- Have you ever heard of metabolic syndrome?
It's something you should know about
if you take antipsychotic medications
and I'll explain what it is.
I'm Dr. Tracey Marks, a psychiatrist,
and I make mental health education videos.
All of the antipsychotic medications increase the risk
of developing metabolic syndrome;
some do it more than others.
You may be put on an antipsychotic medication
for depression, bipolar disorder, schizophrenia,
borderline personality disorder,
and even obsessive compulsive disorder.
Some of the common antipsychotic medications
used today are aripiprazole or brand name Abilify,
quetiapine or Seroquel,
brexpiprazole or Rexulti,
olanzapine or Zyprexa,
and risperidone, also known as Risperdal as the brand name,
and ziprasidone also known as Geodon.
And this is not an exhaustive list
but these are the common ones used.
Metabolic syndrome is not a disease
but it's a set of risk factors
that increase your risk of heart disease,
diabetes, and stroke.
And here are the five risk factors
that constitute metabolic syndrome:
increased waist circumference, and for men,
this means having your waist measure greater
than 40 inches around.
You get this number by using a tape measure,
and you start at your hip bone
and wrap it around your waist at the level of your navel.
For women, the measurement is 35 inches or more.
The second factor is increased blood pressure
that measures more than 135 for the top number,
which is your systolic blood pressure,
or greater than 85 for the bottom number,
which is your diastolic blood pressure.
The third factor is a triglyceride level greater
than 150 milligrams per deciliter.
What are triglycerides?
Triglycerides are a type of fat
that your body uses to store unused calories.
A lot of the unused calories come from carbohydrates
that are found in sugars and starches.
So after you eat, your body uses some of the calories
to fuel your activities
and what you don't need at the time gets stored away
in the triglycerides.
Then in between meals,
your body breaks down these triglycerides for energy.
The fourth factor is a low HDL cholesterol.
HDL cholesterol is the good cholesterol,
and this is different from the total cholesterol.
Your cholesterol measurement is made up of HDL,
which is called high-density lipoprotein
and LDL which is low-density lipoprotein.
A lipoprotein is a particle
that you can think of as a package
that contains cholesterol and triglycerides.
Cholesterol and triglycerides are not soluble in water.
They have to be combined with a protein substance
that acts as an escort
to transport these fats through your body.
HDL is considered good
because it absorbs the excess cholesterol
and carries it back to the liver for processing.
So high levels of HDL actually lower your risk
of heart attack and stroke.
This is why having a high total cholesterol
isn't necessarily bad; it depends on how high it is.
But if you have a high HDL,
it's going to raise your total cholesterol.
LDL cholesterol is considered bad
because when you have too much of it,
it can deposit itself on your artery walls
and create plaques that narrow your arteries.
And this contributes to heart disease and risk of stroke,
so you wanna keep your LDL as low as as possible.
For metabolic syndrome,
you're looking at an an HDL cholesterol
less than 40 milligrams per deciliter in men
and less than 50 milligrams per deciliter in women.
The fifth factor is having a fasting blood glucose equal to
or greater than 100 milligrams per deciliter.
This is a measure of how much glucose or sugar
that you have in your blood when you haven't eaten anything
for at least eight hours.
Insulin is the hormone produced by the pancreas
that processes the glucose from the food you eat.
A normal level is under 100 milligrams.
Levels higher than this indicate insulin resistance,
which means that your pancreas isn't keeping up
with the demand.
Fasting blood glucose
of 100 to 125 is considered prediabetes.
And diabetes is a level
that's greater than 126 milligrams per deciliter.
So those are the five factors.
According to the American Heart Association,
you need three out of five of these
to be diagnosed with metabolic syndrome.
Now notice that of these five,
there are only two that you can detect on your own.
You can notice that your abdomen is getting wider
and you can measure your blood pressure.
A 2015 meta-analysis found
that waist size was the most useful predictor
of metabolic syndrome.
You can also measure your blood pressure.
You can't feel your blood pressure rising,
and in certain cases though,
if your blood pressure spikes very high,
you may feel your head pounding
or you may feel lightheaded,
but most of the time, the only one way to know
that your blood pressure is elevated is to check it.
Blood pressure cuffs are easy to get.
You can get a decent digital monitor
on Amazon between 30 and $50.
You want one that measures your blood pressure
from your upper arm.
The ones that are just for the wrist aren't as reliable.
Your blood pressure fluctuates throughout the day,
so if you have a blood pressure
that's in the borderline range of 130s for the top number
or 80 to 90s for the bottom number,
you'll wanna check your blood pressure
a second time of the day, like morning and afternoon.
