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Revista Española de Nutrición Humana y Dietética

versión On-line ISSN 2174-5145versión impresa ISSN 2173-1292

Rev Esp Nutr Hum Diet vol.27 no.2 Pamplona abr./jun. 2023  Epub 04-Mar-2024

https://dx.doi.org/10.14306/renhyd.27.2.1876 

Letter to the Editor

Calf circumference adjusted according to Body Mass Index in nutritional assessment of cardiac patients admitted in Intensive Care Unit

Danielle Brito Alvesa  , extracting and interpreting results; Priscilla Carvalho da Silva Ribeiroa  , extracting and interpreting results; Jamille Souza Costa Barretoa  , extracting and interpreting results; Adriane de Jesus Santosa  , extracting and interpreting results; Vanessa Gomes Santiagoa  , extracting and interpreting results; Thamires Barros dos Santosa  , extracting and interpreting results; Bianca Sena Bitencourta  , extracting and interpreting results; Aline D'Avila Pereiraa  , extracting and interpreting results; Carlos Alberto Soares da Costaa  *  , designing the protocol, wrote the final versión of manuscript

a Applied Nutrition Studies Group, Health and Science Center, Federal University of Reconcavo da Bahia, Santo Antônio de Jesus, Bahia, Brazil.

b Department of Nutrition, University of Vassouras, Campus Maricá, Maricá, Rio de Janeiro, Brazil.

Dear Editor,

The cardiovascular disease as well as admission to the Intensive Care Unit (ICU) are risk factors for muscle loss1-2. The prevalence of muscle loss had been reported to be 19-52% and defined as an independent predictor of death among cardiac patients3. Several measurements are used for determining the body composition, and calf circumference (CC) should be considered in the identification and follow-up of muscle mass decline in these patients4,5. Previously, to the CC evaluation between elderly subjects, the World Health Organization (WHO) recommended a cut-off value of 31 cm for sexes5. And in a survey conducted, by Barbosa-Silva et al.6, in southern Brazil, the cut-off value of 34 cm for men and 33 cm for women was adopted to identify the muscle loss.

Based on the National Health and Nutrition Examination Survey (NHANES 1999-2006), calf circumference can be used clinical populations with probable weight or muscle loss by applying an adjustment for body mass index (BMI), before comparing to cut-off value (34 cm for men and 33 cm for women)7,8. And so, in the context of the ICU, calf circumference becomes a potential indicator for the identification of muscle loss and to guide nutritional therapy, among adults and the elderly9,10.

In this context of clinical population, the aim of this study was to evaluate the calf circumference, adjusted according to body mass index, in nutritional assessment of cardiac patients admitted to an intensive care unit.

For that reason, we present a cross-sectional, descriptive study with an approach to cardiac patients admitted to an intensive care unit (ICU) located in the Recôncavo da Bahia region, in the period from August 2019 to December 2019. The study was approved by the Ethics Committee of the Federal University (CAAE: 7118618.2.0000.0056).

All participants signed an informed consent. In the first 72 hours of ICU admission, the following data were collected: age; with the estimated height and body mass, the body mass index (BMI, kg/m2) was calculated; and calf circunference (CC, cm) was measured. Two cut-offs were used to consider the appropriate CC: 1) Above or equal to 31 cm for both sexes5; 2) Above or equal to 34 cm for males and 33 cm for females6. Subsequently, before comparing CC to suggested sex-specific cut-off 2 (34 cm for males and 33 cm for females), the CC was adjusted according to BMI categories: <18.5 kg/m2 (use original CC value); 18.5-24.9 kg/m2 (use original CC value); 25-29.9 kg/m2 (-3 cm); 30-39.9 kg/m2 (-7 cm) and ≥40 kg/m2 (-12 cm)7,8.

Data were analyzed using the software Graph Pad Prism (Version 5.0, 2007, San Diego, CA, USA) and Microsoft Excel. Data were analyzed by column statistics and expressed as means ± standard deviation. To evaluate the difference between the diagnostic methods (cut-off 1 vs. cut-off 2, with CC adjusted according to BMI categories), the Chi-square test was used, with statistical significance set at 5% (p<0.05).

