The sh oural of ppt aot BJPsych | 2a 10-18, ot 10.1929. 195.177999 Review article Solving a weighty problem: systematic review and meta-analysis of nutrition interventions in severe menial illness' Scott B. Teasdale, Phillp B. Ward, Simon Rosenbaum, Katherine Samaras and Brendon stubos ekground results \titen interventions would appear fundamental for ifervertions led to sigifcant weight los (19 studi, weight managomon: anc cardomerabole risk reductlon reduced body mass index (17 studies, decreased waist in peoole excerincing severe mental ness (SM ‘arcumterence (10 stules) and lower bod gliose levels CCompreversive evauston of nun interventions (5 studs), Dieviansed interventions (6 studes) are stusies ss lackrg elvered at anspsychoric ination f€ stutes) had lrger ‘aims effet 20s, To sibect randomised controled tals of rutiuon ‘conclusions interventions in people wth SMI to systematic revew Evidence supports nuuition intervenons as standard care in ‘2rd metaanajsls, and to measure arthroporetic oreventing end eating weight gain aiong peooke ‘and biochomical parametors and nursonal ake ‘aperinciag SM Method Declaration of interest {neocon detaoase seach identified was with None, rutton intervenen component. Trials were pooled {or meraranaljsis. Metavegression anaQses were oerformes Copyright and usage (on anthropometric mororatos © Tre Royal Calogo of Poychiatsts 2017 People with severe mental illness (SMI) consume dicts that are times higher than those observed in the general population *™* more energy-dense, highly procesed. higher in salt and contain To dat, the efficacy of speci components including modes of les uit and vegetables, compared with the general population’ dbvery, of nutrition interventions has not been systematically People with SMI alo engage in lower level of physical activiy;® evaluated. With irrefutable evidence demonstrating the crucial and have higher rates of smoking and substance use * Antic tole of nutrition in weight management.” and the prevention psychotic medications induce greatly increased hunger, decreased and treatment of metabolic disease in the general population. Sety and increased ravings for sweet foods and drinke®* 4 comprehensive stessment of various ution intervention ‘Additionally, a number of adverse eating styles have Deen strategies employed to asst a highly vulnerable and challenging observed, inching fastening syndrome, disordered eating habits populations is a priority. The specific questions to be answered (ee. only eating one main meal day), incressed consumption of by this review and meta-analysis of randomised conttlled tals junk food and low food literacy" Although the poor physical (RCT) weee the fllowing health of people with SMI is well esublished, consensus on the appropriate prevention andlor tcetment interventions is in cvolation, with call for inereased emphasis on fey inte ventions aimed at reducing overightobesity ad consequent metabolic abnormalities in established SM" andl preventing these Adverse health trajectories in the ely stage of pychore"™” The (b) Do nsiton interventions improve the nurionl intake of rmandate for improved physical healthcare and physical health people living with SMI? protection in severe mental iless has led to an international ‘working group and declaration, Healthy Active Lives (HEAL), that Method thas established goal for the prevention of cardomsetaboli decline in fst-epzode payehoss (wre iphys org au). Strong evidence The sims and method of this systematic evew and meta-anabss now exists for hoitic fete interventions.” and at part ofthis Wf episterd with the PROSPERO database prot to conducting the inclssion of physical activity interventions for people living the review (CRD42014014017). Reporting was conducted in swith severe mental illnes. = accordance with the Prefered Reporting items for Systematic Poor physical health in people experiencing SMI stems Reviews and Met Analyses (PRISMA) statement ™ fom both moaable and nen-modifile rk actor inked to the illnes tue, compounded by significant mediation effects. Search strategy Antipsychotic medications induce” rapid. weight grin with An eectoni database search wat completed fom cals record associated metabolic abnormalities” This weight guin to February 2015 using Medline, EMBASE, the Cochrane Ceateal Contibutes to the high rates of overweight and obesity and Register of Clinical Tals, PayCINFO and CINAHL, using key metabolic complications in people with established SML with nutztonal, anthropometric and psychiatric terminology. Google diabetes and hypercholexerlacmia rates respectively two and five Scholar and relevant published systematic reviews were manually —_EAOT searched for additional tiles, Study clghilty was assessed Te eral pp. 995 ts scconlng to inclusion eiteria by two investigators. Hf agreement {2) Do nuteiton interventions improve anthropometric measures (eight, body mass index and waist circumference) and biochemical profes (Lipide, glucose and insulin) of people living with SMP 110‘was not esblshed,a third investigator acted as arbitrator Data were cetracted by the two investigators and pooled for meta-analysis Quality assessment ‘Trial quality was assessed using « modified version of the Critical Appraisal Skills Programme (GASP) Randomised Controlled Tial Checks.” Til characteristics wete aussie actos four ctrl concealed allocation, assessor masking, weatment equality between groups (excluding intervention) and accounting forall, ppacipants randomised. One point was allocated for cach (rion, giving a maximum score of four Participants Randomised controled trite recruiting participants 18 years old or aver meeting DSM or ICD criteria for SME (schizophrenia spectrum disorder, bipolar active disorder, deptesion with psychotic feaures) were eligible for inclusion. There was 20 Festrition on mediction ue. Interventions Studies of stand-alone nutriion interventions or nutrition interventions delivered ae part of « multdisciplinary intervention, ‘were included. Interventions comprising individualised nutrition counseling, group nutrition education, shopping or cooking clases were eligible. No restriction was placed on intervention sting interventions in in-patient service, out-patient programmes and community volunteer services or otherwise wete included, The process of referal to the study, location where the intervention was delivered, and the profesional background of those who Alelvered the intervention were recorded. No restriction wat placed on intervention intensity or duration. ‘Outcome measures All rake that met inclusion exteria were inchuded in » quatative analysis Thal were included in the melaanalyi if they provided equate data on anthropometric (primary outcomes: weigh, body mais index and wai dreumference) and biochemical andlor nutriional parameters (secondary outcomes: total cholesterol, low-density lipoprotein, high-density lipoprotein, leerdes, blood glucose, insulin and diewry intake). Data collection time points included pre- and postintervention and follow-up. Where necessary, corresponding authors of included trials were contacted to provide additional data for inclusion in the meta-analysis, A follow-up and final email was sent 3 weeks Inter f corresponding authors did 0 reply tothe initial request Statistical analysis Because ofthe atiipated heterogeneity we used a random elects meta-analysis and calculated Hedges’ g and 95% confidence interval ar the sffect ste messize. “The metacanalyas wae conducted in the fllowing stages. First, we calculated Hedges’ g and the 95% CI forthe primary outcome measures: weight, body ‘ass index (BMI) and waist circumference, Second, we conducted subgroup analyses to investigate diferences in the primary futcomes for the main analysis according to whether interventions were delivered by a dietiian or not, and whether they were delivered at initiation of antipsychotic therapy (<3 months exposure to seconé-generaion antipsychotic mediation) or subsequent to antipsychotic use. For each subgroup analysis we invesigated the berween-subgroup dlference in elect size and report the corresponding P value. Third, we conducted meta regression analyses investigating potential moderators of the ‘ution interventions severe mentainess primary outcome results including the percentage of men and ‘mean age in both control and intervention groups, percentage receiving sntipeychotis, duration of intervention, the profesion {elverng the intervention and exercise intensity. In order to tert ‘whether the profession of the petion who debvered the inter: vention (dietian x other healthcare professional) war an independent predictor of our primary outcomes from other variables (in particular, exercise participation in multimodal progiammes), we conducted mulivarate meta-regtssions. In frder to correct for multiple tering of covariates in ou mta- regression, a Bonferroni correction was made and a new P value to indicate significance wae set at 0.005 (0.05 divided by #), In the next stage, we calculated Hedges’ g and 95% Cl forthe secondary outcomes including systolic and diasolic blood pressure, total cholesterol high-density lipoprotein (HDI), low- Sensity lipoprotein (LD), teiglyeerdes, blood glucose and insulin, We investigated heterogeneity with the 1 statisti. Publication bias wat assed with a visual inspection of funnel plots and with the Begg-Mazurndat Kendall tau and Eyger bias test" If we encountered publication bias, we adjusted for this by conducting a trim and fil adjusted analysis to remove the mast ‘extreme small studies ffom the postive side ofthe funnel plot,” tnd recalculated the elfct size at exch ieration unt the funnel plot was symmetrical bout the (new) effect size. Al analyses were ‘ondcted with Comprehensive Meta-Analysis eftware version 3, Results Afr accounting for duplicates, 7085 unique records were Screened from the databace searches, Poll-tert articles were