clinical use of seca mBCA

insight in medical application fields

Vertraulich | Confidential MJM/PM | 31.01.2017 | Page 2

 application fields
• Weight management
• Diabetology
• Age management
• Preventive medicine
• Clinical nutrition
• Sports medicine + rehablitation
• Cardiology
• Nephrology
• Pulmology
• Oncology
• Intensive care

• Outlook: children & elderly

MJM/PM | 31.01.2017 | Page 2

 weight management
• Multi-modal conservative treatment (+/-
pharmacotherapy)
• Bariatric surgery

 Visualization of therapy effects

 Motivation of patient

MJM/PM | 31.01.2017 | Page 3

 problem
37,6kg/m² 35,8kg/m²

good?

37,6kg/m² 36,7kg/m²

bad?

MJM/PM| 23.05.2017 | Seite 4

 problem
• Various reports suggest suboptimal weight loss in 10-30% of patients undergoing
bariatric surgery
• Number may even be higher when the amount of drop outs is accounted for

• FFM loss accounted for almost 1/3 of weight loss after RYGB surgery
• FFM preservation plays an important role in metabolic rate regulation

• Without metabolic rate regulation, weight will be regained and the surgery was for
nothing
• Without FFM preservation, the older patient will develop sarcopenia and experience
negative impacts on physical function and quality of life

Wittgrove AC. Obes Surg 2000; 10: 233–239.
Sugerman HJ. Am J Clin Nutr 1992; 55(2 Suppl.): 560S–566.
Yale CE. Arch Surg 1989; 124: 941–946.
te Riele WW. Br J Surg 2010; 97: 1535–1540.
Chaston TB. Int J Obes 2007; 31: 743–750.
Marks BL. Sports Med 1996; 22: 273–281
Miller SL. J Nutr Health Aging 2008; 12: 487–491.
Faria SL. Obes Surg 2009; 19: 856–859.
Coen PM. Diabetes Obes Metab 2016; 18: 16-23
MJM/PM| 23.05.2017 | Seite 5
 physiology
bariatric surgery

hypocaloric diet physical exercise

uncontrolled
weight loss
boosted proteolysis stimulated protein synthesis

loss of muscle mass maintained muscle mass

dropped REE stabilized REE

unhealthy
weight loss

weight regain in long term body composition maintained

De Auino LA. Obes Surg 2012; 22: 195–200.

MJM/PM| 23.05.2017 | Seite 6
Metcalf. Obes Surg 2005; 15: 183–186.
 problem
• Most patients who underwent bariatric surgery
didn’t exercise enough

• Patient reports for physical exercise can be

wrong, faked or misinterpreted

• Patient is focused on the scale alone and is

demotivated if weight loss doesn’t happen fast
enough (although FFM is preserved)

Coen PM. Diabetes Obes Metab 2016; 18: 16-23 MJM/PM| 23.05.2017 | Seite 7
 solution
medical body composition analysis

MJM/PM| 23.05.2017 | Seite 8

 solution

bad!

37,6kg/m² 35,8kg/m²

good!

37,6kg/m² 36,7kg/m²

MJM/PM| 23.05.2017 | Seite 9

 solution
bariatric surgery

hypocaloric diet + physical exercise

controlled
weight loss
quantify & qualify weight loss

control therapy and goals intervene early and adapt

visualize achievements motivate the patient

healthy
weight loss patient comes back

ongoing
healthy body composition maintained controlled
weight loss

MJM/PM| 23.05.2017 | Seite 10

 résumé
• More exercise = more preserved FFM = more
sustainable weight loss
• Medical body composition analysis can control
exercise results
• Medical body composition analysis can quantify and
qualify weight loss
• Visualization and individual goals will motivate the
patient
• Motivated patients will follow-up on therapy = more
sustainable weight loss

MJM/PM| 23.05.2017 | Seite 11

 diabetology
• Decrease of FM & VAT
• Maintenance of SMM

 Lowering and stabilizing of glucose levels and

HbA1c
 Motivation of patient

MJM/PM | 31.01.2017 | Page 12

 age management
• Hormonal Replacement Therapy (SMM, FM)
• Body Composition optimization (SMM, FM,
VAT)

