Heart Failure: Correlation between Anthropometric Parameters, Body Composition and Cell Integrity

Abstract

Background:

Knowledge about phase angle and its use as a prognostic determinant in patients with heart failure is still scarce.

Objective:

To evaluate the correlation between anthropometric indicators, cardiac function and cell integrity in patients with heart failure with reduced ejection fraction.

Methods:

This was a cross-sectional study that evaluated patients with heart failure with reduced ejection fraction by anthropometry and bioelectrical impedance analysis. Chi-square test and Student's t test were used to analyze differences, and Pearson's linear correlation was used to evaluate associations, using p < 0.05 to indicate statistical significance.

Results:

We evaluated 41 subjects aged 30-74 years, of which 34 were men (82.9%). Mean phase angle was higher among women (7.1%), but significant differences between men and women were found only for body fat percentage. Phase angle correlated with body mass index (r = 0.44, p = 0.004) and there was a trend of correlation of the phase angle with waist-to-height ratio (r = 0.29, p = 0.06) and the left ventricular ejection fraction (r = 0.29, p = 0.07).

Conclusions:

Phase angle showed a good correlation with body mass index and showed a trend of correlation with the left ventricular ejection fraction, supporting the obesity paradox and the prognostic importance of this marker. Further studies on the applicability of the phase angle in the prognosis of these patients are still needed.

Keywords:
Heart Failure; Body Composition; Obesity; Stroke Volume; Body Mass Index

Resumo

Fundamentos:

O conhecimento do ângulo de fase e seu uso como determinante prognóstico em pacientes com insuficiência cardíaca ainda é escasso.

Objetivo:

Avaliar a relação entre indicadores antropométricos, função cardíaca e integridade celular em pacientes com insuficiência cardíaca com fração de ejeção reduzida.

Métodos:

Trata-se de um estudo transversal que avaliou pacientes com insuficiência cardíaca com fração de ejeção reduzida por meio da antropometria e da bioimpedância elétrica. Foram empregados os testes do Qui-quadrado e teste t de student para analisar as diferenças e a correlação linear de Pearson para avaliar associação, adotando p < 0,05 para indicar significância estatística.

Resultados:

Foram avaliados 41 indivíduos, com idade entre 30-74 anos, sendo 34 homens (82,9%). O ângulo de fase mostrou-se com maior média entre as mulheres (7,1°), porém houve diferença estatisticamente significativa entre os sexos apenas para as médias do percentual de gordura. O ângulo de fase correlacionou-se com o índice de massa corporal (r = 0,44; p = 0,004) e houve uma tendência na correlação do ângulo de fase com a razão cintura/estatura (r = 0,29; p = 0,06) e fração de ejeção do ventrículo esquerdo (r = 0,29; p = 0,07).

Conclusões:

O ângulo de fase apresentou boa correlação com o índice de massa corporal e mostrou uma tendência de correlação com a fração de ejeção do ventrículo esquerdo, sustentando o paradoxo da obesidade e a importância prognóstica deste marcador. Ressalta-se ainda, a necessidade de novos estudos sobre a aplicabilidade do ângulo de fase no prognóstico nesta população.

Palavras-chave:
Insuficiência Cardíaca; Composição Corporal; Obesidade; Volume Sistólico; Índice de Massa Corporal

Introduction

Systemic arterial hypertension (SAH) and coronary artery disease (CAD) are common causes of heart failure (HF). One of their main risk factors is obesity, which causes several adverse effects to health, particularly to cardiovascular health.¹

According to the International Diabetes Federation (IDF),² although increased body mass index (BMI) may lead to these conditions, excessive abdominal fat, estimated by waist circumference (WC), is the main indicative of metabolic syndrome. Therefore, central body fat has been increasingly recognized as an independent risk for cardiovascular disease (CVD).³

On the other hand, in established HF, mild to moderate overweight has been associated with a substantial increase in survival as compared with normal weight individuals, the so called "obesity paradox".^1,4 One of the several theories that may explain such paradox is the fact that excessive adipose tissue provides greater storages that may exert a protect role against disease-related metabolic changes that may lead to cardiac cachexia. Cardiac cachexia is a syndrome that involves progressive weight loss and changes in body composition, bearing a devastating prognosis for HF patients.⁴

Besides, most data related to this paradox identify obesity by BMI,⁴ which although is the most widely used method in nutritional assessment, does not clearly reflect individual's body composition, and has a relatively low sensitivity in predicting excessive body fat.⁵ In this context, other nutritional assessment methods may be used, such as densitometry by dual-energy X-ray absorptiometry (DXA) and computed tomography (CT). These methods, however, although more accurate, are also more costly and complex.⁶

