An approach to the management of unintentional weight loss in elderly people.

Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period. A variety of physical, psychological and social conditions, along with age-related changes, can lead to weight loss, but there may be no identifiable cause in up to one-quarter of patients. We review the incidence and prevalence of weight loss in elderly patients, its impact on morbidity and mortality, the common causes of unintentional weight loss and a clinical approach to diagnosis. Screening tools to detect malnutrition are highlighted, and nonpharmacologic and pharmacologic strategies to minimize or reverse weight loss in older adults are discussed.

Weight change, body weight and mortality: the impact of smoking and ill health.

OBJECTIVES: This paper examines the influence of cigarette smoking and ill health on the relationship between weight change, body weight and subsequent mortality to determine whether weight loss and leanness in middle to older age is deleterious to health. METHODS: Men aged 40-59 years at screening drawn from one general practice in each of 24 British towns, who completed a questionnaire 5 years after screening (Q5) and provided full information on changes in weight and smoking status (n = 7065) were then followed up for an average of 13.8 years. RESULTS: In all men a shallow U-shaped relationship was seen between body mass index (BMI) at Q5 and all-cause mortality rates. weight loss and substantial weight gain (> or =10%) were associated with increased mortality rates compared to the stable weight group. The increased risk associated with weight loss was seen in long- term non-smokers (n = 4101) and recent ex-smokers (n = 722) but not in current smokers (n = 2242) after adjustment for a wide range of potential confounders. However, the increased risk was markedly attenuated after exclusion of those with ill health (relative risk [RR] = 1.16, 95% CI : 0.84-1.59 and RR = 0.79, 95% CI : 0.29-2.20 for long-term non-smokers and recent ex-smokers, respectively). Moderate weight gain (4-10%) was associated with lower risk of mortality than observed in those with stable weight but only in recent ex-smokers and in current smokers, not in long-term non-smokers. A positive association was seen between BMI at Q5 and all-cause mortality in non-smokers and this was strengthened by exclusion of men with weight loss. CONCLUSION: The increased risk of mortality associated with weight loss or low body weight in middle-aged and older men appears to be a direct consequence of ill health leading to weight loss and leanness. In healthy non-smoking men weight loss and leanness are not associated with increased mortality and moderate weight gain (4-10%) was neither deleterious nor beneficial.

Development and validation of a hospital screening tool for malnutrition: the short nutritional assessment questionnaire (SNAQ).

OBJECTIVE: For the early detection and treatment of malnourished hospital patients no valid screening instrument for the Dutch language exists. Calculation of percentage weight loss and body mass index (BMI) by the nurse at admission to the hospital appeared to be not feasible. Therefore, the short, nutritional assessment questionnaire (SNAQ), was developed. RESEARCH, DESIGN AND METHODS: Two hundred and ninety one patients on the mixed internal and surgery/oncology wards of the VU University medical center were screened on nutritional status and classified as well nourished (<5% weight loss in the last 6 months and BMI>18.5), moderately malnourished (5-10% weight loss in the last 6 months and BMI>18.5) or severely malnourished (>10% weight loss in the last 6 months or >5% in the last month or BMI<18.5). All patients were asked 26 questions related to eating and drinking difficulties, defecation, condition and pain. Odds ratio, binary and multinomial logistic regression were used to determine the set of questions that best predicts the nutritional status. Based on the regression coefficient a score was composed to detect moderately (2 points) and severely (3 points) malnourished patients. The validity, the nurse-nurse reproducibility and nurse-dietitian reproducibility was tested in another but similar population of 297 patients. RESULTS: The questions 'Did you lose weight unintentionally?'. 'Did you experience a decreased appetite over the last month?' and 'Did you use supplemental drinks or tube feeding over the last month?' were most predictive of malnutrition. The instrument proved to be valid and reproducible. CONCLUSION: SNAQ is an easy, short, valid and reproducible questionnaire for early detection of hospital malnutrition.

The effect of rate of weight loss on erythrocyte glutathione concentration and synthesis in healthy obese men.

Obesity is commonly associated with a high incidence and prevalence of dyslipidaemia, cardiovascular disease and Type II diabetes. Interestingly, studies have also reported decreased antioxidant levels in obese subjects. This may constitute an independent risk factor in the pathogenesis of coronary artery disease as obese subjects would have a decreased capacity to prevent the oxidative modification of low-density lipoproteins, which is a mechanism suggested as central to the development of atherogenesis. As part of a study to investigate responses to weight loss, we have assessed the effects on GSH status of a decrease in body mass of 5%, either after 6 days of complete starvation or 11 days of a very low calorie diet (2.55 MJ/day). There were significant differences between the two groups in the synthesis rate of erythrocyte GSH in response to weight loss. Both the fractional and the erythrocyte synthesis rate of GSH decreased significantly (P<0.01) in the starvation group by 22% and 16% respectively. In contrast, no change in synthesis rates was observed in the very low calorie diet group (P>0.05). Total erythrocyte concentration of GSH was unaffected by the weight loss within both groups. These results suggest that erythrocyte GSH synthesis is depressed in response to a very rapid weight loss induced by fasting. An acute reduction in GSH synthesis in response to a rapid weight loss may constitute a risk factor during periods of increased GSH demands.

