Cardiometabolic effects of physical activity interventions for people with schizophrenia

Cardiometabolic effects of physical activityinterventions for people with schizophrenia

Davy Vancampfort1,2, Jan Knapen1,2, Marc De Hert1, Ruud van Winkel1,Seppe Deckx1,2, Katrien Maurissen1,2, Joseph Peuskens1, Johan Simons2 andMichel Probst1,2

1University Psychiatric Centre K.U.Leuven, Campus Kortenberg, Belgium2Faculty of Kinesiology and Rehabilitation Sciences, Catholic University of Leuven, Leuven,

Belgium

Objectives: To identify and evaluate the recent evidence of physical activity (PA) with or without

diet counselling on cardiometabolic parameters in people who have schizophrenia.

Methods: Keyword searches were used to identify articles since 2003 up to August 2009 from

PubMed, SPORTDiscus, Cochrane Central Register of Controlled Trials, EMBASE, PEDro, DARE,

ProQuest Dissertations and Theses and PsycINFO. There were no limitations in terms of study

design and sample size. Data were extracted from each included study using key items that

included participants, study design, intervention modalities, and outcome measures.

Results: Thirteen studies met the inclusion criteria. Physical activity with or without diet counselling

results in modest weight loss, reductions in systolic and diastolic blood pressure and decreases

in fasting plasma concentrations of glucose and insulin. Identifying an optimal dose or intervention

strategy for PA is not yet possible. Compliance to PA seems to be an important predictor of the PA

response.

Discussion: There is evidence that PA with or without diet counselling is feasible and effective in

reducing weight and improving obesity-related cardiometabolic risk profile in people with

schizophrenia. More research focussing on the effectiveness of different PA interventions in

prevention and treatment of the metabolic syndrome in people with schizophrenia is highly

needed.

Keywords: metabolic syndrome, physical activity, schizophrenia

Introduction

Schizophrenia is one of the most debilitating psy-

chiatric disorders.1 The Diagnostic Statistical

Manual-IV (DSM-IV) criteria2 for schizophrenia

include positive and negative symptomatology severe

enough to cause social and occupational dysfunction

over a period of at least 6 months. Positive

symptomatology reflects an excess or distortion of

normal functions and manifests itself in symptoms

such as delusions, hallucinations, and disorganised

speech and behaviour. Negative symptoms reflect a

reduction or loss of normal functions, consisting

of symptoms such as affective flattening, apathy,

avolition, social withdrawal and cognitive impair-

ments. The lifetime prevalence is estimated at 1%

with a typical onset during adolescence and early

adulthood.3 According to the Global Burden of

Disease Study,4 schizophrenia accounts for 1.1% of

the total DALYs (disability-adjusted life years) and

2.8% for men and 2.6% for women of YLDs (years

lived with disability). Schizophrenia is listed as the

5th leading cause of DALYs worldwide in the age

group 15–44 years.

People with schizophrenia have a 20–25 year

reduced life expectancy compared to the

general population,5 primarily due to premature

388� W. S. Maney & Son Ltd 2009DOI 10.1179/108331909X12540993898053 Physical Therapy Reviews 2009 VOL 14 NO 6

cardiovascular disease6–9 (CVD). They have nearly

twice the normal risk of dying from CVD.6,7,9,10 This

has led to a growing concern about physical illness in

the course of schizophrenia, specifically CVD

risk.7,11–15 The metabolic syndrome (MetS) brings

together a series of abnormal clinical and metabolic

findings including obesity, hypertension, hypergly-

caemia and dyslipidemia, which are predictive of this

CVD risk.16–18 The most important criteria for MetS

are summarised in Table 1.

In the general population, the presence of MetS is a

strong predictor of CVD, diabetes and mortality.19–22

Persons with schizophrenia are known to have a two

to threefold increased relative risk for MetS com-

pared to healthy individuals.23,24 With an overall

increased risk of somatic co-morbidities, people with

schizophrenia have poorer access and quality of

physical health care.13,14,25

In part the worse cardiometabolic profile in people

with schizophrenia is attributable to the use of

antipsychotic agents which can have a negative

impact on some of the modifiable risk factors.23,24,26

But over recent years, it has become more apparent

that also in schizophrenia an unhealthy lifestyle

including smoking, a poor diet and sedentary

behaviour is associated with adverse cardiometabolic

effects.23,24,27–29 People with schizophrenia are less

physically active than healthy controls. Total energy

expenditure is more than 20% lower than the

minimum recommendations of the American

College of Sports Medicine and the American Heart

Association30 while only 25% meet the minimum

public health recommendation of 150 min a week of

at least moderate-intensity activity.31 On weekdays

they spend less time taking part in strenuous activities

than healthy individuals while during leisure time a

greater proportion of people diagnosed with schizo-

phrenia are not involved in sport activities.32 Only

about 30% can be classified as being regularly active

relative to 62% of a non-psychiatric comparison

group.33

Effective treatment of MetS emphasises increasing

physical activity (PA) and decreasing sedentary

behaviour combined with low-calorie diet.29

The existing systematic reviews for PA with or

without diet counselling in people with schizophrenia

focus in particular on the mental health benefits of

PA, offer relatively limited qualitative data and

include studies from the pre-atypical antipsychotic

era.34–36 Other reviews appear to have wide inclusion

criteria in terms of types of interventions.37,38

The purpose of this paper is to review and present

the current evidence since the first paper39 on MetS in

people with schizophrenia for PA with or without

diet counselling on cardiometabolic parameters in

this specific population. The present review is the first

to focus especially on the role of PA with or without

diet counselling in the prevention and treatment of

the cardiometabolic risk profile in people with

schizophrenia. Whilst from a research perspective it

is more appropriate to only investigate one type of

healthy living intervention, for example only PA, we

consider that factors related to a healthy lifestyle in

people with schizophrenia are complex and multi-

faceted. Consequently, we decided to review PA

interventions including diet counselling as a co-

intervention as well. A narrative review rather than

a meta-analysis has been used due to concerns about

the variability in PA protocols, and large hetero-

geneity between various studies.

