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11/13/24, 8\:13 PM Guide | Weight loss history

Weight loss history

Table of contents

Background

Weight loss is a common symptom experienced by patients in both primary and secondary care settings. Unintentional
weight loss is a phenomenon in which an individual unintentionally experiences a signi
The degree of weight loss is often between 5% - 10% of the total body weight and typically occurs within the preceding 3 to 12
months.
1
Changes in body weight directly re
environmental exposures, and hormonal control. 2
We often intentionally or unintentionally modify these factors, resulting in a
change in body weight that patients do not typically
However, an unintentional change in body weight can be a concerning sign of an underlying medical condition and requires
careful investigation not to miss a serious cause.
For this reason, unintentional weight loss often requires more urgent specialist review and features as a red-
several NICE urgent suspected cancer referral pathways.
Understanding the potential causes and conducting a comprehensive assessment is essential in ruling out more serious
causes of weight loss. 3
Although this article only covers history taking, a full patient assessment will always include a focused
physical examination guided by the history.
Di
Cachexia and unintentional weight loss are often seen as the same.
Cachexia is a metabolic condition related to an underlying disease process characterised by muscle tissue loss with or
without fat loss. Normal homeostatic and cytokinetic signalling is disrupted in cachexia, while these mechanisms are
typically preserved in weight loss.
In short, while all patients with cachexia have unintentional weight loss, not all patients with unintentional weight loss
have cachexia.
4
One of the most common causes of cachexia is malignancy. Cancer can trigger an in
releasing various cytokines and cortisol, altering the body's metabolism. The metabolism is then shifted towards
catabolic processes, thus increasing muscle breakdown whilst inhibiting anabolic processes such as muscle protein
synthesis.
The imbalance in energy homeostasis ultimately leads to unintentional muscle and overall weight loss.

Causes of weight loss

There is a broad range of causes of unintentional weight loss, including medical diseases, psychiatric illnesses, and social
factors. These conditions may occur in isolation or in combination.
Causes of weight loss may include\:
5
Malignancy\: gastrointestinal, lung, lymphoma, leukaemia, renal, prostate
Gastrointestinal\: ulcers, malabsorption conditions (e.g. coeliac disease, in
gastrointestinal infection, hepatobiliary disease
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Advanced chronic disease causing cachexia\: heart failure, chronic obstructive pulmonary disease, advanced chronic
kidney disease, liver failure
Endocrine\: hyperthyroidism, diabetes mellitus, adrenal insu
Infection\: tuberculosis, HIV, tropical diseases, parasitoses
Pharmacological and substance-related\: medication side erecreational drugs
Rheumatological\: rheumatoid arthritis, giant cell arthritis, systemic lupus erythematosus
Psychological\: eating disorders, severe depression, paranoia
Social\: neglect, deprivation, abuse

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient, including your name and role.
Con
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
“ W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?”
“ T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
“ O k , c a n y o u t e l l m e m o r e a b o u t w h a t' s b e e n g o i n g o n ?”
Open vs closed questions
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History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

Establish weight loss

The patient's presenting complaint may not include weight loss. You may only identify weight loss with direct questioning as
part of the history\:
" H a v e y o u n o t i c e d a n y w e i g h t l o s s r e c e n t l y ?"
Sometimes, it can be di
that is relatable to their everyday life\:
“ H a v e y o u n o t i c e d y o u r c l o t h e s f e e l i n g l o o s e r t h a n b e f o r e ?”
“ H a v e y o u h a d t o c h a n g e y o u r c l o t h e s b e c a u s e t h e y a r e t o o b i g ?”
“ H a v e y o u n o t i c e d t h a t y o u’ v e g o n e d o w n a f e w n o t c h e s i n y o u r b e l t ?”

Quantify weight loss

If possible, clarify the amount of weight that has been lost\:
" D o y o u k n o w h o w m u c h w e i g h t h a v e y o u l o s t ?"
" W h e n d i d y o u l a s t w e i g h y o u r s e l f ?"

