Hello and welcome. I'm Alexia Wolf, Director of the Behavioral Health Consortium in Delaware and Social Determinants of Care Expert for SMI Advisor. I'm so pleased that you're joining us for today's SMI Advisor webinar, Achieving Healthy Weight Loss for People Living with Serious Mental Illness. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next slide. Today's webinar has been designated for one AMA PRA Category 1 credit for Physicians, one Continuing Education credit for Psychologists, one Continuing Education credit for Social Workers, and one Nursing Continuing Professional Development contact hour. Content for participating in today's webinar will be available until January 3, 2023. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for the Q&A. And now I'd like to introduce you to the faculty for today's webinar, Dr. Gail Dommett. Gail L. Dommett, MD, MHS, is the Vice Dean for Clinical Investigation at the Johns Hopkins University School of Medicine. She is a professor in the Departments of Medicine and Psychiatry and Behavioral Sciences, as well as the Samsung Professor of Medicine at the Johns Hopkins University. Dr. Dommett's research has focused on developing innovative ways to improve the physical health of people with mental illness through descriptive epidemiology, health services research, clinical trials, and implementation science. She has obtained continuous NIH funding for this work since 2000 and has published more than 100 peer-reviewed articles. Dr. Dommett, thank you for leading today's webinar. Thank you so much, Alexia, for that nice introduction. I'm so happy, one moment, to be here with you all. And I am a primary care physician and a general internist, and my work and my clinical practice have led me to this area, and I look forward to being with you all this afternoon. So thanks for your patience with the technical difficulties. I have no disclosures or conflicts of interest. So this afternoon, our learning objectives are we're going to describe the prevalence of overweight and obesity among those with serious mental illness and why it's important. I'm going to identify for you key lifestyle behaviors for weight management, propose some strategies of simple messaging and repetition for weight management, and talk about explaining the value of tracking and high-impact behavior goal-setting to increase success and accountability. And really, this presentation is meant to be really to give you tools to work with your own patients and clients in your own organizations and communities and is meant to be very practical. I realize that the webinar format makes it seem a little more formal, but we will have plenty of time at the end for Q&A, and I can address any of your questions or comments at that time. So thanks again for being with us. Just a brief framing of the problem. So overweight is a body mass index of 25 kilograms per meter square between 25 and 30. And then once you have 30 or above, this is considered obesity. Now we know that certain individuals of certain racial and ethnic backgrounds, BMI cutoffs might in reality be different, but this is a standard that's currently being used. So this is just to show that over 60% of adults in the U.S. with serious mental illness are overweight or obese. And this data slide, which is just kind of really a picture for you, was a meta-analysis of 120 studies across the world showing that obesity in people with serious mental illness was over 25%, and overweight and obesity was over 60%, and that these are increasing over time. They're not getting better. So why do we have this? You all probably know these answers as well as me. So it's not just specific anti-psychotic medications, but really almost all, not all, but almost all psychotropic medications can promote weight gain. This is often through increased appetite mechanisms. And while we definitely support and encourage people being on the best medication for them, and hopefully one that has minimal weight gain propensity, we know that often people are taking more than one medication, and medications may not be modifiable for many clients. In addition, compounding this, we know that unhealthy diet and limited physical activity are not atypical for individuals living with serious mental illness. And these are really important modifiable risk factors that can reduce heart disease risk. And that's what I'm going to be focusing with you on this afternoon. So just to kind of review, what's important about being overweight? So overweight is its own risk factor for heart disease. And it also is a risk factor for diabetes, high blood pressure, and high cholesterol, which in and of themselves are risk factors for heart disease. We also know that overweight and obesity can lead to cancer, lower quality of life, and are independently related to all-cause mortality. So it's a really important issue. We also know that there are a lot of economic burdens associated with overweight and obesity, both in the overall population and in those with mental illness. So this is certainly an issue. Now hopefully we all believe that there are solutions here. However, several years ago, or a little bit more longer than that, there wasn't really great evidence about how we should work with clients living with serious mental illness to have them be able to improve their weight. In fact, the main large clinical trials in the U.S. and world population, such as the DASH diet, many, many trials funded by the National Heart and Lung Association, the National Institute for Research for Diabetes and Kidney Disease, NIDDK, all excluded people with