Muscle mass measured using bioelectrical impedance analysis, calf circumference and grip strength in older adults

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Please cite this article in press as: Qui˜nonez-Olivas CG, et al. Muscle mass measured using bioelectri-www.elsevier.es/rmuanl

ORIGINAL

ARTICLE

Muscle

mass

measured

using

bioelectrical

impedance

analysis,

calf

circumference

and

grip

strength

in

older

adults

C.G.

Qui˜

nonez-Olivas

a_,_∗

_,

_R.

_{Salinas-Martínez}

a

_,

_X.A.

_{Ortiz-Jiménez}

b

_,

D.G.

Gámez-Trevi˜

no

a

_,

_G.

_{Guajardo-Álvarez}

a

_,

_B.

_{González-García}

a

a_Geriatric_Services_at_the_‘‘Dr._José_Eleuterio_{González’’}_Hospital_{Univeristario}_de_la_Universidad_Autónoma_de_Nuevo_León,

NuevoLeón,Mexico

b_School_of_Psychology,_Universidad_Autónoma_de_Nuevo_León,_Nuevo_León,_Mexico

Received4March2016;accepted7June2016

KEYWORDS Muscle; Gripstrength; Calfcircumference

Abstract

Objective: Todeterminethecorrelationbetweenmusclemass,measuredusingbioelectrical impedanceanalysis(BIA),withcalfcircumferenceandgripstrength.

Materialsandmethods: Cross-sectionalandobservationalstudy.Includingallfunctionaladults over60 yearsofageseeninourGeriatricClinicduringthemonthsofMarch2013---February 2014.Measurementsofweight,height,BMI,calfcircumference,gripstrengthandmusclemass byBIAweremadeafterthesignatureofinformedconsent.

Results:105patients wereevaluated,73 womenand32 men,withameanageof76years (SD±7.3).Musclemassshowedamildpositive correlationwithcalf circumference:Pearson (r=0.31;p=0.000)andamoderatepositivecorrelationwithgripstrength:Pearson(r=0.50; p=0.000).

Discussion: Muscle massby BIA has apositive correlation with calf circumference andgrip strength,andisareliablemeasuretoassessmusclemassandphysicalperformanceinolder adultsingeriatricambulatoryclinicsandcanbeusedinthediagnosisofsarcopeniainMexican patients.

∗_{Corresponding}_author_at:_Servicio_de_Geriatría,_Hospital_{Universitario}_‘‘Dr._José_Eleuterio_{González’’,}_Universidad_Autónoma_de_Nuevo León,ColoniaMitrasCentro,AvenidaGonzalitosyMaderoenMonterrey,NuevoLeón,Mexico.Tel.:+528181232436.

E-mailaddress:[email protected](C.G.Qui˜nonez-Olivas).

http://dx.doi.org/10.1016/j.rmu.2016.06.005

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Please cite this article in press as: Qui˜nonez-Olivas CG, et al. Muscle mass measured using

bioelectri-Introduction

Therelationbetweenmusclemassandaginghasled scien-tiststoinvestigate itschanges,causes andconsequences. Initially,IrwinRosenbergproposedtheterm‘‘sarcopenia’’ in 1989(from theGreek ‘‘sarx’’ or ‘‘meat’’+‘‘penia’’ or ‘‘loss’’)todescribethedecreaseofmusclemassrelatedto age.1 _Since _its_deﬁnition, _authors _have _demonstrated_the absolute loss of muscle mass from the age of 50, witha decreaseof1.1and1.9kgperdecadeformanandwomen, respectively.2

Epidemiological studies of sarcopenia, with more rep-resentative samples from Europe and the U.S., show prevalenceﬁgureswhichrangefrom10%inadultsolderthan 60upto60%inadultsolderthan80.3,4

In 2010, the European Working Group on Sarcopenia in Older People (EWGSOP)5,6 _aided _studies _by Baumgart-ner,etal.andJanssen etal.tocreatediagnosticcriteria. TheyuseddualenergyX-rayabsorptiometry(DEXA)and bio-electricalimpedanceanalysis(BIA)todeterminemuscular mass.6---8 _The _EWGSOP’s _final _intended _result_was_an algo-rithm for sarcopenia that fulfilled the following criteria: lowphysicalperformancemeasuredbywalkingspeed(4m course)and/or decreasedgripstrength,plusacriterionof lowmuscularmassbelowthestandarddeviations,tomake adefinitivediagnosis.6,9

