DID YOU KNOW... Addressing Risk Factors for Cardiovascular Disease & Metabolic Syndrome of individuals with Serious Mental Illness through Exercise, nutrition and case-management support

Prepared by John. A. Sawdon M.Sc. Public Education & Special Projects Director,
Cardiac Health Foundation of Canada, July 2018

Introduction

Individuals with a serious mental illness including Bipolar Disorder, Schizophrenia and major Depressive disorder experience higher morbidity and mortality rates from cardiovascular disease and metabolic syndrome than the general population. A meta-analytic study of serious mental illness and cardiovascular disease involving 113million people from the general population and 3.2 million individuals with severe mental illness that was conducted across 16 countries found that 11.8 % of people with schizophrenia , 11.7% with major depression and 8.7% with bipolar disorder had cardiovascular disease.1 This same study found that 85% of this population were at higher risk of dying from cardiovascular disease with life expectancy being 15 to 20 years shorter than the general population. Many factors contribute to this including psychotropic medications, metabolic syndrome, high cholesterol, hypertriglyceridemia, lifestyle including tobacco use and substance abuse, physical inactivity and diet.

Antipyschotics are associated with inducing weight gain, worsening lipid profiles and blood glucose levels. Antipyschotic treatment are associated with increases in low density lipoprotein, cholesterol, tryglycerides, decreased HDL cholesterol and Lithium in particular is associated with weight gain and adversely affects glucose metabolism. This is compounded by nutrition risk that is a contributor to cardiovascular disease and metabolic syndrome. This includes eating meals at irregular times, poor eating habits, fewer meals, difficulty in both obtaining food and cooking food along with high caloric intake. Diets high in sugars, calories and fats contribute to both of these diseases.

Researchers also found Americans with severe mental illness were twice as likely to develop Type 2 Diabetes. Researchers studied 15,000 patients with severe mental illness and found 28% had type 2 diabetes compared to 12% in the general population. This study found Hispanic prevalency rates were 37%, Blacks were 36%, Asians were 31% and Whites were 25%. Researchers also found that 50% of individuals with severe mental illness had prediabetes.2)


In addressing the type of programs that might be effective in reducing the risk factors that contribute to cardiovascular disease and metabolic syndrome, we reviewed the literature on exercise, lifestyle change and casemanagment to see what has been effective. The majority of programs that have been designed to reduce risk factors for CVD and Metabolic Syndrome include smoking cessation, symptom and medication management, physical exercise including walking, nutrition and healthy eating, motivational counselling and goal setting. Most of these programs including cardiovascular rehabilitation do not include persons with serious mental illness. The first such attempts within the literature were aimed at veterans who either had a serious mental illness or were suffering from Post Traumatic Stress Disorder.

A summary of the programs reviewed and their findings is presented below:

  • The Achieve Program: Achieving Healthy Lifestyles in Psychiatric Rehabilitation was a randomized trial with 10 sites across Maryland that was supervised by John Hopkins Institutional Review Board. It included individual and group weight management sessions, group activity classes, a 6 month intervention phase and a 12 month maintenance phase. Kitchen staff were trained to offer nutrition programs on site. Incorporated concepts from social cognitive theory, behavioural self management, and relapse prevention. The curriculum tailored to address neurocognitive deficits. Didactic interventions and narrow skill focus along with repetitive and rehearsal of behavioural skills was implemented. Signs, cues and labels that sequenced behaviour were used. At a minimum the following components were included: -reducing caloric intake by avoiding sugar including sugar drinks and junk food; eating 5 fruits and vegetables a day; choosing smart portions and snacks,increasing calori expenditure by participating 3 times a week in moderate intensity aerobic exercise- initial routine 10 minute warm up, 10 minute moderate intensity, 5 minute cool down; later 5minute warm up, 40 minute moderate intensity, 5 minute cool down; each person completed a tracker and were rewarded with gift cards and track clothing as motivational aides.
    There were frequent and extended contacts along with social support. The program included goal setting, self negotiation, problem solving and new behavioural options. The program was aimed at men and women over 18 years with a chronic serious mental illness who attended day rehabilitation programs and can participate two times a week. A community meeting with Individuals was undertaken to determine capacity to consent and those deemed to have capacity were both admitted to program and asked to sign a two page consent form. The focus was on weight loss at 6 months and 18 months with outcomes based on physical fitness by submaximal bicycle ergometer, waist circumference, blood pressure, lipids, Framingham CV risk Scale, health status with SF-12 and Depression with CES-D.
    A comparison control group was used that received information on nutrition and physical exercise along with quarterly meetings to reinforce messages Two types of costs were also undertaken, direct cost per participant and costs associated over ten years on reduction of risk for cardiovascular disease. Before interpreting results the reader should be aware of the benefits of weight loss; 5 lbs of weight loss equal to reduction in systolic blood pressure by ~3mHG. 5lbs weight loss reduces stroke by 6% to 8%, reduces cardiovascular mortality by 4 to 5%, reduces incident hypertension by 20%.
    Results of Achieve: at 18 months lost 7lbs, 38% of intervention group compared to 23% control lost 5% of body weight and 18% of Intervention group lost 10% body weight compared to 7% of control. Long term costing has not been completed.
  • SMAHRT ( The Self Management Program Addressing Heart Risk Trial) program ran from April 2008 to May 2010 with follow up until May 2012 was targeted to individuals with Bipolar Disorder. The focus and intensity of program involved four 2 hour sessions per week based on life goals psychotherapy program that was enhanced to include the management of CVD risk factors within context of bipolar disorder. There was a twelve mnonth follow up casemanagement component that tracked symptoms, medical needs and progress on health behaviour change plans. If patients had a mental health or medical issue, contact with the coordinator for in person appointments occurred. Ongoing information sharing on weight, blood pressure, and lab bloodwork results were also shared. A comparison group was also recruited and convened. The Enhanced Usual Care group received follow up mailings on wellness topics. Their mental health specialist and medical specialist also received guideline information. This group also took part in follow up casemanagment and group therapy sessions focused on mental health treatment. Data was collected on blood pressure, cholesterol, physical quality of life, and most common risk factors for bipolar disorder. A 12 item short form health survey, the Framingham risk score, plus weight, waist circumference, lipoprotein both HDL and LDL-C, world health organization disability assessment- a 12 item survey on selfcare, mobility, cognition, social functioning and role functioning, a Internal State Scale – a 16 item assessment of depression and manic symptoms. Results LGCC group 58 individuals and Enhanced Ususal Care group was 60 individuals with 62% having Bipolar ll, 59% had 10 year CVD risk and 97% were prescribed hypertension medications. LGCC versus enhanced ususal care had positive blood pressure results by 4 points, reduced stroke mortality by 14%, reduced CVD mortality by 9% and reduced total mortality by 7%.The LGCC group had reduced manic symptoms and quality of life scores were 30% less than Average Americans. 70% of the cost of bipolar disorder attributed to general medical care and CVD was the highest cause of mortality.
  • Aspire Trial – VA Behavioural Weight loss intervention Trial September 2016 . This was a VA trial comparing ASPIRE group in person, ASPIRE telephone and MOVE program on Obesity. The target group are men and women with BMI over 30 along with one obesity related chronic health condition. ASPIRE Group In person- encourages participants to set individual goals related to realities of their lives. Goals are established to achieve modest success in physical activity, modified eating patterns, log books are provided to track food intake and pedometers to track daily steps. Diet choices are guided by StopLight Food Guide . Groups are led by Lifestyle coaches who promote self-efficiency and mastery of lifestyle habits. Coaches receive three day training plus booster sessions every six months. ASPIRE is based on social cognitive theory, problem solving therapy and motivational counselling. Group size is 8 particpants. The first three months meet once a week for 90 minutes, for next six months meet bi-weekly for 60 minutes and for next three months meet once monthly for 60 minutes for a total of 33 hours. MOVE is a group format whereby the group is open and individuals can join at any time. Handouts are given on health behaviour change topics, counselling and behaviour modification. Psycho educational topics are discussed with an interdisplinary team comprised of dietitian, psychologist, physical therapist. Pedometers and self monitoring logs utilized. The group meets for 90 minutes weekly from 1 to 3 months. This is followed by Maintenance phase of 4 to 12 months on a drop in follow up group basis. Treatment dose is 22 to 35 hours with measures at baseline, then in 3 months and 12 months. There were 481 veterans ( men 409, women 72) with 160 in ASPIRE Group, 162 in ASPIRE Telephone Support and 159 in MOVE group. 409 individuals were followed up for 12 months . Women did not lose weight at three months but did at 12 months. Men lost weight with each measurement. At twelve months the ASPIRE Group was superior in terms of weight loss and confidence in coaches.
  • Minding Our Bodies was developed by Canadian Mental Health Association of Ontario in partnership with Mood Disorders Association of Ontario, Nutrition Resource Centre, YMCA Ontario and York University from 2008 to 2013 . The research behind this initiative was based on green exercise, Walk England and research on how mental illness affects a person’s nutrition choices, their commitment to exercise and adherence to medical therapies. People with serious mental illness are at high risk of chronic physical conditions such as diabetes and cardiovascular disease which are associated with sedentary behaviours, poor nutrition and reduced access to primary healthcare. The goal of this project was to promote physical activity and healthy eating for people with serious mental illness. The project was launched in three phases with the third phase witnessing the delivery of full day knowledge exchange forums designed to share lessons from the pilot phases, to present successful models, facilitate networking and partner ship building, introduce particpants to the toolkit created and to foster new local programs. Minding our Bodies supported the launch of 32 programs in communities across Ontario. In phase one and two training was delivered in person and in phase three training was delivered via teleconference and webinar. During Phase two Mood Disorders of Ontario developed BOOST YOUR MOOD designed to be delivered by a Dietition, a fitness instructor and a mental health peer facilitator. This was expanded in phase three of the project and delivered as train the trainer in Hamilton, Ottawa and Thunder Bay.CMHA then worked with Dietitions Canada to deliver two full day workshops for dietetic interns to improve mental health literacy. In terms of evaluation CMHA worked to implement an evaluation course through York Unviersity for people running courses throughout the province. CMHA also worked with Dietitions of Canada on a Nutrion and Mental Health paper that was delivered at the National Conference and provided to Nutrition Faculties in raising awareness of mental illness, chronic disease and nutrition. This intiative led to MOOD Walks which is a province wide intiative that promotes physical activity in nature or green exercise in partnership with Hike Ontario, Conservation Ontario, The Centre for Innovation In Campus Mental Health and the Ontario Council of Agencies Serving Immigrants Mood Walks. While this program addresses depression and social exclusion , it has not been evaluated in terms of impact on chronic disease for individuals with severe mental illness including major depression, schizophrenia and bipolar disorder.

