Personalizing Exercise, Nutrition, and Anabolic Agents in Prehab and Recovery- Paul Wischmeyer, MD

not just the patients should eat better and more or they should just go home and exercise we can tell them exactly how they should and we'll talk about that so again as I always start again it's our responsibility not only to ensure our patients are cared for so they will survive till tomorrow but also so that they will survive for a lifetime and that is always our priority is we need to be thinking every day how we're going to help our patients become survivors survivors that go back to their families and back to life that's worth living and not victims where even though they live and survive their illness they are so debilitated that they can't live the life that they came to us to restore and so again the key message right is our patients come to us to get back the life they started with so they can walk down the street with the people they love and hold their children again and live the life that they wanted so the key message right of course is surviving critical illness or cancer or surgery is like running a marathon who here has run a marathon before raise your hands who's run a race outside on the road who's run before so you know there's a few so you know that you don't just wake up one morning and run a marathon you have to train you have to eat right you have to prepare and for our patients surviving cancer and critical illness and surgery is the marathon of their lives it's the most important race they will ever run and so what happens when our patients run the marathon without the right nutrition and training and how can we make it right and to tell you about that I want to tell you about a patient that is very meaningful to me and his family asked that I share his story with you because I think it illustrates how we can use some of these techniques for our patients His Name Was Elijah and he was an 89-year-old coming for surgery for rectal cancer he had had cancer diagnosed and he'd been losing weight for about 3 months he had a 10 kilo weight loss because of his cancer so he's malnourished when he comes to us he's feeling a little more run down but he's very active in fact just the day before surgery he was up on the roof of his church fixing the roof so this is a very active 89-year-old who has a lot of quality of life he's very fit and he has a lot to live for he tells me that he's just had a new granddaughter who was born that he's having the surgery so he can be well enough to go meet her so he's got a new granddaughter he's anxious to meet and so the question is is he ready for surgery of course we know he's malnourished and this is not optimal but he goes to surgery anyway as all too common and he did well for the first few days after surgery but then the third day he woke up with severe abdominal pain and rectal bleeding and he was in shock and so he was rushed to the CT scanner where es schic bow was diagnosed and ultimately he went to the operating room in the operating room he had a cardiac arrest his heart stopped now remember he's 89 years old he gets CPR for 2 minutes on the operating room table and he's resuscitated and his heart comes back but he's very very elderly and now he's at a cardiac arrest and so again they fix his an nomatic leak and he comes back to me in the ICU with an open abdomen after having a cardiac arrest and already being malnourished and so the questions from the nurses and from The Young doctors began to be can we save this man he's quite old perhaps it's too late for him perhaps there's nothing we can do for someone that's this old that's had a cardiac arrest and they began to ask maybe we should just let him die we should let him pass away because it's just too much but we knew the surgeon and I that he wanted to live and he wanted to fight he had a lot to live for and he was a very active man and so what are we going to do for him how are we going to save an 89-year-old who's had a cardiac arrest who's already malnourished on a ventilator with an open abdomen so again the family and he agree they want to keep fighting and remember he's very active so he wants not just to live but he wants to go back to a meaningful active life so we not only need to save him but we need to fight for him and give him back his life at ' 89 so how are we going to save this patient what are we going to do differently right to create a survivor of Elijah even at 89 because the reality is even patients that are young that are on a ventilator for a few days will have months to years of physical disabilities many times and even major surgery patients who aren't in the ICU have significant physical limitations in disabilities so these are critical for all of our patients and why is it our patients have such difficulties with their quality of life after illness well again we know a patient can lose a kilogram of lean body mass a day after a surgery or after ICU stay and they remain hyper metabolic and catabolic for years often after injury even a burned child will remain catabolic for two years after they've left the hospital again Mother Nature never intended us to survive these kinds of illnesses and they'll gain weight back but it's mostly fat they gain back there's probably dietitians in the room that have fed 40K Cals per kiler to their patients and they don't gain weight and so we need to be better for our patients and the bed is a problem beds are as big a problem as the illness if I lay down a 21-year-old in the bed for 28 days they won't be able to walk they won't be able to walk astronauts do those experiments if you lay an elderly person down who's not sick who's healthy for 20 for just 10 days they lose three times more muscle mass so as we age we lose more muscle mass and if