WEIGHT LOSS (PowerPoint download)

							BY DR NAGANATH NARASIMHAN PREM
DEFINITION
 Loss of 4.5Kg or more than 5% baseline body weight
  over a period of 6-12 months.

 Could be due to—
 Decreased energy intake
 Increased energy expenditure
 Loss of energy in urine or stools
PHYSIOLOGY OF WEIGHT LOSS
 Appetite ,metabolism---neural ,hormonal factors
 Hypothalamus-feeding and satiety centers important
 Neuropeptides– CRH,alpha MSH,Cocaine and
    Amphetamine related transcript centrally acts on
    satiety center.
   Leptin
   Cytokines like TNF alpha,IL-6,IL-1,Interferon alpha,
   Ciliary Neurotrophic factor(CNTF),
   Leukemia inhibitory factor(LIF)
WEIGHT LOSS
 1. Involuntary---with increased appetite
                ----with decreased appetite
 2.Voluntary
CAUSES
 INVOLUNTARY WITH INCREASED APPETITE
 1.Hyperthyroidism


 2.Uncontrolled Diabetes Mellitus


 3.Malabsorption Syndromes


 4.Marked increased physical activity
CAUSES
 INVOLUNTARY WITH DECREASED APPETITE
 MEDICAL CAUSES
 1.Malignancy(GIT,lung,lymphoma,prostate and renal
    cancer)

 2.Gastrointestinal Diseases
 Peptil ulcer disease     Malabsorption
   Diabetic enteropathy    Dysphagia
   Inflammatory Bowel Disease Hepatitis
   Zenkers Diverticulum
   Paraoesophageal hernia
CAUSES
 3.Endocrine
 Hyperthyroidism
 Diabetes Mellitus
 Adrenal Insuffiency


 4.Infections
 HIV              Tuberculosis
 Viral Hepatitis   Chronic fungal/Bacterial Diseases
 Chronic Helminth Infections
 Lung abscess
CAUSES
 5.Severe Heart,Lung and kidney diseases
 Cardiac cachexia from heart failure
 Pulmonary from Obstructive/Restrictive Lung Disease
 Renal Failure
 Chronic Glomerulonephritis
 Nephrotic Syndrome


 6.Neurological
 Stroke          Parkinson’s Disease
 Dementia
 Dysphagia
CAUSES
 7.Non Infectious Chronic Inflammatory Diseases
 Sarcoidosis
 Severe Rheumatoid Arthritis
 Giant cell Vasculitis


 Psychiatric
 Depression              Bipolar Disorder
 Generalised Anxiety     Food related delusions
DRUGS
 Alcohol                  Opiates
   Amphetamines ,Cocaine
   Drug withdrawal Syndromes
   Adverse effects of prescribed drugs
   Topiramate          Zonisamide
   SSRI’S              Levodopa
   Digoxin              Metformin
   Exenatide            NSAID’S
   Anticancer            Antiretroviral
VOLUNTARY WEIGHT LOSS
 1.Drugs
 Used for treatment of obesity
 Rimonabant           Simtramine
 Orlistat             Metformin
 Phentermine           Bupropion

 Prescription drugs abused for weight loss
 Amphetamines
 Thyroid hormones


 Herbal and other non prescription drugs
Causes
 2.Dieting


 3.Anorexia nervosa and Bullemia


 4.Chronic vigourous exercise combined with dieting
 Distance runners
 Models
 Ballet Dancers
 Gymnasts
Cancer                   Cardiac disorders
                          Chronic ischemia
Endocrine and             Chronic congestive
metabolic                heart failure
 Hyperthyroidism
 Diabetes mellitus       Respiratory disorders
 Pheochromocytoma         Emphysema
 Adrenal insufficiency    Chronic obstructive
                         pulmonary disease
Gastrointestinal
disorders                Renal insufficiency
 Malabsorption
 Obstruction             Rheumatologic disease
 Pernicious anemia
Infections             Medications
 HIV                   Antibiotics
 Tuberculosis          NSAID’S,SSRI’S
 Parasitic infection   Metformin,Levodopa
 Subacute bacterial    ACE inhibitors Others
endocarditis
                        Neurologic
Disorders of the mouth Stroke, Dementia
and teeth               Parkinson's disease
Age-related factors     Neuromuscular
Physiologic changes     disorders
Decreased taste and
smell                   Social
Functional disabilities Isolation
                         Economic hardship
Psychiatric and behavioral
 Depression
 Anxiety
 Bereavement
 Alcoholism
 Eating disorders

