Factors affecting the 2H to 18O dilution space ratio in infants

A standard calculation methodology for human doubly labeled water studies

The doubly labeled water (DLW) method measures total energy expenditure (TEE) in free-living subjects. Several equations are used to convert isotopic data into TEE. Using the International Atomic Energy Agency (IAEA) DLW database (5,756 measurements of adults and children), we show considerable variability is introduced by different equations. The estimated rCO₂ is sensitive to the dilution space ratio (DSR) of the two isotopes. Based on performance in validation studies, we propose a new equation based on a new estimate of the mean DSR. The DSR is lower at low body masses (<10 kg). Using data for 1,021 babies and infants, we show that the DSR varies non-linearly with body mass between 0 and 10 kg. Using this relationship to predict DSR from weight provides an equation for rCO₂ over this size range that agrees well with indirect calorimetry (average difference 0.64%; SD = 12.2%). We propose adoption of these equations in future studies.

Body composition reference charts for UK infants and children aged 6 weeks to 5 years based on measurement of total body water by isotope dilution

Background

Until recently, pediatric body composition reference data were very limited, hindering interpretation of measurements. In the last decade, such data emerged for several techniques for children ≥ 5 years, but equivalent data for younger age groups remain lacking, due to their poor compliance with most techniques.

Objectives

To provide reference data for use in clinical practice and research from 6 weeks to 5 years, that are based on measurements of total body water (TBW) by isotope dilution.

Design

The data on anthropometry and TBW were available from studies of 463 infants and children aged 6 weeks to 7 years, conducted between 1988 and 2010. Both breast-fed and formula-fed infants were included. TBW was measured by ²H- or ¹⁸O-labeled water, and converted to fat-free mass (FFM) using published hydration coefficients. Reference charts and SD scores (SDS) were constructed for FFM, fat mass (FM), FFM index and FM index for each sex, using the lambda-mu-sigma method.

Results

Both sexes were significantly heavier and longer than UK 1990 reference data (p < 0.01), but did not differ in body mass index SDS. Breast-fed infants were longer than formula-fed infants but did not differ in body composition.

Conclusions

These reference data will enhance the ability of clinicians to assess and monitor body composition and FFM/FM accretion in clinical practice in younger age groups. Total body water can be measured in most patients, though abnormalities of hydration must be addressed. However, the centiles do not overlap exactly with those published for older age groups, limiting comparability between younger and older children.

Development of an estimated glomerular filtration rate formula in cats

Background

Estimated glomerular filtration rate (eGFR) formulas are routinely used in human patients to provide a more accurate evaluation of GFR compared to serum creatinine concentration alone. Similar formulas do not exist for cats.

Objectives

To validate a prediction formula for eGFR in cats based on adjusting serum creatinine concentration.

Animals

Client‐owned cats with various levels of renal function.

Methods

The study was cross‐sectional. Glomerular filtration rate was determined by iohexol clearance. Variables including signalment, biochemical markers, and noninvasive measurements considered to represent surrogate markers of muscle mass were evaluated with the reciprocal of serum creatinine concentration in a multivariable regression model. The derived eGFR formula was subsequently tested in another group of cats and agreement with GFR assessed.

Results

The formula was developed in 55 cats. Only a single morphometric measurement (pelvic circumference) along with the reciprocal of serum creatinine concentration (creatinine⁻¹) independently predicted GFR in the final multivariate model. The derived eGFR formula was 0.408 + (243.11 × creatinine⁻¹ [μmol/L]) ‐ (0.014 × pelvic circumference [cm]). When the formula was tested in another 25 cats it was not found to offer any advantage over creatinine⁻¹ alone in its relationship with GFR (eGFR, R² = 0.44, P < .001 vs reciprocal of creatinine, R² = 0.45, P < .001). Furthermore, agreement between eGFR and GFR was poor.

Conclusions and Clinical Importance

An eGFR formula for cats that adjusted serum creatinine concentration for a marker of muscle mass was developed. The formula did not provide a reliable estimate of GFR, and therefore, its routine use cannot be recommended.

Deuterium dilution technique for body composition assessment: resolving methodological issues in children with moderate acute malnutrition

Childhood malnutrition is highly prevalent and associated with high mortality risk. In observational and interventional studies among malnourished children, body composition is increasingly recognised as a key outcome. The deuterium dilution technique has generated high-quality data on body composition in studies of infants and young children in several settings, but its feasibility and accuracy in children suffering from moderate acute malnutrition requires further study. Prior to a large nutritional intervention trial among children with moderate acute malnutrition, we conducted pilot work to develop and adapt the deuterium dilution technique. We refined procedures for administration of isotope doses and collection of saliva. Furthermore, we established that equilibration time in local context is 3 h. These findings and the resulting standard operating procedures are important to improve data quality when using the deuterium dilution technique in malnutrition studies in field conditions, and may encourage a wider use of isotope techniques.

