Nutritional status in disabled children or the cause of malnutrition. Nutritional support for cancer patients Nutritional status of the patient

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Methods for studying nutritional status in children and adolescents

CONVENTIONAL ABBREVIATIONS

FFM – lean body mass

PEM – protein-energy malnutrition

DK – respiratory coefficient

Gastrointestinal tract - gastrointestinal tract

BMI – body fat mass

IUGR – intrauterine growth retardation

BMI – body mass index

IEC – “ideal” creatinine excretion

CRI – creatinine-height index

CT – computed tomography

ICD-10 – International Classification of Diseases, 10th Revision

MRI – magnetic resonance imaging

MS – metabolic syndrome

NP – malnutrition

TBO - total body water

OO - basic exchange

POWM – body weight deviation indicator

MCT – medium chain triglycerides

TMB – lean body mass

FEC – actual excretion of creatinine

BMR – basal metabolic rate

INTRODUCTION

Currently, the number of children with nutritional disorders in the Russian Federation, as well as throughout the world, is steadily increasing. At the same time, the main efforts of researchers are aimed at studying the problem associated with overweight and obesity, and to a lesser extent, with malnutrition. It should be noted that in young children, nutritional status disorders are more often caused by malnutrition, while older children, especially adolescents, are more likely to be overweight and obese. In Russia and the CIS countries, there is a problem of low body weight among low-income social groups of the population. About 10% of children in Russia are underweight or short stature, which is associated with acute or chronic malnutrition or intestinal malabsorption. According to Sanja Kolacek (2011), in European countries, malnutrition occurs in 20–30% of young children, 10–40% of children are overweight, and 15% are obese.

There is a relationship between increased protein intake, accompanied by accelerated weight gain in children in the first year of life, and the subsequent development of metabolic syndrome. Although, at the end of the last century, D. J. Barker (1993) first identified the relationship between low birth weight and an increased risk of developing arterial hypertension, coronary heart disease and type II diabetes mellitus, i.e. the so-called metabolic syndrome (MS). It has been proven that fasting in childhood aggravates somatic diseases in later life. There is an assumption that the cause of MS is increased nutrition of low birth weight children, including children with intrauterine malnutrition. At the same time, with prolonged nutritional deficiency, metabolic changes occur aimed at maximizing energy conservation. This leads to a decrease in growth rate and lean body mass with an increase in the fat component (abdominal fat). That is, both excess and insufficient nutrition can cause the development of metabolic syndrome. However, with a deficiency of nutrients, in addition to this, intelligence also decreases, and osteopenia, anemia and other deficiency conditions that have long-term negative consequences develop.

Maintaining health and reducing the risk of developing diseases is important at any age, but it is especially important during childhood, when the foundations of health, active longevity and intellectual potential are laid. Changes in children's diets lead to pathological disorders that are realized through changes in gene expression, membrane structure and receptors (with insufficient intake and unequal replacement of necessary nutrients). Premature activation of certain functions occurs due to forced adaptation to foods that do not correspond to age, and, as a result, metabolic changes in older periods of childhood, “rejuvenation” of a number of diseases, the appearance of developmental heterochronies, leading to disturbances in the growth and differentiation of organs and systems.

The growing body of a child quickly reacts to a lack or excess of certain nutrients in the diet by changing the most important functions, disrupting physical and mental development, disrupting the functioning of organs that carry the main functional load to ensure homeostasis, weakening natural and acquired immunity.

Assessing nutritional status is important to identify both undernutrition and overnutrition. According to WHO experts, stunting is a sensitive indicator of poverty and is associated with low birth weight. It causes impaired development of cognitive functions and decreased performance at later stages of an individual's life.

In this regard, a comprehensive assessment of nutritional status in pediatric practice seems extremely important and indicative, as it helps to identify nutritional disorders and carry out timely correction.

Chapter 1. NUTRITIONAL STATUS AND ITS IMPORTANCE IN ASSESSING THE HEALTH OF CHILDREN AND ADOLESCENTS

Nutritional status is the state of the body, its structure and functions, formed under the influence of the quantitative and qualitative characteristics of actual nutrition, as well as genetically determined or acquired characteristics of digestion, absorption, metabolism and excretion of nutrients. In the domestic literature, the terms “nutritional status”, “nutritional status”, “trophological status”, “protein-energy status”, “nutritional status” are found. Therapists, taking into account international terminology, more often use the concept of “nutrition status”. In pediatrics, when assessing the nutrition and physical development of young children, terms such as “eutrophy”, “normotrophy”, “dystrophy” (“hypotrophy” and “paratrophy”) are used. Any of these terms reflects the morphofunctional state of the body, determined by previous nutrition, constitution, age and gender of a person, the state of his metabolism, the intensity of physical and mental activity, the presence of diseases and injuries and is characterized by a number of somatometric and clinical laboratory indicators.

Normotrophy, eutrophy- a state of normal nutrition, which is characterized by physiological height and weight indicators, clean velvety skin, a properly developed skeleton, moderate appetite, normal frequency and quality of physiological functions, pink mucous membranes, the absence of pathological disorders of the internal organs, good resistance to infection, correct nervous system mental development, positive emotional mood.

Dystrophies – pathological conditions in which persistent disturbances in physical development, changes in the morphofunctional state of internal organs and systems, disturbances in metabolic processes, and immunity are observed due to insufficient or excessive intake and/or absorption of nutrients.

Hypotrophy– a chronic nutritional disorder characterized by a deficiency of body weight in relation to the height and age of the child. This condition is observed mainly in young children due to high growth rates and the activity of metabolic processes that require a sufficient supply of nutrients and energy. The pathogenesis of malnutrition is determined by the disease that caused it, but in all cases it includes gradually deepening metabolic disorders with depletion of fat and carbohydrate reserves, increased protein catabolism and a decrease in its synthesis. There is a deficiency of many essential microelements responsible for the implementation of immune functions, optimal growth, and brain development. Therefore, long-term malnutrition is often accompanied by a lag in psychomotor development, delayed speech and cognitive skills and functions, and a high incidence of infectious diseases due to decreased immunity, which in turn aggravates nutritional disorders. However, when defining the concept of “hypotrophy”, possible growth retardation (body length), which characterizes the most severe manifestations of nutritional deficiency, is not taken into account.

In 1961, the Joint FAO/WHO Expert Committee on Nutrition proposed the term “protein-energy malnutrition.”

Protein-energy deficiency (PEM) is a nutrition-dependent condition caused primarily by protein and/or energy starvation, manifested by a deficiency of body weight and/or height and a complex violation of the body’s homeostasis in the form of changes in basic metabolic processes, water-electrolyte imbalance, changes in composition body, disorders of nervous regulation, endocrine imbalance, suppression of the immune system, dysfunction of the gastrointestinal tract (GIT) and other organs and systems (ICD-10, 1990, E40 - E46).

