|Year : 2019 | Volume
| Issue : 3 | Page : 179-182
Metabolic syndrome and its impact on functioning in participants with schizophrenia: A hospital-based cross-sectional study
KN Nishanth1, Rakesh Kumar Chadda2, Mamta Sood2, Ashutosh Biswas3, R Lakshmy4
1 Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
3 Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
4 Department of Cardiac Biochemistry, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||06-Aug-2018|
|Date of Decision||24-Sep-2018|
|Date of Acceptance||08-Oct-2018|
|Date of Web Publication||30-Sep-2019|
Dr. K N Nishanth
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Hosur Road, Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
Background: The prevalence of metabolic syndrome is shown to be high in patients with schizophrenia when compared to the general population. Metabolic syndrome can itself increase the morbidity and mortality in these patients who already have other risk factors. The aim of this study was to assess the prevalence of metabolic syndrome and its correlation with sociodemographic profile, with severity of schizophrenia and functionality in patients with schizophrenia. Materials and Methodology: A total of 100 patients with schizophrenia attending a tertiary care center were assessed for metabolic syndrome in this cross-sectional study. The severity of schizophrenia was assessed using positive and negative syndrome scale, and global assessment of functioning (GAF) and social and occupational functioning assessment scale (SOFAS) were used to assess functionality. Results: Mean age of the participants (n = 100) was 35.12 years (standard deviation = 10.7) with mean duration of schizophrenia being 8.3 years (standard error = 0.58). The prevalence of metabolic syndrome was 37%. Metabolic syndrome was more commonly seen in relatively older participants (P < 0.00), females (P = 0.002), homemakers (P = 0.006), with longer duration of schizophrenia (P = 0.013), and with longer duration of treatment (P = 0.027). The mean score of GAF and SOFAS in the participants with metabolic syndrome was low, suggesting poor functioning. Conclusion: Identification of metabolic syndrome needs to be further stressed as the functioning is impaired due to it.
Keywords: Functionality, metabolic syndrome, schizophrenia
|How to cite this article:|
Nishanth K N, Chadda RK, Sood M, Biswas A, Lakshmy R. Metabolic syndrome and its impact on functioning in participants with schizophrenia: A hospital-based cross-sectional study. Indian J Soc Psychiatry 2019;35:179-82
|How to cite this URL:|
Nishanth K N, Chadda RK, Sood M, Biswas A, Lakshmy R. Metabolic syndrome and its impact on functioning in participants with schizophrenia: A hospital-based cross-sectional study. Indian J Soc Psychiatry [serial online] 2019 [cited 2019 Dec 9];35:179-82. Available from: http://www.indjsp.org/text.asp?2019/35/3/179/268342
| Introduction|| |
Patients with schizophrenia usually suffer from metabolic abnormalities during illness. These abnormalities have been identified even at the onset of schizophrenia which led to a suggestion that they are an integral part of schizophrenia. Metabolic abnormalities along with insulin resistance, elevated blood pressure, and visceral adiposity constitute metabolic syndrome which leads to increased mortality due to cardiovascular disease.
The prevalence of metabolic syndrome is fairly high in patients with schizophrenia. It ranges from 17% in patients with duration of illness <1.5 years to as high as 49% with duration of illness for more than 20 years. The average body mass index in the participants with schizophrenia has been reported to be 22.5–29., Central obesity as assessed using waist circumference is independently associated with each component of metabolic syndrome including insulin resistance. It contributes to hypertension, high serum cholesterol, low high-density lipoprotein (HDL) cholesterol, and hyperglycemia. Obesity along with other components further increases the risk of cardiovascular disease.,
In patients with schizophrenia, death due to cardiovascular event is a leading cause for increased mortality. Cardiovascular risk factors such as smoking, physical inactivity, diabetes mellitus, hypertension, and obesity are more common in patients with schizophrenia. Along with these risk factors, antipsychotic-induced weight gain increases the prevalence of metabolic syndrome., The risk for metabolic syndrome is higher in patients with long duration (>10 years) of schizophrenia , and antipsychotic treatment of more than 6 months.
The impact of metabolic syndrome on cognition and functioning has been assessed in few studies. Executive functioning assessed using tests such as trail making test B, clock drawing task score, EXIT25, and controlled oral word association test has shown poorer performance in participant with metabolic syndrome. Performance is also associated with socioeconomic background of the participants which can be a confounding factor. Verbal fluency and verbal memory impairment have been seen in participants with schizophrenia having comorbid metabolic syndrome. Poor scores are also seen in the quality of life scale (WHOQOL) and global assessment of functioning scale (GAF) in such participants.