it's a sick elderly patient they lose that much muscle mass in in 3 days so I tell my patients I don't want to see you in the bed they're evil during the day beds are for sleeping during the day I want you in the chair or I want you walking not in the bed beds are for dying if you're in them during the day so again we have to be better if we're going to save this man and to do that we're going to need therapeutic personalized nutrition good physical therapy and prescription of exercise like professional athletes do it and we can do this for our patients now I'll show you so what are our goals right we have to recover and maintain their muscle mass and we have to keep them fit their aerobic fitness so that they can have the endurance they need to survive and so if we're going to do that we have to personalize the nutrition and the exercise giving the right amount to the right patient at the right time and to do that we need to measure we have to measure how many calories and protein our patients need because one size does not fit all and that's critical if you can't measure you can't improve it and this is a paper that I was asked to write on personalized nutrition I'm to share with you if you're interested that talks about how we can do this so how do we make someone fit how do we give back this Fitness to them so again you can't look at someone and tell if they're fit how many of you have run behind someone who you don't think should be running in front of you but they are and so you can't just look at a patient and tell if they're fit or not fit and so again perhaps it's muscle mass that makes them fit and so we need to be able to measure muscle mass and this is part of how we personalize what's happening to our Pat and so we have the skin fold ways which aren't very accurate we have CT scans CT scans are the future we should all be learning to use CT scan to measure muscle mass it's measured at the L3 cut you can use free software from catic our dietitians in some hospitals do this and you have to be able to do this and how does it affect outcome so we know that if you enter the ICU with low muscle mass by CT scan you can see your mortality in green is much higher I'm sorry your mortality in is much higher survival is much better if you have muscle and much lower if you do not have muscle so again even just the muscle you start with is so important that's why muscle is so important for all of us as we get older we need to be building muscle mass all the time if you're a cancer patient and you start treatment for your cancer like Elijah and you've lost weight like he has your average lifespan is 8 months if you've not lost weight or you don't have low muscle mass you live 2 years longer longer this is the impact that having a robust muscle mass has for us and our patients so how do we measure this are there other tools that we can use at the bedside besides the TT scanner and there are of course the ultrasound there's new ultrasound technology called the muscle sound that we can use at the bedside our dietitians do it you measure the leg we also measure the temporalis muscle this is a very good mixed slow and fast twitch muscle it's very easy to get at very reliable and so we have a muscle specific specific ultrasound that can also give us muscle glycogen muscle quality and muscle fat as well as muscle mass and it actually is like taking a muscle biopsy we get a lot of data from it and it's a little probe about this big that plugs into your iPad and gives you muscle mass muscle quality and muscle fat in a few minutes and so we hope all our dietitians and nutrition Physicians will have one of these probes soon it's very easy to use it tells you if you've taken the image correctly you can see we can teach anyone to do this and this is a device that we are really excited exced about for the future of nutrition gives us a lot of information and so again in addition of course Bia is a technique that many of us use and the new Bia devices are quite useful the new generation Bas give us phase angle and other critical measurements that can be very helpful in diagnosing muscle mass and other body compositions and now we know that the new glim criteria say that muscle mass must be measured in all patients in fact ensures in the United States are asking for it to diagnose malnutrition and so again we need to be creating indices using TC scan and ultrasound to do that and so again this is the kind of data that we get and what happens to the muscle over time and actually the darker the purple the more glycogen they have in their muscle so we can actually tell if the muscles using the nutrition we're giving the patient with this device it's the first device I've ever had that can see if the patients are taking in their nutrition and using it for storage in their muscle so what were Elijah's muscle measurements so this is is what his muscle measurement looked like you can see his muscle and his leg was very small that's the purple area and even though he's very thin he has a lot of body fat so he has very low muscle mass and actually a fair bit of body fat even though he's lost weight and so this is the Bia measure and the muscle ultrasound measure that we get from a patient like this and this is critical because if you lose 40% of your muscle mass patients will get out of the hospital but they won't survive they won't live more than a few months and so loss of muscle mass is devastating for our patients it's critical we stop this and so what about how much to feed patients and how do we measure and personalize that because we need to do that I going to do an exercise with you it's late in the day everybody stand up everybody stand up I'm going to ask you some questions okay so we all agree that nutrition is critical for our patients