Q: My 88-year-old father lives in his own home about 100 miles from us. He’s been living alone since my mother died five years ago. I thought he looked rather thin last time we saw him. I’m starting to feel worried about his nutrition. Should I be concerned? Would you recommend he start drinking a supplement such as Boost or Ensure?
A: This question comes up a lot for families. It is indeed very common for older adults to experience unintentional weight loss at some point in late life.
The brief answer is that yes, you should be concerned. But I wouldn’t recommend you jump to purchasing Boost or Ensure.
Now, in most cases, some nutritional supplementation is in order. But before focusing on this, you should first get help figuring out why your father is losing weight.
For doctors, unintended weight loss is a major red flag when it comes to the health of an older person.
So in geriatrics, we usually recommend that an older person — or their caregivers — monitor weight regularly. This enables us to spot weight loss sooner rather than later.
Once we’ve spotted unintentional weight loss, the next step is to figure out what might be causing it. And then we’re in a better position to recommend a treatment plan, which might well include a nutritional supplement.
In this post, I’ll go over each of these steps in more detail.
Why you should monitor for unintentional weight loss
Unintentional weight loss means losing weight without dieting or otherwise deliberately trying to slim down.
This often goes hand-in-hand with malnutrition in aging. Now, they aren’t quite the same thing: it’s possible to be malnourished without obviously losing weight. But they tend to go together.
Both problems are common in older adults. One study found that 39% of hospitalized older adults were malnourished.
It’s important to detect and evaluate weight loss and malnutrition for several key reasons:
- They are often caused by underlying health problems which need to be diagnosed and managed.
- They leave older adults weakened and more vulnerable to additional illnesses and injuries.
- They may be a sign that an older person is impaired, or otherwise needs more support with daily life.
Fortunately, there’s an easy way to screen for these problems: tracking an older person’s weight.
How to track weight and nutrition in an older person
Tracking Weight:
This is a terrific quick-and-easy way to monitor overall health and nutrition in an older adult.
To track the weight of an older person who lives at home or in assisted-living, I usually recommend checking and recording the weight at least once a month.
(Note that nursing homes are usually required to weigh residents monthly; some assisted-living facilities may do so as well.)
You should keep records of the weight checks, preferably in a way that makes it easy to bring the information to the doctor’s office. Some families keep the information in a paper chart, but it’s potentially better to keep it in a shared computer file; see this article on keeping and organizing information for more details.
You can also consider one of the newer “connected” scales. These are devices that can wirelessly connect to a mobile device or even the home’s wifi. The weight record can then be accessed through an app or website.
Once you start tracking weight: at what point should you be concerned?
A general rule of thumb is that unintentionally losing 5% of one’s original body weight over 3-6 months is cause for concern. But it’s also reasonable to be worried if you notice a steady downward trend.
Once you’ve become concerned and documented a change in weight, you’ll want to bring it up with a doctor or other health professional.
Tracking Nutrition:
Monitoring for unintended weight loss, as detailed above, is probably the easiest way to screen for nutrition problems.
Other red flags to take note of are:
- Loss of appetite.
- Decreased strength and/or ability to get around.
Note: The term “nutrition” can be used differently in different contexts. In geriatrics, the focus is often first on ensuring that an older person is getting enough calories and protein to maintain energy needs and muscle mass. Obviously, there is more to nutrition than just this; it’s also important that people meet their body’s needs for vitamins and minerals, and that they eat a “healthy diet.” Exact definitions of a “healthy diet” differ, but it’s generally one that promotes health and well-being, and doesn’t cause or aggravate health problems. A Mediterranean-style diet can work well for many people.
Common causes of weight loss and malnutrition
It’s important for an older person to get a clinical evaluation, once you’ve noticed weight loss or other signs of possible malnutrition. A simple initial assessment tool that many clinics will use is the Mini Nutritional Assessment.
(You can view and download a “Self-MNA” here.)
