Good morning, everyone. Thank you for coming to Making Sense of Muscle Wasting. My name is Jessica Engel. I'm from John Hopkins School of Medicine. I have some great folks here today to talk about muscle wasting, including Dr. Ishan Roy. And Dr. Roy is MD, PhD. He's an attending physician scientist and a principal investigator for Translational Cancer Rehabilitation Lab, an assistant professor of the Department of Physical Medicine and Rehab at the Shirley Ryan Ability Lab at Northwestern University, Dr. Hannah Hunter, who is assistant professor of University of Washington Medicine, Department of Rehab Medicine, Medical Director of Cancer Rehabilitation at Fred Hutchinson Cancer Center, and Hannah Manella, who is a registered dietitian and a clinical exercise physiologist at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. So without further ado, I'm going to present our objectives. Just put them up to here real quick. And that is to compare and contrast existing classification for muscle wasting for L-decocexia sarcopenia, implications on biology and therapeutics, define interdisciplinary team for assessment and treatment of muscle wasting, identify the most important factors in muscle wasting diagnosis, treatment, and the rehabilitation community. And then I'm going to hand it over to Dr. Roy. Thanks Dr. Engel. So thanks for those of you who are here today. We've been talking about this particular topic as a group for over a year now. And I think part of the reason that I was really interested in giving my portion of this session is that I've seen the use of some of these terms that you see on the screen over the years in the literature, both in the oncology world and in the rehab world. And it's oftentimes people kind of use these as synonymous terms or interchangeably. And as someone who has focused my career on the research of muscle wasting, I kind of wanted to kind of reset the table for people so that they understand kind of what are the biological concepts behind these terms. So we're going to start with sarcopenia. And so the original sort of literal translation of this word is poverty of flesh. But in reality, if you look at the definition from the Society for Sarcopenia, Cacaxia, and Wasting Diseases, it's really just age-dependent loss of muscle mass and function. Now that definition has evolved over time. And importantly, the diagnostic criteria for sarcopenia has evolved with it so that in order to truly diagnose sarcopenia, you'd have to demonstrate a threshold-based loss, muscle strength, muscle mass, and physical performance. And the problem with this term, though, is that it is frequently interchangeably used with secondary sarcopenia, which would be a loss of muscle mass alone due to a particular disease. And so for example, you'll see in the surgical literature and a lot of the oncologic literature just the use of the term sarcopenia. And really what they're just talking about is that loss of muscle mass. And they oftentimes don't include that additional component of strength or physical performance. So next we have cacaxia, which literal translation from Greek was bad appearance. And what that has evolved to mean is body weight loss due to muscle loss and sometimes fat loss as well due to an underlying illness. Does it quite match up with the diagnostic criteria that are established by the consensus group, which is either 5% weight loss over the last six months in the absence of simple starvation, or if your BMI is a little bit lower, less than 20, or if your skeletal muscle index is consistent with sarcopenia from a muscle mass standpoint, then the weight loss criteria only has to be greater than 2%. The inherent problems with this, of course, is that there's still not a link with physical performance or physical function. And then second is, of course, you can lose weight for a number of different reasons, and not all of that is due to muscle. Fatty is another term frequently used in the literature. Literal translation of the word is easily broken. There's actually no consensus definition for this. There's two camps in the literature in the research world that have evolved. One camp thinks about it as a syndrome of loss of strength, speed, weight, energy, and inability to perform demanding activities. The other camp thinks about it as simply just a state of age-related deficit accumulation. The issues with this are that in the context in which it's mostly used in literature is for risk assessment. So it's harder to know what the value of tracking frailty is over time. It's also been mostly co-opted by the geriatric field. So again, its broader use in the cancer world or any other disease-specific community is still not clear. The other part that I think the geriatric community in particular is prone to is that they kind of assume that disability is part of this just inevitable spectrum if you have frailty, which of course doesn't really align up with the WHO classification of disability and doesn't really incorporate the societal components as opposed to the pathophysiologic components that lead to disability. Next is disuse atrophy. Perhaps the simplest concept that I think everybody in the room is already aware of. It's just worth noting that from a biological standpoint, this is due to lack of mechanical loading and lack of consistent contractile activity. And what that means is that it's not actual muscle wasting. In reality, it's just a lack of stimulus, that regular stimulus that leads to protein synthesis. Perhaps the most reversible of the concepts that we're talking about today. And then the other issue is that it does overlap with sort of the umbrella term of critical illness-related muscle issues, which have not been distinguished in terms of the biology. Additional terms that you see in literature sometimes are dynopenia and myopenia, just really descriptive terms saying low strength or low muscle, haven't really been consistently connected to clinical outcomes or pathophysiology. Just to kind of hammer home this concept a little bit more, I want everyone to kind of think about the homeostatic environment of muscle. So all muscle in all human beings, whether you're healthy or not, is in some balance between protein breakdown and protein synthesis. And those things can tip in either direction depending on sort of transient and acute issues. But if you're exposed to different chronic conditions, then of course the balance can change. So on the left, bottom left, we have atrophy due to simple disuse. And that, again, is primarily due to lack of synthesis and not due to actual wasting or breakdown. In the middle, you have atrophy due to sarcopenia. And that's associated with a little bit of chronic inflammation. And so there is a little bit of breakdown that happens on those people. But in reality, it's still a lack of anabolic stimulus that's happening due to aging and therefore, lack of synthesis. And on the right, you then have atrophy due to catabolic states. So this is cachexia. It can be due to a number of different conditions. And there, you have dramatic breakdown, increasing breakdown, and dramatic increase in synthesis or decrease in synthesis. This pyramid was also taken from the Society for Sarcopenia, Cachexia, and Wasting Diseases. And I encourage everybody to go to their website if you want further clarification on some of these definitions that I'm using. And so if we look at the top here, let me just pull up the power laser pointer. If you look at the top up here, you see what's the etiology of the muscle wasting that we're talking about, either aging or disease. And then as we go through cachexia, which is associated with high inflammation, or sarcopenia, which is associated with a lower degree of inflammation, both of them still lead to skeletal muscle dysfunction. And this is where the research, I think, kind of stops in terms of distinguishing these biological conditions. Not a lot of study has been done to sort of separate these two out at the functional level. But nevertheless, I think you can layer on the other two concepts that we've been talking about. I think disuse atrophy is then additive in terms of that muscle dysfunction. And frailty is really a outcome of all of this and downstream of these concepts. So why focus on cachexia versus others? And so this is where you kind of get to see my perspective on this. My clinic focuses on cachexia rehabilitation. It's jointly between Shirley Reinability Lab and our Comprehensive Cancer Center. I work very closely with Hannah Minella, who's here today. And I'm going to talk a little bit about how I came to land on studying cachexia versus some of these other concepts. So one of the bigger reasons is that in cancer patients, about half of all cancer patients will develop cachexia at some point during their disease. And if you look at the prevalence in different types of cancers, I think some cancers, like pancreatic cancer, gastric cancer, are almost synonymous with having muscle wasting and cachexia. But other diseases still get it. And so, for example, prostate cancer patients, especially those who have even solitary metastases, are susceptible to cachexia. Same with colorectal cancer and lung cancer. And so it doesn't really matter what cancer you have. There is still a risk of cachexia developing. And partially, that's because once you get advanced disease, that prevalence really increases. And about a third of all cancer-related deaths can be linked to some of the mechanisms that are linked to cachexia. And