CRITICAL APPRAISAL

MATA KULIAH PENENTUAN STATUS GIZI

Validation of a bioelectrical impedance analysis system for body

composition assessment in patients with COPD

Disusun Oleh :

Tri Wahyuni

22030121410023

PROGRAM STUDI MAGISTER ILMU GIZI

DEPARTEMEN ILMU GIZI FAKULTAS KEDOKTERAN
UNIVERSITAS DIPONEGORO
SEMARANG
2021
 CRITICAL APPRAISAL

Judul Jurnal : Validation of a bioelectrical impedance analysis system for

body composition assessment in patients with COPD
Penulis : Fernanda Rodrigues Fonseca, Manuela Karloh2, Cintia Laura

Pereira de Araujo, Cardine Martins dos Reis, Anamaria Fleig

Mayer
Publikasi : Journal Brassil Pneumologia 2018;44(4):315-320
http://dx.doi.org/10.1590/S1806-37562017000000121
Tahun Terbit : 15 Desember 2017

I. Deskripsi Jurnal

A. Latar Belakang Penelitian :

Penurunan berat badan dan penipisan massa otot adalah manifestasi

sistemik yang umumnya terjadi pada Pasien PPOK dan sering dikaitkan
dengan prognosis penyakit. Diketahui bahwa ada hubungan antara Body
Mass Index (BMI), jumlah pasien rawat inap dan lama rawat inap dengan
dampak pada kematian pada pasien PPOK eksaserbasi akut. Namun
penelitian lain menyebutkan bahwa Fat-Free Mass (FFM), dan keparahan
penyakit tampaknya menjadi prediktor kematian yang lebih kuat daripada
BMI. Oleh karena itu, perlu dilakukan pengukuran komposisi tubuh pada
pasien PPOK secara rutin.

Pengukuran komposisi tubuh pada pasien PPOK dengan

menggunakan alat ukur Dual Energy X-ray Absorptiometry (DEXA) sangat
direkomendasikan dan dianggap sebagai gold standard. Sistem ini
membedakan komposisi tubuh dalam tiga kompartemen dengan perbedaan
redaman sinar-X di antara jaringan tubuh. Akan tetapi tidak semua rumah
sakit atau fasilitas kesehatan memiliki alat tersebut. Salah satu alternatif
metode pengukuran komposisi tubuh yang sering dijumpai adalah dengan
menggunakan Bioelectrical Impedance Analysis (BIA). Dibandingkan
dengan DEXA, sistem Bioelectrical Impedance Analysis (BIA)
 konvensional, dengan empat elektroda gel perekat juga memiliki akurasi
klinis yang memuaskan dalam memperkirakan komposisi tubuh pada
pasien PPOK. Sistem BIA, yang didasarkan pada oposisi diferensial terhadap
arus listrik di antara jaringan tubuh, juga sering digunakan untuk menilai
komposisi tubuh pada pasien PPOK dalam berbagai penelitian.

