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Journal of Clinical Endocrinology & Metabolism , doi:10.1210/jc.2006-0431
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The Journal of Clinical Endocrinology & Metabolism Vol. 91, No. 8 2952-2959
Copyright © 2006 by The Endocrine Society

Comparison of Body Composition Assessment Methods in Patients with Human Immunodeficiency Virus-Associated Wasting Receiving Growth Hormone

John G. Esposito, Scott G. Thomas, Lori Kingdon and Shereen Ezzat

Graduate Department of Rehabilitation Science (J.G.E., S.G.T.), University of Toronto, Toronto, Ontario, Canada M5G 1V7; Department of Medicine (S.E.), Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada, M5G 2C4; Graduate Department of Exercise Sciences (S.G.T.), Faculty of Physical Education and Health, University of Toronto, Toronto, Ontario, Canada M5S 2W6; and Freeman Centre for Endocrine Oncology (L.K., S.E.), Mount Sinai Hospital, Toronto, Ontario, Canada M5G 1X5

Address all correspondence and requests for reprints to: Shereen Ezzat, M.D., FRCP(C), FACP, Freeman Centre for Endocrine Oncology, Mount Sinai Hospital, 600 University Avenue, Room 437, Toronto, Ontario, Canada M5G 1X5. E-mail: sezzat{at}mtsinai.on.ca.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Discussion
 References
 
Context: Bioelectrical impedance spectroscopy (BIS) and skinfold anthropometry (SKF) have been used to monitor body composition among patients with HIV wasting; however, validation of these techniques during recombinant human GH (rhGH) treatment has not been performed.

Objective: Our objective was to evaluate the degree of agreement between criterion measurements of dual-energy x-ray absorptiometry (DXA) and those of BIS and SKF in patients with HIV wasting treated with rhGH.

Design and Setting: We conducted a randomized, double-blinded, placebo-controlled, two-period crossover trial at the University of Toronto and Mount Sinai Hospital (Toronto, Canada).

Patients: A referred sample of 27 community-dwelling men with HIV-associated weight loss (≥10% over preceding 12 months) despite optimal antiretroviral therapy participated in the study.

Intervention: Intervention was one daily injection of rhGH (6 mg) or placebo self-administered for 3 months in a crossover fashion with a 3-month washout.

Main Outcome Measures: Fat-free mass (FFM) and fat mass (FM) were measured by BIS, SKF, and DXA before and after rhGH and placebo treatment.

Results: FFMBIS was not significantly different from FFMDXA after rhGH treatment (P = 0.10). Mean differences (bias ± SD) according to Bland-Altman analysis were smaller for SKF than for BIS (P < 0.05) at all time points, yet treatment-induced change in FM was better detected with BIS than with SKF. BIS estimates of FFM and FM showed better agreement with those of DXA after rhGH treatment (1.6 ± 4.6 kg and –2.1 ± 3.9 kg) compared with baseline (3.8 ± 3.5 kg and –4.1 ± 3.6 kg) and placebo (2.7 ± 4.4 kg and –3.1 ± 4.6) (P < 0.05). BIS overestimated and SKF underestimated the treatment-induced changes in FFM and FM.

Conclusions: SKF was more accurate than BIS when measuring body composition in patients with HIV wasting before and after rhGH treatment; nonetheless, the accuracy of BIS increased after treatment. Change in FM because of treatment was not accurately assessed with SKF.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Discussion
 References
 
PROGRESSIVE INVOLUNTARY WEIGHT loss or wasting is among the most debilitating complications accompanying HIV. The loss of metabolically active lean tissue has long been established as a strong predictor of morbidity and mortality (1, 2, 3). Although highly active antiretroviral therapy has changed the time course of the disease by significantly reducing morbidity and mortality (4), HIV-associated wasting continues to be of clinical concern (5, 6).

The recognition that HIV-associated wasting is intimately related to survival and quality of life has led to the proliferation of clinical techniques to measure body composition. At the same time, there has been considerable interest in developing nutritional and pharmacological treatment strategies to prevent or reverse the wasting. However, assessment of the efficacy of these treatment interventions ultimately relies on the accurate determination of body composition before and after implementation.

