Journal of the American College of Nutrition

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Calf Circumference Is a Good Predictor of Longer

Hospital Stay and Nutritional Risk in Emergency
Patients: A Prospective Cohort Study

Micheli Tarnowski, Elana Stein, Aline Marcadenti, Jaqueline Fink, Estela

Rabito & Flávia Moraes Silva

To cite this article: Micheli Tarnowski, Elana Stein, Aline Marcadenti, Jaqueline Fink, Estela
Rabito & Flávia Moraes Silva (2020): Calf Circumference Is a Good Predictor of Longer Hospital
Stay and Nutritional Risk in Emergency Patients: A Prospective Cohort Study, Journal of the
American College of Nutrition, DOI: 10.1080/07315724.2020.1723452

To link to this article: https://doi.org/10.1080/07315724.2020.1723452

Published online: 21 Feb 2020.

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JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
https://doi.org/10.1080/07315724.2020.1723452

Calf Circumference Is a Good Predictor of Longer Hospital Stay and Nutritional

Risk in Emergency Patients: A Prospective Cohort Study
Micheli Tarnowskia, Elana Steina, Aline Marcadentib,c,d, Jaqueline Finke, Estela Rabitof, and Fl
avia Moraes Silvag
a
Department of Nutrition Science, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil; bInstitute of Research
of the Heart Hospital (IP-HCor), S~ao Paulo, Brazil; cPostgraduate Program in Health Sciences: Cardiology, Institute of Cardiology/University
Foundation of Cardiology (IC/FUC), Porto Alegre, Brazil; dPostgraduate Program in Nutrition Sciences, Federal University of Health Sciences
of Porto Alegre (UFCSPA), Porto Alegre, Brazil; eDivision of Nutrition, Dietetics of Nossa Senhora da Conceiç~ao Hospital, Porto Alegre, Brazil;
f
Department of Nutrition, Postgraduate Program in Food and Nutrition, Federal University of Paran
a, Curitiba, Brazil; gDepartment of
Nutrition, Postgraduate Program in Nutrition, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil

ABSTRACT ARTICLE HISTORY

Objective: This study aimed to evaluate the validity of calf circumference (CC) in identifying mal- Received 24 October 2019
nourished patients and patients at nutritional risk and determine the association between CC and Accepted 23 January 2020
clinical outcomes of hospitalized patients.
KEYWORDS
Methods: A prospective cohort study was conducted involving patients admitted to the emer-
Calf circumference;
gency department of a tertiary hospital in the first 48 hours of admission. Nutritional risk was nutritional assessment;
determined using Nutritional Risk Screening, malnutrition was diagnosed using subjective global mortality; length of
assessment, and CC was manually measured. Brazilian cutoff points for CC were used to identify hospital stay
low muscle mass. The outcomes of interest were length of emergency care and hospital stay,
occurrence of infection, and death, besides nutritional risk and malnutrition.
Results: In total, 528 patients (52.76 ± 16.18 years; 54.6% females) were followed up for 9.0
(3.0–19.0) days; 39.6% of them had reduced CC values. The accuracy of CC in identifying patients
at nutritional risk and malnourished patients was 67.7% and 54.1%, respectively. The cutoff value
of 36.5 cm was highly accurate in identifying nutritional risk [AUC-ROC curve ¼ 0.764 (95% CI:
0.704–0.825) for men, and AUC-ROC curve ¼ 0.716 (95% CI: 0.659–0.774) for women]. Patients
with low CC had a 1.59-fold (95% CI: 1.07–2.36) greater likelihood of a long hospital stay than
patients with normal CC.
Conclusions: Low CC values have satisfactory validity in identifying nutritional risk and are associ-
ated with long hospital stay.