Time frame

Establish the relevant time frame in which weight loss has occurred\:
" H o w l o n g d i d i t t a k e f o r y o u t o l o s e t h a t m u c h w e i gh t ?"
" D o y o u k n o w w h e n y o u

Appetite

Ask about appetite\:
" H o w h a s y o u r a p p e t i t e b e e n l a t e l y ?"
" H a s y o u r a p p e t i t e c h a n g e d a t a l l ?"
" H a s a n y o n e e x p r e s s e d t h a t t h e y a r e c o n c e r n e d a b o u t t h e a m o u n t y o u a r e e a t i n g ?"

Establish caloric intake

Ask about what they eat and how much they eat\:
" C a n y o u d e s c r i b e y o u r u s u a l e a t i n g h a b i t s a n d m e a l p a t t e r n s ?"
" C a n y o u t a l k m e t h r o u g h a t y p i c a l d a y o f m e a l s ?"

Diet and exercise

Establish how much exercise and what kind of exercise they are doing\:
" D o y o u e x e r c i s e r e g u l a r l y ?"
Establish whether they are currently on a diet and what type of diet this is (weight gain or weight loss). Weight loss in the
context of calorie restriction is far less concerning than weight loss during caloric excess.
" A r e y o u c u r r e n t l y o n a d i e t ?"
" A r e y o u t r y i n g t o l o s e a n y w e i g h t ?"

Associated symptoms

Unintentional weight loss is a non-speci
underlying cause (see systemic enquiry section).
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It is important to identify any associated symptoms, especially red
Red
In a patient with weight loss, the following red
Rapid unintentional weight loss over a short period (often noticed incidentally by the patient or others around them)
Constitutional/'B' symptoms including night sweats, lethargy and malaise\:
" H o w h a v e y o u r e n e r g y l e v e l s b e e n
r e c e n t l y ?"
,
“ H a v e y o u n o t i c e d a n y n i g h t s w e a t s ?
Dysphagia ( oesophageal/oral malignancy) \:
" H a v e y o u h a d a n y d i
Melaena or change in bowel habit (gastrointestinal malignancy)\:
" H a v e y o u n o t i c e d a n y b l o o d o r b l a c k t a r r y s t o o l ?"
Unresolving cough with or without haemoptysis (lung cancer)\:
" H a v e y o u h a d a p e r s i s t e n t c o u g h o r a n y h a e m o p t y s i s ?"

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns, and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred, and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue\:
“ W h a t d o y o u t h i n k t h e p r o b l e m i s ?”
“ W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g ?”
“ I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u gh t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
”
Concerns
Explore the patient’s current concerns\:
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?”
“ W h a t’ s y o u r n u m b e r o n e c o n c e r n r e g a r d i n g t h i s p r o b l e m a t t h e m o m e n t ?”
“ W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i g h t b e ?”
Expectations
Ask what the patient hopes to gain from the consultation\:
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
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Explain what you have covered so far\:
a c h i e v e t o d a y .
”
What you plan to cover next\:
h i s t o r y .
”
“ O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u’ r e h o p i n g w e
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: night sweats, fever, fatigue, lumps and bumps
Cardiovascular\: chest pain, palpitations, ankle swelling
Respiratory\: shortness of breath, cough, haemoptysis
Endocrine\: thirst, polyuria,
Rheumatological\: joint pains and sti
Gastrointestinal\: change in bowel habit, vomiting, early satiety, distension, dysphagia, gastrointestinal blood loss
(haematemesis, melaena or fresh rectal bleeding)
Neurological\: persistent headache, motor, sensory or visual disturbances of insidious/subacute/gradual onset