Single-frequency bioelectrical impedance analysis (SFBIA), bioelectrical impedance spectroscopy (BIS), and skinfold anthropometry (SKF) have been used to monitor body composition changes in patients with HIV-associated wasting receiving recombinant human (rh)GH treatment (7, 8, 9). These simple bedside methods have been validated in the era of highly active antiretroviral therapy, however, only in HIV-infected patients who had not received anabolic agents (10, 11). Treatment with rhGH increases lean body mass and decreases total body fat, as determined by dual-energy x-ray absorptiometry (DXA), in patients with HIV-associated wasting (12), and similar changes in body composition have been observed using SFBIA (8, 9), yet it is not known whether these rhGH treatment-induced changes are comparable to those observed using DXA. Moreover, the agreement between DXA and SKF and DXA and BIS [a presumably better alternative to SFBIA when there are disturbances in body fluid distribution (13, 14)] has not been previously assessed in patients with HIV-associated wasting undergoing rhGH treatment. Therefore, the aim of this study was to determine, using DXA as a criterion measure for comparison, whether the two field methods of BIS and SKF are able to accurately assess the changes in fat-free mass (FFM) and fat mass (FM) that accompany rhGH treatment in patients with HIV-associated wasting.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Discussion
 References
 
Patients

Male patients (20–70 yr old) with documented HIV-associated wasting from an earlier study (7) were selected for inclusion in the study. Wasting was defined as unintentional weight loss of at least 10% over the preceding 12 months. Eligible patients had to have been receiving a stable regimen of antiretroviral therapy for at least 1 month before study entry and were to continue with the same regimen for the duration of the study. Patients must not have had rhGH treatment for at least 2 yr or received systemic glucocorticoids for at least 6 months before study entry. Those already receiving androgenic agents (i.e. testosterone) had to be receiving them for at least 6 continuous months before entry and were to continue for the duration of the study. Patients with kidney, liver, cardiovascular, or metabolic disease or any other condition that would interfere with study compliance were excluded. Detailed exclusion criteria are cited in an earlier study (7).

Study design

The study was reviewed and approved by the local ethics review committees. After written and informed consent was obtained, the referred patients underwent a prestudy evaluation for eligibility, completed within 1 month of proposed study entry, which included a physical examination (i.e. weight, height, electrocardiogram, chest x-ray, routine hematology, blood biochemistry and urinalysis, and routine ophthalmology) and medical history assessment. Eligible patients were then studied for 9 months in a randomized, double-blinded, placebo-controlled, two-period crossover trial conducted at the University of Toronto and Mount Sinai Hospital in Toronto, Canada.

Treatment consisted of rhGH or placebo, which was self-administered as a nightly sc injection, at a dose of 6 mg/d. The rhGH (Serostim) was provided by Serono, Inc. (Rockland, MA) and was identical to placebo in preparation and packaging. The two-period x two-group trial was an A/B B/A design. Participants were randomized to receive either drug A, rhGH, or drug B, placebo, for 3 months (period 1). After a 3-month washout period, participants crossed over to receive the alternative treatment for 3 months (period 2). Participants randomized to group 1 received drug A (rhGH) in period 1 and drug B in period 2 (A/B); the treatment order for group 2 was B/A. Compliance was assessed from returned vials and self-reporting cards. Dose reduction was permitted if side effects were alleged to be consequent of rhGH treatment.

All measures were made on four major study visits (month 0, 3, 6, and 9). Baseline measurements (month 0 and 6) preceded each treatment period, and identical procedures were undertaken for both periods. In addition, 2 wk after the start of each period, patients were clinically examined for safety (i.e. routine hematology, blood biochemistry and urinalysis, and monitoring of adverse events). Participants were asked not to alter their physical activity throughout the study; this was monitored with the use of patient diaries. The randomization code was computer generated at month 0 after baseline measurements were completed. Unblinding occurred after full completion of the trial by all participants.

Body composition assessment

Total body mass and stature were measured to the nearest 0.1 kg and 0.5 cm, respectively, in light clothing and without shoes and were used to calculate body mass index (kg/m2). All measurements of FFM and FM obtained from BIA and SKF were performed by the same trained observer and those from DXA by a laboratory technician.

SKF

Skinfold thicknesses were measured at four sites (biceps, triceps, subscapular, suprailiac) on the right side of the body using a Harpenden Skinfold Caliper (British Indicators Ltd., London, UK) according to an established protocol (15). Body density was calculated using the formula of Durnin and Womersley (16), and percentage of body fat was then calculated using Siri’s equation (17). FFM was determined from the estimate of percentage of body fat by subtracting FM from total body mass.