of course, my interest in this has to do with function. And a majority of cancer patients, really a vast majority of cancer patients who have cachexia will eventually develop disability. I'm a basic scientist in my training. And so one of the other reasons why I'm focused on cachexia is sort of that it's been well described as a biological or pathophysiological issue. And that starts with muscle. And so the inflammatory mechanisms that attack muscle and fat also attack the cardiovascular system but also attack other organ systems within the body. So the same mechanisms that are affecting muscle affect the brain, affect bone metabolism, affect gut physiology, affect liver physiology, affect endocrine physiology. And so in my opinion, cachexia is more of a systemic and immune reaction that happens in the context of cancer or other chronic diseases. And muscle is really just the tip of the iceberg whereby we're recognizing that this larger systemic issue is happening. So a little bit more about confusing cachexia and sarcopenia. And at this point, I'm not talking about age-related sarcopenia, the way that term is sort of used and tied to a specific pathophysiologic condition, but rather the secondary sarcopenia term that's so broadly used in the cancer literature. And so a couple things. One is, particularly when you see it used by oncologists, it's typically defined just by imaging or bioimpedance. The second thing is really then what that's telling you is someone's static body composition. And then really what that means is you don't understand someone's change over time. And that progression component is a key component of cachexia and any sort of understanding of how that muscle loss is really developed. So cancer-related sarcopenia, as that term is frequently used, I think is just an anatomical snapshot. It doesn't tell us the biology or the underlying etiology. So with that in mind, I kind of sought to develop an outpatient cachexia rehab program. Different versions of this have existed at different institutions over time. There was one at MD Anderson run by Adidio Del Fabbro for a long time. He moved to VCU later on. There's another version of this at USF. McGill has had probably the longest standing one in North America. And then there's ones in Australia as well. Typically these clinics have been run by palliative care with less input from the rehab side. Now what these clinics focus on, and I think this is partly due to the fact that it's run by palliative care, is focus on symptom evaluation, trying to tie different pharmacologic interventions to specific nutritional symptoms. And so the physical assessment part of this or the functional assessment part of this has been a little bit sort of one size fits all. They might work with an exercise physiologist. They might work with a PT. But there's not a lot of customization that's happening. Nevertheless, these clinics have demonstrated that you can increase weight in these populations. You can increase quality of life. And so then my goal became, well, if we sort of took more of a rehab forward approach to a cachexia program, could we get better functional evaluations and better customized and integrated rehab plans? Now I mentioned, of course, the issues with sarcopenia and sort of the imaging-based descriptive static issues. But there are still issues with cachexia diagnosis as well. Of course, weight-based criteria, as I already said, is not sensitive. You don't understand a lot about the actual muscle in a patient. You also don't understand about the inflammatory status for them. And then it's not directly linked to any functional metrics. So how can you potentially better identify these folks? With the help of Hannah at our cancer center, we've been developing a tool that's built into Epic that we are kind of at sort of like an intermediate stage of implementing on the oncology side. But we're already actively using. It incorporates a few different markers of cachexia. One is the Fearon criteria that I already explained. Another is something called weight loss grading scale, which I think came about because, of course, if you have different BMI, the amount of weight loss you have is probably likely different in severity. And so the goal was to try and create a spectrum of severity for cachexia. And so what we have here is quintiles of BMI versus quintiles of body weight loss. And the numbers in these squares are overall survival. And so you can see there's different groupings. And those groupings are already colored for us. So there's a group that's 4 to 6 months, overall survival 6 to 9 months, 10 to 12 months, and so on. And so then they've turned that into a 0 to 4 scale. And so I use this in my clinic every day. I don't discuss the scores with the patients, but I use that to sort of shape what we think is an appropriate functional intervention for the timeline that the score is laid out. One scoring system that I don't use but I felt was worth mentioning is the modified Glasgow prognostic score. This was developed in Scotland. It's used widely in Europe for assessing cachexia. It's dependent on CRP and albumin. Unfortunately, CRP is not routinely collected in the United States. And so I think it's been falling out of favor in North America in particular. The blood-based markers that I instead use are neutrophil to lymphocyte ratio, which I think is a good proxy for CRP. So certainly in the cancer population, you can have both neutrophilia or neutropenia depending on what the clinical context is. And so the other blood-based marker that we use is prognostic nutritional index, which focuses on albumin and absolute lymphocyte count. And again, both of these I use to sort of secondarily assess someone's pro-inflammatory state. Now before the talk this week, we also kind of crowdsourced a little bit for what are potential questions that you as an audience might have. And one of the questions was, what tools in the clinic could you be using beyond the weight-based metrics? So one of them is bioimpedance. I think bioimpedance does have some value. Now the strengths of it are that it's convenient. There are established norms for lean body mass that have been validated over and over again in the literature. And I think it's a good alternative to tracking someone's weight in terms of potential recovery from cachexia so you can follow that lean body mass specifically. The weaknesses of it are the same as any other imaging modalities in that lean body mass does not actually equal muscle mass, and it definitely doesn't equal functional muscle mass. And of course, it's still a snapshot. And so you can't use it by itself. I think you'd have to still combine it with those blood-based markers and weight-based markers at a first visit. Ultrasound. Now people have been talking about this for a while, and the issue remains that the current evidence for it is incredibly limited. The sample size is quite low in all the studies that exist out there, and most of them are single provider studies. So an individual provider might be quite confident in their ability to track someone's muscle mass over time, but no one has really shown that there are established norms that we as a community can follow. And so I think we're still way behind in terms of being able to use ultrasound for tracking muscle mass in particular. And then the CT part. So obviously, CTs are used quite frequently to diagnose that sort of anatomical part of sarcopenia. But I see a couple issues with this in the long run. One is that the frequency of CTs is usually only about three months for the most part for someone with active cancer. And cachexia develops way faster than that in a lot of people. It can develop in a couple of weeks. And so if you're waiting every three months to diagnose someone with cachexia, then you might have missed the best window in which to intervene. The second part is that the vast majority of studies that are being put out there that use CT-based imaging are actually research-based studies and have funding behind them to support the calculation of the skeletal muscle index in CTs. And it's expensive. Either you have to have a radiologist who's willing to do it, which most radiologists are not, or you need the software that does it automatically, which again is quite expensive. So I see some issues with implementation in terms of CTs in the long run compared to something like bioimpedance. So what do we do in my clinic? So in addition to those weight and blood-based markers assessment, we spent a lot of time trying to figure out what are the inflammatory contributions to a particular patient's presentation. So we look, of course, at their cancer history, their treatment history, but then figure out which of those components are specifically adding up to the muscle wasting. And that can include things like, have they been having chronic infections? Do they have chronic wounds? Specific chemos that are prone to causing muscle wasting as well. And then the third component that's not functional inherently is the nutrition impact symptoms or intake symptoms. And so basically we're addressing a lot of GI function-related issues along with fatigue. My physical exam, I think, is pretty straightforward and familiar to most people. The history evaluation is really just triaging ADLs, IADLs, functional mobility, activity tolerance, and exercise tolerance. The exam itself, in addition to a sort of, I would say, standard neuromuscular screen, I focus a lot on balance, a lot on gait, and then a lot