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MCO 200509

REVIEW

CURRENT
OPINION Assessment of adult malnutrition and prognosis
with bioelectrical impedance analysis: phase angle
and impedance ratio
Henry C. Lukaski a, Ursula G. Kyle b, and Jens Kondrup c

Purpose of review
Malnutrition affects prognosis in many groups of patients. Although screening tools are available to identify
adults at risk for poor nutritional status, a need exists to improve the assessment of malnutrition by
identifying the loss of functional tissues that can lead to frailty, compromised physical function, and
increased risk of morbidity and mortality, particularly among hospitalized and ill patients and older adults.
Bioimpedance analysis (BIA) offers a practical approach to identify malnutrition and prognosis by assessing
whole-body cell membrane quality and depicting fluid distribution for an individual.
Recent findings
Two novel applications of BIA afford opportunities to safely, rapidly, and noninvasively assess nutritional
status and prognosis. One method utilizes single-frequency phase-sensitive measurements to determine
phase angle, evaluate nutritional status, and relate it to prognosis, mortality, and functional outcomes.
Another approach uses the ratio of multifrequency impedance values to indicate altered fluid distribution
and predict prognosis.
Summary
Use of basic BIA measurements, independent of use of regression prediction models and assumptions of
constant chemical composition of the fat-free body, enables new options for practical assessment and
clinical evaluation of impaired nutritional status and prognosis among hospitalized patients and elders that
potentially can contribute to improved patient care and clinical outcomes. However, these novel
applications have some technical and physiological limitations that should be considered.
Keywords
impedance ratio, nutritional status, phase angle, prognosis

INTRODUCTION from lack of intake or uptake of nutrition that leads to

Malnutrition is a significant public health problem
worldwide. Surveys reveal that up to 50% of adults
admitted to hospital enter with malnutrition [1–3],
and 40–90% of older adults in both community
and healthcare settings are malnourished [4,5].
Untreated malnutrition increases morbidity and
mortality, resulting in substantial annual economic
costs estimated to be £20 billion in the United King-
dom and $157 billion in the United States [1,4].
Many patients who are identified by nutrition
screening tools [6–9] need to be further evaluated by
a detailed nutritional assessment tool that includes
weight, diet, and disease history and may include a
physical examination, anthropometric measure-
ments, or an assessment of functional capacity.
Movement toward consensus criteria for diagnosis
of malnutrition independent of cause is growing [10–
13] with a common definition of ‘a state resulting
altered body composition [decreased lean body mass
(LBM) and body cell mass (BCM)] and can result in
diminished physical and mental function and
impaired clinical outcome from disease.’
The term malnutrition in the clinical setting
includes both the actual presence of an impaired
nutritional status [10] and the risk of developing
a
Department of Kinesiology & Public Health Education, University of
North Dakota, Grand Forks, North Dakota, bNutrition Consultant Serv-
ices, The Woodlands, Texas, USA and cClinical Nutrition Unit, Rigsho-
spitalet University Hospital, Copenhagen, Denmark
Correspondence to Henry C. Lukaski, Department of Kinesiology &
Public Health Education, University of North Dakota, Room 101 Hyslop
Sports Center, 2571 2nd Ave. North, Grand Forks, ND 58202-8235,
USA. Tel: +1 701 777 4324; e-mail: henry.lukaski@email.und.edu
Curr Opin Clin Nutr Metab Care 2017, 20:000–000
DOI:10.1097/MCO.0000000000000387