Introduction cutoff point of 33 cm for women and 34 cm for

Malnutrition is prevalent in hospitalized patients, at a rate
of 20%–50% (1), depending on the patient’s country of resi-
dence and clinical condition (2). Malnutrition has been asso-
ciated with a long hospital stay, high risk of infection, high
rate of hospital readmission, and high hospital costs (3–6).
Malnutrition is characterized by changes in body compos-
ition, including loss of lean mass (7) due to the release of
cytokines and poor immunity (8), with consequent reduc-
tion in the ability to perform basic functional activities (9).
Therefore, in clinical practice, determining muscle mass
is important to correctly diagnose malnutrition. In this
regard, calf circumference (CC) is a simple, noninvasive,
and cheap measurement (10) that reflects body muscle mass
(11). The performance of CC as a predictor of lean mass
loss depends on the cutoff point, which varies among popu-
lations. In a study involving French women aged 70 years or
above, the value of 31 cm was defined as a cutoff point for
identification of lean mass loss (12). A study conducted in
the South of Brazil involving elderly individuals defined a
men (13).
Some studies have shown that CC can be an accurate
predictor of muscle mass loss (14), sarcopenia (15), nutri-
tional risk (16), low disability (17), death (18–20), and hos-
pital readmission (21). A study involving 108 consecutive
patients with esophageal and gastric cancer showed that low
CC was associated with low skeletal muscle mass index (22).
Most previous studies involved elderly outpatients using dif-
ferent cutoff points to define loss of muscle mass. A pro-
spective longitudinal study involving the Brazilian
population, using cutoff values, showed that patients with
low CC had a 3.89-fold higher risk of hospital readmission
in 30 days (21). To the best of our knowledge, there is no
study on the performance of the Brazilian cutoff point for
CC in predicting malnutrition, length of hospital stay, and
death in hospitalized patients. Therefore, the aim of this
study was to determine the association between low CC and
nutritional risk, malnutrition, and poor clinical outcomes
(long duration of emergency care and hospital stay,

CONTACT Fl
avia Moraes Silva flaviams@ufcspa.edu.br Departamento de Nutriç~ao, Universidade Federal de Ci^encias da Sa

