Medications generally have side effects that can be mild, moderate, or severe. Most psychiatric medications can cause some weight gain. Antipsychotics that are being used now for a number of conditions are more on the higher end of causing weight gain, although not all antipsychotics cause the same degree of weight gain.

We have pretty good probabilities which have the highest degree of weight gain, and also which have the highest degree of metabolic abnormalities that are either related to the weight gain, or can occur just because of the medication. By “metabolic” I mean changes in blood sugar and blood fats that have a negative outcome on the risk for cardiovascular illness, similar to the weight gain, later on.

We’ve very concerned about this side effect cluster because of its potential negative effect on cardiovascular risk factors and illness like diabetes, heart attack, stroke, in the future. The worry is that if weight gain occurs early in life, these occurrences that happen usually late in life might happen in mid-adulthood and shorten people’s lives. So we’re really concerned about that.

But on the other hand, we’re also concerned about the mental illness that can also shorten and impair people’s lives. So we need to weigh the risk of the medication against the risk of the illness. But how can we reduce the risk of weight gain with antipsychotics?

Lower risk medications

First of all, we should use the lower risk medications first.

In terms of weight gain, the highest risk medications are Zyprexa (olanzapine) and Clozaril (clozapine). Clozaril is given for the refractory patients, and it’s more effective than others. But Zypreza has not shown to be that much better than others, and it has clearly more side effects.

Seroquel (quetiapine), which is used a lot for certain conditions even involving mood or anxiety or sleep, has similar weight gain as Risperdal (risperidone), but has more metabolic abnormalities.

On the lower end we have Abilify (aripiprazole), Geodon (ziprasidone), and also Latuda (lurasidone).

We don’t know exactly about Saphris (asenapine), but that might be somewhere in the middle. So it’s important to choose those lower risk agents first, see whether there’s a response, and only if people don’t respond then to move it up.

Healthy lifestyle

At the same time, healthy lifestyle instruction should always accompany psychotropic medication—prescribing and taking. Exercising ideally thirty minutes a day, even brisk walking, can be helpful. Eat healthily, replacing fast food with particularly vegetables and fruit. It’s very important to also have family meals.

It’s been shown that when families have meals together the diet is also improved.

If your child has a problem with weight, either originally even without medication or now accentuated or started through the medication, trying to diet can be very hard. Research shows in non-psychiatrically ill patients that kids succeed the most when parents do the same thing. Unless you help your kid, they will not succeed. You need to change the diet for the family, and you need to change the activity behavior for the family.

There is still the school meal that can be a problem, because in the US the school meals are not as healthy as they should be, but maybe you want to have a plan to bring some food to school with you—make it at home and then give it to your kid.

It should be fun to eat healthily and act healthily, so you should make it a family occurrence and have rewards built in, because it’s hard. It’s easier to gain weight than to lose weight, that’s clear for all of us, and if you have mental illness and if you take medication even more so.

So if you’ve done the healthy lifestyle instruction and it didn’t work, maybe then a weight management program. Go to a clinic and try to get guidance there. On the Internet, there is also the American Academy of Pediatrics weight management program that you should follow. One of the things it recommends is that parents shouldn’t be too stringent; diet should be somewhat flexible and kids shouldn’t always need to try to be super good because then they might give up.

Adding medications

So if you’ve tried the healthy lifestyle, the lower risk agent, and either you had to go to a higher risk agent or your child still gained weight, then there are also medications you can add to reduce the weight gain and reduce the metabolic problems even below the threshold of having a clear dyslipidemia or diabetes. There are two medications that can be added. One is Glucophage (metformin), which is originally an anti-diabetic medication, but it’s been shown in now 11 studies that when you add it to antipsychotics there is a reduction in weight of about three kilograms in three months. That’s not the world, but on the other hand, it’s a mean, meaning some lose less and some lose quite a bit more. In addition, there’s also an improvement in the metabolic abnormalities, particularly the blood sugar problems and insulin resistance.

The second medication is Topamax (topiramate). That is an antiepileptic medication that can be added and people can lose weight, again about three kilograms in three months. Sometimes kids can have word finding difficulties, so you should do this obviously only together with a doctor, and then monitor whether your kid has some cognitive problems.

Those are the two best-studied medications, then there are a couple of other medications that are approved for pediatric obesity, but they haven’t been studied enough in conjunction with antipsychotics or psychotropic drugs. But they can be tried, and you should discuss that with your doctor. There are novel approved combination treatments for obesity, but I think one should only go to that after the Glucophage or Topamax have been tried

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