[June Edition] Personalized Protein Targets in the ICU: Moving Beyond Body Weight |
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Welcome to the June edition of BWA Insights!
InBody Co., Ltd. is a medical device company with over 30 years of experience in body composition analysis. Our technology has been clinically validated, showing up to 98% correlation with DXA in studies conducted by the Mayo Clinic, and further verified across diverse populations by the University of North Carolina at Chapel Hill. Today, InBody devices are featured in more than 6,000 peer-reviewed publications across fields including nephrology, clinical nutrition, and intensive care.
If you have any questions about the research featured in this issue or would like to request a device demonstration, feel free to reply to this email or click this link to sign up. |
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Executive Summary
Critically ill patients frequently face protein-energy malnutrition, driven by inflammation and hypercatabolic stress.
Standard nutritional targets based on actual body weight (ABW) may overestimate requirements in patients with altered body composition, such as those with obesity or fluid retention.
The COFEED-19 study demonstrated that ICU patients who achieved ≥70% of their energy and ≥80% of their protein needs - calculated using fat-free mass (FFM) - had significantly better 90-day survival outcomes.
Bioelectrical Impedance Analysis (BIA), particularly when adjusted for fluid overload, offers a non-invasive and bedside-accessible method to estimate FFM and support individualized nutritional strategies in the ICU. |
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Why It Matters
Malnutrition is common in ICU patients and contributes to poorer outcomes - including infections, prolonged stays, and higher mortality.¹ Muscle loss from hypercatabolism is rapid and severe, and conventional nutrition targets based on ABW may misrepresent true needs in patients with abnormal body composition.² ⁻ ⁴ Thus, FFM is increasingly used to personalize energy and protein delivery in critical care settings.⁵
📑Study Focus: COFEED-19
A retrospective cohort study conducted at Gelderse Vallei Hospital in the Netherlands evaluated 85 mechanically ventilated COVID-19 ICU patients between March 2020 and December 2021.⁶ Bioelectrical Impedance Analysis (BIA) using the InBody S10® was performed within 24 hours of ICU admission and repeated every three days to monitor fluid and body composition changes. To enhance accuracy in patients with fluid imbalance, the researchers applied a fluid overload correction:
Excess ECW was estimated by comparing the ECW/TBW ratio to a reference value of 0.380 (normal in healthy individuals). This excess was subtracted from the measured ECW to yield an adjusted FFM.⁶
🗝️Key Metrics Explained
- Total Body Water (TBW): The combined volume of all fluid within the body—typically 50–70% of body weight.
- Extracellular Water (ECW): Water outside the cells, including interstitial and plasma fluids; may increase with edema.
- Intracellular Water (ICW): Fluid inside the cells, essential for cellular metabolism and function.
- Fat-Free Mass (FFM): All mass excluding fat (muscle, bone, organs); estimated using BIA.
- ECW/TBW Ratio: Indicates fluid distribution; values >0.390 often suggest fluid overload.
☑️ Nutritional Targets
Nutritional requirements were calculated using both Actual Body Weight (ABW) and Fat-Free Mass (FFM), and were reassessed every 3 days starting from ICU Day 4 to reflect dynamic clinical status.
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- Actual Body Weight (ABW): Measured weight using ICU-calibrated bed scales.
- Fat-Free Mass (FFM): Derived from BIA (InBody S10®)
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Takeaway: ICU patients who achieved both ≥70% of their energy and ≥80% of their protein targets - when calculated using Fat-Free Mass (FFM) - had a significantly lower
90-day mortality rate, underscoring the importance of personalized, composition-based nutritional strategies. |
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Clinical Implications
- Rethink ABW-based dosing: In critically ill patients, especially those with obesity or edema, relying solely on actual body weight (ABW) may overestimate protein needs, potentially leading to inappropriate nutritional support.
- Leverage FFM for Personalization: Fat-Free Mass (FFM), as measured by Bioelectrical Impedance Analysis (BIA), offers a more physiologically relevant estimate of protein-requiring tissue, allowing for more individualized energy and protein targets.
- Correct for Fluid Overload: In ICU patients, fluid accumulation can skew BIA measurements, leading to overestimated FFM values. Applying fluid-correction methods helps enhance the accuracy and clinical usefulness of body composition data.
About BIA and InBody BWA 2.0S
Bioelectrical Impedance Analysis (BIA) is a validated, non-invasive technique for quantifying body composition at the bedside. It measures parameters such as:
- Fat-Free Mass (FFM)
- Total Body Water (TBW)
- Intracellular/Extracellular Water (ICW/ECW)
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It is also endorsed by the Global Leadership Initiative on Malnutrition (GLIM) as a supportive tool for assessing muscle mass in clinical nutrition evaluations.⁷
The InBody BWA 2.0S enhances traditional BIA methodologies by offering advanced, research-informed adjustments that may be particularly relevant in critical care:
- Adjusted FFM and Adjusted SMI: These values account for excess extracellular water (ECW) by referencing a normative ECW/FFM ratio of 28%, helping clinicians interpret muscle and lean mass more accurately in fluid-overloaded patients.
- Reference-Based Calibration: Outputs are contextualized using InBody’s extensive internal dataset, comprising over 130 million body composition measurements across healthy populations, stratified by age and sex.
⚠️Important
These adjusted parameters use InBody’s proprietary method and differ from the fluid correction technique applied in the COFEED-19 study. They are not validated for diagnostic use but may provide helpful context for monitoring trends and guiding clinical decisions. |
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Final Thoughts
The COFEED-19 study reinforces the clinical relevance of using fat-free mass (FFM) to guide individualized energy and protein targets in critically ill patients, particularly those with complex body composition profiles.
Emerging technologies such as the InBody BWA 2.0S enable the bedside assessment of FFM and hydration status, supporting a more tailored approach to nutrition management.
While these tools are not diagnostic devices and protocols for their use in ICU settings are still evolving, they may complement clinical judgment by offering real-time insights into patient status.
As interest in precision nutrition grows, bioimpedance-based solutions may play an increasingly supportive role in aligning nutritional strategies with patient-specific needs.
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📜References
1. Rezaeian M, Monfared-Parizi S, Mousavi Shirazifard Z, Sayadi A, Khodadadi H, Ghaseminasab-Parizi M. Evaluation of nutritional intake and malnutrition in critically ill patients and its relationship with 28-day death. Sci Rep. 2025;15(1):7425. Available from: https://www.nature.com/articles/s41598-025-00780-2
2. McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and ASPEN. JPEN J Parenter Enteral Nutr. 2016;40(2):159–211. doi:10.1177/0148607115621863
3. Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48–79. doi:10.1016/j.clnu.2018.08.037
7. Cederholm T, Jensen GL, Correia MITD, Gonzalez MC, Fukushima R, Higashiguchi T, et al. GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community. Clin Nutr. 2019;38(1):1–9. doi:10.1016/j.clnu.2018.08.002 |
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