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| ORIGINAL ARTICLE |
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| Year : 2015 | Volume
: 63
| Issue : 4 | Page : 531-536 |
Study of trends in anthropometric nutritional indices and the impact of adiposity among patients of subarachnoid hemorrhage
Sivashanmugam Dhandapani1, Ankur Kapoor1, Sachin Gaudihalli1, Manju Dhandapani2, Kanchan K Mukherjee1, Sunil K Gupta1
1 Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| Date of Web Publication | 4-Aug-2015 |
Correspondence Address:
Sivashanmugam Dhandapani
Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.162026
Background: Nutritional status and adiposity have not been studied to a significant extent in subarachnoid hemorrhage (SAH). The aim of this study was to determine the trends in anthropometric indices and assess their impact on patients with SAH.
Methods: We prospectively studied in 56 patients with SAH, the triceps skinfold thickness (TSF), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), and other factors, and their relationship to clinical vasospasm and mortality.
Results: The median MAC decreased significantly from 29.3 cm (interquartile range [IQR] 28-31 cm) at admission to 27 cm (IQR 26-29 cm) at 1-week (P < 0.001). The median TSF decreased significantly from 34 mm (IQR 30-40 mm) at admission to 30 mm (IQR 25-35 mm) at 1-week (P < 0.001). MAMC values did not show a significant change over a week. The patients who developed clinical vasospasm had significantly higher median admission TSF of 40 mm (IQR 35-45 mm), compared to the median admission TSF of 35 mm (IQR 30-40 mm) among those who did not develop vasospasm (P = 0.03). MAMC values did not differ significantly in relation to vasospasm. Patients who expired by 3 months had significantly greater fall in median MAMC values at 1-week (7.7% [IQR 5.2-11.5%]), compared to the fall in median MAMC values at 1-week among those who were alive at 3 months (2.6% [IQR 2.1-6.6%]) [P = 0.03]. However, the fall in TSF values did not differ significantly in relation to mortality. In multivariate analysis, only the admission TSF, Hunt and Hess and Fisher grades had a significant association with vasospasm. This association was independent of other prognostic factors and of each other.
Conclusion: Excessive adiposity of patients, measured as an increased TSF value, is significantly associated with clinical vasospasm independent of other prognostic factors, while fall in MAMC, indicating somatic protein catabolism, has some impact on mortality.
Keywords: Adiposity; anthropometry; mid-arm circumference; mid-arm muscle circumference; nutrition; subarachnoid hemorrhage; triceps skin-fold thickness; vasospasm
How to cite this article:
Dhandapani S, Kapoor A, Gaudihalli S, Dhandapani M, Mukherjee KK, Gupta SK. Study of trends in anthropometric nutritional indices and the impact of adiposity among patients of subarachnoid hemorrhage. Neurol India 2015;63:531-6 |
How to cite this URL:
Dhandapani S, Kapoor A, Gaudihalli S, Dhandapani M, Mukherjee KK, Gupta SK. Study of trends in anthropometric nutritional indices and the impact of adiposity among patients of subarachnoid hemorrhage. Neurol India [serial online] 2015 [cited 2023 Dec 7];63:531-6. Available from: https://www.neurologyindia.com/text.asp?2015/63/4/531/162026 |
| » Introduction | |  |
In spite of immense changes in management, the morbidity and mortality in spontaneous subarachnoid hemorrhage (SAH) are still high, and are mainly attributed to the presence of clinical vasospasm. [1] The variety of metabolic perturbations following a SAH, that occur due to sympathetic nervous system activation and the presence of a systemic inflammatory response, create a milieu of nutritional demands for neurological and systemic recovery. In addition, the energy requirement to combat the pathophysiological challenges posed by cerebral vasospasm also increases significantly. [2],[3] At the same time, the excess adipose tissue in the body per se can increase the release of fatty acids and pro-inflammatory molecules, resulting in a greater vulnerability of the brain to ischemia. [4],[5]
Despite the availability of numerous indices for the assessment of nutritional status and adiposity, there is a paucity of studies on their role in patients of SAH. Anthropometric indices are simple measures of the nutritional reserve, having the advantage of being objective, rapid, repeatable, noninvasive and inexpensive in comparison to other laboratory investigations. Mid-arm circumference (MAC) reflects the overall nutritional status, whereas triceps skinfold thickness (TSF) and mid-arm muscle circumference (MAMC) reflect body fat and somatic protein reserves, respectively. [6] This study is probably the first to evaluate the trends and impact of simple anthropometric indices on clinical vasospasm and mortality following SAH.
| » Materials and Methods | | |
All adult patients with spontaneous SAH, within 2 days of their ictus, who were admitted to the Neurosurgery Department of Postgraduate Institute of Medical Education and Research, Chandigarh, India, were included. Patients with Hunt and Hess (H and H) grade [7] of five were excluded from the study.
