Nutrition, Weight Gain and Exercise in the Treatment of Tobacco Dependence

1. Nutrition, Weight Gain and Exercise in the Treatment of Tobacco Dependence Amy Cober RDN MPH CTTS Florida State University College of Medicine AHEC

2. Session Objectives At the conclusion of this presentation, the attendee should be able to- • Discuss post smoking cessation weight gain including patterns of post cessation weight gain, risk factors for post cessation weight gain and mechanisms of post cessation weight gain. • Identify possible evidence based interventions for preventing weight gain with smoking cessation. • Discuss the significance of smoking and smoking cessation on nutrition related diseases.  

3. Common Biological Basis of Obesity & Nicotine Addiction • Brain reward system involved in control of food and tobacco intake • Absence of nicotine shown to increase reward value of certain foods • Heavy smokers weigh more than light smokers • 32 common variants in regulation of appetite for tobacco & food Thorgeirsson et al., Transl Psychiatry (2013)

4. Body Weight & Smoking • Association between obesity and number of cigarettes smoked daily • Historical practice of smoking to “stay slender” • Tobacco marketing strategy • Risk factor for smoking initiation by adolescents • Excuse for not initiating Tobacco treatment • Decreased confidence in quitting • Cause of relapse?

5. Risk Factors for Post Cessation Weight Gain • Gender • Body weight • Mental Health status • Race • Age • Level of tobacco Use • FTND Score • Socioeconomic status • Initiation age • Physical activity level • Coffee consumption • Genetic factors • Triglyceride levels • Presence of a comorbidity Taniguchi, et al., Nursing Research (2013); Komiyama et al., PlosOne (2013); Levine et al., Nic & Tob Research (2012); Yoon et al., Atherosclerosis (2010)

6. Post Cessation Weight Gain • Average weight gain is 4.7 kg • Standard deviation of 4.7 kg • 16% of quitters lose weight • 25% will gain < 1 kg or lose weight • 25% will gain more than 8 kg • 13% will gain more than 10 kg • Rapid weight gain in 1st three months Aubin et al., BMJ (2012)

7. Is it better to be a fat ex-smoker than a thin smoker? Siahpush, M., et al. (2013). "It is better to be a fat ex-smoker than a thin smoker: findings from the 1997-2004 National Health Interview Survey-National Death Index linkage study." Tob Control.

8. Mechanisms of Post Cessation Weight Gain • Reduction in nicotine & CO exposure • Decreased resting metabolic rates • Altered efficiency of calorie storage • Increased appetite • Decreased physical activity • Increased lipoprotein lipase activity • Increased energy intake Gray et al., J Subst Abuse (1995); Grunberg, Add Behaviors (1982); Hofstetter, NEJM (1982); Wack, Am J ClinNutr(1982); Filozof et al., Obes Rev (2004)

9. Weighty Questions • Do repeated periods of abstinence lead to incremental weight gains? • Does resumption of smoking lead to weight loss? • Is the weight gain permanent? • How much of a weight gain will smokers be willing to tolerate?

10. How many pounds would you be willing to gain after quitting smoking? Pomerleau et al., J Subst Abuse (1996)

11. The Effects of Nicotine and Cigarette Smoking on Food Consumption and Taste Preferences • Nonsmokers • Smokers allowed to smoke • Smokers not allowed to smoke • Test foods-chocolate, coffee cake, gumdrops, salami, salted peanuts, pretzels, unsalted crackers, cheese & unsalted peanuts Grunberg, Addictive Behaviors (1982)

12. Fruit & Vegetable Consumption and Smoking • Higher F &V Consumption associated with- • Fewer cigarettes smoked/day • Longer time to first cigarette • Lower nicotine dependence score (NDSS) • Likelihood of making a quit attempt was higher among persons with the highest vegetable consumption • F & V Consumption predicted abstinence at follow-up Prevent or resolve post cessation constipation Dietary improvement as a smoking cessation tool? Haibach et al., Nicotine & Tobacco Research (2013)

13. Effects of Food & Beverages on Cigarette Palatability • Factors that worsen the taste of cigarettes can decrease smoking behavior • Post prandial cigarette particularly satisfying • Biological factors may play a causal role • Clinical implications- • Assess which foods & beverages enhance or worsen taste • Consider advising patients to increase or decrease during a quit attempt McClernon et al., Nicotine & Tobacco Research (2007)

14. Dietary Intake After Smoking Cessation Energy Intake Total calories by smoking status over time Levine, M. D., et al. (2012). "Dietary intake after smoking cessation among weight-concerned women smokers." Psychol Addict Behav26(4): 969-973.

15. 100 CALORIES 100 calories x 365 days = 36,500 calories/year 36,500 Calories/year divided by 3,500 calories/pound= 10.42 pounds

16. Evidence Based Weight Management Rx • During Tobacco Treatment • Lower fat/calorie food choices while increasing Fruit & Vegetable intake • Nicotine Replacement Therapy (NRT) • Increased Physical Activity • Nutritional assessment & treatment • Dietary interventions • Physical Activity interventions • Behavioral interventions • FDA approved medications for weight loss • Bariatric surgery Veldheer et al., Intl J Clin Pract (2014)

17. NRT: Effects on PostcessationWeight Gain • 50% reduction in cessation related weight gain • Dose response relation • Follow-up data suggest a delay rather than prevention of eventual weight gain Use of nicotine gum may allow time for acceptance of weight gain and/or implementation of new diet & exercise behaviors. Gross et al., J Consult Clin Psych (1989)