on sort of hip pelvic girdle strength, trying to assess gluteal strength and sit to stand, for example. So in terms of the approach to treating things, I'll let Hannah Minnella kind of talk more about the optimizing nutrition part of it. I view my role as trying to reinforce what she's been teaching patients. If for some reason I see someone before they've seen her, then I might do a little more education and then make sure that she is looped in. In terms of the nutrition impact symptoms, oftentimes oncology or palliative care has already started to address these, but it's really not been tweaked properly. And so oftentimes my role is to sort of connect back with them and say, hey, try this instead of that. And then the customized rehab program, I've tried to summarize in a table that's a little complicated, but this is by no means comprehensive. But generally speaking, the sort of two categories I have to think about are, where are they in the sort of trajectory of their disease? And then what's the degree of their functional impairments? So if someone is in active treatment or in a true and pro-inflammatory state, if they have higher functional issues, then, of course, we're still going to PT or OT. But we're thinking about how to schedule that in a cycle-adjusted way. And the same is for a progressive decline. But we are going to have that discussion with oncology about whether or not cancer treatment should be held so we can be a bit more aggressive in terms of the functional interventions. And then if people have stable or completed treatment, then we can be even more aggressive in terms of the intensity of rehab. So something like day rehab, where we're talking about multiple hours per day per week. At the functional mobility and exercise or activity tolerance level, you start to have that sliding scale of, do they need something like PT that's focused on gait? Or can they potentially have an exercise program that you establish with them in the clinic? Or can they go, if you have the resources, to a certified exercise physiologist who specializes in cancer patients? And I think you have to clinically gauge your patients to be able to know which of those is the best approach. In terms of goals, for that active treatment population, the main goal at the beginning is not to recover weight. It's really just to maintain their current function and maintain their current muscle mass. And then if, through the course of the cycles of their treatment, you're successful in that initial goal, then you can start to focus on improving their muscle mass. In the progressive decline population, I don't think it's realistic to try and recover weight. And we don't really even talk about it that much. We're mainly talking about the consequences from a functional standpoint, trying to maintain their functional independence. And then for the completed treatment group, of course, you can be more aggressive in terms of the goals for them. And so with that, I'll hand it over to Hannah Minnella. Thanks. Hello. Good morning. So again, I'm Hannah Minnella. I'm an exercise physiologist and dietitian at Northwestern. So I work very closely with Dr. Roy. So first, just wanted to start by saying a dietitian may very well approach a patient differently depending on where they're at in their cancer continuum. So from a prevention and a survivorship standpoint, we're very much focused on, say, the AICR guidelines on prevention survivorship, plant forward diet pattern, adequate physical activity participation, healthy eating behaviors, all things prevention, all things healthy eating. But then once a patient is diagnosed with cancer, our focus or our conversations are likely going to shift. The whole phrase of eat whatever you want while you're going through treatment doesn't exactly work. Maybe in some situations, we might have that conversation depending on the severity of symptoms. But really, the emphasis is ensuring adequate nutrition to maintain weight, but then also managing treatment-related side effects as well, too. We may also manage nutrition support, whether that's tube feeds or TPN. And then we oftentimes are really just debunking a lot of fad diet questions and kind of going through all of the myths and all of those things individuals will read online. When an individual then transitions to, say, more of a palliative care or hospice care route, conversation does shift even a little bit more. It's a little bit more relaxed, I would say. A lot of the times, it's just focusing on quality of life, meeting a patient where they're at, working with their caregivers, and trying just to be realistic with recommendations at that point. During active treatment, like I mentioned, the whole phrase of eat whatever you want, we don't really approach it like that. We still want individuals to eat as healthy as possible. We still want them to eat a well-rounded diet, if possible, with emphasis on a high-calorie diet to ensure their nutrient needs are met. But then we also need to ensure they're eating adequate protein as well, too. If someone, say, is following a vegetarian, vegan, pescatarian diet, we do also need to ensure their baseline nutrient needs are being met. So we will look and analyze that. We'll talk about fluid. We'll talk about food safety as well, too. But then, really, the big piece and the reason why a dietitian should be established with a patient throughout their cancer treatment is to help work through nutrition-related side effects. Because as we know from a cancer perspective, a lot of these side effects are cumulative. So they might start off relatively mild for the first couple of treatments, but get progressively worse as they continue. So if a dietitian can be there throughout the process and continue to advance and adjust diet recommendations based on symptoms, that's going to be a really important thing. But we also need to also be aware of previous diet restrictions. Say if an individual has kidney disease or diabetes, our recommendations, our discussions, will be adjusted that way. What I will say, 9 times out of 10 when we're talking to a patient and they're dealing with a lot of serious side effects, we're going to encourage smaller, more frequent meals. By eating smaller, more frequent meals, it gives us a little bit more flexibility with our diet restrictions. Say from a diabetes perspective, if they're eating smaller, more frequent meals, they're eating less carb load at one time. And so they're likely not going to have as aggressive of a blood sugar response. Additionally, if they are consistently incorporating protein every single time they eat, that protein metabolism slows down the carbohydrate metabolism. They're not going to have as large of a blood sugar response. So we do get a little bit more flexibility if they do shift to smaller meals based on their previous diet restrictions. All right, then when we look at key nutrients, I've already briefly mentioned this. And I'll talk about it more later on as well, too. But really, the priority during active treatment is maintaining weight, specifically maintaining muscle mass. We know that if an individual loses weight during active cancer treatment, they're at higher risk of losing muscle stores. So we want to ensure that they're taking in enough calories that their body can utilize the nutrients that they're getting from their diet. And it's not going to have to pull and get its energy from their skeletal muscle stores. So we do want to ensure they're eating enough calories to maintain their weight. So I have that conversation with a lot of patients up front. A lot of patients say, Hannah, but I need to lose some weight. Right now is not the time. Let's just try to maintain. And so really, when we look at calorie-dense foods, we're going to get the most bang for our buck from fat sources. So healthy fats is what I encourage from the start. More avocado, more nut butters, more olive oil. Say if they're eating a lot of soup, that's fine. Put a squig of olive oil in there. It'll add 100 calories. You won't even know it. So that's usually the place I start. If it's someone, say, with a GI malignancy, maybe having more malabsorptive issues, a little bit more difficult to tolerate fats, I will maybe encourage being a little more aggressive with their carbohydrates. It's usually an easy food source for people to eat, right? People like bread. People like pasta and potatoes and those kind of things. So I try to start with fats. But then we also absolutely encourage carbohydrates as well, too. And then, of course, protein-rich foods to ensure they're having adequate amino acids circulating. I do start with lean proteins as much as possible. I find 9 times out of 10, people don't really tolerate red meat very well during treatment. So I encourage more lean proteins, but then also plant proteins. Beans, lentils, tofu, tempeh, for some reason, those are very appealing during treatment. It's probably because of the texture. They're smooth. They're creamy. You don't have to chew. You don't have to work at them for a long time. There's a lot more appealing to people during treatment. And then also, there is the role for protein powders, protein supplements. There's hundreds on the market. It's hard to know where to start. I start with food first. And then if individuals are having a challenging time, then we can talk about additional protein options. All right, so then you guys may be familiar with the plate method. This is how dieticians really like to talk to people about