Health Centers > Mental Health Center > Schizophrenia and Other Psychotic Disorders > Schizophrenia > Obesity in Patients With Schizophrenia
Obesity and its related sequelae represent a growing epidemic in the United States. Overweight is defined by the World Health Organization as a body mass index (BMI) of 25.029.9 kg/m2, and obesity as BMI ≥ 30 kg/m2. Recent data estimate that more than 50% of U.S. adults are overweight, with 31% of men and 35% of women considered obese, or at least 20% above their ideal body weight (Yanovski and Yanovski 1999).
Obesity in Schizophrenia
Results of the 1999 National Health and Nutrition Examination Survey (NHANES), released in December 2000 by the National Center for Health Statistics, noted that the proportion of obese individuals in the United States in 1999 was 80% greater than the proportion measured by NHANES II in 19761980, and 17% greater than that measured by NHANES III in 1997 (Flegal and Troiano 2000).
Similarly, the Centers for Disease Control (CDC) performed a telephone survey in 1991 that found that only 4 of the 47 states surveyed had obesity rates of 15% or greater, whereas the 2000 survey, which was repeated in all 50 states, found that every state except Colorado had an obesity rate ≥ 15%
In the pre-antipsychotic era, Kraepelin noted that some patients with schizophrenia exhibited bizarre eating habits, and not uncommonly were obese. "The taking of food fluctuates from complete refusal to the greatest voracity. The body weight usually falls at first often to a considerable degree. . . . [L]ater, on the contrary we see the weight not infrequently rise quickly in the most extraordinary way, so that the patients in a short time acquire an uncommonly well-nourished turgid appearance" (Kraepelin 1919, p. 125).
It is worth noting that this tendency to weight loss during more active phases of the illness has been borne out by results from a recent meta-analysis of multiple antipsychotic drug trials, which noted that placebo-treated patients on average lost weight (Allison et al. 1999a). Nevertheless, there are a number of reasons that patients with schizophrenia might be prone to obesity, including the effect of symptoms such as paranoia and negative symptoms such as apathy and social withdrawal, which may independently contribute to schizophrenic patients' lack of adherence to proper diet and their overall sedentary lifestyle (Davidson et al. 2001).
Moreover, the economic conditions of chronically mentally ill individuals also contribute to poor dietary habits. One theory about the major vector of the obesity epidemic in this country and abroad correlates obesity trends with the growth of the fast-food industry (Schlosser 2001). Fast food is an affordable option for those on limited budgets, yet unfortunately is often very high in saturated fat and total calories ..
A common and serious mental disorder characterized by loss of contact with reality (psychosis), hallucinations (false perceptions), delusions (false beliefs), abnormal thinking
The effects of antipsychotic-related weight gain have both medical and psychiatric components. In particular, medication compliance is adversely affected by excessive weight gain, with weight gain being a wellknown cause of treatment nonadherence (Bernstein 1988; Silverstone et al. 1988) and subsequent psychotic relapse (Rockwell et al. 1983).
During the 2000 American Psychiatric Association meeting, investigators at the ColumbiaSt. Luke's Obesity Research Center released survey data examining this link between obesity and antipsychotic medication compliance. They found that obese patients were 13 times as likely to request discontinuation of their current antipsychotic agent because of concerns about weight gain and 3 times as likely to be noncompliant with treatment compared with nonobese individuals (Weiden et al. 2000).
Weight gain is a common side effect of antipsychotic medications and is of particular concern with most of the newer "atypical" antipsychotics. It is, therefore, increasingly important to understand the impact of obesity and perceived weight problems on compliance with these medications.
Peter J. Weiden, Joan A. Mackell and Diana D. McDonnell SUNY Health Sciences Center at Brooklyn, 450 Clarkson Avenue, Box 1203, Brooklyn, NY 11203-2098, USA Pfizer, Inc., New York, NY, USA Consumer Health Sciences, Princeton, NJ, USA Schizophrenia Research - doi:10.1016/S0920-9964(02)00498-X
The literature thus far suggests that some of the novel antipsychotic medications cause less weight gain than others; thus it may be possible to switch patients on agents associated with the most weight gain to those with lower weight gain liability (Allison et al. 1999a; Wirshing et al. 1999); however, prior to switching, it is important to recall that the most difficult symptoms to control are those of psychosis.
