Weight gain induced by Psychotropic medication

Sue Henderson

Introduction

• Over half (54%) adult Australian pop overweight or obese (Australian Bureau of Statistics, 2007), Up from 45% decade ago. low incomes & education levels, rural areas, males more likely overweight/obese (Australian Bureau of Statistics, 2007).

• Individuals schizophrenia 3 times more likely obese than general pop (Catapano& Castle, 2004)

• Overweight/obese major risk to long term health by increasing risk of chronic illness (Marder et al., 2004) lessening life expectancy markedly, especially among younger adults (Fontaine, Redden, Wang, Westfall, & Allison, 2003).

Psychotropic medications contributing to weight gain

Anti-psychotics - AtypicalHighest risk • Clozapine • Olanzapine Moderate risk• Risperidone Minimal risk• Ziprasidone Typicals - Chlorpromazine – dose dependent

Mood stabilisers

• Lithium (more than half on long term treatment gain weight) Chen and Silverstone (1990) cited in Malhi,

Mitchell and Caterson (2001).

• Sodium valproate

Antidepressants

• Tricyclic

• Amitriptyline

• Imipramine

• MAOI

• phenelzine

Other contributions

• Diet high in fat and low in fibre (Brown, Birtwistle, Roe, & Thompson, 1999)

• Lack of exercise (Brown, Birtwistle, Roe, & Thompson, 1999) sedentary lifestyle, may have to stop work due to symptoms, restricted activity due to hospitalisation or pharmacotherapy

• Hypothyroidism (mood stabilisers can produce thyroid dysfunction)

• Family history of obesity or diabetes (Marder et al., 2004)

Health risks of obesity

• Osteoarthritis • Sleep apnoea (increased risk with BMI of 30 or greater) • Gallbladder disease, Liver disease• Polycystic ovarian disease• Cancer (oesophageal, colon, endometrial, kidney,

breast)• Coronary Heart Disease (CHD), Cardiovascular disease

(CVD), Hypertension, Stroke, Hyperlipidemia• Type 2 Diabetes Mellitus (T2DM) • Metabolic syndrome

Psychological risks: Obesity

• Altered body image

• Depression

• Restricted lifestyle and quality of life

• Significant factor in non compliance with psychotropic medication thus increasing the risk of relapse

Assessment

3 main measures:

1. Body Mass Index (BMI),

2. Waist circumference

3. Waist to hip ratio (WHR).

BMI

• Weight (kilograms) ÷ Height (metres) squared or

• Weight (pounds) ÷ Height (inches) squared X 704.5

• Use online calculator

• More reliable than scales because weight varies with height

Classification BMI (WHO, 2000)

BMI Classification

≤ 18.5 Underweight

18.5 – 24.9 Healthy

25.0 – 29.9 Overweight

30 – 39.9 Obese

≥ 40.0 Morbidly obese

Waist circumference

• 1. Loosen and lift clothing away from around waist

• 2. Position the tape mid-way between the top of hip bone and the bottom of the rib cage

• 3. When taking the measurement, the abdomen should be relaxed and breathing out

• 4. Record the measurement

Waist to Hip Ration

Measure hip circumference

• maximum circumference over the buttocks.

• Divide the waist circumference by the hip circumference to get the WHR.

Waist circumference

Men Women Health Risk

< 94 cm < 80 cm Low

≥ 94 – 101.9 cm ≥ 80 – 87.9 cm Increased

≥ 102 cm ≥ 88 cm High

Focus on Prevention

• “subsequent weight loss is very difficult to achieve and existing interventions to promote weight loss are often ineffective” (Marder, et al., 2004, p. 1336).

• Take full health history – if patient has a family history of obesity, diabetes or has a BMI of 25 or higher, consider weight gain profile of different medication (Marder, et al., 2004)

Prevention cont…

• Monitor & chart BMI & waist circumference of every patient on psychotropic medication. For those on medication’s known to be associated with weight gain, weigh, measure and chart at each outpatient visit (or admission) for 6 months, or after any medication change. Encourage the patient to monitor and chart their own measurement and weight.

Prevention cont…

• Unless a patient is underweight (BMI ≤ 18.5), a weight gain of one BMI unit indicates the need for an intervention. If the waist circumference is ≥ 102 cm (men) or ≥ 88 cm (women) an intervention is needed (Marder et al., 2004).

• Aim to maintain therapeutic effects while minimising weight gain and consider substituting a suitable antipsychotic with a low weight gain profile.

Reducing weight gain

• Multidisciplinary approach• Mortality/morbidity can be reduced by loss of 5%

to 10% of body weight.• If the WHR is over the recommended limits a

medical review by a (GP) is indicated.• Address issues underlying weight gain for

example, if weight gain is related to medication reduce the dose to minimise weight gain while maintaining therapeutic effect or substitute with another psychotropic drug.

Reducing weight gain

• Educate patient/carers on lifestyle changes.• low cost or no cost programs • Caloric reduction diet of 5 or more servings of fresh food

and vegetables daily and reduce saturated and trans fatty acid intake ≤ of total energy intake (National Heart Foundation of

Australia, 2007). • Regular exercise by gradually building up tolerance to at

least 30 minutes of moderate exercise for most days of the week (National Heart Foundation of Australia, 2007).

• Reduction alcohol intake• Self monitoring, stress management, cognitive

restructuring • Bolster self-efficacy, emotional, moral support

Weight loss meds/surgery

• Weight loss medications are a last resort as they may reduce the effectiveness of antipsychotic medication (Green, Canuso, Brenner, & Wojcik,

2003).

• Severe cases surgical intervention may be considered.

References• Australian Bureau of Statistics. (2007). Overweight and obesity (No. 4102.0).

Canberra.• Brown, S., Birtwistle, J., Roe, L., & Thompson, C. (1999). The unhealthy lifestyle of

people with schizophrenia. Psychological Medicine, 29(3), 697-701.• Catapano, L., & Castle, D. (2004). Obesity in schizophrenia: What can be done about

it? Australasian Psychiatry, 12(1), 23-25.• Fontaine, K. R., Redden, D. T., Wang, C., Westfall, A. O., & Allison, D. B. (2003).

Years of life lost due to obesity. JAMA, 289(2), 187-193.• Green, A. I., Canuso, C. M., Brenner, M. J., & Wojcik, J. D. (2003). Detection and

management of comorbidity in patients with schizophrenia. Psychiatric Clinics of North America, 26(1), 115-139.

• Malhi, G. S., Mitchell, P. B., & Caterson, I. (2001). 'Why getting fat, Doc?' Weight gain and psychotropic medications. Australian & New Zealand Journal of Psychiatry, 35(3), 315-321.

• Marder, S. R., Essock, S. M., Miller, A. L., Buchanan, R. W., Casey, D. E., Davis, J. M., et al. (2004). Physical health monitoring of patients with schizophrenia. American Journal of Psychiatry, 161(8), 1334-1349.

• National Heart Foundation of Australia. (2007). Reducing risk in heart disease 2007 • World Health Organisation. (2000). Obesity: Preventing and managing the global

epidemic (No. 894). Geneva: WHO.