Transcript Weight Gain in Mental Health

Antipsychotics
and Healthy Lifestyle
Garalynne Binford
Dietitian – Mental Health
September 2010
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Metabolic Complications are…
 Increased
weight
 Increased fat mass
 Increased blood lipids
 Decreased glucose tolerance
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Prevalence of Metabolic
Complications
60
50
40
30
Mental Illness
20
10
No Mental
Ilness
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ei
gh
t&
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ty
0
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Overweight and obesity are major risk
factors for cardiovascular disease and
diabetes
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Lifestyle factors that contribute to
metabolic complications
Smoking
 Inactivity
 Excessive alcohol
 Stress (increased cortisol levels)
 Low intake “healthy foods”
 High intake “unhealthy foods”
 Too much of any food

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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Atypical v Atypical
Atypical v typical
Any antipsychotic
medication
Schizophrenia
Schizophrenia
(2-3
fold increased risk)
Traditional risk
factors
e.g. family history, obesity,
ethnicity, exercise, age
Holt and Peveler: Diab Obes Metab 2006: 8:125-135
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Medications that contribute to
metabolic complications
Major contributors:
Clozapine
Quetiapine
Olanzapine
Risperidal
Others:
Valproic acid
SSRIs
Lithium
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Potential Causes of Metabolic
Changes with Antipsychotics
Decreased
satiety
Carbohydrate
cravings
Inflammation
Weight Gain
Decreased
metabolism
Increased thirst
Feeling tired
Constipation
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Hunger vs. Stimulated Appetite

Hunger =
 “rumbly
stomach”
 Physiologic need for more energy

Stimulated appetite =
 “a
need to eat”
 Inability to feel full
 MEDICATION-RELATED
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
NCMH Healthy Lifestyle Pathway
Assess risk of metabolic
complications (ongoing)
Medication prescribed
Prevention
Metabolic Monitoring
Education
Clinically Relevant
Threshold met
Healthy Lifestyle
Refer to Dietitian
Recommendations
Refer to Healthy
Lifestyle Group
Healthy Lifestyle
Poor success
Recommendations
Refer to Dietitian
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Review prescription
Assessing risk of developing
Metabolic Complications

Personal and family medical history
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Includes cardiovascular disease and diabetes
Baseline, then annually
Prescriber
Lifestyle behaviours
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Includes diet, physical activity
and sleep
Baseline, then at each visit
Prescriber (and key worker)
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Prevention Education

Increased hunger and decreased satiety
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Increased thirst
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Eat three meals a day
Avoid foods that are high in fat/sugar
Choose foods that are low in fat/sugar
Eat foods that are high in fibre
Try not to snack between meals
Sit down to all meals
Watch what you drink
Fatigue

Increase physical activity
Avoiding Weight Gain
while on Psychiatric
Medications
Weight gain is a common side effect of certain
medications for psychiatric illness. You gain weight
because your medication:
causes you to be more hungry than usual
causes you to be more thirsty than usual
makes you feel more tired
makes it harder to tell when you are full - so
you may overeat
Once you are able to recognise these side effects,
there are things you can do to prevent weight gain.
Your actions (what you eat and drink and how
much activity you do) will determine whether you
gain weight or not.
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Metabolic Monitoring
Monitored by prescriber
 Weight, BMI
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Blood pressure, pulse
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Baseline, frequently during titration
Fasting blood glucose
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Baseline, weekly for 3 months, then monthly
Baseline, 3 months, then annually
Fasting lipids

Baseline, 3 months, then annually
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Clinically Relevant Thresholds
Weight (gain >7% with BMI >25)
 Waist circ. (>88 cm [f] >102 cm [m])
 BMI (>25)
 Fasting blood glucose (>6.1)
 Triglycerides (>2)
 Total/HDL cholesterol (4.5)

A New Zealand Mental Health Metabolic Working Group Initiative
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Heart Forecast
www.yourheartforecast.org.nz
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Healthy Lifestyle
Recommendations

Drink less sugar in drinks
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Plain water
Diet soft drinks
Soda water
Fruit flavored herbal teas
Dilute ¼ cup juice with ¾ cup water
Tea or coffee with low fat milk (up to 4 cups a day)
Avoid adding sugar to drinks
Use artificial sweeteners
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
300 ml of apple juice has as much calories as 3 apples
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Healthy Lifestyle
Recommendations

Eat less sugar in food
 Use
tinned fruit in juice instead of syrup
 Avoid adding sugar to cereal
 Use artificial sweeteners
 Try fruit and yoghurt for healthy desserts
 Add fresh or dried fruit to cereals instead of
sugar
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Healthy Lifestyle
Recommendations

Eat less fat overall
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Trim fat off meat before cooking
Drain fat from meat after browning or boiling before
adding other ingredients
Eat less meat and cheese
Steam, grill, poach, bake, boil, microwave
Put less spread on bread
Choose low fat dairy (ie. green top milk, edam
cheese)
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Chips have about 5 times as much fat as potatoes
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Healthy Lifestyle
Recommendations

Eat poly- or monounsaturated fat more often
than saturated fat

Polyunsaturated
– Most margarines, soyabean oil, corn oil, safflower oil, rice
bran oil, seeds and most nuts

