International Journal of Psychiatry in Clinical Practice, 2009; 13(3): 173183
REVIEW ARTICLE
Diet blues: Methodological problems in comparing non-pharmacological weight management programs for patients with schizophrenia
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TINA VEIT & CHRISTIAN BARNAS Department of Biological Psychiatry, Medical University Vienna, Vienna, Austria
Abstract Obesity is an evident problem in patients with schizophrenia because it involves serious risks of health and has major effects on morbidity and mortality. Compared with the general population the prevalence of obesity is significantly increased in people with schizophrenia. Since second-generation antipsychotics have been established, the problem has become even more prevalent. Causes and treatment of obesity are both very complex issues. This article analyzes weight management programs for people with schizophrenia in regard to scientific methodology like intervention criteria, target definition and study design.
Key Words: Obesity, weight gain, weight management, schizophrenia
Introduction Compared to the general population patients with schizophrenia have a higher risk of premature death [1]. In fact, mortality rate is elevated by 1.62.6 times, average expectation of life is reduced by 20% [2]. The most important factors responsible for the extensive mortality are cardiovascular disease and other obesity associated diseases like hypertension and type 2 diabetes [3]. In comparison to the general population obesity is found significantly more often in patients with schizophrenia [4]. Particularly young schizophrenic women have a higher risk of being obese [5]. Coodin [6] found in a Canadian sample that the prevalence of obesity in people with schizophrenia is 3.5 times higher than in the general population. Obesity has some major effects on mortality and health [7]. Concerning the weight gain of schizophrenic patients different factors have to be considered: disease-specific factors, e.g., genetics, side-effects of the medication and behavioural factors such as diet and physical activity [8]. Since the introduction of second generation antipsychotics, obesity has become an even more relevant
problem. Almost every antipsychotic medication was linked to at least some weight gain [9]. The EUFEST authors report a weight gain of 7% of baseline from 37% of patients randomised to ziprasidone to 86% of those randomised to olanzapine [10]. In addition to that, many patients with schizophrenia are not able to keep a healthy lifestyle containing well-balanced diet and sufficient physical exercise [2]. Obesity represents a basic component of the metabolic syndrome. The metabolic syndrome itself stands for a cluster of metabolic abnormalities with an increased risk of cardiovascular disease and includes obesity, hypertension, dyslipidemia and insulin resistance. Visceral adiposity is the primary determent of insulin resistance. Abdominal adiposity increases the risk of the metabolic syndrome. For these reasons the waist circumference is considered to be a better parameter than the BMI [4]. Besides the medical issues, quality of life is reduced due to obesity [8]. Patients consider their overweight as stigmatising, a fact, which may influence the medication compliance. Weight gain under antipsychotic medication may play a critical role and
Correspondence: Christian Barnas, MD, Waehringer Guertel 1820, 1090 Vienna, Austria. Tel: 43 1 40400 3541. Fax: 43 1 40400 3099. E-mail: [email protected]
(Received 16 November 2008; accepted 15 January 2009) ISSN 1365-1501 print/ISSN 1471-1788 online # 2009 Informa UK Ltd. DOI: 10.1080/13651500902763840
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could reduce the compliance for the antipsychotic therapy [2]. Changing (‘‘Switching’’) antipsychotics can be taken into account, in case of a clear relationship between medication and weight gain and when the patient is about to stop or has stopped taking the antipsychotics. The benefit of antipsychotics in terms of their antipsychotic properties should, as far as possible, not be lowered by metabolic side effects [11]. The CAMP Study (Comparison of Antipsychotics for Metabolic Problems in the treatment of people with schizophrenia and schizoaffective disorder), which is currently recruiting participants, is comparing the effectiveness of antipsychotics in case of an indication of change of medication because of an increased risk of cardiovascular disease [12]. As the causes of obesity are a very complex issue, so too is the treatment. Therefore intervention strategies have to pay attention to a lot of different factors. The treatment of obesity consists of surgical, pharmacological and non-pharmacological behaviour modifying interventions. Non-pharmacological interventions should always be chosen first and only in the second step be combined with pharmacological treatment if necessary. Anti-obesity agents inhibit intestinal fat absorption, suppress appetite, increase satiety or increase thermogenesis. Proven average weight loss by anti-obesity agents were modest. The pharmacological treatment of obesity is addressed to a large body of literature, which is far beyond the scope of this paper [8]. Surgical interventions, as for example gastric banding or gastric bypass, are usually not considered appropriate for patients with affective or schizophrenic psychosis. In weight loss treatments different psychological interventions are used. Cognitive and behavioural therapy have improved weight loss in people who are overweight or obese, especially when they are combined with dietary and exercise strategies [13]. Behavioural, cognitive and social aspects should be combined in weight management treatments [8]. Several programs for weight reduction in people with schizophrenia have been published. This paper analyzes interventions to control weight gain in patients with schizophrenia. Large differences can be found in intervention strategies, results, duration of the program and target criteria, which are going to be pointed out in this article. Method The databases Pubmed, Medline and PsycInfo were searched for weight management programs in people with schizophrenia in October 2007, February 2008 and December 2008. A keyword search strategy with the following terms was used: ‘‘schizophrenia’’, ‘‘weight’’, ‘‘antipsychotics’’, ‘‘program’’
and ‘‘intervention’’. Further papers were found by hand-searching the references of articles and reviews. Included were reports on weight management programs, which have been published since 1980. The reports found by this procedure were analyzed regarding usual criteria of scientific investigations. These criteria included the number of participants, description of included subjects and definition of inclusion criteria. It was determined whether a control group was used and if yes, how patients were assigned to treatment or control group. Next step was to determine how many studies described the intervention procedure, which target criteria were used and how these target criteria were determined. The last point was to describe, how many programs report long term results, a point, which is known as important especially in the evaluation of weight management programs. Results Table I gives a summary of the published studies about interventions to either lose weight or keep normal body weight in patients under antipsychotic treatment. Author, population, design, period of time, intervention, size of sample, target criteria and results are mentioned. A total of 39 such studies could be found. The earliest study was published in 1968 [53]. Apart from one single intervention [40] all studies showed either reduction or at least maintenance of weight, and have thus to be judged as successful. Thirty of these studies (77%) defined schizophrenia or schizoaffective disorder as inclusion criteria, but only one quarter set both schizophrenia or schizoaffective disorder and overweight or obesity as inclusion criteria [15,17,18,23,24,28,39,42,50]. The other investigations had intake of antipsychotics or the intake of a specific antipsychotic medication as inclusion criterion (see Table I). A majority of the studies did not report details about the patients included. This did not only concern demographic data. In fact, not a single study described psychopathology of the included subjects. No information was given about possible negative symptoms or whether the included patients were remitted or not. Weight management programs varied extremely in terms of sample sizes and dropout rates. The smallest sample included six patients [19,41,42], the largest one 966 patients [47]. One-third of the published studies (n 13) did not report any details on dropout rates (see Table I). There were huge differences concerning the nature of intervention, either in terms of the intervention
