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My Head is Better but How About My Heart Health?

My Head is Better but How About My Heart Health?. Metabolic Syndrome in Patients with Schizophrenia. “There is No Health Without Mental Health”. “There is No Health Without Physical Health”. Successful PCP/Psychiatric provided partnerships.

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My Head is Better but How About My Heart Health?

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  1. My Head is Better but How About My Heart Health? Metabolic Syndrome in Patients with Schizophrenia

  2. “There is No Health Without Mental Health”

  3. “There is No Health Without Physical Health”

  4. Successful PCP/Psychiatric provided partnerships Partners in Health - Primary Care/County Mental Health Collaboration Toolkit, Integrated Behavioral Health Project (IBHP), October 2009

  5. Obesity Trends Among Canadian and U.S. Adults, 1985 No Data <10% 10%-14% 15-19% 20% AH Mokdad et al, JAMA 289:76-79, 2003 PT Katzmarzyk, Can Med Assoc J 166:1039-1040, 2002

  6. Obesity Trends Among Canadian and U.S. Adults, 2004 10%-14% 15-19% 20% 25% 30% AH Mokdad, CDC M Shields, Statistics Canada, 2005

  7. Projected Increases in Obesity

  8. Assessing Obesity 1 25 to <30 30 to <35 ≥40 35 to <40 BMI Class 1 Class 3 Class 2 OVERWEIGHT OBESITY European, Sub-Saharan African, Eastern Mediterranean and Middle Eastern (Arab) ♂94 cm | ♀80 cm South Asian, Chinese, Japanese, South and Central American ♂90 cm | ♀80 cm 2 3 Diabetes: FPG, A1C Hypertension: Blood pressure (BP) Dyslipidemia: Lipid profile NAFLD: ALT Other weight-related comorbidities ALT = alanine aminotransferase; BMI = body mass index; FPG = fasting plasma glucose; NAFLD = non-alcoholic fatty liver disease. Adapted from Jensen MD et al. J Am CollCardiol. 2014;63:2985-3023; Lau DCW et al. CMAJ. 2007;176:1103-6; CDA Guidelines. Can J Diabetes. 2013;37(suppl 1):S1-212. 9

  9. CV disease Cancer All other causes 2.4 2.1 1.8 1.5 1.2 0.9 0.6 3.0 2.4 1.8 1.2 0.6 Women Men Relative risk of death Relative risk of death <18.5 18.5 - 20.4 20.5 - 21.9 22.0 - 23.4 23.5 - 24.9 25.0 - 26.4 26.5 - 27.9 28.0 - 29.9 30.0 - 31.9 32.0 - 34.9 35.0 - 39.9 > 40.0 <18.5 18.5 - 20.4 20.5 - 21.9 22.0 - 23.4 23.5 - 24.9 25.0 - 26.4 26.5 - 27.9 28.0 - 29.9 30.0 - 31.9 32.0 - 34.9 > 35.0 Obesity and Mortality BMI BMI From Calle EE, et al. N Engl J Med 1999; 341:1097-105

  10. Diet

  11. Exercise

  12. Side Effects “an Epidemic within an Epidemic”

  13. * Estimated Weight Change at 10 Weeks on “Standard” Dose 6 13.2 5 11.0 4 8.8 3 6.6 Weight Change (kg) 4.4 2 Weight Change (lb) 2.2 1 0 0 -2.2 -1 -4.4 -2 -6.6 -3 *4–6 week pooled data (Marder SR et al. Schizophr Res. 2003;1;61:123-36; †6-week data adapted from Allison DB,Mentore JL, Heo M, et al. Am J Psychiatry. 1999;156:1686-1696; Jones AM et al. ACNP; 1999. Placebo Clozapine Olanzapine Quetiapine Ziprasidone Haloperidol Risperidone Aripiprazole Fluphenazine Chlorpromazine Thioridazine

  14. Obesity Increases the Risk of Disease Willet et al. Guidelines for Healthy Weight (1999) NEJM 341, 427 - 433

  15. Risk Factors and Death Rates from CAD 6 yr mortality /1,000 Stamler J et al. JAMA 1986;256:2823-8 (MRFIT)

  16. Multiple Risk Factors and CAD Risk MI / 1000 men /4 year None HBP Diabetes HBP+DM Dyslipidemia Dyslipidemia + DM or HBP Assman et al, Am Heart J 116:1713-24, 1988 (PROCAM)

  17. INTERHEART: Exponential Increase in CAD Risk with Multiple Risk Factors 2.9 2.4 1.9 3.3 13.0 42.3 68.5 182.9 333.7 512 256 128 64 32 16 Odds ratio for 1s MI (99% CI) 8 4 2 1 All risk ApoB All 4 HTN Smk DM - All 4 All 4 1+2+3 factors ApoA1 (1) (2) (3) + Obes + Ps (4) Note: odds ratio plotted on a doubling scale. Yusuf S, et al. Lancet. 2004;364:937-52. Smk = smoking; DM = diabetes; HTN = hypertension; ApoB = apolipoprotein B; ApoA1 = apolipoprotein A-1; Obes = obesity; Ps = psychosocial factors.

