Role of Diet in Weight

Role of Diet in Weight Gain of Severely Mentally Ill

SMI & DIABETES COMORBIDITY: THE EXPANDING ROLE of the NURSE PRACTITIONER

This work intends to relate that all the problems of comorbidity and resulting morbidity and mortality of SMI may be problems, which are "combined to the one metabolic syndrome. (Kato, Currier, Gomez, Hall, & Gonzalez-Blanco, 2004; Toalson, Ahmed, Hardy, & Kabinoff, 2004) One of the causes is antipsychotic treatment (Ascher-Svanum, Stensland, Zhao, & Kinon, 2005; Chue & Cheung, 2004; Tirupati & Ling-Ern, 2007) Another cause is poor diet (Brown, Birtwistle, Roe, & Thompson, 1999) the problem. In order to help these SMI individuals that long-term educational program about dieting with clients with SMI and their families involvement. Nurses and dietitians will play the main roles. There are positive experiences of the long-term program in population of diabetes and weight loss (Albarran, Ballesteros, Morales, & Ortega, 2006; Boltri et al., 2007; Lang & Froelicher, 2006) the Dietetic association is ready to participate (Hampl, Anderson, Mullis, & Mullis, 2002) the previous experiences in SMI weight gain were successful in the short-term and the necessity to provide this nursing implementation is vital (Centorrino et al., 2006; El-Mallakh, 2006; Houltram & Scanlan, 2004; Klam, McLay, & Grabke, 2006; Littrell, Hilligoss, Kirshner, Petty, & Johnson, 2003; Muir-Cochrane, 2006; O'Melia, Shaw, & Dickinson, 2004; Timmerman, Reifsnider, & Allan, 2000; Usher, Foster, & Park, 2006; Vreeland & Kim, 2004; Weber & Wyne, 2006) the conclusion. The importance such an intervention is to improve and expend the lives of SMI, to decrease number of diseases and expense for the treatment.

ROLE of DIET in WEIGHT GAIN of SEVERELY MENTALLY ILL

SMI & DIABETES COMORBIDITY: THE EXPANDING ROLE of the NURSE PRACTITIONER

DESCRIPTION of the PROBLEM

According to the Mental Illness Foundation there is "...no agreed definition of severe mental illness, although many services had adopted one operationally. In referring to other people with a severe mental illness, those experiencing some of the following conditions were included: (1) Those who are diagnosed as having a mental illness, including schizophrenia, maniac depression and dementia; (2) Those who experience substantial disability as a result of their illness; (3) Those who are currently displaying florid symptoms or who have a chronic, enduring condition; (4) Those who have experienced recurring crises leading to frequent hospital admissions or interventions; and (5) Those who display occasional significant risk to their own safety or to that of others." (2007)

I. RISK FACTORS of COMORBIDITY (SMI and PHYSICAL HEALTH)

Risk Factors of Comorbidity with SMI and Physical Health include those stressed in the work of Robson and Gray (2007) entitled: "Serious Mental Illness and Physical Health Problems: A Discussion Paper" published in the International Journal of Nursing Studies states that: "People with serious mental illness have higher chronic disease morbidity and mortality rates that the general population." Robson and Gray additionally state that due to limitations in health services, "the effect of having a severe mental illness, health behaviors, and the effects of psychotropic medicine...physical health can be enhanced by improved monitoring and lifestyle interventions initiated at the start of treatment. There are opportunities for mental health nurses to play a significant role in improving both the physical and mental health of people with serious mental illness." (Robson and Gray, 2007) SMI is defined in the work of Colton & Manderscheid (2006) which means severely mentally ill (SMI) and Bush and Holt (2004); Chafetz, White, Collins-Bride and Nickens (2005); Hammerz and Borga (2000); Miller, Paschall and Svendsen (2006); Neelman (2003); and Perse and Perese, (2003) all stress the high number of morality and morbidity among these SMI individuals. SMI individuals are said to possess higher rates of both "...morbidity and mortality rates for cardiovascular disease, infectious diseases, non-insulin-dependant diabetes, respiratory diseases, some forms of cancers, and HIV infection than the general population. It has been estimated that the life expectancy of people with schizophrenia is reduced by 10 years." (Robson and Gray, 2007)

II. RISK FACTORS INCLUDE LACK of CLARITY

Findings arising from surveys report that there is a "...lack of clarity about whose role it is to provide health promotion, and detect and manage physical problems in people with SMI, which add to the service-related barriers to promoting health." (Robson and Gray, 2007) Individuals who are severely mentally ill are faced with a second disease that all to often accompanies which is the increased risk for developing type 2 diabetes. This is well documented in the work of Kumra, et al. (2007) entitled: "Efficacy and Tolerability of Second Generation Antipsychotics in Children and Adolescents with Schizophrenia" which states: "...Antipsychotic medications were consistently found to reduce the severity of psychotic symptoms in children and adolescents when compared with placebo. The superiority of clozapine has been now demonstrated relative to haloperidol, standard-dose olanzapine, and "high-dose" olanzapine for EOSS disorders. However, limited comparative data are available regarding whether there are differences among the remaining second-generation antipsychotics (SGAs) in clinical effectiveness" (Kumra, et al., 2007)