A switch of antipsychotic medication makes sense particularly if the patient is nonresponsive to the current antipsychotic. As discussed, weight gain can be a significant cause of nonadherence with a medication regimen; thus, in cases where a patient refuses to take medication due to weight gain concerns, a switch is advisable (Bernstein 1988; Silverstone et al. 1988). A switch study sponsored by Pfizer demonstrated that subjects switched from olanzapine to ziprasidone lost a statistically significant 2.2 kg on average over 6 weeks (Kingsbury et al. 2001).
Obesity in schizophrenia: what can be done about it?
Obesity is a common problem for people with schizophrenia, with an estimated 40-60% of this population being obese or overweight. Obesity among the mentally ill may contribute to adverse medical and psychological consequences as well as medication non-compliance and poorer quality and enjoyment of life. This review discusses the issues related to obesity in schizophrenia and the role of pharmacological and behavioural treatments in the reduction of obesity and maintenance of gains.
Lisa Catapano; David Castle Affiliations: George Washington University, Washington, DC, USA Mental Health Research Institute and University of Melbourne, Melbourne, Vic., Australia DOI: 10.1046/j.1039-8562.2003.02054.x Published in: Australasian Psychiatry, Volume 12, Issue 1 March 2004 , pages 23 - 25
Although most persons with schizophrenia do not have a family history of it, genetic factors have been implicated. Persons who have a first-degree relative with schizophrenia have about a 15% risk of developing the disorder, compared with a 1% risk among the general population. A monozygotic twin whose co-twin has schizophrenia has a > 50% probability of developing it. Sensitive neurologic and neuropsychiatric tests often indicate that aberrant smooth-pursuit eye tracking, impaired performance on tests of cognition and attention, and deficient sensory gating occur more commonly among patients with schizophrenia than among the general population. These psychophysiologic markers also occur among first-degree relatives of persons with schizophrenia and may indicate vulnerability before overt onset of illness.
Various environmental stressors can trigger the emergence or recurrence of symptoms in vulnerable persons. Examples are stressful life events such as ending a relationship or leaving home for the armed forces, work, or college and biologic stressors such as substance abuse. Stressful family relations can cause or result from frequent illness exacerbation. Protective factors that may mitigate the effect of stress on symptom formation or exacerbation are discussed under Treatment, below.
Behavioral interventions such as calorie restriction, exercise, and behavioral modification are key elements to successful, sustained weight loss (NHLBI 2000; NHLBI also has posted on its Web site a practical guide for obesity evaluation and management: www.nhlbi.nih.gov/guidelines/ obesity/practgd_c.pdf). There is little in the way of published data on behavioral interventions for weight loss in psychotic patients, and the few studies tend to be methodologically weak. In one small (n = 14) 14-week study, patients in a residential setting achieved, on average, 10 pounds more weight loss when given behavioral interventions compared with a control group (Rotatori 1980).
Work by Wirshing and colleagues demonstrated that simple stepwise behavioral interventions were modestly successful in risperidone- and olanzapine-treated subjects, but had little effect in clozapine-treated subjects (Wirshing et al. 1999). The interventions are listed below ....
Antipsychotic medications have been the mainstay of treatment for schizophrenia for over half a century. A link between weight gain and treatment with chlorpromazine and other low-potency conventional antipsychotic agents, such as thioridazine, was noted in early studies of the metabolic effects of these agents. (Bernstein 1988; Rockwell et al. 1983). A recent study by Allison et al. (1999b) based on 1989 National Health Interview Survey data revealed that a significantly greater proportion of female patients with schizophrenia had BMI distributions in the overweight and obese spectrum compared with their counterparts in the general medical population, with a trend toward greater BMI seen among male schizophrenic patients.
In addition to their chronic psychiatric illness, persons with schizophrenia are at increased risk for a number of physical health problems. They have higher mortality and morbidity than the general population, which is not all accounted for by their higher rates of suicide (Harris & Barraclough, 1998). Their rates of obesity (Meyer et al., 2005), dyslipidemia (Meyer & Koro, 2004), glucose dysregulation, and type 2 diabetes (Dixon et al., 2000) combine to increase their risk for cardiovascular disease approximately 12-fold over that of the general population. Abdominal obesity is a key modifiable contributor that impacts several factors known to contribute to the health risks of those with schizophrenia. Excess visceral fat (as opposed to subcutaneous fat) increases the circulatory workload, leading to an increased likelihood of type 2 diabetes, hypertension, and elevated triglycerides, all of which ultimately increase cardiovascular mortality and morbidity (Van Gaal, 2006).
Beebe, Lora Humphrey "Obesity in Schizophrenia: Screening, Monitoring, and Health Promotion". Perspectives in Psychiatric Care
Donna A. Wirshing, M.D.
Jonathan M. Meyer, M.D.