Entry Level Clinical Nutrition™- Redefining What We Do In A New Age Of Increased Sickness & Increased Scarcity – Part I

“…a tidal wave of chronic illness…”

 – The New York Times – 9/09/09

“You don’t need a weather man
To know which way the wind blows”

Subterranean Homesick Blues
– 
Bob Dylan

In the article “Summer of work exposes medical students to system’s ills,” from which the first quote above is derived, the experiences of a group of medical students is discussed after they were assigned to work in a variety of different medical clinics located, by and large, in areas hard hit by the recession.  As suggested by the title of the article, these students faced the stark reality of what it is like to treat sickness and be treated as a sick person in today’s world of health care in the United States.  Needless to say, the students were sobered in a way that could never happen in any lecture hall or any university clinic.  Of course, in the many discussions and articles that have appeared in the media over the last few months during the health care debate that is raging with no clear resolution in sight, this type of commentary is nothing new.  What did catch my attention, though, because it seemed to me a statement that rarely appears in commentaries on the health care crisis was “…a tidal wave of chronic illness…”

The student who made this statement was truly taken back by how many chronically ill patients suffering from ailments such as diabetes were appearing at the clinic.  Is this finding noted by a single medical student in a remote rural medical clinic an anomaly or a true reflection of a disturbing, nationwide trend?  As you will see, the answer is most decidedly the latter.  Furthermore, this greatly expanding group of chronically ill patients is truly becoming a “500 pound gorilla in the room” in that, despite being treated repeatedly for their illnesses, they rarely “get better.”  In contrast, they receive an endless amount of treatments for the ongoing acute exacerbations of their relentless, never ending, ever expanding list of chronic ailments that form “a ball and chain” that they drag with them for months and years.  Evidence of this stark reality was discussed in the January 2009 edition of the journal Health Affairs which had the theme “The Crisis in Chronic Illness.”  In an editorial from this edition entitled “Reform chronic illness care?  Yes, we can” by Susan Dentzer (1) some sobering statistics were presented that quantify what I have just stated:

“Now three-quarters of the $2 trillion-plus that we spend on U.S. health care each year goes to paying bills for chronic illness: cardiovascular and pulmonary disease, cancers, diabetes, arthritis, high blood pressure, depression.  Globally, the World Health Organization (WHO) estimates, three out of every five deaths – four out of five in low- and middle-income countries – stem from chronic disease.”

In “Confronting the growing burden of chronic disease: Can the U.S. health care workforce do the job?” by Bodenheimer et al (2), the authors elaborate:

“Not surprisingly, the proportion of the population diagnosed with chronic conditions increases with age.  More worrisome is the striking gap between the high prevalence of chronic conditions among people who are below the federal poverty level compared with the average prevalence in the general population.  The cost burden of chronic illness – currently 78 percent of the total health spending-will increase markedly by 2023.  The number of people with diabetes is expected to double in the next twenty-five years, from twenty-four million to forty-eight million.  By 2023, the number of people with chronic mental disorders may increase from thirty million to forty-seven million.  Similar increases are forecast for virtually every common chronic condition.”

Of course, some suggest that these numbers are over inflated.  However, one reason for this skepticism may be a misunderstanding of the difference between acute and chronic illness.  For some assume that all hospitalized patients are suffering from an acute illness.  In fact, this assumption is, for the most part incorrect, as noted by Dentzer (1):

“…even the care given to patients in hospitals increasingly goes to those in acute phases of chronic illness.”

What is the reason for these staggering increases?  For us, the reasons given by Bodenheimer et al (2) are nothing new:

“Reasons for the increased prevalence of chronic conditions are multifactorial-including an aging population plus a rise in disease-specific risk factors such as obesity.  A comparison of chronic disease prevalence in the United States and in ten European countries reveals a markedly lower prevalence in Europe of heart disease, hypertension, diabetes, obesity, and arthritis.  This difference may be attributable to a healthier diet and lower poverty rates in Europe than in the United States.”

With the above in mind, Dentzer (1) presents the following statement in relation to how well we are addressing chronic illness in this country:

“The United States is doing an especially rotten job of delivering chronic care, at a spectacular cost.”

