Unintentional Weight Loss
AIMGP Seminar MSH/UHN
January 2008
Yash Patel
Seminar Objectives
 Develop an approach to unintentional
weight loss
 Define unintentional weight loss
 Review the incidence and prevalence
of weight loss
 Review the common causes of weight
loss
 Cover treatment strategies
Selected References
 An approach to the management of
unintentional weight loss in elderly
people. Alibhai S. et al; CMAJ: Mar 15, 2005
 Rational approach to patients with
unintentional weight loss. Bouras E. et al;
Mayo Clin Proc: Sept 2001
 Evaluating and treating unintentional
weight loss in the elderly. Huffman G.; Am
Fam Physician: Feb 15, 2002
Case
 You are referred a 69 F for evaluation
of unintentional weight loss.
 She has lost 5 kg in the past 12
months, her current weight is 60 kg.
 Is her weight loss clinically important?
 How common is weight loss in the
elderly?
Is her weight loss clinically
important?
 Definition
 Clinically important weight loss can be defined
as loss of 5 kg or more than 5% of usual weight
over 6-12 months
 Why it’s important!
 Unintentional weight loss may reflect disease
severity of a chronic illness or a yet undiagnosed
illness.
 Even after adjusting for co-morbidities weight
loss of 5% or more of body weight is associated
with increased mortality (approx increase in RR
1.6)
How common is weight loss in the
elderly?
 Prevalence estimates of weight loss are quite
variable
 15-20% elderly patients experience weight loss
(defined as loss of 5 kg or 5% body wt over 5-10
years)
 The prevalence can be as high as 27% in high-risk
populations such as the frail elderly
 The incidence of unintentional weight loss in
clinical studies of adults seeking health care
is also quite variable
 Depending on the setting and definition it varies
from 1.3 to 8%
Case
 HPI:
 She confirms that her weight was 65 kg
1 year ago when it was measured at the
family doctors office
 Her appetite is “normal” and she reports
no other constitutional symptoms
 The clinical review is negative for
cardiac, respiratory, gastrointestinal, and
neurologic symptoms
Case
 PMHx:
 Hypertension (on ACEI and HCTZ)
 Dyslipidemia (on statin)
 OA of both kness (on prn acetominophen)
 Social Hx:
 Widowed 3 years ago
 Lives in apartment, independent in ADLs and
iADLs
 X-smoker (quit 10 years ago), occasional ETOH
use
Case
 Physical Exam:
 VS: BP-118/74, HR-74 regular, T-37.3 C
 H+N: normal thyroid and no lymph
nodes
 CV/RS: normal heart sounds, clear lungs
 GI: negative Castell’s sign, and normal
liver span
 NE: normal muscle bulk, strength, and
tone
Case
 Now What?
 What are the common causes of
unintentional weight loss?
What are the common causes of
unintentional weight loss?
 Causes of unintentional weight loss
can classified into 3 broad groups
 Organic
 Psychosocial
 Idiopathic (up to 10-36% of cases)
What are the common causes of
unintentional weight loss?
 Organic Causes - top three
 Malignancy (16-36%)
 Usually it’s clear from the history, physical, or
routine lab data that malignancy is a potential
cause
 Gastrointestinal (most common non-malignant
organic cause, 6-19%)
 PUD, IBD, dysmotility, hepatobiliary/pancreatic
disease, or oral problems
 Endocrine (4-11%)
 DM, thyroid disease, and adrenal insufficiency
What are the common causes of
unintentional weight loss?
 Organic causes (less common)

