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Nutrition and Diet Information

Manual of Nutritional Therapeutics, 6 th Edition David H. Alpers, MD • Beth E. Taylor, DCN, RDN, LD, CNSC, FCCM • Dennis M. Bier, MD • Samuel Klein, MD

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Nutritional Considerations in Chronic Diseases

GENERAL CONSIDERATIONS Cachexia

Many chronic diseases are associatedwithweight loss and decreasedmusclemass, although the relationships of these changes to alterations in nutrition vs. the underlying disease process are difficult if not impossible to separate.Cachexia has been variably defined, but it is a syndrome of multifactorial cause, characterized by decreased body weight, loss of muscle and fat, and increased protein catabolism (1). Because cachexia is the result of the underlying disease and disease-relatedmetabolic changes, its phenotype differs from that of starvation, although losses in bodyweight andmusclemassmay be similar (Table 15-1).Cachexia is characterized by in- creasedproteindegradation, even in thepresence of adequatenutrient intake. Anorexia frequently accompanies the cachexiaof cancer.Proposedmediatorsof cachexiahave included hypothalamic serotonin, leptin, proinflammatory cytokines (tumor necrosis factor- α [TNF- α ], interleukin-1 [IL-1], IL-6, interferon- γ [IFN- γ ]), prostaglandins, and tumor-specific products (2).Manyof these circulating catabolic factors canbeproducedby either thehostor tu- mor itself.However,noneof thesehasbeendocumented tobe causative in the anorexiaof cancer (3).Starvation is characterizedby an excessive lossofnutrients,but cachexia is associatedwith the acute-phase responses that are part of underlying inflammatory or malignant conditions. Thus, feedingdoesnot reverse themacronutrientdeficiency.Body compartment analysis in cachexia, in contrast to starvation, shows increases in resting energy expenditure,proteindegradation, and se- rum insulinandcortisol levels (4).Thesechanges lead to increases inurinarynitrogen loss, skeletal protein breakdown, and lipolysis and to glucose intolerance. Despite aggressive caloric replace- ment, leanbodymassdecreases in critically illpatientswithunderlying infectionor tumor (3). Sarcopenia Sarcopenia is defined as an “age-associated loss of skeletalmusclemass and function” (5).Mus- cle mass can be lost alone or in conjunction with increased fat mass (Table 15-1).The causes of sarcopenia include chronic disease, disuse, altered endocrine function, and/or nutritional

Optimize your patients’ nutrition with this quick-reference manual. Coauthored by three physicians and a dietitian, this manual provides practical, state-of-the-art, evidence- based nutrition recommendations for healthy adults, hospitalized patients, and people with a full range of health conditions. It’s an ideal source to help you meet the nutrition needs of your patients of all ages. d d Provides specific guidance for patients who are pregnant or lactating d d Find information on individual nutrients (e.g., vitamin D, iron) in a dedicated section that covers nutrient components d d Chapters include detailed information on protein and calories, vitamins, minerals, and dietary supplements d d Access advice specific for metabolic disorders (diabetes, dyslipidemia, and renal disease), obesity, and chronic wasting diseases (cancer, AIDS) d d Make informed decisions on enteral and parenteral nutritional therapy

TABLE 15-1

Nutritional Alterations in Starvation, Cachexia, and Sarcopenia

Variable

Starvation

Cachexia

Sarcopenia

↓

0/ ↓ ↓↓

↓ ↓ ↓ ↓ ↓ ↓ ↑

Bodyweight Caloric intake

↓↓↓

↓↓ ↓↓ ↓↓

↓

Total energy expenditure Resting energy expenditure Musclemass& function

↑↑

↓

↓↓↓

↓↑

Protein synthesis

↓

↑

Muscle protein synthesis

↓↓↓ ↓↓↓

↑↑↑

↑↓

Protein degradation

↓↓

↑ ↑

Body fat

↑↓ ↑↓

↑

Insulin resistance

Serum cortisol ↑↓ Adapted from KotlerDP. Cachexia. Ann InternMed . 2000;133:622; EvansWJ. Skeletalmuscle loss: cachexia, sarcopenia, and inactivity. Am J ClinNutr . 2010;91(Suppl):1123S. ↑↑

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