Acta Psychiatr Scand 2014: 130: 279–289 All rights reserved DOI: 10.1111/acps.12245

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd ACTA PSYCHIATRICA SCANDINAVICA

Review

A systematic review of controlled interventions to reduce overweight and obesity in people with schizophrenia Hjorth P, Davidsen AS, Kilian R, Skrubbeltrang C. A systematic review of controlled interventions to reduce overweight and obesity in people with schizophrenia. Objective: Overweight and obesity are generally found among patients with schizophrenia. This may lead to serious implications for health and wellbeing. The aim was to review controlled intervention studies on reducing overweight/obesity and/or reducing physical illness in patients with schizophrenia. Method: A systematic literature search was carried out in the bibliographic databases PubMed (MEDLINE), Embase (Ovid), PsycInfo (Ovid) and Cinahl (Ebsco). We included all randomised and nonrandomised clinically controlled studies that compared a nonpharmacological intervention, aimed at weight reduction and/or reducing physical illness, with standard care for patients with schizophrenia. Results: All 1713 references were evaluated for inclusion in the review. Twenty-three met the inclusion criteria and were categorised into four subgroups according to tested interventions: diet, exercise and cognitive behavioural therapy, or mixed combinations of the three. In this review, interventions showed efficacy in reducing weight and improving physical health parameters confirming that physical health improvement was possible in patients with schizophrenia. Conclusion: The included studies indicate that the interventions reduced weight and improved physical health parameters in patients with schizophrenia.

P. Hjorth1,2, A. S. Davidsen3,

R. Kilian4, C. Skrubbeltrang5

1 Aarhus University Hospital, Aalborg Psychiatric Hospital, Aalborg, 2Department M, Aarhus University Hospital, Risskov, 3Research Unit for General Practice and Section of General Practice, Centre of Health and Community, University of Copenhagen, Copenhagen, Denmark, 4Clinic for Psychiatry and Psychotherapy, Ulm University, G€unzburg, Germany and 5Medical Library, Aalborg Hospital, Aalborg, Denmark

Key words: behavioural therapy; body weight changes; diet; exercise; schizophrenia Peter Hjorth, Aarhus University Hospital, Risskov, Department M, Skovagervej 2, 8240 Risskov, Denmark. E-mail: [email protected]

Accepted for publication December 11, 2013

Summations

• Efficacy of non-pharmalogical intervention for reducing weight in patients with schizophrenia. • Health improvement was possible in patients with schizophrenia. • Unwanted side-effects from intervention were rarely described. • Presentation of a selection of interventions suitable for most psychiatric settings. Considerations

• The interventions are, to some extent, complex and often a mixture of different methods. • Intervention with switching antipsychotic medication and medicine for weight loss were excluded. • The systematic literature search only included studies in English. Introduction

Obesity and physical illness are recognised problems among individuals with schizophrenia (1, 2).

This has been attributed to a sedentary lifestyle, unhealthy eating habits, the effects of the mental illness itself (3) and, finally, to the side-effects of medication (2, 4). Obese patients are at higher risk 279

Hjorth et al. of developing various physical comorbidities, such as diabetes, cardiovascular diseases and cancer (5). These effects would be expected to contribute to even higher mortality in the coming years (6). Furthermore, obese patients typically have a poorer quality of life; they are exposed to stigmatisation, and they are less likely to remain on antipsychotic medication (7). Weight gain as a consequence of antipsychotic treatment has been demonstrated in clinical trials, and up to 80% of individuals treated with antipsychotic medication suffer from overweight and obesity (8). Young patients experiencing their first episode of psychosis are especially at risk to a rapid and pronounced weight gain (9). The mean weight change found in clinical trials does not always reflect a patient’s reality. There is great individual variation regarding weight gain as a result of antipsychotic medication (4, 10, 11). Additionally, this group of patients typically uses antidepressants and anticonvulsants in combination with antipsychotics. Some of these drugs have also been associated with weight gain (11), and the total effect on the patient’s weight can be considerable. To counteract physical illness, a European group named HELPS (European Network for Promoting the Health of Residents in Psychiatric and Social Care Institutions) succeeded in the planning and management of improving physical health in patients with severe mental illness (12). Additionally, there are interventions for healthy living for patients with early psychosis (13). Guidelines for screening and monitoring health problems are available (14), and studies initiated by the pharmaceutical industry have aimed at reducing the weight gain caused by antipsychotic medication (15). Management of patients’ psychiatric and physical health problems is a multiprofessional challenge, and methods of organisation are not the same in psychiatric hospitals and out-patient clinics. Nurses are often the main care providers for patients with schizophrenia. Physical health and prevention of physical and mental illness are main obligations for nurses who are trained in this form of work (16). The highest evidence level can be accessed from meta-analyses and systematic reviews of blinded, randomised controlled trials. Studies with a control group are considered as high-quality evidence, but not as high as randomised controlled studies. A control group is a group of participants that closely resemble the treatment group in many demographic and clinical variables, but who are not receiving the active intervention or medication 280

