2 Introduction Always ask about weight change Relative change is also importantSignificant weight loss-marker of serious illnessPersistence & periodic evaluation to identify the cause - important
3 Mechanisms of weight loss Increased energy expenditureIncreased energy lossDecreased food intake
4 IntroductionResult of decreased energy intake or increased energy expenditure.Classified as voluntary or involuntary.Progressive involuntary weight loss often indicates a serious medical or psychiatric illness.Voluntary weight loss in overweight or obeseVoluntary weight loss is usually a manifestation of psychiatric disease.
5 CaseYou are referred a 69 F for evaluation of unintentional weight loss.She has lost 5 kg in the past 6 months, her current weight is 60 kg.Is her weight loss clinically important?How common is weight loss in the elderly?
6 Is her weight loss clinically important? DefinitionClinically important weight loss can be defined as loss of 5 kg or more than 5% of usual weight over 6 monthsWhy 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)
7 EPIDEMIOLOGY 9000 adults in (US), 5 percent reported involuntary weight loss of at least 5 percent of their usual body weight during the preceding year8 percent reported voluntary weight loss of the same magnitude.No important differences in weight loss incidence by gender.Independent predictors of involuntary weight loss were age, smoking, and poor self-reported health. None of these risk factors was associated with voluntary weight lossStrongest independent predictors of voluntary weight loss were higher baseline body mass index (BMI) and higher education level.
8 EPIDEMIOLOGYThe majority of people will eventually meet the criteria for significant involuntary weight loss if they live long enough. Many studies, especially of nursing home residents, report a prevalence of weight loss exceeding 50 percent,
9 How common is weight loss in the elderly? Prevalence estimates of weight loss are quite variable15-20% 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 elderlyThe incidence of unintentional weight loss in clinical studies of adults seeking health care is also quite variableDepending on the setting and definition it varies from 1.3 to 8%
10 Unintentional Weight Loss in the Elderly Weight loss is associated with increased mortality or morbidity or both15-20% prevalence, though estimates vary widely; no gender differenceSimilar causes as non-elderly but additional factorsPerson with dementia or late-life psychotic d/o may be paranoid and suspicious that food being poisonedPerson with dementia and habitual wandering may expend significant energy in pacingPhysiologic changes in elderly early satiety and anorexiaDecline in taste and smellReduced efficiency of chewingSlowed gastric emptyingAlternations in neuroendocrine axis
12 MORTALITY Involuntary : increased (NHANES) II Mortality Study evaluated over participants age ≥50 years, who were followed for at least 12 years . Seven percent of the sample reported involuntary weight loss of 5 percent or more over six months.. Prevalence increased with age and was also higher among those with obesity.Involuntary weight loss was associated with a 24 percent relative increase in mortality during the follow- up period, even among those with obesity.
13 Voluntary : unclear whether voluntary weight loss in the general population is associated with reduced mortality.In prospective cohort studies, voluntary weight loss may be associated with a decrease in mortality in overweight and obese individuals
14 Now What?What are the common causes of unintentional weight loss?
15 What are the common causes of unintentional weight loss? Causes of unintentional weight loss can classified into 3 broad groupsOrganicPsychosocialIdiopathic (up to 10-36% of cases)
16 Causes of weight loss Involuntary with increased appetite A. Increased energy expenditure-HyperthyroidismPheochromocytomaExtensive exerciseB-Increased energy lossDiabetes MellitusMalabsorptionChronic pancreatitisUlcerative colitisChrohn diseaseCeliac sprue
17 Causes of weight loss (cont′d) Involuntary with decreased appetiteMedical disorder__Cancer__Infection :HIV ,TB ,Endocarditis ,lung abscess ,hepatitis ,Chronic helminthInfection__Chronic illnessesCHF,COPD,CKD__Endocrine diseasesAdrenal insufficiencyHypercalcemia_GI DiseasesPUDDysphagiaDiabetic gasteroparesisCompressive massInfiltrating cancer__Hyperemesis gravidarumB-Psychiatric DisordersDepressionC-Chronic drug useAlcoholMetforminAnti cancers
18 Causes of weight loss (cont′d) 3-Voluntary Weight loss__Diet and exercise__Treatment of Obesity__Anorexia Nervosa , Bulimia
20 Anorexia Nervosa Description Characterized by excessive weight loss Self-starvationPreoccupation with foods, progressing restrictions against whole categories of foodAnxiety about gaining weight or being “fat”Denial of hungerConsistent excuses to avoid mealtimesExcessive, rigid exercise regimen to “burn off” caloriesWithdrawal from usual friends
21 AnorexiaSymptomsResistance to maintaining body weight at or above a minimally normal weight for age and heightIntense fear of weight gain or being “fat” even though underweightDisturbance in the experience of body weight or shape on self-evaluationLoss of menstrual periods in girls and women post-puberty
24 Psychological changes Depressed mood , social withdrawalLoss of interest usual activitiesAnxietyFatigue
25 Anorexia What do counselors look for? Rapid loss of weight Change in eating habitsWithdrawal from friends or social gatheringsPeach fuzzHair loss or dry skinExtreme concern about appearance or dieting
