Nutritional Status of Schizophrenic Patients at Department Of
Blood Glucose Control in a Schizophrenic Population in an Outpatient Setting
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Transcript of Blood Glucose Control in a Schizophrenic Population in an Outpatient Setting
DANIEL MOLLOY, MDMENTOR: JAMES STEPHEN, MD
Blood Glucose Control in a Schizophrenic Population in an Outpatient Setting
Schizophrenia
Meltzer H.Y., Bobo W.V., Heckers S.H., Fatemi H.S. (2008). Chapter 16. Schizophrenia. In M.H. Ebert, P.T. Loosen, B. Nurcombe, J.F. Leckman (Eds), CURRENT Diagnosis & Treatment: Psychiatry, 2e.
Complex psychiatric disorder with many medical and psychosocial complications.
Characterized by a heterogeneous mixture of clinical features psychosis (1).
Incidence: 10 to 40 / 100,000 population
High risk for poverty, unemployment, homelessness or inadequate housing, ill health, and poor access to health care(1).
Background
American Psychiatric Association. DSM-IV. Diagnostic and statistical manual of mental disorders. 4th ed. Washington: American Psychiatric Association, 1994: 273-315
Per DSM – IV TR (2), to diagnose schizophrenia, a patient must have at least 2 of the following:
Delusions Hallucinations Disorganized speech and/or Disorganized behavior, Negative symptoms (alogia, avolition, and flat affect).
These must be at least 6 months in duration and produce disturbances in work, self-care, and interpersonal relations.
Background
McGrath J, Saha S, Welham J, El Saadi O, Macauley C, Chant D. “ A systematic review of the incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status and methodology.” BMC Med . 2:13 (2004).
Associated medical issues(3):
20% decreased life expectancy
Increased rates of cardiovascular and metabolic abnormalities.
Overall poorer health – related quality of life .
Background
‘Schizophrenia and Diabetes 2003’ Expert Consensus Meeting, Dublin, 3–4 October 2003: consensus summary, The British Journal of Psychiatry (2004) 184: s112-s114.
Prevalence of type 2 diabetes in schizophrenic populations can be 2–4 times higher than in the general population, 15–18%(4).
The exact reason in unclear, but likely to include
Poor dietSedentary lifestyleSubstance abuseFamily association - monozygotic twins/1st
degree relatives
Hemoglobin A1c
Diabetes Care January 2012 vol. 35 no. Supplement 1 S11-S63
Formed by the irreversible, nonenzymatic binding of glucose to the terminal end of the beta chain of hemoglobin
Serves as a predictable measure of average blood glucose over period of 90 – 120 days.
• ADA Clinical Practice Recommendations now recommend using HbA1c to diagnose diabetes using a NGSP-certified method and a cutoff of HbA1c ≥6.5%(5).
Hemoglobin A1c
Certain limitations to hemoglobin A1c are known:
Dependent on lifespan of RBC
Influenced by hemoglobin variety
Laboratory –dependent standardization
Antipsychotic medications
Gautam, S., and PS Meena. "Drug-emergent Metabolic Syndrome in Patients with Schizophrenia Receiving Atypical (second-generation) Antipsychotics." Indian Journal of Psychiatry 53.2 (2011): 128-33
Antipsychotic medications commonly used in the treatment of schizophrenia have a well – documented tendency to cause hyperglycemia and/or insulin resistance (6).
Particularly pronounced in patients receiving certain members of the class of second – generation antipsychotics(6).
Cause is not entirely elucidated
Rationale
• Quality outcome measurements are becoming an increasingly important aspect of day – to –day practice.
Rationale
Mittal, Dinesh, MD. "Does Serious Mental Illness Influence Treatment Decisions of Physicians and Nurses?" Lecture. American Psychiatric Assocation 2012 Annual Meeting. San Francisco. 20 May 2013. APA 166th Meeting. American Psychiatric Association, May 2013
Bias towards mentally ill patients influences healthcare provider decision making (4).
One study with standardized patient showed HCP less likely to prescribe appropriate therapies/medications to schizophrenic patients(4).
Also includes mental health professionals (4).
Aims
Primary Objective: To determine whether a difference in average blood glucose control exists between a schizophrenic and a non - schizophrenic population in an outpatient setting.
Aims
Secondary Objectives:
To determine whether an association exists between A1c levels and the number of healthcare contact events during study period.
To assess the prevalence of vascular disease between schizophrenic and non – schizophrenic patients.