In turn, Bob Dylan’s quote that began this commentary, “You don’t need a weather man to know which way the wind blows” is very apropos in that it is quite obvious that radical changes must occur if the ominous statistics pointed out above are to be reversed.

Of course, if it is true that chronic illness presentations will become the norm for many if not most health care practices, two important questions need to be asked.  First, where do we as clinical nutritionists “fit in” to this scenario?  Secondly, though, and possibly even more importantly, are we part of the problem or part of the solution?  Of course, I realize that many of you may be very upset that I would even begin to suggest that we are anything less than a very obvious solution.  However, while I understand such a reaction, I would also ask that you consider the following commentary on the efficacy and practicality of the different approaches to nutritional therapy most often used given the “…tidal wave of chronic illness…” that will be coming our way:

Treatment based on symptoms – This is often impractical and of questionable efficacy in chronically ill patients.  Why?  Chronically ill patients, for the most part, present with highly complex, highly varied lists of signs, symptoms, and diagnoses that make efficacy more difficult to attain and patient compliance a challenge due to issues of practicality and finances.  As an example, consider the long held tradition of dosing supplements based on symptoms where, for example, a supplement is given for fatigue, another supplement is given for headaches, a supplement is given for…well, I guess you get the point.  Certainly several years ago when our patient population consisted of relatively healthy people experiencing a few symptoms of fairly short duration, this approach had merit and demonstrated reasonable clinical efficacy.  Furthermore, even today, when one of these patients presents to us, this approach continues to have reasonable efficacy and practicality.  However, what about today’s chronically ill patient who usually reports sometimes as many as 1-2 dozen symptoms that have been present often for decades.  It seems obvious to me that giving one supplement for each symptom with these patients will most often be impractical from the both the standpoint of cost and of shear quantities of pills, not to mention issues of questionable efficacy.

Organ-based treatment approaches carry similar doubts in relation to practicality and efficacy – Another traditional way of administering supplements is based on organs or organ systems.  Therefore, a staple of clinical nutrition has long been the “liver supplement,” the “adrenal supplement,” or the “gall bladder supplement,” etc.  Again, this approach has and continues to deliver a good level of efficacy and practicality with reasonably healthy patients with dysfunction of relatively short duration.  However, chronically ill patients often present with several areas of suboptimal organ function that has persisted for long periods of time.  In these instances, are traditional organ-based approaches to supplementation going to be practical and efficacious a high percentage of the time?  Based on my own experiences and feedback from you, the answer to this question is often no.

What about traditional disease-based protocols? – As most of you know, giving out disease-based protocols such as a multiple sclerosis protocol or an ulcerative colitis protocol has been and continues to be a staple of clinical nutrition.  Unfortunately, given that today’s chronically ill patient sometimes presents with several disease diagnoses of very long duration, this approach demonstrates the limitations of practicality and sometimes efficacy that are true for the other two.  For example, if a chronically ill patient presents with disease diagnoses that range from multiple sclerosis to fibromyalgia to depression, what disease-based protocol, each containing at least three or more supplements, is dosed first?  This question is becoming more and more difficult to answer from both a practicality and efficacy standpoint.

What about functional medicine approaches? – As many of you know, functional medicine based approaches where key physiologic systems such GI, detoxification and immune are addressed with the idea that environmental and genetic factors have contributed to suboptimal function have been a true answer to the limitations of the old symptom-, organ-, and disease-based approaches to supplementation.  As many of you also know, I have been and continue to be a tremendous advocate of functional medicine approaches with chronically ill patients.  However, functional medicine has three major “weak links in the chain” that many of you emphatically brought to my attention two to three years ago when we were heavily promoting use of functional medicine tests with your patients on a routine basis:

  • Implementation of functional medicine approaches is heavily reliant on functional medicine tests such as stool analysis, stress hormone analysis, etc.  You felt that the cost and sometimes, as with stool analysis, the complexity, made these tests completely impractical in terms of routine use with most patients as part of your initial diagnostic workup.
  • You also made it clear that clinical interpretation of functional laboratory tests was often too complicated to understand and too complicated to explain to the average patient.
  • Finally, you made it clear that supplemental programs derived from the results of functional medicine testing were often too large and cumbersome to be of practical value for those many chronically ill patients who are concerned about cost and are reluctant to ingest large amounts of pills.