secesed for 176 records; 150 did not meet the inclusion enter snd were subsequently exchded (Fig. 1), Twenty-six stuciee ‘met the inclusion entra” but 6 studies reported incomplete data and could not be pooled for metaanalyis 29H For the primary outcomes measures, 19 studies were pooled for weigh ZNO IMTS adie for Barats arnemse5 and 11 geudics for wane circumference "97940440892" Bop secondary outcomes studies were pooled reporting the impact of triton interventions on biochemical outcomes (blood prerute, lipids, elucos, inslin) 7987" *50” veasures of mutntional intake were reported in 6 studies" These measures could not be pooled for quantitative analysis, hst were included in ‘qualitative analysis, Longerterm followup of 2 included studies ‘wat reported in separate publications” Comprehensive dats- sets were obtained ditecly fiom conesponding authors for 2 wale” Characteristics of included trials “The sample size within studies ranged from n= 18 to n=291 ‘Mean parcipant age ranged ffom 26 years (sd.= 155) to 548 years (6d.=82). Diagnoses within included studies were schizophrenia (18 studies), schizoalTectve disorder (12 studies), schizophreniform disorder (3 stuies, bipolar aflectve disorder (7 sti), delusional disorder (2 studies), brie reactive psychosis (2 studies), pychosis not otherwise specified (2 ate) personality disorder (2 studies), ansiety (2 studies) and depresion| (2 studies) Rastepisode psychosis, major affective sess, major Aepressive diordet, psychotic depresion and posttraumatic strese disorder were identified in one study each, More general Giagnostic descriptors were ao employed in a minority of studies SMI (4 studies), psychosis (2 studies), schizophrenia spectrum (1 study) and autism spectrum (1 study). Participants were recruited ftom out-patient stings (21 studies), in-patient m1‘estate ta “preg insure reco ened rough ¥ ¥ ects setae Ful arcs assoc igi ctx rics xcs — States neta ateve yess thax arta eon st Lick tracomeston, settings (3 studies) oF included a mix of outpatients and in-patients (2 studies), Characteristics of included. tials are summarised in online Table DSI Interventions Notrtion intervention delivery methods included individualised counseling (12 studies, group education (12 studies) and a mixture of group and individual components (2. studies) imarily used dietitians to deliver inte: with an additional 5 studir including 4 nutrition professional ae a smaller part of the intervention Fourteen profesional UWE ASAE! Seven ais adopted predominantiy delivered by mental heath clinicians, Studice —dlivered predominantly by dietitians involved individualised assessment and intervention approaches. Other interventions included feneral nutrition eeation aimed at improving food lteracy (not individualised counseling), weight management guidance and healthy-eating education. Cooking classes were reported A studies?" One study incorporated two meal replacements per day?” and another solely asesed the impact of providing free Seven studies Prima eiveed. by other nana 2" udiee did not_ "report input from 4 A manval-based lifestyle intervention 2777784982 fruit and vegetables to participant householis* All studies described strategies to alter participant behaviour, such a5 cue elimination, food diaryitecord-keeping and food sampling, although the specific behaviour change models used ‘were more dificult to identify and interpret. Peychoeducation PSS" Copnitve-behavioural was described in 7 studies 12 oe Ni dgraes preaie T sults! ratrecelegcal insufeere ea on Stes nee Pesczien af enpsytote sponte sess era ‘reesei ot sore or FA ised oucones 3 oar sues longterm flown ‘vii ses rowed wot areumfernce et ker therapy was identified in 3 studies” and social cognitive therapy in 1 study. Within the cognitive framework, Imotivtiona) interviewing and more generally” motivational ‘counseing/support were commonly wasd"?88!89833040 ty Addition, the ‘sages of change’ model war described in 2 studies where motivational interviewing was used” Finally. 1 study Aescrbed the se of behaviour self-management thera.” Prychoeducation wat combined with motivational counseling! support in 3 studien”*""* Contzol groups received treatment a usual with or without written physical heakh information, ‘Outcome measures ‘Twenty-five studies attested anthtopometrie measures predominantly weight and BML" additonal measures included waist circumference, wait-tochip ratio and body ft percentage Heven studies (42%) induded biochemical outcome measures, predominantly lipids (cholesterol studies and ‘wilyceries), glucose and insulin ™™947 914484687519 studies inchuding measures of nutritional intake were limited to 6 studies (25%), which recorded energy. intake (hlojoulestealories servings of food groups (such as fruit and vegetables), mac nitients (including fat and subgroups unsaturated and saturated fat), fibre and portion size ™64" In addition, one study used "ten good food score’ Trial quality Seven studies (27%) scored the maximum four points 984044 4 sudies (15%) scored threes?" 