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MCO 200509
Assessment of nutritional and metabolic status
KEY POINTS
 Phase angle is not diagnostic. It is a parameter, similar
to body temperature, that can be used to monitor
progression of a disease or effectiveness of
intervention. Values at, above, or below reference
values may be useful in patient care and
clinical outcomes.
 Use of phase angle as a biomarker of malnutrition
should include an assessment of hydration because
inflammation, which is present in disease-related
malnutrition and aging, affects fluid distribution.
 Clinical trials of patients with low phase angle are
needed to ascertain the appropriate treatments
(nutritional support, treatment for inflammation, or both)
that affect prognosis.
 Phase-sensitive bioimpedance instruments and low
inherent impedance electrodes are required for valid
measurements of phase angle.
 Preliminary evidence suggests that impedance ratio and
phase angle are similar in prognosis for cancer patients
and critically ill patients. Studies with large sample
sizes estimated with power analysis are needed to
clarify the benefit of these putative indicators
of prognosis.
such malnutrition in the short term. The inter-
national consensus of disease-related malnutrition
emphasized the role of inflammatory processes
associated with most diseases that can cause
decreased intake and/or increased nutritional
requirements [10,11]. The inflammatory response
in itself has a number of effects on tissue hydration
and vascular/cellular permeability that leads, for
instance, to hypoalbuminemia which is only rarely
a consequence of malnutrition [9].
The current criteria for diagnosis of impaired
nutritional status (actual malnutrition) emphasize
deleterious changes in body composition that are
not determined with the standard questionnaires
for assessment of risk of malnutrition [11,12]. Prac-
tical considerations (cost, availability, time, etc.)
restrict the routine assessment of muscle, LBM,
and BCM in in-patient and out-patient settings
[13]. However, the bioimpedance analysis (BIA)
method affords a practical alternative that over-
&& &&
comes these limitations [14 ,15 ].
BIOELECTRICAL IMPEDANCE: UNIQUE
METHOD TO ASSESS MALNUTRITION AND
PROGNOSIS IN ADULTS
Bioelectrical impedance (BIA) is a safe, noninvasive,
portable, and reliable method to measure passive
2 www.co-clinicalnutrition.com
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electrical characteristics of living organisms. It does
not directly determine body composition; use of
regression models derived in healthy individuals
to predict body composition in patients with vari-
&&
ous diseases is not recommended [14 ,16]. The BIA
method utilizes a phase-sensitive impedance instru-
ment that introduces a constant, low-level alternat-
ing current with a tetrapolar surface electrode
placement on the hands and feet for whole-body
&& &&
determinations [14 ,15 ]. Impedance (Z), and the
delay of current, caused by the lag of current pen-
etrating cell membranes and tissue interfaces, is
measured by low Z electrodes, and expressed as
phase shift or phase angle. Impedance is a complex
number that comprises the resistance (R) or purely
resistive component (water and electrolytes in fluids
and tissues) and the reactance (Xc) or capacitative
component in tissues (cells and tissue interfaces).
Complex electronic circuitry permits the determi-
nation of the time delay between voltage and cur-
rent at the cell membrane and tissue level and thus
determines the phase angle. The complex Z of an
organism can be differentiated into R and Xc com-
ponents with simple mathematics, Z  (sin phase
angle) and Z  (cos phase angle), respectively, of a
R–Xc series circuit for the body. Routinely, a 50-kHz
phase-sensitive BIA instrument measures phase
angle and Z, and calculates R and Xc.
Alternatively, some tetrapolar multifrequency
BIA devices determine Z through a range of frequen-
cies from low (5 kHz) to less than 2 MHz. The theory
is that the ratio of high (200 kHz) to low (5 kHz)
frequency Z (Z200/Z5), termed an impedance ratio
[total body water/extracellular water (ECW)] it is
postulated to indicate conduction in these fluid
&&
spaces [17 ]. Current penetration into cells is fre-
quency-dependent, thus, the Z200/Z5 indicates the
ratio of greater to lesser current entry into cells and is
similar to a phase shift.
PHASE ANGLE, NUTRITIONAL STATUS,
AND PROGNOSIS IN DISEASE
Cell mass and cell membrane integrity depend on
age, sex, fluid distribution, and BMI, thus affect
phase angle values of healthy people [18]. In
addition, disease, inflammation, malnutrition,
and prolonged physical inactivity adversely impact
tissue electrical properties, resulting in prominent
decreases in phase angle values compared with
&&
healthy individuals [19 ]. The phase angle is charac-
terized physiologically as an index of cell membrane
integrity and vitality, and expresses the quantity
and quality of soft tissues. Higher values of phase
angle are considered to indicate greater cellularity
(e.g., less water relative to cell mass), cell membrane
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Assessment of adult malnutrition and prognosis Lukaski et al.
integrity and function, and, thus cellular health.
The phase angle is significantly and positively cor-
related with LBM and BCM but inversely related to
the ratio of extracellular to intracellular fluid (ECW/
ICW) in healthy adults [18]. Disease-related malnu-
