Body and Mind: Metabolic Syndrome
and Mental Health
A workshop to discuss the management of metabolic
issues in people with mental illness
Overview
• A meeting was convened by the World Federation for
Mental Health in September 2004 to discuss mental illness
and metabolic syndrome
– Attended by ten physicians, consumers and caregiver groups from
around the world
– Output: “Advancing the treatment of people with mental illness: a callto-action in the management of metabolic issues”, published in
Journal of Clinical Psychiatry in June 2005
• Aim of today’s workshop
– Summarise the findings published in the JCP article
– Discuss practical implementation of the recommendations
What is metabolic syndrome?
• Metabolic syndrome:
– a complex disorder consisting of multiple risk factors that promotes
cardiovascular disease and overall mortality and morbidity1,2
– Obesity and insulin resistance are two of the most important
causative factors3
– Components may have genetic or environmental basis
Hypertension
Dyslipidemia
1Ninomiya
Impaired
glucose
tolerance
Obesity
JK et al. Circulation 2004;109:42-46; 2Malik S et al. Circulation 2004;110:1245-1250;
3Grundy SM et al. Circulation 2005;112(17):e285-90
ATP III definition: the metabolic syndrome
• 3 or more risk factors required to meet the definition
Factor
Measurement
Obesity
• Waist circumference
– Male
– Female
>102cm (>40in)
>88cm (>35 in)
Dyslipidaemia
• Triglycerides
150 mg/dL (1.7mmol/L)
• HDL cholesterol
– Male
– Female
<40mg/dL (<1.0mmol/L)
<50mg/dL (<1.2mmol/L)
Hypertension
130/85mmHg
Fasting glucose
100mg/dL (5.5mmol/L)
ATP III = National Cholesterol Education Program Adult Treatment Panel III
JAMA 2001; 285: 2486-2497
Prevalence of metabolic syndrome in the
general population
Country
Prevalence of metabolic syndrome
USA
20 – 30%1-3
Japan
11.0%4
France
12.4%5
Germany
19.8%6
Italy
14.4%7
Spain
19.5%8
UK
19.6%6
Greece
20%9
Urban Indians
30 – 40%10,11
1Ford
ES et al. Diabetes Care 2004;27:2444-2449; 2Park YW et al. Arch Intern Med 2003;163:427-436; 3Haffner S et al. Circulation
2003;108:1541-1545; 4AnuurAD e ET AL. Journal of Occupational Health 2003;45(6):335-43; 5Balkau B et al. Diabetes and
Metabolism 2003;29(5):526-32; 6Sattar N et al. Circulation 2003:108(4):414-9; 7Bonora E et al. Int J Obes Relat Metab Disord
2003;27:1283-1289; 8Alverez Leon EE et al. Medicina Clinica 2003;120(5):172-4; 9Panagiotakos DB et al. Am Heart J 2004;147:106112; 10Gupta R et al. Int J Cardiol 2004;97:257-261; 11Ramachandran A et al. Diabetes Res Clin Prac 2003;60:199-204
Metabolic syndrome and mental illness
•
Metabolic syndrome may
be more prevalent in
people with mental
illness1
–
•
Their lifestyle factors
may contribute to the
development of
metabolic syndrome2,3
People with mental
illness have a reduced
life expectancy compared
to the general population
–
Metabolic syndrome
(especially CVD)
contributes to this4
•
Poor diet
•
Lack of exercise
•
Smoking
•
Stress
•
Medication that causes weight gain
•
Inadequate self-care
•
Adherence to prescribed medication
•
Financial hardship
•
Poor self-esteem and lack of motivation
•
Limited availability and co-ordination of
medical care
1Holt RI. Diabet Med 2004;21:515-523; 2McCreadie RF et al. Br J Psychiatry 2003;183:534-539;
3Kumar CT. Br J Psychiatry 2004;184:541; 4Marder SR et al. Am J of Psy 2004:161(8);1334-49
Recommendations for metabolic
disorder management in people with
mental illness
Issues
• Healthcare professionals (HCPs) need to be fully informed
of the increased risk of metabolic disorders and need for
intensive monitoring
• Collaboration required between HCPs, caregivers and
individuals concerned
Who should manage physical health
monitoring?
• Will vary from country to country and from urban to rural
setting
• Ideally, physical health monitoring should be incorporated
into community mental health services
– Mental health clinics may be poorly equipped
– Psychiatrists may lack familiarity with metabolic monitoring
• However, PCPs may be ideally placed
–
–
–
–
Oversee patients’ complete healthcare programmes
Long-term relationship with person and family
Co-ordinate general and mental health services
But, PCPs often have little specialised training in mental health
Conclusion: the prescriber of the medication for the mental disorder
should take responsibility for ensuring that monitoring occurs
What needs to be monitored?