13, studies (5086) scored 0277 7%4-845655 apd 2 studies (686) scored one (see online Table DS2)** ‘Group treatment ‘equa’ and ‘sl parcipants being accounted for’ were reported fin 25 studie (96%) and 22 studies (85%) respectively Methodological uncertainties included ‘concealed group allocation” and ‘assessor blinding, described in 12 studies (46%) and 9 studies (3586) respectively. Meta-analysis results Al the meta-analyses results incliding subgroup analyses are presented in Table rary outcomes Pooled analysis showed that nutrition interventions were significandy more effective im reducing weight ». contol (19 studies g= 039, 95% Cl 056 to 021, P0001, 1°=559%; Fig 2), There was evidence of publication bias (Bees O4i, P=001; Egger 17, P=0.08), wherese the Duval & ‘Tweedie trim and Gl effect sie adjusting for publation bi remained similar and statticlly sgnieant (g=—0.35, 95% CE “044 to —022). Nutition interventions aso reduced BMI compared with contra groups (17 studies: ¢= 0.38, 95% CI 036 to ~022, P< 0001, 1°=514%) (sce online Fig. DS23). ‘The results remained statistically significant when adjusted for publication bias in the tim and fill analysis (p= —0.34, 959% CI 045 to 0.23). Nutrition interventions were also effective in redcing wait circumference » contol (11 studies: ¢= —027, 95% CI —0.2 to 02, P0001, 1°=17%: se online Fig DS5a). The reslls remained statistically sgniiant the trim aoa ll analysis (g= ~0.25, 9586 CI —0.88 to —0.12). susroun analyse: antpayehotic use A larger effect size was found for studies delivered at the start ‘of antipsychotic pharmacotherapy (4 studies: ¢= —0.61, 959% CI‘ution interventions severe mentainess a 150 ° 00 8 so 6 90 * zoo ued ciatsu= 180" tooo geez a vsee— 000 0 ° 2000 we too 0> ovo exo bs 1000 eisor soo o> a & tooo» 08 oo o> . too> wo 6 t000> so- tooo> —se¥tm ogee su 13 per 908i tp 15779 Pabedan by Caras Uy Pras14 study state or asen sy eoges’ gang 9 OL edges! tower User Ai See soterg et a 01a our ome 0422 a7%6 less-crcn et ora" ogo 097 age1 1600 cores eta po nonts 0759 srs osss Usher ec zon wot 0457 0338 oso race a aor Hors ~a42s 020 056 Lovet es oat 030d -o4ea 0277 05s Bron eta cor H01o7 -080 0am os” Cant ett gora?” 0210-0757 on oass 1 Bor oat ox” Hoas “om 02% 0275 — Leet ot al aos? Ho2m -97m 03" 0299 — ene zoe” Hono -095% 097 098% + Dunit wor noua =r 02" com = Seoceo et a 20” Host 7505 03M 021 = Aboceesivenec eta 0H” — 08K — 88, oot + non tt oa? 07 08 jp ene mye cons nose om srs 4+ arse 05" a6 out occa — vwuet a zon man 0708 0000 a] ur et a 0 csi “a0 0597 9900 J moass H07« oso 2 200 =m om mam =102 to —0.18, P=0.006, F'=34%) compared with statics Aetiveed subsequent to antipychotie ute (5 etude g= —0.35, 958% CI —054 19 016, P0001, 1°=57% see online Fig DSla). Similar results were seen’ for BMI (g> -056 ¥, = ~038) and waist circumference (g=—053 y. g= —023) (Gee online Figs DS2 and DS3b). Between-group differences did rot reach statistical significance after applying a. Bonferoni correction (Table 1), Subgroup anahss: profession delering intervention Subgroup analysis inveigaing the effet of who delivered the nutrtion eveled that Aelvering specialised ditary interventions (6 studies Hedges’ = 0.9, 9595 CL —122 to 0.58, P<0.001, = 48%) had a igniicanty larger elect (P=0.0005) compared with interventions predominantly delivered by other health professionals or mental Inealth clinicians (13 studies: Hedges’ g= ~0.23, 95% CI —038 to ~008, P=0.002, = 86 (online Figs DS1B, DS2c and DS3C). intervention dietitians Meta-regression analyses Wiig Single metategresion analyses found that the profesion delivering the intervention (ietan » other healtheare professions, B= 0568, 95% CI ~1.05 to ~0.32, P<0.001) wat significant predictor of weight change (Table 2). Multivariate regresion Analysis found that profession remained a significant predictor of weight change independent of excise (B= —0.72, 954% CI =106 to —037, P<0.01). The percentages of men in the contzl group (B= 0.01, 954 CI 0.0 to 0.02, P= 005) and in the nutrition group (B=0.02, 95% CI —00 to 005, P=0.01) were positive predictors of weight (ie. more dificult to lose weight) Body mass index A diettian-delivered intervention was a significant moderator of BM result (= —053, 95% CI —039 t0 ~0.16, P=0.005). This finding was confirmed through multivariate regression analysis and the results remained significant independent of exercise particpation (B= —052, 95% CI 085 t9 020, P= 0001), with exereise not found to be significant” moderator (B= —021, 98% Cl —0.44 to 002, P=0.07) Waist circumference ‘There was a non-significant trend for dietiiandelvered inter. ventions to moderate waist circumference results (B= 037, 95% CI -075 to 002, P=006). Motivate regression analysis confirmed the tend for the profession delivering the intervention at a moderstor independent of exercue intensity (B= —0.36, 95% CI 0.75 to ~003, P=0072). Secondary outcomes ‘The meta-anaiyses forthe secondary outcomes are presented in Table 1. the analyses demonstrated that nutrition intervensons reduced glucose (g= 0.37, 95% CI —069 to ~005, P=0.02 1=68%; online Fig. DSA); however, this wat not statistically ‘sgnifieant aller applying the Bonferroni correction, Trgheeride levels (¢= ~0.15, 954% Cl ~0.30 to 0.01, P= 0.07, = 0%) were snot signiicany affected by nutrition interventions, although tuends were evident. Other secondary outcome measures were ot significant Impact on nutritional intake Revlte forall sc studee that assessed changes in astritiona intake favoured the intervention group but could not be pooled for mete-analyss owing to the varying outcomes‘ution interventions severe mentainess mn Tore te on2s owns 0 Dwcarage men cnt gous eon peo to ones ose ont Pecerage mn ution yous ois 0908 9 ones oe oar Darton ot ieveron| ona Toes to ante as3e 0 Profession cetverng rtrventon nous Toso ts =0320 ow utara stays ‘roesson oat vei nenersn mont 1064 te -0374 100 ‘Mean age canal group coma 0017 twonzt one oo Mean ofe rar cup oon Tomoteaor? ons ear ecoregion cnt gous eo Toons to o0zs Daas ont becerage men ution yous omy Tonos onze bass 02 Durton of ireworten om Tonos te ont 0108 80 Profssn setveng rarventon os Tonse to 0:60 ose or unartesnas "roesson cater nenersen n0s2e Hosea te ~0208 one 120 Persie mlersty “ozo Toaas to dare a est erumerence Mean age canta group 0009 0027 o000%| ate 0 ean oge nator up Zoro Tongy e300 ute 0 Pecertege nn contol mm Zonra to aa De 820 Pmcaringa mr non oe om Topas to 3018 oan 220 Darton of epson ‘ Tons to 3008 Das 890 Professndelverng rterventon 030) Topse te 0021 nae 00 ‘roesson caver tenersn nos 076219 ~0003 oon 0 ce OEE cca eased 489846 throe sede used the Dietary Instument| for Nutrition Fucation (DINE) to assess fat (unsaturated and surated) and fbr itake*** One study providing hourlong Weekly discussion groups did not Sind significant changes in stheopometsc measures and alo didnot find significant changes in ft or fibre intake" Two studies delivered by keyworkere using 4 lifestyle manual, individually, which found small but significant improvement in anthropometie measures, found improvements in saturated ft and fibre intake,” and improvements in saturated fa, fruit and vegetable intake." One study used the Block Frit Vegetable, and Dietary Fat Screeners to asess dietary change in a intervention providing healthy cating and weight-loss advice, Aelivered by reeezch salt Thi study did not Gnd significant Aifeences in dietary behaviours. A Sith study used a food feequency questionnste, which appears validated ip women in the general population” this questionnaire assessed the frequency often foods associated with better diet and ten fonds associated ‘with poorer dist. Individual poychoeducation and. gosleting significantly improved the sore of foods astociated with good dit compared with the control group, but not the score of foode aucocinted with poorer dict Finally, one trial involved using the Scottish Health Survey to acess whether providing fee frut and vegetables to families improved nutritional intake* Although improvement in uit and vegetable lake were found, thee were not sustained after the tial = and subsequent acces to fee frit and vegetables ~ had ceased, Discussion ‘To our knowledge this isthe frst systematic review to assess the impact of hey components that comprice, and modes of delivery ‘of, nutition interventions on physica health measures of people swith severe mental illness, We found that netiton interventions Improved anthropometic measures by redvcing weight BMI and. waist circumference. Important, our review provides ‘evidence about the most effective goals and delivery methods, including preventing weight gtin ftom the initistion of anti= piychotic therapy and the use of qualified health profsionals fuch at dictitane to deliver indivaduslied interventions. Our results indicat that nuttion interventions were most effective when delivered by a dietitian, with metaregression analyses ‘confirming this in muluvanate model Theee Sndings show a clear and important role for dietitians ar past of the mali “Sseipinary mental heal team, Although the overall elect size for anthropometric measures war within the small to moderate range, st provided further ‘evidence to support implementation of lifestyle interventions Although between-group diferences did not seach statistical Significance, the larger effect size (g~ —01) seen in a pooled analysis of studies providing intervention in the ealy stages of anupeychotic therapy, where weight guin is most rapid, provides ‘evidence for the achievabilty of goa 5 ofthe Healthy Active Lives ‘eclration ~that is to restrict weight gain to no more than 7% of presillness weight in 75% of people experiencing fnst 115‘estale ta 116 1k was not posible to conduct « meta-analysis on nuteitionl intake owing toa lack of consensus on data collection methods