Patients with subarachnoid hemorrhage in a good clinical grade or those with large lobar hematomas underwent urgent computed tomography angiography (CTA). Poor grade patients were stabilized and then taken up for CTA. A ventriculoperitoneal shunt or an external ventricular drainage was performed in poor grade patients with hydrocephalus, depending on the clinical status and the amount of intraventricular bleed. Patients underwent surgical clipping or endovascular coiling as per their choice and feasibility, as early as possible. Poor grade patients were preferentially offered coiling. The management protocol included the administration of phenytoin and nimodipine, cardiovascular monitoring, and maintenance of fluid and electrolyte homeostasis. Induced hypertension was employed during the period of symptomatic vasospasm after ensuring aneurysmal occlusion. Enteral feeding was initiated either through a nasogastric tube or orally as early as possible, and the volume of feed increased gradually according to the gastric tolerance so that total nutritional supplementation was achieved by 1-week.
Anthropometric nutritional indices [6] were measured at admission and later at 1-week. A non-stretchable measuring tape was used to measure the MAC in cm from the midpoint between the acromion and olecranon processes of the non-dominant arm with the forearm flexed at 90° and the mean of three measurements were recorded. TSF (in mm) was noted from the mean of three measurements taken with McGay caliper applied over a pinch of skin and subcutaneous fat around the same point. MAMC was calculated from MAC and TSF, providing an index of muscle mass (MAMC [cm] = MAC [cm] - {3.14 × TSF [cm]}).
The basic demographic data of patients, associated serious systemic diseases (inadequately treated or severe hypertension or diabetes mellitus), the H and H grade and computed tomography (CT) Fisher grade at admission, [8] the site of aneurysm, treatment details, and adverse events were recorded in a preplanned prospective database. The follow up neurological status was entered in the same database. New onset neurological impairment, not apparent immediately after aneurysmal occlusion, not due to other causes based on clinico-radiological and laboratory findings, was noted as clinical vasospasm (delayed cerebral ischemia). Patients who had died because of any cause at 3 months were considered under the mortality statistics.
SPSS 21 software (IBM Corp., New York, USA) was used for the statistical analyses. Continuous variables were assessed for normality with the Shapiro-Wilk test and were considered nonparametric. Continuous data were reported as a median with interquartile range (IQR). Categorical data were reported as counts and proportions in each group. Univariate analyses of continuous variables across binary categories were compared using the Mann-Whitney U test and across multiple categories using the Kruskal-Wallis test. The changes in anthropometric nutritional indices over time were analyzed by using the Wilcoxon signed-rank test. The bivariate relationship between two continuous variables was assessed using the Spearman's correlation coefficient. Proportions were compared using Chi-square or Fisher's exact test wherever appropriate. Two-sided significance tests were used throughout, and the significance level was kept at P < 0.05. Multivariate analyses were conducted using binary logistic regression with mandatory significance of the model coefficient being <0.05, after adjusting for known prognostic factors such as age, gender, serious systemic disease, H and H grade, Fisher grade, and definitive treatment in relation to anthropometric indices.
| » Results | | |
There were a total of 56 patients included in our study. There were 29 female and 27 male patients. The median age was 49 years (IQR 41-60 years). Their ages were normally distributed ranging from 20 to 85 years. Of the total 56 patients with SAH, 17 (30%) had clinical evidence of inadequately treated or severe systemic disease (hypertension or diabetes). There were 2, 27, 16, and 11 patients, who had presented in H and H grades 1, 2, 3, and 4, respectively. There were 4, 28, and 24 patients who had Fisher grades 2, 3, and 4, respectively. Of the 53 patients, who were clinically stable enough to undergo CT angiography, 52 (98%) had aneurysms in the anterior circulation (25 in the anterior communicating artery, 3 in the distal anterior cerebral artery, 10 in the internal carotid segment and 14 in the middle cerebral artery), and 1 (2%) had aneurysm in the posterior inferior cerebellar artery. Of the total of 56 patients, 48 (86%) underwent surgical clipping, and 4 (7%) underwent endovascular coiling, while the remaining 4 (7%) patients were in poor clinical grade and continued on supportive medical management.
