Smoking cessation, weight gain, and changes in cardiovascular risk factors during menopause: the Healthy Women Study

Meta-analysis of the effects of smoking and smoking cessation on triglyceride levels

Smoking increases lipid levels, including triglycerides, leading to increased cardiovascular disease risk. We performed a meta-analysis to quantify the effects of smoking and smoking cessation on triglyceride levels. The PubMed and Scopus databases were searched to identify studies reporting either triglyceride levels in smokers and non-smokers or the effects of smoking cessation on triglyceride levels. Fixed- and random-effects models were used to perform the analyses when three or more studies/comparisons were available. We identified 169 and 21 studies evaluating the effects of smoking and smoking cessation, respectively, on triglyceride levels. Triglyceride levels were 0.50 mmol/L (95% confidence interval: 0.49-0.50 mmol/L) higher in smokers than non-smokers, but the effect differed widely across studies. No statistically significant effect was observed on triglyceride levels between baseline and 6 weeks (mean difference [MD] = 0.02 [-0.09, 0.12] mmol/L), 2 months (MD = 0.03 [-0.21, 0.27] mmol/L), 3 months (MD = 0.08 [-0.03, 0.21] mmol/L), or 1 year (MD = 0.04 [-0.06, 0.14] mmol/L) after quitting. However, a slightly significant decrease in triglyceride levels was observed at 1 month after cessation (MD = -0.15 [-0.15, -0.01] mmol/L). The results of this meta-analysis provide a basis for understanding the effects of smoking and smoking cessation on triglyceride levels, which could have important implications for public health.

The association between quitting smoking and weight gain: a systematic review and meta-analysis of prospective cohort studies

This systematic review and meta-analysis aimed to quantify weight gain after smoking cessation and the difference in weight gain between quitters and continuing smokers. Five electronic databases were searched before January 2015. Population-based prospective cohort studies were included if they recorded the weight change of adult smokers from baseline (before smoking cessation) to follow-up (at least 3 months after cessation). Thirty-five cohort studies were identified, including 63,403 quitters and 388,432 continuing smokers. The mean weight gain was 4.10 kg (95% confidence interval [CI]: 2.69, 5.51) and body mass index (BMI) gain was 1.14 kg m(-2) (95% CI: 0.50, 1.79) among quitters. Compared with continuing smoking, quitting smoking was significantly associated with absolute weight (adjusted mean difference [MD]: 2.61 kg; 95% CI: 1.61, 3.60) and BMI gain (adjusted MD: 0.63 kg m(-2) ; 95% CI: 0.46, 0.80). Subgroup analyses using geographic region found that the difference in weight gain was considerably greater in studies from North America than from Asia. Follow-up length was identified as a source of heterogeneity, such that studies with longer follow-up showed greater difference in weight gain. Effective strategies are needed to encourage smokers to quit irrespective of potential weight gain and to help quitters avoid excess weight gain.

Smoking relapse and weight gain prevention program for postmenopausal weight-concerned women: A pilot study

OBJECTIVE

Postmenopausal women have substantial concerns about weight gain when quitting smoking, which may contribute smoking relapse. There is a need for smoking cessation and weight gain prevention programs effective in this population.

METHODS

Two formats of a smoking cessation/weight gain prevention follow-up intervention in postmenopausal weight concerned women were compared: a minimally-tailored group format and a highly tailored, multidisciplinary individual format. Effects on sustained abstinence and postcessation weight gain were assessed. Postmenopausal smokers received 6 sessions of behavioral counseling over a 2-week period, 8weeks of the nicotine transdermal patch, and subsequent random assignment to receive follow-up relapse prevention sessions at 1, 3, 8, and 16weeks postcessation in either group or individual format.

RESULTS

The sample (N=98) was 67% Caucasian and 33% African-American. Age: m=52.3 (7.8) years, follicle stimulating hormone: m=42.6 (25.7), body mass index (BMI): m=27.4 (6.2), daily smoking rate: m=20.3 (11.5), for m=29.4 (10.7) years, Fagerström Test for Nicotine Dependence (FTND): m=6.4 (2.1), and carbon monoxide: m=23.8 (13.0) ppm. Abstinence rates in the group condition were significantly higher at 8weeks posttreatment. Group format significantly predicted abstinence rates at 8 and 16weeks posttreatment, even while controlling for age, race, BMI, CPD, years smoking, FTND, and weight concern. Weight concern predicted postcessation weight gain at 8 and 16weeks posttreatment.

CONCLUSIONS

Results indicate that smoking cessation programs for postmenopausal women may best be delivered in a group format and that postcessation weight concerns be dealt with prior to a quit date.

The effect of quitting smoking on HDL-cholesterol - a review based on within-subject changes

A higher concentration of high density lipoprotein cholesterol (HDL-C) in ex-smokers than smokers has consistently been observed. Better evidence of quitting effects comes from within-subject changes. We extend an earlier meta-analysis to quantify the reduction, and investigate variation by time quit and other factors. We conducted Medline and Cochrane searches for studies measuring HDL-C in subjects while still smoking and later having quit. Using unweighted and inverse-variance weighted regression analysis, we related changes (in mmol/l) to intra-measurement period, and estimated time quit, and to study type, location and start year, age, sex, product smoked, validation of quitting, baseline HDL-C, baseline and change in weight/BMI, and any study constraints on diet or exercise. Forty-five studies were identified (17 Europe, 16 North America, 11 Asia, 1 Australia). Thirteen were observational, giving changes over at least 12 months, with most involving >1000 subjects. Others were smoking cessation trials, 12 randomized and 20 non-randomized. These were often small (18 of <100 subjects) and short (14 of <10 weeks, the longest a year). Thirty studies provided results for only one time interval. From 94 estimates of HDL-C change, the unweighted mean was 0.107 (95% CI 0.085-0.128). The weighted mean 0.060 (0.044 to 0.075) was lower, due to smaller estimates in longer term studies. Weighted means varied by time quit (0.083, 0.112, 0.111, 0.072, 0.058 and 0.040 for <3, 3 to <6, 6 to <13, 13 to <27, 27 to <52 and 52+ weeks, p=0.006). After adjustment for time quit, estimates varied by study constraint on diet/exercise (p=0.003), being higher in studies requiring subjects to maintain their pre-quitting habits, but no other clear differences were seen, with significant (p<0.05) increases following quitting being evident in all subgroups studied, except where data were very limited. For both continuing and never smokers, the data are (except for two large studies atypically showing significant HDL-C declines in both groups, and a smaller decline in quitters) consistent with no change, and contrast markedly with the data for quitters. We conclude that quitting smoking increases HDL-C, and that this increase occurs rapidly after quitting, with no clear pattern of change thereafter.

Identifying the Energy Gap: Magnitude and Determinants of 5-Year Weight Gain in Midage Women

OBJECTIVE

The aims of this study were to estimate average yearly weight gain in midage women and to identify the determinants of weight gain and gaining weight at double the average rate.

RESEARCH METHODS AND PROCEDURES

The study sample comprised 8071 participants (45 to 55 years old) in the Australian Longitudinal Study on Women's Health who completed mailed surveys in 1996, 1998, and 2001.

RESULTS

On average, the women gained almost 0.5 kg per year [average 2.42 kg (95% confidence interval, 2.29 to 2.54) over 5 years]. In multivariate analyses, variables associated with energy balance (physical activity, sitting time, and energy intake), as well as quitting smoking, menopause/hysterectomy, and baseline BMI category were significantly associated with weight gain, but other behavioral and demographic characteristics were not. After adjustment for all of the other biological and behavioral variables, the odds of gaining weight at about twice the average rate (>5 kg over 5 years) were highest for women who quit smoking (odds ratio = 2.94; 95% confidence interval, 2.17, 3.96). There were also independent relationships between the odds of gaining >5 kg and lower levels of habitual physical activity, more time spent sitting, energy intake (but only in women with BMI > 25 at baseline), menopause transition, and hysterectomy.

DISCUSSION

The average weight gain equates with an energy imbalance of only about 10 kcal or 40 kJ per day, which suggests that small sustained changes in the modifiable behavioral variables could prevent further weight gain.

