Nutrition Focused Physical Exam: Identifying Malnutrition The application of hand grip strength in dietetic practice Jane McClinchy Principal Lecturer University of Hertfordshire

Content The equipment and methods used to assess hand grip strength The research relating to the use of hand grip strength and the assessment of nutritional status Relate this to dietetic practice

Jamar® Hydraulic Hand Dynamometer Takei A5401 Digital Hand Grip Dynamometer £431 Also: Smedley Hand grip Dynamometer Nottingham electronic dynamometer

Introduction Handgrip strength is useful as a test of skeletal function The test was developed by hand therapists Chking out

Indicator of concurrent and future status Frailty and Sarcopaenia Bohannon et al 2015 in his review of the clinical and prognostic value of hand-grip dynamometry pulled together this illustration showing that the measurement has a concurrent and prognostic value Research examples for the concurrent value: Martin-Ponce et al 2014 examined 310 patients admitted to Hospital Universitario de Canarias –public hospital in the Canaries found a low but significant correlations between grip strength and the serum albumin and subjective nutritional scores of hospitalized older adults 310 over 60 Bohannon (2015) page 468

The use of hand grip strength as a predictor of nutritional status in hospital patients Change in mean percent ideal HGS (left) and mean PG-SGA score (right) between baseline and two weeks (n = 18).HGS: hand grip strength.PG-SGA: patient generated subjective global assessment.25Patients who remained in or returned to hospital two weeks Flood et al looked at patients referred to the dietetic department . The figures show that as the HGS went down , the SGA score went up. The dotted line is a repeat in the measurements after 2 weeks- undertaken on just 18 patients, Flood et al 2014

Visual representation of variables significantly associated with handgrip strength in the multivariate regression analysis model. In a public hospital in Portugal 89 in patients over 6 consecutively admitted were recruited for the longitudinal study30% were malnourished in admission Visual representation of variables significantly associated with handgrip strength (HGS) in the multivariate regression analysis model. BMI, body mass index; kgF, kilogram force. Grip strength was independently associated with undernutrition as defined by BMI z scores User a Jamar that was fitted to the size of the child’s hand Silva et al 2014 Copyright © by The American Society for Parenteral and Enteral Nutrition

Hypotheses for the pathogenesis of impaired muscle function in malnutrition. Change in muscle calcium Norman et al 2011

Recommended use in dietetics? For diagnosing ‘severe’ malnutrition (White et al 2012) Screening for malnutrition in patients with renal disease (Wright and Jones, 2010) Nutritional status and disease severity in adults with cystic fibrosis (Mead et al., 2014) Prognostic predictor in: Haemodialysis patients (Isoyama et al., 2012) Alcoholic liver disease (Plauth et al., 2006) Liver disease (Alvares-da-Silva and Reverbel da Silveira., 2005) Potential to show impact of intervention (Gandy, 2014) Patients with renal disease have lower hand grip strength, but also a low hand grip strength has been found to be more strongly associated with the risk of mortality than low muscle mass in dialysis patients

Application to dietetics Where changes in fluid status make BMI unreliable For auditing the outcome of our clinics Would like to use it more frequently Plan to review the values being used Specialist areas Liver patients Haemodialysis patients Children and adults with cystic fibrosis GI Clinic Malnutrition in the elderly Liver patients Quicker to show changes in nutritional status than other methods In combination with mid upper arm circumference, tricep skinfold thickness and mid arm muscle circumference Not affected by fluid status TAKEI Reference ranges from Klidjan et al 1982 Haemodialysis patients Recommended as part of nutritional assessment Non-dominant and non fistula arm Taken at regular intervals across their care Helps to show patients how well they are doing after surgery Links to BMI but BMI does not accurately assess sarcopaenic obesity Children and adults with cystic fibrosis Annual review Those with liver and kidney disease and transplanted patients Encourages enteral intake Jamar is used GI Clinic As an audit tool to show overall outcomes for the clinic The method for TAKEI used is: Using the non-dominant hand with the patient in a standing position and the arm held straight by the side but not touching the side. The highest value of a series of three measures are recorded, to the nearest kilogram. This is converted to percentage of predicted normal handgrip strength for age and gender using published reference values.  

Southampton protocol for adult grip strength measurement. (1) Sit the participant comfortably in a standard chair with legs, back support and fixed arms. Use the same chair for every measurement. (2) Ask them to rest their forearms on the arms of the chair with their wrist just over the end of the arm of the chair—wrist in a neutral position, thumb facing upwards. (3) Demonstrate how to use the Jamar handgrip dynamometer to show that gripping very tightly registers the best score. (4) Start with the right hand. (5) Position the hand so that the thumb is round one side of the handle and the four fingers are around the other side. The instrument should feel comfortable in the hand. Alter the position of the handle if necessary. (6) The observer should rest the base of the dynamometer on the palm of their hand as the subject holds the dynamometer. The aim of this is to support the weight of the dynamometer (to negate the effect of gravity on peak strength), but care should be taken not to restrict its movement. (7) Encourage the participant to squeeze as long and as tightly as possible or until the needle stops rising. Once the needle stops rising the participant can be instructed to stop squeezing. (8) Read grip strength in kilograms from the outside dial and record the result to the nearest 1 kg on the data entry form. (9) Repeat measurement in the left hand. (10) Do two further measurements for each hand alternating sides to give three readings in total for each side. (11) The best of the six grip strength measurements is used in statistical analyses so as to encourage the subjects to get as high a score as possible. (12) Also record hand dominance, i.e. right, left or ambidextrous (people who can genuinely write with both hands). Equipment: Model J00105 JAMAR Hydraulic Hand Dynamometer. Roberts et al 2011 © The Author 2011. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Measurement top tips Calibrate the equipment Set to kg Use the same method Standing or sitting does not seem to matter (see Dodds et al 2014) Dominant vs non dominant –studies vary Aiming to get the maximal grip strength Give patients time to get used to the equipment Compare to normative values for your population Eg for HD patients, they will all have lower values Dodds

Grip strength varies with different population groups In order to use as an outcome measure there is a need for normative values Higher in: Men than women Younger than older Farming back ground Also affected by mental health-lower in anxiety and affected by medications Gibson, R. S. (2005). Page 429

Standards in use in practice Gandy (2014) Page 54 Todorovic and Micklewright (2011) page 2.21 Technique: Squeeze as hard as possible on three occasions using the non-dominant arm. The highest reading should be taken.

