| | Nutritional status assessed from anthropometric measures in the HEMO study☆Abstract Objective: Anthropometric methods are screening techniques for assessing nutritional stores of fat and lean tissues among persons with renal disease. This report presents cross-sectional baseline data on anthropometric indicators of nutritional status from a group of hemodialysis patients in a multicenter clinical trial, the Hemodialysis (HEMO) Study. Design: The HEMO Study is a prospective, multicenter, randomized, 2 × 2 factorial clinical trial to evaluate the efficacy of the delivered dose of dialysis, defined by Kt/V, and membrane flux in reducing morbidity and mortality in (maintenance) hemodialysis patients. Standardized measures of weight, stature, body mass index (BMI), arm and calf circumference, and triceps and subscapular skinfolds were taken immediately after dialysis. The analytic methods consisted of univariate statistics, including means, standard deviations, and selected percentiles presented as tables of descriptive statistics. Study findings were compared with corresponding national reference data from the Second National Health and Nutrition Examination Survey (NHANES II). Patients: Eligible patients between 18 and 80 years of age on chronic hemodialysis for at least 3 months, receiving hemodialysis 3 times per week and with a residual renal clearance of < 1.5 mL/min were examined. Patients also had to be able to attain an eKt/V of ≥ 1.45 in 4.5 hours or an anthropometric volume < 45 to 50 L thus excluding persons with body weights over about 85 kg. The study sample consisted of the first 1,000 randomized patients, 464 men and 536 women; 642 blacks, 318 whites; and 40 of other racial backgrounds out of 1,847 randomized. Results: Differences in nutritional status by sex, race, duration of dialysis, and comorbid disease were found among these patients enrolled in the HEMO Study. In comparison with NHANES II, these hemodialysis patients were, on average, lighter with less adipose and muscle tissue than healthy persons of the same ages. These findings can be indicators of persons with chronic disease. Those with diabetes were overweight based on their BMI values. Conclusion: These HEMO Study data provide a clinical reference for the use of these anthropometric indicators in assessing the nutritional status of contemporary hemodialysis patients weighing < 85 kg. © 2003 by the National Kidney Foundation, Inc.
Major treatment objectives for patients with end-stage renal disease (ESRD) who are undergoing chronic hemodialysis include improvements in their nutritional status and general health.1 Factors affecting nutritional status in such patients are dietary intake, the presence of protein-energy malnutrition (PEM), and other comorbidities, including diabetes, cardiovascular disease, metabolic abnormalities, such as uremia, low levels of physical activity, and the duration and adequacy of dialysis.2, 3, 4 As a group, ESRD patients include a large and increasing proportion of older adults who frequently are in poor nutritional health.5 Many have low body weights, low levels of body fat and muscle stores, and low body mass indices (BMIs) caused by the disease, its comorbidities, and complications such as PEM.2, 6 Because PEM is prevalent among ESRD patients, many will enter hemodialysis already debilitated.7 PEM is a powerful predictor of morbidity and mortality in ESRD cases, but if recognized and treated early these sequelae can be attenuated or avoided.8, 9 Adverse changes in anthropometric measures are possible early markers of the onset of PEM, and thus important indicators of potentially modifiable risk factors among ESRD patients.5, 6
Anthropometric methods are simple, practical, clinically available, and cost-effective screening techniques that provide meaningful information about nutritional stores of fat and lean tissues and the potential risk of PEM among persons with renal disease.10 In using anthropometry to assess nutritional status in ESRD patients or those with other chronic diseases, a reference population or appropriate disease-specific reference data must be available for comparison purposes.11 Early in the course of chronic renal failure, the use of normative reference data from healthy populations may be appropriate because some individuals maintain a reasonable level of nutritional health and quality of life for some period of time. After several years of ESRD, normative reference data becomes inappropriate, especially when comorbidities and other chronic infections affecting body composition are present.11 Disease-specific anthropometric reference data would provide meaningful information for the nutritional management of hemodialysis patients and the potential risk of PEM.11 Because there is no cure for ESRD, treatment must include care that maximizes the nutritional health of ESRD patients.1
This report presents cross-sectional baseline data on anthropometric indicators of nutritional status from a group of hemodialysis patients who participated in a multicenter clinical trial, the Hemodialysis (HEMO) Study. These anthropometric data provide a disease-specific reference against which the nutritional status of long-term dialysis patients or others with ESRD can be compared. However, these data are limited in that HEMO patients are not representative of the general dialysis population.
