Do sick people need more or fewer calories?Based on research and my personal experience, I’ve found that illness is associated with increased resting energy expenditure, which means chronically ill patients need more calories.
When we are chronically sick, our metabolisms get worn out. And for every degree colder our bodies get, the slower our metabolisms get.
But if sick people have sloppy metabolisms, does that mean they should be fasting and keeping their calories to a minimum? Does that mean sick people should eat more fat, since the energy in fat is stored longer than the energy from carbs?
Nope.
First of all, if you don’t eat adequate calories, your body assumes food is scarce and your metabolism slows down.
Secondly, if you are not dead yet it means your body is fighting. Fighting takes a lot of energy.
This means that if you are lying in bed with a cold, you burn more calories than you do lying in bed without a cold.
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Metabolic interventionist, Dr. Rifka Schulman, has gathered research based on decades of experience with critical care patients. The goal of metabolic intervention is to provide adequate nutrition in the perfect ratios of macrobiotics (carbs, proteins, fats) and to ensure all body systems maintain their functionality in times of critical care.
Over decades of metabolic intervention on CCI patients, here is what has been gathered:
- Providing adequate nutrition early on can assist immune and catabolic responses, preserve gastrointestinal integrity, and support healing.
- Underfeeding and overfeeding are equally detrimental, but underfeeding is more common.
- Underfeeding proteins, carbs and fats have specific distinguishable outcomes:
- Protein deficiency can slow healing, increase infections, cause muscle wasting, and deplete diaphragmatic muscles.
- Low-carb, high-fat diets may cause delayed gastric emptying. Carb deficiencies are particularly devastating to the metabolism and the endocrine system.
- Fat deficiencies deprive us of a transport system for fat-soluble vitamins, as well as the precursors for cortisol and sex hormones.
LET ME JUST SAY, I think Lyme Disease patients are generally underfed. We have so many dietary restrictions (and fears about food) that we just don’t reach our caloric needs. This slows down our metabolisms further, and it becomes increasingly uncomfortable to eat much. We are also told to cut back on carbs, so a lot of us have developed a fear of sugar. Sugar may feed bacteria, but it also nourishes essential amino acids and minerals. If we stop ingesting amino acids, necessary bodily processes will not happen…and if we stop eating carbs, necessary metabolic processes slow down.
I for one would rather catabolize carbs for energy than have my own muscles torn down to provide me with the energy my body requires. I’d rather have my body and the critters well fed than have my body eat itself.
(PS: Our stomachs have immune cells that can be disrupted by starvation, allowing antigens to leak into our circulatory systems. This is one reason underfeeding is linked to increased infections. Makes me think twice about fasting, which may actually be making your critters bite holes in your stomach lining in their desperation to survive.)
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BUT (and there is always a but) adding calories too quickly can also be detrimental. What’s more, some people are overfeeding and actually do need to cut back on calories.
Refeeding syndrome
Refeeding syndrome can occur when sick people start adding calories too quickly. It can generate electrolyte imbalances, along with a whole array of and hematological problems.
Dr. Schulman says it best:
“Starvation, with minimal or no carbohydrate intake, reduces insulin and increases glucagon levels. In the absence of insulin, metabolic pathways shift to promote lipolysis, free fatty acid oxidation, and ketone production for energy. With the reintroduction of carbohydrates there is an increased demand for phosphorylated intermediates of glycolysis (adenosine triphosphate [ATP] and 2,3-diphosphoglycerate [2,3-DPG]), depleting phosphate stores, which are already low due to poor nutrition and usually vitamin D deficiency. A surge in insulin secretion in response to carbohydrate load shifts phosphorus, potassium, and magnesium into cells, lowering serum levels further, and has a renal anti-natriuretic effect, with resultant sodium and water retention. Demand for thiamine is raised as well, predisposing to deficiency and associated complications. Other micronutrients are abnormally redistributed as well in the refeeding syndrome. Severe hypophosphatemia can impair diaphragmatic function and impede weaning from the ventilator. For these reasons precautions must be taken when instituting nutrition support in patients at high risk for the refeeding syndrome.”
If refeeding syndrome is suspected, then carbohydrates should be limited until the phosphate levels have stabilized. Vitamin D should be raised in cases of hypophosphatemia.
For the overfed
Overfeeding can be just as harmful as caloric restriction. In general it’s linked to increased infection and liver dysfunction.
Specifically, carb overfeeding can impair glycemic control. Lipid overfeeding can increase inflammation through the production of inflammatory eicosanoids. And protein overfeeding can increase oxidative deamination, dehydration, and ammonia levels.
Who should reduce caloric intake?
Certain drugs and conditions reduce energy needs.
It terms of drugs, sedatives, analgesics and neuromuscular blocking agents reduce resting energy expenditure.
In terms of conditions, obesity complicates resting energy expenditure. Excess fat lowers the metabolism because adipose tissue is storage tissue with lower metabolic activity. Also, fat is almost too good at storing energy, so it doesn’t need to be burned as much. This means that our metabolism slows down when we are overweight simply because it can.
Pay attention to signs of overfeeding:
Measure your BUN levels to determine if your protein intake should be reduced. Dr. Schulman suggests “Clinically important elevations in BUN (> 70 mg/dL) or ammonia (> 70 μg/dL) should prompt a reduction of protein and/or an increase in hydration.”
Conversely, if you have hyperglycemia, consider reducing non-protein calories.
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Okay, so how do you know if you are underfed or overfed?
Calculate your REE to determine how many calories you need
Your resting energy expenditure (REE) is the minimum amount of calories you need when you are sedentary in order to fuel your body without leaching energy from your muscles. The REE is higher in chronically sick people because their bodies are constantly fighting. So the sicker you are, the more calories you burn just sitting on your ass.
A simple formula recommended by the American College of Chest Physicians’ 1997 consensus statement is to ingest 25 kilocalories for every kilogram of body weight to avoid both overfeeding and underfeeding.
If you are ill and active, then the amount of calories you need goes up.
We need 1-2 grams of protein per kilogram of body weight and the rest of our calories can be from carbs and fats.
The more energy we expend, the more carbs we need. Extremely sedentary people may do better with high-fat low-carb diets, but too few carbs causes a lot of hormonal problems. Personally I do best with a diet of 45% carbs, 35% proteins and 20% fats, but this takes into account 5 days a week of anaerobic exercise.
Something to consider while you figure out your ratios: one gram of carbs is 4 calories; one gram of protein is 4 calories; and one gram of fat is 9 calories.
There is no one perfect equation for caloric intake and macronutrient ratios for chronically ill people (or healthy people for that matter). All we know is that age, sex, presence of fever or inflammation, variations in thyroid function, and so much more can influence REE.
Like all things Lyme, you really need to experiment to find out what works for you.
In summary, underfeeding and overfeeding work against chronically ill patients. Either extreme can increase infections, so avoid both starvation and bingeing. If you are underfed, eat more calories to give your body the hint to speed up your metabolic rate to burn your fuel. The more fuel you have, the easier it is to burn that fuel. If you are overfed, determine whether you should reduce protein, carbs, or fats.
Enjoy your food. You’re probably going to need a lot more of it.
