Balanced View

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Balanced View is a free evidence-informed online learning resource designed to reduce weight bias and stigma among medical professionals, mental health professionals, allied health professionals and public health professionals across the province.

 

Developed for busy professionals, this 3-module resource is an interactive and online tool that takes approximately 3 hours to complete. The resource can be completed any time, from any computer, tablet or smart phone. Upon completion of Balanced View, health providers can submit for professional development or continuing education credits.

Originally developed in 2015, this updated version of Balanced View features new evidence regarding the impacts of weight bias and stigma, as well as updated functionality and engagement. This includes:

  • Updated patient scenarios
  • New and improved platform catering to different learning styles
  • Information around cultural and intersectional considerations regarding the impacts of weight stigma

Why is Balanced View Important?

While it may be hard to imagine weight stigma taking place in health care settings, significant research demonstrates that health professionals may endorse stereotypes and negative attitudes about patients with higher weights.

Extensive evidence also suggests that there is a significant impact of weight bias on mental and physical health, independent of weight. These impacts include:

  • Poor body image and body dissatisfaction
  • Low self-esteem and low self-confidence
  • Depression, anxiety, and other psychological disorders
  • Maladaptive eating patterns and eating disorders
  • Avoidance of physical activity

What Will I Learn?

Balanced View has 3 modules, designed to enhance the awareness, knowledge and skills of health professionals in the area of weight bias and stigma.

  • Module 1: Understanding Weight Stigma
  • Identify some the consequences of weight bias and stigma
  • Module 2: Weight & Health
  • Commonly held beliefs about weight
  • Understanding medicalization
  • Module 3: New Approaches & Lessons Learned
  • Health centred approaches
  • Special considerations for children and youth
  • Practical tools & resources

Balanced View is supported by the Ministry of Health

“I appreciate those who shared about their lived experience all throughout the course. It really added something special to the experience of learning.”

“I love the various ways of receiving and learning information – the narratives, audio, video (and the designed animated videos), text, the interactive components of clicking through tabs."

“I really enjoyed the look and set up of the learning tool.”

Course Content

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Course Includes

  • 1 Module
  • Course Certificate

Schizophrenia:
Many SGAs are indicated as a first line therapy for schizophrenia in adolescents and for the positive symptoms of psychotic disorders in general. SGAs treat active psychosis as well as decrease relapses if remission from active symptoms is achieved.

Depression:
SGAs are not indicated for treatment of depression in adolescents unless a psychotic depression was present. For a depression without psychotic symptoms, first line treatment is an SSRI antidepressant. The potential side effects of SGAs and lack of clinical evidence supporting efficacy of SGAs in depression in adolescents without psychotic symptoms are both reasons SGAs would not be prescribed for this condition.

Bipolar Disorder:
Some SGAs are indicated for treatment of bipolar disorder in adolescents. They stabilize mood as well as treat psychotic symptoms associated with mania. SGAs can be used alone or in combination with mood stabilizers to treat bipolar disorder. Often they are used in combination with mood stabilizers especially to stabilize mania in its initial phase as the mood stabilizers are titrated up.

ADHD:
SGAs are not indicated to treat ADHD. They are sometimes used in conjunction with expert consultation for off-label, preferably third-line use, for short-term treatment for significant irritability and explosive emotions/behaviours while stabilizing on first-line and/or second-line treatment. First-line treatment for ADHD includes monotherapy with long acting stimulants; second-line treatment includes short-acting stimulants, atomoxetine, or guanfacine XR (alone or in combination with long-acting stimulants). Third-line treatments include clonidine (monotherapy or in combination with stimulants), bupropion or noradrenergic tricyclic antidepressants. Comorbidities should be treated with first-line treatments specific to the individual condition.

Eating Disorders (AN, BN, ARFID):
SGAs are primarily prescribed for symptom management in severe eating disorders in children and adolescents. There are mixed results for enduring effects on weight restoration and any potential benefits are balanced with the well-established risks. For treatment of AN, there are limited positive open-label studies with the use of olanzapine. Quetiapine and aripiprazole have even fewer studies with mild benefit noted at times. Risperidone does not have evidence for use in AN. Olanzapine has limited positive reports for use in ARFID. Use of SSRIs, specifically fluoxetine, has the most evidence for bulimia nervosa, in which high doses are demonstrated to reduce purging behaviour. There are risks for increased binging with SGAs in BN. SGAs are sometimes used off-label to help with emotional and behavioral regulation or depression and anxiety symptoms, but experts should be consulted prior to initiating treatment. Comorbidities should be treated with first line agents (NOTE: bupropion is contraindicated in eating disorders secondary to increased seizure risk).

1. Weight gain management guidelines:

Situation 1:

Normal weight gain associated with growth and development

Recommendation: Repeat weight measurement at next scheduled screen. Provide information on the importance of lifestyle for decreasing risk of weight gain.

 

 

Situation 2:

Significant weight gain noted, especially within first three months of medication use and/or child is overweight, obese or has pre-existing metabolic conditions prior to starting SGA treatment

Recommendation:

1.Lifestyle intervention

Second generation antipsychotic medication use in children and youth is associated with weight gain and metabolic complications. It is therefore strongly recommended that patients receive counselling (nutrition, lifestyle and exercise) at the initiation of therapy regardless of baseline body mass index. This is particularly important in a child who is overweight, obese or has existing metabolic symptoms prior to treatment with a second generation antipsychotic medication.

