UNINTENTIONAL WEIGHT LOSS DR GHOSON Introduction o Always

UNINTENTIONAL WEIGHT LOSS DR. GHOSON

Introduction o Always ask about weight change o Relative change is also important o Significant weight loss-marker of serious illness o Persistence & periodic evaluation to identify the cause - important

Mechanisms of weight loss o Increased energy expenditure o Increased energy loss o Decreased food intake

Introduction o Result of decreased energy intake or increased energy expenditure. o Classified as voluntary or involuntary. o Progressive involuntary weight loss often indicates a serious medical or psychiatric illness. o Voluntary weight loss in overweight or obese o Voluntary weight loss is usually a manifestation of psychiatric disease.

Case o You are referred a 69 F for evaluation of unintentional weight loss. o She has lost 5 kg in the past 6 months, her current weight is 60 kg. n Is her weight loss clinically important? n How common is weight loss in the elderly?

Is her weight loss clinically important? o Definition n Clinically important weight loss can be defined as loss of 5 kg or more than 5% of usual weight over 6 months o Why it’s important! n Unintentional weight loss may reflect disease severity of a chronic illness or a yet undiagnosed illness. n 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 o 9000 adults in (US), 5 percent reported involuntary weight loss of at least 5 percent of their usual body weight during the preceding year o 8 percent reported voluntary weight loss of the same magnitude. o No important differences in weight loss incidence by gender. o Independent predictors of involuntary weight loss were age, smoking, and poor self-reported health. o None of these risk factors was associated with voluntary weight loss o 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? o Prevalence estimates of weight loss are quite variable n 15 -20% elderly patients experience weight loss (defined as loss of 5 kg or 5% body wt over 5 -10 years) n The prevalence can be as high as 27% in highrisk populations such as the frail elderly o The incidence of unintentional weight loss in clinical studies of adults seeking health care is also quite variable n Depending on the setting and definition it varies from 1. 3 to 8%

Unintentional Weight Loss in the Elderly n Weight loss is associated with increased mortality or morbidity or both n 15 -20% prevalence, though estimates vary widely; no gender difference n 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 n Physiologic changes in elderly early satiety and anorexia Decline in taste and smell Reduced efficiency of chewing Slowed gastric emptying Alternations in neuroendocrine axis

Unintentional weight loss can result in:

MORTALITY 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 follow-up period, even among those with obesity.

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

o Now What? n What are the common causes of unintentional weight loss?

What are the common causes of unintentional weight loss? o Causes of unintentional weight loss can classified into 3 broad groups n Organic n Psychosocial n 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) o 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 post-puberty

Physical changes

Psychological changes o o Depressed mood , social withdrawal Loss of interest usual activities Anxiety Fatigue

Anorexia What do counselors look for? – 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 o Females are 10 -20 times more frequently affected than males o 0, 5 -1% of female adolescents, 5% have subclinical forms o 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 1519 – 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 o Ten-year outcome study in the US : o 25% complete recovery o 50% improve , functioning well with residual symptoms o 25% functioning poorly , including 7% mortality rate

Bulimia Nervosa o 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 30 s 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 1 -2% 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 o Wrappers/containers indicating consumption of large amounts of food q Frequent trips to bathroom after meals q Signs of vomiting e. g staining of teeth , calluses on hands q Excessive and rigid exercise routine q 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 o Dental problems o Stomach rupture o Menstruation irregularities

What are the common causes of unintentional weight loss? o Organic Causes - top three n Malignancy (16 -36%) o Usually it’s clear from the history, physical, or routine lab data that malignancy is a potential cause n Gastrointestinal (most common non-malignant organic cause, 6 -19%) o PUD, IBD, dysmotility, hepatobiliary/pancreatic disease, or oral problems n Endocrine (4 -11%) o DM, thyroid disease, and adrenal insufficiency

Unintentional Weight Loss Cancer (16%-36%) o weight loss and tumor size not related o mediated by incr. cytokines incl. TNF-alpha & IL-6 o decreased calorie intake from anorexia and symptoms caused directly by the cancer n n n GI cancer most common lung lymphoma renal prostate