In the study, fifty-four (n=54) cardiac patients admitted to the ICU were evaluated, thirty-six (n=36) males and eighteen (n=18) females. The CC, regarding cut-off 1 (31cm): 30.55% of males and 27.77% was below the recommended. To cut-off point 2 (34cm and 33cm): 50% of males and females was below the recommended. However, after adjusting to BMI, all the patients (100%) showed CC below the cut-off 2. In addition, it was observed that there is a significant difference between the methods, in which the CC adjusted to BMI categories, before comparing to cut-off 2 (vs. cut-off 1) interfered with the assessment of nutritional status in both sexes (Table 1)

Table 1. Anthropometric data of the patients admitted to an intensive care unit. 

Parameters Male (n=36) Female (n=18)
Age (years) 61.92 ± 12.87 64.56 ± 12.10
BMI (kg/m2) 23.61 ± 5.59 23.44 ± 5.52
CC (cm) 34.85 ± 5.62 32.97 ± 3.91
Cut-off 1 to CC:
CC above 31 cm (M=25 and F=13) 37.25 ± 5.09 (69.44%) 34.82 ± 2.83 (72.22%)
CC below 31 cm (M=11 and F=5) 29.41 ± 1.15 (30.55%) 28.17 ± 1.12 (27.77%)
Cut-off 2 to CC:
CC above 34 cm (M=18) and 33 cm (F=9) 39.15 ± 4.77 (50%) 36.09 ± 2.38 (50%)
CC below 34 cm (M=18) and 33 cm (F=9) 30.56 ± 1.77 (50%) 29.85 ± 2.23 (50%)
CC adjusted to BMI categories, before comparing to Cut-off 2:
CC (<18.5 kg/m2. M, n=5 and F, n=2) 30.12 ± 3.34 (13.88%) 27.97 ± 0.04 (11.11%)
CC (18.5-24.9 kg/m2. M, n=18 and F, n=11) 33.02 ± 6.33 (50%) 31.95 ± 4.39 (61.11%)
CC (25-29.9 kg/m2. M, n=7 and F, n=2) 32.40 ± 2.84 (19.44%) 30.88 ± 3.42 (11.11%)
CC (30-39.9 kg/m2. M, n=6 and F, n=3) 33.64 ± 4.40 (16.66%) 30.39 ± 4.10 (16.66%)
CC (≥40 kg/m2) - -
Cut-off 1 vs. Cut-off 2 (with CC adjusted according to BMI categories) by the chi-square test
Male (n=36) CC above 31 cm CC below 31 cm
CC above 34 cm 11 (37.9%) 0 (0.0%)
CC below 34 cm 18 (62.1%) 7 (100.0%)
p-value*** <0.0001
Female (n=18) CC above 31 cm CC below 31 cm
CC above 33 cm 6 (46.2%) 0 (0.0%)
CC below 33 cm 7 (53.8%) 5 (100.0%)
p-value* 0.016

BMI: Body mass index; CC: Calf circumference; M: Male; F: Female. Mean ± Standard Deviation (Column statistics). Cut-off 1 proposed by WHO5. Cut-off 2 proposed by Barbosa-Silva et al.6. CC adjusted according to BMI categories, before comparing to Cut-off 2, as proposed by Gonzalez et al.7 and Prado et al.8. *Represent significant difference (*p<0.05; ***p<0.0001; Chi-square test).

Cardiac patients admitted to the intensive care unit had a mean age above 60 years. In fact, the number of older people (>60 years) in intensive care unit is increasing substantially, as population ages9. And ageing is associated with increased fat mass and decreased muscle mass10. In present study no patient had a BMI over 40 kg/m2. However, the calf circumference adjusted according to BMI categories, before comparing CC to cut-off 27,8 was a more sensitive method for diagnostic (as observed in the Chi-square test, regarding cut-off 15). And in fact, all cardiac patients (including those with overweight and obesity) evaluated in the ICU showed probable weight or muscle loss.