how to balance your plate, because it's visual. People understand it. It's a lot easier than, say, the food pyramid that was out 10 years ago or so. So from a general eating perspective, this is someone, just anyone, I would encourage to try to do this. Fill half your plate with vegetables, one quarter with lean proteins, one quarter with multigrains. But for someone that's going through active treatment, we kind of have to adjust it a little bit. We have to be practical. We have to meet them where they're at. As you can see here, this meal example is significantly smaller, because we are going to probably encourage smaller, more frequent meals. I want them first to think, what's an appealing protein source? This is a great example of something like scrambled eggs. It's easy to eat. It's soft. You can really load the calories in if you add, say, a high-fat milk or milk alternative, if you put cheese on top, something like that. And then you add some colorful vegetables that are appealing. In this one, you can see they're cooked vegetables, which is likely going to be better tolerated. A lot of roughage, a lot of raw veggies typically aren't very well tolerated during treatment. And then you put a grain or a starchy food that's appealing. Here's just a small piece of toast. So it really does, you can still have a well-rounded meal. But we just kind of have to adjust it a little bit. If you can add a little extra fat, maybe a little avocado, cheese, oil, those kind of things, just to up the calories even better. All right, so when we're talking about muscle wasting, as we know, we don't believe that muscle wasting is solely impacted by nutrition or solely impacted by physical activity. We think it's a combination of a lot of other things that need to come together to really help impact and mitigate any muscle-wasting symptoms. From a nutrition perspective, there are a few interventions that are currently being studied that I think will really start seeing a lot more literature in the next upcoming years on specific interventions to combat muscle wasting from a nutrition perspective. First and foremost, they have to meet their calorie needs, right? So calorie perspective, anywhere from 25 to 30 calories per kilogram per day, roughly. It really is very patient-dependent. And again, it's an estimation. So we give patients an estimated calorie need, but we might have to adjust it depending on how they're doing. Protein, 1.2 to 1.5 grams per kilogram per day. I find that is the most practical recommendation to give to patients just from an eating perspective. I have rarely seen someone being able to achieve a 2 gram per kilogram per day protein intake. Just practically, patients just have a really hard time meeting that. So I do find 1.2 to 1.5 is practical. There are some amino acids and amino acid derivatives that are starting to be evaluated. Still very early research. We still don't have a lot of strong conclusions. Some that I am going to point out, though, and I apologize, they're kind of being covered a little bit. But say, for example, HMB. So that is one that has been added to an Ensure product. So one of our protein shakes has HMB added. HMB has been recognized to potentially prevent protein breakdown. However, HMB is metabolized on the mTOR pathway, as well as a number of chemotherapy agents, as well, too. So it may not be something that we can recommend across the board, because it could potentially interfere with various chemotherapy agents. Glutamine is one I personally think we'll start seeing most frequently. Right now it is being used, say, in the head and neck population to assist with mucositis. There is some new evidence out there on the benefit of muscle synthesis, as well, too. So I think that's probably the first one we'll start seeing. And then carnitine, creatine, we've seen that one for years. There's some evidence in the cancer population. But again, it's not very strong at this point. Vitamins and minerals, just ensuring their vitamin mineral needs are met. It's really essential. Vitamin D always is in the literature. We're always learning more about the benefit of vitamin D. Fish oil EPA does have a role on here. I would say from a practical standpoint, it is not the most appealing or well-tolerated to individuals during cancer treatment. If you think about it, so under here, it says 2 to 2.2 grams per day of EPA. If you actually look at that from a capsule standpoint, it could be upwards of four to six capsules of fish oil supplement a day. From a practical standpoint, a patient going through chemotherapy treatment is not going to be taking four to six capsules of fish oil every day. And then when you add the fish burps to it, there's no way. We can really get a patient to do that. So also, high doses of fish oil or EPA has been found to interact with blood thinners as well, too. And a lot of our patients are on blood thinners as well, too. So again, a lot of these nutrition interventions are early. I think we will start seeing more of them in the upcoming years. But really, our main focus at this time is adequate energy and protein needs, and then going from there. All right, so I will hand it off now to him. Hi, everyone. I'm Hannah Hunter. I'm an oncology rehab physician at the University of Washington. And we heard a little bit about the importance of collaboration between nutrition and rehab medicine for these patients. I'm going to share a little bit about our clinical programs that we've developed to try to pragmatically collaborate at Fred Hutch, as well as a little bit of research that we're doing for body composition and sarcopenia. So I think of trying to reach patients as like a three-tiered approach. If anyone has a way that we can somehow risk stratify all patients and figure out what, when, and how to refer to rehab, that would be awesome. But we've found that rather than just a single algorithm, we've had to kind of take on this three-tiered approach. One being that clinic visit or disease-specific pathway. So patients undergoing a transplant have nutrition on board early, or patients with head and neck cancer see nutrition at initial screening, as well as an SLP. And so these are the referrals to our medical nutrition team, PT, to myself, that are happening kind of organically through a clinic visit or through a clinical pathway that's disease-specific. The second program that we've been working on is a supportive care screening tool, which I'll share a little bit about. This is a patient-filled-out survey that is pushed to every new oncology patient seen at our institution as a initial kind of screen of services, whether it's spiritual care, integrative medicine, rehab, pain, palliative, that we can identify early, even before they meet their oncologist. And the third approach is this web of supportive care. And while we have a robust supportive care team, we've also found that we need to find the right time and mechanism to refer to each other to make sure we're meeting the needs of our patients throughout their cancer care. So in terms of malnutrition screening, at our institution, we just have a more robust medical nutrition team than clinical providers for rehab. And we found that we have needed to collaborate closely because a lot of times in rehab, patients ask questions about nutrition. And in nutrition, a lot of times patients will ask questions about exercise. So even polling the room, of the rehab providers here, have your patients asked you what they should eat or not eat? Yeah. And so there's definitely a lot of. And so out of that, we have come up with a program where every other month, our medical nutrition team and PT team meet together to make sure that we're sending the same message to patients. Because from a practical perspective, it's really helpful when patients are getting the same message from multiple providers. And the biggest, or let's say the most common thing that we recommend is protein snacks and exercise snacks. We know that a lot of our patients in treatment cannot do an hour yoga program or do the same vigorous intensity exercise that they've been doing after a 30 pound weight loss. So a lot of times we will recommend frequent sit to stands, inspired by Dr. Serkin, as well as frequent protein-rich meals. So in terms of malnutrition screening, this is kind of our initial strategy of making sure patients are seen by nutrition at different time points. And this could be during treatment, sorry, at initial intake. It could be before and after surgery. It's at every cycle of chemo, before, during, and after radiation, and even in surveillance. So during these screening and re-screening episodes with our registered dietitians, patients receive an individualized nutrition plan and are screened for malnutrition. And I mention kind of these points in red because of the importance of re-screening. Because at different time points, depending on the intervention, patients will develop structural or mechanical changes in terms of their ability to eat, or in terms of their ability to digest, or their ability to make muscle. And that could be dysphagia from head and neck surgery. That could be fatigue or decreased activity tolerance, where the type of food that they're eating plays a huge role because they may not want to chew that steak. Maybe lymphedema, and it could be trismus. So in our collaboration with medical nutrition, when patients are diagnosed with malnutrition, and we use a malnutrition screening tool, and our registered dietitians do something