B. Tujuan Utama Penelitian :

Tujuan dari penelitian ini adalah untuk mengetahui validitas

pengukuran komposisi tubuh total pada sampel pasien PPOK dengan
kondisi yang sedang hingga sangat parah dengaan menggunakan BIA 8
elektroda kontak. Serta membandingkan pengukuran dengan menggunakan
DEXA sebagai metode evaluasi standar.
II. Metode
Tabel 1. Komponen Metode Penelitian
Desain Cross Sectional
Sampel Pasien PPOK
Kriteria Sampel Inklusi :
- Pasien Penyakit Paru Obstruktif Kronis
(GOLD) tahap 2, 3, atau 4 (adanya rasio
FEV / FVC presensi post-bronkodilator
< 0,70 dan FEV < 80% dari nilai
prediksi)
- Memiliki riwayat merokok 20 pak-
tahun
- Jenis kelamin : Pria/ Wanita
- Usia ≥ 40 tahun
- Kondisi stabil secara klinis empat
minggu sebelum masuk penelitian
Eksklusi :
- Masih merokok saat ini
- adanya penyakit terkait, seperti
kardiomiopati, penyakit
muskuloskeletal, kanker, tuberkulosis,
atau asma
Jumlah Sampel 17 orang
Variabel - Fat-Free Mass
- Lean Mass
- Fat Mass
- Bone Mineral Content
Alat Ukur/Instrumen - BIA dengan 8 elektroda kontak
- DEXA
Cara Pengukuran :
Selama penelitian, penilaian status gizi sampel dengan
penimbangan berat badan dilakukan dengan cara tanpa alas kaki dan
tanpa hiasan, hanya mengenakan celemek. Tinggi badan diukur dengan
stadiometer yang dipasang di dinding). BIA dengan Variabel berat badan
dan komposisi tubuh diukur dengan monitor komposisi tubuh segmental
rumah tangga (BC-558 Ironman; Tanita Corp., Tokyo, Jepang). Monitor
komposisi tubuh itu beroperasi pada 50 kHz dan berisi delapan elektroda
kontak, dua pasang elektroda yang digabungkan ke platform logam untuk
kaki dan dua pasang untuk pegangan tangan. Platform logam terpasang
ke transduser gaya untuk pengukuran berat, dan delapan elektroda kontak
terhubung ke sirkuit digital. Pengukuran variabel komposisi tubuh
dengan sistem BIA elektroda delapan kontak dilakukan sesuai dengan
instruksi penggunaanya. Pengukuran dilakukan sepuluh menit setelah
pasien diposisikan dalam posisi ortostatik, untuk meminimalkan
kesalahan yang disebabkan oleh perubahan akut pada cairan tubuh.
distribusi.Data komposisi tubuh total—persentase lemak tubuh, massa
otot, dan massa tulang— dikumpulkan.
Pada hari yang sama, komposisi tubuh juga dinilai dengan
pemindaian DEXA seluruh tubuh, yang dilakukan oleh teknisi radiologi
medis yang disertifikasi oleh Brazilian Society of Clinical Densitometri.
Sampel berbaring diam dalam posisi terlentang selama evaluasi. untuk
memperoleh variabel komposisi tubuh sebagai berikut: Bone Mineral
Content (BMC); Lean Mass (LM), Fat Mass (FM); dan Fat-Free Mass
(FFM) dalam bentuk Kg. Untuk analisis antar-metode, berikut ini
dipertimbangkan: FM = (berat badan total × FM%) /100, FFM = berat
badan total – FM , LM = masa otot dan BMC = masa tulang.
Analisis data :
Analisis data dilaporkan dengan rerata mean ± SD. Uji Shapiro-
Wilk digunakan untuk menguji normalitas data. Uji paired t-test
digunakan untuk membandingkan rata-rata variabel komposisi tubuh
yang diperoleh melalui pengukuran BIA dan DEXA. Koefisien korelasi
Pearson digunakan untuk menguji hubungan antara variabel yang
diperoleh dengan dua metode penilaian, sedangkan Bland & Altman
scatter plots digunakan untuk menilai kesepakatan antara metode.
Signifikansi statistik ditetapkan pada p <0,05. Semua analisis statistik
 dilakukan dengan paket perangkat lunak IBM SPSS Statistics, versi 20.0.

III. Hasil dan Pembahasan :

Tabel 2. Karakteristik Sampel

Karakteristik Rata – Rata ± SD Jangkauan
Usia 67 ± 8 56-79
Riwayat merokok 50 (24-74)A 21-150
FEV 1/FVC b 0,45 ± 0,11 0,26-0,65
FEV1, Lb 1,17 ± 0,48 0,54-2,04
FEV 1, % predicted b 38.6 ± 16,1 15-65
FVC, Lb 2,53 ± 0,61 1.51-3.49
FVC, % predicted b 64,5 ± 16,0 42-103
BMI, kg/m2 24,7 ± 5,4 16,9-33,9

Keterangan :
BMI: indeks massa tubuh.
A : Nilai yang dinyatakan sebagai median (rentang interkuartil).
B : Nilai pasca-bronkodilator

Sampel terdiri dari 17 subjek (14 laki-laki) diklasifikasikan menjadi :

stadium 2 (PPOK sedang; n = 4), stadium 3 (PPOK berat; n = 6), dan stadium4
(PPOK sangat berat; n = 7). Usia rerata 67 tahun, riwayat merokok rerata 50
pak / tahun. Mengenai obat-obatan, 14 orang (80%) subjek melaporkan
penggunaan long-acting β2 agonists yang dikombinasikan dengan
corticosteroids; 11 (67%) , penggunaan long acting anticholinergics; 9 (53%)
penggunaan long-acting β2 agonists; 3 (20%) penggunaan short-acting β2
agonists yang dikombinasikan dengan anticholinergics; dan 1 (7%) menggunakan
short-acting xanthines. Karakteristik sampel ditunjukkan pada Tabel 2.

