Guidelines for Integrated Care (Psychiatric & Medical)

In the Community

Module II: Metabolic Syndrome

Objectives1. Identify patients in their caseload who have or are at risk for

developing metabolic syndrome.

2. Understand the implications of identifying and supporting the management of metabolic syndrome through reduction in obesity and tobacco use.  

3. Appreciate the concept of stages of change needed to support life-style changes for prevention/reduction of obesity and tobacco use, including use of tools for self-care, education and referral.

4. Assist persons at risk for or diagnosed with metabolic syndrome to engage in activities that reduce the impact of obesity and smoking in their recovery.

 

Overarching Principle:Overall Health is Essential to

Mental Health

Recovery Includes Mental Health

What is Metabolic Syndrome?A group of conditions/factors that increase risks of

heart disease and other acute or chronic medical conditions. All of the conditions outlined below put the person at risk for cardiovascular disease and premature death.

Quiz: What does this have to do with Metabolic Syndrome?

Hint…..

Diagnosis of Metabolic Syndrome = 3 or more of the following:

Prothrombotic state (a predisposition to venous or arterial thrombosis which is the formation or presence of a clot within a blood vessel)

Insulin resistance as identified by type 2 diabetes, impaired fasting glucose or impaired glucose tolerance

Abdominal obesity (picture in next slide)

Body mass index over that recommended for your height

Elevated triglycerides (normal<150; elevated, cause for concern >200)

Elevated fasting blood glucose (>100)

Low HDL (“good”) cholesterol (men<40; women<50 is problematic)

High blood pressure (>120/80)

Abdominal Obesity

At Risk for Metabolic Syndrome Weight gain/obesity (central obesity – waist line greater than 40 inches in men and 35 inches in women)

Taking second generation anti-psychotics, and other medications that include some mood stabilizers: Abilify, Clozaril, Zyprexa, Invega, Seroquel, Geodon, etc.

BMI > 25 BMI= (Wt / h*h)*703

High LDL (“bad cholesterol”) and Low HDL (“good cholesterol”)

High blood pressure (above 120/80)

Ethnicity-African or Mexican American

Family history of diabetes Increased age

Tobacco use Heavy alcohol use

Stress Sedentary life-style

High fat diet

Prevention and Treatment of Metabolic Syndrome

Lifestyle management – a program of weight loss and exercise

Tobacco cessation

Limiting alcohol consumption

Changes in dietary habits, including eating a heart-healthy diet

Medication to help lower blood pressure, improve insulin metabolism, improve cholesterol and increase weight loss

Weight-loss surgery (bariatric surgery) to treat morbid obesity in individuals for whom conservative measures have failed.

Why is metabolic syndrome a relevant health issue to consumers?Up to 83% of persons with serious mental illness in the

US are overweight or obese.

Persons with mental illnesses, including schizophrenia and mood disorders, have a higher rate of metabolic syndrome compared with the general population:

24% rate for US Adults

60% rate for persons with schizophrenia

75% rate for Hispanics with mood disorder

Additional Environmental & Personal Factors that Lead to Cardiac Events

Sedentary life-stylePoor nutritionOvereatingSmoking (44% of all

cigarettes smoked in the US)

Substance abuseSome medications

Irregular and inadequate sleep

Lack of access to adequate/coordinated medical care

Lack of access to nutrition and exercise programs

Goals of life-style changes: Lower Risk for Cardiovascular Disease

Blood cholesterol

10% decrease = 30% decrease in coronary heart disease

Cigarette smoking cessation = 50-70% decrease in coronary heart disease

Maintenance of ideal body weight (BMI = 25) 35-55% decrease in coronary heart disease

High blood pressure (> 140 systolic or 90 diastolic)4-6 mm Hg decrease 16% decrease in coronary heart

disease and 42% decrease in stroke

Two Preventable Risk FactorsBesides monitoring and intervening on Diabetes Mellitus (Previous Module), two other modifiable risk factors:

Obesity

Smoking

Obesity

Common Misconceptions about Persons with Mental Illness and

Obesity:Contrary to popular belief, research shows that person

with mental illness are: Self-conscious about their weight Interested in reducing their weight Able to adopt healthier choices to improve their

health

(Vreeland, 2007)

Barriers to Addressing Obesity in Persons with Mental Illness

Psychiatric disease processes, e.g. Negative symptoms in schizophrenia, depressive symptoms

Treatment processes:Certain medications: Atypical Antipsychotics; SSRIInfrequent, or no contact with primary care providers

