INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 48(3) 175-183, 2014
LOW RATE OF OBESITY AMONG PSYCHIATRIC INPATIENTS IN INDONESIA M. MARTHOENIS, MSC, MPH Charité Universitäts Klinki at St. Hedwig Hospital Berlin, Germany MARION AICHBERGER, MD, MSC Charité Universitätmedizin Berlin, Germany IBRAHIM PUTEH, SPKJ Syiah Kuala University, Darussalam, Indonesia MERYAM SCHOULER-OCAK Charité Universitäts Klinki at St. Hedwig Hospital Berlin, Germany
ABSTRACT
Objective: A vast majority of psychiatric medication causes weight gain, however the rate of obesity in psychiatric patients has yet to be thoroughly studied in Indonesia. The present study aims to assess the prevalence of obesity among psychiatric inpatients in Indonesia. Methods: This cross sectional study was conducted in Banda Aceh Psychiatric Hospital, Indonesia from December 2012 to January 2013. The Body Mass Index (BMI) and blood pressure of a total 242 inpatients was measured, and data on their demographic information and medication were collected from the patient’s chart. Results: The prevalence rate of obesity among psychiatric inpatients was 5% (95% CI = 2.6–8.5%), and overweight was 8% (95% CI = 5.1–12.4). The mean BMI was 21.44 kg/m2 (SD: 3.43). Stage I hypertension and stage II hypertension was found among 7% (95% CI = 4.1–11), and 2% (95% CI = 0.9–5.3%) inpatients, respectively. Conclusions: The findings suggest that the rate of overweight, obesity and hypertension in the present study population was relatively low compared to rates of the general population. The inpatients have limited access to food and only eat meals that are provided to them by the hospital. (Int’l. J. Psychiatry in Medicine 2014;48:175-183) Key Words: prevalence, obesity, hypertension, antipsychotics, Indonesia, underweight, inpatient 175 Ó 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.48.3.c http://baywood.com
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INTRODUCTION Psychiatric patients experience physical problems more frequently compared to the general population, but they are often neglected and left untreated [1, 2]. The simultaneous burden of having both physical and mental illnesses diminishes their quality of life, which leads them to die younger than the general population [3]. Unhealthy lifestyle factors such as eating an unhealthy diet, lack of physical exercise, smoking, and abusing substances also increases the mortality rate among this group [4]. A growing body of evidence shows that the majority of antipsychotic drugs (AP) is related to weight gain [5, 6]. So does the use of AP increase appetite and reduce the level of physical activity, which can lead to weight gain and high blood pressure [7]. The overall effect differs between gender [8, 9], age, and the clinical outcome (completing remission) [9]. Previous studies show that the burden of overweight and obesity is somewhat higher among people with mental illness (PWMI) compared to the general population [1, 10]. Studies in the United States and Canada reported that 57.8% of obese people suffered from depression [11], 42 to 60% suffered from schizophrenia [1], and 68% suffered from bipolar disorder [12]. The national basic health survey conducted in 2007 refers that the prevalence rate of obesity in Indonesian general population was 19.1%, and hypertension was 29.8% [13]. The survey also indicates that the rate of obesity among the Acehnese population was 8.45%, and the rate of hypertension was 30.2% [14]. Meanwhile, information on the prevalence of obesity and other health-risk factors among PWMI in Indonesia is scarce. The present study, therefore, was aiming to assess the prevalence of obesity among psychiatric inpatients in a psychiatric institution in Indonesia. METHODS Two hundred and forty-two respondents were randomly selected from a source population of 639 inpatients, who were being hospitalized at Banda Aceh Psychiatric Hospital. The hospital is the main and the only referral center for psychiatric disorders in this province, serving a population of 5 million in Aceh Province. There are eight psychiatrists, fourteen general practitioners (GP), four clinical psychologists, and a number of nurses working in the hospital. The teaching hospital serves both in- and outpatients and has a unit for substance abuse rehabilitation. Some data were also collected from a new filial in Jantho, which serves as a distance ward of the main psychiatric hospital in Banda Aceh. Data collection for this cross sectional study was conducted from December 2012 to January 2013. Written consent to conduct the study was obtained from the director of the hospital, and the ethical approval was obtained from the ethics committee of the medical faculty—Syiah Kuala University in Banda Aceh. A number of patients (19 persons in first randomization) who were unable to provide