BIS

Whole-body BIS was performed with the patient in the supine position, arms abducted from the body and legs comfortably separated, using a multifrequency spectrum analyzer (Hydra ECF/ICF Model 4200; Xitron Technologies, Inc., San Diego, CA). The electrodes were placed in the standard tetrapolar positions (18), and a variable current (50–700 µA RMS dependent upon frequency output and load) was delivered. The Hydra ECF/ICF software estimated the volume of extracellular fluid (ECF) and intracellular fluid (ICF) by measuring resistance and reactance at 50 programmed frequencies between 5 kHz and 1 MHz. The measured raw spectral data were fit to the Cole biophysical model using least-squares nonlinear curve fitting, and the modeled resistances of ECF and ICF for each subject were used in equations formulated from the Hanai mixture theory to predict ECF and ICF volume (19). Total body water and FFM are then calculated as ECF + ICF, assuming FFM is 73.2% total body water (20). FM was determined by subtracting FFM from total body mass.

DXA

DXA was used for the measurement of whole-body composition, including FM, lean tissue mass, and bone mineral content, using a Lunar DPX-L Plus bone densitometer (Model 2288; Lunar Corp., Madison, WI) in accordance with standardized procedures recommended by the manufacturer. DXA measurements were performed with the patient in the supine position, dressed in light clothing, and wearing no metal objects. Total body scanning time was approximately 11 min, and the total x-ray radiation received by each patient was approximately 0.03 mrem. FFM was derived from the sum of the estimates of lean tissue mass and bone mineral content. DXA was the reference method.

Statistical analysis

All statistical analyses were performed using SigmaStat for Windows (version 3.1; Systat Software Inc., Point Richmond, CA). Data are expressed as mean ± SD unless stated otherwise. Differences in baseline characteristics between groups 1 and 2 were analyzed using a two-sample t test. All measures were examined for equality of carryover effects using a two-sample t test of patient totals for period 1 plus period 2 values at P < 0.10 (21). When there was no evidence of a carryover effect, the two patient groups were combined and comparisons between methods were made for each time point. Changes in FFM and FM within (pre vs. post) and between (rhGH vs. placebo) treatment periods, estimated using each method, were assessed using a two-factor (period x time) repeated-measures ANOVA. Change over time (pre vs. post) within each period (rhGH and placebo) was assessed when there was a significant period x time interaction. Post hoc comparisons were made using Tukey’s test.

FFM and FM measured using DXA were compared with those estimated using BIA and SKF by paired t tests, and the Pearson’s correlation coefficient was used to evaluate the strength of the relationships between the methods. Agreement between measurements of DXA and those of BIA and SKF was evaluated using the method of Bland and Altman (22). The limits of agreement between methods were defined as the mean ± 1.96 SD of the difference between the methods. Similar analyses were conducted to compare the changes ({Delta}) in FFM and FM after treatment (rhGH and placebo).

Changes in agreement (bias ± SD) within (pre vs. post) and between (rhGH vs. placebo) treatment periods, for BIS (DXA-BIS) and SKF (DXA-SKF), were assessed using a two-factor (period x time) repeated-measures ANOVA. Change over time (pre vs. post) within each period (rhGH and placebo) was assessed when there was a significant period x time interaction. Post hoc comparisons were made using Tukey’s test. Also, paired t tests were used to compare the absolute values of the biases of BIS with those of SKF (DXA – BIS vs. DXA – SKF for FFM and FM) at each time point to determine which method had better agreement with DXA. Similar analyses were conducted to compare the biases of {Delta}FFM and {Delta}FM ({Delta}DXA – {Delta}BIS vs. {Delta}DXA – {Delta}SKF ) after treatment (post-rhGH and post-placebo). All reported P values are two-sided and the level of significance was P < 0.05.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Discussion
 References
 
