Lifestyle modification in severe mental illness
People with severe mental illness have a 2-3 fold increase risk of diabetes compared with the general population. Furthermore the prevalence of obesity is increased 2 fold. Although the aetiology of diabetes is multifactorial, it is well known that people with severe mental illness are more likely to have diets that are rich in saturated fat and refined carbohydrate and are poor in fruit and vegetables. Furthermore people with severe mental illness are less physically active than the general population.
Studies in the general population have demonstrated that lifestyle interventions to improve diet and increase physical activity have reduced the incidence of diabetes by more than a half. There are significant barriers to introducing lifestyle interventions to people with severe mental illness but in this chapter, the experience of a weight management clinic that ran in Salford, Manchester from 2000 to 2011 is described.
The weight management clinic started in May 2000. The clinic was set up at the request of patients who had gained weight whilst receiving antipsychotic medications. The design of the clinic was discussed and developed at the group during the first meeting. The basic format of the clinic subsequently remained throughout the 11 years of the running of the clinic. Attendance at the group clinic was open ended and patients were able to refer themselves. Patients who attended were diagnosed with various forms of severe mental illness (SMI), most commonly schizophrenia and bipolar disorder.
The clinic is initially staffed by a community mental health nurse and an occupational therapist, but later the group had additional nurses and group workers involved. The programme ran as an 8-week rotational topic cycle with weekly 1-hour group sessions. Sessions are divided into three parts: weighing, group discussion and educational topic sessions.
At the beginning of the session, each participant was weighed in private and was and informed of their actual weight on a card to maintain individual privacy.
The group voluntarily shared details of their weight change together with personal dietary and other lifestyle experiences from the previous week. Participants were asked to keep and discuss a dietary record. The therapist did not advocate any specific diet. Instead, the principle was to negotiate changes in individual patients’ diets adding additional changes as required. These changes included:
- switching from sugary carbonated drinks to sugar free drinks
- eating more fruit and vegetables
- changing from full fat milk to semi or skimmed milk
- the use of artificial sweeteners or no sweetener instead of sugar in tea and coffee
- the use of low fat spread instead of butter
- Consuming less alcohol were discussed
Changes in the method of food preparation, such as frying less, were also considered. Within the group, patients were encouraged to increase their levels of physical activity. Members of the group have also taken up a formal exercise routine. Self-monitoring skills formed an important part of the agenda.
The Educational topics included:
- Healthy eating
- Meal planning and demonstrations
- Activity scheduling
The topics were presented in a flexible and informal manner by the group leader and additional sessions were incorporated to address specific weight issues such as Christmas, Easter, birthdays, and school holidays. Patients did not receive any written materials within the clinic.
There was no limit (maximum or minimum) on the number of sessions a patient could attend. For the purpose of analysis a gap in clinic visits of >3 months was determined to represent the start of a new treatment course.
52 men and 68 women enrolled into the programme. The average age of the patients was 42.3 ± 1.2 years (range 18-71 years). 18 patients dropped out from the weight management programme and re-joined the programme more than 3 months after leaving the programme. Six patients enrolled on the programme three times and one person enrolled four times giving a total of 153 patient episodes. The number of sessions attended per episode ranged from 1 to 402 (mean 67.4 ± 7.0, median 45). 93 patients had schizophrenia, 26 had an affective disorder and 1 had suffered a brain injury.
The mean baseline weight for the first visit to the clinic was 90.5 ± 1.6 kg (BMI 32.1 ± 0.5 kg/m2). On enrolment, 12 patients had a normal BMI (19-25kg/m2), 48 were overweight (BMI 25-30 kg/m2) and 93 were obese (BMI >30 kg/m2). The patients who re-joined the clinic had gained an average of 11.9 ± 1.7 kg in the interim between leaving and re-registering with the programme. There was no significant difference in weight or BMI between those re-joining the clinic and those joining for the first time (Wt: 96.0 ± 3.5 kg v 89.0 ± 1.7 kg; BMI 33.2 ± 1.2 kg/m2 v 31.8 ± 0.5 kg/m2).
6 patients dropped out of the programme within 4 weeks and a further 25 withdrew between 4 and 8 weeks. Thus dropouts within the first 8 weeks were 20%. 108 (71%) and 88 (58%) were still attending the clinic after 12 weeks and 6 months respectively. Data are available for 73 and 57 patients who have completed 1 year and 18 months of the programme respectively.
There was a progressive statistically significant reduction in mean weight and BMI throughout the duration of the study with no suggestion of a plateau. At 3 months, 100 of the 108 patients had lost weight while after 6 months, 84 of the 88 patients had lost weight. At 1 year, 70 of the 73 patients had lost weight. At 2 years, 42 of the 45 patients had lost weight. The final weight was reduced in all but 11 patients of whom, 6 had no weight change and 5 gained weight. The mean final weight loss was 7.6 ± 0.6 kg (range -43.7 to +17.0 kg).
Determinants of weight loss
There was no significant difference in percentage weight loss between men and women. There was no correlation between percentage weight loss and baseline weight. There was no correlation between percentage weight loss and baseline BMI.
In the first 3 months, younger people lost more weight, as demonstrated by an inverse correlation between and age and percentage weight loss in the first 3 months (r= 0.286 p=0.004) but there was no significant difference after 6 months.
There was no significant difference in percentage weight loss between patients who were new to the programme or re-joining the programme after a break of 3 months or more.
Weight loss was only correlated with the number of sessions attended (r=0.44, p<0.0001). On average, patients lost 0.43 ± 0.08 kg per session. There was no significant difference in percentage weight loss between those with schizophrenia and those with affective disorders.
Although any interpretation of this data should be limited to motivated patients, the findings support the effectiveness of long term, open-ended programmes designed to address weight change and lifestyle factors in people with severe mental illness. Patients continuing to attend a weight clinic over 10 years progressively lost weight. The only predictor of weight loss was number of sessions attended. Weight loss in a motivated cohort of people with severe mental illness was found in 93% of patients, weight maintenance 4% and weight gain 3%.
^ Holt RI, Pendlebury J, Wildgust HJ, Bushe CJ. Intentional weight loss in overweight and obese patients with severe mental illness: 8-year experience of a behavioural treatment program. J Clin Psychiatry. 2010 Jun;71(6):800-5
^ Pendlebury J, Bushe CJ, Wildgust HJ, Holt RI. Long-term maintenance of weight loss in patients with severe mental illness through a behavioural treatment programme in the UK. Acta Psychiatr Scand. 2007 Apr;115(4):286-94
^ Pendlebury J, Haddad P, Dursun S. Evaluation of a behavioural weight management programme for patients with severe mental illness: 3 year results. Human Psychopharmacology. 2005;20:447–448