Individual dietetic consultations in first episode psychosis: a novel intervention to reduce cardiometabolic risk

Dietary intake, physical activity and sedentary behaviour patterns in a sample with established psychosis and associations with mental health symptomatology

BACKGROUND

People with psychosis experience cardiometabolic comorbidities, including metabolic syndrome, coronary heart disease and diabetes. These physical comorbidities have been linked to diet, inactivity and the effects of the illness itself, including disorganisation, impairments in global function and amotivation associated with negative symptoms of schizophrenia or co-morbid depression.

METHODS

We aimed to describe the dietary intake, physical activity (PA) and sedentary behaviour patterns of a sample of patients with established psychosis participating in the Improving Physical Health and Reducing Substance Use in Severe Mental Illness (IMPaCT) randomised controlled trial, and to explore the relationship between these lifestyle factors and mental health symptomatology.

RESULTS

A majority of participants had poor dietary quality, low in fruit and vegetables and high in discretionary foods. Only 29.3% completed ⩾150 min of moderate and/or vigorous activity per week and 72.2% spent ⩾6 h per day sitting. Cross-sectional associations between negative symptoms, global function, and PA and sedentary behaviour were observed. Additionally, those with more negative symptoms receiving IMPaCT therapy had fewer positive changes in PA from baseline to 12-month follow-up than those with fewer negative symptoms at baseline.

CONCLUSION

These results highlight the need for the development of multidisciplinary lifestyle and exercise interventions to target eating habits, PA and sedentary behaviour, and the need for further research on how to adapt lifestyle interventions to baseline mental status. Negative symptoms in particular may reduce patient's responses to lifestyle interventions.

Halting the Metabolic Complications of Antipsychotic Medication in Patients with a First Episode of Psychosis: How Far Can We Go with the Mediterranean Diet? A Pilot Study

Patients with first-episode psychosis (FEP) often adopt unhealthy dietary patterns, with a risk of weight gain and metabolic and cardiovascular disease. In 21 FEP patients receiving nutritional intervention based on the Mediterranean diet (MedDiet), we explored differences in anthropometric and biometric parameters, according to their antipsychotic (AP) medication: AP1, associated with a lower risk, or AP2, associated with a higher risk of weight gain and metabolic complications. The blood biochemical profile was recorded before and after dietary intervention, and dietary habits and body composition were monitored for six months. Following intervention, all of the patients recorded significant increases in the consumption of fruit and vegetables and decreases in red meat and poultry consumption, with closer adherence to the MedDiet and a reduction in the daily intake of calories, carbohydrates, and sodium. Vegetable consumption and energy, protein, and carbohydrate intake were lower in AP1 patients than in AP2 patients. There was no significant weight gain overall. A reduction was demonstrated in total and LDL cholesterol, sodium, urea, and iron (lower in AP1 patients). It was evident that AP medication affected blood levels of lipids, urea, and iron of FEP patients, but MedDiet nutritional intervention led to a significant improvement in their eating habits, with a restriction in weight gain and a decrease in blood sodium and urea.

Improving the physical health of young people with early psychosis with lifestyle interventions: Scoping review

People with mental illness experience a shorter life expectancy compared to the general population. Poor physical health trajectory emerges following the onset of psychosis and is further compounded by the initiation of antipsychotic treatment. Young people are particularly at risk as the onset of mental illness mostly occurs between the age of 12 and 25 years. This represents a crucial period for early intervention to prevent a physical ill health trajectory. Furthermore, those who are at ultra-high risk for psychosis should also be targeted for early intervention. Lifestyle interventions have been identified as the first-line physical health promotion practice for improving the physical health of people with severe mental illness. The aim of this study was to conduct a scoping review following the JBI methodological guidance on scoping reviews to explore the current literature on lifestyle intervention trialled for early psychosis, including first-episode psychosis and those who are at ultra-high risk for psychosis. This review also explores the extent of literature examining physical health literacy in this specific population. The literature search was conducted on Medline, Embase, PsycINFO and Scopus. Twenty-two studies were included for the purpose of this scoping review, 21 of which examined the effects of lifestyle interventions and one of which reported on physical health literacy. This scoping review indicates the need for co-designed lifestyle interventions with the involvement of service users, families and carers and a focus on promoting physical health literacy, social support, and an incorporation of a health behaviour change model focus on promoting autonomous motivation. The findings of this study can inform future development of a novel co-designed lifestyle intervention for the targeted population.

Prevalence of food insecurity in community-dwelling people living with severe mental illness

AIM

The present study aimed to measure the prevalence and severity of food insecurity in people with a severe mental illness, defined as schizophrenia and related psychoses, and bipolar disorder; and explore relationships between food insecurity status, and sociodemographic and clinical characteristics.