Many types of health problems can cause weight loss. According to this Canadian Medical Journal review article, common causes to consider are:
- Depression and other psychiatric conditions (9-42% of cases)
- Cancer (16-36%)
- Gastrointestinal disease (e.g. problems with the stomach or other parts of the digestive tract; 6-19%)
- Thyroid imbalances, diabetes, and other types of endocrine disorders (4-11%)
- Cardiovascular disease (2-9%)
- Alcoholism and other forms of nutritional disorders (4-8%)
- Chronic obstructive pulmonary disease (COPD) and other respiratory disorders (~6%)
- Neurologic disorders, including those that interfere with swallowing (2-7%)
- Medication side-effects (~2%)
- Unknown after extensive evaluation (10-36%)
Some additional issues that particularly come up in older adults include:
- Difficulty leaving the house to purchase food. This can be due to limited mobility (e.g. due to pain, fear of falling, etc), lack of transportation, or cognitive problems.
- Difficulty affording food. Some older adults live on a very limited income.
- Difficulty or pain with chewing and swallowing. Many seniors fall behind on dental care for various reasons. This can lead to painful mouth conditions, or a lack of suitable dentures.
- Constipation. This is quite common in older adults and can interfere with appetite and eating enough.
- Paranoia about food, due to dementia or a psychiatric condition. A fair number of older adults become suspicious of others during early dementia. Occasionally this leads them to not eat enough.
- Forgetting to eat or having difficulty organizing meal preparation. This is especially common for those with Alzheimer’s and other dementias, but can also be due to problems like depression or even mobility limitations.
- Unappetizing food. Sometimes the food is not to an older person’s taste, especially if it is a low-salt, low-fat, low-carb, low-sugar, or other medically “recommended” diet.
Generally, to sort through all these possibilities, doctors will need to interview the older patient and the family. For instance, they will want to know:
- How is the older person’s appetite? Do they like to eat or seem uninterested? How has this changed over the past year?
- Any pain or difficulty with chewing or swallowing?
- Any problems with nausea, vomiting, or feeling full easily? Any abdominal pain?
- Any problems with diarrhea or constipation?
- Who does the shopping for food? Who cooks the meal and organizes the time to eat? Does the older person do this alone or usually with someone else involved?
It’s also very helpful for the doctors to have as much information on what food — and how much food — the person is actually eating.
Last but not least, during the clinical evaluation, the doctor will physically examine the older person and then probably order some bloodwork as well.
How you can help doctors evaluate weight loss
The main way to help doctors is two-fold. One is to bring in a weight record, showing how the older person’s weight has changed over the past several months.
The other is to bring in information related to symptoms and ability to obtain food. You can do this by asking your older relative — and anyone else who is familiar with the person’s daily life — the interview questions listed above.
Of course, the doctor will still need to ask these questions, but it’s extremely helpful for patients and families to have thought through the questions ahead of time.
You can also download and complete the “Self-MNA” (self Mini-Nutritional Assessment) and bring it in to discuss with your health providers.
How to “treat” unintentional weight loss
The best treatment plans are based on a careful evaluation and correct diagnosis of what health problems — and social factors — are causing the weight loss.
Unfortunately, it’s common for many doctors to quickly turn to prescribing high-calorie supplements like Ensure, or even prescription appetite stimulants.
In fact, this is such a common problem that the American Geriatrics Society chose to address it in their Choosing Wisely recommendations:
Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia (loss of appetite) or cachexia (loss of muscle mass) in older adults.
Instead, optimize social supports, discontinue medications that may interfere with eating, provide appealing food and feeding assistance, and clarify patient goals and expectations.
(Learn more here: Choosing Wisely: 5 More Treatments For Older Adults You Should Question)
Now, even when social issues and medical problems are addressed, it’s often necessary to provide some extra nutritional support to those older adults who have been losing weight.
This usually means providing extra protein and extra calories. Fat is dense in calories, so this can be a good way to increase energy intake. Technically it’s better to provide “good fat” like olive oil, but in the short-term, I encourage people to consider whatever fatty foods the older person really likes to eat, which might mean ice-cream or peanut butter.
Research also suggests that many older adults may benefit from supplemental protein, especially if they’ve been showing signs of lean muscle loss. Many studies have used milk or whey protein.
So should you consider Ensure or Boost? You should discuss more with your father’s doctor, but my take is that such commercial supplements should be used only as a last resort. They are expensive, usually contain a lot of sugar, and contain various additives. So it’s better to make your own smoothies or otherwise provide nutrient-dense snacks and protein to your father, if at all possible.
