We had a great lecture about unintentional weight loss last week for resident academics. I wanted to share my takeaways here for a couple of reasons: First, it will solidify what I learned. Second, it ties into a recent podcast I heard that served as a reminder about weight bias in healthcare.
Checking our Assumptions about Weight Loss
When I was a physiotherapist, I treated a lovely patient with knee osteoarthritis. She did well with her home exercise program, and I discharged her from my care.
She returned about a year later to see me for a different issue. She had lost at least forty pounds, and the first thing I said when I saw her was, “Wow, you look great!”
You can guess where this is going.
She replied, “Thank you, it’s the cancer.”
Yikes.
It’s been nine years since I made that mistake, and I’m careful not to make it again.
We revere weight loss and thinness in our society. We equate skinny with healthy, and worse; we equate a low body weight with some sort of moral value.
I’ve had viral gastroenteritis three times this year. Due to many factors (like being sick, frequently carrying my sick son around, breastfeeding, and the GERD I’ve had since pregnancy making it hard to eat big meals) I’m now at the lowest weight I’ve ever been as an adult.
People with whom I haven’t shared my story have been complimenting me on how good I look. And it’s weird. I’m the least healthy I think I’ve ever been, but our society would have us assume the opposite.
One of my favourite podcasts, Mayo Clinic Talks, recently released an episode about breaking down weight bias. Dr. Bhagra explains the main cause of weight bias in healthcare:
“If we introspect into the origin of the bias, we’ll notice that the belief that people are 100 percent in control of their body weight is probably the basis for the bias. Because if we truly understand the systemic nature of any health problems, particularly weight gain, we can probably empathize more with the person who lives in a larger body as opposed to blaming them for being in that shape.” — Sumit Bhagra, MD
It’s important to be aware of our assumptions about weight.
Onwards!
Assessing Unintentional Weight Loss in Primary Care
Unintentional weight loss is defined as an unexpected loss of more than 5% of someone’s body weight over 6-12 months.
There are many causes that we have to think about in primary care. The most common are cancer, psychological disorders (especially depression), and non-cancer gastrointestinal issues. In about a quarter of cases, in spite of an appropriate investigation, a cause isn’t identified.
Below is a great table from Up to Date listing a broad differential diagnosis for unintentional weight loss.
On history, it’s important to ask questions to elicit common causes of weight loss. For instance, did the patient start a new medication? Do they use recreational drugs? Have they had a recent change in their mood? Might they have food insecurity or an eating disorder? And of course, we need to ask about all the body systems that can be a source of unintentional weight loss.
On physical exam, we’d assess all the body systems that may be a culprit. We’d look at their general appearance for pallor or jaundice, listen to their heart and lungs, press on their belly for any masses, and feel their neck for any swollen lymph nodes.
The lecturer also highlighted the importance of regularly taking patients’ weights so that we can track it over time and have an objective measure of their weight loss. Some patients prefer not to know their weight, which is perfectly fine! You can always ask them to stand on the scale facing away from the number so that they don’t see it.
Next up – investigations.
In medicine, we’re slowly but surely adopting a less-is-more approach. This means going about investigations in a stepwise fashion, with the most helpful and least invasive tests being done first. For weight loss, this includes basic bloodwork, a chest x-ray, and making sure the patient is up to date on their cancer screening.
I made a stamp you can find here that summarizes the initial assessment for unintentional weight loss. (Stamps are pre-formatted blocks of texts that healthcare providers can put into a patient’s electronic chart in order to document faster.)
I hope this helps the next time you see a patient who has unexpectedly lost weight. Let me know what I missed in the comments below!
Stay well friends,
Dr. Kuhnow
Comentários