 Lowering long term health risks

 Better well-being

MJM/PM | 31.01.2017 | Page 13

 preventive medicine
• Cardiovascular risk factors (VAT, FM)

 Lowering long term cardiovascular risks

 Promoting healthy life style

MJM/PM | 31.01.2017 | Page 14

 clinical nutrition
• Detection of malnutrition (FFM/SMM)
• Detection of sarcopenia (SMM)
• Follow up on interventions (SMM, FFM, FM)

 Identifying high risk patients

 Reducing costs in healthcare

MJM/PM | 31.01.2017 | Page 15

 prevalence of malnutrition
Geriatrics

Oncology
N=1886
Gastroenterology

Other medical

Cardiology

Urology

Surgery

Gynaecology

0 10 20 30 40 50 60 70

Prevalence of malnutrition [%]

Pirlich et al., “The German hospital malnutrition study,” Clinical Nutrition, Volume 25,
pp. 563-572, 2006. MJM/PM | 31.01.2017 | Page 16
challenges of malnutrition

Norman et al., “Prognostic impact of disease-related malnutrition," Clinical Nutrition,

Volume 27, No. 1, pp. 5-15, 2008.

MJM/PM | 31.01.2017 | Page 17

 costs of malnutrition
country costs per year
Germany €9 billion
CEPTON study, 2007
UK £19.6 billion
BAPEN, Elia et al., 2015
USA $157 billion
Snider et al., 2014
China $66 billion
Linthicum et al., 2015

Costs of malnutrition worldwide are the same as overweight and obesity!

MJM/PM | 31.01.2017 | Page 18

 costs of malnutrition
Costs of malnutrition:
• Hard to convince a decision maker in the hospital with the argument of increased
costs for the healthcare system
• BUT decreased length of hospital stay is an economic factor for him/her!

Norman et al., “Prognostic impact of disease-related malnutrition," Clinical Nutrition,

Volume 27, No. 1, pp. 5-15, 2008. MJM/PM | 31.01.2017 | Page 19
 sports medicine + reha
• Injury / Trauma (segmental SMM)
• Detection of exhaustion (PhA)
• Follow up during season / reha (SMM, FM)

 Quality control on intervention

 Return to former form

MJM/PM | 31.01.2017 | Page 20

 cardiology
• Chronic heart failure
• Congestion (BIVA, Fluids)
• Malnutrition (FFM/SMM)
• Cardiovascular Risk (VAT, FM)

 Early detection of congestion

 Reduction of c/v risk factors
 Treatment of malnutrition
MJM/PM | 31.01.2017 | Page 21
 Example 1 w/o BIA
• Q1 2016 • Q2 2016
• Quarterly check-up of a patient with • Quarterly check-up of the same
compensated chronic CHF patient
12 weeks

• RR 131/82mmHg, Pulse 69 bpm • RR 130/81mmHg, Pulse 68 bpm

• No signs of edema, NYHA class II • No signs of edema, NYHA class II

• Medikation ACE inhibitor, beta • Medikation ACE inhibitor, beta

blocker unchangend blocker unchangend

• Check-up next quarter • Check-up next quarter

MJM/PM| 05.10.2016 | Seite 22

 Example 1 w/o BIA
• Q2 2016 • Q2+8 weeks 2016
• Quarterly check-up of the same • Presenting problems: pronounced
patient edema of the lower extremity,
8 weeks pronounced Dyspnae at less than
ordinary activity
• RR 130/81mmHg, Pulse 68 bpm
• No signs of edema, NYHA class II
• RR 129/81mmHg, Pulse 76 bpm
• Edema, NYHA class III
• Medikation ACE inhibitor, beta
• TTE: LVEF 37% (last: 48%)
blocker unchangend

• D: acute biventricual
• Check-up next quarter
decompensation of chronic CHF
• P: Admission to hospital for
inpatient Re-compensation and
diuretics