ude de Porto Alegre, Rua
Sarmento Leite, 245, Centro Hist

orico, Porto Alegre, RS 90050-170, Brazil
ß 2020 American College of Nutrition
2 M. TARNOWSKI ET AL.
occurrence of infection, and death) in patients admitted to
the emergency department of a public hospital.
Materials/subjects and methods
This was a prospective cohort study involving patients
admitted to the emergency department of a tertiary public
hospital in Porto Alegre (Rio Grande do Sul, Brazil) that
aimed to compare the predictive and concurrent validity of
different screening nutritional tools. Three trained clinical
dietitians performed data collection between September 2013
and January 2015. The Ethics Committee of the hospital
approved the study protocol (approval number 360.639),
and all patients granted written informed consent. This
research was conducted according to the guidelines of the
Declaration of Helsinki and Brazilian regulations on ethical
issues in research involving human subjects. The protocol
has been described previously (23).
Briefly, the participants were consecutively selected from
among the patients admitted to the emergency department
during the study period, namely patients aged >18 years,
who were conscious and able to move. Data were collected
within 48 hours of hospitalization. Sociodemographic data
including gender, age, and ethnicity were collected. Hospital
admission date, reason for admission, and medical history
were obtained from electronic medical records. Nutritional
risk screening was performed with the Nutritional Risk
Screening (NRS-2002) tool and patients were classified as at
nutritional risk or not at nutritional risk (24). The subjective
global assessment (SGA) was used for nutritional diagnosis,
and patients were classified as well nourished, moderately
malnourished, or severely malnourished, as proposed by
Detsky et al. The metabolic demand of a disease was classi-
fied as mild, moderate, or severe (25). Anthropometric
measurements, i.e., height, weight, and CC, were manually
recorded, with patients instructed to wear as little clothing
as possible and no shoes. The CC was measured using an
inelastic tape at the point of the greatest CC in patients
without edema.
In the current study, only the data of patients whose CC
measures were available were analyzed. CC values equal to
or below the cutoff points of 34 cm for men and 33 cm for
women were defined as low CC (13). The clinical outcomes
of interest were length of emergency care and hospital stay,
occurrence of infection registered in the medical records,
and death. We also reported as outcomes the presence of
nutritional risk and malnutrition.
Data analysis was performed using the SPSS software,
and p values <0.05 were considered significant. Quantitative
variables were expressed as mean and standard deviation or
median and interquartile range, and categorical variables
were expressed as absolute and relative frequencies.
Student’s t-test, Mann–Whitney U test, or Chi-square test
was performed to compare the outcomes/features of patients
with low and normal CC. The area under the ROC curve
was calculated to evaluate the performance of CC in identi-
fying malnutrition, considering the Brazilian cutoff points,
with CC as a continuous variable. Logistic regression was
performed to evaluate the association between low CC and
length of hospital stay, and Cox regression was performed
to evaluate the association between low CC and death. Age
and metabolic demand of the disease were considered con-
founders, and the analysis was adjusted for these variables.
Results
A total of 752 patients were considered eligible, but 224
(29%) of them were not included in the analysis because
they had edema in lower limbs, limiting the measurement of
the CC. Therefore, the current study included 528 patients
aged 52.76 ± 16.18 years. Most of them self-reported as white
(85.4%), and half of the study population comprised women
(54.6%). The most common reasons for hospitalization were
gastroenterological disorders (21.0%), cancer and related
complications (18.6%), cardiac diseases (11.8%), and neuro-
logic diseases (9.0%); 42.9% of the patients had a disease
resulting in high metabolic demand.
Those not included in the analysis were significantly
younger those included (55.88 ± 13.35 versus
52.76 ± 16.18 years, respectively). Gender, frequency of mal-
nutrition diagnosis, length emergency care and hospital stay,
frequency of infection, and death rate did not differ between
the groups (p > 0.05 for all analyses [data not shown]).
The length of emergency care was 3.0 (2.0–5.0) days and
hospital stay was 9.0 (3.0–19.0) days. The death rate was
3.9%. Occurrence of infection was reported in the medical
records of 32.5% of the study sample.
The mean values of current weight and body mass index
(BMI) of the patients were 70.92 ± 16.75 kg and
27.29 ± 5.93 kg/m2, respectively. The mean CC was
36.71 ± 12.85 cm for men and 35.74 ± 5.34 cm for women
(p ¼ 0.205). About 30.0% of the patients were at nutritional
risk according to the NRS-2002. According to the SGA,
65.9% of the patients were classified as well nourished,
24.8% of patients, as moderately malnourished, and 9.4%, as
severely malnourished. Considering the cutoff points of CC
for both genders, 39.6% of the patients had low CC values.
The frequency of low CC values was higher in patients at
nutritional risk than in those who were not at nutritional
risk (64.9% vs. 29.6%, respectively, p < 0.001). The area
under the ROC curve regarding the performance of CC in
identifying patients at nutritional risk was 0.677 (95% CI:
0.626–0.728; p < 0.001), with 64.9% sensitivity and 70.4%
specificity. When CC was considered a continuous variable
in the ROC curve, the area under the ROC curve improved
for both men (area under the ROC curve ¼ 0.764; 95% CI:
0.704–0.825) and women (area under the ROC curve ¼
0.716; 95% CI: 0.659–0.774). For a high sensitivity and
acceptable specificity (>50%), the cutoff point of CC should
be 36.5 cm both for men (sensitivity ¼ 79.8%; specificity ¼
52.8%) and for women (sensitivity ¼ 77%; specificity
¼ 53.9%).
The frequency of low CC values was higher in malnour-
ished patients than in well-nourished patients, but it did not
reach statistical significance (45.3% vs. 37.2%, respectively;
p ¼ 0.070). The performance of CC in identifying
 JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 3