Of course, with the above being stated, you also made it clear that functional medicine has definite value in your practices under certain circumstances.  How?  Use of functional medicine testing and the supplemental/lifestyle recommendations derived from them has been extremely helpful for the occasional very difficult patient for whom initial alternative medicine efforts performed by either you or others has been unsuccessful.  However, as an entry level modality to be used with the first encounters with virtually every patient, you have strongly suggested that functional medicine is too expensive and too cumbersome to practically use on a routine basis.

Given the limitations stated above of all the commonly used criteria for supplementation when dealing with chronically ill patients during initial encounters, how can we proceed with the “…tidal wave of chronic illness…” that is now becoming more prevalent in our offices?  To answer this question, I would like to, as suggested in the title of this series, introduce the idea to you that we redefine ourselves in terms what we do.  In this series I will be offering to you the possibility that we could better serve the needs of chronically ill patients, many of whom have very limited finances, by replacing some of the old thought patterns and habits described above with the following new ways of thinking and acting:

We must realize that if we are to succeed from both a clinical and financial standpoint in this new world of increased sickness, scarcity and minimal involvement in third party payment reform, we must focus as never before on optimal patient outcome, as defined by the patient – With the assumption that most of us will receive payment directly from patients as opposed to third party providers, we must thoroughly focus on the fact that we must, like any other entrepreneur, create satisfied customers.  Specifically, what does that mean in terms of patient care?  We must maximize the possibility that the chief complaint that brought the patient to our offices will be resolved satisfactorily as determined by the patient.  How often do we hear about the patient whose cholesterol, triglycerides, and blood pressure are optimal but feels fatigued and out of sorts constantly?  How often do we hear patients mention that their previous health care provider seemed to care more about issues like weight loss and clear skin rather than the chief complaint of headaches that brought the patient to that health care provider in the first place?  Certainly resolution of secondary patient issues is to be commended.  However, I would suggest that, in the eyes of patients in this new world of sickness and scarcity, unless the chief complaint is resolved to the patient’s satisfaction in a time efficient, cost efficient manner, the patient’s evaluation of our care and the patient’s comments about our work to friends and relatives will not be what we would desire no matter how well we resolve secondary issues.

We must recognize that the chief complaints and other key signs and symptoms that patients are presenting are not, most often, a result of a disease process.  Rather, more often than not, they are reflective of a response to certain environmental or psychological stressors.  In turn, to address chief complaints with a high degree of efficacy, we must understand the stress response and how it is uniquely manifesting in every chronically ill patient.

To elaborate:  When we see elevated blood sugar we conventionally define this as a disease called type II diabetes.  When we see bone loss we conventionally define this as a disease called osteoporosis.  When we see an inflamed colon we conventionally define this as a disease called inflammatory bowel disease.  But, in reality, could these be something completely different than what we usually regard as a random situation where an unfortunate individual was struck with a chronic malady due to a combination of bad luck and bad genes?  Yes!  An ever growing body of research is stating just this:  In reality, the key signs and symptoms presented by our patients are, in fact, manifestations of very logical and rational efforts on the part of the body to cope with one or more stressors via a stress response that includes much more than hypothalamic/pituitary/adrenal (HPA) axis with which we are all familiar.  In fact, this stress response includes the HPA axis and almost every other major component of human physiology.  This collective, whole body response to stress is called allostasis. 

If this effort is so logical and rational, then why is the patient suffering?  The reason is that this stress response is only designed to last a short period of time.  To use the popular analogy of the caveman and the saber toothed tiger, the caveman either escapes quickly or is eaten.  Either way, the stress response only lasts a short period of time.  In contrast to the caveman, though, our chronically ill patients have been dealing with environmental and psychological saber toothed tigers for years where the chase never ends either by escape or by death.  Under these circumstances, the whole body stress response (allostasis) persists much longer than designed and, invariably, evolves into a destructive process that is every bit as dangerous to health as the proverbial real and perceived saber toothed tigers that started the process in the first place.  This destructive effect of an allostatic process that has gone on longer than designed has been termed allostatic load.  In turn, the signs and symptoms that we see that are the result of this allostatic load have been described using terms such as hypermetabolic syndrome, sickness response, and sick syndrome.  As you might expect, there exists a vast body of research that documents what I have just described, which I will discuss in detail as this series progresses.

