Weight loss/gain (unintentional)

CHAPTER 36 Weight loss/gain (unintentional)


Unintentional weight loss is a decrease in body weight that is not voluntary. Weight loss in the adult is clinically significant when it exceeds 5% of usual body weight over a 6 to 12 month period. Weight loss in the newborn may occur immediately after birth but weight should begin to increase by 2 weeks of age. Weight loss will occur with reduced energy (food) intake and increased metabolism or energy output. Every day individuals adjust energy balance to maintain a healthy weight through healthy eating and regular physical activity. Malignancy and endocrine disorders are at the top of the list of causes of unintentional weight loss, followed by gastrointestinal, cognitive, behavioral, and functional disorders, as well as age-related changes.


Weight gain occurs when caloric intake exceeds body requirements, causing the body to store fat. Most adults do not intentionally gain weight, but as we age, a decrease in physical abilities leads to a decrease in metabolic rate (amount of energy used in a given period), which in turn contributes to weight gain. Unexplained weight gain may be more difficult to identify, especially in the U.S., where the prevalence of obesity is 32.2% among adult men and 35.5% among adult women. The prevalence of childhood obesity is increasing. Unexplained weight gain may be endocrine-related, age-related, or associated with cognitive impairments.



Diagnostic reasoning: focused history



Unexplained weight loss





Has the patient lost weight? is the weight loss really unexplained?



Key questions




image How do you know that you (or the child) have lost weight?


image How old are you?


image How is your appetite?


image Can you describe your typical diet and activity patterns?


image If an infant: If breastfeeding, how is breastfeeding going?


image If an infant: If feeding formula, what kind is it and how do you prepare it?



Measuring weight


Individuals might note that their clothes are too loose or too tight. Weight is usually measured by asking the patient to step on a balance or electric scale clothed and without shoes. Height is measured by asking the patient to stand with the back against a wall with heels touching the wall. There are several ways to classify and measure body weight, but the most commonly used method is the body mass index (BMI) formula, which is BMI = weight (kg)/height (m2) (see Appendix C). To enhance the reliability of measurement of weight changes, ask the patient to weigh himself or herself at the same time each day using the same scale.


Weight and height in infants and children is measured by a scale and plotted on a National Center for Health Statistics growth chart. Infants and children should be measured in a supine position until the age of 2 years. Head circumference is also measured and plotted.



Age


Aging can be associated with both weight loss and weight gain. Normally with aging there is less lean muscle tissue, fat is deposited in the trunk and less in the limbs, and metabolism slows. In the elderly it is especially important to assess what medications are being taken that could suppress appetite, cognitive status, and memory. Functional limitations that may impact nutrition include the ability to chew and swallow, prepare meals, and shop for food. Social isolation can also contribute to eating less.



Appetite


Appetite can be suppressed due to the presence of acute or chronic illness. Cachexia will result from inadequate energy intake and pathologic wasting of muscle or fat tissue. The key symptom in cachexia is anorexia, or loss of appetite. Psychosocial factors, such as anxiety or depression, can contribute to a loss of appetite or lifestyle habits that include skipping meals or eating foods of poor nutritional value.



Eating habits/nutritional adequacy and physical activity


Weight maintenance is a balance of energy expended and energy consumed. General healthy dietary guidelines can be found in the Dietary Guidelines for Americans (Box 36-1) and on MyPyramid (http://mypyramid.gov). Daily caloric needs vary by age, gender, pregnancy, and level of physical activity. Athletes in training may underestimate their caloric needs (Box 36-2).



Box 36-1 Key Recommendations for Maintaining A Healthy Weight




• To maintain body weight in a healthy range, balance calories from foods and beverages with calories expended.


• To prevent gradual weight gain over time, make small decreases in food and beverage calories and increase physical activity.



Key recommendations for specific population groups




• Those who need to lose weight. Aim for a slow, steady weight loss by decreasing calorie intake while maintaining an adequate nutrient intake and increasing physical activity.


• Overweight children. Reduce the rate of body weight gain while allowing growth and development. Consult a healthcare provider before placing a child on a weight-reduction diet.


• Pregnant women. Ensure appropriate weight gain as specified by a healthcare provider.


• Breastfeeding women. Moderate weight reduction is safe and does not compromise weight gain of the nursing infant.


• Overweight adults and overweight children with chronic diseases and/or on medication. Consult a healthcare provider about weight loss strategies prior to starting a weight-reduction program to ensure appropriate management of other health conditions.


From U.S. Department of Health and Human Services, U.S. Department of Agriculture: Dietary guidelines for Americans, 2005. Available online at www.healthierus.gov/dietaryguidelines. Accessed August 5, 2010.



Box 36-2 Key Recommendations for Physical Activity


Engage in regular physical activity and reduce sedentary activities to promote health, psychological wellbeing, and a healthy body weight.



• To reduce the risk of chronic disease in adulthood: Engage in at least 30 minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of the week.


• For most people, greater health benefits can be obtained by engaging in physical activity of more vigorous intensity or longer duration.


• To help manage body weight and prevent gradual, unhealthy body weight gain in adulthood: Engage in approximately 60 minutes of moderate- to vigorous-intensity activity on most days of the week while not exceeding caloric intake requirements.


• To sustain weight loss in adulthood: Participate in at least 60 to 90 minutes of daily moderate-intensity physical activity while not exceeding caloric intake requirements. Some people may need to consult with a healthcare provider before participating in this level of activity.


