Alzheimer's, sleep, and diabetes--three very interesting amigos

I didn't realize until reading this abstract that Alzheimer's disease affects sleep patterns as well as memory. It makes sense, since adequate sleep is necessary in order to retain memory of information gained during the day.

The medication reviewed in this article is galantamine (Reminyl), and the authors suggest that it is important to time medication administration in order to gain maximum effectiveness and sleep. And, that certain medications help (and interfere with) sleep more than others.

Disrupted sleep can worsen diabetes. Since many people with Alzheimer's also have diabetes--in fact, the two diseases are starting to be recognized as being very strongly linked to each other--this connection between sleep and medication can be very important to understand.

My guess is that if you are on this blog looking for information about Alzheimer's, it is a loved one, not you, that the information is for. Here is the bottom line:
1. If your loved one had problems with sleep before being recommended or placed on medication, it might be a good idea to check with the prescribing physician to be sure this was taken into account when choosing which Alzheimer's medication to prescribe.
2. If your loved one has developed changes in sleep habits since starting an Alzheimer's medication, be sure to let the prescribing physician know.
3. If your loved one's diabetes has become worse despite diligent attention to medications and food intake, consider the influence of sleep or lack thereof.
4. Be sure to ask your physician and/or pharmacist if there is a time of day your particular medication needs to be taken for maximum effectiveness.

Nieoullon A, Bentué-Ferrer D, Bordet R, Tsolaki M, Förstl H. Importance of circadian rhythmicity in the cholinergic treatment of Alzheimer's disease: focus on galantamine*. Curr Med Res Opin. 2008 Dec;24(12):3357-67.

Which came first? Who's on first? Medications and weight gain

As I mentioned in a recent post, olanzapine (Zyprexa) is strongly correlated with weight gain. It's no ordinary kind of weight gain, it's the kind that is associated with hyperlipidemia, diabetes, and even diabetic ketoacidosis. Because of this, it is a popular drug for researchers to study, with regards to its nutritional and metabolic implications. My own fact sheet lists almost 300 references with regard to these interactions.

Now, researchers are starting to look at whether or not certain genetic profiles are more likely to induce weight gain when using this drug. And it turns out, how the leptin gene is expressed may be significantly affecting how a person responds to this medication. Leptin is a hormone that helps to regulate body weight, metabolism, and even reproductive function.

What is interesting is that as I read the research, there are also studies coming out suggesting that the people who best respond to some of these medications may also be the ones who experience the most weight gain when using them. And the whammy there is that the people who experience the most weight gain when using the drugs, are the ones most likely to have low compliance with regard to using them. A medical "Who's on first?" dilemma.

It's fascinating that the brain, weight, and metabolism are all so intricately linked. It certainly means there will be plenty of information for me to blog about, way into the future.

I very much look forward to that!

Srivastava V, Deshpande SN, Nimgaonkar VL, Lerer B, Thelma B. Genetic correlates of olanzapine-induced weight gain in schizophrenia subjects from north India: role of metabolic pathway genes. Pharmacogenomics. 2008 Aug;9(8):1055-68.

Kuzman MR, Medved V, Bozina N, Hotujac L, Sain I, Bilusic H. The influence of 5-HT(2C) and MDR1 genetic polymorphisms on antipsychotic-induced weight gain in female schizophrenic patients. Psychiatry Res. 2008 Sep 30;160(3):308-15. Epub 2008 Aug 20.

Oh, the tangled web we weave, when science we manipulate in order for profits to achieve...

Oh, this story just won't go away.

Years ago, when olanzapine (Zyprexa) was fairly new to the market, my colleagues started commenting that they noticed huge weight gains (like 40-50 pounds) in short time intervals (like a month). No matter where we attempted to get information, Lilly, this drug's manufacturer, insisted that this drug did not increase weight gain.

I had the opportunity to meet one of Lilly's lead marketing guys at a national conference. We exchanged cards and when I got home I emailed him with a proposal that the team of nutritionists I was training in the area of psychotropic medications and hormone imbalances, work with Lilly to create a diabetes management educational program targeted specifically at psychiatrists, who were not specialized in this area but who appeared to need support in order to use these new medications in safe and appropriate ways.