We must recognize that much of what we are trying to accomplish in functional medicine and clinical nutrition in general is based on certain foundational issues that are often compromised in chronically ill patients – In functional medicine and clinical nutrition in general we are, from an overall standpoint, making efforts to “build” something.  For example, if we are treating a patient suffering from musculoskeletal injuries or degenerative phenomena such as osteoporosis or osteoarthritis, we are making efforts to build muscle tissue, collagen, bone, etc.  With the patient who suffers from frequent bouts of colds and flu, we often make efforts to increase immunity by building white blood cells.  In functional medicine we are often making efforts to repair the gut lining or increase levels of phase II detoxification enzymes.  While there are certainly many unique aspects to these efforts, they share two important, very foundational necessities in common:

  • All of the above require protein.  Unfortunately, your chronically ill patients under high levels of psychological or physiological stress are, due to reasons I will explain, experiencing significant protein depletions due to increased gluconeogenesis and, very often, low intake of quality protein.
  • All of the above anabolic processes occur intracellularly.  Unfortunately, your chronically ill patients are experiencing insulin resistance, which means that the primary anabolic stimulator responsible for escorting not only glucose but all other macronutrients and many micronutrients into the intracellular milieu is functioning suboptimally.  Again, I will go into much more detail on this important foundational issue later in this series.
  • The anabolic, intracellular pathways involved in constructing the factors mentioned above such as detoxification enzymes, muscle cells, bone cells, white blood cells, etc. all require optimal intracellular pH and fluid/electrolyte balance.  Unfortunately, the vast majority of your chronically ill patients, due to increased acid production from upregulated, catabolic, gluconeogenic processes plus highly processed, acid forming diets, lack the proper intracellular pH and the optimal levels of fluid and electrolytes such as potassium, bicarbonate, and magnesium to allow anabolic processes to flourish.  Again, much more information plus research data will follow on this incredibly important, vastly under appreciated cornerstone of improving quality of life in chronically ill patients.
  • In chronically ill patients optimal absorption does not guarantee that the macro- and micronutrients you are supplementing will automatically go where you want them to go.  A large body of research suggests that chronic inflammation, which is now considered by many experts to be a universal finding in chronically ill patients, can profoundly alter the levels of nutrients in key tissue and organ compartments.  What impact might this have on your efforts to successfully deal with the chief complaint in your patient?  Consider B vitamins, which are often dosed to chronically ill patients.  A large body of research now clearly demonstrates that serum levels of many B vitamins can be profoundly decreased by inflammation.  Next, consider zinc, which is very often dosed to patients suffering from chronic colds and flu.  In such situations it is assumed that the zinc will travel to the thymus to increase thymus-mediated immune function.  However, research that I will present has demonstrated that in patients with heavy metal toxicity, which is often present in chronically ill, inflamed patients, the zinc will, instead, be used to form increased levels of metallothionein, a key endogenous constituent involved in heavy metal detoxification.  Thus, the popular assumption that, if we can optimize dietary levels of nutrients and optimize absorption, we are “home free” so to speak, in terms of accomplishing improvements in health, for the most part only applies in purely preventive situations in optimally health individuals or in situations with reasonably healthy people experiencing recent onset health problems.  In contrast, there is a very good chance that you and your chronically ill patient will be profoundly disappointed with your outcome if your focus is exclusively on optimal dietary and supplemental levels of nutrients and optimal absorption, and does not also include the major intracellular and extracellular macro- and micronutrient imbalances that can be induced via chronic inflammation and toxicity.

WITH ALL THIS COMPLEXITY AND DEVIATION FROM LONG HELD BELIEFS AND ASSUMPTIONS ABOUT THE NATURE OF CHRONIC ILLNESS, WHERE DO WE GO FROM HERE?