The calf circumference, adjusted according to body mass index categories, was relevant for the diagnostic/classification of nutritional risk of cardiac patients admitted to the intensive care unit.

Acknowledgments

We are grateful to the staff of the intensive care unit service and healthcare administration of the Luiz Argolo Maternity Hospital for the technical support.

References

1. Bahia FC, Barreto JSC, Ribeiro PCS, Santos AJ, Alves DB, Santos TB, et al. Estado nutricional de idosos cardiopatas admitidos em uma unidade de terapia intensiva em Santo Antônio de Jesus, Bahia. Res Soc Dev. 2022; 11(8): e23311830953. doi: 10.33448/rsd-v11i8.30953. [ Links ]

2. Teixeira CS, Barreto JSC, Ribeiro PCS, Santos AJ, Alves DB, Santos TB, et al. Utilização da circunferência do pulso na avaliação nutricional de pacientes cardiopatas admitidos em uma unidade de terapia intensiva. Res Soc Dev. 2022; 11(10): e233111032599. doi: 10.33448/rsd-v11i10.32599. [ Links ]

3. Haehling S, Garfias Macedo T, Valentova M, Anker MS, Ebner N, Bekfani T, et al. Muscle wasting as an independent predictor of survival in patients with chronic heart failure. J Cachexia Sarcopenia Muscle. 2020; 11(5): 1242-9. doi: 10.1002/jcsm.12603. [ Links ]

4. Pagotto V, Santos KFD, Malaquias SG, Bachion MM, Silveira EA. Calf circumference: clinical validation for evaluation of muscle mass in the elderly. Rev Bras Enferm. 2018; 71(2): 322-8. doi: 10.1590/0034-7167-2017-0121. [ Links ]

5. WHO Expert Committee. Physical Status: the Use and Interpretation of Anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser. 1995:854:1-452. PMID: 8594834. [ Links ]

6. Barbosa-Silva TG, Bielemann RM, Gonzalez MC, Menezes AMB. Prevalence of sarcopenia among community-dwelling elderly of a medium-sized South American city: results of the COMO VAI? study. J Cachexia Sarcopenia Muscle. 2016; 7(2): 136-43. doi: 10.1002/jcsm.12049. [ Links ]

7. Prado CM, Landi F, Chew STH, Atherton PJ, Molinger J, Ruck T, et al. Advances in muscle health and nutrition: A toolkit for healthcare professionals. Clin Nutr. 2022; 41(10): 2244-63. doi: 10.1016/j.clnu.2022.07.041. [ Links ]

8. Gonzalez MC, Mehrnezhad A, Razaviarab N, Barbosa-Silva TG, Heymsfield SB. Calf circumference: cutoff values from the NHANES 1999-2006. Am J Clin Nutr. 2021; 113(6): 1679-87. doi: 10.1093/ajcn/nqab029. [ Links ]

9. Ferretti-Rebustini REL, Nogueira LS, Silva RCGE, Poveda VB, Machado SP, Oliveira EM, et al. Aging as a predictor of nursing workload in Intensive Care Unit: results from a Brazilian Sample. Rev Esc Enferm USP. 2017; 51: e03216. doi: 10.1590/S1980-220X2016237503216. [ Links ]

10. Lee ZY, Loh CTI, Lew CCH, Ke L, Heyland DK, Hasan MS. Nutrition therapy in the older critically ill patients: A scoping review. Ann Acad Med Singap. 2022; 51(10): 629-36. doi: 10.47102/annals-acadmedsg.2022160. [ Links ]

Funding The authors declare that there has been no funding to carry out this study.

Received: July 18, 2022; Accepted: August 25, 2022; pub: September 14, 2022

* nutcarlos@ufrb.edu.br

Asigned Editor

Rafael Almendra-Pegueros. Institut de Recerca de l’Hospital de la Santa Creu i Sant Pau, Barcelona, España.

Competing Interests

The authors state that there are no conflicts of interest when writing the manuscript.

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License