METHODS

This cross-sectional study recruited community-dwelling people with severe mental illness receiving clozapine and/or a long-acting injectable antipsychotic medication within three mental health services in Sydney, Australia. Participants completed the 18-item Household Food Insecurity Access Scale. Sociodemographic and medical information was obtained from participants' medical records. Independent samples t-test and chi-square analyses were used to test for between group differences based on food insecurity status. Binary logistic regression analyses adjusting for age and gender were used to determine the odds ratio.

RESULTS

One-hundred and eighty-eight people completed the assessment: 63% were male, mean age was 49.2 ± 12.4 years, and the majority (85%) had a diagnosis of schizophrenia. Food insecurity was detected in 31% of participants. Of those who were food insecure, 12% were classified as severe, 13% as moderate and 7% as mild. Tobacco smoking was higher in food insecure people compared to food secure people (odds ratio = 3.1, 95% CI 1.3 to 7.1, p = 0.01). Food insecurity status was not associated with demographic, diagnostic or other clinical data.

CONCLUSIONS

Food insecurity is highly prevalent among community-dwelling people with severe mental illness receiving clozapine and/or long-acting injectable antipsychotic medication. Food security screening should be considered as routine care for this population group.

Physical health interventions for patients who have experienced a first episode of psychosis: a narrative review

Objectives:

Service users with severe psychiatric illnesses, such as schizophrenia, major depressive disorder and bipolar disorder, are more likely to suffer from ill health. There is evidence that lifestyle interventions, for example, exercise, dietary advice and smoking cessation programmes for service users with severe mental illness can be of health benefit. This review was carried out to identify the literature pertaining to physical health interventions for service users who have experienced a first-episode psychosis (FEP), to examine the nature of the interventions which were carried out and to assess these interventions in terms of feasibility and efficacy.

Methods:

A narrative review was conducted in August 2019 by searching ‘Pubmed’ and ‘Embase’ electronic databases. Studies investigating the effect a physical health intervention had on service users who had experienced a FEP were included in the review.

Results:

Fifteen studies met inclusion criteria: 12 quantitative studies and 3 qualitative. Exercise, dietary advice, smoking cessation and motivational coaching were some of the physical health interventions utilised in the identified studies. Positive effects were seen in terms of physical health markers wherever they were investigated, particularly when the intervention was delivered early. The impact on psychiatric symptoms and longer-term impacts on health were less frequently assessed.

Conclusions:

Physical health interventions have a positive impact on service users who have experienced a FEP. More research is warranted in this area in Ireland. These studies should include controls, have longer follow-up periods and should assess the impact on psychiatric health.

Effectiveness of Education Interventions Designed to Improve Nutrition Knowledge in Athletes: A Systematic Review

BACKGROUND

A range of nutrition education strategies are used to assist athletes to improve nutrition knowledge. Evaluation of nutrition education interventions guides the delivery of efficacious nutrition education for athletes.

AIM

Our aim was to systematically review sport/general nutrition education interventions delivered to athletes, and to evaluate their effectiveness.

METHODS

A search was conducted using terms related to nutrition knowledge, athletes, education, and intervention. Included studies had to be conducted in athletes (all calibres), use a scored nutrition knowledge assessment tool, and measure knowledge before and after a nutrition education intervention. Peer-reviewed and unpublished theses were included.

RESULTS

Thirty-two manuscripts (randomised controlled trial, n = 13; single-arm pre/post design, n = 19) met the inclusion criteria. Participants (n = 2180; mean age 17.4 ± 1.7 years) were mostly female (66.1%), university-level (56.3%) athletes based in the US (75%). Comparison of different education methods was limited since the majority of interventions (n = 28/36, 77.8%) used face-to-face education. Most intervention conditions (n = 19) had a total contact time of < 300 min (5 h). The majority of interventions (n = 30, 85.7%) reported significant knowledge improvement, with a mean increase of 16.1 ± 0.7% (mean effect size 1.72; range 0.4-17.1). Only 15.6% of studies used well-validated knowledge assessment tools (more than three types of validity or reliability testing).

CONCLUSIONS

Most interventions reported a significant improvement in nutrition knowledge. Unfortunately, the wide range of knowledge assessment tools with limited validation, and the predominant use of face-to-face interventions, prohibits identification of the most effective modality and dose for nutrition education in athletes.

Non-pharmacological interventions for preventing weight gain in patients with first episode schizophrenia or bipolar disorder: A systematic review

Weight gain is a side effect of antipsychotic medication and highly prevalent in people with schizophrenia or bipolar disorder, increasing their overall cardio-metabolic risk. We conducted a systematic review on non-pharmacological interventions for preventing/reducing weight gain or increase in waist-circumference in young, newly diagnosed patients with schizophrenia or bipolar disorder. We searched major electronic databases from inception to 04/2019 on RCTs, pre- and post-test studies, and non-randomized controlled clinical trials. From a potential of 2963 hits, eight studies met the inclusion criteria (n = 438, mean age of 18.8 (13-45) years). The interventions comprised supervised and individually adjusted aerobic exercise activities (5 studies), individual lifestyle counselling vs. control condition (2 RCTs), and dietetic counselling and practical training of cooking and shopping (1 study). Physical activity and practical dietetic interventions seem to be more efficient than lifestyle counselling. However, the results shall be taken with caution due to the non-randomized designs and other methodologically deficits in the majority of the included studies.