trition is characterized by an early shift of fluids
from ICW to ECW space with increased ECW/ICW
and a concomitant decrease in BCM, both lowering
phase angle. Such disease-related alterations in fluid
distribution are reflected in phase angle measures
&&
[19 ].
&&
Norman et al. [19 ] concluded that phase angle
is an indicator of survival and other clinical out-
comes and could be used as a screening tool to
identify patients at risk because of impaired nutri-
tional or functional status. However, they also speci-
fied that bioelectrical impedance vector analysis
(BIVA) provides additional information on
&
hydration and cell mass integrity [20 ] and should
be considered an assessment and monitoring tool
that can distinguish any effect of hydration on signs
of malnutrition.
Many of the initial studies used raw phase angle
values to determine relative risk. This approach can
limit the sensitivity and specificity of prediction of
risk associated with illness because of heterogeneity
of characteristics between healthy and ill patients.
Other investigations used phase angle data from
national reference databases and stratified the refer-
ence phase angle values by sex, age, and occasion-
ally BMI. The patient phase angle data were
compared either with a predetermined reference
percentile (e.g., 5th or 15th) or geometric distri-
bution (e.g., quartile or quintile) derived from the
healthy reference population. Clinical investigators
more recently derived a standardized phase angle
(SPA) score [SPA ¼ (observed phase angle  mean
phase angle)/SD of the phase angle, where the mean
and SD are from sex-stratified, age-stratified, and
BMI-stratified phase angle reference values]. Trans-
formation of phase angle values into Z-scores ena-
bles the quantification of the individual deviation of
a patient from sex-specific, age-specific, and BMI-
specific population averages and augments its
predictive power.
Diverse observational clinical studies support
the use of phase angle as a predictor of prognosis
(Table 1). It should be emphasized that a number of
the comparisons in these studies are ambiguous in
relation to malnutrition including serum albumin,
which is considered an indicator of inflammation.
Subjective global assessment (SGA) includes the
presence of edema in the ‘nutritional’ rating and
Nutritional Risk Screening (2002) incorporates an
estimate of the severity of disease, in most cases
associated with disease-related inflammation.
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Mini-nutritional assessment (MNA) contains a score
for acute illness. Therefore, the information about
phase angle and prognosis is particularly relevant,
whereas the relation of phase angle to malnutrition
is probably not specific in most of these studies.
Consistently, a low phase angle value predicted
the increased risk of malnutrition and poor prog-
nosis assessed with conventional screening tools
and blood biochemical measures [21–24]. A signifi-
cant and practical advantage of phase angle is the
lack of requirement to measure weight and height to
assess nutritional risk. Low phase angle also was
inversely related to impaired nutritional status
and risk of complications, notably cachexia, after
chemotherapy, and has been associated with
reduced survival in patients with various cancers
[25–31]. Cancer patients with phase angle values
below the 5th percentile of stratified reference
healthy phase angle ranges had decreased physical
function and quality of life, and increased mortality
[31]. Similarly, patients with low phase angle values
(below 25th percentile of reference population
ranges) before hematopoietic cell transplantation
had decreased survival [32].
Low phase angle values, either raw or low per-
centile values from population reference ranges,
predicted prognosis in other clinical conditions.
Noteworthy is the repeated finding of increased
inflammatory markers and low serum albumin
levels predicted by low phase angle values among
surgical and hemodialysis patients [33–37]. Impor-
tantly, inflammation and low albumin are associ-
ated with altered fluid distribution into extracellular
space which may decrease phase angle. The severity
and risk of malnutrition, assessed with SGA
categories B and C and differentiated by at least
0.58, increased with decreasing phase angle values
[36]. Prospectively, low phase angle was associated
with decreased mid-arm muscle circumference and
muscle strength, and increased ascites and inflam-
mation [37].
Low phase angle predicted increased postsurgi-
cal hospital and ICU length of stay (LOS) as well as
increased risk of morbidity [38]. Low phase angle
values predicted the severity of illness among crit-
ically ill patients, particularly in patients without
sepsis [39], and independently predicted 28-day
mortality among ICU patients [40]. It also indicated
poor nutritional status and independently predicted
mortality in patients with cirrhosis [41,42] and pre-
dicted the progression of fibrosis in adults with
hepatitis C infection [43].
Consistent with earlier observational findings
&&
[19 ,27], low phase angle predicts impaired muscle
function, physical performance, and decreased sur-
vival. Adults with chronic obstructive pulmonary
www.co-clinicalnutrition.com 3
 4
Table 1. Impact of low phase angle on nutritional status and prognosis of adults since 2012
Clinical Nutritional assessment or clinical outcome
condition Reference n BIA device PA cutoff value of patients below PA cutoff value Comments