The course of PEM can be acute or chronic. Acute PEM is characterized by low body weight for a given height, i.e., wasting. Chronic PEM is more characterized by low growth rates for a given age, i.e., growth retardation (below (–)2δ). The classification of PEM by course and severity is presented in Appendix 1.

Severe forms of PEM include kwashiorkor (ICD-10, E40), marasmus (ICD-10, E41) and a mixed form - marasmic kwashiorkor (ICD-10, E42).

Kwashiorkor - stress fasting. Develops as a response to a combination of starvation and inflammation. It is characterized by a deficiency of the visceral protein pool, hypoalbuminemia and edema. The main role in the genesis is the inadequate response of the adrenal system and the release of a huge amount of pro-inflammatory cytokines. Insanity is the result of a partial or complete cessation of the supply of energy substrates. It is characterized by a decrease in body weight, mainly due to the loss of fat and lean mass, a decrease in the somatic pool of protein, as well as exhaustion of the body with the gradual extinction of all life processes, atrophy of organs and tissues (nutritional dystrophy).

The mixed form (marasmic kwashiorkor) has features of both peripheral and visceral protein deficiency, as well as energy deficiency. This form is most often encountered in clinical practice.

V. A. Skvortsova, T. E. Borovik [et al.] (2011) propose to designate such conditions leading to impairment of physical and, in many cases, mental development (deficiency of protein, iron, long-chain polyunsaturated fatty acids, etc.), term "nutrition disorder".

Chapter 2. ALGORITHM FOR ASSESSING NUTRITIONAL STATUS

The purpose of determining nutritional status in children is:

1. Study of growth and development rates.

2. Identification of inadequate height and weight gains, developmental heterochronies.

3. Determination of the risk of development and degree of protein-energy malnutrition.

4. The choice of treatment tactics depending on the underlying disease and the nature of the nutritional status.

5. Deciding on the need for nutritional support for the patient.

Algorithms for assessing nutritional status were developed by employees of the Research Institute of Nutrition of the Russian Academy of Medical Sciences A.V. Vasiliev and Yu.V. Khrushcheva (2004). A comprehensive step-by-step assessment of nutritional status is proposed.

First stage involves a clinical examination, including a nutritional history (information about actual food intake, food preferences, tolerance to individual foods, and others).

Second phase– general assessment of body composition according to nutritional status criteria using anthropometric (somatometric) indicators and modern highly informative non-invasive methods: bioimpedancemetry, osteodensitometry and others.

Third stage is based on the study of energy production using direct (metabolic chambers) and indirect calorimetry, based on a stable relationship between the heat released and the amount of oxygen absorbed.

Fourth stage includes the study of biochemical markers of nutritional status, which make it possible to identify preclinical forms of nutritional disorders and the body’s supply of nutrients and energy that do not manifest external clinical symptoms.

2.1. Clinical assessment of nutritional status

At parent survey it is necessary to obtain information about their health status and the health status of their closest relatives on both the maternal and paternal lines, the course of pregnancy and childbirth in the mother. It is important to determine the height, weight and body mass index of the child’s parents, especially the mother, before, during pregnancy and after childbirth.

The approximate average final height of a child who has a “bone” age corresponding to the passport age can be calculated by knowing the height indicators of both parents and calculating the arithmetic mean between the father’s body length and the mother’s body length. When using the formula, it is necessary to take into account that when calculating the final body length for boys, 5 cm is added to the resulting value, and for girls, 5 cm is subtracted.

Parents' body mass index for subsequent child weight is also a prognostic factor. The cumulative incidence of obesity in the first 6 years of a child’s life is 3.2% when the mother’s BMI is less than 20; 5.9% – with a BMI in the range of 20 – 25; 9.2% – with a BMI from 25 to 30. When the mother’s BMI is more than 30, the accumulated incidence of obesity in preschool children increases sharply to 18.5% of cases. There is evidence that if one of the parents is overweight, the obesity rate of children reaches 40%. If both parents are obese, the risk doubles and is 80% (Savva S.C., Tornaritis M.A., 2005).

An equally serious problem is maternal malnutrition. Thus, according to I.M. Vorontsov, the frequency of protein-energy deficiency in pregnant and nursing mothers currently reaches 50%, and micronutrient deficiency of varying degrees - 70%. The consequences for the child of a lack of certain nutrients in the diet of a pregnant woman have been well studied (Table 1).

Table 1

Consequences of lack of certain nutrients in a pregnant woman's diet(Vorontsov I.M., 1999)

Therefore, when collecting anamnesis, special attention should be paid to the mother’s nutrition during pregnancy and lactation. The basic nutrient requirements of a pregnant woman and nursing mother are given in Appendix 2, Table. 3.

The history of the child’s development from the moment of his birth is examined during a conversation with the parents and the study of an outpatient development chart.

Be sure to find out the body weight and height of the child at birth. Thus, low birth weight in older children can lead to the development of protein-energy malnutrition (Shakya S. R., Bhandary S., 2004) and metabolic syndrome (Barker D. J., 1993). At the same time, children born with a body weight of 3800 g or more have high rates of metabolic processes and a liposynthetic orientation of carbohydrate-lipid metabolism, which can contribute to the development of obesity in subsequent periods of life.

Definition matters Tour index– the ratio of body weight at birth (g) to body length at birth (cm). An index value of less than 60 indicates intrauterine nutritional deficiency or so-called prenatal malnutrition.

In recent years, prenatal malnutrition is considered as a manifestation intrauterine growth retardation(IUGR). The hypotrophic variant of IUGR has analogues in ICD-10: “Small for term” (O36.5), “Small for gestational age fetus” (R05.0) and “Fetal malnutrition” (R05.2). This variant of IUGR develops when the fetus is exposed to unfavorable factors in the last months of pregnancy. The impact of these factors in the first weeks of pregnancy leads to the formation of the hypoplastic type of IUGR, the analogues of which in ICD-10 are the following diagnoses: “Small for term” (O36.5), “Small fetal size for gestational age” (R05.1).

When studying a child’s developmental chart, it is important to assess the level and harmony of physical development during different periods of observation, the rate of growth and development of the child (weight and height gains throughout life), to identify the presence of possible developmental heterochronies and their causes (acute or exacerbation of chronic diseases, injuries, operations , change in nutritional pattern). The most convenient method seems to be centile graphs, which allows you to clearly present all the information about your nutritional status.

As an example, let us give data on the physical development of a child 10 years 9 months old. (Table 2).

table 2

Data on the physical development of a boy 10 years 9 months old.

From the approximate assessment of the physical condition at the time of examination (using empirical formulas) it follows that none of the indicators corresponds to the child’s passport age. The height of the boy (age group 11 years), like all signs dependent on him, is low and corresponds to 7–8 years. According to age centile tables, height, body weight, and chest circumference fall into the zone of less than the 3rd centile. The necessary clarification in this case of the position of growth-dependent characteristics according to non-age centile tables indicates a harmonious level of anthropometric indicators.

