Transcript Unintentional Weight Loss

UNINTENTIONAL WEIGHT
LOSS
DR. GHOSON KANAYA
Introduction
 Always ask about weight change
 Relative change is also important
 Significant weight loss-marker of
serious illness
 Persistence & periodic evaluation to
identify the cause - important
Mechanisms of weight loss
 Increased energy expenditure
 Increased energy loss
 Decreased food intake
Introduction
 Result 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
obese
 Voluntary weight loss is usually a
manifestation of psychiatric disease.
Case
 You 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?
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 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)
EPIDEMIOLOGY
9000 adults in (US), 5 percent reported
involuntary weight loss of at least 5 percent of their
usual body weight during the preceding year
 8 percent reported voluntary weight loss of the same
magnitude.
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 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 loss
 Strongest independent predictors of voluntary
weight loss were higher baseline body mass index
(BMI) and higher education level.
EPIDEMIOLOGY

The 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,
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 highrisk 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%
Unintentional Weight Loss in the Elderly

Weight loss is associated with increased mortality or morbidity or
both
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15-20% prevalence, though estimates vary widely; no gender
difference
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Similar causes as non-elderly but additional factors

Person with dementia or late-life psychotic d/o may be paranoid and
suspicious that food being poisoned
 Person with dementia and habitual wandering may expend significant
energy in pacing
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Physiologic changes in elderly  early satiety and anorexia
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Decline in taste and smell
 Reduced efficiency of chewing
 Slowed gastric emptying
 Alternations in neuroendocrine axis
Unintentional weight loss can result in:
MORTALITY
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Involuntary : increased
(NHANES) II Mortality Study evaluated over 5000
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 followup period, even among those with obesity.
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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
 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)
Causes of weight loss
A. Involuntary with increased appetite
A. Increased energy expenditure
-Hyperthyroidism
Pheochromocytoma
Extensive exercise
B-Increased energy loss
Diabetes Mellitus
Malabsorption
Chronic pancreatitis
Ulcerative colitis
Chrohn disease
Celiac sprue
Causes of weight loss (cont′d)
 Involuntary with
decreased appetite
A. Medical disorder
__Cancer
__Infection :HIV ,TB ,
Endocarditis ,lung abscess
,hepatitis ,
Chronic helminth
Infection
__Chronic illnesses
CHF,COPD,CKD
__Endocrine diseases
Adrenal insufficiency
Hypercalcemia
_GI Diseases
PUD
Dysphagia
Diabetic gasteroparesis
Compressive mass
Infiltrating cancer
__Hyperemesis gravidarum
B-Psychiatric Disorders
Depression
C-Chronic drug use
Alcohol
Metformin
Anti cancers
Causes of weight loss (cont′d)
3-Voluntary Weight loss
__Diet and exercise
__Treatment of Obesity
__Anorexia Nervosa , Bulimia
Anorexia nervosa
Anorexia Nervosa
Description
– Characterized by excessive weight loss
– Self-starvation
– Preoccupation with foods, progressing restrictions against whole
categories of food
– Anxiety about gaining weight or being “fat”
– Denial of hunger
– Consistent excuses to avoid mealtimes
– Excessive, rigid exercise regimen to “burn off” calories
– Withdrawal from usual friends
Anorexia
Symptoms
– Resistance to maintaining body weight at or above a
minimally normal weight for age and height
– Intense fear of weight gain or being “fat” even though
underweight
– Disturbance in the experience of body weight or shape
on self-evaluation
– Loss of menstrual periods in girls and women postpuberty
Physical changes
Psychological changes
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Depressed mood , social withdrawal
Loss of interest usual activities
Anxiety
Fatigue
Anorexia
What do counselors look for?
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Rapid loss of weight
Change in eating habits
Withdrawal from friends or social gatherings
Peach fuzz
Hair loss or dry skin
Extreme concern about appearance or dieting
Epidemiology
 Females are 10-20 times more
frequently affected than males
 0,5-1% of female adolescents,5%
have subclinical forms
 Age at onset is in the early
adolescence , it may be delayed till
the early 20′s
Anorexia
Age Range
– Most cases are in women ranging in age from early
teens to mid-twenties
– Recently there have been more cases of women and
men in 30’s and 40’s suffering from an eating disorder
– 40% of newly identified cases are in girls 15-19
– Significant increase in women aged 15-24
Anorexia
Prevalence in Population
– 0.5%-1% of women from late adolescence to early
adulthood meet the full criteria for anorexia
– Even more are diagnosed under a subthreshold
– Limited data on number of males with anorexia
– 10 million people have been diagnosed with having an
eating disorder of some type
Complication of Anorexia Nervosa
Complication of Anorexia Nervosa
Course And Prognosis
 Ten-year outcome study in the US :
 25% complete recovery
 50% improve , functioning well with