This study aims to assess the prevalence of metabolic syndrome and its correlation with sociodemographic profile, with the severity of schizophrenia and functionality in patients with schizophrenia.
| Materials and Methodology|| |
For the study, 100 patients of schizophrenia attending outpatient setting in New Delhi were included in the study. It was a cross-sectional study conducted over a period of 7 months in 2013. The participants diagnosed with schizophrenia as per the Diagnostic and Statistical Manual of Mental Disorders, fourth edition TR criteria aged more than 18 years and duration of schizophrenia more than 2 years were included in the study. Those not consenting and pregnant were excluded from the study. The full details of methodology are given elsewhere. For metabolic syndrome, International Diabetes Federation criterion, central obesity measured as waist circumference (males ≥90 and females ≥80) along with any two of the following triglycerides more than or equal to 150 mg/dl, HDL (males ≤40 mg/dl and females ≤50 mg/dl), blood pressure (systolic ≥130 mmHg and diastolic 85 mmHg), and fasting blood sugar more than equal to 100 mg/dl was used. Severity of schizophrenia was assessed with positive and negative syndrome scale (PANSS) and functionality with GAF  scale and social and occupational functioning assessment scale (SOFAS). An informed consent was taken from the patient and the family member. Ethical approval was taken from the institutional ethics committee. SPSS (version 20) for Microsoft software (IBM, Armonk, NY, USA) was used for analysis. Tests used for association were independent sample t-test, Mann–Whitney test, and Chi-square test.
| Results|| |
Among the participants recruited in the study (n = 100), 55% were male and 45% female. They were in an age group ranging from 18 years to 72 years (mea n = 35.12 and standard deviation = 10.7). Almost all the participants (99%) were on antipsychotic medications (86% on the second generation, 12% on the first generation, and 1% on both) with one maintaining well without any medication. The mean duration of illness and the mean duration of treatment were 8.3 years and 7.8 years, respectively [Table 1]. Family history of diabetes mellitus was present in 18% of participants, hypertension in 13%, coronary artery disease in 2%, epilepsy in 4%, thyroid disease in 1%, and tuberculosis in 1%.
|Table 1: Association of metabolic syndrome (MetS) with socio-demographic and clinical variables|
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There was a significant difference in the age of participants with metabolic syndrome (P < 0.001). The mean age of participants with metabolic syndrome was 42.6 years and without metabolic syndrome, it was 30.7 years. It was significantly common in females (P = 0.002) and married individuals (P = 0.006). It was significantly more common in homemakers (P = 0.001). There was a significant difference with regard to total duration of schizophrenia (P = 0.013), and the total duration of treatment (P = 0.027) was obtained for it. Participants with metabolic syndrome had longer duration of schizophrenia (median = 10 years) and were on treatment for longer duration (median = 10 years) [Table 1]. The detail of the variables of metabolic syndrome is given in [Table 2].
There was significant difference in GAF score (P = 0.034) and SOFAS score (P = 0.028). The mean score of GAF and SOFAS in the participants with metabolic syndrome was low suggesting poor functioning when compared with that of the participants without metabolic syndrome. There was no significant difference in other parameters.
| Discussion|| |
The prevalence of metabolic syndrome was comparable to some of the studies.,,,, The prevalence rate was higher than that seen in the general population and also drug naïve participants with schizophrenia., Metabolic syndrome was assessed and identified for the first time in these individuals. Metabolic syndrome was significantly associated with age, female gender, married individuals, total duration of schizophrenia, and total duration on treatment. It corroborates with the findings of other studies although there are contradicting results regarding gender prevalence.,, Poor functioning was seen in participants with metabolic syndrome with GAF and SOFAS. Similar result was seen in other study  along with impairment in quality of life (WHOQOL-Bref) in domains of physical and psychological health. A study has shown deficits in cognitive domains such as processing speed, verbal fluency, working memory, and problem solving in participants with schizophrenia having metabolic syndrome., General population suffering from metabolic syndrome are shown to have impairment in executive functioning, which suggests that metabolic syndrome can result in these impairments irrespective of comorbid schizophrenia. These impairments can result in difficulty in holding job, social interactions, and can increase the burden on family member. It also affects the self-assessment of physical symptoms and seeking treatment for the same. It would be interesting to see whether functionality improves with early identification and initiation of steps to reverse the metabolic abnormality.
With increasing age, multiple factors such as food habits, physical activity, substance use, and genetic predisposition can cumulatively lead to metabolic abnormality. Suffering from schizophrenia and being on treatment can exaggerate these factors which explain the higher prevalence than the general population.
It is a known fact that the use of second-generation antipsychotics can increase the prevalence of metabolic syndrome due to propensity to cause weight gain, impaired glucose metabolism, and impaired lipid metabolism. In this study, there was no significant association between antipsychotic treatment and metabolic syndrome. The second-generation antipsychotics may have played a role in these participants as all of them have received it at some point. The presence of other illnesses such as diabetes mellitus, hypertension, and sedentary lifestyle may also have contributed. Among the participants with metabolic syndrome, 12 were suffering from diabetes mellitus, 18 were hypertensive, and 4 were obese.
There was no significant association between psychopathology and metabolic syndrome. A study has shown that participants with metabolic syndrome have more psychopathology on PANSS. Negative symptoms of schizophrenia can increase risk factor for metabolic syndrome as it can lead to unemployment, sedentary lifestyle, and increase nicotine use. To ascertain any association with metabolic syndrome, a longitudinal study with repeated evaluation is required as severity of psychopathology fluctuates during the course of schizophrenia.
