**2.2.3 Body mass index (BMI)**

Usually, body mass-height ratio is used as an indicator of body mass index (BMI = body mass kg/height m²).

The BMI classification is described below:


Nutritional Care in Amyotrophic Lateral Sclerosis:

% adq OW = % adequacy from the optimal weight % adq TSF = % adequacy of tricipital skinfold % adq AC = % adequacy of arm circumference

% adq AMA = % adequacy of arm muscle area

**2.3.1 Percentage of weight loss (% WL***)*

**2.4 Bioelectrical impedance analysis** 

Eutrophy: > 100%

Severe PEM: < 60%

Young; Sawka, 2002).

(Laskey, 1996).

Mild PEM: < 100% and > 80% Moderate PEM: < 80% and > 60%

% adq AMC = % adequacy of arm muscle circumference

The value obtained by PEM score allows for the classification of patients as:

using the patient's usual and current weights, as per the following equation:

An Alternative for the Maximization of the Nutritional State 599

 PEM Score= % adq OW + % adq TSF + % adq AC + % adq AMC + % adq AMA Numbers of parameters

The percentage change of usual weight or percentage of weight loss (% WL) is determined

Usual Weight – Current Weight % WL = ×100 Usual Weight

The % WL highly reflects the extent of the disease. Patients with % WL values > 10% are classified as malnourished and above 10% severe malnutrition (Mahan; Escott-Stump, 2005).

Bioelectrical impedance analysis (BIA) is a non-invasive technique that can be used to estimate body composition. The method uses low amperage current (single or multiple frequencies) that passes between two electrodes placed on the skin under the assumption that the current resistance (impedance) ranges on an inversely proportional basis to the fluid contained in the tissues and the content of electrolytes. BIA has a good correlation with body composition made with the isotope dilution, under controlled conditions (O'Brien;

In ALS, due to the limitations and difficulties during nutritional assessment, BIA has been a good tool in nutritional diagnosis. It is an easy, non-invasive technique, where fat-free and fat mass are obtained, in addition to the estimation of the degree of hydration. In 2003, the equation for BIA was validated in patients with ALS through cross-sectional and

The dual-emission X-ray absorptiometry (DEXA) is an invasive method that has become a popular measure for the assessment of body composition in developed countries (Madsen; Jensen; Sorensen, 1997; Tothill et al., 1996; Snead; Birge; Kohrt, 1993). This method allows the structural assessment of body composition, dividing the body mass by three basic components: mineral- and fat-free soft tissue, bone mineral content and fat

Some studies show the use of such technique in ALS patients (Tadan et al., 1998; Nau et al., 1995; Kanda et al., 1994), however Desport et al. (2003) emphasizes the equipment is

longitudinal studies, which was optimized at 50 kHz (Desport et al., 2003).

**2.5 Dual-emission X-ray absorptiometry (DEXA)** 

Kasarskis *et al*. (1996) confirm the correlation between reduced BMI and decreased life expectancy. In studies carried out by Mazzini *et al.* (1995), 53% of ALS patients showed BMI < 20Kg/m2 and 55% had weight loss > 15% of usual weight.

### **2.2.4 Arm circumference (AC)**

The arm circumference is measured at the non-dominant arm extended along the body, measured at the midpoint between the acromion and the olecranon process, using a flexible, non-elastic, plastic measuring tape (Lohman; Roche; Martorell, 1991). Desport; Maillot (2002) uses the AC to calculate the arm muscle circumference (AMC) and monitor the nutritional status of patients with ALS.

### **2.2.5 Skinfolds**

**Tricipital skinfold (TSF)** is determined along the longitudinal axis of the arm, on its posterior face, whereas its exact point of repair is the average distance between the superior lateral edge of the acromion and the olecranon.

**Bicipital skinfold (BSF)** is determined towards the longitudinal axis of the arm, on its anterior face, in the mid-point of the humeral biceps.

**Subscapular skinfold (SCSF)** is obtained obliquely to the longitudinal axis following the direction of the ribs, and located 2 cm distant from the lower angle of the scapula.

**Suprailiac skinfold (SISF)** is measured by slightly placing the patient's right arm behind, trying not to influence the attainment of the measure. This fold is obliquely individualized 2 cm above the anterior superior iliac crest, at the anterior axillary line.