Table I. Summary of weight management programs for patients with schizophrenia. Author
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Rotatori et al. [14]
Ball et al. [15]
Aquila et al. [16]
Vreeland et al. [17]
Menza et al. [18]
Fogarty et al. [19] Archie et al. [20]
Mixed diagnosis, most common was adjustment reaction or schizophrenia Schizophrenia or schizoaffective disorder, treated with olanzapine; weight gain of 7% of body weight; 1860a Treatment with atypical antipsychotics for at least 1 year
Schizophrenia or schizoaffective disorder; treated with atypical antipsychotics; BMI26 or weight gain 2.3 kg Schizophrenia or schizoaffective disorder; treated with atypical antipsychotics; BMI of at least 26 or weight gain 2.3 kg Schizophrenia
Schizophrenia or schizoaffective disorder, treated with olanzapine for at least 4 weeks Treated with conventional antipsychotics
Design
Period
Randomized control 14 weeks and intervention group
Intervention
N
Target criteria
Results
Behavioural treatment package
14
Body weight
Significant difference between treatment and control group
Weekly sessions of Weight-watchers 123-program Exercise sessions 3 times a week; tokens Low-calorie, monitored diet; nutritional education and other supportive care Two group sessions and one 15-min individual session per week
21/10 finished (8 paticipated in exercise, 6 m, 2 f)
Body weight, BMI
Non-significant
32/28 completed
Body weight
Non-significant weight change
31/27 completed
Body weight, BMI, hunger rating, nutrition knowledge
Significant difference between control and intervention group
10 weeks
No control group
Not specified; weighing 12, 18 months after intervention
Non-randomized control and intervention group
12 weeks
Non-randomized control and intervention group
Completed Vreeland, 2003 to 52 weeks
Nutrition, exercise, behavioral intervention
31/20 completed
Body weight, BMI, hunger rating, nutrition knowledge
Significant difference between control and intervention group
No control group
12 weeks
Individualized exercise program
6
No control group
24 weeks
Free membership for YMCA fitness
10 started Dropout rates:90% at 6 months
Body weight, heart rate, grip strength Body weight, BMI
No statistical analyses, description of each participant One patient with complete attendance over 6 months lost 15 kg
Randomized control and intervention group
16 weeks
Nutrition, exercise, living a healthy lifestyle 1-h psychoeduc. class
70 started, dropouts not specified
Body weight, BMI
Significant difference between control and intervention group
175
Non-randomized control and intervention group
Diet blues
Littrell et al. [21]
Population
176
Table I (Continued)
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O’Melia et al. [22]
Kalarchian et al. [23]
Brar et al. [24]
Evans et al. [25]
Population
Design
Period
Intervention
N
Target criteria
Results
Treated with antipsychotics, having experienced a weight gain or being concerned about the issue Schizophrenia or related psychosis; Antipsychotic medication; BMI30
No control group
8 weeks/25 weeks
7/ 5 completed Group session/ 8/6 completed advice and educational talks from relevant health care professionals
Body weight
No control group
12 weeks
35/29 completed
BMI decreased BMI; Self-reported eating behaviour, significantly eating physical activity and behaviour improved health-related quality of life
Schizophrenia or schizoaffective disorder; switched from olanzapine to risperidone; BMI26 Diagnosis not specified. Treated with olanzapine
Randomized control 14 weeks and intervention group
Adapted the stoplight diet Weekly group sessions; self monitoring records Tokens ‘‘Behavioural treatment’’ 20 sessions
72/71 completed
Body weight
Loss of body weight in both groups, no significant difference
Randomized control 12 weeks and intervention group
Six 1-h nutrition education sessions
Body weight, BMI, waist circumference; quality of life; health and body image Body weight
Significant less weight gain in the intervention group
Weekly 1-h group sessions about healthy eating, exercise and motivation, open group, voluntary Treadmill walking group 3 times a week
29 intervention group (6 dropouts), 22 control group (11 dropouts) 70
10 (2 dropouts)
BMI; percent of body fat; severity of psychiatric symptoms
17/15 completed
Body weight, BMI Waisthip ratio, fasting glucose levels
Pendlebury et al. [26]
Schizophrenia
No control group
3 years
Beebe et al. [27]
Schizophrenia
Randomized control 16 weeks and intervention group
Weber & Wyne [28]
Schizophrenia or schizoaffective disorder; only one oral atypical antipsychotic BMI25
Control and intervention group
16 weeks
Weekly 1-h group sessions Food and activity diary
No statistical analyses, descriptive statistics only
Weight loss correlated with the number of attended sessions
Non significant difference between intervention and control group in BMI but in percent of body fat Weight loss in both groups, more weight loss in treatment group, non significant difference
T. Veit & C. Barnas
Author
Table I (Continued)
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Author
Population
Design
Period
Kwon et al. [29]
Schizophrenia or schizoaffective disorder; treated with olanzapine
Randomized control 12 weeks and intervention group
Centorrino et al. [30]
Schizophrenia or schizoaffective disorder; a weight gain of 4.5 kg and an increase in BMI of 5% since starting antipsychotics Schizophrenia or schizoaffective disorder; clinical stability for at least 6 months, stable physical health status
No control group
24 weeks
Non randomized control and intervention group
32 weeks
Voruganti et al. [31]
Schizophrenia and diabetes mellitus, 40 years or older
Mauri et al. [33]
Mixed diagnosis body No control group mass index (BMI) had increased by more than 7% after starting an AP therapy (for at least 3 months) Patients of an acute No control group inpatient schizophrenia treatment unit No control group Schizophrenia or schizoaffective disorder; antipsychotic medication
Wirshing et al. [34] Klam et al. [35]
Randomized control 24 weeks and intervention group
12 weeks
1 day
32 weeks
N
Target criteria
Results
Individual sessions diet and exercise management weekly sessions in the first 4 weeks, then every other week Weight reduction program TRIAD twice weekly sessions
33 intervention group (11 dropouts), 15 control group (1 dropout)
Body weight BMI quality of life
Significant difference between intervention and control group
17/12 completed
Body weight BMI, blood pressure, pulse, serum cholesterol, triglyceride
Significant change in weight, BMI, blood pressure and pulse
Therapeutic intervention based on experiential learning theory and adventure and recreational activities Psychoeducational intervention focused on diabetes education, nutrition, and lifestyle exercise Low calorie diet, increased physical activity one visit per month (meeting with dietician included) 30 min didactic presentation
23 treatment group, 31 control group
Symptom severity, self-esteem, self-appraised cognitive abilities
Significant weight loss in the treatment group
64/57 completed
Significant difference Body weight, BMI, Waist circumference, between treatment self-reported physical and control group activities