I received an email in return, carbon copied to quite a few people at Lilly, stating that "weight gain on our medication is an unscientific rumor". (I now call this correspondence my "60 Minutes E-mail").

It wasn't 6 months before Lilly was required to put a black box warning on this very medication regarding its potential to cause diabetes. Apparently the timing of my original email struck a raw nerve.

What really bothered me about this whole situation was at the very time Lilly was insisting that that this drug did not cause weight gain, they were marketing it to eating disorder specialists as a treatment option for anorexia nervosa.

Yes, you heard me correctly. Lilly apparently wanted us to believe that the drug doesn't cause weight gain if you use it in people who don't want to gain weight, but it is very effective in causing weight gain in people who desperately need to gain weight.

Fast forward to last Friday. I'm scanning new research abstracts in Pub Med and right next to each other I see these two titles:

Olanzapine in the treatment of low body weight and obsessive thinking in women with anorexia nervosa: a randomized, double-blind, placebo-controlled trial.

Olanzapine (LY170053, 2-methyl-4-(4-methyl-1-piperazinyl)-10H-thieno[2,3-b][1,5] benzodiazepine), but not the novel atypical antipsychotic ST2472 (9-piperazin-1-ylpyrrolo[2,1-b][1,3]benzothiazepine), chronic administration induces weight gain, hyperphagia, and metabolic dysregulation in mice.

There is also, in Pub Med, research to suggest that this medication may trigger binge eating disorder.

So apparently, the newest, quickest way to cure anorexia is to replace it with another eating disorder. Never mind that it creates hormone imbalances that are strongly documented and have mandated a warning be placed on this drug.

I thought when we helped people with anorexia, they were supposed to be healthy in all respects. Not just normal weight with a risk of developing diabetes. Which, by the way, is starting to be associated with Alzheimer's disease.

Insert huge, frustrated, sigh...

Bissada H, Tasca GA, Barber AM, Bradwejn J. Olanzapine in the treatment of low body weight and obsessive thinking in women with anorexia nervosa: a randomized, double-blind, placebo-controlled trial. Am J Psychiatry. 2008 Oct;165(10):1281-8. Epub 2008 Jun 16.

Coccurello R, Caprioli A, Conti R, Ghirardi O, Borsini F, Carminati P, Moles A. Olanzapine (LY170053, 2-methyl-4-(4-methyl-1-piperazinyl)-10H-thieno[2,3-b][1,5] benzodiazepine), but not the novel atypical antipsychotic ST2472 (9-piperazin-1-ylpyrrolo[2,1-b][1,3]benzothiazepine), chronic administration induces weight gain, hyperphagia, and metabolic dysregulation in mice. J Pharmacol Exp Ther. 2008 Sep;326(3):905-11. Epub 2008 Jun 20.

Theisen FM, Linden A, König IR, Martin M, Remschmidt H, Hebebrand J. Spectrum of binge eating symptomatology in patients treated with clozapine and olanzapine. J Neural Transm. 2003 Jan;110(1):111-21.

Gebhardt S, Haberhausen M, Krieg JC, Remschmidt H, Heinzel-Gutenbrunner M, Hebebrand J, Theisen FM. Clozapine/olanzapine-induced recurrence or deterioration of binge eating-related eating disorders. J Neural Transm. 2007;114(8):1091-5. Epub 2007 Mar 20.

Kluge M, Schuld A, Himmerich H, Dalal M, Schacht A, Wehmeier PM, Hinze-Selch D, Kraus T, Dittmann RW, Pollmächer T. Clozapine and olanzapine are associated with food craving and binge eating: results from a randomized double-blind study. J Clin Psychopharmacol. 2007 Dec;27(6):662-6.

When it takes more than a minute to describe how many medications you're taking...time to take a closer look.

Yesterday I was lunching with a dear friend, who mentioned that one of HIS friends has started to have problems with diabetes. I knew this friend also has Alzheimer's disease, so, knowing that many brain and nervous system-targeted medications can provoke insulin resistance and diabetes, I started asking questions about this person's medications.