When these recommended methods are not available, some anthropometric measures and indexes seem to be good alternatives for estimating body composition. In addition to WC, the conicity index (C-index), proposed by the World Health Organization (WHO) to evaluate obesity and body fat distribution is of equal importance.⁷ Also, waist-to-height ratio (WHtR), which is based on the assumption that for each height, there is an acceptable level of fat stored in the upper body, has also a good relationship with central body fat.⁸

Bioelectrical impedance analysis (BIA) has also been widely used, especially due to the high data processing speed, its non-invasiveness, easiness of use and relatively low cost. BIA provides estimates of fat mass and fat-free mass components using predictive equations, and of phase angle (PA).^9,10

Left ventricular ejection fraction (LVEF) is another parameter to be evaluated in these patients due to its prognostic importance. Its reduction is associated with lower survival, and distinction of HF patients with (HFREF) and without reduced ejection fraction is increasingly required because of different clinical manifestations and forms of treatment for each case.¹¹

Therefore, due to the association between obesity and cardiovascular changes, assessment of HFREF by methods that estimate not only total fat, but also central fat, is extremely relevant. Besides, the applicability of PA in HF has not been well established in the literature.

Thus, the aim of the present study was to evaluate the relationship between anthropometric indicators, cardiac function and cell integrity in HFREF.

Methods

This was a cross-sectional study of patients treated at the Heart Failure Outpatient Center of Pedro Ernesto University Hospital.

A convenience sample was used, and HFREF of both sexes, aged from 18 to 74 years were considered eligible. Exclusion criteria were patients with clinical evidence of edema and ascites, amputee patients and patients using pacemakers. Patients with a BMI lower than 16 kg/m² or greater than 34 kg/m² were also excluded, because estimation of body composition by most of BIA predictive equations using these BMI values is not considered reliable.¹² We also excluded patients who did not meet the standardized BIA protocol, and those with a higher percentage of extracellular water compared with intracellular water, indicating a water imbalance that had not been identified at the physical exam,⁹ and patients with an electrocardiography performed longer than one year before the date of the anthropometric assessment.

Outcome measures were: sex, age, LVEF (electrocardiography), etiology of the disease, functional class (New York Heart Association, NYHA),¹³ comorbidities, previous myocardial revascularization surgery (MRS), valve replacement, stent implantation, acute myocardial infarction (AMI), and anthropometric parameters (body mass, kg; height, m; WC, cm; BMI, kg/m²; WHtR and C index), measured by one trained examiner.

Body mass was measured using a digital medical scale (Welmy®) with maximum capacity of 200 kg at the nearest 0.1kg. Height was measured to the nearest 0.1 cm using a wall mounted stadiometer (Sanny®, 220 cm). Measurements were performed as proposed by Lohman et al.¹⁴

WC was measured using an inelastic tape at the nearest 0.1 mm, according to the IDF criteria.¹⁵ Patients were divided into the following groups - WC ≥ 80 cm and < 80 cm for women; WC ≥ 90 cm and < 90 cm for men.

WHtR was calculated by dividing WC (cm) by height (cm), and the cutoff points adopted were 0.52 for men and 0.53 for women. C-index was obtained according to the equation proposed by Valdez,¹⁶ with the cutoff points of 1.25 and 1.18 for men and women, respectively. The WHtR and the C-index cutoff points indicating an increased coronary risk were defined based on the study by Pitanga and Lessa.¹⁷

Nutritional diagnosis was determined by BMI, which was calculated by dividing body mass by height squared and classified according to the WHO criteria.¹⁸

Body composition and cell integrity were evaluated by tetrapolar BIA (Biodynamics 450®), according the Brazilian Medical Association criteria.¹² BIA results of PA and body fat percentage (BF%) were used for analyses. For BF% classification, we used the cutoff points of 25% for men and 32% for women.¹⁹

The study was approved by the Research Ethics Committee of the institution (approval number 47828915.3.0000.5259). All patients were informed about the study's purpose, and signed an informed consent form before being included, as volunteers, in the study.

