13 The systematic review team called for larger trials with long-term follow-up and a focus on weight maintenance following initial intervention. Of the few studies with long-term follow-up, not all sustained long-term weight control. The sample size of RCTs was generally small (median 53, range 15-110) and most participants were not followed up beyond 12 weeks. Most interventions contained cognitive behavioural elements as well as diet or exercise-based content. group setting), behaviour change versus educational content or whether they aimed to prevent weight gain or promote weight loss. 12 Programmes offered benefits regardless of treatment duration, modality (individual vs. Prior to the STEPWISE project, a systematic review of randomised controlled trials (RCTs) reported that non-pharmacological interventions lead to a mean 3.12-kg weight reduction over a period of 8-24 weeks in people with schizophrenia, with commensurate change in other cardiovascular risk factors. However, when the intervention was designed, the developers also considered the effect of the illness and treatment and how these could interact with lifestyle modification. The STructured lifestyle Education for People WIth SchizophrEnia, schizoaffective disorder and first episode psychosis programme (STEPWISE) intervention was intended to promote weight loss through lifestyle modification. Given the underlying mechanisms associated with weight gain, these have taken three, usually exclusive, approaches: (1) lifestyle interventions to improve diet and physical activity, (2) adjustment of antipsychotic medication to minimise the use of drugs associated with the greatest weight change and (3) the use of adjunctive medications that may attenuate the antipsychotic effect. The British Association of Psychopharmacology has reviewed interventions designed to promote weight loss or attenuate weight gain in people taking antipsychotics. 11 Interventions to control or reduce antipsychotic-related weight gain 9 Much of this weight gain occurs within 12 weeks of treatment initiation 10 but continues in the longer term, albeit at a slower rate. 8 Weight gain is observed early in treatment between 37% and 86% of people with a first episode of psychosis gain > 7% of their body weight over 12 months.
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The cause of the increase in obesity is multifactorial and includes environmental factors (such as poverty, urbanisation, poor diet 6, 7 and physical inactivity), disease effects (such as altered neuroendocrine functioning, altered reward perception) and treatment effects antipsychotics cause weight gain in 15–72% of patients. 4 The rates of obesity have increased substantially and have risen faster than in the general population over the past three decades. Weight gain is a key contributor to excess morbidity and mortality, with obesity being two or three times more prevalent in people with schizophrenia than in the general population.
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1– 3 Around 75% of people with schizophrenia die from physical illness, most commonly cardiovascular disease. Mortality rates in people with schizophrenia are increased twofold to fourfold, with life expectancy reduced by 10–20 years. Schizophrenia, a psychotic illness, affects ≈1% of the population. Chapter 1 Introduction Obesity and weight gain in people with schizophrenia