if you agree with that stay standing okay I'm going to let her translate that for everybody who has on vasopressors in your ICU would you ever give the vasopressors without measuring a blood pressure with a cuff or an aine if you would do that if you would use a cuffer an Aline to measure the blood pressure on pressors phasa pressors stay standing if not sit down okay so we'd all do that what about on a ventilator stay standing if you would check a blood gas or check oxygen saturation on every patient on a ventilator we always would measure these things if you wouldn't do that sit down okay so we all agree we have to measure things when we're caring for our sickest patients who here has a metabolic cart in your hospital stay standing if you have an indirect Comer stay standing who has one one person this needs to change one person right so again the reason nutrition doesn't get the resp and attention it deserves is because we don't generate personalized objective numbers like other Specialties do but we can now and I'll tell you that we need to all be thinking about how we can get indirect coms in our hospital so that we have numbers we can show our doctors that we work with and that will give us the respect the other Specialties have so again predictive equations are guesses they aren't useful they are right using an equation about a third of the time it's worse than the flip of a coin a third of the time you're overfeeding a third of the time you're underfeeding a third of the time you hopefully are right this is not okay so these equations are worse than flipping a coin in fact some of these equations are accurate only one out of 10 times this is unacceptable this is bad medical care right we can't do this overfeeding causes complications and death underfeeding does too we need to be right at every patient is different so how are we going to change this and what do our guidelines say well our guidelines say we should all be using indirect cometes and I'll talk about the challenges of that but we know they reduce mortality what just happened I lost my slides we lose a cable I don't know what happened okay we got it back so we know from the data from multiple meta analyses now that using an indirect carer for saves lives so when you go to your hospital and are trying to justify them buying you one this is the kind of data you show them because this saves lives it's not just that it's a good thing to do but the challenge has always been these devices have been hard to calibrate you need a respiratory therapist they're not very accurate the older ones they're very expensive sometimes and there was a lot of patients you couldn't use them on so we got a grant from Espen a group of us from around the world to work with industry to build a new better cheaper metabolic cart and so we did that and we validated it in this study this device is accurate and it measures in 10 minutes it's much different than the old devices the old devices took an hour to set up and you need a restorate therapist to calibrate these calibrate themselves in five minutes so our dietitians do all of the measurements and in any physician dietician or anyone else can do this they're very small and compact so they're easy to transport and you can use them any anywhere they're very accurate we have gone Great Lengths to ensure their accuracy they can be used in intubated and spontaneously ventilated patients so anyone can use them so we wanted to build the metabolic cart that we all needed the indirect comry that anyone could use at measures in 10 minutes and then the key is we need to use it throughout stay you can't just do it once patients change throughout their stays their metabolic needs go up and down so we need to measure twice a week in the ICU and at least once a week on the floor and that's how we practice now and then we need to account real quickly they need more than one times metabolic resting energy when they're doing exercise right so we need to be able to account for their needs later on and again protein is critical as well as calories right we can't build a house without protein you can't build muscle without protein right so the key thing for our patient Elijah is he's almost 90 years old and so he has anabolic resistance and that means as we age it takes more grams of prote to build the same amount of muscle than when we're young right so he's almost 90 he needs more protein now not all old people lose muscle mass you don't have to lose muscle mass as you age but he does More Than Just Eat Right to look like this and we'll talk about that so again we can learn from athletes though we need to take in protein as boluses who Bolis feeds your ICU patients does anyone do that raise your hand not so much that's a that's we do that now in about half of our patients that's a more physiologic IC way to gain muscle and taking in protein at night when we're anabolic overnight is very key and again exercise is critical as well and so again critically ill patients are the most anabolically resistant and so the combination of age and illness leads to our patients needing the most protein and then needing help from other nutrients and drugs like testosterone or hmbb or creatine which is something we use commonly but challenging getting to Gold nutrition inally is very difficult in our patients and so we need to be starting paral nutrition sooner and the other key message is there is no association of paral nutrition with infection or tpn with infection anymore thousands of patients studied in big journals you've heard of like do England Journal shows it's just as safe to put pral nutrition through a central line as saline there's no association of any kind and so the data would say now in our guidelines that is the same as interal you can