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Chapter 39 • Weight Loss/Gain (Unintentional)
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459
Appetite
Appetite can be suppressed because of the presence of
acute or chronic illness. Cachexia will result from inadequate energy intake and pathological wasting of
muscle or fat tissue. The key symptom in cachexia is
anorexia, or loss of appetite. Psychosocial factors, such
as anxiety or depression, can contribute to a loss of
appetite or lifestyle habits that include skipping meals
or eating foods of poor nutritional value.
Eating Habits/Nutritional Adequacy and Physical Activity
Weight maintenance is a balance of energy expended
and energy consumed. General healthy dietary guidelines can be found in the Dietary Guidelines for Americans (Box 39-1) and on www.choosemyplate.gov. Daily
caloric needs vary by age, gender, pregnancy, and
level of physical activity. Athletes in training may
underestimate their caloric needs (Box 39-2).
Excess intake of fruit juices may decrease a child’s
appetite and cause weight loss. Conversely, excess intake of fruit juices with high caloric content may cause
weight gain.
Breastfeeding
Observing and discussing issues regarding breastfeeding with the mother may reveal important information.
Infants should be breastfed 8 to 12 times in a 24-hour
period. Breastfeeding requires more energy expenditure
from the infant, and occasionally infants fall asleep
while feeding and thus do not receive an adequate
amount of breast milk. Nipple soreness caused by improper positioning and/or poor latching or unlatching
can lead to a diminished milk supply. Maternal hydration is important for adequate milk supply.
Formula-Fed Infant
Investigating what formula the infant is being fed and
how the formula is prepared is important. Formulas
come in powder and liquid forms. Powder formula requires reconstitution with water. Liquid formula comes
in two forms: concentrated (requiring the addition of
water) and ready-to-feed. Reviewing how the formula
is prepared is important to determine whether incorrect
preparation is causing weight loss.
What cues indicate a pathological process?
Key Questions
l
Have you had a fever or any signs of illness?
l
Have you ever been diagnosed with cancer?
l
Have you had a change in urinary or bowel habits?
l
Do you experience fatigue?
l
In a room where others are comfortable, are you
often too cold or too warm?
l
Have you had a change in appetite or thirst?
l
If a child: Has your child’s appetite changed?
l
If a child: Has your child’s activity level changed?
Acute or Chronic Conditions
Fever associated fatigue and lymphadenopathy may
indicate an infection. Chronic conditions, such as
cough, shortness of breath, nausea, vomiting, anemia,
fatigue, weakness, change in moles, pain, abnormal
menstrual bleeding, breast discharge, or headaches,
Box 39-1
• Balance calories with physical activity to manage weight
• Consume more of certain foods and nutrients such as
fruits, vegetables, whole grains, fat-free and low-fat dairy
products, and seafood
• Consume fewer foods with sodium (salt), saturated fats,
trans fats, cholesterol, added sugars, and refined grains
KEY RECOMMENDATIONS FOR SPECIFIC POPULATION GROUPS
• Those who need to lose weight. Aim for a slow, steady
weight loss by decreasing calorie intake while maintaining an adequate nutrient intake and increasing physical
activity.
• Overweight children. Reduce the rate of body weight gain
while allowing growth and development. Consult a health
From US Department of Health and Human Services, US Department of Agriculture: Dietary guidelines for Americans, 2010. Available online at
www.health.gov/dietaryguidelines/2010.asp
Key Recommendations for Maintaining a Healthy Weight
care provider before placing a child on a weight-reducing
diet.
• Pregnant women. Ensure appropriate weight gain as specified by a health care provider.
• Breastfeeding women. Moderate weight reduction is
safe and does not compromise weight gain of the nursing
infant.
• Overweight adults and overweight children with chronic
diseases and/or on medication. Consult a health care
provider about weight loss strategies before starting a
weight-reducing program to ensure appropriate management of other health conditions.
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Chapter 39 • Weight Loss/Gain (Unintentional)
Box 39-2
Engage in regular physical activity and reduce sedentary
activities to promote health, psychological well-being, and
healthy body weight.
• To reduce the risk of chronic disease in adulthood: Engage
in at least 30 minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of
the week.
• For most people, greater health benefits can be obtained
by engaging in physical activity of more vigorous intensity
or longer duration.
• To help manage body weight and prevent gradual, unhealthy body weight gain in adulthood: Engage in approximately 60 minutes of moderate- to vigorous-intensity activity on most days of the week while not exceeding caloric
intake requirements.
• To sustain weight loss in adulthood: Participate in at least
60 to 90 minutes of daily moderate-intensity physical activity while not exceeding caloric intake requirements. Some
people may need to consult with a health care provider
before participating in this level of activity.
