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!
Great clinical-pearl article. I’d love a follow-up article that describes more details about the pathophys and the situations in which pre-albumin is helpful.
In a county jail-type situation, where the complaints of weight-loss occur shortly after they arrive and often correlate with safety situations such as giving food away for favors, coercion or bullying,—I’ve found it most helpful to start with weekly wt checks and if wt is confirmed to be decreasing step 2 is either a) they eat their meals while observed (booking desk or medical desk) and no bathroom for 1 hr afterwards then they can go back to gen pop til their next meal or b) complete medical segregation with toilet shut off (prevents flushing of food or emesis) for three days with q day wt check. Most of the time, their weight-loss ceases while under close observation and the process of monitoring helps break the cycle of whatever behavior or threat was causing their decreased caloric intake.
What is “nutritional supplementation”. More food? Fortified (foods with added cho, pro, and/or fats added)? Supplements like Ensure?
Complaints of weight loss are very frequent and often not objectively supported in my experience. Frequently, inmate patents are looking for a medical pass to receive extra meals, snacks or supplements which they can trade to others for other items or favors. However, these complaints cannot be dismissed and have to be investigated if there is evidence of weight loss or at least followed up if there is none.
A workup for unexplained weight loss can be difficult but should be undertaken, IMHO. Part of the investigation I initiate usually includes a drug screen (with urinalysis to look for signs of tempering). Many of my patients, young or old, who complain of weight loss are positive for methamphetamine, which is apparently easily smuggled into the ‘secure’ environment in which we work. In a recent informal study I did, 43% of the drug screens I ordered on such patients returned positive for methamphetamine in the last six months! Unbelievable!
I think that a weight should be done every time vital signs are checked. I have found that most inmates who say that they are losing weight actually are not–which you will know if you have a running record of weight checks!