Cachexia

What Is Cachexia?

[dropcap]C[/dropcap]achexia is a state of ill health involving deteriorating body composition that is characterized by general malnutrition and loss of lean tissue such as muscle.

Q: What are typical findings in cachexia?

A: Arm muscle triceps (the muscles at the back of the upper arm), skin folds, subscapular skin folds, fat area index, and bone mineral content are significantly lower than normal.

Cachexia may develop in protein-losing enteropathy such as celiac disease, chronic or severe infection such as pneumonia, tuberculosis, malaria, or many chronic diseases such as heart failure and cancer.

Cachexia can develop in persons of any age.

What Is Cachexia In Celiac Disease and/or Gluten Sensitivity?

• Cachexia is a classic feature of celiac disease and a common presenting manifestation that brings the patient to the doctor.
• Cachexia in patients with iron deficiency anemia and celiac disease involves low cholesterol, low albumin, and low body mass index.¹
• Anthropometric, biochemical, and bone densitometric assessment performed in 23 celiac children aged 1 to 12 years at diagnosis and one year after gluten free diet demonstrated that a year of gluten free diet allows virtually complete return in body mass composition.²

How Prevalent Is Cachexia In Celiac Disease and/or Gluten Sensitivity?

Cachexia is common in patients with untreated celiac disease.³

What Are The Symptoms Of Cachexia?

Cachexia is marked by these symptoms:

• Loss of appetite.
• Loss of weight.
• Loss of muscle.
• Fatigue.
• Weakness.
• Apathy.
• Lethargy.

How Does Cachexia In Celiac Disease and/or Gluten Sensitivity Develop?

• Cachexia results from protein malabsorption in gluten sensitive enteropathy (active celiac disease), with or without diarrhea.⁴
• Nutritional deficiencies may include iron causing iron deficiency anemia, vitamin B12 causing macrocytic anemia, calcium causing bone loss, and thiamin (vitamin B1), causing impaired energy.

Does Cachexia Respond To Gluten-Free Diet?

Yes. Celiac disease-related cachexia improves quickly on gluten free diet.²

6 Steps To Improve Cachexia in Celiac Disease:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both body composition and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁵
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁶
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁶
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁶.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁶
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁶
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁶[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes lettuce, kale, onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

 

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

 

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]

Certain prescription drugs deplete these nutrients that cause cachexia: iron, vitamin B12, calcium, and vitamin B1 (thiamin). Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Calcium, Iron, Vitamin B12.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Calcium, Iron, Vitamin B12.
• Prevacid®, Prilosec® deplete Vitamin B12.

ANTI-DEPRESSANTS

• Adapin®, Aventyl®, Elavil®, Pamelor®, and others deplete Vitamin B12.

ANTIBIOTICS disrupt intestinal permeability.

• Gentomycin, Neomycin, Streptomycin, Cephalosporins, Penicillins deplete B Vitamins.
•  Tetracyclines deplete Calcium, Iron.

ANTI-INFLAMMATORIES disrupt intestinal permeability.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Calcium,Vitamin B12.
• Aspirin and Salicylates deplete Calcium, Iron.

ANTICONVULSANTS

• Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Calcium, Vitamin B12, Vitamin B1.

ANTIVIRAL AGENTS

• Zidovudine (Retrovir®, AZT and other related drugs) deplete Vitamin B12.
• Foscanet depletes Calcium. 

CARDIOVASCULAR DRUGS

• Antihypertensives (Catapres®, Aldomet) deplete Vitamin B1.

CHOLESTEROL DRUGS

• Colestid® and Questran® deplete Iron.

DIABETIC DRUGS 

• Metformin® depletes Vitamin B12.

DIURETICS

• Loop Diuretics (Lasix®, Bumex®, Edecrin®) depletes Calcium, Vitamin B1.
• Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete Calcium.

FEMALE HORMONES disrupt intestinal permeability.

