Obesity Management of patients with mental illness

Transcription

1 Obesity Management of patients with mental illness Prof. Dr. Mohamed Aboulghate Faculty of Medicine, Cairo University Secretary General, EMASO

2 Points to be discussed Is obesity a psychiatric disorder(addiction, Food dependence)? Very common association. The mediator/ moderator relationship between obesity and common mental health disorders. The very serious complications of both obesity and MI if left without treatment. Examples of mental diseases related to obesity. Aim of obesity management. Modified obesity management with MI. Is any of the mentally ill patients should be excluded from obesity management?

3 IS OBESITY A PSYCHIATRIC DISORDER (Addiction, Food dependence)? Obese individuals often eat more than they intend and make frequent yet ultimately unsuccessful efforts to control overeating. Obesity can reduce an individual s ability to participate in a full range of social, occupational, and recreational activities. Many individuals continue to overeat despite knowledge that overeating causes obesity and may contribute to or complicate serious health problems.

4 Yet, Food, unlike drugs and alcohol, is necessary for life, that it is impossible to abstain from food. Physiological markers of dependence like tolerance, withdrawal, and craving for food are not well characterized or understood at this time. National Task Force on the prevention and ttt of obesity

5 Is it important to modify the regular obesity management for the mentally ill? Definitely yes Yet, Why???

6 Both obesity and common mental health disorders account for a significant proportion of the global burden of disease. PsychINFO 2005

7

8 Association Most recent systemic review of longitudinal studies: Bidirectional association between depression and obesity. Positive association between obesity and anxiety disorders. National Health and Nutritional examination Survey. Obesity(silver spring) 2010

9 55% of obese pts risk of developing depression over time. 58% of depressed pts risk of becoming obese. International Journal of obesity 2010;34;407-19

10 Many people with SMI experience poorer physical health compared to others in the general population reduced life expectancy of up to(25 yrs). Individuals with SMI have been shown to lead unhealthy lifestyles compared to others. Healthcare(Basel) Jun; 2(2):

11 Model for the mediator/ moderator relationship between obesity and common mental health disorders

12 The very serious complications of obesity if left without treatment.

13 Complications of Mental illness Lack of Education. Antisocial Attitudes. Antisocial Personality Pattern. Antisocial Friends and Peers. Substance Abuse. Family and/or Marital factors. Lack of personal Leisure Activities. Poor Employment History.

14 So, Obesity with mental illness must be viewed as 2 chronic illnesses that each requires long-term management.

15 Examples of mental disorders related to obesity 1. Bipolar disorders 2. Schizophrenia 3. Depression 4. Binge Eating Disorder (BED) 5. Anxiety of aging. 6. Neurodegenerative diseases 7. ADHD (Attention Deficit Hyperactivity Disorder) 8. Suicide

16 Aim of obesity management Classic Prevention of more weight gain. Weight loss. Weight loss maintenance. Special Preventing or delaying the onset of the mental disease. Improving treatment outcome. Preventing the complications. (Am Psychol Oct;66(7): doi: /a )

17 Preventing or delaying the onset of the mental disease. Over 50% of all Alzheimer's cases may be prevented through lifestyle changes.. Reducing important risk factors that increase vascular disorders: - Diabetes Mellitus - Dyslipidemia - Blood pressure Stroke Dementia

18 Improving treatment outcome of the mental disease Anxiety of aging Weight loss: - Enhances neurovascular functions. - Enhances vascular signaling markers and shifts metabolism. - Decelerates the rate of decline of cerebral blood flow in aging mice. - Preserves learning and long-term memory of aging mice. - Reduces anxiety of aging mice. Hebebrand,2009, Adolesc Psychiatr Clin N Am18:49-65

19 Improving the outcome of the mental disease ADHD (Attention Deficit Hyperactivity Disorder) The promotion of healthy eating and activity should form a part of secondary prevention and management strategies for children with disruptive behavior disorders. International Journal of Obesity (2012) 36, ; doi: /ijo ; published online 10 January 2012

20 When to start obesity management of the mentally ill patient? Once diagnosed.

21 Obesity Management Assessment Treatment Routine Specific Routine Specific

22 Assessment tools(routine) A. Direct Assessment: 1. Anthropometric measurements. 2. Biochemical methods. 3. Clinical assessment 4. Dietary intake B. Indirect Assessment: Use of Health statistics as: 1. Age-specific mortality rates. 2. Cause-specific morbidity and mortality. 3. Health service statistics

23 Assessment of psychological status (Specific) Self concept Eating disturbances Social problems Stress levels Current life situation. Sources of social support like family and friends.

24 Assessment of eating disorders Eating disorders: Anorexia Nervosa. Binge eating. Bulimia.

25 1-Anorexia Nervosa Refusal to maintain body weight over the minimum normal weight for age and height. Intense fear of gaining weight or becoming fat even though underweight. Disturbance in the way in which one s body weight, size or shape is experienced or the denial of the seriousness of low body weight. In females, absence of at least 3 consecutive menstrual cycles(1ry or 2ry amenorrhea).

26 2- Binge eating Episodes should have at least 3 of the following : Eating faster than usual. Eating past the point of fullness. Eating when not hungry. Eating alone or in secret. Feeling upset or guilty after overeating. Feeling Taken over or Driven as if by another person in respect of eating.

27 Extreme concern (abnormal) and distress about eating behavior. Binge eating at least 1 or 2 times weekly and at least 3 months duration. No purging strategies or excessive weight control methods like over exercising or fasting.

