Today’s Post was written by Todd Wilcox, MD. Todd is the Medical Director of the Salt Lake County Jail in Salt Lake, Utah. He is a past president of the American College of Correctional Physicians and a frequent–and excellent–lecturer. This article was originally published in CorrDocs, the journal of the ACCP.
Weight loss is a common complaint among our patients and the evaluation of this problem takes up a lot of clinical and administrative time. In many instances, the weight loss complaints are unfounded and the patients are not medically compromised by their weight loss. However, there are a lot of situations where the weight loss is indeed medically concerning and sorting out the two groups presents some challenges.
The evaluation of weight loss really has to begin at intake. We have a high precision, high weight limit scale in the intake area and every patient has an accurate intake weight and height performed as part of the booking medical screening. Prior to implementing this, we were frequently handicapped in our ability to assess weight loss because we had inaccurate weights taken by one of the many portable scales and the variability between them made the data incomprehensible. Although we do calculate it, a BMI is useful in this setting only to identify patients who present at arrest as chronically malnourished. It is critical to identify these patients as they have very limited physiologic reserves and they need extra special handling and assessment during the first days of incarceration since they are such high risk for withdrawal complications and death. Anybody who presents to us with a BMI of 17 or less is flagged for extra assessment, supplementation of nutrition, and ongoing monitoring.
Patients who present with weight loss and malnourishment while incarcerated require a detailed assessment. Body Mass Index is a notoriously insensitive way to assess nutritional status, and although we do calculate it, we do not utilize it as a means to make clinical decisions. I frequently encounter correctional systems whose policies are set up to utilize BMI exclusively to determine whether someone qualifies for nutritional supplementation. BMI is an inappropriate means to assess nutritional status and by the time the BMI falls to the point that these institutions would initiate supplementation, it is frequently too late to intervene effectively.
In my facility, we initially begin with weekly weight checks and we draw a starting baseline of labs to include a CMP, CBC, prealbumin, and TSH. The prealbumin test is ideal for this assessment because it provides a quick and inexpensive answer to whether the complaint is truly a problem and it also provides the ability to do serial testing to monitor corrective nutritional supplementation. The half-life of prealbumin is approximately 2 days so it really reflects the current state of nutritional intake and you see rapid changes as you increase nutritional status. Albumin levels are of almost no clinical value in this assessment.
In my practice, I would estimate that 85% of weight loss complaints turn out to be clinically insignificant and we end up doing nothing but reassuring the patient. However, the remaining 15% present with suppressed pre-albumin levels and we have to sort out the reasons why. Most of these patients correct quickly with additional nutritional supplementation and we are able to track that easily. In these instances, rising prealbumin levels indicate that at least 65% of the patient’s protein/calorie needs are being met with the supplementation. Failure to correct the prealbumin level with enhanced nutritional intake over two weeks is associated with a poor long term prognosis.
What do you do to assess complaints of weight loss at your facility? Please comment!