From US Department of Health and Human Services, US Department of Agriculture: Dietary guidelines for Americans, 2010. Available online at
www.health.gov/dietaryguidelines/2010.asp.
can contribute to unintentional weight loss. Crohn
disease is an inammatory bowel disease that can be
associated with reduced appetite.
Unintentional weight loss is a red ag for cancer
occurrence or recurrence. Weight loss can occur from
loss of appetite and decreased caloric intake or from
the body’s inability to absorb nutrients because of the
cancer.
Key Recommendations for Physical Activity
Achieve physical fitness by including cardiovascular conditioning, stretching exercises for flexibility, and resistance exercises
or calisthenics for muscle strength and endurance.
KEY RECOMMENDATIONS FOR SPECIFIC POPULATION GROUPS
• Children and adolescents. Engage in at least 60 minutes
of physical activity on most, preferably all, days of the
week.
• Pregnant women. In the absence of medical or obstetric
complications, incorporate 30 minute s or more of moderate-intensity physical activity on most, if not all, days of
the week. Avoid activities with a high risk of fa lling or
abdominal trauma.
• Breastfeeding women. Be aware that neither acute nor
regular exercise adversely affects the mother’s ability to
successfully breastfeed.
• Older adults. Participate in regular physical activity to
reduce functional declines associated with aging and
to achieve the other benefits of physical activity identified
for all adults.
insidious and involves every organ system. A history
will reveal symptoms of lethargy, dry skin, dry and
brittle hair, cold intolerance, deepening of voice, and
facial pufness. Cushing syndrome is a result of prolonged exposure to excessive levels of glucocorticoid
cortisol, which has a catabolic effect on most tissues.
Muscle wasting and weakness are caused by generalized protein catabolism.
Diabetes
Diabetes is a disease caused by insulin secretion deciency and insulin resistance resulting in elevated
blood glucose levels that do not allow nutrients to
enter cells. Along with weight loss, untreated diabetes
is often associated with increased hunger, excessive
thirst, and frequent urination.
Endocrine Disorders
Hyperthyroidism speeds up metabolism, thus burning
more calories. It is the most common thyroid function
disorder. Symptoms include trembling, insomnia, and
hair loss.
In hypothyroidism, thyroid hormones are insufcient. In developing countries, it is most often because
of iodine deciency; in the United States, autoimmune
processes are the major cause. Onset of symptoms is
Appetite/Activity Level Change
A change in an infant or child’s appetite and activity
level is a good indicator of illness. Appetite can decrease
with an inactive lifestyle or the presence of chronic pain,
irritable bowel syndrome, or other conditions that might
be exacerbated by eating.
Are emotional issues contributing to weight loss?
Key Questions
l
Have you recently had a stressful event in your life?
How are you coping?
l
Do you or anyone in your family have a problem
with anxiety or depression?
l
How are you doing in school or at work?
l
If a child: Is the child gaining weight appropriately?
Chapter 39 • Weight Loss/Gain (Unintentional)
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461
Psychosocial Factors
Emotions have a big impact on appetite and eating
behavior. One reaction to extreme stress or depression
may be a loss of appetite. Individuals may have pat-
terns of coping with stress by controlling food intake.
Anorexia nervosa and bulimia are eating disorders
most often diagnosed in young females. With these
two disorders, despite the low or normal weight, the
individual perceives herself or himself as overweight.
Anorexia nervosa carries a high risk of complications
caused by electrolyte imbalances.
Failure to Thrive
Failure to thrive in infants may have a nonorganic
etiology. Causes include but are not limited to care-
taker’s employment status, social isolation, family
stress, substance abuse, postpartum depression, and
poor parenting skills.
What other symptoms might help narrow the
possibilities?
Key Questions
l
When was your last cancer screening?
l
If a child: Has your child recently switched to solid
food?
l
Do you have a family history of cystic brosis (CF)?
l
Does anyone in your household have a history of
tuberculosis?
Cancer Screening
Cancer screening recommendations vary by gender
and age and include colon cancer screening, and for
women, screening mammography for breast cancer
and Pap smears/human papilloma virus (HPV) tests
for cervical cancer screening. Other cancer screening
will depend on associated symptoms and history of
risk factors and may include skin, lung, and for men,
prostate. The United States Preventive Services Task
Force (USPSTF) conducts rigorous assessments of
the scientic evidence for the effectiveness of a range
of clinical preventive services, including screening,
counseling, and preventive medications (www.ahrq.
gov/clinic/uspstx.htm). Lack of regular screening
places patients at an increased risk for undetected
cancer.
Diet Change
Infants who were on formula or breast milk but
switched to solid food may exhibit malabsorption
conditions (such as lactose intolerance or celiac
disease) that can cause weight loss or slowed weight
gain.