Tabel 3. Hasil pengukuran komposisi tubuh dengan DEXA dan BIA

DEXA BIA P
Variabel Rata – Rata Rata – Rata ±
Jangkauan Jangkauan
± SD SD
FFM, kg 50,7 ± 8,5 35.1-64.3 50.6 ± 8.6 38.9-63.0 0,848
LM, kg 48,3 ± 8,2 33.6-61.4 48,0 ± 8,2 36.9-59.9 0,73
BMC, kg 2,43 ± 0,46 1.59-3.35 2,56 ± 0,39 2.00-3.10 0,107
FM, kg 20,7 ± 9,4 5.06-33.9 21,3 ± 8,3 9.89-35.3 0,471

Tidak ada perbedaan yang signifikan antara variabel komposisi tubuh

yang diperoleh dengan pengukuran DEXA dan BIA (Tabel 3), keduanya
berkorelasi positif. Variabel yang diukur dengan BIA (FFM, LM, dan FM)
menunjukkan korelasi yang kuat dengan masing-masing variabel yang diukur
dengan DEXA(p>0,05).

Gambar 1. Menunjukkan Variabel yang diukur dengan BIA (FFM, LM, dan
FM) menunjukkan korelasi yang kuat dengan masing-masing variabel yang
diukur dengan DEXA. Sedangkan variabel (Bone Mineral Content) BMC
mempunyai korelasi yang sedang (moderat) antara metode (p = 0,107)
Gambar 2 menunjukkan kesepakatan antara variabel komposisi tubuh yang
diukur menggunakan DEXA dan BIA dengan Inter-Method Differences
(IMD) dan Limit of Agreement (LOA) untuk nilai FFM, LM, BMC, dan FM
masing – masing adalah 0,15 kg (−6,39 hingga 6,70 kg), 0,26 kg (−5,96 hingga
6,49 kg), 0,13 kg (−0,76 hingga 0,50 kg), dan 0,55 kg (−6,71 hingga 5,61 kg).
Variabel komposisi tubuh berada dalam LOA, kecuali nilai BMC satu pasien.
Pengukuran FFM, LM, dan FM yang diperoleh kedua metode menunjukkan
korelasi positif yang kuat.

Hasil analisis data terdapat sedikit perbedaan (IMD) yang diamati antara
variabel komposisi tubuh yang diperoleh dari hasil pengukuran dengan
menggunakan DEXA dan sistem BIA, akan tetapi tidak signifikan secara
statistik. Sepengetahuan penulis, validitas sistem BIA untuk menilai
komposisi tubuh pada pasien PPOK belum pernah diteliti sebelumnya.
 Dalam penelitian ini, hasil pengukuran Lean Mass menggunakan BIA
lebih rendah dibandingkan dengan DEXA. Diketahui bahwa Fat-Free Mass
terutama disusun oleh Lean Mass, oleh karena itu, ketika ada perkiraan Fat-
Free Mass yang terlalu rendah maka perkiraan Lean Mass juga rendah.
Sedangkan nilai Fat Mass yang yang diukur menggunakan BIA lebih tinggi
dibandingkan dengan DEXA.

Berdasarkan hasil penelitian, diketahui bahwa nilai Bone Mineral

Content (BMC) yang diukur dengan menggunakan BIA lebih tinggi
dibandingkan dengan DEXA. Oleh karena nya hasil korelasi antara BMC
menggunakan BIA dan DEXA menunjukan hasil sedang (moderat). BMC
adalah komponen Fat-Free Mass, dan tampak menurun pada pasien PPOK.
Perlu diketahui juga bahwa DEXA memungkinkan identifikasi kehilangan
mineral tulang (BMC) pada pasien PPOK. Hal ini menunjukkan bahwa sistem
BIA tidak seakurat metode DEXA untuk mengevaluasi status tulang pasien
PPOK.