To evaluate the AC and skinfolds, the reference standard used is the work of Frisancho (1981).

### **2.3 Classification of nutritional status**

According to the Percentile Distribution Table, the percentage of adequacy for the abovementioned parameters is calculated by considering the 50th percentile (P50) as standard.

% adequacy = studied parameter value/P50 value x 100


Values in Table 1 are used for the classification of nutritional status.

1PEM: Protein-energy malnutrition; 2AC: arm circumference; 3TSF: Tricipital skinfold.

Table 1. Classification of nutritional status according to the parameters proposed by Blackburn; Harvey (1982) and Blackburn; Thornton (1979).

For the determination of the nutritional status, the anthropometric parameters are analyzed together. The values obtained according to the percentage adequacy are classified by Protein-Energy Malnutrition (PEM) Score. The PEM Score is the sum of all parameters of nutritional assessment in percentage adequacy divided by the number of parameters assessed (Blackburn; Harvey, 1982).

Kasarskis *et al*. (1996) confirm the correlation between reduced BMI and decreased life expectancy. In studies carried out by Mazzini *et al.* (1995), 53% of ALS patients showed BMI

The arm circumference is measured at the non-dominant arm extended along the body, measured at the midpoint between the acromion and the olecranon process, using a flexible, non-elastic, plastic measuring tape (Lohman; Roche; Martorell, 1991). Desport; Maillot (2002) uses the AC to calculate the arm muscle circumference (AMC) and monitor the

**Tricipital skinfold (TSF)** is determined along the longitudinal axis of the arm, on its posterior face, whereas its exact point of repair is the average distance between the superior

**Bicipital skinfold (BSF)** is determined towards the longitudinal axis of the arm, on its

**Subscapular skinfold (SCSF)** is obtained obliquely to the longitudinal axis following the

**Suprailiac skinfold (SISF)** is measured by slightly placing the patient's right arm behind, trying not to influence the attainment of the measure. This fold is obliquely individualized 2

To evaluate the AC and skinfolds, the reference standard used is the work of Frisancho (1981).

According to the Percentile Distribution Table, the percentage of adequacy for the abovementioned parameters is calculated by considering the 50th percentile (P50) as

% adequacy = studied parameter value/P50 value x 100

ht Eutrophy mild

110-90% 110-90%

For the determination of the nutritional status, the anthropometric parameters are analyzed together. The values obtained according to the percentage adequacy are classified by Protein-Energy Malnutrition (PEM) Score. The PEM Score is the sum of all parameters of nutritional assessment in percentage adequacy divided by the number of parameters

PEM1

90-80% 90-80% moderate PEM

> 80-70% 80-70%

severe PEM

≤ 70% ≤ 70%

direction of the ribs, and located 2 cm distant from the lower angle of the scapula.

cm above the anterior superior iliac crest, at the anterior axillary line.

Values in Table 1 are used for the classification of nutritional status.

120-110% 120-110%

1PEM: Protein-energy malnutrition; 2AC: arm circumference; 3TSF: Tricipital skinfold.

Table 1. Classification of nutritional status according to the parameters proposed by

< 20Kg/m2 and 55% had weight loss > 15% of usual weight.

**2.2.4 Arm circumference (AC)** 

**2.2.5 Skinfolds** 

standard.

AC2 TSF3

nutritional status of patients with ALS.

lateral edge of the acromion and the olecranon.

**2.3 Classification of nutritional status** 

Parameters Obesity Overweig

assessed (Blackburn; Harvey, 1982).

≥ 120% ≥120%

Blackburn; Harvey (1982) and Blackburn; Thornton (1979).

anterior face, in the mid-point of the humeral biceps.

PEM Score= % adq OW + % adq TSF + % adq AC + % adq AMC + % adq AMA

### Numbers of parameters

% adq OW = % adequacy from the optimal weight % adq TSF = % adequacy of tricipital skinfold % adq AC = % adequacy of arm circumference % adq AMC = % adequacy of arm muscle circumference % adq AMA = % adequacy of arm muscle area The value obtained by PEM score allows for the classification of patients as: Eutrophy: > 100% Mild PEM: < 100% and > 80% Moderate PEM: < 80% and > 60% Severe PEM: < 60%
