People with mental illness face the harsh reality that they may die decades earlier than people without mental illness. Much of the increased morbidity and mortality in this population is due to preventable medical conditions. Lifestyle choices, adverse effects of psychotropic medication, disparities in living and working conditions, and lack of access to and use of health care contribute to poor physical health outcomes. Obesity—one of the most common physical health comorbidities with psychiatric disorders—is a major contributor to medical morbidity and mortality, and is the focus of this article. To address the multitude of factors that influence obesity in patients with psychiatric conditions adequately, a confluence of patient, provider, and system factors is highlighted.
Obesity is a significant and growing health crisis that affects both developed and developing countries. Nearly 70% of adults in the United States are overweight or obese.1 Projections are that this percentage might increase to 75% by 2015. Excess body weight increases the risk for many medical problems, including diabetes, heart disease, osteoarthritis, hypertension, and many cancers. Obesity rates are higher in people with psychiatric conditions and vary by psychiatric diagnosis. Individuals with schizophrenia have a 2.8 to 3.5 increased likelihood of being obese, and those with MDD or bipolar disorder have a 1.2 to 1.5 increased risk.2,3 An expert panel identified obesity and mental illness as an “. . . epidemic within an epidemic, which requires a public health perspective, including prevention and early intervention across the lifespan.”4
What new information does this article provide?
This article provides information about new strategies and approaches at the patient, provider, and system levels that address obesity in individuals with psychiatric conditions. It highlights how promising lifestyle interventions and collaboration with primary care providers can reduce obesity in these individuals. New research about patient awareness of having a weight problem and how this relates to psychiatric intervention is discussed.
What are the implications for psychiatric practice?
Obesity is a major contributor to excess medical morbidity and mortality in individuals with psychiatric conditions. The selection of medication and monitoring of weight and other health factors as well as collaboration between psychiatrists, patients, and primary care providers can affect psychotropic-associated weight gain and obesity, which may improve both physical and psychiatric outcomes.
An unhealthy lifestyle, the effects of psychotropic medications, insufficient income for a healthy diet and/or exercise program, and inadequate knowledge and life skills contribute to weight problems in persons with psychiatric conditions. Obesity also affects self-esteem and is associated with stigma and discrimination. Research suggests that persons with psychiatric disorders are less likely to know that they have a weight problem.5 Unawareness and motivation are key factors that require assessment and implementation of stage-appropriate interventions.
The role of the psychiatrist/prescriber
Medications are often the mainstay of behavioral health treatment, especially for psychotic disorders. However, since the advent of the atypical antipsychotics, obesity has become more prevalent. Efficacy may differ from drug to drug, and patient to patient, as may the degree of weight change, making medication selection and monitoring for weight gain a complex issue. Moreover, weight gain and metabolic disturbances are major adverse effects of several classes of psychotropic medications, including antidepressants, antipsychotics, and mood stabilizers. Psychiatrists are increasingly aware that weight gain and its complications may cause significant distress among patients. This can complicate medication selection, medication adherence, and medication management.
Monitoring body weight is essential, and weight gain early in treatment may predict those at risk for substantial weight gain. Showing a patient his or her BMI on a BMI chart can help the patient understand the health risks of weight gain (Table 1). Waist measurement also helps screen for possible health risks related to overweight and obesity in adults. The risk of coronary artery disease and diabetes increases with a waist size greater than 35 inches in women or greater than 40 inches in men. An elevated BMI and waist circumference help in diagnosing obesity, which should be documented on Axis III (under general medical conditions) of the multiaxial system of DSM.
Many clinicians feel that in addition to monitoring weight, monitoring blood pressure, glucose and lipid levels, and waist circumference also falls within the scope of psychiatric practice. Practice guidelines and expert consensus urge behavioral health care providers to play a larger role in the detection and intervention of medical conditions such as metabolic disturbances.6,7 A multidisciplinary team approach, including monitoring support, allowing the patient an active role, and collaborating with a primary care provider (PCP), may help meet practice guidelines, facilitate the integration of physical health into behavioral health care, and improve weight and other outcomes.
Many weight management interventions, such as using a scale and BMI chart, selecting medications with lower risk of weight gain, and assessing the patient’s awareness of a weight problem, can be easily implemented in most psychiatric settings. During the initial appointment, obtain a baseline height and weight, then ask: “Do you consider yourself underweight, normal weight, or overweight?” This simple question provides invaluable information about awareness of having a weight problem. If a person is overweight or obese, using a motivational approach such as asking permission to discuss the persons’ weight and its health effects can initiate a discussion: “Is it okay if we discuss whether your weight is in a healthy range for your height?”
Tyler is a 29-year-old man with schizoaffective disorder and obesity (BMI = 35). When weight gain was observed in medication sessions, Tyler was given brief nutritional and physical activity counseling for losing weight. Because Tyler looked confused, his psychiatrist assessed Tyler’s awareness of the problem. Tyler knew that he had gained weight since high school, but he believed his body weight was normal.
According to the Transtheoretical Model of Change, Tyler was in the precontemplation stage (unaware of the problem); the appropriate stage-based intervention at this point is to raise awareness of the problem. It was too soon to offer advice on weight loss strategies; however, showing Tyler his health risk on a BMI chart (high risk of health problems), discussing his weight-related health problems (hyperlipidemia and elevated blood pressure), and offering to make a referral to a PCP helped move him toward action-oriented interventions. Within 2 months, Tyler had lost 5 lb.
Ms Vreeland is Advanced Practice Nurse at the University of Medicine and Dentistry of New Jersey (UMDNJ)–University Behavioral HealthCare (UBHC) in Voorhees, NJ, and Clinical Assistant Professor, department of psychiatry, at UMDNJ–Robert Wood Johnson Medical School in Piscataway, NJ. Dr Sharma is a psychiatrist at UMDNJ–UBHC and Instructor at UMDNJ–Robert Wood Johnson Medical School. Ms Miller is Vice President, Acute and Nursing Services, at UMDNJ-UBHC. Dr Mravcak is Assistant Professor, department of family and community medicine, at UMDNJ–Robert Wood Johnson Medical School, Eric B. Chandler Health Center, in New Brunswick, NJ. Ms Vreeland reports that she is coauthor of Solutions for Wellness; Ms Miller and Drs Sharma and Mravcak report no conflicts of interest concerning the subject matter of this article.
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