Treating Malnutrition: A Look at the Evidence

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Peter A. McCullough, MD: There have been a variety of studies that support the idea that increasing protein intake does work toward preserving muscle mass and improving a variety of our laboratory measures, including key proteins like albumin, globulin, and pre-albumin, otherwise known as transthyretin. However, recently, there’s been a very important clinical trial published, and it was called the NOURISH trial. The NOURISH trial approached patients who were acutely ill in the hospital and randomized them to a standard nutritional approach that is given as a standard of care or that standard of care plus two oral nutritional supplements per day with HMB. That stands for beta-hydroxy beta-methylbutyrate, and this supplement, its brand name is Ensure Enlive, was given twice a day.

And what the NOURISH trial showed is that there was, statistically, significantly reduced mortality over the course of time. There was an improvement in the overall nutritional assessment of patients, so it was very internally consistent. And we had a backdrop of studies suggesting that HMB, in particular, does improve muscle mass in individuals, and it does so safely. There was no signal of adverse events or any other concerns with this trial. In fact, the NOURISH trial gives us great hope now that a broad-based approach to chronically ill patients, who are hospitalized, with oral nutritional supplement really is a form of therapy given twice a day that can improve outcomes.

Nicolaas Deutz, MD, PhD: We recently published a very large study. More than 600 malnourished patients were admitted to the hospital and half of them were treated with a specialized nutritional supplement that contained a lot of protein, but also HMB. This study showed that the mortality can be reduced by 50% by providing this nutritional supplement. The first time this is done, this is an enormous result. And when I talk to physicians and other healthcare workers, they all say, “Oh, now I have absolutely proved that nutrition works.” So, I really think this is a game changer in our world. And there is so much attention from all over the world for this study, to see that now we finally have the large clinical trial that shows that nutritional supplements can really reduce mortality in people that are malnourished.

We should start treating our malnourished patients with oral nutritional supplements, because it really matters. It’s an absolute game changer. It takes a while before physicians really start believing it, but the physicians that I speak to, they do exactly what I hoped for. They immediately say, “Okay. Now it reduced malnutrition. Now we have to start with it.” They are very easily convinced with this type of data. But we just have to convince almost on an individual basis.

I have seen a lot of patients with COPD. And in COPD, a lot of people are wasted because they have to breathe. They actually need more-than-normal people, because they have to breathe and be active. I’ve met this patient, 60 years old, really had a low muscle mass and didn’t know what to do. No physician advised how to increase intake or how to increase muscle mass. I advised him, first of all, to increase his protein intake, start doing more exercise, and also I advised, at that time, to take a nutritional supplement. And I followed this patient. This patient actually gained weight. Every time I saw him, he had gained weight, and that helped very much. Because not only did he gain just the weight, he became more positive in the sense that he could do something about his condition. At some point, he looked like a normal person. He had a normal muscle mass, and he was so helpful. He still came back to me asking, “Can I help you with other patients with COPD and how to help them improve?” I think if patients feel that by treating the malnutrition, they start to increase body weight, that is really so important. Because it will keep them motivated.

Peter A. McCullough, MD: I’ve had a very favorable experience with oral nutritional supplements over the course of my career. I think one of the most frustrating things is to find a patient with obesity who actually on the outside looks quite big. But, our assessment, including whole body densitometry, shows a reduced lean muscle mass. And our laboratories indicate signs of malnutrition, including a low albumin, pre-albumin, and low globulin levels. In fact, there may be a normocytic anemia, a lower ferritin level. All of these are signs of malnutrition. So, in fact, patients who are obese who have chronic illness may fall into a malnutrition pattern. And the body really works to preserve fat at the expense of muscle loss. In this case, oral nutritional supplements serve two roles: they provide nutrition, and they allow a patient to get healthy nutrition and prevent them, in many ways, from making bad choices in terms of moving to carbohydrates or other less desirable forms of calories. They assist both in weight loss of fat tissue, but also preserving lean mass.