In Mexico, the public health care system does not havethenecessary toolstomeasuremuscularmass.Thus, dynamometryhasbeenwidelyusedtoevaluategripstrength andphysical performance in older adults.10 _Grip_strength is a predictive factor of adverse results such as institu-tionalization or mortality, but is limited in patients with deterioratedcognitiveability, duetothedifﬁcultiesin its executionor alackofmotivation.11 _{Anthropometric} meas-uressuchascalfcircumference(CC)havealsobeensought asawaytomeasuremuscularmassandfunctionality,based principallyonastudyby Rollandetal.whodemonstrated thatolder adultswitha CCof less than31cmhada high speciﬁcity(91%)inasarcopeniadiagnosis,andwere associ-atedwithdisabilityintheactivitiesoftheirdailylives.12

Arangoetal.intheCoyoacancohort,alsousedaCCless than31cmtoestimatesarcopeniaprevalence.13 _However, itisimportanttoconsiderthananthropometricssuchasCC arepronetoerrorduetoadiposedepositsinmuscleﬁbers andlossofskinelasticityinolderadults,whichcancausean underestimationinsarcopenia’sprevalenceinpersonswith obesity.14

Bioelectricalimpedanceanalysis(BIA)is areproducible methodtomeasurebody composition,andhas been used topredictmusclemassdecreasesinolderadults.However, therelimitations,suchashydrationstate,inadequate pro-teiningestionandphysicalcondition.Despitethis,BIAcould be a useful tool to measure muscular mass in the Mex-ican population, with a lower cost compared to imaging studiesanda decreaseinlimitations comparedtoCCand grip strength in patients with obesity, depression or cog-nitive deterioration,which arecommonsyndromes in the olderly.15---17

The objective of this study is to determine the rela-tionbetweenmuscular massmeasured byBIA andCCand gripstrengthintheolderadultpopulationofNortheastern Mexico.

Material

and

method

Design

This was a transversal study in Monterrey, Nuevo León between March 2013 and February 2014 in the ambula-tory populationof olderadultsthatcametotheGeriatric Services at the ‘‘Dr. José Eleuterio González’’ University Hospital of the AutonomousUniversity of Nuevo Leónfor theirﬁrstconsultation.

Population

Anon-probabilisticsamplewasusedforthisstudy,included allpatientswhichcameforaconsultationduringthestudy’s timeperiod. The totalsample size of thosewhocame to theirconsultation betweenMarch2013andFebruary 2014 was283.

Out of these 283 patients, we selected 105 that met theinclusioncriteria,whichwere:independetintheirbasic dailylivingactivities,withKatzindex≥5.Weexcludedany patientwithanarticularprosthesisorosteosynthesis,useof pacemakers,hormonereplacementtherapywithandrogens, growthhormoneor steroiduse inthepast yearandother chronicoracuteseverecomorbiditythatcausecachexia(or secondarysarcopenia)duetothecatabolicdiseaseprocess itself,suchasNYHAIIIheartfailure,chronicobstructive pul-monarydiseaseGOLDCorD,chronicliverdiseaseCHILDBor Cand/orstage5chronickidneydisease(Terminaldisease). ThestudywasapprovedbytheEthicsandResearch Com-mittee of the ‘‘Dr. José Eleuterio González’’, University HospitalwiththecodenumberGE12-001.

Instruments

A routine clinical service case history, including relevant pathologicalhistory andclinimetry,composedofscales of functionandcognitivestatus,wasperformed.

Toevaluatethefunctionality,weusedtheBasicActivity ofDailyLivingIndex,developedbyKatzetal.18_and Lawton-Brody’sof InstrumentalActivities of DailyLifeIndex.19 _To evaluatecognitivestate, weappliedtheMini-MentalState Examination(MMSE)developedbyFolsteinetal.20 _and_the GeriatricScaleofDepression(GDS)byYesavageetal.21_was usedtoevaluatestateofmind.Theanthropometrywas reg-isteredusingweight,height,bodymassindex(BMI)andcalf circumference(CC).