53/26 completed
Body weight, BMI, physical activity
Significant weight reduction, no significant change in physical activity
50
Knowledge of food and nutrition
One weekly group session (1 h education, 1 h exercise)
35/16 completed
Body weight, BMI, waist circumference, blood pressure
Significant difference between pre and post test in knowledge Non significant decrease in body weight
Diet blues
McKibbin et al. [32]
Intervention
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Table I (Continued)
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Population
Design
Period
Significant difference in weight between treatment and control group
93/41 completed
Body weight, BMI
1: simple nutrition information, light jogging 3 times a week; 2: olanzapine
1: 22/18 completed 2: 14/10 completed
Body weight, BMI
Significant reduction in body weight and BMI Significant reduction of body weight in group one
Randomized control 24 weeks and intervention group
Diet (reduced calorie intake), regular physical activity
56/3 dropouts in the control group
Body weight, BMI, waist and hip circumference
Significant decrease in the treatment group in comparison to the control group
No control group
28 weeks
Education on diet and on exercise
22
Body weight
Weight gain in the sample
No control group
32 weeks
Body weight, BMI
Significant weight loss
No control group
12 weeks
Body weight
Weight loss
No control group
24 weeks
Counselling on 6 (4 dropouts) diet and exercise, behavioural therapy 6 (1 dropout) Wonderful me programme: diet, exercise and self-assertiveness training, group sessions 1000 kcal diet 73 (1 death)
Body weight
In 74% weight loss, 18% achieved ideal weight No significant difference between the groups
Schizophrenia or affective disorder
No control group
1 year
Milano et al. [38]
One group hypomania in bipolar disorder, one group schizophrenia; treated with olanzapine Schizophrenia; treated with olanzapine; BMI27, hospitalized patients Schizophrenia, schizoaffective disorder or bipolar disorder treated with olanzapine Schizophrenia, bipolar disorder, treated with atypical antipsychotics Schizophrenia, psychosis, psychopathic personality disorder ; BMI25 Overweight psychiatric patients
Two groups (different diagnosis with and without treatment)
8 weeks
Schizophrenia
Randomized control 24 weeks and intervention group
Merriman et al. [42]
Knox et al. [43] McCreadie [44]
Results
Body weight, fasting glucose level
Pendlebury et al. [37]
Umbricht et al. [41]
Target criteria
18/(4 dropouts)
Randomized control 16 weeks and intervention group
Nguyen et al. [40]
N
Modified LEARNProgramme weekly meetings, group, pedometers Voluntary group sessions
Jean-Baptiste et al. Antipsychotic [36] medication; BMI30
Wu et al. [39]
Intervention
Free fruits and vegetables, instruction in meal planning and food preparation
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Number of portions of fruits and vegetables per week, BMI, level of physical activity, cardiovascular risk factors
T. Veit & C. Barnas
Author
Table I (Continued) Author
Design
Period
Intervention
N
Target criteria
Results
Randomized control 16 weeks and intervention group
Behavioural intervention
27 treatment group, 23 control group
Body weight
Significant less weight gain in the intervention group
Non-randomized control and intervention group
24 weeks
Restriction in calorie intake
40
Body weight
Weight gain moderated by dieting
No control group
2 years
966 (20% dropout rate)
Poulin et al. [48]
Schizophrenia, schizoaffective disorder, bipolar disorder; treated with antipsychotics
Control group
18 months
A minimum of six consultations (health checks), lifestyle advice, healthy living groups Education on diet and physical activity; exercise programme
Bushe et al. [49]
No control group Schizophrenia, affective disorders, personality disorder, anxiety, alcohol misuse No control group Schizophrenia, schizoaffective disorder; patients have not been in the acute psychotic, manic or hypomanic state within 4 weeks, antipsychotic treatment for at least 8 weeks; BMI25 Schizophrenia Control group
4 weeks
Education on diet, appetite, physical activity
47 (30 dropouts)
Body weight, BMI, No significant change diet, physical activity, in BMI; significant smoking; self esteem improvement in diet, physical activity, smoking and selfesteem Body weight, BMI, Significant reduction waist circumference, in body weight, BM, LDL, HDL, waist circumference, triglycerides, fasting HDL increased, glucose LDL, triglycerides, concentration fasting glucose concentration decreased Body weight No weight gain in 70% of patients
12 weeks
12 weekly group sessions; Food diary, nutrition education, self-monitoring exercise record, education about lifestyle modification
232
Body weight, BMI
Significant reduction in weight and BMI
No information
Dietary, general health and exercise advice
51 (9 out of these 51 attended the programme)
BMI
Weight loss
Heimberg [46]
Smith et al. [47]
Lee et al. [50]
Feeney et al. [51]
110 (25% dropout rate)
Diet blues
Schizophrenia or schizoaffective disorder; within 30 days of started treatment with novel antipsychotic Schizophrenia, schizoaffective disorder; treated with clozapine Schizophrenia, schizoaffective disorder, bipolar disorder (2 years) outpatients
Ganguli [45]
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Population
179
Body weight, BMI, eating and weight related cognitions, binge eating symptomatology
Target criteria
61 Cognitive and behavioural treatment (CBT) on eating and health related cognitions weekly (adapted for patients with psychotic disorders) vs. brief nutritional education Randomized control 12 weeks vs. 1 day 24 Patients treated with antipsychotic drug for and intervention group weeks follow-up a minimum of 2 months who reported weight gain 2 kg over 6 months following treatment Khazaal et al. [52]
Author
Table I (Continued)
Population
Design
Period
Intervention
N
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Improvement in weight-related cognitions and binge eating symptomatology; greater weight loss in CBT group
T. Veit & C. Barnas
Results
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method or the time span of the treatment. The time of the weight management programs ranged from one single session [34] up to 3 years [26]. Considering long term-effects three out of 39 studies showed a significant weight reduction after 1 year [18,37], and after 18 months [48], while the other studies did not report long-term data. Almost half of the intervention studies did not use a control group at all, 70% did not use a randomized controlled study design (see Table I). All, except one study [34], which defined the knowledge about nutrition as target criteria, had body weight or BMI as target criteria. Only a few programs defined further goals: Three out of 39 intervention studies took eating behaviour into account [23,44,47] and five of them collected data about physical exercise [23,32,33,44,47]. Psychoeducational goals, such as nutrition knowledge, were reported by three studies [17,18,34]. Quality of life as target criteria was measured by three programs [23,25,29]. One single study reports data about eating and weight related cognitions [52]. Six studies referred to known weight management programs and adapted them for the special needs of schizophrenic patients [14,15,23,24,30,36]. In these cases a clear description of the method used could be found. Discussion It is evident, that obesity has become an important concern in the treatment of patients with schizophrenia. Since atypical antipsychotics have been established and weight gain is a significant side effect of several antipsychotics, the need of a solution has become clear. There is consent about the importance of the topic and about the fact that something has to be done, but standard procedures do not exist and good clinical practice could not be defined yet. Clinical practice with psychotic patients shows that it is not easy for schizophrenic patients to follow diet instructions and to motivate themselves to physical exercise, mainly because of possible negative symptoms, sometimes also because of direct medication effects. Thus it has become evident that intervention programs for schizophrenic patients have to take into account these schizophrenia specific factors and that specific programs for this group of patients should be developed. Several reports about weight management programs, which have been either developed or adapted for psychotic patients, have already been published (see Table I). Interpretation and comparability are limited because of considerable differences in target
