The attention of the audience was captured when Philip Ward (University of New South Wales, Sydney, Australia) opened his presentation at EPA 2016, by stating that failure to prevent the physical deterioration of mental health patients is a major medical scandal of our times. As a consequence, the loss in life expectancy compared with the general population shows no signs of being reduced. But much can be done to prevent treatment-associated weight gain and metabolic risks in young people with first episode psychosis.
People with severe mental health problems can expect to die twenty years earlier than those in the general population without psychiatric disorders. They suffer from what is in effect lethal discrimination.
Typically, a first episode psychosis (FEP) patient gains around 12 kg within the first two years of treatment with antipsychotics. This is as a big deal since it paves the way to metabolic disturbance and cardiovascular morbidity and mortality.
However, such weight gain is not inevitable. This has been shown in the Bondi suburb of Sydney through introduction of the pioneering Keeping the Body in Mind programme of intensive intervention to encourage exercise and healthy eating.
The community health centre which cares for FEP patients did not just talk the talk. It decided to use its kitchen to demonstrate healthy cooking; and it turned one of its rooms into a gym.
Where there’s a will there’s less weight
In a controlled study, the intervention group (n=16) put on a mean of 1.8 kg over the initial twelve weeks of study while FEP patients (n=12) who had standard care at another centre gained 7.8 kg. Intervention, which was tailored to the circumstances of the individual patient, included access to a nutritionist who did everything from accompanying them to buy food to supervising its cooking; assistance of exercise physiology students in the gym; encouragement of “peer wellness coaches” who had been through the experience of putting on weight with antipsychotics and then struggling to lose it.
Waist circumference, which is a major marker of metabolic risk, increased by 0.1 cm compared with 7.1 cm in the two groups respectively. The proportion of intervention patients who experienced clinically significant weight gain was 13%, compared with 75% of the controls.
On all three endpoints, the differences were statistically as well as clinically significant. But could they be maintained?
The answer seems to be Yes.
If we prescribe a medication which has consequences, it is our responsibility to address those consequences. And the Australian experience shows how this can be done.
At two years, 12 of the initial 16 Bondi intervention patients could be followed up. Their average weight was 70.8 kg, only 1.3 kg more than at baseline. And their waistline had grown by a mere 0.1 cm.
Over the intervening period, patients continued to have access to the gym and they continued to have access to nutritional and other advice, but they had not been intensively encouraged to maintain their healthy diets and exercise.
So it seems that once the seed is sown, it largely nurtures itself. But sowing the seed requires effort.
Preventing weight gain in the first place is probably the easier option. And it means you never stop looking good on the beach.
For the future
Much remains to be done on the lifestyle front. An as yet unfulfilled aim is to halve tobacco consumption among young people with FEP. But in terms of preventing weight gain, Keeping the Body in Mind has met its first target.