Preventing Unintentional Weight Loss
Unintentional weight loss is a 4-letter word in my practice. Learn more about how to prevent unintentional weight loss in older adults.
It’s about Independence
Unintentional weight loss steals one of the most import pieces of an older adult’s life: their independence.
Key word: “unintentional”. With unintentional weight loss comes loss of muscle. We need muscle to function. To get out of bed in the morning, get dressed, feed ourselves… we need muscles for independence.
We live in a world where weight loss is glamorized. Weight loss is something to be congratulated and encouraged… regardless of how it came off. For older adults, particularly sick frail older adults, unintentional weight loss is something to fear. It can rob an older adult of their independence or even lead to early death.
Do you know what to do when unintentional weight loss in the elderly strikes?
Keep reading to learn more about how you can help stop unintentional weight loss in older adults. By doing this, you are helping to preserve their independence. You will help them to thrive in their final years.
Statistics in Older Adults
It is estimated that 13% of ambulatory older adults experience unintentional weight loss. For older adults in a nursing homes, that number goes way up. It’s estimated that 50 – 60% of older adults in nursing homes experience unintentional weight loss (1).
Malnutrition, which goes hand-in-hand with unintentional weight loss, is also prevalent among older adults. While there is wide variation in estimates of older adults with malnutrition, we know many more are at risk for malnutrition.
Malnutrition is estimated to affect 1-15% of older adults living independently in Europe and North America. Older adults who live in care facilities experience higher rates of malnutrition, anywhere from 25-60%. And approximately 35-65% of older adults in hospitals have malnutrition (2).
So, what exactly is unintentional weight loss?
Unintentional Weight Loss definitions
Unintentional or unintended weight loss can be any amount of weight that is lost accidentally. Meaning, they didn’t intentionally cut back on calories or increase physical activity to lose the weight. It just happened.
The Centers for Medicare and Medicaid Services (CMS) provides guidance for defining for unintended weight loss. These definitions are based on the percentage of body weight lost over a specific period of time (3). This information is frequently used within healthcare facilities.
- Unintended weight loss (3)
- 5% body weight lost in 30 days
- 7.5% body weight lost in 90 days
- 10% body weight lost in 180 days
Percentage of loss= Usual Body Wt-Current Body Wt x 100
. Usual Body Wt
Keep in mind, you do not need to wait to hit these numbers to begin intervention. Some older adults will never lose weight at such a rapid rate, but their weight loss can still be an issue.
Gradual unintended weight loss over time is known as “insidious weight loss”. This can be where an older adult loses only 1-2 pounds per month, but for a continued period of time. Insidious weight loss can be just as important as rapid. But sometimes it can be trickier to detect since the weight loss is so gradual.
Before moving on I would like to emphasize the importance of obtaining accurate weights in older adults. Different scales can vary in their readings, particularly if they have not been calibrated as recommended by the manufacturer. It is ideal to use the same scale with the same person.
Also, it never hurts to double check a weight if a reading seems completely out of left field. Particularly if you were not the one who recorded the weight. Errors do happen when recording weights.
Unintentional Weight Loss is a Symptom
Unintentional weight loss is the problem we are addressing in this article. But the reality is, unintended weight loss is not really a problem, but a symptom. When unintentional weight loss occurs, we need to figure out the root cause on WHY weight loss is occurring. Then we focus interventions (what we do to fix it!) towards that cause.
And sometimes it’s not just one thing, it can be multiple issues contributing to unintentional weight loss in older adults. Maybe the older adult has no appetite and is losing weight because they are actively sick, on medications that cause weight loss, and because they have dementia.
When addressing unintentional weight loss, we need to figure out the WHY. We want to find the root cause of unintended weight loss, if possible. However, for one in four older adults with unintended weight loss, no obvious cause can be identified (1).
Let’s look at known reasons for unintentional weight loss in older adults.
What Causes unintentional Weight Loss
Older adults are at increased risk for unintentional weight loss for several reasons. Risk factors include physiological, psychological, and social factors (1).
Physiological factors include things that cause the body to use up energy (read: calories) faster. It makes it hard to keep on the weight if the body is burning more calories than are being eaten. Examples include when someone has pressure injuries or non-healing wounds or cancer. They need more calories.