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sufficient information, mostly due to the severity of their mental problems were excluded from the study beforehand. Weight and height of the inpatients were measured and the Body Mass Index (BMI) was calculated based on the formula kg/m2. Weight was measured in kilogram and height was measured in centimeter. BMI was categorized according to the Indonesian National Institute of Health Research and Development, using the following categories: underweight (BMI < 18.5), normal (18.5 ³ BMI < 24.9), overweight (25 ³ BMI < 27), and obese (BMI ³ 27) [13]. Blood pressure was measured of each selected inpatient by the use of an electronic blood pressure monitor to circumvent the subjectivity of blood pressure judgment. Hypertension was defined along the JNC 7 criteria, with hypertension I being 140–159 of systolic or 90-99 diastolic and hypertension II being ³ 160 of systolic or ³ 100 diastole [15]. This one time measurement was not intended to diagnose the hypertension but only used as an indicator of patients’ blood pressure. Demographic data, including the duration of stay and medication, were generated from the inpatient’s chart. Age was measured in years and inferred by year of birth; duration of hospital stay was measured in month. The inpatients were also briefly interviewed about their eating habits and access to food. Statistical Analysis To test for significant associations in BMI and gender, independent student t-tests were performed, to test for differences in age, duration of stay, weight, and height between gender, Mann-Whitney U tests were used. Spearman’s rho correlation coefficient was used to assess the correlation between BMI and age as well as between BMI and duration of stay. All analyses were conducted using SPSS statistical software version 20. RESULTS From a total of 242 respondents, about 87.19% were male and more than half (54.55%) were aged 24-35 years. The mean age was 33.68 years (SD: 8.82), and the mean hospital stay was 15 months (SD: 28.47). When the long-term inpatients (stay of more than 36 months) were excluded from the analysis, the mean hospital stay shortened to 8 months (SD: 7.80). All patients suffered from psychosis and all were treated with antipsychotic medication. The dose of antipsychotic is varied between patients and the duration of treatment was similar to the duration of hospital stay, as long as the patients were hospitalized, they were required to take medication. All patients should take the medication in front of the ward nurse after each meal, the patients have to stay in line to take their medication from the ward nurse, and take it in front of the nurse with water. There is a possibility for patients to get rid of the medication afterwards, and the medication level in blood had never been checked.
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The vast majority of the inpatients were originally from Aceh province; only one inpatient was from North Sumatra province. Eight respondents were previously homeless or their origin was unknown (3.31%). More than 92% of the inpatients were diagnosed with Schizophrenia, including residual type, disorganized, undifferentiated, and paranoid. The most common type was paranoid Schizophrenia, with 55.37% of the inpatients suffering of the disorder. Other diagnoses were Depression (0.41%), mental and behavioral disorder related to psychoactive substances (4.13%), and bipolar disorder (0.83%). A dual diagnosis of schizophrenia and epilepsy was found in two patients (0.83%). An overview of the characteristics of the sample is provided in Table 1.
