II. Epidemiology: Incidence

III. Definition

  1. Unintentional Weight Loss of >5% of body weight within 6-12 months

V. Precautions

  1. Substantial weight loss should not be attributed to aging alone
    1. See Body Composition Changes with Aging

VI. History

  1. How much weight loss over how much time?
    1. Patients down play weight changes
    2. Clothing or belt size changes
    3. Impressions of friends and family on weight change
  2. Associated Gastrointestinal Symptoms
    1. Nausea or Vomiting
    2. Dysphagia
      1. See Dysphagia
      2. Poorly fitting dentures
      3. Poor Dentition (e.g. Dental Caries)
      4. Esophageal Stricture
    3. Chronic Diarrhea
      1. Infectious Diarrhea
      2. Inflammatory Bowel Disease
      3. Malabsorption (e.g. Celiac Sprue)
    4. Abdominal Pain
      1. Peptic Ulcer Disease
      2. Biliary Colic, Cholecystitis or Cholelithiasis
      3. Mesenteric Ischemia
      4. Small Bowel Obstruction
      5. Inflammatory Bowel Disease
  3. Associated Symptoms
    1. Fever, Fatigue or weakness
      1. Malignancy
      2. Infection
      3. Autoimmune disorder
      4. Diabetes Mellitus
      5. Hyperthyroidism
      6. Underlying neuromuscular condition
      7. Alcohol or Drug Abuse
    2. Dyspnea or exertional Fatigue
      1. Congestive Heart Failure
      2. Lung infection
      3. Chronic Obstructive Lung Disease
      4. Anemia
    3. Preoccupation with thinness
      1. Anorexia Nervosa
  4. Dietary history
    1. See Nutritional Health Checklist
    2. Are meals skipped?
    3. Does the patient need help preparing meals?
    4. Are meals well balanced (Food Pyramid)?
    5. Are any Nutritional Supplements used?
    6. Is patient following any dietary restrictions?
  5. Secondary cause history
    1. Medication and substance use
      1. See Unintentional Weight Loss due to Medications
      2. See Polypharmacy
      3. Over-the-counter medications or herbal supplement use?
      4. Is there concurrent drug or Alcohol use?
    2. Food is not appealing
      1. Malignancy
      2. Medication adverse effects
      3. Major Depression
    3. Altered Taste Sensation (Dysgeusia)
      1. Medication adverse effects
      2. Acute Hepatitis or Chronic Liver Disease
      3. Sinusitis
      4. Vitamin B Deficiency
      5. Zinc Deficiency
      6. Mental health concerns
    4. Mechanical problems (affects chewing and swallowing)
      1. See Dysphagia
      2. See Dyspnea
      3. Poorly fitting Dentures
      4. Painful Oral Lesions (e.g. Candidiasis, Gingivitis)
    5. Weight loss despite increased appetite
      1. Hyperthyroidism
      2. Diabetes Mellitus
      3. Celiac Sprue
      4. Pancreatic Insufficiency
    6. Significant comorbidity
      1. See Unintentional Weight Loss Causes
      2. See Dementia Related Malnutrition
      3. See Malnutrition Following ICU Admission
      4. See Cachexia in Cancer
      5. HIV Infection or AIDS

VII. Exam

  1. Record accurate weights on same scale at every visit
    1. Unexplained weight loss >5% should be investigated
    2. Anticipated time for 15% weight loss
      1. Complete starvation: 15% of weight lost in 3 weeks
      2. Half of normal food intake: 3 months
      3. Half food intake and comorbid conditions: 3 weeks
  2. Vital Sign clues
    1. Fever
    2. Tachycardia
  3. Body Mass Index (BMI) predicts mortality in elderly
    1. Women: BMI <22 kg/m2 predicts increased mortality
    2. Men: BMI <23.5 kg/m2 predicts increased mortality
    3. Calle (1999) N Engl J Med 341:1097-105 [PubMed]
  4. Head and neck changes
    1. Dentition
    2. Glossitis
    3. Thyromegaly
  5. Other examination focus areas
    1. Loss of soft tissue mass in face and extremities
    2. Abdominal masses
    3. Lymphadenopathy
    4. Peripheral Neuropathy

VIII. Labs: Approach

  1. Start with basic lab evaluation
    1. Complete Blood Count
    2. Comprehensive Metabolic Panel
    3. Urinalysis
    4. Thyroid Stimulating Hormone (TSH)
    5. Fecal Occult Blood Testing
    6. Serum Lactate Dehydrogenase (LDH)
    7. Erythrocyte Sedimentation Rate (ESR)
    8. C-Reactive Protein (CRP)
  2. Lab testing should be directed by history and physical
    1. See below for potentially indicated labs

