The use of upper extremity anthropometrics in the clinical assessment of patients with amyotrophic lateral sclerosis

Malnutrition in Amyotrophic Lateral Sclerosis: Insights from Morphofunctional Assessment and Global Leadership Initiative on Malnutrition Criteria

Amyotrophic Lateral Sclerosis (ALS) is a progressive neurodegenerative disease frequently accompanied by malnutrition due to weight loss, increased energy expenditure, and muscle mass loss. This study aimed to evaluate morphofunctional assessment tools as predictors of malnutrition and to investigate their relationship with muscle status and disease severity in ALS patients. A cross-sectional study was conducted with 45 ALS patients at the San Cecilio University Hospital in Granada. Malnutrition was assessed using the Global Leadership Initiative on Malnutrition (GLIM) criteria. Morphofunctional assessment was performed using Bioimpedance Vectorial Analysis (BIVA), handgrip strength (HGS), and Short Physical Performance Battery (SPPB). Malnutrition prevalence was 38% according to GLIM criteria. Significant differences were observed between malnourished and non-malnourished groups in age (70 ± 9 vs. 62 ± 10 years, p = 0.01), sex (female prevalence: 58.8% vs. 25.0%, p = 0.02), dysphagia prevalence (83% vs. 29%, p < 0.001), PEG/PRG use (35.3% vs. 3.6%, p = 0.01), and ALSFRS-R scores (30 ± 12 vs. 34 ± 12, p = 0.02). Malnourished patients had lower values in anthropometric measurements, muscle mass obtained by BIVA, and phase angle (PA) (4.05 ± 0.8° vs. 5.09 ± 0.8°, p < 0.001). No significant differences were found in muscle strength or functional status. PA showed significant correlations with muscle strength (r = 0.52, p < 0.001) and muscle mass measures (r = 0.48, p < 0.001). Moreover, PA was associated with poorer disease progression and physical performance. In our sample, BIVA metrics such as PA (<4.3°), SPA (<-0.8), body cell mass (<9.2 kg/m), and extracellular water (>49.75%) were identified as malnutrition risk factors. The study underscores the critical importance of comprehensive morphofunctional assessment and the use of advanced diagnostic criteria, for early identification and intervention in malnutrition among people with ALS. Further research is warranted to validate these findings and develop targeted nutritional strategies into routine clinical practice.

Body composition in amyotrophic lateral sclerosis subjects and its effect on disease progression and survival

BACKGROUND

Motor neuron degeneration and malnutrition alter body composition in amyotrophic lateral sclerosis (ALS). Resulting losses of weight, fat mass (FM), and fat-free mass (FFM) shorten survival. Nutritional management relies on body weight or BMI; neither reliably indicates malnutrition nor differentiates body compartments.

OBJECTIVES

We aimed to 1) develop an equation to compute FM and FFM using clinical data, validated against DXA; and 2) examine the effect of computed FM and FFM on disease course and survival.

METHODS

We studied 364 ALS patients from 3 cohorts. In Cohort #1 we used logistic regression on clinical and demographic data to create an equation (test cohort). In Cohort #2 we validated FM and FFM computed using this equation against DXA (validation cohort). In Cohort #3, we examined the effect of computed body composition on disease course and survival.

RESULTS

In Cohort #1 (n = 29) the model incorporated sex, age, BMI, and bulbar-onset to create an equation to estimate body fat: % body fat = 1.73 - [19.80*gender (1 if male or 0 if female)] + [0.25*weight (kg)] + [0.95*BMI (kg/m2)] - (5.20*1 if bulbar-onset or *0 if limb-onset). In Cohort #2 (n = 104), body composition using this equation, compared to other published equations, showed the least variance from DXA values. In Cohort #3 (n = 314), loss of body composition over 6 mo was greater in males. Adjusted survival was predicted by low baseline FM (HR: 1.39; 95% CI: 1.07, 1.80), and loss of FM (HR: 1.87; 95% CI: 1.30, 2.69) and FFM (HR: 1.73; 95% CI: 1.20, 2.49) over 6 mo.

CONCLUSIONS

Our equation broadens the traditional nutritional evaluation in clinics and reliably estimates body composition. Measuring body composition could target FM as a focus for nutritional management to ensure adequate energy intake and complement measures, such as the ALS functional rating scale-revised score and forced vital capacity, currently used.

Muscle Function Differences between Patients with Bulbar and Spinal Onset Amyotrophic Lateral Sclerosis. Does It Depend on Peripheral Glucose?

BACKGROUND

One of the pathogenic mechanisms of ALS disease is perturbed energy metabolism particularly glucose metabolism. Given the substantial difference in the severity and the prognosis of the disease, depending on whether it has a bulbar or spinal onset, the aim of the study was to determine metabolic differences between both types of ALS, as well as the possible relationship with muscle function.