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Diet blues criteria, intervention strategies and duration of the program. In contrast to experiences in the clinical practice all of the published papers, except of one [46], reported successful outcome. Unfortunately the vast majority of the published reports did not fulfil the requirements, which should be expected of scientific studies. The first point to be mentioned in this context is a proper description of the investigated sample. Besides of demographic data it would be necessary to describe the current reason to be included into the study (obesity or maintenance of normal weight). In cases of obesity or overweight information about degree and time course of weight gain, before and after the start of antipsychotic medication should be given. A key feature to compare studies is the description of the investigated patients in terms of psychopathology, which doubtlessly has an important impact on the kind of intervention and the outcome of such studies. It is a little disappointing that not even one single study did take this point into consideration. Another key point is whether a control group is used and if yes, how assignment to the groups has been done. Only 21 of the 39 studies that we analyzed used a control group, 12 of them used some kind of randomized group assignment, nine did not (see Table I). In most of the studies the randomization procedure is not exactly described, which means a high risk of bias. In terms of conclusions drawn from these studies, caution is advised. Especially in this field it is very difficult to carry out properly randomized controlled trials because of the amount of external confounding influences, which have to be controlled. It should also be mentioned, whether participants received payment for the participation in the study. Payment to trial subjects and the willingness to participate in a weight management program in itself can influence the results. Next issue is the definition of target criteria, how they are measured and a time schedule to measure them. Most studies used only weight or BMI as target criteria. It should be noted that BMI is not adjusted for age or sex, a fact that has been criticised by some authors [6]. Five studies collected data about physical activity [23,32,33,44,47]. Only two surveys considered the combination of physical activity and eating behaviour [23,47]. It is evident that there is an obvious need of studies going into detail on these aspects. Most of the studies measured the outcome only during the time span of the intervention itself. Only two papers [23,52] report 1-year follow-up data. This is a clear drawback, especially in studies on body weight reduction interventions, because of the
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high likelihood that patients will regain weight as soon as the intervention is finished [54]. The most important point, which is necessary to compare weight reduction programs, is the method used. Unfortunately many of the analyzed reports lack a detailed description of the method. As far as we were able to gain the details from the reports we can conclude in addition to duration and intensity, that particularly interventions differ a lot. These differences have an impact on comparability. Some use behavioural treatment, others offer psychoeducation in order to include diet or exercise or both combined. Only six out of 39 programs go back to already known weight management programs and adapt them for the special needs of people with schizophrenia if necessary [14,15,23,24,30,36]. Obese patients with schizophrenia know about their body weight and wish to reduce it, but weight loss methods do not always agree with established recommendations. Only one third of the study participants reported the recommended combination of diet and exercise. Especially women use unsafe and questionable methods in order to lose weight [55]. Besides the methodological issues discussed above a few principal questions about health care strategies in schizophrenic patients arise. Currently research focuses on eating behaviour and physical activity. But is it sufficient to focus on only two factors? Health awareness as the main goal could be a reasonable approach that includes in addition to diet and physical activity for example aspects like non-smoking, stress management, hygienic habits and preventive medical check-ups. Encouraging health awareness and giving patients the possibility to look after their own health could mean more quality of life. Especially in view of long term results, a broad approach in terms of health awareness, that does not disregard quality of life, seems to gain increased significance. A question that should be posed is, whether only patients should be included into health care programs or whether close relatives should also participate. In many cases relatives bear a large part of responsibility for the lifestyle of the patients, especially, if they live together. The points mentioned above apply as well to weight management programs for people without any mental disorders. A medical discipline which has long experience with this topic is cardiac rehabilitation, and also in this field we find a similar situation: Studies are very heterogeneous concerning intervention strategies and there are hardly any long term results. The combination of behavioural therapy and dietary and exercise intervention has proved best results [13].
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There is no doubt about the importance of the current problem. Guidelines and recommendations for a psychiatrist to look better after the physical health of their patients and to monitor metabolic effects were established [56]. Clear methods and goals should be established in psychiatry concerning obesity management in order to develop good clinical practice and standard procedures. Regarding obesity clear definitions of success and explicit guidelines have to be set up. Prevention of weight gain in a person of normal weight at the start of antipsychotic therapy differs from reducing weight in an obese patient. In the literature this distinction between prevention and therapy is left behind in most cases. Although clear recommendations on optimal procedures are still missing, the results show that behavioural treatment may be helpful for obese patients with schizophrenia [57] the same way as for obese people without any mental illness [8]. Behavioural therapy is understudied and there are relatively few controlled trials [58].
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Key points . Obesity is an increasingly prevalent problem in patients with schizophrenia and is associated with serious health concerns . Compared with the general population the prevalence of obesity is significantly increased in people with schizophrenia . The literature on weight management programs for people with schizophrenia is reviewed . There are large differences in intervention strategies, results, duration of the program and target criteria
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Statement of interest The authors have no conflict of interest with any commercial or other associations in connection with the submitted article.
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Acknowledgements None.