To assess the physical development of a boy, as in other cases, when all or one of the assessed anthropometric characteristics fall into the extreme zones of centile tables (1st or 7th zones), it is always necessary, first of all, to analyze growth rates from birth to by determining its level at the time of examination, then monitoring rate increases and clarifying the level of dependent characteristics using non-age centile graphs.

Rice. 1. An example of the dynamics of anthropometric data of a boy 10 years 9 months old: A– body length; b– body weight; V– nutritional status: body weight by body length

In the example under consideration (Fig. 1, A, b, V) a decrease in growth rates took place from the age of 5 with a clear slowdown in the interval of 9–10 years and the emergence of subnanism. Moreover, the boy’s nutrition level remained average throughout the entire observation period (interval of the 25th – 75th centile according to non-age charts). In differential diagnosis, it is essential that the short stature present at the time of examination is not accompanied by gross violations of body proportions (head height 21 cm, leg length 64 cm, midpoint at the symphysis), which, together with anamnestic and clinical data, will help in differential diagnosis growth disorders.

It should be noted that the difference of centile zones of the assessed characteristics, often equal to one, obtained from age tables, will not reflect the “harmony of development.” For example, a boy 11 months old. with a body length of 77 cm (according to the 4th zone of the centile table) has a body weight of 8900 g (3rd zone of the age centile table). However, the conclusion on the analysis of the child’s nutrition according to the age-appropriate centile table indicates “low nutrition” (weight along the length of the body - 2nd zone), which clearly cannot correlate with the harmonious development of the child, reflecting the state of malnutrition.

Obviously, it is advisable, when performing a nonparametric (centile) assessment of the main anthropometric indicators, to clarify the state of dependent characteristics (primarily body weight) using non-age tables for the corresponding height for any difference in centile zones, even equal to one. More objective is a systematic analysis of the child’s nutritional status using non-age centile charts (using other methods for assessing nutritional status), which can be used to identify borderline delays in body weight and take appropriate measures.

1. With systematic observation of the child and constant compliance of anthropometric data with the average age, approximately calculated using empirical formulas, a conclusion about an average, harmonious physical condition or “stable” pace of physical development is valid.

2. If there is a discrepancy between anthropometric and estimated average age indicators (more than one age interval), all indicators are assessed using centile tables (graphs):

a) if the centile zones are equal for all parameters (except for the 1st and 7th), a conclusion is made about low (high), below (above) average, harmonious physical condition. The timing and severity of the decrease (acceleration) in growth rates, analyzed from birth, can play a significant role in the differential diagnosis of growth disorders;

b) in all other situations (any difference in centile zones; 1st and 7th zones for all or one indicator) assessment of physical development requires mandatory clarification of growth rates from birth according to centile graphs with determination of the level of growth at the time of examination, with subsequent analysis dependent characteristics according to non-age graphs (tables). It is advisable to conduct such studies even if the centile zones of indicators differ by one.

Any of the conclusions proposed by the algorithm on the physical condition of the child, discussed in paragraph 2, b, will certainly require an analysis of the dynamics of development:

– if growth corresponds to age standards and subsequent assessment of dependent characteristics, a conclusion about a harmonious physical condition is possible (usually with a difference in centile zones equal to one). Monitoring rate increases, primarily body weight, will help identify borderline nutritional delays. We should not forget that the latter (moderate heterochrony of development) are characteristic of children during certain periods of ontogenesis (for example, growth shifts);

– if growth corresponds to age standards, but there is a difference in centile zones between characteristics, a situation of disharmonious physical condition (for example, with deficiency or excess body weight) will more often occur. In combination with clinical data, information about the duration and severity of developmental heterochrony using centile graphs will make it possible to judge the severity and severity of the disease;

– if growth does not correspond to age indicators and there is a harmonious ratio of dependent characteristics, analysis of growth rates from birth, constitutional features according to objective examination data will facilitate the differential diagnosis of various types of growth disorders;

– if growth does not correspond to age standards and disharmonious physical condition, the need to control the dynamics of development, clarify the timing of the appearance and degree of heterochrony is beyond doubt. Taking into account the rate of development of the child from birth in conjunction with the analysis of family anamnestic data, the absence (presence) of pathology on the part of organs and systems will make it possible to distinguish constitutional features of growth from possible pathological conditions.

It is important that as the child grows and develops, all anthropometric measurements are carried out exactly at the prescribed time and recorded in the outpatient card. The rate of growth and weight gain calculated using weight and height gain curves is compared with standard rates obtained from population studies.

At the Research Laboratory of Physiology and Pathology of Childhood, Federal Center for Geology and Epidemiology, named after. V. A. Almazova developed computer program for assessing physical development(Automated assessment of the physical condition of a child, certificate of state registration of a computer program 2011616976 2011), which, based on the measurement of 4 main anthropometric indicators (height, weight, chest and head circumference) allows you to assess the physical condition of a child of any age group, makes it possible to identify developmental deviations with further appointment of appropriate advisory and diagnostic measures.

Centile graphs of the dynamics of anthropometric indicators depending on age and gender provide a visual and objective characteristic of both individual static indicators and dynamic growth processes.

Variants of dynamic characteristics of physical development are presented in graphs that reflect the characteristics of tempo changes in the main anthropometric characteristics characteristic of healthy children. The curves of the graphs are similar to the tabular centile columns and reflect the quantitative boundaries of changes in the corresponding characteristics during the growth process. The space between the curves is similar to the tabular centile zones, reflecting the level of development of traits.

Centile graphs for body length beyond the 3rd and 97th centiles are supplemented with zones of sigma deviations of the trait. This makes it possible to perform diagnostics when assessing the level of growth subnanism, subgigantism(when determining body length in the zone from the 3rd centile to –3 or from the 97th centile to +3), nanism, gigantism(when determining body length in the zone below –3 or above +3).

In the process of dynamic observation of a child, the use of centile graphs makes it possible to obtain a conclusion on the physical condition with an analysis of the level and harmony of indicators not only at the time of the examination, but also at any other period of life, as well as to judge the rate characteristics of growth in general from birth.

We can talk about stable rates of dynamics of anthropometric indicators (body length and weight, chest and head circumference), regardless of their level, if the line of the individual graph constantly passes in the same centile zone. If the graph curve moves above or below the average centile zone, an acceleration or deceleration of growth rates is noted. With systematic monitoring of a child, borderline delays in growth and weight gain can be diagnosed even before the level of the corresponding signs changes. Changes in the graph in the form of flattening or stopping make it possible to clarify the time and strength of the pathological effect, and the so-called growth spurts in the graphs allow us to evaluate the effectiveness of treatment and nutritional support.

It is not possible to objectively judge the acceleration or deceleration of the dynamics of anthropometric indicators when their level goes beyond ±3σ or beyond 3% (97%) centile zones using this method. In such cases, to judge the dynamics of development, it is advisable to clarify the age corresponding to the child’s height at the time of the examination.