Sample and methods  The HEMO Study is a prospective, multicenter, randomized, 2 × 2 factorial clinical trial to evaluate the efficacy of the delivered dose of dialysis, defined by Kt/V (where K is dialyzer clearance [mL/min], t is treatment time, and V is total body area distribution volume), and membrane flux in reducing morbidity and mortality in maintenance hemodialysis patients.12 The Institutional Review Boards at each of the participating clinical centers approved the study and written consent was obtained from all study participants. Briefly, eligible patients between 18 and 80 years of age who were not malnourished and had been receiving hemodialysis 3 times a week and with a residual renal clearance of < 1.5 mL/min for at least 3 months were examined. This study included only patients able to attain an eKt/V of ≥ 1.45 in 4.5 hours or an anthropometric volume < 45 to 50 L. Thus, persons with body weights in excess of approximately 85 kg were excluded from enrollment. Persons with diabetes comprised a larger percentage than in the general population. Details of the design for the HEMO Study and a list of the 15 participating institutions with a total of 67 dialysis units have been reported.12 The study limitations from the standpoint of developing disease-specific reference data for the ESRD population are caused chiefly by exclusions from the study sample.12 Exclusion criteria included severe malnutrition indicated by a predialysis albumin of < 2.8 g/dL, current malignances requiring radiation or chemotherapy, symptomatic acquired immunodeficiency syndrome, liver cirrhosis with encephalopathy, severe congestive heart failure, unstable angina, chronic pulmonary disease, and current hospitalization. Patients who refused to receive dialysis for longer than that of usual clinical practice (eg, 3-4 hours) also were excluded. Despite these exceptions, the randomized groups presented here reflect many of the representative characteristics of the ESRD population in the United States. The study group consisted of the first 1,000 randomized patients out of 1,847 finally enrolled. These 1,000 patients were recruited and randomized from March, 1995 through March, 1999 at the 15 participating clinical centers. There were 464 men and 536 women, of whom there were 642 blacks, 318 Whites, and 40 persons of other racial backgrounds. Standardized body measures13 similar to those in the Third National Health and Nutrition Examination Survey (NHANES III)14 were taken immediately after dialysis in each research center during the baseline period: postdialysis (dry) weight and stature, (from which BMI was calculated) and arm circumference (Arm Circ), calf circumference (Calf Circ), triceps (Triceps) and subscapular skinfolds (Subscap) from the nonaccess side of the body. The analytic methods consisted of univariate statistics, including means, standard deviations, and selected percentiles. The baseline anthropometric data are presented as tables of descriptive statistics. Group differences were determined using t-tests and significance levels set at 0.01 caused by the numerous comparisons. Study findings were compared with corresponding national reference data from NHANES II.15 Results Sex and race comparisons As expected, significant (P < .01) sex- and race-specific differences in means for body size and fatness were evident in the total sample (Table 1).
The men were heavier than the women, but the women had larger skinfold thicknesses than the men. No racial differences were evident for body size among the men, but the black women were heavier and had larger arm circumferences and skinfold thicknesses than the white women. Comparisons with normative reference data National normative reference data from the NHANES II was used for comparison with these findings. For the white and black women and men (Table 1) the means for weight, BMI, arm circumference, and the skinfolds were similar to or smaller than corresponding means from NHANES II (data not shown). For corresponding NHANES II, tenth, fiftieth, and ninetieth percentiles, arm circumference values from the HEMO Study for both white and black males were smaller by 2 to 4 cm. Arm circumference percentiles for white and black women in the HEMO Study were similar to their corresponding NHANES II percentiles. An example of these comparisons is presented in Fig. 1 for the arm circumference percentiles.
For the triceps and subscapular skinfolds, this pattern was reversed with the tenth, fiftieth, and ninetieth percentiles for both white and black HEMO men being generally similar to the NHANES II values, with the exception of the nietieth percentile for subscapular skinfold, which was about 5 cm smaller than the NHANES II value. In contrast, both white and black women in the HEMO Study had triceps and subscapular skinfolds percentiles that were 2 to 13 mm less than the corresponding NHANES II percentiles. These findings indicate that these HEMO Study participants had average or slightly smaller values for weight and BMI. The men had small arm circumferences, but approximately average amounts of body fat whereas the HEMO women had average arm circumferences, but small amounts of body fat ( Fig. 1). Diabetes status Type II diabetes is a common comorbid condition in ESRD. In the present sample, diabetics of both sexes had significantly larger means for weight, BMI, arm circumference and skinfold thicknesses than nondiabetics (Table 2).