start interal nutrition or peral nutrition interchangeably the just as safe so if you don't get your nutrition in you start supplemental or paral nutrition within two or 3 days they're just as safe they're just as effective and in fact now a data from a large study in Jamma surgery the highest impact factor surgery journal in the world shows giving P nutrition in surgery patients like Elijah reduces infection so starting penal nutrition at day three rather than waiting to day seven reduces infection in patients we should be using it more than we are that's critical so again he had poor tolerance and so he was started on peral nutrition on the second day of his ICU stay which is critical because the average time to feed these patients is a couple days and so that's critical get forward here okay so what else can we do for this patient besides nutrition to help him survive and recover remember he's 90 at a cardiac arrest it's going to take more than nutrition to do that is nutrition enough to win the war for our patients well it helps clearly but won't stop muscle mass loss it will slow it down if you feed well but they'll continue to lose muscle because they're anabolically resistant and they become catabolic right Mother Nature never intended us to survive these kinds of injuries at age 40 much less at age 90 practically and so again we have to defeat this catabolism because this is persistent in our patients and our calories won't go to muscle and so we can learn from athletes like this who of course don't look like this because they eat right they do more than eating right right they use anabolic drugs to help them and our patients need that too so the right anabolic agents we believe is probably crucial for our patients to recover you don't use them in the first few days you wait for the first few days the patient needs to be catabolic and break down for the first few days but then after that there's a lot of good data mostly in burn patients right now that shows it saves lives to use anabolic agents like oxandrin and testosterone they have shorter lengths of stay they have better muscle mass growth they have better physical function these are kids and adults that receive these men and women both do better because they get an anabolic agent so I check testosterone frequently and almost all the levels I check often they're zero or 50 a normal level is above 300 so I check total testosterone about day five on all my patients and what I found is it increases your risk of death if your testosterone's low even if you're a healthy man and your testosterone's low your risk of death is much higher if your testosterone is lower but in our patients this is dramatic these are hospitalized patients that they had testosterone levels measured with a normal of 250 and they're all over 65 like Elijah half the patients had a testosterone that was below 200 which is very low and you can see what mortality does in a patient who has a low admission testosterone testosterone deficiency increases death this is bad for you whether you're healthy or sick and it's dramatic it increases death dramatically so if you're going to do this right how do you do it so one question you're going to get isn't it increasing cardiovascular risk of stroke and heart attack the answer is no it reduces your risk of having a stroke or a heart attack that's true if you're healthy and it's likely true if you're sick this was a 43,000 patient study of men with testosterone deficiency done in jamama patients who had their testosterone replaced had 30% less heart attacks 30% less strokes and 30% less cardiac events overall for every man in the audience this is a good motivation to get your testosterone check but for our patients it saves them from these events too and so what about patients who already have had a heart attack or stroke this is studied as well if you've had a heart attack or a stroke in the last year and your testosterone is low if you get it repleted with testosterone replacement therapy your chance of having another heart attack is 80% lower this saves lives reduces heart attacks reduces Strokes even in people who have heart disease it doesn't cause blood clots it doesn't cause prostate cancer none of those things are true that was all old data so again it's this protects our patients and helps them recover why aren't we using it more so I check total testosterone you don't need to check a free they're always very low almost everyone's deficient if it's below 300 I replete it I use testosterone cenate I give 100 milligrams for 70 kilos and I give it weekly instead of every two weeks because otherwise they levels go up and down the halflife is N9 days in women I start 50 to 75 migr and I'll do it for about 6 months again men and women if you have oxandrolone and that's better it's purely anabolic you can give it to men and women without a problem so that's the best because it's an oral form we don't have that in our hospital I check the level at 6 days after the first dose I want it above 500 men and above 300 in women and these are what I try to Target and so this is how you can do this successfully the halflife is about nine days of course you got to feed them adequately as well this is a paper we wrote on all the different kinds of anabolic steroid rep if you want to learn more about them you can read this this will tell you all about them so this is the new paper on that so again we need to address all the different causes of our patients weakness and muscle loss if we're going to help them recover and again if we're going to help a 90-year-old recover like Elijah we have to KCK all these boxes we need exercise we need nutrition we need them out of the bed and we need anabolic agents like testosterone to give them back their quality of life