Friday, March 20, 2009

Obesity and Mental Illness

"Research addressing obesity and other health risk factors that contribute to the disproportionate morbidity and mortality of those with mental disorders is an urgent public health need."

I definitely agree with the statement above that I came across while reading an article from the American Journal of Preventive Medicine. The article entitled Obesity Among Those With Mental Disorders: A National Institute of Mental Health Meeting Report Obesity Among Those With Mental Disorders: A National Institute of Mental Health Meeting Report was published in the April 2009 issue. It is a review by D. Allison et al. of a meeting held in October 2005 at NIMH to review the literature on obesity, nutrition, and physical activity among those with mental illness and also includes the current literature on the subject.

Obesity if one of the most common medical problems I see on a daily basis in the clinic. I am guilty of not addressing it as seriously as I should. I definitely have the syndrome of "Why should anyone listen to the obese doctor on nutrition and exercise." However, I am doing my patients a huge injustice since obesity has been shown to reduce years off a person's life. People with severe mental illness tend to live shorter lives than those without mental illness. Cardiovascular Disease is a large culprit in the deaths of these individuals. Obesity causes a 40% increase in Cardiovascular Disease, so I am definitely doing a large disservice to my patients.

The review listed above points out that the population of those with a mental illness have larger incidence of obesity. While it is not entirely known if that increased incidence is due to the disorders, genetic factors, or the treatment.

The review points out that depression may even be linked with obesity. One study associated adolescent depression with the increased risk of developing obesity in the future. Another study associated the two by stating that obese women were more likely to be depressed than their non-overweight counterparts. So what comes first, the obesity or the depression? That still remains unknown. Factors that could play a role are low self-esteem from the obesity could lead to depression, inactivity from the low energy level and anhedonia could cause depression, and changes in hormone levels in either could cause the other one. Probably all these factors, and other ones not mentioned, play a role.

Individuals with Schizophrenia tend to have higher BMI's than the average population, as was pointed out in the review. There may be a predisposition there, but our treatments do not help the situation. Atypical Anti-Psychotics are known to carry an increased risk of metabolic syndrome. Many patients have told me that they experience an increase in appetite when placed on risperidone, olanzapine, and quetiapine. I intentionally first turn to ziprasidone and aripiprazole in those individuals where weight gain would be an issue. However, even these carry a risk and they do not always work.

The study points out that a study found that 88% of patients with mental illness who had dyslipidemia were not being treated with a lipid-lowering medication. While in part, some clinicians might argue that compliance may be an issue, those stable on a medication regime definitely could take one more pill if necessary. A common issue in my patients is that they do not want to go to a primary care physician. Limited resources, paranoia, lack of trust of the medical community, and poor treatment all can play a role. Psychiatrist should take it upon themselves to make sure their patients' medical conditions are adequately treated. I definitely keep in contact with my patients' primary care physicians and assure that they receive good medical care. The patient's vitals, weight, height, and BMI should be monitored at every visit. A fasting lipid panel and fasting glucose should also be periodically monitored in addition to Hemoglobin A1C, electrolytes, and liver function.

Finally, the most important take-home message. The psychiatrist should discuss physical activity and nutrition at every visit. I talk about fruit and vegetables and healthy alternatives with the patients. I keep in mind the limited resources of patients and I also discuss one of the cheapest methods of exercising available. I keep it small and encourage walking ten minutes three times a day. While I had no part in this patient's weight loss, one of my patients with a severe mental illness lost 70 pounds by cutting soda out of his diet and walking. I challenge all doctors out there to discuss simple little changes in diet and exercise with their patients and target obesity.

1 comment:

  1. Thanks for submitting this post to our blog carnival. We just published the 45th edition of Brain Blogging and your article was featured!

    Thank you.