These findings indicate that patients with diabetes in the HEMO Study had, on average, larger body weights and amounts of body fat than nondiabetic participants. In comparison with the NHANES II data, the means and the tenth and fiftieth percentiles for weight, BMI, arm circumference (ninetieth percentile also) and subscapular skinfold thickness for the women with diabetes were larger than the corresponding NHANES II values (data not shown). For the men, means and tenth and fiftieth percentiles for weight, BMI, and triceps and subscapular skinfold thicknesses also were larger than the corresponding NHANES II values. In the women, the mean BMI was 25.2 and in the men it was 24.9. A BMI ≥ 25 is an indicator of overweight.16 Duration of dialysis Dialysis vintage (eg, years on dialysis) had an effect on some of these anthropometric indicators of nutritional status. In the HEMO Study, the subgroup on dialysis for 5 years or longer had significantly smaller means for body weight, arm circumference, and triceps and subscapular skinfolds than those on dialysis for less than 5 years (Table 3).
This finding suggests that body weight and subcutaneous fat may decline with the increasing number of years of dialysis treatment. Age associations There was an association of the anthropometric measures of nutritional status with age. At enrollment, women ≥ 55 years of age had significantly larger (P < .01) means for BMI and arm circumference than did younger women (Table 4).
Similarly, men ≥ 55 years of age had significantly larger (P < .01) means for triceps and subscapular skinfold thicknesses and a lower mean calf circumference than did younger men. Similar to the general population, the older dialysis patients tended to be heavier and had more subcutaneous fat than younger ones.17 Discussion The selection of HEMO Study subjects was limited by their body size because of the entrance constraints imposed by the required clinical procedures.12 This constraint affected more men than women because of their larger body sizes. The body sizes of the men enrolled were in the lower 2 thirds to 1 half of that of the available healthy male population. These body size constraints truncated the distributions of the variables at the higher percentiles. Also, the limits on the anthropometric volume of total body water placed the men at or below the mean for total body water among men from 20 to 80 years of age.18 Fifty percent of the study group had had ESRD for longer than 5 years, and only those who met the inclusion criteria were randomized at baseline.12 As a result, the HEMO Study group is not representative of the ESRD population in the United States, but because many of the group's characteristics are representative of those with ESRD, the present findings can be generalized at least to some members of this population. As such, they provide more appropriate reference norms for ESRD patients of < 85 kg on hemodialysis than do reference values based on healthy adults. The sex and race differences noted in these data (Table 1) were similar to those present in the general population. The prevalence of obesity in the United States adult population has increased, and among black women it approaches 50%.16 Because of the increased prevalence of obesity in the United States population, we chose to compare the present results with corresponding national data from NHANES II15 to provide a clearer interpretation without the added bias of the increased prevalence of obesity evident in the NHANES III.16 In comparison with NHANES II data, these hemodialysis patients as a group were, on average, shorter, lighter and generally leaner as reflected by less subcutaneous adipose tissue than healthy persons without ESRD of the same ages. These same differences between the NHANES II and HEMO data persisted for the subgroupings of nondiabetic men and women (Table 2, Table 4). The NHANES II is a nationally representative sample of the United States population of which these HEMO patients are members. Some of the values for the HEMO patients were several units less than the corresponding NHANES II value. The clinical significance of these difference from the NHANES II values is difficult to determine because no measure of clinical or health significance has been associated with the NHANES II values except for the prognostic relationships for BMI. Furthermore, these differences may be caused in part to the selection criteria that restricted the HEMO Study sample to excluding patients who had weights ≥ 85 kg. In all of these several groups of HEMO patients, the means and percentiles for the anthropometric indicators were similar to or slightly below the corresponding NHANES II percentiles. These differences are caused in part to the restrictive selection criteria of the HEMO Study on body size. The only exception was for the subgroup of diabetic men and women in the HEMO Study. These diabetic HEMO participants, most of whom had Type II diabetes, had elevated indicators of body fatness consistent with the occurrence of this disease in addition to the presence of ESRD. The means and/or most of the percentiles for weight, BMI, arm circumference, and subscapular skinfold thickness in the women were larger than the corresponding NHANES II values. In the men, this same pattern existed for weight, BMI, and triceps and subscapular skinfold thicknesses. Even among these HEMO participants, whose weights, BMI, and