Annals of Clinical Nutrition and Metabolism

Original Articles

Impact of immune-supplementation on muscle health and inflammation status of South Indian patients who have undergone gastrointestinal resection: a pilot randomized-controlled study: Nivedita Pavithran, Catherine Bompart, Alisa Alili, Sudheer Othiyil Vayoth; Ann Clin Nutr Metab 2024;16(2):78-86. Published online August 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.2.78

Abstract PDF: Purpose: Gastrointestinal (GI) resection significantly impacts nutritional and physical health, causing stress and inflammation that increase energy needs. Post-operative caloric intake often falls short, disrupting protein homeostasis and compromising muscle health. Nutritional supplementation is crucial to reduce inflammation and maintain muscle health. This study aimed to evaluate the impact of a three-week oral nutritional immuno-supplement (IMM) intervention compared to a control (CTL) on post-operative inflammatory status and muscle health in patients receiving limb and chest physiotherapy from June to August 2023.
Methods: A randomized, controlled, blinded cohort of 20 patients (ages 30–75) undergoing GI surgery was established. Participants were recruited on the day of surgery and assigned to either the CTL, which received standard protein supplementation, or the IMM group, which received protein immune-enriched supplementation for three weeks. All participants also received chest and limb physiotherapy. Follow-up and data collection were conducted at three post-surgery time points: 3 days, 7 days, and 3 weeks. Assessments included body composition, handgrip strength, basal metabolic rate, 24-hour dietary intake, and C-reactive protein (CRP) levels.
Results: Fifteen patients completed the study (IMM=9, CTL=6). After three weeks of supplementation, the IMM group showed a significant increase in lean mass percentage and handgrip strength, along with a significant decrease in CRP levels, compared to the CTL.
Conclusion: A 3-week oral immuno-supplement provided to patients post-GI resection, in conjunction with limb and chest physiotherapy, is more effective in reducing inflammation and preserving muscle health compared to standard protein supplementation.

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Body composition assessment using bioelectrical impedance analysis and computed tomography in patients who underwent pancreatoduodenectomy in Korea: a before and after study: Juwan Kim, Seung-seob Kim, Ho Kyoung Hwang, Chang Moo Kang, Kyung Sik Kim, Sung Hyun Kim; Ann Clin Nutr Metab 2023;15(3):72-80. Published online December 1, 2023; DOI: https://doi.org/10.15747/ACNM.2023.15.3.72

Abstract PDF Supplementary Material: Purpose: This study focuses on the need for standardized body composition measurements in the hepatobiliary-pancreatic field. It evaluates and compares the effectiveness of bioelectrical impedance analysis (BIA) and computed tomography (CT) scans in assessing body composition of patients undergoing pancreatoduodenectomy (PD), aiming to establish correlations among different body composition indexes.
Methods: Ninety-seven patients who underwent PD between August 2022 and March 2023, were enrolled in this study. Muscular and fatty parameters related to BIA and CT were assessed both preoperatively and on postoperative day 6. The correlation between each parameter related to muscle fat was analyzed according to the measurement modalities.
Results: There was an increase of skeletal muscle area (SMA), total muscle area, and low attenuated muscle area after surgery. Skeletal muscle mass (SMM) measured using BIA exhibited a strong correlation with the SMA and normal attenuated muscle area (NAMA) measured using CT (r=0.86, P<0.001; r=0.76, P<0.001). The trunk muscle measured using BIA demonstrated moderate to strong correlations with SMA and NAMA measured using CT (r=0.84 P<0.001; r=0.73, P<0.001). Body fat measured using BIA and total fat area (TFA) measured using CT showed strong correlations (r=0.74, P<0.001). In the postoperative analysis, a similar trend was observed (SMM vs. SMA: r=0.80, P<0.001; SMM vs. NAMA: r=0.70, P<0.001), (trunk muscle vs. SMA: r=0.79, P<0.001; trunk muscle vs. NAMA: r=0.69, P<0.001), and (body fat vs. TFA: r=0.83, P<0.001).
Conclusion: BIA, akin to CT, serves as a valuable tool for assessing body composition ratios in patients undergoing PD.