• Oral Contraceptives (Norinyl®, Ortho-Novum®, Triphasil®, and others) deplete Vitamin B12.
• Oral Estrogen/Hormone Replacement (Evista®, Prempro®, Premarin®, Estratab® and others)Vitamin B12.

MAJOR TRANQUILIZERS  

• Thorazine®, Mellaril®, Prolixin®, Serentil® and others deplete Vitamin B12.[/box]

• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications. Contains vitamin B1 (thiamin).
• Calcium citrate is the best absorbed of calcium supplements. Calcium carbonate is a poor choice.
• Ferrous fumarate or gluconate for iron deficiency as prescribed following blood test for status.
• Vitamin B12 as prescribed  following blood test for status.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Cachexia In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Low plasma cholesterol: a correlate of nondiagnosed celiac disease in adults with hypochromic anemia.” This study defining the correlates of celiac disease in 100 anemic adults without overt malabsorption demonstrated that compared to anemic patients without celiac disease, anemic patients with celiac disease had significant or borderline significant differences for plasma cholesterol, albumin, and body mass index but not for blood hemoglobin, mean corpuscular volume, plasma iron, and ferritin.⁷

“Restoration of body composition in celiac children after one year of gluten-free diet.” In this study, anthropometric, biochemical, and bone densitometric assessment performed in 23 celiac children aged 1 to 12 years at diagnosis and one year after gluten free diet demonstrated that a year of gluten free diet allows virtually complete return in body mass composition.

At diagnosis, the patients had height, arm muscle triceps, skin folds, subscapular skin folds, fat area index, and bone mineral content significantly lower than controls. After one year on gluten free diet, no significant difference was found between patients and controls in all parameters studied except in height and arm muscle area, which, however, were very near to the normal expected. Serum hemoglobin, iron, and zinc values were below the normal range in more than half of patients at diagnosis and with the normal range in almost all of them after 1 year of gluten free diet. Serum hemoglobin, iron, zinc, triglycerides, proteins, albumin, and calcium values rose significantly during the year of gluten free diet.²

CASE REPORT SUMMARIES

“Celiac disease causing symptomatic hypocalcaemia, osteomalacia and coagulopathy.” This case report describes diagnosing celiac disease in a 36-year-old gentleman who presented with 6 months of poor energy, tingling in fingers and weight loss with a change in bowel habit. He appeared cachectic and had clubbing, demineralisation of teeth, pectus carinatus, kyphosis, spinal tenderness, proximal muscle weakness and generalised muscle wasting (atrophy).

Chvostek’s and Trosseau’s signs were positive. His hemoglobin (Hb) was 8.7 g/dl, MCV 64.7 fl with low iron. Calcium corrected was 1.30 nmol/l, parathyroid hormone 440.4 ng/l, vitamin D <12.5 nmol/l; INR was 2.7 with coagulation inhibitor studies negative. Radiographs of spine and pelvis commented on osteopenia with thoracic kyphosis and mild anterior wedging of thoracic vertebrae. Antitissue transglutaminase was 145 U/ml, and antiendomysial antibodies were positive. An esophagogastroduodenoscopy was consistent with celiac disease. A diagnosis of osteomalacia and coagulopathy secondary to celiac disease was made.

The hypocalcaemia was treated with calcium gluconate infusions with symptomatic relief. Coagulopathy was treated with vitamin K intravenously with normalization of INR (international normalised ratio), a lab measurement to determine coagulation.⁸

“Carpopedal spasm in an elderly man: an unusual presentation of celiac disease.” This case report describes diagnosis of celiac disease in a 68-year-old single Caucasian man admitted to the hospital with a 24-hour history of carpopedal spasm of both hands. Apart from generalized weakness, he reported no other symptoms. Physical examination revealed carpopedal spasm, clubbing of fingers and cachexia (body mass index 14 kg/m2). This patient was found to have several unusual features of celiac disease, including the advanced age at presentation, severe hypocalcemia and electrolyte disturbances as the initial manifestations, minimal gastrointestinal symptoms, and negative tTG-antibodies.