There are some limitations to the study. It was a cross-sectional study with purposive sampling. The study was conducted in an apex institute due to which the participants included in the study were not from any specific regions. Moreover also in addition, the cases were taken from the study population who are usually referred from other centers due to difficulty in management. There was no control group. Hence, it is difficult to generalize this finding to general population.
| Conclusion|| |
The study highlights the importance of regular monitoring of the participants with schizophrenia for metabolic abnormalities as it not only increases mortality but also affects the functioning of the participants. To prevent increase mortality, it would be prudent to regularly monitor waist circumference, metabolic parameters, check weight gain due to medications, and to change antipsychotics whenever it is required.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
De Hert M, van Winkel R, Van Eyck D, Hanssens L, Wampers M, Scheen A, et al.
Prevalence of diabetes, metabolic syndrome and metabolic abnormalities in schizophrenia over the course of the illness: A cross-sectional study. Clin Pract Epidemiol Ment Health 2006;2:14.
Amouzegar A, Mehran L, Hasheminia M, Kheirkhah Rahimabad P, Azizi F. The predictive value of metabolic syndrome for cardiovascular and allcause mortality: Tehran lipid and glucose study. Diabetes Metab Res Rev 2017;33:e2819.
Bajaj S, Varma A, Srivastava A, Verma AK. Association of metabolic syndrome with schizophrenia. Indian J Endocrinol Metab 2013;17:890-5.
Coodin S. Body mass index in persons with schizophrenia. Can J Psychiatry 2001;46:549-55.
Carr DB, Utzschneider KM, Hull RL, Kodama K, Retzlaff BM, Brunzell JD, et al.
Intra-abdominal fat is a major determinant of the national cholesterol education program adult treatment panel III criteria for the metabolic syndrome. Diabetes 2004;53:2087-94.
Anderson PJ, Critchley JA, Chan JC, Cockram CS, Lee ZS, Thomas GN, et al.
Factor analysis of the metabolic syndrome: Obesity vs. insulin resistance as the central abnormality. Int J Obes Relat Metab Disord 2001;25:1782-8.
Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risks of cardiovascular disease. Am Heart J 2005;150:1115-21.
De Hert M, Correll CU, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I, et al.
Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 2011;10:52-77.
De Hert M, Cohen D, Bobes J, Cetkovich-Bakmas M, Leucht S, Ndetei DM, et al.
Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry 2011;10:138-51.
Falkowski J, Atchison T, Debutte-Smith M, Weiner MF, O'Bryant S. Executive functioning and the metabolic syndrome: A project FRONTIER study. Arch Clin Neuropsychol 2014;29:47-53.
Goughari AS, Mazhari S, Pourrahimi AM, Sadeghi MM, Nakhaee N. Associations between components of metabolic syndrome and cognition in patients with schizophrenia. J Psychiatr Pract 2015;21:190-7.
Malhotra N, Kulhara P, Chakrabarti S, Grover S. Lifestyle related factors & impact of metabolic syndrome on quality of life, level of functioning & self-esteem in patients with bipolar disorder & schizophrenia. Indian J Med Res 2016;143:434-42.
] [Full text]
Nishanth KN, Chadda RK, Sood M, Biswas A, Lakshmy R. Physical comorbidity in schizophrenia & its correlates. Indian J Med Res 2017;146:281-4.
] [Full text]
Alberti KG, Zimmet P, Shaw J. Metabolic syndrome – A new world-wide definition. A consensus statement from the international diabetes federation. Diabet Med 2006;23:469-80.
Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 1987;13:261-76.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision, DSMIVTR. 4th ed. Washington, DC USA: American Psychiatric Association; 2000.
Subashini R, Deepa M, Padmavati R, Thara R, Mohan V. Prevalence of diabetes, obesity, and metabolic syndrome in subjects with and without schizophrenia (CURES-104). J Postgrad Med 2011;57:272-7.
] [Full text]
Pallava A, Chadda RK, Sood M, Lakshmy R. Metabolic syndrome in schizophrenia: A comparative study of antipsychotic-free/naïve and antipsychotic-treated patients from India. Nord J Psychiatry 2012;66:215-21.
Mackin P, Bishop D, Watkinson H, Gallagher P, Ferrier IN. Metabolic disease and cardiovascular risk in people treated with antipsychotics in the community. Br J Psychiatry 2007;191:23-9.
Malhotra N, Grover S, Chakrabarti S, Kulhara P. Metabolic syndrome in schizophrenia. Indian J Psychol Med 2013;35:227-40.
] [Full text]
Lindenmayer JP, Khan A, Kaushik S, Thanju A, Praveen R, Hoffman L, et al.
Relationship between metabolic syndrome and cognition in patients with schizophrenia. Schizophr Res 2012;142:171-6.
Arango C, Bobes J, Aranda P, Carmena R, Garcia-Garcia M, Rejas J, et al.
A comparison of schizophrenia outpatients treated with antipsychotics with and without metabolic syndrome: Findings from the CLAMORS study. Schizophr Res 2008;104:1-2.
[Table 1], [Table 2]