Table 1. Sample Characteristics Including BMI, Blood Pressure, Duration of Stay and Age Group Female N (%)
Male N (%)
Total N (%)
Number
31 (13)
211 (87)
242 (100)
Body mass index Underweight Normal Overweight Obese
1 (3) 19 (61) 4 (13) 7 (23)
39 (18) 151 (72) 16 (8) 5 (2)
40 (17) 170 (70) 20 (8) 12 (5)
Blood pressure Hypotension Normal Prehypertension Stage 1 Hypertension Stage 2 Hypertension
1 (3) 24 (77) 4 (13) 1 (3) 1 (3)
8 (4) 117 (55) 65 (31) 16 (8) 5 (2)
9 (4) 141 (58) 69 (29) 17 (7) 6 (2)
Duration of stay (month) 1-2 3-5 6-12 13-24 ³ 25
10 (32) 4 (13) 8 (26) 7 (23) 2 (6)
50 (24) 49 (23) 45 (21) 36 (17) 31 (15)
Age group (years) 12-23 24-35 36-47 48-60 > 60
4 (13) 9 (29) 13 (42) 5 (16) 0
20 (9) 123 (58) 55 (26) 11 (5) 2 (1)
60 53 53 43 33
(25) (22) (22) (18) (14)
24 (10) 132 (55) 68 (28) 16 (7) 2 (1)
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More than half (70%) of the inpatients had a healthy BMI and more inpatients were found to be underweight than overweight or obese (17% vs. 8% and 5% respectively). The mean BMI was 21.44 kg/m2 (SD: 3.43) and significantly differed between gender (t = 4.46, p = .001). Hypertension rate was 9%, with 7% (4.2–11%) of stage I hypertension and 2% (0.9–5.3%) of stage II hypertension. More than half of psychiatric inpatients (58.3%) had a normal blood pressure and nine had hypotensive values (3.7%). The difference of BMI and blood pressure categories between genders can be found in Table 1. On average, male respondents were taller than the female (t = 7.61, p = 0.001) but no difference in weight between gender was found. The association between BMI and the duration of stay in the hospital was not identified (t = 0.11, p = 0.85). Age of the inpatients was also not associated with the BMI (t = 0.25, p = 0.69). (See Table 2.) In this hospital, AP medication for new inpatients was prescribed by the psychiatrist. Varieties of branded APs as well as the generics medication were in use. The most commonly prescribed medicines were Risperidone, Clozapine, Trihexyphenidyl, Olanzapine, Haloperidol, and Chlorpromazine. Details of medication taken by the patients is provided in Tables 3 and 4. DISCUSSIONS In this study of the psychiatric inpatient population in Aceh Province, Indonesia we found a low prevalence of overweight, obesity, and hypertension among PWMI. They were also relatively lower compared to a previous report [14] in Acehnese general population. To our knowledge, this is the first study examining physical health indicators in a psychiatric in-patient population in Indonesia. The finding of low obesity rate in the current study is in contrast to the majority of previous reports from similar settings in Western or high-income countries. Studies on obesity among psychiatric inpatients show a rate of 30.3% in Australia [16], 47.4% in the United Kingdom [17], and 21.6% in Japan [18], but the obesity rate was only 5% in the current study.
Table 2. Differences of Central Tendencies between Genders Female
Male
p-Value
Mean age in year (SD)
36.7 (10.23)
33.1 (8.52)
0.25
Mean duration of stay in month (SD)
14.4 (30.35)
15.7 (28.25)
0.42
Mean body weight in kilogram (SD)
56.3 (11.22)
56.6 (9.42)
0.56
153.7 (8.79)
163.8 (6.53)
0.001
23.9 (4.82)
21.0 (3.0)
0.001
Mean height in centimeter (SD) Mean BMI (SD)
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Table 3. Medication and Number of Patients Using Each Drug Medication group
Drug
N
%
Anti-psychosis
Chlorpromazine Clozapine Haloperidol Olanzapine Risperidone Others
28 136 41 46 154 13
12 56 17 19 64 5
Anticholinergic
Trihexyphenidyl
135
56
Anti-anxiety
Diazepam Merlopam (Lorazepam) Others
17 7 3
7 3 1
Mood stabilizer
Carbamazine Depakote (valproic acid)
2 15
1 6
Note: Each patient may take one to four different drugs.
Table 4. Antipsychotic and BMI Antipsychotic groups
Baseline BMI Underweight Normal Overweight Obese
Chlorpromazine N (%)
Clozapine N (%)
Haloperidol N (%)
Olanzapine N (%)
Risperidone N (%)
3 (1.2) 21 (8.7) 4 (1.6) 0 (0)
18 (7.4) 96 (39.7) 13 (5.4) 9 (3.7)
5 (2) 26 (10.7) 6 (2.5) 4 (1.6)
8 (3.3) 36 (14.9) 1 (0.4) 1 (0.4)
29 (12) 109 (45) 11 (4.5) 5 (2)
Another major finding of the present study was the high rate of underweight in psychiatric inpatients. This finding corresponded with two studies in Japan where the authors reported that underweight occurred more frequently among schizophrenic inpatients than in the control group or normal population [18, 19]. An inadequate (low) dietary intake of the current study population was considered among the possible explanations [20]. Yet, the nutritionist of the psychiatric hospital stated that the average diet in the hospital was about 2500 kilocalories, meaning that the patients obtain the minimum daily nutrition need. Economic affordability and lifestyle [21] as well as eating habits [22] of the patients were also considered as explanations of the reported findings.