MethodsSearch strategy for identification of studies

The aim of the current review was to identify

all studies from 2003 until August 2009

investigating PA with or without diet counselling in

people who have schizophrenia. A number of search

methods were applied as suggested by Hart.40 The

eight databases searched included PubMed,

SPORTDiscus, Cochrane Central Register of

Controlled Trials, EMBASE, PEDro, DARE,

ProQuest Dissertations and Theses and PsycINFO.

Medical Subject Headings (MeSH) terms ‘schizo-

phrenia’ (OR ‘psychosis’) AND ‘physical activity’

(OR ‘exercise’) were used. Secondly, literature was

also identified by citation tracking using reference

lists from selected papers.

Table 1 Working criteria for the metabolic syndrome

ATP-III ATP-III-A IDF

Waist (cm) M.102, F.88 M.102, F.88 M>94, F>80Blood pressure (mmHg) >130/85 >130/85 >130/85HDL (mg dl21) M,40, F,50 M,40, F,50 M,40, F,50Triglycerides (mg dl21) >150 >150 >150Glucose (mg dl21) >110 >100 >100

ATP5Adult Treatment Protocol16, ATP-A5Adult Treatment Protocol-Adapted17, IDF5International Diabetes Federation.18

Vancampfort et al. Effects of physical activity interventions for people with schizophrenia

Physical Therapy Reviews 2009 VOL 14 NO 6 389

Inclusion and exclusion criteria

There were no limitations in terms of study design.

Studies using qualitative or quantitative methodolo-

gies were included. Inclusion criteria were:

1. Studies needed to be published in an English

language, peer-reviewed journal.

2. Participants had to be individuals with schizo-

phrenia or other types of schizophrenia-

spectrum psychoses (schizoaffective or schizo-

phreniform disorder excluding bipolar disorder

and major depression with psychotic features)

meeting DSM-IV criteria. Participants could be

either young people with first-episode schizo-

phrenia or adults with chronic schizophrenia,

hospitalised or out-patients, during treatment

with first- or second-generation antipsychotic

medication.

3. Performing PA should count for at least 50% of

the time spent on the intervention. The only co-

intervention allowed was diet counselling.

4. At least one cardiometabolic parameter needed

to be investigated.

If any of the four inclusion criteria were not fulfilled,

then the study was excluded from the literature

review.

Quality assessment

Articles were categorised according to Campbell and

Stanley41 in pre-experimental, quasi-experimental

and experimental designs. Methodological quality

factors were derived from the Downs and Black

checklist (1998). The Downs and Black checklist42

consists of 27 items with a maximum count of 32

points. Higher scores indicate better methodological

quality. The risk of bias assessment was carried out

by two independent assessors (KM and SD) and

when disagreements between assessors occurred,

consensus was achieved through discussion.

ResultsStudy selection

Thirty-one abstracts were retrieved out of 229 dif-

ferent search results possible for inclusion. A further

18 studies were excluded for the following reasons:

not published in English (N52), no peer-review

(N51), no full-text available (N51), performing PA

did not count for at least 50% of the time spend on

the intervention (N56), included participants not

limited to only individuals with schizophrenia,

schizoaffective or schizophreniform disorder (N53),

no cardiometabolic parameter included (N55).

Thirteen studies43–55 met all inclusion criteria.

Study characteristics

One of the 13 included articles was pre-experimental.

In the study of Fogarty, Happell and Pinikahana46

case reports were used to document the individual

cardiometabolic responses on PA interventions. Of

the remaining 12 studies, six are quasi-experimental

and six experimental randomised controlled designs.

An overview of the (quasi-) experimental designs is

presented in Table 2.

Study quality assessment

Only the (quasi-)experimental trials could be sub-

jected to the evaluation of the methodological

quality. The methodological quality scores, major

methodological flaws and the use of diet counselling

as a co-intervention are shown in Table 2.

Data synthesis

Participants and settings

The case report of Fogarty, Happell and

Pinikahana46 included six male participants. The

Table 2 Methodological evaluation of the (quasi)-experimental designs

Study (ref. no.) Design* Score{ Major limitationsDietcounselling

43 Quasi-experimental 20 Limited sample size, no intention-to-treat No44 Quasi-experimental 24 Possible selection bias Yes45 Quasi-experimental 24 Possible selection bias, no intention-to-treat Yes47 Experimental 22 Possible selection bias, single blind nature, small sample size,

no intention-to-treatNo

48 Quasi-experimental 27 – Yes49 Experimental 28 Single blind nature, no intention-to-treat Yes50 Quasi-experimental 22 Limited sample size, possible selection bias, no intention-to-treat Yes51 Experimental 26 No use of blinding, no intention-to-treat Yes52 Experimental 27 No use of blinding, no intention-to-treat Yes53 Quasi-experimental 23 No data on drop-outs and follow-up, no intention-to-treat Yes54 Experimental 31 – Yes55 Experimental 28 Small sample size, single blind nature No

*According to Campbell and Stanley (1963).{A score was derived from the Downs and Black checklist (1998).


