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Key Clinical Updates in Involuntary Weight Loss
Some patients with cancer-associated weight loss may benefit from nutritional assessment and intervention, since decreased food intake may play a role.
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ESSENTIAL INQUIRIES
Age; caloric intake; secondary confirmation (eg, changes in clothing size).
Fever; change in bowel habits.
Substance abuse.
Age-appropriate cancer screening history.
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GENERAL CONSIDERATIONS
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Body weight is determined by a person’s caloric intake, absorptive capacity, metabolic rate, and energy losses. Body weight normally peaks by the fifth or sixth decade and then gradually declines at a rate of 1–2 kg per decade. In NHANES II, a national survey of community-dwelling elders (aged 50–80 years), recent involuntary weight loss (more than 5% usual body weight) was reported by 7% of respondents, and this was associated with a 24% higher mortality. In contrast, one study found that a body mass index of 33 or less is not associated with an increased mortality in adults aged 65 years or older. In postmenopausal women, unintentional weight loss was associated with increased rates of hip and vertebral fractures. Weight loss may include a loss of fat and muscle mass. Involuntary weight loss combined with low muscle mass was more strongly associated with poor quality of life than involuntary weight loss alone.
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Involuntary weight loss is regarded as clinically significant when it exceeds 5% or more of usual body weight over a 6- to 12-month period. It often indicates serious physical or psychological illness. Physical causes are usually evident during the initial evaluation. The most common causes are cancer (about 30%), gastrointestinal disorders (about 15%), and dementia or depression (about 15%). Nearly half of patients with Parkinson disease have weight loss associated with disease progression. When an adequately nourished–appearing patient complains of weight loss, inquiry should be made about exact weight changes (with approximate dates) and about changes in clothing size. Family members can provide confirmation of weight loss, as can old documents such as driver’s licenses. A mild, gradual weight loss occurs in some older individuals because of decreased energy requirements. However, rapid involuntary weight loss is predictive of morbidity and mortality. In addition to various disease states, causes in older individuals include loss of teeth and consequent difficulty with chewing, medications interfering with taste or causing nausea, alcoholism, and social isolation.
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Once the weight loss is established, the history, medication profile, physical examination, and conventional laboratory and radiologic investigations (eg, complete blood count, liver biochemical tests, kidney panel, serologic tests including HIV, thyroid-stimulating hormone [TSH] level, urinalysis, fecal occult blood test, chest radiography, and upper gastrointestinal series) usually reveal the cause. Whole-body CT imaging is increasingly used for diagnosis; one study found its diagnostic yield to be 33.5%. When these tests are normal, the second phase of evaluation should focus on more definitive gastrointestinal investigation (eg, tests for malabsorption, endoscopy) and cancer ...