We called the friend we were discussing for a complete list. Sure enough, in the battery of medications he had been prescribed...was valproic acid, or Depakote. Depakote is well documented to promote the development of metabolic syndrome--a cluster of problems including hypertension, insulin resistance, diabetes, and high cholesterol. Much of the research in this area has focused on women, because polycystic ovary syndrome, a feminine variant of metabolic syndrome, is also correlated with Depakote use. If you're looking for research on the effects of Depakote in men, it's there, it's just a little harder to find.

New research is suggesting that there is a link between diabetes and Alzheimer's disease. Some researchers even call it diabetes of the brain, and there is some evidence to suggest that diabetes medications such as metformin can help delay the progression of Alzheimer's syndrome.

So here we have a guy who has been prescribed a seizure medication, which has likely provoked his problems with diabetes, which is likely worsening his Alzheimer's disease...and what do you know? It seems as though now that he is on galantamine (Reminyl) for his Alzheimer's disease, he's started noticing tremors. I'd bet money on the possibility that the seizure meds are adjusted upward as a result.

So you can see where I'm going. Not only does this keep this poor guy's physicians busy, it pads the pockets of more than one pharmaceutical company, in progressively more expensive chunks.

My friend asked me what I would do? Well, I must qualify that I am not a prescribing medical doctor. I am a registered dietitian who studies the brain and nervous system. But this is where I'd go.

1. Based on the evidence that seizure disorders respond well to omega-3 fatty acids, I'd up those to a DHA equivalent of 1000 mg per day.
2. To help those omega-3's be most effective, I'd teach this person my "S" and "C" rule (avoid, as much as possible, all fats and oils beginning with the letters "S" and "C"...canola being the only exception). I know my friend and his friend eat out quite a bit and it likely is a significant source of these oils.
3. If you reduce the seizure and tremor activity, you reduce the need for seizure medication, and minimizing medications is always very important.
4. I would consider an alternative seizure medication with less potential for disrupting hormone balance. The one that I have seen repeatedly and successfully used in women to achieve this is lamotrigine (Lamictal). Of course, there may be a reason we do not know of that this would not be appropriate, but if this has not been considered it's certainly worth a try.
5. Less Depakote (or potentially no Depakote) potentially also means less insulin resistance, which provides the possibility that the Alzheimer's medication could be reduced. Again, less meds....fewer side effects.
6. Finally, acetyl l-carnitine has been shown to effectively reduce symptoms of diabetes as well as Alzheimer's disease. It also improves cholesterol profiles. And...it has repeatedly and specifically been found to effectively counter the negative side effects of Depakote. I have seen this cited so often recently I can't understand why it is not automatic for any physician prescribing Depakote to simultaneously recommend carnitine.

This trend, of treating one symptom, letting side effects develop, then treating them with other meds that create other side effects, which eventually build vicious cycles of ever-increasing doses of medications...in recent years...has spiraled out of control. The field of nutritional psychiatry is just out of the starting gate. But I'm hooked on its potential. Hopefully in this case, and for others who find this blog, we can help back our friends out of these pharmaceutical corners, save them some money, and improve their overall quality of life.



Luef G, Abraham I, Trinka E, Alge A, Windisch J, Daxenbichler G, Unterberger I, Seppi K, Lechleitner M, Kramer G, Bauer G. Hyperandrogenism, postprandial hyperinsulinism and the risk of PCOS in a cross sectional study of women with epilepsy treated with valproate. Epilepsy Res 2002 Jan;48(1-2):91-102.

Tan H, Orbak Z, Kantarci M, Kocak N, Karaca L. Valproate-induced insulin resistance in prepubertal girls with epilepsy. J Pediatr Endocrinol Metab 2005 Oct;18(10):985-9.

Aydin K, Serdaroglu A, Okuyaz C, Bideci A, Gucuyener K. Serum insulin, leptin, and neuropeptide y levels in epileptic children treated with valproate. J Child Neurol 2005 Oct;20(10):848-51.

Pylvanen V, Pakarinen A,Kniop M, Isojarvi J. Insulin-related metabolic changes during treatment with valproate in patients with epilepsy. Epilepsy Behav 2006 May;8(3):643-8.