IX. Labs: As directed by history and physical

  1. Stool studies
    1. Fecal Occult Blood (3 samples)
    2. Stool for Ova and Parasites
  2. Complete Blood Count
    1. White Blood Cell Count with differential
    2. Hemoglobin
  3. Acute phase reactants
    1. Erythrocyte Sedimentation Rate
    2. C-Reactive Protein
  4. Endocrine tests
    1. Thyroid Stimulating Hormone (TSH)
    2. Serum Testosterone in men
  5. Comprehensive Metabolic Panel
    1. Serum Glucose
    2. Electrolytes
    3. Renal Function tests
    4. Liver Function Tests
    5. Serum Lactate Dehydrogenase
  6. Infectious disease
    1. Blood Culture (if febrile)
    2. Tuberculin Skin Test (PPD)
    3. HIV Test
    4. Urinalysis
    5. Rapid Plasma Reagin (RPR)
  7. Malnutrition Assessment
    1. See Lab Markers of Malnutrition
  8. Malabsorption
    1. Fecal fat (sudan stain)
    2. Serum carotene
    3. Serum Folic Acid
    4. Celiac Sprue serologies (IgA Tissue Transglutaminase or TTG)

X. Imaging

  1. Chest XRay
  2. Abdominal Ultrasound
  3. Mammogram
  4. Screening with CT Scan not recommended (low yield)

XI. Diagnostics: Testing to consider

  1. Upper gastrointestinal series or Upper Endoscopy
  2. Flexible Sigmoidoscopy or Colonoscopy

XIII. Management: Empiric

  1. Identify underlying cause
    1. Evaluation for secondary cause may stop after initial tests if no obvious etiologies are identified
    2. Empiric management with reevaluation at 3-6 month intervals is recommended approach
      1. At serial evaluations, additional testing should be directed by interval history
  2. Referrals
    1. Dietician
    2. Speech Therapy (swallowing evaluation)
    3. Social services
  3. General Measures
    1. Increase meal frequency with manageable servings
    2. Consider flavor enhancers (indicated in Hyposmia)
      1. Example: Ham, bacon or roast beef flavors sprinkled on food
    3. Eliminate or reduce dietary restrictions
    4. Consider Meals on Wheels or senior dining facility
    5. Choose foods with high calorie density
    6. Consider liquid oral dietary supplements (e.g. Ensure)
      1. Give 2 hours before a scheduled meal
      2. Should be an adjunct to meals (not a meal replacement)
    7. Correct ill fitting dentures
    8. Encourage Physical Activity
  4. Medications
    1. Treat Major Depression: SSRI
      1. Mirtazapine (Remeron)
        1. Risk of Dizziness, Orthostatic Hypotension and fall risk
        2. May be preferred SSRI in Failure to Thrive
        3. Raji (2001) Ann Pharmacother 35:1024-7 [PubMed]
      2. Fluoxetine (Prozac)
      3. Sertraline (Zoloft)
    2. Cannabinoid: Dronabinol (Marinol)
      1. Adverse effects: sedation and confusion
  5. Medications that are no longer recommended due to risks outweighing efficacy
    1. Growth Hormone
      1. Increased mortality risk
    2. Megestrol (Megace)
      1. Typical dose: 320 mg to 800 mg PO qd
      2. Adverse effects: edema, Constipation and Delirium; thrombosis risk
      3. Low efficacy in appetite stimulation outside of Cachexia in AIDS and cancer

XIV. Complications: Weight loss more than 10-20% below normal weight

  1. Increased mortality approaches 16%
    1. Sullivan (1991) Am J Clin Nutr 53:599-605 [PubMed]
  2. Overall increase in morbidity
    1. Weakness or Fatigue
    2. Muscle wasting
    3. Immunosuppression
    4. Skin breakdown
    5. Mood changes (Apathy, Irritability)
    6. Hip Fracture (women)

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Ontology: Anorexia (C0003123)