The baseline anthropometric measurements of patients in different categories are depicted in [Table 1]. The median admission MAC was 29.3 cm (IQR 28-31 cm), and TSF was 35 mm (IQR 30-40 mm). The median calculated MAMC was 18.4 cm (IQR 16.5-20.3 cm). There was no significant correlation of any of these anthropometric indices with age. Furthermore, there was no significant difference in their values with respect to any of the baseline clinical and radiological parameters, and with definitive treatment. | Table 1: Influence of various baseline factors on admission anthropometric indices
Click here to view |
The changes in anthropometric nutritional indices over 1-week are shown in [Figure 1]. The median MAC decreased significantly from 29.3 cm (IQR 28-31 cm) at admission to 27 cm (IQR 26-29 cm) at 1-week (P < 0.001). The median TSF decreased significantly from 34 mm (IQR 30-40 mm) at admission to 30 mm (IQR 25-35 mm) at 1-week (P < 0.001). The median MAMC did not show any significant change at 1-week compared to the admission value (18.2 vs. 18.4 cm, P = 0.07).
Of the total of 56 patients, 10 (18%) developed features of clinical vasospasm. Differences in median (IQR) values of admission TSF and MAMC between patients who developed clinical vasospasm and those who did not develop vasospasm are shown in [Figure 2]. The patients who developed clinical vasospasm had significantly higher median admission TSF of 40 mm (IQR 35-45 mm) in comparison to the median admission TSF of 35 mm (IQR 30-40 mm) among those who did not develop clinical vasospasm (P = 0.03). The median admission MAMC values did not differ significantly between those who developed clinical vasospasm and those who did not develop vasospasm (17.9 vs. 18.6 cm, P = 0.29). | Figure 2: Differences in median, interquartile range values of admission triceps skin-fold thickness (a) and mid-arm muscle circumference (b) between patients who did not develop vasospasm and those who developed clinical vasospasm
Click here to view |
Of the total of 56 patients, 10 (18%) had expired at 3 months due to various causes. Differences in median percent fall in TSF and MAMC values at 1-week between patients who were alive and those who were dead at 3 months is depicted in [Figure 3]. Patients who expired by 3 months had significantly greater fall in median MAMC values at 1-week (7.7% [IQR 5.2-11.5%]), compared to the fall in median MAMC values at 1-week among those who were alive at 3 months (2.6% [IQR 2.1-6.6%]) (P = 0.03). However, the fall in median TSF values did not differ significantly in relation to mortality. | Figure 3: Differences in median percent fall in triceps skin-fold thickness (a) and mid-arm muscle circumference (b) at 1-week between patients who were alive and those who were dead at 3 months
Click here to view |
Overall, in the univariate analyses, higher admission TSF values had significant association with clinical vasospasm (P = 0.03), while higher H and H grade (P = 0.003), greater percentage fall in MAMC (P = 0.03), and no definitive aneurysm management (P = 0.001) had significant association with mortality [Table 2].
Multivariate analysis of clinical vasospasm using binary logistic regression model was significant while the model for mortality was found to be insignificant. Higher H and H grade (P = 0.05), higher Fisher grade (P = 0.02), and higher admission TSF value (P = 0.04) were noted to have significant association with clinical vasospasm, independent of age, gender, systemic disease, and of each other [Table 2].
| » Discussion | | |
Enhanced metabolic responses following the stress of spontaneous SAH are likely to result in increased nutritional demands, similar to that seen in head injury. [2],[9] On the other hand, excessive body fat constitutes a pro-inflammatory and pro-thrombotic state, potentially further increasing the vulnerability of patients to cerebral vasospasm. [5],[10] However, there have not been many studies on the impact of anthropometric nutritional indices on patients with spontaneous SAH.