Hospital patients Kyle et al. [21] 649 RJL-101 M: 58; W: 4.68 PA sensitivity: M/W; NRS-2002: 70/58%; SGA: 73.3/
64.5%; albumin: 59/24%; PA specificity: M/W; NRS-
2002: 85/82%; SGA: 77/76%; albumin: 93/97%;
PA ROC AUC: M/W; NRS-2002: 0.85/0.80; SGA:
0.83/0.80; albumin: 0.85/0.91
Patients with albumin levels <35 g/l had a RR of 7.5 to
have low PA compared with patients with 35 g/l
The consistent sensitivity and specificity
between PA and three screening tool
confirms the validity of PA as a useful
indicator of nutritional risk without
need to measure weight or height
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Kyle et al. [22] 983 RJL-101 M: 58; W: 4.68 Risk of low PA compared with NRS-2002: No risk: 1.7 A similar RR for low PA was also
times (CI 1.2–2.3); moderate risk: 4.5 times (CI 3.4– associated with SGA
5.8); severe risk: 7.5 times (CI 5.9–9.4)
LOS: compared with 1–4 days: 21 days: (RR 6.9, 95% Low PA was significantly related to LOS

www.co-clinicalnutrition.com
CI 5.1–9.1); 5–20 days (RR 5.2, 95% CI 3.9–6.9); and nonsurvival
survival: RR 3.1, 95% CI 2.1–3.4
Guerra et al. [23] 682 Biodynamics M: 58; W: 4.68 Low PA predicted undernutrition [HR: 0.62 (0.48–0.61)] Low PA predicts increased hospital stay
450 and increased LOS (>7 day)
Varan et al. [24] 122 Bodystat 4.78 NRS-2002 Grade 3: 50% patients at risk for PA is a valid predictor of poor
Assessment of nutritional and metabolic status

Quadscan malnutrition; PA lower in at risk than not at risk patients: nutritional status
4000 4.2  1.88 vs. 5.75  2.968 (P < 0.003; ROC: 79.6%
sensitivity, 64.6% specificity)
Cancer Hui et al. [25] 222 RJL Quantum <4.48; <95th PA was directly related to survival up to 220 days PA is novel predictor of survival
MCO 200509

IV percentile (P < 0.001); survival: HR 0.86 (CI 0.74–0.99) per 18 independent of other prognostic
PA increase (P < 0.04) factors
Lee et al. [26] 28 Biodynamics <4.48 PA directly related to survival time (r ¼ 0.395, P < 0.001); PA is an independent predictor of
450 survival: HR 0.64 per 18 increase (CI 0.42–0.95, survival
P < 0.028)
Norman et al. 430 Data Input Age-stratified, sex- Low PA: independent predictor of muscle strength, quality Low PA predicts mortality in elderly
[27] Nutrigard stratified, and of life, fatigue. Low PA increased risk of 1-year cancer patients
M BMI-stratified mortality HR: 2.112 (1.443–3.109, P < 0.001)
population PA
value: 5th
percentile
Sch€
utte et al. [28] 51 BIACORPUS 4.88 Increased risk of poor survival: OR 4.779 (CI 1.045– PA is an independent prognostic factor
RX 4000 21.855, P < 0.04); survival with PA  4.88 was 298 of malnutrition and survival in cancer
days (CI 229–365 days) compared with 397 days patients
(351–446 days) (P < 0.044)
Małecka- 75 Impedimed 4.738 Compared with SGA: ROC: 80% sensitivity, 56% PA is valid predictor of malnutrition
Massalska SFB7 specificity; AUC ¼ 0.70, 95% CI: 0.57–0.83,
et al. [29] P < 0.0005
Stegel et al. [30] 55 Bodystat >5.49; <4.99 Higher PA in well nourished (NRS-2002) compared with PA significant predictor of complications
Quadscan malnourished patients (P < 0.045). Risk of malnutrition/ after treatment
4000 cachexia increased by 1.71 (CI 1.11–2.66) per 18
decrease in PA (P < 0.018)
Risk of malnutrition/cachexia increased by 1.71 (CI
1.11–2.66) per 18 decrease in PA (P < 0.018)
Władysiuk et al. 75 Impedimed <4.738 PA directly related to SGA score (r ¼ 0.35, P < 0.002); Low PA was associated with shorter
[31] SFB7 shortened survival: 19.6 vs. 45 months, P < 0.0489; survival
HR: 1.889 (CI 1.003–3.545)

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 Table 1 (Continued)
Clinical Nutritional assessment or clinical outcome
condition Reference n BIA device PA cutoff value of patients below PA cutoff value Comments