called the nutrition focused physical exam, where they examine patients kind of head to toe to look for clinical signs of muscle wasting or muscle loss. And when patients are diagnosed with malnutrition, they are referred to physical therapy. So this is not necessarily based on a functional assessment, but our goal is to see patients before the cachexia kind of clinically manifests, or before the muscle loss is functionally manifesting. So a lot of times by the time when they're diagnosed with malnutrition by our registered dietitian, it may be earlier in their clinical course. And we kind of think of it as falls, right? So we want to see patients before the fall. We want to see patients before the malnutrition kind of manifests. So during that physical therapy, I'll share a little bit about our data. We've only been doing this for about eight months. In our six month pilot, we really focused on cancer populations that are pretty metabolically active. So GI oncology, bone marrow transplant, and head and neck. So in our GI oncology patient population, within the six months we've had 43 referrals to PT, 10 of whom had a concomitant malnutrition diagnosis, and eight of them who came to physical therapy. In our head and neck patient population, the majority of referrals were for lymphedema, but 14 of 37 were for deconditioning, with four of them diagnosed with malnutrition, and all four came to physical therapy. Of those visits, it was a one-time visit on a home exercise program. They're followed by our registered dietitians because of their cancer treatment. And from their notes, they all had an improvement in overall physical activity. Next, I'll share a little bit about our pilot. Before that, so during the physical therapy visit, we're trying to standardize what we're measuring during these visits for kind of a malnutrition referral. Patients fill out a SARC-F, which is just a really easy five-question questionnaire about function, like ability to walk upstairs and do sit-to-stands. We're measuring hand grip with hand dynamometry, doing a 30-second sit-to-stand. Right now, we're only rolling out bioimpedance in our transplant patient population, just because of time. But we do have a SOZO device in our physical therapy clinic. And then they're given an exercise prescription for moderate-intensity aerobic activity in a home-based strengthening program. So next, I'll talk about our supportive care questionnaire and the little research that we're doing. So all of our supportive care services have kind of worked together to build a kind of a massive questionnaire that patients receive on intake. It's pushed through them via our electronic health record, includes things like the PHQ-9 for depression, questions regarding financial and housing insecurity, as well as the malnutrition screening tool, which is a quick two-to-three-question survey. Have you lost weight recently? How much weight, a guesstimation? And have you been eating poorly because of decreased appetite. If they screen positive, they're seeing nutrition. So if they see nutrition, they see a reason for PT referral. That's how we're using that kind of supportive care web for physical therapy. And then our specific physical therapy questions are actually dependent on palliative care questions, not to add to question burden. So our two questions are related to fatigue and activity, rather than talking about specific function. We are using a general fatigue question and a question regarding how much assistance patients are needing per day. So initially, when we rolled this out in April 2023, in one month, we ended up with over 100 referrals to PT because we were like, what if they screen positive for both? And we were like, that's just unfortunately not sustainable for our institution. And we wanted this kind of to be a really true baseline because this is not the only way we're getting a true kind of safety net, as this is not the only way we're getting physical therapy referrals. So instead of referring patients who are just screened positive for both, it's if they answer both questions in the yellow, they're referred to physical therapy. And we found that that was a much more manageable number. So with this questionnaire, instead of the primary oncologist getting 20 clicks of referrals to order, every questionnaire from each service has its own pathway to end up in a referral. Some are auto-referrals, and some go to a specific nursing team to help generate that referral and make that happen, which we've also found to just be more practically sustainable. And the last thing I'll share about is our clinical trial in bladder cancer using a digital health intervention to study physical function outcome measures, as well as body composition. So we were lucky to receive a generous grant to implement a digital health intervention called ExerciseRx. This is a exercise digital health kind of app that we developed at the University of Washington. The PIs on this study are Sarah Suka, who is a urologic oncologist, and Cindy Lin, who is a physiatrist specializing in sports medicine, and myself and Sean Munson as co-eyes. And the primary aim of this study is to see if we can maintain or improve physical function measured by the SPPB, the short physical function battery, in patients undergoing treatment for muscle-invasive bladder cancer. This is a patient population at high risk for frailty and functional decline. And they're actually going to be using this app to track sedentary activity steps, as well as a home-based exercise program that's prescribed by myself and individualized to each patient and modifiable at any point in their intervention during three months of neoadjuvant chemo, a month break before a radical cystectomy, and three months post-op. And this is a little schematic of what the trial looks like. But the things I want to focus on is the things in red. So our primary outcome, while we are looking at patient-reported outcomes in terms of quality of life, as well as surgical outcomes, morbidity, and mortality, our primary outcome is improvement in the SPPB from an intervention to control group. And in terms of assessments that we're performing at baseline before their major surgery and three months after their surgery is body comp measured by CT, skeletal muscle index, and a frailty assessment. And I mention that because while I commend Dr. Roy on his research endeavors in cachexia, part of my interest in sarcopenia and body composition has just been what's feasible and easy to do. And these patients get CTs, so it's something that we can measure. And I may not give a full picture, and it is kind of in large time points between these assessments are done. But the nice thing about using a digital health tool is that we get real-time feedback from patients on what their sedentary activity is, whether they're doing their exercise, and the adherence is measured through the app. We're using sonar and video to track patient adherence to exercise, as well as these patient-reported outcomes. And next, I think we'll have a panel with some questions. Perfect. All right, thank you very much for that. So I think the next question that I have is, Dr. Roy, you're at Shirley Ryan, and you have a cachexia clinic. And Dr. Hunter, you see folks for sarcopenia at Fred Hutch in Seattle. Can you tell us more about building your clinics and your typical referral sources? So part of the, can everyone hear me? I'll go first. So for me, I don't have 100% clinical time. Majority of my time is research, so the strategy I took for building my clinical population might be a little bit different. One thing was that I realized that there were certain providers that I wanted to do research with. And so then I reached out to them to talk about my rehab research interests, and that kind of led to relationships that then fed into a clinical population as well. But more importantly, I cared a lot about the GI oncology population, since that was the population that seemed to be most dramatically affected by cachexia. And so luckily, I was able to reach out directly to that group. And it also helped that some of that group was also in the leadership of the cancer center. So then we were able to start to implement some structural mechanisms. The barrier that I initially faced quite a bit was that because, can you hear me now? Yeah, better. So the barrier that we initially faced quite a bit was that because we're a freestanding hospital, there's not internal mechanisms for referral that you can rely on that are consistent. We actually have a different EHR than our cancer center, for example. So kind of building in backup communication mechanisms where people could directly communicate with me and my administrative staff for placing referrals was a big component. And so that's smooth now, but it took a lot of time talking to oncologists over and over again and talking to advanced practice providers, who are typically the gateway for a lot of orders, to make sure that that was streamlined. Now, in terms of the actual screening process, that has evolved. I've worked a lot with Hannah to develop that. And I think we've taken a similar approach to what Dr. Hunter was talking about at UW, where there's more dieticians in our cancer center than affiliated cancer physiatrists. And so we've kind of relied on the dietary medicine group as sort of the initial gatekeepers for determining when someone might be at risk of cachexia, or age-dependent sarcopenia, for that matter, and then referring to us if and