The ‘obesogenic’ environment of adolescent inpatient units: A call for action to support the promotion of better physical wellbeing

Dr Rebekah Carney


Rebekah is a research associate at a new Youth Mental Health Research Unit at Greater Manchester Mental Health NHS Trust. Having completed a PhD in Manchester on physical health for young people at-risk for developing psychosis, Rebekah has embarked on a career of health promotion within mental health services. This involves research on physical health across settings including early intervention, adolescent inpatient and youth forensic services.

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Summary

Young people with mental health disorders have poorer physical health than their peers and are more likely to experience difficulties living a healthy lifestyle (Firth et al., 2019). This is particularly the case for those who need to spend time in adolescent inpatient units. The term ‘obesogenic’ has been used to describe the unique set of circumstances people experience on mental health inpatient units which results in a propensity for weight gain (Faulkner et al., 2009; Gorczynski et al., 2013). Weight gain and preventable physical health problems contribute to the shocking statistic that people with serious mental illness have a reduction in life expectancy of 20 years (Correl et al., 2017). By delivering better informed, designed and targeted research we can help to ensure physical health needs are better considered, and we can do more to alleviate the burden of preventable disease, short term and across the lifetime.

What is the issue?

Young people’s mental health is a major area of concern. A recent study revealed that mental health problems in young people are higher than previously thought. Out of 28,000 adolescents assessed in the UK, two in five young people were above threshold for emotional and conduct problems (Deighton et al., 2019). It is likely that many of these young people will receive treatment from adolescent mental health services (such as Child and Adolescent Mental Health Services, CAMHS), and may access help via community or charitable organisations. However, some young people will unfortunately experience more severe difficulties with their mental health which require admissions to adolescent inpatient units and more intense, specialised treatment. This is often an important and sometimes necessary step to keep young people safe and help them get the support they need.

Although there has been a large focus on ensuring young people receive access to high-quality mental health care, their physical health has received less attention. However, it has long been recognised that people with mental health conditions are also at risk for serious physical health problems, such as obesity, diabetes and cardiovascular disease (De Hert et al., 2009). Many of these comorbidities are preventable, yet people are less likely to receive efficient physical health care and monitoring. This is often the case even prior to the onset of serious illness.

What causes poor physical health?

There are many factors which contribute to poor physical health for young people with mental health disorders. This includes:

1. People within mental health services are less likely to receive adequate physical health care and monitoring of physical health is often inconsistent. Quite often physical health conditions go undetected, for example an Australian study found adolescents in inpatient units were often experiencing physical health problems such as obesity and high blood pressure, yet they often went unnoticed and untreated (Eapon et al., 2009).
2. Individuals with mental health difficulties are more likely to live an unhealthy lifestyle than others, through high levels of inactivity, poor diet and increased likelihood of smoking, substance and alcohol use (Correll et al., 2019) This occurs even prior to the onset of serious illness (Carney et al., 2016) .
3. Some may receive medication such as antipsychotics which although can be effective for symptoms such as delusions and hallucinations, can have serious metabolic side effects resulting in weight gain and metabolic dysfunction (Correll et al., 2017).

Aside from the risk factors discussed above, for those who spend time as an inpatient their environment can pose an additional risk factor to young people.

Why inpatient wards are so ‘obesogenic’

The term ‘obesogenic’ has been used to describe adult and young peoples’ mental health inpatient units. According to Faulkner et al., (2009) this refers to the propensity for an individual to gain weight during an inpatient stay, and therefore poses an additional risk to people already vulnerable to poor physical health (Gorczynski et al., 2013). Although adolescent inpatient units provide important and rapid access to mental health care and support, physical health often gets left behind. This is evident from studies which show physical health monitoring is inconsistent in adolescent mental health services (Pasha et al., 2015; Gnanavel & Hussain, 2018; Carney et al., 2015), and that many physical health conditions are often undetected and untreated (Eapen et al., 2012).

