Nicolaas Deutz, MD, PhD: For physicians to be aware of, that patients become malnourished or have muscle loss, there are some simple tools to screen. But, my suggestion always is that involuntary weight loss is by far the most important thing that a physician could notice. And, it is a very simple question, so that it can bring them on the idea that there is malnourishment. The basic idea is that if a physician found signs of malnourishment, then there need to be other tools to assess the malnutrition. And I think dietitians and nutritionists can very much help in this. Physicians are aware of the issue of malnutrition. They are actually not so aware of how important it is to treat in malnutrition, which I understand. Because if there is no proof that treating malnutrition actually is in the benefit of a patient, it’s hard to do. So, I think that a lot of physicians are aware of this problem. For instance, physicians that treat cancer patients are absolutely aware that if cancer patients start losing weight, this is not a good sign. But, they are not so convinced that doing something about it really will help the patient. It’s not only the awareness; it’s actually also that physicians should be made aware that it will have a benefit for the patient to treat the malnutrition. And, then, it will become more important even to better screen.
The most important reason for the malnutrition is that people stop eating because they have less desire to eat. Their appetite is very important here. And, think about it, if somebody is sick or gets the flu, the desire to eat has become less immediately. These older people with their chronic disease have this on a daily basis. They have just less desire to eat. So, in my opinion, the reduced food intake is by far the most important reason for the malnutrition. There are other causes that maybe play a role in the sense that the body starts to need more nutrients. Or, in the case of reducing this intake, the body also needs more nutrients, which makes it even more important to consume enough nutrients. But, the most important reason why people get malnourished is actually by reducing their food intake.
Peter A. McCullough, MD: In my daily practice, in each and every patient, I do take a very brief nutritional history. And I think it really is an eye-opener for physicians’ and other care providers who just very quickly walk through a day of what is typically consumed by a patient. So, my practice is heavily dominated by heart failure. Heart failure is a common condition. It’s the most common reason why adults are hospitalized in the United States today, and heart failure for the majority of patients is a terminal diagnosis. In fact, most heart failure patients will die of heart failure. There is a condition called cardiac cachexia, where there is a whole array of signaling proteins, very prominent—and there is a tumor necrosis factor alpha, as well as several other interleukins. These signals actually increase over time. And, as the heart begins to fail, the muscle mass begins to reduce, and patients develop generalized weakness. This tends to accentuate breathlessness, because it involves the muscles of respiration, both the voluntary and involuntary muscles of respiration. And so, we have a limitation in aerobic capacity. How we combat this is when we identify sarcopenia and this loss of muscle mass, we immediately start to work on protein targets. We commonly recommend nutritional supplementation beyond food diets. There’s a key micronutrient that’s in trace amounts in avocadoes and grapefruits. But, in fact, we just now move in the supplementation form of this, and it’s called beta-hydroxy-beta-methylbutyrate, or HMB. HMB has been recently incorporated into a widely available nutritional supplement, specifically and ideally fitted for patients with heart failure, which is called Ensure Enlive. And this supplement contains, if taken two a day, would give about 3 grams of HMB, which is more than enough to maintain muscle mass and, in fact, build muscle mass over time.