  18. Something Really BadIs Going To Happen

  19. SILENT KILLER

  20. Cardiovascular Disease is Primary Cause of Death in Persons with Mental Illness* 50 40 30 Percentage of deaths 20 10 0 MO OK RI TX UT VA Heart disease Cancer Cerebrovascular Chronic respiratory Accidents Diabetes Influenza/pneumonia Suicide Data From Colton & Manderscheid 2006 *Average data from 1996–2000

  21. Schizophrenia & Diabetes Mellitus • Many studies shown  risk in schizophrenia: • IGT, Insulin resistance • Type 2 Diabetes mellitus • 10% Schizophrenia > 6–8% general population • Studies over several decades, predating both typical & atypical neuroleptics

  22. 30 General population Patients 25.0 25 20 Prevalence of diabetes (%) 15 12.7 10 6.1 5.8 5 3.2 2.4 2.0 0.9 1.1 0.4 0 55–65 15–25 25–35 35–45 45–55 Age group (years) Prevalence of Diabetes in Schizophrenia Compared to General Population Slide thanks to De Hert et al 2006 8.6% diabetes; n=415

  23. Clinical Practice GuidelinesMacrovascular Complications, Dyslipidemia and Hypertension Approximately 80% of people with diabetes mellitus will die as a result of vascular event. DIABETES CANADA RECOMMENDATION The 1st priority in the prevention of diabetes complications should be reduction in CV risk by vascular protection through a comprehensive multifaceted approach… Clinical Practice Guidelines Canadian Journal of Diabetes, 2003 p S64-S72

  24. † Lower extremity amputation or fatal peripheral vascular disease * p=0.035; **p<0.0001 Diabetes-Related Complications and A1C Observational Analysis from UKPDS Any diabetes related endpoint Peripheral vascular disease† Micro- vascular disease Diabetes related death Allcause mortality Myocardial infarction Stroke 12% 14% 14% * 21% 21% ** Percentage Decrease in Risk Corresponding to a 1% Decrease in A1C ** ** ** 37% 43% ** ** Adapted from Stratton IM, et al.BMJ2000;321:405–12.

  25. Hypertension in Patients with Diabetes: BP target and Treatment

  26. Benefits of Treating Hypertension • Younger than 60: • reduces the risk of stroke by 42% • reduces the risk of coronary event by 14% • Older than 60: • reduces cardiovascular mortality by 33% • reduces incidence of stroke by 40% Adapted with permission from CHS: 2000 Canadian Recommendations for the Management of Hypertension.

  27. 1.3 1.8 2.3 2.8 3.4 3.9 4.4 4.9 5.4 Treating to Target: TNT Hypothesis 4S-Pl Secondary prevention Primary prevention 25 TNT Entry 20 Lipid-Pl 4S-Rx With CAD event (%) 15 CARE-Rx CARE-Pl 10 WOS-Pl Lipid-Rx WOS-Rx TNT 10 mg 5 AFCAPS-Rx TNT 80 mg AFCAPS-Pl 0 LDL-cholesterol [mmol/L] * Hypothetical Results

  28. The Global Approach andDisease Continuum Smoking Diabetes Vascular Insult Cardiovascular Damage HIGH BLOOD PRESSURE DYSLIPIDEMIA Endothelial Dysfunction Acute Coronary Syndrome- acute myocardial infarction- unstable angina Angina Congestive Heart Failure Peripheral Vascular Disease- erectile dysfunction- intermittent claudication- abdominal aortic aneurysm Cerebrovascular Disease- transient ischemic attack- stroke- vascular dementia Adapted with permission from Dr. S. Kouz, 2001.

  29. Screening Guidelines American Association of Clinical Endocrinologists, North American Association for the Study of Obesity: Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 2004; 27:596–601

  30. Steno-2: Intensive Therapy Resulted in Improved Combined CV Outcoms Conventional therapy Intensive therapy Number needed to treat (NNT) = 5 Hazard ratio (HR) = 0.47 (95% confidence interval [CI] = 0.24-0.73)RRR= relative risk reduction p=0.007 20 10 60 50 40 0 30 53%RRR Cumulative Incidence of Any Cardiovascular Event (%) 72 24 36 0 No. at risk Months of follow-up 12 60 84 48 96 80 72 70 63 59 50 44 41 13 Conventional therapy 80 78 74 71 66 63 61 59 19 Intensive therapy Gaede et al. N Engl J Med 2003; 348(5):383-93.

  31. Steno-2: Cardiovascular Benefits of Intensive Therapy Maintained for Up to 13 Years of Follow-Up Conventional therapy Intensive therapy 10 70 60 80 20 40 0 50 30 p<0.001 Cumulative Incidence of Any Cardiovascular Event (%) 13 9 5 3 2 0 No. at risk Years of follow-up 80 70 60 46 38 29 25 25 Conventional therapy 12 10 11 7 4 1 8 6 80 72 65 61 56 50 47 31 Intensive therapy Gaede P et al. N Engl J Med 2008; 358(6):580-91.

  32. What I Do and Say- DIET PLAN • Sugar free beverages only • Limit alcohol • Eat until you are not hungry, not until you are full • Fresh fruits only for dessert unless it is a special occasion • Low calorie in between meal snacks, ie celery and carrot stick with low fat dressing, popcorn with seasoning. • Consider Weight Watchers or Overeaters Anon

  33. What I Do and Say- EXERCISE PLAN • 30 minutes of aerobic activity 3 x weekly. Start with a walking program and walk at a speed where you are slightly short of breath and slightly sweaty • 30 minutes of resistance exercises 2x weekly because it converts fat to muscle and muscle has a higher metabolic rate than fat • Pick an activity that you enjoy and can get addicted to

  34. What I Do and Say- Goal and Follow-up • Your goal is to loose 1-2 pounds per month. It’s doesn’t sound like much but in a year that is 12-24 pounds. • If you do what we have talked about, I promise you that you will meet this target. • I will see you in 3 months for follow up • If you are not successful, I have a backup strategy

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