under study, thereby serving as a comparison group when treatment results are evaluated. Aims of the study

To review randomised and non-randomised controlled trials on interventions directed towards improving physical health in patients with schizophrenia. Material and methods

A systematic literature search was performed. The PubMed (MEDLINE), Embase (Ovid), PsycInfo (Ovid) and Cinahl (Ebsco) bibliographic databases were searched for relevant articles in the period from the start date of each database until June 2013. The search strategy was divided into three parts: one covering the overweight aspect, one the intervention/therapy part and one the psychiatric disease. The search was customised for each database using both controlled thesaurus terms and natural language terms for synonyms (see Appendix 1). The search retrieved a total of 2315 studies – 490 from PubMed, 1179 from Embase, 499 from PsycInfo and 147 from CINAHL. All references were entered into the reference managing tool RefWorks, and 602 duplicates were deleted. The remaining 1713 studies were evaluated for inclusion in the review. Inclusion criteria

We included randomised studies and studies with a control group published in an English language, peer-reviewed journal. There was no limit as to the number of patients, so even small sample size studies were included. There was no limit to study length. Weight loss and weight maintenance were the key outcome measures of this review. Furthermore, studies aimed at improving physical health were included because this review also covers interventions improving physical health in general. Patients had to be diagnosed with schizophrenia, schizoaffective or schizophreniform disorder. Studies with a subgroup (5.4 kg, and, in addition, patients’ self-esteem and global functioning were improved. There was only little information about the economic cost of the interventions, although economy is of great importance for the healthcare system in considering the implementation of health interventions into daily routine.

Discussion

The studies included involved, for the most part, patients with schizophrenia from a wide range of settings, including both in- and out-patients. Only one of 23 studies did not produce any physical health improvement. In summary, interventions in this review showed efficacy in reducing weight and improving physical health, confirming that intervention for physical health changes is possible in patients with schizophrenia. Another important finding in one of the studies was the positive efficacy from intervention that was beneficial to the individual patients, such as improvement in psychiatric symptoms, higher self-esteem and higher scores in the quality of life test (32). This intervention was extensive, but can be appealing and interesting for patients and staff interested in outdoor life and adventurous physical activity. The validity of the review findings is influenced by the lack of studies with high evidence owing to short study periods and small sample sizes. Furthermore, the interventions are, to some extent, 283

284

28/35 Randomisation Clozapine

Matched control group

28/31 Randomisation

23/31 No randomisation

31/15 No randomisation

314/59 No randomisation

31/20 No randomisation

24/17 Cluster-randomised 56% had schizophrenia 29/14 Randomisation Olanzapin treatment 28/33 Randomisation

33/30 Matched subject without psychiatric disorders were controls

Wu et al. (29)

Ball et al. (30)

Melamed et al. (31)

Voruganti et al. (32)

Vreeland et al. (33)

Porsdal et al. (15)

Menza et al. (34)

Forsberg et al. (35)

Kuo et al. (38)

BMI, body mass index; HbA1c, glycosylated haemoglobin.