Isojarvi JI, Laatikainen TJ, Pakarinen AJ, Juntunen KT, Myllyla VV. Polycystic ovaries and hyperandrogenism in women taking valproate for epilepsy. N Engl J Med 1993 Nov 4;329(19):1383-8.

Rasgon NL, Reynolds MF, Elman S, Saad M, Frye MA, Bauer M, Altshuler LL. Longitudinal evaluation of reproductive function in women treated for bipolar disorder. J Affect Disord 2005 Dec;89(1-3):217-25.

Roste LS, Tauboll E, Morkrid L, Bjornenak T, Saetre ER, Morland T, Gjerstad L. Antiepileptic drugs alter reproductive endocrine hormones in men with epilepsy.  Eur J Neurol. 2005 Feb;12(2):118-24.

Pylvanen V, Pakarinen A, Knip M, Isojarvi J. Characterization of insulin secretion in Valproate-treated patients with epilepsy. Epilepsia 2006 Sep;47(9):1460-4. Neurology. 2008 Sep 2;71(10):750-7.

Beeri MS, Schmeidler J, Silverman JM, Gandy S, Wysocki M, Hannigan CM, Purohit DP, Lesser G, Grossman HT, Haroutunian V. Insulin in combination with other diabetes medication is associated with less Alzheimer neuropathology. Prescrire Int. 2007 Oct;16(91):197-8.

McCain KR, Sawyer TS, Spiller HA. Evaluation of centrally acting cholinesterase inhibitor exposures in adults. Ann Pharmacother. 2007 Oct;41(10):1632-7.

López-Pousa S, Garre-Olmo J, Vilalta-Franch J. [Galanthamine versus donepezil in the treatment of Alzheimer's disease] Rev Neurol. 2007 Jun 1-15;44(11):677-84.

Schrauwen E, Ghaemi SN. Galantamine treatment of cognitive impairment in bipolar disorder: four cases. Bipolar Disord. 2006 Apr;8(2):196-9.

Aarsland D, Hutchinson M, Larsen JP. Cognitive, psychiatric and motor response to galantamine in Parkinson's disease with dementia. Int J Geriatr Psychiatry. 2003 Oct;18(10):937-41.

Isojarvie JI, Rattya J, Myllyla VV, Knip M, Ovine R, Pakarinen AJ, Tokay A, Tapaneinen JS. Valproate, lamotrigine, and insulin-mediated risks in women with epilepsy. Ann Neurol 1998 Apr;43(4):446-51.

Ribacoba-Montero R, Martinez-Faedo C, Diaz C, Salas Puig J. [Remission of polycystic ovary syndrome associated with valproic acid in an epileptic female]. Rev Neurol 2003 Apr 1-15;36(7):639-42.

Bruno G, Scaccianoce S, Bonamini M, Patacchioli FR, Cesarino F, Grassini P, Sorrentino E, Angelucci L, Lenzi GL. Acetyl-L-carnitine in Alzheimer disease: a short-term study on CSF neurotransmitters and neuropeptides. Alzheimer Dis Assoc Disord. 1995 Fall;9(3):128-31.

Thal LJ, Carta A, Clarke WR, Ferris SH, Friedland RP, Petersen RC, Pettegrew JW, Pfeiffer E, Raskind MA, Sano M, Tuszynski MH, Woolson RF. A 1-year multicenter placebo-controlled study of acetyl-L-carnitine in patients with Alzheimer's disease. Neurology. 1996 Sep;47(3):705-11.

Sano M, Bell K, Cote L, Dooneief G, Lawton A, Legler L, Marder K, Naini A, Stern Y, Mayeux R. Double-blind parallel design pilot study of acetyl levocarnitine in patients with Alzheimer's disease. FASEB J. 1992 Dec;6(15):3379-86.

Speak up! There may be options that don't cause weight gain

Schizophrenia is a challenging problem to manage. I'm not a huge fan of medication, but I AM a huge fan of keeping people safe as well as healthy. And in the case of schizophrenia, that often means medication MUST be part of the treatment plan.

