Barriers to Positively Impact Weight Gain in a Psychiatric Inpatient Unit

Barriers to Positively Impact Weight Gain in a Psychiatric Inpatient Unit

Gwen A. Levitt, DO, DFAPAa,*

ABSTRACT

Weight gain is a problematic issue for patients with serious mental illness. A previously published study found that hospitalized psychiatric patients gained over 6 lb in stays ≥ 30 days. Furthermore, hospital-wide changes to promote healthy eating were unsuccessful in stemming weight gain. A second study was initiated to institute further interventions to decrease the amount of weight gained by inpatients. Sadly, these interventions were unsuccessful. As inpatient weight gain is a chronic and significant medical problem faced by mental health providers, this report outlines the hurdles faced in this project so that others can glean important insights into tackling this issue.

Prim Care Companion CNS Disord 2019;21(3):18br02400

To cite: Levitt GA. Barriers to positively impact weight gain in a psychiatric inpatient unit. Prim Care Companion CNS Disord. 2019;21(3):18br02400.

To share: https://doi.org/10.4088/PCC.18br02400

© Copyright 2019 Physicians Postgraduate Press, Inc.

aDepartment of Psychiatry, University of Arizona College of Medicine, Maricopa Integrated Health System Behavioral Health Annex, Phoenix, Arizona

*Corresponding author: Gwen A. Levitt, DO, DFAPA, Department of Psychiatry, Maricopa Integrated Health System-BHA, 2619 East Pierce St, Phoenix, AZ 85008 ([email protected]).

Obesity is a serious health issue in the United States, and weight gain is particularly problematic in patients with serious mental illness. A previously published study1 conducted by the author found that patients in an acute psychiatric facility gained an average of 6.81 lb with stays ≥ 30 days. Those who stayed longer gained an average of 5 lb each subsequent month (recorded for 3 months). For those patients who returned to the facility during the study period, 50% had retained the gained weight from the previous admission and then gained more weight. The study1 also reviewed the impact of changes made to dietary practices to promote healthy eating to investigate if they had an impact on patients’ weight. The changes were found to be unsuccessful, as patients actually gained more weight than before the changes were implemented.1

On completion of the aforementioned study, a second phase of research was undertaken. The plan was to empower patients to make healthy food choices by providing written educational material about healthy eating, food choices, and exercise. These options were tailored to be realistic while in an inpatient setting. A large poster was hung by the unit kitchen for all patients to see that showed the calorie counts of the foods commonly served on the unit and guidance for portion control. An incentive form was created for patients to track all the activities they participated in each day that promoted healthy eating and weight management.

Staff members were also educated on similar topics and were asked to engage with patients to promote healthy food choices. An educational poster was hung inside the kitchen for staff to remind them of the calorie counts for common food items that they provided to the patients. Staff members were asked to prompt patients to be active during the designated exercise periods. They were urged to promote healthy eating, create movement groups, lead discussions in community meetings on the topics of healthy eating and the benefits of exercise, and encourage patients to share their progress utilizing incentive forms. Two staff members were designated as the unit leads to promote the project. Both leads were very invested in the project and provided valuable feedback to improve on the educational material provided to staff and patients and introduced interventions such as fresh fruit-flavored water and a healthy eating informational wall calendar. Ultimately, and sadly, the project was stopped as the momentum for change fizzled and was unsustainable over the long term. The 2 project leads both took extended medical leave. Many attempts were made to revamp and reboot the project, but, ultimately, a myriad of issues stalled it.

NOTED BARRIERS

Staff Knowledge

Medical students receive less than 20 hours of education on nutrition during the 4 years of medical school.2 A study3 of residency programs in family medicine, internal medicine, and obstetrics-gynecology in Ohio found that resident physicians received only 2.8 hours of education on obesity, nutrition, and physical activity. Hankey et al4 demonstrated that there is a clear understanding by medical professionals about nutrition, healthy eating, and weight management, but providers are unclear as to how to effectively impart advice on these topics to their patients.

Most nursing programs provide at least 1 course in nutrition. In a study5 assessing if nurse’s utilized their knowledge about healthy eating habits and exercise, 30% to 53% of nurses were found to be overweight, similar to the general population.