when appropriate. Now what we're doing is moving away from just doing that to using those EHR-based biomarkers that are weight-based, blood-based, that are automatically calculated in the chart. And so we do have a specific cachexia screening tool built into Epic now at our cancer center. And by the way, if anyone's interested in that, I'm happy to have our Epic team connect to your Epic teams if you use Epic at your institutions so that they can essentially copy that code and use it where you are. And so we're still trying to figure out what's that threshold, depending on the resources we have. And I think that's always the issue we have in cancer rehab is there's not as many of us as there should be. And so then we have to triage who we can see. And nevertheless, I think the weight loss grading scale, if nothing else, is probably going to be our biggest tool for sort of deciding what population we can try to reach as quickly as possible. My answer is primarily I kind of did whatever was pragmatic and implementable, I would say. A lot of the teams are already using this malnutrition screening tool, so we just built off that. I partnered with oncologists who kind of, I say, drank the rehab Kool-Aid. They're already doing frailty assessments and SPPB in clinics, so we developed our research protocols based on that. I think if it's OK, we're going to take questions at the end and do a little bit of a panel first. I'm so sorry, but if that's OK. Yes, I always have a couple of questions for the panel first. And then I wanted to ask as well, we often see in our own loved ones, as well as patients and families, will report a lot of concern about not being able to tolerate meals they once loved, being even nervous about Thanksgiving, and maybe that one time they loved a turkey dinner, and now that's a big burden for them. And it's very distressing to see this, and these foods no longer being appealing. So Hannah Manella, can you talk a little bit more about that and some solutions, maybe, for those folks? Yeah, absolutely. Can you guys hear me? I can't really hear you. You can't? Really close? OK, oh, yeah, I have to be really close. So what I have found from my personal experience is with the caregivers, always my encouragement for them is just keep trying. Keep trying. Don't take it personally. A lot of the times, it's not a personal thing. It's just the patient can't physically tolerate or they just don't have the appeal of eating like they used to. So for a caregiver, I'm like, just keep offering, keep trying, but I give them a couple of recommendations. First and foremost, I never give the recommendation of eating six to eight small meals a day. That phrase in itself is extremely overwhelming to a patient, because then they have to count how many times they've eaten over the course of the day. For someone with a low appetite, it might be 4 PM, and they're like, I'm only at four meals. I still have to eat four times. There's no way. Instead, I ask them to do the same thing, but I just word it a little differently. I encourage them to try to eat or drink something with calories every two to three hours. It ends up being the same exact thing, but they take the counting out of it. And rather than focusing on how much they need to eat, they just need to try to do something every two to three hours. If they eat, say, one hard-boiled egg, that's better than nothing, right? So we just really just try to meet them where they're at. Focus on small amounts. Focus on frequency, not on quantity. Additionally, if someone's having a really hard time with eating, they can't pinpoint why something doesn't sound good. A lot of the times, it has to do with the work of eating. So if someone's sitting there, and they're not feeling great, the last thing you want to do is put a grilled chicken breast in front of them that they have to sit there and chew for a while. So the longer that food is in their mouth, the more time they have to get tired of it. So I tell caregivers, make it as soft as you can. So say if something like chicken sounds great, that's fine. Maybe we do a pulled chicken, and maybe we put a sauce on it so it's nice and moist, easy to eat. Furthermore, for some reason, during active treatment, foods that are sweet, tart, or sour tend to taste a lot better. I don't know if it has to do with the fact that it stimulates saliva production for people that have dry mouth. Those flavors tend to maintain their flavor profile with taste changes as well, too. So then I tell patients, can we add something sweet to this? Can I put a little lemon on this? Can I add a little vinegar? And maybe we put some pickles on the side. So always try to ask yourself, how can I make this flavor a little bit more appealing to patients as well, too? So those are a lot of my big recommendations I give to family members. But again, I tell them, don't give up. Keep trying. Keep offering. If they take a bite, that is better than nothing. So they take a bite, and you move on. And you approach it again in two hours. Thank you. Another question we sometimes get from oncologists and primary care and other patients is they feel very discouraged, especially patients that have breast cancer or maybe have prostate cancer. And they gained weight, but they're weak. When is a great time to refer? And can you talk a little bit more about this? So from my perspective, it's as soon as possible. But if people are talking about weakness, then I think it's pretty simple in terms of referring to rehab in terms of what level of rehab. Should it be directly to physical therapy? Or should it be to a physiatrist? I think that is very dependent on the resources that you have. I would say that I think it's very important I would say, especially if they're having any functional changes, critical to refer to both medical nutrition and rehab services. I think things that are helpful in a patient population where we may not see this dramatic weight loss and what I often term metabolically active cancers. But when patients are having weakness and they're noticing an increase in weight or no change in weight is having bioimpedance, especially as an option if you have a baseline. And then you can track lean body mass or skeletal muscle in a tangible number that we can improve over time rather than looking at weight. And that takes incredible collaboration with medical nutrition because patients do want to decrease their intake, but then we're not rebuilding or maintaining muscle. I think another important piece to recognize when patients are in active treatment and have a higher BMI is that sarcopenic obesity is often correlated to many worse outcomes in multiple different disease groups. So it's not just about looking at BMI or about someone's weight, but that's why it's important to have those functional outcomes, do intake or malnutrition or nutrition screening, and look at the whole picture. And to be clear, I think actually the breast cancer population is the one population where the cachexia definitions have really failed them because of this increase in adipose tissue that happens over the course of disease initially. And one of the best pieces of evidence that I have to think about that is the fact that once someone with breast cancer or prostate cancer, for that matter, has a metastasis, even if it's a solitary met, then the prevalence of cachexia based on the weight-based criteria really shoots up. So it's not as though it's only that population. Clearly, there's something smoldering there in that population where they're still susceptible to muscle wasting due to their disease and inflammatory condition. But we need better mechanisms to identify them earlier on. And I think that's where the bioimpedance in particular really comes into play. I also wanted to ask the panel, what do you talk about as far as looking for a goal or certain outcomes that you're looking for for the patient? And I think that kind of goes for everyone. So I kind of had this in my slides. But the key thing is it depends on where they are in the course of their cancer treatment. If someone's actively undergoing treatment, it's not just a matter of whether they're treatment. If someone's actively undergoing treatment, it's really not about recovery in terms of weight. It's more about recovery in terms of function and then maintaining the weight that they have. If they demonstrate over a long enough period of time that at least things have plateaued in terms of the weight loss, then I think we can start to be more aggressive in terms of goals. And as I said before, in that aggressive or progressive decline population, we're not really talking about weight recovery. We're talking about trying to maintain functional independence. And then in the groups that have had maybe stable disease or recovered from disease, it kind of flips a little bit to trying to understand where they're coming from. Oftentimes, this population doesn't have active cachexia. But we do a fair amount of history taking to determine if they had cachexia in the past. And so then to understand really where their sort of floor is and how long it's going to take to recover back substantially in terms of both function and weight. I would say when I first established with a patient, a lot of the times the conversation stems around the fact that we want them to maintain their weight in hopes of maintaining their muscle, in hopes of maintaining their strength, their energy, so that they can go through treatment and be able to withstand the stress