Nutrition in the Patient with Anorexia and CachexiaJeanette N.
Keith, M.D.Associate Professor of MedicineDepartments of Nutrition
Sciences and MedicineUniversity of Alabama at Birmingham
Protein-Energy MalnutritionTwo major typesMarasmusKwashiorkor
(AKA: Protein Calorie Malnutrition)Heimburger DC, Ard JD. Handbook
of Clinical Nutrition 4/e, 2006
MarasmusHeimburger DC, Ard JD. Handbook of Clinical Nutrition
KwashiorkorHeimburger DC, Ard JD. Handbook of Clinical Nutrition
Minimum Diagnostic CriteriaHeimburger DC, Ard JD. Handbook of
Clinical Nutrition 4/e, 2006
Physiology of Starvation & StressHeimburger DC, Ard JD.
Handbook of Clinical Nutrition 4/e, 2006
Metabolic RateLong CL, et al. JPEN 1979;3:452-6Normal range
Protein CatabolismLong CL. Contemp Surg 1980;16:29-42Normal
The Course of Protein-Energy
catabolicHeimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e,
Case Presentation27-year old female with a 35 pound weight loss
in the last six months presents to your morning clinic with her
In the last two weeks, she has lost an additional 10 pounds. She
reports decreased po intake, mild epigastric discomfort and
The patients main concern is the loss of appetite, and
She is 57 tall and weighs 67 pounds, (BP 90/40, P60, R18,
Case PresentationThe patients mother calls you at 6 pm stating
that her daughter is having palpitations and is on her way to the
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 PresentationWhat do you recommend now?Immediate placement
of a PICC catheter for TPN initiation.
Have the inpatient team place a dobhoff and begin tube
Call GI procedures to arrange for PEG placement and enteral
Call Dietary for a 1600 kcal diet and begin a calorie count
Intravenous fluids while correcting the potassium and awaiting
other lab studies.
Case PresentationThe patients 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
What do you recommend next? Advance her diet to clear
liquidsBegin TPNPlace a post-pyloric feeding tube and begin enteral
Case PresentationYou place a post pyloric feeding tube for
enteral nutrition.What weight do you use for caloric provision?
Ideal Body WeightActual WeightAdjusted Body WeightHow many calories
per kilogram per day do you recommend?35-40 kcal/kg/d25-30
kcal/kg/d15-20 kcal/kg/d20-30 kcal/kg/d
Case PresentationOn the morning after beginning her enteral
feeding, the patient complains of palpitations and pain in her
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
Refeeding SyndromePatient at risk = cachectic/marasmic
patientUnderlying low cardiac output:
Low metabolic rate
Predominantly fatty acid utilization
Superimposed demand for increased CO:
Increased catecholamines & metabolic rate
Cardiac & respiratory decompen-sation
Case PresentationThe 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.
Selective Refeeding ApproachesHypometabolic, cachectic/marasmic
patientAim = rebuild cautiously to avoid hypophosphatemia &
repletion heart failureRefeed gradually with a portion of fuel as
fatADEQUATE PHOSPHORUSDays 1-2 BEE x 0.8Days 3-4 BEE x 1.0Days 4-6
BEE x 1.1-1.4Days 7+ BEE x 2 if weight gain is desired
Selective Refeeding ApproachesHypermetabolic, stressed
patientAim = Replace catabolic lossesRefeed aggressively but not
excessivelyCan often achieve calorie & protein goals within 48
Patient with mixed marasmic/kwashiorkor (starved but also
stressed)Metabolism is accelerated by stressTherefore, generally
feed as you would a patient with kwashiorkorBut watch carefully for
Key Points To RememberThe 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
Monitor for re-feeding syndrome with oral, enteral or parenteral
Take Home PointsThe 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.