The environmental factors of mental health inpatient wards which ultimately increase the risk of poor physical health have been described in several studies (Faulkner et al., 2009; Gorczynski et al., 2013; Every-Palmer et al., 2018). Young people admitted to generic and secure mental health wards may potentially experience several of the following risk factors which can be detrimental to their physical health. Many of these factors have been personally observed in the adolescent inpatient units, and discussed by young people in various service user engagement events. Some of these factors include:

• Fewer opportunities to be physically active
• Increased time spent engaged in sedentary activity
• Restricted living space and general daily activity
• Increased severity of symptoms such as low mood, anxiety and symptoms of psychosis
• Increased access to highly calorific and nutritionally poor foods
• Low access to home-cooked foods due to restrictions on foods allowed on the wards
• Side-effects of medication (for example those prescribed antipsychotics)
• ‘Culture’ of the inpatient wards e.g. pizza night

Although there may be exceptions to this in units across the UK, many young people on adolescent wards will likely experience more than one of these barriers to healthy living (Faulkner et al., 2009; Gorzynski et al. 2013). It is important to quantify this risk in the future, and optimize physical health opportunities for young people.

Moving forward and moving more

Although there has been increasing awareness of living a healthy lifestyle for mental wellbeing, adolescent inpatients are still at a significant disadvantage when it comes to physical health. There is a dearth of evidence for use of physical health interventions in adolescent inpatient units, as found in a recent review of the literature which identified only three studies which have been conducted to date (Carney et al., in press). Furthermore, there is little research focusing on what physical health support young people actually need and might benefit from on mental health inpatient units. More research is needed to identify ways to promote health and wellbeing taking into account the nature of the inpatient environment. Specifically research is needed to tackle the following areas:

1. Increasing activity
It is important to identify effective ways to help young people become more active in inpatient settings. Given the difficulties experienced by this group in terms of restricted living space and lack of outdoor access, more innovative ways need to be developed to try an increase activity within the challenging environment. This could include more structured physical activity taking place within the wards, and using leave productively to encourage young people to move more, e.g. meet friends and family at parks or outdoor spaces.

2. The role of nutrition
Hospital provided food will likely make up a large proportion of young people’s diets. Therefore, this represents an ideal opportunity to ensure they consume nutritionally balanced meals, regardless of any additional snacks they chose to consume. Similarly, hygiene restrictions are generally in place on the wards which prevent family members and visitors from bringing in home cooked food. Visitors therefore often bring in prepackaged snack foods which are generally low in nutritional value e.g. share-size crisps. There is growing evidence for the link between diet and mental health, (Firth et al., 2019). Therefore, future work should look at educating parents and young people on the benefits of a healthy diet, and exploring the opportunity to improve nutrition on the wards.

3. Improved monitoring
Ensuring physical health is monitored and assessed routinely within all mental health settings will enable any emerging risk factors to be picked up at an early stage. As this is an area many mental health services struggle with, it is important to establish set guidelines and mandate monitoring of key physical health parameters routinely, such as weight, height, blood pressure, and activity levels. Although physical health assessments may be conducted in mental health inpatient settings, the current literature does not provide a strong evidence base for this and there are several studies which show monitoring and assessment is below standard for young people (Eapen et al., 2012; Pasha et al., 2015; Gnanavel & Hussain, 2018; Carney et al., 2015).

Conclusions

Many co-morbid physical health problems are reversible and indeed preventable; early intervention is critical to prevent these from occurring in the first place. Young people with mental health difficulties are a particularly vulnerable group, embarking on a negative trajectory for physical health at an early stage. It is especially the case for those who experience additional barriers to healthy living in the ‘obesogenic’ inpatient wards. Therefore promoting physical health in young people is imperative to improve both mental and physical wellbeing. Doing so may prevent the onset of premature mortality of up to 20 years of life lost due to disability.

