In response to Professor Thiels letter, intra-abdominal fat (IAF) is critical in determining the overall risk of physical morbidity and one does not need to be overweight, or indeed obese in the conventional sense, to have an excess of IAF (Reference ThakoreThakore, 2005). For example, patients with melancholic depression, who by definition have usually lost weight, have twice as much visceral fat as matched controls, and have higher mortality rates than the general population (Reference Thakore, Richards and ReznekThakore et al, 1997). Hence, the patients with schizophrenia described by Kretschmer may have been underweight or of normal weight but still have carried excessive amounts of IAF, which would have increased their risk of developing a host of physical problems.

The waist/hip ratio is an indirect anthropometric measure of IAF whose value is greatly influenced by exactly where the tape measure is placed. Using a direct measure of IAF, computed tomographic scanning, we have shown in two separate studies that first-episode drug naïve non-obese patients with schizophrenia have over three times as much IAF as matched controls (Reference Thakore, Mann and VlahoosThakore et al, 2002; Reference Ryan, Flanagan and KinsellaRyan et al, 2004). The amounts of IAF in both of these samples were far in excess of what one would see in simple obesity, but were similar to what one might observe in patients with Cushing's syndrome. There is little doubt that most of the widely used neuroleptics (old and new) cause weight gain. Yet, using computed tomographic scanning, an acknowledged gold standard, we have shown that there is no significant increase in IAF with two commonly used atypical antipsychotics (Reference Ryan, Flanagan and KinsellaRyan et al, 2004). Therefore, we should be asking questions such as what has a greater physical impact on patients with schizophrenia – the illness, with all of its associated stress and poor lifestyle choices, or the medications used to control symptomatology?