mental illness, even people who were just maybe taking like one antidepressant medication, who just had one hospitalization for psychiatric reasons. And so we didn't have data or evidence, even in interventions that were being tested in those without serious mental illness. So there was this real lack of data. And so we did a study that was funded by NIMH called the ACHIEVE trial, where we worked with almost 300 participants in psychiatric rehabilitation programs in Maryland, in 10 programs. And we had an 18-month weight management lifestyle, healthy lifestyle intervention. We randomized people to either receive it or receive their usual psychiatric rehabilitation classes, and we had individual and group sessions and exercise sessions. And we saw that there was a seven-pound weight loss in those in the intervention group compared to control. Now, that might not seem like that much weight, but actually over an 18-month period, that actually matched studies that, large studies that were done in the overall population, not just those people with serious mental illness. So this was an important study, and a lot of what I'm going to talk with you about this afternoon is what we've learned from that study and subsequent work we've done in this area. Okay, so now let's move into behavioral lifestyle changes for weight loss. These messages, what I'm going to talk to you about is in some ways specific to those living with serious mental illness, in some ways it's not, it's really applicable for everyone. So just roll back to basics, weight loss occurs when we eat less than our body needs. And it's pretty much when we have more calories out than calories in. I think it's important to think about weight loss as lifestyle change rather than dieting. A lot of diets can be helpful in the short term, but can be very restrictive and are not sustainable in the long term. Now, I'm not talking about like the Mediterranean diet or kind of the DASH diet, like healthy approaches, but I'm talking about more of like fad diets. Behavioral lifestyle change for weight loss really involves making gradual lasting changes to eating and exercise behaviors. So I think like framing this as something that's step by step that can occur over time. So what are some lifestyle behaviors for weight management? Now, many of us who may have been involved in, oh, sorry, I like have these, I hope you guys are seeing my, sorry about my screen here. Many of you that may have had other lifestyle, you know, you've been working on weight loss yourself, you know, may be familiar with calorie counting or other things like different kinds of fat or, you know, and things like ratio of protein to carbs and things like that. When we work with individuals with mental illness, we focus on behaviors and not calorie counting. And so it's not, there's nothing wrong with calorie counting, but it can be very, it can be complex. So we focus on things like for healthy eating, avoiding sugary drinks, avoiding junk food, smart portions and vegetables. And I'm going to go into more detail about these in this talk. And then for exercise, we try for 30 minutes a day. That's not, you know, always feasible, but that's a goal. And really, really important is decreasing sedentary time. In this Zoom world, that's potentially even more important. Okay. So let's go into some detail about some of these behaviors. So sugary beverages. We have found in the clients that we work with that this can be one of the easiest things to change. And we can, they can get some of the biggest bang for their buck because there is, are a lot of calories in sugar beverages. So I'm talking about soda, energy drinks, juice, coffee drinks that have, you know, a bunch of stuff in them, not just the coffee itself, sweetened tea. Healthier choices are water, flavored waters, black coffee, plain tea, or potentially diet soda. Okay. Sugary beverages. Let's move on. Junk food. I think we all probably have a sense of what junk food is. But, you know, it's something that's high in calories, low in nutritional value, things with a lot of salts, fats, and sugar. When we work with our clients, we are focusing on sweets, cookies, candies, pastries, and salty and greasy foods. So chips, fast food, things that are fried. We tell people when they're eating out, you know, try for grilled options and try to fill up on any vegetables that are offered. Junk food is a, can be a hard one. You know, people can be attached to their, to their junk food. So I'm right now, I'm just going through the different behaviors we are going to help people with. And then after this, we're going to talk about how to help people with those behaviors. Smart portions. Okay. We all know that portions are referred to the amount of food consumed. This is something that it can be, it can be taught and learned. If we eat too much of something, even if it's a good thing, we, people will gain weight. So what are smart portions? It can be one serving size, which is on, you know, labeled food or eating less than what someone would normally eat. This can control the amount of calories consumed. Again, we're not talking with people about counting calories, but sorry. But this, but portion size is really important. Vegetables. These are low in calories, high in fiber and nutrients. They can be filling and can be a really good way to replace high calorie foods and beverages. And it can give people a positive focus because the other things I've just talked about are like kind of, you know, don't eat junk food, don't have sugar drinks. And this is something that people can do. That's like