Transcript Guidelines for Integrated Care (Psychiatric & Medical) In the Community Module II: Metabolic Syndrome.

Guidelines for Integrated Care
(Psychiatric & Medical)
In the Community
Module II:
Metabolic Syndrome
Objectives
1. 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 Insulin resistance as identified by
to venous or arterial thrombosis
type 2 diabetes, impaired fasting
which is the formation or presence of glucose or impaired glucose tolerance
a clot within a blood vessel)
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 antipsychotics, 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-style
 Irregular and inadequate
 Poor nutrition
sleep
 Lack of access to
adequate/coordinated
medical care
 Lack of access to nutrition
and exercise programs
 Overeating
 Smoking (44% of all
cigarettes smoked in the
US)
 Substance abuse
 Some medications
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 Factors
Besides 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; SSRI
 Infrequent, 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 health
 Exercise goal: 30 minutes/day (not necessarily all at
one time)
 Walking 10 minutes 3 X per day
 Chair exercises
 Key—combined exercise with cutting calories
 Structured and gradual
 Techniques for attitude change regarding the role of food, etc.
 Strategies to increase social support
Stages of Change
Stage
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 Strategies
 Self 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 therapymay need other medication to assist
 There may be provider barriers to overcome:
 Beliefs that persons with mental illness cannot live healthy lifestyles 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
Personal/
Family
history
x
Wt/BMI
x
Waist
Measure
x
Blood
Pressure
x
x
Fasting
Glucose
x
x
Fasting
Lipid
Profile
x
x
12 mths 5 yrs
x
x
x
x
x
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 Facts
MYTH
To quit smoking all you need is will
power
FACT
Only 3% of people who quit “cold
turkey” succeed
People with mental illness are more
Studies show that nicotine
addicted to nicotine and are unable to replacement therapy and
quit
psychotherapies are effective
Light or low tar cigarettes are safer
No such thing as safe smoking
“Natural” tobacco and clove cigarettes They increase your risk of cancer,
are healthier
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’s
 RELEVANCE: 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 Model
 ASK: 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?