27 EpidemiologyFemales are times more frequently affected than males0,5-1% of female adolescents,5% have subclinical formsAge at onset is in the early adolescence , it may be delayed till the early 20′s
28 AnorexiaAge RangeMost cases are in women ranging in age from early teens to mid-twentiesRecently there have been more cases of women and men in 30’s and 40’s suffering from an eating disorder40% of newly identified cases are in girls 15-19Significant increase in women aged 15-24
29 Anorexia Prevalence in Population 0.5%-1% of women from late adolescence to early adulthood meet the full criteria for anorexiaEven more are diagnosed under a subthresholdLimited data on number of males with anorexia10 million people have been diagnosed with having an eating disorder of some type
32 Course And Prognosis Ten-year outcome study in the US : 25% complete recovery50% improve , functioning well with residual symptoms25% functioning poorly , including 7% mortality rate
33 Bulimia Nervosa Bulimia Nervosa is an eating disorder in which one starts toconsume large amount offood at once and then isfollowed by purging , usinglaxatives , or overexercising torid themselves of the foodthey ate
34 EpidemiologyThe average onset of Bulimia begins in late adolescence or early adult lifeUsually between the ages of 16 and 21However, more and more women in their 30s are reporting that they suffer from Bulimia
35 EpidemiologyThe prevalence of Bulimia Nervosa among adolescent and young adult females is approximately 1%-3%.The rate of occurrence in males is approximately one-tenth of that in females.
36 Bulimia Nervosa *onset and course usually begins in late adolescence or early adult life and affects 1-2% of young women90% of individuals are femalefrequently begins during or after an episode of dietingcourse may be chronic or intermittentfor a high percentage the disorder persists for at least several yearsperiods of remission often alternate with recurrences of binge eatingpurging becomes an addiction
37 Bulimia Nervosa *onset and course cont.. occurs with similar frequencies in most industrialized countriesmost individuals presenting with the disorder in the U.S. are Caucasian.only 6% of people with bulimia receive mental health carethe incidence of bulimia in year old women TRIPLED between 1988 and 1993
38 Symptoms Eating large amounts of food uncontrollably (binging) Vomiting, using laxatives, or using other methods to eliminate food (purging)Excessive concern about body weightDepression or changes in moodIrregular menstrual periodsUnusual dental problems, swollen cheeks or glands, heartburn, or bloating (swelling of the stomach)
39 Bulimia Nervosa: Warning Signs Wrappers/containers indicating consumption of largeamounts of foodFrequent trips to bathroom after mealsSigns of vomiting e.g staining of teeth , calluses on handsExcessive and rigid exercise routineWithdrawal from usual friends / relatives
40 Health Consequences of Bulimia Nervosa Causes electrolyte imbalances that can lead to irregular heartbeats and possibly heart failure and death. Electrolyte imbalance is caused by dehydration and loss of potassium and sodium from the body as a result of purging behaviors.Inflammation and possible rupture of the esophagus from frequent vomiting.Tooth decay and staining from stomach acids released during frequent vomiting.Chronic irregular bowel movements and constipation as a result of laxative abuse.Gastric rupture is an uncommon but possible side effect of binge eating.
41 Health Risks With Bulimia Dental problemsStomach ruptureMenstruation irregularities
42 What are the common causes of unintentional weight loss? Organic Causes - top threeMalignancy (16-36%)Usually it’s clear from the history, physical, or routine lab data that malignancy is a potential causeGastrointestinal (most common non-malignant organic cause, 6-19%)PUD, IBD, dysmotility, hepatobiliary/pancreatic disease, or oral problemsEndocrine (4-11%)DM, thyroid disease, and adrenal insufficiency
44 Unintentional Weight Loss Cancer (16%-36%)weight loss and tumor size not relatedmediated by incr. cytokines incl. TNF-alpha & IL-6decreased calorie intake from anorexia and symptoms caused directly by the cancerGI cancer most commonlunglymphomarenalprostate
45 Weight Loss Is Significant 50%–90% of people with cancer experience weight lossA weight loss of as little as 5% of body weight can cause reduced response to treatmentWeight loss is associated with poor quality of life and reduced survival
46 Unintentional Weight Loss Infection (2-5%)HIVwt loss due mostly to decr. calorie intake in contrast w/ cancer where energy consumption increasesrapid wt loss (>5% in 6 months) often due to 2’ary infectionsanti-retroviral therapyTBchronic bacterial, fungal & parasitic diseaseslung abscess
47 Unintentional Weight Loss Substance abuse (4%-8%)----amphetamines & cocaineOpiatesalcoholismsmokingcannabis withdrawal
48 Unintentional Weight Loss Medications (~2%)bupropion, fluoxetine & other SSRIs initially, lithium, L-dopametformin, L-thyroxinedigoxin, aspirin, diuretics, ACEI, Ca channel blockersNSAIDS, bisphosphonates, allopurinol, colchicineanticancer & antiretroviral drugs, opiatesiron, potassium
49 Unintentional Weight Loss Endocrine & Metabolic (4% - 11%)Hyperthyroidism_ increased catabolism, increased intestinal motility and malabsorption-Appetite may be increased or decreased (elderly)_average weight loss is 16 percent of usual body weight_Weight gain occurs quickly with treatment.
