Skip to main navigation menu Skip to main content Skip to site footer

Review article: Biomedical intelligence

Vol. 144 No. 1718 (2014)

Loss of appetite in acutely ill medical inpatients: physiological response or therapeutic target?

  • Philipp Schütz
  • Martina Bally
  • Zeno Stanga
  • Ulrich Keller
DOI
https://doi.org/10.4414/smw.2014.13957
Cite this as:
Swiss Med Wkly. 2014;144:w13957
Published
20.04.2014

Abstract

Loss of appetite and ensuing weight loss is a key feature of severe illnesses. Protein-energy malnutrition (PEM) contributes significantly to the adverse outcome of these conditions. Pharmacological interventions to target appetite stimulation have little efficacy but considerable side effects. Therefore nutritional therapy appears to be the logical step to combat inadequate nutrition. However, clinical trial data demonstrating benefits are sparse and there is no current established standard algorithm for use of nutritional support in malnourished, acutely ill medical inpatients. Recent high-quality evidence from critical care demonstrating harmful effects when parenteral nutritional support is used indiscriminately has led to speculation that loss of appetite in the acute phase of illness is indeed an adaptive, protective response that improves cell recycling (autophagy) and detoxification. Outside critical care, there is an important gap in high quality clinical trial data shedding further light on these important issues. The selection, timing, and doses of nutrition should be evaluated as carefully as with any other therapeutic intervention, with the aim of maximising efficacy and minimising adverse effects and costs. In light of the current controversy, a reappraisal of how nutritional support should be used in acutely ill medical inpatients outside critical care is urgently required. The aim of this review is to discuss current pathophysiological concepts of PEM and to review the current evidence for the efficacy of nutritional support regarding patient outcomes when used in an acutely ill medical patient population outside critical care.