28 Unable to stop eating when full(usually after emotional stress). Binge continues until the urge of eating is gone, tension is reduced, satiation is reached to the point of pain or the person is interrupted. Binges are sometimes planned and become part of the daily routine. Feelings of shame, guilt, hopelessness, depression and anxiety following the binge.

29 3- Bulimia Recurrent and regular episodes of binge eating. Followed by purge ( vomiting, abusing laxatives) to flush out their digestive track.

30 The classic treatment of Obesity Diet Physical activity Behaviour modification Life style modification Pharmacotherapy Bioenteric Intragastric Balloon (BIB) Bariatric surgery

31 Research shows that people who participate in groups lose more weight than doing it alone. Research Support, N.I.H., Extramura.2013 April 25

32 Modified treatment of obesity with mental illness: 1- Diet: - Counseling attitude - Weight loss - Macro and micro nutrients content of the diet.

33 1)Counseling attitude Working with individuals and families. Discussion about history and concerns including weight management goals. Goal setting: - Specific. - Ambitious. Monitoring Feedback and reinforcement. Boosting the belief that the patient can do it. Incentives.

34 2)Weight loss Cutting down of portions while eating the same food. Then: healthier diet with support groups. Avoid restrictive diets that encourage rapid weight loss. Adopting new habits that foster a healthier lifestyle Not to attempt radical changes to the patient s diet or activity patterns.

35 3)Macro and micro nutrients content of the diet Omega 3 FA. Omega 6/omega 3 ratio Antioxidants intake(serotonin) Probiotics. Fruits and vegetables Processed foods and sugar Fibers Complex carbohydrates Mediterranean diet

36 Procedures with the Anorexic Anorexia Nervosa can not be treated unless the weight is stable. Engage the patient. Understand resistance. Re-establish healthy control with appropriate resources. Facilitate family therapy if possible.

37 Procedures with the obese-binge eater. Agree together on eating guidelines. Sufficient calories distributed throughout the day. No long gaps(prevent hunger to prevent binges).

38 No weight loss before healthy habits are well established. Use diaries to note trigger: times /patterns /feeling. Consider weight loss after about 3-6 months of binge-free eating before you can think of losing weight.

39 Procedures with the Bulimic Same as Binge eating + Explain that vomiting and laxative abuse turns the body into a fat-making machine. Information about the side effects of purging. Treat the vomiting. Come off laxatives very slowly, not all in one go. Reassurance. Explain the addictive nature of purging behaviors.

40 Modified management of obesity 2- Exercise : with mental illness: Regular exercise programs are possible in mentally ill patients. Exercise improves both the physical and mental health and well-being of individuals with schizophrenia. cochrane library12 May 2010

41 Modified management of obesity with mental illness: 3- Behaviour modification A behavioral weight-loss intervention significantly reduces weight over a period of 18 months in overweight and obese adults with serious mental illness. Given the epidemic of obesity and weight-related disease among persons with serious mental illness, findings support implementation of targeted behavioral weight-loss interventions in high-risk population. Journal Article; Multicenter Study; Randomized Controlled Trial; Research Support, N.I.H., Extramura.2013 April 25

42 Modified management of obesity 4- Pharmacotherapy: 1) Phentermine. 2) Qsymia. 3) Belviq. 4) Contrave. 5) Orlistat. 6) Saxenda. with mental illness:

43 1) Phentermine: XMental Disorder with Loss of Normal Personality & Reality.

44 4- Pharmacotherapy: 2)Qsymia: XMental Disorder with Loss of Normal Personality & Reality.

45 4- Pharmacotherapy: 3) Belviq: XMental disorders and mood swings.

46 4- Pharmacotherapy: 4) Contrave: XBulimia or anorexia nervosa, which increase the risk for seizure. XPatients undergoing an abrupt discontinuation of alcohol, Benzodiazepines, barbiturates and antiepileptic drugs.

47 4- Pharmacotherapy: 5) Orlistat: XAnorexia Nervosa, Bulimia.

48 4- Pharmacotherapy: 6) Saxenda: Warnings and Precautions Suicidal Behavior and Ideation In Saxenda clinical trials, 6 (0.2%) of 3384 Saxenda-treated patients and none of the 1941 placebotreated patients reported suicidal ideation; one of these Saxenda-treated patients attempted suicide. Patients treated with Saxenda should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior. Discontinue Saxenda in patients who experience suicidal thoughts or behaviors. Avoid Saxenda in patients with a history of suicidal attempts or active suicidal ideation.

49 5-BIB Absolutely Contraindicated: Psychiatric disorders

50 6- Bariatric surgeries Patients with psychiatric co-morbidities should not be excluded from the procedure if adequate post-operative support is provided. Int J Surg Case Rep 2014; 5(12): The bulk of evidence shows no relationship between psychiatric disease and total weight loss after bariatric surgery. Bauchowitz AU, Gonder-Frederick LA, Olbrisch ME et al (2005) Psychosocial evaluation of bariatric surgery candidate.

51 7-MAESTRO There are no specific contraindications for use of the MAESTRO 4000 Cardiac Ablation System.

52 So, Is any of the mentally ill patients should be excluded from obesity management? Definitely NO

53 Conclusion Obesity and mental illness are very interrelated. The relationship is bidirectional. Obesity and mental illness are serious chronic diseases necessitating long-term management. Obesity management should be a routine practice in the mentally ill patient as soon as diagnosis is established with no exclusion. Modifying the classic management of obesity is a must in MI patients in both assessment and treatment.

54 Thank You