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Medical Mysteries
As a lover of mystery stories, and medical mysteries in particular, I enjoyed reading the story of the patient with unexplained weight loss.1 Dr Bischof gave an excellent description of the patient's waning physique, mysterious weight loss, and the physician's search for clues to the cause. At first, common culprits were sought via symptom review and laboratory tests. As weeks went by with the cause still unexplained, more and more tests were ordered as the physician searched for increasingly rare diseases that could be stealing his patient's health.
The title of the essay, "One More Test," sums up a process we use often in our offices. As I was reading the narrative, I asked myself several times, "When will the doctor order ____?" The "one more test" I had in mind is simple, inexpensive, and poses no risk to the patient. The information from this test, if it had been obtained at the patient's first visit, would have explained the cause of the weight loss. The "test" I am suggesting is a simple dietary diary.
Whenever I see a patient who complains about unexplained weight loss or weight gain, I ask the patient to keep track of everything he or she eats and drinks for 2 weeks. I also obtain a patient history and perform a physical examination, and, depending on the situation, may order laboratory testing. The patient then returns in 2 weeks with the food diary and is weighed again. The results of this "low-tech test" are often astonishing and always informative.
A patient complaining of unexplained weight loss may not be ingesting enough calories to maintain body weight. This fact, to some readers, may seem so obvious as to be pedantic, but the patient or caregiver may honestly be unaware that caloric intake has decreased. The patient in the story probably falls into this category: the initial visit revealed that "he hadn't been eating as much," which is when I first wondered if a dietary diary would be "ordered." The final heart-wrenching scene describes the patient slumped over a "half-empty cup of coffee and snack cake on the plate in front of him," the bare kitchen teeming with scavenging flies.
Another common scenario in my office involves overweight patients who complain of weight gain despite "eating like a bird." Two weeks later the patients bring me a food diary listing enough calorie sources to sustain a 400-lb ostrich. Some of these patients are genuinely surprised by the amount of food they actually eat and drink, and we now have a good starting point for a nutrition plan.
In some cases, the simple process of keeping a food diary itself is curative. I have seen many patients stop losing weight when they begin to write down all they eat and drink. Consciously or not, they are more aware of their nutrition and adopt healthier eating habits. Overweight patients, too, often lose weight simply by being aware of the calories they ingest, and by knowing that the physician will review their eating habits.
The limitations of self-reported dietary records have been well documented.2-3 Nonetheless, the dietary diary remains a valuable tool and a simple test that helps me focus on a patient's nutrition.
Pamela Ann Camosy, MD
San Antonio, Tex
1. Bischof RO. One more test [Living in Medicine]. Arch Fam Med. 1998;7:490-491.
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2. Brown JE, Tharp TM, Dahlberg-Luby EM, et al. Videotape dietary assessment: validity, reliability, and comparison of results with 24-hour dietary recalls. J Am Diet Assoc. 1990;12:1675-1679.
3. Buzzard IM, Faucett CL, Jeffrey RW, et al. Monitoring dietary change in a low-fat diet intervention study: advantages of using 24-hour dietary recalls vs food records. J Am Diet Assoc. 1996;6:574-579.
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In reply
As the name of this regular feature, Living in Medicine, suggests, "One More Test" is a story, not a traditional medical case report. Consequently, most of the details of the medical workup were intentionally omitted. However, some additional details about the case will help address the issues in Dr Camosy's letter.
Nutritional factors were important considerations from the beginning of "Mr Roberts'" illness and throughout its course. Nutrition was an ongoing concern, not just a one time test or issue. He did attempt to keep a dietary diary, but poor compliance greatly limited its usefulness. We often discussed dietary issues, although his reports never matched the clinical picture. He also had formal nutritional consultation, which was helpful and one of few therapeutic options. These efforts, however, had little effect on the course of his illness.
The dietary diary in this case did not reveal the "ultimate cause" of the weight loss, as Dr Camosy asserts it would have. While a food diary in general can often provide very useful information, it is by itself unlikely to identify the underlying disease process in most clinical situations. Simple awareness of energy intake may indeed motivate a patient to achieve the proper intake, particularly in cases where energy intake is the primary issue. However, knowing the energy intake is little help when the problem is more involved. Is the high or low energy intake the main problem, or is it merely a sign of an underlying depression, infection, or malignancy?
Although a dietary diary was of limited use in this case, I have also found the use of a diary very helpful and informative for other medical problems, such as headaches, vague gastrointestinal complaints, and transient dermatitis. An event diary can provide key information, particularly in tough cases where the symptoms are vague or the diagnosis remains elusive after a thorough workup. The occurrence of symptoms and simultaneously occurring events over time is recorded in the diary by the patient, and the resulting pattern can be enough to narrow down or even pinpoint the diagnosis. Event diaries have helped me to diagnose cholelithiasis, school phobia, and irritant contact dermatitis in patients who presented with vague histories and little or no physical findings. This technique resulted in very satisfying solutions to these otherwise ill-defined and frustrating cases.
Dietary and event diaries are a useful and relatively simple tool that is often underused in busy medical practice. I concur with their value in general and support their more widespread use. "Mr Roberts" would be pleased to know that his story has stimulated discussion that may help other patients.
Ralph O. Bischof, MD
Cranbury, NJ
Arch Fam Med. 1999;8:294-295.
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