Gender-specific differences in the kinetics of nonfasting TRL, IDL, and LDL apolipoprotein B-100 in men and premenopausal women

OBJECTIVE

To investigate mechanisms underlying gender differences in serum lipoprotein concentrations, the kinetic behavior of apoB-100 was assessed.

METHODS AND RESULTS

Twenty subjects (<50 years; 12 men and 8 premenopausal women) were provided a Western diet for 4 to 6 weeks, after which the kinetics of apoB-100 in triglyceride-rich, intermediate-density, and low-density lipoprotein (TRL, IDL, and LDL) were determined in the fed state. Nonfasting plasma TC, LDL-C, and triglyceride concentrations were 23%, 34%, and 57% lower, respectively, in the women compared with men. Plasma TRL and LDL apoB 100 pool sizes were lower by 40% and 30%, respectively. These differences were accounted for by higher TRL and LDL apoB 100 fractional catabolic rates (FCR), rather than differences in production rates (PR). Plasma TRL-C and LDL-C were positively correlated with TRL and LDL apoB 100 concentrations and pool size, and negatively correlated with TRL and LDL apoB 100 FCR (women: r=-0.59, P<0.01 and r=-0.54, P<0.04, and men: r=-0.43, P<0.05 and r=-0.44, P<0.05). No significant associations were observed between plasma TRL-C and LDL-C and PR.

CONCLUSIONS

These data suggest the mechanism for lower TRL-C and LDL-C concentrations in women was determined predominantly by higher TRL and LDL FCR rather than lower PR. This could explain, in part, the lower CVD risk in premenopausal women relative to men.

Treatment of tobacco dependence: integrating recent progress into practice

Tobacco use is one of the leading preventable causes of death in developed countries. Adoption of approaches that have demonstrated efficacy to improve the treatment of tobacco dependence are critical to reduce the health consequences of tobacco use. We summarize the latest epidemiologic data on tobacco use, the mechanisms that underlie tobacco dependence, and advances in pharmacotherapy and nonpharmacologic interventions available for the treatment of tobacco dependence. Specifically, we discuss the use of nicotine replacement therapy, bupropion and varenicline in primary care settings.

Aging and the prevalence of cardiovascular disease risk factors in older American Indians: the Strong Heart Study

OBJECTIVES

To describe longitudinal changes in the prevalence of major cardiovascular disease (CVD) risk factors in aging American Indians.

DESIGN

Population-based ongoing epidemiological study.

SETTING

The Strong Heart Study is a study of CVD and its risk factors. Standardized examinations were repeated in 1993 to 1995 and again in 1997 to 1999.

PARTICIPANTS

A diverse cohort of 4,549 American Indians aged 45 to 74 at the initial examinations in 1989 to 1991.

MEASUREMENTS

Changes in the prevalence of hypertension, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), current smoking, and type 2 diabetes mellitus.

RESULTS

The prevalence of hypertension rose rapidly and steadily with aging. A nonsignificant decrease in LDL-C was seen in men, and men and women initially had rapid increases in the prevalence of low HDL-C. The prevalence of smoking decreased, but the prevalence of diabetes mellitus continued to rise for men and women.

CONCLUSION

Overall, unfavorable changes in CVD risk factors were seen in the aging participants and will likely be reflected in worsening morbidity and mortality.

Predictors of pretreatment attrition from smoking cessation among pre- and postmenopausal, weight-concerned women

The present study sought to determine whether postcessation weight gain concerns influenced pretreatment attrition differently for pre- versus postmenopausal women smokers. Participants were pre- and postmenopausal women smokers drawn from two clinical trials for smoking cessation and weight gain prevention [the Smoking Treatment/Obesity Prevention (STOP) studies]. Predictors of attrition from baseline assessment visits prior to entering smoking cessation treatment were identified among these women. Pretreatment attrition was significantly higher among the premenopausal women. The premenopausal women had significantly higher weight concern but lower restraint and disinhibition than the postmenopausal women. Weight concern explained variance in treatment attrition from the programs, while controlling for variables such as Body Mass Index (BMI), smoking rate, number of years smoking, nicotine dependence level, dietary restraint, disinhibition, and hunger, such that the higher the weight concern, the more likely women were to drop out of treatment programs prior to a quitting attempt.