Alvarez-Jimenez et al. (37)

Kwon et al. (36)

Participants intervention/ control group

Author (reference)

Table 4. Mixed interventions

Behavioural Nutrition Exercise Weight reduction programme, behaviour therapy and exercise

Study-circle Diet Physical activity Weight management programme

Nutrition Exercise Behaviour interventions

Nutrition counselling Exercise (walks) Behaviour interventions Nutrition Physical activity

Intervention: 3.9  3.6 kg Control: 1.5  1.9 kg Intervention gained 4.1 kg Control gained 6.9 kg Significant decrease in weight

3 month

10 weeks

Significant weight reduction after 3 months and 1 year after study end Weight loss of >5.4 kg Improved self-esteem and global functioning Intervention: weight loss of 2.7 kg Controls: gained 2.9 kg Significant results Intervention: weight loss of 0.5 kg ( 0.9; 0.2) Controls gained 0.9 kg (0; 1.8) Intervention: weight loss of 3 kg. P = 0.02 Controls: weight gain of 3.2 kg Improvement in HbA1c A decrease in number of patients with metabolic syndrome

Men lost 3.3 kg ( 2.7; 2.7)

Effect: BMI decrease of 5.4% and waist decreased 3.3 cm Improvement in metabolic profile

Average changes in health parameters

12 weeks

52 weeks (nutrition) 12 weeks (exercise) 12 months

12 weeks

12 weeks

8 months

3 months

10 weeks

‘Weight Watcher’ Exercise walks Behaviour intervention Diet and information Physical exercise Adventure – recreation

6 months

Length

Diet and physical activity programme

Intervention

Can be implemented as practice

Patients with schizophrenia were able to adhere to this programme

Can be implemented in clinical praxis

In day-care units, lifestyle modification and behaviour therapy can reduce body weight

Selected patients on olanzapine. Weight gain of more than 7% of body weight prior to entering the study Early behavioural intervention can lessen antipsychotic weight gain

Patients are satisfied with the programme

Acceptable for patients Maintained loss over 1 year

Substantial healthy living programme for patients under staff guidance

Can be performed as part of daily practice

Relevant to perform in psychiatric facilities Study funded by Eli Lilly

The programme is effective in in-patient settings

Promising results might lead to better lifestyle

Owing to selection bias and small sample, it is not possible to evaluate the effect of the programme Patients can lose weight and maintain the loss

Improvement in physical health

Conclusion

Healthcare staff can help psychiatric patients to control their weight

Suitable as hospital programme Can be performed by the staff

Useful in practice where staff have the qualifications required

Can be used in in-patients Rather strict diet and exercise programme makes it questionable to implement in practice No adverse event from either diet or exercise. The programme can be implemented in practice Easy to implement in hospitalised patients Can be performed by staff

Utility in clinical practice

Hjorth et al.

Systematic review complex and often a mixture of different parts. This makes it difficult to compare the outcome effect from this review with other reviews, and this is in accordance with the paper by van Hasselt et al. (39) on evaluating interventions to improve somatic health in severe mental illness. Studies among the general population testing short-term interventions for weight reduction have uncertain effects in the long run as lifestyle changes can be maintained in a study period of a few months, but are difficult to continue over longer periods of time (40). This finding is probably also the case among patients with schizophrenia. Other studies in this review did not have sufficient power to reach significant results. Nevertheless, as a whole, the studies demonstrated that tailored intervention to patients with schizophrenia can improve health parameters and induce weight reductions during the study period. Adverse effects and unwanted side-effects from intervention are rarely described in the studies in this review. This lack of information can be caused by information bias. Additionally, it is the authors’ beliefs that many of the interventions are close to everyday living and, for most patients, will be experienced as enjoyable, for example healthy and tasty food instead of fast food, walks in the neighbourhood or forest and other leisure activity incorporating physical activity. Healthcare managers and policymakers must be aware that the weight gain commonly seen in patients with schizophrenia is a serious clinical problem related to increased morbidity (5). The long-term effect of the high prevalence of obesity in this population will result in an economic burden (41). However, interventions for preventing or treating weight gain in patients with schizophrenia create weight reductions. Changing health behaviours could possibly be difficult, and frequent reinforcement may play a critical role in the successful long-term adoption of regular physical activity and diet modification. Mental health-specific barriers to physical activity and dietary change can be more appropriately eliminated by staff trained to be sensitive and supportive in regard to these issues. We only included randomised intervention studies and studies with a control group. This limited the number of studies included. We were well aware that there were important and inspiring studies that did not meet these requirements, such as The Cromwell House Program in Manchester, UK, where patients succeeded in long-term maintenance of weight loss through a behavioural treatment programme (42). We also excluded studies with weight-reducing medications well aware that