Blood tests showed severe hypocalcemia, with a total serum calcium of 1.06 mmol/L (normal range [NR] 2.05-2.55 mmol/L). He also had low serum potassium (2.8 mmol/L; NR 3.5-5.5 mmol/L) and magnesium (0.36 mmol/L; NR 0.65-1.05 mmol/L). Other significant results included hemoglobin 10.6 g/dL (NR 13-18 g/dL), mean corpuscular volume 98.1 fl (NR 82-98 fl), vitamin B12 157 ng/L (NR > 165 ng/L), folate 2.8 g/L (NR 3.1-17.5 μg/L), ferritin 252 μg/L (NR 30-250 μg/L), prothrombin time 20 s (NR 11-14 s), thyroid stimulating hormone 0.87 mu/L (NR 0.35-4.5 mu/L), phosphate 0.57 mmol/L (NR 0.8-1.45 mmol/L), albumin 32 g/L (NR 34-48 g/L) and alkaline phosphatase 313 IU/L (NR 47-141 IU/L). His serum total bilirubin, alanine amino-transferase, urea and creatinine levels were normal. Subsequent results revealed vitamin D deficiency with a low serum 25-OH vitamin D of < 7 μg/L (NR 7-40 μg/L), a low 24-hour urinary calcium excretion of 0.9 mmol (NR 2.5-7.5 mmol) and a raised serum parathyroid hormone of 22.7 pmol/L (NR 1.6-6.9 pmol/L). Serology for tissue transglutaminase (tTG) antibodies was negative, and a serum IgA level of 4.95 g/L (NR 0.8-4.0 g/L) excluded selective IgA deficiency. Electrocardiograph at admission showed prolonged QT interval (corrected QT interval 0.54 s; NR < 0.44 s).

In view of cachexia, clubbing and negative tTG-antibodies, he was further investigated for an occult malignancy. Chest X ray was unremarkable. Computerized tomographic scan of abdomen and pelvis showed simple liver cysts but no evidence of malignancy. Barium meal and follow through showed dilated proximal bowel loops and absence of normal feathery pattern of the jejunum, features suggestive of a malabsorptive state. Upper gastroscopic examination was normal; however, the duodenal biopsy showed partial and subtotal villous atrophy with increased intra-epithelial lymphocyte infiltration, consistent with the diagnosis of celiac disease.⁹

Sources:

1. Ciacci C, Cirillo M, Giorgetti G, et al. Low plasma cholesterol: a correlate of nondiagnosed celiac disease in adults with hypochromic anemia. American Journal of Gastroenterology. Jul 1999;94(7):1888-91. [↩]
2. Rea F, Polito C, Marotta A, et al. Restoration of body composition in celiac children after one year of gluten-free diet. Journal of Pediatric Gastroenterology and Nutrition. Nov 1996;23(4):408-12. [↩] [↩] [↩]
3. Delco F, El-Serag HB, Sonnenberg A. Celiac sprue among US military veterans: associated disorders and clinical manifestations. Digestive Diseases and Sciences. May 1999;44(5):966-72. [↩]
4. Krause’s Food, Nutrition, & Diet Therapy. 10th Edition. Kathleen Mahan, Sylvia Escott-Stump. 2000. W.B. Saunders Company. [↩]
5. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
6. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
7. Ciacci C, Cirillo M, Giorgetti G, et al. Low plasma cholesterol: a correlate of nondiagnosed celiac disease in adults with hypochromic anemia. American Journal of Gastroenterology. Jul 1999;94(7):1888-91. [↩]
8. McNicholas BA, Bell M. Coeliac disease causing symptomatic hypocalcaemia, osteomalacia and coagulapathy. BMJ Case Rep. 2010 Dec 1;2010. pii: bcr0920092262. doi: 10.1136/bcr.09.2009.2262. [↩]
9. Schmidt K, Powari M, Shirazi T, Vaidya B. Carpopedal spasm in an elderly man: an unusual presentation of coeliac disease. J R Soc Med. 2007 Nov;100(11):524-5. [↩]