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Studies on eating habits in Western countries found that the PWMI tend to eat more meals high in fat compared to the general population [4]. So do e.g. patients with Schizophrenia in Germany not frequently eat healthy groceries and mostly eat instant meals for supper, they also tend to snack more regularly than non-psychiatric patients [23]. Conversely, the current study populations consume low fat meals but have relatively normal carbohydrate and protein contents. They eat rice regularly, sometimes with fish, eggs, vegetables, and fruit. Apart from regular meals (breakfast, lunch, and dinner) that are provided by the hospital, the patients rarely eat junk food, fast food, or meals with high salt and fat contents. Most of the patients are locked inside the nursing wards and eat only what the hospital provides to them. Provision of food by family and friends is also limited since the majority of inpatients will not receive visits after being admitted to the psychiatric hospital. Thus, the access to food from external parties is generally impossible. In the present study, we also found that AP medications which have a weight gain side effect, such as Risperidone, Clozapine, Chlorpromazine, and Haloperidol, were also commonly given to patients. During acute and maintenance treatment of Schizophrenia, weight gain side effect of antipsychotics were reported to affect between 15% to 72% of the patients [24]. Treatment with Clozapine and Olanzapine at a standard dose for 10 weeks was reported to increase the weight up to 4.5 kg [25]. Nevertheless, the rate of overweight and obesity in the present study population is relatively low. Similarly, to obesity we found low hypertension prevalence in the current population. This may likely be related to the young mean age of the population and also a side-effect of the medication. Along with other lifestyle factors, eating low-risk diets has been suggested to contribute to lower incidence of and to prevent the development of hypertension [26]. The prevalence of physical health problems in psychiatric inpatients in Indonesia is largely unknown; our findings suggest differing patterns from Western countries in terms of overweight and hypertension. In particular, limited access to (junk) food may be related to the low rate of overweight and hypertension in this study population. A higher rate of underweight compared to the general population show the difference in Western countries and that high underweight rate might be due to the poverty in the general community. Limitation of the Study We did not measure the exact amount of food intake of the patients but relied on information provided by the nutritionist. Furthermore, one-time blood pressure measurement cannot be used to diagnose hypertension but was used as an indicator of inpatients’ blood pressure. Lastly, detailed analysis of antipsychotic use was not performed in the present work. Further study should consider the exact food intake, lifestyle factor, dose of medication, and the weight gain since treatment start of psychiatric inpatients.
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17. Haw C, Bailey S. Body mass index and obesity in adolescents in a psychiatric medium secureservice. Journal of Human Nutrition and Dietetics 2012;25(2):2012. 18. Inamura Y, Sagae T, Nakamachi K, Murayama N. Body mass index of inpatients with schizophrenia in Japan. International Journal of Psychiatry in Medicine 2012; 44(2):171-181. 19. Kitabayashi Y, Narumoto J, Kitabayashi M, Fukui K. Body mass index among Japanese inpatients with schizophrenia. International Journal of Psychiatry in Medicine 2006;36(1):93-102. 20. Hardy S, Gray R. The secret food diary of a person diagnosed with schizophrenia. Journal of Psychiatric and Mental Health Nursing 2012;19(7):603-609. 21. Padmavati R, McCreadie RG, Tirupati S. Low prevalence of obesity and metabolic syndrome in never-treated chronic schizophrenia. Schizophrenia Research 2010; 121(1-3):199-202. 22. Dipasquale S, Pariante CM, Dazzan P, Aguglia E, McGuire P, Mondelli V. The dietary pattern of patients with schizophrenia: A systematic review. Journal of Psychiatric Research 2013;47(2):197-207. 23. Roick C, Fritz-Wieacker A, Matschinger H, Heider D, Schindler J, Riedel-Heller S, et al. Health habits of patients with schizophrenia. Social Psychiatry and Psychiatric Epidemiology 2007;42(4):268-276. 24. De Hert M, Cohen D, Bobes J, Cetkovich-Bakmas M, Leucht SM, Ndetei D, et al. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry Official Journal of the World Psychiatric Association (WPA), Elsevier, Italy 2011;10(2):138-151. 25. Connolly M. Lifestyle and physical health in schizophrenia. Advances in Psychiatric Treatment 2005;11(2):125-132. 26. Forman JP, Stampfer MJ, Curhan GC. Diet and lifestyle risk factors associated with incident hypertension in women. Journal of the American Medical Association 2009;302(4):401-411.