III. YOUTH SMI MORE SENSITIVE to ADVERSE SIDE-EFFECTS

The available data from short-term studies suggest that youth might be more sensitive than adults to developing antipsychotic-related adverse side effects (eg, extrapyramidal side effects, sedation, prolactin elevation, weight gain). In addition, preliminary data suggest that SGA use can lead to the development of diabetes in some youth, a disease which itself carries with it significant morbidity and mortality. Such a substantial risk points to the urgent need to develop therapeutic strategies to prevent and/or mitigate weight gain and diabetes early in the course of treatment in this population." (Kumra, et al., 2007) the work of Duiverman, Cohen, van Oven, and Nieboer (2007) entitled: "A Patient Treated with Olanzapine Developing Diabetes De Novo: Proposal for Hyperglycemia Screening" reports a patient who has been diagnosed and treated for schizophrenia ad who "developed diabetes mellitus during treatment with olanzapine." (2007) This case is stated to confirm "pattern of atypical antipsychotic-related diabetic emergencies: rapid onset in relatively young patients, often with severe glucose derangements and serious complications. As diabetic emergencies have a high morbidity and mortality, regular glucose screening should be performed in patients with schizophrenia treated with atypical antipsychotics." (Duiverman, Cohen, van Oven, and Nieboer, 2007) the work of Sridhar (2007) entitled: "Psychiatric Co-Morbidity & Diabetes" states: "...Use of antidepressant medications can disturb glycaemic control: tricyclic antidepressants stimulate appetite, whereas selective serotonin reuptake inhibitors suppress appetite, enhance insulin sensitivity and lead to hypoglycaemia if diet is not regulated. Besides, once depression is treated eating habits exercise and drug compliance may change, leading to unstable metabolic control. In the presence of autonomie neuropathy tricyclic antidepressants may worsen orthostatic hypotension, induce constipation and urinary retention." (2007) the work of Albarran, Ballestereos, Morales and Ortega entitled: "Dietary Behavior and Type 2 Diabetes Care" reports a study conducted to explore the risk factors modification in additional to barriers and facilitators for behavior change in those with type 2 diabetes and their families. The method reported in this study was a risk assessment and impact evaluation, which included measurements on anthropometrics, diet, physical activity, and nutrition knowledge. "The intervention included discussion groups and promoted behavioral change on dietary risk, physical exercise, and basic diabetic knowledge of 48 urban diabetic patients and 38 relatives. The educational method consisted of cognitive reframing and situational problem solving during five meetings over an 8-month period." (Albarran, Ballestereos, Morales and Ortega, 2007) Study results indicates that diabetics are older and less educated than the relatives participating in the study. Factors such as diet, degree of obesity, physical activity and HbA is stated to reflect that "92% of diabetic patients and 83% of their relatives were at high health risk." (Albarran, Ballestereos, Morales, and Ortega, 2007) it is noted that factors such as: "...diet, degree of obesity, physical activity and HbA (1c), reflected that 92% of diabetic patients and 83% of their relatives were at high health risk. After the intervention, nutritional knowledge and diet-health awareness increased (p=.013 and.001 respectively); however, no significant health-risks reduction was observed." (Albarran, Ballestereos, Morales, and Ortega, 2007) in a separate work, Wright and Vandenberg report a case in which a male 20 years of age with schizoaffective disorder, bipolar type, and insulin dependent diabetes mellitus has been stable on risperidone 6mg at night for 8 years." (2007) After the patient develop cholestatis this was resolved upon discontinuation of risperadone. While the patient tolerated diprasidone and olanzapine, once having been administered quetiapione the patient again developed symptoms of cholestatis which resolved when quetiapine was removed. It is well-known that atypical antipsychotics can cause isolated asymptomatic increases in aminotransferase levels. Liver injury, both the hepatic and cholestatic type, has been described previously, although the incidence with atypical antipsychotics is rare." (Wright and Vandenberg, 2007) Conclusions are stated as follows: "To the best of our knowledge, this is the first case of cholestasis that developed after years of treatment and reappeared with another antipsychotic agent. Given that liver failure, of either the hepatic or cholestatic type, is a relatively rare phenomenon with atypical antipsychotics, it seems that the most reasonable approach to manage this risk is through education. By educating patients on early warning signs of hepatotoxicity, this rare but potentially fatal consequence could be detected early to allow appropriate intervention." (Wright and Vandenberg, 2007) it is extremely critical to understand the nature of psychiatric nursing in today's clinical environment.