residual symptoms
 25% functioning poorly , including 7%
mortality rate
Bulimia Nervosa
 Bulimia Nervosa is an eating
disorder in which one starts to
consume large amount of
food at once and then is
followed by purging , using
laxatives , or overexercising to
rid themselves of the food
they ate
Epidemiology
The average onset of Bulimia begins in late
adolescence or early adult life
– Usually between the ages of 16 and 21
However, more and more women in their 30s are
reporting that they suffer from Bulimia
Epidemiology
The 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.
Bulimia Nervosa
*onset and course
usually begins in late adolescence or early adult life and affects 12% of young women
90% of individuals are female
frequently begins during or after an episode of dieting
course may be chronic or intermittent
for a high percentage the disorder persists for at least several years
periods of remission often alternate with recurrences of binge eating
purging becomes an addiction
Bulimia Nervosa
*onset and course cont..
occurs with similar frequencies in most
industrialized countries
most individuals presenting with the disorder in the
U.S. are Caucasian.
only 6% of people with bulimia receive mental
health care
the incidence of bulimia in 10-39 year old women
TRIPLED between 1988 and 1993
Symptoms
Eating large amounts of food uncontrollably (binging)
Vomiting, using laxatives, or using other methods to
eliminate food (purging)
Excessive concern about body weight
Depression or changes in mood
Irregular menstrual periods
Unusual dental problems, swollen cheeks or glands,
heartburn, or bloating (swelling of the stomach)
Bulimia Nervosa: Warning Signs
 Wrappers/containers indicating consumption of large
amounts of food
 Frequent trips to bathroom after meals
 Signs of vomiting e.g staining of teeth , calluses on hands
 Excessive and rigid exercise routine
 Withdrawal from usual friends / relatives
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.
Health Risks With Bulimia
 Dental problems
 Stomach rupture
 Menstruation
irregularities
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
Unintentional Weight Loss
Cancer (16%-36%)
 weight loss and tumor size not related
 mediated by incr. cytokines incl. TNF-alpha
& IL-6
 decreased calorie intake from anorexia and
symptoms caused directly by the cancer
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GI cancer most common
lung
lymphoma
renal
prostate
Weight Loss
Is Significant
50%–90% of people with cancer experience
weight loss
A weight loss of as little as 5% of body
weight can cause reduced response to
treatment
Weight loss is associated with poor quality of
life and reduced survival
Unintentional Weight Loss
Infection (2-5%)
 HIV
 wt loss due mostly to decr. calorie intake in
contrast w/ cancer where energy
consumption increases
 rapid wt loss (>5% in 6 months) often due to
2’ary infections
 anti-retroviral therapy
 TB
 chronic bacterial, fungal & parasitic
diseases
 lung abscess
Unintentional Weight Loss
 Substance abuse (4%-8%)
----amphetamines & cocaine
 Opiates
 alcoholism
 smoking
 cannabis withdrawal
Unintentional Weight Loss
Medications (~2%)
 bupropion, fluoxetine & other SSRIs initially,
lithium, L-dopa
 metformin, L-thyroxine
 digoxin, aspirin, diuretics, ACEI, Ca channel
blockers
 NSAIDS, bisphosphonates, allopurinol,
colchicine
 anticancer & antiretroviral drugs, opiates
 iron, potassium
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.
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 mellitus
 malabsorption from intestinal autonomic
neuropathy
 Gastroparesis,
 anorexia, depression, pain,
Unintentional Weight Loss
 Chronic Adrenal
insufficiency
 a anorexia,
nausea & weight loss
Unintentional Weight Loss
 Hypercalcemia a, esp. if caused by cancer
 primary hyperparathyroidism are
asymptomatic and do not have weight loss
 hyperadrenergic state among patients with
pheochromocytoma,
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only 5 percent weight loss
Unintentional Weight Loss
GI (6%-19%)
 Loss of appetite in most GI diseases
 dysphagia, early satiety, vomiting &
regurgitation, abdo pain, chronic
inflammation, malabsorption, surgical &
spontaneous fistulas & bypasses, superior
mesenteric artery syndrome
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PUD
IBD (Sharon)
Hepatitis
Celiac disease
What are the common causes of
unintentional weight loss?
 Organic causes (less common)
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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%)
Unintentional Weight Loss
Cardiac (2%-9%) & pulmonary (~6%)
 mechanisms not well understood
 “cardiac cachexia” if severe CHF
 ?disuse muscle atrophy
 TNF-alpha elevation
 Pulmonary weight loss is proportional to
disease severity
 ?disuse muscle atrophy
 TNF-alpha elevation
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
Approach to Weight Loss
Investigations
 individualize based on the history,
physical and your differential
diagnosis (symptom based)
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?
 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?
 Additional tests are ordered as clinically
indicated
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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
Management
 Identify and treat the underlying
cause
 Screen for depression & dementia
 Exercise (physiotherapy referral)
 Nutrition referral & counseling
 Limited evidence & role for
pharmacologic therapy
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
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