In cases where the graphs of the main anthropometric indicators diverge by more than one centile zone, we should talk about developmental heterochrony. This is the reason for a more thorough analysis of characteristics dependent on body length using non-age graphs, which provide the most objective information about the dynamics of tempo changes in body weight or chest circumference for the corresponding body length.

Table 3

Increased excretion of food ingredients caused by medications(Sergeev V.N., 2003)

The versatility of using centile graphs lies in the fact that with a one-time assessment of dynamic indicators of physical development (growth rate, rapid body weight gain, etc.), one can obtain information about the level and harmony of the child’s physical condition both at the time of the study and at any other time. period of life. Appendix 3 provides a series of centile graphs for assessing a child's nutritional status.

When collecting an early life history, it is necessary to find out the duration of breastfeeding, the timing of the introduction of complementary foods, as well as analyze the child’s morbidity and the nature of the therapy. It is known that some medications promote increased excretion of various food ingredients from the child’s body (Table 3).

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And indeed it is. Preventive medicine is one of the main areas of work of the modern healthcare system. What is its disadvantage? Preventive measures are widespread and do not take into account the characteristics of each person. Nowadays, you can increasingly hear “Preventive medicine”. In Russia, this area is just beginning to develop, but European specialists have been actively developing it for several years. Preventive medicine deals with each person individually, taking into account his characteristics. Thus, the specialist works with each patient using an individual approach, which significantly increases the effectiveness of the preventive measures taken.

The program for assessing the functional state of the body was developed to study hemostasis (a complex biological process in the body that ensures its viability) in patients over 18 years of age.

At the first stage, you take a blood test to study your nutritional status. Must be observed Based on the results of the examination, the nutritionist will draw up an individual plan for observation and correction of identified violations.

Composition of research within the framework of a comprehensive program:

• Basic nutritional status - 3900 rub.

includes: AST, ALT, GGT, alkaline phosphatase, ferritin, creatinine, urea, uric acid, total protein, albumin, total bilirubin, total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, CRP, CPK, glycated hemoglobin, ionized calcium, calcium general, sodium, potassium, chlorine, complete blood count, TSH, LDH

Quantitative assessment of a patient's nutritional status is an important clinical parameter and should be performed for every patient.

The cost of inpatient treatment for a patient with normal nutritional status is 1.5-5 times less than for a patient with malnutrition. In this regard, the most important task of the clinician is to recognize states of malnutrition and adequate control over their correction. Numerous studies have proven that the state of protein-energy malnutrition significantly affects morbidity and mortality rates among patients.

Obesity and severe malnutrition can be recognized by history and clinical examination, but subtle signs of malnutrition are often overlooked, especially in the presence of edema.

Quantitative assessment of nutritional status allows early detection of life-threatening disorders and assessment of positive changes as recovery begins. Objective measures of nutritional status correlate with morbidity and mortality. However, none of the indicators of quantitative assessment of nutritional status has a clear prognostic significance for a particular patient without taking into account the dynamics of changes in this indicator.

• Nutritional (nutritional, trophological) status of the patient and indications for its assessment

  In the domestic literature there is no generally accepted term for assessing a patient’s nutrition. Different authors use the concepts of nutritional status, nutritional status, trophological status, protein-energy status, nutritional status. When assessing nutritional status, it is most correct to use the term “nutrition status of the patient,” since it reflects both the nutritional and metabolic components of the patient’s condition. The ability to timely diagnose nutritional disorders is necessary in the practice of doctors of all specialties, especially when working with geriatric, gastroenterological, nephrological, endocrine and surgical patients.

  Nutritional status should be determined in the following situations:

  • When diagnosing protein-energy malnutrition.
  • When monitoring the treatment of protein-energy deficiency.
  • When predicting the course of the disease and assessing the risk of surgical and unsafe treatment methods (chemotherapy, radiation therapy, etc.).

• Methods for assessing nutritional status
  • Physical examination

    A physical examination allows the doctor to diagnose both obesity and protein-energy malnutrition, as well as determine specific nutrient deficiencies. If a patient is suspected of having a nutrient deficiency after examination, it is necessary to confirm the assumption with laboratory tests.

    WHO experts describe the following clinical signs of protein-energy malnutrition: protrusion of skeletal bones; loss of skin elasticity; thin, sparse, easily pulled out hair; depigmentation of skin and hair; swelling; muscle weakness; decreased mental and physical performance.

    • Nutrients	Deficiency Disorders and Symptoms	Laboratory results
      Water	Thirst, decreased skin turgor, dry mucous membranes, vascular collapse, mental disorders	Increased concentration of electrolytes in the blood serum, serum osmolarity; decrease in the total amount of water in the body
      Calories (energy)	Weakness and lack of physical activity, loss of subcutaneous fat, muscle wasting, bradycardia	Decrease in body weight, GIFT, OMP, SOOV
      Protein	Psychomotor changes, graying, thinning and hair loss, scaly dermatitis, edema, muscle wasting, hepatomegaly, growth retardation	Reducing OMP, serum concentrations of albumin, transferrin associated with retinol protein; anemia; decrease in creatinine/height, the ratio of urea and creatinine in urine; increasing the ratio of essential and essential amino acids in the blood serum
      Linoleic acid	Xerosis, desquamation, thickening of the stratum corneum, baldness, fatty liver disease, delayed wound healing	Increased ratio of trienoic and tetraenoic fatty acids in blood serum
      Vitamin A	Xerosis of the eyes and skin, xerophthalmia, formation of Bitot's plaques, follicular hyperkeratosis, hypogeusia, hyposmia	Decreased concentration of vitamin A in blood plasma; increasing the duration of dark adaptation
      Vitamin D	Rickets and growth disorders in children, osteomalacia in adults	Increased serum concentrations of alkaline phosphatase; decrease in the concentration of 25-hydroxycholecalciferol in the blood serum
      Vitamin E	Anemia	Decrease in plasma tocopherol concentration, hemolysis of erythrocytes
      Vitamin K	Hemorrhagic diathesis	Increased prothrombin time
      Vitamin C (ascorbic acid)	Scurvy, petechiae, ecchymosis, perifollicular hemorrhage, loosening and bleeding gums (or tooth loss)	Decrease in the concentration of ascorbic acid in the blood plasma, platelet count, whole blood mass and leukocyte count; decrease in the concentration of ascorbic acid in urine
      Thiamine (vitamin B1)	Beriberi, muscle soreness and weakness, hyporeflexia, hypersthesia, tachycardia, cardiomegaly, congestive heart failure, encephalopathy	Reducing the activity of thiamine pyrophosphate and transketolase contained in erythrocytes and enhancing the in vitro effect of thiamine pyrophosphate on it; decrease in thiamine content in urine; increase in blood levels of pyruvate and ketoglutarate
      Riboflavin (vitamin B2)	Zaeda (or angular scars), cheilosis, Gunter's glossitis, atrophy of the tongue papillae, corneal vascularization, angular blepharitis, seborrhea, scrotal (vulvar) dermatitis	Reduced EGR activity and increased effect of flavin adenine dinucleotide on EGR activity in vitro; decreased activity of pyridoxal phosphate oxidase and increased effect of riboflavin on it in vitro; decreased concentration of riboflavin in urine
      Niacin	Pellagra, a bright red and ragged tongue; atrophy of the tongue papillae, fissures of the tongue, pellagrossic dermatitis, diarrhea, dementia	Decrease in the content of 1-methyl-nicotinamide and the ratio of 1-methyl-nicotinamide and 2-pyridone in urine