Family History
The CF gene is autosomal recessive. Four percent of
white people in the United States are estimated to be
carriers (heterozygous) of the CF gene. CF may present as lack of weight gain between the rst and sixth
months.
Tuberculosis is often associated with reduced appetite and weight loss and is contracted among individuals
who are exposed to an active infection, especially within
a family or household.
What self-treatment was used? Did it help?
Key Questions
l
Are you taking any prescribed or over-the-counter
preparations to lose weight?
l
How would you describe your eating habits and di-
etary practices?
Medication History
There are numerous weight loss drugs on the market
and many of them contain ephedrine, a stimulant that
suppresses appetite. These drugs can be associated
with cardiac arrhythmia and blood pressure elevation.
In general, drugs to lose weight are not commonly
prescribed but are readily available over the counter.
Individuals may use fasting or purging as a method of
rapid weight loss; fasting is also often done as a religious or spiritual practice.
Some drugs cause an altered taste sensation and
decreased appetite. Maternal ingestion of drugs while
nursing may affect breast milk supply. Dopamine
agonists, such as cabergoline, reduce prolactin and
are sometimes used therapeutically to stop lactation.
Dopamine antagonists, such as metoclopramide and
most antipsychotics, may increase prolactin and milk
production. Other drugs that have been associated
with hyperprolactinemia include selective serotonin
reuptake inhibitors and opioids.
How serious is this situation? Is this a recent change?
Key Questions
l
How long have you been concerned about your
weight loss?
l
Is anyone else concerned about your weight loss?
l
What is your ideal or usual weight?
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Chapter 39 • Weight Loss/Gain (Unintentional)
Validate Weight Change
A careful history may document changes in activity
lightweight. Note if the person was weighed with or
without shoes.
level or a precipitating incident before weight loss was
noticed as a problem.
Concern About Weight Loss
Anorexic patients do not believe they have a weight
loss problem and have a morbid fear of weight gain.
Often family members or friends become concerned
and refer the patient to be evaluated.
Ideal or Usual Weight
Normal or ideal weight for age and gender can be
checked against actuarial tables, such as the 1999 Metropolitan Height and Weight Tables for Men and
Women (http://www.bcbst.com/mpmanual/hw.htm).
Continued unintended weight loss noted for more than
6 months should be evaluated. Weight can be veried
by using a reliable weight scale. Clothing should be
Table 39-1
The estimates are rounded to the nearest 200 calories. An individual’s calorie needs may be higher or lower than these
average estimates.
SEX AGE (YEARS) SEDENTARY MODERATELY ACTIVE ACTIVE
Child 2-3 1000 1000-1400
Female 4-8 1200 1400-1600 1400-1800
Male 4-8 1400 1400-1600 1600-2000
From US Department of Health and Human Services, US Department of Agriculture: Dietary guidelines for Americans, 2010. Available online at
www.health.gov/dietaryguidelines/2010.asp.
*
Based on Estimated Energy Requirements (EER) from the Institute of Medicine Dietary Reference Intakes Macronutrients Report, 2002, calculated
by gender, age, and activity level for reference-sized individuals. “Reference size,” as determined by the Institute of Medicine, is based on median
height and weight for ages up to age 18 years and median height and weight for that height to give a BMI of 21.5 for adult females and 22.5 for
adult males.
†
Sedentary means a lifestyle that includes only light physical activity associated with typical day-to-day life.
‡
Moderately active means a lifestyle that includes physical activity equivalent to walking about 1.5 to 3 miles per day at 3 to 4 miles per hour, in
addition to the light physical activity associated with typical day-to-day life.
§
Active means a lifestyle that includes physical activity equivalent to walking more than 3 miles/day at 3 to 4 miles/hr, in addition to the light physical
activity associated with typical day-to-day life.
The calorie ranges shown are to accommodate needs of different ages within the group. For children and adolescents, more calories are needed at
older ages. For adults, fewer calories are needed at older ages.
Estimated Calorie Needs/Day (in kilocalories) by Age, Gender, and Physical
Activity Level
511
511
*
9-13 1600 1600-2000 1800-2200
14-18 1800 2000 2400
19-30 2000 2000-2200 2400
31-50 1800 2000 2200
1600 1800 2000-2200
9-13 1800 1800-2200 2000-2600
14-18 2200 2400-2800 2800-3200
19-30 2400 2600-2800 3000
31-50 2200 2400-2800 2800-3200
2000 2200-2400 2400-2800
Unexplained Weight Gain
Is the weight gain explained by diet and exercise habits?
Key Questions
l
Can you describe what you eat in a typical day?
l
Has your eating pattern changed?
l
Can you describe your level of physical activity?