Past medical history

Ask if the patient has any medical conditions\:
“ D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?”
“ A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e gu l a r l y ?”
Ask if the patient has previously undergone any surgery (e.g. gastrointestinal surgery)\:
“ H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?”
“ W h e n w a s t h e o p e r a t i o n / p r o c e d u r e , a n d w h y w a s i t p e r f o r m e d ?”
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition,
including hospital admissions.
Examples of relevant medical conditions
Relevant medical conditions in the context of unintentional weight loss include\:
Cancer\: particularly cancers of the gastrointestinal tract, pancreas, lung, or haematological malignancies
Gastrointestinal disorders\: coeliac disease, Crohn's disease, ulcerative colitis, and chronic pancreatitis can impair
nutrient absorption and cause weight loss
Endocrine disorders\: hyperthyroidism, diabetes, and adrenal insu
loss
Chronic infections\: HIV/AIDS, tuberculosis, and many other chronic infections can cause weight loss due to increased
energy expenditure and decreased appetite
Mental health conditions\: depression, anxiety, and eating disorders can a
Heart failure\: congestive heart failure can result in
wasting
Neurological disorders\: Alzheimer's disease, Parkinson's disease, and motor neurone disease can a
and lead to weight loss
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Autoimmune diseases\: rheumatoid arthritis and systemic lupus erythematosus can cause in
weight loss.
Liver disease\: cirrhosis or hepatitis can a
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form
and route.
Ask the patient if they’re currently experiencing any side e
“ H a v e y o u n o t i c e d a n y s i d e e
“ D o y o u t h i n k y o u r c o u g h s t a r t e d a f t e r y o u b e g a n t a k i n g a n y o f y o u r c u r r e n t m e d i c a t i o n s ?”
Medication examples
Patients may be taking medications to help them lose weight (e.g. orlistat, GLP-1 agonists).
Other medications may cause weight loss as a side e
Topiramate
SGLT2 inhibitors (e.g. dapagli
Fluoxetine
Laxatives

Family history

Ask the patient if there is any family history of gastrointestinal conditions (e.g. in
“ D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y m e d i c a l c o n d i t i o n s ?”
Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic
factors).
If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death\:
“ I’ m r e a l l y s o r r y t o h e a r t h a t , d o y o u m i n d m e a s k i n g h o w o l d y o u r d a d w a s w h e n h e d i e d ?”
“ D o y o u r e m e m b e r w h a t m e d i c a l c o n d i t i o n w a s f e l t t o h a v e c a u s e d h i s d e a t h ?”

Social history

General social context
Explore the patient’s general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
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if they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
See our smoking cessation guide for more details.
Smoking is a major risk factor for developing COPD, lung cancer and cardiovascular disease.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history taking guide for more information.
Excessive alcohol use is associated with malnutrition.
Recreational drug use
Ask the patient if they use recreational drugs, and if so, determine the type of drugs used and their frequency of use.
Intravenous drug use increases the risk of developing blood-borne infections, including HIV, hepatitis B/C and bacterial
infections (e.g. endocarditis).

Travel history

If the patient’s symptoms suggest an infective aetiology, take a travel history to assess exposure risk.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

Reviewer

Dr Bahig Aziz
Geriatric registrar
Eastbourne District General Hospital

References

1. Wong, C. J. (2014). Involuntary weight loss. M e d i c a l C l i n i c s , 9 8 (3), 625-643.
2. Guyenet, S. J., & Schwartz, M. W. (2012). Regulation of food intake, energy balance, and body fat mass\: implications for the
pathogenesis and treatment of obesity. T h e J o u r n a l o f C l i n i c a l E n d o c r i n o l o g y & M e t a b o l i s m , 9 7 (3), 745-755.
3. BMJ Best Practice. A s s e s s m e n t o f u n i n t e n t i o n a l w e i g h t l o s s . 2023. Available from\: [LINK]
4. Evans, W. J., Morley, J. E., Argilés, J., Bales, C., Baracos, V., Guttridge, D., ... & Anker, S. D. (2008). Cachexia\: a new de
n u t r i t i o n , 2 7 (6), 793-799.
5. McMinn, J., Steel, C., & Bowman, A. (2011). Investigation and management of unintentional weight loss in older adults. B m j , 3 4 2 .
Source\: geekymedics.com
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