Table 1. Features of Patients According to Calf Circumference Classification. Table 2. Multivariate Analysis of the Association between Calf Circumference
Low CC Normal CC and Clinical Outcomes.
Feature (n ¼ 209) (n ¼ 319) p value Longer hospital stay (>16 days)
Age (years) 55.37 ± 17.15 50.87 ± 15.28 0.0021 OR (95% CI)1 p value
BMI (kg/m2) 30.96 ± 5.63 22.78 ± 3.87 <0.0011 Low CC (crude) 1.65 (1.11–2.43) 0.012
Nutritional risk (NRS-2002) 48.8% 17.5% <0.0012 Low CC (adjusted) 1.59 (1.07–2.36) 0.023
Malnutrition (SGA) 39.7% 32.3% 0.0612 Mortality
Metabolic demand of disease
Low 11.1% 10.8% HR (95% CI)2 p value
Moderate 37.0% 52.2% 0.0022 Low CC (crude) 2.16 (0.82–5.73) 0.121
High 51.9% 37.0% Low CC (adjusted) 2.02 (0.76–5.36) 0.160
Emergency department LOS 3.0 (2.0–5.0) 3.0 (2.0–4.25) 0.8373 Abbreviations: CC ¼ calf circumference, OR ¼ odds ratio, HR ¼ hazard ratio.
Hospital LOS 10.0 (4.0–21.0) 7.0 (3.0–16.0) 0.0083 1
Logistic regression.
Longest hospital stay (16 days) 34.4% 26.6% 0.0102 2
Cox regression.
Occurrence of infection 34.0% 31.9% 0.6352 Adjusted for age and stress of disease.
Death 6.2% 2.2% 0.0332
Abbreviations: CC ¼ calf circumference, BMI ¼ body mass index, NRS-
2002 ¼ nutritional risk screening, SGA ¼ subjective global assessment, specificity of 71.4% for a CC of <32.5 cm in identifying a
LOS ¼ length of stay. high score of NRS-2002 (16). However, the applicability of
1
Student’s t-test.
2
Chi-square test. CC in clinical practice is questionable since it requires an
3