an, you know, a yes do thing. And understandably many individuals we work with are on a limited budget or maybe in a food desert. For those individuals, frozen vegetables are definitely an option or even canned vegetables, as long as, you know, people are looking at salt level or making sure they're not like in corn syrup or something like that. Okay. What about physical activity? You know, of course we know they're both physical and mental health benefits to participating in exercise. I feel sometimes both even internal medicine physicians are sort of sheepish and they, they, they aren't sure, you know, what they can really recommend to people and like what they can recommend safely, because we don't want people to go out and hurt themselves or have any, you know, cardiac issues. So essentially for most people, for almost everyone, moderate intensity, physical activity, aerobic activity should be safe. Walking, bicycling, swimming, if possible. Walking is safe. If you are guiding someone about, you know, what is moderate versus vigorous activity, people can feel an increased heart rate and that their breathing is increasing, but they should, they should not feel out of breath doing the activity and kind of working up to a level of activity is generally what we recommend. We wouldn't necessarily to tell someone just go walk briskly for an hour if they, if they haven't been walking regularly. 10 minutes is a very nice guide to give someone in terms of like about or like a bout, not about, of physical activity or like a, an episode of physical activity. And what about sedentary time? So, you know, I used to think of sedentary time as sort of just people watching TV, but again, now with all of our Zoom, even on this webinar that you're on right now, could be sedentary time if you're not standing up and watching me. So we really want to try to encourage people to find ways to not be sedentary or at least take breaks when they're working or watching TV and to get up and move maybe for example, for 10 minutes. And of course, if you're moving, you're also probably not likely to be eating. Okay. So let's talk about weight management now and like kind of healthy eating and exercise. We know that both are important and we know that people generally underestimate how much they're eating and probably overestimate their physical activity. It really, you can't out exercise a poor diet. So for example, if you walk for five miles, that's about like 20 ounces of soda in terms of like calorie burn. So truthfully is we do really, really encourage the physical activity and physical activity is independently associated with decreased mortality. So physical activity is very important and for mental health, but in terms of weight loss, we know that reducing sugary beverages and junk food, for example, is going to have a bigger impact on weight. Okay. So now let's talk more specifically about how can we help our clients adopt some of these behaviors or all of these behaviors. So we're going to go through some different strategies that we've used in our programs and that we think work. One is simple messaging. We also have repetition, setting high impact behavioral goals and accountability in some way. You all are the experts in treating those with mental illness, but what we found is the simpler, the better. As I said before, we are not really focused on different kinds of fats or carbohydrates or calories and just more on behaviors like avoiding junk food. Now that, of course, depends on the person you're working with. If they want more information or you think that's totally fine, but generally we work on simplicity. And I think depending on your individual patients, we would recommend that. Repetition. The curriculum for the ACHIEVE trial that we did for the intervention really only had those key messages I gave you before. And I think like increasing water, it didn't have, it was like that was all it is. So I think repetition for all of us is helpful. The ability to focus on core messages and really stay focused on those and consistency of messaging in particular, you know, depending on how often people are seeing you or other clinicians that you work with. And I think, you know, one, I think advantage of this is that, you know, if people that are getting mental health services, if they have a nurse or a psychiatrist or a therapist or a case manager and different individuals, different practitioners that they're seeing, if the messages are simple and can be repeated and reinforced or on the person's goals or treatment plan or recovery plan that they have, which I'll be talking about in a minute, then it can really help reinforce and encourage people to make change. Taking advantage of the team. Okay. So what are high impact behavioral goals? What is all that? And it sounds kind of like something that would like take work. So let's break that down. So a high impact behavioral goal is a change in this for weight loss to an eating or exercise behavior that we believe that should impact weight. So one of the things that you could do if you are going to work with your patient client on this is that you could help them identify a goal, a high impact goal that they're willing to change until the next time you see them or the next time someone on your team could see them. You could then, you could talk about how and when they're going to implement the goal. And really we have had good experience in starting small to build confidence and self-efficacy. So for example, I talked about the sugar beverages for one meal where let's say they normally would drink like apple