Pengukuran komposisi tubuh menggunakan metode DEXA sering

dianggap sebagai standar emas dan sering di gunakan untuk pasien PPOK.
Akan tetapi terdapat beberapa kelemahan pengukuran dengan menggunakan
DEXA yaitu ; biaya tinggi, ketersediaan alat dan ketrampilan petugas saat
menggunakan alat tersebut karena tidak semua orang dapat mengoperasikan
DEXA. Oleh karena itu penggunaan DEXA dalam praktek klinis juga terbatas.
BIA memiliki biaya yang lebih rendah dan mudah digunakan, BIA telah
dipilih sebagai metode untuk menilai komposisi tubuh pada pasien PPOK
dalam beberapa penelitian. BIA memiliki biaya lebih rendah dan
memungkinkan penilaian komposisi dan berat tubuh dengan mudah dan
segera. Penulis menemukan bahwa sistem BIA selain kesederhanaan,
kepraktisan, dan kenyamanannya, dapat digunakan sebagai alternatif metode
yang lebih kompleks untuk komposisi tubuh secara rutin terutama komposisi
tubuh pada pasien dengan PPOK dalam praktek klinis dan studi
epidemiologi.
IV. Kesimpulan
Pengukuran komposisi tubuh dengan menggunakan BIA dengan 8
elektroda kontak adalah alat yang sederhana dan berguna untuk penilaian
komposisi seluruh tubuh pada pasien PPOK sedang hingga sangat berat yang
stabil secara klinis.

V. Telaah Jurnal

A. Fokus Utama Penelitian Penelitian

Penelitian ini membandingkan pengukuran komposisi tubuh pada pasien

PPOK dengan menggunakan 2 alat ukur yaitu Bioelectical Impedance Analysis
(BIA) dengan 8 elektroda kontak dan Dual Energy X-ray Absorptiometry
(DEXA)

B. Kelebihan Penelitian

Dalam penelitian ini dapat dilakukan pengukuran komposisi tubuh dengan

menggunakan 2 alat ukur sekaligus yaitu Bioelectical Impedance Analysis (BIA)
dengan 8 elektroda kontak dan Dual Energy X-ray Absorptiometry (DEXA)
sehingga dapat digunakan sebagai referensi dalam memilih alat untuk
mengukur komposisi tubuh pada pasien sesuai dengan tujuannya.

C. Kelemahan Penelitian

Jumlah sampel yang kecil dapat mengurangi validitas eksternal

penelitian karena besar sampel mungkin tidak mewakili populasi PPOK,
analisis kelompok menurut tingkat keparahan obstruksi aliran udara, variasi
jenis kelamin karena sebagian besar sampel adalah pria. Judul penelitian
kurang menggambarkan isi karena pada penelitian ini juga di lakukan
pengukuran dengan menggunakan alat DEXA.

D. Saran

Sebaiknya di lakukan penelitian lebih lanjut dengan menggunakan sampel

pasien PPOK yang lebih besar dan dipilih secara randomized (acak)
direkomendasikan untuk menyempurnakan penelitian ini.
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 J Bras Pneumol. 2018;44(4):315-320
http://dx.doi.org/10.1590/S1806-37562017000000121 ORIGINAL ARTICLE

Validation of a bioelectrical impedance

analysis system for body composition
assessment in patients with COPD
Fernanda Rodrigues Fonseca1,2,a, Manuela Karloh2,3,b, Cintia Laura Pereira de Araujo1,2,c,
Cardine Martins dos Reis1,2,d, Anamaria Fleig Mayer1,2,3,e