The significant fall in median TSF, without a significant fall in median MAMC at 1-week, indicate the initial mobilization of fat reserves for the needs of the metabolic response, in preference to the somatic protein reserves. The fall in TSF, contributing to the fall in MAC, in spite of adequate nutritional support, has been described previously in patients with ischemic stroke, [6] but not in SAH.
In our study, those who expired had significantly greater fall in median MAMC at 1-week than among those who were alive at 3 months. Although the somatic protein reserves were usually retained, whenever they were mobilized, the process carried a significant impact on mortality. This somatic protein breakdown, resulting in negative nitrogen balance, has been noted to be influenced by systemic inflammation with the attendant risk of a poor outcome. [2],[11] This combination of malnutrition and inflammation has been observed to influence the outcome in ischemic stroke, [6] SAH, [5] and head injury. [12] While our study is consistent with the findings of other studies on negative nitrogen balance, the simple bedside test of assessing MAMC as a marker of somatic protein reserve is of paramount importance and unique to this study.
Excessive accumulation of body fat has been defined based on different measures. Despite the obvious adverse health consequences of enhanced cardiovascular morbidity and mortality, its association with stroke had initially been ambiguous. [4],[13] This was because of over-reliance on body mass index (BMI) to define obesity and thinness due to preclinical illness, confounding the effect of excessive adiposity. [4] Subsequently, other measures of adiposity such as waist-hip ratio and skinfold measurements were noted to be independent risk factors for the occurrence of ischemic stroke, [4],[14] but not for hemorrhagic stroke. [13] The association of obesity with the occurrence of SAH is conflicting. [15] While some studies [16],[17] have shown a negative association of obesity with the occurrence of SAH, a few others have noted no such association. [15],[18]
Irrespective of the variable relationship of the incidence of obesity with stroke, it has an indisputable association with both the severity and outcome following ischemic stroke. [19] However, its impact on patients with SAH has not been studied much. While Juvela et al., noted BMI to have significant positive association with cerebral infarction following SAH, [20] a few others could not find any association with vasospasm or neurological outcome. [21],[22] Although literature favors skin fold thickness as a measure of adiposity, as compared to BMI, for assessing the impact on health, [4],[14] it has never been studied in patients with SAH. Furthermore, it may not always be feasible to ascertain BMI in these bed-ridden patients. This necessitated the study of the impact of skin fold measures in patients of SAH. This is probably the first study showing clinical vasospasm to be related to triceps skinfold measure of adiposity.
This impact of TSF on clinical vasospasm may be due to the release of pro-inflammatory adipokines, [5] free fatty acid (FFA) induced lipid peroxidation, [21] neurotoxicity due to leptin resistance, [23] a pro-coagulant and pro-thrombotic state, [24] or the presence of vasculopathy, endothelial dysfunction or a combination of these. Among the adipokines, monocyte chemo-attractant protein-1 has been noted in obese mice to exaggerate the inflammatory-injury response after ischemia-reperfusion. [10] Excess of n-6 FFA in serum has also been noted to correlate with vasospasm following SAH. [21]
Though the effects of somatic protein catabolism-induced malnutrition and excessive adiposity-induced inflammatory-oxidative injury response were marked on mortality and vasospasm respectively in univariate analyses, only the impact of excess adiposity remained significant in multivariate analysis.
Anthropometric nutritional indices utilized by us, although simple and quick to measure, have never been previously undertaken in patients with SAH. As there were no data on normal values of these anthropometric nutritional indices in our population, we utilized internal controls for various analyses. The limitations of our study are the small number of patients, the absence of data on premorbid nutritional status and lack of other molecular markers. Furthermore, definite validation of these anthropometric parameters in larger samples is required to arrive at the normal range for the particular community. Due to the huge variations in anthropometric indices, nutritionally controlled larger studies are needed to ratify the impact of skin fold thickness measures of obesity and of muscle mass on the outcome following SAH.
| » Conclusion | | |
Higher TSF at admission is significantly associated with clinical vasospasm independent of other prognostic factors, probably due to exaggerated inflammatory and oxidative injury response of excessive adipose tissue. Fall in MAMC, indicating negative nitrogen balance, had some impact on mortality.
| » References | | |
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]
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