Cachexia incorporates a constellation of symptoms including unintentional weight loss, muscle wasting, and weakness. It commonly occurs in patients with end-stage diseases such as cancer, chronic obstructive pulmonary disease (COPD), multiple sclerosis (MS), acquired immunodeficiency syndrome (AIDS), chronic kidney disease, and congestive heart failure (CHF).
Stages of Cachexia
According to the consensus definition of cachexia, there are three stages:
1. Pre-cachexia – Less than 5% weight loss accompanied by loss of appetite and metabolic abnormalities like, glucose intolerance.
2. Cachexia – Patient presents with at least one of the following:
- Greater than 5% weight loss in the past six months.
- Greater than 2% weight loss and BMI less than 20 kg/m2.
- Greater than 2% weight loss and sarcopenia as detected by mid-upper arm circumference, dual energy x-ray absorptiometry (DXA), CT scan, or bioelectrical impedance (BIA).
3. Refractory cachexia – Terminal stage of cachexia. Patient presents with limited self-care abilities or complete disability, and life expectancy is less than three months.
Although many features of cachexia overlap with malnutrition, they are two separate conditions. Cachexia is often resistant to nutrition interventions, and this points to the likelihood of underlying metabolic abnormalities.
Unlike malnutrition and simple starvation in which resting metabolic rate (RMR) decreases, patients with cachexia experience an increase in RMR. Despite this, cachectic patients typically show a complete disinterest in eating and minimal appetite.
In addition, cachexia accelerates lean muscle and fat breakdown to much higher rates compared to malnutrition. Researchers believe that pathways intended to promote muscle breakdown and reduce lean muscle synthesis are activated. Even cardiac muscle tissue is reduced, which is believed to play a role in high cachexia-related mortality rates. Fat metabolism is also altered, shifting the body to a “fat burning” state. The alterations in fat metabolism are thought to also promote muscle breakdown, which creates a dangerous cycle.
Recommendations vary when it comes to interventions for cachexia. However, most experts agree that patients should receive universal nutrition screening to identify those at risk and provide tailored nutrition interventions. Interventions should be focused on improving nutritional intake, increasing physical activity, and reducing inflammation.
The first line of treatment is usually focused on the patient’s ability to eat. If the patient has mouth sores, difficulty chewing or swallowing, nausea or vomiting, gastroparesis, or pain, these symptoms are targeted first. Approaches such as modifying the texture of the diet, adding enhanced foods and antiemetics are often used. Nutrition support should be reserved for those patients with a barrier to eating by mouth or a nonfunctional GI tract.
Medications may be considered as well. Appetite stimulants (e.g., megestrol acetate), anti-inflammatories (e.g., corticosteroids and celecoxib), and vitamin supplementation are commonly prescribed by doctors to treat some of the symptoms that lead to weight loss. Clinical trials are underway to determine the efficacy of medications and their potential to reverse cachexia.
Cachexia is a serious condition and causes complications on top of an already critical point in a person’s health journey. In many cases, cachexia negatively impacts the way a person responds to treatment. For example, when a patient has cancer, their body may no longer respond to chemotherapy and radiation when cachexia is present. This forces the patient to decide whether they wish to continue treatment. Often, the decline in one’s overall quality of life is the most challenging complication and unfortunately, this is difficult to reverse.
Currently, there is no one specific treatment for curing cachexia. Early detection and intervention are key components in achieving the most positive outcome. Research continues to develop around medication management, as studies thus far point to the possibility of certain drugs being able to target areas of the body which could change the way the body responds to being in this state.
For now, prevention is the best defense. Maintaining a healthy, balanced diet and regular exercise can help prevent chronic illnesses from occurring and offer a good baseline foundation if a disease develops.
Sarah Hammaker, RDN is a clinical dietitian working primarily in long-term care and acute rehabilitation hospital settings in Pennsylvania. Outside of work, Sarah enjoys spending time with her husband and their four children. She loves running and being outdoors. Her hobbies include reading, planting and shopping.
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Fearon K, Strasser F, Anker SD, et al. Definition and classification of cancer cachexia: an international consensus. The Lancet Oncology. 2011;12(5):489-495.
Gaafer OU, Zimmers TA. Nutrition challenges of cancer cachexia. JPEN. 2021;45:S16-S25.