Nutrition Connection: Tackling Unplanned Weight Loss • Winter 2009

Individuals, who make New Years Resolutions, often include weight loss as one of their goals for the year. The average weight gain during the holiday season is 5-7 pounds, on top of the creeping weight gain that plagues the majority of middle-aged adults during the rest of the year. Yet for the older adult, maintaining body weight or regaining lost weight is a challenge. Medical professionals call this unplanned weight loss or involuntary weight loss.

Unplanned weight loss sounds like an oxymoron- meaning two normally contradictory terms. How can weight loss be ‘unplanned’ when dieting adults carefully monitor every morsel consumed just to hold their current weight? The difference in how the body utilizes food is related to age, functional status and presence of chronic and acute diseases. The loss of weight is due to inadequate energy intake to meet needs or a change in the way the body metabolizes food. Slow weight loss in older adults is not a response to normal aging.

Unplanned weight loss is cause for concern because it is an indicator of declining nutritional status and may be a sign of a significant change in health status. Its presence may signal worsening of a life threatening illness and possibly an indicator of the risk for sudden decline.

Assessment of Causes of Unplanned Weight Loss

Addressing unplanned weight loss requires a multidisciplinary approach. First, the health care team needs more information to determine the cause of the weight loss. Some questions to ask include:

• How much weight has been lost?
• When did the weight loss start?
• Does the person’s recent health history include medical procedures that affect body weight such as removal of a cast or amputation of a leg?
• Has the person’s appetite or thirst level changed?
• Does the person complain that ‘the food is tough’ or ‘does not taste good?’
• Has the person’s nutrition prescription (diet order) changed?
• Has the person’s total daily food and fluid intake changed?
• Has the person’s activity level changed?
• Has there been a change in the person’s bladder or bowel habits?
• Has the person’s mood changed?
• What medicines, herbs or other substances is the person taking?
• Have the person’s prescription medications or dosage of current medications changed? New diuretics or increased dosages of diuretics may alter body weight due to loss of water.
• Is the person taking medications associated with anorexia?
• Are there any other symptoms such as fever or weakness?
• Are there any signs of chewing or swallowing problems?
• Does the person have a diagnosis associated with weight loss such as dementia, depression or failure to thrive? Are these conditions worsening?
• Are the person’s cultural and religious food preferences being honored?

The initial investigation will evaluate the weight loss in light of the person’s former lifestyle, health history and current medical status. If there is significant or severe weight loss, the medical team is expected to assess the weight loss and formulate a plan of care to address the problem. CMS parameters for evaluating the significance of unplanned weight loss are noted in Table 1.

Table 1. Significance of Unplanned Weight Loss

Interval	Significant Weight Loss	Severe Weight Loss
30 days	5 percent	Greater than 5 percent
90 days	7.5 percent	Greater than 7.5 percent
180 days	10 percent	Greater than 10 percent

To determine the percentage of weight lost, you must know the usual weight and the current weight. Usual weight may not be ideal or desirable body weight. It is the most recent stable weight prior to the change in weight. Be sure that the weights you are using have been taken from the same scale. If the available weights are from different facilities or different scales, document the scale used for each weight. There can be as much as a 10 to 15 percent variation in weights on different scales.

The formula for calculating percentage weight loss with an example is noted below.

Percentage Weight Loss Formula

(Usual Wt – Actual Wt) X 100 = Percent body weight loss
       Usual Wt

Example: Usual weight 150 lb.
Actual weight 135 lb
(150 – 135 ) X 100 = 10 percent weight loss
       150

The most common causes of unplanned weight loss in older adults include anorexia, depression and dementia. There are two types of anorexia—physiologic and pathologic. Physiologic anorexia is common in older adults because it is in response to a decline in physical activity, social isolation, altered sense of taste and smell, chewing or swallowing difficulties, and changes in gastrointestinal function that leads to early satiety. Pathological anorexia is caused by both physical and psychological factors resulting in loss of muscle mass, malnutrition, dehydration and increased risk for infections.

Goal Setting

First, identify nutrition care goals for the patient/resident. For example: Prevent nutritional decline/ adverse event in 30 days (goal time). The patient/resident and family should be aware of the change in weight status and the goals to address the issues. Families may want to be involved in the goal setting process. The goals must be consistent with the advanced directives.

