1/22 Medical Disorder of Nutrition

Question 1

What is the medical consensus for the meaning of Cachexia?

Answer 1

1. Presence of a chronic disease PLUS
2. Loss of body weight > or = to 5%, within previous year or less, PLUS
3. Presence of at least 3 of the following:
   a. Reduced Muscle Strength
   b. Fatigue
   c. Anorexia
   d. Low fat-free mass index
   e. Abnormal biochemistry (inflammation, Anemia, Low albumen)

Question 2

What is the overall prevalence of cachexia in industrialized countries?

Answer 2

1% or about 9 million people. 5 million people in the USA.

Question 3

What is the prevalence of death from cachexia in cancer patients?

Answer 3

> 30% of patients who have cancer die from cachexia. >50% of patients who die from CA have cachexia present. Other chronic illnesses causing death have >30% w/ cachexia present.

Question 4

What are the top 4 conditions where cachexia is present but underestimated or under-recognized?

Answer 4

COPD, Chronic heart failure, malignant cancer, chronic kidney disease.

Question 5

What are 3 main contributors to cachexia?

Answer 5

1) anorexia and/or malnourishment
2) immune overactivity and systemic inflammation
3) endocrine disorders

Question 6

2 general causes of anorexia?

Answer 6

1) decreased desire to eat

2) persistent nausea / GI inhibitors to eating

Question 7

4 general causes of malnutrition?

Answer 7

1) medications
2) effects of radiation treatment
3) Cancers
4) Food intolerance

Question 8

Basic inflammatory response leading to cachexia?

Answer 8

up regulation of pro-inflammatory cytokines –> increases C-reactive protein –> chronic inflammation –> anemia from chronic disease and decreased body weight.

Question 9

In endocrine disorder, what is the consequence of anabolic/ catabolic imbalance?

Answer 9

favors protein degradation
inhibits protein synthesis
resistance to growth hormone

Question 10

There is no specific treatment for cachexia now, but what treatments are under development?

Answer 10

anabolics, anti-catabolic therapies, appetite stimulants, nutritional interventions.

Question 11

What a 4 symptoms/signs related to cancer cachexia?

Answer 11

anorexia, insulin resistance, hypogonadism, inflammation.

Question 12

how is cancer cachexia treated?

Answer 12

1) best = treat cancer
2 )appetite stimulants, progestins, herbal medicine.
3) diet modification & exercise

Question 13

What are possible benefits for exercise in cancer cachexia?

Answer 13

increased: insulin sensitivity, protein synthesis rate, anti-oxidant enzyme activity, immune function.
decreased: CRP (inflammatory response).

Question 14

What are some modes of exercise for cancer cachexia?

Answer 14

endurance exercise (reduces CA related fatigue),
resistance training (may decrease effects of muscle wasting)

Question 15

How does COPD contribute to cachexia?

Answer 15

increases protein degradation pathways. Decreases physical activity and possibly causes arterial hypoxemia.

Question 16

What is the prevalence of cachexia in COPD patients?

Answer 16

20-40% of COPD patients. Very predictive of increased mortality.

Question 17

Can patients with COPD and cachexia increase their peripheral skeletal muscle mass and increase exercise capacity as much as someone who has COPD alone?

Answer 17

can still gain some peripheral skeletal muscle, and they CAN increase exercise capacity as much. High intensity cycle training, 45min/day, 3x/week, X 10 weeks.

Question 18

How are chronic heart failure and cachexia related?

Answer 18

worse outcomes assoc. w/ low BMI. BMI is an independent predictor of survival. Cachexia most likely in NYHA Class 4.

Question 19

why is it difficult to identify cachexia in patients with RA?

Answer 19

because loss of fat free mass is offset by increase in fat mass.

Question 20

what percentage of patients with RA have cachexia?

Answer 20

> 50%

Question 21

What are signs and symptoms of cachexia in pt w/ RA?

Answer 21

Joint pain, restricted mobility, fatigue, reduced muscle mass, strength & endurance. Type II muscle fibers affected more.

Question 22

What are factors leading to cachexia in the ICU, and how quickly is muscle mass lost in the ICU? ICUAW = ?