MATERIALS AND METHODS

A descriptive, analytical, quantitative, and transversal study was carried out in hospitals and Primary Care centers in the region of Valencia, Spain. Fasting glucose and alkaline phosphatase (AP) levels in venous blood, muscle percentage, fat percentage, muscle strength (MRC scale), and functional capacity (Barthel Index) were measured in 31 patients diagnosed with ALS (20 with spinal onset ALS and 11 with bulbar onset ALS). A healthy control of 29 people was included.

RESULTS

No significant differences were observed in blood AP and glucose levels between spinal onset and bulbar onset ALS patients. However, a significant positive correlation was observed between the mean values of both substances in patients with spinal onset ALS. Moreover, a lower percentage of muscle mass and a higher percentage of fat mass were also seen in spinal ALS patients, who also presented lower muscle strength and lower functional capacity.

CONCLUSION

The results of this study seem to point to a possible difference in the peripheral use of glucose between patients with bulbar onset ALS and spinal onset ALS, who appear to have possible insulin resistance. These metabolic differences could explain the lower muscle percentage and lower muscular function in spinal onset ALS patients, although further studies are required.

Assessment and nutrition education in patients with amyotrophic lateral sclerosis

Neurological patients with amyotrophic lateral sclerosis (ALS)often deteriorate to a worsening nutritional status. The aim of this study was to compare the nutritional status and food intake after nutrition education in patients with ALS. Clinical, anthropometric and functional variables were analyzed. Fifty-three patients were monitored at an early stage of the disease. The average score on the functionality scale was 33 points. Initially only 3.8% were classified as low body weight. After three months, 50% showed significant variation in anthropometric measures related to muscle mass and body fat reserves without association with clinical variables. After nutritional guidance, there was an increase in the intake of all food groups, especially the dairy group (p <0.05).The change of the nutritional status occurs early in patients with amyotrophic lateral sclerosis, even in those previously eutrophic or over weight. There was an increase in food intake after nutritional guidance according to the food guide adapted to the Brazilian population.

Anthropometry of Arm: Nutritional Risk Indicator in Amyotrophic Lateral Sclerosis

The aim of the paper is to examine the correlation between clinical data, nutritional, respiratory and functional parameters in amyotrophic lateral sclerosis (ALS). This is a descriptive study of 111 ALS patients [91 spinal onset (GS) and 20 bulbar onset (GB)] carried on using nutritional and respiratory parameters and amyotrophic lateral sclerosis functional rating scale (ALSFRS). ALSFRS was analyzed in the main domains (D1, D2 and D3). Forced vital capacity and anthropometric measurements, there was significant association for GS and GB, and in GS there was positive correlation with midarm circumference (MAC) (r=0.30; P=0.020), midarm muscle circumference (r=0.29; P=0.026), arm muscle area (r=0.28; P=0.033) and protein-caloric malnutrition score (r=0.27; P=0.039), while for GB only with body weight (r=0.64; P=0.024). On correlation of nutritional parameters and ALSFRS for GS patients we observed that MAC and %MAC presented positive association with both issues of D1 and D2. For GB, the total score in addition to correlate positively with anthropometric parameters related to lean body mass also presented negative association with a parameter associated with body fat. In summary, it is suggested that the application of anthropometry of arm could be useful in routine monitoring of ALS patients.

Nutrition assessment and management in amyotrophic lateral sclerosis

In recent years nutrition assessment and management in amyotrophic lateral sclerosis (ALS) have drawn increased attention. Frequent evaluation of nutrition status is warranted in ALS, given the common occurrence of dysphagia and hypermetabolism and varying disease progression rates. Nutrition management includes dietary and swallow strategies, possible gastrostomy tube placement, and recommendations for vitamin and mineral supplementation. Strategies to assess and optimize nutrition status and prolong survival in ALS patients are reviewed with recommendations based on current research.

Áreas de secção transversa do braço: implicações técnicas e aplicações para avaliação da composição corporal e da força dinâmica máxima