Key take-home points on weight loss in older adults
I’ve provided a lot of information while answering your question, so let me summarize the most important take-aways.
- Tracking monthly weights is a good way to keep an eye on the health of an older adult. Put it on the calendar. A “connected” scale can make it easier to log and share the weight record.
- Unintended weight loss is a major red flag. Take action and consult a doctor if an older person loses 5% of more of their body weight, or if you’re otherwise concerned.
- Be sure to check for problems related to purchasing, preparing, and eating food. These are easily overlooked in older adults. They may be related to mobility difficulties, cognitive impairments, dental problems, depression, or unappetizing diets.
- Commercial supplements and/or appetite stimulants should be used only after careful consideration with the doctor, and after considering alternatives. They often feel like the “easiest” solution (assuming one can afford them) but they’re usually not the best way to maintain an older person’s nutrition and well-being.
If you want a more scholarly take on nutrition in aging, here are a few good articles:
- Assessment and management of nutrition in older people and its importance to health
- Nutrition in the very old
- Nutrition and the gut microbiome in the elderly
- Protein Requirements and Recommendations for Older People: A Review
- Perspective: Protein Requirements and Optimal Intakes in Aging: Are We Ready to Recommend More Than the Recommended Daily Allowance?
- Position of the Academy of Nutrition and Dietetics: Food and Nutrition for Older Adults: Promoting Health and Wellness
Have you been concerned about an older person’s weight loss? Post your questions and comments below.
[This article was reviewed & updated in October 2022.]
Kydra says
My Dad is 74 years old. He has gone from 309 lbs in March 2019 to 210 lbs currently. He’s had every test ran thinkable. A colonoscopy which was normal. He recently had an EGD and that came back normal. They thought that he might have pylori bacteria. That tested negative. At this point he is frustrated because his appetite is steadily decreasing. He basically has to force himself to eat. Any advice would be helpful.
Nicole Didyk, MD says
Hi Kydra and sorry to her about your dad. You mention some imaging studies, which thankfully you report have been unremarkable, and remember that there are blood tests that can reveal causes of weight loss as well. Here is an answer to a similar question that I provided recently. Loss of appetite can be due to a variety of causes, ranging from depression to a medication side effect. I would suggest that you keep being inquisitive and working with your dad’s health care team.
Jim Doherty says
Dr. Kernisan, just “found” you and subscribed. Your conscientious response to queries and down-to-earth, common-sensical advice are . . . well . . . really impressive! I’m 82. A workout regular. Good appetite. Healthy diet. Great zest for life. But I’ve unintentionally lost 30 pounds over the last two years, and still losing. Chronic digestive problems. Six or more BMs daily (including middle of the night), very loose, gassy, very OILY! Malabsorption? Doc recommends colonoscopy but I had one just 3 years ago. Aren’t there other tests, short of invasive procedures, to check out possible pancreatitis, gall bladder, liver and other factors that might cause malabsorption and weight loss? Thank you!
Leslie Kernisan, MD MPH says
Thank you for joining our reader community. Sorry to hear of your digestive issues though. Yes there are blood tests that can help check for pancreatitis, liver issues, and gall bladder conditions, but I imagine you’ve already had them done. Ultrasounds are also sometimes used, as are CT scans. That said, an internal procedure would allow the doctors to visualize the lining of your gut and also take some biopsies.
I’m not a gastroenterologist so I really can’t advise on whether this is strictly necessary or a reasonable next step. If you have doubts, I would recommend considering a second opinion, preferably at an academic medical center. And of course, ask the doctors what they hope to learn from the colonoscopy and is there any other way to get this diagnostic information?
Since you mention oily stools, this sounds like “steatorrhea” and you can learn more here: https://www.ncbi.nlm.nih.gov/books/NBK541055/
I do think you keep getting it looked into as you are relatively young and fit, and likely to benefit from getting this diagnosed and treated. Good luck!