Increased activity or exercise

Idiopathic
APPROACH IN WEIGHT LOSS
 Initial History Questions


 Whether voluntary/involuntary
 Has the patient have increased/decreased appetite
 Poor appetite –more causes
 Increased appetite—Less


 Has patients physical activity increased recently
 Magnitude of weight loss in Kgs and % of weight loss.
 Time interval of weight loss defines onset and helps in
 calculating caloric deficit
 If measurement cannot be done objectively then
 Changes in the belt notch position
 Fitting of clothes may be confirmatory
 Routine documentation during office visits is
 important

 Sudden weight loss of a stable person >>> dangerous
 than a person with fluctuating weight loss
Signs/symptoms
 Associated with weight loss
 Fever                     Pain
 Cough                     Palpitations
 Dyspnoea
 Evidence of neurological disease


 GIT Symptoms
 Difficulty in eating      Dysphagia
 Anorexia                  Nausea
 Changes in bowel habits
History Continued
 Travel History
 Addiction—smoking ,alcoholism
 All Medications
 Previous Illness ,Surgery
 Disease in family members
 Risk factors for HIV infection
 Sexual History
 Depression
 Dementia
 Social factors,Financial issues
Physical Examination
 Weight determination
 Vital signs
 Pallor,icterus
 Turgor
 Scars from previous surgery
 Stigmata of Systemic diseases
 Oral Thrush
 Dental Diseases
 Thyroid gland Enlargement
 Adenopathy
 RS,CVS abnormalities
Physical examination continued
 Detailed Per Abdominal Examination
 Rectal examination—including prostate
 Pelvic examination---In women


 Neurological Examination


 Mental status assesment


 Screening for dementia,depression
INVESTIGATIONS
 INITIAL TESTING
 CBC
 Electrolytes
 Glucose
 LFT,RFT
 TSH
 Urinalysis
 CXR
 ECG
 All cases recommended cancer screening tests for
  particular age group and gender should be done
 Mammography
 Colonoscopy
 PSA
 ADDITIONAL TESTING
 HIV test
 Tuberculosis Screening
 Upper and Lower GI Endoscopy
 CT abdomen/MRI
 CT chest


 ETIOLOGY OF WEIGHT LOSS IF NOT
 FOUND,CAREFUL CLINICAL FOLLOW UP,RATHER
 THAN PERSISTENT UNDIRECTED TESTING IS
 MORE SENSIBLE
INVOLUNTARY WEIGHT LOSS
 WITH INCREASED APPETITE
 Increased energy expenditure
 Increased caloric loss in urine/stool
 Increased appetite not sufficient to overcome the
  deficit in energy balance
HYPERTHYROIDISM
 Increased Energy expenditure
 Can be associated with malabsorption,increased GI
  motility
 Frank anorexia in elderly(APATHETIC
  HYPOTHYROIDISM)
 Degree variable


 In some young patients,increase in appetite exceeds
 rise in energy expenditure hence weight gain rather
 than weight loss.
UNCONTROLLED DIABETES
 M/C cause
 Prominent with new onset Type 1 DM
 Insulin Deficiency --> severe hyperglycaemia--
  >Glycosuria-->Osmotic diuresis-->ECF vol
  Decreases Loss of weight
 In treated patients of diabetes poor metabolic
  control HBA1c estimation can help in coorelation.

 Young woman,with type 1 DM,decreasing isulin dose
  on purpose in order to lose weight
 Should be considered in young patients
MALABSORPTION
 Most,but not all have diarrhaea


 Large volume/frequent bowel movements


 IBD-Weight loss with poor appetite
PHAEOCHROMOCYTOMA
 Increase Adrenergic activity increased BMR
 Loss of weight with increased appetite
INCREASED PHYSICAL ACTIVITY
 Intense training should be supplemented with
  increased intake of calories to maintain weight and
  muscle mass
 Sometimes appetite might not increase
  sufficientlytransient/persistent loss of weight
INVOLUNTARY WEIGHT LOSS
 WITH DECREASED APPETITE
 CANCER
 Cancer anorexia cachexia syndrome
 Weight loss and tumour both increased energy
  expenditure and decreased intake maybe present
 Production of cytokines(TNF alpha,IL-6)
 C reactive protein
 Other tumorous substances maybe released in
  circulation
 Factors causing decreased nutrient intake/absorption