Direct reprint requests to: M. Marthoenis, MSc, MPH c/o PD Dr Meryam Schouler-Ocak Psychiatric University Clinic of Charité at St. Hedwig Hospital Berlin Große Hamburgerstraße 5-11 10115 Berlin, Germany e-mail: [email protected]
LOW RATE OF OBESITY AMONG PSYCHIATRIC INPATIENTS IN INDONESIA M. MARTHOENIS, MSC, MPH Charité Universitäts Klinki at St. Hedwig Hospital Berlin, Germany MARION AICHBERGER, MD, MSC Charité Universitätmedizin Berlin, Germany IBRAHIM PUTEH, SPKJ Syiah Kuala University, Darussalam, Indonesia MERYAM SCHOULER-OCAK Charité Universitäts Klinki at St. Hedwig Hospital Berlin, Germany
ABSTRACT
Objective: A vast majority of psychiatric medication causes weight gain, however the rate of obesity in psychiatric patients has yet to be thoroughly studied in Indonesia. The present study aims to assess the prevalence of obesity among psychiatric inpatients in Indonesia. Methods: This cross sectional study was conducted in Banda Aceh Psychiatric Hospital, Indonesia from December 2012 to January 2013. The Body Mass Index (BMI) and blood pressure of a total 242 inpatients was measured, and data on their demographic information and medication were collected from the patient’s chart. Results: The prevalence rate of obesity among psychiatric inpatients was 5% (95% CI = 2.6–8.5%), and overweight was 8% (95% CI = 5.1–12.4). The mean BMI was 21.44 kg/m2 (SD: 3.43). Stage I hypertension and stage II hypertension was found among 7% (95% CI = 4.1–11), and 2% (95% CI = 0.9–5.3%) inpatients, respectively. Conclusions: The findings suggest that the rate of overweight, obesity and hypertension in the present study population was relatively low compared to rates of the general population. The inpatients have limited access to food and only eat meals that are provided to them by the hospital. (Int’l. J. Psychiatry in Medicine 2014;48:175-183) Key Words: prevalence, obesity, hypertension, antipsychotics, Indonesia, underweight, inpatient 175 Ó 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.48.3.c http://baywood.com
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INTRODUCTION Psychiatric patients experience physical problems more frequently compared to the general population, but they are often neglected and left untreated [1, 2]. The simultaneous burden of having both physical and mental illnesses diminishes their quality of life, which leads them to die younger than the general population [3]. Unhealthy lifestyle factors such as eating an unhealthy diet, lack of physical exercise, smoking, and abusing substances also increases the mortality rate among this group [4]. A growing body of evidence shows that the majority of antipsychotic drugs (AP) is related to weight gain [5, 6]. So does the use of AP increase appetite and reduce the level of physical activity, which can lead to weight gain and high blood pressure [7]. The overall effect differs between gender [8, 9], age, and the clinical outcome (completing remission) [9]. Previous studies show that the burden of overweight and obesity is somewhat higher among people with mental illness (PWMI) compared to the general population [1, 10]. Studies in the United States and Canada reported that 57.8% of obese people suffered from depression [11], 42 to 60% suffered from schizophrenia [1], and 68% suffered from bipolar disorder [12]. The national basic health survey conducted in 2007 refers that the prevalence rate of obesity in Indonesian general population was 19.1%, and hypertension was 29.8% [13]. The survey also indicates that the rate of obesity among the Acehnese population was 8.45%, and the rate of hypertension was 30.2% [14]. Meanwhile, information on the prevalence of obesity and other health-risk factors among PWMI in Indonesia is scarce. The present study, therefore, was aiming to assess the prevalence of obesity among psychiatric inpatients in a psychiatric institution in Indonesia. METHODS Two hundred and forty-two respondents were randomly selected from a source population of 639 inpatients, who were being hospitalized at Banda Aceh Psychiatric Hospital. The hospital is the main and the only referral center for psychiatric disorders in this province, serving a population of 5 million in Aceh Province. There are eight psychiatrists, fourteen general practitioners (GP), four clinical psychologists, and