Psychological factors include a variety of factors. Many older adults experience depression and anxiety (treated or untreated). This can impact appetite and intake. Older adults with dementia also experience unintentional weight loss because they may forget to eat or how to eat.
And let’s not forget about bereavement- that period of time a person mourns the loss of someone they love. The older you get, the older the people you have known over your lifetime. And when those people you know and love start passing away, it can be hard. It can cause decline in intake and loss of weight.
Finally, social factors like living in poverty, living alone, not having a support system, and not being able to get food or prepare meals can contribute to unintended weight loss in older adults.
When an older adult in your life starts losing weight unintentionally, start investigating the why. Here is a quick list to review with potential causes of unintentional weight loss:
- Poor appetite (Sick, side-effect of medication, mental health, no known cause)
- Difficulty chewing or swallowing
- Pressure injury, non-healing wound
- Cancer, AIDS, ALS
- Dementia or Alzheimer’s disease
- Unable to prepare meals or shop for food
- Unable to afford food
Knowing the WHY can help you fix the ROOT ISSUE and STOP unintentional weight loss in older adults.
Weight Loss at End of Life
I would like to take a moment to address unintended weight loss that occurs at very end of life. This type of weight loss is a part of the dying process and does not require the same interventions outlined in this article. To learn more, check out my blog post on nutrition at end of life.
Risk of Weight Loss and Malnutrition
We’ve covered a lot about what can cause unintentional weight loss in older adults, but why is it such a problem? What’s the big deal if an older adult loses a little weight? Well, it’s usually a big deal. It can contribute to small issues and significant problems.
The biggest issues I would like to discuss are malnutrition and loss of independence.
Malnutrition is defined as (4):
“An acute, subacute or chronic state of nutrition, in which a combination of varying degrees of overnutrition or undernutrition with or without inflammatory activity have led to a change in body composition and diminished function.”
And it’s a major problem among older adults. Up to 1 in 2 older adults are at risk for malnutrition. And rates of malnutrition increase with age. Adults 85 years and older have the highest rates of malnutrition of any age group (4).
Learn more here:
Keep in mind that malnutrition can be present regardless of total body weight. And malnutrition increases risk of hospitalization, health complications, and risk of death. Let’s talk about why older adults are at a higher risk for malnutrition.
One of the key reasons is sarcopenia.
Sarcopenia in Older Adults
Sarcopenia is the decline of skeletal muscle tissue with age. It is a major cause of functional decline and loss of independence in older adults. Sarcopenia actually starts when we are quite young. In general, sarcopenia starts around age 30 and the loss of muscle mass continues each year of life (5).
In other words, older adults have less muscle.
Loss of muscle, or sarcopenia, is one of the main reasons unintentional weight loss is so detrimental in older adults. Older adults already have diminished muscle due to sarcopenia and their age. When unintentional weight loss strikes, they are losing EVEN MORE muscle.
This further increases their fall risk, decreases their ability to do activities around the house (like getting dressed, cooking, etc.), decreases their level of independence, and increased their risk of death (5).
Independence in Older Adults
Let’s talk independence. In my opinion, one of the biggest issues with unintentional weight loss is that it contributes to a loss of independence and function.
We need muscle to function. We need it to get out of the bed in the morning, get dressed, use the restroom, walk into the next room, make our meals… without muscle we are unable to be independent. We need to rely on others to do these tasks for us.
Can you imagine what life would be like if you were so frail you couldn’t even button your shirt? Such frailty and disability may mean the older adult can no longer live at home alone- they would need to move to a higher level of care or hire caregivers in the home to help them do everyday tasks.
Think about how our elders imagined their retirement and final days. Likely they imagined being independent (for the most part) and being in control of their daily life like they always have.
We can help them maintain that level of independence and quality of life by preventing unintentional weight loss and malnutrition. This is 1000% about quality of life. About dignity. About respect. So, what can we do about it?
Interventions to Stop Unintentional Weight Loss
Let’s take a look at the toolbox we have for stopping unintentional weight loss in older adults.
The most important thing to remember is: in whatever you do, it should be individualized for the specific older adult you are working with. There is no one-size fits all approach for nutrition care, especially with older adults.
Working with a geriatric dietitian is ideal because they are uniquely qualified to utilize medical nutrition therapy in treating unintentional weight loss. Now I know not everyone has access to a geriatric dietitian (enter tears here), but here some other things you can do to help.
