High prevalence of malnutrition among patients with solid non-hematological tumors as found by using skinfold and circumference measurements

ABSTRACT CONTEXT AND OBJECTIVE: Malnutrition in cancer patients has many causes. Nutritional status is usually assessed from weight/height indices. These present limitations for the nutritional assessment of cancer patients: their weights include tumor mass, and lean mass changes are not reflected in weight/height indices. The objective was to evaluate differences between two anthropometric methods and compare deficits, in non-hematological tumor patients and hematological disease patients. DESIGN AND SETTING: Cross-sectional study at Instituto de Oncologia Pediátrica, Universidade Federal de São Paulo. METHODS: Children and adolescents were evaluated between March 1998 and January 2000. Traditional anthropometric measurements were obtained in the first month of treatment (induction therapy), by weight-for-height (W/H) using z-scores index for children and body mass index (BMI) for adolescents. Body composition evaluations consisted of specific anthropometric measurements: triceps skinfold thickness (TSFT), mid-upper arm circumference (MUAC) and arm muscle circumference (AMC). Data were analyzed to compare nutritional assessment methods for diagnosing malnutrition prevalence. The chi-squared test was used for comparative analyses between tumor patients and hematological disease patients. RESULTS: Analysis was done on 127 patients with complete data. Higher percentages of deficits were found among tumor patients, by W/H z-scores or BMI and by MUAC and AMC. Higher percentages of deficits were shown by TSFT (40.2%) and MUAC (35.4%) than by W/H z-scores or BMI (18.9%). CONCLUSION: Non-hematological tumor patients presented higher malnutrition prevalence than did hematological disease patients. Body composition measurements by TSFT and MUAC detected more patients with malnutrition than did W/H or BMI.


PATIENTS AND METHODS
The subjects were children aged over one year and adolescents who were evaluated between March 1998 and January 2000 within the support group for children with cancer [Grupo de Apoio à Criança com Câncer (GRAACC)] at the Pediatric Oncology Institute [Instituto de Oncologia Pediátrica (IOP)], Universidade Federal de São Paulo.The patients were evaluated during their first month of treatment, in the form of a cross-sectional study while they were undergoing therapy to induce clinical remission.They were divided according to their disease type (solid non-hematological tumors and hematological malignancies).
The inclusion criteria for subjects were that they should be children and adolescents referred to Instituto de Oncologia Pediátrica with a diagnosis of malignant disease; they should be aged over one year; and a dietitian should have made an initial assessment.
The exclusion criteria for subjects were that they should not present any cancerrelated diseases such as diabetes mellitus, cardiopathy, chronic obstructive pulmonary disease (COPD), gastrointestinal diseases, nephropathy etc; and they should not be relapsed patients.

Nutritional assessment
The weight-for-height (W/H) z-score was classified in accordance with the World Health Organization (WHO) 1999 criteria for malnutrition in children, 7 and the body mass index (BMI) percentiles in accordance with the WHO 1995 criteria for malnutrition in adolescents. 8

Antonio Sérgio Petrilli
High prevalence of malnutrition among patients with solid non-hematological tumors as found by using skinfold and circumference measurements Instituto de Oncologia Pediátrica, Department of Pediatrics, Universidade Federal de São Paulo -Escola Paulista de Medicina, São Paulo, Brazil CONTEXT AND OBJECTIVE: Malnutrition in cancer patients has many causes.Nutritional status is usually assessed from weight/height indices.These present limitations for the nutritional assessment of cancer patients: their weights include tumor mass, and lean mass changes are not reflected in weight/height indices.The objective was to evaluate differences between two anthropometric methods and compare deficits, in non-hematological tumor patients and hematological disease patients.

DESIGN AND SETTING:
Cross-sectional study at Instituto de Oncologia Pediátrica, Universidade Federal de São Paulo.