what about the exercise piece I'm going to finish with that how do you prescribe exercise exercise what can we learn from professional athletes to help our patients exercise for our patients doesn't look like this it looks like this this is what we're doing now we use cpet testing or cardiopulmonary exercise testing the same way an athlete does to prescribe exercise heart rate intervals for our patients I want to tell you about another patient we did this in this is one of the first patients we ever did this in his name was Joshua and he had gotten burned he had a burn injury he was very fit was when I was living in Colorado he was a biker and he got a burn he was out of the burn unit in 24 days he did very well and he went home and he tried to go back to biking and he couldn't get up the hill outside his house for months he would be exhausted in a few minutes and so he came back to us and said how can I become active and fit again because I keep trying and I keep not being able to do the things I want to do so we we talked to him and learned that he couldn't even bike up the hills outside his house and so so we did an exercise test like this you can do it stepping in place as well and the beauty of what this test tells us is it tells us both what the mitochondria is doing that's where you utilize fats and it tells you what the TCA cycle is doing that's where you utilize carbohydrates you can see how these pathways are working this is what an elite athlete looks like when you test them they can use fat in that red line up to very high workloads and they can generate and use lactate very efficiently they have a high mitochondrial density in their muscle so again this is the lactic part this is what an obese person looks like they have a very low mitochondrial content they can only use fat for a little bit of the time they're exercising and they immediately switch to carbohydrates and get tired when they burn their glycogen down this is what about our patient this is what our patient test look like he couldn't use any fat at all at any workload his mitochondria weren't working this is mitochondrial failure and lots of our patients have it but we never test for it we tested them twice this was the first patient our athletic testing people have ever seen in their lives that couldn't use fat in any way shape or form and thousands of patients thousands of people this is what happens to our patients and why they have persistent weakness and so we put him on an interval training regimen based on his heart rate targets to get him back and a few months later in Orange you can see he began to use fat again and he began to be able to bike up the hill again we were able to recover him by prescribing interval training with target heart rates and so so this is the exercise dysfunction our patients have and this is how you treat it now he competes as a competitive bike rider but he would have never gotten there if we hadn't diagnosed and treated him with prescription of exercise so again how many of our patients suffer this and never have it treated properly because no one teaches them how to exercise properly this can be done before surgery too Elijah could have benefited we're doing this in our hospital now this is another patient we treated is a 63-year-old who was very frail coming for bladder cancer surgery she' been turned down at lots of hospitals she couldn't walk across a room without getting short of breath we put her on the bike and tested her and the we get her heart rate intervals they get printed on a card the card goes in the bike and it takes them through an interval training program up to heart rate targets and then she rests she does hit training then we give them H high protein drinks with hmb in this patient in just four weeks we increased her leg muscle mass by a kilogram more than a kilogram people who have never exercised before have the best response to this we can do the best with people who have learned gone from no exercise to exercising they have the biggest jump and she gained a whole V2 peak one met increase in her in her endurance this is a huge increase in just four weeks that we're able to make for this patient again this gives her a 15% lifetime mortality reduction if she can persist in it so we have great Effects by prescribing exercise very quickly not everybody can come to the hospital the US and Brazil are big countries we've done now gotten a big Grant from the ni to do this training at home so we bring in patients before they go home from the hospital we test them get their heart rate targets we send them home with an iPhone and an eyewatch we teach them an exercise they can do and they interact with a physical therapist over the iPhone who coaches them three times a week it's like having a personal trainer in your house and they coach them through this this is what it looks like you can do this in a hospital room this is me doing it actually before I had surgery this mask cost us $2,000 it's not expensive it's a blue Bluetooth mask we test all of our covid patients cancer patients surgery patients this way whenever they're in our studies and we hope to start a program soon and this is the data they show us that the physical therapist sees when they're coaching them their interval heart rates go up and we want to bring them down and we have to coach them to do it correctly our patients who are having Bomer transplants exercise an extra day a week they exercise four days a week they like it so much and they improve their V2 Peak by 25% so these are and they work in a month they get these dramatic improvements so again if you want to learn more about these is are papers where we talk about these strategies and these modalities and as we finish what happened to Elijah remember he's 89 he's at a