390 Physical Therapy Reviews 2009 VOL 14 NO 6

number of participants in the (quasi-)experimental

designs varied between 10 (Ref. 47) and 232

(Ref. 53). All (quasi-)experimental studies used both

male and female participants. Overall, the number of

male participants was higher than female. This is not

surprising as males have a higher lifetime risk of

developing schizophrenia with a male/female relative

risk of y1.4 (Ref. 56). Age ranged from 15 to 65.

Participants represented both in-patient and out-

patient populations. In most studies the majority had

a diagnosis of more chronic schizophrenia with

residual negative symptoms. Table 3 provides the

main characteristics of all participants.

PA strategies

Duration of the PA interventions varied from 10–14

sessions49 to 52 weeks.45 The predominant type of PA

was aerobic (cycling, walking and swimming), only

sometimes in combination with resistance train-

ing.43,45,50,54,55 No studies investigated the cardiome-

tabolic effects of resistance training as a single

intervention. Frequency of interventions ranged from

once weekly49 to seven times a week.54,55 Frequency

not only differed between the studies but often varied

in time within the same study. In the same way the

intensity of the PA interventions differed (ranging

from light to moderate) between and within the

different studies. Some PA schedules were very well

structured47,55 and elaborated from the beginning

until the end, while in other protocols only self-

monitoring was supported49 or a structured phase

was followed by a period with less supervision.50

Cardiometabolic outcomes of PA with or without dietcounselling in schizophrenia

Main cardiometabolic outcomes of the 13 selected

studies are presented in Table 3.

Cardiovascular fitness: Increases in cardiovascular

fitness levels were reported.46 Improved functional

capacity (ranging from 5.2 to 10%) could be observed

using a six-minute walk test.47,55

Obesity: All studies found moderate weight loss

ranging from 2.2% after 12 weeks in first-episode

patients who already gained more than 10% of pre-

drug weight54 to 5.7% in chronic patients after 24

weeks of PA.50 PA is also preventively effective in

attenuating antipsychotic induced weight gain in

drug-naıve first-episode patients.49

Hypertension: Reductions in systolic and diastolic

blood pressure ranged from 3% (3.7 mmHg) to

10.8% (14 mmHg) and from 7.6% (5.6 mmHg) to

11.3% (9.4 mmHg) respectively in quasi-experimental

studies.45,50 The reduction of resting blood pressure

was more pronounced in hypertensive participants.50

The decrement in blood pressure can even be

sufficient enough to produce normotension (i.e.

,130/85 mmHg). In normotensive participants with

schizophrenia blood pressure did decrease, however

this was not significant.49,51

Hyperglycaemia: Only one experimental study inves-

tigated the evidence for PA on hyperglycaemia (i.e.

>100 mg dl21 according to ATP-III-A and IDF,

Table 1) in schizophrenia.52 Fasting glucose concen-

tration decreased by 7.1% after 6 months from 103.3

to 96.4 mg dl21; however, this decrease was non-

significant. Furthermore, in people with schizophre-

nia, baseline fasting glucose concentrations less than

100 mg dl21 did decrease significantly (8.1%)54 and

non-significantly (2.9%).50

Insulin resistance: In schizophrenia, PA with diet

counselling is associated with a significantly

decreased insulin resistance index54 indicating an

improved ability of cells to respond to the action of

insulin in transporting glucose from the bloodstream

into muscle and other tissues. Physical activity with

diet counselling also significantly decreases fasting

plasma insulin concentration by 79% (Ref. 52) and

11.2% (Ref. 54) and insulin-like growth factor-bind-

ing protein-3 (IGFBP-3) by 22.8%.52

Dyslipidemia: Total serum cholesterol remained

stable45 or decreased non-significantly by 4.2%

(Ref. 50) and 13% (Ref. 51). Circulating levels of

triglycerides remained stable45 or decreased signifi-

cantly by 42% (Ref. 52) and non-significantly by

15.4%.50 The ratio of low density lipoproteins (LDL)

to high density lipoproteins (HDL) decreased sig-

nificantly, by 7.4%.51

Attendance rates in PA programmes

Without support of health care professionals, people

with schizophrenia seemed to exercise only sporadi-

cally50 while dropout rates in PA programmes rose

until 90% after 6 months.43 Poor motivation43,50 and

side-effects of medication50 were often perceived as

an important barrier to participation. Reduction in

depressive symptoms correlated with greater adher-

ence to PA.55 With the application of motivational

strategies, attendance rates increased ranging from

35% in a 12-week home-based exercise programme55

to 90% for all participants in a 6-month, 3 days a

week programme in an in-patient setting.52

Observed motivational strategies include motiva-

tional counselling,44 cognitive behavioural techniques



Ta

ble

3R

ec

en

tk

no

wle

dg

eo

nc

ard

io-m

eta

bo

lic

pa

ram

ete

rsw

ith

reg

ard

top

hy

sic

al

ac

tiv

ity

for

pe

op

led

iag

no

se

dw

ith

sc

hiz

op

hre

nia

Stu

dy

(ref.

no

.)P

art

icip

an

tsP

hysic

al

acti

vit

ystr

ate

gie

sM

ain

ou

tco

mes

(vers

us

co

ntr

ols

)D

rop

-ou

tan

datt

en

dan

ce

43

10

sta

ble

out-

patients

with

schiz

op

hre

nia

or

schiz

oaff

ective

dis

ord

er

(male

58);

16–

55

years

Fre

e6-m

onth

access

tofitn

ess

facili

ties.