18. Transdermal Nicotine Therapy & Post Cessation Weight Gain • Control group • 8 weeks patch therapy plus 16 weeks placebo • 10.37 lb average weight gain • Intervention group • 24 weeks patch therapy • 5.83 lb average weight gain Smokers who express a fear of abstinence-induced weight gain could be encouraged to utilize extended nicotine patch treatment as a therapeutic option. Schnoll et al., Addictive Behaviors (2012)

19. Combination Pharmacological Interventions • Successful combinations • Nicotine inhaler plus nicotine patch • Nicotine patch plus bupropion • Naltrexone plus patch (2) • ProBAN plus gum • Naltrexone plus bupropion • Rimonabant plus patch Yang et al., Addictive Behaviors (2013)

20. Offering a Weight Management Program • Available after treatment for tobacco dependence • Overweight & obese smokers who expressed moderate concern about weight gain Smokers offered a weight management program were five times more likely to attend the first session of tobacco treatment. Smokers offered a weight management program were three times more likely to be abstinent 6 months after treatment. Love, et al. Am J Addict 2010;20:1-8

21. Predicting Weight Concerns • Gender • Education level • Income • BMI • Age • Social support • Depressive symptoms • Motivation • Confidence in quitting • Daily number of cigarettes • Gained weight on a prior quit attempt • Special populations Veldheer et al., Int J ClinPract(2014); Collins, B. N., et al., Am J Health Behav(2009)

22. Smoking Related Weight Concerns Levine, M. D., et al. (2012). "Smoking-Related Weight Concerns and Obesity: Differences among Normal Weight, Overweight, and Obese Smokers Using a Telephone Tobacco QuitLine." Nicotine Tob Res.

23. Cognitive Behavioral Therapy • CBT to reduce weight concerns improves smoking cessation outcomes. • Does CBT plus Bupropion enhance abstinence for weight concerned women smokers? • Counseling for Weight Concerns • Therapy Foci • Restructuring thoughts about food, eating & weight • Reevaluating beliefs about the importance of a low weight & ideal shape • Education topics • Cessation related weight gain • Benefits of cessation relative to a modest weight gain • Disadvantages of trying to diet while quitting • Restrained eating • Moderate consumption of healthy between meal snacks Perkins et al., J Cons & ClinPsych(2001); Levine et al., Arch Intern Med (2010)

24. Associations between Exercise and Smoking Behaviors • Levels of physical activity are inversely related to smoking rates • Gender and mode specific • Adolescents- smoking is negatively associated with sports participation • Smokers trying to quit are likely to be more receptive to an active lifestyle than smokers in general • Disease reduction strategy • Associated with less depression • Positive association between exercise and- • Initiating a quit attempt • Confidence in staying abstinent • Quit success Ussher et al., Cochrane Review (2012)

25. Exercise- Effect on Post Cessation Weight Gain • Findings • Excess 2.4 kg weight gain associated with smoking cessation This weight gain is minimized if smoking cessation is accompanied by a moderate increase in the level of physical activity. Kawachi et al., Am J of Pub Health (1996)

26. Exercise- Effect on Post Cessation Weight Gain • Intervention • Group 1 • Counseling & NRT • Group 2 • Counseling, NRT & Exercise • Results • Exercise during smoking cessation can successfully prevent weight gain. • Adding an exercise program results in a cessation rate higher than that of traditional approaches alone. Chaney et al., AAOHN Journal (2008)

27. Effects of exercise on tobacco withdrawal and cravings • Reduced psychological withdrawal symptoms • Reduced desire to smoke • Alternative reinforcerto smoking • Influence on cognitive functioning by reducing attentional bias to smoking images • There is STRONG evidence to recommend exercise as an aid for reducing tobacco withdrawal and cravings. • Ussher et al., Cochrane Review (2012)

28. Smoking and the Risk of Diabetes • Cigarette smoking is an independent and modifiable risk factor for type 2 diabetes • No dose response or threshold relationship foundin long term studies • No relationship between pack years of smoking • Biological mechanisms Wannamethee et al., Diabetes Care (2001)

29. Smoking Cessation and the Risk of Diabetes • Smoking cessation results in a higher short term risk for diabetes • Highest risk within first 3 years of quitting • Decreases to no excess risk by 12 years • Consistent across numerous studies • Greatest risk group • Heavy smokers with evidence of systemic inflammation who gain substantial weight after quitting Yeh et al., Ann Intern Med (2010)

30. Effects of Smoking on Bone Health • Key risk factor for bone loss & fractures • Mechanisms poorly understood • Dose dependent • May be partially reversible • Effect of smoking on falls Wong et al., Clinical Science (2007)

31. Dietary Sodium & Smoking Increases Risk for Rheumatoid Arthritis • Purpose of the study was to evaluate the impact of NaCl intake on the risk of developing RA • Sodium intake more than doubled the risk for RA among smokers • High sodium intake (taken as the median of the uppermost tertile) was 2.15 grams per day Sundstrom et al., Rheumatology (2014)

32. Practice Implications • Recommend NRT for withdrawal symptoms, delaying weight gain and decreasing concerns of weight gain. • Incorporate exercise to prevent or minimize weight gain, reduce withdrawal symptoms and increase cessation success. • Follow-up to reduce weight gain anxiety and encourage continued abstinence. • Educate on a healthy diet to prevent or minimize weight gain, prevent chronic diseases and reduce cancer risk. • Include or offer a weight management program (to weight concerned smokers) for treatment initiation and improved abstinence. (And let smokers know it will be included.) • Tailor messages to highlight the greater reduction in mortality associated with quitting, compared with potential weight gain.

33. Tailored Messages to Negate Fears of Weight Gain Clinical Practical Guidelines; “Clinician statements” (page 176)