IV. ROLE of NURSE PRACTITIONER in TRANSITION

Specifically stated in the work of Kathryn R. Puskar entitled; "The Nurse Practitioner Role in Psychiatric Nursing" published in the Online Journal of Issues in Nursing is: "Commercialization of psychiatric care is underway. Psychiatric inpatient admissions have decreased, admissions to general hospitals have decreased, while outpatient admissions are increasing. Academic centers are purchasing smaller hospitals as affiliates; satellite clinics and networks of services are being established. Physicians in solo practice are merging into group practices. New health care professional roles must be restructured and "cross trained" to maintain competitiveness by offering flexible, cost-saving effective care. This is the background environment in which the PPCNP is competing for a piece of the managed care dollar. The PPCNP provides a "Commodity or product" of quality psychiatric care combined with primary care emphasizing the psychotherapeutic skills. In her editorial in Archives in Psychiatric Nursing in December 1995, Krauss emphasized that in managing costs and care, psychiatric nursing must make mental health systems humane. She advocates that the core of psychiatric nurse's work is "therapeutic engagement with patients." The PPCNP is an example of this notion, a mesh of psychotherapeutic skills, of neurobiological knowledge, behavioral interventions, and physical assessment skills." (Puskar, 2007) Wess, Eglen and Guatam (2007) state: "Muscarinic acetylcholine receptors (mAChRs), M (1)-M (5), regulate the activity of numerous fundamental central and peripheral functions. The lack of small-molecule ligands that can block or activate specific mAChR subtypes with high selectivity has remained a major obstacle in defining the roles of the individual receptor subtypes and in the development of novel muscarinic drugs. Recently, phenotypic analysis of mutant mouse strains deficient in each of the five mAChR subtypes has led to a wealth of new information regarding the physiological roles of the individual receptor subtypes. Importantly, these studies have identified specific mAChR-regulated pathways as potentially novel targets for the treatment of various important disorders including Alzheimer's disease, schizophrenia, pain, obesity and diabetes." (2007)

V. ASSISTING SMI in DIABETES COMORBIDITY

Patients with diabetes are required to have much skill and information if they are to become 'self-regulating. In order to manage Type 2 diabetes effectively, one must understand...the basic pathological and physiological nature of diabetes, for example, what causes blood sugars to rise and fall as well as the effects of these high and low blood sugars." (Wess, Eglen and Guatam, 2007) Knowledge may also be needed for management of oral medicals or insulin..." (Wess, Eglen and Guatam, 2007) it is highlighted in this work that the social workers who are diabetes informed' are an especially important asset to diabetes educators and programs. The social worker "...can interject, affirm, and interpret relevant psychosocial factors during initial assessments and progress evaluations -- highlighting strengths, needs, family involvement and functioning, and the effects of patient, family, and group cultures on outcomes. They are invaluable as consultants or instructors to diabetic clients also dealing with cognitive deficits, learning disabilities, or chronic mental illnesses. Likewise, social workers are indispensable in designing and implementing education programs and materials tailored to meet the information and skill needs of people with learning challenges or educational deficits and especially young or elderly patients. In particular, social work practitioners are ideally suited to develop and teach the psychosocial component of a diabetes program that may include presentations on behavior modification, emotions, depression, stress and time management, and community resources. Social workers also can serve as resources to those lacking access to traditional diabetes programs, such as rural, homebound, uninsured, or underinsured populations or in medical settings with limited diabetes education resources." (Wess, Eglen and Guatam, 2007) the second tool is facilitation of the family-centered approach or 'family as the focus of intervention'. The family centered interventions are stated to include: "...Family-centered interventions may include soliciting and addressing family concerns, encouraging family attendance and participation at appointments, fostering shared responsibility and credit for treatment outcomes, incorporating family members' talents and health needs in the care plan, enlisting participation in classes, and selling everyone on the benefits of healthy habits for wellness and delaying or preventing the onset of diabetes. A large study is reported in the work of Koholokula, Schirmer, and Elting (2004) entitled: "Identifying and Prioritizing Diabetes Care Issues Among Mental Health Professionals of a Multi-Ethnic, State Psychiatric Hospital" relates the fact that those who have been diagnosed with schizophrenia and other severe mental illnesses are an increased risk for developing type 2 diabetes. This work reports an aggregated list identified by NGT groups of concerns for those with diabetes and who also are considered to be severely mentally ill. The technique used is the 'nominal group technique (NGT) which various mental health professional from the hospital. The goal of this study was the identification and prioritization of diabetes care issues among health professionals of a state psychiatric inpatient hospital using the nominal group technique (NGT) described by Delbecq et al." (Koholokula, Schirmer, and Elting, 2004) Several overlapping ideas are stated to be ranked in the top seven by at least two of the three NGT groups which include: (1) Lack of knowledge of diabetes and its care by both patients and staff; (2) Lack of proper training in diabetes care among staff; (3) Poor communication between hospital units and mental health disciplines; and (4) the need for multi-modal (e.g. diabetes support groups, focus on diabetes-specific behavioral skills, addressing attitude toward disease)