Patient characteristics

Demographic, clinical, and biochemical data of the patients are summarized in Table 1Go. Thirty male patients met inclusion criteria and gave informed consent to participate in the study. Two patients, one from each group, withdrew before completion of the study on account of arthralgia and headaches and another, from group 1, died from a cerebrovascular accident during the washout period. Therefore, 27 patients (26 White/Caucasian, one Hispanic/Latino) completed the 9-month trial. Three patients had the additional diagnosis of lipodystrophy. Blinded dose reduction to 3 mg/d was required in 10 patients as a result of side effects (arthralgias) during the rhGH treatment period. Thus, the actual mean ± SD dose administered was 74.5 ± 17.5 µg/kg·d. Side effects resolved after the dose reduction. Treatment with rhGH did not lead to the development of insulin resistance or changes in fasting glucose, glycosylated hemoglobin, and blood pressure (data not shown). There were no significant differences among baseline characteristics (Table 1Go) between groups 1 (treatment order rhGH/placebo) and 2 (treatment order placebo/rhGH). There was also no significant carryover effect for the FFM and FM estimates obtained from each of the techniques.


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  		TABLE 1. Patient characteristics by group at baseline

 
Changes in body composition

FFM estimated using each of the three methods (DXA, BIS, and SKF) significantly increased after rhGH treatment (+3.8 ± 2.8 kg, +5.7 ± 4.6 kg, and +1.9 ± 2.7 kg) relative to placebo. On the other hand, only FM estimated using DXA and BIS decreased significantly after active treatment (–1.9 ± 2.3 kg and –3.7 ± 3.6 kg) compared with placebo (Fig. 1Go). A significant period x time interaction for the change in SKF measurements of FM was not observed.


Figure 1
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  		FIG. 1. FFM and FM measurements by the three methods before and after rhGH and placebo treatment. Bars represent mean ± SEM. *, P < 0.05, BIS or SKF vs. DXA from paired t test; {dagger}, P < 0.05, between treatment period difference (post-rhGH vs. post-placebo from post hoc Tukey’s test).

 
Comparison of methods

The comparison of FFM and FM between DXA and the two field techniques (BIS and SKF), before and after rhGH and placebo treatments, is demonstrated in Fig. 1Go. Pearson’s correlation coefficient (r), mean difference (bias), SD of the difference, limits of agreement, and P value for each comparison are listed in Table 2Go. FFMBIS and FFMSKF showed very strong correlations with FFMDXA at all time points. Correlations for FM ranged from moderate to strong. Compared with DXA, BIS significantly underestimated FFM at all time points except after rhGH treatment and correspondingly overestimated FM significantly at all time points. There were no significant differences between FFMDXA and FFMSKF at any of the time points, yet SKF tended to overestimate FFM at all time points except after rhGH treatment. On the other hand, SKF significantly overestimated FM only after rhGH treatment.


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  		TABLE 2. Comparison of FFM and FM using BIS and SKF vs. DXA in patients with HIV-associated wasting, before and after rhGH and placebo treatment

 
FFMBIS demonstrated significantly better agreement with FFMDXA after rhGH treatment relative to baseline and placebo. A significant period x time interaction for the change in agreement between FFMSFK and FFMDXA was not observed. Only FMBIS showed better agreement with FMDXA after active treatment compared with baseline and placebo; the agreement between FMSKF and FMDXA evidently worsened (Table 2Go).

Table 3Go shows Pearson’s correlation coefficient (r), mean difference (bias), SD of the difference, limits of agreement, and P value for each comparison of {Delta}FFM and {Delta}FM after treatment with rhGH and placebo. Correlations for {Delta}FFM and {Delta}FM after treatment with rhGH and placebo ranged from moderate to strong. BIS significantly overestimated, and SKF significantly underestimated, {Delta}FFM and {Delta}FM by approximately 2 kg after rhGH treatment (Fig. 2Go). There were no significant differences between DXA and either of the two field methods after treatment with placebo for {Delta}FFM and {Delta}FM.


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  		TABLE 3. Comparison of change in FFM and FM using BIS and SKF vs. DXA after rhGH and placebo treatment in patients with HIV-associated wasting

 

Figure 2
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  		FIG. 2. Bland-Altman plots depicting bias as a function of the mean of the two techniques for the change in FFM ({Delta}FFM) and FM ({Delta}FM) after rhGH treatment. The middle solid line represents the mean difference between the measurements; the upper and lower dashed lines represent the upper and lower limits of agreement.