Balance of Energy Intake and Expenditure
Maintaining an ideal body weight depends on achieving a balance of energy intake and energy expenditure
(Table 39-1). Calorie intake can exceed expenditure
when a person consumes large quantities of food and
food with high calorie content but gets little aerobic
exercise. Factors that contribute to inactivity are sedentary jobs, television watching, and reliance on the
ACTIVITY LEVEL
†,‡,§
e
1000-1400
automobile. Environmental and genetic factors con-
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tribute to a small percentage of cases of obesity.
Chapter 39 • Weight Loss/Gain (Unintentional)
l
Have you noticed any other symptoms or changes in
463
your appearance?
Is the weight gain associated with aging?
Key Questions
l
What is your age?
l
For females: When was your last menstrual period?
Aging
Normal aging is associated with slower metabolism
and reduced energy requirements.
Menopause
Menopause is dened as the absence of a menstrual
period for 1 year. About 90% of menopausal women
gain some weight between the ages of 35 and 55 with
an average age of 51 years. Hormones have a direct
impact on appetite, metabolism, and fat storage. Lower
levels of progesterone, androgen, and testosterone contribute to lower metabolism and weight gain.
Could weight gain be related to other behaviors?
Key Questions
l
How much alcohol do you consume in a week or a
day?
l
Do you smoke? If so, how much do you smoke?
How long have you smoked? At what age did you
start smoking? Have you recently quit?
l
Do you take any medications?
Alcohol and Smoking
Drinking multiple glasses or bottles of alcohol daily or
weekly will increase calorie intake. Many adults will
gain 5 to 10 lb in the rst few months after quitting
smoking and report an increased appetite. Adults at
greatest risk for excessive weight gain with smoking
cessation are those who smoke more and are less
physically active.
Medications
Corticosteroids, lithium, tranquilizers, phenothiazines,
and tricyclic antidepressants may lead to uid retention.
Could this be caused by an endocrine disorder?
Key Questions
l
Has the weight gain been sudden or gradual?
l
How much do you weigh now compared to a year
ago?
Acuity of Weight Gain
Women who are premenopausal may note gradual
weight gain over a few years. Some medications, such
as b-blockers, corticosteroids, and antidepressants, are
associated with weight gain. Edema from congestive
heart failure or renal failure can cause weight gain in a
few days or weeks.
Endocrine Symptoms
Hypothyroidism is associated with fatigue, constipation,
and inability to tolerate cold temperatures. Cushing
syndrome is associated with truncal weight gain, moon
facies, and a “buffalo hump.” Both of these disorders
may develop over an extended period of time. Polycystic
ovary syndrome is associated with obesity and hirsutism.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
A thorough health history and general physical examination, including screening for psychosocial causes
(see Chapter 4), will help to identify behavioral risk
factors or a pattern of associated symptoms that
suggest a systemic disorder.
Note General Appearance
Observe the patient entering the room. Especially note
the t of clothing as well as general hygiene and signs
of stress or anxiety.
When examining an infant, observe interaction with
the caregiver. Failure-to-thrive infants may avoid eye
contact, may not smile or make sounds, and have poor
interaction with their environment. The infant may also
prefer not to be cuddled and be difcult to comfort and
may appear withdrawn even from the caregiver.
Take Vital Signs
Vital signs will provide information on cardiovascular
and respiratory function. Height and weight can be
compared to actuarial tables to see norms for weight
by age and gender. Calculate BMI. Bradycardia may
indicate hypothyroidism; tachycardia may indicate
anemia, dehydration, or hyperthyroidism. Fever may
indicate infection.
Weigh and Measure Newborn
A decrease in weight of more than 8% necessitates
follow up within 48 hours, and a bilirubin level should
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Chapter 39 • Weight Loss/Gain (Unintentional)
EVIDENCE-BASED PRACTICE
Does Screening for Obesity in Adults Have an Impact
on Long-Term Health Outcomes?
The United States Preventive Services Task Force (USPSTF)
found adequate evidence that intensive, multicomponent
behavioral interventions for obese adults can lead to an average weight loss of 4 to 7 kg (8.8 to 15.4 lb) in the first year
with 12 to 26 treatment sessions compared with little or no
weight loss in a control group. These interventions also improve glucose tolerance and other physiological risk factors
for cardiovascular disease. The USPSTF found inadequate
direct evidence about the effectiveness of these interventions
on long-term health outcomes (e.g., death, cardiovascular
Data from Moyer VA, U.S. Preventive Services Task Force: Screening for and management of obesity in adults: US Preventive Services Task Force
recommendation statement, Ann Intern Med 157:373, 2012.
be drawn to assess for hyperbilirubinemia. A loss of
more than 10% of birth weight warrants careful
assessment of possible causes and consideration of
hospital admission.