Definition (MSHCZE) nechutenství - příznak, který může mít řadu příčin, vč. vlivu některých léků. Běžně vzniká i u horečnatých infekcí, ale může být též příznakem vážnějšího onemocnění. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) Loss of appetite.
Definition (NCI_NCI-GLOSS) An abnormal loss of the appetite for food. Anorexia can be caused by cancer, AIDS, a mental disorder (i.e., anorexia nervosa), or other diseases.
Definition (NCI_CTCAE) A disorder characterized by a loss of appetite.
Definition (CSP) clinical manifestation consisting of a physiopathological lack or loss of appetite accompanied by an aversion to food and the inability to eat.
Definition (MSH) The lack or loss of APPETITE accompanied by an aversion to food and the inability to eat. It is the defining characteristic of the disorder ANOREXIA NERVOSA.
Concepts Disease or Syndrome (T047)
MSH D000855
ICD9 783.0
ICD10 R63.0
SnomedCT 206915006, 206917003, 158272007, 158268008, 79890006
English Anorexias, ANOREXIA, APPETITE ABSENT, APPETITE IMPAIRED, APPETITE LOST, Anorexia NOS, Anorexia, [D]Anorexia (context-dependent category), [D]Anorexia NOS (context-dependent category), [D]Anorexia, [D]Anorexia NOS, Anorectic, Loss of appetite, Anorexia [Disease/Finding], no appetite, lack of appetite, loss of appetite, anorectic, appetite loss, anorexic, lost appetite, [D]Anorexia (situation), [D]Anorexia NOS (situation), Anorexic, anorexia
French ANOREXIE, ABSENCE D'APPETIT, PERTE D'APPETIT, TROUBLE DE L'APPETIT, Anoréxique, Anorexique, Anorexie
Portuguese ANOREXIA, AUSENCIA DE APETITE, PERDA DE APETITE, Anoréxico, DIMINUICAO DO APETITE, Anorexia
Spanish ANOREXIA, [D]anorexia (categoría dependiente del contexto), [D]anorexia, SAI (categoría dependiente del contexto), APETITO DEBILITADO, APETITO, AUSENCIA, APETITO, PERDIDA, Anoréxico, [D]anorexia, SAI (situación), [D]anorexia, SAI, [D]anorexia, [D]anorexia (situación), Anorexia
German ANOREXIE, APPETIT FEHLEND, APPETIT VERMINDERT, APPETITLOSIGKEIT, anorektisch, Anorexie
Swedish Aptitlöshet
Finnish Ruokahaluttomuus
Russian ANOREKSIIA, АНОРЕКСИЯ
Korean 식욕부진
Italian Anoressico, Anoressia
Dutch anorexie, anorectisch, Verminderde eetlust, Anorexia nervosa, Anorexie
Czech Anorexie, Anorektický, nechutenství, anorexie
Croatian ANOREKSIJA
Japanese 食欲不振, ショクヨクフシン
Polish Brak łaknienia, Łaknienie zmniejszone, Anoreksja
Hungarian Anorexiás, Anorexia, Anorecticus
Norwegian Appetittløshet

Ontology: Cachexia (C0006625)

Definition (NCI_NCI-GLOSS) The loss of body weight and muscle mass frequently seen in patients with cancer, AIDS, or other diseases.
Definition (MSH) General ill health, malnutrition, and weight loss, usually associated with chronic disease.
Definition (CSP) state of general ill health characterized by malnutrition, weakness, and emaciation; occurs during the course of a chronic disease.
Concepts Sign or Symptom (T184)
MSH D002100
ICD9 799.4
ICD10 R64
SnomedCT 207558009, 207560006, 158737005, 28928000, 238108007, 285384003
French CACHEXIE, Cachexie
English CACHEXIA, Cachexia NOS, [D]Cachexia, [D]Cachexia NOS, Cachexia, [D]Cachexia (context-dependent category), [D]Cachexia NOS (context-dependent category), cachectic (physical finding), cachectic, cachexia, Cachexia [Disease/Finding], Cachexia (disorder), [D]Cachexia NOS (situation), [D]Cachexia (situation), Wasting, General body deterioration, Cachectic, Cachexia (finding), Cachexia, NOS, Cachexia (disorder) [Ambiguous]
Spanish CAQUEXIA, [D]caquexia, SAI (categoría dependiente del contexto), [D]caquexia (categoría dependiente del contexto), [D]caquexia, SAI, [D]caquexia, SAI (situación), [D]caquexia (situación), [D]caquexia, caquexia (trastorno), Consunción, caquexia (concepto no activo), caquexia (hallazgo), caquexia, deterioro corporal general, Caquexia
German KACHEXIE, Auszehrung, Kachexie
Japanese 悪液質, アクエキシツ
Swedish Utmärgling
Czech kachexie, Kachexie
Finnish Kakeksia
Russian KAKHEKSIIA, КАХЕКСИЯ
Portuguese CAQUEQUEXIA, Consunção, Caquexia
Korean 악액질
Polish Charłactwo, Kacheksja
Hungarian Cachexia
Norwegian Kakeksi
Dutch cachexie, Cachexie
Italian Cachessia