Statistical analysis

Normality of the variables was tested by the Kolmogorov-Smirnov test. Descriptive statistics was used for characterization of the sample. Continuous variables were expressed as mean and standard deviation (±SD); the Student's t-test and the Pearson correlation were used to analyze differences and correlations between independent samples, respectively. Categorical variables were expressed as percentage, and associations between them were analyzed by the chi-square test or the Fisher's exact test. Analyzes were performed using the STATA 14 softwae, and statistical significance was set at p < 0.05.

Results

In the present study, 41 volunteers of both sexes (n = 34, 82.9% were men) aged 61 ± 10.8 years were studied.

The most common comorbidity was SAH (n = 33; 80.5%), followed by DM (n = 21, 51.2%), chronic kidney disease (n = 3; 7.3%) and chronic obstructive pulmonary disease (n = 3, 7.3%).

With respect to HF classification, NYHA functional class I was the most prevalent (n = 18, 43.9%), and 34.1% (n = 14) of patients had ischemic HF. Eighteen (43.9%) patients had previous AMI, 14.6% (n = 6) had previous MRS, 9.8% (n = 4) had previous valve replacement, and 21.9 (n = 9) had previous stent implantation. No differences were found between men and women, except for the prevalence of DM, which was higher in women (n = 6, 85.7%) than men (n = 15, 44.1%) (Table 1).

Table 1
Comorbidities, heart failure etiology, New York Heart Association (NYHA) functional class, previous acute myocardial infarction and previous surgeries by sex in the study population (n = 41)

	Men (n=34)	Women (n=7)	Total (n=41)	p-value*
	n (%)	n(%)	n(%)
Comorbidities
SAH	27 (79.4)	6 (85.7)	33 (80.5)	0.7
DM	15 (44.1)	6 (85.7)	21 (51.2)	0.04
CKD	2 (5.9)	1 (14.3)	3 (7.3)	0.4
COPD	3 (8.8)	0 (0.0)	3 (7.3)	0.4
HF etiology
Ischemic	12 (35.3)	2 (28.6)	14 (34.1)	0.7
Non-ischemic	22 (64.7)	5 (71.4)	27 (65.9)
FC (NYHA)
I	16 (47.1)	2 (28.6)	18 (43.9)
II	11 (32.3)	2 (28.6)	13 (31.7)	0.2
III	7 (20.6)	2 (28.6)	9 (22.0)
IV	0 (0.0)	1 (14.2)	1 (2.4)
AMI
Yes	16 (47.1)	2 (28.6)	18 (43.9)	0.4
No	18 (52.9)	5 (71.4)	23 (56.1)
Surgery
MRS	6 (17.6)	0 (0.0)	6 (14.6)	0.2
VR	3 (8.8)	1 (14.3)	4 (9.8)	0.7
Stent implantation	8 (23.5)	1 (14.3)	9 (21.9)	0.6

• ^*
  comparison between men and women. SAH: systemic arterial hypertension; DM: diabetes mellitus; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; HF: heart failure; FC: functional class; AMI: acute myocardial infarction; MRS: myocardial revascularization surgery; VR: valve replacement

Regarding the anthropometric variables, BF% was significantly lower in men (mean of 27.2%) than women (mean of 35.8%). No differences were found in the other anthropometric parameters between men and women. PA (7.1º ± 1.4), estimated by BIA, and LVEF (37.4%) were higher in women than men, with no significant difference though. Clinical and anthropometric characteristics of the study population are described in Table 2.

Table 2
Clinical and anthropometric variables of the study population, by sex

Variables	Men (n = 34)	Women (n = 7)	Total (n = 41)	p-value *
	Mean (±SD)	Mean (±SD)	Mean (±SD)
Age (years)	60.5 (11.3)	63 (8.7)	61 (10.8)	0.29
BMI (Kg/m2)	26.4 (3.4)	26.5 (4.8)	26.4 (3.6)	0.48
WC (cm)	96.8 (11.4)	93.6 (13.0)	96.3 (11.6)	0.26
WHtR	0.57 (0.06)	0.61 (0.1)	0.57 (0.07)	0.05
C-index	1.32 (0.09)	1.35 (0.08)	1.32 (0.09)	0.22
BF%	27.2 (4.3)	35.8 (4.6)	28.7 (5.4)	< 0.001
PA (º)	6.7 (1.0)	7.1 (1.4)	6.8 (1.1)	0.18
LVEF (%)	34.5 (8.6)	37.4 (7.3)	35.0 (8.4)	0.21

• ^*
  comparison between men and women. SD: standard deviation; BMI: body mass index; C-index: conicity index; WC: waist circumference; WHtR: waist‑to-height-ratio; BF%: body fat percentage; PA: phase angle; LVEF: left ventricular ejection fraction

Mean BMI was 26.4 ± 3.6 Kg/m², with no difference between men (26.4 ± 3.4 Kg/m²) and women (26.5 ± 4.8 Kg/m²) (Table 2). Most participants were overweight (41.5%), followed by normal weight (39.0%) and obese subjects (19.5%).