for some patients adjunctive weight-reducing medicine can be accepted and produce positive changes in weight and health (43, 44). In addition, we excluded intervention with a switch in antipsychotic medication knowing that such switching can lead to a reduction in body weight and that guidelines recommend the selection of appropriate antipsychotic treatment (14). Many of the studies involved complex interventions where the main intervention was supplemented by additional encouragement to maximise physical activity and/or improve diet. This makes it difficult, or even impossible, to assess the effective part of the intervention. This mix of interventions can be owing to the fact that physical health initiatives are reflecting daily practice where people select their individual elements in the maintenance and improvement of physical health. For some patients, the diet will be effective in health improvement, and for others, physical activity will be more appealing and effective. Even though a systematic literature search was performed, there is no certainty that all studies were found in the search. Nevertheless, we included the four most relevant databases, and we used both controlled thesaurus terms and natural language terms for synonyms to enhance the possibility of capturing all relevant studies (see Appendix 1). By limiting our search to English language, peer-reviewed journals we might have missed studies published in other language. We are not aware if these limitations have lowered the number of identified studies in our review. To facilitate a healthier lifestyle among patients with schizophrenia, it is important to be aware of the fact that patients might have greater difficulty in breaking the pattern of unhealthy lifestyles and preventing the consequences owing to factors related to their illness and treatment (45). In addition, low physical activity might be due to negative symptoms, cardio-metabolic comorbidity, side-effects of antipsychotic medication and social isolation (46). For these reasons, it is even more important that health care for patients with severe mental illness is proactive and has a high level of professional expertise. Bleich et al. (47) showed that physicians in the normal BMI category were more likely to believe that physicians should model healthy weightrelated behaviours and maintain a healthy weight and exercise regularly. Furthermore, it was shown that the probability of a physician initiating a weight loss conversation with their obese patients was higher when the physicians’ perception of the patients’ body weight met or exceeded their own personal body weight. These results suggest 285

Hjorth et al. that more normal-weight physicians provided recommended obesity care to their patients and felt confident in doing so. If these results are in any way transferrable to staff working in psychiatric facilities, it is important that the staff members are in a normal BMI category to ensure that the staff will take care of their obese patients in a constructive way. In a not jet published study from psychiatric facilities in Denmark by the same first author as this review, the majority of staff was female with an average BMI of 26 kg/m2, which seems moderate compared with the level of obesity (BMI: 33.8 kg/m2) among staff in the study from Vieweg et al. (48) where obesity may be a greater problem among staff than among the patients. But staff with a BMI just above normal may be better off regarding promotion of healthy lifestyle among themselves and among the patients. It has been shown that lifestyle intervention can be beneficial for controlling and limiting overweight and obesity among patients with schizophrenia. A wide range of interventions showed an effect, and the task for the staff and the patients is to select the intervention most suitable in the specific psychiatric setting to the individual patients and their respective staff. Health strategies must be implemented within each setting as part of everyday life, as interventions must be lifelong and, hopefully, enjoyable for both patients and staff. This review reveals many manageable interventions suitable for clinical practice for patients diagnosed with schizophrenia, independent of whether they are in-patients or out-patients, and with different severity of illness. However, there was marked heterogeneity across the studies and the methodological problems, which limits drawing substantial conclusions. No specific intervention can be pointed out as the most suitable. Accordingly, beneficial interventions should be implemented in a way suitable for one’s own daily practice, and as part of normal care and treatment offered in the local psychiatric settings. Declaration of interest All authors declare that they have no conflict of interests.

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Appendix 1 Literature search strategy The PubMed (MEDLINE), Embase (Ovid), PsycInfo (Ovid) and Cinahl (Ebsco) bibliographic databases.

PubMed (MEDLINE) 1. 2. 3. 4. 5. 6. 7. 8.

‘Body Weight’[Mesh:noexp]) ‘Body Weight Changes’[Mesh]) ‘Overweight’[Mesh]) weight[tiab] waist[tiab] body mass[tiab] bmi[tiab] overweight[tiab]

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Hjorth et al. 9. obes*[tiab] 10. ‘Body Weights and Measures’[Mesh] 11. 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 12. sport*[tiab] 13. ‘Sports’[Mesh] 14. diet*[tiab] 15. ‘Diet’[Mesh] 16. ‘Diet Therapy’[Mesh]) 17. (behav*[Title/Abstract]) OR cogni*[Title/Abstract]) AND (therap*[Title/Abstract]) 18. ‘Behaviour Therapy’[Mesh] 19. physical activit*[tiab] OR physical therap*[tiab] 20. ‘Physical Therapy Modalities’[Mesh] 21. exercise*[tiab] 22. ‘Exercise’[Mesh] 23. 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20 OR 21 OR 22 24. ‘Schizophrenia’[Mesh] OR 25. schizophren* 26. 24 OR 25 27. 11 AND 23 AND 26

