Medication Side Effects: Doctor I’m Gaining Weight!

One of the biggest challenges we face in the field of psychiatry is medication adherence. A large portion of the people fail to get better either because they do not start the medication, or do not take it as prescribed. One of the most common reason cited by patients for stopping medication is weight gain. In this article I will detail the approach I take to weight management for patients on psychiatric medications. 

Initial Visit: 

Weight management is a discussion that should happen between the patient and clinician at the first meeting. It’s important to use primary prevention (preventing the onset of weight gain) if possible. We always obtain some objective measures such as height, weight, and calculate the BMI on the initial visit and subsequent visits. Additional tests that may be ordered include HBA1C, fasting blood glucose, and lipid profile. This is where I will take the opportunity to discuss the importance of diet and exercise. For people with little diet or exercise experience I will keep the information very basic. The discussion will center around eliminating processed foods, calorie containing beverages, increasing fruit and vegetable intake, and making good choices when shopping at the food store. I have several handouts with food choices on them that help guide the patient when making food choices at the grocery store. I also recommend patient’s keep a food diary or track their food intake on a mobile app such as my fitness pal. This will help us to understand more about the patient’s eating habits and identify potential areas for improvement. I will build on diet interventions and monitor progress with the food diary or app at each visit. I do not recommend a specific diet, as it’s far more important for the patient to pick something they can be consistent with, and there are multiple ways to achieve weight management goals. At this time the closest diet we have that I’m comfortable recommending is the Mediterranean diet. There is some good evidence that the Mediterranean diet can have an antidepressant effect which is an added bonus.

Exercise

Exercise is the next area to address. I like to ask some screening questions about what type of physical activity the patient engages in, and how much experience they have with fitness/athletics. I will then ask them to track their exercise over the subsequent weeks prior to returning for follow up visit. On the initial visit I will recommend they begin a basic walking program of at least 30 minutes per day preferably seven days per week. This is a simple thing to incorporate on a daily basis, and does not require any special equipment or gym membership. We can improve on this routine and incorporate resistance training on a case by case basis. 

Medication Choice

The next step in the process is to make a medication choice that limits the potential for weight gain. Most psychiatric medications cause weight gain. This is an unavoidable fact. Avoiding the use of medications with the highest propensity of weight gain including Clozapine, Olanzapine, and Mirtazapine is good planning on the physician’s part. It’s important to note that it’s not always possible to avoid these medications. Medications such as Aripiprazole which are considered to be weight neutral, from clinical experience are not weight neutral at all. It’s important for the clinician to make good choices if weight gain is a potential issue that will interfere with treatment.

Medication For Weight Management

My last line of defense against weight gain which often comes too late is medication management. I like to start with Metformin extended release 500 mg daily after the largest meal. This is to test the patient’s tolerance for the medication. The goal is to titrate to 2000 mg/day in divided doses. A B12 level should be checked once per year as Metformin has been known to reduce levels. There is evidence in the literature from a Meta-analysis of all RCTs supporting the use of Metformin for antipsychotic induced weight gain. The important thing to remember is to start the medication at the earliest signs of weight gain, or even before the onset of weight gain in high risk patients. The patients most likely to benefit are those who are younger, more recently started on antipsychotics, overweight but nor obese, and those that had rapid weight gain. 

The second medication I will talk about is Topiramate There is evidence from RCTs to support the use of Topiramate for antipsychotic induced weight gain. There is greater weight loss with Topiramate over placebo, with a mean decrease of 2.8 kg. The effective dose for the medication is 100 to 200 mg/day depending on the patient’s tolerance. Getting to an effective dose can often take some time with this medication.

Final Points

Weight management discussions begin day one when medications are going to be used. Prevention is the first line option with lifestyle modification including diet and exercise. Medication choice also plays a big role. When initiating medication being mindful of the propensity for weight gain, and using medications that are weight neutral if possible, can help. If these measures fail, there are a few options backed by research evidence which can be used but I believe lifestyle modification is the best option. 

