PHYSICAL HEALTH

IMPROVEMENT PROGRAMME

AT THE WESTERN

COMMUNITY MENTAL HEALTH

CENTRE

Eunju Cha , Adelaide Australia

Eunju.Cha@health.sa.gov.au

26 November 2015 at National Mental Health Conference

Contents

> Prevalence and inequities of poor physical health in

people with SEMI

> Health improvement interventions at the Western

Community Mental Health Centre in Adelaide (Self-

Care Management Support Interventions)

> The need to change the culture SEMI: Severe and enduring mental illness

What is already known about the topic?

The average life expectancy of someone diagnosed with SEMI is between 13 - 30 years LESS than the general population

The life expectancy gap with the general population is widened

(De Hert et al. 2011a )

What is already known about the topic? Approximately 60 % of this excess mortality is due to physical illness

• Cardiovascular disease is the most prevalent cause of death

• Diabetes

• Respiratory disease

• HIV, Hepatitis

• Cancer

• Etc.

(Parks et al. 2006 & De Hert et al. 2011a)

Metabolic Health Action Plan

Source: Advertiser 2014

‘It’s not just about your head’

Things to assess physical health

Physical health assessment over four months (03/10/2013 - 06/02/2014)

> Male – n.87, Mean age 40.8 years

(Min 18 - Max 69 years)

> Female – n.46, Mean age 49.5 years

(Min 24 - Max 67 years)

> GP referrals - 39 people

The result of initial physical health assessment : Overweight and central obesity

> Body Mass Index (BMI)

• 63.2 % in above abnormal range of BMI

• 42.4 % of BMI was greater than 30

> Waist circumference

• 64% in above normal range of waist circumference

• 39.1 % were > 110 cm

Barriers for people in pursuing optimal physical health

> Internal

Lifestyle

Side effects of medication

Inadequate seeking of physical care

> External

Poverty

Discrimination, social isolation

Distrust of medical establishment

Healthcare provision (De Hert et al.2011b ,Van Hasselt et al. 2013)

Why don't people do what they know is good for their health?

Why don't people just do what health care

professionals tell them to do?

How to support..... > Consider the individual situation

> Adopt an holistic approach

> Aim to empower the individual

How to support.... Self-Care Management:

> Self-Care Management refers to what the person with a health condition does by taking action to cope with the impacts of their chronic conditions

> Self-Care Management Support refers to what others such as services, health & welfare professionals, family, friends and carers do to support the person to achieve effective self-care management

(Adams et al. 2004)

Successful Self-Care Management Support

1. Assessment of self-care management

2. Collaborative problem definition

3. Targeting, goal setting & planning

4. Self-care management training and support services

5. Active and sustained follow-up

(Lawn & Battersby 2009)

Assessment Assess physical wellbeing issues holistically

> lifestyle

> diet

> exercise

> sleep

> dental care

> eyes

> feet

> breast check

> prostate check

> smoking status

> alcohol intake

> caffeine intake

> cannabis use

> voiding issues

> bowel activities

> safe sexual activities

> general mood and

outlook

Interventions in practice

> Breathing techniques

> Mindfulness

> Spot meditation

> Cardio-metabolic health education

> Material (to improve health literacy) including newsletters

> Visual aids to assist in physical health improvement education

> More depending on individual needs

> Etc.

Tools of my trade

Tools of my trade

Newsletters

ISSUE1 2013 October

AT LEAST 30 MINUTES PER DAY (AND PERHAPS UP TO 60 MINUTES PER DAY)

OPTIMAL BODY WEIGHT

BALANCED DIET

METABOLIC SYNDROME; Abdominal obesity and elevated body mass index ( BMI),

hypertension, high blood triglycerides and low levels of high density lipoproteins (HDL)

, and insulin intolerance, pre-diabetes or type 2 diabetes.

(Harvard health publication)

at t ssue as an ndo r ne or an Body fat was once regarded as little

more than a storage depot waiting

passively to be used for energy. But Fat

cells — particularly abdominal fat cells

— are biologically active, producing

hormones and other substances that

can profoundly affect health.

One such hormone is leptin, which is

normally released after a meal and

dampens appetite. Fat cells also produce

the hormone adiponectin, which is

thought to influence the response of

cells to insulin. Visceral fat pumps out

immune system chemicals called

cytokines (e.g. tumor necrosis factor

and interleukin-6) that can increase the

risk of cardiovascular disease by

promoting insulin resistance and low-

level chronic inflammation. These and

other biochemicals, some not yet

identified, are thought to have harmful

e t ne s etter to means that muscle d v do ’ po d d q o o m v of

insulin, insulin being the pancreatic hormone that carries glucose into the cells.

Glucose levels in the blood rise, worsening the risk for diabetes. Together, insulin

resistance, high blood glucose, excess abdominal fat, abnormal cholesterol levels

(including high triglycerides), and high blood pressure constitute the metabolic

syndrome, a major risk factor for heart disease and stroke.

ff o ’ v o ,

blood pressure, and blood clotting.

One reason excess visceral fat is so

harmful could be its location near the

portal vein, which carries blood from

the intestinal area to the liver.

Substances released by visceral fat,

including free fatty acids, enter the

portal vein and travel to the liver, where

they can influence the production of

blood lipids.

