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Katherine Lyman doesn't want to see her patients only when they're wearing an exam gown; she wants to observe them with their street clothes on, too. That's how the geriatric nurse practitioner at Harvard-affiliated Beth Israel Deaconess Medical Center can readily assess how much weight an older adult may have lost without even noticing.

One of the conditions Lyman is trying to spot is anorexia of aging, an under-the-radar phenomenon that often carries a host of health implications. These include a breakdown of muscle and bone mass that can lead to frailty, falls, delayed recovery from illness or surgery, and earlier death.

Not to be confused with anorexia nervosa (an eating disorder that causes people to obsess about their weight and what they eat), anorexia of aging is marked by diminished appetite, even when ample food is available. Affecting approximately a quarter of older adults — and women more often than men — the condition is often overlooked by clinicians. Worse, it's commonly accepted as a normal, inevitable part of aging, according to a 2019 study published in the Journal of Nutrition, Health, and Aging.

"Your first impression is 'little old lady,' and I hate that phrase, because it means a lot more than just that," Lyman says. "But when people become more frail with weight loss, that's what it looks like. They all look like a broken bone waiting to happen."

But, she adds, "I do not see it as unavoidable. Is it common? Yes. Is it a normal part of aging? No."

Risk factors

Before diagnosing anorexia of aging, clinicians first rule out other conditions that can provoke unintended weight loss, including cancer, thyroid problems, diabetes, or gastrointestinal disorders. "Our job is to medically dig down and make sure nothing is amiss," Lyman says.

Additional factors that can place someone at greater risk of unintended weight loss include

• changes in smell and taste
• swallowing problems
• slower digestion
• medications that lead to dry mouth
• dental problems such as tooth decay or loose dentures
• cognitive decline
• loneliness or social isolation.

"There are so many little things that can add up," Lyman says. "I'm concerned when people say the weight loss is no big deal, because it should not be dismissed. Anorexia of aging has serious implications, and very often there's an underlying reason that we can fix, whether it's medical or social."

Treatment and prevention

Exercise is a cornerstone of treating anorexia of aging, since movement tends to make people hungry and thirsty. It also boosts muscle mass and strength, reducing the risk of frailty. Additionally, physical activity lowers the risk of constipation — and keeping food moving through the digestive tract may counteract the sensation of feeling full too quickly after eating.

Exercise should include both resistance and weight-bearing activities, which help build muscle. If Lyman's patients are sedentary, she advises them to start with short amounts of simple walking — five minutes in the morning and another five in the afternoon, working up to longer durations. "I tell them that I do not have a pill that can take the place of physical movement," she says.

Dietary changes center on boosting protein intake, which supports muscle growth and maintenance as well as overall health. The U.S. government's Recommended Dietary Allowance (RDA) is 0.8 grams per kilogram (2.2 pounds) of body weight, but older adults should aim to consume 1.0 to 1.2 grams of lean protein per kilogram of body weight. That means an older person weighing 120 pounds should eat at least 55 to 65 grams of protein daily. To treat anorexia of aging — or stave it off — try to eat protein-rich foods at all meals and snacks, including poultry, eggs, lean meat, tofu, and Greek yogurt. You can also add protein powders to smoothies and other foods for an extra boost, but that shouldn't be your sole source of protein. And snacking is encouraged.

"Maybe someone is turned off by the idea of eating three meals, so they need to be grazing all day," she says. "Try to squirrel extra calories into your day where you can."

Appetite-stimulating drugs are sometimes prescribed for anorexia of aging, but side effects (which can include delirium and gastrointestinal upset) can make them tricky to stay on, Lyman notes. But with a holistic approach encompassing exercise, diet, and maintaining social contacts, people can often avoid anorexia of aging or nip it in the bud.

"If you can reverse your weight loss, you'll feel stronger physically and emotionally," she says. "People are happier when they're independent."

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