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obesity in patients taking antipsychotic medications. J Clin Psychiatry 2005;66(8):105863. Brar JS, Ganguli R, Pandina G, Turkoz I, Berry S, Mahmoud R. Effects of behavioral therapy on weight loss in overweight and obese patients with schizophrenia or schizoaffective disorder. J Clin Psychiatry 2005;66(2): 205 12. Evans S, Newton R, Higgins S. Nutritional intervention to prevent weight gain in patients commenced on olanzapine: a randomized controlled trial. Aust NZ J Psychiatry 2005; 39(6):47986. Pendlebury J, Haddad P, Dursun S. Evaluation of a behavioural weight management programme for patients with severe mental illness: 3 year results. Hum Psychopharmacol 2005;20(6):4478. Beebe LH, Tian L, Morris N, Goodwin A, Allen SS, Kuldau J. Effects of exercise on mental and physical health parameters of persons with schizophrenia. Issues Ment Health Nurs 2005;26(6):66176. Weber M, Wyne K. A cognitive/behavioral group intervention for weight loss in patients treated with atypical antipsychotics. Schizophr Res 2006;83(1):95101. Kwon JS, Choi JS, Bahk WM, Yoon Kim C, Hyung Kim C, Chul Shin Y, et al. Weight management program for treatmentemergent weight gain in olanzapine-treated patients with schizophrenia or schizoaffective disorder: A 12week randomized controlled clinical trial. J Clin Psychiatry 2006;67(4):54753. Centorrino F, Wurtman JJ, Duca KA, Fellman VH, Fogarty KV, Berry JM, et al. Weight loss in overweight patients maintained on atypical antipsychotic agents. Int J Obes (London) 2006;30(6):10116. Voruganti LN, Whatham J, Bard E, Parker G, Babbey C, Ryan J, et al. Going beyond: an adventure-and recreationbased group intervention promotes well-being and weight loss in schizophrenia. Can J Psychiatry 2006;51(9):57580. McKibbin CL, Patterson TL, Norman G, Patrick K, Jin H, Roesch S, et al. A lifestyle intervention for older schizophrenia patients with diabetes mellitus: a randomized controlled trial. Schizophr Res 2006;86(13):3644. Mauri M, Castrogiovanni S, Simoncini M, Iovieno N, Miniati M, Rossi A, et al. Effects of an educational intervention on weight gain in patients treated with antipsychotics. J Clin Psychopharmacol 2006;26(5):4626. Wirshing DA, Smith RA, Erickson ZD, Mena SJ, Wirshing WC. A wellness class for inpatients with psychotic disorders. J Psychiatr Pract 2006;12(1):249. Klam J, McLay M, Grabke D. Personal empowerment program: addressing health concerns in people with schizophrenia. J Psychosoc Nurs Ment Health Serv 2006;44(8): 208. Jean-Baptiste M, Tek C, Liskov E, Chakunta UR, Nicholls S, Hassan AQ, et al. A pilot study of a weight management program with food provision in schizophrenia. Schizophr Res 2007;96(1):198205. Pendlebury J, Bushe CJ, Wildgust HJ, Holt RI. Long-term maintenance of weight loss in patients with severe mental illness through a behavioural treatment programme in the UK. Acta Psychiatr Scand 2007;115(4):28694. Milano W, Grillo F, Del Mastro A, De Rosa M, Sanseverino B, Petrella C, et al. Appropriate intervention strategies for weight gain induced by olanzapine: a randomized controlled study. Adv Ther 2007;24(1):12334. Wu MK, Wang CK, Bai YM, Huang CY, Lee SD. Outcomes of obese, clozapine-treated inpatients with schizophrenia
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REVIEW ARTICLE
Diet blues: Methodological problems in comparing non-pharmacological weight management programs for patients with schizophrenia
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TINA VEIT & CHRISTIAN BARNAS Department of Biological Psychiatry, Medical University Vienna, Vienna, Austria
Abstract Obesity is an evident problem in patients with schizophrenia because it involves serious risks of health and has major effects on morbidity and mortality. Compared with the general population the prevalence of obesity is significantly increased in people with schizophrenia. Since second-generation antipsychotics have been established, the problem has become even more prevalent. Causes and treatment of obesity are both very complex issues. This article analyzes weight management programs for people with schizophrenia in regard to scientific methodology like intervention criteria, target definition and study design.
Key Words: Obesity, weight gain, weight management, schizophrenia
Introduction Compared to the general population patients with schizophrenia have a higher risk of premature death [1]. In fact, mortality rate is elevated by 1.62.6 times, average expectation of life is reduced by 20% [2]. The most important factors responsible for the extensive mortality are cardiovascular disease and other obesity associated diseases like hypertension and type 2 diabetes [3]. In comparison to the general population obesity is found significantly more often in patients with schizophrenia [4]. Particularly young schizophrenic women have a higher risk of being obese [5]. Coodin [6] found in a Canadian sample that the prevalence of obesity in people with schizophrenia is 3.5 times higher than in the general population. Obesity has some major effects on mortality and health [7]. Concerning the weight gain of schizophrenic patients different factors have to be considered: disease-specific factors, e.g., genetics, side-effects of the medication and behavioural factors such as diet and physical activity [8]. Since the introduction of second generation antipsychotics, obesity has become an even more relevant
problem. Almost every antipsychotic medication was linked to at least some weight gain [9]. The EUFEST authors report a weight gain of 7% of baseline from 37% of patients randomised to ziprasidone to 86% of those randomised to olanzapine [10]. In addition to that, many patients with schizophrenia are not able to keep a healthy lifestyle containing well-balanced diet and sufficient physical exercise [2]. Obesity represents a basic component of the metabolic syndrome. The metabolic syndrome itself stands for a cluster of metabolic abnormalities with an increased risk of cardiovascular disease and includes obesity, hypertension, dyslipidemia and insulin resistance. Visceral adiposity is the primary determent of insulin resistance. Abdominal adiposity increases the risk of the metabolic syndrome. For these reasons the waist circumference is considered to be a better parameter than the BMI [4]. Besides the medical issues, quality of life is reduced due to obesity [8]. Patients consider their overweight as stigmatising, a fact, which may influence the medication compliance. Weight gain under antipsychotic medication may play a critical role and
Correspondence: Christian Barnas, MD, Waehringer Guertel 1820, 1090 Vienna, Austria. Tel: 43 1 40400 3541. Fax: 43 1 40400 3099. E-mail: [email protected]
(Received 16 November 2008; accepted 15 January 2009) ISSN 1365-1501 print/ISSN 1471-1788 online # 2009 Informa UK Ltd. DOI: 10.1080/13651500902763840
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could reduce the compliance for the antipsychotic therapy [2]. Changing (‘‘Switching’’) antipsychotics can be taken into account, in case of a clear relationship between medication and weight gain and when the patient is about to stop or has stopped taking the antipsychotics. The benefit of antipsychotics in terms of their antipsychotic properties should, as far as possible, not be lowered by metabolic side effects [11]. The CAMP Study (Comparison of Antipsychotics for Metabolic Problems in the treatment of people with schizophrenia and schizoaffective disorder), which is currently recruiting participants, is comparing the effectiveness of antipsychotics in case of an indication of change of medication because of an increased risk of cardiovascular disease [12]. As the causes of obesity are a very complex issue, so too is the treatment. Therefore intervention strategies have to pay attention to a lot of different factors. The treatment of obesity consists of surgical, pharmacological and non-pharmacological behaviour modifying interventions. Non-pharmacological interventions should always be chosen first and only in the second step be combined with pharmacological treatment if necessary. Anti-obesity agents inhibit intestinal fat absorption, suppress appetite, increase satiety or increase thermogenesis. Proven average weight loss by anti-obesity agents were modest. The pharmacological treatment of obesity is addressed to a large body of literature, which is far beyond the scope of this paper [8]. Surgical interventions, as for example gastric banding or gastric bypass, are usually not considered appropriate for patients with affective or schizophrenic psychosis. In weight loss treatments different psychological interventions are used. Cognitive and behavioural therapy have improved weight loss in people who are overweight or obese, especially when they are combined with dietary and exercise strategies [13]. Behavioural, cognitive and social aspects should be combined in weight management treatments [8]. Several programs for weight reduction in people with schizophrenia have been published. This paper analyzes interventions to control weight gain in patients with schizophrenia. Large differences can be found in intervention strategies, results, duration of the program and target criteria, which are going to be pointed out in this article. Method The databases Pubmed, Medline and PsycInfo were searched for weight management programs in people with schizophrenia in October 2007, February 2008 and December 2008. A keyword search strategy with the following terms was used: ‘‘schizophrenia’’, ‘‘weight’’, ‘‘antipsychotics’’, ‘‘program’’
