Involuntary Weight Loss

By Michael R. Wasserman, MD, California Association of Long Term Care Medicine

Reviewed/Revised Feb 2023

Pathophysiology | Etiology | Evaluation | Treatment |

Geriatrics Essentials | Key Points

Involuntary weight loss generally develops over weeks or months. It

can be a sign of a significant physical or mental disorder and is
associated with an increased risk for mortality. The causative disorder
may be obvious (eg, chronic diarrhea due to a malabsorption
syndrome) or occult (eg, an undiagnosed cancer).

This discussion focuses on patients who present for weight loss rather than those who lose
weight as a more-or-less expected consequence of a known chronic disorder (eg, metastatic
cancer, end-stage chronic obstructive pulmonary disease [COPD]).

Weight loss is typically considered clinically important if it exceeds 5% of body weight or 5 kg

over 6 months. However, this traditional definition does not distinguish between loss of lean
and fat body mass, which can lead to different outcomes. Also, accumulation of edema (eg,
in heart failure or chronic kidney disease) can mask clinically important loss of lean body
mass.

In addition to weight loss, patients may have other symptoms, such as anorexia, fever, or
night sweats, due to the underlying disorder. Depending on the cause and its severity,
symptoms and signs of nutritional deficiency (see Overview of Vitamins) may also be
present.

The overall incidence of significant involuntary weight loss is about 5% per year in the US.
However, incidence increases with aging, often reaching 50% among nursing home patients.

Pathophysiology of Involuntary Weight Loss

Weight loss results when more calories are expended than taken in (ingested and absorbed).
Disorders that increase expenditure or decrease absorption tend to increase appetite. More
commonly, inadequate caloric intake is the mechanism for weight loss and such patients
tend to have decreased appetite. Sometimes, several mechanisms are involved. For example,
cancer tends to decrease appetite but also increases basal caloric expenditure by cytokine-
mediated mechanisms.

Etiology of Involuntary Weight Loss

Many disorders cause involuntary weight loss, including almost any chronic illness of
sufficient severity. However, many of these are clinically obvious and have typically been
diagnosed by the time weight loss occurs. Other disorders are more likely to manifest as
involuntary weight loss (see table Some Causes of a Presenting Symptom of Involuntary
Weight Loss).

With increased appetite, the most common occult causes of involuntary weight loss are

Hyperthyroidism

Uncontrolled diabetes
Disorders that cause malabsorption

With decreased appetite, the most common occult causes of involuntary weight loss are

Psychiatric disorders (eg, depression)

Cancer

Drug adverse effects

Drug use disorder

In some disorders that cause involuntary weight

loss, other symptoms tend to be more prominent,
so that weight loss is usually not the chief TABLE

complaint. Examples include the following: Some Causes of a

Presenting Symptom of
Some malabsorptive disorders:
Involuntary Weight Loss
Gastrointestinal tract surgery and cystic
fibrosis
Chronic inflammatory disorders: Severe
rheumatoid arthritis
TABLE
Gastrointestinal disorders: Achalasia, celiac
disease, Crohn disease, chronic pancreatitis,
esophageal obstructive disorders, ischemic
 colitis, diabetic enteropathy, peptic ulcer Drugs and Herbal

disease, progressive systemic sclerosis, Products That Can Cause

ulcerative colitis (late) Weight Loss

Severe, chronic heart and lung disorders:

Chronic obstructive pulmonary disease (COPD), heart failure (stage III or IV),
restrictive lung disease

Mental disorders (known and poorly controlled): Anxiety, bipolar disorder,

depression, schizophrenia

Neurologic disorders: Amyotrophic lateral sclerosis, dementia, multiple sclerosis,

myasthenia gravis, Parkinson disease, stroke

Social problems: Poverty, social isolation

With chronic kidney disease and heart failure, accumulation of edema may mask loss of lean
body weight.

Evaluation of Involuntary Weight Loss

Evaluation focuses on detection of otherwise occult causes. Because these are numerous,
evaluation must be comprehensive.

History
History of present illness includes questions about the amount and time course of weight
loss. A report of weight loss may be inaccurate; thus, corroborating evidence should be
sought, such as weight measurement in old medical records, changes in size of clothes, or
confirmation by family members. Appetite, food intake, swallowing, and bowel patterns
should be described. For repeat evaluations, patients should keep a food diary because
recollections of food intake are often inaccurate. Nonspecific symptoms of potential causes
are noted, such as fatigue, malaise, fevers, and night sweats.

Review of systems must be complete, seeking symptoms in all major organ systems.

Past medical history and social history may reveal a disorder capable of causing weight
loss. Also addressed should be use of prescription medications, over-the-counter
medications, recreational drugs, and herbal products. Social history may reveal changes in
living situations that could explain why food intake is decreased (eg, loss of loved one, loss of
independence or job, loss of communal eating routine).

Physical examination
Vital signs are checked for fever, tachycardia, tachypnea, and hypotension. Weight is
measured and body mass index (BMI) is calculated. Triceps skinfold thickness and mid upper
arm circumference can be measured to estimate lean body mass. BMI and lean body mass
estimates are helpful mainly for detecting a trend in follow-up visits.

