Implementation of a Diet Program for Inpatients With Schizophrenia

January 2007, Vol. XXIV, No. 1

Weight gain is a major concern in patients with schizophrenia, especially in those taking atypical antipsychotics. Although the exact mechanism of weight gain associated with atypical antipsychotics is unknown, we often hear patients complain about an increase in appetite and a decrease in satiety. In fact, patients have come to our office holding a soda in one hand and a cookie in the other after finishing a fast-food meal. With an increase in total caloric intake, weight gain quickly ensues.

Management of weight gain in patients treated with atypical antipsychotics can be challenging. Strategies often focus on pharmacologic interventions or behavior modification. Although studies involving both of these approaches have demonstrated success in reversing weight gain, the ideal approach would be to provide early intervention to prevent weight gain.^1-7 Several trials have attempted to minimize weight gain before the start of treatment with antipsychotics, but most of these were not randomized and controlled.^8-10 Evans and colleagues¹⁰ looked at weight gain with olanzapine in a randomized controlled trial and found that individualized nutritional intervention provided by a dietitian was highly successful in reducing weight gain compared with subjects in the control group who received no nutritional intervention by a dietitian (2.0 kg vs 9.9 kg, P < .013) after 6 months of treatment. A study by Aquila and Emanuel,¹¹ conducted in a residential care center, found that patients treated primarily with olanzapine were able to maintain a stable weight over 2 years by consuming a 2000-calorie diet with restrictions on soda, juice, and second portions.

Based on the success of other programs, Nguyen and colleagues implemented a diet modification program, dubbed the WIN Nguyen diet, designed to minimize atypical antipsychoticinduced weight gain at the acute psychiatric ward at the University of California, Irvine (UCI) (Table). The WIN Nguyen diet includes 4 simple nutritional changes: (1) the elimination of second servings, (2) the replacement of high-calorie snacks with fruits and vegetables, (3) the elimination of desserts, and (4) the substitution of water for sodas and juices. This diet was enforced for all hospitalized patients in the psychiatric unit.

The WIN Nguyen diet is designed to reduce hunger and enhance satiety, which addresses 2 of the main side effects noted by patients taking atypical antipsychotics.^12-15 Restricting meals to single portions ensures that patients have adequate time to appreciate feelings of satiety. This teaches patients that additional meals are not necessary to satisfy initial feelings of hunger. Eliminating desserts and sodas reduces the ingestion of high-calorie foods that only satisfy a patient's appetite temporarily and often cause cravings for additional high-calorie foods.¹⁶ Replacing high-carbohydrate, high-calorie snacks with fruits and vegetables allows patients to satisfy their hunger with low-calorie foods that contain large amounts of fiber, thereby slowing absorption time and increasing the duration of satiety.¹⁷ These diet changes can help reduce a patient's appetite and increase the duration of satiety.

Implementation of the WIN Nguyen diet at UCI resulted in improved weight and body mass index (BMI) profiles in 143 patients who had schizophrenia or schizoaffective disorder treated with olanzapine. A 6-year retrospective review showed that patients hospitalized prior to diet changes experienced a weight gain of 9.4 lb over 22.7 days.¹⁸ In comparison, patients hospitalized after diet modification gained a significantly lower 3.7 lb over 20.2 days (P < .0001). BMI changes had a similar pattern and increased by a significantly larger amount in patients who received a standard diet (1.5) than in patients with diet modifications (0.61) (P = .003).

Unlike the Atkins diet or South Beach diet, the WIN Nguyen diet is not a weight-loss program. It is a diet that addresses cravings and increases in appetite by instituting healthier nutrition practices. Many patients who successfully implement the WIN Nguyen diet notice a significant decrease in cravings for sugar and carbohydrates after several weeks.

Challenges in implementing a diet program
There were many challenges encountered in implementing the WIN Nguyen diet at the acute psychiatric ward at UCI. Before the diet changes, it was extremely common for patients to consume double portions at most meals. Snacks would include ice cream, cookies, cake, or potato chips. Fruits and vegetables were rarely available, and soda was readily consumed.

In addition, family members would often bring in additional food and patients were allowed to order take-out food from restaurants. Given the combination of increased appetite and nearly unlimited food, it was no surprise that many of our patients gained a significant amount of weight during their inpatient hospital stays. It required time and patience to change a routine that had been practiced for many years.

The following case vignette illustrates some of the challenges faced during the implementation of the WIN Nguyen diet.

Case Vignette
SO was a 45-year-old man with a history of schizoaffective disorder, diabetes, hypertension, and morbid obesity. He weighed 378 lb and had a BMI of greater than 40. He was taken off of olanzapine because of its metabolic side effects and subsequently decompensated and required hospitalization. The patient's family reported that other antipsychotics had failed in the past and that the patient had had the best symptom control with olanzapine and valproate. After weighing the risks versus the benefits with the patient and his family, olanzapine and divalproex were started, but this time with a change in diet. With the patient's consent, he was placed on an 1800-calorie American Diabetes Association diet with special instructions to restrict family members from bringing him food.

During the first week of treatment, SO had an increased appetite. After hearing him continuously complain about food cravings, the nursing staff began to disagree with his diet. They openly questioned whether the diet violated SO's rights. Some nurses began to give him additional cookies and allowed him to eat other patients' food. This resulted in SO gaining weight despite the diet order.

