Schizophrenia Research 121 (2010) 277–278

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Schizophrenia Research

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Letter to the Editor

Schizophrenia and obesity: Addressing obesogenicenvironments in mental health settings

Table 1Demographic data; weight change 3 and 6 mth following dietary intervention.

Baseline demographic data

PatientsN 53BMI m/kg2 (SD) 29.8 (8.1)Diabetes n (%) 17 (32%)Age yr. (SD) 50.5 (8.2)Male n (%) 29 (55%)Schizophrenia n (%) 42 (79%)Schizoaffective n (%) 11 (21%)Caucasian 43 (81%)African 6 (11%)Korean 2 (4%)Chinese 2 (4%)

Anthropometric dataWeights (lb) Sig.Pre intervention (baseline)weight (SD)

178.2 (44.3)

Weight 3 mth postbaseline (SD)

174.4 (42.1)

Weight 6 mth postbaseline (SD)

172.3 (41.0)

Weight loss at 3 mth (SD)95% CI

3.8 (8.2) 1.5 to 6.1 t=3.35, df=52,pb0.003

Weight loss at 6 mth (SD)95% CI

6.0 (10.5) 3.1 to 8.8 t=4.15, df=52,pb0.001

Dear Editors:

Obesity disproportionally affects those with schizophrenia,impacting quality of life and reducing life expectancy (Allisonet al., 2009). In a systematic review of obesity interventions inschizophrenia, we found that effect sizes were small andinterventions were focused exclusively on changing individualbehaviour (physical activity and dietary modification) andpharmacological approaches (Faulkner et al., 2007). In practicethese interventions are challenging to implement in popula-tions composed of individuals with active psychotic orcognitive impairment and severe motivational deficits. Tohave a greater impact, systems-based, environmental inter-ventions are needed to complement the modest impact ofindividual interventions and education programs.

A framework such as the ANGELOmodel (analysis grid forenvironments linked to obesity) can be applied to mentalhealth settings such as psychiatric units, group homes andday hospitals to identify foci for intervention across variousenvironmental domains (Swinburn et al., 1999). A recentqualitative study identified potential “obesogenic” environ-mental factors influencing both diet and physical activity inhospitalized patients (Faulkner et al., 2009). For example, themodified buffet service form of food delivery (food is plated inthe dining area by food service staff based on patient choice)was associated with overeating.

In the present uncontrolled natural experiment (seeRamanathan et al., 2008), we report the impact of introducingan individualized tray service that allowed for control overportion size (Young and Nestle, 2002). To the best of ourknowledge, this is the first report of a service modification totarget body weight among people with schizophrenia. Thestudy was approved by the Centre for Addiction and MentalHealth (CAMH) Research Ethics Board as a retrospective chartreview.

Those included in the study (n=53) were resident on apsychiatric rehabilitation unit at CAMH in Toronto during theobservation period (March to September 2007). There wereno exclusions. Patients on this Unit are diagnosed withschizophrenia or schizoaffective disorder and have refractorypsychosis. Many have cognitive impairment, medical co-morbidity, and disruptive behaviour. Meals are provided onthe Unit. In addition, patients can purchase food off the Unitwithin a limited budget of approximately $5 per day.

0920-9964/$ – see front matter © 2010 Elsevier B.V. All rights reserved.doi:10.1016/j.schres.2010.05.024

Baseline weights, heights, medication and demographicdata were recorded in March 2007. The intervention beganApril 2007 and consisted of: 1) single tray/portion for eachindividual; 2) sugar, creamers, butter, margarine, bread,condiments kept “behind the counter”with monitored access;3) juice eliminated with meals; 4) modifications made to“Regular Diet” (1800 to 2100 Kcal/day) to promote currentdietary recommendations (i.e. high fibre and low saturatedfat); and 5) 18 of the 53 patients (mostly diagnosedwith type 2diabetes) placed on reduced calorie diets (1600–1800 K);“Diabetes Diet”.

Patient characteristics are summarized in Table 1. All had adiagnosis of schizophrenia or schizoaffective disorder; 33 (62%)were on clozapine; 25 (47%) were obese (BMI≥30) and11 (21%) overweight (BMI 25-29.9); 17 (32%) were diagnosedwith diabetes.

