Involuntary weight loss Angel Carlos Matía Cubillo Family and Community Medicine Specialist Health Technician. GAP Valladolid East

1. KeyInvoluntary weight loss
Angel Carlos Matía Cubillo
Family and Community Medicine Specialist
Health Technician. GAP Valladolid East
Points
Involuntary weight loss in adults is considered clinically important when it represents 5% or
more of the usual weight, in a period of between 6 months and 1 year.
Its importance lies in the fact that it is associated with an increase in morbidity and mortality.
There are three main causes: organic (including cancer), psychiatric, and idiopathic. In older
people, the most common cause is depression.
When weight loss is involuntary, it is usually documented or corroborated by the family,
without apparent cause, and in people without previously significant fluctuations in weight.
The analytical alterations used as predictors do not appear to be specific for neoplastic
etiology, in the same way, tumor markers are useful in the follow-up of certain neoplasms,
but not as a screening method.
The initial diagnostic approach is the responsibility of Primary Care (PC), includes a detailed
anamnesis, a complete examination by equipment and basic complementary tests (basic
analysis with systematic blood and urine, biochemistry, thyroid-stimulating hormone [TSH],
serology for immunodeficiency virus [HIV] and fecal occult blood, chest X-ray and abdominal
ultrasound), additional tests are necessary based on initial findings or if the cause is still not
found and symptoms persist.
The risk of serious organic pathology, including neoplasms, is low if the initial evaluation is
normal.
Treatment is primarily etiological.
Definition or concept
Involuntary weight loss in adults is not unusual and represents between 1.3-3% of
hospitalized patients in Internal Medicine 1, 13% of the elderly in outpatient consultation, and
more than 50% of institutionalized elderly 2.
It is considered clinically important when it supposes a loss > 5% with respect to the usual
one in a period of 6 months 3,4, although most authors consider up to 1 year 1,5-7.
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2. Its importance lies in the fact that it is associated with an increase in morbidity and mortality
4-6,8, although this varies according to the follow-up period. After the etiologic study, they
have a better prognosis than those considered idiopathic in which a diagnosis is reached in
May.
Classification of possible causes
Several variables have been found associated with a greater risk of involuntary weight loss 5
: age, comorbidity, disability, smoking, previous hospitalization, cognitive impairment, low
educational level, and low body mass index. The first four stand out as predictors 4 .
There are three main causes:
• Organic (includes cancer).
• Psychiatric.
• Idiopathic.
In many cases the etiology is multifactorial. In fact, according to the studies collected in the
bibliography 1,4-7, the proportion attributable to each one of them presents a wide range:
organic (cancer 6-38%, gastrointestinal non-tumor 6-34%), psychiatric 9-42 % and idiopathic
5-36%.
In Table 1 the main trials are shown on unintentional weight loss, after review of the main
integrated primary or secondary studies and sources.
In older people, the most frequent cause is psychiatric pathology and, specifically,
depression 5,6.
In Table 2 the possible causes of unintentional weight loss are presented.