Barriers to Addressing Obesity in Persons with Mental Illness

Culture expectations for persons with mental illnesses tend to support less activity e.g. getting a ride, taking the bus, sitting in groups

Providers may feel that addressing obesity issues may interfere with people taking their medications

Community mental health providers have insufficient training and time to work on weight and other health issues

Barriers to Addressing Obesity in Persons with Mental Illness

Fragmented medical care

Low socio-economic status

Attitude of Caregivers: Perhaps eating is one of few pleasures left consumers they have

A Little Weight Loss Makes A Big Difference:

Research shows that helping people make choices that result in modest weight loss (2-6% of body weight) is associated with:

Decrease in high blood pressure by 20-40%

Decrease in incidence of diabetes by 30-60%

Decrease in cardiac events by 30-40%

2% off a 300 pound person = 6 pounds 4% off a 300 pound person = 12 pounds 6% off a 300 pound person = 18 pounds

A Little Weight Loss Makes A Big Difference:

4-5% weight loss can lower or eliminate the need for antihypertensive medications in adults and elderly

6-7% weight loss improves metabolic syndrome by decreasing LDL

10% weight loss can reduce lifetime risk for heart disease by 4%

A Little Weight Loss Makes A Big Difference:

Reduced calories support weight loss, increased physical activity improves physical healthExercise goal: 30 minutes/day (not necessarily all at

one time)Walking 10 minutes 3 X per dayChair exercises

Key—combined exercise with cutting caloriesStructured and gradualTechniques for attitude change regarding the role of food, etc.Strategies to increase social support

Stages of ChangeStage Definition Goal of Intervention

Precontemplation Unaware of need

To change behavior

Increased awareness

Contemplation Thinking about change Motivate-tip the balance

Preparation Making a plan Concrete action plan

Action Implementing plan Assist with feedback, support

Maintenance Continuation of desirable actions

Reminders, avoiding slips, what to do if/when slips occur

Behavioral StrategiesSelf monitoring (record diet and activity)

Goal setting

Stimulus control

Behavioral substitution (portion control, slow eating, life-style activity

Problem solving

Cognitive restructuring

Relapse management

Nutrition education

Small Steps Work for an Action Plan:

Consider this…If a person gains more that 5% of initial weight or

develops worsening blood sugar or LDL during therapy-may need other medication to assist

There may be provider barriers to overcome:Beliefs that persons with mental illness cannot live healthy life-

styles because: Obesity is related to the persons mental illness People with mental illness lack motivation to improve their health

and well-being

(NASMHPD 2008)

American Diabetes Association Recommendation

Monitoring Protocols for Persons on Second Generation Antipsychotics

Start 4 wks 8 wks 12 wks 3 mths 12 mths 5 yrs

Personal/

Family history

x x

Wt/BMI x x x x x

Waist Measure

x x

Blood Pressure

x x x

Fasting Glucose

x x

Fasting Lipid Profile

x x x

NASMHPD and SAMHSA Standards of Care Recommendation:

Educational/behavioral interventions for weight management

If possible switch to low weight gain antipsychotics when weight increases

Medical/surgical treatment (may not be available for people with mental illness)

NASMHPD = National Association of State Mental Health Program Directors SAMHSA = Substance Abuse and Mental Health Services Administration

Additional Recommendations• Promote opportunities for health care providers, including

peer specialists to teach healthy life styles through state vocational-rehabilitation agencies (such as COVA in Columbus, Ohio)

• Adopt American Diabetes Association and American Psychiatric Association second generation antipsychotics (medication) monitoring

• Collaboration between State Health Authority and Mental Health Authority

• Monitor consumers with diabetes and metabolic syndrome in community mental health centers

• Link with public health and community-based programs in diabetes, cardiovascular disease and health weight management

Smoking Kills!

Some Stats on Mental Illness and Smoking Rates of smoking are 2-4 x higher among people with

psychiatric disorders and substance use disorders

Nearly 41% of current smokers report having a mental health diagnosis in the last month

60% of current smokers report a past or current history of a mental health diagnosis sometime in their life time.

Mental Illness and Smoking When seeking mental health treatment heavy

smokers report substantially poorer well-being, greater symptom burden, and more functional disability compared to non-smokers

Public mental health clients have a higher relative risk of death than the general population due, in part, to tobacco use.