I realize that it may appear that, due to complexities described above plus the reality that patients are increasingly demanding solutions that are not only effective but very time and cost efficient, we are facing an impossible situation in trying to deal with “…a tidal wave of chronic illness…”  Fortunately, as I will demonstrate, there is a very effective solution that has been utilized by many nutritional practitioners for years.  However, to truly appreciate this solution, one other very popular assumption about complicated, chronically ill patients must be relegated to the trash heap.  What is this assumption?  Very simply:

COMPLICATED SITUATIONS AND CONDITIONS MUST HAVE COMPLICATED ANSWERS!!

As I hope to demonstrate, a large body of research and clinical data makes it abundantly clear that simple, time and cost efficient modalities can have a major positive impact on resolving chief complaints in some of the most complicated chronically ill patients.  Where does all this research and clinical data come from?  As you see, it comes from some of the world’s most brilliant nutritionists whose work has been ignored and under appreciated for years by those of us in the clinical nutrition community because of one simple, highly flawed belief.

As you will see, critical care nutritionists have been using some very simple, cost effective modalities for years to effectively and relatively quickly improve quality of life for some of the most complicated patient situations any health care practitioner will ever face.  Of course, you may counter this statement with another statement noting that there is a good reason why clinical nutritionists have been ignoring the work of critical care nutritionists.  What might this statement suggest?  I would guess it would emphatically point out that the patients we see suffering from fatigue, obesity, chronic pain, etc. have little in common with burn, severe trauma, and surgical patients in terms of metabolic and nutritional needs.  What is my response to this?  While this logic is common, an overwhelming amount of research and clinical data makes it clear that, as I mentioned, it is tragically flawed.  In contrast, as I will point out, other than a matter of degree and longevity, the metabolic and nutritional issues faced by patients with severe burns, for example, are exactly the same as those faced by our chronically ill patients.  In turn, I hope you will agree with me when I conclude, based on the large amount of data that I will be presenting, that we can take the metabolic and nutritional model used by critical care nutritionists for years with a high degree of success and apply it to our sometimes complicated chronically ill patients simply, quickly, inexpensively, with a very high degree of efficacy.

Very basically, what am I suggesting?

For the relatively healthy patient presenting with a few chief complaints of short duration, turn to the symptom/organ/disease based protocols we have traditionally employed.  The odds are that they will provide a high degree of positive results in these instances.

For the “…tidal wave of chronic illness…” patients that are now beginning to populate our practices, though, who are reluctant to invest in the cost and complexities of a functional medicine approach at the onset of care, start with Entry Level Clinical Nutrition as modeled successfully for years by critical care nutritionists.  Using this entry level approach, once these patients have been stabilized, (to use the language of critical care) then move on, if necessary, to functional medicine testing and therapeutic modalities.  I feel strongly, based on a large body of research that I will present, that not only will compliance be better using this approach, but efficacy will be greater and side effects, such as “detox reactions” will be fewer.

THE CRITICAL CARE NUTRITION MODEL – AN OVERVIEW

As I mentioned, a core concept of the critical care nutrition model is that much of what is being seen in the patient in terms of signs and symptoms is not a disease per se, but part of a response broadly described as the acute phase response.  Essentially, this acute phase response is a stress response that is fundamentally the same whether the patient has experienced burns, trauma, major surgery, or any other significant physiologic stressor.  However, it encompasses much more than just the adrenal endocrinology about which we tend to focus upon when we in clinical nutrition generally discuss stress physiology.  Yes, critical care literature does point out that the acute phase response includes the alterations in cortisol, catecholamines, and hypothalamic/pituitary hormones with which we are all familiar.  However, as I also suggested, it includes the responses of many other organ systems.  Why are critical care nutritionists so concerned about this acute phase response?  They realize that, if not controlled fairly quickly and effectively, it could lead to what is known as multiple organ failure syndrome (MOFS).  MOFS is a major cause of serious illness in critical care patients that often leads to death.  An example of this is the infectious pneumonia that can occur in burn patients, which is often so severe that it can be the ultimate cause of death rather than the burns.  What is often the source of the infectious bacteria that infects burn patients, even in ultra clean intensive care units?  Gut microflora that entered the bloodstream in massive amounts due to a phenomenon we discuss everyday, leaky gut.  Because of this, critical care nutritionists know that, no matter what the initial case presentation, basic stabilization procedures must occur first to bring the acute phase response under control.  In turn, I hope you see enough similarities between what I described above and what we see in our complex chronically ill patients to realize that maybe we can do the same, which is to start initial stabilization procedures similar to what are used in critical care to control what has been described in the literature as the “chronic phase response” that is seen in all of our chronically ill patients no matter what the initial case presentation.