a number of nurses working in the hospital. The teaching hospital serves both in- and outpatients and has a unit for substance abuse rehabilitation. Some data were also collected from a new filial in Jantho, which serves as a distance ward of the main psychiatric hospital in Banda Aceh. Data collection for this cross sectional study was conducted from December 2012 to January 2013. Written consent to conduct the study was obtained from the director of the hospital, and the ethical approval was obtained from the ethics committee of the medical faculty—Syiah Kuala University in Banda Aceh. A number of patients (19 persons in first randomization) who were unable to provide
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sufficient information, mostly due to the severity of their mental problems were excluded from the study beforehand. Weight and height of the inpatients were measured and the Body Mass Index (BMI) was calculated based on the formula kg/m2. Weight was measured in kilogram and height was measured in centimeter. BMI was categorized according to the Indonesian National Institute of Health Research and Development, using the following categories: underweight (BMI < 18.5), normal (18.5 ³ BMI < 24.9), overweight (25 ³ BMI < 27), and obese (BMI ³ 27) [13]. Blood pressure was measured of each selected inpatient by the use of an electronic blood pressure monitor to circumvent the subjectivity of blood pressure judgment. Hypertension was defined along the JNC 7 criteria, with hypertension I being 140–159 of systolic or 90-99 diastolic and hypertension II being ³ 160 of systolic or ³ 100 diastole [15]. This one time measurement was not intended to diagnose the hypertension but only used as an indicator of patients’ blood pressure. Demographic data, including the duration of stay and medication, were generated from the inpatient’s chart. Age was measured in years and inferred by year of birth; duration of hospital stay was measured in month. The inpatients were also briefly interviewed about their eating habits and access to food. Statistical Analysis To test for significant associations in BMI and gender, independent student t-tests were performed, to test for differences in age, duration of stay, weight, and height between gender, Mann-Whitney U tests were used. Spearman’s rho correlation coefficient was used to assess the correlation between BMI and age as well as between BMI and duration of stay. All analyses were conducted using SPSS statistical software version 20. RESULTS From a total of 242 respondents, about 87.19% were male and more than half (54.55%) were aged 24-35 years. The mean age was 33.68 years (SD: 8.82), and the mean hospital stay was 15 months (SD: 28.47). When the long-term inpatients (stay of more than 36 months) were excluded from the analysis, the mean hospital stay shortened to 8 months (SD: 7.80). All patients suffered from psychosis and all were treated with antipsychotic medication. The dose of antipsychotic is varied between patients and the duration of treatment was similar to the duration of hospital stay, as long as the patients were hospitalized, they were required to take medication. All patients should take the medication in front of the ward nurse after each meal, the patients have to stay in line to take their medication from the ward nurse, and take it in front of the nurse with water. There is a possibility for patients to get rid of the medication afterwards, and the medication level in blood had never been checked.
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The vast majority of the inpatients were originally from Aceh province; only one inpatient was from North Sumatra province. Eight respondents were previously homeless or their origin was unknown (3.31%). More than 92% of the inpatients were diagnosed with Schizophrenia, including residual type, disorganized, undifferentiated, and paranoid. The most common type was paranoid Schizophrenia, with 55.37% of the inpatients suffering of the disorder. Other diagnoses were Depression (0.41%), mental and behavioral disorder related to psychoactive substances (4.13%), and bipolar disorder (0.83%). A dual diagnosis of schizophrenia and epilepsy was found in two patients (0.83%). An overview of the characteristics of the sample is provided in Table 1.