together with the wide variety of outcome measures used Notrtona intake ean be notoriously dificult to asess accurately Iheeause of intake variability and the wide range of nutrients to consider, particularly i the assesment method isnot targeted to the specie population. To date, there is no validated notation susestment tool developed for use in people living with severe mental illes, a significant gap in the Ineratute requiring urgent aMtenton, In addition, improvements in cardiometaboic health as a result of changes in nutritional intake, independent of ‘weight change, have not been acseesed in thie population, This isa significant area reqiting researc, given the enduring weight challenges i thie popslation (ur results ate broadly similar to previous non-pharm- acological and physical activity intervention analyses completed bby Alvarezfimenes et al, Bruins et al and Rosenbaum et al!” Bifect sizes (ES) ftom these analyses op anthropometric measures were tespecively 27.85, E5=063 and standardised mean difference =0.24. Howeves, ours is the fist review to Consider the impact of nutition interventions and provides further recommendation? for detitanled interventions incorporated from the early sages in SMI. As with the general ‘population, nutrition interventions are most likely to be elective when combined with physical activity Limitations and future research Several factors may have influenced the results obtained by this review, largely reectng limitations in the primary studies. Fs hutition interventions were often delivered as part of & comprehensive lifestyle programme, thus participants were potentially reeiving concomitant additional lifestyle interventions such as physial activity, which may have had a synergistic effect on participant outcomes, Although it was not posable to separate the impact of the motnvon ilervention from additonal components, we attempted to investigte the impact of nutrition interventions through series of adjustments for potenti confounders, For instance, for the primsry outcome, out multivariate meta-regreision anclyies consistently demonstrated that nutrition interventions were mot effective when delivered by a dicttian, even when we adjusted for concomitant excise elements Although the results from our subgroup analyses consistently demonstrated higher effect sizes of dictitianded nutrition interventions and interventions delivered 3¢ amtpsyehotie initiation, thee findings did not reach statistical significance after applying the Bonferroni correction. although Bonferroni corrections are not routinely used in meta-analyses,” we have opted for a conservative approach, and although our findings didnot rach significance they suggest more favourable outcomes and warrant further investigation. Second, the RCTs included a range of nutrition interventions including. group cucation, individualised plans, practical shopping and cooking sessions and meal replacements, Subgroup analyses were rin ‘where possible, but were limited by the small numbers of studies and highly vaviable methods. Future research should seek to fstablish homogeneity in the ue of appropriate outcome measures snd nutrition interventions. Thitd, the potential for significant effects on relevant biochemical measures may have been affected by the short duration of interventions in many studies and the target outcomes frequently being limited to anthropometric measures Future long-term studies encompassing specific ditay strategies to target dyslipidaemia are required, ‘with adequate follow-up to see the impact of nutrition inte. ‘ventions in this population” Fourth, we did encounter some ‘evidence of publication bias, but afer recalculating the effect sizes using Duval & Tweedie's tim and fil method our results were ‘roadly similar Fit, we did encounter moderate heterogeneity jn some of our analyses, Nonetheless, our mulivaiste meta regression analyses explained all (R’=10) of the observed Dpterogencity for weight and BME meta-analyses results, We were, however, unable to explain the heterogeneity in waite ‘ézcumfetence: hgh levels of variability and inaccuracies in waist ‘éxcumference mestuting may be a factor” Finaly, we were unable to access data fom some of the identified studies, reducing the numberof studies included and sample sizes included in some fof the meta-analyses. In addition, some studies did nat clearly identify the spciti psychiatric diagnoses of participants limiting the ability to deawe further conclssions regarding the potential impact of diagnosis on the intervention outcomes obtained Nevertheless, allowing for these caveats, the reels of thie ‘meta-analysis offer hope to clinical teams and patent aie that, providing nutrition interventions as part of a wider multi ‘isciplinary lifestyle intervention can be effective in preventing ‘weight gun, particuaty when delivered by a deta, University dictec programmes will also need to evolve to increase the Iknowiedge and understanding