The responses included in the acute phase response and the typical treatments as discussed in critical care nutrition literature include the following that, as I emphasized before, are basically the same no matter what the stressor or clinical presentation:

  • Increases in inflammatory mediators, particularly cytokines such as TNFα and acute phase proteins such as C-reactive protein.  This is addressed with anti-inflammatory substances such as fish oil.
  • Hypermetabolism leading to increases in gluconeogenesis and resultant losses of protein in key organ systems such as the musculature.  This is addressed by feeding of protein or free form amino acids.
  • Hyperinsulinemia and insulin resistance leading to what is known as stress hyperglycemia.  This is addressed by therapies that optimize insulin metabolism and reduce serum glucose.
  • Increases in hypermetabolism/gluconeogenesis-induced acid production leading to metabolic acidosis and attendant imbalances in intracellular/extracellular fluid ratios and intracellular/extracellular ratios of key electrolytes such as potassium, sodium, and magnesium.  Furthermore, in the process of buffering these acids, losses of potassium, magnesium, and calcium via the urine often occur.  This is addressed by feeding fluid and electrolytes
  • Loss of gut lining protein leading to gut mucosal atrophy and increased permeability or “leaky gut.”  This protein loss is mediated by the same hypermetabolic/gluconeogenic processes that led to loss of muscle mass.  This is addressed by feeding nutrients such as glutamine.
  • Profound alterations in micronutrient metabolism.  For example, serum levels of many B vitamins are decreased by the inflammation described above.  In turn, serum levels of key trace minerals such as zinc, selenium, and iron are also altered.  This is addressed by micronutrient supplementation.

Another phenomenon often seen in critical care nutrition is what as known as refeeding syndrome.  Refeeding syndrome occurs when carbohydrate based nutriture is introduced after a period of low food intake that might occur in the elderly when long periods of low food intake are followed by refined carbohydrate ingestion.  In such a situation rapid increases in serum insulin lead to increased intracellular uptake of key electrolytes such as potassium and phosphate.  The imbalances in extracellular and intracellular levels that often follow can lead to sometimes life threatening signs and symptoms.  The ideal treatment is preventive via increased attention to carbohydrate:protein ratios.

Before leaving this discussion, I would like to ask a question.  How much of what I have just described appears to be very similar to what we have discussed for years as being major issues and common treatments in our chronically ill patients?  Hopefully, the answer to this question is obvious.  In turn, as I have been repeatedly pointing out, researchers have noted the same, making it very clear that the critical care model can easily be extrapolated to the outpatient clinical nutrition situations we experience every day with complex chronically ill patients.

EXTRAPOLATING THE CRITICAL CARE MODEL TO THE CHRONICALLY ILL PATIENTS WE NOW SEE MORE AND MORE

While I certainly hope you agree with me concerning the parallels I have suggested, I am certainly not naive about the obvious fact that there are still many differences between burn and surgical patients and the chronically ill patients that are now populating our practices.  Therefore, some degree of extrapolation is necessary.  To begin this discussion of how the similarities and differences between critical care and outpatient, chronic illness situations can be distilled into a practical and cost effective modality that we can use initially on a routine basis, I would like to briefly review a seminal paper written by one of the world’s experts on critical care nutrition and probiotic therapy, Stig Bengmark.  This paper gave me confirmation that the parallels I first started noticing fifteen years ago were not just rambling fantasies of the mind but insights on how we can better address nutritionally some very difficult and challenging cases.  In “Acute and ‘chronic’ phase reaction – a mother of disease” (3) Bengmark begins by discussing the acute phase response and the allostatic phenomena that I discussed earlier in the commentary:

“A series of complex reactions occur in the body when an individual is threatened by stress, mental or physical; infection trauma, surgical operation, advanced medical treatment or child delivery-all aimed to provide optimal protection against progress of disease.  These changes are usually summarized under the name of acute phase reaction (APR).  These changes involve the whole body, but especially the central nervous system (CNS), the hypothalamus and the hypophysis, which via the so called neuro-endocrine axis activates all the organs in the body, particularly the adrenals, the thyroid, the gonads, the liver, the gut and its mucosa and lymphatic system, but also, as more recently recognized the intestinal flora.”