and ‘‘intervention’’. Further papers were found by hand-searching the references of articles and reviews. Included were reports on weight management programs, which have been published since 1980. The reports found by this procedure were analyzed regarding usual criteria of scientific investigations. These criteria included the number of participants, description of included subjects and definition of inclusion criteria. It was determined whether a control group was used and if yes, how patients were assigned to treatment or control group. Next step was to determine how many studies described the intervention procedure, which target criteria were used and how these target criteria were determined. The last point was to describe, how many programs report long term results, a point, which is known as important especially in the evaluation of weight management programs. Results Table I gives a summary of the published studies about interventions to either lose weight or keep normal body weight in patients under antipsychotic treatment. Author, population, design, period of time, intervention, size of sample, target criteria and results are mentioned. A total of 39 such studies could be found. The earliest study was published in 1968 [53]. Apart from one single intervention [40] all studies showed either reduction or at least maintenance of weight, and have thus to be judged as successful. Thirty of these studies (77%) defined schizophrenia or schizoaffective disorder as inclusion criteria, but only one quarter set both schizophrenia or schizoaffective disorder and overweight or obesity as inclusion criteria [15,17,18,23,24,28,39,42,50]. The other investigations had intake of antipsychotics or the intake of a specific antipsychotic medication as inclusion criterion (see Table I). A majority of the studies did not report details about the patients included. This did not only concern demographic data. In fact, not a single study described psychopathology of the included subjects. No information was given about possible negative symptoms or whether the included patients were remitted or not. Weight management programs varied extremely in terms of sample sizes and dropout rates. The smallest sample included six patients [19,41,42], the largest one 966 patients [47]. One-third of the published studies (n 13) did not report any details on dropout rates (see Table I). There were huge differences concerning the nature of intervention, either in terms of the intervention
Table I. Summary of weight management programs for patients with schizophrenia. Author
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Rotatori et al. [14]
Ball et al. [15]
Aquila et al. [16]
Vreeland et al. [17]
Menza et al. [18]
Fogarty et al. [19] Archie et al. [20]
Mixed diagnosis, most common was adjustment reaction or schizophrenia Schizophrenia or schizoaffective disorder, treated with olanzapine; weight gain of 7% of body weight; 1860a Treatment with atypical antipsychotics for at least 1 year
Schizophrenia or schizoaffective disorder; treated with atypical antipsychotics; BMI26 or weight gain 2.3 kg Schizophrenia or schizoaffective disorder; treated with atypical antipsychotics; BMI of at least 26 or weight gain 2.3 kg Schizophrenia
Schizophrenia or schizoaffective disorder, treated with olanzapine for at least 4 weeks Treated with conventional antipsychotics
Design
Period
Randomized control 14 weeks and intervention group
Intervention
N
Target criteria
Results
Behavioural treatment package
14
Body weight
Significant difference between treatment and control group
Weekly sessions of Weight-watchers 123-program Exercise sessions 3 times a week; tokens Low-calorie, monitored diet; nutritional education and other supportive care Two group sessions and one 15-min individual session per week
21/10 finished (8 paticipated in exercise, 6 m, 2 f)
Body weight, BMI
Non-significant
32/28 completed
Body weight
Non-significant weight change
31/27 completed
Body weight, BMI, hunger rating, nutrition knowledge
Significant difference between control and intervention group
10 weeks
No control group
Not specified; weighing 12, 18 months after intervention
Non-randomized control and intervention group
12 weeks
Non-randomized control and intervention group
Completed Vreeland, 2003 to 52 weeks
Nutrition, exercise, behavioral intervention
31/20 completed
Body weight, BMI, hunger rating, nutrition knowledge
Significant difference between control and intervention group
No control group
12 weeks
Individualized exercise program
6
No control group
24 weeks
Free membership for YMCA fitness
10 started Dropout rates:90% at 6 months
Body weight, heart rate, grip strength Body weight, BMI
No statistical analyses, description of each participant One patient with complete attendance over 6 months lost 15 kg
Randomized control and intervention group
16 weeks
Nutrition, exercise, living a healthy lifestyle 1-h psychoeduc. class
70 started, dropouts not specified
Body weight, BMI
Significant difference between control and intervention group
175
Non-randomized control and intervention group
Diet blues
Littrell et al. [21]
Population
176
Table I (Continued)
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O’Melia et al. [22]
Kalarchian et al. [23]
Brar et al. [24]
Evans et al. [25]
Population
Design
Period
Intervention
N
Target criteria
Results
Treated with antipsychotics, having experienced a weight gain or being concerned about the issue Schizophrenia or related psychosis; Antipsychotic medication; BMI30
No control group
8 weeks/25 weeks
7/ 5 completed Group session/ 8/6 completed advice and educational talks from relevant health care professionals
Body weight
No control group
12 weeks
35/29 completed
BMI decreased BMI; Self-reported eating behaviour, significantly eating physical activity and behaviour improved health-related quality of life
Schizophrenia or schizoaffective disorder; switched from olanzapine to risperidone; BMI26 Diagnosis not specified. Treated with olanzapine
Randomized control 14 weeks and intervention group
Adapted the stoplight diet Weekly group sessions; self monitoring records Tokens ‘‘Behavioural treatment’’ 20 sessions
72/71 completed
Body weight
Loss of body weight in both groups, no significant difference
Randomized control 12 weeks and intervention group
Six 1-h nutrition education sessions
Body weight, BMI, waist circumference; quality of life; health and body image Body weight
Significant less weight gain in the intervention group
Weekly 1-h group sessions about healthy eating, exercise and motivation, open group, voluntary Treadmill walking group 3 times a week
29 intervention group (6 dropouts), 22 control group (11 dropouts) 70
10 (2 dropouts)
BMI; percent of body fat; severity of psychiatric symptoms
17/15 completed
Body weight, BMI Waisthip ratio, fasting glucose levels
Pendlebury et al. [26]
Schizophrenia
No control group
3 years
Beebe et al. [27]
Schizophrenia
Randomized control 16 weeks and intervention group
Weber & Wyne [28]
Schizophrenia or schizoaffective disorder; only one oral atypical antipsychotic BMI25
Control and intervention group
16 weeks
Weekly 1-h group sessions Food and activity diary
No statistical analyses, descriptive statistics only
Weight loss correlated with the number of attended sessions
Non significant difference between intervention and control group in BMI but in percent of body fat Weight loss in both groups, more weight loss in treatment group, non significant difference
T. Veit & C. Barnas
Author
Table I (Continued)
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Author
Population
Design
Period
Kwon et al. [29]
Schizophrenia or schizoaffective disorder; treated with olanzapine
Randomized control 12 weeks and intervention group
Centorrino et al. [30]
Schizophrenia or schizoaffective disorder; a weight gain of 4.5 kg and an increase in BMI of 5% since starting antipsychotics Schizophrenia or schizoaffective disorder; clinical stability for at least 6 months, stable physical health status
