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(BIA)
BIA is increasingly used to estimate body composition in dietetic practice, largely due to its simple,
quick, non‐invasive nature and portability (Lukaski, 1985). Although different BIA meters will record
different results on individuals, using the correct equations for the population studied can produce
consistent intra‐group data (Oldman, 1996). The most salient feature of BIA is its reproducibility on
individual patients on serial testing showing changes over time with altered nutrition therapy and/or
activity. The reference groups for testing were HIV and Renal patients (Stall et al 1995, Madore et al
1994 & Zabetakis et al 1994). Reproducibility makes BIA an ideal clinical tool (Ghosh et al 1997).
The electrical impedance of the body is measured by introducing a small alternating electrical current
(for example: 800A: 50KHz, varies with equipment used) into the body and measuring the potential
difference that results (Foster KR and Lukaski HC, 1996). Fat free mass contains electrolytes and acts as
a conductor, whereas fat mass does not and acts as an insulator. BIA has been validated against other
body composition methods and in healthy adults (Khaled et al, 1988). In addition, BIA continues to be
researched and validated in a variety of populations and conditions. Please check this manual by
condition to look for disease specific standards and normal values.
Systems Measuring Fat Free Mass/Lean Body Mass and Fat Mass
There are two types of BIA meters available containing validated equations or computer software. One
type of system measures resistance/impedance only and may or may not use electrodes. The meters
may be hand held or are 'step‐on' scales. These systems provide a measure of fat free mass and fat
mass. They are used primarily in weight loss programs to assess and monitor changes in body fat. Some
will state the number of pounds/kg of fat and fat free mass, which may be more useful than percent
body fat alone. Percent body fat and BMI have been criticized because they are not a reflection of the
other components of the human body. Muscle mass and bone weight can vary greatly in individuals and
by race. High quality diets and excellent fitness programs will produce fat loss and minimal loss of
muscle mass. It is not possible to determine the loss of active cell mass with these systems therefore it
is prudent to combine this test with a MAMA test. Because BIA may underestimate body fat in
abdominal obesity, it is wise to collect serial waist circumference data. 'Applied Body Composition
Assessment`, (Heyward) includes detailed information on current equations from experts in the field by
race, age and for obese subjects. Software for the text is also available from Human Kinetics. These
equations will not provide the detailed clinical output outlined below.
Systems Measuring Clinical Nutritional Indicators
The second type of system requires a patient to lie supine with electrode placement on the right hand
and foot or on body segments (Lukaski, 1996), provides a large array of information. These systems may
measure resistance and reactance in the body. Resistance being the opposition of the conductor to the
flow of the current (Lukaski, 1996). Reactance is associated with several types of polarization (separation
of charges or electrochemical gradients) that may be produced by cell membranes and tissue interfaces.
Capacitance causes the administered current to lag behind the voltage and creates a phase shift that is
represented by the phase angle (Lukaski, 1996). The clinical systems may have more than one
frequency setting (5 to 200 kHz) to improve accuracy when testing very thin or very obese subjects
(Hannan, 1995 & Lukaski, 1996).
BIA Testing
The ideal test time is in the morning before breakfast and before having had a physical workout or if
later in the day, at least four hours since the last meal with no workout, coffee or alcohol during the day
of the test (Heyward, 1996). This assures a more accurate body fat mass measure but in not necessary if
the goal is to test random hydration. Good hydration is essential for very muscular subjects because of
the water content of muscle. Lukaski (1985) reported dehydration increases resistance (approximately
40 ohms) resulting in an underestimation of fat free mass and overestimation of fat mass. Morning test
results may be slightly different from those taken after lunch. Using a consistent time of day for repeat
tests with individual patients is advised. Lower hydration scores may also be recorded at the end of the
week in the active working population. In general follow the guidelines and use electrodes and supplies
recommended by the manufacturer. When developing equations for a specific population group use a
meter that provides both resistance and reactance scores. Height, weight, sex and age are usually
entered into the programs. Where height and weight are not available some research is underway to
use a resistance/impedance or reactance measure alone (e.g. frail elderly or critically ill patients) (Olde
et al 1997).
BIA Test Interpretation
The following is an explanation of the type of information seen on a software printout. Equations used
in software are patented and will vary slightly from system to system.
Total Body Water (TBW) is an estimate of total hydration level, including intracellular and extracellular
water (Kushner et al, 1986). It should be available in litres and as a percent with a normal range. For
optimal hydration this reading should be in the upper half of the normal range and vary with age, sex
and body fat. If not, check the patient's fluid intake. The more obese a subject, the lower the percent
total hydration and this may be normal for them given a good fluid intake. However litre volumes will be
normal or high normal. Clinicians have mistakenly tried increased the fluid intake of obese individuals to
improve this score. In general percent TBW will go up as weight goes down.
