Patients with mental illness show higher rates of obesity and metabolic problems than the general population. There are an increasing number of guidelines regarding physical health in schizophrenia. These include recommendations for metabolic monitoring (weight, waist circumference, blood pressure, blood glucose and lipid levels) and non-metabolic monitoring (cardiac monitoring, prolactin and sexual side-effects, neuromotor side-effects) as well as thresholds for intervention. Metabolic effects are of particular concern as they often go unnoticed and can have serious consequences for overall health. Recent evidence has shown increased understanding and awareness of physical health issues in psychiatry, although much remains to be done concerning implementation into routine psychiatric practice; and effectively managing side effects when they do occur. Weight evaluation should be incorporated in routine clinical evaluations. Monitoring of waist circumference is also a sensitive measure, and combined with fasting blood glucose levels, provides a simple, cost-effective screening for metabolic risk. Treatment strategies should focus on prevention and will involve a combination of continued patient and health staff education, nutritional and exercise interventions, appropriate baseline screening, ongoing monitoring of metabolic risk and consideration to appropriate choice of antipsychotic agent. The ADA Consensus (Diabetes Care 2004;27:596-601) on antipsychotic agents and obesity and diabetes provides useful information on the comparative metabolic effects of atypical antipsychotics that can guide treatment and switching, where necessary. Clear practical recommendations should provide patients with the best chance of treatment success without neglecting physical health issues.