Metabolic risk factor
How to monitor
When to monitor1
Weight (BMI / waist
circumference)
Body Mass Index
1 – 3 months
Insulin resistance
Fasting blood glucose test
4 months – 1 year
HbA1c test
Blood pressure
Standard method
6 weeks – every visit
Lipid profile
Blood sample (total
cholesterol, HDL-cholesterol,
LDL-cholesterol and
triglycerides)
6 months – 2 years
1Marder
SR et al. Am J Psychiatry 2004;161(8):1334-1349
What should be done when evidence of
metabolic disorders is identified?
• Inform concerned individual of their condition and provide
support in making lifestyle changes
• Refer for treatment to appropriate HCP
– Impaired glucose tolerance / diabetes
– Elevated blood pressure
– Dyslipidaemia
• Review antipsychotic medication
– May be associated with weight gain and impaired glucose tolerance1
• Risk / benefit (risk factors vs. efficacy) differs from person to
person
1Allison
DB et al. Am J Psychiatry 1999;156:1686-96
How can people with mental illness be
supported in making lifestyle changes?
• HCPs need to provide significant support
– Achieving and maintaining weight loss is more likely to be successful when
there is a physician-patient partnership1
– Referral of consumers, when relevant, to
• Nutritionist or dietician
• Substance abuse professionals2
– Motivational interviewing may be helpful when lifestyle changes are being
made
• Family members / caregivers
– Involve where relevant, encourage participation in healthy diet and exercise
and provide information
1Hill
JO et al. Obes Res 2002;10(suppl 2):124S-130S; 2Steinberg ML et al. Consult Clin
Psychol 2004;72:723-728
Conclusions
• People with mental illness are at particular risk of
developing the components of metabolic syndrome
• Prevention of metabolic disorders is key to ensuring the
physical health of people with mental illness
• Regular and comprehensive monitoring is necessary to
ensure proper risk management
• Greater overall awareness of metabolic disorders in people
with mental illness within the broad medical community is
urgently needed
• Treatment of people with mental illness is a collaborative
effort between clinicians, the person involved and their
family / caregivers
Discussion
Discussion
Primary Care Practitioners
Goals of discussion
• Explore the importance of physical health monitoring in
people with mental illness, and how and when monitoring
should take place
• Develop awareness of key considerations when working
with people with mental illness
• Discuss tools to facilitate best practice in recording and
sharing important information regarding the mental and
physical health of people with mental illness
• Discuss a best practice checklist for working with people
with mental illness
Discussion topics
• Monitoring metabolic syndrome risk factors
– How to monitor
– Frequency of monitoring
• Encouraging self-monitoring
– Obesity – weight change of 3-5kg
– Blood sugar – increased thirst / urination
• Encouraging healthy behaviour
–
–
–
–
Healthy eating
Increased physical activity
Quit / cut down on smoking
Decrease alcohol consumption
Discussion topics (cont.)
• Considerations for people with mental illness
–
–
–
–
Mental health history
Personal stressors / triggers
Unusual behaviours to watch out for
Other HCPs seen by the individual
• Involve families and caregivers
– Establish source of support
– Build a familiar and trusting relationship with them
• Working with mental health specialists
– Sharing of information
Discussion
Mental Health Practitioners
Goals of discussion
• Share experiences of advising people with mental illness on
physical health matters.
• Develop awareness of how to listen attentively to people
with mental illness and assist them in developing their own
healthy living plans
• Discuss tools to facilitate and encourage these individuals
to take more responsibility for their own health
• Discuss a best practice checklist for discussing metabolic
syndrome with people with mental illness
Discussion topics
• Healthy living curve
• Identifying unhealthy behaviour
– Diet / exercise / smoking
• Healthy living pros and cons
• Developing a healthy living plan
– Diet / exercise / smoking / alcohol / self-help groups / supportive
relationships / medication
• Implementing a healthy living plan
Discussion topics (cont.)
• Supportive people
– Family members / friends / other HCPs to help put healthy strategies
into action
• Self-monitoring
– Obesity / blood sugar
• Medication review
Discussion
Mental Health Consumer and Family
Goals of discussion
• Explain how to develop a healthy living plan, and how to
talk to physicians and mental health practitioners about
metabolic syndrome
• Empower you/your relative to take responsibility for physical
health and develop a healthy living plan
• Discuss tools to facilitate and enable you/your relative to
become more involved in decisions about mental and
physical health
• Discuss a checklist of suggested activities to ensure
physical health and help prevent metabolic syndrome
Discussion topics
• Asking your doctor for physical health monitoring
– Weight / blood sugar / blood pressure / fats in blood
• Talking to your doctor
– Clarify what you want to discuss
• Self-monitoring
– Weight / blood sugar
• Identifying unhealthy behaviour
– Diet / exercise / smoking
Discussion topics (cont.)
• Identifying personal goals
• Healthy living plan
– Diet / exercise / smoking / drinking / self-help group / supportive
relationships / medication
• Getting support for a healthy living plan
– Family / friends / HCPs
• Medication review