Sushil says
Hey my father suffered from heart attack about 1 years ago due to blockage in the arteries causeof increased level of cholesterol, 2 stent were placed. He was very healthy before the operation but after it he is being losing weight and by my observation leam muscles too , he also have diabetes and for few months his appetite is also not that good , as he got diabetes most of food is limited cause of fats and sugar . Can you suggest what can be the problem.
Nicole Didyk, MD says
Sorry to hear about your Dad’s health issues. It is difficult to say precisely what the cause of his challenges is however a good place to start might be documenting exactly how his weight is changing. Sometimes when we weigh someone regularly (every week or 2 should be sufficient) we find that things are actually stable or improving slowly. After a heart attack many people start medications which can affect appetite and energy levels and subsequently weight. Other things that are common after heart attack are dietary changes that can take off a few pounds and depression. Is also possible that because of the heart attack your Dad suffered some damage to his heart muscle which has affected his energy and activity level and subsequently his appetite. Here’s another answer from Dr. Kernisan to someone in a similar situation. I hope this is helpful and best of luck.
Francisca says
70 years old Lossing weight in the last 7 months.. I used to weight 140 down to 133 I did have endescopy done last month I was having burning sensation on upper stomach. Biopsy came back positive for H. Pylori & some inflametion.
Feeling good now but every 3 months I may get same burning goes away by itself… Why taking a strong course of antibiotics I really feel this is not the real problem.. colonoscopy was normal I don’t have any issues with stool, except I noticed the smell is very different than 7 months ago..why the strong smell? I eat healthy don’t eat red meat. Never smoke don’t drink thanks
Leslie Kernisan, MD MPH says
Well, in some cases it can take some investigation to figure out why an older person might be losing weight. I would recommend continuing to monitor your weight and your symptoms, so that your providers can continue to monitor to you and see if more clarity emerges regarding what might be going on. You may also want to consider getting a second opinion.
Jo Abramowitz says
My husband has Parkinson and diabetes he has lost a lot if weight he was about 180 4 years ago drop to 171 since then he has progressively losed know 149 been to many dr. Two complete cat scans and mri of brain. He has Parkinson trouble sawallowing medication seem to help he does eat three meals a day not like he did but he does eat. Also dieabets so doesn’t try to eat to many sweets. No one seems to no why he is losing so much weight. It is becoming more loss in the pass weeks. Takes supplements.
L
Leslie Kernisan, MD MPH says
Sorry to hear of his weight loss, I can see why you are worried. It can sometimes be difficult to figure out why a person is losing weight. I would recommend continuing to bring this to your husband’s health providers. It might also help to see if they can assist with some kind of calorie counting and evaluation of how much he is actually taking in. Good luck!
Mrs j Carter says
I am a 91 year old female was very fit playing golf body surfing no medicationuntil 5 years ago I had Giant cell arthritis Started on 40 Prednisolone reduced to 6 but had further symptoms so have remained on this medication. Normally weighed about 9stone which had reduced from 10stone before illness In last 6 months no longer play golf – stopped body surfing 2 years ago. Now find I am regularly losing weight – down to about 8lbs 4 ozs gone from size 16 to 12. Eat Weetabix or porridge breakfast. Midday Main Meal meat or pasta or fish with veg evening sandwich & yoghurt Do not feel hungry but always eat very reasonably for my age compared with others. People comment on my loss of weight – lots of loose skin. Do not feel ill – but tire. Live with 91 year old husband -large family close by. Try to eat things to increase weight but no luck. No difference in bowel action – regular once each morning. Have regular 2 monthly blood test because of being on Prednisolone so far no negative result from doctor Advice please how to put on weight – my clothes are all getting too big !!
Leslie Kernisan, MD MPH says
Sorry to hear of this recent weight loss. If you are still continuing to lose weight, I would recommend bringing it up to your usual health provider and asking them to help you figure out WHY you are losing the weight. How to stabilize or increase your weight will really depend on why it’s going down now. In the article, I cover the more common causes, so ask your health provider about those.
Otherwise, to stabilize weight, we generally recommend calorie-dense foods with extra protein. It’s also a good idea to eat plenty of vegetables and fruit, but that’s for overall health and bowel health, and won’t necessarily help increase weight. Good luck!