References

  1. Heidegger CP, Berger MM, Graf S, Zingg W, Darmon P, Costanza MC, et al. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet. 2013;381(9864):385–93.
  2. Doig GS, Simpson F, Sweetman EA, Finfer SR, Cooper DJ, Heighes PT, et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA: the journal of the American Medical Association. 2013;309(20):2130–8.
  3. Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365(6):506–17.
  4. Heyland D, Muscedere J, Wischmeyer PE, Cook D, Jones G, Albert M, et al. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med. 2013;368(16):1489–97.
  5. Alberda C, Gramlich L, Jones N, Jeejeebhoy K, Day AG, Dhaliwal R, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive care medicine. 2009;35(10):1728–37.
  6. Sorensen J, Kondrup J, Prokopowicz J, Schiesser M, Krahenbuhl L, Meier R, et al. EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clinical nutrition. 2008;27(3):340–9.
  7. Schuetz P, Hausfater P, Amin D, Haubitz S, Fassler L, Grolimund E, et al. Optimizing triage and hospitalization in adult general medical emergency patients: the triage project. BMC Emerg Med. 2013;13(1):12.
  8. Katona P, Katona-Apte J. The interaction between nutrition and infection. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 2008;46(10):1582–8.
  9. Hiesmayr M, Schindler K, Pernicka E, Schuh C, Schoeniger-Hekele A, Bauer P, et al. Decreased food intake is a risk factor for mortality in hospitalised patients: the NutritionDay survey 2006. Clinical nutrition. 2009;28(5):484–91.
  10. Morley JE, Thomas DR, Wilson MM. Cachexia: pathophysiology and clinical relevance. Am J Clin Nutr. 2006;83(4):735–43.
  11. Kirkland LL, Kashiwagi DT, Brantley S, Scheurer D, Varkey P. Nutrition in the hospitalized patient. Journal of hospital medicine: an official publication of the Society of Hospital Medicine. 2013;8(1):52–8.
  12. Anthony PS. Nutrition screening tools for hospitalized patients. Nutrition in clinical practice: official publication of the American Society for Parenteral and Enteral Nutrition. 2008;23(4):373–82.
  13. Kondrup J, Rasmussen HH, Hamberg O, Stanga Z, Ad Hoc EWG. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clinical nutrition. 2003;22(3):321–36.
  14. Johansen N, Kondrup J, Plum LM, Bak L, Norregaard P, Bunch E, et al. Effect of nutritional support on clinical outcome in patients at nutritional risk. Clinical nutrition. 2004;23(4):539–50.
  15. Kubrak C, Jensen L. Malnutrition in acute care patients: a narrative review. Int J Nurs Stud. 2007;44(6):1036–54.
  16. Kuhlmann MK, Levin NW. Potential interplay between nutrition and inflammation in dialysis patients. Contrib Nephrol. 2008;161:76–82.
  17. Oner-Iyidogan Y, Gurdol F, Kocak H, Oner P, Cetinalp-Demircan P, Caliskan Y, et al. Appetite-regulating hormones in chronic kidney disease patients. Journal of renal nutrition: the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2011;21(4):316–21.
  18. Guttridge DC, Mayo MW, Madrid LV, Wang CY, Baldwin AS, Jr. NF-kappaB-induced loss of MyoD messenger RNA: possible role in muscle decay and cachexia. Science. 2000;289(5488):2363–6.
  19. Acharyya S, Ladner KJ, Nelsen LL, Damrauer J, Reiser PJ, Swoap S, et al. Cancer cachexia is regulated by selective targeting of skeletal muscle gene products. J Clin Invest. 2004;114(3):370–8.
  20. Mitch WE, Goldberg AL. Mechanisms of muscle wasting. The role of the ubiquitin-proteasome pathway. N Engl J Med. 1996;335(25):1897–905.
  21. Pende A, Musso NR, Vergassola C, Puppo F, Ioverno A, Criscuolo D, et al. Neuroendocrine effects of interferon alpha 2–a in healthy human subjects. Journal of biological regulators and homeostatic agents. 1990;4(2):67–72.
  22. Schuetz P, Muller B. The hypothalamic-pituitary-adrenal axis in critical illness. Endocrinol Metab Clin North Am. 2006;35(4):823–38, x.
  23. Ellingsgaard H, Hauselmann I, Schuler B, Habib AM, Baggio LL, Meier DT, et al. Interleukin-6 enhances insulin secretion by increasing glucagon-like peptide-1 secretion from L cells and alpha cells. Nat Med. 2011;17(11):1481–9.
  24. Schetz M, Casaer MP, Van den Berghe G. Does artificial nutrition improve outcome of critical illness? Critical care. 2013;17(1):302.
  25. Derde S, Vanhorebeek I, Guiza F, Derese I, Gunst J, Fahrenkrog B, et al. Early parenteral nutrition evokes a phenotype of autophagy deficiency in liver and skeletal muscle of critically ill rabbits. Endocrinology. 2012;153(5):2267–76.
  26. Vanhorebeek I, Gunst J, Derde S, Derese I, Boussemaere M, Guiza F, et al. Insufficient activation of autophagy allows cellular damage to accumulate in critically ill patients. J Clin Endocrinol Metab. 2011;96(4):E633–45.
  27. Gunst J, Derese I, Aertgeerts A, Ververs EJ, Wauters A, Van den Berghe G, et al. Insufficient autophagy contributes to mitochondrial dysfunction, organ failure, and adverse outcome in an animal model of critical illness. Crit Care Med. 2013;41(1):182–94.
  28. Starke J, Schneider H, Alteheld B, Stehle P, Meier R. Short-term individual nutritional care as part of routine clinical setting improves outcome and quality of life in malnourished medical patients. Clin Nutr. 2011;30(2):194–201.
