Sarcopenia and visceral obesity assessed by computed tomography are associated with adverse outcomes in patients with Crohn's disease

doi:10.1016/j.clnu.2020.01.001

Clinical Nutrition

Volume 39, Issue 10, October 2020, Pages 3024-3030

https://doi.org/10.1016/j.clnu.2020.01.001 Get rights and content

Summary

Background

Altered body composition may impact on the clinical course of Crohn's disease (CD) but is not detected by the simple body mass index (BMI) assessment.

Aim

To assess the prevalence of sarcopenia and visceral obesity by a single computed tomography (CT) slice, and its association with adverse events in an adult hospitalized CD cohort.

Methods

88 CD patients who had abdominal CT scans during hospitalization were retrospectively enrolled. The skeletal muscle index (SMI) at the third lumbar vertebra level was used to assess sarcopenia. Sarcopenia was defined as a SMI <38.5 cm²/m² in women, <52.4 cm²/m² in men and visceral obesity as a visceral fat area ≥130 cm². Clinical malnutrition was defined by a BMI <18.5 kg/m². Univariate analysis was performed, and predictors for surgery in the follow-up were entered in a stepwise logistic regression model for multivariate analysis.

Results

The prevalence of sarcopenia was 58%, malnutrition 21.6%, and visceral obesity 19.3%. Among sarcopenic patients, 49% had a normal BMI, 13.7% were overweight, and 1(2%) was obese. Sarcopenic CD patients had significantly more abscesses (51% vs 16.7%, p = 0.001), hospitalizations (61.2% vs 36.1%, p = 0.022) and digestive surgery (63.3% vs 27.8%, p = 0.001) than non-sarcopenic patients during the follow-up, whereas usual malnutrition assessment was not correlated with disease outcomes. In multivariate analysis, both sarcopenia and visceral obesity were associated with further occurrence of digestive surgery.

Conclusion

Both sarcopenia and visceral obesity were associated with adverse outcomes in severe CD patients whereas usual nutritional assessment was not.

Introduction

Crohn's disease (CD) is a chronic progressive and disabling inflammatory bowel disease (IBD) which may lead to hospitalizations, surgery and impact quality of life. CD is well known to be associated with malnutrition [[1], [2], [3], [4]], lower body mass index (BMI) [5] and lower lean body mass [6,7]. Indeed, 75% of hospitalized CD patients are malnourished and 1/3 has a low BMI [8]. There are multiple causes: limited food intake, malabsorption, increased nutrients losses and potentially treatment adverse events. Current data indicate that IBD patients, particularly CD patients, have alterations in their body composition (lean and fatty mass) that the simple BMI assessment may fail to detect [[9], [10], [11]]. Also, growing evidence suggests that altered body composition in IBD is associated with more severe phenotypes [12] and may negatively impact on the clinical course of the disease, response to treatments, and quality of life [8,[13], [14], [15]], although some discordant results have been reported regarding surgery indications and outcomes [16].

While the deuterium oxide dilution method, or to a lesser extent a proxy by the whole-body dual-energy X-ray absorptiometry (DXA), would be the best measures of body composition, these techniques are neither routinely accessible nor feasible in clinical practice. Recently, the development of an accessible method to assess body composition, using a third lumbar (L3) computed tomography (CT) slice, has demonstrated its reliability and prognostic ability in other diseases such as cancer and obesity [[17], [18], [19], [20], [21], [22]]. This tool has extended nutritional assessment possibilities in routine clinical care, and can be applied to CD patients [23]. CT can differentiate body tissues (adipose, muscular, skeletal), water and air, based on tissue specific attenuation values, and easily provides a body composition analysis, including quantification of abdominal circumference, abdominal adipose tissues (AT) (subcutaneous, visceral, and intermuscular), and skeletal muscle (SM) [24].

The aims of this study were to assess the body composition of hospitalized CD patients by a L3 single CT slice and to investigate the association between body composition and adverse outcomes during the follow-up of this cohort of patients.

Section snippets

Study population

From our cohort of patients with a confirmed diagnosis of CD and follow-up at Besançon University Hospital, those aged 18–65 years who had an abdominal CT scan and were hospitalized in the Gastroenterology unit between the 1st of January 2010 and the 15th of June 2016, were retrospectively enrolled for this study. Only hospitalized CD patients were included, as they fulfilled the criteria to have both CT scan examination and full conventional nutritional assessment in the same time period and

Demographic and disease characteristics

Among our CD cohort patients, a total of 175 patients had an abdominal CT during the inclusion period, among them 105 were hospitalized and 88 were meeting all inclusion criteria (Supplementary Fig. 1). Follow-up data were subsequently available for 85 patients.