Unintentional Weight Loss Tool Box:
- Food first approach
- Provide FAVORITE foods
- Ensure display of meals look appetizing
- Create a pleasant dining environment
- Increase calories in the foods already being eaten
- Weight gain smoothies/shakes (store-bought or homemade)
- Appetite stimulants (*use with caution)
- Tube feeding (*use with caution)
Foods First Approach
The first approach in the treatment of unintentional weight loss is always FOOD FIRST. We don’t jump to supplements- we start with real food. We want to provide more calories to stop the weight loss. Aim for providing at least 6 meals/snacks per day with lots of calories.
Above all, provide favorite foods. Foods they actually feel like eating. Go ahead and ask- what sounds good to you? What are your favorite foods? What you can you eat even when you aren’t hungry? Keep in mind favorite foods can change over time. Maybe foods taste different and they now have new favorite foods.
Be mindful of the way food is served. Eating starts with our eyes and our noses. Food that looks appealing and smells delicious will be easier to consume than dull, single colored, mushed food served with an ice-cream scoop. The extra effort to serve meals on nice dinnerware with some extra garnish goes a long way.
The same goes for the environment in which we eat in. Is it cluttered, dirty, distracting, dark, or maybe they eat in their rooms or at their bedside? If at all possible, create a pleasant space for the older adult to dine in. A pleasant environment is important for mealtimes.
High Calorie Foods
Increasing calories in the foods already being eaten is what I like to call, getting more “bang for your buck.” If an older adult is already eating certain foods, why not maximize the number of calories they are getting in the same volume?
An example of this would be with oatmeal. If the older adult in your life eats oatmeal every morning- what can you add to increase the calories? Whole milk, butter, sugar, nuts, peanut butter, dried fruit, all of the above?
Here is a list of foods you can add to too foods to bump up the calories:
- Soft spread margarine
- Whole milk
- Half and half
- Olive oil
- Nut butters
- Dried fruit
I’m sure you can imagine areas you can add these foods. For instance, you can add these foods to cereals, soups, sandwiches, in cooking, and in baking. My High Calorie Foods SERIES on RD2RD includes a high calorie food list, grocery list, and meal planner if you are interested!! And be sure to snag my free High Calorie Snacks handout.
Smoothies & Shakes
Weight gain smoothies and high calorie shakes are another great option to stop unintended weight loss in older adults.
Weight gain smoothies are simply smoothies with a lot of calories in a small volume- we call this calorically dense. You can buy them or make them. There are so many varieties you can make or buy.
If you choose to buy weight gain smoothies or shakes from the store- look at the nutrition facts label for calories and protein. The more calories you can get per serving the better! The particular name brand doesn’t usually matter. These products can be expensive, so you don’t need to pay more for good advertising.
You can also make your own weight gain smoothies at home. All you need is a good blender and some creativity. You can start with an ice-cream base and add in some chocolate syrup, banana, and peanut butter to make a delicious weight gain smoothie. Check out my FREE High Calorie Shakes handout on RD2RD!
We also have the High Calorie SHAKES e-Cookbook available for purchase. It contains 25 delicious recipes, color photos, and tips on stopping weight loss!
And to learn more about how to gain weight, check out our Weight Gaining SECRETS e-book!
You can start with fruits and vegetables as a base, add in some whole milk or Greek yogurt, even an avocado which will make it creamy and high in heart healthy calories. There are so many different options for weight gain smoothies, so get creative.
Appetite Stimulants & Tube Feedings
Other last-ditch effort interventions MAY include appetite stimulants or tube feedings.
Please keep in mind that while several medications have been investigated to stimulate appetite in older adults, none are typically recommended in routine clinical practice. Why? There are just too many side effects and risks. Additionally, the science hasn’t shown much benefit to appetite stimulants in older adults (6).
Tube feeding means getting nutrition directly to the stomach or gut through a tube. This tube may go through the mouth or nose. It may also be surgically inserted into the stomach (PEG tube) or start in the upper part of the intestines. This is an invasive procedure and not meant for everyone. For older adults with advanced dementia, be sure to review the section below on tube feeding.
Ditch the Diets!
I want to take a moment to tell you it’s OK to ditch the diets. Particularly those of you who are so health conscious that you cringe at the idea of adding big dollop of butter to someone’s oatmeal. Please hear me out.