MJM/PM| 05.10.2016 | Seite 23

 Example 1 w/ BIA
• Q1 2016 • Q2 2016
• Quarterly check-up of a patient with • Quarterly check-up of the same
compensated chronic CHF patient

• RR 131/82mmHg, Pulse 69 bpm • RR 130/81mmHg, Pulse 68 bpm

• No signs of edema, NYHA class II • No signs of edema, NYHA class II

12 weeks

ACE Inhibitor, Beta blocker unchangend ACE Inhibitor, Beta blocker, Diuretic

progressive overhydratation, occult edema, starting diuretics, follow up in 2 weeks

MJM/PM| 05.10.2016 | Seite 24
 nephrology
• Overhydration (BIVA, Fluids)
• Malnutrition (FFM/SMM)

 Detection of overhydration
 Dry weight determination
 Detection and treatment of malnutrition
 Quality indicator for dialysis
MJM/PM | 31.01.2017 | Page 25
 pulmology
• COPD – extrapulmonary symptoms (FFM/FM)
• Malnutrition + sarcopenia
• Severity and prognosis (PhA)

 Detection of malnutrition
 Treatment of malnutrition + follow up

MJM/PM | 31.01.2017 | Page 26

pulmology

MJM/PM | 31.01.2017 | Page 27

 oncology
• Malnutrition/Sarcopenia (SMM/FFM/FM)
• Sarcopenic obesity
• Severity and prognosis (PhA)
• Water retention (BIVA + Fluids)

 Detection of malnutrition/sarcopenia
 Treatment of malnutrition + follow up
MJM/PM | 31.01.2017 | Page 28
 prevalence of malnutrition
Prevalence:
40% of the cancer patients are malnourished

Metabolic cancers: high risk for sarcopenic obesity

Stratton et al., Disease-related malnutrition. An evidence based approach to treatment,

Oxon 2003, UK: CABI Publishing. MJM/PM | 31.01.2017 | Page 29
 causes for malnutrition
Causes for malnutrition:
• cancer → hypermetabolism (insulin resistance, inflammation, wasting of muscle)
• dysphagia (difficulty in swallowing) – especially in head/neck and oesophagus cancer
• malabsorption – especially in stomach, pancreatic and small bowel cancer
• loss of appetite
• pain, depression
• nausea and vomiting
• chemotherapy, adverse effects of pain medication
• diarrhea
• chemotherapy, adverse effects of various medication

MJM/PM | 31.01.2017 | Page 30

 consequences
Malnutrition influences negatively:
• response to chemotherapy
• higher numbers of dose toxicity in sarcopenic patients
• leading to termination of chemotherapy (no anti-cancer-effect)
• leading to dose reduction of chemotherapie (lesser anti-cancer-effect)
• leading to worse survival due to the adverse effects of chemotherapy
• tolerance to cancer treatment
• quality of life
• outcome (survival)

Prado, CM, et al.: Sarcopenia as a determinant of chemotherapy toxicity and time to

tumour progression in metastatic breast cancer patients receiving capecitabine
MJM/PM | 31.01.2017 | Page 31
treatment, Clinical Cancer Research 2009; 15, 8: p. 2920-2926.
 consequences
Mortality of malnutrition in cancer:
one of five cancer patients die due to malnutrition

Holm E: Stoffwechsel und Ernährung bei Tumorkrankheiten. Analysen und

Empfehlungen. Stuttgart, Thieme 2007. MJM/PM | 31.01.2017 | Page 32
 cancer & body composition
Wasting Cancers Metabolic Cancers

• Head/Neck, Lung, Stomach • Breast, Colorectal, Endometrial

• high weight loss • obesity-related
• disposition to cachexia • disposition to sarcopenic obesity
• poor survival • curative
MJM/PM | 31.01.2017 | Page 33
 sarcopenic obesity
„Hidden“ malnutrition: sarcopenic obesity
• worst outcome of all cancer populations

MJM/PM | 31.01.2017 | Page 34

 sarcopenic obesity
BCC:
• at first glance detection of malnourished patients
• effective in diagnosing sarcopenic obesity

MJM/PM | 31.01.2017 | Page 35

 ICU
• Overhydration (BIVA)
• De-escalation
• Weaning
• Malnutrition (BIVA)