and the demand of their chemotherapy treatment. So I usually go in and I tell them, you know, the way that you're eating prior to diagnosis, that maintained your weight at that time. As of today, your chemotherapy starts, your calorie needs increase, your protein needs increase. So we actually have to eat more than you did prior to diagnosis to continue maintaining your weight and your muscle mass during treatment. So a lot of the times, having that really blunt conversation with them up front is really helpful for them, because they think and they expect that they're going to lose weight or they're going to become weak. And the way that we come in and we try to empower them is, no, you can fuel your body to be able to fight and withstand this chemo. So and then, you know, that first one, we kind of give them general calorie protein goals. Then the second one, we have a better understanding of how they're feeling. We have a better understanding of their symptoms, and then we work from there and we adjust based on symptom severity. And I think my final question for the panel, before we let the audience go, is where do you see research going in the future for muscle wasting? So I think that's a great question. It's one of the main reasons I'm kind of motivated to be on this panel. I think, so the cachexia field is quite well-developed, but it is full of mostly researchers, some palliative care physicians, some ecologists. And, you know, they've done a good job of developing a bunch of therapies that are in the pipeline. But the truth is that, you know, the field has existed for over 25 years. They have yet to develop an FDA-approved medical therapy for cachexia. And one of the main reasons, I think, is that they haven't figured out, you know, what are the proper functional outcomes. And so if you look at the clinical trials for cachexia, it's super variable in terms of what functional outcomes and metrics they're using. And we, as a field, are not at the table for these discussions. And the second part, and one of the reasons why I really want to talk about definitions, is that I think a huge failure is the lack of consistency in terms of how to define cachexia, muscle-wasting disorders, and sarcopenia, for that matter. And so it's very difficult to compare different observation or clinical trials that include physical activity interventions. The last point I'll make is that the cachexia field clearly understands that it's going to be a multidisciplinary approach to address muscle-wasting cachexia. And again, how those individual components of that multidisciplinary approach are connected together is super unclear. And at the moment, we, as a field, are not at the table for those discussions. And I think we need to move towards that if we want to see real improvements. I agree with everything Dr. Roy said. And I think rehab physicians or rehab professionals need a seat at the table when it comes to research or a consensus statement or some working group related to cachexia, especially in the oncology patient population, because we can't address problems with muscle-wasting without a stimulus to make muscle work better. I also think any times we're looking at research in terms of risk stratifying patients or prehab or in exercise interventions, we have to look at some of, I think we should look at a mix of body comp as well as functional measures, nutrition factors, to paint the full picture rather than looking at one specific measure. I think there's a lot of work that we can do to have a consensus on what those outcomes are. And yeah. I have a bunch of patients with prostate cancer who are on hormone blockers, and so they finished their treatment, and now I have them doing some nutrition and some exercise, and their gains are very, very, very slow. And so are there different things that you can do beyond arguing with the oncologist of when they can start testosterone back again because their testosterone is at 10? So conceptually, I think about that population like I think about age-dependent sarcopenia much more so than cachexia, because hormonal changes in muscle are a component of age-dependent sarcopenia much more, actually, than cachexia. And to be honest with you, I think the effects of sarcopenia, because they are cumulative over longer periods of time, and that clearly happens with androgen deprivation, which is much longer courses of therapy, really, you have to think about it in terms of how long it took for all that muscle to become less functional and decrease in mass, which is very unrealistic to expect increases in body composition that are going to be that dramatic, for sure. And functionally, the age-dependent sarcopenia and androgen-dependent sarcopenia are more of a neuromuscular mechanism than they are an inflammatory mechanism. And so we all know kind of what the recovery timeline for any neuromuscular disease is even in terms of function. So I think kind of framing it that way will help kind of others understand, like, look, this is not just muscle wasting that's the same as dysusatrophy or even cachexia, for that matter. A quick pragmatic thing is, I think, really being specific with what these patients, what their intake is like in terms of protein and calorie, as well as, like, what they're doing for physical activity. I'd say a lot of times these are not the patients we can tell, like, do 150 to 300 minutes of moderate-intensity aerobic exercise, because they're doing 20. And so finding a current sustainable kind of physical activity program and making sure that there's an incremental increase that's also sustainable, because I think anecdotally a lot of times patients will do something and just flip-flop or see-saw between overexertion and rest without being able to make substantial, like, exercise gains. Hi. Thank you. That was a really wonderful talk. Just a question to the panelists about when you're trying to measure sarcopenia at a physiological level at the individual muscle groups, like, for example, back pain, when I look at the back muscles on MRI or on a CT abdomen that I happen to get, you know, there's different patterns of wasting. The extensor groups tend to have much more fatty infiltration as well as loss of cross-sectional area, as opposed to the flexor side with the psoas that's mostly a cross-sectional area seems to decrease without as much fatty infiltration. Is there some understanding of physiology of why some muscle groups decide to marble out like a steak and some stay just shrink and don't marble? And does that have any implications in terms of, like, when we eventually come up for treatments for sarcopenia, how do we metricize this measurement change if we're seeing it without looking at functional outcomes, just physiologic? So that's a great question. That's some of what my lab is focused on at a basic science level. What I can tell you is that I think a lot of that has to do with sort of how those muscles are used from a functional standpoint. So, you know, extensor muscles in the back are used isometrically constantly, whereas, you know, especially the proximal muscles of the leg are sort of used eccentrically and concentrically. And so you see changes in cross-sectional area happen much more dramatically in muscles that are used eccentrically and concentrically, whereas the isometric muscles, you have sort of less of that sort of abrasive mini trauma that happens during contraction. And so there's that sort of inflammatory component evolves in a very different way. There's less turnover of that tissue. And so there's the more opportunity for some things like fatty infiltration to happen. Similar fatty infiltration happens in, for example, kids with CP, you know, in contracted muscles. So it's sort of dependent on how those muscles are used that those mechanisms change. And I think this is the other sort of potential flaw in using individual muscles to diagnose whole body sarcopenia or whole body cachexia. And I'll also add what you're describing in terms of the change of not just atrophy of the muscle, but what it looks like is also a emerging field in radiology. So while we historically use like an L3 cut and looking at the psoas or paraspinals, radiologists are trying to find a way not just to quantify muscle mass, but the quality of muscle. Because you can have the same muscle, but it doesn't mean the function or the quality is the same. And the fatty infiltration is something that they want to assess. Thanks for bringing this interesting topic. I have a couple questions, but I promise they're all quick. One is when you calculate the protein, are you doing that off of ideal body weight, current body weight? What do you, when you say grams per kilogram, what kilogram are you using? So it really depends on the patient. If they are considered obese, say their ideal body weight is over 120%, or if their current body weight is over 120% of their ideal body weight, we will use an adjusted. But again, it's a protein estimation really at the end of the day. But if you're going to give them a goal, you might give them a number. A lot of people want a number for their goal. A lot of people want a number. A lot of people, I will say probably I only give a number probably to 25% of patients because the majority- So for those, you use ideal body weight? If I will use actual body weight if they are not 120% over their ideal body weight. So usually it's just someone, we'll calculate that if it's a BMI over 30, typically. But most patients, we don't give it to them because