Answer 22

multi-factorial (multiple organ failure, immobilization, hyperglycemia, corticosteroids, neuromuscular blockers). protein degradation > protein synth. Can lose over 3lbs per day! ICU acquired weakness.

Question 23

In 2 weeks in the ICU how much muscle mass can be lost compared to admission?

Answer 23

up to HALF

Question 24

list some examples of ICU conditions and percent metabolism increases?

Answer 24

postop ~10% metabolism increase. bone fracture ~15%. Sepsis ~ 40%. 40% body burn ~ 80%. 70% body burn ~ 120% metab. increase.

Question 25

What is parenteral feeding?

Answer 25

nutrients enter blood directly. Uses IV pump. risk of catheter injection. expensive.

Question 26

Why do they try to use the gut if it works compared to parenteral feeding?

Answer 26

maintains mucosal integrity. restores immune function (70% of body immune globulin production in gut). decreases morbidity in pts with critical illness.

Question 27

why is enteral feeding not used sometimes?

Answer 27

if gut does not have adequate perfusion. if patient is severely malnurished

Question 28

What do they give in the ICU to help prevent wasting?

Answer 28

insulin, which decreases wasting by stimulating protein synthesis.

Question 29

what is a normal Albumen level? abnormal?

Answer 29

3.5-5 g/dL. decreased is <3.2 g/dL.

Question 30

What is normal C-reactive protein level? abnormal?

Answer 30

norm 5.

Question 31

Normal hemoglobin level? Men? Women? abnormal?

Answer 31

men 14-18 g/dL. Women 12-16 g/dL. decrease <12 g/dL.

Question 32

normal phosphorus level? abnormal?

Answer 32

2.4-4.1 mg/dL. decreased <2.

Question 33

What is refeeding syndrome?

Answer 33

if someone loses 20-30% of body weight they are at risk of mortality. in this case, the body makes everything smaller, smaller heart, organs etc. so when team tries to bring back food, the phosphate starts going back into skeletal muscle, but now smaller heart may not handle new load. So is something we have to watch someone for first 5 days to 2 weeks after refeeding has started.

Question 34

In eating disorders, which macro nutrient leads to the greatest amount of wasting, when restricted,?

Answer 34

protein. Though usually fat restricted > carbohydrate >protein.

Question 35

What is the psychiatric criteria for diagnosing anorexia nervosa?

Answer 35

1) self induced weight loss, usually ~85% of normal weight.
2) duration > 3 months.
3) intense drive for fitness/ irrational fear of fat
4) body image distortion
5) signs consistent w/ medical starvation >3 mo. (esp. amenorrhea or decreased testosterone in men.)

Question 36

What are some physical signs of anorexia nervosa?

Answer 36

emaciation, hypothermia, cold hands/feet, hyperactivity. Bradycardia (< 90), heart murmur. hypoactive bowel sounds, pressure sores, brittle hair & nails, scalp hair loss, edema at ankles.

Question 37

What is the PT’s goal for working with a pt w/ anorexia?

Answer 37

maximize function, while minimizing calorie burning.

Question 38

What are some PT precautions for working with a pt w/ anorexia?

Answer 38

don’t share the pt’s weight with them. osteoporosis precautions: avoid spinal flexion, encourage weight bearing activities), closely monitor heart rate and BP.

Question 39

What BMI is recommended to start PT treatment for a pt w/ anorexia?

Answer 39

14 (though at UCH they usually have pts with BMI 9-12, and get them started)

Question 40

What are keys to the Norway “body awareness” anorexia treatment?

Answer 40

> sensing and interpreting body signals. > improving emotional awareness. >”body as one’s own”

Question 41

What are impairements observed in the Norway “body awareness” anorexia treatment?

Answer 41

pts have poor body awareness. >restricted breathing pattern. >significant muscular tension. > compulsive physical activity.

Question 42

What does the PT need to consider concerning bone density for pts w/ anorexia?

Answer 42

in early recovery, when bones are brittle, bone loading is risky. But as they recover bone loading will increase bone recovery.