The epidemiology of recent involuntary weight loss in the United States population.

BACKGROUND: Although recent involuntary weight loss (RIWL) has been associated with mortality, no national studies described the prevalence among the general population, characteristics and long-term outcomes of people with RIWL. METHODS: The authors analyzed data from the NHANES II Mortality Study of 5838 individuals 50-74.9 years old who between 1976-1980 underwent a physical examination that included height and weight measurements, biochemical tests and responded to questions about involuntary weight loss within the past six months. Vital status was determined through 1992. Logistic regression was used to examine characteristics associated with RIWL and Cox proportional hazard modeling was used to measure associations between RIWL and mortality. RESULTS: 13.3% of the population reported RIWL with 6.9% reporting > or = 5% RIWL. Obese individuals were at significantly higher risk of RIWL of > or = 5% compared to those with BMI 19-24.9 (OR=1.57. 95% CI: 1.13, 2.18). Other significant risk factors for RIWL included; poor self-reported health, cancer, high white blood cell count, low albumin and low hemoglobin levels, age and current smoking status. RIWL of > or = 5% was significantly associated with mortality (RR=1.24, 95% CI: 1.01, 1.53). CONCLUSION: In summary, RIWL is fairly common among community-dwelling older adults, occurs disproportionately among obese individuals, is associated with characteristics of poor health and independently associated with mortality. These results indicate that RIWL needs to be considered an adverse health indicator even among obese individuals and despite the absence of several clinical indicators of disease.

Association between a polymorphism of the 5-HT2C receptor and weight loss in teenage girls.

Receptors of the 5-HT2C subtype are assumed to be involved in the influence of serotonin on food intake. A polymorphism in the coding region of the gene for this receptor, resulting in a cysteine to serine substitution, has been reported. Fifty-seven somatically healthy teenage girls displaying weight loss and 91 normal-weight girls of the same age, all recruited by means of a population-based screening study, were compared with respect to this polymorphism. Subjects in the weight loss group displayed a higher frequency of the serine allele than those in the comparison group (23.7% vs. 7.7%, p =.0001). Seventy-two percent of the weight loss girls fulfilled the diagnostic criteria of anorexia nervosa, whereas 28% did not; when these two groups were separately analyzed, both differed significantly from controls with respect to serine allele frequency. The results support the notion that the studied gene may be involved in the regulation of food intake in young women.

Effect of the learning curve on the early outcomes of laparoscopic Roux-en-Y gastric bypass.

Open gastric bypass has been demonstrated to provide durable weight loss in morbidly obese patients. As laparoscopic techniques have evolved surgeons are offering patients such an approach for performance of gastric bypass. The purpose of this study was to evaluate the relationship between increasing experience and outcome for this technically challenging operation. A retrospective analysis was performed on the initial 160 consecutive patients undergoing laparoscopic gastric bypass by a single surgeon over a 24-month period. Patients were divided into quartiles for data analysis. Duration of surgery decreased significantly between quartiles: 324 +/- 124, 225 +/- 70, 190 +/- 47, and 168 +/- 40 minutes, respectively (P < 0.01). However, the conversion rate (3.1%) and mean hospital length of stay (2.1 +/- 2.4 days) were unaffected by surgeon experience. The early and late postoperative complication rates were 9.4 and 3.1 per cent, respectively. Early complications included: leak (1.3%), bleeding (3.8%), obstruction (1.9%), acute gastric distention (0.6%), subphrenic abscess (0.6%), and wound infection (0.6%). Late complications include: obstruction (1.3%), anastomotic stricture (1.3%), and marginal ulcer (0.6%). The complication rates did not change statistically between quartiles. The excess weight loss at one year was 77.4 +/- 16.7 per cent. These data suggest that throughout the learning curve laparoscopic gastric bypass can be accomplished with acceptable complication rates, conversion rates, and hospital length of stay. Duration of surgery improves with experience. Early weight loss results compare favorably with those of open gastric bypass.

Perspectives: A Practical Approach to the Dietary Treatment of Hypertriglyceridemia.

Reducing high plasma triglyceride (TG) levels is an important step in the treatment and prevention of coronary artery disease. The rise in plasma TGs seen after subjects consume low-fat, high-carbohydrate diets for a period of time may be due to the simple form of carbohydrate provided and/or prevention of weight loss in these studies. Ad libitum low-fat, high-carbohydrate intake often results in weight loss and decreases in plasma TGs. Replacing dietary carbohydrate with monounsaturated fat lowers serum TG levels and maintains serum high-density lipoprotein levels but fails to result in weight loss. Low-fat, high-complex carbohydrate intake reduces incidence rates of coronary artery disease. On the basis of the evidence, a low-fat, high-complex carbohydrate diet combined with limited alcohol and sugar intake is recommended for the treatment of hypertriglyceridemia. (c)2001 CHF, Inc.