Weight Loss

I. Problem/Condition.

Weight loss is generally defined as a decrease in one’s body weight that is due either to voluntary measures (e.g., changes in diet and energy expenditure) or to involuntary circumstances, such as malignancy or endocrinopathy. Clinically significant weight loss has been defined as the loss of ten pounds or more, but a more precise definition states that weight loss is the reduction of 5 percent or more in one’s body weight over six months. However, these definitions may not accurately reflect the concerns of older, frail adults, in whom the loss of even 3 percent of body weight can be significant.

II. Diagnostic Approach

A. What is the differential diagnosis for this problem?

Weight loss can be objectively determined by following serial measurements of the patient’s weight. If this information is lacking, getting subjective information from the patient, close family, or friends can help. Querying patients about how well their clothing fits can offer supporting evidence.

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B. Describe a diagnostic approach/method to the patient with this problem.

Some patients are more prone to weight loss, including those with multiple comorbidities, especially malignancy, substance abuse, or neurologic and/or psychiatric diseases, as well as those at an advanced age. Since patients with involuntary weight loss have higher morbidity and mortality, particular attention should be paid to patients with this symptom.

1. Historical information important in the diagnosis of this problem.

When assessing a patient with possible weight loss, the hospitalist must determine whether the loss of weight is voluntary or involuntary. Some patients are unaware that they have lost weight, while others may believe they have lost significant weight when objective information argues otherwise.

Taking a careful history from the patient and his or her caregivers is critical to isolating the cause of weight loss. Understanding whether a patient has symptoms of an occult malignancy, an endocrinopathy, emotional difficulties, trouble with swallowing or with appetite, difficulty accessing or preparing food, or difficulty chewing or tasting food can help isolate the cause of the weight loss. Older patients are particularly vulnerable to side effects of medications that lead to involuntary weight loss because of effects on appetite, nausea, vomiting, dry mouth, or dysphagia. Therefore, taking a careful medication history can help identify the cause of weight loss. Ask about symptoms of psychiatric illnesses such as depression, dementia, anorexia nervosa, or other emotional problems. Screening for alcohol or illicit drug use.

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.

When assessing a patient with weight loss, the clinician should look for signs of the underlying cause(s). In particular, look for the stigmata of hyperthyroidism (e.g., tachycardia, hypertension, tremor, proximal muscle weakness), evidence of malabsorptive syndromes (e.g., bleeding that is due to Vitamin K deficiency, edema from protein deficiency), and evidence of cognitive dysfunction on neurologic examination or depression/psychosis on psychiatric exam.

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

Diagnostic testing should be tailored to the patient’s symptoms to help guide an appropriate evaluation. Most patients require CBC with differential; assessment of basic electrolytes, glucose and kidney function; liver function panel; and a TSH. If the cause of weight loss is unknown, an HIV test, a ESR/CRP, and a chest X-ray should be considered.

If the above tests are unrevealing, consider gastrointestinal work up, including tests for malabsorption and endoscopy. Also consider screening for cancer with tests like PAP smear or mammogram in women, a PSA in men, colonoscopy in both men and women, if the patient is not up to date on their recommended screening.

C. Criteria for Diagnosing Each Diagnosis in the Method Above.

With the patient’s history, physical exam, and diagnostic evaluation, it may be possible to identify the cause of the weight loss.

D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.

If no cause of the weight loss can be identified through the history, physical examination, and basic diagnostic testing, more significant evaluation may be warranted. However, some experts caution against ordering testing and imaging without clear-cut evidence or symptoms, as there will be a low diagnostic yield. Some argue for a “watchful waiting” approach of closely monitoring the patient for an additional six months and reassessing at that time.

III. Management while the Diagnostic Process is Proceeding

A. Management of weight loss.

Management of weight loss should be a two-fold approach of addressing/treating the underlying cause of the weight loss and caloric supplementation. Removing dietary restrictions can help improve caloric intake. Some recommend nutritional supplements to augment intake; supplements can be helpful particularly if offered between meals so as not to interfere with appetite for regular meals. Older patients are more prone to dental difficulties (e.g., ill-fitting dentures, poor oral health, or dry mouth), and if these are addressed, oral intake may improve. Similarly, patients who are depressed or socially isolated may benefit from community programs (e.g., Meals on Wheels).

B. Common Pitfalls and Side Effects of Management of this Clinical Problem

Weight loss of even minor amounts (3% of total body weight) in older adults can increase risk of fracture and morbidity.

Appetite stimulants may be beneficial in select populations, including those with cachexia associated with malignancy. Using appetite stimulants like megestrol in older adults should be done with caution, given the possible side effects of anxiety and CNS toxicity.

IV. What’s the evidence?

Alibhai, SM, Greenwood, C, Payette, H. “An approach to the management of unintentional weight loss in elderly people”. CMAJ. vol. 172. 2005. pp. 773-80.

Blaum, CS, Fries, BE, Fiatarone, MA. “Factors associated with low body mass index and weight loss in nursing home residents”. J Gerontol A Biol Sci Med Sci. vol. 50. 1995. pp. M162-8.

Bouras, EP, Lange, SM, Scolapio, JS. “Rational approach to patients with unintentional weight loss”. Mayo Clin Proc. vol. 76. 2001. pp. 923-9.

Huffman, GB. “Evaluating and treating unintentional weight loss in the elderly”. Am Fam Physician. vol. 65. 2002. pp. 640-50.

Karcic, E, Philpot, C, Morley, JE. “Treating malnutrition with megestrol acetate: literature review and review of our experience”. J Nutr Health Aging. vol. 6. 2002. pp. 191-200.

Shay, K, Ship, JA. “The importance of oral health in the older patient”. J Am Geriatr Soc,. vol. 43. 1995. pp. 1414-22.

Wannamethee, SG, Shaper, AG, Lennon, L. “Reasons for intentional weight loss, unintentional weight loss, and mortality in older men”. Arch Intern Med. vol. 165. 2005. pp. 1035-40.

Yeh, SS, Wu, SY, Lee, TP, Olson, JS, Stevens, MR, Dixon, T, Porcelli, RJ, Schuster, MW. “Improvement in quality-of-life measures and stimulation of weight gain after treatment with megestrol acetate oral suspension in geriatric cachexia: results of a double-blind, placebo-controlled study”. J Am Geriatr Soc. vol. 48. 2000. pp. 485-92.