Weight Loss Possible on Antipsychotics

Fran Lowry

September 29, 2014

Individuals with serious mental illness who are taking antipsychotic medications can lose weight and even improve fasting glucose levels with the help of a weight loss and lifestyle intervention that teaches them about the benefits of physical exercise and healthy eating, a new study shows.

Dr. Carla Green

Patients who were randomly assigned to the STRIDE program lost an average of 4.4 kg more than their counterparts who received usual care after 6 months, researchers report in an article published online September 15 in the American Journal of Psychiatry.

They also experienced reductions in their fasting glucose levels, in contrast to the patients in the control group, whose fasting glucose levels rose.

"People with serious mental health problems are at vastly greater risk for the common comorbidities that kill Americans, the obesity-related conditions like heart disease and diabetes," lead author Carla A. Green, PhD, MPH, from Kaiser Permanente Northwest Center for Health Research, Portland, Oregon, told Medscape Medical News.

"Also, many of the antipsychotics they take increase the risk of metabolic problems, and almost all antipsychotics can lead to weight gain. This is an underserved population with much higher risk," Dr. Green said.

Such patients have traditionally been excluded from lifestyle intervention studies because of their mental health problems. As a result, "no one knew if it was even possible to help them lose weight and change their lifestyle," she noted.

Making Strides

In the current study, Dr. Green and her team randomly assigned 96 patients to receive usual care and 104 patients to receive the STRIDE intervention. Underlying psychiatric diagnoses included schizophrenia spectrum disorder, bipolar disorder or affective psychosis, and posttraumatic stress disorder.

Patients were excluded if they were pregnant or planning to become so, had had an inpatient psychiatric hospitalization within the last 30 days (although deferred participation was allowed), had a history of bariatric surgery or plans for an upcoming procedure, a history of cancer in the last 2 years, a history of heart attack or stroke in the last 6 months, or cognitive impairment sufficient to interfere with consent or participation.

The STRIDE weight loss and lifestyle intervention consisted of 6 months of weekly 2-hour-long group meetings and a further 6-month maintenance phase, which consisted of a monthly 2-hour-long group meeting.

Included in the meetings were a 20-minute exercise session, which was usually walking, a weigh-in, problem-solving, and education about healthy foods.

Participants were taught to keep records of the following: food, beverages, and calories consumed; servings of fruits, vegetables, and low-fat dairy products consumed; fiber and fat intake; number of minutes of daily exercise; and nightly hours slept.

The patients were encouraged to engage in at least 25 minutes of moderate physical activity per day, primarily through walking, to increase their consumption of fruits, vegetables, and low-fat dairy, and to improve sleep quality.

They also received a workbook to guide them with their calorie, fat, and carbohydrate content, as well as a resistance exercise band for strength training.

In the group sessions, the participants received support and learned self-management and problem-solving skills. The emphasis was on moderate caloric consumption, stress management, and how to eat healthfully on a budget.

"This is a low-income population in general, and they tend to have poor-quality diets. We focused on the DASH [Dietary Approaches to Stop Hypertension] dietary plan, with its emphasis on increased fruits and vegetables and low-fat dairy, and we tried to teach our participants how to do that when they are on a limited budget. We also taught them about portion control," Dr. Green said.

The STRIDE participants were also taught how to talk to their physicians about their medications and their weight gain to see whether adjustments might be made that would lessen some of the associated metabolic effects.

All study participants had to have been taking antipsychotic agents for at least 30 days, have a body mass index of at least 27, and be 18 years of age or older. Their mean age was 47.2 years (standard deviation, 10.6), and all were living in the community.

A total of 181 participants (91%) completed assessments at 6 months, and 170 (85%) completed assessments at 12 months.

Participants who were randomly assigned to STRIDE attended an average of 14.5 sessions in the first 6-month intervention period, for an average attendance rate of 60%, and an average of 2.7 sessions in the maintenance period, for an average attendance rate of 44.5%.

Weight Loss, Glucose Reduction

At 6 months, the STRIDE group lost 4.4 kg more than the control group (95% confidence interval [CI], -6.96 kg to -1.78 kg), and at 12 months, they lost 2.6 kg more than the control group (95% CI, -5.14 kg to -0.07 kg).

STRIDE participants also experienced decreases in their fasting blood glucose levels, whereas control participants showed increases.

At 12 months, fasting glucose levels in the STRIDE group decreased to 100.4 mg/dL, from 106.3 mg/dL at baseline. In contrast, levels in the control group rose from 106.0 mg/dL to 109.5 mg/dL.

"We feel that the STRIDE program was very successful," Dr. Green said.

"One of the concerns people had at the beginning of the study was whether we might destabilize patients who might not want to take their medications if we taught them about side effects and so on, but in fact we found no differences in psychiatric hospitalizations," she said.

Importantly, hospitalizations for medical conditions actually decreased among STRIDE patients, she said.

There were significantly fewer medical hospitalizations in the STRIDE group than in control patients during the 12-month period. Compared with 18.8% of control participants, 6.7% of STRIDE participants reported medical hospitalizations (P = 0.01).

The proportion of psychiatric hospitalizations was similar between groups, 15.6% among control patients and 15.4% in STRIDE participants.

"As far as I know, we are the first study to show that patients with severe mental illness can successfully lose weight and adopt a healthy lifestyle," Dr. Green said.

"Getting together in a group motivates people, and this is especially so for a disenfranchised population," she said. "For this population, that support of being able to come together with other people who have similar experiences and confronting the same kinds of problems is really important. We found from interviews that the group support and camaraderie was very important to them.

"I would very much hope that other centers implement our program," she added.

More information about the STRIDE program, including all program materials, is available online.

The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Green reported no relevant financial relationships.

Am J Psychiatry. Published online September 15, 2014. Abstract

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