Special Considerations for Measuring Energy Expenditure with Doubly Labeled Water under Atypical Conditions

The global increase in the prevalence of obesity has dramatically increased interest in understanding the factors that influence human total energy expenditure (TEE). This in turn has increased interest in the doubly labeled water (DLW) method, a technique for measurement of total energy expenditure in free-living humans. The increasing use of this method is attributed to its portability, objectivity, minimal invasiveness, high accuracy and good precision. Although a relatively standard protocol for the method has emerged, the new generation of users often is unfamiliar with rationale behind aspects of the protocol as well as the approaches to avoid or correct for in situations that are not covered by the standard protocol procedure. The primary uncommon situations like introduction of isotopically different diet and fluids with or without geographical relocation, seasonal and temperature variations, activity level of participants etc. during or prior to the DLW measurements can lead to shift in baseline abundance of ²H and ¹⁸O or tracer elimination, resulting in moderate to large errors in the measured TEE. These unique situations call for special modifications to the conventional protocol to minimize errors. The objective of the present review was to assemble a list of frequently asked questions and the issues they represent, and then examine the available literature to describe and explain the modifications to the standard DLW protocol to maintain the method's accuracy. This discussion of DLW protocol modification can be an excellent resource for investigators who intend to use this measurement technique for interesting and uncommon study designs.

Body composition assessment in the infant

Body composition assessment provides a sharper picture of the human biological response to genetic and environmental influences than measures of body size and weight. Infant body composition is particularly important as a marker of fetal adaptation and developmental programming of subsequent health and disease, but until recently, the range of options for measuring infant body composition was relatively narrow. The purpose of this Toolkit: Methods in Human Biology review is to provide a comprehensive overview of methods of body composition methods currently used in infants 0 to 2 years of age, including anthropometric prediction equations, air displacement plethysmography (ADP), dual energy X-ray absorptiometry (DXA), bioelectrical impedance analysis (BIA), isotope dilution, and magnetic resonance imaging (MRI). Information on the reliability, validity, and accuracy of the methods is provided. Unique aspects of infant physiology and behavior create challenges for body composition assessment, but this review provides guidance on suitable testing approaches and environments that may aid researchers in this important area of investigation.

Prediction of total body water in infants and children

BACKGROUND

In paediatric clinical practice treatment is often adjusted in relation to body size, for example the calculation of pharmacological and dialysis dosages. In addition to use of body weight, for some purposes total body water (TBW) and surface area are estimated from anthropometry using equations developed several decades previously. Whether such equations remain valid in contemporary populations is not known.

METHODS

Total body water was measured using deuterium dilution in 672 subjects (265 infants aged <1 year; 407 children and adolescents aged 1-19 years) during the period 1990-2003. TBW was predicted (a) using published equations, and (b) directly from data on age, sex, weight, and height.

RESULTS

Previously published equations, based on data obtained before 1970, significantly overestimated TBW, with average biases ranging from 4% to 11%. For all equations, the overestimation of TBW was greatest in infancy. New equations were generated. The best equation, incorporating log weight, log height, age, and sex, had a standard error of the estimate of 7.8%.

CONCLUSIONS

Secular trends in the nutritional status of infants and children are altering the relation between age or weight and TBW. Equations developed in previous decades significantly overestimate TBW in all age groups, especially infancy; however, the relation between TBW and weight may continue to change. This scenario is predicted to apply more generally to many aspects of paediatric clinical practice in which dosages are calculated on the basis of anthropometric data collected in previous decades.

Indices of whole-body and central adiposity for evaluating the metabolic load of obesity

BACKGROUND

To assess the relative metabolic load or risk imposed by fatness, fat mass (FM) is commonly expressed as a proportion of weight (% fat), while central adiposity is assessed using the ratio of triceps (TRI) to subscapular (SUBS) skinfolds. The statistical validity of these indices, defined as independence of the index from its denominator, has received inadequate evaluation.

OBJECTIVE

To critically examine commonly used obesity indices, and to propose more appropriate approaches.

DESIGN

Cross-sectional studies.

SUBJECTS

In total, 148 infants; 2195 adult men aged 18 y.

METHODS

log-log regression analysis was used to explore the relationships between FM and weight (WT) or fat-free mass (FFM) (adults), and between TRI and SUBS (infants and adults).

RESULTS

The simple indices FM/WT, FM/FFM, TRI/SUBS and SUBS/TRI remained related to their denominators, showing their rankings of individuals to be biased by size or fatness. The appropriate power (p) by which to raise the denominator was determined from regression analyses, and differed from unity in all cases. Both skinfold ratios showed a nonlinear relationship with their denominators.