Monounsaturated
– Olive oil, canola oil, some nuts, avocados, olives

Saturated
– Butter, cream, dripping, fat on meat, cheese, whole milk,
chocolate
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
A side note about omega 3 fatty acids
 EPA/DHA is mostly in oily fish
(eg. herring, kipper, mackeral,
sardines, pilchards, tuna, salmon,
trevally, kahawai, kingfish, dory,
eel, squid, mussels, oysters).
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300 grams oily fish weekly meets recommendations
Also in grass-fed beef/lamb, eggs and fortified foods
ALA sources include canola oil, linseed oil, dark
leafy green vegetables, peanuts, almonds,
soyabeans, walnuts
Fish oil supplements…
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Recommendations by Scientific Organizations
 Hypertriglyceridemia (Am Heart Assoc 2002)
6-8g/day
pills/day
2-4
 Heart Disease (Am Heart Assoc 2002)
3-4 pills/day
1g/day
 Patients w/ Mood, Impulse-Control or Psychotic
Disorders (Am Psych Assoc 2006)
13-4
g/ pills/day
day
 Mood Disorders (Am Psych Assoc 2006)
1-9
g/day
3-36
pills/day
1 gram = 3-4 pills!!
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Healthy Lifestyle
Recommendations

Limit take-aways to no more than twice weekly
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Healthy fast food:
–
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Sitr-fry with steamed rice
Whole grain sandwiches or filled rolls
Grilled fish instead of battered fish
Toasties with baked beans, spaghetti or corn
Burgers (small size) and kebabs
Thick chunky chips instead of thin chips
Ask for meals without sour cream, creamy sauce or cheese
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Healthy Lifestyle
Recommendations

Have healthy snacks around

Snack Ideas:
– Low fat crackers (Ryvita, rice) topped with cottage cheese,
salsa, toamtoes or hummus
– Fresh fruit
– Vegetable sticks dipped in salsa or hummus
– English muffins, fruit bread or whole grain toast with
thinly spread jam or honey
– Cup of soup
– Yoghurt alone or with fruit
– Popcorn
– Cereal and low fat milk
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Healthy Lifestyle
Recommendations

At least 25-30 grams fibre per day

To get adequate fibre:
– At least 5 servings fruits and vegetables daily (about 5
handfuls of fresh, frozen or tinned)
– Whole grain or wholemeal bread
– High fibre breakfast cereal like All Bran, Sultana Bran,
muesli, Weetbix or porridge
– Baked beans, dried beans, peas or lentils several days
each week
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Healthy Lifestyle
Recommendations
Eat 3 meals every day

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Helps regulate appetite
Prevents constipation
Eat at the table and chew slowly
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Makes the food last longer
Plan to do something enjoyable after meals
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Reduces the chance of overeating
Manage stress without food
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Keep a food diary with feelings and hunger rated 1-10
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Healthy Lifestyle
Recommendations

Aim for to be physically active for at least
30 minutes daily
 Can
split it up through the day
 May need more in order to lose weight
 Green Prescription
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Healthy Lifestyle
Recommendations

Identify what the real issue is by asking…

Why?
– Hunger vs boredom vs peer pressure, etc

What?
– Too much well-balanced food vs “junk food”

Where?
– Table vs television vs car, etc

When?
– Too often vs not often enough
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Healthy Lifestyle
Recommendations
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Healthy Lifestyle at MHIPS

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Nursing constantly encouraging healthful behaviours (low
calorie snacks, adequate fibre, appropriate beverages, etc)
Constant nursing reminders about the appetite effects of the
medications
Selections on menus:
–
–
–
–
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Regular portions
Extra vegetables
Fresh fruit for dessert
No fizzy drink or juice
Strong nursing encouragement to engage in physical activity
daily – utilize OT groups
Participation in weekly nutrition/cooking group, designed to
encourage healthy food choices
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
NCMH Healthy Lifestyle Pathway
Assess risk of metabolic
complications (ongoing)
Medication prescribed
Prevention
Metabolic Monitoring
Education
Clinically Relevant
Threshold met
Healthy Lifestyle
Refer to Dietitian
Recommendations
Refer to Healthy
Lifestyle Group
Healthy Lifestyle
Poor success
Recommendations
Refer to Dietitian
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Review prescription
Using Dietitian Services

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Existing team to support patients around general
healthy lifestyle and increasing motivation first
Refer to dietitian when patients are motivated to make
changes, but..
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Don’t know what to change
Have tried before without success
Have complicating co-existing disorders (eg. kidney disease,
diabetes)
Type ‘refer’ or ‘referral’ into an email addressed to me
to get an auto-replied referral form
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
Resources

http://shran/rexiserver/GetImage.aspx?Imag
eID=2334a17c-a08b-4a57-b8ff-0dc8213bf05b

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www.5aday.co.nz and www.vegetables.co.nz
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Recipes and interesting information on fruits and
vegetables
www.healthyfoodguide.co.nz
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Psychotropic Drug Monitoring guidelines (HBDHB)
Lots of recipes and credible articles on healthy
eating, special diets and allergies
Why Weight booklet from Eli Lilly
Lots of printed resources downstairs
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga
References
Petty, Richard: lecture in Seoul, South Korea, Jan 2005
A New Zealand Mental Health Metabolic Working Group Initiative
Pronsky et al. Psychotropic Drugs, nutritional and weight
management considerations. Developmental Issues: a publication
of DDPD. 2005
Tribole. E. Ultimate Omega-3 Diet.(2007) McGraw-Hill: NY, NY
Meyer J et al. Medical Illness and Schizophrenia (2009): 33-375
Elmslie, Jane and Foulds, Margaret. Why Weight 2004
http://www.rcpsych.ac.uk/mentalhealthinformation/mentalhealthp
roblems/nutritionandmentalhealth.aspx
http://www.moh.govt.nz/moh.nsf/pagesmh/5223/$File/mentalhealth-survey-2006-comorbidity.pdf
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Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga