youth with schizophrenia are at high risk of diabetes ... · dame professor sue bailey past...
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Youth with schizophrenia are at high risk
of diabetes:
Opportunities for prevention and early intervention.
Katherine Samaras
Department of Endocrinology, St Vincent’s Hospital
Diabetes and Obesity Program, Garvan Institute of Medical Research
Sydney, AUSTRALIA
REAL WORLD FAMILY EXPERIENCES: Will my daughter become like the rest of her group?
Health trajectories in youth with psychosis
12 kg gain by 12 weeks APM initiation Secondary amenorrhea Acne, hirsutism Interrupted tertiary education
-to keep the health they currently possess
-to develop in education, life skills and fulfilling life experiences
-parity of life expectancy
These would be ours aims if the diagnosis was type 1 diabetes
if youth with psychosis could expect
Mind the life expectancy gap
Lawrence et al 2013 BMJ
‘That people with SMI
die 20 years earlier ..,
the majority from
preventable causes,
is one of the greatest health
scandals of our time.”
Dame Professor Sue Bailey
Past President
Royal College of Psychiatrists
Health trajectories in people with severe mental illness
• weight gain
• hyperlipidemia
• polycystic ovary syndrome
• diabetes
• heart disease
• hypertension
• cancer
kg
Months
12 24 0 48 36
Established SMI
10
5
20
15
12 kg
4 kg
3 kg
The trajectory to poor health: weight gain on APM
Alvarez-Jimenez et al; CNS Drugs, 2008
Khan et al, Lancet 2008
First episode psychosis
kg
Months
12 24 0 48 36
Established SMI
10
5
20
15
First episode psychosis
12 kg
4 kg
3 kg
Opportunity #1: Prevent APM-induced weight gain
Alvarez-Jimenez et al; CNS Drugs, 2008
Khan et al, Lancet 2008
Start
HERE,
NOW!
STOP
natural
history
The effects of neglect after APM initiation in FEP
• Weight gain in 60% of treatment-naïve by 2-4 months – 60-100% after 1-2 years Alvarez-Jimenez, 2008
• 3-months in APM-naïve youth – 4.4kg aripiprazole
– 8.5kg olanzapine vs 0.2kg weight gain in controls Correll, 2009
• weight gain (>7%) by 12 months in APM-naïve • olanzapine 86% haloperidol 53%
• quetiapine 65% ziprasidone37% Kahn, 2008
• Rapid onset metabolic abnormalities
• – hyperlipidaemia by 12 weeks Perez-Iglesias, 2007
– insulin resistance by 52 weeks Perez-Iglesias, 2009
– In healthy volunteers, antipsychotics induced fasting and postprandial hyperinsulinaemia
within 12 days Teff, 2013
http://www.heti.nsw.gov.au/cmalgorithm http://guidance.nice.org.uk/CG155/InterventionFramework
http://www.heti.nsw.gov.au/cmalgorithm http://guidance.nice.org.uk/CG155/InterventionFramework
• It’s simple
– sharing diabetes prevention principles and expertise with mental
health co-workers
– Address the barriers to healthy lifestyle
– Weekly individualised counselling: dietitian and exercise physiologist
– Weekly classes for life-skills training: • health coaching
• cooking
• shopping
• Budgeting
– Daily access to a gym within the FEP Unit
– Controls: STANDARD CARE: FEP from a demographically matched service
The “Keeping the Body in Mind” Program
Curtis J et al, Early Int Psych 2015:DOI: 10.1111/eip.12230
Who gained >7% baseline weight?
Curtis J et al, Early Int Psych 2015:DOI: 10.1111/eip.12230
13% 75%
P<0.001
Never miss an opportunity: weight neutrality
• APM- induced weight gain can be halted through
individualized lifestyle interventions
• Weight neutrality is a realistic and attainable goal
– Replication: NHS undertaking studies in collaboration
Curtis J et al, Early Int Psych 2015:DOI: 10.1111/eip.12230
Grass roots co-ordinated person-centered care
Family physician
Exercise
physiologist
Psychiatrist MH Nurse
Dietitian Endocrinologist Occupational
therapist
Not-so-sweet young things
Diabetes & antipsychotic use in children and youth
Could diabetes rates be even higher?