I wish, though, that in the process of keeping our schizophrenic loved ones safe with regards to reducing self-harming and otherwise destructive behaviors, we could keep them metabolically safe. In other words, I wish we could also create an antipsychotic that didn't significantly increase weight gain, as well as risk of diabetes and heart disease. The most we seem to be able to do, right now, it seems, is be aware of the relative health risks that medications in this category pose.

One medication that seems to be working well, is ziprasidone (Geodon). One hundred eighty five individuals with schizophrenia or schizoaffective disorder who were initially on either risperidone (Risperdal), olanzapine (Zyprexa), or conventional antipsychotic agents, were switched to ziprasidone, and maintained on this medication for one year. Cholesterol, triglyceride, weight, and behavioral measures were recorded at regular follow-up intervals during this time.

In the individuals who had been switched from risperidone or olanzapine, there were overall significant improvements in weight, total cholesterol, and triglyceride levels. These changes did not seem to show up, however, in those who were switched over from other antipsychotics.

The take home message here is that there seems to be a spectrum along which these medications lie, from most weight-neutral to least weight-neutral. It's important to be aware that if you or someone you know is on medications and you notice changes in metabolic health, that you ask about alternatives.

I know that there are many other reasons why psychiatrists make medication choices in their treatment planning. I have several clients in my case load who simply are not well managed unless they are using the weight-promoting antipsychotics. Their treatment goals are different than what I am referring to here.

If there is a weight/cholesterol/diabetes issue whose onset seems to correlate with the use of an antipsychotic medication, and there are medication options that have not been considered, it is surely worth inquiring about the possibility of using them. Often times, the burden of this communication falls on the loved one, as the person with the problem is not in a cognitive place to be able to do this for himself/herself.

Just know, often times there are options, and it is your right to ask for a discussion about what those options are.

Weiden PJ, Newcomer JW, Loebel AD, Yang R, Lebovitz HE. Long-Term Changes in Weight and Plasma Lipids during Maintenance Treatment with Ziprasidone. Neuropsychopharmacology. 2008 Apr;33(5):985-94

Your meds, your beverages, and your weight

As beautiful as the weather is here in Phoenix right now, it's clear, summer is just around the corner. It always catches me off guard in the spring, when it's so beautiful outside and I want to spend as much time as possible out there...but it's not warm enough for me to be aware of the fact that I'm losing water to the atmosphere. It's only when my eyes start to burn that I realize I've allowed myself to become dehydrated.

This past week I worked with a client who learned the same lesson the hard way. In the month since I'd seen her, despite following a very healthy diet, she gained weight instead of losing the weight she'd wanted to. As we chatted, it became clear that the problem was not in what she was eating, it was in what she was drinking. With our record low humidity readings, it would have been a challenge for anyone to stay hydrated. But in her case, she is also on medications that were increasing her thirst. And she was coping with it by heading to the refrigerator and drinking as much as she could of anything she could find that would quench her insatiable thirst.

Her experience is not unusual. Many psychiatric medications increase thirst. If you compound that with a change in weather, you've got to really be smart about your choices.

Here are some of the rules we discussed, which I hope are helpful to you all as well.

1. Read your labels! Many beverages are sweetened with high fructose corn syrup, which adds calories and can promote the development of diabetes. You've already got more of that risk if you're on many psychiatric meds, so don't double the trouble.

2. Watch out for fruit juices. Even though they've got vitamins, antioxidants, etc., they also have calories. Read the serving size on the label and stick to one serving at a time. I like to freeze fruit juice into ice cubes and then use those cubes in mineral water. I also throw a shot of fruit juice into a smoothie to help intensify the flavor. You can also add juices to marinades and salad dressings if you like to cook and feel creative. It's just not the best idea to drink large quantities right out of the bottle.

3. Look for mineral waters and waters flavored with essences. One of my current favorites is Metro Mint, which tastes like a liquid mint candy. Essences are calorie free, and it's a great way to get flavor in what you're drinking without calories, sugar, or artificial sweeteners.