Behavioral health technicians (BHT) are not provided with nutritional education as part of their certification, according to the online curriculums posted for training programs. (On a psychiatric unit, the primary interactions with patients throughout the day are with BHTs.) The following example exemplifies the limited knowledge that staff, especially BHTs, have about healthy eating. A male patient was admitted with insulin-dependent diabetes and was placed on a carbohydrate-consistent diet. After a few weeks of blood sugar stability, it was noted that his blood sugar levels were increasing for no obvious reason. It was found that a BHT was giving the patient up to 6 bananas per day. Asked why he was giving the patient so many bananas, the BHT responded that fruit was "healthy."

• Weight gain is a significant issue on inpatient psychiatric units.
• Weight gain is difficult to address and manage in an inpatient setting and requires a multidisciplinary approach to review hospital policies and processes.
• Education of patients and staff is crucial for management of weight gain in the psychiatric inpatient population.

If hospital staff are limited in their knowledge of healthy eating and do not practice healthy eating habits or exercise, they may be unable to help patients eat well and engage in physical activity. Whether staff realize it or not, they do serve as role models and mentors to patients.

Food as a Behavioral and Emotional Management Tool

In an inpatient setting, there are limited freedoms and options for managing behaviors in the form of incentives or positive reinforcement such as patio privileges and extra recreational activities. If a patient is having anxiety, is becoming upset, or is refusing to follow direction, offering a snack is a simple way to avoid a larger conflict. Some patients then learn that if they act a certain way, staff will give them extra food.

Stress eating is very common. An American Psychological Association survey6 found that 38% of adults queried admitted to overeating in the past month due to feeling stressed and 49% admitted to weekly stress eating. It stands to reason that the stress of an inpatient stay might drive patients to snack. Boredom is often cited by patients, and snacking is a way to combat this on an inpatient unit.

Patients often request for their visitors to bring in food such as pizza, burgers, soda, candy, or cookies. Many psychiatric facilities allow personal snacks to be given out to patients, and the hospital staff has limited control over these items.

Hospital Food

Hospitals aim to keep raw food costs at $6 to $8 per patient per day, which translates to about $3 per meal per day.7 It can be a challenge to stay within the allotted budget when purchasing healthy foods such as fresh fruits, vegetables, and good quality meats. Food items, especially snacks, are often pre-processed packaged foods that are typically high in calories.

Inpatients in many facilities do not have the ability to choose their meals. If patients are unhappy with the items on their tray, they may compensate by eating more snacks. Many psychiatric hospitals serve meals cafeteria style, which can cause a patient to obtain more food than is necessary or healthy.

Exercise

Options for exercising in an inpatient setting are limited. Most times, staff members have to organize and initiate exercise to motivate patients to participate. Primarily, hospitalized patients tend to be sedentary.

Lack of Patient Education

Education about healthy eating and exercise is not part of the care offered to most psychiatric inpatients.

INTERVENTIONS

Research has addressed weight control and health promotion in various outpatient mental health populations.1 Interventions that include nutritional counseling, exercise, behavioral modification, and healthy eating programs do demonstrate modest benefits in weight loss and biometric markers (eg, lipids and glucose). There is little if any information on the use of these types of interventions in an inpatient setting. As the length of stay in inpatient settings tends to be short, it would be difficult to quantify if educational interventions such as these would make a significant impact. Expansion of educational opportunities for patients to learn about such topics is a start to tackle the issue of weight control.

Antiobesity pharmacotherapy such as sibutramine and orlistat have shown some benefit for addressing weight gain as well.8,9 These medications are not without side effects and may be contraindicated in many of the patients who might be at high risk for weight gain. Use of these medications may be a simple Band-Aid to avoid weight gain but does little to change overall habits and behaviors that lead to weight gain. These medications are not commonly found on government formularies, and orlistat costs, on average, more than $600 a month (sibutramine costs about $100 a month).