Only

reg

ula

rp

hysic

alactivity

isre

late

dto

decre

ase

inw

eig

ht.

Dro

p-o

ut

was

40%

at

4,

70%

at

5and

90%

at

6m

onth

s.

Main

reason

was

poor

motivation.

44

46

in-p

atients

with

schiz

op

hre

nia

or

schiz

oaff

ective

dis

ord

er

(male

529);

BM

I>26;

43¡

9years

12-w

eeks;

1of

2sessio

ns/w

eek;

encoura

ged

tod

olig

ht

tom

od

era

teexerc

ise

20

min

,3

to5

tim

es/w

eek;

twic

e/w

eek

aero

bic

walk

ing

was

incorp

ora

ted

ing

roup

sessio

ns.

Decre

ase

inw

eig

ht

(2. 7

%,

p5

0. 0

03)

inth

ein

terv

ention

gro

up

(n5

31)

[vers

us

3. 1

%in

cre

ase

inw

eig

ht

(n5

15)]

.

Att

end

ance

was

77%

for

the

gro

up

sessio

ns.

No

dro

p-o

uts

.M

otivation

counselli

ng

techniq

ues

were

used

.45

6m

ale

in-p

atients

with

schiz

op

hre

nia

;20–

42

years

A3-m

onth

ind

ivid

ualis

ed

physic

alcond

itio

nin

gp

rog

ram

me

with

em

phasis

on

gro

up

dynam

ics.

Incre

ased

physic

alstr

eng

thand

end

ura

nce,

incre

ased

fitn

ess,

imp

roved

weig

ht

contr

ol,

incre

ased

perc

eiv

ed

energ

y,

red

uced

blo

od

pre

ssure

.

Hig

hattend

ance

rate

sin

dic

ate

dth

at

part

icip

ants

perc

eiv

ed

benefits

.

46

51

in-p

atients

with

schiz

op

hre

nia

or

schiz

oaff

ective

dis

ord

er

(male

529);

BM

I>

26

or

aw

eig

ht

gain

of

at

least

2. 3

kg

within

2m

onth

sof

sta

rtin

gaty

pic

alag

ents

;43¡

9years

A52-w

eek

pro

gra

mm

ew

ith

light-

to-m

od

era

teexerc

ise

(at

least

as

inte

nse

as

susta

ined

walk

ing

)fo

r20

min

3to

5tim

es/w

eek;

inte

nsiv

e12-w

eek

phase

(tw

ice/w

eek,

with

2op

port

unitie

sto

part

icip

ate

inaero

bic

walk

ing

or

aero

bic

walk

ing

vid

eo

cla

ss)

follo

wed

by

12-w

eek

ste

p-d

ow

n(o

nce

aw

eek)

and

6-m

onth

follo

w-u

p(o

nce

am

onth

).

Decre

ase

inw

eig

ht

(3%

,p

,0. 0

2);

HB

A(1

c)

(0. 2

%,

p,

0. 0

01),

dia

sto

lic(7

. 6%

,p

,0. 0

01)

and

systo

lic(3

%,

p,

0. 0

5)

blo

od

pre

ssure

,self-r

ep

ort

ed

exerc

ise

level(f

rom

53

min

/week

to124

min

/week,

p,

0. 0

03)

(n5

31)

[vers

us

weig

ht

gain

(n5

20)]

;no

chang

ein

tota

lchole

ste

roland

trig

lycerid

es

inexp

erim

enta

lg

roup

.

65%

com

ple

ted

the

entire

12-m

onth

sp

rog

ram

me.

Patients

attend

ed

am

ean

of

69%

of

the

sessio

ns

(rang

e9–96%

).O

nly

hig

h-

attend

ance

ind

ivid

uals

(cut-

off

:75%

of

the

sessio

ns)

show

ed

red

uced

(p5

0. 0

4)

BM

I,th

isis

incom

parison

with

low

att

end

ers

who

did

not.

47

10

out-

patients

dia

gnosed

with

schiz

op

hre

nia

(male

58);

40–63

years

A16-w

eek

str

uctu

red

tread

mill

walk

ing

pro

gra

mm

e3

tim

es/w

eek:

10

min

of

warm

-up

str

etc

hes

follo

wed

by

walk

ing

at

targ

et

heart

rate

and

10

min

of

cool-

dow

n.

Fro

mw

alk

ing

for

5m

inon

the

firs

td

ay

to30

min

over

the

firs

t3

weeks;

the

next

13

weeks

30

min

,3

tim

es/w

eek.

Decre

ase

inb

od

yfa

t(3

. 69%

,p

50. 0

3)

and

BM

I(4

%,

p.