3. Tracks
• When weight loss is involuntary, it is usually documented or corroborated by the family,
without apparent cause, and in people without significant prior weight fluctuations.
• If the dietary intake is inadequate, psychosocial causes should be investigated and, in the
elderly, physiological alterations of aging (dry mouth, loss of teeth, taste alteration, etc.).
• When it is associated with asthenia and anorexia, it is referred to as a "constitutional
syndrome" and is usually related to digestive neoplasms.
Diagnostic management
When considering possible causes, cancer is a frequent concern for both patients and
physicians; one of the priorities is to differentiate serious or malignant organic pathologies
from those that do not have an organic basis.
Classically, from the study by Hernández JL, et al. 9 some laboratory abnormalities have
been considered as predictors of malignancy in isolated involuntary weight loss without
specific symptoms, supplemented with age 4 and summarized in Table 3 ; although a recent
study that used these variables did not effectively predict the possibility of cancer 10 .
Tumor markers are useful in the monitoring of certain neoplasms but they are not efficient as
a screening method 2 due to their low sensitivity, specificity 1 , or both, in the same way that
the analytical alterations used as predictors do not seem to be specific for neoplastic
etiology.
The initial diagnostic approach is the responsibility of the PC, and a detailed anamnesis, a
complete examination by equipment, and basic complementary tests (basic analysis with
systematic blood and urine, biochemistry, TSH, serology for HIV and occult blood in feces,
chest X-ray are essential and abdominal ultrasound). Additional tests are necessary based
on the initial findings or if the cause is not found and the symptoms persist, as described in
Figure 1.
Anamnesis
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4. The most important thing is to verify the existence of a significant weight loss since it is
subjective in a significant percentage 1.5 of the patients who report it; if the weight is
documented in the medical history it is easy, alternatively by asking family or close friends,
or by changes in clothing size. The duration, previous existence of fluctuations in weight, and
whether it is progressive or has stabilized must be recorded. Consider and ask about the
possibility of weight loss being voluntary. Assess whether the dietary intake is adequate and
the usual physical activity.
You should always ask about associated symptoms, especially if the appetite is preserved.
Anamnesis by apparatus can add indicative symptoms, such as a change in bowel rhythm.
Elderly people should be screened for cognitive impairment and depression, 5 with the
Pfeiffer, Yesavage, or similar tests.
We must bear in mind the medical history and chronic use of medication, toxic habits related
to the consumption of tobacco, alcohol, or other drugs, risky sexual behavior, travel to
underdeveloped countries, and psychosocial aspects.
Physical exploration
A detailed physical examination should be performed by apparatus: general condition, skin
and appendages, the existence of adenopathies, otorhinolaryngology and oral cavity,
thyroid, cardiopulmonary, abdominal, neurological, musculoskeletal, breast and prostate by
rectal examination.
In several studies 1,4, findings on examination were found in more than 50% of cases when
a neoplasm or serious organic disease was the underlying cause.
Initial complimentary tests
They should be requested when there are no findings with the anamnesis and physical
examination to guide the diagnosis.

5. There is no established initial battery of tests, and there is great variability between the
various studies, although most include the following:
• Analytical: systematic blood and urine, biochemistry with glucose, kidney and liver function,
electrolytes and calcium and phosphorus ions, nonspecific reactants (C-reactive protein and
erythrocyte sedimentation rate), lactate dehydrogenase, albumin, TSH, HIV serology, and
test of occult blood in the stool.
• Chest X-ray.
• Abdominal ultrasound.
Successive tests
Special examinations oriented to the findings of the initial study. Some correspond to the
second level of care.
The main special tests used in studies on the subject are described below, although
depending on the diagnostic orientation the list is much broader:
• Thoracic or abdominal computed tomography (CT), or both: if alterations are detected in
the chest radiograph or abdominal ultrasound or in the case of neoplasia for extension study.
• Cranial CT: if there is a previously unknown headache or neurological symptoms.
• Colonoscopy: if the occult blood in the stool is positive, there is anemia, melena, or Crohn's
disease is suspected.
• Upper endoscopy: if dysphagia, epigastralgia, or hemorrhage of the upper digestive tract.
• Mammography: if a breast lump is detected.
• Blood and urine culture: if the fever is of unknown origin.
• Autoantibodies and urine biochemistry: suspected connective tissue disease.
• Serum immunoglobulins and electrophoretic protein gram: if hypercalcemia or elevation of
acute phase reactants, suspicion of gammopathies or myeloma.
• Adrenocorticotropic hormone: if asthenia, hyperpigmentation, or hyperkalemia with
hyponatremia.
• Parasites in feces: if there is a history of travel to the tropical zone.

