Ms. Guzik and Dr. Wirshing are affiliated with the Department of Psychiatry, Veterans Affairs Greater Los Angeles Healthcare Center, 11301 Wilshire Blvd., Bldg. 210, Los Angeles, CA 90073 (e-mail: lisa.guzik@gmail.com). Dr. Wirshing is also an associate clinical professor in the Department of Psychiatry at the University of California, Los Angeles, School of Medicine.

There is much skepticism and stigma about whether patients with severe mental illness can participate in, understand, and benefit from a behavioral approach to weight loss. Many fitness programs, even those provided by medical facilities to their outpatient population, exclude patients with severe mental illness. This leaves this population without a source of information or support for weight loss, and obesity is a problem often caused by such psychiatric medications as second-generation antipsychotics. The purpose of our study was to adapt the behavioral weight loss program that was used in the Diabetes Prevention Program for use in a population with mental illness. Our three pilot studies found that patients with severe mental illness not only have the capacity to learn from such programs but also have the commitment to benefit from them.

We prescribed a diet and exercise program to achieve 7% weight loss by following the Diabetes Prevention Program recommendations. The program is carried out through weekly classes and individual case management. The materials for implementation are available at www.bsc.gwu.edu/dpp. The goal is to help patients achieve a 500-calorie deficit per day that will result in roughly one pound of weight loss per week. Patients are asked to exercise 30 minutes per day for at least five days per week, with a weekly group walking session being held immediately after class. Each patient is provided with a pedometer as a reward and a reminder to walk. Personal fat-intake goals are given to each patient, ranging from 33 to 55 grams per day. Patients are asked to keep a daily diary of food intake and exercise performed.

Patients attend 16 Lifestyle Balance sessions, based largely on the Lifestyle Balance classes used in the Diabetes Prevention Program (which come with an extensive training manual, available at www.bsc.gwu.edu/dpp/lifestyle/dppdcor.html). These sessions take approximately eight weeks to complete, with an average of two sessions being taught per week. On completion of the weekly classes, patients attend classes monthly for the remainder of the 12 months of the program to review important concepts and address any problems that might arise. Because of possible motivational problems and knowledge deficits in a population with severe mental illness, some participants may require additional time to complete the classes. In order to facilitate patient adherence, instructors are urged to offer flexible class schedules that can be performed at the patients' convenience.

Each patient is assigned a case manager who provides individualized nutritional counseling. The model we use in our treatment of patients is intensive case management with a minimum of biweekly contact for each patient, plus continual contact with his or her treating physician. For example, several patients are housed at nearby board-and-care homes, and it is not uncommon for case managers to make house calls to assist patients who inadvertently missed appointments.

Case managers work together as a team to help patients. For example, if patients are having difficulty with losing weight, they may be asked to allow a case manager to attend their meals for a few days to assist them in making healthy choices. In general we have found that one-on-one assistance with skills training is particularly beneficial.

Dietary adherence depends, in part, on environmental and caregiver influences. Many of our patients have little choice over the food that is fed to them in board-and-care homes. Accordingly, we assess patients' involvement in food preparation and their willingness to involve their caregivers in helping to make necessary dietary changes. In our program a professional chef and a nutritionist act as liaisons to patients' caregiver families and board-and-care operators and provide on-site nutritional and cooking education. They also assist care providers in understanding the dietary needs of our patients. In some cases we have recommended meal replacements, such as Slim-Fast, when patients are having difficulty with portion control. We also organize monthly field trips to local grocers to help patients learn how to purchase healthier foods while staying within their financial budgets.

Our patients responded well to consistent positive reinforcement for every step forward. We tempered our expectations to each patient's individual needs and applauded any and all positive change. With this approach, we slowly saw changes in the patients' attitudes, behaviors, and ability to maintain weight loss. A more formal assessment of our behavioral weight loss program is ongoing.