Table 1. Sample Characteristics Including BMI, Blood Pressure, Duration of Stay and Age Group Female N (%)
Male N (%)
Total N (%)
Number
31 (13)
211 (87)
242 (100)
Body mass index Underweight Normal Overweight Obese
1 (3) 19 (61) 4 (13) 7 (23)
39 (18) 151 (72) 16 (8) 5 (2)
40 (17) 170 (70) 20 (8) 12 (5)
Blood pressure Hypotension Normal Prehypertension Stage 1 Hypertension Stage 2 Hypertension
1 (3) 24 (77) 4 (13) 1 (3) 1 (3)
8 (4) 117 (55) 65 (31) 16 (8) 5 (2)
9 (4) 141 (58) 69 (29) 17 (7) 6 (2)
Duration of stay (month) 1-2 3-5 6-12 13-24 ³ 25
10 (32) 4 (13) 8 (26) 7 (23) 2 (6)
50 (24) 49 (23) 45 (21) 36 (17) 31 (15)
Age group (years) 12-23 24-35 36-47 48-60 > 60
4 (13) 9 (29) 13 (42) 5 (16) 0
20 (9) 123 (58) 55 (26) 11 (5) 2 (1)
60 53 53 43 33
(25) (22) (22) (18) (14)
24 (10) 132 (55) 68 (28) 16 (7) 2 (1)
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More than half (70%) of the inpatients had a healthy BMI and more inpatients were found to be underweight than overweight or obese (17% vs. 8% and 5% respectively). The mean BMI was 21.44 kg/m2 (SD: 3.43) and significantly differed between gender (t = 4.46, p = .001). Hypertension rate was 9%, with 7% (4.2–11%) of stage I hypertension and 2% (0.9–5.3%) of stage II hypertension. More than half of psychiatric inpatients (58.3%) had a normal blood pressure and nine had hypotensive values (3.7%). The difference of BMI and blood pressure categories between genders can be found in Table 1. On average, male respondents were taller than the female (t = 7.61, p = 0.001) but no difference in weight between gender was found. The association between BMI and the duration of stay in the hospital was not identified (t = 0.11, p = 0.85). Age of the inpatients was also not associated with the BMI (t = 0.25, p = 0.69). (See Table 2.) In this hospital, AP medication for new inpatients was prescribed by the psychiatrist. Varieties of branded APs as well as the generics medication were in use. The most commonly prescribed medicines were Risperidone, Clozapine, Trihexyphenidyl, Olanzapine, Haloperidol, and Chlorpromazine. Details of medication taken by the patients is provided in Tables 3 and 4. DISCUSSIONS In this study of the psychiatric inpatient population in Aceh Province, Indonesia we found a low prevalence of overweight, obesity, and hypertension among PWMI. They were also relatively lower compared to a previous report [14] in Acehnese general population. To our knowledge, this is the first study examining physical health indicators in a psychiatric in-patient population in Indonesia. The finding of low obesity rate in the current study is in contrast to the majority of previous reports from similar settings in Western or high-income countries. Studies on obesity among psychiatric inpatients show a rate of 30.3% in Australia [16], 47.4% in the United Kingdom [17], and 21.6% in Japan [18], but the obesity rate was only 5% in the current study.
Table 2. Differences of Central Tendencies between Genders Female
Male
p-Value
Mean age in year (SD)
36.7 (10.23)
33.1 (8.52)
0.25
Mean duration of stay in month (SD)
14.4 (30.35)
15.7 (28.25)
0.42
Mean body weight in kilogram (SD)
56.3 (11.22)
56.6 (9.42)
0.56
153.7 (8.79)
163.8 (6.53)
0.001
23.9 (4.82)
21.0 (3.0)
0.001
Mean height in centimeter (SD) Mean BMI (SD)
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Table 3. Medication and Number of Patients Using Each Drug Medication group
Drug
N
%
Anti-psychosis
Chlorpromazine Clozapine Haloperidol Olanzapine Risperidone Others
28 136 41 46 154 13
12 56 17 19 64 5
Anticholinergic
Trihexyphenidyl
135
56
Anti-anxiety
Diazepam Merlopam (Lorazepam) Others
17 7 3
7 3 1
Mood stabilizer
Carbamazine Depakote (valproic acid)
2 15
1 6
Note: Each patient may take one to four different drugs.