No control group
24 weeks
Non randomized control and intervention group
32 weeks
Voruganti et al. [31]
Schizophrenia and diabetes mellitus, 40 years or older
Mauri et al. [33]
Mixed diagnosis body No control group mass index (BMI) had increased by more than 7% after starting an AP therapy (for at least 3 months) Patients of an acute No control group inpatient schizophrenia treatment unit No control group Schizophrenia or schizoaffective disorder; antipsychotic medication
Wirshing et al. [34] Klam et al. [35]
Randomized control 24 weeks and intervention group
12 weeks
1 day
32 weeks
N
Target criteria
Results
Individual sessions diet and exercise management weekly sessions in the first 4 weeks, then every other week Weight reduction program TRIAD twice weekly sessions
33 intervention group (11 dropouts), 15 control group (1 dropout)
Body weight BMI quality of life
Significant difference between intervention and control group
17/12 completed
Body weight BMI, blood pressure, pulse, serum cholesterol, triglyceride
Significant change in weight, BMI, blood pressure and pulse
Therapeutic intervention based on experiential learning theory and adventure and recreational activities Psychoeducational intervention focused on diabetes education, nutrition, and lifestyle exercise Low calorie diet, increased physical activity one visit per month (meeting with dietician included) 30 min didactic presentation
23 treatment group, 31 control group
Symptom severity, self-esteem, self-appraised cognitive abilities
Significant weight loss in the treatment group
64/57 completed
Significant difference Body weight, BMI, Waist circumference, between treatment self-reported physical and control group activities
53/26 completed
Body weight, BMI, physical activity
Significant weight reduction, no significant change in physical activity
50
Knowledge of food and nutrition
One weekly group session (1 h education, 1 h exercise)
35/16 completed
Body weight, BMI, waist circumference, blood pressure
Significant difference between pre and post test in knowledge Non significant decrease in body weight
Diet blues
McKibbin et al. [32]
Intervention
177
178
Table I (Continued)
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Population
Design
Period
Significant difference in weight between treatment and control group
93/41 completed
Body weight, BMI
1: simple nutrition information, light jogging 3 times a week; 2: olanzapine
1: 22/18 completed 2: 14/10 completed
Body weight, BMI
Significant reduction in body weight and BMI Significant reduction of body weight in group one
Randomized control 24 weeks and intervention group
Diet (reduced calorie intake), regular physical activity
56/3 dropouts in the control group
Body weight, BMI, waist and hip circumference
Significant decrease in the treatment group in comparison to the control group
No control group
28 weeks
Education on diet and on exercise
22
Body weight
Weight gain in the sample
No control group
32 weeks
Body weight, BMI
Significant weight loss
No control group
12 weeks
Body weight
Weight loss
No control group
24 weeks
Counselling on 6 (4 dropouts) diet and exercise, behavioural therapy 6 (1 dropout) Wonderful me programme: diet, exercise and self-assertiveness training, group sessions 1000 kcal diet 73 (1 death)
Body weight
In 74% weight loss, 18% achieved ideal weight No significant difference between the groups
Schizophrenia or affective disorder
No control group
1 year
Milano et al. [38]
One group hypomania in bipolar disorder, one group schizophrenia; treated with olanzapine Schizophrenia; treated with olanzapine; BMI27, hospitalized patients Schizophrenia, schizoaffective disorder or bipolar disorder treated with olanzapine Schizophrenia, bipolar disorder, treated with atypical antipsychotics Schizophrenia, psychosis, psychopathic personality disorder ; BMI25 Overweight psychiatric patients
Two groups (different diagnosis with and without treatment)
8 weeks
Schizophrenia
Randomized control 24 weeks and intervention group
Merriman et al. [42]
Knox et al. [43] McCreadie [44]
Results
Body weight, fasting glucose level
Pendlebury et al. [37]
Umbricht et al. [41]
Target criteria
18/(4 dropouts)
Randomized control 16 weeks and intervention group
Nguyen et al. [40]
N
Modified LEARNProgramme weekly meetings, group, pedometers Voluntary group sessions
Jean-Baptiste et al. Antipsychotic [36] medication; BMI30
Wu et al. [39]
Intervention
Free fruits and vegetables, instruction in meal planning and food preparation
102
Number of portions of fruits and vegetables per week, BMI, level of physical activity, cardiovascular risk factors
T. Veit & C. Barnas
Author
Table I (Continued) Author
Design
Period
Intervention
N
Target criteria
Results
Randomized control 16 weeks and intervention group
Behavioural intervention
27 treatment group, 23 control group
Body weight
Significant less weight gain in the intervention group
Non-randomized control and intervention group
24 weeks
Restriction in calorie intake
40
Body weight
Weight gain moderated by dieting
No control group
2 years
966 (20% dropout rate)
Poulin et al. [48]
Schizophrenia, schizoaffective disorder, bipolar disorder; treated with antipsychotics
Control group
18 months
A minimum of six consultations (health checks), lifestyle advice, healthy living groups Education on diet and physical activity; exercise programme
Bushe et al. [49]
No control group Schizophrenia, affective disorders, personality disorder, anxiety, alcohol misuse No control group Schizophrenia, schizoaffective disorder; patients have not been in the acute psychotic, manic or hypomanic state within 4 weeks, antipsychotic treatment for at least 8 weeks; BMI25 Schizophrenia Control group
4 weeks
Education on diet, appetite, physical activity
47 (30 dropouts)
Body weight, BMI, No significant change diet, physical activity, in BMI; significant smoking; self esteem improvement in diet, physical activity, smoking and selfesteem Body weight, BMI, Significant reduction waist circumference, in body weight, BM, LDL, HDL, waist circumference, triglycerides, fasting HDL increased, glucose LDL, triglycerides, concentration fasting glucose concentration decreased Body weight No weight gain in 70% of patients
12 weeks
12 weekly group sessions; Food diary, nutrition education, self-monitoring exercise record, education about lifestyle modification
232
Body weight, BMI
Significant reduction in weight and BMI
No information
Dietary, general health and exercise advice
51 (9 out of these 51 attended the programme)
BMI
Weight loss
Heimberg [46]
Smith et al. [47]
Lee et al. [50]
Feeney et al. [51]
110 (25% dropout rate)
Diet blues
Schizophrenia or schizoaffective disorder; within 30 days of started treatment with novel antipsychotic Schizophrenia, schizoaffective disorder; treated with clozapine Schizophrenia, schizoaffective disorder, bipolar disorder (2 years) outpatients
Ganguli [45]
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Population
179
Body weight, BMI, eating and weight related cognitions, binge eating symptomatology
Target criteria
61 Cognitive and behavioural treatment (CBT) on eating and health related cognitions weekly (adapted for patients with psychotic disorders) vs. brief nutritional education Randomized control 12 weeks vs. 1 day 24 Patients treated with antipsychotic drug for and intervention group weeks follow-up a minimum of 2 months who reported weight gain 2 kg over 6 months following treatment Khazaal et al. [52]
Author
Table I (Continued)
Population
Design
Period
Intervention
N
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Improvement in weight-related cognitions and binge eating symptomatology; greater weight loss in CBT group
T. Veit & C. Barnas
Results
180