Allogeneic Urbain et al. [32] 150 Fresenius Lower 25th Survival: HR ¼ 1.97 (CI 1.02–3.81), P < 0.043; Decreased survival with low
hematopoietic Body Scout percentile of SPA nonrelapse mortality: HR ¼ 3.18 (CI 1.23–8.27), pretransplant SPA
cell transplant P < 0.017; relapse mortality: HR ¼ 1.91 (CI 1.0–3.5),
P < 0.039
Hemodialysis Beberashvili et al. 91 Data Input <4.88 at baseline Decreases in PA related to increases in IL-6 over 2 years Both baseline and rate of change of PA
[33] Nutrigard (r ¼ 0.32, P < 0.005); PA change predicts mortality: predict mortality in HD patients
M 0.458/2 years; sensitivity: 61%, specificity: 63%;
ROC AUC 0.65 (CI 0.53–0.76, P < 0.017)
Lee et al. [34] 82 Biospace <48 PA of elderly (>65 years) PA: 4.0  1.0 and 4.9  1.28 Older HD patients had lower PA values;
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InBody S10 (P < 0.002); ECW/TBW: OR 1.067, 95% CI: 1.164 low PA predicted overhydration and
to 0.971 (P < 0.001); MIS: OR 0.797, 95% CI: malnutrition
1.373 to 0.220 (P ¼ 0.008)
Rimsevicius et al. 99 Biospace Age-stratified, sex- Compared with SGA, pre-HD PA OR: 3.69 (CI:1.59– PA was best predictor of malnutrition.
[35] InBody S10 stratified 8.62); P < 0.002; PA increased after HD: 4.87  1.8 Reduced PA indicated severity of
population PA vs. 5.0  0.978; P < 0.001; moderate malnutrition: malnutrition
value <25th percentile: AUC ¼ 0.70, 95% CI 0.60–0.81
(P < 0.01); severe malnutrition: <15th percentile:
AUC ¼ 0.74; 95% CI 0.62–0.85 (P < 0.05)
Santin et al. [36] 104 Biodynamics PA correlated with SGA grades in older females Decreasing PA was strong predictor of
450 (P < 0.002) and males (P < 0.03) during a 12-month risk of malnutrition and associated
period with decreased muscle strength and
increased inflammation and ascites
MCO 200509

Surgery Martin et al. [37] 131 Body Scout Low PA significant predictor of increased CRP (>10 mg/l) PA predicted increased levels of
[OR 1.63 (CI 1.02–2.6)] and low albumin (<30 g/l) inflammatory markers
[OR 2.1 (CI 1.24–3.57)] during 60-day period after

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surgery
Ringaitiene et al. 342 Biospace Age-stratified, sex- PA correlated with FFMI (r ¼ 0.515, P < 0.001); postop Low PA significantly related to postop
[38] InBody S10 stratified morbidity: low PA (21.3%) compared with normal PA morbidity (P < 0.016) and increased
population PA (10.71%); risk of 1-month postop morbidity: low PA: LOS (P < 0.063)
value OR 2.5 (CI: 1.18–5.29); LOS (14 days): 50.8 vs.
37.8%; postop stay: 14 vs. 12 days
Critical illness da Silva et al. 95 Biodynamics <5.18 PA correlated modestly with APACHEII score (r ¼ 0.241, Low PA predicts increased severity of
[39] 450 P < 0.02). PA correlation with APACHEII score critical illness. Sepsis affects PA
increased (r ¼ 0.506, P < 0.001) with patients without values
sepsis
Thibault et al. 931 Data Input Mortality: adj. OR: 0.86 (0.78–0.96, P < 0.008) Low PA independently predicts 28-day
[40] Nutrigard mortality in ICU
M
Cirrhosis Ruiz-Margáin 249 RJL Quantum 4.98 Prospective study: 48-month follow-up; mortality: HR 2.15, PA is independent predictor of mortality
et al. [41] IV 95% CI: 1.18–3.92 (P < 0.02)
Belarmino et al. 134 Bodystat 4.98 Prospective study: 36-month follow-up; mortality: HR 2.05, PA is an independent predictor of
[42] 4000 95% CI: 1.11–3.77 (P < 0.021); lower (P < 0.05) mid- mortality and metabolic, functional,
arm muscle circumference, hand-grip strength and and disease progression
increased (P < 0.05) ascites, CRP, and IL-6/IL-10
Hepatitis C virus Dorna Mde et al. 135 Biodynamics M: 6.728; F: 5.948 M: AUC: 0.747 (CI: 0.629–0.866, P < 0.001); F: AUC: PA was associated with hepatic disease
[43] 450 0.698 (CI: 0.554–0.843, P < 0.013); OR: 0.227 (CI: progression

www.co-clinicalnutrition.com
0.09–0.569, P < 0.013); each 18 decrease in PA
increased risk of hepatic fibrosis  4

5
Assessment of adult malnutrition and prognosis Lukaski et al.

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 6
Table 1 (Continued)
Clinical Nutritional assessment or clinical outcome
condition Reference n BIA device PA cutoff value of patients below PA cutoff value Comments

Chronic Maddocks et al. 502 Bodystat Age-stratified, sex- PA correlated with measures of strength and walking PA relates to functional measures,
obstructive [44] Quadscan stratified, and (r ¼ 0.35–0.66, P < 0.0001); survival was less in disease severity, and prognosis
pulmonary 4000 BMI-stratified patients with low PA (8.2 vs. 3.6%, P < 0.02)
disease population PA
value: 5th
percentile
Neuromuscular Roubeau et al. 117 Bodystat PA at diagnosis predicted poorer survival HR: 11.5 (CI PA was associated with shorter survival
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disease [45] Quadscan 3.93–29.2, P < 0.0001)