Assess Mental Status
The major cognitive changes to detect as related to
weight loss or gain are dementia and depression (see
Chapter 9). Dementia can be assessed using the Mini
Mental State Examination (see Figure 9-1) and distinguished from depression (see Box 9-1). Screen for the
presence of an eating disorder.
Conduct a Comprehensive Physical Examination
Assess the Skin
Examine the skin for intactness, turgor, and presence
of lesions to determine hydration status and overall
nutrition status. Hypothyroidism is associated with
dry, aky skin; skin darkening occurs with Addison
disease.
Assess the Heart
Palpate the anterior thorax for the point of maximal
impulse, lifts, and heaves. Auscultate for adventitious
sounds (see Chapter 8).
Examine the Head and Neck
Assess the head and neck for presence of lymphadenopathy. Moon facies, also called moon face, indicates
Cushing syndrome. Palpate the thyroid for masses or
asymmetry.
Assess the condition of the teeth and gums. Test the
patient’s ability to swallow using water or test for the
gag reex. Patients with diabetes may have xanthomas
associated with hyperlipidemia.
disease, and hospitalizations). The USPSTF concluded with
moderate certainty that screening for obesity in adults has
a moderate net benefit. There is also benefit to offering or
referring obese adults to intensive behavioral interventions to
improve weight status and other risk factors for important
health outcomes. The USPSTF recommends that clinicians
screen adults for obesity. Clinicians should offer or refer
patients with a body mass index 30 kg/m2 to intensive,
multicomponent behavioral interventions. This is a B recommendation.
Examine the Abdomen
Observe for contour. Patients with diabetes tend to
have truncal obesity. Redistribution of fat in older patients may also cause them to have truncal obesity.
Palpate for tenderness or lumps, auscultate for bowel
sounds, and check for rebound tenderness. Patients
with malabsorption may have ascites.
Examine the Extremities
Conduct a musculoskeletal exam to assess strength,
mobility, and balance (see Chapters 22 and 23). Assess
for loss of muscle mass and subcutaneous fat associated with cachexia, malabsorption, and aging. Patients
with hypothyroidism may have generalized edema and
delayed recovery of deep tendon reexes. Patients with
hyperthyroidism may have overly brisk deep tendon
reexes. Patients with diabetes may have peripheral
neuropathy.
Complete Blood Count With Indices and
Differential
A complete blood count (CBC) with indices will provide
information about the degree and cause of anemia; microcytic hypochromic anemia reects chronic blood loss
and normocytic normochromic anemia suggests acute
blood loss. An elevated white blood cell (WBC) count
indicates the presence of inammation or infection.
Fasting Blood Glucose
A fasting blood glucose (FBG) is a blood specimen
taken at least 8 hours after a meal. The reference value
for FBG is below 100 mg/dL of glucose; a FBG of 100
to 125 mg/dL indicates prediabetes. If a random blood
glucose is obtained within 2 hours after a meal, the
reference value is #140 mg/dL.
Chapter 39 • Weight Loss/Gain (Unintentional)
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465
Glycosylated Hemoglobin
Glycosylated hemoglobin (A1c) reects the average
blood glucose over a 3-month period. An A1c below
5.7% is normal, between 5.7 to 6.4% indicates predia-
betes, and 6.5% or above is diagnostic for diabetes.
The reference value is at or below 7% for someone
with diagnosed diabetes. The A1c result is not depen-
dent on when the most recent meal was consumed, but
the results may be affected by the presence of anemia
or sickle cell disease. The A1c result may be a poor re-
ection of blood glucose when severe anemia or sickle
cell disease is present.
Thyroid-Stimulating Hormone
Hypothyroidism is characterized by a decient thyroid
hormone production by the thyroid gland, which can
be severe or moderate. Severe decit of thyroid hor-
mones denes overt hypothyroidism. The moderate
form, called subclinical hypothyroidism, seldom has
signs and symptoms and is dened by an elevated se-
rum thyroid-stimulating hormone (TSH) concentration
and within-normal-range thyroid hormone levels. A
low or undetectable level of TSH indicates hyperthy-
roidism.
Bilirubin
Bilirubin values are usually reported as two fractions:
conjugated (direct) and unconjugated (indirect). Conju-
gated hyperbilirubinemia is present if more than 50% of
elevated total bilirubin is the conjugated form. The ref-
erence value for total conjugated bilirubin in newborns
is less than 2 mg/dL; the level peaks at 12.9 mg/dL at 3
to 4 days of life and then decreases. A tool designed to
help clinicians assess the risks of the development of
hyperbilirubinemia in newborns over 35 weeks’ gesta-
tional age can be found at www.bilitool.com. CF can
lead to liver failure and hyperbilirubinemia.