References

Carney, R., Cotter, J., Bradshaw, T., Firth, J., & Yung, A.R. (2016). Cardiometabolic risk factors in young people at ultra-high risk for psychosis: A systematic review and meta-analysis. Schizophrenia Research, 170, pp.290-300.
Carney, R., Bradshaw, T., & Yung, A.R. (2015). Monitoring of physical health in services for young people at ultra-high risk of psychosis. Early Intervention in Psychiatry. In press: https://dx.doi.org/10.1111/eeip.12288
Correll, C.U., Solmi, M., Veronese, N., Bortolato, B., Rosson, S., Santonastaso, P., Thapa‐Chhetri, N., Fornaro, M., Gallicchio, D., Collantoni, E. and Pigato, G., 2017. Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large‐scale meta‐analysis of 3,211,768 patients and 113,383,368 controls. World Psychiatry, 16(2), pp.163-180.
De Hert, M., Schreurs, V., Vancampfort, D. and Van Winkel, R., 2009. Metabolic syndrome in people with schizophrenia: a review. World psychiatry, 8(1), pp.15-22.
Deighton, J., Lereya, S.T., Casey, P., Patalay, P., Humphrey, N. and Wolpert, M., 2019. Prevalence of mental health problems in schools: poverty and other risk factors among 28 000 adolescents in England. The British Journal of Psychiatry, pp.1-3.
Eapen, V., Faure-Brac, G., Ward, P.B., Hazell, P., Barton, G.R., Asghari-Fard, M. and Dullur, P., 2012. Evaluation of weight gain and metabolic parameters among adolescent psychiatric inpatients: role of health promotion and life style intervention programs. J Metabolic Synd, 1(109), pp. 2167-0943.
Every-Palmer, S., Huthwaite, M.A., Elmslie, J.L., Grant, E. and Romans, S.E., 2018. Long-term psychiatric inpatients’ perspectives on weight gain, body satisfaction, diet and physical activity: a mixed methods study. BMC psychiatry, 18(1), p.300.
Faulkner, G.E., Gorczynski, P.F. and Cohn, T.A., 2009. Psychiatric illness and obesity: recognizing the” obesogenic” nature of an inpatient psychiatric setting. Psychiatric Services, 60(4), pp. 538-541.
Firth J, Siddiqi N, Koyanagi A, Siskind D, Rosenbaum S, Galletly C, Allan S, Caneo C, Carney R, Carvalho AF, Chatterton ML. The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. The Lancet Psychiatry. 2019 Aug 1;6(8):675-712.
Firth, J., Marx, W., Dash, S., Carney, R., Teasdale, S.B., Solmi, M., Stubbs, B., Schuch, F.B., Carvalho, A.F., Jacka, F. and Sarris, J., 2019. The effects of dietary improvement on symptoms of depression and anxiety: a meta-analysis of randomized controlled trials. Psychosomatic medicine. 81(3), pp. 265-280.
Gnanavel, S. and Hussain, S., 2018. Audit of physical health monitoring in children and adolescents receiving antipsychotics in neurodevelopmental clinics in Northumberland. World journal of psychiatry, 8(1), p.27.
Gorczynski, P., Faulkner, G. and Cohn, T., 2013. Dissecting the obesogenic environment of a psychiatric setting: client perspectives. Canadian Journal of Community Mental Health, 32(3), pp.51-68.
Pasha, N., Saeed, S. and Drewek, K., 2015. Monitoring of physical health parameters for inpatients on a child and adolescent mental health unit receiving regular antipsychotic therapy. BMJ Open Quality, 4(1), pp.u202645-w3700.

Discussion

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Amazing article by a exceptional person

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An shimiúil. ‘Very good paper. The problem is compounded by medical doctors in psychiatry no day doing minimal if any general medicine to the extent that if I show psychiatric trainees the results of a blood test and asked them to interpret it, they scratch their heads and look at me quizzically as if I had asked them that to decipher hieroglyphics. Many outpatient paediatrics psychiatry clinics have no access to physical examination or bloods. Doctors are ‘specialising’ too early. To the detriment of our patients.

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