Gripstrengthofthedominanthandwasdeterminedwith a Takei A5401 digital dynamometer (MedicalSystems Plus IndustryandCommerceMarketingCo.Ltd.,Besiktas Istan-bul,Turkey).Thismeasurementwasperformedthreetimes, withanintervalofoneminutebetweeneachmeasurement, andweusedtheaverageofthethreeresults.

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bioelectri-Table1 Clinimetricandanthropometriccharacteristics.

Variables Average(_±SD)

Gender(%) 73M(69.5)/32(30.5)

Age(years) 76(±7.3)

Height(cm) 154(±9)

Weight(kg) 65.6(±13.9)

BMI(kg/m2₎ _27.5₍_±_5.2)

Gripstrength(kg) 20.86(_±7.9) Calfcircumference(cm) 34.3(±4.1) Muscularmass(kg) 12.98(_±4.6)

KATZ(points) 5.8(±0.35)

Lawton-Brody(points) 5(±1.90)

MMSE(points) 23.0(±5.20)

GDS(points) 4.0(±3.50)

The tetrapole bioimpedometer (BIA Quantum IV Body CompositionAnalyzer,RJLsystems)evaluatesthebody tis-sue’s resistance to an electric current. The analysis was performedwiththepatientlyingdown,withfourattached electrodes,twoonthebackofthewristandtwoontheright ankle.Theresultsarepresentedasresistanceandreactance inohms, tolaterbeusedin oneofthevalidmusclemass (MM) estimationequations. We used a formuladeveloped byJanssenetal.7

Musclemass(kg)=[(height2_/_R_×_0.401)₊₍₃₈₂₅_×_gender) +(age×−0.071)]+5.102.

Height=cm,R=resistanceinohmsmeasuredbytheBIA. Gender=male:0,female:1.

Statisticalanalysis

Descriptive statistics were performed and expressed as mean and standard deviation (SD) for all variables and means of analysis werecompared between both genders. The normality of the variables was analyzed using the Kolmogorov---Smirnovtest.APearsoncorrelationcoefﬁcient analysis was performed to calculate the association of quantitativevariables.Thevaluesofp=0.05orlesswas con-sideredstatisticallysigniﬁcant.Allanalyzeswereperformed usingSPSSforWindows(SPSSInc.,Chicago,IL,version20.0).

Results

Theseresultsarefromthetotalsampleof105patients,73 women(69.5%)and32men(30.5%)whohadanaverageage of76(±7.3)years.

Overall means of instruments, clinimetric evaluations andanthropometriccharacteristicssuchastheKatzIndex, Lawton-Brody,MMSE,GDS,weight,height,BMI,calf circum-ference, grip strength and muscle mass are described in

Table1.

Intheanalysisbygender,menhadhighervalues, show-ingstatisticallysigniﬁcantdifferencesinmeanmusclemass andgripstrength,which wasexpectedduetotheirlarger sizeandweight,buttherewerenosigniﬁcantdifferencesin calfcircumference,showingthelowsensitivityofthecalf muscleasabiomarkerofsarcopenia(Table2).

Finally,a slightpositivecorrelation wasfoundbetween muscle mass by BIA and calf circumference (p=<0.001

45

r=0.312

40

35

30

25

0 5 10 15 20 25 30 35

Figure1 The resultofthe Person’s association testwas a slightpositivecorrelationbetweenmusclemassbyBIAandcalf circumference,r=0.312(p=<0.001).Muscularmass(kg).Calf circumference(cm).

50

r=0.505

40

30

20

10

0

0 5 10 15 20 25 30 35

Figure2 The resultofthe Person’s association testwas a moderatepositivecorrelationbetweenmusclemassbyBIAand gripstrength,r=0.505(p=<0.001).Gripstrength(kg).Muscular mass(kg).

is=0.31),aswellasamoderatepositiveassociationbetween muscle mass and grip strength (r=0.50, p=<0.001) and calfcircumference and grip strength (r=0.28, p=<0.001)

(Figs.1---3).