 Controlled fluid de-escalation

 Detection of malnutrition
 Treatment of malnutrition + follow up
MJM/PM | 31.01.2017 | Page 36
 outlook
• Children
• Childhood obesity
• Growth restriction

• Elderly
• Malnutrition/Sarcopenia
• Dehydration

MJM/PM | 31.01.2017 | Page 37

printout

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printout

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printout

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printout

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printout

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printout

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printout

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printout

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phase Angle & BIVA

MJM/PM | 31.01.2017 | Page 46

 read a printout

Nutritional Focus:

Hydration Focus:

MJM/PM | 31.01.2017 | Page 47

 nutrition

Nutritional Focus:

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 nutrition

Name, age, height and weight of the patient, date of the measurement
• Is it the correct patient and the correct measurement you want to interpret?
• Acts as a security net to avoid mix-ups.
• Although the BMI has its obvious limits it can give a first look into the nutritional
status of the patient which the medical body composition analysis can refute or
verify.

MJM/PM | 31.01.2017 | Page 49

 nutrition

BIVA
• Gives you a first impression on the hydration status and nutritional status.
• Also verifies the plausibility of the calculated values
• The BIVA measurement counts as raw data, so even in extreme body composition
aberrations you can always rely on the BIVA and PhA measurement.

MJM/PM | 31.01.2017 | Page 50

 nutrition

PhA
• Although trained BIA users can see the PhA in the BIVA chart, in the beginning the
PhA should be the second thing to look at.
• Gives you a first impression on health status.
• If PhA is abnormal the next values will most likely give you the answer why.

MJM/PM | 31.01.2017 | Page 51

 nutrition

Body Composition Chart

• At first glance you can easily categorize your patient in the four vectors thanks to
FMI and FFMI in one graph.
• For the detailed normal ranges you can refer to the FMI and FFMI graphs.

MJM/PM | 31.01.2017 | Page 52

 nutrition

Visceral adipose tissue (VAT)

• Not only the entirety of fat is decisive, also the fat distribution is utmost
importance.
• In obese patients the amount of metabolic active VAT is a great marker to follow-
up and motivate the patient - with the comprehensive complications like
cardiovascular diseases and diabetes mellitus.
• In malnourished patients you obviously can skip this step.
MJM/PM | 31.01.2017 | Page 53
 nutrition

6. Skeletal Muscle
• FFM alone cannot distinguish between SMM and Water.
• Segmental SMM shows you the effects of physical therapy in total and for every
extremity.
• Useful for aSMMI.

MJM/PM | 31.01.2017 | Page 54

 hydration

Hydration Focus:

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 hydration

Name, age, height and weight of the patient, date of the measurement
• Is it the correct patient and the correct measurement you want to interpret?
• Acts as a security net to avoid mix-ups.

MJM/PM | 31.01.2017 | Page 56

 hydration

BIVA
• Gives you a first impression on the hydration status and nutritional status.
• Also verifies the plausibility of the calculated values
• The BIVA measurement counts as raw data, so even in extreme body composition
aberrations you can always rely on the BIVA and PhA measurement.

MJM/PM | 31.01.2017 | Page 57

 hydration

PhA
• Although trained BIA users can see the PhA in the BIVA chart, in the beginning the
PhA should be the second thing to look at.
• Gives you a first impression on health status.
• If PhA is abnormal the next values will most likely give you the answer why.

MJM/PM | 31.01.2017 | Page 58

 hydration

Fluid
• TBW, ECW and ECW/TBW give you a good overview about the characteristic of
the fluid shift and its severity

MJM/PM | 31.01.2017 | Page 59

 hydration

6. Skeletal Muscle
• When a patient suffers from peripheral edema, you saw an abnormal fluid state
under point 4., additionally the bioelectrical impedance analysis generally will
attribute this water retention in the lower extremities to the muscle mass. As a
result you will see implausible muscular legs in the BIA measurement.

MJM/PM | 31.01.2017 | Page 60

MJM/PM | 16.12.2016 | Page 61