  29. Rufenacht U, Ruhlin M, Wegmann M, Imoberdorf R, Ballmer PE. Nutritional counseling improves quality of life and nutrient intake in hospitalized undernourished patients. Nutrition. 2010;26(1):53–60.
  30. Gariballa S, Forster S, Walters S, Powers H. A randomized, double-blind, placebo-controlled trial of nutritional supplementation during acute illness. Am J Med. 2006;119(8):693–9.
  31. Delmi M, Rapin CH, Bengoa JM, Delmas PD, Vasey H, Bonjour JP. Dietary supplementation in elderly patients with fractured neck of the femur. Lancet. 1990;335(8696):1013–6.
  32. Larsson J, Unosson M, Ek AC, Nilsson L, Thorslund S, Bjurulf P. Effect of dietary supplement on nutritional status and clinical outcome in 501 geriatric patients – a randomised study. Clin Nutr. 1990;9(4):179–84.
  33. Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane database of systematic reviews. 2009; (2): CD003288.
  34. Koretz RL, Avenell A, Lipman TO, Braunschweig CL, Milne AC. Does enteral nutrition affect clinical outcome? A systematic review of the randomized trials. Am J Gastroenterol. 2007;102(2):412–29; quiz 68.
  35. Arends J, Bodoky G, Bozzetti F, Fearon K, Muscaritoli M, Selga G, et al. ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology. Clin Nutr. 2006;25(2):245–59.
  36. August DA, Huhmann MB. A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr. 2009;33(5):472–500.
  37. Brown RO, Compher C. A.S.P.E.N. clinical guidelines: nutrition support in adult acute and chronic renal failure. JPEN J Parenter Enteral Nutr. 2010;34(4):366–77.
  38. Cano NJ, Aparicio M, Brunori G, Carrero JJ, Cianciaruso B, Fiaccadori E, et al. ESPEN Guidelines on Parenteral Nutrition: adult renal failure. Clin Nutr. 2009;28(4):401–14.
  39. Choban P, Dickerson R, Malone A, Worthington P, Compher C. A.S.P.E.N. Clinical Guidelines: Nutrition Support of Hospitalized Adult Patients With Obesity. JPEN J Parenter Enteral Nutr. 2013.
  40. McMahon MM, Nystrom E, Braunschweig C, Miles J, Compher C. A.S.P.E.N. clinical guidelines: nutrition support of adult patients with hyperglycemia. JPEN J Parenter Enteral Nutr. 2013;37(1):23–36.
  41. Mueller C, Compher C, Ellen DM. A.S.P.E.N. clinical guidelines: Nutrition screening, assessment, and intervention in adults. JPEN J Parenter Enteral Nutr. 2011;35(1):16–24.
  42. Plauth M, Cabre E, Riggio O, Assis-Camilo M, Pirlich M, Kondrup J, et al. ESPEN Guidelines on Enteral Nutrition: Liver disease. Clin Nutr. 2006;25(2):285–94.
  43. Sobotka L, Schneider SM, Berner YN, Cederholm T, Krznaric Z, Shenkin A, et al. ESPEN Guidelines on Parenteral Nutrition: geriatrics. Clin Nutr. 2009;28(4):461–6.
  44. Vanek VW, Borum P, Buchman A, Fessler TA, Howard L, Jeejeebhoy K, et al. A.S.P.E.N. position paper: recommendations for changes in commercially available parenteral multivitamin and multi-trace element products. Nutrition in clinical practice: official publication of the American Society for Parenteral and Enteral Nutrition. 2012;27(4):440–91.
  45. Vanek VW, Matarese LE, Robinson M, Sacks GS, Young LS, Kochevar M. A.S.P.E.N. position paper: parenteral nutrition glutamine supplementation. Nutrition in clinical practice: official publication of the American Society for Parenteral and Enteral Nutrition. 2011;26(4):479–94.
  46. Volkert D, Berner YN, Berry E, Cederholm T, Coti Bertrand P, Milne A, et al. ESPEN Guidelines on Enteral Nutrition: Geriatrics. Clin Nutr. 2006;25(2):330–60.
  47. Tangvik RJ, Guttormsen AB, Tell GS, Ranhoff AH. Implementation of nutritional guidelines in a university hospital monitored by repeated point prevalence surveys. Eur J Clin Nutr. 2012;66(3):388–93.
  48. Guest JF, Panca M, Baeyens JP, de Man F, Ljungqvist O, Pichard C, et al. Health economic impact of managing patients following a community-based diagnosis of malnutrition in the UK. Clin Nutr. 2011;30(4):422–9.
  49. Schneider SM, Veyres P, Pivot X, Soummer AM, Jambou P, Filippi J, et al. Malnutrition is an independent factor associated with nosocomial infections. Br J Nutr. 2004;92(1):105–11.
  50. Rasmussen HH, Kondrup J, Staun M, Ladefoged K, Lindorff K, Jorgensen LM, et al. A method for implementation of nutritional therapy in hospitals. Clin Nutr. 2006;25(3):515–23.
  51. Starke J, Schneider H, Alteheld B, Stehle P, Meier R. Short-term individual nutritional care as part of routine clinical setting improves outcome and quality of life in malnourished medical patients. Clin Nutr. 2011;30(2):194–201.
  52. Gariballa S, Forster S, Walters S, Powers H. A randomized, double-blind, placebo-controlled trial of nutritional supplementation during acute illness. Am J Med. 2006;119(8):693–9.
  53. Hickson M, Bulpitt C, Nunes M, Peters R, Cooke J, Nicholl C, et al. Does additional feeding support provided by health care assistants improve nutritional status and outcome in acutely ill older in-patients? – a randomised control trial. Clin Nutr. 2004;23(1):69–77.

Most read articles by the same author(s)

1 2 > >>