Cachexia and wasting

Definition

Cachexia and wasting refer to the unintended loss of significant amounts of body weight, usually more than 10%. The weight loss usually involves loss of both fat and significant amounts of lean muscle.

Description

Cachexia and wasting occur when the body uses many more calories and nutrients than are being taken in. This leads to the breakdown of both fat tissue and lean muscle mass. Cachexia and wasting are sometimes temporary, such as when the occur in conjunction with radiation therapy or chemotherapy for cancer. In other cases cachexia and wasting are caused by diseases that are not expected to resolve, such as advanced HIV or system-wide cancers. In these cases the goal of treatment is to reduce, reverse, and postpone cachexia and wasting as much as possible. Cachexia and wasting often occur with long-term serious illness and treating them can be a very important part of palliative care.

Demographics

Many individuals with serious, long-term illness may experience cachexia or wasting. Individuals who are unable to feed themselves, are confined to bed or a wheelchair, or who have diseases or conditions that cause loss of appetite or difficulty digesting are especially likely to experience cachexia and wasting. Cachexia and wasting are common during many types of cancer treatments. Individuals with HIV and AIDS are also at extremely high risk for cachexia and wasting because many medications reduce appetite, induce nausea, or cause diarrhea, and individuals with AIDS are more likely to get infections that affect the ability to eat and digest normally. In some cases seniors can experience cachexia or wasting if they are unable to shop for or prepare meals for themselves, which can lead to weakness and an increased inability to provide nutritious meals. This can lead to a downward spiral that eventually causes cachexia or wasting.

Causes and symptoms

Cachexia and wasting are caused by a variety of problems. In many cases they are caused by lack of appetite or nausea that causes reduced food consumption. In other cases they are caused by diarrhea, which can cause the body to absorb less nutrition from food. In some cases such as cancer and AIDS cachexia and wasting can be caused by a combination of decreased food intake or nutrient absorption, and an increase in the body's need for energy due to infection or cancer. The body uses large amounts of energy to fight infection, and many cancers release chemicals into the blood that cause the breakdown of fat and muscle tissue. Many cancers also increase the amount of energy the body uses. This means that many patients with cancer or AIDS need more calories every day just to maintain their body weight. This can be especially difficult at a time when most individuals are experiencing decreased appetite. Most individuals who have advanced HIV or AIDS or who have cancer throughout their body will experience cachexia and wasting.

The main symptom of cachexia and wasting is an unintended decrease in body weight by 10% or more. This is usually a decrease in both fat and lean muscle mass. Individuals experiencing cachexia and wasting are often increasingly weak as wasting decreases interest in food and ability to prepare it, which leads to increased wasting. Decreased muscle tone, increased fatigue, and difficulty concentrating can also be symptoms of cachexia and wasting.

Diagnosis

Cachexia and wasting are generally diagnosed by a physical examination, a health history, and a recording of patient-reported symptoms. The doctor will also need to know all medications the individual is taking, because many medications treating cancer and HIV can cause wasting on lead to increased wasting. In most cases a loss of 10% of the body weight is required for a diagnosis of cachexia or wasting. In some cases, however, such as an individual who was extremely thin originally, a loss of less than 10% may still receive a diagnosis of cachexia or wasting. In some cases a doctor may order a test called a bioelectrical impedance analysis to determine the amount of lean muscle mass present in the individual.

Treatment

Treating cachexia and wasting focuses on helping the individual ingest more calories, improving absorption of nutrients, and rebuilding or retaining muscle mass. This can be done in a variety of ways depending on the causes of the cachexia or wasting and the desires of the patient.

Anti-nausea medications can help improve desire to eat when nausea occurs as a side-effect of a medication or treatment. Appetite-stimulants may be appropriate when the individual is experiencing a generalized lack of appetite. The doctor may refer the individual to a nutritionist to help the individual create meal and snack plans that maximize nutrition. If the cachexia or wasting is being caused in part by something that can be treated such as a sore throat, swollen throat or tongue, or intestinal parasite, treating that problem can significantly improve cachexia or wasting. Regular exercise if it is possible can help rebuild lost muscle and help prevent the loss of additional muscle mass.