Don’t worry about dietary restrictions or “health foods” when treating unintentional weight loss. The risk of unintentional weight loss, malnutrition, muscle loss, loss of independence, and potentially death is the highest priority. And it doesn’t matter how “healthy” the foods you provide are if they aren’t eaten.
If those “healthy foods” aren’t eaten, they will lose weight, they will get worse, and sometimes… sometimes foods perceived as “less healthy” are exactly the kinds of “health foods” a sick, frail older adult needs. Focus on the immediate issue at hand. And that is STOPPING unintentional weight loss.
Now this is the tricky part and why I want all of you to have access to a geriatric dietitian. Food is medicine. It can be complicated (it’s why it takes so much schooling to be a dietitian!).
Each individual is unique and there are certain circumstances when certain foods should not be provided. Whether it’s due to a critical medical condition, allergy, medication interaction, etc. But the information I’m providing here is “in general”. So, please always be sure to consult a medical provider and/or dietitian first.
Tube Feeding in Older Adults with Advanced Dementia
I wanted to come back to tube feedings. This topic frequently comes up when unintended weight loss occurs in older adults with advanced dementia.
As previously covered, when it comes to unintended weight loss, food should always be first. But there are times when tube feedings may be appropriate. Some older adults with gastrointestinal (GI) issues may need to be on tube feedings full time. Some may have a clinical need to be on a short-term tube feeding.
There are also times when tube feeding may not be appropriate. We are going to specially cover tube feedings in older adults with advanced dementia. It is not uncommon to see unintended weight loss in older adults with advanced dementia.
Tube feedings in this population are generally not recommended. Let’s dig deeper.
Dementia (including Alzheimer’s) is a terminal illness similar to incurable cancer. Research indicates that unintended weight loss and muscle wasting usually accompany dementia. Individuals with end stage dementia often lose interest in food/fluid, become too confused to focus on meals, and may refuse to eat by turning their heads away from food or clamping their mouths shut.
So, in this population, weight loss is very common.
What the Research Says
There is controversy in the research regarding tube feedings in older adults with advanced dementia. While it does lead to more calories, the translation to actual health benefits is unclear.
There is no evidence that tube feedings prevents aspiration (food going into the lungs instead of the stomach), reduces pressure injury risk (sores from sitting too long), improves function or cognitive ability, improves quality of life, or prolongs survival (7). All of the reasons you may want to start a feeding tube in this population in the first place!
Additionally, feeding tubes do not come without complications or inconveniences. Side effects of tube feeding include aspiration, infection, increased oral secretions, tube malfunction, and discomfort.
A study in 2014 even found that feeding tubes in nursing home patients were associated with being in the hospital and intensive care unit more. It also showed an increase in hospital health care costs (8).
So, increased calories are the benefit of tube feeding. But research has shown this doesn’t translate to improved health outcomes, cost, or quality of life. So how many people does this effect? How many older adults with advanced dementia are getting tube feedings?
Rates of Tube Feedings
A research article published in 2016 investigated tube feeding rates in nursing home patients with advanced dementia from 2000-2014. This study looked at 71,251 nursing home residents with advanced dementia and recent dependence for eating (meaning they couldn’t feed themselves) (9).
The study then looked at the proportion of residents receiving feeding tubes over the next 2 months. Who was getting feeding tubes when they could no longer feed themselves? They found that in 2000, 11.7% were getting feeding tubes. And in 2014, 5.7% were getting feeding tubes. A decline of 5.7% (9).
What this research is telling us it that overall rates of feeding tube insertion rates among US nursing home residents with advanced dementia have declined over the past 14 years. So, it seems word is getting out that feeding tubes in older adults with advanced dementia is not the best way to go.
What we Should do About it?
Sometimes well-meaning family members of those with dementia don’t understand that dementia is a terminal illness and a tube feeding will not stop the disease progression. Education and information go a long way in helping people making informed choices and understand disease processes.
The American Geriatrics Society’s position on feeding tubes in advanced dementia states: When eating difficulties arise, feeding tubes are not recommended for older adults with advanced dementia (10).
However, health care provides should promote choice, endorse shared and informed decision making, and honor preferences regarding tube feeding (10).