 
The absolute values of the bias for FFM and FM were significantly smaller for SKF compared with BIS at all time points (Table 2Go), indicating that SKF had better agreement with DXA than did BIS. Additionally, the absolute values of the bias for {Delta}FFM and {Delta}FM were significantly smaller for SKF compared with BIS only after treatment with placebo (Table 3Go).


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
References
 
There is a paucity of scientific literature on the agreement of methods for measuring changes in body composition resulting from treatment interventions for wasting in patients with HIV infection. This study is the first to report comparisons of body composition measurements made using noninvasive bedside techniques (BIS and SKF) with those made using DXA before and after rhGH treatment in patients with HIV-associated wasting. Moreover, it is the first to assess the validity of BIS measurements of FFM and FM in these patients. The main findings of the study are that: 1) compared with BIS, SKF demonstrates better agreement with DXA before and after rhGH treatment when measuring FFM and FM and the changes therein; 2) the agreement between BIS and DXA, for both FFM and FM measurements, improves after rhGH treatment; 3) the agreement between FMSKF and FMDXA worsens after rhGH treatment; and 4) BIS overestimates, and SKF underestimates, rhGH treatment-induced changes in FFM and FM.

It is essential to be able to measure changes in body composition using readily available and validated techniques so that nutritional and pharmacological interventions can be evaluated. In our study, DXA was selected as the reference method. It has been validated against other methods of body composition analysis (23, 24, 25) and has shown little bias based on age, sex, physical activity levels, race, or proportion of fat (26). BIS was chosen over SFBIA as a bedside method in this study because of its sensitivity to changes in ECF. Traditional SFBIA, at a frequency of 50 kHz, is not useful when there are gross changes in ECF, and parallel-transformed SFBIA seems to be sensitive to changes in ICF (or body cell mass) but not to changes in ECF, thereby making the evaluation of FFM or FM by SFBIA rather challenging when there is abnormal hydration (27, 28). HIV infection can cause shifts in body water compartments (29), and tissue edema is known to accompany rhGH treatment (30). Hence, BIS may be more accurate than SFBIA in populations that experience potential alteration in body fluid distribution, such as those with HIV infection and/or receiving rhGH treatment.

In the present study, the traditional method of SKF revealed smaller differences with DXA than did BIS for FFM and FM, before and after rhGH treatment. Moreover, differences between FFMSKF and FFMDXA were not significant at all time points, indicating a high level of comparability between the two measurements. In men with HIV-associated wasting not receiving anabolic agents, SKF demonstrates a lower degree of bias with DXA in comparison with several SFBIA equations in the determination of FFM and FM (11). In patients with other disease states, such as those on long-term hemodialysis therapy and with chronic renal failure, SKF is more accurate than SFBIA in estimating FFM and FM when DXA is the reference method (31, 32). However, the larger errors produced by SFBIA in these studies might have been attributable to variations in hydration status among the patients, which could potentially be reduced with the use of alternative bioelectrical impedance models, such as BIS. Nonetheless, for measuring changes in body composition among patients with HIV-associated wasting, SKF has been shown to agree well with total body water by deuterium dilution (a gold standard technique) in the evaluation of FFM (33).

In healthy individuals, multifrequency BIA tends to overestimate FM when subjects are relatively lean and underestimate FM when subjects are overweight or obese (34). More importantly, BIA overestimates FFM compared with DXA in patients with HIV-associated wasting with greater FM (11) and lipodystrophy (35). When patients with HIV-associated wasting are treated with nandrolone decanoate, the change in FFM estimated using BIS accurately reflects the change in nitrogen balance (36). In our study, the degree of bias between BIS and DXA, for both FFM and FM, significantly improved after rhGH treatment, and FFMBIS was comparable to FFMDXA after treatment. Taken together, we hypothesize that the improvement in bias is attributable to the well-known improvement in body composition after rhGH treatment in HIV-infected patients demonstrating wasting (12) and lipodystrophy (37, 38, 39).

Contrastingly, the degree of bias between SKF and DXA was maintained for FFM after treatment with rhGH but worsened for FM. We found no significant change in FMSKF after rhGH treatment, yet FMDXA (and FMBIS) significantly decreased. Furthermore, we have previously shown that rhGH treatment has no significant effect on the sum of trunk skinfold thicknesses (7). Thus, FMSKF is less sensitive to rhGH treatment, and consequently the degree of bias between FMSKF and FMDXA is greater after treatment. FMSKF should therefore be interpreted with prudence in patients with HIV-associated wasting receiving rhGH treatment.