4000
Geriatrics Wilhelm-Leen 4667 Valhalla 1990 M: 5.68 F: 5.48 Frailty: W [OR: 4.4 (2.6–7.7)] and M [OR: 3.1 (1.2– PA in lowest quintile predicts frailty and
et al. [46] 7.9)]; mortality: W [OR: 5.9 (2.4–14.3)] and M [OR: mortality

www.co-clinicalnutrition.com
3.8 (1.4–10.3)]
Basile et al. [47] 207 Akern PA correlated with grip strength (r ¼ 0.49, P < 0.001) and PA indicates muscle function and mass
Quantum S muscle mass (r ¼ 0.60, P < 0.001)
Slee et al. [48] 69 Maltron 916S Identified PA relative to nutritional at risk from screening Low PA associated with increased risk
tools; MNA-SF: M 4.48 W 3.98; MUST: M 4.78 W for poor nutrition
Assessment of nutritional and metabolic status

3.98
Kilic et al. [49] 263 Bodystat 4.558 PA ROC AUC: 0.703 (CI 0.644–0.758. sarcopenia: PA useful for diagnosis of sarcopenia
Quadscan phase angle (OR: 0.59, 95% CI: 0.40–0.87,
4000; P ¼ 0.008)
InBody S10
MCO 200509

Buscemi et al. 225 RJL BIA-103 4.68 Low PA was associated with highest mortality 48 months Low PA was associated with increased
[50] after discharge from hospital. PA [OR: 0.69 (CI 0.51– mortality. Low PA predicted
0.95, P < 0.02)] and MNA scores [OR: 0.86 (CI readmission rate
0.78–0.96, P < 0.006] were independently related to
readmission rates
Genton et al. [51] 1307 Data Input Risk of mortality decreased progressively as the SPA PA was associated with mortality
Nutrigard quartile increased HR 0.71 (95% CI 0.58, 0.86), 0.53 independent of age, sex, BMI, and
M (95% CI 0.42, 0.67), 0.32 (95% CI 0.23, 0.43). The setting (ambulatory or hospitalized)
discriminative value of continuous SPA, assessed as the
area under the ROC curve, was 0.72 (95% CI 0.70,
0.75)

BIA devices: RJL Systems, Clinton Township MI; Biodynamics Customer Service, Shoreline, WA; Bodystat LTD, Isle of Man, UK: Body Scout, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany; Inbody
S10 device (Biospace, Seoul, Korea); Data Input, Pocking, Germany; BIOCORPUS, MEDICAL Healthcare GmbH, Karlsruhe, Germany; Impedimed, Pinkenba, QLD 4008 Australia; Valhalla Scientific, San Diego,
California, USA; Akern SRL, Florence, Italy; Maltron International Ltd, Rayleigh, Essex UK. APACHE II, Acute Physiology and Chronic Health Evaluation II; AUC, area under the curve; BIA, bioimpedance analysis; CI,
confidence interval; CRP, C-reactive protein; ECW, extracellular water; FFMI, fat-free mass index; HD, hemodialysis; HR, hazard ratio; LOS, length of stay; M, men; MIS, malnutrition-inflammation score; MNA, Mini-
Nutritional Assessment; MUST, Malnutrition Universal Screening Tool; NRS-2002, Nutritional Risk Screening; OR, odds ratio; PA, phase angle; ROC, receiver operating curve; RR, relative risk; SGA, subjective global
assessment; SPA, standardized phase angle (observed phase angle  mean of reference value/SD of reference value); TBW, total body water; W, women.