Methods
Retrospective case – control study
IRB approval obtained prior to study commencement
Data collected over a one year period from April 2012 to April 2013
Chart – based; information obtained from EMR
Methods
Inclusion criteria:
Diagnosis of Schizophrenia
Treated in outpatient setting
At least one hemoglobin A1c obtained within the study period
Methods
Exclusion criteria:
End stage renal disease
Hemolytic anemia/ hemoglobinopathy
No hemoglobin A1c within study period
Methods
245 Schizophrenic patients identified.
72 diagnoses of Diabetes mellitus.
7 excluded due to exclusion criteria
Total of 65 patients included
Methods
A control cohort of 65 randomly sampled diabetic patients was recruited based on several matching variables:
Age Race Gender.
Variables
Age Gender Race BMI LDL level Triglyceride level HDL level Smoking status Number of clinic visits
during study period
Medications for schizophrenia
Use of Insulin therapy Anemia Kidney disease Vascular
complications
Statistical Analysis
ANCOVA, t-tests, chi-square (χ2) tests as appropriate.
SPSS software (SPSS Inc, Chicago, Illinois) was used for data analysis.
P<0.05 was considered significant
Variable Schizophrenic Nonschizophrenic
p-value
Age 56.46 56.02 0.81
Gender M 28F 37
M 30F 35
0.72
Race Caucasian 36AA 22Hisp 6
Caucasian 38AA 22Hisp 5
0.76
A1c 6.645 8.409 0.001
Number of Clinic visits
4.6 4.83 0.71
Smoking Y 29N 36
Y 20N 45
0.10
Kidney Disease
Y 10N 55
Y 10N 55
N/A
Variable Schizophrenic Nonschizophrenic
p-value
Mean Age 56.46 56.02 0.81
Gender M 28F 37
M 30F 35
0.72
Race Caucasian 36AA 22Hisp 6
Caucasian 38AA 22Hisp 5
0.76
A1c 6.645 8.409 0.001
Number of Clinic visits
4.6 4.83 0.71
Smoker Y 29N 36
Y 20N 45
0.10
Kidney Disease
Y 10N 55
Y 10N 55
N/A
Variable Schizophrenic
Nonschizophrenic
P-value
LDL 103.5 102.9 0.93
HDL 44.3 44.9 0.84
Triglycerides
158.4 190.5 0.21
Anemia Yes 15N o 50
Yes 10No 55
0.266
BMI 34.0 35.0 0.736
Diabetes treatment
Insulin 16Oral 43Diet 6
Insulin 36Oral 25 Diet 4
0.002
0.008 (without insulin)
Vascular complications
Schizophrenia P-valueYes No
0.001
Yes 6 22No 59 43
Schizophrenia and diabetes – associated vascular complications
Vascular complications defined as coronary artery disease, peripheral vascular disease, and cerebrovascular disease
Hemoglobin A1c inSchizophrenic patients treated with typical vs
Atypical Antipsychotics
Number of Schizophrenics
A1c
Typical Atypical Other p-value14 45 6
6.45 6.94 7.40 0.323
No. Variable P – value1 Age 0.0062 Gender 0.8203 Race 0.0304 Smoking status 0.3065 Anemia 0.5166 Number of clinic visits 0.4577 BMI 0.2728 Schizophrenia 0.001
Limitations of Study
Retrospective
Chart based
Multiple providers participating in patient care
Conclusions
1. There was a significant difference in the hemoglobin A1c between patients with schizophrenia {mean A1c 6.6, SD =1.3} and without schizophrenia {mean A1c 8.4, SD =2.6} after controlling the effect of age, race, gender, BMI, anemia and number of clinic visits (p <0.001).
Conclusions
2. There was a significant difference in the prevalence of vascular diseases between patients with schizophrenia {9.2%} and without schizophrenia {33.8%} after controlling the effect of age, race, gender, BMI, anemia and number of clinic visits (p <0.001).
Conclusions
3. There was no significant difference in the hemoglobin A1c between schizophrenic patients taking atypical antipsychotics {mean A1c 6.9, SD =1.1} and patients taking typical antipsychotics{ mean A1c =6.4, SD = 1.6} (p<0.323).
Conclusion/Discussion
A diagnosis of schizophrenia does not mean that a patient is incapable of managing their medical conditions.
Caretakers must be careful to avoid letting bias influence their decision – making.
Further prospective study may uncover reasons for this difference.
Acknowledgements
Srikrishna Varun Malayala, MBBS
Khalid J Qazi, MD, MACP
Henri Woodman, MD
Nikhil Satchidanand, PhD
Thank You