Through a program that teaches simple nutrition messages and involves both counseling and regular exercise classes, people with serious mental illness can make healthy behavioral changes and achieve significant weight loss, according to new Johns Hopkins research.
These weight loss amounts were similar to those in other successful programs studied with subjects in the general population — studies that specifically excluded people with serious mental illnesses, the researchers say.
Results of the new research, believed to be the first large study of its kind to involve people with schizophrenia, bipolar disorder or major depression, suggest that a population many consider to be unable to engage in a behavior management program can make substantial lifestyle changes to improve their health. People with serious mental illness often are overweight or obese and have mortality rates two to three times higher than that of the general population, primarily from obesity-related conditions. Many are sedentary and take several psychotropic medications, which include weight gain as a side effect.
Results of the research are being published online March 21 in the New England Journal of Medicine and presented that day at the American Heart Association's Epidemiology and Prevention/Nutrition, Physical Activity and Metabolism 2013 Scientific Sessions (EPI/NPAM).
"We sought to dispel the perception that lifestyle programs don't work in this population," says study leader Gail L. Daumit, M.D., M.H.S., an associate professor of general internal medicine at the Johns Hopkins University School of Medicine. "There's this really important need to find ways to help this population be healthier and lose weight. We brought a weight-loss program to them, tailored to the needs of people with serious mental illness. And we were successful."
Known as ACHIEVE (Randomized Trial of Achieving Healthy Lifestyles in Psychiatric Rehabilitation), the study enrolled 291 overweight or obese patients with serious mental illness. Some 144 were randomly placed in an intervention group, while 147 made up the control group. The intervention took place at 10 Baltimore area outpatient psychiatric rehabilitation day facilities that already offered vocational and skills training, case management and other services for people with mental illness not well enough to work full time.
The researchers added a schedule of regular group and individual weight-management sessions, thrice-weekly exercise classes and a weekly weigh-in for the first six months of the trial. The sessions and weigh-ins continued, though less frequently, for the following year, though the exercise class schedule remained the same.
At the 18-month point, on average, the intervention group lost seven more pounds than the control group. Nearly 38 percent of the intervention group lost 5 percent or more of their initial weight, as compared with 23 percent of the control group. More than 18 percent of those in the intervention arm of the study lost more than 10 percent of their body weight after 18 months, compared with 7 percent in the control group.
Participants lost more weight as the intervention went on. This suggests it took a while to make behavioral change, but once these modifications took hold, the changes yielded positive results, Daumit says.
Of the people in the study, 50 percent had schizophrenia, 22 percent had bipolar disorder and 12 percent major depression. Many with serious mental illness, particularly schizophrenia, have impairments in memory and executive function, as well as residual psychiatric symptoms that impede learning and adoption of new behaviors.
What the study suggested, Daumit says, is that tailored programs can overcome these impediments.
The average number of psychotropic medications study participants took was three; the medications, often required for long-term symptom control, are known to cause weight gain in part by stimulating appetites and increased eating.
Instead of asking participants to keep detailed food logs and counting every calorie they consume — a practice common to other weight-loss programs — Daumit's program instead focused on relatively simple messages and goals, she says. They were encouraged to avoid junk food and sugary beverages, monitor portion sizes and include more fruits and vegetables in their diet. They had regular exercise at the rehabilitation facilities as part of the study, and were encouraged to exercise 30 minutes on other days, too.
Daumit says she thinks the weight-loss program could be adopted by other psychiatric rehabilitation facilities.
"This population is often stigmatized," she says. "This study's findings should help people think differently about people with serious mental illness. Our results provide clear evidence that this population can make healthy lifestyle changes and achieve weight loss."
The research was funded by a grant from the National Institutes of Health's National Institute of Mental Health (R01 MH080964).
Other Johns Hopkins researchers involved in the study include Nae-Yuh Wang, Ph.D.; Arlene Dalcin, R.D.; Gerald J. Jerome, Ph.D.; Kevin D. Frick, Ph.D.; Airong Yu, M.S.; Joseph V. Gennusa III, Ph.D., R.D., L.D.N.; Meghan Oefinger; Rosa M. Crum, M.D., M.H.S.; Jeanne Charelston, R.N.; Eliseo Guallar, M.D., Dr.PH., M.P.H.; Richard W. Goldberg, Ph.D.; Leslie M. Campbell; and Lawrence J. Appel, M.D., M.P.H.
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