Discussion

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bioelectri-Table2 Clinicalcharacteristicsbygender.

N=105 Men

N=32

Women N=73

pValue(IC95%)

Age(years) 77.84±5.4 75.4±7.9 0.075(-0.2---5.0)

Height(cm) 163±7 150±8 <0.001(0.9---.15)

Weight(kg) 72.5±13.7 62.5±12.9 <0.001(4.4---15.5)

BMI(kg/m2₎ _27.5_±_4.8 _27.6_±_5.4 _0.917₍₋_2.2_to_2.0)

Gripstrength(kg) 28.0_±8.3 17.9_±5.2 <0.001(7.1---13.5)

Calfcircumference(cm) 34.7±4.3 34.1±4.1 0.376(−0.52to2.4)

Muscularmass(kg) 16.5_±5.2 11.4_±3.3 <0.001(3.0---7.1)

KATZ(points) 5.8±0.3 5.7±0.3 0.589(−0.10to0.18)

Lawton-Brody(points) 5.2±1.7 4.9±1.9 0.556(−0.55to1.01)

MMSE(points) 23.9±5.2 22.6±5.1 0.254(−0.92to3.45)

GDS(points) 3.2±3.2 4.3±3.6 0.146(−2.4to0.37)

50

40

30

20

10

0

25 30 35 40 45

Figure3 The resultofthe Person’s association test was a slightpositivecorrelationbetweencalfcircumferenceandgrip strength,r=0.288(p=<0.001).Gripstrength(kg).Calf circum-ference(cm).

calfcircumference showed nostatistically signiﬁcant dif-ferencebetweenwomen andmen,suggestingalimitation withthisformof measurement indiscriminating between musclemass,water,fatandbone,likeallanthropometric measurements.22 _This _is _consistent _with _a _study _by Rol-land,etal.whichshowedthatacalfcircumferencelower than 31cm had high speciﬁcity but low sensitivity 44% in thepredictionof sarcopenia,limitingitsuseindiagnosing sarcopenia.12

BIA has been studied for over 10 years andhas a high positive correlation (r=0.095) with MRI, which is consid-eredthegoldstandardformeasuringmuscularmass.16 _Our studysupportstheuseofBIAtomeasuremusclemasswith greaterreliabilitythancalfcircumferenceandalsoasatool toindirectlymeasurepatients’physicalperformancedueto thepositiveassociationwithgripstrength.Thereare stud-ieswhichshow thatthe lowergrip strengthincreasesthe

relativeriskofdisabilityinactivitiesinvolvedwithdaily liv-ing to 2.0 (95% CI 1.14---3.17). These have also shown an associationwithsarcopenia,withariskincreaseof4.8(95% CI1.4---16.8).9,23_The_measurement_of_muscle_mass_by_BIA_is particularlyrelevantinpatientswithdepressionand/or cog-nitiveimpairmentthatcannotcarryoutothermeasuresof forceorphysicalperformanceproperly.

Thelimitationofthisstudywasthesmalland unrepresen-tativesamplesizeweusedtogeneralizetheﬁndingsforall olderadultsinNortheasternMexico.Weneedmorestudies toexaminethereliabilityofthesetoolstomeasuremuscle massintheelderly.

Ethical

norms

This studywasapprovedbytheEthicsand Research Com-mittee of the ‘‘Dr. José Eleuterio González’’ Hospital Univeristario dela Universidad AutonomadeNuevo Leon, withthecodenumberGE12-001.

Funding

Property of the Geriatric Service of the ‘‘Dr. José Eleu-terio González’’ Hospital Univeristario de la Universidad AutonomadeNuevoLeon.

Conﬂicts

of

interest

Theauthorshavenoconﬂictsofinteresttodeclare.

Acknowledgements

To Luis Miranda Plata and Carlos Beltrán García, social servicemedicalinternsattheGeriatricServiceofthe‘‘Dr. José EleuterioGonzález’’Hospital Univeristariodela Uni-versidadAutonomadeNuevoLeon.

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