Anthropometric indicators of obesity (Table 3) showed that 61.8% of men and 57.1% of women were overweight/obese, and 100% of women and 91.2% of men were at increased risk according to the C-index (totaling 92.7% of the study population). According to WC, 82.4% of men and 85.7% of women were at increased risk, and 76.5% of men had increased WHtR. With respect to BF%, 67.7% of men and 71.4% of women were obese. No statistically significant difference in any of the indicators was found between men and women.

Table 3
Obesity anthropometric indicators in the study population by sex

Variables	Men	Women	Total	p-value*
	n(%)	n(%)	n (%)
BMI
Normal weight	13 (38.2)	3 (42.9)	16 (39.0)	0.09
Overweight/obesity	21 (61.8)	4 (57.1)	25 (61.0)
C-index
Normal	3 (8.8)	0 (0.0)	3 (7.3)	0.4
Increased	31 (91.2)	7 (100.0)	38 (92.7)
WC
Normal	6 (17.6)	1 (14.3)	7 (17.1)	0.8
Increased	28 (82.4)	6 (85.7)	34 (82.9)
WHtR
Normal	8 (23.5)	2 (28.6)	10 (24.4)	0.8
Increased	26 (76.5)	5 (71.4)	31 (75.6)
BF%
Normal	11 (32.3)	2 (28.6)	13 (31.7)	0.8
Obesity	23 (67.7)	5 (71.4)	28 (68.3)

• ^*
  comparison between men and women. BMI: body mass index; C-index: conicity index; WC: waist circumference; WHtR: waist-to-height-ratio; BF%: body fat percentage.

Table 4 shows the correlation between obesity anthropometric indicators, PA and LVEF of the studied population. BMI showed a significant positive correlation with C-index, WC, WHtR, BF%, and PA; there was a positive significant correlation of C-index with WC, WHtR and BF%, a positive significant correlation of WC with BF% and WHtR, and between WHtR and BF%. The strongest correlations were observed of BMI with WC (r = 0.84) and WHtR (r = 0.83), of C index with WC (r = 0.80) and WHtR (r = 0.81), and between WC and WHtR (r = 0.85). PA showed a significant correlation with BMI and a marginal correlation with WHtR (r = 0.29, 0.06) and LVEF (r = 0.29, p = 0.07).

Table 4
Correlation between obesity anthropometric indicators, phase angle and left ventricular ejection fraction

	BMI	C-index	WC	WHtR	BF%	PA
BMI
C-index	(0.46)
p-value	0.002
WC	(0.84)	(0.80)
p-value	< 0.001	< 0.001
WHtR	(0.83)	(0.81)	(0.85)
p-value	< 0.001	< 0.001	< 0.001
BF%	(0.36)	(0.38)	(0.32)	(0.53)
p-value	0.02	0.01	0.04	< 0.001
PA	(0.44)	(-0.01)	(0.22)	(0.29)	(0.06)
p-value	0.004	0.95	0.17	0.06	0.7
LVEF	(0.17)	(0.12)	(0.15)	(0.17)	(0.23)	(0.29)
p-value	0.29	0.47	0.34	0.29	0.15	0.07

• BMI: body mass index; C-index: conicity index; WC: waist circumference; WHtR: waist-to-height-ratio; BF%: body fat percentage; PA: phase angle; LVEF: left ventricular ejection fraction

Discussion

Some studies have demonstrated the relationship of excess weight with left ventricular hypertrophy and concentric and eccentric remodeling, and with diastolic dysfunction followed by long-term systolic dysfunction,^20,21 indicating a direct effect of body composition on cardiovascular system.

In this context, anthropometric assessment is crucial in the clinical practice, since an early diagnosis of obesity and an adequate intervention contribute to improve patients' quality of life and prevent the worsening of health.²² Borné et al.²³ investigated 26,653 individuals aged 45-73 years and showed that increased BMI, WC and BF% increased the risk of hospitalization for HF, and that this risk was even greater with combined exposure to both increased BMI and WC.