Mann–Whitney U test. accuracy of at least 75%, which was probably was not
CC < 34 cm for men and < 33 cm for women. reached because CC reflects only the muscle mass (26) and
does not take into account other aspects related to nutri-
malnourished patients was not satisfactory because the area tional status (27). It should be further tested in a representa-
under de ROC curve was 0.541 (95% CI: 0.489–0.593; tive sample of hospitalized adults. The use of CC as a
p ¼ 0.125), which did not improve when CC was considered nutritional screening tool could be interesting. In our other
a continuous variable (data not shown). recent study that developed and validated a new screening
Table 1 describes the general and clinical features of tool for identifying the risk of malnutrition among patients
patients according to CC classification. The frequency of in the emergency department (NRE-2017), muscle mass loss,
occurrence of infection did not differ between patients with determined by physical examination, was a predictor of high
normal and low CC values. The frequency long hospital stay NRE-2017 scores (28). This should also be confirmed in
future studies.
was higher among those with low CC values than among
In the present study, low CC values were not able to effi-
those with normal values as was the frequency of death.
ciently identify malnutrition. A study involving 1164
Table 2 presents the strength of the association between CC,
Japanese elderly patients showed a good accuracy of CC in
long hospital stay, and death. The odds of long hospital stay
predicting malnutrition according to the ESPEN diagnostic
were 1.6-fold greater for patients with low CC than for those
criteria for malnutrition in both women (CC ¼ 26.4 cm;
with normal CC. When CC was considered a continuous
AUC ¼ 0.79; 95% CI: 0.76–0.83) and men (CC ¼ 28.3 cm;
variable in the Cox regression adjusted for age and meta-
AUC ¼ 0.83; 95% CI: 0.80–0.87) (14). However, the cutoff
bolic demand, it was inversely associated with the risk of
point used by the authors was lower than that adopted in
death (HR ¼ 0.864; 95% CI: 0.786–0.949; p ¼ 0.002). The
the current study and the reference diagnostic method pro-
analysis was also performed considering the cutoff point of posed by the ESPEN. A previous study stated that the
36.5 cm, but it was not a significant predictor of long hos- ESPEN criteria might not have satisfactory concurrent valid-
pital stay or death (data not shown). ity when considering the SGA as reference method (29).
Malnutrition is a complex condition that involves changes
Discussion in muscle and fat mass, biochemical parameters, food con-
sumption, functional capacity, and inflammation status (30).
The current study evaluated the performance of CC in iden- Although low CC is notably an important factor in the diag-
tifying patients at nutritional risk and malnourished patients nosis of malnutrition, representing a phenotypic criterion
and in predicting clinical outcomes of patients admitted to according to the Global Leadership Initiative on
the emergency department of a public hospital. CC values of Malnutrition group, it needs to be combined with an etio-
<36.5 cm showed satisfactory validity in identifying patients logic criterion, such as reduced food intake or assimilation,
at nutritional risk, but not malnutrition. On the other hand, disease burden, or inflammation, to result in a confirmed
patients with low CC (considering the Brazilian cutoff diagnosis (31). Furthermore, our study involved adults and
points) had higher odds of long hospital stay than patients elderly patients in whom loss of lean mass is a physiological
with normal CC. finding related to aging, and the elderly are expected to have
The low CC values had an accuracy of 67% in identifying lower CC values than adults, which can impact
patients at nutritional risk in the current study, improving the outcomes.
discretely with the cutoff point of 36.5 cm. This performance Several studies have investigated the performance of CC
was similar to that reported in another Brazilian study as a predictor of mortality and survival (18–20, 32–34). In
involving patients with cancer that reported an area under the present study, low CC was not a predictor of death after
the ROC curve of 0.66, with a sensitivity of 62.7% and adjustment for age and disease-related metabolic demand,
4 M. TARNOWSKI ET AL.
probably due to the small number of individuals who died
(it may lack statistical power). In a cohort study involving
599 Japanese elderly patients with cardiovascular disease,
low CC values were associated with short survival time, but
they did not predict mortality in a multivariate analysis (33).
In another cohort study involving 104 non-hospitalized
patients with chronic obstructive pulmonary disease
(COPD), low CC (<30 cm) was positively associated with a
4.5-fold increase in mortality. The small number of deaths
in our study could be explained by the low cutoff point
used, age of patients, and severity of disease (68.2% of the
sample had severe COPD) (32).
In the present study, low CC was a good predictor of
long hospital stay, increasing by 1.59 times, the odds of a
hospital stay longer than 16 days – this cutoff point was con-
sidered important because a national multicenter study dem-
onstrated that this period of hospitalization increased the
odds of being diagnosed with malnutrition (35). On the
other hand, in a prospective cohort study involving 733
Canadian patients, CC was not a significant predictor of
long hospital stay (OR 0.98, 95% CI; 0.95–1.00) (34). In our
study (36), hospitalization for seven or more days was con-
sidered long hospital stay, which could explain the contrast-
ing results. Recently, a Brazilian study showed a 3.89-fold
increase in the risk of hospital readmission in 30 days
among patients with low CC values, using the same cutoff
points that we used in the present study (21). Individuals
with low CC in our study seemed to be more unwell than
those with high CC, requiring more medications and overall
care (contributing to prolonged hospitalization but
not death).
CC is a noninvasive measurement that is simple and
cheap to perform, and it reflects body muscle mass (10, 13).
However, it cannot be performed in the presence of edema
since it may lead to overestimated measures. In the current
study, 29% of the sample had edema and hence were not
included in the study. These patients were older than the
patients studied, so our results should be interpreted with
caution even though we considered age as a confounder in
the multivariate analysis. Furthermore, it is important to
reinforce that the cutoff points of CC used in the current
study were established for older people, which may not be
sufficiently accurate for adults aged 18 years or older.
Further studies are needed to confirm this speculation. A
limitation of the current study is that disease severity was
assessed using scoring systems, such as Charlson comorbid-
ity index. We considered the metabolic demand of the dis-
ease as an indirect marker of severity, but we recognize the
drawbacks of this method. Therefore, the results of our
multivariate analysis should be interpreted with caution.
According to our results, low CC (34 cm for men and
33 for women) should be considered a predictor of poor
outcomes in patients admitted to the emergency department,
since it was associated with long hospital stay, regardless of
the patients’ age and metabolic demand. Also, measuring
CC could be an easy and cheap way to identify nutritional
risk during hospital admission. These results need to be con-
firmed with further studies involving hospitalized patients.
In addition, repeated measurements of CC during hospital-
ization could help determine muscle mass loss and predict
poor outcomes, albeit warranting further studies.
Conclusions
Low CC values showed satisfactory validity in identifying
nutritional risk and were associated with long hospital stay.
Further studies should investigate the validity of CC as a
prognostic marker for patients admitted in the emergency
department considering the cutoff points applied in
this study.
Author contributions
F.M.S., A.M., J.F., E.R. contributed to conception and design of the
study. F.M.S. and J.F. contributed to acquisition of the data. F.M.S.
analyzed the data. M.T., E.S., and F.M.S. interpreted the results and
draft the manuscript. All authors critically revised the manuscript, gave
final approval and agree to be accountable for all aspects of work
ensuring integrity and accuracy.
Disclosure statement
The authors declare no conflict of interest.
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