Total Serum Protein
A total serum protein measures the amount of total
protein and albumin (from the liver) and globulin
(from the liver and immune system) in the blood.
Normally there is more albumin than globulin with
a ratio of greater than 1. Albumin checks kidney func-
tion and reects dietary protein. Elevated globulin may
indicate infection.
Sweat Chloride Test
The quantitative pilocarpine iontophoresis test mea-
sures the amount of chloride and sodium in the sweat
of patients with CF. Normal sweat contains less than
60 mEq/L of chloride and sodium. Two tests on different occasions are needed for accurate diagnosis of CF.
Urinalysis
The extent of diagnostic investigation of urine will
depend on history and physical examination ndings.
Dipstick urinalysis can point out infection, proteinuria,
and glycosuria (see Chapter 34).
Fecal Occult Blood Testing
The fecal occult blood test is an initial screening
method to detect GI bleeding (see Chapter 29).
Chest Radiograph
A chest x-ray study can reveal the presence of consolidation, lung lesions, and heart contour.
Tests of the Gastrointestinal Tract
A barium upper GI series is used to examine the upper
GI region, but small lesions may not be detected. Any
abnormality needs to be evaluated by endoscopy. The
lower GI tract is evaluated using sigmoidoscopy or
colonoscopy. A colonoscopy will detect the presence
of polyps and lesions along the entire large intestine
(see Chapter 3).
Computed Tomography
Computed tomography (CT) scanning can be done on
different body regions. Abdominal CT examines the
uterus, pancreas, GI tract, and other abdominal organs.
Mammography
Screening mammograms consist of two views, craniocaudal and medial lateral oblique, to detect nonpalpable breast lesions. Compare results to previous screening mammograms (see Chapter 6).
Cervical Cancer Screening
Screening includes the Pap test in women aged 21 to
65 years and also HPV testing for women aged 30 to
65 years. The Pap test is designed to detect cancer cells
in the cervix and vagina. HPV testing detects high-risk
HPV strains (16 and 18) associated with cervical cancer.
Metabolic Rate
Estimated energy needs should be based on resting or
basal metabolic rate (BMR). BMR decreases with age
and loss of lean body mass. An equation using actual
weight, height, gender, and age is the most accurate for
estimating BMR and calculating daily caloric requirements (Box 39-3).
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Chapter 39 • Weight Loss/Gain (Unintentional)
Box 39-3
WOMEN
BMR 5 65.5 1 (4.35 3 Weight in pounds) 1 (4.7 3 Height
in inches) 2 (4.7 3 Age in years)
Basal Metabolic Rate (BMR) Formula
DIFFERENTIAL DIAGNOSIS
Unintentional Weight Loss
Cancer
Cancer alters the body’s appetite signals and metabolism resulting in cachexia, a condition in which body
fat stores are depleted and muscle mass decreases. The
most common malignancies that cause weight loss are
GI, lung, hematological, and musculoskeletal. As many
as 40% of people diagnosed with cancer reported unexplained weight loss at the time of diagnosis. Some
people notice weight loss despite a good appetite. Others lose their appetite and may even become nauseated
by food or have difculty swallowing.
Nutritional Status
Assess nutritional status by obtaining a history of dietary
habits and physical activity patterns, as well as anthropometric measures (such as height and weight to calculate
BMI and waist and hip circumference to determine
distribution of body fat). One 24-hour or two consecutive
days of 24-hour recall are reliable methods to assess
dietary intake. Poor or inadequate nutrition in severe
forms is most often found in developing countries and is
manifested in two forms: kwashiorkor, which is a protein
deciency, and marasmus, which is caused by inadequate
food intake. Weight loss not explained by dietary intake
is most likely caused by systemic disease.
Endocrine Disorders
Diabetes mellitus. More than 90% of all cases of
diabetes are type 2. Type 1 diabetes is more often associated with weight loss despite increased appetite.
Persons with type 2 diabetes may experience increased thirst and urinary frequency but often are asymptomatic. Some symptoms, such as blurred vision
or peripheral neuropathy, may reect long-term manifestations of an undiagnosed disease. Despite weight
loss, patients tend to exhibit central obesity.
