Cigarette Smoking and Weight Loss in Nursing Home Residents
Margaret-Mary G. Wilson, MD,MRCP
Division of Geriatric Medicine,
Saint Louis University
Shahnaz Habib MBBS,
Clinical research assistant
Division of Geriatric Medicine,
Saint Louis University
Carolyn Philpot CGNP
Clinical Nurse Practitioner
Division of Geriatric Medicine,
Saint Louis University
Margaret-Mary G. Wilson MD, MRCP
Division of Geriatric Medicine,
St Louis University Health Sciences Center,
1402, S. Grand Blvd, Rm M238,
St. Louis, MO 63104.
Tel No.: (314) 577-8462.
Fax No: (314) 771-8575.
Key words: Smoking, weight loss, aging, Long-term care
To evaluate body weight trends of elderly smokers following admission into a Long Term Care Facility.
STUDY DESIGN AND POPULATION:
Cross-sectional survey of 88 nursing home residents with six month follow-up.
MAIN OUTCOME MEASURES:
Fifty-one of 88 residents were included in the study.
Body weight, height, body mass index (BMI) and serum albumin were documented
on admission into the nursing home. Data collection was repeated at monthly
intervals over a six-month period.
RESULTS: The study population comprised 17(8M, 9F) smokers and 34(19M, 15F) non-smokers. Smokers had a lower body mass index on admission compared with non-smokers (24.2"3 and 27.4"9 respectively; p=0.04; Odds ratio [95% CI] for smokers versus non-smokers = 1.629 [0.498 to 5.32] ).Twelve (71%) smokers and 20 (59%) non-smokers gained weight (p=0.2). Four (24%) smokers and 12 (35%) non-smokers lost weight (p=0.3). Smokers who lost weight did so at a faster rate than non-smokers (13.3 "3.8 lbs and 7.8"2.4 lbs respectively over six months; p=0.02). Similarly, weight gain occurred at a slower rate in smokers compared with non-smokers (5.6"1.3lbs and 8.2lbs respectively over six months; p=0.004)
Weight loss in cigarette smokers may occur at a more rapid in residents who smoke compared with non-smokers. Similarly, weight gain occurs at a slower rate in smokers. Smoking cessation should be encouraged as a critical adjunct to nutritional intervention in nursing home residents with nicotine dependence and weight problems.
Intensive public health education has led to a decline in cigarette smoking
over the past four decades. Increasingly, organizations and institutions are
adopting non-smoking policies 1,2. Within long-term care (LTC), residents' rights
to autonomy and self-determination preclude the enforcement of mandatory non-smoking
policies 3. Epidemiological studies show that cigarette smoking is associated
with progressive weight loss 4,5,6. However, although weight loss is an index
of poor outcomes and increased mortality in nursing home residents, smoking
cessation strategies are excluded from most nutritional and weight management
LTC pathways 7,8. 9,10.
Our study was designed to examine the relationship between cigarette smoking and body weight of residents admitted to a long-term care facility over a six-month period. Non- smokers were compared with smokers.
The study was conducted in a long-term care geriatric facility affiliated with
Saint Louis University. All residents of the facility were screened for the
study. Exclusion criteria included congestive cardiac failure, malabsorption
syndrome, chronic diarrhea, chronic obstructive airway disease, cor pulmonale,
liver cirrhosis, or chronic renal failure. Residents with a Mini-mental State
Examination score < 18 or a Geriatric Depression score > were also excluded
11,12. Enteral tube feeding and life expectancy less than six months were additional
Data collated included admission weight and monthly weights for six months following admission into the facility. The height and body mass index (BMI) on admission and monthly thereafter for six months were also obtained. Serum albumin levels within one month of admission and within one month of termination of the study were obtained. Residents were identified as smokers or non-smokers. Smokers were defined as residents who had smoked 10 cigarettes daily for at least ten years. Non-smokers were defined as residents who had not smoked any cigarettes over the preceding ten years. Residents who fell into neither category were excluded from the study. Data obtained from non-smokers were compared with data obtained from smokers. Significant differences between groups was evaluated using Sato's method to determine odds ratios (OR) and 95% confidence intervals (CI) and the Student's t-test with two-tailed tests of significance for continuous variables 13. A p value of less than 0.05 was considered significant. Informed consent was obtained from all subjects. The study was approved by the Institution Review Board of the Saint Louis University and the Executive Board of the Long Term Care facility.
Eighty-eight residents were screened for the study. Fifty-one residents were
eligible for inclusion, comprising 17 (8M, 9F) residents who smoked and 34 (19M,
15F) residents who were non-smokers. Eight (7M, 1F) smokers were admitted with
body mass indices (BMI) less than 22, compared with 12 (7M, 5F) non-smokers
(OR [95% CI] for smokers versus non-smokers = 1.629[0.498 to 5.32] ).
Table 1 shows the admission data for both smokers and non-smokers.
Fig 1 shows the trend of weight change over the six-month study period among smokers and non-smokers. Among the subset of residents that gained weight the mean weight gain among smokers was 5.6 "1.3lbs compared with 8.2"2.4lbs among non-smokers (p=0.004). Among the subset of residents that lost weight over the study period, the mean weight lost among smokers was 13.3"3.8lbs compared with 7.8"2.4lbs among non-smokers (p=0.02).
