III. Anticatabolic and Anabolic Strategy, (Nutrition) 

(Maintaining Energy, Protein and Micronutrient Intake)

The maintenance of optimum nutrition through both the stress response or catabolic phase and the recovery or anabolic phase is the most important strategy to decrease lean mass loss and to regain lost lean mass.

The remaining strategies are additions to adequate macro and micronutrient intake.

What is the Optimum Macronutrient Mix To Meet the Needs?

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1.  Protein Supplements

Numerous studies demonstrate the need for increased protein intake during both the catabolic and recovery phase after wound injury. The increased protein demands, especially if restoration of depleted body lean mass is required, exceed that which a severe wound injury patient can achieve with intake of food alone. This concept is particularly well documented in the management of the wound when the addition of protein supplements to maintain intake at 1.5-2.0 g/kg/day significantly increased healing rate.

As described, the protein intake correlates best with healing rate. Nutrient supplements should be selected based on the following criteria.

Most high protein supplements are non palatable and not for oral consumption, e.g. Criticare-HN, Jevity, etc. and are really used only for tube feeding. There are now available more palatable formulations which have a high protein content in a palatable form. In addition, all proteins are not equal. Some proteins and their peptide content have a higher biologic value, i.e. increased nitrogen retention, based on their structure and composition. In addition, specific peptides can act like growth factors or added anabolic stimuli. In a recent randomized trial in wound patients we noted the protein composition of a case in hydrolysate (Met-Rx) doubled lean mass gain when compared to standard whey hydrolysates, reflecting an added anabolic stimulus present in the casein hydrolysate.

It has been demonstrated that bioactive peptides in a hydrolysate of protein have anabolic activity, wound healing and immunologic effects in excess of that seen with whole protein or amino acid intake alone. Bioactive peptides are absorbed intact by the gastrointestinal tract. A number of peptides have been identified which have anabolic and neuroendocrine activity. However, the majority of the active growth factor-like peptides in protein hydrolysates have not been identified.

2.  Appetite Stimulating Drugs (Non-anabolic agents)

A critical component in the process of maintaining and restoring lost lean mass is to optimize nutrient intake. Suppression of appetite is a common characteristic of the stress response during the catabolic phase of injury as well as during recovery. Adequate energy and protein intake is essential for any anabolism to occur, especially with the use of anabolic agents.

The most widely used non-anabolic agents are megestral acetate, a synthetic progestational steroid and dronabinol (delta -9 tetra hydro-cannabinol)

To date appetite stimulants which are not anabolic agents, have not been shown to be beneficial to maintain lean mass.

Micronutrient Support

Delivery of increased quantities essential micronutrients is required for the success of any anticatabolic or anabolic strategy as micronutrient depletion occurs after wounds and trauma.