One of the most pervasive problems with quitting cigarettes, is the accompanying weight gain – in fact, post-cessation weight gain is reportedly the number one reason why smokers, especially women, fail to stop smoking or relapse after stopping.
But what exactly happens when you stop smoking?
This is the topic of a comprehensive review article by Kindred Harris and colleagues published in Nature Reviews Endocrinology.
The paper begins by examining the magnitude of weight gain generally experienced after smoking cessation – an amount that can vary considerably between individuals.
As for mechanisms, the authors note that,
“Several theories have been proposed to explain increased food intake after smoking cessation. One theory is that the ability of nicotine to suppress appetite is reversed. Substitution reinforcement, which replaces the rewards of food with the rewards of cigarettes could occur. Nicotine absence increases the rewarding value of food. Reward circuitries in the brain, similar to those activated by smoking, are activated by increased intake of food high in sugar and fat. Furthermore, nicotine withdrawal leads to an elevated reward threshold, which might cause individuals to eat more snacks that are high in carbohydrates and sugars.”
There are also known effects of smoking on impulsive overeating and individuals with binge eating disorder are at risk of even greater weight gain with cessation.
Smoking cessation also has metabolic effects including a drop in metabolic rate that may promote weight gain and new evidence shows that smoking cessation can even change your gut microbiota.
The authors provide evidence that behavioural interventions can prevent much of the cessation weight gain and argue that such programs should be offered with cessation programs.
Finally, it is important to always remember that the health benefits of smoking cessation by far outweigh any health risks from weight gain, which is why fear of weight gain should never stop anyone from quitting.
In 2008, the Canadian Obesity Network’s Board of Directors identified weight bias and stigma as one of the Network’s top strategic priority.
The board firmly believes that everyone deserves to be treated with respect and dignity independent of size.
To this end, the Network is working hard towards reducing weight bias and stigma through research, education and action.
The following are just some of the examples resulting from the Network’s many collaborates with researchers, patients, knowledge users and partners to develop education initiatives and practitioner resources to address weight bias in health care settings, the media and public policies:
- Incorporated weight bias and stigma in all CON-RCO education and knowledge exchange programs such as the Canadian Obesity Summits (2009, 2011, 2013, 2015 and biennially thereafter); Dietitian Learning Retreats (2010-present); Canadian Obesity Student Meetings (2010, 2012, 2014); Obesity Research Summer School (formerly known as Obesity Research Boot Camp); Obesity Management Certificate for Post-Graduates (2013-2015).
- In collaboration with health services and primary care experts, CON-RCO has developed the 5As of Obesity Management framework to support primary care practitioners in their interactions with patients with obesity. This was a two-year initiative supported by the Canadian Institutes of Health Research (Knowledge Translation Supplement Grant) and the Public Health Agency of Canada (Innovation Strategy Grant). The resources incorporate weight bias sensitivity training and have now been adapted for pediatric and pregnancy populations.
- CON-RCO under the leadership of Dr. Mary Forhan, associate professor, University of Alberta, Faculty of Rehabilitation Medicine, Department of Occupational Therapy, coordinated the first Canadian Weight Bias and Discrimination Summit in Toronto, Ontario (January 2011). The purpose of the summit was to raise awareness about weight bias and discrimination as it relates to obesity and its association to the health and well being of Canadians. The event drew a capacity crowd of 150 health professionals, students, policy makers, industry representatives, and educators who heard from an expert panel of eight speakers from Canada and the United States.
- CON-RCO partnered with the Canadian Institutes of Health Research to inform a Canadian Bariatric Research Agenda, which included a priority on weight bias and discrimination.
- CON-RCO and the Public Health Agency of Canada collaborated to poll CON-RCO members to identify and counteract some of the most common obesity myths. Results of this study were published and disseminated to CON members and partners.
- CON-RCO partnered with the Rudd Centre for Food Policy and Obesity to develop an image bank to combat stigmatizing images of people with obesity in the media.
- In 2012, CON-RCO partnered with the World Obesity Federation (formerly known as International Association for the Study on Obesity) to host the first International Hot Topic Conference on Obesity and Mental Health. The outcome of this conference was a Charter calling for action for health system funders, researchers and health practitioners to deal with the stigma associated with both obesity and mental illness.
- In 2015, CON-RCO partnered with the University of Calgary research leaders Drs. Angela Alberga, Shelly Russell-Mayhew, Kristin Von Ranson and Lindsay McLaren to participate in a two-day Weight Bias Summit (March 12-13, 2015). The objective of the summit was to bring together stakeholders (researchers, practitioners and policy makers) to discuss and facilitate the design of research projects aimed to reduce weight bias in three sectors (education, health care & public policy) in the province of Alberta.
- In May 2015, CON-RCO established its first Public Engagement Committee (PEC) comprised of people living with obesity from across the country. The mandate of the PES Committee is to be the voice of individuals affected by obesity within CON-RCO and to elevate the conversation of obesity and its impact on health in the community.