Approximately 25% of nursing home residents smoke cigarettes 10, 14. Available
evidence indicates that smoking cessation strategies are less successful within
the long-term care setting. Studies show that adults who continue to smoke into
late life are less likely to cease smoking out of concern for long-term health
effects. Some older smokers erroneously believe that the passage of time has
proven that they are no longer susceptible to the adverse health consequences
of smoking. Likewise, older adults who suffer from smoking related illness often
consider the damage permanent and irreversible and are therefore difficult to
convince of the benefits of smoking cessation 15. Within the nursing home environment,
low levels of perceived self-efficacy, the presence of other smokers and the
reluctance of some health professionals to aggressively educate residents regarding
the dangers of smoking pose additional obstacles to smoking cessation 16.
Currently, in most long-term care facilities in the United States, the institutional smoking policy is driven mainly by fire and safety concerns 17,18. Thus, residents are more likely to perceive smoking cessation policies as intrusive legislation rather than as an integral component of effective health maintenance. Development of more comprehensive smoking policies that highlight specific adverse health effects relevant to nursing home residents may be more successful in encouraging smoking cessation.
Body weight is a critical parameter of care and outcomes determinant within the nursing home setting. Convincing evidence indicates increased mortality in long term care residents with weight loss 19,20,21. Our data showed that smokers admitted into long term care had a BMI compared with non-smokers possibly as a result of the long-term effect of smoking on suppressing weight gain 5,8,22. In addition, although the prevalence of weight loss was not significantly different between smokers and non-smokers, smokers who lost weight in the nursing home, did so at a faster rate than non-smokers (Fig 1). Our study also showed that nursing home residents who smoked gained weight at a slower rate, compared with their non-smoking counterparts. It is conceivable that negative effects of smoking on food intake, such as anorexia and reduced olfactory and gustatory receptor sensitivity, may have a synergistic effect in the presence of other adverse nutritional risk factors, thereby accelerating weight loss 23,24,25, 26.
Cytokine-mediated weight loss is an attractive hypothesis to explain smoking related weight loss. However, available data is controversial. Cancer related cachexia is driven by increased elaboration of pro-inflammatory cytokines. The resultant metabolic abnormalities have been thought to account for the failure of conventional nutritional supplementation to maintain weight in affected cancer patients 27. Similar studies in smokers have failed to reveal a consistent alteration in cytokine levels 28,29. However, evidence indicates that smoking reduces baseline levels of soluble IL-1 receptor antagonist serum levels thereby resulting in reduced antagonism of pro-inflammatory interleukins 30. Weight loss in smokers may therefore result from a dual mechanism involving increased catabolism and reduced energy consumption.
These findings justify a more aggressive approach to nutritional support in
smokers with low body weight or significant weight loss. Effective strategies
include the administration of fortified meals and frequent nutritional supplementation
with energy dense food supplements. Additionally, flavor-enhanced foods may
be effective in increasing energy intake in older smokers as enhanced gustatory
stimulation may combat the hypoageusia associated with both smoking and aging
In smokers who continue to lose weight despite aggressive nutritional supplementation, orexigenic agents, such as megesterol acetate and dronabinol, may be helpful. Recent evidence indicates that megesterol acetate may enhance weight gain in nursing home residents. However, the absence of relevant data mandates cautious use of megesterol in smokers to avoid the possibility of a synergistic or additive increase in the risk of thrombo-embolic events. Dronabinol (delta-9-tetrahydrocannabinol) is the active ingredient of Cannabis sativa, approved for use by the Food and Drug Administration (FDA) as an orexigenic agent in Acquired Immune Deficiency Syndrome (AIDS). Recent evidence indicates that Dronabinol induces weight gain in older persons with dementia. However, it remains unclear whether weight gain in such patients is due to a direct orexigenic effect or a reduction in physical energy expenditure. Further research is needed to determine the precise role of Dronabinol as an orexigenic agent in older persons 32,33,34.
Effective weight loss intervention programs in long term care must incorporate parallel smoking cessation strategies. Clinical Practice Guidelines, such as those issued by the United States Department of Health and Human Services offer practical templates for such strategies 35,36, 37. In addition, emphasis should be placed on the immediate benefits of discontinuing smoking, such as enhanced taste, increased appetite, weight gain and an increased feeling of well-being. Residents with weight loss who opt to participate in a smoking cessation program may benefit from a structured support group directed toward both smoking cessation and weight maintenance.
The role of medication in LTC residents with weight loss is unclear. Nicotine replacement therapy may not be appropriate, as animal studies have shown that nicotine administration reduces food consumption and decreases body weight 38. Data in humans is lacking. However, residents who lose weight on nicotine replacement therapy may benefit from a trial of Bupropion in the absence of a history of seizures or co-existent antidepressant therapy.
Limitations of this study include lack body weight measurements prior to admission, small sample size and the imbalance in numbers between smokers and non-smokers. Larger prospective studies may prove helpful.
Smokers in long-term care facilities lost weight more rapidly than non-smokers.
Similarly, weight was regained more slowly in smokers. Long term care health
professionals must be cognizant of the role of smoking in perpetuating weight
loss. Interdisciplinary programs that integrate nutritional support and smoking
cessation strategies should be an integral component of resident care in LTC
facilities that permit smoking.
Acknowledgements: The authors gratefully acknowledge the valuable editorial assistance of Janice D. Hicks.
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|Smokers (n = 17)||Non-smokers (n = 34)||P value|
|Admission weight (lbs)||158+/-27||165+/-44||0.27|
|Serum albumin (g/dl)||3.8+/-0.3||3.4+/-0.5||0.16|
Values are expressed as means " SEM.
BMI (Wt [kg] / Ht [m2] [accepted normal range: 22 - 27]) 39
Fig 1: Weight trends in smokers and non-smokers six months after admission