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


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Cardiovascular disease (2-9%)
Respiratory disease (~6%)
Chronic infections (2-5%)
Renal disease (~4%)
Drugs/Medication Side effects (~2%)
Neurologic disorder (2-7%)
What are the common causes of
unintentional weight loss?
 Psychosocial Causes
 Psychiatric disorder (9-42%)
 Depression
 Dementia (2-5%)
 Poor nutritional intake
 Due to poverty or inadequate access to
meals
What are the common causes of
unintentional weight loss?
 Psychosocial Causes
 Depression and dementia are poorly recognized
in clinical practice
 All elderly patients with weight loss should
undergo screening for
 dementia with the MMSE
 depression with the Geriatric Depression Scale
 Screen for malnutrition with one of these
validated tools (ENS or SCREEN) at
www.dietitians.ca/seniors/index.asp
What are the common causes of
unintentional weight loss?
 Several key concepts emerge from
etiologic studies of unintentional
weight loss
 Among organic causes cancer is most
common
 Etiology of weight loss is evident without
extensive evaluation in most patients
 Psychiatric illness and nondiagnostic
evaluations are common
Case
 So far her history and physical is
unremarkable
 You explore other issues…
 You ask her about medication side effects - she
reports none.
 You do a MMSE and she scores 30/30!
 Access to food and meals is not an issue for her.
 What further assessment or investigations
are now indicated?
What further assessment or
investigations are now indicated?
 The diagnostic utility of the medical history
and physical examination in identifying the
cause of weight loss has not been
evaluated
 The same can be said about screening
investigations
 Despite the lack of systematic evaluation, a
complete history, physical examination and
selected “routine” investigations are
recommended
What further assessment or
investigations are now indicated?
 Routine Investigations



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CBC
Biochemistry (lytes, glucose, Ca, PO4)
TSH
Liver enzymes
Urinalysis
CXR
What further assessment or
investigations are now indicated?
 Additional tests are ordered as clinically
indicated




HIV test
SPEP
PSA, mammogram
GI investigations (if there are symptoms,
microcytic anemia, or abnormal liver enzymes)
 OGD or colonoscopy plus biopsies
 Stool analysis
 Celiac serology
 Abdominal imaging
Case
 She is send for the “routine
investigations” and returns for followup
 All the investigations are normal or
negative
 She is relieved, but still wants to
know why she has lost 5 kg?
 Now What?
Case
 You pursue the assessment further and ask
about symptoms of depression
 She does occasionally feel lonely since her
husband passed away but…the Geriatric
Depression Scale is negative
 You reassure her that she does not have an
organic or pyschosocial cause for her
weight loss
 Her diagnosis is idiopathic unintentional weight
loss
 How should weight loss be treated?
 What follow up does she need?
How should weight loss be treated?
 Treat the underlying organic cause
 When pyschosocial issues are involved then
a multi-disciplined approach is required to
address the key issues
 including social work, dietician, community
services and psychiatrist
 For idiopathic weight loss seek advice from
a dietician for strategies to increase caloric
intake
What follow up does she need?
 Reassess her weight in 3 months
 If it remains stable or goes up then
further assessment is not necessary
 If she is continuing to lose weight then
repeat the evaluation process, with
emphasis on searching for an organic or
psychosocial cause
Case
 She returns after 3 months and her weight
has remained stable
 She is following the advice of the dietician to
increase her caloric intake
 You feel confident that she has idiopathic
weight loss
 At this point you discharge her from clinic
and ask her family doctor to monitor her
weights every 3-6 months.
Summary
 Unintentional weight loss is a common
concern especially in the elderly
 Common causes can be grouped into one of
3 categories: organic, psychosocial, or
idiopathic
 Psychosocial causes are under appreciated
by clinicians
 Extensive investigations are usually not
necessary
Appendix
 The following are some figures and
tables from Shabir Alibhai’s review
article from the CMAJ
 And my approach to weight loss
summarized in a figure
Alibhai, S. M.H. et al. CMAJ 2005;172:773-780
Copyright ©2005 CMA Media Inc. or its licensors
Alibhai, S. M.H. et al. CMAJ 2005;172:773-780
Copyright ©2005 CMA Media Inc. or its licensors
Fig. 1: Strategies for treating weight loss in elderly patients
Alibhai, S. M.H. et al. CMAJ 2005;172:773-780
Copyright ©2005 CMA Media Inc. or its licensors
Table 3.
Alibhai, S. M.H. et al. CMAJ 2005;172:773-780
Copyright ©2005 CMA Media Inc. or its licensors
Approach to Weight Loss
Weight Loss
Voluntary…dieting, anorexia/bulimia
(>5% body wt)
Increased Appetite…DM, malabsorption, hyperthyroidism
Involuntary
Cancer
(20%)
Decreased Appetite
Organic
Noncancer
(40%)
Psychiatric…depression, dementia
(15%)
Idiopathic
(25%)
GI
Endocrine
Infectious
Medications
CV
Neurologic
Pulmonary
Renal
CTD