      
      Note: MRV – basal metabolic rate; BUN – blood urea nitrogen; creatinine/height – the ratio of the concentration of creatinine in daily urine to height; ECG – electrocardiogram; EGSHUT – erythrocyte glutamic oxaloacetic transaminase; EGR – erythrocyte glutathione reductase; OMP – shoulder muscle circumference; SFST – skin-fat fold above the triceps; RAI – radioactive iodine; T – triiodothyronine; T – thyroxine; TSH is the thyroid-stimulating hormone of the pituitary gland.
  • Anthropometric measurements and body composition analysis

    Anthropometric measurements are of particular importance in the physical examination. Anthropometric measurements are a simple and accessible method that allows, using calculation formulas, to assess the composition of the patient’s body and the dynamics of its changes. However, when analyzing the data obtained, it must be remembered that tabular data is not always suitable for a particular person. The existing standards were initially designed for healthy people and cannot always be accepted for the patient. It is correct to compare the identified indicators with the data of the same patient in his favorable period.

    • Body mass

      Determination of body weight (BW) is a basic indicator in assessing nutritional status.

      Body weight is usually compared with the ideal (recommended) body weight. The recommended weight can be taken as the body weight calculated according to one of the numerous formulas and normograms or the body weight that was most “comfortable” in the past for a given patient.

      The reliability of body weight assessment may be affected by edema syndrome. In the absence of edema, body weight calculated as a percentage of ideal body weight is a useful indicator of adipose tissue plus lean body mass. Ideal body weight can be calculated using a standard height/weight chart.

      With a disproportionate loss of various components of the body, the absence of significant changes in the patient’s body weight may mask a protein deficiency while maintaining a normal or slightly excess fat component (for example, the body weight of an emaciated patient who was initially obese may be equal to or exceed the recommended one).

      A decrease in the measured body weight/ideal body weight ratio to 80% or less usually signals insufficient protein-energy nutrition.

      • Body weight limits (kg)
        Height, cm	Low	Average	High
        MEN
        157,5	58,11-60,84	59,47-64,01	62,65-68,10
        160,0	59,02-61,74	60,38-64,92	63,56-69,46
        162,6	59,93-62,65	61,29-65,83	64,47-70,82
        165,1	60,84-63,56	62,20-67,19	65,38-72,64
        167,6	61,74-64,47	63,11-68,55	66,28-74,46
        170,2	62,65-65,83	64,47-69,92	67,65-71,73
        172,7	63,56-67,19	65,83-71,28	69,01-78,09
        175,3	64,47-68,55	67,19-72,64	70,37-79,90
        177,8	65,38-69,92	68,55-74,00	71,73-81,72
        180,3	66,28-71,28	69,92-75,36	73,09-83,54
        182,9	67,65-72,64	71,28-77,18	74,46-85,35
        185,4	69,01-74,46	72,64-79,00	76,27-87,17
        188,0	70,37-76,27	74,46-80,81	78,09-89,44
        190,5	71,73-78,09	75,82-82,63	79,90-91,71
        193,04	73,55-79,90	77,63-84,90	82,17-93,98
        WOMEN
        147,3	46,31-50,39	49,49-54,93	53,57-59,47
        149,9	46,76-51,30	50,39-55,84	54,48-60,84
        152,4	47,22-52,21	51,30-57,20	55,39-62,20
        154,9	48,12-53,57	52,21-58,57	56,75-63,56
        157,5	49,03-54,93	53,57-59,93	58,11-64,92
        160,0	50,39-56,30	54,93-61,29	59,47-66,74
        162,6	51,76-57,66	56,30-62,65	60,84-68,55
        165,1	53,12-59,02	57,66-64,01	62,20-70,37
        167,6	54,48-60,38	59,02-65,38	63,56-72,19
        170,18	55,84-61,74	60,38-66,74	64,92-74,00
        172,72	57,20-63,11	61,74-68,10	66,28-75,82
        175,26	58,57-64,47	63,11-69,46	67,65-77,18
        177,8	59,93-65,83	64,47-70,82	69,01-78,54
        180,34	61,29-67,19	65,83-72,19	70,37-79,90
        182,88	62,65-68,55	67,19-73,55	71,73-81,27

    • Body composition

      Body composition assessment is based on the concept of distinguishing between extracellular and intracellular body mass.

      The cellular mass consists mainly of visceral organs and skeletal muscles. The assessment of cell mass is based on the determination of potassium content in the body by various, mainly radioisotope, methods. The extracellular mass, which primarily performs a transport function, anatomically includes blood plasma, interstitial fluid, adipose tissue and is assessed by determining metabolic sodium. Thus, the intracellular mass reflects predominantly the protein component, and the extracellular mass the fat component of the body.

      The ratio of plastic and energy resources can be described through two main components: the so-called lean or lean body mass (TMB), which includes muscle, bone and other components and is primarily an indicator of protein metabolism, and adipose tissue, which indirectly reflects energy metabolism .

      MT = TMT + fat component.

      Thus, to assess body composition, it is enough to calculate one of these values. A normal body fat content is considered to be 15–25% for men and 18–30% of total body weight for women, although these figures may vary. Skeletal muscle on average makes up 30% of the TMT, the mass of visceral organs is 20%, bone tissue is 7%.

      A decrease in fat reserves in the body is a sign of a significant deficiency in the energy component of nutrition.

      • Methods for determining body composition

        To assess body fat content, the method of assessing the average skin fold (anthropometric data) is usually used. There are also various methods for calculating the content of adipose tissue, which are based on determining the density of the human body. Based on the difference in density of various tissues, the fat component is estimated.

        To assess lean body mass, creatinine excretion is studied or bioimpedance measurements are performed.

        • The main method for determining body fat content is based on assessing the middle skin-fat fold (MSF) with a caliper using several SFAs (most often over the triceps, over the biceps, subscapular and supraileal).

          A caliper is a device that allows you to measure FLC and has a standard degree of fold compression of 10 mg/cm 3 . Caliper production is available on an individual basis.

          
          
          

          Rules for measuring skin-fat folds with a caliper.