Emily says
My father is 71 years old. He is about 5 feet 9 inches tall and he used to weigh around 65kg back in 2006. He had lost around 16kg over 7 years. Since then he has maintained at 49kg. He only has hypertension. Blood test two years ago was normal including thyroid levels. He saw the doctor in 2013 but the doctor mentioned it wasn’t a drastic weight loss and concluded it was due to aging as he had no concern given my father’s appetite. He can eat a lot (breakfast, lunch, dinner, snack and supper) and he eats very healthy (lots of fruits, vegetables, oats, bread). He also has a good bowel movement everyday and stools are normal. Is there any value in doing a colonoscopy? Also, he has tried Appeton 60+ and Ensure powder but still not seeing any weight gain. I read about whey protein isolate for sports people and was wondering if it would be a better option than the ones he has tried? Thank you.
Leslie Kernisan, MD MPH says
It sounds like he lost weight but for some time now has been stable at a lower weight? If this is the case, and he doesn’t have any other particular symptoms, then colonoscopy should only be done in the context of regular colon cancer screening. (See here for the options.)
If you are concerned about him, you could consider getting a second opinion, to confirm that he’s had a reasonably thorough and appropriate evaluation so far.
To gain weight, it’s important to counter whatever is causing weight loss (if it can be identified). Otherwise, we generally recommend calorie-dense foods and extra protein. Whey protein has been studied and can be helpful. You can also try eggs, tofu, yogurt. Some research suggests older adults benefit from 1.0 to 1.3 g/kg/day of protein. You can also increase calorie content with olive oil, avocado, and other healthy fats. Good luck!
Cathy says
My mother in law, keeps dropping weight. She has moderate dementia. She will sometimes eat if something is put front of her. She keeps rejecting meals on wheels saying she is fine. We think she forgets to eat. She refuses home healthcare or assisted living. She is down to 112 lbs. How can we get her to eat? She has rejected all doctors suggestions
Leslie Kernisan, MD MPH says
First of all, I hope she has had a thorough medical evaluation to look for medical problems that might be affecting her eating or her weight. If she’s had such an evaluation and nothing turned up, then it’s possible that it’s because of her dementia that she is forgetting to eat, or otherwise is too disorganized. If she lives alone and cannot feed herself reliably, then she is potentially experiencing self-neglect, and if she really endangers her health, she may eventually have to be forced to move. Below is a good site explaining self-neglect:
https://www.dshs.wa.gov/altsa/home-and-community-services/self-neglect
Self-neglect is challenging, especially when people have dementia. The usual recommended approach is to ask the doctor for help and also report to Adult Protective Services. If she cannot be persuaded to accept whatever help is necessary to eat and maintain her weight, this might be grounds for moving her, even if it’s against her wishes. These are difficult situations. Good luck!
Sandra Kraft says
As a 70 year old woman who has lost 35 pounds in the last 4 months I became concerned and found your site. Thank you so much for your insight and encouragement. As I am eating less and less and not enjoying food at al. Your no nonsense approach was what I needed. Off to the Doctor for a frank discussion. Thanks to this article I know how to approach the issue and what questions to ask. Thank you again.
Leslie Kernisan, MD MPH says
I am sorry to hear of your weight loss but delighted to know that the article was useful. I hope your conversations with your providers bring you the information and advice that you need.
I do recommend going with a family member or other trusted companion if possible, as there is a lot to cover and it’s always good to have an extra person there to take notes and otherwise support you. Good luck!
Stoic says
Hi,
My Dad has been a heart patient (valve regurgitation) for almost 7 years. At first his weight didn’t effect much and staid the same but for the last couple of years he lost weight significantly (25 pounds) and his muscle mass seems to be reducing by the time. I’ve read this article that says it could be because of less nutrients absorption due to decreased intestinal blood flow and weak overall blood circulation.
I was wondering what should we do or how do we modify his diet to control this unintentional weight loss.
Sincerely,
Leslie Kernisan, MD MPH says
If your father has been losing weight these past few years, then it’s important that he get a careful evaluation, as explained in the article. Effective treatment of his weight loss needs to target the underlying cause of his weight loss.
Otherwise, general dietary approaches that tend to help is to make sure the food is appealing to him, easily accessible, calorie-dense, and includes a lot of protein. Good luck!