juice, drink water instead. And another one would be, I'm going to choose to go for a 15 minute walk instead of my usual eating dessert after dinner. So it's replacing a behavior that is more likely to contribute to weight gain with something that would potentially help with weight loss. We have, the good thing about the behavioral goals is that it's not something you're telling people, you know, it's more of a partnered approach and we have found this works very well because obviously people need to be bought into a goal. It's their goal. They're going to go make the change. Okay. It's one of the kind of very simple like things that we've done to help people with these goals and this little tool, it is published in a supplement in one of our papers. So I'm happy to provide that to Alexia's team if people want to know where this is, is to use something we call an options tool. So again, depending on the different patients that you work with and their, you know, kind of how you think that they would respond to this, but basically these are different examples of things that you would recommend they do less of like these salty greasy foods, fries, donuts. Here's an example of a sugar beverage. Here's something very processed. And here is, here's something to mention portions and here's fruits and vegetables, really vegetables is what we, we prefer. Fruits can also have a lot of sugar, but are better than other things like French fries. So something like this can be very helpful to focus the conversation. Okay. Okay, now let's talk about accountability. And I do understand this is, you know, can be sensitive, especially since individuals are seeing you all for their mental health care and you're probably working on other things with them as well. So this should all, you know, be kind of in a positive light and you know, we don't want this to be a burden, but in terms of how you can help people, one of the ways is, is by weight and we'll, I'm going to talk about that in the next slide. And then another one is checking in on the progress towards the goals that they are, have made. And then we're going to, I'll also talk about tracking. Okay. So what's the deal with weight? You know, there's people often now have scales in their office or people will have them at home. You know, what, what is about that? We certainly don't want people, you know, obsessing and checking their weight every day. There can be fluctuations up and down women, you know, in, in who are, you know, menstruate, you know, in who are not yet in menopause can have changes with their menstrual cycle, et cetera. So we don't want to overweigh people, but it can be helpful. Let's say weekly approximately, or maybe a little bit less than that, depending on, you know, when you see people to record weight and to establish a routine. And it can be helpful to look at weight trends over time. So for example, if someone's weight goes up how is that? Is that related to them not reaching their goal potentially how would you know, thinking about why that might be now, if it's something where it's just like they're gaining a couple of pounds and it's been a week you know, that some of this, there can be like some, you know, natural variation of a couple of pounds in either direction, but it's still, it's a good way to, to track and be able to have some, give some guidance or was the goal that they set like not high impact enough. When we think about healthy weight loss, generally it's gradual. So generally healthy weight loss is not going to be more than two pounds a week. It can be less. And as I said before, people's weights can fluctuate. So you don't want to read too, too much into a small amount of weight change in either direction. Although that being said, if someone comes in and they've lost weight and they said, okay, I've decreased sugar drinks and they lost a pound, you know, I think you can, you know, definitely congratulate, congratulate them. Okay. In terms of checking in on people's progress, if you're going to be working with them, you would follow up on the high impact behavioral goal or goals that you've previously set. The goals hopefully are generally additive so that hopefully they don't give up one goal when they're, when they're going to another goal. And just patience, you know, may take people a few weeks before they're able to fully accomplish any goal, especially ones that are things that they, you know, if it's changing something that they really, something that they love to do or that, you know, gives them a lot of pleasure, like desserts, affirm their project, their progress, and encourage them to stick with their goal. So some questions in the little blurb, how did it go? What helped you be successful and what were some of the challenges? Some of the tracking that we do around weight loss, and again, I can, I'm happy to show Alexia to share with you all where this is, if you all want to use it or something like it. Tracking can increase self-awareness, identify patterns in people's eating and exercise, and help identify an appropriate high impact behavioral goal. Clients may be, may have different capacity or interest in tracking. They might prefer something very simple like this with, you know, the key behaviors that you may be sharing with them or for sure, I mean, if they want to use an app or a fitness tracker or something like that, but you know, by all means. There's no one right way to track, but the tracking shouldn't be more complex than necessary. Okay, let's take a moment to talk about addressing healthy weight in our client populations with regard to