Hyperthyroidism. Patients with hyperthyroidism
may report a variety of signs and symptoms such as
palpitations, nervousness, emotional lability, fatigue,
muscle weakness, weight loss despite good appetite,
hyperdefecation, heat intolerance, menstrual changes
MEN
BMR 5 66 1 (6.23 3 Weight in pounds) 1 (12.7 3 Height
in inches) 2 (6.8 3 Age in years)
(oligomenorrhea), increased appetite, insomnia, and
tremors. On physical examination, exophthalmos,
warm skin, onycholysis, increased sweating, and thinning hair may be evident. Patients may have localized
myxedema (edematous skin thickening) of legs (pretibial) or dorsa of feet. The thyroid may be enlarged
and a bruit may be present. Deep tendon reexes
(DTRs) may be brisk. High fever, congestive heart
failure, and mental status changes suggest thyroid
storm. TSH level will be low or undetectable.
Addison disease. Addison disease occurs when the
adrenal glands do not produce enough of their
hormones. Associated symptoms may include changes
in blood pressure or heart rate, darkening of the skin,
weakness, salt craving, and loss of appetite.
Malabsorption
In malabsorption, the absorption and digestion of nutrients are disrupted. The disorder is caused by an insufciency of a variety of digestive enzymes. In celiac disease,
there is an immunological response to gluten. The degree
of weight loss varies and is accompanied by chronic
diarrhea and growth retardation. Patients exhibit muscle
wasting and loss of subcutaneous fat. In the presence of
severe hypoproteinemia, ascites may be present.
Anorexia Nervosa
Anorexia most often affects young females who, despite
weight loss, have a self-image of being overweight and
an intense fear of gaining weight. Diagnosis is based on
a body weight 15% below what is expected, a distorted
body image, and the absence of at least three menstrual
periods. Examination demonstrates loss of body fat and
dry, scaly skin.
Depression or Anxiety
Mood regulation through eating is a way some individuals cope with depression or anxiety (see Chapter 4).
Major depression is diagnosed by the presence of a
depressed mood or loss of interest or pleasure in usual
activities. Bipolar disorder involves episodes of mania
or hypomania, often followed by depression. In mania,
the patient experiences an elevated or irritable mood,
often described as a “high” (see Chapter 4).
Chapter 39 • Weight Loss/Gain (Unintentional)
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Cognitive Impairment
Dementia or compromised cognitive function can disrupt
normal self-regulation of appetite and hunger (see Chapter
9). Dementia is a nonspecic syndrome in which affected
areas of cognition may include memory, attention,
language, and problem solving. When it occurs early in
life it is labeled as organic brain syndrome. In the elderly,
dementia has a rate of memory and cognitive loss that
exceeds that of normal aging (see Chapter 9).
Psychosocial Factors (Alcohol Use, Social Isolation,
Economic Status)
Excessive alcohol intake may reduce appetite, which
can lead to poor nutrition. Individuals are generally
social beings and social isolation may reduce any mo-
tivation to prepare balanced meals or to eat when
alone. Older adults and young families may have nan-
cial constraints in purchasing healthy foods, because
fresh fruits and vegetables cost more than fast foods
and snack foods (see Chapter 4).
Human Immunodeficiency Virus/Acquired Immune
Deficiency Syndrome
Acquired immune deciency syndrome is a disease of the
immune system caused by the human immunodeciency
virus (HIV). This condition progressively reduces the
effectiveness of the immune system and leaves individuals
susceptible to opportunistic infections and tumors. Risk
factors for infection include multiple sexual partners,
unprotected sex, and intravenous drug use. HIV is trans-
mitted through direct contact of a mucous membrane or
the bloodstream with a bodily uid containing HIV, such
as blood, semen, vaginal uid, preseminal uid, and breast
milk. Persons with HIV infection develop opportunistic
infections because of their impaired immune response, and
they often have systemic symptoms of infection such as
fevers, sweats (particularly at night), swollen glands,
chills, weakness, and weight loss.
Gastroesophageal Reflux in Infants
Regurgitation is commonly seen in newborns and young
infants while feeding. Immature upper gastrointestinal
motility is thought to be the cause. Excessive reux may
cause caloric deprivation resulting in weight loss.
Crohn Disease
Crohn disease is an inammatory bowel disease that
presents with abdominal cramping, rectal bleeding,
and bloody diarrhea. Weight loss is common because
of malabsorption. There is a genetic link in families
with a two- to fourfold increase in risk when a rstdegree relative has the disease. The disease can affect
any part of the tract from the mouth to the anus. Disease affecting the small bowel affects nutritional status
and weight loss.
Tuberculosis
Tuberculosis is caused by Mycobacterium tuberculosis
and is spread by droplets through the respiratory tract
(see Chapter 11). Weight loss is a common symptom of
tuberculosis. Diagnosis is based on a positive sputum
culture.
Cystic Fibrosis
CF is an exocrine gland disorder that produces mucus blockage in major organs and is associated with
an autosomal recessive trait (see Chapter 11). Growth
retardation and weight loss are common symptoms
of CF.
