The New Age of Sickness and Scarcity:Is there a solution? Introducing Entry Level Clinical Nutrition™ - Part III
The New Age Of Sickness And Scarcity: Is There A Solution?
In previous posts, I've discussed the fact that chronic illness has been increasing dramatically. At the same time, many patients seem to be harder to diagnose and harder to treat, patients have less money to spend on care, and costs continue to rise.
When we think about all these challenges, it can feel like the ground itself is shifting beneath us. How can we regain our footing? How can we provide the best health care to our patients?
In my previous posts, I also discussed the limitations of traditional approaches. It's important to say that that these "status quo" approaches aren't bad, or wrong. It's more that complex new challenges almost always require new solutions.
Personally, I've been very excited to find that new solutions are available that are simple, effective and comparatively inexpensive. However, to be open to those solutions, we are going to have to rethink some of our assumptions.
To begin with,
We must drop our own belief that COMPLICATED SITUATIONS
AND CONDITIONS MUST HAVE COMPLICATED ANSWERS!
Can we accept that there may be simple, workable solutions, even in these challenging times? If so, it will open up some unexpected opportunities for us, and for our patients.
Of course, while these solutions may be available, that doesn't mean that they will be easy to find. We will, in fact, have to look in places we wouldn't typically expect.
One unexpected place we can look is the field of critical care medicine.
The Importance of Critical Care Nutrition
When we start looking into critical care medicine, as I did a few years ago, something jumps out at us right away. We find that the nutritional aspects of critical care have produced very high quality, expert research. What's more, that body of excellent research clearly shows that the principles of critical care nutrition can easily be extrapolated to the complex, chronically ill patients we see every day.
How is this possible? How can the metabolic and nutritional needs of severely ill burn and trauma patients be compared with patients suffering from fatigue, obesity, chronic pain, etc?
Great question. Here's the answer: the research and clinical data unequivocally shows that 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. To help you examine the data, I've included a few key references at the end of this post for your review.
As you'll see, the data is substantial, and convincing. However, if you're like me, you'll want to know why. Why is there a parallel between critical care patients and the chronically ill? To understand this, we must see that many patients' chronic illnesses are actually a response to environmental or psychological stressors and NOT a result of a disease process.
Seeing stress as a key to chronic disease is the foundation of Entry Level Clinical NutritionTM. The following sections will explain why.
The Critical Care Nutritional Model - An Overview
Recently, experts have been using the term the acute phase response (APR) to describe the stress response seen in many chronically ill patients.
If that term sounds familiar, it's the same one typically used to describe the metabolic response in critical care patients.
Critical care nutritionists take the APR very seriously. They know that, if not controlled quickly and effectively, the APR can lead to multiple organ failure syndrome (MOFS) - and MOFS frequently leads to death.
As an example, many burn patients die from infectious pneumonia, rather than from the burns. Why does this happen? In critical care patients, the body immediately seeks sources of protein for stability, as part of the APR. One readily available source of that protein is the gut lining. In fact, the acute phase response leads directly to gut mucosal atrophy. In other words, in cases of serious burns, the APR causes a condition we discuss every day: leaky gut! And as we all know, in leaky gut, microflora are able to enter the bloodstream in massive amounts through the damaged gut lining. Some of those microflora can cause pneumonia.
This is an example of why critical care nutritionists know that survival depends first and foremost on bringing the APR under control - whatever the critically ill patient's initial case presentation may be.
Chronic Illness and the APR
If we extrapolate from critical care medicine to chronic illness - as many experts have - it makes sense to start initial stabilization procedures in our chronically ill patients that are parallel to the stabilization done for the critically ill. In short, we need to do for chronic illness what is done for critical illness: control the APR.
Listed below are responses included in the acute phase response and also the typical treatments discussed in critical care nutrition literature.
- 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.
Critical care nutrition also addresses refeeding syndrome. This occurs when carbohydrate based nutriture is introduced after a period of low food intake. This can cause rapid increases in serum insulin leading to increased intracellular uptake of key electrolytes such as potassium and phosphate. This creates imbalances in extracellular and intracellular levels that often lead to life threatening signs and symptoms. The ideal treatment is preventive via increased attention to carbohydrate:protein ratios.
Applying These Modalities
The extrapolation of the critical care stabilization procedures to chronically ill patients is the basis of Entry Level Clinical NutritionTM. As you can see from the above bullets, the critical care stabilization modalities are simple and cost-effective. Do they work? Critical care nutritionists have been using these modalities for years. What's more, your colleagues - MDs, DCs, NDs and others - are applying these solutions right now and successfully resolving many of their chronically ill patients' chief complaints.
Yes, it's true that there is a "...tidal wave of chronic illness...". Thanks to critical care nutrition, there is a way to help them. If we start with Entry Level Clinical NutritionTM, as modeled successfully for years by critical care nutritionists, we can begin to meet the difficult challenges we face.
I'll present more detailed discussions of Entry Level Clinical NutritionTM in upcoming articles.
- Dentzer S. Reform chronic illness care? Yes, we can. Health Affairs. 2009;28(1):12-13.
- 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.
- Bengmark S. Acute and "chronic" phase reaction - a mother of disease. Clin Nutr. 2004;23:1256-1266.
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