Table 4. Antipsychotic and BMI Antipsychotic groups
Baseline BMI Underweight Normal Overweight Obese
Chlorpromazine N (%)
Clozapine N (%)
Haloperidol N (%)
Olanzapine N (%)
Risperidone N (%)
3 (1.2) 21 (8.7) 4 (1.6) 0 (0)
18 (7.4) 96 (39.7) 13 (5.4) 9 (3.7)
5 (2) 26 (10.7) 6 (2.5) 4 (1.6)
8 (3.3) 36 (14.9) 1 (0.4) 1 (0.4)
29 (12) 109 (45) 11 (4.5) 5 (2)
Another major finding of the present study was the high rate of underweight in psychiatric inpatients. This finding corresponded with two studies in Japan where the authors reported that underweight occurred more frequently among schizophrenic inpatients than in the control group or normal population [18, 19]. An inadequate (low) dietary intake of the current study population was considered among the possible explanations [20]. Yet, the nutritionist of the psychiatric hospital stated that the average diet in the hospital was about 2500 kilocalories, meaning that the patients obtain the minimum daily nutrition need. Economic affordability and lifestyle [21] as well as eating habits [22] of the patients were also considered as explanations of the reported findings.
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Studies on eating habits in Western countries found that the PWMI tend to eat more meals high in fat compared to the general population [4]. So do e.g. patients with Schizophrenia in Germany not frequently eat healthy groceries and mostly eat instant meals for supper, they also tend to snack more regularly than non-psychiatric patients [23]. Conversely, the current study populations consume low fat meals but have relatively normal carbohydrate and protein contents. They eat rice regularly, sometimes with fish, eggs, vegetables, and fruit. Apart from regular meals (breakfast, lunch, and dinner) that are provided by the hospital, the patients rarely eat junk food, fast food, or meals with high salt and fat contents. Most of the patients are locked inside the nursing wards and eat only what the hospital provides to them. Provision of food by family and friends is also limited since the majority of inpatients will not receive visits after being admitted to the psychiatric hospital. Thus, the access to food from external parties is generally impossible. In the present study, we also found that AP medications which have a weight gain side effect, such as Risperidone, Clozapine, Chlorpromazine, and Haloperidol, were also commonly given to patients. During acute and maintenance treatment of Schizophrenia, weight gain side effect of antipsychotics were reported to affect between 15% to 72% of the patients [24]. Treatment with Clozapine and Olanzapine at a standard dose for 10 weeks was reported to increase the weight up to 4.5 kg [25]. Nevertheless, the rate of overweight and obesity in the present study population is relatively low. Similarly, to obesity we found low hypertension prevalence in the current population. This may likely be related to the young mean age of the population and also a side-effect of the medication. Along with other lifestyle factors, eating low-risk diets has been suggested to contribute to lower incidence of and to prevent the development of hypertension [26]. The prevalence of physical health problems in psychiatric inpatients in Indonesia is largely unknown; our findings suggest differing patterns from Western countries in terms of overweight and hypertension. In particular, limited access to (junk) food may be related to the low rate of overweight and hypertension in this study population. A higher rate of underweight compared to the general population show the difference in Western countries and that high underweight rate might be due to the poverty in the general community. Limitation of the Study We did not measure the exact amount of food intake of the patients but relied on information provided by the nutritionist. Furthermore, one-time blood pressure measurement cannot be used to diagnose hypertension but was used as an indicator of inpatients’ blood pressure. Lastly, detailed analysis of antipsychotic use was not performed in the present work. Further study should consider the exact food intake, lifestyle factor, dose of medication, and the weight gain since treatment start of psychiatric inpatients.
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Direct reprint requests to: M. Marthoenis, MSc, MPH c/o PD Dr Meryam Schouler-Ocak Psychiatric University Clinic of Charité at St. Hedwig Hospital Berlin Große Hamburgerstraße 5-11 10115 Berlin, Germany e-mail: [email protected]