Election Anxiety Solutions

Anxiety is a part of life; we all experience it. The amount of anxiety a person experiences is to some degree related to how important a particular outcome is to that person. It seems like everything these days is high stakes and anxiety provoking. There is a global pandemic that continues to create chaos around the world, economic uncertainty, gender and racial inequality, and now a presidential election.

People are more anxious than ever about this presidential election. According to a recent article by the American Psychological Association 68% of U.S. adults say the 2020 U.S. presidential election is a significant source of stress. This is compared to the 2016 election where 52% of U.S. adults found the election stressful. It might just be a symptom of the times, but it remains a significant concern. If you are having election anxiety here are some simple ways to reduce stress and anxiety during this election cycle. 

  1. Make sure you are getting enough sleep. Set a regular sleep time and wake time. Make sure the room you sleep in is as conducive to sleep as possible (e.g. dark room with no ambient light). Limit the bed to sleep and sex only, do not play games on your phone or read in bed. If you can’t sleep get out of the bed and do a mildly strenuous activity. A good example is a crossword puzzle, then come back to bed when you feel tired. If you are not sleeping well it can cause problems in other areas of life such as mood and cognitive function. 
  2. Get outside or stay inside whichever you prefer, but make sure to move. Exercise is a great way to cope with stress and anxiety. There are countless free guided exercise routines on sites like YouTube that require little or no equipment to perform. If you do not like that option, take a walk in your favorite park, take a bike ride, or go for a hike on your favorite trail. 
  3. Limit your consumption of news throughout the day. Set aside one or two times per day to check the news and see what is going on with the election. Resist the urge to continually check in and get play by play updates. This simple, but difficult to follow advice will save you a lot of stress and anxiety. 
  4. Avoid talking to people in your life about the election who are unable to keep their emotions under control while discussing the topic. You should have a good idea of who these people are in your life. This will save you a lot of stress and anxiety by simply choosing to talk about other topics with those individuals.
  5. The last thing I recommend for people who want an activity they can perform to reduce stress is a thought journal . This can be as simple as a piece of paper that you record the thoughts on. There are printable versions of this online. I will provide a link to one such example here. This is a common technique used in cognitive behavioral therapy (CBT) all the time.

What Can We Do to Help Prevent Alzheimer’s disease (AD)

Introduction

The other day I had a conversation with a friend, and the topic of Alzheimer’s disease (AD) came up. My friend’s opinion was basically why would I want to know I have a disease that results in steady decline in function, and lacks any disease modifying treatments? This is in large part true, there have been multiple clinical trials of both symptomatic and disease modifying drugs that failed to produce adequate results. However, this is a very limitted view and neglects the benefits of focusing on modifiable risk factors and primary prevention. We know approximately 1/3rd of AD cases are due to modifiable risk factors, and the implementation of lifestyle modification early may prevent or delay the onset of AD. 

Modifiable Risk Factors

Common modifiable risk factors for AD include hypertension, hyperlipidemia, diabetes, obesity and smoking. Management of these risk factors as early as possible may offer a preventative approach for AD. Equally important are lifestyle modifications such as physical exercise, diet, mediation/mindfulness, and social activity.

Physical Activity

Physical inactivity has a significant influence on the development of AD. Twenty-one percent of AD cases are attributable to physical inactivity. There is a significant number of studies in the literature that indicate physical activity is neuroprotective. We know one of the areas in the brain affected by physical activity is the hippocampus which is involved in memory. Exercise leads to increased neurogenesis and neuroplasticity in the hippocampus. Other benefits of exercise on the brain include increased blood flow, modulation of inflammatory markers, and increased brain-derived neurotrophic factor (BDNF). The exact definition of adequate exercise varies in the literature. Any activity that is sufficient to increase heart rate and can be sustained for 30-60 minutes is my definition. A basic example would be brisk walking for 30-60 minutes. Physical activity two times a week beginning in middle age is associated with reduced risk of AD. Aerobic exercise is associated with additional cognitive benefits including improved processing speed, attention, and memory in adults with mild cognitive impairment. This recommendation is especially important for ApoE4 carriers, as exercise is associated with reduced amyloid deposits. 

