Are we killing psychiatric patients with food?

Managing weight gain among psychiatric inpatients is a serious but often neglected problem. These patients aremore likely to gain weight than others for a number of reasons.

• People requiring inpatient psychiatric care are often in crisis and commonly lack capacity, insight and motivation. Unsurprisingly, achieving control of their symptoms is often prioritised, with less attention paid to dietary intake and physical activity.

• High doses of psychotropic medication increase sedation and lethargy.

• Inadequate staffing levels and time constraints often preclude regular weight monitoring.

• Many psychiatric inpatients must stay within the premises of their units due to their mental and/or legal status and are therefore dependent on hospital food.

• Hospital meals often involve high-calorie foods (such as fried fish, chips, pies, sausages and desserts) and it stands to reason that such meals, often involving repeat servings and consumed on a daily basis, perpetuate weight gain.

• Fruits and healthy foods are often not easily available in psychiatric units (though it is debatable whether people with mental disorders would choose healthy options over unhealthier but perhaps tastier foods).

• Opportunities to exercise are severely limited, so that even patients with the motivation to exercise are often unable to do so. Confinement and a lack of structured activities result in a sedentary lifestyle, with patients spending their time watching television, ruminating, sleeping and smoking.

• Psychiatric patients commonly remain in hospital for long periods - it is therefore not surprising that they are often substantially heavier and more physically compromised at the time of discharge than at admission.

Human rights

The issue of weight management in people with mental disorder raises important questions about ethics and human rights. Ethical considerations preclude us from dictating what patients may and may not consume, while the principle of acting in the best interests of the patient would justify the same.

The issue is perhaps clearer for patients with compromised insight and cognition, in that a weight management programme could be justifiably administered in the best interests of the patient. Many patients, however, have enough intelligence, insight and decision-making ability to choose their foods - and imposing compulsory weight management skirts dangerously close to infringing fundamental human rights.

However, given psychiatric patients' lack of awareness and capacity to make informed food choices, the provision of unhealthy cuisine arguably constitutes wilful contribution towards compromising their health.

Individual choice

Because patients all have different needs, having dedicated staff to influence their food choices would be expensive. However, offering amenu that included only healthy foods would not violate patients' human rights and would protect their best interests by providing a balanced and healthy diet.

Weight management in mental health remains an inexplicably neglected problem, with few comprehensive strategies or formal training programmes for clinicians to tackle this complex issue.It poses a unique challenge that demands a preventive approach, ideally involving screening, monitoring and health promotion.

Given the lack of motivation among many psychiatric patients, this may be easier to achieve in a structured hospital environment than in a community-based setting. It is therefore imperative to use the opportunity to positively influence patient attitudes and habits during the inpatient phase of treatment.

There is an urgent need to review dietary provision and levels of physical activity offered in psychiatric units. An integrated multidisciplinary approach, involving regulating energy intake and increasing physical activity, along with rigorous weight management education, offers some promise of long-term success - especially if such healthy habits, once established during hospital stay, persist after discharge back to the community.