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Body Compositions of Elderly and Non-Elderly Patients Following Gastrectomy for Gastric Cancer: Ji Hoon Kang, Mi Ran Jung, Sung Eun Kim, Oh Jeong; Ann Clin Nutr Metab 2022;14(2):81-87. Published online December 1, 2022; DOI: https://doi.org/10.15747/ACNM.2022.14.2.81

Abstract PDF: Purpose: Radical gastric resection is the mainstay of treatment in gastric cancer. However, patients can suffer from eating restrictions, weight loss, and malnutrition after gastrectomy, to which elderly patients are more vulnerable. We compared body composition changes in elderly patients and non-elderly patients after gastrectomy.
Materials and Methods: This prospective study enrolled patients who underwent gastrectomy for gastric carcinoma between 2019 and 2021. Body composition was measured using bioelectrical impedance analysis (InBody S10) before surgery and up to 12 months after surgery. Patients were divided into an elderly group (>70 years) and a non-elderly group (≤70 years), and body composition changes were compared between the two groups using the linear mixed model.
Results: There were 69 patients in the elderly group and 164 patients in the non-elderly group. The groups showed no significant differences in gastric resection or pathologic stage. Overall, body composition, including total body water, body weight, lean body mass, skeletal muscle mass, and fat mass, decreased immediately after surgery and gradually improved until postoperative 12 months. A linear mixed model showed no significant time×group interactions for any body composition factors between groups.
Conclusion: Body composition changes did not significantly differ between elderly patients and non-elderly patients after gastrectomy.

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Validity of Bioelectrical Impedance Analysis for Older Amputees with Leprosy: Jihyun Lee, Seorin Doo, Yeonhee Lee, Jaeyoung Ahn, Yookyoung Park, Hyun Joo Shin, Jae-myeong Lee; Surg Metab Nutr 2021;12(1):7-15. Published online June 30, 2021; DOI: https://doi.org/10.18858/smn.2021.12.1.7

Abstract PDF: Purpose: Bioelectrical impedance analysis (BIA) evaluates body composition and electrical resistance according to weight and height but assumes all limbs are intact. This study evaluated the validity and accuracy of BIA in older amputees with leprosy.
Materials and Methods: We evaluated BIA’s effectiveness for determining body composition by measuring muscle mass, water percentage, and physical resistance, including phase angle, in older amputees with leprosy. BIA was performed on 42 individuals with leprosy aged ≥65 years. Comparative analyses were performed by amputation types (left lower limbs, right lower limbs, bilateral lower limbs, and non-amputees). Twenty people without leprosy or amputations of similar age, height, and weight were considered controls.
Results: Between the controls, amputee, and the controls without leprosy, BIA showed significant mean differences in skeletal muscle mass (22.5±5.6 kg, 19.6±5.6 kg, 18.2±3.9 kg, respectively; P=0.037); whole-body extracellular water (ECW) ratios (0.410±0.011, 0.401±0.007, 0.393±0.009, respectively; P<0.001) and phase angle (4.2±1.2, 4.4±0.7, 5.0±0.8, respectively; P=0.029). The bilateral lower limb amputation group (median, 0.415; range, 0.407–0.426) showed significantly higher whole-body ECW values than the non-amputee group (median, 0.401, range: 0.391–0.415) (P=0.013). Right leg lean mass was highest in the right lower limb amputation group, followed by bilateral lower limb amputation, non-amputee, and left lower limb amputation groups (median: 9.86, 6.04, 5.02, 3.95, respectively, P=0.001). As the length of the amputated lower limb was shortened, the lower limb's impedance decreased. However, BIA was evaluated without reflecting the shortened length, resulting in an error in the skeletal muscle mass readings.
Conclusion: Phase angle, ECW ratio, and bioelectrical impedance vector analysis obtained by BIA appeared accurate, but the skeletal muscle mass showed significant errors for amputated areas.

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Impact of Visceral Fat Area Measured by Bioelectrical Impedance Analysis on Clinico-Pathologic Outcomes of Colorectal Surgery: Kyeong Eui Kim, Woo Jin Song, Minji Seok, Sung Uk Bae, Woon Kyung Jeong, Seong Kyu Baek; J Clin Nutr 2021;13(1):17-23. Published online June 30, 2021; DOI: https://doi.org/10.15747/jcn.2021.13.1.17

