What interventions can be implemented for patients with involuntary weight loss?

From the Guidelines

For patients trying to gain weight, a comprehensive approach involving dietary changes, lifestyle modifications, and sometimes medical interventions is recommended, prioritizing caloric supplementation to match elevated energy requirements and maintain or restore body weight and fat mass, as indicated by the American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation 1. To implement this approach, consider the following key points:

• Increase caloric intake by 300-500 calories above daily requirements, focusing on nutrient-dense foods like lean proteins, healthy fats, complex carbohydrates, and high-calorie nutritious options such as nuts, avocados, and olive oil.
• Eat smaller, more frequent meals (5-6 per day) to make increased intake more manageable.
• Incorporate protein supplements like whey protein (20-25g per serving) between meals, and consider weight gain supplements such as Ensure Plus or Boost Plus which provide 350-360 calories per serving.
• Resistance training 2-3 times weekly helps build muscle mass rather than just fat.
• For medical causes of underweight, addressing underlying conditions is essential, and in severe cases, medications like megestrol acetate (400-800mg daily), mirtazapine (15-30mg at bedtime), or dronabinol (2.5mg twice daily) may be prescribed to stimulate appetite, as supported by the concept of significant involuntary weight loss being more than 5% over 3 months, as noted in the ESPEN guidelines for nutrition screening 2002 1. The importance of adequate protein intake is crucial for stimulation of protein synthesis to maintain or restore fat-free mass (FFM) not only in underweight but also in normal-weight patients, as highlighted in the American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation 1. Key considerations for caloric supplementation intervention include:
• A BMI less than 21 kg/m2
• Involuntary weight loss of more than 10% during the last 6 months or more than 5% in the past month
• Depletion in FFM or lean body mass By addressing these factors and integrating nutritional intervention into a comprehensive rehabilitation program, patients can achieve significant weight gain and improvement in FFM, as demonstrated by controlled studies that have shown nutritional supplementation combined with supervised exercise training can increase body weight and FFM in underweight patients with COPD 1.

From the FDA Drug Label

Weight gain is a frequent side effect of megestrol. This gain has been associated with increased appetite and is not necessarily associated with fluid retention. For patients trying to gain weight, megestrol acetate can be used as it has been associated with weight gain due to increased appetite 2.

• The weight gain is not necessarily associated with fluid retention.
• It is essential to monitor patients for potential adverse reactions and consider the warnings associated with megestrol acetate therapy, including glucocorticoid effects and adrenal insufficiency 2.

From the Research

Methods for Weight Gain

For patients trying to gain weight, several methods can be employed:

• Increasing energy intake by 300-500 kcal/day with an emphasis on adequate protein and carbohydrate, as well as judicious inclusion of energy-dense foods, in combination with rigorous resistance training 3
• Consuming larger portions, incorporating energy-dense foods, and prioritizing liquid over solid foods to promote calorie surplus 3
• Using megestrol acetate, a semi-synthetic progestational steroid, to stimulate appetite and increase body weight 4, 5, 6, 7
• Providing optimal mealtime feeding assistance to increase oral food and fluid intake 5
• Considering dietary counseling, nutritional supplements, and prophylactic enteral tube feeding to maintain or improve nutritional status 7

Medications for Weight Gain

Megestrol acetate has been shown to be effective in promoting weight gain in various patient populations, including:

• Older persons 4
• Patients with acquired immuno-deficiency syndrome or non-hormone responsive cancers 4
• Children with weight loss due to cancer and/or cancer therapy 6
• Patients with head and neck cancer receiving radiotherapy 7

Important Considerations

When using megestrol acetate, it is essential to monitor for potential side effects, such as adrenal suppression 6 Optimal mealtime feeding assistance is crucial to increase oral food and fluid intake in patients using megestrol acetate 5 Further research is needed to determine the most effective interventions for weight gain in different patient populations 3, 7