they're just so overwhelmed with the quantity. So as long as we're telling them every time you eat, try to incorporate a protein source, they will likely meet their needs at that point. Or like, please do better. They do better. They do better. Yes. I'll just quickly add, if someone asked me for a number in clinic, if I have an ideal body weight number, I'll use it. But if not, then most patients know what their weight is if they're a cancer patient, and you will quickly convert it to kilograms. And then I'll say, well, you need to be at least one gram per kilogram. And so most people know what their weight is in kilograms at that point. And so you need to get that number and above it. So at least if they can- Yeah, the problem, the challenge is you really obese patients, you tell them to eat three times more because they're 300 pounds. It's true. Yeah. Those are the hard ones. Another quick question. I understand why from a research perspective, you're trying to sort out sarcopenia from cachexia and looking at inflammatory markers, but I was trying to analyze on your slide from a clinical perspective, is there utility to looking at the inflammatory markers because you're going to do anything different, or is it just for prognosis? I think it's mainly for prognosis at this point. And I think it's important for patients to really understand that too, so that you can calibrate their expectations. But hopefully, and I think the field of cachexia is moving that way, we are going to have anti inflammatory therapies for cachexia, I would say within the next five years. I hope so. Yeah, it's about time. And then my final question, it was interesting to see your algorithm that you're using for referrals and then getting overwhelmed and then needing to change it. But I was curious where PMNR is in your algorithm. So I saw when you trigger a PT referral, but where you are in that. Great question. So part of that is in that first bucket of just clinic generated kind of organic referrals or in a disease process. So with certain disease groups, I'm just part of that clinical pathway. And then for these, a nice benefit that we can have at our institution with that web of supportive care referrals is that PT can always kind of instigate a referral to me if they notice that there's an impairment that would benefit from a physiatric assessment. So it triggers the PT referral, and then the PT decides if they need to see you, right? Thank you. Thank you very much for this really wonderful presentation. I truly value what you do. And I truly value the professional relationship that we have with our dieticians at our institution, Miami. My question is based on an observation that I have that certain types of cancer patients head and neck cancer, GI cancers, you almost know that they're going to lose weight. They're going to kind of go down that slippery slope where they are going to become very, very cactic and so forth and functional implications. And they come in and they tell you they're not eating very much, and you encourage and the family encourages. There comes a point though, a tipping point where you start having to think about feeding tubes. And I'm just wondering your experience, knowledge, et cetera, what are some guidelines as to when you can have that conversation first when you have a patient that's just referred to for cachexia, but second, in the patients that are at high risk that you know are going to lose weight, and introducing that conversation about these things. That's a great question. When to have the conversation about feeding tubes and nutrition support with a patient. It's very controversial. In the cancer field, especially in the nutrition field, there are some centers that will provide prophylactically placed feeding tubes for high risk populations, say head and neck cancers or gastric cancers or any diagnosis that we know is going to have significant nutrition impairments. It really is center dependent, oncologist dependent. But I would say from a nutrition piece, if we have a high risk diagnosis coming in, so a head and neck cancer, an esophageal cancer, a gastric cancer, they're already presenting with significant impairment to eat. They're not tolerating any solid foods and are primarily dependent on full liquids. We should have that conversation right away. Just because we know with the initiation of chemo, sometimes people get a relief. Some people actually might, say an esophageal cancer patient, they start treatment, they get a couple treatments, or actually their swallowing function improves. But that's pretty rare. I would say if it is a patient presenting with a high risk diagnosis already on full liquids, we need to have that conversation up front. If they get to the point where they really are only tolerating full liquids, that's when that conversation of feeding tube should happen. But really I think with a diagnosis, someone should just mention that that could be a path that that patient might go on right away. I don't know why that conversation gets delayed so often. Just because I don't think it's fair to the patient. Once they're really struggling, having a hard time, then that's thrown on them at the same time. I think it's kinder to have it up front that it could be a possibility. To be clear, the ESPN guidelines for feeding tubes are a little bit unclear. Basically there isn't great evidence in either direction, so it's sort of based on practice based recommendations. Basically the point is that it's not necessarily inappropriate or appropriate to have a feeding tube generically, but no one has established what those threshold criteria should be. Anecdotally, at least in my practice, I see the ones that do have the feeding tubes in these high risk patients, they tend to do better on functional metrics as well as on weight and so forth. When that conversation is had, there are some anecdotal tangible benefits. I'm not sure in your experience if you've seen that. What I'd like to see in the research of the future is what the inflammatory state has, what the contribution is there. I suspect there's a pretty big fraction of head and neck cancer patients who have cachexia, but are not in a pro-inflammatory state. I bet they would improve the most using a feeding tube. Thank you. Great stuff. Quick question. We've talked cellular level and nutrition. I get asked functional levels, SPBB. Someone mentioned grip strength. Someone, we use six minute walk tests. This is pretty controversial in the cachexia field, because in clinical trials they're mainly anchored on grip strength, but as we all know, grip strength is highly specific for mortality, but not much else. In my clinic, we do six-minute walk tests for research purposes, but we do 30-second sit-to-stand for clinical purposes and research purposes. And testing interval to show change, how frequently do you do it, and what's the sensitivity of that? Right. I think that we've left it up to therapy and then clinical visits, so that part I think is not clear. But we also have a very selected population that come to us. I think these questions need to also be answered at the broader oncology population level. Thank you for a great talk. I have a question about using the SOZO. So for those of you that use it in your clinic, not in the therapy space or the oncology space, I'm just thinking about how to interpret their results and what to do with them. So if I'm seeing a patient, let's just say a lung cancer patient, who has fatigue, functional decline, I have them in a therapy program, I'm managing some pain, and I get a measurement baseline, and then I see that it's declining, and the patient's already plugged in to, say, seeing a nutritionist, what is my next step? Is it to alert the whole team that, hey, we are not going in the right direction? Is it to alert the dieticians that we need to step up our game? How do you guys use those measurements? So the research for using bioimpedance has been mostly limited to threshold-based diagnosis. So in terms of its utility for recovery, it's simply not there. So the answer to your question objectively is we don't know. How I use it in my clinic is if someone meets the threshold for sarcopenia, I definitely will bring up with the patient that, hey, compared to your peers of your age, you are low, and so that's just another indicator that you have low muscle mass, and we should be focusing on protein in particular from a dietary standpoint. I then do follow that number over time with that population especially, but I'm following it with everyone, and if we don't see recovery, it's just another indicator that maybe, you know, we're not in that state from a clinical standpoint where we're going to expect to see recovery, especially if they've effectively been doing the interventions we're talking about. But in terms of tracking what's significant recovery or not from a skeletal muscle index standpoint, the research is not there. So have you seen recovery, meaning over a long period of time on the SOZO in the same patient? Yes, especially in that population where they have stable disease or completed treatment. Okay. Thank you. Thank you very much for all the questions. Unfortunately, we're going to have to end because another group is coming in, but I really appreciate everyone for staying, and thank you for coming. Thank you.

muscle wasting

sarcopenia

cachexia

interdisciplinary collaboration

nutrition

diagnosis

treatment

calorie intake

protein intake

physical therapy

malnutrition

cancer patients