Nutrition/Dietetic concerns

Individuals experiencing wasting need to increase caloric consumption. They should especially try to increase protein consumption to help rebuild lost muscle mass. Below are some tips for increasing caloric consumption:

• Try eating many small meals throughout the day instead of a few large meals.
• Add calorie dense condiments and sauces such as butter or gravy to foods.
• Try prepared protein or nutrition shakes for a quick, calorie dense snack.
• Drink beverages with calories such as fruit juice instead of calorie free beverages such as diet soda.
• Add peanut butter or powdered milk to shakes and smoothies.
• Avoid eating favorite foods when experiencing an episode of nausea, this can make those foods unappealing later.
• Ask the doctor about appetite stimulants or antinausea medications.
• Ask the doctor about vitamin and mineral supplements.
• Have high protein, high calorie foods such as nuts available for a quick snack at all times.

QUESTIONS TO ASK YOUR DOCTOR

• What types of supplementary nutrition products might be a good fit for me?
• Am I a good candidate for anti-nausea or appetite stimulating medications?
• Can you recommend light exercise that might be appropriate for me, or can you refer me to someone who can?
• Can you refer me to a nutritionist who can help me plan meals and snacks to meet my current needs?

Therapy

Physical therapy can help regain muscle mass lost to cachexia and wasting, and can help prevent or slow down the loss of additional muscle mass. Nutrition therapy can help the individual make good food choices and determine which food might be healthy and appealing. Hydrotherapy and other therapeutic treatments may be helpful for some people.

Prognosis

The prognosis for wasting depends on the cause of the wasting and the individual's response to various interventional techniques. For individuals who are experiencing wasting due to cancer treatment, wasting generally improves after the conclusion of treatment. For individuals experiencing wasting due to end-stage cancer, the wasting may be somewhat improved but is unlikely to be completely reversed. As the disease progresses wasting often becomes worse and increasingly difficult to treat successfully. Individuals experiencing wasting due to AIDS can sometimes see significant improvement if the underlying problem, such as swelling of the throat or intestinal parasites is treated successfully. In all cases treatment of wasting can improve quality of life by improving energy and increasing the body's ability to fight off infections. Treating wasting, even if only moderate improvement is seen, can also help extend life for individuals experiencing wasting due to end stage disease.

KEY TERMS

HIV —Human immunodeficiency virus, the virus which causes AIDS.

Prevention

Although not all wasting can be prevented, it can be significantly delayed or reduced. Close monitoring of eating habits and weight can help ensure that the beginning signs of wasting are noticed quickly so the wasting can be treated. Making sure that an individual who is at risk for wasting eats enough calories by providing favorite foods, making foods available for frequent snacking, and making high calorie additions to meals can help prevent the onset of wasting. Treating symptoms likely to cause wasting, such as nausea and sore throat, as soon as they occur can also help to prevent wasting.

Caregiver concerns

Trying to help an individual experiencing wasting can be a very frustrating experience for the caregiver. The individual may refuse food, complain of not being hungry, and only pick at favorite foods, even as the caregiver watches him or her continue to weaken and lose weight. The caregiver can talk to the individual's doctor, a nutritionist, or get information from reputable internet sites about ways to help the individual consume more calories. Encouraging the individual to eat by provide food whenever increased appetite does occur can help. However, cooking thoughtful meals that are then not eaten, or being asked to prepare foods that the individual suddenly no longer wants can be very frustrating and upsetting. To help both the patient and the caregiver, the care giver can keep plenty of instant snacks such as nuts, fruit juices, dried fruits, instant protein shakes, and nutrition bars on hand so that a quick snack is available at any time. Many different support groups for caregivers caring for individuals undergoing cancer treatment or experiencing chronic disease can provide support, shared experiences, and many helpful suggestions.

Resources

BOOKS

Hofbauer, Karl G., ed. Pharmacotherapy of Cachexia. Boca Raton, FL: CRC/Taylor & Francis, 2006.

Mantovani, Giovanni, and Stefan D. Anker, eds. Cachexia and Wasting a Modern Approach. Berlin: Springer, 2006.

PERIODICALS

Bosaeus, Ingvar. “Nutritional Support in Multimodal Therapy for Cancer Cachexia.” Supportive Care in Cancer 16, no. 5 (May 2008): 447–452.

Bruera, Eduardo, Florian Strasser, J. Lynn Palmer, JieWilley, Kathryn Calder, Gail Amyotte and Vickie Baracos “Effect of Fish Oil on Appetite and Other Symptoms in Patients With Advanced Cancer and Anorexia/Cachexia: A Double-Blind, Placebo-Controlled Study.” Journal of Clinical Oncology 21, no. 1 (January, 2003): 129–134.

Thomas, David R. “Loss of Skeletal Muscle Mass in Aging: Examining the Relationship of Starvation, Sarcopenia and Cachexia.” Clinical Nutrition 26, no. 4 (August 2007): 389–400.

Helen Davidson