4. Have fun with herbal teas! There are dozens of flavors, and you can mix and match to create your own concoctions. Here in Arizona a favorite is sun tea. If you have a big glass jar, fill it to the top, add some tea bags, and let the sun brew it over the course of a day.

5. Green tea is one of my favorites. It's full of antioxidants, and it also helps to increase blood flow to the brain. Be sure to look for the decaffeinated version to be sure hydration and sleep don't interfere with each other.

6. Get creative! Just before I sat down to write this blog, I took some decaf green tea I'd brewed in my coffee maker earlier today and then refrigerated, and poured a shot of Metro Mint water in it to wake it up a bit. Mmmmmmm.....!

7. Beware of caffeinated drinks. Caffeine not only makes it hard to sleep, it can promote insulin resistance. And both insulin resistance AND caffeine can promote weight gain. That's a double whammy you absolutely don't want on your plate.

8. Decaf ice coffees, as long as they're not Frappabinos with extra whipped cream, are ok...but remember, even decaffeinated coffee has a little bit of caffeine in it. If you are an all-or-nothing kind of person and tend to go over the top with things you perceive to be "good", then you still might overdo it in the caffeine department.

9. Be sure to eat lots of fruits and vegetables. They are high in water content and can help to keep you hydrated.

10. Drink lots of smoothies and eat lots of soups. Again, it doesn't matter if you "eat" or drink your liquids, it matters that liquids get into you!

A painful reminder: drugs aren't always the answer

I have two reasons for writing this post this morning.

First of all, I spend a couple of hours a day reading new research on psychiatric medications, and it seems that there is a real trend toward throwing all kinds of medications at people with neuropathic pain. If you're the head of marketing at a major pharmaceutical organization, and you're looking at the health statistics in this country, and you see how many people are overweight and headed toward a diagnosis of diabetes...well...anyone looking at you sitting at your desk looking at those numbers is going to see a gazillion dollar signs in that cartoon bubble floating over your head.

To put it another way, anyone who can come up with a sure-fire way to treat neuropathic pain is sitting on a pile of money.

My second reason for posting this is a lot more personal. I have a private client, not overweight at all, whose bulimia has progressed to the point where she has developed diabetes. She got herself into big trouble with her medications because the one she wanted to use, insulin, was the only one she felt controlled her neuropathic pain. Her physician didn't see eye to eye with her...so she decided to use both his meds and hers. We almost lost her over the conflict.

I know why the physician is holding his ground, and I support his choice. But I also have compassion for the physical pain this person must be enduring, which must be a constant reminder, thanks to the ruthless negative voices in her head, that she's really screwed up this time.

So...I've been researching some other options that would allow her to manage her pain, allow her to focus on recovering from the eating disorder, and make the doctor happy.

Enter alpha-lipoic acid. This is an anti-oxidant that isn't all that easy to find in foods, but is right there in the health food store. Not only does it help to regulate diabetes, it's turning out to be very effective in addressing neuropathic pain.

A European study looked at a group of 443 patients who had successfully managed their neuropathic pain with alpha-lipoic acid for at least 5 years. About 300 of them were switched to gabapentin (Neurontin), and 150 of them with no acute symptoms went without any treatment at all during this period of time.

Seventy-three percent of the untreated group started experiencing pain as early as two weeks after discontinuing alpha-lipoic acid. In the gabapentin group, 45% had to stop taking the drug because they could not tolerate its side effects. Fifty-five percent of those using the drug, even though they had done well with alpha-lipoic acid, did not respond to gabapentin. They ended up requiring another medication...which in this study ended up being pregabalin, carbamazepine, amitriptyline, tramadol, and/or morphine .

The researchers commented on the cost of using alpha-lipoic acid as compared to a prescription medication. Not only was there the direct medication cost, but those on medication had almost twice as many office visits during the three months of the study as those who were on the supplement. Not mentioned but important to consider, was the likely additional costs of treating the medication side effects.

The moral of the study? Drug companies, the better mousetrap has already been built. Let's do the right thing and, rather than looking at those dollar signs, get it into the nerves of people like my client who deserve to not have to live like this anymore.