• Ascertainment:
• diabetes symptoms
(symptoms at >300 mg/dL, N<100)
• need for medication:
worst hyperglycaemia
• Asymptomatic / untreated cases
missed
• No routine glucose screening
• Likely underestimation
Samaras K, Correll C, Mitchell A, De Hert M. JAMA Psych 2014; 71: 209-210
Medication-associated risk of future diabetes in SMI
• Antipsychotic medications:
– 2-5 fold increased risk
– High rates of undiagnosed diabetes (5-14%)
– High rates of pre-diabetes (33%)
• Antidepressants:
– Double risk for diabetes, even with lifestyle intervention Rubino et al
– Nurses Health Study: tripled rate Pan et al 2012
Missed Opportunity: No blood glucose screening
Prevention/Intervention Opportunity 2: glucose screen�
Pre-diabetes:
F. Glucose > 5.5 mmol/L
100 mg/dl
Diabetes:
F. Glucose > 7.0 mmol/L
126 mg/dl
R. glucose > 11.1 mmol/L
200 mg/dl
HbA1c > 6.4%
http://www.heti.nsw.gov.au/cmalgorithm http://guidance.nice.org.uk/CG155/InterventionFramework
A sweet calamity synchronous schizophrenia and diabetes
• Worse control
• More frequent diabetic complications
• Worse CV risk factors
• More frequent amputations
• Higher rates of non-attendance
• Evidence of sub-standard care when they do attend
– Less treatment of CVD risk
– Less change in glucose lowering medications
Challenges in diabetes care
• Complex disease: highly organized, health-obsessed, adherent do better
• Costly: medications, monitoring, better foods
• Accessing the right food: challenges – Poor nutritional choices: low quality, cheap foods
– “Food literacy” and access to kitchen
• Accessing physical activity: challenges – Am I AWAKE enough?
– Can I leave home? Paranoia, safety
– Where do I exercise?
• Accessing medical care – Clinics are in the mornings
– Clinics are noisy, loud
– I forgot….. (cognition, sedation)
– I was treated like a leper (treatment discrimination evidence)
Metformin with antipsychotic use
Wu RR et al, Am J Psychiatry 2008; 165:352–358
MF at initiation olanzepine 15mg N=40, FEP mean age 25y
MF after 10% weight gain, various antipsychotics N=128, mean age 26y, 9m schizophrenia
Wu RR et al, JAMA 2008; 299:185–193
More on metformin
Curtis, Newall, Myles, Shiers, Samaras 2012.
2012; 27: 69-75.
HeAL: Healthy Active Lives
www.iphys.org.au
Jackie Curtis
David Shiers
Katherine Samaras
Philip Ward
Mario Alvarez Jimenez
Debra Foley
Eoin Killackey
Stephanie Webster
Christoph Correll
Davy Vancampfort
Richard Holt
Jonathan Campion
Healthy Active Lives Ambitious 5 year targets
• The majority of people have:
– Regular review of medications
– No more than 7% weight gain
– Maintain healthy blood glucose, lipids and blood pressure
Healing is a matter of time but sometimes also a matter of opportunity Hippocrates
Physical Fall-out of Anti-psychotic Medications
• Impacts of physical burden of disease in mental health:
– Disease in those who are most unable to deal with complex diseases
– Late presentation
– Economic costs of:
• Health, now and the future
• Lost potential workforce
• Premature loss of life: OECD
Changing our expectations of health in SMI
• weight gain
• hyperlipidemia
• polycystic ovary syndrome
• diabetes
• heart disease
• hypertension
• cancer
http://guidance.nice.org.uk/CG155/InterventionFramework
Results
Weight
KBIM Standard care20
40
60
80
kg
Glucose
KBIM Standard care2
3
4
5
mm
ol/L
BMI
KBIM Standard care10
20
30
kg
/m2
High density lipoprotein
KBIM Standard care1.0
1.1
1.2
1.3
1.4
1.5
mm
ol/L
Waist circumference
KBIM Standard care60
70
80
90
cm
0w
12w
Triglycerides
KBIM Standard care
0.6
0.8
1.0
1.2
1.4
mm
ol/L
P<0.001 P<0.001 P<0.001
Curtis J et al, Early Int Psych 2015:DOI: 10.1111/eip.12230
HeAL Plus International Network
• Objective: Collect data to record and report physical health
» Examine if HeAL Outcome Targets are met
• Standardized:
– Sociodemographics
– Physical and mental health characteristics
– QoL
– Physical examination
– Metabolic and other measures
– Lifestyle measures
– Canadian iPhys Satellite Symposium: Thursday 21st May
– Early Psychosis Intervention Ontario Network (EPION)
Future practice in action: international links
Are we being honest when we talk about parity?
• How would we treat the 18 yo girl obese /pre-diabetic/PCOS?
– Metformin use off-label?
– Evidence in:
• Pre-diabetes, impaired glucose tolerance,
• PCOS,
• obesity,
• early puberty
– RCT evidence in psychosis: APM-initiation AND long term