diversity. In different groups of people, different cultural backgrounds, there can be different perceptions around weight. I think it's really important to acknowledge that. And I think that pretty much regardless of kind of actually weight loss per se, healthy eating is good. So even if people are not, you know, bought into a weight loss, you know, it's still good for them to eat in a healthy way. And so you can tailor your message around that. And it's good for you to kind of think about what or ask maybe what people's perceptions are around weight in general, and to again, personalize the messaging that you're giving them. And really, you can focus on health benefits of eating in a healthy way instead of weight loss. You can also identify some healthy alternatives, let's say to traditional foods that they are eating. Okay, so where are, you know, what these messages that we've talked about and these strategies, you know, where are these applicable? Like where, you know, and I think that pretty much, they're reasonably, I think applicable in a lot of different places. So if people have therapy visits, or seeing a care manager or care coordinator, they can be delivered in briefly in those kinds of sessions. If individuals have access, or you all are delivering group type programming, they can fit there, certainly in a residential or group home program setting with healthy food purchasing and providing healthy meal options. And then in a, even a physician or nurse practitioner visit, brief messaging can be helpful. So I think that these can be kind of dialed up or down depending on what works best for you all. And again, if more than one practitioner or staff member is seeing a client, then kind of triangulating on the messages in their goal plans that they have would be great. So just a little reminder here that, you know, making change is not always easy. I'm sure we can all agree that in our own lives, it's not. And a behavior that someone has been doing for a long time can be hard to change. So that's one of the reasons why it's really okay to start with small goals, small successes can lead to big successes and consistency and just kind of continuing to work on things and getting those small wins are key. So in summary, and then I think soon we'll go into the Q&A. We've talked about that there's a high prevalence of overweight and obesity among those living with serious mental illness, and it has a significant impact on health and on quality of life. Focusing on key lifestyle behaviors for weight management can help those mental health consumers, patients lose weight as the rest of us too can lose weight this way. Simple messaging and repetition are important strategies that can help people learn weight management behaviors and high impact behavioral goal setting and accountability are also important factors in weight loss success. The bibliography, I guess you guys can look at when, if you're downloading the slides. And thank you very much. I think I want to make sure I'm doing the right thing here, but, oh, okay. And thank you for such an interesting presentation, Dr. Domet, and before we shift into Q&A, I want to take a moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org backslash app. And a check-in on time, we are extending until 110, so there's plenty of time for people to ask questions with Dr. Domet. And then in the meantime, Dr. Domet, when you are working with consumers, what have been some of the barriers to weight loss that you commonly encounter? Thanks. One of the barriers that we have seen is really has been environmental, so that people, some of our clients, some have not had as much agency over the food that they are getting. So whether it's shopping for food, preparing food, this is, again, in groups that are in more psychiatric rehabilitation program settings. So in that case, it's really a multi-pronged approach. It's not just working with the individual, but trying to work with their supports as well. Excellent. And we have a great question in the chat about what advice you would give to a client who's skipping meals to lower his or her weight. Yeah, so that is a really, really important question. And this is not something that, yeah, this is really, really important. So we do not want people to skip meals. And in fact, some individuals will have like a prior eating disorder history. It's not uncommon in the US and certainly our clients may have that also. So we would recommend against that because really safety first, and it's not necessary. And your body needs energy throughout the day. And if it gets to the situation where that does seem like someone is doing that, then I would advise working with an internist or getting that person additional supports, additional clinical supports. And another great question. There is someone who has a client who qualified for bariatric surgery, but her mental health may disqualify her. Doctors are asking for an updated psychological evaluation. Could you help flesh out why that would be? Yeah, so I think that this is also a really important issue. And I don't know if this varies like state by state or like surgical practice by surgical practice, but, or, and I have to admit, I don't know what the current bariatric surgery, if they're like national guidelines. But I do know that there are many individuals, including those with bipolar disorder and other conditions that have had successful bariatric surgery. So I think that hopefully this is something that's a partnership with the evaluating team and the treating mental health clinician. So that, you know, surgery can