The Challenges of providing an evidence based cardiovascular rehabilitation program is compounded by characteristics of each illness. For those with bipolar disorder the mania stage means the person will have above normal energy, may not eat nor sleep and may become irritable. In the depression phase the individual will have difficulty engaging in exercise and interpersonal interaction. The design of any program will need to take into account the impact of psychotropic medication on weight gain, blood glucose levels and insulin resistance. The ACHIEVE program with built in coaching support may hold the best approach in reducing risk levels for chronic disease among those with a severe mental illness. In HF ACTION (Heart Failure: A controlled Trial; Investigating outocmes of Exercise Training) which includes exercise training along with self care counseling has several components that should be considered for any cardiovascular rehab program for individuals with severe mental illness.3 We know that a higher level of fitness for those with depression is associated with a 56% lower risk of death from CVD. In terms of addressing the nutrition aspect. 4 The Health Partners Plan 5 paid for 560,000 meals to be delivered to 2100 of its members with chronic conditions such as heart disease, diabetes and kidney failure. This type of direct intervention reduces complications and consequently hospitalizations and potentially mortality. This could also be considered in addressing the idiosyncrasies of various severe mental health illnesses.

In summary I have attempted to illustrate what works in addressing the high rates of cardiovascular and diabetic disease in individuals with severe mental illness . Currently Sunnybrook Hospital and the Centre for Mental Health and Addiction in Toronto are researching various approaches for addressing risk factors for cardiovascular disease for those with a severe mental illness. Both of these Centres should be consulted on the design of a comprehensive cardiovascular rehabilitation program for this target population.

If you have questions about this topic or would like us to address an area related to cardiovascular disease, please let us know by sending an email to jsawdon@cardiachealth.ca. We hope this particular article has been helpful for you.

References:

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The articles, on the Cardiac Health Foundation of Canada website, are presented with the understanding that the Foundation is providing information only and not rendering medical advice. Please check with your family physician, specialist or health care professional before implementing any of the ideas expressed in these articles.