EMBASE 1. body weight/ 2. lean body weight/or liveweight gain/or weight change/or weight control/or weight fluctuation/or weight gain/or weight reduction/ 3. waist circumference/or waist-hip ratio/ 4. body mass/ 5. exp obesity/ 6. (waist or body mass or bmi or overweight or obes* or weight).ab. 7. (waist or body mass or bmi or overweight or obes* or weight).ti. 8. 1 or 2 or 3 or 4 or 5 or 6 or 7 9. exp sport/ 10. diet/or diet therapy/ 11. behaviour therapy/ 12. exp cognitive therapy/ 13. exp physical activity/ 14. exp exercise/ 15. exp physiotherapy/ 16. (physical activit* or physical therap* or exercise*).ab. 17. (physical activit* or physical therap* or exercise*).ti. 18. 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 19. (behav* or cogni*).ab. or (behav* or cogni*).ti. 20. therap*.ab. or therap*.ti. 21. 19 and 20 22. 18 or 21 23. exp schizophrenia/ 24. schizophren*.ti. or schizophren*.ab. 25. 23 or 24 26. 8 and 22 and 25

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PsycInfo 1. body weight/ 2. lean body weight/or liveweight gain/or weight change/or weight control/or weight fluctuation/or weight gain/or weight reduction/ 3. waist circumference/or waist-hip ratio/ 4. body mass/ 5. exp obesity/ 6. weight.mp. [mp=title, abstract, heading word, table of contents, key concepts, original title, tests & measures] 7. (waist or body mass or bmi or overweight or obes*).mp. [mp=title, abstract, heading word, table of contents, key concepts, original title, tests & measures] 8. 1 or 2 or 3 or 4 or 5 or 6 or 7 9. behav* or cogni*).mp. [mp=title, abstract, heading word, table of contents, key concepts, original title, tests & measures] 10. therap*.mp. [mp=title, abstract, heading word, table of contents, key concepts, original title, tests & measures] 11. 9 and 10 12. exp sport/ 13. sport*.mp. [mp=title, abstract, heading word, table of contents, key concepts, original title, tests & measures] 14. diet/or diet therapy/ 15. behaviour therapy/ 16. exp cognitive therapy/ 17. exp physical activity/ 18. exp exercise/ 19. exp physiotherapy/ 20. (physical activit* or physical therap* or exercise*).mp. [mp=title, abstract, heading word, table of contents, key concepts, original title, tests & measures] 21. 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 22. exp schizophrenia/ 23. schizophren*.mp. [mp=title, abstract, heading word, table of contents, key concepts, original title, tests & measures] 24. 22 or 23 25. 8 and 21 and 24

CINAHL 1. (MH ‘Body Weight’) OR (MH ‘Obesity+’) OR (MH ‘Thinness’) OR (MH ‘Weight Gain’) OR (MH ‘Weight Loss’) 2. (MH ‘Body Weights and Measures’) OR (MH ‘Body Mass Index’) OR (MH ‘Waist Circumference’) OR (MH ‘WaistHip Ratio’) 3. (MH ‘Body Weight Changes+’) 4. weight 5. waist 6. body mass 7. bmi 8. overweight 9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8

Systematic review 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

behav* OR cogni* therap* 10 and 11 (MH ‘Behaviour Therapy+’) (MH ‘Sports+’) sport* (MH ‘Physical Therapy+’) physical activit* physical therap* (MH ‘Exercise+’)

20. 21. 22. 23. 24. 25. 26. 27. 28.

exercise* (MH ‘Diet Therapy+’) (MH ‘Diet+’) diet* 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 (MH ‘Schizophrenia’) schizophrenia* 25 or 26 9 or 24 or 27

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A systematic review of controlled interventions to reduce overweight and obesity in people with schizophrenia.

Overweight and obesity are generally found among patients with schizophrenia. This may lead to serious implications for health and wellbeing. The aim ...
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