Physical activity should be a recommendation for all patients without major health concerns preventing physical activity. The earlier in life a patient begins an exercise routine the better. Some of these studies have looked specifically at starting exercise routines in middle age, but there is no reason to wait. The physical and cognitive benefits of exercise are beneficial regardless of age. It’s much easier to begin training when you are young and healthy. If you build healthy lifestyle habits earlier in life, they are likely to last as you age. Guidelines for regular exercise can be found on the American Heart Association or American College of Sports Medicine websites. 

Meditation

Meditation or mindfulness is a topic that is beginning to get more attention in the medical literature. Chronic stress is believed to effect brain structures involved in memory and may contribute to AD. Psychological stress increases oxidative stress and telomere shortening which could contribute to the neuronal loss seen in AD. Meditation has emerged as a possible way to reduce the stress associated with daily life. The techniques of mindfulness involve directing one’s attention to the present moment to reduce the stress associated with constant thinking and worrying. Randomized controlled trials (RCTs) have shown significant improvements in overall well-being and attention. Improved executive function and reduced inflammatory processes implicated in AD. Additional research and larger RCTs are needed to improve the evidence base. Given the data we currently have there is no reason to not begin mindfulness practices. The techniques are relatively simple and can be learned from a variety of sources. If you are looking for low cost options for learning mindfulness, YouTube has a variety of guided mediations available. I personally like Headspace for beginners because it provides a solid foundation, has a variety of meditation courses, and allows you to track your progress. There is a fee for access to all the courses, but the first 10 sessions are free. Whichever route you choose, spending 10-15 minutes per day practicing mindfulness will lead to a happier and healthier brain. 

Diet

A great deal of research has been conducted over the last several years on the role of diet with respect to cognition. People with high calorie diets, specifically those high in fat are at higher risk for AD. Traditional western diets high in processed carbohydrates, simple sugars, and saturated fatty acids can impact the hippocampus and memory. When Japan transitioned to western diet the incidence of AD increased. Lower calorie diets with lower saturated fat content are linked to lower oxidative stress, decreased Beta amyloid burden, and decreased inflammation. One diet with proven benefits for preventing AD is the Mediterranean diet. This diet is rich in fruits, vegetables, whole grains, olive oil, and fish. There is moderate intake of low-fat dairy products and low intake of red meat, saturated fats, and sugar. Most of the data supporting the reduce risk of AD with this diet comes from epidemiological studies. Studies have shown combining this diet with exercise further reduces the risk of AD. The Mediterranean diet is associated with better cognitive function and reduced cognitive decline. This is one specific example, but the basic principles can be applied without the need to adhere to one specific named diet. 

Some specific foods you may want to add to your diet to prevent AD include fresh berries which have the highest amounts of antioxidants among the fruits. They are also low in calories and work well in diets where weight loss is a goal. Green leafy vegetables and tomatoes have the highest nutritional value when it comes to brain health amongst the vegetables. Foods high in omega-3 fatty acids are considered to be helpful in supporting brain function. The omega-3 fatty acid most important in brain function is docosahexaenoic acid (DHA), which is mostly found in fish. The anti-inflammatory and antioxidant properties of DHA are thought to be responsible for its role in preventing AD. Patients with diagnosed AD are known to have low levels of DHA. Omega-3 fatty acids recommendations from the American Heart association for adults is to eat fish rich in omega-3s two or more times per week. If using a supplement 1-3 grams per day is an adequate dose. Over 3 grams per day, you should consult with your doctor before moving above 3 grams per day. 

Finally, curcumin which is derived from turmeric has anti-inflammatory, antioxidant, and anti-amyloid properties. There is low bioavailability of the curcumin lead to mixed results in the initial trials. A new more bioavailable form called Theracumin demonstrated positive results in a randomized double-blind placebo-controlled study on memory, attention, and amyloid plaques in older adults without dementia. 

Conclusion

While there is no guarantee that lifestyle modification alone will prevent AD, there are some promising studies indicating it plays a role in the development of this disorder. Most of these interventions are things patients can implement in their lives immediately. They will not only improve cognitive function and lower the risk of developing AD, but it will improve and potential reverse other diseases of lifestyle. 

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