Usually your blood pressure is lowest at night
when you're sleeping
and it rises sometime after you wake up.
It tends to peak in the early afternoon.
The other three factors require blood testing
to check your fasting sugar, HDL, and triglycerides.
If you are overweight and have high blood pressure,
these are signals
that you should get your blood levels checked.
What makes this happen?
There are medical conditions
that can cause metabolic syndrome
and obesity is a common one.
What does it mean to be obese?
Obesity is defined by your body mass index,
or BMI as it's called.
To calculate your BMI,
you take your weight in kilograms
and divide it by your height measured in meters squared.
There are handy calculators online
that make it easy for you to input your height
and feet in inches and your weight in pounds
without having to convert to metric units.
One such site is the
National Heart, Lung, and Blood Institute.
They also have an app that you can download
to your mobile device.
A normal BMI is considered to be between 18.5 and 24.9,
overweight is considered to be 25 to 29.9,
and you're considered obese when your BMI is 30 or greater.
There's a lot of things that can lead to obesity,
but in psychiatry, the antipsychotic medications we use
cause a lot of weight gain and lead to metabolic syndrome.
A 2017 article ranked the antipsychotic medications
in order of weight gaining tendency.
I'll have a reference to that article in the description.
The three highest weight gainers were clozapine,
olanzapine, and chlorpromazine.
Chlorpromazine was the first antipsychotic produced in 1952
and became FDA approved
under the brand name Thorazine in 1957.
It transformed psychiatric treatment
because it was the first drug
to effectively and reliably treat psychosis and mania.
It's also seen as responsible for deinstitutionalization,
which was a policy that was started in 1955
that moved severely mentally ill people
out of large state institutions that were called asylums.
Part two of the policy involved closing many
of these institutions
and effectively defunding psychiatric care.
We don't use chlorpromazine much these days
because of all the side effects.
It's extremely sedating in addition to weight gaining.
But before chlorpromazine, people who were psychotic,
either because of schizophrenia or manic depression
as it was called back then,
were put in institutions and managed instead of treated.
So chlorpromazine allowed people to regain their sanity.
So I digress with a little bit of psychiatric history.
The next three moderate weight gaining medications
are quetiapine, risperidone, and paliperidone.
Low on the weight gain scale are aripiprazole,
asenapine, haloperidol, ziprasidone, and lurasidone.
The antipsychotics usually cause weight gain
by increasing your appetite
especially for carbohydrates and sweets.
It's not a minor appetite increase that you may experience
when you wanna watch a movie with friends.
Instead, you can feel famished
and no amount of eating satisfies your hunger.
On a positive note, this is something
that you can control if you're aware of it.
Many people don't realize that they're eating more.
They just eat because they're hungry
and don't pay attention to the fact
that they're hungrier more than usual.
This matters because the sensation to eat is driven
by a biological need that your body has for energy.
But in this case, your hunger is artificially in hyperdrive.
So refusing to yield to the urges
won't make you malnourished.
It takes a lot of discipline to hold back though,
but if you do, you can control your weight gain.
So antipsychotic weight gain is a big contributor
to metabolic syndrome,
but some of the antipsychotics have also been shown
to directly interfere with your glucose metabolism
independent of weight gain.
In the studies, the main culprits of this were clozapine,
olanzapine and quetiapine.
And this has been my experience as well.
These three drugs are very good,
but unfortunately cause the most weight gain
and insulin resistance.
It doesn't happen to everyone
but they increase your risk more than the others,
so the decision to take one of these medications boils down
to a risk/benefit analysis.
And for some people, these medications are like magic
and work better than anything and the others.
What can you do about this?
Well, first, knowing that this can happen
can put you on alert to watch your weight.
Sometimes your doctor may put you
on one of these medications for a short while.
But if you're gonna take one of these medications
for more than six months,
you should make sure that you have regular checkups
with blood work to keep up with your lipids
and your blood sugar.
If you gain more than about 10% of your body weight
despite your best efforts to modify your eating,
you and your doctor should revisit
whether or not you really need the medication.
For example, with treatment-resistant depression
or psychotic depression, we may add Abilify
for a few months to treat your symptoms
then taper off the Abilify once your symptoms improve
and you're only left on the antidepressant.
Another option is to add a medication called metformin
to help you lose weight and improve your insulin resistance.
A typical weight loss
for metformin is between 5 to 10% of your weight,
and this isn't a huge amount of weight but it is something.
Probably the bigger impact
from metformin is the effect it has
on lowering your blood sugar
if you're having elevated blood sugars.
So that's metabolic syndrome.
I hope this was helpful for you.
See you next time.