In our study, mean BMI was 26.4 ± 3.4 Kg/m², and most patients (41.5%) were overweight. Gastelurrutia et al.²⁴ evaluated HFREF and patients without reduced ejection fraction and identified that 42% of patients were overweight and 27% were obese. Although BMI has been used as an important indicator of body composition in epidemiologic studies, individual BMI values should be interpreted with caution.¹⁰ Different from the general population, in HF patients, BMI is inversely correlated with mortality and rehospitalization.²⁵ However, some studies have shown that not only BMI but also other anthropometric variables should be used in the assessment of HF patients, for a better assessment of body compartments and central obesity.^24,26

BIA has been currently validated to estimate body composition and nutritional status in healthy individuals, and in several clinical conditions, including malnutrition and chronic diseases.⁹ The validity of its use in HF patients has been questioned, since the method is known to be influenced by the amounts of body fluids, and to not be appropriate for situations of altered hydration of tissues.^12,25 Therefore, in our study, we used standardization criteria for BIA; only stable patients participated in the study, and those with altered hydration were excluded.¹² According to BF% measured by this method, 67.7% of men and 71.4% of women were identified as obese, corresponding to the majority (68.3%) of the study population.

Central obesity indicators are positively correlated with the amount of visceral adipose tissue and cardiometabolic disorders.²⁵ Our subjects had excess central adiposity according to all indicators studies (WC, C-index and WHtR). Similar findings were reported in the study by Quirino et al.²⁷ showing that mean WC and WHtR values were higher than recommended in both men and women.

Regarding the analysis of associations between anthropometric variables, Gomes et al.²⁸ found a positive significant correlation between BMI and WC. Colombo et al.²⁹ showed that BMI had a positive significant correlation with BF%, obtained by the sum of skinfold thickness measures, and both BMI and BF% had a significant correlation with WC. These correlations were found in our study also.

Lobato et al.,³⁰ found correlations between BMI and WC, and positive significant correlations of WC with WHtR and C-index, and between WHtR and C-index. In the study by Mendes et al.,³¹ involving patients with diabetes mellitus (DM), obesity and/or SAH, BMI was positively correlated with BF% (p < 0.001) and C-index (p = 0.009).

Studies on C-index and WHtR as coronary risk predictors have been carried out in the Brazilian population and demonstrated the importance of these indicators in diagnostic assessment of patients.^15,17

We also obtained PA measures using BIA. These parameters have been increasingly used as a diagnostic tool in the clinical practice. In our study group, mean PA was 6.8º ± 1.1, with greater values in women (7.1º ± 1.4), but not significantly different than men. In healthy individuals, these values can vary from 4 to 10 degrees.⁹ When increased, PA may be associated with greater amounts of intact cell membranes, indicating adequate health status, whereas low PA values suggest worsening of disease and cell death.⁹ PA cutoff points vary between diseases - in HIV-infected patients, a PA lower than 5.3º was associated with a unfavorable prognosis,³² whereas lower survival rates were found in advanced cancer patients with PA lower than 4.4º.³³

With respect to HF, Colín-Ramírez et al.³⁴ investigated a cohort of 389 HF patients in Mexico city and demonstrated that PA is a good prognostic indicator. A PA lower than 4.2º was more strongly associated with mortality (even after adjusting for age), serum hemoglobin and presence of DM. Another study reported a significant reduction in PA values in HF patients as compared with healthy controls (5.5º vs. 6.4º).³⁵

Colín-Ramirez et al.³⁴ demonstrated the prognostic value of PA in HF patients, and showed that a lower PA was associated with markers of malnutrition, such as decreased BMI, worsening of functional class and kidney failure.

In the study by Tajeda et al.,³⁶ a lower PA (4.32º) was associated with changes in glomerular filtration rate and cardiac troponin T levels. Martínez et al.³⁷ showed that a lower PA was associated with worsening of functional class (from III to IV), even after adjusting for age and sex, and that PA values were significantly lower in patients with preserved systolic function. Colín-Ramírez et al.³⁸ evaluated patients with systolic and diastolic HF and observed that those with volume overload and anemia had reduced PA values, and such reduction was associated with thyroid disorders in the study by Silva-Tinoco et al.³⁹

In the present study, PA had a significant correlation with BMI and a marginal significant correlation with WHtR and LFEV. Therefore, the higher the BMI and WHtR, the higher the PA, indicating that excess weight and body fat could be a protective factor for HF patients, corroborating the results of previous studies on the obesity paradox.^1,4 Besides, the correlation between LVEF and PA supports the use of the latter as a prognostic indicator of HF.