Recognizing the difficulties of the situation, a team meeting was called to discuss the issues at hand. Many of the nurses stated that it was cruel to restrict SO's diet, despite his consent. "He has schizophrenia, he can't comprehend what he's agreeing to." They argued that the diet changes made their jobs more difficult because they had to listen to SO's complaints.

After a lengthy discussion, the treatment team decided to act as a cohesive unit and help SO follow through with the reduced-calorie diet. The family was in full support. During the next few days, the patient was redirected from other patients' food and politely reminded why he had agreed to the modified diet. Every time, the patient would reply, "I know, but I am just so hungry." The patient was not given additional snacks. One day, the patient was found in a corner eating a slice of pizza. He had ordered a large pizza and sneaked it past the nurses. When confronted, the patient replied, "I am sorry, but I was so hungry I could not help it." After again discussing the importance of the modified diet and the impact on his health, he further apologized and stated that he wouldn't do it again.

He kept his word. By the end of the second week, the patient reported that his cravings and appetite had decreased. By the end of the fourth week, the patient had no problem with his 1800-calorie diet. He was placed on a conservatorship during that time and stayed in the hospital for 7 weeks. At the time of discharge, he had lost 51 lb.

Changing the mindset
The biggest hurdle in implementing diet modification for the patients was obtaining the support of staff. It was important to change the staff's preconceived notion that patients with schizophrenia were too ill to comprehend and comply with a more nutritious eating plan. The staff often commented that they personally had a difficult time trying to follow a diet, thus there was no way a patient with schizophrenia would have any success.

However, after long discussions about the increased risk of heart disease, hyperlipidemia, hypertension, and cerebrovascular disease as a consequence of obesity among patients with schizophrenia, the staff began to understand that a healthy diet is as important to a patient's physical health as psychotropic medications are to a patient's mental health. Ultimately, the staff agreed to help patients fight their cravings by enforcing the diet modifications, and the practice of sneaking extra food to patients ended.

Patients' rights
The WIN Nguyen diet was initially given to patients with preexisting risk factors such as obesity, hypertension, hyperlipidemia, diabetes, and heart disease. However, in 2003, we instituted diet modifications for all patients on the acute psychiatric ward at UCI. After the generalized implementation of the WIN Nguyen diet, an issue of patients' rights arose. Some staff wondered if the rights of patients without identifiable risk factors were being violated as a consequence of the new diet restrictions.

A patient-rights advocate came to our unit to discuss this matter further. After review, the advocate found that the diet modifications were not considered a violation of patients' rights. Given the potential of atypical antipsychotics to induce weight gain and the cardiovascular risks associated with obesity, denying patients double portions and additional take-out food was deemed a valid means of minimizing future medical morbidity.

Family involvement
In order for diet changes to work, it is crucial to involve family members. They are the ones who bring additional food to patients and provide extra money so that the patient can order take-out food. More important, they play a major role in helping patients maintain a healthy diet after leaving the hospital.

At UCI, patients' families are routinely educated about the importance of diet modifications. When families understand the physical risks of mental illness, including a 2- to 3-fold higher incidence of heart disease, diabetes, and metabolic syndrome, they are more likely to appreciate why prophylactic measures are necessary.^19-23 If families want to bring food to patients, they should be encouraged to bring healthier items such as fruits and vegetables. Families can further support patients by offering positive reinforcement when patients adopt healthy eating habits. Once family members agree with the need for diet modifications, they become important allies in helping patients comply with the diet changes, both in the hospital and after discharge.

Patient involvement
Even if the nursing staff and family members are in favor of diet modifications, successful behavior modifications will not occur until patients accept responsibility for maintaining a healthy lifestyle. As demonstrated in the case vignette, if patients are not completely committed to making changes, they will find a way to subvert the most carefully orchestrated system. Therefore, it is important that patients be included in all decisions regarding diet changes. Education is a valuable tool in this process. Patients should be taught about the dangers of weight gain, the likelihood of increased cravings with atypical antipsychotics, and the ways by which diet changes minimize both cravings and weight gain. This education is most effective when coming from a number of different people. If patients sense that their physicians, nurses, and family members are all in agreement about the need for a healthy lifestyle, they will be more likely to accept it themselves. Throughout the educational process, patients should be reminded that they have ultimate responsibility for taking care of their health.

Summary
The clinical importance of minimizing weight gain in the schizophrenic population cannot be overstated. Reducing weight gain can significantly decrease the risk of cardiovascular disease, diabetes, dyslipidemia, hypertension, and a number of other medical comorbidities.

A reduction in weight gain can be successfully accomplished in the inpatient setting through the implementation of 4 simple diet changes. However, as was demonstrated in the case vignette, a written order for diet changes is not enough. Patients, family members, and the nursing staff must all be educated about why diet changes are necessary in order to maximize patient compliance.

Despite stereotypes to the contrary, patients with schizophrenia are capable of following a healthy diet. It is time for physicians, families, and friends to both believe and expect that.

Dr Nguyen is assistant clinical professor and associate director of residency training and Dr Jensen is resident physician in the department of psychiatry and human behavior at the University of California, Irvine, School of Medicine.

Dr Nguyen reports that he has received research grants from Eli Lilly, Novartis, Bristol-Myers Squibb, and Indevus; he is on the speakers bureau for Eli Lilly and Pfizer; and he is a consultant for Eli Lilly and Roche.

Dr Jensen reports that she has no conflicts of interest concerning the subject matter of this article.

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