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Sunday, August 17, 2025

Weight loss (unintentional)


Introduction

Unintentional weight loss refers to a clinically significant reduction in body weight without deliberate dieting or increased exercise. Typically, losing more than 5% of body weight within 6–12 months is considered medically relevant. Unlike intentional weight reduction, unintentional weight loss is often a symptom of an underlying disorder and may indicate serious pathology, especially in older adults.

This symptom warrants thorough medical evaluation, as it can be the first sign of metabolic disease, malignancy, psychiatric illness, or chronic infection.

Causes of Unintentional Weight Loss

1. Malignancy (Cancer)

  • One of the most concerning causes.

  • Associated cancers: gastrointestinal (stomach, colon, pancreas), lung, lymphoma, leukemia.

  • Mechanism: Tumor-induced hypermetabolism, anorexia, and systemic inflammation.

2. Endocrine and Metabolic Disorders

  • Hyperthyroidism: Increased metabolism → weight loss despite good appetite.

  • Diabetes Mellitus (Type 1 and advanced Type 2): Loss of glucose in urine and fat/muscle breakdown.

  • Adrenal Insufficiency (Addison’s disease): Weight loss, fatigue, low blood pressure, skin hyperpigmentation.

3. Gastrointestinal Disorders

  • Malabsorption syndromes: Celiac disease, Crohn’s disease, chronic pancreatitis.

  • Peptic ulcer disease or gastric outlet obstruction: Reduced intake and absorption.

  • Chronic diarrhea: Loss of nutrients and calories.

4. Infections

  • Chronic infections: Tuberculosis, HIV/AIDS, parasitic infestations (worms), chronic hepatitis.

  • Recurrent or occult infections: Abscesses, osteomyelitis, endocarditis.

5. Psychiatric and Neurological Disorders

  • Depression: Reduced appetite and neglect of nutrition.

  • Anorexia nervosa and bulimia: Intentional restriction but may present as unexplained.

  • Dementia: Forgetting to eat, poor access to food.

6. Cardiopulmonary Disorders

  • Chronic heart failure: Increased metabolic demands, reduced appetite.

  • Chronic obstructive pulmonary disease (COPD): High energy expenditure from labored breathing.

7. Other Causes

  • Chronic kidney disease or liver disease: Uremia or cirrhosis leading to anorexia and catabolism.

  • Substance abuse: Alcohol, cocaine, methamphetamines.

  • Medications: Chemotherapy, digoxin, SSRIs, metformin, topiramate.

Clinical Presentation

  • History: Duration and degree of weight loss, appetite changes, dietary intake, systemic symptoms (fever, night sweats, cough, diarrhea).

  • Associated symptoms by system:

    • GI: Dysphagia, vomiting, abdominal pain, altered bowel habits.

    • Endocrine: Palpitations, sweating, tremors, polyuria, polydipsia.

    • Psychiatric: Low mood, anhedonia, changes in sleep patterns.

  • Physical Examination:

    • BMI, muscle wasting, signs of dehydration, lymphadenopathy, hepatosplenomegaly, thyroid enlargement.

Diagnostic Workup

Baseline Investigations

  • Complete blood count (CBC): Anemia, infection, leukemia.

  • ESR/CRP: Chronic inflammation, infection, or malignancy.

  • Blood glucose/HbA1c: Diabetes screening.

  • Thyroid function tests: TSH, T4 for hyperthyroidism.

  • Liver and kidney function tests.

  • Urinalysis: Proteinuria, glycosuria.

Targeted Tests

  • Chest X-ray: TB, lung cancer.

  • Stool tests: Occult blood, parasites, fat content.

  • Endoscopy/Colonoscopy: GI malignancy, ulcers, IBD.

  • CT/MRI scans: For suspected malignancy or organ involvement.

  • HIV and hepatitis serology.

Management

Treatment focuses on underlying cause and nutritional support.

1. Nutritional and Supportive Therapy

  • High-calorie, high-protein diet.

  • Oral nutritional supplements (Ensure®, Resource®).

  • Enteral feeding (NG tube, PEG) if oral intake inadequate.

  • Parenteral nutrition in severe malabsorption or GI dysfunction.

2. Pharmacological Treatment (Cause-Specific)

Endocrine Disorders

  • Hyperthyroidism:

    • Carbimazole 20–40 mg orally daily (titrated to effect).

    • Propylthiouracil 100–150 mg orally three times daily.

  • Diabetes Mellitus (Type 1):

    • Insulin therapy (dose individualized: starting 0.2–0.4 units/kg/day).

Malabsorption Disorders

  • Celiac Disease: Strict lifelong gluten-free diet.

  • Chronic Pancreatitis: Pancreatic enzyme replacement (Creon®: 25,000–50,000 units lipase with meals).

Infectious Causes

  • Tuberculosis:

    • Isoniazid 300 mg + Rifampicin 600 mg + Pyrazinamide 1500 mg + Ethambutol 1200 mg daily (6-month regimen).

  • HIV/AIDS:

    • Antiretroviral therapy (e.g., Tenofovir + Lamivudine + Dolutegravir).

  • Parasitic Worms: Albendazole 400 mg single dose, repeated if necessary.

Psychiatric Causes

  • Depression: SSRIs (Fluoxetine 20 mg daily) + psychotherapy.

  • Anorexia Nervosa: Multidisciplinary approach—nutritional rehab, psychotherapy, sometimes olanzapine 2.5–10 mg daily to stimulate appetite.

Cancer-Associated Cachexia

  • Megestrol acetate (appetite stimulant): 160–320 mg orally daily.

  • Corticosteroids (short-term): Dexamethasone 2–4 mg daily for appetite stimulation.

Precautions and Monitoring

  • Elderly patients with unintentional weight loss should always be screened for malignancy.

  • Monitor for nutrient deficiencies (iron, B12, folate, vitamin D).

  • Avoid appetite stimulants without ruling out serious disease.

  • Regular weight and BMI tracking.

Drug Interactions

  • Carbimazole + Warfarin: May increase anticoagulant effect.

  • Rifampicin (TB treatment) + Oral contraceptives: Reduces contraceptive effectiveness.

  • SSRIs + NSAIDs/anticoagulants: Increased risk of bleeding.

  • Megestrol acetate + Antidiabetics: May worsen hyperglycemia.

  • Corticosteroids + Immunosuppressants: Increased infection risk.

Red-Flag Signs Requiring Urgent Referral

  • Rapid weight loss (>10% of body weight in 6 months).

  • Associated fever, night sweats, persistent cough (TB, cancer).

  • Blood in stool or urine.

  • Progressive difficulty swallowing.

  • Confusion, severe depression, or suicidal ideation.




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