Obesity

Obesity is a major problem nationwide and even more prevalent among people with psychiatric disabilities. This study examined the efficacy of a psychiatric rehabilitation weight loss program. Twenty-one individuals participated in the 12-week intervention. Another 15 individuals served as matched controls. Results indicate the intervention group improved more than the control group for weight, body mass index, waist circumference and physical activity. The intervention group lost 2.7 kg (6 lbs) and the control group gained 0.5 kg (1 lb). A weight loss program incorporating psychiatric rehabilitation principles was effective for people with psychiatric disabilities at a community based program.

Background

Healthy People 2010 lists overweight and obesity as a Leading Health Indicator and estimates that over half the adults in the United States are affected by this concern (U.S. Department of Health and Human Services, 2000). Obesity is a chronic disorder related to many physical conditions including hypertension, high cholesterol, diabetes, heart disease, stroke, osteoarthritis, sleep apnea, and certain cancers. In addition, obesity contributes to social stigma.

Individuals with psychiatric disabilities are more vulnerable to weight gain than the general public due to several risk factors. Obesity is more prevalent among individuals with lower incomes (U.S. Department of Health and Human Services, 2000), and most people with serious mental illness live below the poverty line. People with psychiatric disabilities have limited access to health care and are less likely to report physical symptoms to their health provider (Dixon, Postrado, Delahanty, Fischer, & Lehman, 1999; Jeste, Gladsjo, Lindamer, & Lacro, 1996). Another risk for obesity is poor health behaviors. Two studies indicate people with schizophrenia rarely exercise and have diets high in fat and low in fiber (Holmberg & Kane, 1999; Brown, Birtwistle, Roe, & Thompson, 1999). Another study finds, individuals with schizophrenia eat more volume of food (24 hour recall) than the general population (Strassnig, Brar, & Ganguli, 2003). Likewise individuals with bipolar disorder have an increased risk for weight gain and obesity compared to the general public (reviewed by Keck & McElroy, 2003).

Medications to treat people with psychiatric disabilities have come under scrutiny for contributing to weight gain (Allison et al., 1999). Growing concern about the association of obesity and diabetes, along with inadequate preventive health care for people with psychiatric disabilities, has led to a consensus report advocating baseline and follow-up screening (ADA, APA, AACE & NAASO, 2004). Since the risk for Type Il diabetes in schizophrenia is double the general population (USD-HHS, 2000), increased weight secondary to medication compounds their vulnerability.

Although health promotion programs have become more prevalent for the general population, people with serious mental illness have for the most part been neglected in these efforts (Phelan, Stradins, & Morrison, 2001). Pharmacological interventions, Orlistat and Sibutramine, combined with low calorie diets and life style modification produce greater weight loss than placebo in the general population (Leung, Neil, Chan, STomlinson, 2003). These and other pharmacological agents are less promising in individuals with schizophrenia where they have shown inconsistent results (Werneke, Taylor, & Sanders, 2002; Faulkner, Soundy, & Lloyd, 2003). In addition, pharmacological interventions are problematic for individuals with psychiatric disabilities. Commonly prescribed anti-obesity agents add side effects (e.g. gastrointestinal, dry mouth and insomnia) that exacerbate existing side effects from antipsychotic medications, increase the possibility of drug-drug interactions and offer no long-term solution to weight control that can decrease morbidity for diabetes, endocrine, cardiovascular and muscular skeletal disorders.

Studies of behavioral weight reduction programs (primarily in-patient settings) for people with psychiatric disabilities using dietary reduction and behavior modification indicate modest weight loss is possible (as reviewed in Faulkner, 2003). For example, in a small study using the Weight Watchers program, Ball, Coons and Buchanan (2001) found that men but not women lost weight. Littrell, Petty, Hilligoss, Peabody, and Johnson (2003) found that individuals with schizophrenia who were randomly assigned to a 16week program that focused on nutrition, wellness and exercise did not lose weight but gained significantly less weight than individuals receiving usual care. Weight control was sustained in the 6-month follow-up. In a 12-week intensive weight reduction program consisting of two weekly group sessions and a weekly individual session, individuals with schizophrenia lost significantly more weight and significantly lowered their BMI compared to a control group (Vreeland et al., 2003). The program used motivational counseling and behavioral interventions. These studies show that weight control and weight loss is challenging for people with psychiatric disabilities but can be achieved with teaching and behavior interventions. However all of these studies were conducted in in-patient or partial hospitalization settings. Few studies target community living individuals with psychiatric disabilities where investigators have less control of the environment, food intake and physical activity engagement. The purpose of this study was to examine the efficacy of a community-based weight loss program for people with psychiatric disabilities that incorporated evidence-based weight reduction strategies and psychiatric rehabilitation principles.

Methods

Participants

Fifty-nine participants were initially recruited for the study from a local community support program for people with psychiatric disabilities via posters, announcements at consumer meetings, and case managers. For recruitment purposes, the intervention program was offered twice and the data were combined. No randomization procedures were applied as individuals were initially recruited to participate in the intervention. Control participants were recruited following the initiation of the intervention program and were matched by diagnosis, gender, and age. Inclusion criteria included diagnosis of a serious mental illness, BMI ЎЭ 25, and age 21 to 65. Individuals with mental retardation or physical conditions that prevented participation in physical activity were excluded. Twenty-one completed the study as intervention participants, and 15 completed the study as control participants (see Table 1 for demographics). The 23 non-completers