          • Anthropometric measurements are taken on the non-working (non-dominant) arm and the corresponding half of the torso.
          • The direction of the folds created during measurement should coincide with their natural direction.
          • Measurements are carried out three times, the values ​​are recorded 2 seconds after releasing the device lever.
          • The skin-fat fold is grasped by the examiner with 2 fingers and pulled back approximately 1 cm.
          • Shoulder measurements are taken with the arm hanging freely along the body.
          • Mid-shoulder: the middle of the distance between the articulation of the shoulder with the acromion process of the scapula and the olecranon process of the ulna (the shoulder circumference is also determined at this level).
          • The FLC above the triceps is determined at the level of the middle of the shoulder, above the triceps (in the middle of the back surface of the arm), and is located parallel to the longitudinal axis of the limb.
          • The LCS above the biceps is determined at the level of the middle of the shoulder, above the triceps (on the front surface of the arm), and is located parallel to the longitudinal axis of the limb.
          • The subscapular (subscapular) CL is determined 2 cm below the angle of the scapula, usually located at an angle of 45° to the horizontal.
          • LCS above the iliac crest (supraileal): determined directly above the iliac crest along the midaxillary line, usually located horizontally or at a slight angle.
          • Anthropometric indicators are determined in the middle third of the shoulder of the non-working arm. Their proportions make it possible to judge the relationship of tissues throughout the body.
          • Typically, measurements are taken of the triceps skin fold (TSF) and upper arm circumference, from which the upper arm muscle circumference (AMC) is calculated.

          The calculated values ​​characterizing the masses of the shoulder muscles and subcutaneous adipose tissue correlate with fairly high accuracy, respectively, with lean (LMP) and fat (LFT) body masses, and, accordingly, with the total peripheral reserves of proteins and the fat reserves of the body.

          On average, anthropometric indicators corresponding to 90–100% of the generally accepted values ​​are characterized as normal, 80–90% as mild malnutrition, 70–80% as moderate, and below 70% as severe.

          Basic anthropometric indicators of nutritional status (according to Heymsfield S.B. et al., 1982)

          
          

          Index	Norms
          	men	women
          Skinfold over the triceps (SFST), mm	12,5	16,5
          Shoulder circumference (UA), cm	26	25
          Shoulder muscle circumference (UMC), cm = OP – π×KZhST	25,3	23,2
          Area of ​​subcutaneous adipose tissue, cm 2 = KZhST×ΟΜΠ/2 – π×KZhST2/4	17	21
          Shoulder muscle area, cm 2 = (ΟΠ – π × KZhST)2/4p	51	43

          
          

          Note: Average values ​​shown. Somatometric indicators vary depending on the age group.

          Immunological indicators for assessing nutritional status.

        • Comprehensive methods for assessing nutritional status

          A large number of complex indices and methods have been developed that make it possible to assess the nutritional status of a patient with varying degrees of reliability. All of them include a combination of anthropometric, biochemical and immunological indicators.

          1. Reduction of body weight by more than 10%.
          2. Decrease in total blood protein below 65 g/l.
          3. A decrease in blood albumin below 35 g/l.
          4. Decrease in the absolute number of lymphocytes less than 1800 per μl.

          Subjective global assessment according to A. S. Detsky et al. (1987) includes clinical assessment of 5 parameters:

          1. Loss of body weight over the past 6 months.
          2. Dietary changes (diet assessment).
          3. Gastrointestinal symptoms (anorexia, nausea, vomiting, diarrhea) lasting more than 2 weeks.
          4. Functional capacity (bed rest or normal physical activity).
          5. Disease activity (degree of metabolic stress).

          In parallel with the listed studies, a subjective and physical examination is carried out: loss of subcutaneous fat, muscle wasting, presence of edema.

          According to the above indicators, patients are divided into three categories:

          • With normal nutritional status.
          • With moderate exhaustion.
          • With severe exhaustion.

          The most common is a score of 8 diverse markers of nutritional status. Among these indicators, different authors include clinical assessment, anthropometric and biochemical indicators, results of a skin test with an antigen, etc.

          Each of the indicators is scored: 3 points - if it is within the normal range, 2 points - if it corresponds to a mild degree of protein-energy malnutrition, 1 point - to a moderate degree, 0 points - to a severe degree. A score of 1–8 points allows a diagnosis of mild protein-energy malnutrition, 9–16 points – moderate, and 17–24 points – severe. A total score of 0 points indicates the absence of nutritional disorders.

          According to the order of the Ministry of Health of the Russian Federation No. 330 dated August 5, 2003, the nutritional status is assessed according to indicators, the totality of which characterizes the nutritional status of the patient and his need for nutrients:

          • Anthropometric data: height; body mass; body mass index (BMI); shoulder circumference; measurement of the triceps skin-fat fold (TSF).
          • Biochemical indicators: total protein; albumen; transferrin.
          • Immunological indicators: total number of lymphocytes.

Malnutrition is a striking and frequent manifestation of chronic obstructive pulmonary disease (COPD), which affects the frequency of exacerbations, respiratory parameters and the quality of life of patients. The purpose of the study is to assess the nutritional status of COPD patients using anthropometry and bioimpedance measurements in a comparative aspect. 60 patients with stages I, II and III COPD were examined. According to the results of the study, a decrease in body mass index (BMI) was established in stages II and III of COPD compared to the control group. Loss of the muscle component or lean body mass (LBM) occurs already at stage I of COPD, the most significant decrease in LBM was found at stage III of the disease. When comparing two diagnostic methods, no significant differences were found in BMI and TMT in the general group of COPD patients and at different stages of the disease. When dividing the examined people into groups with normal, reduced and increased body mass index, significant differences in BMI indicators were established in the group of patients with BMI >25 kg/m2. In this group, the bioimpedansometry method had lower TMT indicators compared to the anthropometry method. Accordingly, the bioelectrical impedance method can be recommended for a more accurate assessment and early diagnosis of protein-energy malnutrition in COPD patients with BMI>25 kg/m2.

chronic obstructive pulmonary disease

nutritional deficiency

anthropometry method

bioimpedansometry method

1. Avdeev S. N. Chronic obstructive pulmonary disease as a systemic disease // Pulmonology. - 2007. - No. 2.

2. Nevzorova V. A., Barkhatova D. A. Features of the course of exacerbation of COPD depending on the nature of the pathogen and the activity of systemic inflammation // Bulletin of Physiology and Pathology of Respiration. - 2006. - No. S 23. - pp. 25-30.

3. Nevzorova V. A. Systemic inflammation and the state of skeletal muscles of patients with COPD / V. A. Nevzorova, D. A. Barkhatova // Therapist. arch. - 2008. - T. 80.

4. Nevzorova V. A. Content of adipokines (leptin and adiponekin) in blood serum at different nutritional status of COPD patients / V. A. Nevzorova, D. A. Barkhatova // Collection of proceedings of the XVIII National Congress on Respiratory Diseases. - Ekaterinburg, 2008.