Of course, as I mentioned, this response has conventionally been considered to be significant only in situations of severe, acute illness.  Bengmark (3) dispels this conventional thinking with the following:

“Similar, but not identical, defensive mechanisms are activated when an individual is affected by a long-lasting, continuous but discretely wearing mental and/or physical stress.  The observed mechanisms have similarities with APR but also important differences.  There are good reasons to keep them apart by defining the later as chronic phase response (CPR).  Characteristic to APR is increase in temperature, chills, somnolence, anorexia and profound changes in blood levels of plasma proteins, lipids, minerals, hormones, cytokines as well as cellular elements.  CPR manifests itself mainly as chronic fatigue, asthenia, reduced appetite, reduced physical activity, reduced mood, sometimes mental depression and in reduced muscle mass.  The changes in chemical and cellular parameters in CPR, although obvious, are more discrete.”

Before continuing, I would like to emphasize and comment on three key points from the above quote.  First, please note again the main characteristics of the APR which include temperature increase, chills, etc. and, in particular, altered metabolism of key nutrients such as proteins, lipids, and minerals.  Where do most of us see this set of circumstances in action most often?  This is basically what happens with colds and flu.  In turn, what I will be describing with Entry Level Clinical Nutrition, while aimed most directly at chronically ill patients, will be very applicable with patients with colds and flu in terms of reducing signs and symptoms and hastening recovery times.  Next, please note again the manifestations of the CPR such as chronic fatigue, depression, and, in particular, reduced muscle mass.  As you know, these are very often primary components of the chief complaints presented by many chronically ill patients.  In turn, I want to again emphasize, as suggested by Bengmark (3), that what we have conventionally described as “diseases” in many of our chronically ill patients are, in fact, responses to long-term environmental stressors.  Finally, please note again the last sentence in the above quote about the subtleties of alterations in chemical and cellular parameters in the CPR.  In turn, we need to use laboratory testing in a different way than what is used conventionally with acute illness, which has been well defined by the new generation of functional medicine tests and by the innovative methodologies recently developed for evaluating routine blood chemistries.

The next quote I would like to present from the Bengmark (3) paper notes the important biochemical similarities between the APR and CPR that has formed an important biochemical and physiological basis for the approach I am advocating in using Entry Level Clinical Nutrition with chronically ill patients:

“Common to both APR and CPR is hypermetabolism, increased hepatic glycogenesis, increased glucose turnover, reduced muscle uptake of glucose, hyperlipidemia and increased lipolysis of adipose tissues, especially visceral fats (NEFAs), increased protein synthesis in the liver and increased protein turnover in the body, increased glucose levels, increased insulin secretion and insulin resistance.”

In particular, please note again the portion of the quote that notes alteration in protein metabolism.  This quote supports my hypothesis that, in your chronically ill patients, important proteins in gut and muscle tissue are being lost and more protein is going to the liver to produce protein-based inflammatory mediators such as cytokines.

With this comparison between the acute and chronic situations in mind, I would like to now present a simple overview of what needs to be addressed in your chronically ill patient based on the vast amount of biochemical/physiologic/nutritional information available from critical care nutrition literature:

Optimization of muscle mass and amino acid levels

Muscle strength is a consistent predictor of morbidity and mortality. Preventing or reversing sarcopenia (aging-associated ‘normal’ muscle wasting) is an essential component of fostering health and reducing the likelihood of age-related disability Amino acid and protein supplementation therapies stimulate muscular protein synthesis and directly improve energy performance by encouraging an anabolic shift. Data suggests that AA and fish oil supplements help counteract muscle wasting and cellular energy reduction, and may improve cardiac function and muscle performance, thereby enhancing the patient’s quality of life.