In clinical trials of treatment interventions for wasting, longitudinal changes in body composition are the most appealing. However, studies assessing the agreement between methods for measuring changes in body composition among patients with HIV-associated wasting are virtually nonexistent. This study is the first to evaluate the comparability of bedside (BIS and SKF) measurements with those of criterion DXA, before and after treatment with rhGH, in patients with HIV-associated wasting. Moreover, it is the first to elucidate the degree of agreement between these techniques for measuring the rhGH treatment-induced changes in FFM and FM among these patients. On the basis of our analysis, BIS overestimated both {Delta}FFM and {Delta}FM, whereas SKF underestimated the changes after rhGH treatment in comparison with those of DXA. On average, for both {Delta}FFM and {Delta}FM, each method differed from DXA by approximately 2 kg. However, the relatively broad limits of agreement suggest that some caution be used in clinical application. Nevertheless, we have demonstrated that BIS and SKF possess their own individual strengths, and we therefore suggest that the assessment of body composition, and the changes therein among patients with HIV-associated wasting receiving rhGH treatment, would be better served by their use in a complementary fashion.

A limitation of the present study is that BIS was not compared with SFBIA. It was assumed that BIS would be superior to SFBIA considering its alleged sensitivity to changes in body water compartments, which would potentially result from treatment with rhGH. Previous studies evaluating the comparability of DXA and BIA in HIV-infected patients have exposed a high degree of bias between SFBIA and DXA for the determination of FFM that was specific to the BIA equation used (10, 11). In our study, the degree of bias and limits of agreement between BIS and DXA before rhGH treatment were larger than those published between SFBIA and DXA (10, 11) for several SFBIA equations, indicating that BIS may not offer any practical advantage over SFBIA in the determination of FFM and FM in those patients with HIV-associated wasting who are not receiving rhGH treatment. This supports the results of another study that showed no marginal superiority of BIS over SFBIA in the prediction of body water compartments in patients with HIV-associated wasting (40). It is also unknown whether the bias between SFBIA and DXA would follow a similar trend of improvement as that observed in our study for the bias between BIS and DXA. Another study limitation is that our analysis included only male patients. The comparability of various techniques for assessing body composition is different in males compared with females with HIV-associated wasting (11), and therefore, our results cannot be readily applied to females with the disease. Finally, although the mean differences observed between DXA and both bedside methods are reasonably acceptable for the estimation of FFM and FM in this population as a whole, the relatively wide limits of agreement, especially for BIS measurements, are reflections of the small sample size and the great variation among the individual differences. Body composition can affect the estimation of FFM and FM by BIA. BIA tends to overestimate FM when subjects are relatively lean and underestimate FM when subjects are overweight or obese (34). Furthermore, body fatness has a significant effect on the prediction of FFM by BIA in patients with HIV-associated wasting (11). Therefore, the clinical evaluation of body composition to assess treatment efficacy should be exercised with caution when using BIS and SKF.

In summary, we have shown that the simple, inexpensive, and long-established method of SKF is more accurate than BIS in estimating FFM and FM, before and after rhGH treatment. However, FMSKF is insensitive to rhGH treatment, and as a result, the accuracy of SKF diminishes when estimating FM after rhGH treatment, which in turn leads to an underestimation of the change in FM altogether. On the other hand, the accurateness of BIS in estimating FFM and FM improves after treatment with rhGH, making BIS a better alternative to SKF in detecting rhGH treatment-induced changes in body composition. We recommend that the two bedside techniques be used jointly in the evaluation of FFM and FM, and the changes therein, in patients with HIV-associated wasting receiving rhGH treatment.


   Footnotes
 
Serono Inc. provided partial funding support for the study and the study drug and placebo.

Disclosure summary: The authors have nothing to disclose.

First Published Online June 6, 2006

Abbreviations: BIS, Bioelectrical impedance spectroscopy; DXA, dual-energy x-ray absorptiometry; ECF, extracellular fluid; FFM, fat-free mass; FM, fat mass; ICF, intracellular fluid; rh, recombinant human; SFBIA, single-frequency bioelectrical impedance analysis; SKF, skinfold anthropometry.

Received February 24, 2006.

Accepted May 26, 2006.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 References
 

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