After reading less than half of ‘Metabolic syndrome and schizophrenia’ (Reference ThakoreThakore, 2005) I checked the Declaration of interest and found the expected link to the pharmaceutical industry. On rereading the whole paper carefully I could not pinpoint a single statement that seemed wrong. However, the uneasy general impression remained that the author attempted to suggest that the metabolic syndrome was rather a result of schizophrenia itself and/or the associated stress than the antipsychotic drugs. Therefore, I would like to draw attention to the high probability that patients with schizophrenia were rarely overweight before the advent of neuroleptics. First, Kretschmer (Reference Kretschmer1961) found that 50.3% of 5233 people with schizophrenia had a leptosome (or asthenisch) body build, for which he measured an average waist/hip ratio of 0.67 (74.1/84.7 cm) in men and 0.82 (67.7/82.2 cm) in women. Only 13.7% of 5233 people with schizophrenia were pyknisch, characterised by a strong development of circumference of the holes for the intestines (starke Umfangsentwicklung der Eingeweidehöhlen) and an average waist/hip ratio of 0.97 (88.8/92.0 cm) in men and 0.84 (78.7/94.2 cm) in women. The rest of the schizophrenia sample was classified as athletic, dysphasic or uncharakteristisch (not typical of any of the aforementioned). Among the 1361 people with manic–depressive illness, 64.6% were pyknisch and only 19.2% leptosome. The leptosome body build, which does not seem to indicate a risk of developing the metabolic syndrome, was thought of as typical for schizophrenia.

Second, I asked a student to classify the patients with schizophrenia on old photographs in Bleuler's textbook (Reference Bleuler1969) as probably underweight, normal weight or overweight, without letting her know the reason. She quite rightly protested that she could not carry out the task with any certainty. However, as she appears rather underweight herself and as most people tend to use themselves as a yardstick, it is unlikely that she underestimated the number of overweight patients with schizophrenia. She classified 25% (5 out of 20) as overweight, 60% (12 out of 20) as normal weight and 15% (3 out of 20) as underweight. Thus, in spite of Thakore's paper, I still think that neuroleptic drugs contribute considerably to the development of obesity and its consequences.