As áreas do tecido muscular (A MB) e do anel de gordura do braço (A GB), podem ser estimadas por medidas antropométricas. OBJETIVO: Investigar a validade e o erro intertestador da antropometria para inferência A MB e do A GB. Secundariamente, estudou-se a previsão da força dos membros superiores e tronco através da A MB. MÉTODOS: Foram voluntários para este estudo 40 adultos masculinos jovens (25 ± 6 anos; 72,6 ± 9,4kg), divididos aleatoriamente nos grupos de validade interna (VI, n = 30) e validade externa (VE, n = 10). Determinou-se para VI, através de conceitos geométricos, a área total do braço (A TB), A MB, A GB e área percentual de gordura do braço. O somatório de oito dobras cutâneas (S DC8) foi empregado como índice da adiposidade corporal. A força dos membros superiores e do tronco foi medida através da carga máxima alcançada no exercício supino reto livre (1-RM). As medidas antropométricas foram realizadas por dois avaliadores independentes. Os dados foram tratados por meio da análise de regressão, coeficiente de correlação intraclasse (ICC) e teste t de Student pareado (a < 0,05). RESULTADOS: A variância do S DC8 pode ser explicada em 93% (EPE = 14,6mm) a partir da A GB e do peso corporal. A A MB explicou em 66,1% (EPE = 9kg) a 1-RM. Não se observou diferença significativa, para o grupo VE, entre os valores medidos (84,2 ± 16,2kg) e preditos (78,4 ± 14,2kg) de 1-RM. Observou-se pouca variação entre os avaliadores para A MB (ICC = 0,99), A GB (ICC = 0,96) e A TB (ICC = 0,99). CONCLUSÃO: A antropometria pode ser empregada para inferência da A MB e do A GB, com boa concordância entre avaliadores, para estimativa da adiposidade corporal e da força dos membros superiores e tronco.

Validation of bioelectrical impedance analysis in patients with amyotrophic lateral sclerosis

BACKGROUND

Amyotrophic lateral sclerosis (ALS) is a neurologic disease with an unfavorable prognosis that may be accompanied by malnutrition or overweight. Nutritional status is difficult to evaluate in these patients because of their physical limitations and the asymmetry of their disease involvement. Bioelectrical impedance analysis (BIA), which enables bedside analysis of body compartments, has not been adequately validated for use in patients with ALS.

OBJECTIVE

We compared reference measures of fat-free mass (FFM(a)), obtained by dual-energy X-ray absorptiometry, with FFM obtained by BIA and by the skinfold-thickness technique.

DESIGN

We measured FFM(a) in 32 ALS patients. Anthropometric measures included weight, height, skinfold thickness, and arm and wrist circumferences. The fat mass obtained from the skinfold-thickness measures enabled us to calculate FFM. BIA was performed by measuring the bioimpedances at 5, 50, and 100 kHz of each side of the body and from one side to the other. FFM was calculated by using the instrument's internal software and by using 3 standard equations. The concordance between the methods was evaluated by the Bland-Altman test.

RESULTS

Two of the 16 measured FFM values were not significantly different from FFM(a). However, the risk of dispersion was too high to be acceptable in practice. An equation was then developed by using multivariate analysis, with impedance at 50 kHz. This equation was validated in a second population of 15 ALS patients and with the use of 2 successive measurements performed on 18 patients.

CONCLUSION

BIA is a simple technique that is valid for use in ALS patients, both for a single exam measure and for longitudinal monitoring, with the use of an adapted equation and a frequency of 50 kHz.

Relative validity of clinical techniques for measuring the body composition of persons with amyotrophic lateral sclerosis

Tracking body composition is necessary to understand how amyotrophic lateral sclerosis (ALS) is affecting a patient's morphology and to provide a basis for appropriate nutritional advice throughout disease progression. Dual X-ray absorptiometry (DEXA) has been shown to reliably detect body composition changes in persons with ALS. However, this procedure is expensive and available primarily for research. The purpose of this study was to determine the relative validity of two common clinical techniques, anthropometry and bioelectrical impedance analysis (BIA), for measuring the body composition of persons with ALS. Twenty-three persons with ALS volunteered for the study; seven with primarily bulbar symptoms, five with primarily arm weakness, five with primarily leg weakness, and six with significant weakness in all extremities. On a single day subjects underwent body composition analysis by the three techniques, with DEXA serving as the criterion method. Anthropometry and BIA results were converted to lean and fat mass using eight prediction equations commonly cited in the literature. Anthropometry measures were also converted to estimates of muscle mass using two additional equations. Both BIA and anthropometry tended to overestimate lean mass and underestimate fat mass compared to DEXA. However, the BIA prediction equations had smaller mean differences, larger correlations, and smaller standard errors of estimate than the anthropometry equations. The Lukaski et al. BIA equation (Lukaski, H.C., Bolonchuk, W.W., Hall, C.B., Siders, W.A., 1986. Validation of tetrapolar bioelectrical impedance method to assess human body composition. J. Appl. Physiol. 60, 1327-1332) most closely matched the values derived by DEXA and is probably the best method for measuring the lean and fat mass of persons with ALS, as long as they maintain adequate hydration levels. The Heymsfield et al. equation (Heymsfield, S.B., McManus, C., Smith, J., Stevens, V., Nixon, D.W., 1982. Anthropometric measurement of muscle mass: revised equations for calculating bone-free arm muscle area. Am. J. Clin. Nutr. 36, 680-690) for estimating muscle mass may also be a useful clinical tool for this population. Further longitudinal studies are needed to determine whether the equations that correlated best with DEXA at a single point in time are also sensitive enough to detect changes in body composition over a period of time.