levels of body fatness were at or below average for healthy adults, those with Type II diabetes were, on average, overweight based on criteria from the World Health Organization. The World Health Organization has defined cut points for BMI as indicators of levels of overweight (BMI ≥ 25) and obesity (BMI ≥ 30) for all adults regardless of race or sex that are correlated with increased risk of morbidity and mortality.16 The vintage of dialysis was associated with poor nutritional status (Table 3). Those on dialysis for over 5 years had significantly smaller BMI and skinfold values than those on dialysis for a lesser time as has been reported by others.21, 22 It is difficult to determine whether these differences were caused by dialysis treatment per se or by the longer duration of ESRD. Wasting is thought to be associated with the dialysis process.22 These findings could be biased by the high mortality associated with hemodialysis. The differences in anthropometric measurements by age within each sex may be the result of several possible causes (Table 4). The greater fatness in the older subjects is an expected aspect of normal aging,23, 24, 25 but it also may be caused by the later onset of ESRD as a result of diabetes and thus shorter duration of ESRD in these older patients as compared with the younger ones. The relative leanness of the younger group could reflect a possible longer duration of ESRD before dialysis was started. Another possible explanation is that the men have lost muscle, whereas the women have lost body fat. The smaller calf circumferences in the older men (Table 4) also suggest a differential loss of muscle and fat in the men. This finding in the men may imply a loss of underlying muscle tissue because of a cachectic condition or simply may be attributable to sampling. Calf circumference is a potential marker for reduced muscle mass,26, 27 but no current NHANES reference data are available for comparison. Nelson et al 11published the only other set of anthropometric reference data from 274 whites and 466 blacks with ESRD who were undergoing maintenance dialysis. These earlier findings for men were not significantly different from the corresponding NHANES II data, but the values for the women were significantly lower. Similar to the present findings, Nelson noted that diabetics (especially the females) were fatter than nondiabetics and similar to the corresponding NHANES II data.11 Persons with ESRD present a variety of problems in the assessment of nutritional status. The effects of ESRD alter many of the relationships or assumptions between body measurements and body composition on which anthropometric assessment methods are based.10 Changes in weight generally parallel hydration status, energy, and protein balance. Measurements of body weight should be accompanied by other anthropometric indices of body composition at regular (eg, quarterly) but not necessarily frequent intervals. Taken together, these measurements provide a better understanding of the underlying parameters of a change in weight, such as alterations in the relative amounts and anatomic distributions of adipose and muscle tissues.17 In the present study, the body measurements were taken on the nonaccess side. There are no significant lateral differences in body measurements except for arm circumference.28 Conclusion There are differences by sex, race, presence of diabetes, duration of dialysis, and age in the anthropometric indicators of nutritional status of patients enrolled in the HEMO Study. In comparison with national reference data, these HEMO Study patients were, on average, lighter and had less adipose and muscle tissue than healthy persons of the same ages, and this underscores the need to use ESRD-specific reference standards for the hemodialysis population. These characteristics can be indicators of persons with chronic disease at risk of undernutrition. 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Age Nutr. 1993;4:138–141. * Fels Professor, Department of Community Health, Wright State University, S.O.M., Lifespan Health Research Center, Kettering, OH. † Director, Frances Stern Nutrition Center, Tufts New England Medical Center Hospitals, Boston, MA. ‡ Renal Dietition, Lankenau Hospital Medical Research Center, Lankenau Medical Bldg, Division of Nephrology, Wynnewood PA. § Professor of Medicine and Nephrology, Wake Forest Univ Baptist Med Center, Department of Internal Medicine, Section of Nephrology, Winston-Salem NC. ∥ Biostatistician, Department of Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, OH. ¶ Renal Dietition Study Coordinator, Department of Veteran Affairs, Westside Medical Center, Dept of Research (151), Chicago IL. # Research Scientist, Medical Nutrition Research and Development, Ross Products Division, Abbott Laboratories, Columbus, OH. ** Director, Renal and Urological Clinical Trials, Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive Kidney Diseases, Bethesda, MD. †† Study Coordinator, Division of Nephrology, Clinical Trials Center/Vanderbilt Univ Med Center, Nashville TN. ☆ Address reprint requests to Wm. Cameron Chumlea, PhD, Lifespan Health Research Center, 3171 Research Blvd, Kettering, OH 45420. E-mail: cameron.chumlea@wright.edu PII: S1051-2276(02)13404-2 doi:10.1053/jren.2003.50003 © 2003 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved. | |
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