1. Programa de Pós-Graduação em ABSTRACT

Fisioterapia, Universidade do Estado de
Santa Catarina – UDESC – Objective: To investigate the validity of an eight-contact electrode bioelectrical
Florianópolis (SC) Brasil. impedance analysis (BIA) system within a household scale for assessing whole body
2. Núcleo de Assistência, Ensino e composition in COPD patients. Methods: Seventeen patients with COPD (mean age =
Pesquisa em Reabilitação Pulmonar, 67 ± 8 years; mean FEV1 = 38.6 ± 16.1% of predicted; and mean body mass index = 24.7
Universidade do Estado de
± 5.4 kg/m2) underwent dual-energy X-ray absorptiometry (DEXA) and an eight-contact
Santa Catarina – UDESC –
Florianópolis (SC) Brasil. electrode BIA system for body composition assessment. Results: There was a strong
3. Programa de Pós-Graduação em inter-method correlation for fat mass (r = 0.95), fat-free mass (r = 0.93), and lean mass (r
Ciências do Movimento Humano, = 0.93), but the correlation was moderate for bone mineral content (r = 0.73; p < 0.01 for
Universidade do Estado de all). In the agreement analysis, the values between DEXA and the BIA system differed by
Santa Catarina – UDESC –
Florianópolis (SC) Brasil.
only 0.15 kg (−6.39 to 6.70 kg), 0.26 kg (−5.96 to 6.49 kg), −0.13 kg (−0.76 to 0.50 kg),
a. http://orcid.org/0000-0003-4620-9064 and −0.55 kg (−6.71 to 5.61 kg) for fat-free mass, lean mass, bone mineral content, and
b. http://orcid.org/0000-0003-2082-2194 fat mass, respectively. Conclusions: The eight-contact electrode BIA system showed
c. http://orcid.org/0000-0001-6184-9495 to be a valid tool in the assessment of whole body composition in our sample of patients
d. http://orcid.org/0000-0003-3992-924X with COPD.
e. http://orcid.org/0000-0003-0320-4810 Keywords: Pulmonary disease, chronic obstructive; Body composition; Electric
impedance.
Submitted: 30 April 2017.
Accepted: 15 December 2017.
Study carried out at the Núcleo de
Assistência, Ensino e Pesquisa em
Reabilitação Pulmonar, Universidade do
Estado de Santa Catarina – UDESC –
Florianópolis (SC) Brasil.

INTRODUCTION The BIA system, which is based on differential opposition

Weight loss and depletion of muscle mass are common
systemic manifestations in COPD(1) and have been
associated with the disease prognosis. It is known that
body mass index (BMI) is related to the number of
hospitalizations(2) and length of hospital stay(3) for acute
exacerbation in patients with COPD, with an impact on
mortality.(4,5) The fat-free mass (FFM) index, however,
seems to be a stronger predictor of mortality(6) and disease
severity(7) than does BMI in those patients, justifying the
routine assessment of their body composition.
The use of dual-energy X-ray absorptiometry (DEXA)
is recommended to assess body composition in COPD
patients. (8,9) This system distinguishes the body
composition in three compartments by a difference
in the attenuation of X-rays among body tissues. In
comparison with DEXA, conventional bioelectrical
impedance analysis (BIA) system, with four adhesive
gel electrodes, has satisfactory clinical accuracy in
estimating body composition in patients with COPD.(10)
to the electrical current among body tissues, has been
used to assess body composition in COPD patients in
various studies.(11-13)
The measurement of lean mass (LM) by an eight-contact
electrode BIA system has already been validated against
DEXA in people ranging in age from 6 to 64 years.(14)
Additionally, this simple, practical, and convenient system
was used in an epidemiological study in which FFM and
FFM index were determined in men and women of white
ethnicity ranging from 45 to 69 years of age.(15) However,
to the best of our knowledge, the assessment of body
composition using this system has yet to be studied in
patients with COPD. In those patients, factors other
than age contribute to muscle atrophy, such as disuse,
inflammation, oxidative stress, hypoxemia, hypercapnia,
low levels of anabolic hormones or growth factors,
impaired energy balance, corticosteroid use, and vitamin
D deficiency.(16) Thereby, the objective of the present
study was to investigate the validity of an eight-contact

Correspondence to:
Anamaria Fleig Mayer. Núcleo de Assistência, Ensino e Pesquisa em Reabilitação Pulmonar, Universidade do Estado de Santa Catarina, Rua Paschoal Simone,
358, CEP 88080-350, Florianópolis, SC, Brasil.
Tel.: 55 48 3664-8608. E-mail: anamaria.mayer@udesc.br
Financial support: This study received financial support from the Fundação de Amparo à Pesquisa do Estado de Santa Catarina/Brazilian Conselho Nacional de
Desenvolvimento Científico e Tecnológico (FAPESC/CNPq, Foundation for the Support of Research in the State of Santa Catarina/National Council for Scientific
and Technological Development; Grant no. 3509/2010-2).