There is more to this topic than just the science. The decision to get a feeding tube may be influenced by personal choice, culture, religion, social and emotional value systems (11). And all should be respected.
So, what should be done to address unintentional weight loss if tube feedings aren’t pursued?
Rather than feeding tubes, preferred interventions for providing nutrition for individuals with advanced dementia may be to provide education on tips to minimize distractions at meals, maximize caloric intake with high calorie foods, focusing on favorite foods that the patient wants to and will eat, and using verbal cuing. Focus should be on comfort and enjoyment of food.
Wrapping it Up
As I wrap up this article, I want to quickly share a word on weight loss and our culture.
One of the biggest problems I see with unintentional weight loss is that people don’t often see it as a problem. Frequently it is disregarded by the elderly, their family, or caregivers. How can a little weight loss be a bad thing? Why would this need to be reported to their healthcare team?
Our culture glamourizes weight loss and sees it as a noble and healthy pursuit. My hope is that after reading this article you realize what a serious issue it is. And when we ignore or praise unintentional weight loss in the older adult, we are doing them a disservice.
I have created a free resource that explains why unintended weight loss in older adults is so detrimental. Snag your copy of the Unintended Weight Loss Resource. Let’s worth together to spread the word and change the conversation about unintended weight loss in older adults!
What to do if They Want/Need to Lose Weight
I would like to address a final issue on what to do if an older adult wants to or needs to lose weight. Maintaining a healthy weight is always the goal, but the older adults’ rights and choices must be respected.
If the issue is, they want to weigh the same as they did when they graduated high school (I hear this a lot!), have a discussion about body composition, muscle, and sarcopenia. In most cases, to be the same weight in high school they would have so little muscle that it would risk their health and independence.
If they are being told they need to lose weight for a medical procedure or just want to lose weight regardless, I have 2 tips. Ensure they are getting adequate protein and resistance exercise– these are the two biggies to preserve muscle. But as always, consult a medical provider and dietitian.
Unintentional Weight Loss Summary
So, to summarize what we’ve learned:
- Unintentional weight loss is a BAD thing in older adults
- Regularly weight older adults to monitor for unintended weight loss
- If weight loss is occurring, find out the WHY
- Provide individualized interventions to prevent and treat weight loss
- Consult with a dietitian or medical provider as applicable
I hope you learned something new today and remember that unintentional weight loss in older adult is the thief of independence. Let’s help keep our elders healthy!
- Niedert K. Nutrition Care of the Older Adult: A Handbook for Nutrition Throughout the Continuum of Care. Academy of Nutrition and Dietetics: Chicago, IL; 2016.
- Fávaro-Moreira NC, Krausch-Hofmann S, Matthys C, et al. Risk factors for malnutrition in older adults: a systematic review of the literature based on longitudinal data. Advances in nutrition. 2016 May 9;7(3):507-22.
- Center for Medicare and Medicaid Services (CMS). State Operations Manual (Appendix PP). Washington DC: US Department of Health and Human Services; Revised 2017.
- Malnutrition Solution Center. ASPEN website. https://www.nutritioncare.org/Malnutrition/. Accessed October 4, 2020.
- Walston, J. Sarcopenia in older adults. Curr Opin Rheumatol. 2012: 24(6):623-627.
- Landi F, et al. Anorexia of aging: Risk factors, consequences, and potential treatments. Nutrients. 2016: 8(2): 69.
- Candy B, E Sampson, L Jones. Enteral tube feeding in older people with advanced dementia: findings from a Cochrane systematic review. International journal of palliative nursing. 2009:15(8): 396-404
- Hwang D, Teno J, Gozalo P, Mitchell S. Feeding Tubes and health Costs Post Insertion in Nursing Home Residents with Advanced Dementia. 2014;47(6):1116-1120.
- Mitchell S, Mor V, Gozalo P, et al. Tube Feeding in US Nursing Home Residents with Advanced Dementia, 200-2014. 2016; 316(7):769-770.
- Clinical, Practice, and Models of Care Committee. “American Geriatrics Society feeding tubes in advanced dementia position statement.” Journal of the American Geriatrics Society. 2014; 62(8): 1590.
- Schwartz D, et al. Gastrostomy Tube Placement in Patients with Advanced Dementia or Near End of Life. Nutr Clin Pract. 2014; 29(6): 829-840.