cardiac arrest he had an open abdomen and he's malnourished can we save him he wants to live and he wants to go back to a life worth living so what did we do for him so we started him after he got off his tpn and was able to eat again we started on a high protein drink with hmb and think hmb inre are critical we start a testosterone for him you have to correct vitamin D if you don't correct vitamin D patients will not gain muscle vitamin D is critical to muscle function it takes 100,000 units of D3 not 2,000 not 50,000 in an ICU patient so you have to give enough so we corrected all those things we gave them creatine which we use a lot it's very very evidence-based supplement and then he moved on to also doing physical therapy oops let me go back back so he did sit to stand that's the best exercise you can do for your patients this is the hardest thing for them to do and the most important they have to be able to stand up he brought in his own weights from home as family did and he was able to use them so even after all these things what happened to Elijah can we save this 90-year-old man well I will tell you that 28 days after he had a cardiac arrest he walked out of the hospital on his 90th birthday and that's the truth and his family wanted me to share this with you because he was a hero it was an amazing it was the most memorable patient I've ever cared for none of us no one thought we could save him much less have him go back to a life that's worth living he lived for two more years at home he met his granddaughter he fixed the roof of his church again he led the life he wanted when everyone else told us there was no way he'd even survive this is what personalizing nutrition and exercise can do you can save even the patients no one thinks you can save and give them their lives back this is actually Elijah he asked his family asked me to say this picture he passed away peacefully at home with his family around him two years later and they've asked me to tell this story so that's why I'm telling it to you today so again as we close we have to train our patients for the marathon of recovery and illness that they're facing and we have to be good examples ourselves so we have to practice what we preach we have to do this ourselves too but we can create survivors of even the sickest and oldest patients and not victims like Elijah but we have to be better we have to do better we have to measure our calories and measure our exercise and prescribe it using metabolic carts and CET testing and personalize it with anabolic testosterone therapy things of that nature to save these patients these are all the things we can do for our patients there's many many things new technologies new measurement devices new ways to train patients to prescribe exercise and nutrition these are many of the treatments we can give to our patients and of course we need to ramp our calories and protein up slowly we need to use peral nutrition sooner we need to be aggressive with our physical therapy and then we need to be willing to use anabolic agents to help our patients recover because otherwise they won't be able to use the calories and protein we're giving them if you want to learn more this is what Isabelle was talking about we have started an online nutrition Fellowship that anyone in the world can participate in and the best and I think the most wonderful experts in the world are the professors president I got to pick them myself they're the people I like to listen to lecture and so we have a module that goes every week for about half the year and you get to interact personally with your classmates we have people from 13 countries including Brazil and four continents so people around the world and you get to interact with these professors people like meta burger and Isabelle is another one of our faculty I teach in many of the experts in the world and you get to know them and meet them and interact with them and ask questions and so we' love all of you to join we'll start another course in January we have also started a research clinical nutrition training program to teach people to do clinical nutrition research and we'll have a set of courses that specifically talk about how to do research in clinical nutrition starting in the fall that you can sign up for as well and we've gotten funding to fund let me go back to that fund two people a year to do research projects we'll pay for your project we'll help you status ditions we'll help you get to meetings to present them whether it's Aspen or Espen we'll help you do all those things and so we're we have a physician Ecuador who's doing it and we have a dietitian doing it so we have we funding for nutrition um and dietitians and nutrition Physicians and so we hope to start an inperson program where you can come to Duke and we'll teach you these personalized techniques as well so in the end if we do these things we can take patients who look like this whoops have them walking on their ventilar like this have them exercising in their beds like this these beds exist you can do curls in them you can do leg presses in them they're pretty amazing beds this is the future of what we can do in the ICU and then have them leave the hospital looking like this like Elijah did or maybe like this but at least like this and with that this is what we're left I encourage you to share what you've learned today on social media so your colleagues can learn and they can learn to take better care of their patients and follow on Instagram and YouTube I have my lectures posted there for free and I'm happy to send you the papers of the slides that the slides may be the best I'm happy to share these with you if you want to email me I will send them to you with that I'd be happy to take your questions thank you [Applause]