© 2018 Sociedade Brasileira de Pneumologia e Tisiologia ISSN 1806-3713 315

 Validation of a bioelectrical impedance analysis system for body composition assessment in patients with COPD
electrode BIA system within a household scale for
assessing whole body composition in COPD patients,
using DEXA as the standard method.
METHODS
This was a cross-sectional study conducted between
July and December of 2011. The study sample was
selected by convenience and included COPD patients
classified as the Global Initiative for Chronic Obstructive
Lung Disease (GOLD) stages 2, 3, or 4 (presence of a
post-bronchodilator FEV1/FVC ratio < 0.70 and FEV1
< 80% of the predicted value),(17) of both genders,
who had a smoking history ≥ 20 pack-years, had
been clinically stable four weeks prior to study entry,
and were ≥ 40 years of age. Exclusion criteria were
current smoking and presence of associated diseases,
such as cardiomyopathy, musculoskeletal diseases,
cancer, tuberculosis, or asthma. A total of 17 clinically
stable COPD patients (14 men) from public or private
pulmonary outpatient clinics agreed to participate in
the study. The study was approved by the Research
Ethics Committees of the Universidade do Estado de
Santa Catarina and the Universidade Federal de Santa
Catarina (Protocol numbers 85/2010 and 865.2010,
respectively). All participants gave written informed
consent.
Pulmonary function
Lung function was assessed using a previously
ca librated spirometer (EasyOne®; ndd Medical
Technologies, Zurich, Switzerland). Spirometry was
performed before and after the inhalation of 400 µg
of albuterol in accordance with the American Thoracic
Society/European Respiratory Society standards.(18) The
predicted values were calculated based on equations
proposed by Pereira et al.(19)
Nutritional status
During the assessment of nutritional status, the
individuals remained barefoot and unadorned,
wearing only an apron. Height was measured with
a wall-mounted stadiometer (Standard; Sanny, São
Bernardo do Campo, Brazil) in accordance with the
standardization proposed by Gordon et al.(20) Weight
and body composition variables were measured with a
household segmental body composition monitor (BC-
558 Ironman; Tanita Corp., Tokyo, Japan). That body
composition monitor operates at 50 kHz and contains
eight contact electrodes, two pairs of electrodes being
coupled to a metal platform for the feet and two pairs
for hand grasping. The metal platform is attached to
a force transducer for the measurement of weight,
and the eight contact electrodes are connected to a
digital circuit. The measurement of body composition
variables by the eight-contact electrode BIA system was
performed as per the instructions of the manufacturer
and as recommended by Kyle et al.(21) Measurements
were taken ten minutes after the patients had
been positioned in orthostatic position, in order to
minimize errors caused by acute changes in body fluid
316 J Bras Pneumol. 2018;44(4):315-320
distribution.(22) Data on total body composition—body
fat percentage, muscle mass, and bone mass—were
collected.
On the same day, body composition was also assessed
by whole-body DEXA scanning, which was conducted by
a medical radiology technician certified by the Brazilian
Society of Clinical Densitometry. The subjects laid still
in the supine position during the evaluation. A Lunar
Prodigy Advance bone densitometer (GE Healthcare,
Madison, WI, USA) was previously calibrated in
accordance with the manufacturer’s recommendations
and used with the enCORE software, version 12.30 (GE
Healthcare) for the acquisition of the following body
composition variables: bone mineral content (BMC);
LM, fat mass (FM); and FFM (in kg for all). For the
inter-method analysis, the following was considered:
FM = (total body weight × FM%)/100; FFM = total
body weight − FM; LM = muscle mass; and BMC =
bone mass.
Statistical analysis
The data were reported as means ± SD. The Shapiro-
Wilk test was used to analyze data normality. A paired
t-test was used in order to compare the means of the
body composition variables obtained via BIA and DEXA.
Pearson’s correlation coefficient was used in order to
test the association between the variables obtained by
the two assessment methods, whereas Bland & Altman
scatter plots were used to assess agreement between
the methods. Statistical significance was set at p <
0.05. All statistical analyses were performed with the
IBM SPSS Statistics software package, version 20.0
(IBM Corporation, Armonk, NY, USA).
RESULTS
The sample comprised 17 subjects (14 men)
classified as GOLD stage 2 (moderate COPD; n = 4),
3 (severe COPD; n = 6), and 4 (very severe COPD;
n = 7). Regarding medications, 14 (80%) of the
subjects reported the use of long-acting β2 agonists
combined with corticosteroids; 11 (67%) used long-
acting anticholinergics; 9 (53%) used long-acting
β2 agonists; 3 (20%) used short-acting β2 agonists
combined with anticholinergics; and 1 (7%) used
short-acting xanthines. The characteristics of the
sample are shown in Table 1.
There were no significant differences between body
composition variables obtained by DEXA and by BIA
(Table 2), both correlating positively. The variables
measured by BIA (FFM, LM, and FM) showed strong
correlations with the respective variables measured by
DEXA, whereas the BMC values showed a moderate
correlation between the methods (Figure 1).
Figure 2 shows the agreement between body
composition variables measured by DEXA and by BIA.
The inter-method differences (IMDs) and the limits of
agreement (LOA) for FFM, LM, BMC, and FM values
were 0.15 kg (−6.39 to 6.70 kg), 0.26 kg (−5.96 to
6.49 kg), −0.13 kg (−0.76 to 0.50 kg), and −0.55 kg
 Fonseca FR, Karloh M, Araujo CLP, Reis CM, Mayer AF