CONCLUSION

Simple indices for evaluating whole-body or central adiposity are statistically flawed, and remain influenced by size or fatness of the subject. The index FM/WT is conceptually flawed because FM appears in both numerator and denominator, and the index FM/FFM(p) is preferable. Skinfold ratios are also problematic, and to evaluate central adiposity SUBS alone, or SUBS/FFM(p), may represent more appropriate approaches. These issues should be investigated in other studies in order to address possible influences of age, ethnicity, gender and nutritional status.

Longitudinal investigation of energy expenditure in infants with cystic fibrosis

OBJECTIVE

To determine when energy expenditure becomes elevated in infants with cystic fibrosis (CF).

DESIGN

Longitudinal studies of total energy expenditure (TEE) using doubly labeled water were conducted in infants identified with CF by newborn screening through the first year of life.

SETTING

Hospital and community based studies in Denver, Colorado, USA and Cambridge, UK.

RESULTS

Eight of the 12 infants enrolled had begun enzyme therapy but were clinically asymptomatic. Four of the 12 infants were heterozygous for the delta F508 mutation, however no difference was seen in TEE from the remaining homozygous infants. TEE was compared to control cohorts at 2, 6 and 12 months of age. There was no difference from the control groups in TEE/kg fat free mass (FFM)/day at 2 months. However, by 6 months of age TEE/kg FFM/day in infants with CF exceeded that of age-matched controls by 25% (P<0.001). This elevation in TEE continued at 12 months of age exceeding that of controls by 30% (P<0.05).

CONCLUSIONS

These results indicate that infants with CF have increased energy needs by 6 months of age and that early diagnosis alone does not prevent the development of increased caloric requirements. These findings emphasize the need for close nutritional monitoring to prevent suboptimal growth during infancy in this population.

SPONSORSHIP

This research was supported by grant number 5 MO1 RR00069, General Clinical Research Centers Program, National Center for Research Resources, NIH.

Validation of the doubly-labelled water technique in the domestic dog (Canis familiaris)

We validated doubly-labelled water (DLW) by comparison to indirect calorimetry and food intake-mass balance in eight Labrador dogs (24-32 kg) over 4 d. We used several alternative equations for calculating CO2 production, based on the single- and two-pool models and used two alternative methods for evaluating the elimination constants: two-sample and multiple-sampling. In all cases the DLW technique overestimated the direct estimate of CO2 production. The greatest overestimates occurred with the single-pool model. Using two samples, rather than multiple samples, to derive the elimination constants produced slightly more discrepant results. Discrepancies greatly exceeded the measured analytical precision of the DLW estimates. The higher values with DLW probably occurred because the dogs were extremely active during the 1 h in each 24 spent outside the chamber. Estimates of CO2 production from food intake-mass balance, which include this activity, produced a much closer comparison to DLW (lowest mean discrepancy 0.3 % using the observed group mean dilution space ratio and an assumption that the mass changes reflected changes in hydration for all except one animal). We recommend an equilibration time of 6 h and use of the two-pool model based on the observed population dilution space for future studies of energy demands in dogs of this body mass.

Body composition measurements during infancy

Infancy is the period of most rapid postnatal growth and is accompanied by major changes in body composition (BC). There are many challenges to successfully measuring BC of infants in vivo, which include the inherent limitations in the underlying assumptions for each technique. The small body mass and rapid nonuniform changes in body parts, that is, the components of BC during infancy, can strain the technical limits of all methods. Many techniques for in vivo BC measurement used in older people have been applied to infants. However, the vast majority of them either are difficult to adapt for widespread use in infants, or the roles and limitations for using them during infancy are ill-defined because of limited or no critical validation and cross-calibration studies. Based on validation data from animals, well-defined methodological issues in data acquisition and analyses, availability of normative data, and pertinent accuracy and precision of the technique to allow us to determinate clinically relevant changes in BC within a reasonable time interval, three techniques appear to be most suitable for in vivo BC measurement in infants. Anthropometric measurements can be used in field studies or for group comparisons, and total body electrical conductivity (TOBEC) and selected dual-energy X-ray absorptiometry (DXA) measurements can be used to compare BC in individual infants. DXA has the advantages of being able to measure bone mass and the potential to be adaptable to the widely available existing instruments. However, regardless of the techniques used in measuring BC in infants, meticulous attention to details in data acquisition and data analysis, and a knowledge of the limitations of the particular technique are the prerequisites for generating valid data.

Energy metabolism in infants and children

Energy is used continuously in the body and is fundamental to physiologic processes. Requirements of individuals vary in relation to a wide variety of factors, making energy metabolism an issue of great importance to the pediatrician. Techniques are available for short- and long-term measurements of energy expenditure, which serve different purposes. The principal techniques are suitable for the age range from birth to adolescence. The theory of energy metabolism is briefly discussed, including a summary of the different working definitions. The principles and practicalities of classical indirect calorimetry, the doubly labeled water method, the bicarbonate method, and heart rate monitoring are then described.