Ruessmann HJ; on behalf of the German Society of out patient diabetes centres AND (Arbeitsgemeinschaft niedergelassener diabetologisch tätiger Ärzte e.V.). Switching from pathogenetic treatment with alpha-lipoic acid to gabapentin and other analgesics in painful diabetic neuropathy: a real-world study in outpatients. J Diabetes Complications. 2008 Apr 8

I'm offering a nutrition class in Tempe, Arizona and Marina del Rey, California

Hello visitor!

If you are female, and your psychiatric medication has caused weight gain, insulin resistance/diabetes, high cholesterol, and/or infertility, please join me in a class designed especially for you!

I will be at the Tempe Whole Foods on Monday, April 7, and at Panera Bread in Marina del Rey on Wednesday, April 16, from 6:30-8:30 pm in both locations. There is a fee of $15 to participate, and I do ask that you reserve your spot and pay in advance.

For more information, please visit the following link: http://afterthediet.com/inCYST.htm

I have also been asked if I will do personal consultations on my trips to California. I can do that if arranged and paid in advance. I can consult with men as well, the reason the class is for women only is because so much of the agenda is about the infertility aspect of the problem...which makes most men squirm!

Hope to see you in class!

Antipsychotics, weight gain, and beautiful minds

My very first experience in mental health was with a young man with schizophrenia who was also diabetic. It was very challenging to help him with his diet, because he was pretty obsessed with telling me how he'd been recruited away from his professional football career to invent the atomic bomb, and that he'd recently invented the Toyota Corolla. I remember thinking, even as a young intern, that it was sad that someone with so much creative energy was sitting in a locked psychiatric unit instead of focusing his mind in a productive direction.

It turns out, schizophrenia and diabetes are a very common combination. No one really knows why, but my guess is that with time, we'll learn that there is some kind of genetic link between the two problems. What makes this relationship especially important to understand, is that there are medications for schizophrenia that can exacerbate the diabetes, as well as other metabolic syndrome-related problems such as increased triglycerides.

A recent study showed that while rates of metabolic syndrome increased over time in patients prescribed antipsychotics, regardless of the specific type of medication, that the risk of developing metabolic syndrome was three times greater in those individuals using second generation antipsychotics. These people also experienced a greater degree of weight gain. The two medications that appeared to be the most problematic were olanzapine (Zyprexa) and clozapine (Clozaril).

The good news is, that there is also research supporting the fact that behavioral and nutrition "training" with individuals who are on these medications can help to lessen the degree of the negative side effects. I have worked with individuals who have not been able to manage their schizophrenia without using one of these two medications, so I understand their value and necessity for the well-being, productivity, and SAFETY of many people who use them. I just wish that every physician who prescribed them also automatically referred their patient to a nutrition professional who could maximize the benefit of the medication while minimizing the risks these medications pose. And I wish that insurance companies would recognize the importance of utilizing this kind of professional help in mental health, so that reimbursement was available. That would encourage many of these people to actually seek help before problems even started.

Sometimes we assume that when a person has a diagnosis such as schizophrenia, or bipolar disorder, that they aren't a candidate for certain types of services. I've not experienced that at all. In fact, some of my most motivated clients have been individuals with these diagnoses. I love my time with them because they are often highly intelligent and creative. They just need people in their lives who take them seriously, who assume that they're intelligent and treat them as such, and who are willing to show them the ropes as far as being healthy.

I think, if I went through my life being treated as if I was not intelligent, that I'd start to believe it myself. Maybe someday, we won't be so afraid of diagnoses such as schizophrenia, and we'll be as comfortable interacting with people who have mental diagnoses as we are with people who have diabetes or high cholesterol.

Imagine how many potential Vincent Van Goghs and John Forbes Nash Jrs. (A Beautiful Mind) are out there just waiting for us to help them access their potential?

De Hert M, Schreurs V, Sweers K, Van Eyck D, Hanssens L, Sinko S, Wampers M, Scheen A, Peuskens J, van Winkel R. Typical and atypical antipsychotics differentially affect long-term incidence rates of the metabolic syndrome in first-episode patients with schizophrenia: A retrospective chart review. Schizophr Res. 2008 Feb 23 [Epub ahead of print]

Kalarchian MA, Marcus MD, Levine MD, Haas GL, Greeno CG, Weissfeld LA, Qin L. Behavioral treatment of obesity in patients taking antipsychotic medications. J Clin Psychiatry 2005 Aug;66(8):1058-63.