The baseline characteristics of the 88 patients are shown in Table 1. Overall, median age was 35.4 ± 12.4 years, half were men (44 patients), half were current smokers (44 patients), and the mean HBI was 7.4 ± 4.4. Regarding disease

Discussion

In this observational cohort of hospitalized CD patients, we demonstrated that the evaluation of the body composition using a single CT slice was a suitable tool to assess their nutritional status, and was predictive of adverse events in the course of the disease: abscesses, digestive surgery and hospitalization, whereas BMI and/or serum albumin levels were not. We also found that both sarcopenia and visceral obesity were independently associated with surgery during the follow-up. This study

Authors’ contributions

Guarantor of the article: Lucine Vuitton, MD, PhD.

JG was involved in the design of the study, the conception of the case report form (CRF), patients’ recruitment, data collection and drafting of the manuscript. LV supervised the study design and drafting. LV, SB and GP contributed to data interpretation and manuscript preparation. JG and ALP contributed to statistical analysis and interpretation of data. CDE, SK, CG, DC, MdB recruited patients and recorded clinical data. All authors contributed

Funding source

None.

Conflicts of interest

J Grillot has received lecture fees from Baxter, Pfizer and MSD.

S Koch has received lecture fees from Abbvie, Mayoli, MSD, FujiFilm.

C Gay has received lecture fees from Abbvie, MSD and Takeda.

L Vuitton has received lecture fees from Abbvie, Ferring, MSD, Pfizer, Janssen and Takeda, consulting fees from Abbvie, Ferring and Gilead and research grants from MSD, Pfizer and Takeda.

CDE, ALP, DC, GP, MdB, ZL and SB declare no conflict of interest.

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There is growing evidence of increased muscle atrophy in IBD patients, likely resulting in a higher sarcopenia prevalence in IBD. The aims of this systematic review are A1; to estimate sarcopenia prevalence in IBD patients, A2; to investigate its impact on IBD patients, and A3; the effectiveness of nutritional interventions on muscle mass and/or strength in IBD patients.
On 28 July 2021, three electronic databases were used to identify eligible studies, including peer-reviewed studies (randomised controlled trials [RCTs], non-RCTs, observation studies) in adult (⩾ 18 years) IBD patients. For A1 and A2 only, studies defined low muscle mass and/or strength cut-off points. For A2, studies assessed association between sarcopenia and IBD complication. For A3, studies assessed the nutrition effect among IBD patients.
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358 patients were included. Sarcopenia was found in 18.2% of patients, and it was associated with a lower rate of ER (14.8% vs 47.7%; p = 0.002) after 12 months of therapy, while it was not associated with SFCR (65.1% vs 70.1%; p = 0.435), hospitalisation (9.2% vs 7.8%; p = 0.801) and surgery (3.1% vs 6.1%; p = 0.549). Sarcopenia was identified as a predictor of lack of ER (odds ratio [OR]=5.2; p = 0.006), as well as smoking (OR=2.5; p = 0.028) and perianal disease (OR=2.6; p = 0.020).
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Original articleSarcopenia and visceral obesity assessed by computed tomography are associated with adverse outcomes in patients with Crohn's disease

Summary

Background

Aim

Methods

Results

Conclusion

Introduction

Section snippets

Study population

Demographic and disease characteristics

Discussion

Authors’ contributions

Funding source

Conflicts of interest

Gastroenterol Clin N Am

Clin Nutr

Am J Gastroenterol

Clin Gastroenterol Hepatol

Clin Nutr

Clin Nutr ESPEN

Lancet Oncol

Clin Nutr

J Gastrointest Surg

Nutrition in Crohn disease

Curr Opin Gastroenterol

Nutrition in adult patients with inflammatory bowel disease

Curr Drug Targets

Body mass index is associated with inflammatory bowel disease: a systematic review and meta-analysis

PLoS One

Sarcopenia is prevalent in patients with Crohn’s disease in clinical remission

Inflamm Bowel Dis

Sarcopenia is common in overweight patients with inflammatory bowel disease and may predict need for surgery

Inflamm Bowel Dis

Comparison between handgrip strength, subjective global assessment, anthropometry, and biochemical markers in assessing nutritional status of patients with Crohn’s disease in clinical remission

Dig Dis Sci

Systematic review: body composition in adults with inflammatory bowel disease

Aliment Pharmacol Ther

Sarcopenia is a predictive factor for intestinal resection in admitted patients with Crohn’s disease

PLoS One

Low muscle mass at initiation of anti-TNF therapy for inflammatory bowel disease is associated with early treatment failure: a retrospective analysis

Eur J Clin Nutr

Lower subcutaneous or visceral adiposity assessed by abdominal computed tomography could predict adverse outcome in patients with Crohn’s disease

J Crohns Colitis

Original article
Sarcopenia and visceral obesity assessed by computed tomography are associated with adverse outcomes in patients with Crohn's disease