be achieved if that is what the client wants. I think that the guidance against, my sense was that that issue was improving, but I might need to get more informed about that. I don't know if that's a helpful response or not. Thank you for that. And we have a question about whether the study intervention is available in a manualized or packaged form that could be implemented clinically. Yeah, that's a great, that's a great question. And we are, we do have, I can share the materials that we can share and we are in the process of testing it in a wider arena, which I'd be, you know, if people are interested, they can, I'm happy to have people contact me through SMI advisor, but there are some materials that definitely we can share now. So just to kind of clarify, the intervention was delivered by research staff, not high level research staff, but by the people that we trained in some of the counseling techniques. And we are, we have now adapted it so that it can be delivered much more easily by those who are treating people with serious mental illness, including more lay providers. So that part is just not completely final yet, but I will definitely share what I can. So thanks. And we have a great strategy that one of the participants shared when working with African American women around weight loss is to have them define the why behind losing weight, and then go back to the why when it becomes challenging to stick with the plan. Yeah, is that a, it's sort of like a state, is that a question or it's like a statement? Right? Or? Yeah, it's a strategy that someone in the audience is sharing. I think that's a great strategy. We the goal is we do not want to be necessarily changing people's perceptions about, you know, what they should or should be doing. We want to be like working with them. So. And would you encourage weight lifting for weight loss? Is there a recommended, and an additional question is, is there a recommended program for youth and young adults? Okay, so that's two parts. So, in terms of weightlifting, so I believe, and so strength training is not bad. I wanna make sure I have my facts straight on this. I believe that cardio work, or like walking, bicycling, et cetera, like I talked about is preferred. I know that certainly if people are lifting weights, then we're gonna be converting more fat to muscle, and that kind of independently is good. I don't know if that by itself is necessarily, we wouldn't necessarily recommend it for weight loss, but I think it's a good thing. In terms of youth, I mean, so interestingly, so first of all, I think like these principles that we've shared today, they're not, they could definitely apply to youth. I have a separate program study that had just finished and is that kind of tested a program that took some of these principles, but that was more directed towards like parents and youth together and more like tailored for like youth ages eight to 18, that like addresses more about also like how's the family eating in the home and things like that. So I'd be happy to speak separately about that, but I do think that these principles that we talked about apply. I think one of the things with kids with youth is screen time is a big thing, which is kind of like sedentary time, right? But screen time, decreasing screen time. And then also the physical activity recommendations for youth depending on the age are even higher, more like 60 minutes a day. And so more physical activity, less screen time is what would be other things to emphasize for kids. Thanks. Excellent. And we have a question asking about any suggestions regarding the effects of certain neuroleptics and lithium. You mean for weight? So I think that I don't, well, anyway, the thing's over. I mean, I have some, I do have a slide on this. I didn't put it in the stack. So, I mean, lithium has weight gain propensity and other, you know, most neuroleptics also do. And it's a trade-off, right? Between kind of, you know, certainly if people are using first generation medication, anti-psychotics, I mean, there are other issues around those with, you know, neurologic side effects. So I think that, and I think that everything is just kind of a trade-off and it's, you know, finding, you know, well, finding the best medication for the person that you're treating. And if it, that medication, if that's going to be the best for their psychiatric symptoms, then prevent weight gain or, you know, work towards weight loss. So, I don't know if that answers the question. And there's a question about new GIP-1 medications being used for obesity in patients with SMI and with anti-psychotics like lithium or others. I need to, I might need to look that up to see if there's a known, like, I'm not sure if there's like a known issue there. So I don't want to, I can't look it up while I'm on this because it's live, but I can, I can check that because those are good medications. Great. And what are your thoughts on supplementing metformin along with lifestyle interventions? That is a great question. So we know that from the diabetes prevention program studies that metformin can be, can prevent diabetes. And we know that it's, you know, can be helpful for managing weight. And so, and there have been studies in persons with SMI with metformin. So I think that it's not bad and can be used. And so I definitely think that's something that can be considered. I, most of my work has focused on more of like a strict lifestyle intervention approach in part because it didn't require coordinating with primary care or measuring, you know, with metformin, you have to make sure