The one unavoidable variable that impacts weight gain in psychiatric patients is medication. Antipsychotics, mood stabilizers, and, to some extent, antidepressants are known to promote weight gain. Prescribers can attempt to mitigate this problem by avoiding medications known to promote weight gain, but doing so is often impossible.

Formation of a multidisciplinary committee including physicians, nurses, nutritionists, dieticians, hospital administration, and food service staff to review hospital practices may be the best approach to making an impact on inpatient weight gain. Assessment of current menus and snack options to ensure that healthy foods and well-balanced meals are provided is important, as is a review of policies about snacks and outside food items. Also, creating a short and impactful patient education program and looking at ways to provide patients an exercise program and safe equipment could mitigate weight gain. It would also be helpful to have a staff mentor (exercise trainer) teach and encourage physical fitness and to have the physician write an order for the patient to participate in interventions to assist staff in obtaining cooperation from patients.

Nutrition education about not only healthy eating but also the impact of diet in patients is necessary for all staff. Refresher courses should be completed routinely to keep staff informed of new information and to reinforce the importance of a healthy lifestyle. Campaigns to promote healthy eating and exercise aimed at staff can also serve as a powerful reinforcement tool. It is important to teach staff ways to manage patient behaviors other than utilizing food as a panacea and to have alternative tools available.

CONCLUSION

Weight gain in an inpatient setting is bound to happen. Simple measures such as changing food trays, limiting portions, controlling types and amounts of snacks, and removing vending machines are not enough to combat the problem. Promotion of healthy eating and exercise must be a multidisciplinary effort and should be seen as a priority. Without the support and prioritization from the management team, staff "in the trenches" will not actively tackle this problem.

In a time when costs of medical care are skyrocketing and reimbursements for that care are diminishing, the issue of food and exercise may not be high on the priority list. Management of weight and promotion of healthy eating and exercise help patients maintain overall health and avoid future serious medical issues that have the potential to be very costly. It is crucial that providers monitor for obesity and associated illnesses such as diabetes and cardiac and vascular disease. After all, our goal as medical providers is to promote health and do no harm.

Submitted: October 24, 2018; accepted February 13, 2019.

Published online: May 9, 2019.

Potential conflicts of interest: None.

Funding/support: None.

REFERENCES

1. Levitt GA, Shinault K, Patterson S, et al. Weight gain in psychiatric inpatients: are interventions making a positive impact? Prim Care Companion CNS Disord. 2017;19(4):17m02111. PubMed CrossRef

2. Greger M. How much nutrition education do doctors get? https://nutritionfacts.org/2017/06/08/how-much-nutrition-education-do-doctors-get/. Accessed August 20, 2018.

3. Colino S. How much do doctors learn about nutrition? https://health.usnews.com/wellness/food/articles/2016-12-07/how-much-do-doctors-learn-about-nutrition. Accessed August 10, 2018.

4. Hankey CR, Eley S, Leslie WS, et al. Eating habits, beliefs, attitudes and knowledge among health professionals regarding the links between obesity, nutrition and health. Public Health Nutr. 2004;7(2):337-343. PubMed CrossRef

5. Ross A, Bevans M, Brooks AT, et al. Nurses and health-promoting behaviors: knowledge may not translate into self-care. AORN J. 2017;105(3):267-275. PubMed CrossRef

6. Stress in America. Are teens adopting adults stress habits. American Psychological Association website. https://www.apa.org/news/press/releases/stress/2013/stress-report.pdf. February 2014. Accessed October 10, 2018

7. Non-patient service rules. FoodService Director website. Foodservicedirector.com. 2009. Accessed August 18, 2018.

8. Apfelbaum M, Vague P, Ziegler O, et al. Long-term maintenance of weight loss after a very-low-calorie diet: a randomized blinded trial of the efficacy and tolerability of sibutramine. Am J Med. 1999;106(2):179-184. PubMed CrossRef

9. Finer N, James WP, Kopelman PG, et al. One-year treatment of obesity: a randomized, double-blind, placebo-controlled, multicentre study of orlistat, a gastrointestinal lipase inhibitor. Int J Obes Relat Metab Disord. 2000;24(3):306-313. PubMed CrossRef