Table 1. Characteristics of the study group. (−6.71 to 5.61 kg), respectively. The body composition
Characteristic Mean ± SD Range variables were within the LOA, except for the BMC
Age, years 67 ± 8 56-79 value of one patient.
Smoking history, pack-years 50 (24-74)a 21-150
FEV1/FVCb 0.45 ± 0.11 0.26-0.65 DISCUSSION
FEV1, Lb 1.17 ± 0.48 0.54-2.04
The aim of the present study was to investigate
FEV1, % predictedb 38.6 ± 16.1 15-65 the validity of an eight-contact electrode BIA system
FVC, Lb 2.53 ± 0.61 1.51-3.49 for the assessment of total body composition in a
FVC, % predictedb 64.5 ± 16.0 42-103 sample of patients with moderate to very severe
BMI, kg/m2 24.7 ± 5.4 16.9-33.9 COPD, using DEXA as the standard evaluation method.
BMI: body mass index. aValue expressed as median Measurements of FFM, LM, and FM obtained by the
(interquartile range). bPost-bronchodilator values. two methods showed strong positive correlations. In

Table 2. Body composition of the study group.

Variable DEXA BIA p
Mean ± SD Range Mean ± SD Range
FFM, kg 50.7 ± 8.5 35.1-64.3 50.6 ± 8.6 38.9-63.0 0.848
LM, kg 48.3 ± 8.2 33.6-61.4 48.0 ± 8.2 36.9-59.9 0.730
BMC, kg 2.43 ± 0.46 1.59-3.35 2.56 ± 0.39 2.00-3.10 0.107
FM, kg 20.7 ± 9.4 5.06-33.9 21.3 ± 8.3 9.89-35.3 0.471
DEXA: dual-energy X-ray absorptiometry; BIA: bioelectrical impedance analysis; FFM: fat free mass; LM: lean mass;
BMC: bone mineral content; and FM: fat mass.

A B

80 80

60 60
BIA FFM (kg)

BIA LM (kg)

40 40

20 20
20 40 60 80 20 40 60 80
DEXA FFM (kg) DEXA LM (kg)

C D

4 40

30
3
BIA FM (kg)
BIA BMC (kg)

20

2
10

1 0
1 2 3 4 0 10 20 30 40
DEXA BMC (kg) DEXA FM (kg)

Figure 1. Correlation between body composition variables assessed by dual-energy X-ray absorptiometry and the eight-
contact electrode bioelectrical impedance analysis system. DEXA: dual-energy X-ray absorptiometry; BIA: bioelectrical
impedance analysis; FFM: fat free mass; LM: lean mass; BMC: bone mineral content; and FM: fat mass.

J Bras Pneumol. 2018;44(4):315-320 317

 Validation of a bioelectrical impedance analysis system for body composition assessment in patients with COPD

A B

Difference between DEXA and BIA LM (kg)

Difference between DEXA and BIA FFM (kg)

6.70 6.49 mean + 2SD

0.15 0.26 mean

-5.96 mean – 2SD

-6.39

0 20 40 60 80 100 0 20 40 60 80 100
Average of DEXA and BIA FFM (kg) Average of DEXA and BIA BMC (kg)

C D
Difference between DEXA and BIA BMC (kg)

Difference between DEXA and BIA FM (kg)

5.61 mean + 2SD

0.50

-0.55 mean
-0.13

-6.71 mean – 2SD

-0.76

0 1 2 3 4 5 0 10 20 30 40 50
Average of DEXA and BIA LM (kg) Average of DEXA and BIA FM (kg)