Unintentional Weight Gain
Energy Balance
A 24-hour food intake history is the rst approach
to assessing nutritional and caloric intake. A history
of physical activity or energy expenditure is done to
assess the balance between calories consumed and
energy expended.
Aging
In women, cessation of estrogen secretion during
menopause is associated with lower levels of progesterone, androgen, and testosterone, which can lead to
weight gain and greater truncal fat deposition.
Endocrine Disorders
Hypothyroidism. Hypothyroidism (myxedema) is
associated with weight gain and symptoms of cold
intolerance, constipation, hoarseness, depression, and
fatigue. Physical examination reveals bradycardia, dry
skin, and delayed recovery of deep tendon reexes. In
overt hypothyroidism the TSH is elevated and thyroid
hormone level is low.
Cushing syndrome. Cushing syndrome is associated
with weight gain. Diagnosis is made through the presence
of associated symptoms, glucose tolerance tests, and
the dexamethasone suppression test. Cushing syndrome
is associated with central truncal obesity, moon faces,
supraclavicular fat pads and thin extremities.
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Chapter 39 • Weight Loss/Gain (Unintentional)
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Unintentional Weight Loss/Gain
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
WEIGHT LOSS
Cancer
Undernutrition Poor calorie/nutrient intake,
Diabetes mellitus Polyuria, polyphagia, polydipsia Truncal obesity; xanthomas FBG, hemoglobin A1c,
Gastroesophageal reflux
(infants)
Addison disease Salt craving, fatigue Darkening of the skin Serum electrolytes, 24-hr
Hyperthyroidism Tachycardia, heat intolerance,
Malabsorption Intolerance to gluten; chronic
Depression or anxiety Loss of appetite and/or interest
Cognitive impairment Disorientation to person,
Anorexia nervosa Female to male ratio 10:1,
Psychosocial factors Alcohol consumption, social
HIV/AIDS Fever, fatigue, multiple sexual
Crohn disease Weight loss, fever, diarrhea,
Cystic fibrosis Weight loss, cough, chronic di-
Nonorganic failure
to thrive
Tuberculosis (TB) Contact with person who has
Loss of appetite None or may look cachectic Diagnostic imaging studies,
Loss of body mass Total serum protein
error in formula preparation
History of regurgitation None Upper GI, barium swallow
Exophthalmos, warm skin,
sweating
diarrhea, growth retardation
in food
time, or place
perfectionist, high achiever,
amenorrhea
isolation, financial resources
partners, unprotected sex,
IV drug use
family history
arrhea, positive family history
Weight loss, maternal isola-
tion, maternal depression
TB, travel to endemic area,
HIV
onycholysis, thinning hair,
pretibial myxedema, enlarged
thyroid, brisk DTRs
Muscle wasting, loss of subcuta-
neous fat; may have ascites
None or may have poor personal
hygiene
None or loss of body mass;
poor personal hygiene
Cachexia, hair loss, dry skin,
orthostatic hypotension
None or poor personal hygiene
with chronic alcoholism
Redness or swelling of tissues
or lymph nodes
Perirectal fissure, anal skin tag CBC, colonoscopy, barium
Digital clubbing, growth retarda-
tion, weight loss
Decreased skin fold thickness,
decrease subcutaneous fat
Cough, weight loss PPD, HIV, chest x-ray
CT, MRI, x-ray, CBC
glucose tolerance test
urine for aldosterone
TSH, T
4
Colonoscopy, stool
culture, fecal fat
Thyroid function tests,
refer for psychological
evaluation
MMSE
Thyroid function tests,
serum electrolytes
Liver function tests
Blood or tissue
culture, CBC
enema, small bowel
follow-through
Sweat test
Normal laboratory results
in 98%
WEIGHT GAIN
Intake/energy balance Excessive calorie intake;
Aging Menopause history;
Hypothyroidism Cold intolerance, weight gain,
Cushing syndrome Thirst, polyuria Moon facies, truncal obesity,
CBC, Complete blood count; CT, computed tomography; DTR, deep tendon reflex; FBG, fasting blood glucose; GI, gastrointestinal; HIV, human
immunodeficiency virus; IV, intravenous; MMSE, Mini Mental State Examination; MRI, magnetic resonance imaging; PPD, purified protein
derivative; T4, thyroxine; TB, tuberculosis; TSH, thyroid-stimulating hormone.
inactivity
metabolism change
constipation; medication
history
Generalized excess of
subcutaneous fat
Truncal obesity; loss of peripheral
subcutaneous fat; loss of
muscle mass
Bradycardia, dry skin, general-
ized edema, delayed recovery
of DTRs
thin extremities
None
Serum estrogen level
TSH, T
4
FBG, dexamethasone
suppression test
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