0. 0

5)

(n5

4)

[vers

us

20. 0

2in

bod

yfa

tand

20. 0

2in

BM

I];

incre

ase

inaero

bic

fitn

ess

(10%

,p

.0. 0

5)

on

6M

WT

[vers

us

z4%

]

33%

of

the

exerc

ise

gro

up

dro

pp

ed

out

leavin

g4

inth

eexerc

ise

cohort

for

finalanaly

sis

.A

ttend

ance

rang

ed

from

43

to91%

of

the

sessio

ns,

75%

att

end

ed

more

than

half

of

the

sessio

ns

and

50%

over

2/3

.48

35

out-

patients

(male

519);

BM

I>

30;

43¡

10

years

12

weekly

follo

wed

by

2b

iweekly

and

2m

onth

lysessio

ns;

decre

ase

sed

enta

ryactivitie

s;

incre

ase

walk

ing

up

to10,0

00

ste

ps/d

ay.

A3-m

onth

post-

treatm

ent

weig

ht

red

uction

(3. 2

%,

p5

0. 0

03);

red

uction

rem

ain

ssta

ble

12-m

onth

post-

treatm

ent

follo

w-u

p.

83%

com

ple

ted

the

pro

gra

mm

e;

behavio

ura

lte

chniq

ues

were

used

.

49

61

dru

g-n

aıv

eout-

patients

firs

t-ep

isod

ep

sychosis

(male

546);

15–60

years

10

to14

ind

ivid

ualis

ed

sessio

ns;

weig

ht

check,

ag

end

asett

ing

,re

vie

wof

self-m

onitoring

,hom

ew

ork

assig

nm

ents

.

Weig

ht

gain

(5. 7

%,

p,

0. 0

1)

(n5

28)

[vers

us

z10. 4

%]

64. 5

%of

the

part

icip

ants

com

ple

ted

the

pro

gra

mm

e.



Stu

dy

(ref.

no

.)P

art

icip

an

tsP

hysic

al

acti

vit

ystr

ate

gie

sM

ain

ou

tco

mes

(vers

us

co

ntr

ols

)D

rop

-ou

tan

datt

en

dan

ce

50

17

chro

nic

ally

psychotic

out-

patients

(male

57);

incre

ase

>4. 5

kg

and

>5%

BM

I;40¡

10

years

24-w

eeks

ind

ivid

ualis

ed

fitn

ess,

twic

ew

eekly

45

min

with

card

iovascula

rw

ork

-outs

and

str

eng

th-

train

ing

;ad

ditio

nal24-w

eek

less

inte

nsiv

eexte

nsio

np

hase

(min

1sessio

nevery

4w

eeks).

Weig

ht

loss

(5. 7

%,

p,

0. 0

01).

With

less

inte

nsiv

em

anag

em

ent

min

imalw

eig

ht

gain

(0. 4

3kg

)aft

er

anoth

er

24-w

eeks;

seru

mchole

ste

rol(4

. 2%

,p

50. 0

9)

and

systo

lic(1

0. 8

%,

p,

0. 0

01)

and

dia

sto

lic(1

1. 3

%,

p,

0. 0

01)

blo

od

pre

ssure

decre

ased

aft

er

48

weeks.

Sp

ecia

latt

ention

for

sid

e-

eff

ects

of

med

ication

and

the

use

of

music

and

dancin

g;

hig

hatt

end

ance

info

llow

-up

isre

late

dto

weig

ht

loss,

low

att

end

-ance

tow

eig

ht

gain

;only

sp

ora

dic

ally

exerc

isin

gat

hom

e.

51

48

non-a

cute

out-

patients

(male

515);

19–

64

years

12-w

eeks;

keep

ing

ap

hysic

alactivity

dia

ryand

ed

ucation;

sup

port

inp

lannin

gand

evalu

ation

of

physic

alactivity;

firs

t4

weeks

once

aw

eek,

aft

er

week

4every

oth

er

week

Red

uction

inb

od

yfa

t(3

. 94%

,p

,0. 0

5)

and

BM

I(5

. 6%

,p

,0. 0

5)

(n5

33);

[vers

us

(p5

0. 0

4)

21. 4

8]

aft

er

week

8:

ad

ecre

ase

(p5

0. 0

67)

of

7. 4

%in

LD

L/H

DL

[vers

us

21. 2

%].

75%

of

the

part

icip

ants

com

ple

ted

the

stu

dy;

36. 4

%w

ere

over

80%

com

plia

nt

with

exerc

ise

manag

em

ent.

52

53

sta

ble

in-p

atients

(male

522);

BM

I>

27;

18–

65

years

A6-m

onth

lifesty

lep

rog

ram

me

with

levelw

alk

ing

for

1. 6

2km

for

ab

out

40

min

and

walk

ing

on

sta

irs

up

to20

min

,3

tim

es/w

eek.

Decre

ase

inb

od

yw

eig

ht

(25. 4

%,

p,

0. 0

5)

(n5

28)

[vers

us

z1. 1

%],

wais

t(2

3. 5

%,

p,

0. 0

01)

[vers

us

z1%

]and

hip

(23. 2

%,

p,

0. 0

01)

[vers

us

z2. 5

%]

circum

fere

nce,

insulin

concentr

ation

(279%

,p

,0. 0

5)

[vers

us

229%

],tr

igly

cerid

es

(242%

,p

,0. 0

5)

[vers

us

z1%

]and

IGFB

P-3

decre

ased

(222. 8

%,

p,

0. 0

5)

after

6m

onth

s.