- In August 2015, CON-RCO established a collaborative called EveryBODY Matters. This group is composed of CON-RCO members working in research, healthcare, education, public engagement and policy. The mandate of this collaborative is to exchange knowledge, identify opportunities for collaboration across research and practice/policy sectors, and support CON-RCO’s efforts to reduce weight bias and obesity stigma in Canada.
Not least as a result of these many activities, the Network has seen an impressive increase in weight bias and obesity stigma research in Canada.
Thus, while the first Canadian Obesity Summit (2009) only received a handful of abstracts focused on obesity stigma. CON-RCO began to see a shift at the second (2011) and third (2013) Canadian Obesity Summits with more inclusion of weight bias research in the program.
In 2015, the summit included four plenary presentations on weight bias, three workshops, and ten oral and poster abstract presentations on this topic.
This remarkable shift in research interest in better understanding and addressing weight-bias is reflective of the Network’s considerable efforts to increase awareness of weight bias as well as the growing body of literature focused in this area.
Clearly, all of this should be of interest to anyone living with obesity, who, unfortunately, continue to suffer the emotional, physical, social, and financial consequences of weight-bias and discrimination.
To learn more about the Network’s continuing efforts to foster greater respect and a better understanding of people living with obesity click here.
New York, NYC
There is no doubt that bariatric surgery is currently the most effective long-term treatment for severe obesity, however, there is also some evidence to suggest that patients seeking bariatric surgery (or for that matter any kind of weight loss) are more likely to have accompanying mental issues that individuals with obesity who don’t and that such issues may affect the outcomes of surgery.
Now, a paper by Aaron Dawes and colleagues from Los Angeles, CA, published in JAMA presents a meta-analysis of mental health conditions among patients seeking and undergoing bariatric surgery.
They identified 68 publications meeting inclusion criteria: 59 reporting the prevalence of preoperative mental health conditions (65,363 patients) and 27 reporting associations between preoperative mental health conditions and postoperative outcomes (50,182 patients).
Among patients seeking and undergoing bariatric surgery, the most common mental health conditions, each affecting about one-in-five patients were depression and binge eating disorder.
However, neither condition was consistently associated with differences in post-surgical weight outcomes. Nor was there a consistent relationship between other mental health conditions including PTSD or bipolar disease and post-surgical outcomes.
Interestingly, bariatric surgery was consistently associated with a significant decrease in the prevalence and/or severity of depressive symptoms.
So what do these findings mean for clinical practice?
As the authors note,
“Guidelines from the American Society for Metabolic and Bariatric Surgery and the Department of Veterans Affairs/Department of Defense recommend routine preoperative health assessments, including a review of patients’ mental health conditions. Other groups advocate for a more comprehensive, preoperative mental health examination in addition to the general evaluation currently performed by medical and surgical teams. The results of our study do not defend or rebut such a recommendation.”
So why are these data not clearer than they should be? Here is what the authors have to offer:
“Much of the difficulty in determining the effectiveness of preoperative mental health screening is due to the limitations of current screening strategies, which use a variety of scales and focus on mental health diagnoses rather than psychosocial factors. Previous reviews have suggested that self-esteem, mental image, cognitive function, temperament, support networks, and socioeconomic stability play major roles in determining outcomes after bariatric surgery. Future studies would benefit from including these characteristics as well as having clear eligibility criteria, standardized instruments, regular measurement intervals, and transparency with respect to time-specific follow-up rates. By addressing these methodological issues, future work can help to identify the optimal strategy for evaluating patients’ mental health prior to bariatric surgery.”
At this time, perhaps to err on the side of caution, our centre (like many others) continues to screen for and address any relevant mental health issues in patients wishing to undergo bariatric surgery.
Yesterday’s guest post on the issue of food addiction (as expected) garnered a lively response from readers who come down on either side of the discussion – those, who vehemently oppose the idea and those, who report success.
Fact is, that we can discuss the pros and cons of this till the cows come home, because the simple truth is that the whole notion lacks what my evidence-based colleagues would consider “strong evidence”.
Indeed, I did try to find at least one high-quality randomized controlled study on using an addictions approach to obesity vs. “usual” care (or for that matter anything else) and must admit that I came up short. The best evidence I could find comes from a few case series – no controls, one observer, nothing that would compel anyone to believe that this approach has more than anecdotal merit.
Yet, the biology (and perhaps even the psychology) of the idea is appealing. Self-proclaimed “food addicts” that I have spoken to readily identify with the addiction model and describe their relationship to “trigger foods” as an uncontrollable factor in their lives that calls for complete abstinence. Animal studies confirm that foods do indeed stimulate the same parts of the brain that are sensitive to other hedonic pleasures and substances.