Smoking cessation guidelines: evidence-based recommendations of the French Health Products Safety Agency

Tobacco use is the leading preventable cause of death in developed countries. Millions of smokers are willing to stop, but few of them are able to do so. Clinicians should only use approaches that have demonstrated their efficacy in helping patients to stop smoking. This article summarizes the evidence-based major findings and clinical recommendations for the treatment of tobacco dependence of the French Health Products Safety Agency (AFSSAPS). Clinicians should enquire about the smoking status of each patient and provide information about health consequence of smoking and effective treatments available. These treatments include counseling (mainly individual or social support and behavioral and cognitive therapy) and pharmacological treatment with either nicotine replacement therapy (NRT) or bupropion LP. Pharmacological treatments should be used only for proven nicotine dependence, as assessed by the Fagerstrom test for Nicotine Dependence. The choice of pharmacologic treatment depends of the patient's preference and history and of the presence of contra-indications. The clinician should start with a single agent, but these treatments may be used in combination. Smoking behavior is a chronic problem that requires long-term management and follow-up. Access to intensive treatment combining pharmacological treatment and extensive behavioral and cognitive therapy should be available for highly dependent patients.

TRL, IDL, and LDL Apolipoprotein B-100 and HDL Apolipoprotein A-I Kinetics as a Function of Age and Menopausal Status

Objective— To determine mechanisms contributing to the altered lipoprotein profile associated with aging and menopause, apolipoprotein B-100 (apoB-100) and apoA-I kinetic behavior was assessed.

Methods and Results— Eight premenopausal (25±3 years) and 16 postmenopausal (65±6 years) women consumed for 6 weeks a standardized Western diet, at the end of which a primed-constant infusion of deuterated leucine was administered in the fed state to determine the kinetic behavior of triglyceride-rich lipoprotein (TRL), intermediate-density lipoprotein (IDL), and low-density lipoprotein (LDL) apoB-100, and high-density lipoprotein (HDL) apoA-I. Data were fit to a multicompartmental model using SAAM II to calculate fractional catabolic rate (FCR) and production rate (PR). Total cholesterol, LDL cholesterol (LDL-C), TRL-C, and triglyceride levels were higher (50%, 55%, 130%, and 232%, respectively) in the postmenopausal compared with the premenopausal women, whereas HDL-C levels were similar. Plasma TRL, IDL, and LDL-apoB-100 levels and pool sizes (PS) were significantly higher in the postmenopausal than premenopausal women. These differences were accounted for by lower TRL, IDL, and LDL apoB-100 FCR ( P <0.05), with no difference in PR. There was no significant difference between groups in HDL-C levels or apoA-I kinetic parameters. Plasma TRL-C concentrations were negatively correlated with TRL apoB-100 FCR ( r =−0.46; P <0.05) and positively correlated with PR ( r =0.62; P <0.01). Plasma LDL-C concentrations were negatively correlated with LDL apoB-100 FCR ( r =−0.70; P <0.001) but not PR.

Conclusions— The mechanism for the increase in TRL and LDL apoB-100 PS observed in the postmenopausal women was determined predominantly by decreased TRL and LDL catabolism rather than increased production. No differences were observed in HDL apoA-I kinetics between groups.

Development and preliminary testing of a patient decision aid to assist pharmaceutical care in the prevention of cardiovascular disease

STUDY OBJECTIVE

To develop and test a decision aid for patients with hypertension and/or dyslipidemia because a decision aid may assist in pharmaceutical care by providing relevant evidence-based information.

DESIGN

Before and after use of a decision aid.

SETTING

Hypertension clinic of a university hospital and a specialized coronary heart disease-prevention clinic.

PATIENTS

A convenience sample of 16 patients receiving pharmacologic treatment for hypertension and/or dyslipidemia.

INTERVENTION

A face-to-face interview was conducted before using the decision aid. This was followed by a telephone interview after the patient used the decision aid to assess the acceptability of the decision aid to the patient, as well as the patient's knowledge, risk perception, and decisional conflict.

