± 1.7 vs. 16.0 ± 1.6 kg/m2).3 The low FFMI is correlated with clinical prognosis in numerous clinical conditions (Table 1).
Body composition contributes documenting the efficiency of nutrition support
The assessment of body composition may help to document the efficiency of nutrition support during patient’s follow-up of numerous clinical conditions, such as surgery (Fig. 9),33 anorexia nervosa (Fig. 10),74, 75 hematopoietic stem cell transplantation (Fig. 11),76 COPD (Fig. 12),77 ICU (Fig. 13),78 lung transplantation (Fig. 14),79 ulcerative colitis,32 Crohn’s disease,80 cancer81, 82 and VIH/AIDS.83 Body composition measurement allows to characterize the increase in body mass in terms of FFM
Body composition allows tailoring treatments to patient’s characteristics
The regular assessment of body composition should be used to tailor treatment doses according to the FFM and/or FM values of each subject. This point has been recently illustrated in oncology patients with sarcopenic obesity. In a prospective study performed in 441 patients with non-small cell lung cancer, low appendicular FFM (sarcopenia) assessed by CT was shown in each body mass index category,27 indicating that the clinical assessment of nutritional status is insufficient. The increase in
Simplification of body composition for daily use
The assessment of body composition is not well implemented in the clinical practice, despite the strong scientific rational for its relevance. To implement routine assessment of body composition during the course of treatments and rehabilitation phase, it is necessary to simplify its use. First, the simplest and least expensive method should be used: BIA meets these criteria. For example, FFM reference values from BIA analysis55, 95 were recently used in a controlled randomized trial performed
Conclusion
Body composition methods allow a quantitative measurement of tissues changes through time, and have higher sensitivity than BMI and weight loss for detecting FFM impairment. Body composition impairment is associated with decreased survival, worse clinical outcome and quality of life, as well as increased therapy toxicity in cancer patients. Thus, body composition methods should be implemented in clinical practice at each step of the disease course with the aim of optimizing the screening and
Conflict of interest
Ronan Thibault, Laurence Genton and Claude Pichard declare no conflict of interest.
Statement of authorship
RT, LG and CP drafted the manuscript and approved its final content.
Acknowledgments
R Thibault and C Pichard are supported by research grants from the public Foundation Nutrition 2000 Plus. Mrs Ursula Kyle (Baylor College of Medicine, Pediatric Critical Care Medicine, Houston, USA), Pr Daniel Slosman and his team (Department of Nuclear Medicine, University Hospital, Geneva, Switzerland) have made major contributions to our body composition research programme.
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This review is adapted from the Wretlind Lecture given by Claude Pichard at the 2009 ESPEN Congress, Vienna, Austria.