Cross-cohort centile curves for grip strength. Centile curves 10, 25, 50, 75 and 90 Dodds developed normal values from 12 British studies Ie what could be expected for their gender and age One used TAKEI, a further 4 used similar equipment (Smedley and Nottingham) and 7 used Jamar Participants were measured either siting or standing We can see that the grip strength is highest at ages 29 to 29 with a peak of 51kg and women 31 kg at ages 26 to 42. followed by a gradual lowering at 50 and then steeper declines over 80 years. It is lower in women than men They suggest that in application to clinical practice that rather than taking 85% of normal value for age that instead the peak value in early adult life as a cut off for weak grip at subsequent ages using t-scores Dodds et al 2014 Dodds RM, Syddall HE, Cooper R, Benzeval M, Deary IJ, et al. (2014) Grip Strength across the Life Course: Normative Data from Twelve British Studies. PLOS ONE 9(12): e113637. doi:10.1371/journal.pone.0113637 http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0113637

Clinical application Klidjian et al 1980 propose 85% of normative value by age which is equivalent to 1 SD Having grip strength comparable to younger adults is more desirable than having grip strength comparable to other older adults whose strength has also declined with age’ (Bohannon 2015) Dodds et al 2014 propose -2.5 SD from the maximal value to define a weak grip Men Women Maximal -2.5 SD 51.9 27 (23% aged 80) 31.4 16 (26.6% aged 80)

Country setting of included samples by UN region. Country setting of included samples by UN region. The chart shows the country setting of the 63 included samples, grouped by UN region. Dodds et al. 2016 © The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.

Grip strength mean values from included samples, by UN region. Grip strength mean values from included samples, by UN region. Each point represents the mean value of grip strength for each item of normative data, plotted against the mid-point of the age range it relates to. Values from the same sample are connected. Data from developing and developed regions are shown with triangles and circles, respectively. For comparison, the grey curve shows the mean values from our normative data for 12 British studies. Dodds et al. 2016 © The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.

Use in research as a dietetic intervention outcome measure in adults (hand grip strength or dynamometry) AND (nutritional assessment or nutritional status) (nutritional intervention) 2007-2016 15 accessible 12 RCT One prospective One SR One meta-analysis 60% (9) showed improvement 80% (12) referred to a specific dynamometer As muscle function reacts earlier to nutritional deprivation as well as restoration than muscle mass itself it could be that changes in handgrip strength could be used to detect and monitor changes in nutritional status and therefore as an outcome measure of nutritional status. Norman et al present the results of their review To find out what research is being undertaken in this area a search of the research literature published between 2007 and 2016. The terms used were (hand grip strength or dynamometry) AND (nutritional assessment or nutritional status) AND (nutritional intervention). 15 articles that were accessible, in English and that related to adults were reviewed. Twelve were RCTs, one was a prospective study, one was a systematic review and one was a meta-analysis. 60% (9) studies showed an improvement in grip strength following the intervention. 80% (12) referred to using a specific hydraulic dynamometer 5% sat it was th Jamar . No study used the assessment of grip strength alone as the outcome measure

Research outcomes 80% (12) specifically investigated supplementing nutritional intake in grip strength, 27% (4) investigated the impact of a dietitian as part of patient care on grip strength and 40% (6) of the studies explored the impact of the intervention on the grip strength of older people. 53% specifically mention the Jamar 3 did not specify Others mentioned –tanita taki, digimax 7 gave a specific method all used maximal data, 3 said seated, the rest did not state, 1 dominant, 2 non dominant and 2 used both hands 9 of the studies were able to show positive outcomes through the use of the HGS, but this was alongside other measures

Effects of food fortification on nutritional and functional status in frail elderly nursing home residents at risk of malnutrition 52 residents, 22 intervention and 30 control randomised (in a nursing home by ward) The intervention group received protein- and energy-enriched soups and sauces and two additional snacks high in protein and energy that were served between meals. This group is referred to as the food-fortification (FF) group. The approximate nutrient content of the standard diet was 2000 kcal of energy, 80 g of protein, 60 g of fat, and 260 g of carbohydrates. Protein powder derived from hydrolyzed milk was used to enrich soups and sauces, adding 5 g of protein powder per 100 mL. Energy was added in the form of 5 g of rapeseed oil per 100 mL of sauce and 10 mL of heavy cream per 100 mL of soup. Snacks on a milk basis were served in 150-mL cups containing approximately 300 kcal, 20 g of protein (including 15 g from added protein powder), 20 g of fat, and 20 g of carbohydrates. The intervention group though took the same amount of energy but their protein intake was higher. Fig. 2. Handgrip strength (kilograms) was maintained after 12 wk of intervention in the FF group but decreased in the standard group. However, the difference between groups was not significant. Box plots indicate minimum, maximum, and 25th, 50th, and 75th perc... Smoliner et al 2008

Conclusion Standard method Normative values for your community Use 1 SD to define weak grip Simple ‘bedside’ / clinical parameter Useful in dietetics as a tool to monitor nutritional status Alongside other methods

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