5. Rudmen D. Assessment of nutritional status // Internal diseases. - M.: Medicine, 1993. T. 2.

6. Bernard S., LeBlanc P. et al. Peripheral muscle weakness in patients with chronic obstructive pulmonary desease // Am.J.Respir.Crit.Care. Med. -1998.

7. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO workshop report. Last updated 2008. www.goldcopd.org/.

8. Body composition by bioelectrica-impedance analysis compared with deuterium dilution and skinfold and thropometry in patients with chronic obstructive pulmonary disease / A.M.W.J.Schols, E.F.M.Wouters, P.B.Soeters et al // Am.J.Clin.Nutr. - 1991.- Vol. 53.- P. 421-424.

9. Prevalence and characteristics of nutritional depletion in patients with stable COPD eligible for pulmonary rehabition / A.M.W.J.Schols, P.B.Soeters, M.C.Dingemans et al // Am.Rev.Respir.Dis. -1993. - Vol. 147. - P. 1151-1156.

Nutritional status reflects the state of the body's plastic and energy resources and is closely related to the processes of systemic inflammation, oxidative stress, and hormonal imbalance. Malnutrition is a striking and frequent manifestation of chronic obstructive pulmonary disease (COPD), which affects the frequency of exacerbations, respiratory parameters and quality of life. It has been established that the appearance of protein-energy deficiency aggravates the course of the underlying disease and worsens its prognosis.

Anthropometric measurements are a simple and accessible method that allows, using calculation formulas, to assess the composition of the patient’s body and the dynamics of its changes. The ratio of plastic and energy resources can be described through two main components: lean body mass (LBM), which includes muscle, bone and other components and is an indicator of protein metabolism, as well as adipose tissue, which indirectly reflects energy metabolism. With nutritional deficiency in patients with COPD, a disproportionate loss of various components of the body occurs, in which the absence of significant changes in the patient’s body weight can mask protein deficiency while maintaining a normal or slightly excess fat component.

The method of anthropometric measurements is not recommended for use in elderly patients, as well as in cases of edema syndrome, due to the disproportionate distribution of adipose tissue and its predominant localization in the abdominal cavity. An alternative or more accurate measurement of composite body structure is the bioelectrical impedance method, which is based on the estimation of water volume distribution and evaluates the electrical conductivity of tissues. When conducting impedance measurements, the determination of body composition is based on the greater conductivity of TMT compared to body fat mass, which is associated with different fluid contents in these tissues.

Comparison of the information content of widely used methods for assessing nutritional deficiency in COPD determines the relevance of the study.

Purpose of the study:

To assess the nutritional status of COPD patients using anthropometry and bioimpedance measurements in a comparative aspect.

Materials and methods:

We examined 60 patients with phenotypic manifestations of the European race, living in the Primorsky Territory for more than 15 years at the age of 63 ± 12.1 years, who were treated in the pulmonology department of City Clinical Hospital No. 1 and the allergy-respiratory center of Vladivostok during 2009-2010. with a diagnosis of COPD (general group of patients). All patients were informed about the study in full and filled out informed consent. The control group consisted of 10 healthy non-smoking volunteers, 8 men and 2 women aged 59 ± 10.7 years, who were not relatives of the main group. To diagnose the stage of COPD, the recommendations of the international classification GOLD 2008 were used. All examined patients were divided into 3 groups based on the indicators of the post-bronchodilation test FEV1: group I - 20 patients with COPD stage I (FEV1=85±1.3), group II - 20 people with COPD stage II (FEV1=65±1.8), group III - 20 people with COPD stage III (FEV1=40±1.5). The exclusion criteria from the study were the presence of bronchial asthma, myocardial infarction, stroke and other serious diseases, alcohol and drug abuse, elderly people who are unable to understand the goals and objectives of the study, and patients’ refusal to participate in the study. To assess nutritional deficiency, methods of anthropometric measurements and calculations of BMI, BMI, as well as bioimpedance measurements and determination of BMI, BFM (fat-free mass, expressed in %) were used. When calculating anthropometric indicators of TMT, the Durnin-Womersley method (1972) was used, which is based on assessing the average skin-fat fold (ASF) with a caliper, followed by calculating TMT using a formula depending on the patient’s gender, age and BMI. Determination of BMI, which allows for the primary diagnosis of the degree of malnutrition, was determined according to the formula of A. Ketele: BMI = MT (kg) / height (m 2).

Bioimpedansometry was carried out using a rheoanalyzer "Diamant" St. Petersburg. The results obtained were processed on an IBM PC personal computer running Windows-XP using the Statistica 6.0 program with the calculation of the arithmetic mean (M), its error (± m), and relative error (± m%). Statistical processing when comparing two independent groups was carried out using the nonparametric Mann-Whitney test and determining significant differences between groups according to this criterion. Differences between comparative values ​​were considered statistically significant at the p significance level<0,05. Анализ взаимосвязей проводился непараметрическим методом корреляционного анализа Спирмена для ненормального распределения с вычислением ошибки коэффициента корреляции.

Research results

The following anthropometric data were established in the main group of patients: average height 172 ± 5.3 cm, average weight 76.5 ± 5.5 kg. The smoking person's index (SCI) averaged 33 ± 2.3, smoking experience was 30 ± 3.3 years, which indicates a high degree of nicotine-associated risk. We analyzed the ratio of BMI (body mass index) and BMI%, as well as BWMI using anthropometry and bioimpedansometry methods in COPD patients depending on the stage of the disease (Table 1).

Table 1. Correlation of BMI, BMI and BMI in patients with COPD

Note. Significance of differences (p<0,05): * - между группой контроля, общей группой и стадиями ХОБЛ, # - significance of differences between stages I and II of COPD, stages I and III of COPD , & - between stages II and III of COPD.

According to the presented results, BMI indicators in COPD patients in the general group are lower than in the control group, both when studied by anthropometry and bioimpedansometry. Analysis of BMI values ​​depending on the stage of COPD showed that at stage I of the disease, BMI does not change compared to the control. Its significant decrease occurs only in stages II and III COPD (p<0,05). Несмотря на снижение показателей ИМТ по сравнению с контрольной группой, при всех стадиях ХОБЛ ИМТ находится в пределах референсных значений для нормальных показателей или превышает 20 кг/м 2 . Различий в значениях ИМТ, определенных как методом антропометрии, так и импедансометрии не установлено. Выяснено, что показатели ИМТ при II и III стадиях ХОБЛ достоверно ниже, чем при I стадии ХОБЛ (p<0,05), более того установлено наибольшее снижение показателей ИМТ при III стадии заболевания (p< 0,05).

Data characterizing TMT in the general group of COPD patients, obtained by anthropometry and bioimpedancemetry, were significantly reduced compared to the control group (p<0,05).