The main limitation of this study was the sample size, as a larger sample size could result in stronger correlations between the variables and yield more definite results.

Conclusion

In our study, most patients had excessive total and central body fat, and correlations of BMI and C-index with WC and WHtR, and of WHtR with WC were found. Besides, there was a trend of correlation of WHtR and LVEF with PA, and a correlation between PA and BMI. We thereby demonstrate a possible example of obesity paradox. Also, we highlight the need for further studies on the use of PA in HFREF, to establish PA cutoff points and enable their application as a prognostic parameter in this population.

• Sources of Funding
  The present study had no external sources of funding.
• Study Association
  This manuscript is part of the final course work of the residency program presented to the Division of Nutrition, Pedro Ernesto University Hospital, in partial fulfillment of the requirements for the certificate in Residency in Clinical Nutrition by Tathiana Carestiato Faria.
• Ethics approval and consent to participate
  This study was approved by the Ethics Committee of the Pesquisa da Universidade do Estado do Rio de Janeiro under the protocol number 47828915.3.0000.5259. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study.

References

• ¹
  Lavie CJ, Alpert MA, Arena R, Mehra MR, Milani RV, Ventura HO. Impact of obesity and the obesity paradox on prevalence and prognosis in heart failure. JACC Heart Fail. 2013;1(2):93-102. doi: 10.1016/j.jchf.2013.01.006.
  » https://doi.org/10.1016/j.jchf.2013.01.006
• ²
  The IDF consensus worldwide definition of metabolic syndrome. International Diabetes Federation, 2006 [Acesso em 2015 maio 10]. Disponível em: http://www.idf.org
  » http://www.idf.org
• ³
  Tankó LB, Bagger YZ, Alexandersen P, Larsen PJ, Claus Christiansen C. Central and peripheral fat mass have contrasting effect on the progression of aortic calcification in postmenopausal women. Eur Heart J. 2003;24(16):1531-7. PMID: 12919778.
• ⁴
  Gupta PP, Fonarow GC, Horwich TB. Obesity and the obesity paradox in heart failure. Can J Cardiol. 2015;31(2):195-202. doi: 10.1016/j.cjca.2014.08.004.
  » https://doi.org/10.1016/j.cjca.2014.08.004
• ⁵
  Lavie CJ, Milani RV, Ventura HO, Romero-Corral A. Body composition and heart failure prevalence and prognosis: getting to the fat of the matter in the "obesity paradox". Mayo Clin Proc. 2010;85(7):605-8. doi: 10.4065/mcp.2010.0333.
  » https://doi.org/10.4065/mcp.2010.0333
• ⁶
  Rezende F, Rosado L, Franceschinni S, Rosado G, Ribeiro R, Marins JC. Revisão crítica dos métodos disponíveis para avaliar a composição corporal em grandes estudos populacionais e clínicos. Arch Latino Am Nutr. 2007;57(4):327-34.
• ⁷
  Christmann AC, Zanelatto C, Semchechem CC, Novello D, Schiessel DL. Perfil de risco de doenças cardiovasculares e estado nutricional de idosos ativos de Guarapuava - Paraná. UNOPAR Cient Ciênc Biol Saúde. 2013;15(ESP):349-56.
• ⁸
  Ho SY, Lam TH, Janus ED; Hong Kong Cardiovascular Risk Factor Prevalence Study Steering Committee. Waist to stature ratio is more strongly associated with cardiovascular risk factors than other simple anthropometric indices. Ann Epidemiol. 2003;13(10):683-91. PMID: 14599732.
• ⁹
  Eickemberg M, Oliveira CC, Roriz AK, Sampaio LR. Bioelectric impedance analysis and its use for nutritional assessments. Rev Nutr Campinas. 2011;24(6):883-93.
• ¹⁰
  Guedes DP. Clinical procedures used for analysis of the body composition. Rev bras cineantropom desempenho hum. 2013;15(1):113-29. doi: http://dx.doi.org/10.5007/1980-0037.2013v15n1p113
  » http://dx.doi.org/10.5007/1980-0037.2013v15n1p113
• ¹¹
  McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Bohm M, Dickstein K, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 (version 2012). Rev Port Cardiol. 2013;32(7-8):641.e1-641.e61.
• ¹²
  Associação Brasileira de Nutrologia. Sociedade Brasileira de Nutrição Parenteral e Enteral. Projeto Diretrizes: utilização da bioimpedância para avaliação da massa corpórea. 2009. p. 1-13.
• ¹³
  The Criteria Committee of the New York Heart Association. Diseases of the heart and blood vessels: Nomenclature and criteria for diagnosis. 6th ed. Boston (Mass): Little Brown; 1964.
• ¹⁴
  Lohman TG, Roche AF, Martorell R. Anthropometric standardization reference manual. Champaign (IL): Human Kinetics Books; 1991.
• ¹⁵
  Pitanga FJ, Lessa I. Waist-to-height ratio as a coronary risk predictor among adults. Rev Assoc Med Bras. 2006;52(3):157-61. doi: http://dx.doi.org/10.1590/S0104-42302006000300016
  » http://dx.doi.org/10.1590/S0104-42302006000300016
• ¹⁶
  Valdez R. A simple model-based index of abdominal adiposity. J Clin Epidemiol. 1991;44(9):955-6. PMID: 1890438.
• ¹⁷
  Pitanga FJ, Lessa I. Anthropometric indexes of obesity as an instrument of screening for high coronary risk in adults in the city of Salvador - Bahia. Arq Bras Cardiol. 2005;8(1):26-31. doi: http://dx.doi.org/10.1590/S0066-782X2005001400006
  » http://dx.doi.org/10.1590/S0066-782X2005001400006
• ¹⁸
  World Health Organization. (WHO). Obesity preventing and managing the global epidemic. Report of a WHO consultation on obesity. Geneve; 1998.
• ¹⁹
  Lohman TG. Advances in body composition assessment. Champaign, IL: Human Kinetics Publishers; 1992.
• ²⁰
  Neeland IJ, Gupta S, Ayers CR, Turer AT, Rame JE, Das SR, et al. Relation of regional fat distribution to left ventricular structure and function. Circ Cardiovasc Imaging. 2013;6(5):800-7. doi: 10.1161/CIRCIMAGING.113.000532.
  » https://doi.org/10.1161/CIRCIMAGING.113.000532
• ²¹
  Reis JP, Allen N, Gibbs BB, Gidding SS, Lee JM, Lewis CE, et al. Association of the degree of adiposity and duration of obesity with measures of cardiac structure and function: the CARDIA Study. Obesity (Silver Spring). 2014;2(11):2434-40. doi: 10.1002/oby.20865.
  » https://doi.org/10.1002/oby.20865
• ²²
  Moyer VA; U.S. Preventive Services Task Force. Screening for and management of obesity in adults: U.S. preventive services task force recommendation statement. Ann Intern Med. 2012;157(5):373-8. doi: 10.7326/0003-4819-157-5-201209040-00475.
  » https://doi.org/10.7326/0003-4819-157-5-201209040-00475
• ²³
  Borné Y, Hedblad B, Essén B, Engström G. Anthropometric measures in relation to risk of heart failure hospitalization: a Swedish population-based cohort study. Eur J Public Health. 2012;24(2):215-20. doi: 10.1093/eurpub/cks161.
  » https://doi.org/10.1093/eurpub/cks161
• ²⁴
  Gastelurrutia P, Lupón J, Domingo M, Ribas N, Noguero M, Martinez C, et al. Usefulness of body mass index to characterize nutritional status in patients with heart failure. Am J Cardiol. 2011;108(8):1166-70. doi: 10.1016/j.amjcard.2011.06.020.
  » https://doi.org/10.1016/j.amjcard.2011.06.020
• ²⁵
  Schommer VA, Vogel P, Marcadenti A. Antropometria, composição corporal e prognóstico em pacientes com insuficiência cardíaca. Rev Soc Cardiol Est RG Sul. 2015;28:1-7.
• ²⁶
  Puig T, Ferrero-Gregori A, Roig E, Vazquez R, Gonzalez-Juanatey JR, Pascual-Figal D, et al; REDINSCOR Researchers. Prognostic value of body mass index and waist circumference in patients with chronic heart failure (Spanish REDINSCOR Registry). Rev Esp Cardiol (Engl Ed). 2014;67(2):101-6. doi: 10.1016/j.rec.2013.06.022.
  » https://doi.org/10.1016/j.rec.2013.06.022
• ²⁷