Visceral fat is directly linked with

higher total cholesterol and LDL (bad)

cholesterol, lower HDL (good)

cholesterol, and insulin resistance.

Although scientists are still deciphering

o of d v d o mo , ’

becoming clear that excess body fat,

especially abdominal fat, disrupts the

normal balance and functioning of these

hormones. (Harvard Health Publication)

he e e t o o he a se reted ro at t ssues to hea th

Visceral obesity: a form of obesity due to excessive deposition of fat in the abdominal area.

Glycogen: the storage form of glucose in animals and humans which is like the starch in plants.

Glucagon: a hormone secreted by the pancreas, raises blood glucose levels.

Synthesis: the production of chemical compounds by reaction from simpler materials.

Lipoproteins: a biochemical assembly that contains both proteins and lipids.

Fatty acids: are the building blocks of the fat in the body and in the food.

Adipose tissue: body fat or just fat is loose connective tissue composed mostly of adipocytes.

Adipocytes: are the cells that primarily compose adipose tissue, specialized in storing energy as fat.

Triglycerides: derived from glycerol and three fatty acids. There are many triglycerides. They are the main constituents of vegetable oil

(typically more unsaturated) and animal fats (typically more saturated). Triglycerides are made from carbohydrate.

ISSUE2 2013 November

Physical Health

hhealth focus METABOLIC SYNDROME; Abdominal obesity and elevated body mass index ( BMI),

hypertension, high blood triglycerides and low levels of high-density lipoproteins (HDL) ,

and insulin resistance, pre-diabetes or type 2 diabetes.

Insulin resistance is a precursor to a variety of metabolic abnormalities, including systemic inflammation, visceral obesity, and type 2 diabetes.

Insulin resistance may make you fat For most of us, insulin is most readily associated with diabetes mellitus. Most people do not often pay insulin a second thought until they experience problems with insulin. However, insulin does more than just regulating blood glucose levels, insulin may make you fat and increase the risk of cardiovascular disease. So it is important to understand key actions of insulin regarding weight gain and increasing risk of cardiovascular disease, as well as type 2 diabetes etc. What is Insulin? Insulin is a hormone that is secreted by the pancreas. Most actions of insulin are

directed at metabolism of carbohydrates (sugars and starches), lipids (fats), and proteins.

Insulin is necessary for uptake of amino acids to tissues and for protein synthesis.

Insulin activates glucose uptake. When blood glucose levels rise above about 5

mmol/l , glucose is stored as glycogen in the liver and skeletal muscles and also as triglycerides in the fat cells by insulin.

Insulin actions in fat cells may cause you fat and cholesterol problems. As mentioned above, the liver stores excess glucose as glycogen. However, over-eating carbohydrates can and does lead to fat production and storage (triglyceride). Insulin also inhibits breakdown of fat in adipose tissue (or fat tissue). Insulin promotes synthesis of fatty acids, which are exported from the liver as lipoproteins (e.g. low density (LDL) and high density ( HDL) lipoproteins . The lipoproteins are torn apart in the circulation, providing free fatty acids for use in other tissues, including adipocytes, which synthesise triglycerides.( which means your lipid profile becomes imbalanced)

The effect of

Insulin and Glucagon

Outcomes Numbers of people in weight changes following one initial physical health assessment

Outcomes Numbers of People in weight changes following two consultations

Outcomes Numbers of People in weight changes following more than 3 consultations

Outcomes Average weight (kg) changes following consultations

1.7

-2.2

-5.6

-6

-5

-4

-3

-2

-1

0

1

2

3

Attended only initial consultation Attended 2 consultations Attended > 3 consultations

Weight change (kg) over 6 months since 03.10.13 (data colleted in 04/2014)

Summary of the project

> Poor physical health in people with SEMI does not

have to be inevitable

> Mental health care professionals have an opportunity to

improve the physical and mental health of people with

SEMI through systematic monitoring and collaborative

health promotion interventions

Clinical Pearls > Individualised/ tailored and specialised one-on-one nurse-led

self-care management support interventions in multiple sessions have great potential to achieve improved health outcomes and quality of life of people with SEMI

> nhan ed nd v dua hea th are rov ders’ a ab ty or se -care management support is essential to success self-care management support interventions

> Opportunistic and preventative health care support can obtain equity of people with SEMI in health

SEMI: Severe and enduring mental illness

References

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> Adams KG, Greiner AC, Corrigan JM.,eds. 2004, Reoport of summit. The 1st annual crossing the quality chasm summit: a focus on communities; Jan 6-7. Washington, DC:National Academies Press.

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References

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> S.A. Health 2012 Guidelines for completion MR 77D Clozapine Patient Protocol - Monthly government of South Australia S.A. health, <http://www.sahealth.sa.gov.au/wps/wcm/connect/31aec9004c330e7cb3d8b7e408a887aa/MR77D+ClozapinePatient+Protocol+-+Monthly+Form+Guidelines+for+Completion+Revised+March+2012FINAL.pdf?MOD=AJPERES&CACHEID=31aec9004c330e7cb3d8b7e408a887aa>.

> S.A. Health 2012 Metabolic Health Action Plan S.A. health ,

<http://www.sahealth.sa.gov.au/wps/wcm/connect/6a080d004c3f313b95a2b5e408a887aa/Metabolic-action-

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Presenter : Eunju Cha Eunju.Cha@health.sa.gov.au