Reduction of inflammation

The recognition that inflammation occurs concurrent with ailments such as cardiovascular disease, obesity, and diabetes has led to major inroads in improving outcomes in patients suffering from these maladies. Even with this knowledge, practitioners often fail to address the role of subclinical inflammation in chronic illness. Inflammation, as a constant systemic stressor (particularly in the chronically ill patient) simply must be kept in check. Dramatic improvement has been documented in the cachetic patient with supplementation of fish oil and herbs such as curcumin. The benefit to all patients should be evident.

Improvement of insulin sensitivity

Insulin is the major anabolic hormone. Any effort to restore the anabolic condition, with increases in protein synthesis and ATP production, must incorporate efforts to enhance insulin activity and sensitivity. Efforts to increase muscle mass, which are an integral part of this program, will contribute greatly to the optimization of glucose utilization and insulin sensitivity. This sequence of events can be significantly enhanced through wise use of herbs and nutrients that may help increase insulin sensitivity and glucose utilization.

Optimization of pH

Metabolic acidosis is a factor in the creation of ill health for almost every patient you see each day. With a modern diet that is overwhelmingly acidogenic and a natural tendency toward more acidic status with aging, Americans face a significant challenge to maintaining acid / alkaline homeostasis. Long term low-grade acidosis takes its toll throughout the body in the form of bone loss, as well as a shift toward muscle protein catabolism and proteolysis. The promotion of an anabolic physiology can be assisted through simple dietary changes, plus magnesium glycinate and potassium bicarbonate supplementation. These steps have been demonstrated to reverse the catabolic effects described above.

Optimization of dietary carbohydrate / protein ratio

Diet is the most significant daily influence upon the health of us all. Providing appropriate fuel to the system starts with a diet of ample quality protein sources and moderate consumption of less glycemic carbohydrates and of high quality fats. The optimization of diet helps to create a desired anabolic trend. Judicious supplementation in the form of protein-based drinks and bars is available when we are not in a setting that allows for the convenient sourcing of quality foods.

Optimization of gastrointestinal function

The catabolic nature of chronic illness makes gut mucosal atrophy a frequent occurrence no matter what the chronic illness may be.  Furthermore, poor diet and poor lifestyle choices relating to sleep and eating habits can cause further deterioration of gut health.  In turn, GI symptoms such as gas, bloating, constipation, and/or diarrhea along with findings of maldigestion and malabsorption often accompany other chronic illness findings.  In this situation consider the addition of betaine HCl and digestive enzymes to the supplemental and lifestyle recommendations.

Optimizing deficiencies of key micronutrients such as vitamin D, iodine, and zinc

The catabolic, inflammatory nature of chronic illness can profoundly alter micronutrient metabolism leading to relative deficiencies where insufficient amounts of key micronutrients are available for optimal functioning of intracellular mechanisms that are involved in the creation of optimal anabolic physiology.  This detrimental state of affairs can be exacerbated by low dietary intake, which is particularly prevalent with vitamin D, iodine, and zinc.  In turn, consider the use of micronutrient supplementation in the form of a quality multivitamin/mineral product with possible addition of increased amounts of vitamin D, iodine, and/or zinc.

SIMPLIFIED OVERVIEW OF THE METABOLIC IMBALANCES DESCRIBED ABOVE PLUS DIAGNOSTIC AND TREATMENT CONSIDERATIONS

To conclude part I of this series, I would like to leave you with a chart I developed which gives an overview of the physiologic basis plus general diagnostic and treatment parameters.  This chart can be seen by clicking on the following link. It will also show on the full PDF version which is linked at the top of this page.  PDF Version of Chart

In part II of this series I will explore in detail the nature of the chronic phase response seen in virtually all chronically ill patients and how it creates one of the greatest contributors to common chief complaints, sarcopenia, which is, primarily, loss of muscle mass but certainly can include loss of other protein-based functional tissues.

Moss Nutrition Report #229 – 10/01/2009 – PDF Version

REFERENCES

  1. Dentzer S. Reform chronic illness care?  Yes, we can. Health Affairs. 2009;28(1):12-13.
  2. Bodenheimer T et al. Confronting the growing burden of chronic disease: Can the U.S. health care workforce do the job? Health Affairs. 2009;28(1):64-74.
  3. Bengmark S. Acute and “chronic” phase reaction – a mother of disease. Clin Nutr. 2004;23:1256-1266.