IJCS | Volume 32, Nº2, March/April 2019

144 Rocha et al. Nutritional assessment in heart failure Int J Cardiovasc Sci. 2019;32(2)143-151 Original Article individuals and is related to the prognosis of the disease. 7 Other parameters of indirect musculature assessment, such as the arm muscle circumference (AMC) and corrected armmuscle area (cAMA) are widely accepted, but there are few studies that consolidate its use in HF. 8 Another parameter used as an indicator of musculature reserve is the adductor pollicismuscle thickness (APMT). 9 More accuratemethods for assessing body composition, such as computed tomography and magnetic resonance imaging, are costly and difficult to perform. 10 As an alternative, electrical bioimpedance (EBI) has been suggested and can be used to evaluate the prognosis and follow-up of individuals with HF. 11 However, the higher cost of acquiring the equipment makes anthropometry the most feasiblemethod for outpatient evaluation and follow- up, despite its still questionable sensitivity and accuracy. 12 Given the controversies between the methods of anthropometric evaluation and body composition in individuals with HF, and the scarcity of specific indicators in the literature, the objective of this study was to evaluate the accuracy and concordance of the diagnosis of protein malnutrition and excess fat among anthropometric and body composition methods. Methods Selection of participants and study design The accuracy study was developed at Hospital Universitário Onofre Lopes (HUOL) – UFRN/Natal, in Ambulatório Interprofissional de Insuficiência Cardíaca (AMIIC). This study was approved by the Ethics and Research Committee of Onofre Lopes University Hospital /UFRN (Nº: CAAE 59827516.2.0.0.0.0.5292). All individuals signed an Informed Consent Form. Inclusion criteria were adult and elderly individuals of both sexes, with a diagnosis of HF, according to the Boston point system and the Framingham criteria, confirmed by the Doppler echocardiogram. The study did not include adolescents, pregnant women, patients with cognitive deficit, with renal dysfunction and under dialysis, and consumptive diseases such as cancer. Individuals with pacemaker, metal valve, orthopedic prostheses/metal implants on the left or right side, as well as those with abnormal limb or trunk limitations, amputation and/or dystrophies were not included. 13 We considered a convenience sample composed of individuals with HF followed up on an outpatient basis. Of 112 individuals enrolled from January to November 2017, 60 individuals were included in the study. The most frequent causes of sample losses included refusals to participate and the presence of exclusion criteria. The participants came for a routine outpatient visit and were examined by the medical staff for their cardiac condition, including clinical history and clinical examination, to determine functional capacity and classify HF based on disease progression, according to the American Heart Association criteria, investigation of the etiology and type of HF and left ventricular ejection fraction. The clinical datawere collected by going through the participants’ online records. For anthropometric and body composition assessment, the participants were instructed to do a food and liquid fasting and to exercise for at least 8 hours before the evaluation. 13 Anthropometric evaluation and body composition Anthropometric and body composition assessment was performed by a single well trained anthropometrist with calibrated equipment. The intraevaluator technical error of measurements (TEM). 14 The score assigned according to the TEM calculations was of TST (1.03), for the APMT (0.77) and perimeter of the arm circumference (AC) (0.31), characterizing the evaluator as capable of taking the measurements. The evaluationwas performed twice and a third measurement was taken in case of discrepancy to obtain the mean. To measure body mass, a digital scale with capacity of 150 kg and 0.1 kg precision (Balmak Premium ® ) was used. Stature was measured using a stadiometer. BMI was calculated and classified according to cut-off points proposed by the Food and Nutrition Surveillance System. 15 AC and TST measurements were taken as defined in standardized protocols. TST was evaluated using a Lange Skinfold Caliper ® and classified according to Frisancho. 16,17 AC and TST measurements were used to calculate the anthropometric indicators of muscle reserve, arm muscle circumference (AMC) and corrected arm muscle area (cAMA), according to Frisancho. 16 The APMT measurement was assessed according to previously published guidelines, considering the classification proposed by Lameu. 9 Body composition was assessed using a tetrapolar EBI (Biodynamics 450 ® ) toanalyze thebody compartments of fat freemass, fatmass andwater. Themeasurementwas taken with the individual lying down with the limbs apart and the emitter electrodes placedon the surface of the hand and