of SME ‘study Implications [Nutritional intske i fundamental to weight management and future phyicel health. Ths syrtematic review and meta-analysis found that nutition interventions significantly improved weight, [BME, waist circumference and glucose levels in people with SME Farther, nutrition interventions delivered by dietitians, and those fuming to prevent weight gain at antipsychotic initiation had the largest effect sizes. "The evidence supports the ely inclusion ‘of ution intervention in mental health service delivery to people with SMI Further RCT are required to determine the ‘ost effective nutrition intervention to optimise weight and ‘catdiometabolic heath in people with SM ‘Stn ac ea a a, nf py, ny eta yy Bitp 8, mar, sel tea, Une teste ie Re rome ar opie ara tse tera he tery aan Ss es, rey mehr sume 55 Drm etcma resp are tis hety IESG enon stat, 0 ce: are Sete a esr tse sapeiren, tse hehe, iO ee ‘een re cale aren taser References 1 Dpasquae 5, pane om oazzanP, Aqua Mesure P, Monee V. The ‘iy pater patents wn schzoptena 8 Ssamate rele. 2 ree Young OR sen A atestn J Asha, Hayes) hyaluronate stein sense rebitton oeans sehaopr her 207 08 750-7, 2 cooper) Manes So, Band Rs cae C, caste 9 ebacca Sinotirg among aol ng the pjeate tess the secon salar Sey Pssst AE) sje 20124. 4 sor AL Newt CE, queen 6, EK SM Vernon of ru ‘Ero cunts win senate prance a ers. PIC‘Teue, tian WP chen A, Hn came Mar 6, el Factors “Ssodeted wih wel gon duit olzopre Ueatnent geet wh Sehaopieia or Bol ste ests om a sieoe teszecve, ralatent ebseateal stay, Won Be Psy 200% 1: 729-40 {abun m, Tomy A, aber ME. ves i BELA Ri Ry MA, a ‘ast ar eat'g bravo patos ne second gereraton fmpwyereten Obs eh 1678 2 nay, eas ang Sree nig ae cht onto Het Less, Mae FB Lea promt Mese "ever fo weet mane ajc aster ee a ‘etoana of endrd canoted Wa Me PNG 20% 1: urs atin Aosta s, Teasley, amar Kota Evaistng an iter Wess sels Freer o orn smsyvete ince wag gon frtapsace peers, Fn er 0 Teast s.r 5, osranun ans Samaras Kat J ea Pica tee cneatstens ny a eps ayant» ae! "tance cue kan ath 20 1 shes, curs 1. caorstante Rea youn Boal wi pcos. cet jae 2088 1 Sa 1 hosenoaum 8, Tara A, shetrngton G us J War 8, Pyseal fet avers er eal tert es SA ee an Tetearayi J cn Pena 2016 78 967 12 AlescrimeneeW,canzalecslneh ,Ceiprace 8 His Soiguysancher it Perr less Ret arseyereerdiced wah [nin crane and oops pyetote sere cNS bugs one 2 ‘4 cone cu, a P, Oban V, Napa 8, Kane, Mao AX idol ic el oeneqrrio wire nas Oe ier Pascal 8, Senden OP. Maratyané medical earartety one pars hens eral Pen Sy 2090 67 142-7 16 Newcaer 1 Aosjeoe meses: etal nd card Jinan ae 68 13 1 nooks Ci, Nepean 8 ato, Casey 9. sehiep eri an 18 Vacant, stutbs9, Mehl A De Hr M Wapets M ard, ‘st metab yee es componets peel wh sccepen = tne rete pyre Soares, boa Gere” ane mee opessve ora tomate ew ad metarayss Wend Pay 2095; Me 49 Frew, Vane), Ca Sou Hon T ap Wt \Wegntlc utes: tm roe and metas of we ae ‘ncaa wih a revmum Lye abonip. J am Bt ase 507 107 20 Sale, Eh 2, Peay strat ee a meters of ‘dferen etary approaches tothe management ye 2 dae ‘rode Nat 209, 97 SES 21 Yanan. Tango. ets otesyemodcaton on metabo sare tomate reve ane retaanays. CMe 202 0", 22 Mone, bea A Teta) lian 06 PRIMA rp, rroe ‘ooring tame freer reves ane metre she PVA al gel a Rogane 8 Rao aT 26 ser co, Mazur Mone characters fa rane covelan test 25 caper Davey Sry 6, Senne” M, Me im metas ‘ecto: by 4 ipl, pagie Ps 997518 62738 26 us, Ieee Hen ae sna fart pba meted at fevtng and sug fer pleton bain ete anaes ames 20; 27 Atecsinens cara nen €,Vzsuersargto Peeps Mates 0, Pret ea terdotin of rbsjetotetaiced lee ga wih ey et aval neveriton i Gup-le fstepsace Dojhes part wrandomaed corte al cn eyehaty 2m; 6: 28 Rew, Neri 6, Ee, Taal Fras A Camargo MO, al ‘Sept ae ciated alo et he ene 3 Wese Ineeveton for wap gan managenent mn schecprena BMC PT ‘ution interventions severe mentainess 29 1a, cre A, Panna 6, Tuto | Seny 5, Maou ets et Deora teay on wet ssn oer ana oes ales wih Senzopnrena or seostecve dare) Pe hat 205 66 20-12 430 brown c, cot. aera. eet ss een fo pose wih se Inova ines a ancomed eotreled al he RENE ogra Poet Ser 24t -2, 1 brown chan KA randomized colt i eas poration ‘Geneon ¢ pdt it srs nv es ha rena heats key woresIorove eens psc! bea a atebrces 238 cones) Tune Regerreht 6, Zee Coal C,Semcaeptn etal can an ea wou manogaret pram (M2) ever incaie 102 meee evurbamees Mody Wet ee Hes 2 le meron twenlourane teen eshe om erent raomee i Noa) Bet Pee 2 98 22, 24 baum DikeranF3, Mang RY ar A sre), nceon CM, ra A behatoral wah lee rteveronn desert seo eal Ieee wen!) Mes 2b a8 ots, 15 on §, New gis. Nurenalteventon opens wag {arn pers commenced on rape! a rendened enolase ‘ast NE see 208,39 ae Fexserg KA. Blecinan seeran PO, SandunéM, rc of 2 ese Intervention arene eters wth a sjehabe eal cher Fademsed cents on syrgtoms,cuy ef eae sre of Ceernea, lr 2040 99 Tota 27 cho Gas ial Maren ©, Tale), Sal eee ‘ulsmaes ale mare