METHODS:
Children and adolescents were evaluated between March 1998 and January 2000.Traditional anthropometric measurements were obtained in the first month of treatment (induction therapy), by weight-for-height (W/H) using z-scores index for children and body mass index (BMI) for adolescents.Body composition evaluations consisted of specific anthropometric measurements: triceps skinfold thickness (TSFT), mid-upper arm circumference (MUAC) and arm muscle circumference (AMC).Data were analyzed to compare nutritional assessment methods for diagnosing malnutrition prevalence.The chi-squared test was used for comparative analyses between tumor patients and hematological disease patients.Triceps skinfold thickness (TSFT), midupper arm circumference (MUAC) and arm muscle circumference (AMC) were measured at the same time, during the first month of treatment, in the first chemotherapy cycle.TSFT was determined by grasping the skin and adjacent subcutaneous tissue between the thumb and forefinger, shaking it gently to exclude underlying muscle, and pulling it away from the body just far enough to allow the jaws of the caliper (Harpenden and Cescorf models) to impinge on the skin.Duplicate readings were made at this site to improve the accuracy and reproducibility of the measurements.MUAC was determined at the midpoint between the acromion and olecranon.From these two measurements, AMC was calculated as follows: AMC = MUAC -(TSFT x 0.314) These variables were interpreted in accordance with the Frisancho (1993) percentiles charts 9 and their percentages of adequacy were demonstrated, which were obtained as follows:

Observed value Percentage adequacy = _____________X 100 Ideal value
The oncological treatment protocols used consisted of chemotherapy, radiotherapy and surgery, depending on the tumor diagnosis (Table 1).
The Medical Ethics Committee of Universidade Federal de São Paulo gave its approval for the nutritional study protocol.The corresponding consent from all the subjects' parents or guardians was obtained after the study protocol had been explained to them.

Data analysis
Data were analyzed qualitatively by percentage values, to compare the nutritional assessment methods for diagnosing malnutrition.The Pearson chi-squared test and its degree of association by the phi (ϕ) coefficient was utilized for comparative analyses between the two groups (solid tumors and hematological disease) and between the deficits found using z-scores and other methods.A p-value of less than 0.05 was considered significant. 10

RESULTS
Out of a total of 137 patients evaluated, 127 presented complete data and were used in the analysis.The evaluation was done during the first month of treatment, in the first chemotherapy cycle of the induction therapy.Among the 127 patients analyzed, 68 (53.5%) had solid tumors and 59 (46.5%) hematological malignancies; 56.7% were male and 43.3% female.The mean and median ages were 8.98 ± 5.77 and 6.67 years (range: 1.92 -24.58 years) for the hematological disease group and 9.72 ± 6.42 and 10.5 years (range: 1.08 -23.75 years) for the solid tumor group, respectively.Table 1 shows the cancer diagnoses of the 127 patients.
The comparative analysis of deficits according to z-scores and TSFT, MUAC and AMC demonstrated significant differences between z-score and TSFT, and z-score and MUAC (p < 0.05).Thus, the overall analysis showed significantly higher percentages of deficits using TSFT (40.2%) and MUAC (35.4%) than when using W/H z-scores or BMI (18.9%).Patients with solid tumors presented greater deficits than did those with hematological malignancy diseases, but statistical differences were observed only for z-score, TSFT and AMC, with a low degree of association (Table 2).It was further observed that TSFT, MUAC and AMC identified greater numbers of malnourished patients than did the z-score, particularly in the hematological disease group.