MEASUREMENTS AND MAIN RESULTS

The decision aid consists of a booklet containing general, evidence-based information and a personal worksheet. The worksheet provides information on patient risk factors, personal estimates of cardiovascular disease (CVD) risk, the benefits of treatment options, and values clarification exercise. It invites patients to specify an action plan and follow their own progress over time. Most patients (86-93%) rated the presentation of the information as excellent or very good, 80% judged the information about lifestyle changes and drug therapy to be balanced, 93% rated the amount of information "just right," and 100% found the decision aid useful. After using the decision aid, patients had higher knowledge scores for general risk factors (before, 91%; after, 100%, p=0.014), personal risk factors (73%, 92%, p=0.016), and treatment options (68%, 99%, p<0.001). More patients were able to estimate correctly their CVD risk category (50%, 93%, p=0.03) and their absolute 10-year CVD risk (0%, 93%, p<0.001), whereas the overall decisional conflict score decreased (p=0.007).

CONCLUSION

The decision aid was acceptable to patients and improved their knowledge, risk perception, and decisional conflict. Therefore, the feasibility and impact of using the decision aid in community pharmacies and medical clinics should be assessed.

The effects of cessation from cigarette smoking on the lipid and lipoprotein profiles: a meta-analysis

BACKGROUND

Cross-sectional studies revealed that cigarette smokers have lower high-density lipoprotein cholesterol (HDL-C) levels and higher levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and triglycerides (TG) than nonsmokers. But prospective studies on the effects of cigarette smoking cessation on lipid profile have yielded inconclusive results.

METHODS

Relevant English articles were retrieved by keyword searches of MEDLINE (1966-October 2000), Cochrane Library (2000, Issue 2), and cited references. Twenty-seven studies met the following inclusion criteria: (1) prospective cohort study including clinical trials, (2) measuring smoking status and lipid profile of HDL-C, TC, LDL-C, and TG, (3) reporting the changes of lipid concentrations in abstinent smokers, and (4) not using adjuvant antihyperlipidemic drugs.

RESULTS

Overall Q statistics for net change of HDL-C, TC, LDL-C, and TG showed heterogeneity. Using a random-effects model, HDL-C level increased significantly [0.100 (CI 0.074 to 0.127) mmol/L] after smoking cessation. However, levels of TC [+0.003 (CI -0.042 to 0.048)], LDL-C [-0.064 (CI -0.149 to 0.021)], and TG [+0.028 (CI -0.014 to 0.071)] did not change significantly after smoking cessation.

CONCLUSIONS

Cigarette smoking cessation increases serum levels of HDL-C but not of TC, LDL-C, and TG.

Longitudinal changes in weight in perimenopausal and early postmenopausal women: effects of dietary energy intake, energy expenditure, dietary calcium intake and hormone replacement therapy

OBJECTIVE

To investigate whether energy intake or energy expenditure affects 5-7 y weight gain in perimenopausal and early postmenopausal women, and whether hormone replacement therapy (HRT) use or dietary calcium (Ca) intake are contributory factors.

DESIGN

Longitudinal, observational study of healthy women around the menopause.

SUBJECTS

A total of 1064 initially premenopausal women, selected from a random population of 5119 women aged 45-54 y at baseline. In all, 907 women (85.2%) returned 6.3+/-0.6 y later for repeat measurements. Of these, 36% were postmenopausal (no HRT) and 45% had taken HRT, and 898 women completed the questionnaires.

MEASUREMENTS

Weight, height, estimation of energy intake by food frequency questionnaire and physical activity level (PAL) by questionnaire.

RESULTS

Change in PAL influenced weight change explaining 4.4% (P=0.001) of the variation. Alterations in dietary energy intake also had a small but significant effect (0.6% P=0.013). Dietary Ca intake had no effect on weight or weight change.

CONCLUSION

Mean weight had increased and was influenced more by reduced energy expenditure rather than increased energy intake. HRT and dietary Ca intake did not influence weight gain.

Changes in cardiovascular disease risk factors among American Indians. The Strong Heart Study

PURPOSE

This study describes changes in cardiovascular disease (CVD) risk factors in older American Indians over a 4-year period.

METHODS

The Strong Heart Study, a longitudinal population-based study of CVD and CVD risk factors among American Indians aged 45-74 years, measured CVD risk factors among 3638 members of 13 tribes in three geographic areas during examinations in 1989 to 1991 and 1993 to 1995.