  Quirino CS, Maranhão RV, Giannini DT. Metabolic syndrome among patients enrolled in a cardiac rehabilitation program. Rev Bras Cardiol. 2014;27(3):180-8.
• ²⁸
  Gomes MN, Maciel MG, Torres RS, Barbosa SN. Relação entre variáveis antropométricas, bioquímicas e hemodinâmicas de pacientes cardiopatas. Int J Cardiovasc Sci. 2015;28(5):392-9.
• ²⁹
  Colombo RC, Aguillar OM, Gallani MC, Gobatto CA. Obesity in patients with myocardial infarction. Rev Latino-Am Enfermagem. 2003;11(4):461-7. doi: http://dx.doi.org/10.1590/S0104-11692003000400008
  » http://dx.doi.org/10.1590/S0104-11692003000400008
• ³⁰
  Lobato TA, Torres RS, Guterres AS, Mendes WA, Maciel AP, Santos FC, et al. Anthropometric indicators of obesity among patients with acute myocardial infarction. Rev Bras Cardiol. 2014;27(3):203-12.
• ³¹
  Mendes WA, Carmin SE, Pinho PM, Silva AC, Machado LM, Araújo MS. Relationship between anthropometric variables and pressure/lipid profiles in adults with chronic non-communicable diseases. Rev Bras Cardiol. 2012;25(3):200-9.
• ³²
  Schwenk A, Beisenherz A, Römer K, Kremer G, Salzberger B, Elia M. Phase angle from bioelectrical impedance analysis remains an independent predictive marker in HIV-infected patients in the era of highly active antiretroviral treatment. Am J Clin Nutr. 2000;72(2):496-501. PMID: 10919947.
• ³³
  Lee SY, Lee YJ, Yang JH, Kim CM, Choi WS. The Association between phase angle of bioelectrical impedance analysis and survival time in advanced cancer patients: preliminary study. Korean J Fam Med. 2014;35(5):251-6. doi: 10.4082/kjfm.2014.35.5.251.
  » https://doi.org/10.4082/kjfm.2014.35.5.251
• ³⁴
  Colín-Ramírez E, Castillo-Martínez L, Orea-Tejeda A, Vázquez-Durán M, Rodríguez AE, Keirns-Davis C. Bioelectrical impedance phase angle as a prognostic marker in chronic heart failure. Nutrition. 2012;28(9):901-5. doi: 10.1016/j.nut.2011.11.033.
  » https://doi.org/10.1016/j.nut.2011.11.033
• ³⁵
  Doesch C, Suselbeck T, Leweling H, Fluechter S, Haghi D, Schoenberg SO, et al. Bioimpedance analysis parameters and epicardial adipose tissue assessed by cardiac magnetic resonance imaging in patients with heart failure. Obesity (Silver Spring). 2010;18(12):2326-32. doi: 10.1038/oby.2010.65.
  » https://doi.org/10.1038/oby.2010.65
• ³⁶
  Orea-Tejeda A, Sánchez-González LR, Castillo-Martínez L, Valdespino-Trejo A, Sánchez-Santillán RN, Keirns-Davies C, et al. Prognostic value of cardiac troponin T elevation is independent of renal function and clinical findings in heart failure patients. Cardiol J. 2010;17(1):42-8. PMID: 20104456.
• ³⁷
  Castillo Martínez L, Colín Ramírez E, Orea Tejeda A, Asensio Lafuente E, Bernal Rosales LP, Rebollar González V, et al. Bioelectrical impedance and strength measurements in patients with heart failure: comparison with functional class. Nutrition. 2007;23(5):412-8. doi: 10.1016/j.nut.2007.02.005.
  » https://doi.org/10.1016/j.nut.2007.02.005
• ³⁸
  Colín-Ramírez E, Castillo-Martínez L, Orea-Tejeda A, Asensio Lafuente E, Torres Villanueva F, Rebollar González V, et al. Body composition and echocardiographic abnormalities associated to anemia and volume overload in heart failure patients. Clin Nutr. 2006;25(5):746-57. doi: 10.1016/j.clnu.2006.01.009
  » https://doi.org/10.1016/j.clnu.2006.01.009
• ³⁹
  Silva-Tinoco R, Castillo-Martínez L, Orea-Tejeda A, Orozco-Gutiérrez JJ, Vázquez-Díaz O, Montaño-Hernández P, et al. Developing thyroid disorders is associated with poor prognosis factors in patient with stable chronic heart failure. Int J Cardiol. 2011;147(2):e24-5. doi: 10.1016/j.ijcard.2009.01.012.
  » https://doi.org/10.1016/j.ijcard.2009.01.012

Publication Dates

• Publication in this collection
  May-Jun 2018

History

• Received
  06 Apr 2017
• Reviewed
  18 Sept 2017
• Accepted
  22 Sept 2017