Achieve physical fitness by including cardiovascular conditioning, stretching exercises for flexibility, and resistance exercises or calisthenics for muscle strength and endurance.



Key recommendations for specific population groups




• Children and adolescents. Engage in at least 60 minutes of physical activity on most, preferably all, days of the week.


• Pregnant women. In the absence of medical or obstetric complications, incorporate 30 minutes or more of moderateintensity physical activity on most, if not all, days of the week. Avoid activities with a high risk of falling or abdominal trauma.


• Breastfeeding women. Be aware that neither acute nor regular exercise adversely affects the mother’s ability to successfully breastfeed.


• Older adults. Participate in regular physical activity to reduce functional declines associated with aging and to achieve the other benefits of physical activity identified for all adults.


From U.S. Department of Health and Human Services, U.S. Department of Agriculture: Dietary guidelines for Americans, 2005. Available online at www.healthierus.gov/dietaryguidelines. Accessed August 5, 2010.


Excess intake of fruit juices may decrease a child’s appetite and cause weight loss. Conversely, excess intake of fruit juices with high caloric content may cause weight gain.



Breastfeeding


Observing and discussing issues regarding breastfeeding with the mother may reveal important information. Infants should be breastfed 8 to 12 times in a 24-hour period. Breastfeeding requires more energy expenditure from the infant, and occasionally infants fall asleep while feeding and thus do not receive an adequate amount of breast milk. Nipple soreness is usually caused by improper positioning and/or poor latching or unlatching and can lead to a diminished milk supply. Maternal hydration is important for adequate milk supply.



Formula-fed infant


Investigating what formula the infant is being fed and how the formula is prepared is important. Formulas come in powder and liquid forms. Powder formula requires reconstitution with water. Liquid formula comes in two forms: concentrated (requiring the addition of water) and ready-to-feed. Taking a history of how the formula is prepared is important to determine whether incorrect preparation is causing weight loss.





Are emotional issues contributing to weight loss?



Key questions



image Have you recently had a stressful event in your life? How are you coping?


image Do you or anyone in your family have a problem with anxiety or depression?


image How are you doing in school or at work?


image If a child: Is the child gaining weight appropriately?



Psychosocial factors


Emotions have a big impact on appetite and eating behavior. One reaction to extreme stress or depression may be a loss of appetite. Individuals may have patterns of coping with stress by controlling food intake. Anorexia nervosa and bulimia are eating disorders most often diagnosed in young females. With these two disorders, despite the low or normal weight, the individual perceives herself or himself as overweight. Anorexia nervosa carries a high risk of complications due to electrolyte imbalances.



Failure to thrive


Failure to thrive in infants may have a nonorganic etiology. Causes include but are not limited to caretaker’s employment status, social isolation, family stress, substance abuse, postpartum depression, and poor parenting skills.





What cues indicate a pathologic process?



Key questions



image Have you had a fever or any signs of illness?


image Have you ever been diagnosed with cancer?


image Have you had a change in urinary or bowel habits?


image Do you experience fatigue?


image In a room where others are comfortable, are you often too cold or too warm?


image Have you had a change in appetite or thirst?


image If a child: Has your child’s appetite changed?


image If a child: Has your child’s activity level changed?



Acute or chronic conditions


Fever associated fatigue and lymphadenopathy may indicate an infection. Chronic conditions, such as cough, shortness of breath, nausea, vomiting, anemia, fatigue, weakness, change in moles, pain, abnormal menstrual bleeding, breast discharge, or chronic headaches, can contribute to unintentional weight loss. Crohn disease is an inflammatory bowel disease that can be associated with a reduced appetite.


Unintentional weight loss is a red flag for cancer occurrence or reoccurrence. Weight loss can occur from loss of appetite and decreased caloric intake, or from the body’s inability to absorb nutrients because of the cancer.



Diabetes


Diabetes is a disease caused by insulin secretion deficiency and insulin resistance resulting in elevated blood glucose levels that do not allow nutrients to enter cells. Along with weight loss, untreated diabetes is often associated with increased hunger, excessive thirst, and frequent urination.



Endocrine disorders


Hyperthyroidism is a condition that speeds up metabolism, thus burning more calories. It is the most common thyroid function disorder. Symptoms include trembling, insomnia, and hair loss.


Hypothyroidism is when thyroid hormones are insufficient. In less developed countries, it is most often due to is iodine deficiency; however, in the U.S., autoimmune processes are the major cause. Onset of symptoms is insidious and involves every organ system. A history will reveal symptoms of lethargy, dry skin, cold intolerance, deepening of voice, and facial puffiness. Cushing syndrome is a result of prolonged exposure to excessive levels of glucocorticoid cortisol, which has a catabolic effect on most tissues. Muscle wasting and weakness is due to generalized protein catabolism.



Appetite/activity level change


A change in an infant or child’s appetite and activity level is a good indicator of illness. Appetite can decrease with an inactive lifestyle or the presence of chronic pain, irritable bowel syndrome, or other conditions that might be exacerbated by eating.





What other symptoms might help narrow the possibilities?



Key questions



image When was your last cancer screening?


image If a child: Has your child recently switched to solid food?


image Do you have a family history of cystic fibrosis?


image Does anyone in your household have a history of tuberculosis?

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Apr 10, 2017 | Posted by in NURSING | Comments Off on Weight loss/gain (unintentional)

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