Nutrition in the Patient with Anorexia and Cachexia

1. Nutrition in the Patient with Anorexia and Cachexia Jeanette N. Keith, M.D. Associate Professor of Medicine Departments of Nutrition Sciences and Medicine University of Alabama at Birmingham

2. Two major types Marasmus Kwashiorkor (AKA: Protein Calorie Malnutrition) Protein-Energy Malnutrition Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

3. Marasmus Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

4. Kwashiorkor Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

5. Minimum Diagnostic Criteria Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

6. Physiology of Starvation & Stress Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

7. Metabolic Rate Normal range Long CL, et al.JPEN 1979;3:452-6

8. Protein Catabolism Normal range Long CL.Contemp Surg 1980;16:29-42

9. The Course of Protein-Energy Malnutrition Mild Severity of PEM Mildly catabolic Severely catabolic Moderate Severe Kwashiorkor Marasmus Days Weeks Months Years Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

10. 27-year old female with a 35 pound weight loss in the last six months presents to your morning clinic with her mother In the last two weeks, she has lost an additional 10 pounds. She reports decreased po intake, mild epigastric discomfort and bloating The patient’s main concern is the loss of appetite, and fatigue She is 5’7” tall and weighs 67 pounds, (BP 90/40, P60, R18, T97.8) Case Presentation

11. The patient’s mother calls you at 6 pm stating that her daughter is having palpitations and is on her way to the emergency room. The ER staff pages you. Her ECG reveals torsade des pointes and her potassium is 1.9. She is admitted to the Cardiology service and you are consulted for feeding recommendations. Case Presentation

12. What do you recommend now? Immediate placement of a PICC catheter for TPN initiation. Have the inpatient team place a dobhoff and begin tube feedings Call GI procedures to arrange for PEG placement and enteral feedings. Call Dietary for a 1600 kcal diet and begin a calorie count Intravenous fluids while correcting the potassium and awaiting other lab studies. Case Presentation

13. The patient’s potassium is now normal but her course has been complicated by recurrent vomiting. EGD reveals a decreased gastric motility and a dilated duodenum bulb with normal motility in the second portion of the duodenum. What do you recommend next? Advance her diet to clear liquids Begin TPN Place a post-pyloric feeding tube and begin enteral nutrition Case Presentation

14. You place a post pyloric feeding tube for enteral nutrition. What weight do you use for caloric provision? Ideal Body Weight Actual Weight Adjusted Body Weight How many calories per kilogram per day do you recommend? 35-40 kcal/kg/d 25-30 kcal/kg/d 15-20 kcal/kg/d 20-30 kcal/kg/d Case Presentation

15. On the morning after beginning her enteral feeding, the patient complains of palpitations and pain in her hands. On exam, her hands are swollen and she has pedal edema. Pulmonary exam reveals rales. Her potassium is now 2.9, phophorus is 1.8 and magnesium is 1.4. Diagnosis? Case Presentation

16. Patient at risk = cachectic/marasmic patient Refeeding Syndrome Underlying low cardiac output: Cardiac atrophy Low metabolic rate Predominantly fatty acid utilization Superimposed demand for increased CO: Fluid challenge Glucose challenge Increased catecholamines & metabolic rate Hypophospha-temia Heart failure: Fluid overload Cardiac & respiratory decompen-sation

17. The patient is admitted to inpatient psychiatry for the treatment of anorexia/bulimia nervosa. After 4 weeks on tube feedings, she was successfully transitioned to oral diet. At discharge, her weight was 99 pounds. Case Presentation

18. Hypometabolic, cachectic/marasmic patient Aim = rebuild cautiously to avoid hypophosphatemia & repletion heart failure Refeed gradually with a portion of fuel as fat ADEQUATE PHOSPHORUS Days 1-2 – BEE x 0.8 Days 3-4 – BEE x 1.0 Days 4-6 – BEE x 1.1-1.4 Days 7+ – BEE x 2 if weight gain is desired Selective Refeeding Approaches

19. Hypermetabolic, stressed patient Aim = Replace catabolic losses Refeed aggressively but not excessively Can often achieve calorie & protein goals within 48 hours Patient with mixed marasmic/kwashiorkor (starved but also stressed) Metabolism is accelerated by stress Therefore, generally feed as you would a patient with kwashiorkor But watch carefully for refeeding syndrome Selective Refeeding Approaches

20. The metabolic response to starvation for the hypometabolic patient is to reduce their metabolic rate and use fat as the primary fuel source Visceral protein stores are preserved in early in the clinical course of the hypometabolic, starved state In underweight patients, use the actual body weight to avoid overfeeding. Monitor for re-feeding syndrome with oral, enteral or parenteral nutrition. Key Points To Remember

21. The stressed hypermetabolic patient is more likely to suffer the consequences of underfeeding. The starved, unstressed patient is at risk for the complications of overfeeding and rapid re-feeding. If protein calorie malnutrition (kwashiorkor-type) predominates, vigorous nutrition therapy is urgent. If marasmus predominates, feeding should be more cautious. Take Home Points