2. Re-evaluate use of SGA to minimize weight gain

Consider the following questions:

  • Is the lowest effect dose being used? In particular, higher doses of risperidone and olanzapine have been associated with greater weight gain in children.
  • Can an alternative SGA be prescribed that has a lower side effect profile for weight gain?
  • Is the patient taking other medications that also cause weight gain? If yes, can they be stopped, reduced or altered?

1. Abnormal prolactin management guidelines:

Elevations in prolactin levels may be associated with signs and symptoms such as gynecomastia, galactorrhea, infertility, menstrual irregularities, oligomenorrhea, amenorrhea, sexual dysfunction, decreased libido, acne and hirsutism in females. However, hyperprolactinemia may be asymptomatic in some individuals, particularly in prepubertal children.

Situation 1:

Normal Prolactin

Recommendation: Repeat prolactin measurement at next scheduled screen.

Situation 2:

Abnormal Prolactin

Recommendation: Re-evaluate use of SGA:

  1. Is the lowest effective dose of the SGA being used?
  2. Can the SGA be switched to a prolactin-sparing agent, which can result in return to normal levels of prolactin within weeks?

If continued treatment with the current SGA is essential for the patient’s psychiatric illness, consult with a specialist regarding further management of the hyperprolactinemia. There are potential long-term effects of hyperprolactinemia, particularly osteoporosis, even in asymptomatic patients. This is concerning given the importance of bone mineral accrual through adolescence with peak bone mass occurring in late adolescence.

If there are clinical concerns, consider specialist consultation for further investigation regarding other causes of hyperprolactinemia and/or amenorrhea.

2. Abnormal lipid fasting profile – triglycerides management guidelines:

B. Fasting lipid profile — Triglycerides

Situation 1:

Normal TG < 1.5 mmol/L

Recommendation: Repeat TG measurement at next scheduled screen.

Situation 2:

Normal TG ≥ 1.5 mmol/L

Recommendation: Re-evaluate use of SGA to minimize weight. Consider cognitive/behavioural lifestyle intervention aimed at weight loss. Consider consultation with specialist if TG ≥ 5 mmol/L for possible medical therapy.

1. Weight gain management guidelines:

Situation 1:

Normal weight gain associated with growth and development

Recommendation: Repeat weight measurement at next scheduled screen. Provide information on the importance of lifestyle for decreasing risk of weight gain.

 

 

Situation 2:

Significant weight gain noted, especially within first three months of medication use and/or child is overweight, obese or has pre-existing metabolic conditions prior to starting SGA treatment

Recommendation:

1.Lifestyle intervention

Second generation antipsychotic medication use in children and youth is associated with weight gain and metabolic complications. It is therefore strongly recommended that patients receive counselling (nutrition, lifestyle and exercise) at the initiation of therapy regardless of baseline body mass index. This is particularly important in a child who is overweight, obese or has existing metabolic symptoms prior to treatment with a second generation antipsychotic medication.

2. Re-evaluate use of SGA to minimize weight gain

Consider the following questions:

  • Is the lowest effect dose being used? In particular, higher doses of risperidone and olanzapine have been associated with greater weight gain in children.
  • Can an alternative SGA be prescribed that has a lower side effect profile for weight gain?
  • Is the patient taking other medications that also cause weight gain? If yes, can they be stopped, reduced or altered?

2. Fasting plasma glucose and insulin complications management guidelines:

Situation 1:

Normal FPG = FPG < 6.1 mmol/L

Recommendation: Repeat FPG check at next scheduled screen. If the fasting insulin is above the upper limit of normal for the assay being used, consider an oral glucose tolerance test (OGTT) and specialist consultation. For those individuals with an FPG value of 5.6 to 6.0 mmol/L, consider an OGTT.

Situation 2:

Impaired FPG = 6.1 to 6.9 mmol/L

Recommendation: Consider OGTT and specialist consultation if abnormal. Consider metformin in consultation with a specialist.

Situation 3:

Abnormal FPG = FPG ≥ 7 mmol/L

Recommendation: Consult with specialist for the management of diabetes.

Situation 1:

Normal weight gain associated with growth and development

Recommendation: Repeat weight measurement at next scheduled screen. Provide information on the importance of lifestyle for decreasing risk of weight gain.

 

 

Situation 2:

Significant weight gain noted, especially within first three months of medication use and/or child is overweight, obese or has pre-existing metabolic conditions prior to starting SGA treatment

Recommendation:

1.Lifestyle intervention

Second generation antipsychotic medication use in children and youth is associated with weight gain and metabolic complications. It is therefore strongly recommended that patients receive counselling (nutrition, lifestyle and exercise) at the initiation of therapy regardless of baseline body mass index. This is particularly important in a child who is overweight, obese or has existing metabolic symptoms prior to treatment with a second generation antipsychotic medication.

2. Re-evaluate use of SGA to minimize weight gain

Consider the following questions:

  • Can the medication be stopped? Give strong consideration if severe side effects are encountered.
  • Is the lowest effect dose being used? In particular, higher doses of risperidone and olanzapine have been associated with greater weight gain in children.
  • Can an alternative SGA be prescribed that has a lower side effect profile for weight gain?
  • Is the patient taking other medications that also cause weight gain? If yes, can they be stopped, reduced or altered?