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CE: Swati; MCO/200509; Total nos of Pages: 10;
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Assessment of adult malnutrition and prognosis Lukaski et al.
disease with phase angle values below the 5th per-
centile of healthy controls had significantly
decreased muscle strength and walking capacity
[44]. Similarly, patients with amyotrophic lateral
sclerosis who had low phase angle values at diag-
nosis had an increased risk of mortality [45].
The strong correlation between phase angle,
muscle mass, and strength stimulated research to
determine the prognosis of phase angle in geriat-
rics. Observational studies reported that low phase
angle values were significant predictors of risk of
poor nutritional status [46,47], decreased muscu-
lar strength [48], frailty [49], and mortality
[47,49]. Among older patients discharged from a
hospital emergency outpatient department, a low
phase angle was a significant predictor of
mortality in the subsequent 48 months and was
superior to the MNA in the prognosis of survival
[50]. Genton et al. [51] retrospectively found that
low phase angle values predicted mortality and a
higher SPA was protective of mortality among
elders.
Strength training, supplementation, and
phase angle in geriatrics
These findings advanced research to determine
the effects on phase angle of interventions to
attenuate sarcopenia and boost muscle function
in vulnerable groups and to ascertain the effects of
nutritional support on outcomes of patients with
low phase angle values. One common interven-
tion is resistance training to increase strength and
LBM of the elderly. Fukuda et al. [52] identified an
increase (P < 0.005) in phase angle with resistance
training from baseline to 6-month assessments
(4.80–5.048) with significant gains in strength
of elderly women. Souza et al. [53] found that
phase angle increased (P < 0.001; 5.5–5.9 vs.
5.6–5.58) with gains (P < 0.01) in muscle mass
(16.8–17.3 kg compared with 17–16.8 kg) after
12 weeks of resistance training compared with
&
untrained elders. Rondanelli et al. [54 ] observed
an increased phase angle (unpublished data; 0.28;
P < 0.001) among octogenarian women with low
mean phase angle values (4.78) who participated
in a 12-week progressive physical activity program
designed to enhance muscle gain and received a
supplement (whey protein, amino acids, and vita-
min D) as compared with placebo. Increased
phase angle was associated with gains in strength
(P < 0.001), LBM (P < 0.001), and insulin-like
growth factor (P < 0.002) and decreases in C-reac-
tive protein (CRP) (P < 0.038). Importantly,
hydration, assessed with BIVA, was within normal
limits.
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IMPEDANCE RATIO, FLUID DISTRIBUTION,
AND CLINICAL OUTCOME
Few studies have evaluated the impedance ratio
(Z200/Z5) as a potential indicator of nutritional sta-
tus and fluid overload. Higher impedance ratio has
been associated with low lumbar muscle mass [55 ],
&
worsening renal function in patients with decom-
&
pensated heart failure [56 ], and greater risk of
malnutrition [57]. The potential widespread appli-
cation of impedance ratio in the evaluation of nutri-
tional and fluid status is hampered by the need
for a multifrequency instrument that accurately
measures resistance at 5 and 200 kHz, and the lack
of determination of standardized cutoff. Further
research of this concept is warranted to determine
whether impedance ratio can independently
identify individuals with malnutrition and abnor-
mal hydration.
COMPARISON OF PHASE ANGLE AND
IMPEDANCE RATIO IN PROGNOSIS
Practicality and encouraging results from clinical
investigations using phase angle and impedance
ratio as indicators of prognosis encouraged the com-
parison of these new approaches. Kuchnia et al. [55 ]
&
evaluated the prognostic ability of these bioimpe-
dance methods to predict clinical outcomes of 71
patients admitted to ICU. Each impedance method
explained a similar (P < 0.05) but moderate (21%)
amount of variance in computed tomography-
determined regional muscle area determined at
admission with receiver operating curve area under
the curve of 0.78 and 0.76 for phase angle and
impedance ratio, respectively. Evaluation of low
phase angle and high impedance ratio as prognostic
indicators revealed that each was a significant pre-
dictor of ICU, but not hospital, discharge. Alterna-
tively, fat-free mass index criteria were better
predictors of outcome than the impedance vari-
ables. Serial measurements of nutritional status
[9], phase angle, and impedance ratio were obtained
before, during, and after chemoradiotherapy of 19
&
adults diagnosed with head and neck cancer [56 ].
Body weight (93–88 kg) decreased significantly.
Patients classified as malnourished had decreased
phase angle (5.2 vs. 5.98; P < 0.03) and increased
impedance ratio (0.82 vs. 0.79, P < 0.03) compared
with other patients characterized as well nourished.
Phase angle and impedance ratio were correlated
moderately with higher patient-guided SGA scores
(r ¼ 0.35 and 0.36, respectively; P < 0.01) and
handgrip strength (r ¼ 0.48 and 0.47, respectively;
P < 0.01). These findings indicate no differences
between phase angle and impedance ratio as pre-
dictors of malnutrition or prognosis in patients.
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MCO 200509
Assessment of nutritional and metabolic status
CONSIDERATIONS FOR USE OF PHASE
ANGLE IN ASSESSMENT OF
MALNUTRITION AND PROGNOSIS
Increased use of phase angle in prognosis resulted in
generally positive reviews for patient management
in hepatology and cancer [57,58]. Grundmann et al.
[59], however, noted the high interpatient variabil-
ity in phase angle and suggested that this factor
hinders comparisons with healthy reference values.
Whether differences in disease progression and
comorbidities may contribute to this suggestion,
other factors may be responsible.
Technical concerns
Small differences in phase angle values (<0.58) dis-
criminate healthy adults from ill, nutritionally at