Ontology: Wasting Syndrome (C0043046)

Definition (MSH) A condition of involuntary weight loss of greater then 10% of baseline body weight. It is characterized by atrophy of muscles and depletion of lean body mass. Wasting is a sign of MALNUTRITION as a result of inadequate dietary intake, malabsorption, or hypermetabolism.
Concepts Disease or Syndrome (T047)
MSH D019282
ICD10 R64
SnomedCT 207559001, 271878009, 288517002, 28928000
English Wasting Disease, Wasting Diseases, Wasting Syndrome, Wasting Syndromes, [D]Wasting disease, [D]Wasting disease (context-dependent category), WASTING DIS, Wasting generalized, Wasting Syndrome [Disease/Finding], wasting diseases, wasting disease, wasting syndrome, Wasting syndrome, Wasting disease (finding), [D]Wasting disease (situation), Wasting generalised, Malnutrition/starvation/cachexia, Wasting disease, Wasting disease (disorder), disease (or disorder); wasting, disease; wasting, syndrome; wasting, wasting; disease, wasting; syndrome, Wasting disease, NOS
Dutch algehele vermagering, aandoening; slopend, slopend; aandoening, syndroom; uittering, uittering; syndroom, ziekte; uittering, Syndroom, Wasting-, Wasting-syndroom
German Verfall generalisiert, Auszehrungssyndrom, Wasting-Syndrom, Auszehrungskrankheit
Italian Deperimento generalizzato, Wasting sindrome
Spanish Consunción generalizada, [D]enfermedad emaciante (categoría dependiente del contexto), [D]enfermedad emaciante, [D]enfermedad emaciante (situación), Síndrome de Consunción, enfermedad consuntiva (trastorno), enfermedad consuntiva, enfermedad emaciante, Enfermedad Debilitante, Síndrome Debilitante
Swedish Tärande syndrom
Czech syndrom chřadnutí, Generalizované chřadnutí
Finnish Näivetysoireyhtymä
French Syndrome de dépérissement, Cachexie généralisée, Syndrome cachectique, Syndrome de cachexie progressive, Syndrome de cachexie
Russian ISTOSHCHENIIA SINDROM, ИСТОЩЕНИЯ СИНДРОМ
Polish Choroba wyniszczająca, Zespół wyniszczenia
Japanese 消耗疾患, 消耗性症候群, ゼンシンセイショウモウ, 全身性消耗, 消耗症候群, 消耗性疾患, 消耗病
Norwegian Tærende syndrom, Tæring sykdom, Tærende sykdom
Hungarian Generalizált sorvadás
Portuguese Consumpção generalizada, Síndrome do Definhamento, Doença do Definhamento, Doença do Emagrecimento, Doença Consumptiva, Doença de Emaciação, Síndrome de Emaciação

Ontology: Malnutrition (C0162429)

Definition (MEDLINEPLUS)

Food provides the energy and nutrients you need to be healthy. If you don't get enough nutrients -- including proteins, carbohydrates, fats, vitamins, and minerals - you may suffer from malnutrition.

Causes of malnutrition include:

  • Lack of specific nutrients in your diet. Even the lack of one vitamin can lead to malnutrition.
  • An unbalanced diet
  • Certain medical problems, such as malabsorption syndromes and cancers

Symptoms may include fatigue, dizziness and weight loss, or you may have no symptoms. Your doctor will do tests, depending on the cause of your problem. Treatment may include replacing the missing nutrients and treating the underlying cause.