General examination should be particularly comprehensive, including examination of the

heart, lungs, abdomen, head and neck, breasts, neurologic system, rectum (including
prostate examination and testing for occult blood), genitals, liver, spleen, lymph nodes,
joints, skin, mood, and affect.

Red flags
Fever, night sweats, generalized lymphadenopathy
Bone pain

Dyspnea, cough, hemoptysis

Inappropriate fear of weight gain in an adolescent or young woman

Polydipsia and polyuria

Headache, jaw claudication, and/or visual disturbances in an older adult

Roth spots, Janeway lesions, Osler nodes, splinter hemorrhages, retinal artery
emboli

Interpretation of findings
Interpretations of some findings are listed in the table Interpretation of Selected Findings in
Involuntary Weight Loss. Abnormal findings suggest the cause of weight loss in about half or
more patients, including patients eventually diagnosed with cancer.

Although many chronic disorders can cause weight loss, the clinician must not be too quick
to assume that an existing disorder is the cause. Although the existing disorder is the likely
cause in patients whose condition has remained poorly controlled or is deteriorating, stable
patients who suddenly begin losing weight without a worsening of that disorder may have
developed a new condition (eg, patients with stable ulcerative colitis may begin losing weight
because they developed a colon cancer).

Testing
Pearls & Pitfalls
Age-appropriate cancer screening (eg, colonoscopy,
mammography) is indicated if not previously done. When a chronic disease
Other testing is done for disorders suspected based has been stable, do not

on abnormal findings in the history or examination. assume that it is the

There are no widely accepted guidelines on other cause of acute weight
testing for patients without such focal abnormal loss.
findings. One suggested approach is to do the
following tests:

Chest x-ray
TABLE
Urinalysis
Interpretation of Selected
Complete blood count (CBC) with differential Findings in Involuntary
count Weight Loss
Erythrocyte sedimentation rate (ESR) or C-
reactive protein

HIV testing

Serum chemistries (serum electrolytes, calcium, hepatic and renal function tests)
Thyroid-stimulating hormone (TSH) level

Abnormal results on these tests are followed with additional testing as indicated.

If all test results are normal and clinical findings are otherwise normal, extensive further
testing (eg, CT, MRI) is not recommended. Such testing is very low yield and can be
misleading and harmful by revealing incidental, unrelated findings. Such patients should be
taught how to ensure adequate caloric intake and have a follow-up evaluation in about 1
month that includes a weight measurement. If patients have continued to lose weight, the
entire history and physical examination should be repeated because patients may share
important, previously undisclosed, information, and new, subtle physical abnormalities may
then be detected. If weight loss continues and all other findings remain normal, further
testing (eg, CT, MRI) should be considered.

Treatment of Involuntary Weight Loss

The underlying disorder is treated.

If an underlying disorder causes undernutrition and is difficult to treat, nutritional support

should be considered. Helpful general behavioral measures include encouraging patients to
eat, assisting them with feeding, offering snacks between meals and before bedtime,
providing favorite or strongly flavored foods, and offering only small portions at each sitting.

If behavioral measures are ineffective and weight loss is extreme, enteral tube feeding can
be tried if patients have a functioning gastrointestinal tract.
Measures of lean body mass are followed serially.

Appetite stimulants have not been shown to prolong life.

Geriatrics Essentials: Involuntary Weight Loss

Normal age-related changes that can contribute to weight loss include the following:

Decreased sensitivity to certain appetite-stimulating mediators (eg, orexins,

ghrelin, neuropeptide Y) and increased sensitivity to certain inhibitory mediators
(eg, cholecystokinin, serotonin, corticotropin-releasing factor)

A decreased rate of gastric-emptying (prolonging satiety)

Decreased sensitivities of taste and smell

Loss of muscle mass (sarcopenia)

In older people, multiple chronic disorders often contribute to weight loss. Dental problems
(eg, periodontitis) become more common with aging and can compromise nutrient intake
and digestion. Social isolation tends to decrease food intake. Particularly in nursing home
patients, depression is a very common contributing factor. It is difficult to sort out the exact
contribution of specific factors because of the interactions between factors such as
depression, loss of function, drugs, dysphagia, dementia, and social isolation.

When evaluating older patients with weight loss, a useful checklist is of potential contributing
factors beginning with the letter D:

Dentition

Dementia

Depression
Diarrhea

Disorders (eg, severe renal, cardiac, or pulmonary disorders)

Drugs

Dysfunction

Dysgeusia
Dysphagia

Older patients who have lost weight should be evaluated for deficiency of vitamin D and
deficiency of vitamin B12.
Enteral (tube) feeding is rarely beneficial in older patients, except for specific patients in
whom such feeding may possibly be a short-term bridge to eating normally.

Key Points

Particularly among nursing home patients, multiple factors commonly

contribute to weight loss.
Involuntary weight loss > 5% of body weight or 5 kg warrants investigation.

The highest yield aspects of the evaluation are a thorough history and
physical examination.
Advanced imaging or other extensive testing is not usually recommended
unless suggested by clinical findings.
Emphasize behavioral measures that encourage eating and try to avoid
enteral feeding, particularly in older adults.

Fatigue Involuntary Weight Loss