risk, or poor prognosis patients (Table 1). Thus, it is
imperative to identify and control moderating tech-
nical factors to ensure valid measurements of phase
angle. Although the reliability of BIA is high
&& &&
[14 ,15 ], an important limitation is measurement
differences between BIA devices from different man-
ufacturers. Genton et al. [60] recently found that
phase angle differed significantly between patients
measured with Eugedia, RJL-101, and Xitron instru-
ments. As there are no international manufacturing
standards, synchronization of technology and cross-
calibration of the electrical accuracy of the different
instruments should be a mandatory future goal for
impedance companies. Also, only BIA devices that
measure complex Z and the time delay of current
and voltage, which indicate capacitance (Xc), can be
used for assessment of phase angle.
Another key technical concern is the need to use
contact electrodes that are electrically neutral. Nesco-
larde et al. [61] found large variations in the R and Xc
among nine commercial pregelled silver/silver
chloride adhesive electrodes reported in the BIA liter-
ature. Inherent R (11–665 V) and Xc (0.25–2.5 V) were
variable, which systematically and significantly
affected vector position on the RXc graph and
adversely influenced phase angle values and vector
lengths of healthy adults. Thus, standardization of
contact electrodes is necessary for valid BIA measure-
ments to assess nutritional status and prognosis.
Pathophysiological issues
Phase angle is a composite measure consisting of R and
Xc and therefore includes contributions from fluids
and cells. Thus, it is appropriate to consider hydration
per se as a possible confounder of interpretations of
phase angle in malnutrition assessment [19 ]. One
&&
approach is to utilize the RXc graph as a qualitative and
semiquantative represention of differences in cell mass
8 www.co-clinicalnutrition.com
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FIGURE 1. Vector positions on the RXc graph indicating
theoretical body composition differences with similar phase
angles but different hydration shown as vector length
(unpublished data).
&
and hydration of an individual [20 ]. Hemodialysis
patients may have a similar phase angle but length-
ened vector lengths after the dialytic procedure (Fig. 1).
Although nutritional assessments may be comparable,
clinical complications (syncope, hypertension, etc.)
differ appreciably because of divergent fluid levels
characterized by vectors of differing length. A muscular
athlete and an overweight adult may have the same
phase angle but a shorter vector in the overweight
individual indicates excess fluid. However, an over-
weight, overhydrated, a normal weight but dehydrated
and a malnourished adult may share a common phase
angle but have progressively lengthening vectors and
fluid status. Finally, a normal weight but edematous
individual may have a similar phase angle as a dehy-
drated, cachexic individual. Thus, interpretation of
phase angle values within the context of hydration
status will enhance the valid assessment of malnu-
trition and improve prognosis for an individual.
Inflammation is a pervasive component of the
cause of disease-related malnutrition and aging [10].
It ranges from low to high levels and is present in
cachexia, acute disease and injury, and end-stage
organ diseases. It impacts energy balance, body
composition, and function with adverse outcomes.
Inflammation adversely affects prognosis and is
&&
associated with low phase angle values [19 ] (Table
1). Recent findings indicate that 12  2 weeks anti-
inflammatory (infliximab) therapy increased phase
angle (4.6  0.3 to 6.2  0.48, P < 0.05) and decreased
CRP (10.6  7.3 to 3.4  2.4 mg/l) of patients with
Crohn’s disease [62]. However, the effects of such
anti-inflammatory therapy on phase angle changes
and prognosis remains to be determined.
CONCLUSION
The phase angle is a simple measure that gives
important information about the prognosis of the
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MCO 200509
patient. It is measured directly by a phase-sensitive
BIA device, and it is independent of the individual
patient’s body weight and height. A low phase angle
may be due to overhydration and/or malnutrition
(Fig. 1). Accordingly, many studies find a correlation
between phase angle and other measures of nutri-
tional status and/or muscle mass. However, a low
phase angle does not specifically reflect impaired
nutritional status particularly in patients with
inflammatory processes in which the associated dys-
hydration (overhydration) may lower phase angle
more than explained by their nutritional status (body
composition). Changes in hydration may be an early
sign of disease-related malnutrition, for example, due
to lower activity of ATP-dependent cell membrane
functions related to energy deficiency (reduced func-
tion of cellular mass), but other effects of the inflam-
mation on hydration may be responsible.
The necessary test of phase angle as a clinically
useful measure of nutritional status still awaits. It
ideally will be a randomized controlled trial of out-
come(s) among patients selected because of a low
phase angle who are randomized to nutrition sup-
port or standard treatment.
Furthermore, although BIA-determined phase
angle is a simple, easy test to perform to assess patient
nutritional risk and assess prognosis, it is imperative
that measurements must be performed based on
rigorous protocols with a phase-sensitive instrument
that is regularly validated with a precision circuit that
includes R, capacitance and phase angle. Patient
results must be confirmed by a BIVA analysis (RXc
graph) before low phase angle values can be ascribed
to loss of cell mass. Operators of BIA instruments
should be trained and certified to follow standardized
protocols and should question results that are out of
range or clinically not plausible.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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