beams eas pater ih Dalat Serer andre canesed ra Pi exe compa) cn. Pais 240, 58 olde, Reeves 6, Ips 5, Meda 9, Diesen F,Calber , fal ove: Gace of wis wegen raced fer tens 239 ect Daven A, an 8 Paar rst, ensen $0, Sorensen 4, fat more te psc Fea of lotr ayer patents: Ast fe penny ove a 9670 20 escarole A Ancona Wl, Pet ty fhe etesey ‘fan eae! yorarne fo rece weg on oeruey =e eBee tenes win eval ale svaphenia) Pena Mena hae 1 Jean apie MT lt, Cahn UR Nols, Hassan AG a ‘pl cy os weigh menage prog with fed poo o Shbopiven. Spt Rs 200 9679-25, 142 en, C1, 20 WM, Yoon Ken CE KI Cha hn Ya ‘we management ropa fr Cewereeerte. wig gah ‘lzapine'vestee patents Wt sehzoprenso schaeaecte duce {eoneetrrdomaes conte eel Wal) Cin Pye 206 47 Lite gs WM, Kahne co Paty, semrsen 6 Te cs an ‘fuetanal steven on tyetotesced we fan) Mare Schon 9a 5°37, 14 orl esrden A, raha, Tenn 8, Paley Dales Mt Dn sir rencorse errs yf aly ig everson ‘ay iteveron seve: for unas. the icra ereourae Détje mote dt rl euce weigh gon INTERAC sty.) CP Peay Ye 78 96, MUM, simone’ M,casovans,oere , ceca, et Agee (lets psjehoecicaorel bop weg sn pales he have ‘eric weg gan suing avsyeote eater wh alazare ‘amaceospty 908 489723, crea RO, Kel Comal, as 5, Baer, Lea Desay oroveresn prone th sewootrena: ancomsed ear toled ‘a Br Pope 208 7 86-8, 17 exuie cl,Paseran Nirman Gate Jn Rese Sa a Hermie reverses schpirne pars wth sens els ‘ranconsed cates til Sehr fes 004 84 34-8 48 tat, Foe Mast De Asa, Saseer no 8 Paves et a ‘oatepraeervertonsuteis or weit gu nce 3 aap ¢ 2 bapnoeaneatoaeppeen fx wate 2006 7 te 50 Uster Kare Fat Sutra Ancona cn Uncevaker fea nueledwelpht managers and serece Ireventon gener peel wth sraus eval nes no tte cond {everson sone: rs 7 49 Todt "7‘ostale ta 1 ener Wine KA cetera uD mre or wee Dssin paves ested ith apa etosjebtes Sehzepe fas 208, 52 Wun, wong Yang CY, Lee S.Cucones af ase, derpre. ‘ested pants wth soptren lsced on sacrarh tno yea acy pape, Pena Sev 0788 Seo, 8 ahrermanezM, Marner carci, Peres Rare? Mt Vazgiearauer i CreseFacoro 8. een 0 sbasjratcoucee “ih can wth ei ehscoural meres neeapenes pose {yen rene ot aancomae cntlne ia Senzohr Re 20° Me 4 wenn i, Gaba 5, cer Khan ke LA ey es Dtewertin ar male-aged ene oe snopes tert wit debetes melts a eer low aes. Seep es 2010 124 2004 55 Waker E, Medee 2 Se BO, Morty nmr czorcers ne el ‘dese a-eon masters senate reve areata AMA 6 srersnere Hee SE, rman Cen , Wscary Nerprammacabgeal Maneehet of enosicateinauee we ah Syseate reve a motes odamised convobed ab Bry Poe 208 98 9082 5 bps rg ,auageran Rs core neon Me hee f Hesle arersans on Yongerm weet rage [onetnoe rok egress satan aoe wt yeote Gordes a rateantat Ps ove 2014 7 e127 54 tagons JT, ren 5. Map systema reves. cotrane Findon ste news of erntanee? 2 cactrane Shuang Fre gsnrensk AP he gue far ages ed (Stay suptemers Ip ri cat J ea 201%, 27 2050S 40 paola vr, Av Fasl ad Kanal Rh, Neng Pa. eal Trteropersarabiyn msnsrme ait sreurererce me Dm spucr onthe dagro fhe mesa Sone. acta Mes Pochny 2018 7 psychiatry’ in history 118 James Foulis Duncan (1812-1895) Brendan D. Kelly mas ute Duncan sa the ast ofthe Duncan fai ton Fara Hout, 8 pivate asylum Frei, Cosrty Dub, Velenc, He see as president of ‘hang ara Queens Colege of Pyslans in velana 1673-1873} and of he Modio-sycholoealAssolaion WA 1875, Duncan's moter ded when he was young so he grew up wih his father a, the asylan. They ate with the palts end Duncan's earlest lessons in Late, mathemates arc sconce wore orovides by oatants whom a te escibed s he best a noblest persons of our race, of ged eect ad high avant Bulking on this unusual out efacye foundation, Duncan gradused fom Tiny College Outtn In 187, Throughout hs meceal ana syle earee, buneen ae setely saclay ave, especialy f the eects ot poverty on hath Ho spores te use of stetiecoroarisons to tst weatmets In Enguoge that pregured ler Ides. aout nea! Ul) ard was Nery ralgous i utlooe, as evidences ins 1852 publeaton, od in isease, ‘The Manesttions of Design in Morb Prenomera In is presidental adess 2 te MPA 1875, Duncan vehemently derounced a eat many features of 1r-cetuy We Fangng ‘rom te susehuten of machina Yor hands lasour tothe emolyent of chen in actors avd coneeduent Dbosenng of family bonds He was not Powever,a mano be easly defs:e, rox ever by reat unstoooabe forces ory. Duncan Saw eduton ab the snsver to al of ese preeles and aaiocaied for beter medical eduction, broader pe educator, and moral educator young which ha elt el the greatest hope fr orevering moral disorder Duncan typed a certain mosel af "et-cenury asym cector entering, smerf prolific an keen ta promt apy Ieceine the eyes of otter doctors ana the pale. He econ 2 Ar 1895 at he age of 83 years, Ootuses nthe Bish Medica ural ane Medial ress rated na professioral esteem in which he was al, a well ass dewoten tthe poration freon anc ns reutaton as a an of cay. Image repecucod by kné permission of he Royal Collegeof Prins of ean. nat ietabpast iss