50 Unintentional Weight Loss Diabetes Type 1 & 2:a loss in lean body mass ,loss of extracellular and cellular water due to the osmotic diuresis from glucosuria.Uncontrolled diabetes mellitusmalabsorption from intestinal autonomic neuropathyGastroparesis,anorexia, depression, pain,
51 Unintentional Weight Loss Chronic Adrenalinsufficiencya anorexia,nausea & weight loss
52 Unintentional Weight Loss Hypercalcemia a, esp. if caused by cancerprimary hyperparathyroidism are asymptomatic and do not have weight loss hyperadrenergic state among patients with pheochromocytoma,only 5 percent weight loss
53 Unintentional Weight Loss GI (6%-19%)Loss of appetite in most GI diseasesdysphagia, early satiety, vomiting & regurgitation, abdo pain, chronic inflammation, malabsorption, surgical & spontaneous fistulas & bypasses, superior mesenteric artery syndromePUDIBD (Sharon)HepatitisCeliac disease
54 What are the common causes of unintentional weight loss? Organic causes (less common)Cardiovascular disease (2-9%)Respiratory disease (~6%)Chronic infections (2-5%)Renal disease (~4%)Drugs/Medication Side effects (~2%)Neurologic disorder (2-7%)
55 Unintentional Weight Loss Cardiac (2%-9%) & pulmonary (~6%)mechanisms not well understood“cardiac cachexia” if severe CHF?disuse muscle atrophyTNF-alpha elevationPulmonary weight loss is proportional to disease severity
56 What are the common causes of unintentional weight loss? Psychosocial CausesPsychiatric disorder (9-42%)DepressionDementia (2-5%)Poor nutritional intakeDue to poverty or inadequate access to meals
57 What are the common causes of unintentional weight loss? Psychosocial CausesDepression and dementia are poorly recognized in clinical practiceAll elderly patients with weight loss should undergo screening fordementia with the MMSEdepression with the Geriatric Depression ScaleScreen for malnutrition with one of these validated tools (ENS or SCREEN) at
58 What are the common causes of unintentional weight loss? Several key concepts emerge from etiologic studies of unintentional weight lossAmong organic causes cancer is most commonEtiology of weight loss is evident without extensive evaluation in most patientsPsychiatric illness and nondiagnostic evaluations are common
59 Approach to Weight Loss Investigationsindividualize based on the history, physical and your differential diagnosis (symptom based)
60 What further assessment or investigations are now indicated? Routine InvestigationsCBCBiochemistry (lytes, glucose, Ca, PO4)TSHLiver enzymesUrinalysisCXR
61 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 evaluatedThe same can be said about screening investigationsDespite the lack of systematic evaluation, a complete history, physical examination and selected “routine” investigations are recommended
62 What further assessment or investigations are now indicated? Additional tests are ordered as clinically indicatedHIV testSPEPPSA, mammogramGI investigations (if there are symptoms, microcytic anemia, or abnormal liver enzymes)OGD or colonoscopy plus biopsiesStool analysisCeliac serologyAbdominal imaging
64 Management Identify and treat the underlying cause Screen for depression & dementiaExercise (physiotherapy referral)Nutrition referral & counselingLimited evidence & role for pharmacologic therapy
65 What follow up does she need? Reassess her weight in 3 monthsIf it remains stable or goes up then further assessment is not necessaryIf she is continuing to lose weight then repeat the evaluation process, with emphasis on searching for an organic or psychosocial cause
66 SummaryUnintentional weight loss is a common concern especially in the elderlyCommon causes can be grouped into one of 3 categories: organic, psychosocial, or idiopathicPsychosocial causes are under appreciated by cliniciansExtensive investigations are usually not necessary