Narrator: Welcome to the E-View Series “Strategies to Integrate Physical Health Care Into Mental Health,” chaired by John W. Newcomer, MD, from the Department of Psychiatry, Washington University School of Medicine in St. Louis, Missouri. This E-View, entitled “Monitoring and Managing Weight Gain in the Mentally Ill,” includes presentations by Rohan Ganguli, MD, and Betty Vreeland MSN, APRN, NP-C, BC.
Narrator: Ms. Vreeland, from University Behavioral HealthCare, the School of Nursing, and the Robert Wood Johnson Medical School, Departments of Psychiatry and Family Medicine, at the University of Medicine and Dentistry of New Jersey in Piscataway, will now present “A Multidisciplinary Approach to Managing Weight in the Mentally Ill.” She will talk about the need for teamwork among physical and mental health care providers in managing weight in mentally ill patients and will present an effective multidisciplinary weight management program.
Ms. Vreeland: I would like to start out saying that a lot of behavioral healthcare professionals really want to know, “Are health and wellness possible in people with major mental illnesses?” I think that our typical image is someone who is a couch potato, not interested in health and wellness, and I have some research that helps to dispel this myth.
Ms. Vreeland: There is growing evidence of the need to address physical and mental health together, and in the President's new Freedom Commission on Mental Health, they talk about how improving services for people with serious mental illnesses will require paying close attention to how mental health care and general medical care systems work together in order to bridge this gap.
Ms. Vreeland: If we are going to be able to bridge this gap, we need to look at the whole person. Behavioral healthcare providers are used to looking at people from the neck up, but we also need to look at people from the neck down. I think that nurses are ideally prepared to bridge this gap because of their holistic training. We operate out of a biopsychosocial spiritual approach to addressing the whole person, so, when we are looking at how we can improve some of these physical health outcomes, utilizing the nurse as an important part of the multi-disciplinary team can really help make a difference.
Ms. Vreeland: Additionally, we want to look at all of the members on our treatment team—behavioral healthcare professionals, social workers, psychologists, and all members of the treatment team.
Ms. Vreeland: There are many treatment team strategies that can help bridge this gap. It is important to increase communication with clinic staff, reminding patients by phone the day before the appointment and certainly reinforcing any patient education that comes up during clinic visits. I think that this is something that nurses can play an essential role in, reinforcing good clinical care. I have worked in a number of different settings where we see that nurses are making links with primary care centers and really helping people to get there and keep appointments and also getting the communication going back and forth.
Narrator: Choose the best answer. The correct answer is "D," all of the above.
Ms. Vreeland: The issue that I really want to focus on is lifestyle. Many of the major health problems—heart disease, cancer, stroke, respiratory diseases, diabetes—are all affected by lifestyle. Repeatedly we see that smoking, exercise, obesity, and diet are issues that we can be looking at in people with major mental illnesses.
Ms. Vreeland: Research from the Nurses' Health Study shows that there are some simple lifestyle rules that can reduce the risk of disease. Again we see that smoking, being physically active, eating a healthy diet, and maintaining a healthy weight are all lifestyle issues that can affect health.
Ms. Vreeland: It is very important to look at Prochaska and DiClemente's stages of change approach when we are looking at any type of lifestyle interventions. If we move someone from not having any interest in addressing the problem to thinking, "Well, you know what? I should quit, but it would be hard to," this is making progress.
Ms. Vreeland: Even more so than the average American, people who are living with major mental illnesses are more likely to have unhealthy lifestyle behaviors, such as smoking heavily, eating diets that are high in fat and sugars and low in fiber, and have addiction problems and other types of lifestyle behaviors that put them at higher risk of medical problems. There also is research that suggests that people with major mental illness can also adopt healthier lifestyles. We have research that shows that people can recover from addiction, stop smoking, and adopt a healthy diet. We can prevent and reverse psychotropic-associated weight gain, and I have some research that shows that, when we reverse the weight gain, it also improves physiologic measures just like in non-psychiatric populations.
Ms. Vreeland: There are national guidelines that have been established about how we identify, evaluate, and treat overweight and obesity. Treatment is recommended if anyone has a BMI of 30 or higher, or if they are in the overweight range or have a large waist circumference and have 2 or more risk factors.
Ms. Vreeland: Moderate weight loss has significant health benefits. Between 4% and 5% can lower or eliminate the need for antihypertensive treatment. 5% to 7% is associated with a 58% reduced risk for Type 2 diabetes. 6% to 7% can improve the metabolic syndrome. So, we see that a small amount of weight loss can really make a major difference in health.
Ms. Vreeland: If we look at a database of the National Weight Control Registry, over 5,000 individuals, what are the most successful strategies? Engaging in high levels of physical activity, between 60 to 90 minutes per day. Eating a diet low in calories and fat. Most of these people eat breakfast every day. They self-monitor weight regularly and maintain a consistent eating pattern. Also, they catch slips before they turn into large problems. I think this is also key: that these people initiate weight loss after a medical event, which can be defined as easily as a healthcare professional advising someone to lose weight.
Ms. Vreeland: Weight gain is not exclusive to people with serious and persistent mental illness, but we know it is associated with many psychotropics. It can affect forming all of these medical problems that we are seeing, but we also have research that shows that weight gain can be reversed, minimized, and prevented in this population.
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Abbreviations
BID = twice a day
BMI = body weight index
FDA = Food and Drug Administration
LDL = low density lipoprotein
NHLBI = National Heart, Lung, and Blood Institute
USDA = United States Department of Agriculture