Metabolic Syndrome

1. Metabolic Syndrome AND ITS IMPACT ON PEOPLE WITH SERIOUS MENTAL ILLNESS Sandra Gore, Team Lead; Anna Mapes, Registered Nurse; Eva Oveson, Case Manager Wallowa County ACT team

2. What is Metabolic Syndrome? • Also known as: Syndrome X, Metabolic Disease and Insulin Resistance • A grouping of conditions that increase one’s risk of heart disease, stroke, Type II Diabetes and early death. • Diagnosis is made on having at least 3 of 5 of the following risk factors:

5. Waist circumference: >40 inches for men and >35 inches for women. High blood pressure: >130/85 mm Hg High fasting triglycerides: >150 mg/dL It is (unfortunately) all about the numbers: Low HDL (“good”) cholesterol: <40 mg/dL for men and <50 mg/dL for women High fasting glucose: >100 mg/dL

6. Weight gain (specifically fat around your abdominal organs) churns out inflammatory chemicals that make it harder for cells to respond to insulin release. • Cells in the muscles, body fat and liver become insulin resistant and stop responding to the signal to pick up glucose. Metabolic SyndomeIInsulin Resistance Highfastingglucose • Glucose does not enter cells= the pancreas then reacts to more sugar by making more insulin. • Eventually, the pancreas becomes tired and cannot keep up, leading to high blood sugar = more fat = harder to get insulin across fat regions to the muscle and eventually to Type II Diabetes. InsulinResistance • Diabetes= damage blood vessels and nerves= increased risk of heart disease. • High blood pressure and High Cholesterol all = plaque build up= risk of heart attack or stroke HeartDisease

7. Why are we focusing on this?Metabolic SyndromeI Mental Illness • Heart Disease is the #1 killer of people with mental illness- largely due to a high prevalence of metabolic syndrome in this population which goes undertreated. • Individuals with psychosis from age 19-46 are 3x more likely to die from cardiovascular disease. • People with Schizophrenia have a decreased life expectancy of 25-30 years, primarily due to premature cardiovascular mortality. Ehret M, et al. "The Effect of Metformin on Anthropometrics and Insulin Resistance in Patients Receiving Atypical Antipsychotic Agents: A Meta-Analysis," Journal of Clinical Psychiatry (Oct. 2010): Vol. 71, No. 10, pp. 1286–92. Faulkner G, et al. "Interventions to Reduce Weight Gain in Schizophrenia," Cochrane Database of Systematic Reviews (2007): Doc. No. CD005148.

8. Metabolic SyndromeI Mental Illness • ¼ of all Americans have metabolic syndrome, but those with mental illness like Schizophrenia and Bipolar Disorder are vulnerable secondarily to: • Antipsychotic (Dopamine-blocking) medications causing significant weight gain • Higher rates of smoking and substance abuse • Inadequate/poor nutrition • Lack of exercise • Poor sleep hygiene • Limited access to or underutilization of quality Primary/Seconday healthcare • Low socioeconomic status

9. What can be done? Thehigher risk profile means that these clients need anincreasein screeningandmonitoring!

10. Enter… “The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.” The Grant “SAMHSA makes grant funds available through the Center for Substance Abuse Prevention, the Center for Substance Abuse Treatment, and the Center for Mental Health Services.”

11. NOMS (National Outcome Measurement Survey) • Voluntary scripted interview every 6 mo. for those who agree to participate. • Questions range from demographic data to everyday functioning, mood, drug use, housing, financial comfort, military deployment, trauma, health-care access and social connectedness.

12. And concludes with Health Measurements #1 #2 Bloodwork is fasting #3 #4 #5

13. The LABSOrders and follow-up • Once the interview is conducted, the nurse is prompted to initiate ordering bloodwork. • Client is not charged, which increases participation. • Clients are assigned # and results are reported and only associated with a #, not name, to the study database. • Bloodwork is ordered through the PCP so that a Provider is accountable to the results for follow-up in addition to the ACT team.

14. Case Study: • 37yoM with h/o Paranoid Schizophrenia, h/o alcohol and drug use and many changes in psychiatric medications throughout the years to keep his paranoia stabilized so as to control behaviors that were leading to frequent arrests. • This client smokes cigarettes “for the buzz” since he was “on probation and not allowed to drink alcohol.” He drinks two energy drinks/day, coffee, and uses nicotine pouches. • He has been kicked out of our only two grocery stores b/c of stealing/staring and making customers uncomfortable so he has no access to fresh food. • Client has been on weekly doses of 50mg IM Risperdal for three years! • Weight gain over three years on this dosing: 231lbs to 327lbs. Average 2.66Ibs/mo. • ACT team raised concern that this client has significant weight gain, high heart rate and increased BP at visits with PCP. Average BP 140/100 & Pulse 105. • Favorite Food: Hot dog buns and canned green beans!

15. 5 A’sI Intervention Strategy ASK: Ask permission to discuss personal health. • Ask to be a NOMS participant and do bloodwork. • Asked client’s permission to discuss weight loss and “numbers.” ASSESS: Assess readiness for change and awareness of medical concerns, barriers. ADVISE: Advise on benefits of addressing Metabolic Syndrome and its components. • Advised on Lisinopril, medications vs. other modifiables. AGREE: Agree on realistic goals and treatment plan. • Set goal of decreasing Energy Drink intake to once daily. • Acknowledge side effects of Risperdal injections. ASSIST: Assist drivers and barriers, provide educational resources, refer to appropriate providers and follow-up. • Assisted client with a gym membership. • Cook healthy meals with him once monthly . • Encourage him to attend our gardening group to grow fresh vegetables.

16. Metabolic SyndromeI Mental Health MedicationsAntipsychotics/Dopamine Antagonists • Dopamine blocking medications have a global effect on the body: • They may exacerbate negative side-effects leading to decreased motivation and a more sedentary lifestyle. • Risperdal and Haldol block the feedback loop to the pituitary gland to say that it does not need prolactin= increased breast tissue and even breast milk production in men. • Zyprexa triggers hyperglycemia, appears to generate apoptosis in pancreatic Beta cells (which produce insulin). One in six patients who take Zyprexa will gain more than 33 pounds after two years of use, the label says. 

17. Second Generation Antipsychotics (SAGs) https://www.uspharmacist.com/article/assessment-and-management-of-atypical-antipsychotic-induced-metabolic-abnormalities Tschoner A, Engl J, Laimer M, et al. Metabolic side effects of antipsychotic medication. Int J Clin Pract.2007;61:1356-1370. 

18. How can we help??IMedication Management • Be aware of and ask PCP/Psychiatrist about antipsychotics that are least likely to increase risk of metabolic syndrome, such as ziprasidone (Geodon) or aripiprazole (Abilify) if possible. • Be aware of dosing and if client is at the lowest dose of a medication that works for them. • Assist in a conversation with client’s PCP or Psychiatrist around Metformin, which has been shown to decrease insulin resistance for some people. • Treat individual risk factors (hyperlipidemia, high blood pressure and high blood glucose) according to established guidelines.

19. How can we help??INon-Pharmaceutical Managment • EDUCATE your clients and staff on Metabolic Syndrome and its components. • The only visible or symptomatic component can be waist circumference or possibly symptoms of HTN or Diabetes. • What is the difference between Triglycerides & Cholesterol? • Monitor risk factors by regularly measuring: • Weight, waist circumference, blood sugar, cholesterol levels, and Blood Pressure. • Offer or find classes for client around smoking cessation and substance abuse.

20. How can we help??I • Encourage client to adopt healthy lifestyle habits such as a nutritious diet, more exercise. • Losing weight, getting regular exercise and not skimping on sleep can improve insulin sensitivity. • University of NM school of Medicine study showed that overweight people who lost 10% of weight through diet plus exercise saw insulin sensitivity improve by 80%. Those who lost same weight through diet alone got a 38% increase. And those who simply do more exercise but didn’t lose much weight, saw no shift in their level of insulin resistance.

21. How do I start the conversation? Common Treatment Goals are an easy way: Decrease my medications Lose Weight Sleep Better Socialization Find a job Eat healthier

22. How do I start the conversation? Utilizing established Tx goals PLUS Mechanical Indicators WITH Educational Materials Easy way to begin a conversation

23. Metabolic Syndrome EXCESS FAT AROUND THE WAIST VISCERAL OBESITY A waistline at or above 35 inches for women and 40 inches for men

24. Metabolic Syndrome LOW LEVELS OF GOOD CHOLESTEROL OR HDL High Levels of good cholesterol or HDLs work like Crisco preventing bad cholesterol or LDLs from building up in your veins

25. Metabolic Syndrome HIGH TRIGLYCERIDE LEVELS 150 mg/dL or higher of this type of fat found in the bloodstream

26. Metabolic Syndrome HIGH BLOOD PRESSURE 130/85 mmHg or higher

27. Metabolic Syndrome HIGH BLOOD SUGARS Ø 100mg/dL or higher (fasting)

28. Change the verbiage: • Say healthy eating plans/habits instead of diet which implies a short-term fix by cutting out foods. • Talk about weight or healthy weight instead of fat • Say activity in place of exercise- get away from connotation of exercise/gym/running.

29. QUESTIONS