6%

dro

p-o

ut

only

because

of

dis

charg

efr

om

the

hosp

ital;

patients

were

com

pensate

dw

ith

gro

cery

sto

reg

ifts

;all

patients

com

ple

ted

at

least

90%

of

the

physic

alactivity

pro

gra

mm

e.

53

232

in-

and

out-

patients

(male

597);

BM

I>

25;

15–60

years

12

weekly

gro

up

sessio

ns,

6w

ere

focussed

on

physic

alactivity

manag

em

ent

and

dis

cussio

nab

out

self-m

onitoring

(dia

ry)

rep

ort

s.

Mean

red

uction

inw

eig

ht

(3. 4

%,

p,

0. 0

01).

Part

icip

ants

att

end

ed

at

least

75%

of

the

sessio

ns;

76%

att

end

ed

all;

hig

her

com

plia

nce

isan

ind

ep

en-

dent

pre

dic

tor

of

the

resp

onse

(extr

are

duction

of

1kg

m2

2in

BM

I).

54

128

ind

ivid

uals

firs

tep

isod

eschiz

op

hre

nia

(male

564)

who

gain

ed

more

than

10%

of

pre

-dru

gw

eig

ht;

18–45

years

Walk

ing

or

jog

gin

g7

tim

es/w

eek

during

30

min

,firs

tw

eek

at

70%

of

heart

rate

reserv

e.

Aft

er

firs

tw

eek

hom

e-b

ased

without

sup

erv

isio

nra

ng

ing

from

light

exerc

ise

(walk

ing

,...

)to

mod

era

te-t

o-v

igoro

us

exerc

ise

(bic

yclin

g,

resis

tance

train

ing

,skiin

g,

jog

gin

g,

ball

gam

es,

chop

pin

gw

ood

or

cle

aring

bru

sh).

Lifesty

lez

metf

orm

in(n

532)

and

lifesty

lez

pla

ceb

o(n

532)

mean

decre

ase

(p,

0. 0

5)

inw

eig

ht

of

7. 3

and

2. 2

%,

and

inin

sulin

resis

tance

ind

ex

of

3. 6

and

1. 0

resp

ectively

(p,

0. 0

5);

lifesty

lez

metf

orm

insup

erior

tom

etf

orm

inalo

ne

(n5

32)

and

tolif

esty

lep

lus

pla

ceb

ofo

rw

eig

ht

and

BM

I.

Inlif

esty

lez

pla

ceb

og

roup

60%

had

ag

ood

ad

here

nce

toth

eexerc

ise

pro

tocol.

Ta

ble

3C

on

tin

ue

d



including self-monitoring,45,48,49,51,53 a very well

structured physical activity protocol,47,55 compensa-

tion with grocery store gifts,48,52 the use of music, and

emphasis on group dynamics.46,50,55 Review findings

provide some evidence that compliance is a predictor

of the PA response as only high attendance seems to

be related to weight loss.43,45,50,53

DiscussionMethodology

Summarising the evidence for PA with or without

diet counselling on cardiometabolic parameters in

people with schizophrenia is difficult, due to the

limited number of appropriate studies of rigorous

methodological quality.

Given the differences in in- or out-patients, in

research designs (for example type of depending

variables, outcome measures, age ranges, duration of

illness, sample sizes) and in PA approaches (duration,

intensity, frequency), generalising results is very

tenuous. The study of Wu et al.52 in a rigorous in-

patient regime was, for example, successful in terms

of results but the question arises as to how replicable

it would be in an out-patient open setting. The given

grocery store rewards for attendance48,52 would in the

same way clearly be problematic in routine practice

settings.

Studies often declare randomisation and blindness

protocols but how these procedures were performed

is not always clearly reported.

A main problem is the lack of intention-to-treat

analysis in almost all studies. It is known that per-

protocol analyses will often lead to substantial

overestimation of treatment effects.57 To date, the

lowest weight reducing effect (2.2%) was found in a

study applying intention-to-treat analyses.54

Recent evidence for PA with or without diet counselling oncardiometabolic parameters for people with schizophrenia

Despite the methodological limitations some conclu-

sions can certainly be drawn from the available

research. All studies investigating the effect of PA

with or without diet counselling on weight in people

with schizophrenia taking antipsychotic medication

resulted in modest weight loss. Previous systematic

reviews on short-term non-pharmacological interven-

tions in schizophrenia found similar reductions in

weight.58–60 The study of Kalarchian et al.48 indicated

that if provided with adequate information and an

appropriate framework, individuals with schizophre-

nia can maintain this significant weight loss for at

least 1 year post-treatment.48 A recent study confirms

that people with severe mental illness can reduceStu

dy

(ref.

no

.)P

art

icip

an

tsP

hysic

al

acti

vit

ystr

ate

gie

sM

ain

ou

tco

mes

(vers

us

co

ntr

ols

)D

rop

-ou

tan

datt

en

dan

ce

55

13

out-

patients

(male

58);

45¡

3years

12

weeks;

twic

e/w

eek

90

min

(10

min

warm

-up

,20

min

weig

ht

resis

tance,

60%

1R

Mor

,15

on

Borg

RP

E)

and

60

min

walk

ing

at

60%

heart

rate

reserv

eand

11–14

on

Borg

RP

E;

pro

gre

ssio

nevery

2w

eeks

up

to6. 4

km

and

then

incre

asin

gin

tensity

up

to80%

;once

aw

eek

aero

bic

exerc

ise

sessio

non

their

ow

nor

during

ahom

evis

it.