 Chemotheraphy and radiotheraphy induced
 Anorexia,Nausea,Vomiting,infections,dysphagia,abdo
 minal pain,distension

 Early satiety due to
 Hepatic/Splenic Enlargement
 Abdominal mass/distension
 Hypercalcemia
 Malabsorption GI tumor/Intestinal resection
HIV INFECTION
 Muscle wasting/weight loss common
 Total energy expenditure similar to (N) people
 Weight lossdecreased energy intake,during periods
 of rapid weight lossenergy expenditure falls below
 normal(decreased physical activity) but>>> intake

 TWO types of weight loss
 RAPID secondary infection
 GRADUALGIT diseases with diarrhaea & decreased
 reduction in energy intake.
ENDOCRINOPATHIES
 Adrenal insufficiency
 Chronic Glucocorticoid
  deficiencyanorexia,nausea,weight loss
 Young childrenmineralocorticoid deficiencyECF
  volume contractiondecrease in weight

 HYPERCALCEMIA
 Anorexia,Nausea,Weight loss
 In patients with Cancer.
 HYPERTHYROIDISM
 Elderlyloss of appetite + increased energy
  expenditureweight loss more than usual


 DIABETES MELLITUS
 Poor appetite,weight lossGastroparesis,diarrhaea,
  Malabsorption from autonomic intestinal
  neuropathy,coeliac disease,renal insufficiency

 Type 1 DM,loss of weightconcomittant Addison’s
  disease,in setting of decreased insulin requirements &
  frequent hypoglcyaemia
Diabetic Neuropathic Cachexia
 Painful Diabetic Neuropathy


 Cause of weight loss not known


 Chronic pain,poor diabetic control,reactive depression


 Associated Diabetic
  gastroparesis/enteropathy,autonomic
  neuropathy,autonomic vagotomy may play a role
 Subsides in 6-10 months,once metabolic control is
  achieved.
Cardiac/Pulmonary disease
 Complication of CCF and COPD
 Loss of lean body mass& adipose tissue marked in
  patients in presence of increased oedema.
 Mechanism for muscle atrophy and weight loss not
  known
 Oxidative stress contributes imbalance between
  protien degradation & synthesis.
 Skeletal muscle loss & lean body mass exacerbates
  functions & worsens prognosis.
Chronic Illness
 Chronic systemic/infectious diseases affecting any
 sytem anorexia/weight loss

 In absence of feverweight lossdecreased food
 intake,increased energy expenditure possible in some
 disorders

 In feverincreased metabolic rate and energy
 expenditure
Gastrointestinal Diseases
 Loss of appetite with decreased food intake & weight
    loss direct /indirect mechanisms
   Dysphagia
   Sensation of satiety
   Vomiting & regurgitation
   Abdominal pain/discomfort
   Chronic inflammation
   Malabsorption
   Spontaneous and surgical fistulas and bypasses
   Superior mesenteric artery syndrome
Depression/other disorders
 Unexplained weight loss >5% of body weight in a
 month(Diagnostic for major depression)

 Manic Depressive diseases


 Munchausen syndrome


 Delusion/Paranoid disorders


 Cannabis Withdrawal syndrome
Neuroleptic Withhdrawal Cachexia
 Marked weight losstreated for years with high doses
 of major neuroleptic drugs(Chloropromazine),when
 the drug is rapidly tapered or stopped

 Anorexia/Weight lossbehavioral alteration /central
 neuroendocrine alteration due to decreased dose
Substance abuse/Medications
 Smokers
 Opiates inhibit appetite centerdecrease
  gastric,biliary & pancreatic secretions and GI motility.
 Amphetamines/Cocaineadrenergic stimulatory
  affects on satiety center in Hypothalamus.
 Herbal productsadulterated with weight reducing
  medication.
 Prescription Drugs
Voluntary Weight Loss
 Many people lose weight voluntarily.
 For the obese,this is encouraged and not abnormal.
 DIETARY METHODS
 Total fasts
 Mixed hypocaloric diets
 Carbohydrate lacking Ketogenic diets
 Drugs like Sibutramine and Orlistat.
Voluntary Weight loss
 Young women
 Poor food intake(Anorexia Nervosa)
 Increase exercise
 Self induced vomiting
 Diuretic/Laxative abuse


 Distance runners,models,ballet dancers,gymnasts.
THANK YOU