Figure 2. Mean differences and limits of agreement between body composition variables assessed by dual-energy
X-ray absorptiometry and the eight-contact electrode bioelectrical impedance analysis system. DEXA: dual-energy
X-ray absorptiometry; BIA: bioelectrical impedance analysis; FFM: fat free mass; LM: lean mass; BMC: bone mineral
content; and FM: fat mass.

the agreement analysis, slight IMDs were observed 0.81), LM (r = 0.94), and FM (r = 0.97) measured
between the body composition variables obtained by by an eight-contact electrode BIA system and DEXA).
DEXA and the BIA system, with no statistical differences. When analyzing the agreement between the methods
To our knowledge, the validity of that BIA system for in the present study, we found that the eight-contact
assessing body composition in COPD patients has electrode BIA system slightly underestimated FFM values
never been investigated before. However, previous when compared with those by DEXA. Corroborating
studies have used DEXA as the criterion method for this result, underestimated values for FFM obtained
analyzing the ability of various equations to estimate by conventional BIA systems compared with those
body composition by conventional BIA systems as an measured by DEXA in COPD patients were also observed
evaluation method for those patients.(10,23-26) in other studies.(10,25,26) The bias ranged between 0.57
In the current study, a strong inter-method correlation and 4.1 kg, which is greater than that observed in
was found for FFM, LM, and FM values. Lerario et al.(10) the current study.(10,25,26) However, FFM values were
also observed a strong correlation between FFM values overestimated by BIA when compared with DEXA in
measured by DEXA and by a conventional BIA system other studies involving patients with chronic respiratory
in patients with COPD (r = 0.95; p < 0.001). That had failure, with biases between 0.1 and 8.0 kg.(23,24)
been previously shown by Kyle et al.(24) in patients with In the present study, the eight-contact electrode BIA
chronic respiratory failure (r = 0.952; p < 0.0001). system underestimated LM when it was compared with
Pichard et al.(23) studied the association between DEXA DEXA. It is known that FFM is primarily composed by
and several equations for the estimation of body LM, and, therefore, when there is FFM underestimation,
composition by using a conventional BIA system in LM underestimation is also expected. Overestimated
patients with chronic respiratory failure. Those authors FM values were obtained by the eight-contact electrode
found a minimum correlation coefficient of 0.66 (p < BIA system when they were compared with those by
0.001) for FFM and FM. In heavy smokers, Rom et DEXA. However, Rom et al.(27) found underestimated
al.(27) showed a strong correlation between BMC (r = FM values obtained by an eight-contact electrode

318 J Bras Pneumol. 2018;44(4):315-320


BIA system when compared with those obtained by
DEXA (IMDs = 0.19 kg) in heavy smokers. In healthy
elderly Europeans, Mally et al.(28) found that an
eight-contact electrode BIA system underestimated
LM (IMDs = 1.0 kg) and overestimated FM (IMDs =
−5.8 kg) when compared with the values obtained by
DEXA in men, which confirms the results observed in
the current study, since our sample was composed
mostly by males. In the present study, we also found
that the eight-contact electrode BIA system slightly
overestimated BMC values when compared with those
by DEXA and that the BMC values measured by the
two methods showed a moderate correlation. BMC is a
component of FFM, and it appears to be decreased in
COPD patients.(29) It is known that DEXA enables the
identification of bone mineral loss in these patients(8)
and is considered the gold standard for bone mass
determination. This suggests that the eight-contact
electrode BIA system is not as accurate a method
as DEXA for the evaluation of the skeletal status of
patients with COPD.
Although DEXA is not considered the gold standard
for body composition evaluation,(30) it has been
recommended as a reference method for this purpose
in COPD patients.(8,9) Its high cost and demand on
training and technological resources, however, limit its
use in clinical practice. Because BIA has lower costs
and is easy to use, it has been chosen as a method
for assessing body composition in patients with COPD
in some studies.(11,12) The eight-contact electrode BIA
system associated with household scales dispenses with
the use of adhesive gel electrodes, has lower costs than
does a conventional BIA monitor, and enables easy
and immediate assessment of body composition and
weight. We found that the eight-contact electrode BIA
system, in addition to its simplicity, practicality, and
convenience, can be used as an alternative to more
complex methods for routine assessment of body
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