someone's kidney function is good. But it's definitely something to be considered. And if the patient is willing to take it in addition to his or her other medications, I think it's great. And given the high percentage of smoking among people with SMI, how does that impact your work with weight management? That's a really interesting question. And hopefully before too long, we're gonna have results of a study out that was a smoking cessation intervention where we actually included some of these weight management principles in the tobacco smoking cessation intervention. I mean, I think, you know, look, people quit smoking. It's known that people can gain weight. And that's been shown. I think that everything is a trade-off. Cardiovascular and truthfully, the risk, the killer and other, if people smoking, I think that's great. I think if they are going to work towards quitting smoking, then combining that work that they're doing, that whatever program they're going to be working with with smoking cessation, combining weight management principles in there could be beneficial. For example, cutting down on cigarettes, then you wouldn't want someone to then like start eating candy or start, right? So how do you kind of put strategies in there that are like healthy all around strategies? Like, so if someone has a craving, how do you work with them to choose other non-weight? Gain, activities that don't have potential for weight gain. So that's a really good question. And what are some common misconceptions about weight loss among people with SMI that your work has helped to dispel? Thanks for this question. So I actually think that one of the most important myths, and I mean, I hope it doesn't exist that much anymore, but one of the most important myths I think is that people can't lose weight if they have schizophrenia or another serious mental illness. I mean, certainly when I was writing the early grant proposals around this work, I mean, literally the NIMH reviewers who were academics, experts in their field, who were psychiatrists, psychologists, they said in the reviews, this population will not exercise. They have too many negative symptoms, et cetera. This is not feasible. Luckily, I was able to kind of be persistent and overcome that. But I think that that could still be a myth. I think that we know that the antipsychotic medications can have strong proclivity for weight gain, but actually this ACHIEVE trial, the first one, one of the first couple of slides I showed you, people had the same amount of weight loss whether or not they were taking clozapine or olanzapine. So I think that we need, that myth is not true and we need to believe in the people that we're working with that they can make change and we need to hopefully believe in ourselves more that we can also help them make those changes. And is moderate intensity physical activity safe for people with SMI? Yes, thank you so much for bringing that up. I touched a little bit on that before. Yes, it really is safe. Walking is safe and other moderate intensity physical activity is safe. I think that one of the things that we recommend is that people do things gradually so that they don't necessarily need to start doing something for two hours a day when they haven't done anything in years. But moderate intensity physical activity recommendations are safe for the US public. If someone does have diabetes, then it is helpful to check with their primary care physician because sometimes those individuals could have like a chest pain or for example that they might, or like someone else would have a chest pain but people with diabetes might not. So I think it's important to check for those who have diabetes. But we should not be afraid of encouraging people to do moderate intensity physical activity and particularly to start with a basic walking regimen. And what is the target heart range for a moderate intensity exercise or heart rate? Yeah, I have to like, it depends on age. So I would have to like look up the, like what that is, it depends on how old you are. So I can, I don't know, provide like a table or something. I guess I should know that off the top of my head, but it's like, yeah. And many individuals with SMI may experience food insecurity that contributes to an unhealthy weight. Are there additional strategies that you could share for people who may be seeing those unhealthy options as more filling and less expensive than healthy options? Absolutely. So for people that have this, which it's not, unfortunately, it's not uncommon. I think that looking for frozen vegetables, which are really good, is a really good option. Those can often be bought at a lower price, especially those that are not branded, you know, but the local store brand. Canned vegetables is, you know, low sodium is better, but canned vegetables are very good options. And the other thing that we suggest is that people working with those with serious mental illness try to find out about community resources, such as like a food bank or some grocery stores have like certain options where they can provide food for clients or like a farmer's market or something like that, or like a trip to the farmer's market or something that's offered in the community. Excellent. And could you share some practical strategies that a busy clinician or a busy team could use to start implementing these questions on weight management? Some strategies. If people have many competing demands, what's a good starting point to start integrating? Yeah. So I think that depending on if the organization has a scale that they can measure people's