Wu MK, Wang CK, Bai YM, Huang CY, Lee SD. Outcomes of obese, clozapine-treated inpatients with schizophrenia placed on a six-month diet and physical activity program. Psychiatr Serv 2007 Apr;58(4):544-50.

Scocco P, Longo R, Caon F. Weight change in treatment with olanzapine and a psychoeducational approach. Eat Behav 2006 May;7(2):115-24.

Kwon JS, Choi JS, Bahk WM, Yoon Kim C, Hyung Kim C, Chul ShinY, Park BJ, Geun Oh C. Weight management program for treatment-emergent weight gain in olanzapine-treated patients with schizophrenia or schizoaffective disorder: A 12-week randomized controlled clinical trial. J Clin Psychiatry 2006 Apr;67(4):547-53.

Alvarez Jimenez M, Gonzalez Glanch C, Vazquez Barquero JL, Perez Iglesias R, Matinez Garcia O, Perez Pardal T, Ramirez Bonilla ML, Crespo Facorro B. Attenuation of antipsychotic-induced weight gain with early behavioral intervention in drug-naive first-episode psychosis patients: A randomized controlled trial. J Clin Psychiatry 2006 Aug;67(8):1253-60.

Mauri M, Simoncini M, Castrogiovanni S, Iovieno N, Cecconi D, Dell'agnello G, Quadrigli M, Rossi A, Donda P, Fagiolini A, Cassano GB. A Psychoeducational Program for Weight Loss in Patients who have Experienced Weight Gain during Antipsychotic Treatment with Olanzapine. Pharmacopsychiatry. 2008 Jan;41(1):17-23.

Olanzapine and stuttering

This is science the way I love to see it.

Olanzapine (Zyprexa) is a popular antipsychotic for which I've found about 30 reported off-label uses in the literature. Rationales for off-label uses of medications are not always bad, but since this medication also has a large body of research documenting its potential to provoke diabetes and heart disease, it has always seemed to me that off-label uses for this medication should be very judicious and sparing.

The reference below challenges one of those off-label uses--stuttering. After reviewing literature, the authors concluded that there was insufficient evidence to support the use of olanzapine as a treatment modality for this problem.

Medications are chemicals. Yes, they can be miraculous in some cases. But they are not always the answer.

As I've encouraged before, I'll remind you again. If you're prescribed a medication, understand before agreeing to use it if the intended use is FDA-approved or off-label. And even if it's FDA-approved, know beforehand what the risks and potential side effects of this medication can be. Be informed.

Bothe AK, Franic DM, Ingham RJ, Davidow JH. Pharmacological approaches to stuttering treatment: reply to meline and harn (2008). Am J Speech Lang Pathol. 2008 Feb;17(1):98-101.

Metabolic syndrome and psychiatric medications

I've been busy videotaping a home study course in my home office, but today it's pouring rain and I don't have enough light. It's a good time to get caught up on blogging.

One of the reasons I designed the home study course I'm videotaping is because of the rapid increase in the use of psychiatric medications for more than purely psychiatric reasons. The metabolic side effects of these medications caught a lot of health professionals off guard. Most nutrition professionals do not anticipate that they will be working in psychiatry when they decide to enter the field.

So people come into their office for help losing weight, and as well-intended as the professional in that office might be...they don't have all the information they need in order to provide the right kind of help.

Many psychiatric medications cause hormone changes, high cholesterol, diabetes, weight gain, and other changes. In women, this cluster of problems can also cause infertility. If you're reading this blog and it sounds like you might benefit from more information on eating well when you have this combination of problems to manage, I wanted to let you know about a second blog that I write. Its original intent is for women with polycystic ovary syndrome (PCOS), the infertility syndrome I just described. But the information is also very pertinent to others who may not be female or who may not be worried about fertility.

If you're interested, please visit us! www.incyst.blogspot.com