Definition (NCI) Inadequate nutrition resulting from poor diet, malabsorption, or abnormal nutrient distribution.
Definition (NCI_NCI-GLOSS) A condition caused by not getting enough calories or the right amount of key nutrients, such as vitamins and minerals, that are needed for health. Malnutrition may occur when there is a lack of nutrients in the diet or when the body cannot absorb nutrients from food. Cancer and cancer treatment may cause malnutrition.
Definition (MSH) An imbalanced nutritional status resulted from insufficient intake of nutrients to meet normal physiological requirement.
Definition (CSP) disorder of nutrition due to unbalanced or insufficient diet or to defective assimilation or utilization of nutrients.
Concepts Disease or Syndrome (T047)
MSH D044342 , D009748
ICD9 269.9, 260-269.99
ICD10 E40-E46.9 , E63.9, E46, E40-E46
SnomedCT 47563007, 154722002, 238106006, 267409003, 302868002, 267495004, 190678008, 154730001, 190595009, 190608007, 2492009, 70241007, 65404009, 248325000
LNC LA18401-2
English Unspecified nutritional deficiency, Disorder of nutrition, Malnutrition NOS, Nutritional deficiency NOS, Nutritional deficiency, unspecified, NUTRITIONAL DEFIC, malnutrition, malnutrition (diagnosis), Nutrition deficiency NOS, Malnutrition [Disease/Finding], poor nutrition, Deficiency;nutritional, deficiency nutritional, undernourished, deficiencies nutritional, nutrition poor, undernutrition, deficiencies disorders nutritional, deficiency disorders nutritional, Malnutrition (E40-E46), dietary deficiency, nutritional deficiencies, nutritional deficiencies (diagnosis), Nutritional deficiencies (disorder), Deficiency -nutritional, Nutritional deficiency NOS (disorder), Insufficiency - dietary, Malnutrition NOS (disorder), malnourished, Undernutrition, Nutritional Deficiency, Nutritional deficiencies, Deficiency state, Deficit, Undernutrition syndrome, Acquired deficiency, Deficiency, Malnourished, Underfed, Undernourished, Dietary deficiency, Nutritional deficiency (disorder), Nutritional deficiency (finding), Nutritional deficiency disorder, Nutritional deficiency, Undernourished (finding), Undernutrition (disorder), deficiency; diet, deficiency; nutritional, diet; deficiency, insufficiency; dietary, insufficiency; nourishment, nourishment; insufficiency, nutritional; deficiency, Nutritional deficiency disorder, NOS, Nutritional deficiency, NOS, Undernutrition syndrome, NOS, Undernutrition, NOS, Deficit, NOS, Undernutrition [Ambiguous], Malnutrition, Nutritional Deficiencies, NUTRITIONAL DEFICIENCIES, nutritional deficiency
Spanish deficiencia nutricional, Déficit nutricional no especificado, Desnutrición NEOM, desnutrición, SAI (trastorno), deficiencias nutricionales, deficiencias nutricionales (trastorno), deficiencia nutricional, SAI, carencia nutricional, SAI, deficiencia nutricional, SAI (trastorno), desnutrición, SAI, Subalimentación, Subnutrición, Malnutrición, deficiencia, carencia alimenticia, carencia nutricional (trastorno), carencia nutricional, carencia nutritiva, deficiencia adquirida, deficiencia nutricional (hallazgo), desnutrición (trastorno), desnutrición, desnutrido (hallazgo), desnutrido, déficit, estado de deficiencia, síndrome de desnutrición, Desnutrición
Dutch ondervoeding NAO, niet-gespecificeerde voedingsdeficiëntie, deficiëntie; dieet, deficiëntie; voeding, dieet; deficiëntie, insufficiëntie; door voeding, insufficiëntie; voeding, voeding; deficiëntie, voeding; insufficiëntie, Voedingsdeficiëntie, niet gespecificeerd, ondervoeding, Ondervoeding, Malnutritie
French Malnutrition SAI, Carence nutritive non précisée, Déficit nutritionnel, Malnutrition, Sous-nutrition
German unspezifischer Ernaehrungsmangel, Mangelernaehrung NNB, Alimentaerer Mangelzustand, nicht naeher bezeichnet, Mangelernaehrung, Malnutrition
Italian Carenze nutrizionali non specificate, Malnutrizione NAS, Sottonutrizione, Deficit nutrizionale, Malnutrizione
Portuguese Malnutrição NE, Carência nutricional NE, Subnutrição, Subalimentação, Malnutrição, Desnutrição
Japanese 栄養障害NOS, 栄養欠乏症、詳細不明, 栄養障害, エイヨウショウガイ, エイヨウケツボウショウショウサイフメイ, エイヨウショウガイNOS, 栄養不足, 栄養失調症, 栄養不良, 低栄養, 栄養失調, 栄養欠乏
Swedish Undernäring
Finnish Virheravitsemus
Russian PITANIE NEDOSTATOCHNOE, ПИТАНИЕ НЕДОСТАТОЧНОЕ
Czech Malnutrice, Blíže neurčený deficit výživy, Malnutrice NOS, nesprávná výživa, podvýživa, poruchy výživy, malnutrice, výživa - poruchy
Korean 상세불명의 영양 결핍증
Croatian PREHRANA, POREMEĆAJI, Not Translated[Malnutrition]
Polish Niedożywienie, Niedobory żywieniowe, Niedobory pokarmowe
Hungarian Alultápláltság, Alultápláltság k.m.n., Nem meghatározott táplálkozási hiány
Norwegian Feilernæring, Underernæring, Malnutrisjon