Mental Illness and Smoking Potential genetic base: Shared genetic factors with

depression, schizophrenia

Self-medication-manage adverse events related to medication/reduce symptoms

Trauma: Link history of grief and PTSD with increased use

Social: Link to limited education, poverty, unemployment; peers, and the mental health system where tobacco use is generally tolerated/not seen as a health issue

Smoking Cessation Myths and FactsMYTH FACT

To quit smoking all you need is will power

Only 3% of people who quit “cold turkey” succeed

People with mental illness are more addicted to nicotine and are unable to quit

Studies show that nicotine replacement therapy and psychotherapies are effective

Light or low tar cigarettes are safer No such thing as safe smoking

“Natural” tobacco and clove cigarettes are healthier

They increase your risk of cancer, heart disease and emphysema

People with mental illness should smoke to reduce symptoms

There are more effective ways that do not hurt your health

What can I do? Help people realize that:

Reduction often happens before cessation. (Stages of Change Model)

Measuring amount smoked helps with decreasing amount

Everyone needs support—Peer support is especially effective

Stress reduction techniques (e.g. substitute behaviors)

What can I do? Standardized assessment of smoking status and interest

in stopping

Include nicotine dependence and withdrawal on Axis I

Develop protocols for and access to pharmacotherapy

Help for staff who smoke (Mental health providers are significantly more likely to smoke

that other health care providers)

De-normalize tobacco use: The 5 R’sRELEVANCE: Relevant to the Person.

“Johnny, I noticed that you smoke. How is that going to help you run that race?”

RISKS: Of continued smoking• “… do you know the risks of smoking?”

REWARDS: What can be gained• “… what are some benefits to quitting smoking?”

ROADBLOCKS: Barriers to quitting• “… so what’s stopping you from quitting?”

REPETITION: Reinforce motivational message at every contact

Intervene: The 5 A’s ModelASK: Identify and document tobacco use

ADVISE: Key Message Point => Quitting smoking is the most important thing you can do for your health

ASSESS: Willingness to make an attempt to stop—give it a try

ASSIST: For those who are ready, provide or refer to counseling and medication

ARRANGE: Follow up supportive contacts

Look at Your Purple Bookmark!

Case Study 1

Mary Beth is a 37 year old Caucasian female who is has a diagnosis of bipolar disorder. She has been taking Depakote and Prozac. She recently started taking Seroquel to assist with stabilizing her mood and helping her sleep.

Her primary healthcare provider has been checking her weight and waist circumference every month. Over the last 3 months, her waist circumference has increased 10 inches (42 to 52 inches) and her weight has increased by 60 lbs (240-300 lbs at 5’4”).

She states she has been under a lot of stress lately since her son was incarcerated and hasn’t been sticking to her dietary plan. She notes that she does not have “time to cook” and has been eating at her neighborhood Rally’s hamburger place for her meals. She orders either the #4 or #7 meals.

Questions:• What are important assessment questions for Mary Beth?• What are some of the risk factors that predispose Mary Beth for

metabolic syndrome?• You are a CPST worker or a counselor who is preparing for an

appointment with Mary Beth. Armed with the current information about her weight changes, how would you plan to approach Mary Beth?

• What if you realize that Mary Beth is embarrassed with her weight-gain? She has been feeling very depressed but does not feel that she can change her lifestyle. Use the Stages of Change Model to plan your conversation with Mary Beth. What are some things you plan to talk with her about? How do you help her move from one stage to another stage?

Case Study 2 James is a 45 year old African American male with a diagnosis of

schizophrenia. He smokes approximately 1 pack of cigarettes per day for the last 25 years. He has stopped taking his medication since he was laid off six months ago. He is 5’6” and 178lbs.

Since he was laid off, he has been picking up cigarette butts off the ground and smoking them. His “smoker’s cough” has been more pronounced, expelling deposits, especially in the morning. According to his mental status exam, his insight and judgment is “fair to low”. Motivation for change is low. He has very low expectation that things will improve for him.

Recently, at a health fair his CPST worker took him to, his blood sugar was 187. His blood pressure was 170/92. His LDL cholesterol was 200 and his HDL cholesterol was 30.

Questions:1. What are some of the risk factors James has for metabolic

syndrome?

2. You are a CPST worker or counselor for James, and have just attended a workshop on Metabolic Syndrome. You want to help James look at how his smoking is affecting his health, but you know James is not really interested in dealing with it. He says that smoking is one of the two things that give him pleasure. Plan your conversation with him. Anticipate his counter-arguments. Use the 5As and 5Rs approach.

3. What else are you concerned about? What can you do to help James out?