6. • Faecal fat excretion: suspected malabsorption.
Aspects that should not be forgotten in the diagnostic process
The first thing to do should be to check the weight loss and quantify it, since it is clinically
important when it is 5% or higher than usual in a period of 6 to 12 months (grade of
recommendation C).
In most patients with involuntary weight loss, the history, physical examination, and initial
investigations will guide the diagnosis or the need for further tests.
The risk of serious organic pathology, including neoplasms, is low if the initial evaluation by
anamnesis, physical examination, basic laboratory tests, chest X-ray, and abdominal
ultrasound, are normal 1,7.
It is not necessary to request tumor markers or special explorations in the diagnostic
approach unless the findings or alterations are found to point towards a specific pathology 4
(grade of recommendation B).
Treatment
It is fundamentally etiological.
The use of energy protein supplements in older people is associated in the short term with
weight gain and improvement of biochemical, anthropometric, and quality of life parameters,
but in the long term the beneficial effects have yet to be demonstrated, although a Cochrane
systematic review seems to show a decrease in mortality (grade of recommendation B).
Megestrol acetate increases appetite and produces weight gain, with the risk, as a possible
side effect, of deep vein thrombosis, being indicated in cancer patients.
Corticosteroids produce an increase in appetite and a euphoric effect, although their side
effects limit their use to cancer patients.

7. Follow-up
There is great variability between the different studies when reviewing patients with
involuntary weight loss, especially depending on the etiology.
The patient should be reviewed within 1 to 6 months in the following cases (grade of
recommendation C):
• When there is no involuntary weight loss, without other associated symptoms.
• If the dietary intake is inadequate.
• When there are problems without an organic basis.
• If after a complete study no cause is found.
Recommended reading
Vanderschueren S, Geens E, Knockaert D, Bobbaers H. The diagnostic spectrum of
unintentional weight loss. Eur J Intern Med. 2005;16:160-4.
Review of the studies published until then on the diagnosis and prognosis of involuntary
weight loss, collect the definition, incidence, and diagnostic approach and follow-up.
Evans AT, Gupta R. Approach to the patient with weight loss. UpToDate review version
2010. Disponible
enhttp://www.uptodate.com/contents/approach-to-the-patient-with-weight-loss?source=searc
h_result&selectedTitle=1~150Consultado 18-2-2011.
Updated review of articles published on the subject, includes all aspects of voluntary and
involuntary weight loss, definition, epidemiology, etiology, evaluation, and management.
Bibliography
Vanderschueren S, Geens E, Knockaert D, Bobbaers H. The diagnostic spectrum of
unintentional weight loss. Eur J Intern Med. 2005;16:160-4.
Wu JM, Lin MH, Peng LN, Chen LK, Hwang SJ. Evaluating diagnostic strategy of older
patients with unexplained unintentional body weight loss: A hospital-based study. Arch
Gerontol Geriatr. 2010 nov; doi:10.1016/j.archger.2010.10.016
Bilbao-Garay J, Barba R, Losa-García JE, Martín H, García de Casasola G, Castilla V, et al.
Assessing clinical probability of organic disease in patients with involuntary weight loss: a
simple score. Eur J Intern Med. 2002;13:240-5.
Evans AT, Gupta R. Approach to the patient with weight loss. UpToDate review version 2

8. to-the-patient-with-weight-loss?source=search_result&selectedTitle=1~150 Consultado
18-2-2011.
Alibhai SM, Greenwood C, Payette H. An approach to the management of unintentional
weight loss in elderly people. CMA. 2005;172:773-80.
Rolland Y, Kim M, Gammack JK, Wilson MG, Thomas DR, Morley JE. Office Management of
Weight Loss in Older Persons. Am J Med. 2006;119:1019-26.
Metalidis C, Knockaert DC, Bobbers H, Vanderschueren S. Involuntary weight loss. Does a
negative baseline evaluation provide adequate reassurance? Eur J Intern Med.
2008;19:345-9.
Knudtson MD, Klein B, Klein R, Shankar A. Associations with weight loss and subsequent
mortality risk. Ann Epidemiol. 2005;15:483-91.
Hernández JL, Riancho JA, Matorras P, González-Macías J. Clinical evaluation for cancer in
patients with involuntary weight loss without specific symptoms. Am J Med. 2003;114:631-7.
Chen S, Peng L, Lin M, Lai H, Hwang S, Chen L. Evaluating the probability of cancer among
older people with unexplained, unintentional weight loss. Arch Gerontol Geriatr Suppl.
2010;50:S27-9.
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