What are the treatment options for low appetite in adults?

Treatment Options for Low Appetite in Adults

For older adults with low appetite, prioritize individualized nutritional counseling with a registered dietitian and consider a short-term trial of megestrol acetate or corticosteroids only after addressing reversible causes and optimizing the meal environment. 1

Initial Assessment and Reversible Causes

Before initiating treatment, identify and address underlying factors contributing to poor appetite:

• Screen for malnutrition early using standardized assessment tools, as poor appetite significantly increases risk of undernutrition, weight loss, and adverse outcomes including increased mortality 1, 2
• Evaluate medication side effects, particularly metformin which can cause gastrointestinal symptoms and appetite reduction that may necessitate dose reduction or discontinuation 1
• Assess for depression, vitamin B12 deficiency, and hypothyroidism in patients with cognitive impairment or appetite changes 1
• Consider practical barriers including finances, grocery shopping ability, meal preparation capacity, changes in taste/smell, dental problems, swallowing difficulties, and gastrointestinal conditions 1

Non-Pharmacologic Interventions (First-Line)

Nutritional Counseling and Meal Modifications

• Refer to a registered dietitian for medical nutrition therapy to personalize meal planning based on the patient's preferences, culture, and goals 1
• Liberalize restrictive diets in patients over 70 years or those at risk of malnutrition, as therapeutic diets can inadvertently decrease food intake and contribute to unintentional weight loss 1
• Provide regular, individualized meals tailored to cultural preferences rather than restrictive diabetic or cardiac diets, which increases quality of life and nutritional status 1
• Emphasize nutrient-dense foods including vegetables, legumes, whole grains, and protein-rich foods (1.0-1.2 g/kg daily if healthy; 1.2-1.5 g/kg with acute/chronic disease) 1
• Avoid energy- and protein-dense supplements as primary intervention, as evidence shows they may not improve food consumption or prevent weight loss 1

Environmental and Behavioral Strategies

• Optimize meal timing and portion sizes rather than focusing on complex carbohydrate counting, particularly for those with cognitive impairment 1
• Ensure adequate hydration to prevent constipation and fecal impaction which can worsen appetite 1
• Address social isolation by including family members and caregivers in meal planning and diabetes management discussions 1

Pharmacologic Interventions (Second-Line)

Evidence-Based Medication Options

The evidence for appetite stimulants remains limited, with no FDA-approved medications specifically for appetite stimulation outside cancer cachexia. 1, 3

Megestrol Acetate (Strongest Evidence)

• Consider a short-term trial for patients with significant weight loss and poor appetite who have not responded to nutritional interventions 1, 4
• Dosing: Higher doses show greater weight improvement, though optimal duration remains uncertain 1
• Important warnings from FDA labeling: May cause new-onset diabetes, exacerbation of pre-existing diabetes, Cushing's syndrome, and adrenal insufficiency with chronic use 4
• Monitor for adrenal suppression, particularly during stress or illness, as failure to recognize hypothalamic-pituitary-adrenal axis inhibition may result in death 4
• Increased mortality risk: Meta-analysis shows increased risk of death (RR 1.42) in some populations 1

Corticosteroids

• May offer short-term improvement in appetite and weight, but should be used cautiously given side effect profile 1
• Reserve for time-limited trials with specific goals and regular reassessment 1

Other Agents (Limited Evidence)

• Dronabinol and mirtazapine have been used off-label but lack robust evidence for efficacy in hospitalized or community-dwelling adults 3, 5
• Current data show limited efficacy on improving appetite and meal intake with no significant weight change in the inpatient setting 3

Special Populations

Older Adults with Diabetes

• Simplify insulin regimens in those with variable appetite by administering rapid-acting insulin after meals to match actual carbohydrate intake 1
• Avoid holding insulin due to poor appetite, as this may cause hyperglycemia and diabetic ketoacidosis, particularly in long-term care settings 1
• Use less stringent glycemic targets (HbA1c <8.0%) for frail individuals or those with multiple comorbidities 1

Long-Term Care Residents

• Implement regular nutritional screening due to variable nutritional impairment and unpredictable meal consumption 1
• Provide diabetes education to nursing staff to improve management of residents with variable food intake 1
• Monitor for hypoglycemia risk given variable appetite, particularly in insulin-treated residents 1

Common Pitfalls to Avoid

• Do not use parenteral nutrition routinely in patients with advanced illness; reserve for specific situations with non-functioning alimentary tract and relatively indolent disease, with time-limited trials and specific functional goals 1
• Avoid overly restrictive diets that worsen nutritional status in the name of disease management 1
• Do not prescribe appetite stimulants without first addressing reversible causes and optimizing nutritional counseling 1
• Recognize that loss of appetite in acute illness may be adaptive, and indiscriminate nutritional support can be harmful 6