The results of the analysis of TMT values ​​depending on the stage of COPD demonstrated that, unlike BMI, loss of TMT occurs already at stage I of COPD. Thus, in stage I COPD, TMT indicators are lower compared to controls (p<0,05). При II и III стадиях ХОБЛ значения ТМТ становятся еще меньше (p<0,05), достигая минимальных результатов при III стадии ХОБЛ (p=0,004). В последнем случае показатели ТМТ достоверно ниже результатов, полученных при исследовании пациентов с I и II стадий ХОБЛ (p<0,05). Во всех группах различий в данных, относящихся к ТМТ, в результате использования методов антропометрии и биоимпедансометрии не установлено.

In contrast to BMI, which is within the reference interval, for healthy people (BMI 18.5-25 kg/m2) at all stages of COPD, BMI indicators at stage III of the disease decrease below the recommended values ​​and become below 70%.

Based on the main goal of our study and relying on the results of the authors, indicating the greater sensitivity of the bioimpedansometry method when assessing indicators of the nutritional status of patients with signs of obesity and uneven distribution of fat and muscle tissue, we compared BMI and TMI indicators in groups of patients depending on the mass index bodies.

For this purpose, COPD patients were divided into three groups: group I - BMI from 20-25 kg/m2, group II - BMI< 20 кг/м 2 и III группа ИМТ >25 kg/m2. The results of the study are presented in Table 2.

Table 2. Indicators of MI, BMI, BMI in patients with COPD depending on BMI values

Note: Significance of differences(p<0,05): *- между ТМТ метода антропометрии и БЖМТ биоимпедансометрии у пациентов ХОБЛ.

As follows from the presented results, significant differences were obtained between the values ​​of BWM as a result of using the anthropometry method and BWM values ​​using bioimpedance measurements in COPD patients with BMI>25 kg/m2. In this group of patients, the indicators of TMT turned out to be significantly higher than BWMT and amounted to 78.5 ± 1.25 and 64.5 ± 1.08 p<0,05 соответственно. Очевидно, что использование метода биоимпедансометрии в группе пациентов ХОБЛ с ИМТ>25kg/m2 has clear advantages for diagnosing LBW loss compared to standard anthropometric measurements.

Discussion of the results obtained

COPD is characterized by weight loss associated with protein-energy imbalance. In clinical practice, when determining the nutritional status of patients, they are often limited to calculating only BMI. As a result, it was found that BMI indicators in COPD patients in the general group are lower than in the control group, both when studied by anthropometry and bioimpedansometry. Analysis of BMI values ​​depending on the stage of COPD showed that at stage I of the disease, BMI does not change compared to the control. Its significant decrease occurs only in stages II and III of COPD. Moreover, regardless of the stage of COPD, BMI indicators are within the reference values ​​for healthy people or exceed 20 kg/m2. Accordingly, determining BMI is not sufficient to assess nutritional status in COPD. To assess body composition, it is necessary to differentiate body fat mass from muscle mass, since COPD, with normal or increased BMI, is characterized by a decrease in muscle mass.

According to our study, TMT values ​​in the general group of COPD patients, assessed by anthropometry and bioimpedansometry, were significantly reduced compared to the control group (p<0,05). Анализ результатов измерения ТМТ в зависимости от стадии ХОБЛ показал, что в отличие от показателей ИМТ при I стадии заболевания ТМТ достоверно ниже по сравнению с контролем (p<0,05).

In stages II and III of COPD, an even more pronounced loss of the protein component of patients’ body weight occurs. This is evidenced by a significant decrease in data characterizing TMT in stages II and III of COPD compared to stage I of the disease. The lowest TMT values ​​were found in stage III COPD. Noteworthy is the fact that the reduction in TMT is lower than the recommended values ​​in stage III COPD. In other words, our study established an accelerated loss of TMT in patients with COPD compared to BMI. A distinctive feature of our sample is that for all COPD patients, regardless of stage, BMI remained within the recommended values ​​for a healthy population. Despite this, we recorded the fact of a true decrease in TMT in stage III COPD using both research methods used. Considering the most pronounced changes in the values ​​of BMI and TMT in stage III COPD, it seemed interesting to us to conduct a correlation analysis between the indicators of BMI, TMT and FEV1.

The correlation analysis showed the absence of significant relationships between FEV1, a diagnostic indicator of the stage of COPD and BMI, in anthropometry and bioimpedance measurements. At the same time, a direct relationship of average strength was established between the values ​​of TMT as a result of the study of the anthropometry method and FEV1 (R=0.40+/-0.9; p<0,001) и прямая связь средней силы между данными БЖМТ в результате измерений методом биоимпедансометрии и ОФВ1 (R=0,55+/-0,9; p<0,0005).

Obviously, in COPD, such an indicator of the composite body structure as TMT or BWMT suffers most significantly. Regardless of the presence or absence of signs of hypoxemia, the loss of TMT is directly related to the progression of COPD and a decrease in respiratory function.

Based on the purpose of the study, the indicators of BMI and BMI, diagnosed using anthropometry and bioimpedansometry methods, do not differ significantly, however, these methods were used with BMI in patients who were not divided into groups with normal, reduced and increased body mass index, which must be taken into account. We analyzed the comparative characteristics of TMT and BWMT as a result of the methods used for various BMI indicators. Significant differences were revealed between BMI obtained by anthropometry and BMI, as a result of measurement using the bioimpedansometry method, with BMI>25 kg/m 2 in patients with COPD (p<0,05). Однако при ИМТ (20-25 кг/м 2), находящегося в пределах референсного значения для здоровых людей и при ИМТ<20кг/м 2 , достоверных различий не выявлено.

Obviously, the method of anthropometric measurements is not recommended for use in patients with a BMI>25 kg/m2, due to the predominant concentration of adipose tissue in the abdominal cavity, which leads to an underestimation of total fat mass.

The bioelectric impedance method makes it possible to more accurately determine protein-energy deficiency with a predominant decrease in muscle mass in COPD patients with a BMI>25 kg/m2.

conclusions

1. COPD is characterized by the development of nutritional deficiency, the phenotypic manifestations of which are loss of lean body mass, recorded even with a normal body mass index. There is a loss of lean body mass, the muscular component of the body, already at stage I of COPD, the most significant decrease in BMT was found at stage III of the disease (p<0,05).
2. Unlike body mass index, loss of lean body mass has a direct relationship with the stage of COPD, as evidenced by the correlation analysis.
3. In the general group of patients without taking into account body weight indicators, when comparing the methods of anthropometry and bioimpedanceometry, the indicators of BMI and TMI do not differ significantly. The bioelectric impedance method makes it possible to more accurately determine protein-energy deficiency with a predominant decrease in muscle mass in COPD patients with a BMI>25 kg/m2.

Reviewers:

• Duizen I.V., Doctor of Medical Sciences, Professor of the Department of General and Clinical Pharmacology of VSMU, Vladivostok.
• Brodskaya T. A., Doctor of Medical Sciences, Dean of the Faculty of Advanced Studies of VSMU, Vladivostok.

Bibliographic link