Level of Acuity

Next, determine the level of acuity based on the assessment. Some factors that increase the level of acuity include:

• Poor oral intake
• BMI less than 20
• Severe weight loss
• GI problems (nausea, vomiting, diarrhea)
• Infections
• Skin breakdown
• Loss of strength

Individuals with one or more factors contributing to unplanned weight loss are at higher risk for adverse medical outcomes than those with no contributing factors. All individuals with unplanned weight loss require moderate risk interventions, and those with one or more factors require high-risk interventions. The RD should be consulted with all patients/residents with unplanned weight loss.

Intervention Strategies

Once it is determined that the person has experienced an unexplained, involuntary weight loss, formulate a plan of care to address the unique needs of the patient/resident. Your plan may include both nutrition care interventions as well as collaborative interventions with other members of the healthcare team. Ask family members for suggestions to increase oral intake, to gain their support and hopefully participation in the plan of care.

The nutrients of greatest concern for the person with unplanned weight loss are:

• Calories
• Protein
• Fat
• Fiber
• Folate
• Vitamin B12
• Vitamin D
• Calcium
• Iron
• Zinc
• Fluid

Review the laboratory test results with the RD to determine possible nutrient deficiencies. Be sure your nutrition interventions address all nutrients that may be deficient in the diet.

Selection of intervention strategies should follow a continuum of care starting with food and ending with aggressive nutrition support. Always start with your menu and current meal service. Next, enhance the nutrient density of menu items using food fortifiers. Always taste test fortified items to be sure the enhanced product meets taste and texture expectations. If it is determined that fortified menu items do not meet nutrient needs of the patient/resident, consider adding oral nutritional supplements. These products may be more palatable to the patient/resident if enhanced with favorite foods. For example, add ice cream and flavored syrup to the milk shake products or add pureed fruit and yogurt to make a smoothie. Be sure to taste test these products for flavor and texture before serving them to the patient/resident. Avoid serving the same oral nutritional supplements several times a day unless the patient/resident refuses to accept alternate flavors. Variety in the selection of oral nutritional supplements is important to ensure intake.

Sample nutrition care and collaborative interventions are listed below. The list below is not designed to be a complete list of all the possible interventions. Generally speaking, moderate risk interventions are those that focus on food, meal service and fortified foods. High-risk interventions include food, meal service, fortified foods and nutrition support products. The collaborative interventions can apply to either the moderate or high-risk patient/resident. Your plan of care should include only the interventions you plan to use. Avoid using a ‘one size fits all’ approach to unplanned weight loss.

Sample Interventions for Unplanned Weight Loss

Interventions that Focus on Food & Meal Service

• Adjust the menu to provide more favorite foods
• Adjust the times of meals
• Increase the time allowed for a meal
• Serve 5-6 small meals/day
• Serve foods in individual dishes
• Present 1-2 menu items at a time instead of serving the full tray at the beginning of the meal
• Change the form of menu items i.e. finger foods, frozen juice bars
• Add a variety of high energy snacks between meals

Interventions that Focus on Fortification of Food

• Enhance favorite menu items with additional protein and energy
• Enhance current snacks with additional protein and energy

Interventions that Focus on Nutrition Support Products

• Provide oral nutritional supplements between meals
• Collaborate with RD on tubefeeding or parenteral feeding

Collaborative Interventions

• Collaborate with RD and MD to liberalize nutrition prescription
• Collaborate with nursing to provide verbal cueing and/or assistance at meals
• Collaborate with nursing on weekly weights
• Collaborate with RD on evaluation of lab test results
• Collaborate with RD to request additional of lab tests
• Collaborate with nursing and pharmacy to recommend a vitamin mineral supplement
• Collaborate with rehabilitation services to recommend restorative dining
• Collaborate with pharmacy on need for appetite stimulant
• Collaborate with RD, MD and nursing on tubefeeding or parenteral feeding

Monitoring & Evaluation

The healthcare team needs a system of monitoring the success of intervention strategies in a timely manner. Not all interventions will be successful. Patients/residents may initially accept a change in food or meal service or fortified food, but later refuse the enhanced item or change in meal service. Be prepared to adjust interventions as necessary. Document all efforts to meet nutrient needs even when the outcomes are not as planned. Collaborate with the RD and other healthcare team members to ensure continuity of care. Follow up with families to seek their suggestions and to let them know you are doing everything possible to meet the nutrition needs of their loved one.

 

By Mary D. Litchford PhD, RD, LDN