Weight Loss

Significant unintentional weight loss in a previously healthy individual is often

a harbinger of underlying systemic disease. The routine medical history should

always include inquiry about changes in weight. Rapid fluctuations of weight

over days suggest loss or gain of fluid,whereas long-term changes usually

involve loss of tissue mass. Loss of 5% of body weight over 6–12 months

should prompt further evaluation.

Etiology

A list of possible causes of weight loss is extensive (Table 49-1). In older

persons the most common causes of weight loss are depression,cancer, and

benign gastrointestinal disease. In younger individuals diabetes mellitus,hyperthyroidism,

anorexia nervosa, and infection, especially with HIV, should be

considered.

Causes of Weight Loss

Cancer

Endocrine and metabolic causes

Hyperthyroidism

Diabetes mellitus

Pheochromocytoma

Adrenal insufficiency

Gastrointestinal disorders

Malabsorption

Obstruction

Pernicious anemia

Cardiac disorders

Chronic ischemia

Chronic congestive heart failure

Respiratory disorders

Emphysema

Chronic obstructive pulmonary

disease

Renal insufficiency

Rheumatologic disease

Infections

HIV

Tuberculosis

Parasitic infection

Subacute bacterial endocarditis

Medications

Antibiotics

Nonsteroidal anti-inflammatory drugs

Serotonin reuptake inhibitors

Metformin

Levodopa

ACE inhibitors

Other drugs

Disorders of the mouth and teeth

Age-related factors

Physiologic changes

Decreased taste and smell

Functional disabilities

Neurologic causes

Stroke

Parkinson’s disease

Neuromuscular disorders

Dementia

Social causes

Isolation

Economic hardship

Psychiatric and behavioral causes

Depression

Anxiety

Bereavement

Alcoholism

Eating disorders

Increased activity or exercise

Idiopathic

Clinical Features

Before extensive evaluation is undertaken,it is important to confirm that weight

loss has occurred. In the absence of documentation,changes in belt notch size

or the fit of clothing may help to determine loss of weight.

The history should include questions about fever,pain,shortness of breath

or cough,palpitations, and evidence of neurologic disease. A history of GI

symptoms should be obtained,including difficulty eating, dysphagia, anorexia,

nausea,and change in bowel habits. Travel history, use of cigarettes, alcohol,

and all medications should be reviewed,and pts should be questioned about

previous illness or surgery as well as diseases in family members. Risk factors

for HIV should be assessed. Signs of depression,evidence of dementia, and

social factors,including financial issues that might affect food intake, should

be considered.

Physical examination should begin with weight determination and documentation

of vital signs. The skin should be examined for pallor,jaundice,

turgor,surgical scars,and stigmata of systemic disease. Evaluation for oral

thrush, dental disease,thyroid gland enlargement,and adenopathy and for respiratory, cardiac, or abdominal abnormalities should be performed. All men

should have a rectal examination,including the prostate; all women should have

a pelvic examination; and both should have testing of the stool for occult blood.

Neurologic examination should include mental status assessment and screening

for depression.

Initial laboratory evaluation is shown in Table 49-2,with appropriate treatment

based on the underlying cause of the weight loss. If an etiology of weight

loss is not found,careful clinical follow-up,rather than persistent undirected

testing,is reasonable.