Intracellular Water (ICW) is an estimate of the water in active tissue and should be provided in litres and
as a percent of a normal range (near 60% of TBW). ICW will be in the high range with a large amount of
muscle in a well hydrated subject and may a proxy for muscle mass. Drops in this compartment indicate
lower hydration or a loss of active cell mass in catabolic patients. Nutrition plans are implemented to
restore or increase ICW litre volume.
Extracellular Water (ECW) is water in tissues and plasma and should be provided in litres and as a
percent of a normal range (near 40% of TBW). It should be close to the low normal range in males and
may be in the low or mid range for females. Subjects with very low body fat will have a lower ECW and
subjects with high body fat will have an associated high ECW. Women on OCA have consistently higher
scores while women not on OCA may have more varied scores. Heyward (1996) discusses women's
cycles in detail. In catabolic patients the litre volume in this compartment will increase with poor cell
membrane transport. Nutrition plans or medication may be implemented to reduce ECW litre volume
(Coodley et al 1995).
Body Cell Mass (BCM) is an estimate of total pounds/kg of all active cells. The percent BCM will be in the
normal range if the subject is close to his/her ideal body weight. It appears as a low percent in obese
subjects but the pounds/kg will be high normal in the active obese individual and low in the catabolic
obese patient. Many overweight subjects have very high BCM in pounds/kg even though their percent
BCM does not appear to be in the normal range. It is important to maintain or improve BCM when
writing nutrition care plans or exercise program. As body fat is lost, BCM percent will come into the
normal range. BCM declines in catabolic patients or with drops or changes in physical activity or with
conditions producing muscle loss. Nutrition plans are implemented to maintain, restore or increase
BCM, ICW litre volume and to prevent excess gain of ECW.
Extracellular Tissue (ECT)/Extracellular Mass (ECM) is an estimate of the mass of all other non‐muscle
inactive tissues including ligaments, bone and ECW. ECT is usually higher than BCM but will be lower
than BCM in very anabolic subjects with normal or low ECW(BCM/ECT ratio >1. German researchers
(Fischer & Ott, 1990) have used a ratio of ECM/BCM (.7 ‐ 1.0 normal range) to monitor improvements in
nutrition in HIV patients. Increasing scores on serial tests were consistent with a decline in status.
Fat Free Mass (FFM)/Lean Body Mass (LBM) is an estimate of the entire mass that is not fat. It should be
available in pounds/kg and may be presented as a percent with a normal range. This compartment will
change with hydration and loss or gain of BCM. This alone is not as sensitive a measure when trying to
determine loss of body cell mass.
Fat Mass (FM) is an estimate of pounds/kg of body fat and percentage body fat. The notion comparing
pounds/kg of Fat Mass with BCM has revealed a clinical comparison measure for practice (FM/BCM
ratio). Qualitative assessment of clinical data on satisfaction with body size, showed women are content
with the same number of pounds of fat mass as BCM and men are content with half as much Fat Mass
as BCM independent of percent body fat (BIA unpublished observations, Schneider (1996‐99). The client
goal for women is to reach a ratio of FM/BCM of 1.0. For men the ratio would be .5). Athletic
individuals are not satisfied with this high a ration and may have lower pounds of body fat than these
standards depending on their sport and the body weight requirement. Percent body fat alone as a
measure continues to discourage large framed, physically active individuals and reduces satisfaction
with body image because of unrealistic normal values well established in the popular press. In fact
clinical BIA data collected (Schneider, 1996‐99) on large numbers of men and women with ideal body
weight, shows that both men and women carry 40 to 45 pounds (18 to 20 kg) of body fat for a wide
range of heights. Using the FM/BCM ratio is a more positive way to present information to patients and
allow active goal setting in relation to BCM maintenance and gradual loss or gain of body fat. More
qualitative/quantitative research is being carried out on this subject.
Phase Angle (PA) is believed to be associated with both nutrition and physical fitness. For example a
stroke patient with one source of nutrition (via mouth), will have a higher phase angle on his/her active
side of the body than on the inactive side of the body. It is believed that the phase angle may indicate
the presence of fully functional cell membrane transport systems. Phase angle scores are between 3
and 10 degrees and vary with age, sex, race, physical activity and the presence of health and disease.
Scores rise in the teen age years from 5 to 7 as growth becomes complete. Similar individual scores may
continue until the forth and fifth decade when scores begin to drop and gradually reduced to the 4‐6
range in seniors. Scores of 8 or 9 are rare, only seen in well nourished physically active subjects such as
body builders. High scores may be seen in well nourished obese subjects. Research is being carried out
to determine variations by race. In catabolic patients, there will be an associated drop in ICW, BCM and
an increase in ECW, which will be improved effectively with an implemented nutrition plan (Scalfi et al,
1999). Studies on HIV and renal patients found the phase angle was correlated with serum albumin, pre
albumin, creatinine and was the most predictive indicator of impending mortality in critically ill patients
(Cherlow et al, 1997; Ott et al, 1995). More research is being done in Canada and the U.S. to determine
applications by age, sex, race, rehabilitation programs and specific catabolic conditions and nutrition
interventions with monitoring of several assessment variables to determine the best practices.
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