Weight Loss Is Significant o 50%– 90% of people with cancer experience weight loss o. A weight loss of as little as 5% of body weight can cause reduced response to treatment o. Weight loss is associated with poor quality of life and reduced survival

Unintentional Weight Loss Infection (2 -5%) o HIV n wt loss due mostly to decr. calorie intake in contrast w/ cancer where energy consumption increases n rapid wt loss (>5% in 6 months) often due to 2’ary infections n anti-retroviral therapy o TB o chronic bacterial, fungal & parasitic diseases o lung abscess

Unintentional Weight Loss o Substance abuse (4%-8%) ----amphetamines & cocaine o Opiates o alcoholism o smoking o cannabis withdrawal

Unintentional Weight Loss Medications (~2%) o bupropion, fluoxetine & other SSRIs initially, lithium, L-dopa o metformin, L-thyroxine o digoxin, aspirin, diuretics, ACEI, Ca channel blockers o NSAIDS, bisphonates, allopurinol, colchicine o anticancer & antiretroviral drugs, opiates o iron, potassium

Unintentional Weight Loss o 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 n Diabetes Type 1 & 2: a loss in lean body mass , loss of extracellular and cellular water due to the osmotic diuresis from glucosuria. n Uncontrolled diabetes mellitus o malabsorption from intestinal autonomic neuropathy o Gastroparesis, o anorexia, depression, pain,

Unintentional Weight Loss o Chronic Adrenal insufficiency o a anorexia, nausea & weight loss

Unintentional Weight Loss o Hypercalcemia a, esp. if caused by cancer o primary hyperparathyroidism are asymptomatic and do not have weight loss o hyperadrenergic state among patients with pheochromocytoma, only 5 percent weight loss

Unintentional Weight Loss GI (6%-19%) n Loss of appetite in most GI diseases o dysphagia, early satiety, vomiting & regurgitation, abdo pain, chronic inflammation, malabsorption, surgical & spontaneous fistulas & bypasses, superior mesenteric artery syndrome n n PUD IBD (Sharon) Hepatitis Celiac disease

What are the common causes of unintentional weight loss? o Organic causes (less common) n n n 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%) o mechanisms not well understood n “cardiac cachexia” if severe CHF o ? disuse muscle atrophy o TNF-alpha elevation n Pulmonary weight loss is proportional to disease severity o ? disuse muscle atrophy o TNF-alpha elevation

What are the common causes of unintentional weight loss? o Psychosocial Causes n Psychiatric disorder (9 -42%) o Depression n Dementia (2 -5%) n Poor nutritional intake o Due to poverty or inadequate access to meals

What are the common causes of unintentional weight loss? o Psychosocial Causes n Depression and dementia are poorly recognized in clinical practice n All elderly patients with weight loss should undergo screening for o dementia with the MMSE o depression with the Geriatric Depression Scale n 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? o Several key concepts emerge from etiologic studies of unintentional weight loss n Among organic causes cancer is most common n Etiology of weight loss is evident without extensive evaluation in most patients n Psychiatric illness and nondiagnostic evaluations are common

Approach to Weight Loss Investigations o individualize based on the history, physical and your differential diagnosis (symptom based)

What further assessment or investigations are now indicated? o Routine Investigations n n n CBC Biochemistry (lytes, glucose, Ca, PO 4) TSH Liver enzymes Urinalysis CXR

What further assessment or investigations are now indicated? o The diagnostic utility of the medical history and physical examination in identifying the cause of weight loss has not been evaluated o The same can be said about screening investigations o 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? o Additional tests are ordered as clinically indicated n n HIV test SPEP PSA, mammogram GI investigations (if there are symptoms, microcytic anemia, or abnormal liver enzymes) o OGD or colonoscopy plus biopsies o Stool analysis o Celiac serology o Abdominal imaging

Management o o o 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? o Reassess her weight in 3 months n If it remains stable or goes up then further assessment is not necessary n If she is continuing to lose weight then repeat the evaluation process, with emphasis on searching for an organic or psychosocial cause

Summary o Unintentional weight loss is a common concern especially in the elderly o Common causes can be grouped into one of 3 categories: organic, psychosocial, or idiopathic o Psychosocial causes are under appreciated by clinicians o Extensive investigations are usually not necessary