Incre

ase

(p5

0. 1

)of

5. 2

%in

aero

bic

fitn

ess

on

6M

WT

[vers

us

25. 8

%],

astr

eng

thin

cre

ase

for

exerc

ise

(28. 3

%,

p5

0. 0

1)

[vers

us

no

sig

nific

ant

chang

e].

Att

end

ance

avera

ged

72

%w

ith

no

dro

p-o

uts

.P

art

icip

ants

att

end

ed

at

least

50%

of

physic

al

activity

cla

sses.

Gro

up

-b

ased

att

end

ance

(72%

)w

as

sup

erior

tohom

e-

based

(35%

).

BM

I5b

od

ym

ass

ind

ex,

6M

WT

56-m

inw

alk

ing

test,

HB

5hem

og

lob

in,

HD

L5

hig

hd

ensity

lipop

rote

ins,

LD

L5

low

density

lipop

rote

ins,

IGFB

P-3

5in

sulin

like

gro

wth

facto

rb

ind

ing

pro

tein

-3,

1R

M5

one

rep

etition

maxim

um

,R

PE

5ra

ting

of

perc

eiv

ed

exert

ion.

Ta

ble

3C

on

tin

ue

d



weight and maintain the loss.61 These findings

indicate that patients, their families and professional

caregivers are aware of the dangers of weight gain,

and are willing and capable of supporting and

participating in weight reduction programmes.

Only one randomised controlled trial has shown

the effectiveness of preventive strategies in attenuat-

ing antipsychotic-induced weight gain in drug-naıve

first-episode schizophrenia.49 Although there is only

one study, it seems apparent that there is also great

potential for PA interventions before weight gain

takes place. Apart from somatic co-morbidity, weight

gain seriously impairs quality of life through

decreased functioning, associated pain, financial

consequences, as well as social stigmatisation and

discrimination.62,63 People with schizophrenia who

experience recent weight gain have lower psychoso-

cial adjustment and self-esteem, and thus might be

more willing to avoid all causative factors, including

discontinuation of medication.63,64 Young patients

are even more sensitive to these issues of body image

and self-esteem.65 Early PA intervention could

prevent or attenuate these consequences derived from

weight gain.

A moderate weight loss of 3 to 5% is known to be

related to a reduction in CVD risk factors.66,67 The

review findings indicate that this is likely to be

observed also in people with schizophrenia. The

observed reductions in CVD risk factors are

comparable with those reported in the general

population.68–71

Adherence to PA seems to be an important

predictor of these outcomes. When motivation

techniques are used, adherence to PA is encouraging

and compares favourably with rates for sedentary

individuals becoming active.72 Attendance to struc-

tured, supervised group-based PA sessions seems to

be superior to individual PA performance.46,50,55

Implications for clinical practice

The review findings provide evidence to support

the recommendations made by the Consensus

Development Conference on Antipsychotic Drugs

and Obesity and Diabetes. Clinicians who prescribe

atypical antipsychotic medication should not only

assess and continuously monitor CVD risk factors

but preferably also refer patients to a physical health

care programme with expertise in weight manage-

ment.73 As people with schizophrenia have poorer

access and quality of physical health care, attention

should in the first place be given to making

these facilities easily accessible and available. Both

structured facility-based PA programmes and

interventions that focus on the accumulation of

moderate-intensity PA throughout the day seem to

be effective. Structured PA programmes have the

advantage that adherence can be more easily verified

and safety is better guaranteed, but these pro-

grammes require potentially costly space, equipment

and staffing.74 In offering more structured or lifestyle

PA, physical therapists should provide their patients

with a supportive environment and opportunities for

social interaction and exchange. Group-based PA

programmes can provide consistent support and help

build initial motivation by helping participants

understand how PA will benefit them. As participants

become more physically active, such programmes can

help them address barriers that may arise. Structure,

supportive feedback and encouragement seem to be

important for people with schizophrenia who may

experience avolition. Special attention should be

given to medication-related impaired balance and

coordination.

Given the limited review findings, identifying an

optimal dose or intervention strategy for PA pro-

grammes for cardiometabolic health in people who

have schizophrenia is not (yet) possible. However,

taking into account the individual responses in the

presented qualitative research and the observation

that compliance to PA may be a predictor of the PA

response, it is clear that a PA programme should be

adapted to the patients’ previous experiences, their

attitude towards PA, their personal preferences and

objectives and their individual physical abilities. For

example, physical therapists should provide people

with schizophrenia with choices and options about

the type and content of their programme; they could

discuss with the individual what types of PA best fit

with his or her current preferences.

Until there is more clarity concerning an optimal

PA dose or strategy for the prevention and treatment

of the cardiometabolic risk profile in people with

schizophrenia, current general guidelines of the

American College of Sports Medicine and the

American Heart Association67 for weight loss and

prevention of weight regain in the general population,

should also be applied to people who have schizo-

phrenia. According to the guidelines, moderate-

intensity PA between 150 and 250 min a week will

provide modest weight loss and is effective to prevent

weight gain. Greater amounts of PA (.250 min a

week) can be associated with clinically significant

weight loss. In order to promote general health the

guidelines of the American College of Sports

Medicine and the American Heart Association75



should be applied. Moderate-intensity aerobic

(endurance) PA for a minimum of 30 min on 5 days

each week or vigorous-intensity aerobic PA for a

minimum of 20 min on 3 days each week is needed.

