Independence of diabetes and obesity in adults with serious mental illness: Findings from a large urban public hospital
Introduction
Metabolic syndrome is a cluster of conditions that tend to occur together and increase a patient's risk of cardiovascular disease, T2DM, stroke, and all-cause mortality (Kaur, 2014). Metabolic syndrome is associated with a three times higher risk of death from coronary heart disease and twice the risk of all-cause mortality (Lakka et al., 2002). T2DM and obesity are chronic medical diseases associated with metabolic syndrome that have increased dramatically in the U.S. population (Barnes, 2011). These trends are particularly alarming for patients with SMI who demonstrate 1.5–2 fold the prevalence of T2DM, dyslipidemia, hypertension, and obesity compared to the general population (Newcomer and Hennekens, 2007), along with less favorable outcomes, which contributes to an estimated 10–20 year decreased life expectancy (Chesney et al., 2014). Factors posited to explain the increased rate of metabolic disorders among those with SMI include psychotropic medications, genetics, unhealthy lifestyles, low socioeconomic status, cigarette smoking, and healthcare inequalities (Lawrence and Kisely, 2010, Padmavati, 2016).
Antipsychotic use is reported to increase the risk of T2DM, although of an uncertain magnitude, and almost all antipsychotics are associated with weight gain (Correll et al., 2015). Mood stabilizers, including lithium and valproic acid, and many antidepressants, such as amitriptyline and mirtazapine, produce lesser weight gain than that associated with antipsychotic use (Correll et al., 2015, Mcknight et al., 2012). Although mood stabilizers also increase the risks for insulin resistance and T2DM (Belcastro et al., 2013, Chien et al., 2012), findings are inconclusive regarding a possible association between antidepressants and T2DM (Correll et al., 2015).
While the relationship between psychotropic medications and metabolic syndrome has long been known, there is emerging evidence of an inherent predisposition to certain metabolic conditions among some patients with SMI. Research on psychotropic-naïve or first-episode patients has primarily focused on patients with schizophrenia. Multiple studies have demonstrated an increased prevalence of impaired fasting glucose tolerance in psychotropic-naïve patients with schizophrenia (Ryan et al., 2003, Spelman et al., 2007), although some studies have not found such elevations in fasting plasma glucose (Padmavati et al., 2010). A recent meta-analysis, however, demonstrated elevations in several indicators of dysglycemia including fasting plasma glucose levels in first-episode patients with schizophrenia compared to matched controls (Pillinger et al., 2017a). While one small study in 2002 with 15 patients found that psychotropic-naïve patients with schizophrenia had increased central obesity compared to matched controls (Thakore et al., 2002); more recent larger studies do not show an increased prevalence of obesity in psychotropic-naïve patients with schizophrenia (Padmavati et al., 2010, Verma et al., 2009).
Effects of sex and race/ethnicity are rarely considered in studies of metabolic parameters in patients with SMI. In the general population, males have a slightly higher rate of diabetes than females, 8.7% vs. 7.7% (CDC, 2009); however, there is limited research on sex differences in T2DM risk among patients with SMI. One community study of 1123 patients with schizophrenia in Canada showed no significant differences (Voruganti et al., 2007). Regarding sex differences in obesity, females with SMI have a significantly higher prevalence of obesity than their male counterparts (Carliner et al., 2014, Jonikas et al., 2016).
A review examining racial/ethnic differences in diabetes found that persons with African ancestry and Hispanics appear to be at a higher risk of diabetes than whites with SMI (Carliner et al., 2014), but studies on the association between race/ethnicity and obesity in patients with SMI are limited and inconclusive. Some studies showed increased obesity in those with African ancestry and Hispanics compared to whites with SMI, while others demonstrated no significant differences in obesity by race/ethnicity (Carliner et al., 2014).
Our metabolic screening study at Bellevue Hospital Center, a large public hospital in New York City, provided a unique opportunity to analyze the cross-sectional prevalence of two metabolic conditions, hyperglycemia and obesity, in patients with SMI with respect to duration of psychotropic medication treatment and demographic variables. The primary aim of our study was to look at the prevalence of metabolic conditions in psychotropic-naïve patients with schizophrenia and other SMI as there is a scarcity of studies with large, diverse samples of psychotropic-naïve patients. We also examined associations between the two metabolic conditions and the hypothesized predictors: years on psychotropics, sex, and race/ethnicity. Additionally, this study explored the likelihood of hyperglycemia and obesity by years on psychotropics in psychotic and non-psychotic patients separately in order to draw comparisons between these two groups.
Section snippets
Data sources
In accordance with FDA recommendations, a protocol was implemented to screen all adult psychiatric inpatients for metabolic syndrome from 2006 to 2009. The human subjects committee at Bellevue Hospital Center approved the protocol. On admission, patients underwent a set of metabolic laboratory tests and physical measurements, and an attending psychiatrist on the inpatient unit obtained additional information through patient interview, medical records, and collateral sources. The data included
Results
The analytic sample included 923 adults with SMI (age range: 17–90, mean: 43.9, SD: ±14.9 years) (Table 1). There were 150 psychotropic-naïve adults (age range: 17–90, mean: 45.1, SD: ±18.9 years), 95 psychotropic-naïve psychotic adults (age range: 19–83, mean: 43, SD: ±18.3 years), 32 psychotropic-naïve adults with schizophrenia (age range: 19–75, mean: 45.7, SD: ±17.9 years), and 55 psychotropic-naïve non-psychotic adults (age range: 19–90, mean: 48.8, SD: ±19.4 years). The sample was
Discussion
Our study found an elevated prevalence of hyperglycemia meeting criteria for T2DM and a decreased prevalence of obesity in psychotropic-naïve patients with SMI compared to the general population at the time of the study. This finding held true across all subgroups of psychotropic-naïve patients. The rate of hyperglycemia meeting criteria for T2DM was 20% in psychotropic-naïve patients (22.1% in the psychotic subgroup, 18.8% in the schizophrenia subgroup, and 16.4% in the non-psychotic
Conclusion
The findings from our study suggest separate pathways for the development of T2DM and obesity in patients with SMI and demonstrate important sex and race/ethnicity effects. Certain groups, including non-psychotic patients, females, Hispanics, and Asians with SMI, may be particularly vulnerable to obesity or T2DM; therefore, careful selection of psychotropic medications is essential, along with healthy lifestyle interventions and regular monitoring of metabolic conditions. Future research should
About the authors
Langston Sun is a medical student at NYU School of Medicine, Mara Getz is a research coordinator at NYU School of Medicine, Sulaima Daboul, M.D. is a research assistant at NYU School of Medicine, Melanie Jay, M.D., M.S. is an Associate Professor in DGIMCI, Scott Sherman, M.D. is an Associate Professor in the Department of Population Health at NYU School of Medicine, Erin Rogers, MPH, Ph.D is an Assistant Professor in the Department of Population Health at NYU School of Medicine, Nicole Aujero
All authors provided
(1) Substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data for the article; (2) drafting of the article or reviewing it and revising it critically for important intellectual content; and (3) final approval of the version to be published.
Conflicts of interest
None.
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