DISCUSSION
Many studies have demonstrated that patients with cancer are malnourished.Sanchez  et al. (1992) found a malnutrition rate of 14% from weight-for-height indices and 47% from biochemical indices.However, patients with solid tumors seem to be more prone to developing malnutrition. 11A study by Schiavetti et  al. (2001) found a malnutrition rate of 26% from weight-for-height indices among Italian children with solid tumors, during antineoplastic therapy. 12Elhasid et al. (1999) evaluated biochemical indices rather than anthropometric indices among 50 children with solid tumors. 13hey observed that 36% of them had prealbumin levels that were lower than normal at the time of diagnosis.Another study, among osteosarcoma patients only, demonstrated that malnutrition prevalence increased during oncological treatment, as measured both by BMI and by TSFT, MUAC and AMC. 14ur results have demonstrated that the z-score or BMI and the AMC and MUAC indexes were, statistically, significantly more depleted among children and adolescents with solid tumors than with hematological diseases.Patients with solid tumors seem to be nutritionally depleted, while those with lymphoma and leukemia tend to demonstrate fewer nutritional problems.This effect may be associated with the nature of the disease as well as with the therapy.
Hematological malignancies consist of cells that proliferate rapidly, and this characteristic enables earlier diagnosis and greater response to chemotherapy. 15On the other hand, in the present study, the children and adolescents with hematological disease received corticosteroids as therapy to induce remission.These drugs are associated with several side effects: the effects most relevant to nutritional status are increased appetite, gains in fat mass and loss of muscle protein. 16n spite of this, in the present study we did not observe statistical differences in TSFT between patients with solid tumors and hematological malignancies, but the percentage deficit was higher for the solid tumor group.Because corticosteroids improve fat stores further, in order to increase the catabolism of muscle protein, it should be expected that more differences would be found in fat tissue. 16On the other hand, catabolism of lean body mass is associated with a poor quality of life, co-morbidity factors like infection and organ complications, and increased mortality risk. 17Children and adolescents with cancer, especially solid tumors, have reduced body protein stores, due to greater whole-body protein breakdown.This catabolic state may occur as a consequence of the malignant disease itself, anticancer therapy or complications of the therapy, e.g.infections and organ failure. 18Therefore, catabolism of lean body mass is a common effect of the disease, thereby making the evaluation of body composition an essential part of the assessment of such patients.Furthermore, children and adolescents with cancer present problems with their weight measurements because of tumor size, amputation and sometimes edema.Thus, measurement of body composition is an important procedure in evaluating patients in several situations, especially with regard to catabolic diseases. 19lthough there are numerous methods for such assessments, the majority are too expensive and impractical for day-to-day use at the bedside or in the field.However, the anthropometric parameters of TSFT and circumferences are practical and, if properly measured, may provide good nutritional indicators in pediatric cancer populations. 20mith et al. (1991) observed a malnutrition prevalence of 5% at the time of diagnosis, among children and adolescents with cancer, as measured by the z-scores of weight-forheight and height-for-age.However, in the same study, 20 and 23% of the patients were depleted, accordance to MUAC and TSFT, respectively.These results thus demonstrated that anthropometry of the arm was more efficacious for detecting early malnutrition. 21n the present study, we observed that weight measurements underestimated the malnutrition prevalence among children and adolescents with cancer, in comparison with TSFT, MUAC and AMC.Brennan et al. 22 compared three methods for evaluating nutritional status.They demonstrated that weight and height overestimated the status, while anthropometry of the arm was shown to be independent of tumor size and, hence, was a better indicator of nutritional status.Their findings indicated positive correlation between MUAC or skinfold thickness and insulin-like growth factor I (IGF-I).In the same study, they observed that solid tumor patients were more depleted, as measured by MUAC and skinfold thickness, than were leukemia patients.The prevalence analysis showed that 1 out of the 12 children with acute leukemia was malnourished, but 13 out of the 26 children with solid tumors fulfilled the definition of malnutrition.
Our results corroborate those of Brennan  et al. (1999), 22 and have also demonstrated that the AMC and MUAC indices were, statistically, significantly more depleted among children and adolescents with solid tumors than among children and adolescents with hematological diseases.
Taskinen & Saarinen-Pihkala (1998) 23 evaluated the nutritional status of children with solid tumors, at the time of diagnosis and during preoperative and postoperative chemotherapy.They found that the traditional methods (weight-for-height, loss of weight and albumin) for assessing protein energy malnutrition did not detect more than two-thirds of the patients with reduced muscle protein mass, as indicated by muscle thickness ultrasonography.However, midarm muscle area and prealbumin had the best validity.
Thus, our study has confirmed the results of Brennan and others regarding nutritional status in solid tumor cases, and has shown the importance of body composition measurements in both the solid tumor and hematological disease groups.Our study has also demonstrated that the fat tissue and circumference indices were more powerful indicators of nutritional deficits than were weight indices, especially when using the WHO definitions for the classifications.This may be associated with the corticosteroid therapy that the hematological group underwent and the weight of the tumor in the other cancer patients.Nonetheless, additional factors such as the sensitivity and specificity of the methods should also be investigated.

CONCLUSIONS
Patients with solid tumors presented higher malnutrition prevalence than those with hematological tumors.It is imperative that clinicians and dieticians be aware of the need for more accurate assessment of nutritional status in children and because of the catabolism of the disease, and the side effects of the oncological treatment, particularly in muscle tissue.TSFT and MUAC detected a greater number of cancer patients with malnutrition than did W/H or BMI.

Table 2 .
Distribution of 127 malnourished children and adolescents according to tumor group and nutritional assessment methods