So why the lack of good data? After all, the idea is hardly new – intervention programs for “food addicts” using the 12 steps or other approaches have been around for decades.
Can it be simply the lack of academic interest in this issue? I find that hard to imagine – but nothing would surprise me.
Is it perhaps because addiction researchers do not take obesity seriously and obesity researchers don’t like the addiction model?
I certainly don’t buy the argument that there is no commercial interest in such an approach – if there were strong and irrefutable evidence, I’m sure someone would figure out how to monetize it.
So again, I wonder, why the lack of good data?
Honestly, I don’t know.
I’m open to any views on this (especially if substantiated by actual evidence).
Today’s guest post is a response to my recent post about Oprah and her weight-loss struggles. The post comes from Dr Vera Tarman, MD, FCFP, ABAM, and author of Food Junkies: The Truth About Food Addiction and Mike MacKinnon a fitness trainer (Fit in 20).
Oprah’s experience of losing and regaining her weight on a regular basis, alongside Sarah, the Duchess of York and Kristie Allie – all spokespersons for weight loss programs ‐ certainly send us a dismal message. Sure, weight loss can occur but keeping it off is the challenge that trips up 90% of people who have tried these and other programs. So, isn’t it more compassionate to dissuade people from the inevitable yo‐ yo lifestyle and accept their current obese weight?
But … what if there are actually many success stores that we are not hearing about?
As an addictions physician I witnessed patients who have lost an average of 60 to 100 pounds and have kept that weight off for years. They are food addicts in recovery from their addiction. They have adopted a radical diversion from the traditional bariatric or eating disorder menu recommendations: Rather than ‘learning’ how to eat all foods in moderation, these people have identified and abstained from the trigger foods that spur their addictive eating. Sobriety, food serenity and long term weight loss result – on a consistent basis.
Look to the recovery circles and addiction treatment programs. Here you will unearth people who have succeeded where Oprah has not. We don’t hear about these victories because many have pledged anonymity in the church basements where they meet, strategize and buffer the messages that we are saturated with by our food‐obsessed culture. Because there is no money to be made with the simple abstinence of sugar, flour or processed foods, and no drugs, herbs or patented food packages to sell – no one is advertising or promoting this approach. Abstinence.
Here is the story of one clinician who has found long ‐ term weight loss. His is a case in point: Weight loss for 13 years and counting. He is not a “rare’” individual who has achieved the impossible. He and his clients have simply applied the solution to the underlying problem of their obesity – an undiagnosed food addiction.
I’m a strength and nutrition coach who specializes in helping people lose weight. My typical clients are female, age 35 and up, who have tried EVERYTHING under the sun, to no avail. Most have had some success, but usually they have lost their weight and gained back even more.
Often, by the time they get to me, they’re frustrated, angry and feel hopelessness.
Over the course of two years, I lost 95 lbs of body fat. I have maintained my weight loss for almost 13 years. I have also helped many others maintain similar weight loss. Last week I interviewed an ex‐client of mine ‐ a doctor ‐ who lost almost 50 lbs six years ago. How did we both do it?
How did we maintain our loss in the face of those who would tell us that it’s not possible, that most can’t?
We addressed the problem, not the symptom. The symptom is excess body fat. The problem however is multi‐factorial:
1) It is mental in that overweight people greatly misunderstand what healthy eating and healthy exercising looks like.
2) It is emotional. Overweight people tend to turn to food instead of healthier coping mechanisms when they experience stress or overwhelming emotions.
3) It is physical: they eat too much of the wrong stuff, and end up eating it compulsively.
I work with people to re‐program their thinking, so they learn to have a better relationship with food. I teach them reality‐based therapies (CBT, DBT, ACT, REBT) that help them deal with harmful thinking and negative emotions more constructively.
Mainly, I teach them what to eat, what foods are healthy versus which lead to addictive eating. Clients learn the tools they need to stay on track so that they don’t relapse back to compulsive eating. The truth is, for some, there are foods they must avoid permanently. This approach is not popular. But, I have found that some people treat certain foods the same way a drug addict treats their drug of choice. Once they start, they cannot stop.
Not everyone fits this category, but some do. When these people agree to give up the foods that are causing them trouble, they succeed.
So, when I hear someone say that most who are overweight are doomed to never lose their weight, my first thought is “nonsense”. What I suggest to my clients is a paradigm shift in thinking. We, who are led by the diet industry, misunderstand the nature of the problem. It is not a simple matter of eating less and excising more. People must accept that an equal portion of mental, emotional and physical work needs to be done AND they may also have to accept that there are certain foods they can never eat again.
Are you a food addict?
If you are, you may have to identify and abstain from your favorite foods in order to achieve long‐term weight loss. Those processed savory or sugary ‘drugs’ that comprise our daily snacks and fast food meals.
Is there good news? There are plenty of people out there who have sustained weight loss, but we have yet to capture them in our studies. They will tell you: You can, you can, you can.