method or the time span of the treatment. The time of the weight management programs ranged from one single session [34] up to 3 years [26]. Considering long term-effects three out of 39 studies showed a significant weight reduction after 1 year [18,37], and after 18 months [48], while the other studies did not report long-term data. Almost half of the intervention studies did not use a control group at all, 70% did not use a randomized controlled study design (see Table I). All, except one study [34], which defined the knowledge about nutrition as target criteria, had body weight or BMI as target criteria. Only a few programs defined further goals: Three out of 39 intervention studies took eating behaviour into account [23,44,47] and five of them collected data about physical exercise [23,32,33,44,47]. Psychoeducational goals, such as nutrition knowledge, were reported by three studies [17,18,34]. Quality of life as target criteria was measured by three programs [23,25,29]. One single study reports data about eating and weight related cognitions [52]. Six studies referred to known weight management programs and adapted them for the special needs of schizophrenic patients [14,15,23,24,30,36]. In these cases a clear description of the method used could be found. Discussion It is evident, that obesity has become an important concern in the treatment of patients with schizophrenia. Since atypical antipsychotics have been established and weight gain is a significant side effect of several antipsychotics, the need of a solution has become clear. There is consent about the importance of the topic and about the fact that something has to be done, but standard procedures do not exist and good clinical practice could not be defined yet. Clinical practice with psychotic patients shows that it is not easy for schizophrenic patients to follow diet instructions and to motivate themselves to physical exercise, mainly because of possible negative symptoms, sometimes also because of direct medication effects. Thus it has become evident that intervention programs for schizophrenic patients have to take into account these schizophrenia specific factors and that specific programs for this group of patients should be developed. Several reports about weight management programs, which have been either developed or adapted for psychotic patients, have already been published (see Table I). Interpretation and comparability are limited because of considerable differences in target
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Diet blues criteria, intervention strategies and duration of the program. In contrast to experiences in the clinical practice all of the published papers, except of one [46], reported successful outcome. Unfortunately the vast majority of the published reports did not fulfil the requirements, which should be expected of scientific studies. The first point to be mentioned in this context is a proper description of the investigated sample. Besides of demographic data it would be necessary to describe the current reason to be included into the study (obesity or maintenance of normal weight). In cases of obesity or overweight information about degree and time course of weight gain, before and after the start of antipsychotic medication should be given. A key feature to compare studies is the description of the investigated patients in terms of psychopathology, which doubtlessly has an important impact on the kind of intervention and the outcome of such studies. It is a little disappointing that not even one single study did take this point into consideration. Another key point is whether a control group is used and if yes, how assignment to the groups has been done. Only 21 of the 39 studies that we analyzed used a control group, 12 of them used some kind of randomized group assignment, nine did not (see Table I). In most of the studies the randomization procedure is not exactly described, which means a high risk of bias. In terms of conclusions drawn from these studies, caution is advised. Especially in this field it is very difficult to carry out properly randomized controlled trials because of the amount of external confounding influences, which have to be controlled. It should also be mentioned, whether participants received payment for the participation in the study. Payment to trial subjects and the willingness to participate in a weight management program in itself can influence the results. Next issue is the definition of target criteria, how they are measured and a time schedule to measure them. Most studies used only weight or BMI as target criteria. It should be noted that BMI is not adjusted for age or sex, a fact that has been criticised by some authors [6]. Five studies collected data about physical activity [23,32,33,44,47]. Only two surveys considered the combination of physical activity and eating behaviour [23,47]. It is evident that there is an obvious need of studies going into detail on these aspects. Most of the studies measured the outcome only during the time span of the intervention itself. Only two papers [23,52] report 1-year follow-up data. This is a clear drawback, especially in studies on body weight reduction interventions, because of the
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high likelihood that patients will regain weight as soon as the intervention is finished [54]. The most important point, which is necessary to compare weight reduction programs, is the method used. Unfortunately many of the analyzed reports lack a detailed description of the method. As far as we were able to gain the details from the reports we can conclude in addition to duration and intensity, that particularly interventions differ a lot. These differences have an impact on comparability. Some use behavioural treatment, others offer psychoeducation in order to include diet or exercise or both combined. Only six out of 39 programs go back to already known weight management programs and adapt them for the special needs of people with schizophrenia if necessary [14,15,23,24,30,36]. Obese patients with schizophrenia know about their body weight and wish to reduce it, but weight loss methods do not always agree with established recommendations. Only one third of the study participants reported the recommended combination of diet and exercise. Especially women use unsafe and questionable methods in order to lose weight [55]. Besides the methodological issues discussed above a few principal questions about health care strategies in schizophrenic patients arise. Currently research focuses on eating behaviour and physical activity. But is it sufficient to focus on only two factors? Health awareness as the main goal could be a reasonable approach that includes in addition to diet and physical activity for example aspects like non-smoking, stress management, hygienic habits and preventive medical check-ups. Encouraging health awareness and giving patients the possibility to look after their own health could mean more quality of life. Especially in view of long term results, a broad approach in terms of health awareness, that does not disregard quality of life, seems to gain increased significance. A question that should be posed is, whether only patients should be included into health care programs or whether close relatives should also participate. In many cases relatives bear a large part of responsibility for the lifestyle of the patients, especially, if they live together. The points mentioned above apply as well to weight management programs for people without any mental disorders. A medical discipline which has long experience with this topic is cardiac rehabilitation, and also in this field we find a similar situation: Studies are very heterogeneous concerning intervention strategies and there are hardly any long term results. The combination of behavioural therapy and dietary and exercise intervention has proved best results [13].
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T. Veit & C. Barnas
There is no doubt about the importance of the current problem. Guidelines and recommendations for a psychiatrist to look better after the physical health of their patients and to monitor metabolic effects were established [56]. Clear methods and goals should be established in psychiatry concerning obesity management in order to develop good clinical practice and standard procedures. Regarding obesity clear definitions of success and explicit guidelines have to be set up. Prevention of weight gain in a person of normal weight at the start of antipsychotic therapy differs from reducing weight in an obese patient. In the literature this distinction between prevention and therapy is left behind in most cases. Although clear recommendations on optimal procedures are still missing, the results show that behavioural treatment may be helpful for obese patients with schizophrenia [57] the same way as for obese people without any mental illness [8]. Behavioural therapy is understudied and there are relatively few controlled trials [58].
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Key points . Obesity is an increasingly prevalent problem in patients with schizophrenia and is associated with serious health concerns . Compared with the general population the prevalence of obesity is significantly increased in people with schizophrenia . The literature on weight management programs for people with schizophrenia is reviewed . There are large differences in intervention strategies, results, duration of the program and target criteria
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Statement of interest The authors have no conflict of interest with any commercial or other associations in connection with the submitted article.
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Acknowledgements None.
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