weight, I don't necessarily think, you don't necessarily have to measure their height, but measuring people's weight. And then I think doing some very brief education with their clients around those key behaviors. So the sugar beverages, the vegetables, portion size junk food and brief, it could be just a few minutes. And then asking about a high impact behavioral goal. So, I mean, it may be that the first conversation could be more than five minutes to kind of get all that in. But I think that a lot of this is more about the repetition and less about the length of time of any given encounter, if that makes sense. That's excellent. And I would love to know what clients who have participated have shared about the impact of this on their overall wellbeing and their mental health. Oh, thanks for asking that. So we have had so much positive feedback from the clients that have participated in the active intervention group arm of these studies. And we have published on that and I can also share that if that isn't in the bibliography. But one example would be someone lost like 10 pounds and was able to better and participated in the exercise classes we had and was better able to like lift things and work with his father or to build something in the house like a garage on the outside or some structure so that he was better able to like engage with his family and do something physical. We have other people that just saw the decrease in pant size that they realized and just felt better about themselves overall. And just that gave them more confidence overall. We have another individual that reported that because of his feeling better about himself and his increased like mobility and strength that he was able to get a raise at the retail store, the large retail store that he worked at because he was able to do more like participate more in stocking the shelves, et cetera. And he got a raise. So we've really found that even what we might consider, relatively small weight loss of several pounds has had large impact on people's quality of life. That's fascinating. And as we get to the final few minutes, we do have time for some additional questions. If there are any remaining questions to please put in the chat. And then in the meantime, could you elaborate on future directions of your work? This is such an important topic and I know people will be interested. Oh, thank you so much. So I alluded to this a little bit before with one of the previous questions. So the original project that I showed you with the seven pound weight loss, that was delivered by research staff, which at that time was very appropriate because while we were in real world settings and we did have psychiatric rehabilitation program staff deliver the exercise portion in part, the dietary counseling, we delivered ourselves. Again, with like bachelor level staff, but still research staff. The next part of the work that I'm working on now is we have adapted the intervention, the achieve intervention and made it shorter, made it much more video based and added training that is meant for people working directly with clients with serious mental illness, whether that be a peer specialist, a lay staff in a day program, or any other kind of the therapist, any care manager, anyone can deliver with relatively little, I don't wanna say little preparation, but to deliver much more easily. So that it's not, yes, there's group facilitation involved, but it's not like needing to like read through all these detailed leaders guides and do all this preparation in advance, that it's an easy way to do get this curriculum and get this work with people on behavior change. So we are finishing up that project, which was also funded by NIMH. And we were preparing for a larger project that will be scaling up this adapted program, hopefully statewide. And to really see what are the different strategies that are useful to support organizations and providers, clinicians, staff, and how they will really work in a successful way with people to help them attain a healthier weight and something that would be sustainable. Well, thank you to the audience for such great questions. And thank you again to Dr. Domette as we shift into the housekeeping portion. If there are any topics covered in this webinar that you'd like to discuss with colleagues in the mental health field, post a question or comment on SMI advisors webinar round table topics discussion board. This is an easy way to network and share ideas with other clinicians who participate in this webinar. And if you have questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of SMI advisors, national experts on SMI. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. It is a completely free and confidential service. SMI advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the mental health addiction and prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select next to advance and complete the program evaluation before claiming your credit. Please join us next week on November 10th as Dr. Mindy Asbury, Dr. Anna Kostakis, Dr. Jessica Gorin, and Dr. Rob Coates present Overcoming Barriers and Unlocking Clozapine, a panel shares clinic system and statewide strategies. Again, this free webinar will be November 10th from 3 to 4 p.m., that's a Thursday. Thank you for joining us, and until next time, take care. Thank you for joining us, and until next time, take care.

Achieving Healthy Weight Loss

Serious Mental Illness

Overweight and Obesity

Weight Management

Lifestyle Behaviors

Physical Activity

Sedentary Time

Simple Messaging

Goal Setting

Accountability