As outlined in Table 1, there was a significant reduction inbody weight compared with pre-intervention measures at 3and 6 months. At six months 74% of the 53 patients lostweight with 14 (26%) losing more than 7% body weight. As agroup, mean BMI dropped 1 point over 6 months, from 29.8 to

278 T. Cohn et al. / Schizophrenia Research 121 (2010) 277–278

28.8, t=4.08, df=52, pb0.001. Weight loss did not differ byage, sex, race, baselineweight, antipsychotic group or diabeticstatus.

The environments in which mental health services areprovided may contribute to the high prevalence of obesity inthose with schizophrenia. While we acknowledge the limita-tions of our uncontrolled research design, we demonstratedthat a relatively simple modification in food delivery wasassociated with weight loss which increased after 6 months.In a recent Cochrane Review, weight loss in 3 short-termbehavioural trials (12–16 week) with a pooled sample of 71patients with schizophrenia was 3.8 lbs (95% CI 1.3–6.1)(Faulkner et al., 2007). This is similar to what was seen in ourstudy at mid-point although patients in the current studywent on to lose an average of 6 lbs (95% CI 3.1 to 8.8) by studyend. What is notable about the success of this intervention isthat most of these patients would not be consideredcandidates for behavioural interventions because of deficitsin motivation, cognitive impairment, behaviour disturbanceand paranoid mistrust.

There was initial resistance from staff who expressedconcern that a tray service would restrict choice; would beless client centered, and that individuals with mental illnesshave the right to choose what and howmuch they eat, even ifthey are perceived as making poor choices. However, patientsprovided positive feedback and appreciated having their owntrays with their predetermined choices. In addition, therewere cost savings in reducing wasted food because a trayservice allows for more accurate estimates of food require-ments. The change in food services has now generalized tothe entire facility servicing 500 inpatients.

Interventions need to be targeted at multiple levels —

individual, group and environment (Faulkner et al., 2009).This study illustrates the potential effectiveness of a simpleenvironmental intervention in assisting individual andpopulation level approaches to weight management.

Role of funding sourceNo external funding.

ContributorsDr. Cohn conducted the study, completed the statistical analysis and

wrote the first draft of the manuscript.Shannan Grant participated in data collection, reviewed and revised the

manuscript.Dr. Faulkner guided the project, reviewed and revised the manuscript

and developed the discussion points.All authors approved the final manuscript.

Conflict of interestDr. Cohn has received speaker’s fees from Pfizer Canada Shannan Grant

and Guy Faulkner declare no conflict of interest.

AcknowledgementsWe thank food service managers Maria Delima, Charmaine Saarinen and

food service staff; dietitian Henia Solomon; and staff and patients on theIntegrated Rehabilitation Unit at The Centre for Addiction and Mental Healthfor their participation in this project.

References

Allison, D.B., Newcomer, J.W., et al., 2009. Obesity among those with mentaldisorders: a National Institute of Mental Health meeting report. Am. J.Prev. Med. 36 (4), 341–350.

Faulkner, G., Cohn, T., et al., 2007. Interventions to reduce weight gain inschizophrenia. Cochrane Database Syst. Rev. 1, CD005148.

Faulkner, G.E., Gorczynski, P.F., et al., 2009. Psychiatric illness and obesity:recognizing the “obesogenic” nature of an inpatient psychiatric setting.Psychiatr. Serv. 60 (4), 538–541.

Ramanathan, S., Allison, K.R., et al., 2008. Challenges in assessing theimplementation and effectiveness of physical activity and nutritionpolicy interventions as natural experiments. Health Promot. Int. 23 (3),290–297.

Swinburn, B., Egger, G., et al., 1999. Dissecting obesogenic environments: thedevelopment andapplicationof a framework for identifyingandprioritizingenvironmental interventions for obesity. Prev. Med. 29 (6 Pt 1), 563–570.

Young, L.R., Nestle, M., 2002. The contribution of expanding portion sizes tothe US obesity epidemic. Am. J. Public Health 92 (2), 246–249.

Tony CohnCentre for Addiction and Mental Health, Ontario, Canada

Department of Psychiatry, Faculty of Medicine,University of Toronto, Canada

Department of Nutritional Sciences, Faculty of Medicine,University of Toronto, Canada

Corresponding author. Centre for Addiction and MentalHealth, 1001 Queen Street West, Toronto ON,

Canada M5S 2M8. Tel.: +1 416 535 8501x2573;fax: +1 416 944 9679.

E-mail address: Tony_Cohn@camh.net.

Shannan GrantDepartment of Nutritional Sciences, Faculty of Medicine,

University of Toronto, Canada

Guy E. FaulknerFaculty of Physical Education and Health,

University of Toronto, Canada

25 April 2010