Abstract PDF: Purpose: This study investigated the relationship between the visceral fat area (VFA) and clinico-pathological outcomes in patients with colorectal cancer (CRC).
Methods: This retrospective study included 204 patients who underwent anthropometric measurement by bioelectrical impedance analysis (BIA) before surgical treatment for CRC between January 2016 and June 2020.
Results: According to the average value of the visceral fat area, 119 (58.3%) patients had a low visceral fat area, and 85 (59.1%) patients had a high visceral fat area. Patients with visceral obesity showed a higher BMI compared to patients without visceral obesity, (21.8±1.9 vs. 25.7±2.5, P<0.001). There was no significant difference in the overall perioperative outcomes including total operation time, time to gas out, sips of water, soft diet, hospital stay, and morbidity between patients in the low and high VFA groups. We divided patients into two subgroups according to the degree of cancer progression and more advanced cases with low VFA showed significantly more total and positive retrieved lymph nodes (LNs) (20.9±10.3 vs. 16.1±7.1, P=0.021 and 3.3±2.9 vs. 2.2±2.3, P=0.019, respectively) and a higher proportion of more than 12 retrieved LNs compared to patients with a high VFA (95.1% vs. 90.0%, P=0.047). Body composition analysis showed that phase angle, muscle composition, and body fluid composition were not statistically different between the two groups. However, body fat mass was statistically higher in the high VFA group (22.0±4.6 vs. 12.8±3.1, P<0.001).
Conclusion: Visceral obesity measured by BIA showed lower total and positive retrieved LNs and was not associated with adverse peri-operative outcomes, inflammatory and nutritional, and pathologic outcomes for CRC.

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Effect of the Remnant Stomach Volume on the Nutritional and Body Composition in Stage 1 Gastric Cancer Patients: Koen Lee, Kyung Won Kim, Jung-Bok Lee, Yongbin Shin, Jin Kyoo Jang, Jeong-Hwan Yook, Byung-Sik Kim, In-Seob Lee; Surg Metab Nutr 2018;9(2):41-50. Published online December 30, 2018; DOI: https://doi.org/10.18858/smn.2018.9.2.41

Abstract PDF: Purpose:

During the first year after surgery, gastric cancer patients experience weight loss and a decline in physical activity. In addition, depravation of the nutritional status and anemia is observed. The decrease in stomach volume is believed to be one of the causes for these changes. The purpose of this study was to investigate the effects of the remnant stomach volume on nutrition, anemia, and body composition-related parameters in gastric cancer patients after surgery.

Materials and Methods:

A total of 110 patients with stage 1 gastric cancer, who underwent a laparoscopic gastrectomy in 2015 were evaluated in this prospective observational study. Among them, 78 patients received a distal gastrectomy (Billroth 1: 52, Billroth 2: 12, Roux en Y: 14) and 32 underwent a total gastrectomy. The weight, height, and blood test results of the patients were collected during the observation period. The remnant stomach volume, total abdominal muscle area, and subcutaneous/visceral fat area were measured using CT images.

Results:

Patients with a larger remnant stomach volume showed a smaller decrease in the nutritional parameters and better recovery of the hemoglobin level during the first year after surgery. Among the body composition parameters, visceral fat was affected to the greatest extent and subcutaneous/visceral fat were better preserved in the group with a larger remnant stomach volume. In the group with a total gastrectomy, the parameters were worsened significantly compared to the distal gastrectomy group.

Conclusion:

The remnant stomach volume has a protective effect on the body mass index, body weight change, hemoglobin, total protein, cholesterol, and visceral/subcutaneous fat area during the first year after surgery.

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Sequential Changes in Body Composition Using Bioelectrical Analysis during the Metabolic Response in Critically Ill Surgical Patients: Seok Rae Park, Seung Hwan Lee, Kyung Sik Kim, Hosun Lee, Tae Hwa Hong, Jae Gil Lee; Surg Metab Nutr 2017;8(1):13-16. Published online June 30, 2017; DOI: https://doi.org/10.18858/smn.2017.8.1.13

Abstract PDF: Purpose:

Assessment of sequential changes in body composition during the metabolic response in critically ill surgical patients is essential for optimal nutritional support and management. Bioelectrical impedance analysis (BIA) is an easy, portable, and quick way to assess body composition. Thus, the aim of this study was to evaluate the sequential changes in body composition and the validity of Direct segmental Multi-frequency BIA in critically ill surgical patients.

Materials and Methods:

Twenty-three patients admitted to the intensive care unit (ICU) after major surgery were measured for body composition by multiple-frequency BIA after intensive care unit admission as well as 3 and 7 days later. Repeated-measures analysis of variance (ANOVA) was used to detect significant changes over time.

Results:

The average length of intensive care unit stay was 4.3 days. Total body water, extracellular water, skeletal muscle mass (SMM), soft lean mass, and fat-free mass (FFM) increased during the first 72 h of intensive care unit admission, after which they decreased slightly. On the other hand, fat mass decreased during the first 72 h of intensive care and then increased. However, arm circumference (AC), arm muscle circumference (AMC), and waist circumference (WC) gradually decreased by day 7 (P<0.001).

Conclusion:

In this study, AC, AMC, WC, and direct segmental Multi-frequency BIA were less affected by initial resuscitation in the intensive care unit (ICU). Therefore, segmental BIA may be useful for critical ill patients in altered hydration states.

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