Colocating an accredited practising dietitian to an adult community mental health service: An exploratory study

For people with severe mental illness, accredited practising dietitians may assist with a nutrition care plan that considers the medical, psychiatric, psychological, social, spiritual, and pharmacological aspects of their care. However, consumers' access to care has been limited by difficulties attending appointments and suboptimal interface between nutritional and mental health services. Therefore, the objectives of this exploratory study were to describe access to, and key stakeholder perspectives of, the accredited practising dietitian role colocated in a community mental health service. A total of 16 key stakeholders participated in one-to-one interviews. Two main themes with subthemes were derived from analysis of interviews: (i) 'building empowerment and collaboration' and included the subthemes, (a) nutrition awareness and education and (b) healthy lifestyle changes, and (ii) 'overcoming challenges to optimal nutrition and effective health care'. In addition, improved access to the role was demonstrated with 124 (79%) consumers attending at least one appointment with an accredited practising dietitian. A total of 15 (12%) consumers attended more than 10 appointments during their outpatient admission to the community mental health service. Colocating an accredited practising dietitian was perceived to build empowerment and collaboration, and overcome challenges to optimal nutrition and effective health care for consumers, carers, and clinicians. The colocation of a dietitian can empower consumers' to make health-informed decisions and support their willingness to engage with physical healthcare provision when it is prioritized alongside mental healthcare provision.

A review of the nutritional challenges experienced by people living with severe mental illness: a role for dietitians in addressing physical health gaps

People experiencing a severe mental illness (SMI), such as schizophrenia, schizoaffective disorder, bipolar affective disorder or depression with psychotic features, have a 20-year mortality gap compared to the general population. This 'scandal of premature mortality' is primarily driven by preventable cardiometabolic disease, and recent research suggests that the mortality gap is widening. Multidisciplinary mental health teams often include psychiatrists, clinical psychologists, specialist mental health nurses, social workers and occupational therapists, offering a range of pharmacological and nonpharmacological treatments to enhance the recovery of clients who have experienced, or are experiencing a SMI. Until recently, lifestyle and life skills interventions targeting the poor physical health experienced by people living with SMI have not been offered in most routine clinical settings. Furthermore, there are calls to include dietary intervention as mainstream in psychiatry to enhance mental health recovery. With the integration of dietitians being a relatively new approach, it is important to review and assess the literature to inform practice. This review assesses the dietary challenges experienced by people with a SMI and discusses potential strategies for improving mental and physical health.

Bridging the gap: What have we done and what more can we do to reduce the burden of avoidable death in people with psychotic illness?

Despite overwhelming evidence demonstrating a persisting gap in life expectancy between those with psychotic illness and the general population, there has been no widespread implementation of interventions to improve the physical wellbeing of people with psychotic illness. This article explores opportunities to 'Bridge the Gap' in life expectancy. We describe an Australian evidence-based intervention that has substantially improved the physical health of young people recently commenced on antipsychotic medication. Further epidemiological research, accompanied by cultural change within mental health services, is an essential precursor to the implementation of effective and sustainable lifestyle interventions. There are other relatively neglected areas of physical wellbeing for people with psychotic illness, such as screening and diagnosis of malignancies, which need more research and clinical attention. While there has been progress with intervention development and evaluation, translation of evidence-based short-term intervention studies into feasible and sustainable system-wide changes within routine mental health service settings remains a challenge. Developing an implementation framework to support such change is an urgent priority so as to bridge the persisting premature mortality in people living with psychotic illness.

Implementing evidence-based physical activity interventions for people with mental illness: an Australian perspective

OBJECTIVES

Physical activity (PA) and exercise is increasingly being recognised as an efficacious component of treatment for various mental disorders. The association between PA and cardiometabolic disease is well established, as is the strong link between mental illness, sedentary behaviour and poor cardiometabolic health. Examples of successful integration of clinical PA programs within mental health treatment facilities are increasing. The aim of this review was to summarise the evidence regarding PA and mental illness, and to present examples of clinical exercise programs within Australian mental health facilities.

METHODS

A narrative synthesis of systematic reviews and clinical trials was conducted.

RESULTS

Evidence supporting the inclusion of PA programs as an adjunct to treatment for various conditions was presented; including depression, schizophrenia, anxiety disorders, post-traumatic stress disorder and substance abuse. In light of the available evidence, the inclusion of clinical PA programs within mental health treatment, facilitated by dedicated clinicians (exercise physiologists / physiotherapists) was justified.

CONCLUSIONS

PA is a feasible, effective and acceptable adjunct to usual care for a variety of mental disorders. There is a clear need for greater investment in initiatives aiming to increase PA among people experiencing mental illness, given the benefits to both mental and physical health outcomes.