Combinations of moderate- and vigorous-intensity

PA can be performed to meet this recommendation.

For example, a person can meet the recommendation

by walking briskly for 30 min twice during the week

and then jogging for 20 min on 2 other days.

Moderate-intensity aerobic activity, which is gener-

ally equivalent to a brisk walk and noticeably

accelerates the heart rate, can be accumulated toward

the 30-min minimum by performing bouts each

lasting 10 or more min. Vigorous-intensity activity

is exemplified by jogging, and causes rapid breathing

and a substantial increase in heart rate. In addition,

individuals should perform activities that maintain or

increase muscular strength and endurance a mini-

mum of 2 days each week.

Limitations of the review

A number of limitations prevented us from making

any firm conclusions. A lack of resources to enable

translations meant the inclusion of only studies in the

English language, although this resulted in just two

studies being excluded.

Second, the strategies used to identify the ‘grey

literature’ of non-indexed and unpublished studies

may not have identified all possible studies. Trials

that are unpublished generally tend to have negative

results, so it is important to identify this to avoid

overestimation of the beneficial effects of PA in

schizophrenia.

Third, almost all studies had only short-term

follow-up periods. As a result, we could not draw

firm conclusions on the real long-term effectiveness of

PA interventions.

Fourth, studies were not limited to solely PA.

However, had the inclusion criteria been more

stringent to avoid diet counselling, the number of

studies included would have been reduced even

more. The combination of PA with appropriate

diet counselling was also used as it reflects the

current evidence-based medicine in the prevention,

treatment and rehabilitation of cardiometabolic

diseases.76,77

Fifth, the quality checklist employed in this review

is considered valid and reliable, yet Downs and

Black42 suggest that more testing is required before

its regular use is encouraged. The checklist was used

because it is considered appropriate for both rando-

mised and non-randomised studies.

Future directions

Future research needs to address several salient

issues. At present, too few studies confirm that

short-term beneficial effects of PA in people with

schizophrenia result in long-term changes. Long-term

trials involving multi-centres may further enhance

our knowledge of PA prescription for people with

schizophrenia.

In terms of the most successful interventions, the

relative contribution of the different components of a

lifestyle intervention (PA and diet counselling)

remains unclear. Furthermore, the dominance of

aerobic PA interventions and the lack of studies

using resistance training prevent a comparison

between the merits of different PA interventions.

Well-designed trials are required, including compar-

ison studies of one PA intervention against another

(lifestyle versus structured, aerobic PA versus resis-

tance training). These trials should identify associa-

tions between somatic health benefits, positive and

negative symptoms, social integration and cognitive

benefits. In addition, it is also not possible to

establish whether outcomes for PA with or without

diet counselling match those for pharmacological

treatment, and whether combination treatment

enhances outcome. Only one study54 indicated that

PA with diet counselling and a pharmacological

intervention with metformin alone and in combina-

tion demonstrated efficacy for antipsychotic-induced

weight gain.

Also no study examined if and in which ways

age variation, illness duration and gender might

affect a patient’s response to PA interventions.

Future studies should therefore determine the effect

of a patient’s age, gender, illness duration but also

dietary and smoking habits, substance abuse, medi-

cation regime, motivation towards PA, and physical

health status on the PA response. Broader clinical

outcomes including compliance to medication and

rates of relapse need to be examined. Barriers to

becoming active should be determined and

motivational strategies to increase adherence to PA

identified.

Lastly, none of the studies reported any cost-

effectiveness of PA. In a systematic review78 in the

general population, PA appeared to reduce disease

incidence, to be cost-effective, and, compared with

other well-accepted preventive strategies, to offer

good value for money. Cost-effectiveness of PA will

be an important determinant of its future use within

the healthcare of people with schizophrenia and may

need further investigation.



Conclusion

An increasing body of evidence suggests that PA with

or without diet counselling is feasible and effective in

reducing weight and obesity-related cardiometabolic

risk profile in people with schizophrenia. Identifying

an optimal PA dose or intervention strategy is however

not (yet) possible. This review adds to current knowl-

edge that adherence to PA seems to be an important

predictor of the cardiometabolic outcome of PA

interventions. The most important research questions

this review poses are summarised in Table 4.

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Table 4 Research questions on physical activity interventions for people with schizophrenia

N In which way are the benefits of and the adherence to physical activities influenced by the characteristics of a physical activityprogramme (i.e. preferred versus prescribed, type and format of physical activities, whether or not it is voluntary, its intensity, thetiming, the duration, the number and frequency of the sessions and the motivational strategies used)?

N In which way are the duration of illness, severity of symptoms, age, gender and physical health status confounding the effectivenessof physical activity interventions in people who have schizophrenia?

N What are the associations among cardiometabolic health benefits, positive and negative symptoms, social integration and cognitivedecline?

N What are the long term effects of supervised physical activity programmes in people who have schizophrenia?N What is the cost-effectiveness of physical activity interventions within the healthcare of people with schizophrenia?N In which way do smoking, substance abuse and dietary intake influence the outcome of physical activity interventions in people who

have schizophrenia?



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DAVY VANCAMPFORTUniversity Psychiatric Centre K.U.Leuven, Campus Kortenberg, Leuvensesteenweg 517, B-3070 Kortenberg, Belgium

E-mail: [email protected]



Cardiometabolic effects of physical activity interventions for people with schizophrenia

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