RESULTS

Changes in mean low-density lipoprotein (LDL) cholesterol and the prevalence of elevated LDL cholesterol were inconsistent. Mean high- density lipoprotein (HDL) cholesterol decreased, and the prevalence of low HDL cholesterol increased throughout. Mean systolic blood pressure and hypertension rates increased in nearly all center-sex groups, and hypertension awareness and treatment improved. Smoking rates decreased but remained higher than national rates except among Arizona women. Mean weight and percentage body fat decreased in nearly all center-sex groups but the prevalence of obesity did not change significantly in any group. Diabetes and albuminuria prevalence rates increased throughout the study population. The prevalence of alcohol use decreased, but binge drinking remained common in those who continued to drink.

CONCLUSIONS

Improvements in management and prevention of hypertension, diabetes, renal disease, and obesity, and programs to further reduce smoking and alcohol abuse, are urgently needed.

Changes in body mass index around menopause: a population study of Chilean woman

OBJECTIVE

To evaluate the influence of menopause and hormone replacement therapy (HRT) on weight and the effect of weight gain on coronary risk factors.

DESIGN

From 1991 to 1992 cardiovascular risk factors were assessed in 271 premenopausal women between the ages of 40 and 53 years. The women were not receiving HRT at that time. Five years later, these women were reevaluated.

RESULTS

Weight and body mass index (BMI) increased steadily with age. During the observation period there was an average increase of 4.0 kg +/- 4.6 (p < 0.0001). Women who experienced menopause and those who did not experience menopause had a similar weight increase (3.8 +/- 4.4 kg vs. 4.3 +/- 4.8, p = 0.37). Likewise, weight gain was similar in those who did or did not use HRT (nonusers, 4.3 +/- 4.6 kg; users, 3.5 +/- 3.7 kg; ex-users, 3.4 +/- 5.8 kg). At their first checkups, overweight women and obese women already had significant differences in their risk factors, including higher systolic pressure (p < 0.02), diastolic pressure (p < 0.01), glucose (p < 0.02) and triglycerides (p < 0.0001), and lower high-density lipoprotein cholesterol (p < 0.004) as compared with women of normal weight. Unexpectedly, women of normal weight who became overweight or obese during the monitoring period did not show any deterioration in their risk factors.

CONCLUSIONS

During the perimenopausal period there is a weight gain that does not seem to depend on the menopause or HRT. Being overweight or obese during the menopausal transition is not necessarily associated with deterioration in coronary risk factors. This seems to imply the existence of different metabolic populations within this group of women.

Menopausal status and risk factors for cardiovascular disease

OBJECTIVES

Changes in cardiovascular risk factors with menopausal status are difficult to study, owing to the high correlation of menopausal status with age. Therefore we examined cardiovascular risk factors in a meticulously selected population in which the contrast in oestrogen status between pre- and postmenopausal women of the same age was maximized.

DESIGN

Risk factors were compared in 93 premenopausal and 93 postmenopausal women who were matched on age (range 43-55 years).

SETTING

The women were selected from respondents to a mailed questionnaire about the menopause, which was sent to all women aged 40-60 years in the Dutch town of Zoetermeer (n = 12 675; response 54%).

SUBJECTS

Postmenopausal women who were at least 3 years after menopause or whose menses had stopped naturally before age 48 were age-matched with premenopausal women with regular menses and without menopausal complaints.

RESULTS

Compared to premenopausal women, postmenopausal women had significantly increased levels of total cholesterol (10.0%, 95% confidence interval 5.1-14.0), low density lipoprotein (LDL) cholesterol (14.0%, 6.9-19.9), and apolipoprotein B (8.2%, 0.6-15.5). The difference was present within 3 years after onset of menopause and did not show a trend towards an increase with the number of postmenopausal years. No differences were found in high density lipoprotein (HDL) cholesterol, triglycerides, apolipoprotein A1, blood glucose, insulin, body mass index, waist-to-hip ratio, and systolic and diastolic blood pressure.

CONCLUSIONS

The results of this study add to the evidence that total cholesterol, LDL cholesterol and apolipoprotein B are the primary cardiovascular risk factors affected by menopause.